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obs & gynae > Complications of pregnancy > Flashcards

Complications of pregnancy Flashcards

1
Q

Define pre-eclampsia

A

New onset HTN in pregnancy with end-organ dysfunction, with proteinuria

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2
Q

When does pre-eclampsia typically occur?

A

20+ weeks gestation

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3
Q

What is the brief pathophysiology behind pre-eclampsia?

A

Spiral arteries of placenta form abnormally -> leads to high vascular resistance in these vessels.

Systemic BP increases

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4
Q

What are complications of pre-eclampsia?

A 
Maternal organ damage
FGR
Seizures
Preterm labour
Death
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5
Q

What is the triad of pre-eclampsia?

A

Hypertension
Proteinuria
Oedema

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6
Q

Difference between pregnancy-induced HTN and pre-eclampsia?

A

Pregnancy-induced HTN does not result in proteinuria

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7
Q

Define eclampsia

A

Seizures resulting from pre-eclampsia

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8
Q

What are HIGH risk factors for pre-eclampsia?

A 
Pre-existing HTN
Previous HTN in pregnancy
Exisiting autoimmune conditions (e.g. SLE)
Diabetes
CKD
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9
Q

What are MODERATE risk factors for pre-eclampsia?

A 
40 yo+
BMI >35
10 years+ since previous pregnancy
Multiple pregnancy
First pregnancy
Family history of pre-eclampsia
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10
Q

What is the criteria for giving prophylactic aspirin to women to protect against pre-eclampsia?

A

1 high risk factor
or
1+ moderate risk factor

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11
Q

At which gestational age onwards are women offered aspirin against pre-eclampsia?

A

12 weeks on wards

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12
Q

What drug is used prophylatically against pre-eclampsia?

A

Aspirin

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13
Q

Give symptoms of pre-eclampsia

A 
Headache
Visual disturbance/blurred
Nausea/vomiting
Upper abdo/epigastric pain
Oedema
Reduced urine output
Brisk reflexes
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14
Q

NICE recommends using _____ between 20-35 weeks gestation to rule out pre-eclampsia

A

PIGF

Placental growth factor - stimulates development of new blood vessels

PIGF is low in pre-eclampsia

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15
Q

Give pre-eclampsia BP values (NICE guidelines)

A

140+ systolic

90+ diastrolic

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16
Q

Apart from BP, what other NICE criteria are used to diagnose pre-eclampsia?

A

Organ dysfunction (raised CK, raised liver enzymes, seizures, thrombocytopenia, haemolytic anaemia)

Proteinuria (1+ on urine dipstick)

Placental dysfunction (FGR, abnormal Doppler studies)

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17
Q

What two measurements can be used to quantify proteinuria?

A

Urine albumin:creatinine ratio (30+mg/mmol significant)

Urine protein:creatinine ratio (8+mg/mmol significant)

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18
Q

How is pre-eclampsia monitored at every antenatal appointment?

A

BP
Urine dip ?proteinuria
Symptom check

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19
Q

How is gestational hypertension (without proteinuria) managed?

List 6 ways

A

Aim lower than 135/85mmHg

Admit women with BP 160/100+ mmHg

Urine dip weekly

Blood tests weekly (FBC, liver enzymes, renal profile)

Serial growth scans to monitor fetal growth

PIGF testing (1x occasion)

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20
Q

How is pre-eclampsia managed differently to gestational hypertension?

List 4 differences

A

Same as gestational HTN but:

  • scoring systems used to determine whether to admit woman fullPIERS or PREP-S
  • BP monitored more frequently (48 hrs)
  • Urine dip not necessary as diagnosis made
  • USS monitoring of fetus, amniotic fluid and doppler performed 2 weekly
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21
Q

What scoring systems are used with pre-eclampsia to decide whether to admit the woman?

A

fullPIERS

or

PREP-S

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22
Q

Pre-eclampsia hypertension is managed by the drug ______ first line as anti-HTN.

Second line drug is _______

A

1st line: Labetolol

2nd line: Nifedipine

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23
Q

What drug can be used as a critical-care anti-HTN in severe pre-eclampsia/eclampsia?

A

IV hydralazine

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24
Q

What drug is given IV during labour and 24hr after to prevent eclampsia seizures?

A

IV magnesium sulfate

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25
Q

____ _____ is used during labour in severe pre-eclampsia/eclampsia to avoid fluid overload

A

Fluid restriction

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26
Q

What drug is given to women having premature birth to help mature the fetal lungs?

A

Corticosteroids

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27
Q

AFTER delivery, what drug is given 1st line to control BP in pre-eclampsia?

A

Enalapril

Nifedipine/amlodipine first-line in black African/Carrib patients

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28
Q

What is HELLP syndrome?

What does it stand for?

A

Combination of pre-eclampsia/eclampsia features

H - Haemolysis
EL - Elevated Liver enzymes
LP - Low Platelets

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29
Q

How is HELLP syndrome best treated?

A

Deliver the baby ASAP

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30
Q

What are complications of HELLP syndrome?

A

Stroke

Organ problems (pulmonary oedema, kidney failure, liver failure)

DIC

Baby delivered early -> neonatal respiratory distress

Stillbirth

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31
Q

_____ insulin sensitivity during pregnancy causes _____ _____

A

Reduced

Gestational diabetes

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32
Q

What are the most significant complications of GDM?

A

LGA (macrosomia)

Neonatal hypoglycaemia

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33
Q

What is a long-term complication of GDM?

A

T2DM later after pregnancy

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34
Q

Anyone with risk factors for GDM should be screened with an _________ at 24-28 weeks gesetation.

A

OGTT

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35
Q

When is the OGTT carried out?

A

24-28 weeks gestation

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36
Q

What are risk factors for GDM?

List 5

A

Previous GDM

Previous macrosomic baby (>4.5kg)

BMI > 30

Ethnic origin

Family history of DM (1st degree relative)

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37
Q

If no risk factors, when is OGTT used?

A

LGA fetus

Polyhydramnios

Glucose on urine dipstick

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38
Q

When are the blood sugar measurements taken for OGTT?

A

Before 75g glucose drink (fasting BG)

After 2 hours post-drink

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39
Q

What are normal results for blood sugar in the OGTT?

A

Fasting <5.6mmol/l

At 2 hours >7.8mmol/l

Results higher means GDM

*(remember results cutoff using 5,6,7,8)

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40
Q

When are the 4 USS scans done with GDM?

A

Between 28 to 36 weeks

The scans monitor fetal growth and amniotic fluid volume.

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41
Q

GDM: Fasting glucose less than 7 mmol/l

How is it managed?

A 
Diet and exercise 1-2 weeks
then
Metformin
then
Insulin
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42
Q

GDM: Fasting glucose more than 7 mmol/l

How is it managed?

A

Insulin
then
Metformin

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43
Q

GDM: Fasting glucose above 6 mmol/l plus macrosomia

How is it managed?

A

Insulin
then
Metformin

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44
Q

If a woman declines insulin or cannot tolerate metformin, what drug can be given?

A

Glibenclamide (sulfonylurea)

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45
Q

What are the NICE target levels for blood sugar?

  1. Fasting
  2. 1 hour post-meal
  3. 2 hours post-meal
  4. Avoid levels ___ or below
A
  1. 5.3 mmol/l
  2. 7.8 mmol/l
  3. 6.4 mmol/l
  4. 4 mmol/l
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46
Q

What supplement should women with existing diabetes take when concieving?

When should this be taken?

A

5mg Folic acid

From preconception until 12 weeks gestation

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47
Q

How are women with existing T2DM managed in pregnancy?

A

Metformin + insulin only (other oral diabetic meds are stopped!)

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48
Q

How does planned delivery differ between woman with pre-existing diabetes and GDM?

A

Pre-existing diabetic women - must give birth 37 - 38+6 weeks

GDM can give birth up to 40+6

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49
Q

What medication therapy is given to women in labour who have T1DM?

(also for women with poor control of BG in GDM or T2DM)

A

Insulin sliding-scale regime

Dextrose and insulin titrated to blood sugar levels

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50
Q

What screening is important during pregnancy for women with existing diabetes?

A

Retinopathy

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51
Q

When can GDM women stop their diabetic meds?

When should they follow up their fasting glucose after the baby is born?

A

Can stop meds immediately after birth

6 weeks post birth

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52
Q

Why does neonatal hypoglcaemia occur in the neonate with a GDM mother?

A

Increased insulin sensitivity after birth and with breastfeeding

(Babies become accustomed to large supply of glucose during pregnancy. After birth, they struggle to maintain the supply they are used to with oral feeding alone)

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53
Q

Babies of mothers with diabetes are at risk of:

List 5

A 
Neonatal hypoglycaemia
Polycythemia
Jaundice
Congenital heart disease
Cardiomyopathy
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54
Q

How are babies monitored for neonatal hypoglycaemia?

What is the cutoff blood sugar?

A

Regular BG checks and frequent feeds

Maintain 2+ mmol/l

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55
Q

How is neonatal hypoglycaemia treated?

A

IV dextrose via NG tube

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56
Q

Anaemia is defined as a low _____ in the blood

A

Haemoglobin

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57
Q

When are women routinely screened for anaemia during pregnancy?

(Hint there are 2 times)

A
  1. Booking clinic

2. 28 weeks gestation

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58
Q

Why does anaemia occur in pregnancy?

A

Plasma volume increases

Hb concentration reduces (blood diluted due to higher plasma volume)

59
Q

Why is it important to treat anaemia during pregnancy?

A

To ensure woman has enough blood reserves in case there is significant blood loss during delivery.

60
Q

Give features of anaemic women presenting.

A

SOB
Fatigue
Dizziness
Pallor

61
Q

What are normal ranges for Hb during pregnancy at:

  1. Booking bloods
  2. 28 weeks gestation
  3. Post-partum
A
  1. > 110 g/l
  2. > 105 g/l
  3. > 100g/l
62
Q

What blood test measurement can indicate the CAUSE of the anaemia?

A

MCV

63
Q

What does low MCV in anaemia show?

A

Iron deficiency

64
Q

What does normal MCV in anaemia show?

A

Physiological anaemia due to increased plasma voluime of pregnancy

65
Q

What does raised MCV in anaemia show?

A

B12/folate deficiency

66
Q

What other blood tests apart from FBC can establish cause of anaemia?

A

Ferritin
B12
Folate

aka Haematinics

67
Q

What are women with anaemia in pregancy started on?

A

Ferrous sulphate (iron replacement)

68
Q

Women with low B12 should be tested for what condition? And how?

A

Perniciuous anaemia

Check for Intrinsic Factor antibodies

69
Q

How is low B12 treated in anaemia?

Give 2 drugs

A

IM hydroxocobalamin injections

Oral cyanocobalamin tablets

70
Q

How much folic acid should women take normally per day?

A

400mcg per day

71
Q

Women with folate deficiency are started on how much folic acid per day?

A

5mg daily (5000mcg)

72
Q

What supplements should be given to women with thalassaemia or sickle cell anaemia?

A

5mg folic acid daily

Close monitoring and transfusions when required

Requires specialist haematologist input

73
Q

How is SCD detected prenatally?

A

Chorionic villus sampling

Screening partners of heterozygotic pregnant women

74
Q

What are maternal complications of SCD?

A

Acute painful crsises
Pre-eclampsia
Thrombosis

75
Q

What are fetal complications of SCD?

A

Miscarriage
FGR
Preterm labour
Death

76
Q

What lab test detects SCD?

A

Hb electrophoresis

77
Q

How is SCD managed:

a) conservatively
b) medically

A

a) avoid dehydration
b) penicillin V, folic acid. aspirin vs pre-eclampsia, LMWH

monthly urine cultures

78
Q

Why is hydroxycarbamide stopped pre-pregnancy for SCD?

A

Teratogenic

79
Q

Why is iron avoided in SCD pregnancies?

A

Iron overload

Can lead to pregnancy loss

80
Q

Does obstretric cholestasis resolve after ______ of the baby?

A

Delivery

81
Q

Obstretric cholestasis usually develops _____ in pregnancy - around __ weeks

A

Later (28 weeks)

82
Q

Obstetric cholestasis is the results of increased ______ and ______ levels

A

Oestrogen

Progesterone

83
Q

Obstetric cholestasis is more common in women of _________ ethnicity

A

South Asian

84
Q

Itching of the palms and soles of feet in pregnancy can indicate what?

A

Obstetric cholestasis

85
Q

What is the danger of untreated obstetric cholestasis?

A

Increased risk of stillbirth

86
Q

Fatigue, dark urine, pale greasy stools and jaundice in pregnancy indicate what?

A

Obstetric cholestasis

87
Q

Is there a rash with obstetric cholestasis?

A

No

If there is: consider either polymorphic eruption of pregnancy or pemphigoid gestationis

88
Q

List differentials of obstetric cholestasis

A

Gallstones
Acute fatty liver
Autoimmune hepatitis
Viral hepatitis

89
Q

Which investigations are needed for obstetric cholestasis?

A

LFTs (deranged ALT, AST, GGT) *ALP normally raised in pregnancy due to placental production, doesn’t indicate liver pathology

Bile acids (raised)

90
Q

What is the primary treatment for obstetric cholestasis?

A

Ursodeoxycholic acid

Itching: emollients, antihistamines for sleeping

91
Q

If clotting (prothrombin time) is deranged, what medication can be given?

A

Water-soluble vitamin K

92
Q

How would obstetric cholestasis affect delivery?

A

Planned delivery after 37 weeks considered (especially if LFTs/bile acids deranged)

Stillbirth difficult to predict, early delivery reduces risk

93
Q

What are maternal risks associated with obesity?

A 
VTE
Pre-eclampsia
Diabetes
C-section delivery
Would infections
Difficult surgery
PPH
Maternal death
94
Q

What are fetal risks associated with obesity?

A

Congenital abnormalities (NTD)
Perinatal mortality
USS is less accurate

95
Q

What advice can be given to obese women before pregnancy?

A

Lose weight before conception

*Weight loss DURING pregnancy not advised!

96
Q

What medication/supplement can be given to obese pregnant women?

A 
Folic acid high dose (5mg)
Vitamin D
VTE prophylaxis (if BMI >40)
97
Q

What are the 3 most common causes of antepartum hemorrhage?

A

Placental abruption

Placenta praevia

Vasa praevia

98
Q

An APH is small and painless but the placenta is not praevia.

What is the likely cause?

A

Impossible to find a cause.

USS is useless. Perhaps is a minor placental abruption.

99
Q

What is placenta praevia?

A

Placenta attached in lower part of the uterus, lower than the presenting part of the foetus.

It is a cause of APH.

(placenta is OVER the internal cervical os)

*Low-lying placenta is used when placenta is within 20mm of internal cervical os. (RCOG guidelines)

100
Q

What are causes of spotting or minor bleeding in pregnancy?

A

Cervical ectropion
Infection
Vaginal abrasions (intercourse/procedures)

101
Q

What are risks of placenta praevia for the mother?

A

APH
Emergency C-section
Emergency hysterectomy
Maternal anaemia/transfusions

102
Q

What are risks of placenta praevia for the foetus?

A

Preterm birth
Low birth weight
Stillbirth

103
Q

What are risk factors for placenta praevia?

A 
Previous C-sections
Previous placenta praevia
Older maternal age
Maternal smoking
Fibroids (+ other uterine structure issues)
IVF
104
Q

When and how is placental praevia diagnosed in the UK?

A

20-week anomaly scan assesses position of placenta (diagnoses placenta praevia)

105
Q

How would women with placenta praevia present usually?

A

Mostly asymptomatic

Perhaps painless vaginal bleeding around 36 weeks+

106
Q

How is low-lying/placenta praevia managed?

A

Repeat transvaginal USS (32, 36 weeks)

Corticosteroids (mature fetal lungs)

Planned delivery (reduce risk of spontaneous labour, bleeding)

C-section (planned or emergency)

107
Q

How is hemorrhage with placenta praevia managed?

A 
Emergency C-section
Blood transfusions
Intrauterine balloon tamponade
Uterine artery occlusion
Emergency hysterectomy
108
Q

What is placental abruption?

A

Placenta separates from wall of uterus during pregnancy.

Site of attachment bleeds extensively after placenta separates.

It is a cause of APH.

109
Q

How is the severity of antepartum haemorrhage graded? (Hint: 4 points)

A
  1. Spotting (blood on underwear)
  2. Minor haemorrhage (<50ml)
  3. Major haemorrhage (50-1000ml)
  4. Massive haemorrhage (1000ml+ or shock)
110
Q

What are risk factors for placental abruption?

A 
Previous placental abruption
Pre-eclampsia
Bleeding early in pregnancy
Trauma (?domestic violence)
Multiple pregnancy
Fetal growth restriction
Multigravida
Increased maternal age
Smoking
Cocaine or ampetamine
111
Q

Sudden onset, continuous, severe abdo pain

Vaginal bleeding

Shock (hypotension and tachycardia)

CTG shows foetal distress

“Woody” abdomen on palpation (suggesting large haemorrhage)

All these features suggest what pathology?

A

Placental abruption

112
Q

What is concealed placental abruption vs revealed placental abruption?

A

Concealed = cervical os closed, any bleeding contained within uterine cavity.

Revealed = cervical os opened, blood loss observed coming out of vagina

113
Q

How is placental abruption diagnosed?

A

Clinical diagnosis based on presentation

*no reliable test for diagnosis

114
Q

The urgency of placental abruption depends on which 4 factors?

A
  1. Amount of placental separation
  2. Extent of bleeding
  3. Haemodynamic stability of mother
  4. Condition of foetus
115
Q

In placental abruption, if a major/massive occurs what are the initial management steps?

A

Senior obs, midwife, anaesthetist all involved

Cannulate

Bloods (FBC, U&E, LFT, coag)

Crossmatch 4 units of blood

Fluid and blood resuscitation as required

CTG monitoring

Close monitoring of mother

116
Q

Is USS useful for diagnosing or assessing abruption?

A

No, but can exclude other causes of APH (placenta praevia)

117
Q

What test detects the amount of foetal blood mixed with maternal blood?

(Done in order to determine dose of anti-D required)

A

Kleihauer test

118
Q

What is a major complication after delivery in women with placental abruption?

A

PPH

119
Q

What is vasa praevia?

A

When foetal vessels travel across the internal cervical os, thus being exposed.

The vessels are therefore unprotected by either the umbilical cord (Wharton’s jelly) or placenta

120
Q

What vessels does the umbilical cord contain?

A

Umbilical arteries and vein

121
Q

What is Wharton’s jelly?

Which condition is it implicated in?

A

Layer of soft connective tissue that surrounds blood vessels in umbilical cord, protecting them

Wharton’s jelly does not protect the vessels in vasa praevia

122
Q

What 2 instances can occur with vasa previa involving the position of the blood vessels?

A

Type 1. Velamentous umbilical cord (vessels run from placenta to umbilical cord)

Type 2. Multi-lobed placenta with vessels running between the 2 lobes of placenta

123
Q

What are risk factors for vasa praevia?

A

Low-lying placenta
IVF
Multiple pregnancy

124
Q

How is vasa praevia diagnosed and why is this done?

A

USS - not always reliable however

Allows planned C-section to reduce risk of hemorrhage

125
Q

How can vasa praevia present?

What can be found on examination?

A

APH

Vaginal examination = pulsating fetal vessels seen in the membranes through the dilated cervix

126
Q

During labour, how may vasa praevia present?

Why is this important?

A

Fetal distress

Dark-red bleeding following rupture of membranes

Very high fetal mortality, even with emergency C-section

127
Q

For asymptomatic women with vasa praevia, what management is recommended?

A

Corticosterids (@32wks,
mature fetal lungs)

Elective C-section (34-36 wks)

128
Q

After stillbirth or unexplained fetal compromise during delivery, why may the placenta be examined?

A

?vasa praevia as a possible cause

129
Q

What is ectopic pregnancy?

A

Pregnancy implanted outside uterus - most commonly fallopian tube.

*can also be ovary, cervix or abdomen

130
Q

What are risk factors for ectopic pregnancy?

A

Previous ectopic pregnancy

Previous PID

Previous surgery to fallopian tubes

Intrauterine devices (coils)

Older age

Smoking

131
Q

What gestational age does ectopic pregnancy usually present?

A

6-8 weeks gestation

132
Q

What are the classic features of an ectopic pregnancy?

A

Missed period

Constant lower abdo pain in RIF or LIF

Vaginal bleeding

Lower abdo or pelvic tenderness

Cervical motion tenderness (pain when moving cervix during bimanual exam)

*sometimes dizziness/syncope - blood loss or shoulder tip pain (peritonitis)

133
Q

What USS findings can be seen with ectopic pregnancy?

A

Empty gestational sac (blob sign)

Tubal ectopic pregnancy (mass moves separate to ovary - unlike corpus luteum which moves with ovary)

Empty uterus

Fluid in uterus - pseudogestational sac

134
Q

What is pregnancy of unknown location?

A

Positive pregancy test and no evidence of pregnancy on USS

135
Q

How can normal and ectopic/miscarriage pregnancy be differentiated on hCG?

A

hCG doubles every 48 hours with intrauterine pregnancy

does not double with miscarriage or ectopic pregnancy!

136
Q

How are ectopic pregnancies managed?

List the 3 broad options

A

Expectant management (await natural termination)

Medical management (methotrexate)

Surgical management (salpigectomy or salpingotomy)

137
Q

Why is methotrexate used to manage ectopic pregnancies?

A

Highly teratogenic

Given IM into buttock - halts pregnancy and results in spontaneous termination

138
Q

Which hormone produced by placenta is responsible for hyperemesis gravidarum?

A

hCG (higher = worse)

139
Q

Hyperemesis gravidarum worse in what kind of pregnancies due to high hCG?

A

Molar pregnancies

Multiple pregnancies (twins etc)

Worse in first pregnancy and with obese women)

140
Q

How is hyperemesis gravidarum diagnosed?

A

History taking

Protracted Nausea and vomiting in pregnancy (NVP)

More than 5% weight loss compared with before pregnancy

Dehydration

Electrolyte imbalance

Ketosis (sometimes)

141
Q

Which score is used to determine the severity of hyperemesis gravidarum?

A

Pregnancy-Unique Quantification of Emesis (PUQE)

142
Q

Which medications can be used to manage hyperemesis gravidarum?

A

Antiemetics - e.g. cyclizine and ondanestron

Anti-acids - Ranitidine/omeprazole if acid reflux is a problem

143
Q

Severe cases of hyperemesis gravidarum need to be managed with what?

A

EPAU or admission to hospital

IV fluids (normal saline with added potassium chloride)

Daily monitoring of U&Es while having IV therapy

Thiamine supplementation to prevent deficiency (Wenicke-Korsakoff syndrome)

Thromboprophylaxis (TED stocking + LMWH during admission)

obs & gynae (13 decks)

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