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Y4 - GOSH > High Risk Pregnancy > Flashcards

High Risk Pregnancy Flashcards

1
Q

what are some of the maternal conditions leading to high risk pregnancy

A 
obesity 
GDM or DM in general 
pre-eclampsia 
epilepsy 
HTN, pregnancy induced hypertension
CKD 
chronic respiratory disease 
SLE 
infection - TORCH syndrome 
previous abdo surgery 
VTE (4x risk if FHx of oestrogen related VTE)
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2
Q

what are some of the social conditions leading to high risk pregnancy

A 
teenage pregnancy 
maternal age > 35 
smoking/alcohol/substance abuse 
high parity > 4 (PPH), low interpregnancy interval 
Poor socioeconomic conditions
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3
Q

what are some of the obstetrics issues leading to high risk pregnancy

A 
prev. preterm labour 
C-section 
recurrent miscarriage (3+) 
stillbirth 
pre-eclampsia 
GDM 
3rd degree tear
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4
Q

what is the definition of small for gestational age

A

EFW > 10th percentile for its gestational age.

SGA is a surrogate marker for IUGR

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5
Q

complications of IUGR

A

perinatal mortality if 6-10x higher
cerebral palsy 4x greater
30% of stillbirth are growth restricted

intrapartum foetal distress and asphyxia 
meconium aspiration 
emergency CS 
NEC
Hypoglycaemia and hypocalcemia
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6
Q

what are the maternal causes of IUGR?

A

chronic maternal disease - HTN, cardiac disease, CKD

Substance abuse - alcohol, smoking, drugs

autoimmune disease - antiphospholipid antibody syndrome, SLE

genetic disease - phenylketonuira

poor nutrition

low socio-economic status

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7
Q

what are the placental causes of IUGR

A

abnormal trophoblast invasion - pre-eclampsia, placenta accreta

abnormal umbilical cord or cord insertion - 2 vessel cord

abruption

placental praevia

tumor - chorioangiomas

infarction

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8
Q

what are the foetal causes of IUGR

A

genetic abrno - trisomy 13, 18, 21

turner’s syndrome

Triploidy

congenital abnor - cardiac, gastroschisis

TORCH syndrome

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9
Q

what are the 2 different types of IUGR that can occur

A

symmetric growth restriction - entire body small, early onset and tends to be chromosomal abnor

asymmetric growth restriction - undernourished foetus, head sparing, secondary to placental insufficiency

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10
Q

management of IUGR

A

early identification
intensive foetal monitoring - serial growth scans

continue pregnancy safely for as long as possible - dec prematurity complications, but ultimately delivery and good care of neonate is the solution

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11
Q

long- term complications of IUGR

A

most are fine

1/3 of children not reaching their predicted adult height

childhood attention and performance deficit

higher rates of coronary heart disease, high BP, high cholesterol and abnor glucose-insulin metabolism

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12
Q

what is the aetiology of IUGR

A 
FHx
previous multiple pregnancies 
increasing parity 
inc maternal age
ethnicity 
assisted reproduction
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13
Q

what are the signs/symptoms of IUGR

A

Hyperemesis gravidarum
large for date
3 or more foetal poles maybe palpable > 24 weeks
2 fetal hearts may be heard on auscultation
USS evidence on booking or any scans in 1st trimester

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14
Q

what are some of the antenatal care of multiple pregnancy

A

consultant led care

need to establish chorionicity - most accurate in 1st trimester

double the amount of iron and folate

detailed anomaly scan

serial growth scans + inc frequency of appointment

close eye on ketons and pre-eclampsia - due to increase demands from placenta and so will more likely to cause pre-eclampsia

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15
Q

in what situation would you get dichorionic diamniotic twins

A

1) when 2 eggs are fertiliserised

2) when the fertilised egg splits into 2 in the first 3 days of cell division

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16
Q

in what situation would you get monochorionic diamniotic twins

A

when the ferilised egg divide into 2 in first 4-7 days of cell division since it has already implanted into the endometrium but has yet to divide any further

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17
Q

in what situation would you get monochorionic Monoamniotic twins

A

when the ferilised egg divide into 2 in first 8-12 days of cell division since it has already implanted into the endometrium and cells already develop into placenta

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18
Q

when should multiple pregnancies be delivered

A

consider induction at 38 weeks

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19
Q

what are the maternal risks to multiple pregnancy

A 
hyperemesis gravidarum 
anaemia - due to 2x inc need of Hb production 
pre-eclampsia 
GDM 
polyhydramnios  
placenta praevia - due to lack of spaces 
APH & PPH 
operative delivery
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20
Q

what are the foetal risks to multiple pregnancy

A

inc risk of miscarraige - esp with monochorionic twins

congenital abnor more common in monochoriontic twins - neural tube defects, cardiac abnor, gastrointesiontal atresia

IUGR

PROM

inc perinatal mortality

inc risk of stillbirth

inc risk o disability

inc risk of cerebral palsy

Vanishing twin syndrome - 1 twin apparently being reabsorbed at an early gestation

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21
Q

what is twin to twin transfusion syndrome

A

aberrant vascular anastomoses within the placenta which redistributes the foetal blood

blood from the donor twin is transfused to the recipient twin

the placenta in this case only have 2 vessels, 1 artery which is directed to the recipient twin and vein to the donor twin

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22
Q

what is the clinical features of the donor twin in twin to twin syndrome

A

Less arterial blood to donor twin - less nutrient

IUGR –> oligohydramnios, hypovolemia, anaemia

because of the apparent less volume of placenta. it appears to be stuck to the placenta/uterine wall and much smaller

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23
Q

what is the clinical features of the recipient twin in twin to twin syndrome

A

relatively more arterial blood to the recipient twin

hypervolemia and polycythemia

larger bladder and polyhydramnios

evidence of foetal hydrops (ascites, pleural and pericardial effusions)

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24
Q

which twin in the twin to twin transfusion syndrome tend to do worse post-natally

A

the recipient twin because fetus is not built to sustain more nutrient naturally therefore the donor twin tends to do better although both have a terrible outcome

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25
Q

what does a lambda sign found in antenatal USS mean for the number of placenta in a pregnancy

A

lambda sign = dichrionic

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26
Q

what does a T sign found in antenatal USS mean for the number of placenta in a pregnancy

A

T sign = monochrionic

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27
Q

what is the dosage of folic acid for twin pregnancy

A

5mg

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28
Q

what is the treatment plan for MCMA

A

elective C-section at 32-34 weeks

1 twin normal delivery and 1 twin C-section

beware of first twin non-vertex which will be risk of locked twin

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29
Q

what is pregnancy-induced hypertension

A

hypertension in the 2nd half of pregnancy in the absence of proteinuria or any other marker of pre-eclampsia

BP >140 or > 90 or an inc of BP of >30/>15

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30
Q

when should delivery of the baby be if the pregnant lady have PIH

A

around EDD

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31
Q

what is the general trend of BP in a pregnant woman

A

from conception to 24 wks, slight dec in BP then from 24 till delivery, BP will return to normal value

BP dec after delivery but many peaks 3-4 days post-partum

32
Q

when should delivery of the baby be if the pregnant lady have chronic hypertension

A

around EDD but inc risk of re-eclampsia

33
Q

what is post-partum hypertension

A

inc BP in the postpartum period

BP can peak 3-4 days post-partum

34
Q

how common is pre-eclampsia

A

10% of all population

35
Q

definition of pre-eclampsia

A

BP > 140/90 + > 300mg proteinurua in 24 hour collection after 20 weeks (or protein:creatinine ration > 30 or albumin:craetinine ration >8)

or

a rise in systolic BP > 30 or Diastolic BP > 15

36
Q

what are the different classification of pre-eclampsia

A

mild - proteinuria and mild/moderate hypertension

Moderate - proteinuria + severe HTN with no maternal complications

Severe - proteinuria and any HTN <34 weeks (160/110) it with maternal complications

37
Q

symptoms of pre-eclampsia?

A

headache (esp. frontal)
visual disturbance (esp. flashing light)
epigastric or RUQ pain
N+V
rapid oedema (esp antigravity eg face)
symptoms only really occur with severe cases

38
Q

signs of pre-eclampsia?

A

HTN - 140/90 (160/110 if severe)
proteinuria (>300mg in 24 hour urine collection)
facial oedema
epigastric/RUQ tenderness - signs of liver involvement and capsule distension

confusion
hyperreflexia +/- clonus - cerebral irritability
uterine tenderness or vaginal bleeding from a placental abruption
IUGR on USS

39
Q

what are some of the RF for pre-eclampsia

A

previous pre-eclampsia Hx

Primp

FHx

BMI > 30

Maternal age > 40

multiple pregnancy

sub-fertility

DM

PCOS

autoimmune disease - antiphospholipid syndrome

renal impairment

pre-existing cardiovascular disease and chronic HTN

40
Q

investigation for pre-eclampsia

A

FBC - high HB, thrombocytopenia, anaemia

coag profile = prolonged PT and APTT

urinary test for proteinuria

LFT

U&Es

41
Q

what is eclampsia

A

the occurrence of tonic-clonic seizure in association with a diagnosis of pre-eclampsia

42
Q

what is HELLP syndrome

A

Hamolysis Elevated Liver Enzyme, Lower Platelet

43
Q

what is the management of pre-eclampsia

A

definitive management = delivery of placenta + baby

44
Q

management of outpatient management of pre-eclampsia (BP<160 and <110 + no proteinuria)

A

warn about the development of symptoms

1-2 per weeks review of BP and urine

Weekly review of blood biochemistry

45
Q

management of mild-moderate management of pre-eclampsia (BP<160 and <110 + significant proteinuria >300mg per 24 hours)

A

admission advised

daily urinalysis

daily CTG

Oral labetalol

46
Q

management of mild-moderate management of pre-eclampsia (BP>160 and >110 + significant proteinuria >300mg per 24 hours +/- maternal complications

A

BP control - aim for <160 and <110

1st line - labetalol
2nd line - nifedipine (if labetalol can not be used due to asthma) or methyldopa
IV labetalol or hydralazine

use Magnseium sulphate if seizures

Dexamethsaone 12mg PO as adjunt to prepare for baby delivery

47
Q

what is the percentage of seizure take place post-natally

A

44%

48
Q

complications for pre-eclampsia

A

SHAME

Stroke 
HELLP syndrome 
Abruption 
multi-organ failure +/- DIC +/- Death 
Eclampsia
49
Q

what are some of the maternal complications of pre-gestation diabetes

A

DM lower the body’s immune system

UTI 
recurrent vulvovaginal candidiasis 
PIH/ Pre-eclampsia 
operative deliveries: CS and assisted vaginal deliveries 
inc risk of retinopathy 
inc risk of nephropathy 
cardiac disease
50
Q

what are some of the foetal complications of pre-gestation diabetes

A

SMASHED

S - shoulder dystocia 
M - macrosomia 
A - Amniotic Fluid Excess 
S - stillbirth 
H - Hypoglycaemia/Hypothermias/HTN
E - Error inbound 
D - Disability (neural tube defects, microcephaly, cardiac abnor, sacral agenesis, renal abnor)

preterm labour
IUGR
unexplained IUD

51
Q

what are some of the post-natal complications of pre-gestation diabetes

A

polycythemia –> jaundice + cardiomegaly + RDS
hypoglycemia
birth trauma - shoulder dystocia, fractures, Erb’s palsy, asphyxia

hypoglycaemia/hypocalcaemia/hypomagnesaemia

52
Q

what are the specific management of the baby whose mother is diabetic pre-pregnancy

A

folic acid 5mg - due to inc risk of neural tube defect

Down’s screening - DM reduce aFP and so less accurate screening

5-10 fold inc risk of foetal anatomy anomaly - anatomy screening

foetal echocardiography - due to risk of foetal cardiomegaly due to polycythemia

serial growth scans - polyhydramnios, macrosomia or IUGR

hypoglycaemia - educate patient and family and supply with glucagon

advise earlier delivery at 38-39 weeks, lower the already heightened risk of shoulder dystocia

53
Q

what is the insulin management of the mother post-natally

A

the requirement of the insulin drops dramatically after birth (insulin is required for the foetus as it is a growth factor)

therefore, mother should go onto a sliding scale initially then slowly return to pre-pregnancy SC insulin

54
Q

when is oral glucose tolerance test usually carried out

A

26-28 weeks

55
Q

when is oral glucose tolerance test usually carried out if the patient had previous GDM

A

16 weeks

56
Q

how is OGTT carried out?

A

fasted overnight for 8 hours - water only, no smoking

75g glucose load in 250-300ml of water

plasma glucose measured both fasted and at 2 hours

57
Q

what plasma glucose reading form a OGTT would you diagnose GDM

A

> 7 for fasting

> 11.1 for 2 hour gloucse

58
Q

what plasma glucose reading form a OGTT would you diagnose glucose impairment

A

fasting gluose < 7

2 hours > 7.8 and < 11.0

59
Q

RF for GDM

A 
previous GDM 
FHX of DM 
previous macrosomic baby 
previous unexplained stillbirth 
obesity (BMI >30) 
glycosuria 
polyhydramnios 
LGA 
ethnicity - south asian
60
Q

measurement of GDM?

A

MDT approach
measure glucose QDS

diet should be first line - aim for normoglycaemia and avoid ketons

scanning every 2 weeks for polyhydramnios, IUGR & macrosomia

start insulin if

  • pre-meal glucose > 6
  • 1 hour after meal glucose >7.5
  • AC > 95th centile despite apparent good control
61
Q

when will you start insulin in a pregnant woman who has GDM

A

pre-meal glucose > 6
1 hour post meal glucose > 7.5
AC > 95th centil despite good control

62
Q

how would you give insulin when the pregnant lady is in labour

A

sliding scale

63
Q

when is DVT more likely than PE during the pregnancy periods

A

DVT is more common antenatally

64
Q

when is the highest risk of VTE during pregnancy?

A

in the puerperium period

65
Q

RF for VTE in pregnancy

A

All pregnant women are at risk of thrombosis- Increase coagulant factor during pregnancy, decrease anticoagulant activity

Congenital thrombophilia
Antiphospholipid syndrome
age > 35 
BMI > 30 
parity > 4 
varicose veins 
paraplegia 
sickle cell disease 
IBD
nephrotic syndrome 
cardiac disease

hperemesis
dehydrations
lon-haul trael
severe infection eg pyelonephritis

immobility (>4 days bed rest)
pre-eclampsia
prolonged labnour
excessive blood loss

66
Q

what is the drug of choice? for anti-coagulant during pregnancy?

A

LMWH

67
Q

what is considered high risk of VTE in antenatal periods

A

any prev VTE except a single event related to major surgery

start antenatal prophylaxis with LMWH

68
Q

what is considered to be the Intermediate risk of VTE in antenatal periods?

A

Hospital admission

Single Previous if ETA
related to major surgery

High risk thrombophilia and no VTE

Medical comorbidities - Cancer, heart failure, activities early, IBD or inflammatory polyarthropathy, nephrotic syndrome, T1DM with nephropathy, sickle cell disease, current IVDU

any surgical procedure appendicectomy
Ovarian hyperstimulation syndrome

If any of the above considerate antenatal prophylaxis of LMWH

69
Q

What is considered to be high risk of VTE in postnatal period

A

Any previous VTE

anyone requiring antenatal LMWH

high risk thrombophilia

low risk thrombophilia & FHx

at least 6 weeks of post-natal prophylactic LMWH

70
Q

What is considered to be intermedate risk of VTE in postnatal period

A

C-section in labour
BMI > 40
readmission or prolonged admiss (> 3 days) in the puerperium
any surgical procedure in the peerperium excepy immediate repair of the perineum

medical conditions - cancer, HF, active SLE, IBD or inflammatory polyarthropathy, nephrotic syndrome, T1DM with nephropathy, sickle cell disease, current IVDU

if any of the above - at least 10 days of post-natal prophylactic LMWH

71
Q

what is the treatment of VTE during pregnancy?

A

LMWH

BD regimen, weight adjusted

target range for heparin - 0.35 - 0.7

treatment should continue for 6 months after delivery

72
Q

what is the reason for VBAC

A

good physical and psychological benefits for both mum and baby

VBAc is safer than a repeat C-section

repeated C-secton associated with small inc risk of placenta praevia ± accreta in future pregnancies and pelvic adhesion

73
Q

what is the reason against VBAC

A

must be on the labour ward

risk of uterine rupture - v. rare but slight inc in VBAC esp if induction of labour is ultilised

CTG is recommended

complete C/I if classical cut of C-section

74
Q

what is the management of cardiac disease during pregnancy

A

symptoms and signs in antepartum and postpartum

  • fatigue
  • fainting
  • chest pain
  • SOB
  • difficulty breathing when sleeping
  • palpitations

mx

  • MDT
  • early delivery
75
Q

what is the management of epilepsy during pregnancy

A

mx

  • MDT
  • antiepileptics causes –> foetal abnor (NTD, cardiac, facial)

Y4 - GOSH (12 decks)

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