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Obs and gynae > Other problems with pregnancy > Flashcards

Other problems with pregnancy Flashcards

1
Q

Features of obstetric cholestasis?

A
  • 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

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2
Q

Ix for obstetric cholestasis?

A
  • 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
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3
Q

Bloods signs of OC?

A
  • 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
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4
Q

Complications of OC?

A

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

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5
Q

Mx of OC?

A
  • 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
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6
Q

Drugs used in OC?

A

o Ursodeoxycholic acid (reduces pruritis in 1 to 7days)
o Antihistamine
o Calamine

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7
Q

DDx of OC?

A

Gallstones.
• Acute or chronic viral hepatitis.
• Primary biliary cirrhosis (antimitochondrial antibody +ve).
• Chronic active hepatitis (antismooth muscle antibody +ve).

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8
Q

delivery in OC?

A

induction of labour at 37-38 weeks is common practice but may not be evidence based

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9
Q

PPX of increased risk of thromboembolism?

A
  • 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
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10
Q

Obstetric RFs for thromboembolism?

A 
multi pregnancy
PET
CS
prolonged labour >24hrs
stil birth 
preterm birth
PPH>1L
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11
Q

Ix of DVT in pregnancy?

A

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

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12
Q

Describe thromboprophylaxis in pregnancy.

A

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.

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13
Q

Ix of suspected DVT?

A

Compression duplex ultrasound

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14
Q

Ix of suspected PE?

A

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

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15
Q

Compare CTPA and V/Q scan in pregnancy.

A

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

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16
Q

Tx of VTE in pregnancy?

A

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.

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17
Q

Tx of massive PE in pregnancy/puerperium?

A

IV unfractionated heparin

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18
Q

Maintenance therapy for VTE?

A

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

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19
Q

define zygosity?

A

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

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20
Q

Define chorionicity

A

number of palcenta of a pregnancy

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21
Q

Complications of twin pregnancy?

A

Maternal: hyperemesis, preeclampsia, anaemia, CS, miscarriage, PPH

Fetal: IUGR, IUFD, twin to twin transfusion syndrome, preterm birth, congenital malformations

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22
Q

What additional antenatal appointments are needed for twin pregnancy?

A

if uncomplicated dichorionic diamniotic twin pregnancy - offer at least 8 antenatal appointments

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23
Q

When is chorionicity most accurately diagnosed?

A

1st trimester

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24
Q

Early sign of twin pregnancy?

A

fundus palpable before 12wks or exaggerated symptoms of early pregnancy

25
Q

Describe the antenatal care for twin pregnancies.

A

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.

26
Q

delivery of multiple pregnancy?

A

Offer delivery at 37–38wks: induction or lower segment Caesarean
section (LSCS).

27
Q

what type of multi pregnancy does TTTS affect? describe it. Mx?

A

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

28
Q

monitoring of MC twins?

A

serial USS every 2wks from 16–24wks and every 3wks until delivery

29
Q

What are the effects of TTTS of the fetus?

A

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.

30
Q

Intrapartum risks of twin pregnancy?

A

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.

31
Q

Describe the types of breech presentation.

A

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.

32
Q

Causes and associations of breech presentation?

A

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.

33
Q

Consequences of breech presentation?

A

Fetal: increased risk of hypoxia and trauma in labour

Maternal - most breeches delivered by CS.

34
Q

Examination findings of breech presentation?

A

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.

35
Q

WHen is ECV performed?

A

From 36wks in nullip women, 37wks in multiparous women

36
Q

Mx after ECV?

A

CTG performed and anti-D given if Rh -ve

37
Q

Factors meaning ECV will be more difficult?

A

Nulliparity, diffi culty palpating the head, high uterine tone, an
engaged breech, less amniotic fl uid, and white ethnicity

38
Q

CIs to ECV?

A 
Absolute
• Caesarean delivery already indicated.
• Antepartum haemorrhage.
• Fetal compromise.
• Oligohydramnios.
• Rhesus isoimmunization.
• Pre-eclampsia.
Relative
• One previous CS.
• Fetal abnormality.
• Maternal hypertension.
39
Q

Ideal conditions for vaginal breech delivery?

A 
Fetus is not compromised.
• Estimated fetal weight is <4kg.
• Spontaneous onset of labour.
• Extended breech presentation.
• Non-extended neck.
40
Q

define unstable lie? Mx of unstable lie?

A

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

41
Q

Risks of abnormal lie?

A

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.

42
Q

Causes and associations of abnormal fetal lie?

A

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.

43
Q

define prematurity, and different types of preterm.

A

premature = born before 37wks
extremely preterm = <28wks
very preterm = 28-32wks
moderate to late preterm = 32-36+6

44
Q

Neonatal risks of prematurity?

A 
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
45
Q

Causes of neonatal morbidity and mortality associated with PPROM?

A

Prematurity
– Sepsis and chorioamnionitis
– Cord prolapse
– Pulmonary hypoplasia

46
Q

Hx and exam findings for PPROM? Ix?

A

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

47
Q

What does actim-prom detect?

A

insulin-like growth factor binding protein-1

– Produced by decidual cells
– Present in amniotic fluid in high amounts
– Not normally found in vagina

48
Q

PPROM Mx?

A

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

49
Q

Define preterm labour.

A

Labour/regular contractions resulting in changes in cervix before 37/40

50
Q

RFs for preterm labour?

A 
Smoking, drug abuse, teenager or advance maternal age, 
multiple pregnancy, 
previous cervical procedure (eg. LLETZ)
previous late miscarriage
asymptomatic bacteruria
previous preterm, bacterial vaginosis
51
Q

Methods to prevent preterm labour?

A

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)

52
Q

Ix for ?preterm labour?

A

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

53
Q

What does ACTIM PARTUS look for?

A

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

54
Q

Mx of preterm labour?

A

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

55
Q

Indications for rescue cerclage?

A

If dilated cervix with exposed fetal membranes

<28 wks, no PPROM, no infection, no contractions

56
Q

Features suggestive of chorioamniotis?

A

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.
57
Q

Risks to fetus from PPROM?

A

Prematurity.
• Infection.
• Pulmonary hypoplasia.
• Limb contractures.

58
Q

Fetal risks of prolonged pregnancy?

A

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.

Obs and gynae (10 decks)

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