CP1 Final Flashcards
DM- T1
how do you explain risks to woman and rationale for transfer of care
pregnancy makes it harder to control DM
-change in pregnancy hormones (hPL / oestrogen, cortisol) reduce insulin resistance
poorly controlled DM can have risks for baby + mum
-worsen existing conditions (retinopathy / nephropathy, neuropathy)
risk of diabetic ketoacidosis / coma
-increase risk of Pregnancy conditions (PE, PIH, placenta abruption,)
- congenital abnormalities (hyperglycaemia prenatally/
-IUGR, stillbirth, PTL, macrosomia
by controlling your BGLs, you can have very normal outcomes
Recommendation- Transfer of care
- multidisciplinary team- obstetric, MW dietician, social, opthalmologist, urologist etc, scans, blood tests)
- MW can still be a part of your care- can discuss what role i play
- informed consent
- recognise it is high surveillance
Herpes Simplex Virus
discussion at booking + outbreak
Booking
1)information sharing-
risk of neonatal herpes simplex - baby at more risk due to permeability of blood brain barrier ( damage to brain / spinal cord /heart/ lungs / kidney)
baby will require treatment
transmission- mainly during vaginal transmission. increased risk with outbreak.
**2) recommendation
**prophylactic antiviral (Acyclovir) from 36wks to reduce risk of outbreak
report active lesions in pregnancy- requires referral for consult
Unexpected outbreak close to birth
1) information sharing
reassurance- very common.
may not be first infection, symptoms can first occur during stress (E.g. pregnancy).
risk of neonatal herpes simplex- especially if first outbreak as virus more active, less maternal antibodies
2) ask to do PRC (diagnose herpes) + serology bloods (to assess levels of antibodies- can indicate primary / secondary infection)
3) offer referral for consult
- 3way consult to:
- offer antivirals (acyclovir to reduce viral load)
- review AB’s and recommend vagianl / caesarean birth)
reinforce mum’s right to decline
1) Anaemia
what is anaemia and what are types of anaemia
deficient Hb / RBC’s - impacting oxygen carrying capacity of blood.
pregnancy- ~<110 Hb / L
Types
- iron deficiency: iron required to Hb (which carries oxygen)- IDA = serum ferritin <30
- megaloblastic: B12/ Folate deficiency
- sickle cell / thalassaemia (genetic)
1) anaemia
2)describe screening
booking viist
observe / ask about symptoms (tiredness, breathlessness, low mood, pallor dizzy, weak muscle tone)
ask about hx of anaemia / heavy bleeding / genetic issues / hx using oral supplements
Diet *
- Booking bloods (12 weeks)
CBC( Hb >110?), B12, Folate, iron studies (serum ferritin >30), **CRP
**(confirm Hb not masked by inflammation)
26-28 weeks
recheck iron levels (unles**CRP
**s indicated to check it earlier)
Anaemia
MW Management of IDA
- Hb >90, Ferritin ~20 (28wks).
- Hb<90, not responding to treatment. (Esp close to birth)
information sharing-
explain risks of anaemia (mum- tiredness/ low mood/ weakness/ dizzy/ cog function, bresatfeeding ).
baby- severe anaemia - growth / stillbirth/ impaired dev.
explain risk of anaemia higher in pregnancy (need more iron, difficulty ingesting/metabolising iron / risk of bleeding)
recommendations
- - Hb >90, Ferritin 12(28wks)-
Diet (iron with Vit c (Eg juice/ fruit), avoid Ca (dairy) + caffeine
- oral iron, 60-80mg, intermittant. discuss adverse effects (Constipation)
- recheck in 1mth
- ask about it at next appointment
Hb<90, not responding to treatment. (Esp close to birth) - Consult.
recommend Iron infusion
may influence place of birth (increased risk of PPH)
recommend managed 3rd stage- increased risk of PPH
Important to do CBC after birth, review iron again
Consider checking for other reason for low iron (folate / B12)
2) Thrombophlebitis
MW management
- diagnosis
- information sharing ( treatment / ongoing)
Diagnosis
- vein is swollen / gnarly/ raised above skin
- uncomfortable, may be tender along vein.
- purple / blue skin after inflammation settles
- temperature
**information sharing
**common, usually goes away after pregnancy ( but not always)
caused by 1) vessel stasis (blood pooling due to CO increased / progesterone/ uterine pressure on IVC/ pelvic arteries) 2) increased coagulation
small risk of developing into thromboembolism - DVT/ pulmonary embolism
treatment -warm compress, elevation, analgesia (paracetamol), anti-inflammatory cream (pp), compression stockings, keep active,
monitor-
-signs of DVT- increased swelling ,throbbing, pain when putting pressure on it, pain in back of leg, rednes throughout area (not just vein),
signs of pulmonary embolism - unsual feeling anxiety / shortness of breath, tightness in chest, coughing up blood-emergency
signs of infection- feel unwell / pain becoming worse / redness spreading- antibiotics.
**prevention- **
hydration, mobility, avoid prolonged sitting, may consider coagulation therapy if further risks (E.g. caesarean birth)
if concerned it is DVT- can do USS on affected area
if there are recurrent thrombophelbitis- could consider bloot test to look at coagulapathy
3) Asthma
condition / risks in pregnancy / MW care
condition
inflammatory response to allergins
causes overproduction of mucous + damage to epithelium = bronchoconstriction
cauess airway lumen to narrow.
makes it difficult to breath / expiratory exhalation- temporary hypoxia
risks in pregnancy
pregnancy hormones / changes in respiratory system can affect asthma
1/3 people get better (progesterone reduces brochoconstriction)
1/3 worse (respiratory output increased / more presure)
1/3 no change.
uncontrolled asthma can be dangerous for baby + mum (PE, hypertension, SGA, IUGR miscarriage, preterm labour + birth)
MW care
hx taking (understand current asthma control): - triggers , - symptoms (wheezing/ breathlesness, coughness, tightness in chest), effects at night / waking, any activities restricted, what meds do you use / how often
information sharing
- risks in pregnancy of uncontrolled asthma
-importance of monitoring / meds (aerosol has low risk to baby)
recommendations
know your triggers and avoid in pregnancy
consider vaccine for flu / Covid
review / titrate meds- offer referral for primary consult (GP)
4) PCOS- characteristics / pathophysiology
endocrine disorder
characteristics
- cysts on uterus
- increased androgen activity (male sex hormones)
- anovulation/ oligo ovulation
- metabolic condition ( central adipose tissue/ insulin production / insulin resistance)
- male hair distribution, acne
Pathophysiology
altered ovarian hormones - low FSH / high Ovarian hormones
increased androgen hormones
follicles don’t develop properly-
ovulation may not occur (oligo ovulation / anovulation)
progesterone release disrupted
menstruation / fertilisation may not occur.
immature follicles form fluid filled cysts that remain on follicle.
increased androgens cause hair / acne / insulin resistance
**treatment
**weight loss , surgery to remove follicles, contraceptive pill (Reduce androgen / manage acne)
5) endometriosis
(presentation, pathophysiology, diagnosis, treatment)
presentation
pelvic pain / pain during sex / menstruation
variation bleeding
bowl issues
**pathophysiology
*** endometrial cells found outside uterus- trapped in pelvic cavity
* endometrial cells respond to uterine cycle hormones-proliferate/ secrete / menstruate (Shed)
* bleeding irritates surrounding tissue - forms lesions, cysts that can rupture and form scar tissue.
* scar tissue can obstruct pelvic structures, and cause pain ( pelvic pain, during sex/ menstruation / bowel movements/ infertility)
**diagnosis **
laparascopy - size / # / distribution of lesion
**treatment **
laparascopy to remove lesions / cysts
pain relief
contraceptive pill- may reduce endometrial tissue
6) ART- MW management
ART
1) detailed hx about ART
conception jouney - reason for ART / type of ART used / feelings associated with experience
2) full hx- other medical conditions/ risk factors / family history
3) gently / sensitively explain ART is associated with icnresed risk of pregnancy challenges
- misccariage, preterm labour + birth, SGA + IUGR.
at this stage no referrals required (unless other indicators).
4) encoruage importance of diet nutrition, stress.
5) explain that there is montiroing recommended for all women that will screen for risks and then can provide additional management
(explain BP, urinalysis, palpation)
5) acknowledge high level of medicalisation up to this point, ask how they want the rest of hte pregnancy to be- and discuss how you can support this.
7 ) MW management -obesity
Hx taking, information sharing, Referrals
Hx
- diet (what + how much is she eating / access + availability + knowledge of nutrition)
- lifestyle ( stress /exercise)
- family / personal conditions (DM/ CVS /endocrine/ mental health)
information sharing
-promote value of nutrition + healthy lifestyle to optimise pregnancy outcomes
- explain that you recognise BMI is not perfect measure- promote health at every size.
- yet also
- - high bMI associated with pregnancy risks for mum and baby (PE, PIH, GDM, having caesarean + assisted birth), PTL + birth, large and small baby, growth restriction, stillbirth.
**-offer referral for consult BMI 30-49/ Referral for transfer of care (>50)
**Explain benefit is that can have multidisciplianry team to asses risk / provide support (dietician/ preventative support e.g. lda calcium )
acknowledge that health system is focused on BMI- intimidating.
demonstrate desire to support / not jduge - encourage informed cosnent.
9) Hyperthyroidism
definition / Pathology/ signs / risks in pregnancy
definition
* increased TH / reduced TSH
Pathology
* overactive Thyroid gland - increased blood flow / iodine consumption / hyperplasia of gland (goitre)
excess thyroid hormones - increased basal metabolic rate + SNS activation
effect on cells = thyrotoximosis
when hyperthyroidism is poorly controlled- physical / emotional pressure (e..g L&B, diabetic ketoacidosis, PET) can cause Thyrotoximosis to become “thyroid storm”
Thyroid storm- acute life threatening emergency (congestive heart failure, angina, tachycardia, fever, Delirium, agitation)- intensive care.
Risks
uncontrolled hyperthyroidism
-IUGR / PTL+Birth/ Stillbirth/ neonatal graves disease/ thyroid storm
MW management
take history - ask about current thyroid levels, symptoms (nervousness, tachycardia, weight loss, bulging eyes, tachyapnoea, irritation), management (endocrinologist / GP? / meds)
*information sharing
* pregnancy may improve hyperthyroidism (oestrogen)
* pegnancy hormones can make it difficult to assess effects of hyperthyroidism
* uncontrolled hyperthyroidism can be dangerous (thyroid storm)
* recommendation is specialist review + ongoing medication
Assessments
include thyroid assement in Bloods- T4/ TSH levels
Offer **Referral for consult
**three way consult to discuss risks of hyperthyroidism + review current levels, recommend management (likely oral antithyroid)
may recommend ongoing clinic to manage / titrate thyroid medication
10) Renal condition and PE
recognise mutual relationship between renal + PE
1) impaired renal condition is risk factor for PE
* renal impairment can elevate BP( BP may rise in effort to help clear waste in blood)
* renal impairement may impact GFR, which is beleived to be a cuase of PE
2) PE can worsen pre-existing renal condition
* excess proteinurea damages nephrons
* elevated BP leads to athlerosclerosis of renal arteries
12) Hep B -
describe condition + effect in pregnancy
describe MW management (Screening / referrals)
Condition
most common serious liver infection
viral transmission- affects liver
transmission- blood and fluids- highly infectious
most people develop resistance to “acute infection” within 6mths
small proportion become carriers - “chronic infection” . asymptomatic initiatally but then long term liver damage.
-treated with immunosuppresents
effect in pregnancy
risk that mum can pass hep b to baby in vitro- baby can develop chronic liver damage (cancer/ liver failure/ cirrhosis)
MW management
Hep B screening at booking
- ask if you / partner have / have had hep B / include hep B in serology / ask about Hep B vaccine
- ask how long you’ve had Hep B
**
information sharing**
- in vitro risk of transmission- baby can develop chronic liver disease
- recommendation -
-maternal- immunosuppressant in 3rd trimester
- neonate Hep B vaccine + immunoglobulin within 12hrs (baby has 95% chance of protection)
**Offer referral
**Consult- acute / chronic active
transfer- active chronic on immunosuppressants
Codeine abuse in pregnancy- MW management
understand usage / abuse
how much + how often / duration of use / withdrawal symptoms / have you tried to stop? what have you tried / motivation to stop?
information sharing
codeine is an opioid- very addictive.
in pregnancy, codeine deemed to be safe occasoinal use- but not long term.
Risk to baby: IUGR SGA Preterm labour, stillbirth. withdrawal symptoms at birth.
risks to sudden cessation (withdrawal symptoms on baby)
also not recommended with breatfeeding
recommendation
**referral to CDHB multidisciplinary drug cessattion clinic-
**support codeine cesastion with gradual withdrawal, using substitution replacement that is safer for baby.
obstetric / diet / psychologist / specialsist midiwfe/ social support.
depending on exposure to baby-
consider place of birth/ monitoring / **NICU involvement **
