obs Flashcards
What is gestational diabetes and what is it caused by? What are the main complications of gestational diabetes
Gestational diabetes refers to diabetes triggered by pregnancy. It is caused by reduced insulin sensitivity during pregnancy, and resolves after birth.
remember macrosomia and neonatal hypoglycaemia. Babies become accustomed to a large supply of glucose during the pregnancy, and after birth they struggle to maintain the supply they are used to with oral feeding alone
What are the risk factors of gestational diabetes?
The NICE guidelines (2015) list the risk factors that warrant testing for gestational diabetes:
Previous gestational diabetes
Previous macrosomic baby (≥ 4.5kg)
BMI > 30
Ethnic origin (black Caribbean, Middle Eastern and South Asian)
Family history of diabetes (first-degree relative)
How do you know if someone has gestational diabetes?
Everyone who has the rf’s must undergo OGTT
and also when there are features that suggest gestational diabetes:
Large for dates fetus
Polyhydramnios (increased amniotic fluid)
Glucose on urine dipstick
Normal results are:
Fasting: < 5.6 mmol/l
At 2 hours: < 7.8 mmol/l
Results higher than these values are used to diagnose gestational diabetes.
TOM TIP: It is really easy to remember the cutoff for gestational diabetes as simply 5 – 6 – 7 – 8.
What is the NICE mx of women with gestational diabetes?
Fasting glucose less than 7 mmol/l: trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin
Fasting glucose above 7 mmol/l: start insulin ± metformin
Fasting glucose above 6 mmol/l plus macrosomia (or other complications): start insulin ± metformin
Mx in women with pre-existing diabetes in preg?
- 5mg folic acid till week 12
- Retinopathy screening at booking and at 28 weeks - preg can make this worse
- NICE (2015) advise a planned delivery between 37 and 38 + 6 weeks for women with pre-existing diabetes. (Women with gestational diabetes can give birth up to 40 + 6).
- stop oral hypoglycaemic agents, apart from metformin, and commence insulin
What is Uterine atony?
Uterine atony is the failure of the uterus to contract adequately following delivery. Contraction of the uterine muscles during labor compresses the blood vessels and slows flow, which helps prevent hemorrhage and facilitates coagulation.
Causes of PPH ?
“Four Ts” mnemonic:
T – Tone (uterine atony – the most common cause)
T – Trauma (e.g. perineal tear)
T – Tissue (retained placenta)
T – Thrombin (bleeding disorder)
How can you reduce the risks and consequences of pph?
*Treating anaemia during the antenatal period
*Giving birth with an empty bladder (a full bladder reduces uterine contraction)
*Active management of the third stage (with intramuscular oxytocin in the third stage)
*Intravenous tranexamic acid can be used during caesarean section (in the third stage) in higher-risk patients
Rf’s for a PPH:
- Previous PPH
- Prolonged labour
- Polyhydramnios
- Emergency C-section
Plus many more ….
How would you mx a PPH?
You would not - Leave it to your seniors to sort out this mess but if you were a senior :
1. ABCDE - 2 large bore cannulas + bloods + lie lady flat
2. Mechanical: Palpate the uterine fundus to stimulate contractions + catheterise
3. Medical: Oxytocin (slow infusion) 40 units in 500 mls usually, Ergometrine, carboprost and misoprostol
4. Surgical: Intrauterine balloon tamponade – inserting an inflatable balloon into the uterus to press against the bleeding, Uterine artery ligation and last resort is a hysterectomy
What do the medical drugs given during a PPH even do?
Oxytocin (slow injection followed by continuous infusion)
Ergometrine (intravenous or intramuscular) stimulates smooth muscle contraction (contraindicated in hypertension)
Carboprost (intramuscular) is a prostaglandin analogue and stimulates uterine contraction (caution in asthma)
Misoprostol (sublingual) is also a prostaglandin analogue and stimulates uterine contraction
Tranexamic acid (intravenous) is an antifibrinolytic that reduces bleeding
What is a secondary PPH?
24hrs - 12 weeks post partum
This is more likely to be due to retained products of conception (RPOC) or infection (i.e. endometritis).
What is the difference between Pre-eclampsia and Gestational HTN?
Pregnancy-induced hypertension or gestational hypertension is hypertension occurring after 20 weeks gestation, without proteinuria.
Pre-eclampsia is pregnancy-induced hypertension associated with organ damage, notably proteinuria.
What is the Pre-eclampsia Triad?
It is classically a triad of 3 things:
new-onset hypertension
proteinuria
oedema
What is the formal definition of Pre-eclampsia?
new-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of the following:
proteinuria
other organ involvement (see list below for examples): e.g. renal insufficiency (creatinine ≥ 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction
What are the moderate and High-risk factors in Pre-eclampsia?
High-risk factors are:
Pre-existing hypertension
Previous hypertension in pregnancy
Existing autoimmune conditions (e.g. systemic lupus erythematosus)
Diabetes
Chronic kidney disease
Moderate-risk factors are:
Older than 40
BMI > 35
More than 10 years since previous pregnancy
Multiple pregnancy
First pregnancy
Family history of pre-eclampsia
With Pre-eclampisa what can you offer based on certain RF’s?
These risk factors are used to determine which women are offered aspirin as prophylaxis against pre-eclampsia. Women are offered aspirin from 12 weeks gestation until birth if they have one high-risk factor or more than one moderate-risk factors.
What are the Pre-eclampsia Sx?
Headache
Visual disturbance or blurriness
Nausea and vomiting
Upper abdominal or epigastric pain (this is due to liver swelling)
Oedema
Reduced urine output
Brisk reflexes
High blood pressure fucks with the organs so anything can go top shit baso
How does NICE say we go about diagnosing Pre-eclampsia?
BP > 140/90 after week 20 and any of:
*Protein urea (1+ or more on dipstick)
* Organ dysfunction
*Placental dysfunction
Note: Placental growth factor is a protein released by the placenta that functions to stimulate the development of new blood vessels. In pre-eclampsia, the levels of PlGF are low. NICE recommends using PlGF between 20 and 35 weeks gestation to rule-out pre-eclampsia.
What is used for Pre-eclampsia prophylaxis?
Aspirin is used for prophylaxis against the development of pre-eclampsia. It is given from 12 weeks gestation until birth to women with:
A single high-risk factor
Two or more moderate-risk factors
Plus there is continuous monitoring of their BP, Sx and urine dipstick
What is the mx of Pre eclampsia?
Initial: Arrange an emergency secondary care assessment if sus
* Women with over 160/10 are likely to be admitted for obs
Further:
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
If this woman fell down the swiss cheese hole and ended up with eclampsia, what would you do?
Eclampsia refers to the seizures associated with pre-eclampsia. IV magnesium sulphate is used to manage seizures associated with pre-eclampsia.
What are the main post natal MH stuff you will probs see?
Look at the time scale!!!!!
Baby blues is seen in the majority of women in the first week or so after birth
Postnatal depression is seen in about one in ten women, with a peak around three months after birth
Puerperal psychosis is seen in about one in a thousand women, starting a few weeks after birth
