Antenatal Problems 1 Flashcards
What are some risk factors for hyperemesis gravidarum?
- Multiple pregnancies
- Molar pregnancies
- First pregnancy
- Hormone administration e.g. infertility treatment
- Raised BMI
Due to higher levels of hCG
What are some signs/symptoms of hyperemesis gravidarum?
Usually 1st trimester
- Nausea and vomiting
- Weight loss
- Excess salivation, ptyalism (inability to swallow saliva)
- Reduced urine output
- Epigastric pain
- Haematemesis (mallory-weirs tears)
What are some maternal and foetal complications of hyperemesis gravidarum?
Maternal
- Liver and renal failure
- Hyponatraemia and rapid reversal of hyponatraemia leading to central pontine myelinosis
- Thiamie deficiency can lead to Wernicke’s encephalopathy
- Can be fatal if untreated
Foetal
- IUGR if mother loses 10%+ of body weight
What is the diagnostic triad of hyperemesis gravidarum?
- More than 5% pre-pregnancy weight loss
- Dehydration
- Electrolyte imbalances
What investigations are done in hyperemesis gravidarum?
- Urinalysis = detect ketones
- MSU to exclude UTI
- FBC = raised haemaocrit
- U&Es to exclude hypokalaemia or hyponatraemia
- LFTs = transaminases may be abnormal and albumin may be low
- US to diagnose multiple pregnancies or a molar pregnancy
DDx of hyperemesis gravidarum? When would you be more suspecting of alternative diagnosis?
Particularly consider if the symptoms start after week 10
- Gastroenteritis
- Cholecystitis
- Hepatitis
- Pancreatitis
- Peptic ulcer
- Pyelonephritis
- Metabolic cause eg diabetic ketoacidosis
- Neurological cause eg migraine
What is the treatment hyperemesis gravidarum?
Admit if not tolerating oral fluids
IV fluids - 0.9% NaCl + KCl as guided by electrolyte monitoring (daily U&Es)
Antiemetics
- 1st line: cyclizine 50mg TDS
- 2nd line: metoclopramide 10mg TDS
If vomiting unresponsive to fluids and antiemetic, consider a trial of corticosteroids:
- Prednisolone 40-50mg PO daily in divided doses
OR
- Hydrocortisone 100mg/12hr IV
IV thiamine if prolonged
Define:
- SGA
- Severe SGA
Small for gestational age = an infant born with a birth weight less than 10th percentile for its gestational age
Severe SGA = birth weight less than 3rd centile
Can either be constitutionally small (not pathological) or IUGR (placenta or non-placenta mediated)
What can cause placental insufficiency?
- Low pregnancy-weight
- Nutritional status
- Substance abuse
- Altitude (lower oxygen = smaller baby)
- Pre-existing disease
- Pregnancy-related disease eg Diabtes/hypertension
- Infections
What are the main antenatal complications of SGA?
Antenatal
- Stillbirth
- Preterm labour
- Low birth weight linked with sudden infant death syndrome
How may SGA present? What would indicate need for referral for USS?
Serial measurements of symphysis fundal height may be reduced or slow down
Refer for USS if:
- Single SFH measurement < 10th centile
- SFH is 2cm less than gestation
- Static growth
What investigation is used to assess growth velocity? What indicates constitutionally small vs IUGR?
USS
Estimated foetal weight is plotted
If baby remains in same growth centile as it grows, suggests it is constitutionally small
If baby drops down centiles indicates IUGR
What are the most reliable foetal measurements between:
8-10 weeks
16-20 weeks
8-10 weeks = crown-rump length
16-20 weeks = biparietal diameter
What is the primary surveillance tool for SGA foetus? What is the management using this?
UAD (uterine artery doppler)
- If normal UAD, growth scans and UAD should be carried out every 2-3 weeks - if UAD remains normal, aim for IOL at 37 weeks
- If high resistance on UAD, review growth scans and UAD weekly - aim to prevent in utero damage associated with placental dysfunction whilst maximising the gestation to avoid prematurity complications
Define:
- LGA
- Macrosomia
LGA = above 90th centile in weight for gestation
Macrosomia = excessive intrauterine growth beyond a specific threshold regardless of gestational age (birth weight > 4000 or 4500g)
What are some causes of LGA?
- Gestational DM (most common)
- Gestational trophoblastic disease
- Constitutional
- Obesity
- Fetal abnormality
- Intrauterine infection
How does gestational DM increase fetal weight?
Mother’s increased blood glucose circulates to the baby which in response produces insulin = fetal pancreatic cell hyperplasia leads to hyperinsulinaemia and fat deposition
What is polyhydramnios?
Increased liquor (increased amniotic fluid)
What must be normal in order for an LGA to be considered constitutional?
- Normal maternal blood glucose
- Normal placenta
- Normal liquor volume
What are some potential complications of LGA?
- Dystocia (obstructed labour) especially shoulder dystocia - brachial plexus injury
- Birth trauma - perineal tearing, blood loss, damage to coccyx
- Hypoglycaemia of baby after delivery
- Left colon syndrome = self-limiting condition where temporary bowel obstruction occurs (mimicks Hirshsprung’s disease)
- Hyperbilirubinaemia
What investigations should be done for LGA?
- Glucose tolerance test - check for gestational DM
- If polyhydraminos is found in the absence of gestational DM, fetal infection may be cause so check IgM and IgG to toxoplasma, rubella, CMV and herpes
- USS
- CTG
- Umbilical artery doppler - not useful unless pre-eclampsia or IUGR develop
What is the management of LGA?
- Position adjustment during birth to reduce need for episiotomy
- Induction of labour if gestational diabetes
What is prolonged pregnancy?
Pregnancy that exceeds >42wks gestation (294 days)
What happens beyond 41 weeks gestation?
- Increased potential for placental insufficiency - higher risk of foetal acidaemia and meconium aspiration in labour
- Neonatal hypoglycaemia - reduced oxygen and nutrient transfer due to placental degradation can deplete foetal glycogen stores
How common is prolonged pregnancy?
Common (3-10%)
Recognised cause of increased morbidity and mortality
What are some risk factors for prolonged pregnancy?
- Nulliparity
- Maternal age > 40
- Previous prolonged pregnancy
- High BMI
- Family history of prolonged pregnancies
What is the main risk of prolonged pregnancy?
The rate of stillbirth rises exponentially after 37/40 gestation
What interventions may be done in prolonged pregnancy?
- Membrane sweeps - offered from 40+0 in nulliparous women and 41+0 in parous women
- Induction of labour - offered between 41+0 and 42+0 weeks - IOL in nulliparous women may fail to establish labour and lead to c section
What investigations should be done in prolonged labour?
Confirm EDD (most accurate is 1st trimester USS between 11+0 and 13+6 weeks)
Assess RF which may be an indicator to induce close to EDD:
- Pre-eclampsia
- DM
- Antepartum haemorrhage
- IUGR associated with placental insufficiency
USS assessment of growth and amniotic fluid volume
What is a cephalhematoma? What are the 2 main causes?
Swelling of an infants scalp as a result of haemorrhaging or collection of blood between infant’s skull, most commonly parietal or occipital bone and periosteum (a tough thin tissue that surrounds the bone)
Causes:
- Assisted delivery - forceps, Ventouse
- Prolonged labour
Goes away weeks-months
Which clotting disorder is most common in young women?
What does it make young women at risk of?
Antiphospholipid syndrome = combination of arterial and venous thrombosis and bleeding
Makes young women at high risk of foetal loss
What is symmetrical IUGR?What is often the cause?
Fetus whose entire body is proportionally small and tensds to be seen with very early onset IUGR
Often due to chromosomal abnormalities
What is asymmetrical IUGR? What is often the cause?
Foetal hypoxia and hypoglycaemia leads to shunting of blood flow to vital foetal organs (brain, heart, adrenal glands) and bypassing other organs (liver, muscle, fat tissue)
= ‘head-sparing effect’ leads to normal head size with small abdo circumference and thin limbs
Often due to placental insufficiency. If it occurs for too long, the fetus loses its ability to sufficiently compensate and head growth too becomes affected
List some placental causes for IUGR (5)
- Abnormal trophoblast invasion eg pre-eclampsia or placenta accrete
- Infarction
- Placenta praevia
- Tumours eg chorioangiomas
- Abnormal umbilical cord or cord insertion eg two vessel cord
How does pre-eclampsia lead to IUGR?
Pre-eclampsia occurs due to poor placental perfusion, secondary to abnormal placentation
Due to impaired trophoblast invasion in the first stage of pregnancy, the remodelling of the spiral arteries is incomplete so they are constricted meaning there is a high resistance to blood flow into the placenta
The mother’s BP increases to ensure the foetus is sufficiently supplied, which leads to leaky blood vessels and microthrombosis
The consequence of vasoconstriction and microthrombosis is chronic hypoperfusion of the placenta, leading to placental insufficiency which ultimately results in IUGR