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Year 4 GOSH > Antenatal Problems 3 > Flashcards

Antenatal Problems 3 Flashcards

1
Q

What are the effects of diabetes on pregnancy?

A
  • 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)
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2
Q

What happens to insulin requirements during pregnancy?

A

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%

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3
Q

What may be associated with ketoacidosis in those with diabetes in pregnancy? (4)

A

(Rare)

  • Hyperemesis gravidarum
  • Infection
  • Tocolytic agents eg terbutaline (used to suppress premature labour)
  • Steroid therapy
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4
Q

What effect may pregnancy have on retinopathy in those who are pregnant and have diabetes?

A
  • Exacerbation and complication of diabetic retinopathy
  • All diabetic women should have retinopathy assessment and proliferative retinopathy requires treatment
  • Early changes usually revert after delivery
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5
Q

What effect may pregnancy have on nephropathy in those who are pregnant and have diabetes?

A
  • Renal function and proteinuria may worsen during pregnancy

- This is usually temporary

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6
Q

What effect may pregnancy have on IHD in those who are pregnant and have diabetes?

A
  • 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
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7
Q

How many times a day should a pregnant woman with gestational diabetes monitor her glucose? What are the target levels?

A

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

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8
Q

What antenatal surveillance may be required for diabetic women?

A

Serial USS every 2-4 weeks to detect:

  • Polyhydraminous
  • Macrosomia
  • IUGR

Extra-detailed anomaly scan at 18-22 weeks

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9
Q

What presentations in a pregnant woman would make you concerned about potential gestational diabetes?

A

Recurrent infections
Persistent glycosuria
Large for date foetus with macrosomia or polyhydraminos

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10
Q

What is the method of OGTT? Also, when is it done in pregnancy?

A

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

  1. Overnight fasting - 8hrs minimum, water only and no smoking
  2. Do fasting blood glucose measurement
  3. 75g load in 250-300ml water
  4. Take blood glucose measurement 2 hours later
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11
Q

What are the diagnostic thresholds for gestational diabetes?

A

Fasting >5.6mmol/L = diabetes diagnosis

2 hour >7.8mmol/L = diabetes diagnosis

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12
Q

What is the management of gestational DM depending on their fasting blood glucose result?

A

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

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13
Q

What risks do women who have had gestational DM pose in the future?

A

Inc risk of developing T2DM

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14
Q

What is the leading cause of maternal morbidity and mortality in developed countries?

A

VTE

= Leading cause of direct maternal death

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15
Q

Why is pregnancy a hypercoagable state?

A

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

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16
Q

When is a woman most at risk from a VTE?

A

First 10 days post natally

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17
Q

Where are clots most commonly formed in pregnancy?

A

Ileofemoral on L side

Where the left common iliac artery crosses over the iliac vein

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18
Q

What is the medication of choice for antenatal thrombopropylaxis?

A

LMWH

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19
Q

Who may be offered antenatal thrombopropylaxis?

A

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

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20
Q

What is the management of an intrauterine death?

A

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

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21
Q

What can be given to following a stillbirth to suppress lactation?

A

Cabergoline

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22
Q

What is defined as recurrent pregnancy loss? How common is it?

A

Recurrent miscarriage = loss of 3+ consecutive pregnancies with the same partner

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23
Q

What can cause recurrent pregnancy loss?

A

Antiphospholipid syndrome

Chromosomal defects

Anatomical factors e.g. uterine abnormalities, cervical incompetence

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24
Q

What investigations may be performed in cases of recurrent pregnancy loss?

A

· 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

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25
Q

What is a miscarriage?

A

The loss of a pregnancy before viability (24 weeks)

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26
Q

When do most spontaneous miscarriages occur?

A

Before 12 weeks (first trimester)

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27
Q

What is a threatened miscarriage?

A

Painless vaginal bleeding occurring before 24 weeks (typically weeks 6-9)
Pregnancy continues
Closed cervical os
Uterus size correct for gestational age

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28
Q

What is an inevitable miscarriage?

A

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

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29
Q

What is an incomplete miscarriage?

A

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

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30
Q

What is a complete miscarriage?

A

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

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31
Q

What is a septic miscarriage?

A

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

32
Q

What is a missed miscarriage?

A

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

33
Q

What is the main cause of ‘one off’ or sporadic miscarriages?

A

Chromosomal abnormalities account for >60%

3 or more usually indicates a rarer cause

34
Q

When may a non-viable intrauterine pregnancy be managed expectantly? What is the success rate?

A

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

35
Q

Is a large intact sac associated with a greater or lower success of expectant management of a non-viable intrauterine pregnancy?

A

Lower

36
Q

What is the medical management of a miscarriage?

A

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

37
Q

What is the surgical management of a non-viable intrauterine pregnancy?

A

Vacuum aspiration (suction curettage) under local anaesthetic as an outpatient

Evacuation of retained products of conception is done under GA in theatre

38
Q

What are the delivery options following a previous CS?

A

Elective repeat CS (ERCS)

Vaginal birth after CS (VBAC)

39
Q

When can VBACs safely be carried out?

A

Singleton pregnancies with cephalic presentation at 37+0 and beyond

40
Q

What are some contraindications to VBACs?

A

Absolute
• Classical caesarean scar
• Previous uterine rupture
• Placenta praevia

Relative
• Complex uterine scars
• >2 prior LSCS

41
Q

What is the strongest predictor of success in VBAC?

A

Successful previous VBAC

42
Q

What are the pros and cons of VBAC vs ERCS?

A

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

43
Q

What is the management of VBAC?

A

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

44
Q

How would a uterine rupture present in a VBAC?

How is it managed

A 
Fetal distress
Scar pain
Cessation of contractions
Vaginal bleeding
Maternal collapse

Immediate laparotomy and CS indicated

45
Q

What are direct causes of maternal death?

A

Causes associated only with pregnancy, delivery and the puerperal period

Eg genital tract sepsis, VTEs

46
Q

What are indirect causes of maternal death?

A

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

47
Q

What is ‘late’ maternal death?

A

42 days after pregnancy up to a year

48
Q

What are physiological changes to the cardiovascular system during pregnancy?

A

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

49
Q

What murmur may occur in pregnancy?

A

Inc blood flow produces an ejection systolic murmur in 90% of pregnant women

50
Q

What ECG changes may be noted in pregnancy?

A

Left axis deviation and inverted T waves

51
Q

What is Eisenmenger’s syndrome and what does this mean for pregnancy?

A

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)

52
Q

Is pulmonary HTN a concern in pregnancy?

A

High maternal mortality = 40%

Pregnancy CI and usually terminated

53
Q

What is the management of aortic stenosis in pregnancy?

A

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

54
Q

What is peripartum cardiomyopathy?

A

Rare cause of heart failure specific to pregnancy

1 / 3,000

55
Q

What is the management of peripartum cardiomyopathy?

A

Diuretics

ACEi’s

56
Q

What are the safest anti-epileptic drugs are safest in pregnancy?

A

Carbamazepine

Lamotrigine

57
Q

At what point does fetal production begin, ie when is the fetus no longer dependant on maternal thyroxine?

A

Week 12

Prior to this it is dependent on maternal thyroxine

58
Q

What is the management of hypothyroidism in pregnancy?

A

Replace thyroxine

TSH levels monitored 6 weekly

59
Q

What is the risk of hyperthyroidism in pregnancy?

A 
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

60
Q

How is hyperthyroidism managed in pregnancy?

A

Propylthiouracil (PTU)

Rather than carbimazole - can sometimes cross the placenta and cause neonatal hypothyroidism

61
Q

What is the pathophysiology behind obstetric cholestasis?

A
  • 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

62
Q

What pregnancy complications are associated with intrahepatic cholestasis?

A

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

63
Q

What is the management of intrahepatic cholestasis in pregnancy?

A

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

64
Q

What is the management of antiphospholipid syndrome in pregnancy?

A
  • Low-dose aspirin once pregnancy confirmed

* LMWH (enoxaparin) once foetal heart seen on USS then discontinue at 34 weeks

65
Q

What is the management of bipolar affective disorder in pregnancy?

A

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

66
Q

What cardiac abnormality is associated with lithium use in pregnancy?

A

Ebstein’s anomaly - a right ventricular outflow obstruction defect

67
Q

What is the mainstay of antidepressant medication in pregnancy?

A

SSRIs eg fluoxetine

Better than TCAs

Avoid paroxetine as it can cause cardiac defects

68
Q

What is the mainstay of the management of anxiety in pregnancy?

A

CBT

BDZ can cause facial clefts and neonatal hypotonia

69
Q

Which antipsychotics are used most during pregnancy?

A

Olanzapine, risperidone and quetiapine used most

Avoid clozapine

70
Q

What is the law surrounding FGM?

A

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

71
Q

What are the four types of FGM?

A

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

72
Q

What are some short term complications of FGM? (4)

A

1) Haemorrhage
2) Urinary retention
3) Genital swelling
4) Infection and fever

73
Q

What are some long term complications of FGM?

A

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

74
Q

What is the management plan of a pregnant woman who has undergone FGM?

A

Consultant led care as increased likelihood of complications

However if have had previous uncomplicated vaginal delivery they may be suitable for midwife care

75
Q

When in pregnancy does obstetric cholestasis usually present?

A

Third trimester

76
Q

How does obstetric cholestasis present?

A

Intense pruritis +/- excoriations - particularly palms and soles of feet and abdomen

Worse at night, interfering with sleep

77
Q

What are the main diagnostic markers of obstetric cholestasis?

A

LFTs

  • Raised ALP
  • Raised bile acids

AST and ALT also raised but not main diagnostic markers

Year 4 GOSH (16 decks)

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