Pregnancy Complications Flashcards
What is a post-term pregnancy?
one that has extended to or beyond 42 weeks
What are maternal and neonatal complications of a post-term pregnancy?
Neonatal complications:
Reduced placental perfusion
Oligohydramnios
Maternal complications:
Increased rates of intervention including forceps and caesarean section
Increased rates of labour induction
When are women screened for anaemia in pregnancy?
At booking visit and at 28 weeks
What are the cut-offs for oral iron therapy in pregnancy?
1st: 110g/L
2nd/3rd: 105g/L
Postpartum: 100g/L
How is anaemia in pregnancy managed?
oral ferrous sulfate or ferrous fumarate - treatment should be continued for 3 months after iron deficiency is corrected to allow iron stores to be replenished
How should a suspected DVT be investigated?
Compression duplex ultrasound should be undertaken where there is clinical suspicion of DVT
How should a suspected PE be investigated?
ECG and CXR
Compression duplex ultrasound - if DVT found, start VTE treatment pathway and no further investigations needed
Decision to perform a V/Q or CTPA should be taken at a local level after discussion with the patient and radiologist
Can D-dimer be used in pregnancy for DVT?
No as it is often raised anyway
Compare CTPA to V/Q scanning in pregnancy
CTPA slightly increases the lifetime risk of maternal breast cancer - 13.6% rise
V/Q scanning carries a slightly increased risk of childhood cancer compared with CTPA
What is the most common liver disease of pregnancy?
Intrahepatic cholestasis - occurs in 1% of pregnancies in 3rd trimester
What are features of intrahepatic cholestasis?
pruritus, often in the palms and soles
no rash (although skin changes may be seen due to scratching)
raised bilirubin
How is intrahepatic cholestasis managed?
ursodeoxycholic acid is used for symptomatic relief
weekly liver function tests
women are typically induced at 37 weeks
What is a possible complication of intrahepatic cholestasis?
increased rate of stillbirth
not associated with increased maternal morbidity
What is acute fatty liver of pregnancy?
rare complication which may occur in the third trimester or the period immediately following delivery.
What are features of acute fatty liver of pregnancy?
abdominal pain
nausea & vomiting
headache
jaundice
hypoglycaemia
severe disease may result in pre-eclampsia
What is found on investigation of acute fatty liver of pregnancy?
ALT is typically elevated e.g. 500 u/l
How is acute fatty liver of pregnancy managed?
support care
once stabilised delivery is the definitive management
How and when is obesity in pregnancy defined?
BMI >30 at booking visit
What are maternal risks from obesity during pregnancy?
miscarriage
venous thromboembolism
gestational diabetes
pre-eclampsia
dysfunctional labour, induced labour
postpartum haemorrhage
wound infections
higher C-section rate
What are fetal risks from maternal obesity?
congenital anomaly
prematurity
macrosomia
stillbirth
increased risk of developing obesity and metabolic disorders in childhood
neonatal death
What advice should be given to pregnant women about weight loss during pregnancy?
Should not attempt to diet
Risks will be managed by their healthcare professionals
How is obesity in pregnancy managed?
obese women should take 5mg of folic acid, rather than 400mcg
all obese women should be screened for gestational diabetes with an oral glucose tolerance test (OGTT) at 24-28 weeks
if the BMI >= 35 kg/m² women should give birth in a consultant-led obstetric unit
if the BMI >= 40 kg/m² should have an antenatal consultation with an obstetric anaesthetist and a plan made
What are the risks of smoking in pregnancy?
Increased risk of miscarriage (increased risk of around 47%)
Increased risk of pre-term labour
Increased risk of stillbirth
IUGR
Increased risk of sudden unexpected death in infancy
What are the risks of drinking alcohol in pregnancy?
Fetal alcohol syndrome (FAS)
learning difficulties
characteristic facies: smooth philtrum, thin vermilion, small palpebral fissures, epicanthic folds, microcephaly
IUGR & postnatal restricted growth
What are the risks of cannabis, cocaine and heroin use in pregnancy?
Cannabis: Similar to smoking due to tobacco
Cocaine:
Maternal risks:
hypertension in pregnancy including pre-eclampsia
placental abruption
Fetal risks:
prematurity
neonatal abstinence syndrome
Heroin: Neonatal abstinence syndrome
What are the risks of prematurity?
- increased mortality depends on the gestation
- respiratory distress syndrome
- intraventricular haemorrhage
- necrotizing enterocolitis
- chronic lung disease, hypothermia, feeding problems, infection, jaundice
- retinopathy of prematurity
- important cause of visual impairment in babies born before 32 weeks gestation
- the cause is not fully understood and multivariate.
- One of the contributing factors is thought to be over oxygenation (e.g. during ventilation) resulting in a proliferation of retinal blood vessels (neovascularization) - screening is done in at-risk groups - hearing problems
What is PPROM and its epidemiology?
Preterm prelabour rupture of the membranes
Happens in 2% of pregnancies and 40% of all preterm deliveries
What are maternal and fetal complications of PPROM?
fetal: prematurity, infection, pulmonary hypoplasia
maternal: chorioamnionitis
How is PPROM confirmed?
a sterile speculum examination should be performed (to look for pooling of amniotic fluid in the posterior vaginal vault) but digital examination should be avoided due to the risk of infection
if pooling of fluid is not observed NICE recommend testing the fluid for placental alpha microglobulin-1 protein (PAMG-1) (e.g. AmniSureµ) or insulin-like growth factor binding protein-1
ultrasound may also be useful to show oligohydramnios
How is PPROM managed?
- admission
- regular observations to ensure chorioamnionitis is not developing
- oral erythromycin should be given for 10 days
- antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome
- delivery should be considered at 34 weeks of gestation - there is a trade-off between an increased risk of maternal chorioamnionitis with a decreased risk of respiratory distress syndrome as the pregnancy progresses
How do RA symptoms change in pregnancy?
improve in pregnancy but only resolve in a small minority. Patients tend to have a flare following delivery.
Are RA drugs safe in pregnancy?
methotrexate is not safe in pregnancy and needs to be stopped at least 6 months before conception
leflunomide is not safe in pregnancy
sulfasalazine and hydroxychloroquine are considered safe in pregnancy
low-dose corticosteroids may be used in pregnancy to control symptoms
NSAIDs may be used until 32 weeks but after this time should be withdrawn due to the risk of early close of the ductus arteriosus
Why do RA patients need obstetric anaesthetist assessment?
due to the risk of atlanto-axial subluxation
What is the incubation and infection period of rubella?
incubation period is 14-21 days and individuals are infectious from 7 days before symptoms appear to 4 days after the onset of the rash
What is the risk of rubella in pregnancy?
in first 8-10 weeks risk of damage to fetus is as high as 90%
damage is rare after 16 weeks
What is congenital rubella syndrome?
sensorineural deafness
congenital cataracts
congenital heart disease (e.g. patent ductus arteriosus)
growth retardation
hepatosplenomegaly
purpuric skin lesions
‘salt and pepper’ chorioretinitis
microphthalmia
cerebral palsy
How is rubella in pregnant women diagnosed?
- suspected cases should be discussed immediately with the local Health Protection Unit (HPU) as type/timing of investigations may vary
- IgM antibodies are raised in women recently exposed to the virus
- it should be noted that it is very difficult to distinguish rubella from parvovirus B19 clinically. It is therefore important to also check parvovirus B19 serology as there is a 30% risk of transplacental infection, with a 5-10% risk of fetal loss
How is rubella in pregnancy managed?
- Women no longer routinely screened at booking visit
- Suspected cases of rubella in pregnancy should be discussed with the local Health Protection Unit
- Non-immune mothers should be offered the MMR vaccination in the post-natal period - MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant
