High risk pregnancies Flashcards

Question

Recommended blood pressure medication for women with pre-eclampsia

Answer 1

Labetolol 1st line Nifedipine for those who cannot take abetolol Methyldopa if the above are not suitable

Answer 2

Any adverse features such as inability to control BP, maternals sats \<90%, HELLP syndrome, neurological features, placental abruption, abnormal CTG or reversed end diastolic flow in the umbilical artery Warrant planned early birth Timing: \<34 weeks continue surveillance unless delivery is absolutely necessary, 34-36 weeks is acceptable, 37 weeks+ initiate birth within 24-48hrs

Answer 3

Liver disease unique to pregnancy, develops in third trimester, resolves after delivery Slows or stops the normal flow of bile from the gallbladder causing jaundice

Answer 4

Increased oestrogen levels impair sulphation of bile acids and inhibit a bile acid export pump in hepatocytes. This blocks excretion of bile salts and these are deposited in the skin which causes itching and damages hepatocytes. This can also occur if women take the combined pill because it contains oestrogen

Answer 5

* Severe itching due to cholestasis, especially on palms and soles * Skin excoriation due to scratching * Dark urine * Pale stools * Jaundice * Steatorrhoea

Answer 6

Unexplained abnormalities in liver enzymes but other causes should be excluded \*symptoms can develop before LFTs are deranged so if symptoms are present, repeat bloods every 1-2 weeks **_Investigations:_** * LFTs: increased ALT and GGT, normal pregnancy adjusted ALP and bilirubin * Bile acids: most specific test for obstetric cholestasis - raised * Viral hepatitis screen to exclude othr causes * Autoimmune hepatitis screen to exclude other causes * Liver USS: exclude FLD and gallstones * BP and urinalysis: exclude pre-eclampsia

Answer 7

Serum ALP levels are elevated in late pregnancy, usually in the third trimester. This increase is mainly due to the production of placental isoenzyme rather than elevation of hepatic isoenzyme Levels in a pregnant woman can be as much as 2x the normal upper limit

Answer 8

Acute fatty liver of pregnancy (AFLP) is a rare, potentially fatal complication that occurs in the third trimester or early postpartum period. Although the exact pathogenesis is unknown, this disease has been linked to an abnormality in fetal fatty acid metabolism Often confused with HELLP Causes hypoglycaemia, marked increase in serum iron acid conc. and coagulopathy

Answer 9

Supportive, medication to relieve symptoms Delivery of the baby is the only known cure **Medication:** * Topical emollients with menthol to block the action of histamine which is responsible for activating C fibres which transmit the sensation of itch * Ursodeoxycholic acid 500mg 2-3x a day relieves itching and improves liver function by binding bile acids but not licensed for use in pregnancy * If clotting abnormal: vitamin k * Vitamin K given to babies when born to prevent haemorrhagic disease of the newborn **Delivery:** * Increased risk of meconium and foetal distress so women give birth in obstetric unit * Delivery induced after 37 weeks because of the risk of stillbirth **Prognosis:** * Improves with delivery, can take time so repeat LFTs at least 10 days after delivery * 90% risk of recurrence in future pregnancy

Answer 10

Excess amniotic fluid Affects 1% of pregnancies Classification: according to single deepest pool depth * Mild: 8-11cm * Moderate polyhydramnios: 12-15cm * Severe: \>16cm

Answer 11

Mixture of maternal and foetal factors **Maternal** - Gestational diabetes - Cardiac failure - Haemolytic disease of the newborn - Placental chorioangioma - 80% unexplained Foetal - TORCH infections - Oesophageal/ duodenal atresia - Diaphragmatic hernia - Anencephaly - Twin to twin transfusion syndrone - Chromosomal abnormalities - Skeletal dysplasia

Answer 12

* Higher than expected symphysis fundal height * Maternal abdo skin is stretched and shiny * Tense uterus * Difficult to palpate parts of the foetus * Splinting of diaphragm by enlarged uterus causes SOB

Answer 13

* USS to measure amniotic fluid pool depth * Amniocentesis offered if generic anomaly suspected * Maternal blood checked for evidence of TORCH infection * Oral GTT to screen for diabetes

Answer 14

**Management:** * Mild and asymptomatic cases managed expectantly - no intervention * Medication: indometacin decreases volume of fluid by reducing urine production by the foetal kidneys but it causes premature closure of DA * Surgery: amniocentesis but procedure carries risk of miscarriage and fluid builds up again **Prognosis:** * Risks of increased uterine stretch: * Preterm labour * Abruption * Rupture of the membranes * Post partum haemorrhage * Unstable foetal lie

Answer 15

Reduced amniotic fluid, \<500ml at 32-36w

Answer 16

**Foetal:** urethral obstruction, bilateral renal agenesis, ARPKD, chromosomal abnormalities, multiple pregnancies **Maternal:** late term, PROM, pre-eclampsia, placental insufficiency

Answer 17

Describes the typical physical appearance caused by pressure in utero due to oligohydramnios. It can occur in conditions such as infantile polycystic kidney disease, renal hypoplasia, and obstructive uropathy Urine is not produced \>\> oligohydramnios \>\> baby is squashed in utero and does not develop properly

Answer 18

Abnormal size for dates, ultrasound, Amniotic fluid index (\<5cm)

Answer 19

**TORCH organisms** Toxoplasmosis Other: syphilis, varicella-zoster, parvovirus Rubella Cytomegalovirus Herpes

Answer 20

* Infection with toxoplasma gondii is asymptomatic in the mother in most cases but can present as flu with lymphadenopathy * Infections can cause miscarriage especially if within the first 10 weeks of pregnancy * Can cause hydrocephalus and intellectual disability in the foetus, cerebral calcification, chorioretinitis which can cause blindness later in life

Answer 21

* Presents in the mother with fever, malaise and a maculopapular rash **(chickenpox)** * No increased risk of miscarriage * Can cause foetal varicella syndrome which presents with scarring in dermatomal distribution, eye defects, microcephaly, cortical atrophy, learning disability, bladder and bowel sphincter dysfunction * Mortality rate of 30% in babies

Answer 22

* Asymptomatic in the mother in 20-30% of cases, otherwise presents with a non vesicular (slapped cheek) facial rash, malaise, sore throat, mild fever, arthropathy, anaemia and anaplastic crisis * No increased risk of congenital abnormalities * Hydrous fetalis (accumulation of fluid in two or more foetal compartments) is a complication of foetal anaemia and cardiac failure

Answer 23

Parvovirus 19

Answer 24

* Presents in mother with malaise, fever, conjunctivitis, coryzal symptoms, macular rash, arthropathy, post auricular lymphadenopathy * Foetal complications: miscarriage, stillbirth, growth restriction, deafness, microcephaly, cataracts, cardiac defects

Answer 25

* Most cases asymptomatic in mother but can cause flu like symptoms and lymphadenopathy * Foetal complications: hepatosplenomegaly, thrombocytopenia, intracranial calcification, hearing loss, chorioretinitis, microcephaly and learning disability, growth restriction and stillbirth * Of the 5-15% of infected babies symptomatic at birth, 30% die and 80% have serious consequences. 10-15% of asymptomatic babies will develop auditory, visual or neurological defects

Answer 26

* Mother: painful genital ulcers, encephalitis, hepatitis and skin lesions if disseminated herpes * No increased risk of miscarriage * Morbidity \<2% with antivirals * 70% of cases there is disseminated disease with or without CNS involvement Herpes can be contracted as the baby passes through birth canal causing baby to be irritable, blisters over body, difficulty breathing, jaundice and easy bleeding Can be fatal if not treated with antivirals

Answer 27

* HIV+ women have viral load and CD4 levels checked once a trimester * Women with hep C or B have viral load assessed early in pregnancy * Positive immunoglobulin M antibodies to a TORCH organisms are diagnostic of a recent infection and increasing IgG confirms acute disease * Amniocentesis and viral detection by PCR or culture confirm foetal infection * Serial USS scans to screen for complications of infection

Answer 28

Aim is to reduce transmission Termination offered to women with TORCH infections depending on the organism, gestation when infection occurred and presence of foetal abnormalities **Medication:** * **HIV**: women continue antiretrovirals throughout pregnancy. Cabergoline is used to suppress lactation. Some retrovirals cause gestational diabetes * **Hepatitis**: antivirals used in third trimester for women with hep B and high viral load. No safe treatment for hep C in pregnancy * **Toxoplasmosis**: spiramycin given prophylactically to reduce risk of parasite transmission, doesn’t reduce risk of foetal anomalies. If foetus is infected, pyrimethamine and spiramycin are given to reduce severity. * \*pyrimethamine is teratogenic so not used in first trimester. It also antagonises folate so supplements are needed to prevent folate deficiency * **Parvovirus**: no drug treatment available, intrauterine infusions to treat foetal anaemia * **Rubella**: no drug treatment available, cochlear implants and cardiac surgery may be needed after birth * **CMV**: antivirals given to babies with congenital infection to reduce risk of hearing loss * **Herpes**: primary disease treated with aciclovir and given from 36 weeks to reduce need for c-section

Answer 29

No ## Footnote HIV: viral load \<50 RNA copies/mL at 36 weeks means woman can have vaginal delivery otherwise c-section. If load \>1000 IV zidovudine is given

Answer 30

Indication for c-section

Answer 31

* HIV: avoid in high income countries * Hep B and C: encouraged * TORCH: all ok apart from CMV but even in CMV transmission is rare

Answer 32

* Babies born to mothers with hep B receive the first dose of the vaccine and a dose of hep B immunoglobulin within 12hrs birth * Further doses of hep B vaccine given at 1 and 6mo * No vaccinations against TORCH

Answer 33

Parvovirus suppresses EPO

Answer 34

No treatment

Answer 35

VZV IgG antibodies:– if not immune (IgG negative give VZIG ASAP - effective up to 10d after exposure Acyclocir within 24h of rash

Answer 36

CMV - affects 1/100

Answer 37

**To mother:** - Gestational diabetes - Gestational HTN and pre-eclampsia - Difficulty with epidurals - Wound infection - PPH - VTE **To foetus:** - Miscarriage - Foetal anomalies: neural tube defects, cardiac defects, omphalocele - Stillbirth - Prematurity - Shoulder dystocia - Childhood obesity

Answer 38

Advised to maintain weight neutral pregnancy meaning they don’t lose or gain weight but light exercise and diet modification is recommended

Answer 39

* USS to screen for abnormalities, assess growth * Blood pressure and urinalysis for pre-eclampsia * Organ GTT for gestational diabetes

Answer 40

* BMI \>35 - babies delivered in obstetric led centres * BMI \>40 - heparin injections for at least 1 week after delivery

Answer 41

Epilepsy Affects 0.5% women of childbearing age

Answer 42

First seizure - measure blood pressure and urinalysis for proteinuria * first seizure in pregnancy is eclampsia until proven otherwise Bloods to check platelets, renal and liver function, coagulation tests, glucose levels and calcium concentration, drug screen to check for other causes of seizure CT or MRI head to exclude mass lesions or haemorrhage EEG if epilepsy suspected

Answer 43

* Balance between teratogenic risk of drugs and worsening seizure control * Medication: many are teratogens and cause neural tube defects, cleft lip and palate, cardiac defects * **Sodium valproate has the highest rate of genetic abnormalities, twice that of other anti-epileptics** * Carmabazepine and lamotrigene have a 2-2.5% incidence of malformations * Generally drugs should be continued because risk of seizure is higher than risk to foetus but women on sodium valproate are encouraged to switch to a different drug before pregnancy. If sodium valproate is the only drug that works, the dose is split over the day * All anti-epileptics have the potential to cause foetal anticonvulsant syndrome

Answer 44

Vitamin K from 36 weeks to reduce risk of vitamin K dependant clotting deficiency

Answer 45

No indication for c-section but seizures can be triggered by pain, anxiety and lack of sleep so early epidural may be beneficial

Answer 46

* Increasing as more women with congenital cardiac disease are surviving into adulthood * In high income countries 80% of cardiac disease in pregnancy is congenital * Outside of Europe and North America rheumatic heart disease is the most common cause of cardiovascular disease

Answer 47

* Rising incidence of obesity leading to cardiovascular disease * Peripartum cardiomyopathy is a dilated cardiomyopathy, cause unknown, causes loss of cardiac function. Unique to pregnancy and presents between the last month of pregnancy and 6 months after birth

Answer 48

Increased strain on the heart Circulating volume inceases so heart is working overtime

Answer 49

**Maternal:** ECG: palpitations or arrhythmias Echo: ventricular and valve function Exercise testing: Functional capacity and heart failure **Foetal:** - Cardiac USS: detect congenital heart disease - Genetic testing: to identify abnormalities associated with congenital heart disease e.g. Down's - Serial assessment of foetal growth from 28 weeks: detect placental dysfunction and foetal compromise (increased risk if mother has cardiac disease)

Answer 50

Extent of intervention depends on extent of cardiac function Medication: aspirin used prophylactically in women with coronary artery disease Women with metallic heart valves take warfarin outside of pregnancy but it is a teratogenic so it is avoided. Heparin is safe but thrombosis more likely **Delivery:** * Takes place in obstetric led departments * Vaginal delivery preferred

Answer 51

Outcome is good if woman has left to right shunt and minimal symptoms but those with stenotic valves and reduces ventricular function do less well Pulmonary hypertension is a contraindication to pregnancy because the maternal mortality rate is 30-50%

Answer 52

* Severe form of anaemia caused by incompatibility between maternal and foetal blood. * Caused by passage of maternal RBC across the placenta to foetus. * The antibodies are created in response to previous exposure to incompatible blood Most commonly the rhesus group of antigens but also ABO and Kell and Duffy antigens

Answer 53

* Atypical antibodies are detected in 1.2% of pregnancies but only 0.4% are clinically relevant * Severe haemolytic disease of the newborn affects 7-8 per 100,000 pregnancies

Answer 54

IgM antibodies are produced when cells of the maternal immune system are exposed to a foreign antigen on foetal RBCs This doesn’t affect the current pregnancy because the mothers immune system is exposed to a small amount of antigen but the immune system is sensitised for subsequent pregnancies. This results in immune mediated haemolysis in the foetus which results in haemolytic disease of the newborn * Most commonly caused by rhesus antibodies which are produced when a rhesus negative woman becomes pregnant by a rhesus positive father and the foetus is rhesus positive * The rhesus incompatibility between the mother and the foetus causes immune sensitisation in the mother in the first pregnancy and destruction of foetal RBCs in future pregnancies - IgG antibodies cross the placenta and mediate this

Answer 55

* Anaemia * Increased erythropoiesis and hepatosplenomegaly * Jaundice arising from hyperbilirubinaemia * Oedema and polyhydramnios as a consequence of high output heart failure * In severe cases foetal death can occur

Answer 56

* Blood group screening to detect atypical antibodies if offered at the first booking visit and 28 weeks * Women with clinically significant antibodies are referred

Answer 57

* Antibody titres are used to guide management * Significantly high antibodies warrants foetal genotype being determined * To detect anaemia in at-risk pregnancies Doppler USS is used weekly to measure blood velocity in middle cerebral artery of foetus * An anaemia foetus tries to maintain oxygen delivery by increasing cardiac output * Blood viscosity of the foetus is also reduced because of decreased RBCs * The combination of an increased CO and decreased viscosity results in high blood flow velocity in the middle cerebral artery * If the velocity is \>1.5x the median for gestation a sample of foetal blood is taken from the umbilical cord or hepatic vein to determine Hb concentration

Answer 58

**Management:** * Depends on gestation and degree of foetal compromise * Delivery: brought forward when the risk of the foetus remaining in the womb \> risk of prematurity - usually at 37-38 weeks * Intrauterine transfusion: can be carried out weekly to treat significant anaemia but not used after 35 weeks as delivery more appropriate at that time **Prognosis:** * 50% of affected babies have normal Hb * 25% have moderate disease requiring transfusion * 25% have severe disease * Survival is 84-90% * \<40% survival if cardiac failure is not reversed in utero

Answer 59

* Increased risk of most pregnancy related complications such as pre-eclampsia, growth restriction and pre-term birth * Twin-twin transfusion syndrome if a single placenta is shared

Answer 60

* Multiple births = 1-2% of all but proportion is increasing due to fertility treatments * 1 in 80 naturally conceived pregnancies produce twins and 1 in 6400 produce triplets

Answer 61

Refers to whether a multiple pregnacy shares amniotic sac and foetal part of placenta (chorion) * **Chorionicity** - can be dichorionic or monochorionic - refers to whether the foetuses have one or two placenta between them * The chorionicity and amnionicity of monozygotic twins is determined by the time at which the zygote splits, or cleaves. If the cleavage occurs by day 3, you will have two separate blastocysts, and therefore, two sites of implantation, resulting in dichorionic-diamniotic (di-di) twins * This can be determined using USS before 14 weeks gestation

Answer 62

USS Dichorionic = 2 placentas (in twin pregnancy) - accounts for 80% Monochorionic = 1 shared placenta - 20% and higher risk

Answer 63

* Combined test is used to screen for Down’s syndrome in twin pregnancies whereas nuchal thickness and maternal age are use in triplet pregnancies - both performed \<14 weeks * Serum screening for downs is used if the nuchal thickness can’t be measured * It’s difficult to measure foetal growth in multiple pregnancy so serial ultrasound is used from 24 weeks - a size discordance of \>25% is clinically significant * Monitoring is more frequent in early stages of monochorionic pregnancies because of twin-twin transfusion syndrome so fortnightly USS are carried out from 16-24 weeks

Answer 64

**Management:** * Managed in obstetric led units * Monoamniotic and triplet pregnancies are referred to tertiary foetal medicine units **Delivery:** * Preterm delivery is common * 60% twins arrive before 35 weeks and 75% of triplets * To reduce risk of late stillbirth delivery is induced at 36 weeks * Labour is induced for twin pregnancies when the first twin presents cephalically regardless of how the other one is presenting * Monochorionic monoamniotic twins are the exception - they should be delivered at 32 weeks by c-section to reduce risk of cord entanglement

Answer 65

Twine 15:1000 Triplets 1:5000 Quads 1: 360 000 1 in 34 children in the UK are a twin or triplet

Answer 66

- Prev. mutliple pregnancy - Family hx - Increasing parity - Increasing maternal age - Assisted reproduction

Answer 67

IUGR PTB Cerebral palsy Disability Miscarriage

Answer 68

Early on - at the morula stage before implantation has occurred and the the two separate blastocysts implant

Answer 69

3-8 days after fertilisation Single placenta but 2 amniotic sacs

Answer 70

8-13 days after fertilisation Same amniotic sac, same placenta

Answer 71

Monochorionicity

Answer 72

37-38 weeks

Answer 73

HG Anaemia Pre-eclampsia (5x risk) Gestational DM Antepartum and PPH Polyhydramnios Placenta praevia Operative delivery

Answer 74

Caused by shared circulation in monochronionic twins Affects 8-25% of monochorionic pregnancies 80% mortality of not treated Caused by abberant vascular anastomosies in the placenta which redistibute foetal blood from one to the other but not in the opposite direction One twin receives too much blood and the other too little

Answer 75

MC twins monitored by USS every 2 weeks from 16-24 weeks Then monitored every 3 weeks until delivery Treatment: - Laser ablation of placental anastamoses - Selective foetice if the condtion is not retractable

Answer 76

Donor: hypovolaemia, anaemia, oligohydramnios, IUGR Recipient: hypervolaemia, polycythaemia, large bladder, polyhydramnios, cardiac overload and failure, foetal hydrop Recipient twin is at greater risk than donor

Answer 77

Second twin is at higher risk of perinatal mortality Usually induced at 38 weeks although many deliver before then Foetal distress is more common so CTG is carried out - esp. after first baby has been born due to risk of foetal hypoxia in the second Increased risk of uterine atony so oxytocin and syntometrine infusion recommended

Answer 78

Pre pregnancy: counselling - achievement of optimal control Screening for retinopathy, nephropathy, heart defects 5mg folic acid due to increased risk of NTD Antenatal: monitor glucose 4x daily, monthly HbA1c measurements (normal = \<39mmol or 5.7%), dietician review Anomaly scan: those with DM are at 5-10x increased risk of foetal anomalies depending on control

Answer 79

24-28 weeks for those at risk: obese, previous macrosomia, FHx DM Unless hx of GD in which case screening ASAP (@booking visit) 5678 rule \<5.6mmol/L when fasted, \<7.8mmol/L after OGTT Threshold values are lower than DM outside of pregnancy due to the risk of DM during pregnancy

Answer 80

Some advise IOL at 38-39 weeks Vaginal delivery preferred, CTG advised Consider elective CS if EFW \>4.5kg Shoulder dystocia is more common in DM regardless of EFW Sliding scale used during labour - insulin rate depends on blood glucose

Answer 81

4-9mmol/L \*50% of those with GD develop T2DM over the next 25yrs

Answer 82

BP decreases until 24 weeks due to decreased systemic vascular resistance BP increases after 24 weeks due to increased stroke volume BP decreases again after delivery but may peak again 3-4 days PP

Answer 83

\>140/90 OR an increase of \>30/\>15 compared to booking visit BP should be measured sitting or supine with a left sided tilt because the uterus can compress the IVC and give a falsely low BP reading

Answer 84

- 7x increased risk if PMHx in previous pregnancy - Low PAPP = increased risk of pre-eclampsia - USS uterine artery dopplers at 11-13 weeks or 22-24 weeks are predictive of early onset/ severe pre-eclampsia

Answer 85

No - most are asymptomatic

Answer 86

Frontal headache associated with flashing lights

Answer 87

HTN: \>140/90 \>0.3g proteinuria/ 24hrs Hyperreflexia IUGR

Answer 88

Cure = delivery of placenta Oupatient monitoring is suitable if BP \<160/110, no or low proteinuria and asymptomatic Mild-moderate pre-eclampsia: \<160/110 with significant proteinuria and no complications Admission advised when proteinuria occurs: - 4x BP measurement daily - 24hr urine collection for protein - 2x weekly doppler - 2x monthly USS If BP \>160/110 - start labetolol

Answer 89

BP \>160/110 and presence of significant proteinuria (\>1g/ 24hrs or 2++ on urine dip) - Involve senior midwives and obstetricians Indications for immediate delivery: - Worsening thrombocytopenia, worsening liver or renal function - Severe maternal symptoms e.g. RUQ pain and derranged LFTs - HELLP - Eclampsia - Foetal distress

Answer 90

Labetolol = first line Nifedipine if labetolol not tolerated Methyldopa = 3rd line If expediting delivery and \<34 weeks: give steroids

Answer 91

Magnesium sulfate ⚠️ Can cause resp. depression - this is counteracted by calcium gluconate Treatment is continued for 24hrs after delivery or 24hrs after last seizure If seizures continue, give diazepam

Answer 92

Confusion, loss of reflexes, resp. depression and hypotension

Answer 93

15% 25% mortality rate due to liver rupture, cerebral oedema and haemorrhage

Answer 94

HTN causes endothelial dysfunction and vasoconstriction Vasoconstriction leads to Na+ retention and this causes vasospasm Vasospasm reduces blood flow to liver causing injury, elevated liver enzymes and RUQ pain which is essentially hepatic angina Low platelet levels due to endothelial injury which causes clot formation which consumes platelets

Answer 95

1. Epigastric or RUQ pain: liver hypoxia 2. N&V 3. Tea coloured urine: haemolysis

Answer 96

Obstetric cholestasis Typically causes itchy palms 1/3 have a FHx of obstetric cholestasis Diagnosis of exlusion when bloods show abnormal LFTs, raised bile acids in the absence of any other cause of hepatic dysfunction

Answer 97

Bile acids: raised = most specific LFTs: ALT raised, GGT raised PTT increased because there is reduced fat absorption therefore less vitamin K available to make clotting factors Liver USS needed to exclude gallstones and acute fatty liver of pregnancy

Answer 98

Vitamin K deficiency - PPH PTB Stillbirth Increased risk of meconium stained liqour

Answer 99

Faily - affects 0.5-1% pregnancies

Answer 100

Water soluble vitamin K Topical menthol emollients Ursodeoxycholic acid 90% risk of recurrence in future pregnancies

Answer 101

Single deepest amniotic pool depth Mild: 8-11cm Moderate: 12-15cm Severe: \>16cm

Answer 102

Higher than expected SFH Maternal skin stretched and shiny Tense uterus Difficult to palpate foetus SOB due to enlarged uterus

Answer 103

Mild/ aysmptomatic: no intervention Indometacin: decreases fluid volume by reducing fluid made by foetal kidneys but cases premature DA closure Amniocentesis

Answer 104

\<500mL at 32-36 weeks Amniotic fluid index \<5cm

Answer 105

Virus disrupts mitosis and retards cellular division which causes vascular damage in baby Major malformations occur during organogenesis and severity decreases as gestation increases Defects: sensorineural deafness, cardiac anomalies, cataracts, glaucoma, microcephaly

Answer 106

\<13 weeks: almost all infection, TOP offered 13-16 weeks: main issue is deafness, can be diagnosed by foetal blood sampling \>16 weeks: rarely causes defects, reassure

Answer 107

White spots in mouth - pathognomonic for measles

Answer 108

No but associated with foetal loss and PTB

Answer 109

Peak systolic velocity in MCA via USS - The greater the velocity the greater the chance of anaemia

Answer 110

Common herpes virus transmitted through bodily fluids

Answer 111

40% foetuses will be infected 90% normal at birth: 20% go on to develop minor sequelae 10% symptomatic at birth: 33% die, 67% have long term problems

Answer 112

Check if good hx of having chicken pox, if not then test VZV IgG antibodies - If antibodies detected within 10 days of contact, reassure - If antibodies not detected, give VZ immunoglobulin within 10 days of exposure

Answer 113

If mother exposed \<20 weeks 1-2% risk of foetal varicella syndrome - consider TOP If exposed \>20 weeks not associated with congenital abnormality If exposed in 2nd or 3rd trimester: 1-2% risk of shingles in infancy Exposed within 4 weeks of delivery 20% develop neonatal varicella syndrome which is fatal in 20% - give VZIG ASAP

Answer 114

If \<20 weeks and not immune give VZIG ASAP within 10 days exposure If \>20 weeks and not immune then VZIG or aciclovir given 7-14 days after exposure **(not given immediately)**

Answer 115

Transmission if mother has 1st degree infection during vaginal delivery Neonatal herpes occurs during first 2 weeks - 25% confined to eyes and mouth, 75% widely disseminated and 70% die Management: aciclovir may decrease severity and duration of primary attack if given \<5 days within symptom onset - Deliver via CS

Answer 116

Culture of vesicle fluid

Answer 117

Spontaneous miscarriage is common if infected in 1st trimester If exposed \<12 weeks, 17% infected and 75% chance of congenital abnormality

Answer 118

Spiramycin @ diagnosis may decrease risk of foetal infection If foetus has infection confirmed - combination anti-toxoplasmosis therapy given: leukovarin, pyrimethamine (teratogen, do not give in 1st trimester), sulphadiazine Pyrimethamine - antifolate so give supplement

Answer 119

Avoid until maternal IgM cleared - can take 12 months

Answer 120

Hep B IgG and vaccination Up to 95% effective in preventing neonatal HBV infection

Answer 121

Streptococcus agalactiae 20% women carry it vaginally Asymptomatic

Answer 122

Not routinely screened for Women who've had GBS in previous pregnancy have 50% risk of recurrence - offer antibiotic prophylaxis or testing in late pregnancy then give antibiotics if positive Swabs done at 35-37 weeks or 3-5 weeks before anticipated delivery

Answer 123

**Early onset: \<4 days from delivery** - 20% mortality, presents within pneumonia, sepsis of unknown origin, meningitis **Late onset: \>7 days from delivery** - not associated with maternal GBS carriage, 20% mortality, 50% have neuro deficits e.g. cortical blindness, deafness

Answer 124

Treponema pallidum spirochaete bacterium - causes syphilis - can cross placenta Can cause PTB, stillbirth and **congenital syphilis** - 8th nerve deafness - Saddle nose - Sabre shins Management: penicillin

Answer 125

1/700 women giving birth are HIV⁺ HIV+ women have viral load and CD4 levels checked once/ trimester Continue anti-retrovirals during pregnancy Cabergoline to suppress lactation If viral load \<50 then can deliver vaginally

Answer 126

Live attenuated vaccines are contraindicated e.g. MMR, rubella, polio Passive immunisation via specific immunoglobulin is safe e.g. VZIG Vaccinations for travel on case by case basis

Answer 127

Autoimmune condition causing destructive thyroiditis Presents PP as immunity returns to normal following a period of suppresion during pregnancy Pre-formed T4 is released = initial hyperthyroid state Hypothyroidism develops as T4 is used up Most recover spontaneously If hyperthyroid state needs treatment b-blockers are used

Answer 128

Miscarriage, brain damage, GD Management: contnue thyroxine - often dose is increased in pregnancy due to higher requirement

Answer 129

IUGR, PTB, miscarriage Management: propythiouracil in 1st trimester Can use carbimazole but lowest dose Radioactive iodine is contraindicated

Answer 130

Severe form of anaemia cuased by incompatability between maternal and foetal blood - caused by passage of maternal RBCs across the placenta to the foetus - Most commonly Rh group Epidemiology: abnormal antibodies are detected in 1-2% pregnancies, 0.4% are clinically relevant Severe HDN affects 7-8 per 100,000 pregnancies Aetiology: - IgM antibodies produced when cells of the maternal immune system are exposed to a foreign antigen on foetal RBCs - Sensitisation occurs during 1st pregnancy and this causes immune mediated haemolysis in the newborn Prevention: - Anti-D given to Rh negative women during pregnancy to mop up any foetal RBCs in the mother's circulation before she becomes sensitised Clinical features: - Anaemia - Increased erythropoesis - Hepatosplenomegaly - Oedema and polyhydramnios - Jaundice - If severe: foetal death Investigation: To detect anaemia in foetus - Anaemic foetus will increase HR to maintain o2 delivery, blood is less viscious because fewer RBCs - This causes higher velocity blood flow in MCA detected via doppler - If 1.5x median for gestationa. sample of foetal blood is taken from umbilical cord or hepatic vein to test Hb conc. Management: - Depends on gestation - Delivery usually expedited to 37-38 weeks - Intrauterine transfusion can be carried out weekly to treat significant anaemia but not used beyond 35 weeks as delivery more apt Prognosis - 50% have normal Hb - 25% moderate disease and need tranfusion 25% severe disease: survival 84-90%

High risk pregnancies Flashcards

(160 cards)