Obstretrics Pt. 2

Question 1

Why is prenatal diagnostic testing performed?

Answer 1

• Usually performed if there is suspicion of disease in the foetus, for example:
  
  • Family history
  • Past obstetric history (RhD alloimmunisation)
  • Serum screening tests
  • Ultrasound scanning (12 week dating or 20 week anomaly)
• Prenatal diagnosis often happens after some form of screening test

Question 2

What are the attributes of a screening test?

Answer 2

• Relevance of the disease
• Effect of early diagnosis on management (e.g. offering termination)
• Sensitivity
• Specificity
• Predictive value
• Affordability
• Equity (available to all)

Question 3

What are different types of prenatal diagnostic tests?

Answer 3

• Ultrasound diagnosis
• Invasive test- CVS or amniocentesis
• Invasive test- cordocentesis
• Ultrasound then invasive test

Question 4

What conditions are diagnosed with ultrasound?

Answer 4

• Neural tube defect
• Gastroschisis
• Cystic adenomatoid malformation of lung
• Twin to twin transfusion syndrome

Question 5

What conditions are diagnosed with CVS or amniocentesis?

Answer 5

• Downs syndrome
• Thalassaemia
• Cystic Fibrosis

Question 6

What conditions are diagnosed with cordocentesis?

Answer 6

• Alloimmune thrombocytopaenia

Question 7

What conditions are diagnosed with ultrasound first then invasive test?

Answer 7

• Congenital diaphragmatic hernia
• Exomphalos
• Ventriculomegaly
• Duodenal atresia

Question 8

What does it mean when a woman initially has no IgM or IgG for a particular virus early in pregnancy but develops IgM or IgG later on?

Answer 8

• Had a clinical or subclinical infection with virus at some point during pregnancy
• This is usually only done if there are ultrasound results suggestive of infection or if there is a history of exposure to a particular virus

Question 9

Describe cell-free foetal DNA (cffDNA)?

Answer 9

• Extracted from the maternal blood
• Uses
  
  • Determination of foetal blood group in cases of RhD alloimmunisation
  • Determine the sex of the foetus in X-linked disorders
  • Diagnose skeletal dysplasias (e.g. achondroplasia)
• The levels of cffDNA increases with gestation, however, it decreases to undetectable levels by the first day after birth

Question 10

What are the two most common invasive tests for prenatal diagnosis?

Answer 10

• Amnioncentesis and Chorion Villous Sampling are the two MOST COMMON invasive tests that are used to check the karyotype of the foetus or diagnose single gene disorders
• These tests carry a small but significant risk of miscarriage
• So, the seriousness of the condition should be enough to warrant the risk

Question 11

What are three options usually available following results of a prenatal test?

Answer 11

• Continue
  
  • May facilitate care around the time of delivery and may help the mother/partner prepare for the birth of a baby with a serious condition
• Termination of pregnancy
• Terminate, but provide information which may prove useful when counselling about recurrence risks in future pregnancies

Question 12

What cells are sampled Chorion Villous Sampling? (Chorion Villous Biopsy)
How is CVS done?

Answer 12

• Foetal trophoblast cells in the mesenchyme of the villi divide rapidly in the first trimester
• CVS aims to take a sample of these rapidly dividing cells from the developing placenta
• This can either be done by:
  
  • Passing a needle under ultrasound guidance through the abdominal wall and myometrium into the placenta
  • Passing a fine catheter (or biopsy forceps) through the cervix into the placenta
• The laboratory can check the sample for aneuploidy

Question 13

Why should the woman be ultrasound scanned initially before CVS?

Answer 13

• To confirm that the pregnancy is viable before the CVS
• To ensure that it is a singleton pregnancy (prenatal diagnosis in multiple pregnancy is more complicated)
• To confirm gestational age (CVS should NOT be performed < 10 weeks gestation)
• To localise the placenta and determine whether a transabdominal or transcervical approach is more appropriate

Question 14

Which type of CVS is most commonly performed? (Transabdominal or transcervical)

Answer 14

• Transabdominal

Question 15

What is the additional risk of miscarriage with CVS?

Answer 15

• 2%

Question 16

What is placental mosaicism?

Answer 16

• Is sometimes found where two different cell types are found in the same sample (one cell line is normal and the other is abnormal)
• This pattern may be present in the placenta and NOT the foetus (confined placental mosaicism)

Question 17

What is amniocentesis?

Answer 17

• Amniotic fluid contains amniocytes and fibroblasts shed from foetal membranes, skin and the foetal genitourinary tract
• Amniocentesis takes a sample of 15-20 mL of amniotic fluid containing these cells
• It is done by passing a needle under continuous direct ultrasound through the abdominal wall and myometrium into the amniotic cavity and aspirating fluid
• The total post-amniocentesis pregnancy loss risk = 1.9% (if performed > 15 weeks)
• Laboratories can provide a result for common aneuploidies (T21, 18, 13, X and Y) within 48 hours
• Full culture takes around 7-10 days
• Amniotic fluid can also be used to check for foetal viral infections

Question 18

What is the advantage of CVS over amniocentesis?

Answer 18

• CVS can be performed earlier in the pregnancy
• This is at a stage where surgical termination of pregnancy is possible
• CVS also provides a larger sample of DNA

Question 19

What is Cordocentesis?
What is the most common reason for it?
How does it work?

Answer 19

• This is performed when foetal blood is needed
• The MOST COMMON reason for cordocentesis is:
  
  • Suspected severe foetal anaemia
  • Thrombocytopaenia
• A needle is passed under ultrasound guidance through the abdominal wall and myometrium into the umbilical cord at the point where it insert into the placenta
• Can be performed from about 20 weeks
• Risk of miscarriage varies with indication and position of the placenta

Question 20

Describe the prenatal diagnosis of Downs Syndrome?

Answer 20

• The screening test involves a combination of:
  
  • Nuchal translucency (NT)
    
    • Thicker in foetuses with Down syndrome
  • Crown-rump length (CRL) from 11+2 to 14+1 weeks
  • Maternal blood test showing hCG and PAPP-A levels from 10 - 14+1 weeks
• The mother’s age is also taken into account when determining risk
• A quadruple test (hCG, AFP, unconjugated oestriol and inhibin A) is the screening strategy of choice in the 2nd trimester

Question 21

Describe Prenatal Diagnosis of Foetal Single Gene Disorders

When are prenatal tests offered?

Answer 21

• Certain autosomal dominant single gene disorders can be diagnosed antenatally
• Offered when:
  • Father is known to be affected
  • Risk of recurrence
  • Condition is suspected on ultrasound:
    
    • E.g. autosomal dominant severe skeletal dysplasia (achondroplasia, thanatophoric dysplasia)
      
      • These are caused by a mutation in FGFR3
      • PCR can be done to identify the FGFR3 mutation in cffDNA

Question 22

Describe Foetal Blood Group test

Answer 22

• If RhD-positive DNA is amplified from the blood of an RhD-negative woman, it must have come from the foetus (thereby showing that the foetus is RhD-positive)
• This test is used in RhD-negative mothers with anti-D antibodies to determine the blood group of the foetus
  
  • If the foetus is RhD-positive, it is at risk of alloimmune haemolytic disease
• Foetal blood group can be determined from samples taken in the first trimester

Question 23

What are common musculoskeletal antenatal obstretric complications

Answer 23

• Backache
• Symphysis Pubic Dysfunction
• Carpal Tunnel Syndrome

Question 24

As an antenatal obstetric complication, what is backache caused by and what are its complications?

How to manage backache?

Answer 24

• Very common
• Caused by:
  
  • Hormone induced laxity of the spinal ligaments
  • Shifting in the centre of gravity as the uterus grows
  • Additional weight gain
• Causes exaggerated lumbar lordosis
• Advise correct posture, avoid lifting heavy objects, avoid high-heels, regular physiotherapy and simple analgesia (paracetamol or co-codamol)

Question 25

What is Symphysis Pubic Dysfunction?

Answer 25

• Excruciatingly painful usually occurring in the 3rd trimester
• The symphysis pubis becomes loose causing the two halves of the pelvis to rub against each other when walking or moving
• Improves after delivery
• Management involves simple analgesia
• A low stability belt may help

Question 26

What is Carpal Tunnel Syndrome?
What are the symptoms?
How is it managed?

Answer 26

• Compression neuropathies occur due to increased soft tissue swelling
• The median nerve is compressed as it passes through the carpal tunnel
• Symptoms include numbness, tingling and weakness of the thumb and forefinger and often severe pain at night
• Simple analgesia and splinting of the affected hand can help
• Surgical decompression is rarely performed in pregnancy

Question 27

What are common gastrointestinal antenatal obstretric complications?

Answer 27

• Constipation
• Hyperemesis gravidarum
• Gastro-oesophageal reflux
• Haemorrhoids
• Obstretric cholestasis

Question 28

Describe constipation (antenatal obstretric complication)

Answer 28

• COMMON
• Usually results from a combination of hormonal and mechanical factors that slow gut motility
• Women should be reassured and given advice regarding adopting a high-fibre diet
• Medications are best avoided if possible
• Mild (non-stimulant) laxatives such as lactulose may be suggested

Question 29

What is hyperemesis gravidarum?

Answer 29

• Hyperemesis gravidarum is a severe, intractable form of nausea and vomiting
• The likely cause is multifactorial
• Nausea and vomiting in pregnancy is extremely common
• The symptoms are usually most pronounced in the first trimester
• Most cases of nausea and vomiting in pregnancy are mild and self-limiting

Question 30

What are the consequences of hyperemesis gravidarum?

Answer 30

• Electrolyte imbalances
• Disturbs nutritional intake and metabolism
• Physical and psychological debilitation
• Adverse pregnancy outcome (increased risk of preterm birth and LBW)

Question 31

What can severe cases of hyperemesis gravidarum cause?

Answer 31

• Malnutrition
• Vitamin deficiencies (e.g. Wernicke’s encephalopathy)
• Intractable retching can lead to Mallory Weiss tears

Question 32

What is general treatment of hyperemesis gravidarum?

Answer 32

• Fluid replacement
• Thiamine supplementation
• Antiemetics (e.g. phenothiazines)

Question 33

How is hyperemesis gravidarum diagnosed?
How is severity assessed?
How is it managed?
(RCOG Green Top Guidelines)

Answer 33

• Diagnosed when there is a triad of:
  
  • More than 5% pre-pregnancy weight loss
  • Dehydration
  • Electrolyte imbalance
• Severity should be assessed using Pregnancy-Unique Quantification of Emesis (PUQE)
• Mild
  
  • Use antiemetics in the community
  • Ambulatory day care management can be used if primary care fails and PUQE score < 13
• Consider inpatient treatment if:
  
  • Continued N/V and can’t keep down oral antiemetics
  • Continued N/V + ketonuria and/or weight loss (> 5% body weight) despite oral antiemetics
  • Confirmed or suspected comorbidity (e.g. UTI) and inability to tolerate oral antibiotics
• Antiemetics
  
  • Antihistamines (e.g. cyclizine) and phenothiazines (e.g. promethazine) should be used as first-line
    
    • Second-line: metoclopramide, ondansetron
  • Combinations can be used if women fail to respond to a single agent
  • Parenteral or rectal route if oral is not tolerated
  • WARNING: extra-pyramidal side-effects and oculogyric crises can occur with phenothiazines and metoclopramide
• Rehydration and Correction of Electrolyte Imbalance
  
  • Normal saline with additional potassium chloride in each bag, with administration guided by monitoring of electrolytes
  • Check urea and electrolytes daily
  • Thiamine supplementation should be given to all women admitted with prolonged vomiting
  • Women who are admitted should also be offered thromboprophylaxis with LMWH
• Alternative therapy
  
  • Ginger, acupressure and hypnosis are alternative options
• MDT
• Discharge
  
  • Individualised management plan
  • If symptoms continue into second and third trimester, should offer serial scans to monitor foetal growth
  • Advise about a risk of recurrence in future pregnancies
• Other
  
  • Assess mental health status (refer to psychological support if necessary)
  • Advise adequate resting

Question 34

Describe gastro-oesophageal reflux (antenatal obstretric complication)

Answer 34

• VERY COMMON
• Weight effect of pregnant uterus and hormonally induced relaxation of the oesophageal sphincter leads to reflux
• Lifestyle modification (e.g. smoking cessation, frequent light meals and lying with the head propped up at night) are usually helpful
• If this is insufficient, antacids, histamine inhibitors and PPIs can be used

Question 35

Why are haemorrhoids more common in pregnancy?

How can they be managed?

Answer 35

• This is more common during pregnancy due to the effects of circulating progesterone on the vasculature, pressure on the superior rectal veins by the gravid uterus and increasing circulating volume
• Conservative measures are usually taken such as local anaesthetic/anti-irritant creams and a high-fibre diet

Question 36

What is Obstretric Cholestasis?

Answer 36

• Also known as intrahepatic cholestasis of pregnancy
• Normally presents in the second half of pregnancy with pruritus and abnormal LFTs without an alternative cause
• This is associated with an increased risk of spontaneous preterm birth, iatrogenic preterm birth and foetal death
• The pruritus can affect sleep
• Normally treated with ursodeoxycholic acid which improves pruritus and liver function but has no effect on maternal or foetal outcome
• Women with obstetric cholestasis are offered delivery after 37 weeks

Question 37

Describe varicose veins in pregnancy
What are potential causes and complications of varicose veins?
How can you manage varicose veins?

Answer 37

• May occur for the first time in pregnancy or pre-existing veins may become worse
• Maybe due to relaxant effect of progesterone on vascular smooth muscle
• Weight of the pregnant uterus can also contribute
• Conservative measures include support stockings, avoid standing for long periods of time and simple analgesia
• Thrombophlebitis may occur in a large varicose vein
• A large superficial varicose vein may bleed profusely

Question 38

Describe oedema in pregnancy

Answer 38

• COMMON
• There is generalised soft-tissue swelling and increased capillary permeability, allowing intravascular fluid to leak into the extravascular compartment
• Fingers, toes and ankles are often worst affected
• Exacerbated by hot weather
• Best dealt with by frequently resting ad elevating the legs
• Sometimes, support stockings are indicated
• Rings and jewellery may need to be removed
• IMPORTANT: generalised (rather than lower limb) oedema may be a feature of pre-eclampsia so it is important to check blood pressure and urine for protein

Question 39

What are other minor disorders of pregnancy?

Answer 39

• Itching
• Urinary incontinence
• Nosebleeds
• Thrush
• Headache
• Fainting
• Breast soreness
• Tiredness
• Altered taste
• Insomnia
• Leg cramps
• Striae gravidarum and chloasma (skin discoloration)

Question 40

What are fibroids?

Answer 40

• These are compact masses of smooth muscle found:
  
  • In the cavity of the uterus (submucous)
  • Within the uterine muscle (intramural)
  • On the outside surface of the uterus (subserous)
• They may enlarge in pregnancy causing problems later in pregnancy or during delivery (e.g. a large fibroid near the cervix and may obstruct vaginal delivery)
• A subserous pedunculated fibroid can tort
  
  • This can also cause acute abdominal pain and tenderness (and hence present very similarly to red degeneration)

Question 41

What is one of the most common complications of fibroids in pregnancy and what is its treatment?

Answer 41

• Red degeneration
• As it grows, the fibroid can become ischaemic
• This manifests as acute pain, tenderness over the fibroid and vomiting
• If severe, it can precipitate uterine contractions causing miscarriage or preterm labour
• This requires treatment with potent analgesics (opiates) and IV fluids
• Symptoms usually settle after a few days

Question 42

What is the differential diagnosis for red degeneration?

Answer 42

• Acute appendicitis
• Pyelonephritis/UTI
• Ovarian cyst accident
• Placental abruption

Question 43

What is used to diagnose fibroids and red degeneration?

Answer 43

• History and ultrasound scanning is used to diagnose both conditions

Question 44

Describe retroversion of the Uterus

Answer 44

• 15% of women have a retroverted uterus
• Most of the time, as the uterus grows through pregnancy, a retroverted uterus would flip out of the pelvis and begin to fill the abdominal cavity (as an anteverted uterus would)
• Occasionally, the uterus remains retroverted as it grows and it will eventually fill up the entire pelvic cavity
• This leads to stretching of the base of the bladder and the urethra
• This can lead to urinary retention (usually at 12-14 weeks)
• This is painful and can cause long-term bladder damage
• Catheterisation is essential until the position of the uterus has changed

Question 45

What are some congenital uterine abnormalities?

Answer 45

• The shape of the uterus is embryologically determined by fusion of the Mullerian ducts
• Abnormalities of fusion can lead to several anomalies such as:
  • Subseptate Uterus
  • Bicornuate uterus (deep indentation at the fundus of the uterus)
  • Uterus didelphys

Question 46

What are associated problems with a Bicornuate uterus?

Answer 46

• Miscarriage
• Preterm labour
• Preterm premature rupture of membranes
• Abnormalities of lie and presentation
• Higher C-section rate

Question 47

Describe Ovarian cysts in pregnancy

Answer 47

• COMMON
• Malignancy is uncommon
• Most common pathological ovarian cyst:
  
  • Serous cyst
  • Benign teratoma
• Physiological cysts of the corpus luteum may grow to several centimetres but rarely require treatment
• Asymptomatic cysts may be followed up by clinical/ultrasound examination
• Large cysts may require surgery
  
  • Surgery is usually postponed until the late 2nd/early 3rd trimester (this means that the baby could survive if it had to be delivered)
• Symptomatic cysts usually require an EMERGENCY laparotomy and ovarian cystectomy or may be an oophorectomy
• Full assessment includes a family history of ovarian or breast malignancy, tumour markers and ultrasound investigation of both ovaries

Question 48

What are major problems with ovarian cysts in pregnancy?

Answer 48

• Large cysts could undergo torsion, haemorrhage or rupture
• This causes acute abdominal pain
• The pain and inflammation may result in miscarriage or preterm labour

Question 49

Describe cervical cancer in pregnancy and how does it present?

Answer 49

• The cervix is more difficult to visualise using colposcopy in pregnancy
• Cervical cancer is often asymptomatic or may present with vaginal bleeding (especially post-coital)
• The diagnosis of cervical cancer in pregnancy raises difficult questions about termination of pregnancy

Question 50

What is a urinary tract infection?
What is a UTI associated with?
What are predisposing factors?

Answer 50

• > 105 colony forming units/mL in urine culture
• UTI and pyelonephritis are associated with LBW and preterm delivery
• Predisposing factors:
  
  • History of recurrent cystitis
  • Renal tract abnormalities (e.g. duplex system, scarred kidneys, ureteric damage and stones)
  • Diabetes mellitus
  • Bladder emptying problems (e.g. multiple sclerosis)
• The classic UTI presentation of frequency, dysuria and haematuria are rarely seen

Question 51

What do you see O/E for a UTI?

Answer 51

• tachycardia, pyrexia, dehydration and loin tenderness may be present

Question 52

What are the investigations for a UTI?

Answer 52

• FBC

- MSU

Question 53

What is the management of a UTI?

Answer 53

• If there is strong suspicion of UTI< treatment with antibiotics should be started straight away
• Encourage plentiful fluid intake
• Use simple analgesics (e.g. paracetamol)
• First-line antibiotic: amoxicillin or oral cephalosporins

Question 54

What are the organisms responsible for a UTI?

Answer 54

• MOST COMMON organism is E. coli
• Other organisms:
  • Proteus
  • Pseudomonas
  • Klebsiella

Question 55

What signs is pyelonephritis characterised by?

Answer 55

• Dehydration
• Very high temperature
• Systemic disturbance
• Shock (occasionally)

Question 56

What is the management of pyelonephritis?

Answer 56

• IV fluids
• Opiate analgesia
• IV antibiotics (cephalosporins or gentamicin)
• Check renal function (baseline urea and electrolytes)
• Monitor baby with CTG

Question 57

What should happen if there are recurrent UTIs in pregnancy?

Answer 57

• MSU specimens should be sent to microbiology at each antenatal visit
• Low-dose prophylactic oral antibiotics
• Further investigations should be delayed until after delivery (unless serious symptoms (e.g. frank haematuria) suggest that urgent diagnosis is necessary)

Question 58

What investigations should be done for recurrent UTIs in pregnancy?

Answer 58

• Renal ultrasound
• DMSA scan
• Creatinine clearance
• IV urogram
• Cystoscopy

Question 59

Describe VTE in pregnancy

Why is pregnancy a hypercoagulable state?

Answer 59

• MOST COMMON cause of direct maternal death in the UK
• Pregnancy is a hypercoagulable state because of an alteration in the thrombotic and fibrinolytic systems
  
  • Increase in factors 8, 9, 10 and fibrinogen
  • Decrease in protein C and antithrombin-III
• These changes are thought to be evolutionary in order to reduce the risk of haemorrhage following delivery
• The weight of the gravid uterus places pressure on the IVC leading to venous stasis, thereby further increasing the risk of thromboembolism
• Immobility also contributes to VTE risk
• Pregnancy is associated with a 6-10 fold increase in VTE risk

Question 60

What are the risk factors of getting a VTE in pregnancy?

Answer 60

• Pre-existing
  
  • maternal age (> 35 years)
  • thrombophilia
  • obesity (> 80kg)
  • previous thromboembolism
  • severe varicose veins
  • smoking
  • malignancy
• Specific to pregnancy
  
  • Multiple gestation
  • Pre-eclampsia
  • Grand multiparity
  • C-section
  • Sepsis
  • Prolonged bed rest

Question 61

What are the hereditary forms of thrombophilia?
What is acquired thrombophilia associated with?
What is APS?

Answer 61

• Some changes in the coagulation/fibrinolytic system may be inherited or acquired
• Main hereditary forms of thrombophilia
  
  • Protein C deficiency
  • Protein S deficiency
  • AT-III deficiency
  • Factor V Leiden
  • Prothrombin mutation G20210A
• Heritable thrombophilias are present in 15% of the Western population
• Acquired thrombophilia is most commonly associated with anti-phospholipid syndrome (APS)
• APS is the combination of lupus anticoagulant with or without anticardiolipin antibodies, with a history of recurrent miscarriage and/or thrombosis
• It may be associated with SLE
• Women with a history of thrombotic events should be screened for thrombophilia
• If thrombophilia is present, thromboprophylaxis should be considered

Question 62

What is the diagnosis of acute DVT?

Answer 62

• Usually presents with calf pain with redness and swelling (and tender)
• NOTE: women’s legs often swell during pregnancy so unilateral symptoms should ring alarm bells
• Check for symptoms of PE
• Compression ultrasound is the first investigation used in suspected DVT
• NOTE: a thrombus that is confined to the calf veins is unlikely to lead to a PE
• Venography is invasive (requires contrast injection and use of X-rays) but allows excellent visualisation of veins above and below the knee

Question 63

What is the diagnosis of acute PE?

Answer 63

• Usually presents with mild SOB or inspiratory chest pain
• The woman may be slightly tachycardic with mild pyrexia
• More rarely, massive PE could cause sudden cardiorespiratory collapse
• If suspected, ECG, CXR and ABG should be performed to exclude other diagnoses
• You may investigate the presence of DVT using ultrasound
• If PE is strongly suspected, a VQ scan or a CTPA may be performed
• NOTE: D-dimer levels are physiologically elevated in pregnancy

Question 64

What is the treatment of acute VTE?

Answer 64

• Warfarin is contraindicated in pregnancy (except in women with mechanical heart valves) because it crosses the placenta and can cause limb and facial defects and foetal intracerebral haemorrhage
• LMWH is the treatment of choice
• They do NOT cross the placenta and it is easy to administer
• After delivery, women can choose to change to warfarin or remain on LMWH
• Graduated elastic stockings should be used for the initial treatment of DVT and should be worn for 2 years after DVT to prevent post-thrombotic syndrome

Question 65

What is the management of Acute VTE (RCOG Green Top Guidelines)?

Answer 65

• Treatment with LMWH (until the diagnosis is excluded)
• The therapeutic dose should be calculated based on the woman’s booking or early pregnancy weight
• DVT
  
  • Compression duplex ultrasound should be performed if there is clinical suspicion of DVT
    
    • If negative and low clinical suspicion - stop anticoagulants
    • If negative and high clinical suspicion - stop anticoagulants and repeat ultrasound on days 3 and 7
  • Initial management includes elevating the leg and applying a graduated elastic stocking
• PE
  
  • Perform ECG and CXR
    
    • If the CXR is abnormal and there is clinical suspicion of PE, a CTPA should be performed in preference to a VQ scan
  • If they also have symptoms of DVT, compression duplex ultrasound should be performed
  • If they have NO symptoms of DVT, a VQ scan or CTPA should be performed
  • Alternative or repeat testing should be carried out if the VQ scan and CTPA are normal but the clinical suspicion of PE remains
  • Anticoagulant treatment should be continued until PE is definitively excluded
  • VQ scanning has a higher risk of childhood cancer, but CTPA has a higher risk of maternal breast cancer (BUT, the absolute risk is very small)
  • NOTE: IVC filters may be considered in the peripartum period for patients with iliac vein VTE or in patients with proven DVT and those who have recurrent PE despite anticoagulation
  • Massive PE
    
    • Options include IV unfractionated heparin, thrombolytic therapy, thoracotomy or surgical embolectomy
    • IV unfractionated heparin preferred when cardiovascular compromise
    • Urgent portable echocardiogram or CTPA should be arranged
    • If massive PE is confirmed, immediate thrombolysis should be considered
  • Maintenance Treatment of VTE
    
    • Treatment with therapeutic doses of subcutaneous LMWH should be continued for the remainder of the pregnancy and for at least 6 weeks posnatally and until at least 3 months of treatment in total
  • Women should be taught to self-inject
  • Watch out for heparin-induced thrombocytopaenia and heparin allergy
  • Women should be offered a choice of LMWH or oral anticoagulant (this requires routine INR monitoring)
  • NOACs may be used in patients who cannot tolerate heparin
  • NOTE: neither heparin nor warfarin are contraindicated in breastfeeding
  • Anticoagulation during labour and delivery
    
    • If VTE occurs at term, IV unfractionated heparin should be considered
    • If a woman on LMWH maintenance therapy goes into labour, they should NOT inject any more
    • If delivery is planned, LMWH should be discontinued 24 hours before
    • Regional anaesthetic (e.g. epidural) should not be undertaken until at least 24 hours after the last dose of LMWH
    • LMWH should not be given until 4 hours after the use of spinal anaesthesia or after the epidural catheter has been removed
    • Women who are at HIGH RISK OF HAEMORRHAGE who require continuous heparin should be managed with IV unfractionated heparin
  • Prevention of Post-Thrombotic Syndrome
    
    • Prolonged use of LMWH (> 12 weeks) is associated with lower risk of post-thrombotic syndrome
    • Graduated elastic compression stockings also reducer risk

Question 66

How does alcohol affect pregnancy?

Answer 66

• > 1 pint per day = FGR
• Foetal alcohol syndrome
• Foetal alcohol syndrome is not seen consistently in women who are heavy consumers of alcohol (there appears to be some difference in the susceptibility of foetuses to foetal alcohol syndrome)
• May have to involve social workers
• May have to arrange formal psychiatric/addiction assessment
• Markers of acute alcohol abuse like MCV and GGT are not reliable in pregnancy
• Malnutrition and required vitamin B and iron supplementatio

Question 67

How does smoking affect the placenta?

What is smoking associated with?

Answer 67

• Smoking acutely reduces placental perfusion
• It is associated with:
  
  • Increased perinatal mortality
  • Smaller babies
  • Higher risk of placental abruption
• Quitting by 15 weeks gestation reduces the risk as much as quitting before pregnancy
• ALL women should be counselled regarding smoking cessation at the booking visit

Question 68

What is amniotic fluid?

Answer 68

• Almost exclusively comes from foetal urine from the 2nd trimester onwards
• Roles
  • Protection from pressure or trauma
  • Allows limb movement
  • Permits foetal lungs to expand and develop through breathing

Question 69

What is oligohydramnios?

Answer 69

• Commonly defined as amniotic fluid index (AFI) < 5th centile for gestation
• AFI is an ultrasound estimation of amniotic fluid volume
• May be suspected if there is a history of clear fluid leaking from the vagina
• On palpation of the abdomen, the foetal poles may be very obvious and hard with a small for dates uterus
• Prognosis depends on cause of oligohydramnios
• In severe early-onset oligohydramnios, pulmonary hypoplasia and limb deformities are common
• Renal agenesis (Potter syndrome) and bilateral multicystic kidneys carry a LETHAL prognosis because life is impossible without functioning kidneys
• Oligohydramnios due to FGR/utereroplacental insufficiency tends to be less severe

Question 70

What are the causes of oligohydramnios?

Answer 70

• Renal agenesis (Ultrasound: no kidneys or bladder)|
• Multicystic kidneys (Ultrasound: enlarged kidneys with multiple cysts, no visible bladder)
• Urinary tract abnormality/obstruction (Ultrasound: kidneys may be present but urinary tract dilatation)
• FGR and placental insufficiency (Clinical: reduced SFH, reduced foetal movements, possibly abnormal CTG, Ultrasound: FGR, abnormal fetal Doppler wave forms)
• Maternal drugs e.g. NSAIDs (Withdrawing NSAIDs causes amniotic fluid to accumulate)
• PPROM (Leakage) diagnosed by speculum examination: pool of amniotic fluid on posterior blade

Question 71

What is polyhydramnios?

What does it present with?

Answer 71

• Commonly defined as AFI > 95th centile for gestation
• May present with severe abdominal swelling and discomfort
• The abdomen may appear distended out of proportion with the woman’s gestation
• The abdomen may be tense and tender, and the foetal poles will be difficult to palpate
• Polyhydramnios that may be caused by maternal diabetes will correct itself once glycaemic control is optimised

Question 72

What is the management of polyhydramnios?

Answer 72

• Identifying the cause
• Relieving discomfort (e.g. amniodrainage)
• Assessing the risk of preterm labour due to uterine overdistension

Question 73

What are the three type of breech presentations?

Answer 73

• Extended (frank) breech (MOST COMMON)
• Flexed (complete) breech
• Footling breech

Question 74

What are predisposing factors for breech presentation?

Answer 74

• Maternal
  
  • Fibroids
  • Congenital uterine abnormalities (e.g. bicornuate uterus)
  • Uterine surgery
• Foetal
  
  • Multiple gestation
  • Prematurity
  • Placenta praevia
  • Abnormality (e.g. anencephaly, hydrocephalus)
  • Foetal neuromuscular condition
  • Oligo/polyhydramnios

Question 75

What is the management of breech (RCOG Green Top Guidelines)?

Answer 75

• If Breech at or after 36 weeks = confirm with ultrasound
• This should look at foetal biometry, amniotic fluid volume, placental site and position of the foetal legs
• If breech:
  
  • External cephalic version
  • Vaginal breech delivery
  • Elective Caesarean section
• Planned vaginal delivery of a breech linked to 3% increased risk of death or serious morbidity to the baby
• The BEST METHOD of delivering breech singleton is by planned Caesarean section
• Planned C-section for breech at term carries a small risk of increased maternal complications
• Rate of maternal complications are lowest for successful vaginal birth and higher for planned C-section
• BUT the risks are highest with emergency C-section which is needed in about 40% of planned vaginal breech deliveries
• Women should be informed about the risks of C-section:
  
  • Risks of opting for vaginal birth after C-section
  • Increased risk of complications at repeat C-sections
  • Risk of an abnormally invasive placenta
• C-sections are associated with a small increase in risk of stillbirth for subsequent babies (but this may not be causal)
• If a woman presents with an unplanned breech presentation in labour, offering planned C-section depends on the stage of labour (women near or in active second stage of labour should NOT routinely be offered C-section)
• Induction of labour is NOT usually recommended

Question 76

What are the features of HIGH RISK planned vaginal breech?

Answer 76

• Hyperextended neck on ultrasound
• High estimated foetal weight
• Low estimated weight
• Footling presentation
• Evidence of antenatal foetal compromise

Question 77

What is external cephalic version?

Answer 77

• This is technique that reduces the number of C-sections due to breech presentations
• Success rates vary depending on the experience of the operator (but is around 50%)
• Performed at or after 37 weeks gestation
• Should be performed with a tocolytic (prevents contractions e.g. nifedipine)
• Woman is laid flat
• The obstetrician uses their hands to make the baby do a forward role thereby correcting the breech position
• Foetal heart rate should be monitored before and after the procedure
• Anti-D should be administered if the woman is Rhesus-negative

Question 78

What are the contraindications of external cephalic version?

Answer 78

• Foetal abnormality (e.g. hydrocephalus)
• Placenta praevia
• Oligo/polyhydramnios
• History of antepartum haemorrhage
• Previous C-section or myomectomy scar on the uterus
• Multiple gestation
• Pre-eclampsia or hypertension
• Plan to deliver by C-section anyway

Question 79

What are the risks of external cephalic version?

Answer 79

• Placental abruption
• Premature rupture of membranes
• Cord accident
• Transplacental haemorrhage (hence why anti-D is important in Rhesus-negative women)
• Foetal bradycardia

Question 80

Describe vaginal breech delivery technique

Answer 80

• Delivery of the Buttocks
  
  • Most of the time, full dilatation and descent of the breech will have occurred naturally
  • The buttocks will lie in the anterior-posterior diameter
  • An episiotomy can be cut once the anterior buttock is delivered and the anus is seen over the fourchette (frenulum of labia minora)
• Delivery of Legs and lower body
  
  • If the legs are flexed, they will deliver spontaneously
  • If extended, they may need to be delivered with Pinard’s manoeuvre
  • This involves using a finger to flex the leg at the knee and extend the hip, first anteriorly then posteriorly
  • Maternal effort and contractions help
• Delivery of the Shoulders
  
  • The baby is initially lying with the shoulders in the transverse diameter of the pelvic midcavity
  • As the anterior shoulder rotates into the anterior-posterior diameter, the spine or the scapula will become visible
  • A finger can then be placed gently above the shoulder to help deliver the arm
  • As the posterior arm reaches the pelvic floor, it will rotate anteriorly
  • Once the spine becomes visible, the second arm will be delivered
  • Loveset’s manoeuvre copies these natural movements
• Loveset’s manoeuvre is unnecessary to do routinely
• Delivery of the Head
  
  • Delivered using Mauriceau-Smellie-Veit Manoeuvre
  • The baby lies on the obstetrician’s arm with downward traction on the head via a finger in the mouth and one on each maxilla
  • Delivery occurs with first downward then upward movement
  • Forceps may be used if this manoeuvre is difficult

Question 81

What are complications of vaginal breech delivery?

Answer 81

• The baby getting stuck

- Inappropriate use of oxytocic agents and trying to pull the baby out will increase the risk of obstruction

Question 82

What are some other foetal malpresentations?

Answer 82

• Transverse lie (usually results in shoulder presentation)
• Oblique lie
• These women are at risk of cord prolapse following spontaneous rupture of membranes
• They are also at risk of prolapse of the hand, shoulder or foot once in labour
• In most cases, the woman is multiparous with a lax uterus and abdominal wall musculature
• Gentle version of the baby’s head will restore the presentation to cephalic
• In these women, the abdomen may appear asymmetrical
• On palpation, the foetal head or buttocks may be in the iliac fossa
• Palpation over the pelvic brim may reveal an empty pelvis
• A woman in labour with a baby who’s lie is anything other than longitudinal will NOT be able to deliver vaginally
• C-section is required - if it is NOT performed, the baby and the mother are at considerable risk of morbidity and mortality
  
  • EXCEPTION: preterm/small babies

Question 83

What is post-term pregnancy?
What are risks of post-term pregnancy?
How can risks be reduced?
When should immediate induction of labour take place?

Answer 83

• Defined as a pregnancy that has extended to or beyond 42 weeks gestation
• This affects 10% of pregnancies
• Associated with increased risk to both foetus and mother such as:
  
  • Stillbirth
  • Perinatal death
  • Prolonged labour
  • C-section
• Foetal surveillance and induced labour are two strategies to reduce risk
• CTG should be performed at and after 42 weeks
• Ultrasound can help assess amniotic fluid volume and foetal growth rate
• IMMEDIATE induction of labour should take place if:
  
  • Reduced amniotic fluid on ultrasound
  • Foetal growth is reduced
  • Reduced foetal movements
  • CTG is not perfect
  • Mother is hypertensive or suffers from a significant medical condition

Question 84

Describe vaginal bleeding in pregnancy

Answer 84

• COMMON but causes anxiety
• Vaginal bleeding:
  • < 24 weeks is defined as a threatened miscarriage
  • 24+ weeks is defined as antepartum haemorrhage (APH)

Question 85

What are the causes of Antepartum Haemorrhage (3% of pregnancies)?

Answer 85

• Placental
  
  • Placental abruption
  • Placenta praevia
  • Vasa praevia
• Local Causes
  
  • Cervicitis
  • Cervical ectropion
  • Cervical carcinoma
  • Vaginal trauma
  • Vaginal infection
• NOTE: of the 3%, 1% is caused by placental abruption, 1% by placenta praevia and the remaining 1% from the other causes
• APH must ALWAYS be taken seriously

Question 86

What would you state in a history for vaginal bleeding?

Answer 86

• How much bleeding?
• Triggering factors (e.g. post-coital?)
• Associated with pain or contractions?
• Is the baby moving?
• Last cervical smear (date/normal or abnormal)

Question 87

How would you examine a pregnant woman with vaginal bleeding?

Answer 87

• Pulse, BP
• Is the uterus soft or tender and firm?
• Foetal heart auscultation/CTG
• Speculum vaginal examination

Question 88

What investigations would you do for vaginal bleeding?

Answer 88

• Depends on degree of bleeding - FBC, clotting and cross-match 6 units of blood (if praevia or abruption)
• Ultrasound - assess foetal size, presentation, amniotic fluid, placental fluid and morphology

Question 89

Describe Rhesus antigens

Answer 89

• There are at least 40 Rhesus antigens and the most clinically important are C, D and E
• They are coded on two adjacent genes on chromosome 1
  
  • One gene encodes C/c and E/e
  • The other codes for D (Rhesus antigen)
• In practice, only anti-D (mostly) and anti-c (rarely) cause haemolytic disease of the foetus and newborn (HDFN)

Question 90

How does HDFN from rhesus isoimmunisation occur?

Answer 90

• A rhesus-negative mother must conceive a baby who has inherited the rhesus-positive phenotype from the father
• Foetal cells must gain access to the maternal circulation in a sufficient volume to provoke a maternal antibody response
• Maternal antibodies must cross the placenta and cause immune destruction of red cells in the foetus

Question 91

Why doesn’t Rhesus disease affect the first pregnancy?

Answer 91

• Rhesus disease does NOT affect the first pregnancy because the primary immune response is usually weak and consists mainly of IgM which does NOT cross the placenta
• In a subsequent pregnancy with a Rhesus-positive foetus, Rhesus-positive cells pass from the baby to the mother and cause resensitisation
• Then, B cells produce a much larger response with IgG antibodies that can cross the placenta into the foetal circulation
• This can lead to severe anaemia due to haemolysis and the foetus may die unless transfusion is performed
• RhD-negativity is present in 15% of the Caucasian population in the UK (and is lower in all other ethnic groups)

Question 92

What are potential sensitising events for rhesus disease?

Answer 92

• Miscarriage
• Termination of pregnancy
• Antepartum haemorrhage
• Invasive prenatal testing (CVS, amniocentesis, cordocentesis)
• Delivery

Question 93

How do you prevent Rhesus isoimmunisation?

Answer 93

• Rhesus isoimmunisation can be prevented by administration of IM anti-D immunoglobulin to the mother
• This ‘mops up’ circulating Rhesus-positive cells before an immune response is elicited in the mother
• Anti-D immunoglobulin should be administered ASAP after a potential sensitising event (ideally within 72 hours of exposure to foetal red cells)
  
  • If this deadline is missed, administration up to 10 days after sensitising event may be of benefit
• Dose is dependent on gestation at which sensitising event occurred and size of foeto-maternal haemorrhage
• Kleihauer test of maternal blood shows the proportion of foetal cells present in the maternal sample (allows calculation of size of foeto-maternal transfusion and amount of extra anti-D required)
• ALL RhD-negative women who have NOT been previously sensitised should be offered routine antenatal prophylaxis with anti-D either with a single dose regimen at 28 weeks or a two-dose regimen at 28 and 34 weeks

Question 94

What is the management of Sensitising Events in the RhD-negative Pregnant Woman?

Answer 94

• 1st trimester
  
  • Foetal blood volume is small so sensitisation is unlikely
  • Anti-D is only indicated following ectopic pregnancy, molar pregnancy, therapeutic TOP and in cases of uterine bleeding which is heavy/repeated or accompanied by abdominal pain
  • 250 IU should be given
• 12-20 weeks
  
  • A minimum dose of 250 IU should be administered within 72 hours
  • Kleihauer test should be performed and further anti-D given if indicated
• 20+ weeks
  
  • A minimum dose of 500 IU should be given within 72 hours
  • Kleihauer test required to determine added dose

Question 95

What are signs of foetal anaemia?

Answer 95

• NOTE: not usually obvious unless < 6 g/dL
• Polyhydramnios
• Enlarged foetal heart
• Ascites and pericardial effusions
• Hyperdynamic foetal circulation
• Reduced foetal movement
• Abnormal CTG with reduced variability, eventually a sinusoidal trace

Question 96

What is the management of Rhesus disease in a sensitised woman?

Answer 96

• Anti-D wont make a difference once the mother has been sensitised
• Close surveillance is required
• Rhesus disease gets worse with successive pregnancies
• It is also important to take into account the rhesus status of the father in subsequent pregnancies (in case the father is different)
• Antibody levels should be monitored every 2-4 weeks after booking
• However, titrations of anti-D do not correlate well with the development of HDFN (standard quantification using IU is better)
• If antibody levels rise, the foetus should be examined for signs of anaemia
• Middle cerebral artery Doppler scans (peak velocity measurement) correlate with foetal anaemia
• Treatment includes delivery (if sufficiently mature) or foetal blood transfusion
• At delivery, blood should always be ready for transfusion
• ALL babies born to RhD-negative women should have cord blood taken at delivery for blood count, blood group and indirect Coombs’ test

Question 97

What are the routes of adminstration through transfusions for anti-D?

Answer 97

• Into the umbilical vein at the point of the cord insertion
• Into the intrahepatic vein
• Into the peritoneal cavity
• Into the foetal heart

Question 98

What are the conditions that require transfused blood?

Answer 98

• RhD-negative
• Crossmatched with maternal sample
• Densely packed (so small volumes can be used)
• White cell depleted
• Screened for infections (e.g. CMV)

Question 99

Describe ABO Incompatibility

Answer 99

• Occurs when the mother is group O and the baby is A or B
• Anti-A and anti-B antibodies are present naturally in the maternal circulation
• So, ABO incompatibility may occur in a FIRST pregnancy
• However, most anti-A and anti-B antibodies are IgM so do NOT cross the placenta
• In addition, A and B antigens are NOT fully developed in the foetus
• So, ABO incompatibility generally only causes mild haemolytic disease in the newborn
• NOTE: it is possible to identify the blood group of the foetus by genotyping of cffDNA (this can prevent unnecessary use of anti-D prophylaxis in RhD-negative mothers)

Question 100

What percentage of live births are multiple pregnancies?

Answer 100

• 3%

Question 101

Why are the number of multiple pregnancies increasing?

Answer 101

• Increasing use of assisted fertility

Question 102

What are complications of multiple pregnancies?

Answer 102

• preterm birth, FGR, cerebral palsy and stillbirth

Question 103

What is the classification of multiple pregnancies?

Answer 103

• Number of foetuses: twins, triplets etc.
• Number of fertilised eggs: zygosity
• Number of placentae: chorionicity
• Number of amniotic cavities: amniocity

Question 104

Describe dichorionic diamniotic twins

Answer 104

• NOTE: dichorionic diamniotic twins may appear to have one placenta because they anatomically fused together, but they are separate
• With monozygotic twins, they will be dichorionic diamniotic if the splitting of the zygote occurs soon after fertilisation
• If the splitting occurs later, they will be monochorionic diamniotic
• Most monochorionic twins have two amniotic cavities but the dividing membrane is thin, and consists of a single layer of amnion alone
• If separation occurs even alter (days 8-12), the twins will be monochorionic monoamniotic
• If it occurs after day 13, the twins will be conjoined

Question 105

Are women with multiple pregnancies at a higher risk of anaemia than single pregnancies?
What should be done for women with multiple pregnancies?

Answer 105

• Yes
• FBC should be checked at 20 and 28 weeks
• Supplementation of iron, folic acid and vitamin B12 should be offered

Question 106

What physiological changes are exaggerated in multiple pregnancy?

Answer 106

• increased cardiac output, volume expansion, relative haemodilution, diaphragmatic splinting, weight gain and lumbar lordosis
• ‘minor’ symptoms of pregnancy such as nausea and vomiting may be exaggerated

Question 107

What are complications of multiple pregnancies?

Answer 107

• Increased morbidity risk
• About 60% result in spontaneous birth vefore 37 weeks
• For monochorionic twins, increased chance of preterm birth
• Increased perinatal mortality in monochorionic twins
• Infant mortality rate for twins is 5.5 x higher than singletons
• Stillbirth rate is also higher for twins
• The death of one foetus in utero, can lead to severe complications for the co-twin (e.g. death, brain damage)
  
  • It can also lead to onset of labour

Question 108

How does Multiple pregnancy affect FGR?

Answer 108

• Risk of FGR is higher in each twin compared to singletons
• This makes certain Doppler studies (e.g. ductus venosus, middle cerebral artery) very difficult
• Priorities with antenatal management of FGR is to predict the severity of impaired foetal oxygenation and selecting an appropriate time for delivery
• In dichorionic twins where one foetus is growth restricted, elective preterm delivery may lead to iatrogenic complications to the previously healthy twin
• In general, delivery should be avoided until after 28-30 weeks
• The death of one monochorionic twin may result in death or handicap of the co-twin because of acute hypotension due to placental vascular anastomoses between the two circulations

Question 109

What is twin-to-twin transfusion syndrome?

Answer 109

• Caused by abnormal unbalanced vascular anastomoses
• Only occurs in monochorionic pregnancies
• If the vascular connections are unbalanced with more AV connections in one direction than the other, changes in hydrostatic and osmotic forces will occur resulting in the manifestation of TTTS

Question 110

What are the four types of vascular connections in monochorionic pregnancies?

Answer 110

• Arteriovenous
• Venoarterial
• Arterioarterial
• Venovenous

Question 111

Which vascular anastamoses are protective against TTTS?

Answer 111

• Arterioarterial

Question 112

How is TTTS diagnosed?

Answer 112

• Based on ultrasound criteria
• Single placental mass (i.e. monochorionic)
• Concordant gender
• Oligohydramnios with maximum vertical pool < 2 cm in one sac and polyhydramnios in the other sac (> 8 cm)
• Discordant bladder appearances
• Haemodynamic and cardiac compromise

Question 113

How is TTTS graded?

Answer 113

• According to the Quintero staging
• Stage I: Oligohydroamnios and polyhydroamnios sequence and visualised donor twinbladder. Normal Dopplers in twins
• Stage II: Oligohydroamnios and polyhydroamnios sequence but non-visualised bladder. Normal dopplers in both twins
• Stage III: Oligohydroamnios and polyhydroamnios sequence, non-visualised bladder and abnormal Dopplers. There is absent/reverse end-diastolic velocity in the umbilical artery, reverse flow in a-wave of the DV or pulsatile flow in the umbilical veins in either fetus
• Stage IV: One or both of the fetus show signs of hydrops
• Stage V: One or both fetuses have died

Question 114

What is twin anaemia polycthymia sequence?

Answer 114

• a rarer chronic forms of TTTS in which a large inter-twin haemoglobin difference occurs
• NOTE: the oligohydramnios polyhydramnios sequence is NOT seen (unlike in TTTS)
• Thought to be due to small AV unidirectional anastomoses without accompanying AA anastomoses
• This leads to gradual development of anaemia in one twin and polycythaemia in the other
• Polycythaemia can lead to foetal or placental thrombosis
• Anaemia can lead to hydrops fetalis
• NOTE: mirror syndrome = combination of foetal hydrops and maternal pre-eclampsia

Question 115

What is recommended to assess growth in multiple pregnancies?

Answer 115

• Serial ultrasound is recommended to assess growth in multiple pregnancies
• Generally, monochorionic pregnancies will be assessed fortnightly by ultrasound from 16 to at least 24 weeks

Question 116

What is the treatment of twin-to-twin transfusion syndrome?

Answer 116

• Expectant management
• Amnioreduction
• Septostomy
• Selective feticide
• Fetoscopic laser ablation of vascular anastomoses
  
  • Considered definitive treatment for severe TTTS (between 16-26 weeks)
  • Involves ablating the AV anastomoses under fetoscopic guidance
• Above 26 weeks - delivery may be considered

Question 117

What is Monochorionic Monoamniotic Twin Pregnancy?

Answer 117

• Associated with high morbidity and mortality
• High rate of perinatal morality is due to cord entanglement leading to foetal loss and neurological morbidity
• They also have increased risk of congenital anomalies (e.g. neural tube defects, abdominal wall malformations)
• Close surveillance is essential
• Delivery by Caesarean at 32-34 weeks is generally recommended
• Usually, patients are hospitalised from 28 weeks gestation and foetal heart auscultation is performed daily (using CTG) to detect signs of cord compression

Question 118

How many appointments should women with uncomplicated dichorionic twin pregnancies be offered?

Answer 118

• At least 8 antenatal appointments

Question 119

How many appointments should women with uncomplicated monochorionic diamniotic twin pregnancies be offered?

Answer 119

• At least 9 antenatal appointments

Question 120

Routine antenatal care for multiple pregnancies involves screening for which conditions?

Answer 120

• Hypertension
• Gestational diabetes
• These occur more frequently in MP

Question 121

When should the first trimester scan be done (multiple pregnancy)?

Answer 121

• First trimester scan should be offered when crown-rump length (CRL) measures 45-84 mm
  
  • This equates to 11 weeks to 13 weeks 6 days

Question 122

What is the purpose of screening (antenatal)?

Answer 122

• To accurately estimate gestational age (based on CRL)
• To determine chorionicity (by assessing number of placental masses and assessing for lambda or T-sign and membrane thickness)
• To screen for Down’s syndrome

Question 123

How should amniocentesis and CVS be done in twin pregnancies?

Answer 123

• In dichorionic pregnancies both foetuses must be sampled

Question 124

Describe the anomaly scan and multiple pregnancies

Answer 124

• Higher rates of congenital anomalies (e.g. anencephaly, holoprosencephaly) in MP
• Only one foetus normally affected by anomalies
• If only one is affected, it can be managed expectantly or with selective fetocide
• Non-lethal abnormality may result in handicap, the parents may need to decide whether the potential burden of a handicapped child outweighs the risk of loss of the normal twin from fetocide-related complications
• If the abnormality is lethal, it may be best to avoid risk to the normal foetus unless the condition itself threatens the survival of the foetus (e.g. anencephaly)
• Rate of spontaneous dizygotic twinning increases with age

Question 125

Describe growth assessments and multiple pregnancies

Answer 125

• Foetal weight should be calculated from 20 weeks gestation at a maximum of 4 week intervals
• A growth discrepancy of 25% or more should be considered clinically significant
• Other indications for tertiary referral include: discordant foetal growth, foetal anomaly, discordant foetal death or TTTS

Question 126

Why must a delivery plan be made for women with multiple pregnancies?

Answer 126

• MP have a high prevalence of preterm delivery

Question 127

What topics to include in the delivery plan of multiple pregnancies?

Answer 127

• Desired mode of delivery
• Gestation for induction of labour if no spontaneous onset
• Process of delivery of twin 1 and twin 2
• Risk of C-section
• Complications following delivery (e.g. PPH)
• Desire to breastfeed or not

Question 128

What is the intrapartum management for multiple pregnancies?

Answer 128

• Antenatal education and pre-agreed birth plan
• Continuous foetal heart monitoring
• Two neonatal resuscitation trolleys, two obstetricians and two paediatricians
• Analgesia (ideally an early epidural to allow for internal podalic version of twin 2 if needed)
• Standard oxytocin solution for augmentation for use in the delivery of the second twin
• Oxytocin infusion (in anticipated PPH)
• Portal ultrasound

Question 129

What delivery is recommended for uncomplicated dichorionic diamniotic pregnancy?

Answer 129

• Vaginal delivery provided that the presenting twin is cephalic
• Complications are less likely if the membranes are not ruptured until the feet of the second twin are held by the operator

Question 130

What happens if the foetus is transverse during delivery?

Answer 130

• External cephalic version can be successful

Question 131

What should happen if external cephalic version is unsuccessful?

Answer 131

• Internal podalic version can be undertaken
  
  • This is performed by identifying a foetal foot through intact membranes
  • The foot is grasped and pulled gently and continuously into the birth canal
  • The membranes are ruptured as late as possible

Question 132

When is delivery advised for dichorionic twin pregnancy?

Answer 132

• From 37 weeks

Question 133

When is delivery advised for uncomplicated monochorionic twin pregnancy?

Answer 133

• elective delivery from 36 weeks should be offered (it should be performed after a course of antenatal corticosteroids)

Question 134

What does continuing uncomplicated twin pregnancies beyond 38 weeks increase the risk of?

Answer 134

• Intrauterine foetal death

Question 135

What is a support group for multiple pregnancy?

Answer 135

• Twins and Multiple Birth Association (TAMBA)

Question 136

What is preterm labour?

Answer 136

• the onset of labour < 37 weeks gestation

Question 137

What does PPROM stand for?

Answer 137

• preterm premature rupture of membranes

Question 138

What happens to the uterus and cervix during pregnancy?

Answer 138

• During pregnancy the uterus expands to accommodate the growing foetus and remains quiescent
• At the same time, the cervix remains rigid and closed to retain the developing foetus within the uterus

Question 139

What inhibits myometrial contractility during pregnancy?

Answer 139

• pro-pregnancy factors such as progesterone, relaxin, hCG and pro-relaxation prostaglandins (e.g. prostacyclin)

Question 140

How does onset of labour occur?

Answer 140

• involves synchronisation of myometrial activity through greater expression of gap junctions connecting myometrial cells

Question 141

How is labour diagnosed?

Answer 141

• painful uterine contractions + changes in the structure of the cervix, leading to cervical dilatation and effacement
• This is part of a gradual process that starts several weeks before delivery

Question 142

What are changes in the cervix during labour due to? (Cellular)

Answer 142

• Breakdown of collagen
• Changes in proteoglycan concentration
• Infiltration of leukocytes and macrophages
• Increase in water content

Question 143

What is increased myometrial activity during labour due to? (ECM)

Answer 143

• Activation of cassette of contraction-associated proteins (CAPs)
• This converts the myometrium from a quiescent to a contractile state
• CAPs include gap junction proteins, oxytocin and prostanoid receptors, enzymes for PG synthesis and cell signalling proteins
• Contractions are a relatively late event in this process, preceded by cervical remodelling and foetal membrane activation

Question 144

What maintain uterine quiescence during pregnancy?

Answer 144

• Progesterone
• In humans, circulating levels of progesterone remain elevated throughout pregnancy
• Administration of progesterone receptor antagonist RU486 can induce labour
• This suggests that the onset of human labour either involves a functional withdrawal of progesterone action or occurs independent of any loss in progesterone activity
• Current theories for this:
  
  • Invoking a change in progesterone receptor isoform expression
  • Increase in antagonist PRA isoform
  • Decline in the agonist PRB isoform
  • Repression in PRB activity through activation of NFkB

Question 145

How is Labour an inflammatory process?

Answer 145

• Increased proinflammatory factors (e.g. prostaglandins, cytokines, chemokines)
• Influx of inflammatory cells into the labouring uterine tissues may result in increased levels of pro-inflammatory cytokines
• Inflammation is also implicated in infection-driven preterm labour

Question 146

What are the roles of the oxytocin/oxytocin receptor (OTR) system in the pregnant uterus?

Answer 146

• Stimulate contractions
• Produce prostaglandins
• There is NO increase in oxytocin production during labour but the sensitivity of the myometrium to oxytocin at term increases

Question 147

What mediates the sensitivity of the myometrium to oxytocin?

Answer 147

• Increased expression of OTR
• Activation of OTR triggers the release of intracellular calcium, leading to calmodulin-mediated activation of MLCK, which phosphorylates myosin and promotes interaction of myosin with actin and the onset of contractions

Question 148

What do prostaglandins do during labour?

Answer 148

• promote cervical ripening and myometrial contractility
• Used to induce labour
• There are both pro-contractile (e.g. PGF2a) and pro-relaxatory (PGI2) prostaglandins

Question 149

What are prostaglandin inhibitors used for? (Labour)

Answer 149

• To inhibit preterm labour (however, they have adverse side-effects such as premature closure of PDA)

Question 150

What is the rate limiting step in PG synthesis?

Answer 150

• PG synthesis enzymes PGHS-2

Question 151

What is the dominant site of PG synthesis?

Answer 151

• Amnion

Question 152

What is the main site of PG action?

Answer 152

• Myometrium

Question 153

What is the main site of PG metabolism?

Answer 153

• Chorion
• Expresses the enzyme responsible for PG metabolism (15-hydroxyprostaglandin dehydrogenase (PGDH))
• The expression of PGDH falls with the onset of labour, thus facilitating the transfer of PGs from the amnion to the myometrium

Question 154

What are causes of preterm labour?

Answer 154

• Cervical weakness
• Infection
• Uterine Mullerian Anomalies
• Haemorrhage
• Stress
• Multiple pregnancies

Question 155

How does cervical weakness cause preterm labour?

Answer 155

• associated with painless premature cervical dilatation
• Suggested by a history of painless second trimester pregnancy loss
• Relationship between cervical length and the risk of preterm delivery
• Previous history of cervical surgery is a risk factor for cervical weakness

Question 156

How does infection cause preterm labour?

Answer 156

• Infection of the foetal membranes (chorioamnionitis) is a major cause of preterm birth
• Most of the time the infection ascends from the vagina, however it could be transplacental or introduced through invasive procedures
• Cervical weakness can predispose to ascending infections
• 33% of all pregnancies delivered after PPROM are complicated by infection
• Abnormal vaginal flora (e.g. bacterial vaginosis) is associated with PPROM and PTL
• Antibiotic treatment of BV does NOT consistently reduce the risk of PTD

Question 157

What is chorioamnionitis associated with in the foetus?

Answer 157

• foetal brain damage due to a foetal inflammatory response
• Can cause periventricular leukomalacia
• High levels of amniotic fluid IL-6 is associated with intraventricular haemorrhage and PVL

Question 158

How do Uterine Mullerian Abnormalities cause preterm labour?

Answer 158

• Occur due to abnormal embryologic fusion and canalisation of the Mullerian ducts resulting in an abnormally formed uterine cavity
• This can range from an arcuate uterus (minimal fundal cavity indentation) to uterine didelphys (complete failure of fusion)
• These are associated with adverse pregnancy outcomes in up to 25% of women (e.g. PPROM, preterm birth, FGR)

Question 159

How does haemorrhage cause preterm labour?

Answer 159

• Antepartum haemorrhage and placental abruption may lead to spontaneous PTL
• Acute bleeding —> thrombin release —> myometrial contraction

Question 160

What is placental abruption?

Answer 160

• Separation of the placenta from the wall of the uterus during pregnancy, especially when it occurs prematurely

Question 161

What are risk factors for placental abruption?

Answer 161

• Pre-eclampsia
• Hypertension
• Previous abruption
• Trauma
• Smoking
• Cocaine
• Multiple pregnancy
• Polyhydramnios
• Thrombophilia
• Advanced maternal age
• PPROM

Question 162

How does stress cause preterm labour?

Answer 162

• Corticotrophin-releasing hormone is implicated

Question 163

How is PTL tested?

Answer 163

• Cervicovaginal fluid level of foetal fibronectin (fFN)
• glycoprotein found in the cervicovaginal fluid, amniotic fluid, placental tissue and in the interface between the chorion and decidua
• a glue at the maternal-foetal interface
• Its presence in the cervicovaginal fluid between 22-36 weeks is a predictor of PTD
• Negative fFN has a high negative-predictive value (i.e. if it’s negative, you’re almost certainly not in preterm labour)

Question 164

How is preterm labour managed?

Answer 164

• Tocolytics may delay delivery long enough for corticosteroid administration (for neonatal lung function)
• First choice
  
  • Calcium channel blocker (e.g. nifedipine)
  • OTR antagonist (e.g. atosiban)
• Other drugs
  
  • Beta-sympathomimetics
  • Magnesium Sulphate
  • NSAIDs
  • Corticosteroids
  • Antibiotics

Question 165

How do beta-sympathomimetics manage preterm labour?

Answer 165

• Beta-agonists (ritodrine, salbutamol and terbutaline) are mainly beta-2 agonists
• Stimulate cAMP production –> myometrial relaxation
• Delay delivery but do NOT improve neonatal outcome or PTD rates
• significant maternal side-effects (e.g. pulmonary oedema) `

Question 166

How does magnesium sulphate manage preterm labour?

What does it reduce the risk of in surviving infants?

Answer 166

• Decreases smooth muscle depolarisation by modulating calcium in smooth muscle cells
• Inhibits uterine contraction
• American College of Obstetricians believe that it reduces the risk of cerebral palsy in surviving infants

Question 167

How do NSAIDs manage preterm labour?

What risks is Indomethacin associated with?

Answer 167

• Indomethacin is effective
• Have several adverse foetal effects
• Inhibition of prostaglandins can lead to premature closure of the ductus arteriosus
  
  • can lead to persistent pulmonary hypertension
  • This is reversible but requires early identification and discontinuation of treatment
• Indomethacin is also associated with increased risk of:
  
  • Necrotising enterocolitis
  • Neonatal renal dysfunction

Question 168

How do CCBs and Oxytocin Receptor Antagonists manage preterm labour?
What is an example of an OTR?

Answer 168

Calcium Channel Blockers

• Relax the contraction of the myometrium
• They bind to L-type calcium channels and reduce intracellular calcium levels

Oxytocin Receptor Antagonists

• OTRs are important in the onset and progression of labour
• Atosiban is a competitive antagonist of oxytocin and vasopressin V1a receptors within the myometrium
• Atosiban results in a dose-dependent inhibition of uterine contractility and oxytocin-mediated PG release
• Similar efficacy to beta-agonists but better tolerated

Question 169

How do corticosteroids manage preterm labour?

Answer 169

• Most influence on preterm neonatal outcome
• Significantly reduces RDS rates
• Betamethasone and dexamethasone are both recommended

Question 170

How do antibiotics manage preterm labour?

Answer 170

• 10 days of erythromycin is the treatment of choice for PPROM
• However, antibiotic treatment has no effect in women with intact membranes

Question 171

What is PPROM?

Answer 171

• In 2% of all pregnancies
• Responsible for 1/3 of preterm deliveries
• The earlier in pregnancy that PPROM occurs, the shorter the interval to delivery
• 50% of women deliver within 1 week of PPROM
• PPROM before 23 weeks may cause pulmonary hypoplasia –> increased risk of neonatal death even if delivery occurs at a later gestational age
• Diagnosed through clinical history and a pool of liquor on the vagina on speculum examination
• Management
  
  • Balancing prematurity risk (if delivery is encouraged) with the risk of maternal/foetal infection (if delivery is delayed)
• Generally, conservative management is followed in PPROM before 34 weeks unless there is chorioamnionitis
• Immediate induction of labour is advised in women > 37 weeks gestation

Question 172

What is the conservative management of PPROM?

Answer 172

• Look for signs of chorioamnionitis (including regular recording of maternal temperature, heart rate, CTG and maternal biochemistry)
  
  • Rising WCC or CRP indicates development of chorioamnionitis
• Lower genital tract swabs are routinely taken but cultures do NOT correlate well with risk of chorioamnionitis
• Tocolysis is CONTRAINDICATED due to the increased risk of maternal and foetal infection

Question 173

How can preterm delivery be predicted?

Answer 173

• Past obstetric history
  
  • Having previous PTD increases risk of PTL
• Ultrasound measurement of cervical length
  
  • Direct link between cervical length and risk of PTD
  • Transvaginal ultrasound is better than transabdominal ultrasound
  • Cervical length surveillance with serial measurement of cervical length throughout the 2nd and early 3rd trimester is used to monitor patients at high risk of PTD

Question 174

What are the two main interventions to prevent preterm delivery?

Answer 174

• Progesterone

- Cervical cerclage

Question 175

How does progesterone prevent preterm delivery?

Answer 175

• In women with previous preterm birth, IM hydroxyprogesterone caproate is effective in reducing risk of recurrence
• It is licensed in the USA for preterm birth prevention in women with previous preterm birth
• There is NO evidence to show that progesterone can reduce the longer-term adverse effects of preterm birth (e.g. neurodevelopmental disability, respiratory morbidity)

Question 176

How does cervical cerclage?

Answer 176

• May be placed in THREE different circumstances:
  
  • History indicated cerclage: following multiple midtrimester losses or preterm deliveries
  • Ultrasound indicated cerclage: when the cervix shortens (usually < 25 mm) in women with a history of cervical surgery or previous preterm birth
  • Rescue cerclage: when the cervix is dilating in the absence of contractions
• Cerclage provides structural support to a weakened cervix
• This enhances the cervical immunological barrier by improving retention of the mucous plug and preventing ascending infection by maintaining cervical length
• If transvaginal cerclage fails, transabdominal cerclage may be considered

Question 177

What are the NICE guidelines for prophylactic vaginal progesterone or cervical cerclage?

Answer 177

• Offer progesterone OR cervical cerclage if:
  
  • History of spontaneous preterm or mid-trimester loss (between 16-34 weeks) of pregnancy
  • AND if transvaginal ultrasound has been carried out between 16-24 weeks of pregnancy and reveals a cervical length < 25 mm
• Offer progesterone in women with:
  
  • NO history of preterm birth or mid-trimester loss and transvaginal US scan has been carried out (16-24 weeks) and shows a cervical length < 25 mm
• Consider cervical cerclage if:
  
  • A transvaginal US (16-24 weeks) shows cervical length < 25 mm and have either:
    
    • Had PPROM before
    • OR history of cervical trauma

Question 178

What are the NICE guidelines for diagnosing PPROM?

Answer 178

• If there symptoms suggesting PPROM, offer a speculum examination to look for pooling of amniotic fluid:
  • If pooling is observed: do NOT perform any diagnostic tests but offer care consistent with the woman having PPROM
  • If pooling is NOT observed: consider performing an insulin-like growth factor binding protein-1 test or alpha-microglobulin-1 test of vaginal fluid
    
    • If these tests are POSITIVE: interpret the results based on the clinical condition and consider offering treatment consistent with the women having PPROM
    • If these tests are NEGATIVE: do NOT offer antibiotic prophylaxis and explain the woman that they are unlikely to have PPROM
• Do NOT perform diagnostic tests for PPROM if labour becomes established in a woman reporting symptoms suggestive of PPROM

Question 179

What are the NICE guidelines for antibiotic prophylaxis for PPROM?

Answer 179

• Oral erythromycin 250 mg 4/day for 10 days or until labour happens
• If erythromycin is contra-indicated –> oral penicillin

Question 180

What are the NICE guidelines for identifying infection in women with PPROM?

Answer 180

• Use clinical assessment and tests (CRP, WCC and CTG)

- NOTE: none of these should be used in isolation

Question 181

What are the NICE guidelines for Rescue Cervical Cerclage?

Answer 181

• Do NOT offer to women with any of the following:
  
  • Signs of infection
  • Active vaginal bleeding
  • Uterine contractions
• Consider rescue cervical cerclage for women between 16-27 weeks with a dilated cervix and exposed, unruptured foetal membranes
  
  • Take into account gestational age (benefits are greater for earlier gestations) and extent of cervical dilatation
• Explain to woman
  
  • Risks of rescue cerclage
  • That it aims to delay birth, thereby increasing the likelihood of the baby surviving and of reducing serious neonatal morbidity

Question 182

What are the NICE guidelines for diagnosing Preterm Labour with Intact Membranes?

Answer 182

• Clinical assessment should include
  
  • Clinical history taking
  • Observations
  • Speculum examination (and digital vaginal examination if the extent of cervical dilatation cannot be assessed)
• If clinical assessment suggests that the woman is in preterm labour and she is < 29+6 weeks pregnant, advise that treatment is necessary
• If clinical assessment suggests that the woman is in preterm labour and she is > 30 weeks pregnant
  
  • Consider transvaginal ultrasound measurement of cervical length to determine likelihood of birth within 48 hours
    
    • If cervical length > 15 mm explain that it is unlikely that she is in preterm labour
    • If cervical length < 15 mm make a diagnosis of preterm labour and treat accordingly
  • Consider foetal fibronectin testing if transvaginal measurement of cervical length is unavailable or unacceptable
    
    • If negative (concentration < 50 ng/mL) explain that they are unlikely to be in preterm labour
    • If positive (concentration > 50 ng/mL) make a diagnosis of preterm labour and treat accordingly

Question 183

What factors need to be considered when giving tocolysis?

Answer 183

• Is there suspected or diagnosed preterm labour?
• Other clinical features (e.g. bleeding) which suggest that stopping labour is contraindicated
• Gestational age at presentation
• Likely benefit of maternal corticosteroids
• Availability of neonatal care
• Maternal preference

Question 184

What are the NICE guidelines for tocolysis?

Answer 184

• Consider Nifedipine if between 24-25+6 weeks, intact membranes and are in suspected or diagnosed preterm labour
• Nifedipine if between 26-33+6 weeks who have intact membranes and are in suspected or diagnosed preterm labour
• If nifedipine is contraindicated, offer oxytocin receptor antagonists
• Do NOT offer beta-mimetics

Question 185

What are the NICE guidelines for maternal corticosteroids?

Answer 185

• For women 23-23+6 weeks in suspected or established preterm labour, having a planned preterm birth or have PPROM, discuss the use of maternal corticosteroids
• Consider maternal corticosteroids if < 36 weeks with suspected or established preterm labour, having a planned preterm birth or PPROM

Question 186

What are the NICE guidelines for magnesium sulphate for neuroprotection?

Answer 186

• IV magnesium sulphate for women between 24-29+6 weeks who are:
  
  • In established preterm labour
  • OR having a planned preterm birth within 24 hours
• Consider IV magnesium sulphate if 30-33+6 weeks who are in preterm labour or having a planned preterm birth within 24 hours
• Give 4 g IV bolus over 15 mins followed by IV infusion of 1 g/hour until birth or for 24 hours
• Monitor for clinical signs of magnesium toxicity every 4 hours (pulse, blood pressure, respiratory rate, deep tendon reflexes)

Question 187

What foetal monitoring is considered for preterm labour/delivery?

Answer 187

• CTG is useful
• Foetal scalp electrode may be considered
• Foetal blood sampling may be considered

Question 188

What are the NICE guidelines for preterm birth/delivery?

Answer 188

• Discuss benefits of C-section vs vaginal delivery
• Highlight the difficulties of performing C-section for preterm birth, particularly the increased likelihood of vertical incision and its implications for future pregnancies
• Explain that there are NO known benefits or harms for the baby from C-section (but evidence is limited)
• Consider C-section if in breech position and preterm

Question 189

Describe pre-pregnancy counselling for women with renal disease

Answer 189

• Women should be made aware of the risks to the foetus and the impact on long-term renal function before conception
• Topics to discuss
  • Safe contraception
  • Fertility issues if indicated
  • Genetic counselling if inherited disorder
  • Risks to mother and foetus during pregnancy
  • Avoid known teratogens and contraindicated drugs
  • Treatment of blood pressure and adjustment of antihypertensives
  • Low-dose aspirin
  • Need for anticoagulation once pregnant in women with significant proteinuria
    
    • Need for strict surveillance
    • Likelihood of prolonged admission and early delivery
    • Possibility of accelerated decline in maternal renal function
    • Need for postpartum follow-up

Question 190

What is the effect of pregnancy on CKD?

Answer 190

• Women with CKD stages 1-2 will usually be fine
• Women with CKD stages 3-5 = at risk of complications during pregnancy and decline in renal function
• Diagnosis of pre-eclampsia can be difficult because of pre-existing hypertension/proteinuria

Question 191

What is the effect of CKD on pregnancy outcome?

Answer 191

• Increased risk of:
  
  • Preterm delivery
  • Delivery by C-section
  • FGR

Question 192

How do you monitor patients with CKD?

Answer 192

• Blood pressure
• Renal function
  
  • Creatinine
• Urine
  
  • Infection
  • Proteinuria
• FBC
  
  • Haemoglobin
  • Ferritin
• Renal ultrasound
• Foetal ultrasound
  
  • Anatomy
  • Uterine artery Doppler 20-24 weeks
  • Growth

Question 193

What are the complications of dialysis in pregnancy?

Answer 193

• Preterm delivery
• Polyhydramnios
• Pre-eclampsia
• Caesarean delivery
• Dialysis should be adjusted to allow for physiological changes in pregnancy (plasma volume, fluid retention, electrolytes)
• Haemodialysis is more effective

Question 194

How do renal transplants affect pregnancy?

Answer 194

• Conception is rare in end-stage kidney disease but fertility returns rapidly after renal transplantation
• Pregnancy is generally safe after the 2nd post-transplantation year
• ALL pregnancies in transplant recipients are high risk
• Vaginal delivery is considered safe
• Tacrolimus, azathioprine, ciclosporin and prednisolone are considered SAFE in pregnancy and breastfeeding
• Screening for GDM is necessary with prednisolone and tacrolimus
• Mycophenolate and sirolimus should be avoided in transplant recipients considering pregnancy and alternative regimes should be considered

Question 195

What are the complications of pregnancy in transplant recipients?

Answer 195

• Preterm delivery
• Pre-eclampsia
• UTI

Question 196

Describe pre-pregnancy counselling for diabetes mellitus

Answer 196

• Counsel to achieve the best possible glycaemic control before pregnancy
• Educate about the implications of diabetes in pregnancy
• Poor glycaemic control is associated with increased risk of congenital anomalies (particularly NTDs and cardiac anomalies)
• The most critical period for the embryo is the first 42 days, during organogenesis
• HbA1c in early pregnancy correlated with the risk of early foetal loss
• Adequate contraception should be encouraged until glucose control is good
• Target for pre-pregnancy = pre-meal glucose levels of 4-7 mmol/L
• Women with complications of diabetes (e.g. retinopathy) will benefit from an MDT approach
• Diabetic nephropathy is associated with significantly increased risk of complications arising in pregnancy warranting preterm delivery

Question 197

What are the maternal and foetal complications in diabetes mellitus?

Answer 197

• Congenital abnormality is 2-4 times more likely in diabetic pregnancies
• Foetal macrosomia (and consequently traumatic birth, shoulder dystocia)
• Accelerated growth patterns in the late second and third trimesters
• Stillbirth
• Increased risk of pre-eclampsia
• Progression of diabetic retinopathy
• Infection
• Severe hyper- or hypoglycaemia and DKA
• IMPORTANT: all women with diabetes should be offered low-dose (75 mg) aspirin from 12 weeks gestation until delivery

Question 198

What is the management of diabetes mellitus in pregnancy?

Answer 198

• MDT approach involving:
  
  • Diabetic specialist midwives and nurses
  • Dietician
  • Obstetrician
  • Physician
• Monitor blood glucose 7 times per day (before and 1 hour after meals)
• Pre-meal target < 5.3 mmol/L
• 1-hour postprandial target < 7.8 mmol/L
• Support for diet, oral hypoglycaemics and insulin adjustments
• IMPORTANT: hypoglycaemia is more common in pregnancy and is very dangerous
• Insulin resistance INCREASES throughout pregnancy, so women with DM need to increase metformin or insulin during the second half of pregnancy
• Pregnancy plan should include
  
  • Renal and retinal screening
  • Foetal surveillance
  • Plan for delivery
• Women with DM to have a foetal anomaly scan at 19-20 weeks with an assessment of cardiac outflow tracts
• Serial growth scans to assess foetal growth and diagnose macrosomia and polyhydramnios
• IMPORTANT: if antenatal corticosteroids are needed, additional insulin therapy is required to maintain normoglycaemia (often requires admission)
• If the pregnancy has gone well, the aim should be to achieve vaginal delivery between 38-39 weeks
• However, presence of complications means that the C-section rate amongst diabetic women is quite high (around 50%)
• For women with T1DM or T2DM requiring insulin, a sliding scale or insulin and glucose should be commenced in labour
• Maternal glucose levels should be maintained at 4-7 mmol/L
• Insulin requirements return to pre-pregnancy levels following delivery and insulin doses should be adjusted accordingly

Question 199

What are the effects of pregnancy on diabetes?

Answer 199

• Nausea and vomiting (particularly early on)
• Greater importance of tight glucose control
• Increase in insulin dose requirements in second half of pregnancy
• Increased risk of severe hypoglycaemia
• Risk of deterioration of pre-existing retinopathy
• Risk of deterioration of established nephropathy

Question 200

What are the effects of diabetes on pregnancy?

Answer 200

• Increased risk of miscarriage
• Risk of congenital malformation
• Risk of macrosomia
• Increased risk of pre-eclampsia
• Increased risk of stillbirth
• Increased risk of infection
• Increased operative delivery rate

Question 201

Describe gestational diabetes

Answer 201

• Complicates 10-15% of pregnancies
• Women with GDM are at increased risk of T2DM in later life
• Education about diet and lifestyle important
• Screening is targeted at HIGH RISK groups (e.g. ethnicity, family history, maternal obesity)
• IMPORTANT: different diagnostic criteria are used in different hospitals

Question 202

What are the NICE recommendations for diagnosing gestational diabetes?

Answer 202

• Fasting blood glucose > 5.6 mmol/L

- 2-hour OGTT (75 g glucose) > 7.8 mmol/L

Question 203

What are the WHO recommendations for diagnosing gestational diabetes?

Answer 203

• Fasting blood glucose > 5.1 mmol/L
• 1-hour OGTT > 10 mmol/L
• 2-hour OGTT > 8.5 mmol/L

Question 204

What is the management of gestational diabetes?

Answer 204

• Principles are the same as diabetes mellitus
• Encourage women to maintain blood glucose levels:
  
  • Pre-meal < 5.3 mmol/L
  • Postprandial (1 hour) < 7.8 mmol/L
• Metformin and/or insulin if unable to achieve levels with diet/lifestyle
• IMPORTANT: in women with GDM, a diagnosis of T2DM should be excluded after pregnancy
  
  • Screening with fasting blood glucose or HbA1c should be offered at 6-13 weeks after childbirth

Question 205

What are the factors associated with poor pregnancy outcome in diabetes?

Answer 205

• Maternal social deprivation
• No folic acid intake pre-pregnancy
• Suboptimal approach of the woman to managing her diabetes
• Suboptimal preconception care
• Suboptimal glycaemic control at any stage
• Suboptimal maternity care during pregnancy
• Suboptimal foetal surveillance of big babies

Question 206

What are thyroid related physiological changes in pregnancy?

Answer 206

• Plasma volume expansion
• Increased thyroid binding globulin
• Relative iodine deficiency

Question 207

What happens to the thryoid in the first trimester?

Answer 207

• Fall in TSH and rise in free T4 is expected

- Free T4 will then fall with advancing gestation

Question 208

What is the most common cause of hypothyroidism?
How should hypothyroidism be managed in pregnancy?
What is suboptimal management associated with?

Answer 208

• Hashimoto’s thyroiditis is the most common cause of hypothyroidism in the developed world
• Women should continue thyroid replacement therapy throughout pregnancy and should aim for biochemical euthyroidism (TSH < 4 mmol/L)
• TFTs performed each trimester, or more often if dose adjustments are required
• Corrected hypothyroidism has no influence on pregnancy outcome or complications
• Suboptimal replacement is associated with developmental delay and pregnancy loss

Question 209

How should hyperthyroidism be treated in pregnancy?
Why is radioactive iodine contraindicated in pregnancy?
What is the medication for hyperthyroidism?

Answer 209

• Should be treated medically in pregnancy
• Radioactive iodine is CONTRAINDICATED because it obliterates the foetal thyroid
• Carbimazole or propylthiouracil at the lowest acceptable dose
  
  • High doses may cross the placenta causing foetal hypothyroidism
  • WARNING: both drugs can cause agranulocytosis so regularly check maternal WCC
• Thyroid function should be closely monitored and many women can reduce their dose (1/3 are able to stop treatment)
• Doses readjusted postpartum to prevent relapse
• TSH-receptor stimulating antibodies can cross the placenta, so babies born to women with positive antibody titres should be reviewed by the neonatology team

Question 210

What are the risks of uncontrolled thyrotoxicosis in pregnancy?

Answer 210

• Increased risk of miscarriage
• Preterm delivery
• FGR

Question 211

What is thyroid storm and what are its features?

Answer 211

• LIFE-THREATENING
• Usually caused by under-treatment or infection
• Features
  
  • Excessive sweating
  • Pyrexia
  • Tachycardia
  • Atrial fibrillation
  • Hypertension
  • Hyperglycaemia
  • Vomiting
  • Agitation
  • Cardiac failure

Question 212

What is the management of a thyroid storm?

Answer 212

• Propylthiouracil
• High-dose corticosteroids
• Beta-blockers (to block peripheral effects)
• Rehydration

Question 213

How is hyperparathyroidism managed in pregnancy?

Answer 213

• Parathyroidectomy for severe cases

- Mild hyperparathyroidism= adequate hydration and low calcium diet

Question 214

What are the risks of hyperparathyroidism in pregnancy?

Answer 214

• Increased rates of miscarriage
• Intrauterine death
• Preterm labour
• Neonatal tetany

Question 215

What are the risks of hypoparathyroidism in pregnancy?

Answer 215

• Increased risk of second trimester miscarriage
• Foetal hypocalcaemia
• Neonatal rickets

Question 216

What is the management of hypoparathyroidism in pregnancy?

Answer 216

• Vitamin D
• Oral calcium supplements
• Regular monitoring of calcium and albumin

Question 217

What is hyperprolactinaemia caused by?
What does it cause?
How is it treated?

Answer 217

• Hyperprolactinaemia is usually caused by a benign pituitary microadenoma
• NOTE: it is an important cause of infertility
• 80% of cases are treated with a dopamine agonist (bromocriptine or cabergoline) which causes tumours to reduce in size
• Larger tumours may require surgery or radiotherapy (should be done before pregnancy)
• The pituitary gland enlarges by 50% during pregnancy
• Microadenomas do NOT tend to cause issues during pregnancy
• Dopamine agonists are usually stopped during pregnancy
• Visual fields and relevant symptoms (e.g. frontal headache) are monitored
• If there is evidence of tumour growth, dopamine agonist should be recommenced

Question 218

How does Cushing’s syndrome affect pregnancy?

Answer 218

• Rare because most affected women are infertile
• In pregnancy, adrenal causes are more common
• Diagnosis can be difficult because a lot of symptoms are normal in pregnancy (e.g. abdominal striae, weight gain, weakness, glucose intolerance)

Question 219

What are the risks of Cushing’s syndrome in pregnancy?

Answer 219

• Pre-eclampsia
• Preterm delivery
• Stillbirth

Question 220

How does Conn’s syndrome affect pregnancy?
What are its features?
How is it diagnosed?

Answer 220

• One of the more common causes of secondary hypertension
• Characterised by hypertension and hypokalaemia
• Diagnosed by detecting high aldosterone and low renin
• Enlargement of adrenals can be seen on CT or US

Question 221

What are the symptoms of Addison’s disease?

Answer 221

• Exhaustion
• Nausea
• Hypotension
• Hypoglycaemia
• Weight loss

Question 222

Why is diagnosis of Addison’s disease difficult in pregnancy?

Answer 222

• Diagnosis can be difficult because the cortisol levels may be erroneously in the normal range because of an increase in cortisol-binding globulin during pregnancy

Question 223

How should pregnant Addison’s patients be managed?

Answer 223

• If the patient presents in an Addisonian crisis, they should be treated with fluid rehydration and corticosteroids
• Replacement steroids should continue throughout pregnancy with increased doses at times of stress (e.g. delivery)

Question 224

How does Phaeochromocytoma in pregnancy present and how is it diagnosed?

Answer 224

• May present as a hypertensive crisis (may appear similar to pre-eclampsia)
• Diagnosed by measurement of catecholamines in 24-hr urine collection and adrenal imaging

Question 225

How is phaeochromocytomas in pregnancy managed?

Answer 225

• Alpha and beta blockade (e.g. prazosin, phenoxybenzamine)
• Surgical removal is the only cure
• C-section is the preferred mode of delivery (prevents sudden increases in catecholamines associated with vaginal delivery)
• Maternal and perinatal mortality is increased if NOT diagnosed before pregnancy

Question 226

What is the antenatal management of heart disease?

Answer 226

• Joint obstetric/cardiac management
• Assess level of heart failure (NYHA classification)
• Routine physical examination should include pulse rate, blood pressure, jugular venous pressure, heart sounds, ankle and sacral oedema and the presence of basal crepitations
• Most women will remain well throughout pregnancy
• An echocardiogram at booking and at 28 weeks
• Anticoagulation is essential in patients with congenital heart disease who have pulmonary hypertension or artificial valves and those at risk of AF
• WARNING: warfarin is teratogenic if used in the first trimester
  
  • LMWH is used as an alternative (especially in 1st and 3rd trimester)

Question 227

What are high risk cardiac conditions in pregnancy?

Answer 227

• Systemic ventricular dysfunction
• Pulmonary hypertension
• Cyanotic congenital heart disease
• Aortic pathology (e.g. Marfan syndrome)
• Ischaemic heart disease
• Left heart obstructive lesions (e.g. aortic/mitral stenosis)
• Prosthetic heart valves
• Previous peripartum cardiomyopathy

Question 228

What are foetal risks of maternal cardiac disease?

Answer 228

• Recurrence (congenital heart disease)
• Maternal cyanosis (foetal hypoxia)
• Iatrogenic prematurity
• FGR
• Effects of maternal drugs (teratogenesis, growth restriction, foetal loss)

Question 229

What is the management of labour and delivery in heart disease?

Answer 229

• In most cases, try wait for spontaneous labour
• Induction maybe in very high-risk women so delivery occurs at a predictable time with all the personnel present
• Epidural anaesthesia recommended (reduces pain-related stress)
  
  • NOTE: there is, however, risk of maternal hypotension
• Prophylactic antibiotics given to woman with a structural heart defect to reduce the risk of bacterial endocarditis
• If labour progresses normally, the second stage may be kept short with an elective forceps or ventouse delivery
• This reduces maternal effort and the requirement for increased cardiac output
• C-section should be reserved for cases where the maternal condition is too unstable to tolerate the demands of labour
• Postpartum haemorrhage may lead to cardiovascular instability
• Ergometrine may be dangerous (causes vasoconstriction, hypertension and heart failure) so active management of the third stage is with syntocinon ALONE
  
  • NOTE: syntocinon is a vasodilator so should be introduced slowly

Summary
- Avoid induction of labour if possible  
- Use prophylactic antibiotics  
- Ensure fluid balance  
- Avoid supine position  
- Discuss regional/epidural anaesthesia with senior anaesthetist 
- Keep the second stage short  
Use syntocinon judiciously

Question 230

What is the treatment of heart failure in pregnancy?

Answer 230

• The principles of treatment are the same as in non-pregnant people
• Clinical examination and echocardiography to confirm ventricular dysfunction is important
• Typical management of heart failure
  
  • Sit up
  • Oxygen
  • Diamorphine
  • Furosemide
  • GTN
• Arrhythmias require urgent correction and drug therapy
• Assess foetal wellbeing (US and CTG)
• Consider premature delivery if foetal compromise

Question 231

(What is the primary cause of MI in the postpartum period?
Why should PCI be considered carefully?
What does thrombolysis increase the risk?)

Answer 231

• Coronary artery dissection is the primary cause of MI in the postpartum period
• PCI increases risk of radiation to the foetus)
• Thrombolysis may increase haemorrhage risk

Question 232

Describe mitral and aortic stenosis in pregnancy

Answer 232

• Obstruction of the left heart leads to an inability to increase cardiac output to meet the demands of pregnancy
• 40% of those with mitral stenosis (usually due to rheumatic fever) will experience worsening symptoms during pregnancy
• Treatment aims to reduce heart rate (through bed rest, oxygen, beta-blockade and diuretic therapy)
• Balloon mitral valvotomy is the treatment of choice after delivery
• The risk of maternal morbidity and mortality is correlated to the severity of the disease

Question 233

Describe pulmonary hypertension in pregnancy

Answer 233

• Pulmonary hypertension has a poor survival

- Pregnancy is associated with high risk of maternal death

Question 234

How does bacterial and viral pneumonia occur in pregnancy?

Answer 234

• Viral pneumonia follows a more complicated course in pregnancy and can lead to quicker decompensation
• Bacterial pneumonias are managed in the same way as in non-pregnant women

Question 235

What are warning signs of pnuemonia?

Answer 235

• Respiratory rate > 30/minute
• Hypoxaemia: pO2 < 7.9 kPa on room air
• Acidosis: pH < 7.3
• Hypotension
• DIC
• Elevated blood urea
• Evidence of multiple organ failure

Question 236

Describe asthma and pregnancy

Answer 236

• Asthma severity and suboptimal control are associated with adverse outcomes
• Labour and delivery are NOT usually affected by asthma
• Regular medications should be continued throughout labour (ALL the asthma drugs are safe to use)
• Bronchoconstrictors (e.g. ergometrine or prostaglandin F2a) should be avoided in women with severe asthma
• Regional anaesthesia is favoured over general anaesthesia
• Postpartum, there is NO increased risk of exacerbations

Question 237

How is asthma managed in pregnancy?

Answer 237

• Pregnancy is a time to improve asthma care
• Encourage smoking cessation
• Ensure patient education regarding condition and adequate use of medications
• Ensure optimal control and response to therapy throughout pregnancy
• Manage exacerbations aggressively and avoid delays in treatment
• Manage acute attacks as in non-pregnant individual
• Offer an MDT approach

Question 238

Describe cystic fibrosis and pregnancy

Answer 238

• High rate of prematurity
• 70-90% live births
• The prognosis for the mother depends on the severity of the CF
• Most women will have daily physiotherapy and prolonged antibiotic therapy
• Close attention should be paid to maternal nutritional status and weight gain during pregnancy, with screening for GDM
• CF is associated with FGR so foetal ultrasound scans should be regularly performed
• Check the CF carrier status of the partner
• Ideally, a vaginal delivery should be the aim

Question 239

Does pregnancy affect sarcoidosis?

Answer 239

• Pregnancy does NOT affect the long-term natural history of sarcoidosis

Question 240

How does epilepsy affect pregnancy?

Answer 240

• No consistent effect of pregnancy on epilepsy
• 10 fold increase in mortality amongst pregnancy women with epilepsy
• Seizures should be controlled with the minimum possible dose of the optimal anticonvulsant drug
• Epilepsy is associated with an increased risk of congenital abnormality caused by anticonvulsant medication (2-3 fold increase)
• Use of several AEDs further increases risk

Question 241

What is the pre-pregnancy counselling of epilepsy?

Answer 241

• Alter medication according to seizure frequency
• Reduce to monotherapy where possible
• Stress importance of compliance with medication
• Preconceptional folic acid 5 mg
• Explain risk of congenital malformation
• Explain risk from recurrent seizures

Question 242

What are the main abnormalities associated with AEDs?

Answer 242

• Neural tube defects
• Facial clefts
• Cardiac defects
• (developmental delay, nail hypoplasia, growth restriction and midface abnormalities)
• NOTE: valproate should be avoided unless unresponsive to other AEDs
• Many of these can be detected during an anomaly scan

Question 243

What can stopping anticonvulsant therapy during pregnancy result in?

Answer 243

• Increased frequency of epileptic seizures resulting in both maternal and foetal hypoxia

Question 244

What is the management of pregnant epilepetic patients ?

Answer 244

• Switched to monotherapy before pregnancy
• 5 mg folic acid to reduce risk of NTDs
• Delivery mode and timing is unaltered by epilepsy unless there is accelerated seizure frequency
• Breastfeeding should be encouraged

Question 245

What are causes of seizures in pregnancy?

Answer 245

• Epilepsy
• Eclampsia
• Encephalitis or meningitis
• SOL
• Cerebrovascular accident
• Cerebral malaria or toxoplasmosis
• TTP
• Drug and alcohol withdrawal
• Toxic overdose
• Metabolic abnormalities (e.g. hypoglycaemia)

Question 246

Describe multiple sclerosis in pregnancy

Answer 246

• Pregnant women with MS have no higher risk of complications
• Women will have a lower relapse rate during pregnancy
• They will, however, have a higher relapse rate in the 3 months postpartum
• Delivery is NOT more complicated in MS patients

Question 247

Describe migraines in pregnancy

Answer 247

• Usually improves in pregnancy
• 20% of pregnant women experience migraines
• Management should include analgesics and antiemetics
• Low-dose aspirin and beta-blockers may be used to prevent attacks

Question 248

Describe Bell’s palsy in pregnancy

Answer 248

• Incidence increases 10 fold in the third trimester
• Complete recovery is expected if it occurs within 2 weeks of delivery
• Corticosteroids and antivirals may be used in pregnancy

Question 249

How does pregnancy affect sickle cell disease?

What medication is recommended for pregnancy?

Answer 249

• Pregnancy is associated with increased risk of sickle cell crises
• High-dose folate (5 mg) is recommended preconception
• Low-dose aspirin (75 mg) daily from early pregnancy to delivery
• HbSC is associated with mild anaemia but can cause very severe crises that occur more often in pregnancy

Question 250

What are sickle cell crises precipitated by?

Answer 250

• Hypoxia
• Stress
• Infection
• Haemorrhage

Question 251

What are sickle cell mothers at increased risk of?

Answer 251

• Miscarriage
• Pre-eclampsia and eclampsia
• FGR
• Premature labour
• Thromboembolic disease

Question 252

What is the management of sickle cell crisis in pregnancy?

Answer 252

• Prompt treatment
• Adequate hydration
• Oxygen
• Analgesia
• Screen for infection (urinary, respiratory)
• Antibiotics
• Blood transfusion
• Exchange transfusion
• Prophylaxis against thrombosis (heparin)
• Foetal monitoring

Question 253

Describe thalassaemia in pregnancy

Answer 253

• MOST COMMON genetic blood disorder
• If alpha or beta thalassemia minor, the patients will be mildly anaemic but there are no other issues
• Iron and folate supplements should be given
• The partner should be screened

Question 254

What is thrombocytopaenia defined as in pregnancy?

How is gestational thrombocytopaenia diagnosed?

Answer 254

• Platelet count < 150 x 109/L
• Gestational thrombocytopaenia occurs in 7-8% of pregnancies
• Bleeding is rarely a complication unless platelet count drops < 50 x 109/L
• Autoimmune and other causes of thrombocytopaenia should be excluded before arriving at a diagnosis of gestational thrombocytopaenia
• NO intervention is required other than monitoring platelet count
• Spontaneous resolution occurs after delivery

Question 255

What are the causes of thrombocytopaenia in pregnancy?

Answer 255

• Idiopathic
  
  • Increased consumption or destruction
  • Autoimmune
  • Antiphospholipid syndrome
  • Pre-eclampsia
  • HELLP syndrome
  • DIC
  • TTP
  • Hypersplenism
• Decreased production
  
  • Sepsis
  • HIV
  • Malignant bone marrow infiltration

Question 256

Describe autoimmune thrombocytopaenia in pregnancy

Answer 256

• Autoantibodies destroy platelets

- Maternal haemorrhage may occur if platelet count < 50 x 109/L

Question 257

What is the management of autoimmune thrombocytopaenia in pregnancy?

Answer 257

• Serial monitoring of platelet count
• Treatment should be considered if count falls < 50 x 109/L approaching 37 weeks
• Corticosteroids suppress platelet autoantibodies (but high doses can lead to weight gain, hypertension and diabetes)
• IVIG increases platelet count more quickly
• Vaginal delivery should be facilitated and regional anaesthesia should be avoided 80 x 109/L
• A cord blood sample should be collected for platelet count

Question 258

What are different bleeding disorders during pregnancy and delivery?

Answer 258

• Inherited
  
  • Vascular abnormalities
  • Platelet disorders
  • Coagulation disorders
• Acquired
  
  • Thrombocytopaenia
  • DIC
  • Acquired coagulation disorders
  • Marrow disorders

Question 259

What are inherited coagulation disorders in pregnancy?

Answer 259

• Carriers of haemophilia A and B usually have clotting factor activity that is 50% of normal
• Factor 8C and vWF antigen activity increase during pregnancy (may buffer the effect of mild disease)
• In haemophilia carriers, tests to confirm foetal sex should be offered (either ultrasound or cffDNA)
• Women with bleeding disorders are at significant risk of postpartum haemorrhage
• Planning for delivery is guided by third trimester clotting factor levels (taking into account the bleeding tendency)
• Factor concentrate, tranexamic acid and desmopressin may be used in labour and delivery for women deemed to be at significant risk
• NOTE: DDAVP increases levels of factor 8 and vWF
• Invasive foetal monitoring, ventouse and rotational forceps should be avoided if there is a risk that the foetus may be affected by the disease

Question 260

Describe Peptic Ulcer Disease in pregnancy?

Answer 260

• Less common in pregnancy and pre-existing ulceration tends to improve
• Probably due to altered oestrogen levels and improved diet
• Antacids and antiulcer medication is safe
• Pregnancy is NOT a contraindication for endoscopy

Question 261

What is untreated coeliac disease associated with in pregnancy?

Answer 261

• Spontaneous miscarriage
• FGR
• Gluten-free diet enables healthy pregnancy outcome

Question 262

Describe IBD and pregnancy

Answer 262

• Women with IBD have lower fertility rates
• Disease flares during pregnancy is more likely if the disease is active at conception
• Uncontrolled disease activity at conception is associated with an adverse pregnancy outcome
• Flares in the first trimester and postpartum are most common
• High-dose (5 mg) folic acid is recommended
• Other vitamin supplementation may be required

Question 263

What are the risks of IBD in pregnancy?

Answer 263

• Increased rate of delivery by C-section
  
  • NOTE: it is indicated if there is active perianal disease
• Preterm labour
• SGA

Question 264

Which IBD medication is contraindicated in pregnancy?

How is IBD managed in pregnancy?

Answer 264

• Methotrexate CONTRAINDICATED in pregnancy
• Other medications (e.g. 5-ASA, azathioprine, ciclosporin, infliximab and corticosteroids) are low risk
• A relapse of IBD during pregnancy should be treated with STEROIDS (tablets, IM injection or enema)

Question 265

How are pancreatitis and pregnancy linked?

Answer 265

• Uncommon
• Usually caused by gallstones or alcohol
• Management is supportive

Question 266

Describe viral hepatitis and pregnancy

Answer 266

• MOST COMMON cause of jaundice in pregnancy worldwide

- Acute viral hepatitis in the first trimester is associated with increased risk of spontaneous miscarriage

Question 267

Describe Hepatitis E and pregnancy
Which pregnancy factors are more commonly associated with Hep E?
What complications is Hep E associated with?

Answer 267

• Hepatitis E infection is more likely to lead to fulminant hepatic failure in pregnancy
• Most common in primigravida and in the third trimester
• It is also associated with
  
  • Preterm delivery
  • FGR
  • Stillbirth

Question 268

What virus can also cause hepatitis in pregnancy?

Answer 268

• Herpes simplex

Question 269

Describe Hep B & C in pregnancy

Answer 269

• Hepatitis B is associated with a 20-30% risk of foetal transmission
• Hepatitis C is associated with:
  • Preterm rupture of membranes
  • GDM
  • LBW
  • Neonatal unit admission

Question 270

How does autoimmune hepatitis affect pregnancy?

Answer 270

• Characterised by progressive hepatic parenchymal destruction (eventually leading to cirrhosis)
• Diagnosed on liver biopsy and is associated with ASMA and ANA
• High foetal loss rate when autoimmune hepatitis is active during pregnancy
• Immunosuppressive therapy should be continued during pregnancy according to disease activity

Question 271

Describe gallstones in pregnancy

Answer 271

• Increased oestrogen levels leads to increased cholesterol secretion and supersaturation of bile
• Increased progesterone levels leads to decreased small intestinal motility
• Conservative management is recommended initially (especially in 1st and 3rd trimester)
• Medical management involves:
  
  • IV fluids
  • Correction of electrolytes
  • Bowel rest
  • Pain management
  • Broad-spectrum antibiotics
• Relapse rates are high during pregnancy and may require surgery (ideally in 2nd trimester)

Question 272

How does pregnancy affect SLE?
What are the risks of SLE and pregnancy?
Which SLE women have the highest risk of adverse outcomes?

Answer 272

• Pregnancy increases the risk of flares
• They are most common in the late 2nd and 3rd trimester
• Risks
  
  • Miscarriage
  • Foetal death
  • Pre-eclampsia
  • Preterm delivery
  • FGR
• Women with lupus nephritis are at highest risk of adverse outcomes

Question 273

What is antiphospholipid syndrome?

What are its clinical features?

Answer 273

• Association of anticardiolipin antibodies and/or lupus anticoagulant with the typical clinical features of:
  
  • Arterial or venous thrombosis
  • Foetal loss after 10 weeks’ gestation
  • 3+ miscarriages at < 10 weeks gestation or delivery < 34 weeks due to FGR or pre-eclampsia
• Furthermore, positive antibody titres must be present on 2 occasions, 3 months apart
• Antiphospholipid syndrome may be primary or found in SLE

Question 274

How should antiphospholipid syndrome be managed in pregnancy?

Answer 274

• Intensive monitoring
• Low-dose aspirin to start by 12 weeks gestation
• Baseline renal studies including a 24-hour urine collection for protein
• Monitor BP (because of risk of pre-eclampsia)
• Serial ultrasonography should be performed to assess foetal growth, umbilical artery Doppler and liquor volume
• If treatment is required, steroids, azathioprine, sulfasalazine and hydroxychloroquine can be given safely
• NSAIDs can be given until week 32
• Some mother with SLE will have anti-Ro/La antibodies which cross the placenta and can cause neonatal lupus (usually manifests as cutaneous lesions) and congenital heart block (high perinatal mortality)

Question 275

How is rheumatoid arthritis affected in pregnancy?

Answer 275

• Most women experience improvement during pregnancy
• 90% will flare up postpartum
• There are no adverse effects in pregnancy
• Corticosteroids are preferred to NSAIDs

Question 276

What physiological changes occur in the skin during pregnancy?

Answer 276

• Increased pigmentation
• Spider naevi
• Pruritus without rash

Question 277

How does pregnancy affect pre-existing skin disease?

Answer 277

• Atopic eczema and acne can worsen in pregnancy

Question 278

What is Pemphigoid Gestationis?

How is it managed?

Answer 278

• Rare pruritic autoimmune bullous disorder
• Lesions begin on the abdomen progressing to widespread clustered blisters sparing the face
• Managed using topical and oral steroids

Question 279

What is polymorphic eruption of pregnancy?

Answer 279

• Self-limiting pruritic inflammatory disorder usually presenting in 3rd trimester
• Often begins on the lower abdomen involving pregnancy striae and extends to the thighs, buttocks, legs and arms
• Tends to spare the umbilicus, face, hands and feet
• The lesions usually become confluent and widespread
• No tendency to recur
• No impact on pregnancy

Question 280

What is prurigo of pregnancy?

Answer 280

• Common
• Excoriated papules on extensor limbs, abdomen and shoulders
• More common in women with a history of atopy
• Usually starts around 25-30 weeks
• Resolves after delivery
• Treated with topical steroids and emollients

Question 281

What is pruritic folliculitis of Pregnancy?

Answer 281

• Pruritic follicular eruption with papules and pustules mainly affecting the trunk
• Looks similar to acne
• Usually starts in 2nd and 3rd trimester
• Resolves within weeks of delivery