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Y4 - GOSH > High Risk Pregnancy > Flashcards

High Risk Pregnancy Flashcards

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1
Q

what are some of the maternal conditions leading to high risk pregnancy

A 
obesity 
GDM or DM in general 
pre-eclampsia 
epilepsy 
HTN, pregnancy induced hypertension
CKD 
chronic respiratory disease 
SLE 
infection - TORCH syndrome 
previous abdo surgery 
VTE (4x risk if FHx of oestrogen related VTE)
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2
Q

what are some of the social conditions leading to high risk pregnancy

A 
teenage pregnancy 
maternal age > 35 
smoking/alcohol/substance abuse 
high parity > 4 (PPH), low interpregnancy interval 
Poor socioeconomic conditions
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3
Q

what are some of the obstetrics issues leading to high risk pregnancy

A 
prev. preterm labour 
C-section 
recurrent miscarriage (3+) 
stillbirth 
pre-eclampsia 
GDM 
3rd degree tear
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4
Q

what is the definition of small for gestational age

A

EFW > 10th percentile for its gestational age.

SGA is a surrogate marker for IUGR

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5
Q

complications of IUGR

A

perinatal mortality if 6-10x higher
cerebral palsy 4x greater
30% of stillbirth are growth restricted

intrapartum foetal distress and asphyxia 
meconium aspiration 
emergency CS 
NEC
Hypoglycaemia and hypocalcemia
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6
Q

what are the maternal causes of IUGR?

A

chronic maternal disease - HTN, cardiac disease, CKD

Substance abuse - alcohol, smoking, drugs

autoimmune disease - antiphospholipid antibody syndrome, SLE

genetic disease - phenylketonuira

poor nutrition

low socio-economic status

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7
Q

what are the placental causes of IUGR

A

abnormal trophoblast invasion - pre-eclampsia, placenta accreta

abnormal umbilical cord or cord insertion - 2 vessel cord

abruption

placental praevia

tumor - chorioangiomas

infarction

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8
Q

what are the foetal causes of IUGR

A

genetic abrno - trisomy 13, 18, 21

turner’s syndrome

Triploidy

congenital abnor - cardiac, gastroschisis

TORCH syndrome

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9
Q

what are the 2 different types of IUGR that can occur

A

symmetric growth restriction - entire body small, early onset and tends to be chromosomal abnor

asymmetric growth restriction - undernourished foetus, head sparing, secondary to placental insufficiency

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10
Q

management of IUGR

A

early identification
intensive foetal monitoring - serial growth scans

continue pregnancy safely for as long as possible - dec prematurity complications, but ultimately delivery and good care of neonate is the solution

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11
Q

long- term complications of IUGR

A

most are fine

1/3 of children not reaching their predicted adult height

childhood attention and performance deficit

higher rates of coronary heart disease, high BP, high cholesterol and abnor glucose-insulin metabolism

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12
Q

what is the aetiology of IUGR

A 
FHx
previous multiple pregnancies 
increasing parity 
inc maternal age
ethnicity 
assisted reproduction
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13
Q

what are the signs/symptoms of IUGR

A

Hyperemesis gravidarum
large for date
3 or more foetal poles maybe palpable > 24 weeks
2 fetal hearts may be heard on auscultation
USS evidence on booking or any scans in 1st trimester

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14
Q

what are some of the antenatal care of multiple pregnancy

A

consultant led care

need to establish chorionicity - most accurate in 1st trimester

double the amount of iron and folate

detailed anomaly scan

serial growth scans + inc frequency of appointment

close eye on ketons and pre-eclampsia - due to increase demands from placenta and so will more likely to cause pre-eclampsia

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15
Q

in what situation would you get dichorionic diamniotic twins

A

1) when 2 eggs are fertiliserised

2) when the fertilised egg splits into 2 in the first 3 days of cell division

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16
Q

in what situation would you get monochorionic diamniotic twins

A

when the ferilised egg divide into 2 in first 4-7 days of cell division since it has already implanted into the endometrium but has yet to divide any further

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17
Q

in what situation would you get monochorionic Monoamniotic twins

A

when the ferilised egg divide into 2 in first 8-12 days of cell division since it has already implanted into the endometrium and cells already develop into placenta

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18
Q

when should multiple pregnancies be delivered

A

consider induction at 38 weeks

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19
Q

what are the maternal risks to multiple pregnancy

A 
hyperemesis gravidarum 
anaemia - due to 2x inc need of Hb production 
pre-eclampsia 
GDM 
polyhydramnios  
placenta praevia - due to lack of spaces 
APH & PPH 
operative delivery
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20
Q

what are the foetal risks to multiple pregnancy

A

inc risk of miscarraige - esp with monochorionic twins

congenital abnor more common in monochoriontic twins - neural tube defects, cardiac abnor, gastrointesiontal atresia

IUGR

PROM

inc perinatal mortality

inc risk of stillbirth

inc risk o disability

inc risk of cerebral palsy

Vanishing twin syndrome - 1 twin apparently being reabsorbed at an early gestation

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21
Q

what is twin to twin transfusion syndrome

A

aberrant vascular anastomoses within the placenta which redistributes the foetal blood

blood from the donor twin is transfused to the recipient twin

the placenta in this case only have 2 vessels, 1 artery which is directed to the recipient twin and vein to the donor twin

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22
Q

what is the clinical features of the donor twin in twin to twin syndrome

A

Less arterial blood to donor twin - less nutrient

IUGR –> oligohydramnios, hypovolemia, anaemia

because of the apparent less volume of placenta. it appears to be stuck to the placenta/uterine wall and much smaller

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23
Q

what is the clinical features of the recipient twin in twin to twin syndrome

A

relatively more arterial blood to the recipient twin

hypervolemia and polycythemia

larger bladder and polyhydramnios

evidence of foetal hydrops (ascites, pleural and pericardial effusions)

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24
Q

which twin in the twin to twin transfusion syndrome tend to do worse post-natally

A

the recipient twin because fetus is not built to sustain more nutrient naturally therefore the donor twin tends to do better although both have a terrible outcome

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25
what does a lambda sign found in antenatal USS mean for the number of placenta in a pregnancy
lambda sign = dichrionic
26
what does a T sign found in antenatal USS mean for the number of placenta in a pregnancy
T sign = monochrionic
27
what is the dosage of folic acid for twin pregnancy
5mg
28
what is the treatment plan for MCMA
elective C-section at 32-34 weeks 1 twin normal delivery and 1 twin C-section beware of first twin non-vertex which will be risk of locked twin
29
what is pregnancy-induced hypertension
hypertension in the 2nd half of pregnancy in the absence of proteinuria or any other marker of pre-eclampsia BP >140 or > 90 or an inc of BP of >30/>15
30
when should delivery of the baby be if the pregnant lady have PIH
around EDD
31
what is the general trend of BP in a pregnant woman
from conception to 24 wks, slight dec in BP then from 24 till delivery, BP will return to normal value BP dec after delivery but many peaks 3-4 days post-partum
32
when should delivery of the baby be if the pregnant lady have chronic hypertension
around EDD but inc risk of re-eclampsia
33
what is post-partum hypertension
inc BP in the postpartum period BP can peak 3-4 days post-partum
34
how common is pre-eclampsia
10% of all population
35
definition of pre-eclampsia
BP > 140/90 + > 300mg proteinurua in 24 hour collection after 20 weeks (or protein:creatinine ration > 30 or albumin:craetinine ration >8) or a rise in systolic BP > 30 or Diastolic BP > 15
36
what are the different classification of pre-eclampsia
mild - proteinuria and mild/moderate hypertension Moderate - proteinuria + severe HTN with no maternal complications Severe - proteinuria and any HTN <34 weeks (160/110) it with maternal complications
37
symptoms of pre-eclampsia?
headache (esp. frontal) visual disturbance (esp. flashing light) epigastric or RUQ pain N+V rapid oedema (esp antigravity eg face) symptoms only really occur with severe cases
38
signs of pre-eclampsia?
HTN - 140/90 (160/110 if severe) proteinuria (>300mg in 24 hour urine collection) facial oedema epigastric/RUQ tenderness - signs of liver involvement and capsule distension confusion hyperreflexia +/- clonus - cerebral irritability uterine tenderness or vaginal bleeding from a placental abruption IUGR on USS
39
what are some of the RF for pre-eclampsia
previous pre-eclampsia Hx Primp FHx BMI > 30 Maternal age > 40 multiple pregnancy sub-fertility DM PCOS autoimmune disease - antiphospholipid syndrome renal impairment pre-existing cardiovascular disease and chronic HTN
40
investigation for pre-eclampsia
FBC - high HB, thrombocytopenia, anaemia coag profile = prolonged PT and APTT urinary test for proteinuria LFT U&Es
41
what is eclampsia
the occurrence of tonic-clonic seizure in association with a diagnosis of pre-eclampsia
42
what is HELLP syndrome
Hamolysis Elevated Liver Enzyme, Lower Platelet
43
what is the management of pre-eclampsia
definitive management = delivery of placenta + baby
44
management of outpatient management of pre-eclampsia (BP<160 and <110 + no proteinuria)
warn about the development of symptoms 1-2 per weeks review of BP and urine Weekly review of blood biochemistry
45
management of mild-moderate management of pre-eclampsia (BP<160 and <110 + significant proteinuria >300mg per 24 hours)
admission advised daily urinalysis daily CTG Oral labetalol
46
management of mild-moderate management of pre-eclampsia (BP>160 and >110 + significant proteinuria >300mg per 24 hours +/- maternal complications
BP control - aim for <160 and <110 1st line - labetalol 2nd line - nifedipine (if labetalol can not be used due to asthma) or methyldopa IV labetalol or hydralazine use Magnseium sulphate if seizures Dexamethsaone 12mg PO as adjunt to prepare for baby delivery
47
what is the percentage of seizure take place post-natally
44%
48
complications for pre-eclampsia
SHAME ``` Stroke HELLP syndrome Abruption multi-organ failure +/- DIC +/- Death Eclampsia ```
49
what are some of the maternal complications of pre-gestation diabetes
DM lower the body's immune system ``` UTI recurrent vulvovaginal candidiasis PIH/ Pre-eclampsia operative deliveries: CS and assisted vaginal deliveries inc risk of retinopathy inc risk of nephropathy cardiac disease ```
50
what are some of the foetal complications of pre-gestation diabetes
SMASHED ``` S - shoulder dystocia M - macrosomia A - Amniotic Fluid Excess S - stillbirth H - Hypoglycaemia/Hypothermias/HTN E - Error inbound D - Disability (neural tube defects, microcephaly, cardiac abnor, sacral agenesis, renal abnor) ``` preterm labour IUGR unexplained IUD
51
what are some of the post-natal complications of pre-gestation diabetes
polycythemia --> jaundice + cardiomegaly + RDS hypoglycemia birth trauma - shoulder dystocia, fractures, Erb's palsy, asphyxia hypoglycaemia/hypocalcaemia/hypomagnesaemia
52
what are the specific management of the baby whose mother is diabetic pre-pregnancy
folic acid 5mg - due to inc risk of neural tube defect Down's screening - DM reduce aFP and so less accurate screening 5-10 fold inc risk of foetal anatomy anomaly - anatomy screening foetal echocardiography - due to risk of foetal cardiomegaly due to polycythemia serial growth scans - polyhydramnios, macrosomia or IUGR hypoglycaemia - educate patient and family and supply with glucagon advise earlier delivery at 38-39 weeks, lower the already heightened risk of shoulder dystocia
53
what is the insulin management of the mother post-natally
the requirement of the insulin drops dramatically after birth (insulin is required for the foetus as it is a growth factor) therefore, mother should go onto a sliding scale initially then slowly return to pre-pregnancy SC insulin
54
when is oral glucose tolerance test usually carried out
26-28 weeks
55
when is oral glucose tolerance test usually carried out if the patient had previous GDM
16 weeks
56
how is OGTT carried out?
fasted overnight for 8 hours - water only, no smoking 75g glucose load in 250-300ml of water plasma glucose measured both fasted and at 2 hours
57
what plasma glucose reading form a OGTT would you diagnose GDM
> 7 for fasting | > 11.1 for 2 hour gloucse
58
what plasma glucose reading form a OGTT would you diagnose glucose impairment
fasting gluose < 7 | 2 hours > 7.8 and < 11.0
59
RF for GDM
``` previous GDM FHX of DM previous macrosomic baby previous unexplained stillbirth obesity (BMI >30) glycosuria polyhydramnios LGA ethnicity - south asian ```
60
measurement of GDM?
MDT approach measure glucose QDS diet should be first line - aim for normoglycaemia and avoid ketons scanning every 2 weeks for polyhydramnios, IUGR & macrosomia start insulin if - pre-meal glucose > 6 - 1 hour after meal glucose >7.5 - AC > 95th centile despite apparent good control
61
when will you start insulin in a pregnant woman who has GDM
pre-meal glucose > 6 1 hour post meal glucose > 7.5 AC > 95th centil despite good control
62
how would you give insulin when the pregnant lady is in labour
sliding scale
63
when is DVT more likely than PE during the pregnancy periods
DVT is more common antenatally
64
when is the highest risk of VTE during pregnancy?
in the puerperium period
65
RF for VTE in pregnancy
All pregnant women are at risk of thrombosis- Increase coagulant factor during pregnancy, decrease anticoagulant activity ``` Congenital thrombophilia Antiphospholipid syndrome age > 35 BMI > 30 parity > 4 varicose veins paraplegia sickle cell disease IBD nephrotic syndrome cardiac disease ``` hperemesis dehydrations lon-haul trael severe infection eg pyelonephritis immobility (>4 days bed rest) pre-eclampsia prolonged labnour excessive blood loss
66
what is the drug of choice? for anti-coagulant during pregnancy?
LMWH
67
what is considered high risk of VTE in antenatal periods
any prev VTE except a single event related to major surgery start antenatal prophylaxis with LMWH
68
what is considered to be the Intermediate risk of VTE in antenatal periods?
Hospital admission Single Previous if ETA related to major surgery High risk thrombophilia and no VTE Medical comorbidities - Cancer, heart failure, activities early, IBD or inflammatory polyarthropathy, nephrotic syndrome, T1DM with nephropathy, sickle cell disease, current IVDU any surgical procedure appendicectomy Ovarian hyperstimulation syndrome If any of the above considerate antenatal prophylaxis of LMWH
69
What is considered to be high risk of VTE in postnatal period
Any previous VTE anyone requiring antenatal LMWH high risk thrombophilia low risk thrombophilia & FHx at least 6 weeks of post-natal prophylactic LMWH
70
What is considered to be intermedate risk of VTE in postnatal period
C-section in labour BMI > 40 readmission or prolonged admiss (> 3 days) in the puerperium any surgical procedure in the peerperium excepy immediate repair of the perineum medical conditions - cancer, HF, active SLE, IBD or inflammatory polyarthropathy, nephrotic syndrome, T1DM with nephropathy, sickle cell disease, current IVDU if any of the above - at least 10 days of post-natal prophylactic LMWH
71
what is the treatment of VTE during pregnancy?
LMWH BD regimen, weight adjusted target range for heparin - 0.35 - 0.7 treatment should continue for 6 months after delivery
72
what is the reason for VBAC
good physical and psychological benefits for both mum and baby VBAc is safer than a repeat C-section repeated C-secton associated with small inc risk of placenta praevia ± accreta in future pregnancies and pelvic adhesion
73
what is the reason against VBAC
must be on the labour ward risk of uterine rupture - v. rare but slight inc in VBAC esp if induction of labour is ultilised CTG is recommended complete C/I if classical cut of C-section
74
what is the management of cardiac disease during pregnancy
symptoms and signs in antepartum and postpartum - fatigue - fainting - chest pain - SOB - difficulty breathing when sleeping - palpitations mx - MDT - early delivery
75
what is the management of epilepsy during pregnancy
mx - MDT - antiepileptics causes --> foetal abnor (NTD, cardiac, facial)

Y4 - GOSH (12 decks)

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