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Obstetrics and Gynaecology > Maternal Health > Flashcards

Maternal Health Flashcards

1
Q

What normally happens to blood pressure in pregnancy?

A

Fall during first trimester - lowest at 20wks

Increase again to pre-pregnancy levels by term

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2
Q

How can hypertension in pregnancy be categorised?

A

Pre-existing - >140/90 before 20wks
Gestational - >140/90 after 20wks or >30/15 rise in booking BP
Pre-eclampsia - hypertension + proteinurea (+- oedema)

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3
Q

What complications are associated with hypertension in pregnancy?

A 
Pre-eclampsia
Placental abruption
IUGR
Intrauterine death
Prematurity
DIC
Cardiovascular disease later in life
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4
Q

How should pre-existing hypertension be managed?

What BP should be aimed for?

A

!! Labetalol (Can continue normal BP meds if not ACE-i or ARB)
!! 75mg aspirin daily - 12 weeks to birth

Urine dip at each antenatal visit
Assess for pre-eclampsia
Obstetrician review - give lifestyle advice

Aim for <150/100

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5
Q

When should a patient with gestational hypertension be urgently admitted for obstetric review?

A

Signs of pre-eclampsia

BP >160/110

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6
Q

How should patients with gestational hypertension be managed?

A

Regular BP and urine dip monitoring
!! Labetalol
!! Aspirin 75mg daily from week 12
Foetal growth and amniotic fluid volume measured
Monitor postnatally and stop antihypertensives as appropriate

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7
Q

What medication can be used in the management of hypertension in pregnancy?

A

Labetalol
Nifedipine
Methyldopa
Hydralazine

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8
Q

What class of drug is labetalol? What are the CI’s and SE’s?

A

Beta-blocker
CI - asthma and cardiogenic shock
SE - Postural hypo , fatigue, headache, N&V, epigastric pain

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9
Q

What class of drug is nifedipine? What are the CI’s and SE’s?

A

Calcium channel blocker
CI - angina and aortic stenosis
SE - Peripheral oedema, flushing, headache, constipation

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10
Q

What class of drug is methyldopa? What are the CI’s and SE’s?

A

Alpha-agonist
CI - depression
SE - drowsiness, headache, oedema, GI disturbance, dry mouth, postural hypo, bradycardia, hepatotoxicity

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11
Q

What class of drug is hydralazine? What are the CI’s and SE’s?

A

Vasodilator
CI - Heart failure and cor pulmonale
SE - Angina, diarrhoea, dizziness, headache

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12
Q

How is pre-eclampsia defined?

A

Seen after 20 weeks

Pregnancy induced hypertension
Proteinurea (>0.3g in 24hrs
Oedema)

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13
Q

What is the pathophysiology of pre-eclampsia?

A

Inadequate remodelling of spiral arteries

Constrictive muscular walls of spiral arteries maintained - high resistance, low flow

Maternal inflammatory response and endothelial dysfunction - leaky vessels

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14
Q

What women are at high risk of pre-eclampsia?

A

Hypertension/pre-eclampsia/eclampsia in past pregnancy
Chronic hypertension
CKD
Autoimmune disease - SLE/antiphospholipid
T1/T2 Diabetes Mellitus

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15
Q

How should women at high risk of pre-eclampsia be managed?

A

75mg aspirin daily from 12 weeks

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16
Q

What symptoms are associated with pre-eclampsia?

A

Often asymptomatic
Severe headache - frontal
Visual problems - blurring/flashing before eyes (papilledema)
Severe epigastric pain - hepatic capsule distention
Vomiting
Swelling - hands, face or feet
Hypereflexic

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17
Q

What could bloods reveal in patients with pre-eclampsia?

A

Falling platelet count <100
Raised ALT/AST
HELLP syndrome

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18
Q

What would place a patient at moderate risk of pre-eclampsia?

A 
First pregnancy
Multiple pregnancy
>10yr since last pregnancy
Age >40
BMI >35
Family Hx of pre-eclampsia
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19
Q

How would patients at moderate risk of pre-eclampsia be managed?

A

75mg aspirin daily from 12 weeks

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20
Q

What are the risks of pre-eclampsia?

A

Fetal

  • IUGR
  • Premature birth
  • Hypoxia = neurological damage

Maternal

  • Eclampsia
  • Placental abruption
  • AKI
  • DIC
  • Cerebrovascular haemorrhage
  • Multi-organ failure
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21
Q

How should patients with pre-eclampsia be managed postnatally?

A

Should resolve following delivery of placenta
Monitor for 24hr - risk of seizure
Day 5 - considered safe

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22
Q

How is pre-eclampsia managed?

A

Monitoring - BP, urinalysis, blood tests, fetal growth, CTG

Aspirin - 75mg daily from 12 weeks

Antihypertensives - Labetalol (Nifedipine/methyldopa)

VTE prophylaxis - LMWH

Delivery - cure for pre-eclampsia, balance risks and benefits. If <34 weeks, IM steroids

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23
Q

What is eclampsia?

A

Seizures in association with pre-eclampsia

Tonic-clonic normally

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24
Q

When do eclamptic convulsions occur?

A

Postnatal - 44%
Antepartum - 38%
Intrapartum - 18%

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25
Q

What investigations would you request for eclampsia?

A

Look for complications:
FBC - DIC
CTG - fetal distress
etc.

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26
Q

How is eclampsia managed?

A

ABCDE - resus in left lateral position

  • Magnesium sulphate -continue for 24hr after delivery or last seizure
  • IV antihypertensives
  • Delivery of baby - only when mother stable
  • Fluid restrict
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27
Q

What are the signs of hypermagnesaemia?

How is hypermagnesemia reversed?

A

Hyper-reflexia
Respiratory depression

Calcium gluconate

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28
Q

What is HELLP syndrome?

A

Haemolysis
Elevated Liver enzymes
Low Platelet count

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29
Q

How does HELLP syndrome present?

A

RUQ pain - liver distention
Tiredness
N&V
+/- headache and vision problems

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30
Q

How is HELLP syndrome managed?

A

Delivery of baby
Blood transfusion
Antihypertensives

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31
Q

What are the complications of HELLP syndrome?

A

DIC
Liver rupture
Placental abruption

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32
Q

How many pregnancies does HELLP syndrome affect?

A

0.1-0.6% of all pregnancies

15% of pre-eclampsia

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33
Q

What general advice is given for women with diabetes in pregnancy?

A

Role of diet, body weight and exercise - individualised
BMI >27 - lose weight
Risks of hypoglycaemia and to be aware of it
Effect of vomiting on blood glucose
Assess diabetic retinopathy and nephropathy
Possibility of temporary health problems in baby in neonatal period
Risk of poor glycemic control

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34
Q

What are the maternal complications of diabetes in pregnancy?

A

Hypertension and pre-eclampsia
Injury from delivering large baby
Worsening retinopathy and nephropathy
CVS risks

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35
Q

What are the foetal complications of diabetes in pregnancy?

A 
Hyperinsulinaemia
Miscarriage or still birth
Pre-term labour
Birth adaptions - hypoglycaemia, jaundice
Obesity and diabetes later in life
Transient tachypnoea of newborn
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36
Q

What can foetal hyperinsulinaemia cause?

A

Macrosomia and shoulder dystocia
Polyhydramnios
Cardiomegaly
Erythropoiesis causing polycythaemia

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37
Q

Why does foetal hyperinsulinaemia cause problems?

A

Glucose can cross placenta but insulin can’t

Maternal hyperglycaemia = fetal hyperglycaemia = fetal increase in insulin levels

Insulin similar structure to growth promoters

Insulin cause reduced pulmonary phospholipids = reduced surfactant = transient tachypnoea of newborn

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38
Q

What is the capillary glucose target for pregnant women?

A

Fasting <5.3mmol/L
1hr after meal <7.8mmol/L
2hr after meal <6.4mmol/L

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39
Q

What fetal monitoring is done for pregnant women with diabetes?

A

20 week scan - structural abnormalities

Amniotic fluid volume assessment - 28 weeks

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40
Q

How should delivery be planned for pregnant women with diabetes?

A

Induction of labour or C-Section between 37 and 38+6 weeks

If macrosomia diagnosed - advice on risks and benefits of vaginal delivery

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41
Q

For a mother with diabetes, how should the newborn baby be cared for?

A

Feeding within 30 mins

Test blood glucose 2-4hr post birth unless signs of hypo - test immediately

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42
Q

What are the signs of hypoglycaemia in a newborn and how is it managed?

A

Abnormal muscle tone
Apnoea
Fits
Loss of consciousness

IV dextrose

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43
Q

What is the postnatal care plan for mothers with diabetes?

A

Reduce insulin immediately - monitor carefully

Risk of hypo while breastfeeding so advise to snack during feeding

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44
Q

What medication can be used for a breastfeeding mother with diabetes?

A

Metformin and Glibenclamide

Other hypoglycaemic agents should be avoided

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45
Q

What are the pre-conception glucose targets for a woman with pre-existing diabetes?

A

Capillary glucose normal
HbA1C <48 (6.5%)
Strongly advise against pregnancy if HbA1C >10% (86)

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46
Q

What medication (diabetes related and other) is used for women with pre-existing diabetes?

A

Stop all oral hypoglycaemics except Metformin
Commence insulin - isophane insulin

Commence 75mg aspirin daily from week 12
Folic acid 5mg until 12 weeks

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47
Q

What is gestational diabetes and how common is it?

A

Any degree of glucose intolerance beginning in pregnancy

2-5% of pregnancies

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48
Q

What are the risk factors for gestational diabetes?

A 
BMI>30
Previous gestational diabetes
Previous macrosomic baby >4.5kg
Family Hx of diabetes (1st degree relative)
PCOS
Asian
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49
Q

How is gestational diabetes screened? When is screening done?

A

Oral Glucose Tolerance Test - fasting, 75g glucose drink, test again 2hr later

If previous GD - booking and 24-28 weeks
If risk factor - 24-28 weeks

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50
Q

How is gestational diabetes diagnosed?

A

Fasting >5.6mmol/L

OGGT (2 hours post glucose) - >7.8mmol/L

51
Q

What happens to insulin in pregnancy?

A

Progressive resistance meaning more insulin is needed

Women’s borderline pancreatic reserves unable to respond to need - transient hyperglycaemia

52
Q

How does gestational diabetes present?

A

Normally asymptomatic

As with any diabetes - polydipsia, polyuria, fatigue

53
Q

What is the specific management for gestational diabetes?

A

Fasting glucose 5.6 - 7:
1 - Trial of exercise and diet changes for 2 wks
2 - + Metformin
3 - + Insulin

Fasting glucose >7 or >6 with macrosomia/polyhydramnios
1 - Insulin + diet and exercise changes +- metformin

54
Q

When should birth be scheduled for in gestational diabetes?

A

No later than 40+6 weeks

55
Q

How are women with gestational diabetes followed up?

A

Fasting glucose test 6-13 weeks post birth - exclude diabetes

Continue to advise regarding weight, diet and exercise

Annual HbA1C

56
Q

What happens in obstetric cholestasis?

What are the key points to remember about its presentation?

A

Impaired bile flow allow bile salts to be deposited in skin and placenta

Abnormal LFT’s + intense pruritis

57
Q

What effects do bile acids have?

A

Vasoconstrict placental veins - sudden asphyxial events

Increase oxytocin receptor expression - increased response to oxytocin

58
Q

What are the risk factors for obstetric cholestasis?

A 
Past obstetric cholestasis
Family Hx
Multiple pregnancy
Gallstones
Hep C
59
Q

How may obstetric cholestasis present?

A

3rd trimester

Intense itching - palms, soles and abdomen worst, worst at night, excoriation marks but NO rash
Pale stools and dark urine
Jaundice

60
Q

What are the differentials for obstetric cholestasis?

A 
HELLP syndrome
Hep C
Acute fatty liver of pregnancy
Polymorphic eruption of pregnancy
Pemphigoid gestationis
61
Q

What are the risks associated with obstetric cholestasis?

A

Fetal distress - meconium passage
Intrauterine death
Pre-term delivery
PPH due to reduced vit K

62
Q

What should you be aware of when interpreting blood results in obstetric cholestasis?

A

LFT’s have pregnancy specific ranges - UL 20% lower than in non-pregnant level

63
Q

How is obstetric cholestasis managed?

A

Weekly LFT monitoring
Topical antihistamines
Ursodeoxycholic acid
Vit K - esp if steatorrhoea or clotting affected
Delivery is only cure - often induced at 37 weeks

64
Q

When is a pregnant women at highest risk of VTE?

A

Post-partum

65
Q

What pre-existing factors increase risk of VTE during pregnancy?

A 
Thrombophilia
Co-morbidities - cancer
Age >35
BMI >30
Parity >3
Smoking
Varicose veins
Paraplegia
66
Q

What obstetric factors/conditions increase risk of VTE?

A 
Multiple pregnancy
Pre-eclampsia
C-Section
Prolonged labour
Stillbirth
Preterm birth
PPH
Hyperemesis (dehydration)
Ovarian hyperstimulation syndrome
Immobility eg pubic symphysis dysfunction
67
Q

How do VTE’s present?

A

DVT - unilateral leg pain and swelling +- pitting oedema +- pyrexia

PE - Sudden dyspnoea, pleuritic chest pain, cough

68
Q

How are DVT’s diagnosed in pregnancy?

A

Compression duplex ultrasound

69
Q

How are PE’s diagnosed in pregnancy?

A

Initial ECG and CXR

Weigh up need for imaging vs risk:
CTPA = maternal breast cancer
V/Q mismatch = childhood cancer

D-dimer raised anyway so useless

70
Q

When is VTE prophylaxis given?

A

Previous VTE - LMWH post partum

BMI >40 or emergency C-section - 7 days LMWH post delivery

Risk factor dependant
3 = from wk 28 - 6wk post
4 = immediate - 6wk post
(RF: Age >35, BMI >30, thrombophilia, immobile, smoker, varicose veins, parity >3)

71
Q

How are VTE’s managed?

A

Immediate LMWH until diagnosis confirmed

Once confirmed - LMWH for remainder of pregnancy and until 6-12 weeks post partum

72
Q

What should happen in an emergency VTE situation?

A

IV unfractionated heparin in major life threatening situation

73
Q

What should happen to LMWH dose when a women is in labour?

A

Omit 24 hrs before induction
OR
Stop as soon as they think they are going into labour

74
Q

How safe are VTE medications in breastfeeding?

A

LMWH - safe as not absorbed through GI tract

Warfarin - safe as metabolites not active

75
Q

When do you check for maternal anaemia? What is the cut off for anaemia at these points?

A

Booking visit <11g/dl
28 weeks <10.5g/dl
Post partum <10g/dl

76
Q

What are your differentials for anaemia in pregnancy?

A

Iron deficient
Thalasaemia (carriers are asymptomatic until pregnancy)
Sickle cell

77
Q

What should be done if a pregnant woman is diagnosed with a thalassaemia?

A

Folate supplementation and blood transfusion

Paternal testing
Genetic counselling

78
Q

How may sickle cell affect a pregnant woman and how should it be managed?

A

25% chance of miscarriage
10% chance of stillbirth

Folate and iron supplementation required

79
Q

If a pregnant woman is found to have micro or normocytic anaemia, what is the most likely cause and how would it be managed?

A

Iron deficiency anaemia

Trial oral iron (100-200mg) and repeat FBC after 2 weeks of treatment

If no rise then further diagnostic testing

80
Q

What are the effects of anaemia on pregnancy?

A

Prematurity
Low birth weight
Increased maternal mortality from haemorrhage

81
Q

What is the overarching principle of epilepsy management in pregnancy?

A

Aim for monotherapy

82
Q

What is the major risk associated with anti-epileptic drugs in pregnancy?

A

Neural tube defects

83
Q

How should pregnant (or planning to be) women on anti-epileptic medication be managed?

What is given to the newborn and why?

A

Folic acid 5mg per day before conception if planning pregnancy
18-20 week scan for abnormalities

1mg vit K at delivery - reduce risk of neonatal haemorrhage

84
Q

What is the risk of sodium valproate in pregnancy?

A

Neural tube defects
ADHD
Reduced cognitive ability

NOT USED

85
Q

What is the risk of Carbamazepine in pregnancy?

A

Lower IQ

NOT USED

86
Q

What is the risk of Phenytoin in pregnancy? How is one of these risks minimised?

A

Cleft palate

Newborn clotting disorders: women takes vit K in last month

87
Q

If a pregnant women takes lamotrigine, what needs to be remembered/ considered?

A

Dose may need to be increased since oestrogen can result in significantly lower levels

88
Q

What is the risk of Topiramate in pregnancy?

A

Cleft palate

89
Q

What is the risk of Phenobarbital and Benzodiazepines in pregnancy?

A

Withdrawal effects in baby

90
Q

What emergency contraception should be used for a women on AEDs?

A

Copper IUD

91
Q

What contraception can epileptic women use?

A 
Depot medroxyprogesterone acetate
Copper IUD
Levonorgestrel IUS
Barrier methods
Family planning methods
92
Q

How is the foetus affected by seizures?

A

Fetus at higher risk of harm during tonic-clonic seizure
- Hypoxia, acidosis, fall trauma, miscarriage

Fetus not affected by other seizure types (unless fall trauma)

93
Q

What is the guidance on breastfeeding while taking anti-epileptic medication?

A

Safe and encouraged

94
Q

What do women who have seizures in the 2nd half of pregnancy need to be assessed for?

A

Eclampsia

95
Q

What is fatal anticonvulsant syndrome?

A

Seen in children exposed to valproate and carbamazepine

Epicanthic folds
Thin upper lip
Abnormal philtrum (long)
Triangular forehead
Micrognathia
Medial deficiency of eyebrows
Anteverted nose
96
Q

How common are mental health problems in pregnancy?

A

10-15% suffer from depression and/or anxiety

97
Q

What can a low BMI during pregnancy predispose to?

A

Low birth weight
Pre-term delivery
Anaemia

98
Q

How and when does baby-blues present?

A

First week post-partum

Tearful, anxious, irritable but it doesn’t impair function

99
Q

How are baby blues managed?

A

Reassurance and support esp. from health visitor

100
Q

What is the timing of postnatal depression?

A

Depressive episode within first 12 months postpartum

Generally start within 1 month and peak at 3

101
Q

How is postnatal depression managed?

A

Reassure and support
CBT
Paroxetine or duloxetine

102
Q

How does puerperal psychosis present?

A

First 2-3 weeks

Severe mood swings, disordered perceptions, hallucinations

103
Q

How is puerperal psychosis managed?

A

Hospital admission

Future pregnancies req. monitoring

104
Q

How is postnatal depression screened?

A

Edinburgh Postnatal Depression Scale

  • 10 item questionnaire with max score of 30
  • Indicate how mother feel in prev. week
  • Score >13 indicate depressive illness
105
Q

What is the guidance on antidepressants and breastfeeding?

A

Paroxetine recommended - low milk/plasma ratio
Fluoxetine avoided - long half life

Encourage women with mental health problem to breastfeed

106
Q

How can HIV transmit to young children?

A

Usually mother-child transmission

Can be transplacentally - rare

107
Q

What are the risk factors for mother-child HIV transmission?

A 
Higher levels of maternal viraemia
Low CD4 count
HIV core antigens
Instrumental delivery
Premature rupture of membranes
Vaginal delivery
108
Q

How is HIV in pregnant women managed?

A

Early diagnosis reduce transmission - screening

Risk of transmission 1% if:

  • Antiretroviral therapy - usually combined therapy
  • Elective caesarian 38-39 weeks
  • Avoid breastfeeding following delivery
109
Q

When can vaginal delivery be planned for women with HIV?

A

Viral load <50copies/ml at 36 weeks

110
Q

What is the period of greatest risk when prescribing medication in pregnancy?

A

Week 3-11

1st trimester - congenital malformations

111
Q

What effect can drugs have on a foetus in 2nd and 3rd trimester of pregnancy?

A

Drugs can affect growth or functional development

Can have toxic effects on foetal tissues

112
Q

What effects can medication around the time of labour?

A

Adverse effects on labour or neonate after delivery

113
Q

What must you be aware of when prescribing in pregnancy?

A

Maternal drug doses may req. adjustment

Expected benefit must outweigh risk to foetus

No drug safe beyond all doubt

114
Q

How does acute fatty liver of pregnancy present? (Timing, symptoms, bloods)

A

3rd trimester/ after delivery

  • acute N&V, abdo pain, headache, pruritis, jaundice
  • raised ALT, AST, bilirubin
  • low fibrinogen and prolonged PTT
115
Q

When is cervical circulate indicated?

A

Previous poor obstetric hx - >=3 2nd trimester losses
Cervical length shortening on USS - <25mm before 24 weeks and 2nd trimester loss
Symptomatic women with premature cervical dilatation and exposed foetal membranes

116
Q

What are the complications of cervical cerclage?

A

Bleeding
Membrane rupture
Stimulate uterine contractions

117
Q

What can women with a Hx of 2nd trimester miscarriage and cervical weakness who haven’t undergone cervical cerclage be offered?

A

Cervical sonographic surveillance

118
Q

Which contraception should be avoided in a women who had obstetric cholestasis during pregnancy?

A

COCP - it can cause cholestasis to recur

119
Q

What is polymorphic eruption of pregnancy?

A

itchy rash starting in the abdominal striae

120
Q

What is pemphigoid gestationalis

A

itchy, blistering, periumbilical rash often occurring in multiparous women

121
Q

What monitoring is required for women on LMWH?

A

Only if extremes of weight

Anti-Xa

122
Q

A pregnant women has asymptomatic bacteriuria on culture, what should be done?

A

7 day course abx

123
Q

What are your differentials for chest pain during pregnancy?

A

PE
Aortic dissection
Mitral stenosis
GORD

Obstetrics and Gynaecology (21 decks)

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