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Antenatal Complications Flashcards

1
Q

What to do first is presenting complaint of reduced fetal movements?

A

check for foetal heartbeat with foetal USS doppler, then do SFH and CTG

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2
Q

When to offer IOL in RFM?

A

OFFER IOL IF RECURRENT RF, AFTER 36+8 WEEKS AS ASX WITH STILLBIRTH

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3
Q

When to discuss IOL in RFM?

A

Single episode of RFM post 38 weeks

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4
Q

2 main causes of abdominal pain in pregnancy

A

Threatened preterm labour

Uterine rupture

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5
Q

How does threatened preterm labour present?

A

Contraction/period-like pain
coming in waves
uterine origin

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6
Q

What to do first if suspecting threatened preterm labour?

A

Abdo and speculum exam

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7
Q

What would be seen on examination in threatened preterm labour?

A

Dilated, bulging membrane

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8
Q

Dilated, bulging membrane on examination

A

Preterm labour

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9
Q

RFs for threatened preterm labour

A

anything that weaken the uterus

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10
Q

Gow does uterine rupture present?

A

Contraction/period-like pain
continuous
may feel head free in abdomen

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11
Q

What may be seen on CTG in uterine rupture?

A

Pathological

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12
Q

RFs for uterine rupture

A

Precious uterine surgeries
Multiple pregnancy
Previous CS
Age
Obstetric Intervention

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13
Q

Clinical features of uterine rupture

A

Rapid deterioration during labour (associated with significant haemodynamic instability)

Acute abdominal pain followed by features of shock and intra-abdominal haemorrhage.

Uterine scar tenderness (over suprapubic area)

Abnormal CTG trace or absent fetal heart rate

Cessation of uterine contractions

Vaginal bleeding - This may not always be apparent as bleeding can be concealed

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14
Q

Types of uterine rupture

A

Incomplete or complete

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15
Q

When to admit in uterine rupture?

A

scar tenderness

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16
Q

Management of uterine rupture

A

OBSTETRIC EMERGENCY

Emergency CS
Resuscitation
If unable to control the bleeding, a hysterectomy or internal iliac ligation will be performed

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17
Q

PACES: Counselling of patient for uterine rupture

A

need for emergency caesarean section , possibility of laparotomy, sterilization after the repair of scar

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18
Q

Complications of uterine rupture

A

If the patient survives, late sequels are intestinal obstruction, repeat rupture of uterus

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19
Q

Differentials for vaginal leaking during pregnancy

A

Urine
Liquor
Discharge

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20
Q

What is most common cause of discharge in pregnancy?

A

Thrusy

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21
Q

What is used to manage thrush in pregnancy?

A

Only treat if symptomatic –> clotrimazole pessary and cream

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22
Q

Do you use oral thrush management in pregnancy?

A

No, use clotrimazole pessary and cream

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23
Q

what to check if complaint of dizziness in pregnancy?

A

Hb,ferritin

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24
Q

What to check if complaints of SOB in pregnancy

A

Anaemia
Rule out PE/cardiac cause

NB: may be physiological

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25
Q

What is done if suspicious of PE in pregnancy?

A

CTPA

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26
Q

What to check if complaint of palpitations in pregnancy?

A

Bloods - Hb, electrolytes, TFTs

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27
Q

What diagnosis to consider if itching in pregnancy? How to manage?

A

Obstetric cholestasis

Manage with IOL at 39 weeks and ursdeoxycholic acid for Sx

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28
Q

Bleeding in pregnancy <24 weeks

A

Threatened miscarriage

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29
Q

Bleeding in pregnancy >24 weeks

A

Antepartum haemorrhage

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30
Q

Causes of antepartum haemorrhage

A

Placental
Placenta praevia
Placental abruption
Vasa praevia

Local
Cervicitis
Cervical ectropion
Vaginal trauma
Vaginal infection

NB: bleeding can come from any part of genital tract

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31
Q

Most likely cause if painful antenatal bleeding

A

PLACENTA

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32
Q

MOST IMPORTANT DRUG TO GIVE IF ANTENATAL BLEEDING

A

ANTI-D IF RHESUS NEGATIVE

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33
Q

What is placenta praevia?

A

Placenta attaches low in the uterus and covers the cervix

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34
Q

How does placenta praevia present?

A

painless, bright red bleeding at around 32 weeks

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35
Q

Complications of placental praevia

A

maternal haemorrhage and foetal IUGR

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36
Q

How to diagnose placenta praevia?

A

Abdominal exam: soft and non-tender uterus, abnormal foetal position

Transvaginal ultrasound: confirms diagnosis, measures distance between placenta and os

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37
Q

Management of placenta praevia

A
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38
Q

What is placental abruption?

A

Placenta separates from the uterus prematurely

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39
Q

RFs for placental abruption

A

prior abruptions, pre-eclampsia and smoking crack

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40
Q

What can abruption feel like to the woman?

A

Continous contractions

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41
Q

Types of abruption and what they can result in

A

Abruption caused by arterial bleeding (majority) results in sudden, severe symptoms like DIC and severe haemorrhage

Abruption caused by venous bleeding is more likely to cause oligohydramnios and IUGR

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42
Q

What type of abruption is more likely to result in sudden, severe symptoms like DIC and severe haemorrhage?

A

Arterial bleeding (majority)

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43
Q

What are the majority of abruptions due to?

A

Arterial bleeding

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44
Q

What is an abruption that leads to oligohydramnios and IUGR
likely to be due to?

A

Venous bleeding

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45
Q

What is a concealed abruption

A

No blood seen but signs of placental abruption

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46
Q

How to diagnose placental abruption?

A

Abdominal exam: woody, tender and enlarged uterus

Transvaginal ultrasound: NOT diagnostic, but used to rule out praevia

Abruption is a diagnosis of exclusion –> can be diagnosed on clinical suspicion alone, even if no blood seen,

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47
Q

Painless vaginal bleeding

A

Praevia

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48
Q

Painful vaginal bleeding

A

Abruptuion

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49
Q

Woody, tender and enlarged uterus on abdo exam

A

Abruption

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50
Q

What would be seen on abdo exam of placental abruption?

A

woody, tender and enlarged uterus

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51
Q

What condition to rule out before diagnosis of abruption?

A

Transvaginal ultrasound: NOT diagnostic, but used to rule out praevia

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52
Q

Is abruption a diagnosis of exclusion?

A

Yes, can be diagnosed on clinical suspicion alone, even if no blood seen,

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53
Q

Management of placental abruption

A
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54
Q

Who to prioritise in placental abruption?

A

Mum –> if pathological –> transfer to LW/theatre

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55
Q

When is admission needed in placental abruption?

A

If bleeding seen

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56
Q

What is pre-eclampsia defined as?

A

New-onset of hypertension with proteinuria after 20 weeks’ gestation.

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57
Q

What is chronic hypertension defined as?

A

high BP diagnosed <20 weeks

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58
Q

What is gestational hypertension defined as?

A

new high BP diagnosed >20 weeks WITHOUT PROTEINURIA

NB: If proteinuria too –> pre-eclampsia

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59
Q

Features of pre-eclampsia

A

headaches, oedema, right UQ pain, visual disturbance, low platelets

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60
Q

What can untreated pre-eclampsia lead to?

A

eclampsia (seizures)

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61
Q

RFs for pre-eclampsia

A

Moderate risk factors: 1st pregnancy, multiple pregnancy, family history, age > 40, BMI > 35, > 10 year pregnancy interval

High risk factors: hypertensive disease in previous pregnancy, chronic hypertension, CKD, autoimmune disease, diabetes

NOTE: To reduce risk of pre-eclampsia, give aspirin from 12 weeks onwards if 2 or more moderate RFs present OR 1 or more high RFs present

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62
Q

When is aspirin given to prevent risk of pre-eclampsia?

A

12 weeks onwards if 2 or more moderate RFs present OR 1 or more high RFs present

NOTE: Moderate risk factors: 1st pregnancy, multiple pregnancy, family history, age > 40, BMI > 35, > 10 year pregnancy interval

High risk factors: hypertensive disease in previous pregnancy, chronic hypertension, CKD, autoimmune disease, diabetes

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63
Q

Hypertensive drugs in pregnancy

A

Labetalol - alpha and beta blocker, oral or IV
Nifedipine – calcium channel blocker, oral
Methyldopa – alpha 2 agonist, oral or IV
Hydralazine – direct acting smooth muscle relaxant and vasodilator, oral IM or IV

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64
Q

1st line hypertensive in pregnancy

A

Labetalol

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65
Q

Who is labetalol contraindicated in?

A

Asthmatics –> give Nifedipine

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66
Q

2nd line hypertensive in pregnancy

A

Nifedipine

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67
Q

Mnemonic for pre-eclampsia management

A

Labetalol → Largely Used, Lung disease caution (asthma)
Nifedipine → Narrow airways (asthma) friendly
Magnesium Sulfate → Seizure Prevention and neuroprotection

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68
Q

BP medication if asthmatic

A

Nifedipine

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69
Q

Pre-eclampsia management

A
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70
Q

How often to monitor BP in hospital for pre-eclampsia?

A

4 times a day

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71
Q

Why monitor bbloods in pre-eclampsia?

A

worsening haematology/biochemistry with features of HELPP syndrome would be an indication for delivery

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71
Q

W

A
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72
Q

When to offer antenatal steroids?

A

Offer antenatal steroids if delivery is anticipated before 34 weeks’ gestation

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73
Q

What drug to avoid in pre-eclampsia?

A

Ergometrine

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74
Q

Indications for urgent delivery in pre-eclampsia

A

Uncontrollable Blood Pressure
Rapidly Worsening Biochemistry/Haematology (e.g. HELLP syndrome)
Eclampsia
Foetal Distress, Severe IUGR or Reduced Umbilical Artery End-Diastolic Flow

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75
Q

Is eclampsia an obstetric emergency?

A

Yes, call 2222 and say obstetric emergency

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76
Q

What position to place patient in if eclamptic?

A

Left lateral

NOTE: GIVE OXYGEN

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77
Q

What is eclampsia?

A

Onset of seizures or coma in the context of pre-eclampsia.

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78
Q

Management of Eclampsia

A

Summon senior help immediately
Secure the airway
Early ITU and neonatal team input

Magnesium Sulphate
Loading Dose: 4 g over 5-10 mins
Maintenance Dose: 1 g/hour until 24 hours after delivery
Monitor deep tendon reflexes, respiratory rate and oxygen saturation (to be able to identify magnesium toxicity)
Antidote for magnesium toxicity: 10 mL 10% calcium gluconate (slow IV infusion)

Discuss Delivery
Urgent delivery recommended
Administer steroids if deemed necessary
Strict fluid balance monitoring (at risk of pulmonary oedema)

Treat High Blood Pressure
1st Line: IV Labetalol
2nd Line: PO Nifedipine or Methyldopa
3rd Line: IV Hydralazine

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79
Q

What to do immediately in eclampsia management?

A

Summon senior help, secure airway

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80
Q

How to give Magnesium Sulphate in eclampsia?

A

Loading Dose: 4 g over 5-10 mins
Maintenance Dose: 1 g/hour until 24 hours after delivery

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81
Q

What to monitor when giving magnesium sulphate in pregnancy?

A

Monitor deep tendon reflexes, respiratory rate and oxygen saturation (to be able to identify magnesium toxicity)

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82
Q

Antidote for magnesium sulphate toxicity

A

Antidote for magnesium toxicity: 10 mL 10% calcium gluconate (slow IV infusion)

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83
Q

When is delivery recommended in eclampsia?

A

Urgently

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84
Q

What hypertensives should be avoided in pregnancy?

A

WARNING: ACE Inhibitors and ARBs are associated with an increased risk of congenital malformations
Thiazide diuretics should be avoided as they are associated with an increased risk of neonatal electrolyte abnormalities, jaundice and thrombocytopaenia

85
Q

What is pre-existing diabetes defined as?

A

diabetes diagnosed <20 weeks

86
Q

What is gestation diabetes defined as?

A

new diabetes diagnosed >20 weeks

87
Q

How does diabetes present?

A

Classic diabetes symptoms of polyuria, polydipsia, fatigue etc.

88
Q

How is diabetes diagnosed?

A

Diagnosis using either fasting blood glucose or OGTT
Rule of 5,6,7,8: fasting glucose > 5.6 or OGTT > 7.8

89
Q

What diagnostic test is used for pateints with risk factors?

A

2-hour 75 g Oral Glucose Tolerance Test (at 24-28 weeks)
Recommended to patients with risk factors
Diagnostic: > 7.8 mmol/L

90
Q

What diagnostic test is used for pateints without risk factors?

A

Urine Dipstick
Glycosuria is usually how GDM is diagnosed in patients without risk factors

91
Q

What effect does pregnancy have on diabetes?

A

Increased insulin requirements
Increased risk of hypos
Deterioration of existing complications like retinopathy and nephropathy

92
Q

What effects does pregnancy have on diabets?

A

Miscarriage and stillbirth
Macrosomia and congenital malformations
Pre-eclampsia, infections
Complicated birth, shoulder dystocia

93
Q

GDM management

A
94
Q

Management of GDM

A

1st Line (provided fast blood glucose < 7 mmol/L): Changes in diet and exercise
Caveats
If fasting blood glucose is > 7 mmol/L at the time of diagnosis, commence insulin therapy straight away
If fasting blood glucose is 6.0-6.9 mmol/L with complications (e.g. macromsomia) then consider commencing insulin treatment

2nd Line (if targets not met by diet and exercise after 1-2 weeks): Metformin

3rd Line: Add Insulin

95
Q

When to offer insulin straightaway in GDM?

A

Fasting glucose > 7 OR 6 – 6.9 with evidence of complications

96
Q

1st line management in GDM with fasting glucose <7 without complications

A

Diet and exercise 1–2-week trial

Followed by Metformin and Insulin

97
Q

What can be offered if metformin can’t be tolerated?

A

If metformin can’t be tolerated, an alternative is glibenclamide

98
Q

How many times to check BM’s per day in GDM?

A

BMs should be checked 7 times per day: fasting, pre-meal, 1-hour post-meal, bedtime

99
Q

Target GM’s in GDM

A

Fasting < 5.3
1-hour post-prandial < 7.8
2-hour post-prandial < 6.4

100
Q

When is USS monitoring offered in GDM

A

Offer ultrasound monitoring of foetal growth and amniotic fluid volume every 4 weeks from 28-36 weeks
Offer appointments at diabetes clinic every 2 weeks

101
Q

Maternal complications of GDM

A

Postpartum haemorrhage
Prolonged labour
Increased rates of assisted or instrumental delivery

102
Q

Foetal complications of GDM

A

Stillbirth
Neonatal hypoglycaemia
Macrosomia
Shoulder dystocia

103
Q

Definition of HELLP syndrome

A

Acronym for Haemolysis, Elevated Liver enzymes and Low Platelets.

104
Q

What is HELLP syndrome associated with?

A

pre-eclampsia

105
Q

Clinical features of HELLP syndrome

A

Right upper quadrant pain
Oedema
Blurred vision
Nausea and vomiting
Headache
Bleeding
Seizures (rare)

106
Q

Investigations for HELLP syndrome

A

Bedside
Blood Pressure
Urine Dipstick (check for proteinuria)

Bloods
Full blood count (evidence of haemolysis and thrombocytopaenia)
LFT
Coagulation Screen

107
Q

Management of HELLP syndrome

A

Best supportive care with fluids and blood products
Treatment involves prompt delivery of the baby

108
Q

Which pregnant women should be screened for HIV? Why?

A

All pregnant women should be offered HIV screening
This is because measures can be taken (e.g. commencing antiretrovirals and suppressing viral load) that can decrease the risk of vertical transmission of HIV

109
Q

How is HIV monitored during pregnancy? How often?

A

CD4 count should be measured at baseline and at delivery
Viral load should be checked every 2-4 weeks, at 36 weeks and after delivery

110
Q

When should viral load be monitored in pregnancy for HIV?

A

Viral load should be checked every 2-4 weeks, at 36 weeks and after delivery

111
Q

What does the mode of delivery depend on in HIV in pregnancy?

A

For women with a plasma viral load of <50 HIV RNA copies/mL at 36 weeks, and in the absence of obstetric contraindications, planned vaginal delivery should be supported.

For women with a plasma viral load of 50–399 HIV RNA copies/mL at 36 weeks, pre-labour CS (PLCS) should be considered, taking into account the actual viral load, the trajectory of the viral load, length of time on treatment, adherence issues, obstetric factors and the woman’s views.

Where the viral load is ≥400 HIV RNA copies/mL at 36 weeks, PLCS is recommended.

112
Q

What is the mode of delivery for women with a plasma viral load of <50 HIV RNA copies/mL at 36 weeks, and in the absence of obstetric contraindications?

A

planned vaginal delivery should be supported.

113
Q

What is the mode of delivery for omen with a plasma viral load of 50–399 HIV RNA copies/mL at 36 weeks?

A

pre-labour CS (PLCS) should be considered

114
Q

What is the mode of delivery when the viral load is ≥400 HIV RNA copies/mL at 36 weeks?

A

pre-labour CS (PLCS) is reccomended

115
Q

How to reduce the risk of vertical transmission in HIV in pregnancy?

A

Antiretroviral Therapy

Delivery by Elective C-Section (if the mother has a high viral load at the time of delivery)
Planned vaginal delivery is possible if the viral load is < 50 copies/mL at 36 weeks’ gestation

Avoidance of breastfeeding

116
Q

What intervention can be done to reduce the risk of vertical transmission in HIV in pregnancy if mother has a high viral load at time of delivery?

A

Delivery by Elective C-Section (if the mother has a high viral load at the time of delivery)
Planned vaginal delivery is possible if the viral load is < 50 copies/mL at 36 weeks’ gestation

117
Q

Should you breastfeed in HIV in pregnancy?

A

NO, breastfeeding should be avoided

118
Q

What should patients with a high or unknown viral load of HIV in pregnancy receive? When should they receive it?

A

Patients with a high or unknown viral load should receive IV Zidovudine if undergoing a planned C-section or presenting with spontaneous rupture of membranes

119
Q

Who should receive IV Zidovudine in pregnancy?

A

Patients with a high or unknown viral load should receive IV Zidovudine if undergoing a planned C-section or presenting with spontaneous rupture of membranes

120
Q

How are infants managed when mother has HIV in pregnancy?

A

Clamp cord as soon as possible after birth
Advise women NOT to breastfeed
All infants should receive zidovudine for the first 4-6 weeks after birth
Infants can only be diagnosed with HIV by PCR carried out at birth, upon discharge, at 6 weeks and 12 weeks

121
Q

What should infants receive postnatally if mother has HIV?

A

All infants should receive zidovudine for the first 4-6 weeks after birth

122
Q

How long should IV Zidovudine be given for after birth if mother has HIV?

A

4-6 weeks

123
Q

When can infants be diagnosed with HIV?

A

Infants can only be diagnosed with HIV by PCR carried out at birth, upon discharge, at 6 weeks and 12 weeks

124
Q

What is used to diagnose infants with HIV?

A

PCR

125
Q

What is hyperemesis gravidarum defined as?

A

Severe nausea and vomiting associated with pregnancy and characterised by dehydration, electrolyte imbalance and more than 5% pre-pregnancy weight loss.

126
Q

Diagnostic criteria for hyperemesis gravidarum

A

dehydration, electrolyte imbalance and more than 5% pre-pregnancy weight loss.

127
Q

What condition can cause hyperemesis gravidarum? Why?

A

molar pregnancies produce extremely high levels of hCG and, hence, are strongly associated with hyperemesis gravidarum

128
Q

RFs for hyperemesis gravidarum

A

Previous hyperemesis gravidarum
Multiple pregnancy
Primiparous

129
Q

Clinical features of hyperemesis gravidarum

A

Nause and vomiting
Dehydration

130
Q

What score is used to calculate severity in hyperemesis gravidarum?

A

PUQE

131
Q

Investigations for hyperemesis gravidarum

A

Bedside
Body Weight
Urine Dipstick (likely to be positive for ketones)

Bloods
U&E (check electrolyte derangement)
Bone Profile
Magnesium
TFTs (high circulating levels of hCG can cause thyrotoxicosis)

Imaging & Other
Ultrasound Scan (can be used to explore possible diagnosis of gestational trophoblastic disease)

132
Q

What can high circulating levels of HCG cause?

A

Thyrotoxicosis

133
Q

Why might you do an US scan in hyperemesis gravidarum?

A

Ultrasound Scan (can be used to explore possible diagnosis of gestational trophoblastic disease)

134
Q

Pharmacological management of hyperemesis gravidarum

A

First-Line: Antihistamines (Cyclizine, Promethazine, Chlorpromazine), Prochlorperazine
Second-Line: Domperidone, Metoclopramide, Ondansetron
Third-Line: IV Hydrocortisone or Oral Prednisolone (if tolerated)

135
Q

1st line pharmacological management for hyperemesis gravidarum

A

First-Line: Antihistamines (Cyclizine, Promethazine, Chlorpromazine), Prochlorperazine

Followed by: Second-Line: Domperidone, Metoclopramide, Ondansetron
Third-Line: IV Hydrocortisone or Oral Prednisolone (if tolerated)

136
Q

2nd line management for hyperemesis gravidarum

A

Second-Line: Domperidone, Metoclopramide, Ondansetron

Preceded by: First-Line: Antihistamines (Cyclizine, Promethazine, Chlorpromazine), Prochlorperazine

Followed by: Third-Line: IV Hydrocortisone or Oral Prednisolone (if tolerated)

137
Q

What should be offered to all patients with hyperemesis gravidarum?

A

IV Fluids (including potassium)
Thiamine Supplementation
Thromboprophylaxis

138
Q

What are patients with hyperemesis gravidarum at risk of?

A

VTE

139
Q

What is Obstetric cholestasis defined as?

A

Liver disorder associated with pregnancy characterised by non-obstructive cholestasis.

140
Q

RFs for obstetric cholestasis

A

Personal or family history of intrahepatic cholestasis of pregnancy
Maternal age
Pre-existing gallstones

141
Q

Risks of Obstetric cholestasis

A

Premature Birth
Stillbirth

142
Q

Clinical features of obstetric cholestasis

A

Pruritus (often affecting the palms and soles of the feet)
Right upper quadrant discomfort
Jaundice
Excoriation marks
Nausea

143
Q

Investigations for obstetric cholestasis

A

Bloods
LFTs
Bile Acids
Clotting Screen

Imaging & Other
Ultrasound Abdomen

144
Q

Medical management of obstetric cholestasis

A

Ursodeoxycholic Acid (reduces itching and improves LFTs)
Chlorphenamine (to reduce itching)
Vitamin K Supplementation (if PT is prolonged)
Topical Emollients

145
Q

How is delivery managed in obstetric cholestasis?

A

IOL at 38-39 weeks

146
Q

Why is IOL offered in obstetric cholestasis?

A

Increased risk of stillburth

147
Q

What should be monitored during obstetric cholestasis?

A

Advise monitoring foetal movements
Weekly LFTs
Twice-Weekly Ultrasound Doppler and CTG until delivery

148
Q

What is large for gestational age defined as?

A

Infants who weight more than 4 kg at birth or are above the 90th centile on measures of growth during pregnancy.

149
Q

Another word for LGA

A

Macrosomia

150
Q

RFS for LGA

A

Maternal diabetes (includes gestational diabetes mellitus)
Previous large for gestational age baby
Obesity
Post-term delivery

151
Q

Complications of LGA

A

Prolonged labour
Perineal tears
Uterine rupture
Instrumental delivery
Neonatal hypoglycaemia
Shoulder dystocia
Postpartum haemorrhage

152
Q

Clinical features for LGA

A

Noted on antenatal assessments of symphysis fundal height and ultrasound scans measuring foetal growth
May be noted at delivery due to failure to progress

153
Q

When may LGA babies be noticed?

A

Noted on antenatal assessments of symphysis fundal height and ultrasound scans measuring foetal growth
May be noted at delivery due to failure to progress

154
Q

Investigations for LGA

A

Ultrasound
Oral Glucose Tolerance Test (screen for gestational diabetes)

155
Q

Management of LGA

A

Management of modifiable risk factors (e.g. good glycaemic control)
May require C-section if labour fails to progress adequately
Offer elective C-section if estimated foetal weight is over 4.5 kg

156
Q

When may you offer ELCS in LGA?

A

Offer elective C-section if estimated foetal weight is over 4.5 kg

157
Q

What may be required if labour fails to progress adequately in LGA?

A

May require C-section if labour fails to progress adequately

158
Q

What is small for gestational age defined as?

A

Defined as below the 10th centile for their gestational age on measures of growth (foetal abdominal circumference and foetal weight).

159
Q

Another name for SGA

A

Microsomia

160
Q

Causes of SGA

A

Constitutionally small (based on genetics and ethnic backgrounds)
Intrauterine Growth Restriction

161
Q

Causes of intrauterine growth restriction

A

Placenta Mediated
Maternal smoking or alcohol use
Anaemia
Malnutrition
Pre-eclampsia
Non-Placenta Mediated
Prenatal infection
Inborn errors of metabolism
Structural abnormalities

162
Q

Placenta mediated causes of IUGR (leads to SGA)

A

Maternal smoking or alcohol use
Anaemia
Malnutrition
Pre-eclampsia

163
Q

Non-placenta mediated causes of IUGR (leads to SGA)

A

Prenatal infection
Inborn errors of metabolism
Structural abnormalities

164
Q

RFs for SGA

A

Maternal Age
Previous SGA
IVF
Obesity
Chronic Disease in the Mother (e.g. hypertension)
Multiple Pregnancy

165
Q

Clinical features of SGA

A

Noted on antenatal assessments of symphysis fundal height and ultrasound scans measuring foetal growth

166
Q

When may SGA be noted?

A

Noted on antenatal assessments of symphysis fundal height and ultrasound scans measuring foetal growth

167
Q

Management of SGA

A

Treatment of modifiable risk factors (e.g. smoking cessation, management of hypertension)
Serial growth scans for high risk pregnancies
May need to consider induction of labour following MDT discussion (i.e. including involvement of the neonatal team)

168
Q

What may need to be carried out in high risk SGA pregnancies?

A

Serial growth scans

169
Q

Risks of SGA pregnancies

A

Stillbirth
Neonatal Hypoglycaemia
Neonatal Hypothermia
Long-Term Complications for Child: Increased risk of cardiovascular disease, type 2 diabetes mellitus and obesity

170
Q

Long term risks for SGA children

A

Increased risk of cardiovascular disease, type 2 diabetes mellitus and obesity

171
Q

What changes in glucose metabolism are seen during pregnancy?

A

Pregnancy is associated with an increase in insulin resistance and glucose tolerance

172
Q

What will happen to patient’s insulin/metformin dose during pregnancy?

A

Insulin resistance increases during the pregnancy, so the patient’s dose of metformin or insulin will need to be up-titrated in the second half of the pregnancy

173
Q

What scans need to be offered in GDM?

A

A foetal anomaly scan should be offered at 19-20 weeks with assessment of cardiac outflow tracts
Serial growth scans (every 2-4 weeks) should be carried out from 28-36 weeks (check for macrosomia and polyhydramnios)

174
Q

What are you looking for on serial growth scans in GDM between 29-36 weeks?

A

macrosomia and polyhydramnios

175
Q

How should delivery be planned in GDM?

A

In the absence of complications, aim to achieve vaginal delivery between 38-39 weeks’ gestation
Patients on insulin should be started on a variable-rate insulin infusion upon the onset of labour (maintaining glucose levels between 4-7 mmol/L)
Insulin requirements should return to pre-pregnancy levels after delivery

176
Q

Management of intrapartum sepsis

A
177
Q

What is CTG done for in intrapartum sepsis?

A

CTG to assess for foetal distress and how urgently the baby needs to be delivered

178
Q

Sources of sepsis in pregnancy

A

UTI / pylonephritis
Chorioamnionitis / endometritis
Mastitis

179
Q

What is the threshold for admission in intrapartum sepsis?

A

Low threshold for admission and IV antibiotics – can deteriorate quickly

180
Q

Management of sepsis follows what protocol

A

sepsis 6

181
Q

Who defines reduced fetal movements?

A

mother

182
Q

What is reduced fetal movements?

A

reduction in the frequency or intensity of foetal movements perceived by the mother.

183
Q

What should patients be advised to do if they have RFM after 28 weeks?

A

they should be advised to lie on their left side and focus on foetal movements for 2 hours - if they do not feel 10 or more discrete movements in 2 hours, they should contact their midwife or maternity unit immediately.

184
Q

After lying on their left side and focusing on fetal movements for 2 hours, how many discrete movements should they have felt?

A

10

if they do not feel 10 or more discrete movements in 2 hours, they should contact their midwife or maternity unit immediately.

185
Q

RFs for RFM

A

Anterior placenta
Alcohol intake
Benzodiazepine use
Obesity
Small for Gestational Age

186
Q

Assessment of RFM in less than 24 weeks gestation

A

Confirm the presence of a foetal heartbeat by auscultation with a Doppler handheld device
If foetal movements have NOT been felt by 24 weeks’ gestation, refer to a specialist foetal medicine centre

187
Q

When should fetal movements have been felt by? What should you do if they haven’t?

A

24 weeks

If foetal movements have NOT been felt by 24 weeks’ gestation, refer to a specialist foetal medicine centre

188
Q

Assessment of RFM in foetus of 24-28 weeks gestation

A

Confirm the presence of a foetal heartbeat by auscultation with a Doppler handheld device

189
Q

Assessment of RFM in foetus more than 28 weeks gestation

A

Confirm the presence of a foetal heartbeat by auscultation with a Doppler handheld device
Once foetal viability is confirmed, arrange CTG
Consider ultrasound scan if perception of reduced foetal movements persists despite a normal CTG or if there are additional risk factors for FGR or stillbirth
Offer induction of labour if recurrent episodes of reduced foetal movement or if foetal movements are reduced at term

190
Q

1st line investigation for foetus of all ages presenting with RFM

A

Confirm the presence of a foetal heartbeat by auscultation with a Doppler handheld device

191
Q

After what gestation is CTG typically used?

A

28 weeks

192
Q

In a foetus more than 28 weeks gestation presenting with RFM, what is used after confirmation of foetal viability with an USS doppler?

A

CTG

193
Q

RFs for VTE in pregnancy

A

Previous VTE
1st degree relative
>35
Parity

194
Q

Investigations for VTE in pregnancy

A

’Walking’ / exertional HR and saturations
ECG
US doppler LL
CTPA (+/- CXR)
MRV

195
Q

How is VTE treated in pregnancy?

A

LMWH throughout pregnancy, at least 3 months post- partum

Haematology follow up 3 months post partum

196
Q

How long should LMWH be carried on for in pregnancy?

A

3 months post partum

197
Q

How can placenta praevia be categorised?

A

Minor (Grade I/II) ‘close to’ os
Major (Grade III/IV) ‘covering’ os

198
Q

What are 50% of APH due to?

A

Praevia

199
Q

What should you NOT do if suspecting praevia?

A

Vaginal exam

200
Q

Grading of placenta praevia

A

I - placenta reaches lower segment but not the internal os
II - placenta reaches internal os but doesn’t cover it
III - placenta covers the internal os before dilation but not when dilated
IV (‘major’) - placenta completely covers the internal os

201
Q

When is placenta praevia often picked up?

A

20 week scan

202
Q

What to do if placenta is ‘low’ on 20 week scan?

A

follow up scan at 32 weeks, and then again at 36 weeks if still low.

203
Q

What to do if placenta is <2cm from os at term?

A

Elective CS

204
Q

Management of fetus if alive and <36 weeks in abruption

A

fetal distress: immediate caesarean
no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation

205
Q

Management of fetus if alive and >36 weeks

A

fetal distress: immediate caesarean
no fetal distress: deliver vaginally

206
Q

Sudden onset constant abdominal pain, with PVB in a pregnant women

A

Placental abruption

207
Q

What is vasa praevia?

A

When the fetal vessels run in membranes below the presenting part

208
Q

What does vasa praecia present with?

A

MASSIVE PPH

209
Q

What happens to reflexes in pre-eclampsia?

A

increased

210
Q
A

Obs (5 decks)

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