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Later pregnancy Flashcards

1
Q

What happens to BP across pregnancy

A

Initially is a drop particularly the diastolic then after 20 weeks it returns to pre-gestational levels

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2
Q

Who is at high risk for pre-eclampsia and needs aspirin from week 12 of pregnancy

A

If 1 of
- HTN during previous pregnancy
- CKD
- DM
- autoimmune condition

If 2 of
- family history of pre-eclampsia
- 10 year gap between pregnancy
- multiple pregnancy
- over 40
- BMI over 35

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3
Q

How assess positive proteinuria on dipstick in pregnancy

A

Do PCR OR ACR
Cut offs
- 30 for PCR
- 8 for ACR

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4
Q

Management of chronic HTN in pregnancy

A

Stop thiazides, ARB and ACEi
Continue old treatment unless under 70/110
If over 90/140 start labetalol
CI use nifedipine
Both CI use methyldopa
Give aspirin from week 12 and offer PIGF past week 20 to check for pre-eclampsia
Measure every 2-4 weeks

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5
Q

How to diagnose preterm prelabour rupture of membranes

A

Sterile speculum looking for fluid in posterior vaginal vault
2nd line measure insulin like growth factor binding protein or placental alpha microglobulin 1
Can use USS to help diagnosis by looking for oligohydramnios

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6
Q

How to manage preterm prelabour rupture of membranes

A

Admit
Notify neonatologist
Close monitoring for chorioamnionitis
Antenatal corticosteroids up to 34+0 weeks but can do up to 36
Erythomycin until 10 days post rupture or delivery

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7
Q

What are risks of PPROM

A

Chorioamnionitis to mother
Prematurity, infection, pulmonary hypoplasia

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8
Q

When to suspect chorioamnionitis

A

Clinically
- abdo pain, fever, discharge, RFM
Histologically
- rising CRP and WCC but be careful as steroids can do this

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9
Q

Can magnesium sulphate be given in PPROM

A

If in labour or within 24 hours of planned preterm delivery
- deffo if 24-29+6 weeks
- consider if post 30weeks

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10
Q

Why is magnesium sulphate given in suspected preterm birth

A

Neuroprotective against CP

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11
Q

When should woman with PPROM deliver

A

If no pressing risks to mother or baby then expectant management until 37 weeks

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12
Q

Postnatal mangement if someone with chronic HTN or gestational HTN has given birth

A

Measure BP daily for first 2 days
Once between 3-5 days
Keep below 140/90
Stop methylopa within 2 days

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13
Q

What defines gestational HTN

A

BP over 140/90 past 20 weeks without proteinuria
OR
Increase in 30 systolic or 15 diastolic from booking visit after 20 weeks gestation

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14
Q

Management of gestational HTN

A

If 140/90-159/109 then refer to be seen within 24 hours by obstetrician- use pharmacological agents to reduce below 135/85
If over 160/110 then admit immediately and treat until below 160/110- measuring every 15-30 mins

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15
Q

How are people with gestational HTN monitored

A

Weekly
- BP
-Urine dip
- FBC, LFT and renal function
Every 2 weeks
- USS

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16
Q

Who should be offered placental growth factor

A

Everyone with gestational HTN or chronic HTN post 20 weeks
If low indicates high risk of eclampsia

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17
Q

How can risk prediction in pre-eclampsia be assessed

A

PREP-S prediction model

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18
Q

When admit for pre-eclampsia

A

HTN over 160/110
Rise in creatinie or ALP
Fall in platelets
Signs of impending eclampsia
Signs of impending pulmonary oedema
Fetal compromise signs

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19
Q

If pre-eclampsia how are you monitored

A

If treated as outpatient for mild pre-eclampsia
- BP every 48 hours
- FBC, LFTs, renal function 2x a week
- fetal USS every 2 weeks

If in patient for severe
- FBC, LFTs, renal function 3x a week

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20
Q

How manage an eclamptic fit

A

IV magnesium sulphate IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour
Monitor urine output, reflexes and o2 sats

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21
Q

What is risk of magnesium sulphate mangement

A

Resp depression from hypermagnesaemia

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22
Q

How manage resp depression from pre-eclampsia

A

Calcium gluconate

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23
Q

Other than eclampsia when can consider magnesium sulphate

A

Signs of impending eclampsia
- ongoing headaches
- visual scotomata
- N&V
- epigastric pain
- oligouria

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24
Q

What causes resp depression in mag sulphate treatment

A

Hypermagnesaemia which can be monitored with reflexes and o2 sats

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25
Q

Management plan for premature labour

A

Determine if rupture of membranes
If no rupture just dilation and contractions
- admit for tocolytics and steroids (in case goes into labour)
If rupture
- admit
- steroids if before 34 weeks
- mag-sulphate if before 30
- erythomycin until delivery/10 days
- contact neonatologist

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26
Q

What is HELLP syndrome

A

A complication of pre-eclampsia where get haemolysis, elevated liver enzymes and low platelets

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27
Q

What is the only cure for pre-eclampsia

A

Delivery of baby

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28
Q

In pre-eclampsia what is recommened anaesthetic for labour

A

Epidural as can help lower BP

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29
Q

Risk factors for pre-eclampsia

A

First child
Multiple gestation
Over 35
HTN
Obestiy
DM

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30
Q

What is pathophysiology behind pre-eclampsia

A

Due to abnormal development of the placenta- the spiral arteries become fibrosed and constricted which limits blood flow. This releases pro-inflammatory proteins into mothers circulation leading to systemic vasoconstriction and endothelial injury

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31
Q

What are problems with endothelial injury in pre-eclampsia

A

Microthrombi formation to plug holes
- uses platelets
- microthrombi shear RBC
- therefore HELLP syndrome

Injury leads to fluid loss
- oedema in legs, lungs and brain

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32
Q

What are organs affected by pre-eclampsia

A

Kidneys
- oligouria
- protein loss
Liver
- raised liver enzymes
- swelling and injury
- epigastric pain
Eyes
- scotoma
- blurred vision
- flashing lights
Lungs
- SOB and cough from oedema
Brain
- confusion
- seizures
- headaches

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33
Q

What do with delivery in pre-eclampsia

A

If before 36 weeks continue with surveillance and consider antenatal steroids unless
- sats less than 90
- failure to control BP with 3 anti-hypertensives
- placental abruption
- continuining deterioration of symptoms and blood results
If after 36+6 then deliver within 48 hours

34
Q

How long is magnesium sulphate infusion given for eclampsia

A

24 hours after last seizure or delivery

35
Q

What do if no fetal movements felt by 24 weeks

A

Referral to foetal medicine unit

36
Q

In pregnancy what constitutes reduced fetal movements

A

Normally it is at mothers discretion
Past 28 weeks less than 10 movements within 2 hours

37
Q

If are reduced foetal movements after feeling them pre 24 weeks what is investigation

A

Handheld doppler to identify a heartbeat
No indication for further investigations

38
Q

If reduced foetal movements 24-28 weeks what is management

A

Handheld doppler to identify heartbeat

39
Q

If reduced foetal movements after 28 weeks what do

A

Handheld doppler to identify heartbeat
Even if fine do CTG for 20 minutes
Do USS if suspicion of FGR or SGA looking at abdo circumfrence, estimated foetal weight and amniotic

40
Q

What do if no heartbeat felt on handheld doppler

A

Immediate USS

41
Q

If patient unsure about reduced foetal movements what ask them to do

A

Lie on side for 2 hours and ask them to concentrate on number of foetal movements
Less than 10 a cause for concern

42
Q

What can affect foetal movements felt

A

Less felt when standing up
Person can be easily distracted
Obese less likely to feel
SGA baby
Amniotic fluid volume
Anterior foetal position means less likely to be felt

43
Q

Which medications can reduce foetal movements

A

Benzodiazepams
Opiates

44
Q

Causes of oligohydramnios

A

Premature rupture of membranes
IUGR
Post-term gestation
Pre-eclampsia
Potter sequence
Posterior urethral valve

45
Q

What is potter sequence

A

Bilateral renal agenesis
Pulmonary hypoplasia

46
Q

What defines oligohydramnios

A

Less than 5th centile amniotic fluid index
Less than 500ml at 32-36 weeks gestation

47
Q

When have suspicious SFH measurement what do

A

US to confirm SGA

48
Q

What is fetal fibronectin

A

Protein released from amniotic sac which may indicate impending labour

49
Q

How does false labour present

A

In the last 4 weeks of pregnancy you get contractions in lower abdomen which occur every 20 minutes ans are irregular
Cervical changes are absent

50
Q

How to differentiate false labour from real labour

A

Cervical changes are absent in false labour

51
Q

Management of false labour

A

Cervical examination
Check foetal heart
Reassure and discharge

52
Q

What happens to reflexes in pre-eclampsia

A

Hyperreflexia- very specific sign

53
Q

What is cervical cerclage

A

Tying the cervix to prevent preterm

54
Q

Who is cervical cerclage indicated in

A

3 previous preterm births
Either preterm birth (<34 weeks) or spontaneous second trimester loss AND cervical length under 25mm

55
Q

Who is regular US surveillance to measure cervical length indicated in

A

History of preterm birth or spontaneous loss in second trimester but cervical length over 25mm
If found to go under 25mm pre 24 weeks then do TV cerclage

56
Q

What do if no rfx but cervical length under 25mm

A

Cerclage not indicated

57
Q

What are types of cerclage

A

Transvaginal
Transabdominal which is done laparasocopically

58
Q

Who is a transabdominal cerclage done in

A

Unsuccessful vaginal cerclage attempted
DONE PRECONCEPTION OR EARLY PREGNANCY

59
Q

Who is vaginal progesterone indicated in for prevention of preterm birth

A

History of spontaneous preterm birth or miscarriage in second trimester
Cervical length under 25mm identified between 16-24 weeks

60
Q

When in pregnancy is vaginal progesterone given as prophylaxis of preterm birth

A

16-34 weeks

61
Q

Second line to magnesium sulphate in eclampsia

A

Diazepam or phenytoin

62
Q

What is contraindication for methyldopa

A

Depression history

63
Q

Presentation of intrahepatic cholestasis of pregnancy

A

Itching without rash worse at night
Pale stools and dark urine

64
Q

What is severe sign of intrahepatic cholestasis of pregnancy

A

Malabsorption of Vitamin K leading to coagulopathy

65
Q

Risks of intrahepatic cholestasis of pregnancy

A

Stillbirth
Preterm
Meconium passage

66
Q

How is ICP diagnosed

A

Bile acids over 19
Itching in skin of normal appearance

67
Q

How long after birth should people with ICP have LFTs measured

A

4 weeks
Resolution of LFTs and itching constitutes diagnosis

68
Q

How should ICP be monitored

A

1 week after initial blood tests then on individual basis

69
Q

When give birth with ICP

A

Depends on levels of bile acids
If 19-39: by 40 weeks
If 39-100: 38-39
Over 100: 35-36

70
Q

What is symmetrical versus asymmetrical IUGR

A

In symmetrical is similar growth restriction of head and rest of body
In asymmetrical get sparing of head which maintains growth along expected chart

71
Q

Difference in cause of symmetrical versus asymmetrical IUGR

A

Asymmetrical- placental insufficiency
Symmetrical- maternal malnourishment, infection or congenital abnormalities

72
Q

If have asymmetrical IUGR how are monitored

A

USS every 2 weeks
Doppler USS twice weekly

73
Q

What are causes of large for dates

A

DM
High maternal BMI

74
Q

Problems of large for dates babies

A

Slow labour
High chance of progression to c-section
Trauma to perineum
Shoulder dystocia

75
Q

Causes of FGR

A

Congenital infections
Placental insufficiency
Pre-eclampsia
Smoking
Maternal disease/malnutrition

76
Q

What is most useful measure of fetal growth

A

Abdo circumfrence as where is liver, the babies glycogen store

77
Q

What happens later in life to babies who are born small

A

There is programming of baby where adapts its metabolism to impoverished environment which means increased rates of CVD, obesity and DM

78
Q

How often are bloods monitored a week with severe pre-eclampsia

A

3x

79
Q

If develop chorioamnionitis after PPROM how manage labour

A

Induce in 24 hours

80
Q

What is measured in ICP

A

Bile acids

81
Q

What can be given alongside ECV

A

Beta mimetic such as terbutaline

Obs (9 decks)

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