OBGYN Flashcards
Risk factors of gestational diabetes
- Previous macrosomic baby (≥4.5kg)
- BMI >30kg/m2
- Polycystic ovarian syndrome (PCOS)
- Previous gestational DM
- DM in a first-degree relative
- Family origin associated with high prevalence of DM: South Asian
(especially Indian subcontinent); black Caribbean; Middle eastern
Effects of gestational diabetes on the fetus
Large for dates or IUgR
fetal hyperinsulinaemia
increased risk of congenital abnormalities (cardiac, renal, and neural tube defects)
hypoxia and intrauterine death (especially >36wk)
Effects of gestational diabetes on baby postnatally
Hypoglycaemia
transient tachypnoea of the newborn or
respiratory distress syndrome
neonatal jaundice
Effects of gestational diabetes on mother in pregnancy
First-trimester miscarriage
premature labour
pre-eclampsia
pyelonephritis
polyhydramnios
increased retinopathy
Effects of gestational diabetes on mother during labour
Fetal distress; obstruction (especially shoulder dystocia)
management of diabetes pre-pregnancy
Suggest counselling via a diabetic specialist.
Pay careful attention to diabetic control (aim blood glucose level 4–6mmol/L pre- meals).
Advise folate supplements 5mg od until 13wk.
Stop drugs contraindicated in pregnancy, e.g. ACe inhibitors, sulfonylureas.
management of pre-existing diabetes during pregnancy
Refer to an obstetrician early.
Most women with type 1 DM continue to use their pre-pregnancy insulin regimen but requirements increase 2–3× in pregnancy.
Metformin is safe in pregnancy for women with type 2 DM.
USS is used to monitor fetal growth and exclude structural abnormalities.
Delivery should always take place in a specialist unit with neonatal care facilities.
management of GDM
Initially diet; some may require metformin (unlicensed) and up to 30% require insulin.
Insulin is stopped immediately postpartum.
Check a 6wk postpartum oral glucose tolerance test.
gestational DM usually recurs in future pregnancies; >30% develop DM in <10y.
Maria is a 32 year old woman who has attended you for her first antenatal first. Her LMP was 5 weeks ago. She has never been pregnant before. She has a past medical history of depression and is currently prescribed escitalopram 10mg OD. She lives with her husband and their two cats. She works as a primary school teacher and enjoys running at the weekends. She does not smoke or drink alcohol.
What advice would you give Maria at the first antenatal visit?
Early pregnancy counselling p 762.
Avoid changing the cat litter tray
Recommend influenza and pertussis vaccination
Folate supplementation (0.4m/ (400 micrograms/ d from when pregnancy is being planned until 13wk gestation)
OTHERS for revision
Stop smoking (miscarriage, ectopioc, low birth weight, praevia, abruption, cleft deformaities etc.)
Stop alcohol (Fetal alcohol syndrome, miscarriage)
Stop illicit drugs (poor motor skills in cannabis etc)
Does having one or two miscarriages put the person at significantly increased risk of having another?
Nope
How much folate recommended during pre-pregnancy/ early pregnancy counselling? Until waht time should it be taken?
0.4mg/400micrograms every day from stopping contraception until 13wk pregnant
Maria attends you for a first antenatal appointment. She is 5 weeks into her second pregnancy. She had a missed miscarriage diagnosed at 12 weeks on her last pregnancy. She is feeling well and taking folic acid.
Your clinical examination is as follows:
Urine HCG: positive
Urinalysis: no abnormality
BMI: 30
Blood pressure: 112/58 mmHg
Abdomen: Fundus not palpable
What are the components screened furing first antenatal visit?
Screening the mother:
All pregnant women having screening blood tests at their first antenatal visit in the maternity hospital. These are:
1. FBC to screen for anaemia
2. Group and rhesus status to identify women who are Rhesus negative
3. Infectious disease screen (HIV, Hep B & C, Syphilis)
4. Immunity to Varicella and Rubella
The urine is also screened for asymptomatic bacteriuria and for chlamydia and gonorrhoea in women aged < 25 years.
Screening for haemoglobinopathies is offered to those of African or Mediterranean origin.
During routine antenatal visits the urine is checked for protein and the blood pressure monitored to screen for pre-eclampsia.
Women with risk factors are screened for gestational diabetes between 24 - 28 weeks gestation. OHGP p. 786
Psychiatric illness is screened for at every visit especially the first visit and the post natal visits.
Screening the baby:
Non invasive prenatal testing: NIPT involves detecting fetal DNA in the maternal blood stream. It is used to screen for genetic conditions such as Down’s syndrome, Patau’s syndrome and Edward’s syndrome. It is not available on the public system. It is a sensitive screening test but the results are not conclusive and must be confirmed with invasive testing such as amniocentesis. Whether or not to have NIPT is a preference sensitive decision. The woman should be adequately informed about the risks and benefits so that she can make an informed decision.
Most maternity units offer a fetal anomaly scan between 18 -22 weeks gestation to screen for problems with the baby such as spina bifida or congenital cardiac anomalies.
Maria attends with her two weeks old baby Tom for his routine 2 week check. He was born by spontaneous vaginal delivery at 39 weeks and had a birth weight of 3.5kg. He was discharged with Maria to the care of the community midwives the day after birth. He is exclusively breastfed. Maria says he is feeding frequently every 2 to 3 hours and sometimes more frequently than that in the evenings. Sometimes he will sleep for a four hour stretch. He has plenty of wet and dirty nappies. She has no pain or discomfort while breastfeeding.
She is worried he may not be getting enough milk and is asking for your advice about topping up with formula.
Tom’s examination is entirely normal. His weight today is 3.6kg.
What advise do you give?
Select one:
a. Advise her to top up with 30ml of formula after every breastfeed
b. Refer her to a lactation consultant
c. Advise her to space the feeds out to every 3 hours
d. Advise her to continue to feed on demand and refer her to the local breastfeeding support group
e. Advise her to express milk and top up using expressed milk
Breastfeeding is the preferred method of infant feeding. It is associated with reduced risk of infection to the baby, reduced childhood obesity, possibly reduced incidence of childhood atopy and helps with maternal weight loss and reduced maternal risk of breast cancer.
Breastfeeding rates are low in Ireland. Concern about supply is a common reason for discontinuing breastfeeding.
Most breastfed babies lose weight in the first few days of life. At the two week check most babies will have regained their birth weight. A lot of mothers find breastfeeding demanding and exhausting and benefit from support. If a baby is gaining weight and the mother has no pain when breastfeeding these are signs that breastfeeding is going well.
Common breastfeeding problems OHGP p 849
answer is D
