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OBGYN > Pregnancy problems > Flashcards

Pregnancy problems Flashcards

1
Q

Ectopic pregnancy RF

A

Assisted conception

Hx of PID

Endometriosis

Tubal surgery

Previous ectopic (recurrence is 10-20%)

Higher maternal age

Smoking

IUCD POP - if pregnant, more likely to be ectopic

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2
Q

S+S Ectopic

A

Amenorrhoea, pain, bleeding (small amounts, often brown), shoulder tip pain, cervical excitation, adnexal tenderness

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3
Q

Ectopic investigations

A

TVUSS

Serum hCG - should double in 48 hours. Suboptimal rise = ectopic Laparoscopy = gold standard

Serum progesterone is helpful to see if pregnancy is failing (<20 = failing)

hCG >1500 should be seen with TVUSS if viable intrauterine

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4
Q

Management of ectopic (circumstances for each) + risk of death

A

Expectant = if stable AND: asymptomatic, hCG <1500, no fetal cardiac activity, can come into hospital easily

Medical = methotrexate IM - measure hCG at day 4 and day 7. Choice is given if gCG 1500-5000

Another dose given if hCG decrease is <15% on days 4-7.

Use reliable contraception for 3 months.

Side effects: conjunctivitis, stomatitis, GI upset. Give anti-D

Surgical (if there is fetal heart activity, pain, hCG >5000, adnexal mass >35mm) = salpingostomy if rupture has not occurred.

Salpingectomy if there is a rupture

Risk of death 1:2000

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5
Q

Molar pregnancy aetiology + types

A

Abnormal overgrowth of placenta Hyatidiform mole = overgrowth is benign.

Partial mole = part develops normally, due to 2 sperm entering egg. May be a developing fetus but has genetic abnormalities

Complete = whole placenta is abnormal, no developing fetus. Due to 1 sperm entering egg but only half genetic material present.

Appears as snowstorm on USS, with hydropic villi + large theca lutein cysts

Choriocarcinoma = placenta becomes malignant

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6
Q

Molar pregnancy RF

A

>40 or <15 y/o

Previous molar pregnancy (10% risk of recurrence)

Ethnicity: higher in east Asia

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7
Q

S+S Molar pregnancy

A

Irregular first trimester bleeding

Uterus large for dates

Pain from theca lutein cysts due to ovarian hyperstimulation (due to increased hCG)

Exaggerated pregnancy symptoms = hyperemesis, hyperthyroidism, early pre-eclampsia

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8
Q

Molar pregnancy investigations + management (+ follow up)

A

USS - snowstorm appearance, large lutein cysts

High hCG. Must be taken every 14 days

SURGICAL EVAC

Once levels normal, test urine every month for hCG

Do not become pregnant til normal for 6 months

If abnormal levels after surgical evac, methotrexate + folinic acid are given

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9
Q

How does BP change in pregnancy

A

Decreases in early pregnancy until 24 weeks due decrease in vascular volume

Increases after 24 weeks due to increase in stroke volume

Decreases after delivery but may peak again 3-4 days postpartum

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10
Q

Existing HTN in pregnancy - what are you at risk of, management of HTN

A

At risk of: pre-eclampsia, IUGR, placental abruption, stroke

Stop ACEi + ARBs

Use Ca ch blockers or B blockers

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11
Q

Pre-eclampsia pathology + diagnosis

A

HTN + proteinuria

Blood vessel endothelial cell damage - exaggerated maternal inflammatory response

Vasospasm, increased capillary permeability + clotting dysfunction

Increases vascular resistance, permeability + reduced placental blood flow

140/90 + >300mg protein in 24hr collection or PCR >30

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12
Q

Pre-eclampsia risk factors

A

Previous pre-e

Extremes of age

Fam hx

Obesity

Primip

Twins

Fetal hydrops

Hyatidiform mole

HTN, DM, thrombophilias

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13
Q

Pre-eclampsia complications for mother + fetus

A

Mother: eclampsia, CVAs, liver/ renal failure, HELLP, DIC, pulmonary oedema

Fetal: IUGR, morbidity, placental abruption, pre-term birth, hypoxia

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14
Q

Pre-eclampsia blood results

A

High Hb

Low platelets

Prolonged PT + APTT

Abnormal LFTs

Increased urea + creatinine

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15
Q

Pre-eclampsia treatment

A

Magnesium sulphate to prevent eclampsia

Labetalol to reduce BP

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16
Q

Indications for immediate delivery in pre-eclampsia

A

Worsening thrombocytopaenia - beware - this means epidural CI

Worsening liver/ renal function

Severe maternal symptoms

Fetal distress HELLP/ eclampsia

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17
Q

Effect of diabetes on pregnancy

A

Hyperglycaemia in fetus - high insulin through B cell hyperplasia

Insulin acts as growth promoter - macrosomia, organomegaly + erythropoesis

Fetal polyuria = polyhydraminos

Neonatal hypoglycaemia after birth

Surfactant deficiency due to reduced production of pulmonary phospholipids = respiratory distress syndrome

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18
Q

Effect of pregnancy on diabetes

A

Ketoacidosis (associated with hyperemesis, infection, steroids + tocolytics)

Retinopathy, nephropathy = increased risk

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19
Q

Complications of diabetes in pregnancy (maternal, fetal, neonatal)

A

Maternal: UTI, candidiasis, HTN, pre-eclampsia, obstructed labour, retinopathy + nephropathy

Fetal: Miscarriage, preterm labour, polyhydraminos, macrosomia, IUGR

Neonatal: jaundice, hypoglycaemia, hypocalcaemia, hypothermia, shoulder dystocia, Erb’s palsy, respiratory distress syndrome

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20
Q

Glycaemic control in pregnancy

A

Continue insulin until in established labour then convert to sliding scale

Hyperglycaemia may occur with steroid use

Insulin requirements fall after delivery of placenta

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21
Q

Treatment of constipation, thrush + epilepsy in pregnancy

A

Constipation = laxatives but avoid stimulants

Thrush = imidazole/ clotrimazole

Epilepsy = lamotrigine - avoid sodium valproate

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22
Q

Treatment of chorioamnionitis, UTI, endometritis + resp infections

A

Chorioamnionitis = cefuroxime + metronidazole

UTI = trimethoprim (not 1st trimester) or nitrofurantoin (not 3rd trimester)

Resp infection = penicillins/ macrolides

Endometritis = co-amoxiclav

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23
Q

Risk factors for gestational DM

A

Fam hx

Obesity

Previous large baby

Previous stillbirth

PCOS

Polyhydraminos

24
Q

GDM S+S

A

Recurrent infections

Glycosuria

Large for dates

25
Q

Diagnosis of GDM

A

Oral glucose tolerance test at 26 weeks

>7.8 after 2 hours

If previous GDM, do OGTT at 16 weeks

26
Q

Complications of GDM

A

Macrosomia - shoulder dystocia

CS

Pre-eclampsia

NTD

27
Q

Rhesus disease pathology

A

Mendelian inheritance

Fetal cells cross into maternal circulation

Mothers exposed to foreign antigen mount immune response (sensitisation) - initially IgM so current pregnancy not at risk

Re-exposure in subsequent pregnancy causes memory B cells to produce IgG which crosses placenta

IgG binds to fetal red cells which are then destroyed in reticuloendothelial system

Causes haemolytic anaemia = fetal hydrops, high output cardiac failure

Haemolysis can cause jaundice from increase bilirubin levels

If fetus is Rhesus +ve, and mother is -ve, mother will create anti-D antibodies

28
Q

Sensitising events

A

Termination or miscarriage

Ectopic

Vaginal bleeding >12 weeks or heavy bleeding

ECV

Trauma

Amniocentesis/ CVS

Intrauterine death

Delivery

29
Q

Management of rhesus

A

Check for Ab at booking

Anti D given at 28 weeks + within 72 hours of any sensitising event

Given after delivery if baby is +ve

30
Q

Small for dates - causes, RF, diagnosis

A

Constitutional: low maternal height/ weight, nulliparity, femal fetus

RF: fibroids, polyhydraminos, IVF

Diagnose with CRL at 8-10 weeks and biparietal diameter at 16-20 weeks

Serial USS + umbilical artery

Doppler to diagnose IUGR

31
Q

Large for dates - causes, risk to the fetus

A

Causes: maternal diabetes

Risks to fetus: hypoglycaemia after birth, respiratory disease, shoulder dystocia (damage to brachial plexus - Erb’s + Klumpky’s palsy)

32
Q

What is MacRoberts position?

A

To aid with shoulder dystocia

33
Q

IUGR - what is it, diagnosis, risks to fetus

A

Growth normal initially then slows

Reversed/ absent end diastolic flow or increased pulsatile index = IUGR

Mortality is higher, CP risk is higher

More likely to meconium aspirate, necrotising enterocolitis, hypoglycaemia and hypocalcaemia

34
Q

Causes of IUGR (maternal, placental, fetal)

A

Maternal: maternal disease, substance abuse, poor nutrition, low SES

Placental: pre-eclampsia, placenta accreta, infarction, placenta praevia, tumours, abnormal cord insertion

Fetal: genetic abnormalities, congenital infection, multiple pregnancy

35
Q

IUGR management

A

Steroids before birth for fetal lung maturation

Absent end diastolic flow = admit for steroids + daily CTG

36
Q

Dizygotic twins - how common, pathology

A

2 separate ova being fertilised by 2 different sperm

Dichorionic + diamniotic (DCDA)

75% multiple pregnancies

37
Q

Monozygotic twins pathology

A

Division of a single embryo

<3 days = DCDA

4-7 days = MCDA

8-12 days = MCMA Genetically identical

38
Q

RF for multiple pregnancy

A

Previous or fam hx

Increasing maternal age

Assisted reproduction

39
Q

Fetal risks associated with multiples

A

Risk of miscarriage

NTD, cardiac abnormalities + gastrointestinal atresia

IUGR

Preterm labour

Risk of mortality, disability, CP

40
Q

Maternal risks with multiples

A

Hyperemesis, anaemia, pre-eclampsia, GDM, HTN, polyhydraminos, placenta praevia, APH + PPH

41
Q

Twin to twin transfusion syndrome - pathology, effect on donor + recipient. Management

A

Affects monochorionic twins

Caused by abherrant vascular anastamoses within the placenta - blood from donor twin is transferred to recipient

Effect on donor: hypovolaemic, anaemic, oligohydraminos, growth restriction

Effect on recipient: hypervolaemic, large bladder, polyhydraminos, fetal hydrops

Monochorionic twins scanned every fortnight from 12 weeks.

Laser ablation or placental anastomoses, selective feticide by cord occlusion or septostomy

42
Q

Intrauterine death of a twin - effect on pregnancy (other fetus + mother)

A

Dichorionic = loss in first trimester - no issue.

Loss in 2nd or 3rd precipitates labour

Monochorionic = due to shared circulation, death occurs in the other twin

Increased risk of DIC in mother

43
Q

Intrapartum risks for twins

A

Malpresentation

Fetal hypoxia

Cord prolapse

PPH

Cord entanglement (MCMA)

Head entrapment

44
Q

Selective termination - how, when, risks

A

When 1 twin has an abnormality.

Injection of KCl in DC twins.

In monochorionic = cord must be occluded

Risk of miscarriage

Can occur up to 34 weeks

45
Q

Risk of anti-convulsants in pregnancy

A

Phenytoin + carbamazepine cause fetal hydantoin syndrome:

IUGR, microcephaly, cleft lip, hypoplastic fingernails + distal limb deformities

46
Q

Management of existing thyroid disease in pregnancy

A

Hypothyroidism = increase thyroxine by 25mg due to physiological increase in T4 until 12 wks (which doesn’t occur in hypothyroidism)

47
Q

Most common site for ectopic pregnancy

A

Ampulla then isthmus

48
Q

Complications of ectopic pregnancy

A

Rupture + internal bleeding

49
Q

Why is an ectopic pregnancy in the uterine horn worrying?

A

Can reach 10-14 weeks gestation before rupture

50
Q

How are women managed in pregnancy if they’ve had a previous molar?

A

Serum hCG measured at 6 + 10 weeks postpartum due to risk of choriocarcinoma

51
Q

S+S pre-eclampsia

A

Frontal headache, visual disturbances, RUQ pain, N+V, rapid oedema (face), hyperreflexia + clonus

52
Q

USS findings for multiples

A

Widely separated sacs = dichorionic. Membrane insertion showing lambda sign = dichorionic. Absence of lambda sign <14 weeks = monochorionic

53
Q

What is the most common cause of recurrent miscarriage + how to manage?

A

Antiphospholipid ab = likely cause of recurrent miscarriage = treat with aspirin + LMWH

54
Q

What reduces the risk of pre-eclampsia?

A

Smoking

55
Q

When would you give aspirin in a subsequent pregnancy?

A

If severe pre-eclampsia requiring delivery before 34 weeks

56
Q

What are the indications for 5mg folic acid?

A

Previous NTD

Diabetes

Sickle cell

On anti-epileptic treatment

OBGYN (18 decks)

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