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Yr4: Obstetrics & Gynaecology > Obstetrics: Antenatal Care- Complications 1 > Flashcards

Obstetrics: Antenatal Care- Complications 1 Flashcards

1
Q

When are women routinely screened for anaemia during pregnancy?

A
  • Booking clinic
  • 28 weeks

*Remember women with multiple pregnancy have additional screening between 20-28 weeks

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2
Q

Explain why anaemia is common in pregnancy

A

During pregnancy, both the plasma volume and red blood cell mass increase. However, the plasma volume increases disproportionately – resulting in a haemodilution effect. This predisposes pregnant women to developing anaemia.

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3
Q

What are the Hb thresholds for pregnant women

A

NOTICE threshold lower than normal reference range for women (115-165g/L)

  • 1st trimester: <110g/L
  • 2nd & 3rd trimester: <105g/L
  • Post-partum: <100g/L

Remebmer booking bloods will be in 1st trimester so should be ≥110g/L and second routine check at 28 weeks should be ≥105g/L

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4
Q

State some potential consequences of anaemia in pregnancy

A
  • Premature birth
  • Low birth weight
  • Stillbirth
  • Placental abruption
  • Fe deficiency in baby
  • Developmental delay
  • Decreased reserves in labour
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5
Q

Why is it important to treat anaemia in pregnancy (in terms of delivery)?

A

To ensure woman has reasonable reserves in case there is significant blood loss during delivery

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6
Q

Anaemia in pregnancy is often symptomatic; true or false?

A

FALSE; often asymptomatic

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7
Q

MCV can give an indication of cause of anaemia. Discuss likely cause of anaemia in pregnant woman with:

  • Microcytic
  • Normocytic
  • Macrocytic

… anaemia

A
  • Microcytic → Fe deficiency
  • Normocytic → physiological due to increased plasma volume (disproportionately to RBC mass increase)
  • Macrocytic → B12 or folate deficiency
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8
Q

Are additional investigations, to find underlying cause, routinely performed in anaemic pregnant women?

A

Not routinely performed but may do ferritin, B12, folate to help identify underlying cause

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9
Q

Discuss the management of anaemia in pregnancy

A

Management depends on suspected underlying cause:

  • If normocytic or microcytic anaemia most likely cause is Fe deficiency → Fe supplementation (e.g. ferrous sulphate 200mg TDS)
  • If microcytic could be B12 or folate deficiency:
    • B12 deficiency: seek advice from haematologist and test for pernicious anaemia (intrinsic factor antibodies). Treatment options include PO cyanocobalamin, IM hydroxocobalamin injections
    • Folate deficiency: should already be taking 400mcg folic acid a day. If have deficiency start on 5mg folic acid daily
  • If have haemoglobinopathy: managed jointly with specialist haematologist. Require 5mg folic acid daily, close monitoring & transfusions when required

*NOTE: Fe treatment should be continued for 3/12 following Fe deficiency correction to allow Fe stores to be replenished

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10
Q

State some risk factors for DVT in pregnancy

A
  • Smoking
  • Parity ≥ 3 (NICE → ignore image that says >3)
  • Age > 35 years
  • BMI > 30
  • Reduced mobility
  • Multiple pregnancy
  • Pre-eclampsia
  • Gross varicose veins
  • Immobility
  • Family history of VTE
  • Thrombophilia
  • IVF pregnancy
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11
Q

Explain why pregnant women are at increased risk of VTE/pathophysiology of VTE in pregnancy

A
  • increase in factors VII, VIII, X and fibrinogen
  • decrease in protein S
  • uterus presses on IVC causing venous stasis in legs
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12
Q

Discuss when VTE prophylaxis is given during pregnancy

A
  • If there are 3 risk factors → start prophylaxis at 28 weeks until 6 weeks post partum
  • If there are 4 or more risk factors → start prophylaxis in first trimester (as soon as possible) until 6 weeks post partum

*NOTE: passmed says if had previous DVT automatically high risk so should be started on prophylaxis ASAP

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13
Q

What is used as VTE prophylaxis in pregnancy?

A
  • LMWH unless contraindicated (e.g. edoxaban, dalteparin, tinzaparin)
  • If contraindications to LMWH, mechanical prophylaxis should be given e.g.:
    • Intermittent pneumatic compression (IPC)
    • Anti-embolism compression stockings
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14
Q

VTE prophylaxis is stopped when woman goes into labour and can be started immediately after delivery; true or false?

A
  • True
  • Can start again as long as no contraindications e.g. postpartum haemorrhage, spinal anaesthesia or epidurals
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15
Q

What investigations are required for a woman with suspected:

  • DVT
  • PE
A

Suspected DVT

  • Compression duplex ultrasound
    • If negative but have high suspicion RCOG recommend repeating on day 3 and day 7
  • Bloods
    • FBC, U&Es, LFTs, coagulation

Suspected PE

  • First line: ECG & CXR
  • If woman also has symptoms & signs of DVT, then compression duplex ultrasound should be done. If this confirms DVT no further investigations required.
  • Further investigations:
    • CTPA
    • V/Q scan
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16
Q

Remind yourself how a V/Q scan works

A

Ventilation-perfusion (VQ) scan involves using radioactive isotopes and a gamma camera, to compare the ventilation with the perfusion of the lungs. First, the isotopes are inhaled to fill the lungs, and a picture is taken to demonstrate ventilation. Next, a contrast containing isotopes is injected, and a picture is taken to demonstrate perfusion. The two images are compared. With a pulmonary embolism, there will be a deficit in perfusion, as the thrombus blocks blood flow to the lung tissue. This area of lung tissue will be ventilated but not perfused.

*Copied from ZtoF

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17
Q

Discuss whether a CTPA or VQ scan should be used in pregnant women

A
  • CTPA is the test for choice for patients with an abnormal chest xray
  • CTPA carries a higher risk of breast cancer for the mother (minimal absolute risk)
  • VQ scan carriers a higher risk of childhood cancer for the fetus (minimal absolute risk)
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18
Q

The Wells score is validated for use in pregnancy; true or false?

A

False

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19
Q

Why is it pointless to measure d-dimers in pregnant woman with suspected VTE?

A

Pregnancy is a cause of raised d-dimers

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20
Q

Discuss the management of VTE (not including massive PE) in pregnancy

A

Treatment for VTE is with LMWH. Important points:

  • Should be started immediately before confirming diagnosis if there is delay in getting required scans)
  • Continue for remainder of pregnancy plus 6 weeks postnatally OR 3 months- whichever is longer
  • Stop LMWH 24hrs before planned delivery or if think going into labour
  • Option to switch to DOAC after pregnancy (ONLY if not breastfeeding, DOACs not safe in breastfeeding)

Alternatives, if LMWH contraindicated, include unfractionated heparin and new oral anticoagulants (e.g rivaroxaban). Warfarin should never be used in the treatment of VTE during pregnancy as it is teratogenic, and can lead to foetal loss through haemorrhage.

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21
Q

Discuss the management of massive PE in pregnant woman

A

Immediate management from experienced MDT. Treatment options:

  • Unfractionated heparin
  • Thrombolysis
  • Surgical embolectomy
22
Q

A 10-day course of LMWH should be considered in all women who have had a Caesarean section (particularly in emergency cases); true or false?

A

True

23
Q

Why are pregnant women at increased risk of UTIs? (3)

A
  • Progesterone causes dilation of ureters and decreased bladder tone; this can lead to urinary stasis
  • Compression of bladder or ureters by uterus can lead to further stasis
  • Glycosuria also increases risk (during pregnancy renal threshold for glucose excretion is lowered hence increased risk of glycosuria)
24
Q

For asymptomatic bacteriuria, discuss:

  • What it is
  • When we test pregnant women for it and how
A
  • Bacteria is present in urine but person has no symptoms of infection
  • Test via mid-stream urine sample that is sent for M,C&S at booking clinic. If this is negative, second sample not required
25
Q

Why is it important to detect and treat any asymptomatic bacteriuria or UTI in pregnant women?

A

Asymptomatic bacteriuria increases risk of lower UTIs and pyelonephritis which subsequently increases risk of preterm birth. Thought that UTIs may also increase risk of other complications e.g. low birth weight, pre-eclampsia

26
Q

Describe typical presentation of UTI

A
  • Dysuria (pain, stinging or burning when passing urine)
  • Suprapubic pain or discomfort
  • Increased frequency of urination
  • Urgency
  • Incontinence
  • Haematuria
27
Q

Describe typical presentation of pyelonephritis

A
  • Fever (more prominent than in lower urinary tract infections)
  • Loin, suprapubic or back pain (this may be bilateral or unilateral)
  • Looking and feeling generally unwell
  • Vomiting
  • Loss of appetite
  • Haematuria
  • Renal angle tenderness on examination
28
Q

Discuss which out of nitrites and leucocytes is more accurate indication of UTI

A
  • Nitrites produced by gram -ve bacteria that break down nitrates (normal product in urine) into nitrites
  • There are normally small number of leukocytes (WBCs) in urine but increase can suggest infection or alternative cause of inflammation. Dipstick tests for leukocyte esterase (product of leukocytes)

Nitrites more accurate indication of infection then leukocytes

*NOTE: we don’t use dipsticks to look for asymptomatic bacteriuria or UTIs in pregnancy, we use M,C&S. Just included here for completeness.

29
Q

State some common causes of UTI in pregnancy- highlighting the most common

A
  • Escherichia coli
  • Klebsiella pneumoniae
  • Enterococcus
  • Pseudomonas aeruginosa
  • Staphylococcus saprophyticus
  • Candida albicans (fungal)
30
Q

Discuss the management of asymptomatic bacteriuria and UTIs in pregnancy

A

7 days of abx, options include:

  • Nitrofurantoin (100mg BD)
  • Cefalexin (500mg BD)
  • Amoxicillin (only after sensitivities known. 500mg TDS)
31
Q

When do the following abx need to be avoided in pregnancy and why:

  • Nitrofurantoin
  • Trimethoprim
A

Nitrofurantoin

  • Avoid in 3rd trimester
  • Risk of neonatal haemolysis

Trimethoprim

  • Avoid in 1st trimester as works as folate antagonist and folate required for healthy development of fetus- in particular neural tube development. Use can cause neural tube defects e.g. spina bifida
  • Not known to be harmful later in pregnancy BUT GENERALLY AVOIDED unless necessary
32
Q

When, during pregnancy, can Rubella (German measles) infection lead to congenital rubella syndrome?

A
  • Infection in first 20 weeks of pregnancy/gestation
  • Risk highest before 10 weeks gestation
33
Q

What advice should be given to women planning to become pregnant regarding rubella?

A
  • Women should ensure they have had MMR
  • If unsure, they can be tested for rubella immunity
  • If not had vaccine or after testing don’t have antibodies they should be vaccinated with 2 doses of MMR vaccine 3 months apart
  • MUST WAIT AT LEAST 4 WEEKS FOLLOWING 2ND VACCINE BEFORE GETTING PREGNANT
34
Q

Can pregnant women have the rubella vaccine?

A

No, it is a live vaccine

Would have to wait until after given birth

35
Q

If a pregnant woman develops rubella, what is the management?

A

Self-limiting. Give antipyretics for fever.

If occurs in first 12 weeks pregnancy high likelihood of defects so reasonable to consider termination

36
Q

State some features of congenital rubella syndrome

A
  • Congenital deafness
  • Congenital cataracts
  • Congenital heart disease (PDA and pulmonary stenosis)
  • Learning disability
37
Q

State some potential complications of chickenpox during pregnancy (think about maternal & fetal complications)

A

In the mother:

  • Varicella pneumonitis
  • Varicella hepatitis
  • Varicella encephalitis

In the fetus:

  • Severe neonatal varicella infection (if mother infected around delivery)
  • Fetal varicella syndrome
38
Q

If there is doubt about whether a woman is immune to chicken pox, what can be done?

A

IgG levels for VZV can be tested

39
Q

If a non-immune pregnant lady has been exposed to chickenpox, what is the management?

If a pregnant lady develops chicken pox rash during pregnancy, what is the management?

A

If a non-immune pregnant lady has been exposed to chickenpox:

  • <20 weeks: IV varicella immunoglobulin ASAP
  • ≥ 20 weeks: IV varicella immunoglobulins 7-10 days after exposure as prophylaxis

If a pregnant lady develops chicken pox rash during pregnancy:

  • PO aciclovir if they present within 24hrs AND are ≥ 20 weeks gestation
  • <20 weeks consider aciclovir with caution
40
Q

State some features of congenital varicella syndrome

A
  • Fetal growth restriction
  • Microcephaly, hydrocephalus and learning disability
  • Scars and significant skin changes located in specific dermatomes
  • Limb hypoplasia (underdeveloped limbs)
  • Cataracts and inflammation in the eye (chorioretinitis)
41
Q

Pregnant women are just as likely as non-pregnant women to develop listeriosis; true or false?

A

FALSE; Listeriosis is many times more likely in pregnant women compared with non-pregnant individuals

42
Q

For listeria, discuss:

  • Gram stain
  • Transmission
  • Disease it causes
  • Presentation
A
  • Gram -ve
  • Transmitted from:
    • Unpasteurised dairy products (e.g. camembert, brie)
    • Processed meats (e.g. cooked slices of meat)
    • Contaminated foods
  • Causes listeriosis
  • Presentation:
    • Asymptomatic
    • Flu-like illness
    • Pneumonia (less common)
    • Meningoencephalitis (less common)
43
Q

State some risks associated with listeriosis in pregnancy

A
  • Miscarriage
  • Fetal death
  • Severe neonatal infection
44
Q

How is CMV most commonly spread?

Do most cases of CMV in pregnancy cause congenital CMV?

A
  • Infected saliva or urine of asymptomatic children
  • Most cases of CMV in pregnancy do not cause congenital CMV (only ~5%)

**NOTE: Cytomegalovirus is a member of the herpesvirus family (herpesvirus 5). It is the most common virus transmitted to the fetus during pregnancy. Approximately 1 in 100 women become infected with cytomegalovirus during pregnancy (although most remain asymptomatic). Around one third of maternal CMV infections are then vertically transmitted to the fetus.

45
Q

Discuss the management of a pregnant woman infected with CMV

A
  • No treatment in immunocompetent woman
  • If immunosuppressed would usually like to treat but drugs licensed to treat CMV are teratogenic
  • Can diagnose fetal CMV via amniocentesis after 21 weeks; no treatment if fetal CMV is confirmed- either terminate or continue pregnancy
46
Q

State some features of congenital CMV

A
  • Fetal growth restriction
  • Hepatosplenomegaly
  • Microcephaly
  • Sensorineural hearing loss
  • Vision loss
  • Learning disability
  • Encephalitis → eizures
47
Q

For congenital toxoplasmosis, discuss:

  • Causative organism
  • Whether maternal infection symptomatic or asymptomatic
  • Transmission
  • Triad of features in congenital toxoplasmosis
A
  • Toxoplasma gondii parasite
  • Usually asymptomatic
  • Spread by contamination with faeces from infected cat
  • Congenital toxoplasmosis:
    • Intracranial calcification
    • Hydrocephalus
    • Chorioretinitis
48
Q

State some potential complications of infection with parvovirus B19 in pregnancy

A
  • Miscarriage or fetal death
  • Severe fetal anaemia
  • Hydrops fetalis (fetal heart failure)
  • Maternal pre-eclampsia-like syndrome (rare complication of hydrops fetalis: triad of hydrops fetalis, placental oedema & oedema in mother. May also have hypertension & proteinuria)

NOTE: parvovirus infects erythroid progenitor cells in fetal bone marrow & liver. These cells produce RBCs and infection causes them to produce faulty RBCs with shorter life span. This lead to anaemia which leads to heart failure/hydrops fetalis

49
Q

Discuss the management of pregnant women with suspected and confirmed parvovirus infection

A

Women suspected of parvovirus infection need tests for:

  • IgM to parvovirus, which tests for acute infection within the past four weeks
  • IgG to parvovirus, which tests for long term immunity to the virus after a previous infection
  • Rubella antibodies (as a differential diagnosis)

Treatment is supportive. Women with parvovirus B19 infection need a referral to fetal medicine to monitor for complications and malformations.

50
Q

For zika virus, discuss:

  • How it is spread
  • Symptoms
  • Features of congenital Zika syndrome
  • Management of Zika infection in pregnancy
A
  • Aedes mosquito in areas of world where virus prevalent or by sex with infected person
  • No symtpoms, minimal symptoms or flu-like illness
  • Congenital zika syndrome;
    • Microcephaly
    • Fetal growth restriction
    • Other intracranial abnormalities e.g. ventriculomegaly, cerebellar atrophy
  • Management:
    • Viral PCR and antibodies to confirm diagnosis
    • Refer to fetal medicine for close monitoring of pregnancy
51
Q

State some risk associated with obesity in pregnancy- categorise into pregnancy risks and delivery risks

A

Pregnancy

  • Gestational diabetes
  • VTE
  • Gestational HTN
  • Pre-eclampsia
  • Miscarriage
  • Pre-term labour
  • Stillbirth
  • Neural tube defects

Labour

  • Fetal macrosomia → shoulder dystocia
  • Difficulty getting venous access, spinal anaesthetic and increased GA risks
  • Increased risk of needing IOL
  • Increased risk needing caesarean section
  • Increased risk wound infection
  • Increased risk PPH
52
Q

Discuss the management of obesity in pregnancy

A
  • Educate on risks
  • Weight reduction through healthy diet & lifestyle
  • BMI >30 need to take 5mg folic acids
  • If BMI >35 SFH will be unreliable so will need serial ultrasounds to assess fetal growth
  • Difficulty regarding spinal anaesthetic & venous access during labour
  • Intrapartum fetal monitoring
  • Increased risk of PPH so active management highly recommended

Yr4: Obstetrics & Gynaecology (24 decks)

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