pregnancy stuff Flashcards
What is meant by early Pregnancy?
name some issues that can happen in early pregnancy
Pregnancy in the first trimester that is completed up to 13 weeks
- Ectopic P
- miscarriages and Recurrent miscarriages
- HG
- Molar P
Bleeding DDx in pregnancy
(divide according to trimesters)
Alongside the pregnancy related causes, conditions such as STI’s and cervical polyps should be excluded.
Teratogenic Drugs & their effects on pregnancy
- T
- Epilpetics (SV, Phenytoin)–>NTD
- Retinoids (Roaccutane)–>Misscarriage
- ACE inhib & ARB’s–>Oligohydramnios,hypocalvaria
- Lithium–> Ebstein’s anomaly (cardiac problems)
- Opiods–> cx w/drawl symp “neonatal abstinence syndrome (NAS)” /Oral contraceptives
- Warfarin
- Antibiotics
MCAT
Folic Acid in requirments in pregnancy
which women r considered “high risk”? (3)
- Prevention of neural tube defects (NTD) during pregnancy*
- ALL women should take 400mcg until 12th week*
HIGH risk of conceiving a child with a NTD should take 5mg B4 conception until the 12th week
HIGH RISK
- Either partner has a NTD, had a previous preg w/ NTD, or FHx of NTD
- she’s taking antiepileptic drugs or has coeliac disease, diabetes, or thalassaemia trait.
- the woman is OBESE (BMI of 30 kg/m2 or more).
safe drug prescribing in early Pregnancy
What placental problems can occur in pregnancy?
key distiguishing feautures of each
Placenta previa–> NO pain & Non-tender uterus w/ ABnormal lie
Placenta accreta--> RFx is previous uterine surgery
Placental abruption–>SUDDEN Constant lower abdo PAIN, Tender, WOODY uterus w/ normal lie, FHR DISTRESSED
Vasa praevia-->dark-red bleeding occur following rupture of the membrane, Fetal BRADYCARDIA is classically seen
Placenta Previa Vs Accreta
Rf, CF, Ix, Mx
What is the difference between placenta previa and a low-lying placenta.
Low-lying placenta is used when the placenta is within 20mm of the internal cervical os
Placenta praevia is used only when the placenta is over the internal cervical os
Placental abruption
- Rfx (6)
- CFx
- complications for mum and fetus
- managment (depends of fetus)
Fetus alive and LESS 36 weeks
- fetal distress: immediate caesarean
- no fetal distress: observe closely, steroids, NO tocolysis, threshold to deliver depends on gestation
Fetus alive and MORE than 36 weeks
- fetal distress: immediate caesarean
- no fetal distress: deliver vaginally
Fetus dead
induce vaginal delivery
what is Vasa Previa?
Rf?
Mx
Vasa previa is when unprotected fetal vessels traverse the fetal membranes over the internal cervical os. These exposed vessels are prone to bleeding, particularly when membranes rupture during labour and at birth.
This can lead to dramatic fetal blood loss & death.
- These vessels may be from either a velamentous insertion of the umbilical cord ORR
- May be joining an _ac_cessory (succenturiate) placental lobe to the main disk of the placenta.
There are 2 types
- Type I – fetal vessels are exposed as a velamentous umbilical cord
- Type II – fetal vessels are exposed as they travel to an accessory placental lobe
RFx
- low lying placenta
- multiple pregnancy
- IVF
Mx
Corticosteroids, given from 32 weeks gestation to mature the fetal lungs
Elective C- section, planned for 34 – 36 weeks gestation
ectopic pregnancy
Rfx? (7)
Where is the most common location of a ectopic pregnancy?
is when a pregnancy is implanted outside the uterus.
The most common site is a fallopian tube.
An ectopic pregnancy can also implant in the entrance to the fallopian tube (cornual region), ovary, cervix or abdomen.
alaa anything that can cause damage to the fallopian tube is a risk factor for example surgeries & smoking
symp & signs of Ectopic pregnancy
what 5 qs do u wanna ask?
- have u missed your period?
- any vaginal bleeding?
- shoulder tip pain (peritonitis)?
- low abdo pain?
- any brownish vaginal discharge? (due to decidua breaking down)
Ex:
- lower abdo mass
- cervical motion tenderness
- vaginal examination = fullness in pouch of dougles
- pallor, abdominal distension, shock, and hypotension.
Diagnosis of ectopic pregnancy (2)
referrels?
⇒⇒ serum β-HCG
⇒⇒TRANSVAGINAL USS–> identify the location of pregnancy and if theres a fetal pole and heartbeat.
>>Consider a transabdominal USS if enlarged uterus or other pelvic pathology, such as fibroids or an ovarian cyst
Immediate admission to (EPAU) or out-of-hours gynaecology service
Management of Ectopic pregnancy (3)
- Expectant management* if hcg less than 1,000→ repeat hCG levels on days 2, 4 and 7 after the original test
- Medical → IM Methotrexate
- Surgical → Salpingectomy or Salpingotomy
**also called ‘wait and watch’, when no medical or surgical treatment is given. The aim is to see if the condition will resolve naturally as an option to specific women
Role of methotrexate in ectopic pregnancy?
when would u not give it?
It is aDihydrofolate reductase inhibitor cytotoxic agent that disrupts the folate dependent cell division of the developing fetus.
NOT GIVEN WHEN……
- if theres fluid
- if theres fetal cardiac activity
- if a mass is seen on USS
- if ruptured ectopic P.
Surgical options for ectopic pregnancy and follow-ups
Sapingotomy or salpingostomy is done If there is damage to the contralateral tube from infection, disease or surgery, so unwould do this to preserve the the fallopian tube and save fertility!
In a salpingotomy, HCG follow up is required until the level reaches <5iU (negative), to ensure there is no residual trophoblast. The risk of recurrent ectopic pregnancy in the salvaged tube will be increased.
Expectant management of an EP can only be performed in those women who…(
- clinically STABLE and PAIN FREE
- a tubal ectopic pregnancy < 35 mm
- NO visible heartbeat on USS
- serum hCG levels of 1,000 IU/L or less
- are able to return for follow-up.
what is Pregnancy of Unknown Location (PUL)
causes
how do you investigate and manage it?
woman has a + pregnancy test and there is no evidence of pregnancy on the USS ectopic pregnancy
- viable IU pregnancy*
- complete miscarriage*
- In this scenario, an ECTOPIC cannot be excluded, and careful follow up needs to be in place until a diagnosis can be confirmed*.
what is Miscarriage? (early vs late)
type of Miscarriages?
spontaneous loss of a pregnancy before _24 weeks_ (6 months) of gestation.
- Early miscarriage is before 12 wks
- Late miscarriage is between 12 and 24 weeks
Missed miscarriage – fetus is no longer alive, but no symp have occurred
Threatened miscarriage – vaginal bleeding with a closed cervix and a fetus that is alive
Inevitable miscarriage – vaginal bleeding with an open cervix
Incomplete miscarriage – retained products of conception remain in the uterus after the miscarriage
Complete miscarriage – a full miscarriage and theres no products of conception left in the uterus
Anembryonic pregnancy – a gestational sac is present but contains no embryo
When repeated in 48 hrs B- HCG decreases by 50% in a failed pregnancy!
risk factors for miscarriage
- Age >30-35 (mainly due to increase in chromosomal abnormalities)
- Previous miscarriage
- Obesity
- Chromosomal abnormalities (maternal or paternal)
- Smoking
- Uterine anomalies
- Previous uterine surgery
- Anti-phospholipid syndrome
- Coagulopathies
ways in which miscarriage can occur
Miscarriage: management (3)
include advice
What can happen if Products of conception is stuck in the cervix?
Expectant⇒ If LESS THAN 6 WEEKS. 1st line involves waiting for 7-14 days for miscarriage to complete spontaneously, then in 1 week repeat pregnancy test. give info on what to expect, advice on analgesia, and on how to get help in an emergency
Medical⇒ Vaginal misoprostol (can take orally) + antiemetics and pain relief
- Advise them to contact EPAU if the bleeding hasn’t started in 24 hours.
- Advise take a urine pregnancy test _3 weeks_ after medical management
- advise that bleeding might take up to 3 weeks , but if so heavy contact local hospital
Surgical⇒
Manual vacuum aspiration under LA as an outpatient
Electric vacuum aspiration under GA in theatre
Anti-rhesus D prophylaxis is given to rhesus - women having Sx management of ectopic pregnancy.
- Misoprodtol is a Prostaglandin analogou which soften the cervix and stimulate uterine contractions.*
- Products of conception and clots lodged in the cervical canal induce a vasovagal response, resulting in hypotension and bradycardia (so called cervical shock). Immediate action to remove any clot or tissue from the cervix will result in rapid resolution of the symptoms.*
How should I follow up a woman after a miscarriage?
Discuss any questions after miscarriage.
- When can I have sexual intercourse? wait until symptoms have all gone
- When can I try for a next baby? 4-6 wks until periods come back
Assess the woman’s psychological well-being, and offer counselling if appropriate.
Ensure that all rhesus-negative women who have had a surgical procedure to manage miscarriage have received anti-D immunoglobulin.
what is Multiple Pregnancy?
Types? (6)
a pregnancy with more than one fetus
Monozygotic: identical twins (from a single zygote)
develop from a single ovum which has divided to form two embryos
Dizygotic: non-identical (from two different zygotes)
develop from two separate ova that were fertilized at the same time
Monoamniotic: single amniotic sac
Diamniotic: two separate amniotic sacs
Monochorionic: share a single placenta
Dichorionic: two separate placentas
Talking about Dizigotic (identical) what factor depends on what type of twin will be made?
it depends on the timing of when the embryos split during development.
complications of multiple pregnancy
1st trimester
o Maternal
- Anaemia
- Miscarriage
- HG
o Foetal
- risk of congenital anomalies
2nd trimester-3rd trimester
o Foetal
- Polyhydramnios
- IUGR
- Placental abruption
- Twin-twin transfusion syndrome (most common with monochorionic, diamniotic)
o Maternal
- Pre-eclampsia 3-4x
- Gestational diabetes
Delivery complicx
- Instrumental delivery
- Prematurity
Postpartum complicx
- PPH
- Post-natal depression
what is Twin-Twin transfusion syndrome?
treatment and referrel
which type of multiple pregnancy is a RFx?
when the fetuses share a placenta
the 2 fetuses share the blood supply, one will end up getting more than the other!>> diamniotic Monochorionic
- the Recipient who gets majority of blood is overloaded with fluid —> polyhydramnios
- the Donor who is starved of blood —> anaemia, GR
refer to _TERTIARY SPECIALIST FETAL MEDICINE CENTRE_
Severe cases – laser treatment required to destroy connection between two blood supplies
Delivery of multiple pregnancies?
Monoamniotic twins – requires elective C-section at around 32-34 weeks
· Diamniotic twins —> induction/C-section between 37 weeks and 38 weeks
Delivery >38 weeks – assoc. w/ increased risk of fetal death
o Vaginal delivery is possible when presenting twin is cephalic presentation
§ 2nd baby may require C-section after delivery of the first baby
o Elective C-section advised when presenting twin not cephalic presentation
· Antenatal steroids prior if delivery at <36 week
Antenatal surveillance/care for Multiple pregnancies
A specialist multiple pregnancy obstetric team
At booking:
- 5mg folic acid (as opposed to 400micrograms in single pregnancy)
- Iron supplements to prevent anaemia
- Vitamin D
- it is 1 RFx for pre-eclampsia so if they have one more e.g. nulliparous then they require ASpirin 75mg prophylaxis
FBC Check at:
- Booking clinic
- 5 mnths
- 7 mnths
Down Syndrome screening – only suitable for 1st trimester nuchal translucency scan, combined testing and quadruple testing is not accurate since hormones are higher in multiple pregnancy
USS scans -viability, chorionicity, nuchal translucency, malformation:
close monitoring look for growth restrict /TTTS/Unequal growth
o Monochorionic – 2 weekly scans from 16 weeks
(membrane folding sug- gests TTTS )
o Dichorionic – 4 weekly scans from 20 weeks
investigations for miscarriage suspect (3)
where should u refer them to?
(+ urine pregnancy test + vaginal bleeding +/- pain)–> Early Pregnancy Assessment Unit (EPAU)
TRANSVAGINAL USS–> most important finding to exclude miscarriage is fetal cardiac activity.
things the sonographer will look for:
- fetal heartbeat
- fetal crown rump length (CRL)–>estimate gestation
- Measure mean sac diameter (MSD)–>measure gestational sac in 3 dimensions:
define reccurent miscarriage
causes of reccurent miscarriage (6)
3 or more consecutive miscarriages.
Epidemiological factors (age)
**ANTIPHOSPHOLIPID SYNDROME**
Genetic factors (parental /embryonic)
Structural factors (Congenital uterine malformations, cervical weakness)
Endocrine factors (diabetes, thyroid, PCOS)
Infective agents (bacterial vaginosis)
Inherited thrombophilic defects (factor V Leiden, factor II (prothrombin) gene mutation and protein S)
what do u wanna ask in the Hx of recurrent miscarrige
Menstrual cycle history
Medical Hx: clotting (DVT, PE>–> APS), Lupus?
endocrinopathy (diabetes mellitus, thyroid dysfunction)
Surgical Hx –> uterine Sx (cervical incompetence, Asherman’s syndrome)
Hx of congenital abnormalities that may be heritable
FHx of bleeding disorders
Exposure to environmental toxins (e.g. occupational exposures)
Investigate couples with recurrent miscarriages (4)
Blood tests and genetic testing
- ALLL women should be screened b4 pregnancy for **antiphospholipid antibodies**
To diagnose APS it is mandatory that she has 2 positive tests at least 12 weeks apart for either lupus anticoagulant or anticardiolipin antibod
- Karyotyping
⇒ Cytogenetic analysis of the products of conception from the 3rd or future miscarriages
if unbalanced structural chromosomal abnormality seen…
⇒ Parental peripheral blood karyotyping of both partners
- Pelvic USS–> uterine abnormalities
- Testing for hereditary thrombophilias
- Blood tests: HbA1c, antiphospholipid/thrombophilia screen, TFT’s
benefits of pregnancy planning
Abortion Act 1967
Subject to the provisions of this section, a person shall not be guilty of an offence under the law relating to abortion when a pregnancy is terminated by a registered medical practitioner if two registered medical practitioners are of the opinion, formed in good faith
► that the pregnancy has not exceeded its 24th week and that the continuance of the pregnancy is riskier than termination, of injury to the physical or mental health of the pregnant woman or any existing children of her family; or
► that the termination is necessary to prevent permanent injury to the physical or mental health of the pregnant woman; or
► that the continuance of the pregnancy would involve risk to the LIFE of the pregnant woman, greater than if the pregnancy were terminated; or
► that there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.
principles of safe access to abortion care
diagnose and manage Molar pregnancy
features?
behaves like a normal pregnancy. a few things that can indicate a molar pregnancy vs a normal pregnancy:
- More severe morning sickness
- Vaginal bleeding
- Increased enlargement of the uterus
- Abnormally high hCG
- Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4)
REFER TO gestational trophoblastic disease centre
chemotherapy bc mole may Metastasize
What is a Molar pregnancy?
A hydatidiform mole is a type of tumour that grows like a pregnancy inside the uterus. This is called a molar pregnancy.
A complete mole occurs when 2 sperm cells fertilise an ovum that contains NO genetic material (an “empty ovum”). These sperm then combine genetic material, and the cells start to divide and grow into a tumour called a complete mole. NO FETAL MATERIAl will form.>>Dads genetics codes for development of an abnormal placenta
A partial mole occurs when 2 sperm cells fertilise a normal ovum (containing genetic material) at the same time. The new cell now has three sets of chromosomes (it is a haploid cell). The cell divides and multiplies into a tumour called a partial mole. In a partial mole, SOME FETAL MATERIAL MAY form.
RFx hyperemesis gravidarum (6)
what scoring can be used to classify the severity of NVP?
- 1st pregnancy
- Previous Hx of HG
- Obesity
- Multiple pregnancy
- Hyperthyroidism
- Hydatidiform mole
Pregnancy-Unique Quantification of Emesis (PUQE)
what is Hyperemesis gravidarum? why do u get it?
diagnostic criteria triad?
when is it most common? and when may it persist up to?
refers to persistent & severe vomiting during pregnancy, which leads to
- 5% pre-pregnancy weight loss
- DEHYDRATION
- electrolyte imbalance
rapidly increasing levels of B- hCG → CTZ → Vommit
most common between 8 and 12 weeks but may persist up to 20 weeks*.
Investigations hyperemesis gravidarum (3)
bedside tests, labs and imaging.
ELECTROLYTE LEVELS r SOO important to monitor as deranged levels are a hallmark of HG
Bedside Tests
- BMI
- Urine dipstick: quantify ketonuria (1+ ketones)
- Mid-stream urine
Labs
- FBC: anaemia, infection, haematocrit (can be raised)
- U&E: hypokalaemia, hyponatraemia, dehydration, renal d.
- BM: exclude DKA if diabetic
- LFT’s: exclude liver d. ex hepatitis or GS, monitor malnutrition
- Amylase: exclude pancreatitis
- TFT’s: hypo-/hyper-thyroid
Imaging
- USS: confirm viability, confirm gestation, exclude multiple pregnancy and trophoblastic disease.
when do u admit ptx with HG? (3)
- Continued N & V and is unable to keep down liquids or oral antiemetics
- Continued N & V + ketonuria and/or weight loss (greater than 5% of body weight), despite treatment with oral antiemetics
- A confirmed or suspected comorbidity (for example she is unable to tolerate oral antibiotics for a urinary tract infection)
Management of HG?
Managment of normal vommiting?
what factors determine if thet need admission or not(3)
Mild cases
- Oral anti-emetics at home
- complementary therapies:
- Ginger & Peppermint
- dry bicuits in morning
- eat less and more frequent
- Acupressure on wrist at P6 point (inner wrist)
- Acupuncture
Severe cases
factors requiring Admission!
- Unable to tolerate oral anti-emetics/keep down fluids
- Ketones present on urine dip (2+)
- Electrolyte imbalances
Admission:
- Thromboprophylaxis ex: TED stockings, LMWH
- IV anti-emetics
- IV fluids to rehydrate
- Thiamine ⇒ to prevent Wernicke-Korsakoff’s
1st line: Antihistamines (Promethazine) or Cyclizine
2nd line: Ondansetron (contraindicated in 1st trimester) and metoclopramide (may cause extrapyramidal side effects)
3rd line : Corticosteroids
IV hydration–>may need to admit
Thiamine: for prolonged vomiting to prevent Wernicke’s encephalopathy
Thromboprophylaxis: for all requiring admission
life threatening complications of HG and how to prevent them
Complications
- Wernicke’s encephalopathy
- Mallory-Weiss tear
- central pontine myelinolysis
- ATN
- fetal: SGA, pre-term birth
PUL managment
principles of safe access to abortion
Pain infection bleeding uterine rupture haemorrhage
After abortion
Discuss how long bleeding will last after abortion
It is normal to feel emotions after abortion
How to get help out of hours if complications arise
Discuss contraception after abortion
Can try again after her period comes back
Went to do sexual intercourse again
Advice woman to seek support if they need it
Peer support or support groups with other woman who have had abortion
Investigations for miscarriage?
Alaa check geeky medics
