High Risk Pregnancies

Question 1

Monitoring of suspected IUGR pregnancy

Answer 1

Abdominal circumference
Estimated Fetal Weight

Symmetrical (chromosomal) / Asymmetrical (placental insufficiency)

Question 2

Management of multiple pregnancy

Answer 2

^ iron/folate supplementation
^ frequency of BP/proteinuria checks for pre-eclampsia
Establish presentation of leading twin at 34 weeks
Consider induction at 38 weeks

Triplets+ must be delivered by CS

Question 3

Normal effects of pregnancy on blood pressure

Answer 3

0-24 weeks - blood pressure drops, due to decreased SVR, and action of progesterone (vasodilator)

24 weeks - delivery - BP^ due to ^stroke volume

Question 4

Definition of Pregnancy Induced Hypertension (PIH)

Answer 4

BP >140/90 mmHg
After 20 weeks gestation
Absence of proteinuria or other markers for pre-eclampsia

Question 5

Management of PIH

Answer 5

1st line - lifestyle modification

2nd line - Methyldopa OR labetalol OR nifedipine

If >37 weeks gestation, consider induction

Question 6

Management of Chronic Hypertension (i.e. Hypertensive at Booking Visit)

Answer 6

If taking ACEi/ARB - STOP (adverse fetal effects in 2nd/3rd trimester)

SWITCH - to Labetalol/Methyldopa/Nifedipine
+ ADD - Aspirin 75mg OD, from 12 weeks gestation
+ dipstick urine at each antenatal visit

Question 7

Criteria for diagnosis of pre-eclampsia

Answer 7

> 20 weeks gestation
BP >140/90 mmHg AND 1 of the following 3:

1) >300mg proteinuria/24hr collection
2) systemic involvement - renal (^creatinine), liver (^ALT/AST/RUQ pain), neurological
3) Fetal growth restriction

Question 8

Criteria and management for mild-moderate pre-eclampsia

Answer 8

BP <160/110
Admit - observe - manage as an outpatient if stable/BP controlled

Monitor BP 4x daily
2x weekly blood tests, urine tests
If BP >150 - start labetalol/methyldopa/nifedipine/hydralazine (severe)
Fluid restriction - 80ml/hr

Question 9

In who should methyldopa be first line over labetalol

Answer 9

Asthmatics - beta-blockers CI

Afro-Caribbean women - poor efficacy of beta-blockers

Question 10

What is HELLP syndrome

Answer 10

A subtype of severe pre-eclampsia:

Haemolysis = bilirubin >20 micromol/L

Elevated liver enzymes - Raised ALT/AST >70I/mol

Low platelets = <10 x 10^9

Question 11

How does HELLP syndrome present?

Answer 11

HTN, proteinuria
N+V, headache, malaise
RUQ/epigastric pain

Associated with rapid maternal and fetal deterioration

Question 12

Management of HELLP syndrome?

Answer 12

Immediate delivery - even delaying by 48-72hrs not recommended, even in <23 week gestation fetus
\+
IV Dexamethasone
\+
Labetalol OR nicardipine OR hydralazine

Question 13

Criteria for diagnosis of GDM?

Answer 13

Typically made between 24-28 weeks
HbA1c - not used during pregnancy

OGTT = >5.1 mmol/L (fasting)
= >10 mmol/L (after 1hr)

Question 14

Management for GDM

Answer 14

1st line - lifestyle modification most important
+ self monitoring of post-prandial glucose levels

Insulin therapy if severe (Fasting OGTT >6.9, random >11.1)

Question 15

Fetal risk due to GDM?

Answer 15

Macrosomic baby - traumatic delivery, dystocia
^ risk of intrauterine death after 40 weeks

Hyperinsulinaemia –> neonatal hypoglycaemia, ARDS due to low phospholipids

Question 16

Principles regarding delivery in GDM

Answer 16

Should take place no later than 40+6 weeks
Discontinue insulin immediately
Offer OGTT 6-13 weeks post-natal to exclude diabetes

Question 17

Protocol according to VTE assessment?

Answer 17

2 risk factors = prophylactic LMWH for 10 days post-partum

3 risk factors = prophylactic LMWH from 28 weeks, + 6 weeks post-partum, +post natal risk assessment

4+ risk factors = prophylactic LMWH throughout antenatal period, + 6 weeks post-partum, +post-natal risk assessment

Question 18

Advice given to women with genetic thrombophilias

Answer 18

Many will already be on long-term anticoagulants (Warfarin, DOACs)

STOP these as soon as +ve pregnancy test, switch to treatment dose LMWH (S/C)

Question 19

Management of previous stillbirth/recurrent miscarriage

Answer 19

Induce 1 week before previous stillbirth

Genetic testing of both parents/products of conception if recurrent

Question 20

Contra-indications of VBAC?

Answer 20

Previous uterine rupture
Classical CS scar
CIs to vaginal birth (e.g. placenta praevia)

Question 21

Success rates of planned VBAC?

Answer 21

72-75%

If previous successful vaginal birth - rate is 85-90%

Question 22

Risks associated with VBAC?

Answer 22

Uterine rupture - 1 in 200 (0.5%)
2-3x increase in risk if induced

Risk of perinatal death lower than that of a Nulliparous woman