Obstetrics: Antenatal Care and Diseases in Pregnancy Flashcards
(130 cards)
1
Q
What is a booking visit? When should it be performed?
A
A pregnant woman’s first appointment with a midwife, ideally before 10 weeks (ideal for screening tests)
2
Q
What should be discussed in an antenatal care/ Booking visit?
A
- Place of birth and pregnancy care
- Breastfeeding (can refer to workshops)
- Antenatal classes
- Exercises (e.g. pelvic floor exercises)
- Offer antenatal screening
- Discussion of mental health issues
- Health and lifestyle advice given (e.g. pregnancy vitamins, what foods to avoid, smoking and alcohol cessation)
3
Q
What vitamins are important to take during pregnancy?
A
- Folic Acid 400mcg daily is essential
- Vitamin D is recommended
- Any supplements with Vitamin A should be avoided
4
Q
What foods should be avoided during pregnancy and why?
A
To reduce the risk of food acquired infections women should avoid:
- Milk apart from pasteurised or UHT
- Soft cheeses (e.g. Camembert or Brie)
- Blue veined cheeses
- Pate
- Uncooked/undercooked meals
- Raw or partially cooked eggs (including mayonnaise)
- Raw or partially cooked meat and fish (including sushi)
5
Q
What organisms are the dietary precautions taken in pregnancy meant to avoid?
A
Listeriosis and Salmonella
6
Q
What is the current UK CMO guidance regarding drinking in pregnancy?
A
- Safest approach = not to drink at all
- Increased drinking leads to increased risk to baby
- Mothers drinking above 1-2 units per day during pregnancy put their baby at risk of low birth weight, preterm birth and being small for gestational age
7
Q
What clinical examinations are performed during the booking appointment?
A
- Weight and BMI
- General clinical exam if not already assessed by healthcare in the UK
- Look for signs of domestic violence –> safeguarding
- Breast and Pelvic examination only necessary in FGM (also –> safeguarding)
8
Q
What blood tests should be offered to all pregnant women at 10 week booking appointment?
A
- Anaemia
- Sickle cell
- Thalassemia
- Blood Group and Non-Rhesus Antibodies
- Resus Status and risk of Rhesus Isoimmunisation
- Infection screening (HIV, Syphilis, HBV, Rubella susceptibility)
- Early Down’s Test
N.B: Can also dip urine for Glycosuria, Proteinuria, Haematuria
9
Q
What are the 3 important roles of ultrasound scanning in pregnancy?
A
- Dating (@ 8-14 weeks)
- Nuchal Translucency (@ 11-14 weeks)
- Detailed Anomaly Ultrasound @ (18-21 weeks)
This is why most women get scanned once in the first trimester at 8-14 weeks (for dating + NT) and once during the second (the anomalies scan)
10
Q
What is checked for in the first trimester (dating) scan?
A
- Viability
- Dating
- Multiple pregnancies + Chorionicity
- Nuchal translucency
- Anencephaly
- Large anterior abdominal wall defects
- Cystic Hygroma
11
Q
What could raised Nuchal Translucency indicate?
A
- Foetal heart failure (confirmed with echocardiogram)
- Chromosomal abnormalities (confirmed with blood tests) e.g. Down’s, Patau’s, Edward’s
12
Q
What is checked for in the second trimester (anomaly) scan?
A
- Anencephaly
- Open spina bifida
- Cleft lip
- Diaphragmatic hernia
- Gastroschisis
- Exomphalos
- Serious cardiac abnormalities
- Bilateral renal agenesis
- Lethal skeletal dysplasia (lethal as they prevent the chest and lungs from developing normally)
- Edward’s (T18)
- Patau’s (T13)
Also check for growth, viability, liquor volume, placental location
13
Q
What is the difference between Gastroschisis and Omphalocele?
A
Both are rare birth defects where abdominal content exists outside of the abdominal wall:
- In G the abdominal contents are outside the abdomen through a hole in the wall
- In O they are outside the wall but remain within the confines of a sac
14
Q
How do you screen for gestational diabetes?
A
Based on a risk assessment incorporating…
- BMI > 30
- Previous macrosomic baby (>4.5kg) OR Previous gestational diabetes
- First degree relative with diabetes
- Ethnicity (south Asian, middle eastern, black Caribbean)
15
Q
What are the symptoms of gestational diabetes?
A
Same as most diabetes:
- Excessive thirst
- Frequent urination
- Nausea
- Fatigue
- Blurry vision
- Infections (e.g. skin, vagina)
16
Q
How do you screen for pre-ecampsia?
A
At Booking appointment look for risk factors:
- Age 40+
- Nulliparity
- Pregnancy interval of more than 10 years
- Family or previous history of pre-eclampsia
- BMI of 30+
- Pre-existing HTN
- Pre-existing renal disease
- Multiple pregnancies
All women get a BP and Urinalysis (checking for proteinuria) test at every screen.
17
Q
What are the symptoms of pre-eclampsia?
A
- Severe headaches
- Visual problems e.g. blurring and flashing lights
- Severe heartburn
- Pain below the ribs
- Nausea or Vomiting
- Fluid retention (e.g. oedema at ankles)- look especially for a sudden increase as most women retain a bit of fluid.
All pregnant women should be educated about these symptoms as part of booking appointment so they know to seek advice
18
Q
At what point do you treat pre-eclampsia?
A
SBP:
- 160+, admit and treat
- 150-159 on two consecutive readings 4 hours apart, consider treatment
DBP:
- 110+, admit and treat
- 90-109. on two consecutive readings 4 hours apart, increase surveillance
Significant proteinuria (1+), increased surveillance.
19
Q
If NT measurement is not feasible OR women comes to you after 14 weeks for first scan what can you offer to screen for trisomy?
A
Serum Screening Quadruple Test. Only screens for Down’s, is not as accurate.
Edward’s and Patau’s can be screened for in the second trimester abnormalities scan.
20
Q
What is the ‘combined test’?
A
First trimester scan (11 weeks to 13 weeks 6 days).
Method that combines Nuchal Translucency + B-hCG + PAPP + Patient age to calculate risk of baby being born with T13/18/21
21
Q
What is PAPP?
A
Pregnancy Associated Plasma Protein.
Low levels of PAPP are linked to small gestational age, but most importantly to T13/T18/T21.
22
Q
If the combined test indicates high risk baby has a trisomy, what tests can be used to confirm diagnosis?
A
Chorionic Villus Sampling and Amniocentesis.
23
Q
In summary, how can you test for trisomy in pregnancy?
A
- First trimester scan using combined method (NT +b-hCG + PAPP)
- After 14 weeks, Quadruple test for Down’s
- Anomaly screen for Patau and Edward
- CVS and Amnio confirm diagnosis
24
Q
What limits US screening for trisomies?
A
- Type of foetal abnormality
- Patient BMI
- Position of the baby at the time of scan
25
What is the purpose of screening for foetal anomalies?
- Reproduction choice e.g. termination
- Allows parents to prepare (treatment/disability/palliative care)
- Managed birth at specialist centre
- Intrauterine therapy
26
What are the three forms of hypertension in pregnant women?
- Essential Hypertension (either exists pre-pregnancy or just in first 20 weeks)
- Pregnancy Induced Hypertension
- Pre-Eclampsia
27
What distinguishes pregnancy induced HTN (aka Gestational HTN) from Pre-Eclampsia?
Proteinuria (present in PE, absent in GHTN)
28
What distinguishes essential Hypertension from Pre-Eclampsia or GHTN?
The role of the placenta- both Pre-Eclampsia and GHTN are caused by placental disfunction, whereas primary or essential HTN is unrelated and actually normally resolves around 20 weeks when the placenta fully develops.
29
What is hypertension in pregnancy a manifestation of?
Placental disease.
30
How does the placenta normally develop, and how is this process disrupted in a way that causes hypertension?
Normally:
- Placenta grows Chorionic Villi
- Mother's spiral arteries respond to this by remodelling/relaxing
- Leading to a low resistance system which bathes the CV in maternal blood, supplying the baby
In HTN:
- Insufficient trophoblast invasion
- Lack of Spiral artery remodelling/relaxing
- High resistance system
- Causes maternal HTN
31
In mothers with essential hypertension/existing hypertension at time of pregnancy, what medications must they stop taking?
Any ARBs or ACE inhibitors, can damage baby's kidneys.
32
What should be looked for in the booking visit to manage HTN?
- Essential hypertension
| - Risk factors for Pre-Eclampsia
33
What are the moderate risk factors for Pre-Eclampsia and at what point do you offer intervention?
- Premiparous
- Age over 40
- BMI over 35
- Family History
- Twin pregnancy
- Pregnancy interval greater than 10 years
Give aspirin when patient has 2+
34
Why is first pregnancy or 10 year interval in pregnancy a RF for pre-eclampsia?
Spiral arteries aren't used to forming placental system, therefore more likely to fail to remodel
35
What are the serious risk factors for Pre-Eclampsia and at what point do you offer intervention?
- HTN in previous pregnancy
- CKD
- Diabetes
- SLE
- Chronic Hypertension
Give aspirin when patient has 1
36
What prophylactic therapy is offered to mothers at risk of pre-eclampsia
Aspirin, 150mg, from 12 weeks until delivery.
Should also safety net by reiterating the symptoms of (pre-)eclampsia.
37
What does epigastric pain in Pre-eclampsia indicate
Liver involvement, serious case and at risk of serious complications
38
How do you manage pre-eclampsia once it has developed?
BP Control: Aim for 135/85
1st Line = Labetalol
2nd Line = Nifedipine
3rd Line = Methyldopa
Also should refer to HTN clinic for monitoring and safety net by providing information on the warning signs of eclampsia.
39
When should Labetalol be avoided?
- Diabetic patients- as pregnant women lose the ability to notice hypos coming on, main symptom they do notice is palpitations, these can be masked if on Labetalol
- Asthma
40
When should Methyldopa be given with caution?
Patients with a history of depression.
Methyldopa can inhibit serotonin release, increasing risk of peri-partum depression in mothers with an existing history of depression or other mood disorders.
41
Why is Nifedipine given with modified release?
To avoid sudden drop in BP, which can cause placental hypoperfusion.
In all women on BP drugs in pregnancy, should look out for sudden BP drops.
42
What are the main complications of HTN in pregnancy affecting the MOTHER?
- CVA
- AKI
- HELLP syndrome
- DIC (due to HELLP syndrome)
- Hepatic rupture
- Eclamptic seizures
43
What are the main complications of HTN in pregnancy affecting the BABY?
- Placental abruption
- Inter-Uterine growth restrictions
- Prematurity
44
What is HELLP syndrome?
Severe form of Pre-Eclampsia marked by Haemolysis, Elevated Liver enzymes and Low Platelets.
45
What are the symptoms of HELLP syndrome?
- Epigastric or RUQ pain
- Nausea
- Vomiting
- Dark urine
46
How is HELLP syndrome treated?
As with eclampsia, with delivery of the foetus.
47
How is eclampsia distinguished from pre-eclampsia?
Just the presence of seizures.
To diagnose eclampsia all you need is evidence of PE and a tonic-clonic seizure.
48
What investigations should be ordered in a suspected eclampsia case?
Role of investigations is to rule out reversible causes (e.g. hypos) and screen for complications (e.g. HELLP, DIC).
- FBC (reduced Hb and platelets)
- Us and Es (raised urea, creatinine, urate, reduced urine output)
- LFTs (all raised)
- Clotting studies
- BMS
Abdominal US to rule out placental abruption
CTG monitoring to look for foetal distress and bradycardia
49
What are the 5 steps taken in eclampsia management?
First patient must be stabilised:
1) Resus: ABCDE, lie patient in left lateral position, Oxygen as needed
2) Seizure Cessation: Magnesium Sulphate
3) BP Control: IV Labetalol
Once stable:
4) Delivery of Foetus and Placenta (once hypertension, hypoxia and seizures have been controled): C section is ideal.
Then:
5) Monitoring: Fluid balance, BP control, adequate urine output, discontinuation of Mag Sulph
50
What doses of Magnesium Sulphate are given for Eclampsia?
Prophylaxis or on First seizure give 4g in 100ml Saline bolus.
Maintenance is 1g hourly for 24 hours.
Recurrent seizures = 2g bolus
51
When should obstetricians become involved with provision of pregnancy care?
During complicated pregnancies:
- Age 35+
- Multiple pregnancies
- Maternal HTN, Diabetes, Epilepsy, Thyroid diseases, Cardiac or Haem conditions, Poorly controlled asthma
- Infection with potential to affect baby
- Abnormal foetal position, growth below 10th percentile, Rhesus sensitisation
- History of diabetes, pre-eclampsia or premature birth
Otherwise no evidence for greater outcomes compared to Midwife + GP led provision of care
52
How many antenatal appointments should nulliparous and parous women get?
NP- 10
| P- 7
53
What investigations should occur at each antenatal visit?
- BP
- Urine dip
- 24 weeks onwards: Symphysis-fundal height
- 36 weeks onwards: check foetal presentation (can do an USS if uncertain)
- CTG if complicated
54
What tests should be performed at 28 weeks?
- FBC
- Red cell alloantibodies
- GTT if indicated
- If Rhesus negative, give Anti-D prophylaxis
55
What points from a maternal history could increase suspicion of foetal abnormality?
- Advanced maternal age
- Maternal DM or Phenylketonuria
- Previous child with structural abnormality, genetic disorder or aneuploidy (trisomy)
- Consanguinity (incest)
- Parent with known balanced translocation
- Exposure to antiepileptics, warfarin or Vit A
- Intrauterine infections e.g. Rubella, CMV, Parvovirus
56
What is AFP and what could raised levels indicate?
Alpha-Fetoprotein. Tested for as part of quad screen in second trimester.
Raised levels can indicate:
- Open neural tube defect (e.g. spina bifida, anencephaly)
- Gastroschisis
- Fetal Infection
- Oesophageal Atresia
Lower levels could indicate Down's syndrome.
57
What would a low AFP but raised b-hCG indicate?
Foetus could have Down's.
This pair of tests has a 60-70% detection rate.
58
What are the soft markers of aneuploidy?
Nonspecific and often transient factors that can be used to detect aneuploidy during 2nd/3rd trimester scans
- Nuchal fold
- Short femur
- Choroid plexus cysts
- Echogenic focus in heart
- Dilated renal pelvis
- Talipes
59
What are the indications for amniocentesis and when should it be performed?
After 15 weeks gestation.
Main purpose = karyotype assessment so indications include:
- maternal age
- high risk for Down's
- USS findings
- parental translocation
Can perform on maternal request, can also be used for Virology screen
60
What is the miscarriage risk for both amniocentesis and CVS?
About 1%, so not negligible.
61
What are the indications for CVS and when should it be performed?
After 10 weeks gestation.
Indication = assessment of karyotype when a rapid result is desirable, assessment of genetic abnormalities such as cystic fibrosis or thalassaemia
62
What investigations would you order for a pregnant woman presenting with hypertension?
- Blood pressure profile
- CTG to look for foetal distress
- Dip urine for protein, consider Protein:Creatinine ratio
- LFTs, clotting Us and Es to look for HELLP syndrome
63
How is anaemia defined in pregnancy?
Hb below...
- 110 in the first trimester
- 105 in the second trimester
- 110 PPT
64
Why is anaemia in pregnancy taken so seriously?
- Predisposes to PPH, and makes even small PPHs more lethal
- Increases infection risk
- Worsens heart failure
Main reason why poorer women have higher rates of PP mortality than wealthier women
65
What sort of screening exists in the antenatal period to look for anaemia?
- Hb measured at booking and at 18 weeks
| - In black mothers, sickle cell test
66
What investigations are important in suspected maternal anaemia?
- FBC
- Serum iron
- TIBC
- Serum ferritin
67
Why does anaemia occur commonly in pregnancy?
- Foetal and placental need for iron skyrockets during second trimester
- Many mothers are already iron deficient when they get pregnant
68
What are the effects on mother and child of anaemia?
Mother: Lethargy, immunosuppression and infections, low mood, increased PP blood loss
Baby: Low birth weight, neuro complications
69
How should anaemia in pregnancy be managed?
- Dietary; increase consumption of iron risk foods
- Pharm; Sytron is first line as low side effect profile, can give Ferous Sulfate if not working, can give IV Iron Dextran if still anaemic
Oral iron should be taken with a glass of OJ on an empty stomach.
70
Why are VTEs so common in pregnant women?
- Pregnancy leads to reduction in anti-thrombotic factors + rise in thrombotic factors (prepare for childbirth) AND venous stasis as womb compresses ascending veins.
- Increasingly mothers are fatter, older and possibly smokers (all RFs for VTE)
71
How should VTE be managed prophylactically?
- Must fill out a pregnancy and a post-natal VTE risk assessment
- Identifies women at risk
- Prophylactic Dalteparin
72
How is a PE in pregnancy managed?
Twice daily Dalteparin/Enoxaparin:
- Continue anticoagulation for 6 months and 6 weeks after birth, although consider switching to Warfarin
- Advice woman she will need prophylaxis throughout next pregnancy
73
How should a haemoglobinopathy be managed in pregnancy?
- Increased dose of folic acid (100mg)
- Higher infection risk
- Monitor for heart failure, VTE, Pre-eclampsia
74
How can you prevent HDN in cases of ABO/Rhesus incompatibility?
Give Anti-D prophylaxis to all RH negative mothers.
75
How should you manage pregnancy in a woman with Sickle cell disease?
Preconception advice:
- Pregnancy increases risk of infection, crises, acute chest symptoms
- Stop ACE/A2A drugs
- Get up to date with jabs
- Screen for iron overload
Antenatal care:
- 75-150mg of aspirin from 12 weeks onwards reduces risk of pre-eclampsia
- Suggest TEDS
- Heparin thromboprophylaxis if hospitalised
- Offer 4 weekly scanning to monitor growth
- Test for iron deficiency, give iron as needed
76
How often should uncomplicated pregnancies be visited by their midwives?
9 times if first baby, 7 if not.
77
When should amniocentesis be offered?
If combined test (b-hCG, PAPA, nuchal translucency) suggest Down's BUT only from 15 weeks of pregnancy!
If investigating a pregnancy younger than this have to do chorionic villous sampling
78
What is the diagnostic criteria for hypertension in pregnancy?
BP greater than 140/90 on 2 occasions more than 4 hours apart, or a single reading of diastolic BP greater than 110
Same as normal.
79
What are the different forms of hypertension in pregnancy?
- Gestational Hypertension (NON proteinuric, benign)
- Chronic hypertension
- Pre-Eclampsia (proteinuric, not benign)
- Pre-Eclampsia superimposed on chronic hypertension
- Eclampsia
80
How do you diagnose Gestational or Pregnancy Induced Hypertension?
- New onset HTN after 20/40 gestation
- No proteinuria, normal blood tests
N.B: 25% go on to develop pre-eclampsia
81
How do you diagnose pre-eclampsia?
- Raised BP (above 140/90) +
| - Proteinuria (>300mg per 24 hours)
82
What are the maternal complications of pre-eclampsia?
CNS:
- Eclampsia
- ICH/Stroke
- Cortical blindness
Non-CNS:
- AKI
- Pulmonary oedema
- HELLP Syndrome
- DIC
- VTE
- Placental abruption
83
What are the leading causes of death due to pre-eclampsia?
- Stroke or ICH
| - Pulmonary oedema
84
What is HELLP Syndrome?
Life threatening complication of pre-eclampsia marked clinically by:
Haemolysis + Elevated Liver enzymes + Low Platelets
85
What are the main foetal complications of pre-eclampsia?
Pre-Eclampsia is a major risk factor for:
- Stillbirth (single greatest)
- SGA
- Prematurity
86
What causes pre-eclampsia?
- Unclear, likely multifactorial
- Genetics play a part in it
- Poor/abnormal placentation
- Immunological (poorly developed gestational immune tolerance)
87
Outline the pathological processes seen in pre-eclampsia?
- Failed trophoblastic invasion + adaptation of spiral arteries -->
- Reduced placental perfusion -->
- Ischaemia -->
- Oxidative stress and endothelial dysfunction -->
All this causes maternal responses...
- High levels of circulating pro-inflammatory cytokines -->
- Increased capillary permeability -->
- Release of vasoconstrictive substances -->
- High BP
In summary: Poor placentation causes exaggerated maternal response after 20 weeks, leading to increased rather than reduced systemic vascular resistance.
88
Briefly summarise the pathophysiology of pre-eclampsia?
Poor placentation causes exaggerated maternal response after 20 weeks, leading to increased rather than reduced systemic vascular resistance.
89
What are the risk factors of pre-eclampsia?
- Primigravida
- More than 10 years since last pregnancy
- Age 40+
- BMI 35+
- Fam history
- Personal P-E history, hypertensive history
- CKD
- Diabetes
90
How can you reduce risk of P-E?
- If possible reduce risk factors (e.g. renal disease, diabetes)
- ASPIRIN 150mg, daily, from 12 weeks to 38 weeks
- If mother has a pro-coagulant disorder e.g. anti-phospholipid syndrome give DALTEPARIN
91
How does P-E present? (signs and symptoms)
Mostly asymptomatic, picked up at antenatal appointment based off BP and urinalysis.
Symptoms:
- Headache
- Visual disturbance
- Sudden increase in swelling
- Vomiting
- Abdo pain
- Reduced foetal movements
- Bleeding
Signs:
- HTN + Proteinuria
- Oedema
- Hyper-reflexia
- Foetal growth restriction
- Oligohydramnios
- Abnormal doppler
92
What is meant by temporising management?
Best management for mother is to get baby out straightaway.
Best management for baby is deliver as close to term as possible.
TM is an attempt to strike a balance between the two.
93
How do you investigate a mother with pre-eclampsia?
Maternal:
- Platelet count (watch out for HELLP)
- Renal function (Us and Es, eGFR)
- LFTs
- Coagulation profile
- Level or proteinuria (PCR with 24 hour collection)
Foetal:
- Growth velocity
- Foetal well-being
94
How do you investigate foetal well being?
- CTG
- Amniotic fluid volume
- Foetal Doppler
- Growth velocity (two scans, two weeks apart)
95
What is the ideal management of confirmed pre-eclampsia?
What considerations should be made?
Delivery of baby, but Delivery vs Temporisation is dependent on a number of factors inc:
- Gestation
- Severity of maternal disease
- Speed of progression (fulminant pre-eclampsia)
- Presence of complications e.g. HELLP)
- Foetal well-being
96
At what level of blood pressure must you implement anti-hypertensive meds?
160/110, but offer BP meds at 140/90.
Aim for 135/85, review meds if drops to consistently below 110/70.
97
What meds are used to treat P-E?
Orally:
- Labetolol (modified release)
- Methyldopa
Emergency Mx of serious hypertension = IV Labetolol or Hydralazine.
Prevent seizures with MAGNESIUM INFUSION.
Administer steroids to aid foetal lung maturation.
98
How do you manage severe or fulminating pre-eclampsia?
IV Labetolol, IV Magnesium, Steroids to aid lung maturation, Delivery by most appropriate route, Strict fluid balance, HDU care.
99
What is Eclampsia?
Seizures occurring in pregnancy or within 10 days of delivery + with at least two of the following within 24h of the seizure:
- HTN
- Proteinuria
- Thrombocytopenia
- Raised transaminases
100
How do you manage eclampsia?
- IV access
- Bolus of 4g Magnesium Sulphate
- Continuous infusion of Magnesium Sulphate
- Control hypertension
- Plan for delivery ASAP by most appropriate route
- Strict fluid balance
- HDU care
101
What management is needed after a mother with P-E gives birth?
- May require anti-hypertensives for 6-12 weeks
- Increased risk of VTE
- Postnatal hypertension clinic referral
- Discuss contraception and implications for future pregnancy
- COUNSEL!
102
Why is counselling so important post pre-eclampsia?
Many women with P-E feel as if they have let their baby down or somehow missed out on an important part of their lives by ending their pregnancy early.
Need to be reassured that it isn't their fault, it's nothing they did, it's a random thing that affects many mums, their baby will be okay and this was the best thing for them.
103
What are the risks/adverse outcomes associated with Gestational Diabetes (GDM)
- Leading cause of maternal mortality
- Causes higher incidence of maternal morbidity
- Higher incidence of perinatal and neonatal morbidity
- Significant long term consequences for mother and baby
- Maternal comps include nephropathy, retinopathy, DKA, gastroperesis
104
Which women are at greatest risk of GDM?
Those with pre-existing RFs for insulin resistance:
- Black/asian
- Physical inactivity
- Obesity
- Dietary composition
- PCOS
105
What advice should women with existing T1 or T2 DM be given re pregnancy?
- All women with T1, T2, GDM should receive counselling
- Optimise glucose control as well as weight prior to conception
- Avoid unplanned pregnancy until then
- This helps reduce the risk of poor outcomes for the baby e.g. miscarriage, diabetic embryopathy (a set of congenital malformations), stillbirth, neonatal death
- Does not eliminate these risks but mitigates them
106
What are the major congenital abnormalities associated with pre-gestational DM?
Cardiac:
- VSD
- Transposition of the great vessels
- Tetralogy of Fallot
- Persistent foetal circulation
- Truncus arteriosus
CNS:
- Spina Bifida
- Anencephaly
MSK:
- Caudal regression /Sacral agenesis (spectrum of disorders related to lack of sacral spine development- highly associated with DM)
107
Outline the NICE recommendations for pre-pregnancy care in women with existing DM?
- Aim for a HbA1c of less than 6.5%, strongly advice against pregnancy at 10%
- Offer women with DM and BMI above 27 to lose weight
- Offer retinal assessment
- Offer women a renal assessment
- Extra scan at 32 weeks (as well as the normal 28 and 36 weeks)
Medication:
- Folic acid 5mg/day from 3 months before to 3 months after conception
- Aspirin 75mg from 12 weeks onwards
- Assess VTE prophylaxis
- Stop any unsafe medications they might be on e.g. Statins, ACEis, ARBs
108
What monitoring should women with pre-existing diabetes go through during their pregnancy?
- BM monitoring a few times a day
- USS Scans: dating at 12, detailed with a focus on cardiac abnormalities at 20, then every 4 weeks looking at growth and liquor volumes
- Should be seen in Diabetic ANC every 1-2 weeks
- Recheck retinopathy assessment at 28 weeks (can rapidly deteriorate in pregnancy)
109
When should you aim to deliver a baby in a women with pre-existing DM?
37-38+6 weeks.
Plan for elective CS between 38 and 39 if not delivered yet.
110
What conditions are associated with high pre-conceptual HbA1c?
- Causal regression syndrome
- Cardiac abnormalities
- Neural tube defects
Foetal macrosomia, however, is more associated with HbA1c throughout pregnancy.
111
What is GDM and what are it's major RFs?
Diabetes, first developed in pregnancy.
RFs =
- BMI above 30
- Previous GDM
- Previous macrosomic baby
- First degree relative with DM
- Family origin with high prevalence DM
112
How is GDM screened for?
Any mother with risk factor is screened:
- @ 26-28 weeks routinely or @ 16-18 weeks if previous GDM
- Given a 75g load of Rapilose gel
- Normal results are no more than 5.6 (pre-load) and 7.8 (post-load), any greater = GDM
5.6.7.8
113
How is GDM managed?
- Regular DANC visits (every 1-4 weeks)
- Self-monitoring of blood glucose
- Unless seriously abnormal results, start with Diabetic Diet as management
- Cons Mx = Nutrition counselling, physical activity
- Med Mx = Metformin, Glyburide, Insulin (all safe and effective)
- Regular foetal growth scans
Planned delivery:
- Aim for 39-40+6 weeks
- Consider risks of shoulder dystocia/ vaginal birth in macrosomic babies
114
How are women with GDM managed post-natally?
Stop all treatment and monitoring at delivery.
Measure FBG and HbA1d at 13 weeks, offer lifestyle advice on how to prevent future diabetes (RF)
115
What is Obstetric Cholestasis?
Cholestasis (a failure of bile to flow from the liver to the duodenum) which occurs in pregnancy, aetiology unclear.
116
What are the symptoms of OC?
Commonly:
- Itching! Quite distinct in that it's worse in the evenings, particularly affects palms and soles and occurs WITHOUT A RASH (although there may be some skin trauma)
- Dark urine
- Insomnia
Less Commonly:
- Light stools
- Fatigue
- Nausea
- Loss of appetite
- Jaundice
- URQ pain
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How is OC diagnosed?
- Itching without a rash should lead to high index of suspicion.
- Dx is based on serum bile acid test (up to x100) + raised LFTs (Alk Phos, ALT, Gamma-GT)
- Also look to exclude other causes of itching and for symptoms to resolve soon after birth
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What tests should be ordered in a woman presenting with OC?
- LFT and Bile acid (likely to be diagnositc)
- Viral screen (Hep A/B/C, Epstein Barr, CMV)
- Liver autoimmune screen
- USS abdomen for liver and gallstones
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What is the main maternal risk associated with OC?
Increased risk of PPH (due to Vitamin K deficiency inhibiting clotting mechanisms).
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What is the main foetal risk associated with OC?
- Perinatal mortality is increased by up to 11%
- Foetal distress
- Passage of meconium in utero
- Preterm labour
- Intracranial haemorrhage
- Stillbirth
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How is OC managed?
- Maternal Vitamin K from 36 weeks
- Neonatal Vitamin K from birth
- Foetal surveillance
- Drug treatments can reduce puritis
- Delivery planned for foetal maturity
- Monitoring- weekly LFTs.
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What drugs can be used to treat puritis in pregnancy?
- Ursodeoxycholic acid (aka Urso)
- Antihistamine
- Calamine
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Why is VTE in pregnancy taken so seriously?
- Leading cause of maternal death
- Pregnancy increases risk of VTE 4-6 fold
- Significant risk remains after giving birth
- Worse in diabetic mums
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Why is VTE more common in pregnancy?
Pregnancy = a hyper coagulable state:
- Increase in fibrinogen and factors 8,9,10
- Concentration of endogenous anticoagulants decreases
- Venous stasis in lower limbs
- Additional risk is present for at least 6 weeks postpartum
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What are the RFs of VTE?
Normal: Obesity, Age, Parity above 3, Smoking, Paraplegia
Obstetric: Multiple pregnancy, PET, CS, Prolonged labour, Preterm birth, Hyperemesis
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How do you diagnose VTE in pregnancy?
Gold standard = Venography with Foetal Shield
Alternative = Doppler USS of leg veins
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How do you investigate/diagnose PE in a pregnant woman?
- Mostly a clinical assessment, do not wait for Ix results
- CXR to exclude other causes of breathlessness
- ECG may show sinus tachycardia (S1 Q3 T3 is rare)
- Test FBC, Us and Es and LFTs (may see leukocytosis)
- ABG may show hypocapnia with or without hypoxaemia
- Dx confirmed with a lung scan (V/Q if normal chest x-ray, CTPA if chest x-ray is abnormal)
- Duplex USS to look for VTE
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How do you manage a VTE/PE in a pregnant woman?
- Full anticoagulation with Dalteparin or Enoxaparin
- TEDS
- Advise re: future need for prophylaxis in pregnancy, surgery, flying
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What are the main differentials for PV bleeding in early pregnancy?
Over 50% have no identified cause
- Cervical causes e.g. ectropion
- Ectopic pregnancy
- Spontaneous abortion
- Implantation bleeding (benign)
- Fibroids
- Low-lying placenta
- Gestational trophoblastic disease
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What are the main differentials for PV bleeding in late pregnancy?
- Cervical causes e.g. ectropion
- Placenta previa
- Placental abruption
- Vasa previa
- Placenta Accreta, Increta, Percreta
- Uterine rupture
