High Risk Pregnancies Flashcards
Maternal conditions resulting in high risk pregnancy?
Obesity Diabetes HTN Chronic disease (renal/AI) Infections Previous surgery (adhesions) VTE
Social factors resulting in a high risk pregnancy?
Teenage pregnancy Maternal age >35 High parity and low interpregnancy interval Poor SE conditions Alcohol intake Substance abuse
Obstetric issues in previous pregnancy resulting in high risk pregnancy?
Caesarean section Preterm delivery Recurrent miscarriage Stillbirth Pre-eclampsia Gestational diabetes Third degree perineal tear
Problems in this pregnancy resulting in high risk pregnancy?
Multiple pregnancy Small for dates Placenta praevia Gestational diabetes Pre-eclampsia
Problems during labour resulting in high risk pregnancy?
Meconium/blood stained liquor
Worrying CTG
Need for oxytocin infusion
Lack of progress
Actions if pregnancy deemed high risk?
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.
Maternal risk factors for IUGR?
- Smoking, poor nutrition (social class)
- High altitude
- Pre-existing renal, cardiac, vascular disease
- Pregnancy related disease: Hypertension/pre-eclampsia = small babies
Foetal risk factors for IUGR?
- Nutrition – abnormal placenta development
- Teratogenic – tobacco, narcotics, alcohol, medication
- Infection – rubella, CMV, measles
Two things that encompass ‘small for gestational age’ and how to diferentiate?
- Constitutionally small - Mum is small, From an ethnic group that produces small baby
- 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.
Monitoring in IUGR?
- Symphysis-fundal height – should match number of weeks +/- 2 or 3 cm
- 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
Liquor volume and umbilical artery doppler in IUGR monitoring?
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
Management of IUGR?
Weekly umbilical artery doppler
Daily CTG if doppler abnormal
Delivery at 37 weeks or earlier if foetal/maternal compromise
Incidence of multiple pregnancy?
1%
What is the main factor in determining multiple pregnancy outcome?
Chorionicity
What do you look for on ultasound to determine chorionicity?
Lamda sign = Y sign that signifies dichorionicity
T-sign = monochorionic
Division times of identical twins in relation to chorionicity?
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
Maternal complications of multiple pregnancy?
Hyperemesis gravidarum, anaemia, pre-eclampsia, gestational diabetes, operative delivery, preterm labour
Foetal complications relating to all multiple pregnancies?
↑morbidity+mortality – miscarriage, preterm labour, IUGR, antepartum haemorrhage, chromosomal/structural abnormalities
Complications in monochorionic twins?
Congenital abnormalities, twin-twin-transfusion syndrome, IUGR even more common
Antenatal care in multiple pregnancy?
• 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.
Timing and mode of delivery in multiple pregnancy?
- 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
What is TTTS?
15% of all MC twins – unequal blood distribution in shared placenta leading to discordant blood volumes, liquor and growth.
Diagnosing TTTS? Complications?
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.
Management and prognosis of TTTS?
Management = USS surveillance from 12 weeks (every fortnight). Laser therapy if TTTS diagnosed.
Prognosis = v poor if untreated – 60% both survive, 80% one survives.
How does BP change in pregnancy?
Goes down in 1st trimester, then up in 2nd and 3rd trimesters
What is pre-eclampsia?
Hypertension and proteinuria in 2nd half of pregnancy, usually with oedema
What is the pathophysiology of pre-eclampsia?
Reduced placental bloodflow –> inflammatory response.
Endothelial cell damage –> increased vascular permeability, vasoconstriction and coagulopathy
Only cured by delivery
Risk factors for pre-eclampsia?
Nulliparity Previous history, FH Older maternal age Chronic hypertension Diabetes Twin pregnancies Autoimmune disease Renal disease Obesity
Screening and prevention of pre-eclampsia?
High-risk pregnancies screened - uterine artery doppler, sFlt-1, VEGF
Prevention - 75mg aspirin OD
Degrees of pre-eclampsia?
Mild = Proteinuria and hypertension <170/110
Moderate = Proteinuria and hypertension >170/110
Severe = Proteinuria and hypertension <32weeks or with maternal complications
Clinical features of pre-eclampsia?
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
Maternal complications of pre-eclampsia? (indications for delivery)
Eclampsia CVA HELLP syndrome – Haemolysis, elevated liver enzymes, low platelet count DIC Liver failure Renal failure Pulmonary oedema
Foetal complications of pre-eclampsia?
IUGR – in pregnancies affected before 36 weeks – results from placental ischaemia
Preterm birth
Placental abruption
Hypoxia
What is HELLP syndrome? How is it managed?
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.
Investigating pre-eclampsia? (confirm diagnosis)
MSU
Urine protein measurement (PCR >30)
Investigating pre-eclampsia? (maternal complications)
BP
Serial FBC, U+E, LFTs
Investigating pre-eclampsia? (foetal complications)
Foetal wellbeing – umbilical artery Doppler and (if abnormal), daily CTG
Management of pre-eclampsia?
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
Complications of pre-existing hypertension in pregnancy?
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
Maternal/foetal monitoring in pre-existing hypertension?
BP and urine, extra growth scans (due to association with foetal growth restriction)
Incidence of gestational diabetes?
2%
What is worse, gestational or established diabtes in pregnancy?
Established - related to glucose levels
Pathophysiology of gestational diabetes?
↓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)
Risk factors for gestational diabetes?
Family or previous history, polycystic ovary syndrome, previous large baby/ unexplained still birth, weight >100kg, persistent glycosuria, polyhydraminos
Who gets screening for gestational diabetes?
South Asians, BMI >30, first degree relative with DM - PEOPLE WITH RISK FACTORS
How is gestational diabetes screened for?
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
Maternal complications of GDM?
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
Foetal complications of GDM?
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
Risks of macrosomia?
Shoulder dystocia
Perineal tears
Management of GDM?
- 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
Why is pregnancy a pro-thrombotic state?
More clotting factors
Less fibrinolysis
Blood flow altered by mechanical obstruction/immbolity
How do you confirm a VTE/PE in pregnancy?
Doppler, chest X ray or V/Q scan
- D dimer and wells score ineffective in pregnancy – although normal level means VTE unlikely
Management of VTE in pregnancy?
LMWH subcut (treatment dose) LMWH (maintenance dose) until 6 weeks post-partum
Delivery in VTE?
At term unless maternal complications indicate earlier delivery necessary to treat effectively
VTE prophylaxis in pregnancy?
General measures – hydration and mobilization
Antenatal – restricted to very high risk women (LMWH)
Postpartum (where most death happens) – LMWH/warfarin given for 6 weeks
Who is VTE prophylaxis given to postnatally?
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)
Contraindications to VBAC?
- Usual absolute contraindications
- Vertical uterine scar
- More than 2 previous c-sections
Chance of success of VBAC?
- 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%
Safety of VBAC?
- 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.
Risks of VBAC?
- 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
Management of labour during VBAC?
- 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
Management of uterine scar rupture?
Immediate laparotomy and cesarean
Monitoring of cardiac disease in pregnancy?
- USS for foetal abnormalities (3%) – 20 weeks
- Regular ECG monitoring throughout pregnancy
- Regular FBC check for anaemia
Management of cardiac disease in pregnancy?
Seen in conjunction with a cardiologist
Control hypertension if present.
Delivery in cardiac disease in pregnancy?
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
Consequences of hyperthyroidism in pregnancy?
↑HR and IUGR
Treatment of hyperthyroidism in pregnancy?
carbimazole safe in pregnancy (although does cross placenta)
Consequences of hypothyroidism in pregnancy?
learning difficulties (slow)
Treatment of hypothyroidism in pregnancy?
thyroixine - does not cross the placenta
Is grave’s disease bad in pregnancy?
• Grave’s disease antibodies do cross the placenta so early control of this in pregnancy is paramount
Is psychiatric cause of death indirect or direct?
Direct
Risk factors for postpartum psychosis?
- Pre-existing mental health disorders
- Personal and social demands of pregnancy and caring for new baby
Monitoring of psychiatric disorders in pregnancy?
Ask about mood and emotions at EVERY antenatal and post-natal interaction.
Need good support network – counsel with phone numbers for crisis etc.
Management of postpartum depression/psychosis?
- CBT
- Antidepressants
- Antipsychotics and admission to MBU if required.
When does a mother need urgent referral to specialist perinatal mental health team (mother and baby unit)?
o New thoughts of violent self-harm
o Sudden onset or rapidly worsening mental symptoms
o Persistent feelings of estrangement from their baby
Risks of epilepsy in pregnancy?
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)
Monitoring of epilepsy in pregnancy?
- Anomaly scan for foetal defects
* If incomplete seizure control, check drug doses 4 weekly and increase if necessary
Preconceptional management of epilepsy?
Management of seizure on the minimum number of drugs and Folic acid 5mg/day throughout pregnancy
Should not suddenly stop taking anticonvulsants
Safest anticonvulsants to take during prego?
• Lamotrigine/carbamazepine are safest in pregnancy
DO NOT use sodium valproate (lower intelligence in children)
When is mother at risk of seziures? Triggers?
Intrapartum and postpartum
Triggers = tired, stressed, dehydrated, lack of sleep, exhaustion
What must you exclude if mother has an epileptic seizure?
pre-eclampsia
Delivery in epilepsy?
If mother stable, prolong until delivery indicated.
May have to be pre-term if maternal complications
