Problems in Pregnancy Flashcards
what is defined as pre-term birth
Delivery between 24 and 36+6 weeks
what can cause a pre-term birth
infection
over distention [Multiple, polyhydraminos]
vascular [placental abruption]
intercurrent illness [UTI/pyelonephritis, appendicitis, pneumonia]
cervical incompetence
idiopathic
risk factors for pre-term birth
previous pre term labour multiple uterine anomalies age parity (=0 or >5) poor socio-economic status smoking/drugs [esp cocaine] low BMI [<20]
what is definition of small for gestational age (SGA)
Infant with a birthweight that is less than 10th centile for gestation corrected for maternal height, weight, fetal sex and birth order
what is another cause of the baby being less than 10th centile
IUGR
what is IUGR
Intra Uterine Growth Restriction
i.e. poor growth
what are the 3 factors that contribute to IUGR
maternal
fetal
placental
what are the maternal factors that can cause IUGR
Lifestyle: Smoking, Alcohol, Drugs
Height and weight
Age
Maternal disease e.g. HTN
what are the fetal factors that can cause IUGR
Infection e.g. rubella, CMV, toxoplasma
Congenital anomalies e.g. absent kidneys
Chromosomal abnormalities e.g. Down’s syndrome
what are the placental factors that can cause IUGR
infarcts
abruption
often secondary to hypertension
what is the two sub categories of IUGR
symmetrical
asymmetrical
what is symmetrical IUGR
small head
small abdomen
what is asymmetrical IUGR
normal head
small abdomen
consequences of IUGR in labour/antenatal
risk of hypoxia
risk of death
consequences of IUGR in post natal
Hypoglycaemia Effects of asphyxia Hypothermia Polycythaemia Hyperbilirubinaemia Abnormal neurodevelopment
what are the clinical features seen that are suggestive of IUGR
Predisposing factors
Fundal height less than expected
Reduced liquor/amniotic fluid
Reduced fetal movements
what can be used to assess the fetal heartbeat
Cardiotocography
what can be seen on a cardiotocoaphy that indicates good reflex reactivity of the fetal circulation
Accelerations
- an increase in fetal HR at the start of a uterine contraction returning to baseline rate before next contraction
what can cause loss of baseline variability seen on Cardiotocography and why is this worrying
loss of baseline variability may be caused by sedative or analgesic drugs
in general, the less baseline variability present the greater the possibility of asphyxia
what other reading on the Cardiotocography suggests fetal asphyxia
any deceleration whose lowest point is past the peak of contraction [i.e. decelerations with lag time]
associated with asphyxia = longer the lag time, more serious the fetal asphyxia
what is the causes of large for dates pregnancy
wrong dates
multiple pregnancy
diabetes
polyhydramnios
what is the definition of polyhydramnios
excess amniotic fluid
what are cause of polyhydramnios
Monochorionic twin pregnancy Fetal anomaly Maternal diabetes Hydrops fetalis Ideopathic
what is Hydrops fetalis
abnormal accumulation of fluid in 2 or more fetal compartments, including ascites, pleural effusion, pericardial effusion, and skin edema
what are Sx of polyhydramnios
discomfort
labour
membrane rupture
cord prolapse
Ix of polyhydramnios
ultrasound
in relation to multiple pregancies, what does zygosity mean
refers to number of eggs fertilised to produce twins
in relation to multiple pregancies, what does chorionicity refer to
membrane pattern of the twins
what type of twins are at a higher risk of pregnancy complications
monochorionic/monozygous
what is meant by monovular zygosity
one ovum + one sperm fertilised
1 zygote splits into 2
think identical twins
what is meant by binovular zygosity
two ova + two sperm fertilised
2 zygotes
think non-identical twins
what type of chorionicty will dizygotic twins always have
Dichorionic Diamniotic
i.e. no contact been amniotic fluid/sacs or membrane
what are the types of chorionicty monozygotic twins can have
Monochorionic Diamniotic
Monochorionic Monoamniotic
what is Monochorionic Diamniotic
One membrane but two separate amniotic sacs
what is Monochorionic Monoamniotic
one membrane with one amniotic sac between the 2 fetus
how can we tell the chrionicity before birth
ultrasound
- shape and thickness of membrane
- twin peak at 12 weeks
how are multiple pregnancies diagnosed
usually ultrasound @ 12 weeks
Also
- exaggerated pregnancy Sx e.g. excessive sickness
- high AFP
- large for dates uterus
- feeling more than 2 fetal poles
what can cause perinatal mortality in multiple pregnancies
Congenital anomalies Pre term labour Growth restriction Pre eclampsia Antepartum haemorrhage Twin to twin transfusion
Mx of multiple pregnancies
More frequent antenatal visits
Detailed anomaly scan @ 18 weeks
Regular scans from 28 weeks for growth
Routine iron supplementation
Warning to mother risk and signs of pre term labour
Delivery of multiple pregnancies
Triplets or more – Caesarean section
Twins if twin one cephalic aim for vaginal delivery
what is the definition of gestational diabetes
carbohydrate intolerance resulting in hyperglycaemia of variable severity with onset or first recognition during pregnancy
what are the consequences of gestational diabetes
Overgrowth of insulin sensitive tissues and macrosomia
Hypoxaemic state in utero
Short term metabolic complications
Fetus has an increased long term risk of obesity, insulin resistance and diabetes
what is seen in a fetus when the mother has GDM
hyperinsulinaemia
- decreased arterial O2 and increased EPO
when is GDM screened for
at 28 week gestation
what are the diagnostic values of GDM
Fasting >=5.1 mmol/l
2 hour >=8.5 mmol/l
what are risk factors of GDM
Family history of diabetes Previous big baby Previous unexplained still birth Recurrent glycosuria Maternal obesity Previous gestational diabetes
what complications of diabetes in pregnancy is specific to pre-existing DM
Congenital anomalies
Miscarriage
Intra uterine death
what are the other complications of diabetes in pregnancy
Pre eclampsia Polyhydramnios Macrosomia Shoulder dystocia Neonatal hypoglycaemia
Mx of GDM
1st line = diet, weight control, exercise
2nd line = Metformin/Insulin
at what week are women with large for dates babies offered to be delivered on
38 weeks gestation
what should women with pre existing diabetes be offered during pregnancy
Fetal anomaly scan at 18 weeks
Regular eye checks for retinopathy
what affects does hypertension have on the kidneys
decreased GFR proteinuria increased serum uric acid increased creatinine/potassium/urea oliguria/anuria acute renal failure
what affects does hypertension have on the liver
RUQ pain
abnormal liver enzyme
hepatic capsule rupture
HELLP syndrome
what is HELLP syndrome
HELLP syndrome is a subtype of severe pre-eclampsia characterised by haemolysis (H), elevated liver enzymes (EL), and low platelets (LP)
how can HTN affect the placenta
IUGR
placental abruption
intrauterine death
what cardio medication should be stopped in pregnancy
ACEi
ARBs
what medication is used to Tx HTN in pregnancy
1st line = Labetalol
2nd line = Methyldopa
3rd line = Nifedipine [usually add if mono therapy fails]
when should Tx be started in HTN in pregnancy
when BP is ≥150 mmHg systolic and/or ≥100 mmHg diastolic
what is the target BP control
Aim for BP <150/80-100 mmHg
If target organ damage aim for BP <140/90 mmHg
< 140/90 consider reducing dose
< 130/90 Reduce dose
if there is pre-eclampsia, when should the baby be aimed to be delivered
at 37 weeks
gestational diabetes but the neonate are risk of hypoglycaemia - what does this put that at risk of
cerebral palsy
when is a labour induced in pre-existing DM
37-38 weeks
when is a labour induced in GDM on insulin
may be at 41 weeks if normal BMs and fetal growth
what does macrosomia put the foetus at risk of
shoulder dystocia
Tx of VTE
LMWH
why is pregnancy thought to be pro-thrombotic
think Virchow’s triad
Stasis
- Secondary to venous compression by pregnant uterus
Hypercoagulability
Vascular damage
- Varicose veins
what causes hyper coagulability state in pregnancy
↑ levels factor 7,8,9,10,12 and Fibrinogen
↑ numbers of platelets
↓ levels factor 11 and antithrombin 3
in a suspected DVT, what investigation is not done in pregnancy
D-Dimer
Ix of DVT in pregnancy
Duplex ultrasound
Tx of DVT in pregnancy
Heparin
what is the rule about Tx of a suspected DVT in pregnancy
Treat then see
what can be prophylaxis for DVT
TED stockings
why is heparin good in pregnancy
doesn’t cross the placenta so safe for the foetus
side effects of heparin
haemorrhage
Heparin induced thrombocytopenia
osteopenia
how does Heparin induced thrombocytopenia present
early in 5 days usually mild
Ix for suspected PE
1st line = CTPA
2nd line = X-ray
If CTPA -ve = bilateral compression Duplex Dopplers
why should an x-ray also be done in a suspected PE
as PE may also cause effusion, pulmonary oedema etc
should heparin be continued when in labour?
no should be stopped
if a women had a thrombotic episode during her pregnancy, how long should she remain on LMWH
Remainder of Pregnancy,
6 weeks postnatal,
total 3 months at least.
why is warfarin not used at certain points in pregnancy
Avoided in pregnancy 6-12 weeks
Teratogenic 5 %, miscarriage, neurological problems, still birth
Stopped 6 weeks before labour
why is warfarin used after pregnancy
is OK with breast feeding
if a women has hypothyroid and becomes pregnant, what is the management
increase Levothroxine by 25-50mcg in first trimester
Repeat TFTs every trimester
if a women has hyperthyroid and becomes pregnant, what is the management
Carbimazole / PTU Beta Blockers (propranolol)
TFT every trimester
Growth scans
what are the effects on the pregnancy of hyperthyroid in the mother
IUGR, preterm labour Thyroid storm
how does the pregnancy effect the mother’s hyperthyroid
Gets worse due to HCG in first trimester
Improves second and third trimesters
what are resp changes seen in pregnancy
Increased resp rate-
Causes resp alkalosis
increased oxygen demand
tidal volume increases
residual volume decreases
expiratory reserve decreases
what is unchanged in pregnancy in regards to respiration
FEV1
PEFR [peak flow]
Mx of asthmatics in pregnancy
optimise control
use of B2 agonist +/- inhaled corticosteroids
what is the concern of epilepsy in pregnancy on the effect it will have on the foetus
major malformations due to the drug treatment
- neural tube defects, orofacial and heart defect
why is there an increased chance of seizures in the 1st trimester
due to hyperemesis and haemodilution
what needs to be given to mothers taking hepatic enzyme inducing anticonvulsants
Vitamin K at 36 weeks
what is the effect of the pregnancy on the woman’s epilepsy
in 25% increase in seizure frequency
If seizure free unlikely to have seizures UNLESS stops medications
when is risk of seizure highest
in peripartum period
why is there deterioration of control of epilepsy in pregnancy
Decreased drug levels due to nausea and vomiting
Decreased drug levels due to ↑volume of distribution and ↑drug clearance
Lack of sleep towards term and during labour
Lack of absorption of drugs during labour
Hyperventilation during labour
what anticonvulsant is most associated with neural tube defects
valproate and carbamazepine
what anticonvulsant is most associated with orofacial clefts
phenytion
what anticonvulsant is most associated with cardiac clefts
phenytion and valproate
what minor malformations are seen in fetal anticonvulsant syndrome
Dysmorphic features (V-shaped eyebrows, lowset ears, broad nasal bridge, irregular teeth)
Hypertelorism [wide apart set eyes]
Hypoplastic nails and distal digits
how does the teratogenic risk of anticonvulsants change
increases with number of drugs
phenytion + valproate + carbamazepine = 50% risk to fetus
what do epileptic women need to take pre conceptually
5mg folic acid
what do epileptic women need to take during the pregnancy
continue folic acid
Vit K 10-20mg orally from 34-36 weeks if on enzyme inducers due to reduce risks of fetal Vit K deficiency and Haemorrhagic Disease Newborn
should anti epileptic drugs be continued in labour
yes
as increase in fits around time of delivery
what is postpartum management in epileptic cases
Neonate should have 1mg IM Vit K
