PREGNANCY Flashcards
What is placenta praevia?
low-lying placenta: overlying cervix os
How does placenta praevia present?
painless bleeding during late pregnancy or picked up on ultrasound
How do you manage placenta praevia?
most will resolve so rescan at 32 and 36 weeks
if not and complete –> c section
2 causes of haemolytic disease of the newborn
- rhesus
- kell
What is sensitivity?
ability to identify those with disease
- true positive
What is specificity?
abiltiy to identify those without the disease
- true negative
When is the booking visit?
around 12 weeks
What investigations are part of the booking visit?
check haemoglobin
confirm bood type and rhesus group
screen for STI and BBV - HIV/AIDs, syphilis, hepatitis B and C.
Urinalysis for UTI and diabetes
Culture and sensitivity of mid-stream urine
US
What does an ultrasound at 12 weeks look at?
- confirm viable pregnancy
- single or multiple pregnancy
- estimate gestational age
- detect major structural abnormality
OFFER: down syndrome screening
When is the second ultrasound normally carried out in pregnancy?
18-21 weeks
What does FASP screen look for?
anencephaly, open spina bifida, cleft lip, gastroschisis, edward’s and patau’s
–> not down’s
What Down’s screening is offered in the first trimester (11-14 weeks)?
CUBS (combined ultrasound and biochemical screening)
- looks at NT, HCG and PAAP-a
What Down’s screening is offered in the second trimester?
serum screening
- maternal age and biochemical markers
When can chromosomal diagnostic tests be carried out?
amniocentesis after 15 weeks
CVS after 12 weeks
What conditions cause a raised AFP?
multiple pregnancy, gastroschisis, spina bifida
When is the initial anti-D given?
28 weeks
What does the placenta develop from?
trophoblast and decidual tissue
When is the placenta functional?
week 5 onwards
What is the role of HCG in pregnancy?
prevents corpus luteum from degeneration so progesterone continues to be secreted
What is the role of progesterone in pregnancy?
development of decidual cells
decreases uterus contractility
preparation for lactation
What is the role of oestrogen in pregnancy?
enlarges uterus
breast development
relaxation of ligaments
What is the estriol level?
urinary oestrogen that is an indicator of fetal vitality and wellness
? chromosomal conditions
Which cardiac factors increase in pregnancy?
CO
heart rate
blood volume
stroke volume
Which cardiac factors decrease in pregnancy?
peripheral resistance
BP in 2nd trimester
Which respiratory factors increase in pregnancy?
oxygen demand and consumption
respiratory rate
tidal and minute volume
Which respiratory factors decrease in pregnancy?
PCO2
Functional residual capacity (due to diaphragmatic elevation)
Which acid/base disturbance is physiological in pregnancy?
respiratory alkalosis
inc ventilation > inc O2 consumption = hyperventilation
What are the 2 stages of metabolism during pregnancy?
week 1-20: anabolic, small demand
week 21-40: high demand, starvation
During which part of pregnancy is there insulin resistance?
week 21-40 due to HCS, cortisol and growth hormone
Which hormone is HCS and what is its role in pregnancy?
human chorionic somatomammotropin
- growth hormone-like (protein formation)
- dec insulin sensitivity
- breast development
During which part of pregnancy can there be increased insulin sensitivity?
week 1-20
What is the difference between insulin sensitivity and insulin resistance?
insulin sensitivity = interaction of insulin with its receptor, increased sensitivity means they need less insulin to lower blood glucose
insulin resistance = seen in type 2 diabetes where body doesn’t respond to insulin so high blood glucose
What type of hormone is insulin?
peptide
How is gestational diabetes diagnosed?
2 hour OGTT at 24-28 weeks
What are the diagnosis criteria for gestational diabetes?
Fasting glucose ≥ 5.1mmol/l
2 hour level ≥ 8.5mmol/l
What are the diagnosis criteria for normal diabetes?
Fasting glucose ≥ 7mmol/l
2 hour level ≥ 11.1mmol/l
HbA1c ≥ 48
Random glucose ≥ 11.1mmol/l
Which hormones increase contractility in labour?
oestrogen
oxytocin
mechanical stretch of myometrium and cervix
What controls onset of labour?
foetal hromones (oxytocin, adrenal hormones and prostaglandins)
What are the 3 stages of labour?
- cervical dilation (8-24 hours)
- passage through birth canal (few to 120 min)
- expulsion of placenta
Which hormones inhibit milk production?
oestrogen and progesterone
Which hormone causes enlargement of the mammary glands and stimulates milk production?
prolactin
Which hormone stimulattes milk ejection?
oxytocin
In which cardiac conditions should a woman not get pregnant?
pulmonary hypertension heart failure 3 and 4 cyanosis TIA/ arrythmia left heart obstruction aortic root >45mm Ejection fraction <40%
What additional drug needs to be provided for asthmatic patients who have been on steroids for more than 2 weeks?
IV hydrocortisone as their body can’t produce its own
If a pregnant woman has had a previous VTE how should she be managed?
prophylaxis with LMWH
Give risk factors for VTE in pregnancy
obesity, age>35, parity>3, smoker, varicose veins, current pre-eclampsia, immobility, first degree relative, low-risk thrombophilia, multiple pregnancy, IVF
When is prophylactic LMWH given if a woman has
a) 4 or more risk factors?
b) 3 risk factors?
a) first trimester
b) 28 weeks
What is Virchow’s triad?
hypercoagulability
venous stasis
vascular damage
What is anti phospholipid syndrome?
Elevated antiphospholipid antibodies cause thromboses and pregnancy-related morbidity
Which antibodies are associated with APS?
lupus anticoagulant, anticardiolipin antibody, and/or anti-beta2-glycoprotein
When should we suspect APS?
any young patient with arterial thrombosis.
unexplained venous/arterial events,
foetal death after 10weeks, premature birth due to severe preeclampsia,
unexplained thrombocytopaenia
How is APS diagnosed?
clinically (any vascular thrombosis or pregnancy morbidity:
≥ 3 miscarriages <10 weeks
≥ 1 fetal loss >10 weeks (morphologically normal fetus)
≥1 preterm birth (<34 weeks) due to PET or utero-placental insufficiency
lab (confirm twice, 6 weeks apart)
IgM/ IgG aCL
LA
How is APS treated?
with life-long warfarin (LMWH in pregnancy)
also give low dose aspirin in pregnancy
When is the placenta the sole source of fetal nutrition?
6 weeks - birth
What is the cut-off between early and late bleeding in pregnancy?
24 weeks
How much blood is lost in a) minor b) major c) massive haemorrhage ?
a) <50ml
b) 50-1000ml
c) >1000ml +/- shock
What is a couvelaire uterus?
a life-threatening condition where the uterus forces into the peritoneal cavity following placental abruption with bleeding into the myometrium
What is the normal position of the foetal head in labour?
OA
How do you manage normal labour with reassuring CTG but meconium stained liquor?
reassure and reexamine in 2 hours
What supplements should all pregnant women take?
folic acid 400mcg and Vitamin D 10mcg daily during pregnancy.
- 5mg folic acid if diabetic, epileptic…
What happens to blood pressure in pregnancy?
The blood pressure decreases in the second trimester due to the expansions of uteroplacental circulation and decreased peripheral resistance.
it returns to normal by the third trimester
What happens to erythropoiesis and haemoglobin in pregnancy?
erythropoietin increases by 25%
haemoglobin reduced by dilution
What happens to the vital capacity of the lungs in pregnancy?
stays the same
What is placenta accreta?
placenta is abnormally attached to uterine wall. As the placenta does not properly separate during labour there is a risk of post-partum haemorrhage.
How do you investigate placenta accreta?
MRI
What is placental abruption?
when the placenta partly or completely separates from the uterine wall before birth
How does placental abruption present?
continuous, severe abdo pain
bleeding
large, tense uterus
How does uterine rupture present?
severe abdominal pain shoulder tip pain maternal collapse PV bleeding acute abdomen foetal distress
Causes of IUGR
smoking
IVF
PMH
low maternal BMI
When is the fundus normally palpable?
12 weeks
What is the landmark to administer a pudendal nerve block?
ischial spine
management for minimal bleeding from suspected mild placental abruption , not in labour, and a normal fetal well being at 32 weeks
admit
give steroids
monitor closely
risk factors for pre-eclampsia
maternal age >40 multiple pregnancy family history first pregnancy long birth interval Bilateral abnormalities of Maternal Uterine Artery Doppler waveform at 20 weeks gestation
Does pelvic girdle pain in one pregnancy put you at risk of it for subsequent pregnancies?
no
In Down syndrome what would the expected values be for
a) HCG?
b) PAAP-a?
c) nuchal thickness?
d) estriol?
a) high
b) low
c) above 3.5
d) low
Treat UTI in pregnancy
trimester 1-2: nitrofurantoin
trimester 3: trimethoprim
Presentation of mastitis
unilateral pain
breast engorgement + erythema in wedge-shaped distribution
Sudden collapse after AROM
amniotic fluid embolism
If urine dip shows ++ proteins, what blood tests are needed to diagnose pre-eclampsia?
Full blood count, urea & electrolytes and liver function tests
Which condition presents with preterm-PROM with a triad of maternal pyrexia, maternal tachycardia, and fetal tachycardia
chorioamnionitis
Which oral hypoglycaemic agent can be continued in pregnancy?
metformin
Investigate placenta praevia
transvaginal ultrasound
is lithium contraindicated in breast-feeding?
yes
What is the normal birth weight for a
a) baby born at 28 weeks?
b) term baby?
a) 1150g
b) 3550g
Which foetal abnormalities are T1DM more at risk of?
neural tube defect eg spina bifida
cardiac abnormality
What is the normal fundal height?
gestation +/-3cm
Which antihypertensives can be used in pregnancy?
methyldopa, labetalol
nimodipine second line
Why are ACE-inhibitors contraindicated in pregnancy?
damage to foetal kidneys
How can we classify the causes of PPH?
4Ts tone trauma tissue thrombin
What is Asherman’s syndrome?
scar tissue in the uterus
What is sheehan’s syndrome?
pituitary necrosis due to blood loss
How long is labour on average for
a) prim?
b) multi?
a) 8
b) 5
What weeks are
a) trimester 1?
b) trimester 2?
c) trimester 3?
a) 0-12
b) 13-26
c) 27-birth
What congenital defect is most linked with t1dm?
Neural tube eg spina bifida
