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Obs & Gyn > High risk pregnancy > Flashcards

High risk pregnancy Flashcards

1
Q

incidence of twins and triplets in UK

A

twins 15.1 per 1000 maternities

triplets 2.6 per 10000

quads >3 in uk in 2012

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2
Q

risk factors for having twins 4

A

assisted conception -IVF

maternal age- 4x greater chance at 37 than 18

Ethick origin- west Africa

FHx- maternal inheritance

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3
Q

define the terminiology of the following
-zygosity

chorionicity

amnionicity

A

zygosity- number of fertilitsed eggs

chorionicity- number of placentas

amnionicity - number of sacs

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4
Q

define dizygotic twins

A

2 eggs, 2 sperm

-may look identical but not any more genetically identical than sibinngs

2/3 of twins in UK are dizygotic [18]

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5
Q

define monozygotic twins

A

one fertilized egg
-then splits
-identical twins [18]

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6
Q

how can in monozygotic twins when the one fertilized egg split at different stages in the womb and what are they called 3

A

before day 4
-prior to chorion development
-called: dichorionic diamniotic (approx 1/3) [18]

day 4-8
-prior to amnion development
-called: monochronionic diamniotic (approx 2/3) [18]

from day 9
-after amnion development
-called: monochorionic monoamniotic
-(if late split (after day 13) risk of conjoined twins) [18]

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7
Q

antenatal maternal risk of multiple pregnacy 5

A

all maternal complications increased wit increased fetal/placental number

esp:
-hyperemesis gravidarum
-pre-eclampsia
-gestational diabetes
-placental praevia
-all minor complications

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8
Q

fetal antenatal complications of multiple pregnancy 4

A

miscarriage
-spontanous first trimester loss is common

congenital anomaly
-roughly doubled compared to singletons
-structural anomalies increased- eg two babies

growth restirciotn

preterm devlier y

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9
Q

prenatal diagnosis of multiple pregnnacy 2

A

serum screening / free fetal DNA do not work

Ultrasound

invasice procedures- CVS, amniocenteiss

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10
Q

specific complications of monochorionic twins 3

A

acute transfusion

twin-twin transfusion syndroem

twin reversed arterial perfusion sequence

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11
Q

monitoring of fetal growth in mutiple pregnnacy

A

high risk of intrauterine growth restirction

clinican exam unreliable

require regular ultrasound
-DC twins 4 weekly from 24 weeks
-MC twins 2 weekly from 16 weeks

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12
Q

prematurity in multiple pregnnacies

A

maternal an dfettal reasons for delivery
-major cause of neoatal death in multiples

median gestation for twins 37, triplets 34

parents need to be informed of syx and sx of preterm labour

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13
Q

managing preterm labour in multiple pregnanceis 3

A

steroids

obstetrics labour ward

neonatal cot availability

tocolysis

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14
Q

what influences mode of delivery in twins

A

presenation of first twin
-vaginal delviery if twin1 is cephalic

C-section for twin 2 high likelihood

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15
Q

when is elective delivery of twims

A

37 weeks for DCDA

36 weeks for MCDA

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16
Q

management of twin delivery

A

often epidural for mother

monitor during labour
-BP, IV access, fluids , ranitidine

fetal- continuous CTG, abdo and fetal scalp electrode
-FSE applied to bottoms

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17
Q

management of second twin after first twin is delivered as normal 4

A

cord clamped
-experied obstertican determines presenation of second twin
-US
-internally position second baby
-can allow up to 30mins if CTG ok
-can result in a Csection

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18
Q

immediate maternal post-natal care in twins 3

A

increased risk of postpartum haemorhage
-uterine blood flow high at term

with multiple pregnacies
-tone (big floppy uterus), tissue (double the placentas)m trauma (two babies to fit out)

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19
Q

what are mums of mutiple pregnancies at increased risk of postnatally (psychological) 3

A

postnatl depresion and bereavemnt

anxiety

relationship difficulties

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20
Q

why do monochorinoinc twins have specfiic complications

A

problem due to communicaiton between twins cirucation via placental anastomoses

intern-twin transfusion normal but problems arise when it becomes unbalanced

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21
Q

state the three monochorioinc complicaitons in twins 3

A

acute transfusion

twin-twin transfusion syndrome

twin revered arterial perfusion sequence

*MONOCHOROINIC TWINS SHARE PLACENTA BUT HAVE DIFFERENT SACS

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22
Q

define acute tranfusion as a complication of monochorionic twins

A

death of one twin in uterus-> increased risk of hypoxic-ischaemia injury in survivor
-due to acute transfusion from healthy to dying twin
-risk of exsanguination of healthy twin into dying twin

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23
Q

managemetn of acute transfusion as a complication of monochorionic twins

A

delivery needs to be expeidietd if compormise detected
-TO SAVE BOTH TWINS

IF UID already occurred
-delveiry not indicated except near term
-increased monitoring of surviro for anaemia and transfusions brain injury

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24
Q

define twin to twin transfussion as a complication of monochorionic twins

A

occurs in 15%
-mechanism is chronic net shunting from one twin to other

donor twin
-growth restricted, oliguric, anydramnios

recipient twin
-polyuric, polyhydramnios, cardiac problems, hydrops

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25
Q

twin to twin transfusion syndrome presenation and diagnosis 5

A

presenation
-16-25wks, different liquor volume s

Dx- USS
-liquor volume
-bladder seen
-cord dopples
-oedema/acites

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26
Q

staging system use for twin to twin transfusion syndrome

A

quintero stagin
5 stages from discordatn liquor volumes to death of one or both twins

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27
Q

staging system use for twin to twin transfusion syndrome

A

quintero stagin
5 stages from discordatn liquor volumes to death of one or both twins

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28
Q

management options of twin to twin transfusoin 2

A

fetoscopic laser ablation of anastamoses

cord occulsion

-Mx at quaternary referral centre

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29
Q

outcomes for twin to twin transfusion

A

2/3 have a dead or brain damaged baby
-outcomes imrpvoing

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30
Q

define twin reveresed arterial perfusion syndrome (TRAPS) as a complication of monochorionic twins

-*management

A

v rare

-2 cords linked by big arterio-arterial anastamossi
-retrograde perfusion
-pump twin and perfused twin

*- ablation of anastomosis

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31
Q

incidene of monoamniotic twins

A

1%

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32
Q

risks with monoamniotic twins

A

almost all develpo cord entanglement
-high perinatal mortality due to cord accidents

lots of placental anastomoses
-deaath of one twin rapidly leads to death of second twin

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33
Q

managemtn of high order mutiple pregnacies

A

good parental counselling

*usually due to assisted reporduction
-tight regulations of IVF in UK

option of selective fetal reduction
-referral to tertiary centre
-generally, C section

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34
Q

managemtn of high order mutiple pregnacies

A

good parental counselling

*usually due to assisted reporduction
-tight regulations of IVF in UK

option of selective fetal reduction
-referral to tertiary centre
-generally, C section

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35
Q

managemtn of high order mutiple pregnacies

A

good parental counselling

*usually due to assisted reporduction
-tight regulations of IVF in UK

option of selective fetal reduction
-referral to tertiary centre
-generally, C section

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36
Q

incidence of breech presentation at 20 wks, 32wks and term

A

20wks- 40%

32wks- 25%

term 3-4%

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37
Q

associations with breech presentaion 6

A

mutiple pregnacy

bicornuate uterus (uterus heart shaped_)

fibroids

placental praevia

poly/oligohydramnios

fetal anaomlies

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38
Q

what fetal anomalies are assocaited with breech presentation 3

A

NTDs

neuromusuclar disorders

autosomal trisomies

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39
Q

state the three types of breech presentation 3

A

complete

footling

Frank [19]

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40
Q

risks withvaginal delivery in breech presenation 6

A

intracranial injury

widespread bruising

damaeg to internal organs

spinal cord transection

umbilical cord prolapse

hypoxia

41
Q

risks with C section delviery of breech presentation

A

mainly maternal

surgical mrobidiy and mortality

42
Q

preferred mode of delviery for breech presentations

A

planned C section
-reduces perinatal mrotaity and early neonatal morbidity

43
Q

info given to mother about C section for breech presentation 2

A

planned C section
-caries small increase in serious immediate complications compared to vaginal birth
-does not carry any long term health risk
-

44
Q

define external cephalic version

A

externaly rotaates fetus from breech to vertex presenation

45
Q

use of external cephalic version in breech presenation

A

all women w breech presenation offerd it unless contraindicated

from 36wk if nulliparous and 37weeks if multiparous

CTG-before and after procedure
-consider Anti-D if Rhesus negative

46
Q

contraindications to external cephalic version
absolute 5 relative 5

A

absolute
-when C section reuiqred regardles of presenation (placenta praevia)
-antepartum ahemorrhage in last 7 days
-abnormal CTG
-ruptiured membranes
-mutiple pregnacy

relative
-nuchal cord
-fetal growth restriction
-pre-eclampisa
-oligohydramnios
-major fetal anomalies

47
Q

define preterm labour by date

A

less than 37wk gestaion

48
Q

define very preterm by date

A

28-32

49
Q

define extreemly preterm by dart

A

<28weeks

50
Q

define preterm labour

A

regular uterine contractions
-accompanised by effacemtn and dilatation of cervix after 20weeks and before 37weeks

51
Q

define preterm pre-labour rupture of memrbanes

A

rupture of fetal membranes before 37wks and before onset of labour

52
Q

define low birth weight by value

A

<2501g

53
Q

define very low brith weight by value

A

<1501g

54
Q

define extremely low birth weight by value

A

<1000g

55
Q

incidenec of preterm birth

A

10%

56
Q

causes of preterm birht 4

A

spontaneous labour-unknown

elective delivery
-maternal HT, fetal growth problems, antepartum haemorrhage

preterm-preamture ruptured membranes

multiple pregnancies

57
Q

chances of surviing follownig preterm delievry at:
<22wks
24wks
27wks
31wks
34wks

A

<22 weeks: close to zero
22 weeks: 10%
24 weeks: 60%
27 weeks: 89%
31 weeks: 95%
34 weeks: equivalent to baby born at full term

58
Q

complications of pre-term delivery 2

A

before 33wks
-immaturity of organ ssytems esp lungs, brain and GI tract

of those who survive 10% will suffer long term health problems

59
Q

benefits of maternal corticosteroids in pregnacies at risk of preterm delivery 4

A

IM betamethsone or dexamethasone

reduce incidnece of repsiraroty distress syndrome
reduece Intraventricular cererbral haemorhae
-reduce neonatal death
-reduce necrotising enterocoiltis and NICU admissions

60
Q

when are maternal corticosteroids given to mothers

A

between 23+0 and 23+6 who are suspected or established preterm labour

offer for between 24-33+6wks

consider in 34+0- 35+6

61
Q

causes of antepartum haemorrhage

A

3-5% of pregnnaies

placental abruption and placemeta praevia
-most important
-not most common

62
Q

classifications of antepartum haemorrhage 3

A

minor <50ml

major 50-1000ml
-no hypovolaemic shock

massive >1000ml ± hypovolaemic shock

63
Q

local causes of antepartum haemorrhage 3

A

vulva

vagina

cervix- cervical ectropion or cervical polyp
rare cervical carinoma

64
Q

antepartum haemorrhage placental causes 2

A

placenta praevia

placental aburiosn

65
Q

antepartum haemorrhage unexplained causes

A

most commoon
amnged expectantly if no fetal or maternal compromise
-recurrent is risk factor for fetal growth compromise

66
Q

define plaeceta praevia

A

placenta encroaches upon lower segement of uterus
-lower segment of uterus= extending 5cm from interternal cervical os

67
Q

risk factor for plaeceta praevia 1

A

most no discernible risk factors

previous C section is one

68
Q

plaeceta praevia diagnosis

A

transvaginal ultrasound
-can determine distance between edge of placenta and internal os

69
Q

classifications of plaeceta praevia 4

A

minor 1: encroaches the lower uterine segemnt [20]

minor 2- reaches internal os of the cervix (marginal) [20]

major 3- covers part of internal os [21]

major 4- completely covers the internal os [21]

70
Q

risk with major placenta praevia

A

haemorrhae at labour is inevitable

71
Q

is vaginal delivery possibble with minor placenta previa

A

maybe
-assess engagement of presenting part and actual distance of placental from internal os
-MUST BE >2CM

72
Q

screening for placenta praevia
-how can this change

A

placenta location determined at fetal anomaly scan (18-22wks)

may be low at that stage
-as uterus grows from lower segment upwards , placenta can move upwards with advancing gestation

73
Q

describe the differnet gestations times and if a placenta praevia is present the chance of it being low at term 3

A

Low placenta at 24 weeks: 2% will be low lying at term
At 24-29 weeks: 5% will still be low at term
At >30 weeks: 25% will still be low at term

74
Q

risks of placenta praevia

A

sudden unpredicatble major/massive haemorrhage

massive haemorrhaeg at C section

mrobidily adherent placenta

75
Q

managment of placenta praevia 3

A

may be admited from 30-32 weeks until delviery
-often outpatient management if no bleeding

elective delivery 38-39 weeks

early eremgency delivery if haemorrhage occurs

76
Q

define abnormally invasive placenta

A

placenta invades myometrium and cannot be readily separated from uterus following delivery

77
Q

how is abnormally invasive placenta diagnosed

A

usually w USS antenataly
-evaluate presence of degree of invasion

78
Q

risks with abnormally invasive placenta 1

A

massively increase risk of massive postpartum haemorrhage

79
Q

managemtn of abnormally invasive placenta 1

A

MDT delievry approach

may require hysterectomy
-women should be warned prior to delivery by C section

80
Q

define placenta abruption

A

retroplacetal haemorrhage
-bleeding between the placenta and uterus

usually involves some degree of placental separation

81
Q

risk with placenta separation

A

reduced gas exchange between fetal and amternal circulations-> can cause fetal hypoxia and acidosis

82
Q

risk factors for placenta abruption 9

A

previous abruption

HT/pre-eclampsia

thrombophillia

premature membrane rupture

mutople pregnacy

folic acid deficieny

cocaine

smoking

social deprication

*-most occur without identifiable risk factors

83
Q

what is important to note about placenta abruption

A

if women bleeding from vainga this may not reflect total blood loss

-some can also have no external loss at all
-this is a ‘concealed abruption’ and is the most hazourdous type

84
Q

types of placenta abruption 3

A

complete separion
-concealed haemorrhage [22]

partial sepation (concealed haemorrhage) [23]
partial separation (apparent haemorrhage) [23]

85
Q

managemtn of placental abruption

A

dpends on amount of bleeding, any maternal haemodyrnamic compromise, maturity of fetus

if delivery indicated
-decision between vaginal and C section influence by degree of bleeding and maternal and fetal conditions

86
Q

managemtn of a light bleeeding placental abruption 3

A

not normally compromisefetus

breif in patient obseaiont
-surveillance of fetal growth and USS

repeated episodes-> consider early delivery

87
Q

managemtn of a major haemorrhage placental abruption 1

A

urgent devliery usuallt required

88
Q

how is a major concealed placental abruption identified 3

A

degree of pain

uterine tenderness

evidence of hypovolaemic shock

89
Q

vaginal or C section in intrauterine fetal death

A

vaginal preferred
-mother shouldnt be subjected to unnecessary C section

90
Q

why is section sometimes necessary for delviery in intrauterine fetal death 3

A

*-likely to have been major blood los
-hypovolaemic shock and multisystem organ failure can occur if not correct
-release of thromboplastin from damaged plaenta can lead to DIC
therefore C section may be needed

91
Q

what does placental abruption predispose the mother to

A

post partum haemorrhage

‘abruption kills the baby, PPH kills the mother’

92
Q

presenation of placental praevia 3 (EXAM)

A

usually PAINLESS bleeding

non-engaged presenting part

soft uterues

93
Q

presenation of placental abruption 2 (exam)

A

usually PAINFUL bleeding

hard WOODY uterus

94
Q

what to ask in history of antepartum haemorrhage 3

A

when did bleeding start

how much blood loss

when did baby last move

95
Q

what to observe in antepartum harmorrhage 4

A

is mother in pain (suggests abruption or labour)

blood on bed, legs or floor?

mother pale?

signs of hypocolaemic shock- low BP, tachycardia

96
Q

examination points in antepartum haemorrhaeg 4

A

abdomonial exam

USS to deterimen placental site
-asssess fetla wellbeing

CTG if gestation >26wks
fetal heart doppler if <26wks

speculum carried out if placenta not low

97
Q

managemtn of antepartum haemorrhage 4

A

admit until bleeding stops

Anti-D if rhesus negative

major/massive APH- matrenal resus (correct hypovolemia and coagulation defects) and consider devliery

fetal compromise- consider delivery

98
Q

causes of post partum haemorrhage (4 Ts)

A

tone

trauma

tissue

thrombin

Obs & Gyn (23 decks)

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