Major disorders of pregnancy Flashcards
Which women are more at risk of hyperemesis gravidarum?
NB peak onset = 8-12 weeks
-First pregnancy
-Obesity
-Hyperthyroidism
-Trophoblastic disease
-Multiple pregnancy (large placental site)
-Hormone administration eg fertility treatment
How does HG present?
-N+V
-Excessive salivation
-Weight loss (5% of pre-pregnancy weight)
-Reduced urine output
-Epigastric pain
-Ketonuria
DIAGNOSTIC CRITERIA =
-5% pre-pregnancy weight loss
-Dehydration
-Electrolyte imbalance
How should you investigate HG?
-PUQE (Pregnancy-Unique Quantification of Emesis)
–<6 = mild, 7-12 = moderate, 13-15 = severe
-Exclude other causes eg UTI, thyrotoxicosis
How should HG be managed?
-Can often be managed with reassurance and self-help
-If dehydrated and not tolerating oral fluids –> admission (IV fluids + promethazine / ondansetron)
-In prolonged disease
–Vitamin supplements especially thiamine
What are the potential complications for the foetus and mother in HG?
FOETUS
-Growth restriction + pre-term birth
MOTHER
-Wernicke’s encephalopathy
-Mallory-Weiss tear
-Ventral pontine myelysis
-Acute tubular necrosis
What are the definitions of IUGR + SGA for the newborn + foetus?
IUGR = foetus that has failed to achieve its growth potential by a specific gestational age
SGA (foetus) = estimated foetal weight <10th percentile for gestational age
SGA (newborn) = birth weight <10th percentile for gestational age
What causes the different categories of SGA?
WRONG SMALL
-?Wrong dates
ABNORMAL SMALL
-Chromosomal / structural anomalies
-Infection eg rubella, CMV, toxoplasmosis, syphilis
-Genetic syndromes
NORMAL SMALL
-Genetic / constitutional
-Multiple pregnancy
STARVED SMALL (asymmetrical)
-Placental infarction / abruption / malposition
-HTN, anaemia, chronic disease
-Pre-eclampsia
-Drug / alcohol abuse
What pregnancies are considered high risk for IUGR?
-Multiple pregnancy
-Previous IUGR (20% recurrence)
-Pre-eclampsia (40%)
-Maternal medical disorders eg HTN, renal disease, APLS
-Drug abuse, smoking
How should IUGR be screened for?
-Dating scan (repeat in 2 weeks if concerned)
-Identify high risk pregnancies
-Low threshold if growth scan suspicious of SGA even in low-risk mothers
How should SGA pregnancies be monitored and managed?
-Growth scans + fundal height every 2-3 weeks
-If umbilical artery dopplers are normal –> aim for IOL at 37 weeks
-If umbilical artery dopplers abnormal and baby pre-term –> consider delivery + steroids
-Close monitoring of foetal movements, ?amniocentesis, weight checks for mother
What complications can arise from IUGR in pregnancy?
PREGNANCY
-Oligohydramnios
-Preterm birth
-Birth asphyxia –> brain damage
NEONATE
-Poor stress tolerance of vaginal delivery
-Hypothermia
-Hypoglycaemia
-Polycythaemia (chronic hypoxia)
-Infection risk
-Complications of prematurity eg intraventricular haemorrhage, respiratory distress, necrotising enterocolitis
What sign is seen on ultrasound to distinguish between normal small and IUGR?
-Head sparing effect
-Placental insufficiency means the limited blood supply is directed to the head as a matter of prioritising the brain
What are the main complications arising from LGA newborns?
-Increased risk of shoulder dystocia
-Prone to hypoglycaemia, hypocalcaemia and polycythaemia
In a woman with reduced foetal movements, what is important to ask for in the history>
-Duration - how long since last foetal movement felt?
–Ask about pattern as may be subjective eg more aware when lying down in bed
-Any vaginal loss, pain, systemic symptoms?
-Is baby SGA?
-Any problems with pregnancy so far?
What is the main priority when assessing reduced foetal movements and how should it be monitored?
-Rule out intra-uterine death
-Doppler if <28 weeks
-If >28 weeks doppler and:
–If no heartbeat –> USS
–If heartbeat –> CTG
What foetal characteristics can be assessed to determine how well the baby is doing?
-Foetal breathing movements (training intercostal muscles + diaphragm - healthy babies)
-Foetal movements (unhealthy baby won’t waste energy on moving)
-Foetal tone (flaccid = abnormal)
-Amniotic fluid volume (less = abnormal - less urine produced due to reduced blood flow to kidneys)
How is the placental function assessed?
-Doppler studies
-Pulsatility index and resistance index produced by waves on US screen
-Want PI/RI to be as low as possible (low resistance)
-End-diastolic flow can be positive (good), absent or negative (bad)
What is the definition of a prolonged pregnancy?
-Any pregnancy exceeding 42 weeks
Who is most at risk of a prolonged pregnancy?
-Primips
-Previous prolonged pregnancy
-Obesity
NB dates cannot be relied upon if there is uncertainty surrounding LMP eg irregular periods, recent COCP use
What are the risks to foetus in prolonged pregnancy?
-Perinatal mortality increased after 42w
-Meconium aspiration
-Assisted ventilation
-Oligohydramnios
-Macrosomia
-Shoulder dystocia
-Foetal injury
-Cephalohaematoma
-Foetal distress in labour
-Neonatal hypothermia, hypoglycaemia, polycythaemia
What are the risks to mother in prolonged pregnancy?
-Increased maternal anxiety and psychological morbidity
-Increased intervention eg IoL, operative delivery
-Increased risk of genital tract trauma
What is foetal post-maturity syndrome?
-Post-term infants who show signs of intrauterine malnutrition (small proportion of babies born >42w)
PRESENTATION:
-Scaphoid abdomen
-Little subcutaneous fat on body / limbs
-Peeling skin over palms + feet
-Overgrown nails
-Meconium stained skin
How should a prolonged pregnancy be managed?
-Attempt to confirm EDD as accurately as possible
-Offer stretch and sweep at 41w
-Offer IoL at 41-41w
-Foetal monitoring (CTG + USS)
What features are suggestive of chorioamnionitis?
-Fever / malaise
-Abdo pain (including contractions)
-Purulent / offensive vaginal discharge
-Maternal and foetal tachycardia
-Uterine tenderness
-Brown / yellow discharge seen on speculum
NB avoid VE
How should chorioamnionitis be managed?
-Betamethasone 12mg IM, 2 doses 24h apart
-Delivery
-Broad spectrum abx
How should PPROM be managed in absence of chorioamnionitis?
-Conservative management
-Betamethasone 12mg IM to prevent RDS
-Erythromycin 250mg QDS for 10 days
–If severely unwell IV cefurexime and metronidazole
-Consider delivery at 34w
What risks are associated with LGA?
MATERNAL
-Shoulder dystocia
-Failure to progress
-Perineal tears
-Instrumental delivery / LSCS
-PPH
FOETAL
-Birth injury - asphyxia
When should foetal movements normally be felt?
-Felt from 18-20 weeks (16 for multiparous)
-Established by 24 weeks
-Pattern by 28 weeks
