O&G Written - Other disorders of pregnancy Flashcards
USS schedule in multiple pregnancy
Monochorionic: every 2 weeks from 16 weeks –> delivery
Diochorionic: every 4 weeks from 20 weeks –> delivery
Important complications of monochorionic twins
Twin to twin transfusion syndrome (TTTS)
- 1 donor becomes anaemic + oligohydramnios
- 1 recipient becomes overloaded, polycythaemia + polyhydramnios
- can be fatal for 1 or both
- Tx = laser ablation of anastomoses
Management of pre-term labour without ROM
A-E + resus as needed
Admit
Corticosteroids
Tocolysis - nifedipine, terbutaline
Magnesium sulphate - 4g slow IV injection
+/- in utero transfer to Level 3 NICU facility
Pre-conception management of existing diabetes
Glycaemic control
- offer monthly HbA1c <6.5 = ideal, pregnancy not advised if >10%
- fasting glucose target = 4-7 (if achievable without hypos)
- insulin + metformin only
Weight loss if BMI >27
Start 5mg folic acid
Stop statins, swap HTN meds as needed
Refer for diabetic retinopathy & nephropathy assessment
Additional monitoring & appts throughout pregnancy in diabetic
<12 weeks = booking appt as normal
20 weeks = anomaly scan + extra cardiac outflow, retinal & renal scanning
28-36 weeks = 4 weekly foetal surveillance
- USS at 32 and 36 weeks for liquor volume + foetal growth
- Doppler not recommended unless PET or IUGR
Joint antenatal diabetes clinic every 2 weeks throughout
Delivery in (existing) diabetic pregnant woman?
IOL or ELCS between 37 - 39 weeks
- CS often if baby >4kg
- sugars controlled with dextrose + insulin infusion
Measures for neonate after birth (diabetic mother)
Check blood glucose within 4 hours
Early + regular feeding encouraged
Criteria for gestational diabetes
Fasting 5.6 +
2 hour OGTT 7.8+
Management of gestational diabetes
2 week trial lifestyle
+ BM monitoring at home twice weekly
Metformin
Insulin (+/- metformin)
- jump straight to this step if fasting glucose >7 or 6-6.9 but complications
Post-partum management of gestational diabetes
Stop hypoglycaemic Tx post-natally
Fasting glucose 6-13 weeks later
- <6 = need annual test, moderate risk for T2DM
- 6-6.9 = high risk
- > 7 = 50% chance, offer diagnostic test
General principles of pre-conception planning in cardiac disease
Adapt medications to be safe
- no ACEi, warfarin
- beta blockers preferred for HTN
- LMWH e.g. enoxparin
Regular checks for anaemia
Principle of delivery in cardiac disease
Wait for SVD
Avoid supine position
Maintain fluids
Epidural / regional anaesthesia - reduces pain related stress + afterload
- BUT contraindicated in severe aortic stenosis
Prophylactic Abx if structural heart defecrt
Minimise duration of 2nd stage - ventouse or forceps
Active management of 3rd stage with syntocin only (no ergometrine)
Very high risk = IOL (but hypotension risk) or CS
Tx of asthma in pregnancy
As per normal adult guidelines
- SABA
- If using 3x/week –> SABA + low dose ICS
- SABA + low dose ICS + LTRA (or + LABA)
- can give ICS + LABA as MART - Increase ICS dose
- Trial tioptropium, refer to specialist
- Oral corticosteroids
NOTE: if taking regular steroids, will need more during labour (adrenal cortex chronocally suppressed so cannot make more for stress of labour)
Seizure control during pregnancy (known epileptic)
Monotherapy at lowest dose possible
Carbamazepine & lamotrigine safest - AVOID sodium valproate.
NOTE: lamotrigine (and levetiracetam) plasma levels fall during pregnancy - may need to increase dose.
Additional management of epilepsy in pregnancy
Invite to UK Epilepsy & Pregnancy Register
Counsel:
- medication adherence
- risk of congenital abnormalities
- uncontrolled epilepsy –> foetal hypoxia WORSE than congenital abnormality risk
Folic acid 5mg until 12 weeks
Oral vitamin K 10mg from 36 weeks (if taking enzyme inducing meds)
Additional management of epilepsy in pregnancy
Invite to UK Epilepsy & Pregnancy Register
Counsel:
- medication adherence
- risk of congenital abnormalities
- uncontrolled epilepsy –> foetal hypoxia WORSE than congenital abnormality risk
Folic acid 5mg until 12 weeks
Oral vitamin K 10mg from 36 weeks (if taking enzyme inducing meds)
Delivery in epilepsy
Mode & timing unaffected unless seizure frequency increasing
Epidural recommended - reduced stress –> reduced seizures
Normal changes in thyroid hormones during pregnancy?
TSH falls in first trimeter + free T4 rises
Free T4 falls as pregnancy progresses
Management of hyperthyroidism in pregnancy
Propylthiouracil > carbimazole - use lowest doses possible!
- PTU during 1st trimester
- CBZ in 2-3rd trimester
33% women can stop Tx during pregnancy but re-adjust postpartum
Symptomatic Tx in obstetric cholestasis
Ursodeoxycholic acid
Sedating antihistamines e.g. promethazine
Topical emollients
+ vitamin K 10mg oral tail from 36 weeks
Other aspects of monitoring & tx in Obstetric cholestasis
Consultant led care
Weekly - bi-weeky LFTs + bile acids
2x/week Doppler & CTG until delivery
Advise paying close attention to foetal movements
IOL at 37-38 weeks
6 week follow up with GP to ensure LFTs normalise
Main risks of obstetric cholestasis
Meconium aspiration
Stillbirth
PPH - low vitamin K
Recurrence 45-90%
Main risks of obstetric cholestasis
Meconium aspiration
Stillbirth
PPH - low vitamin K
Recurrence 45-90%
Antenatal care & planning for obese women
Exercise, diet advice BUT advise to maintain not lose weight - impractical during pregnancy + may cause malnutrition
Folic acid 5mg up until 12 weeks Vitamin D Aspirin 75-150mg from 12 weeks OGTT at 24-28 weeks \+ Thromboprophylaxis if BMI 40+
Delivery:
- BMI 35+ = high risk, deliver in consultant led unit
- BMI 40+ = anaesthestic consultation
Cut offs for anaemia in pregnancy
115 = non pregnant 110 = early 105 = late 100 = postpartum
Pemphigoid gestations - presentation
Pruritic bulbous disorder
Late 2nd-3rd trimester
Start on abdomen –> widespread clustered blisters
Spares the face
Polymorphic eruption of pregnancy (PEP) - presentation
Pruritic 3rd trimester or immediately post-partum Lower abdo --> extends to thighs, buttocks, legs, arms Spares umbilicus Lesions usually confluent
Prurigo of pregnancy - presentation
Excoriated papule on extensor surfaces of limbs, abdo, shoulders
Resolves after delivery
Criteria for hyperemesis gravidarum
Severe N+V of pregnancy that causes:
5% pre-pregnancy weight loss
Dehydration
Electrolyte imbalance
Risk factors for hyperemesis gravidarum
Multiple pregnancy Trophoblastic disease Hyperthyroidism Nulliparity Obesity
Smoking = protective
Management of hyperemesis gravidarum
1st line = antihistamine e.g. promethazine, cyclizine, prochlorperazine
2nd line = ondansetron or metoclopramide
- Ondansetron = small increase in cleft lip/palate
- metoclopramide = EPSE
Steroids if severe/refractory
+/- ADMISSION
+/- parenteral thiamine, IV fluids, VTE prophylaxis
Criteria for admission in hyperemesis gravidarum
Continued N&V and:
- unable to keep down liquids or oral antiemetics
- ketonuria and/or weight loss >5% despite oral antiemetics
Confirmed or suspected comorbidity e.g. unable to keep down Abx for UTI
+ lower threshold for admission if pre-exisitng condition that may be exacerbated e.g. diabetes
Symphysis pubis dysfunction / pelvic girdle pain - Tx options
Conservative
- exercises
- warm baths
- support belt
Paracetamol
Threatened miscarriage - features / findings
Vaginal bleeding +/- pain in early pregnancy (<20 weeks)
Closed cervical os
Viable intrauterine pregnancy - gestational sac + foetal heart beat on USS
Inevitable miscarriage - features / findings
Vaginal bleeding +/- abdo pain
Cervical os open - may contain visible blood
Complete miscarriage - features / findings
Previous abdo pain + vaginal bleeding with full expulsion of pregnancy tissue
Closed cervical os
Uterus empty on USS
Missed miscarriage - features / findings
No Sx
Closed cervical os
In utero death - no foetal HR on USS
Most common cause of miscarriage?
Chromosomal abnormalities - 90%
Risk factors for miscarriage
Maternal age Previous miscarriage Uterine / cervix pathology Smoking, EtOH, recreational drugs Extremes of BMI
Recurrent miscarriage - definition + work up
3+ miscarriages
Exclude medication conditions - diabetes, SLE, renal
Bloods
- clotting: factor V leiden, AT-III deficiency
- Abs: lupus anticoagulant, anti-phospholipid, anti-cardiolipin
Cytogenetic analysis of patient + partner / products of conception
TV USS
Recurrent miscarriage - definition + work up
3+ miscarriages
Exclude medication conditions - diabetes, SLE, renal
Bloods
- clotting: factor V leiden, AT-III deficiency
- Abs: lupus anticoagulant, anti-phospholipid, anti-cardiolipin
Cytogenetic analysis of patient + partner / products of conception
TV USS
Management of miscarriage > 6 weeks
Any pain, bleeding >6 weeks (or gestation unknown) –> Early pregnancy assessment service / Out of hours gynae
Expectant Tx: 7-14 days, oral hydration + pelvic rest, close follow up.
Medical tx: vaginal misoprostol, anti-emetics, pain relief. Pregnancy test 3 weeks later.
Surgical tx: manual vacuum aspiration under local, surgical ERPC under GA.
+ anti D if Rh -ve mother and >12 weeks OR any surgical Tx
Management of miscarriage <6 weeks
Bleeding but no pain + no risk factors (e.g. previous ectopic) –> expectant Tx
Pregnancy test in 7-14 days
+ve = review
-ve = miscarriage
Important to remember in diagnosing ‘complete’ miscarriage?
May actually be a PUL if no previous scan to confirm intrauterine pregnancy
Features of miscarriage on USS
Crown-rump length >7mm with no heartbeat
OR gestational sac >25mm + no visible foetal pole
BUT cannot diagnose form 1 USS only - get 2nd opinion and/or re-scan in 7 days (14 days for TA USS)
