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Y5 O+G > Pregnancy Risk Assessment > Flashcards

Pregnancy Risk Assessment Flashcards

1
Q

What features are investigated in a maternity risk assessment during the booking appointment

A

Gestational diabetes risk
Pre-eclampsia
Foetal growth restriction
Venous thromboembolism

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2
Q

What are the risk factors for a high risk pregnancy

A

Any previous complicated pregnancies (biggest risk for another abnormal pregnancy)
Maternal factors
- Age <15yo or >35yo
- Pre-pregnancy weight under 45kg or obese
- Height under 5 ft (1.5m)
- Hypothyroid/Hyperthyroid
Gynaecological
- Incompetent cervix
- Uterine malformations
- Small pelvis
- Previous obs hx for recurrent miscarriages
Social
- Being single
- Smoker or alcohol
- Illicit drugs
- No access to early prenatal care
- Low socioeconomic status

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3
Q

What should be done for women with a high risk pregnancy

A

Refer for obstetrician led care
Continued surveillance - more frequent scans
Consider aspirin, high dose folic acid etc.

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4
Q

Who is given high dose folic acid

A

Previous child with NTD
Diabetes mellitus
Woman on an anti-epileptic
Obesity (>30 BMI)
HIV positive taking co-trimoxazole
Sickle cell disease

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5
Q

What are the methods of monitoring pregnancy

A

Cardiotocography
Growth scans
Foetal doppler
Foetal blood sampling

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6
Q

Describe the production of amniotic fluid as the pregnancy progresses

A

0-12 weeks: Passive transfer of fluid across the amniotic membranes from chorionic cavity
Before 20 weeks: Amniotic fluid isotonic like maternal plasma
19 weeks: Keratinisation of foetal skin AF circulation from foetus

Production: foetal urination, the respiratory tract system, oral secretion and transfer across the cord and placenta
Removal: foetal swallowing, intra-membranous, respiratory fluid

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7
Q

Define oligohydramnios

A

Decreased volume of amniotic fluid, <5th centile
Deepest pool <2cm

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8
Q

What are the risk factors for oligohydramnios

A

Reduced input fluid: placental insufficiency, pre-eclampsia
Reduced output fluid: structural pathology (AR PKD), medications (ACEi, NSAIDs)
Lost fluid: ROM, IUGR, post-term pregnancy carry, TTTS
Chromosomal abnormalities
Multiple pregnancy
Infections

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9
Q

What are the signs and symptoms of oligohydramnios

A

History of fluid leak PV, rupture of membranes – commonly asymptomatic
Abdominal exam – decreased fundal height, foetal parts easily palpable
Speculum – assess for membrane rupture if appropriate

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10
Q

What investigations should be done for oligohydramnios

A

USS – liquor volume, foetal anomalies
CTG– foetal wellbeing

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11
Q

What is the management for oligohydramnios

A

Term – delivery is appropriate, IOL if no CI
Pre-term – monitor serial USS for growth, liquor volume, dopplers, regular CTGs, delivery if further abnormalities arise (note: amnioinfusion has a very limited role or effect)

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12
Q

What are the complications of oligohydramnios

A

Labour – increased incidence of CTG abnormalities, meconium liquor, emergency CS
Neonate – pulmonary hyperplasia, limb deformities
Prognosis – increased perinatal mortality rates with early onset oligohydramnios

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13
Q

Define polyhydramnios

A

AFI >95th centile, 2-3L fluid
Deepest pool >8cm

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14
Q

What are the risk factors for polyhydramnios

A

Failure of foetal swallowing:
- Neurological - neurology, chromosomal abnormalities
- GIT - duodenal atresia, oesophageal atresia
Congenital infections
Foetal polyuria: maternal diabetes, TTTS

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15
Q

What are the signs and symptoms of polyhydramnios

A

Symptoms of underlying cause
Abdomen – increased fundal height, impalpable foetal parts, tense abdo

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16
Q

What investigations should be done for polyhydramnios

A

Liquor volume, foetal growth, umbilical artery dopplers, exclude foetal anomalies
Other – exclude maternal diabetes

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17
Q

What is the management for polyhydramnios

A

Antenatal monitoring of foetus, ensure diabetes control, paediatrician present at delivery
Amnioreduction (if gross polyhydramnios + discomfort)
COX inhibitors to decrease foetal urine output

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18
Q

What are the complications and prognosis of polyhydramnios

A

Pre-term labour (PTL), malpresentation, placental abruption, cord prolapse, PPH, increased risk CS
Prognosis – increased perinatal morbidity and mortality, related to PTL/congenital

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19
Q

What are the types of doppler scan

A

Umbilical artery
Cerebral circulation: middle cerebral artery
Venous circulation: ductus venosus

20
Q

What is a sign of foetal compromise in the doppler

A

severe placental dysfunction: Absent end diastolic flow or reverse end diastolic flow (suggests high resistance circulation) in the UMBILICAL doppler
Compromise: low-resistance pattern in comparison to thoracic aorta or renal vessels (MCA)
Ratio of the pulsatility index (PI) (MCA vs UmbA)

21
Q

Describe chorionic villi sampling and what is the miscarriage rate

A

USS-guided needle aspirate of placental tissue
performed 10-13/40 (i.e. week 12)
1% miscarriage rate

22
Q

Describe amniocentesis and what is the miscarriage rate

A

USS guided needle, avoid entry of placenta, small aspirate of amniotic fluid
performed ≥15/40
1% miscarriage rate

23
Q

What supportive management must be done for diagnostic procedures (amniocentesis and CVS)

A

anti- RHD given to RH-neg women (sensitising event)

24
Q

What are the indications for diagnostic testing of the foetus

A

Demonstrated risk at antenatal screening
Suspected foetal anomaly on USS
FHX of inherited disorder
Known carrier status for inherited disorder
Previous pregnancy with chromosomal disorder
Increased maternal age

25
Q

What are the complications of foetal diagnostic testing

A

Generic: bleeding, infection, damage to local structures, procedural failure
Abdominal pain
Miscarriage (both CVS and amniocentesis at 1%)
Chorioamnionitis
Limb abnormalities if CVS performed before 10/40

26
Q

What are the two ways of CTG monitoring in labour

A

Intermittent auscultation
- At least 60s immediately after a contraction
- First stage: at least every 15 minutes
- Second stage: at least every 5 minutes

Continuous:
- for any antenatal or intrapartum risk factors

27
Q

What are some of the indications for continuous CTG monitoring in labor

A

Maternal: previous c-section, cardiac problems , PET, prolonged pregnancy, PROM >24h, IOL, GDM, haemorrhage
Foetal: IUGR, prematurity, oligohydramnios, abnormal doppler, multiple pregnancy, meconium stained liquor, breech
Intrapartum: maternal HR >120, temp >38, suspected sespsis, vaginal bleeding, delay, oxytocin use

28
Q

What is the structure for interpreting a CTG

A

DR C BRAVADO
DR - Define the risk
C - contractions

Bra - Baseline rate
V - Variability
A - Accelerations
D - Decelerations
O - Overall impression

29
Q

How should one assess contractions on CTG

A

The number of contractions present in a 10 minute period
Assess for:
- Duration: how long do they last?
- Intensity: How strong are they? (assessed in palpation)

30
Q

How should one assess baseline rate

A

Baseline rate = The average heart rate of the foetus within a 10 minute window
Normal foetal heart rate is between 110-160bpm
<100bpm for 3 minutes → Foetal bradycardia → emergency → immediate delivery if cause not found

31
Q

What are the causes of foetal tachycardia

A

Foetal hypoxia
Chorioamnionitis
Hyperthyroidism
Foetal or maternal anaemia
Foetal tachyarrhythmia

32
Q

What are the causes of foetal bradycardia

A

Postdate gestation
Prolonged cord compression
Cord prolapse
Epidural and spinal anaesthesia
Maternal seizure
Rapid foetal descent

33
Q

How should one assess variability

A

Variation of foetal heart rate from one beat to the next (Look at how much the peaks and troughs of the heart rate deviate from the baseline rate in bpm)
Normal variability (5-25bpm)
- <5bpm for 20-50mins is non-reassuring, >50 abnormal
- >20bpm for 15-25 minutes is non-reassuring, >25 abnormal

34
Q

What are the causes of reduced variability

A

Foetal sleeping
Foetal acidosis
Foetal tachycardia
Drugs e.g. opiates/benzodiazepines/methyldopa/magnesium sulphate
Prematurity - variability is reduced at earlier gestation <28 weeks
Congenital heart abnormalities

35
Q

How should one assess accelerations

A

Abrupt increase in the baseline foetal heart rate of greater than 15bpm for greater than 15 seconds
The presence of accelerations is reassuring

36
Q

How should one assess decelerations

A

Abrupt decrease in the baseline foetal heart rate of greater than 15bpm for greater than 15 seconds
Occurs due to hypoxic stress (foetus reduces HR to preserve myocardial oxygenation and perfusion)

Are they
Early
Variable
Late
Prolonged

37
Q

Describe early decelerations

A

start when contraction begins, stops when contraction stops
Increased foetal intracranial pressure →stimulation of the parasympathetic nervous system via the vagus nerve
Physgiological

38
Q

Describe variable decelerations

A

Rapid fall in FHR with variable duration and relationships to contractions
Usually caused by umbilical cord compression
Variable decelerations without the shoulders or with Biphasic (W) shape are more worrying - suggests the foetus is becoming hypoxic

39
Q

What is shouldering

A

Accelerations before and after a variable deceleration

40
Q

Describe late decelerations

A

begins at the peak of the uterine contraction and recovers as it ends
Oxygen in retroplacental reservoir used up during contractions → hypoxaemia until full reoxygenation after relaxation
Seen in maternal hypotension, PET, uterine hyperstimulation
Very concerning → foetal blood sampling, expedite delivery

41
Q

Describe prolonged decelerations

A

> 3 minutes (2-3 = non-reassuring)
→ FBS, emergency C-section

42
Q

What is a sinusoidal pattern

A

Smooth, regular, wave-like pattern
Frequency of around 2-5 cycles a minute
No beat to beat variability
Indicates severe foetal hypoxia or anaemia and/or foetal/maternal haemorrhage
→ requires immediate caesarean section

43
Q

What are the outcomes of overall impression from the CTG

A

Reassuring (BHR 110-160)
Non-reassuring (BHR 100-109 or 161-180)
Abnormal (BHR <100 or >180), sinusoidal pattern, decelerations for 30 minutes, bradycardia >3 minutes

Normal: all features reassuring
Suspicious: 1 non reassuring feature
Pathological: 2 non reassuring feature or 1 abnormal feature

44
Q

What should be done if CTG is suspicious

A

Correct underlying causes
Obs
Inform obstetrician or senior midwife
Document plan for reviewing the clinical picture and CTG findings

45
Q

What should be done if CTG is pathological

A

Obtain review by obstetrician AND senior midwife
Exclude acute events e.g. cord prolapse, suspected placental abruption, suspected uterine rupture
Correct underlying causes
Brief the mother and any companions
Digital foetal scalp stimulation
Consider foetal blood sampling, expediting birth

Y5 O+G (70 decks)

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