O&G - Normal Antenatal Progress / Diabetes

Question 1

In what foods is Folic acid found natuurally?

Answer 1

Folic acid is a vitamin found naturally in:

• Dark green leafy veg e.g. spinach, kale
• Broccoli
• Asparagus
• Eggs
• Citrus fruits e.g. oranges
• Wholegrain
• Yeast
• Some margerine, bread and breakfast cereals (these have folic acid added)

Question 2

Who needs to take Folic acid supplements?

Answer 2

1. Woman planning a pregnancy
2. Pregnant women up to 12-weeks gestation

Question 3

Why do women need to take Folic acid for pregnancy?

Answer 3

1. Low folic acid supply can cause neural tube defects (e.g. spina bifida) and cleft palate
2. Folic acid supply from diet alone is insufficient

Question 4

What is the normal dose for folic acid supplementation i.e. low-risk of NTDs?

Answer 4

400 micrograms daily

Question 5

What is the dose of folic acid to be taken in women at high-risk of conceiving a child with NTD?

Answer 5

5 mg daily

Question 6

What factors can make a woman ‘high-risk’ for concieving a child with a NTD?

Answer 6

1. Previous NTD pregnancies
2. FHx of NTDs
3. Antiepileptic drugs (AEDs e.g. sodium valproate, carbamazepine, lamotrigine)
4. Antifolate drugs e.g. methotrexate (DMARD), trimethoprim (Abx)
5. Obesity (BMI > 30)
6. Diabetes
7. Sickle cell disease
8. Bowel disease e.g. Coeliac or Crohn’s disease

Question 7

What is the most important antigen of the Rhesus system?

Answer 7

D-antigen

Question 8

What can happen if a mother is Rh -ve and her fetus us Rh +ve (first pregnancy)?

Answer 8

If a Rh -ve mother dlivers a Rh +ve child a leak of fetal RBCs can occur (e.g. during delivery) –> this causes anti-D IgG antibodies against the rhesus D antigen on the surface of fetal RBCs

In future Rh +ve pregnancies the mothers anti-D IgG antibodies can cross the placenta –> causing haemolysis of fetal RBCs –> Rhesus disease

Note: this can occur during the 1st Rh +ve pregnancy due to fetal blood leaks when in utero

Question 9

In Rh -ve pregnancies to a Rh +ve what type of antibody is at risk of being produced?

Answer 9

Anti-D IgG antibody

Question 10

How are pregnancies in Rh -ve mothers managed?

Answer 10

1. Screening - all Rh -ve mothers are tested for D antibodies at booking appointment
2. Anti-D immunoglobulin- given to non-sensitised Rh -ve mothers at 28-weeks (or 28-weeks + 34-weeks)

Question 11

How does giving a Rh -ve mother anti-D antibodies prevent rhesus disease?

Answer 11

Anti-D immunoglobulin (IM injection) are cause haemolysis of any fetal RBCs in mothers circulation BEFORE her immune system can become sensitised and produce her own anti-D antibodies

The dose of anti-D immunoglobulin given is insufficient to cause harm to the fetus

Question 12

There are certain situations in which Anti-D immunoglobulin should be given ASAP (always < 72-hrs) - name some of these situations.

Answer 12

Anti-D immunoglobulin given ASAP to prevent Rh -ve mother becoming sensitised to rhesus D antigen:

1. delivery of Rh +ve infant - whether live or stillborn
2. any termination of pregnancy
3. miscarriage - if gestation is > 12-weeks
4. ectopic pregnancy - if managed surgically, if managed medically with methotrexate anti-D is not required
5. external cephalic version (ECV) - process of turning a breech baby to head-first presentation
6. antepartum haemorrhage
7. amniocentesis, chorionic villus sampling, fetal blood sampling
8. abdominal trauma

Question 13

What is Rhesus disease?

Answer 13

Rhesus disease, also called haemolytic disease of the newborn (HDFN)

is the result of a Rh -ve mother with a Rh +ve fetus, producing anti-D antibodies

against the rhesus D antigen present on her fetus’ RBCs –> haemolysis

Question 14

What are the features of Rhesus disease / haemolytic disease of the newborn?

Answer 14

• Haemolytic anaemia
• Jaundice (haemolysis –> ↑ bilirubin)
• Hepatosplenomegaly
• Hydrops fetalis - oedema in 2 or more compartments (e.g. scalp, pericardium, pleura, ascities and skin)
• HF
• Kernicterus - preventable brain dmg in jaundiced newborns due to ↑ bilirubin

Question 15

How does Hydrops Fetalis occur during Rhesus disease?

Answer 15

1. Haemolytic anaemia –> hyperdynamic circulation –> ↑ CO –> left-sided HF –> pulmonary oedema –> pulmonary HTN –> right-sided HF –> ↑ venous hydrostatic pressure –> peripheral oedema + ascites (etc.)
2. Haemolytic anaemia –> physiological extramedullary haematopoiesis (haematopoiesis outside of medulla of bone marrow) occurs in liver to aid bone marrow with blood cell production –> liver dysfunction –> ↓ albumin –> ↓ oncontic pressure –> peripheral oedema + ascites (etc.)

Question 16

If a child is born with heamolytic disease of the newborn due to Rhesus incompatibility what management options are there?

Answer 16

1. Refer to paediatrician for emergency consult
2. Phototherapy for jaundice - specific spectrum of light is used to oxidise bilirubin to make its water-soluable –> clearable in urine / stool
3. Exchange transfusion
4. IVIG

Question 17

Besides folic acid what other supplement is recommended in pregnancy?

Answer 17

Vitamin D

Woman planning pregnancy or currently pregnant should:

• ↑ diet sources of vitamin D
• Take 10mg Vitamin D supplement daily - take for duration of pregnancy + breast-feeding

Question 18

Which women are at greater risk of ↓ vitamin D?

Answer 18

Particular care should be given to the following women - ↑ risk of low vitamin D:

1. Asian
2. Obese
3. Poor diet

Question 19

Antenatal care:

What is a Booking visit?

Answer 19

• 1st appointment a pregnant mother has
• Often at ~ 8-weeks (8-12)
• With midwife
• Purpose = risk-assess:
  
  • Low risk –> managed by mid-wives going forward
  • High risk –> managed by consultant going forward
• Go through long proforma (like MOT) to cover:
  
  • Height, weight, BP, urinalysis (in case of asymptomatic UTI)
  • Blood tests: Hb, platelets, HIV, HBV, syphilis, blood group, rhesus status, sickle cell, haemaglobinopathies et.c
  • Ethnic risks
  • PMH / PSH
  • Med Hx
  • FHx of illness or pregnancy issues
  • Previous pregnancies / births (gravidity, parity)
  • Smoking - personal or family in home
  • Alcohol
  • Illicit drug use
  • Previous obstetric and gynaecological hx including smears
  • Last menstrual period - to estimate due date

Question 20

Name some factors that would make a woman’s pregnancy ‘high-risk’ at their booking appointment?

Answer 20

• Advanced maternal age e.g. > 40-yrs OR low age < 20-yrs
• PMH e.g. diabetes, sickle cell, thalassaemia
• Previous surgeries e.g. caesarean-sections
• IVF treatment
• Previous pregnacy issues e.g.
  
  • HTN, pre-eclampsia
  • growth restriction, diabetes
  • antepartum haemorrhage, postpartum haemorrhage
  • fetal abnormalities, previous stillbirth or miscarriage, premature labour
  • postpartum depression / psychosis

Question 21

Antenatal care:

What is a Growth scan?

Answer 21

Occurs at 10-14 weeks gestation

1. Combined test - combination of scan + blood tests –> screens for aneuploidy (abnormal no. of chromosomes)
   
   • Scan –> measures Nuchal translucency
   • Bloods –> serum B-HCG + PAPP-A (pregnancy associated plasma protein A)
   • Nuchal translucency + maternal age + bloods = risk of aneuploidy conditions
   • If risk of Down’s, Edward’s or Patau’s is > 1 in 150 –> offer diagnostic test
   • It is pt’s choice whether to screen for all, none or a specific one:
     
     • T13 = Patau’s
     • T18 = Edward’s
     • T21 = Down’s
2. Measure fetus size (this is the ‘Dating scan’ which can be done with or without the combined test)

Question 22

What is Quadruple blood screening?

Answer 22

Quadruple blood screening is done to screen for Down’s

• Not as accurate as combined test
• Can be done at 14-20 weeks gestation
• Blood tests = AFP, unconjugated oestriol, beta-HCG and inhibin-A
  
  • AFP = alpha-fetoprotein
  • HCG = human chorionic gonadotrophin
• Done IF:
  
  1. If it was not possible to obtain a nuchal translucency at Growth / Dating scan
     
     • OR
  2. Woman is > 14-weeks into pregnancy

Question 23

Antenatal care:

What is a Dating Scan?

Answer 23

It is a scan done at ~ 12-weeks

to determine fetus age + estimate due date

• Often done at same time as Growth scan

Question 24

Antenatal care:

What is an Anomaly scan?

Answer 24

Anomaly scan occurs at 18-21 weeks

• Checks for structural abnormalities –> if abnormal then detailed scan at fetal medicine unit (FMU)
• Looks for 11 (rare) conditions:
  
  • Edwards (T18) & Patau’s (T13)
  • Anencephaly - absence of telencephalon (majority of brain)
  • Open spina bifida
  • Cleft lip
  • Diaphragmatic hernia
  • Gastroschisis - bowel protrudes through abdominal wall and develops outside body
  • Exomphalos - abdominal wall weakness causing contents to protrude through umbilicus in loose sac
  • Cardiac abnormalities
  • Bilateral renal agenesis
  • Lethal skeletal dysplasia

Question 25

Antenatal care: What / when is the Oral Glucose Tolerance Test (OGTT) in pregnancy?

Answer 25

OGTT is done at **~ 26-weeks** (**24-28 weeks**) * Done if you have **1 or more risk factors for gestational diabetes** (determined at booking appointment) * If woman has had gestational diabetes before --\> OGTT ASAP after booking appointment + 24-28 weeks (if 1st test is normal) * Involves: * Morning blood glucose before food/drink * Then given 75 g glucose drink * 2-hrs later --\> measure blood glucose * Gestational diabetes: * **Fasting** glucose **≥ 5.6** mmol/L * 2-hour (**OGTT**) **≥ 7.8** mmol/L

Question 26

What are the fasting glucose & OGTT thresholds for gestational diabetes?

Answer 26

Gestational diabetes: * **Fasting** glucose **≥ 5.6** mmol/L * 2-hour (**OGTT**) **≥ 7.8** mmol/L

Question 27

What are some risk factors for gestational diabetes?

Answer 27

Gestational diabetes risk factors: 1. **Previous gestational diabetes** 2. **BMI \> 30** kg/m² 3. **Previous baby weight \> 4.5 kg** i.e. 10 lbs (macrosomia = newborn heavier than avg i.e. \> 4 kg) 4. **1st degree relative** with **diabetes** 5. **PCOS** - polycystic ovarian syndrome 6. Ethnicity - **South Asian, black Caribbean** and **Middle Eastern** ANY of the above --\> screen for gestational diabetes (via OGTT) ASAP after booking appointment + at 28-weeks (if 1st was -ve)

Question 28

How is gestational diabetes managed?

Answer 28

If fasting glucose **\< 7** mmol/L at diagnosis then: * **1st** line = **trial of exercise + diet** (low glycaemic food) --\> if glucose targets not met in 1-2 weeks then 2nd line * **2nd** line = **metformin** + diet + exercise --\> if glucose targets not met then 3nd line * **Glibenclamide** - offer if pt can't tolerate metformin or if metformin not working but refuses insulin * **3rd** line = **insulin** + metformin + diet + exercise If fasting glucose **\> 7** mmol/L at diagnosis then: * **1st** line = **insulin** If fasting glucose is between **6.0 - 6.9** + **complications** e.g. macrosomia, hydramnios: * **1st** line = **insulin**

Question 29

How do you manage pre-existing diabetes in a pregnant woman?

Answer 29

1. If BMI **\> 27** kg/m² --\> **weight loss** 2. **Stop oral hypoglycaemic agents** (not metformin) + **commence insulin** 3. **Folic acid 5 mg/day** - from pre-conception to 12-weeks gestation 4. **Detailed anomaly scan** at 20-weeks + four-chamber view of the heart & outflow tracts 5. **Tight glycaemic control** --\> ↓ complication rates 6. **Retinal assessment** - at 1st appointment (booking) + 28/40 7. **Treat retinopathy** - as can worsen during pregnancy

Question 30

What are the blood glucose targets for the following in pregnant women (gestational diabetes or pre-existing): * Fasting glucose * 1 hr after meals * 2 hrs after meals

Answer 30

* **Fasting** glucose target **\< 5.3** mmol/L * **1 hr after** meal target **\< 7.8** mmol/L * **2 hr after** meal target **\< 6.4** mmol/L

Question 31

What are the symptoms of gestational diabetes?

Answer 31

* Polydipsia * Polyuria * Dry mouth * Tiredness

Question 32

How can gestational diabetes affect pregnancy?

Answer 32

* **Macrosomia** - fetus larger than avg --\> can complicate delivery e.g. require induced labour or caesarean section * Macrosomia = risk factor for **shoulder dystocia** (complication of vaginal cephalic delivery) * **Polyhydramnios** - excess amniotic fluid --\> can cause premature labour * **Premature birth** (i.e. \< 37-weeks gestation) * **Pre-eclampsia** - high BP during pregnancy * **Neonatal hypoglycaemia** (↓ glucose post-delivery) * **Stillbirth**

Question 33

If a pregnant woman has has gestational diabetes before when should she have OGTT done?

Answer 33

OGTT **ASAP** after booking appointment (8-12 weeks) then at **24-28 weeks** (if 1st OGTT was normal)

Question 34

When are pregnant women screened for anaemia?

Answer 34

Screen for anaemia: 1. **Booking appointment** (8-12 weeks) **AND** 2. **28-weeks**

Question 35

What are the anaemia cut-offs for pregnant women at the booking appointment and at 28-weeks blood test?

Answer 35

**Booking** Hb **\< 11** g/dl **28-weeks** Hb **\< 10.5** g/dl If Hb is below either of the above cut-off then: * **Investigate** anaemia * Consider **iron supplementation** e.g. ferrous sulphate * Continue iron supplements after anaemia is corrected **for 3/12** + **at least 6/52 pp**

Question 36

When is diagnostic testing for Down's, Edward's and Patau's aneuploidies offered to pregnant women?

Answer 36

If the **screening test** (**combined** **test**) indicates the chance of Down's, Edward's or Patau's is **\> 1 in 150**

Question 37

What diagnostic tests can be used to confirm Down's, Edward's and Patau's?

Answer 37

**Amniocentesis** or **chorionic villus sampling** (CVS) 'cell-free' DNA tests are available privately - these are non-invasive * **~ 0.5 to 1 in 100** diagnostic tests result in **miscarriage** * CVS done between 11-14 weeks * Amniocentesis is done at ~ 15 weeks

Question 38

What physiological changes occur in pregnancy? **Cardiovascular**

Answer 38

* **↑ CO** (due to ↑ HR + ↑ SV) * BP: * **Systolic** BP --\> **stays the same** - if systolic ↑ * **Diastolic** --\> **↓ in 1st / 2nd trimester** then returns to norm by term * Enlarged uterus --\> ↓ venous return --\> can cause: * **Ankle oedema** * **Supine hypotension** * **Varicose veins**

Question 39

What physiological changes occur in pregnancy? **Respiratory**

Answer 39

1. **↑ ventilation** 2. **↑ tidal volume** (from 500 - 700 ml) - effect of progesterone 3. **↓ PCO₂** - oxygen requirements increase by only ~ 20% but ventilation increases disproportionately so more CO₂ is breathed-off 4. **elevated diphragm** - ↑ intra-abdominal pressure due to enlarged uterus

Question 40

What physiological changes occur in pregnancy? **Haematological**

Answer 40

1. **↑ plasma volume** by ~ 50% (mainly 2nd half of pregnancy) - contribute to oedema e.g. ankles 2. **↑ RBC volume** by ~ 20% 3. **Anaemia** - RBC vol ↑ but not as much as plasma vol --\> thus concentration of Hb goes down i.e. anaemia 4. **Small ↑ in clotting factors** - fibrinogen, factors VII, VIII and X --\> **hypercoaguable** state * **↑ risk of VTE** 5. **↓ platelet count** \< 150-400 ×10⁹/L i.e. '**gestational thrombocytopenia**' --\> does NOT carry increased risk of thrombus 6. **↓ in protein S** (endogenous anti-coagulant) 7. ↑ WCC 8. ↑ ESR

Question 41

What physiological changes occur in pregnancy? **Endocrine**

Answer 41

**↑ Thyroxine** (T4) --\> find **warm conditions uncomfortable** (others less noteworthy)

Question 42

What physiological changes occur in pregnancy? **Liver**

Answer 42

1. **↑ ALP** by 50% 2. **↓ Albumin**

Question 43

What physiological changes occur in pregnancy? **Gynaecological**

Answer 43

1. Breast enlargement 2. Areolar pigmentation 3. Utrerine hyperplasia --\> then hypertrophy 4. Cervical gland hypertrophy --\> thick mucus plug 5. Oestrogen --\> ↑ lactiferous duct system for breast-feeding 6. Braxton-Hicks --\> non-painful contractions in late pregnancy ( \> 30-weeks)

Question 44

What physiological changes occur in pregnancy? **Renal**

Answer 44

* ↑ renal blood flow (~30%) + ↑ GFR by 30-60% --\> **urinary frequency** * **↑ urinary protein loss** * **↑ kidney size**

Question 45

What physiological changes occur in pregnancy? **Gastrointestinal**

Answer 45

* Oesophageal relaxation --\> **reflux** * ↑ intra-abdominal pressure --\> **haemorroids** * ↓ bowel motility (progesterone) --\> **constipation**

Question 46

What antenatal recommendations should pregnant women or women planning to be pregnant be given?

Answer 46

1. **Folic acid** - **400 mcg OD**, before conception until 12-weeks * May require 5 mg dose e.g. AEDs 2. **Vitamin D 10mg OD** - more important in darker skin + covering skin due to culture 3. **No alcohol** 4. **Smoking cessation** prior to pregnancy - no varenicline or bupropion in pregnancy or breast-feeding 5. **Listeriosis** - avoid; unpasteurised milk + ripened soft cheese (e.g. Camembert, Brie and blue-veined cheeses) + pate + undercooked meats 6. **Salmonella** - avoid raw / partially cooked egg + meat (especially poultry) 7. Most women are **safe to work** 8. Discuss **maternity rights + benefits** 9. **Air travel** - avoid if: 1. \> 37-weeks + single pregnancy + no risk factors 2. \> 32-weeks + uncomplicated multiple pregnancies 3. ↑ risk of VTE --\> wear compression stockings 10. **Minimise OTC drug** use 11. Continue **moderate exercise** - but avoid; contact sports + scuba 12. Can **continue intercourse**

Question 47

Which is considered the safest anti-epileptic drug to take during pregnancy?

Answer 47

**Lamotrigine** * Only safe compared to other AEDs * ↑ risk of congenital malformations compared to no AED

Question 48

What are the risks associated with NSAIDs during pregnancy?

Answer 48

1. **Oligohydramnios** - less amniotic fluid than norm for gestational age 2. **Premature closure** fetal **ductus arteriosus**

Question 49

When is Nitrofurantoin avoided in pregnancy? Why?

Answer 49

**Nitrofurantoin** should be avoided in pregnancy at **term** i.e. **\> 36/40 weeks** due to association with **haemolytic anaemia** (neonatal haemolysis)

Question 50

Why is **Carbimazole** avoided in pregnancy?

Answer 50

**Carbimazole** is avoided in pregnancy (especially **1st trimester**) due to risk of **aplasia cutis** (rare skin disorder) - it can cross the placenta Aplasia cutis congenita = **congenital absence of skin** e.g. no scalp

Question 51

What is Isotreninoin used for? Why is it avoided in pregnancy?

Answer 51

**Isotreninoin** - is an **acne** medication It is **teratogenic** and thus has a **high risk** of **congenital defects** * Must take **contraception simultaneously** due to teratogenic risk

Question 52

Which of the following medications are safe to take in pregnancy? * Metformin * Propylthiouracil (PTU) * Isotretinoin * Ramipril * Carbimazole * Nitrofurantoin * Amoxicillin * Sodium valproate * Trimethoprim * Cyclizine * NSAIDS * Citalopram * Lamotrigine

Answer 52

1. Metformin 2. Amoxicillin 3. Cyclizine

Question 53

What is the incidence of gestational diabetes?

Answer 53

**2 - 9%** (very common complication of pregnancy)

Question 54

What causes gestational diabetes?

Answer 54

1. Pregnancy --\> **↑ insulin resistance** 2. **↑ anti-insulin hormones** from placenta i.e. 1. **glucagon** 2. **cortisol** 3. **HPL** (human placental lactogen)

Question 55

When can a Growth scan occur during pregnancy?

Answer 55

1st is done at **10-14 weeks** but multiple growth scans can be done throughout pregnancy to monitor the fetus e.g. every **4-weeks** in **diabetic** mothers to monitor for **macrosomia** & **polyhydramnios**

Question 56

When do the majority of VTEs (i.e. DVT / PE) occur during pregnancy?

Answer 56

**3rd trimester**

Question 57

Pregnancy is a hypercoaguable state - why?

Answer 57

1. Small **↑ in some clotting factors** i.e. fibrinogen, VII, VIII and X 2. **↓ in protein S** (endogenous anti-coagulant) 3. **Uterus presses on IVC** causing **venous stasis** in legs

Question 58

How is the ↑ risk of VTE managed in pregnancy?

Answer 58

**Sub-cut** **LMWH** preferred to IV heparin NOT WARFARIN!! NOT DOACS!!

Question 59

What is amniotic fluid index (AFI)?

Answer 59

Amniotic fluid index (AFI) is a quantitative **estimate of amniotic fluid** * An indicator of **fetal well-being** * AFI measured in cm * **Normal** AFI = **8-24 cm** * AFI \< 5-6 = oligohydramnios * AFI \> 24-25 = polyhyramnios

Question 60

What is shoulder dystocia?

Answer 60

Shoulder dystocia = a **complication** of **vaginal cephalic delivery** in which we are **unable to deliver the body**, with the head having already been delivered * Impaction of fetal shoulder on maternal pubic symphysis * Can cause maternal + fetal morbidity: * Maternal - postpartum haemorrhage + perineal tears * Fetal - brachial plexus injury etc.

Question 61

What are the risk factors for shoulder dysotcia?

Answer 61

1. **macrosomia** 2. **↑ maternal BMI** 3. **diabetes** in pregnancy 4. **previous shoulder dystocia** pregnancy 5. **epidural** 6. **instrumental** delivery 7. **induction** of labour 8. **prolonged labour**

Question 62

What is the optimal timing for Lower segment Cesarean section (LSCS)? How does this change if the pt has T1DM or T2DM managed with insulin?

Answer 62

LSCS in **non-diabetic** pt is optimal at **\> 39/40** LSCS for diabetic pt on **insulin by 38/40** * LSCS prior to 39/40 are associated with **↑ risk of ARDS** (acute respiratory distress syndrome)

Question 63

Pts due to have LSCS prior to 39/40 are recommended to recieve what?

Answer 63

**Steroids** --\> for fetal lung maturity (cause ↑ in surfactant) * This should be done with caution in diabetic mothers as steroids --\> hyperglycaemia (peaks 24-48hrs after steroid dose) * Steroids + diabetic mother --\> may need insulin sliding scale

Question 64

What are some risk factors for VTE in pregnant women? Presence of how many-risk fators warrants LMWH?

Answer 64

* Age \> 35 * BMI \> 30 * Parity \> 3 * Smoker * Gross varicose veins * Current pre-eclampsia * Family history of unprovoked VTE * Immobility e.g. paraplegia or hospital admission * Long-distance travel * Current systemic infection (requiring IV Abx or hospital admission) * Low risk thrombophilia * Multiple pregnancy * IVF pregnancy

Question 65

Presence of how many risk factors for VTE warrants immediate LMWH? How long must LMWH be taken in this case?

Answer 65

**4 or more risk factors** for VTE --\> **immediate** LMWH continue LMWH until **6/52 postnatal**

Question 66

If a pt has 3 risk factors for VTE, what action should be taken?

Answer 66

**LMWH** from **28-weeks until 6/52 posnatal**

Question 67

In the management of HTN during pregnancy which medications are avoided + which are commonly used?

Answer 67

HTN medications: Avoided in Pregnancy: 1. **ACE**-**inhibitors** - due to ↑ CV and neuro malformations 2. **ARBs** - similar to ACE-inhibitors 3. **Diuretics** Commonly used in Pregnancy (doesn't necessarily mean they're safe): 1. **Labetalol** (beta-blocker) 2. **Nifedipine** (dihydropyridine calcium channel blocker) 3. **Doxazosin** (alpha-1 receptor antagonist) 4. **Methyldopa** - not often used as anti-hypertensive but is safer than alternatives in pregnancy (acts on CNS to cause ↓ sympathetic tone i.e. vasodilation)

Question 68

What 3 effects does Pregnancy have on Diabetes?

Answer 68

1. **↑ dose of insulin** needed during pregnancy 2. **Worsening nephropathy** and/or **retinopathy** 3. **Increase hypoglycaemic** attacks

Question 69

If a pregnant woman is admitted to hospital during pregnancy what should she be given?

Answer 69

Thromboprophylaxis i.e. **LMWH** Unless specific contraindication e.g. risk of labour or active bleeding

Question 70

What are the features of significant Pre-eclampsia?

Answer 70

* **HTN** - typically **\> 170/110** mmHg * **Proteinuria** - dipstick ++ / +++ * **Headache** * **Visual disturbances** e.g. blurring, flashing in front of eyes * **Papilloedema** * **RUQ / epigastric pain** * Hyperreflexia * Vomiting * May have acute oedema of face, hands or feet (non-specific)

Question 71

What is pre-eclampsia?

Answer 71

Pre-eclampsia is a **hypertensive syndrome** that occurs in pregnant women and is characterised by: 1. **Pregnancy-induced hypertension** (PIH): * BP **\> 140/90** on **two occasions 4-hrs apart** * **\> 20-weeks** gestation 2. **Proteinuria \> 0.3g / 24 hours** or **\> 30** mg/mmol on spot protein:creatinine ratio (**PCR**) Note: pre-eclampsia is a placental disease i.e. no placenta no pre-eclampsia

Question 72

What are '**high**-risk' factors for pre-eclampsia? How are women identified at 'high-risk' of pre-eclampsia managed?

Answer 72

1. **Hypertensive** disease during **previous** **pregnancy** 2. **CKD** 3. **Autoimmune** condition e..g LSE or antiphospholipid syndrome 4. **T1DM** or **T2DM** 5. **Chronic** **HTN** If ANY of the above --\> **75-150 mg Aspirin daily** from **12-weeks until birth**

Question 73

What are '**moderate**-risk' factors for pre-eclampsia? How many 'moderate-risk' factors does a woman need to have to warrant Aspirin?

Answer 73

* **1st pregnancy** * age **\> 40** * pregnancy **interval \> 10**-yrs * **BMI \> 35** at 1st visit * **FHx** of pre-eclampsia * **Multi-fetal** pregnancy If **\> 1** of above --\> **75-150 mg Aspirin daily** from **12-weeks until birth**

Question 74

What complications are associated with pre-eclampsia?

Answer 74

* Fetus: * **prematurity** * **growth retardation** * **Eclampsia** * **Haemorrhage:** * **​**placental abruption * antepartum * intra-abdominal * intra-cerebral * **HF** * **Multi-organ failure**

Question 75

How is pre-eclampsia managed?

Answer 75

1. **Aspirin 75-150 mg daily** from **12-weeks to birth** IF 'high-risk' factor present or \> 1 'moderate-risk' factor 2. Guidelines recommend always treating BP \> 160/110 and treating BP \> 140/90 if it stays elevated * 1st line = **Oral** or **IV Labetalol** (beta-blocker) * 2nd line = **Oral** **Nifedipine** * 3rd line = **Oral Methyldopa** 3. **Fluid restriction** - can reduce risk of pulmonary oedema 4. **Magnesium sulphate** infusion - prevents fits associated with pre-eclampsia / eclampsia

Question 76

When should women with uncomplicated T1DM or T2DM be offered an elective delivery e.g. LSCS?

Answer 76

\< 37-38+6 / 40 weeks

Question 77

In mothers with gestational diabetes when should delivery be offered?

Answer 77

\< 40+6 weeks

Question 78

When do women with gestational diabetes normally stop their glucose reducing agents e.g. metformin / insulin?

Answer 78

Immediately after delivery

Question 79

When should pregnant women with any meternal or fetal complications be offered delivery?

Answer 79

\< 37 /40

Question 80

How often should growth scans be done in diabetic mothers and from when?

Answer 80

Growth scans **every** **4-weeks** from **28-week**s - if mother has diabetes

Question 81

What is **Pregnancy induced hypertension** (PIH)?

Answer 81

**Pregnancy induced hypertension** (PIH) is characterised by: 1. **Hypertension** i.e. **\> 140/90** occuring **after \> 20-weeks** * or increase above booking reading of \> 30 systolic or \> 15 diastolic 2. **NO proteinuria!!** or oedema (the latter is not part of criteria)

Question 82

Does PIH resolve or continue?

Answer 82

PIH often **resolves following birth** (often after 1/12) Women with PIH are at **increased risk** of: * **Pre-eclampsia** - thus regular urine-dip to monitor for proteinuria * **HTN in later life**

Question 83

What is given to manage fits due to pre-eclampsia?

Answer 83

**Magnesium sulphate infusion**

Question 84

What is the Kleihauer test for?

Answer 84

**Kleihauer** test: * Measures **amount** of **fetal haemoglobin** transferred to **mothers bloodstream** * Used on Rh -ve mothers to **determine dose of Anti-D immunoglobulin** to inhibit formation of Rh antibodies