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High risk pregnancy Flashcards

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1
Q

incidence of twins and triplets in UK

A

twins 15.1 per 1000 maternities

triplets 2.6 per 10000

quads >3 in uk in 2012

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2
Q

risk factors for having twins 4

A

assisted conception -IVF

maternal age- 4x greater chance at 37 than 18

Ethick origin- west Africa

FHx- maternal inheritance

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3
Q

define the terminiology of the following
-zygosity

chorionicity

amnionicity

A

zygosity- number of fertilitsed eggs

chorionicity- number of placentas

amnionicity - number of sacs

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4
Q

define dizygotic twins

A

2 eggs, 2 sperm

-may look identical but not any more genetically identical than sibinngs

2/3 of twins in UK are dizygotic [18]

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5
Q

define monozygotic twins

A

one fertilized egg
-then splits
-identical twins [18]

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6
Q

how can in monozygotic twins when the one fertilized egg split at different stages in the womb and what are they called 3

A

before day 4
-prior to chorion development
-called: dichorionic diamniotic (approx 1/3) [18]

day 4-8
-prior to amnion development
-called: monochronionic diamniotic (approx 2/3) [18]

from day 9
-after amnion development
-called: monochorionic monoamniotic
-(if late split (after day 13) risk of conjoined twins) [18]

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7
Q

antenatal maternal risk of multiple pregnacy 5

A

all maternal complications increased wit increased fetal/placental number

esp:
-hyperemesis gravidarum
-pre-eclampsia
-gestational diabetes
-placental praevia
-all minor complications

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8
Q

fetal antenatal complications of multiple pregnancy 4

A

miscarriage
-spontanous first trimester loss is common

congenital anomaly
-roughly doubled compared to singletons
-structural anomalies increased- eg two babies

growth restirciotn

preterm devlier y

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9
Q

prenatal diagnosis of multiple pregnnacy 2

A

serum screening / free fetal DNA do not work

Ultrasound

invasice procedures- CVS, amniocenteiss

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10
Q

specific complications of monochorionic twins 3

A

acute transfusion

twin-twin transfusion syndroem

twin reversed arterial perfusion sequence

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11
Q

monitoring of fetal growth in mutiple pregnnacy

A

high risk of intrauterine growth restirction

clinican exam unreliable

require regular ultrasound
-DC twins 4 weekly from 24 weeks
-MC twins 2 weekly from 16 weeks

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12
Q

prematurity in multiple pregnnacies

A

maternal an dfettal reasons for delivery
-major cause of neoatal death in multiples

median gestation for twins 37, triplets 34

parents need to be informed of syx and sx of preterm labour

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13
Q

managing preterm labour in multiple pregnanceis 3

A

steroids

obstetrics labour ward

neonatal cot availability

tocolysis

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14
Q

what influences mode of delivery in twins

A

presenation of first twin
-vaginal delviery if twin1 is cephalic

C-section for twin 2 high likelihood

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15
Q

when is elective delivery of twims

A

37 weeks for DCDA

36 weeks for MCDA

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16
Q

management of twin delivery

A

often epidural for mother

monitor during labour
-BP, IV access, fluids , ranitidine

fetal- continuous CTG, abdo and fetal scalp electrode
-FSE applied to bottoms

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17
Q

management of second twin after first twin is delivered as normal 4

A

cord clamped
-experied obstertican determines presenation of second twin
-US
-internally position second baby
-can allow up to 30mins if CTG ok
-can result in a Csection

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18
Q

immediate maternal post-natal care in twins 3

A

increased risk of postpartum haemorhage
-uterine blood flow high at term

with multiple pregnacies
-tone (big floppy uterus), tissue (double the placentas)m trauma (two babies to fit out)

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19
Q

what are mums of mutiple pregnancies at increased risk of postnatally (psychological) 3

A

postnatl depresion and bereavemnt

anxiety

relationship difficulties

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20
Q

why do monochorinoinc twins have specfiic complications

A

problem due to communicaiton between twins cirucation via placental anastomoses

intern-twin transfusion normal but problems arise when it becomes unbalanced

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21
Q

state the three monochorioinc complicaitons in twins 3

A

acute transfusion

twin-twin transfusion syndrome

twin revered arterial perfusion sequence

*MONOCHOROINIC TWINS SHARE PLACENTA BUT HAVE DIFFERENT SACS

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22
Q

define acute tranfusion as a complication of monochorionic twins

A

death of one twin in uterus-> increased risk of hypoxic-ischaemia injury in survivor
-due to acute transfusion from healthy to dying twin
-risk of exsanguination of healthy twin into dying twin

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23
Q

managemetn of acute transfusion as a complication of monochorionic twins

A

delivery needs to be expeidietd if compormise detected
-TO SAVE BOTH TWINS

IF UID already occurred
-delveiry not indicated except near term
-increased monitoring of surviro for anaemia and transfusions brain injury

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24
Q

define twin to twin transfussion as a complication of monochorionic twins

A

occurs in 15%
-mechanism is chronic net shunting from one twin to other

donor twin
-growth restricted, oliguric, anydramnios

recipient twin
-polyuric, polyhydramnios, cardiac problems, hydrops

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25
twin to twin transfusion syndrome presenation and diagnosis 5
presenation -16-25wks, different liquor volume s Dx- USS -liquor volume -bladder seen -cord dopples -oedema/acites
26
staging system use for twin to twin transfusion syndrome
quintero stagin 5 stages from discordatn liquor volumes to death of one or both twins
27
staging system use for twin to twin transfusion syndrome
quintero stagin 5 stages from discordatn liquor volumes to death of one or both twins
28
management options of twin to twin transfusoin 2
fetoscopic laser ablation of anastamoses cord occulsion -Mx at quaternary referral centre
29
outcomes for twin to twin transfusion
2/3 have a dead or brain damaged baby -outcomes imrpvoing
30
define twin reveresed arterial perfusion syndrome (TRAPS) as a complication of monochorionic twins -*management
v rare -2 cords linked by big arterio-arterial anastamossi -retrograde perfusion -pump twin and perfused twin *- ablation of anastomosis
31
incidene of monoamniotic twins
1%
32
risks with monoamniotic twins
almost all develpo cord entanglement -high perinatal mortality due to cord accidents lots of placental anastomoses -deaath of one twin rapidly leads to death of second twin
33
managemtn of high order mutiple pregnacies
good parental counselling *usually due to assisted reporduction -tight regulations of IVF in UK option of selective fetal reduction -referral to tertiary centre -generally, C section
34
managemtn of high order mutiple pregnacies
good parental counselling *usually due to assisted reporduction -tight regulations of IVF in UK option of selective fetal reduction -referral to tertiary centre -generally, C section
35
managemtn of high order mutiple pregnacies
good parental counselling *usually due to assisted reporduction -tight regulations of IVF in UK option of selective fetal reduction -referral to tertiary centre -generally, C section
36
incidence of breech presentation at 20 wks, 32wks and term
20wks- 40% 32wks- 25% term 3-4%
37
associations with breech presentaion 6
mutiple pregnacy bicornuate uterus (uterus heart shaped_) fibroids placental praevia poly/oligohydramnios fetal anaomlies
38
what fetal anomalies are assocaited with breech presentation 3
NTDs neuromusuclar disorders autosomal trisomies
39
state the three types of breech presentation 3
complete footling Frank [19]
40
risks withvaginal delivery in breech presenation 6
intracranial injury widespread bruising damaeg to internal organs spinal cord transection umbilical cord prolapse hypoxia
41
risks with C section delviery of breech presentation
mainly maternal surgical mrobidiy and mortality
42
preferred mode of delviery for breech presentations
planned C section -reduces perinatal mrotaity and early neonatal morbidity
43
info given to mother about C section for breech presentation 2
planned C section -caries small increase in serious immediate complications compared to vaginal birth -does not carry any long term health risk -
44
define external cephalic version
externaly rotaates fetus from breech to vertex presenation
45
use of external cephalic version in breech presenation
all women w breech presenation offerd it unless contraindicated from 36wk if nulliparous and 37weeks if multiparous CTG-before and after procedure -consider Anti-D if Rhesus negative
46
contraindications to external cephalic version absolute 5 relative 5
absolute -when C section reuiqred regardles of presenation (placenta praevia) -antepartum ahemorrhage in last 7 days -abnormal CTG -ruptiured membranes -mutiple pregnacy relative -nuchal cord -fetal growth restriction -pre-eclampisa -oligohydramnios -major fetal anomalies
47
define preterm labour by date
less than 37wk gestaion
48
define very preterm by date
28-32
49
define extreemly preterm by dart
<28weeks
50
define preterm labour
regular uterine contractions -accompanised by effacemtn and dilatation of cervix after 20weeks and before 37weeks
51
define preterm pre-labour rupture of memrbanes
rupture of fetal membranes before 37wks and before onset of labour
52
define low birth weight by value
<2501g
53
define very low brith weight by value
<1501g
54
define extremely low birth weight by value
<1000g
55
incidenec of preterm birth
10%
56
causes of preterm birht 4
spontaneous labour-unknown elective delivery -maternal HT, fetal growth problems, antepartum haemorrhage preterm-preamture ruptured membranes multiple pregnancies
57
chances of surviing follownig preterm delievry at: <22wks 24wks 27wks 31wks 34wks
<22 weeks: close to zero 22 weeks: 10% 24 weeks: 60% 27 weeks: 89% 31 weeks: 95% 34 weeks: equivalent to baby born at full term
58
complications of pre-term delivery 2
before 33wks -immaturity of organ ssytems esp lungs, brain and GI tract of those who survive 10% will suffer long term health problems
59
benefits of maternal corticosteroids in pregnacies at risk of preterm delivery 4
IM betamethsone or dexamethasone reduce incidnece of repsiraroty distress syndrome reduece Intraventricular cererbral haemorhae -reduce neonatal death -reduce necrotising enterocoiltis and NICU admissions
60
when are maternal corticosteroids given to mothers
between 23+0 and 23+6 who are suspected or established preterm labour offer for between 24-33+6wks consider in 34+0- 35+6
61
causes of antepartum haemorrhage
3-5% of pregnnaies majority unexpained after clinical exam and USS - placental abruption and placemeta praevia -most important -not most common
62
classifications of antepartum haemorrhage 3
minor <50ml major 50-1000ml -no hypovolaemic shock massive >1000ml ± hypovolaemic shock
63
local causes of antepartum haemorrhage 3
vulva vagina cervix- cervical ectropion or cervical polyp rare cervical carinoma
64
antepartum haemorrhage placental causes 2
placenta praevia placental aburiosn
65
antepartum haemorrhage unexplained causes
most commoon amnged expectantly if no fetal or maternal compromise -recurrent is risk factor for fetal growth compromise
66
define plaeceta praevia
placenta encroaches upon lower segement of uterus -lower segment of uterus= extending 5cm from interternal cervical os
67
risk factor for plaeceta praevia 1
most no discernible risk factors previous C section is one
68
plaeceta praevia diagnosis
transvaginal ultrasound -can determine distance between edge of placenta and internal os
69
classifications of plaeceta praevia 4
minor 1: encroaches the lower uterine segemnt [20] minor 2- reaches internal os of the cervix (marginal) [20] major 3- covers part of internal os [21] major 4- completely covers the internal os [21]
70
risk with major placenta praevia
haemorrhae at labour is inevitable
71
is vaginal delivery possibble with minor placenta previa
maybe -assess engagement of presenting part and actual distance of placental from internal os -MUST BE >2CM
72
screening for placenta praevia -how can this change
placenta location determined at fetal anomaly scan (18-22wks) may be low at that stage -as uterus grows from lower segment upwards , placenta can move upwards with advancing gestation
73
describe the differnet gestations times and if a placenta praevia is present the chance of it being low at term 3
Low placenta at 24 weeks: 2% will be low lying at term At 24-29 weeks: 5% will still be low at term At >30 weeks: 25% will still be low at term
74
risks of placenta praevia
sudden unpredicatble major/massive haemorrhage massive haemorrhaeg at C section mrobidily adherent placenta
75
managment of placenta praevia 3
may be admited from 30-32 weeks until delviery -often outpatient management if no bleeding elective delivery 38-39 weeks early eremgency delivery if haemorrhage occurs
76
define abnormally invasive placenta
placenta invades myometrium and cannot be readily separated from uterus following delivery
77
how is abnormally invasive placenta diagnosed
usually w USS antenataly -evaluate presence of degree of invasion
78
risks with abnormally invasive placenta 1
massively increase risk of massive postpartum haemorrhage
79
managemtn of abnormally invasive placenta 1
MDT delievry approach may require hysterectomy -women should be warned prior to delivery by C section
80
define placenta abruption
retroplacetal haemorrhage -bleeding between the placenta and uterus usually involves some degree of placental separation
81
risk with placenta separation
reduced gas exchange between fetal and amternal circulations-> can cause fetal hypoxia and acidosis
82
risk factors for placenta abruption 9
previous abruption HT/pre-eclampsia thrombophillia premature membrane rupture mutople pregnacy folic acid deficieny cocaine smoking social deprication *-most occur without identifiable risk factors
83
what is important to note about placenta abruption
if women bleeding from vainga this may not reflect total blood loss -some can also have no external loss at all -this is a 'concealed abruption' and is the most hazourdous type
84
types of placenta abruption 3
complete separion -concealed haemorrhage [22] partial sepation (concealed haemorrhage) [23] partial separation (apparent haemorrhage) [23]
85
managemtn of placental abruption
dpends on amount of bleeding, any maternal haemodyrnamic compromise, maturity of fetus if delivery indicated -decision between vaginal and C section influence by degree of bleeding and maternal and fetal conditions
86
managemtn of a light bleeeding placental abruption 3
not normally compromisefetus breif in patient obseaiont -surveillance of fetal growth and USS repeated episodes-> consider early delivery
87
managemtn of a major haemorrhage placental abruption 1
urgent devliery usuallt required
88
how is a major concealed placental abruption identified 3
degree of pain uterine tenderness evidence of hypovolaemic shock
89
vaginal or C section in intrauterine fetal death
vaginal preferred -mother shouldnt be subjected to unnecessary C section
90
why is section sometimes necessary for delviery in intrauterine fetal death 3
*-likely to have been major blood los -hypovolaemic shock and multisystem organ failure can occur if not correct -release of thromboplastin from damaged plaenta can lead to DIC therefore C section may be needed
91
what does placental abruption predispose the mother to
post partum haemorrhage 'abruption kills the baby, PPH kills the mother'
92
presenation of placental praevia 3 (EXAM)
usually PAINLESS bleeding non-engaged presenting part soft uterues
93
presenation of placental abruption 2 (exam)
usually PAINFUL bleeding hard WOODY uterus
94
what to ask in history of antepartum haemorrhage 3
when did bleeding start how much blood loss when did baby last move
95
what to observe in antepartum harmorrhage 4
is mother in pain (suggests abruption or labour) blood on bed, legs or floor? mother pale? signs of hypocolaemic shock- low BP, tachycardia
96
examination points in antepartum haemorrhaeg 4
abdomonial exam USS to deterimen placental site -asssess fetla wellbeing CTG if gestation >26wks fetal heart doppler if <26wks speculum carried out if placenta not low
97
managemtn of antepartum haemorrhage 4
admit until bleeding stops Anti-D if rhesus negative major/massive APH- matrenal resus (correct hypovolemia and coagulation defects) and consider devliery fetal compromise- consider delivery
98
causes of post partum haemorrhage (4 Ts)
tone trauma tissue thrombin

Obs & Gyn (23 decks)

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