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Obs and gynae > Pregnancy > Flashcards

Pregnancy Flashcards

1
Q

What is the definition of small for gestational age

A

Birth weight <10th centile for gestational age

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2
Q

What is severe SGA

A

Birth weight <3rd centile

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3
Q

What are the measurements used to calculate size for gestational age

A

Estimated fetal weight

Abdominal circumference

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4
Q

What would be classed as a low birth weight

A

<2500g

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5
Q

What is fetal growth restriction

A

Pathological process restricting genetic growth potential

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6
Q

How does fetal growth restriction present

A

Fetal compromise

  • Reduced liquor volume
  • Abnormal doppler
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7
Q

What does normal (constitutionally) small mean

A

Small size at every stage

Following along for their own centile

No pathology present

Due to ethnicity, sex, parental height

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8
Q

What is placenta-mediated growth restriction

A

Normal growth initially

Growth slows in utero

Common cause of fetal growth restriction

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9
Q

What are the maternal factors that can cause placenta-mediated growth restriction

A

Low pre-pregnancy weight

Substance abuse

Autoimmune disease

Renal disease

Diabetes

Chronic hypertension

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10
Q

What is non-placenta mediated growth restriction

A

Growth affected by fetal factors

  • Chromosomal abnormalities
  • Structural anomalies
  • Metabolic errors
  • Fetal infection
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11
Q

When are risk factors for small for gestational age assessed

A

Booking

20 week scan

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12
Q

What are the minor risk factors for small for gestational age

A

Age >35

Smoking 1-10 per day

Nulliparity

BMI <20 or 25-35

IVF singleton

Previous pre-eclampsia

Pregnancy interval <6 or >60 months

Low fruit intake pre-pregnancy

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13
Q

What are the major risk factors for small for gestational age

A

Age >40

Smoking >11 per day

Previous SGA baby

Maternal/paternal SGA

Previous stillbirth

Cocaine use

Daily vigorous exercise

Maternal chronic disease

Heavy bleeding

Low PAPP-A

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14
Q

How is small for gestational age diagnosed

A

Ultrasound

Values plotted on customised centile chart

Measure head circumference and abdominal circumference

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15
Q

What does the head to abdominal circumference ratio tell us

A

Symmetrically small
- More likely to be constitutionally small

Asymmetrically small
- More likely to be placental insufficiency

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16
Q

What would be seen on doppler for small for gestational age

A

‘Brain-sparing’ effect

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17
Q

What investigations are used to assess for small for gestational age

A

Ultrasound

Detailed fetal anatomical survey

Uterine artery doppler

Karyotyping

Screening for infections (cytomegalovirus, toxoplasmosis, syphilis, malaria…)

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18
Q

What can be done to prevent small for gestational age babies

A

Smoking cessation

Optimise maternal health

If high risk of pre-eclampsia, start aspirin

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19
Q

What surveillance is needed as part of the management of small for gestational age

A

Uterine artery doppler every 14 days

Symphysis fundal height

Middle cerebral artery doppler

Ductus venosus doppler

CTG

Amniotic fluid volume

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20
Q

When would you decide to deliver small for gestational age babies

A

If considering delivery before 35 weeks, give antenatal steroids

Before 37 weeks, C-section

After 37 weeks, offer induction

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21
Q

What are the complications associated with small for gestational age babies

A

Increased risk of stillbirth

Neonatal complications: birth asphyxia, meconium aspiration, hypothermia, hyper/hypoglycaemia…

Long-term complications: cerebral palsy, T2DM, obesity, HTN, precocious puberty…

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22
Q

When do pregnant women have maternal blood group and antibody tests

A

Booking (8-12 weeks)

28 weeks

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23
Q

When are RhD- women routinely given anti-D prophylaxis

A

28 and 34 weeks

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24
Q

What are some ‘sensitisation events’ that can cause RBC isoimmunisation

A

Antepartum haemorrhage

Abdominal trauma

Delivery

Invasive obstetric testing

Ectopic pregnancy

External cephalic version

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25
Q

How do anti-D immunoglobulins work

A

Bind RhD+ cells in maternal circulation

Prevent mounting of an immune response

Intrauterine death/miscarriage

Termination of pregnancy

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26
Q

What blood tests should be done following a sensitisation event for RBC isoimmunisation

A

Maternal blood group and antibody screen

Feto-maternal haemorrhage test (Kleihauer test)
- Assesses how much fetal blood has entered maternal circulation

Check Rhesus status of baby after delivery

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27
Q

How long post-partum should anti-D be given

A

72 hours

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28
Q

What is a prolonged pregnancy

A

Pregnancy that goes beyond 42 weeks

5-10% of pregnancies

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29
Q

What are the risk factors for prolonged pregnancy

A

Nulliparity

Age >40

Previous prolonged pregnancy

Obesity

Family history

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30
Q

What are the complications associated with prolonged pregnancy

A

Significant increase in stillbirths

Increased chance of placental insufficiency

Placental degradation

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31
Q

What are the clinical features of prolonged pregnancy

A

Static growth

Potential macrosomia

Oligohydramnios

Reduced fetal movements

Presence of meconium

Dry/flaky skin (reduced vernix)

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32
Q

What is the main differential diagnosis for prolonged pregnancy

A

Inaccurate dating

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33
Q

What is the management for prolonged pregnancy

A

Deliver by 42 weeks to reduce risk of stillbirth

Membrane sweep (from 40 in nulliparous, from 41 in multiparous)

Induction of labour

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34
Q

If a mother declines induction in prolonged pregnancy, how should she be monitored

A

Twice weekly CTG monitoring

USS with amniotic fluid measurement

Look out for fetal distress

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35
Q

What is miscarriage

A

Loss of pregnancy at <24 weeks

Early miscarriage: 12-13 weeks

Late miscarriage: 13-24 weeks

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36
Q

Roughly how many pregnancies end in miscarriage

A

20-25%

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37
Q

What are the risk factors for miscarriage

A

Age >35

Previous miscarriage

Obesity

Chromosomal abnormalities

Smoking

Uterine anomalies

Previous uterine surgery

Anti-phospholipid syndrome

Coagulopathies

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38
Q

How might a woman with a miscarriage present

A

Vaginal bleeding (may pass products of conception)

Suprapubic cramping pain

Many found incidentally

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39
Q

What might you see on speculum examination of a woman with a miscarriage

A

Abnormal diameter of cervix

Products of conception in cervical canal

Localised bleeding

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40
Q

What are the differential diagnoses for miscarriage

A

Ectopic pregnancy

Hydatidiform mole

Cervical/uterine malignancy

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41
Q

What investigations are needed in miscarriage

A

Transvaginal ultrasound

Mean sac diameter (>25mm = failed pregnancy, <25mm = repeat scan in 10-14 days)

Bloods (beta-HCG, FBC, CRP…)

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42
Q

What is the management of miscarriage in RhD- women

A

If >12 weeks, need anti-D prophylaxis

If surgical management, need anti-D regardless of gestational age

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43
Q

What is the conservative management of miscarriage

A

Allow for products of conception to pass naturally

Can stay at home, no side effects…

Unpredictable timing, heavy bleeding, pain…

Follow up scan in 2 weeks or pregnancy test in 3 weeks

Contraindications: infection, high risk haemorrhage, haemodynamic instability

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44
Q

What is the medical management of miscarriage

A

Vaginal misoprostol (prostaglandin analogue)

Stimulates cervical ripening and myometrial contraction

Give mifepristone 24-48 hours before admission

Follow up pregnancy test in 3 weeks

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45
Q

What is the surgical management of miscarriage

A

Manual vacuum aspiration with local anaesthetic if <12 weeks

Or evacuate retained products of conception under GA

Definitive indications: haemodynamic instability, infected tissue, gestational trophoblastic disease

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46
Q

What is recurrent miscarriage

A

3 or more consecutive pregnancies that end in miscarriage before 24 weeks

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47
Q

What can cause recurrent miscarriage

A

Antiphospholipid syndrome (15% of women with recurrent miscarriage)

Chromosomal abnormalities

Diabetes

Thyroid disease

PCOS

Anatomical abnormalities

Infection

Inherited thrombophilias

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48
Q

What are the risk factors for recurrent miscarriage

A

Advanced maternal age

Number of previous miscarriages

Smoking

Heavy alcohol

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49
Q

What investigations are needed for recurrent miscarriages

A

Blood tests (antiphospholipid antibodies, inherited thrombophilia screen)

Karyotyping

Pelvic USS

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50
Q

What is the management for recurrent miscarriage

A

Refer to specialist clinic

Genetic abnormalities

  • Genetic counselling/familial chromosomal studies
  • Other reproductive options

Anatomical abnormalities
- Cervical cerclage (suture cervix closed), serial cervical sonographic surveillance

Thrombophlias and antiphospholipid syndrome
- Heparin therapy throughout pregnancy

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51
Q

What are the most common sites of implantation in ectopic pregnancy

A

Ampulla or isthmus of fallopian tube

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52
Q

What are the rare sites of implantation of ectopic pregnancy

A

Ovary, cervix, peritoneal cavity

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53
Q

What is an ectopic pregnancy

A

Pregnancy implanted outside uterine cavity

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54
Q

What are the risk factors for an ectopic pregnancy

A

Previous ectopic pregnancy

PID

Endometriosis

Coil

POP

Pelvic surgery

Assisted reproduction

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55
Q

How may a woman with an ectopic pregnancy present

A

Pain

Vaginal bleeding

Shoulder tip pain

Brown vaginal discharge

Abdominal tenderness

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56
Q

What would you find on vaginal examination of a woman with an ectopic pregnancy

A

Cervical excitation

Adnexal tenderness

Fullness in pouch of Douglas (if ruptured)

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57
Q

What are the differential diagnoses for an ectopic pregnancy

A

Miscarriage

Ovarian cyst haemorrhage/torsion/rupture

Acute PID

UTI

Appendicitis

Diverticulitis

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58
Q

What investigations are needed for an ectopic pregnancy

A

Pregnancy test

Pelvic/transvaginal USS

b-HCG

  • > 1500 and no pregnancy seen, ectopic until proven otherwise
  • <1500, redo in 48 hours (double in pregnancy, half in miscarriage)
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59
Q

What is the medical management for ectopic pregnancy

A

IM methotrexate (anti-folate cytotoxic agent)

Monitor b-HCG to make sure that it is declining

Indications: b-HCG <1500, unruptured, no visible heartbeat

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60
Q

What is the surgical management for ectopic pregnancy

A

Tubal ectopics: laparoscopic salpingectomy

If have damage to contralateral tube, try salpingostomy (preserve tube)

Indications: severe pain, b-HCG >5000, adnexal mass >34 mm, visible heartbeat

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61
Q

What is the conservative management for ectopic pregnancy

A

Watchful waiting

Only if rupture is very unlikely

Monitor b-HCG every 48 hours

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62
Q

What are the complications of ectopic pregnancy

A

Rupture

Hypovolaemic shock

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63
Q

What is gestational trophoblastic disease

A

Group of pregnancy-related tumours

Can be pre-malignant (more common) or malignant

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64
Q

What are some examples of pre-malignant gestational trophoblastic disease

A

Partial molar pregnancy

Complete molar pregnancy

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65
Q

What are some examples of malignant gestational trophoblastic disease

A

Invasive mole

Choriocarcinoma

Placental trophoblastic site tumour

Epithelioid trophoblastic tumour

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66
Q

What is a molar pregnancy

A

A gestational trophoblastic disease

Abnormality in chromosomal number during fertilisation

Partial = 69 chromosomes

Complete = 46 chromosomes

Usually benign but can become malignant

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67
Q

What is a choriocarcinoma

A

A gestational trophoblastic disease

Malignancy of trophoblastic cells of placenta

Often co-exists with molar pregnancy

Metastasises to lung

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68
Q

What is a placental site trophoblastic tumour

A

A gestational trophoblastic disease

Malignancy of intermediate trophoblasts (anchor placenta to uterus)

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69
Q

What is an epithelioid trophoblastic tumour

A

A gestational trophoblastic disease

Malignancy of trophoblastic placental cells

Mimics a squamous cell carcinoma

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70
Q

What are the risk factors for gestational trophoblastic disease

A

Age <20 or >35

Previous gestational trophoblastic disease

Previous miscarriage

Oral contraceptive use

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71
Q

What are the clinical features of a molar pregnancy

A

Vaginal bleeding and abdominal pain early in pregnancy

Large, soft, boggy uterus

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72
Q

If gestational trophoblastic disease goes undiagnosed, what might the mother develop

A

Hyperemesis (higher b-HCG)

Hyperthyroidism (gestational thyrotoxicosis due to b-HCG)

Anaemia

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73
Q

What investigations are needed for gestational trophoblastic disease

A

Urine/blood b-HCG

Ultrasound (complete mole = granular/snowstorm appearance)

Histological examination of products of conception (post-treatment for molar pregnancy)

If suspect metastases, staging CT/MRI

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74
Q

What is the management of gestational trophoblastic disease

A

Register patient with GTD centre for follow up and monitoring of future pregnancies

Molar pregnancy

  • Suction curette
  • Medical evacuation
  • May need chemotherapy
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75
Q

What is placental abruption

A

Part/all of placenta separates from uterine wall prematurely

Important cause of antepartum haemorrhage

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76
Q

What is the pathophysiology of placental abruption

A

Rupture of maternal vessels in basal layer of endometrium

Blood accumulation splits placenta from uterine wall

Detached bit of placenta unable to function - get fetal compromise

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77
Q

What are the 2 main types of placental abruption

A

Revealed
- Blood drains through cervix, get PV bleeding

Concealed
- Blood stays in uterus, get a retroplacental clot

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78
Q

What are the risk factors for placental abruption

A

Placental abruption in previous pregnancy

Pre-eclampsia

Abnormal lie

Polyhydramnios

Abdominal trauma

Smoking

Drug use

Bleeding in 1st trimester

Underlying thrombophilia

Multiple pregnancy

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79
Q

What are the clinical features of placental abruption

A

Painful vaginal bleeding

Woody uterus

Pain on abdominal examination

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80
Q

What are the differential diagnoses for placental abruption

A

Placenta praevia

Marginal placental bleeding (small abruption, not big enough to cause compromise)

Vasa praevia

Uterine rupture

Polyps/carcinoma/cervical ectropion

Candida/bacterial vaginosis, chlamydia

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81
Q

What investigations are needed for placental abruption

A

Bloods

Assess fetal wellbeing (if >26 weeks, use CTG)

Ultrasound

82
Q

What is the management of placental abruption

A

ABCDE

Emergency delivery (if have compromise)

Induction of labour (at term, everyone stable)

Conservative management (partial abruption)

Anti-D within 72 hours of onset of bleeding for RhD- women

83
Q

What is placenta praevia

A

Placenta fully/partially attached to lower uterine segment

Important cause of antepartum haemorrhage

Placenta may be damaged by presenting part of baby

84
Q

What are the 2 main types of placenta praevia

A

Minor
- Placenta low, but not covering internal os

Major
- Placenta lying over internal os

85
Q

Placentas in what position are most susceptible to haemorrhage

A

Low-lying placentas

86
Q

What are the risk factors for placenta praevia

A

Previous C-section

High parity

Age >40

Multiple pregnancy

Previous placenta praevia

History of uterine infection

Curette of endometrium (after miscarriage/termination)

87
Q

What are the clinical features of placenta praevia

A

Painless vaginal bleeding

Not tender on palpation

88
Q

What are the differential diagnoses of placenta praevia

A

Placental abruption

Vasa praevia

Uterine rupture

Polyps/carcinoma/cervical ectropion

Candida/bacterial vaginosis/chlamydia

89
Q

How does vasa praevia present

A

Vaginal bleeding

Rupture of membranes

Fetal compromise

90
Q

What are the investigations needed for placenta praevia

A

Bloods

Assess fetal wellbeing (if >26 weeks, use CTG)

Ultrasound scan

91
Q

What is the management of placenta praevia

A

ABCDE

Minor - repeat scan an 36 weeks, placenta likely to have moved

Major - repeat scan at 32 weeks and make plan for delivery

(Initial scan at 20 weeks)

Confirmed placenta praevia - C-section at 38 weeks

Anti-D within 72 hours of bleeding for RhD- women

92
Q

What is a breech presentation

A

When fetus presents with buttocks or feet first

20% breech at 28 weeks, but most move to have cephalic presentation

93
Q

What are the 3 different types of breech presentation

A

Complete (flexed)

Frank (extended)

Footling

94
Q

What is a complete (flexed) breech

A

Both legs flexed at knees and hips

In a ‘cross-legged’ position

95
Q

What is a frank (extended) breech

A

Both legs flexed at hip, extended at knees

Most common type of breech

96
Q

What is a footling breech

A

One or both legs extended at hip

Foot presents first

97
Q

What are the uterine risk factors for breech presentation

A

Multiparity

Uterine malformation (septate uterus…)

Fibroids

Placenta praevia

98
Q

What are the fetal risk factors for breech presentation

A

Prematurity

Macrosomia

Polyhydramnios

Twins

Anencephaly

99
Q

When does a diagnosis of breech presentation become significant

A

32-35 weeks

100
Q

What is found on clinical examination in breech presentations

A

Round head at upper end of uterus

Irregular mass at pelvis

Fetal heart auscultated in abdomen

101
Q

How many breech presentations are spotted at labour

A

20%

Significant fetal distress (meconium-stained liquor)

Sacrum/foot coming through cervix

102
Q

What are the differential diagnoses for breech presentation

A

Oblique lie

Transverse lie

Unstable lie

103
Q

What investigations are needed in breech presentations

A

Ultrasound

104
Q

What are the methods of management for breech presentations

A

External cephalic version

C-section

Vaginal breech delivery

105
Q

What is external cephalic version

A

Manipulation of fetus to cephalic presentation through maternal abdomen

Aim to attempt vaginal delivery

40% success in primips, 60% success in multips

106
Q

What are the complications of external cephalic version

A

Fetal heart rate abnormalities (most revert back to normal)

Placental abruption

May need emergency C-section

107
Q

What are the contraindications for external cephalic version

A

Recent antepartum haemorrhage

Ruptured membranes

Uterine abnormalities

Previous C-section

108
Q

What is a vaginal breech delivery

A

For those that choose to deliver vaginally, or present in advanced labour

Contraindicated in footling breech

No traction applied (head can expand and get stuck)

Can use specific manoeuvres if baby gets stuck, may need forceps

109
Q

What are the complications of breech presentations

A

Cord prolapse

Fetal head entrapment

Premature rupture of membranes

Birth asphyxia (if have delay in delivery)

Intracranial haemorrhage (rapid compression of head)

110
Q

What does the lie of a fetus describe

A

Relationship between long axis of fetus and maternal pelvis

Longitudinal, transverse, or oblique

111
Q

What does the presentation of a fetus describe

A

Fetal part that first enters maternal pelvis

Cephalic, breech, shoulder, face, or brow

112
Q

What does the position of a fetus describe

A

Position of fetal head as it exits birth canal

Head usually emerges in occipito-anterior position

113
Q

What are the risk factors for abnormal fetal lie/presentation/position

A

Prematurity

Multiple pregnancies

Uterine abnormalities

Fetal abnormalities

Placenta praevia

Primiparity

114
Q

What investigations are needed for abnormal fetal lie/presentation/position

A

Ultrasound

115
Q

What is the management for abnormal fetal lie

A

External cephalic version

At 36-38 weeks

116
Q

What is the management for malpresentation

A

Breech

  • Attempt ECV
  • Vaginal breech/C-section

Brow
- C-section

Face
- Chin anterior = vaginal, chin posterior = C-section

Shoulder
- C-section

117
Q

What is the management for malposition

A

90% revert to occipito-anterior position as labour progresses

If head does not rotate, can physically rotate/use operative vaginal delivery

C-section may be needed

118
Q

What is oligohydramnios

A

Low levels of amniotic fluid

Below 5th centile for gestational age

119
Q

What happens to the level of amniotic fluid as a pregnancy progresses

A

Increases until 33 weeks

Plateaus from 33-38 weeks

Decreases after 38 weeks

Around 500ml at term

Mostly fetal urine output

120
Q

What can cause oligohydramnios

A

Preterm premature rupture of membranes

Placental insufficiency

Renal agenesis (Potter’s syndrome)

Non-functioning fetal kidney

Obstetric uropathy

Genetic/chromosomal abnormalities

Viral infections

121
Q

How is oligohydramnios diagnosed

A

Ultrasound

Amniotic fluid index
- Measures maximum pockets of fluids in 4 quadrants and adds them together

Maximum pool depth
- Vertical measurement of the area

122
Q

What is the management of oligohydramnios due to ruptured membranes

A

Labour likely to commence in 24-48 hours

If <37 weeks, steroids, induce, antibiotics

123
Q

What is the management of oligohydramnios due to placental insufficiency

A

Deliver at 36-37 weeks

124
Q

What is the prognosis for oligohydramnios

A

In second trimester, poor prognosis (PROM, prematurity, pulmonary hypoplasia)

Disability (not able to move muscles as much in utero)

125
Q

What is polyhydramnios

A

Abnormally large amounts of amniotic fluid

Above 95th centile

126
Q

What are the causes of polyhydramnios

A

Idiopathic (60% cases)

Conditions stopping fetus swallowing (oesophageal atresia, CNS abnormalities, muscular dystrophy…)

Duodenal atresia (‘double bubble’ sign on USS)

Anaemia

Fetal hydrops

Twin-to-twin transfusion syndrome

Increased lung secretions

Genetic/chromosomal abnormalities

Maternal diabetes

Maternal ingestion of lithium

Macrosomia

127
Q

How is polyhydramnios diagnosed

A

Ultrasound

Amniotic fluid infex
- Measures maximum pockets of fluids in 4 quadrants and adds them together

Maximum pool depth
- Vertical measurement of the area

128
Q

How is polyhydramnios managed

A

Usually need no intervention

Amnioreduction

Indomethacin (enhances water retention, reduces fetal urine output, not to be used past 32 weeks)

If idiopathic, need paeds review before 1st feed

129
Q

What are the complications of polyhydramnios

A

High perinatal mortality

Increased rates of malpresentation

Cord prolapse

PROM

PPH

130
Q

What is pre-eclampsia

A

A hypertensive disorder of pregnancy

A placental disease (due to poor placental perfusion)

Can lead to life-threatening maternal/fetal compromise

131
Q

What is the pathophysiology of pre-eclampsia

A

Incomplete remodelling of spiral arteries

High resistance, low-flow uteroplacental circulation

Get high blood pressure, hypoxia, and oxidative stress

132
Q

What are the moderate risk factors for pre-eclampsia

A

Nulliparity

Age >40

BMI > 35

Family history

Pregnancy interval >10 years

Multiple pregnancy

133
Q

What are the high risk factors for pre-eclampsia

A

Chronic hypertension

HTN/pre-eclampsia/eclampsia in previous pregnancy

Pre-existing CKD

Diabetes

Autoimmune disease

134
Q

What is the prophylactic treatment for pre-eclampsia

A

For those with 1 high or 2 moderate risk factors

75 mg aspirin daily

From 12 weeks to birth

135
Q

What are the 3 criteria of pre-eclampsia

A

Hypertension (>140 or >90 on 2+ occasions)

Significant proteinuria

> 20 weeks gestation

136
Q

What are the symptoms of pre-eclampsia

A

Most asymptomatic

Headaches (frontal)

Visual disturbances

Epigastric pain

Sudden onset non-dependent oedema

Hyper-reflexia

137
Q

What are the 3 classifications of pre-eclampsia

A

Mild
- 140/90 - 149/99

Moderate
150/100-159/109

Severe
>160/110 or >140/90 with proteinuria and symptoms

138
Q

When is the prognosis of pre-eclampsia poorest

A

Onset before 34 weeks

139
Q

What are the maternal complications of pre-eclampsia

A

HELPP syndrome (haemolysis, elevated liver enzymes, low platelets)

Eclampsia

AKI

DIC

Adult respiratory distress syndrome

Post-partum hypertension

Cerebrovascular haemorrhage

Death

140
Q

What are the fetal complications of pre-eclampsia

A

Prematurity

Intrauterine growth restriction

Placental abruption

Intrauterine fetal death

141
Q

What are the differential diagnoses of pre-eclampsia

A

Essential hypertension (<20 weeks)

Pregnancy-induced hypertension (>20 weeks, but no proteinuria)

Eclampsia (pre-eclampsia with seizures)

142
Q

What investigations are needed in pre-eclampsia

A

Blood pressure

Urine dip

Monitoring for signs of organ damage (U&Es, LFTs…)

143
Q

What is the management for pre-eclampsia

A

Monitor maternal and fetal wellbeing

VTE prophylaxis (LMWH)

Antihypertensives

Delivery (definitive cure)

Post-natal care

144
Q

What anti-hypertensives are used in pre-eclampsia

A

Labetalol

  • First line
  • Beta blocker

Nifedipine
- CCB

Methyldopa
- Alpha agonist

ACE inhibitors contraindicated (linked to congenital abnormalities)

145
Q

What post-natal care is needed for pre-eclampsia

A

Monitor mother for 24 hours post-partum

  • Risk of eclamptic seizures
  • Considered ‘safe’ after 5 days

Monitor blood pressure

  • First 2 days post-partum
  • Once between day 3-5
  • Reassess need for antihypertensives
146
Q

What is hyperemesis gravidarum

A

Persistent and severe vomiting during pregnancy

Leads to weight loss, dehydration, and electrolyte imbalance

147
Q

What are the normal patterns of nausea and vomiting in pregnancy

A

Starts at 4-7 weeks

Peaks in 9th week

Settles by 20 weeks

Due to b-HCG stimulating chemoreceptor trigger zone in brain

148
Q

What is the diagnostic criteria for hyperemesis gravidarum

A

Prolonged and severe vomiting

> 5% pre-pregnancy weight loss

Dehydration

Electrolyte imbalance

149
Q

What are the risk factors for hyperemesis gravidarum

A

First pregnancy

Previous hyperemesis gravidarum

High BMI

Multiple pregnancy

Hydatidiform mole

150
Q

What scoring system is used for hyperemesis gravidarum

A

Pregnancy-unique quantification of emesis (PUQE)

  • Up to 6 = mild
  • 7-12 = moderate
  • 13-15 = severe
151
Q

What are the differential diagnoses for hyperemesis gravidarum

A

Gastroenteritis

Cholecystitis

Hepatitis

Pancreatitis

Peptic ulcer

UTI/pyelonephritis

Drug-induced

152
Q

What investigations are needed for hyperemesis gravidarum

A

Weight

Urine dip, MSU

Bloods

Glucose

Ultrasound

153
Q

What is the management of hyperemesis gravidarum

A

Mild managed in community, moderate managed in ambulatory daycare, severe managed as inpatient

IV rehydration

H2 receptor antagonist/PPI
- For reflux, oesophagitis or gastritis

Thiamine
- Prevents Wernicke’s encephalopathy in prolonged vomiting

Thromboprophylaxis

Antiemetics

154
Q

What are the recommended antiemetics for hyperemesis gravidarum

A

First line
- Cyclizine, prochlorperazine, promethazine, chlorpromazine

Second line
- Metoclopramide, domperidone, ondansetron

Third line
- IV hydrocortisone

155
Q

What is gestational diabetes

A

Any degree of glucose intolerance with onset or first recognition during pregnancy

Increasing in incidence

156
Q

What happens to insulin resistance during pregnancy

A

Increases

Those with poor pancreatic reserve can not deal with increased demand

157
Q

What are the risk factors for gestational diabetes

A

BMI >30

Asian

Previous gestational diabetes

1st degree relative with diabetes

PCOS

Previous macrosomic baby

158
Q

What are the clinical features of gestational diabetes

A

Mostly asymptomatic

Polyuria

Polydipsia

Fatigue

159
Q

What are the fetal complications of gestational diabetes

A

Macrosomia

Organomegaly

Erythropoiesis

Increased rates of pre-term delivery

Reduced surfactant production

160
Q

What happens to babies of mothers with gestational diabetes after birth

A

Fetal insulin levels stay high

No longer getting glucose from mother

Risk of hypoglycaemia

Need to ensure regular feeding

161
Q

What are the investigations needed for gestational diabetes

A

Oral glucose tolerance test

  • Diagnostic criteria: fasting >5.6, 2hrs postprandial >7.8

Offered at

  • Booking
  • 24-28 weeks (if have risk factors)
  • Any point in pregnancy if have glycosuria
162
Q

What is the management for gestational diabetes

A

Lifestyle advice

Measure capillary glucose 4 times per day

Medical management

Additional growth scans (at 28, 32 and 36 weeks)

Aim to deliver at 37-38 weeks if on treatment

Post-natal care

163
Q

What is the medical management for gestational diabetes

A

Metformin

Insulin

  • If fasting >7
  • If abdominal circumference >95th centile

Gibenclamide
- If metformin not tolerated and insulin refused

164
Q

What post-natal care is needed in gestational diabetes

A

Stop all anti-diabetic medication immediately after delivery

Do fasting glucose test at 6-13 weeks post-partum

Yearly screen for diabetes

165
Q

What is cytomegalovirus

A

Member of herpesvirus family

Most common virus transmitted to fetus during pregnancy

Highest risk in first trimester

166
Q

What are the clinical features of cytomegalovirus in pregnancy

A

Mostly asymptomatic

Mild flu-like symptoms

Fever

Splenomegaly

Impaired liver function

167
Q

What investigations are needed if maternal cytomegalovirus infection is suspected

A

Viral serology for CMV specific IgM and IgG

168
Q

What is the management of cytomegalovirus in pregnancy

A

Refer to fetal medicine specialist

Maternal
- No treatment for immunocompetent women

Fetal

  • Diagnosis via amniocentesis and PCR
  • Test done after 21 weeks
  • Termination of pregnancy offered (chances of malformations and congenital CMV)
169
Q

What are the congenital cytomegalovirus effects on the baby

A

Intrauterine growth restriction

Hepatosplenomegaly

Thrombocytopenia purpura

Jaundice

Microcephaly

Chorioretinitis

20-30% mortality

If born without symptoms, 15% chance that they will soon develop: sensorineural hearing loss, psychomotor developmental delay, visual impairment

170
Q

What are the risk factors for GBS infection of the neonate

A

GBS infection in previous baby

<37 weeks

Rupture of membranes >24 hours before delivery

Pyrexia during labour

Positive test for GBS in mother

Mother diagnosed with UTI due to GBS in pregnancy

171
Q

What are the maternal symptoms of GBS infection

A

UTI

Chorioamnionitis

Endometritis

172
Q

What are the symptoms of neonatal GBS infection

A

Pyrexia

Cyanosis

Difficulty breathing and feeding

Floppiness

173
Q

What investigations are needed to detect GBS in the mother

A

Swab (first in vagina, then in rectum)

Urine culture (if have UTI)

174
Q

What is done to prevent GBS infection of the newborn

A

High dose IV penicillin (benzylpenicillin) throughout labour for women with:

  • GBS +ve swab
  • UTI due to GBS in pregnancy
  • Previous baby with GBS infection
  • Pyrexia during labour
  • Labour at <37 weeks
  • Rupture of membranes >18 hours
175
Q

What is Parvovirus B19

A

Mild, self-limiting infection in adults

Can cause spontaneous miscarriage and intrauterine death

176
Q

What are the symptoms of parvovirus B19 infection

A

Asymptomatic in adults

In children: URTI, malaise, headaches, low grade fever, erythema infectiosum (slapped cheek syndrome)

177
Q

What investigations are needed for parvovirus B19 infection

A

Viral serology (IgM and IgG antibodies)

178
Q

What is the management of parvovirus B19 infection in pregnancy

A

Refer to fetal medicine specialist

Maternal

  • No need for treatment
  • Consider antipyrexials and analgesia

Fetal

  • Risk of fetal hydrops (abnormal accumulation of fluid in fetal compartments)
  • Serial USS and doppler (start 4 weeks post-infection, every 1-2 weeks until 30 weeks)

If evidence of fetal hydrops, refer to tertiary care for intrauterine erythrocyte transfusion

179
Q

What are the symptoms of fetal hydrops

A

Ascites

Subcutaneous oedema

Pleural effusion

Pericardial effusion

Scalp oedema

Polyhydramnios

Severe anaemia

180
Q

What are the signs and symptoms of Rubella infection

A

Often asymptomatic

Malaise, headaches, coryza, lymphadenopathy, diffuse fine maculopapular rash

Incubation 14-21 days

181
Q

What investigations are needed in Rubella infection

A

ELISA to look for IgG and IgM antibodies

182
Q

What is the maternal management for Rubella

A

Refer to fetal medicine specialist

Antipyrexials

183
Q

What is the fetal management for Rubella

A

Risk of transmission decreases with increasing age

<12 weeks

  • High likelihood of defects
  • Consider termination of pregnancy

12-20 weeks

  • Consider termination of pregnancy
  • Serial ultrasound surveillance

> 20 weeks
- No action needed

184
Q

What is congenital Rubella syndrome

A

Neonatal manifestation of Rubella virus during pregnancy

Present at birth:
Sensorineural hearing loss, pulmonary stenosis, patent ductus arteriosus, ventricular septal defect, retinopathy, congenital cataracts, learning disability, microencephaly, thrombocytopenia

Late onset: diabetes, thyroiditis, growth hormone abnormalities, behaviour disorders

185
Q

What are the clinical features of Varicella zoster infection

A

Primary infection
- Fever, malaise, purpuric maculopapular rash

Incubation 10-21 days

Associated with maternal:
- Pneumonia, hepatitis, encephalitis, mortality

186
Q

What investigations are needed for Varicella zoster infection

A

Clinical diagnosis

PCR

IgG and IgM testing

187
Q

What is the management of Varicella zoster in pregnancy

A

Enquire about previous exposure

If no previous infection, IgG test needed

If not immune
- Give varicella zoster immunoglobulin within 10 days of contact

Maternal chicken pox

  • Aciclovir within 24 hours of rash appearing
  • Refer to fetal medicine specialist
  • Serial USS from 5 weeks post-infection

Varicella vaccination not recommended during pregnancy

188
Q

What are the complications of Varicella zoster infection

A

Varicella of the newborn

  • Significant risk if mother infected in last 4 weeks of pregnancy
  • Treat with varicella zoster immunoglobulin and aciclovir

Fetal varicella syndrome

  • Reactivation of virus in utero as herpes zoster
  • Only if mother infected at <20 weeks
  • Skin scarring, eye defects, hypoplasia of limbs, neurological abnormalities
189
Q

What are the thresholds for diagnosing anaemia in pregnancy

A

1st trimester <100

2nd/3rd trimester <105

Postpartum <100

190
Q

What are the risk factors for anaemia in pregnancy

A

Haemoglobinopathies (thalassaemia, sickle cell disease)

Increased maternal age

Low socioeconomic status

Anaemia during previous pregnancy

191
Q

What are the clinical features of anaemia in pregnancy

A

Dizziness

Fatigue

Dyspnoea

Pallor

Koilonychia

Angular cheilitis

192
Q

What investigations are needed for anaemia in pregnancy

A

FBC

Haemoglobinopathy screen

Women screened at booking and at 28 weeks

193
Q

What is the management for anaemia during pregnancy

A

Iron deficiency anaemia

  • Oral iron (repeat bloods in 2 weeks)
  • Parenteral iron infusion

Other causes

  • Folate supplements
  • Blood transfusion
194
Q

What is antiphospholipid syndrome

A

Autoimmune condition where antibodies are targeted against phospholipid-binding protein

Linked with adverse pregnancy outcomes

Major cause of recurrent miscarriage

195
Q

What are the signs and symptoms of antiphospholipid syndrome

A

Thrombosis formation (ischaemic stroke, DVT…)

Recurrent pregnancy loss

196
Q

What are the complications of antiphospholipid syndrome

A

Pre-eclampsia

Intrauterine growth restriction

Livedo reticularis (blue pattern on skin)

Valvular heart disease

Renal impairment

Thrombocytopenia

197
Q

What is catastrophic antiphospholipid syndrome

A

Rare complication

Acute formation of microthrombosis

Infarction of multiple organs

198
Q

What are the investigations for antiphospholipid syndrome

A

Needed in all women with

  • Recurrent miscarriage
  • Atypical vascular thrombosis
  • Recurrent thromboses

Bloods
- Anticardiolipin
- Lupus antibodies
Anti-B2-glycoprotein 1

199
Q

What is the management for antiphospholipid syndrome

A

Presentation with recurrent pregnancy loss
- LMWH and low does aspirin throughout future pregnancies

Presentation with previous pre-eclampsia or intrauterine growth restriction
- Low dose aspirin throughout future pregnancies

Presentation with VTE
- Long-term anticoagulation with warfarin

200
Q

What are the obstetric risk factors for VTE

A

Multiple pregnancy

Pre-eclampsia

C-section

Prolonged labour

Stillbirth

Pre-term birth

PPH

201
Q

What investigations are needed for VTE in pregnancy

A

Basic bloods

Compression duplex USS

ECG and CXR

CTPA or V/Q scan

Do not measure D-dimer (normally raised in pregnancy)

202
Q

What is the management for VTE in pregnancy

A

LMWH
- Start at suspicion

Confirmed VTE
- Maintain anticoagulation throughout pregnancy and to 6-12 weeks post-partum

Do not use warfarin (teratogenic)

Obs and gynae (6 decks)

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