Early Pregnancy Flashcards
1
Q
USS findings up to 4+3
A
nil
2
Q
USS findings up to 5/40
A
small sac + decidual reaction
3
Q
USS findings up to 5+5/40
A
gestation sac
4
Q
USS findings up to 6/40
A
yolk sac, gestation sac ~6mm double bleb sign
5
Q
USS findings up to 7/40
A
fetal pole 1-2mm
FHR 100-115bpm
Sac ~10mm
6.5= 5mm FP
6
Q
USS findings up to 8/40
A
CRL 11-16mm
caudal and cephalad ends
7
Q
USS findings up to 9mm
A
CRL 17-23mm
limb buds
head
8
Q
USS findings up to 10mm
A
CRL 20-30mm
FHR 170-180
movements
nuchal translucency
?brain/rhombencephalon
9
Q
Group A strep in pregnancy
A
Risk of sepsis, necrotising fasciitis and toxic shock syndrome
treat with oral penicillin/vaginal clindamycin
10
Q
Choriocarcinoma staging
A
FIGO classification
1- womb
2- womb + vagina/ovary
3- lungs + around womb
4- liver +brain
11
Q
Choriocarcinoma poor prognostic factors
A
AGE- >40
antecedent pregnancy mole<TOP<birth
months taken (longer=worse)
hcg1000, 10000, 100000, 100000
size <3, 3-5cm, >5cm
mets
number of mets
failed chemo, 1 drug, 2 drug
12
Q
Choriocarcinoma treatment
A
low risk – 6 or less (single drug CT)
high risk – 7 to 12 (multi drug CT)
ultra high risk – 13 or above (induction CT then immunotherapy)
13
Q
Screening <10/40
A
Sickle cell/thalassemia
14
Q
Screening 8-12/40
A
FBC, G+S (Rhesus status)
HIV/STS/HBcAb
15
Q
Screening 11-14/40
A
fetal anomaly scan
Screen for Downs/Edwards/Patau
Nuchal translucency + PAPP-A + HCG
+ve = <1 in 150 or 2 abnormalities on USS
16
Q
Definitive testing
A
CVS
11-14/40
placental biopsy
1% risk loss
Amnio
15-20/40
99.9% accuracy
0.5-1% risk loss
await BBV screen (wait until VL undetectable)
1 in 1000 risk sepsis
17
Q
Quadruple test
A
18
Q
Screening 18-20 weeks
A
fetal anomalies (anatomy scan)
placental location- confirm at 32 and 36/40
19
Q
Anti D
A
Give 28 weeks
(also if ectopic, SMM)
1) fetomaternal haemorrhage- sensitising event
2) 2nd exposure (eg in next pregnancy), maternal antibodies cross placenta= haemolysis and anaemia
Anti D binds to Rh+ve cells in maternal circulation so that no immune response is triggered
20
Q
How many antenatal appointments?
A
Primip- 10
multip- 7
21
Q
Smoking in pregnancy
A
risk of:
prematurity, still birth, low birtweight
Nicotine replacement= ok
buproprion/varenicline= avoid
22
Q
Epilepsy
A
10 fold increase risk of death
5mg folate 3/12 prior to conception, ideally seizure free 12 months
tonic clonic seizure= risk of fetal hypoxia/SUDEP
Optimal treatment:
monotherapy
Keppra, Lamotrigine or Carbamazepine
23
Q
Cardiac Disease
A
40-50% increase in CO/plasma volume, 75% in 1st trimester
changes uteroplacental flow
increase VTE risk
WHO 4= termination (EF <30%)
24
Q
warfarin
A
crosses placenta
limb changes, nasal hypoplasia, ocular/CNS changes, Intracerebral haemorrhage
25
rivaroxaban
crosses placenta (avoid)
26
ACEI/ARB
teratogenic- avoid
change fetal RAAS:
reduce vascular tone
renal tubular dysgenesis
oligohydramnios
hypocalcuria
27
IBD
active disease- adverse outcomes
time of conception:
IBD in remission- 30% chance of flare (same as non pregnant)
active- flares and adverse outcomes more likely
28
steroids and hydroxycholoroquine
for IBD in periconception/first trimester
29
methotrexate
avoid 3/12 prior to conception
30
Monoclonal antibodies for IBD
ok, except:
tocilizumab- stop 3/12 before
rituximab- stop 6/12 before
31
sulfasalazine
changes folate pathway
5mg folate is taking
32
Obesity
Increased risks if BMI >30
good to lose 5-10% of weight
5mg folate 1/12 prior and 1st trimester
33
Vaccinations
2 x MMR
- at least 1 month before trying to concieve
HBV
- safe in pregnancy
Varicella
- if no history of chickenpox and IgG negative, and immunocompromised/healthcare or lab worked- vaccinate
-then wait 1/12 to concieve
34
Vitamin D
10mcg/day (400 IU)
35
Zika virus
wait 8 weeks if female went to area
wait 6 months if male went to area
36
Who needs 5mg folate?
either partner neural tube defect or FHx of this
Anti-epileptic medications
Diabetic
sickle cell
thalassemia/trait
BMI >30
37
Syphilis- risk
still birth, prematurity, neonatal death, delayed development, blindness/deafness, seizures
38
Gonorrhoea- risk
chorioamnionitis, PROM, preterm birth, conjunctivitis
39
Chlamydia- risk
conjunctivitis, pneumonia
40
HIV- risk
low birthweight, prematurity, still birth
41
Toxoplasmosis
intracellular protozoan parasite found in uncooked meat/cat faeces
most severe if <10/40
diagnosis bia PCR
treat if immunocompromised (spiromycin)
risk- chorioretinitis, hydrocephalus, rash, intracranial calcifications
42
Rubella
Single stranded RNA togovirus
droplet infection (incubation 2 weeks)
mum- lymphadenopathy, polyarthritis, rash
baby- sensorineural deafness, cataracts, rash, cardiac problems
no treatment
live vaccine- avoid if pregnant
43
CMV
1 in 4 babies have long term neurodevelopmental problems
10% neonates asymptomatic
-petechia, jaundice, hepatosplenomegaly, CNS problems, LBW
-15% isolated sensorineural hearing loss
increased risk if primary in pregnancy (30-40% transmission, less if recurrent)
diagnosis by amnio
avoid children's saliva, sharing food and good hand hygiene after nappy changes
44
HSV
primary in 1st trimester or 6/52 priro to delivery
rarely transplacental infection
aciclovir 400mg BD from 32/40
CNS problems, eye, skin, mouth disease
45
VZV
DNA virus in herpes family
mum- pneumonia, perihepatitis, encephalitis
-droplet/contact/fomite spread (infectious from 48hr before rash until crusted)
Incubation 1-3 weeks
fetal varicella syndrome
-skin scarring (dermatomal distribution)
-eye defects
-limb hypoplasia
-neurological problems
46
Folate in pregnancy
essential for growth/development
inhibit dihydrofolate reductase:
methotrexate, sulfasalazine, trimethoprim
-stop folate being metabolised to active form
reduce absorption/increase degradation:
-valproate, phenytoin, carbamazepine
47
Neural crest
Needs vitamin A
-retinoids
features:
growth delay, craniofacial changes, CNS, VSD, thyroid issues
48
Oxidative stress
cell death/changes to gene expression
birth defects, growth retardation, intrauterine death
eg;
thalidomide, valproate, amiodarone (class 3 antiarrhythmics)
49
Vascular disruption
hypoxia, peripheral vasculature most susceptible (intestine/limbs)
misoprostol, ergotamine, aspirin, pseudoepinephrine
50
Statins
HMG-CoA reductase inhibitors
reduce cholesterol (important precursor for growth and steroid hormones)
birth defects
51
acetazolamide
carbonic anhydrase inhibitos
changes pH of cells
limb deformities
52
alcohol
crosses placenta and fetal liver cannot metabolise- prolonged exposure
changes to nervous system
1/3 of alcoholic mothers= FAS in neonate
short nose, low nasal bridge, small head/eyes, indistinct philtrum
53
valproate/topiramate
neural tube defects
facial cleft
hypospadias
reduce cognition
autism
54
phenobarbital
cardiac abnormalities
55
phenytoin/carbamazepine
clef palate
56
lithium
cardiac abnormalities
57
NSAIDs
>30/40- premature closure of ductus arteriosus
pulmonary hypertension
oligohydramnios
58
Recurrent miscarriage
3 or more first trimester
guideline is to use judgement and investigate after 2 if suspect pathology
Advice
BMI between 19 and 25
stop smoking/alcohol
<200mg caffeine/day
59
Tests for recurrent miscarriage
acquired thrombophilia- lupus anticoagulant and anticardiolipin
3D USS (resect if septum)
TFTs + thyroid peroxidase antibodies (only treat if not euthyroid)
60
Tests for second trimester miscarriage
Factor V Leiden
prothrombin gene mutation
protein S deficiency
61
Cytogenetics of POC
third miscarriage or 2nd trimester loss
62
Antiphospholipid syndrome
aspirin and heparin from +ve test to at least 34/40
63
Threatened miscarriage
FH and IUP and vaginal beeding
If previous hx of miscarriage:
400 mg micronised vaginal progesterone twice daily at the time of bleeding until 16 weeks
64
Risk factors for recurrent miscarriage
advanced maternal>paternal age
black
alcohol/smoking/caffeine/BMI
previous miscarriage
65
Diagnosis of miscarriage
1) check for FH
2) FH + CRL >7mm- 2nd opinion to confirm
<7mm- repeat USS 7/7
3) No CRL? MSD (should equal 30 + days of pregnancy)
>25mm= 2nd opinion
<25mm- repeat USS 7/7
(do repeats in 14/7 if TA only)
66
Expectant management of miscarriage
7-14/7
c/i if: high risk haemorrhage, previous trauma, infection
review in 2/52, UPT 3/52
67
Medical management of miscarriage
Vaginal (oral if declines) misoprostol
800mcg if complete
600mcg if incomplete
give analgesia and antiemetics
safety net to return 24hrs nil bleeding
68
Surgical management of miscarriage
MVA+ LA
SMM + GA
Should offer choice of either if clinically appropriate
69
PUL
absence of a intrauterine or extrauterine gestation sac
hcg >63% in 48hr- likely viable IUP, USS 7-14/7 (sooner if >1500)
hcg >50% 48hr- likely miscarriage, UPT 2/52
somewhere in between- review in 48hrs
Stop progesterone as can prevent expulsion
70
M6 model
hcG + progestoerone
P>2= continuing
P<2= failing
71
Ectopic pregnancy USS findings
adnexal mass moving separately to ovary
inhomogenous/non-cystic
pseudosac (20-40%)
extrauterine GS (15-20%)
free fluid (although also present in IUP)
BHCG >1500
Different managements do not have differing impacts on future fertility
72
Ectopic- expectant management
clinically stable, no pain
<35mm, no FH
hcg 1000-1500
can return for follow up
HCG on D2, 4 and 7
drop >15% then weekly reviews until <20
drop <15%= review
73
Ectopic- medical management
no significant pain
unruptured
<35mm
no FH
<5000 hcg
no IUP
74
Methotrexate for ectopic
50mg/m2 IM STAT
BHCG on d4 and 7
drop >15% then weekly
65-95% sucess, up to 1/3 need another dose
s/e
Serious: BM suppression, pulmonary fibrosis, liver cirrhosis, gastric ulcers, renal failure
Common: stomatitis, transient transaminitis, flatulence, bloating
await 3/12 before trying to concieve- cleft lip/spina bifida
75
Surgical management of ectopic
unable to attend follow up
mass >35mm
significant pain
fetal heartbeat
bHCG >5000
Anti D if rhesus negative, 250IU
76
Gestational Trophoblastic disease
abnormal trophoblast proliferation
1 in 714 livebirths
increased risk- asian, extremes of age
Symptoms:
HG
uterine size larger than expected
early pre-eclampsia
theca lutein cysts
diagnosis (histology):
absence of fetal tissue (complete) some if partial
hydropic villi
suction + Anti D
77
Complete mole
diploid (empty ovum, 2 sperm (80%) or 1 sperm double DNA)
hcg d56, if normal repeat in 6/12 (or until 6/12 after normal)
78
Partial mole
9/10 2 sperm and 1 egg
follow up until hcg normal on two samples 4 weeks apart
79
Molar pregnancy
1 in 500-1000
abnormal trophoblast proliferation and fetal development due to abnormal chromosomes
more paternal chromosomal material
GTN (0.5% partial, 15% complete)
Common cause of 1st trimester loss
80
Choriocarcinoma
1 in 50000
most common after molar pregnancy, sometimes live birth
localised/metastatic disease
months/years later
81
Placental site tumour
<5 cases/year
changes to bleeding/amenorrhoea after pregnancy
highly curable
82
Further treatment for molar pregnancy
chemo
0.5%-1% after partial mole
13-16% after complete
cure= 100%, 80% have subsequent pregnancy
FIGO <6= MTX
>6= multiagent CT (94% cure)
83
Conceiving after molar pregnancy
12/12 if had chemotherapy
when follow up complete otherwise
84
Mifepristone
anti-progestational synthetic steroid
compete with progesterone at its receptors
antagonises endometrial/myometrial effects
sensitise to misoprostol
dilates and softens cervix
1 in 2 will have light bleeding
85
Misoprostol
synthetic PGE1 analogue
contractions of smooth muscle fibres of myometrium (uterotonic)
relaxation of cervix
800mcg, then 400mcg every 4 hours (especially if >9/40)
More sensitive at higher gestations- lower dose/longer intervals
86
Dilapan
4mm to 15mm
moisture from cervix into rods
87
Abortion- side effects
1 in 20 (Common)
pain
bleeding
infection
ERPC (often conservatively treated)
failure
1 in 100-1000 (Uncommon)
trauma/perforation of cervix
damage to surrounding structures
88
Contraindications to mifepristone
?ectopic
asthma
porphyria
previous allergy
adrenal failure
89
Anti D- abortion care
>12/40
90
What is beta thalassemia?
major need >7 transfusions a year
intermedia <7
minor/carrier= no transfusions
change to globin chain synthesis (red cells do not carry enough haemoglobin)
autosomal recessive (major= both, minor=one)
91
Management of beta thalassemia
may have reduced fertility
higher risk DM/thyroid/parathyroid issues
iron chelators are teratogenic
5mg folate
hep B vaccine (test for Hep C)
higher risk of poor outcome ie miscarriage/FGR
92
Pregnancy test sensitivity
HSUP 20
LSUP 1500-2000
93
Pre-implantation screening
If undergoing IVF
autosomal dominant
serious autosomal recessive
chromosomal disorders (eg deletion, translocation etc)
sex linked disorders
single gene defects
confirmed with amniocentesis/cvs
94
Screening at Booking appt
MC+S (asymp bactiuria)
Blood group
anemia (and at 28/40)
-haemoglobinopathies
HIV/HBV/Sickle/thalassemia (alpha and beta)
BP/BMI
95
First Scan screening
National Screening Programme (aneuploidy/neural tube defects)
Patau, Edwards and Down's
11-14 /40
High risk >1 in 150
Maternal Age + NT + PAPP-A + HCG
-Pappa A low in Tr21
-HCG high in Tr21
78% pick up, 3% false positive
- off NIPT to confirm
96
Low Papp-A
placental insufficiency
high risk:
PET
IUGR
PTB
Aspirin 150mg PO OD until 36/40, need serial growth scans
97
Quadruple Testing
If missed combined test
14-20/40
HcG, UE3, AFP, Inhibin A
only screens for Tr21
98
Mid T scan
18-21/40
Lethal abnormalities
33 conditions looked for, check anatomy
eg anencephaly, gastroschisis, T18/13, spina bifida
should be seen by FMU in 5 days
if unable to complete, need to repeat before 23/40 (so can have TOP)
99
Diabetes screening in pregnancy
BMI >30
previous baby >4.5kg
1st degree relative DM
country of birth
glycosuria +2 1 occasion or >1 on 2 occasions
OGTT- 2 hr 75g glucose at 24-28 weeks
Previous GDM
early checking of BMs or OGTT at 16-18 weeks
100
OGTT results
fasting >5.6
2 hour >7.8
101
Retina screening
pre pregnancy and each trimester if previous diabetes
102
Aspirin in pregnancy
>40yo
BMI >30
IPI >10 years
Family/personal hx of PET
HTN
Vascular/renal disease
Multip
103
Placental localisation
20/40
32/40
36/40
104
When is GBS screening performed?
36/40 (not universal)
Intrapartum antibiotics (benzylpenicillin)
If treated >4hrs before delivery, nil rx for baby
105
Ectopic pregnancies by location
95% Tubal (75% ampulla, then isthmus, then fimbria)
1-6% interstitial
3% ovarian
1% abdominal
<1% cervical
<0.1% heterotopic
106
Parvovirus b19
fetal anaemia, heart failure, and hydrops
<15 weeks gestation - 15%
15 - 20 weeks - 25%
Term - 70%
If pregnant woman has had exposure- serology needed
IgG +ve = immune
IgM +ve= recent infection
Refer to fetal medicine
107
Management of chickenpox exposure
Serology
Exposure:
Non immune- aciclovir d7-14
if c/i can give IG up to d10
Infection:
aciclovir within 24hrs of rash onset
IV if severe
live vaccine= avoid if pregnant
108
HBV
HbSAg +ve- refer to gastro within 6 weeks
possible rx in 3rd trimester
TDF if dna >10000000 to reduce hbv to baby
-risk 10% if HBsAg
90% if also eAg
most infections occur at time of delivery, 90% prevented if vaccinated baby
increased risk- miscarriage, preterm birth, low birth weight
can BF
109
HAV
not teratogenic but increased miscarriage/prematurity
proportional to severity
?vertical transmission (case reports)
case based decision re BF
