WH: Complications in Pregnancy Flashcards
Why do pregnant women have a greater UTI risk?
- Urine has more sugar, protein and hromones
- Uterus presses on bladder so more difficult to fully empty
Which UTIs are pregnant women at greater risk of?
upper and lower
(cystitis and pyelonephritis)
what does UTI in pregnancy increase the risk of?
increase risk of preterm delivery
- and low birth weight + preeclampsia
what is asymptomatic bacteriruea ?
bacteria presen in urine without symptoms of infection
what does asymptomatic bacteriuear increase the risk of?
increased risk of upper + lower UTI => increase risk of preterm labour
when do pregnant women get their urine tested antenatally ?
at booking clinic and throughout pregnancy (MSU)
LUTI presentation ?
- Dysuria (pain, stinging, burning)
- suprapubic pain
- increased frequency of urination
- urgency
- incontinence
- Haematuria
Pyelonephtirits presentation?
- Fever
- Loin/suprapubic/back pain
- General malaise
- Vomiting
- Loss of appetitie
- Haematuria
- Renal angle tenderness
What is most common UTI causative organism ?
E.coli
what type of bacteria is e.coli? gram staining? shape? often found where?
gram -ve, anaerobic, ro-shaped bacteria found in faeces
what does e.coli produce in urine ? from what?
gram -ve bacteria (e.coli) break down nitrates (normal waste product in urine) to nitrites => nitrite presence suggest bacterial infection
Apart form nitrites, what could indicate infection in the urine?
leukocytes
UTI in pregnancy management ?
- 7 days Abx (nitrofurantoin, amoxicillin)
what antibiotic should be avoided in the 3rd trimester?
nitrofurantoin
What is anaemia
low concentration of haemoglobin as result of underlying disease
when are pregnant women screening for anaemia?
- booking clinic (may also then get screened for thallasaemia and sickle cell disease)
- 28 weeks gestation
why pregnant women more prone to be anaemic?
during pregnancy, plasma vol increases => decreased haemoglobin conc
anaemia presentation (5)
- asymptomattic
- sob
- fatigue
- dizziness
- pallor
what could cause low MCV anaemia?
iron deficiency (+TAILS)
what could cause normal MCV anaemia?
pregnancy (physiological response)
what could cause raised MCV anaemia ?
b12 or folate deficiencya
anaemia management in pregnancy?
- Iron supplements (ferrous sulphate)
- Folate (should already be taking)
When and what is the does of folate in pregnancy?
400 micrograms before and during pregnancy (usualy first 1 weeks but if at risk of anaemia => whole prengnacy (maybe))
why is there increased VTE risk in pregnancy?
due to hyper coagulable stat => blood clot more likely
when is risk of DVT/PE greatest during pregnancy ?
highest during post partum period
DVT RF?
- Smoking
- age > 35
- BMI > 30
reduced mobility - multiple pregnancy
- pre-eclampsia
- thrombophilia
- IVF pregnancy
when start DVT prophylaxis during pregnancy ?
if 3 RF, start at 28 weeks
if 4 RF, start immediately
What is used for DVT prophylaxis in pregnancy ?
LMWH
(daltparin, tinzeparin, enoxaparin)
how long is the DVT prophylaxis taken for?
continued throughout pregnancy until 6 weeks post fatally
(stopped during labour)
what is offered if LMWH is contraindicated for DVT prophylaxis ?
mechanical prophylaxis
- Intermiiten pneumatic ompression
- Antiembolic comp stockings
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)
what is used to diagnose DVT during pregnancy?
Doppler US
(not D-dimer!)
why can d-dimer not be used in pregnancy?
pregnancy is a cause of raised d-dimer
what risk score is used for DVT? is this used in pregnancy?
wells score
- NOT used in pregnancy
DVT management ?
same as prophylaxis but higher dose
- LMWH (enoxa/tinza/dalteparin)
what is used to diagnosis PE in pregnancy?
- CTPA or VQ scan
What is pre-ecclampsia a disease of?
placental disease
what is pre-eclampsia ? when?
Hypertension in pregnancy with en organ failure (most often proteinuria) after 20 weeks gestation
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)
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)
What is the pre-ecclampsia triad?
- Hypertension
- Proteinurea
- Oedema
What is chronic hypertension (related to pregnancy)
High BP that exists before 20 weeks gestation + is long standing
what is gestational hypertension?
hypertension occurring after 20 weeks gestation without proteinuria
what is eclampsia ?
it is when seizures occur as a result of pre-eclampsia
Pre eclampsia RF ?
- Pre-existing hypertension
- preve hypertension in pregnancy
- diabetes
- CKD
- maternal age >40
pre-eclampsia symptoms ?
present as complications
- Headache (most common)
- Visual disturbance
- N&V, epigastric pain
- Oedema
- Low urine output
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)
how many weeks gestation does patient need to be for it to be pre-eclampsia ?
after 20 weeks gestation
what are the aims of pre-eclampsia management ?
- Prevent development to acclampsia
- Minimise complication risk
therefore regular BP monitoring is important
When should you treat patients prophylactically for pre-eclampsia ?
single high risk factor of 2 moderate RF
what is pre-eclampsia prophylaxis ? when started? how long?
aspirin from 12 weeks gestation until birth
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)
why might IV Mg Sulphate be given during labour to women with pre-eclampsia ?
given during labour + next 24 hrs to prevent seizures
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)
What is HELLP syndrome?
complications associated with eclampsia + pre-eclampsia
what does HELLP syndrome stand for?
subtype of sever pre-eclampsia characterised by:
- Haemolysis
- Elevated Liver enzsymes
-Low Platelets
complication of pre ecclmpasia ?
- Ecclampsia
- HELLP syndrome
- DIC
- Fetal distress
What is congenital rubella syndrome ? caused by what ? what GA ?
caused by maternal infection with rubella virus during first 20 weeks of pregnancy
another name for rubella ?
German measles
what is rubella (pathogen) ? describe
single strand RNA virus
how is rubella transmitted ?
highly contagious by airborne droplets
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
Maternal features of rubella infection ?
- Often asymptomattic
- Malaise
- Headache
- Coryza
- Fine macula papular rash
Fetal affects of maternal rubella infections ? presentation of this ?
congenital rubella syndrome
- congenital deafness, congenital cataracts, congenital heart defects, LD
- Triad: deafness, blindness, CHD
what CHD are associated with rubella ? (2)
- PDA
- pulmonary stenosis
How is rubella transmitted to fetus ? when is risk greatest?
risk of vertical transmission is great the earlier on in the pregnancy
explain the IgM and IgG responses to rubella infection/meaning of them
- IgM (present in acute infection)
- IgG (present following infection/vaccination)
rubella management in pregnancy ?
no treatment
- symptomatic
What pathogen causes chicken pox ?
varicella zoster virus (VZV)
what causes shingles
a result viral reactivation (VSV)
What can maternal chicken pox infection cause ?
- more severe maternal infection
- fetal varicellar syndrome
- Severe neonatal varicella infection
what effects can maternal chicken pox cause for the mother? (3)
- varicella pneumonitis
- hepatitis
- encephalitis
what investigation would you do for maternal chicken pox infection ? describe
testing immunity: +ve for VZV IgG indicates immunity
when would you treat maternal chicken pox infection ?
- no prev infection
- no vaccine
- IgG -ve
how would you manage a pregnant woman with no chicken pox immunity ?
IV varicella immunoglobulins (prophylaxis)
how would you manage a symptomatic pregnant woman with chicken pox ?
aciclover (>20 weeks)
fetal complications of maternal chicken pox infection ?
congenital varicella syndrome
features of congenital varicella syndrome ?
- FGR
- Microcephaly
- Hydrocephalus
- Congenital cataracts
What is gestational diabetes mellitus (GDM) ?
diabetes triggered by pregnancy
- resolves after birth
what causes GDM ?
caused by reduced insulin sensitivity during pregnancy
(progressive insulin resistance)
GDM RF ? (5)
- Prev GDM
- Prev macrosomic baby
- BMI >30
- diabetes FHx
- PCOS
what is used to screen for GDM ? who is offered this ?
Oral glucose tolerance test (OGTT)
- those with RF
- or features of GDM
What are some features of those with GDM ? mother ? baby ?
- Polyuria, polydipsia, fatigue
- Large for date, polyhydramnios
When is OGTT done ?
at 24 - 28 weeks
(plus 13 - 14 if prev GDM)
what are the abnormal fasting and 2 hr results for the OGTT
5678
- fasting >5.6 mmol/L
- 2 hr > 7.8 mmol/L
GDM management ?
- Education (dietary, regular exercise)
- US to monitor fetal growth
- Medical: metformin (first line), then PLUS insulin
what does metformin do ?
acts on liver to lower glucose production
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
When retinopathy screen in pregnancy ? why important ?
offered to diabetic mothers as pregnancy increases risk of diabetic retinopathy
- shortly after booking + 28 weeks gestation
when plan delivery for diabetic mother
37 to 38+6 weeks gestation
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
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
What is breech presentation ? occurs how often ?
breech is when presenting part of fetus is legs/bottom
- occurs in <5% by 37 weeks
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
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)
what does managmetn of breech presentation involve ?
from 37 weeks: ECV (external cephalic version)
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)
if ECV unsuccessful, what breech management ?
- vaginal birth (but risk of fetal birth asphyxia/trauma)
- elective CS (better for baby)
What is antepartum haemorrhage ?
genital trac bleeding from 24 + 0 weeks gestation
most important causes of APH (3) ?
plus other causes ?
- Placenta praevia
- Placental abruption
- Vasa praevia
other: cervical polyps, cervical ectropion, vaginal abrasions, vaginitis
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
if placenta does not cover internal os, what is this ?
low lying placenta
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
Placenta praevia RF ?
- Prev CS (uterine scarring)
- Prev placental praecia
- Increasing maternal age
- Maternal smoking
- Structural abnormalities (fibroids)
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
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
What investigations would you do for placenta praevia ?
- USS (abdo or TVUS)
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)
What is management for low lying placenta ?
similar to placenta praevia
- consider CS
(check this one)
What is placental abruption ?
complete or partial detachment of the placenta from the uterine wall during pregnancy
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
placental abruption RF ?
- Maternal ae >35
- multiparity
- pre-eclampsia/hypertension
- prev abruptions
- trauma (consider domestic violence !)
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)
placental abruption investigations ? diagnosis ?
- CTG abnormalities (fetal distress)
- clinical Dx based on presentation)
- US to exclude placenta praevia
what might be seen on examination of placental abruption ?
woody abdomen (constituted contracted)
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
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
what is another name for the fetal membranes ?
chorioamniotic membranes
what are the vessels found in the umbilical cord ?
two umbilical arteries + one umbilical vein
vasa praevia RF ? (3)
- Low lying placenta/placenta praevia
- IVF pregnancy
- Multiple pregnancy
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
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
Px presents with antepartum haemorrhage plus abdo pain. what most likely ?
placental abruption
(placenta praevia and vasa pravia dont present with pain as often)
Px presents with antepartum haemorrhage plus a tender uterus
placental abruption
Px presents with antepartum haemorrhage plus abnormal lie
placenta praviea
(presentation/lie usually normal in placental abruption and vasa praevia)
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
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
where should the placenta usually attach ?
usually placenta attaches to endometrium => can easily detach in 3rd stage of labour
RF for placenta accreta ? (4)
- can implant into defect (prev Endo curettage (miscarriage, TOP), prev CS)
- prev placenta accreta
- placenta praevia
- increasing age
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
what is superficial placental accreta ?
placental accretion that implants in surface of myometrium
what is polenta increta ?
placental accreta where placenta attaches deeply into myometrium
what is placenta percreta ?
placental accreta where placenta implants past Myometrium + permetrium (may be reaching other organs (bladder))
placenta accreta presentation ?
typically no symptoms during preg
- incidentally of US
- diagnosed at birth (with PPH)
placenta accreta management ?
- if diagnosed antenatally: antenatal steroids, planned CS (35-36 weeks)
- plus: hysterectomy, uterus perverse surgery, expectant (risky)
What is still birth ?
birth of a dead fetus (after 24 weeks gestation) as a result of intrauterine fetal death
causes of sitllbirth ? (7)
- unexplained (50%)
- pre-ecclampsia
- placental abruption
- Vasa praevia
- Cord prolapse
- obstetric cholestais
- DM
what key 3 symptoms should pregnant women immediately report ?
- Reduced fetal movements
- Abdo pain
- Vaginal bleeding
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
What is obstetric cholestatis ? aka ? characterised by ?
intrahepatic cholestatis of pregnancy
- characterised by reduced outflow of bile acids from the liver
what is an important complication of obstetric cholestasis ?
increase risk of stillbirth
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
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
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
causes of pruritus ? (4)
- gall stones
- acute fatty liver
- autoimmune hepatitis
- viral hepatitis (B,C)
obstetric cholestasis Ix ?
LFT, bile acids
which liver enzyme usually rises during pregnancy ?
normal for ALP-regnancy to rise in pregnancy (placenta produces ALP)
obstetric cholestasis Mx ? (2)
ursodeoxycholic acid
- for the itching sx: emollients, antihistamines (help with sleeping)
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
acute fatty liver of pregnancy pathophys ?
fetal genetic condition (LCHAD deficiency) that impairs fatty acid metabolism => impaired placental processing of fatty acids
acute fatty liver of pregnancy px ?
vague Sx associated with hepatitis: malaise, fatigue, N&V, jaundice, abdo pain, anorexia, ascites
acute fatty liver of pregnancy Ix ?
- LFT (raised ALT + AST), raised bilirubin, raised WCC, low platelets
pregnancy women presents with raised liver enzymes and low platelets. consider what ?
HELLP syndrome
(but keep in mind acute fatty liver of pregnancy)
acute fatty liver of pregnancy mx ?
obs emergency
- prompt admission + delivery of baby
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)
polymorphic eruption of pregnancy Mx ?
- topical emollients
- topical steroids
- oral antihistamines
- oral steroids (if severe)
causes of cardiac arrest (in adults) (8) ?
4Ts, 4Hs
- Thrombosis (PE, MI), tension pneumonthorax, toxins, tamponade
- Hypoxia, hypovolaemia, hypothermia, hyperkalaemia/hypoglycaemia
main causes of cardiac arrest in pregnancy ? (3)
- obstetric haemorrhage
- PE
- Sepsis
causes of massive obstetric haemorrhage ? (5)
- ectopic preg
- placental abruption
- placenta praevia
- placenta accreta
- uterine rupture
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)
cardiac arrest during pregnancy Mx ?
emergency CS after >4mins of CPR (improve survival of mother)
