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4th Year GOSH > High Risk Pregnancies > Flashcards

High Risk Pregnancies Flashcards

1
Q

Maternal conditions resulting in high risk pregnancy?

A 
Obesity
Diabetes
HTN
Chronic disease (renal/AI)
Infections
Previous surgery (adhesions)
VTE
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2
Q

Social factors resulting in a high risk pregnancy?

A 
Teenage pregnancy
Maternal age >35
High parity and low interpregnancy interval
Poor SE conditions
Alcohol intake
Substance abuse
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3
Q

Obstetric issues in previous pregnancy resulting in high risk pregnancy?

A 
Caesarean section
Preterm delivery
Recurrent miscarriage
Stillbirth
Pre-eclampsia
Gestational diabetes
Third degree perineal tear
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4
Q

Problems in this pregnancy resulting in high risk pregnancy?

A 
Multiple pregnancy
Small for dates
Placenta praevia
Gestational diabetes
Pre-eclampsia
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5
Q

Problems during labour resulting in high risk pregnancy?

A

Meconium/blood stained liquor
Worrying CTG
Need for oxytocin infusion
Lack of progress

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6
Q

Actions if pregnancy deemed high risk?

A

Consultant-led care

Counselling - mode of delivery, weight
Special investigations - GTT
Ultrasound scans - growth scans
Specialised clinics - i.e. diabetic
Anaesthetic reviews - BMI
Close observation - BP, diabetes, urine etc.
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7
Q

Maternal risk factors for IUGR?

A
  • Smoking, poor nutrition (social class)
  • High altitude
  • Pre-existing renal, cardiac, vascular disease
  • Pregnancy related disease: Hypertension/pre-eclampsia = small babies
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8
Q

Foetal risk factors for IUGR?

A
  • Nutrition – abnormal placenta development
  • Teratogenic – tobacco, narcotics, alcohol, medication
  • Infection – rubella, CMV, measles
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9
Q

Two things that encompass ‘small for gestational age’ and how to diferentiate?

A
  1. Constitutionally small - Mum is small, From an ethnic group that produces small baby
  2. Intrauterine growth restriction (IUGR) - Placental insufficiency. Higher risk of still birth .

To differentiate, repeat scan in 2 weeks
If continues to grow then probably constitutionally small
If plateau or tail off in growth may be IUGR and placental insufficiency.

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10
Q

Monitoring in IUGR?

A
  1. Symphysis-fundal height – should match number of weeks +/- 2 or 3 cm
  2. USS for foetal measurements
    - Abdominal circumference, head circumference, femur length
    - Beware head sparing (relatively large head to abdominal circumference) – could be sign of IUGR as blood/oxygen going to the brain and neglecting the abdomen due to insufficiency of placenta
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11
Q

Liquor volume and umbilical artery doppler in IUGR monitoring?

A

LIQUOR - Happy babies produce urine as they have a normal blood supply to the abdomen rather than head sparing = normal liquor volume

DOPPLER - shows resistance of the placenta (SD ratio) (want low resistance) - Look to see if there is end diastolic pressure.
• In a low resistance, healthy placenta, blood will continue to flow in diastole as well, so baby is constantly oxygenated (will always be blood flow above zero)
o Absent end diastolic flow (EDF): with a high resistance placenta, there will be no flow to baby during diastole
o Reversed EDF: In very unhealthy placenta, flow may even reverse and the baby will be losing blood and oxygen - VERY BAD

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12
Q

Management of IUGR?

A

Weekly umbilical artery doppler
Daily CTG if doppler abnormal

Delivery at 37 weeks or earlier if foetal/maternal compromise

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13
Q

Incidence of multiple pregnancy?

A

1%

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14
Q

What is the main factor in determining multiple pregnancy outcome?

A

Chorionicity

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15
Q

What do you look for on ultasound to determine chorionicity?

A

Lamda sign = Y sign that signifies dichorionicity

T-sign = monochorionic

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16
Q

Division times of identical twins in relation to chorionicity?

A

Morula - Day 1-3 - DC/DA
Blastocyst - Days 4-8 - MC/DA
Implanted blastocyst - days 8-13 - MA/MA
Formed embryonic disc - days 13-25 - conjoined twins

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17
Q

Maternal complications of multiple pregnancy?

A

Hyperemesis gravidarum, anaemia, pre-eclampsia, gestational diabetes, operative delivery, preterm labour

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18
Q

Foetal complications relating to all multiple pregnancies?

A

↑morbidity+mortality – miscarriage, preterm labour, IUGR, antepartum haemorrhage, chromosomal/structural abnormalities

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19
Q

Complications in monochorionic twins?

A

Congenital abnormalities, twin-twin-transfusion syndrome, IUGR even more common

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20
Q

Antenatal care in multiple pregnancy?

A

• USS at 11-14 weeks
• Oral Iron and Folic acid 5mg
• Detailed anatomy scan and cardiac scans
• Regular serial growth scans
o DCDA 4 weekly (from 24 weeks)
o MC twins 2 weekly (from 16 weeks)
• Regular BP and urine checks – increased surveillance for pre-eclampsia, diabetes and anaemia.

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21
Q

Timing and mode of delivery in multiple pregnancy?

A
  • DCDA = 37-38 weeks
  • MCDA = 34-37 weeks (MCMA = 34 weeks by CS)
  • Presenting twin (one closest to cervix) = cephalic –> Vaginal delivery recommended
  • Presenting twin = breech/transverse lie –> Caesarean section
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22
Q

What is TTTS?

A

15% of all MC twins – unequal blood distribution in shared placenta leading to discordant blood volumes, liquor and growth.

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23
Q

Diagnosing TTTS? Complications?

A

Diagnosis = discordant liquor volumes, recipient twin larger, polyhydramnios, fluid overload, heart failure, donor twin smaller, ‘stuck’ with oligohydramnios.

Complications = late miscarriage an severe preterm delivery, in utero death, neurological damage.

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24
Q

Management and prognosis of TTTS?

A

Management = USS surveillance from 12 weeks (every fortnight). Laser therapy if TTTS diagnosed.

Prognosis = v poor if untreated – 60% both survive, 80% one survives.

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25
Q

How does BP change in pregnancy?

A

Goes down in 1st trimester, then up in 2nd and 3rd trimesters

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26
Q

What is pre-eclampsia?

A

Hypertension and proteinuria in 2nd half of pregnancy, usually with oedema

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27
Q

What is the pathophysiology of pre-eclampsia?

A

Reduced placental bloodflow –> inflammatory response.
Endothelial cell damage –> increased vascular permeability, vasoconstriction and coagulopathy

Only cured by delivery

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28
Q

Risk factors for pre-eclampsia?

A 
Nulliparity
Previous history, FH
Older maternal age
Chronic hypertension
Diabetes
Twin pregnancies
Autoimmune disease
Renal disease
Obesity
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29
Q

Screening and prevention of pre-eclampsia?

A

High-risk pregnancies screened - uterine artery doppler, sFlt-1, VEGF

Prevention - 75mg aspirin OD

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30
Q

Degrees of pre-eclampsia?

A

Mild = Proteinuria and hypertension <170/110

Moderate = Proteinuria and hypertension >170/110

Severe = Proteinuria and hypertension <32weeks or with maternal complications

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31
Q

Clinical features of pre-eclampsia?

A

History - Usually asymptomatic. At late stage –> headache, drowsiness, visual disturbances, nausea/vomiting, epigastric pain

Examination - Hypertension = first sign usually. Oedema may be massive. Epigastric tenderness. Protein in urinalysis

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32
Q

Maternal complications of pre-eclampsia? (indications for delivery)

A 
Eclampsia
CVA
HELLP syndrome – Haemolysis, elevated liver enzymes, low platelet count
DIC
Liver failure
Renal failure
Pulmonary oedema
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33
Q

Foetal complications of pre-eclampsia?

A

IUGR – in pregnancies affected before 36 weeks – results from placental ischaemia
Preterm birth
Placental abruption
Hypoxia

34
Q

What is HELLP syndrome? How is it managed?

A

Haemolysis, elevated liver enzymes, low platelet count –> DIC, liver failure and liver rupture can occur.

Symptoms = severe epigastric pain. Haemolysis turns urine dark.

Treatment = supportive –> magnesium sulphate prophylaxis against eclampsia, high dose steroids, ICU therapy needed in severe cases.

35
Q

Investigating pre-eclampsia? (confirm diagnosis)

A

MSU

Urine protein measurement (PCR >30)

36
Q

Investigating pre-eclampsia? (maternal complications)

A

BP

Serial FBC, U+E, LFTs

37
Q

Investigating pre-eclampsia? (foetal complications)

A

Foetal wellbeing – umbilical artery Doppler and (if abnormal), daily CTG

38
Q

Management of pre-eclampsia?

A

Investigate if BP >140/90 –> admit if proteinuria ++ or moderate/severe disease

Antihypertensives (labetolol, methyldopa, nifedipine) if >170/110; steroids if moderate/severe at <34 weeks.

Delivery – after 34-36 weeks if possible. Deliver if maternal complications whatever the gestation.

Magnesium sulphate if eclampsia, consider prophylactic use in severe disease.

Postnatally – watch BP, fluid balance, bloods; FBC, U+E, LFTs

39
Q

Complications of pre-existing hypertension in pregnancy?

A

Increases the risk of:
o Maternal pre-eclampsia/eclampsia and placental abruption
o Maternal morbidity and mortality, especially with very high systolic blood pressure
o Intrauterine fetal growth restriction and preterm delivery
o Neonatal morbidity and mortality

40
Q

Maternal/foetal monitoring in pre-existing hypertension?

A

BP and urine, extra growth scans (due to association with foetal growth restriction)

41
Q

Incidence of gestational diabetes?

A

2%

42
Q

What is worse, gestational or established diabtes in pregnancy?

A

Established - related to glucose levels

43
Q

Pathophysiology of gestational diabetes?

A

↓Glucose tolerance due to altered carbohydrate metabolism + antagonistic effects of human placental lactogen, progesterone and cortisol.

↑Foetal blood glucose levels –> foetal hyperinsulinaemia –> foetal fat deposition –> excessive growth (macrosomia)

44
Q

Risk factors for gestational diabetes?

A

Family or previous history, polycystic ovary syndrome, previous large baby/ unexplained still birth, weight >100kg, persistent glycosuria, polyhydraminos

45
Q

Who gets screening for gestational diabetes?

A

South Asians, BMI >30, first degree relative with DM - PEOPLE WITH RISK FACTORS

46
Q

How is gestational diabetes screened for?

A

OGTT - between 24 and 28 weeks. If previous GDM - 16 weeks

75g of glucose - 2h later BM should be <7.8
Fasting should be <6

47
Q

Maternal complications of GDM?

A

Increased insulin requirements

Hypoglycaemia – due to attempts to control

Diabetic retinopathy

Pre-eclampsia

Infections - UTI/endometrial

Operative delivery – more likely because of foetal compromise and larger size

Rarely ketoacidosis

48
Q

Foetal complications of GDM?

A

Macrosomia

Sudden IUD/foetal distress in labour – associated with poor control in 3rd trimester

Congenital abnormalities – neural tube/cardiac defects

Shoulder dystocia/birth trauma – because larger

Neonatal hypoglycaemia – because is used to hyperglycaemia

Preterm labour – and reduced foetal lung maturity

49
Q

Risks of macrosomia?

A

Shoulder dystocia

Perineal tears

50
Q

Management of GDM?

A
  • Preconceptual glucose stabilization; patient education/involvement
  • Increase insulin to achieve tight control – between 4 and 6 mmol/L - reduce post-delivery
  • 5mg folic acid until 12 weeks and 75mg aspirin from 12 weeks (reduce risk of pre-eclampsia)
  • Anomaly and specialist cardiac USS – close foetal surveillance (serial USS to assess growth and liquor volume) - every 4 weeks
  • Planned delivery at term (39/40) via induction/lower segment c-section (LSCS) – early if uncontrolled
51
Q

Why is pregnancy a pro-thrombotic state?

A

More clotting factors
Less fibrinolysis
Blood flow altered by mechanical obstruction/immbolity

52
Q

How do you confirm a VTE/PE in pregnancy?

A

Doppler, chest X ray or V/Q scan

  • D dimer and wells score ineffective in pregnancy – although normal level means VTE unlikely
53
Q

Management of VTE in pregnancy?

A 
LMWH subcut (treatment dose)
LMWH (maintenance dose) until 6 weeks post-partum
54
Q

Delivery in VTE?

A

At term unless maternal complications indicate earlier delivery necessary to treat effectively

55
Q

VTE prophylaxis in pregnancy?

A

General measures – hydration and mobilization

Antenatal – restricted to very high risk women (LMWH)

Postpartum (where most death happens) – LMWH/warfarin given for 6 weeks

56
Q

Who is VTE prophylaxis given to postnatally?

A

LMWH heparin/warfarin 6 weeks

• Previous or strong family history
• Known prothrombotic tendency
• Those who have had caesarean section and three or more moderate risk factors
(Age >35, high parity, obesity, gross varicose veins, infection, pre-eclampsia, immobility, major illness)

57
Q

Contraindications to VBAC?

A
  • Usual absolute contraindications
  • Vertical uterine scar
  • More than 2 previous c-sections
58
Q

Chance of success of VBAC?

A
  • First-timer = 80% vaginal delivery, 20% c-section
  • Previous c-section = 75% vaginal delivery, 25% c-section
  • Previous vaginal delivery (regardless of previous c-section) = 90%
59
Q

Safety of VBAC?

A
  • No RCTs to compare risks of VBAC to C-section – no evidence, mum should decide
  • Maternal – depends on chance of emergency c-section. Risk of blood transfusion or uterine infection = 1% higher with attempt at VBAC.
60
Q

Risks of VBAC?

A
  • Main risk = rupture of uterine scar from previous caesarean section – rare – 0.7%, and of those 10% will die.
  • Risk of stillbirth related to VBAC is approximately the same risk as in a first labour.
  • Maternal and foetal morbidity increases with increasing number of prior c-sections
61
Q

Management of labour during VBAC?

A
  • Delivery in hospital and CTG advised
  • Induction (particularly with prostaglandins) avoided - associated with risk of rupture (3x higher than spontaneous labour)
  • Epidural = safe, but labour should not be prolonged
62
Q

Management of uterine scar rupture?

A

Immediate laparotomy and cesarean

63
Q

Monitoring of cardiac disease in pregnancy?

A
  • USS for foetal abnormalities (3%) – 20 weeks
  • Regular ECG monitoring throughout pregnancy
  • Regular FBC check for anaemia
64
Q

Management of cardiac disease in pregnancy?

A

Seen in conjunction with a cardiologist

Control hypertension if present.

65
Q

Delivery in cardiac disease in pregnancy?

A

Labour more appropriate than C section - Elective forceps delivery to reduce strain of active pushing

Delivery in a labour unit with ICU

Continued cardiac monitoring for 24 hours post-delivery

66
Q

Consequences of hyperthyroidism in pregnancy?

A

↑HR and IUGR

67
Q

Treatment of hyperthyroidism in pregnancy?

A

carbimazole safe in pregnancy (although does cross placenta)

68
Q

Consequences of hypothyroidism in pregnancy?

A

learning difficulties (slow)

69
Q

Treatment of hypothyroidism in pregnancy?

A

thyroixine - does not cross the placenta

70
Q

Is grave’s disease bad in pregnancy?

A

• Grave’s disease antibodies do cross the placenta so early control of this in pregnancy is paramount

71
Q

Is psychiatric cause of death indirect or direct?

A

Direct

72
Q

Risk factors for postpartum psychosis?

A
  • Pre-existing mental health disorders

- Personal and social demands of pregnancy and caring for new baby

73
Q

Monitoring of psychiatric disorders in pregnancy?

A

Ask about mood and emotions at EVERY antenatal and post-natal interaction.
Need good support network – counsel with phone numbers for crisis etc.

74
Q

Management of postpartum depression/psychosis?

A
  • CBT
  • Antidepressants
  • Antipsychotics and admission to MBU if required.
75
Q

When does a mother need urgent referral to specialist perinatal mental health team (mother and baby unit)?

A

o New thoughts of violent self-harm
o Sudden onset or rapidly worsening mental symptoms
o Persistent feelings of estrangement from their baby

76
Q

Risks of epilepsy in pregnancy?

A

Foetal risk:

  • Neural tube defects, orofacial clefts due to polypharmacy
  • 3% risk of developing epilepsy

Maternal risk:

  • Frequent seizures
  • Status epilepticus (continuous refractory epileptic fit)
77
Q

Monitoring of epilepsy in pregnancy?

A
  • Anomaly scan for foetal defects

* If incomplete seizure control, check drug doses 4 weekly and increase if necessary

78
Q

Preconceptional management of epilepsy?

A

Management of seizure on the minimum number of drugs and Folic acid 5mg/day throughout pregnancy

Should not suddenly stop taking anticonvulsants

79
Q

Safest anticonvulsants to take during prego?

A

• Lamotrigine/carbamazepine are safest in pregnancy

DO NOT use sodium valproate (lower intelligence in children)

80
Q

When is mother at risk of seziures? Triggers?

A

Intrapartum and postpartum

Triggers = tired, stressed, dehydrated, lack of sleep, exhaustion

81
Q

What must you exclude if mother has an epileptic seizure?

A

pre-eclampsia

82
Q

Delivery in epilepsy?

A

If mother stable, prolong until delivery indicated.

May have to be pre-term if maternal complications

4th Year GOSH (23 decks)

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