High risk pregnancies Flashcards
(94 cards)
1
Q
Define IUGR
A
Neonates weighing below the 10th centile for gestational age
2
Q
What are the causes of IUGR?
A
Maternal illness
Toxin exposure
Placental insufficiency
Foetal infection
3
Q
What are the risk factors for IUGR?
A
Malformation Multiple pregnancy Infection Smoking HTN Diabetes Pre-eclampsia Heart disease Asthma
4
Q
What signs on USS may indicate IUGR?
A
Oligohydramnios
Poor foetal movements
5
Q
What level of PAPP-A may indicate SGA?
A
Low PAPP-A
6
Q
Which tool is used to assess the severity of IUGR and determine scan interval?
A
Uterine artery Doppler
7
Q
When should sympyseal-fundal height measurement correlate with gestational age?
A
From 20weeks
8
Q
How is IUGR monitored?
A
Serial fundal height measurements and serial USS gorwth scans (HC, AC, FL)
9
Q
Describe how Doppler is used to determine when to induce a women with an IUGR foetus?
A
Absent end diastolic flow = C section before 37wks
Abnormal uterine artery doppler OR normal uterine artery doppler: induce by 37weeks
10
Q
What monitoring in labour is required in IUGR?
A
CTG
11
Q
What are the complications of IUGR?
A
Birth asphyxia
Hypoglycaemia
Jaundice
Hypothermia
12
Q
What factors predispose women to a multiple pregnancy?
A
Previous multiple preg
FH of twins (on maternal side, dizygotic)
Increased maternal age
Induced ovulation and IVF
13
Q
What symptoms may indicate multiple pregnancy?
A
Hyperemesis
Early bump
14
Q
What features on USS indicate multiple pregnancy?
A
”+ foetal poles
Multiplicity fo foetal parts
“ x HR
15
Q
What is important to distinguish on USS in multiple pregnancy?
A
If the pregnancy is mono or dichorionic
16
Q
What are the types of twins?
A
Dichorionic diamniotic
Monochorionic, diamniotic
Monochorionic, monoamniotic
17
Q
How frequently should USS be in multiple pregnancy and from when?
A
Monochorionic: 2 weekly
Dichorionic: monthly
18
Q
What monitoring is KEY in multiple pregnancy?
A
Pre-eclampsia: weekly antenatal BPs
19
Q
When should twins be delivered in an uncomplicated pregnancy?
A
Dichorionic: 37 weeks
Monochorionic: 36 weeks
20
Q
What are the complications of multiple pregnancy?
A
Pre-eclampsia APH Prematurity IUGR PPH Malpresentation
21
Q
When can twins be delivered vaginally?
A
if Baby 1 is head down
22
Q
What are the three kinds of hypertension in pregnancy?
A
Chroinc hypertension
Gestational hypertension
Pre-eclampsia (HTN withh proteinuria)
23
Q
What are all women with hypertension in pregnancy at risk of?
A
Intracranial haemorrhage
24
Q
What is chronic hypertension in pregnancy?
A
Hypertension that predates pregnancy or occurs before 20wks gestation
25
Define gestational hypertension?
HTN at 20+wks in the absence of proteinuria
26
What is pre-eclampsia?
Hypertension occuring after 20wks with proteinuria and often associated oedema
27
What advice should be given pre-conception to women with chronic hypertension
DO NOT take ACEi or ARBs - safe switch to labetaol
28
What is the target BP antenatally for women with chronic hypertensions?
Under 150/90
29
What drugs should a women with chronic hypertension in pregnancy be given and from when?
Labetalol (from beginning)
(if contraindicated - nifedipine, then methyldopa)
Aspirin 75mg OD from 12wks until delivery
30
How is labour managed in a woman with chronic hypertension?
Monitor BP hourly if under 150/90, continuously if above 160/100.
Oxytocin should be given in the third stage
31
Should a woman with chronic hypertension continue labetalol after delivery?
Yes, if breastfeeding. If not breasfeeding, return to regime of medication which worked previously (e.g. ACEi)
32
What investigations confirm gestational hypertension?
BP >150/90 AND normal urinary protein:creatinine ratio
33
How is gestational hypertension treated?
Labetalol
34
Should women with gestational hypertension be induced?
Yes, at 37wks
35
Should a women with gestational hypertension carry on taking labetalol after birth?
Yes - continue as normal.
Measure BP at day 2m week 2 and week 6.
Only reduce when BP falls below 130/80
36
What is the cause of pre-eclampsia?
Placenta: failure of trophoblastic invasion of the spiral arteries, whcih leaves them vasoactive. Increasing the BP compensates
37
What groups of women should take 150mg of aspirin from 12wks in pregnancy as prophylaxis for pre-eclampsia?
```
Previous HTN in pregnancy
Chronic kidney disease
Autoimmune disease
Diabetes
Chronic HTN
```
38
What are the moderate RF for pre-eclampsia and how should this be managed?
```
Primiparous
Age 40+
Pregnancy interval of 10yrs +
BMI of 35+
Multiple pregnancy
FH of pre-eclampsia
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39
What are the symptoms of pre-eclampsia?
```
Epigastric pain
Vision spots
Headache
Facial oedema
Generalised seizure
Vomiting
```
40
What might be notice on examination in pre-eclampsia?
Facial oedema
Hyperreflexia
Clonus
41
What blood tests and results are diagnostic of pre-eclampsia
LFTs: elevated (expect ALP)
| Urinary P:Cr: 30+mmol
42
How is pre-eclampsia managed?
Labetalol (nifedipine or methyldopa if labetalol not tolerated)
Consider magnesium sulfate if severe
Delivery from 34-36wks with MgSO4 and steroids
43
What is the target BP in pre-eclampsia?
135/85 or less
44
Should women taking antihypertensives continue taking them after delivery?
Yes: monitor BP regualrly as inpatient, then daily for 2 weeks to check decreasing, then reduce dose when BP is below 130/80
45
What does HELLP syndrome stand for?
Hameolysis
Elevated Liver enzymes (not ALP)
Low Platelets
46
How might HELLP syndrome present?
```
Epigastric pain
Headaches
Vision changes
Facial oedema
N+V
Hyperreflexia
Clonus
```
47
How is HELLP diagnosed?
```
BP and urinary PCR (30mmol+)
BP may not be raised
LFTS: raised (not ALP)
Platelets: low
TEG: thromboelastogram may be helpful
```
48
How is HELLP syndrome managed?
Prompt delivery of the foetus
IV MgSO4 for seizure prophylaxis
IV steroids: foetal lung maturation
Labetalol/nifedipine/methyldopa
49
How are eclamptic seizures managed?
ABCDE: position on L lateral side
IV MgSO4 4g in 100ml 0.9% NaCl
IV labetalol/nifedipine/methyldopa
Prompt delivery via C section
50
What doses of MgSO4 should be used in the following situations:
a) prophylaxis in HELLP syndrome
b) first seizure treatment
c) maintenance following 1st seizure
d) recurrent seizure
a) 4g in 100ml NaCl
b? 4g in 100ml NaCl
c) 1g every hour for 25hrs
d) 2g bolus
51
What is the definition of GDM?
Any degree of glucose intolerance with onset or first recognition during pregnancy
52
What are the RF for GDM?
```
GDM in previous pregnancy
FH of GDM or diabetes
Asian
Obesity (BMI 30+)
PCOS
```
53
How might GDM present?
Usually asymptomatic
| If symptomatic: classically polyuria, polydipsia, fatigue
54
How is GDM diagnosed and what result is diagnostic?
Oral glucose tolerance test (GTT)
Fasting glucose 5.6mmol/L+
2hrs post load 7.8+mmol/L
55
How is GDM managed?
Metform or insulin therapy with consultant led care
56
Do women with GDM get additional growth scans and when?
Yes, at 28, 32 and 36 weeks
57
When should a women with GDM give birth?
Between 37-39wks - earlier if large baby
58
What are the complications of GDM?
```
Macrosomia
Shoulder distocia
Organomegaly
Neonatal hypoglycaemia
Polyhydramnios
Preterm delivery
```
59
Should treatment continue after giving birth?
NO: stop treatment immediately after delivery and measure BMs before discharge. An OGTT should be carried out at 6-13wks post partum
60
How should women with existing diabetes be managed in pregnancy?
Continue with metforming or insulin therapy, though dose may change
61
Should women with pre-existing DM be induced?
Yes, by 38+6 or by elective C-section
62
When should additional growth scans be completed in all woman with diabetes in pregnancy (GDM and pre-existing)?
28.32 and 36
63
What is the highest risk period for VTE in pregnancy?
Post-partum period
64
What is the pathophysiology behind the increased VTE risk in pregnancy?
Increased fibrinogen AND decreased protein S
65
How might VTE present in women who are pregnant?
Same as in non-pregnant people; however it is important that these are not mistaken for the physiological effects of pregnancy (e.g. SOB and leg swelling)
66
Where is a DVT most likely to form in a pregnant woman?
Proximal veins of the L leg
67
How is a DVT diagnosed in pregnancy?
USS of affected limb and Doppler
68
How is a PE diagnosed in pregnancy?
V/Q perfusion scan OR CTPA
69
WHat are the risks associated with CTPA and V/Q perfusions scans in pregnancy?
CTPA: higher risk of childhood cancer
| V/Q scan: higher risk of breast cancer
70
What are CTPA scans usually accepted in pregancy?
Post-12wks, once organogenesis is complete
71
Why is a D-Dimer not used in pregnancy to establish a DVT or PE?
There is a physiological rise in the D-dimer value in pregnancy, so it is no longer sensitive
72
How is a VTE managed in pregnancy?
LMWH; dose dependent on local guidelines
73
If a DVT or PE is suspected in pregnancy, what should be done immediately?
Administration of LMWH: treat until excluded.
74
How long should a DVT or PE be treated for in pregnancy?
The remainder of the pregnancy and 6wks PP
75
When a woman on VTE/DVT treatment is labouring or due a C-section, when should her LMWH be omitted?
24hrs pre-C section or when established labour is confirmed.
76
What outcomes are described in the term "previous poor obstetric history"?
```
Stillbirth
Low birth weight
Prolonged labour (Passenger, passage or power)
IU foetal death
Recurrent miscarriage
```
77
What is the success rate of VBAC?
75%
78
What is the concern in VBAC and how common is it?
Uterine rupture, 0.5%
79
How is a VBAC managed?
Hospital, consultant led delivery
Continuous CTG monitoring
Avoid induction
If after 39wks: elective C-section recommended
80
What are the absolute contraindications to VBAC?
Previous uterine rupture
Major placenta praevia
Vertical C-section scar
81
What are the relative contraindications to C-section?
2+ previous C-sections - a VBAC is not advised.
82
What types of FGM should be reported to the police?
ALL of them
83
Following a delivery in a woman with FGM, is it allowed to return the genitalia to it's pre-birth state (outside of tear repair etc)?
NO - even if just repairing what was previously present, FGM is ILLEGAL
84
What is deinfibulation?
Dividing of the scar tissue which narrows the vaginal opening in type 3 FGM
85
What type of delivery is encouraged in FGM?
Normal vaginal
86
Describe the 4 types of FGM
Type 1: clitoris removal
Type 2: clitoris and labia minora removal
Type 3: clitoris, labia majora and labia minora removed with or without stitching the vulva together.
Type 4: any other incisions, burns, piercings or manipulation of the external genitalia
87
Define recurrent miscarriage?
The loss of 3 or more CONSECUTIVE preganncies pre-24wks
88
Whar si the most prevalent treatable cause of recurrent miscarriage?
Antiphospholipid syndrome
89
What are the RF for recurrent miscarriage?
```
Balanced structural chromosomal abnormalities
Congenital uterine abnormalities
Cervical weakness
Thrombophilia
Advanced parental age
Previous miscarriage
Obesity
```
90
What is mid-trimester loss?
Pregnancy loss between 12 and 24 weeks gestation
91
What is stillbirth?
A baby delivered with no signs of life, known to have died after 24wks gestation
92
What are the RF for stillbirth?
Maternal obesity
| Increased maternal age
93
How is stillbirth confirmed?
Realtime USS to confirm absence of foetal heart activity AND doppler of foetal heart and umbilical cord
94
How is stillbirth investigated?
Maternal bloods: screen for infection or pre-eclampsia
Coagulation screen for DIC
Genetic testing
Post-mortem of baby
