Obstetrics Flashcards
(241 cards)
1
Q
What is the most common site for an ectopic pregnancy?
A
Fallopian tube
2
Q
Where (apart from the fallopian tube) can an ectopic pregnancy implant?
A
- Entrance of the fallopian tube (cornual region)
- Ovary
- Cervix
- Abdomen
3
Q
Name some risk factors for a ectopic pregnancy
A
- Previous ectopic pregnancy
- Previous PID
- Previous surgery to the fallopian tubes
- Intrauterine devices (coils)
- Older age
- Smoking
4
Q
At what weeks of gestation does an ectopic pregnancy typically present?
A
6-8 weeks of gestation
5
Q
What are the classic features of an ectopic pregnancy?
A
- Missed period
- Constant lower abdominal pain in the RIF or LIF
- Vaginal bleeding
- Lower abdominal or pelvic tenderness
- Cervical motion tenderness (pain when moving the cervix during a bimanual examination
6
Q
What are two additional questions to ask if you suspect an ectopic pregnancy?
A
- Dizziness or syncope (blood loss)
- Shoulder tip pain (peritonitis)
7
Q
What is the gold standard investigation for an ectopic pregnancy?
A
Transvaginal ultrasound scan
8
Q
What finding is seen on a transvaginal ultrasound for an ectopic pregnancy?
A
A gestational sac containing a yolk sac or fetal pole may be seen
- Sometimes a non-specific mass is seen within the tube → mass containing an empty gestational sac = ‘blob sign’, ‘bagel sign’ or ‘tubal ring sign’
- A mass representing a tubal ectopic pregnancy = moves separetely to the ovary (mass may look similar to corpus luteum, however, a corpeus luteum = will move with the ovary)
9
Q
Apart from the empty gestational sac, what are other features of an ectopic pregnancy?
A
- Empty uterus
- Fliud in the uterus (may be mistaken as a gestational sac ‘pseudogestational sac’)
10
Q
What is a pregnancy of unknown location (PUL)?
A
PUL = when a woman has a positive pregnancy test + no evidence of pregnancy of the ultrasound
In this scenario, an ectopic pregnancy cannot be excluded, and careful follow up needs to be in place until a diagnosis can be confirmed.
11
Q
What can be tracked to monitor a pregnancy of unkonown location (PUL)?
A
Human chorionic gonadotrophin (hCG)
(The serum hCG level = repeated after 48 hours - to measure the change from baseline)
12
Q
What produces hCG?
A
The syncytiotrophoblast = produces hCG
13
Q
What will happen to the hCG levels from baseline for an intrauterine pregnancy?
A
hCG will double every 48 hours = suggests an intrauterine pregnancy
(This will not be the case in a miscarriage or ectopic pregnancy)
14
Q
What % rise in hCG indicates an intrauterine pregnancy?
A
More than 63% rise in hCG = indicates intrauterine pregnancy
- A repeat ultrasound scan is required after 1 – 2 weeks to confirm an intrauterine pregnancy.
- A pregnancy should be visible on an ultrasound scan once the hCG level is above 1500 IU / l.
15
Q
What % rise in hCG indicates an ectoptic pregnancy?
A
A rise less than 63% = indicates an ectopic pregnancy
(When this happens the patient needs close monitoring and review)
16
Q
What % fall in hCG indicates a miscarriage?
A
More than 50% = likely to suggest miscarriage
A urine pregnancy test = should be performed after 2 weeks to confirm the miscarriage is complete.
17
Q
What is more important than monitoring hCG levels when when present with gynae problems?
A
Monitoring the clinical signs + symptoms = more important than tracking the hGC
Any change in symptoms = needs careful assessment
18
Q
What % rise and fall in hCG levels indicate an intrauterine pregnancy, ectopic and miscarriage?
A
- Rise more than 63% → intrauterine pregnancy
- Rise less than 63% → ectopic pregnancy
- Fall more than 50% → miscarriage
19
Q
What investigation should you perform in all women who present with abdominal pain or pelvic pain - that may be caused by an ectopic pregnancy?
A
Pregnancy test
20
Q
A woman presents with pelvic pain or tenderness and has an positive pregnancy test. Who does she need to be referred to?
A
Early pregnancy assessment unit (EPAU) or gynaecology service
21
Q
What are the 3 options for terminating an ectopic pregnancy?
A
- Expectant management (awaiting natural termination)
- Medical management (methotrexate)
- Surgical management (salpingectomy or salpingotomy)
22
Q
What is the criteria for expectant management for an ectopic pregnancy?
A
- Follow up needs to be possible to ensure successful termination
- The ectopic needs to be unruptured
- Adnexal mass < 35mm
- No visible heartbeat
- No significant pain
- HCG level < 1500 IU / l
23
Q
What is the criteria for methotrexate (medical management) for an ectopic pregnancy?
A
Same as expectant management, except:
* HCG level must be < 5000 IU / l
* Confirmed absence of intrauterine pregnancy on ultrasound
24
Q
How is methotrexate given to a women for medical management of an ectopic pregnancy?
A
Intramuscular injection of methotrexate into the buttock
(Halts the progression of the pregnancy + results in spontaneous termination)
Methotrexate = highly teratogenic (harmful to pregnancy)
25
After medical management (methotrexate) for an ectopic pregnancy, how long should women wait to become pregnant again?
**3 months**
(This is because the harmful effects of methotrexate on pregnancy can last this long)
26
Name two S/Es of methotrexate
* Vaginal bleeding
* Nausea + vomiting
* Abdominal pain
* Stomatitis (inflammation of the mouth)
27
When is surgical management appropriate for an ectopic pregnancy?
When they don't meet the criteria for expectant or medical management
Most patients = will require surgical management
28
What is the criteria for surgical management for an ectopic pregnancy?
* Pain
* Adnexal mass > 35 mm
* Visible heartbeat
* hCG levels > 5000 IU / l
29
What are the 2 surgical management options for an ectopic pregnancy?
**Laparoscopic salpingectomy (first line)**
* GA + key-hole surgery to remove affected fallopian tube with the ectopuc pregnancy inside the tube
**Laparoscopic salpingotomy**
* Used in women at increased risk of infertility due to damage to the other tube. Aim = avoid removing the affected tube
* Increased risk of failure (1 in 5 need further methotrexate or salpingectomy)
30
What drug is given to **rhesus negative women** having **surgical management** of **ectopic pregnancy**?
Anti-rhesus D prophylaxis
31
Define an early and late miscarriage
Miscarriage = spontaneous termination of a pregnancy
* **Early miscarriage** = **before 12 weeks** of gestation
* **Late miscarriage** = **between 12 and 24** weeks of gestation
32
Define missed miscarriage
Fetus is no longer alove - but no symptoms have occurred
33
Define threatened miscarriage
Vaginal bleeding with a closed cervix + a fetus that is alive
34
Define an inevitable miscarriage
Vaginal bleeding with an open cervix
35
Define an incomplete miscarriage
**Retained products of conception** remain in the iterus after the miscarriage
36
Define complete miscarriage
A full miscarriage has occurred - there is no products of conception left in the uterus
37
38
Define an anembryonic pregnancy
A gestational sac is present - but contains no embryo
39
The gold standard Ix for diagnosing a miscarriage
Transvaginal ultrasound scan
40
What are the **3 key features** of a **transvaginal USS** when looking at an **early pregnancy**?
These appear sequentially as the pregnancy develops - as each appears - the previous feature becomes less relevant in assessing the viability of the pregnancy
* **Mean gestational sac diameter**
* **Fetal pole + crown-rump length**
* **Fetal heartbeat**
41
Is the pregnancy considered viable if there is a fetal heartbeat?
Yes
42
At what crown-rump length is then the fetal heartbeat expected?
**7mm** or more
43
What happens when:
* **Crown-rump length = 7mm or more**
* **No fetal heartbeat**
Transvaginal USS = repeated after one week before confirming a **non-viable pregnancy**
44
At what **mean gestational sac diameter** is the **fetal pole** then expected?
**25mm or more**
45
What is concluded if:
* Mean gestational sac diameter of 25mm or more
* No fetal pole
Scan repeated after one week before confirming an **anembryonic pregnancy**
46
A woman with a pregnancy less than 6 weeks gestation presents with bleeding, no pain, no other complications or risk factors (e.g. previous ectopic). What is the management of choice?
**Expectant management**
Involves awaiting the miscarriage without Ix or treatment
(An ultrasound is unlikely to be helpful this early as the pregnancy will be too small to be seen)
* A **repeat urine pregnancy test is performed after 7 – 10 days**, and if **negative**, a **miscarriage** **= confirmed**.
* When bleeding continues, or pain occurs, referral and further investigation is indicated.
47
If a woman presents with a **positive pregnancy test (w/ more than 6 weeks gestation) + bleeding**, what do you do?
Refer to **early pregnancy assessment service (EPAU)**
The early pregnancy assessment unit will arrange an **ultrasound scan** → confirm the **location + viability** of the pregnancy
It is essential always to consider and **exclude** an **ectopic pregnancy**.
48
What are the 3 options for managing a miscarriage?
* **Expectant management** (do nothing and await a spontaneous miscarriage)
* **Medical management (misoprostol)**
* **Surgical management**
49
What is the **first-line** **management** for a **miscarriage** - without risk factors for heavy bleeding or infection?
**Expectant miscarriage**
* 1 – 2 weeks are given to allow the miscarriage to occur spontaneously.
* A **repeat urine pregnancy test** = performed **3 weeks after bleeding + pain settle** to confirm the miscarriage is complete.
50
A woman undergos expectant management for a miscarriage - however she is experiencing persistant and worsening bleeding. What should happen? What may this mean?
Further assessment + **repeat ultrasound**
May indicate an **incomplete miscarriage** → requiring additional management
51
What drug is given in the medical management for a miscarriage?
**Misoprostol** = a **prostaglandin analogue**
* = Binds to prostaglandin receptors + activates them
* **Prostaglandins = soften the cervix + stimulates uterine contractions**
Dose: **Oral** or **vaginal suppository**
52
What are the key S/Es for misoprostol?
* Heavier bleeding
* Pain
* Vomiting
* Diarrhoea
53
What are the 2 surgical options for a miscarriage?
* **Manual vacuum aspiration** under local anaesthetic as an outpatient
* **Electric vacuum aspiration** under general anaesthetic
54
What are the 2 drugs used for the medical management of an ectopic pregnancy and miscarriage?
* Methotrexate
* Misoprostal
55
What drugs are given in the surgical management of a miscarriage?
* **Misoprostal (prostaglandins)** = given before to **soften the cervix**
* **Anti-rhesus D prophylaxis** = given to **rhesus negative women**
56
When is manual vacuum aspiration appropriate to manage a miscarriage?
* **Below 10 weeks** of gestation
* **Parous women** = women that have previously given birth
57
What is the traditional surgical management for a miscarriage?
Electric vacuum aspiration
58
What is an incomplete miscarriage and what is an associated risk?
**Incomplete miscarriage** = occurs when **retained products of conception** **(fetal or placental tissue)** = **remain in the uterus** after miscarriage
**Risk of infection**
59
What are the 2 options for treating an incomplete miscarriage?
* Medical management (**misoprostol**)
* Surgical management (**evacuation of retained products of conception**)
60
What does evacuation of retained products of conception (ERPC) involve?
* Under GA
* **Cervix** = gradually widened using dilators
* Retained products removed through cervix using **vacuum aspiration + curettage (scraping)**
**Key complication = endometritis** (infection of the endometrium)
61
What is classed as **recurrent miscarriage**?
**3 or more consecutive** miscarriages
62
Info: Rate of miscarriages for ages
The risk of miscarriage increases with age, with the rate of miscarriage approximately:
* 10% in women aged 20 – 30 years
* 15% in women aged 30 – 35 years
* 25% in women aged 35 – 40 years
* 50% in women aged 40 – 45 years
63
When are Ix for miscarriages performed?
* Three or more first-trimester miscarriages
* One or more second-trimester miscarriages
64
Name some causes for recurrent miscarriages
* **Idiopathic** (particularly in older women)
* **Antiphospholipid syndrome**
* **Hereditary thrombophilias**
* **Uterine abnormalities**
* **Genetic factors in parents** (e.g. balanced translocations in parental chromosomes)
* Chronic histiocytic intervillositis
* Other **chronic diseases** such as **diabetes**, **untreated thyroid disease** and **systemic lupus erythematosus (SLE)**
65
What is antiphospholpid syndrome?
Antiphospholipid syndrome = a disorder associated with **antiphospholipid antibodies** → where **blood becomes prone to clotting** → patient = in a hyper-**coagulable state**
The main associations:
* **Thrombosis**
* Complications in pregnancy, particularly **recurrent miscarriage**.
66
Aetiology of antiphospholipid syndrome
Antiphospholipid syndrome = occurs:
* On its own
* **Secondary** to an **autoimmune** condition e.g. **systemic lupus erythematosus**
67
What **drugs** are used to **reduce the risk** of **miscarriage** in a woman with **antiphospholipid syndrome**?
* Low dose aspirin
* Low molecular weight heparin (LMWH)
68
Tom Tip
If you remember one cause of **recurrent miscarriages** → remember **antiphospholipid syndrome**.
Consider this in **patients presenting** in exams with **recurrent miscarriages.** There may be a **past history of deep vein thrombosis**.
* **Test** **=** **antiphospholipid antibodies**,
* **Treatment = aspirin + LMWH**
69
A woman presents with 3 consecutive miscarriages (recurrent miscarriages) and a past medical history of a deep vein thrombosis. Underlying diagnosis?
**Antiphospholipid syndrome**
* Test: Antiphospholipid antibodies
* Treatment: Aspirin + LMWH
70
Name a hereditary thrombophilias
* Factor V Leiden (most common)
* Factor II (prothrombin) gene mutation
* Protein S deficiency
71
Name a couple of **uterine abnormalities** that can cause **recurrent miscarriages**
* **Uterine septum** (a partition through the uterus)
* **Unicornuate uterus** (single-horned uterus)
* **Bicornuate uterus** (heart-shaped uterus)
* **Didelphic uterus** (double uterus)
* **Cervical insufficiency**
* **Fibroids**
72
What obstetric complications can chronic histiocytic intervillositis cause?
**Chronic histiocytic intervillositis** = rare cause of **recurrent miscarriage** - particularly in the **second trimester**
Can also lead to:
* **Intrauterine growth restriction** (IUGR)
* **Intrauterine death**
73
What is chronic histiocytic intervillositis and how is it diagnosed?
* **Histiocytes + macrophages** = **build up** in the **placenta** → causing **inflammation** + **adverse outcomes**
* Diagnosis: **placental histology** → showing **infiltrates** of **mononuclear cells** in the **intervillous spaces**
74
What investigations are performed for recurrent miscarriages?
* **Antiphospholipid antibodies**
* Testing for **hereditary thrombophilias**
* **Pelvic ultrasound**
* **Genetic testing** of the **products of conception from the third** or **future miscarriages**
* **Genetic testing** on parents
75
Info: Types of multiple pregnancy
* **Monozygotic**: identical twins (from a single zygote)
* **Dizygotic**: non-identical (from two different zygotes)
* **Monoamniotic**: single amniotic sac
* **Diamniotic**: two separate amniotic sacs
* **Monochorionic**: share a single placenta
* **Dichorionic**: two separate placentas
The best outcomes are with diamniotic, dichorionic twin pregnancies, as each fetus has their own nutrient supply.
76
What is ultrasound used to determine?
(Think of multiple pregnancies too)
* Gestational age
* Number of **placentas (chorionicty) + amniotic sac (amnionicity)**
* Risk of Down's syndrome (as part of the **combined test**)
77
When determining the types of twins using an ultrasound, what are the signs you look for?
* **Dichorionic diamniotic** twins = have a membrane between the twins, with a **lambda sign** or **twin peak sign**
* **Monochorionic diamniotic** twins have a membrane between the twins, with a **T sign**
* **Monochorionic monoamniotic** twins have no membrane separating the twins
78
What are the **risks** to the **mother** for a **multiple pregnancy?**
* Anaemia
* Polyhydramnios
* Hypertension
* Malpresentation
* Spontaneous preterm birth
* Instrumental delivery or caesarean
* Postpartum haemorrhage
79
What are the **risks** to the **fetuses + neonates** when in a **multiple pregnancy**?
* Miscarriage
* Stillbirth
* Fetal growth restriction
* Prematurity
* Twin-twin transfusion syndrome
* Twin anaemia polycythaemia sequence
* Congenital abnormalities
80
What is **twin-twin transfusion syndrome**?
Occurs when the** 2 fetuses** **share** a **placenta**
Callled **feto-fetal transfusion syndrome** in pregnancies with **more than 2 fetuses **
81
What happens in twin-twin transfusion syndrome?
Share a placenta
There is a connection between the blood supplies of the 2 fetuses → one fetus (**recipient**) = receives majority of blood; one fetus (**donor**) = starved of blood
82
What are the complications to the donor and recipient twins in twin-twin transfusion syndrome?
**Recipient**: Receives majority of blood → **fluid overload → heart failure + polyhydramnios**
**Donor**: Starved of blood → **growth restriction + anaemia + oligohydramnios**
**Discrepancy** in **sizes** between fetuses
83
Treatment of twin-twin transfusion syndrome
Referred to a tertiary specialist fetal medicine centre
Severe cases: **Laser treatment** = used to destroy the connection between the two blood supplies
84
What is **twin anaemia polycythaemia sequence**?
Similar to twin-twin transfusion syndrome (but less acute)
**One twin = becomes anaemic; other develops polcythaemia (rased Hb)**
85
What additional Ix do women need for multiple pregancies?
Additional:
* Monitoring for **anaemia (FBC)**
* **Ultrasounds** monitoring **fetal growth restriction, unequal growth, twin-twin transfusion syndrome**
* **Planned birth** is offered
* 2 weekly scans from 16 weeks for monochorionic twins
* 4 weekly scans from 20 weeks for dichorionic twins
86
What drug is given before the delivery of a multiple pregnancy to help mature the lungs?
Corticosteroids
87
What mode of delivery is required for monoamiotic twins?
Elective caesarean section
(Between 32 and 33+6 weeks)
88
What is the recommended mode of delivery for diamniotic twins (aim to deliver between 37 and 37 + 6 weeks)?
* **Vaginal delivery** is possible when the **first baby has a cephalic presentation** (head first)
* **Caesarean section** may be required for the **second baby** after successful birth of the first baby
* **Elective caesarean** is advised when the **presenting twin is not cephalic presentation**
89
Define pre-eclampsia
**New high blood pressure** (hypertension) in pregnancy **with end-organ dysfunction** - notably with **proteinuria** (protein in the urine).
It occurs **after 20 weeks gestation**, when the s**piral arteries of the placenta form abnormally** → leading to a **high vascular resistance in these vessels**.
90
Triad of pre-eclampsia features
HOP:
H - Hypertension
P - Proteinuria
O - Oedema
91
Define **chronic hypertension**
**High blood pressure** that exists **before 20 weeks gestation** and is **longstanding**.
This is not caused by dysfunction in the placenta and is not classed as pre-eclampsia
92
Define **pregnancy-induced hypertension** or **gestational hypertesnsion**
Hypertension occurring after 20 weeks gestation - without proteinuria
93
Define **pre-eclampsia**
**Pre-eclampsia = pregnancy-induced hypertension** associated with **organ damage**, notably **proteinuria**.
94
Define **eclampsia**
When **seizures** occur as a result of pre-eclampsia
95
What is pre-eclampsia caused by?
* Pre-eclampsia = caused by **high vascular resistance** in the **spiral arteries + poor perfusion** of the placenta.
* This causes **oxidative stress** in the placenta → **release of inflammatory chemicals** into the systemic circulation → **systemic inflammation + impaired endothelial function** in the blood vessels
96
What are the **high-risk** factors for pre-eclampsia?
* Pre-existing hypertension
* Previous hypertension in pregnancy
* Existing autoimmune conditions (e.g. systemic lupus erythematosus)
* Diabetes
* Chronic kidney disease
97
What are the **moderate-risk** factors for pre-eclampsia?
* Older than 40
* BMI > 35
* More than 10 years since previous pregnancy
* Multiple pregnancy
* First pregnancy
* Family history of pre-eclampsia
98
What **prophylaxis** should women with **one high-risk factor** OR **more than one moderate-risk factor** for **pre-eclampsia**?
**Aspirin** from **12 weeks gestation until birth**
99
What are the symptoms of pre-eclampsia?
Pre-eclampsia has symptoms of the complications:
* 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
100
What is the diagnostic criteria for pre-eclampsia?
* **Systolic blood pressure** above **140 mmHg**
* **Diastolic blood pressure** above **90 mmHg**
**PLUS** any of:
* **Proteinuria** (1+ or more on urine dipstick)
* **Organ dysfunction** (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia)
* **Placental dysfunction** (e.g. fetal growth restriction or abnormal Doppler studies)
**Proteinuria** can be quantified using:
* **Urine protein:creatinine ratio** (**above 30mg/mmol** is significant)
* **Urine albumin:creatinine ratio** (**above 8mg/mmol** is significant)
101
What testing can you perform to rule-out pre-eclampsa?
NICE recommends: **Placental growth factor (PlGF)** **testing** on one occasion during pregnancy in women suspected of having pre-eclampsia
* **Placental growth factor (PlGF)** = a protein released by the placenta - it stimulates new blood vessel development
* In **pre-eclampsia PlGF levels = low**
* **PlGF between 20-35 weeks gestation = rule-out pre-eclampsia**
102
What drug is used for prophylaxis against the development of pre-eclampsia?
**Aspirin 75mg (12 weeks to birth)**
* A single high-risk factor
* Two or more moderate-risk factors
103
What is monitored in pregnant woman at every antenatal appointment for evidence of pre-eclampsia?
* Symptoms
* Blood pressure
* Urine dipstick for proteinuria
104
What is the management for gestational hypertension (without proteinuria)?
* Treating to aim for a blood pressure below 135/85 mmHg
* Admission for women with a blood pressure above 160/110 mmHg
* Urine dipstick testing at least weekly
* Monitoring of blood tests weekly (full blood count, liver enzymes and renal profile)
* Monitoring fetal growth by serial growth scans
* PlGF testing on one occasion
105
What is the general management for pre-eclampsia?
Similar to gestational hypertension - except:
* **Scoring systems** are used to determine whether to admit the woman (**fullPIERS or PREP‑S**)
* **Blood pressure** is monitored closely (at least **every 48 hours**)
* Urine dipstick testing is not routinely necessary (the diagnosis is already made)
* **Ultrasound monitoring** of the **fetus**, **amniotic fluid** and **dopplers** is **performed two weekly**
106
What is the medical management for pre-eclampsia?
First to third line
* First line: **Labetolol** (antihypertensive)
* Second line: **Nifedipine** (modified-release)
* Third line: **Methyldopa** (needs to be stopped within two days of birth)
* **Intravenous hydralazine** (antihypertensive) in **critical care** in **severe pre-eclampsia** or **eclampsia**
* **IV magnesium sulphate** = given **during labour** and in the **24 hours afterwards** to **prevent seizures**
* **Fluid restriction** = used **during labour** in **severe pre-eclampsia or eclampsia** - to **avoid fluid overload**
107
What is the first line drug for pre-eclampsia while pregnant?
Labetolol
108
Planned early birth may be necessary if the blood pressure cannot be controlled or complications occur in a pregnant woman with pre-eclampsia. What drug is given to help mature the fetal lungs?
Corticosteroids
109
True or false:
Blood pressure will return to normal over time once the placenta is removed
110
What is the first-line, second-line and third-line management for the medical treatment for pre-eclampsia after delivery?
* First line: **Enalapril**
* First-line in black African or Caribbean patients: **Nifedipine** or **amlodipine**
* Third-line: **Labetolol** or **atenolol**
111
What is the first line medical treatment for pre-eclampsia after delivery?
**Enalapril**
Black africian or Caribbean: **Nifedipine** or **amlodipine**
112
What is eclampsia and what is the treatment?
* **Ecampsia** = refers to the **seizures** associated with **pre-eclampsia**
* Management: **IV magnesium sulphate**
113
What drug is used to treat the seizures in eclampsia?
IV magnesium suplate
114
What is HELLP syndrome?
**HELLP syndrome** = combination of **features** that occur as a complication of **pre-eclampsia + eclampsia**
**H**aemolysis
**E**levated **L**iver enzymes
**L**ow **P**latelets
## Footnote
pre-eclampsia with thrombotic microangiopathy. Endothelial dysfunction in the liver leads to platelet aggregation and subsequent microangiopathic haemolytic anaemia.
115
A 23-year-old pregnant woman at 28 weeks gestation reports abdominal pain and a headache. Urinalysis shows proteinuria with a blood pressure of 160/110 mmHg. She is admitted for labetalol.
Diagnosis?
Pre-eclampsia
116
Complications for mother with pre-eclampsia
* **Stroke**
* **Eclampsia** (seizures)
* **HELLP**
* **Pulmonary oedema** (secondary to proteinuria + subsequent hypoalbuminia)
117
Foetal complications associated with pre-eclampsia
* **Intrauterine growth restriction**: occurs in 30% of patients with pre-eclampsia
* **Premature delivery**: iatrogenic if there is evidence of foetal or maternal compromise
* **Placental abruption**
118
What is placenta praevia?
The **placenta** = attached to the **lower portion** of the **uterus** - **lower** than the **presenting part of the fetus**
**Praevia** = latin for 'going before'
119
Definitions for placenta praevia
* **Low-lying placenta** = when the **placenta** is within **20mm** of the **internal cervical os**
* **Placenta praevia** = **placenta is over** the **internal cervical os**
120
Name 3 major causes of **antepartum haemorrhage**
* Placenta praevia
* Placental abruption
* Vasa praevia
121
Name some causes of spotting or minor bleed in pregnancy
* Cervical ectropian
* Infection
* Vaginal abraasions from intercourse or procedures
122
What are risks of placenta praevia?
* Antepartum haemorrhage
* Emergency caesarean section
* Emergency hysterectomy
* Maternal anaemia and transfusions
* Preterm birth and low birth weight
* Stillbirth
123
The grades of placenta praevia
THIS IS OUTDATED - use **low-lying placenta** and **placenta praevia**
* * **Minor praevia (grade I)** = the **placenta** is in the **lower** uterus but not reaching the internal cervical os
* **Marginal praevia (grade II)** = the **placenta** is **reaching** - but not covering the internal cervical os
* **Partial praevia (grade III)** = the **placenta** is **partially covering** the internal cervical os
* **Complete praevia (grade IV)** = the **placenta** is **completely covering** the internal cervical os
124
Risk factors for placenta praevia
* Previous caesarean sections
* Previous placenta praevia
* Older maternal age
* Maternal smoking
* Structural uterine abnormalities (e.g. fibroids)
* Assisted reproduction (e.g. IVF)
125
How does placenta praevia present?
* **Asymptomatic** (many women)
* **Painless vaginal bleeding in pregnancy (antepartum haemorrhage)**
Usually occurs **later in pregnancy** (around or after **36 weeks**)
126
A 32-year-old woman who is 8 months pregnant presents with painless vaginal bleeding and has changed 2 pads in the last hour. She has had a previous caesarian section. Possible diagnosis?
Placenta praevia
127
Definition of placenta praevia
**Placenta praevia** = a cause of **antepartum haemorrhage (bleeding > 24 weeks)** which occurs when the **placenta overlies the lower uterine segment**.
5% of women have a low-lying placenta at their 20-week scan, but only 0.5% at delivery. This is because the **placenta = migrates during pregnancy.**
128
Management for placenta praevia
* **Corticosteroids** = given between **34 and 35 + 6 weeks** gestation → to **mature** the **fetal lungs** - given the risk of preterm delivery.
No active bleeding:
* **Planned Caesarian section** **(36-37 weeks gestation)** → reduce the risk of spontaneous labour + bleeding
* Anti-D immunogobulins
Active bleeding:
* **Resuscitation** **(fluids, +/- transfusion, +/- tranexamic acid)**
* Emergency Caesarean section
* Anti-D immunoglobulins
129
What is required in a woman with **placenta praevia** that is undergoing **premature labour** or **antenatal bleeding**?
Emergency caesarean
130
The main complication of **placenta praevia** is **haemorrhage** before, during and after delivery. When this occurs, urgent management is required and may involve....
* Emergency caesarean section
* Blood transfusions
* Intrauterine balloon tamponade
* Uterine artery occlusion
* Emergency hysterectomy
131
Complications of placenta praevia
**Maternal:**
* **Massive haemorrhage**
* **Disseminated intravascular coagulation (DIC):** bleeding can lead to consumption of clotting factors with susbsequent DIC
**Foetal:**
* **Preterm birth:** Increased risk of prematurity
* **Foetal death**
132
A 32-year-old pregnant woman at 31 weeks gestation presents with abdominal pain, contractions and mild, dark red vaginal bleeding. She is tachycardic and hypotensive. Underlying diagnosis?
Placental abruption
133
What is placental abruption?
When the **placenta = separates** from the **wall during pregnancy** (> 24 weeks)
The **site of the attachment** = can **bleed extensively** after the placenta separates → causing **antepartum haemorrhage**
134
What are the risk factors for placental abruption?
* Previous placental abruption
* Pre-eclampsia
* Bleeding early in pregnancy
* Trauma (consider domestic violence)
* Multiple pregnancy
* Fetal growth restriction
* Multigravida
* Increased maternal age
* Smoking
* Cocaine or amphetamine use
135
What are the types of placental abruption?
* Total → entire placenta
* Partial → only a part of the placenta
* Concealed → if no blood passes through the vagina
(Google
136
Differences & similarities between placenta praevia and placental abruption
**Placenta praevia:**
* Vaginal bleeding > 24 weeks
* **Painless**
* **Bright** red blood
* Bleeding = not concealed
**Placental abruption:**
* Vaginal bleeding > 24 weeks
* **Painful**
* **Dark** red blood
* Bleeding may be concealed
137
What is the typical presentation of placental abruption?
Symptoms:
* **Sudden onset lower severe abdominal pain (constant)**
* Uterine contractions: **Patients often present in labour **
Signs:
* **Dark red** vaginal bleeding; may be concealed instead (**antepartum haemorrhage**)
* **Shock** (tachycardia + hypotension)
* Tender + tense uterus '**woody uterus**' → suggesting **large haemorrhage**
* Abnormalities on **CTG** → indicating **fetal distress**
138
The severities of antepartum haemorrhage
* Spotting: spots of blood noticed on underwear
* Minor haemorrhage: less than 50ml blood loss
* Major haemorrhage: 50 – 1000ml blood loss
* Massive haemorrhage: more than 1000 ml blood loss, or signs of shock
139
What is a concealed abruption?
**Concealed abruption** = where the **cervical os remained closed** → the bleeding remains within the uterine cavity
The severity of bleeding can be significantly underestimated with concealed haemorrhage.
## Footnote
**Concealed** abruption is opposed to revealed abruption → where the blood loss is observed via the vagina
140
How do you diagnose placental abruption?
**Clinical diagnosis** based on presentation
141
What is the important to consider with placental abruption?
It is important to consider **concealed haemorrhage**, where the vaginal bleeding may be disproportionate to the uterine bleeding.
142
What are the initial steps with a major or massive (antepartum) haemorrhage?
* Urgent involvement of a senior obstetrician, midwife and anaesthetist
* 2 x grey cannula
* Bloods include FBC, UE, LFT and coagulation studies
* Crossmatch 4 units of blood
* Fluid and blood resuscitation as required
* CTG monitoring of the fetus
* Close monitoring of the mother
143
Management for placental abruption
Acute bleeding:
* **Resuscitation**: fluids, +/- transfusion, +/- tranexamic acid
* **Emergency caesarian section**
* **Anti-D immunoglobulin**: if rhesus negative
No foetal or maternal compromise:
* **Conservative management: regular monitoring**
* **Corticosteroids + tocolytics (nifedipine = first line)**: if gestational age < 34 weeks; steroids promote foetal lung maturation
* **Vaginal delivery**: >34 weeks with contractions
* **Anti-D immunoglobulin**: given if rhesus negative
144
Complications of placental abruption
Maternal:
* **Massive haemorrhage**: if concealed → hypovolaemic shock out of proportion to visible blood loss
* **Disseminated intravascular coagulation (DIC)**
* Increased risk of **postpartum haemorrhage**
Foetal:
* **Preterm birth**
* **Foetal death**
145
A 32-year-old pregnant woman at 31 weeks gestation presents with abdominal pain, contractions and mild, dark red vaginal bleeding. She is tachycardic and hypotensive. Diagnosis?
Placental abruption
146
Define primigravida
A woman who is pregnant for the first time
147
A 30-year-old primigravida at 36 weeks gestation presents to the emergency department with sudden onset of painless, bright red vaginal bleeding after a gush of clear fluid. Diagnosis?
Vasa praevia
148
What is vasa praevia ?
Where the **fetal vessels** are within the fetal membranes (chorioamniotic membranes) = **travel across the internal cervical os**
Vasa = vessel
Praevia = going before
**Vasa praevia = where the vessels are placef over the internal cervical os - befire the fetus**
149
Info:
* The **fetal membranes** = surround the **amniotic cavity + developing fetus**
* **Fetal vessels = 2 umbilical arteries + 1 umbilical vein**
150
Pathophysiology of vasa praevia
* **Vasa praevia** = cause of **antepartum haemorrhage** (bleeding >24 weeks)
* **Vasa praevia** **= foetal blood vessels cross the internal cervical os**
* Foetal vessels = 2 umbilical arteries + 1 umbilical vein - contained within the chorioamniotic membranes
* **Vasa praevia = foetal vessels** are **unprotected** by the umbilical cord or placental tissue
* These vessels = then **exposed + prone to haemorrhage** - when the **amniotic membranes rupture**
151
2 types of vasa praevia
* **Type I vasa praevia** = the fetal vessels are exposed as a **velamentous umbilical cord**
* **Type II vasa praevia** – the fetal vessels are exposed as they travel to an **accessory placental lobe**
* **Type I vasa praevia:** **Velamentous cord insertion** = the **umbilical vessels insert into the chorioamniotic membranes** = rather than the placental margin
* **Type II vasa praeva:** **Accessory (succenturiate) lobe** = a vessel crosses the internal os to connect the **main placenta** and a smaller, **accessory lobe** of the placenta
152
What layer of soft connective tissue surrounds the blood vessels in the umbilical cord protecting the umbilical vessels?
Wharton's jelly
153
Why can vasa praevia cause an antepartum haemorrhage?
The **foetal vessels** = are **prone to bleeding** - particularly when the **membranes** are **ruptured during labour + birth** → can lead to **foetal blood loss + death**
154
Risk factors for vasa praevia
* Low lying placenta
* IVF pregnancy
* Multiple pregnancy
155
What are the symptoms + signs of vasa praevia?
**Symptom**: **Painless** antepartum vaginal bleeding: this often occurs in the second or third trimester or **after rupture of the membranes**
**Sign**: Foetal distress or death
156
When might vasa praevia be picked up?
* USS during pregnancy → can then plan caesarian section to reduce risk
* Antepartum haemorrage - bleeding during the 2nd or 3rd prgnancy
* Vaginal examination during labour - pulsating fetal vessels = seen in the membranes of through the dilated cervix
* During labour - fetal distress + dark red bleeding
157
What is the primary investigation for vasa praevia?
**Doppler ultrasound**: this can identify the aberrant vessel(s) crossing the internal cervical os
158
Management for vasa praevia
Asymptomatic women:
* **Corticosteroids** = given from **32 weeks** gestation to mature the fetal lungs
* **Elective caesarian section** = planned for 34-36 weeks gestation
**Antepartum haemorrhage: Emergency caesarian section** (before foetal death)
159
What is a molar pregnancy?
A **hydatiidiform mole** (type of tumour) that grows like a pregnancy inside the uterus
2 types of molar pregnancy:
* Complete mole
* Partial mole
Molar pregnancies (MPs; hydatidiform moles) are chromosomally abnormal pregnancies that have the **potential to become malignant.**
160
What a complete molar pregnancy?
**Complete mole = 2 sperm fertilise an ovum that contains no genetic material** (an 'empty ovum')
* These sperm then combine genetic material, and the cells start to divide and grow into a tumour called a **complete mole**
* **No fetal material will form**
161
What is a partial molar pregnancy?
**A partial mole = 2 sperms fertilise a normal ovum** (containing genetic material) at the same time
* The new cell now has **3 sets of chromosomes**
* The cell divides and multiplies into a tumour called a **partial mole**
* In a partial mole, **some fetal material may form**
162
How does a molar pregnancy present?
Molar pregnancy = behaves like a normal pregnancy (periods stop + hormonal changes of pregnancy will occur).
There are a few things that can indicate a molar pregnancy versus a normal pregnancy:
* **More severe morning sickness**
* **VAGINAL BLEEDING**
* **Increased enlargement of the uterus**
* **Abnormally high hCG**
* **Thyrotoxicosis** (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4)
163
Ix for molar pregnancy
* Serum human chorionic gonadotrophin (hCG)
* Pelvic ultrasound ('**snowstorm appearance**')
* Histological examination of placental tissue
164
Management of singleton molar pregnancy
* **Suction evacuation**
* **Hysterectomy** (if not desiring fertility)
* **hCG levels** = **monitored** until they return to normal.
* Occasionally the mole can **metastasise**, and the patient may require **systemic chemotherapy**.
165
What should pregnant women who are high-risk of developing pre-eclampsia take?
Aspirin 75 mg OD
From 12 weeks until birth
166
What are the ranges of hypertension in pregnancy defined as?
Hypertension in pregnancy in usually defined as:
* **systolic > 140 mmHg** or **diastolic > 90 mmHg**
* or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic
167
After establishing that a pregnant woman has hypertension, what are potential groups that it can be categorised into?
* **Pre-existing hypertension** → before 20 weeks gestation
* **Pregnancy-induced hypertension** (PIH, or gestational hypertension) → after 20 weeks gestation (second half of pregnancy)
* **Pre-eclampsia** → also also **proteinuria** (>0.3g/24hrs) + **oedema**
168
What is the management for gestational hypertension?
* First line: Oral **Labetalol**
* Oral **Nifedipine** (if asthmatic) and hydralazine
169
If a woman with pre-existing hypertension, and takes an ACEi or ARB what action should be taken?
**Immediately stop → start alternative (labetalol)**
170
What is pre-existing hypertension?
* A history of **hypertension before pregnancy** OR an **elevated blood pressure > 140/90 mmHg before 20 weeks gestation**
* **No proteinuria, no oedema**
* Occurs in 3-5% of pregnancies and is more **common in older women**
171
What is pregnancy-induced hypertension (PIH, aka gestational hypertension)?
**Hypertension** occurring in the** second half of pregnancy** (i.e. **after 20 weeks**):
* ** Systolic > 140 mmHg** or **diastolic > 90 mmHg**
* or an increase above booking readings of** > 30 mmHg systolic** or **> 15 mmHg diastolic**
* **No proteinuria, no oedema**
* Occurs in around 5-7% of pregnancies
* **Resolves following birth** (typically after one month).
* **Women with PIH are at increased risk of future pre-eclampsia** or hypertension later in life
172
What is pre-eclampsia?
* **Pregnancy-induced hypertension** + **proteinuria (> 0.3g / 24 hours)**
* **Oedema** (may occur but is now less commonly used as a criteria)
* Occurs in around 5% of pregnancies
173
What is oligohydramnios?
**Oligohydramnios = reduced amniotic fluid**
**Less than 500ml at 32-36 weeks** and an **amniotic fluid index (AFI) < 5th percentile**.
174
Name some causes of oligohydramnios
* **Premature rupture of membranes**
* **Potter sequence** (bilateral renal agenesis + pulmonary hypoplasia)
* **Intrauterine growth restriction**
* **Pre-eclampsia**
* Post-term gestation
175
What is polyhydramnios?
polyhydramnios = defined as an excessive accumulation of amniotic fluid during pregnancy.
This condition is typically identified through an ultrasound where the amniotic fluid index (AFI) is greater than 25 cm or the single deepest vertical pocket (SDVP) of amniotic fluid is greater than 8 cm.
176
Name some causes of polyhydramnios
* **Diabetes Mellitus** (particularly **gestational diabetes**): Elevated blood glucose levels in the mother can lead to increased fetal urine production, contributing to polyhydramnios.
* **Fetal Anomalies**: Conditions like esophageal atresia, anencephaly, or neural tube defects can impair the fetus's ability to swallow amniotic fluid, leading to its accumulation.
* **Multiple Pregnancies**: Especially in cases of **twin-to-twin transfusion syndrome (TTTS)**, where one twin receives too much blood flow, resulting in excess urine and amniotic fluid.
* **Infections**: Certain infections during pregnancy, such as cytomegalovirus or toxoplasmosis, can cause polyhydramnios by affecting the fetus.
* **Idiopathic**: In many cases, no clear cause of polyhydramnios can be identified, and it is classified as idiopathic.
* **Placental Issues**: Conditions like placental chorioangioma (a benign tumor of the placenta) can lead to polyhydramnios due to increased blood flow and fluid production.
177
What is the legal framework for a termination of a pregnancy?
**1967 Abortion Act**
(The 1990 Human Fertilisation and Embryology Act = altered and expanded the criteria for an abortion, and reduced the latest gestational age where an abortion is legal from 28 weeks to **24 weeks**)
178
What are the criteria for an abortion?
An abortion can be performed **before 24 weeks** if continuing the pregnancy involves greater risk to the **physical or mental health** of:
* **The woman**
* **Existing children of the family**
The threshold for when the risk of continuing the pregnancy outweighs the risk of terminating the pregnancy is a matter of clinical judgement and opinion of the medical practitioners.
179
When can an abortion be performed at any time during the pregnancy?
* Continuing the pregnancy is likely to risk the life of the woman
* Terminating the pregnancy will prevent “grave permanent injury” to the physical or mental health of the woman
* There is “substantial risk” that the child would suffer physical or mental abnormalities making it seriously handicapped
180
What are the two legal requirements for an abortion?
* **Two registered medical practitioners** must sign to agree abortion is indicated
* It must be carried out by a **registered medical practitioner** in an NHS hospital or approved premise
181
What drugs are used in a medical abortion?
A medical abortion is most appropriate earlier in pregnancy, but can be used at any gestation. It involves two treatments:
* **Mifepristone** (anti-progestogen)
* **Misoprostol** (prostaglandin analogue) 1 – 2 day later
* Mifepristone = anti-progestogen (blocks progesterone) → halting the pregnancy + relaxing the cervix
* Misoprostol = prostaglandin analogue (binds to prostaglandin receptors → activates them). Prostaglandins = soften the cervix + stimulate uterine contractions. From 10 weeks gestation, additional misoprostol doses (e.g. every 3 hours) = required until expulsion
**Rhesus negative** women with a gestational age of **10 weeks or above** having a medical TOP should have **anti-D prophylaxis**.
182
What is involved in a surgical abortion?
Anaesthetic:
* Local
* Local + sedation
* General
Prior to surgical abortion:
* **Cervical priming** medications given → softening + dliating the cervix with **misoprostol**, **mifepristone**, or **osmotic dilators**
* **Osmotic dilators** = devices inserted into the cervix - that gradually expand as they absorb fluid, opening the cervical canal.
2 options for a surgical abortion:
* **Cervical dilatation + suction** of the contents of teh uterus (usually **up to 14 weeks**)
* **Cervical dilatation + evacuation using forceps** (between **14-24 weeks**)
**Rhesus negative women having a surgical TOP should have anti-D prophylaxis**. The NICE guidelines (2019) say it should be considered in women **less than 10 weeks gestation**.
183
What does post-abortion care involve?
* Women may experience **vaginal bleeding + abdominal intermittently up to 2 weeks** after the procedure
* **Urine pregnancy test = performed 3 weeks after the abortion to confirm**
* Contraception + counselling = offered
184
Complications of an abortion
* Bleeding
* Pain
* Infection
* Failure of abortion (pregnancy continues)
* Danage to the cervix, uterus or other structures)
185
What is gestational diabetes?
The underlying cause of GDM is **insulin resistance** due to **hormonal changes** and **increased demand for insulin production**
186
What are some risk factors for gestational diabetes?
* **Obesity**: BMI>30
* **Family history of diabetes**
* **Past medical history of GDM**
* **Advanced maternal age: >40**
* **Ethnicity**: South Asian, Black Afro-Caribbean, Middle Eastern [3]
* **Previous child born large: >4.5kg**
187
What are the clincial features of gestational diabetes?
Many women with GDM may not experience noticeable symptoms
Signs:
* Large for dates uterus
Symptoms:
* Polydipsia (increased thirst)
* Polyuria (increased urination)
* Fatigue
* Dry mouth
* Blurred vision
188
When are women at risk of GDM offered an OGTT?
* Women at risk = 24-28 weeks gestation
* Previous GDM = at booking + again at 24-28 weeks
189
What are the investigations for GDM?
Primary investigations:
* **Oral glucose tolerance test (OGTT)**: used for screening and diagnosis of GDM by assessing the body's response to a glucose load (75g) after an overnight fast. Glucose **levels ≥7.8mmol/L are considered diagnostic for GDM.**
* **Fasting glucose**: glucose levels **≥5.6mmol/L** are considered diagnostic for GDM
* **HbA1c testing:** To monitor blood glucose control in women with **pre-existing diabetes**
* **Fetal ultrasound**: To assess **fetal growth** and wellbeing, and to screen for **potential complications**
Investigations to consider:
**Urine dip**: although not diagnostic, urinalysis is frequently performed throughout pregnancy and glycosuria can be an indication for further GDM testing [2]
190
What glucose levels are diagnostic for GDM, in a OGTT and fasting glucose?
* OGTT: ≥7.8mmol/L
* Fasting glucose: ≥5.6mmol/L
191
What blood test do you use to monitor blood glucose control in a pregnant woman with pre-existing diabetes?
Hb1Ac
192
Management for GDM
Need **four weekly ultrasound scans** to monitor the **fetal growth + amniotic fluid** **volume** from **28 to 36 weeks** gestation.
The initial management suggested by the NICE guidelines (2015) is
* **Fasting glucose less than 7 mmol/l**: trial of **diet + 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 + macrosomia** (or other complications): start **insulin ± metformin**
**Glibenclamide (a sulfonylurea)** = suggested as an option for women who decline insulin or cannot tolerate metformin.
193
What medication is used for pregnant women with GDM who decline insulin or cannot tolerate metformin?
**Glibenclamide** (sulfonylurea)
194
If a woman with pre-existing diabetes wants to become pregnant, what should she take from precomception?
**5 mg folic acid**
(From preconception to 12 weeks gestation)
195
What diabetes medication should pregnant woman with pre-existing type 2 diabetes be on?
**Metformin + insulin**
(Other oral diabetic medications should be stopped)
196
What screening should be performed at booking and at 28 weeks gestation for a pregnant woman with pre-existing diabetes?
**Retinopathy screening** → check for **diabetic retinopathy**
## Footnote
Diabetes carries a risk of rapid progression of retinopathy, and interventions may be required
197
When should planned deliveries be planned for with pregnant women with pre-existing diabetes + GDM
Planned deliveries:
* **Pre-existing diabetes**: between **37 and 38 + 6**
* **GDM**: Up to **40 + 6**
198
What is used in labour for a pregnant woman with type 1 diabetes (or poorly controlled blood sugars with GDM or T2DM)?
**Sliding-scale insulin regime**
A **dextrose + insulin infusion** is titrated to blood sugar levels, according to the local protocol
199
What is a key complication for pregnant mothers with pre-existing diabetes?
**Diabetic retinopathy** → conduct retinopathy screening at booking and at 28 gestation
200
Does GDM improve after birth?
Yes!
Diabetes improves immediately after birth. Women with gestational diabetes can stop their diabetic medications immediately after birth. They need follow up to test their fasting glucose after at least six weeks.
201
What should women with pre-existing diabetes be wary of in the postnatal period?
**Hypoglycaemia** (so they should **lower their insulin doses**)
The insulin sensitivity = will increase after birth and with breastfeeding.
202
What are babies of mothers with diabetes at risk of?
* **Neonatal hypoglycaemia**
* Polycythaemia (raised haemoglobin)
* Jaundice (raised bilirubin)
* Congenital heart disease
* Cardiomyopathy
203
What should be closely monitored in a baby whose mother is diabetic?
Close monitoring for **hypoglycaemia** (with regular blood glucose checks and frequent feeds).
* Aim: maintain blood glucose above 2 mmol/l → if falls below this → need **IV dextrose** of **nasogastric feeding**
204
What are the top 2 comlpications of gestational diabetes for the neonate?
**Macrosomia + 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.
205
How does obesity affect pregnancy?
Obesity = affects pregnancy through various mechanisms, including:
* Insulin resistance
* Increase pro-inflammatory cytokines
* Changes in vascular function
These changes can lead to complications for both mother + baby
206
Classes of obesity (using BMI)
* Class I: BMI 30-34.9
* Class II: BMI 35-39.9
* Class III: BMI ≥40
207
Epidemiology & risk factors of obesity in pregnancy
Obesity affects = 1 in 5 pregnant women in UK
Risk factors:
* Sedentary lifestyle
* High-calorie diet
* Socioeconomic status
* Genetic predisposition
208
What investigations would you carry out in a pregnant woman who is obese?
Primary: **BMI** (height + weight)
Ix to consider:
* **OGTT** (≥7.8mmol/L for GDM)
* **Lipid profile**
209
Management for obesity in pregnancy
First line:
* Lifestyle modifications
* **Folic acid 5mg** starting at least 1 month pre-conception and during the first trimester
Second line:
* **Metformin** (for GDM, if lifestyle changes are insufficent)
210
Name some maternal complications of obesity in pregnancy
* Gestational diabetes
* Pre-eclampsia
* Venous thromboembolism
* Caesarean birth
* Postpartum haemorrhage
* Difficulty breastfeeding
211
Name some foetal complications due to obesity in pregnancy
* Congenital anomalies: spina bifida
* Stillbirth
* Prematurity
* Macrosomia
* Childhood obesity
212
What is a first line medication for obesity in pregnancy?
**Folic acid 5mg**
(Starting at least 1 month pre-conception and during the first trimester)
Spina bifida = a foetal complication of obesity in pregnancy
213
When are pregnant women screened for anaemia when pergnant?
* Booking clinic
* 28 weeks gestation
214
Why are pregnant women screen for anaemia?
During pregnancy → plasma volume = increases → leads to reduced haemoglobin conc.
(**Blood is diluted due to the higher plasma volume**)
215
Why is it important to treat anaemia in pregnancy?
Incase there is significant blood loss during delivery
216
How may a pregnant woman with anaemia present?
* SOB
* Fatigue
* Dizziness
* Pallor
(Often it is asymptomatic)
217
What are the normal ranges of haemoglobin during pregnancy?
* Booking bloods: >110 g/l
* 28 weeks gestation > 105 g/l
* Post partum > 100 g/l
218
What measurement can indicate the cause of anaemia?
**Mean cell volume!** **(MCV)**
219
In pregancy:
What causes can a low, normal and raised MCV indicate?
* **Low MCV** → **iron deficiency**
* **Normal MCV** → **physiological anaemia** (due to increased plasma volume of pregnancy)
* **Raised MCV** → **B12** or **folate deficiency**
220
Apart from MCV, what other tests can be offered to pregnant women at booking?
**Haemoglobinopathy screening**, for:
* **Thalassaemia** (all women)
* **Sickle cell disease** (women at higher risk)
Both are causes of significant anaemia in pregnant
221
A pregnant women presents with SOB, pallor, fatigue and dizziness. You suspect it is anaemia, apart from the MCV, what additional investigations can you perform?
* Ferritin
* B12
* Folate
* **Low MCV** → **iron deficiency**
* **Normal MCV** → **physiological anaemia** (due to increased plasma volume of pregnancy)
* **Raised MCV** → **B12** or **folate deficiency**
222
What is the management for a pregnant woman with iron deficiency anaemia?
**Iron replacement** (e.g. **ferrous sulphate** 200 mg TDS)
When women are **not anaemic**, but have a **low ferritin** (indicating **low iron stores**), they may be started on **supplementary iron**.
223
The **increased plasma volume + B12 requirements** → often result in a **low B12** in pregnancy. What should women with low B12 be tested for?
**Pernicious anaemia**
(Checking for **intrinsic factor antibodies**)
224
What are the management options for low B12 (in pregnancy)?
* **IM hydroxycobalamin**
* Oral **cyanocobalamin**
225
What does of folate acid should all pregnant women be on?
**400 mcg** per day
226
What dose of folic acid should a pregnant woman be on if she is folate deficient?
**Folic acid 5mg** per day
227
What dose should pregnant women with thalassaemia or sickle cell anaemia be on?
**Folic acid 5mg**
(+ close monitoring + transfusions whne required)
228
Why is venous thromboembolisms (VTE) such a common + potentially fatal condition in pregnancy?
Thrombosis = develops in the circulation as a result of:
* **Stagnation of blood**
* **Hypercoagulable states** during pregnancy
229
What is a thrombosis called that develops in the venous circulation called?
Deep vein thrombosis (DVT)
230
How can a DVT turn into a PE?
Thrombosis = mobilises (embolisation) from the deep veins → travels to the lungs → becomes lodged in the pulmonary arteries → This blocks blood flow to related areas of the lungs → = called a pulmonary embolism
231
When is the risk for a PE at its highest (for women that are/ have been pregnant)?
Postpartum period
232
Risk factors for VTE in pregnancy?
Non-modifiable:
* Familiy history of VTE
* IVF pregnancy
* Thrombophilia
* Multiple pregancy
* Gross varicose veins
* Pre-eclampsia
* Parity ≥ 3
* Age > 35 years
Modifiable:
* Smoking
* BMI > 30
* Reduced mobility
233
When should you start VTE prophylaxis in pregnancy?
* **28 weeks**: if there are **3 risk factors**
* **First trimester**: if there are **4 or more risk factors**
234
Under what circumstances is prophylaxis for VTE in pregnancy considered (even in the absence of other risk factors)?
* **Hospital admission**
* **Surgical procedures**
* **Previous VTE**
* Medical conditions such as cancer or arthritis
* High-risk thrombophilias
* Ovarian hyperstimulation syndrome
235
A 28-year-old woman at 28 weeks gestation presents with sudden onset left calf pain and swelling. She has a history of a previous deep vein thrombosis (DVT) after a long-haul flight 5 years ago. She denies chest pain or shortness of breath. Most likely diagnosis?
DVT in pregnancy
236
What are the signs and symptoms of a DVT?
Signs:
* **C**alf tenderness
* **E**rythema
* **O**edema
Symptoms:
* Leg pain: typically unilateral
* Leg swelling
| Signs of DVT - **CEO** (Calf tenderness, Erythema, Oedema)
237
Signs and symptoms of a PE
Signs:
* Tachypnoea
* Tachycardia
* Hypoxic
* Haemoptysis
* Hypotension
Symptoms:
* **Pleuritic chest pain**
* SOB
## Footnote
BP and O2 low → increases HR and RR
238
What are the investigations for VTE in pregnancy (DVT and PE)?
Ix:
* **Compression duplex ultrasound**: direct visualisation of DVT
* **CXR**
* **ECG**: look for evidence of right side heart strain
* **CT pulmonary angiography (CTPA)**: CTPA minimally increases the lifetime risk of maternal breast cance
Investigations to consider:
* **Ventilation-perfusion (VQ) scan**: pulmonary embolism results in perfusion deficit due to blocked blood flow to the lung tissue. V/Q scanning minimally increases the risk of childhood cancer .
* **ABG**: this may show respiratory failure with PE
239
Management for VTE in pregnancy
First line:
* **Low molecular weight heparin (LMWH) (dalteparin, enoxaparin)**: Continued for ≥6 weeks postnatally (treatment totalling 3 months)
* **DOAC or warfarin**: Swicthed to this after delivery
* **Thrombolysis, embolectomy, and unfractionated heparin**: these should be used in cases of **massive PE** with haemodynamic instability
## Footnote
LMWH = doesn't cross the placenta - so is therefore safe for the baby
240
What are the prophylaxis options for VTE in pregnancy?
* From 28 weeks gestation (3 risk factors)
* From first trimester (≥4 risk factors)
First line:
* **LWMH** (Prophylaxis is continued until 6 weeks postnatally, with a temporary pause during labour)
* **Intermittent pneumatic compression**
* **Anti-embolic compression stockings**
241
What are the complications of a VTE in pregnancy (DVT and PE)?
* Recurrent VTE
* Post-thrombotic syndrome
* Chronic thromboembolic pulmonary hypertension
