Problems in pregnancy Flashcards
Hyperemesis Gravidarum : Diagnosis
- 5% pre-pregnancy weight loss
- dehydration
- electrolyte imbalance
Severity scale : PUQE score
Hyperemesis Gravidarum : Diagnosis
- 5% pre-pregnancy weight loss
- dehydration
- electrolyte imbalance
Severity scale : PUQE score
Hyperemesis Gravidarum : Risk factors
- increased levels of beta-hCG
*multiple pregnancies
*trophoblastic disease - nulliparity
- obesity
- family or personal history of NVP
Hyperemesis Gravidarum : Diagnosis
- 5% pre-pregnancy weight loss
- dehydration
- electrolyte imbalance
Severity scale : PUQE score
Hyperemesis Gravidarum : Management : First line
- Antihistamines: oral cyclizine or promethazine
- Phenothiazines: oral prochlorperazine or chlorpromazine
Hyperemesis Gravidarum : Management : Second line
- Oral Ondansetron
Risk : First trimester is associated with a small increased risk of the baby having a cleft lip/palate - Oral Metoclopramide or Domperidone:
Risk : metoclopramide may cause extrapyramidal side effects. I
t should therefore not be used for more than 5 days
Epilepsy in pregnancy : Epileptic drugs risk (3)
- Sodium valproate : risk of neural tube defects
- Carbamazepine : teratogenic
- Phenytoin : cleft palate
Epilepsy in pregnancy : Epileptic drugs risk - Phenytoin
- Phenytoin : cleft palate
-Vitamin K needs to be given in last month of the pregnancy to prevent clotting disorder in the new born
Epilepsy in pregnancy : Epileptic drugs risk - which anti-epileptic is the safest in pregnancy?
Lamotrogine
Although - doses may need to be increased
Epilepsy in pregnancy : Breastfeeding
Breast feeding is considered safe for mothers taking antiepileptics
Pre-existing diabetes in pregnancy : Management
-
Tight glycemic control
* Weight loss : for women with BMI of > 27 kg/m^2
* Stop oral hypoglycaemic agents : apart from metformin, and commence insulin -
Higher risk of developing foetal neural tube defects
* Folic acid 5 mg/day from pre-conception to 12 weeks gestation -
Higher risk of cardiomyopathy 2nd to hyperglycaemia
* detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts
* tight glycaemic control reduces complication rates
Gestational diabetes : Definition
- Glucose intolerance during pregnancy -> maternal and foetal hyperglycaemia
- Resolves after deliver } Placenta is delivered and Human placental lactogen is no longer produced
Gestational diabetes : Physiology in normal pregnancy
- Placenta secreted Human placental lactogen
- hPL binds to systemic insulin receptors and causes insulin resistance } more glucose available for foetus
- This in turn causes Pancreatic beta cell hyperplasia
- Gestational diabetes occurs when}
- Insulin resistance > Beta cell hyperplasia leading to hyperglycaemia
Gestational diabetes : Foetal complications
- Macrosomia } increased risk of shoulder dystocia
-
Respiratory distress syndrome :
Impaired lung surfactant development : High insulin levels reduce surfactant production, leading to impaired lung development -
Jaundice / Cardiomyopathy :
Increased erythropoiesis }
Polycycthaemia } less iron available to developing organs }
3x increased risk of congenital malformations + excess red cell break down at birth - Hypoglycaemia : Beta cell hyperplasia
Gestational diabetes : Risk factors
- BMI > 30
- Previous gestational diabetes or Macrosomia in foetus
- First degree relative with diabetes or Ethnic origin with high prevalence of diabetes
Gestational diabetes : Investigation
Oral glucose tolerance test : 24 - 28 weeks
Gestational diabetes : Diagnosis
fasting glucose is >= 5.6 mmol/L
2-hour glucose is >= 7.8 mmol/L
Gestational diabetes : Management
- Glucose self monitoring initiated
* Fasting plasma glucose < 7
i) Diet and exercise : 1-2 weeks
ii) + Metformin
ii) + Insulin
- Insulin should be started first line if;
i) Fasting glucose > 7
ii) Plasma glucose 6 - 6.9 and evidence of complications such as macrosomia
Hypertension in pregnancy : Normal Physiology of BP
- Blood pressure falls in the first trimester } especially diastolic
- Continues to fall until 20-24 weeks
- BP increases to pre-pregnancy levels
Hypertension in pregnancy : Pre existing hypertension
Definition : >140/90 before 20weeks
1. Switch to oral labetamol or nifedipine and hydralazine (if asthmatic)
1. Aspirin 75mg from 12 weeks
Hypertension in pregnancy : Gestational hypertension
Definition : >140/90 after 20 weeks without proteinuria
* Increases risk of pre-eclampsia
* Aspirin 75mg from 12 weeks
Jaundice in pregnancy : Intrahepatic cholestasis of pregnancy : Features + Incidence
Incidence
* Third trimester
* Most common liver disease in pregnancy
Clinical features
* Pruritus in palms and soles
* Raised bilirubin
Jaundice in pregnancy : Intrahepatic cholestasis of pregnancy : Risk to foetus
- Risk of preterm labour
- Stillbirth
- Foetal distress
Jaundice in pregnancy : Intrahepatic cholestasis of pregnancy : Management
- Sx relief : Urseodeoxycholic acid
* Weekly LFTS
* Induced at 37 weeks
Jaundice in pregnancy : Acute fatty liver of pregnancy : Features + Incidence
Incidence
* Third trimester / immediate following delivery
Clinical features
* Abdominal pain, N`+V
* Jaundice
* Hypoglycaemia
* } ? Following HELLP syndrome in pre=eclampsia
Jaundice in pregnancy : Acute fatty liver of pregnancy : Ix and Mx
- ALT > elevated
Management - Supportive care - definitive mx is delivery
PE in Pregnancy
Thromboembolism - leading cause of maternal death.
* LMWH used for mx
Pyelonephritis in pregnancy
- Pyelonephritis - common in 20 weeks
- Risk with with asymptomatic bactaemaemia - treated with antibiotics as soon as it is confirmed
- Cefelexin - avoid trimethoprin
Symphysis pubis dysfunction (SPD)
- condition that affectspregnantwomen, causing pain and discomfort in the pelvic region.
- It occurs due to the separation of the pubic symphysis, which is the joint that connects the two halves of the pelvis.
Symphysis pubis dysfunction (SPD) - Clinical features and Mx
Symptoms of SPD
include pain in the pubic area, lower back, hips, and thighs, difficulty walking or standing, and a clicking or popping sensation in the pelvis.
Management
Advice and reassurance - consider adjusting movements, pelvic exercises
Pre eclampsia : Diagnosis
New onset hypertension >140/90 after 20 weeks of pregnancy
AND 1 or more of the following;
1. Proteinuria
- Other organ involvement such as;
* Renal insufficiency
* Liver dysfunction
* Neurological deficit
Pre eclampsia : Pathophysiology
- Uteroplacental arteries are fibroses —> narrow
- Hypoperfused placenta —> Proinflammatory marker released into mother’s circulation
- Systemic vasoconstriction of vessels } Increases blood pressure
- Leads to end organ dysfunction and damage
Pre eclampsia : Clinical features
Systemic vasoconstriction, reduces blood flow to end organs resulting in;
- Kidney impairment } Proteinuria - loss of proteins } Oedema
- Retinal impairment } flashing lights, blurred vision and Papilloedema
- Liver injury and inflammation : Abdominal pain and deranged LFTSs
- Vessel damage / Endothelial injury : Uses up a lot of platelets leading to microthrombi
-Thrombi result in damage to RBCS } Haemolysis
Pre eclampsia : Clinical signs
- Hyper - reflexia
- RUQ/Epigastric pain
Pre eclampsia : High risk factors
- Hypertensive disease in a previous pregnancy
- Chronic kidney disease
- Autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
- Type 1 or type 2 diabetes
- Chronic hypertension
Pre eclampsia : Moderate risk factors
- First pregnancy
- Age 40 years or older
- Pregnancy interval of more than 10 years
- Body mass index (BMI) of 35 kg/m² or more at first visit
- Family history of pre-eclampsia
- Multiple pregnancy
Pre-eclampsia : Complications
- Eclampsia (Seizures)
Assoc with : Cerebral oedema } Severe headache, altered mental state, myoclonus, RUQ pain
Extreme blood pressure rise;
1. Haemorrhagic stroke
2. Placental abruption
Foetal compromise
1. Intrauterine growth retardation
2. Prematurity
Pre eclampsia : Mx of risk in pregnancy
- ≥ 1 high risk factors
Or - ≥ 2 moderate factors
Mx : Aspirin 75-150mg daily from 12 weeks gestation until the birth
Pre eclampsia : Referral for Pre-eclampsia
- BP >30/20
- BP>160/100
- Or 149/90> with protein urea or symptomatic IUGR
Pre eclampsia : Acute management
Indic : BP > 160/110 } need admission and observation
1. Oral labetalol (Nifedipine if asthmatic)
2. Deliver baby } definitive management
Eclampsia : Definition
Development of seizures in association with Pre-eclampsia
Eclampsia : Management
- First line : Magnesium sulphate
* Indication : Prevent seizures in severe pre eclampsia and treat them once they start
* Administeration : 4mg IV bolus then 1g/hr } continue for 24 hours after seizure or delivery
* Adverse effect : MgSO4 induced respiratory depression
Tx : Calcium Gluconate
Pre-eclampsia : HELLP syndrome
Complication of severe pre-eclampsia
* H- haemolytic
* Elevated liver enzymes
* Low platelets
Anaemia in Pregnancy : Screening
- Booking visit 8-10 weeks
Risk : Higher is twin and triplet pregnancies
FBC - 20-24 weeks
FBC repeated - 28 weekend
Anaemia in Pregnancy : Investigation
- First trimester : < 110 g/L
- Second / Third trimester : < 105 g/L
- Postpartum : < 100 g/L
Anaemia in Pregnancy : Management
Oral ferrous sulfate or Ferrous fumarate : Continue for 3 months after deficiency is corrected
Obesity in Pregnancy : Definition
BMI > 30
Obesity in Pregnancy : Risks :
Maternal
Maternal :
1. Early pregnancy :Miscarriage
2. During pregnancy : Increased risk of Gestational diabetes and Pre eclampsia
3. Delivery : Difficult labour and miscarriage
Obesity in Pregnancy : Management
Obesity in Pregnancy : Management
1. Weight and diet modification
2. 5mg folic acid
3. >35/>40 } consultant led obstetric unit and antenatal consultation with anaesthetist
Rheumatoid A in Pregnancy : Management
Avoid :
* Methotrexate >6 months prior to conception
If required:
* Sulfasalazine and hydroxychloroquinine } safe
* NSAID upto 32 weeks } risk of early close of Ductus arteriorsis after this
* Low dose corticosteroids
Rhesus - in pregnancy : Pathophysiology
- Rhesus antigens are found on RBCs
- Rh - ve mother delivers a Rh +ve child
- Immune system : Anti-D antibodies against Rh antigen of the foetal RBC
- Later pregnancies : Anti-D antibodies can travel across the placenta and attack fetal RBC } Haemolysis
Rhesus - in pregnancy : Management
IM Anti-D injections
1. Attaches to the rhesus-D antigens on the fetal red blood cells in the mothers circulation
2. Destroys fetal RBC in the mother’s blood
3. Prevents the mother’s immune system recognising the antigen creating it’s own antibodies to the antigen.
4. It acts as a prevention for the mother becoming sensitised to the rhesus-D antigen.
Given at : 28 weeks gestation and birth
HIV in Pregnancy : Management
Aim : Reduce indigence of vertical transmission
* ART : Anti-retroviral therapy given to all pregnant women
* Delivery :
< 50 } Vaginal delivery if load >50 } C-section
Foetus : Tripe ART given after therapy for 4-6 weeks
HIV in Pregnancy : factors affecting risk of transmission
- Prolonged rupture of membranes
- Delivery before 34 weeks
- application of foetal scalp electrode monitoring - all increase risk of hIV transmission
**Except for C-section **
Infections in Pregnancy : Chicken pox : Mx of exposure
- Check for varicella antibodies
If no antibodies found;
* < 20 weeks } Varicella-zoster Immunoglobulin
* >20 weeks } VZIG or acyclovir - given 7-14 days after exposure due to higher effectiveness
Infections in Pregnancy : Chicken pox : Mx of infection
> 20 weeks } Acyclovir
Infections in Pregnancy : Rubella : Following exposure
- Risk for foetus : Risk of congenital rubella syndrome highest 8 - 10 weeks } rare beyond this
- Ix : IgM antibodies raised
- Mx : If no immunity - MMR given postnatally - not during pregnancy
Congenital rubella
Cataracts, cardiac lesions, cerebral palsy and splenomegaly
Oligohydramnios : Definition
reduced amniotic fluid
less than 500ml at 32-36 weeks
Oligohydramnios : Causes
- premature rupture of membranes
- Potter sequence
- bilateral renal agenesis + pulmonary hypoplasia
- intrauterine growth restriction
- post-term gestation
- pre-eclampsia
Puerperal Pyrexia : Definition
temperature of > 38ºC in the first 14 days following delivery.
Puerperal Pyrexia : Causes
- endometritis: most common cause
* Infection of the endometrial lining following childbirth - urinary tract infection
- wound infections (perineal tears + caesarean section)
Puerperal Pyrexia : Management
If endometritis suspected - admit for IV antibiotics
Chorioamnionitis : Definition
infection of the amniotic fluid and fetal membranes, usually caused by ascending bacterial infection from the vagina and cervix.
Chorioamnionitis : Clinical presentation
The patient’s presentation with PPROM;
- abdominal pain, uterine contractions
- ‘flu-like symptoms’, fever, and foul-smelling discharge are all characteristic features of chorioamnionitis.
- This diagnosis is further supported by her current gestational age (24 weeks), as chorioamnionitis is more common in preterm pregnancies.
Chorioamnionitis : Management
- Prompt delivery - may need C section
- IV antibiotic
