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Year 4 - O&G > O&G - Normal Antenatal Progress / Diabetes > Flashcards

O&G - Normal Antenatal Progress / Diabetes Flashcards

1
Q

In what foods is Folic acid found natuurally?

A

Folic acid is a vitamin found naturally in:

  • Dark green leafy veg e.g. spinach, kale
  • Broccoli
  • Asparagus
  • Eggs
  • Citrus fruits e.g. oranges
  • Wholegrain
  • Yeast
  • Some margerine, bread and breakfast cereals (these have folic acid added)
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2
Q

Who needs to take Folic acid supplements?

A
  1. Woman planning a pregnancy
  2. Pregnant women up to 12-weeks gestation
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3
Q

Why do women need to take Folic acid for pregnancy?

A
  1. Low folic acid supply can cause neural tube defects (e.g. spina bifida) and cleft palate
  2. Folic acid supply from diet alone is insufficient
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4
Q

What is the normal dose for folic acid supplementation i.e. low-risk of NTDs?

A

400 micrograms daily

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5
Q

What is the dose of folic acid to be taken in women at high-risk of conceiving a child with NTD?

A

5 mg daily

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6
Q

What factors can make a woman ‘high-risk’ for concieving a child with a NTD?

A
  1. Previous NTD pregnancies
  2. FHx of NTDs
  3. Antiepileptic drugs (AEDs e.g. sodium valproate, carbamazepine, lamotrigine)
  4. Antifolate drugs e.g. methotrexate (DMARD), trimethoprim (Abx)
  5. Obesity (BMI > 30)
  6. Diabetes
  7. Sickle cell disease
  8. Bowel disease e.g. Coeliac or Crohn’s disease
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7
Q

What is the most important antigen of the Rhesus system?

A

D-antigen

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8
Q

What can happen if a mother is Rh -ve and her fetus us Rh +ve (first pregnancy)?

A

If a Rh -ve mother dlivers a Rh +ve child a leak of fetal RBCs can occur (e.g. during delivery) –> this causes anti-D IgG antibodies against the rhesus D antigen on the surface of fetal RBCs

In future Rh +ve pregnancies the mothers anti-D IgG antibodies can cross the placenta –> causing haemolysis of fetal RBCs –> Rhesus disease

Note: this can occur during the 1st Rh +ve pregnancy due to fetal blood leaks when in utero

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9
Q

In Rh -ve pregnancies to a Rh +ve what type of antibody is at risk of being produced?

A

Anti-D IgG antibody

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10
Q

How are pregnancies in Rh -ve mothers managed?

A
  1. Screening - all Rh -ve mothers are tested for D antibodies at booking appointment
  2. Anti-D immunoglobulin- given to non-sensitised Rh -ve mothers at 28-weeks (or 28-weeks + 34-weeks)
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11
Q

How does giving a Rh -ve mother anti-D antibodies prevent rhesus disease?

A

Anti-D immunoglobulin (IM injection) are cause haemolysis of any fetal RBCs in mothers circulation BEFORE her immune system can become sensitised and produce her own anti-D antibodies

The dose of anti-D immunoglobulin given is insufficient to cause harm to the fetus

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12
Q

There are certain situations in which Anti-D immunoglobulin should be given ASAP (always < 72-hrs) - name some of these situations.

A

Anti-D immunoglobulin given ASAP to prevent Rh -ve mother becoming sensitised to rhesus D antigen:

  1. delivery of Rh +ve infant - whether live or stillborn
  2. any termination of pregnancy
  3. miscarriage - if gestation is > 12-weeks
  4. ectopic pregnancy - if managed surgically, if managed medically with methotrexate anti-D is not required
  5. external cephalic version (ECV) - process of turning a breech baby to head-first presentation
  6. antepartum haemorrhage
  7. amniocentesis, chorionic villus sampling, fetal blood sampling
  8. abdominal trauma
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13
Q

What is Rhesus disease?

A

Rhesus disease, also called haemolytic disease of the newborn (HDFN)

is the result of a Rh -ve mother with a Rh +ve fetus, producing anti-D antibodies

against the rhesus D antigen present on her fetus’ RBCs –> haemolysis

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14
Q

What are the features of Rhesus disease / haemolytic disease of the newborn?

A
  • Haemolytic anaemia
  • Jaundice (haemolysis –> ↑ bilirubin)
  • Hepatosplenomegaly
  • Hydrops fetalis - oedema in 2 or more compartments (e.g. scalp, pericardium, pleura, ascities and skin)
  • HF
  • Kernicterus - preventable brain dmg in jaundiced newborns due to ↑ bilirubin
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15
Q

How does Hydrops Fetalis occur during Rhesus disease?

A
  1. Haemolytic anaemia –> hyperdynamic circulation –> ↑ CO –> left-sided HF –> pulmonary oedema –> pulmonary HTN –> right-sided HF –> ↑ venous hydrostatic pressure –> peripheral oedema + ascites (etc.)
  2. Haemolytic anaemia –> physiological extramedullary haematopoiesis (haematopoiesis outside of medulla of bone marrow) occurs in liver to aid bone marrow with blood cell production –> liver dysfunction –> ↓ albumin –> ↓ oncontic pressure –> peripheral oedema + ascites (etc.)
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16
Q

If a child is born with heamolytic disease of the newborn due to Rhesus incompatibility what management options are there?

A
  1. Refer to paediatrician for emergency consult
  2. Phototherapy for jaundice - specific spectrum of light is used to oxidise bilirubin to make its water-soluable –> clearable in urine / stool
  3. Exchange transfusion
  4. IVIG
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17
Q

Besides folic acid what other supplement is recommended in pregnancy?

A

Vitamin D

Woman planning pregnancy or currently pregnant should:

  • ↑ diet sources of vitamin D
  • Take 10mg Vitamin D supplement daily - take for duration of pregnancy + breast-feeding
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18
Q

Which women are at greater risk of ↓ vitamin D?

A

Particular care should be given to the following women - ↑ risk of low vitamin D:

  1. Asian
  2. Obese
  3. Poor diet
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19
Q

Antenatal care:

What is a Booking visit?

A
  • 1st appointment a pregnant mother has
  • Often at ~ 8-weeks (8-12)
  • With midwife
  • Purpose = risk-assess:
    • Low risk –> managed by mid-wives going forward
    • High risk –> managed by consultant going forward
  • Go through long proforma (like MOT) to cover:
    • Height, weight, BP, urinalysis (in case of asymptomatic UTI)
    • Blood tests: Hb, platelets, HIV, HBV, syphilis, blood group, rhesus status, sickle cell, haemaglobinopathies et.c
    • Ethnic risks
    • PMH / PSH
    • Med Hx
    • FHx of illness or pregnancy issues
    • Previous pregnancies / births (gravidity, parity)
    • Smoking - personal or family in home
    • Alcohol
    • Illicit drug use
    • Previous obstetric and gynaecological hx including smears
    • Last menstrual period - to estimate due date
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20
Q

Name some factors that would make a woman’s pregnancy ‘high-risk’ at their booking appointment?

A
  • Advanced maternal age e.g. > 40-yrs OR low age < 20-yrs
  • PMH e.g. diabetes, sickle cell, thalassaemia
  • Previous surgeries e.g. caesarean-sections
  • IVF treatment
  • Previous pregnacy issues e.g.
    • HTN, pre-eclampsia
    • growth restriction, diabetes
    • antepartum haemorrhage, postpartum haemorrhage
    • fetal abnormalities, previous stillbirth or miscarriage, premature labour
    • postpartum depression / psychosis
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21
Q

Antenatal care:

What is a Growth scan?

A

Occurs at 10-14 weeks gestation

  1. Combined test - combination of scan + blood tests –> screens for aneuploidy (abnormal no. of chromosomes)
    • Scan –> measures Nuchal translucency
    • Bloods –> serum B-HCG + PAPP-A (pregnancy associated plasma protein A)
    • Nuchal translucency + maternal age + bloods = risk of aneuploidy conditions
    • If risk of Down’s, Edward’s or Patau’s is > 1 in 150 –> offer diagnostic test
    • It is pt’s choice whether to screen for all, none or a specific one:
      • T13 = Patau’s
      • T18 = Edward’s
      • T21 = Down’s
  2. Measure fetus size (this is the ‘Dating scan’ which can be done with or without the combined test)
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22
Q

What is Quadruple blood screening?

A

Quadruple blood screening is done to screen for Down’s

  • Not as accurate as combined test
  • Can be done at 14-20 weeks gestation
  • Blood tests = AFP, unconjugated oestriol, beta-HCG and inhibin-A
    • AFP = alpha-fetoprotein
    • HCG = human chorionic gonadotrophin
  • Done IF:
    1. If it was not possible to obtain a nuchal translucency at Growth / Dating scan
      • OR
    2. Woman is > 14-weeks into pregnancy
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23
Q

Antenatal care:

What is a Dating Scan?

A

It is a scan done at ~ 12-weeks

to determine fetus age + estimate due date

  • Often done at same time as Growth scan
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24
Q

Antenatal care:

What is an Anomaly scan?

A

Anomaly scan occurs at 18-21 weeks

  • Checks for structural abnormalities –> if abnormal then detailed scan at fetal medicine unit (FMU)
  • Looks for 11 (rare) conditions:
    • Edwards (T18) & Patau’s (T13)
    • Anencephaly - absence of telencephalon (majority of brain)
    • Open spina bifida
    • Cleft lip
    • Diaphragmatic hernia
    • Gastroschisis - bowel protrudes through abdominal wall and develops outside body
    • Exomphalos - abdominal wall weakness causing contents to protrude through umbilicus in loose sac
    • Cardiac abnormalities
    • Bilateral renal agenesis
    • Lethal skeletal dysplasia
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25
Q

Antenatal care:

What / when is the Oral Glucose Tolerance Test (OGTT) in pregnancy?

A

OGTT is done at ~ 26-weeks (24-28 weeks)

  • Done if you have 1 or more risk factors for gestational diabetes (determined at booking appointment)
  • If woman has had gestational diabetes before –> OGTT ASAP after booking appointment + 24-28 weeks (if 1st test is normal)
  • Involves:
    • Morning blood glucose before food/drink
    • Then given 75 g glucose drink
    • 2-hrs later –> measure blood glucose
  • Gestational diabetes:
    • Fasting glucose ≥ 5.6 mmol/L
    • 2-hour (OGTT) ≥ 7.8 mmol/L
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26
Q

What are the fasting glucose & OGTT thresholds for gestational diabetes?

A

Gestational diabetes:

  • Fasting glucose ≥ 5.6 mmol/L
  • 2-hour (OGTT) ≥ 7.8 mmol/L
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27
Q

What are some risk factors for gestational diabetes?

A

Gestational diabetes risk factors:

  1. Previous gestational diabetes
  2. BMI > 30 kg/m²
  3. Previous baby weight > 4.5 kg i.e. 10 lbs (macrosomia = newborn heavier than avg i.e. > 4 kg)
  4. 1st degree relative with diabetes
  5. PCOS - polycystic ovarian syndrome
  6. Ethnicity - South Asian, black Caribbean and Middle Eastern

ANY of the above –> screen for gestational diabetes (via OGTT) ASAP after booking appointment + at 28-weeks (if 1st was -ve)

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28
Q

How is gestational diabetes managed?

A

If fasting glucose < 7 mmol/L at diagnosis then:

  • 1st line = trial of exercise + diet (low glycaemic food) –> if glucose targets not met in 1-2 weeks then 2nd line
  • 2nd line = metformin + diet + exercise –> if glucose targets not met then 3nd line
    • Glibenclamide - offer if pt can’t tolerate metformin or if metformin not working but refuses insulin
  • 3rd line = insulin + metformin + diet + exercise

If fasting glucose > 7 mmol/L at diagnosis then:

  • 1st line = insulin

If fasting glucose is between 6.0 - 6.9 + complications e.g. macrosomia, hydramnios:

  • 1st line = insulin
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29
Q

How do you manage pre-existing diabetes in a pregnant woman?

A
  1. If BMI > 27 kg/m2 –> weight loss
  2. Stop oral hypoglycaemic agents (not metformin) + commence insulin
  3. Folic acid 5 mg/day - from pre-conception to 12-weeks gestation
  4. Detailed anomaly scan at 20-weeks + four-chamber view of the heart & outflow tracts
  5. Tight glycaemic control –> ↓ complication rates
  6. Retinal assessment - at 1st appointment (booking) + 28/40
  7. Treat retinopathy - as can worsen during pregnancy
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30
Q

What are the blood glucose targets for the following in pregnant women (gestational diabetes or pre-existing):

  • Fasting glucose
  • 1 hr after meals
  • 2 hrs after meals
A
  • Fasting glucose target < 5.3 mmol/L
  • 1 hr after meal target < 7.8 mmol/L
  • 2 hr after meal target < 6.4 mmol/L
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31
Q

What are the symptoms of gestational diabetes?

A
  • Polydipsia
  • Polyuria
  • Dry mouth
  • Tiredness
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32
Q

How can gestational diabetes affect pregnancy?

A
  • Macrosomia - fetus larger than avg –> can complicate delivery e.g. require induced labour or caesarean section
    • Macrosomia = risk factor for shoulder dystocia (complication of vaginal cephalic delivery)
  • Polyhydramnios - excess amniotic fluid –> can cause premature labour
  • Premature birth (i.e. < 37-weeks gestation)
  • Pre-eclampsia - high BP during pregnancy
  • Neonatal hypoglycaemia (↓ glucose post-delivery)
  • Stillbirth
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33
Q

If a pregnant woman has has gestational diabetes before when should she have OGTT done?

A

OGTT ASAP after booking appointment (8-12 weeks)

then at 24-28 weeks (if 1st OGTT was normal)

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34
Q

When are pregnant women screened for anaemia?

A

Screen for anaemia:

  1. Booking appointment (8-12 weeks) AND
  2. 28-weeks
35
Q

What are the anaemia cut-offs for pregnant women at the booking appointment and at 28-weeks blood test?

A

Booking Hb < 11 g/dl

28-weeks Hb < 10.5 g/dl

If Hb is below either of the above cut-off then:

  • Investigate anaemia
  • Consider iron supplementation e.g. ferrous sulphate
    • Continue iron supplements after anaemia is corrected for 3/12 + at least 6/52 pp
36
Q

When is diagnostic testing for Down’s, Edward’s and Patau’s aneuploidies offered to pregnant women?

A

If the screening test (combined test) indicates the chance of

Down’s, Edward’s or Patau’s is > 1 in 150

37
Q

What diagnostic tests can be used to confirm Down’s, Edward’s and Patau’s?

A

Amniocentesis or chorionic villus sampling (CVS)

‘cell-free’ DNA tests are available privately - these are non-invasive

  • ~ 0.5 to 1 in 100 diagnostic tests result in miscarriage
  • CVS done between 11-14 weeks
  • Amniocentesis is done at ~ 15 weeks
38
Q

What physiological changes occur in pregnancy?

Cardiovascular

A
  • ↑ CO (due to ↑ HR + ↑ SV)
  • BP:
    • Systolic BP –> stays the same - if systolic ↑
    • Diastolic –> ↓ in 1st / 2nd trimester then returns to norm by term
  • Enlarged uterus –> ↓ venous return –> can cause:
    • Ankle oedema
    • Supine hypotension
    • Varicose veins
39
Q

What physiological changes occur in pregnancy?

Respiratory

A
  1. ↑ ventilation
  2. ↑ tidal volume (from 500 - 700 ml) - effect of progesterone
  3. ↓ PCO2 - oxygen requirements increase by only ~ 20% but ventilation increases disproportionately so more CO2 is breathed-off
  4. elevated diphragm - ↑ intra-abdominal pressure due to enlarged uterus
40
Q

What physiological changes occur in pregnancy?

Haematological

A
  1. ↑ plasma volume by ~ 50% (mainly 2nd half of pregnancy) - contribute to oedema e.g. ankles
  2. ↑ RBC volume by ~ 20%
  3. Anaemia - RBC vol ↑ but not as much as plasma vol –> thus concentration of Hb goes down i.e. anaemia
  4. Small ↑ in clotting factors - fibrinogen, factors VII, VIII and X –> hypercoaguable state
    • ↑ risk of VTE
  5. ↓ platelet count < 150-400 ×109/L i.e. ‘gestational thrombocytopenia’ –> does NOT carry increased risk of thrombus
  6. ↓ in protein S (endogenous anti-coagulant)
  7. ↑ WCC
  8. ↑ ESR
41
Q

What physiological changes occur in pregnancy?

Endocrine

A

↑ Thyroxine (T4) –> find warm conditions uncomfortable

(others less noteworthy)

42
Q

What physiological changes occur in pregnancy?

Liver

A
  1. ↑ ALP by 50%
  2. ↓ Albumin
43
Q

What physiological changes occur in pregnancy?

Gynaecological

A
  1. Breast enlargement
  2. Areolar pigmentation
  3. Utrerine hyperplasia –> then hypertrophy
  4. Cervical gland hypertrophy –> thick mucus plug
  5. Oestrogen –> ↑ lactiferous duct system for breast-feeding
  6. Braxton-Hicks –> non-painful contractions in late pregnancy ( > 30-weeks)
44
Q

What physiological changes occur in pregnancy?

Renal

A
  • ↑ renal blood flow (~30%) + ↑ GFR by 30-60% –> urinary frequency
  • ↑ urinary protein loss
  • ↑ kidney size
45
Q

What physiological changes occur in pregnancy?

Gastrointestinal

A
  • Oesophageal relaxation –> reflux
  • ↑ intra-abdominal pressure –> haemorroids
  • ↓ bowel motility (progesterone) –> constipation
46
Q

What antenatal recommendations should pregnant women or women planning to be pregnant be given?

A
  1. Folic acid - 400 mcg OD, before conception until 12-weeks
    • May require 5 mg dose e.g. AEDs
  2. Vitamin D 10mg OD - more important in darker skin + covering skin due to culture
  3. No alcohol
  4. Smoking cessation prior to pregnancy - no varenicline or bupropion in pregnancy or breast-feeding
  5. Listeriosis - avoid; unpasteurised milk + ripened soft cheese (e.g. Camembert, Brie and blue-veined cheeses) + pate + undercooked meats
  6. Salmonella - avoid raw / partially cooked egg + meat (especially poultry)
  7. Most women are safe to work
  8. Discuss maternity rights + benefits
  9. Air travel - avoid if:
    1. > 37-weeks + single pregnancy + no risk factors
    2. > 32-weeks + uncomplicated multiple pregnancies
    3. ↑ risk of VTE –> wear compression stockings
  10. Minimise OTC drug use
  11. Continue moderate exercise - but avoid; contact sports + scuba
  12. Can continue intercourse
47
Q

Which is considered the safest anti-epileptic drug to take during pregnancy?

A

Lamotrigine

  • Only safe compared to other AEDs
  • ↑ risk of congenital malformations compared to no AED
48
Q

What are the risks associated with NSAIDs during pregnancy?

A
  1. Oligohydramnios - less amniotic fluid than norm for gestational age
  2. Premature closure fetal ductus arteriosus
49
Q

When is Nitrofurantoin avoided in pregnancy?

Why?

A

Nitrofurantoin should be avoided in pregnancy at term i.e. > 36/40 weeks

due to association with haemolytic anaemia (neonatal haemolysis)

50
Q

Why is Carbimazole avoided in pregnancy?

A

Carbimazole is avoided in pregnancy (especially 1st trimester)

due to risk of aplasia cutis (rare skin disorder) - it can cross the placenta

Aplasia cutis congenita = congenital absence of skin e.g. no scalp

51
Q

What is Isotreninoin used for?

Why is it avoided in pregnancy?

A

Isotreninoin - is an acne medication

It is teratogenic and thus has a high risk of congenital defects

  • Must take contraception simultaneously due to teratogenic risk
52
Q

Which of the following medications are safe to take in pregnancy?

  • Metformin
  • Propylthiouracil (PTU)
  • Isotretinoin
  • Ramipril
  • Carbimazole
  • Nitrofurantoin
  • Amoxicillin
  • Sodium valproate
  • Trimethoprim
  • Cyclizine
  • NSAIDS
  • Citalopram
  • Lamotrigine
A
  1. Metformin
  2. Amoxicillin
  3. Cyclizine
53
Q

What is the incidence of gestational diabetes?

A

2 - 9%

(very common complication of pregnancy)

54
Q

What causes gestational diabetes?

A
  1. Pregnancy –> ↑ insulin resistance
  2. ↑ anti-insulin hormones from placenta i.e.
    1. glucagon
    2. cortisol
    3. HPL (human placental lactogen)
55
Q

When can a Growth scan occur during pregnancy?

A

1st is done at 10-14 weeks

but multiple growth scans can be done throughout pregnancy to monitor the fetus

e.g. every 4-weeks in diabetic mothers to monitor for macrosomia & polyhydramnios

56
Q

When do the majority of VTEs (i.e. DVT / PE) occur during pregnancy?

A

3rd trimester

57
Q

Pregnancy is a hypercoaguable state - why?

A
  1. Small ↑ in some clotting factors i.e. fibrinogen, VII, VIII and X
  2. ↓ in protein S (endogenous anti-coagulant)
  3. Uterus presses on IVC causing venous stasis in legs
58
Q

How is the ↑ risk of VTE managed in pregnancy?

A

Sub-cut LMWH preferred to IV heparin

NOT WARFARIN!!

NOT DOACS!!

59
Q

What is amniotic fluid index (AFI)?

A

Amniotic fluid index (AFI) is a quantitative estimate of amniotic fluid

  • An indicator of fetal well-being
  • AFI measured in cm
  • Normal AFI = 8-24 cm
  • AFI < 5-6 = oligohydramnios
  • AFI > 24-25 = polyhyramnios
60
Q

What is shoulder dystocia?

A

Shoulder dystocia = a complication of vaginal cephalic delivery in which

we are unable to deliver the body, with the head having already been delivered

  • Impaction of fetal shoulder on maternal pubic symphysis
  • Can cause maternal + fetal morbidity:
    • Maternal - postpartum haemorrhage + perineal tears
    • Fetal - brachial plexus injury etc.
61
Q

What are the risk factors for shoulder dysotcia?

A
  1. macrosomia
  2. ↑ maternal BMI
  3. diabetes in pregnancy
  4. previous shoulder dystocia pregnancy
  5. epidural
  6. instrumental delivery
  7. induction of labour
  8. prolonged labour
62
Q

What is the optimal timing for Lower segment Cesarean section (LSCS)?

How does this change if the pt has T1DM or T2DM managed with insulin?

A

LSCS in non-diabetic pt is optimal at > 39/40

LSCS for diabetic pt on insulin by 38/40

  • LSCS prior to 39/40 are associated with ↑ risk of ARDS (acute respiratory distress syndrome)
63
Q

Pts due to have LSCS prior to 39/40 are recommended to recieve what?

A

Steroids –> for fetal lung maturity (cause ↑ in surfactant)

  • This should be done with caution in diabetic mothers as steroids –> hyperglycaemia (peaks 24-48hrs after steroid dose)
  • Steroids + diabetic mother –> may need insulin sliding scale
64
Q

What are some risk factors for VTE in pregnant women?

Presence of how many-risk fators warrants LMWH?

A
  • Age > 35
  • BMI > 30
  • Parity > 3
  • Smoker
  • Gross varicose veins
  • Current pre-eclampsia
  • Family history of unprovoked VTE
  • Immobility e.g. paraplegia or hospital admission
  • Long-distance travel
  • Current systemic infection (requiring IV Abx or hospital admission)
  • Low risk thrombophilia
  • Multiple pregnancy
  • IVF pregnancy
65
Q

Presence of how many risk factors for VTE warrants immediate LMWH?

How long must LMWH be taken in this case?

A

4 or more risk factors for VTE –> immediate LMWH

continue LMWH until 6/52 postnatal

66
Q

If a pt has 3 risk factors for VTE, what action should be taken?

A

LMWH from 28-weeks until 6/52 posnatal

67
Q

In the management of HTN during pregnancy which medications are avoided + which are commonly used?

A

HTN medications:

Avoided in Pregnancy:

  1. ACE-inhibitors - due to ↑ CV and neuro malformations
  2. ARBs - similar to ACE-inhibitors
  3. Diuretics

Commonly used in Pregnancy (doesn’t necessarily mean they’re safe):

  1. Labetalol (beta-blocker)
  2. Nifedipine (dihydropyridine calcium channel blocker)
  3. Doxazosin (alpha-1 receptor antagonist)
  4. Methyldopa - not often used as anti-hypertensive but is safer than alternatives in pregnancy (acts on CNS to cause ↓ sympathetic tone i.e. vasodilation)
68
Q

What 3 effects does Pregnancy have on Diabetes?

A
  1. ↑ dose of insulin needed during pregnancy
  2. Worsening nephropathy and/or retinopathy
  3. Increase hypoglycaemic attacks
69
Q

If a pregnant woman is admitted to hospital during pregnancy what should she be given?

A

Thromboprophylaxis i.e. LMWH

Unless specific contraindication e.g. risk of labour or active bleeding

70
Q

What are the features of significant Pre-eclampsia?

A
  • HTN - typically > 170/110 mmHg
  • Proteinuria - dipstick ++ / +++
  • Headache
  • Visual disturbances e.g. blurring, flashing in front of eyes
  • Papilloedema
  • RUQ / epigastric pain
  • Hyperreflexia
  • Vomiting
  • May have acute oedema of face, hands or feet (non-specific)
71
Q

What is pre-eclampsia?

A

Pre-eclampsia is a hypertensive syndrome that occurs in pregnant women and is characterised by:

  1. Pregnancy-induced hypertension (PIH):
    • BP > 140/90 on two occasions 4-hrs apart
    • > 20-weeks gestation
  2. Proteinuria > 0.3g / 24 hours or > 30 mg/mmol on spot protein:creatinine ratio (PCR)

Note: pre-eclampsia is a placental disease i.e. no placenta no pre-eclampsia

72
Q

What are ‘high-risk’ factors for pre-eclampsia?

How are women identified at ‘high-risk’ of pre-eclampsia managed?

A
  1. Hypertensive disease during previous pregnancy
  2. CKD
  3. Autoimmune condition e..g LSE or antiphospholipid syndrome
  4. T1DM or T2DM
  5. Chronic HTN

If ANY of the above –> 75-150 mg Aspirin daily

from 12-weeks until birth

73
Q

What are ‘moderate-risk’ factors for pre-eclampsia?

How many ‘moderate-risk’ factors does a woman need to have to warrant Aspirin?

A
  • 1st pregnancy
  • age > 40
  • pregnancy interval > 10-yrs
  • BMI > 35 at 1st visit
  • FHx of pre-eclampsia
  • Multi-fetal pregnancy

If > 1 of above –> 75-150 mg Aspirin daily

from 12-weeks until birth

74
Q

What complications are associated with pre-eclampsia?

A
  • Fetus:
    • prematurity
    • growth retardation
  • Eclampsia
  • Haemorrhage:
    • ​placental abruption
    • antepartum
    • intra-abdominal
    • intra-cerebral
  • HF
  • Multi-organ failure
75
Q

How is pre-eclampsia managed?

A
  1. Aspirin 75-150 mg daily from 12-weeks to birth IF ‘high-risk’ factor present or > 1 ‘moderate-risk’ factor
  2. Guidelines recommend always treating BP > 160/110 and treating BP > 140/90 if it stays elevated
    • 1st line = Oral or IV Labetalol (beta-blocker)
    • 2nd line = Oral Nifedipine
    • 3rd line = Oral Methyldopa
  3. Fluid restriction - can reduce risk of pulmonary oedema
  4. Magnesium sulphate infusion - prevents fits associated with pre-eclampsia / eclampsia
76
Q

When should women with uncomplicated T1DM or T2DM be offered an elective delivery e.g. LSCS?

A

< 37-38+6 / 40 weeks

77
Q

In mothers with gestational diabetes when should delivery be offered?

A

< 40+6 weeks

78
Q

When do women with gestational diabetes normally stop their glucose reducing agents e.g. metformin / insulin?

A

Immediately after delivery

79
Q

When should pregnant women with any meternal or fetal complications be offered delivery?

A

< 37 /40

80
Q

How often should growth scans be done in diabetic mothers and from when?

A

Growth scans every 4-weeks from 28-weeks - if mother has diabetes

81
Q

What is Pregnancy induced hypertension (PIH)?

A

Pregnancy induced hypertension (PIH) is characterised by:

  1. Hypertension i.e. > 140/90 occuring after > 20-weeks
    • or increase above booking reading of > 30 systolic or > 15 diastolic
  2. NO proteinuria!! or oedema (the latter is not part of criteria)
82
Q

Does PIH resolve or continue?

A

PIH often resolves following birth (often after 1/12)

Women with PIH are at increased risk of:

  • Pre-eclampsia - thus regular urine-dip to monitor for proteinuria
  • HTN in later life
83
Q

What is given to manage fits due to pre-eclampsia?

A

Magnesium sulphate infusion

84
Q

What is the Kleihauer test for?

A

Kleihauer test:

  • Measures amount of fetal haemoglobin transferred to mothers bloodstream
  • Used on Rh -ve mothers to determine dose of Anti-D immunoglobulin to inhibit formation of Rh antibodies

Year 4 - O&G (12 decks)

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