Pregnancy Flashcards
Describe the Excitement Phase of Coitus
Vaginal Lubrication
Clitoral Engorgement
Inner 2/3 of Vagina lengthens and expands
Describe the Plateau Phase of Coitus
Further increase in muscle tone/HR/BP
Bartholin Gland Secretion
Describe the Orgasmic Phase of Coitus
Orgasmic platform contracts rhythmically 3-15 times
Describe the resolution phase of Coitus
Everything returns to normal
No refractory period so multiple orgasms possible
Describe the 6 stage process of conception
1) Sperm is deposited at External Os, where it stays in reservoir at posterior fornix, becoming more liquified
2) Oxytocin stimulates Uterine Contraction along with sperms own propulsive movements
3) Sperm becomes capacitated (changes from beat to whip like action, exposes acrosome enzymes)
4) Sperm binds to ZP3 protein on Zona Pellucida allowing Calcium to enter, increasing CAMP
5) Proteolytic enzymes are released, allowing penetration of Zona Pellucida
6) Increased Calcium causes egg cell membrane to depolarise (preventing polyspermy), cortical reaction causes secondary block
State four endocrine Maternal adaptations in Pregnancy
Increased Oestrogen
Increased Progesterone
Increased Thyroid Binding Globulin
Increased Anti Insulin Hormones
What is the role of increased Oestrogen in pregnancy?
Increases breast tissue growth
Water Retention
What is the role of increased Progesterone in pregnancy?
Relaxes smooth muscle
What is the effect of increased Thyroid Binding Globulin in Pregnancy?
Oestrogen causes the increase in TBG
Results in more T3/T4 binding, and subsequently less free T3/T4
TSH then increases, to bring free T3/T4 up to normal level
So overal free T3/T4 remains the same but total T3/T4 increases
Important as baby’s thyroid gland doesn’t function until second trimester therefore is reliant on maternal hormones until that point
Name three Anti Insulin Hormones
Human Placental Lactogen
Prolactin
Cortisol
Why are Pregnant Women at increased risk of Ketoacidosis?
Mother switches to lipids as an alternative source of energy to conserve free glucose for foetus
State 5 Maternal CVS changes in Pregnancy
Blood Pressure (drops for first and second, rises slightly for third)
Cardiac Output increases by around 40%
Plasma Volume Increases
Varicose Veins (Uterus compresses pelvic veins)
Maximum intensity shifted to left (diaphragm pushes on Heart)
Why does blood pressure decrease in early trimesters?
Due to Progesterone causing relaxation of Smooth Muscle
Why does Plasma Volume increase in Pregnancy? What happens as a result?
Increased RAAS stimulation increasing salt and water reabsorption
Gestational Anaemia due to reduced haematocrit
State four respiratory changes in Pregnancy
Tidal Volume increases
Minute Ventilation increases by around 15%
Hyperventilation resulting in Resp Alkalosis
Vascular Engorgement (Nasal Stuffiness, Nose Bleeds)
State four Maternal changes to GI System in Pregnancy
Relaxation of Smooth Muscle (Heart Burn, Constipation, Biliary Tract Stasis - Gall Stones)
Upward displacement of Stomach
Appendix may move to RUQ
High bHCG may cause morning sickness
State three Renal Maternal Adaptations in Pregnancy
GFR increased by around 55% (due to increased plasma volume)
Smooth Muscle Relaxation causes Hydronephrosis/Hydroureters
Increased risk of UTI
State three Haematological changes in Pregnancy
Increase in Fibrinogen/Clotting Factors
Increased Venous Stasis/Venodilation
Gestational Anaemia
Describe the two different types of nutrition during foetal life
Histiotrophic - up to 12th week (not from maternal blood)
Haemotrophic - after 12th week (from maternal blood)
Where is Brown Fat stored?
Around neck
Behind Scapulae
Sternum
Around Kidneys
How should the foetus appear at 12 weeks?
Skin translucent
Reactant to stimuli
External Genitalia undifferentiated
How should the foetus appear at 16 weeks?
CRL of 122mm
External Genitalia now distinguishable
How should the foetus appear at 24 weeks?
CRL is 210mm
Eyelids separated
Skin Opaque
How should the foetus appear at 28 weeks?
Eyes are open
Scalp growing hair
What is the Embryonic vs Gestational Age?
Embryonic - time since fertilisation
Gestational - Time since LMP (ie: Embryonic + 2 weeks)
Describe the three periods of foetal development
Germinal Stage - first two weeks
Embryonic Period - Start of third to end of 8th week
Foetal Period - Start of 9th until birth
Describe the 6 stages of placental development
1) Blastocyst hatches and dedidual reaction occurs
2) Trophoblast differentiates into Cytotrophoblast and Syncytiotrophoblast
3) Lacunar network of maternal spiral arteries forms in Syncytiotrophoblast, Primary Chorionic Villi form (Inner Cytotrophoblast invading Outer Syncytiotrophoblast)
4) Mesenchyme core develops in villi (secondary chorionic villi)
5) Which then develops into blood vessels (tertiary chorionic villi)
6) Throughout the latter trimesters the barrier thins and Cytotrophoblast is lost
What are the two parts of the placenta?
Maternal - Decidua Basalis
Foetal - Chorion Frondosum
How does the placenta appear at full term?
15-25cm
500-600g
What is the Umbilical Cord?
Paired Arteries and a Vein embedded in Wharton’s Jelly
State a substance that is transported across the placenta by simple/active and facilitated transport respectively
Simple - Oxygen
Active - Amino Acids
Facilitated - Glucose
What is the endocrine function of the Placenta?
hCG to maintain corpus luteum
Produced Oestrogen and Progesterone to maintain pregnancy from 4th month
HPL
How do you calculate EDD
LMP + 1 year and 7 days, minus 3 months
State four signs you might see on Inspection in an Obstetric Exam
Linea Nigra (pigmented line from Xiphisternum to Suprapubic)
Striae Gravidarum (new, purple)
Striae Albicans (old, white)
Flattening/Eversion of Umbilicus
State five features of palpation on an Obstetric Examination
Symphysis Fundal Height (able to measure this from 20 weeks)
Estimation of Foetal Number
Foetal Lie
Presentation
Amniotic Fluid Volume
How would you listen the Foetal heart in an Obstetric Examination?
From 16 weeks - Doppler USS, Sonicaid
From 28 weeks - Foetal Stethoscope
State 6 symptoms of Pregnancy
Amenorrhoea
Morning Sickness
Increased Micturition Frequency
Excess Fatigue
Breast Tenderness
Pica
Describe the pattern of hCG in Pregnancy
Increases exponentially from day 8
Peaks at 8-12 weeks
Home (Urine) Kits are sensitive to levels >50IU/L
How is a pregnancy dated?
Via the Dating scan between 8-13 weeks, using CRL
What else should be offered at the dating scan (if not already)?
Urine screen for Pre- Eclampsia
Haemoglobinopathy screen
Rhesus screen
Downs Syndrome Screen
When would you carry out the Structural Anomaly Scan? Y
Between 18-20 weeks
What should be done at the 28 week scan?
Another opportunity for Anaemia/ Atypical Antibody screening
Anti D Prophylaxis if Rhesus Negative
Measure BP/Proteinuria/SFH
When should you offer a second dose of Anti D?
At 34 weeks
What Supplements does a Pregnant Woman require?
Folic Acid - 400mcg/d for the first 12 weeks to minimise risk of neural tube defects
Iron/Iodine - only if deficient area
Zinc&Calcium - if dairy free
Vitamin A - can be teratogenic if >700mcg/d
She requires an extra 350kcal a day
Name four foods a pregnant woman should avoid
Pâté
Soft Cheeses
Raw Fish
Unpasteurised Milk
Other than CRL, name four other USS measurements
Biparietal Diameter
Head Circumference
Abdominal Circumference
Femur Length
Define ‘Small for Gestational Age’
Infant with weight <10th centile for its gestational age
State the three types of Small for Gestational Age
Normal/Constitutionally Small (growing at a normal rate but just small)
Placenta Mediated Growth Restriction (Normal growth that initially slows due to placental insufficiency - substance abuse/autoimmune/diabetes/ renal disease)
Non Placenta Mediated Growth Restriction (Chromosomal/Structural Abnormalities)
Give three minor and three major risk factors for ‘Small for Gestational Age’
Minor - Nulliparity, Previous Pre - Eclampsia, Low fruit intake pre pregnancy
Major- Smoker>10 per day, Maternal Age>40, Previous SGA baby
How would you investigate a suspected SGA baby?
Ultrasound Scan
Uterine Artery Doppler
Karyotyping
Why is the ratio of HC:AC important in SGA babies?
If constitutionally small, they are likely to be similar
If placental insufficiency it’s likely to be asymmetrical/head sparing
How often should an SGA baby be monitored?
At least every 14 days
When should an SGA be delivered by C Section before 37 weeks?
If Absent Doppler or Reverse End Diastolic
State four complications of SGA baby
Asphyxia
Hypothermia
Cerebral Palsy
Precocious Puberty
Give three examples of sensitising events with Red Cell Isoimmunisation
Antepartum Haemorrhage
Abdominal Trauma
Delivery
What is Anti-D and when should it be given?
Binds to Rhesus D Antibodies preventing immune response
Should be given after ANY sensitising event in Rhesus Negative Women
Even if no sensitising event, should be given at 28 and 34 weeks in Rhesus Neg Women
What is the Fetomaternal Haemorrhage test?
Assesses how much foetal blood has entered maternal circulation
If occurring after 20 weeks it is used to assess how much Anti D is required
What sort of sensitising events could occur before 12 weeks?
Ectopic Pregnancy
Molar Pregnancy
Termination of Pregnancy
Heavy Bleeding
Define Prematurity
Delivery between 24 and 37 weeks gestation
(Very preterm is <32 weeks)
What is PPROM (Preterm Prelabour Rupture of Membranes)?
Rupture of foetal membranes before 37 weeks and before labour onset
Give 5 associations of prematurity
Multiple pregnancies
Foetal Growth Restriction
Iatrogenic
Cervical Incompetence
Systemic Maternal Infection (bacterial toxins initiate inflammatory response and release of prostaglandins)
Name three ways you can identify women at risk of prematurity
Clinical Risk Scoring (smoking status, socioeconomic, pmh)
Cervical Assessment - short is high risk
Foetal Fibronectin (maintains placental decidual matrix)
Give three ways that you could PREVENT preterm labour
Antibiotics
Cervical Cerclage (purse string)
Progesterone (Antagonises Oxytocin, Anti Inflamm, Maintains Integrity)
How can you INHIBIT pre term labour (AKA Tocolysis)?
Nifedipine
Oxytocin Antagonist (Atosiban)
COX Inhibitors (may cause problems with DA as required to be patent)
What is Prolonged Pregnancy?
Refers to the 5-10% of pregnancies persisting beyond 42 weeks gestation
Give three clinical features of prolonged pregnancy
Macrosomia
Reduced foetal movement
Meconium
How would you manage Prolonged Pregnancy?
Membrane sweeps 40 weeks in nulliparous and 41 weeks in parous
Induction of labour between 41 and 42 weeks
Any signs of placental insufficiency- deliver
Define Miscarriage
The loss of pregnancy at less than 24 weeks gestation (early - before 12 weeks)
Does not include Ectopic/ GTD
What are the 6 classifications of Miscarriage
Threatened - USS is viable
Inevitable - likely to proceed to complete/incomplete
Missed (Early Foetal Demise)- No foetal heart beat when CRL>7mm
Incomplete - POC partially expelled
Complete - No POC on USS
Septic - Infected POC
How might a Miscarriage present?
Vaginal bleeding (may be passing clots or POC)
Suprapubic Cramping
May have annexal masses/collections
What imaging would you use to investigate a Miscarriage?
Transvaginal Ultrasound
If CRL>7mm and Gestation 5.5-6.5 weeks, a feral heartbeat should be heard
If foetal pole not visible, confirmed presence with gestational and yo,m sac (if greater than 25mm - likely miscarriage)
What would the bloods of a Woman who has just miscarried show?
Declining Serum b-HCG
Low Progesterone
Describe the conservative/expectant management of Miscarriage, it’s advantages and disadvantages
Anti D and Allow POC to pass naturally, repeat scan in two weeks/pregnancy test three weeks later
Advantages: can remain at home, no anaesthetic or surgical risk
Disadvantages: unpredictable, heavy bleeding, chance of failure
Describe the Medical management of a miscarriage, it’s advantages and disadvantages
Uses Misoprostol (PG Analogue) to stimulate cervical ripening and myometrial contractions
Advantages: Can be done at home, avoids surgical/anaesthetic risk
Disadvantages: Vomiting, Heavy Bleeding/ Pain, chance of requiring op
Describe the surgical management of a Miscarriage, it’s advantages and disadvantages
If under 12 weeks, manual vacuum aspiration with local anaesthetic. If over 12 weeks, evacuation of retained products of conception under GA
Advantages: Planned Procedure, Unaware During
Disadvantages: Anaesthetic risk, Perforation, Haemorrhage, Ashermans
When is surgical management of Miscarriage indicated?
Haemodynamically Unstable
Infected Tissue
Gestational Trophoblastic Disease
Define Recurrent Miscarriage
Occurrence of three or more consecutive pregnancies that end in the miscarriage of the foetus before 24 weeks
State 5 causes for Recurrent Miscarriage
Antiphospholipid Syndrome
Genetic Abnormalities (eg Robertsonian)
Endocrine (PCOS, Thyroid Disease, DM)
Anatomical (Uterine Malformations, Ashermans)
Inherited Thrombophilias
Give 3 risk factors for recurrent miscarriage
Advancing Maternal Age
Number of Previous Miscarriages
Smoking
Name three investigations for recurrent miscarriage
Bloods (Lupus/Anti Cardiolipin/Anti B2 Glycoprotein/Inherited Thrombophilia Screen)
Karyotyping (can test parents if foetus comes back abnormal)
Pelvic USS
Describe the genetic counselling given to women suffering from recurrent miscarriage
Offers prognosis for future pregnancies
Offers other reproductive options
If the cause of the recurrent miscarriage is Cervical Weakness how would you manage?
Cervical Cerclage
If the cause of the recurrent miscarriage was Antiphospholipid Syndrome, how would you manage?
Low dose Aspirin (from positive pregnancy test)
LMWH (from foetal HB)
What is an Ectopic Pregnancy?
One occurring anywhere outside the uterus (most commonly ampulla and isthmus)
Can coincide with Intrauterine Pregnancy - Heterotropic Pregnancy
What is a Cornual Pregnancy?
Pregnancy in the rudimentary horn of the uterus (technically uterine but ectopic)
Give 5 risk factors for Ectopic Pregnancy
Previous Ectopic
PID
Endometriosis
Progesterone only contraception (alters fallopian ciliary motility)
Assisted Reproduction
How would a (non ruptured) Ectopic Pregnancy present?
Pelvic Pain
Vaginal Bleeding (due to reduced HCG)
Shoulder tip pain
Brown vaginal discharge
How would a ruptured Ectopic Pregnancy present?
Haemodynamically unstable
Peritonism
Fullness in PoD during Vaginal Exam
Give 3 differentials for an Ectopic Pregnancy
Miscarriage
Ovarian Torsion
Acute PID
How would you investigate a suspected Ectopic Pregnancy?
1) Pregnancy Test
2) Transvaginal USS (if nothing is seen then it is termed Pregnancy of Unknown Location)
What is Pregnancy of Unknown Location and how can you investigate?
Could be an ectopic, a very early intrauterine pregnancy or a miscarriage
If serum HCG>1500 IU - Offer diagnostic laparoscopy
If serum HCG<1500 IU - as long as patient is stable, do repeats (miscarriage halves every 48hrs, viable doubles)
How are Ectopic Pregnancies managed medically?
IM Methotrexate - disrupts folate metabolism causing pregnancy to resolve, may require repeat dose
Remains teratogenic so should not aim to conceive for the following 6 months
How are tubal ectopics managed?
Laproscopic Salpingectomy
When could you manage ectopics with a conservative approach?
Stable patients with well controlled pain
Low baseline hCG
What is Gestational Trophoblastic Disease?
Spectrum of diseases caused by placental overgrowth
Pregnancy related tumours
Define Hydatidiform Moles (Partial and Complete)
Premalignant tumours that can become invasive
Partial - One ovum is fertilised by two sperm causing triploidy, foetus may be present
Complete - One ovum with no chromosomes is fertilised by a sperm which then duplicates itself (all paternal origin)
How are Hydatidiform Moles diagnosed?
Irregular first trimester bleeding
Large uterus for dates
Pain
Excessively high serum hCG
USS - complete =snowstorm
How are Hyatidiform Moles managed?
Surgical evacuation and histological analysis of POC
Chemo if: persistently high HCG >4 weeks later, persistent symptoms, metastases evidence, choriocarcinoma evidence
Name three malignant Gestational Trophoblastic Diseases
Choriocarcinoma
Placental Site Trophoblastic Tumours
Epithelioid Trophoblastic Tumour
Why do Choriocarcinomas present with Dyspnoea?
Metastases to lung
Give three risk factors for GTD
COCP
Maternal Age<20 and >35
Previous Miscarriage
Define Placental Abruption
Where all/part of the placenta separates from the uterine wall prematurely
Important cause of antepartum haemorrhage
Define Antepartum Haemorrhage
Vaginal bleeding from 24 weeks
Describe the pathophysiology of Placental Abruption
Maternal vessels in basal layer of endometrium rupture
Blood accumulates and splits placental attachment from basal layer
What are the two types of Placental Abruption?
Revealed - bleeding drains through cervix causing vaginal bleeding
Concealed - bleeding remains in uterus and clots retroperitoneally (can cause shock)
Give three risk factors for Placental Abruption
Pre-eclampsia
Abnormal lie
Trauma
How would Placental Abruption present?
Painful vaginal bleeding
If woman is in labour, enquire about pain between contractions
What is Vasa Praevia and how would it present?
Where one of the branches of the foetal umbilical vessels lies across cervical os
Triad: Painless Vaginal Bleeding, Rupture of Membranes, Foetal Compromise
Give three differentials for Antepartum Haemorrhage
Placenta Praevia
Vasa Praevia
Uterine Rupture
How would you investigate Placental Abruption?
Haematology: FBC, Clotting, U and Es , LFTs, Foetal Maternal Haemorrhage test, Group and Save
CTG foetus is greater than 26 weeks
How would you manage Placental Abruption?
Emergency delivery if any sign of compromise
Induction of labour (if at term with no compromise)
Anti D if Rhesus Neg
What is Couvelaire Uterus?
Bleeding penetrates uterine myometrium, forcing way into peritoneal cavity
What is Placenta Praevia?
Placenta is fully or partially attached to lower uterine segment
A common cause of Antepartum Haemorrhage
Describe the pathophysiology of Placenta Praevia
Delay in implantation of blastocyst causing it to implant in lower uterus
Can be minor or major (major covering the os)
Give three risk factors for Placenta Praevia
High Parity
Previous Caesarean
Maternal age>40
How does Placenta Praevia present?
Painless Vaginal bleeding (varies between spotting and massive haemorrhage)
Pain helps differentiate it from Placental Abruption
How is Placenta Praevia Managed?
C Section at 38 weeks
Anti D within 72hrs of onset
Give three physiological causes of abdominal pain in Pregnancy
Stretching of abdominal muscles and ligaments
Constipation
Braxton Hicks
Why is Heartburn common in pregnancy and how should it be managed?
Delayed gastric emptying, reduced LOS pressure, increased intra-abdo pressure
Conservative and Antacids/PPI/H2 blockers
Why does Syncope occur in pregnancy and how should it be managed?
Relaxation of smooth muscle from progesterone, Caval pressure when lying down
Avoid prolonged standing/supine/dehydration
Why do Variscocities occur in pregnancy and how should they be managed?
Due to the pressure on Pelvic Veins from Uterus and the effect of Progesterone relaxing Smooth Muscle
Elevation and Compression stockings
If other risk factors - prophylactic heparin
Why is Carpal Tunnel common in pregnancy?
Due to fluid retention causing compression of Median Nerve
What is Pelvic Girdle Dysfunction?
Relaxin causes expansion of Pelvic Ring for birth, can be exaggerated in some causing discomfort
Characteristic pain on walking/standing with tenderness over pelvic ring
Define Oligohydramnios
Amniotic fluid index that’s below the 5th centile for gestational age
Describe the production of amniotic fluid throughout gestation
Early - dialysate of foetal and maternal components
Later - after onset of kidney function it’s primarily foetal urine
Foetus breathes and swallows the fluid
Volume increases until 33 weeks, and then it plateaus before declining
Give 3 causes of Oligohydramnios
Preterm Membrane Rupture
Placental Insufficiency
Non functioning Kidney
How should you use Ultrasound to examine Oligohydramnios ?
Amniotic Fluid Index - maximum vertical pockets of fluid in four quadrants and add them together
Maximum Pod Depth - vertical measurements in any area
Look for any structural abnormalities, renal agenesis, foetal size (placental insufficiency)
If you thought Membrane Rupture was a cause of Oligohydramnios, what could you measure?
IGFBP-1
Protein found in amniotic fluid
What is the prognosis of Oligohydramnios and how should it be managed?
If due to placental insufficiency, likely to be delivered before 36 weeks
Amniotic Fluid allows foetal limb movement, without this ability you get muscle contracture
Define Polyhydramnios
Amniotic fluid above the 95th centile for gestational age
Causes higher incidence of PPH and Malpresentation
Give five causes of Polyhydramnios
Oesophageal Atresia
Macrosomia
Maternal Diabetes
Maternal ingestion of Lithium (DI)
TORCH Infections (Toxoplasmosis, Other, Rubella, CMV, Hepatitis)
Describe the management for Polyhydramnios (if required)
Amnioreduction - only if maternal symptoms are severe
Indomethacin - enhances water retention and reduced foetal urine, can cause closure of PDA so cant be used after 32 weeks
If idiopathic the baby must be checked by paediatrician to check for fistula etc
What is a Monozygotic Twin Pregnancy
One ovum splits
Both embryos have the same gender
If within first four days there will be two chorions
What is a Dizygotic Twin Pregnancy?
Fertilisation of separate Ova by different sperm
Can share a placenta (risk of twin twin transfusion - one is oliguric and growth restricted and the other is at risk of Polyhydramnios and cardiomegaly) or have two
Describe some complications of Multiple Pregnancy
IUGR
Pre - Eclampsia
Vanishing Twin Syndrome (resorption of foetus between 6 and 10 weeks)
How is Twin to Twin transfusion treated?
Serial Amniocentesis
Laser ablation of communicating vessels
Define Pre- Eclampsia
Placenta disease causing a hypertensive disorder
Describe the pathophysiology of Pre- Eclampsia
Decidual reaction is incomplete leading to low flow in high resistance spiral arteries
This causes hypertension, hypoxia and oxidative stress
Give three high risk factors for Pre- Eclampsia
Chronic Hypertension
Previous CKD
Pre-eclampsia in previous pregnancy
Prophylaxis with 75mg Aspirin from 12 weeks
What are the three clinical criteria for Pre-Eclampsia
Hypertension - at least >140/90 on two occasions more than four hours apart
Significant Proteinuria - >300mg protein over 24hrs or urinary p:cr>30
Greater than 20 weeks gestation
Give four other symptoms of Pre Eclampsia
Headaches
Visual Disturbances
Epigastric Pain (Hepatic Capsule Distension)
Oedema
What antihypertensives should be used in Pre- Eclampsia?
1) Labetolol
2) Nifedipine
3) MethylDopa
Describe the Post Natal care of a pre-eclamptic patient
Not considered safe until 5 days after delivery
Monitor BP daily for first two days, then once every 3-5 days, reassessing need for antihypertensives
Advise of risk in further pregnancies
What is HELLP Syndrome?
Haemolysis (tea coloured urine)
Elevated Liver Enzymes
Low Platelets
A complication of Pre- Eclampsia
How would you manage HELLP
If less than 34 weeks - MgSO4 for lung development and supportive
DELIVER
Platelet infusions only if bleeding or going for surgery
What is Hyperemesis Gravidarum?
Persistent and severe vomiting in pregnancy leading to weight loss,dehydration and electrolyte abnormalities
bHCG stimulates CTZ and vomiting centre
Give four risk factors for Hyperemesis Gravidarum
First Pregnancy
Raised BMI
Multiple Pregnancies
Hyatidiform Mole
How is Hyperemesis Gravidarum Scored?
PUQE - Pregnancy Unique Quantification of Emesis
Mild - 6
Moderate - 7 to 12
Severe - 13 to 15
Describe the management of Hyperemesis Gravidarum
Oral Antiemetics (first line cyclizine, promethazine, prochlorperazine, chlorpromazine)
May require IV rehydration
Consider Thiamine and Thromboprophylaxis depending on severity
What is Gestational Diabetes?
Any degree of glucose intolerance with onset/first recognition in pregnancy
Occurs when women are unable to respond to the physiological insulin resistance in pregnancy (due to borderline pancreatic reserves)
How does Gestational Diabetes present in the mother?
Asymptomatic or classic diabetes triad
Describe four foetal manifestations of Gestational Diabetes
Macrosomia
Organomegaly
Polycythaemia
Polyhydramnios
How is Gestational Diabetes diagnosed?
OGTT
Fasting Glucose >5.6 mmol/l
2hrs Post Prandial >7.8 mmol/l
Offered at booking if previous, 24-28 weeks if risk factors and at any point if glycosuria
How is Gestational Diabetes managed?
Lifestyle advice and BGC measured qts
Metformin
Insulin if fasting glucose >7 mmol/l
Additional growth scans at 28,32,36 weeks and aim to deliver at 37 and 38 weeks
Describe the antenatal screening for Rubella Virus
Via ELISA
IgM - indicates acute infection
IgG - present following infection/vaccination
If neither present then give Post Delivery Rubella Vaccine (live vaccine so not when pregnant)
How does the mother with Rubella present?
Often asymptomatic
Malaise/Headache/Coryza/Lymphadenopathy
Describe the features of Congenital Rubella Syndrome at birth
Sensorineural Deafness
Pulmonary Stenosis
Retinopathy
Learning Disabilities
Thrombocytopenia
Describe the late onset features of Congenital Rubella Syndrome
Diabetes Mellitus
Thyroiditis
GH abnormalities
Behavioural Disorders
How should a foetus with Rubella be managed?
<12 weeks - consider ToP
12-20 weeks - ToP or US Surveillance
>20 weeks - no action required
Describe the epidemiology of CMV in pregnancy
1 in 100 Women become infected in Pregnancy
1/3 of maternal infections are transmitted vertically
5% of foetal CMV causes actual damage
Describe the maternal clinical features of CMV
Asymptomatic
Or
Mononucleosis Syndrome (fever, splenomegaly, impaired liver function)
Describe the early and late features of Congenital CMV
Early: IUGR, Hepatosplenomegaly, TTP, Jaundice
Late : Sensorineural deafness, Psychomotor delay
How should you treat the mother infected with CMV?
No treatment required as long as immunocompetent
Generally licensed CMV drugs have potential toxicity and teratogenicity
How should a foetus diagnosed with CMV (via amniotic fluid PCR) be managed?
Offered ToP
Can trial with IV CMV specific hyper immune globulin
Describe the epidemiology of Parvovirus in Pregnancy
1 in 400 get infected during Pregnancy
1/3 transmitted vertically
9% miscarriage or IUGR
How does Parvovirus present in the mother?
Normally asymptomatic
May get Symmetrical Arthralgia
How would you manage foetal Parvovirus?
Serial Ultrasound and Dopplers
Any sign of Hydrops - intrauterine erythrocyte transfusion
What is Foetal Hydrops?
Abnormal accumulation of fluid in more than one foetal compartment (ie ascites, subcutaneous oedema, pleural effusion, pericardial effusion, scalp oedema, Polyhydramnios)
Describe the clinical features of Primary Varicella Zoster infection
Fever, Malaise, Maculopapular Rash
Infectivity is from 48hrs before vesicles appear to crusting
What is Varicella of the Newborn and how is it treated?
Occurs within the last four weeks of pregnancy
Can be asymptomatic
Treated with VZIG with or without Acyclovir
What is Foetal Varicella, how does it present and how is it treated?
Reactivation of virus in utero as Herpes Zoster
Skin scarring in dermatomal distribution, Eye Defects, Limb Hypoplasia, Microcephaly, Seizures
What should you do if a pregnant woman has had a suspected Varicella contact?
Previous infection - no action required
No Previous Infection - IgG test for immunity
Not Immune? - VZIG within 10days/before rash
When can you give a Varicella vaccination?
Pre or Post Partum only
What is Group B Strep Infection
Streptococcus Agalactiae
Commensal bacterium found in Vagina/Rectum of around 25% pregnant women
Generally causes no symptoms in mother but infection of neonate
May cause Chorioamnionitis/Endometritis in Mother
Give four risk factors for neonatal GBS infection
GBS infection in previous baby
Prematurity <37 weeks
Rupture of membranes >24 hrs before delivery
Pyrex is during labour
How would Chorioamnionitis and Endometritis present respectively?
Chorioamnionitis - fevers, lower abdo tenderness, foul discharge
Endometritis - Fever, Lower abdo pain, intermenstrual bleeding
How would Neonatal GBS present?
Pyrexia
Cyanosis
Difficulty breathing
Floppiness
How would you investigate GBS infection?
Vaginal then rectal swab
Urine culture
Why is GBS screening not routine?
Most common in preterm population so likely already delivered by the time swab is taken
Not all who are positive are positive at delivery leading to inappropriate treatment
When should high dose penicillin be given to prevent GBS?
Positive swab
Previous GBS baby
Pyrexia in labour
Labour onset <37 weeks
Membrane rupture >18 hours ago
Give three reasons why mothers are more at risk of complications from Influenza
Immune shift from cell mediated to humoral
Increased Heart Rate
Increased Oxygen Consumption
How should influenza be managed in pregnancy?
Treatment with antiviral agents
Vaccination should be advised
Describe vertical transmission of HIV
Risk is up to 15% without medical intervention
Can be transplacentally in antenatal period, during vaginal birth, post nasally through breast feeding
What other risks are there to the foetus from HIV
Miscarriage
Foetal Growth Restriction
Prematurity
Stillbirth
How should HIV mothers be managed in pregnancy?
Start HAART if haven’t already (if already check - may be teratogenic levels)
Avoid invasive procedures
How should HIV mothers be managed in delivery and the post natal period?
Viral load <400 can deliver vaginally, otherwise C Section
Neonate requires PEP for several weeks
Avoid breast feeding (can give Cabergoline to suppress)
What is Zika Virus and how does it present in mothers?
Mosquito borne flavivirus
Fever, Headache, Back Pain, Rash and Pruritus (similar to dengue and chickungunya)
Give two cranial and two extracranial foetal manifestations of Zika Virus
Cranial - Microcephaly, Cerebral Calcification
Extracranial - Foetal Growth Restriction, Oligohydramnios
How should Zika Virus be managed in pregnant women?
Refer to foetal medicine specialist
May request ToP
Serial Ultrasound Scans
State three manifestations of Syphilis in pregnancy
Spontaneous Abortion
IUGR
Congenital Syphilis
What are the features of Congenital Syphilis?
Hepatosplenomegaly
Jaundice
Generalised Lymphadenopathy
Hydrops (scalp oedema, polyhydramnios)
How would you investigate Syphilis in pregnancy?
Treponemal enzyme immunoassay
Ultrasound foetus
How would you manage Syphilis in pregnancy?
Penicillin regime appropriate for stage
NOTE: Jarisch Herxheimer reaction can precipitate uterine contractions and labour
What is the effect of COVID 19 on pregnancy?
Three times greater risk of preterm pregnancy
Increased risk of caesarean birth
Define Gestational Anaemia
First trimester Hb<110g/l
Second/Third Trimester Hb<105g/l
Postpartum Hb<100g/l
Give four clinical features of Gestational Anaemia
Dizziness
Fatigue
Pallor
Koilonychia
How would you investigate Gestational Anaemia?
FBC
Serum Ferritin
Haemaglobinopathies
Serum folate
Describe the pathophysiology of Antiphospholipid Syndrome (In Vitro and In Vivo)
In Vitro - inhibits assembly of phospholipid complexes, inhibiting coagulation
In Vivo - produces a procoagulation state
Causes thrombosis of uteroplacental vasculature
Give four clinical features of Anti Phospholipid Syndrome
Recurrent Pregnancy Loss
Livedo Reticularis (red/purple/blue pattern on trunk/arms/legs)
Valvular Heart Disease
Renal Impairment
What are the three main tests for Antiphospholipid Syndrome?
Anticardiolipin
Lupus Anticoagulant
Anti B2 Glycoprotein
What is the diagnostic criteria for Antiphospholipid?
One clinical and one laboratory
Clinical: Vascular Thrombosis, pregnancy morbidity
Laboratory: Lupus/Anticardiolipin/Anti B2 Glycoprotein on at least two separate occasions
How is Antiphospholipid managed?
Low dose aspirin from positive pregnancy test
LMWH from visible heart beat (until around 34 weeks)
Consider warfarin post natally
Describe the pathophysiology of VTE in pregnancy
Due to change in clotting cascade (increased fibrinogen, decreased protein S)
Become more pronounced as pregnancy progresses so greatest post partum
Give two pre existing and two obstetric risk factors for VTE in Pregnancy
Pre-Existing: Thrombophilia, Smoker
Obstetric: Multiple Pregnancy, Pre- Eclampsia
How are VTEs investigated in Pregnant Women?
DVT - duplex ultrasound
PE - VQ Perfusion Scan, ECG, CXR
How are VTEs in Pregnancy managed?
LMWH - continued until 6-12 weeks post partum, dose omitted 24hrs before planned IOL/C Section
At term - IV UFH (can be stopped immediately in case they go into labour)
May require LMWH prophylaxis depending on risk factors
What is Pregnancy Induced Hypertension?
Hypertension in the second half of pregnancy, in the absence of Proteinuria/Other Pre-Eclampsia markers
How is Pregnancy Induced Hypertension managed?
With antihypertensives such as Labetolol/MethylDopa/Nifedipine/Atenolol
Switch from MethylDopa post partum to prevent Post Partum Depression
What are the effects of Pre-Existing Poorly Controlled Diabetes on Pregnancy?
Increased risk of congenital abnormalities
Macrosomia
Foetal death
Describe the effect of Pregnancy on Insulin requirements
1st Trimester: Static or Decrease
2nd and 3rd Trimester: Increase
How should pregnant women with Pre Existing Diabetes be managed?
Aspirin Prophylaxis
Retinal and Renal Screening
CBG measured QTS
Basal Bolus Insulin
IOL between 37-39 weeks (if pre term be aware that steroids will decrease diabetic control so consider starting VRIII)
A lot of the clinical features of Heart Disease in pregnancy are hard to distinguish from normal pregnancy features, when should you investigate further?
Murmur is Loud
Diastolic Murmur
Migrant Murmur
How should a pregnant woman with Cardiac Disease be managed?
Potential haemodynamic compromise: MDT follow up and delivery plan
ToP advised if: Eisenmenger, Pulmonary HTN, Impaired LVF
During delivery, any Syntocinon should be administered slowly (as it causes vasodilation)
How does Pregnancy affect Epilepsy?
Only 1/3 will have deterioration of seizures
If seizure free beforehand they’re likely to remain so
AED levels fall (dilution, increased metabolism, reduced absorption)
Describe the safety of AEDs in Pregnancy
Carbemazepine normally the drug of choice, Lamotrigine doses will need to be increased
Single drug regimes are less teratogenic than multi
Sodium Valproate carries the highest risk (Autism, ADHD etc)
How should Epilepsy be managed in a Pregnancy?
Preconception should ideally be on mono therapy
Folate supplements until at least 12 weeks
Detailed USS from 18 weeks to monitor any anomalies
Oral Vit K from 36 weeks and IM Vit K for newborn (if Phenytoin)
How does Obstetric Cholestasis present?
Usually in third trimester
Pruritus of trunk and limbs without skin rash (often worse at night)
Anorexia and Malaise
Epigastric Discomfort/Steatorrhoea/Dark Urine
What investigations should be done for Obstetric Cholestasis?
LFTs (up to 3 fold increase)
Bile Acids (increased)
Clotting Screen, Autoimmune Screen, Viral Serology
How is Obstetric Cholestasis managed?
Water Soluble Vitamin K commenced from diagnosis
Ursodeoxycholic Acid For Pruritus
Emollients
What is the relevance of raised AFP in Pregnancy screening?
Low AFP: Downs Syndrome, Diabetic Mothers
High AFP: Open NTD, Turners Syndrome, Teratomas
What is the Combined Test for Downs Syndrome?
Nuchal Translucency + free BHCG + PAPP-A + Woman’s Age
Between 10weeks 3 days and 13 weeks 6 days
What is the potential effect of Anti Depressants on Neonates?
Withdrawal : Agitation, Respiratory Depression
Describe how medications used to treat Anxiety can affect the foetus
Diazepam - floppy baby syndrome (if given around birth)
Beta Blockers - Foetal Growth Retardation
Give three roles of Betamethasone in Pregnancy
Encourage foetal surfactant production
Encourage PDA Closure
Protect against periventricular malacia (a cause of Cerebral Palsy)
Name 11 conditions the 20 week scan looks for
Gastroschisis/Exomphalos
Cardiac Anomalies
Anencephaly
Cleft Lip
Spina Bifida
Diaphragmatic Hernia
Bilateral Renal Agenesis
Lethal Skeletal Dysplasia
Patau
Edwards
What should be discussed at the booking visit? (<10wks)
Health and Lifestyle
Folic Acid 400mcg
Food Hygiene and foods to avoid (unpasteurised, soft cheeses, pâté)
Smoking and Alcohol Cessation
Antenatal screening
Risk Assessment
What Antenatal ‘Screening’ is done at booking?
Electrophoresis (Haemaglobinopathy)
FBC
Blood groups and Antibodies
Infection screen
Urinalysis (glucose,protein, blood)
When is the dating scan done?
Between 10 - 13+6 weeks
How frequently should you have antenatal appointments?
Uncomplicated Nulliparous - 10
Uncomplicated Parous - 7
What should be discussed in Antenatal Appointments in the third trimester?
Breastfeeding information
Birth Plan
Recognition of active labour
Care of the new baby
Vit K Prophylaxis
Newborn screening
Post Natal self care and awareness of baby blues
What is the Quadruple test for Down’s Syndrome?
Quadruple blood test (15-17 weeks): ↓αFP, ↓unconjugated estradiol, ↑βHCG, ↑inhibin A
If chance is >1/150, invasive testing is offered
