medical problems in pregnancy

Question 1

common symptoms of pregnancy

Answer 1

nausea and vomiting in early pregnancy

heartburn

constipation

haemorrhoids

vaginal discharge

backaches

Question 2

when should nausea and vomiting resolve and what advise should be given to women

Answer 2

resolve spontaneously within 16-20 weeks

should not be associated with a poor pregnancy outcome

Question 3

what treatment can be offered to women who wants to reduce their nausea and vomiting symptoms

Answer 3

non‑pharmacological:
---- ginger
---- P6 (wrist) acupressure
---- eating small but frequent meals
---- avoiding triggers
---- having lots to drink
rest

pharmacological:
—- antihistamines - prometazine, cyclizine or prochlorperazine

Question 4

what advise to give pregnant women complaining about constipation

Answer 4

increase water content

diet modification - bran or wheat fibre supplementation

exercise

Question 5

advise about varicose veins

Answer 5

common symptom of pregnancy that will not cause harm and that compression stockings can improve the symptoms but will not prevent varicose veins from emerging.

Question 6

whst Sx of vaginal discharge might prompt Ix

Answer 6

tch, soreness, offensive smell or pain on passing urine

Question 7

advise for backache during pregnancy

Answer 7

exercising in water, massage therapy and group or individual back care classes

Question 8

what is hyperemesis gravidarum

ass with

Answer 8

the sickness and vomiting are prolonged and very severe.

lacking in fluid in the body (dehydrated) and to lose weight.

vitamin deficiencies.

not able to eat, the pregnant woman can develop signs of starvation

multiple pregnancies
trophoblastic disease
hyperthyroidism
nulliparity
obesity

Question 9

signs of hyperemesis gravidarum

Answer 9

ketones in urine
tachycardia
hypotension

Question 10

RFs that make you more likely to experience N/V

Answer 10

If you are having a female baby.
If this is your first pregnancy.
If you have had - or your mother or sister has had - nausea and vomiting in previous pregnancies.
If you are having twins or another multiple pregnancy.
If you have a history of motion sickness.
If you have a history of migraines.
If you have experienced nausea when taking the combined oral contraceptive pill.
If you are stressed or anxious about something.
If you are obese.
If you are a younger woman

Question 11

why does reflux occur in pregnant women

Answer 11

The increased level of certain hormones that occurs has a relaxing effect on the sphincter muscle. That is, the tightness (tone) of the sphincter is reduced during pregnancy.

The size of the baby in the tummy (abdomen) causes an increased pressure on the stomach.

Question 12

Sx of reflux in pregnant women

Answer 12

Heartburn. This is a burning feeling which rises from the upper tummy (abdomen) or lower chest up towards the neck.

Waterbrash. This is a sudden flow of sour-tasting saliva in your mouth.

Upper abdominal pain or discomfort.
Pain in the centre of the chest behind the breastbone (sternum).
Feeling sick (nausea) and being sick (vomiting).
Bloating.
Quickly feeling ‘full’ after eating.

Question 13

lifestyle modification advise for reflux in pregnant women

Answer 13

avoid triggers

good posture

bedtime

Question 14

what foods to avoid that may prompt pregnancy

Answer 14

Peppermint.
Tomatoes.
Chocolate.
Fatty and spicy foods.
Fruit juices.
Hot drinks.
Coffee.
Alcoholic drinks. (Current advice is t

Question 15

medication for reflux to give pregnant women

Answer 15

antacids - contain Mg or Al ‘as required basis’

contain SODIUM CARBONATE OR MAGNESIUM TRISILLICATE SHOULD BE AVOIDED AS THEY CAN HARM BABY

take it 2 hours before or after iron supplements

alginates

omeprazole

ranitidine

Question 16

Sx of constipation in pregnancy

Answer 16

Opening the bowels less than usual.

Passing hard, pellet-like stools.

Tummy cramps.

Wind.

Question 17

if lifestyle modification for contsipation fails what meds can be given

Answer 17

‘Softening’ laxatives
These simply soften the stools. They tend to cause more wind and are not always helpful in pregnancy. This is because they don’t tend to speed the passage of the stool very well through the bowel.

‘Stimulant’ laxatives
These tend to make the bowel work faster. They are more effective than softening laxatives in pregnancy. However, they can cause cramping pains and wind as they start to work.

Question 18

why can pregnant women feel breathless

Answer 18

diaphragm gets squashed by baby so less space for it to expand

lead to hyperventilation
- panicky, tingly, dizzy and faint.

Question 19

other causes of breathlessness in pregnancy

Answer 19

asthma

anaemia

Question 20

Sx of piles

Answer 20

swollen veins around the back passage
itchy, ache, throb
bleeding

Question 21

what are the Sx of varicose veins in pregnancy

Answer 21

Aching and pain in the legs.

Swelling of the feet and ankles.

Vulval varicose veins, which cause aching and throbbing in the vulval area. This is worse on standing.

Question 22

what is pelvic girdle pain

Answer 22

symphysis pubis is the joint between the two halves of the pelvis at the front - down low, over the front of your bladder. It can become very painful in pregnancy

Question 23

why does pelvic girdle pain occur in pregnant women

Answer 23

joint in the bone can become loosened and the bones separate a little and then rub against one another.

Question 24

Mx pelvic girdle pain

Answer 24

pillow between the knees

exercise
phsiotherapy

Question 25

when should screening for anaemia should take place

Answer 25

booking 28 weeks of gestation

Question 26

level of Hb to diagnsoe anaemia at booking and at 2/3rd tirmester

Answer 26

less than 110 less that 150

Question 27

most common symptoms of anaemia in pregnant women

Answer 27

Fatigue Dyspnoea Dizziness

Question 28

Ix for anaemia in pregnant women

Answer 28

Hb MCV less than 76 normal MCV - (76-96)

Question 29

Mx of anaemia in pregnant women

Answer 29

established iron deficiency anaemia 100-200mg of iron daily should continue for at least three months and at least six weeks postpartum

Question 30

Ix for thalasseamias

Answer 30

MCV ≤80 fl requires investigation, with an HbA2 ≥3.5% being positive for B2-thalassaemia. Chorionic villus sampling in the first quarter of pregnancy and fetal cord blood sampling under ultrasound guidance in the second quarter can be used to detect B2-thalassaemia major, and termination of pregnancy offered.

Question 31

If sickle cell anaemia is suspected what do u do

Answer 31

Where suspected, women should receive folate supplementation of 5 mg per day. FBC should be routinely checked at 20, 28 and 32 weeks.

Question 32

complications of anaemia

Answer 32

``` Maternal death. Fetal death. Premature delivery. Low birth-weight babies. Cardiac failure. Their babies having subsequent developmental problems. Poor work capacity/performance. Susceptibility to infection. ```

Question 33

when can u say a preg woman has had significant exposure to VZV

Answer 33

Significant exposure to chickenpox includes having face-to-face contact, being in the same room for 15 minutes of more, or in a large open ward. It is also important to enquire about contact before the chickenpox rash develops (as infectivity begins 2 days before the onset of the rash until lesions crust).

Question 34

how do you check if women is immune to VZV or not

Answer 34

blood test to VZV

Question 35

If exposure is deemed to be significant and the pregnant woman is non-immune AND <20 WEEKS what do u fo

Answer 35

give VZIG within 10 days of the exposure as it help prevent or attenuate chickenpox IF GESTATION <20 WEEKS

Question 36

If exposure is deemed to be significant and the pregnant woman is non-immune AND >20 WEEKS what do u fo

Answer 36

VZIG or aciclovir within days 7 to 14 after exposure

Question 37

VZV risk to mother

Answer 37

varicella pneumonitis, hepatitis or encephalitis

Question 38

features of fetal varicella syndrome

Answer 38

- Fetal growth restriction - Microcephaly, hydrocephalus and learning disability - Scars and significant skin changes located in specific dermatomes - Limb hypoplasia (underdeveloped limbs) - Cataracts and inflammation in the eye (chorioretinitis) skin scarring eye defects (microphthalmia) limb hypoplasia microcephaly learning disabilities

Question 39

if women gets chickenpox while pregnant

Answer 39

>20 weeks guve aciclovir within 24 hours of onset of the rash

Question 40

RFs of HELLP syndrome

Answer 40

``` Age >35. Nulliparity. Previous gestational hypertension. Multiple pregnancy. Previous HELLP syndrome. Caucasian racial origin. Antiphospholipid syndrome (APS) - 10.5% of patients with HELLP syndrome have APS ```

Question 41

presentation of HELLP syndrome

Answer 41

onspecific symptoms including malaise, fatigue, right upper quadrant or epigastric pain, nausea, vomiting, or flu-like symptoms. worst at night but gets better during the day

Question 42

OE of HELLP

Answer 42

oedema HTN proteinuria

Question 43

Ix of HELLP

Answer 43

Haemolysis with fragmented red cells on the blood film, due to microangiopathic haemolytic anaemia. raised LDH and bilirubin due to destruction of RBCs AST/ALT is also elevated

Question 44

Mx of HELLP

Answer 44

delivery of fetus

Question 45

maternal and fetal complications of HELLP

Answer 45

eclampsia placental abruption DIC AKI fetal perinatal death intrauterine growth restriction

Question 46

causes of jaundice in pregnancy

Answer 46

intrahepatic cholestasis of pregnancy acute fatty liver of pregnancy

Question 47

what is intrahepatic cholestasis of pregnancy

Answer 47

seen in third trimester

Question 48

features of intrahepatic cholestasis of pregnancy

Answer 48

- pruritus, often in the palms and soles - can be skin trauma from intense scratching - no rash (although skin changes may be seen due to scratching) - intense in night - insomnia and malaise - raised bilirubin

Question 49

Mx of intrahepatic cholestasis of pregnancy

Answer 49

maternal Vit K neonatal Vit K ``` Drug treatment to reduce pruritus --- Ursodeoxycholic acid --- Antihistamine --- Calamine - Delivery at fetal maturity LFTS measured weekly until they go into labour - PN f up LFT 10days PN ``` - risk reduced by IOL after 37 weeks if PTT prolonged - Maternal Vitamin K - Neonatal Vitamin K as soon as they born - Fetal surveillance

Question 50

when does acute fatty liver of pregnancy occur

Answer 50

rare complication which may occur in the third trimester or the period immediately following delivery.

Question 51

Features of acute fatty liver of pregnancy

Answer 51

``` abdominal pain nausea & vomiting headache jaundice hypoglycaemia severe disease may result in pre-eclampsia ```

Question 52

Ix of acute fatty liver of pregnancy

Answer 52

ALT above 500u/l

Question 53

Mx of acute fatty liver or pregnancy

Answer 53

support care | once stabilised delivery is the definitive management

Question 54

what is eclampsia

Answer 54

is a serious complication of pre-eclampsia where the high BP causes seizures

Question 55

Mx to prevent exclampsia or treat it

Answer 55

magnesium sulphate in eclampsia an IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour urine output, reflexes, respiratory rate and oxygen saturations should be monitored during treatment respiratory depression can occur: calcium gluconate is the first-line treatment for magnesium sulphate induced respiratory depression treatment should continue for 24 hours after last seizure or delivery (around 40% of seizures occur post-partum) - a woman at moderate or high risk of pre-eclampsia should take aspirin 75mg daily from 12 weeks gestation until the birth - consensus guidelines recommend treating blood pressure > 160/110 mmHg although many clinicians have a lower threshold - oral labetalol is now first-line following the 2010 NICE guidelines. Nifedipine (e.g. if asthmatic) and hydralazine may also be used delivery of the baby is the most important and definitive management step. The timing depends on the individual clinical scenario (AFTER 34 WEEKS SSAME DAY DELIVERY IS AN OPTION) Epidural reduces BP

Question 56

risks of smoking to the baby

Answer 56

- increased risk of miscarriage (increased risk of around 47%) - Increased risk of pre-term labour - Increased risk of stillbirth - IUGR - Increased risk of - sudden unexpected death in infancy

Question 57

risks of alcohol to the baby

Answer 57

Fetal alcohol syndrome (FAS) - learning difficulties - characteristic facies: smooth philtrum, thin vermilion, small palpebral fissures, epicanthic folds, microcephaly - IUGR & postnatal restricted growth Binge drinking is a major risk factor for FAS

Question 58

cocaine risks to the baby

Answer 58

Maternal risks hypertension in pregnancy including pre-eclampsia placental abruption Fetal risk prematurity neonatal abstinence syndrome

Question 59

heroin risk to the baby

Answer 59

Risk of neonatal abstinence syndrome

Question 60

what is placental abrutpion

Answer 60

premature separation of a normally placed placenta before delivery of fetus blood starts collecting between the placenta and the uterus

Question 61

presentation of placental abruption

Answer 61

May present with vaginal bleeding, abdominal pain (usually continuous), uterine contractions, shock or fetal distress ``` shock out of keeping with visible loss pain constant tender, tense uterus normal lie and presentation fetal heart: absent/distressed coagulation problems beware pre-eclampsia, DIC, anuria ```

Question 62

intrahepatic cholestasis increases risks of what

Answer 62

foetal distress intrauterine death maternal morbidity

Question 63

if u see rash in pregnancy what should u rule out

Answer 63

Polumorphic Eruption Pregnancy pemphigoid gestations

Question 64

Ix for obstetric cholestasis

Answer 64

- LFT and Bile acid - Viral screen Hepatitis A, B, and C, Epstein Barr and cytomegalovirus, - Liver autoimmune screen chronic active hepatitis and primary biliary cirrhosis anti-smooth muscle and antimitochondrial antibodies USS abdomen –Liver and Gall stones

Question 65

what will be seen in OC Ix

Answer 65

- Elevated transaminases - Alkaline phosphatase - Raised gamma-glutamyl transferases - Mild elevation in bilirubin - Primary bile acids increased up to 100 fold

Question 66

maternal risks of O Cholestasis

Answer 66

Vit K deficiency - disturbs coagulation pathway | increased risk of PPH

Question 67

fetal risks of OC

Answer 67

- Perinatal mortality is increased to up to 11% - Fetal distress - Meconium - Preterm labour - Intracranial haemorrhage - Stillbirth No effective fetal monitoring available!!

Question 68

what are the procoagulant pathophysiological changes in pregnancy

Answer 68

- Hypercoagulable state - Increase in fibrinogen and factors VIII, IX and X - Concentration of endogenous anticoagulants decreases - Additional risk is present for at least 6 weeks postpartum - Venous stasis in lower limbs - Trauma of pelvic veins at the time of delivery

Question 69

pre-existing risk factors of thromboembolism

Answer 69

- Obesity BMI>30 - Age>35 - Parity>3 - Smoking - Gross varicose veins - Paraplegia - Medical comorbidities - Thrombophilia - Previous VTE

Question 70

obstetric RFs of thromboembolism

Answer 70

``` Multiple pregnancy PET CS Prolonged labour >24 hrs Mid-cavity or rotational operative delivery Still birth Preterm birth PPH>1L ```

Question 71

new onset reversible factors of thromboembolism

Answer 71

``` Bone fracture Surgical procedure in pregnancy and puerperium Hyperemesis, dehydration OHSS/ART Immobility >3 days Long Haul travel >4 hours Current systemic infection ```

Question 72

gold standard Ix of DVT

Answer 72

venography with fetal shield

Question 73

Ix for PE

Answer 73

Chest X-ray often -normal but excludes other causes of breathlessness may - atelectasis, wedge shaped infarction, pleural effusion ECG may only show sinus tachycardia, the classical S1Q3 T3 is rare There may be Leukocytosis Arterial blood gases may show hypocapnia +/- hypoxaemia Oxygen saturation may fall 3-4% after exercise

Question 74

diagnosis can be made w which Ix

Answer 74

lung scan

Question 75

first line Ix for DVTq

Answer 75

doppler

Question 76

suspect PE what do u do

Answer 76

–  clinical assessment –  perform CXR and ECG –  test FBC, U&E, LFTs –  commence LMWH (unless treatment is contraindicated) - Duplex USS for S/S of DVT - VQ scan if chest x-ray normal - CTPA if chest x-ray abnormal

Question 77

Mx of PE

Answer 77

- Full anticoagulation with low molecular weight Heparin, e.g. Dalteparin, /Enoxaparin - TEDS - Leg care advice - Advice re need for future prophylaxis for pregnancy, surgery, flying etc. - In high risk cases consider vena cava filters

Question 78

what is given to women who have epilepsy and want to get pregnant

Answer 78

Epilepsy + pregnancy = 5mg folic acid before conception to reduce neural tube defects

Question 79

``` what is sodium valporate carbamazepine phenytoin lamotrigine ass w ```

Answer 79

sodium valproate: associated with neural tube defects carbamazepine: often considered the least teratogenic of the older antiepileptics phenytoin: associated with cleft palate lamotrigine: studies to date suggest the rate of congenital malformations may be low. The dose of lamotrigine may need to be increased in pregnancy

Question 80

what is given to pregnant women taking phenytoin

Answer 80

Vitamin K | prevent clotting disorders in the newborn

Question 81

associated factors of placental abruption

Answer 81

``` proteinuric hypertension cocaine use multiparity maternal trauma increasing maternal age ```

Question 82

what is the hyperemesis gravidarum triad and this is the diagnosis

Answer 82

5% pre-pregnancy weight loss dehydration electrolyte imbalance

Question 83

when is hyperemesis gravidarum common

Answer 83

between 8-12 weeks may persist upto 20 weeks

Question 84

hyperemesis gravidarum ass

Answer 84

- multiple pregnancies - trophoblastic disease - hyperthyroidism - nulliparity - obesity

Question 85

what is the referral criteria for N&V in pregnancy

Answer 85

- Continued nausea and vomiting and is unable to keep down liquids or oral antiemetics - Continued nausea and vomiting with ketonuria and/or weight loss (greater than 5% of body weight), despite treatment with oral antiemetics - A confirmed or suspected comorbidity (for example she is unable to tolerate oral antibiotics for a urinary tract infection)

Question 86

what is used to classify the severity of nausea and vomitng of pregnancy

Answer 86

Pregnancy-Unique Quantification of Emesis (PUQE)

Question 87

Mx for hyperemesis gravidarum

Answer 87

1) antihistamines - promethazine cyclizine 2) ondansetron and metoclopramide - extrapyramidal side effects

Question 88

complications of hyperemesis gravidarum

Answer 88

``` Wernicke's encephalopathy Mallory-Weiss tear central pontine myelinolysis acute tubular necrosis fetal: small for gestational age, pre-term birth ```

Question 89

in first week of life if breastfeeding baby loses more than 10% of weight what do u do

Answer 89

breastfeeding clinic

Question 90

common breastfeeding problems and their Mx

Answer 90

mastitis mx - flucoxacillin for 10-14 days engorgement mx - just give milk raynauds - no caffein no smoking heat packs

Question 91

what is extrapyramidal side effects

Answer 91

drug-induced movement disorders

Question 92

Ix for hyperemesis gravidarum

Answer 92

- urine dipstick -> ketonuria - MSU - U&Es - hypokalaemia, hyponatraemia, dehydration, renal disease FBC - infection, anaemia, haematocrit Glucose - DKA US scan - confirm viable intrauterine pregnancy - exclude multiple pregnancy and trophoblastic disease TFTS, LFTs, calcium and phosphate, amylase: exclude pancreatitis ABG

Question 93

what is oligohydraminos

Answer 93

reduced amniotic fluid <500 ml at 32-36 weeks AFI <5TH PERCENTILE

Question 94

Causes of oligohydraminos

Answer 94

``` fetal Chromosomal factors. Congenital factors. Intrauterine growth restriction. Post-term pregnancy. Premature ROM (PROM). Fetal demise. ``` placental abruption twin-to-twin transfusion syndrome ``` maternal Maternal dehydration. Uteroplacental insufficiency. Hypertension. Pre-eclampsia. Diabetes (either pre-existing or gestational diabetes). Chronic hypoxia. ``` indometacin adn ACE inhibitors idiopathic

Question 95

Mx of VTE

Answer 95

- Four or more risk factors warrants immediate treatment with low molecular weight heparin continued until six weeks postnatal. If a woman has three risk factors low molecular weight heparin should be initiated from 28 weeks and continued until six weeks postnatal. If diagnosis of DVT is made shortly before delivery, continue anticoagulation treatment for at least 3 month, as in other patients with provoked DVTs.

Question 96

what Mx should be avoided in pregnancy

Answer 96

DOAC | warfarin

Question 97

which antiepileptic safe in pregnancy and is not

Answer 97

Levetiracetam, lamotrigine and carbamazepine NOT sodium valporate phenytoin

Question 98

pre-eclampsia predisposes u to

Answer 98

fetal: prematurity, intrauterine growth retardation eclampsia haemorrhage: placental abruption, intra-abdominal, intra-cerebral cardiac failure multi-organ failure

Question 99

what is rubella

Answer 99

German measles. Congenital rubella syndrome is caused by maternal infection with the rubella virus during the first 20 weeks of pregnancy. The risk is highest before ten weeks gestation. MMR vaccine if in doubt test for rubella immunity can be vaccinated with two doses of the MMR three months apart before conception NOT PREGNANT

Question 100

features of congential rubella syndrome

Answer 100

Congenital deafness Congenital cataracts Congenital heart disease (PDA and pulmonary stenosis) Learning disability

Question 101

what is listeria

Answer 101

infectious gram-positive bacteria that causes listeriosis. high rate of miscarriage or fetal death. It can also cause severe neonatal infection. transmitted by unpasteurised dairy products, processed meats and contaminated foods. Pregnant women are advised to avoid high-risk foods (e.g. blue cheese) and practice good food hygiene.

Question 102

features of CMV

Answer 102

``` Fetal growth restriction Microcephaly Hearing loss Vision loss Learning disability Seizures ``` virus is mostly spread via the infected saliva or urine of asymptomatic children

Question 103

features of toxoplasmosis

Answer 103

Intracranial calcification Hydrocephalus Chorioretinitis (inflammation of the choroid and retina in the eye) faeces from a cat that is a host of the parasite

Question 104

what is parvovirus B19 features

Answer 104

ifth disease, slapped cheek syndrome and erythema infectiosum self limiting -> rash and symptoms usually fade over 1 – 2 weeks. on-specific viral symptoms. After 2 – 5 days, the rash appears quite rapidly as a diffuse bright red rash on both cheeks, as though they have “slapped cheeks”. A few days later a reticular mildly erythematous rash affecting the trunk and limbs appears, which can be raised and itchy. Reticular means net-like.

Question 105

complications of parvovirus B19

Answer 105

Miscarriage or fetal death Severe fetal anaemia - infects the erythroid progenitor cells in the fetal bone marrow and liver Hydrops fetalis (fetal heart failure) Maternal pre-eclampsia-like syndrome -> hydrops fetalis, placental oedema and oedema in the mother. It also features hypertension and proteinuria.

Question 106

Ix for parvovirus B19

Answer 106

IgM to parvovirus, which tests for acute infection within the past four weeks IgG to parvovirus, which tests for long term immunity to the virus after a previous infection Rubella antibodies (as a differential diagnosis)

Question 107

Zika virus

Answer 107

Aedes mosquitos spread by sex with someone infected with the virus. Microcephaly Fetal growth restriction Other intracranial abnormalities, such as ventriculomegaly and cerebellar atrophy Mx viral PCR and ABs to the zika virus

Question 108

how should OC be monitored

Answer 108

Once obstetric cholestasis is diagnosed, it is reasonable to measure LFTs weekly until delivery. Postnatally, LFTs should be deferred for at least 10 days