High Risk Pregnancy Flashcards
A _______ is one in which the fetus is
at increased risk of stillbirth, neonatal morbidity or
death, and/or the expectant mother is at increased
risk for morbidity or mortality
high-risk pregnancy
The WHO definition of maternal mortality is the
death of a woman during ______, _______, __________, irrespective of
duration or site of the pregnancy, from any cause
related to or aggravated by the pregnancy or its
management.
pregnancy, childbirth or
in the 42 days of the puerperium
The ________ is the number of deaths per 100 000 confinements. In first world countries it is approximately 10.
maternal mortality ratio
The latest
triennium statistics for Australia was ____________ confinements—
_______ for non-Indigenous
Australians and 21.5 for ASTI people (c.f. Africa
approx. 900).
8.4 deaths per
100 000
8
The main causes of direct maternal deaths in Australia are (in order)
- amniotic fluid embolism
- thrombosis and thromboembolism
- haemorrhage
- hypertensive disorders of pregnancy
- cardiac conditions
- anaesthetic-associated deaths
Some Australian obstetric statistics for 2003:
- average age of all mothers was _____
- spontaneous vaginal births—______
- caesarean section (CS) rate—______
- instrumental delivery rate—_____
- multiple pregnancies—____
- 5 years
- 3%
- 5%
- 7%
- 7
The_______ is the total number of deaths
of children within 28 days of birth (early neonatal
deaths) plus fetal deaths at a minimum gestation
period of 20 weeks or a minimum fetal weight of 400 g
expressed per 1000 births
perinatal mortality
The major factors associated with perinatal mortality in NSW are 1 2 3
very premature birth, congenital
abnormalities and hypoxia during the antenatal
period or in labour.
A review of perinatal deaths
occurring in 2003 in Australia found that _____
of perinatal deaths (or 45.7% of stillbirths) were
unexplained antepartum deaths
30.9%
The earlier that ultrasound is performed after _______of gestation, the more accurate the determination.
6–7 weeks
Hypertensive disorders complicate about _____ of all
pregnancies
10%
________ which in
fact complicates 2–8% of pregnancies, can occur at
any time in the second half of pregnancy or even just
following delivery
Pre-eclampsia,
What is pregnancy induced HPN
— SBP >140 mmHg and DBP >90 mmHg,
occurring for first time after 20th week of
pregnancy and regressing postpartum
or
— Rise in SBP >25 mmHg or DBP >15 mmHg
from readings before pregnancy or in first
trimester
_____________BP up to 170/110 mmHg in
absence of associated features (
Mild pre-eclampsia.
Severe pre-eclampsia. BP >170/110 mmHg and/or associated features, such as 1 2 3 4 5
kidney impairment, thrombocytopenia, abnormal liver transaminase levels, persistent headache, epigastric tenderness or fetal compromise
____________ Chronic
underlying hypertension occurring before the
onset of pregnancy or persisting postpartum
Essential (coincidental) hypertension.
__________ Underlying
hypertension worsened by pregnancy
Pregnancy-aggravated hypertension.
Test for pre-eclampsia:
1
2
3
spot urinary albumin– creatinine ratio, or 24-hour urinary protein excretion
The following are risk factors for pregnancy-induced
hypertension
- nulliparity/primigravida
- family history of hypertension/pre-eclampsia
- chronic essential hypertension
- diabetes complicating pregnancy
- obesity
- donor sperm or oocyte pregnancy
- multiple pregnancy
- hydatidiform mole
- hydrops fetalis
- hydramnios
- kidney disease
- autoimmune disease (e.g. SLE)
Clinical features of superimposed pre-eclampsia include 1 2 3
hypertension, excessive weight gain,
generalised oedema and proteinuria (urinary protein
>0.3 g/24 hours).
Risks of severe pre-eclampsia/ hypertension
Maternal risks (poor control)
- Kidney failure
- Cerebrovascular accident
- Cardiac failure
- Coagulation failure
Risks of severe pre-eclampsia/ hypertension
Risks to baby
- Hypoxia
- Placental separation
- Premature delivery
In pre-eclampsia
The BP level should be kept below _______
mmHg because at this level intra-uterine fetal death is
likely to occur and there is a risk of maternal stroke
160/100
Contraindicated drugs for pre-eclampsia are
ACE inhibitors and diuretics
Commonly used medications for pre-eclampsia
• beta blockers (e.g. labetalol, oxprenolol and
atenolol) (used under close supervision and after
20 weeks gestation)
• methyldopa: good for sustained BP control
• nifedipine
_____, _______ and _______are useful
for rapid control of BP in hypertensive crises (e.g.
hydralazine 5 mg IV bolus every 20–30 minutes or
continuous infusion).
Labetalol, hydralazine and diazoxide
Guidelines for urgent referral/admission
to hospital
Maternal factors
•Progressing pre-eclampsia including development
of proteinuria
• Inability to control BP
• Deteriorating liver, blood (platelets), kidney
function
• Neurological symptoms and signs
Guidelines for urgent referral/admission
to hospital
Fetal factors
• Abnormal cardiotocograph (CTG) indicating fetal
distress
• Intra-uterine growth retardation
Treatment of severe pre-eclampsia: prevention of convulsions
1
2
3
• Control BP: use IV hydralazine or diazoxide—don’t
suppress to <140/80 as this can induce fetal hypoxia
• Magnesium sulphate 50% 4 g IV (given over
10–15 minutes) followed by an infusion 1 g/hour
for a minimum of 24 hours (if normal kidney
function)
• Corticosteroid therapy IM for fetal lung maturity
if gestation ≤ 34 weeks
What to monitor is severe pre-ecl
Monitor fetus and maternal BP, urine output,
urine protein, coagulation profile
The best treatment for pre-ecl is
termination of pregnancy with early delivery—by CS or vaginal delivery if favourable circumstances
Treatment of convulsion
bolus of 2 g MgSO 4 .
Consider an alternative—IV diazepam or clonazepam
In Mx of eclampsia
- Avoid _____ in the third stage.
- Be prepared for a possible _____
ergometrine
postpartum haemorrhage
What is HELLP syndrome
Haemolysis Elevated Liver enzymes Low Platelets is
a severe form of pre-eclampsia occurring in 20% of
these patients. Treat as for severe pre-eclampsia with
early delivery
Anaemia is defined as a haemoglobin _____.
Levels below this, particularly less than __, require
investigation.
<110 g/L
100 g/L
Important types of anaemia in pregnancy:
1
2
3
• iron deficiency (approximately 50%)
• megaloblastic anaemia (usually due to folic acid
deficiency)
• thalassaemia (most commonly β -thalassaemia
Treatment of anemia according to cause:
— iron deficiency: ______
— megaloblastic anaemia: ______
— thalassaemia: no treatment is possible but
_____
ferrous sulphate 0.9 g (o) daily, iron infusion may be required
folic acid 5 mg (o) bd
partner also needs to be screened
Fetal effects of DM
Large for dates (macrosomia), fetal abnormalities
(neural tube, cardiac, kidney, vertebral, etc.
defects), hypoxia and intra-uterine death (IUFD),
miscarriage, malpresentation, IUGR, preterm
delivery
Postnatal effects on fetus of DM
Early hypoglycaemia, respiratory distress
syndrome, jaundice
Effects on the mother of DM
Increased risk of pre-eclampsia, diabetic
ketoacidosis, polyhydramnios, intercurrent
infection, psychological effects, first trimester
miscarriage, obstructed labour (shoulder
dystocia), placental abruption, CS
Aim for diabetic control:
FBS and Hba1c
fasting blood sugar 4–7
mmol/L: HbA1c <7%
When to do fetal morphology tests in DM mothers
• Screen for fetal morphology and growth:
ultrasound at 18 weeks then 4 weekly and as
required; cardiotocography as required—usually
weekly from 32–34 weeks until delivery
Aim to deliver in DM mothers at term at latest:
— vaginally if optimal control
— CS if __________
large fetus (>90th weight percentile
or >4000 g) or evidence of fetal distress or
breech presentation
In DM, postpartum care involves:
Cease insulin infusion and ↓ insulin to
pre-pregnancy regimen immediately after
delivery; organise contraception; avoid oral
hypoglycaemics during breastfeeding
Gestational diabetes is the onset or initial recognition
of abnormal glucose tolerance during pregnancy. If
suspected a diagnostic________
oral glucose (75 g) tolerance test is indicated.
GDM
Diagnosis: fasting blood glucose ______
or
2-hour level______
> 5.5 mmol/L
> 8.5 mmol/L
_______ in pregnancy is unhelpful for
screening because it is common in pregnancy and
lacks specificity
Glycosuria
On GDM
Follow up GTT at 6 weeks and then every
5 years. Gestational diabetes is likely in subsequent
pregnancies and there is a ______ risk of developing
diabetes in later life—even <10 years
30%
_______ in pregnancy is uncommon and
usually mild. It is associated with infertility. It is
associated with a higher rate of fetal loss, miscarriage,
fetal abnormalities and IUGR
Hypothyroidism
When to do testing for TFT
TFTs should be checked at first presentation if past history is relevant and at 36 weeks
_______ is usually the preferred agent in Graves in pregnancy
Propylthiouracil
The highest risk of maternal mortality during pregancy is where
pulmonary blood flow cannot be increased
(e.g. pulmonary hypertension, Eisenmenger
syndrome
______ and _______ may be a pointer to a
cardiac disorder
Syncope and dyspnoea
________is important for those
with structural cardiac problems (e.g. valvular
problems), most congenital malformations
Antibiotic prophylaxis
Patients with an increased risk of bacterial
endocarditis (especially with rheumatic heart
disease) require an antibiotic cover in labour of
______ and _______
penicillin and gentamicin
What to avoid in Cardiac do
As a rule avoid lithotomy, ergometrine,
sympathomimetic drugs
Crea level with increased CX
↑ maternal and fetal complications in moderate
failure (s. creatinine 0.125–0.25 mmol/L) and
severe kidney failure (>0.25 mmol/L).
T or F
Pregnancy does not seem to cause exacerbations
of SLE.
T
SLE in pregnancy
Increased incidence of spontaneous abortions
and stillbirths—related to_____ and ______
lupus anticoagulant
and anticardiolipin antibodies
_________ includes blood
disorders and cardiac abnormalities in the
neonate.
Neonatal lupus syndrome
SLE
___________if anticardiolipin antibodies present, to prevent onset of preeclampsia or IUGR.
• Low molecular weight heparin may be used
as alternative to aspirin and in presence of
________
Low dose aspirin (100 mg daily)
prolonged APTT.
The two most common causes of significant
thrombocytopenia (TCP) in an otherwise normal
pregnancy blood film are _______ and ______
gestational thrombocytopenia
and immune thrombocytopenia
Other causes of TCP
SLE, anti-phospholipid syndrome (APS), drug-induced thrombocytopenia and HIV infection.
Because of the increasing hazard of epidural
anaesthesia in platelet counts under 75/nL, a 2-week
course of _______ is often prescribed at 37–38
weeks gestation, aiming for a platelet count in excess
of 100/nL at the time of delivery
prednisolone
Although less common than gestational ITP, it is
clinically more significant since it is typically severe
and arises earlier in pregnancy
Immune TCP
_________ are found in at least
50% of ITP patients
Platelet-specific antibodies
________ results from the transplacental passage of
maternal IgG anti-platelet antibody into the fetal
circulation
Fetal ITP
________ accounts for 40% of all cases of jaundice
during pregnancy
Viral hepatitis
This condition is due to an oestrogen sensitivity. The
symptoms, which are mild, include low-grade jaundice
and pruritus during the latter half of pregnancy
Cholestasis of pregnanc
Cholestasis of pregnancy
The condition clears up rapidly after delivery,
but it often recurs in future pregnancies and if the
patient is prescribed _______ which are
contraindicated
oral contraceptives,
About 25% of women have
an increased number of seizures, due mainly to a_______________ with a small increased
frequency during labour and the puerperium
fall
in anti-epileptic drug levels
It is important to take oral folic acid supplementation
(5 mg daily) during pre-pregnancy and up to_____
12 weeks
gestation,
For subsequent contraception a higher dose oestrogen
pill is recommended because
the anti-epileptic agent
usually increases liver enzyme activity
Bleeding from the genital tract after the
20th week of gestation and before the onset of labour
Antepartum haemorrhage
If haemorrhage occurs at less than 24 weeks
treat as for ___________
threatened miscarriage
Main causes og Hge post 26 wks
The main causes are placental, namely
placenta praevia (unavoidable APH) and placental
abruption (accidental).
_______ in
particular has a high risk of causing fetal death in
utero with coagulopathy complications
Placental abruption
The placenta has a low attachment onto the lower
uterine segment and may cover the cervix. Incidence
is about 1%.
PP
PP SSx
Presentation usually
includes painless bleeding at 28–30 weeks gestation.
There is a high presenting part on palpation
__________is always required for major
placenta praevia
Caesarean section
__________ is retroplacental
bleeding from a normally situated placenta resulting
in detachment of a segment of decidua from
the uterine wall
Placental abruption (incidence 1%)
SSx of AP
The patient presents with midabdominal
pain, bleeding PV, and a tense and tender
uterus (large for dates) and signs of hypovolaemic
shock.
It is
the commonest obstetric cause of coagulopathy
Abruptio Placenta
Tests for AP
Perform tests—FBE, coagulation profile,
Kleihauer test to define any feto-maternal
haemorrhage, blood for cross-matching, kidney
function, electrolytes
AP
Give course of ________ if <34 weeks to
mature the baby’s lungs as urgent delivery may
be necessary
corticosteroids
What is the aim for AP
The objective is to aim for vaginal delivery, especially
if the baby is dead
AP
Caesarean
section has been recommended where the baby’s life
is immediately threatened, but this is hazardous in the
presence of ________
coagulopathy.
______ is a rare cause of APH due to rupture of
fetal blood vessels. It coincides with rupture of the
membranes
Vasa praevia
Diagnosis of VAsa Previa is by a
1
2
characteristic ominous pattern on CTG and the
Apt test. Emergency delivery is indicated
Primary postpartum haemorrhage is loss of _____
of blood within 24 hours of delivery. A severe PPH is
defined as ______ blood loss.
> 500 mL
> 1000 mL
Causes of Primary postpartum Hge (PPH)
• Uterine atony • Retained placenta/placental fragments • Soft tissue laceration of genital tract (e.g. episiotomy, cervical tear) • Ruptured or inverted uterus • Coagulation disorder
Mx of PPH
• IV oxytocin (Syntocinon) 10 IU followed by 40 IU
in IV infusion of Hartman solution
• If continuing heavy bleeding ergometrine
PPh
If retained placenta—deliver ________
with cord traction
or manual removal
If a persistent atonic uterus is not controlled
by oxytocics, 1–2.5 mg doses of _______
intramyometrial prostaglandin F2- α can be injected through the abdominal wall
Life-saving measures for PPH can include 1 2 3 4
insertion of a Bakri balloon for tamponade, uterine
artery ligation, internal iliac artery ligation (usually
bilateral) or hysterectomy
Blood group or red cell isoimmunisation is primarily
related to Rhesus D (RhD) isoimmunisation leading
to ______________from the effect
of the development of anti-D antibodies
haemolytic disease of the newborn
Cause of Blood group isoimmunisation
These
antibodies develop from feto-maternal haemorrhage/
transfusion in RhD-negative women carrying an
RhD-positive fetus.
Blood group isoimmunisation
Effects of haemolytic disease on the fetus includes
__________
hydrops (oedema), FDIU
Blood group isoimmunisation
Effects on the neonate include 1 2 3 4
anaemia, heart failure, jaundice and hepatosplenomegaly
Indications for giving anti-D Ig to the RhD-negative mother free of immune anti-D: 1 2 3 4 5
• after spontaneous miscarriage at any stage of
pregnancy
• after threatened miscarriage
• after delivery of an RhD-positive baby
• following termination of pregnancy or ectopic
pregnancy
• following any sensitising event during pregnancy
that may provoke a transplacental haemorrhage
• prophylactically at 28 and 34 weeks in an
apparently normal pregnancy
This is a test on maternal blood after a sensitising event
to detect the degree of feto-maternal transfusion and
whether increased anti-D Ig is required
Kleihauer test
This usually occurs when the mother is group O and
the baby A or B and can occur in the first pregnancy
without a tendency to become increasingly severe
in subsequent pregnancies
ABO incompatibility
ABO incompatibility
A small number of babies have ______
mild jaundice while severe haemolytic consequences are rare
Pregnancy is associated with an increased risk of
thromboembolism with an incidence of about _____
1%
of deep venous thrombosis (DVT)
Untreated DVT
carries about ______ risk of pulmonary embolism.
15%
If a______ is suspected, low molecular weight heparin
is recommended until investigation and specialist
advice are obtained.
DVT
________ is an overgrowth of gestational
trophoblastic tissue.
Hydatidiform mole
Types of H mole
The moles may be complete (no
fetal tissue) or partial (some fetal tissue)
SSx of H mole
Bleeding in early pregnancy ± passage of grapelike
debris
• May be exaggerated symptoms of pregnancy
(e.g. hyperemesis)
• Uterus large for dates
UTz of H mole
typical ‘snow-storm’ appearance
FF up for h mole
• Weekly serum (or urine) hCG until zero (usually
takes 8–12 weeks), then monthly for 12 months
• Avoid pregnancy for 12 months after hCG levels
norma
H mole Tx
Refer for possible cytotoxic therapy (e.g.
methotrexate and folinic acid) if hCG does not
become normal or the process is >3 months, or it
becomes elevated again and a new pregnancy has
been excluded
Maternal Cx of multiple pregnancy
increased risk anaemia; symptoms of
pregnancy (e.g. morning sickness, varicose veins);
pre-eclampsia × 3; antepartum and postpartum
haemorrhage; malpresentation; cord prolapse; CS
Fetal/neonatal Cx of multiple pregnancy
increased risk abnormalities,
preterm delivery (premature labour, premature
rupture membranes); intra-uterine growth
restriction of one fetus; twin–twin transfusion;
perinatal mortality × 5; prematurity;
malformations × 2–4; (also those of mother)
Monozygotic twins need a scan every 2–3
weeks from 16 weeks until delivery to recognise
evidence of ___________
twin-to-twin transfusion syndrome
TTTS
Multiple pregnancy
As a rule, elective CS is favoured at_______
37 or 38 weeks
Preterm or premature labour is confirmed labour
after ________ and before ________
20 weeks and before 37 weeks gestation
Causes of spontaneous preterm labour
• unknown (approx. 40%) • multiple pregnancy • cervical incompetence • polyhydramnios • uterine abnormality • maternal medical conditions (e.g. diabetes, drug abuse, infection) • antepartum haemorrhage
________________ is
rupture of the membranes with amniorrhoea before
labour commences
Premature rupture of the membranes (PROM)
___________is rupture of the
membranes at <37 weeks gestation.
Preterm PROM (PPROM)
50% of PPROM progress to labour within_____
24
hours (80% within 7 days).
Differential diagnosis of PROM includes profuse
`
vaginal discharge, incontinence of urine—20%
false alarms for amniorrhoea (amniorrhexis).
T or F
PROM
Do not perform a vaginal examination.
T
Abx to be given for PROM
Give prophylactic antibiotics (erythromycin) until
culture results indicate that no infection is present
PROM
Give corticosteroid therapy if delivery prior to______
34
weeks likely
Prolonged pregnancy is pregnancy lasting longer than
________
42 weeks
Induce labour at 42 weeks as perinatal mortality
rate is ↑ ___________ from 42–43 weeks and more so after
43 weeks.
× 2
Induction is probably best achieved using
___ and ________, followed by ARM if labour does not
follow
prostaglandin E2 vaginal gel, or oral or vaginal
misoprostol
What is the dx
• Liquor volume: usually >2000 mL
• Multiple risks (e.g. PROM, prem labour, cord
prolapse, APH, malpresentation)
Polyhydramnios
Causes of polyhydramnios
• Fetal abnormalities: CNS, upper GIT atresia, ectopic vesicae • Hydrops fetalis • Diabetes • Multiple pregnancy • Chorioangioma of placenta • Fetal infection—cytomegalovirus, toxoplasmosis • Unknown caus
Fundus less than dates
• oligohydramnios—liquor volume usually <500 mL • small baby • intra-uterine growth restriction • wrong dates • ruptured membranes
Oligohydramnios is associated with conditions such as 1 2 3 4 5
fetal abnormality, prolonged pregnancy,
kidney disease, pre-eclampsia, congenital infections
(CMV, toxoplasmosis), PROM and placental
insufficiency
____________ is defined
as an estimated birth weight <10th percentile
Intra-uterine growth restriction (IUGR)
PE of oligohydramnios
symphysis–fundal height is at least 2 cm less than that expected for the appropriate gestation.
Fresh meconium is______ and ______
dark green and sticky.
_______ is an important cause of Meconium-stained liquor
Cord prolapse
The important malpresentations are breech (4% of all
babies) and transverse or oblique lie. A primary concern is
the high risk of _____ and______
cord presentation and prolapse
Breech presentation
The general rule is to deliver by _________
caesarean section (CS),
If spontaneous version to a cephalic presentation has not occurred, what to do next?
If appropriate, an external cephalic version can be attempted (with a small risk of haemorrhage).
These presentations are more common in
multigravida. Perform an ultrasound examination
to exclude placenta praevia
Transverse or oblique lie
What to do if transverse lie persists beyond __________: admit to hospital and if it persists or labour
commences CS is the best option
37
weeks
Impacted shoulders causing sudden arrest of delivery
after delivery of the baby’s head is a terrifying complication of childbirth
Shoulder dystocia
Manuevers for the delivery during shoulder dystocia
(Consider
McRoberts manoeuvre 12 —suprapubic pressure,
shoulder rotation performed vaginally, delivery of
the posterior shoulder.)
Mx of inverted uterus
The easiest way to manage this complication is to return the uterus to its normal position with the cord still attached immediately after the event
Considerations for induction
- post-term (41 weeks or over)
- maternal hypertension
- maternal distress
- diseases of pregnancy (e.g. pre-eclampsia)
- intra-uterine growth restriction
- intra-uterine fetal death
- diabetes mellitus
- isoimmunisation
- unstable lie
Obstetric indications for CS
• previous CS (commonest) • failed progress of labour • cephalo-pelvic disproportion—relative or absolute • cord prolapse and presentation • placenta praevia
Complications of CS
• increased risk of maternal mortality
• anaesthetic complications
• damage to adjacent viscera (e.g. bladder, bowel)
• infection
• adhesions
• need for repeat (maximum of three) CS advised
• increased risk of placenta praevia in subsequent
pregnancies
Abdominal trauma in pregnancy is usually associated
with _________ during motor vehicle
accidents
seat-belt restraints
The incidence of__________ following
accidents is related to the severity of the accident and
the extent of the external injuries
placental abruption
