Antenatal Flashcards
(40 cards)
Early pregnancy <20w PV bleeding with/without abdominal pain assessment?
Haemodynamically stable? History Confirm pregnancy Beta hCG Physical assessment USS (TSV preferred)- confirm pregnancy location FBC +group MSU/STI if indicated
Early pregnancy bleeding/ abdominal pain differentials?
Implantation bleeding Ectopic Miscarriage STI Molar pregnancy
What level of hCG is pregnancy?
When is hCG first detected?
What is the rate of increasing hCG?
levels over 25 mIU/ml = pregnant
Detectable by urine/blood test 6-12 days after fertilisation, 3-4 days after implantation (missed period)
Serum hCG levels rise exponentially up to six to seven weeks of gestation, increasing by at least 66% every 48 hours
Presentation of ectopic?
Irregular PV bleeding Abdominal/shoulder tip pain cervical motion tenderness tachycardia and hypotension Palpable adnexal mass (50% women- any mass in structures related to uterus) Absence of intrauterine pregnancy
What are the 3 different management options for ectopic pregnancy? Describe first option- indication, ongoing management?
Expectant, medical or surgical
Expectant
Indication : only if haemodynamically stable, not ruptured, low and falling hCG (<1500IU/L at initial presentation), minimal/no fluid in pelvis on USS, tubal mass <3cm, pain free
Ongoing management:
hCG every 48hours for 8 days
If resolution occurring- hCG weekly until resolved
Describe the medical pathway for ectopic?
Indications
Caution
Ongoing management
Indications: haemodynamically stable, no evidence of rupture, no signs active bleeding, normal FBC/LFTs
Caution: if ectopic >3cm, hCG >5000IU/L
Methotrexate: If hCG <3000IU- IM injection
If hCG >3000IU/L- IV
Ongoing management:
Serum hCG as per methotrexate protocol
USS in 1 week
Avoid conception for 4 months- TERATOGEN
Describe the surgical pathway for ectopic?
Indication
Procedure
Ongoing management
Indications: Hameodynamically unstable Signs of rupture Persistent excessive bleeding heterotypic pregnancy
Procedure:
Laparascopic
Laparotomy
Ongoing management:
GP 14 days post op
If sapling)s)tomy- weekly hCG
What is a heterotypic pregnancy?
A rare complication of pregnancy in which both extra-uterine (ectopic pregnancy) and intrauterine pregnancy occur simultaneously
Describe the expectant management for non-viable IUP?
Indications
Contraindications
Ongoing Management
Indication:
Woman’s preference
Incomplete miscarriage
Contraindications:
Haemodynamically unstable
GTD
Risk of haemorrhage/infection
Ongoing management:
Follow up 7-10 days
Repeat hCG day 8
Consider USS for retained POC
What is cervical shock?
Vasovagal syncope produced by stimulation of the cervical canal during dilatation which can occur after abortion or miscarriage. This causes bradycardia and hypotension
What is Ashermans syndrome and treatment?
An acquired uterine condition which involves adhesion in the uterus and/or cervix from recurrent dilatation and curettage, it may also develop following pelvic infection. This may cause infertility and possible complications during pregnancy. Treatment includes hysteroscopic surgery to remove the adhesion, a balloon may be inserted and left for several days to prevent further adhesions from forming, oestrogen can also be taken to aid healing of endometrium
What does the Kleinhauer test show and when is it used?
A sample of maternal blood is analysed for presence of fetal cells to ensure adequate dose of anti-D. The Kleinhauer test is taken from a Rh negative woman after any sensing event eg APH, ECV, amniocentesis (within 72hrs). Each 100 IU of RhD-Ig protects against 1 mL fetal red cells. If the Kleihauer test indicates FMH is greater than that covered by the RhD-Ig dose administered, give an additional dose(s) within 72 hours sufficient to provide immunoprophylaxis
What is the dose of Anti-D at different stages of pregnancy?
After event Singleton pregnancy 1-12+6w = 250IU Multiple pregnancy (Any gestation) or >13w = 625IU
Routinely offered at 28 and 34weeks
What are the 2 premalignant GTD disorders?
Complete and partial hyaditiform mole. A molar pregnancy is when the placenta grows abnormally. There is distention of the chorionic villi by fluid which appears like a bunch of grapes. A complete mole there is no signs of embryonic/fatal development. embryonic/fetal development may be seen but the fetus is always malformed and is never viable
Presentation of complete mole?
Vaginal bleeding, hyperemesis, hyperthyroidism (high levels of HCG may stimulate thyroid gland), fundal height inconsistent with gestation, theca Lutein cysts of USS (ovarian cysts >6cm in diameter with accompanying ovarian enlargement), may be accompanied by preeclampsia
Diagnosis and treatment of complete/incomplete mole?
USS- a ‘snowstorm’ or ‘grapes’ pattern representing the fluid filled chorionic villi. A CXR should be taken as lungs primary site of metastasis if malignant GTD.
Treatment: D+C
Register with QLD Trophoblastic centre
Aim to exclude persistent GTD
Weekly serum hCG
What are the 3 GTD malignant disorders?
Choriocarcinoma, placental site trophoblastic tumour (PSTT) and epithelioid trophoblastic tumour (ETT)).
What is the pathophys of GDM?
Exact cause is unknown. The foetus is dependent on maternal glucose to grow. Pregnancy hormones such as human placental lactinogen and oestrogen are believed to increase circulating glucose. Maternal insulin production increases however fails to store the glucose which causes GDM. Insulin is unable to cross the placenta therefore the foetus creates its own insulin to counteract the hypeglycemia therefore is at risk of hypoglycaemia at birth.
When is the OGTT performed in pregnancy?
24-28 weeks gestation
What are risk factors for GDM?
Obesity Asian/Indigenous cultures Previous macrocosmic baby Maternal age >40yrs PCOS Multiple pregnancy
If risk factors OGTT in first trimester
What is the diagnostic values for GDM by OGTT?
Fasting >5.1
1 hour >10
2 hrs >8.5
If HbA1c: >41mmol/ 5.9%
Describe pharmacological management of GDM?
Metformin: 500mg orally with food max 2g per day
Insulin regime depends on time of hyperglycaemia
Describe protocols for woman on metformin or insulin therapy before labour?
Cease metformin when in established labour or 24hours prior to elective section
Titrate insulin according to BSL in labour
With evening IOL: administer normal act rapid with dinner, if not in active labour administer long acting for bed. Caese insulin when in active labour
Describe intrapartum management of woman with GDM?
Aim for BSL 4.0-7.0mmol
CTG if on pharmacological therapy, suboptimal BSLs or macrocosmic baby
Non-pharma:
BSL on arrival then 4th hourly
Pharma:
On arrival then 2nd hourly
