HD2 Revision2 Flashcards
Name 5 risk factors for gestational diabetes
Previous gestational diabetes
Family history of diabetes
Previous macrosomic baby
Previous unexplained stillbirth
Obesity
Glycosuria
Polyhydramnios
Large for gestational age in present pregnancy
Explain pathophysiology of gestational diabetes
Pregnancy is a state of insulin resistance - gestational diabetes is an extreme of this
Foetus needs glucose to grow: gets from mother
Via the placenta: foetus puts out hormones HPL, cortisol and glucagon that makes the mother insulin resistant, so that she cannot use glucose as readily.
Mother will make more amino acids and fatty acids as a result of insulin resistance and some of these pass through to placenta too.
Glucose is transported to the foetus: causes the foetus to have hyperinsulinaemia
This increases growth of baby as glucose is turned into carbs / fats and birth weight goes up
Name short term [4] and long term [3] potential consequences to the baby of having gestational diabetes
Short term:
* Macrosomia
* Neonatal hypoglycaemia
* Shoulder dystocia
* C section liklihood
Long term:
* Obesity
* DMT2
* CVD
* Respiratory distress syndrome
* Polyhydramnios
Which hormones are secreted by the baby that causes insulin resistance in the mother? [4]
HPL (Human placental lactogen - causes insulin resistance), hPGF (human placental growth hormone) cortisol and glucagon
What are potential complications for mother of gestational diabetes? [5]
- Pre-eclampsia
- Infection
- Thromboembolic disease
Other potential complications:
* Nephropathy
* Retinopathy
* Coronary artery disease
* Poor wound healing
* DMT2 in the future
How do you manage gestational diabetes? [4]
Dietary modification: calorie reduction
If not successful in reducing hyperglycemia: give insulin
Can also give metformin: crosses the placenta so also helps treat foetus
Regular ultrasound every 2 weeks to monitor fetal growth
The screening test of choice for gestational diabetes is? [1]
The screening test of choice for gestational diabetes is an oral glucose tolerance test (OGTT).
An OGTT is used in patients with risk factors for gestational diabetes, and also when there are features that suggest gestational diabetes:
What type of anaemia normally occurs during pregnancy? [1]
Explain physiology of why anemia occurs in pregnancy [1]
How do you treat? [1]
Usually IDA
Blood volume goes up but erythrocyte number doesn’t increase to same extent
Treatment: oral iron tablets
What is the name of this consequence of oligohydramnios? [1]
Potters facies / sequence
When is cytomegalovirus (CMV) the biggest risk for a baby? [1]
How does CMV appear histoligically
(CMV: 50% of adults are CMV IgG +ve)
Problematic if mother becomes infected during early pregnancy / first trimester
Histologically: owl eye in cells
What are pathological consequences of cytomegalovirus infection in early trimester for baby? [4]
- Sensorineural deafness: Hearing loss; Vision loss
- Severe intrauterine growth retardation (IUGR)
- hepatosplenomegaly
- microcephaly
What score on oral glucose tolerance test would indicate GD fir fasting and at 2 hrs? [2]
Normal is:
Fasting: < 5.6 mmol/l
At 2 hours: < 7.8 mmol/l
cutoff for gestational diabetes as simply 5 – 6 – 7 – 8.
What are the 8 types of spontaneous miscarriage [8]
State in each if there is vaginal bleeding or not [8]
Complete: vaginal bleeding, both placenta and embryo expelled
Incomplete: vaginal bleeding, embryo commonly lost, placenta retained
Threatened: vaginal bleeding, fetal activity (can be potentially saved)
Missed: embryo and placenta is still in uterus, but embryo is dead. no vaginal bleeding
Recurrent: history of more than 3 spontaneous abortions
Inevitable: vaginal bleeding embryo and placenta are on the way out / coming
Septic (Rare often results from non sterile use pelvic instrumentation)
Therapeutic
Which causative agents commonly cause a septic miscarriage? [3]
Explain why a septic miscarriage occurs [1]
What are causes of septic miscarriage? [2]
Usually due to Staph aureus
N. gonorrhea, C. trachomatis
Causes the contents of the uterus to be infected & causes endometritis (so may present with signs of pelvic infection)
Causes:
* Unsafe abortion
* Cervical incompetence
How do you investigate for a spontaneous miscarriage? [3]
- Ultrasound scan: ID if placenta is attached to the uterus
- Serum BetaHCG indicates that placenta is there (doubles every two-three days) - if placenta not attached to uterus the hCG levels will not rise
- Rhesus status
Management of miscarriage?
- medical [1]
- surgical [1]
- for rhesus negative women [1]
Medical:
* misoprostol - cause the uterus to contract to expel the products of conception that are still there
Surgical:
* Surgical aspiration - gentle suction to remove the pregnancy
* Curettage (spoon-shaped instrument) to remove abnormal tissues.
Anti D to rhesus negative women
How do you ID cervical incompetence
Funnel shaped cervix on ultrasound
How do you manage cervical incompetence? [1]
Transvaginal cerclage: Ring of stiches around cervix
(In a transvaginal cerclage (TVC), doctors sew the cervix closed, usually during the 13th or 14th week of pregnancy. At 36 weeks, the stitches are taken out so the woman can deliver her child naturally)
How would person with ectopic pregnancy present? [6]
- Women of reproductive age
- Positive pregnancy test/ Amenorrhoea 4-10 weeks
- PV bleeding
- Low abdominal pain - in right or left iliac fossa
- Collapse +/- shoulder tip pain
- Beta hCG is lower that normal (because no placenta in the uterus)
- No products of conception in the uterus
Define Gestational trophoblastic disease (GTD)
What is a partial mole? [1]
What is a monospermic complete mole? [1]
What is a dispermic complete mole? [1]
GTD: When the trophoblastic tissue that forms part of the blastocyst proliferates more aggressively than normal
Partial mole: two sperm fertilse an egg creating 69 chromosome
Monospermic mole: maternal chromosomes are lost AND paternal chromosomes double up to make 46 chromosome
Dispermic complete mole: maternal chromosomes are lost AND fertilisation by two sperm: 46 chromosome
Explain pathophysiology of complete molar pregnancy: GTD
How do you treat? [2]
Complete molar pregnancy: entirely paternal tissue
No fetal tissue at histology - just placenta.
Effectively a tumour:
* surgical removal - but 15% molar tissue remains in deeper tissues of the womb so:
* need chemotherapy to remove abnormal cells
Define placenta praevia [1]
What are the two types [2]
When placenta is inserted into lower segment of the uterus after 24 weeks
Major = covers cervix and internal os
Minor = marginal <2cm from internal os
Describe pathophysiology of pre-eclampsia
What are effects of pre-eclampsia? [2]
Normal spiral artery in placenta should widen – slows blood flow so nutrient exchange can occur
Pre-eclampsia this doesn’t happen. Spiral arteries stay narrow: goes in at high pressure.
This causes oxidative stress in the placenta, and the release of inflammatory chemicals into the systemic circulation, leading to systemic inflammation and impaired endothelial function in the blood vessels.
Causes: fetal growth restriction or pre-term birth
Explain the pathophysiology behind Hyperemesis Gravidarum
When does it peak? [1]
Correlates closely with hCG levels: which is what controls placental development.
hCG may stimulate oestrogen production from ovary causing vomiting and nausea
May be caused by vitamin B6 (Pyridoxine) deficiency (vit. B supplements cause reduction in symptoms)
Peaks at about 12 weeks
Why might hyperemesis gravidarum cause hosptialisation? [4]
- Dehydration
- Electrolyte imbalance
- ketosis
- weight loss
Name and explain the MoA of the anti-emetics you would use to treat hyperemesis gravidarum [4]
- Prochlorperazine (stemetil)
- Cyclizine: histamine H1 receptor antagonist
- Ondansetron: Blocks 5HT-3 in chemical trigger zone/vomiting centre
- Metoclopramide: Blocks D2 in chemical trigger zone/vomiting centre
- Vitamin B6
Name 5 reasons for bleeding in early pregnancy [5]
What is prognosis for bleeding in early pregnancy? [2]
- Cervical insensitivity
- Infection
- Molar pregnancy
- Subchorionic haemorrhage
- Implantation bleeding
50% will settle
50% will:
Miscarry (spontaneous abortion)
Have an ectopic pregnancy
Have trophoblastic disease (hydatidiform mole)
Have problems in late pregnancy
State in each type if the cervix is opened or closed
Recurrent miscarriage:
How many consecutive miscarriages needed to be classified? [1]
What investigations would you use for recurrent miscarriage? [3]
3 or more consecutive miscarriages before week 20
Investigations:
* Autoimmune + thrombophilia screen
* Karyotyping
* Pelvic US scan
What is twin to twin transfusion? [1]
Which type of pregnancy does it occur in? [1]
How do you treat? [1]
which twins share unequal amounts of the placenta’s blood supply resulting in the two fetuses growing at different rates.
Only affects mono-chorionic pregnancies
Treat with laser ablation on the anastomosing vessels
Explain what a partial molar pregnancy is [1]
Explain how a partial molar pregnancy occurs [1]
How do you treat? [1]
Happens when two sperm fertilise the egg at the same time- one set of chromosomes from the mother and two sets from the father: 69 chromosomes
Some fetal tissue might be seen within the molar tissue
Treatment:
Surgery to remove molar tissue - 1% have some remaining abnormal cells which require chemotherapy
Explain what placental abruption is and the pathophysiology behind it
How serious is a placental abruption? [1]
Blood accumulates behind the placenta: causes uterus to be hard / wood & the placenta comes away from uterine wall
Obstetric emergency!
How is placental abruption treated?
If the baby is dead? [1]
If no fetal or maternal distress? [1]
Deliver baby
Fetal distress: Urgent lower segment caesarean section
If the baby is dead: Coagulopathy likely, Induce labour when safe
If no fetal or maternal distress:
Steroids and observe
Where does trophoblast invasion occur to in normal pregnancy? [1]
Define what placenta Accreta/increta/percreta are [3]
How do you treat if maternal / fetal compromise at more than 37 weeks? [3]
Normal pregnancy: trophoblast invasion stops at the spongiosus layer of the decidua basaslis.
Accreta –chorionic villi attach to myometrium rather than restricted within decidua basalis. Most common
Increta – chorionic villi invade myometrium
Percreta – chorionic villi invade through perimetrium
Treatment:
* Emergency Caesarean plus hysterectomy
* Methotrexate
* Close pelvic vessels
Management of pre-eclampsia:
What BP should you aim for? [1]
What drugs do you use to stabilise mothers BP? [2]
Which anti-hypertensives & anticonvulsants would you use for acute [2] and chronic treatment? [2]
- BP aim: less than 135 / 85 mmHG
- Stabilise mothers BP: aspirin (from week 12 to birth); calcium supplementation (from week 20 onwards)
- Acute treatment:
Labetalol – alpha and beta blocker / antagonist
Hydralazine - Chronic management
Methyldopa – alpha 2 agonist (feeds back and stops noradrenaline being released)
Nifedipine - CCB
What is velamentous insertion of umbilical cord into placenta?
complication that happens when the umbilical cord from a fetus doesn’t insert into the placenta correctly.; instead it goes into amniotic sac
causes compression of own bloody supply
Which syndrome may pre-eclampsia lead to? [1]
What are the symptoms of this syndrome? [3]
Woman with this condition may develop the HELLP syndrome
This is characterised by haemolysis (raised LDH), elevated liver enzymes and low platelets.
Which condition can pre-eclampsia lead to? [1]
How can you prevent progession to this ^? [1]
What is the only definitive treatment for pre-eclampsia? [1]
A complication of pre-eclampsia includes progression to eclampsia, which should be prevented by administration of magnesium sulphate.
The only definitive treatment for pre-eclampsia is delivery
If a women has endometriosis and pain when defecating, where are the locations that might get likely accumulation of blood from the extra-pelvic endometrial tissue? [2]
Pouch of Douglas
Bowel
Diagnosis [2] and prophylactic for congenital toxoplasmosis? [3]
Diagnosis: PCR of amniotic fluid / maternal serology
Give prophylactic in mother:
- Pyrimethamine
- sulfadiazine
- folinic acid
HSV 1 and HSV 2 causes which type of pathologies? [2]
HSV-1: coldsores
HSV-2: genital herpes
Treatment for HSV-2? [1]
Prognosis if left untreated in baby? [1]
Acyclovir
65% chance of mortality if left untreated !
Group B Steptococcus neonatal infection can cause what 4 pathological consequences? [4]
Pneumonia
Meningitis
Non-focal sepsis
Death
Why does giving treatment for group B Strep not work throughout pregnancy? [1]
When can you give? [1] What drug is used to treat? [1]
If treat during pregnancy it just returns lol
Give benzylpenicillin in labour / from week 36
Treatment for UTIs? [3]
NICE Clinical Knowledge Summaries recommend trimethoprim or nitrofurantoin for 3 days
Treatment:
Penicillin’s
Cephalosporins ( β-lactam antibiotics)
Nitrofurantoin
Consequences of untreated Listeria / Listeriosis? [3]
Meningo-encaphalitis
Still birth
Neonatal sepsis / meningitis
Consequences of congenital syphilis
in early years? [6]
in late years? [6]
Early 0-2 years
* Rash
* Rhinorrhoea (mucus full of T.pallidum)
* Osteochondritis
* Perioral fissures
* Lymphadenoapthy
* Pemphigus syphiliticus
Late >2 years
* Hutchinson’s teeth
* Clutton’s joints
* Saber shins
* High arched palate
* Deafness
* Saddle nose deformity
* Frontal bossing
Pathological consequences of chlamdyia or gonorrhoea for new born foetus? [2]
Ophthalmia neonatorum:
* Unilateral or bilateral watery discharge becomes copious and purulent
* With gonococcal infection less inflamed
Pneumonia
Which of the following is caused by chlaymdia and gonorrhoea? [1]
Right is chlamdyia
When is greatest risk for child during pregnancy of parvovirus B19 infection? [1]
What cell type does parvovirus B19 attack? [1]
Biggest risk: 0-20 weeks. 9% of fetal loss
Attacks erythrocytes
Causes fetal anaemia
Potential consequences of parvirus B19 infection in pregnancy? [3]
Miscarriage or fetal death
Severe fetal anaemia
Hydrops fetalis (fetal heart failure)
Maternal pre-eclampsia-like syndrome
Can also cause fetal anaemia
What type of women are at increased risk of COVID-19? [1]
Which pro-inflammatory cytokine does COVID-19 cause to have a negative effect on baby development? [1]
At risk if have co-morbidities (c.f. those with no comorbid) - increased risk of death
Increased IL-6: negative developmental effect
Which pathology is associated with a molar pregnancy? [1]
Hyperemesis gravidarum [1]
What does this surgical treatment treat? [1]
Cervical incompetence (image is a transvaginal cerclage)
What is does the US show? [1]
Cervical incompetence
Listeria is a gram [] bacteria.
Listeria is [] shaped
Listeria is a gram positive bacteria.
Listeria is rod shaped
Listeria is a gram [] bacteria.
Listeria is [] shaped
Listeria is a gram positive bacteria.
Listeria is rod shaped
What does the US depict? [1]
placental abruption
Name this feature of late congential syphilis [1]
Clutton joints
A painless joint effusion in a child, usually in the knee, caused by inflammation of the synovial membranes due to congenital syphilis
Name this feature of late congenital syphilis [1]
Hutchinson teeth
is a sign of congenital syphilis, which occurs when a pregnant mother transmits syphilis to her child in utero or at birth. The condition is noticeable when a child’s permanent teeth come in. The incisors and molars take on a triangular or peglike appearance.
Name this feature of late congenital syphilis [1]
Saber shins
What is the arrow pointing to? [1]
velamentous insertion of umbilical cord into placenta
What is the pathology depicted here? [1]
velamentous insertion of umbilical cord into placenta
Name this early stage congenital syphilis symptom
Pemphigus syphiliticus.
Name this early stage congenital syphilis symptom
Pemphigus syphiliticus.
In cases where a mother has potentially come into contact with parvovirus B19, viral serology can be performed:
Parvovirus specific [] antibodies indicate recent infection
Parvovirus specific [] antibodies indicate past infection and therefore immunity.
In cases where a mother has potentially come into contact with parvovirus B19, viral serology can be performed:
Parvovirus specific IgM antibodies indicate recent infection
Parvovirus specific IgG antibodies indicate past infection and therefore immunity.
The main risk of fetal parvovirus infection is []
The main risk of fetal parvovirus infection is fetal hydrops – the abnormal accumulation of fluid in two or more fetal compartments.
There is a classic triad of features in congenital toxoplasmosis. What are they? [3]
There is a classic triad of features in congenital toxoplasmosis:
Intracranial calcification
Hydrocephalus
Chorioretinitis (inflammation of the choroid and retina in the eye)
