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3a Women's Health > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

What is the most common site for an ectopic pregnancy?

A

Fallopian tube

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2
Q

Where (apart from the fallopian tube) can an ectopic pregnancy implant?

A
  • Entrance of the fallopian tube (cornual region)
  • Ovary
  • Cervix
  • Abdomen
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3
Q

Name some risk factors for a ectopic pregnancy

A
  • Previous ectopic pregnancy
  • Previous PID
  • Previous surgery to the fallopian tubes
  • Intrauterine devices (coils)
  • Older age
  • Smoking
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4
Q

At what weeks of gestation does an ectopic pregnancy typically present?

A

6-8 weeks of gestation

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5
Q

What are the classic features of an ectopic pregnancy?

A
  • Missed period
  • Constant lower abdominal pain in the RIF or LIF
  • Vaginal bleeding
  • Lower abdominal or pelvic tenderness
  • Cervical motion tenderness (pain when moving the cervix during a bimanual examination
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6
Q

What are two additional questions to ask if you suspect an ectopic pregnancy?

A
  • Dizziness or syncope (blood loss)
  • Shoulder tip pain (peritonitis)
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7
Q

What is the gold standard investigation for an ectopic pregnancy?

A

Transvaginal ultrasound scan

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8
Q

What finding is seen on a transvaginal ultrasound for an ectopic pregnancy?

A

A gestational sac containing a yolk sac or fetal pole may be seen

  • Sometimes a non-specific mass is seen within the tube → mass containing an empty gestational sac = ‘blob sign’, ‘bagel sign’ or ‘tubal ring sign’
  • A mass representing a tubal ectopic pregnancy = moves separetely to the ovary (mass may look similar to corpus luteum, however, a corpeus luteum = will move with the ovary)
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9
Q

Apart from the empty gestational sac, what are other features of an ectopic pregnancy?

A
  • Empty uterus
  • Fliud in the uterus (may be mistaken as a gestational sac ‘pseudogestational sac’)
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10
Q

What is a pregnancy of unknown location (PUL)?

A

PUL = when a woman has a positive pregnancy test + no evidence of pregnancy of the ultrasound

In this scenario, an ectopic pregnancy cannot be excluded, and careful follow up needs to be in place until a diagnosis can be confirmed.

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11
Q

What can be tracked to monitor a pregnancy of unkonown location (PUL)?

A

Human chorionic gonadotrophin (hCG)

(The serum hCG level = repeated after 48 hours - to measure the change from baseline)

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12
Q

What produces hCG?

A

The syncytiotrophoblast = produces hCG

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13
Q

What will happen to the hCG levels from baseline for an intrauterine pregnancy?

A

hCG will double every 48 hours = suggests an intrauterine pregnancy

(This will not be the case in a miscarriage or ectopic pregnancy)

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14
Q

What % rise in hCG indicates an intrauterine pregnancy?

A

More than 63% rise in hCG = indicates intrauterine pregnancy

  • A repeat ultrasound scan is required after 1 – 2 weeks to confirm an intrauterine pregnancy.
  • A pregnancy should be visible on an ultrasound scan once the hCG level is above 1500 IU / l.
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15
Q

What % rise in hCG indicates an ectoptic pregnancy?

A

A rise less than 63% = indicates an ectopic pregnancy

(When this happens the patient needs close monitoring and review)

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16
Q

What % fall in hCG indicates a miscarriage?

A

More than 50% = likely to suggest miscarriage

A urine pregnancy test = should be performed after 2 weeks to confirm the miscarriage is complete.

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17
Q

What is more important than monitoring hCG levels when when present with gynae problems?

A

Monitoring the clinical signs + symptoms = more important than tracking the hGC

Any change in symptoms = needs careful assessment

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18
Q

What % rise and fall in hCG levels indicate an intrauterine pregnancy, ectopic and miscarriage?

A
  • Rise more than 63% → intrauterine pregnancy
  • Rise less than 63% → ectopic pregnancy
  • Fall more than 50% → miscarriage
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19
Q

What investigation should you perform in all women who present with abdominal pain or pelvic pain - that may be caused by an ectopic pregnancy?

A

Pregnancy test

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20
Q

A woman presents with pelvic pain or tenderness and has an positive pregnancy test. Who does she need to be referred to?

A

Early pregnancy assessment unit (EPAU) or gynaecology service

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21
Q

What are the 3 options for terminating an ectopic pregnancy?

A
  • Expectant management (awaiting natural termination)
  • Medical management (methotrexate)
  • Surgical management (salpingectomy or salpingotomy)
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22
Q

What is the criteria for expectant management for an ectopic pregnancy?

A
  • Follow up needs to be possible to ensure successful termination
  • The ectopic needs to be unruptured
  • Adnexal mass < 35mm
  • No visible heartbeat
  • No significant pain
  • HCG level < 1500 IU / l
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23
Q

What is the criteria for methotrexate (medical management) for an ectopic pregnancy?

A

Same as expectant management, except:
* HCG level must be < 5000 IU / l
* Confirmed absence of intrauterine pregnancy on ultrasound

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24
Q

How is methotrexate given to a women for medical management of an ectopic pregnancy?

A

Intramuscular injection of methotrexate into the buttock
(Halts the progression of the pregnancy + results in spontaneous termination)

Methotrexate = highly teratogenic (harmful to pregnancy)

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25
Q

After medical management (methotrexate) for an ectopic pregnancy, how long should women wait to become pregnant again?

A

3 months
(This is because the harmful effects of methotrexate on pregnancy can last this long)

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26
Q

Name two S/Es of methotrexate

A
  • Vaginal bleeding
  • Nausea + vomiting
  • Abdominal pain
  • Stomatitis (inflammation of the mouth)
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27
Q

When is surgical management appropriate for an ectopic pregnancy?

A

When they don’t meet the criteria for expectant or medical management

Most patients = will require surgical management

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28
Q

What is the criteria for surgical management for an ectopic pregnancy?

A
  • Pain
  • Adnexal mass > 35 mm
  • Visible heartbeat
  • hCG levels > 5000 IU / l
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29
Q

What are the 2 surgical management options for an ectopic pregnancy?

A

Laparoscopic salpingectomy (first line)
* GA + key-hole surgery to remove affected fallopian tube with the ectopuc pregnancy inside the tube
Laparoscopic salpingotomy
* Used in women at increased risk of infertility due to damage to the other tube. Aim = avoid removing the affected tube
* Increased risk of failure (1 in 5 need further methotrexate or salpingectomy)

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30
Q

What drug is given to rhesus negative women having surgical management of ectopic pregnancy?

A

Anti-rhesus D prophylaxis

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31
Q

Define an early and late miscarriage

A

Miscarriage = spontaneous termination of a pregnancy

  • Early miscarriage = before 12 weeks of gestation
  • Late miscarriage = between 12 and 24 weeks of gestation
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32
Q

Define missed miscarriage

A

Fetus is no longer alove - but no symptoms have occurred

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33
Q

Define threatened miscarriage

A

Vaginal bleeding with a closed cervix + a fetus that is alive

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34
Q

Define an inevitable miscarriage

A

Vaginal bleeding with an open cervix

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35
Q

Define an incomplete miscarriage

A

Retained products of conception remain in the iterus after the miscarriage

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36
Q

Define complete miscarriage

A

A full miscarriage has occurred - there is no products of conception left in the uterus

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37
Q
A
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38
Q

Define an anembryonic pregnancy

A

A gestational sac is present - but contains no embryo

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39
Q

The gold standard Ix for diagnosing a miscarriage

A

Transvaginal ultrasound scan

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40
Q

What are the 3 key features of a transvaginal USS when looking at an early pregnancy?

A

These appear sequentially as the pregnancy develops - as each appears - the previous feature becomes less relevant in assessing the viability of the pregnancy

  • Mean gestational sac diameter
  • Fetal pole + crown-rump length
  • Fetal heartbeat
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41
Q

Is the pregnancy considered viable if there is a fetal heartbeat?

A

Yes

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42
Q

At what crown-rump length is then the fetal heartbeat expected?

A

7mm or more

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43
Q

What happens when:

  • Crown-rump length = 7mm or more
  • No fetal heartbeat
A

Transvaginal USS = repeated after one week before confirming a non-viable pregnancy

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44
Q

At what mean gestational sac diameter is the fetal pole then expected?

A

25mm or more

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45
Q

What is concluded if:
* Mean gestational sac diameter of 25mm or more
* No fetal pole

A

Scan repeated after one week before confirming an anembryonic pregnancy

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46
Q

A woman with a pregnancy less than 6 weeks gestation presents with bleeding, no pain, no other complications or risk factors (e.g. previous ectopic). What is the management of choice?

A

Expectant management
Involves awaiting the miscarriage without Ix or treatment

(An ultrasound is unlikely to be helpful this early as the pregnancy will be too small to be seen)

  • A repeat urine pregnancy test is performed after 7 – 10 days, and if negative, a miscarriage = confirmed.
  • When bleeding continues, or pain occurs, referral and further investigation is indicated.
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47
Q

If a woman presents with a positive pregnancy test (w/ more than 6 weeks gestation) + bleeding, what do you do?

A

Refer to early pregnancy assessment service (EPAU)

The early pregnancy assessment unit will arrange an ultrasound scan → confirm the location + viability of the pregnancy

It is essential always to consider and exclude an ectopic pregnancy.

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48
Q

What are the 3 options for managing a miscarriage?

A
  • Expectant management (do nothing and await a spontaneous miscarriage)
  • Medical management (misoprostol)
  • Surgical management
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49
Q

What is the first-line management for a miscarriage - without risk factors for heavy bleeding or infection?

A

Expectant miscarriage

  • 1 – 2 weeks are given to allow the miscarriage to occur spontaneously.
  • A repeat urine pregnancy test = performed 3 weeks after bleeding + pain settle to confirm the miscarriage is complete.
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50
Q

A woman undergos expectant management for a miscarriage - however she is experiencing persistant and worsening bleeding. What should happen? What may this mean?

A

Further assessment + repeat ultrasound

May indicate an incomplete miscarriage → requiring additional management

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51
Q

What drug is given in the medical management for a miscarriage?

A

Misoprostol = a prostaglandin analogue

  • = Binds to prostaglandin receptors + activates them
  • Prostaglandins = soften the cervix + stimulates uterine contractions

Dose: Oral or vaginal suppository

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52
Q

What are the key S/Es for misoprostol?

A
  • Heavier bleeding
  • Pain
  • Vomiting
  • Diarrhoea
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53
Q

What are the 2 surgical options for a miscarriage?

A
  • Manual vacuum aspiration under local anaesthetic as an outpatient
  • Electric vacuum aspiration under general anaesthetic
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54
Q

What are the 2 drugs used for the medical management of an ectopic pregnancy and miscarriage?

A
  • Methotrexate
  • Misoprostal
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55
Q

What drugs are given in the surgical management of a miscarriage?

A
  • Misoprostal (prostaglandins) = given before to soften the cervix
  • Anti-rhesus D prophylaxis = given to rhesus negative women
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56
Q

When is manual vacuum aspiration appropriate to manage a miscarriage?

A
  • Below 10 weeks of gestation
  • Parous women = women that have previously given birth
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57
Q

What is the traditional surgical management for a miscarriage?

A

Electric vacuum aspiration

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58
Q

What is an incomplete miscarriage and what is an associated risk?

A

Incomplete miscarriage = occurs when retained products of conception (fetal or placental tissue) = remain in the uterus after miscarriage

Risk of infection

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59
Q

What are the 2 options for treating an incomplete miscarriage?

A
  • Medical management (misoprostol)
  • Surgical management (evacuation of retained products of conception)
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60
Q

What does evacuation of retained products of conception (ERPC) involve?

A
  • Under GA
  • Cervix = gradually widened using dilators
  • Retained products removed through cervix using vacuum aspiration + curettage (scraping)

Key complication = endometritis (infection of the endometrium)

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61
Q

What is classed as recurrent miscarriage?

A

3 or more consecutive miscarriages

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62
Q

Info: Rate of miscarriages for ages

A

The risk of miscarriage increases with age, with the rate of miscarriage approximately:

  • 10% in women aged 20 – 30 years
  • 15% in women aged 30 – 35 years
  • 25% in women aged 35 – 40 years
  • 50% in women aged 40 – 45 years
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63
Q

When are Ix for miscarriages performed?

A
  • Three or more first-trimester miscarriages
  • One or more second-trimester miscarriages
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64
Q

Name some causes for recurrent miscarriages

A
  • Idiopathic (particularly in older women)
  • Antiphospholipid syndrome
  • Hereditary thrombophilias
  • Uterine abnormalities
  • Genetic factors in parents (e.g. balanced translocations in parental chromosomes)
  • Chronic histiocytic intervillositis
  • Other chronic diseases such as diabetes, untreated thyroid disease and systemic lupus erythematosus (SLE)
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65
Q

What is antiphospholpid syndrome?

A

Antiphospholipid syndrome = a disorder associated with antiphospholipid antibodies → where blood becomes prone to clotting → patient = in a hyper-coagulable state

The main associations:
* Thrombosis
* Complications in pregnancy, particularly recurrent miscarriage.

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66
Q

Aetiology of antiphospholipid syndrome

A

Antiphospholipid syndrome = occurs:
* On its own
* Secondary to an autoimmune condition e.g. systemic lupus erythematosus

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67
Q

What drugs are used to reduce the risk of miscarriage in a woman with antiphospholipid syndrome?

A
  • Low dose aspirin
  • Low molecular weight heparin (LMWH)
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68
Q

Tom Tip

A

If you remember one cause of recurrent miscarriages → remember antiphospholipid syndrome.

Consider this in patients presenting in exams with recurrent miscarriages. There may be a past history of deep vein thrombosis.
* Test = antiphospholipid antibodies,
* Treatment = aspirin + LMWH

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69
Q

A woman presents with 3 consecutive miscarriages (recurrent miscarriages) and a past medical history of a deep vein thrombosis. Underlying diagnosis?

A

Antiphospholipid syndrome
* Test: Antiphospholipid antibodies
* Treatment: Aspirin + LMWH

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70
Q

Name a hereditary thrombophilias

A
  • Factor V Leiden (most common)
  • Factor II (prothrombin) gene mutation
  • Protein S deficiency
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71
Q

Name a couple of uterine abnormalities that can cause recurrent miscarriages

A
  • Uterine septum (a partition through the uterus)
  • Unicornuate uterus (single-horned uterus)
  • Bicornuate uterus (heart-shaped uterus)
  • Didelphic uterus (double uterus)
  • Cervical insufficiency
  • Fibroids
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72
Q

What obstetric complications can chronic histiocytic intervillositis cause?

A

Chronic histiocytic intervillositis = rare cause of recurrent miscarriage - particularly in the second trimester

Can also lead to:
* Intrauterine growth restriction (IUGR)
* Intrauterine death

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73
Q

What is chronic histiocytic intervillositis and how is it diagnosed?

A
  • Histiocytes + macrophages = build up in the placenta → causing inflammation + adverse outcomes
  • Diagnosis: placental histology → showing infiltrates of mononuclear cells in the intervillous spaces
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74
Q

What investigations are performed for recurrent miscarriages?

A
  • Antiphospholipid antibodies
  • Testing for hereditary thrombophilias
  • Pelvic ultrasound
  • Genetic testing of the products of conception from the third or future miscarriages
  • Genetic testing on parents
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75
Q

Info: Types of multiple pregnancy

A
  • Monozygotic: identical twins (from a single zygote)
  • Dizygotic: non-identical (from two different zygotes)
  • Monoamniotic: single amniotic sac
  • Diamniotic: two separate amniotic sacs
  • Monochorionic: share a single placenta
  • Dichorionic: two separate placentas

The best outcomes are with diamniotic, dichorionic twin pregnancies, as each fetus has their own nutrient supply.

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76
Q

What is ultrasound used to determine?
(Think of multiple pregnancies too)

A
  • Gestational age
  • Number of placentas (chorionicty) + amniotic sac (amnionicity)
  • Risk of Down’s syndrome (as part of the combined test)
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77
Q

When determining the types of twins using an ultrasound, what are the signs you look for?

A
  • Dichorionic diamniotic twins = have a membrane between the twins, with a lambda sign or twin peak sign
  • Monochorionic diamniotic twins have a membrane between the twins, with a T sign
  • Monochorionic monoamniotic twins have no membrane separating the twins
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78
Q

What are the risks to the mother for a multiple pregnancy?

A
  • Anaemia
  • Polyhydramnios
  • Hypertension
  • Malpresentation
  • Spontaneous preterm birth
  • Instrumental delivery or caesarean
  • Postpartum haemorrhage
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79
Q

What are the risks to the fetuses + neonates when in a multiple pregnancy?

A
  • Miscarriage
  • Stillbirth
  • Fetal growth restriction
  • Prematurity
  • Twin-twin transfusion syndrome
  • Twin anaemia polycythaemia sequence
  • Congenital abnormalities
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80
Q

What is twin-twin transfusion syndrome?

A

Occurs when the** 2 fetuses** share a placenta

Callled feto-fetal transfusion syndrome in pregnancies with **more than 2 fetuses **

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81
Q

What happens in twin-twin transfusion syndrome?

A

Share a placenta

There is a connection between the blood supplies of the 2 fetuses → one fetus (recipient) = receives majority of blood; one fetus (donor) = starved of blood

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82
Q

What are the complications to the donor and recipient twins in twin-twin transfusion syndrome?

A

Recipient: Receives majority of blood → fluid overload → heart failure + polyhydramnios

Donor: Starved of blood → growth restriction + anaemia + oligohydramnios

Discrepancy in sizes between fetuses

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83
Q

Treatment of twin-twin transfusion syndrome

A

Referred to a tertiary specialist fetal medicine centre

Severe cases: Laser treatment = used to destroy the connection between the two blood supplies

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84
Q

What is twin anaemia polycythaemia sequence?

A

Similar to twin-twin transfusion syndrome (but less acute)

One twin = becomes anaemic; other develops polcythaemia (rased Hb)

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85
Q

What additional Ix do women need for multiple pregancies?

A

Additional:
* Monitoring for anaemia (FBC)
* Ultrasounds monitoring fetal growth restriction, unequal growth, twin-twin transfusion syndrome
* Planned birth is offered

  • 2 weekly scans from 16 weeks for monochorionic twins
  • 4 weekly scans from 20 weeks for dichorionic twins
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86
Q

What drug is given before the delivery of a multiple pregnancy to help mature the lungs?

A

Corticosteroids

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87
Q

What mode of delivery is required for monoamiotic twins?

A

Elective caesarean section
(Between 32 and 33+6 weeks)

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88
Q

What is the recommended mode of delivery for diamniotic twins (aim to deliver between 37 and 37 + 6 weeks)?

A
  • Vaginal delivery is possible when the first baby has a cephalic presentation (head first)
  • Caesarean section may be required for the second baby after successful birth of the first baby
  • Elective caesarean is advised when the presenting twin is not cephalic presentation
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89
Q

Define pre-eclampsia

A

New high blood pressure (hypertension) in pregnancy with end-organ dysfunction - notably with proteinuria (protein in the urine).

It occurs after 20 weeks gestation, when the spiral arteries of the placenta form abnormally → leading to a high vascular resistance in these vessels.

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90
Q

Triad of pre-eclampsia features

A

HOP:
H - Hypertension
P - Proteinuria
O - Oedema

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91
Q

Define chronic hypertension

A

High blood pressure that exists before 20 weeks gestation and is longstanding.

This is not caused by dysfunction in the placenta and is not classed as pre-eclampsia

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92
Q

Define pregnancy-induced hypertension or gestational hypertesnsion

A

Hypertension occurring after 20 weeks gestation - without proteinuria

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93
Q

Define pre-eclampsia

A

Pre-eclampsia = pregnancy-induced hypertension associated with organ damage, notably proteinuria.

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94
Q

Define eclampsia

A

When seizures occur as a result of pre-eclampsia

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95
Q

What is pre-eclampsia caused by?

A
  • Pre-eclampsia = caused by high vascular resistance in the spiral arteries + poor perfusion of the placenta.
  • This causes oxidative stress in the placenta → release of inflammatory chemicals into the systemic circulation → systemic inflammation + impaired endothelial function in the blood vessels
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96
Q

What are the high-risk factors for pre-eclampsia?

A
  • Pre-existing hypertension
  • Previous hypertension in pregnancy
  • Existing autoimmune conditions (e.g. systemic lupus erythematosus)
  • Diabetes
  • Chronic kidney disease
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97
Q

What are the moderate-risk factors for pre-eclampsia?

A
  • Older than 40
  • BMI > 35
  • More than 10 years since previous pregnancy
  • Multiple pregnancy
  • First pregnancy
  • Family history of pre-eclampsia
98
Q

What prophylaxis should women with one high-risk factor OR more than one moderate-risk factor for pre-eclampsia?

A

Aspirin from 12 weeks gestation until birth

99
Q

What are the symptoms of pre-eclampsia?

A

Pre-eclampsia has symptoms of the complications:

  • Headache
  • Visual disturbance or blurriness
  • Nausea and vomiting
  • Upper abdominal or epigastric pain (this is due to liver swelling)
  • Oedema
  • Reduced urine output
  • Brisk reflexes
100
Q

What is the diagnostic criteria for pre-eclampsia?

A
  • Systolic blood pressure above 140 mmHg
  • Diastolic blood pressure above 90 mmHg

PLUS any of:
* Proteinuria (1+ or more on urine dipstick)
* Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia)
* Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies)

Proteinuria can be quantified using:
* Urine protein:creatinine ratio (above 30mg/mmol is significant)
* Urine albumin:creatinine ratio (above 8mg/mmol is significant)

101
Q

What testing can you perform to rule-out pre-eclampsa?

A

NICE recommends: Placental growth factor (PlGF) testing on one occasion during pregnancy in women suspected of having pre-eclampsia

  • Placental growth factor (PlGF) = a protein released by the placenta - it stimulates new blood vessel development
  • In pre-eclampsia PlGF levels = low
  • PlGF between 20-35 weeks gestation = rule-out pre-eclampsia
102
Q

What drug is used for prophylaxis against the development of pre-eclampsia?

A

Aspirin 75mg (12 weeks to birth)

  • A single high-risk factor
  • Two or more moderate-risk factors
103
Q

What is monitored in pregnant woman at every antenatal appointment for evidence of pre-eclampsia?

A
  • Symptoms
  • Blood pressure
  • Urine dipstick for proteinuria
104
Q

What is the management for gestational hypertension (without proteinuria)?

A
  • Treating to aim for a blood pressure below 135/85 mmHg
  • Admission for women with a blood pressure above 160/110 mmHg
  • Urine dipstick testing at least weekly
  • Monitoring of blood tests weekly (full blood count, liver enzymes and renal profile)
  • Monitoring fetal growth by serial growth scans
  • PlGF testing on one occasion
105
Q

What is the general management for pre-eclampsia?

A

Similar to gestational hypertension - except:
* Scoring systems are used to determine whether to admit the woman (fullPIERS or PREP‑S)
* Blood pressure is monitored closely (at least every 48 hours)
* Urine dipstick testing is not routinely necessary (the diagnosis is already made)
* Ultrasound monitoring of the fetus, amniotic fluid and dopplers is performed two weekly

106
Q

What is the medical management for pre-eclampsia?

First to third line

A
  • First line: Labetolol (antihypertensive)
  • Second line: Nifedipine (modified-release)
  • Third line: Methyldopa (needs to be stopped within two days of birth)
  • Intravenous hydralazine (antihypertensive) in critical care in severe pre-eclampsia or eclampsia
  • IV magnesium sulphate = given during labour and in the 24 hours afterwards to prevent seizures
  • Fluid restriction = used during labour in severe pre-eclampsia or eclampsia - to avoid fluid overload
107
Q

What is the first line drug for pre-eclampsia while pregnant?

A

Labetolol

108
Q

Planned early birth may be necessary if the blood pressure cannot be controlled or complications occur in a pregnant woman with pre-eclampsia. What drug is given to help mature the fetal lungs?

A

Corticosteroids

109
Q

True or false:

A

Blood pressure will return to normal over time once the placenta is removed

110
Q

What is the first-line, second-line and third-line management for the medical treatment for pre-eclampsia after delivery?

A
  • First line: Enalapril
  • First-line in black African or Caribbean patients: Nifedipine or amlodipine
  • Third-line: Labetolol or atenolol
111
Q

What is the first line medical treatment for pre-eclampsia after delivery?

A

Enalapril
Black africian or Caribbean: Nifedipine or amlodipine

112
Q

What is eclampsia and what is the treatment?

A
  • Ecampsia = refers to the seizures associated with pre-eclampsia
  • Management: IV magnesium sulphate
113
Q

What drug is used to treat the seizures in eclampsia?

A

IV magnesium suplate

114
Q

What is HELLP syndrome?

A

HELLP syndrome = combination of features that occur as a complication of pre-eclampsia + eclampsia

Haemolysis
Elevated Liver enzymes
Low Platelets

pre-eclampsia with thrombotic microangiopathy. Endothelial dysfunction in the liver leads to platelet aggregation and subsequent microangiopathic haemolytic anaemia.

115
Q

A 23-year-old pregnant woman at 28 weeks gestation reports abdominal pain and a headache. Urinalysis shows proteinuria with a blood pressure of 160/110 mmHg. She is admitted for labetalol.
Diagnosis?

A

Pre-eclampsia

116
Q

Complications for mother with pre-eclampsia

A
  • Stroke
  • Eclampsia (seizures)
  • HELLP
  • Pulmonary oedema (secondary to proteinuria + subsequent hypoalbuminia)
117
Q

Foetal complications associated with pre-eclampsia

A
  • Intrauterine growth restriction: occurs in 30% of patients with pre-eclampsia
  • Premature delivery: iatrogenic if there is evidence of foetal or maternal compromise
  • Placental abruption
118
Q

What is placenta praevia?

A

The placenta = attached to the lower portion of the uterus - lower than the presenting part of the fetus

Praevia = latin for ‘going before’

119
Q

Definitions for placenta praevia

A
  • Low-lying placenta = when the placenta is within 20mm of the internal cervical os
  • Placenta praevia = placenta is over the internal cervical os
120
Q

Name 3 major causes of antepartum haemorrhage

A
  • Placenta praevia
  • Placental abruption
  • Vasa praevia
121
Q

Name some causes of spotting or minor bleed in pregnancy

A
  • Cervical ectropian
  • Infection
  • Vaginal abraasions from intercourse or procedures
122
Q

What are risks of placenta praevia?

A
  • Antepartum haemorrhage
  • Emergency caesarean section
  • Emergency hysterectomy
  • Maternal anaemia and transfusions
  • Preterm birth and low birth weight
  • Stillbirth
123
Q

The grades of placenta praevia

A

THIS IS OUTDATED - use low-lying placenta and placenta praevia

    • Minor praevia (grade I) = the placenta is in the lower uterus but not reaching the internal cervical os
  • Marginal praevia (grade II) = the placenta is reaching - but not covering the internal cervical os
  • Partial praevia (grade III) = the placenta is partially covering the internal cervical os
  • Complete praevia (grade IV) = the placenta is completely covering the internal cervical os
124
Q

Risk factors for placenta praevia

A
  • Previous caesarean sections
  • Previous placenta praevia
  • Older maternal age
  • Maternal smoking
  • Structural uterine abnormalities (e.g. fibroids)
  • Assisted reproduction (e.g. IVF)
125
Q

How does placenta praevia present?

A
  • Asymptomatic (many women)
  • Painless vaginal bleeding in pregnancy (antepartum haemorrhage)

Usually occurs later in pregnancy (around or after 36 weeks)

126
Q

A 32-year-old woman who is 8 months pregnant presents with painless vaginal bleeding and has changed 2 pads in the last hour. She has had a previous caesarian section. Possible diagnosis?

A

Placenta praevia

127
Q

Definition of placenta praevia

A

Placenta praevia = a cause of antepartum haemorrhage (bleeding > 24 weeks) which occurs when the placenta overlies the lower uterine segment.

5% of women have a low-lying placenta at their 20-week scan, but only 0.5% at delivery. This is because the placenta = migrates during pregnancy.

128
Q

Management for placenta praevia

A
  • Corticosteroids = given between 34 and 35 + 6 weeks gestation → to mature the fetal lungs - given the risk of preterm delivery.

No active bleeding:
* Planned Caesarian section (36-37 weeks gestation) → reduce the risk of spontaneous labour + bleeding
* Anti-D immunogobulins

Active bleeding:
* Resuscitation (fluids, +/- transfusion, +/- tranexamic acid)
* Emergency Caesarean section
* Anti-D immunoglobulins

129
Q

What is required in a woman with placenta praevia that is undergoing premature labour or antenatal bleeding?

A

Emergency caesarean

130
Q

The main complication of placenta praevia is haemorrhage before, during and after delivery. When this occurs, urgent management is required and may involve….

A
  • Emergency caesarean section
  • Blood transfusions
  • Intrauterine balloon tamponade
  • Uterine artery occlusion
  • Emergency hysterectomy
131
Q

Complications of placenta praevia

A

Maternal:
* Massive haemorrhage
* Disseminated intravascular coagulation (DIC): bleeding can lead to consumption of clotting factors with susbsequent DIC

Foetal:
* Preterm birth: Increased risk of prematurity
* Foetal death

132
Q

A 32-year-old pregnant woman at 31 weeks gestation presents with abdominal pain, contractions and mild, dark red vaginal bleeding. She is tachycardic and hypotensive. Underlying diagnosis?

A

Placental abruption

133
Q

What is placental abruption?

A

When the placenta = separates from the wall during pregnancy (> 24 weeks)

The site of the attachment = can bleed extensively after the placenta separates → causing antepartum haemorrhage

134
Q

What are the risk factors for placental abruption?

A
  • Previous placental abruption
  • Pre-eclampsia
  • Bleeding early in pregnancy
  • Trauma (consider domestic violence)
  • Multiple pregnancy
  • Fetal growth restriction
  • Multigravida
  • Increased maternal age
  • Smoking
  • Cocaine or amphetamine use
135
Q

What are the types of placental abruption?

A
  • Total → entire placenta
  • Partial → only a part of the placenta
  • Concealed → if no blood passes through the vagina
    (Google
136
Q

Differences & similarities between placenta praevia and placental abruption

A

Placenta praevia:
* Vaginal bleeding > 24 weeks
* Painless
* Bright red blood
* Bleeding = not concealed

Placental abruption:
* Vaginal bleeding > 24 weeks
* Painful
* Dark red blood
* Bleeding may be concealed

137
Q

What is the typical presentation of placental abruption?

A

Symptoms:
* Sudden onset lower severe abdominal pain (constant)
* Uterine contractions: **Patients often present in labour **

Signs:
* Dark red vaginal bleeding; may be concealed instead (antepartum haemorrhage)
* Shock (tachycardia + hypotension)
* Tender + tense uterus ‘woody uterus’ → suggesting large haemorrhage
* Abnormalities on CTG → indicating fetal distress

138
Q

The severities of antepartum haemorrhage

A
  • Spotting: spots of blood noticed on underwear
  • Minor haemorrhage: less than 50ml blood loss
  • Major haemorrhage: 50 – 1000ml blood loss
  • Massive haemorrhage: more than 1000 ml blood loss, or signs of shock
139
Q

What is a concealed abruption?

A

Concealed abruption = where the cervical os remained closed → the bleeding remains within the uterine cavity

The severity of bleeding can be significantly underestimated with concealed haemorrhage.

Concealed abruption is opposed to revealed abruption → where the blood loss is observed via the vagina

140
Q

How do you diagnose placental abruption?

A

Clinical diagnosis based on presentation

141
Q

What is the important to consider with placental abruption?

A

It is important to consider concealed haemorrhage, where the vaginal bleeding may be disproportionate to the uterine bleeding.

142
Q

What are the initial steps with a major or massive (antepartum) haemorrhage?

A
  • Urgent involvement of a senior obstetrician, midwife and anaesthetist
  • 2 x grey cannula
  • Bloods include FBC, UE, LFT and coagulation studies
  • Crossmatch 4 units of blood
  • Fluid and blood resuscitation as required
  • CTG monitoring of the fetus
  • Close monitoring of the mother
143
Q

Management for placental abruption

A

Acute bleeding:
* Resuscitation: fluids, +/- transfusion, +/- tranexamic acid
* Emergency caesarian section
* Anti-D immunoglobulin: if rhesus negative

No foetal or maternal compromise:
* Conservative management: regular monitoring
* Corticosteroids + tocolytics (nifedipine = first line): if gestational age < 34 weeks; steroids promote foetal lung maturation
* Vaginal delivery: >34 weeks with contractions
* Anti-D immunoglobulin: given if rhesus negative

144
Q

Complications of placental abruption

A

Maternal:
* Massive haemorrhage: if concealed → hypovolaemic shock out of proportion to visible blood loss
* Disseminated intravascular coagulation (DIC)
* Increased risk of postpartum haemorrhage

Foetal:
* Preterm birth
* Foetal death

145
Q

A 32-year-old pregnant woman at 31 weeks gestation presents with abdominal pain, contractions and mild, dark red vaginal bleeding. She is tachycardic and hypotensive. Diagnosis?

A

Placental abruption

146
Q

Define primigravida

A

A woman who is pregnant for the first time

147
Q

A 30-year-old primigravida at 36 weeks gestation presents to the emergency department with sudden onset of painless, bright red vaginal bleeding after a gush of clear fluid. Diagnosis?

A

Vasa praevia

148
Q

What is vasa praevia ?

A

Where the fetal vessels are within the fetal membranes (chorioamniotic membranes) = travel across the internal cervical os

Vasa = vessel
Praevia = going before
Vasa praevia = where the vessels are placef over the internal cervical os - befire the fetus

149
Q

Info:

A
  • The fetal membranes = surround the amniotic cavity + developing fetus
  • Fetal vessels = 2 umbilical arteries + 1 umbilical vein
150
Q

Pathophysiology of vasa praevia

A
  • Vasa praevia = cause of antepartum haemorrhage (bleeding >24 weeks)
  • Vasa praevia = foetal blood vessels cross the internal cervical os
  • Foetal vessels = 2 umbilical arteries + 1 umbilical vein - contained within the chorioamniotic membranes
  • Vasa praevia = foetal vessels are unprotected by the umbilical cord or placental tissue
  • These vessels = then exposed + prone to haemorrhage - when the amniotic membranes rupture
151
Q

2 types of vasa praevia

A
  • Type I vasa praevia = the fetal vessels are exposed as a velamentous umbilical cord
  • Type II vasa praevia – the fetal vessels are exposed as they travel to an accessory placental lobe
  • Type I vasa praevia: Velamentous cord insertion = the umbilical vessels insert into the chorioamniotic membranes = rather than the placental margin
  • Type II vasa praeva: Accessory (succenturiate) lobe = a vessel crosses the internal os to connect the main placenta and a smaller, accessory lobe of the placenta
152
Q

What layer of soft connective tissue surrounds the blood vessels in the umbilical cord protecting the umbilical vessels?

A

Wharton’s jelly

153
Q

Why can vasa praevia cause an antepartum haemorrhage?

A

The foetal vessels = are prone to bleeding - particularly when the membranes are ruptured during labour + birth → can lead to foetal blood loss + death

154
Q

Risk factors for vasa praevia

A
  • Low lying placenta
  • IVF pregnancy
  • Multiple pregnancy
155
Q

What are the symptoms + signs of vasa praevia?

A

Symptom: Painless antepartum vaginal bleeding: this often occurs in the second or third trimester or after rupture of the membranes

Sign: Foetal distress or death

156
Q

When might vasa praevia be picked up?

A
  • USS during pregnancy → can then plan caesarian section to reduce risk
  • Antepartum haemorrage - bleeding during the 2nd or 3rd prgnancy
  • Vaginal examination during labour - pulsating fetal vessels = seen in the membranes of through the dilated cervix
  • During labour - fetal distress + dark red bleeding
157
Q

What is the primary investigation for vasa praevia?

A

Doppler ultrasound: this can identify the aberrant vessel(s) crossing the internal cervical os

158
Q

Management for vasa praevia

A

Asymptomatic women:
* Corticosteroids = given from 32 weeks gestation to mature the fetal lungs
* Elective caesarian section = planned for 34-36 weeks gestation

Antepartum haemorrhage: Emergency caesarian section (before foetal death)

159
Q

What is a molar pregnancy?

A

A hydatiidiform mole (type of tumour) that grows like a pregnancy inside the uterus

2 types of molar pregnancy:
* Complete mole
* Partial mole

Molar pregnancies (MPs; hydatidiform moles) are chromosomally abnormal pregnancies that have the potential to become malignant.

160
Q

What a complete molar pregnancy?

A

Complete mole = 2 sperm fertilise an ovum that contains no genetic material (an ‘empty ovum’)
* These sperm then combine genetic material, and the cells start to divide and grow into a tumour called a complete mole
* No fetal material will form

161
Q

What is a partial molar pregnancy?

A

A partial mole = 2 sperms fertilise a normal ovum (containing genetic material) at the same time
* The new cell now has 3 sets of chromosomes
* The cell divides and multiplies into a tumour called a partial mole
* In a partial mole, some fetal material may form

162
Q

How does a molar pregnancy present?

A

Molar pregnancy = behaves like a normal pregnancy (periods stop + hormonal changes of pregnancy will occur).

There are a few things that can indicate a molar pregnancy versus a normal pregnancy:
* More severe morning sickness
* VAGINAL BLEEDING
* Increased enlargement of the uterus
* Abnormally high hCG
* Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4)

163
Q

Ix for molar pregnancy

A
  • Serum human chorionic gonadotrophin (hCG)
  • Pelvic ultrasound (‘snowstorm appearance’)
  • Histological examination of placental tissue
164
Q

Management of singleton molar pregnancy

A
  • Suction evacuation
  • Hysterectomy (if not desiring fertility)
  • hCG levels = monitored until they return to normal.
  • Occasionally the mole can metastasise, and the patient may require systemic chemotherapy.
165
Q

What should pregnant women who are high-risk of developing pre-eclampsia take?

A

Aspirin 75 mg OD
From 12 weeks until birth

166
Q

What are the ranges of hypertension in pregnancy defined as?

A

Hypertension in pregnancy in usually defined as:
* systolic > 140 mmHg or diastolic > 90 mmHg
* or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic

167
Q

After establishing that a pregnant woman has hypertension, what are potential groups that it can be categorised into?

A
  • Pre-existing hypertension → before 20 weeks gestation
  • Pregnancy-induced hypertension (PIH, or gestational hypertension) → after 20 weeks gestation (second half of pregnancy)
  • Pre-eclampsia → also also proteinuria (>0.3g/24hrs) + oedema
168
Q

What is the management for gestational hypertension?

A
  • First line: Oral Labetalol
  • Oral Nifedipine (if asthmatic) and hydralazine
169
Q

If a woman with pre-existing hypertension, and takes an ACEi or ARB what action should be taken?

A

Immediately stop → start alternative (labetalol)

170
Q

What is pre-existing hypertension?

A
  • A history of hypertension before pregnancy OR an elevated blood pressure > 140/90 mmHg before 20 weeks gestation
  • No proteinuria, no oedema
  • Occurs in 3-5% of pregnancies and is more common in older women
171
Q

What is pregnancy-induced hypertension (PIH, aka gestational hypertension)?

A

Hypertension occurring in the** second half of pregnancy** (i.e. after 20 weeks):

  • ** Systolic > 140 mmHg** or diastolic > 90 mmHg
  • or an increase above booking readings of** > 30 mmHg systolic** or > 15 mmHg diastolic
  • No proteinuria, no oedema
  • Occurs in around 5-7% of pregnancies
  • Resolves following birth (typically after one month).
  • Women with PIH are at increased risk of future pre-eclampsia or hypertension later in life
172
Q

What is pre-eclampsia?

A
  • Pregnancy-induced hypertension + proteinuria (> 0.3g / 24 hours)
  • Oedema (may occur but is now less commonly used as a criteria)
  • Occurs in around 5% of pregnancies
173
Q

What is oligohydramnios?

A

Oligohydramnios = reduced amniotic fluid
Less than 500ml at 32-36 weeks and an amniotic fluid index (AFI) < 5th percentile.

174
Q

Name some causes of oligohydramnios

A
  • Premature rupture of membranes
  • Potter sequence (bilateral renal agenesis + pulmonary hypoplasia)
  • Intrauterine growth restriction
  • Pre-eclampsia
  • Post-term gestation
175
Q

What is polyhydramnios?

A

polyhydramnios = defined as an excessive accumulation of amniotic fluid during pregnancy.

This condition is typically identified through an ultrasound where the amniotic fluid index (AFI) is greater than 25 cm or the single deepest vertical pocket (SDVP) of amniotic fluid is greater than 8 cm.

176
Q

Name some causes of polyhydramnios

A
  • Diabetes Mellitus (particularly gestational diabetes): Elevated blood glucose levels in the mother can lead to increased fetal urine production, contributing to polyhydramnios.
  • Fetal Anomalies: Conditions like esophageal atresia, anencephaly, or neural tube defects can impair the fetus’s ability to swallow amniotic fluid, leading to its accumulation.
  • Multiple Pregnancies: Especially in cases of twin-to-twin transfusion syndrome (TTTS), where one twin receives too much blood flow, resulting in excess urine and amniotic fluid.
  • Infections: Certain infections during pregnancy, such as cytomegalovirus or toxoplasmosis, can cause polyhydramnios by affecting the fetus.
  • Idiopathic: In many cases, no clear cause of polyhydramnios can be identified, and it is classified as idiopathic.
  • Placental Issues: Conditions like placental chorioangioma (a benign tumor of the placenta) can lead to polyhydramnios due to increased blood flow and fluid production.
177
Q

What is the legal framework for a termination of a pregnancy?

A

1967 Abortion Act
(The 1990 Human Fertilisation and Embryology Act = altered and expanded the criteria for an abortion, and reduced the latest gestational age where an abortion is legal from 28 weeks to 24 weeks)

178
Q

What are the criteria for an abortion?

A

An abortion can be performed before 24 weeks if continuing the pregnancy involves greater risk to the physical or mental health of:
* The woman
* Existing children of the family
The threshold for when the risk of continuing the pregnancy outweighs the risk of terminating the pregnancy is a matter of clinical judgement and opinion of the medical practitioners.

179
Q

When can an abortion be performed at any time during the pregnancy?

A
  • Continuing the pregnancy is likely to risk the life of the woman
  • Terminating the pregnancy will prevent “grave permanent injury” to the physical or mental health of the woman
  • There is “substantial risk” that the child would suffer physical or mental abnormalities making it seriously handicapped
180
Q

What are the two legal requirements for an abortion?

A
  • Two registered medical practitioners must sign to agree abortion is indicated
  • It must be carried out by a registered medical practitioner in an NHS hospital or approved premise
181
Q

What drugs are used in a medical abortion?

A

A medical abortion is most appropriate earlier in pregnancy, but can be used at any gestation. It involves two treatments:

  • Mifepristone (anti-progestogen)
  • Misoprostol (prostaglandin analogue) 1 – 2 day later
  • Mifepristone = anti-progestogen (blocks progesterone) → halting the pregnancy + relaxing the cervix
  • Misoprostol = prostaglandin analogue (binds to prostaglandin receptors → activates them). Prostaglandins = soften the cervix + stimulate uterine contractions. From 10 weeks gestation, additional misoprostol doses (e.g. every 3 hours) = required until expulsion

Rhesus negative women with a gestational age of 10 weeks or above having a medical TOP should have anti-D prophylaxis.

182
Q

What is involved in a surgical abortion?

A

Anaesthetic:
* Local
* Local + sedation
* General

Prior to surgical abortion:
* Cervical priming medications given → softening + dliating the cervix with misoprostol, mifepristone, or osmotic dilators

  • Osmotic dilators = devices inserted into the cervix - that gradually expand as they absorb fluid, opening the cervical canal.

2 options for a surgical abortion:
* Cervical dilatation + suction of the contents of teh uterus (usually up to 14 weeks)
* Cervical dilatation + evacuation using forceps (between 14-24 weeks)

Rhesus negative women having a surgical TOP should have anti-D prophylaxis. The NICE guidelines (2019) say it should be considered in women less than 10 weeks gestation.

183
Q

What does post-abortion care involve?

A
  • Women may experience vaginal bleeding + abdominal intermittently up to 2 weeks after the procedure
  • Urine pregnancy test = performed 3 weeks after the abortion to confirm
  • Contraception + counselling = offered
184
Q

Complications of an abortion

A
  • Bleeding
  • Pain
  • Infection
  • Failure of abortion (pregnancy continues)
  • Danage to the cervix, uterus or other structures)
185
Q

What is gestational diabetes?

A

The underlying cause of GDM is insulin resistance due to hormonal changes and increased demand for insulin production

186
Q

What are some risk factors for gestational diabetes?

A
  • Obesity: BMI>30
  • Family history of diabetes
  • Past medical history of GDM
  • Advanced maternal age: >40
  • Ethnicity: South Asian, Black Afro-Caribbean, Middle Eastern [3]
  • Previous child born large: >4.5kg
187
Q

What are the clincial features of gestational diabetes?

A

Many women with GDM may not experience noticeable symptoms

Signs:
* Large for dates uterus

Symptoms:
* Polydipsia (increased thirst)
* Polyuria (increased urination)
* Fatigue
* Dry mouth
* Blurred vision

188
Q

When are women at risk of GDM offered an OGTT?

A
  • Women at risk = 24-28 weeks gestation
  • Previous GDM = at booking + again at 24-28 weeks
189
Q

What are the investigations for GDM?

A

Primary investigations:
* Oral glucose tolerance test (OGTT): used for screening and diagnosis of GDM by assessing the body’s response to a glucose load (75g) after an overnight fast. Glucose levels ≥7.8mmol/L are considered diagnostic for GDM.
* Fasting glucose: glucose levels ≥5.6mmol/L are considered diagnostic for GDM
* HbA1c testing: To monitor blood glucose control in women with pre-existing diabetes
* Fetal ultrasound: To assess fetal growth and wellbeing, and to screen for potential complications

Investigations to consider:
Urine dip: although not diagnostic, urinalysis is frequently performed throughout pregnancy and glycosuria can be an indication for further GDM testing [2]

190
Q

What glucose levels are diagnostic for GDM, in a OGTT and fasting glucose?

A
  • OGTT: ≥7.8mmol/L
  • Fasting glucose: ≥5.6mmol/L
191
Q

What blood test do you use to monitor blood glucose control in a pregnant woman with pre-existing diabetes?

A

Hb1Ac

192
Q

Management for GDM

A

Need four weekly ultrasound scans to monitor the fetal growth + amniotic fluid volume from 28 to 36 weeks gestation.

The initial management suggested by the NICE guidelines (2015) is

  • Fasting glucose less than 7 mmol/l: trial of diet + exercise for 1-2 weeks → followed by metformin → then insulin
  • Fasting glucose above 7 mmol/l: start insulin ± metformin
  • ** Fasting glucose above 6 mmol/l + macrosomia** (or other complications): start insulin ± metformin

Glibenclamide (a sulfonylurea) = suggested as an option for women who decline insulin or cannot tolerate metformin.

193
Q

What medication is used for pregnant women with GDM who decline insulin or cannot tolerate metformin?

A

Glibenclamide (sulfonylurea)

194
Q

If a woman with pre-existing diabetes wants to become pregnant, what should she take from precomception?

A

5 mg folic acid
(From preconception to 12 weeks gestation)

195
Q

What diabetes medication should pregnant woman with pre-existing type 2 diabetes be on?

A

Metformin + insulin
(Other oral diabetic medications should be stopped)

196
Q

What screening should be performed at booking and at 28 weeks gestation for a pregnant woman with pre-existing diabetes?

A

Retinopathy screening → check for diabetic retinopathy

Diabetes carries a risk of rapid progression of retinopathy, and interventions may be required

197
Q

When should planned deliveries be planned for with pregnant women with pre-existing diabetes + GDM

A

Planned deliveries:
* Pre-existing diabetes: between 37 and 38 + 6
* GDM: Up to 40 + 6

198
Q

What is used in labour for a pregnant woman with type 1 diabetes (or poorly controlled blood sugars with GDM or T2DM)?

A

Sliding-scale insulin regime
A dextrose + insulin infusion is titrated to blood sugar levels, according to the local protocol

199
Q

What is a key complication for pregnant mothers with pre-existing diabetes?

A

Diabetic retinopathy → conduct retinopathy screening at booking and at 28 gestation

200
Q

Does GDM improve after birth?

A

Yes!
Diabetes improves immediately after birth. Women with gestational diabetes can stop their diabetic medications immediately after birth. They need follow up to test their fasting glucose after at least six weeks.

201
Q

What should women with pre-existing diabetes be wary of in the postnatal period?

A

Hypoglycaemia (so they should lower their insulin doses)

The insulin sensitivity = will increase after birth and with breastfeeding.

202
Q

What are babies of mothers with diabetes at risk of?

A
  • Neonatal hypoglycaemia
  • Polycythaemia (raised haemoglobin)
  • Jaundice (raised bilirubin)
  • Congenital heart disease
  • Cardiomyopathy
203
Q

What should be closely monitored in a baby whose mother is diabetic?

A

Close monitoring for hypoglycaemia (with regular blood glucose checks and frequent feeds).
* Aim: maintain blood glucose above 2 mmol/l → if falls below this → need IV dextrose of nasogastric feeding

204
Q

What are the top 2 comlpications of gestational diabetes for the neonate?

A

Macrosomia + neonatal hypoglycaemia

Babies become accustomed to a large supply of glucose during the pregnancy, and after birth they struggle to maintain the supply they are used to with oral feeding alone.

205
Q

How does obesity affect pregnancy?

A

Obesity = affects pregnancy through various mechanisms, including:
* Insulin resistance
* Increase pro-inflammatory cytokines
* Changes in vascular function

These changes can lead to complications for both mother + baby

206
Q

Classes of obesity (using BMI)

A
  • Class I: BMI 30-34.9
  • Class II: BMI 35-39.9
  • Class III: BMI ≥40
207
Q

Epidemiology & risk factors of obesity in pregnancy

A

Obesity affects = 1 in 5 pregnant women in UK

Risk factors:
* Sedentary lifestyle
* High-calorie diet
* Socioeconomic status
* Genetic predisposition

208
Q

What investigations would you carry out in a pregnant woman who is obese?

A

Primary: BMI (height + weight)
Ix to consider:
* OGTT (≥7.8mmol/L for GDM)
* Lipid profile

209
Q

Management for obesity in pregnancy

A

First line:
* Lifestyle modifications
* Folic acid 5mg starting at least 1 month pre-conception and during the first trimester

Second line:
* Metformin (for GDM, if lifestyle changes are insufficent)

210
Q

Name some maternal complications of obesity in pregnancy

A
  • Gestational diabetes
  • Pre-eclampsia
  • Venous thromboembolism
  • Caesarean birth
  • Postpartum haemorrhage
  • Difficulty breastfeeding
211
Q

Name some foetal complications due to obesity in pregnancy

A
  • Congenital anomalies: spina bifida
  • Stillbirth
  • Prematurity
  • Macrosomia
  • Childhood obesity
212
Q

What is a first line medication for obesity in pregnancy?

A

Folic acid 5mg
(Starting at least 1 month pre-conception and during the first trimester)

Spina bifida = a foetal complication of obesity in pregnancy

213
Q

When are pregnant women screened for anaemia when pergnant?

A
  • Booking clinic
  • 28 weeks gestation
214
Q

Why are pregnant women screen for anaemia?

A

During pregnancy → plasma volume = increases → leads to reduced haemoglobin conc.

(Blood is diluted due to the higher plasma volume)

215
Q

Why is it important to treat anaemia in pregnancy?

A

Incase there is significant blood loss during delivery

216
Q

How may a pregnant woman with anaemia present?

A
  • SOB
  • Fatigue
  • Dizziness
  • Pallor

(Often it is asymptomatic)

217
Q

What are the normal ranges of haemoglobin during pregnancy?

A
  • Booking bloods: >110 g/l
  • 28 weeks gestation > 105 g/l
  • Post partum > 100 g/l
218
Q

What measurement can indicate the cause of anaemia?

A

Mean cell volume! (MCV)

219
Q

In pregancy:
What causes can a low, normal and raised MCV indicate?

A
  • Low MCV → iron deficiency
  • Normal MCV → physiological anaemia (due to increased plasma volume of pregnancy)
  • Raised MCV → B12 or folate deficiency
220
Q

Apart from MCV, what other tests can be offered to pregnant women at booking?

A

Haemoglobinopathy screening, for:
* Thalassaemia (all women)
* Sickle cell disease (women at higher risk)

Both are causes of significant anaemia in pregnant

221
Q

A pregnant women presents with SOB, pallor, fatigue and dizziness. You suspect it is anaemia, apart from the MCV, what additional investigations can you perform?

A
  • Ferritin
  • B12
  • Folate
  • Low MCV → iron deficiency
  • Normal MCV → physiological anaemia (due to increased plasma volume of pregnancy)
  • Raised MCV → B12 or folate deficiency
222
Q

What is the management for a pregnant woman with iron deficiency anaemia?

A

Iron replacement (e.g. ferrous sulphate 200 mg TDS)

When women are not anaemic, but have a low ferritin (indicating low iron stores), they may be started on supplementary iron.

223
Q

The increased plasma volume + B12 requirements → often result in a low B12 in pregnancy. What should women with low B12 be tested for?

A

Pernicious anaemia
(Checking for intrinsic factor antibodies)

224
Q

What are the management options for low B12 (in pregnancy)?

A
  • IM hydroxycobalamin
  • Oral cyanocobalamin
225
Q

What does of folate acid should all pregnant women be on?

A

400 mcg per day

226
Q

What dose of folic acid should a pregnant woman be on if she is folate deficient?

A

Folic acid 5mg per day

227
Q

What dose should pregnant women with thalassaemia or sickle cell anaemia be on?

A

Folic acid 5mg
(+ close monitoring + transfusions whne required)

228
Q

Why is venous thromboembolisms (VTE) such a common + potentially fatal condition in pregnancy?

A

Thrombosis = develops in the circulation as a result of:
* Stagnation of blood
* Hypercoagulable states during pregnancy

229
Q

What is a thrombosis called that develops in the venous circulation called?

A

Deep vein thrombosis (DVT)

230
Q

How can a DVT turn into a PE?

A

Thrombosis = mobilises (embolisation) from the deep veins → travels to the lungs → becomes lodged in the pulmonary arteries → This blocks blood flow to related areas of the lungs → = called a pulmonary embolism

231
Q

When is the risk for a PE at its highest (for women that are/ have been pregnant)?

A

Postpartum period

232
Q

Risk factors for VTE in pregnancy?

A

Non-modifiable:
* Familiy history of VTE
* IVF pregnancy
* Thrombophilia
* Multiple pregancy
* Gross varicose veins
* Pre-eclampsia
* Parity ≥ 3
* Age > 35 years

Modifiable:
* Smoking
* BMI > 30
* Reduced mobility

233
Q

When should you start VTE prophylaxis in pregnancy?

A
  • 28 weeks: if there are 3 risk factors
  • First trimester: if there are 4 or more risk factors
234
Q

Under what circumstances is prophylaxis for VTE in pregnancy considered (even in the absence of other risk factors)?

A
  • Hospital admission
  • Surgical procedures
  • Previous VTE
  • Medical conditions such as cancer or arthritis
  • High-risk thrombophilias
  • Ovarian hyperstimulation syndrome
235
Q

A 28-year-old woman at 28 weeks gestation presents with sudden onset left calf pain and swelling. She has a history of a previous deep vein thrombosis (DVT) after a long-haul flight 5 years ago. She denies chest pain or shortness of breath. Most likely diagnosis?

A

DVT in pregnancy

236
Q

What are the signs and symptoms of a DVT?

A

Signs:
* Calf tenderness
* Erythema
* Oedema

Symptoms:
* Leg pain: typically unilateral
* Leg swelling

Signs of DVT - CEO (Calf tenderness, Erythema, Oedema)

237
Q

Signs and symptoms of a PE

A

Signs:
* Tachypnoea
* Tachycardia
* Hypoxic
* Haemoptysis
* Hypotension

Symptoms:
* Pleuritic chest pain
* SOB

BP and O2 low → increases HR and RR

238
Q

What are the investigations for VTE in pregnancy (DVT and PE)?

A

Ix:
* Compression duplex ultrasound: direct visualisation of DVT
* CXR
* ECG: look for evidence of right side heart strain
* CT pulmonary angiography (CTPA): CTPA minimally increases the lifetime risk of maternal breast cance

Investigations to consider:
* Ventilation-perfusion (VQ) scan: pulmonary embolism results in perfusion deficit due to blocked blood flow to the lung tissue. V/Q scanning minimally increases the risk of childhood cancer .
* ABG: this may show respiratory failure with PE

239
Q

Management for VTE in pregnancy

A

First line:
* Low molecular weight heparin (LMWH) (dalteparin, enoxaparin): Continued for ≥6 weeks postnatally (treatment totalling 3 months)
* DOAC or warfarin: Swicthed to this after delivery
* Thrombolysis, embolectomy, and unfractionated heparin: these should be used in cases of massive PE with haemodynamic instability

LMWH = doesn’t cross the placenta - so is therefore safe for the baby

240
Q

What are the prophylaxis options for VTE in pregnancy?

A
  • From 28 weeks gestation (3 risk factors)
  • From first trimester (≥4 risk factors)

First line:
* LWMH (Prophylaxis is continued until 6 weeks postnatally, with a temporary pause during labour)
* Intermittent pneumatic compression
* Anti-embolic compression stockings

241
Q

What are the complications of a VTE in pregnancy (DVT and PE)?

A
  • Recurrent VTE
  • Post-thrombotic syndrome
  • Chronic thromboembolic pulmonary hypertension

3a Women's Health (8 decks)

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