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Obstetrics > Other Medical Disorders in Pregnancy > Flashcards

Other Medical Disorders in Pregnancy Flashcards

1
Q

why is pregnancy diabetogenic

A

decreased glucose tolerance due to the antagonistic effects of lactogen, progesterone and cortisol

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2
Q

what are the foetal complications of gestational diabetes

A

Foetal hyperinsulinaemia due to islet cell hyperplasia which leads to increased fat deposition, leading to a large baby (macrosomia)

Congenital abnormalities (especially neural tube defects)

Preterm labour

Reduced Foetal lung maturity

Increased birthweight

Dystocia and birth trauma

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3
Q

how is foetal macrosomia best detected

A

An increase in abdominal width on antenatal scanning

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4
Q

what are the maternal complications of gestational diabetes

A

Increased insulin requirements

Ketoacidosis

UTI

Wound/endometrial infection

Hypertension and pre-eclampsia

Worsening of pre-existing heart disease

C-section or instrumental delivery more likely due to foetal size

Diabetic nephropathy (5-10%)

Diabetic retinopathy

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5
Q

why is glucosuria not a reliable physiological sign for gestational diabetes

A

because it is normal in pregnancy

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6
Q

How do you diagnose gestational diabetes

A

fasting glucose >5.6mmol/L

OGTT >7.8mmol/L 2 hours after 75g of glucose

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7
Q

what is the incidence of gestational diabetes

A

16%

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8
Q

how should you manage pre-existing diabetes in pregnant women

A

Precise glucose control and foetal monitoring
Dietary advice, Metformin and insulin are the only appropriate agents for monitoring in pregnancy

Preconceptual care
Glucose levels should be at normal physiological levels at conception, and pregnancy is not advised beyond 10% HbA1c
5mg folic acid
Statins stopped and antihypertensives given instead
Labetolol/methyldopa most commonly used
Renal function, eyes and blood pressure are measured

During pregnancy the aims are <5.3mmol/L fasting and <7.8mmol/L 1 hour post 75g glucose load

Aspirin 75mg is advised >12 weeks to avoid the risk of pre-eclampsia

Foetal monitoring

Foetal echocardiography is indicated

Extra scans at 32 and 36 weeks are indicated for growth/liquor volume

Neonate commonly develops hypoglycaemia initially due to it being used to higher glucose levels, therefore levels should be checked within 4 hours – breast feeding is strongly advised

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9
Q

what factors put women at risk of developing gestational diabetes

A

Previously large baby

Unexplained stillbirth

1st degree relative with diabetes

BMI >30

Minority ethnic origin

Previous gestational diabetes

Persistent glycosuria

Polyhydramnios

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10
Q

what % of women develop T2DM after an episode of gestational diabetes

A

50%

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11
Q

what is the care after birth for a woman whos had gestational diabetes

A

oral glucose tolerance test 6 weeks post birth

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12
Q

what are the physiological changes to the cardiovascular system in pregnancy

A

Cardiac output increases in pregnancy, due to increased blood volume (40%), increased heart rate and increased stroke volume

There is a 50% decrease in systemic vascular resistance, so BP often drops in 2nd trimester but returns to normal by term

90% of women have an ejection systolic murmur and an abnormal ECG (left axis deviation, inverted T waves)

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13
Q

How is pre-existing valve disease managed in pregnancy

A

Beta-blockers

valve replacement if serious

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14
Q

what are the physiological changes to the respiratory system in pregnancy

A

Tidal volume is increased by 40% in pregnancy

There is no corresponding change in respiratory rate

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15
Q

what respiratory condition is common in pregnancy

A

asthma

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16
Q

what is required for a woman on long term steroids during labour

A

increased dose of steroids due to chronic adrenal suppression

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17
Q

if the mother has epilepsy what is the chance the baby develops it

A

3%

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18
Q

what are the physiological changes to the thyroid system in pregnancy

A

Thyroid status does not change in pregnancy but foetal thyroxine does not get produced until 12 weeks so maternal TSH is increased to cover this deficiency

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19
Q

what are the implications of maternal hypothyroidism in pregnancy

A 
severe perinatal mortality 
miscarriage
preterm delivery 
increased risk of intellectual impairment 
increased risk of pre-eclampsia
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20
Q

why is an untreated thyroid disorder in pregnancy rare

A

hypo/hyper causes anovulation

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21
Q

what is the foetal risk of maternal hyperthyroidism

A

foetal thyrotoxicosis and goitre

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22
Q

what is the treatment for maternal hyperthyroidisim

A

propyluracil - not carbamazepine

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23
Q

what happens to graves disease post partum

A

gets worse

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24
Q

what are features of post-partum thyroiditis

A

Common (5-10%)

May lead to post-natal depression

Risk factors are antithyroid antibodies and T1DM

There is usually a 3 month transient, subclinical hyperthyroidism followed by a 4 month period of hypothyroidism – in 20% this is permanent

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25
Q

what is acute fatty liver + what are some of its features

A

rare obstetric complication causing acute hepatorenal failure, DIC and hypoglycaemia

malaise
vomiting 
jaundice
vague epigastric pain
preceding thirst weeks earlier
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26
Q

how do you treat acute fatty liver of pregnancy

A

early identification key

correction of clotting defects and hypoglycaemia first

supportive treatment:
dextrose
blood products
careful fluid balance
occasional dialysis
recurrence rates low
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27
Q

what is obstetric cholesatasis and what are some common features

A

obstetric intrahepatic cholestasis of unexplained origin

Unexplained pruitis

Abnormal LFTs

Raised bile acids

Resolution post-delivery

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28
Q

if a patient has had obstetric cholestasis previously what is the chance of recurrence

A

50%

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29
Q

what are the complications of obstetric cholestasis

A

Stillbirth (bile acid toxicosis)

Early meconium passage

Postpartum haemorrhage

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30
Q

what is the treatment for obstetric cholestasis

A

No main treatment

Ursodeoxycholic acid (UDCA) may relieve itching

Vit K given after 36 weeks due to risk of post-partum haemorrhage - 10mg/day

Induction is offered
38 weeks if bile acids are high
40 weeks otherwise

6 week follow up mandatory to check liver function returns to normal

31
Q

what physiological changes occur in pregnancy due to the renal system

A

GFR increases by 40% in pregnancy causing creatinine and urea to drop

32
Q

what is the threshold for CKD in pregnancy

A

creatinine >200mmol/L

33
Q

what are some foetal complications of CKD in pregnancy

A

Preterm delivery

Pre-eclampsia

IUGR

Polyhydramnios

34
Q

whats the management for CKD in pregnancy

A

USS for foetal growth

Renal monitoring

Hypertension control

If necessary – dialysis

35
Q

what are the complications of a UTI in pregnancy

A

Preterm labour

Anaemia

Increased perinatal morbidity and mortality

36
Q

what are complications of antiphospholipid syndromes in pregnancy

A

Placental thrombosis

IGUR

Pre-eclampsia

Recurrent miscarriage

37
Q

how should you manage a woman with antiphospholipid syndrome in pregnancy

A

Serial USS

Induction at term

Aspirin + LMWH

Postnatal anticoagulation

38
Q

what are prothrombotic conditions that must be screened for in pregnancy

A

Antiphospholipid syndrome

Prothrombin gene mutation

Factor V leiden heterozygosity

Protein S or C defiency

Antithrombin deficiency

39
Q

what is hyperhomocysteinemia associated within pregnancy and how do you treat

A

increased pregnancy losses
increased risk of preeclampsia

high dose folic acid

40
Q

how is SLE managed in pregnancy

A

if there is no lupus anticoagulation/anticardiolipid antibodies, the main risk comes with the organ associated damage from active disease

41
Q

what physiological change occurs to the hematological system in pregnancy

A

pregnancy is a pro-thrombotic condition

clotting factors are increased, fibrinolytic activity is decreased, blood flow is altered by obstruction

42
Q

what is the leading cause of obstetric related maternal death in the UK

A

pulmonary embolism

43
Q

how does a central venous thrombosis present in pregnancy

A

headache/stroke

44
Q

whats the treatment for a central venous thrombosis in pregnancy

A

LMWH (depending on thrombophilia screen and anti-factor Xa level)

More needed in pregnancy as clearance is increased

If possible, treatment should be stopped around labour

Warfarin is teratogenic and may cause foetal bleeding so seldom used antenatally

Warfarin and LMWH are safe for breastfeeding women

More general measures

Mobilisation

Hydration

Compression stockings (especially if LMWH contraindicated)

45
Q

what are the risks of obesity in pregnancy

A 
Thromboembolism 
Pre-eclampsia 
Diabetes  
C-section  
Wound infection 
Postpartum haemorrhage 
Difficult surgery  
Death  
Higher rates of congenital abnormalities 
Death due to complications of diabetes and pre-eclampsia
46
Q

what extra management is required for obesity in pregnancy

A

high dose folic acid (5mg)

Vitamin D

close monitoring of blood pressure

47
Q

what is required when a pregnant woman has a BMI >40

A

Formal anaesthetic assessment required

Antenatal thromboprophylaxis should be used

48
Q

when is mental illness most affected in pregnancy

A

in the puerperium

49
Q

what are some red flags relating to mental illness in the puerperium

A

Recent significant change in mental health

Emergence of new symptoms

New thought

Acts of violence/self-harm

New and persistent expressions of incompetency as a mother

Estrangement from the infant

50
Q

what is the guidance surrounding the use of SSRIs in pregnancy/post pregnancy

A

they are generally safe, some neonates may go through withdrawal so its important to watch out for that

51
Q

what antipsychotics are safe to use in pregnancy

A

most 2nd generation however olanzipine/quitiapine are associated with weight gain and arent recommended for high BMI/gestational diabetes

52
Q

which of the common recreational drugs are definitely teratogenic

A

cocaine
ecstasy
benzodiazepines

53
Q

what is the use of recretional opiates associated with in pregnancy

A

Stillborn

Preterm delivery

Developmental delay

IUGR

SIDS

neonatal withdrawal/convulsion post-delivery

54
Q

what treatment is required for opiate addiction in pregnancy

A

methadone maintenance

55
Q

what is the use of cocaine associated with in pregnancy

A

IUGR

Stillbirth

SIDS

Preterm delivery

Placental abruption

56
Q

what teratogenic features is ecstasy associated with

A

cardiac defects

gastroschiasis

57
Q

whats associated with benzodiazepine use in pregnancy

A

foetal clefts

Maternal hypotonia

Withdrawal symptoms

58
Q

whats associated with alcohol intake in pregnancy

A

early miscarriage

IUGR

Foetal Alcohol syndrome

59
Q

whats associated with smoking during pregnancy

A

Stillbirth

IUGR

Preterm birth

Placental abruption

SIDS

Childhood illnesses - namely increased risk of asthma

60
Q

why is anaemia common in pregnancy

A

The 40% increase in blood volume in pregnancy is much more of a serum increase than a red cell increase, therefore there is a dilutional anaemia that occurs in pregnancy

Therefore the normal Hb in pregnancy is as low as 11.0 g/dl

61
Q

what is a high Hb associated with in pregnancy

A

IUGR and preterm birth

62
Q

what is the differences between adult and foetal Hb

A

adult Hb has 2 alpha and 2 beta chains

Foetal has 2 alpha and 2 gamma chains

foetal Hb has more affinity to oxygen meaning they’re better saturated at the same oxygen pressure

63
Q

what are the maternal complications of sickle cell disease in pregnancy

A

Acute painful crises (35%)

Pre-eclampsia

Thrombosis

64
Q

what are the foetal complications of sickle cell disease

A

IUGR

Miscarriage

Preterm labour

Death

65
Q

how do you manae sickle cell disease in pregnancy

A

Sickle cell specialist

Hydroxycarbamide is teratogenic and stopped

Penicillin V continued

High dose folic acid

Aspirin + LMWH indicated

Monthly urine culture

Iron used to prevent overload

Crises management
Hydration
Analgesia
Antibiotics/anticoagulation

USS every 4 weeks, induce by 38/40

66
Q

what are maternal complications of thalassaemia in pregnancy

A

Diabetes

Reduced fertility

Hepatic dysfunction

Cardiac failure

67
Q

what are foetal complications of thalassaemia in pregnancy

A

Growth restriction

Foetal death

68
Q

what should be arranged in preconceptual planning of pregnancy with women with sickle cell disease

A

Chelation is teratogenic and avoided in 1st trimester

Deferrioxamine may be used

USS is used 4 weekly

69
Q

what are the 4 types of fmale genital mutilation

A

Type 1 – clitoridectomy

Type 2 – excision

Partial/total removal of the clitoris and labia minora +/- labia majora

Type 3 - Infibulation

Partial closing of the opening of the vagina via repositioning of the labia

+/- removal of the clitoris

Type 4

Other

70
Q

what are common regions for female genital mutilation

A

Africa

Middle east

Malysia

Indonesia

71
Q

what are some common reasons cited for female gential mutilation

A

‘fertility’

Hygeine

Adherence to cultural norms

Religion - although not condoned in the bible or koran

72
Q

what are short term complications of female genital mutilation

A

Pain

Bleeding

Infection

Urinary retention

Damage to pelvic organs

Death

73
Q

what are longer-term complications of female genital mutilation

A

Failure to heal

UTI

Pain during sex

Infertility

Difficulty menstruating

Fistula

Severe perineal trauma during childbirth

Chronic pelvic dysfunction

Vulval pain due to cysts and neuromas

Obstetrics (16 decks)

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