Problems in Pregnancy Flashcards
What is pre-existing hypertension?
Where the woman has had hypertension before her pregnancy.
This is likely if hypertension in early pregnacy
Can also be retrospective diagnosis if BP values have not returned to normal within 3 months of giving birth
What is pregnancy induced hypertension?
High blood pressure in pregnancy.
Seen in the 2nd half of pregnancy and usually resilves within 6 weeks of giving birth
What can be present in pre-eclampsia?
- Hypertension
- Proteinuria (=/+ 0.3g/L)
- Oedema
What is pre-eclampsia?
A pregnancy specific, multi-system disorder with unpredictable, variable and widespread manifestations.
Where is the cut off for early and late pre-eclampsia?
34 weeks
What are the 2 stages of pre-eclampsia?
-
Stage 1= abnormal placental perfusion
- placental ischaemia
-
Stage 2= maternal syndrome
- an anti-angiogenic state associated with endothelial dysfunction
Pre-eclampsia is a multi-system disorder. What systems can be involved?
- CNS
- Renal
- Hepatic
- Haematological
- Pulmonary
- Cardiovascular
- Placental
What is HELLP syndrome?
A rare life-threatening condition seen in pregnancy that is associated with pre-eclampsia. Causes RBCs to break down as well as liver problems
Haemolysis, Elevated Liver Enzymes, Low Platelets
High morbidity/mortality
What is eclampsia?
A tonic-clonic seizure occuring with the features of pre-eclampsia
What is the management of severe PET/Eclampsia?
Control BP
Stop/prevent seizures
Fluid balance
Delivery
What is given in seizure treatment/prophylaxis?
Magnesium Sulphate
- Loading= 4g IV over 5 minutes
- Maintenence= IV infusion 1g per hour
- Further seizures= 2g
If persistant seizures consider diazepam 10mg IV
What are some anti-hypertensives that can be used in the treatment of pre-eclampsia?
IV labetolol
IV hydralazine
What is the commonest chronic medical disorder to complicate pregnancies?
Asthma
What test is carried out if DVT is suspected in pregnancy?
Compression duplex ultrasound
- If normal but clinical suspicion is high then repeat in 1 week to exclude extending calf vein thrombosis
- If iliac vein thrombosis suspected (whole leg swollen + back pain) the consider MRI venography
What alternative should be used in pregnancy instead of warfarin?
LMWH- convert by 6 weeks
Why shouldn’t warfarin be used in pregnancy?
Crosses placenta and is teratogenic
- Midface hypoplasia
- Stippled chondral calcification
- Short proximal limbs
- Short phalanges
- Scoliosis
What can be given for post-natal anticoagulation?
Heparin or Warfarin- neither are contraindicated in breastfeeding
Commence warfarin 5th postnatal day
What is APS?
Anti-phospholipid syndrome
An aqquired thrombophillia with variable presentation and severity
Can result in pregnancy complication
What antibodies are seen in APS?
Antiphospholipid antibodies (aPL)- autoantibodies that react with phospholipid component of the cell membrane
Anticardiolipin antibodies (aCL)
Lupus anticoagulant (LA)
True or False?
Anti-epileptic medication is contraindicated in pregnancy?
False
AEDs containing Valproate are associated with a higher risk but others are safe
What is a normal sympheseal-fundal height?
After around 24 weeks, the fundal hight for a normally growing baby should match the the number of weeks pregnancy +/- 2cm
e.g. for a 27 week pregnant, expect the fundal hight to be around 27cm
What are some possible reasons why a SFH might be large for dates?
- Wrong dates
- Fetal macrosomia
- Polyhydraminios
- Diabetes
- Multiple pregnancy
What is fetal macrosomia?
‘big baby’
Signs are large fundal hight and polyhydramonios
What is polyhydramnios?
Excess amniotic fluid
Amniotic fluid index > 25cm
What condition can cause polyhydraminios?
Diabetes
What are some foetal causes of polyhydramnios?
- Anomoly- GI atresia, cardiac, tumours
- Monochorionic twin pregnancy
- Hydrops fetalis- Rh isoimmunisation
- Viral infection (toxoplasmosis, CMV)
What investigations are carried out in a woman with polyhydramnios?
- OGTT
- Serology- toxoplasmosis, CMV, parovirus
- Antibody screen
- USS- fetal survey- lips, stomach
Define gestational diabetes
Carbohydrate intolerence resulting in hyperglycaemia of variable severity with onset or first recognition during pregnanct
What is SGA?
Small for Gestational Age
IUGR?
Intra Uterine Growth Restriction
FGR?
Fetal Growth Restriction
Define preterm delivery?
Before 37 weeks gestation
Extreme preterm is between 24 - 27+6 weeks
Very preterm is 28 - 31+6 weeks
Moderate to late preterm is 32 - 36+6 weeks
What is LBW?
Low birth weight
below 2.5kg regardless of gestation
What categories can IUGR be divided into?
Symmetrical and Asymmetrical
What are the maternal factors for SGA?
- Lifestyle- smoking, alcohol, drugs
- Height and weight
- Age
- Maternal disease e.g. hypertension
What are some fetal factors that can cause SGA?
- Infection- rubella, CMV, toxoplasma
- Congenital anomalies e.g. absent kidneys
- Chromosomal abnormalities e.g. Down’s Syndrome
What does symmetrical IUGR suggest?
Both head and body are small
Congenital, chromosomal, intrauterine infection, environmental
What does asymmetrical IUGR suggest?
Small body compared to normal sized head
PET, placental causes and smoking. Sign of redistribution
What counts as bleeding in early pregnancy?
Less than 24 weeks
What counts as bleeding in late pregnancy?
In the UK it is bleeding from 24 weeks onwards
US is 20 weeks + and WHO is 22 weeks +
What is antepartum haemorrhage?
Bleeding in or from the genital tract that occurs from 24 weeks pregnancy up until birth of baby.
What are some causes of antepartum haemorrhage?
- Placental- placenta praevia, placental abruption
- Uterine problem- uterine rupture
- Local causes- ectropion, polyp, infection, carcinoma
- Vasa Praevia
- Indeterminate
How is APH quantified?
- Spotting
- Minor
- Major- 500-1000ml
- Massive- 1000ml and/or shock
What is a woody hard uterus a sign of?
Placental abruption
What is placental abruption?
When the placenta separated from the uterus before birth in a previously normally implanted uterus.
What are some symptoms of placental abruption?
Vaginal bleeding, lower abdominal pain, low BP
What is a couvelaire uterus?
Occurs when loosening of the placenta (placental abruption) causes bleeding into the myometrium
True or False?
The pain felt with placental abruption comes in waves similar to a contraction
False
Women will complain of continous abdominal pain
What is placenta praevia?
When the placenta lies over the internal os of the cervix
What counts as a low lying placenta?
Term used after 16/40 weeks when the placental edge is less than 20mm from the internal os on TV or TA ultrasound
What is placenta Accreta?
A condition that occurs when the placenta grows too deeply into the uterine wall.
What is placenta increta?
Where the placenta invades into the myometrium
What is placenta percreta?
When the placenta invades through the uterus to the bladder
What is vas praevia?
Unprotected fetal vessels that traverse part of the membranes, below the presenting part of the fetus and very close to the internal os
Vessels will rupture during labour or amniotomy
What are the types of vas previa?
Type 1- When vessel is connected to a velamentous umbilical cord
Type 2- When the vessel connects to the placenta with an accessory lobe
What is the treatment of APH in vas previa?
Emergency C-section
What is post-partum haemorrhage?
Blood loss of over 500ml following the birth of a baby
What is the difference between primary and secondary PPH?
Primary occurs within 24 hours of delivery
Secondary occurs between 24 hours and 6/52 post delivery
What is minor PPH?
Between 500 and 1000ml without shock
What is major PPH?
Over 1000ml and/or signs of shock and on-going bleeding
What are the 4 Ts of PPH?
- Tone (70%)
- Trauma (20%)
- Tissue (10%)
- Thrombin (<1%)
