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GOSH > Obstetrics (Antenatal care): Common symptoms and complications > Flashcards

Obstetrics (Antenatal care): Common symptoms and complications Flashcards

1
Q

What problems of pregnancy are common in the first trimester and how are they managed?

A
  1. Morning sickness
    - Presents early, typically resolves by 16-20wks
    - due to HCG
    - -> Ginger (natural anti-emetic), anti-emetics: promethazine, cyclizine (1st line) metoclopramde, prochlorperazine (2nd line)
  2. Hyper-emesis gravidum
    - vomiting so severe it causes dehydration, weight loss and deranged electrolytes
    - -> Admission; monitor U+Es; anti-emetics (see above); IV Saline 0.9% and Thiamine; Steroids (last resort)
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2
Q

What problems of pregnancy are seen throughout and how are they managed?

A
  1. Heart burn
    - Presents throughout pregnancy, mostly 3rd
    - -> H2 antagonist: ranitidine or PPI: omeprazole; ant-acids: gaviscon
  2. Constipation
    - Presents throughout pregnancy, decreases with each trimester
    - Progesterone decreases SM tone and causes reduced bowel motility
    - -> Diet: fruit, fibre, fluids; Stool softener: Movicol or Osmotic laxative: Lactulose
  3. Backache
    - Progesterone causes ligament laxity, also compression of sciatic nerve –> sciatica
    - resolves after delivery
    - -> Physio; adjust sleeping; analgesia ladder
  4. Pubic symphysis dysfunction
    - produces pelvic pain around pubis or scare-illiac joints
    - -> Physio; adjust sleeping; analgesia ladder
  5. Fatigue and tiredness
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3
Q

What problems of pregnancy are seen during the 3rd trimester and how are they managed?

A
  1. Itching and rashes
    - must check for jaundice in sclera and deranged LFTs or bile salts to exclude cholestasis
    - -> emollients
  2. Varicose veins
    - -> compression stockings
  3. Leg cramps and ankle oedema
    - must exclude pre-eclampsia and VTE
    - -> raise foot off end of bed; avoid diuretics
  4. Haemorrhoids
  5. Carpal tunnel syndrome
    - -> resolves after delivery; splint or surgery
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4
Q

What are the definitions of hypertension in pregnancy?

A
  1. Pre-existing HTN - occurring prior to pregnancy
  2. Transient PIH - HTN > 140/90 occurring after 20 weeks without any oedema or proteinuria
  3. Pre-eclampsia - HTN > 140/90 occurring after 20 weeks with proteinuria > 300mg ± oedema
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5
Q

What is the criteria for the different grades of pre-eclampsia (mild severe)?

A

Mild - HTN > 140/90 but <170/110 with proteinuria
Mod - HTN >170/110 with proteinuria
Sev - HTN > 170/110 before 32 weeks or with maternal complications

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6
Q

What are the signs and symptoms of pre-eclampsia? (early and severe)

A

Early

  • HTN > 140/90
  • Oedema
  • Headache (maybe)
  • PCR (split) > 30 or Proteinuria > 300mg/24hrs

Severe

  • Headache
  • Oedema - sudden onset of face, hands and feet
  • RUQ or epigastric pain
  • Vomiting
  • Papilloedema
  • Hyper-reflexia
  • Acute foetal distress and reduced foetal movements
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7
Q

What investigative findings would suggest HELLP syndrome?

A
  • Haemolysis on blood film
  • Elevated LFTS (ALT/ALP)
  • FBC: Reduced platelets < 100x10^9
  • Proteinuria ++++++
  • U+Es: rapidly rising uric acid + creatinine
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8
Q

What is the treatment of prophylactic treatment for pre-eclampsia and it’s complications?

A
  1. Aspirin
    - low dose 75mg PO OD
    - reduce risk of foetal compromise
  2. Anti-HTN management
    - PO Labetalol (1st line), Nifedipine (2nd line)
  3. Corticosteroids
    - for mod-severe pre-eclampsia
    - 2 doses of Betamethasone (1 week apart) at < 34 weeks to promote pulmonary maturity
  4. Mg Sulphate
    - to prevent development of eclampsia (one or more grand-mal seizures superimposed on pre-eclampsia)
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9
Q

What is the definitive treatment for pre-eclampsia? How are they managed?

A

DELIVERY OF THE FOETUS

  • Mild by 37 weeks (term)
  • Moderate to severe by 34-36 weeks

Delivery

  • Continous CTG, BP and fluid balance monitoring
  • Avoid pushing in 2nd stage of labour if BP > 160
  • Oxytocin > ergometrine

Post-natal

  • Monitor U+Es, LFTs, platelets and renal function
  • Monitor fluid balance - UO measure, don’t overload
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10
Q

What investigative findings are diagnostic of pre-eclampsia?

A
  1. BP > 140/90 at > 20 weeks

2. Proteinuria > 300mg/24hrs or split PCR > 30

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11
Q

What investigations are essential to monitor during pre-eclampsia?

A
  1. FBC: platelets
  2. U+Es: creatinine + uric acid
  3. LFTs: ALP/ALT
  4. BP:
  5. CTG or doppler - foetal wellbeing (HR + movement)
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12
Q

What are the risk factors for pre-eclampsia?

A 
Personal or family history of pre-eclampsia 
Age > 40 
BMI > 30 
DM 
Previous cardiac, vascular or renal disease 
Multiple preg
Molar preg
Nuliparity 
Autoimmune disease
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13
Q

What are the key investigations and treatment of eclampsia?

A
  1. Bloods: FBC (Platelets, Hb), U+E (uric acid + creatinine), LFT (ALT/ALP)
  2. Cross match - 4L
  3. Reduce HTN - PO Labetalol bolus 500mg
  4. Reduce Seizure - Magnesium Sulphate 4g bolus
  5. Steroids and delivery
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14
Q

What is the difference between stillbirth, miscarriage and recurrent miscarriage?

A

Stillbirth is the delivery of a dead foetus > 24weeks gestation

Miscarriage is the delivery of a dead foetus < 24weeks gestation

Recurrent miscarriage is the 3 consecutive MisC within the 1st trimester with the same biological father

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15
Q

How is gestational DM diagnosed?

A
  1. Oral glucose tolerance test (OGTT)
    - offer at 26-28 wks and 36wks or 16wks if previous gestational DM
    - overnight fasting, 75g of oral glucose
    - Fasting glucose > 7 mmol or Post-2h OGTT glucose > 11.1 mmol = GD
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16
Q

What is the treatment for gestational D?

A
  1. Monitor and diet control
  2. Metformin (1st line med)
    - sulphponylurea is CI
    - use medication if after 1-2 weeks pre-G > 6 or post >7
  3. Insulin (last line)
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17
Q

What is the most common mode of delivery for gestational D baby?

A

Lower segment C-section (LSCS) by 39 wks

It is possible to have normal vaginal delivery with IOL by 30-40wks

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18
Q

Why does gestational D occur?

A

Increased resistance to insulin –> impairs glucose tolerance in pregnancy and therefore increases post-prandial glucose

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19
Q

What is the investigative pathway for VTE in pregnancy?

A
  1. ECG (S1Q3T3, tachycardia), O2 sats (low), ABG (hypoxic)
  2. Thrombophilia screen: FBC, CRP, Coagulation screen
  3. D-dimer
    - likely raised due to pregnancy
    - but if low then VTE is unlikely

DVT
- doppler USS or venogram

PE

  • CXR - exclude other causes
  • V/Q scan
  • CTPA (confirms)
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20
Q

What is the treatment for VTE in pregnancy?

A

1A. UFH bolus then infusion
- Measure APTT 6 hours post bolus

1B. LMWH

  • Enoxiparin (1mg/kg BD) or Dalteparin w/ Aspirin
  • Measure peak anti-Xa 3 hrs after (must be between 0.35-0.7)
  1. if Massive PE consider thrombosis or PCI
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21
Q

What are the precautions to take prior to labour in VTE risk mothers?

A
  1. Stop heparin before patient goes into labour and if giving epidural to avoid haematoma!!!
  • must not administer epidural until > 12h post last heparin dose
  • must not administer heparin until > 4h after catheter removal
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22
Q

For the following drugs state whether they can be given during (a) pregnancy and (b) breast feeding:

  1. UFH
  2. LMWH
  3. Warfarin
A
  1. Warfarin cannot be given during pregnancy or breast feeding
  2. LMWH and UFH can be given during pregnancy and breast feeding as they are large molecules and cannot cross the placenta
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23
Q

What are the symptoms and signs of ectopic pregnancy?

A

Can be asymptomatic

History:

  • Amenorrhoea (6-8wks)
  • Pain: typically vague abdominal or pelvic pain, U/L colic –> constant
  • Irregular vaginal bleeding - small, often brown
  • Vomiting and diarrhoea
  • Light headed and syncope
  • Shoulder tip pain and peritonitis if haemoperitoneum

Exam:

  • Uterus normal size (may be smaller)
  • Cervical os is smaller
  • Adnexal or pelvic mass and tenderness
  • Cervical motion tenderness
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24
Q

What are the investigations for ectopic pregnancy?

A
  1. Pregnancy test
    - in all women of child bearing age with abdominal pain, amenorrhoea, vomiting or collapse
  2. USS or TVS (more sensitive)
    - confirms absence of uterine foetus
    - confirms ectopic as adnexal mass or free fluid
  3. Serial HCG
    - if > 1000 = uterine preg likely
    - if < 1000 but rise >66% in 48hrs = uterine preg likely
    - if slow rise or decline = ectopic or miscarriage
  4. Laparoscopy - gold standard only neccessary if previous investigations are inconclusive and clinical picture indicates ectopic
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25
Q

What is the treatment for ectopic?

A
  1. Expectant (watch and wait)
    - if patient is stable, asymptomatic or mild sx, no foetal cardiac heart beat and EP < 3cm
  2. Medical (common)
    - Single dose of methotrexate
    - measure HCG at 4 and 7 d to confirm absence of trophoblast tissue
  3. Surgical - salpingostomy
    - surgical excision of ectopic
    - measure HCG 7 d post to confirm absence of trophoblastic tissue
    - Give mother Anti-D prophylaxis if required
26
Q

What does shoulder tip pain in ectopic pregnancy indicate?

A

Haemo-peritoneum due to a ruptured ectopic pregnancy

May also present with maternal tachycardia, shock and collapse

27
Q

What is gestational trophoblastic disease?

A

Overgrowth of the placenta causing a spectrum of disorders from hydatiform mole (molar pregnancy) to maligancy

28
Q

What is the difference between partial and complete molar pregnancy? (pathophysiology and appearance)

A

Complete (diploid) - completely paternal, sperm fertilises empty ovum and replicates (mitosis) its own chromosomes (46XX), no foetus

Partial (triploid) - two sperm fertilise single egg, possible to have live foetus

29
Q

What is the symptoms of a hydatiform mole?

A
  1. Heavy bleeding in 1st or early 2nd trimester
  2. Uterus large for date
  3. Pain - due to theca lutein cysts (due to high HCG levels)
  4. Vomiting
  5. Exaggerated pregnancy complications i.e. pre-eclampsia, hyperemesis gravidarum, hyperthyroidism
30
Q

What is the investigative ladder for ectopic pregnancy?

A
  1. Pregnancy test
    - +ve
  2. USS
    - snowstorm appearance of swollen villi and large theca lutein cysts
  3. Serial HCG
    - Exceedingly high or persistently raised HCG levels are likely complete molar or malignancy
31
Q

What is the treatment for molar pregnancy?

A
  1. Suction curetage - evacuation of ectopic pregnancy
    - give oxytocin to prevent haemorrhage
  2. Stop COCP and avoid pregnancy until HCG levels normalise
32
Q

What is the pathophysiology behind trophoblastic disease?

A

Trophoblastic tissue proliferates aggressively
HCG levels rise in excess

  • Proliferation can be localised + non-invasive = molar pregnancy
  • Proliferation can become malignant and confined to uterus = invasive mole
  • proliferation is metastatic = choriocarcinoma
33
Q

What features indicate malignancy from trophoblastic disease?

A

Persistant vaginal bleeding
Persistently high HCG
Evidence of blood borne mets

34
Q

how is malignant trophoblastic disease managed (invasive mole, choriocarcinoma)

A

Methotrexate and Folic acid

  • tumour is highly malignant but very sensitive to chemo so 5 year survival of 100%
35
Q

What is the similarity and difference between molar pregnancy, invasive mole and choriocarcinoma

A

Molar pregnancy = non-invasive localised proliferation

Invasive mole = invasive but confined to uterus only

Choriocarcinoma = metastatic molar malignancy

36
Q

What is the definition of large for dates and what are the risk factors?

A

Foetal fundal height > 2cm of expected size or birth weight of > 4.5kg

Risk factors:

  • Gestational DM
  • Maternal obesity
  • Post-term/dates pregnancy (i.e. >40 weeks)
  • High maternal height + age
  • Multiparity
  • Previous macrosomic infant
  • Beckwith-wiedemann syndrome
37
Q

What are the possible complications to foetus and mother for a large for dates foetus?

A

Maternal

  • High risk of CS, Instrumental, IOL (40 wk multip, 40-41 nulip)
  • PPH, Perineal tear, Puerperal infection
  • Maternal death

Foetal

  • Shoulder dystocia
  • Facial nerve palsy from instrumental delivery
  • Hypoglycaemia (if mother is gestational diabetes)
  • Jaundice
38
Q

What is the definition of small for dates foetus? What are the risk factors?

A

Foetus who’s height falls below the 10th centile for its gestation or birth weight of < 2.5kg

Risk factors:

  • Low maternal weight, height, age, parity
  • Low socio-economic class, poor social support
  • Twins, female
  • Placental insufficiency due to smoking, alcohol, drugs, DM, pre-eclampsia
39
Q

What is the difference between symmetrical and asymmetrical IUGR?

A

Symmetrical

  • whole body of foetus is proportionally small
  • growth restriction presents early and occurs over prolonged period
  • typically due to chromosomal/genetic abnormalities or infection
  • Baby stays small

Assymetrical

  • Occurs over short period of time due to undernourished foetus
  • Baby is disproportionately small with head normal size and abdomen small
  • Baby catches up after birth
40
Q

What can you measure to differentiate between small for dates and IUGR?

A
  1. Serial growth scans (USS)
    - measures biparietal length, head circumference, femur length and abdo circumference
    a. compare actual measurements to expected measurement
    b. plot rate and progression of growth
    c. check disproportionate growth (asymmetric IUGR will have normal head size but small abdo circumference)
41
Q

How can you monitor foetal wellbeing in IUGR?

A
  1. Umbilical artery doppler
    - should have low resistance during diastole = good
    - if reduced diastolic flow –> increased resistance = placental problems
    - if no diastolic flow = serious placental problems
    - if -ve diastolic flow = baby is losing blood during diastole
42
Q

What are the complications of gestational D for foetus and mother?

A

Foetal

  • Macrosomia
  • Shoulder dystocia
  • Neonatal hypoglycaemia
  • Pre-term delivery
  • Congenital abn (CV)

Maternal

  • Operative or instrumental delivery
  • Pre-eclampsia

Tip: SMASH

  • Still birth
  • Macrosomia
  • Amniotic fluid excess
  • Shoulder dystocia
  • HTN (pre-eclampsia) + hypoglycaemia (neonatal)
43
Q

What are the predictors of success for VBAC?

A 
Singleton 
Previous vaginal delivery 
Previous CS was elective 
Low maternal BMI and age 
Small foetus 
Spontaneous labour 
Inter-pregnancy interval < 2 years 
Engagement of head
44
Q

What are the absolute contraindications to VBAC?

A

Uterine rupture
Classic CS
> 2 previous MisC

45
Q

What is the management of a patient for VBAC?

A
  1. Electoral foetal monitoring with CTG
    - determine if high risk during labour
  2. Blood transfusion may be required
  3. Consider emergency CS if required
46
Q

What are the risks vs benefits between VBAC and ERCS?

A

VBAC

  • increased risk of uterine rupture + infection and blood transfusion
  • fewer complications overall

ERCS

  • increased risk of placenta praevia, accreta and adhesions
  • High chance of neonatal respiratory morbidity
47
Q

What is the definition of a stillbirth and how does it present?

A

Still birth is delivery of a dead foetus after 24 weeks

Presents with absent/reduced foetal movements ± antepartum haemorrhage

48
Q

How is still birth diagnosed?

A
  1. USS (trans-abdominal or vaginal) and uterine artery doppler
    - shows absent heart beat in foetus intrauterine
49
Q

What is the management for stillbirth?

A
  1. Delivery
    - some women pass the baby spontaneously within 2 weeks
    - however can expedite the process after 2-3 days by IOL with prostaglandins
  2. Foetus
    - test for chromosomal abn, histology and viral screen
  3. Mother
    - BP
    - Urine dip for protein
    - Temperature
    - Bloods: FBC, clotting, HbA1c, Kleihaur test, serology (CMV, B19, parvovirus)
  4. Death certificate must be given ASAP and registered by mother within 24hrs
50
Q

What is anti-phospholipid syndrome?

A

Autoimmune, hyper-coaguable state resulting in clots forming in veins and arteries thus causing pregnancy related complications such as stillbirht, Misc, preterm labour and severe pre-eclampsia

51
Q

What is the diagnostic criteria for anti-phospholipid syndrome?

A

One event of either thrombus or pregnancy related complication

Two +ve results at least 3 months apart of either:

  1. Glucose lupus anticoagulant
  2. Anti-cardiolipin ab (glycoprotein-B2 - IgG, IgM)
52
Q

What are the features of a threatened miscarriage?

A

Foetus is still alive but threatened

Bleeding - often less than menstrual period and painless
may or may not have pain
Cervical os is closed

50% go on to miscarriage

53
Q

What are the features of an inevitable miscarriage?

A

Threatened miscarriage progresses to cervical dilatation

Heavy bleeding
Clots
Abdominal pain (due to uterine contractions)
Cervical os is open

Either progress to complete or incomplete MisC

54
Q

What are the features of incomplete miscarriage and how is it managed?

A

Not all products have been passed

Bleeding
Abdominal pain
Cervical os is open
Some products of conception retained, some passed

  1. Watch and wait
  2. Medical - Misoprostol
  3. Surgery - cervical dilatation and evacuation
55
Q

What are the features of complete miscarriage and how is managed?

A

All products of conception have been passed

Initially heavy bleeding, clots and pain, cervical os opens –> products of conception pass –> pain and bleeding stops, cervical os closes

Psychological and bereavement

56
Q

What are the features of missed miscarriage and how is it managed?

A

Foetus either not developed or dies in uterus

Some dark brown discharge or light bleeding
Cervical Os is closed
Products of conception retained or blighted or an embryonic uterus

  1. Watch and wait
  2. Medical - Misoprostol
  3. Surgery - cervical dilatation and evacuation
57
Q

What are the features of septic miscarriage and how is it managed

A

Products of conception retained and becomes infected

Bleeding 
Fever and chills 
Abdominal pain 
± Peritonitis 
Cervical Os is closed

Treat as sepsis with BUFALLO

58
Q

What is the investigative ladder for suspected miscarriage ?

A
  1. Pelvic and speculum examination
    - Os closed or open?
    - Products of conception visible?
    - Bleeding from uterus or cervix?
  2. USS (diagnostic)
    - determine absence of foetal heart beat
  3. HCG serial
    - Ectopic or Misc will be slowrising or decreasing
  4. Rhesus status
    - Determine mothers status and provide Anti-D
59
Q

What is the management ladder for suspected miscarriage?

Explain the acute management?

A
  1. Watch and wait
    - only if < 6 weeks and patient is not in pain
    - repeat pregnancy test in 1 week: if +ve come back, -ve then miscarriage
  2. Medical (common)
    - Misoprostol pessary
    - repeat pregnancy test in 3 weeks to confirm
  3. Surgical
    - Suction and retrieval

Acute:

  1. admission if ectopic not excluded or inevitable, incomplete or septic MisC
  2. Analgesia
  3. Resuscitation - patient may lose a lot of blood
  4. Oxytocin - reduces PPH
60
Q

What are the likely causes of miscarriage in 1st trimester and 2nd trimester?

A

1st trimester - congenital abnormalities

2nd trimester - cervical incompetence

GOSH (14 decks)

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