Women's & Reproductive Health Flashcards
What are the diagnostic criteria for gestational diabetes?
Either:
- Fasting plasma glucose of 5.6 mmol/litre or above; or
- 2-hour plasma glucose of 7.8 mmol/litre or above
What are the recommended target plasma glucose levels for gestational diabetes?
- 5.3 mmol/litre for fasting
- 7.8 mmol/litre 1 hour after meals
- 6.4 mmol/litre for 2 hours after meals
Target HbA1C < 48 mmol/mol (6.5%), albeit in pregnancy it is not as useful in monitoring control.
What are the diagnostic criteria for hyperemesis gravidarum?
Diagnostic triad:
- 5% pre-pregnancy weight loss
- Dehydration
- Electrolyte imbalance
What is the differential diagnosis for vaginal discharge?
Infective
- Sexually transmitted: trichomonas, chlamydia, gonorrhea
- Non-sexually transmitted: candida, bacterial vaginosis
Physiological
- Pregnancy
- Ovulation
Cervical ectropion
What are the clinical and diagnostic features of bacterial vaginosis?
- 50% asymptomatic
- Thin, grey discharge with strong fishy odour
- Doesn’t usually cause soreness or itching
- Vaginal PH of > 4.5
- Clue cells on microscopy
How do you manage bacterial vaginosis?
Asymptomatic and not pregnant: treatment not required
Symptomatic or pregnant: oral metronidazole twice a day for 5 to 7 days
General advice:
- Avoid douching and other products targetting BV
- Avoid perfumed soaps, shower gels, and shampoo
Why should all pregnant women be treated for BV?
BV in pregnancy is associated with:
- Late miscarriage
- Preterm birth
- Premature rupture of membranes
- Postpartum endometriosis
What are the causes of postpartum haemorrhage?
The four Ts:
Tone
Tissue
Trauma - genital tract injury
Thrombin - coagulation abnormalities
Risk factors for postpartum haemorrhage?
Tone
- Polyhydramnios, multiple gestation, macrosomnia, fibroids, placenta praevia, uterine abnormalities, prolonged labour, prolonged rupture of membranes
Trauma - genital tract injury
- Operative delivery, previous uterine surgery, implementation (e.g forceps delivery).
Thrombin - coagulation abnormalities
- History of PPH, haemophilia A, Von Willebrand’s disease, idiopathic thrombocytopenic purpura, HELLP, gestational thrombocytopenia, DIC
How do you manage a major obstetric haemorrhage?
Call for help!
Resuscitation
- Airway
- Breathing - oxygen mask (15L)
- Circulation
- Bed head down
- x2 wide-bore IV cannulae
- FBC, coagulation, U&Es, LFTs, cross-match (4 units)
- IV fluids (Hartmann’s or saline)
- Consider blood transfusion (O RhD-negative or group-specific blood)
- Consider blood products (FFP, PLT, factor VII)
- Foley catheter (to empty bladder and monitor fluid output)
Medical treatment
- Bimanual compression
- Oxytocin 5 iu, slow IV
- Ergometrine o.5 mg, slow IV
- Oxytocin infusion (40 iu in 500 ml)
- Carboprost 0.25 mg IM every 15 min up to 8 times
- Misoprostol 800 micrograms subligually
- Consider tranexamic acid 1 g IV
Theatre
- Intrauterine balloon tamponade
- Brace suture
- Consider stepwise uterine devascularisation (requires interventional radiologist)
- Bilateral internal artery ligation
- Hysterectomy
What are the risks of being overweight or obese in pregnancy?
Risks to mother
- Miscarriage
- Gestational diabetes
- Gestational hypertension and pre-eclampsia
- Venous thromboembolism (DVT and PE)
- Macrosomia and shoulder dystocia
- Post-partum haemorrhage
- Instrumental delivery or emergency caesarean section
Risks to baby
- Prematurity
- Stillbirth
- Birth injury
- Congenital abnormality
Who is at risk of gestational diabetes?
Women who:
- are overweight or obese
- have had gestational diabetes before (80% recurrence rate)
- have had a very large baby in a previous pregnancy (4.5kg/10lb or over)
- have first degree relative with diabetes
- are from a South Asian, Black or African Caribbean or Middle Eastern background
Summarise the antenatal care for uncomplicated primiparous and multiparous women.
Booking appointment (ideally by 10 weeks)
16 weeks - review screening tests
18 - 20 weeks - anomoly scan
- 25 weeks - (nulliparous woman)
28 weeks - offer second screening for Hb and antibodies, gestational diabetes and anti-D if Rh neg
- 31 weeks (nulliparous woman)
34 weeks - offer a second dose of ani-D if Rh neg
36 weeks - check position of baby, offer ECV if breech
38 weeks
- 40 weeks (nulliparous woman)
41 weeks - membrane sweep, offer IOL
At each appointment, measure blood pressure, test urine for proteinuria, and measure and plot symphysis-fundal height.
When do we screen for Down’s syndrome?
What are the screening tests?
Ideally by the end of the first trimester (13 weeks 6 days)
The combined test
- Nuchal translucency
- Beta-human chorionic gonadotrophin
- Pregnancy-associated plasma protein-A
- Between 11 weeks and 13 weeks 6 days
The triple or quadruple test
- Beta-human chorionic gonadotrophin
- Alpha-fetoprotein
- Oestriol (E3)
- Inhibin A
- Between 14 weeks and 20 weeks
NB. The presence of an increased nuchal fold (6 mm or above) or two or more soft markers should prompt the offer of a referral to a fetal medicine specialist.
What two diagnostic tests are offered following a higher-chance result for Down’s syndrome?
- Amniocentesis
- Chorionic villus sampling
This will tell you for certain whether or not the baby has Down’s, Edwards’ or Patau’s syndrome.
What are the risk factors for pre-eclampsia?
- Age 40 years or older
- Nulliparity
- Pregnancy interval of more than 10 years
- Family history of pre-eclampsia
- Previous history of pre-eclampsia
- BMI 30 kg/m2 or above
- Pre-existing hypertension
- Pre-existing renal disease
- Multiple pregnancy
- Diabetes
What are the symptoms of pre-eclampsia?
- Severe headache
- Problems with vision, such as blurring or flashing before the eyes
- Severe pain just below the ribs
- Vomiting
- Sudden swelling of the face, hands or feet
What are the diagnostic criteria for pre-eclampsia?
- Blood pressure ≥ 140 mm Hg systolic or ≥ 90 mm Hg diastolic on two separate readings taken at least four to six hours apart after 20 weeks gestation
(In a woman with essential hypertension beginning before 20 weeks gestational age: an increase in systolic blood pressure of ≥30mmHg or an increase in diastolic blood pressure of ≥15mmHg)
- Proteinuria ≥ 300 mg or more of protein in a 24-hour urine sample or a SPOT urinary protein to creatinine ratio ≥ 0.3 or a urine dipstick reading of 1+ or greater
How can women prevent pre-eclampsia?
Take low-dose aspirin
How do you manage pre-eclampsia?
Definitive treatment is delivery
- Expectant management to expedited delivery by induction of labour or caesarian section
In severe hypertension, reduce blood pressure
- Labetolol, Methyldopa and Nifedipine
In severe pre-eclampsia, prevent eclampsia
- Magnesium sulphate
What is the screening pathway for placenta praevia?
Most low-lying placentas detected at the routine anomaly scan will have resolved by the time the baby is born.
Only a woman whose placenta extends over the internal cervical os should be offered another transabdominal scan at 32 weeks.
If the transabdominal scan is unclear, a transvaginal scan should be offered.
Which infections are routinely screened for in pregnancy?
- Hepatitis B virus
- HIV
- Rubella
- Syphilis
Which haemoglobinopathies are routinely screened for in pregnancy?
Sickle cell diseases
Thalassaemias
When is routine antenatal anti-D prophylaxis (RAADP) given?
One or two doses at 28 weeks +/- 34 weeks
What is the purpose of a booking appointment?
Determine whether pregnancy is high or low risk
Measure blood pressure
Calculate BMI
Test urine for proteinuria
Risk factors for pre-eclampsia
Risk factors for gestational diabetes
Offer blood tests (blood group, rhesus D status, anaemia, haemoglobinopathies, red-cell alloantibodies, infections)
Offer screening for asymptomatic bacteriuria
Offer screening for Down’s syndrome
Offer early ultrasound scan for gestational age assessment and structural anomalies
Identify women who have had FGM
Inform women younger than 25 years about National Chlamydia Screening Programme
What nutritional advice should be offered to pregnant women?
- Take folic acid supplements before conception and throughout first 12 weeks (400 microgram per day)
- Take vitamin D supplements during pregnancy and breastfeeding (10 micrograms per day)
- Do not take iron supplements
- Don’t eat liver (excess vitamin A)
- Avoid raw or partially cooked eggs (salmonella)
- Avoid all types of pâté, soft blue-veined cheeses such as danish blue, gorgonzola and roquefort (listeria)
- Do not eat raw or undercooked meat (toxoplasmosis)
- Don’t have more than 200 mg of caffeine a day (one mug of instant coffee: 100mg; one mug of filter coffee: 140mg, one mug of tea: 75mg)
What are the effects of caffeine in pregnancy?
High levels of caffeine can result in babies having a low birthweight, which can increase the risk of health problems in later life, and can cause miscarriage.
What are the risks of smoking during pregnancy?
Increased risk of:
- Stillbirth
- Prematurity
- Small for gestational age baby
- More prone to infection
- Sudden infant death syndrome
- Child asthma
When does the embryonic period and fetal period start and end?
Embryonic period: 2 to 8 weeks
Fetal period: 9 to 40 weeks
What is labetalol and when is it contraindicated?
Alpha- and beta-adrenergic receptor blocker
Asthma and pheochromocytoma
Which three drugs are recommended in the treatment of hypertension during pregnancy?
- Labetalol
- Nifedipine
- Methyldopa
Which antibiotics should be avoided during pregnancy?
Sulphonamides
Quinolones
Aminoglycosides
Tetracyclines
Which drugs can be used to treat a UTI during pregnancy?
Nitrofuantoin
Trimethoprim
Penicillins (amoxycillin; coamoxyclav)
Cephalosporins (cefalexin)
When should nitrofurantoin be avoided and why?
Avoid at term
Haemolytic anaemia in the neonate
When should trimethoprim be avoided and why?
First trimester
Folate antagonist associated with structural defects
Which antibiotic is associated with cholestatic jaundice?
Coamoxyclav
What are the indications for a higher dose of folic acid (5 mg) until 12 weeks of pregnancy?
- Diabetes
- Epilepsy
- BMI of 30 or above
- Coeliac disease
- Thalassaemia trait
- Family history of neural tube defect
- Previous pregnancy affected by neural tube defect
- Mother or father has a neural tube defect
What factors affect drug levels in pregnancy?
Physiological
- Increased blood volume (50% by 34 weeks)
- Increased clearance (GFR 50% by 24 weeks)
- Increased hepatic metabolism
- Vomiting
- Decreased absorption
Non-physiological
- Decreased compliance (fear of teratogenesis)
- Fear of prescribing
What is Becotide, Serevent, and Ventolin?
Asthma medication
- Becotide: Beclomethasone
- Serevent: Salmeterol
- Ventolin: Salbutamal
Which asthma medication should not be started during pregnancy?
Leukotriene receptor antagonists
(Montelukast and Zafirlukast)
What is meant by teratogenic and fetotoxic drugs?
Teratogenic drugs
- Increase the risk of structural abnormalities
- Occurs in the first trimester
- Greatest risk from 3 to 8 weeks after conception (5 to 10 weeks’ gestation)
Fetotoxic
- A substance that increases the risk of functional damage
- Occurs later in pregnancy
What is the risk of major malformation in the general population?
2%
NSAIDs are teratogenic. What two functional abnormalities are they associated with?
- Fetal renal dysfunction in the second and third trimester
- Premature closure of the ductus arteriosus in the third trimester
What are the main principles of prescribing in pregnancy?
- Medication should only be used if the expected benefits (usually to the mother) are greater than the potential adverse effects (usually to the fetus).
- Try to avoid first trimester use
- Use drugs that have been used extensively in pregnancy
- Use the minimum dose required
- Absence of data does not imply safety
What are the key medication considerations for pregnant women with epilepsy?
- If seizure-free for many years, consider dose reduction or withdrawal
- Monotherapy is less teratogenic than polytherapy
- Avoid sodium valproate
- Consider a pre-emptive increase in lamotrigine dose in the second trimester
- Start 5mg folic acid
Compared to valproate, lamotrigine has a lower risk of congenital malformations (2-3% vs 5-11%)
What are the key medication considerations for pregnant women with depression?
If mild to moderate depression:
- Consider gradual withdrawal of antidepressant
- Switch to psychological therapy (e.g. CBT) alone, if possible
If severe depression:
- Consider switching to psychological therapy
- Consider combining drug treatment with psychological therapy
- If medication required,
- SSRIs (Fluoxetine; Citalopram; Sertraline)
- Tricyclic antidepressants (Amitriptyline)
What are the key medication considerations for pregnant women with thyroid disease?
Hypothyroidism
- Most women will require an increase in their thyroxine
- Adequate intake of iodine is also important
Hyperthyroidism
- Avoid radioisotopes
- Propylthiouracil is preferred to carbimazole
Which drugs should not be used to treat hypertension during pregnancy and why?
ACE inhibitors
They are both teratogenic and fetotoxic
What is the mortality rate of pancreatitis in pregnancy?
Almost 40%
Always consider this diagnosis in any woman with unexplained abdominal pain.
What is the frequency (%) of the different types of diabetes in pregnancy?
Gestational: 87.5%
Type I: 7.5%
Type II: 5%
What is Pederson’s hypothesis?
- Fetal hyperglycaemia results from maternal hyperglycaemia stimulating fetal pancreatic β-cell hypertrophy
- This results in inappropriate release of insulin
- Fetal insulin acts as a growth promoting hormone
Maternal insulin does not cross the placenta. Glucose crosses the placenta via facilitated diffusion.
What are the potential complications resulting from fetal hyperinsulinaemia?
Macrosomnia: traumatic delivery; Erbs palsy
Organomegaly: neonatal hypoglycaemia
Increased erythropoiesis: neonatal polycythaemia
Decreased surfactant production: hyaline membrane disease
What are the effects of diabetes on pregnancy?
Increased risk of:
- Congenital malformations
- Miscarriage
- Macrosomia (IOL, difficult birth, caesarian section)
- Baby developing obesity or diabetes later in life
- Pre-eclampsia
- UTI/pyelonephritis
- Diabetic ketoacidosis (50% fetal mortality)
- Vaginal candidiasis
What are the effects of pregnancy on type I and II diabetes?
- Need for greater doses of insulin
- Worsening of renal disease
- Worsening of retinopathy
- Risk of hypoglycaemia
- Risk of aspiration/Mendelson syndrome if general anaesthetic
What is MODY?
Maturity onset diabetes of the young
Several hereditary forms of diabetes mellitus caused by mutations in an autosomal dominant gene
What is LADA?
Latent autoimmune diabetes of adult
Type I DM with slower progression to insulin dependence
Who do we offer the OGTT to and when?
All women who have a risk factor for gestational diabetes
Women with persistent glycosuria, macrosomia, polyhydramnios
Usually offered at 28 weeks, unless previous GDM then 16 to 18 weeks
What postpartum care is required for GDM, Type I DM, Type II DM, and neonate?
GDM: Insulin not required following delivery of the placenta; offer fasting glucose 6 weeks after birth; annual HbA1c (increased risk of Type II DM up to 50% by 10 years)
Type I: Insulin 2/3 pre-pregnancy dose
Type II: Continue metformin
Neonate: Breastfeed within 30 mins and frequent intervals (2-3 hr); monitor blood glucose for at least 24 hours
What is Couvade syndrome?
A condition in which a partner experiences some of the same symptoms and behavious as the expectant mother.
For example, minor weight gain, sleep disturbance, morning nausea, and postpartum depression.