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Specialties > O&G Written - Other disorders of pregnancy > Flashcards

O&G Written - Other disorders of pregnancy Flashcards

1
Q

USS schedule in multiple pregnancy

A

Monochorionic: every 2 weeks from 16 weeks –> delivery

Diochorionic: every 4 weeks from 20 weeks –> delivery

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2
Q

Important complications of monochorionic twins

A

Twin to twin transfusion syndrome (TTTS)

  • 1 donor becomes anaemic + oligohydramnios
  • 1 recipient becomes overloaded, polycythaemia + polyhydramnios
  • can be fatal for 1 or both
  • Tx = laser ablation of anastomoses
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3
Q

Management of pre-term labour without ROM

A

A-E + resus as needed

Admit

Corticosteroids
Tocolysis - nifedipine, terbutaline
Magnesium sulphate - 4g slow IV injection

+/- in utero transfer to Level 3 NICU facility

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4
Q

Pre-conception management of existing diabetes

A

Glycaemic control

  • offer monthly HbA1c <6.5 = ideal, pregnancy not advised if >10%
  • fasting glucose target = 4-7 (if achievable without hypos)
  • insulin + metformin only

Weight loss if BMI >27

Start 5mg folic acid

Stop statins, swap HTN meds as needed

Refer for diabetic retinopathy & nephropathy assessment

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5
Q

Additional monitoring & appts throughout pregnancy in diabetic

A

<12 weeks = booking appt as normal

20 weeks = anomaly scan + extra cardiac outflow, retinal & renal scanning

28-36 weeks = 4 weekly foetal surveillance

  • USS at 32 and 36 weeks for liquor volume + foetal growth
  • Doppler not recommended unless PET or IUGR

Joint antenatal diabetes clinic every 2 weeks throughout

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6
Q

Delivery in (existing) diabetic pregnant woman?

A

IOL or ELCS between 37 - 39 weeks

  • CS often if baby >4kg
  • sugars controlled with dextrose + insulin infusion
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7
Q

Measures for neonate after birth (diabetic mother)

A

Check blood glucose within 4 hours

Early + regular feeding encouraged

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8
Q

Criteria for gestational diabetes

A

Fasting 5.6 +

2 hour OGTT 7.8+

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9
Q

Management of gestational diabetes

A

2 week trial lifestyle
+ BM monitoring at home twice weekly

Metformin

Insulin (+/- metformin)
- jump straight to this step if fasting glucose >7 or 6-6.9 but complications

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10
Q

Post-partum management of gestational diabetes

A

Stop hypoglycaemic Tx post-natally

Fasting glucose 6-13 weeks later

  • <6 = need annual test, moderate risk for T2DM
  • 6-6.9 = high risk
  • > 7 = 50% chance, offer diagnostic test
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11
Q

General principles of pre-conception planning in cardiac disease

A

Adapt medications to be safe

  • no ACEi, warfarin
  • beta blockers preferred for HTN
  • LMWH e.g. enoxparin

Regular checks for anaemia

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12
Q

Principle of delivery in cardiac disease

A

Wait for SVD
Avoid supine position
Maintain fluids

Epidural / regional anaesthesia - reduces pain related stress + afterload
- BUT contraindicated in severe aortic stenosis

Prophylactic Abx if structural heart defecrt

Minimise duration of 2nd stage - ventouse or forceps

Active management of 3rd stage with syntocin only (no ergometrine)

Very high risk = IOL (but hypotension risk) or CS

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13
Q

Tx of asthma in pregnancy

A

As per normal adult guidelines

  1. SABA
  2. If using 3x/week –> SABA + low dose ICS
  3. SABA + low dose ICS + LTRA (or + LABA)
    - can give ICS + LABA as MART
  4. Increase ICS dose
  5. Trial tioptropium, refer to specialist
  6. Oral corticosteroids

NOTE: if taking regular steroids, will need more during labour (adrenal cortex chronocally suppressed so cannot make more for stress of labour)

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14
Q

Seizure control during pregnancy (known epileptic)

A

Monotherapy at lowest dose possible

Carbamazepine & lamotrigine safest - AVOID sodium valproate.

NOTE: lamotrigine (and levetiracetam) plasma levels fall during pregnancy - may need to increase dose.

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15
Q

Additional management of epilepsy in pregnancy

A

Invite to UK Epilepsy & Pregnancy Register

Counsel:

  • medication adherence
  • risk of congenital abnormalities
  • uncontrolled epilepsy –> foetal hypoxia WORSE than congenital abnormality risk

Folic acid 5mg until 12 weeks

Oral vitamin K 10mg from 36 weeks (if taking enzyme inducing meds)

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15
Q

Additional management of epilepsy in pregnancy

A

Invite to UK Epilepsy & Pregnancy Register

Counsel:

  • medication adherence
  • risk of congenital abnormalities
  • uncontrolled epilepsy –> foetal hypoxia WORSE than congenital abnormality risk

Folic acid 5mg until 12 weeks

Oral vitamin K 10mg from 36 weeks (if taking enzyme inducing meds)

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16
Q

Delivery in epilepsy

A

Mode & timing unaffected unless seizure frequency increasing

Epidural recommended - reduced stress –> reduced seizures

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17
Q

Normal changes in thyroid hormones during pregnancy?

A

TSH falls in first trimeter + free T4 rises

Free T4 falls as pregnancy progresses

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18
Q

Management of hyperthyroidism in pregnancy

A

Propylthiouracil > carbimazole - use lowest doses possible!

  • PTU during 1st trimester
  • CBZ in 2-3rd trimester

33% women can stop Tx during pregnancy but re-adjust postpartum

19
Q

Symptomatic Tx in obstetric cholestasis

A

Ursodeoxycholic acid
Sedating antihistamines e.g. promethazine
Topical emollients

+ vitamin K 10mg oral tail from 36 weeks

20
Q

Other aspects of monitoring & tx in Obstetric cholestasis

A

Consultant led care

Weekly - bi-weeky LFTs + bile acids
2x/week Doppler & CTG until delivery
Advise paying close attention to foetal movements

IOL at 37-38 weeks

6 week follow up with GP to ensure LFTs normalise

21
Q

Main risks of obstetric cholestasis

A

Meconium aspiration
Stillbirth

PPH - low vitamin K
Recurrence 45-90%

22
Q

Main risks of obstetric cholestasis

A

Meconium aspiration
Stillbirth

PPH - low vitamin K
Recurrence 45-90%

23
Q

Antenatal care & planning for obese women

A

Exercise, diet advice BUT advise to maintain not lose weight - impractical during pregnancy + may cause malnutrition

Folic acid 5mg up until 12 weeks
Vitamin D
Aspirin 75-150mg from 12 weeks
OGTT at 24-28 weeks
\+ Thromboprophylaxis if BMI 40+

Delivery:

  • BMI 35+ = high risk, deliver in consultant led unit
  • BMI 40+ = anaesthestic consultation
24
Q

Cut offs for anaemia in pregnancy

A 
115 = non pregnant
110 = early
105 = late
100 = postpartum
25
Q

Pemphigoid gestations - presentation

A

Pruritic bulbous disorder
Late 2nd-3rd trimester
Start on abdomen –> widespread clustered blisters
Spares the face

26
Q

Polymorphic eruption of pregnancy (PEP) - presentation

A 
Pruritic
3rd trimester or immediately post-partum
Lower abdo --> extends to thighs, buttocks, legs, arms
Spares umbilicus
Lesions usually confluent
27
Q

Prurigo of pregnancy - presentation

A

Excoriated papule on extensor surfaces of limbs, abdo, shoulders
Resolves after delivery

28
Q

Criteria for hyperemesis gravidarum

A

Severe N+V of pregnancy that causes:

5% pre-pregnancy weight loss
Dehydration
Electrolyte imbalance

29
Q

Risk factors for hyperemesis gravidarum

A 
Multiple pregnancy
Trophoblastic disease
Hyperthyroidism
Nulliparity
Obesity

Smoking = protective

30
Q

Management of hyperemesis gravidarum

A

1st line = antihistamine e.g. promethazine, cyclizine, prochlorperazine

2nd line = ondansetron or metoclopramide

  • Ondansetron = small increase in cleft lip/palate
  • metoclopramide = EPSE

Steroids if severe/refractory

+/- ADMISSION
+/- parenteral thiamine, IV fluids, VTE prophylaxis

31
Q

Criteria for admission in hyperemesis gravidarum

A

Continued N&V and:

  • unable to keep down liquids or oral antiemetics
  • ketonuria and/or weight loss >5% despite oral antiemetics

Confirmed or suspected comorbidity e.g. unable to keep down Abx for UTI

+ lower threshold for admission if pre-exisitng condition that may be exacerbated e.g. diabetes

32
Q

Symphysis pubis dysfunction / pelvic girdle pain - Tx options

A

Conservative

  • exercises
  • warm baths
  • support belt

Paracetamol

33
Q

Threatened miscarriage - features / findings

A

Vaginal bleeding +/- pain in early pregnancy (<20 weeks)

Closed cervical os

Viable intrauterine pregnancy - gestational sac + foetal heart beat on USS

34
Q

Inevitable miscarriage - features / findings

A

Vaginal bleeding +/- abdo pain

Cervical os open - may contain visible blood

35
Q

Complete miscarriage - features / findings

A

Previous abdo pain + vaginal bleeding with full expulsion of pregnancy tissue

Closed cervical os

Uterus empty on USS

36
Q

Missed miscarriage - features / findings

A

No Sx

Closed cervical os

In utero death - no foetal HR on USS

37
Q

Most common cause of miscarriage?

A

Chromosomal abnormalities - 90%

38
Q

Risk factors for miscarriage

A 
Maternal age
Previous miscarriage
Uterine / cervix pathology
Smoking, EtOH, recreational drugs
Extremes of BMI
39
Q

Recurrent miscarriage - definition + work up

A

3+ miscarriages

Exclude medication conditions - diabetes, SLE, renal

Bloods

  • clotting: factor V leiden, AT-III deficiency
  • Abs: lupus anticoagulant, anti-phospholipid, anti-cardiolipin

Cytogenetic analysis of patient + partner / products of conception

TV USS

39
Q

Recurrent miscarriage - definition + work up

A

3+ miscarriages

Exclude medication conditions - diabetes, SLE, renal

Bloods

  • clotting: factor V leiden, AT-III deficiency
  • Abs: lupus anticoagulant, anti-phospholipid, anti-cardiolipin

Cytogenetic analysis of patient + partner / products of conception

TV USS

40
Q

Management of miscarriage > 6 weeks

A

Any pain, bleeding >6 weeks (or gestation unknown) –> Early pregnancy assessment service / Out of hours gynae

Expectant Tx: 7-14 days, oral hydration + pelvic rest, close follow up.

Medical tx: vaginal misoprostol, anti-emetics, pain relief. Pregnancy test 3 weeks later.

Surgical tx: manual vacuum aspiration under local, surgical ERPC under GA.

+ anti D if Rh -ve mother and >12 weeks OR any surgical Tx

41
Q

Management of miscarriage <6 weeks

A

Bleeding but no pain + no risk factors (e.g. previous ectopic) –> expectant Tx

Pregnancy test in 7-14 days
+ve = review
-ve = miscarriage

42
Q

Important to remember in diagnosing ‘complete’ miscarriage?

A

May actually be a PUL if no previous scan to confirm intrauterine pregnancy

43
Q

Features of miscarriage on USS

A

Crown-rump length >7mm with no heartbeat
OR gestational sac >25mm + no visible foetal pole

BUT cannot diagnose form 1 USS only - get 2nd opinion and/or re-scan in 7 days (14 days for TA USS)

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