Antenatal Care and Conditions Flashcards
What is primigravida?
Patient pregnant for the first time
What is multigravida?
Patient pregnant for at least the second time
When is the first trimester?
Start of pregnancy to 12 weeks gestation
When is the second trimester?
13 weeks to 26 weeks
When is the third trimester?
From 27 weeks until birth
When do fetal movements begin?
From around 20 weeks and continue until birth
When is the booking appointment?
Before 10 weeks, offers a baseline assessment and plans the pregnancy
When is the dating scan?
Between 10-13 weeks, gives an accurate gestational age from the crown rump length
Multiple pregnancies are identified
When is the first antenatal appt?
16 weeks, discuss results and future appts
When is the anomaly scan?
Between 18 and 20 +6
When are additional antenatal appts?
25, 28, 31, 34, 36, 38, 40, 41, 42
What additional appointments might be necessary in pregnancy?
Additional appts if higher risk or complications
Oral glucose tolerance test between 24-28 weeks if at risk of gestational diabetes
Anti-D injections if rhesus negative at 28 and 34 weeks
Ultrasound scan at 32 weeks for those with placenta praevia on the anomaly scan
Serial growth scans if increased risk of FGR
What is discussed at each routine antenatal appt?
Plans for the remainder of pregnancy and delivery
Symphysis fundal height measurement - 24 weeks onwards
Fetal presentation from 36 weeks
Urine dipstick for protein for pre-eclampsia
Blood pressure for pre-eclampsia
Urine for microscopy and culture
What vaccines are offered to pregnant women?
Whooping cough - pertussis from 16 weeks
Influenza in autumn or winter
What pregnancy lifestyle advice is given?
Take folic acid 400mcg before pregnancy to 12 weeks
Vitamin D supplement 10mcg daily
Avoid vitamin A supplements, eating liver or pate as vit A teratogenic at high doses
No alcohol or smoking
No unpasteurised dairy or blue cheese - listeriosis
Avoid undercooked or raw poultry - salmonella
Continue moderate exercise, avoid contact sports
Sex is safe
Flying increases risk of VTE
Care seatbelts above or below bump, not across
What can drinking alcohol in early pregnancy lead to?
Effects are greatest in first 3 months
Can lead to miscarriage, small for dates, preterm delivery, fetal alcohol syndrome
What are the features of fetal alcohol syndrome?
Microcephaly
Thin upper lip
Smooth flat philtrum - groove between nose and lip
Short palpebral fissure (width of eyes)
Learning difficulties, behavioral difficulties
Hearing and vision problems
Cerebral palsy
What does smoking in pregnancy increase the risk of?
Fetal growth restriction Miscarriage Stillbirth Preterm labour and delivery Placental abruption Pre-eclampsia Cleft lip or palate Sudden infant death syndrome SIDS
When can you fly in pregnancy?
Up to 37 weeks singleton
Up to 32 weeks with twins
After 28 weeks, usually need letter to airline from midwife, GP or obstetrician that pregnancy is going well
What booking bloods are taken?
Blood group, antibodies, Rhesus D status
Full blood count for anaemia
Screening for thalassaemia and sickle cell disease
Screening for HIV, Hep B, syphilis
Screening for Down’s initiated depending on gestational age, bloods for combined test taken from 11 weeks
What additional risks are measured at the booking clinic, and what plans are put in place?
Rhesus negative - book anti D prophylaxis
Gestational diabetes - book oral glucose tolerance test
Fetal growth restriction - book additional scans
VTE - provide prophylactic LMWH if high risk
Pre-eclampsia - provide aspirin if high risk
What is the combined test for Down’s?
First line and most accurate screening test
Performed between 11-14 weeks
USS and maternal blood tests
USS measures nuchal translucency; thickness on back of neck of fetus, in Down’s is greater than 6mm.
Test beta hCG - higher indicates greater risk
Pregnancy associated plasma protein A - lower indicates greater risk
What is the triple test for Down’s?
Performed between 14-20 weeks, maternal bloods
beta hCG - higher result is greater risk
Alpha fetoprotein - lower indicates greater risk
serum oestriol - female sex hormone, lower indicates greater risk
What is the quadruple test for Down’s?
Identical to triple test but also includes test for inhibin-A
A higher result indicates a greater risk
What is done following screening tests for Down’s?
Provides risk score
If risk is greater than 1 in 150, offered amniocentesis or chorionic villous sampling
Sample enables karyotyping
Amniocentesis US guided aspiration of amniotic fluid
Chorionic villus sampling ultrasound guided biopsy of placental tissue done before 15 weeks
What is non-onvasive prenatal testing?
Blood test from mother
Blood will contain fragments of DNA, some of which comes from placental tissue and represents fetal DNA
What can untreated hypothyroidism in pregnancy lead to?
Miscarriage, anaemia, SGA, pre-eclampsia for example
What is the treatment for hypothyroidism in pregnancy?
Levothyroxine T4
Can cross placenta and provide thyroid hormone to developing fetus, so dose needs to be increased, usually by at least 25-50 mcg
Treatment titrated based on TSH level
What medications to treat hypertension may need to be stopped in pregnancy?
ACEi e.g. ramipril
Angiotensin receptor blockers e.g. losartan
Thiazide and thiazide like diuretics e.g. indapamide
What epilepsy medication is safe in pregnancy?
Levetiracetam, lamotrigine and carbamazepine
What epilepsy drugs should be avoided in pregnancy?
Sodium valproate can cause neural tube defects and developmental delay
Phenytoin can cause cleft lip and palate
What RA drugs are contraindicated in pregnancy?
Methotrexate is teratogenic
can cause miscarriage and congenital abnormalities
What RA drugs are safe during pregnancy?
Hydroxychloroquine is the first line choice
Sulfasalazine considered safe in pregnancy
Corticosteroids may be used in flare ups
Are NSAIDs safe in pregnancy?
No, generally avoided in pregnancy unless really necessary e.g. rheumatoid arthritis
Block prostaglandins, prostaglandins important in maintaining ductus arteriosus, also softens cervix and allows uterine contractions.
Particularly avoided in third trimester as cause premature closure of the ductus arteriosus and can delay labour.
What beta blocker is safe in pregnancy?
Labetolol
First line for hypertension caused by pre-eclampsia.
What effects can beta blockers have during pregnancy?
Fetal growth restriction
Hypoglycaemia in the neonate
Bradycardia in the neonate
What is the effect of ACE inhibitors and angiotensin II receptor blockers in pregnancy?
Can cross the placenta and enter the fetus
Mainly affect the kidneys and reduce the production of urine and therefore - oligohydramnios - reduced amniotic fluid.
Also miscarriage, or fetal death
Hypocalvaria - incomplete formation of the skull bones
Renal failure in the neonate
Hypotension in the neonate
What is neonatal abstinence syndrome?
Withdrawal symptoms from use of opiates in pregnancy
Presentation is 3-72 hours after birth, irritability, tachypnoea, high temperatures and poor feeding.
Is warfarin safe in pregnancy?
Crosses the placenta, is considered teratogenic so should be avoided in pregnancy.
Can cause fetal loss
Congenital malformations, particularly craniofacial problems
Bleeding during pregnancy, PPH, fetal haemorrhage, intracranial bleeding
What are the complications of the use of lithium in pregnancy?
Particularly avoided in first trimester, linked with congenital cardiac abnormalities
Associated with Ebstein’s anomaly; the tricuspid valve is set lower on the right side of the heart towards the apex, causing a bigger right atrium and smaller right ventricle.
If lithium is used, levels need to be closely monitored - every 4 weeks, and then weekly from 36 weeks.
Lithium also enters breast milk and is toxic to the infant so should also be avoided when breastfeeding.
What are the risks of SSRIs in pregnancy?
Risks need to be balanced against the benefits of treatment, as risks of untreated depression can be very significant.
First trimester use has link with congenital heart defects
First trimester use of paroxetine - congenital malformations
Third trimester use has a link with persistent pulmonary hypertension in the neonate
Neonates can experience some mild withdrawal symptoms
What are the complications of using isotretinoin in pregnancy?
isotretinoin/roaccutane is a retinoid medication relating to vitamin A which is used for severe acne.
It is highly teratogenic causing miscarriage and congenital defects. Women need very reliable contraception before, during and one month after taking this.
What is the effect of rubella in pregnancy?
Rubella virus can cause congenital rubella syndrome during the first 20 weeks of pregnancy, and the risk is highest before 10 weeks gestation.
Women should ensure had MMR vaccine, but should not have the MMR vaccination whilst pregnant as is a live vaccine.
What are the features of congenital rubella syndrome?
Congenital deafness
Congenital cataracts
Congenital heart disease - PDA and pulmonary stenosis
Learning disability
What is the effect of chickenpox during pregnancy?
Infection from varicella zoster virus
Can lead to more severe cases in the mother e.g. varicella pneumonitis, hepatitis, encephalitis
Fetal varicella syndrome
Severe neonatal varicella infection if infected around delivery
What is the treatment if not immune against chickenpox during pregnancy?
Check VZV IgG levels, if positive they are safe
Can be treated with IV varicella immunoglobulins as prophylaxis, these should be given within 10 days of exposure
If rash starts to appear in pregnancy, treat with oral aciclovir if present within 24 hours and more than 20 weeks gestation
What are the features of congenital varicella syndrome?
Occurs when infection is in first 28 weeks gestation
Fetal growth restriction
Microcephaly, hydrocephalus, learning disabilities
Scars, skin changes in specific dermatomes
Limb hypoplasia - underdeveloped limbs
Cataracts and inflammation in the eye - chorioretinitis
What is listeria and its effects in pregnancy?
Gram positive bacteria causing listeriosis, many times more likely in pregnant women.
Infection in mother can be asymptomatic, cause flu like illness, pneumonia or meningoencephalitis.
High rate of miscarriage, fetal death, severe neonatal infection.
Found in unpasteurised dairy products, processed meats, and contaminated foods.
What is congenital cytomegalovirus infection?
Occurs due to cytomegalovirus infection in mother during pregnancy.
Virus spread by infected saliva or urine of asymptomatic children.
Features include fetal growth restriction, microcephaly, hearing loss, vision loss, learning distability, seizures.
What is congenital toxoplasmosis?
Infection from toxoplasma gondii, higher risk later on in the pregnancy
Classic triad of intracranial infection, hydrocephalus, chorioretinitis - inflammation of choroid and retina
What is parvovirus B19?
Infection usually affects children, slapped cheek fifth disease with non specific symptoms and rash
What happens in parvovirus B19 infection in pregnancy?
Miscarriage or fetal death
Severe fetal anaemia
Hydrops fetalis - fetal heart failure
Maternal pre-eclampsia like syndrome
What is fetal anaemia following B19 infection and its complication?
Parvovirus infection of the erythroid progenitor cells in the fetal bone marrow and liver.
Infection causes them to produce faulty RBCs with a shorter life span.
This anaemia leads to heart failure - hydrops fetalis.
What is mirror syndrome?
Maternal pre-eclampsia-like syndrome.
Rare complication of severe fetal heart failure.
Triad of hydrops fetalis, placental oedema, oedema in the mother. HTN and proteinuria.
What are the tests for parvovirus in pregnancy?
IgM to parvovirus - acute infection within past four weeks.
IgG to parvovirus tests for long term immunity after previous infection.
Rubella antibodies - for a differential diagnosis.
What is the treatment for B19 infection in pregnancy?
Supportive treatment.
Need a referral to fetal medicine to monitor for complications and malformations.
What is the consequence of the zika virus in pregnancy?
Spread by Aedes mosquitoes or having sex with someone with the virus.
Can cause no symptoms, minimal or a mild flu-like illness.
Can lead to congenital Zika syndrome
Microcephaly, fetal growth restriction
Intracranial abnormalities e.g. ventriculomegaly and cerebellar atrophy
Use of viral PCR and antibodies to zika virus tested. Referral to fetal medicine for monitoring. No treatment.
What does rhesus positive or negative mean?
Whether the rhesus-D antigen in present on red blood cell surface or not.
What is the process of rhesus incompatibility in pregnancy?
If a woman that is rhesus D negative becomes pregnancy, the child could be rhesus positive.
If baby’s blood is in mother’s blood stream the baby’s RBCs display the rhesus D antigen.
Mum’s immune system recognises this as foreign, produces rhesus D antibodies and then is sensitised against the Rhesus D antigens.
In further pregnancies, mother’s antibodies can cross placenta and if baby is rhesus D positive, these will attach to fetus RBCs and cause fetus immune system to attack itself - haemolytic disease of the newborn.
What is the management of rhesus incompatibility?
Prevention of sensitisation
Anti-D injections to rhesus D negative women.
These attach to rhesus D antigens on fetal red blood cells in the mum so they are destroyed and not recognised by mum’s immune system.
When are anti-D injections given?
28 weeks gestation
Birth if baby’s blood group is found to be rhesus positive
Can also be given when sensitisation may occur e.g. antepartum haemorrhage, amniocentesis, abdominal trauma
Given 72 hours after sensitisation event
What is the Kleihauer test?
After 20 weeks gestation, performed to see how much fetal blood has passed into mum during sensitisation.
Acid added to sample of mum’s blood. Fetal haemoglobin more resistant to the acid so resistant to acidosis.
So fetal haemoglobin persists whereas mother’s hb destroyed, so no of cells still containing hb is then fetal cells.
What is small for gestational age?
A fetus that measures below the 10th centile for their gestational age.
What measurements on ultrasound are used to assess the fetal size?
Estimated fetal weight EFW
Fetal abdominal circumference
What are customised growth charts based on?
Ethnic group
Weight
Height
Parity
What is severe SGA?
Below the 3rd centile for their gestational age.
What is low birth weight?
Birth weight of less than 2500g.
What is the difference between SGA and FGR?
SGA small for the dates without stating why.
May be constitutionally small, but growing appropriately and not at risk of any complications. Or may be small due to a pathology e.g. FGR.
What are the causes of FGR?
Also known as IUGR
When small fetus, or not growing as expected due to pathology reducing amount of nutrients and oxygen being delivered to the fetus through the placenta.
What are the causes of fetal growth restriction?
Placenta mediated - idiopathic, pre-eclampsia, maternal smoking, alcohol, anaemia, malnutrition, infection, maternal health conditions
Non-placenta medicated growth restriction - pathology of the fetus, e.g. genetics, structural, infection, errors of metabolism
What signs may indicated a fetal growth restriction?
SGA
Reduced amniotic fluid volume
Abnormal doppler studies
Reduced fetal movements
Abnormal CTGs
What are the complications of a fetal growth restriction?
Short term complications Fetal death or stillbirth Birth asphyxia Neonatal hypothermia Neonatal hypoglycaemia
Cardiovascular disease HTN T2 DM Obesity Mood and behavioural problems
What are the risk factors for a SGA baby?
Previous SGA baby Obesity Smoking Diabetes Existing HTN Pre-eclampsia Older mother - over 35
What are the minor risk factors for SGA babies?
Maternal age >35 IVF singleton Nulliparity BMI <20 Smoker 1-10 Low fruit intake pre-pregnancy Previous pre-eclampsia Pregnancy interval <6 months Pregnancy interval >60 months
What are major risk factors for SGA babies?
Maternal age >40 Smoker >11 a day Paternal SGA Cocaine Daily vigorous exercise Previous SGA Previous stillbirth Maternal SGA Chronic HTN Diabetes with vascular disease Renal impairment Antiphospholipid syndrome Heavy bleeding
What is the screening process for SGA?
Booking assessment demonstrates either 3 or more minor risk factors, or one major risk factor
Consider aspirin at <16 weeks if risk of pre-eclampsia
Reassess at 20 weeks
If 3 or more minor risk factors then, uterine artery doppler at 20-24 weeks
Serial assessment of fetal size, and umbilical artery doppler
What monitoring is advised for SGA?
Estimated fetal weight and abdominal circumference to determine growth velocity
Umbilical arterial pulsatility index to measure flow through umbilical artery
Amniotic fluid volume
What investigations are suggested to identify the underlying cause of SGA?
Blood pressure and urine dipstick for pre-eclampsia
Uterine artery doppler scanning
Detailed fetal anatomy scan by fetal medicine
Karyotyping for chromosomal abnormalities
Testing for infection
What is large for gestational age?
Macrosomia
When the weight of the newborn is more than 4.5kg at birth
During pregnancy; estimated fetal weight is above the 90th centile
What are the causes of macrosomia?
Constitutional Maternal diabetes Previous macrosomia Maternal obesity or rapid weight gain Overdue Male baby
What are the risks to the mother of macrosomia?
Shoulder dystocia Failure to progress Perineal tears Instrumental delivery Caesarean PPH Uterine rupture
What are the risks to the mother in macrosomia?
Birth injury e.g. Erb’s, clavicular fracture, fetal distress, hypoxia
Neonatal hypoglycaemia
Obesity in childhood and later life
Type 2 diabetes in adulthood
What are the investigations for macrosomia/LGA?
Ultrasound to exclude polyhydramnios and estimate fetal weight
Oral glucose tolerance test for gestational diabetes
How can the risks of shoulder dystocia at birth be reduced?
Delivery on consultant led unit
Delivery by an experienced midwife or obstetrician
Access to obstetrician or theatres if required
Active management of third stage delivery - placenta
Early decision for caesarean section if required
Paediatrician attending the birth
What are monozygotic twins?
Identical from a single zygote
What are dizygotic twins?
Non-identical from two different zygotes
What is monoamniotic twins?
Single amniotic sac
What is monochorionic?
Share a single placenta
Which twins have the best outcomes?
Diamniotic dichorionic as each fetus has their own nutrient supply
What is the lambda sign seen on USS?
Twin peak sign
Triangular appearance where the membrane between the twins meets the chorion - indicates a dichorionic twin pregnancy.
What is the T sign seen on USS?
Membrane between the twins abruptly meets the chorion, giving it a T appearance. Indicates a monochorionic twin pregnancy.
What are the risks to the mother in multiple pregnancy?
Anaemia Polyhydramnios Hypertension Malpresentation Spontaneous preterm birth Instrumental delivery or caesarean PPH
What are the risks to fetus/neonates in multiple pregnancy?
Miscarriage Stillbirth FGR Prematurity Twin-twin transfusion syndrome Twin anaemia polycythaemia sequence Congenital abnormalities
What is twin-twin transfusion syndrome?
feto-fetal if more than two fetuses
One fetus is a recipient and gets most of the blood from the placenta, and the other is the donor.
Recipient can become fluid overloaded, heart failure and polyhydramnios whereas donor has GR, anaemia and oligohydramnios.
Laser treatment may be needed to destroy connection between two blood supplies.
When are FBCs required for women with multiple pregnancy?
Additional monitoring for anaemia
FBC at booking, 20 weeks and 28 weeks
What additional USS are required in multiple pregnancy?
Monitors fetal growth restriction, unequal growth and twin-twin transfusion.
2 weekly scans from 16 weeks if monochorionic
4 weekly from 20 weeks if dichorionic
When is a planned birth offered in multiple pregnancy?
32 - 33+6 if uncomplicated monochorionic monoamniotic
37-37+6 if dichorionic and diamniotic
Before 35+6 for triplets
What delivery options are available for diamniotic twins?
Vaginal when first baby has cephalic presentation
Caesarean section may be needed for second baby after successful birth of first
Elective caesarean when presenting twin not cephalic
What is the presentation of a lower UTI in pregnancy?
Dysuria Suprapubic pain Increased frequency Urgency Incontinence Haematuria
What is the presentation of pyelonephritis in pregnancy?
Fever - more prominent than lower UTI Loin, suprapubic or back pain, bilateral or unilateral Look/feel generally unwell Vomiting Loss of appetite Haematuria Renal angle tenderness
What is seen on urine dipstick in UTI in pregnancy?
Nitrites - from gram neg bacteria e.g. E Coli
Leukocytes - WBCs, raised in infection
MSU sample sent to micro for culture and sensitivity
Pregnant women tested for asymptomatic bacteriuria at booking and routinely.
What are the causes of UTI in pregnancy?
E Coli Klebsiella pneumoniae Enterococcus Pseudomonas aeruginosa Staph saprophyticus Candida
What is the management of UTI in pregnancy?
7 days antibiotics
Nitrofurantoin - not in third trimester
Amoxicillin, once sensitivities known
Cefalexin
What is the risk of nitrofurantoin in the third trimester?
Risk of neonatal haemolysis - destruction of neonatal red blood cells
Why must trimethoprim be avoided in pregnancy?
Works as folate antagonist
Folate needed for normal development, otherwise can lead to congenital malformations and neural tube defects e.g. spina bifida
When are women routinely scanned for anaemia during pregnancy?
Booking clinic
28 weeks gestation
Why is anaemia common in pregnancy?
Plasma volume increases
Results in reduction in Hb concentration
Blood is diluted due to higher plasma volume
What is the presentation of anaemia in pregnancy?
Often asymptomatic Shortness of breath Fatigue Dizziness Pallor
What are the normal ranges of haemoglobin during pregnancy?
Booking - >110
28 weeks - >105
Post partum - >100
What are the investigations for anaemia in pregnancy?
FBC Check MCV Low - iron deficiency Normal - physiological anaemia due to increased plasma volume Raised - B12 or folate deficiency
Haemoglobinopathy screening at the booking clinic for thalassaemia and sickle cell
Check ferritin, B12, folate
What is the management of anaemia in pregnancy?
Iron replacement e.g. ferrous sulphate 200mg 3x a day
If not anaemic, but low ferritin indicating low iron, given supplementary iron
If low B12, test for pernicious anaemia - check for intrinsic factor antibodies
IM hydroxocobalamin injections
Oral cyanocobalamin tablets
All women should already be taking 400mcg folic acid every day, if deficiency start on 5mg daily
Those with a haemoglobinopathy managed with haematology, high dose of folic acid needed
When is the risk of PE greatest?
In the postpartum period
What are the risk factors for VTE in pregnancy?
Smoking Parity >3 Age >35 BMI >30 Reduced mobility Pre-eclampsia Gross varicose veins Immobility Family history of VTE Thrombophilia IVF pregnancy
When should VTE prophylaxis be started in pregnancy?
First trimester if there are 4 or more risk factors or history of VTE
28 weeks if there are 3 risk factors
When might VTE prophylaxis be considered, even in the absence of other risk factors?
Hospital admission Surgical procedure Previous VTE Medical conditions e.g. cancer, arthritis High risk thrombophilias Ovarian hyperstimulation syndrome
What VTE prophylaxis is administered in pregnancy?
LMWH - enoxaparin, dalteparin, tinzaparin
Omit 12 hours before labour if possible, or when labour starts, can restart immediately after delivery except if PPH, spinal anaesthesia, epidurals.
If LMWH contraindicated, mechanical prophylaxis with intermittent pneumatic compression and anti-embolism compression stockings.
Continue throughout antenatal period from when first given, and continued for 6 weeks postnatally.
What is the presentation of DVT in pregnancy?
Unilateral, bilateral rare, bilateral symptoms due to chronic venous or pre-eclampsia.
Calf or leg swelling Dilated superficial veins Tenderness to calf, over deep veins Oedema Colour changes to leg
Measure calf 10cm below tibial tuberosity; >3cm difference is significant.
What is the presentation of a PE in pregnancy?
Have low threshold for suspecting PE.
SOB, cough with or without blood Pleuritic chest pain Hypoxia Tachycardia Raised respiratory rate Low grade fever Haemodynamic instability causing hypotension
What is used for the diagnosis of DVT in pregnancy?
Doppler ultrasound
Repeat negative ultrasound scans on day 3 and 7 in patients with high index of suspicion for DVT
What is used for the investigation of PE in pregnancy?
Chest X Ray
ECG
CTPA
VQ scan
What are the risks of CTPA and VQ scan in pregnancy?
CTPA choice for those with abnormal CXR
CTPA higher risk of breast cancer for mother
VQ scan higher risk of childhood cancer for fetus
Both minimal absolute risk
Pts with suspected DVT and PE should have doppler initially, and if DVT present do not require CTPA or VQ.
Is the Wells score valid in pregnancy?
No
D-dimers not helpful in pregnancy either as pregnancy is a cause of a raised D-dimer.
What is the management of VTE in pregnancy?
LMWH
Dose based on woman’s weight at booking
Start immediately, before confirming diagnosis
If confirmed, continue for remainder of pregnancy and 6 weeks postnatally, or 3 months in total whichever is longer.
Can switch to oral anticoagulation e.g. warfarin or DOAC after delivery.
What are the treatment options for massive PE?
Haemodynamically compromised
Unfractionated heparin
Thrombolysis
Surgical embolectomy
What is pre-eclampsia?
New high blood pressure in pregnancy
Endo organ dysfunction with proteinuria
Occurs after 20 weeks gestation, the spiral arteries of the placenta form abnormally so leads to high vascular resistance.
What is the presentation of pre-eclampsia?
Triad of hypertension, proteinuria and oedema
Also headaches, visual disturbance or blurriness
Nausea and vomiting, upper abdo pain, epigastric pain due to liver swelling
Reduced urine output
Brisk reflexes
What is chronic hypertension in pregnancy?
High blood pressure that exists before 20 weeks gestation and is longstanding.
Not caused by dysfunction in placenta.
Not classed as pre-eclampsia.
What is pregnancy-induced hypertension/gestational hypertension?
Hypertension occurring after 20 weeks gestation, without proteinuria.
What is eclampsia?
When seizures occurs as a result of pre-eclampsia.
What is the pathophysiology of pre-eclampsia?
Blastocyst implants in endometrium and syncytiotrophoblast grows into the endometrium and forms chorionic villi containing blood vessels.
Trophoblast invasion causes spiral arteries to become more fragile, so that blood flow to there can increase and create lacunae at 20 weeks gestation.
If lacunae process is inadequate - pre-eclampsia, high vascular resistance in spiral arteries and poor perfusion of placenta.
Causes oxidative stress in the placenta, inflammatory chemicals released in systemic circulation.
What are the high risk factors for pre-eclampsia?
Pre-existing hypertension Previous hypertension in pregnancy Existing autoimmune conditions e.g. SLE Diabetes Chronic kidney disease
What are the moderate risk factors for pre-eclampsia?
Older than 40 BMI > 35 More than 10 years since previous pregnancy Multiple pregnancy First pregnancy Family history of pre-eclampsia
Who is offered aspirin for prophylaxis against pre-eclampsia?
Women offered aspirin from 12 weeks until birth if they have one high risk factor or more than one moderate risk factor
What are the criteria for a diagnosis of pre-eclampsia?
Systolic blood pressure above 140mmHg
Diastolic blood pressure above 90mmHg
Plus any of
Proteinuria - 1+ or more on dipstick
Organ dysfunction e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia, haemolytic anaemia
Placental dysfunction e.g. fetal growth restriction or abnormal Doppler studies
How can proteinuria in pre-eclampsia be quantified?
Urine albumin:creatinine ratio - above 30mg/mmol
Urine protein:creatinine ratio - above 8mg/mmol
What is PIGF testing?
Placental growth factor is a protein released by the placenta that functions to stimulate new blood vessels., in pre-eclampsia levels of PIGF are low.
Test PIGF between 20-35 weeks to rule it out.
What routine tests are done for pre-eclampsia?
Blood pressure, monitor symptoms, urine dipstick for pre-eclampsia
What is the management of gestational hypertension without proteinuria?
Treat to aim for BP below 135/85 Admission if above 160/110 Urine dipstick testing at least weekly Monitoring of blood tests weekly - FBC, LFTs, renal profile PIGF testing on one occasion
What is the general management when pre-eclampsia is diagnosed?
Similar management to gestational diabetes
Scoring system - PREP-S or fullPIERS
BP monitored closely every 48 hours
US of fetus, amniotic fluid, dopplers 2 weekly
What is the medical management of pre-eclampsia?
Labetolol antihypertensive
Nifedipine modified release is second line
Methyldopa third line, stop within two days of birth
IV hydralazine used as antihypertensive in critical care in severe pre-eclampsia or eclampsia
IV magnesium sulphate given during labour and 24 hours afterwards to prevent seizures
Fluid restriction in labour in severe pre-eclampsia or eclampsia to avoid fluid overload
What medical treatment after delivery is available for pre-eclamptic patients?
Enalapril - first line
Nifedipine or amlodipine first line in black Afro-Caribbean
Labetolol or atenolol third line
What is HELLP syndrome?
Combination of features that occurs as a complication of pre-eclampsia and eclampsia
Haemolysis
Elevated liver enzymes
Low platelets
Most often definitive treatment is delivery of baby and placenta
Endothelial cell injury
Elevated BMI, antiphospholipid syndrome increase risk
What is gestational diabetes?
Diabetes triggered by pregnancy, caused by reduced insulin sensitivity during pregnancy, resolves after birth.
What are the most significant complications of gestational diabetes?
Longer term, women at higher risk of developing T2 DM
Glucose transported across placenta but insulin not causing fetal hyperglycaemia.
Baby compensates by increasing own insulin levels.
Insulin has similar structure to growth promoters so causes
macrosomia - shoulder dystocia, obstructed/delayed labour, instrumental delivery
Organomegaly cardiomegaly
Erythropoiesis resulting in polycythaemia
Polyhydramnios
Increased rates of pre-term delivery
What is the pathophysiology of gestational diabetes?
Body unable to produce enough insulin to meet needs of pregnancy
In pregnancy, there is progressive insulin resistance; higher volume of insulin needed in response to normal level of blood glucose
Woman with borderline pancreatic reserve unable to respond to increased insulin requirements, leads to transient hyperglycaemia.
What are the risk factors for gestational diabetes?
Previous gestational diabetes Previous macrosomic baby (>4.5kg) PCOS BMI > 30 FH of diabetes - first degree relative Ethnic origin
What are the clinical features of gestational diabetes?
Most women with borderline pancreatic reserve will be asymptomatic
If present, same as usual ie polyuria, polydipsia, fatigue
What is the investigation for gestational diabetes?
Oral glucose tolerance test - fasting plasma glucose measured, 75g glucose drink given, repeat plasma glucose measurement after 2 hours
When is the OGTT offered in pregnancy?
Booking if previous gestational diabetes
24-28 weeks’ if risk factors present, previous case, large for dates fetus, polyhydramnios, glucose on urine dip
Any point in pregnancy if 2+ glycosuria on one occasion, or 1+ on 2 occasions.
What are the values to diagnose GDM?
Fasting glucose >5.6 mmol/L
2 hours postprandial >7.8mmol/L
What is the initial management for gestational diabetes?
Four weekly ultrasounds to monitor fetal growth and amniotic fluid vol 28-36 weeks gestation.
If fasting level <7 trial diet and exercise, then metformin, then insulin
If fasting glucose >7 insulin +- metformin
If fasting glucose >6, macrosomia or other complications start insulin +- metformin.
What is an alternative to metformin or insulin for pregnant women with GDM?
Glibenclamide a sulfonylurea
What are the target blood glucose levels for GDM?
Fasting 5.3
1 hour post meal 7.8
2 hours post meal 6.4
Avoid levels of 4 or below
What is the management of pregnant women with pre-existing diabetes?
Aim for good control
Take folic acid 5mg preconception until 12 weeks gestation
Retinopathy screening after booking and at 28 weeks
Planned delivery between 37 and 38+6, GDM up to 40 + 6
Sliding scale regime considered for T1, dextrose and insulin infusion titrated
What are babies with mothers with diabetes at risk of?
Neonatal hypoglycaemia - become accustomed to large supply of glucose in pregnancy and after birth struggle to maintain supply used to just with oral feeding Polycythaemia - raised haemoglobin Jaundice Congenital heart disease Cardiomyopathy
Regular monitoring for hypoglycaemia, maintain levels above 2, may need IV dextrose and NG feeds otherwise.
What is the postnatal management of GDM?
All anti-diabetic medication stopped immediately after delivery.
Blood glucose measured before discharge to ensure returned to normal.
Around 6-13 weeks postpartum, fasting glucose test is recommended.
If normal, yearly tests offered as risk of developing diabetes in future is increased.
In subsequent pregnancies, OGTT offered at booking and at 24-28 weeks gestation.
What is obstetric cholestasis?
Reduced outflow of bile acids from the liver, resolves after birth
Thought to be due to increased oestrogen and progesterone.
Associated with increased risk of stillbirth.
What is the presentation of obstetric cholestasis?
Typically presents later in pregnancy, particularly in third trimester
Pruritus, particularly on palms of hands and soles of feet
Fatigue, dark urine, pale and greasy stools, jaundice
No rash
What is a differential of obstetric cholestasis if a rash is present?
Polymorphic eruption of pregnancy
Pemphigoid gestationis
What are the investigations for obstetric cholestasis?
LFTs and bile acids
Abnormal LFTs and raised bile acids are seen
It is normal for ALP to rise in pregnancy because the placenta produces ALP, so rise in ALP without abnormal LFTs is due to pregnancy
What is the management of obstetric cholestasis?
Ursodeoxycholic acid
Emollients e.g. calamine to soothe skin
Antihistamines e.g. chlorphenamine to help sleeping, does not improve itching
Water soluble Vit K can be given if prothrombin time/clotting time deranged
Vit K is a fat solube vitamin, lack of bile acids leads to vit K deficiency which leads to impaired clotting
Need to monitor LFTs weekly in pregnancy and up to 10 days after delivery
Planned delivery after 37 weeks can be considered
What is acute fatty liver of pregnancy?
Condition - rare, occurs in third trimester of pregnancy
Rapid accumulation of fat in hepatocytes causing acute hepatitis
High risk of liver failure and mortality for both mother and baby
What is the pathophysiology of acute fatty liver of pregnancy?
Results from impaired processing of fatty acids in the placenta, due to genetic condition in fetus which impairs fatty acid metabolism
e.g. LCHAD enzyme mutation, autosomal recessive so mum will have one faulty gene
Fetus and placenta cannot break down fatty acids, these enter maternal circulation and accumulate in the liver leads to inflammation and failure
What is the presentation of acute fatty liver of pregnancy?
General malaise and fatigue Nausea and vomiting Jaundice Abdominal pain Anorexia - lack of appetite Ascites
What are the bloods results seen in acute fatty liver of pregnancy?
LFTs show elevated liver enzymes ALT and AST
Other bloods may be deranged e.g. raised bilirubin, raised WCC, deranged clotting with raised PTT and INR, low platelets
What is a differential for acute fatty liver of pregnancy?
Elevated liver enzymes and low platelets could make you think of HELLP syndrome too
What is the management of acute fatty liver of pregnancy?
Obstetric emergency needing prompt admission and delivery
Treatment of acute liver failure, including consideration of liver transplant.
What is polymorphic eruption of pregnancy?
Itchy rash tends to start in third trimester
Usually begins on the abdomen, get striae
Characterised by urticarial papules, wheals, plaques
Management is to control the symptoms e.g. topical emollients, topical steroids, oral antihistamines, oral steroids in severe cases.
What is atopic eruption of pregnancy?
Eczema that flares up during pregnancy
Presents in first and second trimester of pregnancy
Can have had eczema beforehand or never before
E-type with eczematous inflamed red and itchy skin
P-type - prurigo type, intensely itchy papules typically affecting the abdomen, back and limbs
What is the management of atopic eruption of pregnancy?
Topical emollients
Topical steroids
Phototherapy with UV light
Oral steroids may be used in severe cases
What is melasma?
Mask of pregnancy, increased pigmentation to patches of skin on the face, symmetrical and flat.
Thought to be due to increased sex hormones
Can occur with COCP and HRT, sun exposure, thyroid disease and family history.
Avoid sun exposure, use sunscreen, makeup, skin lightening creams but not in pregnancy
Procedures e.g. chemical peels or laser treatment
What is pyogenic granuloma?
Known as lobular capillary haemangioma
A benign rapidly growing tumour of capillaries
Occur more often in pregnancy
Presents with rapidly growing lump that develops over days, up to 1-2cm in size
Can occur on fingers, upper chest, back, neck or head
Treatment usually surgical removal with histology
What is pemphigoid gestationis?
Rare autoimmune skin condition occurs in pregnancy
Autoantibodies created damage connection between epidermis and dermis.
Usually occurs in third trimester, itchy or red papular and blistering rash around umbilicus, fluid filled blisters.
Usually resolves without treatment after delivery.
What is the treatment if needed for pemphigoid gestationis?
Topical emollients Topical steroids Oral steroids may be required Immunosuppressants required if steroids inadequate Antibiotics if needed
What are the risks of pemphigoid gestationis?
Fetal growth restriction
Preterm delivery
Blistering rash after delivery as maternal antibodies pass to the baby - danger of this occurring in response to placenta tissue
What is a low lying placenta?
Placenta is within 20mm of the internal cervical os
What is placenta praevia?
Used only when the placenta is over the internal cervical os
Notable cause of antepartum haemorrhage
What are some key causes of antepartum haemorrhage to remember?
Placenta praevia
Placental abruption
Vasa praevia
What are causes of spotting or minor bleeding in pregnancy?
Cervical ectropion, infection, vaginal abrasions from intercourse or procedures.
What are the risks of placenta praevia?
Antepartum haemorrhage Emergency c-section Emergency hysterectomy Maternal anaemia and transfusions Preterm birth and low birth weight Stillbirth
What is Grade I placenta praevia?
Placenta is in the lower uterus but not reaching the internal cervical os
What is Grade II marginal praevia?
Placenta is reaching but not covering the internal cervical os
What is Grade III partial praevia?
Placenta partially covering the internal cervical os
What is Grade IV complete praevia?
Placenta completely covering the internal cervical os
What are the risk factors for placenta praevia?
Previous caesarean sections Previous placenta praevia Older maternal age Maternal smoking Structural uterine abnormalities e.g. fibroids Assisted reproduction e.g. IVF
What is the presentation of placenta praevia?
Usually asymptomatic
May present with painless vaginal bleeding in pregnancy - antepartum haemorrhage
Bleeding usually occurs later in pregnancy at or after 36 weeks
What is the management of placenta praevia?
If diagnosed at 20 week scan etc, then repeat TV USS at 32 weeks gestation and if present still at 32 week scan then at 36 weeks to decide on method of delivery.
Corticosteroids given as risk of preterm delivery.
Planned delivery between 36 and 37 weeks, to reduce risk of spontaneous labour and bleeding, planned c-section.
Emergency c-section may be required with premature labour or antenatal bleeding.
What is the management of haemorrhage due to placenta praevia?
Emergency c-section
Blood transfusions
Intrauterine balloon tamponade
Uterine artery occlusion
What is vasa praevia?
Where the fetal vessels are within the fetal membranes and travel across the internal cervical os. The fetal membranes surround the fetus and amniotic cavity.
What is the pathophysiology that causes the fetal vessels to be exposed in vasa praevia?
Velamentous umbilical cord - cord inserts into chorioamniotic membranes and fetal vessels are unprotected through the membrane before joining the placenta (Type I)
Accessory lobe of the placenta - succenturiate lobe
Connected by fetal vessels that travel through the chorioamniotic membranes between the placental lobes (Type II)
What is the problem with vasa praevia?
Unprotected fetal vessels exposed, travel through chorioamniotic membranes and pass across internal cervical os
Prone to bleeding, particularly when membranes rupture during labour, can lead to dramatic fetal blood loss and death.
What are the risk factors for vasa praevia?
Low lying placenta
IVF pregnancy
Multiple pregnancy
What is the presentation of vasa praevia?
May be diagnosed by USS during pregnancy, as then allowed planned c-section and reduce risk of haemorrhage.
May present with antepartum haemorrhage with bleeding during second or third trimester of pregnancy.
May be diagnosed following vaginal examination in labour as pulsating fetal vessels in the membranes seen through dilated cervix.
Fetal distress and dark-red bleeding occurs following rupture of membranes, requires emergency c-section
What is the management of vasa praevia?
If asymptomatic; corticosteroids from 32 weeks gestation, elective c-section planned for 34-36 weeks gestation.
If antepartum haemorrhage occurs, emergency c-section.
After stillbirth or unexplained fetal compromise during delivery then placenta is examined for evidence of vasa praevia as a cause.
What is placental abruption?
When the placenta separates from the wall of the uterus during pregnancy
Significant cause of antepartum haemorrhage
What are the risk factors of placental abruption?
Previous placental abruption Pre-eclampsia Bleeding in early pregnancy Trauma - consider domestic violence Multiple pregnancy Fetal growth restriction Multigravida Increased maternal age Smoking Cocaine or amphetamine use
What is the presentation of placental abruption?
Sudden onset severe abdominal pain that is continuous
Vaginal bleeding - antepartum haemorrhage
Shock - hypotension and tachycardia
Abnormalities on CTG indicating fetal distress
Characteristic woody abdomen on palpation - large haemorrhage
What is the class of severity of antepartum haemorrhage?
Spotting - spots of blood noticed on underwear
Minor - less than 50mls blood loss
Major - 50-1000ml
Massive - more than 1000ml blood loss or signs of shock
What is concealed placental abruption?
Where blood collects behind the placenta, with no evidence of vaginal bleeding
Cervical os remains closed, bleeding within uterine cavity
What is a revealed abruption?
Where blood tracks between the membranes, and escapes through the vagina and cervix.
What is the management of a placental abruption?
Clinical diagnosis based on presentation, look for signs of shock
Consider concealed abruption when vaginal bleeding may be disproportionate to the uterine bleeding.
For major or massive haemorrhage Urgent involvement of senior obstetrician, midwife, anaesthestist 2 x grey cannula Bloods - FBC, UE, LFT, coagulation Crossmatch 4 units Fluid and blood resuscitation CTG monitoring of fetus Close monitoring of the mother
Rhesus D negative women need anti-D prophylaxis
Kleihauer test to assess how much fetal blood mixed and therefore the dose needed
Emergency c-section if mother unstable or there is fetal distress
Risk of PPH following delivery in placental abruption, so active management of third stage needed
What is placenta accreta?
When the placenta implants deeper through and past the endometrium making it difficult to separate the placenta after birth, penetrates into myometrium below and beyond
Risk of PPH
What are the different depths of insertion in placenta accreta?
Superficial placenta accreta - implants in surface of myometrium but not beyond
Placenta increta - deep into myometrium
Placenta percreta where placenta invades past myometrium and perimetrium, potentially can reach other organs e.g. bladder
What are the risk factors for placenta accreta?
Previous placenta accreta Previous endometrial curettage procedures e.g. miscarriage or abortion Previous c-section Multigravida Increased maternal age Low lying placenta or placenta praevia
What is the presentation of placenta accreta?
Does not typically cause any symptoms during pregnancy
Can present with antepartum haemorrhage in third trimester
May be diagnosed on antenatal ultrasound scans
May be diagnosed at birth when difficult to deliver placenta
What is the management of placenta accreta?
Ideally diagnosed on USS and allows planning for birth
MRIs to assess depth and width of invasion
Specialist MDT management, may require complex uterine surgery, blood transfusions, intensive care, NICU
Delivery at 35-36+6 to reduce risk of spontaneous labour
Hysterectomy with placenta in uterus at c-section
Uterus preserving surgery, resection of myometrium
Expectant management - leave placenta in place to be reabsorbed over time - many risks, bleeding, infection
What is breech presentation?
When the fetus presents buttocks or feet first rather than cephalic presentation
What are the types of breech presentation?
Complete/flexed breech - both legs are flexed at the hips and knees, cross-legged
Frank/extended breech - both legs flexed at the hip, extended at the knee, legs are straight up
Footling breech - one or both legs extend at the hip, foot is the presenting part
What are the uterine risk factors for breech presentation?
Multiparity
Uterine malformations e.g. septate uterus
Fibroids
Placenta praevia
What are the fetal risk factors for breech presentation?
Prematurity Macrosomia Polyhydramnios - baby tries to move but just flips back Twin pregnancy or higher order Abnormality e.g. anencephaly
What are the clinical features of breech presentation?
Usually identified on clinical examination
Can also be suspected if fetal heart auscultated higher on maternal abdomen
Can be not diagnosed until labour as can present with signs of fetal distress e.g. meconium stained liquor
What are the differentials for breech presentation?
Oblique lie - fetus diagonally in the uterus, head or buttocks on one iliac fossa
Transverse lie - fetus positioned across the uterus, head on one side and buttocks on other, shoulder is presenting part
Unstable lie - presentation changes day to day, can include breech presentation, more likely if polyhydramnios
What are the investigations for breech presentation?
Confirmation with ultrasound scan, can identify type of breech
Can reveal any fetal or uterine abnormalities which may predispose to breech presentation
What is external cephalic version?
Manipulation of the fetus to a cephalic presentation through the maternal abdomen, will then enable an attempt at vaginal delivery.
Used after 36 weeks for nulliparous or after 37 weeks if already have children.
Women give tocolysis - subcutaneous terbutaline a beta agonist like salbutamol. relaxes the uterus beforehand
Reduces contractility of the myometrium making it easier for the baby to turn.
Anti D prophylaxis if anti D negative when ECV performed, and then Kleihauer test done.
What are the complications of ECV?
Transient fetal heart abnormalities which revert to normal
Persistent heart rate abnormalities e.g. fetal bradycardia
Placental abruption
What other management aside from ECV is available for breech presentation?
C-section if ECV is unsuccessful, contraindicated or declined
Vaginal breech delivery, might be an option or only option if present in advanced labour.
Hand off the breech - otherwise traction can cause fetal head to extend and get trapped.
What is a contraindication to vaginal breech delivery?
Footling breech
Feet and legs can slip through a non-fully dilated cervix and then shoulders and head become trapped.
What manoeuvres can be done in vaginal breech birth?
Flexing the fetal knees to enable delivery of the legs
Using Lovsett’s manoevre to rotate body and deliver shoulders
MSV manoeuvre to deliver head by flexion, forceps can be used
What are the complications of breech presentation?
Cord prolapse - umbilical cord drops down below presenting part and becomes compressed
Fetal head entrapment
Premature rupture of membranes
Birth asphyxia - usually secondary to delay in delivery
Intracranial haemorrhage - result of rapid compression of the head during delivery
What is stillbirth?
Birth of a dead fetus after 24 weeks, the result of an intrauterine death
What are some of the causes of stillbirth?
Unexplained in around 50% Pre-eclampsia Placentral abruption Vasa praevia Cord prolapse or wrapped around the neck Obstetric cholestasis Diabetes Thyroid disease Infections e.g. rubella, parvovirus, listeria Genetic abnormalities Congenital malformations
What factors increase the risk of stillbirth?
Fetal growth restriction Smoking Alcohol Increased maternal age Maternal obesity Twins Sleeping on back as opposed to either side
How can stillbirth be prevented?
Risk assessment for SGA and FGR, constant scans to check
Women at risk of pre-eclampsia given aspirin
Any modifiable risk factors treated e.g. stop smoking, avoid alcohol, effective control of diabetes
Ask about symptoms - reduced fetal movements, abdominal pain, vaginal bleeding
What is the management of a stillbirth?
Ultrasound scan for diagnosing intrauterine fetal death, used to visualise fetal heartbeat
Passive fetal movements are possible after IUFD so repeat scan will confirm
Anti-D prophylaxis for Rhesus D negative women and Kleihauer test.
Vaginal birth
either induction of labour
expectant management if labour not imminent e.g. sepsis, pre-eclampsia, haemorrhage
Induction with oral mifepristone and misoprostol a prostaglandin analogue.
Dopamine agonists e.g. cabergoline to suppress lactation
Following stillbirth - offer testing; genetic testing of fetus and placenta, postmortem including x-rays, testing for maternal and fetal infection, test mother for conditions associated with stillbirth e.g. diabetes, thyroid disease, thrombophilia
What are the reversible causes of adult cardiac arrest?
4 Ts and 4Hs
Thrombosis, tension pneumothorax, toxins and tamponade
Hypoxia, hypovolaemia, hypothermia, hyperkalaemia or hypoglycaemia
RCOG adds in eclampsia and intracranial haemorrhage
What are the three major causes of cardiac arrest in pregnancy?
Obstetric haemorrhage
Pulmonary embolism
Sepsis leading to metabolic acidosis and septic shock
What are the main causes of massive obstetric haemorrhage?
Ectopic pregnancy Placental abruption including concealed haemorrhage Placental praevia Placenta accreta Uterine rupture
What is aortocaval compression in pregnancy?
After 20 weeks, uterus is significant size, when woman lies on her back it can compress the inferior vena cava and aorta.
Compression of vena cava leads to reduction in venous return, reduced cardiac output, hypotension.
Can be sometimes enough to lead to cardiac arrest.
Lie on left side, left lateral position to relieve compression on inferior vena cava.
What makes resuscitation in pregnancy more complicated?
Aortocaval compression Increased oxygen requirements Splinting of the diaphragm by the pregnancy abdomen Difficulty with intubation Increased risk of aspiration Ongoing obstetric haemorrhage
What are important considerations for resuscitation in pregnancy?
A 15 degree tilt to the left side for CPR, relieves compression of the inferior vena cava and aorta
Early intubation to protect airway
Early supplementary oxygen
Aggressive fluid resuscitation, but caution in pre-eclampsia to prevent fluid overload
Delivery of the baby after 4 minutes, within 5 minutes of starting CPR
When is delivery required in resuscitation?
Immediate c-section
If no response after 4 mins to CPR performed correctly
CPR continues for more than 4 minutes in a woman more than 20 weeks gestation
Primary reason is to improve survival of mother, delivery improves venous return to the heart and cardiac output.
What is prolonged pregnancy?
Pregnancies which persist up to and beyond 42 weeks gestation
What are the risk factors of a prolonged pregnancy?
Nulliparity Maternal age >40 Previous prolonged pregnancy High body mass index Family history of prolonged pregnancies
What are the complications of a prolonged pregnancy?
Increased risk of stillbirth
Increased potential for placental insufficiency, increased risk of fetal acidaemia and meconium aspiration
Placental degradation can deplete fetal glycogen stores, resulting in neonatal hypoglycaemia
What are the clinical features of a prolonged pregnancy?
Static growth Potentially macrosomia Oligohydramnios Reduced fetal movements Presence of meconium Signs of meconium staining e.g. nails Dry/flaky skin, reduced vernix
What investigations are required for prolonged labour?
USS to check growth, liquor volume and dopplers.
What is the management of prolonged labour?
Recommended delivery is by 42 weeks to reduce risk of stillbirth.
Membrane sweeps from 40 weeks in nulliparous, and 41 in parous women.
Induction of labour between 41 and 42 weeks.
If induction declined, twice weekly CTG monitoring and USS with amniotic fluid measurement to check fetal distress.
What is the position of the fetus?
The position of the fetal head as it exits the birth canal
Usually engages in the occipito anterior position
What are the risk factors for an abnormal fetal lie, malpresentation and malposition?
Prematurity Multiple pregnancy Uterine abnormalities e.g. fibroids, partial septate uterus Fetal abnormalities Placenta praevia Primiparity
What is the management of an abnormal fetal lie?
External cephalic version can be attempted between 36-38 weeks.
Contraindicated in women with recent APH, ruptured membranes, uterine abnormalities or previous C section.
What is the management of malpresentation?
Breech - attempt ECV before labour, vaginal delivery or c-section.
Brow - needs c-section
Face - if chin is anterior normal labour possible but might be prolonged, if chin posterior then c section
Shoulder - c-section needed
What is oligohydramnios?
Low level of amniotic fluid during pregnancy, below the 5th centile for the gestational age.
What is the pathophysiology of oligohydramnios?
Volume of amniotic fluid steadily increases until 33 weeks, plateaus then decreases at around 38 weeks to approx 500mls.
Compromised of fetal urine output, and some placental and fetal respiratory secretions. Anything that reduces the production of urine, blocks output from fetus, or rupture of membranes can lead to oligohydramnios.
What are the main causes of oligohydramnios?
Preterm prelabour rupture of membranes Placental insufficiency - blood flow redistributed to fetal brain rather than abdomen and kidneys, so poor urine output Renal agenesis/Potter's syndrome Non functioning fetal kidneys Obstructive uropathy Genetic/chromosomal anomalies Viral infections
How is oligohydramnios diagnosed?
Via USS examination
Measurement of amniotic fluid index - maximum cord-free vertical pocket of fluid in four quadrants of uterus, add together
Maximum pool depth
What is enquired on clinical assessment for oligohydramnios?
History - symptoms of leaking fluid, feeling damp all the time
Examination - symphysis fundal height, speculum examination
Ultrasound - assess for liquor volume, structural abnormalities, renal agenesis
measure fetal size
Karyotyping if appropriate
How can ruptured membranes be tested?
IGFBP-1
Insulin like growth factor binding protein 1 in the vagina
If protein found in amniotic fluid, likely of membrane rupture
ACTIM PROM test
What is the management of oligohydramnios?
Dependent on underlying cause
Ruptured membranes - labour likely to commence, course of steroids and antibiotics
Placental insufficiency - timing of delivery depends on rate of fetal growth, umbilical artery and middle cerebral artery dopplers, CTG
What is the prognosis of oligohydramnios?
If in second trimester, carries poor prognosis. Usually premature rupture of membranes, subsequent premature delivery and pulmonary hypoplasia.
If associated with placental insufficiency, higher rate of preterm deliveries.
Without enough amniotic fluid, fetus cannot move limbs in utero, can develop severe muscle contractures which may lead to disability.
What is polyhydramnios?
Abnormally large level of amniotic fluid during pregnancy, above the 95th centile for gestational age
What is the aetiology of polyhydramnios?
Idiopathic in most causes
Condition preventing fetus from swallowing, e.g. oesophageal atresia, CNS abnormalities, muscular dystrophies
Duodenal atresia - double bubble sign on USS
Anaemia
Fetal hydrops
Twin-to-twin transfusion
Increased lung secretions
Genetic or chromosomal abnormalities
Maternal diabetes
Maternal ingestion of lithium leads to fetal diabetes insipidus
Macrosomia - larger babies produce more urine
What is a TORCH screen?
Toxoplasmosis Other (parvovirus) Rubella Cytomegalovirus Hepatitis
What is the management of polyhydramnios?
No medical intervention usually required
If maternal symptoms severe e.g. breathlessness, amnioreduction can be considered (but risk of placental abruption)
Baby first examined by paeds if idiopathic before feeding, insert NG to check no fistula or atresia
What is the prognosis of polyhydramnios?
Associated with increased perinatal mortality if severe, as may be likely presence of underlying abnormality or congenital malformation
Increased incidence of preterm labour due to over distention of uterus
Malpresentation as more room to move, higher risk of cord prolapse when membranes rupture.
After delivery higher incidence of PPH as uterus has to contract further to achieve haemostasis.
What are other gestational trophoblastic diseases aside from molar pregnancy?
Choriocarcinoma, usually coexists with a molar pregnancy and is a malignancy of trophoblastic cells of the placenta, mets to the lungs.
Placental site trophoblastic tumour
Epithelioid trophoblastic tumour is a malignancy of trophoblastic placenta cells and hard to distinguish from choriocarcinoma.
What are the risk factors for gestational trophoblastic disease?
Maternal age <20 or >35
Previous gestational trophoblastic disease - risk not decreased by change of partner
Previous miscarriage
Use of oral contraceptive pill
What are the clinical features of molar pregnancies?
Vaginal bleeding, abdominal pain early in pregnancy
Uterus can be larger than expected and soft and boggy
Hyperemesis as increased bHCG
Hyperthyroidism - gestational thyrotoxicosis due to stimulation of thyroid by high HCG
Anaemia
What are the investigations for molar pregnancies?
Urine b-HCG
Blood hCG
USS - granular/snowstorm
Histological examination of products of conception
If metastatic spread suspected, staging investigations required e.g. MRI, CT, USS
What is GBS?
Group B strep found in vagina or rectum of 25% of pregnancy women
Sometimes in presence of some risk factors can cause infection, early onset GBS disease in the newborn
What group of strep can cause chorioamnioitis or endometritis in the mother?
Streptococcus agalactiae
What are the risk factors for GBS infection?
GBS infection in a previous baby
Prematurity <37 weeks
Rupture of membranes >24 hours before delivery
Pyrexia during labour
Positive test for GBS in mother
Mother diagnosed with a UTI found to be GBS during pregnancy
What are the clinical features of GBS?
Maternal vaginal or rectal colonisation does not cause symptoms, but GBS that leads to infection can manifest as
UTI - frequency, urgency, dysuria
Chorioamnioitis - fevers, lower abdo pain, uterine tenderness, foul discharge, maternal or fetal tachycardia
Endometritis - fever, lower abdo pain, intermenstrual bleeding, foul discharge
After delivery, neonatal infection; pyrexia, cyanosis, difficulty breathing and feeding, floppiness
What are the investigations for GBS?
Detected with single swab for the vagina and then rectum, cultured, or PCR can be used
GBS may be detected on urine cultures if asymptomatic for UTI
What is the screening for GBS?
In UK, RCOG suggests not screened routinely, only those high risk for GBS infection.
Most GBS infections occur in preterm population so missed by screening as already delivered by screening date.
Not all women who screen positive are GBS positive at delivery, so would receive inappropriate treatment.
How can GBS infection be prevented?
High dose IV penicillins e.g. benzylpenicillin throughout labour if:
GBS positive swabs UTI caused by GBS during this pregnancy Previous baby with GBS infection Pyrexia during labour Labour onset <37 weeks Rupture of membranes >18 hours
If rupture of membranes >37 weeks and GBS positive, induced immediately to reduce amount of time fetus exposed.
It is the rupture of membranes which exposes the baby, so antibiotics not indicated in planned c-section.
What is the difference in how placenta praevia and placental abruption present?
Placenta Praevia - painless, bright red blood, proportional blood loss to shock, no associated conditions
Placental abruption - painful, bleeding can be concealed, dark coloured, shock out of proportion to blood loss, associated with preeclampsia
What must not be done if a patient has placenta praevia?
Vaginal exam
May start torrential bleeding
If a placenta praevia minor is picked up at a 20 week scan, what should happen?
Repeat scan at 36 weeks
Placenta likely to have moved superiorly in this time
If a placenta praevia major is picked up at a 20 week scan, what should happen?
Repeat scan at 32 weeks
Plan for delivery made at this time
What complications are associated with placenta praevia?
Pre-term delivery
Hypovolaemic shock
Placenta accreta
Fetal hypoxia and asphyxia
What is the difference between placenta praevia and placental abruption on abdominal examination?
PP - Uterus size normal, soft and relaxed, fetus malpresentation common, Fetal heart sounds usually present
PA - Large for date tender, rigid uterus, fetal presentation unrelated, fetal heart sounds usually absent
What would you ask about in the history of an antepartum haemorrhage?
How much blood
What colour
Provoked? - post coital Have waters broken? Any pain Foetal movements Risk factors - smoking, drugs, domestic abuse
What would you look for on examination in a patient with an antepartum haemorrhage?
General appearance - pallor, cap refill
Tender abdomen?
Uterus feel tense and woody? (placental abruption)
Palpable contractions
Lie of foetus
CTG - >26 weeks
What are some causes of an antepartum haemorrhage?
Infections - candida, vaginosis, chlamydia
Vasa praevia
Uterine rupture Placenta praevia Placental abruption Benign or malignant lesions Domestic violence
What investigations should be ordered for a patient with a suspected antepartum haemorrhage?
Depend on presentation
Can include - FBC, platelet, G&S, clotting, USS, foetal monitoring
What complications are associated with an antepartum haemorrhage?
Premature labour
DIC
AKI
Placenta accreta
Foetal hypoxia and death
What features, if accompanying abdominal pain, require urgent midwife assessment?
Bleeding or spotting
Regular cramping or tightening
Vaginal discharge that is unusual
Lower back pain
Pain or burning on urination
Pain is severe or doesn’t go away after 30-60 mins of rest
What are the common causes of abdominal pain in pregnancy?
Constipation
Trapped wind
Growing pain of ligaments
How should pre-existing hypertension be managed?
!! Labetalol (Can continue normal BP meds if not ACE-i or ARB)
!! 75mg aspirin daily - 12 weeks to birth
Urine dip at each antenatal visit
Assess for pre-eclampsia
Obstetrician review - give lifestyle advice
Aim for <150/100
What complications are associated with hypertension in pregnancy?
Pre-eclampsia
Placental abruption
IUGR Intrauterine death Prematurity DIC Cardiovascular disease later in life
What class of drug is labetalol? What are the CI’s and SE’s?
Beta-blocker
CI - asthma and cardiogenic shock
SE - Postural hypo , fatigue, headache, N&V, epigastric pain
What class of drug is nifedipine? What are the CI’s and SE’s?
Calcium channel blocker
CI - angina and aortic stenosis
SE - Peripheral oedema, flushing, headache, constipation
What class of drug is methyldopa? What are the CI’s and SE’s?
Alpha-agonist
CI - depression
SE - drowsiness, headache, oedema, GI disturbance, dry mouth, postural hypo, bradycardia, hepatotoxicity
What class of drug is hydralazine? What are the CI’s and SE’s?
Vasodilator
CI - Heart failure and cor pulmonale
SE - Angina, diarrhoea, dizziness, headache
What are the signs of hypermagnesaemia?
How is hypermagnesemia reversed?
Hyper-reflexia
Respiratory depression
Calcium gluconate
What are the complications of HELLP syndrome?
DIC
Liver rupture
Placental abruption
What are the maternal complications of diabetes in pregnancy?
Hypertension and pre-eclampsia
Injury from delivering large baby
Worsening retinopathy and nephropathy
CVS risks
What are the foetal complications of diabetes in pregnancy?
Hyperinsulinaemia
Miscarriage or still birth
Pre-term labour
Birth adaptions - hypoglycaemia, jaundice
Obesity and diabetes later in life
Transient tachypnoea of newborn
What are the signs of hypoglycaemia in a newborn and how is it managed?
Abnormal muscle tone
Apnoea
Fits
Loss of consciousness
IV dextrose
What medication can be used for a breastfeeding mother with diabetes?
Metformin and Glibenclamide
Other hypoglycaemic agents should be avoided
What medication (diabetes related and other) is used for women with pre-existing diabetes?
Stop all oral hypoglycaemics except Metformin
Commence insulin - isophane insulin
Commence 75mg aspirin daily from week 12
Folic acid 5mg until 12 weeks
What is the overarching principle of epilepsy management in pregnancy?
Aim for monotherapy
What is the major risk associated with anti-epileptic drugs in pregnancy?
Neural tube defects
How should pregnant (or planning to be) women on anti-epileptic medication be managed?
What is given to the newborn and why?
Folic acid 5mg per day before conception if planning pregnancy
18-20 week scan for abnormalities
1mg vit K at delivery - reduce risk of neonatal haemorrhage
What is the risk of sodium valproate in pregnancy?
Neural tube defects
ADHD
Reduced cognitive ability
NOT USED
What is the risk of Carbamazepine in pregnancy?
Lower IQ
NOT USED
What is the risk of Phenytoin in pregnancy? How is one of these risks minimised?
Cleft palate
Newborn clotting disorders: women takes vit K in last month
If a pregnant women takes lamotrigine, what needs to be remembered/ considered?
Dose may need to be increased since oestrogen can result in significantly lower levels
What is the risk of Topiramate in pregnancy?
Cleft palate
What is the risk of Phenobarbital and Benzodiazepines in pregnancy?
Withdrawal effects in baby
What contraception can epileptic women use?
Depot medroxyprogesterone acetate
Copper IUD
Levonorgestrel IUS
Barrier methods
Family planning methods
How is the foetus affected by seizures?
Fetus at higher risk of harm during tonic-clonic seizure
- Hypoxia, acidosis, fall trauma, miscarriage
Fetus not affected by other seizure types (unless fall trauma)
What is the guidance on breastfeeding while taking anti-epileptic medication?
Safe and encouraged
What do women who have seizures in the 2nd half of pregnancy need to be assessed for?
Eclampsia
What is fatal anticonvulsant syndrome?
Seen in children exposed to valproate and carbamazepine
Epicanthic folds Thin upper lip Abnormal philtrum (long) Triangular forehead Micrognathia Medial deficiency of eyebrows Anteverted nose
How can HIV transmit to young children?
Usually mother-child transmission
Can be transplacentally - rare
What are the risk factors for mother-child HIV transmission?
Higher levels of maternal viraemia
Low CD4 count
HIV core antigens
Instrumental delivery
Premature rupture of membranes
Vaginal delivery
How is HIV in pregnant women managed?
Early diagnosis reduce transmission - screening
Risk of transmission 1% if:
- Antiretroviral therapy - usually combined therapy
- Elective caesarian 38-39 weeks
- Avoid breastfeeding following delivery
When can vaginal delivery be planned for women with HIV?
Viral load <50copies/ml at 36 weeks
What is the vaginal bleeding seen in an ectopic pregnancy like?
Less than normal period
Can be dark brown
What history may indicate a threatened miscarriage?
Painless vaginal bleeding <24 weeks
Typically at 6-9 weeks
What history may indicate a missed miscarriage?
Light vaginal bleeding/discharge
Symptoms of pregnancy which disappear
What history would make you think a patient has symphysis pubis dysfunction?
Pain over pubic symphysis
Radiate to groin and medial aspects of thighs
Waddling gait
How would appendicitis present in pregnancy?
RLQ in 1st trimester
Umbilical pain in 2nd trimester
RUQ pain - 3rd trimester
How and when does baby-blues present?
First week post-partum
Tearful, anxious, irritable but it doesn’t impair function
How are baby blues managed?
Reassurance and support esp. from health visitor
What is the timing of postnatal depression?
Depressive episode within first 12 months postpartum
Generally start within 1 month and peak at 3
How is postnatal depression managed?
Reassure and support
CBT
Paroxetine or duloxetine
How does puerperal psychosis present?
First 2-3 weeks
Severe mood swings, disordered perceptions, hallucinations
How is puerperal psychosis managed?
Hospital admission
Future pregnancies req. monitoring
How is postnatal depression screened?
Edinburgh Postnatal Depression Scale
- 10 item questionnaire with max score of 30
- Indicate how mother feel in prev. week
- Score >13 indicate depressive illness
What is the guidance on antidepressants and breastfeeding?
Paroxetine recommended - low milk/plasma ratio
Fluoxetine avoided - long half life
Encourage women with mental health problem to breastfeed
When is cervical circulate indicated?
Previous poor obstetric hx - >=3 2nd trimester losses
Cervical length shortening on USS - <25mm before 24 weeks and 2nd trimester loss
Symptomatic women with premature cervical dilatation and exposed foetal membranes
What are the complications of cervical cerclage?
Bleeding
Membrane rupture
Stimulate uterine contractions
What can women with a Hx of 2nd trimester miscarriage and cervical weakness who haven’t undergone cervical cerclage be offered?
Cervical sonographic surveillance
Which contraception should be avoided in a women who had obstetric cholestasis during pregnancy?
COCP - it can cause cholestasis to recur
How many antenatal appointments should a nulliparous woman have?
10
How many antenatal appointments should a multiparous woman have?
7
What is routinely done at all appointments?
Plot symphysis fundal height
Measure BP
Urine dip - proteinuria
What should pregnant women be informed about at first contact with a healthcare professional?
Folic acid supplementation
Food and nutrition
Lifestyle advice
Antenatal screening information
What folic acid supplementation should pregnant women take?
400 micrograms per day before pregnancy and for first 12 weeks
5mg if BMI >30
Folic acid reduce neural tube defects
What happens at the booking appointment?
Inform about baby development
Reiterate diet, lifestyle, nutrition etc.
Exercise - pelvic floor Reiterate screening and book these Discuss place of birth Pregnancy care pathway Breastfeeding workshops and information Antenatal classes Discuss mental health Measure BMI, BP, urine dip, urine culture Bloods - infection screen, Hb, blood group, haemoglobinopathies
What appointments do all women have?
16 weeks
18-20 weeks
28 weeks 34 weeks 36 weeks 38 weeks 41 weeks
What happens are the 36 week appointment?
Check presentation and offer ECV (external cephalic version) if necessary
Information about:
Breastfeeding
Labour
Vit K prophylaxis
Baby blues
What happens at the 28 week appointment?
Second haematological condition screening
What is the outcome of finding an infection on screening?
HIV - specialist care and treatment, birth plan to avoid transmission, avoid breast feeding
Hep B - B vaccinations given to baby between birth and 1 year
Syphilis - Specialist team - Abx, Baby need blood test and poss Abx at birth
What maternal red flags in labour would require transfer to an obstetric unit?
Pulse >120 on 2 occasions, 30 mins apart
BP >160/110 OR >140/90 on 2 occasions 30 mins apart
2+ protein on urinalysis and BP >140/90 Temp >38 or >37.5 on 2 occasions 1hr apart Vaginal blood loss Presence of significant meconium Pain different from normal contraction Delay in 1st or 2nd stage labour Request of regional anaesthesia
What fetal red flags in labour would require transfer to an obstetric unit?
Abnormal presentation - inc. cord presentation
Transverse or oblique lie
High or free floating head in nulliparous woman
Suspected fetal growth restriction or macrosomia
Suspected anyhydramnios or polyhydramnios
Fetal HR <110 or >160
Deceleration in fetal heart rate heard
What is the management of covid-19 in pregnancy?
All those admitted with confirmed or suspected covid should be offered prophylactic LMWH unless birth expected within 12 hours or risk of haemorrhage.
Chest imaging if unwell
Care escalation if signs of decompensation
Can be associated with thrombocytopenia so if prescribed for pre-eclampsia, discontinue for duration of infection
Oxygen to ensure saturations of 94-98%, escalate to whatever needed
Corticosteroid therapy
Tocilizumab can improve outcomes
Who is at risk of neural tube defects and therefore should be promptly started on 5mg folic acid?
Previous child with NTD Diabetes mellitus Women on antiepileptic Obese (body mass index >30kg/m²) HIV +ve taking co-trimoxazole Sickle cell
