Diseases in and of pregnancy Flashcards
(146 cards)
1
Q
What is oligohydramnios?
A
Amniotic fluid less than expected for gestational age
2
Q
What is polyhydramnios?
A
Amniotic fluid greater than expected for gestational age
3
Q
What is the combination of intrauterine growth restriction and polyhydramnios suggestive of?
A
Trisomy 18 (Edwards syndrome)
4
Q
What strain of GBS is carried by up to 20% of women vaginally?
A
Streptococcus agalactiae
5
Q
What are 3 foetal risks of GBS?
A
- Preterm labour
- Rupture of membranes
- Neonatal infection
6
Q
What is the nuchal translucency test?
A
Done during 11-14w USS
Measures the subcutaneous area between the skin and cervical spine of the foetus in the sagittal section
Nuchal translucency increases when fluid accumulates in the area e.g. in Down Syndrome
7
Q
What tests are done around week 12 to screen for Down Syndrome?
A
Nuchal translucency (USS)
bHCG (elevated)
PAPP-A (decreased)
8
Q
What is PAPP-A?
A
Pregnancy-associated protein A
A serum protein mainly synthesised by the placenta and therefore increases in pregnancy
Decreased in conditions involving chromosomal aberration
9
Q
Why is hepatitis B screened for in pregnancy?
A
High rate of perinatal transmission
If an infant is infected the risk of chronic hepatitis is 90%
10
Q
When in pregnancy is chorionic villus sampling (CVS) performed?
A
10-13 weeks
11
Q
From when in pregnancy can amniocentesis be performed?
A
From the 15th week of pregnancy onwards
12
Q
What is the risk of miscarriage with CVS?
A
1%
0.5% for amniocentesis
13
Q
What is the definition of a spontaneous abortion/miscarriage?
A
Loss of pregnancy before 20 weeks’ gestation
14
Q
What is the definition of a stillbirth?
A
Loss of pregnancy after 20 weeks’ gestation
15
Q
What is a threatened abortion and is the cervical os closed or dilated?
A
Vaginal bleeding has occurred and the cervical os is closed, but the diagnostic criteria for spontaneous abortion has not been met
16
Q
What is an inevitable abortion? Is the cervical os open or closed?
A
The patient has vaginal bleeding and visible/palpable products of conception
The internal cervical os is open
17
Q
What is an missed abortion? Is the cervical os open or closed
A
Abortion in which the products of conception are not expelled spontaneously from the uterus. Symptoms of early pregnancy e.g. nausea, breast tenderness, disappear
The cervical os is closed
18
Q
What is an incomplete abortion? Is the cervical os open or closed
A
Products of conception within the cervical canal or uterus
Open cervical os
19
Q
What is a complete abortion? Is the cervical os open or closed?
A
Products of conception are entirely out of the uterus and cervix
The cervical os is closed, the uterus is small and well-contracted, vaginal bleeding and pain may be mild or resolved
20
Q
How is a threatened abortion managed?
A
Expectant
(symptoms will resolve or progress to inevitable, incomplete or complete abortion)
21
Q
What is a grade 1 perineal tear?
A
Laceration of the vaginal mucosa or perineal skin only
22
Q
What is a grade 2 perineal tear?
A
Laceration involving the perineal muscles
23
Q
What is a grade 3 perineal tear?
A
Laceration involving the anal sphincter muscles
24
Q
What is a grade 4 perineal tear?
A
Laceration extending through the anal epithelium resulting in a communication of the vaginal and anal epithelium
25
What is the quantitiative definition of oligohydramnios?
Amniotic fluid index (AFI) \< 5cm
26
What is the quantitiative definition of polyhydramnios?
Amniotic fluid index (AFI) \> 25cm
27
What are 3 causes of a higher than expected hCG?
1. Molar pregnancy
2. Twins
3. Choriocarcinoma
4. Embryonic carcinoma
28
What are 2 causes of a lower than expected hCG?
1. Ectopic pregnancy
2. Threatened abortion
3. Missed abortion
29
What is the most common cause of abnormal hCG?
Inaccurate dating
30
What is the intrapartum treatment for GBS positive mothers?
IV penicillin or ampicillin
31
When is GBS screened for in pregnancy?
35-37 weeks
## Footnote
*GBS carriage fluctuates so colonisation is screened close to term*
32
What is the treatment of intrahepatic cholestasis of pregnancy?
Ursdeoxycholic acid (a bile acid; symptomatic relief and may improve foetal outcomes)
Delivery at 37 weeks
33
What is the major function of human chorionic somatomammotropin (human placental lactogen)?
Increases maternal insulin resistance
34
What is the definition of gestational hypertension?
Onset after 20 weeks gestation
SBP \> 140
DBP \> 90
On two separate occasions at least 4 hours apart
35
What is the definition of pre-eclampsia?
Gestational hypertension with
- proteinuria
- renal insufficiency
- thrombocytopenia
- evidence of liver damage
- pulmonary oedema
- cerebral oedema
36
What is HELLP syndrome?
A life-threatening form of pre-eclampsia
H = haemolysis
EL = elevated liver enzymes
LP = low platelets
37
What are 3 teratogenic effects of ACE inhibitors?
1. Altered kidney development
2. Neonatal renal failure
3. Pulmonary hyperplasia
4. Foetal growth retardation
38
What is alloimmunisation?
An immune response to foreign antigens after exposure to genetically different cells or tissues
e.g. pregnancy, transplant, transfusion
39
What condition is characterised by hyperthryoidism in the first trimester which spontaneously resolves?
hCG-mediated hyperthyroidism
hCG acts on the maternal thyroid
40
Which drugs are used for hyperthyroidism in pregnancy?
Propylthiouracil until 16 weeks
Carbimazole may be taken after 16 weeks
41
What is postpartum lymphocytic thyroiditis?
Autoimmune thyroiditis within a year of birth
Hyperthyroidism → hypothyroidism → recovery
42
How is hypothyroidism in pregnancy treated?
Levothyroxine
43
What are the adverse effects of cocaine use during pregnancy?
Vasoconstriction
→ placental abruption
→ preterm birth
→ low birth weight
→ small for gestational age
44
How is foetal anaemia assesed?
Blood flow through the middle cerebral artery on US
45
What are the sonographic features of hydrops?
Ascites, pleural and pleural effusions (rims of echolucent fluid inside the abdominal wall, chest and heart)
Skin oedema (subcutaneous tissue thickness on chest or scalp \> 5mm) - late sign
May also be associated with polyhydramnios and placental oedema
46
When do pregnant women have an OGTT?
Weeks 26-28
47
What fasting plasma glucose is diagnostic of GDM?
5.1 mmol/L or greater
48
What 1-hour glucose following 75g oral load is diagnostic of GDM?
10.0 or greater
49
What 2-hour glucose following 75g oral load is diagnostic of GDM?
8.5 or greater
50
What is hydrops fetalis?
Abnormal fluid accumulation in two or more foetal compartments
(ascites, pleural effusion, pericardial effusion, skin oedema)
May also be associated with polyhydramnios and placenta oedema
51
What is the most common cause of recurrent miscarriages in the second trimester?
Bicornate uterus, resulting from incomplete fusion of the paramesonephric ducts during uterine development
52
Name 3 conditions that predispose a women to preeclampsia or eclampsia
1. Hypertension
2. Chronic renal disease
3. Diabetes
53
What is thought to be the initial insult that leads to increased vascular tone in preeclampsia?
Poor dilation of the spiral arteries → placental insufficiency → increased vascular tone
54
If a foetal anomaly has caused polyhydramnios, what process is likely failing to occur?
Swallowing of amniotic fluid
55
Name two congenital conditions associated with polyhydramnios
Oesophageal or dueodenal atresia
Anecephaly
56
If a foetal anomaly has caused oligohydramnios, what process is likely failing to occur?
Decreased urine excretion
57
Name two congenital conditions associated with oligohydramnios
1. Bilateral renal agenesis (no urinary tract)
2. Posterior urethral valves (obstructed urinary excretion)
58
What is the Potter sequence?
Oligohydramnios → decreased amniotic fluid ingestion → pulmonary hypoplasia (severe neonatal respiratory insufficiency) → death
59
What are the main DDx for RUQ pain in pregnancy?
1. Gallstones
2. Severe preeclampsia/HELLP
3. Acute fatty liver
60
Which anticoagulant is preferred for thromboprophylaxis during pregnancy?
LMHW
Clexane/enoxaparin
61
What is the second most common clinical feature of pre-eclampsia, following hypertension?
Proteinuria
62
List 8 clinical features of pre-eclampsia
1. Protienuria
2. Elevated creatinine
3. Oliguria
4. Raised transaminases
5. Epigastric/RUQ pain
6. Convulsions
7. Hyper-reflexia with sustained clonus
8. Headache
9. Visual disturbances (blurring, photopsia, scotoma, cortical blindness)
10. Stroke
11. Pulmonary oedema
63
What is the definition of gestational hypertension?
New-onset hypertension wihtout maternal or foetal signs of pre-eclampsia after 20 weeks gestation
64
What are 5 maternal complications of pre-eclampsia?
1. Placental abruption
2. DIC
3. HELLP syndrome
4. Ascites
5. Pulmonary oedema
6. Acute renal failure
7. Liver rupture
8. ICH
9. Eclampsia
65
What are two foetal complications of pre-eclampsia?
1. Growth restriction
2. Death
66
List 5 risk factors for pre-eclampsia
1. Family history of pre-eclampsia
2. Pre-eclampsia in a previous pregnancy
3. Late maternal age
4. 1st pregnancy
5. New partner
6. Multiple gestation
7. Chronic hypertension
8. Chronic renal disease
9. GDM
10. Thrombophilia
67
Why do mothers with pre-eclampsia have hyper-reflexia with clonus?
Vascular dysfunction → cerebral damage → damage of UMNs → loss on LMN inhibition
68
Why do women with pre-eclampsia have weight gain, oedema, crackles, papilloedema?
Endothelial dysfunction → increased vascular permeability
69
Why do patients with pre-eclampsia have RUQ pain?
Endothelial dysfunction → vasoconstriction → hepatic venous congestion → liver enlargement → stretching of the liver capsule
70
Why can women with pre-eclampsia have an AKI?
Endothelial dysfunction → arterial vasoconstriction → afferent arteriole vasoconstriction → decreased GFR
71
Why can oligohydramnios be a feature of pre-eclampsia?
Decreased placental perfusion → decreased foetal blood flow → redistribution of blood from the kidneys towards more vital organs
72
What signs warrant the use of magnesium sulfate prophylactically in women with pre-eclampsia?
Hyperreflexia/clonus
Severe headache
Visual changes
Severe preeclampsia (DBP \> 110, proteinuria \>300mg, thrombocytopenia)
73
What is a velamentous cord insertion?
Abnormal cord insertion into the chorioamniotic membranes, resulting in exposed vessels only surrounded by foetal membranes in the absence of protective Wharton's jelly
74
What are the glycaemic targets for GDM?
Fasting: \< 5.0 mmol/L
2 hours post-prandial: \< 6.7 mmol/L
HbA1c: \< 6%
75
What is the Kleihauer-Betke test?
Blood test used to measure the amount of foetal haemoglobin transferred from a foetus to a mother's bloodsteam
Usually performed in Rh-negative mothers to determine the required dose of anti-D
76
What dosages of anti-D are used?
625 IU
250 IU is only used for a 1st trimester sensitising event
77
What are the most common congenital abnormalities associated with diabetes in pregnancy?
1. Cardiac (2/3) e.g. TGA, VSD, PDA
2. Ancephaly and spina bifida
Highest risk in women with previous diabetes and poor glycaemic control at conception
* 3. Flexion contracture of the limbs*
* 4. Vertebral abnormalities*
* 5. Cleft palate*
78
How is varicella zoster exposure in non-immune women managed in pregnancy?
Zoster immunoglobulin
79
How should a pregnant woman infected with varicella zoster be managed?
\<24 hours since onset of rash: oral acyclovir
\>24 hours: no treatment, monitor
80
What is alloimmunisation?
An immune response to foreign antigens after exposure to genetically different cells or tissues
81
What are the risks to the recipient twin in twin-twin transfusion syndrome?
Polycythemia
Polyhydraminos (if diamniotic)
82
What are the risks to the donor twin in twin-twin transfusion syndrome?
Anaemia
Growth retardation
Oligohydramnios (if diamniotic)
83
What drug is used to treat UTIs in pregnancy?
Cephalexin
84
What laboratory investigations should be done for a woman who presents with antepartum haemorrhage?
FBC
Coagulation screen
Group and save, crossmatch
Rhesus and Kleihauer if positive
UEC, LFT
85
What is the Kleihauer test?
Examining the blood film of the mother to look for fetal blood cells and hence determine whether there has been feto-maternal haemorrhage (as seen with placental abruption)
Foetal cells are less susceptible to acidic solutions
86
What are the clinical features of placenta praevia?
Painless antepartum haemorrhage
87
What would you expect to find on digital examination of a woman with antepartum haemorrhage caused by placenta praevia?
YOU MUST NEVER DO A DIGITAL EXAMINATION OF A WOMAN WITH SUSPECTED PLACENTA PRAEVIA AS THIS CAN PROVOKE MASSIVE BLEEDING
88
What would you expect to find on abdominal examination of a woman with antepartum haemorrhage caused by placenta praevia?
Soft, non tender uterus
Cephalic presentation not engaged
89
What are the risk factors for developing placental abruption?
**Hypertension**
**Preeclampsia/eclampsia**
Abdominal trauma
Cocaine/smoking
Previous abruption
Young/old maternal age
90
On abdominal palpation of a patient with placental abruption, what would you expect to find?
Tender and firm uterus
91
What test would confirm that blood loss is fetal and therefore possibly as a result of vasa praevia?
Kleihauer test - this must only be done if the CTG is normal as otherwise delivery should not be delayed.
92
What is circumvallate placenta?
A type of placental disease in which the fetal membranes (chorion and amnion) "double back" on the fetal side around the edge of the placenta.
## Footnote
*Does not affect placental function*
93
What are the risk factors for placenta accreta?
Prior damage to the endometrium e.g., ablation, D&C
Previous cesarean section
94
If using hydralazine IV as an antihypertensive in a pregnant woman, what must you give before administering the drug?
Bolus of fluid as can cause rapid hypotension
95
What % of patients with eclampsia have their seizures postnatally?
40% occur within 48 hours of delivery
96
What is the MoA of methyldopa?
Alpha agonist
Prevents vasoconstriction
97
What is the MoA of labetalol?
Alpha and beta blocker
98
When in pregnancy is the risk of seizures at its highest?
Labour and the 24 hours following delivery. Epileptics women are advised against having home births.
99
What are the guidelines surrounding breast feeding and anti-epileptic medications?
Breast feeding is considered safe in epileptic mothers taking medications.
100
How should hyperthyroidism be treated while the mother is breastfeeding?
Carbimazole
101
What is the role of vitamin K in obstetric cholestasis?
Give when prothrombin time is prolonged
102
What are the risk factors for acute fatty liver of pregnancy?
Prior history
Multiple gestation
Pre-eclampsia/HELLP
Male fetal sex
Low BMI
103
How do we treat people with acute fatty liver of pregnancy?
Stabilisation
Correction of hypoglycaemia and coagulopathy
Delivery
104
When in pregnancy does acute fatty liver of pregnancy occur?
Third trimester
105
What are the complications of acute fatty liver of pregnancy?
Acute liver failure
Acute renal failure
Encephalopathy
Fetal and maternal death (10%)
106
What makes pregnancy a pro-thrombotic state?
Increase in certain clotting factors
Increase in fibrinogen levels
Decrease in fibrinolytic activity
Decrease in protein S and antithrombin
Increased venous stasis in lower limbs (left more than right)
107
At what point will pregnant women be screened for HIV?
At booking appointment
108
When does puerperal psychosis usually start?
2-3 weeks postnatally
109
Are anti-psychotic medications safe in pregnancy and breastfeeding?
Data is limited but optimistic
Use the lowest dose of a single antipsychotic
110
What congenital abnormality is associated with Lithium use in bipolar mothers?
Cardiac defects
111
When in pregnancy do women tend to be affected by nausea and vomiting in pregnancy (NVP)?
Onset: 4-7/40
Peak: 9/40
Resolution: 20/40
112
How do you manage hyperemesis gravidarum?
1. H1 antagonists e.g., promethazine/doxylamine
2. Phenothiazines e.g., prochlorperazine
3. Metoclopramide
4. Ondansetron
Ginger, fluids
113
How are VTEs in pregnancy treated?
LMWH
## Footnote
*Continue for the remainder of pregnancy and at least 6 weeks postnatally*
114
What is the loading dose for magnesium sulfate
4g (will be in 8mL)
115
How is hyperemesis gravidarum diagnosed?
1. \> 5% prepregnancy weight loss
2. Dehydration
3. Electrolyte imbalance
116
What happens to urea in pre-eclampsia?
Elevated
Afferent arteriolar vasoconstriction
117
What is the apt test?
Hemoglobin alkaline denaturation test (Apt test)
1. A foetal blood sample is mixed with an alkali
2. If the mixture turns red to green-brown it contains foetal and maternal blood
118
What is the first sign of magnesium toxicity?
Loss deep tendon reflexes (followed by respiratory then cardiac arrest)
119
What is the antidote for magnesium sulfate?
Calcium gluconate
120
Name 10 risk factors on the maternity VTE score
1. Personal history of VTE
2. Thrombophilia
3. Ovarian hyperstimulation syndrome
4. Cancer
5. Pre-existing diabetes with vascular complication
6. Nephrotic syndrome
7. BMI \> 30
8. Non-obstetric surgery in pregnancy
9. Parity 4+
10. Smoker
11. Extensive varicose veins
12. Current sepsis
13. Prolonged restricted mobility
14. Pre-eclampsia in current pregnancy
15. Mulitple pregnancy
16. Hyperemesis
17. PPROM
18. Abruption
19. 1st degree relative with VTE
121
When are pregnant women at the greastest risk of VTE?
Postnatally
122
For which condition is smoking in pregnancy protective?
Pre-eclampsia
123
How is asymptomatic bacteruria/UTIs/pyelonephritis treated in pregnancy?
Cephalexin
OR
Amoxycillin + clavulanate
124
Can trimethoprim be used in pregnancy?
Avoid in the first trimester
Safe in 2nd and 3rd trimesters
125
What is the importance of good glycaemic control intrapartum?
Hyperglycaemia is associated with fetal acidosis and neonatal hypoglycaemia
126
What is the BP target in the management of pre-eclampsia?
140/90 +/- 10
Avoid hypotension
127
Are uterine contractions more characteristic of placental abruption or placenta previa?
Placental abruption
128
What proportion of pregnancies with maternal rubella infection result in fetal damage?
90%
## Footnote
*+ the baby sheds the virus for 6-12 months after birth if it survives*
129
How are children born to HBV +ve mothers treated?
Immunisation and immunoglobulins at birth
130
What is the significance of absent end-diastolic flow (AEDF) in an umbilical artery Doppler?
Indicates foetal vascular stress in mid/late pregnancy
Placental insufficiency → increased placental resistance → reduced diastolic flow
Associated with IUGR
131
In which leg are DVTs in pregnancy more common?
Left (75%)
132
How does maternal age affect Down Syndrome risk? *specific numbers*
20 - 1:1500
30 - 1:900
35 - 1:350
40 - 1:100
45 - 1:30
50 - 1:6
133
How are pregnancy women with antiphospholipid syndrome managed?
Aspirin and LMWH from conception
134
How is single deepest pocket interpreted?
Oligohydramnios - depth \< 2cm
Normal - depth 2-8cm
Polyhydramnios - depth \> 8cm
135
What are the antepartum risks of obesity?
Early pregnancy loss
Preterm birth (induced and spontaneous)
Gestational hypertension
Pre-eclampsia
Obstructive sleep apnoea
Thromboembolism
VTE
136
What are the neonatal risks of GDM?
RDS
Jaundice
Hypoglycaemia
Prematurity
Polycythemia
Macrosomia - shoulder dystocia, fratures, palsies, caesarean section, HIE
Hypocalcaemia
137
What are the teratogenic effects of trimethoprim?
Neural tube defects
Folic acid antagonist
138
What marker on the 2nd trimester quadruple screen is abnormal in neural tube defects?
Alpha feto protein
139
How are mothers with hepatitis B managed in pregnancy?
Tenofovir in the 3rd trimester
## Footnote
*To prevent transmission intrapartum*
140
What does a positive HBsAg suggest?
Hepatitis B surface antigen
Suggests active infection, acute or chronic
141
What does a positive anti-HBs suggest?
Hepatitis B surface antibody
Suggests life-long immunity, either resolved infection or vaccination
142
What does positive anti-HBc IgM suggest?
Current infection
Positive 4-8 months after infection
143
What does a positive anti-HBc IgG suggest?
Resolution of acute infection
OR chronic infection (does not confer immunity)
144
How do HBsAg levels change over time?
Positive: 2-10 weeks after infection
**Negative**: 4-6 months after infection (positive anti-HBc may be the only marker of acute infection)
Positive: \> 6 months after infection (signals chronic infection)
145
What does HBeAg reflect?
Marker of viral replication
Marker of infectibility/transmission
146
What is a high risk first trimester screening result?
1:300
