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Year 5: Conditions > O&G- Pathology During Pregnancy > Flashcards

O&G- Pathology During Pregnancy Flashcards

1
Q

What is pre-eclampsia

A

New Hypertension (>140/90) after 20 weeks of pregnancy WITH end-organ dysfunction

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2
Q

What causes pre-eclampsia

A

• Occurs when spiral arteries of placenta form abnormally (causing high vascular resistance)

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3
Q

What is chronic hypertension (in relation to pregnancy)

A

High BP that exists <20 weeks gestation and is longstanding

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4
Q

What is gestational hypertension

A

High BP >20 weeks gestation WITHOUT proteinuria (can progress to pre-eclampsia)

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5
Q

What is eclampsia

A

more than one seizure in patient with pre-eclampsia

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6
Q

What are the high risk factors for pre-eclampsia

A

• Pre-existing hypertension, previous HTN in pregnancy, autoimmune conditions (SLE), diabetes, CKD

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7
Q

What are the moderate risk factors for pre-eclampsia

A

‣ Age >40, BMI >35, >10 years since last pregnancy. Primigravida, family history of pre-eclampsia

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8
Q

What is management of one high risk factors or 2 moderate risk factors for pre-eclampsia

A

◦ Offer ASPIRIN 150mg from 12 weeks gestation until birth

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9
Q

Presentation of pre-eclampsia

A

• Increased BP (>140/90)

• Headache
• Visual disturbances (flashing lights) or bluriness
• Nausea and vomiting
• Epigastric pain
• Oedema (face, feet, hands)

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10
Q

Presentation of eclampsia

A

‣ Seizures
‣ Hyper-reflex is (clonus)

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11
Q

What is diagnostic criteria of pre-eclampsia

A

BP >140/90 AND proteinuria, organ dysfunction OR placental dysfunction

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12
Q

Investigations for pre-eclampsia

A

• Urine Dipstick:
• Proteinuria (quantify using ACR or protein:creatinine ratio)
• Every antenatal appointment do BP + Urine Dipstick

• Check for other organ dysfunction:
◦ FBC, U&Es, LFTs, platelets

• Placental Growth Factor (PIGF): Level would be LOW in pre-eclampsia (check at 20-35 weeks)

• USS to check foetal growth

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13
Q

If confirmed pre-eclampsia, how often does FBC, U&Es and LFTs need to be done

A

2-3x per week depending on severity

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14
Q

What to do with patients with suspected pre-eclampsia

A

referred for same-day obstetric assessment

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15
Q

When to consider admission for pre-eclampsia

A

if severe HTN (>160/110) or symptoms of late stage disease (e.g. headache, visual disturbances, epigastric pain etc)

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16
Q

Medical management of pre-eclampsia

A

1) Labetalol (contraindicated in asthmatics)
2) Nifedipine (causes tocolysis, switch to methyldopa at term)
3) Methyldopa (stop 2 days after birth)

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17
Q

Blood pressure target for pre-eclampsia

A

• Target BP <135/85

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18
Q

Management if birth planned within 24 hours due to risk of eclampsia

A

• IV Magnesium Sulphate (seizure prophylaxis)

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19
Q

What tests need to be repeated every 2 weeks for pre-eclampsia care (prior to delivery)

A

• USS for foetal growth
• Umbilical artery Doppler
• Dipstick, BP
• Amniotic fluid volume assessment

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20
Q

When to deliver baby for mild/moderate pre-eclampsia

A

• Delivery >37 weeks

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21
Q

When to deliver baby for severe pre-eclampsia

A

‣ Delivery >34 weeks
‣ 34-36 weeks consider Corticosteroids

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22
Q

When to deliver baby for life-threatening pre-eclampsia

A

◦ Deliver regardless of gestational age

			◦ If delivery <34 weeks, then give IV Magnesium Sulphate + Antenatal Corticosteroids
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23
Q

Indication and monitoring of IV magnesium sulphate for pre-eclampsia

A

◦ Continue 24hrs after last seizure or delivery
◦ MONITOR urine output, reflexes, respiratory rate and O2 sats

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24
Q

Side effect and management of IV Magnesium Sulphate

A

Can cause respiratory depression
◦ Reverse it with Calcium Gluconate

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25
Mode of delivery for pre-eclampsia
• Elective C-Section OR Induction of labour
26
If induction of labour chosen for pre-eclampsia, what considerations need to be done
Use epidural anaesthesia (reduces BP) AND avoid ergometrine ◦ Need continuous CTG monitoring ◦ Continue anti-hypertensives during labour
27
When discharged following birth, how often is BP checked
• When discharged, BP checked EVERY OTHER DAY until target reached, then weekly (wean down the anti-HTN)
28
How often is GP follow-up after delivery in pre-eclampsia
• Follow-up at GP at 2 weeks and 6-8 weeks
29
What anti-hypertensives are safe during breast-feeding
• Labetalol and Nifedipine safe for breastfeeding
30
Complications of pre-eclampsia
• Eclamptic seizures • IUGR • Liver derangement • Placental abruption or intracranial haemorrhage
31
What is severe form/complication of pre-eclampsia
• HELLP Syndrome
32
What triad seen in HELLP Syndrome and what symptoms
◦ Haemolysis (MAHA- raised LDH and unconjugated hyperbilirubinaemia) ◦ Elevated liver enzymes ◦ Low platelets ◦ Symptoms: headache, visual symptoms, abnormalities in clotting, hepatomegaly
33
Management of HELLP Syndrome
Prompt Delivery
34
What is gestational diabetes
New onset diabetes during pregnancy, usually occurring at 24-28 weeks. Complications to lesser degree
35
What happens to insulin response in pregnancy
• Insulin resistance increases during pregnancy
36
Risk factors for gestational diabetes
RISK FACTORS: • BMI >30 • Previous personal or family history gestational diabetes • Ethnicity • Previous macrosomic baby (>4.5kg)
37
What does gestational diabetes increase the risk of
◦ Miscarriage ◦ Congenital malformations (e.g. Spina bifida) ◦ Macrosomia-> therefore increased risk of Shoulder Dystocia ◦ Pre-eco-amiss ◦ Polyhydraminos ◦ Maternal risk of developing T2DM after pregnancy
38
What investigation is used for gestational diabetes
• 2 hour 75mg Oral Glucose Tolerance Test:
39
When is the 2-hour OGTT indicated for gestational diabetes and when would you do it
◦ Glycosuria on urine dipstick (do immediately) ◦ Previous GDM (do immediately, if normal repeat at 24-28 weeks) ◦ Any risk factors on clerking (do at 24-28 weeks)
40
How to diagnose gestational diabetes using 2 hour OGTT
DIAGNOSIS (5,6,7,8): ◦ Fasting Plasma Glucose= >5.6mmol/L ◦ 2-hour OGTT= >7.8mmol/L
41
Management of gestational diabetes (clinic, advice, scans)
• Review at Joint Diabetes and Antenatal Clinic within 1 week (every 2 weeks thereafter) • Teach self-monitoring of glucose • Serial growth scans every 4 weeks from 28-36 weeks gestation
42
Medical management of gestational diabetes
1) (ONLY if fasting glucose <7mmol/L) Diet and Exercise 2 week trial: ◦ Low glycemic index foods and walking after meal 2) (IF targets NOT met in 2 weeks) Metformin: 3) (IF 2nd line ineffective or fasting glucose >7) add Insulin: ◦ If fasting glucose >7 then give just insulin straightaway ◦ If 2nd line ineffective, then add insulin to previous treatment
43
What are glucose targets in gestational diabetes
◦ Targets: ◦ Fasting= <5.3mmol/L ◦ 1 hour post meal= <7.8mmol/L ◦ 2 hour post meal= <6.4mmol/L
44
Delivery management of gestational diabetes
• Patients should NOT give birth later than 40+6 ◦ Should be offered C-section or induction before this • Variable rate insulin infusion during labour for those already on insulin
45
Immediate post-natal care for gestational diabetes
• Stop diabetic medication immediately after birth • Baby Monitoring: ◦ Monitor for neonatal hypoglycaemia (early feeding and assess 2-4 hours after birth to prevent this)
46
Follow up for gestational diabetes following birth
• GP follow up in 6 weeks to test for fasting glucose (to check risk of developing T2DM) • Subsequent pregnancies: OGTT at booking visit
47
Complications of gestational diabetes
• Macrosomia • Neonatal hypoglycaemia • Stillbirth
48
What effect does pregnancy have on pre-existing diabetes
• Increased nausea & vomiting • Insulin dose requirements increase in 2nd half of pregnancy • Increased risk of diabetic complications • Tighter glucose control required
49
What pre-conception counselling required for pre-existing diabetic mothers
• Increased risk of miscarriage or stillbirth • Increased risk of Macrosomia • Increased risk of hypoglycaemia after cord is cut • Poor glycaemic control increases risk of malformations (e.g. spina bifida)
50
Management of pre-existing diabetic mothers following birth
• Immediately reduce insulin following birth and monitor blood glucose
51
Definition of small for gestational age
A baby that measures less than or equal to 10th centile for their gestational age (derived from birth weight, <2.5kg)
52
What are 2 measurements on USS used to assess foetal size
◦ Estimated Foetal Weight (EFW) ◦ Foetal Abdominal Circumference (AC) ◦ Growth charts are plotted
53
What is intrauterine growth restriction
Baby with reduced growth rate due to reduction in nutrients and oxygen being delivered vis placenta ‣ Becomes small for gestational age ‣ All IUGR babies are SGA, but not all SGA are IUGR
54
What are two types of intrauterine growth restriction
• Placenta Mediated Growth Restriction: ◦ Affects transfer of nutrients across placenta ◦ E.g. pre-eclampsia, maternal smoking, alcohol, anaemia, malnutrition ◦ ASYMMETRICAL IUGR (head grows, abdomen doesn’t)-> PLACENTAL INSUFFICIENCY • Non-Placenta Mediated Growth Restriction ◦ Pathology of foetus ◦ E.g. genetic abnormalities, structural abnormalities, foetal infection ◦ SYMMETRICAL IUGR (head and abdomen size reduced in parallel)-> CHROMOSOMAL ABNORMALITY OR INTRAUTERINE INFECTION
55
What type of IUGR has asymmetrical growth restriction
• Placenta Mediated Growth Restriction: ◦ ASYMMETRICAL IUGR (head grows, abdomen doesn’t)-> PLACENTAL INSUFFICIENCY
56
What type of IUGR has symmetrical growth restriction
• Non-Placenta Mediated Growth Restriction ◦ SYMMETRICAL IUGR (head and abdomen size reduced in parallel)-> CHROMOSOMAL ABNORMALITY OR INTRAUTERINE INFECTION
57
Risk factors for small for gestational age
• Previous stillbirths • Anti-phospholipid syndrome • Previous SGA baby • Smoking
58
Investigations for small for gestational age
1) Abnormal Symphysis-Fundal Height or risk status determined (at any antenatal visit) 2) Confirm small for gestational age at 20 weeks USS (foetal biometry): check Estimated Foetal Weight 3) Umbilical artery Doppler (20-24weeks):
59
Next step if umbilical artery Doppler is abnormal for suspected small for gestational age
◦ If ABNORMAL (reduced amniotic fluid, abnormal Doppler, reduced foetal movements): serial USS every week + Doppler every 2 weeks
60
Next step if umbilical artery Doppler is normal for suspected small for gestational age
◦ If NORMAL: serial USS every 2 weeks
61
Antenatal management of small for gestational age
• Stop smoking, alcohol, drugs • Serial growth scans and Doppler every 2 weeks at least
62
Indications for immediate delivery for small for gestational age
‣ Abnormal CTG ‣ Reduced foetal movements ‣ Abnormal Doppler (reversal of end-diastolic flow)
63
When would delivery be planned for small for gestational age
• Delivery by 37 weeks: ◦ Give corticosteroids if <36 weeks ◦ Give Magnesium Sulphate if <30 weeks
64
Definition of large for gestational age
Term to describe macrosomic babies (birth weight >4.5kg). During pregnancy, estimated foetal weight >90th percentile
65
Risk factors for large for gestational age
RISK FACTORS: • Gestational diabetes or DM • High BMI • Previous Macrosomia • Multiparity • Overdue
66
Presentation of large for gestational age
• Excessive distention for gestational age • Increased SFH (after 24 weeks normal should only be 1cm increase per week), increased abdominal circumference
67
Investigations for large for gestational age
• At 24-36 weeks if increased growth, arrange Foetal Biometry USS (Estimated Foetal Weight, Abdominal Circumference AND exclude polyhydramnios) ◦ Also offer OGTT to exclude gestational diabetes
68
Management of large for gestational age
• Plan delivery and discuss risk of SHOULDER DYSTOCIA , nerve injuries, prolonged labour, perineal tear • Offer Caesarean

Year 5: Conditions (17 decks)

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