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A - ObsNGynae > Obs - Medical disorders in pregnancy > Flashcards

Obs - Medical disorders in pregnancy Flashcards

1
Q

why do fetus’ of mothers with diabetes become microsomic?

A

high fetal blood sugars

fetal islet cell hyperplasia -> hyperinsulinaemia

increased fat deposition

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2
Q

defien gestational diabetes

A

carbohydrate intolerance which
is diagnosed in pregnancy and may or may not resolve
after pregnancy’

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3
Q

what are the thresholds for gestational diabetes diagnosis ?

A

fasting glucose level ≥ 5.6 mmol/L

or >7.8 mmol 2 hours after a 75 g glucose load (glucose tolerance test:GTT)

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4
Q

which pregnant women are most likely to suffer from complications as a result of diabetes?

A

Complications are related to preeconception glucose levels, therefore Gestational DM are less effected

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5
Q

list some fetal complications of DM?

A

Subclassify into trimester!!

Congenital abnormalities eg cardiac defects

Increased birthweight

10% preterm labour

Polyhydramnios due to increased urine output

Shoulder dystocia

Fetal compromise, fetal distress in labour and sudden fetal death - poor 3rd trimester control

Neonatal hypoglycaemia!

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6
Q

list some maternal complications of DM?

A

1st trimester:
Miscarriage

2nd trimester:
 Pre eclampsia more common
 Hypoglycaemic episodes

Generally:
UTI, wound and endometrial infection more common
Diabetic complications accelerate and detriorate:
 Diabetic nephropathy
 Diabetic retinopathy

Intrapartum:
 CS or instrumental delivery more likely

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7
Q

what is the overview of management of DM?

A

Pre-conceptual care:
- optimise health and sugars for pregnancy

Monitoring & Treating DM:
- Consultant led ANC care

Monitoring Fetus:

Monitoring complications of DM:
Renal function and retinae checked
75mg aspirin daily from 12 weeks

Timing/Mode of Delivery:
- delivery on labour ward with neonatal facilities

Neonate and Puerperium:
- Deliver 37-39 wks
- montor carefully as risk neonatal hypoglycaemia due
to hyperinsulinaemic state in utero

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8
Q

what is the target hba1c in glucose control for diabetics?

A

HbA1c level 48mmol/mol (6.5%) or below

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9
Q

what consideratoin would a diabetic mother need in labour?

A

Sliding scale of insulin and dextrose infusion during labour - if required insulin during pregnancy

Monitor capillary glucose every hour during labour and birth and ensure that it is maintained between 4-7 mmol/L

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10
Q

what additional monitoring might a fetus of a diabetic mum reequire?

A

Echo

Umbilical doppler if PET or IUGR

US - growth and liqour

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11
Q

what are the components of pre-conceptual care for diabetics?

A

 Assess renal function, BP and retina
 Optimise glucose control

 Folic acid 5mg/day
 Labetalol or methyldopa as anti-HTN

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12
Q

what is the screening schedule for gestatoinal diabetees?

A

Previous GDM screened at 18 weeks

28 week GTT screening test

Also check if polyhydramnios or persistent glycosuria

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13
Q

when is insulin indicated?

A

Advise diet and exercise then:

If fasting glucose > 7 at diagnosis

If after 2 weeks of Metformin , fasting levels >5.3 before meals,
or >7.8 1 h after meals, go to Step 4 (insulin)

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14
Q

what drugs for DM ar eallowed in pregnancy?

A

metformin and insulin

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15
Q

what can you say about these drugs;

Warfarin and ACEi

A

are teratogenic in pregnancy

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16
Q

which types of heart defects are a problem in pregnancy?

A

Pulmonary hypertension - absolute contraindication

Mitral valve stenosis/regurg - fix before pregnancy

Aortic stenosis - fix before pregnancy

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17
Q

managemnt of epilepsy in pregnancy?

A

Preconception care:
seizure control with as few drugs as possible
5mg folate a day

Carbamazepine and Lamotrigine are safe

10mg vit K given from 36 weeks onwards

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18
Q

risks of epilepsy in pregnancy?

A

seizure control worse = more seizures

neural tube defect risk with drugs

3% risk of baby getting epilepsy

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19
Q

most common cause of hypothyroid in pregnancy?

A

Hashimoto’s thyroiditis or thyroid surgery

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20
Q

risk of hypothyroid in pregnancy?

A

miscarriage, pre-term delivery and intellectual impairment in childhood

PET if antithyroid antibody

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21
Q

management of hypothyroid and hyperthyroid in pregnacy?

A

Hypothyroid:
thyroxine  6 weekly monitoring

Hyperthyroid:
propylthiouracil (low dose - can still cross placenta)

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22
Q

risk of graves disease in pregnancy?

A

Antithyroid antibodies cross placenta -> neonatal thyrotoxicosis and goitre

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23
Q

how does postpartum thyroditis present and risk in pregnancy?

A

Usually subclinical hyperthyroidism (3m post partum) followed by 4m of hypothyroidism

this hypothyroidism can be permanent in 20%

can cause post natal depression

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24
Q

how does obstetric cholestasis present?

A

itching WITHOUT skin rash WITH abnormal LFTs

and/or raised serum bile acid

Both resovle post delivery

(itching - soles of feet and palms of hand typical)

25
Q

what are the complications of obstetric cholestasis?

A 
Fetal
fetal arrhythmia - > stillbirth
Premature birth
Meconium passage
IUGR

Maternal:
Intense itching affects sleep and overall well-being
Maternal PP haemorrhage (uncharacterised)

26
Q

rx of obstetric cholestasis?

A
  1. Bile acids <40 symptomatic
    Monitor lfts weekly form diagnosis till delivery
Medical:
Topical emollients for itch e.g. Diprobase
Antihistamines
• Cholestyramine + Vit K
• Ursodeoxycholic Acid
  1. Bile acids >40 micromol/L (severe cholestasis) and gestational age <37 weeks

§ Medical
• Ursodeoxycholic Acid or phenobarbital (sedative side-effects)
• Dexamethasone (DM excluded) for symptom relief and prepare foetal lung development for potential preterm delivery - dont give unless in an RCT!

• VitAMIN K daily from 36 wks - if PT prolonged

Intrapartum:
o Offer induction of labour (IOL) at 37 weeks

MONITORING:
LFTS, doppler+ctg

27
Q

pregnant woman presents with

Malaise, vomiting, jaundice and vague epigastric pain and thirst.

what is the dfx?

A

Acute fatty liver of pregnancy

28
Q

what is the rx of acute fatty liver of pregnancy?

A

Critical care support
o IV fluids
o 10% dextrose IV
o Coagulopathy screen every 4-6 hours to asses for DIC
o Continuous foetal monitoring
o Dexamethasone if <37 weeks gestation
o Magnesium sulphate if <32 weeks gestation

• Delivery as soon as possible

29
Q

presence of lupus anticoagulant and/or anticardiolipin antibodies indicates?

A

Antiphospholipid Syndrome

30
Q

list some complications of Antiphospholipid Syndrome and why

A

Placental thrombosis  recurrent miscarriage, IUGR and early preeclampsia

high fetal loss

31
Q

how is Antiphospholipid Syndrome managed?

A

Aspirin and LMWH - only if high antibody level - low levels normal

high risk pregnancy - consultant led care

postnatal LMWH

32
Q

what are the diagnostic criteria for APLS?

A

1 or more of Clinical criteria:

o Vascular thrombosis
o 1+ death of fetus >10 weeks
o PET or IUGR requiring delivery <34 weeks
o 3+ fetal loss <10 weeks, otherwise unexplained

+ laboratory criteria measured twice >3 months apart
o Lupus anticoagulant
o High anticardiolipin antibodies
o Anti-B2 Glp I ab

33
Q

what are the common sites of thromboses in pregnancy?

A

Thromboses

are normally ileofemoral and more common in the left than the right.

34
Q

how would you ivx and mx a patient with suspected dvt?

A

basic ivx on everyone -> cxr, ecg, bloods,
start lmwh

clinical sx and signs of dvt :
Yes - compression duplex ultrasound leg

No:
CXR abnormal - CTPA
CXR normal - V/Q scan

if nothing found but still high suspicion DVT -continue LMWH whilst lookinig for alternate diagnosis

35
Q

how is obesity ivx/ managed in pregnancy?

A

Preconception:
diet and exercisie advise for weight reduction
5mg folate
viitamin d

Pregnancy:
do not lose weight pregnancy - malnutrition
high riisk bmi >35

36
Q

how should BPAD be managed in pregnancy ?

A

 Lithium frequently used and associated with increased rate of cardiac abnormalities

 Discontinuation risks relapse – only stopped in those well or low risk

 Monthly monitoring of lithium levels during pregnancy as increased excretion during pregnancy

37
Q

which antidepressant is contraindicated in pregnancy ?

A

paroxetine - cardiiac defects

38
Q

which treatments can you NOT use in schizophrenia?

A

clozapine and olanzapine

39
Q

how would you help some1 with opiate dependency?

A

opiate replacement: Methadone maintenance

40
Q

what is the risk of benzo use in pregnancy?

A

cleft lip

neonatal hypotonia and withdrawal sx

41
Q

A woman comes in to ANC, their bloods show that they are anaemic

list the causes of a anemia in pregnancy?

A

o Inadequate intake
o Poor absorption - coeliac etc
o Haemolysis e.g. sickle cell

o Excessive demands e.g. twins
o Vaginal loss or pre-existing haemorrhage

42
Q

how is anaemia managed?

A

Considier folate and B12 deficiency (prescribe if so)

Antenatal
o 100-200 mg oral iron (ferrous sulphate)
- iV iron in severe cases
§ Re-check Hb in 2-3 weeks

• Intrapartum may require
o Active management of 3rd stage
o Active management of PPH
o Consider prophylactic syntocinon infusion

43
Q

what is the aetiology of sickle cell?

A

Inherit 2 abnormal copies of B globin gene on chromosome 11.

Abnormal beta chain formation (S chain)
-> Abnormal Hb molecule: 2 alpha and 2 S

44
Q

what is the screening for sickle cell and thalssaemia?

A

all pregant women get elctrophoresis

if are heterozygote - get prenatal diagnosis i.e. amniocentesis or CVS to see if baby has it.

45
Q

what is the prognosis and rx of alpha thalssaemia?

A

Four gene deletions -> death in utero

Heterozygous  one or two deletions -> anaemic and require folate + iron

46
Q

what is the prognosis and rx of beta thalssaemia?

A

Homozygous: affected by iron overload and pregnancy unusual, give folate, NO iron

Heterozygous: chronic anaemia, worsens during pregnancy

47
Q

what are the types of FGM?

A

• Type 1: Clitoridectomy: partial or total removal of
the clitoris, or of the prepuce.

• Type 2: Excision: partial or total removal of the clitoris
and the labia minora, ± the labia majora.

• Type 3: Infibulation: narrowing of the vaginal opening
by cutting and repositioning the labia, with or without
removal of the clitoris.

• Type 4: Other: all other non-medical procedures to
the female genitalia for non-medical purposes.

48
Q

When is LMWH given in pregnancy based on VTE score?

A

Vte of 4 = lmwh from start of pregnancy
Vte of 3 = lmwh from 28 weeks

Vte < 3 = mobilisation and hydration

Lmwh used is clexane

Postpartum - reassess
Vte 2+ = lmwh for 10days
High risk eg previous vte = lwmh for 6 weeks

49
Q

Which kind of monitoring is needed in the following:

  1. 1st plot below 10th centile
  2. Static fundal height
  3. Fundal height slowly decreasing
  4. Steep rise in fundal height centile
A

1-3 growth scan
4 - obstetric ANC referral

Obviously all your basic things eg : CTG

50
Q

Lady comes in and is pregnant, she has hx of severe depression, is not currently on any meds. How would you approach?

A

Take hx - screen current mood -
Current risk assessment - whooley questions: any thoughts to harm yourself

NICE - (May need to:) start psychological intervention - assess need for for meds

Refer to prenatal mental health team
Refer to obstetrician for appointments

51
Q

how do you screen for and manage mental health in pregnant women?

A

At booking, ask:

Whooley questions (depression)
GAD-2  (anxiety)

If yes to any of above questions do PHQ9, Edinburgh PNDS.

Then refer to GP or mental health personnel

52
Q

What are the crucial questoins to ask if suspecting mental health (or to incorporate into any hx)

A
  1. Hx and fox mental health
  2. Physical health problems
  3. Alcohol and drug use
  4. Atttude and experience of pregnancy
  5. Relationship with baby
  6. Current or past rx for mental health
53
Q

A woman books for pregnancy at 13 weeks. she is currently on lithium and has been for some months. how would you counciil her?

A

Confirm pregnancy

May be able to continue drug, often not - seek psychiatry input.

Explain: stopping or changing drug may not remove risk of malformation

Offer screening for fetal anomalies

Offer councelling about continuing pregnancy

54
Q

what counts as severe cholestasis?

A

Bile acids >40micromol/L

55
Q

what are the risks in severe cholestasis?

A

all the risks associated with IHCP are increased so risk of preterm birth etc.

56
Q

what is the prognosis of Obstetriic cholestasis? how can it be predicted?

A

poor outcome cannot be predicted by the biochemical results.

Fetal monitoring isnt particularly predictive of its outcome either. continuous ctg recommended.

all the treatments given are for symptomatic relief, rather than to solve the issue. there is no evidence that theese therapies help prevent fetal stillbirth eetc

57
Q

how do you different a diagnosis of GDM from pre-existing diabetes?

why do we need to do this?

A

Measure HbA1c at the time of diagnosis in newly diagnosed GDM to identify those with pre-existing undiagnosed T2DM

Women with preexisting DM likely to fair less well.

Intrapartum:
o Advise women with T1DM or T2DM to have elective birth by induction
of labour or elective C-section between 37-39 weeks
o Consider birth < 37 weeks if there are complications
o Advise women with GDM to give birth no later than 40+6 weeks

58
Q

complications of vq scan vs ctpa?

A

CTPA - increased risk of breast cancer

VQ scan - increased risk of childhood cancer

59
Q

what is Ebsteins anomaly?

A

Ebstein anomaly is a rare heart defect in which the tricuspid valve — As a result, blood leaks back through the valve and into the right atrium.

symptoms; cyanosis, breathlessness

child adviised to avoid sports but mainly well.

A - ObsNGynae (37 decks)

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