Maternal Problems in Pregnancy Flashcards

1
Q

What are the constituents of antenatal screening?

A
  • History and examination
  • Blood test
  • Urinalysis
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2
Q

What is being looked for in the history and examination stage of antenatal screening?

A

Risk factors, e.g. for gestational diabetes

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3
Q

What is being looked for in a blood test in antenatal screening?

A
  • Rhesus incompatability
  • Haemoglobin
  • Infection
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4
Q

What rhesus incompatability is significant?

A

-ve mother with +ve fetus

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5
Q

Why is it important to intervene early when there is a rhesus incompatability?

A

To prevent this from preventing future pregnancies

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6
Q

Why should haemoglobin be tested in antenatal screening?

A

Because there is a risk of anaemia development in pregnancy due to the high iron demans of the fetus

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7
Q

Why is it important to check for infections in antenatal screening?

A

Because they can be tetragenic

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8
Q

Give two examples of infections it is important to check for in antenatal screening

A
  • Syphilis
  • HIV
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9
Q

Why is it important to check for syphilis in antenatal screening?

A

Can cause congenital defects

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10
Q

Why is it important to check for HIV in antenatal screening?

A

Concerns about vertical transmission

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11
Q

What should be checked for in urinalysis in antenatal screening?

A

Proteinuria

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12
Q

What is the importance of proteinuria in antenatal screening?

A

Sign of pre-eclampsia, indicating systemic organ involvement as a result of maternal syndrome

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13
Q

What systems undergo physiological changes in pregnancy?

A
  • Cardiovascular system
  • Respiratory system
  • Metabolic changes
  • Gastrointestinal system
  • Immune system
  • Haemotology
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14
Q

What happens to the cardiovascular system in pregnancy?

A

Many haemodynamic changes occur

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15
Q

When do the haemodynamic changes occur in pregnancy?

A

Very early

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16
Q

Why do the haemodynamic changes in pregnancy occur very early?

A

Strong anticipatory changes, reflective of the need to supply big utero-placental circulation, required for later need

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17
Q

By how much does the blood volume increase in pregnancy?

A

50%

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18
Q

Why does the blood volume increase by 50% in pregnancy?

A
  • Because there is a new circulation to support
  • Have to increase blood flow to the kidneys
  • Pre-empt blood loss at delivery
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19
Q

Why is there an increased blood flow to the kidneys in pregnancy?

A

Because mum’s kidneys have to act for the fetus

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20
Q

How much blood loss is expected in a normal vaginal delivery?

A

0.5L

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21
Q

How much blood loss is expected in a caeserian?

A

1L

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22
Q

Is systolic BP increased in pregnancy?

A

No

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23
Q

What happens to blood pressure in T1 and T2?

A

Progesterone has effects on systemic vascular resistance, and so decreases BP

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24
Q

What is the result of the decreased blood pressure in T1 and T2?

A

Increased risk of vaso-vagal episodes

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25
Q

What happens in a vaso-vagal episode?

A

Nausea and feeling faint

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26
Q

What is the problem with the hypotension in T1 and T2 of pregnancy?

A

Can mask exisiting hypertension, which is a risk factor for pre-eclampsia

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27
Q

What can happen to blood pressure in T3?

A

May be aortocaval compression by gravid uterus, leading to hypotension

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28
Q

What causes a gravid uterus?

A

Significant hypertrophy of the myometrium and enlarged fetus

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29
Q

What should be considered due to aortocaval compression by a gravid uterus?

A

Shouldn’t leave pregnant woman supine for a long time

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30
Q

Why shouldn’t a pregnant woman be left supine for a long time?

A

Reduces perfusion to the placenta, and so decreases oxygen exchange

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31
Q

What is the important of the endothelium in pregnancy?

A
  • Controls vascular permeability
  • Contributes to the control of vascular tone
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32
Q

How does endothelium contribute to the control of vascular tone in pregnancy?

A

By signalling to smooth muscle

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33
Q

Is there normal vasodilation in pregnancy?

A

Yes

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34
Q

What is the difference in plasma volume between normal pregnancy and pre-eclampsia?

A

Plasma expanded in normal pregnancy, contracted in pre-eclampsia

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35
Q

What is the difference in vasodilation between normal pregnancy and pre-eclampsia?

A

Vasodilation in normal pregnancy, vasoconstriction in pre-eclampsia

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36
Q

Why does blood pressure increase in pre-eclampsia?

A

There is a big strain on the placenta, so not able to support fetus, so increase in BP to try and compensate

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37
Q

What is pre-eclampsia characterised by?

A
  • Defect in placentation
  • Poor uteroplacental circulation
  • Widespread endothelial dysfunction throughout maternal CNS
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38
Q

What is pre-eclampsia a precursor to?

A

Eclampsia

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39
Q

What is eclampsia?

A

Significant generalised seizures

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40
Q

What is the problem with eclampsia?

A

It is bad for the mother and baby, and so is an emergency situation

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41
Q

What happens to cardiac output in pregnancy?

A

+40%

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42
Q

When does cardiac output change in pregnancy?

A

From T1

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43
Q

What happens to stroke volume in pregnancy?

A

+35%

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44
Q

When does stroke volume change in pregnancy?

A

From T1

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45
Q

What happens to heart rate in pregnancy?

A

+15%

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46
Q

When does heart rate change in pregnancy?

A

From T1

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47
Q

What happens to systemic vascular resistance in pregnancy?

A
  • 25-30%
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48
Q

When does systemic vascualr resistance change in pregnancy?

A

From T1

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49
Q

What happens to blood pressure in pregnancy?

A

Decreases in T1 and T2, then returns to normal in T3

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50
Q

What changes occur in the urinary system in pregnancy?

A
  • Glomerular filtration rate increases
  • Renal plasma flow increases
51
Q

What happens to filtration capacity in pregnancy?

A

It remains in tact

52
Q

What happens to the functional renal reserve as GFR increases in pregnancy?

A

It decreases, as there is a limit as to how much the system can stretch

53
Q

What are the consequences of the changes in the urinary system in pregnancy?

A
  • Urinary stasis
  • UTI
54
Q

What causes urinary stasis in pregnancy?

A
  • Progesterones effect on the urinary collecting system
  • Obstruction
55
Q

What does progesterones effect on the urinary collecting system in pregnancy cause?

A

Hydroureter

56
Q

What is urinary obstruction in pregnancy related to?

A

Gravid uterus

57
Q

Are UTIs common in pregnancy?

A

Yes, very

58
Q

What can UTIs lead to in pregnancy?

A

Pyelonephritis, which causes pre-term labour

59
Q

What happens to RPF in pregnancy?

A

+60-80%

60
Q

What happens to GFR in pregnancy?

A

+55%

61
Q

What happens to creatinine clearance in pregnancy?

A

+40-50%

62
Q

What happens to protein excretion in pregnancy?

A

+ up to 300mg/24hours

63
Q

What happens to urea in pregnancy?

A

-50%

64
Q

What happens to uric acid in pregnancy?

A
  • 33%, but rises with gestation
65
Q

What happens to bicarbonate in pregnancy?

A
  • 18-22mmol/L
66
Q

What happens to creatinine in pregnancy?

A
  • 25-27µm/L
67
Q

What anatomical changes are there to the respiratory system in pregnancy?

A
  • Diaphragm displaced
  • A-P and transverse diameters of the thorax increases to compensate for the diaphragm
68
Q

What are the consequences of the anatomical changes in the respiratory system during pregnancy?

A
  • Decreased functional residual capacity
  • Vital capacity unchanged, total lung capacity unchanged
69
Q

What physiological changes are there to the respiratory system during pregnancy?

A
  • Increased minute and alveolar ventilation
  • Increased tidal volume
70
Q

What happens to the respiratory rate in pregnancy?

A

It is unchanged

71
Q

What is the overall effect of pregnancy on the respiratory system?

A

Physiological hyperventilation

72
Q

Why is there physiological hyperventilation in pregnancy?

A

Increased metabolic production of CO2, so increased respiratory drive from the brainstem to blow off excess CO2

73
Q

Why is there increased metabolic production of CO2 in pregnancy?

A

Coming from the fetus, through the placenta, and into maternal circulation

74
Q

What causes the increased respiratory drive in pregnancy?

A

Progesterone

75
Q

What is the result of the increased respiratory drive in pregnancy?

A

Results in respiratory alkalosis, compensated for by renal bicarbonate excretion

76
Q

What is the result of the increase in renal bicarbonate secretion in pregnancy?

A

Decreased buffering capacity, and so increased risk of acidosis, as don’t have reserve bicarbonate

77
Q

Why does physiological dyspnoea occur in pregnancy?

A

Due to progesterone driven hyperventilation

78
Q

What happens to O2 consumption in pregnancy?

A

+ 20%

79
Q

What happens to resting minute ventilation in pregnancy?

A

+ 15%

80
Q

What happens to tidal volume in pregnancy?

A

Increased

81
Q

What happens to respiratory rate in pregnancy?

A

Unchanged

82
Q

What happens to functional residual capacity in pregnancy?

A

Decreased in T3

83
Q

What happens to vital capacity in pregnancy?

A

Unchanged

84
Q

What happens to FEV1 in pregnancy?

A

Unchanged

85
Q

What happens to PaO2 in pregnancy?

A

Increased

86
Q

What happens to PaCO2 in pregnancy?

A

Decreased

87
Q

What molecules are affected by metabolic changes in pregnancy?

A
  • Carbohydrate
  • Lipids
  • Thyroid hormones
88
Q

How does placental transport of glucose occur?

A

By facilitated diffusion

89
Q

What happens, regarding insulin, in pregnancy?

A

Pregnancy increases maternal peripheral insulin resistance

90
Q

What is the result of the increase in materal peripheral insulin resistance in pregnancy?

A

Switches to gluconeogenesis and alternative fuels

91
Q

How is an increase in maternal peripheral insulin resistance achieved?

A

Human placental lactogen, with contributions from prolactin, oestrogen/progesterone, and cortisol

92
Q

What happens to blood glucose in pregnancy?

A

There is a decrease in fasting blood glucose, and an increased in post-prandial blood glucose

93
Q

What is gestational diabetes?

A

Carbohydrate intolerance first recognised in pregnancy, and not persisting after delivery

94
Q

What are the risks associated with poor control of gestational diabetes?

A
  • Macrosomic fetus
  • Stillbirth
  • Increased risk of congenital defects
95
Q

What is a macrosomic fetus?

A

Larger than average, 4kg at delivery

96
Q

What is the problem with a macrosomic fetus?

A

May have problems at delivery, and increased risk of C-section

97
Q

What is required when gestational diabetes is suspected?

A

Oral glucose tolerance test

98
Q

What happens to lipid metabolism in pregnancy?

A

Increase in lipolysis from T2, and increase in plasma free fatty acids on fasting

99
Q

What is the increase in lipolysis in pregnancy under the influence of?

A

Progesterone, from maternal fat stores

100
Q

Why is there an increase in plasma free fatty acids on fasting in pregnancy?

A

Ensures mothers physiology has enough FAs for her metabolism, as only essential fatty acids cross the placental membrane and so leaves glucose, the ideal substrate, for fetal metabolism

101
Q

What happens regarding thyroid hormones in pregnancy?

A

Thyroid binding globulin production increases, and T3 and T4 increases

102
Q

What happens to levels of free T4 in pregnancy?

A

It is in the normal range, due to increase in TBG

103
Q

What has a direct effect on thyroid stimulating hormone production in pregnancy?

A

hCG

104
Q

Is TSH ever decreased in normal pregnancies?

A

Yes, it can be

105
Q

What are the anatomical changes to the GI system in pregnancy?

A

Alterations in the disposition of the viscera, e.g. appendix moves to RUQ as uterus enlarges

106
Q

What is the significance of the movement of the appendix in pregnancy?

A

Can make appendicitis presentation atypical

Still have umbilical pain

107
Q

What are the physiological changes to the GI system in pregnancy?

A

Smooth muscle relaxation by progesterone, leading to;

  • Delayed GI emptying
  • Biliary tract stasis
  • Increased risk of pancreatitis
108
Q

What can delayed GI emptying lead to?

A
  • Nausea
  • Heartburn
109
Q

Why can pregnancy cause biliary tract stasis?

A

Some biochemical changes in bile salts can increase the risk of gallstone formation

110
Q

Why is there an increased risk of pancreatitis in pregnancy?

A
  • Can be related to stones
  • Can be consequence of hyperlipiaemia of pregnancy
111
Q

What is immunological true of the fetus?

A

Allograft

112
Q

What is meant by the fetus being an allograft?

A

It is genetically distinct to the mother, and so will express different HLA molecules to the mother, so is effectively the same as a transplanted organ

113
Q

What happens to the mothers immuner response as a result of the fetus being an allograft?

A

Get non-specific suppression of the local immune response at the materno-fetal interface

114
Q

What is the result of the non-specific supression of the local immune response in pregnancy?

A

Infection more common in pregnancy

115
Q

When may the transfer of antibodies between mother and fetus be damaging?

A

If the maternal circulation has destructive antibodies

116
Q

What can the transfer of destructive antibodies to the fetus cause in pregnancy?

A
  • Haemolytic disease
  • Graves diease
  • Hashimoto’s thyroiditis
117
Q

What happens in fetal Graves disease?

A

Antibodies stimulate the thyroid, so gives the fetus thyrotoxicosis

118
Q

What happens in fetal Hashimotos?

A

Destroys the thyroid, so gives hypothyroidism

119
Q

Is pregnancy a pro- or anti-thrombotic state?

A

Pro-thrombotic

120
Q

Why is pregnancy a pro-thrombotic state?

A

It is preparting for partuition and significant blood loss

121
Q

What prepares for partuition and significant blood loss?

A
  • Substantial fibrin deposition at implantation site
  • Increased fibrinogen and clotting factors
  • Reduced fibrinolysis
  • Stasis
  • Venodilation
122
Q

What is the result of the pro-thrombotic state in pregnancy, coupled with stasis and venodilation?

A

Increases risk of thromboembolic disease

123
Q

What is the problem with treating thromboembolic disease in pregnancy?

A

Warfarin crosses the placenta, and is teratogenic

124
Q

Why can pregnancy cause anaemia?

A
  • Because plasma volume increases by 40-50%, but red cell mass only by 20-30%, and so dilation of RBCs mean that theres fewer RBCs relative to volume, leading to physiological anaemia
  • Anaemia due to Fe- and folate deficiency
  • Haemoglobinopathies