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Obs & Gynae > Complicated Pregnancy > Flashcards

Complicated Pregnancy Flashcards

1
Q

What is Hyperemesis Gravidarum? RF?

A
  • Severe vomiting with onset before 20w of gestation. Most common between 8-12w
  • Related to increased levels of bHCG

RF:

  • Molar pregnancies (higher bHCG)
  • Multiple pregnancies (higher bHCG)
  • First pregnancy
  • Obesity
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2
Q

Dx of Hyperemesis Gravidarum? How is severity assessed? When is admission considered?

A

Prolonged N+V in pregnancy PLUS:

(1. ) >5% wt loss compared with before pregnancy
(2. ) Dehydration
(3. ) Electrolyte imbalance
(4. ) Severity assessed using PUQE.

Admission considered when:

  • Unable to tolerate oral antiemetics/ fluids
  • > 5% wt loss compared with pre-pregnancy
  • Ketonuria
  • Other medical conditions need treating that required admission g. unable to tolerate oral abx for UTI
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3
Q

Management of Hyperemesis Gravidarum?

A

Mild cases, managed at home

  • Antiemetics
  • Omeprazole if reflux problem

Moderate-severe cases

  1. IV/IM antiemetics
  2. IV fluids (saline + KCl)
  3. Daily U&Es
  4. Thiamine + folic acid to prevent Wernicke’s encephalopathy
  5. VTE prophylaxis
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4
Q

Define:

  • Chronic HTN
  • Pregnancy-induced/gestation HTN
  • Pre-eclampsia
  • Eclampsia
A
  • Chronic hypertension = Hi BP <20w, it is not caused by placenta dysfunction and thus not pre-eclampsia.
  • Pregnancy-induced/gestational HTN = hi BP after 20w without proteinuria.
  • Pre-eclampsia = pregnancy-induced HTN associated with organ damage
  • Eclampsia = seizures as a result of pre-eclampsia.
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5
Q

What is pre-eclampsia and complications for it?

A
  • Hi BP in pregnancy with end-organ dysfunction. Occurs >20w due to abnormal spiral arteries of placenta leading to a high vascular resistance.
  • Complications: maternal organ damage, fetal growth restrictions, seizures, early labour, death, HELLP Syndrome (Haemolysis + Elevated Liver enzymes + Low Platelets)
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6
Q

RF for pre-eclampsia

A

High-RF:

  • Pre-existing HTN
  • Prev HTN in pregnancy
  • AI (e.g. SLE), DM, CKD

Moderate-RF:

  • > 40y
  • BMI > 35
  • > 10y since prev pregnancy
  • Multiple pregnancy
  • First pregnancy
  • FH
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7
Q

Presentation of pre-eclampsia, red flags for HELLP

A

Triad of: HTN, proteinuria, oedema

  • Asyx
  • headache
  • visual disturbance
  • N+V
  • frothy urine
  • red flags for HELLP: headache, visual disturbance, RUQ pain, breathless
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8
Q

Dx + Ix for Pre-eclampsia

A

BP >140 systolic or <90mmHg diastolic PLUS one of:

  • Proteinuria (urine dip/PCR/ACR)
  • Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia)
  • Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies)

Investigations

  • Obs
  • Urinedip - assess protein
  • bloods: fbc, clotting, ue, lft
  • CTG
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9
Q

Management of Pre-eclampsia

A

(1. ) Aspirin prophylaxis from 12w if: single high RF or >2 moderate RF
(2. ) Antenatal appt: assess BP, syx, urine dip
(3. ) Plan early birth may be necessary if cannot be controlled + steroids if preterm birth

Medical Mx

(1. ) Labetalol (1st line), Nifedipine (2nd line), Methyldopa (3rd line)
(2. ) IV magnesium sulphate - during labour and 24hrs after to prevent seizures

Severe pre-eclapmisa or eclampsia

(1. ) IV hydralazine in critical care
(2. ) Fluid restriction - during labour to avoid fluid overload

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10
Q

WHat is Gestational diabetes? Complications? RF?

A
  • Diabetes caused by reduced insulin sensitivity during pregnancy and resolves after birth.
  • Complications: macrosomnia, shoulder dystocia, T2DM, neonatal hypoglycaemia

RF

  • Prev GDM
  • Prev macrosomic
  • BMI > 30
  • Ethnic origin (black Caribbean, Middle Eastern and South Asian)
  • FH DM
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11
Q

Ix for GDM

A

(1. ) OGTT at 24-28w
- Indicated in: those with RF, large for dates fetus, polyhydramnios, glucose on urine dipstick
- Performed in morning, pt drinks 75mg glucose, BGL measured before and 2hrs after drink.
- Normal results: Fasting: < 5.6 mmol/l, At 2hrs: < 7.8 mmol/l, If above -> gestational DM

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12
Q

Mx for GDM

A

(1. ) Healthy diet + exercise
(2. ) Monitor BGL several times a day
(3. ) USS - monitor fetal growth + amniotic fluid
(4. ) Metformin +/- insulin, this can stop after birth

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13
Q

What is Ectopic pregnancy + RF?

A

Pregnancy implanted outside uterus - most common site is a fallopian tube.

RF:

  • Prev ectopic
  • Prev surgery to fallopian tube
  • Anything that causes pelvic adhesions: Endometriosis, IBD, PID, Chlamydia
  • IUD
  • Older age
  • Smoking (impairs cilia)
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14
Q

Presentation of Ectopic pregnancy

A

Typically presents 6-8w.

  • Missed period
  • Constant lower abdo pain (RIF/LIF)
  • PV bleeding

O/E

  • Adnexal mass
  • Lower abdo/pelvic tenderness
  • Cervical motion tenderness - pain when moving the cervix during a bimanual examination
  • Dizziness or syncope (blood loss)
  • Shoulder tip pain (peritonitis)
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15
Q

IX for Ectopic pregnancy

A
  • bHCG

- TV USS: exclude intrauterine pregnancy

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16
Q

Mx of Ectopic pregnancy and indications for mx type.

A

Indications:
- Expectant: <35mm, unruptured, no pain, no heartbeat, bHCG <1500

  • Medical: <35mm, unruptured, not much pain, no heartbeat, bHCG <5000
  • Surgery: >35mm, +/-rupture, pain, heartbeat, bHCG >5000

(1. ) Expectant (awaiting natural termination)
- monitor for 48hrs + bHCG. If it rises + syx must intervene

(2.) Medical: IM methotrexate

(3. ) Surgical
- Salpingectomy (removal of fallopian tube with ectopic)
- Salpingotomy (removal of ectopic + no removal of tube, for those at inc risk of infertility)
- Anti-rhesus D prophylaxis is for rhesus negative women

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17
Q

What is a Pregnancy of unknown location (PUL)?

A
  • +ve pregnancy test and no evidence of pregnancy on USS
  • ectopic pregnancy cannot be exclude till dx confirmed
  • hCG can be tracked over time to monitor pregnancy of unknown location

HCG repeated after 48hrs:

  • > 63% hCG rise in 48hrs = intrauterine pregnancy
  • <63% hCG rise in 48hrs = ectopic
  • > 50% fall hCG in 48hrs = miscarriage
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18
Q

What are the legal requirements for abortion

A

1967 Abortion Act: abortion can be performed before 24w. Legal requirements for abortion:

  • Two registered medical practitioners must sign to agree abortion is indicated
  • It must be carried out by a registered medical practitioner in an NHS hospital or approved premise
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19
Q

Mx of TOP

A

Medical

(1. ) Mifepristone (anti-progestogen)
(2. ) Misoprostol (prostaglandin analogue) 1-2d later
(3. ) Anti-D prophylaxis if >10w + rhesus -ve

Surgical

(1. ) Prior to surgery, cervical priming + dilation with misoprostol, mifepristone or osmotic dilators.
(2. ) <14w: cervical dilatation + suction
(3. ) 14-24w: cervical dilatation + evacuation using forceps

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20
Q

What are the different types of miscarriage and what would you expect to see clinically?

A

‘Open your I’s’ - open os for inevitable and incomplete miscarriage

(1. ) Threatened = closed os. PV bleeding at 6-9w.
(2. ) Missed = closed os. No syx, fetus not alive.
(3. ) Inevitable = open os. Heavy PV bleeding.
(4. ) Incomplete = open os. Retained products, pain + PV bleeding.
(5. ) Complete = full miscarriage, no products in uterus.

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21
Q

Ix of miscarriage

A

(1. ) Abdo exam with speculum and bimanual
(2. ) Full set of observations
(3. ) Bloods: FBC, G&S, bHGC, progesterone. If HCG normal and low progesterone = pregnancy is failing
(4. ) TVUS

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22
Q

Mx of miscarriage

A

(1. ) Expectant management (<6w)
- 1-2w for miscarriage to occur spontaneously
- Repeat pregnancy test to confirm miscarriage.
- Persistent/worsening bleed requires repeat USS, as may indicate an incomplete miscarriage and require additional management.

(2.) Medical: PV/PO Misoprostol

(3. ) Surgical:
- manual vacuum aspiration under local anaesthetic
- electric vacuum aspiration under GA

(4.) Anti-rhesus D prophylaxis is given to rhesus negative

23
Q

What is Abruption placenta and its RFs?

A

(1. ) Obstetrics emergency
(2. ) Placental abruption is where placenta separates from uterine wall during pregnancy resulting in antepartum haemorrhage. Bleeding can be concealed within the cavity.
(3. ) Increased risk of PPH after delivery in women with placental abruption.

RF
A- prev Abruption
B - BP i.e. preeclampsia
R - ruptured mb PROM
U - uterine injury - DV, surgery
P - polyhyrdramino
T - twin pregnancies, multiparity
I infection e.g. chorioamniotis
O  - older age
N - narcotic use e.g. cocaine, amphetamines, smoking
24
Q

PResentation of Abruption placenta

A

(1. ) Sudden + Severe abdo pain
(2. ) PV bleed h/e in some cases haemorrhage may be confined to the uterus (concealed)
(3. ) Shock (hypotension + tachy)
(4. ) CTG abnormalities e.g. reduced FM

O/e:
- ‘woody’ hard abdomen suggesting large haemorrhage

25
Q

Management of Abruption placenta

A

It is an emergency.

If mum + fetal unstable: ABCDE

(1. ) Fluids,oxygen
(2. ) EMCS
(3. ) CTG
(4. ) Steroids if 24-34w - to mature fetal lungs
(5. ) Anti D prophylaxis

If mum + foetus table

  • Monitor closley
  • steroids if <36w
26
Q

Three causes of antepartum haemorrhage

A

placenta praevia
placental abruption
vasa praevia

27
Q

what is placenta praevia? complications? RF?

A

(1. ) Placenta is lies in lower portion of uterus, normally placenta implants in upper uterus.
- Low-lying placenta = placenta is within 20mm of the internal cervical os
- Placenta praevia = placenta is over the internal cervical os
(2. ) This means it can easily bleed and can occur after 20w
(3. ) It is a cause of antepartum haemorrhage
(4. ) Complications: pre-term delivery, hypoxia, haemorrhage.
(5. ) RF: Prev c-sections, Prev placenta praevia, Older maternal age, Smoking, Structural uterine abnormalities e.g. fibroids

28
Q

presentation of placenta praevia

A

(1. ) Asyx
(2. ) Painless bleeding
- After 20w, typically 36w
- Intermittent or continuous

29
Q

How may you examine + Ix placenta praevia

A

(1.) Speculum NO bimanual ex

(2. ) Bloods:
- FBC, clotting, G&S, clotting
- Rhesus status
- Kleihauer test: how much of baby’s blood is in mum’s blood

(3. ) 20w USS - allows to visualise where the placenta is lying
(4. ) CTG

30
Q

Mx of placenta praevia

A

(1. ) TV USS at 32w, 36w:
- If low-lying placenta/placenta praevia diagnosed early in pregnancy e.g. 20w scan

(2. ) Steroids at 34w + 35+6w
(3. ) Planned c-section at 36 and 37w.
(4. ) If haemorhage: ABCDE + ECS, blood transfusion, intrauterine balloon tamponade.

31
Q

What is Postpartum haemorrhage (PPH)?

A
  • Significant loss of blood after giving birth and a potential cause of maternal death.
  • It is an obstetric emergency.

To be classified as PPH, there needs to be a loss of:

  • > 500ml after vaginal delivery
  • > 1000ml after c-section delivery

It can also be categorised as:

  • Primary PPH: bleeding <24 hours of birth
  • Secondary PPH: from 24hrs to 12w after birth usually due to retained products or infection/endometritis
32
Q

Causes of Postpartum haemorrhage (PPH)?

A

4T’s

(1. ) Tone = lack of uterine tone (Uterine Atony).
(2. ) Trauma = damage to genital structures e.g. medical instrument - forceps, vacuum extractions, episiotomy.
(3. ) Tissue = retained placenta in uterine cavity
(4. ) Thrombin = bleeding disorder e.g. von Willebrand disease or obstetrics issues e.g. eclampsia, placental abruption

33
Q

What is Uterine Atony? causes? rx?

A
  • Failure of the uterus to contract after delivery and thus blood vessels are not compressed. This can lead to PPH.
  • Lack of uterine tone creates a soft, spongy, boggy uterus which causes slow & steady loss of blood.

Causes
- multiple pregnancies, overstretching from twins/triplets, muscle fatigue from prolonged labour etc.

Rx
- massaging the fundas after birth.

34
Q

Preventative measures and Management of PPH?

A

Preventative measures:

(1. ) Treating anaemia during antenatal period
(2. ) Giving birth with an empty bladder (full bladder reduces uterine contraction)
(3. ) IM oxytocin in third stage
(4. ) IV tranexamic acid during c-section in higher-risk patients

ABCDE

  • Lie flat, keep warm and communicate
  • Bloods: FBC, U&E, clotting, G&S, crossmatch
  • IV fluid (warmed) + blood resus
  • Severe cases -> activate major haemorrhage protocol

Mechanical

(1. ) Rubbing uterus via abdomen to stimulates a uterine contraction
(2. ) Catheterisation

Medical (‘MOM Ct’)

(1. ) 40unit Oxytocin
(2. ) IV/IM Ergometrine - stimulates contraction
(3. ) IM Carboprost stimulates contraction
(4. ) Misoprostol - prostaglandin analogue + stimulates contraction
(5. ) IV Tranexamic acid - reduces bleeding

Surgical

(1. ) Intrauterine balloon tamponade
(2. ) B-Lynch suture - suture around uterus to compress it
(3. ) Uterine artery ligation
(4. ) Hysterectomy “last resort” but will stop the bleeding and may save the woman’s life

35
Q

What is Premature rupture of membranes (PROM)

A
  • Premature rupture of mb (PROM) = amniotic sac rupture 1hr before labour
  • Preterm premature rupture of mb (PPROM) = amniotic sac rupture before 37w
RF for PROM
o	Vaginal or cervical infections: UTI/STI/BV
o	Smoking or drugs during pregnancy 
o	Prev PROM
o	Polyhydramnios.
o	Multiple pregnancy.
o	Cervical insufficiency.
o	Invasive procedures e.g. amniocentesis.
36
Q

Presentation of PROM + signs of complication?

A

(1. ) ‘popping sensation’ or a ‘gush’ with continuous watery liquid draining thereafter. Their underwear or pad may be damp.
(2. ) Signs of ascending infection (chorioamnionitis)
- fetal tachycardia
- mild maternal temp
- PV offensive discharge may be present
- Abdo tenderness

37
Q

Ix of PROM

A

(1. ) Sterile Speculum - visualise amniotic fluid pooling into vagina after women has been lying for 30mins
(2. ) If no fluid consider testing vaginal fluid for IGFBP-1, PAMG-1,
(3. ) Sterile swab + microscopy of fluid. Amniotic fluid = Fern pattern* on micro slide
(4. ) Pad check
(5. ) USS - visualise low amniotic fluid
(6. ) If suspect infection:
- HVS
- FBC, CRP
- MSU
- blood cultures
- Fetal monitoring

38
Q

Mx of PROM

A

(1. ) Urgent admission + 48hrs observations (monitor for any signs of infections)
(2. ) Erythromycin for 10d or till labour (whatever comes first)
(3. ) >34w = IoL

(4. ) <34w = WW
- Tocolytics to prevent beginning of labour
- Mg sulphate + steroids = allows for mx efficacy of steroids for fetal lungs
- Abx

39
Q

What is Rh incompatibility and why is it important?

A

Rh +ve = rhesus-D antigen on RBC
Dx = Coombs test at prenatal

(1. ) Mum and baby have diff blood types + blood do not mix.
(2. ) It is likely at some point blood will mix (senstisation event), this is an issue if mum -ve and baby +ve as:
- Mum will see rh antigen on baby as ‘foreign’ and attack, and thus will produce antibodies to rh antigen. Mum is now sensitised.
(3. ) Sensitisation process does not cause problems during first pregnancy it is subsequent pregnancies as antibodies can cross placenta into fetus and cause haemolytic disease of the newborn.
(4. ) There is no way to reverse the sensitisation process once it has occurred, so prophylaxis is essential.

40
Q

Management of Rh incompatibility + indications

A

IM anti-D given to rh -ve mums in the following situations/indications

(1. ) Routinely at 28w, 34w
(2. ) If indicated by kleinhaur test
(3. ) At birth if baby’s cord blood test is rh +ve
(4. ) Where sensitisation may occur (<72hrs)
- Antepartum haemorrhage e.g. placental abruption
- Amniocentesis procedures
- Abdominal trauma
- Miscarriage <12w
- Surgical management of ectopic

Note: anti-D has no effect once sensitisation has already occurred (it is prophylactic only).

41
Q

What is Dystocia, complications, RF?

A
  • Shoulder dystocia is when anterior shoulder becomes stuck behind pubic symphysis, after head has been delivered.
  • It is an obstetric emergency
  • Often caused by macrosomia secondary to GDM

Complications:

  • Fetal hypoxia (and subsequent cerebral palsy)
  • Brachial plexus injury and Erb’s palsy
  • Perineal tears
  • PPH

RF

  • Maternal GDM
  • Macrosomia (>4kg)
  • Advanced maternal age
  • Maternal short stature or small pelvis
  • Maternal obesity
  • Post-dates pregnancy
42
Q

Management of Dystocia

A

Immediate help + managed by experienced midwives and obstetricians
(1.) McRobert’s manoeuvre (1st line): hyperflexion and abduction of mother’s legs tightly to abdomen

(2. ) After delivery
- Assess and monitor mum for PPH, severe perineal tears, trauma
- Assess and examine baby - brachial plexus injury, hypoxic brain damage, humeral or clavicle fractures

43
Q

What is Gestation trophoblastic disease? RF?

A

(1. ) Gestational trophoblastic disease (GTD) forms a group of disorders which range from molar pregnancies to malignant conditions such as choriocarcinoma
(2. ) They are chromosomally abnormal pregnancies that have the potential to become malignant

(3. ) RF:
- <16y, >45y
- Prev GTD
- Asian

44
Q

Gestation trophoblastic disease presentation, IX, Mx

A

Presentation:

  • PV bleed
  • hyperemesis
  • abnormal uterine enlargement
  • hyperthyroidism
  • anaemia
  • respiratory distress
  • pre-eclampsia

Investigations
bHCG, Histology, USS

Management

  • suction dilation and evacuation
  • hysterectomy
45
Q

What is Molar pregnancy

A

(1. ) Type of gestation trophoblastic disease
(2. ) A hydatidiform mole is a type of tumour that grows like a pregnancy inside uterus. This is called a molar pregnancy.

(3. ) There are two types of molar pregnancy
- Complete mole = two sperm cells fertilise an ovum that contains no genetic material.
- Partial mole = two sperm cells fertilise a normal ovum (containing genetic material) at same time and cell now has three sets of chromosomes, divides into a tumour. Some fetal material may form.

46
Q

Presentation of Molar pregnancy

A

Molar pregnancy behaves like a normal pregnancy - periods stop and hormonal changes occur.

(1. ) More severe morning sickness
(2. ) PV bleeding
(3. ) Increased uterus enlargement
(4. ) Abnormally high hCG
(5. ) Thyrotoxicosis (hCG can mimic TSH and stimulate thyroid to produce excess T3 and T4)
(6. ) USS: ‘snowstorm appearance’ or ‘grape like cysts’. This gives provisional dx, dx confirmed by histology

47
Q

Mx of Molar pregnancy

A

Management

(1. ) Evacuation (suction) of uterus to remove mole
(2. ) Histology: products of conception need to be sent for histological examination to confirm dx.

FU

(3. ) HCG - monitor until return to normal
(4. ) Chemotherapy if mole has metastasised
(5. ) Strongly advised against pregnancy for 1yr

48
Q

What doe folic acid deficiency cause

A
  • macrocytic, megaloblastic anaemia

- neural tube defects

49
Q

When is is 5mg folic acid given?

A

Those at higher risk of NTD

  • partner, prev pregnancy with NTD
  • AED
  • BMI >30
  • Coeliac disease
  • DM
  • Thalassaemia trait
50
Q

For a women looking to conceive, how much folic acid should be taken and how long for?

A
  • 400mcg

- prior and until 12w pregnancy

51
Q

What is the definition of infertility?

A

Unable to become pregnant within one year of unprotected intercourse

52
Q

Causes and RF for infertility

A

Causes

(1. ) ovulatory disorders (25%) - PCOS, hypothalamic amenorrhoea (stress related), hypothyrodisim, hyperpolactinoma, low BMI/hypogonadotrophic hypogonadism
(2. ) tubal damage (20%) - sti/pid
(3. ) male infertility (30%)
(4. ) uterine or peritoneal disorders (10%) - fibroids, polyps, adhesions, vaginal septum
(5. ) no identifiable cause (25%)

RF

  • smoking, obesity, occupational risks, alcohol, drug.
  • Female fertility declines with age.
53
Q

Investigations for infertility

A

Investigation indicated if failed to get pregnant after 1 year unless >35y

(1. ) Semen analysis
(2. ) Day 21 progesterone (for 28d cycle) - >30 = indicates ovulation

(3. ) Serum gonadotrophins
- High FSH indicates low ovarian reserve. Ovarian reserve declines with age
- LH: hi levels indicate PCOS
- Androgen

(5. ) TFT
(6. ) prolactin
(7. ) screen for chlamydia
(8. ) USS - look structural problems
(9. ) Hysterosalpingogram + Xray, visualise tube + performed in secondary care.

54
Q

Treatment for infertility

A

Medical: induce ovulation

  • Clomifene
  • Pulsatile gonadotrophin-releasing hormone

Surgery

  • Tubal microsurgery
  • surgical ablation or resection of endometriosis

Assisted conception

  • intrauterine insemination
  • IVF
  • intracytoplasmic sperm injection

Obs & Gynae (8 decks)

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