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Y4 reproductive health > Medical problems in pregnancy > Flashcards

Medical problems in pregnancy Flashcards

1
Q

Pre-eclampsia

A

One of several hypertensive disorders that can occur during pregnancy

Placental disease, affects up to 5% of women in their first pregnancy

Most severe form → catastrophic maternal and/or fetal compromise

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2
Q

Pre-eclampsia pathophysiology

A

Abnormal placentation

Pre-eclampsia → remodelling of spiral arteries in incomplete; high resistance, low-flow uteroplacental circulation develops, as the constrictive muscular walls of the spiral arterioles are maintained

  • increase in BP, combined with hypoxia and oxidative stress from inadequate uteroplacental perfusion → systemic inflammatory response & endothelial cell dysfunction
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3
Q

Pre-eclampsia risk factors

A

Moderate

  • nuliparity
  • maternal age > 40
  • maternal BMI > 35 at initial presentation
  • FHx
  • pregnancy interval > 10 years
  • multiple pregnancy

High

  • chronic HTN
  • HTN, pre-eclampsia or eclampsia in previous pregnancy
  • pre-existing CKD
  • DM
  • autoimmune diseases eg. SLE, antiphospholipid syndrome

Prophylaxis with aspirin 150mg a day for women with 1 high risk factor or > 2 moderate risk factors; continued from 12 weeks until birth

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4
Q

Pre-eclampsia criteria

A

Three criteria:

1) HTN (systolic BP > 140 mmHg or diastolic BP > 90 mmHg), on two occasions at least 4 hours apart

2) significant proteinuria - >300mg protein in a 24 hours urine sample or > 30mg/mmol urinary protein:creatinine

3) women > 20 weeks gestation

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5
Q

Pre-eclampsia clinical features

A

Asymptomatic

Headaches (frontal)

Visual disturbances - blurred/double vision, halos, flashing lights

Epigastric pain (due to hepatic capsule distension/infarction)

Sudden onset non-dependent oedema

Hyper-reflexia

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6
Q

Pre-eclampsia ix

A

Urine dipstick

BP

FBC - decreased Hb, decreased platelets

U&Es - increased urea, increased creatinine, increased urate & decreased urine output

LFTs - increased ALT, AST

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7
Q

Pre-eclampsia differential diagnosis

A

Essential HTN - HTN prior to 20 weeks’ gestation

Pregnancy induced HTN - new onset HTN presenting after 20 weeks’ gestation, without significant proteinuria

Eclampsia - pre-eclampsia + seizure → emergency

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8
Q

Pre-eclampsia mx

A

Monitoring of maternal & fetal wellbeing → BP, urinalysis, blood tests, fetal growth scans & CTG

VTE prevention - LMWH

Antihypertensives - labetalol (avoid in asthma + diabetes), nifedipine, methyldopa

Delivery → only definitive cure

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9
Q

Pre-eclampsia postnatal care

A

Pre-eclampsia resolves following delivery of the placenta

Important to monitor mother for at least 24 hours post-partum → still at risk of having eclamptic seizures

BP should be monitored daily for the first 2 days post-partum & at least once 3-5 days after

Advised about risk of developing pregnancy-induced HTN & pre-eclampsia in subsequent pregnancies

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10
Q

Pre-eclampsia complications

A

Maternal

  • HELLP - haemolysis, elevated liver enzymes, low platelets
  • eclampsia
  • AKI
  • DIC
  • ARDS
  • HTN
  • cerebrovascular haemorrhage
  • death

Fetal

  • prematurity
  • intrauterine growth restriction
  • placental abruption
  • intrauterine fetal death
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11
Q

Obstetric cholestasis

A

Characterised by the reduced outflow of bile acids from the liver

Condition resolves after delivery of the baby

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12
Q

Obstetric cholestasis clinical features

A

Typically present later, particularly in third trimester

Pruritis, particularly affecting the palms of the hands & soles of the feet

Other symptoms: fatigue, dark urine, pale & greasy stools, jaundice

No rash

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13
Q

Obstetric cholestasis differentials

A

Gallstones

Acute fatty liver

Autoimmune hepatitis

Viral hepatitis

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14
Q

Obstetric cholestasis ix

A

LFTs & bile acids

  • abnormal LFTs, mainly ALT, AST & GGT
  • raised bile acids
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15
Q

Obstetric cholestasis mx

A

Symptomatic management of itching:

  • ursodeoxycholic acid
  • antihistamine
  • calamine lotion

Neonatal vitamin K & maternal vitamin K → if clotting deranged

Weekly LFTs & bile acids

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16
Q

Gestational diabetes

A

Any degree of glucose intolerance with onset or first recognition during pregnancy

17
Q

Gestational diabetes risk factors

A

BMI > 30

Asian ethnicity

Previous gestational diabetes

1st degree relative with diabetes

PCOS

Previous macrosomic baby (>4.5kg)

18
Q

Gestational diabetes fetal complications

A

Macrosomia

Organomegaly - particularly cardiomegaly

Erythropoiesis - polycythaemia

Polyhydramnios

Increased rates of pre-term delivery

Increased risk of hypoglycaemia

Increased risk of transient tachypnoea → high insulin can cause a reduction in pulmonary phospholipids

19
Q

Gestational diabetes ix

A

Oral glucose tolerance test

  • fasting glucose > 5.6
  • 2hrs postprandial glucose > 7.8

OGTT offered:

  • booking - if previous GDM
  • 24-28 weeks - RFs present or previous GDM
  • any point in pregnancy - 2+ glycosuria on one occasion, 1+ on two occasions
20
Q

Gestational diabetes mx

A

Lifestyle advice given regarding diet and exercise

Medication:

  • metformin
  • glibenclamide - if metformin not tolerated & insulin declined
  • insulin - consider started if fasting glucose > 7

Consultant led care, additional growth scans at 28, 32 & 36 weeks

Aim to deliver at 37-38 weeks if on treatment

21
Q

Gestational diabetes postnatal care

A

All medication stopped after delivery

6-13 weeks post-partum, a fasting glucose test recommended; yearly tests offered if normal to check for diabetes

In subsequent pregnancies → OGTT offered at booking & at 24-28 weeks gestation

22
Q

Asthma in pregnancy

A

Medicines used to treat asthma are safe in pregnancy → includes reliever inhalers, preventer inhalers, long-acting & combined relievers, theophylline & steroid tablets

Still taking steroid tablets when go into labour → v important these are not stopped suddenly → make sure continued in labour

23
Q

Epilepsy in pregnancy

A

Should take folic acid 5mg daily from before conception

Ideally, epilepsy should be controlled with a single anti-epileptic drug before becoming pregnant

Levetiracetam, lamotrigine and carbamazepine are safer anti-epileptic medications in pregnancy

24
Q

Existing HTN in pregnancy

A

Existing HTN → may need changing to current medications

Need to be stopped:

  • ACE inhibitors
  • ARBs
  • thiazide & thiazide-like diuretics

Not known to be harmful:

  • labetalol
  • CCBs eg. nifedipine
  • alpha-blockers e.g. doxazosin
25
Q

Rubella mx in pregnancy

A

<12 weeks - high likelihood of defects, reasonable to consider a TOP

12-20 weeks - prenatal diagnosis of fetal rubella infection required

  • if confirmed → TOP or USS surveillance to identify features of congenital rubella syndrome

> 20 weeks - no action required

26
Q

Congenital rubella syndrome

A

Neonatal manifestation of infection with the rubella virus during pregnancy

Present at birth - auditory problems (sensorineural deafness), cardiac defects, ophthalmic defects, CNS abnormalities, haematological

Late onset - diabetes mellitus, thyroiditis, growth hormone abnormalities, behavioural disorders

27
Q

CMV in pregnancy

A

Most cases of CMV in pregnancy do not cause congenital CMV

Features of congenital CMV:

  • fetal growth restriction
  • microcephaly
  • hearing loss
  • vision loss
  • LD
  • seizures
28
Q

Parvovirus in pregnancy

A

Can lead to several complications, particularly in the first & second trimesters

Complications: miscarriage/fetal death, severe fetal anaemia, hydrops fetalis, maternal pre-eclampsia-like syndrome

Ix - IgM, IgG, rubella antibodies

Mx - supportive, referral to fetal medicine to monitor for complications & malformations

29
Q

Chickenpox in pregnancy

A

Exposure to chickenpox in pregnancy

  • previously had chickenpox → safe
  • not sure → test VZV IgG levels, if positive = safe
  • not immune → treated with IV varicella immunoglobulins → 10 days within exposure

Chickenpox rash in pregnancy can be treated with oral aciclovir if present within 24 hours & > 20 weeks gestation

30
Q

Congenital varicella syndrome

A

Occurs when infection occurs in first 28 weeks of gestation

Typical features

  • fetal growth restriction
  • microcephaly, hydrocephalus & LD
  • scars and significant skin changes located in specific dermatomes
  • limb hypoplasia
  • chorioretinitis → cataracts and inflammation in the eye
31
Q

Syphilis in pregnancy

A

Offered antenatal screening at booking

Has potential to cross the placenta/infect the baby during delivery

Important to treat pregnant women early

Untreated → miscarriage, stillbirth, pre-term labour or congenital syphilis (saddle nose, rashes, fever & failure to gain weight)

32
Q

Zika in pregnancy

A

Can lead to congenital Zika syndrome:

  • microcephaly
  • fetal growth restriction
  • other intracranial abnormalities → ventriculomegaly & cerebellar atrophy

Ix - viral PCR & antibodies to Zika virus

Mx - no treatment, referral to fetal medicine for close monitoring

33
Q

HIV in pregnancy

A

Viral load determines the mode of delivery:

  • under 50 copies = normal vaginal delivery
  • over 50 copies = consider a pre-labour CS
  • over 400 copies = pre-labour CS recommended

IV zidovudine - infusion during labour & delivery if viral load unknown/above 1000 copies/ml

Prophylaxis may be given to baby:

  • low-risk babies - zidovudine for 2-4 weeks
  • high risk babies - zidovudine, lamivudine & nevirapine for 4 weeks

Avoid breastfeeding

Y4 reproductive health (11 decks)

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