Chapter 2 - Complications in pregnancy Flashcards
What recommendations can you give for N/V of pregnancy?
- That it tends to resolve by 16-20w
- It not associated with poor outcomes
- Some women need to be admitted if it is severe (hyperemesis
gravidarum) - Eat small meals
- Increase fluid intake
- Try ginger
- Acupressure
- Anti-emetics (prochlorperazine, promethazine, metoclopramide).
What causes N/V in pregnancy?
- It is believed to be caused by hCG
- It is worse in multiple or molar pregnancies (where hCG is higher)
Advice for GERD in pregnancy
Lifestyle modifi cation (e.g. sleep propped up, avoid spicy food)
Alginate preparations and simple antacids
If severe, H2 receptor antagonists (ranitidine).
Advice for constipation in pregnancy
- Usually improves with gestation
- Caused by progesterone reducing smooth muscle tone and bowel movements
- Made worse by iron supplements
- Increase fruit, fibre and water intake
- Fiber supplements
- Osmotic laxatives (lactulose)
Advice for backache and sciatica
- lifestyle modifi cation (e.g. sleeping positions)
- alternative therapies including relaxation and massage
- physiotherapy input (e.g. back care classes)
- simple analgesia.
What causes carpal tunnel syndrome in pregnancy?
- Due to oedema compressing the median nerve
- Wrist splints may help
Suggest advice for haemorrhoids in pregnancy
- Avoid constipation early in pregnancy
- ice packs and digital reduction
- suppositories and topical relief
- if thrombosed, refer for surgery
Explain the cause of varicose veins in pregnancy and management
- Progesterone relaxes vasculature and the fetal mass effect decreasing venous return
- Regular exercise
- Compression hosiery
- thromboprophylaxis if other risk factors present
Why are urinary symptoms more common in the first T?
- increased glomerular filtration rate and uterus pressing on the bladder
- stress incontinence may occur in the 3rd T due to pressure on the pelvic floor
Management of vaginal discharge
- increases due to increased blood flow to vagina and cervix
- Should be white/clear
- Exclude rupture of membranes
- Exclude STI and candidiasis
- Reassure
Management for a new rash in pregnancy
- full hx and examination to exclude infectious causes and obstetric cholestasis
- emolients and simple anti-itch cream
- reassure - very common and usually resolves after delivery
- referral if severe
Define antepartum haemorrhage
Bleeding from the genital tract in pregnancy at >24 weeks before labour
5 Causes of antepartum haemorrhage
1) unexplained (97%) - possibly minor placental abruptions most bleeding in concealed
2) placenta praevia (1%) may be rapid and severe
3) placental abruption (1%)
4) vasa praevia
5) incidental ectropion
What causes vasa praevia?
Occurs when fetal vessels run in membranes below the presenting fetal part
- May present with PV after rupture of fetal membranes and fetal distress
- Mortality 33-100%
- RF: low lying placenta, multiple pregnancy, IVF and bilobed placentas
Antepartum haemorrhage assessment?
History
- Gestation
- Amount of bleeding
- Initiating factors
- Pain
- Fetal movements
- Date of last smear
- Previous PV bleeds
- Previous uterine surgery
- Smoking/cocaine
- Blood group/resus status
- Previous obs hx
- Position of placenta if known
Examination
- BP, pulse, haemodynamic compromise, uterine palpation (size, tenderness, fetal lie, presenting part)
- **DON’T PERFORM PV UNTIL EXCLUDED PP (placenta praevia)
- Speculum examination after PP excluded - assess for trauma, polyps, ectropian
- Fetal heart beat (if heard = >26wks)
Define placenta praevia
When the placenta is inserted wholly or in part into the lower segment of the uterus
What are the grades of placenta praevia?
Major
- Placenta is over the cervical os
- Cervical dilation would cases a catastrophic bleed
Minor
- Placenta lies in the lower segment close to the os
How do you diagnose PP?
Transvaginal USS is safe and is more accurate than transabdominal
Do women with PP have to be admitted?
Women with major PP who have previously bled should be admitted from 34wks
Asymptomatic major PP women could stay at home if:
- they live close
- if they are aware of the risks
- have constant companion
- have a telephone and transport
- CS is usually needed if the placenta is <2cm from the internal os
Describe the management of a minor AH
If minor and settling and no signs of compromise
1) US for fetal growth/vol amniotic fluid + placenta position
2) Umbilical artery doppler (function of placenta)
3) FBC + Kleihauer testing if RhD -ve to determine extent of haemorrhage and if more anti-D is needed
3) Group and save
4) coag screen (if abruption suspected)
**ALL RhD -ve women reuire 500IU anti-D immunoglobulin unless sensitized. More anti-D may be needed depending on Kleihauer
5) Admit for 24hrs (risk of re-bleed highest)
6) Discharge once stable and bleeding stopped. With increased fetal surveillance
** women with previous APH are at high risk
Describe the Kleihauer Test
Is a blood test from EDTA bottles that can determine the extent of feto-maternal haemorrhage (break in the placenta barrier where fetal blood has entered the maternal blood risking sensitisation of RhD -ve women)
True or False:
Women with APH are at increased risk of PPH
TRUE : they will require additional monitoring
Define placental abruption
Placenta separates partly or completely from uterus before delivery. Blood then accumulates behind the placenta in the uterine cavitity or is lost through the cervix
Give the types of placental abruption
1) Concealed (no external bleeding) <20%
2) Revealed (vaginal bleeding)
What are the presenting features of placental abruption?
Sudden/Constant/Severe Abdominal Pain
- Posterior placenta –> backache
- tender uterus
- uterine activity
- hard uterus (woody)
- 50% occur in labour
- Bleeding is variable
- maternal shock
- fetal distress (proceeds death)
Management of abruption
- Admit all women with vaginal bleeding or unexplained abdo pain
- Fetal CTG
- USS asap
- Access + bloods
- If fetal distress or maternal compromise –> resus + deliver
- If no compromise consider delivery by term
Describe the changes in BP during pregnancy and after delivery
Drops initially due to reduction in vascular resistance
After 24weeks stroke vol increases and BP rises
After delivery BP drops but may peak again 3-4 days post-partum
Describe the correct position to measure BP
Upright
OR
Supine with left sided tilt to avoid IVC compression reducing venous return.
- Arm must be at the level of the heart
- Correct sizing
Beware of high BP in booking - check not chronically hypertensive
Define preganancy induced hypertension
Hypertension >/= 140/90 in the second half of pregnancy in the absence of proteinuria or markers of pre-eclampsia
TRUE or FALSE:
PIH increases risk of pre-eclampsia
TRUE
TRUE or FALSE:
Patients who develop PIH later in pregnancy are at increased risk of developing pre-eclampsia than earlier
FALSE
The risk of developing pre-eclampsia is higher with an earlier onset of hypertension
When should delivery be aimed for in women with PIH?
EDD
“will my high blood pressure continue to be high after pregnancy? will i need to be on long term meds?”
Most womens BP returns to normal within 6 weeks of delivery and treatment is not needed unless undiagnosed high BP before pregnancy.
TRUE or FALSE:
PIH increases risk of pre-eclampsia but chronic hypertension dose not.
FALSE: both increase risk of pre-eclampsia
Why is PIH more common now?
Aging population - chronic hypertension
What factors need to be considered in post-partum hypertension?
Is it physiological, pre-excisting chronic HT, D3-5 common rise or new onset pre-eclampsia
Is methyldopa safe to continue postnatally?
It should be changed to BB due to risk of post-natal depression
- Captopril and Nifedipine are safe to use with breast feeding
- arrange follow up 6weeks (by which case most have resolved)
- if still high investigate secondary causes
Name the 5 safe commonly used anti-hypertensives used in pregnancy
1) Labetalol
2) Methyldopa
3) Nifedipine
4) Hydralazine
5) Atenolol
Are ACE inhibitors safe in pregnancy?
NO, only post partum is captopril safe
When should atenolol and labetalol be avoided?
In patients with asthma
What is the prescription range for labetalol?
100mg BD –> 600mg QDS
How can you manage severe refractory hypertension?
IV labetalol
What is the prescription range for methyldopa?
250mg bd up to 1g tds
What is the prescription range for nifedipine?
10mg BD up to 30mg tds
What is the prescription range for atenolol?
50-100mg od
What are the common side-effects of nifedipine?
Tachycardia, flushing,
headache
What are the common side-effects of hydralazine?
Tachycardia, pounding
heartbeat, headache,
diarrhoea
Which anti-hypertensives are safe for breast-feeding?
labetolol, methyldopa, nifedipine, hydralazine, atenolol and captopril
When should you treat hypertension?
> /= 160/110
Escalate treatment until BP under this. DO NOT AIM below 120/80
TRUE OR FALSE:
Treatment of BP protects women from pre-eclampsia and its complications
FALSE
- Treatment of BP protects women from the adverse effects of high BP, it does not alter the course of pre-eclampsia
Define pre-eclampsia
BP >140/90 and >300mg protienuria in 24hrs
- *If already hypertensive
- BP increase of >30/15**
What is the incidence of pre-eclampsia?
5% of pregnancies
- severe = 1% of pregnancies
What are the increased chances of women with pre-eclamsia in a previous pregnancies suffering in subsequent?
7x increased risk
Which bloods should be included in pre-eclampsia screening?
- LOW Plasma protein-A (PAPP-A)
- HIGH uric acid
- LOW platelets
- HIGH Hb
interest in VEGF, placental growth factor and soluble FM-like tyrosine kinase
How may you differentiate PIH from pre-eclampsia prior to the development of proteinura?
high uric acid, low platelets and high Hb suggest pre-eclampsia over PIH
What is the most predictive test for pre-eclampsia?
RFs + PAPP-A + uterine arteries at 12weeks