Maternal Health Flashcards
What advice should a pregnant woman be given for suspected tension headache? When should they be referred?
- most are tension headaches and occur in 1st trimester
- good sleep
- good hydration
- avoid precipitants
- Paracetamol if above doesn’t help
Refer if:
* high risk/complex pregnancy
* severe headaches despite 1st line medication
* any red flags
What are the important differential diagnoses of headache in pregnancy?
- increased coagulability: cerebral venous thombosis, ischaemic stroke, reversible cerebral vasoconstriction
- pre-eclampsia
- non obstetric: IIH, meningitis, SAH, migraine, cluster headache, tension
What causes physiological breathlessness in pregnant women - how does it present?
- increased progesterone causes increased respiratory drive and oxygen requirements increase as pregnancy proceeds
- leads to physiological hyperventilation - felt as breathlessness by the pregnant woman
- Usually present at rest - can affect speech
- may improve with mild activity
- no reduction in oxygen sats
- exclude serious causes of breathlessness first.
What are the important differential diagnoses of breathlessness in pregnancy?
- physiological (suggested by mild symptoms with normal vital signs)
- asthma - new or worsening control. Treat same as non pregnant woman - inhalers and oral steroids as needed.
- anaemia
- VTE
- LRTI/pneumonia- after 28 weeks there is increased risk of serious illness with COVID-19, flu, varicella pneumonitis
- sepsis
- peripartum cardiomyopathy causing heart failure- can occur at any stage, most common postnatally. PND, orthopnoea, peripheral oedema and wheeze.
How common is N&V in pregnancy? When does it usually start and resolve?
- 80% of pregnant women
- Most start with symptoms at 6-7 weeks
- usually resolve by 16 weeks
What score is used to assess the severity of N&V in pregnancy?
PUQE score
What are the important differential diagnoses of nausea and vomiting in pregnancy?
- obstetric: hyperemesis gravidarum, pre-eclampsia, acute fatty liver of pregnancy
- non obstetric: gastroenteritis, medications: ABX, iron. Assoc with abdo pain: pyelonephritis, pancreatitis, appendicitis.
- Reassure.
- Lifestyle: avoid food preparation, frequent small meals, avoid greasy/spicy foods, ginger, acupressure
- If severe & uncontrolled: 1st line antiemetics: cyclizine or promethazine (antihistamines), prochlorperazine or chlorpromazine (phenothiazines), or doxylamine/pyridoxine. Reassess at 24-72h
- Next step: switch to second line. 2nd line antiemetics: metoclopramide or domperidone (dopamine receptir antagonists) or ondansetron (5-HT3 receptor antagonist). Reassess at 24h. Max 5/7 treatment. Can combine up to 3 antiemetics.
- Next step if 2nd line combos ineffective: oral prednisolone 40mg OD - tapered to lowest dose that controls syx. Regular BP and DM monitoring. If this 3rd line treatment ineffective - seek specialist advice.
- Ideally wean/stop treatments around 12-16 weeks.
Consider bloods: FBC, glucose, electrolytes, TFTs, inflamm markers if severe/diagnosis unsure. MSU ?UTI.
Consider H2RAs/PPIs for GORD syx. Thiamine supplements.
Which red flags in nausea and vomiting in pregnancy indicate urgent referral to specialist needed?
- not tolerating oral fluids or medications despite anti-emetics
- suspected hyperemesis gravidarum despite antiemetics
- Any confirmed/suspected comorbidity e.g. UTI, DM
- Severe headache, neurological signs (pre-eclampsia, Wernicke’s)
- Severe abdo pain, esp. epigastric/RUQ
- weight loss >5% TBW
- Clinical dehydration: reduced urine output, dizzy, increased thirst, dry mouth. Haemodynamic instability
- Biochemical abnormality - electrolytes, AKI
- Concerns re mental health
- PUQE score >13
Why is urinary frequency common in pregnancy? How should it be managed?
- physiological changes - increase in plasma volume, pressure of enlarging uterus on the bladder. Cause increased frequency and nocturia.
- UTI must be ruled out- if fever or lumbar/flank pain, consider pyelonephritis. Can lead to premature labour/low birth weight baby. Consider admission for pyelonephritis.
- Start empirical ABX if likely UTI, even if dipstick negative and send MSU. 7 day course. Must also treat asymptomatic bacteriruria. Repeat MSU afterwards to ensure cleared.
- refer if recurrent UTIs/symptoms not improved.
What are the differential diagnoses for abdominal pain in pregnancy?
Gynae and early pregnancy:
* ectopic
* miscarriage - assoc vaginal bleeding.
* ovarian cyst rupture/haemorrhage/torsion - severe unilateral pain
* ovarian hyperstimulation
* fibroid degeneration - severe unilateral pain
Obstetric:
* pelvic girdle pain
* round ligament pain - stitch like pain radiating to groin
* braxton-hicks contractions - intermittent tightening
* labour - intermittent tightening
* abruption - severe constant pain
* chorioamnionitis - assoc foul smelling discharge
* uterine rupture - severe constant pain
* pre-eclampsia - RUQ/epigastric pain
* acute fatty liver of pregnancy
Other:
* UTI/pyelonephritis - lower abdo pain, LUTS, flank pain
* appendicitis
* acute pancreatitis
* constipation - consider ispaghula husk to manage.
What is the definition of hyperemesis gravidarum?
The most severe spectrum of N&V in pregnancy - a clinical diagnosis of exclusion:
* **Prolonged, persistent and severe **nausea and vomiting unrelated to other causes.
* Weight loss (usually at least 5% of pre-pregnancy body weight).
* **Dehydration and electrolyte **imbalance.
What are the risk factors assoc with nausea and vomiting in pregnancy?
- increased placental mass - molar pregnancy, multiple preg.
- First pregnancy
- previous HG
- Hx motion sickness
- Hx migraines
- FHX nausea and vomiting in preg
- Obesity
What side effects should the pregnant woman be advised about ondansetron in pregnancy? How long can it be prescribed for? What are the important drug interactions?
- 4-8mg TDS for MAX 5 days
- QT prolongation
- Exposure to ondansetron in first trimester- assoc small increased risk of baby having a cleft lip and/or palate.
- Interactions:
- Other drugs prolonging QTc: antipsychotics, antidepressants, macrolides (clarithromycin, erythromycin, azithromycin), quinolones (levofloxacin), azole antifungals.
- Corticosteroids, thiazides, salbutamol - hypokalaemia -> torsades de pointes.
- SSRIs - increased risk serotonin syndrome
How long can metoclopramide be prescribed for in pregnancy? what are the side effects?
- 5-10mg TDS MAX 5 days
- CI: epilepsy (increases seizures), GI haemorrhage/obstruction.
- Caution: parkinsons, renal/liver imp, bradycardia
- Adverse effects: acute dystonic reaction - risk increased in young women. Prolonged treatment - tardive dyskinesia. Discontinue immediately.
- Cardiac: QT prolongation, bradycardia
- Neonatal EPSEs if given in 3rd trimester
Domperidone can be prescribed for 7 days. Can prolong QTc but no EPSEs as does not cross BBB.
Routine antenatal care includes two USS. What dates are they performed and what is the purpose?
* 12 weeks - dating scan
* determine gestational age
* detect multiple pregnancies
* confirm viability
* detect early abnormalities e.g. anencephaly.
* part of screening for Downs if woman consented
* 20 weeks - fetal anomaly scan
* locate placenta, assess amniotic fluid, identify 11 conditions that: benefit from Rx, need specialist setting after birth, baby may die after birth, option for termination.
* abdominal wall defects
* renal agenesis
* cleft lip
* diaphragmatic hernia
* Congenital heart disease
* Trisomy 13 (Patau’s)
* Trisomy 18 (Edward’s)
* Neural tube defects
* severe skeletal dysplasia
How many antenatal appointments are advised for routine antenatal care in nulliparous and parous women?
- 10 for nulliparous
- 7 for parous
Which women may require additional care in pregnancy?
- Higher risk of developing complications:
- existing medical problems: HTN, cardiac, CF, renal, liver, endocrine, DM, psychiatric, haem (sickle cell, thalassaemia, thromboembolic), autoimmune, epilepsy, malignancy, severe asthma, HIV, HepB.
- High (>=30) BMI or Low (<18.5) BMI
- Aged over 40 at booking
- Multiple preg
- Complex social - drug abuse, DV
- comps in previous pregnancy
- develop comps in current preg: placenta praevia, HTN, GD, USS abnormalitites, malpresentation.
What advice should women be given about folic acid in pregnancy?
- advise to take folic acid 400mcg/day pre-conception (ideally for 3 months before) until 12wks
- 5mg folic acid up to 12 weeks recommended for:
- previous child with NTD, either partner has an NTD, FHx NTD
- on Antiepileptic drugs
- women with: DM, coeliacs, sickle cell, thalassaemia (or trait)
- BMI>30.
Sickle cell, thalassaemia, or trait - should take 5mg OD throughout pregnancy.
Reduces risk of neural tube defects - spina bifida etc.
What advice should women be given about vitamin D in pregnancy?
- Advise to take a vit D supplement (10 micrograms of vitamin D per day) throughout pregnancy.
- Especially important if: darker skin, housebound, cover skin with headscarf etc.
AVOID vitamin A supplemets - high levels are teratogenic.
Healthy start vitamins have: folic acid, ascorbic acid and vitamin D)
What routine screening is offered to all pregnant women? In time order
- Women with DM offered Diabetic eye screening at first presentation
- Blood test for: FBC, blood group, rhesus status and alloantibodies. At booking and 28 wks.
- Blood test for: syphilis, HepB, HIV. At booking, or any stage.
- Haemoglobinopathy (sickle cell and thalassaemia) screen at booking (best before 10 weeks). Thalassaemia blood test for all. Sickle cell - High prevalence area: blood test. Low prevalence area: Family Origins Questionnaire.
- Urine MC&S for asymptomatic bacteriuria - at Booking.
- **12 week scan **- supports T21, T18, T13 screening.
- Combined screening test - for T21, T18, T13 (Downs, Edwards, Pataus) at 10-14wks. Includes blood hCG, pregnancy associated paraprotein A (PAPP-A), and nuchal translucency on USS.
- **Quadruple screening test **- for Downs at 14wk 2d - 20wk (for women who book late). Includes: blood AFP, hCG, unconjugated estriol (uE3), and inhibin A. (not as accurate)
- 20 week anomaly scan (for 11 conditions incl Edwards and Pataus)
- **BP, urine dip for proteinuria **at each appt - preclampsia screening
- Symphysis-fundal height - from 25 weeks - identify small or large for gestational age
- **Abdominal palpation for breech **position - from 36 weeks.
What results on combined screening test suggest Downs? What are the next steps?
Down’s syndrome is suggested by ↑ HCG, ↓ PAPP-A, thickened nuchal translucency
Both the combined and quadruple tests return either a ‘lower chance’ or ‘higher chance’ result
* ‘lower chance’: 1 in 150 chance or more e.g. 1 in 300
* ‘higher chance’: 1 in 150 chance or less e.g. 1 in 100
NIPT - non-invasive pre-natal screening test or diagnostic test offered next.
* analyses small DNA fragments that circulate in the blood of a pregnant woman (cell free fetal DNA)
* cffDNA derives from placental cells and is usually identical to fetal DNA
* sensitivity and specificity are very high for trisomy 21 (>99%)
What are the differential diagnoses of bleeding during pregnancy?
- Non pregnancy related: STIs, cervical polyps
- Bleeding in early pregnancy (<14 wks): miscarriage, ectopic pregnancy, hyatidiform mole (trophoblastic disease)
- 3rd trimester: Placental abruption, placenta praevia, vasa praevia
What does this image show? How should it be managed?
- Polymorphic eruption of pregnancy. A.k.a: Pruritic Urticarial Papules and Plaques of Pregnancy
- Usually in first pregnancy, third trimester.
- An intense itchy rash - usually lower abdo over stretch marks, buttocks.
- Conservative Rx: emollients, cetirizine/loratadine, topical steroids
What does the image show? How is it managed?
- Pemphigoid gestationis
- May be Hx grave’s disease/FHx autoimmune cond.
- very rare. 2nd/3rd trimester
- intense itch then develop rash - erythematous urticarial papules and plaques on the abdomen (and nearly always the umbilicus region), but which may spread to cover the entire body. Develops into blisters.
- Refer urgently specialist dermatologist.
When is the pregnant woman screened for anaemia? What are the cut offs to decide if she should receive iron therapy - in first trimester, in the rest of pregnancy, and postpartum?
