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Obs 1 Flashcards

1
Q

What is an Amniotic Fluid Embolism?

A

Obstetric emergency in which amniotic fluid and foetal cells enter the maternal circulation causing cardiorespiratory collapse

  • Rare complication of pregnancy
  • High mortality rate
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2
Q

What is the aetiology of Amniotic Fluid Embolism?

A

Unclear…

  • Embolism provokes an anaphylactic reaction, or
  • Complement cascade > pulmonary artery spasm > increases pulmonary artery pressure and RVP > hypoxic myocardial and pulmonary capillary damage > LVF and death
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3
Q

What are the RFs for Amniotic Fluid Embolism?

A

(Often occurs in lack of RFs):

  • Increasing maternal age
  • Induction of labour (use of uterotonics)
  • Placenta praevia/abruption
  • C-section
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4
Q

What are the S/S of Amniotic Fluid Embolism?

A

Majority of cases occur in labour , but can also occur during CS and after delivery in the immediate postpartum.

  • Sudden onset SoB ± cyanosis
  • Chills, shivering, sweating, anxiety and coughing
  • Bleeding / DIC
  • Seizures
  • Tachypnoea/tachycardia
  • Pulmonary oedema
  • Uterine atony
  • Hypotension
  • Bronchospasms
  • Arrhythmia and MI
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5
Q

What are the investigations for Amniotic Fluid Embolism?

A

Clinical diagnosis of exclusion, as there are not definitive diagnostic tests.

  • ABG – hypoxaemia, raised PACO2
  • FBC– low Hb
  • Clotting - low platelets, high PT/APTT, low fibrinogen,
  • U&Es, X-match
  • CXR – cardiomegaly, pulmonary oedema
  • ECG – right heart strain, rhythm abnormalities
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6
Q

What is the management for Amniotic Fluid Embolism?

A

ABC approach and refer to ITU with MDT
Management is predominantly supportive (ventilatory/circulatory/haemodynamic support, ionotropics)

Immediate:

  • Airway = maintain patency
  • Breathing = high flow O2 ± intubation
  • Circulation = 2 large bore cannulae, fluid resus

Pharmacological:

  • Ionotropics as needed
  • Correct coagulopathy - transfusion of RBCs, FFP, CFs
  • Uterine atony > PPH management

Consider immediate operative delivery ± hysterectomy

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7
Q

What are the complications of an Amniotic Fluid Embolism?

A
  • Cardiac arrest, death
  • DIC
  • Seizures
  • Uterine atony, haemorrhage
  • Pulmonary oedema, ARDS
  • Renal failure

Prognosis = poor

  • 75% survive (many mothers and children have sequelae)
  • 25% die within 12 hours
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8
Q

Define anaemia in pregnancy

A

Pregnant women with mean value of Hb:

  • < 110 g/L in 1st trimester
  • < 105 g/L in 2nd/3rd trimester
  • < 100 g/L postpartum
  • < 70 g/L – URGENT REFERRAL
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9
Q

What are the different causes of anaemia in pregnancy?

A

Iron deficiency:

  • Blood loss, decreased absorption/intake, haemolysis
  • > Hypochromic microcytic anaemia, pencil cells

Folate deficiency:
(leafy green veg)

  • Diet, demand, malabsorption, drugs
  • Megaloblastic anaemia (hypersegmented neutrophils, macrocytosis, thrombocytopaenia, leucopaenia)

B12 deficiency:
(Vegans, poultry, dairy, eggs)

  • Diet, malabsorption
  • Megaloblastic anaemia

Also:

  • Chronic illnesses: IBD, UTI
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10
Q

What are the RFs for anaemia in pregnancy?

A
  • Multiple pregnancy
  • 2 pregnancies close together
  • Lots of vomit due to morning sickness
  • Pregnant teenager
  • Anaemia before becoming pregnant
  • DIET (esp. iron deficiency)
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11
Q

What are the S/S of anaemia in pregnancy?

A
  • Tired or weak
  • Dizziness
  • SOB
  • Trouble concentrating
  • Tachycardia/Tachypnoea
  • Pale skin, lips, nails, conjunctiva

B12-specific:

  • Glossitis, depression, psychosis/dementia, paraesthesia, peripheral neuropathy
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12
Q

What are the investigations for anaemia in pregnancy?

A

Screened for anaemia at booking and at 28 weeks…

  • FBC - hb, hct
  • Haematinics / Iron Studies
  • Blood film
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13
Q

What is the management of anaemia in pregnancy?

A

Supplements: Iron, B12 and folate (recheck in 2-3 weeks)

  • Oral ferrous sulphate (note SEs: black stools, constipation, abdominal pain)
  • Oral folic acid (if cause not known, don’t give this as can exacerbate B12 symptoms)
  • IM hydroxocobalamin

Advice:

  • Iron/folate – green leafy vegetables, nuts
  • B12 – meat and dairy
  • Lifestyle: Avoid alcohol, stop smoking

Intra-partum:

  • Deliver in consultant-led unit
  • IV access and group and screen on admission
  • Active management of 3rd stage
  • Active management of PPH
  • Consider prophylactic syntocinon infusion
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14
Q

What are the complications of anaemia in pregnancy?

A
  • Preterm
  • LBW
  • Postpartum depression
  • Child with developmental delays
  • Spina bifida (folate)

Prognosis = good!

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15
Q

Define asthma in pregnancy

A

A diagnosis of asthma BEFORE pregnancy

  • Most common chronic disease in pregnancy (3-12%)
  • Most occur between 24-36 weeks
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16
Q

What are the S/S of asthma in pregnancy?

A
  • Wheeze, breathlessness, cough – worse in morning and at night
  • Precipitating factors – e.g. cold, drugs (beta blocker, NSAIDs), exercise
  • Atopic history
  • Tachypnoea, use of accessory muscles, prolonged expiratory phase, polyphonic wheeze, hyperinflated chest
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17
Q

Describe the different severities of asthma

A

Moderate:

  • PEFR 50-75%

Severe:

  • PEFR 33-50%
  • Pulse >110, RR > 25, inability to complete sentences

Life-threatening:

  • PEFR <33%
  • Silent chest, cyanosis, bradycardia, hypotension, confusion, coma

Near fatal:

  • pCO2 raised
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18
Q

What are the investigations for asthma in pregnancy?

A
  • Peak flow, pulse oximetry
  • Bloods: ABG, FBC (WCC infection?), CRP, U&Es, blood/sputum cultures
  • PEFR monitoring (diary)
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19
Q

What is the management of asthma in pregnancy?

A

Regular medications continued throughout labour > bronchoconstrictors should be avoided

General:

  • Encourage smoking cessation
  • Ensure patient is educated regarding condition, ensure optimal control and response to therapy
  • Manage exacerbations aggressively
  • Flu vaccine
  • Monitor foetal movements daily after 28 weeks

Acute management:
MANAGE ACUTE ATTACKS AS IN NON-PREGNANT INDIVIDUAL, offer MDT approach.

  • High flow oxygen, neb salbutamol, ipratropium
  • Steroid therapy (IV hydrocortisone, PO pred)
  • IV magnesium sulphate and senior help (PCO2 up)
  • Discharge when - PEFR >75% of pts best, diurnal variation <25%, stable on discharge meds for 24h

Chronic management:

  1. SABA
  2. SABA + ICS
  3. SABA + ICS + LRTA
  4. LABA + ICS + LRTA
  5. LABA + higher-dose ICS + LRTA
  6. +Trial drugs e.g. theophylline
  7. +Oral CS
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20
Q

What are the complications of asthma in pregnancy?

A
  • Prolonged hypoxia > FGR, and ultimately, foetal brain injury
  • Oral CS use in first trimester increases cleft lip risk
  • Preterm birth, perinatal mortality

Prognosis = severity of asthma remains stable in 1/3, worsens in another 1/3 and improves in the 1/3

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21
Q

What is the aetiology of cardiac disease in pregnancy?

A

40% rise in blood volume during pregnancy causing strain and women with cardiac disease cannot increase CO leading to uterine hypoperfusion and increased pulmonary oedema

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22
Q

Describe the epidemiology of cardiac disease in pregnancy

A

Increasing due to increased maternal age, increased life expectancy and increased immigrant populations

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23
Q

What are normal cardiac responses expected in pregnancy?

A

Most women will remain well throughout pregnancy; normal cardiac responses:

  • ESM in 96% (more CO)
  • Forceful apex (more CO)
  • 3rd heart sound in 84% (more cardiac volume)
  • Peripheral oedema (more volume)
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24
Q

Describe the NYHA classification

A

Class I:

  • No limitation of physical activity
  • Ordinary physical activity does not cause undue fatigue, palpitation, SOB

Class II:

  • Slight limitation of physical activity
  • Comfortable at rest
  • Ordinary physical activity results in fatigue, palpitation, SOB

Class III:

  • Marked limitation of physical activity
  • Comfortable at rest
  • Less than ordinary physical activity results in fatigue, palpitation, SOB

Class IV:

  • Unable to carry on any physical activity without discomfort
  • Symptoms of HF at rest
  • If any physical activity is undertaken, discomfort increases
25
Q

What are the investigations for cardiac disease in pregnancy?

A

Echo usually performed at booking and at 28 weeks

26
Q

What are high risk cardiac conditions?

A
  • Systemic ventricular dysfunction
  • Pulmonary hypertension
  • Cyanotic congenital heart disease
  • Aortic pathology (e.g. Marfan’s syndrome)
  • Ischaemic heart disease
  • Left heart obstructive lesions (e.g. aortic/mitral stenosis)
  • Prosthetic heart valves
  • Previous peripartum cardiomyopathy
27
Q

What are the foetal risks of maternal cardiac disease?

A
  • Recurrence (congenital heart disease)
  • Maternal cyanosis (foetal hypoxia)
  • Iatrogenic prematurity
  • FGR
  • Effects of maternal drugs (teratogenesis, growth restriction, foetal loss)
28
Q

What is the management of cardiac disease in pregnancy?

A

Anticoagulation is essential in patients with CHD who have pulmonary hypertension or artificial valves and those at risk of AF

(WARNING: warfarin is teratogenic if used in the first trimester)

LMWH is used as an alternative to warfarin

29
Q

What is the management of labour and delivery for women with cardiac disease?

A

Method of delivery:

  • In most cases, aim to wait for spontaneous labour
  • Induction considered in very high-risk women to ensure delivery occurs at predictable time with all personnel present
  • CS for those where any effort is dangerous

Management:

  • Prophylactic abx should be given to any woman with structural heart defect (reduce the risk of bacterial endocarditis)
  • Epidural usually recommended to reduce pain-related stress
  • 2nd stage kept short with elective forceps / ventouse (reduces maternal effort / need for increased CO)
  • Ergometrine contraindicated so active management of 3rd stage with syntocinon ALONE (vasodilator so introduce it slowly)
30
Q

Define diabetes in pregnancy

A

Existing diabetes mellitus in pregnant women

(i.e. known; so, no signs/symptoms or investigations)

31
Q

How does glucose control change during pregnancy?

A

Insulin resistance INCREASES throughout pregnancy

  • Hypoglycaemia is more common in pregnancy and is very dangerous
  • Increase dose of metformin or insulin during pregnancy
  • Postnatally, insulin requirements return to normal levels, so insulin should be adjusted accordingly
32
Q

What are the effects of pregnancy on diabetes?

A
  • Nausea and vomiting (particularly early on)
  • Greater importance of tight glucose control
  • Increase in insulin dose requirements in second half of pregnancy
  • Increased risk of severe hypoglycaemia
  • Risk of deterioration of any retinopathy or nephropathy
33
Q

What are the risks of diabetes during pregnancy?

A

Foetal:

  • Macrosomia
  • Polyhydramnios
  • Neonatal hypoglycaemia
  • Shoulder dystocia
  • Congenital defects
  • Miscarriage
  • Later risk of T2DM and obesity

Maternal:

  • Traumatic delivery due to macrosomia
  • Increased risk of T2DM
  • Increased future risk of GDM (50%)
  • Pre-eclampsia
34
Q

What does it suggest if insulin control gets better in pregnancy?

A

Placental Failure

  • It is BAD if glucose drops with insulin tx in pregnancy - insulin resistance should go up.
  • Human placental lactogen & steroids drive the diabetes in pregnancy so if insulin control gets better – it means the placenta isn’t working as well.

(Doppler USS will not detect this as it is a metabolic change)

35
Q

What pre-conception checks are needed for diabetes in pregnancy?

A
  • HbA1c (glucose control must be tight)
  • Renal testing (U&Es, creatinine)
  • Digital retina assessment (retinopathy needs to be treated before pregnancy begins)
  • BP checks
  • Stop any statin use
  • Start high dose folic acid (5mg, OD) until 12w gestation

Tell them to use contraception until these are checked!

36
Q

What pre-conception counselling is needed for diabetes in pregnancy?

A
  • Embryogenesis is affected by DM and so miscarriage risk is higher
  • Poor glycaemic control is teratogenic (midline deformities such as spina bifida)
  • Growth restriction possible (macrosomic babies can still be growth restricted)
  • Stillbirth risk (from baby outgrowing supply ability of the placenta)
  • Polyhydramnios (baby has osmotic diuresis > cord prolapse & placental abruption)
  • Hypoglycaemic risk for baby after cut cord as loss of glucose and high insulin levels
  • Higher Infection and DKA rate in pregnancy
37
Q

What blood glucose monitoring is needed for diabetes in pregnancy / GD?

A

4 times per day:

  • Before first meal
  • 1-hour post each meal

Targets:

  • Fasting blood glucose target = <5.3mmol/L [4-7mmol/L]
  • 1-hour postprandial target = <7.8mmol/L
  • HbA1c can be used to assess the level of risk in the pregnancy

Extra Checks/Scans:

  • Cardiac outflow scan
  • Retinal scanning
  • Renal scanning
38
Q

What is the management of pre-existing diabetes in pregnancy?

A
  • Weight loss for women with BMI of > 27
  • Stop oral hypoglycaemic agents, apart from metformin, and commence insulin
  • Folic acid 5 mg/day from pre-conception to 12 weeks gestation
  • Detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts
  • Tight glycaemic control reduces complication rates
  • Treat retinopathy as can worsen during pregnancy
39
Q

Describe the timeline of contacts for diabetes in pregnancy

A
  • 12w “booking” checks
  • Every 2w - joint antenatal-diabetes clinics
  • 20w “anomaly” scans
  • 28w, 32w, 36w (4-weekly, serial) - foetal surveillance, Dopplers, liquor volume
  • 37+0 to 38+6w - induction or ELCS
40
Q

What is gestational diabetes?

A

New-onset diabetes during pregnancy (usually disappears after birth; occurs 24-28w gestation)

  • During pregnancy, placenta produces substances that have an anti-insulin effect thereby increasing insulin resistance (progesterone, hCG, cortisol, cytokines).
  • This insulin resistance results in hyperglycaemia
  • Maternal glucose crosses the placenta causing foetal hyperglycaemia, however, maternal insulin cannot cross the placenta
  • The foetal pancreas starts producing high levels of insulin to reduce the blood glucose (this predisposes to neonatal hypoglycaemia)
41
Q

What are the RFs for gestational diabetes?

A
  • BMI >30kg/m2
  • Previous baby weighing ≥4.5kg
  • Asian ethnicity
  • Previous GDM
  • FHx (1st degree) of diabetes
42
Q

What are the investigations for gestational diabetes?

A

2-hour 75g OGTT:

  • Glycosuria on urine dipstick = immediate / 16w
  • Previous GDM = immediate / 16w (if normal, again at 24-28 weeks)
  • Any RF on clerking (not prior GDM) = at 24-28 weeks

Diagnose if: (this is different to the normal values) … 5678

  • Fasting plasma glucose >5.6 mmol/L
  • 2-hour OGTT >7.8 mmol/L

If diagnosed, offer a review at a joint diabetes and antenatal clinic within 1 week

43
Q

What is the management of gestational diabetes?

A

1st line:
(Only if fasting BM <7mmol/L)

  • Changes in Diet and Exercise (CDE) [2 weeks trial]
  • Refer to dietician (change to low glycaemic index foods)
  • Regular exercise (e.g. walking 30 mins after a meal)

2nd line:
(If targets not met by 1st line in 2 weeks and <7mmol/L)

  • Metformin, CDE
  • If metformin is contraindicated/unacceptable, go straight for insulin

3rd line:
(If 2nd line ineffective OR >7mmol/L or 6.0-6.9mmol/L with complications)

  • Offer insulin

4th line:

  • Consider glibenclamide
  • In those that metformin does not work but decline insulin; or cannot tolerate metformin (SEs: decreased appetite, diarrhoea, abdominal pain)
44
Q

Describe the management of delivery with DM or GDM

A
  • DM1/2 = Offer IOL or ELCS between 37+0w and 38+6w
  • GDM = deliver no later than 40+6w
  • Monitor capillary glucose every hour during labour (maintain 4-7 mmol/L)
  • If 2 consecutive high results / DM1/2 = sliding scale
  • Discontinue blood glucose lowering treatment immediately after birth
45
Q

Describe the postpartum management of GDM

A

Postnatal:

  • Newborn should be fed early and at frequent intervals
  • Capillary glucose should be maintained > 2 mmol/L

Follow-up the mother after birth to check whether diabetes has persisted:
GP should perform a fasting plasma glucose (i.e. at 6w post-natal check)

  • <6.0mmol/L = low probability of diabetes, need an annual test, moderate risk of developing T2DM
  • 6.0-6.9mmol/L = high risk of T2DM
  • > 7.0mmol/L = 50% chance of having/developing T2DM > offer diagnostic test to confirm
46
Q

What is contraindicated in diabetes in pregnancy?

A
  • Gliclazide
  • Liraglutide
47
Q

What is an ectopic pregnancy?

A

Implantation of a fertilized ovum outside the uterus results in an ectopic pregnancy (ie pregnancy outside the uterus)

48
Q

Where can ectopic pregnancies occur?

A
  • 98% of the time in the fallopian tubes
  • Can occur in ovary, uterus, broad ligament, abdomen
  • Most common location: Ampulla
  • Highest risk of rupture: Isthmus
49
Q

What are the RFs for an ectopic pregnancy?

A

(Anything slowing the ovum’s passage to the uterus)

  • Previous ectopic
  • Smoking
  • Damage to tubes (PID, previous tubal surgery)
  • Endometriosis
  • Progesterone only pill
  • Assisted pregnancy (3% of pregnancies are ectopic)
  • Pregnancy with IUD/IUS
  • Depo-Provera injection
  • Pregnancy following ECP
50
Q

What are the S/S of an ectopic pregnancy?

A
  • Abdominal pain
  • Amenorrhoea 4-10 weeks, ± PV bleeding (scanty dark blood)
  • Diarrhoea
  • Shoulder tip pain, back pain (blood in recesses irritates surrounding viscera)
  • Dizziness (if ruptured > present with circulatory collapse)

On examination:

  • Abdomen – rebound tenderness ± guarding
  • Vaginal – cervical excitation, adnexal tenderness ± mass
51
Q

What are the investigations for an ectopic pregnancy?

A

Pregnancy test > bimanual/speculum > TVUSS > outcome…

1. Located ectopic

  • Empty uterine cavity
  • Adnexal mass with GS and YS
  • Free fluid in uterine cavity
  • TUBAL: ‘bagel’ sign, ‘blob’ sign
  • CERVICAL: ‘barrel’ cervix, -ve sliding sign, below internal Os

2. Pregnancy of Unknown Location (PUL)

  • Follow PUL management

Also:

  • Bloods – FBC, clotting, cross match
  • bHCG
52
Q

Where are patients with ectopics managed?

A
  • Women who are stable are typically investigated and managed in an early pregnancy assessment unit.
  • If a woman is unstable then she should be referred to the emergency department
  • The first step on confirming an early-pregnancy-related emergency is to call the gynaecology on-call
53
Q

Describe the expectant management of an ectopic

A

Indications:

  • Size <35mm
  • Asymptomatic
  • Unruptured
  • Serum hCG <1000 IU/L and declining
  • No foetal HR
  • Can return for follow up

Management:

  • Repeat HCG day 2, 4 and 7
  • If drops by >15% then repeat weakly until negative
  • If no not drop by >15% then RV and seek senior advice
54
Q

Describe the medical management of an ectopic pregnancy

A

Indications:

  • Size <35mm
  • Asymptomatic / stable
  • Unruptured
  • No FH detected
  • No blood in pouch of Douglas
  • Normal LFTs / U&Es
  • bHCG <1500 IU/L

Management:

  • x1 IM methotrexate injection
  • Repeat HCG day 4, 7:
    If fall >15% then weekly until negative
    If fall <15% then senior RV

Advice:

  • SEs: pain, nausea and diarrhoea (first few days)
55
Q

Describe the surgical management of an ectopic

A

Indications:

  • Size >35mm
  • Can be ruptured
  • Significant pain / symptomatic
  • Visible foetal HR
  • bhCG >5,000IU/L

Management:
Can involve salpingectomy or salpingotomy

  • Salpingectomy is 1st-line for women with no other RFs for infertility
  • Salpingotomy should be considered for women with RFs for infertility such as contralateral tube damage
  • Repeat HCG at day 7 after surgery, and then weekly until negative
  • Anti-D prophylaxis required
  • Copper IUD should not be used if you’ve had a laparoscopic salpingectomy
  • 1 in 5 women who undergo a salpingotomy require further treatment (methotrexate and/or a salpingectomy)
56
Q

What are the complications of an ectopic pregnancy?

A
  • Rupture, haemorrhage, death, tubal infertility, psychological sequelae
57
Q

What are the possible explanations for a PUL?

A
  1. Very early intrauterine pregnancy (intrauterine but too small to see on scan - viability unknown)
  2. Miscarriage (pregnancy ended and developing tissue already passed out of body)
  3. Ectopic pregnancy
58
Q

What is the management of PUL?

A

Serial b-hCG (at 0 and 48 hours):

1. Increase >63% = Early intrauterine pregnancy
>Rescan in 7-14 days

2. Decrease >50% = Complete miscarriage
>Expectant management (UPT in 2-3 weeks)

3. Increase <63% / decrease <50% = Suspicious of ectopic
>RV in EPAU <24 hours and safety net (present to ED if worsening sx)

O&G (17 decks)

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