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OBG: Pregnancy, labour, breast feeding > Common obstetric complications > Flashcards

Common obstetric complications Flashcards

1
Q

What are 4 types of minor complications of pregnancy?

A
  1. Gastrointestinal
  2. Musculoskeletal
  3. Vascular
  4. Genitourinary
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2
Q

What are 9 major complications of pregnancy?

A
  1. Antepartum haemorrhage
  2. Hypertension/ pre-eclampsia/ eclampsia
  3. Multiple pregnancy
  4. Breech presentation
  5. Transverse, oblique and unstable lie
  6. Abdominal pain in pregnancy
  7. Preterm labour
  8. Preterm prelabour rupture of membranes
  9. Prolonged pregnancy
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3
Q

What tends to cause minor symptoms of pregnancy?

A

hormonal, physiological, and increased weight-bearing aspects of pregnancy

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4
Q

When can minor symptoms of pregnancy become a problem?

A

although usually mild and self-limiting, some women may experience severe symptoms which can affect their ability to cope with activities of daily living

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5
Q

What are 3 gastrointestinal minor symptoms of pregnancy?

A
  1. Nausea and vomiting (morning sickness)
  2. Gastro-oesophageal reflux
  3. Constipation
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6
Q

What is the most common symptom complaint in pregnancy?

A

nausea and vomiting

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7
Q

At what period in pregnancy is nausea and vomiting most prevalent?

A

first trimester

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8
Q

What proportion of pregnant women experience 1. nausea and 2. vomiting?

A
  1. 80-85%
  2. 52%
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9
Q

What is believed to cause nausea and vomiting in pregnancy?

A

hormones of pregnancy, especially (alpha)-hCG

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10
Q

What 2 types of pregnancies is nausea and vomiting more common?

A
  1. Multiple pregnancy
  2. Molar pregnancy
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11
Q

When is nausea and vomiting severe enough to warrant hospital admission?

A

hyperemesis gravidarum - persistent and intractable vomiting (inability to keep food or fluid down), weight loss, muscle wasting, dehydration etc.

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12
Q

Is nausea and vomiting associated with poor pregnancy outcome?

A

no not usually

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13
Q

When does nausea and vomiting in pregnancy tend to resolve?

A

16-20 weeks (first trimester is 0-12 weeks)

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14
Q

What are 4 aspects for the management of nausea and vomiting in pregnancy?

A
  1. Lifestyle modification e.g. eat small meals, increase fluid intake
  2. Take ginger
  3. Accupressure
  4. Antiemetics (prochlorperazine, promethizine, metoclopramide)
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15
Q

What are 3 examples of antiemetics which can be used in pregnancy?

A
  1. Prochlorperazine
  2. Promethazine
  3. Metoclopramide
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16
Q

When does gastro-oesophageal reflux occur in pregnancy?

A

Common in all stages of pregnancy:

  1. 1st trimester: 22%
  2. 2nd trimester: 39%
  3. 3rd trimester: 72% - most common
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17
Q

What is the pathophysiology of gastro-oesophageal reflux in pregnancy?

A

progesterone relaxes the oesophageal sphincter allowing gastric reflux, which gradually worsens with increasing intra-abdominal pressure from the growing fetus

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18
Q

What are 3 aspects of the management of gastro-oesophageal reflux in pregnancy?

A
  1. Lifestyle modification (e.g. sleep propped up, avoid spicy food)
  2. Alginate preparations and simple antacids
  3. If severe, H2 receptor antagonists (ranitidine?)
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19
Q

How common is constipation in pregnancy?

A

Common, appears to decrease with gestation

  1. 1st trimester 39%
  2. 2nd trimester 30%
  3. 3rd trimester 20%
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20
Q

What is thought to cause constipation in pregnancy and what makes it worse?

A

Progesterone reduces smooth muscle tone, affecting bowel activity

often made worse by iron supplementation

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21
Q

What are 3 aspects of the management of constipation in pregnancy?

A
  1. Lifestyle modification e.g. increasing fruit, fibre and water intake
  2. Fibre supplements
  3. Osmotic laxatives (lactulose)
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22
Q

What are 3 musculoskeletal minor complications of pregnancy?

A
  1. Symphysis pubis dysfunction (SPD) or pelvic girdle pain
  2. Backache and sciactica
  3. Carpal tunnel syndrome
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23
Q

What is meant by symphysis pubis dysfunction (SPD) or pelvic girdle pain (PGP)?

A

collection of signs and symptoms producing pelvic pain

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24
Q

How severe are SPD / PGP?

A

usually mild but can present with severe and debilitating pain

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25
Q

What is the incidence of SPD/ PGP (symphysis pubis dysfunction/pregancy-related pelvic girdly pain)?

A

up to 10%

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26
Q

What are 4 aspects of the management of SPD/ PGP?

A
  1. Physiotherapy advice and support
  2. Simple analgesia
  3. Limit abduction of legs at delivery
  4. CS not indicated
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27
Q

What is thought to be the cause of backache in pregnancy?

A

hormonal softening of the ligaments exacerbated by altered posture due to the weight of the uterus

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28
Q

What is the estimated prevalence of backache in pregnancy?

A

between 35% and 61%

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29
Q

What is thought to produce sciatica in pregnancy?

A

pressure on the sciatic nerves - may also produce neurological symptoms (as well as backache from hormonal ligament softening and posture from uterus weight)

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30
Q

What are 4 aspects of the management of backache and sciatica in pregnancy?

A
  1. Lifestyle modification e.g. sleeping positions
  2. Alternative therapies including relaxation and massage
  3. Physiotherapy input e.g. back care classes
  4. Simple analgesia
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31
Q

Why is carpal tunnel syndrome common in pregnancy?

A

occurs due to oedema compressing the median nerve in the wrist

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32
Q

When does carpal tunnel syndrome associated with pregnancy usually resolve?

A

spontaneously after delivery

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33
Q

What are 3 aspects of the management of carpal tunnel syndrome in pregnancy?

A
  1. Sleeping with hands over side of bed may help
  2. Wrist splints
  3. If evidence of neurological deficit, surgical referral may be indicated
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34
Q

What are 2 minor vascular problems in pregnancy?

A
  1. Haemorrhoids
  2. Varicose veins
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35
Q

During which part of pregnancy do haemorrhoids tend to occur?

A

third trimester

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36
Q

What is the incidence of haemorrhoids in pregnant women?

A

8-30%

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37
Q

What are 4 aspects of the management of haemorrhoids in pregnancy?

A
  1. Avoid constipation from early pregnancy
  2. Ice packs and digital reduction of prolapsed haemorrhoids
  3. Suppositories and topical agents for symptomatic relief
  4. If thrombosed, may require surgical referral
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38
Q

What is thought to cause varicose veins in pregnancy?

A

progesterone relaxing vasculature and the fetal mass effect decreasing pelvic venous return

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39
Q

What are 3 aspects of the management of varicose veins in pregnancy?

A
  1. Regular exercise
  2. Compression hosiery
  3. Consider thromboprophylaxis if other risk factors are present
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40
Q

What are 2 genitourinary minor symptoms of pregnancy?

A
  1. Urinary symptoms
  2. Vaginla discharge
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41
Q

What are 2 major urinary symptoms which occur commonly in pregnancy and when do they occur?

A
  1. Frequency: 1st semester
  2. Stress incontinence: 3rd trimester
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42
Q

What causes urinary frequency in the first trimester of pregnancy?

A

increased glomerular filtration rate and uterus pressing against the bladder

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43
Q

What causes stress incontinence in the third trimester of pregnancy?

A

pressure on the pelvic floor

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44
Q

What are 2 aspects of the management of urinary symptoms in pregnancy?

A
  1. Screen for UTI (common in pregnancy - nitrite analysis on dipstick)
  2. Avoid caffeine and fluid late at night
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45
Q

What causes increased vaginal discharge in pregnancy?

A

increased blood flow to the vagina and cervix

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46
Q

What should be the normal appearance of vaginal discharge in pregnancy?

A

white/ clear and mucoid

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47
Q

What are 2 types of vaginal discharge in pregnancy that should worry you?

A
  1. Offensive, coloured, itchy: infection
  2. Profuse and watery: ruptured membranes
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48
Q

What are 3 aspects of the management of vaginal disharge in pregnancy?

A
  1. Exclude ruptured membranes
  2. Exclude sexually transmitted infectin (STI) and candidiasis (common in pregnancy)
  3. Reassurance
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49
Q

What are 10 other minor symptoms of pregnancy (excluding GI, MSK, genitourinary, and vascular symptoms)?

A
  1. Itching and rashes
  2. Breast enlargement and pain
  3. Mild breathlessness on exertion
  4. Headaches
  5. Tiredness
  6. Insomnia
  7. Stretch marks
  8. Labile mood
  9. Calf cramps
  10. Braxton Hicks contraction
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50
Q

How common are itching and rashes in pregnancy and how serious are they?

A

Common, usually self-limiting and not serious

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51
Q

What are 4 aspects of management of itching/rashes in pregnancy?

A
  1. Full history and examination to exclude infectious causes e.g. varicella (chicknpox) and obstetric cholestasis
  2. Emollients and simple anti-itch creams OTC
  3. Reassurance - most will resolve after delivery
  4. Referral to dermatologist if severe
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52
Q

How can breast enlargement and tenderness be managed in pregnancy?

A

supportive underwear

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53
Q

What are 2 important things to exclude in mild breathlessness on exertion in pregnancy?

A
  1. Anaemia
  2. PE
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54
Q

What are 2 things to exclude if headaches occur in pregnancy?

A
  1. Pre-eclampsia
  2. Neurological cause (rare)
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55
Q

What are Braxton-Hicks contractions?

A

sporadic contractions and relaxation of uterine muscle - ‘false’ contractions usually in second and third trimesters

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56
Q

What is antepartum haemorrhage (APH) defined as?

A

bleeding from the genital tract in pregnancy at >24 weeks gestation before onset of labour

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57
Q

What are 5 causes of antepartum haemorrhage?

A
  1. Unexplained: usually marginal placental bleeds i.e. minor placental abruptions
  2. Placenta praevia
  3. Placental abruption
  4. Maternal causes: cervical ectropion, local infection of cervix/vagina etc.
  5. Fetal causes: vasa praevia
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58
Q

What are 6 maternal causes of antepartum haemorrhage (APH)?

A
  1. Incidental: cervical erosion/ectropion
  2. Local infection of cervix/ vagina
  3. A ‘show’
  4. Genital tract tumour
  5. Varicosities
  6. Trauma
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59
Q

What type of bleeding is placenta praevia to cause?

A

rapid and severe haemorrhage

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60
Q

What happens to most bleeding from placental abruption?

A

Most bleeding from an abruption is concealed

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61
Q

What is vasa praevia?

A

when fetal vessels run in membranes below the presenting fetal part, unsupported by placental tissue or umbilical cord

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62
Q

What is the incidence of vasa praevia?

A

1:2500 to 1:2700

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63
Q

How may vasa praevia present?

A

PV bleeding after rupture of fetal membranes followed by rapid fetal distress (from exsanguination)

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64
Q

What is the fetal mortality range in vasa praevia?

A

between 33% and 100%

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65
Q

What are 4 risk factors for vasa praevia?

A
  1. Low-lying placenta
  2. Multiple pregnancy
  3. IVF pregnancy
  4. Bilobed and especially succenturiate lobed placentas (accessory placental lobes develop in membranes apaprt from the main placental body, connected by vessels of fetal origin)
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66
Q

What are the 3 steps of assessment in APH?

A
  1. Initial assessment - rapid assessment of maternal and fetal condition to assess if emergency
  2. Maternal assessment
  3. Fetal assessment
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67
Q

What are 13 features of the history that should be performed as an initial assessment in APH?

A
  1. Gestational age
  2. Amount of bleeding (but don’t forget concealed abruption)
  3. Associated or initiating factors (coitus/ trauma)
  4. Abdominal pain
  5. Fetal movements
  6. Date of last smear
  7. Previous episodes of PV bleeding in this pregnancy
  8. Leakage of fluid PV
  9. Previous uterine surgery (including CS)
  10. Smoking and use of illegal drugs (especially cocaine)
  11. Blood group and rhesus status (will she need anti-D)
  12. Previous obstetric history (placental abruption/ FGR/ plcaenta praevia)
  13. Position of placenta, if known from previous scan
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68
Q

What are 6 things that the maternal assessment in APH should include?

A
  1. BP
  2. Pulse
  3. Other signs of haemodynamic compromise e.g. peripheral vasoconstriction or central cyanosis
  4. Uterine palpation for size, tenderness, fetal lie, presenting part (if it is engaged, it is not a placenta praevia)
  5. Speculum exam after placenta praevia excluded
  6. Digital examination
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69
Q

Why should you never immediately perform a vaginal examination in the presence of PV bleeding?

A

must first exclude placenta praevia (no PV until no PP)

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70
Q

Why is a speculum examination performed in women with APH once placenta praevia has been excluded?

A

to assess degree of bleeding and possible local causes of bleeding e.g. trauma, polyps, ectropion and to determine if membranes are ruptured

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71
Q

What is the purpose of a digital examination in a woman with APH?

A

ascertains cervical changes indicative of labour

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72
Q

What are 3 things to do as part of the fetal assessment in APH?

A
  1. Establish whether a fetal heart can be heard
  2. Ensure that it is fetal and not maternal (remember mother may be very tachycardic)
  3. If fetal heart heard and gestation estimated at 26wks, FHR monitoring should be commenced
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73
Q

What is the definition of placenta praevia (PP)?

A

when the placenta is inserted, wholly or in part, into the lower segment of the uterus

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74
Q

What are the 2 grades of placenta praevia?

A
  1. Major (grade III or IV)
  2. Minor (grade I or II)
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75
Q

What is meant by major placenta praevia (type III or IV)?

A

placenta lies over the cervical os

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76
Q

What is meant by minor placenta praevia (grade I or II)?

A

placenta lies in the lower segment, close to or encroaching on the cervical os

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77
Q

What are the key risks associated with placenta praevia?

A

cervical effacement (thinning in labour) and dilatation would result in catastrophic bleeding and potential maternal and therefore fetal death

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78
Q

What proportion of pregnancies are affected by placenta praevia?

A

0.5% pregnancies at term

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79
Q

How is a diagnosis of placenta praevia made?

A

transvaginal USS - safe, and more accurate than transabdominal ultrasound in locating placenta

80
Q

What are 2 ways to manage placenta praevia?

A
  1. Women with major PP who have previously bled should be admitted from 34 weeks gestation
  2. Women with asymptomatic major PP may remain at home if they are close to hospital, aware of risks, constant companion, telecommunication and transport
81
Q

Which women with major placenta praevia should be admitted?

A

women who have previously bled should be admitted from 34 weeks gestation

82
Q

What are 4 conditions that must be met for women with major PP to remain at home?

A
  1. Close to the hospital
  2. Are fully aware of the risks to themselves and their baby
  3. Have a constant companion
  4. Have telecommunication and transport
83
Q

What kind of delivery is typically used in placenta praevia?

A

likely to be by CS if placental edge is <2cm from the internal os, especially if it is posterior or thick

84
Q

What is considered limited antepartum haemorrhage?

A

if bleeding was minor, is settling, and there are no signs of compromise

85
Q

What are 2 types of investigations to perform in limited antepartum haemorrhage?

A

Maternal and fetal investigations

86
Q

What are 4 types of maternal investigations to perform in limited APH?

A
  1. FBC
  2. Kleihauer testing if women known to be RhD -ve, to determine extent of feta-maternal haemorrhage and if more anti-D required
  3. Group and save serum
  4. Coagulation screen may be useful in cases of suspected abruption
87
Q

What is Kleihauer testing?

A

test to confirm transplacental blood loss from fetus to mother; test performed on mother’s blood

88
Q

What are 6 aspects of the fetal management in cases of limited antepartum haemorrhage?

A
  1. Ultrasound to establish fetal wellbeing (growth/volume of amniotic fluid) and to confirm placental location
  2. Umbilical artery Doppler measurement (function of placenta may be compromised by small abruptions
  3. Ongoing antenatal management
  4. Most units admit women who have had an APH for 24hours, as risk of further bleeding is estimated to be greatest during that time
  5. If bleeding settles and mother is discharged, a clear plan for the remaining pregnancy
  6. May need to increase surveillance after due date
89
Q

Why are women who have had APH often admitted for 24 hours?

A

as risk of further bleeding estimated ot be greatest during that time

90
Q

What must be done in every woman who has had APH and why?

A

increase surveillance of mother and fetus as they are all high risk; increased risk of bleeding at delivery (PPH)

91
Q

What is the definition of placental abruption?

A

placenta separates partly or completely from uterus before delivery of fetus. blood accumulates behind placenta in uterine cavity or is lost through cervix

92
Q

What are the 2 types of placental abruption?

A
  1. Concealed: on external bleeding evident (<20%)
  2. Revealed: vaginal bleeding
93
Q

What are 9 symptoms and signs at presentation of placental abruption?

A
  1. Usually present with abdominal pain- usually sudden onset, constant, and severe
  2. Posterior placentas may give rise to severe backache
  3. Tender uterus on palpation
  4. Uterine activity common
  5. Uterus may later become hard (‘woody’)
  6. Many will be in labour (up to 50% on presentation)
  7. Bleeding variable, often dark
  8. Maternal shock
  9. Fetal distress (precedes fetal death)
94
Q

What is important to remember about blood loss in placental abruption?

A

extent of maternal haemorrhage may be much greater than apparent vaginal loss

95
Q

How common is placental abruption?

A

0.5-1.0% of pregnancies

96
Q

How is a diagnosis of placental abruption made?

A

clinically; ultrasound used to confirm fetal wellbeing and exclude placenta praevia

97
Q

What are 6 aspects of the management of placental abruption?

A
  1. Admit all women with vaginal bleeding or unexplained abdominal pain
  2. Establish immediate fetal wellbeing with CTG
  3. Arrange USS as soon as possible
  4. Access and bloods
  5. If fetal distress or maternal compromise, resuscitate and deliver
  6. If no fetal distress, and bleeding and pain cease, consider delivery by term
98
Q

What is the definition of pregnancy-induced hypertension?

A

Hypertension (>140/90) in second half of pregnancy, in the absence of proteinuria or other markers of pre-eclampsia

99
Q

What proportion of pregnancies are affected by pregnancy-induced hypertension?

100
Q

What is the key risk of pregnancy-induced hypertension?

A
  • Increased risk of going on to develop pre-eclampia
  • Risk increases with earlier onset of hypertension
101
Q

When should delivery be aimed for in pregnancy-induced hypertension?

A

at time of EDD

102
Q

When does pregnancy-induced hypertension resolve?

A

BP usually returns to pre-pregnancy limits within 6 weeks of delivery

103
Q

What BP is considered high for a booking BP and therefore likely to be chronic hypertension?

A

130-140/80-90

104
Q

What is the risk of chronic hypertension in a pregnant woman?

A

increased risk of developing pre-eclampsia

105
Q

When should delivery be planned for in chronic hypertension?

A

around time of EDD

106
Q

What is the recent trend in chronic hypertension in pregnancy and why?

A

Now more common because of an older pregnant population

107
Q

What should be done if blood pressure is very high at the booking appointment for pregnancy?

A

important to exclude secondary cause, rather than attributing to essential hypertension

108
Q

What is post-partum hypertension?

A

new hypertension arising in the post-partum period

109
Q

What are 3 possible causes for post-partum hypertesnion?

A
  1. Physiological
  2. Pre-existing chronic hypertension
  3. New-onset pre-eclampsia
110
Q

When does blood pressure normally peak in the post-partum period?

A

peaks on 3rd-5th day postpartum

111
Q

What are 3 features of post-partum hypertension suggestive of post-partum pre-eclampsia?

A
  1. Epigastric pain
  2. Visual disturbance
  3. New-onset proteinuria
112
Q

What are 6 antihypertensive medications that can be used to treat antenatal and/or postnatal hypertension of the mother?

A
  1. Labetalol
  2. Methyldopa
  3. Nifedipine
  4. Hydralazine
  5. Atenolol
  6. ACE inhibitors
113
Q

Which types of antihypertensive medication can only be used postpartum as it is fetotoxic?

A

ACE inhibitors

114
Q

What is the dose of labetalol used to treat antenatal or postnatal hypertension?

A

100mg bd up to 600mg qds; IV infusion for severe fractory hypertension

115
Q

What is the dose of methyldopa used to treat antenatal or postnatal hypertension?

A

250mg bd up to 1g tds

116
Q

What is the dose of nifedipine used to treat antenatal or postnatal hypertension?

A

10mg bd up to 30mg tds

117
Q

What is the dose of hyrdalazine used to treat antenatal or postnatal hypertension?

A

25mg tds up to 75mg qds

118
Q

What is the dose of atenolol used to treat antenatal or postnatal hypertension?

A

50-100mg od

119
Q

What condition should labetalol and atenolol not be used in when treating antenatal/postnatal hypertension?

120
Q

What is a side effect of methyldopa when treating antenatal/postnatal hypertension and what should be done?

A

depression - change postnatally

121
Q

What are 3 side effects of nifedipine when treating antenatal or postnatal hypertension?

A
  1. tachycardia
  2. flushing
  3. headache
122
Q

What are 4 side effects of hydralazine which can be used to treat antenatal or postnatal hypertension?

A
  1. tachycardia
  2. pounding heartbeat
  3. headache
  4. diarrhoea
123
Q

What type of ACE inhibitor can be used if the mother is breastfeeding when treating antenatal/ postnatal hypertension?

124
Q

What 3 types of drugs are best to use in the postnatal management of hypertension?

A
  1. change methyldopa to a beta blocker (if no asthma)
  2. captopril
  3. nifedipine
125
Q

What should be done for women on medication for hypertension postnatally? 3 things

A
  1. GP can follow up BP in community and titrate medication
  2. Offer postnatal follow-up appointment 6 weeks postnatally
  3. Usually resolves by 6 weeks; if still raised, look for secondary causes of hypertension
126
Q

At what level is treatment of blood pressure urgently required for maternal safety, in pregnancy-induced/chronic hypertension?

127
Q

What blood pressure should be aime for when urgently treating hypertension in pregnancy >160/100?

A

shouldn’t get below 120/80

128
Q

How does treatment of hypertension in pregnancy affect the risks associated with it?

A

protects women from adverse effects of blood pressure but doesn’t alter the course of pre-eclampsia

129
Q

What is the definition of pre-eclampsia?

A
  • BP > 140/90 and >300mg proteinuria in a 24hr collection
  • If already hypertensive, rise in systolic BP>30mmHg or diatolic >15mmHg
  • May be other cluse such as abnormal biochemistry or FGR
130
Q

What is the incidence of pre-eclampsia?

A
  • 5% of pregnancies, usually in mild form
  • severe pre-eclampsia affects up to 1% of pregnancies
131
Q

What are 10 risk-factors for pre-eclampsia?

A
  1. Previous severe/ early-onset pre-eclampsia x7
  2. Age >40 or teenager
  3. Family history (mother or sister) x4
  4. Obesity (BMI>30)
  5. Primiparity
  6. Multiple pregnancy x5
  7. Long birth interval (>10 years) x2-3
  8. Fetal hydrops
  9. Hydatidiform mole
  10. Pre-existing medical conditions e.g. HTN, renal disease, diabetes
132
Q

What are 6 pre-existing maternal medical conditions that increase the risk of pre-eclampsia?

A
  1. Hypertension
  2. Renal disease
  3. Diabetes
  4. Anti-phospholipid antibodies
  5. Thrombophilias
  6. Connective tissue disease
133
Q

What are 3 types of blood tests which can inform about the risk of a woman of developing pre-eclampsia?

A
  1. Low pregnancy-associated plasma protein-A (PPAP-A) - increased risk
  2. Raised uric acid, low platelets, high Hb - can help differentiate pre-eclampsia from PIH before proteinuria occurs
  3. VEGF and PIGF (placental growth factor) low before PE develops and soluble FM-like tyrosine kinase 1 (sFlt-1) high before PE develops
134
Q

What are 2 investigations to help determine risk of pre-eclampsia?

A
  1. blood tests - PAPP-A, uric acid, platelets, Hb
  2. Ultrasound: uterine artery Dopplers 11-13 or 22-24 weeks - predictive of early-onset or severe pre-eclampsia
135
Q

What ultrasound should be performed to determine risk of developing pre-eclampsia and when?

A

Uterine artery doppler ultrasound at 11-13 or 22-24 weeks - predictive of early-onset or severe pre-eclampsia

136
Q

What is the most effective way to test for risk of pre-eclampsia overall?

A

Integrated testing: combination of independent risk factors such as history, PAPP-A, and uterine arteries at 12 weeks

137
Q

What treatment for prevention of pre-eclampsia should be given in women who have had severe early-onset pre-eclampsia previously?

A

low dose aspirin 75mg PO od before 16 weeks in the next pregnancy - may reduce incidence of repeat by 20%

138
Q

What are 3 secondary causes of hypertension in pregnant women?

A
  1. Renal disease
  2. Cardiac disease e.g. coarctation of the aorta
  3. Endocrine causes e.g. Cushing’s syndrome, Conn’s syndrome, phaeochromocytoma
139
Q

What are 3 things that women with chronic hypertension are at risk of?

A
  1. Superimposed pre-eclampsia
  2. Fetal growth restriction
  3. Placental abruption
140
Q

What are 5 symptoms of pre-eclampsia?

A
  1. Headache (especially frontal)
  2. Visual disturbance e.g. flashing lights
  3. Epigastric or right upper quadrant pain
  4. Nausea and vomiting
  5. Rapid oedema (especially face - non-dependent oedema)
141
Q

How common is the presence of symptoms in pre-eclampsia?

A

most women are asymptomatic; symptoms usually only occur with severe disease

142
Q

What are 8 signs of pre-eclampsia on examination?

A
  1. Hypertension (>140/90; severe if > 160/110
  2. Proteinuria (>300mg in 24h)
  3. Facial oedema
  4. Epigastric/ RUQ tenderness - liver involvement + capsule distension
  5. Confusion
  6. Hyperreflexia and/or clonus (>3 beats) - cerebral irritability
  7. Uterine tenderness or vaginal bleeding from placental abruption
  8. Fetal growth restriction on US, particularly if <36weeks
143
Q

What are the BP and proteinuria parameters for pre-eclampsia and severe pre-eclampsia?

A

>140/90 BP and >300mg in 24h proteinuria

>160/110 if severe

144
Q

What is the presence of hyperreflexia or clonus in suspected pre-eclampsia indicative of?

A

cerebral irritability

145
Q

What is epigastric or right upper quadrant tenderness in suspected pre-eclampsia indicative of?

A

liver involvement and capsule distension

146
Q

What are 3 findings will be present on the FBC in pre-eclampsia?

A
  1. Relative high Hb due to haemoconcentration
  2. Thrombocytopenia
  3. Anaemia if haemolysis (HELLP syndrome)
147
Q

What are 2 findings on coagulation profile blood tests in pre-eclampsia?

A
  1. Mildly prolonged prothrombin time (PT)
  2. Mildly prolonged activated partial thromboplastin time (APTT)
148
Q

What are 5 findings on biochemistry in pre-eclampsia blood tests?

A
  1. Increased urate
  2. Increased urea and creatinine
  3. Abnormal LFTs (increased transaminases)
  4. Increased lactate dehydrogenase (LDH - marker for haemolysis)
  5. Increased proteinuria (>300mg protein/24h)
149
Q

Overall what are 5 important investigations to perform in suspected pre-eclampsia?

A
  1. FBC
  2. Coagulation profile
  3. U+Es
  4. LFTs
  5. Protein in urine over 24h
150
Q

What is the only cure for pre-eclampsia?

A

delivery of placenta (thought to originate here)

151
Q

What are 6 severe complications of pre-eclampsia?

A
  1. Eclampsia
  2. HELLP
  3. Cerebral haemorrhage
  4. FGR and fetal compromise
  5. Renal failure
  6. Placental abruption
152
Q

What are 3 situations when outpatient management of pre-eclampsia is appropriate?

A
  1. BP <160 systolic and <110 diastolic and can be controlled
  2. no or low (<1+ / <300mg /24h) proteinuria
  3. Asymptomatic
153
Q

What are 3 aspects of management of pre-eclampsia if is being managed as an outpatient?

A
  1. Warn about development of symptoms
  2. 1-2 per week review of BP and urine
  3. Weekly review of blood biochemistry
154
Q

what defines mild-moderate pre-eclampsia?

A

BP <160 systolic and <110 diastolic with significant proteinuria and no maternal complications

155
Q

When is admission advised in pre-eclampsia?

A

once significant proteinuria occurs

156
Q

What are 7 aspects of the management of mild-moderate pre-eclampsia once significant proteinuria occurs?

A
  1. Admit
  2. 4-hourly BP
  3. 24h urine collection for protein
  4. Daily urinalysis
  5. Daily fetal assessment with CTG
  6. Regular blood tests (every 2-3 days unless symptoms or signs worsen)
  7. Regular USS assessment (fortnightly growth and twice weekly Doppler/liqour volume depending on severity of pre-eclampsia)
157
Q

What are 3 key tests that define mild-moderate pre-eclampsia?

A
  1. ≥2+ protein on urine dipstick
  2. >300mg proteinuria/24h
  3. split protein:creatinine ratio - useful screening test for proteinuria - check with your lab for their normal values but in general >30 equates to >300mg proteinuria/24h
158
Q

What is the aim of medication when treating pre-eclampsia?

A

does not cure it but aims to prevent hypertensive complications of pre-eclampsia

159
Q

At what point should antihypertensive therapy be started in pre-eclampsia?

A

if BP increases to >160 systolic or >110 diastolic

160
Q

What is the definition of severe pre-eclampsia?

A

Occurrence of BP >160 systolic or >110 diastolic in presence of significant proteinuria (≥1g / 24 hr or ≥2+ on dipstick) or if maternal complications occur

161
Q

Who is involved in the management of a woman with severe pre-eclampsia?

A

senior obstetric, anaesthetic, midwifery staff

162
Q

What is the management of severe pre-eclampsia?

A

only treatment is delivery but can sometimes be delayed with intensive monitoring if <34 weeks

163
Q

What often happens to pre-eclampsia immediately after delivery?

A

often worsens for 24 hours after delivery

164
Q

What are 5 indications for immediate delivery in pre-eclampsia?

A
  1. Worsening thrombocytopenia or coagulopathy
  2. Worsening liver or renal function
  3. Severe maternal symptoms, especially epigastric pain with abnormal LFTs
  4. HELLP syndrome or eclampsia
  5. Fetal reasons such as abnormal CTG or reversed umbilical artery end diastolic flow (REDF)
165
Q

What is the management of blood pressure in severe pre-eclamspsia?

A
  • aim for <160 / <110
  • initially use PO nifedipine 10mg: can be given twice 30min apart
  • if still high after 2-3 nifedipine doses:
    • start IV labetalol infusion
    • increase infusion rate until BP adequately controlled
  • start maintenance therapy, usually labetalol, methyldopa if asthmatic
166
Q

What are 4 monitoring aspects of management of severe pre-eclampsia?

A
  1. take bloods for FBC, U+Es, electrolytes, LFTs, clotting profile
  2. Strict fluid balance chart; consider catheter
  3. CTG monitoring of fetus until stable
  4. Ultrasound of fetus:
    • evidence of FGR, estimate weight if severely preterm
    • assess condition using fetal and umbilical artery Doppler
167
Q

What should be done if gestation is <34weeks in severe pre-eclamspsia?

A

steroids should be given and pregnancy be managed expectantly unless maternal or fetal condition worsens

168
Q

What is HELLP syndrome?

A

Haemolysis, Elevated Liver enzymes, Low Platelets - considered variant of severe pre-eclampsia

169
Q

What is the definition of eclampsia?

A

occurrence of a tonic-clonic seizure in association with a diagnosis of pre-eclampsia

170
Q

What proportion of pre-eclamptic pregnancies are complicated with eclampsia?

171
Q

How might eclamspia present in terms of sequence of symptoms?

A

could be the initial presentation of pre-eclampsia, and may occur before hypertension or proteinuria

172
Q

What is the management of eclampsia based on?

A

obstetric emergency; every hospital in UK should have eclampsia protocol and eclamspai box with all the drugs for treatment

173
Q

What do most women who die with pre-eclampsia or eclampsia die from? 3 things

A
  1. Blood loss
  2. Intracranial haemorrhage
  3. HELLP
174
Q

What is HELLP syndrome considered to be in relation to pre-eclampsia?

A

regarded as variant of severe pre-eclampsia which manifests with haemolysis, elevated liver enzymes, and low platelets

175
Q

What proportion of pre-eclamptic pregnancies are believed to be affected by HELLP?

176
Q

What is 1. maternal mortality and 2. perinatal mortality in HELLP syndrome?

177
Q

What is the usual course of HELLP syndrome?

A

usually self-limiting, but permanent liver or renal damage may occur

178
Q

What are 3 symptoms of HELLP syndrome?

A
  1. Epigastric or RUQ pain
  2. Nausea and vomiting
  3. Urine is ‘tea coloured’ due to haemolysis
179
Q

What are 2 signs of HELLP syndrome?

A
  1. Tenderness in RUQ
  2. Raised BP and other features of pre-eclampsia
180
Q

What may co-exist with HELLP syndrome?

181
Q

What are 4 aspects of the management of HELLP syndrome?

A
  1. Delivery
  2. supportive treatment
  3. Magnesium sulfate indicated
  4. Although platelet levels may be very low, platelet infusions only required if bleeding, or for surgery and <40
182
Q

What are 2 indications for platelet infusion in HELLP syndrome?

A
  1. Bleeding
  2. Surgery and <40
183
Q

What symptom should you be particularly wary of in pregnancy and what are 3 things you should do to investigate?

A

Epigastric pain

  1. Check blood pressure
  2. Urine
  3. Liver enzymes
184
Q

What is always the first step if a patient has eclampsia (tonic clonic seizure)?

A

call for help - obstetric specialist registrar, SHO, and consultant, anaesthetic SpR and consultant, delivery suite coordinator

185
Q

What is the usual course of most eclamptic fits?

A

short-lasting and terminate spontaneously

186
Q

What are 6 aspects of the management of eclampsia?

A
  1. ABC and IV access
  2. Loading dose of 4g MgSO4 should be given over 5-10 min followed by infusion of 1g/hour for 24 hours
  3. If further fits occur, further 2g MgSO4 can be given as bolus
  4. In repeated seizures use diazepam
  5. if still fitting, patient my need intubation and ventilation and imaging of the head to rule out a cerebral haemorrhage
  6. Deliver fetus once mother is stable
187
Q

Why is magnesium sulfate used in eclampsia?

A

control of fits and preventing further seizures

188
Q

What are 7 aspects of monitoring in a patient with eclampsia?

A
  1. Pulse - every 15min
  2. BP - every 15min
  3. Respiration rate - every 15min
  4. Oxygen saturations every 15min
  5. Urometer and hourly urine
  6. Assessment of reflexes every hour for Mg toxicity (usually knee reflexes but biceps if epidural in situ)
  7. Fetus continuously monitored with CTG
189
Q

What are 4 things that characterise magnesium toxicity?

A
  1. Confusion
  2. Loss of reflexes
  3. Respiratory depression
  4. Hypotension
190
Q

What should you do when treating eclampsia if the patient is oliguric or has raised creatinine?

A

halve/ stop infusion of MgSO4 and seek senior/ renal advice

191
Q

What is the management of magnesium toxicity when treating eclampsia?

A

give 1g calcium gluconate over 10min

192
Q

What is the management if a patient is hypertensive (BP >160/110) and eclamptic (but already being treated for fit)?

A

BP lowering drugs

  • oral nifedipine
  • IV labetalol (avoid in asthmatics)
193
Q

What complication is there a risk of in eclampsia and how should it be managed?

A

pulmonary oedema - fluid restriction (even if oliguric as risk of renal damage low) and then monitor renal function

194
Q

What are 3 indications for CVP line when managing eclampsia?

A
  1. Associated maternal haemorrhage
  2. Fluid balance difficult
  3. Creatinine rises
195
Q

What should be done if HELLP syndrome co-exists with eclampsia?

A

consider high dose steroids and involvement of renal and liver physicians

196
Q

What type of delivery may be performed in eclampsia?

A

vaginal delivery not contraindicated if cervix is favourable

OBG: Pregnancy, labour, breast feeding (14 decks)

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