Other problems with pregnancy Flashcards
Features of obstetric cholestasis?
- Pruritis without rash – can get skin trauma from intense scratching
- Starts on palms and soles
- Intense at night insomnia and malaise
- If rash – think Polymorphic eruption of pregnancy (PEP) and pemphigoids gestations
also Epigastric discomfort, steatorrhoea, and dark urine
Ix for obstetric cholestasis?
- LFTs and bile acids
- Viral screen: Hep A, B, C, EBV, CMV
- Liver autoimmune screen: Anti-smooth muscle and antimitochondrial abx- For chronic active hepatitis and primary biliary cirrhosis
- USS abdo – other liver condition and gall stones
Bloods signs of OC?
- Elevated transaminases and alk phos (already slightly raised in pregnancy – much higher in OC)
- Raised GGT
- Mild elevation in bilirubin
- Primary bile acids increased up to 100 fold
Complications of OC?
Maternal: vit K deficiency (coag pathway disturbance), increased risk of PPH
Fetal: Stillbirth – perinatal mortality increased up to 11%, Fetal distress, Meconium passage, Preterm labour, IC haemorrhage
Mx of OC?
- Maternal Vit K from 36wks
- Babies given Vit K from birth
- Fetal surveillance
- Tx to reduce pruritis: Ursodeoxycholic acid, Antihistamine, Calamine
- Delivery at fetal maturity
- In pregnancy – LFTs repeated weekly until delivery/IOL
- Follow up at 10 days after delivery for LFTs – should be normal
Drugs used in OC?
o Ursodeoxycholic acid (reduces pruritis in 1 to 7days)
o Antihistamine
o Calamine
DDx of OC?
Gallstones.
• Acute or chronic viral hepatitis.
• Primary biliary cirrhosis (antimitochondrial antibody +ve).
• Chronic active hepatitis (antismooth muscle antibody +ve).
delivery in OC?
induction of labour at 37-38 weeks is common practice but may not be evidence based
PPX of increased risk of thromboembolism?
- Pregnancy is hypercoaguable state. Due to: Increased fibrinogen and factor 8, 9, and 10 and Concentration of endogenous anticoags decreases
- Additional risk for at least 6wks postpartum
- Venous stasis in lower limb later in pregnancy
- Trauma to pelvic veins in delivery increased risk
Obstetric RFs for thromboembolism?
multi pregnancy PET CS prolonged labour >24hrs stil birth preterm birth PPH>1L
Ix of DVT in pregnancy?
Gold standard: Venography with fetal shield
1st line: Doppler USS - less risk to baby - Can directly image clot and lack of compressibility of vein – suggest clot
Describe thromboprophylaxis in pregnancy.
if high risk of VTE (hitory of >1VTE, Unprovoked or oestrogen related
VTE, Single previous provoked VTE plus - Known thrombophilia
or Family history VTE
give LMWH.
Ix of suspected DVT?
Compression duplex ultrasound
Ix of suspected PE?
ECG and chest x-ray
if symptoms and signs of DVT, compression duplex ultrasound - If compression ultrasonography confirms the presence of DVT, no further investigation is necessary and treatment for VTE should continue
the decision to perform a V/Q or CTPA should be taken at a local level after discussion with the patient and radiologist
Compare CTPA and V/Q scan in pregnancy.
CTPA slightly increases the lifetime risk of maternal breast cancer - Pregnancy makes breast tissue particularly sensitive to the effects of radiation
V/Q scanning carries a slightly increased risk of childhood cancer compared with CTPA
Tx of VTE in pregnancy?
LMWH initially
given in dose titrated to women’s booking weight
graduated elastic compression stockings
IVC filter if iliac vein VTE to reduce the risk of PE or in patients with proven DVT and
who have recurrent PE despite adequate anticoagulation.
Tx of massive PE in pregnancy/puerperium?
IV unfractionated heparin
Maintenance therapy for VTE?
Treatment with therapeutic doses of subcutaneous LMWH should be employed during the remainder
of the pregnancy and for at least 6 weeks postnatally and until at least 3 months of treatment
define zygosity?
The genetic make-up of the zygote
dizygotic = non-identical, developed from separate ova that were fertilised at the same time
monozygotic = identical - developed from single ovum divided to form two embryos
Define chorionicity
number of palcenta of a pregnancy
Complications of twin pregnancy?
Maternal: hyperemesis, preeclampsia, anaemia, CS, miscarriage, PPH
Fetal: IUGR, IUFD, twin to twin transfusion syndrome, preterm birth, congenital malformations
What additional antenatal appointments are needed for twin pregnancy?
if uncomplicated dichorionic diamniotic twin pregnancy - offer at least 8 antenatal appointments
When is chorionicity most accurately diagnosed?
1st trimester
Early sign of twin pregnancy?
fundus palpable before 12wks or exaggerated symptoms of early pregnancy
Describe the antenatal care for twin pregnancies.
establish chorionicity
Routine use of iron and folate supplements should be considered.
A detailed anomaly scan should be undertaken.
• Advise aspirin 75microgram if additional risk factors for preeclampsia
Serial growth scans at 28, 32, and 36wks for DC twins.
More frequent antenatal checks because of i risk of pre-eclampsia.
delivery of multiple pregnancy?
Offer delivery at 37–38wks: induction or lower segment Caesarean
section (LSCS).
what type of multi pregnancy does TTTS affect? describe it. Mx?
MCDA pregnancy
caused by aberrant vascular anastamoses within the placenta, which redistribute the fetal blood
Laser ablation of the placental anastamoses
Selective feticide by cord occlusion is reserved for refractory disease
monitoring of MC twins?
serial USS every 2wks from 16–24wks and every 3wks until delivery
What are the effects of TTTS of the fetus?
Donor twin
• Hypovolaemic and anaemic.
• Oligohydramnios: appear ‘stuck’ to the placenta or uterine wall.
• Growth restriction.
Recipient twin
• Hypervolaemic and polycythaemic.
• Large bladder and polyhydramnios.
• Cardiac overload and failure.
• Evidence of fetal hydrops (ascites, pleural, and pericardial effusions).
• This twin is often more at risk than the donor.
Intrapartum risks of twin pregnancy?
M alpresentation.
• Fetal hypoxia in second twin after delivery of the fi rst.
• Cord prolapse.
• Operative delivery.
• Post-partum haemorrhage.
Rare:
• cord entanglement (MCMA twins only)
• head entrapment with each other: ‘locked twins’
• fetal exsanguination due to vasa praevia.
Describe the types of breech presentation.
Extended breeches (70%): both legs extended with feet by head; presenting part is the buttocks.
• Flexed breeches (15%): legs flexed at the knees so that both buttocks and feet are presenting.
• Footling breeches (15%): • one leg flexed and one extended.
Causes and associations of breech presentation?
idiopathic (most common).
• P reterm delivery.
• P revious breech presentation.
• U terine abnormalities, e.g. fi broids and Müllerian duct abnormalities.
• P lacenta praevia and obstructions to the pelvis.
• F etal abnormalities.
• M ultiple pregnancy.
Consequences of breech presentation?
Fetal: increased risk of hypoxia and trauma in labour
Maternal - most breeches delivered by CS.
Examination findings of breech presentation?
lie is longitudinal
• t he head can be palpated at the fundus
• t he presenting part is not hard
• t he fetal heart is best heard high up on the uterus.
WHen is ECV performed?
From 36wks in nullip women, 37wks in multiparous women
Mx after ECV?
CTG performed and anti-D given if Rh -ve
Factors meaning ECV will be more difficult?
Nulliparity, diffi culty palpating the head, high uterine tone, an
engaged breech, less amniotic fl uid, and white ethnicity
CIs to ECV?
Absolute • Caesarean delivery already indicated. • Antepartum haemorrhage. • Fetal compromise. • Oligohydramnios. • Rhesus isoimmunization. • Pre-eclampsia. Relative • One previous CS. • Fetal abnormality. • Maternal hypertension.
Ideal conditions for vaginal breech delivery?
Fetus is not compromised. • Estimated fetal weight is <4kg. • Spontaneous onset of labour. • Extended breech presentation. • Non-extended neck.
define unstable lie? Mx of unstable lie?
Unstable lie occurs when the lie is still changing, usually several times
a day, and may be transverse or longitudinal lie, and cephalic or breech
presentation
Admit to hospital from 37wks so that CS can be carried out if labour starts or the membranes rupture and the lie is not longitudinal
Risks of abnormal lie?
Labour with a non-longitudinal lie will result in obstructed labour
and potential uterine rupture.
• Membrane rupture risks cord prolapse because with longitudinal lie,
the presenting part usually prevents descent of the cord through the
cervix.
Causes and associations of abnormal fetal lie?
Multiparity (particularly >para 2) with lax uterus (common).
• Polyhydramnios.
• Uterine abnormalities, e.g. fibroids and Müllerian duct abnormalities.
• Placenta praevia and obstructions to the pelvis.
• Fetal abnormalities.
• Multiple pregnancy.
define prematurity, and different types of preterm.
premature = born before 37wks
extremely preterm = <28wks
very preterm = 28-32wks
moderate to late preterm = 32-36+6
Neonatal risks of prematurity?
Neonatal death • Respiratory distress syndrome • Chronic lung disease • Intraventricular hemorrhage • Necrotizing enterocolitis • Sepsis • Retinopathy of prematurity • <28 weeks: – physical disabilities, – learning disabilities, – behavioural problems, – visual and hearing problems
Causes of neonatal morbidity and mortality associated with PPROM?
Prematurity
– Sepsis and chorioamnionitis
– Cord prolapse
– Pulmonary hypoplasia
Hx and exam findings for PPROM? Ix?
Gush of fluid from vagina
• Leaking vaginal fluid
• Increased watery discharge
• Concern or uncertainty about urinary incontinence
Exam: Sterile speculum examination:
– Pool of fluid –> Confirmed
– No fluid seen –> test (different brands):
• ActimPROM
• AmniSure
FBC, CRP, HVS, MSU
USS - fetal presentation, EFW, liquor volume
What does actim-prom detect?
insulin-like growth factor binding protein-1
– Produced by decidual cells
– Present in amniotic fluid in high amounts
– Not normally found in vagina
PPROM Mx?
Admit for observation at least 48-72h - if going home advise to check temp twice daily
Corticosteroids if between 24-33+6wks
Prophylactic erythromycin - for 10days or until labour - Monitoring: CRP and WBC, temperature, maternal and fetal heart rate
Expectant management until 37 weeks
• Unless signs of maternal or fetal compromise
• If GBS, consider >34 weeks
Define preterm labour.
Labour/regular contractions resulting in changes in cervix before 37/40
RFs for preterm labour?
Smoking, drug abuse, teenager or advance maternal age, multiple pregnancy, previous cervical procedure (eg. LLETZ) previous late miscarriage asymptomatic bacteruria previous preterm, bacterial vaginosis
Methods to prevent preterm labour?
Identify those high risk: Women with history of:
– Spontaneous preterm birth
– Mid-trimester loss (16+)
– PPROM
– Cervical trauma
If high risk, need increased monitorings (TVUSS for cervical length, HVS)
If shortening between 16-24wks - give prophylactic
vaginal progesterone or perform cervical cerclage
– Cerclage needs to be removed before labour
Tx bacterial vaginosis (clindamycin)
Ix for ?preterm labour?
TVUSS - gold-standard
>15mm – unlikely PTL • Discuss benefits/risks of going home vs. monitoring in hospital – <15mm – confirmed PTL and offer treatment
Fetal fibronectin
Alternatives: Actim partus, partosure - insufficient evidence to recommend for diagnosis/confirmation of PTL
FBC, CRP, swabs, MSU
What does ACTIM PARTUS look for?
PHIGFBP-1
– Phosphorylated IGFBP-1
Produced by decidua
Leaks into the cervix when decidua and chorion detach
– phIGFBP-1 in a cervical swab is an indicator for tissue damage
blood interferes with test
Mx of preterm labour?
liaise with neonatology
?in utero teansfer (to hospital with appropriate neonatal unit
Tocolysis - Slow down contractions with nifedipine or atosiban - Allow time for administration of steroids or transfer
Corticosteroids if <34 wk
rescue cerclage - If dilated cervix with exposed fetal membranes <28 wks, no PPROM, no infection, no contractions
In labour -
Neuroprotection with magnesium sulfate for <34 wks
Antibiotics
Continuous monitoring
Indications for rescue cerclage?
If dilated cervix with exposed fetal membranes
<28 wks, no PPROM, no infection, no contractions
Features suggestive of chorioamniotis?
History:
• Fever/malaise.
• Abdominal pain, including contractions.
• Purulent/offensive vaginal discharge.
Examination: • Maternal pyrexia and tachycardia. • Uterine tenderness. • Fetal tachycardia. • Speculum: offensive vaginal discharge—yellow/brown.
Risks to fetus from PPROM?
Prematurity.
• Infection.
• Pulmonary hypoplasia.
• Limb contractures.
Fetal risks of prolonged pregnancy?
perinatal mortality
Meconium aspiration and assisted ventilation.
• Oligohydramnios.
• Macrosomia, shoulder dystocia, and fetal injury.
• Cephalhaematoma.
• Fetal distress in labour.
• Neonatal—hypothermia, hypoglycaemia, polycythaemia, and growth restriction.
