O&G: Antenatal care Flashcards
1
Q
pregnancy timeline
definition of Gestational Age
A
the duration of the pregnancy starting from the date of the last menstrual period
2
Q
pregnancy timeline
definition of Gravida
A
the total number of pregnancies a woman has had
3
Q
pregnancy timeline
definition of para
A
the number of times the woman has given birth after 24w gestation, regardless of whether the fetus was alive or stillborn
4
Q
pregnancy timeline
G4P3
A
a pregnant woman with 3 previous pregnancies
5
Q
pregnancy timeline
a non pregnancy woman with a previous birth of healthy twins
A
G1P1
6
Q
pregnancy timeline
A non-pregnant woman with a previous miscarriage
A
G1 P0 +1
7
Q
pregnancy timeline
A non-pregnant woman with a previous stillbirth (after 24 weeks gestation)
A
G1P1
8
Q
pregnancy timeline
when is the 1st trimester
A
from the start of pregnancy until 12w gestation
9
Q
pregnancy timeline
when is the 2nd trimester
A
13-26w gestation
10
Q
pregnancy timeline
when is the 3rd trimester
A
from 27w - birth
11
Q
pregnancy timeline
when do fetal movements start
A
from around 20w until birth
12
Q
pregnancy timeline
when is the Booking clinic and what is its purpose
A
before 10w
offer a baseline assessment and plan the pregnancy
13
Q
pregnancy timeline
when is the Dating scan
A
between 10 and 13+6
14
Q
pregnancy timeline
what is the purpose of the dating scan
A
- an accurate gestational age is calculated from the crown rump length (CRL)
- and multiple pregnancies are identified
15
Q
pregnancy timeline
when is first antenatal appointment and whats its purpose
A
16w
discuss results + plan future appointments
16
Q
pregnancy timeline
when is the anomaly scan
A
between 18 and 20+6 weeks
17
Q
pregnancy timeline
what is the purpose of the anomaly scan
A
an US to identify anomalies such as heart conditions
18
Q
pregnancy timeline
when are the antenatal appointments and what are they for
A
25, 28, 31, 34, 36, 38, 40, 41 and 42 weeks
monitor the pregnancy and discuss future plans
19
Q
pregnancy timeline
what is covered at each antenatal appointment
A
- plans for remainder of the pregnancy + delivery
- symphysis-fundal height: from 24w on
- fetal presentation: from 36w on
- urine dipstick for protein for pre-eclampsia
- blood pressure for pre-eclampsia
- urine for M+C for asymptomatic bacteriuria
20
Q
pregnancy timeline
what vaccines are offered to all pregnant women
A
- Whooping cough (pertussis) from 16w gestation
- Influenza (flu) when available in autumn or winter
21
Q
pregnancy timeline
what vaccines are avoided in pregnancy
A
live vaccines such as the MMR
22
Q
Placenta praevia
definition
A
when the placenta is over the internal cervical os
23
Q
Placenta praevia
definition of a low-lying placenta
A
when the placenta is within 20mm of the internal cervical os
24
Q
3 causes of antepartum haemorrhage
A
placenta praevia
placental abruption
vasa praevia
25
Placenta praevia
risks
- antepartum haemorrhage
- emergency caesarean section
- emergency hysterectomy
- maternal anaemia + transfusions
- preterm birth and low birth weight
- stillbirth
26
Placenta praevia
Grade 1 or Minor praevia
placenta is in the lower uterus but not reaching the internal cervical os
27
Placenta praevia
grade 2 or marginal praevia
the placenta is reaching, but not covering the internal cervical os
28
Placenta praevia
grade 3 or partial praevia
the placenta is partially covering the internal cervical os
29
Placenta praevia
grade 4 or complete praevia
the placenta is completely covering the internal cervical os
30
Placenta praevia
the grading system is outdates, what 2 descriptions are now used
low-lying placenta
placenta praevia
31
Placenta praevia
RFs (6)
- previous caesarean sections
- previous placenta praevia
- older maternal age
- maternal smoking
- structural uterine abnormalities (e.g. fibroids)
- assisted reproduction (e.g. IVF)
32
Placenta praevia
dx
the 20w anomaly scan is used to assess the position of the placenta and diagnose placenta praevia
33
Placenta praevia
presentation
- many are asymptomatic
- painless vaginal bleeding in pregnancy (antepartum haemorrhage)
bleeding usually occurs later around 36w
34
Placenta praevia
mnx of a low-lying placenta or placenta praevia if diagnosed early
repeat TVUS at 32 and 36w
35
Placenta praevia
mnx of low-lying placenta or placenta praevia
corticosteroids given between 34 and 35+6 w
planned caesarean considered between 36 and 37w
36
Placenta praevia
why is delivery planned early
to reduce the risk of spontaneous labour and bleeding
37
Placenta praevia
when may emergency caesarean section be required
with premature labour or antenatal bleeding
38
Placenta praevia
what is the main complication
haemorrhage before, during and after delivery
39
Placenta praevia
what urgent mnx may be required after a haemorrhage
- Emergency caesarean section
- Blood transfusions
- Intrauterine balloon tamponade
- Uterine artery occlusion
- Emergency hysterectomy
40
Vasa praevia
what is it
a condition where the fetal vessels are within the fetal membranes (chorioamniotic membranes) and travel across the internal cervical os
41
Vasa praevia
what do the fetal vessels consist of
2 umbilical arteries
| 1 umbilical vein
42
Vasa praevia
what does the fetal membrane surround
the amniotic cavity and developing fetus
43
Vasa praevia
what does the umbilical cord contain
the fetal vessels:
2 umbilical arteries
1 umbilical vein
Wharton's jelly
44
Vasa praevia
what is Wharton's jelly
a layer of soft connective tissue that surrounds the blood vessels in the umbilical cord, offering protection
45
Vasa praevia
when can the fetal vessels be exposed, outside the protection of the umbilical cord or placenta
- Velamentous umbilical cord: umbilical cord inserts into the chorioamniotic membranes and the fetal vessels travel unprotected through the membranes before joining the placenta
- an accessory lobe of the placenta (aka succenturiate lobe) is connected by fetal vessels that travel through the chorioamniotic membranes between the placental lobes
46
Vasa praevia
what can exposed vessels leads to
prone to bleeding esp when membranes are ruptures during labour and at birth --> fetal blood loss + death
47
Vasa praevia
what is Type 1
the fetal vessels are exposed as a velamentous umbilical cord
48
Vasa praevia
what is Type 2
the fetal vessels are exposed as they travel to an accessory placental lobe
49
Vasa praevia
RFs
- low lying placenta
- IVF pregnancy
- Multiple pregnancy
50
Vasa praevia
dx
US during pregnancy
but may present with bleeding
51
Vasa praevia
asymptomatic mnx
- corticosteroids, given from 32w gestation to mature the fetal lung
- elective caesarean section planned for 34-36w
52
Vasa praevia
mnx if antepartum haemorrhage occurs
emergency caesarean section is required to deliver the fetus before death occurs
53
Vasa praevia
after stillbirth or unexplained fetal compromise during deliver, why is the placenta examined
for evidence of vasa praevia as a possible cause
54
Placental Abruption
what is it
when the placenta separates from the wall of the uterus during pregnancy
the site of the attachment can bleed extensively after the placenta separates
a significant cause of antepartum haemorrhage
55
Placental Abruption
RFs
- Previous placental abruption
- Pre-eclampsia
- Bleeding early in pregnancy
- Trauma (consider domestic violence)
- Multiple pregnancy
- Fetal growth restriction
- Multigravida
- Increased maternal age
- Smoking
- Cocaine or amphetamine use
56
Placental Abruption
presentation (5)
- Sudden onset severe abdominal pain that is continuous
- Vaginal bleeding (antepartum haemorrhage)
- Shock (hypotension and tachycardia)
- Abnormalities on the CTG indicating fetal distress
- Characteristic “woody” abdomen on palpation, suggesting a large haemorrhage
57
Placental Abruption
what suggests a large haemorrhage
characteristic 'woody' abdo on palpation
58
Placental Abruption
how can the severity of antepartum haemorrhage be defined
- spotting
- minor haemorrhage
- major haemorrhage
- massive haemorrhage
59
Placental Abruption
what is spotting
spots of blood noticed on underwear
60
Placental Abruption
what is a minor haemorrhage
<50ml of blood loss
61
Placental Abruption
what is a major haemorrhage
50-1000ml blood loss
62
Placental Abruption
what is a massive haemorrhage
>1000ml blood loss or signs of shock
63
Placental Abruption
what is a concealed abruption
where the cervical os remains closed
and any bleeding that occurs remains within the uterine cavity
the severity of bleeding can be significantly underestimated with it
64
Placental Abruption
dx
clinical diagnosis based on presentation
65
initial mnx steps with major or massive haemorrhages
- Urgent involvement of a senior obstetrician, midwife and anaesthetist
- 2 x grey cannula
- Bloods include FBC, UE, LFT and coagulation studies
- Crossmatch 4 units of blood
- Fluid and blood resuscitation as required
- CTG monitoring of the fetus
- Close monitoring of the mother
- emergency caesarean if mother unstable or fetal distress
66
Placental Abruption
what is required when bleeding occurs in Rhesus-D negative women
anti-D prophylaxis
Kleihauer test is used to quantify how much fetal blood is mixed with the maternal blood to determine the dose of anti-D required
67
Placental Abruption
what is there an increased risk of after delivery in women with placental abruption
postpartum haemorrhage
active mnx of the 3rd stage is recommended
68
Placenta Accreta
what is it
when the placenta implants deeper, through and past the endometrium,
making it difficult to separate the placenta after delivery
69
Placenta Accreta
what are the 3 layers to the uterine wall
- endometrium (inner layer)
- myometrium (middle)
- perimetrium (outer)
70
Placenta Accreta
what does the endometrium contain
connective tissue (stroma)
epithelial cells
blood vessels
71
Placenta Accreta
what does the myometrium contain
smooth muscle
72
Placenta Accreta
what does the perimetrium contain
a serous membrane similar to the peritoneum (aka serosa)
73
Placenta Accreta
why might the placenta embed past the endometrium
due to a defect in the endometrium:
- previous uterine surgery: C-section or curettage procedure
74
Placenta Accreta
why might it lead to a postpartum haemorrhage
the deep implantation makes it very difficult for the placenta to separate during delivery leading to extensive bleeding
75
Placenta Accreta
what is superficial placenta accreta
the placenta implants in the surface of the myometrium, but not beyond
76
Placenta Accreta
what is placenta increta
where the placenta attaches deeply into the myometrium
77
Placenta Accreta
what is placenta percreta
where the placenta invaded past the myometrium and perimetrium, potentially reaching other organs such as the bladder
78
Placenta Accreta
RFs (6)
- previous placenta accreta
- previous endometrial curettage procedures (e.g. for miscarriage or abortion)
- previous caesarean section
- multigravida
- increased maternal age
- low lying placenta or placenta praevia
79
Placenta Accreta
presentation
usually asymptomatic during pregnancy
can present with bleeding (antepartum haemorrhage) in the 3rd trimester
80
Placenta Accreta
dx
can be diagnosed on antenatal USS
or at birth when it becomes difficult to deliver the placenta
81
Placenta Accreta
mnx if diagnosed antenatally
plan delivery between 35 to 36+6w
give antenatal steroids
82
Placenta Accreta
what are the options during caesarean section
- hysterectomy: w/ placenta remaining in the uterus (recommended)
- Uterus preserving surgery: resection of part of the myometrium along with the placenta
- expectant mnx: leave the palcenta in place to be reabsorbed over time
83
Placenta Accreta
what risks come with expectant mnx
bleeding and infection
84
Placenta Accreta
if placenta accreta is seem when opening abdo for elective caesarean, what do you do
close abdo and delay delivery whilst specialist services are put in place
85
Placenta Accreta
if placenta accreta is discovered after delivery of the baby, what is recommended
hysterectomy
86
Breech Presentation
what is it
when the presenting part of the fetus is the legs and bottom
87
Breech Presentation
complete breech
legs are fully flexed at the hips and knees
88
Incomplete breech
one leg flexed at the hip and extended at the knee
89
Extended breech
aka frank breech
with both legs flexed at the hip and extended at the knee
90
Footling breech
with a foot is presenting through the cervix with the leg extended
91
Breech Presentation
mnx for babies that are breech before 36w
none as they often turn spontaneously
92
Breech Presentation
when is external cephalic version used in babies that are breech
After 36 weeks for nulliparous women
After 37 weeks in women that have given birth previously
93
Breech Presentation
mnx if the first baby in a twin pregnancy is breech
caesarean section
94
Breech Presentation
what is external cephalic version
a technique used to attempt to turn a fetus from the breech position to a cephalic position using pressure on the pregnant abdomen
95
Breech Presentation
what is given to women before ECV
Tocolysis with SC terbutaline to relax the uterus before the procedure
Rhesus-D negative women require anti-D prophylaxis
96
Breech Presentation
what is terbutaline
a beta-agonist similar to salbutamol.
It reduces the contractility of the myometrium, making it easier for the baby to turn.
97
Pre-eclampsia
what is it
HTN in pregnancy with end-organ dysfunction
notably with proteinuria
98
Pre-eclampsia
how many weeks gestation does it occur
after 20w, when the spiral arteries of the placenta form abnormally
leading to high vascular resistance in these vessels
99
Pre-eclampsia
what can it lead to if untreated
- maternal organ damage
- FGR
- seizures
- early labour
- death
100
Pre-eclampsia
triad features
1. hypertension
2. proteinuria
3. oedema
101
Pre-eclampsia
define chronic HTN
high BP that exists before 20w gestation and is longstanding
not caused by dysfunction in the placenta and is not classed as pre-eclampsia
102
Pre-eclampsia
define pregancy induced HTN or gestational HTN
HTN occurring after 20w gestation
without proteinuria
103
Pre-eclampsia
define eclampsia
when seizures occur as a result of pre-eclampsia
104
Pre-eclampsia
pathophysiology
- high vascular resistance in the spiral arteries
- poor perfusion of the placenta
- causes oxidative stress in the placenta
- and release of inflammatory chemicals into the systemic circulation
- leading to systemic inflammation and impaired endothelial function in the blood vessels
105
Pre-eclampsia
high-risk factors (5)
- pre-existing HTN
- previous HTN in pregnancy
- existing autoimmune condition
- diabetes
- CKD
106
Pre-eclampsia
moderate-risk factors (6)
- >40yrs
- BMI>35
- >10 yrs since previous pregnancy
- multiple pregnancy
- first pregnancy
- FH of pre-eclampsia
107
Pre-eclampsia
why are women offered aspirin
as prophylaxis against pre-eclampsia
108
Pre-eclampsia
when are women offered aspirin
from 12w gestation until birth if they have :
- 1 high-risk factor
or
- >1 moderate-risk factor
109
Pre-eclampsia
symptoms
- headache
- visual disturbance / blurriness
- N+V
- upper abdo or epigastric pain (liver swelling)
- oedema
- reduced urine output
- brisk reflexes
110
Pre-eclampsia
NICE diagnosis
BP >140/>90
plus any of:
- proteinuria
- organ dysfunction
- placental dysfunction
111
Pre-eclampsia
examples of organ dysfunction
- raised Cr
- raised LFTs
- seizures
- thrombocytopenia
- haemolytic anaemia
112
Pre-eclampsia
example of placental dysfunction
fetal growth restriction
abnormal Doppler studies
113
Pre-eclampsia
how can proteinuria be quantified
Urine protein:creatinine ratio (> 30mg/mmol is significant)
Urine albumin:creatinine ratio (>8mg/mmol is significant)
114
Pre-eclampsia
what test should be used between 20-35w gestation to rule out pre-eclampsia
placental growth factor (PlGF)
115
Pre-eclampsia
what is placental growth factor
a protein released by the placenta that functions to stimulate the development of new blood vessels
116
Pre-eclampsia
what are the levels of placental growth factor in pre-eclampsia
low
117
Pre-eclampsia
mnx of gestational HTN (without proteinuria)
- aim for BP< 135/85
- weekly urine dipstick
weekly blood tests
- monitor fetal growth by serial growth scans
- placental growth factor testing on one occasion
118
Pre-eclampsia
at what BP should you admit a woman with gestational HTN
>160/110
119
Pre-eclampsia
what scoring system is used to determine whether to admit the woman with Pre-eclampsia
fullPIERS or PREP-S
120
Pre-eclampsia
monitoring for pre-eclamptic women
- BP monitoring every 48h
| - fortnightly US monitoring
121
Pre-eclampsia
1st line medical mnx
labetalol
122
Pre-eclampsia
2nd line medical mnx
nifedipine (modified-release)
123
Pre-eclampsia
3rd line medical mnx
methyldopa (stop within 2d of birth)
124
Pre-eclampsia
what may be used as an antihypertensive in critical care in severe pre-eclampsia or eclampsia
IV hydralazine
fluid restriction
125
Pre-eclampsia
what is given during labour and in the 24h afterwards to prevent seizures
IV magnesium sulphate
126
Pre-eclampsia
after delivery, what medical mnx should be used
one or a combination of:
1st line: enalapril
1st line in black pts: nifedipine
3rd line: labetalol or atenolol
127
Pre-eclampsia
mnx of eclampsia
IV magnesium sulphate
128
Pre-eclampsia
what is HELLP syndrome
a combination of features that occurs as a complication of pre-eclampsia and eclampsia
Haemolysis
Elevated Liver enzymes
Low Platelets
129
Obstetric Cholestasis
aka?
intrahepatic cholestasis of pregnancy.
130
Obstetric Cholestasis
what does chole- mean
relates to the bile and bile ducts.
131
Obstetric Cholestasis
what does stasis refer to
inactivity
132
Obstetric Cholestasis
what is it characterised by
the reduced outflow of bile acids from the liver
133
Obstetric Cholestasis
how is this condition resolved
after the delivery of the baby
134
Obstetric Cholestasis
when does it develop in pregnancy
late (after 28w)
135
Obstetric Cholestasis
cause?
thought to be a result of increased oestrogen and progesterone levels
136
Obstetric Cholestasis
RFs
seems to be a genetic component
more common in women of South Asian ethnicity
137
Obstetric Cholestasis
where do bile acids come from
produced in the liver from the breakdown of cholesterol
138
Obstetric Cholestasis
where do bile acids flow
from the liver
to the hepatic ducts
past the gallbladder
out the bile duct
to the intestines
139
Obstetric Cholestasis
what causes the classic symptom of pruritis
outflow of bile acids is reduced, causing them to build up in the blood
resulting in itch
140
Obstetric Cholestasis
what does it increase the risk of
stillbirth
141
Obstetric Cholestasis
where does the pruritis affect
palms of the hands
soles of the feet
142
Obstetric Cholestasis
sx
- pruritis
- fatigue
- dark urine
- pale, greasy stools
- jaundice
143
Obstetric Cholestasis
is there a rash
no! consider polymorphic eruption of pregnancy or pemphigoid gestationis
144
Obstetric Cholestasis
DDx and other causes of pruritus and deranged LFTs
- gallstones
- acute fatty liver
- autoimmune hepatitis
- viral hepatitis
145
Obstetric Cholestasis
inx and results
- abnormal LFTs (ALT, AST, GGT)
| - raised bile acids
146
Obstetric Cholestasis
which LFT is normal to be raised in pregnancy and why
ALP because the placenta produces it
147
Obstetric Cholestasis
primary trx
ursodeoxycholic acid improves LFTs, bile acids and sx
148
Obstetric Cholestasis
how may the itch be managed
- emollients (calamine lotion)
| - antihistamines (chlorphenamine) can help sleep but not improve itch
149
Obstetric Cholestasis
why can there be impaired clotting of blood
bile acids are important in the absorption of fat-soluble vitamins (vit K) in the intestines
a lack of bile acids can lead to vit K deficiency
Vit K is an important part of the clotting system
150
Obstetric Cholestasis
what can be given if prothrombin time is deranged
water-soluble vit K
151
Obstetric Cholestasis
monitoring mnx
weekly LFTs during pregnancy and after at least 10d
to ensure condition does not worsen and resolve after birth
152
Obstetric Cholestasis
what mnx aims to reduce the risk of stillbirth
planned delivery after 37w
153
Polymorphic Eruption of Pregnancy
aka?
pruritic and urticarial papules and plaques of pregnancy
154
Polymorphic Eruption of Pregnancy
what is it
an itchy rash that tends to start in the 3rd trimester
155
Polymorphic Eruption of Pregnancy
where does it usually begin
on the abdomen
156
Polymorphic Eruption of Pregnancy
what is it usually associated with
stretch marks (striae)
157
Polymorphic Eruption of Pregnancy
characteristics (3)
- urticarial papules
- wheals
- plaques
158
Polymorphic Eruption of Pregnancy
what are urticarial papules
raised itchy lumps
159
Polymorphic Eruption of Pregnancy
what are wheals
raised itchy areas of skin
160
Polymorphic Eruption of Pregnancy
what are plaques
larger inflamed areas of skin
161
Polymorphic Eruption of Pregnancy
when will it get better
towards the end of pregnancy and after delivrey
162
Polymorphic Eruption of Pregnancy
mnx
control sx with:
- topical emollients
- topical steroids
- oral antihistamines
163
Polymorphic Eruption of Pregnancy
what may be used as mnx in severe cases
oral steroids
164
Atopic Eruption of Pregnancy
what is it
eczema that flares up during pregnancy
165
Atopic Eruption of Pregnancy
when does it appear in pregnancy
in the 1st and 2nd trimester
166
Atopic Eruption of Pregnancy
what are the 2 types
- E-type or eczema type
| - P-type or prurigo-type
167
Atopic Eruption of Pregnancy
features of E-type (eczema type)
- eczematous, inflamed, red itchy skin
| - insides of elbows, back of legs, neck, face, chest
168
Atopic Eruption of Pregnancy
features of P-type (prurigo-type)
- intensely itchy papules (spots)
| - abdo, back, limbs
169
Atopic Eruption of Pregnancy
when will it get better
after delivery
170
Atopic Eruption of Pregnancy
mnx
- topical emollients
| - topical steroids
171
Atopic Eruption of Pregnancy
mnx of severe cases
- phototherapy with UVB
| - oral steroids
172
Melasma
aka
mask of pregnancy
173
Melasma
what is it characterized by
increased pigmentation to patches of the skin on the face
symmetrical and flat
affecting sun-exposed areas
174
Melasma
cause
though to be due to the increased female sex hormones associated with pregnancy
175
Melasma
apart from pregnancy, when else can it occur
in pts on COCP or HRT
176
Melasma
what is it associated with
- sun exposure
- thyroid disease
- FH
177
Melasma
mnx
- avoid sun exposure, use suncream
- makeup
- no active trx required
178
Pyogenic Granuloma
aka
lobular capillary haemangioma.
179
Pyogenic Granuloma
what is it
a benign, rapidly growing tumour of capillaries
180
Pyogenic Granuloma
presentation
- rapidly growing lump that develops over days to 1-2cm in size
- red or dark
181
Pyogenic Granuloma
whom do they occur more often
- pregnant ladies
| - pts on hormonal contraceptives
182
Pyogenic Granuloma
triggers
- minor trauma
| - infection
183
Pyogenic Granuloma
where do they occur
on fingers
upper chest, back, neck or head
184
Pyogenic Granuloma
if injured, what may happen
profuse bleeding and ulceration
185
Pyogenic Granuloma
what DDx needs to be excluded
malignancy esp nodular melanoma
186
Pyogenic Granuloma
trx
usually resolve without trx after delivery
surgical removal
187
Pyogenic Granuloma
confirmation of dx
histology
188
Pemphigoid Gestationis
what is it
a rare autoimmune skin condition that occurs in pregnancy
189
Pemphigoid Gestationis
pathophysiology
- autoantibodies destroy connection between the epidermis and dermis
- epidermis and dermis seperate
- creating a space that can be filled with fluid
- resulting in large fluid-filled blisters (bullae)
190
Pemphigoid Gestationis
why does the pregnant woman's immune system produce these autoantibodies
in response to placental tissue
191
Pemphigoid Gestationis
when does it usually occur
in the 2nd or 3rd trimester
192
Pemphigoid Gestationis
typical presentation
initially with an itchy red papular or blistering rash around the umbilicus
then spreads to other parts of the body
over several weeks, large fluid-filled blisters form
193
Pemphigoid Gestationis
trx
- usually resolves without trx after delivery
| - topical emollients and steroids
194
Pemphigoid Gestationis
mnx in severe cases
- oral steroids
| - immunosuppressant where steroids are inadequate
195
Pemphigoid Gestationis
what may be required if infection occurs
abx
196
Pemphigoid Gestationis
risks to the baby
- fetal growth restriction
- preterm delivery
- blistering rash after delivery
197
Pemphigoid Gestationis
why may the baby have a blistering rash after delivery
the maternal antibodies pass to the baby
198
Acute fatty liver of pregnancy
which trimester does it occur
3rd
199
Acute fatty liver of pregnancy
what is it
rapid accumulation of fat within hepatocytes causing acute hepatitis
high risk of liver failure and mortality, for both the mother and fetus.
200
Acute fatty liver of pregnancy
pathophysiology
impaired processing of fatty acids in the placenta.
These fatty acids enter the maternal circulation, and accumulate in the liver.
result of a genetic condition in the fetus that impairs fatty acid metabolism.
201
Acute fatty liver of pregnancy
most common cause
long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency in the fetus
an autosomal recessive condition
202
Acute fatty liver of pregnancy
what is the LCHAD enzyme important for
fatty acid oxidation
| breaking down fatty acids to be used as fuel.
203
Acute fatty liver of pregnancy
presentation
hepatitis sx:
- General malaise and fatigue
- N+V
- Jaundice
- Abdominal pain
- Anorexia
- Ascites
204
Acute fatty liver of pregnancy
what will LFTs show
elevated ALT + AST
205
Ddx of elevated liver enzymes and low platelets
HELLP syndrome
Acute fatty liver of pregnancy
206
Acute fatty liver of pregnancy
mnx
emergency
prompt delivery
207
Gestational Diabetes
what is it caused by
reduced insulin sensitivity during pregnancy and resolves after birth
208
Gestational Diabetes
what is the most significant immediate complication
- large for dates fetus
- macrosomia
which increases risk of sholder dystocia
209
Gestational Diabetes
woman has RFs, what test should she have
oral glucose tolerance test at 24 – 28 weeks gestation
210
Gestational Diabetes
RFs that warrant testing with OGTT
- previous gestational diabetes
- previous macrosomic baby (≥ 4.5kg)
- BMI > 30
- black carribbean, middle eastern, south asian
- 1st degree relative with diabetes
211
Gestational Diabetes
what features may suggest gestational diabetes
- large for dates fetus
- polyhydramnios (increased amniotic fluid)
- glucose on urine dipstick
212
Gestational Diabetes
how is an OGTT performed
- measure blood sugar levels (fasting)
- drink 75g glucose
- measure blood sugar levels 2h later
213
Gestational Diabetes
what are normal results for the OGTT
Fasting: < 5.6 mmol/l
At 2 hours: < 7.8 mmol/l
214
Gestational Diabetes
counselling
- explain condition
- learn how to monitor and track their blood sugar levels
- 4 weekly USS to monitor fetal growth and amniotic fluid volume from 28-36w gestation
215
Gestational Diabetes
mnx if fasting glucose <7
trial of diet and exercise for 1-2 weeks
followed by metformin, then insulin
216
Gestational Diabetes
mnx if fasting glucose >7
start insulin ± metformin
217
Gestational Diabetes
mnx if fasting glucose >6 plus macrosomia (or other complications)
start insulin ± metformin
218
Gestational Diabetes
what medication is an option for women who decline insulin or cannot tolerate metformin
Glibenclamide (a sulfonylurea)
219
Gestational Diabetes
what are the blood sugar level targets
- Fasting: 5.3 mmol/l
- 1 hour post-meal: 7.8 mmol/l
- 2 hours post-meal: 6.4 mmol/l
- Avoiding levels of 4 mmol/l or below
220
Gestational Diabetes
what should women with existing diabetes take before coming pregnant
5mg folic acid from preconception until 12 weeks gestation.
221
Gestational Diabetes
what should women with existing T1 and T2 DM aim for in insulin levels
the same target insulin levels as with gestational diabetes
222
Gestational Diabetes
how are women with T2 managed
metformin and insulin
other PO diabetic meds should be stopped
223
Gestational Diabetes
Pre-Existing Diabetes: what screening shortly after booking and at 28 weeks gestation.
Retinopathy screening
224
Gestational Diabetes
Pre-Existing Diabetes: when should delivery occur
NICE (2015) advise a planned delivery between 37 and 38 + 6 weeks
225
Gestational Diabetes
when should delivery occur
can give birth up to 40 + 6
226
Gestational Diabetes
when is a sliding-scale insulin regime considered during labour
women with type 1 diabetes.
women with poorly controlled blood sugars with gestational or type 2 diabetes.
227
Gestational Diabetes
when can women stop their diabetic medication
immediately after birth
228
Gestational Diabetes
when do they need follow up after birth
after at least six weeks
229
Gestational Diabetes
after birth what should women with pre existing diabetes do
lower their insulin doses and be wary of hypoglycaemia in the postnatal period.
230
Gestational Diabetes
what are babies at risk of
- Neonatal hypoglycaemia
- Polycythaemia (raised haemoglobin)
- Jaundice
- Congenital heart disease
- Cardiomyopathy
231
Gestational Diabetes
when may babies need IV dextrose or nasogastric feeding
if their blood sugar <2
232
Gestational Diabetes
why may babies develop neonatal hypoglycaemia
Babies become accustomed to a large supply of glucose during the pregnancy, and after birth they struggle to maintain the supply they are used to with oral feeding alone.
233
Rubella
features of congenital rubella syndrome
- deafness
- cataracts
- heart disease: PDA + pulmonary stenosis
- learning disability
234
Rubella
aka
German measles
235
Rubella
what is congenital rubella syndrome caused by
maternal infection with the rubella virus during the first 20w of pregnancy
236
Rubella
woman plans to conceive but unsure if had MMR vaccine. What should you do
test for rubella immunity
if no antibodies, they can be vaccinated with 2 doses of the MMR, 3m apart
237
Rubella
should pregnant women receive the MMR vaccine
no as it's a live vaccine
offer them it after giving birth
238
Chickenpox
which virus is it caused by
varicella zoster virus
239
Chickenpox
what can chickenpox in pregnancy lead to
- more severe cases in mother: varicella pneumonitis, hepatitis or encephalitis
- fetal varicella syndrome
- severe neonatal varicella infection
240
Chickenpox
what does a woman with positive IgG for VZV indicate
immunity
241
Chickenpox
woman is not immune to VZV, when do you give vaccine
before or after pregnancy
242
Chickenpox
mnx for woman not immune but was exposed to chickenpox
IV varicella immunoglobulins within 10d of exposure as prophylaxis
243
Chickenpox
chickenpox rash starts in pregnancy mnx
PO aciclovir if they present within 24h and >20w gestation
244
Chickenpox
when does congenital varicella syndrome occur
when infection occurs in the first 28 weeks of gestation
245
Chickenpox
features of congenital varicella syndrome
- fetal growth restriction
- microcephaly, hydrocephalus + learning disability
- scars + significant skin changes located in specific dermatomes
- limb hypoplasia (underdeveloped limbs)
- cataracts + inflammation in the eye (chorioretinitis)
246
Listeria
what is it
an infectious gram-positive bacteria that causes listeriosis.
247
Listeria
presentation of listeriosis in mother
- asymptomatic
- flu-like illness
less commonly:
- pneumonia
- meningoencephalitis
248
Listeria
how is listeria typically transmitted
unpasteurised dairy products, processed meats and contaminated foods
249
Listeria
advice for pregnant women to not get listeria
avoid high-risk foods (e.g. blue cheese) and practice good food hygiene.
250
Listeria
Listeriosis in pregnant women has a high rate of?
- miscarriage
- fetal death
- severe neonatal infection.
251
Congenital Cytomegalovirus
why does it occur
cytomegalovirus (CMV) infection in the mother during pregnancy.
252
Congenital Cytomegalovirus
how is CMV spread
via the infected saliva or urine of asymptomatic children
253
Congenital Cytomegalovirus
features
- Fetal growth restriction
- Microcephaly
- Hearing loss
- Vision loss
- Learning disability
- Seizures
254
Congenital Toxoplasmosis
how is it spread
contamination with faeces from a cat that is a host of the parasite, Toxoplasma gondii
255
Congenital Toxoplasmosis
classic triad
- intracranial calcification
- hydrocephalus
- chorioretinitis (choroid and retina in the eye)
256
Parvovirus B19
aka
fifth disease
slapped cheek syndrome
erythema infectiosum
257
Parvovirus B19
what is significant exposure to parvovirus classes as
15 minutes in the same room, or face-to-face contact, with someone that has the virus
258
Parvovirus B19
complications with infection esp in 1st and 2nd trimester
- miscarriage or fetal death
- severe fetal anaemia
- hydrops fetalis (fetal heart failure)
- maternal pre-eclampsia like syndrome
259
Parvovirus B19
why does fetal anaemia occur
parvovirus infection of the erythroid progenitor cells in the fetal bone marrow and liver
these cells usually produce RBCs, but produce faulty ones that have a shorter life span when infected
260
Parvovirus B19
why does hydrops fetalis occur
This anaemia leads to heart failure
261
Parvovirus B19
Maternal pre-eclampsia-like syndrome is also known as?
mirror syndrome
262
Parvovirus B19
presentation of Maternal pre-eclampsia-like syndrome
rare complication of severe fetal heart failure (hydrops fetalis)
- hydrops fetalis
- placental oedema
- oedema in the mother.
- hypertension
- proteinuria
263
Parvovirus B19
women suspected of parvovirus infection need tests for?
- IgM to parvovirus
- IgG to parvovirus
- Rubella antibodies (as a differential diagnosis)
264
Parvovirus B19
why test for IgM
tests for acute infection within the past four weeks
265
Parvovirus B19
why test for IgG
tests for long term immunity to the virus after a previous infection
266
Parvovirus B19
mnx
- supportive
| - referral to fetal medicine to monitor for complications and malformations
267
Zika Virus
how is it spread
by host Aedes mosquitos
sex with someone infected with the virus
268
Zika Virus
what sx may you get if infected
no symptoms, minimal symptoms, or a mild flu-like illness
269
Zika Virus
presentation of congenital Zika syndrome
- microcephaly
- fetal growth restriction
- other intracranial abnormalities: ventriculomegaly and cerebella atrophy
270
Zika Virus
Pregnant women that may have contracted the Zika virus should be tested with?
viral PCR and antibodies to the Zika virus.
271
Zika Virus
mnx for postive women
referred to fetal medicine for close monitoring
no trx for virus
272
Rhesus incompatibility
what does it mean when she is rhesus negative
she doesn't have the rhesus-D antigen present on her RBC surface
273
Rhesus incompatibility
trx with rhesus-D positive women
none
274
Rhesus incompatibility
what does it mean that the mother has become sensitised to rhesus-D antigens
rhesus-D negative woman with rhesus positive child
mother recognise this rhesus-D antigen as foreign, and produce antibodies to the rhesus-D antigen
275
Rhesus incompatibility
what is haemolytic disease of the newborn
sensitised mother's anti-rhesus-D antibodies can cross the placenta into the fetus
attacks fetus' RBCs (haemolysis)
276
Rhesus incompatibility
how does anti-D injections work
it attaches to rhesus-D antigens on the fetal red blood cells in the mothers circulation, causing them to be destroyed.
mother doesn't become sensitised
277
Rhesus incompatibility
mnx
Anti-D injection routinely:
- at 28w gestation
- birth (if baby is found to be rhesus-positive)
278
Rhesus incompatibility
when else should Anti-D injections be given
at any time where sensitisation may occur:
- antepartum haemorrhage
- amniocentesis procedures
- abdo trauma
within 72h
279
Rhesus incompatibility
what test is performed to see how much fetal blood has passed into the mother’s blood, to determine whether further doses of anti-D are required.
Kleinhauer test
280
Rhesus incompatibility
when is the Kleihauer Test performed
after any sensitising event past 20 weeks gestation
281
Rhesus incompatibility
what does the Kleihauer Test involve
- add acid to sample of mother's blood
- fetal Hb is more resistant to acid so they are protected agaisnt acidosis that occurs around childbirth
- fetal Hb persists while mother Hb is destroyed
- number of cells still containing Hb (the remaining fetal cells) can then be calculated.
282
Small for Gestational Age
definition
a fetus that measures below the 10th centile for their gestational age
283
Small for Gestational Age
what measurements on US are used to assess the fetal size
Estimated fetal weight (EFW)
Fetal abdominal circumference (AC)
284
Small for Gestational Age
what are customised growth charts
used to assess the size of the fetus, based on the mother’s:
Ethnic group
Weight
Height
Parity
285
Small for Gestational Age
definition of severe SGA
when the fetus is below the 3rd centile for their gestational age
286
Small for Gestational Age
definition of low birth weight
birth weight <2.5kg
287
Small for Gestational Age
The causes of SGA can be divided into two categories:
Constitutionally small
Fetal growth restriction (FGR), also known as intrauterine growth restriction (IUGR)
288
Small for Gestational Age
what is FGR/IUGR
small fetus (or a fetus that is not growing as expected)
due to a pathology reducing the amount of nutrients and oxygen being delivered to the fetus through the placenta
289
Small for Gestational Age
difference between SGA and FGR
SGA: the baby is small for the dates, without stating why. could be constitutionally small or FGR
FGR: pathology reducing the amount of nutrients and oxygen being delivered to the fetus through the placenta
290
Small for Gestational Age
cause of FGR can be divided into?
Placenta mediated growth restriction
Non-placenta mediated growth restriction: small due to a genetic or structural abnormality
291
Small for Gestational Age
causes of FGR due to placenta mediated growth restriction
- Idiopathic
- Pre-eclampsia
- Maternal smoking
- Maternal alcohol
- Anaemia
- Malnutrition
- Infection
- Maternal health conditions
292
Small for Gestational Age
causes of FGR due to non-placenta mediated growth restriction
- Genetic abnormalities
- Structural abnormalities
- Fetal infection
- Errors of metabolism
293
Small for Gestational Age
other signs of FGR other than the fetus being SGA
- Reduced amniotic fluid volume
- Abnormal Doppler studies
- Reduced fetal movements
- Abnormal CTGs
294
Small for Gestational Age
short term complications of FGR
- Fetal death or stillbirth
- Birth asphyxia
- Neonatal hypothermia
- Neonatal hypoglycaemia
295
Small for Gestational Age
long term complications of FGR
- CV disease: HTN
- T2 DM
- obesity
- mood + behavioural problems
296
Small for Gestational Age
RFs
- Previous SGA baby
- Obesity
- Smoking
- Diabetes
- Existing hypertension
- Pre-eclampsia
- mother >35 years
- Multiple pregnancy
- Low pregnancy‑associated plasma protein‑A (PAPPA)
- Antepartum haemorrhage
- Antiphospholipid syndrome
297
Small for Gestational Age
monitoring low risk women
- symphysis fundal height monitored at every antenatal appointment from 24w
- plot SFH on customised growth chart
298
Small for Gestational Age
monitoring: when do women get booked for serial growth scans with umbilical artery doppler
- symphysis fundal height is less than the 10th centile
- ≥3 minor RFs
- ≥1 major RFs
- Issues with measuring the symphysis fundal height (e.g. large fibroids or BMI > 35)
299
Small for Gestational Age
monitoring for women at risk or with SGA
serial ultrasound scans measuring:
- Estimated fetal weight (EFW) and abdominal circumference (AC) to determine the growth velocity
- Umbilical arterial pulsatility index (UA-PI) to measure flow through the umbilical artery
- Amniotic fluid volume
300
Small for Gestational Age
mnx
identify cause
- Identifying those at risk of SGA
- Aspirin is given to those at risk of pre-eclampsia
- Treating modifiable risk factors (e.g. stop smoking)
- Serial growth scans to monitor growth
- Early delivery where growth is static, or there are other concerns
301
Anaemia in Pregnancy
when are women routinely screened for anaemia
- Booking clinic
| - 28 weeks gestation
302
Anaemia in Pregnancy
why is anaemia more common
During pregnancy, the plasma volume increases.
This results in a reduction in the haemoglobin concentration.
303
Anaemia in Pregnancy
what are the normal ranges for Hb during pregnancy at
- booking bloods
- 28w gestation
- post partum
- booking bloods >110g/l
- 28w gestation >105
- post partum >100
304
Anaemia in Pregnancy
what may the following indicate:
- low MCV
- normal MCV
- raised MCV
low: iron deficient
normal: physiological anaemia
raised: B12 or folate deficiency
305
Anaemia in Pregnancy
trx for B12 deficinecy
Intramuscular hydroxocobalamin injections
Oral cyanocobalamin tablets
306
Anaemia in Pregnancy
how much folate should pregannt women take
400mcg per day.
unless folate deficient: 5mg/day
307
Anaemia in Pregnancy
mnx for women with a haemoglobinopathy (Thalassaemia and Sickle Cell Anaemia)
high dose folic acid (5mg)
close monitoring
transfusions when required.
308
Stillbirth
definition
the birth of a dead fetus after 24w gestation
it is the result of a intrauterine fetal death
309
Stillbirth
causes
- unexplained (50%)
- pre-eclampsia
- placental abruption
- vasa praevia
- cord prolapse or wrapped around fetal neck
- obstetric cholestasis
- diabetes
- thyroid disease
- infection: rubella, parvovirus, listeria
- genetic abnormalities or congenital malformations
310
Stillbirth
Factors that increase the risk
- FGR
- smoking
- alcohol
- increased maternal age
- maternal obesity
- twins
- sleeping on the back (as opposed to to either side)
311
Stillbirth
3 key symptoms to report immediately
- reduced fetal movements
- abdo pain
- vaginal bleeding
312
Stillbirth
prevention
- risk assessment for a baby that is small for gestational age or with FGR
- those at risk have serial growth scans
- sleep on side
- aspirin if pre-eclamptic
313
Stillbirth
inx of choice for diagnosing intrauterine fetal death (IUFD).
USS: visualise the fetal heartbeat to confirm the fetus is still alove
314
Stillbirth
are fetal movement possible after IUFD
yes, a repeat scan is offered to confirm the situation
315
Stillbirth
1st line for most women after IUFD
vaginal birth:
- induction of labour
- expectant
316
Stillbirth
what does induction of labour involve
combination of:
- oral mifepristone (anti-progesterone)
- vaginal or oral misoprostol (prostaglandin analogue).
317
Stillbirth
what can be used to suppress lactation after stillbirth
Dopamine agonists (e.g. cabergoline)
318
Stillbirth
with parental consent, what testing is carried out after stillbirth to determine the cause
- Genetic testing of the fetus and placenta
- Postmortem examination of the fetus (including xrays)
- Testing for maternal and fetal infection
- Testing the mother for conditions associated with stillbirth: diabetes, thyroid, thrombophilia
319
Large for Gestational Age
definition
aka macrosomia
weight of newborn is >4.5kg at birth
or during pregnancy, estimated fetal weight > 90th centile
320
Large for Gestational Age
causes of macrosomia
- Constitutional
- Maternal diabetes
- Previous macrosomia
- Maternal obesity or rapid weight gain
- Overdue
- Male baby
321
Large for Gestational Age
risks
- shoulder dystocia
- Failure to progress
- Perineal tears
- Instrumental delivery or caesarean
- Postpartum haemorrhage
- Uterine rupture (rare)
322
Large for Gestational Age
risks to baby
- Birth injury (Erbs palsy, clavicular fracture, fetal distress and hypoxia)
- Neonatal hypoglycaemia
- Obesity in childhood and later life
- Type 2 diabetes in adulthood
323
Large for Gestational Age
inx
- USS; exclude polyhydramnios + estimate fetal weight
| - OGTT for gestational diabetes
324
Large for Gestational Age
how may the risk of shoulder dystocia be reduced
- delivery on a consultant lead unit
- Delivery by an experienced midwife or obstetrician
- Access to an obstetrician and theatre if required
- Active management of the third stage (delivery of the placenta)
- Early decision for caesarean section if required
- Paediatrician attending the birth
325
Multiple pregnancy
types: monozygotic
identical twins (from a single zygote)
326
Multiple pregnancy
types: dizygotic
non-identical (from two different zygotes)
327
Multiple pregnancy
types: monoamniotic
single amniotic sac
328
Multiple pregnancy
types: diamniotic
2 separate amniotic sacs
329
Multiple pregnancy
types: monochorionic
share a single placenta
330
Multiple pregnancy
types: dichorionic
2 seperate placentas
331
Multiple pregnancy
types: which types is the best outcome
diamniotic, dichorionic as each fetus has their own nutrient supply
332
Multiple pregnancy
when is multiple preganncy diagnosed
on the booking USS
333
Multiple pregnancy
on USS, what would dichorionic diamniotic twins show
- membrane between the twins
| - with a lambda sign or twin peak sign
334
Multiple pregnancy
on USS, what would monochorionic diamniotic twins show
membrane between the twins, with a T sign
335
Multiple pregnancy
on USS, what would Monochorionic monoamniotic wins show
no membrane separating the twins
336
Multiple pregnancy
what does the lambda or twin peak sign refer to on USS
dichorionic diamniotic
a triangular appearance where the membrane between the twins meets the chorion, as the chorion blends partially into the membrane.
337
Multiple pregnancy
what does T sign refer to on USS
monochorionic diamniotic
where the membrane between the twins abruptly meets the chorion
338
Multiple pregnancy
risks to mother
- Anaemia
- Polyhydramnios
- Hypertension
- Malpresentation
- Spontaneous preterm birth
- Instrumental delivery or caesarean
- Postpartum haemorrhage
339
Multiple pregnancy
risks to fetuses + neonates
- Miscarriage
- Stillbirth
- Fetal growth restriction
- Prematurity
- Twin-twin transfusion syndrome
- Twin anaemia polycythaemia sequence
- Congenital abnormalities
340
Multiple pregnancy
when does twin-twin transfusion syndrome occur
when the fetuses share a placenta.
feto-fetal transfusion syndrome in pregnancies with more than two fetuses.
341
Multiple pregnancy
what is Twin-twin transfusion syndrome
When there is a connection between the blood supplies of the two fetuses
one fetus (the recipient) may receive the majority of the blood from the placenta
while the other fetus (the donor) is starved of blood
342
Multiple pregnancy
Twin-twin transfusion syndrome: how does the recipient present
fluid overloaded, with heart failure and polyhydramnios
343
Multiple pregnancy
Twin-twin transfusion syndrome: how does the donor present
growth restriction, anaemia and oligohydramnios.
344
Multiple pregnancy
Twin-twin transfusion syndrome: mnx
refer to a tertiary specialist fetal medicine centre.
severe: laser trx to destroy connection between the 2 blood supplies
345
Multiple pregnancy
what is the difference between Twin Anaemia Polycythaemia Sequence and
Twin-twin transfusion syndrome
sequence is less acute.
1 twin becomes anaemic whilst the other develops polycythaemia
346
Multiple pregnancy
what additional monitoring is required
FBC
| USS
347
Multiple pregnancy
when is planned birth offered
monochorionic monoamniotic: 32-34w
monochorionic diamniotic: 36-37
dichorionic diamniotic: 37-38
triplets: before 36w
348
Multiple pregnancy
delivery of monoamniotic twins
elective caesarean section at between 32-34w
349
Multiple pregnancy
in diamniotic twins, when is vaginal delivery possible
when the first baby has a cephalic presentation
| Elective caesarean is advised when the presenting twin is not cephalic presentation
1st or 2nd twin
350
difference in presentation between vasa praevia and placenta praevia
vasa praevia: bleeding during rupture of membranes and fetal bradycardia
