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4th Year GOSH > High Risk Pregnancies > Flashcards

High Risk Pregnancies Flashcards

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1
Q

Maternal conditions resulting in high risk pregnancy?

A 
Obesity
Diabetes
HTN
Chronic disease (renal/AI)
Infections
Previous surgery (adhesions)
VTE
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2
Q

Social factors resulting in a high risk pregnancy?

A 
Teenage pregnancy
Maternal age >35
High parity and low interpregnancy interval
Poor SE conditions
Alcohol intake
Substance abuse
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3
Q

Obstetric issues in previous pregnancy resulting in high risk pregnancy?

A 
Caesarean section
Preterm delivery
Recurrent miscarriage
Stillbirth
Pre-eclampsia
Gestational diabetes
Third degree perineal tear
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4
Q

Problems in this pregnancy resulting in high risk pregnancy?

A 
Multiple pregnancy
Small for dates
Placenta praevia
Gestational diabetes
Pre-eclampsia
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5
Q

Problems during labour resulting in high risk pregnancy?

A

Meconium/blood stained liquor
Worrying CTG
Need for oxytocin infusion
Lack of progress

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6
Q

Actions if pregnancy deemed high risk?

A

Consultant-led care

Counselling - mode of delivery, weight
Special investigations - GTT
Ultrasound scans - growth scans
Specialised clinics - i.e. diabetic
Anaesthetic reviews - BMI
Close observation - BP, diabetes, urine etc.
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7
Q

Maternal risk factors for IUGR?

A
  • Smoking, poor nutrition (social class)
  • High altitude
  • Pre-existing renal, cardiac, vascular disease
  • Pregnancy related disease: Hypertension/pre-eclampsia = small babies
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8
Q

Foetal risk factors for IUGR?

A
  • Nutrition – abnormal placenta development
  • Teratogenic – tobacco, narcotics, alcohol, medication
  • Infection – rubella, CMV, measles
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9
Q

Two things that encompass ‘small for gestational age’ and how to diferentiate?

A
  1. Constitutionally small - Mum is small, From an ethnic group that produces small baby
  2. Intrauterine growth restriction (IUGR) - Placental insufficiency. Higher risk of still birth .

To differentiate, repeat scan in 2 weeks
If continues to grow then probably constitutionally small
If plateau or tail off in growth may be IUGR and placental insufficiency.

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10
Q

Monitoring in IUGR?

A
  1. Symphysis-fundal height – should match number of weeks +/- 2 or 3 cm
  2. USS for foetal measurements
    - Abdominal circumference, head circumference, femur length
    - Beware head sparing (relatively large head to abdominal circumference) – could be sign of IUGR as blood/oxygen going to the brain and neglecting the abdomen due to insufficiency of placenta
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11
Q

Liquor volume and umbilical artery doppler in IUGR monitoring?

A

LIQUOR - Happy babies produce urine as they have a normal blood supply to the abdomen rather than head sparing = normal liquor volume

DOPPLER - shows resistance of the placenta (SD ratio) (want low resistance) - Look to see if there is end diastolic pressure.
• In a low resistance, healthy placenta, blood will continue to flow in diastole as well, so baby is constantly oxygenated (will always be blood flow above zero)
o Absent end diastolic flow (EDF): with a high resistance placenta, there will be no flow to baby during diastole
o Reversed EDF: In very unhealthy placenta, flow may even reverse and the baby will be losing blood and oxygen - VERY BAD

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12
Q

Management of IUGR?

A

Weekly umbilical artery doppler
Daily CTG if doppler abnormal

Delivery at 37 weeks or earlier if foetal/maternal compromise

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13
Q

Incidence of multiple pregnancy?

A

1%

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14
Q

What is the main factor in determining multiple pregnancy outcome?

A

Chorionicity

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15
Q

What do you look for on ultasound to determine chorionicity?

A

Lamda sign = Y sign that signifies dichorionicity

T-sign = monochorionic

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16
Q

Division times of identical twins in relation to chorionicity?

A

Morula - Day 1-3 - DC/DA
Blastocyst - Days 4-8 - MC/DA
Implanted blastocyst - days 8-13 - MA/MA
Formed embryonic disc - days 13-25 - conjoined twins

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17
Q

Maternal complications of multiple pregnancy?

A

Hyperemesis gravidarum, anaemia, pre-eclampsia, gestational diabetes, operative delivery, preterm labour

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18
Q

Foetal complications relating to all multiple pregnancies?

A

↑morbidity+mortality – miscarriage, preterm labour, IUGR, antepartum haemorrhage, chromosomal/structural abnormalities

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19
Q

Complications in monochorionic twins?

A

Congenital abnormalities, twin-twin-transfusion syndrome, IUGR even more common

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20
Q

Antenatal care in multiple pregnancy?

A

• USS at 11-14 weeks
• Oral Iron and Folic acid 5mg
• Detailed anatomy scan and cardiac scans
• Regular serial growth scans
o DCDA 4 weekly (from 24 weeks)
o MC twins 2 weekly (from 16 weeks)
• Regular BP and urine checks – increased surveillance for pre-eclampsia, diabetes and anaemia.

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21
Q

Timing and mode of delivery in multiple pregnancy?

A
  • DCDA = 37-38 weeks
  • MCDA = 34-37 weeks (MCMA = 34 weeks by CS)
  • Presenting twin (one closest to cervix) = cephalic –> Vaginal delivery recommended
  • Presenting twin = breech/transverse lie –> Caesarean section
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22
Q

What is TTTS?

A

15% of all MC twins – unequal blood distribution in shared placenta leading to discordant blood volumes, liquor and growth.

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23
Q

Diagnosing TTTS? Complications?

A

Diagnosis = discordant liquor volumes, recipient twin larger, polyhydramnios, fluid overload, heart failure, donor twin smaller, ‘stuck’ with oligohydramnios.

Complications = late miscarriage an severe preterm delivery, in utero death, neurological damage.

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24
Q

Management and prognosis of TTTS?

A

Management = USS surveillance from 12 weeks (every fortnight). Laser therapy if TTTS diagnosed.

Prognosis = v poor if untreated – 60% both survive, 80% one survives.

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25
How does BP change in pregnancy?
Goes down in 1st trimester, then up in 2nd and 3rd trimesters
26
What is pre-eclampsia?
Hypertension and proteinuria in 2nd half of pregnancy, usually with oedema
27
What is the pathophysiology of pre-eclampsia?
Reduced placental bloodflow --> inflammatory response. Endothelial cell damage --> increased vascular permeability, vasoconstriction and coagulopathy Only cured by delivery
28
Risk factors for pre-eclampsia?
``` Nulliparity Previous history, FH Older maternal age Chronic hypertension Diabetes Twin pregnancies Autoimmune disease Renal disease Obesity ```
29
Screening and prevention of pre-eclampsia?
High-risk pregnancies screened - uterine artery doppler, sFlt-1, VEGF Prevention - 75mg aspirin OD
30
Degrees of pre-eclampsia?
Mild = Proteinuria and hypertension <170/110 Moderate = Proteinuria and hypertension >170/110 Severe = Proteinuria and hypertension <32weeks or with maternal complications
31
Clinical features of pre-eclampsia?
History - Usually asymptomatic. At late stage --> headache, drowsiness, visual disturbances, nausea/vomiting, epigastric pain Examination - Hypertension = first sign usually. Oedema may be massive. Epigastric tenderness. Protein in urinalysis
32
Maternal complications of pre-eclampsia? (indications for delivery)
``` Eclampsia CVA HELLP syndrome – Haemolysis, elevated liver enzymes, low platelet count DIC Liver failure Renal failure Pulmonary oedema ```
33
Foetal complications of pre-eclampsia?
IUGR – in pregnancies affected before 36 weeks – results from placental ischaemia Preterm birth Placental abruption Hypoxia
34
What is HELLP syndrome? How is it managed?
Haemolysis, elevated liver enzymes, low platelet count --> DIC, liver failure and liver rupture can occur. Symptoms = severe epigastric pain. Haemolysis turns urine dark. Treatment = supportive --> magnesium sulphate prophylaxis against eclampsia, high dose steroids, ICU therapy needed in severe cases.
35
Investigating pre-eclampsia? (confirm diagnosis)
MSU | Urine protein measurement (PCR >30)
36
Investigating pre-eclampsia? (maternal complications)
BP | Serial FBC, U+E, LFTs
37
Investigating pre-eclampsia? (foetal complications)
Foetal wellbeing – umbilical artery Doppler and (if abnormal), daily CTG
38
Management of pre-eclampsia?
Investigate if BP >140/90 --> admit if proteinuria ++ or moderate/severe disease Antihypertensives (labetolol, methyldopa, nifedipine) if >170/110; steroids if moderate/severe at <34 weeks. Delivery – after 34-36 weeks if possible. Deliver if maternal complications whatever the gestation. Magnesium sulphate if eclampsia, consider prophylactic use in severe disease. Postnatally – watch BP, fluid balance, bloods; FBC, U+E, LFTs
39
Complications of pre-existing hypertension in pregnancy?
Increases the risk of: o Maternal pre-eclampsia/eclampsia and placental abruption o Maternal morbidity and mortality, especially with very high systolic blood pressure o Intrauterine fetal growth restriction and preterm delivery o Neonatal morbidity and mortality
40
Maternal/foetal monitoring in pre-existing hypertension?
BP and urine, extra growth scans (due to association with foetal growth restriction)
41
Incidence of gestational diabetes?
2%
42
What is worse, gestational or established diabtes in pregnancy?
Established - related to glucose levels
43
Pathophysiology of gestational diabetes?
↓Glucose tolerance due to altered carbohydrate metabolism + antagonistic effects of human placental lactogen, progesterone and cortisol. ↑Foetal blood glucose levels --> foetal hyperinsulinaemia --> foetal fat deposition --> excessive growth (macrosomia)
44
Risk factors for gestational diabetes?
Family or previous history, polycystic ovary syndrome, previous large baby/ unexplained still birth, weight >100kg, persistent glycosuria, polyhydraminos
45
Who gets screening for gestational diabetes?
South Asians, BMI >30, first degree relative with DM - PEOPLE WITH RISK FACTORS
46
How is gestational diabetes screened for?
OGTT - between 24 and 28 weeks. If previous GDM - 16 weeks 75g of glucose - 2h later BM should be <7.8 Fasting should be <6
47
Maternal complications of GDM?
Increased insulin requirements Hypoglycaemia – due to attempts to control Diabetic retinopathy Pre-eclampsia Infections - UTI/endometrial Operative delivery – more likely because of foetal compromise and larger size Rarely ketoacidosis
48
Foetal complications of GDM?
Macrosomia Sudden IUD/foetal distress in labour – associated with poor control in 3rd trimester Congenital abnormalities – neural tube/cardiac defects Shoulder dystocia/birth trauma – because larger Neonatal hypoglycaemia – because is used to hyperglycaemia Preterm labour – and reduced foetal lung maturity
49
Risks of macrosomia?
Shoulder dystocia | Perineal tears
50
Management of GDM?
* Preconceptual glucose stabilization; patient education/involvement * Increase insulin to achieve tight control – between 4 and 6 mmol/L - reduce post-delivery * 5mg folic acid until 12 weeks and 75mg aspirin from 12 weeks (reduce risk of pre-eclampsia) * Anomaly and specialist cardiac USS – close foetal surveillance (serial USS to assess growth and liquor volume) - every 4 weeks * Planned delivery at term (39/40) via induction/lower segment c-section (LSCS) – early if uncontrolled
51
Why is pregnancy a pro-thrombotic state?
More clotting factors Less fibrinolysis Blood flow altered by mechanical obstruction/immbolity
52
How do you confirm a VTE/PE in pregnancy?
Doppler, chest X ray or V/Q scan - D dimer and wells score ineffective in pregnancy – although normal level means VTE unlikely
53
Management of VTE in pregnancy?
``` LMWH subcut (treatment dose) LMWH (maintenance dose) until 6 weeks post-partum ```
54
Delivery in VTE?
At term unless maternal complications indicate earlier delivery necessary to treat effectively
55
VTE prophylaxis in pregnancy?
General measures – hydration and mobilization Antenatal – restricted to very high risk women (LMWH) Postpartum (where most death happens) – LMWH/warfarin given for 6 weeks
56
Who is VTE prophylaxis given to postnatally?
LMWH heparin/warfarin 6 weeks • Previous or strong family history • Known prothrombotic tendency • Those who have had caesarean section and three or more moderate risk factors (Age >35, high parity, obesity, gross varicose veins, infection, pre-eclampsia, immobility, major illness)
57
Contraindications to VBAC?
* Usual absolute contraindications * Vertical uterine scar * More than 2 previous c-sections
58
Chance of success of VBAC?
* First-timer = 80% vaginal delivery, 20% c-section * Previous c-section = 75% vaginal delivery, 25% c-section * Previous vaginal delivery (regardless of previous c-section) = 90%
59
Safety of VBAC?
* No RCTs to compare risks of VBAC to C-section – no evidence, mum should decide * Maternal – depends on chance of emergency c-section. Risk of blood transfusion or uterine infection = 1% higher with attempt at VBAC.
60
Risks of VBAC?
* Main risk = rupture of uterine scar from previous caesarean section – rare – 0.7%, and of those 10% will die. * Risk of stillbirth related to VBAC is approximately the same risk as in a first labour. * Maternal and foetal morbidity increases with increasing number of prior c-sections
61
Management of labour during VBAC?
* Delivery in hospital and CTG advised * Induction (particularly with prostaglandins) avoided - associated with risk of rupture (3x higher than spontaneous labour) * Epidural = safe, but labour should not be prolonged
62
Management of uterine scar rupture?
Immediate laparotomy and cesarean
63
Monitoring of cardiac disease in pregnancy?
* USS for foetal abnormalities (3%) – 20 weeks * Regular ECG monitoring throughout pregnancy * Regular FBC check for anaemia
64
Management of cardiac disease in pregnancy?
Seen in conjunction with a cardiologist | Control hypertension if present.
65
Delivery in cardiac disease in pregnancy?
Labour more appropriate than C section - Elective forceps delivery to reduce strain of active pushing Delivery in a labour unit with ICU Continued cardiac monitoring for 24 hours post-delivery
66
Consequences of hyperthyroidism in pregnancy?
↑HR and IUGR
67
Treatment of hyperthyroidism in pregnancy?
carbimazole safe in pregnancy (although does cross placenta)
68
Consequences of hypothyroidism in pregnancy?
learning difficulties (slow)
69
Treatment of hypothyroidism in pregnancy?
thyroixine - does not cross the placenta
70
Is grave's disease bad in pregnancy?
• Grave’s disease antibodies do cross the placenta so early control of this in pregnancy is paramount
71
Is psychiatric cause of death indirect or direct?
Direct
72
Risk factors for postpartum psychosis?
- Pre-existing mental health disorders | - Personal and social demands of pregnancy and caring for new baby
73
Monitoring of psychiatric disorders in pregnancy?
Ask about mood and emotions at EVERY antenatal and post-natal interaction. Need good support network – counsel with phone numbers for crisis etc.
74
Management of postpartum depression/psychosis?
- CBT - Antidepressants - Antipsychotics and admission to MBU if required.
75
When does a mother need urgent referral to specialist perinatal mental health team (mother and baby unit)?
o New thoughts of violent self-harm o Sudden onset or rapidly worsening mental symptoms o Persistent feelings of estrangement from their baby
76
Risks of epilepsy in pregnancy?
Foetal risk: - Neural tube defects, orofacial clefts due to polypharmacy - 3% risk of developing epilepsy Maternal risk: - Frequent seizures - Status epilepticus (continuous refractory epileptic fit)
77
Monitoring of epilepsy in pregnancy?
* Anomaly scan for foetal defects | * If incomplete seizure control, check drug doses 4 weekly and increase if necessary
78
Preconceptional management of epilepsy?
Management of seizure on the minimum number of drugs and Folic acid 5mg/day throughout pregnancy Should not suddenly stop taking anticonvulsants
79
Safest anticonvulsants to take during prego?
• Lamotrigine/carbamazepine are safest in pregnancy DO NOT use sodium valproate (lower intelligence in children)
80
When is mother at risk of seziures? Triggers?
Intrapartum and postpartum Triggers = tired, stressed, dehydrated, lack of sleep, exhaustion
81
What must you exclude if mother has an epileptic seizure?
pre-eclampsia
82
Delivery in epilepsy?
If mother stable, prolong until delivery indicated. | May have to be pre-term if maternal complications

4th Year GOSH (23 decks)

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