Other problems with pregnancy

Question 1

Features of obstetric cholestasis?

Answer 1

• Pruritis without rash – can get skin trauma from intense scratching
• Starts on palms and soles
• Intense at night  insomnia and malaise
• If rash – think Polymorphic eruption of pregnancy (PEP) and pemphigoids gestations

also Epigastric discomfort, steatorrhoea, and dark urine

Question 2

Ix for obstetric cholestasis?

Answer 2

• LFTs and bile acids
• Viral screen: Hep A, B, C, EBV, CMV
• Liver autoimmune screen: Anti-smooth muscle and antimitochondrial abx- For chronic active hepatitis and primary biliary cirrhosis
• USS abdo – other liver condition and gall stones

Question 3

Bloods signs of OC?

Answer 3

• Elevated transaminases and alk phos (already slightly raised in pregnancy – much higher in OC)
• Raised GGT
• Mild elevation in bilirubin
• Primary bile acids increased up to 100 fold

Question 4

Complications of OC?

Answer 4

Maternal: vit K deficiency (coag pathway disturbance), increased risk of PPH

Fetal: Stillbirth – perinatal mortality increased up to 11%, Fetal distress, Meconium passage, Preterm labour, IC haemorrhage

Question 5

Mx of OC?

Answer 5

• Maternal Vit K from 36wks
• Babies given Vit K from birth
• Fetal surveillance
• Tx to reduce pruritis: Ursodeoxycholic acid, Antihistamine, Calamine
• Delivery at fetal maturity
• In pregnancy – LFTs repeated weekly until delivery/IOL
• Follow up at 10 days after delivery for LFTs – should be normal

Question 6

Drugs used in OC?

Answer 6

o Ursodeoxycholic acid (reduces pruritis in 1 to 7days)
o Antihistamine
o Calamine

Question 7

DDx of OC?

Answer 7

Gallstones.
• Acute or chronic viral hepatitis.
• Primary biliary cirrhosis (antimitochondrial antibody +ve).
• Chronic active hepatitis (antismooth muscle antibody +ve).

Question 8

delivery in OC?

Answer 8

induction of labour at 37-38 weeks is common practice but may not be evidence based

Question 9

PPX of increased risk of thromboembolism?

Answer 9

• Pregnancy is hypercoaguable state. Due to: Increased fibrinogen and factor 8, 9, and 10 and Concentration of endogenous anticoags decreases
• Additional risk for at least 6wks postpartum
• Venous stasis in lower limb later in pregnancy
• Trauma to pelvic veins in delivery increased risk

Question 10

Obstetric RFs for thromboembolism?

Answer 10

multi pregnancy
PET
CS
prolonged labour >24hrs
stil birth 
preterm birth
PPH>1L

Question 11

Ix of DVT in pregnancy?

Answer 11

Gold standard: Venography with fetal shield

1st line: Doppler USS - less risk to baby - Can directly image clot and lack of compressibility of vein – suggest clot

Question 12

Describe thromboprophylaxis in pregnancy.

Answer 12

if high risk of VTE (hitory of >1VTE, Unprovoked or oestrogen related
VTE, Single previous provoked VTE plus - Known thrombophilia
or Family history VTE

give LMWH.

Question 13

Ix of suspected DVT?

Answer 13

Compression duplex ultrasound

Question 14

Ix of suspected PE?

Answer 14

ECG and chest x-ray
if symptoms and signs of DVT, compression duplex ultrasound - If compression ultrasonography confirms the presence of DVT, no further investigation is necessary and treatment for VTE should continue

the decision to perform a V/Q or CTPA should be taken at a local level after discussion with the patient and radiologist

Question 15

Compare CTPA and V/Q scan in pregnancy.

Answer 15

CTPA slightly increases the lifetime risk of maternal breast cancer - Pregnancy makes breast tissue particularly sensitive to the effects of radiation

V/Q scanning carries a slightly increased risk of childhood cancer compared with CTPA

Question 16

Tx of VTE in pregnancy?

Answer 16

LMWH initially
given in dose titrated to women’s booking weight

graduated elastic compression stockings

IVC filter if iliac vein VTE to reduce the risk of PE or in patients with proven DVT and
who have recurrent PE despite adequate anticoagulation.

Question 17

Tx of massive PE in pregnancy/puerperium?

Answer 17

IV unfractionated heparin

Question 18

Maintenance therapy for VTE?

Answer 18

Treatment with therapeutic doses of subcutaneous LMWH should be employed during the remainder
of the pregnancy and for at least 6 weeks postnatally and until at least 3 months of treatment

Question 19

define zygosity?

Answer 19

The genetic make-up of the zygote
dizygotic = non-identical, developed from separate ova that were fertilised at the same time
monozygotic = identical - developed from single ovum divided to form two embryos

Question 20

Define chorionicity

Answer 20

number of palcenta of a pregnancy

Question 21

Complications of twin pregnancy?

Answer 21

Maternal: hyperemesis, preeclampsia, anaemia, CS, miscarriage, PPH

Fetal: IUGR, IUFD, twin to twin transfusion syndrome, preterm birth, congenital malformations

Question 22

What additional antenatal appointments are needed for twin pregnancy?

Answer 22

if uncomplicated dichorionic diamniotic twin pregnancy - offer at least 8 antenatal appointments

Question 23

When is chorionicity most accurately diagnosed?

Answer 23

1st trimester

Question 24

Early sign of twin pregnancy?

Answer 24

fundus palpable before 12wks or exaggerated symptoms of early pregnancy

Question 25

Describe the antenatal care for twin pregnancies.

Answer 25

establish chorionicity Routine use of iron and folate supplements should be considered. A detailed anomaly scan should be undertaken. • Advise aspirin 75microgram if additional risk factors for preeclampsia Serial growth scans at 28, 32, and 36wks for DC twins. More frequent antenatal checks because of i risk of pre-eclampsia.

Question 26

delivery of multiple pregnancy?

Answer 26

Offer delivery at 37–38wks: induction or lower segment Caesarean section (LSCS).

Question 27

what type of multi pregnancy does TTTS affect? describe it. Mx?

Answer 27

MCDA pregnancy caused by aberrant vascular anastamoses within the placenta, which redistribute the fetal blood Laser ablation of the placental anastamoses Selective feticide by cord occlusion is reserved for refractory disease

Question 28

monitoring of MC twins?

Answer 28

serial USS every 2wks from 16–24wks and every 3wks until delivery

Question 29

What are the effects of TTTS of the fetus?

Answer 29

Donor twin • Hypovolaemic and anaemic. • Oligohydramnios: appear ‘stuck’ to the placenta or uterine wall. • Growth restriction. Recipient twin • Hypervolaemic and polycythaemic. • Large bladder and polyhydramnios. • Cardiac overload and failure. • Evidence of fetal hydrops (ascites, pleural, and pericardial effusions). • This twin is often more at risk than the donor.

Question 30

Intrapartum risks of twin pregnancy?

Answer 30

M alpresentation. • Fetal hypoxia in second twin after delivery of the fi rst. • Cord prolapse. • Operative delivery. • Post-partum haemorrhage. Rare: • cord entanglement (MCMA twins only) • head entrapment with each other: ‘locked twins’ • fetal exsanguination due to vasa praevia.

Question 31

Describe the types of breech presentation.

Answer 31

Extended breeches (70%): both legs extended with feet by head; presenting part is the buttocks. • Flexed breeches (15%): legs flexed at the knees so that both buttocks and feet are presenting. • Footling breeches (15%): • one leg flexed and one extended.

Question 32

Causes and associations of breech presentation?

Answer 32

idiopathic (most common). • P reterm delivery. • P revious breech presentation. • U terine abnormalities, e.g. fi broids and Müllerian duct abnormalities. • P lacenta praevia and obstructions to the pelvis. • F etal abnormalities. • M ultiple pregnancy.

Question 33

Consequences of breech presentation?

Answer 33

Fetal: increased risk of hypoxia and trauma in labour | Maternal - most breeches delivered by CS.

Question 34

Examination findings of breech presentation?

Answer 34

lie is longitudinal • t he head can be palpated at the fundus • t he presenting part is not hard • t he fetal heart is best heard high up on the uterus.

Question 35

WHen is ECV performed?

Answer 35

From 36wks in nullip women, 37wks in multiparous women

Question 36

Mx after ECV?

Answer 36

CTG performed and anti-D given if Rh -ve

Question 37

Factors meaning ECV will be more difficult?

Answer 37

Nulliparity, diffi culty palpating the head, high uterine tone, an engaged breech, less amniotic fl uid, and white ethnicity

Question 38

CIs to ECV?

Answer 38

``` Absolute • Caesarean delivery already indicated. • Antepartum haemorrhage. • Fetal compromise. • Oligohydramnios. • Rhesus isoimmunization. • Pre-eclampsia. Relative • One previous CS. • Fetal abnormality. • Maternal hypertension. ```

Question 39

Ideal conditions for vaginal breech delivery?

Answer 39

``` Fetus is not compromised. • Estimated fetal weight is <4kg. • Spontaneous onset of labour. • Extended breech presentation. • Non-extended neck. ```

Question 40

define unstable lie? Mx of unstable lie?

Answer 40

Unstable lie occurs when the lie is still changing, usually several times a day, and may be transverse or longitudinal lie, and cephalic or breech presentation Admit to hospital from 37wks so that CS can be carried out if labour starts or the membranes rupture and the lie is not longitudinal

Question 41

Risks of abnormal lie?

Answer 41

Labour with a non-longitudinal lie will result in obstructed labour and potential uterine rupture. • Membrane rupture risks cord prolapse because with longitudinal lie, the presenting part usually prevents descent of the cord through the cervix.

Question 42

Causes and associations of abnormal fetal lie?

Answer 42

Multiparity (particularly >para 2) with lax uterus (common). • Polyhydramnios. • Uterine abnormalities, e.g. fibroids and Müllerian duct abnormalities. • Placenta praevia and obstructions to the pelvis. • Fetal abnormalities. • Multiple pregnancy.

Question 43

define prematurity, and different types of preterm.

Answer 43

premature = born before 37wks extremely preterm = <28wks very preterm = 28-32wks moderate to late preterm = 32-36+6

Question 44

Neonatal risks of prematurity?

Answer 44

``` Neonatal death • Respiratory distress syndrome • Chronic lung disease • Intraventricular hemorrhage • Necrotizing enterocolitis • Sepsis • Retinopathy of prematurity • <28 weeks: – physical disabilities, – learning disabilities, – behavioural problems, – visual and hearing problems ```

Question 45

Causes of neonatal morbidity and mortality associated with PPROM?

Answer 45

Prematurity – Sepsis and chorioamnionitis – Cord prolapse – Pulmonary hypoplasia

Question 46

Hx and exam findings for PPROM? Ix?

Answer 46

Gush of fluid from vagina • Leaking vaginal fluid • Increased watery discharge • Concern or uncertainty about urinary incontinence Exam: Sterile speculum examination: – Pool of fluid --> Confirmed – No fluid seen --> test (different brands): • ActimPROM • AmniSure FBC, CRP, HVS, MSU USS - fetal presentation, EFW, liquor volume

Question 47

What does actim-prom detect?

Answer 47

insulin-like growth factor binding protein-1 – Produced by decidual cells – Present in amniotic fluid in high amounts – Not normally found in vagina

Question 48

PPROM Mx?

Answer 48

Admit for observation at least 48-72h - if going home advise to check temp twice daily Corticosteroids if between 24-33+6wks Prophylactic erythromycin - for 10days or until labour - Monitoring: CRP and WBC, temperature, maternal and fetal heart rate Expectant management until 37 weeks • Unless signs of maternal or fetal compromise • If GBS, consider >34 weeks

Question 49

Define preterm labour.

Answer 49

Labour/regular contractions resulting in changes in cervix before 37/40

Question 50

RFs for preterm labour?

Answer 50

``` Smoking, drug abuse, teenager or advance maternal age, multiple pregnancy, previous cervical procedure (eg. LLETZ) previous late miscarriage asymptomatic bacteruria previous preterm, bacterial vaginosis ```

Question 51

Methods to prevent preterm labour?

Answer 51

Identify those high risk: Women with history of: – Spontaneous preterm birth – Mid-trimester loss (16+) – PPROM – Cervical trauma If high risk, need increased monitorings (TVUSS for cervical length, HVS) If shortening between 16-24wks - give prophylactic vaginal progesterone or perform cervical cerclage – Cerclage needs to be removed before labour Tx bacterial vaginosis (clindamycin)

Question 52

Ix for ?preterm labour?

Answer 52

TVUSS - gold-standard ``` >15mm – unlikely PTL • Discuss benefits/risks of going home vs. monitoring in hospital – <15mm – confirmed PTL and offer treatment ``` Fetal fibronectin Alternatives: Actim partus, partosure - insufficient evidence to recommend for diagnosis/confirmation of PTL FBC, CRP, swabs, MSU

Question 53

What does ACTIM PARTUS look for?

Answer 53

PHIGFBP-1 – Phosphorylated IGFBP-1 Produced by decidua Leaks into the cervix when decidua and chorion detach – phIGFBP-1 in a cervical swab is an indicator for tissue damage blood interferes with test

Question 54

Mx of preterm labour?

Answer 54

liaise with neonatology ?in utero teansfer (to hospital with appropriate neonatal unit Tocolysis - Slow down contractions with nifedipine or atosiban - Allow time for administration of steroids or transfer Corticosteroids if <34 wk rescue cerclage - If dilated cervix with exposed fetal membranes <28 wks, no PPROM, no infection, no contractions In labour - Neuroprotection with magnesium sulfate for <34 wks Antibiotics Continuous monitoring

Question 55

Indications for rescue cerclage?

Answer 55

If dilated cervix with exposed fetal membranes | <28 wks, no PPROM, no infection, no contractions

Question 56

Features suggestive of chorioamniotis?

Answer 56

History: • Fever/malaise. • Abdominal pain, including contractions. • Purulent/offensive vaginal discharge. ``` Examination: • Maternal pyrexia and tachycardia. • Uterine tenderness. • Fetal tachycardia. • Speculum: offensive vaginal discharge—yellow/brown. ```

Question 57

Risks to fetus from PPROM?

Answer 57

Prematurity. • Infection. • Pulmonary hypoplasia. • Limb contractures.

Question 58

Fetal risks of prolonged pregnancy?

Answer 58

perinatal mortality Meconium aspiration and assisted ventilation. • Oligohydramnios. • Macrosomia, shoulder dystocia, and fetal injury. • Cephalhaematoma. • Fetal distress in labour. • Neonatal—hypothermia, hypoglycaemia, polycythaemia, and growth restriction.