Antenatal Obstetric Complications Flashcards
Why does backache occur in pregnancy?
- Hormones induce laxity of spinal ligaments
- Shifting in the centre of gravity as uterus grows
- Additional weight gain
What back position is adopted in pregnancy?
Lumbar lordosis
What advice can you give to someone with backache in pregnancy?
Adopt correct posture Avoid lifting heavy objects Avoid high heels Regular physiotherapy Analgesia (paracetamol)
Why does pubic symphysis disfunction occur?
Pubic symphisis becomes loose to prepare for childbirth, usually in third trimester
Why does pubic symphysis disfunction cause pain?
Because two halves of pelvis rub together when walking
Extremely painful
How do you treat pubic symphysis disfunction
Simple analgesia
Why does carpal tunnel occur in pregnancy?
Due to swelling of soft tissue
CT is a closed compartment
Median nerve is compressed
Why does constipation occur in pregnancy?
Hormones and mechanical factors slow gut motility
How do you treat comstipation in pregnancy?
High fibre diet
Lactulose
Avoid medications if possible
What is hyperemesis gravidarum?
Severe form of nausea and vomiting throughout pregnancy (worse in first trimester) related to excess beta hCG
What are dangerous consequences of hyperemesis gravidarum?
Electrolyte imbalance Dehydration Poor nutritional intake Physical, psychological debilitation Adverse pregnancy outcomes (PTB, LBW)
What can severe hyperemesis gravidarum cause
malnutrition
vitamin deficiencies
mallory weiss tee
How do you treat hyperemesis gravidarum?
IV FLUID REPLACEMENT
thiamine supplementation
Antiemetics
Consider LMWH and PPI
What are first line antiemetics in pregnancy=?
Antihistamines (cyclising)
Phenothiazines (promethazine)
What are second line antiemetics in pregnancy=?
Ondasetron, Metoclopramide
What method do you use to assess severity of hyperemesis gravidarum?
PUQE
Pregnancy Unique Quantification of Emesis
what triad is needed to diagnose HE?
> 5% pre pregnancy weight loss
Dehydration
Electrolyte imbalance
When would you consider admitting a patient with hyperemesis gravidarum?
- 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
Why does GI reflux occur
Weight effect of pregnant uterus
Hormonally induced relaxation of oesophageal sphincter
CAUSE REFLUX
How do you treat GI reflux in pregnancy
Lifestyle: stop smoking, stop alcohol, avoid spicy foods, avoid large meals before bed, sleep with head propped up
medical: antacids, H2 inhibitors, PPI
What is obstetric cholestasis?
Unexplained pruritus in pregnancy with abnormal LFTs and elevated bile salts that resolves spontaneously post part
Where and when does pruritus occur in OC?
Mainly on hands (and feet)
Worse at night
What are. RF for OC?
Ethnicity (south asian) Multiple pregnancy Nulliparity Prior OC / FH OC Poor Diet
What conditions is OC associated with?
PET
GDM
What are complications of OC?
STILLBIRTH
Preterm birth (spontaneous/limitations)
Meconium passage + aspiration
PPH
When do OC symptoms usually onset?
3rd trimester
What are OC symptoms?
Pruritus (hands and feet)
ABSENCE of rash
Obstructive symptoms rare (jaundice, dark urine, pale stool)
Loss of appetite, fatigue
How do you investigate OC?
LFTs (1x/2x weekly)
Bile acids
Dx of exclusion: consider liver screen or USS biliary tract
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
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)
Why do varicose veins occur in pregnancy?
Due to the relaxant effect of progesterone on SM
And the weight of the pregnant uterus
How do you manage varicose veins in pregnancy=
Support stocking, avoid standing for long yimr
What causes oedema in pregnancy?
Increased capillary permeability (allows fluid to leak to extravascular compartment)
What are fibroid problems during pregnancy?
May enlarge
If cervical, may obstruct vaginal delivery
Red degeneration
What is red degeneration?
As the fibroid grows, its blood supply becomes insufficient
So the fibroid becomes ischaemis
What are sx of red degeneration?
Acute pain, tenderness over fibroid, vomiting
How do you treat red degeneration of fibroid?
Potent analgesic (opiate) IV fluids
Symptoms usually self resolve in few days
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»_space; severe bladder damage
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
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
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
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
What is the first ix to do in suspected DVT?
Compression duplex ultrasound
What IX should you do in suspected PE?
ECG, CXR, ABG to exclude dx
VQ scan /CTPA
How accurate are D dimer levels in pregnancy?
NOT AT ALL
THEY are NORMALLY elevated
How do you treat possible VTE?
Start treating before you have confirmation of dx!!!
LMWH / IV unfractionated heparin?
Thrombolysis (once PE confirmed)
Surgical embolectomy
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!
When should you stop LMWH if you are giving an epidural/planned delivery?
Stop LMWH 24h prior to epidural
How long after epidural catheter is removed / spinal anaesthesia can you restart LMWH?
4h
What is smoking associated to in pregnancy?
Reduced placental perfusion
Increased perinatal mortality
SGA babies
Placenta abruption
what are functions of the amniotic fluid?
Protect the baby
Allow limb movement
Allow foetal lung expansion and breathing
What is oligohydramnios?
Amniotic fluid index <5th centile for gestation
What does oligohydramnios feel like on abdomen exam?
Foetal poles are obviious and hard
Small for date uterus
What are causes of oligohyddramnios
INSUFFICIENT PRODUCTIO
- relax agenesis
- multi cystic kidneys
- Urinary tract abnormality/obstruction
- FGR, placental insufficiency
- Maternal drugs (NSAIDS)
LEAKAGE
- PPROM
What are risks of oligohydramnios’
pulmonary hypooplasia
limb deformity
What is foetal renal agesesis also called?
Potter syndrome
What is polyhydramnios?
Amniotic fluid index >95th centile for gestation
How does a polydydramnios present?
Severe abdo distension, discomfort
What are causes of polyhydramnios?
Maternal
- Diabetes
- Placental
- Chorioangioma
- AV fistula
Foetal
- multiple gestation
- Neuromusc condition (prevents swallowing)
- Duodenal atrasia /GI problem
How do you treat polyhydramnios caused by GDM?
Optimise glycemic control
This should correct the polyhydramnios as well
How can you relieve discomfort in polyhydramnios?
Amniodrainage
What must you NEVER offer for footling breech?
Never offer vaginal delivery
There may be cord prolapse / compression
What is the risk of cord prolapse with breech? Compared to cephalic ?
1% risk of cord prolapse
Double the risk in cephalicn
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
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
How do you confirm breech in >36 week gestation?
TAUSS
What are the three management options for breech?
External cephalic version
Vaginal breech delivery
Elective CS
When is external cephalic version done
36 weeks if primip
37 weeks if multip
What is the risk of death in vaginal breech delivery?
3%
When would an elective CS for breech be done?
39 weeks
What medications must you administer with external cephalic version?
Tocolytic
Anti-D
Give examples of tocolytics and the mode of administration
Calcium channel blocker e.g. nifedipine
Beta-2 agonist e.g. Tobutaline, salbutamol SC
WHAT IS success rate of external cephalic version and what does it depend on the most?
50% success rate
Depends on operator experience
What are risks of external cephalic version
Placental abruption PROM Cord accident Transplacental haemorrhage foetal bradycardia
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
How do you delivery vaginal breech?
- Full dilatation and descent of breech occur naturally
- Buttocks lie in AP diameter, usually delivery spontaneously
- Legs - if flexed, deliver spontaneously. If extended, need Pinards manoeuvre
- Deliver shoulders: Loveset’s manoeuvre
- Deliver head: Mauriceau-Smellie-Veit manoeuvre
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
What must you do in a foetus undergoing haemolusis?
give blood transfusion
otherwise foetus may die
What are potentially sensitising events?
Miscarriage TOP APH Invasive prenatal testing (CVS, amniocentesis, cordocentesis) Delivery
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
Explain routine antenatal prophylaxis with antiD
Either single regimen at 28wks
Or two dose regimen at 28, 34 weeks
What does Kleihauer test do?
Measures the proportion of foetal cells in the maternal sample
Indicates the amount of anti-D required
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
How can you tell if foetus is anaemic from scans?
Middle cerebral artery doppler
What is the dose of anti D you give at 28 weeks
1500IU
What are sensitising events for anti D
- miscarriage / ectopic / termination of pregnancy
- placental abruption, other APH
- invasive prenatal testing (choriovillous sampling, amniocentesis, cordocentesis)
- delivery
