Antenatal Obstetric Complications Flashcards
1
Q
Why does backache occur in pregnancy?
A
- Hormones induce laxity of spinal ligaments
- Shifting in the centre of gravity as uterus grows
- Additional weight gain
2
Q
What back position is adopted in pregnancy?
A
Lumbar lordosis
3
Q
What advice can you give to someone with backache in pregnancy?
A
Adopt correct posture Avoid lifting heavy objects Avoid high heels Regular physiotherapy Analgesia (paracetamol)
4
Q
Why does pubic symphysis disfunction occur?
A
Pubic symphisis becomes loose to prepare for childbirth, usually in third trimester
5
Q
Why does pubic symphysis disfunction cause pain?
A
Because two halves of pelvis rub together when walking
Extremely painful
6
Q
How do you treat pubic symphysis disfunction
A
Simple analgesia
7
Q
Why does carpal tunnel occur in pregnancy?
A
Due to swelling of soft tissue
CT is a closed compartment
Median nerve is compressed
8
Q
Why does constipation occur in pregnancy?
A
Hormones and mechanical factors slow gut motility
9
Q
How do you treat comstipation in pregnancy?
A
High fibre diet
Lactulose
Avoid medications if possible
10
Q
What is hyperemesis gravidarum?
A
Severe form of nausea and vomiting throughout pregnancy (worse in first trimester) related to excess beta hCG
11
Q
What are dangerous consequences of hyperemesis gravidarum?
A
Electrolyte imbalance Dehydration Poor nutritional intake Physical, psychological debilitation Adverse pregnancy outcomes (PTB, LBW)
12
Q
What can severe hyperemesis gravidarum cause
A
malnutrition
vitamin deficiencies
mallory weiss tee
13
Q
How do you treat hyperemesis gravidarum?
A
IV FLUID REPLACEMENT
thiamine supplementation
Antiemetics
Consider LMWH and PPI
14
Q
What are first line antiemetics in pregnancy=?
A
Antihistamines (cyclising)
Phenothiazines (promethazine)
15
Q
What are second line antiemetics in pregnancy=?
A
Ondasetron, Metoclopramide
16
Q
What method do you use to assess severity of hyperemesis gravidarum?
A
PUQE
Pregnancy Unique Quantification of Emesis
17
Q
what triad is needed to diagnose HE?
A
> 5% pre pregnancy weight loss
Dehydration
Electrolyte imbalance
18
Q
When would you consider admitting a patient with hyperemesis gravidarum?
A
- Continues N&V, cannot keep down oral antiemetics
- Continued N&V + ketonuria + weight loss
- Continued N&V and unable to tolerate oral antibiotics for comorbidity
19
Q
Why does GI reflux occur
A
Weight effect of pregnant uterus
Hormonally induced relaxation of oesophageal sphincter
CAUSE REFLUX
20
Q
How do you treat GI reflux in pregnancy
A
Lifestyle: stop smoking, stop alcohol, avoid spicy foods, avoid large meals before bed, sleep with head propped up
medical: antacids, H2 inhibitors, PPI
21
Q
What is obstetric cholestasis?
A
Unexplained pruritus in pregnancy with abnormal LFTs and elevated bile salts that resolves spontaneously post part
22
Q
Where and when does pruritus occur in OC?
A
Mainly on hands (and feet)
Worse at night
23
Q
What are. RF for OC?
A
Ethnicity (south asian) Multiple pregnancy Nulliparity Prior OC / FH OC Poor Diet
24
Q
What conditions is OC associated with?
A
PET
GDM
25
What are complications of OC?
STILLBIRTH
Preterm birth (spontaneous/limitations)
Meconium passage + aspiration
PPH
26
When do OC symptoms usually onset?
3rd trimester
27
What are OC symptoms?
Pruritus (hands and feet)
ABSENCE of rash
Obstructive symptoms rare (jaundice, dark urine, pale stool)
Loss of appetite, fatigue
28
How do you investigate OC?
LFTs (1x/2x weekly)
Bile acids
Dx of exclusion: consider liver screen or USS biliary tract
29
What is the management for OC?
```
Symptomatic tx: Emollients, antihistamines
Ursodeoxycholic acid (decreases bile acids and improves LFTs, but does not change chance of stillbirth)
Consider delivery at term (37 weeks) with IOL/ELCS
```
30
What do you do to the mother after delivery in OC?
Repeat LFTs after delivery + 6/8 weeks later
| Avoid future COCP (some link between oestrogen and OC)
31
Why do varicose veins occur in pregnancy?
Due to the relaxant effect of progesterone on SM
| And the weight of the pregnant uterus
32
How do you manage varicose veins in pregnancy=
Support stocking, avoid standing for long yimr
33
What causes oedema in pregnancy?
Increased capillary permeability (allows fluid to leak to extravascular compartment)
34
What are fibroid problems during pregnancy?
May enlarge
If cervical, may obstruct vaginal delivery
Red degeneration
35
What is red degeneration?
As the fibroid grows, its blood supply becomes insufficient
| So the fibroid becomes ischaemis
36
What are sx of red degeneration?
Acute pain, tenderness over fibroid, vomiting
37
How do you treat red degeneration of fibroid?
```
Potent analgesic (opiate)
IV fluids
```
Symptoms usually self resolve in few days
38
What is a problem during pregnancy in women with a retroverted uterus?
Normally the retroverted uterus flips out into the pelvis and fills the abdominal cavity
If the uterus remains retroverted, it fills up the entire pelvic cavity
This causes stretching of the bladder and urethra
Can lead to urinary retention >> severe bladder damage
39
What must you do if the patient has a. retroverted uterus and they are experiencing bladder dysfunction?
IMMEDIATELY CATHERERISE
| To prevent long term bladder damage
40
What is a problem with having ovarian cysts during pregnancy?
They can tort, haemorrhage or rupture
This will cause acute abdominal pain and inflammation
Leading to miscarriage /preterm labour
41
How do you handle ovarian cysts in pregnancy?
If asymptomatic, no surgery
If symptomatic try to postpone surgery as much asmpossible (if in late third trimester baby can be delivered if needed)
If gynae emergency, always perform surgery to ensure health of mother
42
Why is VTE more likely in pregnancy?
```
It is a hypercoaguable state
- Increase F 8,9,10, fibrinogen
- Decreased protein C and antithrombin
Weight of gravid uterus puts pressure on IVC, causing venous stasis
Immobility
```
43
What is the first ix to do in suspected DVT?
Compression duplex ultrasound
44
What IX should you do in suspected PE?
ECG, CXR, ABG to exclude dx
| VQ scan /CTPA
45
How accurate are D dimer levels in pregnancy?
NOT AT ALL
| THEY are NORMALLY elevated
46
How do you treat possible VTE?
Start treating before you have confirmation of dx!!!
LMWH / IV unfractionated heparin?
Thrombolysis (once PE confirmed)
Surgical embolectomy
47
What is maintenance treatment for VTE
subcut LMWH for remainder of pregnancy and min 6 weeks post partum
MINIMUM of 3 months treatment in total!
48
When should you stop LMWH if you are giving an epidural/planned delivery?
Stop LMWH 24h prior to epidural
49
How long after epidural catheter is removed / spinal anaesthesia can you restart LMWH?
4h
50
What is smoking associated to in pregnancy?
Reduced placental perfusion
Increased perinatal mortality
SGA babies
Placenta abruption
51
what are functions of the amniotic fluid?
Protect the baby
Allow limb movement
Allow foetal lung expansion and breathing
52
What is oligohydramnios?
Amniotic fluid index <5th centile for gestation
53
What does oligohydramnios feel like on abdomen exam?
Foetal poles are obviious and hard
| Small for date uterus
54
What are causes of oligohyddramnios
INSUFFICIENT PRODUCTIO
- relax agenesis
- multi cystic kidneys
- Urinary tract abnormality/obstruction
- FGR, placental insufficiency
- Maternal drugs (NSAIDS)
LEAKAGE
- PPROM
55
What are risks of oligohydramnios'
pulmonary hypooplasia
| limb deformity
56
What is foetal renal agesesis also called?
Potter syndrome
57
What is polyhydramnios?
Amniotic fluid index >95th centile for gestation
58
How does a polydydramnios present?
Severe abdo distension, discomfort
59
What are causes of polyhydramnios?
Maternal
- Diabetes
- Placental
- Chorioangioma
- AV fistula
Foetal
- multiple gestation
- Neuromusc condition (prevents swallowing)
- Duodenal atrasia /GI problem
60
How do you treat polyhydramnios caused by GDM?
Optimise glycemic control
| This should correct the polyhydramnios as well
61
How can you relieve discomfort in polyhydramnios?
Amniodrainage
62
What must you NEVER offer for footling breech?
Never offer vaginal delivery
| There may be cord prolapse / compression
63
What is the risk of cord prolapse with breech? Compared to cephalic ?
1% risk of cord prolapse
| Double the risk in cephalicn
64
What are maternal and foetal predisposing factors for breevh=?
Maternal: fibroids, congenital uterine abnormality, uterine surgery
Foetal: multiple gestation, premature, placenta previa, oligo/polyhydramnios, foetal neuromuscular condition
65
How does foetal lie/presentation change during gestation?
Breech is quite common early on in gestation as the baby is moving around
By 36 weeks the baby should be cephalic
66
How do you confirm breech in >36 week gestation?
TAUSS
67
What are the three management options for breech?
External cephalic version
Vaginal breech delivery
Elective CS
68
When is external cephalic version done
36 weeks if primip
| 37 weeks if multip
69
What is the risk of death in vaginal breech delivery?
3%
70
When would an elective CS for breech be done?
39 weeks
71
What medications must you administer with external cephalic version?
Tocolytic
| Anti-D
72
Give examples of tocolytics and the mode of administration
Calcium channel blocker e.g. nifedipine
| Beta-2 agonist e.g. Tobutaline, salbutamol SC
73
WHAT IS success rate of external cephalic version and what does it depend on the most?
50% success rate
| Depends on operator experience
74
What are risks of external cephalic version
```
Placental abruption
PROM
Cord accident
Transplacental haemorrhage
foetal bradycardia
```
75
What are contraindications for external cephalic version
```
Foetal abnormality e.g. hydrocephalus
placenta previa
oligo/polyhydramnios
Hx APH
Prior CS/myomectomy s ar
Multiple gesttion
```
76
How do you delivery vaginal breech?
1. Full dilatation and descent of breech occur naturally
2. Buttocks lie in AP diameter, usually delivery spontaneously
3. Legs - if flexed, deliver spontaneously. If extended, need Pinards manoeuvre
4. Deliver shoulders: Loveset's manoeuvre
5. Deliver head: Mauriceau-Smellie-Veit manoeuvre
77
Explain Rhesus Isoimmunisation
Rhesus neg mother conceives baby who has inherited Rhh+ from father
Foetal cells gain access to maternal circulation in suffienct amount to provoke maternal antibody response
This pregnancy is not affected because primary immune response is weak and IgM cannot cross the placenta
In a subsequent pregnancy, Rh+ antibodies cross the placenta (igG) into foetal circulation
This causes haemolysis of the foetus and severe anaemia
78
What must you do in a foetus undergoing haemolusis?
give blood transfusion
| otherwise foetus may die
79
What are potentially sensitising events?
```
Miscarriage
TOP
APH
Invasive prenatal testing (CVS, amniocentesis, cordocentesis)
Delivery
```
80
What do you give to prevent RhD exposure?
IM anti-D Ig
- within 72h from sensitising event (do kleihauer test)
- to all RhD- mothers give routine antenatal prophylaxis
81
Explain routine antenatal prophylaxis with antiD
Either single regimen at 28wks
| Or two dose regimen at 28, 34 weeks
82
What does Kleihauer test do?
Measures the proportion of foetal cells in the maternal sample
Indicates the amount of anti-D required
83
How do you manage giving anti-D depending on trimester?
First trimester (<12wks): 250IU, Kleihauer not necessary (foetal blood volume is small)
Second trimeste(12-20)r: minimum dose of 25IU + Kleihauer (give more if indicated)
Third trimester(>20): min 500IU + Kleihauer
84
How can you tell if foetus is anaemic from scans?
Middle cerebral artery doppler
85
What is the dose of anti D you give at 28 weeks
1500IU
86
What are sensitising events for anti D
- miscarriage / ectopic / termination of pregnancy
- placental abruption, other APH
- invasive prenatal testing (choriovillous sampling, amniocentesis, cordocentesis)
- delivery
