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Obstetrics > High risk pregnancies > Flashcards

High risk pregnancies Flashcards

1
Q

Define IUGR

A

Neonates weighing below the 10th centile for gestational age

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2
Q

What are the causes of IUGR?

A

Maternal illness
Toxin exposure
Placental insufficiency
Foetal infection

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3
Q

What are the risk factors for IUGR?

A 
Malformation
Multiple pregnancy
Infection
Smoking 
HTN
Diabetes
Pre-eclampsia
Heart disease 
Asthma
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4
Q

What signs on USS may indicate IUGR?

A

Oligohydramnios

Poor foetal movements

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5
Q

What level of PAPP-A may indicate SGA?

A

Low PAPP-A

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6
Q

Which tool is used to assess the severity of IUGR and determine scan interval?

A

Uterine artery Doppler

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7
Q

When should sympyseal-fundal height measurement correlate with gestational age?

A

From 20weeks

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8
Q

How is IUGR monitored?

A

Serial fundal height measurements and serial USS gorwth scans (HC, AC, FL)

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9
Q

Describe how Doppler is used to determine when to induce a women with an IUGR foetus?

A

Absent end diastolic flow = C section before 37wks

Abnormal uterine artery doppler OR normal uterine artery doppler: induce by 37weeks

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10
Q

What monitoring in labour is required in IUGR?

A

CTG

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11
Q

What are the complications of IUGR?

A

Birth asphyxia
Hypoglycaemia
Jaundice
Hypothermia

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12
Q

What factors predispose women to a multiple pregnancy?

A

Previous multiple preg
FH of twins (on maternal side, dizygotic)
Increased maternal age
Induced ovulation and IVF

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13
Q

What symptoms may indicate multiple pregnancy?

A

Hyperemesis

Early bump

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14
Q

What features on USS indicate multiple pregnancy?

A

”+ foetal poles
Multiplicity fo foetal parts
“ x HR

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15
Q

What is important to distinguish on USS in multiple pregnancy?

A

If the pregnancy is mono or dichorionic

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16
Q

What are the types of twins?

A

Dichorionic diamniotic
Monochorionic, diamniotic
Monochorionic, monoamniotic

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17
Q

How frequently should USS be in multiple pregnancy and from when?

A

Monochorionic: 2 weekly
Dichorionic: monthly

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18
Q

What monitoring is KEY in multiple pregnancy?

A

Pre-eclampsia: weekly antenatal BPs

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19
Q

When should twins be delivered in an uncomplicated pregnancy?

A

Dichorionic: 37 weeks
Monochorionic: 36 weeks

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20
Q

What are the complications of multiple pregnancy?

A 
Pre-eclampsia
APH
Prematurity
IUGR
PPH
Malpresentation
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21
Q

When can twins be delivered vaginally?

A

if Baby 1 is head down

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22
Q

What are the three kinds of hypertension in pregnancy?

A

Chroinc hypertension
Gestational hypertension
Pre-eclampsia (HTN withh proteinuria)

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23
Q

What are all women with hypertension in pregnancy at risk of?

A

Intracranial haemorrhage

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24
Q

What is chronic hypertension in pregnancy?

A

Hypertension that predates pregnancy or occurs before 20wks gestation

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25
Q

Define gestational hypertension?

A

HTN at 20+wks in the absence of proteinuria

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26
Q

What is pre-eclampsia?

A

Hypertension occuring after 20wks with proteinuria and often associated oedema

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27
Q

What advice should be given pre-conception to women with chronic hypertension

A

DO NOT take ACEi or ARBs - safe switch to labetaol

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28
Q

What is the target BP antenatally for women with chronic hypertensions?

A

Under 150/90

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29
Q

What drugs should a women with chronic hypertension in pregnancy be given and from when?

A

Labetalol (from beginning)
(if contraindicated - nifedipine, then methyldopa)
Aspirin 75mg OD from 12wks until delivery

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30
Q

How is labour managed in a woman with chronic hypertension?

A

Monitor BP hourly if under 150/90, continuously if above 160/100.
Oxytocin should be given in the third stage

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31
Q

Should a woman with chronic hypertension continue labetalol after delivery?

A

Yes, if breastfeeding. If not breasfeeding, return to regime of medication which worked previously (e.g. ACEi)

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32
Q

What investigations confirm gestational hypertension?

A

BP >150/90 AND normal urinary protein:creatinine ratio

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33
Q

How is gestational hypertension treated?

A

Labetalol

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34
Q

Should women with gestational hypertension be induced?

A

Yes, at 37wks

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35
Q

Should a women with gestational hypertension carry on taking labetalol after birth?

A

Yes - continue as normal.
Measure BP at day 2m week 2 and week 6.
Only reduce when BP falls below 130/80

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36
Q

What is the cause of pre-eclampsia?

A

Placenta: failure of trophoblastic invasion of the spiral arteries, whcih leaves them vasoactive. Increasing the BP compensates

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37
Q

What groups of women should take 150mg of aspirin from 12wks in pregnancy as prophylaxis for pre-eclampsia?

A 
Previous HTN in pregnancy
Chronic kidney disease
Autoimmune disease
Diabetes
Chronic HTN
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38
Q

What are the moderate RF for pre-eclampsia and how should this be managed?

A 
Primiparous
Age 40+
Pregnancy interval of 10yrs +
BMI of 35+
Multiple pregnancy
FH of pre-eclampsia
39
Q

What are the symptoms of pre-eclampsia?

A 
Epigastric pain
Vision spots
Headache
Facial oedema
Generalised seizure
Vomiting
40
Q

What might be notice on examination in pre-eclampsia?

A

Facial oedema
Hyperreflexia
Clonus

41
Q

What blood tests and results are diagnostic of pre-eclampsia

A

LFTs: elevated (expect ALP)

Urinary P:Cr: 30+mmol

42
Q

How is pre-eclampsia managed?

A

Labetalol (nifedipine or methyldopa if labetalol not tolerated)
Consider magnesium sulfate if severe
Delivery from 34-36wks with MgSO4 and steroids

43
Q

What is the target BP in pre-eclampsia?

A

135/85 or less

44
Q

Should women taking antihypertensives continue taking them after delivery?

A

Yes: monitor BP regualrly as inpatient, then daily for 2 weeks to check decreasing, then reduce dose when BP is below 130/80

45
Q

What does HELLP syndrome stand for?

A

Hameolysis
Elevated Liver enzymes (not ALP)
Low Platelets

46
Q

How might HELLP syndrome present?

A 
Epigastric pain
Headaches
Vision changes
Facial oedema
N+V
Hyperreflexia
Clonus
47
Q

How is HELLP diagnosed?

A 
BP and urinary PCR (30mmol+)
BP may not be raised
LFTS: raised (not ALP)
Platelets: low
TEG: thromboelastogram may be helpful
48
Q

How is HELLP syndrome managed?

A

Prompt delivery of the foetus
IV MgSO4 for seizure prophylaxis
IV steroids: foetal lung maturation
Labetalol/nifedipine/methyldopa

49
Q

How are eclamptic seizures managed?

A

ABCDE: position on L lateral side
IV MgSO4 4g in 100ml 0.9% NaCl
IV labetalol/nifedipine/methyldopa
Prompt delivery via C section

50
Q

What doses of MgSO4 should be used in the following situations:

a) prophylaxis in HELLP syndrome
b) first seizure treatment
c) maintenance following 1st seizure
d) recurrent seizure

A

a) 4g in 100ml NaCl
b? 4g in 100ml NaCl
c) 1g every hour for 25hrs
d) 2g bolus

51
Q

What is the definition of GDM?

A

Any degree of glucose intolerance with onset or first recognition during pregnancy

52
Q

What are the RF for GDM?

A 
GDM in previous pregnancy
FH of GDM or diabetes
Asian
Obesity (BMI 30+)
PCOS
53
Q

How might GDM present?

A

Usually asymptomatic

If symptomatic: classically polyuria, polydipsia, fatigue

54
Q

How is GDM diagnosed and what result is diagnostic?

A

Oral glucose tolerance test (GTT)
Fasting glucose 5.6mmol/L+
2hrs post load 7.8+mmol/L

55
Q

How is GDM managed?

A

Metform or insulin therapy with consultant led care

56
Q

Do women with GDM get additional growth scans and when?

A

Yes, at 28, 32 and 36 weeks

57
Q

When should a women with GDM give birth?

A

Between 37-39wks - earlier if large baby

58
Q

What are the complications of GDM?

A 
Macrosomia
Shoulder distocia
Organomegaly
Neonatal hypoglycaemia
Polyhydramnios
Preterm delivery
59
Q

Should treatment continue after giving birth?

A

NO: stop treatment immediately after delivery and measure BMs before discharge. An OGTT should be carried out at 6-13wks post partum

60
Q

How should women with existing diabetes be managed in pregnancy?

A

Continue with metforming or insulin therapy, though dose may change

61
Q

Should women with pre-existing DM be induced?

A

Yes, by 38+6 or by elective C-section

62
Q

When should additional growth scans be completed in all woman with diabetes in pregnancy (GDM and pre-existing)?

A

28.32 and 36

63
Q

What is the highest risk period for VTE in pregnancy?

A

Post-partum period

64
Q

What is the pathophysiology behind the increased VTE risk in pregnancy?

A

Increased fibrinogen AND decreased protein S

65
Q

How might VTE present in women who are pregnant?

A

Same as in non-pregnant people; however it is important that these are not mistaken for the physiological effects of pregnancy (e.g. SOB and leg swelling)

66
Q

Where is a DVT most likely to form in a pregnant woman?

A

Proximal veins of the L leg

67
Q

How is a DVT diagnosed in pregnancy?

A

USS of affected limb and Doppler

68
Q

How is a PE diagnosed in pregnancy?

A

V/Q perfusion scan OR CTPA

69
Q

WHat are the risks associated with CTPA and V/Q perfusions scans in pregnancy?

A

CTPA: higher risk of childhood cancer

V/Q scan: higher risk of breast cancer

70
Q

What are CTPA scans usually accepted in pregancy?

A

Post-12wks, once organogenesis is complete

71
Q

Why is a D-Dimer not used in pregnancy to establish a DVT or PE?

A

There is a physiological rise in the D-dimer value in pregnancy, so it is no longer sensitive

72
Q

How is a VTE managed in pregnancy?

A

LMWH; dose dependent on local guidelines

73
Q

If a DVT or PE is suspected in pregnancy, what should be done immediately?

A

Administration of LMWH: treat until excluded.

74
Q

How long should a DVT or PE be treated for in pregnancy?

A

The remainder of the pregnancy and 6wks PP

75
Q

When a woman on VTE/DVT treatment is labouring or due a C-section, when should her LMWH be omitted?

A

24hrs pre-C section or when established labour is confirmed.

76
Q

What outcomes are described in the term “previous poor obstetric history”?

A 
Stillbirth
Low birth weight
Prolonged labour (Passenger, passage or power)
IU foetal death
Recurrent miscarriage
77
Q

What is the success rate of VBAC?

A

75%

78
Q

What is the concern in VBAC and how common is it?

A

Uterine rupture, 0.5%

79
Q

How is a VBAC managed?

A

Hospital, consultant led delivery
Continuous CTG monitoring
Avoid induction
If after 39wks: elective C-section recommended

80
Q

What are the absolute contraindications to VBAC?

A

Previous uterine rupture
Major placenta praevia
Vertical C-section scar

81
Q

What are the relative contraindications to C-section?

A

2+ previous C-sections - a VBAC is not advised.

82
Q

What types of FGM should be reported to the police?

A

ALL of them

83
Q

Following a delivery in a woman with FGM, is it allowed to return the genitalia to it’s pre-birth state (outside of tear repair etc)?

A

NO - even if just repairing what was previously present, FGM is ILLEGAL

84
Q

What is deinfibulation?

A

Dividing of the scar tissue which narrows the vaginal opening in type 3 FGM

85
Q

What type of delivery is encouraged in FGM?

A

Normal vaginal

86
Q

Describe the 4 types of FGM

A

Type 1: clitoris removal
Type 2: clitoris and labia minora removal
Type 3: clitoris, labia majora and labia minora removed with or without stitching the vulva together.
Type 4: any other incisions, burns, piercings or manipulation of the external genitalia

87
Q

Define recurrent miscarriage?

A

The loss of 3 or more CONSECUTIVE preganncies pre-24wks

88
Q

Whar si the most prevalent treatable cause of recurrent miscarriage?

A

Antiphospholipid syndrome

89
Q

What are the RF for recurrent miscarriage?

A 
Balanced structural chromosomal abnormalities
Congenital uterine abnormalities
Cervical weakness
Thrombophilia
Advanced parental age
Previous miscarriage
Obesity
90
Q

What is mid-trimester loss?

A

Pregnancy loss between 12 and 24 weeks gestation

91
Q

What is stillbirth?

A

A baby delivered with no signs of life, known to have died after 24wks gestation

92
Q

What are the RF for stillbirth?

A

Maternal obesity

Increased maternal age

93
Q

How is stillbirth confirmed?

A

Realtime USS to confirm absence of foetal heart activity AND doppler of foetal heart and umbilical cord

94
Q

How is stillbirth investigated?

A

Maternal bloods: screen for infection or pre-eclampsia
Coagulation screen for DIC
Genetic testing
Post-mortem of baby

Obstetrics (5 decks)

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