Pregnancy Flashcards
Risk factors for ectopic pregnancy
Previous ectopic pregnancy
Previous PID
Previous fallopian tube surgery
IUD
Older age
Smoking
Features of ectopic pregnancy
Missed period
Constant lower abdominal pain
Vaginal bleeding
Pelvic tenderness
Cervical motion tenderness
Dizziness
Syncope
Shoulder tip pain
Transvaginal ultrasound findings in ectopic pregnancy
Gestational sac outside of uterus
Bagel sign
Empty uterus
Fluid in uterus
hCG changes in 48hr and indications
Rise of >63% = intrauterine pregnancy
Rise of <63% = ectopic pregnancy
Fall of >50% = miscarriage
Management options for ectopic pregnancy
Expectant management
Medical management - Methotrexate
Surgical management - Salpingectomy/salpingotomy
Criteria for expectant management of ectopic pregnancy
Follow up possible
Ectopic is unruptured
Adnexal mass <35mm
No visible heartbeat
No significant pain
HCG <1500
Criteria for medical management of ectopic pregnancy
Unruptured ectopic
Adnexal mass <35mm
No visible heartbeat
No significant pain
HCG <5000
Confirmed absence of intrauterine pregnancy on US
Side effects of methotrexate
Vaginal bleeding
Nausea & vomiting
Abdominal pain
Stomatitis
Criteria for surgical management of ectopic pregnancy
Pain
Adnexal mass >35mm
Visible heart beat
HCG >5000
1st line surgical management of ectopic pregnancy
Laparoscopic salpingectomy
When would an ectopic pregnancy be managed with laparoscopic salpingotomy
To preserve fertility
Features of threatened miscarriage
Vaginal bleeding with closed cervical os, viable pregnancy on US
Features of inevitable miscarriage
Vaginal bleeding with open cervical os
Features of incomplete miscarriage
Retained products of conception in the uterus after the miscarriage
US features to determine pregnancy viability
Mean gestation sac diameter
Fetal pole & crown-rump length
Fetal heartbeat
At what crown-rump length would a fetal heartbeat be expected
7mm
At what mean gestational sac diameter would a fetal pole be expected
25mm
Management of miscarriage at less than 6 weeks gestation
Expectant management
Urine pregnancy test after 7-10 days
Medical management of miscarriage
Misoprostol - expedites process
Side effects of misoprostol
Heavier bleeding
Pain
Vomiting
Diarrhoea
Surgical management of miscarriage
Manual vacuum aspiration - LA
Electric vacuum aspiration - GA
Which medications are used for medical abortion
Mifepristone - halts pregnancy
Misoprostol - pregnancy expulsion
Two options for surgical abortion
Cervical dilatation & suction of the contents of the uterus (up to 14 weeks)
Cervical dilatation & evacuation using forceps (14-24 weeks)
Complications of abortion
Bleeding
Pain
Infection
Failure of abortion
Damage to cervix, uterus or other structures
When does nausea & vomiting occur during pregnancy
Weeks 4-20
Criteria for diagnosing Hyperemesis Gravidarum
> 5% weight loss during pregnancy
Dehydration
Electrolyte imbalance
Management of hyperemesis gravidarum
Prochlorperazine
Cyclizine
Ondansetron
Metoclopramide
Ranitidine
Omeprazole
When should a hyperemesis gravidarum patient be admitted
Unable to tolerate oral anti-emetics
Unable to keep down fluids
Ketones in urine
What is a complete molar pregnancy
Two sperm cells fertilise an ovum with no genetic material, making a tumour of combined sperm genetic material
What is a partial molar pregnancy
Two sperm cells fertilise a normal ovum creating 3 sets of chromosomes. Some fetal tissue may form
Features of molar pregnancy
Severe morning sickness
Vaginal bleeding
Enlargement of the uterus
Abnormally high hCG
Thyrotoxicosis
Snowstorm appearance on US
Management of molar pregnancy
Evacuation of uterus
Referral to gestational trophoblastic disease centre
Features of fetal alcohol syndrome
Microcephaly
Thin upper lip
Smooth flat philtrum
Short palpebral fissure
Learning disability
Behavioural difficulties
Hearing & vision problems
Cerebral palsy
Smoking during pregnancy increases risk of:
Fetal growth restriction
Miscarriage
Stillbirth
Preterm labour & delivery
Placental abruption
Pre-eclampsia
Cleft lip/palate
Sudden infant death syndrome
Ideally, when does booking clinic occur
Before 10 weeks gestation
What is tested for in booking bloods
Blood group
Antibodies
Rhesus D status
FBC
Thalassaemia
Sickle cell
Offered screening for HIV, Hep B & Syphilis
Tests available for antenatal Down’s syndrome screening
Combined test (1st line @ 11-14 weeks)
Triple test (14-20 weeks)
Quadruple test (14-20 weeks)
What is involved in the Combined Test for Down’s syndrome
US for nuchal translucency (>6mm in Down’s)
beta-HCG
PAPPA
What is involved in the Triple Test for Down’s syndrome
beta HCG
AFP
Serum oestriol
What is involved in the Quadruple Test for Down’s syndrome
beta HCG
AFP
Serum oestriol
Inhibin-A
What changes to Levothyroxine during pregnancy
Increase dose
Which hypertension medications must be stopped during pregnancy
ACEi
ARBs
Thiazides/thiazide-like diuretics
Side effects of NSAID usage during pregnancy
Premature closure of ductus arteriosus
Delay of labour
Side effects of beta blockers used during pregnancy
Fetal growth restriction
Hypoglycaemia in the neonate
Bradycardia in the neonate
Side effects of ACEi/ARB usage during pregnancy
Oligohydramnios
Miscarriage/fetal death
Hypocalvaria
Renal failure in the neonate
Hypotension in the neonate
Side effects of Warfarin usage during pregnancy
Fetal loss
Congenital malformations
Craniofacial problems
Bleeding during pregnancy
Postpartum haemorrhage
Fetal haemorrhage
When are anti-D injections given
28 weeks gestation
Birth if baby is rhesus positive
Antepartum haemorrhage
Amniocentesis procedures
Abdominal trauma
What are babies at risk of i there is rhesus incompatibility
Haemolytic disease of the newborn
What measurements are used to assess fetal size
Estimated fetal weight
Fetal abdominal circumference
Causes of small for gestational age
Constitutionally small
Fetal growth restriction
Causes of placenta mediated fetal growth restriction
Idiopathic
Pre-eclampsia
Maternal smoking
Maternal alcohol
Anaemia
Malnutrition
Infection
Maternal health conditions
Non placenta mediated causes of fetal growth restriction
Genetic abnormalities
Structural abnormalities
Fetal infection
Errors of metabolism
Signs of fetal growth restriction
Small for gestational age
Reduced amniotic fluid volume
Abnormal Doppler studies
Reduced fetal movements
Abnormal CTG
Short term complications of fetal growth restriction
Fetal death / stillbirth
Birth asphyxia
Neonatal hypothermia
Neonatal hypoglycaemia
Long term risks for growth restricted babies
Hypertension
Type 2 diabetes
Obesity
Mood & behavioural problems
Risk factors for SGA baby
Previous SGA baby
Obesity
Smoking
Diabetes
Existing hypertension
Pre-eclampsia
Older mother
Multiple pregnancy
Low PAPPA
Antepartum haemorrhage
Antiphospholipid syndrome
Monitoring of those at risk of SGA
Serial US scans measuring:
- estimated fetal weight & abdominal circumference
- Umbilical arterial pulsatility index
- Amniotic fluid volume
Causes of large for gestational age
Constitutional
Maternal diabetes
Previous LGA
Maternal obesity
Overdue
Male baby
Risks of large for gestational age babies
Shoulder dystocia
Failure to progress
Perineal tears
Instrumental delivery
Caesarean
Postpartum haemorrhage
Uterine rupture
Erbs palsy
Neonatal hypoglycaemia
Obesity in childhood
Type 2 diabetes in adulthood
Management of LGA baby
Delivery by experienced midwife or obstetrician
Access to theatre
Active management of 3rd stage
Early decision for caesarean section
Paediatrician to attend birth
Types of multiple pregnancy
Monozygotic - identical twins, single zygote
Dizygotic - non identical, different zygote
Monoamniotic - Single amniotic sac
Diamniotic - Two separate amniotic sacs
Monochorionic - single shared placenta
Dichorionic - two separate placentas
Risks to the mother associated with multiple pregnancy
Anaemia
Polyhydramnios
Hypertension
Malpresentation
Spontaneous pre-term birth
Instrumental delivery
Postpartum haemorrhage
Risks to fetuses/neonates associated with multiple pregnancy
Miscarriage
Stillbirth
Fetal growth restriction
Prematurity
Twin-twin transfusion syndrome
Twin anaemia polycythaemia sequence
Congenital abnormalities
What is twin-twin transfusion syndrome
Fetuses share a placenta, one twin receives the majority of the blood. The twin with more blood becomes fluid overloaded with heart failure & polyhydramnios. The donor has growth restriction, anaemia & oligohydramnios
When do you aim to deliver monoamniotic twins
32 + 6 weeks, elective c section
When do you aim to deliver diamniotic twins
37 + 6 weeks
Pre-eclampsia triad
Hypetension
Proteinuria
Oedema
High risk factors for pre-eclampsia
Pre-existing hypertension
Previous hypertension in pregnancy
Autoimmunity
Diabetes
CKD
Moderate risk factors for pre-eclampsia
> 40yrs
BMI >35
More than 10 years since previous pregnancy
Multiple pregnancy
First pregnancy
Family history
When are women offered aspirin in pregnancy
From 12 weeks gestation if 1 high risk factor for pre-eclampsia or 2 moderate risk factors
Symptoms of pre-eclampsia
Headache
Visual disturbance
Nausea & vomiting
Upper abdominal pain
Oedema
Reduced urine output
Brisk reflexes
Management of pre-eclampsia
Aspirin from 12 weeks gestation
Routine screening & monitoring
1st - Labetalol
2nd - Nifedipine
IV magnesium sulphate during labour & following 24hrs
What is HELLP syndrome
Haemolysis
Elevated liver enzymes
Low platelets
Risk factors for gestational diabetes
Previous gestational diabetes
Previous macrosomic baby
BMI >30
Black Caribbean, Middle Eastern or South Asian ethnities
Family history of diabetes
Management of gestational diabetes
Diet & exercise
Metformin
Insulin
Risks to baby associated with maternal diabetes
Neonatal hypoglycaemia
Polycythaemia
Jaundice
Congenital heart disease
Cardiomyopathy
When does obstetric cholestasis typically occur
After 28 weeks
Symptoms of obstetric cholestasis
Itching - particularly palms & soles
Fatigue
Dark urine
Pale, greasy stool
Jaundice
Investigation results in obstetric cholestasis
Abnormal ALT, AST & GGT
Raised bile acids
Management of obstetric cholestasis
Ursodeoxycholic acid
Emollients
Water-soluble vitamin K
Risks associated with placenta praevia
Antepartum haemorrhage
Emergency C section
Emergency hysterectomy
Maternal anaemia
Preterm birth
Low birth weight
Stillbirth
Grades of placenta praevia
I - Placenta in lower uterus, does not reach cervical os
II - Placenta reaches, but does not cover cervical os
III - Placenta partially covers cervical os
IV - Placenta completely covers cervical os
Risk factors for placenta praevia
Previous C section
Previous placenta praevia
Older maternal age
Maternal smoking
Structural uterine abnormalities
Assisted reproduction
When is placenta praevia usually noticed
20 week abnormality scan
Management of placenta praevia
Corticosteroids given between weeks 34 - 35+6
Planned delivery between 36 & 37 weeks
What is vasa praevia
The fetal vessels cover the internal cervical os
Risk factors for vasa praevia
Low lying placenta
IVF pregnancy
Multiple pregnancy
Management of vasa praevia
Corticosteroids from 32 weeks
Elective C section 34-36 weeks
Risk factors for placental abruption
Previous placental abruption
Pre-eclampsia
Bleeding early in pregnancy
Trauma
Multiple pregnancy
Fetal growth restriction
Multigravida
Increased maternal age
Smoking
Cocaine/amphetamine use
Presentation of placental abruption
Sudden onset severe abdominal pain
Vaginal bleeding
Shock
Fetal distress on CTG
Woody abdomen on palpation
Management of placental abruption
Urgent involvement of senior obstetrician, senior midwife & anaesthetist
CTG fetus monitoring
Crossmatch 4 units
Fluid & blood rescucitation
Prepare for potential emergency c-section
Types of placenta accreta
Superficial - placenta implants in the surface of the myometrium
Placenta increta - Placenta attaches deeply into the myometrium
Placenta percreta - Placenta invades past the myometrium & perimetrum
Risk factors for placenta accreta
Previous placenta accreta
Previous endometrial curettage procedures
Previous c section
Multigravida
Increased maternal age
Low-lying placenta
Management of placenta accreta
Planned c section between 35 to 36.6 weeks
Types of breech presentation
Complete breech - legs fully flexed at hip & knee
Incomplete breech - one leg flexed at hip & extended at knee
Extended breech - both legs flexed at the hip & extended at the knee
Footling breech - Foot presents through cervix with leg extended
Management of breech presentation
External cephalic version at 37 weeks
Discuss c section vs vaginal delivery
What pharmacological agent is used for tocolysis
SC terbutaline
Causes of stillbirth
Unexplained in around 50%
Pre-eclampsia
Placental abruption
Vasa praevia
Cord prolapse or wrapped around fetal neck
Obstetric cholestasis
Diabetes
Thyroid disease
Infections (rubella, parvovirus, listeria)
Congenital malformation
Risk factors for stillbirth
Fetal growth restriction
Smoking
Alcohol
Increased maternal age
Maternal obesity
Twins
Sleeping on the back
Red flag symptoms during pregnancy
Reduced fetal movements
Abdominal pain
Vaginal bleeding
