Pregnancy Flashcards
When do you give anti-D to non-sensitised Rh -ve mother’s?
28 and 34 weeks
In what situations should an anti-D be given within 72 hours
delivery of a Rh +ve infant, whether live or stillborn
termination of pregnancy > 10 weeks
miscarriage if gestation is > 12 weeks
ectopic pregnancy (if managed surgically, if managed medically with methotrexate anti-D is not required)
external cephalic version
antepartum haemorrhage
amniocentesis, chorionic villus sampling, fetal blood sampling
abdominal trauma
Tests for rehusus sensitisation ?
all babies born to Rh -ve mother should have cord blood taken at delivery for FBC, blood group & direct Coombs test
Coombs test: direct antiglobulin, will demonstrate antibodies on RBCs of baby
Kleihauer test: add acid to maternal blood, fetal cells are resistant (do after a sensitisation event to see if further foses of anti-d are required)
How will an affected fetus present - rhesus sensitisation
oedematous (hydrops fetalis, as liver devoted to RBC production albumin falls)
jaundice, anaemia, hepatosplenomegaly
heart failure
kernicterus
treatment: transfusions, UV phototherapy
Missed miscarriage
the fetus is no longer alive, but no symptoms have occurred
or
fetus no longer alive but closed os
Threatened miscarriage
vaginal bleeding with a closed cervix and a fetus that is alive
Inevitable miscarriage
vaginal bleeding with an open cervix
Incomplete miscarriage
retained products of conception remain in the uterus after the miscarriage
Complete miscarriage
a full miscarriage has occurred, and there are no products of conception left in the uterus
Anembryonic pregnancy
a gestational sac is present but contains no embryo
Diagnosing miscarriage
transvaginal ultrasound
Gravida (G)
is the total number of pregnancies a woman has had
Primigravida
refers to a patient that is pregnant for the first time
Multigravida
refers to a patient that is pregnant for at least the second time
Para (P)
refers to the number of times the woman has given birth after 24 weeks
Nulliparous (“nullip”)
refers to a patient that has never given birth after 24 weeks gestation
Primiparous
technically refers to a patient that has given birth after 24 weeks gestation once before (see below)
The term primiparous, or “primip” is a bit confusing. Technically, it refers to a woman that has given birth once before. However, it is often used on the labour ward to refer to a woman that is due to give birth for the first time (and has never given birth before). You may hear patients referred to on the labour ward as a “primip” when they have never given birth before.
when do fetal movements start?
20 weeks
If fetal movements have not yet been felt by 24 weeks, referral should be made to a maternal fetal medicine unit
vaccines in pregnancy?
Whooping cough (pertussis) from 16 weeks gestation
Influenza (flu) when available in autumn or winter
Live vaccines, such as the MMR vaccine, are avoided in pregnancy.
what is part of ‘booking bloods’ antenatal?
A set of booking bloods are taken for:
Blood group, antibodies and rhesus D status
Full blood count for anaemia
Screening for thalassaemia (all women) and sickle cell disease (women at higher risk)
Patients are also offered screening for infectious diseases, by testing antibodies for:
HIV
Hepatitis B
Syphilis
Screening for Down’s syndrome may be initiated depending on the gestational age. Bloods required for the combined test are taken from 11 weeks onwards.
What congenital abnormality is lithium associated with, especially in first trimester?
ebsteins anomaly
features of congenital rubella
Congenital deafness
Congenital cataracts
Congenital heart disease (PDA and pulmonary stenosis)
Learning disability
chickenpox in pregnancy complications
More severe cases in the mother, such as varicella pneumonitis, hepatitis or encephalitis
Fetal varicella syndrome
Severe neonatal varicella infection (if infected around delivery)
exposure to chicken pox during pregnancy? Investigation and management
When they are not sure about their immunity, test the VZV IgG levels. If positive, they are safe.
When they are not immune, they can be treated with IV varicella immunoglobulins as prophylaxis against developing chickenpox. This should be given within ten days of exposure.
chickenpox rash in pregnancy and > 20 weeks gestastion
oral aciclovir
congenital varicella syndrome
Fetal growth restriction
Microcephaly, hydrocephalus and learning disability
Scars and significant skin changes located in specific dermatomes
Limb hypoplasia (underdeveloped limbs)
Cataracts and inflammation in the eye (chorioretinitis)
why should pregnanct women avoid foods such as blue cheese, unpasteurised foods, processed meats
Listeriosis in pregnant women has a high rate of miscarriage or fetal death. It can also cause severe neonatal infection.
parovirus b19 in pregnancy?
Miscarriage or fetal death
Severe fetal anaemia
Hydrops fetalis (fetal heart failure)
Maternal pre-eclampsia-like syndrome
causes cleft lip/palate
polygenic inheritance
maternal antiepileptic use increases risk
definiton recurrent miscarriage
three or more consecutive miscarriages.
main causes of recurrent miscarriage
Idiopathic (particularly in older women)
Antiphospholipid syndrome
Hereditary thrombophilias eg factor V leidin
Uterine abnormalities
Chronic Histiocytic Intervillositis
Chronic histiocytic intervillositis is a rare cause of recurrent miscarriage, particularly in the second trimester. It can also lead to intrauterine growth restriction (IUGR) and intrauterine death.
The condition is poorly understood. Histiocytes and macrophages build up in the placenta, causing inflammation and adverse outcomes. It is diagnosed by placental histology showing infiltrates of mononuclear cells in the intervillous spaces.
Small for gestational age vs intrauterine growth restriction
Small for gestational age is defined as a fetus that measures below the 10th centile for their gestational age (doesn’t state if pathoplogical or not)
intrauterine growth restriction (IUGR), is when there is a small fetus (or a fetus that is not growing as expected) due to a pathology
causes of placenta mediated growth restriction
Idiopathic
Pre-eclampsia
Maternal smoking
Maternal alcohol
Anaemia
Malnutrition
Infection
Maternal health conditions
causes of non-placenta mediated growth restriction
Genetic abnormalities
Structural abnormalities
Fetal infection
Errors of metabolism
complications of fetal growth restriction
Short term complications of fetal growth restriction include:
Fetal death or stillbirth
Birth asphyxia
Neonatal hypothermia
Neonatal hypoglycaemia
Growth restricted babies have a long term increased risk of:
Cardiovascular disease, particularly hypertension
Type 2 diabetes
Obesity
Mood and behavioural problems
How is growth of fetus measured
symphysis fundal height (SFH) from 24 weeks
serial growth scans with umbilical artery doppler if need closer invetsigation due to:
- SFH being < 10th centile at 24 weeks
- Three or more minor risk factors
- One or more major risk factors
- Issues with measuring the symphysis fundal height (e.g. large fibroids or BMI > 35)
when is early delivery considered for small for gestational age?
when growth is static
defintion of low birth weight
less than 2500g
main risk for large for gestational age
shoulder dystocia
Investigations for a large for gestational age baby ?
Ultrasound to exclude polyhydramnios and estimate the fetal weight
Oral glucose tolerance test for gestational diabetes
causes macrosmia
Constitutional
Maternal diabetes
Previous macrosomia
Maternal obesity or rapid weight gain
Overdue
Male baby
defintion large for gestational age
large for gestational age (also known as macrosomia) when the weight of the newborn is more than 4.5kg at birth.
An estimated fetal weight above the 90th centile is considered large for gestational age.
what type of twin pregnancy has best outcomes?
diamniotic, dichorionic twin pregnancies
lambda sign or twin peak sign pregnancy
diamniotic, dichorionic
T sign pregnancy
Monochorionic diamniotic
no membrane separating twins pregnancy
monochorionic, monoamniotic
when are monoamniotic twins delivered, how?
elective caesarean section at between 32 and 33 + 6 weeks.
when are diamniotic twins delivered?
36 and 36 + 6 weeks for uncomplicated monochorionic diamniotic twins
37 and 37 + 6 weeks for uncomplicated dichorionic diamniotic twins
Vaginal delivery is possible when the first baby has a cephalic presentation (head first)
Caesarean section may be required for the second baby after successful birth of the first baby
Elective caesarean is advised when the presenting twin is not cephalic presentation
what do UTIs in pregnancy increase the risk of?
pre-term birth
testing for UTIs in pregancy
MSU for sensitivities and cultures routinely (at booking and at appointments) - treat asymptomatic bacteraemia during pregnancy
MSU and dip when symptomatic
folic acid dosage pregnancy
400mcg per day from prior to getting pregnant
Women with folate deficiency/epileptic drugs/pre-existing diabetes/BMI>30 are started on folic acid 5mg daily.
when are pregnant women screened for anaemia
Booking clinic
28 weeks gestation
cut offs for treating anaemia in women? in pregnancy and post partum
Hb
<115 non-pregnant
<110 first trimester (booking appt)
<105 2nd/3rd trimester
<100 post partum
anaemia treatment pregnancy
ferrous sulphate 200mg three times daily
what should people with B12 deficiency be tested for?
pernicious anaemia (checking for intrinsic factor antibodies).
investigation of choice DVT?
Doppler ultrasound
The Wells score is not validated for use in pregnant women. D-dimers are not helpful in pregnant patients, as pregnancy is a cause of a raised D-dimer.
investigations for pulmonary embolism : initial and definitive
Chest xray
ECG
There are two main options for establishing a definitive diagnosis: CT pulmonary angiogram (CTPA) or ventilation-perfusion (VQ) scan.
CTPA is the test for patients with an abnormal chest xray
CTPA carries a higher risk of breast cancer for the mother (minimal absolute risk)
VQ scan carriers a higher risk of childhood cancer for the fetus (minimal absolute risk)
Patients with a suspected deep vein thrombosis and pulmonary embolism should have a Doppler ultrasound initially, and if a DVT is present, they do not require a VQ scan or CTPA to confirm a PE. The treatment for DVT and PE are the same.
The Wells score is not validated for use in pregnant women. D-dimers are not helpful in pregnant patients, as pregnancy is a cause of a raised D-dimer.
Management of venous thromboembolism in pregnancy
low molecular weight heparin (LMWH). Examples of LMWH are enoxaparin, dalteparin and tinzaparin. The dose is based on the woman’s weight at the booking clinic, or from early pregnancy.
LMWH should be started immediately, before confirming the diagnosis in patients where DVT or PE is suspected and there is a delay in getting the scan. Treatment can be stopped when the investigations exclude the diagnosis.
When the diagnosis is confirmed, LMWH is continued for the remained of pregnancy, plus six weeks postnatally, or three months in total (whichever is longer). There is an option to switch to oral anticoagulation (e.g. warfarin or a DOAC) after delivery. An individual risk assessment is performed before stopping anticoagulation, with advice from a haematologist if necessary.
Management pregnant women with PE and haemodynamic compromise
Unfractionated heparin
Thrombolysis
Surgical embolectomy
pathophysiology pre-eclampsia
Pre-eclampsia is caused by high vascular resistance in the spiral arteries and poor perfusion of the placenta. This causes oxidative stress in the placenta, and the release of inflammatory chemicals into the systemic circulation, leading to systemic inflammation and impaired endothelial function in the blood vessels.
pre-eclampsia definition
NICE guidelines for diagnosis:
Systolic blood pressure above 140 mmHg
Diastolic blood pressure above 90 mmHg
PLUS any of:
Proteinuria (1+ or more on urine dipstick)
Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia)
Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies
Triad : hypertension after 20 weeks, proteinuria, oedema
what is eclampsia
seizures due to pre-eclampsia
which factors mean women will be offered aspirin for pre-eclampsia prophylaxis? how long given for?
From 12 weeks until birth
One high-risk factors:
Pre-existing hypertension
Previous hypertension in pregnancy
Existing autoimmune conditions (e.g. systemic lupus erythematosus)
Diabetes
Chronic kidney disease
2 or more moderate risk factors:
Older than 40
BMI > 35
More than 10 years since previous pregnancy
Multiple pregnancy
First pregnancy
Family history of pre-eclampsia
proteinuria in pregnancy values
Urine protein:creatinine ratio (above 30mg/mmol is significant)
Urine albumin:creatinine ratio (above 8mg/mmol is significant)
test to rule out pre-eclampsia
The NICE guidelines (2019) recommend the use of placental growth factor (PlGF) testing on one occasion during pregnancy in women suspected of having pre-eclampsia.
Placental growth factor is a protein released by the placenta that functions to stimulate the development of new blood vessels. In pre-eclampsia, the levels of PlGF are low.
NICE recommends using PlGF between 20 and 35 weeks gestation to rule-out pre-eclampsia.
management of pre-existing diabetes in pregnancy
folic acid 5mg
stick to metformin and insulin
aim for same levels as in gestational diabetes
retinopathy screening after booking and at 28 weeks
planned delivery between 37 and 38 + 6 weeks
complications of gestational diabetes
hypoglycaemia of newborn
macrosmia
Haemolysis
Elevated Liver enzymes
Low Platelets
HELLP SYNDROME - COMPLICATION OF PRE-ECLAMPSIA
management of gestational diabestes
Four weekly ultrasound scans to monitor the fetal growth and amniotic fluid volume from 28 to 36 weeks gestation.
The initial management:
Fasting glucose less than 7 mmol/l: trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin
Fasting glucose above 7 mmol/l: start insulin ± metformin
Fasting glucose above 6 mmol/l plus macrosomia (or other complications): start insulin ± metformin
What can obstetric cholestasis cause?
still birth
Physiological changes renal - pregnancy
Increased perfusion to kidneys (up 30%) → increased GFR (up 30-60%)
Urine : increased protein, increased urea, increased creatinine, trace glucose
Serum: decreased urea, decreased creatinine, reduced albumin
If trace glucose, may offer OGTT at 24 weeks
Physiological changes respiratory - pregnancy
Increased oxygen demands, progesterone increases sensitivity of respiratory centre to CO2
Tidal volume increases
Respiratory rate increases
Physiological changes hematology - pregnancy
There is increased red blood cell production in pregnancy, leading to higher iron, folate and B12 requirements. There is also an increase in calcium req but body absorbs better too so may be unchanged
Plasma volume increases > red blood cell volume, leading to a lower concentration of red blood cells. High plasma volume means the haemoglobin concentration and red cell concentration (haematocrit) fall in pregnancy, resulting in anaemia.
Lower Hb
Lower platelets
Clotting factors such as fibrinogen and factor VII, VIII and X increase in pregnancy, making women hyper-coagulable (ready for delivery). This increases the risk of venous thromboembolism (blood clots developing in the veins). Pregnant women are more likely to develop deep vein thrombosis and pulmonary embolism.
Placental secretion
High ALP (up to 4 times higher)
Physiological changes skin and hair - pregnancy
Increased skin pigmentation due to increased melanocyte stimulating hormone, with linea nigra and melasma
Striae gravidarum (stretch marks on the expanding abdomen)
General itchiness (pruritus) can be normal, but can indicate obstetric cholestasis
Spider naevi (related to increased estrogen)
Palmar erythema
Postpartum hair loss is normal, and usually improves within six months.
Physiological cardiovascualr changes pregnancy
Increased blood volume Increased cardiac output
Higher heart rate
Ejection systolic murmur
Third heart sound
Decreased pulmonary vascular resistance
Decreased diastolic blood pressure in early and middle pregnancy, returning to normal by term (blood being diverted to placenta)
Peripheral vasodilation → oedema (increased levels of estrogen and progesterone) could also be caused by an enlarged uterus impeding venous return
Itching (pruritis) is the main symptom, particularly affecting the palms of the hands and soles of the feet.
obstetric cholestasis
What symptom do you NOT get in Obstetric cholestasis
a rash
Management obstetric cholestasis
Ursodeoxycholic acid is the primary treatment for obstetric cholestasis. It improves LFTs, bile acids and symptoms.
Symptoms of itching can be managed with:
Emollients (i.e. calamine lotion) to soothe the skin
Antihistamines (e.g. chlorphenamine) can help sleeping (but does not improve itching)
Planned delivery after 37 weeks may be considered, particularly when the LFTs and bile acids are severely deranged. Stillbirth in obstetric cholestasis is difficult to predict, and early delivery aims to reduce the risk.
Pathophysiology acute fatty liver of pregnancy
Acute fatty liver of pregnancy results from impaired processing of fatty acids in the placenta. This is the result of a genetic condition in the fetus that impairs fatty acid metabolism. The most common cause is long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency in the fetus, which is an autosomal recessive condition. This mode of inheritance means the mother will also have one defective copy of the gene.
Th LCHAD enzyme is important in fatty acid oxidation, breaking down fatty acids to be used as fuel. The fetus and placenta are unable to break down fatty acids. These fatty acids enter the maternal circulation, and accumulate in the liver. The mother’s defective copy of the gene may also contribute to the accumulation of fatty acids. The accumulation of fatty acids in the mother’s liver leads to inflammation and liver failure.
Presentation acute fatty liver of pregnancy
General malaise and fatigue
Nausea and vomiting
Jaundice
Abdominal pain
Anorexia (lack of appetite)
Ascites
Blood test results acute fatty liver of pregnancy
Liver function tests will show elevated liver enzymes (ALT and AST).
ALT is typically elevated e.g. 500 u/l
Other bloods may be deranged, with:
Raised bilirubin
Raised WBC count
Deranged clotting (raised prothrombin time and INR)
Low platelets
Management of acute fatty liver of pregnancy
Acute fatty liver of pregnancy is an obstetric emergency and requires prompt admission and delivery of the baby. Most patients will recover after delivery.
Management also involves treatment of acute liver failure if it occurs, including consideration of liver transplant.
3rd trimester - pruritic and urticarial papules and plaques of pregnancy. It is an itchy rash that tends to start in the third trimester. It usually begins on the abdomen, particularly associated with stretch marks (striae).
Polymorphic eruption of pregnancy
three causes of antepartum haemorrhage
placenta praveia
placental abruption
vasa praevia
Painless vaginal bleeding
uterus not tender
lie and presentation may be abnormal
foetal heart usually normal
shock in proportion to visible loss
placenta praevia
Management of placenta praevia picked up on scans
recommends a repeat transvaginal ultrasound scan at:
32 weeks gestation
36 weeks gestation (if present on the 32-week scan, to guide decisions about delivery)
Corticosteroids are given between 34 and 35 + 6 weeks gestation to mature the fetal lungs, given the risk of preterm delivery.
Planned delivery is considered between 36 and 37 weeks gestation. It is planned early to reduce the risk of spontaneous labour and bleeding. Planned cesarean section is required with placenta praevia and low-lying placenta (<20mm from the internal os).
Constant lower abdominal pain and, woman may be more shocked than is expected by visible blood loss. Tender, tense uterus/woody uterus* with normal lie and presentation. Fetal heart may be distressed
placental abruption
risk factors for placental abruption
A for Abruption previously;
B for Blood pressure (i.e. hypertension or pre-eclampsia);
R for Ruptured membranes, either premature or prolonged;
U for Uterine injury (i.e. trauma to the abdomen);
P for Polyhydramnios;
T for Twins or multiple gestation;
I for Infection in the uterus, especially chorioamnionitis;
O for Older age (i.e. aged over 35 years old);
N for Narcotic use (i.e. cocaine and amphetamines, as well as smoking)
how to define severity of antepartum haemorrhage
Spotting: spots of blood noticed on underwear
Minor haemorrhage: less than 50ml blood loss
Major haemorrhage: 50 – 1000ml blood loss
Massive haemorrhage: more than 1000 ml blood loss, or signs of shock
management placental abruption
Fetus alive and < 36 weeks
fetal distress: immediate caesarean
no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation
Fetus alive and > 36 weeks
fetal distress: immediate caesarean
no fetal distress: deliver vaginally
Fetus dead
induce vaginal delivery
what is uss good for in antepartum haemorrhage
Ultrasound can be useful in excluding placenta praevia as a cause for antepartum haemorrhage, but is not very good at diagnosing or assessing abruption.
Rupture of membranes followed immediately by vaginal bleeding. Fetal bradycardia is classically seen
vasa praevia
In what instances may fetal vessels be exposed
Velamentous umbilical cord is where the umbilical cord inserts into the chorioamniotic membranes, and the fetal vessels travel unprotected through the membranes before joining the placenta.
An accessory lobe of the placenta (also known as a succenturiate lobe) is connected by fetal vessels that travel through the chorioamniotic membranes between the placental lobes.
Management of vasa pravia when you know about it beforehand
For asymptomatic women with vasa praevia, the RCOG guidelines (2018) recommend:
Corticosteroids, given from 32 weeks gestation to mature the fetal lungs
Elective caesarean section, planned for 34 – 36 weeks gestation
Management of vasa pravia presenting with antepartum haemorrhage
Emergency caesarean section is required to deliver the fetus before death occurs.
Next appropriate step:
positive pregnancy test and either abdominal, pelvic or cervical motion tenderness
immediate referral to early pregnancy unit
complete vs incomplete molar pregnancy
A complete mole occurs when two sperm cells fertilise an ovum that contains no genetic material (an “empty ovum”). These sperm then combine genetic material, and the cells start to divide and grow into a tumour called a complete mole. No fetal material will form. This will have a snowstorm appearance.
A partial mole occurs when two sperm cells fertilise a normal ovum (containing genetic material) at the same time. The new cell now has three sets of chromosomes (it is a haploid cell). The cell divides and multiplies into a tumour called a partial mole. In a partial mole, some fetal material may form.
complication of monochorionic twin pregnancies? invetsigation? management?
Twin-to-twin transfusion syndrome (TTTS)
Ultrasound examinations performed between 16 and 24 weeks focus on detecting this condition. After 24 weeks the main purpose of ultrasound examinations is to detect fetal growth restriction.
The recipient may become fluid-overloaded whilst the donor can become anaemic. One fetus may have oligohydramnios and the other may have polyhydramnios as a result of differences in urine production, causing additional problems.
lazer ablasion of interconnecting vessels
management of the thryrotoxic stage of postpartum thyrotoxicosis
propranolol is typically used for symptom control
Placenta accreta
Placenta increta
placenta percreta
Implantation of placenta past the endometrium into the myometrium
accreta - attach
increta - invade
percreta - perimetrium (invade all the way to perimetrium)
Risk factors for accreta
Previous placenta accreta
Previous endometrial curettage procedures (e.g. for miscarriage or abortion)
Previous caesarean section
Multigravida
Increased maternal age
Low-lying placenta or placenta praevia
presentations accreta
on USS
antepartum bleeding
postpartum bleeding as hard to deliver placenta
Management of accreta
35-36 weeks
Caesarean
Options:
1. hysterectomy including placenta
2. Uterus preserving surgery, with resection of part of the myometrium along with the placenta
3. Expectant (risk of infection)
what to do if placenta accreta is seen when opening the abdomen for an elective caesarean section
the abdomen can be closed and delivery delayed whilst specialist services are put in place.
If placenta accreta is discovered after delivery of the baby, a hysterectomy is recommended.
Complete breech
the legs are fully flexed at the hips and knees
Incomplete breech
one leg flexed at the hip and extended at the knee
Extended breech
also known as frank breech, with both legs flexed at the hip and extended at the knee
Footling breech
a foot is presenting through the cervix with the leg extended
When is ECV done
After 36 weeks for nulliparous women
After 37 weeks in women that have given birth previously
Options if ECV fails
Where ECV fails, women are given a choice between vaginal delivery and elective caesarean section. Vaginal delivery needs to involve experienced midwives and obstetricians, with access to emergency theatre if required.
Drugs used during ECV
tocolysis to relax uterus
anti-d if mum negative
Best fetal position
Left Occiput Anterior position
define stillbirth
the birth of a dead fetus after 24 weeks gestation
3 major causes of cardiac arrest in pregnancy
Obstetric haemorrhage
Pulmonary embolism
Sepsis leading to metabolic acidosis and septic shock
resuscitation in pregnancy
A 15 degree tilt to the left side for CPR, to relieve compression of the inferior vena cava and aorta
Early intubation to protect the airway
Early supplementary oxygen
Aggressive fluid resuscitation (caution in pre-eclampsia)
Delivery of the baby after 4 minutes, and within 5 minutes of starting CPR
tests for down’s 11-14 weeks
combined test (blood and USS)
ABC
low A (PAPPA) <0.5
high B-HCG
High C - nuchal thickness >6mm
Tests for downs 14-20 weeks
Either triple test or quadruple test
Triple:
low alpha-feto protein
High B-HCG
Low S (simialr to C) serum oestrodiol
Quadruple
High A-inhibin
Low alpha-feto protein
High B-HCG
Low Serum oestrodiol
Next step after combined/triple/quadruple
If risk > 1 in 150, offered chorionic villious sampling (<15 weeks) or amniocentesis
- these take a sample of cells for karyotype
Non-invasive prenatal testing is being rolle dout - maternal blood test for fetal DNA fragments
What is an ectopic pregnancy
a pregnancy is implanted outside the uterus
bimanual examination ectopic
cervical motion tenderness
diagnosing miscarriage
A transvaginal ultrasound
most common site ectopic?
most dangerous site?
ampulla
isthmus
Investigations for pregnancy of unknown location
Serum human chorionic gonadotropin (hCG) can be tracked over time to help monitor a pregnancy of unknown location. The serum hGC level is repeated after 48 hours, to measure the change from baseline.
crietria for expectant management ectopic
Follow up needs to be possible to ensure successful termination
The ectopic needs to be unruptured
Adnexal mass < 35mm
No visible heartbeat
No significant pain
HCG level < 1500 IU / l
monitor hCG
criteria for methotrexate management of ectopic
same as for expectant apart from:
HCG level must be < 5000 IU / l
Confirmed absence of intrauterine pregnancy on ultrasound
Medical management ectopic
IM methotrexate
Criteria for surgical management for ectopic
Pain
Adnexal mass > 35mm
Visible heartbeat
HCG levels > 5000 IU / l
What is early miscarriage
<12 weeks
Management ?miscarriage < 6 weeks
No invetsigations or tretament providing no rf
A repeat urine pregnancy test is performed after 7 – 10 days
Management ?miscarriage > 6 weeks
Referral to early pregnancy unit
Expectant - rpt test in 7-10 days
Medical - Vaginal or oral misoprostol - restest in 3 weeks
Surgical - manual vac under local, electric vac under general
Prostaglandins (misoprostol) are given before surgical management to soften the cervix.
anti-d given in surgical
Termination of pregnancy options
Medical abortion:
Mifepristone (anti-progestogen)
Misoprostol (prostaglandin analogue) 1 – 2 day later
Rhesus negative women with a gestational age of 10 weeks or above having a medical TOP should have anti-D prophylaxis.
Surgical:
Cervical dilatation and suction of the contents of the uterus (usually up to 14 weeks)
Cervical dilatation and evacuation using forceps (between 14 and 24 weeks)
Side effects misoprostol
Chills; constipation; diarrhoea; dizziness; fever; flatulence; gastrointestinal discomfort; headache; nausea; skin reactions; vomiting
Investigation of choice ectopic
transvaginal USS
First step if a pregnant woman reports reduced foetal movements
handheld Doppler should be used to confirm fetal heartbea
what may reduced fetal movements indicate
can represent fetal distress, as a method of fetal compensation to reduce oxygen consumption as a response to chronic hypoxia in utero. This is concerning, as it reflects risk of stillbirth and fetal growth restriction. It is believed that there may also be a link between reduced fetal movements and placental insufficiency.
Investigations for reduced fetal movements
If >28 weeks
- handheld doppler to confirm heartbeat
- If no heartbeat heard –> immediate USS
- If heartbeat CTG for 20 mins
- If concern detailed USS within 24 hours
Drugs to be avoided in breastfeeding
antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
psychiatric drugs: lithium, benzodiazepines
aspirin
carbimazole
methotrexate
sulfonylureas
cytotoxic drugs
amiodarone
first line anti-hypertensive for pre-eclampsia in women with severe asthma
nifedepine
symphisis fundal height rule
The symphysis-fundal height (SFH) is measured from the top of the pubic bone to the top of the uterus in centimetres
It should match the gestational age in weeks to within 2 cm after 20 weeks, e.g. if 24 weeks then the a normal SFH = 22 to 26 cm
booking appointment
4 blood - thalassemia, fbc, rhesus and blood group (sickle cell if high risk)
3 viruses - HIV, syphilis, Hep B
2 urines - dip and microscopy
1 physical exam - BP, BMI
blood film shows polychromasia and schistocytes
HELLP
When is OGTT carried out
between 24-28 weeks
Who should get OGTT
risk factors:
Previous gestational diabetes
Previous macrosomic baby (≥ 4.5kg)
BMI > 30
Ethnic origin (black Caribbean, Middle Eastern and South Asian)
Family history of diabetes (first-degree relative)
signs:
Large for dates fetus
Polyhydramnios (increased amniotic fluid)
Glucose on urine dipstick
Management pre-eclampsia
Labetolol is first-line as an antihypertensive
Nifedipine (modified-release) is commonly used second-line or if asthmatic
Methyldopa is used third-line (needs to be stopped within two days of birth)
Intravenous hydralazine may be used as an antihypertensive in critical care in severe pre-eclampsia or eclampsia
IV magnesium sulphate is given during labour and in the 24 hours afterwards to prevent seizures
Fluid restriction is used during labour in severe pre-eclampsia or eclampsia, to avoid fluid overload
Management HTN postpartum
Enalapril (first-line)
Nifedipine or amlodipine (first-line in black African or Caribbean patients)
Labetolol or atenolol (third-line)
Who should be given VTE prophylaxis? when?
Smoking
Parity ≥ 3
Age > 35 years
BMI > 30
Reduced mobility
Multiple pregnancy
Pre-eclampsia
Gross varicose veins
Immobility
Family history of VTE
Thrombophilia
IVF pregnancy
From 28 weeks with 3 RFs
From 12 weeks with 4 or more RFs
Postpartum
For 6 weeks if
Previous VTE, anyone who had antenatal LMWH, high risk thrombophilia, low risk thrombophilia + FHx
At least 10 days if
C-section, BMI >40, readmission/prolonged admission (>3 days), any surgical procedure, medical comorbidities (cancer, HF, SLE, OBD, SCD)
What does IgG indicate
previous infection eg immunity
What does IgM indicate
active infection
think IgMalaise because ill
Quadruple test edwards
A inhibin A =
A alphafetoprotein low
B HCG low
C serum estrodiol low
Quadruple test neural tube defect
A inhibin A high
A alphafetoprotein =
B HCG =
C serum estrodiol =
management antiphospholipid in pregnancy
LMWH
aspirin
bagel/blob sign
ectopic
Antenatal timeline
First visit is from 8, check everything with mum is great, urine, bloods and rhesus state, give advice and educate
from 11 to 13 is the best time to do a downs screen while your at it check the dates
at 16 or 10 plus 6 do BP and multistix
second scan is at twenty to check the fingers and toes to make sure there’s plenty
one again at 28, urine blood and rhesus date
anti D if appropriate
must give anti D once more when the week is 34, and plan for birth, what a chore
check the lie at 36, if breech offer a quick-fix
last visit at 38, all thats left to do wait
G and P currently pregnant, 3 children and 1 miscarriage previously
G5P3+1
Currently pregnant, previous still birth
G2P1
What does molar pregnancy increase liklihood of in future?
management?
Choriocarcinoma OR invasive mole
Methotrexate OR chemotherapy
what does a sonographer look for in early pregnancy
Mean gestational sac diameter to 25mm –>
Fetal pole and crown-rump length 7mm –>
Fetal heartbeat
What to do if gestational sac is 25mm but no fetal pole?
repeat uss in 1 week before confirming anembryonic pregnancy
What to do if fetal pole > 7mm but no heart beat?
repeat uss in 1 week before confirming non-viable pregnancy
Definitive management pre-eclampsia
Delivery of the baby
Antiemetic choice pregnancy
- Antihistamines (Cyclizine, promethazine, prochlorperazine) H1-receptor antagonist
- Metochloropramide inhibition of D2
- Ondesartan 5HT3 receptor antagonist
causes oligohydramnios
premature rupture of membranes
fetal renal problems e.g. renal agenesis
intrauterine growth restriction
post-term gestation
pre-eclampsia
risk factors placenta praevia
Previous caesarean sections
Previous placenta praevia
Older maternal age
Maternal smoking
Structural uterine abnormalities (e.g. fibroids)
Assisted reproduction (e.g. IVF)
risk factors vasa praevia
Low lying placenta
IVF pregnancy
Multiple pregnancy
Risk factors for gestational diabetes
BMI of > 30 kg/m²
previous macrosomic baby weighing 4.5 kg or above
previous gestational diabetes
first-degree relative with diabetes
family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
associations hyperemesis
multiple pregnancies
trophoblastic disease
hyperthyroidism
nulliparity
obesity
Methods of inducing labour
- membrane sweep
- vaginal prostaglandin E2 (PGE2)
- maternal oxytocin infusion
- amniotomy (‘breaking of waters’)
- cervical ripening balloon
passed through the endocervical canal and gently inflated to dilate the cervix
quadruple test patau
inhibin A =
AFPauatu high
BHCG =
oestrodiol =
most common complication TOP
infection
rf for cord prolapse
prematurity
multiparity
polyhydramnios
twin pregnancy
cephalopelvic disproportion
abnormal presentations e.g. Breech, transverse lie
artificial rupture of membranes!!
where does fertilisation occur?
ampulla
Forceps vs ventouse
forceps:
- if < 36 weeks as head softer and could be damaged by ventouse
- more likley to work
- need to rotate baby
ventouse
- needs to be cephalic
- less risk of tears
what twins get twin to twin transfusion
monozygitic, monochorionic, diamniotic
indications for induction
prolonged pregnancy, e.g. 1-2 weeks after the estimated date of delivery
prelabour premature rupture of the membranes, where labour does not start
diabetic mother > 38 weeks
pre-eclampsia
rhesus incompatibility
calculating bishop score
0,1,2,3
position (cervical) posterior , intermediate, anterior, -
consistency firm, intermediate, soft
effacement <30, <50, <70, >80
dilation <1cm, 1-2cm, 3-4cm, >5cm
fetal station -3, -2, -1 and 0, +1+2
normal cervical length
4cm
not had chickenpox and <20 weeks gestation
VcIg ASAP
whooping cough management
clarithromycin
preg - erythromycin
