Obs & Gynae Flashcards
Risk Factors of PET? (pre-eclampsia)
Nulliparity Afrocarribean Prior Hx of PET Extremes of maternal age FH Multiple pregnancy Chronic HTN
Triad of diagnosis of PET?
Hypertension
Proteinuria
Pitting oedema
PET Symptoms?
RUQ pain Severe headache/blurred vision Pitting oedema - swollen face Seizures Reduced foetal movement
What is HELLP syndrome?
Haemolysis
Elevated liver enzymes
Low platelets
It is associated with PET and gestational hypertension - however is different from both of these.
Risk factors for miscarriage?
Increasing maternal age
Increased gravidity
Prior miscarriage
Smoking
Presentation pf miscarriage?
PVB, cramping abdo pain
BhCG - will be over 1000, but rapidly decreasing over repeated measurements
Speculum may see products of conception
Reasons for miscarriage?
Chromosomal abnormality - normally trisomy of some kind
Abnormal development
Uterine defects
Infection/environment
Trauma- although must be major
Types of miscarriage?
Threatened
Incomplete
Complete
Missed
Septic
Treatment of miscarriage?
Conservative
- let it happen naturally. Can happen in a few days/weeks
- bleeding can last for 2/3 weeks, severe bleeding or pain should only last 1-2 hrs
- causes infection in 1 in 4 women
- delay in all the tissue being expelled
Surgical
- operation under GA
- risks such as uterine perforation and infection and major bleeding
Medical
- misoprostol vaginal pessaries (4 pessaries)
- induces the miscarriage
- heavy bleeding and pain
- infection risks are low
- 1 in 100 risk of blood transfusion due to massive haemorrhage
Phases of the menstrual cycle? When does menstruation occur?
Follicular phase (Day 1-14)
Ovulation (Day 14)
Luteal phase (14-28)
Menstruation occurs right at the end of the cycle around day 28/day 1.
Synopsis of the Hypothalamic-Pituitary-Ovarian axis?
Hypothalamus releases Gonadatrophin releasing hormone (GnRH) every 90mins
Anterior Pituitary releases LH and FSH
LH acts on the ovaries to stimulate Oestrogen and Progesterone production (progesterone in luteal phase)
FSH stimulates the growth of follicles in follicular stage.
Synopsis of the actions of the pituitary hormones and the ovarian hormones in the menstrual cycle.
LH:
Rises steadily until day 14 where here is an LH surge causing the rupture of the primary follicle and release of the ovum.
FSH:
pretty stable apart from slight increase at day 14 (Oestrogen feedback)
Oestrogen:
Increase from day 5 to day 13 (produced by developing follicle) This also causes the LH surge - positive feedback.
Progesterone:
Stable until day 16 or so when the corpus luteum starts synthesising - this decreases at day 23 if the corpus luteum regresses.
Hormonal changes in menopause?
LH increases, FSH increases more consistently and this can be used as a diagnostic test (>30).
Oestrogen and Progesterone both decline.
Pros and Cons of HRT?
Pros:
Osteoporosis risk decreased
Reduction of symptoms (not depression)
Cons:
Small increased risk of breast and uterine cancer
Side effects of nausea and breast tenderness
VTE risk in first year
Stroke risk
Ectopic symptoms?
Vaginal bleeding - dark brown
Pelvic pain
Shoulder tip pain
Amenhorroea
Bowel symptoms
Fainting/dizziness
Common causes of PPH?
Uterine atony (most common)
retained placenta
Vaginal and Vulval lacerations
What is uterine atony?
When the uterus can no longer contract leading it bleed profusely.
Definition of PPH?
> 500ml of blood loss within 24 hour of delivery
500-1000ml is minor
>1000ml is major
Way to calculate EDD?
Add 9 months and 1 week to LMP
What is thought to be the cause of hyperemesis gravidarum?
High circulating levels of hCG
causes of IUGR?
Smoking (30-40% of cases) Alcohol HTN Diabetes PET
What does asymmetrical intrauterine growth restriction (normal head circumference with reduced abdominal circumference) suggest?
Placental insufficiency - If the placenta is not supplying adequate blood to the fetus the body directs prioritises brain development at the expense of the body. As a result the abdominal circumference decreases whilst the head circumference remains normal.
Complications of induction?
Uterine hyper stimulation
Prolapsed cord
Section needed
Uterine rupture
When do women begin feeling foetal movement?
At 18-20 weeks
What does symmetrical IUGR normally represent?
It normally represents some kind of foetal abnormality - normally chromosomal.
Two types of abortion?
Medical termination
Surgical
Process of medical abortion?
Mifepristone (antiprogesterone) (600mg) followed by Misoprostol (prostaglandin analogue) (gemeprost 1mg) 48 hours later
> 50% abort within an hour of misoprostol dose
Rough process of surgical abortion? Types?
Cervix is first dilated then uterine cavity is manually evacuated.
Manual vacuum aspiration (6-7 weeks)
Electric vacuum aspiration (6-15 weeks)
Dilatation and evacuation (GA, due to larger size)
How do you do a late pregnancy termination? When would you?
20-24 weeks:
3 methods:
- Dilatation and extraction, KCl or Digoxin to stop fetal heartbeat, then GA and removal of fetus using sopher forceps.
- Induction of labour with misoprostol/mifepristine/oxytocin
- Intra amniotic infusion of hypertonic saline and/or prostaglandin to induce contractions.
Definition of spontaneous miscarriage?
Spontaneous miscarriage:
- loss of recognised pregnancy before 20 weeks or <500g
Types of spontaneous miscarriage?
Threatened miscarriage:
- Closed cervical os with uterine bleeding <20 weeks & confirmed viable gestation.
Inevitable miscarriage:
- Heavy bleeding clots & pain
- Open cervical os
- Pregnancy will miscarraige
Incomplete:
- partially expelled contents
Complete:
- Hx of bleeding and U/S has confirmed no gestation.
Missed:
- Foetus is dead but has not ben expelled
- (early foetal demise)
- Early pregnancy symptoms have gone
- Preg test may still be positive
- Continuous brown discharge & threatened miscarriage
Recurrent:
- Three or more sequentially
Principles of antenatal care?
Educate on normal changes in pregnancies
Identify maternal R/Fs
Screen for fetal problems
Preconception antenatal care? (3)
- Folic acid 3 months prior to conception
- Avoid teratogenic drugs
- Preconception counselling
- Lifestyle changes: Alcohol, smoking weight
- Stabilise medical disorders
Food hygiene advice for pregnancy?
Seafood:
- nothing raw
- 2 portions of fish a week
- No Shark/Swordfish
Don’t eat anything unpasteurised
No raw eggs, or raw meat
Avoid soft cheese
No raw sprouts
Limit caffeine to <300mg daily
Antenatal care at booking (first appointment - as soon as preggers)?
Vitamin D 10mcg from day of booking
Food hygiene advice
Screening
Risk factors for Gestational Diabetes?
Previous large baby >4.5kg 1st degree relative with diabetes Family origin with high prevalence of diabetes (South Asian, black Carribean, Middle Eastern, ) PCOS BMI>30 On any antipsychotic medication
What is MBRRACE UK?
Runs a national programme monitoring and investigating the cause of maternal and fetal deaths in the UK.
Maternal screening?
Medical Screening:
- Pre-existing conditions
- Risk Factors for conditions (PET/GDM)
- HIV, Hep B, Rubella, Syphilis
- Anaemia
- BP
- Blood group (Rhesus status)
- Gestational diabetes
- Placenta praevia
Other screening:
- BMI
- Domestic violence
- Mental health problems
- Migrant women:
- Cardiovascular
- Female Genital Mutilation (FGM)
Scans and screening for the fetus?
Dating scan @ 8-14 weeks
Combined test @ 11-13+6 weeks
- Screening for chromosomal disorders
- Take both blood and nuchal scans
QUAD test @ 15-16 weeks
- alpha-fetoprotein (AFP)
- total human chorionic gonadotrophin (hCG)
- unconjugated oestriol (uE3)
- inhibin-A (inhibin)
Anomaly scan @ 18-20+6 weeks
Growth scans @ (24)-28-32-36 weeks
When can you do SFH measurement from?
24 weeks
What is the puerperium?
Period of time following the birth of the baby ~ 6 weeks
Maternal issues in the puerperium?
Mood:
- Watch out for post-natal depression
- 50% experience low mood, typically in the first week
Nutrition:
- iron rich foods
- Anaemia post pregnancy is common
Involution
- Uterus returns to normal size and position
- Afterpains: Contractions experienced after birth, can be due to oxytocin release when breastfeeding
CSC healing
Lochia (vaginal discharge post-partum
Perineal pain:
- Pelvic floor exercises
Urine output:
- exclude urinary retention
- Think about incontinence
Bowel movements:
- Constipation
- Haemorrhoids
- Urgency and soiling - rule out anal sphincter damage
Legs:
- Exclude DVT/VTE
What is puerperal fever? 5 causes?
Infection post-partum (in the puerperium)
- genital tract/uterine
- UTI
- Breast infection
- VTE
- Other. e.g. flu
Things to consider in perinatal mental health?
- Stress of transition to motherhood
- Postnatal blues
- Postnatal depression - suicide risk
- Traumatic birth - PTSD
- puerperal psychosis.
Physiological endocrine & metabolic changes during pregnancy?
Endocrine:
- FSH and LH drop
- Prolactin increases
- Cortisol increase (lipogenesis and fat storage), followed by insulin.
Metabolic:
- BMR increased by 15-20%, slowly over the course of the pregnancy
- 12-16kg weight gain is recommended
Physiological CVS & haematological changes during pregnancy?
CVS:
- Peripheral vasodilatation
- Cardiac output increases by 20% by week 8, then up to 40%
- Increase in SV and HR
- systolic murmurs are normal, diastolic are not
- Third heart sound is normal
Haematological: - Plasma volume increased by 50% - Dilution anaemia is caused by this - Increased iron demand -
Physiological respiratory changes during pregnancy?
Respiratory system:
- Tidal volume increase by 200ml
- Increased vital capacity and decreased residual volume
- 20% increased oxygen consumption
Physiological renal changes during pregnancy?
Renal:
- GFR increase
- Reduced Urea, creatinine and bicarb
Other general physiological changes during pregnancy?
Others:
- Nausea and vomiting is common
- Appetite is usually increased
- Heartburn
- Constipation is common (motility decreased to increase nutrient absorption
2012-14 maternal mortality?
8.5 per 100,000 (was 90 in 1952)
What is an indirect and direct death in maternity?
Maternal death is death while pregnant or within 42 days of birth
Indirect:
- Deaths resulting form pre-existing disease, or developed during pregnancy as a result of physiological changes of maternity
Direct:
- Death from obstetric complications: interventions, omissions or incorrect treatment.
Top causes of maternal death?
- Cardiac disease
- Sepsis
- Neuro
- Other
What are late and coincidental maternal deaths?
Late:
- between 42 days and 1 year after birth, that are as of a result of direct or indirect causes
Coincidental:
- Deaths that happen to occur in the pregnancy period but are not related
Two big R/F for maternal death in the UK?
> 35
Black ethnic minorities
Physiological changes that affect insulin in pregnancy, and may cause GDM?
- Insulin antagonists are produced by the placenta.
2. Increased insulin resistance (especially 3rd trimester) leads to increased insulin production in normal women
Effect of pregnancy on diabetes complications (type 1)?
Increased insulin requirements (as increased insulin resistance):
- Tight control can lead to hypoglycaemia
- associated with maternal death - diabetic nephropathy and retinopathy may deteriorate
- DKA may occur (should provide home ketone testing kit)
Effect of diabetes on pregnancy complications (maternal and fetal factors)?
Maternal:
- Antepartum haemorrhage
- PET
- Premature labour
Fetal:
- Microsomia (IUGR)
- Macrosomia
- Shoulder dystocia
- Risk of sudden fetal death
- Congenital abnormalities
- Hypoglycaemia
What HbA1c level are we aiming for before pregnancy?
48mmol/mol
Shouldn’t have pregnancy if >86mmol/mol
pre-pregnancy planning for diabetic women?
Stop teratogenic drugs associated e.g. ACE inhibitors, statins
Retinal screen
Renal screen
?Basal-bolus insulin regime
What basal/bolus regime do they use in pregnancy?
Rapid acting insulin for each meal
Long acting at bedtime
What level of glycaemic control are we aiming for during pregnancy?
Fasting: < 5.3mmol/L
1 hour post-prandial <7.8mmol/L
What medication should you give when managing diabetes in pregnancy?
T2DM should continue metformin and often need insulin
Aspirin 75mg from 12 weeks (for PET risk)
Extra scans for diabetes in pregnancy?
Early dating scan and anomaly scan
4 weekly growth scan from 28 weeks
When should you deliver for diabetes in pregnancy?
37 - 38+6
What extra should you do during delivery with a woman who has diabetes?
Good glycaemic control peridelivery - to reduce risk of fetal hypoglycaemia:
- can give infusion
If preterm start steroids and insulin infusion
GDM risks to pregnancy?
Macrosomia, birth trauma, shoulder dystocia, increased induction, increased LSCS, pre-eclampsia
Neonatal hypoglycaemia, polycythaemia, increased perinatal mortality rate
How and when do you test for GDM?
2-hour 75g oral glucose test (OGTT) for women with risk factors for GDM at 26-28 weeks:
- Only water from midnight
- Fasting blood glucose
- 75g glucose challenge
- 2-hour blood glucose
GDM if fasting ≥5.6 mmol/l or 2-hour ≥7.8 mmol/l
In those with previous GDM, either early self monitoring or early OGTT (repeat 26-28 weeks if early OGTT normal).
Management of GDM antenatally?
Explain implications
- Glucose control will reduce risk of macrosomia
- Trauma during birth
- Induction of labour
- C section
- Neonatal hypoglycaemia
- Perinatal death
Teach self monitoring
Diet (low GI) and exercise advice
4 weekly growth scans from 28 weeks
Delivery by 40+6 weeks
GDM management during labour?
May need insulin infusion (maintain glucose within 4-7mmol)
Check blood glucose before leaving explain that insulin requirements rapidly decrease, and may need to stop treatment
Baby needs early feeding and hypoglycaemia management
6-13 week fasting blood sugar test to exclude diabetes, as risk of T2DM in future
How do you manage hypoglycaemia in the pregnant woman?
Pretty much as you would in a non-pregnant lady
Mild (3-4mmol/L)
Administer 10-20g of fast acting glucose:
- 150 - 200ml fruit juice
- 3-4 heaped teaspoons dissolved in water
Moderate (2-3mmol/L)
- 1-2 cubes of dextrose gel
Severe (<2mmol/L)
- ABCDE
- IM glucagon 1mg
- Consider IV glucose bolus
Check glucose level every 15mins, when >4mmol/L eat 15g of carbs - brown bread, banana, digestive biscuits
Recheck glucose again (after 15mins)
What level of glucose is hypoglycaemia
4 ‘hit the floor’ : <4mmol/L = hypoglycaemia
Symptoms of Hypoglycaemia Mild-Severe?
Mild:
- Trembling, sweaty, hungry, palpitations, nausea
Moderate:
- Confusion, weakness, drowsiness, headache, dizzy, nausea
Severe:
- Unconscious/fitting
DKA pathophysiology?
Insulin deficiency:
- Increased glucagon, cortisol, GH, catecholamines
- Peripheral insulin resistance
Lead to
Hyperglycaemia, dehydration, ketosis, electrolyte imbalance
Lipolysis and decraesed lipogenesis = Ketone bodies and acidosis
Hyperglycaemia induced osmotic diuresis:
- Dehydration
- Hyperosmolarity
- Electrolyte loss
- Potassium deficiency
DKA presentation?
High blood glucose (>15mmol/L)
Polyuria
Polydipsia
Lethargy
Blurry vision
Abdo pain, nausea and vomiting
Collapse/unconscious
Difference with DKA in pregnancy? Management?
Can occur at much lower glucose levels.
Need to always consider in anyone with diabetes who is unwell
Always check blood ketones
Fetal monitoring
VTE prophylaxis
Management consists of fluid replacement, insulin and potassium replacement. Address cause.
Refer to diabetes team
Physiological/physical changes to coagulation in pregnancy?
Increased levels of clotting factors (i.e. fibrinogen and prothrombin).
Reduced levels of endogenous anticoagulants
- Slight increase in fibrinolysis (but not enough to offset the original changes)
ALSO baby is compressing vessels in pelvis (left common iliac vein)
R/Fs for VTE in pregnancy?
Prev. VTE
Thrombophilia
> 35
Smoking
Obesity
Immobility
Infection
Surgery
PET
Very high risk factors, high risk factors, intermediate R/Fs and for VTE in pregnancy?
Very high:
- Previous VTE with long-term anticoagulant therapy
- Antithrombin deficiency
- Antiphospholipid syndrome
High risk:
- Prev. VTE (without Tx)
Intermediate risk:
- High risk thrombophilia
- Single prev. VTE assoc. w/ surgery with no throbopilia or FH
Low risk:
- Low risk thrombophilia
Manangement of VTE risk Very high to Low?
Very high:
- Antenatally High dose LMWH, and 6 weeks postnatal anticoag
High:
- Antenatal and 6 weeks postnatal LMWH
Intermediate:
- LMWH from 28 weeks to 6 weeks post natal
Low:
- Just consider as R/F
Contraindications to LMWH?
Known bleeding disorder
Active Antenatal/postpartum bleeding
Placenta praevia
Stroke in prev. 4 weeks (either type)
Severe renal/liver disease
Can you use aspirin or warfarin as an anticoagulant in pregnancy?
Aspirin - no
Warfarin - only postnatally
VTE presentation in pregnancy?
Can be non-specific and asymptomatic, however can present classically:
- As DVT (calf swelling, tenderness)
- As PE (Dyspnoea, chest pain, cough, tachycardia and tachypnoea)
Investigation for DVT in pregnancy?
Leg compression duplex US/S
ECG
CXR
FBC, LFTs, U&Es, Clotting
V/Q or CTPA
D-Dimer NOT reliable in pregnancy
VTE treatment?
LMWH
Thrombolysis
IVC filter
IV hep
Thoracotomy, embolectomy