Pregnancy problems Flashcards
Ectopic pregnancy RF
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
S+S Ectopic
Amenorrhoea, pain, bleeding (small amounts, often brown), shoulder tip pain, cervical excitation, adnexal tenderness
Ectopic investigations
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
Management of ectopic (circumstances for each) + risk of death
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
Molar pregnancy aetiology + types
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
Molar pregnancy RF
>40 or <15 y/o
Previous molar pregnancy (10% risk of recurrence)
Ethnicity: higher in east Asia
S+S Molar pregnancy
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
Molar pregnancy investigations + management (+ follow up)
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
How does BP change in pregnancy
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
Existing HTN in pregnancy - what are you at risk of, management of HTN
At risk of: pre-eclampsia, IUGR, placental abruption, stroke
Stop ACEi + ARBs
Use Ca ch blockers or B blockers
Pre-eclampsia pathology + diagnosis
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
Pre-eclampsia risk factors
Previous pre-e
Extremes of age
Fam hx
Obesity
Primip
Twins
Fetal hydrops
Hyatidiform mole
HTN, DM, thrombophilias
Pre-eclampsia complications for mother + fetus
Mother: eclampsia, CVAs, liver/ renal failure, HELLP, DIC, pulmonary oedema
Fetal: IUGR, morbidity, placental abruption, pre-term birth, hypoxia
Pre-eclampsia blood results
High Hb
Low platelets
Prolonged PT + APTT
Abnormal LFTs
Increased urea + creatinine
Pre-eclampsia treatment
Magnesium sulphate to prevent eclampsia
Labetalol to reduce BP
Indications for immediate delivery in pre-eclampsia
Worsening thrombocytopaenia - beware - this means epidural CI
Worsening liver/ renal function
Severe maternal symptoms
Fetal distress HELLP/ eclampsia
Effect of diabetes on pregnancy
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
Effect of pregnancy on diabetes
Ketoacidosis (associated with hyperemesis, infection, steroids + tocolytics)
Retinopathy, nephropathy = increased risk
Complications of diabetes in pregnancy (maternal, fetal, neonatal)
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
Glycaemic control in pregnancy
Continue insulin until in established labour then convert to sliding scale
Hyperglycaemia may occur with steroid use
Insulin requirements fall after delivery of placenta
Treatment of constipation, thrush + epilepsy in pregnancy
Constipation = laxatives but avoid stimulants
Thrush = imidazole/ clotrimazole
Epilepsy = lamotrigine - avoid sodium valproate
Treatment of chorioamnionitis, UTI, endometritis + resp infections
Chorioamnionitis = cefuroxime + metronidazole
UTI = trimethoprim (not 1st trimester) or nitrofurantoin (not 3rd trimester)
Resp infection = penicillins/ macrolides
Endometritis = co-amoxiclav
Risk factors for gestational DM
Fam hx
Obesity
Previous large baby
Previous stillbirth
PCOS
Polyhydraminos
GDM S+S
Recurrent infections
Glycosuria
Large for dates
Diagnosis of GDM
Oral glucose tolerance test at 26 weeks
>7.8 after 2 hours
If previous GDM, do OGTT at 16 weeks
Complications of GDM
Macrosomia - shoulder dystocia
CS
Pre-eclampsia
NTD
Rhesus disease pathology
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
Sensitising events
Termination or miscarriage
Ectopic
Vaginal bleeding >12 weeks or heavy bleeding
ECV
Trauma
Amniocentesis/ CVS
Intrauterine death
Delivery
Management of rhesus
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
Small for dates - causes, RF, diagnosis
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
Large for dates - causes, risk to the fetus
Causes: maternal diabetes
Risks to fetus: hypoglycaemia after birth, respiratory disease, shoulder dystocia (damage to brachial plexus - Erb’s + Klumpky’s palsy)
What is MacRoberts position?
To aid with shoulder dystocia
IUGR - what is it, diagnosis, risks to fetus
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
Causes of IUGR (maternal, placental, fetal)
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
IUGR management
Steroids before birth for fetal lung maturation
Absent end diastolic flow = admit for steroids + daily CTG
Dizygotic twins - how common, pathology
2 separate ova being fertilised by 2 different sperm
Dichorionic + diamniotic (DCDA)
75% multiple pregnancies
Monozygotic twins pathology
Division of a single embryo
<3 days = DCDA
4-7 days = MCDA
8-12 days = MCMA Genetically identical
RF for multiple pregnancy
Previous or fam hx
Increasing maternal age
Assisted reproduction
Fetal risks associated with multiples
Risk of miscarriage
NTD, cardiac abnormalities + gastrointestinal atresia
IUGR
Preterm labour
Risk of mortality, disability, CP
Maternal risks with multiples
Hyperemesis, anaemia, pre-eclampsia, GDM, HTN, polyhydraminos, placenta praevia, APH + PPH
Twin to twin transfusion syndrome - pathology, effect on donor + recipient. Management
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
Intrauterine death of a twin - effect on pregnancy (other fetus + mother)
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
Intrapartum risks for twins
Malpresentation
Fetal hypoxia
Cord prolapse
PPH
Cord entanglement (MCMA)
Head entrapment
Selective termination - how, when, risks
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
Risk of anti-convulsants in pregnancy
Phenytoin + carbamazepine cause fetal hydantoin syndrome:
IUGR, microcephaly, cleft lip, hypoplastic fingernails + distal limb deformities
Management of existing thyroid disease in pregnancy
Hypothyroidism = increase thyroxine by 25mg due to physiological increase in T4 until 12 wks (which doesn’t occur in hypothyroidism)
Most common site for ectopic pregnancy
Ampulla then isthmus
Complications of ectopic pregnancy
Rupture + internal bleeding
Why is an ectopic pregnancy in the uterine horn worrying?
Can reach 10-14 weeks gestation before rupture
How are women managed in pregnancy if they’ve had a previous molar?
Serum hCG measured at 6 + 10 weeks postpartum due to risk of choriocarcinoma
S+S pre-eclampsia
Frontal headache, visual disturbances, RUQ pain, N+V, rapid oedema (face), hyperreflexia + clonus
USS findings for multiples
Widely separated sacs = dichorionic. Membrane insertion showing lambda sign = dichorionic. Absence of lambda sign <14 weeks = monochorionic
What is the most common cause of recurrent miscarriage + how to manage?
Antiphospholipid ab = likely cause of recurrent miscarriage = treat with aspirin + LMWH
What reduces the risk of pre-eclampsia?
Smoking
When would you give aspirin in a subsequent pregnancy?
If severe pre-eclampsia requiring delivery before 34 weeks
What are the indications for 5mg folic acid?
Previous NTD
Diabetes
Sickle cell
On anti-epileptic treatment
