Antenatal conditions Flashcards
PRE ECLAMPSIA
i) what is it? what is seen in urine? when does it happen? what is the triad of symptoms
ii) name three high risk factors? name three moderate risk factors? what prophylaxis may be offered? when is this given
iii) name four symptoms?
iv) what BP is needed for dx? (2) name three other things that may be seen for dx?
v) what urine measurement is used? what blood marker should be tested if PE is suspected?
i) new high BP in pregnancy with end organ dysfunction - proteinuria
occ after 20 weeks gestation when spiral arteries of placenta form abnormal > high vasc resistance
triad - hypertension, proteinuria, oedema
ii) high RF - pre existing HTN, prev HTN in pregnancy, AI conds, diabetes, CKD
mod RF - > 40yrs, BMI > 30, > 10yrs since prev pregnancy, multiple preg, first preg, FH
offer aspirin prophylaxis from 12 weeks until birth if one high or more than one mod
iii) headache, vis disturb, N+V, ipper abdo pain, oedema, reduced urine output, brisk reflex
iv) systolic >140 or dias >90
plus proteinuria (1+dip), organ dysfunc (raised creat, LFTS, seizures, thrombocyto), placental dysfunction (FGR or abnormal doppler)
v) urine prot creat ratio (> 30) or urine alb creat ratio (> 8)
test placental growth factor on one occasion during pregnancy > levels will be low (use to rule out PE)
MX OF PRE ECLAMPSIA
i) what is used forprophylaxis? when is it given? which three symptoms are all women monitored if they have
ii) what is gestational HTN? name four ways its mx?
iii) what scoring system can be used in PE? how often is BP monitored? does urine need to be dipped again? how often is US monitor of fetus done?
iv) what is the first line anti hypertensive? what is second line? what is third line? what may be given in critical care if severe?
v) what is given to women with PE during labour to prevent seizures?
vi) what is first line tx after delivery? if black/african? what is third line?
i) aspirin for prophylaxis from 12 weeks until birth if one high or two+ mod RFs
monitor for PE at every appt if high blood pressure, symptoms or proteinuria
ii) gestational is same as PE without end organ damage
mx with aim BP 135/85, admit if over 150, urine dip weekly, monitor bloods, serial growth scans, PIGF testing once
iii) full PIERS or PREP-S
BP monitor at least every 48 hours, dont need to re dip urine, fetal US twice weekly
iv) first line is labetalol then nifedipine, then methyldopa (stop within 2 days of birth)
critical care - IV hydralazine
v) give IV Mg sulphate to prevent seizures
vi) after delivery - enalapril is first line, or nifed/amlopidine if black
labetalol or atenolol is third line
COMPLICATIONS OF PRE ECLAMPSIA
i) what is eclampsia? what is used to mx this?
ii) what is HELLP syndrome? what does it involve?
i) eclamp is seizures assoc with PE and mx with IV mg sulphate
ii) complication of pre ec and eclampsia
haemolysis, elevated liver enzymes, low plats
GESTATIONAL DIABETES
i) what is it? what is it caused by? what is the most signif immed complication? when should screening test be done if pt has RF
ii) name four RF? name three features that should prompt OGTT? what does it involve? what are normal results?
iii) what is mx if fasting glucose <7? if > 7? if > 6 and macrosomia? what other medication can be used if first line tx isnt tolerated?
iv) how quick does GD improve after birth? name three things babies are at inc risk of?
v) what blood sugar is neonatal hypogly? how should it be treated?
i) diabetes triggered by preg caused by reduced insulin sensitivity
immed comp is large for dates/macrosomnia and shoulder dystocia and women inc risk of T2DM
OGT 24-28 weeks gestation
ii) RF - prev GD, prev macrosomia baby, high BMI, ethnicity, FH of diabetes
large for dates fetus, polyhydramnios, glucose on urine dip > do OGTT
drink water then 75g glucose and measure gluc before and 2 hours after
normal fasting < 5.6
normal 2 hours < 7.8
iii) fasting < 7 - diet and exercise for 2 weeks then metformin then insulin
fasting > 7 start insulin with without metformin
fasting > 6 and macrosomia start insulin with without metformin
can also use glibenclamide
iv) resolves straight after birth
babies at risk of neonatal hypogly, polycythamiea, jaundice, CHD, cardiomyopathy
v) neonatal hypogly is <2 and tx with IV dextrose of NG feeding
OBSTETRIC CHOLESTASIS
i) what is it? when does it resolve? what is it thought to be due to? what is there an inc risk of?
ii) when does it usually px? what is the main symptom? where? name three others? is there a rash? name three DDs
iii) which two things should be checked? what will be seen?
iv) what is the main tx? name two ways of mx symptoms?
v) what can be given if clotting is deranged? when may delivery be planned for?
i) inactivity of bile ducts - reduced outflow of bile acids from the liver thought to be due to oes and proges levels
inc risk of stillbirth
ii) px in third trimester - itching is the main symptom on palms and soles of feet
other symptoms - fatigue, dark urine, pale greasy stool, jaundice, no rash
DDs - gall stones, fatty liver, AI hepatitis, viral hepatitis
iii) check LFTs and bile acids
abnormal LFTs (ALT, AST GGT), raised bile acids
iv) tx with ursodeoxycholic acid
itch relieved with emollients and anti histamines
v) water soluble vit K if clotting is deranged
keep monitoring LFTs
may plan to deliver at 37 weeks
ACUTE FATTY LIVER OF PREGNANCY
i) when does it happen? what happens? what condition in the fetus can cause it?
ii) name four ways it may px? what will LFT show? what will bilirubin, WCC, clotting and plats be? what is a more common cause of these blood results?
iii) how quick should it be mx? what should be done? what may be considered in extreme cases?
i) rare condition that happens in third trimester > rapid accum of fat in the liver causing acute hepatitis
impaired processing of fatty acids in the placenta due to LCHAD defic in the fetus
ii) px with general malaise/fatigue, N+V, jaundice, abdo pain, anorexia, ascites
LFT will be elevated - ALT and AST
high bili, high WCC, deranged clotting, low plats
HELLP synd is more common cause
iii) emergency mx with prompt admission and delivery - most recover after delivery
mx if severe - acute liver fail > transplant
PLACENTA PRAEVIA
i) what is it? how is it different to low lying placenta? what is it a cause of?
ii) name three risks its assoc with? name four RF? when is it usually dx?
iii) how may it present? what type of scan should be done at 32 and 36 weeks gestation?
iv) when are corticosteroids given? why? when is delivery planned for? why? what type of delivery is req?
v) what is the main complication? name three things that may need to be done?
i) placenta is attached to lower portion of uterus, lower than presenting part of fetus
low lying is when placental is within 2cm of cervical os but not over it
cause of antepartum haemmorhage
ii) risks - haemm, emergency CS, emergency hysterec, maternal anaemia, pre term or still birth
RF - prev CS, prev PP, older age, smoking, struc uterine aborn eg fibroids, IVF
usually dx on 20 week anomaly scan
iii) many are asymp but may have painless vaginal bleeding
do TV US at 32 and 36 weeks
iv) give CS to mature fetal lungs due to risk of preterm delivery (give bet 34 and 35+6)
plan delivery for 36-37 weeks to reduce risk of spont labour and bleeding
need CS to deliver
v) complicat - haemmorhage - may need emergency CS, transfusion, IU balloon tampomnade, uterine artery occlus, hysterectomy
VASA PREVIA
i) what is it? what happens? what can it lead to? what are the two types?
ii) name three RF? how is it usually dx? how may it present? how may it be dx in labour? what is a late sign?
iii) what drugs should be given to asymp women? when should CS be planned for?
iv) when will emergency CS be done?
i) fetal vessels are within the fetal membrane and travel across the internal cervical OS (go before the fetus) fetal vessels exposed outside the protection of the umbillical cord
can lead to fetal blood loss and death
type I - fetal exposed as velamentous umbilical cord
type II - fetal vessels exposed as they travel to an accessory placental lobe
ii) RF - low lying placenta, IVF pregnancy, multiple pregnancy
usually dx on US
can px with antepartum haemmorhage - bleeding during 2nd, 3rd trimester
late sign is vaginal exam during labour - feel pulsating fetal vessels through dilated cervix
iii) give corticosteroids from 32 weeks
CS for 34-36 weeks
iv) emergency CS is antepartum haemmorhage
PLACENTAL ABRUPTION
i) what happens? what is it a significant cause of?
ii) name four RF? how does it commonly px? name three other px features?
iii) what is a concealed abruption?
iv) how is it dx? how is major haemm managed? how many units of blood cross match? which cannula? what is done for the fetus
v) what is there increased risk of? what therefore needs to be done in third stage of labour?
i) placenta seperates from the wall of uterus during pregnancy > can bleed extensively and cause antepartum haemmorhage
ii) RF - prev PA. pre eclampsia, bleed in early preg, trauma, multiple preg, FGR, multigravida, inc maternal age
px with sudden onset severe abdo pain that is continuous
also px with vaginal bleed, shock, abnorm on CTG and fetal distress, woody abdomen on palpation
iii) concealed - cervical os remains closed and bleeding remains in uterine cavity
iv) dx clinically (no dx test)
emergency mx - urgenct consultant involve, 2x grey cannula, cross match 4 units of blood, CTG monitor fetus
v) inc risk of post partum haemm - active mx of third stage
PLACENTA ACCRETA
i) what happens? which layer of the placenta is implicated? why may it happen?
ii) what is sup plac accreta? increta? percreta?
iii) name four RF? does it cause symptoms in pregnancy? how can it px? how may it be dx? (2)
iv) what scan can be used to assess depth and width of invasion? when may delivery be planned for?
v) what are the three mx options? what is reccomended if discovered after delivery of the baby?
i) placenta implants deeper than endometrium so it is hard to seperate after birth
placental implantation into myometrium or deeper - can happen due to previous uterine surgery eg CS of cutterage
deep implant - hard to seperate during delivery
ii) superficial - surface of myomet
increta - deep into myomet
percreta - invades past myomet and may reach other organs eg bladder
iii) RF - prev PA, endometrial cutterage eg for abortion or MC, prev CS, multgravida, inc mat age, low lying placenta
doesnt usually cause symptoms in pregnancy
can px with bleeding in third trimester
dx on antenatal US or at birth when placenta wont sep
iv) MRI to asses depth of invasion
plan devliery for 35 to 36+6
v) mx with hysterectomy, uterus preserving sx (resec part of myomet and placenta),
expectant - leave placenta to be reabs over time (signfic risk)
if discoverd after delivery - hysterectomy
BREECH PRESENTATION
i) what is it? what is normal? what is complete/incomplete/extended/footling breech?
ii) before how many weeks do breech babies usually turn themselves? what can be used at 37 weeks to help turn fetus?
iii) what is ECV? who is it used in? (2)
iv) what are women given to relax the uterus before ECV? how does this work?
v) what is given to rhesus negative women before ECV? what other test may be doen?
i) presenting part of foetus is legs and bottom - cephalic is normal (head is presenting part)
complete - legs flexed at hip and knees (legs crossed)
incomplete - one leg flexed at hip and ext at knee (one leg up)
extended - both legs flexes and ext at knee (legs up)
footling - foot presenting through cervix with leg ext
ii) before 36 weeks can spont turn so no intervention
may do ECV at 37 weeks to help
iii) ECV is external cephalic version - turn fetus from breech to cephalic by using pressure (50% success)
used after 36 weeks for nulliparous
after 37 weeks for previous birth
iv) give tocolysis = sub cut terbutaline which relaxes the uterus and reduces contractility of myometrium making it easier to turn baby
give rh negative anti D prophylaxis
may do kleihauer test to quantify how much fetal blood is mixed with mat blood
STILLBIRTH
i) how is it defined? name three causes? name four factors that increase the risk?
ii) what type of babies are more at risk? what is given in pre eclampia?
iii) what three key symptoms need to be ident early and investigated?
iv) what is first line delivery method? how is labour induced? (2) what drug can supress lactation after still birth?
v) name three tests that may be done after birth?
i) dead fetus after 24 weeks
causes - unexplained, PEc, placental abruption, vasa previa, cord prolapse, obs chole, diabetes, thyroud, infections
inc risk of FGR, smoking, ETOH, inc mat age, mat obesity, twins, sleeping on back as opposed to side
ii) small for gestational age or fetal growth restriction need serial growth scans
give p ec aspirin
iii) reduced fetal movements, abdo pain, vaginal bleeding
iv) vaginal birth is first line - induction or expectant
induce with oral mifepristone and vaginal/ora; misoprostol
DA agonists eg cabergolin to suppress lactation after birth
v) genetic test of fetus and placenta, post mortem inc x rays, test for mat and fetal infection, test mum for conditions assoc with stillbirth
CARDIAC ARREST IN PREGNANCY
i) what are 4Ts and 4Hs reversible causes of cardiac arrest? what two other things are relevant in pregnancy
ii) what are the three major causes of CA in preg?
iii) name four causes of massive obstetric haemm?
iv) what position should women be in? why?
v) when is immed CS performed? (2) how quickly should bbay and placenta be delivered in relation to CPR commencing? what is primary reason for immed delivery
i) Thrombosis, tension pneum, toxins, tamponade
Hypoxia, hypovol, hypothermia, hyerkal/glycaemia
also eclampsia and intracranial haemm
ii) obstetric haemm, PE and sepsis > metab acid and septic shock
iii) OH is cause of hypovol and cardiac arrest
causes - ectopic, placental abrupt (may be concealed), plac previa, plac accreta, uterine rupture
iv) put woman in left lateral position as uterus can compress IVC and aorta on back
v) perform immed CS if no response to CPR after 4 mins or if CPR cont for 4 mins and woman is over 20 weeks gestation
delivery baby and plac within 5mins of CPR starting
primary reason is to improve survival of mother
RASHES IN PREGNANCY
i) what is polymorphic eruption of pregnancy? when does it usually start? where does it start?
ii) name three chracs of PEP? name three ways symptoms can be controlled? when will it resolve?
iii) what is atopic eruption of pregnancy? when does it usually px? what are the two types? name three ways it can be mx
iv) what is melasma? what does it look like? what is it thought to be assoc with? name two other times it may occ outside of pregnancy?
v) how is melasma mx? (3)
i) PEP itchy rash that starts in third trim
starts on abdomen and assoc with stretch marks
ii) urticarial papules (raised itchy lumps), wheals, plaques
control with topical emollient, steroids, oral antihist, oral steroids if severe
resolves end of preg and after delivery
iii) atopic erup - eczema flare up during preg px in first and second trimester
E type (eczema type) eczematous red itchy skin
P type - pruigo type - intense itchy papules on abdo back and limbs
mx with topical emollient, steroids, phototherapy or steroid if severe
iv) melasma is inc pigmentation patches on face
assoc wih female sex hormones of pregnancy
also seen in COCP and HRT
v) mx with avoiding sun expsore, make up, skin lightening cream
RASHES IN PREGNANCY 2
i) what is pyogenic granuloma? how does it px? where do they often occur?
ii) name two other differentials for PG? how is it mx?
ii) what is pemphigoid gestationitis? what happens? when does it occur? how does it px?
iii) where does it usually start? does it need tx? name three risks to baby
i) benign rapid growing tumour of capillaries - discrete lump with red/dark appearance
occ on fingers
ii) DD are nodula melanoma
mx with surgical removal and send for histol
iii) rare AI condition of preg - autoantibodies damage connec bet epi and dermis
antibodies prod in response to placental tissue > sep epi and dermis > fluid filled blisters
occ in 2nd/3rd trimester with itchy red pap blistering rash
iii) starts around umbillicus then spreads to other areas then blisters form over weeks
may self resolve after delivery with no rx
risks to baby - FGR, preterm delivery, blistering rash after delivery as mat ABs are passed on
