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Complications of pregnancy Flashcards

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1
Q

Define pre-eclampsia

A

New onset HTN in pregnancy with end-organ dysfunction, with proteinuria

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2
Q

When does pre-eclampsia typically occur?

A

20+ weeks gestation

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3
Q

What is the brief pathophysiology behind pre-eclampsia?

A

Spiral arteries of placenta form abnormally -> leads to high vascular resistance in these vessels.

Systemic BP increases

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4
Q

What are complications of pre-eclampsia?

A 
Maternal organ damage
FGR
Seizures
Preterm labour
Death
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5
Q

What is the triad of pre-eclampsia?

A

Hypertension
Proteinuria
Oedema

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6
Q

Difference between pregnancy-induced HTN and pre-eclampsia?

A

Pregnancy-induced HTN does not result in proteinuria

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7
Q

Define eclampsia

A

Seizures resulting from pre-eclampsia

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8
Q

What are HIGH risk factors for pre-eclampsia?

A 
Pre-existing HTN
Previous HTN in pregnancy
Exisiting autoimmune conditions (e.g. SLE)
Diabetes
CKD
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9
Q

What are MODERATE risk factors for pre-eclampsia?

A 
40 yo+
BMI >35
10 years+ since previous pregnancy
Multiple pregnancy
First pregnancy
Family history of pre-eclampsia
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10
Q

What is the criteria for giving prophylactic aspirin to women to protect against pre-eclampsia?

A

1 high risk factor
or
1+ moderate risk factor

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11
Q

At which gestational age onwards are women offered aspirin against pre-eclampsia?

A

12 weeks on wards

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12
Q

What drug is used prophylatically against pre-eclampsia?

A

Aspirin

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13
Q

Give symptoms of pre-eclampsia

A 
Headache
Visual disturbance/blurred
Nausea/vomiting
Upper abdo/epigastric pain
Oedema
Reduced urine output
Brisk reflexes
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14
Q

NICE recommends using _____ between 20-35 weeks gestation to rule out pre-eclampsia

A

PIGF

Placental growth factor - stimulates development of new blood vessels

PIGF is low in pre-eclampsia

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15
Q

Give pre-eclampsia BP values (NICE guidelines)

A

140+ systolic

90+ diastrolic

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16
Q

Apart from BP, what other NICE criteria are used to diagnose pre-eclampsia?

A

Organ dysfunction (raised CK, raised liver enzymes, seizures, thrombocytopenia, haemolytic anaemia)

Proteinuria (1+ on urine dipstick)

Placental dysfunction (FGR, abnormal Doppler studies)

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17
Q

What two measurements can be used to quantify proteinuria?

A

Urine albumin:creatinine ratio (30+mg/mmol significant)

Urine protein:creatinine ratio (8+mg/mmol significant)

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18
Q

How is pre-eclampsia monitored at every antenatal appointment?

A

BP
Urine dip ?proteinuria
Symptom check

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19
Q

How is gestational hypertension (without proteinuria) managed?

List 6 ways

A

Aim lower than 135/85mmHg

Admit women with BP 160/100+ mmHg

Urine dip weekly

Blood tests weekly (FBC, liver enzymes, renal profile)

Serial growth scans to monitor fetal growth

PIGF testing (1x occasion)

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20
Q

How is pre-eclampsia managed differently to gestational hypertension?

List 4 differences

A

Same as gestational HTN but:

  • scoring systems used to determine whether to admit woman fullPIERS or PREP-S
  • BP monitored more frequently (48 hrs)
  • Urine dip not necessary as diagnosis made
  • USS monitoring of fetus, amniotic fluid and doppler performed 2 weekly
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21
Q

What scoring systems are used with pre-eclampsia to decide whether to admit the woman?

A

fullPIERS

or

PREP-S

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22
Q

Pre-eclampsia hypertension is managed by the drug ______ first line as anti-HTN.

Second line drug is _______

A

1st line: Labetolol

2nd line: Nifedipine

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23
Q

What drug can be used as a critical-care anti-HTN in severe pre-eclampsia/eclampsia?

A

IV hydralazine

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24
Q

What drug is given IV during labour and 24hr after to prevent eclampsia seizures?

A

IV magnesium sulfate

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25
____ _____ is used during labour in severe pre-eclampsia/eclampsia to avoid fluid overload
Fluid restriction
26
What drug is given to women having premature birth to help mature the fetal lungs?
Corticosteroids
27
AFTER delivery, what drug is given 1st line to control BP in pre-eclampsia?
Enalapril | Nifedipine/amlodipine first-line in black African/Carrib patients
28
What is HELLP syndrome? What does it stand for?
Combination of pre-eclampsia/eclampsia features H - Haemolysis EL - Elevated Liver enzymes LP - Low Platelets
29
How is HELLP syndrome best treated?
Deliver the baby ASAP
30
What are complications of HELLP syndrome?
Stroke Organ problems (pulmonary oedema, kidney failure, liver failure) DIC Baby delivered early -> neonatal respiratory distress Stillbirth
31
_____ insulin sensitivity during pregnancy causes _____ _____
Reduced Gestational diabetes
32
What are the most significant complications of GDM?
LGA (macrosomia) Neonatal hypoglycaemia
33
What is a long-term complication of GDM?
T2DM later after pregnancy
34
Anyone with risk factors for GDM should be screened with an _________ at 24-28 weeks gesetation.
OGTT
35
When is the OGTT carried out?
24-28 weeks gestation
36
What are risk factors for GDM? List 5
Previous GDM Previous macrosomic baby (>4.5kg) BMI > 30 Ethnic origin Family history of DM (1st degree relative)
37
If no risk factors, when is OGTT used?
LGA fetus Polyhydramnios Glucose on urine dipstick
38
When are the blood sugar measurements taken for OGTT?
Before 75g glucose drink (fasting BG) After 2 hours post-drink
39
What are normal results for blood sugar in the OGTT?
Fasting <5.6mmol/l At 2 hours >7.8mmol/l Results higher means GDM *(remember results cutoff using 5,6,7,8)
40
When are the 4 USS scans done with GDM?
Between 28 to 36 weeks The scans monitor fetal growth and amniotic fluid volume.
41
GDM: Fasting glucose less than 7 mmol/l How is it managed?
``` Diet and exercise 1-2 weeks then Metformin then Insulin ```
42
GDM: Fasting glucose more than 7 mmol/l How is it managed?
Insulin then Metformin
43
GDM: Fasting glucose above 6 mmol/l plus macrosomia How is it managed?
Insulin then Metformin
44
If a woman declines insulin or cannot tolerate metformin, what drug can be given?
Glibenclamide (sulfonylurea)
45
What are the NICE target levels for blood sugar? 1. Fasting 2. 1 hour post-meal 3. 2 hours post-meal 4. Avoid levels ___ or below
1. 5.3 mmol/l 2. 7.8 mmol/l 3. 6.4 mmol/l 4. 4 mmol/l
46
What supplement should women with existing diabetes take when concieving? When should this be taken?
5mg Folic acid From preconception until 12 weeks gestation
47
How are women with existing T2DM managed in pregnancy?
Metformin + insulin only (other oral diabetic meds are stopped!)
48
How does planned delivery differ between woman with pre-existing diabetes and GDM?
Pre-existing diabetic women - must give birth 37 - 38+6 weeks GDM can give birth up to 40+6
49
What medication therapy is given to women in labour who have T1DM? (also for women with poor control of BG in GDM or T2DM)
Insulin sliding-scale regime Dextrose and insulin titrated to blood sugar levels
50
What screening is important during pregnancy for women with existing diabetes?
Retinopathy
51
When can GDM women stop their diabetic meds? When should they follow up their fasting glucose after the baby is born?
Can stop meds immediately after birth 6 weeks post birth
52
Why does neonatal hypoglcaemia occur in the neonate with a GDM mother?
Increased insulin sensitivity after birth and with breastfeeding (Babies become accustomed to large supply of glucose during pregnancy. After birth, they struggle to maintain the supply they are used to with oral feeding alone)
53
Babies of mothers with diabetes are at risk of: List 5
``` Neonatal hypoglycaemia Polycythemia Jaundice Congenital heart disease Cardiomyopathy ```
54
How are babies monitored for neonatal hypoglycaemia? What is the cutoff blood sugar?
Regular BG checks and frequent feeds Maintain 2+ mmol/l
55
How is neonatal hypoglycaemia treated?
IV dextrose via NG tube
56
Anaemia is defined as a low _____ in the blood
Haemoglobin
57
When are women routinely screened for anaemia during pregnancy? (Hint there are 2 times)
1. Booking clinic | 2. 28 weeks gestation
58
Why does anaemia occur in pregnancy?
Plasma volume increases Hb concentration reduces (blood diluted due to higher plasma volume)
59
Why is it important to treat anaemia during pregnancy?
To ensure woman has enough blood reserves in case there is significant blood loss during delivery.
60
Give features of anaemic women presenting.
SOB Fatigue Dizziness Pallor
61
What are normal ranges for Hb during pregnancy at: 1. Booking bloods 2. 28 weeks gestation 3. Post-partum
1. > 110 g/l 2. > 105 g/l 3. > 100g/l
62
What blood test measurement can indicate the CAUSE of the anaemia?
MCV
63
What does low MCV in anaemia show?
Iron deficiency
64
What does normal MCV in anaemia show?
Physiological anaemia due to increased plasma voluime of pregnancy
65
What does raised MCV in anaemia show?
B12/folate deficiency
66
What other blood tests apart from FBC can establish cause of anaemia?
Ferritin B12 Folate aka Haematinics
67
What are women with anaemia in pregancy started on?
Ferrous sulphate (iron replacement)
68
Women with low B12 should be tested for what condition? And how?
Perniciuous anaemia Check for Intrinsic Factor antibodies
69
How is low B12 treated in anaemia? Give 2 drugs
IM hydroxocobalamin injections Oral cyanocobalamin tablets
70
How much folic acid should women take normally per day?
400mcg per day
71
Women with folate deficiency are started on how much folic acid per day?
5mg daily (5000mcg)
72
What supplements should be given to women with thalassaemia or sickle cell anaemia?
5mg folic acid daily Close monitoring and transfusions when required Requires specialist haematologist input
73
How is SCD detected prenatally?
Chorionic villus sampling Screening partners of heterozygotic pregnant women
74
What are maternal complications of SCD?
Acute painful crsises Pre-eclampsia Thrombosis
75
What are fetal complications of SCD?
Miscarriage FGR Preterm labour Death
76
What lab test detects SCD?
Hb electrophoresis
77
How is SCD managed: a) conservatively b) medically
a) avoid dehydration b) penicillin V, folic acid. aspirin vs pre-eclampsia, LMWH monthly urine cultures
78
Why is hydroxycarbamide stopped pre-pregnancy for SCD?
Teratogenic
79
Why is iron avoided in SCD pregnancies?
Iron overload Can lead to pregnancy loss
80
Does obstretric cholestasis resolve after ______ of the baby?
Delivery
81
Obstretric cholestasis usually develops _____ in pregnancy - around __ weeks
Later (28 weeks)
82
Obstetric cholestasis is the results of increased ______ and ______ levels
Oestrogen Progesterone
83
Obstetric cholestasis is more common in women of _________ ethnicity
South Asian
84
Itching of the palms and soles of feet in pregnancy can indicate what?
Obstetric cholestasis
85
What is the danger of untreated obstetric cholestasis?
Increased risk of stillbirth
86
Fatigue, dark urine, pale greasy stools and jaundice in pregnancy indicate what?
Obstetric cholestasis
87
Is there a rash with obstetric cholestasis?
No If there is: consider either polymorphic eruption of pregnancy or pemphigoid gestationis
88
List differentials of obstetric cholestasis
Gallstones Acute fatty liver Autoimmune hepatitis Viral hepatitis
89
Which investigations are needed for obstetric cholestasis?
LFTs (deranged ALT, AST, GGT) *ALP normally raised in pregnancy due to placental production, doesn't indicate liver pathology Bile acids (raised)
90
What is the primary treatment for obstetric cholestasis?
Ursodeoxycholic acid Itching: emollients, antihistamines for sleeping
91
If clotting (prothrombin time) is deranged, what medication can be given?
Water-soluble vitamin K
92
How would obstetric cholestasis affect delivery?
Planned delivery after 37 weeks considered (especially if LFTs/bile acids deranged) Stillbirth difficult to predict, early delivery reduces risk
93
What are maternal risks associated with obesity?
``` VTE Pre-eclampsia Diabetes C-section delivery Would infections Difficult surgery PPH Maternal death ```
94
What are fetal risks associated with obesity?
Congenital abnormalities (NTD) Perinatal mortality USS is less accurate
95
What advice can be given to obese women before pregnancy?
Lose weight before conception *Weight loss DURING pregnancy not advised!
96
What medication/supplement can be given to obese pregnant women?
``` Folic acid high dose (5mg) Vitamin D VTE prophylaxis (if BMI >40) ```
97
What are the 3 most common causes of antepartum hemorrhage?
Placental abruption Placenta praevia Vasa praevia
98
An APH is small and painless but the placenta is not praevia. What is the likely cause?
Impossible to find a cause. USS is useless. Perhaps is a minor placental abruption.
99
What is placenta praevia?
Placenta attached in lower part of the uterus, lower than the presenting part of the foetus. It is a cause of APH. (placenta is OVER the internal cervical os) *Low-lying placenta is used when placenta is within 20mm of internal cervical os. (RCOG guidelines)
100
What are causes of spotting or minor bleeding in pregnancy?
Cervical ectropion Infection Vaginal abrasions (intercourse/procedures)
101
What are risks of placenta praevia for the mother?
APH Emergency C-section Emergency hysterectomy Maternal anaemia/transfusions
102
What are risks of placenta praevia for the foetus?
Preterm birth Low birth weight Stillbirth
103
What are risk factors for placenta praevia?
``` Previous C-sections Previous placenta praevia Older maternal age Maternal smoking Fibroids (+ other uterine structure issues) IVF ```
104
When and how is placental praevia diagnosed in the UK?
20-week anomaly scan assesses position of placenta (diagnoses placenta praevia)
105
How would women with placenta praevia present usually?
Mostly asymptomatic | Perhaps painless vaginal bleeding around 36 weeks+
106
How is low-lying/placenta praevia managed?
Repeat transvaginal USS (32, 36 weeks) Corticosteroids (mature fetal lungs) Planned delivery (reduce risk of spontaneous labour, bleeding) C-section (planned or emergency)
107
How is hemorrhage with placenta praevia managed?
``` Emergency C-section Blood transfusions Intrauterine balloon tamponade Uterine artery occlusion Emergency hysterectomy ```
108
What is placental abruption?
Placenta separates from wall of uterus during pregnancy. Site of attachment bleeds extensively after placenta separates. It is a cause of APH.
109
How is the severity of antepartum haemorrhage graded? (Hint: 4 points)
1. Spotting (blood on underwear) 2. Minor haemorrhage (<50ml) 3. Major haemorrhage (50-1000ml) 4. Massive haemorrhage (1000ml+ or shock)
110
What are risk factors for placental abruption?
``` Previous placental abruption Pre-eclampsia Bleeding early in pregnancy Trauma (?domestic violence) Multiple pregnancy Fetal growth restriction Multigravida Increased maternal age Smoking Cocaine or ampetamine ```
111
Sudden onset, continuous, severe abdo pain Vaginal bleeding Shock (hypotension and tachycardia) CTG shows foetal distress "Woody" abdomen on palpation (suggesting large haemorrhage) All these features suggest what pathology?
Placental abruption
112
What is concealed placental abruption vs revealed placental abruption?
Concealed = cervical os closed, any bleeding contained within uterine cavity. Revealed = cervical os opened, blood loss observed coming out of vagina
113
How is placental abruption diagnosed?
Clinical diagnosis based on presentation *no reliable test for diagnosis
114
The urgency of placental abruption depends on which 4 factors?
1. Amount of placental separation 2. Extent of bleeding 3. Haemodynamic stability of mother 4. Condition of foetus
115
In placental abruption, if a major/massive occurs what are the initial management steps?
Senior obs, midwife, anaesthetist all involved Cannulate Bloods (FBC, U&E, LFT, coag) Crossmatch 4 units of blood Fluid and blood resuscitation as required CTG monitoring Close monitoring of mother
116
Is USS useful for diagnosing or assessing abruption?
No, but can exclude other causes of APH (placenta praevia)
117
What test detects the amount of foetal blood mixed with maternal blood? (Done in order to determine dose of anti-D required)
Kleihauer test
118
What is a major complication after delivery in women with placental abruption?
PPH
119
What is vasa praevia?
When foetal vessels travel across the internal cervical os, thus being exposed. The vessels are therefore unprotected by either the umbilical cord (Wharton's jelly) or placenta
120
What vessels does the umbilical cord contain?
Umbilical arteries and vein
121
What is Wharton's jelly? Which condition is it implicated in?
Layer of soft connective tissue that surrounds blood vessels in umbilical cord, protecting them Wharton's jelly does not protect the vessels in vasa praevia
122
What 2 instances can occur with vasa previa involving the position of the blood vessels?
Type 1. Velamentous umbilical cord (vessels run from placenta to umbilical cord) Type 2. Multi-lobed placenta with vessels running between the 2 lobes of placenta
123
What are risk factors for vasa praevia?
Low-lying placenta IVF Multiple pregnancy
124
How is vasa praevia diagnosed and why is this done?
USS - not always reliable however Allows planned C-section to reduce risk of hemorrhage
125
How can vasa praevia present? What can be found on examination?
APH Vaginal examination = pulsating fetal vessels seen in the membranes through the dilated cervix
126
During labour, how may vasa praevia present? Why is this important?
Fetal distress Dark-red bleeding following rupture of membranes Very high fetal mortality, even with emergency C-section
127
For asymptomatic women with vasa praevia, what management is recommended?
Corticosterids (@32wks, mature fetal lungs) Elective C-section (34-36 wks)
128
After stillbirth or unexplained fetal compromise during delivery, why may the placenta be examined?
?vasa praevia as a possible cause
129
What is ectopic pregnancy?
Pregnancy implanted outside uterus - most commonly fallopian tube. *can also be ovary, cervix or abdomen
130
What are risk factors for ectopic pregnancy?
Previous ectopic pregnancy Previous PID Previous surgery to fallopian tubes Intrauterine devices (coils) Older age Smoking
131
What gestational age does ectopic pregnancy usually present?
6-8 weeks gestation
132
What are the classic features of an ectopic pregnancy?
Missed period Constant lower abdo pain in RIF or LIF Vaginal bleeding Lower abdo or pelvic tenderness Cervical motion tenderness (pain when moving cervix during bimanual exam) *sometimes dizziness/syncope - blood loss or shoulder tip pain (peritonitis)
133
What USS findings can be seen with ectopic pregnancy?
Empty gestational sac (blob sign) Tubal ectopic pregnancy (mass moves separate to ovary - unlike corpus luteum which moves with ovary) Empty uterus Fluid in uterus - pseudogestational sac
134
What is pregnancy of unknown location?
Positive pregancy test and no evidence of pregnancy on USS
135
How can normal and ectopic/miscarriage pregnancy be differentiated on hCG?
hCG doubles every 48 hours with intrauterine pregnancy does not double with miscarriage or ectopic pregnancy!
136
How are ectopic pregnancies managed? List the 3 broad options
Expectant management (await natural termination) Medical management (methotrexate) Surgical management (salpigectomy or salpingotomy)
137
Why is methotrexate used to manage ectopic pregnancies?
Highly teratogenic Given IM into buttock - halts pregnancy and results in spontaneous termination
138
Which hormone produced by placenta is responsible for hyperemesis gravidarum?
hCG (higher = worse)
139
Hyperemesis gravidarum worse in what kind of pregnancies due to high hCG?
Molar pregnancies Multiple pregnancies (twins etc) Worse in first pregnancy and with obese women)
140
How is hyperemesis gravidarum diagnosed?
History taking Protracted Nausea and vomiting in pregnancy (NVP) More than 5% weight loss compared with before pregnancy Dehydration Electrolyte imbalance Ketosis (sometimes)
141
Which score is used to determine the severity of hyperemesis gravidarum?
Pregnancy-Unique Quantification of Emesis (PUQE)
142
Which medications can be used to manage hyperemesis gravidarum?
Antiemetics - e.g. cyclizine and ondanestron Anti-acids - Ranitidine/omeprazole if acid reflux is a problem
143
Severe cases of hyperemesis gravidarum need to be managed with what?
EPAU or admission to hospital IV fluids (normal saline with added potassium chloride) Daily monitoring of U&Es while having IV therapy Thiamine supplementation to prevent deficiency (Wenicke-Korsakoff syndrome) Thromboprophylaxis (TED stocking + LMWH during admission)

Obs & Gynae (13 decks)

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