Early Pregnancy Complications Flashcards
What regimen of folic acid should be used pre-pregnancy and for how long?
What patient groups require an alternative regimen? What is the regimen they should be prescribed?
0.4mg/day from 1 month pre-conception to 13 weeks gestation.
5mg/day if previous neural tube defects, on antiepileptics, diabetic, obese, HIV+ on co-trimoxazole prophylaxis, sickle cell disease.
What drugs are teratogenic?
Use TERALOWA + ACT to remember.
Thalidomide Epileptic medications Retinoid (Vitamin A) ACEi/ARB Lithium Oral contraceptive and hormones. Warfarin Alcohol \+ Aminoglycosides Chloramphenicol Tetracyclines
What are 6 main risk factors for ectopic pregnancy?
Damage to tubes Previous ectopic Endometriosis Progesterone-only pill Intrauterine contraception IVF
What is the gold-standard investigation for ectopic pregnancy?
Trans-vaginal USS
What is expectant management for ectopic pregnancy? When may this approach be used?
Monitor over 48 hours, b-hCG should fall. If not, intervention is required.
Only if asymptommatic.
What is the medical management of an ectopic pregnancy?
What follow up tests are required to confirm successful treatment?
A single dose of methotrexate. b-hCG at day 4 and 7 to confirm.
What is the surgical management of ectopic pregnancy?
Laparoscopic salpingectomy (removal of tube) if contralateral tube is ok.
Salpingostomy to preserve fertility if contralateral tube is damaged/absent.
What are the main indications for surgical management of ectopic pregnancy?
> 35mm, has ruptured, heartbeat present, b-hCG > 5000 IU
How is a molar pregnancy managed?
Managed at specialist centre.
Gentle suction to remove molar products.
Anti-D if indicated by mother’s Rhesus status.
Pregnancy to be avoided until b-hCG normalises (utilise contraception for up to 12 months if necessary)
Screen for choriocarcinoma - responds well to methotrexate-based chemotherapy.
What is a threatened miscarriage?
When the cervical os is closed but there has been some PV bleeding. Often no associated pain.
What is an inevitable miscarriage?
When the cervical os is open and there is PV bleeding/clots. Often associated pain.
What is an incomplete miscarriage?
When most of the products have been passed, but some remain. There is pain and PV bleeding.
What is a missed miscarriage?
When the foetus dies or doesn’t develop, but is still present in utero.
The cervical os is closed. Occurs at < 20 weeks. Light PV bleeding, no associated pain.
When would you utilise expectant, medical and surgical management of a miscarriage?
Expectant - most cases will be managed this way initially.
If there is signs of infection or haemorrhage: move straight to surgical.
If expectant management does not work after 14 days, move to medical or surgical.
What does medical and surgical management of miscarriage involve?
Medical - vaginal misoprostol + anti-emetics + analgesia.
Surgical - vacuum aspiration (suction curettage) as out patient OR evacuation of uterus under GA.
How may you treat recurrent miscarriage in antiphospholipid syndrome?
Low-dose aspirin + daily frogmen (dalteparin)
When is abortion typically permitted up until?
24 weeks
How is medical abortion performed? At what length in gestation is medical abortion utilised?
Utilised up to 23+6 weeks. If < 10 weeks, can be performed at home.
From 10+1 to 23+6, a single dose of oral mifepristone is used.
Misoprostol is then given 36-48 hours later, up to 5 times in a day.
How is surgical abortion performed?
< 14 weeks - vacuum aspiration
> 14 weeks - dilation and evacuation.
Misoprostol used to dilate and soften cervix.
What are the 3 considerations post-abortion?
Pain/bleeding? - if not, may be appropriate for same day discharge
Contraception
Anti-D if > 9+6 weeks
When does hyperemesis gravidarum normally occur?
1st trimester (0-13 weeks). Normally settles by 2nd trimester (14-26 weeks)
What are the 1st and 2nd line antiemetics for hyperemesis gravidarum?
1st line - cyclizine, prochlorperazine
2nd line - ondansetron, metoclopramide
What additional treatments can be used for hyperemesis gravidarum, excluding anti-emetics?
Rehydration - 0.9% NaCl + K, or Hartmann’s
H2 receptor antagonist/PPI for associated reflux
Steroids if vomiting is intractable.
What supplements/medications are used in multiple pregnancy?
Folic acid, iron and low-dose aspirin.
When should dichorionic diamniotic twins and monochorionic diamniotic be delivered?
DCDA - 37-38 weeks
MCDA - 36 weeks with use of steroids
How should triplets and monochorionic monoamniotic be delivered?
Triplets - c-section
MCMA - c-section at 34-36 weeks
What is Twin-Twin transfusion syndrome? How is it managed?
One baby gets less blood supply, the other gets two much. Leads to anaemia/oligohydraminos and polycythaemia/polyhydraminos of twins.
<26 weeks - fetoscopic laser ablation
>26 weeks - amnioreduction/septostomy
At what stage in gestation can hypertensive disorders of pregnancy be diagnosed?
> 20 weeks
Before is considered pre-existing hypertension.
How is pre-eclampsia differentiated from pregnancy-induced hypertension
Both have hypertension.
Pre-eclampsia has additional signs (proteinuria, signs of other end-organ involvement - LFTs, creatinine, thrombocytopenia)
When is pre-eclampsia considered mild, moderate and severe?
Mild - 140-149, 90-99
Moderate - 150-159, 100-110
Severe - >160, >110 or neuro signs or end-organ damage
What monitorin is indicated in mild pre-eclampsia? When should delivery occur in these cases?
4-hourly BP
2x weekly FBC, LFT, renal function
Growth scans every 2 weeks
Induction at 37-40 weeks
What monitoring and management is indicated in moderate pre-eclampsia? When should delivery occur in these cases?
4 hourly BP
3x weekly FBC, LFT, renal function
Growth scans every 2 weeks
2x daily CTG
Management:
Admit
Antihypertensives (nifedipine PO, labetalol IV, hydralazine IV)
Induction at 37-40 weeks
What is the management for severe pre-eclampsia?
Antihypertensives (Nifedipine PO, IV labetalol or hydralazine)
If refractory, prophylactic magnesium sulphate.
Deliver > 34 weeks, steroids for lung maturity.
What is eclampsia, how is it treated?
Pre-eclampsia + seizures
Magnesium sulfate
Diazepam if refractory
What is HELLP syndrome? How is it managed?
Haemolysis, elevated liver enzymes, low platelets.
Complication of (pre-)eclampsia.
Managed as per eclampsia, induction also.
How is gestational diabetes managed?
Clinic, dietician, 30 mins daily exercise.
If ineffective: Metformin 1st line
Glibenclamide 2nd line
If macrosomia, or polyhydraminos - offer insulin therapy.
At what gestational period does a miscarriage become a stillbirth?
24 weeks
How is gestational diabetes diagnosed?
Fasting BM > 5.6 or OGTT >7.8.
Perform OGTT if history of diabetes, obesity or family history.
How is pre-term rupture of membranes handled?
10 days erythromycin
Corticosteroids for foetal development
Deliver after 34 weeks
How should cholestasis of pregnancy be managed?
Ursodeoxycholic acid and delivery at 36-37 weeks
