medical problems in pregnancy Flashcards
common symptoms of pregnancy
nausea and vomiting in early pregnancy
heartburn
constipation
haemorrhoids
vaginal discharge
backaches
when should nausea and vomiting resolve and what advise should be given to women
resolve spontaneously within 16-20 weeks
should not be associated with a poor pregnancy outcome
what treatment can be offered to women who wants to reduce their nausea and vomiting symptoms
non‑pharmacological: ---- ginger ---- P6 (wrist) acupressure ---- eating small but frequent meals ---- avoiding triggers ---- having lots to drink rest
pharmacological:
—- antihistamines - prometazine, cyclizine or prochlorperazine
what advise to give pregnant women complaining about constipation
increase water content
diet modification - bran or wheat fibre supplementation
exercise
advise about varicose veins
common symptom of pregnancy that will not cause harm and that compression stockings can improve the symptoms but will not prevent varicose veins from emerging.
whst Sx of vaginal discharge might prompt Ix
tch, soreness, offensive smell or pain on passing urine
advise for backache during pregnancy
exercising in water, massage therapy and group or individual back care classes
what is hyperemesis gravidarum
ass with
the sickness and vomiting are prolonged and very severe.
lacking in fluid in the body (dehydrated) and to lose weight.
vitamin deficiencies.
not able to eat, the pregnant woman can develop signs of starvation
multiple pregnancies trophoblastic disease hyperthyroidism nulliparity obesity
signs of hyperemesis gravidarum
ketones in urine
tachycardia
hypotension
RFs that make you more likely to experience N/V
If you are having a female baby.
If this is your first pregnancy.
If you have had - or your mother or sister has had - nausea and vomiting in previous pregnancies.
If you are having twins or another multiple pregnancy.
If you have a history of motion sickness.
If you have a history of migraines.
If you have experienced nausea when taking the combined oral contraceptive pill.
If you are stressed or anxious about something.
If you are obese.
If you are a younger woman
why does reflux occur in pregnant women
The increased level of certain hormones that occurs has a relaxing effect on the sphincter muscle. That is, the tightness (tone) of the sphincter is reduced during pregnancy.
The size of the baby in the tummy (abdomen) causes an increased pressure on the stomach.
Sx of reflux in pregnant women
Heartburn. This is a burning feeling which rises from the upper tummy (abdomen) or lower chest up towards the neck.
Waterbrash. This is a sudden flow of sour-tasting saliva in your mouth.
Upper abdominal pain or discomfort.
Pain in the centre of the chest behind the breastbone (sternum).
Feeling sick (nausea) and being sick (vomiting).
Bloating.
Quickly feeling ‘full’ after eating.
lifestyle modification advise for reflux in pregnant women
avoid triggers
good posture
bedtime
what foods to avoid that may prompt pregnancy
Peppermint. Tomatoes. Chocolate. Fatty and spicy foods. Fruit juices. Hot drinks. Coffee. Alcoholic drinks. (Current advice is t
medication for reflux to give pregnant women
antacids - contain Mg or Al ‘as required basis’
contain SODIUM CARBONATE OR MAGNESIUM TRISILLICATE SHOULD BE AVOIDED AS THEY CAN HARM BABY
take it 2 hours before or after iron supplements
alginates
omeprazole
ranitidine
Sx of constipation in pregnancy
Opening the bowels less than usual.
Passing hard, pellet-like stools.
Tummy cramps.
Wind.
if lifestyle modification for contsipation fails what meds can be given
‘Softening’ laxatives
These simply soften the stools. They tend to cause more wind and are not always helpful in pregnancy. This is because they don’t tend to speed the passage of the stool very well through the bowel.
‘Stimulant’ laxatives
These tend to make the bowel work faster. They are more effective than softening laxatives in pregnancy. However, they can cause cramping pains and wind as they start to work.
why can pregnant women feel breathless
diaphragm gets squashed by baby so less space for it to expand
lead to hyperventilation
- panicky, tingly, dizzy and faint.
other causes of breathlessness in pregnancy
asthma
anaemia
Sx of piles
swollen veins around the back passage
itchy, ache, throb
bleeding
what are the Sx of varicose veins in pregnancy
Aching and pain in the legs.
Swelling of the feet and ankles.
Vulval varicose veins, which cause aching and throbbing in the vulval area. This is worse on standing.
what is pelvic girdle pain
symphysis pubis is the joint between the two halves of the pelvis at the front - down low, over the front of your bladder. It can become very painful in pregnancy
why does pelvic girdle pain occur in pregnant women
joint in the bone can become loosened and the bones separate a little and then rub against one another.
Mx pelvic girdle pain
pillow between the knees
exercise
phsiotherapy
when should screening for anaemia should take place
booking
28 weeks of gestation
level of Hb to diagnsoe anaemia at booking and at 2/3rd tirmester
less than 110
less that 150
most common symptoms of anaemia in pregnant women
Fatigue
Dyspnoea
Dizziness
Ix for anaemia in pregnant women
Hb
MCV less than 76
normal MCV - (76-96)
Mx of anaemia in pregnant women
established iron deficiency anaemia
100-200mg of iron daily
should continue for at least three months and at least six weeks postpartum
Ix for thalasseamias
MCV ≤80 fl requires investigation, with an HbA2 ≥3.5% being positive for B2-thalassaemia.
Chorionic villus sampling in the first quarter of pregnancy and fetal cord blood sampling under ultrasound guidance in the second quarter can be used to detect B2-thalassaemia major, and termination of pregnancy offered.
If sickle cell anaemia is suspected what do u do
Where suspected, women should receive folate supplementation of 5 mg per day. FBC should be routinely checked at 20, 28 and 32 weeks.
complications of anaemia
Maternal death. Fetal death. Premature delivery. Low birth-weight babies. Cardiac failure. Their babies having subsequent developmental problems. Poor work capacity/performance. Susceptibility to infection.
when can u say a preg woman has had significant exposure to VZV
Significant exposure to chickenpox includes having face-to-face contact, being in the same room for 15 minutes of more, or in a large open ward. It is also important to enquire about contact before the chickenpox rash develops (as infectivity begins 2 days before the onset of the rash until lesions crust).
how do you check if women is immune to VZV or not
blood test to VZV
If exposure is deemed to be significant and the pregnant woman is non-immune AND <20 WEEKS what do u fo
give VZIG within 10 days of the exposure as it help prevent or attenuate chickenpox IF GESTATION <20 WEEKS
If exposure is deemed to be significant and the pregnant woman is non-immune AND >20 WEEKS what do u fo
VZIG or aciclovir within days 7 to 14 after exposure
VZV risk to mother
varicella pneumonitis, hepatitis or encephalitis
features of fetal varicella syndrome
- Fetal growth restriction
- Microcephaly, hydrocephalus and learning disability
- Scars and significant skin changes located in specific dermatomes
- Limb hypoplasia (underdeveloped limbs)
- Cataracts and inflammation in the eye (chorioretinitis)
skin scarring
eye defects (microphthalmia)
limb hypoplasia
microcephaly
learning disabilities
if women gets chickenpox while pregnant
> 20 weeks guve aciclovir within 24 hours of onset of the rash
RFs of HELLP syndrome
Age >35. Nulliparity. Previous gestational hypertension. Multiple pregnancy. Previous HELLP syndrome. Caucasian racial origin. Antiphospholipid syndrome (APS) - 10.5% of patients with HELLP syndrome have APS
presentation of HELLP syndrome
onspecific symptoms including malaise, fatigue, right upper quadrant or epigastric pain, nausea, vomiting, or flu-like symptoms.
worst at night but gets better during the day
OE of HELLP
oedema
HTN
proteinuria
Ix of HELLP
Haemolysis with fragmented red cells on the blood film, due to microangiopathic haemolytic anaemia.
raised LDH and bilirubin due to destruction of RBCs
AST/ALT is also elevated
Mx of HELLP
delivery of fetus
maternal and fetal complications of HELLP
eclampsia
placental abruption
DIC
AKI
fetal
perinatal death
intrauterine growth restriction
causes of jaundice in pregnancy
intrahepatic cholestasis of pregnancy
acute fatty liver of pregnancy
what is intrahepatic cholestasis of pregnancy
seen in third trimester
features of intrahepatic cholestasis of pregnancy
- pruritus, often in the palms and soles - can be skin trauma from intense scratching
- no rash (although skin changes may be seen due to scratching)
- intense in night
- insomnia and malaise
- raised bilirubin
Mx of intrahepatic cholestasis of pregnancy
maternal Vit K
neonatal Vit K
Drug treatment to reduce pruritus --- Ursodeoxycholic acid --- Antihistamine --- Calamine - Delivery at fetal maturity LFTS measured weekly until they go into labour - PN f up LFT 10days PN
- risk reduced by IOL after 37 weeks
if PTT prolonged
- Maternal Vitamin K
- Neonatal Vitamin K as soon as they born
- Fetal surveillance
when does acute fatty liver of pregnancy occur
rare complication which may occur in the third trimester or the period immediately following delivery.
Features of acute fatty liver of pregnancy
abdominal pain nausea & vomiting headache jaundice hypoglycaemia severe disease may result in pre-eclampsia
Ix of acute fatty liver of pregnancy
ALT above 500u/l
Mx of acute fatty liver or pregnancy
support care
once stabilised delivery is the definitive management
what is eclampsia
is a serious complication of pre-eclampsia
where the high BP causes seizures
Mx to prevent exclampsia or treat it
magnesium sulphate
in eclampsia an IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour
urine output, reflexes, respiratory rate and oxygen saturations should be monitored during treatment
respiratory depression can occur: calcium gluconate is the first-line treatment for magnesium sulphate induced respiratory depression
treatment should continue for 24 hours after last seizure or delivery (around 40% of seizures occur post-partum)
- a woman at moderate or high risk of pre-eclampsia should take aspirin 75mg daily from 12 weeks gestation until the birth
- consensus guidelines recommend treating blood pressure > 160/110 mmHg although many clinicians have a lower threshold
- oral labetalol is now first-line following the 2010 NICE guidelines. Nifedipine (e.g. if asthmatic) and hydralazine may also be used
delivery of the baby is the most important and definitive management step. The timing depends on the individual clinical scenario (AFTER 34 WEEKS SSAME DAY DELIVERY IS AN OPTION)
Epidural reduces BP
risks of smoking to the baby
- increased risk of miscarriage (increased risk of around 47%)
- Increased risk of pre-term labour
- Increased risk of stillbirth
- IUGR
- Increased risk of - sudden unexpected death in infancy
risks of alcohol to the baby
Fetal alcohol syndrome (FAS)
- learning difficulties
- characteristic facies: smooth philtrum, thin vermilion, small palpebral fissures, epicanthic folds, microcephaly
- IUGR & postnatal restricted growth
Binge drinking is a major risk factor for FAS
cocaine risks to the baby
Maternal risks
hypertension in pregnancy including pre-eclampsia
placental abruption
Fetal risk
prematurity
neonatal abstinence syndrome
heroin risk to the baby
Risk of neonatal abstinence syndrome
what is placental abrutpion
premature separation of a normally placed placenta before delivery of fetus
blood starts collecting between the placenta and the uterus
presentation of placental abruption
May present with vaginal bleeding, abdominal pain (usually continuous), uterine contractions, shock or fetal distress
shock out of keeping with visible loss pain constant tender, tense uterus normal lie and presentation fetal heart: absent/distressed coagulation problems beware pre-eclampsia, DIC, anuria
intrahepatic cholestasis increases risks of what
foetal distress
intrauterine death
maternal morbidity
if u see rash in pregnancy what should u rule out
Polumorphic Eruption Pregnancy
pemphigoid gestations
Ix for obstetric cholestasis
- LFT and Bile acid
- Viral screen
Hepatitis A, B, and C, Epstein Barr and cytomegalovirus, - Liver autoimmune screen
chronic active hepatitis and primary biliary cirrhosis
anti-smooth muscle and antimitochondrial antibodies
USS abdomen –Liver and Gall stones
what will be seen in OC Ix
- Elevated transaminases
- Alkaline phosphatase
- Raised gamma-glutamyl transferases
- Mild elevation in bilirubin
- Primary bile acids increased up to 100 fold
maternal risks of O Cholestasis
Vit K deficiency - disturbs coagulation pathway
increased risk of PPH
fetal risks of OC
- Perinatal mortality is increased to up to 11%
- Fetal distress
- Meconium
- Preterm labour
- Intracranial haemorrhage
- Stillbirth
No effective fetal monitoring available!!
what are the procoagulant pathophysiological changes in pregnancy
- Hypercoagulable state
- Increase in fibrinogen and factors VIII, IX and X
- Concentration of endogenous anticoagulants decreases
- Additional risk is present for at least 6 weeks postpartum
- Venous stasis in lower limbs
- Trauma of pelvic veins at the time of delivery
pre-existing risk factors of thromboembolism
- Obesity BMI>30
- Age>35
- Parity>3
- Smoking
- Gross varicose veins
- Paraplegia
- Medical comorbidities
- Thrombophilia
- Previous VTE
obstetric RFs of thromboembolism
Multiple pregnancy PET CS Prolonged labour >24 hrs Mid-cavity or rotational operative delivery Still birth Preterm birth PPH>1L
new onset reversible factors of thromboembolism
Bone fracture Surgical procedure in pregnancy and puerperium Hyperemesis, dehydration OHSS/ART Immobility >3 days Long Haul travel >4 hours Current systemic infection
gold standard Ix of DVT
venography with fetal shield
Ix for PE
Chest X-ray
often -normal but excludes other causes of breathlessness
may - atelectasis, wedge shaped infarction, pleural effusion
ECG may only show sinus tachycardia, the classical S1Q3 T3 is rare
There may be Leukocytosis
Arterial blood gases may show hypocapnia +/- hypoxaemia
Oxygen saturation may fall 3-4% after exercise
diagnosis can be made w which Ix
lung scan
first line Ix for DVTq
doppler
suspect PE what do u do
– clinical assessment
– perform CXR and ECG
– test FBC, U&E, LFTs
– commence LMWH
(unless treatment is contraindicated)
- Duplex USS for S/S of DVT
- VQ scan if chest x-ray normal
- CTPA if chest x-ray abnormal
Mx of PE
- Full anticoagulation with low molecular weight Heparin, e.g. Dalteparin, /Enoxaparin
- TEDS
- Leg care advice
- Advice re need for future prophylaxis for
pregnancy, surgery, flying etc. - In high risk cases consider vena cava filters
what is given to women who have epilepsy and want to get pregnant
Epilepsy + pregnancy = 5mg folic acid before conception to reduce neural tube defects
what is sodium valporate carbamazepine phenytoin lamotrigine ass w
sodium valproate: associated with neural tube defects
carbamazepine: often considered the least teratogenic of the older antiepileptics
phenytoin: associated with cleft palate
lamotrigine: studies to date suggest the rate of congenital malformations may be low. The dose of lamotrigine may need to be increased in pregnancy
what is given to pregnant women taking phenytoin
Vitamin K
prevent clotting disorders in the newborn
associated factors of placental abruption
proteinuric hypertension cocaine use multiparity maternal trauma increasing maternal age
what is the hyperemesis gravidarum triad and this is the diagnosis
5% pre-pregnancy weight loss
dehydration
electrolyte imbalance
when is hyperemesis gravidarum common
between 8-12 weeks may persist upto 20 weeks
hyperemesis gravidarum ass
- multiple pregnancies
- trophoblastic disease
- hyperthyroidism
- nulliparity
- obesity
what is the referral criteria for N&V in pregnancy
- Continued nausea and vomiting and is unable to keep down liquids or oral antiemetics
- Continued nausea and vomiting with ketonuria and/or weight loss (greater than 5% of body weight), despite treatment with oral antiemetics
- A confirmed or suspected comorbidity (for example she is unable to tolerate oral antibiotics for a urinary tract infection)
what is used to classify the severity of nausea and vomitng of pregnancy
Pregnancy-Unique Quantification of Emesis (PUQE)
Mx for hyperemesis gravidarum
1) antihistamines - promethazine
cyclizine
2) ondansetron and metoclopramide
- extrapyramidal side effects
complications of hyperemesis gravidarum
Wernicke's encephalopathy Mallory-Weiss tear central pontine myelinolysis acute tubular necrosis fetal: small for gestational age, pre-term birth
in first week of life if breastfeeding baby loses more than 10% of weight what do u do
breastfeeding clinic
common breastfeeding problems and their Mx
mastitis
mx - flucoxacillin for 10-14 days
engorgement
mx - just give milk
raynauds
- no caffein no smoking
heat packs
what is extrapyramidal side effects
drug-induced movement disorders
Ix for hyperemesis gravidarum
- urine dipstick -> ketonuria
- MSU
- U&Es - hypokalaemia, hyponatraemia, dehydration, renal disease
FBC - infection, anaemia, haematocrit
Glucose - DKA
US scan - confirm viable intrauterine pregnancy - exclude multiple pregnancy and trophoblastic disease
TFTS, LFTs, calcium and phosphate, amylase: exclude pancreatitis
ABG
what is oligohydraminos
reduced amniotic fluid
<500 ml at 32-36 weeks
AFI <5TH PERCENTILE
Causes of oligohydraminos
fetal Chromosomal factors. Congenital factors. Intrauterine growth restriction. Post-term pregnancy. Premature ROM (PROM). Fetal demise.
placental
abruption
twin-to-twin transfusion syndrome
maternal Maternal dehydration. Uteroplacental insufficiency. Hypertension. Pre-eclampsia. Diabetes (either pre-existing or gestational diabetes). Chronic hypoxia.
indometacin adn ACE inhibitors
idiopathic
Mx of VTE
- Four or more risk factors warrants immediate treatment with low molecular weight heparin continued until six weeks postnatal.
If a woman has three risk factors low molecular weight heparin should be initiated from 28 weeks and continued until six weeks postnatal.
If diagnosis of DVT is made shortly before delivery, continue anticoagulation treatment for at least 3 month, as in other patients with provoked DVTs.
what Mx should be avoided in pregnancy
DOAC
warfarin
which antiepileptic safe in pregnancy and is not
Levetiracetam, lamotrigine and carbamazepine
NOT
sodium valporate
phenytoin
pre-eclampsia predisposes u to
fetal: prematurity, intrauterine growth retardation
eclampsia
haemorrhage: placental abruption, intra-abdominal, intra-cerebral
cardiac failure
multi-organ failure
what is rubella
German measles. Congenital rubella syndrome is caused by maternal infection with the rubella virus during the first 20 weeks of pregnancy. The risk is highest before ten weeks gestation.
MMR vaccine if in doubt test for rubella immunity
can be vaccinated with two doses of the MMR three months apart before conception NOT PREGNANT
features of congential rubella syndrome
Congenital deafness
Congenital cataracts
Congenital heart disease (PDA and pulmonary stenosis)
Learning disability
what is listeria
infectious gram-positive bacteria that causes listeriosis.
high rate of miscarriage or fetal death. It can also cause severe neonatal infection.
transmitted by unpasteurised dairy products, processed meats and contaminated foods. Pregnant women are advised to avoid high-risk foods (e.g. blue cheese) and practice good food hygiene.
features of CMV
Fetal growth restriction Microcephaly Hearing loss Vision loss Learning disability Seizures
virus is mostly spread via the infected saliva or urine of asymptomatic children
features of toxoplasmosis
Intracranial calcification
Hydrocephalus
Chorioretinitis (inflammation of the choroid and retina in the eye)
faeces from a cat that is a host of the parasite
what is parvovirus B19
features
ifth disease, slapped cheek syndrome and erythema infectiosum
self limiting -> rash and symptoms usually fade over 1 – 2 weeks.
on-specific viral symptoms. After 2 – 5 days, the rash appears quite rapidly as a diffuse bright red rash on both cheeks, as though they have “slapped cheeks”. A few days later a reticular mildly erythematous rash affecting the trunk and limbs appears, which can be raised and itchy. Reticular means net-like.
complications of parvovirus B19
Miscarriage or fetal death
Severe fetal anaemia - infects the erythroid progenitor cells in the fetal bone marrow and liver
Hydrops fetalis (fetal heart failure)
Maternal pre-eclampsia-like syndrome -> hydrops fetalis, placental oedema and oedema in the mother. It also features hypertension and proteinuria.
Ix for parvovirus B19
IgM to parvovirus, which tests for acute infection within the past four weeks
IgG to parvovirus, which tests for long term immunity to the virus after a previous infection
Rubella antibodies (as a differential diagnosis)
Zika virus
Aedes mosquitos
spread by sex with someone infected with the virus.
Microcephaly
Fetal growth restriction
Other intracranial abnormalities, such as ventriculomegaly and cerebellar atrophy
Mx
viral PCR and ABs to the zika virus
how should OC be monitored
Once obstetric cholestasis is diagnosed, it is reasonable to measure LFTs weekly until
delivery.
Postnatally, LFTs should be deferred for at least 10 days
