MATERNAL MEDICINE Flashcards

Question

Whats the breakdown of gestational diabetes, Type 1 diabetes and type 2 diabetes in pregnancy? d

Answer 1

87.5% have gestational diabetes 7.5% have type 1 diabetes 5% have type 2 diabetes

Answer 2

Reduced insulin sensitivity during pregnancy

Answer 3

BMI of > 30 kg/m² previous macrosomic baby weighing 4.5 kg or above previous gestational diabetes first-degree relative with diabetes family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern) Others: PCOS Older maternal age Polyydramniops

Answer 4

For women who’ve previously had gestational diabetes: Oral glucose tolerance test as soon as possible after booking and at 24-28 weeks if first test is normal Women with any other risk factors should be offered OGTT at 24-28 weeks

Answer 5

Fasting glucose >=5.6 2 hour glucose >=7.8

Answer 6

After a fast (i.e in the morning) measure blood sugar level, then give women a 75g glucose drink and then measure again at 2 hours

Answer 7

Once diagnosed see in. A joint diabetes and antenatal clinic within 1 week Teach how to monitor blood glucose Advice about diet, exercise, weight If fasting plasma glucose <7 then start management on diet and exercise. If glucose targets not met within 1-2 weeks then metformin. If glucose targets not met then short acting insulin. If at the time of diagnosis fasting plasma glucose is >=7 then insulin should be started If at time of diagnosis fasting plasma glucose is 6-6.9 ans there is evidence of complications e.g. macrosomia then insulin should be offered Glibenclamide should only be offered for women who cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment

Answer 8

Advise women to test fasting, pre-meal, 1 hour post meal and bedtime BM daily (with target BM levels fasting 5.3 and 1 hour after meals 7.8) Measure HbA1c at booking for women with pre-existing diabetes Insulin treatment Continuous glucose monitoring if type 1 diabetes Ketone testing for type 1 diabetics - for DKA Retinal assessment in pregnancy Renal assessment at first contact and monitor Aspirin to prevent pre-eclampsia Further examination of foetal heart at 20 week scan to detect congenital malformations USS monitoring of foetal growth and amniotic fluid volume every 4 weeks from 28 weeks

Answer 9

Elective birth by induced labour or c-section between 37-38+6 (if complications then earlier!) Advise women not to give birth later than 40+6 Monitor capillary plasma glucose every hour during labour and birth - maintain between 4-7 Consider IV dextrose and insulin infusion from the onset of established labour for women with T1DM of those whose capillary plasma glucose is not maintained between 4-7mmol/litre

Answer 10

Advise women to birth in hospitals Blood glucose testing at 2-4 hours after birth Feed within 30 mins of birth and then every 2-3 hours until feeding maintains pre-feed cap plasma glucose levels >2.0mmol/litre Admit babies if signs of any complications Dont transfer babies to community care until at least 24 hours old and satisfied baby is mianting good BM levels and is feeding well

Answer 11

Hypoglycaemia due to hyper insulin anemia Macrosomia RDS Congenital heart disease Neonatal encephalopathy Polycythemia Jaundice Hypocalcaemia and hypomagnasemia

Answer 12

Women with insulin‑treated pre‑existing diabetes should reduce their insulin immediately after birth and monitor their blood glucose levels to find the appropriate dose - at increased risk of hypoglycaemia so encourage meaning or snacks before baby feeds Women who have been diagnosed with gestational diabetes should stop blood glucose‑lowering therapy immediately after birth Women with pre‑existing type 2 diabetes who are breastfeeding can resume or continue metformin immediately after birth, but should avoid other oral blood glucose‑lowering therapy while breastfeeding For women who were diagnosed with gestational diabetes offer a fasting plasma glucose test 6-13 weeks after birth to exclude diabetes or HbA1c Offer an annual HbA1c test for women with gestational diabetes who have a negative postnatal test for diabetes Offer women with gestational diabetes early self-monitoring of blood glucose or an OGTT for future pregnancies!

Answer 13

weight loss for women with BMI of > 27 kg/m^2 stop oral hypoglycaemic agents, apart from metformin, and commence insulin folic acid 5 mg/day from pre-conception to 12 weeks gestation detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts tight glycaemic control reduces complication rates treat retinopathy as can worsen during pregnancy

Answer 14

Bacteria present in the urine without symptoms of infection Pregnant women who have this are at higher risk of developing lower urinary tract infections and pyelonephritis, and subsequently preterm birth Pregnant women are tested fore it at booking and routinely throughout pregnancy - send MSU for culture and sensitivities

Answer 15

7 day course of antibiotics and follow up - nitrofurantoin (avoid at term) Offer immediate antibiotic prescription!!

Answer 16

Start at 28 weeks if 3 risk factors Start in first trimester if 4 or more risk factors Consider if admitted to hospital, any surgical procedures, previous VTE, medical conditions etc.g. Cancer, high-risk thrombophilia or ovarian hyperstimulation syndrome

Answer 17

Previous VTE Thrombophilia Medical conditions e.g. cancer, nephrotic syndrome, SCD, current IV drug user, SLE Age >35 BMI >30 Parity >=3 Smoking Gross varicose veins Paraplegia Multiple pregnancy Pre-eclampsia C-section Prolonged labour >24 hours Midcavity or rotational operative delivery Stillbirth Preterm birth PPH Any surgical procedure during pregnancy or peurperium Hyperemesis or dehydration Ovarian hyperstimulation syndrome Admission or immobility >3 days of bed rest Current systemic infection Long distance travel >4 hours

Answer 18

Compression duplex ultrasound

Answer 19

ECG and CXR Consider CTPA or V/Q scanning

Answer 20

Often raised in pregnancy anyway so its of limited use

Answer 21

LMWH for at least 3 months (If contraindicated consider intermittent pneumatic compression or anti-embolic compression stockings)

Answer 22

Pregnancy is a prothrombotic state: venous stasis - obstruction of venous flow by enlarging uterus endothelial damage - in delivery or from venous hypertension hypercoaguability - increased clotting factors and hormonal changes

Answer 23

Intrahepatic cholestasis of pregnancy - reduced outflow of bile acids from the liver Affects 1% of pregnancies in UK

Answer 24

Pruritus which may be intense - typically worse on palms, soles, abdomen Clinically detectable jaundice in 20% of pt Raised bilirubin in >90% of cases

Answer 25

Increase the risk of premature or stillbirth

Answer 26

induction of labour at 37-38 weeks - particuarly if LFTs and bile acids are severely deranged as risk of stillbirth ursodeoxycholic acid Symptoms of itching can be managed with emollients e.g. calamine lotion, and antihistamines to help with sleeping (note they actually dont help the itching!!) vitamin K supplementation if prothrombin time is deranged. (Lack of bile acids can lead to vit K deficiency as cannot be absorbed in intestines)

Answer 27

LFTs - ALT, AST and GGT abnormal (note placenta produces ALP so likely to be abnormal anyway) Bile acids raised

Answer 28

A rare complication that may occur in the third trimester or in the immediate peurperal period Genetic condition in foetus impairs fatty acid metabolism e.g. LCHAD = impaired processing of fatty acids in the placenta = fatty acids enter maternal circulation and accumulation in the liver = acute hepatitis

Answer 29

abdominal pain nausea & vomiting headache jaundice hypoglycaemia severe disease may result in pre-eclampsia

Answer 30

LFTs - elevated ALT and AST Raised bilirubin Raised WBC Deranged clotting Low platelets (Think of HELLP syndrome before this if low platelets and elevated liver enzymes as it’s more common!!)

Answer 31

Stabilise pt ans then delivery of baby An obstetrics emergency Treat acute liver failure if it occurs

Answer 32

Intrahepatic cholestasis of pregnancy Acute fatty liver of pregnancy Gilberts - may be exacerbated Dubin-Johnson syndrome - may be exacerbated HELLP syndrome Others: Acute viral or autoimmune hepatitis Cholelithiasis Chronic liver disease

Answer 33

4Ts and 4Hs: Thrombosis - PE or MI Tension pneumothorax Toxins Tamponade cardiac Hypoxia Hypovolaemia Hypothermia Hyperkalaemia, hypoglycaemia and other metabolic disturbances Others: eclampsia and intracranial haemorrhage

Answer 34

Obstetric haemorrhage PE Sepsis

Answer 35

Ectopic pregnancy (early pregnancy) Placental abruption (including concealed haemorrhage) Placenta praevia Placenta accreta Uterine rupture

Answer 36

>20/40, the uterus is a significant size. When a pregnant woman lies supine, the mass of the uterus can compress the IVC + aorta. The compression on the IVC reduces venous return = reduces the cardiac output = hypotension. In some instances, this can be enough to lead to the loss of CO and cardiac arrest. The vena cava is slightly to the right side of the body. The solution to aortocaval compression is to place the woman in the left lateral position, lying on her left side, with the pregnant uterus positioned away from the inferior vena cava. This should relieve the compression on the inferior vena cava and improve venous return and cardiac output.

Answer 37

A 15 degree tilt to the left side for CPR, to relieve compression of the inferior vena cava and aorta Early intubation to protect the airway Early supplementary oxygen Aggressive fluid resuscitation (caution in pre-eclampsia) Delivery of the baby after 4 minutes, and within 5 minutes of starting CPR - delivery will improve the venous return to the heart improving CO = increases chances of baby and mother of surviving

Answer 38

Increased risk of miscarriage 47% Increased risk of preterm labour Increased risk of stillbirth IUGR Increased risk of SUDI

Answer 39

Foetal alcohol syndrome - learning diffiuclties, characteristic facies, IUGR and postnatal restricted growth

Answer 40

Similar to smoking risks due to tobacco content- miscarriage, preterm labour, stillbirth, IUGR, SUDI May also be a risk to mother for triggering onset of mental health problems for the first time or heightening any pre-existing mental health issues

Answer 41

Maternal risks: hypertension in pregnancy including pre-eclampsia placental abruption Fetal risks: prematurity LBW neonatal abstinence syndrome

Answer 42

Neonatal withdrawal syndrome SUDI risk increases

Answer 43

Hi to nine replacement therapy Avoid liquorice-flavoured nicotine products, E-cigs if possible although better than smoking

Answer 44

Induction of labour at 37-38 weeks gestation due to the increased risk of stillbirth

Answer 45

Repeat the OGTT at 24-28 weeks