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Obstetrics and Gynaecology > Antenatal care - done > Flashcards

Antenatal care - done Flashcards

1
Q

What does LMP stand for?

A

Last menstural period (first day of the most recent period)

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2
Q

What does GA stand for?

A

Gestational age (duration of pregnancy from LMP)

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3
Q

What does EDD stand for?

A

Estimated date of delivery (40 weeks gestation)

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4
Q

What does Gravida mean?

A

Total number of pregnancies a woman has had?

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5
Q

What does multigravida stand for?

A

Patient that is pregnant for at least the second time

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6
Q

What does Para (P) mean?

A

Number of times the woman has given birth after 24 weeks gestation, regardless of whether the fetus was stillborn

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7
Q

What does nulliparous (“nullip”) mean?

A

Patient that has never given birth after 24 weeks gestation

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8
Q

What does primiparous mean?

A

Patient that has given birth after 24 weeks gestation once before

Used on the labour ward to refer to a woman that is due to give birth for the first time

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9
Q

How is the gestational age described?

A

In weeks and days

5 + 0 refers to 5 weeks since LMP

13 + 6 refers to 13 weeks and 6 days gestational age

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10
Q

How to represent gravida and para for a previous miscarriage?

A

G1 P0 + 1

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11
Q

How are trimesters divided?

A

First trimester: start of pregnancy until 12 weeks gestation

Second trimester: 13 weeks until 26 weeks

Third trimester: from 27 weeks until birth

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12
Q

When do foetal movements start?

A

From 20 weeks gestation until birth

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13
Q

What are the milestones in Antenatal care?

A

Before 10 weeks = booking

Between 10 and 13 + 6 = dating scan (gestational age is calculated from crown rump length CRL and multiple pregnancies are identified)

At 16 weeks = antenatal appointment (discuss results and plan future appointments

Between 18 and 20 + 6 = anomaly scan

25, 28, 31, 34, 36, 38, 41, 41, 42 = Antenatal appointments (monitor pregnancy and discuss future plans)

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14
Q

When is an oral glucose tolerance test usually completed?

A

Between 24 and 28 weeks

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15
Q

When are Anti-D injections given in rhesus negative women?

A

28 and 34 weeks

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16
Q

When is an ultrasound scan done for women with placenta praevia on the anomaly scan?

A

32 weeks

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17
Q

When are serial growth scans offered?

A

When women are at an increased risk of fetal growth restriction

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18
Q

When is the symphysis-fundal height measured from?

A

24 weeks onwards

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19
Q

When is fundal presentation measured?

A

36 weeks onwards

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20
Q

Why is a urine dipstick and blood pressure taken in pregnancy?

A

For pre-eclampsia

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21
Q

Why is a urine sample taken in pregnant women?

A

Asymptomatic bacteriuria

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22
Q

Which two vaccines are offered to all pregnant women?

A

Whooping cough (pertussis) from 16 weeks gestation

Influenza (flu) when available in autumn

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23
Q

What vaccines are avoided in pregnancy?

A

Live vaccines such as the MMR

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24
Q

What is the folic acid supplement in pregnancy?

A

400mcg from before pregnancy to 12 weeks - reduce neural tube defects

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25
Q

How much vitamin D supplement should be taken in pregnancy?

A

10mcg

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26
Q

What vitamin supplement should be avoided?

A

Vitamin A and eating liver or pate (teratogenic at high doses)

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27
Q

What foods should be avoided in pregnancy?

A

Unpasteurised dairy or blue cheese (risk of listeriosis)

Undercooked or raw poultry (risk of salmonella)

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28
Q

Can pregnant women exercise?

A

Continue moderate exercise but avoid contact sports

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29
Q

Is sex safe in pregnancy?

A

Yes

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30
Q

Where should car seatbelts be placed?

A

Above and below the bump (not across it)

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31
Q

When are the effects of drinking in pregnancy the greatest?

A

First 3 months of pregnancy

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32
Q

What are the effects of alcohol in early pregnancy?

A

Miscarriage

Small for dates

Preterm delivery

Fetal alcohol syndrome

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33
Q

What are the features of fetal alcohol syndrome?

A

Microchephaly (small head)

Thin upper lip

Smooth flat philtrum

Short palpebral fissure (short horizontal distance from one side of the eye to the other)

Behavioural difficulties

Hearing and vision problems

Cerebral palsy

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34
Q

What are the risks of smoking in pregnancy?

A

Fetal growth restriction

Misscarriage

Stillbirth

Preterm labour and delivery

Placental abruption

Pre-eclampsia

Cleft lip or palete

Sudden infant death syndrome (SIDS)

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35
Q

When is flying ok in pregnancy?

A

37 weeks in a single pregnancy

32 weeks in a twin pregnancy

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36
Q

At what point will airlines need a note from a midwife, GP or obstetrician to state the pregnancy is going well?

A

28 weeks gestation

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37
Q

Who conducts a booking clinic?

A

Midwife

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38
Q

What is a discussed at a booking clinic appt?

A
  • What to expect at different stages of the pregnancy
  • Lifestyle advice in pregnancy e.g. not smoking
  • Supplements (folic acid and vit D)
  • Plans for birth
  • Screening tests (e.g. Downs)
  • Antenatal classes
  • Breastfeeding classes
  • Discuss mental health
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39
Q

What booking bloods are taken?

A
  • Blood group
  • Antibodies and rhesus D status
  • FBC for anaemia
  • Screening for thalassaemia (all women) and sickle cell disease (those at risk)
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40
Q

What infectious diseases are pregnant patients offered screening for?

A

HIV

Hep B

Syphilis

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41
Q

What else is done at the booking clinic?

A
  • Weight, height and BMI
  • Urine for protein and bacteria
  • Blood pressure
  • Discuss female genital mutilation
  • Discuss domestic violence
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42
Q

What are the potential conditions a pregnant woman may face and what are the plans for it?

A

Rhesus negative (book anti-D prophylaxis)

Gestational diabetes (book oral glucose tolerance test)

Fetal growth restriction (book additional growth scans)

Venous thromboembolism (provide prophylactic LMWH if high risk)

Pre-eclampsia (provide aspirin if high risk)

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43
Q

What is Down’s Syndrome also known as?

A

Trisomy 21

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44
Q

What is the purpose of screening for Down’s Syndrome during pregnancy?

A

To establish whether more invasive testing is needed

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45
Q

How does the screening test give a measurement of the risk of Down’s syndrome?

A

Using:

  • Measurements from the fetus using ultrasound
  • Mother’s age
  • Mother’s blood results
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46
Q

What does ultrasound measure in Down’s screening?

A

Nural translucency - thickness of the back of the neck of the fetus (greater than 6mm indicates Down’s)

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47
Q

What are the maternal blood tests for Down’s?

A

Beta-human chorionic gonadotrophin (beta-HCG) - higher result indicates a greater risk

Pregnancy-associated plasma protein-A (PAPPA) - lower result indicates a greater risk

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48
Q

When in the Down’s syndrome screening test conducted?

A

Between 11 and 14 weeks gestation

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49
Q

What is the triple test for Down’s syndrome?

A

Screening at 14 to 20 weeks gestation involving only maternal blood tests:

  • Beta-HCG - higher result indicates a greater risk
  • Alpha-feroprotein (AFP) - a lower result indicates a greater risk
  • Serum oestriol (female sex hormone) - a lower result indicates a greater risk
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50
Q

What is the quadruple test for Down’s Syndrome?

A

Similar to the triple test (also at weeks 14 to 20 gestation)

  • Also includes maternal blood testing for inhibin-A (higher indicates greater risk)
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51
Q

What does the antenatal screening test for Down’s syndrome provide?

A

A risk score - if it is greater than 1 in 150 (occuring in 5% of women) then the woman is offered amniocentesis or chorionic villus sampling

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52
Q

What does Chorionic Villus sampling involve?

A

Ultrasound-guided biopsy of the placental tissue (used earlier in pregnancy - before 15 weeks)

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53
Q

What does amniocentesis involve for downs testing?

A

Ultrasound-guided aspiration of amniotic fluid using a needle and syringe - used later in pregnancy when there is enough amniotic fluid to make a sample

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54
Q

What is non-invasive prenatal testing for Down’s?

A

New test for detecting fetal abnormalities - involves a simple blood test from the mother.

Contains fragments of DNA from the fetus which can be tested.

Used as an alternative to invasive testing (CVS and amniocentesis)

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55
Q

How are women with chronic conditions managed in pregnancy?

A

Jointly by the obstetric team and the specialist in their health condition

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56
Q

What can untreated hypothyroidism in pregnancy cause?

A
  • Miscarriage
  • Anaemia
  • SGA
  • Pre-eclampsia)
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57
Q

What is hypothyroidism treated with?

A

Levothyroxine (T4)

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58
Q

How much does the levothyroxine dose need to be increased by?

A

25-50mcg (30-50%)

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59
Q

What hypertension medications must be stopped in pregnancy (cause congenital abnormalities)

A

ACE inhibitors

Angiotensin receptor blockers (e.g. losartan)

Thiazide and thiazide-like diuretics (e.g.indapamide)

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60
Q

What hypertension medication is allowed in pregnancy?

A

Labetalol (a beta-blocker - although other beta blockers may have adverse effects)

CCBs (e.g. nifedipine)

Alpha-blockers (e.g. doxazosin)

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61
Q

What dose of folic acid should women with epilepsy take?

A

5mg daily to reduce the risk of neural tube defects

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62
Q

Why may pregnancy increase the risk of seizures in pregnancy?

A

Additional stress

Lack of sleep

Hormonal changes

Altered medication regimes

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63
Q

Are seizures harmful to the pregnancy?

A

No, only the risk of physical injury

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64
Q

How should epilepsy be managed before becomming pregnant?

A

With a single epileptic drug

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65
Q

What are the safer anti-epileptic medications in pregnancy?

A

Levetiracetam

Iamotrigine

Carbamazepine

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66
Q

What drugs are avoided during pregnancy with epilepsy?

A

Sodium valporate (causes neural tube defects and developmental delay)

Phenytoin (causes cleft lip and palete)

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67
Q

What is Prevent (valporate pregnancy prevention programme)?

A

Programme to prevent pregnancy in epileptic patients on sodium valporate (due to it’s teratogenic effects)

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68
Q

What is rheumatoid arthritis?

A

Autoimmune condition which causes chronic inflammation of the synovial lining of the joints, tendon sheaths and bursa

INFLAMMATORY ARTHRITIS

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69
Q

What is rheumatoid arthritis treated with?

A

Disease modifying anti-rheumatic drug (DMARD)

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70
Q

How long should rheumatoid arthritis be well controlled for before becomming pregnant?

A

3 months

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71
Q

How do the symptoms of rheumatoid arthritis change during pregnancy?

A

Improve but may flare up after delivery

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72
Q

What rheumatoid arthritis drugs are contraindicated in pregnancy?

A

Methotrexate (teratogenic, causing miscarriage and congenital abnormalities)

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73
Q

What rheumatoid arthritis drugs are considered safe during pregnancy?

A

Hydroxychloroquine (often the first-line choice)

Sulfasalazine (safe during pregnancy)

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74
Q

What may be used during flare ups for RA in pregnancy?

A

Corticosteroids

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75
Q

What are some examples of NSAIDs?

A

Iburprofen

Naproxen

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76
Q

How do NSAIDs work?

A

They block prostaglandins

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77
Q

Why are prostaglandins important in fetus and neonate?

A

Maintaining the ductus arteriosus

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78
Q

Why are prostaglandins important at delivery?

A

They soften the cervix and stimulate uterine contractions

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79
Q

Why are prostaglandins avoided in general during pregnancy?

A

Avoided in the third trimester as they can cause premature closure of the ductus arteriosus in the fetus. They can also delay labour.

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80
Q

What are beta blockers commonly used for?

A

Hypertension

Cardiac conditions

Migraine

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81
Q

What medication is first-line for hypertension caused by pre-eclampsia?

A

Labetalol

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82
Q

What complications can beta-blockers cause in pregnancy?

A

Fetal growth restriction

Hypoglycaemia in the neonate

Bradicardia in the neonate

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83
Q

What medications block the renin-angiotensin system?

A

ACE inhibitors and ARBs

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84
Q

Name 2 complications of using ACE inhibitors and ARBs in pregnancy?

A
  • Affect the kidneys causing reduced production of urine (and therefore amniotic fluid)
  • Hypoclavaria (incomplete formation of the skull bones)
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85
Q

What are some other side effects of ACEi and ARBs when used in pregnancy?

A

Oligohydraminos (reduced amniotic fluid)

Miscarriage or fetal death

Hypocalvaria (incomplete formation of the skull bones)

Renal failure in the neonate

Hypotension in the neonate

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86
Q

What happens to the neonate if the mother takes opiates during pregnancy?

A

Withdrawal symptoms in the neonate after birth, called neonatal abstinence syndrome which presents between 3 - 72 hours after birth with irritability, tachypnoea (fast breathing), high temperatures and poor feeding

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87
Q

What are the inications for warfarin use ?

A

Younger patients with recurrent venous thrombosis, atrial fibrillation or metallic mechanical heart valves

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88
Q

Why can’t warfarin be used in pregnancy?

A

Teratogenic, causes:

  • Fetal loss
  • Congenital malformations, particularily craniofacial problems
  • Bleeding during pregnancy, PPH, fetal harmorrhage and intracranial bleeding
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89
Q

Why can’t sodium valporate be used in pregnancy?

A

Neural tube defects

Developmental delay

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90
Q

What is lithium used for?

A

Mood stabilising agent for patients with bipolar disorder, mania, recurrent depression.

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91
Q

Can lithium be used in pregnancy?

A

Avoided in pregnant women or those planning pregnancy unless other options (i.e. antipsychotics) have failed

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92
Q

Why is lithium particularily avoided in the first trimester?

A

It’s linked with congenital

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93
Q

What extra measures need to be taken when lithium is used in pregnancy?

A

Monitored closely (every 4 weeks, then weekly from 36 weeks) it also enters breast milk so should be avoided in breastfeeding

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94
Q

Do SSRIs cross the placenta?

A

Yes

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95
Q

What are the risks of using SSRIs in the first trimester of pregnancy?

A
  • Congenital heart defects
  • Paroxetine has stronger link with congenital malformation
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96
Q

What are the risks of using SSRIs in the third trimester?

A

Persistent pulmonary hypertension

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97
Q

What are the risks to the neonate after using SSRIs?

A

Withdrawal symptoms usually only mild and not requiring medical management

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98
Q

What is isotretinoin (roaccutane)?

A

Retinoid medication (relating to vitamin A) which is used to treat severe acne - should be prescribed and monitored by a specialist dermatologist

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99
Q

What is the risk of using isotretionoin?

A

Highly teratogenic causing miscarriage and congenital defects. Women need very reliable contraception before, during and for one month after taking isotretinoin.

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100
Q

What is Rubella also known as?

A

German measles

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101
Q

What is congenital rubella syndrome caused by?

A

Maternal infection with rubella virus during the first 20 weeks of pregnancy

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102
Q

When is the risk of congenital rubella syndrome the highest?

A

Before 10 weeks gestation

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103
Q

How can women protect against congenital rubella syndrome?

A

Women planning on becomming pregnant should ensure that they have had the MMR vaccine, if in doubt they can be tested for rubella immunity if they do not have antibodies to rubella they can be vaccinated with two doses of the MMR three months apart

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104
Q

Should pregnant women recieve the MMR vaccine?

A

No as this is a live vaccine - they should be given the vaccine after giving birth

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105
Q

What are the features of congenital rubella syndrome?

A

Congenital deafness

Congenital cataracts

Congenital heart disease (PDA and pulmonary stenosis)

Learning difficulty

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106
Q

What is Chickenpox caused by?

A

Varicella zoster virus (VZV)

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107
Q

Why is chickenpox dangerous during pregnancy?

A

Causes more severe cases in the mother, such as varucella pneumonitis, hepatitis or encephalitis

Fetal varicella syndrome

Severe neonatal varicella infection (if infected around delivery)

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108
Q

How to check for immunity to chicken pox?

A

IgG levels for VZV can be tested, if positive then idicated immunity

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109
Q

What can be do to treat a pregnant woman who has been exposed to chicken pox and has no immunity?

A

Treated with IV varicella immunoglobulins as prohylaxis against developing chickenpox, given within 10 days of exposure

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110
Q

What is the treatment for a chickenpox rash in pregnancy?

A

Treament with oral aciclovir if presenting within 24 hours and more than 20 weeks gestation

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111
Q

What is congenital varicella syndrome up until what week of gestation will infection usually cause this?

A

Occurs in around 1% of chickenpox cases with infection in the first 28 weeks of gestation. Features include:

  • Fetal growth restriction
  • Microcephaly, hydrocephalus and learning difficulty
  • Scars and significant skin changes located in specific dermatomes
  • Limb hypoplasia (underdeveloped limbs)
  • Cataracts and inflammation in the eye (chorioretinitis)
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112
Q

How does the Listeria bacteria stain?

A

Gram positive

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113
Q

What infection does the listeria bacteria cause?

A

Listeriosis

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114
Q

How does infection with listeria present in the mother?

A

Asymptomatic or flu-like illness or less commonly pneumonia or meningoencephalitis

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115
Q

What is the result of listeriosis in pregnant women?

A

High rate of miscarriage or fetal death it can also cause severe neonatal infection

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116
Q

Where is listeria typically found?

A

Unpasteurised dairy products

Processed meats

Contaminated food

Advise avoid blue cheese and other high risk fods and practice good food hygiene

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117
Q

What causes congenital cytomegalovirus infection?

A

CMV infection in the mother during pregnancy

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118
Q

How is CMV spread?

A

Via infected saliva or urine of asymptomatic children

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119
Q

What are the features of congenital CMV?

A
  • Fetal growth restriction
  • Microcephaly
  • Hearing loss
  • Vision loss
  • Learning disability
  • Seizures
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120
Q

What is congenital toxoplasmosis caused by?

A

Caused by infection with the toxoplasma gondii parasite

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121
Q

How is toxoplasma gondii usually spread?

A

By contamination with faeces from a cat that is a host of the parasite

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122
Q

What is the classic triad of features in congenital toxoplasmosis?

A
  • Intracranial calcification
  • Hydrocephalus
  • Chorioretinitis (inflammation of the choroid and the retina in the eye)
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123
Q

What is parvovirus B19 also known as?

A

Fifth disease, slapped cheek syndrome and erythema infectiosum.

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124
Q

Who does parvovirus B19 typically affect?

A

Children

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125
Q

What is the treatment of parvovirus B19 in children?

A

Illness is self-limiting and the rash and symptoms usually fade over 1-2 weeks

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126
Q

How does parvovirus typically present?

A

Initally with non-specific viral symptoms

After 2-5 days the rash appears quite rapidly as a diffuse bright red rash on both cheeks as though they have “slapped cheeks”

A few days later a reticular mildly erythmatous rash affecting the trunk and limbs appears which can be raised and itchy.

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127
Q

How does a reticular rash appear?

A

Net like

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128
Q

When are patients with Parvovirus B19 infectious?

A

7-10 days before the rash appears (not infectious once the rash has appeared)

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129
Q

What is ‘significant exposure’ to parvovirus B19?

A

15 minutes in the same room or face-to-face contact with someone that has the virus

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130
Q

When do infections with parvovirus B19 typically cause complications in pregnancy?

A

1st and 2nd trimester

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131
Q

What are the complications of infections with parvovirus B19 during pregnancy?

A

Miscarriage or fetal death

Severe fetal anaemia

Hydrops fetalis (fetal heart failure)

Maternal pre-eclampsia-like syndrome

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132
Q

How is fetal anaemia caused by parvovirus infection?

A

Infection of the erythroid progenitor cells in the fetal bone marrow and liver (the cells which produce red blood cells)

Producing faulty red blood cells which have a shorter life span - less red blood cells results in anaemia, this anaemia leads to heart failure, referred to as hydrops fetalis.

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133
Q

What is maternal pre-eclampsia-like syndrome is also known as?

A

Mirror syndrome

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134
Q

What is mirror syndrome?

A

Rare complication of severe fetal heart failure (hydrops fetalis) involving a triad of:

  • Hydrops fetalis
  • Placental oedema
  • Oedema in the mother
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135
Q

What are the tests to order for women suspected of parvovirus infection?

A

IgM to parvovirus which tests for acute infection within the past 4 weeks

IgG to parvovirus which tests for long term immunity to the virus after a previous infection

Rubella antibodies (as a differential diagnosis)

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136
Q

What is the treatment for infection with parvovirus B19?

A

Supportive

Referral to fetal medicine to monitor for complications and malformations

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137
Q

How is the zika virus spread?

A

By host Aedes mosquitos in aread of the world where the virus is prevalent

Also spread by sex with someone infected

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138
Q

What are the symptoms of Zika virus infection?

A

No symptoms, minimal symptoms or mild flu-like illness

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139
Q

What is the result of congenital Zike syndrome?

A
  • Microcephaly
  • Fetal growth restrictions
  • Other intracranial abnormalities such as ventriculomegaly and cerebellar atrophy
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140
Q

What is the test for Zika virus in pregnancy?

A

Viral PCR

Antibodies to the zika virus

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141
Q

How are pregnant women with zika virus managed?

A

Referred to fetal medicine for close monitoring of the pregnacy

There is no treatment for the virus

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142
Q

What does the name rhesus refer to?

A

Various types of rhesus antigens on the surface or RBCs

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143
Q

Is the rhesus antigents the same as the ABO blood group?

A

No, they are separate

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144
Q

What is the most relevant antigen within the rhesus blood group?

A

rhesus-D antigen

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145
Q

Do women who are rhesus-D positive need treatment during pregnancy?

A

No additional treatment needed during pregnancy

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146
Q

What consideration is there in a pregnant woman who is rhesus negative?

A

Consider possibility that the child will be rhesus positive

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147
Q

What is the problem with a rhesus negative mother who gives birth to a rhesus positive baby ?

A

Blood from the baby will find a way into the mothers blood stream e.g. during childbirth, the baby’s RBCs display the rhesus-D antigen which the mother’s immune system will recognise as foreign and produce antibodies to the rhesus-D antigen - the mother has then become sensitised to rhesus-D antigens

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148
Q

If a mother has been sensitised to rhesus-D antigens what is the risk?

A

During subsequent pregnancies the mother’s anti-rhesus-D antibodies can cross the placenta into the fetus.

If the fetus is rhesus-D positive, these antibodies attach themselves to the RBC of the fetus and cause the immune system of the fetus to attack them, causing the destruction of the RBC = haemolytic disease of the newborn

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149
Q

What is the management of rhesus incompatibility?

A

Prevention of sensitisation - involves giving intramuscular anti-D injections to rhesus-D negative women (there is no way to reverse the sensitisation process once it has occured)

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150
Q

How does the anti-D medication work?

A

Attaches itself to the rhesus-D antigens on the fetal red blood cells in the mothers circulation causing them to be destroyed - thus preventing the mother’s immune system recognising the antigen and creating it’s own antibodies to the antigen - acts as a prevention of sensitisation

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151
Q

When are anti-D injections given routinely?

A

28 weeks gestation

Birth (if the baby’s blood group is found to be rhesus positive)

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152
Q

When else may sensitisation occur, and as such anti-D injections be given?

A
  • Antepartum haemorrhage
  • Amniocentesis procedures
  • Abdominal trauma
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153
Q

How soon after a sensitisation event do anti-D injections need to be given?

A

Within 72 hours

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154
Q

What is the Kleihauer test and when is it done?

A

Test to check how much fetal blood has passed into the mother’s during a sensitisation event

Done at 20 weeks

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155
Q

Why is the Kleihauer test performed?

A

To setermine whether further doses of anti-D are required

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156
Q

How is the Kleihauer test performed?

A

Involves adding acid to a sample of the mother’s blood fetal haemoglobing is more resistant to acid (so they are protected against the acidosis that occurs around childbirth)

Fetal haemoglobin persists in response to the added acid whilst the mothers Hb is destroyed - number of cells still containing the haemoglobin (remaining fetal cells) can then be calculated

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157
Q

What fetus is considered small for gestational age?

A

Fetus which measures below the 10th centile for their gestational age

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158
Q

What measurements on ultrasound are used to assess the fetal size?

A
  • Estimated fetal weight (EFW)
  • Fetal abdominal circumference (AC)
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159
Q

Customised growth charts are used to assess the size of the fetus, what are they based on?

A

Mother’s:

  • Ethnic group
  • Weight
  • Height
  • Parity
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160
Q

What is severe SGA defined as?

A

Below the 3rd centile for their gestational age

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161
Q

What is low birth weight?

A

Birth weight less than 2500g

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162
Q

What are the two categories of causes for causes of SGA?

A

Constitutionally small (matching the mother and other’s in the family) - growing appropriately on the growth chart

Fetal growth restriction also known as intrauterine growth restriction

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163
Q

What is fetal growth restriction?

A

Small fetus due to a pathology reducing the amount of nutrients and oxygen being delivered to the fetus through the placenta

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164
Q

What are the two causes of fetal growth restriction?

A

Placenta mediated growth restriction

Non-placenta mediated growth restriction, where the baby is small due to a genetic or structural abnormality

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165
Q

What are some causes of placenta mediated growth restriction?

A

Conditions which affect the transfer of nutrients across the placenta:

Idiopathic

Pre-eclampsia

Maternal smoking

Maternal alcohol

Anaemia

Malnutrition

Infection

Maternal health conditions

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166
Q

What are some causes of non-placenta mediated growth restriction?

A

Genetic abnormalities

Structural abnormalities

Fetal infection

Errors of metabolism

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167
Q

Other than SGA what are some other features of fetal growth restriction?

A

Reduced amniotic fluid volume

Abnormal Doppler studies

Reduced fetal movements

Abnormal CTGs

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168
Q

What are some short term complications of FGR?

A

Fetal death or stillbirth

Birth asphyxia

Neonatal hypothermia

Neonatal hypoglycaemia

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169
Q

What are growth restricted babies at an increased long term risk of?

A

Cardiovascular disease, particularly hypertension

Type 2 diabetes

Obesity

Mood and behavioural problems

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170
Q

What are the risk factors of SGA?

A

Previous SGA baby

Obesity

Smoking

Diabetes

Existing hypertension

Pre-eclampsia

Older mother (over 35 years)

Multiple pregnancy

Low pregnancy‑associated plasma protein‑A (PAPPA)

Antepartum haemorrhage

Antiphospholipid syndrome

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171
Q

When are women assessed for SGA risk factors?

A

At the booking clinic

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172
Q

How are women with a low risk of SGA minitored?

A

Monitoring of the symphysis fundal height (SFH) at every antenatal appointment from 24 weeks onwards to identify potential SGA

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173
Q

How are women managed with a symphysis fundal height less than the 10th centile?

A

Serial growth scans with umbilical artery doppler

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174
Q

When are women booked for serial growth scans regardless of where they plot on growth charts

A

Three or more minor risk factors

One or more major risk factors

Issues with measuring the symphysis fundal height (e.g. large fibroids or BMI > 35)

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175
Q

What do the serial ultrasound scans measure?

A

Estimated fetal weight (EFW) and abdominal circumference (AC) to determine the growth velocity

Umbilical arterial pulsatility index (UA-PI) to measure flow through the umbilical artery

Amniotic fluid volume

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176
Q

What is the general managment of SGA?

A

Identifying those at risk of SGA

Aspirin is given to those at risk of pre-eclampsia

Treating modifiable risk factors (e.g. stop smoking)

Serial growth scans to monitor growth

Early delivery where growth is static, or there are other concerns

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177
Q

How can the underlying cause of SGA be investigated?

A

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 infections (e.g. toxoplasmosis, cytomegalovirus, syphilis and malaria)

178
Q

When would early deliery be considered for SGA?

A

Growth is statis on the charts or abnormal doppler results

Reducing the risk of stillbirth

179
Q

What is given to the woman when delivery is planned early?

A

Corticosteroids particulary when delivered by C-Section

180
Q

What is large for gestational age also known as?

A

Macrosomia

181
Q

What weight of newborn classes macrosomia?

A

>4.5kg at birth (weight above 90th centile in pregnancy)

182
Q

What are some causes of macrosomia?

A

Constitutional

Maternal diabetes

Previous macrosomia

Maternal obesity or rapid weight gain

Overdue

Male baby

183
Q

What are the risks to the mother if a fetus is LGA?

A

Failure to progress

Perineal tears

Instrumental delivery or caesarean

Postpartum haemorrhage

Uterine rupture (rare)

184
Q

What are the risks to the baby if a fetus is LGA?

A

Shoulder dystocia

Birth injury (Erbs palsy, clavicular fracture, fetal distress and hypoxia)

Neonatal hypoglycaemia

Obesity in childhood and later life

Type 2 diabetes in adulthood

185
Q

What are the investigations for a LGA baby?

A

Ultrasound to exclude polyhydramnios and estimate the fetal weight

Oral glucose tolerance test for gestational diabetes

186
Q

Should labour be induced on the grounds of macrosomia only?

A

No

187
Q

How can the risks of shoulder distocia be reduced in a macrosomia baby?

A

Delivery on a consultant lead unit

Delivery by an experienced midwife or obstetrician

Access to an obstetrician and theatre if required

Active management of the third stage (delivery of the placenta)

Early decision for caesarean section if required

Paediatrician attending the birth

188
Q

What does multiple pregnancy refer to?

A

Pregnancy with more than one fetus

189
Q

What are monozygotic twins?

A

Identical twins (from a single zygote)

190
Q

What are dizygotic twins?

A

Non-identical (from two different zygotes)

191
Q

What are monoamniotic twins?

A

Single amniotic sac

192
Q

What are diamniotic twins?

A

Two separate amniotic sacs

193
Q

What are monochorionic twins?

A

Those that share a single placenta

194
Q

What are dichorionic twins?

A

Those which have two separate placentas

195
Q

Which type of twin pregnancies have the best outcomes?

A

Diamniotic, dichorionic - each fetus has their own nutrient supply

196
Q

When is a diagnosis of multiple pregnancies made?

A

Booking ultrasound scan, along with:

  • Gestational age
  • Number of placentas (chorionicity) and amnionicity
  • Risk of Down’s syndrome (as part of the combined test)
197
Q

For the different type of twin pregnancies, how do the membranes appear on ultrasound?

A

Dichorionic diamniotic twins have a membrane between the twins, with a lambda sign or twin peak sign

Monochorionic diamniotic twins have a membrane between the twins, with a T sign

Monochorionic monoamniotic twins have no membrane separating the twins

198
Q

What is the lambda sign or twin peak sign seen on ultrasound scan?

A

The triangular appearance, where the membrane between the twins meets the chorion as the chorion blends partially into the membrane, indicating a dichorionic twin pregnancy (separate placenta)

199
Q

What is the T-sign seen on ultrasound scan?

A

Where the membrane between the twins abruptly meets the chorion giving a T appearance - indicating a monochorionic twin pregnancy (single placenta)

200
Q

What are the risks to the mother during multiple pregnancy?

A

Anaemia

Polyhydramnios

Hypertension

Malpresentation

Spontaneous preterm birth

Instrumental delivery or caesarean

Postpartum haemorrhage

201
Q

What are the risks to the fetuses and neonates in multiple pregnancies?

A

Miscarriage

Stillbirth

Fetal growth restriction

Prematurity

Twin-twin transfusion syndrome

Twin anaemia polycythaemia sequence

Congenital abnormalities

202
Q

What is twin-twin transfusion syndrome?

A

When fetuses share a placenta called feto-fetal transfusion syndrome in pregnancies with more than two fetuses

One fetus (the recipient) may receive the majority of the blood from the placenta whilst the other (the donor) is starved of blood

Recipent = Heart failure and polyhydraminos

Donor = Growth restriction, anaemia and oligohydraminos

Discrepancy between the size of the fetuses

203
Q

How are women with twin-twin transfusion syndrome managed?

A

Referred to a tertiary specialist fetal medicine centre

Laser treatment may be used to destroy the connection between the two blood supplies

204
Q

What is twin anaemia polycythaemia sequence?

A

Similar to twin-twin transfusion syndrome but less acute, one twin becomes anaemic whilst the other develops polycythaemia (raised Hb)

205
Q

Who manages multiple pregnancies?

A

Multiple pregnancy obstetric team

206
Q

What are women with multiple pregnancies monitored for and when?

A

Anaemia with an FBC at booking clinic, 20 weeks gestation and 28 weeks gestation

207
Q

Why are additional ultrasound scans required in multiple pregnancies?

A

Monitor for fetal growth restriction, unequal growth and twin-twin transfusion syndrome

208
Q

When are the additional ultrasound scans arranged for multiple pregnancies?

A

2 weekly scans from 16 weeks for monochorionic twins

4 weekly scans from 20 weeks for dichorionic twins

209
Q

When is planned birth offered for multiple pregnancies?

A

32 and 33 + 6 weeks for uncomplicated monochorionic monoamniotic twins

36 and 36 + 6 weeks for uncomplicated monochorionic diamniotic twins

37 and 37 + 6 weeks for uncomplicated dichorionic diamniotic twins

Before 35 + 6 weeks for triplets

210
Q

What is given before delivery to help with fetal lung development?

A

Corticosteroids

211
Q

How are monoamniotic twins delivered?

A

Elective C-Section at between 32 and 33+6 weeks

212
Q

How and when are diamniotic twins delivered?

A

Between 37 and 37 + 6 weeks

Vaginal delivery is possible when the first baby has a cephalic presentation (head first)

Caesarean section may be required for the second baby after successful birth of the first baby

Elective caesarean is advised when the presenting twin is not cephalic presentation

213
Q

What is a lower urinary tract infection?

A

Infection in the bladder, causing cyctitis (inflammation of the bladder)

214
Q

What is an upper urinary tract infection?

A

Infection up to the kidneys, called pyelonephritis

215
Q

Who is at a higher risk of developign UTIs and pyelonephritis?

A

Pregnant women

216
Q

What is the risk of UTI in pregnancy?

A

Increased risk of preterm delivery, also increased risk of low birth weight and pre-eclampsia

217
Q

What is asymptomatic bacteriuria?

A

Bacteria present in the urine without symptoms of infection (increases risk of UTI in pregnancy)

218
Q

When are pregnant women tested for asymptomatic bacteriuria?

A

At booking and routinely throughout pregnancy involving sending urine sample to the lab for microscopy, culture and sensitivites (MC&S)

219
Q

How do lower urinaty tract infections present?

A

Dysuria (pain, stinging or burning when passing urine)

Suprapubic pain or discomfort

Increased frequency of urination

Urgency

Incontinence

Haematuria

220
Q

How does pyelonephritis present?

A

Fever (more prominent than in lower urinary tract infections)

Loin, suprapubic or back pain (this may be bilateral or unilateral)

Looking and feeling generally unwell

Vomiting

Loss of appetite

Haematuria

Renal angle tenderness on examination

221
Q

What may appear on dipstick for a urinary infection?

A

Nitrites produced by gram-negative bacteria (such as E. Coli) a breakdown produce of nitrates - a normal waste product in the urine

Leukocytes refer to WBCs (normally a small number anyway in the urine) - dipstick tests for leukocyte esterase which gives an indication to the number of leukocytes in the urine

222
Q

What is the best indicator of infection on urine dipstick?

A

Nitrites

223
Q

What are the common causes of UTI?

A

Escherichia coli (gram negative, anaerobic, rod-shaped bacteria which is part of the normal lower intestinal micobiome - found in faeces normally)

Klebsiella pneumoniae (gram negative anaerobic rod)

Enterococcus

Pseudomonas aeruginosa

Staphylococcus saprophyticus

Candida albicans (fungal)

224
Q

What is the management of UTI in pregnancy?

A

7 days of abx:

Nitrofurantoin (avoid in the third trimester)

Amoxicillin (only after sensitivities are known)

Cefalexin

225
Q

When can nitrofurantoin not be used in pregnancy?

A

Not to be used in third trimester as there is a risk of neonatal haemolysis (destruction of the neonatal RBCs)

226
Q

When can trimethoprim not be used in pregnancy?

A

Not to be used in first trimester as it works as a folate antagonist - folate is important in early pregnancy for the normal development of the fetus

Can cause congenital malformations particularly neural tube defects (i.e. spina bifida)

Not known to be harmful later in pregnancy but is generally avoided

227
Q

What is anaemia?

A

Low concentration of haemoglobin in the blood- as a result of an underlying disease, not the disease itself

228
Q

What is iron needed for in the body?

A

Ingredient in creating Hb

229
Q

When are women screened for anaemia during pregnancy?

A

Booking clinic

28 weeks gestation

230
Q

How does the blood change in pregnancy?

A

Plasma volume increases

Causes a reduction in the Hb concentration

231
Q

Why is it important to optimise the treatment of anaemia during pregnancy?

A

So the woman has reasonable reserves in case there is significant blood loss during delivery

232
Q

How does anaemia present in pregnancy?

A

Often anaemia in pregnancy is asymptomatic, symptoms include:

  • SoB
  • Fatigue
  • Dizziness
  • Pallor
233
Q

What are the normal ranges for Hb in pregnancy?

A

Booking bloods = > 110 g/l

28 weeks gestation = > 105 g/l

Post partum = > 100 g/l

234
Q

What can the MCV tell you about the cause of anaemia in pregnancy?

A

Low MCV may indicate iron deficiency

Normal MCV may indicate a physiological anaemia due to the increased plasma volume of pregnancy

Raised MCV may indicate B12 or folate deficiency

235
Q

What hamatological diseases are women screened for at booking clinic?

A

Thalassaemia (all women)

Sickle cell disease (women at higher risk)

236
Q

What other investigations may be done for anaemia in pregnancy?

A

Ferritin

B12

Folate

237
Q

What is the management of anaemia in pregnancy according to cause?

A

Iron = iron replacement (e.g. ferrous sulphate 200mg three times daily) also for if they just have low ferritin

B12 = tested for pernicious anaemia (checking for intrinsic factor antibodies, advice from a haematologist RE treatment but includes: Intramuscular hydroxocobalamin injections, Oral cyanocobalamin tablets

Folate = 5mg daily if folate deficient (should already be on 400mcg daily)

Thalassaemia and sickle cell anaemia = women with haemoglobinopathy will be managed jointly with a specialist haematologist - require high dose folic acid (5mg), close monitoring and transfusions when required

238
Q

Why is pregnancy a risk for VTE?

A

Pregnancy is a hyper-coagulable state

239
Q

When is the risk of VTE highest in pregnancy?

A

Postpartum period

240
Q

What are the risk factors for VTE in pregnancy?

A

Smoking

Parity ≥ 3

Age > 35 years

BMI > 30

Reduced mobility

Multiple pregnancy

Pre-eclampsia

Gross varicose veins

Immobility

Family history of VTE

Thrombophilia

IVF pregnancy

241
Q

When should prophylaxis be started for VTE?

A

28 weeks if there are three risk factors

First trimester if there are four or more of these risk factors

242
Q

When else is prophylaxis for VTE considered in pregnancy? (Even in the absence of other risk factors)

A

Hospital admission

Surgical procedures

Previous VTE

Medical conditions such as cancer or arthritis

High-risk thrombophilias

Ovarian hyperstimulation syndrome

243
Q

When should pregnant women be assessed for their risk of VTE?

A

At booking and again after birth

(additionally if admitted to hospital, undergo a procedure or develop significant immobility)

244
Q

What is the prophylaxis for VTE in pregnancy?

A

Low molecular weight heparin (e.g. enoxaparin, dalteparin and tinzaparin)

245
Q

How long is prophylaxis for VTE continued for?

A

Until 6 weeks postnatally

246
Q

When is prophylaxis for VTE stopped in pregnancy?

A

When woman goes into labour and can be started immediately after delivery (except with PPH, spinal anaesthesia and epidurals)

247
Q

What are the management options for women with contraindications to LMWH?

A

Mechanical prophylaxis:

  • Intermittent pneumatic compression
  • Antiembolic compression stockings
248
Q

How does a DVT present?

A

Unilateral:

Calf or leg swelling

Dilated superficial veins

Tenderness to the calf (particularly over the deep veins)

Oedema

Colour changes to the leg

249
Q

How to examine for leg swelling in DVT?

A

Measure the circumference of the calf 10cm below the tibial tuberosity

More than 3cm difference between calves is significant

250
Q

What are the presenting features of a PE?

A

Shortness of breath

Cough with or without blood (haemoptysis)

Pleuritic chest pain

Hypoxia

Tachycardia (this can be difficult to distinguish from the normal physiological changes in pregnancy)

Raised respiratory rate

Low-grade fever

Haemodynamic instability causing hypotension

251
Q

What is the investigation of choice for a DVT?

A

Doppler ultrasound (repeated on day 3 and 7 in patients with a high index of suspicion for DVT)

252
Q

What are the investigations for women with suspected PE?

A

Chest X-ray

ECG

253
Q

How can a definitive diagnosis of PE be made?

A

CT pulmonary angiogram

Ventilation-perfusion scan (VQ scan)

254
Q

How does a CT pulmonary angiogram work?

A

Chest CT with IV contrast which highlights the pulmonary arteries to demonstrate any blood clots (helpful as it provides info about alternative diagnoses such as pneumonia or malignancy)

255
Q

How is a ventilation-perfusion scan performed for a PE?

A

Involves using radioactive isotopes and a gamma camera to compare the ventilation with the perfusion of the lungs

First the isotopes are inhaled to fill the lungs and a picture is taken to demonstate ventilation

Next a contrast containing isotopes is injected and a picture is taken to demonstrate perfusion

In a PE, the area of lung tissue will be ventilated but not perfused

256
Q

How is the choice between CTPA and VQ scan determined?

A

CTPA is the test for choice for patients with an abnormal chest xray

CTPA carries a higher risk of breast cancer for the mother (minimal absolute risk)

VQ scan carriers a higher risk of childhood cancer for the fetus (minimal absolute risk)

257
Q

If a diagnosis of DVT is established then is a VQ scan or CTPA required?

A

No as the treatment for DVT and PE are the same

258
Q

Is the Wells score or D-dimer test useful in pregnant women?

A

No and pregnancy is a cause of raised D-Dimers

259
Q

What is the management of VTE in pregnancy?

A

LMWH e.g. enoxaparin, dalteparin and tinzaparin, dose is based on the woman’s weight at the booking clinic or from early pregnancy

260
Q

In symptomatic patients when should LMWH be started?

A

Immediately before confirming the diagnosis, treatment can be stopped when investigations exclude the diagnosis

261
Q

How long is LMWH continued for in pregnancy?

A

Remainder of pregnancy plus 6 weeks

3 months in total (whichever is longer)

262
Q

What can the LMWH be switched to after delivery?

A

Oral anticoagulation (e.g. warfarin or a DOAC)

263
Q

What are the treatment options for a massive PE and haemodynamic compromise?

A

Unfractionated heparin

Thrombolysis

Surgical embolectomy

264
Q

What is pre-eclampsia?

A

New high blood pressure in pregnancy with end organ dysfunction notably proteinuria (protein in the urine)

265
Q

When does pre-eclampsia occur?

A

After 20 weeks gestation, when the spiral arteries of the placenta form abnormally leading to a high vascular resistance in these vessels

266
Q

What can pre-eclampsia lead to without treatment?

A

Maternal organ damage

FGR

Seixures

Early labour

Death

267
Q

What is the triad in pre-eclampsia?

A

Hypertension

Proteinuria

Oedema

268
Q

What is chronic hypertension defined as?

A

High blood pressure existing before 20 weeks gestation and is longstanding - not classified as pre-eclampsia

269
Q

What is pregnancy-induced hypertension or gestational hypertension?

A

Hypertension occuring after 20 weeks gestation, without proteinuria

270
Q

What is pre-eclampsia?

A

Pregnancy induced hypertension associated with organ damage - notably proteinuria

271
Q

What is eclampsia?

A

When seizures occur as a result of pre-eclampsia

272
Q

What is the pathophysiology of preeclampsia?

A

Pathophysiology is poorly understood, by simplified:

  • When the blastocyst implants on the endometrium , the outermost later called the syncytiotrophoblast grows into the endometrium forming finger-like projections called chorionic villi, these villi contain fetal blood vessels
  • Trophoblast invasion of the endometrium sends signals to the spiral arteries in that area of the endometrium, reducing their vascular resistance making them more fragile, blood flow to these areas increases and eventually they break down forming pools of blood called lacunae

- Maternal blood flows from the uterine arteries into the lacunae and back out through the uterine veins- these form at around 20 weeks gestation

  • When the process of forming lacunae is inadequate then the woman can develop pre-eclampsia
  • Pre-eclampsia is caused by high vascular resistance in the spiral arteries and poor perfusion of the placenta causinf oxidative stress in the placenta and the release of inflammatory chemicals into the systemic circulation leadind to a systemic inflammation and impaired endothelial function in the blood vessels
273
Q

What are the high risk factors for pre-eclampsia?

A

Pre-existing hypertension

Previous hypertension in pregnancy

Existing autoimmune conditions (e.g. systemic lupus erythematosus)

Diabetes

Chronic kidney disease​

274
Q

What are the moderate risk factors for pre-eclampsia?

A

Older than 40

BMI > 35

More than 10 years since previous pregnancy

Multiple pregnancy

First pregnancy

Family history of pre-eclampsia

275
Q

Who is offered prophylactic aspirin for pre-eclampsia?

A

Women with one high-risk factor or more than one moderate risk factor from 12 weeks gestation until birth

276
Q

What are the symptoms of pre-eclampsia?

A

Headache

Visual disturbance or blurriness

Nausea and vomiting

Upper abdominal or epigastric pain (this is due to liver swelling)

Oedema

Reduced urine output

Brisk reflexes

277
Q

How is a diagnosis of pre-eclampsia made?

A

Systolic blood pressure above 140 mmHg

Diastolic blood pressure above 90 mmHg

PLUS

Proteinuria (1+ or more on urine dipstick)

Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia)

Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies)

278
Q

How can proteinuria be qualtified on testing?

A

Urine albumin:creatinine ratio (above 30mg/mmol is significant)

Urine protein:creatinine ratio (above 8mg/mmol is significant)

279
Q

How can placental growth factor testing be used for pre-eclampsia?

A

Recommended for use on one occasion during pregnancy in women suspected of having pre-eclampsia

Placental growth factor is a protein released by the placenta which functions to stimulate the development of new blood vessels.

In pre-eclampsia the levels of PIGF are low

NICE recommends using PIGF between 20 and 35 weeks gestation to rule out pre-eclampsia

280
Q

How is pre-eclampsia monitored for at antenatal appts?

A

Blood pressure

Symptoms

Urine dipstick for proteinuria

281
Q

What is the general management for gestational hypertension (without proteinuria)?

A

Treating to aim for a blood pressure below 135/85 mmHg

Admission for women with a blood pressure above 160/110 mmHg

Urine dipstick testing at least weekly

Monitoring of blood tests weekly (full blood count, liver enzymes and renal profile)

Monitoring fetal growth by serial growth scans

PlGF testing on one occasion

282
Q

What is the managment of pre-eclampsia?

A

Similar to gestational hypertension, except:

Scoring systems are used to determine whether to admit the woman (fullPIERS or PREP‑S)

Blood pressure is monitored closely (at least every 48 hours)

Urine dipstick testing is not routinely necessary (the diagnosis is already made)

Ultrasound monitoring of the fetus, amniotic fluid and dopplers is performed two weekly

283
Q

What is the medical management of pre-eclampsia?

A

Labetolol is first-line as an antihypertensive

Nifedipine (modified-release) is commonly used second-line

Methyldopa is used third-line (needs to be stopped within two days of birth)

Intravenous hydralazine may be used as an antihypertensive in critical care in severe pre-eclampsia or eclampsia

IV magnesium sulphate is given during labour and in the 24 hours afterwards to prevent seizures

Fluid restriction is used during labour in severe pre-eclampsia or eclampsia, to avoid fluid overload

284
Q

When may planned early birth be necessary for pre-eclampsia?

A

Blood pressure cannot be controlled or complications occur

285
Q

What is the treatment for pre-eclampsia after delivery?

A

Enalapril (first-line)

Nifedipine or amlodipine (first-line in black African or Caribbean patients)

Labetolol or atenolol (third-line)

286
Q

What is eclampsia?

A

The seizures associated with pre-eclampsia IV magnesium sulphate is used to help manage the seizures

287
Q

What is HELLP syndrome?

A

Combination of features with occur as a complication of pre-eclampsia:

Haemolysis

Elevated Liver enzymes

Low Platelets

288
Q

What is gestational diabetes?

A

Diabetes triggered by birth, caused by reduced insulin sensitivity during pregnancy and resolves after birth

289
Q

What is the most significant complication of gestational diabetes?

A

Large for dates fetus and macrosomia leading to shoulder dystocia and longer term women are at a higher risk of developing type 2 diabetes after pregnancy

290
Q

How to screen for gestational diabetes?

A

Oral glucose tolerance test at 24-28 weeks gestation women with previous gestational diabetes also have an OGTT soon after the booking clinic

291
Q

What are the risk factors for gestational diabetes?

A

Previous gestational diabetes

Previous macrosomic baby (≥ 4.5kg)

BMI > 30

Ethnic origin (black Caribbean, Middle Eastern and South Asian)

Family history of diabetes (first-degree relative)

292
Q

What features may suggest gestational diabetes

A

Large for dates fetus

Polyhydramnios (increased amniotic fluid)

Glucose on urine dipstick

293
Q

How should an OGTT be performed?

A

Performed in the morning after a fast (they can drink plain water)

Patient drinks a 75g glucose drink at the start of the test

Blood sugar level is measured before the sugar drink (fasting) and then at 2 hours

294
Q

What are the normal results for an OGTT?

A

Fasting: < 5.6 mmol/l

At 2 hours: < 7.8 mmol/l

(5, 6, 7, 8)

295
Q

What forms part of the management of gestational diabetes?

A

- Joint diabetes and antenatal clinics with input from a dietician

  • Careful explanation about the condition and to learn how to monitor and track their blood sugar levels
  • Four weekly ultrasound scans to monitor the fetal grwoth and amniotic fluid volume from 28 to 36 weeks gestation
296
Q

What is the initial management of gestational diabetes as suggested by NICE?

A

Fasting glucose less than 7 mmol/l: trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin

Fasting glucose above 7 mmol/l: start insulin ± metformin

Fasting glucose above 6 mmol/l plus macrosomia (or other complications): start insulin ± metformin

297
Q

What medication can be used as an alternative in those who declin insulin or cannot tolerate metformin

A

Glibenclamide (a sulfonylurea)

298
Q

What are the target levels for blood sugar in gestational diabetes?

A

Fasting: 5.3 mmol/l

1 hour post-meal: 7.8 mmol/l

2 hours post-meal: 6.4 mmol/l

Avoiding levels of 4 mmol/l or below

299
Q

What should women with pre-existing diabetes take before becoming pregnant?

A

They should take 5mg folic acid from preconception until 12 weeks gestation

300
Q

What are the target insulin levels for women with existing type 1 and type 2 diabetes?

A

Aim for the same target insulin levels as with gestational diabetes

301
Q

How are women with type 2 diabetes managed during pregnancy?

A

Using metformin and insulin (other oral diabetic medications should be stopped)

302
Q

When should retinopathy screening be performed antenatally in pre-existing diabetics?

A

Shortly after booking and at 28 weeks gestation in pregnancy

Involves referral to an ophthalmologist to check for diabetic retinopathy

303
Q

When should delivery be planned for in pre-existing diabetes?

A

Planned delivery between 37 and 38 + 6 weeks

304
Q

When should women with gestational diabetes give birth?

A

Up to 40+6

305
Q

How are patients with type 1 diabetes managed during labour?

A

Sliding-scale insulin regime

A dextrose and insulin infusion is titrated to blood sugar levels according to the local protocol. Also considered for women with poorly controlled blood sugars with gestational or type 2 diabetes

306
Q

When can women with gestational diabetes stop their diabetic medication?

A

Immediately after birth with follow up testing for their fasting glucose at least 6 weeks after

307
Q

How to women with pre-existing diabetes be managed postnatally?

A

Lower their insulin dose and be wary of hypoglycaemia in the postnatal period - insulin sensitivity will increase after birth and with breast feeding

308
Q

What are babies of mothers with diabetes at risk of?

A

Neonatal hypoglycaemia

Polycythaemia (raised haemoglobin)

Jaundice (raised bilirubin)

Congenital heart disease

Cardiomyopathy

309
Q

What is a neonatal complication of gestational diabetes?

A

Neonatal hypoglycaemia - babies have been accustomed to a large supply of glucose during the pregnancy

Neonates need close monitoring for this with regular blood glucose checks and frequent feeds aiming to maintain thier blood sugar above 2 mmol/l and if it falls they may need IV dextrose or nasogastric feeding

310
Q

What is obstetric cholestasis also known as?

A

Intrahepatic cholestasis of pregnancy

311
Q

What is obstetric cholestasis characterised by?

A

Reduced outflow of bile acids from the liver - resolving after delivery of the baby

312
Q

What percent of pregnancies does obstetric cholestasis occur in?

A

1%

313
Q

What is obstetric cholestasis the result of?

A

Increased oestrogen and progesterone levels

314
Q

What ethnicity is obstetric cholestatsis most common in?

A

South asian ethnicity

315
Q

What are bile acids?

A

Breakdown product of cholesterol produced in the liver

316
Q

Where do bile acids flow from and to ?

A

From the liver to the hepatic ducts past the gallbladder and out of the bile duct into the intesting

317
Q

What is a symptom of increased bile acid in the blood?

A

Itching

318
Q

What is the association of obstetric cholestasis?

A

Increased risk of stillbirth

319
Q

When does cholestasis usually present?

A

Later in pregnancy, particularly in the third trimester

320
Q

What are the symptoms of cholestasis?

A

Itching (pruritis) on the palms of the hands and soles of the feet

Fatigue

Dark urine

Pale, greasy stools

Jaundice

321
Q

Is there a rash associated with obstetric cholestasis?

A

No rash, if this is present then an alternative diagnosis should be considered e.g. polymorphic eruption of pregnancy pr pemphigoid gestationis

322
Q

What are some differentials for pruritis and deranged LFTs?

A

Obstetric chilestasis

Gallstones

Acute Fatty liver

Autoimmune hepatitis

323
Q

What are some investigations of obstetric cholestasis?

A

LFTs (deranged ALT, AST and GGT)

Bile acids (raised)

324
Q

Is a raised ALP normal in pregnancy?

A

Yes as the placenta produces alkaline phosphatase, so normal if the only enzyme to rise

325
Q

What is the management of obstetric cholestasis?

A

Ursodeoxycholic acid - improves LFTs, bile acids and symptoms

326
Q

How can symptoms of itching be managed in obstetric cholestasis?

A

Emollients (i.e. calamine lotion) to soothe the skin

Antihistamines (e.g. chlorphenamine) can help sleeping (but does not improve itching)

327
Q

What can be used to treat deranged clotting in obstetric cholestasis?

A

Water-soluble vitamin K if clotting (prothrombin time) is deranged

Vitamin K is a fat-soluble vitamin, bile acids help absorb fat soluble vitamins - a lack of bile acids can lead tp vitamin K deficiency (this is an impostant part of the clotting system)

328
Q

How often are LFTs monitored during obstetric cholestasis?

A

Weekly and at least 10 days after delivery to ensure condition does not worsen

329
Q

When may planned delivery be considered in obstetric cholestasis?

A

After 37 weeks, particularly when the LFTs and bile acids are severely deranged

330
Q

What is acute fatty liver of pregnancy?

A

Rare condition which occurs in the third trimester of pregnancy with rapid accumulation of fat within the liver cells (hepatocytes) causing acute hepatitis

High risk of liver failure and mortality for both the mother and fetus

331
Q

What is acute fatty liver of pregnancy caused by?

A

Impaired processing of fatty acids in the placenta result of a genetric condition in the fetus which impairs fatty acid metabolism

Most common cause is long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency in the fetus which is an autosomal recessive condition

The LCHAD enzyme is important in fatty acid oxidation breaking down fatty acids to be used as fuel

Fatty acids then enter maternal circulation and accumulate in the liver causing inflammation and failure

332
Q

How does acute fatty liver of pregnancy present?

A

Vague symptoms associated with hepatitis:

General malaise and fatigue

Nausea and vomiting

Jaundice

Abdominal pain

Anorexia (lack of appetite)

Ascites

333
Q

What do the blood show in acute fatty liver of pregnancy?

A

Elevated ALT and AST (liver enzymes)

Raised bilirubin

Raised WBC

Deranged clotting (raised prothrombin time and INR)

Low platelets

334
Q

In pregnancy, what should elevated liver enzymes and low platelets make you think?

A

HELLP syndrome rather than acute fatty liver of pregnancy (HELLP syndrome is much more common)

335
Q

How is acute fatty liver of pregnancy managed?

A

Obstetric emergency which requires prompt admission and delivery of the baby - most patients recover after delivery

336
Q

What are the possible long term complications of acute fatty liver of pregnancy?

A

Acute liver failure - consider liver transplant

337
Q

What is polymorphic eruption of pregnancy?

A

Itchy rash which tends to start in the 3rd trimester

Also known as pruritic and urticarial papulaes and plaques of pregnancy

Usually begins of abdomen and particularly assocuated with stretch marks (striae)

338
Q

What is polymorphic eruption of pregnancy characterised by?

A

Urticarial papules (raised itchy lumps)

Wheals (raised itchy areas of skin)

Plaques (larger inflamed areas of skin)

339
Q

How is polymorphic eruption of pregnancy managed?

A

Control the symptoms:

Topical emollients

Topical steroids

Oral antihistamines

Oral steroids may be used in severe cases

340
Q

What is atopic ertuption of pregnancy?

A

Eczema which flares up during pregnancy (and in those without history of eczema)

Presents in the first and second trimester of pregnancy

341
Q

What are the two types of atopic eruption of pregnancy?

A

E-type or eczema type with eczematous inflamed, red and itchy skin, inside of elbows and knees, face and chest

P-type or prurigo-type intesely itchy papules (spots) typically affecting the abdomen, back and limbs

342
Q

How is atopic eruption of pregnancy managed?

A

Topical emollients

Topical steroids

Phototherapy with ultraviolet light (UVB) may be used in severe cases

Oral steroids may be used in severe cases

343
Q

What is melasma also known as?

A

Mask of pregnancy

344
Q

What is melasma characterised by?

A

Increased pigmentation to patched of the skin on the face - usually symmetrical and flat, affecting sun-exposed areas

345
Q

What is melasma associated with?

A

Increased female sex hormones associated with pregnancy

Also occurs with the COCP and HRT

Associated also with sun exposure, contraceptive pill and HRT

346
Q

What is the management of melasma?

A

No active management if the appearance is acceptable to the woman, otherwise:

Avoiding sun exposure and using suncream

Makeup (camouflage)

Skin lightening cream (e.g. hydroquinone or retinoid creams), although not in pregnancy and only under specialist care

Procedures such as chemical peels or laser treatment (not usually on the NHS)

347
Q

What is pyogenic granuloma also known as?

A

Lobular capillary haemangioma

348
Q

What is pyogenic granuloma?

A

Benign rapidly growing tumour of capillaries

349
Q

How does pyogenic granuloma present?

A

Discrete lump with a red / dark appearace

Occuring more often in pregnancy can also be associated with hormonal contraceptives, minor trauma or infection

350
Q

Where does pyogenic granuloma appear?

A

Rapidly growing lump which develops over days up to 1-2cm in size (but can be larger)

Often occur on the fingers or on the upper chest, back, neck or head.

May cause profuse bleeding and ulceration if injured

351
Q

What is a differential for pyogenic granuloma?

A

Malignancy (nodular melanoma)

352
Q

What is the management of pyogenic granuloma?

A

Usually resolve in pregnancy without any further treatment after delivery

Treatment is with surgical removal with histology to confirm the diagnosis

353
Q

What is pemphigoid gestationis?

A

Rare autoimmune skin condition in pregnancy

Autoantibodies are created with damage the connection between the epidermis and dermis creating a space with can fill with fluid, resulting in large fluid-filled blisters (bullae)

354
Q

What causes the auto antibodies in pemphigoid gestationis?

A

Pregnant woman’s immune system may produce these antibodies in response to placental tissue

355
Q

What stage of pregnancy does pemphigoid gestationis usually occur?

A

Second or third trimester

356
Q

How does pemphigois gestationis usually present?

A

Itchy, red, papular or blistering rash around the umbilicus that then spreads to other parts of the body - over weeks large fluid filled blisters form

357
Q

How is pemphigoid gestationis managed?

A

Rash usually resolves without treatment after delivery, blisters heal without scarring, treatment can be:

Topical emollients

Topical steroids

Oral steroids may be required in severe cases

Immunosuppressants may be required where steroids are inadequate

Antibiotics may be necessary if infection occurs

358
Q

What risks does pemphigoid gestationis pose to the baby?

A

Fetal growth restriction

Preterm delivery

Blistering rash after delivery (as the maternal antibodies pass to the baby)

359
Q

What is placenta praevia?

A

The palcenta is attached in the lower portion of the uterus, lower than presenting part of fetus

360
Q

What is a low-lying placenta?

A

Used when the placenta is within 20mm of the internal cervical os

361
Q

What is placenta praevia?

A

Term used for when the placenta is over the internal cervical os

362
Q

What percent of pregnancy for placent praevia occur in ?

A

1%

363
Q

What are three causes of antepartum haemorrhage?

A

Placenta praevia

Placental abruption

Vasa praevia

364
Q

What are some causes of spotting in pregnancy?

A

Cervical ectropion

Infection

Vaginal abrasions from intercourse

365
Q

What are the risks associated with placenta praevia?

A

Antepartum haemorrhage

Emergency caesarean section

Emergency hysterectomy

Maternal anaemia and transfusions

Preterm birth and low birth weight

Stillbirth

366
Q

What are the traditional four grades of placenta praevia? (system is outdated, now used low lying and placenta praevia)

A

Minor praevia, or grade I – the placenta is in the lower uterus but not reaching the internal cervical os

Marginal praevia, or grade II – the placenta is reaching, but not covering, the internal cervical os

Partial praevia, or grade III – the placenta is partially covering the internal cervical os

Complete praevia, or grade IV – the placenta is completely covering the internal cervical os

367
Q

What are the risk factors for placenta praevia?

A

Previous caesarean sections

Previous placenta praevia

Older maternal age

Maternal smoking

Structural uterine abnormalities (e.g. fibroids)

Assisted reproduction (e.g. IVF)

368
Q

When is the position of the placenta assessed?

A

20 week anomaly scan

369
Q

What are the symptoms of placenta praevia?

A

Usually asymptomatic

Painless vaginal bleeding (around 36 weeks)

370
Q

What is the management of a low-lying placenta/placenta praevia?

A

Repeat scans at 32 weeks and 36 weeks gestation (if present on the 32-week scan, to guide decisions about delivery)

Corticosteroids given between 34 and 35+6 gestation to mature the fetal lungs

Planned delivery between 36 and 37 weeeks to reduce the risk of spontaneous labour and bleeding

Planned C-Section is required with placenta praevia and low-lying placenta

Ultrasound around the time of procedure to locate placenta

Emergency C-Section required with premature labout or antenatal bleeding

371
Q

What is the main complication of placenta praevia?

A

Haemorrhage before, during and after delivery

372
Q

What is the management of haemorrhage in placenta praevia?

A

Emergency caesarean section

Blood transfusions

Intrauterine balloon tamponade

Uterine artery occlusion

Emergency hysterectomy

373
Q

What is vasa praevia?

A

Condition where the fetal vessels are within the fetal membranes (chorioamniotic membranes) and travel across the internal cervical os

374
Q

Where are the fetal membranes?

A

Surrounding the amniotic cavity and developing fetus

375
Q

What are the fetal vessels?

A

Two umbilical arteries

Single umbilical vein

376
Q

What is vasa praevia?

A

The fetal vessels are places over the internal cervical os, before the fetus - exposed, outside the protection of the umbilical cord or placenta - prone to bleeding, particularly when the membranes are ruptured during labour and at birth

377
Q

How do the fetal vessels (umbilical arteries and vein) insert into the placenta?

A

Insert directly into the placenta (always protected by the umbilical cord or the placenta)

378
Q

What is Wharton’s jelly?

A

A layer of soft connective tissue that surrounds the blood vessels in the umbilical cord offering protection

379
Q

When can the fetal vessels be exposed?

A

Velamentous umbilical cord is where the umbilical cord inserts into the chorioamniotic membranes, and the fetal vessels travel unprotected through the membranes before joining the placenta.

An accessory lobe of the placenta (also known as a succenturiate lobe) is connected by fetal vessels that travel through the chorioamniotic membranes between the placental lobes.

380
Q

What can vasa praevia lead to?

A

Dramatic fetal blood loss and death

381
Q

What are the two types of vasa praevia?

A

Type I vasa praevia – the fetal vessels are exposed as a velamentous umbilical cord

Type II vasa praevia – the fetal vessels are exposed as they travel to an accessory placental lobe

382
Q

What are the risk factors for vasa praevia?

A

Low lying placenta

IVF pregnancy

Multiple pregnancy

383
Q

How may vasa praevia present?

A

Maybe diagnosed by ultrasound during pregnancy (allowing planned C-Section to reduce risk of haemorrhage)

Antepartum haemorrhage with bleeding during 2nd or 3rd trimester of pregnancy

Maybe detected on vaginal examintation during labour when pulsatiling vessels are seen in the membranes

Maybe detected during labour when fetal distress and dark-red bleeding occur following rupture of the membranes carries a very high fetal mortality

384
Q

What is the management of vasa praevia?

A

For asymptomatic patients:

  • Corticosteroids from week 32 gestation
  • Elective c-section planned for 34 to 36 weeks gestation

In antepartum haemorrhage:

  • Emergency C-Section is required to deliver fetus
385
Q

How may a cause be found after stillbirth or unexplained fetal compromise?

A

Placenta is examined for evidence of vasa praevia as a possible cause

386
Q

What is placental abruption?

A

When the placenta separates from the walls of the uterus during pregnancy (site of attachment can bleed extensively after the placenta separates - significant cause of antepartum haemorrhage

387
Q

What are some risk factors for placental abruption?

A

Previous placental abruption

Pre-eclampsia

Bleeding early in pregnancy

Trauma (consider domestic violence)

Multiple pregnancy

Fetal growth restriction

Multigravida

Increased maternal age

Smoking

Cocaine or amphetamine use

388
Q

How does placental abruption present?

A

Sudden onset severe abdominal pain that is continuous

Vaginal bleeding (antepartum haemorrhage)

Shock (hypotension and tachycardia)

Abnormalities on the CTG indicating fetal distress

Characteristic “woody” abdomen on palpation, suggesting a large haemorrhage

389
Q

How is the severtity of antepartum haemorrhage estimated?

A

Spotting: spots of blood noticed on underwear

Minor haemorrhage: less than 50ml blood loss

Major haemorrhage: 50 – 1000ml blood loss

Massive haemorrhage: more than 1000 ml blood loss, or signs of shock

390
Q

What is a concealed abruption?

A

Cervical os remains closed, and any bleeding that occurs remains within the uterine cavity. The severity of bleeding can be significantly underestimated with concealed haemorrhage.

391
Q

What is a revealed abruption?

A

Where blood loss is observed via the vagina

392
Q

How is placental abruption diagnosed?

A

No reliable test, clinical diagnosis

393
Q

Is placental abruption an emergency?

A

Obstetric emergency - urgency depends on the amount of fetal separation, extent of bleedin, haemodynamic stability of the mother and condition of the fetus (important to consider concealed haemorrhage where vaginal bleeding may be disproportionate to uterine bleeding)

394
Q

What are the management steps of placental abruption?

A

Urgent involvement of a senior obstetrician, midwife and anaesthetist

2 x grey cannula

Bloods include FBC, UE, LFT and coagulation studies

Crossmatch 4 units of blood

Fluid and blood resuscitation as required

CTG monitoring of the fetus

Close monitoring of the mother

395
Q

In the antenatal period what is the management for placental abruption?

A

Ultrasound to exclude placenta praevia as a cause for antepartum haemorrhage (not good for diagnosing abruption)

Antenatal steroids between 24 and 34 + 6 weeks gestation

Rhesus-D negative women require anti-D prophylaxis when bleeding occurs - a Kleihauer test is used to quantify how much fetal blood is mixed with maternal blood to determine dose

Emergency C-Section if mother is unstable or there is fetal distress

Increased risk of postpartum haemorrhage after delivery in women with placental abruption - active management of the third stage is recommended

396
Q

What is placenta accreta?

A

When the placenta implants deeper, through and past the endometrium - then difficult to separate the placenta after delivery of the baby

397
Q

Why is it called ‘placenta accreta spectrum’?

A

There is a spectrum of severity in how deep and broad the normal implantation extends

398
Q

What are the three layers to the uterine wall?

A

Endometrium, the inner layer that contains connective tissue (stroma), epithelial cells and blood vessels

Myometrium, the middle layer that contains smooth muscle

Perimetrium, the outer layer, which is a serous membrane similar to the peritoneum (also known as serosa)

399
Q

Where does the placenta usually attach to?

A

The endometrium

400
Q

Where does the placenta embed in placenta accreta?

A

Past the endometrium into the myometrium and beyond

401
Q

Why may placenta accreta occur?

A

Previous uterine surgery e.g. C-Section or curettage procedure

402
Q

What is the adverse outcome in placenta accreta?

A

Difficult for the placenta to separate suring delivery, leading to extensive bleeding (post-partum haemorrhage)

403
Q

What are the other definitions of placenta accreta (based on the depth of insertion)?

A

Superficial placenta accreta is where the placenta implants in the surface of the myometrium, but not beyond

Placenta increta is where the placenta attaches deeply into the myometrium

Placenta percreta is where the placenta invades past the myometrium and perimetrium, potentially reaching other organs such as the bladder

404
Q

What are the risk factors for placenta accreta?

A

Previous placenta accreta

Previous endometrial curettage procedures (e.g. for miscarriage or abortion)

Previous caesarean section

Multigravida

Increased maternal age

Low-lying placenta or placenta praevia

405
Q

How does placenta accreta present?

A

Doesnt usually cause symptoms in pregnancy

Can present with antepartum haemorrhage in the third trimester

May be diagnosed on antenatal ultrasound scans with particular attention fiven to women with previous placenta accreta or caesarean during scanning

May be diagnosed at birth when it is difficult to deliver the placenta

406
Q

How are patients with placenta accreta ideally diagnosed?

A

Antenatally by ultrasound - allowing planning for birth

407
Q

What can be used to assess the depth and width of invasion in placenta accreta?

A

MRI scans

408
Q

How are patients with placenta accreta managed?

A

May need additional management at birth due to the risk of bleeding:

Complex uterine surgery

Blood transfusions

Intensive care for the mother

Neonatal intensive care

409
Q

When is delivery planned for in placental accreta?

A

Between 35 to 36+6 weeks gestation to reduce the risk of spontaneous labour and delivery (antenatal steroids given to mature the fetal lungs before delivery)

410
Q

What are the options for caesarean delivery in placenta accreta?

A

Hysterectomy with the placenta remaining in the uterus (recommended)

Uterus preserving surgery, with resection of part of the myometrium along with the placenta

Expectant management, leaving the placenta in place to be reabsorbed over time

411
Q

What are the risks with managing placenta accreta with expectant management?

A

Risks - bleeding and infection

412
Q

How to manage unexpected placenta accreta during delivery?

A
  • During an elective C-section the abdo can be closed and delayed whilst services are put in place
  • If discovered after delivery of baby then a hysterectomy is recommended
413
Q

What is breech presentation?

A

Presenting part of the fetus is the legs and bottom

414
Q

How often does breech presentation occur?

A

Less than 5% of pregnancies by 37 weeks gestation

415
Q

What are the different types of breech presentation?

A

Complete breech, where the legs are fully flexed at the hips and knees

Incomplete breech, with one leg flexed at the hip and extended at the knee

Extended breech, also known as frank breech, with both legs flexed at the hip and extended at the knee

Footling breech, with a foot is presenting through the cervix with the leg extended

416
Q

What is the management of breech babies?

A

Before 36 weeks often turn spontaneously

After 37 weeks external cephalic version cabn be used

417
Q

What happens if an ECV fails?

A

Mothers given a choice between vaginal delivery and elective caesarean section.

Vaginal delivery requires experienced midwives and obstetricians with access to emergency theatre if required

Vaginal birth is safer for mother, c-section is safer for baby

40% chance of needing c-section when vaginal birth is attempted

If first baby of a twin pregnancy is breech then C-section required

418
Q

How successful is an exrternal cephalic version?

A

50%

419
Q

When is an ECV used in breeched babies?

A

After 36 weeks for nulliparous women

After 37 weeks in women that have given birth previously

420
Q

What is given before ECV is attempted? What does it do?

A

Tocolysis to relax the uterus (subcutaneous terbutaline) A beta-agonist similar to salbutamol (reduces the contractility of the myometrium)

421
Q

What is given to a rhesus-D negative woman before an ECV is performed?

A

Anti-D prophylaxis

422
Q

What is a stillbirth?

A

Birth of a dead fetus after 24 weeks gestation (result of intrauterine fetal death) occurs in approx 1 in 200 pregnancies

423
Q

What are the causes of stillbirth?

A

Unexplained (around 50%)

Pre-eclampsia

Placental abruption

Vasa praevia

Cord prolapse or wrapped around the fetal neck

Obstetric cholestasis

Diabetes

Thyroid disease

Infections, such as rubella, parvovirus and listeria

Genetic abnormalities or congenital malformations

424
Q

What are the factors which increase the risk of stillbirth?

A

Fetal growth restriction

Smoking

Alcohol

Increased maternal age

Maternal obesity

Twins

Sleeping on the back (as opposed to either side)

425
Q

How is stillbirth prevented?

A

Risk assesment for SGA / FGR is performed on all pregnant women

Those at risk have serial growth scans (maybe planned early delivery when the growth is static or other concerns)

Risk assessment for pre-eclampsia and given aspirin

Modifiable risk factors for stillbirth are treated e.g. stopping smoking, avoiding alcohol, effective control for diabetes

Sleeping on the side is recommended

426
Q

What are the three key symptoms to always ask during pregnancy?

A

Reduced fetal movements

Abdo pain

Vaginal bleeding

427
Q

How is intrauterine fetal death diagnosed?

A

Ultrasound scan to visualise the fetal heatbeat

Passive fetal movements are still possible so a repeat scan is offered to confirm situation

428
Q

What prophylaxis do rhesus-D negative women require when IUFD is diagnosed?

A

Anti-D

429
Q

How are patients with IUFD managed?

A

Vaginal birth is first line (choice of induction of labour or expectant management - provided there is no sepsis, pre-eclampsia or haemorrhage)

Expectant managment needs close monitoring - condition of fetus will deteriorate with time

Induction of laboue involves use of oral mifepristone (anti-progesterone) and vaginal or oral misoprostol (prostaglandin analogue)

Dopamine agonists (e.g. cabergoline) can be used to suppress lactation after stillbirth

430
Q

How can the cause of stillbirth be determined?

A

With parental consent, testing is carried our after stillbirth:

Genetic testing of the fetus and placenta

Postmortem examination of the fetus (including xrays)

Testing for maternal and fetal infection

Testing the mother for conditions associated with stillbirth, such as diabetes, thyroid disease and thrombophilia

431
Q

What are the causes of cardiac arrest?

A

Thrombosis (i.e. PE or MI)

Tension pneumothorax

Toxins

Tamponade (cardiac)

Hypoxia

Hypovolaemia

Hypothermia

Hyperkalaemia, hypoglycaemia, and other metabolic abnormalities

432
Q

What are the other causes of cardiac arrest in pregnancy?

A

Eclampsia

Intracranial haemorrhage

Obstetric haemorrhage

Pulmonary embolism

Sepsis leading to metabolic acidosis and septic shock

433
Q

What are the causes of massive obstetric haemorrhage?

A

Ectopic pregnancy (early pregnancy)

Placental abruption (including concealed haemorrhage)

Placenta praevia

Placenta accreta

Uterine rupture

434
Q

What is aorto-caval compression?

A

Pregnant woman lies on her back - the mass of the uterus compresses the IVC and aorta (compression on the IVC is most significant as it lowers cardiac output leading to hypotension) can lead to cardiac arrest

435
Q

How to prevent aortocaval compression?

A

Place the owmen in the left lateral position, lying on her left side

436
Q

What factors make resuscitation in pregnancy more difficult?

A

Aortocaval compression

Increased oxygen requirements

Splinting of the diaphragm by the pregnant abdomen

Difficulty with intubation

Increased risk of aspiration

Ongoing obstetric haemorrhage

437
Q

How is resuscitation performed in pregnancy?

A

A 15 degree tilt to the left side for CPR, to relieve compression of the inferior vena cava and aorta

Early intubation to protect the airway

Early supplementary oxygen

Aggressive fluid resuscitation (caution in pre-eclampsia)

Delivery of the baby after 4 minutes, and within 5 minutes of starting CPR

438
Q

When is immediate caesarean section performed in a pregnant woman?

A

There is no response after 4 minutes to CPR when performed correctly

CPR continues for more than 4 minutes in a woman more than 20 weeks gestation

439
Q

How quickly after CPR should a baby be delivered?

A

Within 5 minutes of starting CPR - performed at the site of the arrest e.g. A&E resus or on the ward

440
Q

What is the primary reason for the immediate delivery of the baby during CPR?

A

Improves survival of the mother improving the venous return to the heart, improving cardiac output and reducing oxygen consumption - also helps with ventilation and chest compressions (also increases the chances of the baby surviving, although this is secondary to the survival of the mother)

Obstetrics and Gynaecology (10 decks)

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