WH: Complications in Pregnancy Flashcards
1
Q
Why do pregnant women have a greater UTI risk?
A
- Urine has more sugar, protein and hromones
- Uterus presses on bladder so more difficult to fully empty
2
Q
Which UTIs are pregnant women at greater risk of?
A
upper and lower
(cystitis and pyelonephritis)
3
Q
what does UTI in pregnancy increase the risk of?
A
increase risk of preterm delivery
- and low birth weight + preeclampsia
4
Q
what is asymptomatic bacteriruea ?
A
bacteria presen in urine without symptoms of infection
5
Q
what does asymptomatic bacteriuear increase the risk of?
A
increased risk of upper + lower UTI => increase risk of preterm labour
6
Q
when do pregnant women get their urine tested antenatally ?
A
at booking clinic and throughout pregnancy (MSU)
7
Q
LUTI presentation ?
A
- Dysuria (pain, stinging, burning)
- suprapubic pain
- increased frequency of urination
- urgency
- incontinence
- Haematuria
8
Q
Pyelonephtirits presentation?
A
- Fever
- Loin/suprapubic/back pain
- General malaise
- Vomiting
- Loss of appetitie
- Haematuria
- Renal angle tenderness
9
Q
What is most common UTI causative organism ?
A
E.coli
10
Q
what type of bacteria is e.coli? gram staining? shape? often found where?
A
gram -ve, anaerobic, ro-shaped bacteria found in faeces
11
Q
what does e.coli produce in urine ? from what?
A
gram -ve bacteria (e.coli) break down nitrates (normal waste product in urine) to nitrites => nitrite presence suggest bacterial infection
12
Q
Apart form nitrites, what could indicate infection in the urine?
A
leukocytes
13
Q
UTI in pregnancy management ?
A
- 7 days Abx (nitrofurantoin, amoxicillin)
14
Q
what antibiotic should be avoided in the 3rd trimester?
A
nitrofurantoin
15
Q
What is anaemia
A
low concentration of haemoglobin as result of underlying disease
16
Q
when are pregnant women screening for anaemia?
A
- booking clinic (may also then get screened for thallasaemia and sickle cell disease)
- 28 weeks gestation
17
Q
why pregnant women more prone to be anaemic?
A
during pregnancy, plasma vol increases => decreased haemoglobin conc
18
Q
anaemia presentation (5)
A
- asymptomattic
- sob
- fatigue
- dizziness
- pallor
19
Q
what could cause low MCV anaemia?
A
iron deficiency (+TAILS)
20
Q
what could cause normal MCV anaemia?
A
pregnancy (physiological response)
21
Q
what could cause raised MCV anaemia ?
A
b12 or folate deficiencya
22
Q
anaemia management in pregnancy?
A
- Iron supplements (ferrous sulphate)
- Folate (should already be taking)
23
Q
When and what is the does of folate in pregnancy?
A
400 micrograms before and during pregnancy (usualy first 1 weeks but if at risk of anaemia => whole prengnacy (maybe))
24
Q
why is there increased VTE risk in pregnancy?
A
due to hyper coagulable stat => blood clot more likely
25
when is risk of DVT/PE greatest during pregnancy ?
highest during post partum period
26
DVT RF?
- Smoking
- age > 35
- BMI > 30
reduced mobility
- multiple pregnancy
- pre-eclampsia
- thrombophilia
- IVF pregnancy
27
when start DVT prophylaxis during pregnancy ?
if 3 RF, start at 28 weeks
if 4 RF, start immediately
28
What is used for DVT prophylaxis in pregnancy ?
LMWH
(daltparin, tinzeparin, enoxaparin)
29
how long is the DVT prophylaxis taken for?
continued throughout pregnancy until 6 weeks post fatally
(stopped during labour)
30
what is offered if LMWH is contraindicated for DVT prophylaxis ?
mechanical prophylaxis
- Intermiiten pneumatic ompression
- Antiembolic comp stockings
31
DVT presentaiton
unilateral: calf of leg swelling, dilated superficial veins, tenderness to calf, oedema, colour changes to legs
- more than 3cm difference between calves (10cm below tibial tuberosity)
32
what is used to diagnose DVT during pregnancy?
Doppler US
(not D-dimer!)
33
why can d-dimer not be used in pregnancy?
pregnancy is a cause of raised d-dimer
34
what risk score is used for DVT? is this used in pregnancy?
wells score
- NOT used in pregnancy
35
DVT management ?
same as prophylaxis but higher dose
- LMWH (enoxa/tinza/dalteparin)
36
what is used to diagnosis PE in pregnancy?
- CTPA or VQ scan
37
What is pre-ecclampsia a disease of?
placental disease
38
what is pre-eclampsia ? when?
Hypertension in pregnancy with en organ failure (most often proteinuria) after 20 weeks gestation
39
describe how BP changes in normal pregnancy? describe physiology
normal pregnancy state: vasodilation (by NO + progesterone) => decrease peripheral resistance => decrease BP improved placental perfusion
(starts risking again from 28 weeks)
40
what causes pre-eclampsia ? pathophysiology (long answer)
caused by high vascular resistance in the spiral arteries + poor perfusion of placenta
- spiral arteries form abnormally => high vascular resistance in serial arteries => poor perfusion of the placenta => (fetal growth restriction) + oxidative stress => inflam chemical release into systemic circulation => systemic inflam + impaired endothelial function (in maternal blood vessels)
41
What is the pre-ecclampsia triad?
- Hypertension
- Proteinurea
- Oedema
42
What is chronic hypertension (related to pregnancy)
High BP that exists before 20 weeks gestation + is long standing
43
what is gestational hypertension?
hypertension occurring after 20 weeks gestation without proteinuria
44
what is eclampsia ?
it is when seizures occur as a result of pre-eclampsia
45
Pre eclampsia RF ?
- Pre-existing hypertension
- preve hypertension in pregnancy
- diabetes
- CKD
- maternal age >40
46
pre-eclampsia symptoms ?
present as complications
- Headache (most common)
- Visual disturbance
- N&V, epigastric pain
- Oedema
- Low urine output
47
what is required for pre-eclampsia diagnosis ?
BP >140/90mmHg
PLUS any of:
- proteinurea
- End organ damage
- placental dysfunction
(in pregnancy women after 20 weeks)
48
how many weeks gestation does patient need to be for it to be pre-eclampsia ?
after 20 weeks gestation
49
what are the aims of pre-eclampsia management ?
- Prevent development to acclampsia
- Minimise complication risk
therefore regular BP monitoring is important
50
When should you treat patients prophylactically for pre-eclampsia ?
single high risk factor of 2 moderate RF
51
what is pre-eclampsia prophylaxis ? when started? how long?
aspirin from 12 weeks gestation until birth
52
what is first line managmetn for pre-eclampsia ?
(pre-ecclmapsia can only be cured by delivering the baby)
first line anti-hypertensive: labetolol
(then nifedipine)
53
why might IV Mg Sulphate be given during labour to women with pre-eclampsia ?
given during labour + next 24 hrs to prevent seizures
54
eclampsia management ? (5)
medical emergency
1) Resuscitation (ABCDE)
2) cessation of seizures (magnesium sulphate)
3) Blood pressure control (labetalol)
4) prompt delivery of baby + placenta (usually CS) (only definitive treatment)
5) Monitoring (+ assess for complications: HELLP syndrome, DIC)
55
What is HELLP syndrome?
complications associated with eclampsia + pre-eclampsia
56
what does HELLP syndrome stand for?
subtype of sever pre-eclampsia characterised by:
- Haemolysis
- Elevated Liver enzsymes
-Low Platelets
57
complication of pre ecclmpasia ?
- Ecclampsia
- HELLP syndrome
- DIC
- Fetal distress
58
What is congenital rubella syndrome ? caused by what ? what GA ?
caused by maternal infection with rubella virus during first 20 weeks of pregnancy
59
another name for rubella ?
German measles
60
what is rubella (pathogen) ? describe
single strand RNA virus
61
how is rubella transmitted ?
highly contagious by airborne droplets
62
Should pregnancy women have MMR vaccine? why?
pregnant women should not receive MMR vaccine (as it is live vaccine)
- women planning to get pregnant should have had MMR vaccine
63
Maternal features of rubella infection ?
- Often asymptomattic
- Malaise
- Headache
- Coryza
- Fine macula papular rash
64
Fetal affects of maternal rubella infections ? presentation of this ?
congenital rubella syndrome
- congenital deafness, congenital cataracts, congenital heart defects, LD
- Triad: deafness, blindness, CHD
65
what CHD are associated with rubella ? (2)
- PDA
- pulmonary stenosis
66
How is rubella transmitted to fetus ? when is risk greatest?
risk of vertical transmission is great the earlier on in the pregnancy
67
explain the IgM and IgG responses to rubella infection/meaning of them
- IgM (present in acute infection)
- IgG (present following infection/vaccination)
68
rubella management in pregnancy ?
no treatment
- symptomatic
69
What pathogen causes chicken pox ?
varicella zoster virus (VZV)
70
what causes shingles
a result viral reactivation (VSV)
71
What can maternal chicken pox infection cause ?
- more severe maternal infection
- fetal varicellar syndrome
- Severe neonatal varicella infection
72
what effects can maternal chicken pox cause for the mother? (3)
- varicella pneumonitis
- hepatitis
- encephalitis
73
what investigation would you do for maternal chicken pox infection ? describe
testing immunity: +ve for VZV IgG indicates immunity
74
when would you treat maternal chicken pox infection ?
- no prev infection
- no vaccine
- IgG -ve
75
how would you manage a pregnant woman with no chicken pox immunity ?
IV varicella immunoglobulins (prophylaxis)
76
how would you manage a symptomatic pregnant woman with chicken pox ?
aciclover (>20 weeks)
77
fetal complications of maternal chicken pox infection ?
congenital varicella syndrome
78
features of congenital varicella syndrome ?
- FGR
- Microcephaly
- Hydrocephalus
- Congenital cataracts
79
What is gestational diabetes mellitus (GDM) ?
diabetes triggered by pregnancy
- resolves after birth
80
what causes GDM ?
caused by reduced insulin sensitivity during pregnancy
(progressive insulin resistance)
81
GDM RF ? (5)
- Prev GDM
- Prev macrosomic baby
- BMI >30
- diabetes FHx
- PCOS
82
what is used to screen for GDM ? who is offered this ?
Oral glucose tolerance test (OGTT)
- those with RF
- or features of GDM
83
What are some features of those with GDM ? mother ? baby ?
- Polyuria, polydipsia, fatigue
- Large for date, polyhydramnios
84
When is OGTT done ?
at 24 - 28 weeks
(plus 13 - 14 if prev GDM)
85
what are the abnormal fasting and 2 hr results for the OGTT
5678
- fasting >5.6 mmol/L
- 2 hr > 7.8 mmol/L
86
GDM management ?
- Education (dietary, regular exercise)
- US to monitor fetal growth
- Medical: metformin (first line), then PLUS insulin
87
what does metformin do ?
acts on liver to lower glucose production
88
Management of pregnant patients with pre-existing diabetes ?
- Should take 5mg folic acid instead of 400micrograms
- Metformin + insulin (other diabetic meds should be stopped)
- retinopathy screening
89
When retinopathy screen in pregnancy ? why important ?
offered to diabetic mothers as pregnancy increases risk of diabetic retinopathy
- shortly after booking + 28 weeks gestation
90
when plan delivery for diabetic mother
37 to 38+6 weeks gestation
91
Post-natal care for women with GDM? pre-existing diabetes ? When check HbA1c?
- GDM improves immediately after birth (so can stop meds)
- Pre-existing: lower their insulin + be aware of hypos (as insulin sensitivity increases)
- Check HbAlc 13 weeks later
92
What does obesity during pregnancy increase the risk of ? mum + baby ?
- Pre-eclampsia
- Gestational hypertension
- Blood clotting problems GDM
- CS birth
baby: Macrosomia, LGA, Congenital heart defects
93
What is breech presentation ? occurs how often ?
breech is when presenting part of fetus is legs/bottom
- occurs in <5% by 37 weeks
94
what are the 4 types of breech presentation ? describe each one
- Complete breech: hips + knees fully flexed (cannonball)
- Incomplete breech: on leg flexed at hip + extend at knees
- Extended breech: both legs flexed at hip, extended knee
- Footling: one foot presenting though cervix with leg extended
95
when would you start active management of a breech presentation ? how many week s?
from 37 weeks onwards
(36 weeks in nulliparous women)
(they often turn spontaneously so no intervention required)
96
what does managmetn of breech presentation involve ?
from 37 weeks: ECV (external cephalic version)
97
What is ECV ? when done ? how successful ?
>37 weeks
- technique to tun baby form breech to cephalic using pressure on abdo (50% successful)
- women given tocolysis to relax uterus before procedure (reduce contractility of myometrium => easier for baby to turn)
98
if ECV unsuccessful, what breech management ?
- vaginal birth (but risk of fetal birth asphyxia/trauma)
- elective CS (better for baby)
99
What is antepartum haemorrhage ?
genital trac bleeding from 24 + 0 weeks gestation
100
most important causes of APH (3) ?
plus other causes ?
- Placenta praevia
- Placental abruption
- Vasa praevia
other: cervical polyps, cervical ectropion, vaginal abrasions, vaginitis
101
What is placenta praevia ?
It is where the placenta lies in lower segment of uterus (lower than the rpesenign part of the fetus) => complete or partial covering of internal os
102
if placenta does not cover internal os, what is this ?
low lying placenta
103
What does placenta pravia increase the risk of ? (7) important complication ?
- Haemorrhage (before, during or after delivery)
- emergency CS, emergency hysterectomy, maternal anaemia, low birth weight, stillbirth
104
Placenta praevia RF ?
- Prev CS (uterine scarring)
- Prev placental praecia
- Increasing maternal age
- Maternal smoking
- Structural abnormalities (fibroids)
105
placenta praevia presentation ? (3)often found when
- osten asymptomattic
- Painless vaginal bleeding (at around 36 weeks)
- Light contractions
often found on 20 week anomy scan to assess placental position
106
What may be found in clinical examination of placenta praevia ? (4)
- Non-tender uterus
- Painless vaginal bleeding
- Low lying placenta on 20-week scan
- Lie or présentation may be abnormal
107
What investigations would you do for placenta praevia ?
- USS (abdo or TVUS)
108
placenta praevia management ? When scans ?
- Repeat transvaginal USS at 32 + 36 weeks
- Corticosteroids: between 34 and 35+6 weeks (in case of preterm labour)
- Planned C-section delivery (at 36-37 weeks to avoid spontaneous labour + bleeding, vaginal birth no possible as placenta blocks way out for fetus)
109
What is management for low lying placenta ?
similar to placenta praevia
- consider CS
(check this one)
110
What is placental abruption ?
complete or partial detachment of the placenta from the uterine wall during pregnancy
111
what are the 2 types of placental abruption. describe them ?
- revealed abruption: when blood escapes through vagina
- Concealed abruption: bleeding occurs behind the placenta or cervical os remains closed => no vaginal bleeding
112
placental abruption RF ?
- Maternal ae >35
- multiparity
- pre-eclampsia/hypertension
- prev abruptions
- trauma (consider domestic violence !)
113
Placental abruption presentation ? (3)
abdo pain + painful vaginal bleeding !
- sudden onset severe abdo pain (continuous, not related to contractions)
- vaginal bleeding
- Shock (hypotension + tachycardia, due to blood loss)
114
placental abruption investigations ? diagnosis ?
- CTG abnormalities (fetal distress)
- clinical Dx based on presentation)
- US to exclude placenta praevia
115
what might be seen on examination of placental abruption ?
woody abdomen (constituted contracted)
116
Placental abruption management ? depends on what ? what other things given alongside ?
obs emergency (clinical diagnosis based on presentation)
- US to exclude placenta praevia
- depends on fetus alive/dead/distress (dead=> induce vaginal delivery)
- fetus alive but distressed => immediate CS
- Fetus alive no distress, wait until 36 weeks => IOL + vaginal delivery
- Antenatal steroids (as preterm)
- Anti-D prophylaxis
117
What is vasa praevia ? what sctructure involved ? pathophys
The fetal vessels are exposed (outiside normal protection of umbilical cord) and pass over the internal cervical os => exposed vessels prone to bleeding => fetal blood loss => fetal death
118
what is another name for the fetal membranes ?
chorioamniotic membranes
119
what are the vessels found in the umbilical cord ?
two umbilical arteries + one umbilical vein
120
vasa praevia RF ? (3)
- Low lying placenta/placenta praevia
- IVF pregnancy
- Multiple pregnancy
121
Vasa praevia presentation ? typical triad ? when else might it present ?
rupture of umbilical cord vessels => rapid deterioration in fetal condition)
- vaginal bleeding
- ROM
- fetal compromise
- incidentally on US
- Antepartum haemorrhage
122
management of vasa praevia ? depends on what ?
depends if spotted antenatally
- Asymtpomattic: corticosteroids (from 32 weeks) + elective CS at 34-36 weeks (early del => reduce comp risks)
- Antepartum haemorrhage: emergency CS
123
Px presents with antepartum haemorrhage plus abdo pain. what most likely ?
placental abruption
(placenta praevia and vasa pravia dont present with pain as often)
124
Px presents with antepartum haemorrhage plus a tender uterus
placental abruption
125
Px presents with antepartum haemorrhage plus abnormal lie
placenta praviea
(presentation/lie usually normal in placental abruption and vasa praevia)
126
Px presents with antepartum haemorrhage. describe the fetal HR changes associated with the 3 main types of antepartum haemorrhage ?
- Placenta praevia: normal fetal heart
- Placental abruption: absent/distressed fetal heart
- Vasa praevia: fetal bradycardia
127
What is placenta accreta ? causes what ?
It is when the placenta iplacnts deeper, through + past the endo metric (to Myometrium/perimetrium) => difficult to separate the placenta after delivery => PPH
128
where should the placenta usually attach ?
usually placenta attaches to endometrium => can easily detach in 3rd stage of labour
129
RF for placenta accreta ? (4)
- can implant into defect (prev Endo curettage (miscarriage, TOP), prev CS)
- prev placenta accreta
- placenta praevia
- increasing age
130
describe the spectrum of placenta accreta ? what does it depend on ? what 3 types are there ?
spectrum depending on how deep
- Superficial placenta accreta
- placenta increta
- placenta percreta
131
what is superficial placental accreta ?
placental accretion that implants in surface of myometrium
132
what is polenta increta ?
placental accreta where placenta attaches deeply into myometrium
133
what is placenta percreta ?
placental accreta where placenta implants past Myometrium + permetrium (may be reaching other organs (bladder))
134
placenta accreta presentation ?
typically no symptoms during preg
- incidentally of US
- diagnosed at birth (with PPH)
135
placenta accreta management ?
- if diagnosed antenatally: antenatal steroids, planned CS (35-36 weeks)
- plus: hysterectomy, uterus perverse surgery, expectant (risky)
136
What is still birth ?
birth of a dead fetus (after 24 weeks gestation) as a result of intrauterine fetal death
137
causes of sitllbirth ? (7)
- unexplained (50%)
- pre-ecclampsia
- placental abruption
- Vasa praevia
- Cord prolapse
- obstetric cholestais
- DM
138
what key 3 symptoms should pregnant women immediately report ?
- Reduced fetal movements
- Abdo pain
- Vaginal bleeding
139
still birth Management and diagnosis ? name the drugs
- plus what drug for after birth ?
- US (diagnose IUFD)
- anti-D prophylaxis (for rhesus -ve women)
- Vaginal birth (first line): IOL of expectant: mifepristone, misoprostol
- Dpamine agonist (caberogline): to suppress lactation after birth
140
What is obstetric cholestatis ? aka ? characterised by ?
intrahepatic cholestatis of pregnancy
- characterised by reduced outflow of bile acids from the liver
141
what is an important complication of obstetric cholestasis ?
increase risk of stillbirth
142
obstetric cholestasis RF ? related to which hormones ? when develop ?
developed after 28 weeks
- due to high oestrogen and progesterone levles
- RF: genetic component, south asian ethnicity
143
obstetric cholestasis pathophysiology ? plus normal physiology
bile acids made in liver form cholesterol breakdown => hepatic ducts => bile duct => intestines
- obstruction to outflow => build up of bile acids in blood => pruritus
144
obstetric cholestasis Px ? what state of pregnancy ?
later in preg (often 3rd trimester): itching (main sx, palms + soles of feet)
- fatue, dark urin, pale greasy stools, jaundice
145
causes of pruritus ? (4)
- gall stones
- acute fatty liver
- autoimmune hepatitis
- viral hepatitis (B,C)
146
obstetric cholestasis Ix ?
LFT, bile acids
147
which liver enzyme usually rises during pregnancy ?
normal for ALP-regnancy to rise in pregnancy (placenta produces ALP)
148
obstetric cholestasis Mx ? (2)
ursodeoxycholic acid
- for the itching sx: emollients, antihistamines (help with sleeping)
149
What is acute fatty liver of pregnancy ?
rare condition in 3rd trimester of pregnancy: rapid accumulation of fat within hepatocytes => acute hepatitis (inflam) => liver failure + mortality
150
acute fatty liver of pregnancy pathophys ?
fetal genetic condition (LCHAD deficiency) that impairs fatty acid metabolism => impaired placental processing of fatty acids
151
acute fatty liver of pregnancy px ?
vague Sx associated with hepatitis: malaise, fatigue, N&V, jaundice, abdo pain, anorexia, ascites
152
acute fatty liver of pregnancy Ix ?
- LFT (raised ALT + AST), raised bilirubin, raised WCC, low platelets
153
pregnancy women presents with raised liver enzymes and low platelets. consider what ?
HELLP syndrome
(but keep in mind acute fatty liver of pregnancy)
154
acute fatty liver of pregnancy mx ?
obs emergency
- prompt admission + delivery of baby
155
What is polymorphic eruption of pregnancy ? aka ? affects when in pregnancy ?
pruritic + urticarial papules + plaques of pregnancy
- itchy rash that starts in 3rd trimester (improves toward end of pregnancy + postpartum)
156
polymorphic eruption of pregnancy Mx ?
- topical emollients
- topical steroids
- oral antihistamines
- oral steroids (if severe)
157
causes of cardiac arrest (in adults) (8) ?
4Ts, 4Hs
- Thrombosis (PE, MI), tension pneumonthorax, toxins, tamponade
- Hypoxia, hypovolaemia, hypothermia, hyperkalaemia/hypoglycaemia
158
main causes of cardiac arrest in pregnancy ? (3)
- obstetric haemorrhage
- PE
- Sepsis
159
causes of massive obstetric haemorrhage ? (5)
- ectopic preg
- placental abruption
- placenta praevia
- placenta accreta
- uterine rupture
160
why don't lie on your back when pregnant ? which position is best ?
uterus compresses IVC (+aorta) => reduce venous return => reduce CO => hypotension => loss of CO + cardiac arrest
- place women in left lateral position (reduce aortocaval compression)
161
cardiac arrest during pregnancy Mx ?
emergency CS after >4mins of CPR (improve survival of mother)
