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Year 3- placement > Obstetrics core conditions > Flashcards

Obstetrics core conditions Flashcards

1
Q

Sepsis- risk factors

A

Leading cause of maternal death in the UK

Risk Factors
(1) Pre-existing: obesity, diabetes, impaired immunity (i.e. on immunosupressants), BME groups, hypertension, low socio-economic status, anaemia, hx of PID, hx of GBS infection, ‘Flu season
(2) From presentation: vaginal discharge, recent procedure (i.e. amniocentesis, cervical cerclage) PROM, in contact with individuals with GAS infection or influenza

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2
Q

Sepsis- clinical features

A

(1) One or more of the following: pyrexia, hypothermia, tachycardia, tachypnoea, hypoxia, hypotension, oliguria, impaired consciousness, failure to respond to treatment
(2) Note that genital tract sepsis may present with constant severe abdominal pain and tenderness unrelieved by usual analgesia

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3
Q

Sepsis- common organisms/sources/complications

A

Common organisms: = Group A Beta-haemolytic Streptococcus, E.coli, Influenza

Common sources of AN Sepsis= Chorioamnionitis, Urinary tract

Complications= Preterm labour, preterm delivery (for maternal well being), fetal death, maternal death

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4
Q

Postpartum sepsis- risk factors

A

Same as for AN risk factors plus: prolonged ROM, multiple VEs, vaginal trauma, c-section, wound haematoma, retained products of conception, MROP/other instrumentation of genital tract.

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5
Q

Postpartum sepsis- clinical features: same as for AN clinical features +

A

(1) Mastitis: breast pain, tenderness, “wedge shaped” erythema, palpable abscess
(2) Endometritis: pain, offensive discharge, bleeding (commonest cause of secondary PPH)
(3) Wound Site: pain, tenderness, erythema, discharge from wound, collection

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6
Q

Postpartum sepsis- organisms

A

There has been a recent dramatic rise in maternal deaths attributable to group A beta-hemolytic streptococci (GAS). Others: E.coli, S.Aureus, S.Pneumoniae, MRSA, Influenza

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7
Q

Posttpartum sepsis- sources

A

(1) Genital tract and uterus causing endometritis
(2) Mastitis
(3) UTI
(4) Pneumonia
(5) Skin/soft tissue

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8
Q

Postpartum sepsis- Management

A

(1) See Antenatal (AN) Sepsis for Sepsis 6.
(2) Sepsis is an emergency, and should be managed as such.
(3) Use a maternity specific Early warning score (“MEWS”) chart – allows for early recognition of deterioration.
(4) Get early senior involvement. Consider HDU/ITU involvement.
(5) Consider drainage of collection/abscess if applicable.

Occurs within 6 weeks of giving birth.

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9
Q

Diabetes and pregnancy

A

(1) Pre-existing (Type 1, Type 2): affects around 1% of women, typically these patients will observe an overall increase in insulin requirements as their pregnancy progresses
(2) Gestational: affects around 16% of women, typically diagnosed in the second/ third trimester and resolves postnatally. It can often progress to type 2 diabetes either postnatally or later in life and so requires screening from 12 weeks after delivery and annually thereafter

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10
Q

Diabetes and pregnancy- pathophysiology

A

(1) Maternal fasting blood glucose is lower than in the non-pregnant state, as a result of increased insulin sensitivity.
(2) As pregnancy progresses, insulin resistance increases causing delayed responses to post-prandial glucose.
(3) Human placental lactogen, progesterone & cortisol levels are all increased, which lowers maternal glucose tolerance.

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11
Q

Pre-existing diabetes= risk to fetus

A

(1) Preterm delivery >10% (includes spontaneous and induced labours)
(2) Congenital anomaly (CHD, NTD) 3-4 x increase
(3) Decrease in fetal lung maturity (at any gestation), however must use caution with IM steroids (hyperglycaemia)
(4) Macrosomia (increased insulin & fat stores) – may be associated with polyhydramnios
(5) Shoulder dystocia/ birth trauma
(6) Still birth & fetal growth restriction
(7) Congenital anomaly and growth restriction/still birth (chronic hypoxia)

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12
Q

Pre-existing diabetes risk to the mother

A

(1) Increased insulin requirements (300%)
(2) Increased risk of Pre-eclampsia
(3) Increased risk of caesarean section delivery
(4) Deterioration in pre-existing conditions (BP, nephropathy, retinopathy)

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13
Q

Pre-existing diabetes: pre-conception

A

(1) Optimise blood glucose control – review diet and medication
(2) Commence 5mg folic acid daily
(3) Ensure target end-organ screening is up to date (retinal, renal & footcare)

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14
Q

Pre- existing diabetes= Antenatal care (MDT)

A

(1) Obstetricians, endocrinologists, specialist midwives & dietician input
(2) Frequent AN visits
(3) Early viability / dating scan: commence 75-150mg aspirin after dating complete
(4) Emphasis on fetal anomaly screening, fetal echo as part of 20 week USS; serial growth scans
(5) Increased frequency of BM monitoring with regular medication adjustments
(6) Avoidance of hypoglycaemia

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15
Q

Pre-existing diabetes= Delivery

A

(1) Delivery is recommended at 38 weeks to prevent late IUFD (intrauterine fetal demise) diet controlled GDM can continue up to 40wk.
(2) Tight blood glucose control in labour (may need GKI)
(3) CTG in labour
(4) Resume pre-pregnancy treatments immediately after delivery
(5) Postnatal contraception review

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16
Q

Pre-existing diabetes= neonatal care

A

(1) Increased risk of prematurity and respiratory distress
(2) Increased risk of hypoglycaemia (sudden withdrawal of maternal glucose at delivery) - early and frequent feeding
(3) Hyperbilirubinaemia
(4) Increased risk of birth trauma (shoulder dystocia)

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17
Q

Gestational diabetes

A

Glucose intolerance first diagnosed in the second/ third trimester of pregnancy. Diagnosis earlier can be type 2 diabetes/ MODY which has previously not been recognised.

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18
Q

Gestational diabetes- risk factors

A

(1) Obesity (BMI ≥30)
(2) Family history (1st degree relatives)
(3) Previous GDM
(4) Ethnicity
(5) Previous unexplained SB / NND
(6) Previous 4.5kg baby

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19
Q

Screening/diagnosis of gestational diabetes

A

(1) OGTT 24-28/40 (plus at booking if previous GDM)
(2) Home blood glucose monitoring from 16/40

If either test is abnormal, increased frequency of blood glucose monitoring is needed. Aim to optimise blood sugars through: patient education, diet and hypoglycaemics (metformin +/- insulin)
Degree of risk to mother & fetus is less compared to pre-existing diabetics and is related to the time of onset.

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20
Q

Gestational diabetes- Postnatal screening is recommended

A

(45-50% lifelong risk of T2DM):

(1) Fasting blood glucose at 6-13weeks
(2) Or HBA1C after 13 weeks
(3) Annually thereafter

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21
Q

Gestational diabetes is diagnosed if either:

A

(1) Fasting glucose >5.6mmol/L
(2) 2-hour glucose >7.8mmol/L

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22
Q

Management of gestational diabetes

A

(1) If fasting glucose levels are <7mmol/L. A trial of diet and exercise is offered. If glucose targets are not met within 1-2 weeks of diet/exercise, metformin should be started. If still not met short acting insulin should be added
(2) If at the time of diagnosis the fasting glucose level is >= 7 mmol/l insulin should be started
(3) If the plasma glucose level is between 6-6.9 mmol/l, and there is evidence of complications such as macrosomia or hydramnios, insulin should be offered
(4) Glibenclamide should only be offered for women who cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment

23
Q

Chronic hypertension and pregnancy

A

(1) Hypertension predating pregnancy or presenting at <20 weeks
(2) May be primary or secondary
(3) Increased risk of developing gestation hypertension and pre-eclampsia
(4) No proteinuria or oedemia
(5) If a pregnant woman takes an ACE inhibitor or angiotensin II receptor blocker (ARB) for pre-existing hypertension this should be stopped immediately and alternative antihypertensives started (e.g. labetalol) whilst awaiting specialist review

24
Q

Prevention of gestational hypertension

A

Consider aspirin 150mg at night daily if 1 high or 2 moderate risk factors. Start before 16 weeks and continue through pregnancy

25
Q

Hugh risk factors for gestational hypertension

A

(1) Hypertensive disease during a previous pregnancy
(2) Chronic kidney disease
(3) Autoimmune disease such as SLE or APLS
(4) Type 1 or type 2 diabetes
(5) Chronic hypertension

26
Q

Moderate risk factors for hypertension

A

(1) First pregnancy
(2) Age ≥40
(3) Pregnancy interval of more than 10 years
(4) Booking BMI ≥35
(5) Family history of pre-eclampsia
(6) Multiple pregnancy

27
Q

Definition of gestational hypertension

A

New hypertension in pregnancy presenting at >20 weeks without significant proteinuria

28
Q

Overview of gestational hypertension

A
  • Hypertension (as defined above) occurring in the second half of pregnancy (i.e. after 20 weeks)
  • 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
29
Q

Hypertension in pregnancy is usually defined as:

A
  • systolic > 140 mmHg or diastolic > 90 mmHg
  • or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic
30
Q

Diagnosing pre-eclampsia

A

New onset of hypertension >140/90 at >20 weeks of pregnancy and one of:
a. urine PCR (protein/creatinine ratio) of ≥30 mg/mmol
b. maternal organ dysfunction (renal, hepatic, neurological or haematological abnormalities)
c. Uteroplacental insufficiency (Stillbirth, FGR or abnormal umbilical artery Doppler waveform)

Severe Hypertension is blood pressure >160/110

31
Q

Pre-eclampsia definition

A

Pre-eclampsia describes the emergence of high blood pressure during pregnancy that may be a precursor to a woman developing eclampsia and other complications. It is classically a triad of 3 things:
* new-onset hypertension
* proteinuria
* oedema

32
Q

Pre-eclampsia summary

A
  • condition seen after 20 weeks gestation
  • pregnancy-induced hypertension
  • proteinuria
33
Q

Potential complications of pre-eclampsia

A
  1. Eclampsia- other neurological complications like altered mental status, blindness, stroke, clonus, severe headache or persistent visual scotoma
  2. Fetal complications: intrauterine growth retardation, prematurity
  3. Liver involvement (elevated transaminases)
  4. Haemorrhage: placental abruption, intra-abdominal, intra-cerebral
  5. Cardiac failure
34
Q

Features of severe pre-eclampsia

A
  1. hypertension: typically > 160/110 mmHg and proteinuria as above
  2. proteinuria: dipstick ++/+++
  3. headache
  4. visual disturbance
  5. papilloedema
  6. RUQ/epigastric pain
  7. hyperreflexia
  8. platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome
35
Q

Management: pre-eclampsia

A
  1. Women with blood pressure 160/110mmHg are likely to be admitted and observed
  2. Oral labetalol is first line, Nifedipine and hydralazine may be used
  3. Delivery of the baby is the definitive treatment
36
Q

Eclampsia

A
  • A convulsive condition associated with pre-eclampsia (seizures)
  • Magnesium sulphate (IV) is used for both prophylaxis and treatment of eclamptic seizures
37
Q

Treatment- Eclampsia

A
  1. Magnesium sulphate- in severe pre-eclampsia and eclampsia. In eclampsia an IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour
  2. Urine output, reflexes, respiratory rate and oxygen saturations should be monitored during treatment
  3. Respiratory depression can occur: calcium gluconate is the first-line treatment for magnesium sulphate induced respiratory depression
  4. Treatment should continue for 24 hours after last seizure or delivery (around 40% of seizures occur post-partum)
  5. Fluid restriction to avoid fluid overload
38
Q

Antihypertensive treatment pregnancy

A
  • Recommended antihypertensive drugs in pregnancy: Labetalol (oral or IV), Nifedipine, Methyldopa, Hydrallazine (IV)
  • Postnatal antihypertensive choice includes ACE inhibitors (Enalapril) are recommended as first line agent postnatally. Labetalol or nifedipine may be continued from antenatal treatment
  • BP targets: Antenatally: 135/85; Postnatally: 140/90
39
Q

Pregnancy: timing of delivery in hypertension

A

In cases of well controlled hypertension with no maternal and fetal concerns delivery is recommended at 37 weeks or earlier depending on the clinical situation. Where delivery is indicated prior to 36 weeks a course of antenatal steroids should be considered

40
Q

HELLP syndrome

A
  1. 10-20% of patients with severe pre-eclampsia will go on to develop HELLP, don’t have to have pre-eclampsia to get it
  2. Features: nausea and vomiting, right upper quadrant pain, lethargy
  3. Investigations: bloods (haemolysis, elevated liver enzymes and low platelet)
  4. Treatment: delivery of the baby
  5. Acronym: Haemolysis, elevated liver enzymes and a low platelet count
41
Q

Obesity

A

A BMI >30kg/m at the first antenatal visit

42
Q

Obesity risks pre-conception

A
  1. Subfertility/ Miscarriage
  2. VTE
  3. GDM
  4. Hypertensive disease:
  5. Double risk of pre-eclampsia with booking BMI >35
  6. Maternal UTIs
43
Q

Obesity risks intra-partum

A
  • Slow progress in labour
  • C-Section
  • Shoulder dystocia
  • Anaesthetic risk:
  • Epidural/spinal failure
  • Aspiration
  • Difficult intubation
  • Post-op atelectasis
  • Stillbirth
  • Failed VBAC / uterine rupture (if morbidly obese)
44
Q

Obesity risks to baby and medication

A

Risks to baby
1. Neural tube defects
2. Macrosmia
3. Admission NNU
4. Neonatal death

Women with BMI >30 should be advised to take 5mg Folic acid daily, starting at least one month before conception and continuing during first trimester to reduce the risk of NTDs

45
Q

Antenatal care: BMI 30-35

A

Discuss risks of obesity:
2. Pre-eclampsia
3. VTE - Consider antenatal LMWH (weight adjusted dose) if additional risk factors for VTE
4. Gestational diabetes mellitus - screen with OGTT at 24-28 weeks
5. High dose Vitamin D (10 micrograms daily) throughout pregnancy and breastfeeding, due to increased risk of Vitamin D deficiency in obesity

46
Q

Antenatal care: if BMI >35

A
  1. Offer serial fetal growth USS as measurement of SFH can be unreliable
  2. Consider starting Aspirin 75-150mg if there are additional moderate risk factors for pre-eclampsia
47
Q

Antenatal care if BMI >40

A

Will need antenatal anaesthetic review to identify potential problems with venous access and anaesthesia. Should have an antenatal consultation with an obstetric anaesthetist and a plan made

BMI should be re-measured at 28 weeks

48
Q

Obesity: labour and delivery

A
  1. If BMI >35, advise to give birth in a consultant-led obstetric unit
  2. Obesity alone is not an indication for induction of labour
  3. BMI >40: continuous midwifery care when in established labour & venous access in early labour
  4. Risk of difficult delivery if macrosomic baby eg. shoulder dystocia, maternal and fetal injuries
  5. Increased risk of emergency c-section, and operation may be more technically difficult
  6. Active management of third stage, to reduce the risk of PPH
  7. Postpartum: all women with a BMI >40 should have a LMWH
49
Q

Epilepsy and pregnancy

A

Most deaths are due to SUDEP (Sudden Unexplained Death in Epilepsy), often associated with poorly controlled disease. Nocturnal seizure is a RED flag symptom for SUDEP and should prompt rapid referral

50
Q

Epilepsy and pregnancy- preconception

A
  1. Optimize anti-epileptic medication (AEM): use lowest dose possible, avoid polytherapy to reduce risk of congenital malformations (most commonly neural tube defects and cardiac anomalies)
  2. Carbamazepine and lamotrigine have best safety profile
  3. Commence 5mg folic acid for 3 months pre-conception
  4. Don’t use sodium valproate
51
Q

Epilepsy and pregnancy- Antenatal

A
  • Explain the importance of never stopping or changing AEMs abruptly.
  • Inform of risk factors for seizures (sleep deprivation, stress and adherence to AEMs)
  • Don’t routinely check serum levels of AEMs, only do so on advice from Neurology
  • If taking AEM they require serial growth scans at 28, 32, 36, 40 weeks to detect small for gestational age (SGA) babies
52
Q

Epilepsy and pregnancy- Intrapartum

A
  • Epilepsy is not an indication for Induction of labour or C-Section
  • Ensure adequate analgesia and hydration as pain, stress and dehydration can precipitate seizures
  • Women should continue to take AEMs whilst in labour, and if unable to do so orally, alternate routes should be considered
53
Q

Epilepsy and pregnancy postpartum

A
  • The risk of seizures here is still low, although relatively higher than during pregnancy (due to worsening of risk factors)
  • If AEM dosage was modified in pregnancy, it should be reviewed by a neurologist within 10 days postnatally
  • Babies born to mothers who have been taking enzyme inducing AEMs should be offered 1mg of IM Vitamin K to prevent Haemorrhagic Disease of the Newborn.
  • AEMs are not a contraindication to breastfeed, so women should be supported should they wish to do so.
    Medication

Year 3- placement (34 decks)

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