High Risk Pregnancy Flashcards
what are some of the maternal conditions leading to high risk pregnancy
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)
what are some of the social conditions leading to high risk pregnancy
teenage pregnancy maternal age > 35 smoking/alcohol/substance abuse high parity > 4 (PPH), low interpregnancy interval Poor socioeconomic conditions
what are some of the obstetrics issues leading to high risk pregnancy
prev. preterm labour C-section recurrent miscarriage (3+) stillbirth pre-eclampsia GDM 3rd degree tear
what is the definition of small for gestational age
EFW > 10th percentile for its gestational age.
SGA is a surrogate marker for IUGR
complications of IUGR
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
what are the maternal causes of IUGR?
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
what are the placental causes of IUGR
abnormal trophoblast invasion - pre-eclampsia, placenta accreta
abnormal umbilical cord or cord insertion - 2 vessel cord
abruption
placental praevia
tumor - chorioangiomas
infarction
what are the foetal causes of IUGR
genetic abrno - trisomy 13, 18, 21
turner’s syndrome
Triploidy
congenital abnor - cardiac, gastroschisis
TORCH syndrome
what are the 2 different types of IUGR that can occur
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
management of IUGR
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
long- term complications of IUGR
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
what is the aetiology of IUGR
FHx previous multiple pregnancies increasing parity inc maternal age ethnicity assisted reproduction
what are the signs/symptoms of IUGR
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
what are some of the antenatal care of multiple pregnancy
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
in what situation would you get dichorionic diamniotic twins
1) when 2 eggs are fertiliserised
2) when the fertilised egg splits into 2 in the first 3 days of cell division
in what situation would you get monochorionic diamniotic twins
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
in what situation would you get monochorionic Monoamniotic twins
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
when should multiple pregnancies be delivered
consider induction at 38 weeks
what are the maternal risks to multiple pregnancy
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
what are the foetal risks to multiple pregnancy
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
what is twin to twin transfusion syndrome
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
what is the clinical features of the donor twin in twin to twin syndrome
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
what is the clinical features of the recipient twin in twin to twin syndrome
relatively more arterial blood to the recipient twin
hypervolemia and polycythemia
larger bladder and polyhydramnios
evidence of foetal hydrops (ascites, pleural and pericardial effusions)
which twin in the twin to twin transfusion syndrome tend to do worse post-natally
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
what does a lambda sign found in antenatal USS mean for the number of placenta in a pregnancy
lambda sign = dichrionic
what does a T sign found in antenatal USS mean for the number of placenta in a pregnancy
T sign = monochrionic
what is the dosage of folic acid for twin pregnancy
5mg
what is the treatment plan for MCMA
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
what is pregnancy-induced hypertension
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
when should delivery of the baby be if the pregnant lady have PIH
around EDD
what is the general trend of BP in a pregnant woman
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
when should delivery of the baby be if the pregnant lady have chronic hypertension
around EDD but inc risk of re-eclampsia
what is post-partum hypertension
inc BP in the postpartum period
BP can peak 3-4 days post-partum
how common is pre-eclampsia
10% of all population
definition of pre-eclampsia
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
what are the different classification of pre-eclampsia
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
symptoms of pre-eclampsia?
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
signs of pre-eclampsia?
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
what are some of the RF for pre-eclampsia
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
investigation for pre-eclampsia
FBC - high HB, thrombocytopenia, anaemia
coag profile = prolonged PT and APTT
urinary test for proteinuria
LFT
U&Es
what is eclampsia
the occurrence of tonic-clonic seizure in association with a diagnosis of pre-eclampsia
what is HELLP syndrome
Hamolysis Elevated Liver Enzyme, Lower Platelet
what is the management of pre-eclampsia
definitive management = delivery of placenta + baby
management of outpatient management of pre-eclampsia (BP<160 and <110 + no proteinuria)
warn about the development of symptoms
1-2 per weeks review of BP and urine
Weekly review of blood biochemistry
management of mild-moderate management of pre-eclampsia (BP<160 and <110 + significant proteinuria >300mg per 24 hours)
admission advised
daily urinalysis
daily CTG
Oral labetalol
management of mild-moderate management of pre-eclampsia (BP>160 and >110 + significant proteinuria >300mg per 24 hours +/- maternal complications
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
what is the percentage of seizure take place post-natally
44%
complications for pre-eclampsia
SHAME
Stroke HELLP syndrome Abruption multi-organ failure +/- DIC +/- Death Eclampsia
what are some of the maternal complications of pre-gestation diabetes
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
what are some of the foetal complications of pre-gestation diabetes
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
what are some of the post-natal complications of pre-gestation diabetes
polycythemia –> jaundice + cardiomegaly + RDS
hypoglycemia
birth trauma - shoulder dystocia, fractures, Erb’s palsy, asphyxia
hypoglycaemia/hypocalcaemia/hypomagnesaemia
what are the specific management of the baby whose mother is diabetic pre-pregnancy
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
what is the insulin management of the mother post-natally
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
when is oral glucose tolerance test usually carried out
26-28 weeks
when is oral glucose tolerance test usually carried out if the patient had previous GDM
16 weeks
how is OGTT carried out?
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
what plasma glucose reading form a OGTT would you diagnose GDM
> 7 for fasting
> 11.1 for 2 hour gloucse
what plasma glucose reading form a OGTT would you diagnose glucose impairment
fasting gluose < 7
2 hours > 7.8 and < 11.0
RF for GDM
previous GDM FHX of DM previous macrosomic baby previous unexplained stillbirth obesity (BMI >30) glycosuria polyhydramnios LGA ethnicity - south asian
measurement of GDM?
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
when will you start insulin in a pregnant woman who has GDM
pre-meal glucose > 6
1 hour post meal glucose > 7.5
AC > 95th centil despite good control
how would you give insulin when the pregnant lady is in labour
sliding scale
when is DVT more likely than PE during the pregnancy periods
DVT is more common antenatally
when is the highest risk of VTE during pregnancy?
in the puerperium period
RF for VTE in pregnancy
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
what is the drug of choice? for anti-coagulant during pregnancy?
LMWH
what is considered high risk of VTE in antenatal periods
any prev VTE except a single event related to major surgery
start antenatal prophylaxis with LMWH
what is considered to be the Intermediate risk of VTE in antenatal periods?
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
What is considered to be high risk of VTE in postnatal period
Any previous VTE
anyone requiring antenatal LMWH
high risk thrombophilia
low risk thrombophilia & FHx
at least 6 weeks of post-natal prophylactic LMWH
What is considered to be intermedate risk of VTE in postnatal period
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
what is the treatment of VTE during pregnancy?
LMWH
BD regimen, weight adjusted
target range for heparin - 0.35 - 0.7
treatment should continue for 6 months after delivery
what is the reason for VBAC
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
what is the reason against VBAC
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
what is the management of cardiac disease during pregnancy
symptoms and signs in antepartum and postpartum
- fatigue
- fainting
- chest pain
- SOB
- difficulty breathing when sleeping
- palpitations
mx
- MDT
- early delivery
what is the management of epilepsy during pregnancy
mx
- MDT
- antiepileptics causes –> foetal abnor (NTD, cardiac, facial)
