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Later pregnancy Flashcards

1
Q

What happens to BP across pregnancy

A

Initially is a drop particularly the diastolic then after 20 weeks it returns to pre-gestational levels

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2
Q

Who is at high risk for pre-eclampsia and needs aspirin from week 12 of pregnancy

A

If 1 of
- HTN during previous pregnancy
- CKD
- DM
- autoimmune condition

If 2 of
- family history of pre-eclampsia
- 10 year gap between pregnancy
- multiple pregnancy
- over 40
- BMI over 35

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3
Q

How assess positive proteinuria on dipstick in pregnancy

A

Do PCR OR ACR
Cut offs
- 30 for PCR
- 8 for ACR

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4
Q

Management of chronic HTN in pregnancy

A

Stop thiazides, ARB and ACEi
Continue old treatment unless under 70/110
If over 90/140 start labetalol
CI use nifedipine
Both CI use methyldopa
Give aspirin from week 12 and offer PIGF past week 20 to check for pre-eclampsia
Measure every 2-4 weeks

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5
Q

How to diagnose preterm prelabour rupture of membranes

A

Sterile speculum looking for fluid in posterior vaginal vault
2nd line measure insulin like growth factor binding protein or placental alpha microglobulin 1
Can use USS to help diagnosis by looking for oligohydramnios

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6
Q

How to manage preterm prelabour rupture of membranes

A

Admit
Notify neonatologist
Close monitoring for chorioamnionitis
Antenatal corticosteroids up to 34+0 weeks but can do up to 36
Erythomycin until 10 days post rupture or delivery

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7
Q

What are risks of PPROM

A

Chorioamnionitis to mother
Prematurity, infection, pulmonary hypoplasia

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8
Q

When to suspect chorioamnionitis

A

Clinically
- abdo pain, fever, discharge, RFM
Histologically
- rising CRP and WCC but be careful as steroids can do this

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9
Q

Can magnesium sulphate be given in PPROM

A

If in labour or within 24 hours of planned preterm delivery
- deffo if 24-29+6 weeks
- consider if post 30weeks

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10
Q

Why is magnesium sulphate given in suspected preterm birth

A

Neuroprotective against CP

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11
Q

When should woman with PPROM deliver

A

If no pressing risks to mother or baby then expectant management until 37 weeks

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12
Q

Postnatal mangement if someone with chronic HTN or gestational HTN has given birth

A

Measure BP daily for first 2 days
Once between 3-5 days
Keep below 140/90
Stop methylopa within 2 days

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13
Q

What defines gestational HTN

A

BP over 140/90 past 20 weeks without proteinuria
OR
Increase in 30 systolic or 15 diastolic from booking visit after 20 weeks gestation

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14
Q

Management of gestational HTN

A

If 140/90-159/109 then refer to be seen within 24 hours by obstetrician- use pharmacological agents to reduce below 135/85
If over 160/110 then admit immediately and treat until below 160/110- measuring every 15-30 mins

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15
Q

How are people with gestational HTN monitored

A

Weekly
- BP
-Urine dip
- FBC, LFT and renal function
Every 2 weeks
- USS

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16
Q

Who should be offered placental growth factor

A

Everyone with gestational HTN or chronic HTN post 20 weeks
If low indicates high risk of eclampsia

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17
Q

How can risk prediction in pre-eclampsia be assessed

A

PREP-S prediction model

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18
Q

When admit for pre-eclampsia

A

HTN over 160/110
Rise in creatinie or ALP
Fall in platelets
Signs of impending eclampsia
Signs of impending pulmonary oedema
Fetal compromise signs

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19
Q

If pre-eclampsia how are you monitored

A

If treated as outpatient for mild pre-eclampsia
- BP every 48 hours
- FBC, LFTs, renal function 2x a week
- fetal USS every 2 weeks

If in patient for severe
- FBC, LFTs, renal function 3x a week

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20
Q

How manage an eclamptic fit

A

IV magnesium sulphate IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour
Monitor urine output, reflexes and o2 sats

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21
Q

What is risk of magnesium sulphate mangement

A

Resp depression from hypermagnesaemia

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22
Q

How manage resp depression from pre-eclampsia

A

Calcium gluconate

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23
Q

Other than eclampsia when can consider magnesium sulphate

A

Signs of impending eclampsia
- ongoing headaches
- visual scotomata
- N&V
- epigastric pain
- oligouria

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24
Q

What causes resp depression in mag sulphate treatment

A

Hypermagnesaemia which can be monitored with reflexes and o2 sats

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25
Management plan for premature labour
Determine if rupture of membranes If no rupture just dilation and contractions - admit for tocolytics and steroids (in case goes into labour) If rupture - admit - steroids if before 34 weeks - mag-sulphate if before 30 - erythomycin until delivery/10 days - contact neonatologist
26
What is HELLP syndrome
A complication of pre-eclampsia where get haemolysis, elevated liver enzymes and low platelets
27
What is the only cure for pre-eclampsia
Delivery of baby
28
In pre-eclampsia what is recommened anaesthetic for labour
Epidural as can help lower BP
29
Risk factors for pre-eclampsia
First child Multiple gestation Over 35 HTN Obestiy DM
30
What is pathophysiology behind pre-eclampsia
Due to abnormal development of the placenta- the spiral arteries become fibrosed and constricted which limits blood flow. This releases pro-inflammatory proteins into mothers circulation leading to systemic vasoconstriction and endothelial injury
31
What are problems with endothelial injury in pre-eclampsia
Microthrombi formation to plug holes - uses platelets - microthrombi shear RBC - therefore HELLP syndrome Injury leads to fluid loss - oedema in legs, lungs and brain
32
What are organs affected by pre-eclampsia
Kidneys - oligouria - protein loss Liver - raised liver enzymes - swelling and injury - epigastric pain Eyes - scotoma - blurred vision - flashing lights Lungs - SOB and cough from oedema Brain - confusion - seizures - headaches
33
What do with delivery in pre-eclampsia
If before 36 weeks continue with surveillance and consider antenatal steroids unless - sats less than 90 - failure to control BP with 3 anti-hypertensives - placental abruption - continuining deterioration of symptoms and blood results If after 36+6 then deliver within 48 hours
34
How long is magnesium sulphate infusion given for eclampsia
24 hours after last seizure or delivery
35
What do if no fetal movements felt by 24 weeks
Referral to foetal medicine unit
36
In pregnancy what constitutes reduced fetal movements
Normally it is at mothers discretion Past 28 weeks less than 10 movements within 2 hours
37
If are reduced foetal movements after feeling them pre 24 weeks what is investigation
Handheld doppler to identify a heartbeat No indication for further investigations
38
If reduced foetal movements 24-28 weeks what is management
Handheld doppler to identify heartbeat
39
If reduced foetal movements after 28 weeks what do
Handheld doppler to identify heartbeat Even if fine do CTG for 20 minutes Do USS if suspicion of FGR or SGA looking at abdo circumfrence, estimated foetal weight and amniotic
40
What do if no heartbeat felt on handheld doppler
Immediate USS
41
If patient unsure about reduced foetal movements what ask them to do
Lie on side for 2 hours and ask them to concentrate on number of foetal movements Less than 10 a cause for concern
42
What can affect foetal movements felt
Less felt when standing up Person can be easily distracted Obese less likely to feel SGA baby Amniotic fluid volume Anterior foetal position means less likely to be felt
43
Which medications can reduce foetal movements
Benzodiazepams Opiates
44
Causes of oligohydramnios
Premature rupture of membranes IUGR Post-term gestation Pre-eclampsia Potter sequence Posterior urethral valve
45
What is potter sequence
Bilateral renal agenesis Pulmonary hypoplasia
46
What defines oligohydramnios
Less than 5th centile amniotic fluid index Less than 500ml at 32-36 weeks gestation
47
When have suspicious SFH measurement what do
US to confirm SGA
48
What is fetal fibronectin
Protein released from amniotic sac which may indicate impending labour
49
How does false labour present
In the last 4 weeks of pregnancy you get contractions in lower abdomen which occur every 20 minutes ans are irregular Cervical changes are absent
50
How to differentiate false labour from real labour
Cervical changes are absent in false labour
51
Management of false labour
Cervical examination Check foetal heart Reassure and discharge
52
What happens to reflexes in pre-eclampsia
Hyperreflexia- very specific sign
53
What is cervical cerclage
Tying the cervix to prevent preterm
54
Who is cervical cerclage indicated in
3 previous preterm births Either preterm birth (<34 weeks) or spontaneous second trimester loss AND cervical length under 25mm
55
Who is regular US surveillance to measure cervical length indicated in
History of preterm birth or spontaneous loss in second trimester but cervical length over 25mm If found to go under 25mm pre 24 weeks then do TV cerclage
56
What do if no rfx but cervical length under 25mm
Cerclage not indicated
57
What are types of cerclage
Transvaginal Transabdominal which is done laparasocopically
58
Who is a transabdominal cerclage done in
Unsuccessful vaginal cerclage attempted DONE PRECONCEPTION OR EARLY PREGNANCY
59
Who is vaginal progesterone indicated in for prevention of preterm birth
History of spontaneous preterm birth or miscarriage in second trimester Cervical length under 25mm identified between 16-24 weeks
60
When in pregnancy is vaginal progesterone given as prophylaxis of preterm birth
16-34 weeks
61
Second line to magnesium sulphate in eclampsia
Diazepam or phenytoin
62
What is contraindication for methyldopa
Depression history
63
Presentation of intrahepatic cholestasis of pregnancy
Itching without rash worse at night Pale stools and dark urine
64
What is severe sign of intrahepatic cholestasis of pregnancy
Malabsorption of Vitamin K leading to coagulopathy
65
Risks of intrahepatic cholestasis of pregnancy
Stillbirth Preterm Meconium passage
66
How is ICP diagnosed
Bile acids over 19 Itching in skin of normal appearance
67
How long after birth should people with ICP have LFTs measured
4 weeks Resolution of LFTs and itching constitutes diagnosis
68
How should ICP be monitored
1 week after initial blood tests then on individual basis
69
When give birth with ICP
Depends on levels of bile acids If 19-39: by 40 weeks If 39-100: 38-39 Over 100: 35-36
70
What is symmetrical versus asymmetrical IUGR
In symmetrical is similar growth restriction of head and rest of body In asymmetrical get sparing of head which maintains growth along expected chart
71
Difference in cause of symmetrical versus asymmetrical IUGR
Asymmetrical- placental insufficiency Symmetrical- maternal malnourishment, infection or congenital abnormalities
72
If have asymmetrical IUGR how are monitored
USS every 2 weeks Doppler USS twice weekly
73
What are causes of large for dates
DM High maternal BMI
74
Problems of large for dates babies
Slow labour High chance of progression to c-section Trauma to perineum Shoulder dystocia
75
Causes of FGR
Congenital infections Placental insufficiency Pre-eclampsia Smoking Maternal disease/malnutrition
76
What is most useful measure of fetal growth
Abdo circumfrence as where is liver, the babies glycogen store
77
What happens later in life to babies who are born small
There is programming of baby where adapts its metabolism to impoverished environment which means increased rates of CVD, obesity and DM
78
How often are bloods monitored a week with severe pre-eclampsia
3x
79
If develop chorioamnionitis after PPROM how manage labour
Induce in 24 hours
80
What is measured in ICP
Bile acids
81
What can be given alongside ECV
Beta mimetic such as terbutaline

Obs (9 decks)

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