Antenatal Problems 3 Flashcards
What are the effects of diabetes on pregnancy?
- Maternal hyperglycaemia leads to fetal hyperglycaemia which is potentially harmful to the fetus = leads to hyperinsulinaemia through beta cell hyperplasia in fetal pancreatic cells
- Insulin in fetus acts as a growth promoter = macrosomia, organomegaly and increased erythropoiesis
- Fetal polyuria = polyhydraminos (esp in poor control)
- High levels of insulin in fetus + removal of glucose supply after birth = neonatal hypoglycaemia
- Early feeding and regular blood glucose monitoring should be performed to minimise the risk of cerebral damage
- Surfactant deficiency occurs through reduced production of pulmonary phospholipids = clinically manifests as respiratory distress syndrome (more common in babies born to diabetic mothers)
What happens to insulin requirements during pregnancy?
Insulin requirements increase throughout pregnancy and are maximal at term
There is progressive insulin resistance because the placenta produces hormones such as cortisol, hCG, progesterone, placental lactogen which are all insulin antagonists - therefore, a higher volume is needed than normal - the requirements rise by 30%
What may be associated with ketoacidosis in those with diabetes in pregnancy? (4)
(Rare)
- Hyperemesis gravidarum
- Infection
- Tocolytic agents eg terbutaline (used to suppress premature labour)
- Steroid therapy
What effect may pregnancy have on retinopathy in those who are pregnant and have diabetes?
- Exacerbation and complication of diabetic retinopathy
- All diabetic women should have retinopathy assessment and proliferative retinopathy requires treatment
- Early changes usually revert after delivery
What effect may pregnancy have on nephropathy in those who are pregnant and have diabetes?
- Renal function and proteinuria may worsen during pregnancy
- This is usually temporary
What effect may pregnancy have on IHD in those who are pregnant and have diabetes?
- Pregnancy increases cardiac workload
- Women who have had a previous MI should avoid pregnancy (50% mortality)
- Women with symptoms should be assessed by a cardiologist before conception
How many times a day should a pregnant woman with gestational diabetes monitor her glucose? What are the target levels?
Pre-prandial (before eating) glucose levels <6
One hour post-prandial (after eating) glucose levels <7.8
Two hours post-prandial glucose levels <6.4
Fasting glucose levels <5.3
What antenatal surveillance may be required for diabetic women?
Serial USS every 2-4 weeks to detect:
- Polyhydraminous
- Macrosomia
- IUGR
Extra-detailed anomaly scan at 18-22 weeks
What presentations in a pregnant woman would make you concerned about potential gestational diabetes?
Recurrent infections
Persistent glycosuria
Large for date foetus with macrosomia or polyhydraminos
What is the method of OGTT? Also, when is it done in pregnancy?
OGTT done in a woman with any risk factors at 24-28 weeks. If they’ve previously had gestational diabetes, do OGTT asap after booking and again at 24-28 weeks if first test was normal
- Overnight fasting - 8hrs minimum, water only and no smoking
- Do fasting blood glucose measurement
- 75g load in 250-300ml water
- Take blood glucose measurement 2 hours later
What are the diagnostic thresholds for gestational diabetes?
Fasting >5.6mmol/L = diabetes diagnosis
2 hour >7.8mmol/L = diabetes diagnosis
What is the management of gestational DM depending on their fasting blood glucose result?
If fasting blood glucose <7 = 2 week trial of diet and exercise
- If this doesn’t work give metformin
- Then short-acting insulin if this doesn’t work
If fasting glucose >7 = give insulin straight away
If fasting glucose 6-6.9 and evidence of macrosomia/polyhydramnios = give insulin straight away
Glibenclamide if cannot tolerate metformin or decline insulin
What risks do women who have had gestational DM pose in the future?
Inc risk of developing T2DM
What is the leading cause of maternal morbidity and mortality in developed countries?
VTE
= Leading cause of direct maternal death
Why is pregnancy a hypercoagable state?
1) Clotting factors increase
2) Decreased fibrinolysis in preparation for labour
3) Venous stasis due to large pelvic mass
4) Immobility
5) Medications e.g. warfarin would have to have been stopped
When is a woman most at risk from a VTE?
First 10 days post natally
Where are clots most commonly formed in pregnancy?
Ileofemoral on L side
Where the left common iliac artery crosses over the iliac vein
What is the medication of choice for antenatal thrombopropylaxis?
LMWH
Who may be offered antenatal thrombopropylaxis?
Previous VTE
Thrombophilia e.g. antiphospholipid syndrome
Family history
Antithrombin III deficiency
Those who experience excessive blood loss or a blood transfusion
Medical comorbidities e.g. HF
Surgeries
What is the management of an intrauterine death?
Labour induced using prostaglandins and / or oxytocin infusion (but do not rush delivery unless maternal health at risk - spontaneous labour can begin within 2 weeks of intrauterine death)
Occasionally CS required if mother is unwell and delivery needs to be earlier
4 weeks after foetal death, there is 1/4 risk of develop coagulopathy so assess platelets and coagulation screens regularly
What can be given to following a stillbirth to suppress lactation?
Cabergoline
What is defined as recurrent pregnancy loss? How common is it?
Recurrent miscarriage = loss of 3+ consecutive pregnancies with the same partner
What can cause recurrent pregnancy loss?
Antiphospholipid syndrome
Chromosomal defects
Anatomical factors e.g. uterine abnormalities, cervical incompetence
What investigations may be performed in cases of recurrent pregnancy loss?
· Blood tests for antiphospholipid antibodies and thrombophilia screen
· Transvaginal ultrasound to identify uterine abnormalities
· Cytogenetic analysis of products of conception - if this is abnormal then the parents should be karyotyped
What is a miscarriage?
The loss of a pregnancy before viability (24 weeks)
When do most spontaneous miscarriages occur?
Before 12 weeks (first trimester)
What is a threatened miscarriage?
Painless vaginal bleeding occurring before 24 weeks (typically weeks 6-9)
Pregnancy continues
Closed cervical os
Uterus size correct for gestational age
What is an inevitable miscarriage?
Bleeding is usually heavier, more painful, with clots
Although the fetus may still be alive, the cervical os is open
Miscarriage is about to occur, nothing can be done to save pregnancy
What is an incomplete miscarriage?
Not all products of conception have been expelled from the uterus by the miscarriage process
Continued painful bleeding
Open cervical os
Some tissues seen on USS
What is a complete miscarriage?
All the foetal tissue has been passed
Bleeding and pain has diminished
Uterus no longer enlarged
Closed cervical os
Endometrial thickness >15mm
Empty uterus on USS
What is a septic miscarriage?
The contents of the uterus are infected causing endometritis
Vaginal loss is offensive and the uterus is tender
A fever can be absent
If pelvic infection occurs there is abdo pain and peritonism
What is a missed miscarriage?
Foetus dies but remains in utero
Entire gestation sac is retained within the uterus
Minimal bleeding
Can have no symptoms
No pain
Closed cervical os
The uterus is smaller than expected for dates
What is the main cause of ‘one off’ or sporadic miscarriages?
Chromosomal abnormalities account for >60%
3 or more usually indicates a rarer cause
When may a non-viable intrauterine pregnancy be managed expectantly? What is the success rate?
No signs of infection
No increased risk of haemorrhage (risks would be if she is late in first trimester or has coagulopathies)
Successful in 2-6wks in >80% women with an incomplete miscarriage
And 30-70% of women with a missed miscarriage
Is a large intact sac associated with a greater or lower success of expectant management of a non-viable intrauterine pregnancy?
Lower
What is the medical management of a miscarriage?
Prostaglandins (800mcg PV misoprostol) to induce uterine contractions to expel remaining POC
Antiemetics + analgesia
Advise to contact doctor if bleeding hasn’t started in 24h
Advise to do urine pregnancy test 3 weeks after
What is the surgical management of a non-viable intrauterine pregnancy?
Vacuum aspiration (suction curettage) under local anaesthetic as an outpatient
Evacuation of retained products of conception is done under GA in theatre
What are the delivery options following a previous CS?
Elective repeat CS (ERCS)
Vaginal birth after CS (VBAC)
When can VBACs safely be carried out?
Singleton pregnancies with cephalic presentation at 37+0 and beyond
What are some contraindications to VBACs?
Absolute
• Classical caesarean scar
• Previous uterine rupture
• Placenta praevia
Relative
• Complex uterine scars
• >2 prior LSCS
What is the strongest predictor of success in VBAC?
Successful previous VBAC
What are the pros and cons of VBAC vs ERCS?
VBAC vs ERCS
Longer recovery after ERCS
Higher risk of uterine rupture in VBAC
Risk of anal sphincter injury in VBAC
Higher risk of maternal death in ERCS
Good chance of successful future VBAC vs Subsequent pregnancies likely to require c-section
Higher risk of neonatal respiratory morbidity in ERCS
Higher risk of hypoxic ischaemic encephalopathy (HIE) in VBAC
Increased risk of placental problems and adhesion formation in ERCS
What is the management of VBAC?
Delivery in hospital with continuous CTG monitoring is recommended
IOL usually avoided as there is an increased chance (x2-3) of uterine rupture when prostaglandins / oxytocin are used
Epidural analgesia is safe but increasing analgesic requirements could indicate impending uterine rupture
How would a uterine rupture present in a VBAC?
How is it managed
Fetal distress Scar pain Cessation of contractions Vaginal bleeding Maternal collapse
Immediate laparotomy and CS indicated
What are direct causes of maternal death?
Causes associated only with pregnancy, delivery and the puerperal period
Eg genital tract sepsis, VTEs
What are indirect causes of maternal death?
Death caused by perviously existing disease that is aggravated by the physiological effects of pregnancy
Eg cardiac disease (leading cause of maternal death), renal disease, non genital tract sepsis
What is ‘late’ maternal death?
42 days after pregnancy up to a year
What are physiological changes to the cardiovascular system during pregnancy?
40% inc in blood volume
40% inc in cardiac output
50% reduction in systemic vascular resistance
- BP usually drops in second trimester but then is usually normal again by term
What murmur may occur in pregnancy?
Inc blood flow produces an ejection systolic murmur in 90% of pregnant women
What ECG changes may be noted in pregnancy?
Left axis deviation and inverted T waves
What is Eisenmenger’s syndrome and what does this mean for pregnancy?
Long standing left to right shunt caused by a congenital cardiac defect causing pulmonary HTN which eventually leads to a left to right shunt
TOP should be considered in women with Eisenmenger’s syndrome
NB cardiac disease usually becomes a problem when pulmonary blood flow cannot be increased to meet the demands of pregnancy (R sided HF)
Is pulmonary HTN a concern in pregnancy?
High maternal mortality = 40%
Pregnancy CI and usually terminated
What is the management of aortic stenosis in pregnancy?
Severe disease causes inability to increase CO when required and should be corrected before pregnancy
Beta blockers often used
Epidural analgesia CI in most severe cases
Thromboprophylaxis required for replacement valves
What is peripartum cardiomyopathy?
Rare cause of heart failure specific to pregnancy
1 / 3,000
What is the management of peripartum cardiomyopathy?
Diuretics
ACEi’s
What are the safest anti-epileptic drugs are safest in pregnancy?
Carbamazepine
Lamotrigine
At what point does fetal production begin, ie when is the fetus no longer dependant on maternal thyroxine?
Week 12
Prior to this it is dependent on maternal thyroxine
What is the management of hypothyroidism in pregnancy?
Replace thyroxine
TSH levels monitored 6 weekly
What is the risk of hyperthyroidism in pregnancy?
Uncontrolled disease (rare) increases risk of perinatal mortality, risk of thyroid storm: - Acute symptoms and HF, usually near delivery
Antithyroid antibdoies can cross the placenta and may cause neonatal thyrotoxicosis and goitre
How is hyperthyroidism managed in pregnancy?
Propylthiouracil (PTU)
Rather than carbimazole - can sometimes cross the placenta and cause neonatal hypothyroidism
What is the pathophysiology behind obstetric cholestasis?
- Increased sensitivity to sex steroid hormones in pregnancy
* Oestrogen causes slowed excretion of bile from the liver through bile ducts so there is overspill into the blood
What pregnancy complications are associated with intrahepatic cholestasis?
Increased of foetal distress or still birth (toxic effects of bile salts precipitating foetal arrhythmia)
Increased risk of preterm delivery
Increased risk of maternal and fetal haemorrhage - give vit K 10mg / day from 36wks
What is the management of intrahepatic cholestasis in pregnancy?
Obstetrician led care and birth in hospital
Weekly monitoring of LFTs until delivery
Ursodeoxycholic acid - is a bile acid but less harmful; would see rise in bile acid acid levels but decrease in ALP
Induction of labour/elective CS between 37 and 38 weeks - aim at reducing stillbirth
What is the management of antiphospholipid syndrome in pregnancy?
- Low-dose aspirin once pregnancy confirmed
* LMWH (enoxaparin) once foetal heart seen on USS then discontinue at 34 weeks
What is the management of bipolar affective disorder in pregnancy?
Lithium frequently used but associated with cardiac abnormalities
Stopped if low risk of relapse but continue if there is a high risk of maternal suicide
Monthly monitoring of lithium levels because of increased renal excretion in pregnancy
What cardiac abnormality is associated with lithium use in pregnancy?
Ebstein’s anomaly - a right ventricular outflow obstruction defect
What is the mainstay of antidepressant medication in pregnancy?
SSRIs eg fluoxetine
Better than TCAs
Avoid paroxetine as it can cause cardiac defects
What is the mainstay of the management of anxiety in pregnancy?
CBT
BDZ can cause facial clefts and neonatal hypotonia
Which antipsychotics are used most during pregnancy?
Olanzapine, risperidone and quetiapine used most
Avoid clozapine
What is the law surrounding FGM?
1) Illegal unless medically indicated
2) Illegal to arrange / assist in the arrangement of FGM for a UK citizen, whether the procedure is happening in UK of overseas
3) Illegal for those with parental responsibility to fail to protect the girl
4) If found in a girl under the age of 18yrs then it must be reported to the police within one month of confirmation
What are the four types of FGM?
1) Partial or total removal of the clitoris and/or prepuce (clitoridectomy)
2) Partial or total removal of the clitoris and the labia minora, +/- excision of the labia majora
3) Infibulation - narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (most severe form)
4) All other harmful procedures to the female genitalia for non-medical purposes, eg pricking, piercing, incising, scraping and cauterisation
What are some short term complications of FGM? (4)
1) Haemorrhage
2) Urinary retention
3) Genital swelling
4) Infection and fever
What are some long term complications of FGM?
1) Genital scarring - can cause chronic pain
2) Urinary tract complications
3) Dyspareunia
4) Psychological - flashbacks, anxiety, PTSD
5) Genital infection and PID
6) Hep B and C, HIV
7) Infertility
8) Obstetric complications
What is the management plan of a pregnant woman who has undergone FGM?
Consultant led care as increased likelihood of complications
However if have had previous uncomplicated vaginal delivery they may be suitable for midwife care
When in pregnancy does obstetric cholestasis usually present?
Third trimester
How does obstetric cholestasis present?
Intense pruritis +/- excoriations - particularly palms and soles of feet and abdomen
Worse at night, interfering with sleep
What are the main diagnostic markers of obstetric cholestasis?
LFTs
- Raised ALP
- Raised bile acids
AST and ALT also raised but not main diagnostic markers
