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Complex Care > Week 1-4 > Flashcards

Week 1-4 Flashcards

1
Q

Complications in the first 20 weeks

Define: Miscarriage

A

is a pregnancy loss that occurs before 20 weeks gestation. i.e. before the legal definition of fetal viability.

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2
Q

Complications in the first 20 weeks

Define: Abortion

A

is the medical term used for both spontaneous and elective, induced events occurring before 20 weeks gestation.

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3
Q

Complications in the first 20 weeks

What is the incidence of miscarriage

A

occurs in at least 15% of clinically recognised pregnancies i.e.1 in 6.

Recurrent miscarriage (i.e. 3 or more consecutive miscarriages) affects between 1-2% of fertile couples

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4
Q

Complications in the first 20 weeks

What are some of the causes of a miscarriage

A
  • aneuploidy
  • abnormality at time of conception or soon after
  • maternal conditions/illness (e.g. viral infection)
  • uterine and cervical conditions (e.g. fibroids)
  • medications
  • obesity
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5
Q

Complications in the first 20 weeks

What are the 7 types of Miscarriage

A 
Threatened
Inevitable
Complete
Incomplete
Anembryonic
Missed
Recurrent
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6
Q

Complications in the first 20 weeks

Explain: 7 types of miscarriage

A

Threatened: there is some bleeding but the pregnancy may continue and 85% usually have a normal outcome.

Inevitable (imminent): pregnancy will not continue and will proceed to incomplete/complete abortion.

Complete: products of conception are completely expelled (more common up to 12 weeks).

Incomplete: products of conception are partially expelled (more common at 12-20 weeks).

Anembryonic (blighted ovum): the fetus dies or fails to develop but the placental tissue continues to function. There may be no initial bleeding and may retained for several weeks before bleeding starts.

Missed: When the fetus dies but the woman’s cervix stays closed. There is no bleeding, the pregnancy is non-viable and this is confirmed on ultrasound.

Recurrent: 3 or more consecutive miscarriages by the same woman

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7
Q

Complications in the first 20 weeks

How is a miscarriage diagnosed

A
  • confirmed by the woman’s story,
  • physical examination,
  • laboratory tests and ultrasonography.
  • Observation of presenting signs and symptoms e.g. pain, cramping, degree of blood loss, maternal response.
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8
Q

Complications in the first 20 weeks

What are the types of management for a miscarriage

A

Expectant: wait and see, is effective and acceptable, 50% will have vaginal bleeding have a viable pregnancy

Medical and Surgical: comprehensive history taken, confirmation of dates, U/S to determine viability, speculum exam, curettage, operative care

Prostaglandin administration: oral or vaginal cervical prep,
Misoprostol (‘Cytotec’) – 400μg S/L 2 hours prior to surgery.
PV (‘Cervagem’) – 1mg (gemeprost)

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9
Q

Complications in the first 20 weeks

Explain: Medical termination of pregnancy

A

A combination of misoprostol and mifepristone is approved for medical termination of early intrauterine pregnancy

  • Mifepristone is administered as a single 200mg oral dose, followed by an oral dose of of 800μg misoprostol 36–48 hours later.
  • Effects are seen within 4 hours of administration of second medication.
    92% effective when used in pregnancies up to 49 days (7 weeks).
  • It is essential that patients receive a follow-up examination 14–21 days after the medications
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10
Q

Complications in the first 20 weeks

Explain: Surgical care for as miscarriage management

A
  • I.V Syntocinon is often started before the surgery to reduce blood loss and to decrease the risk of uterine perforation by causing the uterus to contract and thicken.
  • Vacuum aspiration is preferred over sharp curettage in cases of incomplete miscarriage.
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11
Q

Define: EPAS

A

Early Pregnancy Assessment Service

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12
Q

Complications in the first 20 weeks

Explain: Midwifery care in miscarriage management

A
  • Pre and post operative care, includes O.T preparation.
  • Maintenance of NBM status and IVT.
  • Check maternal blood group.
  • Be prepared for the full spectrum of emotions from the woman: relief to extreme sadness and despair.
  • Acknowledge the pregnancy loss and avoid platitudes.
  • Empathy, counselling and social work contact and follow-up offered and as requested.
  • Consider cultural/religious issues re: death.
  • Provide written information leaflets, +/-mementos.
  • DOCUMENTATION ☺→ NB: No margin for error.
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13
Q

Complications in the first 20 weeks

Define: Hyperemesis gravidarum

A

is excessive nausea and vomiting in pregnancy that begins between 4-10 weeks gestation and should resolve by 20 weeks.

  • It is a serious problem leading to dehydration and starvation, electrolyte disturbance and weight loss of up to 10% of pre-pregnant weight.
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14
Q

Complications in the first 20 weeks

What is the incidence of Hyperemesis

A

0.3-2% of the women who experience morning sickness develop hyperemesis gravidarum.

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15
Q

Complications in the first 20 weeks

What conditions are usually associated with Hyperemesis

A
  • ANS disturbance,
  • multiple pregnancy and molar pregnancy,
  • high thyroxine levels,
  • chronic infection with Helicobacter pylori,
  • nutritional deficits e.g. trace elements and Vit B6,
  • psychogenic factors e.g. ambivalence or rejection of the pregnancy, and depression.
  • High pre-pregnancy fat intake increases the risk of severe hyperemesis.
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16
Q

Complications in the first 20 weeks

What are the inital investigations for Hyperemesis

A

Bloods

  • Full blood count
  • Urea and electrolytes
  • Liver function tests (LFTs)
  • Thyroid function tests (TFTs)

Urine

  • Urinalysis for ketones
  • Microscopy and culture

Radiology
- Early pregnancy ultrasound scan

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17
Q

Complications in the first 20 weeks

Explain: Hyperemesis medical management

A

Ensure correct diagnosis- thorough history to rule out causes of vomiting not related to pregnancy e.g. thyroid problems, UTI, gastroenteritis, liver disease.

Assess physical condition: skin-dryness and elasticity, rapid pulse, acetone breath, jaundice.

Treat S/S dehydration: elevated haematocrit, electrolyte disturbance and ketonuria

Initial treatment: NBM and give IV therapy to correct hypovolaemia and electrolyte imbalance.

Drugs that are often considered as additional therapy include:
Anti-emetics (Maxalon, Ondansetron)
Pyridoxine (Vitamin B6 mainly for nausea not vomiting),
Antihistamines (doxylamine, cyclazine, promethazine)
Glucocorticoids?
Short term enteral nutrition or TPN

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18
Q

Complications in the first 20 weeks

Explain: Midwifery management of Hyperemesis

A
  • rest and care
  • emotional, social and psychological support
  • administration of IVT
  • administration of antiemetics
  • Education re: gradual re-introduction of fluids and food in small meals NB: effect of food odours
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19
Q

Complications in the first 20 weeks

Explain: Cervical incompetence

A

Painless dilatation of the cervix in the second or early third trimester, often with bulging membranes through the cervix

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20
Q

Complications in the first 20 weeks

Define: Gestational trophoblastic disease

A

Is a term covering both the benign hydatidiform mole and choriocarcinoma which is malignant.
Also known as molar pregnancy

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21
Q

Complications in the first 20 weeks

What are the 2 types of Hydatidiform mole

A

COMPLETE- arises from an ‘empty egg’ which has lost its maternal genetic material. It shows total hydatidiform change with no evidence of an embryo or normal placental tissue

PARTIAL- is associated with a fetus even if the only evidence is traces of a microscopic fetal circulation. The karyotype is abnormal and has duplicate paternal genetic material

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22
Q

Complications in the first 20 weeks

What are the signs and symptoms of Hydatidiform mole

A

Symptoms

  • bleeding
  • minor intravascular coagulation occurs
  • hyperemesis
  • pallor
  • anxiety

Signs

  • uterine enlargement
  • absent FHR
  • absent fetal parts
  • unexplained anaemia
  • passage of vesicles per vaginum
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23
Q

Complications in the first 20 weeks

What is the management of hydatidiform mole

A

Risks before evacuation are:

  • haemorrhage
  • trophoblastic invasion and perforation of the myometrium
  • dissemination of possibly malignant cells

Risks during evacuation:

  • haemorrhage
  • perforation by instruments
  • dissemination of possibly malignant cells
  • emergency hysterectomy

Suction evacuation and curettage is the preferred method of evacuating a HM, independent of uterine size, for patients who wish to maintain their fertility.

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24
Q

Complications in the first 20 weeks

Define: Ectopic pregnancy

A

Is a pregnancy in which implantation and the products of conception develop outside the uterine cavity. The fallopian tube is the most common site of ectopic implantation (95% cases).

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25
Q

Complications in the first 20 weeks

What is the incidence of ectopic pregnancies

A

approx 2% of pregnancies

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26
Q

Complications in the first 20 weeks

Explain: Ectopic pregnancy

A

Fertilisation is in the ampulla of the tube, the dilated end, furthest away from the uterus.
This is also the most common site of ectopic implantation (90%) followed by the isthmus

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27
Q

Complications in the first 20 weeks

What are the causes of ectopic pregnancies

A
  • Previous tubal or pelvic infection/inflammation with residual endothelial damage or distortion by adhesions. e.g. chlamydia.
  • Previous tubal or pelvic surgery e.g. attempted sterilisation, reversal of sterilisation or salpingostomy as a result of irritation of the mucosal surface.
  • Women who conceive with an IUCD in situ have an increased risk of ectopic pregnancy, ?due to infection or altered tubal motility.
  • Assisted reproduction using ovulation stimulating drugs that can effect tubal motility e.g. Clomid, and IVF techniques e.g. GIFT due to possible existing tubal damage
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28
Q

Complications in the first 20 weeks

What are the signs and symptoms of ectopic pregnancy

A
  • Abdominal pain: constant or cramp-like and always present.
  • Bleeding occurs after the death of the ovum and is an effect of oestrogen withdrawal.
  • Internal blood loss, collapse and shock if severe.
  • Closed cervix.
  • Pelvic and abdominal examination elicit extreme tenderness over the gravid tube and in one or both fossa
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29
Q

Complications in the first 20 weeks

What are the 3 types of ectopic pregnancy

A

S/S: extremely variable depending on whether or not the pregnancy has ruptured

Unruptured: has symptoms of early pregnancy and abdominal and pelvic pain. The uterus still reaches the size of a gravid uterus of the same maturity

Ruptured: collapse and weakness, fast and weak pulse of 110bpm or more, hypotension, hypovolaemia, acute abdominal and pelvic pain, abdominal distension, rebound tenderness and pallor, shoulder pain

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30
Q

Complications in the first 20 weeks- Ectopic Pregnancy

Explain: Methotrexate

A

is the treatment for an unruptured ectopic pregnancy, aids in tubal preservation, and is important for future fertility attempts particularly couples using ART

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31
Q

What percentage of women experience morning sickness in pregnancy

A

80-90%

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32
Q

How often does Hyperemesis gravidarum occur?

A

occurs in 0.5–2% of pregnancies

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33
Q

Hypertensive disorders in Pregnancy

What 2 tests are being recommended to rule out pre-eclampsia in women between 20 and 35wks gestation

A

Triage PIGF test (Alere)

Elecsys immunoassay sFlt-1/PIGF ration (Roche Diagnostics)

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34
Q

Hypertensive disorders in Pregnancy

Explain: Pre-eclampsia’s pathophysiology

A

Pre-eclampsia is a multi-system disorder characterised by hypertension and involvement of one or more organ systems and/or the fetus.

  • Primary trigger of pre-eclampsia is poor placental perfusion due to abnormal placental trophoblastic infiltration of the uterine spiral arteries and this occurs many weeks before S/S manifest
  • Secondary pathology is probably related to reduced blood flow to major organs which causes endothelial damage. Decreased blood flow to the placenta causes inadequate placental perfusion
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35
Q

Hypertensive disorders in Pregnancy

List some of the pathophysiology effects of pre-eclampsia

A 
Abnormal placentation 
CVS and haematological changes
Coagulation system effects
Renal involvement 
Liver involvement
CNS involvement
Fetoplacental changes
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36
Q

Hypertensive disorders in Pregnancy

Define: Blood pressure

A

is the force exerted by the blood on the vessel walls.

Blood pressure measurement usually reflects the arterial blood pressure.

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37
Q

Hypertensive disorders in Pregnancy

Explain: Blood pressure changes in pregnancy, labour and postpartum

A

Changes result from hormonal and anatomical changes, resulting in increased blood volume, increased cardiac output and heart rate.

  • Rises in B.P mediated by progesterone effect on the blood vessel walls which results in decreased peripheral resistance.
  • B.P decreases in the FIRST TRIMESTER, rises gradually from the middle of pregnancy and returns to pre-pregnancy levels by term.

During LABOUR B.P rises as a result of anxiety, pain and during uterine contractions.

In the POSTNATAL period as the blood volume and physiological effects of pregnancy decrease, the blood pressure will return to its pre-pregnancy level.

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38
Q

Hypertensive disorders in Pregnancy

Define: Hypertension in pregnancy

A

Hypertension in pregnancy is defined as:

  • Systolic blood pressure of >140 mmHg
                and/or
  • Diastolic blood pressure (Korotkoff V) of >90mmHg
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39
Q

Hypertensive disorders in Pregnancy

List: risk factors for developing pre-eclampsia

A
  • Primigravidas
  • Women aged ≥40
  • Women with a new partner
  • Women with a past history or family history of pre-eclampsia
  • Multiple pregnancies
  • Women with other medical conditions e.g. diabetes, renal disease, presence of antipohospholipid antibodies
  • Obesity BMI ≥35
  • Autoimmune diseases
  • Women using ART
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40
Q

Hypertensive disorders in Pregnancy

Define: Eclampsia

A

is the occurrence of seizures in the patient with pre-eclampsia.

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41
Q

Hypertensive disorders in Pregnancy

Define: Pre-eclampsia

A

Hypertension arising after 20 weeks gestation, and the onset of one or more of the following:

  • Significant (++) dipstick proteinuria subsequently confirmed by spot urine protein/creatinine ratio > 30 mg/mmol
  • Renal insufficiency- serum or plasma creatinine  0.90 μmol/L or oliguria
  • Liver disease - raised serum transaminases and/or severe epigastric/right upper quadrant pain
  • Neurological problems severe headaches; persistent visual disturbances, hyper-reflexia with clonus, convulsions (eclampsia), stroke
  • Haematological disturbances - thrombocytopenia, HELLP, DIC
  • Fetal growth restriction, placental abruption
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42
Q

Hypertensive disorders in Pregnancy

Define: Gestational Hypertension

A

The new onset of hypertension after 20 weeks gestation without any maternal or fetal features of pre-eclampsia, followed by return of blood pressure to normal within 3 months postpartum

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43
Q

Hypertensive disorders in Pregnancy

Define: Chronic Hypertension

A

inc. essential hypertension and secondary hypertension

Essential- diagnosed in women with blood pressure > 140 mmHg systolic and/or > 90 mmHg diastolic (K5), pre-conception or in the first part of pregnancy, usually before 20/40, without an apparent cause

Secondary- from medical causes e.g. reflux nephropathy, glomerulonephritis, coarctation of the aorta

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44
Q

Hypertensive disorders in Pregnancy

Define: Severe hypertension

A

Is defined as:
Systolic blood pressure ≥ 170mmHg

			and/or

Diastolic blood pressure ≥ 110mmHg
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45
Q

Hypertensive disorders in Pregnancy

Define: White coat hypertension

A

Hypertension in a clinical setting with normal blood pressure away from that setting when assessed by 24 hour ambulatory blood pressure monitoring or home B.P monitoring using an appropriately validated device

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46
Q

Hypertensive disorders in Pregnancy

Explain: Hospital management

A

Fetal Maternal Assessment Unit for B.P profile.

Admission to hospital if indicated:

  • Note: bed rest is not necessary or beneficial in mild pre-eclampsia.
  • Low dose aspirin (100mg) for women with abnormal uterine artery function on Doppler U/S.
  • Women should have no dietary or fluid restrictions.
  • Observation for worsening physical signs of eclampsia.
  • PATIENT and FAMILY EDUCATION.
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47
Q

Hypertensive disorders in Pregnancy

Explain: Antenatal management

A

Appropriately timed delivery.

Consultation with other specialists.

General agreement that B.P ≥170/110mmHg should be lowered rapidly to protect the mother against risk of stroke in ANY setting.

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48
Q

Hypertensive disorders in Pregnancy

Explain: Fetal management

A
  • Early transfer to a tertiary centre for the woman with early onset pre-eclampsia.
  • Fundal height measurements?
  • Ultrasound, umbilical artery Doppler velocimetry, amniotic fluid volume estimation and cardiotocography.
  • Steroids if <34 weeks.
  • Fetal karyotyping in cases of severe SGA and early onset pre-eclampsia
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49
Q

Hypertensive disorders in Pregnancy

Explain: Controlling hypertension

A

AIM: is to reduce the systolic reading by 20-30mmHg and the diastolic reading by 10-15mmHg, avoiding sudden drops.

OUTCOME: to protect the mother from immediate risk of cerebral haemorrhage without jeopardising the fetus

50
Q

Hypertensive disorders in Pregnancy

Explain: Anti-hypertensive medications

A

Treatment is divided in to acute and chronic management

ACUTE -
indicated in cases of severe hypertension e.g. B.P 170/110mmHg due to the risk of intracerebral haemorrhage and eclampsia.
if conscious, commence oral antihypertensive therapy

CHRONIC-
In cases of mild hypertension for B.P maintenance i.e. if B.P reaches 140-160/90-100mmHg on more than one occasion.
For ongoing treatment, initial drugs of choice: methyldopa, oxprenolol, hydralazine, nifedipine, labetolol, clonidine, prazosin.

51
Q

Hypertensive disorders in Pregnancy

Medical Management of Specific Organ Dysfunction: Neurological

A

‘Magnesium sulphate for women with pre-eclampsia halves the risk of eclampsia and is the drug of choice for treating eclamptic fits’.
- Treat the blood pressure

52
Q

Hypertensive disorders in Pregnancy

Medical Management of Specific Organ Dysfunction: Hepatic, Renal and Haematological disturbances

A

The term HELLP (haemolysis, elevated liver enzymes and low platelets) is a manifestation of severe pre-eclampsia and occurs in 2-12% of cases.

53
Q

Hypertensive disorders in Pregnancy

Medical Management of Specific Organ Dysfunction: Disseminated Intravascular Coagulation (DIC)

A

platelet consumption and clotting, that occurs in the placental bed and more widely throughout the circulation, coupled with the anticoagulant effect of fibrin degradation products. This creates a bleeding tendency and organ failure.

Treat the underlying cause, and practice caution with I.V fluid replacement as overload and pulmonary oedema common. Platelet transfusions, FFP and/or cryoprecipitate may all be used in treatment

54
Q

Hypertensive disorders in Pregnancy

Explain: Acute management in antenatal

A
  • Maintain quiet and calm atmosphere
  • Explanation to patient and family
  • Continuous fetal monitoring
  • Frequent B.P measurements, urine output
  • Administration of steroid course if < 34 weeks gestation
  • Blood results for deterioration, I.V. access, medications
  • Delivery after stabilisation (if possible)
  • LSCS
  • Documentation of events
55
Q

Hypertensive disorders in Pregnancy

Explain: Acute management in Postnatal

A
  • ICU/HDU admission. Hypertensive disorders account for 29.3% of obstetric admissions to ICUs in the Netherlands.
  • I.V access : careful fluid replacement, epidural infusion, MgSO4 infusion, ?albumin replacement.
  • Monitoring of cardiac and haematological status by CVP may be indicated, if in I.C.U.
  • Hourly B.P, P, urine measures >30ml/hr.
56
Q

Hypertensive disorders in Pregnancy

Explain: safety of BF and anti-hypertensive meds

A

The most commonly used anti-hypertensives are secreted in small amounts, but all are classified as safe for use in pregnancy and lactation

57
Q

Define: Antepartum Haemorrhage

A

Bleeding from the genital tract after 20 weeks gestation and before the birth of the baby

(6% of women will have bleeding during the 3rd trimester)

58
Q

List some causes of APH in late pregnancy

A

Placenta previa (25%)
Placental abruption (35%)
No specific cause (35%)
Other specific causes (5%)

59
Q

When diagnosing APH what historical factors do you need to consider

A
  • Colour and consistency of blood loss?
  • Were there any predisposing factors?
  • Is the bleeding associated with contractions?
  • Is there constant abdominal or back pain?
  • Is the above pain associated with ROM?
  • Has there been decreased fetal movements?
  • Ask the woman about pregnancy health and any previous ultrasounds.
60
Q

Define: Placenta Previa

A

Placenta is partially or completely implanted in the lower uterine segment on either the anterior or posterior wall.

It either completely or partially covers the cervical os or impinges on the edge of the cervical os.

61
Q

What is the incidence of placenta previa

A

0.5% of pregnancies that reach the third trimester and a 4-8% recurrent risk

62
Q

Placenta previa and LLP occur more frequently in patients with….

A

Endometrial scarring: previous LSCS, TOP, previous placenta previa (4-8% recurrence), increased parity > 4 closely spaced pregnancies.

Impeded endometrial vascularisation: hypertension, diabetes, drug use, smoking, increased maternal age.

Increased placental mass: multiple pregnancy

63
Q

What are the Clinical features of Placenta Previa

A
  • The uterus is soft and non tender.
  • Majority of women present with bright painless bleeding.
  • Most common timing of the first bleed is between 27-32 weeks
  • There is often a malpresentation or abnormal lie.
64
Q

What is the management of bleeding with placenta previa

A
  • Monitor maternal observations.
  • CTG monitoring
  • Place woman in a lateral position and gentle palpation
    • Weigh pads
      NO vaginal examinations
  • IV cannulation and fluid replacement
  • Contact RMO
  • Group and cross match, Kleihauer and steroids if < 34 weeks
  • Ultrasound for placenta site
  • Reassurance
  • Conservative i.e. hospital admission/home vs. LSCS. Issues?
  • No sex
65
Q

Define: Placental Abruption

A

Premature separation of a normally implanted placenta.

- Maternal haemorrhage occurring in the decidua basalis and causing separation.

66
Q

What is the incidence of placental abruption

A

up to 2% of all pregnancies

67
Q

What are the Clinical features of Placental Abruption

A
  • Dark vaginal bleeding
  • Abdominal or lower back pain
  • Uterine hypertonus
  • Uterine contractions:
    ↑frequency and ↓amplitude
  • Uterine tenderness
  • Fetal lie usually normal
  • Fetal distress or fetal death
  • Observations may be normal initially
68
Q

What is the management of a Placental Abruption

A
  • Monitor maternal observations
  • Perform gentle palpation
  • Commence CTG monitoring
  • Place woman in a lateral position
  • Monitor PV loss
  • Notify RMO
  • IV cannulation, steroids if < 34 weeks
  • Group and cross match, Kleihauer, FBC and clotting factors
  • Ultrasound
  • Conservative versus LSCS
  • Remember PPH risks
69
Q

What are some of the complications of placental abruption

A
  • maternal shock
  • anaemia
  • couvelaire uterus
  • infection
  • PPH
70
Q

Describe: Vasa Previa

A

Occurs when a velamentous insertion of the umbilical cord crosses the cervical os ahead of the presenting part.
- Usually presents with significant bleeding associated with ROM

71
Q

What is the management of Vasa Previa

A

LSCS!

After ROM fetal distress is profound and disproportionate to the amount of visible blood loss.
Once vasa previa is confirmed in the presence of a live fetus, LSCS is performed

72
Q

Define: Isoimmunisation

A

sensitisation of a species with antigens from the same species.

  • This can occur where a woman is Rhesus negative and the fetus is Rhesus positive. Fetal blood cells can pass into the maternal circulation which may cause her to produce antibodies against the foreign cells.
73
Q

Define: Rhesus Isoimmunisation

A

Occurs when a pregnant woman is sensitised to produce immunoglobulin G antibodies against fetal red blood cells usually from the Rh or ABO blood group

74
Q

Explain: Pathophysiology of Rhesus Isoimmunisation

A
  • Maximum maternal blood volume increases between 28 and 32 weeks gestation and further facilitates dilation of these vessels.
  • The formation of antibodies is gradual in the mother and not likely to affect the first pregnancy.
  • Changes in fetal blood pressure are responsive to changes in blood flow in the maternal circulation, and may also account for increased chance of fetal erythrocytes breaking into the intervillous space.
75
Q

When does Isoimmunisation occur

A

There is a risk of isoimmunisation in any situation in which Rh positive red blood cells enter the circulation of an Rh negative woman.

The degree of this risk will vary with the amount of rhesus antigen to which she is exposed

76
Q

What are the effects of Isoimmunisation on the fetus

A
  • signs of anaemia
  • baseline rate 180bpm or greater
  • late decels or loss of short-term variability
  • decreased fetal activity
  • fetal congestive heart failure
77
Q

How is Isoimmunisation diagnosed throughout pregnancy

A
  • Antibody screening at booking in (indirect Coombs test)
  • Kleihaure blood test on mother to detect fetal cells in maternal circulation
  • Middle cerebral artery doppler velocity (Colour-flow Doppler now used to visualise the middle cerebral artery)
78
Q

What is the medical management for Isoimmunisation

A

Fetal surveillance

  • U/S
  • MCA
  • FM
  • Monitoring from 16 weeks

Intrauterine Transfusion

Prevention
- prophylactic anti-D

79
Q

Define: Anti-D

A

Is the immunoglobulin offered to Rh negative mothers- It can prevent the mother from developing antibodies to the Rh positive factor which may pass into her circulation during placental separation

80
Q

When should a woman be given Anti-D after a sensitising event

A

within 72 hours

81
Q

When is Anti-D typically given in pregnancy

A

at 28 and 34 weeks gestation

  • within 72 hours of birth if baby is Rh positive
82
Q

What is the incidence of morning sickness and hyperemesis gravidarum

A

Morning sickness- 80-90% of women experience it in pregnancy

Hyperemesis gravidarum- occurs in 0.5-2% of pregnancies

83
Q

Hyperemesis gravidarum is characterised by…

A

persistent, severe nausea and vomiting. Although the exact pathogenesis of this condition is unknown, its aetiology is likely multifactorial

84
Q

Define: Chronic hypertension

A

hypertension diagnosed before pregnancy or in the first 20 weeks of gestation in the absence of any underlying cause.
- Hypertension that is diagnosed for the first time during pregnancy and does not resolve postpartum is also classified as chronic hypertension.

85
Q

Define: Gestational hypertension

A

hypertension detected for the first time after 20 weeks gestation without proteinuria.

  • It usually resolves by 3 months postpartum without any other signs of preeclampsia
86
Q

Define: Preeclampsia

A

a multi-system disorder associated with hypertension and proteinuria, which rarely presents before 20 weeks gestation.

87
Q

Define: Preeclampsia superimposed upon chronic hypertension

A

preeclampsia that occurs in women who are already hypertensive; in such cases, the outlook is much worse than for either condition alone.

88
Q

Define: Eclampsia

A

one or more seizures that occur in association with preeclampsia.

89
Q

What are the 2 classifications of preeclampsia

A

Mild and severe

90
Q

What are the 2 classifications of preeclampsia parameters

A

Mild: BP 140-160/90-110

Severe: BP >160/>110

91
Q

APH can be classified into 3 distinct types, these are….

A

INCIDENTAL, as in localised causes in the genital tract
ACCIDENTAL, as in placental abruption
INEVITABLE, as in placenta praevia

92
Q

What are the 3 classifications of placental abruption

A

Central/Concealed- the separation occurs near the centre of the site of the placental attachment; blood cannot escape so it is retained between the uterine wall and the placenta as a large retroplacental haematoma.

Revealed/marginal- he separation occurs near the edge of the placenta and blood tracks down between the membranes and the decidua, through the cervix and into the vagina and is seen at the vulva

Partially revealed- this is a combination of concealed and revealed bleeding, where some of the blood escapes into the vagina, the rest remaining trapped in the uterus

93
Q

Define: Diabetes

A

is a clinical syndrome characterised by hyperglycaemia due to deficiency or diminished effectiveness of insulin

94
Q

What are the 3 classifications of diabetes

A 
Type 1 (Insulin Dependent Diabetes Mellitus - IDDM)
Type 2 (Non insulin Dependent diabetes mellitus - NIDDM)
Gestational Diabetes Mellitus (GDM)
95
Q

Diabetes in pregnancy

Explain: Fetal metabolism

A
  • The fetus receives glucose from the placenta by facilitated diffusion.
  • Fetus produces insulin from 9 weeks.
  • Increased maternal blood glucose levels lead to hyperinsulinaemia and macrosomia
96
Q

What is the management for Type 1 pre-gestational diabetes

A
  • Ideally pre-conceptual care.
  • Team approach: endocrinologist, obstetrician, midwives, diabetes educator, dietician.
  • Education and self-monitoring of blood glucose levels.
  • Insulin therapy
97
Q

Explain” Ketoacidosis

A

Unless Type 1 diabetes is treated with exogenous insulin, chemical substances accumulate in the blood as a consequence of utilising fat for energy - this is ketoacidosis

98
Q

Monitoring diabetes

Long term glucose control is measured by a blood test to measure glycosylated haemoglobin, this is known as

A

HbA1c

99
Q

What are some of the maternal complications of diabetes in pregnancy

A
  • Spontaneous miscarriage
  • Pre-eclampsia
  • Polyhydramnios
  • Infection
  • Preterm labour
  • Caesarean section
100
Q

What are some of the perinatal and neonatal outcomes of diabetes

A
  • Intrauterine death, (increased risk of stillbirth)
  • Neonatal mortality
  • Congenital abnormalities
  • Respiratory distress syndrome
  • Large for gestational age (LGA) i.e. -Macrosomia or IUGR
  • Hypoglycaemia
  • Hyperbilirubinaemia
101
Q

Explain: Type 2 diabetes

A

is Insulin resistance at the tissue level.

The body either makes too little insulin or is unable to use the insulin it makes

102
Q

Define: Gestational diabetes mellitus (GDM)

A

is carbohydrate intolerance of variable severity with onset at first recognition during the present pregnancy.
- Usually manifests between 24-28 weeks.

103
Q

What are some of the risk factors for GDM

A
  • Obesity, BMI >30
  • previous baby weight >4.5kg
  • family history of diabetes, GDM
  • maternal age >25yrs
104
Q

Whats the limit mmol for a fasting glucose level

A

> 7.0 mmol/l is indicator for diabetes

105
Q

What are the parameters for a GTT to indicate GDM

A

These figures indicate GDM

  • Fasting plasma glucose: 5.1–6.9 mmol/l
  • 1-h post 75 g oral glucose load: ≥10.0 mmol/l*
  • 2-h post 75 g oral glucose load: 8.5–11.0 mmol/l
106
Q

What is the management of diabetes in labour and birth

A
  • Pregnant women with diabetes who have a normally grown fetus may be offered vaginal birth through spontaneous onset of labour, induction of labour, or by elective caesarean section if obstetrically indicated, after 38 weeks.
  • Once in established labour the woman’s BGLs are regularly monitored (often hourly) and an insulin/dextrose infusion commenced to maintain BGL between 4-7 mmol/L and continuous EFM is performed
107
Q

List some signs of neonatal hypoglycaemia

A 
Hypothermia
High pitched cry
Poor temperature control
Sweating
Poor suck or refusal to feed
Tremors
Lethargy
Tachycardia
108
Q

Why do women bleed after sex in pregnancy

A

Vaginal wall is vascularised and bleeds easily after sex

109
Q

When does the lower uterine segment begin forming

A

starts forming from 26 weeks

110
Q

How many mls of blood loss do women begin to present symptomatic

A

1500mls

111
Q

Explain: Role of Insulin

A
  • Facilitates the movement of glucose from the blood to specific cells (liver, muscle etc)
112
Q

Explain: Glucagon

A

mobilises energy reserves and promotes synthesis and glycogen breakdown

113
Q

When is GDM usually diagnosed

A

2nd trimester

24-28 weeks gestation

114
Q

What does HPL do

A

it causes diabetes (along with oestrogen and cortisol)

115
Q

Case:
A woman has Type 1 diabetes and is in spontaneous labour and at term.

What is her care during labour and birth

A
  • Hourly BSL’s
  • Insulin/dextrose infusion commenced to maintain BGL between 4-7mmol/L
  • Continuous FHR monitoring
  • Cannulate
116
Q

Explain: Post coital bleeding

A

bleeding after sex

- aginal wall is vascularised and bleeds easily after sex from the friction

117
Q

When does the lower uterine segment start forming

A

26 weekks

118
Q

What blood loss will women typically become symptomatic

A

1500mls

119
Q

Case:
A woman G4P3, 36wks gestation, B negative presented to A&E after motor vehicle accident.
- She is groaning, complaining of nausea, back and abdominal pain, tenderness on gentle palpation. She also has a small amount of dark red PV loss.
- Obs: BP 90/50, P 120, O2 sat 90%

What is:
Provisional diagnosis
Why
Management

A

Provisional Diagnosis- placenta abruption

Why?- she has the clinical features of a placenta abruption- dark red blood, abdominal and back pain, uterine tenderness

Management-

  • Maternal Obs,
  • Change her position if lying flat
  • CTG- monitor FHR,
  • Call for a clinical review- U/S?
  • Cannulate (for IV therapy/bloods- Kleihaurer, FBC, platelet, group and hold),
  • Give anti-D within 72hrs
  • Check previous Obs history inc. platelet count from previous bloods
  • Provide pain relief?
  • Document
120
Q

Case:
A woman G2P1, 35wks gestation,
- presents to BU with a bright red vaginal loss of approximately 500ml (states it began while she was washing up) -
She has no abdominal pain but is experiencing period pain now. On gentle abdominal palpation the lie is transverse

What is:
Provisional diagnosis
Why
Immediate assessments
Management
A

Provisional diagnosis- placenta Previa,

Why?- red blood loss, transverse lie of fetus

Immediate assessments carried out- CTG, monitor movements, maternal obs, maternal bloods- platelet count, cannulate

Ongoing care- U/S, check maternal history for placenta previa, monitor blood loss (weigh pads if needed)

121
Q

Case:
Rebecca G1P0 was admitted to birth suite for IOL at 41 + 3 weeks gestation.
- Following an ARM by Dr.Bloggs she begins to bleed heavily.

What is:
Provisional diagnosis
Immediate assessments/management

A

Provisional diagnosis- vasa previa

Immediate assessment- FHR- CTG, Em. LSCS, record blood loss, documentation

122
Q

Case:
You assess Tuyet in birth suite who is a G1P0 at 32 weeks.
- she has had indigestion for the past 24 hours which has been unrelieved by antacids and is now complaining of nausea, headache and decreased fetal movements.
- She looks pale, has no vaginal loss
- Obs: B.P 136/80 and Pulse 104bpm.

What is
Provisional diagnosis
Why
Immediate assessment

A

Provisional diagnosis and why-

  • could be epigastric pain,
  • nausea could indicate pending abruption, eclampsia,
  • pale could indicate blood loss (maybe internal)
Immediate assessment-
Review history 
Give steroids 
CTG 
U/S

Complex Care (2 decks)

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