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Pregnancy Flashcards

1
Q

What are some of the causes of bleeding in early pregnancy?

A 
Implantation bleeding 
Chorionic haematoma 
Miscarriage 
Ectopic pregnancy 
Molar pregnancy 
Infection
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2
Q

Describe implantation bleeding

A

Occurs when a fertilised egg implants into the uterine wall

Bleeding is limited and light brownish in colour

Occasionally mistaken as a period

Management; watchful waiting - usually settles

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3
Q

What is the primary symptom of miscarriage?

A

BLEEDING

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4
Q

What are some of the possible symptoms of miscarriage?

A

Bleeding

Period-like cramping pain

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5
Q

What are some of the possible causes of miscarriage?

A

Embryonic abnormality

Immunological conditions e.g APS

Infections e.g CMV/ rubella/ toxoplasmosis e.t.c

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6
Q

What are the different types of miscarriage?

A 
Threatened miscarriage 
Inevitable miscarriage 
Incomplete miscarriage 
Complete miscarriage 
Early fetal demise
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7
Q

What is early fetal demise?

A

Pregnancy in-situ

No heartbeat

*can wait a couple of days to see if the fetus regains a heartbeat, the mother however may miscarry in this time

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8
Q

What is the management of miscarriage?

A

Emotional support

Haemodynamic stabilising

Anti D (for rhesus -ve mothers)

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9
Q

What are some of the causes of recurrent miscarriage (3+ pregnancy losses)

A

Antiphospholipid syndrome

Thrombophilia

Uterine abnormalities

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10
Q

What is the primary symptom of ectopic pregnancy?

A

PAIN

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11
Q

What are some of the possible symptoms of ectopic pregnancy?

A

Pain

Bleeding

Dizziness/ collapse

SOB (caused by internal bleeding)

*Peritonism causes rigidity and rebound tenderness

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12
Q

What might an ultrasound scan show in cases of ectopic pregnancy?

A

Empty uterus

Pseudo sac

Mass

Free fluid

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13
Q

What diagnosis should you always consider in early pregnancy presenting with pain?

A

Ectopic pregnancy

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14
Q

What is molar pregnancy?

A

Non-viable fertilised egg in the womb

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15
Q

What is the difference between a complete and partial mole?

A

COMPLETE MOLE
Egg without DNA
Only paternal DNA
No fetus

PARTIAL MOLE
Egg
1 reduplicated or 2 sperm- forms a triploidy with the egg May have a fetus attached

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16
Q

What are some of the causes of molar pregnancy?

A

Gestational trophoblastic disease

Nonviable fertilised egg

Overgrowth of placental tissue with chorionic villi swollen with fluid

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17
Q

How might a molar pregnancy present?

A

Hyperemesis

Bleeding and passage of “grape-like” tissue

Shortness of breath

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18
Q

What is the typical ultrasound appearance of a molar pregnancy?

A

‘Snow storm appearance’

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19
Q

What is a chorionic haematoma?

A

Pooling of blood between the endometrium and the embryo due to separation

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20
Q

How does a chorionic haematoma present?

A

Bleeding

Cramping

Threatened miscarriage

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21
Q

What is hyperemesis gravidarum?

A

Excessive vomiting in pregnancy which alters QOL

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22
Q

What effects can hyperemesis gravidarum have on the body?

A

Dehydration

Electrolyte and nutritional misbalance

Weight loss

Altered liver function

Emotional instability

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23
Q

How is hyperemesis gravidarum managed?

A

Rehydration and electrolyte replacements

Nutritional and vitamin supplements e.g thiamine and pabrinex

NG feeding

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24
Q

What is the first line anti-emetic for hyperemesis gravidarum?

A

Cyclizine

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25
What is the second line anti-emetic for hyperemesis gravidarum?
Ondansetron
26
HCG doubles by 50% in 48 hours with viable or inviable pregnancies?
Viable pregnancies
27
When is considered term?
37-42 weeks 90% of babies will be delivered in this time
28
When do women deliver with reference to their due date?
4% deliver on the date 60% deliver within the date 90% deliver within term
29
What screening should be done for the mother throughout pregnancy?
Diabetic eye screening and gestational diabetes BBV and infections Maternal anaemia Pre-eclampsia Urinalysis Mental health
30
What screening should be done for the fetus during pregnancy?
Neural tube defects Haemoglobin disorders Growth Aneuploidy
31
Screening for aneuploidy in pregnancy is done to detect which conditions?
Down's syndrome (trisomy 21) Edward's syndrome (trisomy 18) Patau syndrome (trisomy 13)
32
How is Down's syndrome screened for in pregnancy?
1st TRIMESTER - Nuchal thickness (US) (11-14 weeks, <3.5mm is normal) - HCG and PAPP-A 2nd TRIMESTER - Blood samples (at 15- 20 weeks) - HCG and AFP (Low AFP in Down's)
33
What is placental praevia?
When the placenta is low lying in the womb and covers all or part of the cervix
34
What are pre eclampsia and eclampsia?
Pre-eclampsia = pregnancy induced hypertension and proteinuria Eclampsia = extreme pre-eclampsia
35
What are the risk factors for pre-eclampsia?
Previous pre-eclampsia pre-existing hypertension, diabetes , autoimmune disease , renal disease FH of pre-eclampsia Obesity Women with multiple gestation (twins or multiple birth)
36
What are some of the proposed causes of pre-eclampsia?
Secretion of placental hormones Immune response to the fetus Insufficient blood supply to the placenta- causes ischaemia
37
What are some of the treatment options for eclampsia?
Vasodilators Caesarean section
38
What effects do progesterone and oestrogen have on contractility of the uterus?
Progesterone inhibits contractility Oestrogen stimulates contractility
39
Where is oxytocin secreted from and what is its role?`
Posterior pituitary Increases contractions
40
What is the name of the contractions which increase towards the end of pregnancy?
Braxton Hicks contractions
41
What are the risks of pregnancy to the mother if she is obese?
Miscarriage Pre-eclampsia Gestational diabetes
42
What are the risks of pregnancy to the fetus if the mother is obese?
Still birth Macrosomnia Long term obesity Diabetes Metabolic and congenital abnormalities
43
How many extra calories are recommended in pregnancy and breastfeeding?
300 extra calories in the last 3 months of pregnancy 640 extra calories if exclusively breastfeeding
44
What vitamins and supplements are required in pregnancy?
Folic acid Vitamin D and calcium Iron Vitamin B
45
Why is Vitamin K given before parturition?
To prevent intracranial bleeding during labour
46
What foods should be avoided in pregnancy?
Raw meat, tuna, liver Soft cheese Raw or partially cooked eggs Alcohol Vitamin A (teratogenic in high doses - only given to patients with CF)
47
Describe a threatened miscarriage
Light bleeding Closed cervical os Painless Doesn't usually result in miscarriage
48
Describe an inevitable miscarriage
Bleeding (heavy with clots) Cervical os is open Uterine contents are visible on pelvic examination Abdominal cramping pain
49
Describe an incomplete miscarriage
Uterine contents have begun to pass Cervical os is open Painful
50
Describe a complete miscarriage
Uterine cavity is empty Cervix has closed
51
Describe a missed/ delayed miscarriage
gestational sac contains a dead/ non viable fetes May be some light vaginal bleeding but usually n no pain Cervical os is open
52
What is the role of HCG in pregnancy?
Prevents involution of the corpus luteum which stimulates production of oestrogen and progesterone
53
What is the role of HCS in pregnancy and when is it produced?
Produced from week 5 of pregnancy Protein tissue formation Decreases insulin sensitivity in the mother (more glucose for the foetus) Involved in breast development
54
What is the role of progesterone in pregnancy?
Development of decidual cells Decreases uterus contractility Preparation for lactation
55
What is the role of oestrogen in pregnancy?
Enlargement of the uterus Breast development Relaxation of ligaments
56
What cardiovascular changes occur in the mother in pregnancy?
Increased CO Increased HR Increased contractility BP drops in the 2nd trimester
57
What haemolytic changes occur in the mother in pregnancy?
Plasma volume increases Erythropoiesis increases, HB is decreased in proportion - so overall decreases blood viscosity Iron requirements increase
58
What respiratory changes occur in the mother in pregnancy?
``` Increased C02 sensitivity in respiratory centres - Increased RR - Increased tidal volume (to lower C02 levels) - Decreased paC02 ``` Increased Pa02 (02 consumption) Respiratory alkalosis Decreased functional residual capacity
59
What urinary system changes occur in the mother in pregnancy?
GFR and renal plasma flow increase Increased re-absorption of ions and water Increase in urine formation
60
How do postural changes in the mother affect renal function in pregnancy?
Upright position decreases function Supine and lateral position (e.g when sleeping) increase function
61
Describe the hormonal control of lactation
Oestrogen and progesterone inhibit lactation before birth Prolactin stimulates milk production Oxytocin: 'milk let down reflex'
62
What are some of the possible reasons for a small for dates baby?
Pre-term delivery Intra-uterine growth restriction Small for gestational age
63
What are some of the causes of preterm birth?
Infection Over distention and cervical incompetence Vascular problems Intercurrent illness Idiopathic
64
What are some of the risk factors for having a pre-term birth?
Previous PTL (preterm labour) Multiple pregnancies Uterine anomalies Smoking, drugs Low BMI Maternal anaemia
65
What is a small for gestational age fetus?
Estimated fetal weight or abdominal circumference is below the 10th centile
66
What is meant by IUGR (intra uterine growth restriction)?
Failure to achieve growth potential
67
What are some of the clinical features of poor growth which might suggest IUGR?
Fundal height less than expected Reduced liquor Reduced fetal movements
68
When should a baby with IUGR be delivered?
If all is well, should still deliver by 37 weeks
69
What treatment can be offered for to mothers with a SGA fetus?
Steroids - Helps to promote fetal lung maturity Magnesium sulphate - Neurodevelopmental protection for the baby
70
What are some of the causes of large for dates fetus?
Wrong dates estimated Fetal macrosomnia Polyhydramnios Diabetes Multiple pregnancy Fibroid uterus Placenta praevia
71
What are the risks to the mother and fetus with fatal macrosomnia?
Labour dystocia Shoulder dystocia PPH
72
What is polyhydramnios?
Excess amniotic fluid
73
What are some of the possible causes of polyhydramnios?
Diabetes Viral infections Monochorionic twin pregnancy
74
What are some of the symptoms and signs of polyhydramnios?
``` Abdominal discomfort Prelabour rupture of membranes Preterm labour Cord prolapse Tense shining abdomen Inability to feel fatal parts ```
75
How is a large for dates baby diagnosed?
US Oral glucose tolerance test Serology : for toxoplasmosis, CMV etc Antibody screen
76
What are the risk factors for having multiple pregnancies?
Assisted conception African origin Increased maternal age Increased parity Tall women
77
What is the age range for cervical screening?
25-64
78
On abdominal palpation, the fundus of the pregnant uterus is normally palpable at how many weeks gestation?
12 weeks
79
Hyperthyroidism may cause what cardiovascular changes in pregnancy?
ST, SVTs, AF Should check TFTs in anyone presenting with palpitations in pregnancy
80
Phaeochromocytoma can be a cause of palpitations in pregnancy. How does it present? How is it investigated?
Headaches, sweating, hypertension Investigated with 24 hr catecholamines
81
What is the 1/3rds trend with asthma in pregnancy?
1/3 improve 1/3 deteriorate 1/3 remain unchanged
82
Long term PO steroid use for asthma in pregnancy (for >2 weeks) leads to what management being necessary in labour?
IV hydrocortisone is given during labour (the woman will not be able to produce her own response to the stress of labour naturally as she has been on synthetic steroids which has suppressed her natural steroid production)
83
What is the main direct cause of maternal death in the UK?
Thromboembolic disease
84
When is the highest risk of thromboembolic disease?
In the puerperium
85
What is Virchow's triad?
Stasis Hyper-coagulability Vascular damage
86
Where do DVTs usually occur?
LEFT leg Ileofemoral
87
What investigations should be done for a DVT?
FBCs, clotting, U&Es, LFTs Duplex US on the lower limb
88
How is a DVT managed?
TEDs LMWH
89
What are the symptoms of a PE?
Pleuritic chest pain Haemoptysis Faintness and collapse
90
What investigations should be done for a PE?
CTPA or V/Q ABGs, ECG Duplex US of the lower limb (to identify a DVT)
91
What are the possible CXR changes from a PE?
Atelectasis Effusion Focal opacities Regional oligaemia
92
When can LMWH vs warfarin be used?
LMWH Doesn't cross the placenta so safe in pregnancy Used for DVTs and PE in pregnancy Warfarin teratogenic Used post pregnancy Both heparin and warfarin are ok for breastfeeding
93
What is antiphospholipid syndrome?
Acquired type of thrombophilia - the clinical syndrome associated with the antibodies; aPL, aCL, LA
94
What are some of the clinical features of APS?
Arterial/ venous thrombosis Recurrent early pregnancy loss or a late pregnancy loss Placental abruption Severe early onset PET Severe early onset FGR
95
How is APS managed in pregnancy?
Aspirin and or heparin
96
Which drugs used for connective tissue disorders are NOT safe in pregnancy?
Methotrexate Gold, penicillamine Leflunomide Cyclophosphamide NSAIDs >32 weeks
97
What are some of the possible effects of diabetes on the fetus?
Macrosomnia Polyhydramnios Hyperinsulinaemia Polycythaemia (elevated RBCs) Fetal malformations
98
What changes to medications should be done for hypothyroidism in pregnancy?
Increase the levothyroxine dose by 25-50mcg in the first trimester
99
What are the effects of pregnancy on hyperthyroid women?
Get worse due to HCG in the first trimester Improves in the second and third trimesters Thyroid storm
100
What effects can hyperthyroidism have on the pregnancy?
IUGR Preterm labour
101
What is the presumed diagnosis if a woman has her first ever seizure in pregnancy?
Eclampsia
102
When is seizure risk highest in women with epilepsy in pregnancy?
Peripartum period
103
What supplements should all women with epilepsy be taking preconceptually and throughout pregnancy?
Folate | the mechanism of teratogenesis in epilepsy is thought to be folate deficiency
104
What are the reasons for deterioration of control of epilepsy in pregnancy?
Poor compliance with meds (fear of teratogenesis) Hyperemsis causes decreased drug levels Stress, pain, sleep derpivation and over-breathing increase the risk of seizures
105
With a BMI >30, what supplement should pregnant women be on?
5mg folic acid daily
106
What changes happen to BP throughout pregnancy?
BP falls in early pregnancy, peaking at 22-24 weeks BP then rises until term
107
What BP value is considered as hypertension in pregnancy?
140/90mmHg on 2 occasions OR 160/110 mmHg once
108
What are the causes of hypertension in pregnancy?
Pre-existing hypertension Pregnancy induced (gestational) hypertension Pre-eclampsia
109
How is pre-existing (essential) hypertension defined?
Present at booking or at <20 weeks gestation
110
How is pregnancy induced (gestational) hypertension defined?
New hypertension at >20 weeks gestation with no proteinuria
111
How is pre-eclampsia defined?
New hypertension at >20 weeks with significant proteinuria
112
What is the management for pre-eclampsia?
Treat hypertension (labetalol, methyldopa, nifedipine) Aspirin Deliver at 37 weeks
113
What is eclampsia?
Tonic-clonic seizures occurring with features of pre-eclampsia
114
How is eclampsia managed?
IV labetolol or IV hydralazine
115
What infusion can be given to prevent seizures in patients with eclampsia?
Magnesium sulphate IV
116
What is the main cause of maternal death in pre-eclampsia?
Pulmonary oedema
117
Which genetic test can be used to identify more or less chromosomal material (unbalanced) ?
Array comparative genomic hybridisation E.g used for trisomy conditions
118
What genetic test is used to identify balanced chromosomal rearrangements?
Next generation sequencing
119
What kind of sample is taken to test for Huntington's in pregnancy?
Chorionic villous sampling
120
if a fetus has a normal sized head but a small body, what is the likely cause?
Placental insufficiency
121
Antidepressants are generally not too bad in pregnancy, but which ones should be avoided if possible?
Paroxetine (1st trimester) Citalopram
122
Can benzodiazepines be used in pregnancy?
No -avoid when possible!
123
There is no evidence of fetal toxicity with antipsychotics but the fetus should be monitored for what signs?
Sedation and lethargy
124
What's the deal with lithium in pregnancy and breastfeeding?
Lithium should be avoided when possible Avoid stopping suddenly Don't use if breastfeeding
125
Which anticonvulsant is an absolute no in pregnancy but is not contraindicated for breast feeding?
Sodium valproate
126
What are the risks to the baby associated with the different anticonvulsants?
Sodium valproate and carbamazepine - risk of neural tube defects Lamotrigine - risk of oral cleft in pregnancy and Stevens Johnson syndrome with breastfeeding
127
What are the clinical features of fatal alcohol syndrome?
Micrognathia and smooth philtrum Lower IQ Microcephaly Dysplastic kidneys Ventricular septal defect Epilepsy Hearing loss
128
Bleeding in late pregnancy is considered to be from how many weeks?
From 24 weeks
129
What is antepartum haemorrhage (APH)?
Bleeding after 24 weeks gestation and before the end of the second stage of labour
130
What are some of the possible causes of APH?
Placental praevia placental abruption uterine rupture vasa previa local causes; polyps, cancer etc
131
How are minor, major and massive haemorrhage defined in terms of quantities?
Minor = blood loss <50ml Major = blood loss of 50-1000ml Massive = blood loss >1000ml and/0r signs of shock
132
What is placental abruption?
When the placenta detaches from the uterus before the birth of the fetus
133
What are some of the risk factors for placental abruption?
Pre-eclampsia/ hypertension Trauma Substance misuse Thrombophilias and renal disease
134
How does placental abruption present?
Severe continuous abdominal pain Preterm labour Maternal collapse Uterine tenderness/ 'woody hard' uterus/ fetal parts difficult to identify
135
What is placental praevia?
Placenta is partially or totally implanted in the lower uterine segment, covering the cervical os
136
What are some of the risk factors for placental praevia?
Previous C-section or TOP Multiple pregnancies, assisted contraception and multiparty Deficient endometrium e.g endometriosis
137
How does placental praevia present?
Recurrent painless bleeding in the 3rd trimester Uterus is soft and non-tender Presenting part is high/ malpresentation
138
In what circumstances should you do a C-section vs a vaginal delivery in women presenting with placental praevia?
C-section if placenta is <2 cm from the cervical os, vaginal delivery if >2cm from the cervical os
139
What is placental accreta?
The placenta is abnormally adherent to the uterine wall
140
How does placental accreta present?
Severe bleeding Mortality
141
How can placental accreta be managed?
Internal iliac artery balloon Caesarean hysterectomy
142
What are some of the risk factors for uterine rupture?
Previous C-section or uterine surgery Multiparity Obstructed labour
143
How does uterine rupture present?
Severe abdominal pain and shoulder tip pain Loss of contractions Acute abdomen Maternal collapse Fetal distress
144
What is vasa praevia?
Unprotected fatal vessels transverse the membranes over the internal cervical os
145
How does vasa praevia present?
Sudden dark red bleeding Fatal distress
146
How can vasa praevia be investigated for?
Examination to try to feel any vessels US doppler
147
How is vasa praevia managed?
Steroids Early elective c-section
148
What is post partum haemorrhage?
Blood loss >500ml after the birth of the baby
149
What are the 4Ts that cause post partum haemorrhage?
Tone Truama Tissue Thrombin
150
What management options are there for post partum haemorrhage?
Uterine massage Bimanual compression Packs and balloons Syntocinon IV Surgery
151
How should a suspected milk placental abruption be managed?
Admission, steroids and close observation
152
What are the recommendations for folic acid in pregnant epileptic women?
5mg of folic acid should be taken before and until 3 months after conception to reduce the risk of spina bifida
153
What happens to the volume of drug distribution in pregnancy?
The vole of drug distribution in pregnancy is increased by changes in plasma volume and fat stores
154
What are some of the risk factors for developing pelvic girdle pain (PGP) in pregnancy?
High BMI before pregnancy History of low back pain/ pelvic pain or trauma Hard physical labour PGP in previous pregnancy
155
What are the differences in pharmacokinetics in pregnancy? These things must be taken into account when prescribing in pregnancy
Absorption may be affected by morning sickness Increased plasma volume and fat stores increases the volume of distribution Decreased protein binding causes increased free drug in the circulation Increased liver metabolism of some drugs Elimination of renal excreted drugs increases
156
Give some examples of drugs which are teratogenic
ACE Inhibitors and ARBs Androgens Antiepileptics Lithium Methotrexate Warfarin
157
Which anti epileptics must be avoided in pregnancy?
Valproate Phenytoin
158
Which diabetes drug class is not safe for use in pregnancy?
Sulfonylureas
159
Pregnant women with significant risk factors for venous thromboembolism should be treated with what as prophylaxis?
LMWH
160
What adverse effect can tetracycline have when given in pregnancy?
Staining of the teeth
161
Phenytoin can cause what adverse effects when given in pregnancy?
Cleft lip and palate
162
Valproate can cause which adverse effects when given in pregnancy?
Anencephaly Spina bifida
163
What happens to BHCG levels in molar pregnancy?
BHCG is extremely high Causes hyperemesis
164
What happens to BHCG levels in ectopic pregnancy?
BHCG levels stay the same or increase slightly
165
A BHCG level of what suggests pregnancy?
>20LU
166
What are some of the possible causes of raised AFP in pregnancy?
Neural tube defects E.g anencephaly and meningocele Abdominal wall defects E.g omphalocele and gastroschisis Multiple pregnancy
167
What are some of the causes of decreased AFP levels in pregnancy?
Down's syndrome Trisomy 18 Maternal diabetes
168
Increased nuchal thickness may indicate which conditions?
Down's syndrome Congenital heart defects
169
How does obstetric cholestasis present?
Abnormal LFTS Pruritus in the absence of a skin rash
170
What is the most important first medication to administer for eclampsia?
Magnesium sulphate
171
What medication should be given to patients who have preterm prelabour rupture of membranes?
10 days erythromycin | same if they have a penicillin allergy
172
Which antibiotic used for UTIs is not safe in the first trimester of pregnancy?
Trimethoprim
173
Pregnancy induced hypertension refers to new hypertension presenting after what week of pregnancy?
Week 20
174
What are some of the test results that may be suggestive of down's syndrome?
Low AFP , estriol and PAPP-A High HCG Thickened nuchal translucency
175
Why are twin pregnancies and molar pregnancies associated with higher rates of hyperemesis gravidarum?
Twin pregnancies and molar pregnancies involve a greater placental mass which produces higher levels of BHCG - this hormone is associated with hyperemesis gravidarum.
176
Explain why oligohydramnios occurs
In growth restricted fetuses, chronic hypoxia due to impaired placental transfer leads to shunting of blood away from the kidneys towards other vital organs. This causes reduced urine output and low amniotic fluid levels (oligohydramnios).

REPRODUCTION (12 decks)

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