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RNH > Pregnancy > Flashcards

Pregnancy Flashcards

1
Q

Naegele’s rule for EDD

A

first day of LMP + 7 days + 1 year - 3 months

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2
Q

Common medications that are teratogenic

A 
ACEi/ARB
warfarin 
anti-epileptics
carbimazole 
methotrexate 
isotretinoin
lithium
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3
Q

Components to assess during palpation of abdomen /uterus

A 
SFH
uterine tone and tenderness
lie
presentation 
position 
engagement
liquor volume
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4
Q

Causes of bHCG levels being higher/lower than expected

A

higher: multiple gestation, molar pregnancy, trisomy 21
lower: ectopic, miscarriage
both: wrong dates

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5
Q

Major complications of pregnancy

A 
Pre term labour
IUGR
GDM
Miscarriage or stillbirth 
Antepartum or PPH
Pre eclampsia

“PIGMAP”

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6
Q

Pre-conception care

A

Hx: HPC, Obs and gyn hx, PMHx, teratogenic medications, Social (SNAP, home), FHx

Exam: vitals, anthropometry, systems review, breast and cervical screening

Ix: bloods (FBC, blood typing, BBV infections, vaccine serology), urine dipstick, HPV swab

Lifestyle: SNAP and weight loss

Avoid TORCH organisms: avoid raw meats/seafood, cold cheese, cat litter, wash hands, etc

Supplements: folate and iodine

Vaccines: Influenza, dTPa, MMRV

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7
Q

Risk factors for foetal abnormality

- foetal/pregnancy and maternal factors

A

Maternal:

  • previous hx of foetal abnormality
  • increasing age
  • teratogens
  • maternal disease

Foetal/pregnancy:

  • IUGR
  • abnormal amniotic fluid
  • persistent breech or abnormal lie
  • abnormal foetal movements
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8
Q

Routine antenatal screening tests for foetal abnormalities

what is considered high risk

A

CFTS: 11-14 weeks, bHCG, PAPP-A + USS nuchal translucency

2nd trimester screen: 14-18 weeks, bHCG + AFP + UE-3 + inhibin-A

> 1/300 combined risk = high risk = offered diagnostic testing

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9
Q

What is cfDNA / NIPT? aka harmony test

A

cell free DNA / non invasive prenatal testing

alternative to CFTS to detect aneuploidy ie chromosome abnormalities in 21, 18, 13

measures cell free DNA from placenta in maternal plasma

more specific and sensitive but still requires diagnostic testing

$400 self funded

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10
Q

Diagnostic antenatal tests

A

chorionic villus sampling (CVS)
- 11-14 weeks, placental biopsy

amniocentesis
- >15 weeks

risks: spontaneous foetal loss

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11
Q

What does carrier screening test for and when is it done?

A

CF
spinal muscular atrophy
fragile X

before conception or 1st trimester

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12
Q

Definition of antepartum haemorrhage

A

> 20 weeks gestation but before birth

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13
Q

Examination of APH

A

general - LOC, pallor, pain, estimate blood loss by inspecting groin area
Vitals - haemodynamically stable
abdominal - inspect, SFH, palpate foetal lie, uterine tone and tenderness, CTG
pelvic - inspect only! do NOT do bimanual, obstetrician may do speculum

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14
Q

Ix and Mx for APH

A

mother - FBC, coagulation, G&H, cross match
Foetus - transabdominal USS, CTG

medical - TXA, betamethasone IM, anti-D if Rh-

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15
Q

Types of placenta praaevia

A

1 - <2cm from cervical os but clear of os
2 - margin of os
3 - overlying os, part of placenta in upper uterus
4 - covering os, entirely in lower segment

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16
Q

RF for placenta praaevia

A 
hx of placenta praaevia 
past c section 
multiparous 
fibroids 
multiple pregnancy
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17
Q

what is low lying placenta and what is the management

A

low lying placenta = <2cm from os and <26/40

high grade or accreta - F/U 32/40
low grade - F/U 36/40

safety net

accreta - MRI

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18
Q

symptoms and exam features of placenta praaevia bleeding

A

symptoms - painless antenatal vaginal haemorrhage, sudden onset, recurrent bleeding

exam - soft abdomen with normal uterine tone, foetal parts easy to palpate, malpresentation of foetus (transverse or oblique, displaced presenting part to high and central)

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19
Q

Management of placenta praaevia during third trimester ie counselling, plan, mx

A

counselling

  • low lying, blocking passage of baby
  • 2 concerns - massive bleeding, baby cannot get out
  • close monitoring required
  • C section at 37/40
  • +/- blood transfusion
  • +/- hysterectomy

admit for monitoring until 37/40

Rx - betamethasone IM if <34/40, replace iron and blood as required

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20
Q

What is placenta accreta and what is the management

A

placenta implantation over previous c section scar

management similar to placenta praaevia but with higher risk of bleeding

more likely to require hysterectomy due to inability to separate placenta

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21
Q

RF for placental abruption

A 
past abruption 
trauma
poor placentation - smoking, drugs, HTN, IUGR
chorioamnionitis 
sudden reduction in AF - PPROM, IOL
22
Q

Clinical features of placental abruption

A

symptoms - severe constant abdo pain with woody hard uterus, +/- haemorrhage

exam - uterine tenderness, increased tone and rigidity, baby hard to palpate, longitudinal lie

23
Q

What is ‘bloody show’

A

passage of cervical plug

small amount of blood and mucus near end of pregnancy and often before labour

24
Q

5 types of hypertensive obstetric disorders

A 
chronic HTN
gestational HTN
pre eclampsia
eclampsia
chronic HTN with superimposed pre eclampsia
25
Q

gestational HTN

  • definition
  • risk factors
  • management (conservative vs medical)
A

> /=140/90 on 2 separate occasions, arising >20 weeks gestation, NO proteinuria, NO end organ damage

RF: extremes of age, personal or family history, nulliparity, 1st pregnancy with new partner, obesity, DM, CKD, vascular disease

management

  • <160/110 conservative (rest, SNAP)
  • > 160/110 methyldopa, labetolol, nifedipine
26
Q

pre eclampsia definition and evidence of end organ damage

A

> /=140/90 and >20 weeks gestation plus evidence of end organ damage

renal - proteinuria (2+ dipstick, >30mg/mmol PCR, >300mg/day 24hr urine), AKI (Cr >90), oliguria (<0.5mg/kg/hr)

liver - increase ALT and AST, epigastric or RUQ pain

neuro - headache, blurred vision, central scotoma, hyper reflex, clonus

haem - thrombocytopenia, haemolysis, DIC

foetus - growth restriction, distress

27
Q

risk factors for pre eclampsia

A

maternal - extremes of age, DM, obesity, CKD, vascular disease, HTN, thrombophilia, family or personal hx of pre eclampsia, primigravida or 1st pregnancy with new partner

pregnancy related - multiple pregnancy, molar pregnancy

28
Q

pre eclampsia pathophysiology

A
  • trophoblasts have incomplete invasion into endometrium with poor development of spiral arteries (shallow placentation)
  • reduced placental perfusion
  • placenta releases vasoactive and prothrombotic substances
  • systemic vascular dysfunction, capillary leakage and vasospasm
29
Q

complications of pre eclampsia

A

maternal - eclampsia, renal and liver failure, HELLP, DIC, ICH, LVF, APO

foetal - IUGR, hypoxia, placental abruption, death

30
Q

pre eclampsia physical examination

A

general - SOB, LOC, oedema, bruising, n&v
vitals
anthropometry
neuro - eye exam, fundoscopy, hyperreflexia, clonus
cardiorespiratory - S3/S4 (heart failure), APO
peripheries - oedema
abdo - liver tenderness, SFH, lie, position, presentation, engagement
USS of uterus

31
Q

investigations for pre eclampsia

A

bedside - urine dipstick, BP
labs - urine PCR, FBC, UEC, LFT, uric acid, (+/- blood film, coagulation, fibrinogen, LDH)
foetus - CTG, USS

32
Q

management of pre eclampsia

A

resus - call obstetrics, A&B, left lateral position, >160/110 use labetolol / methyldopa / nifedipine, caution IVF (APO), MgSO4 if seizures or neuro symptoms, midazolam if ongoing seizures

admission - immediate with monitoring and consider TOP or delivery

give corticosteroids for baby

33
Q

indications to delivery in pre eclampsia

A 
37 weeks mild PET
34 weeks severe PET
uncontrolled HTN or heart failure 
persistent neuro signs 
seizures
deteriorating renal function 
HELLP
deranged LFTs
severe thrombocytopenia

severe IUGR
foetal distress
placental abruption

34
Q

types of mono and dizygotic twins and when they split

A

dizygotic - always dichorionic diamniotic (DCDA), 2 sperm and 2 ova

monozygotic - MCMA or MCDA or DCDA
DCDA - split before implantation, 1-3 days
MCDA - split as implanting, 4-7 days
MCMA - split after implantation >7 days

35
Q

complications of twin pregnancies

A

general - usual complications of pregnancy but more severe and earlier
eg pre-eclampsia, IUGR, GDM, miscarriage or stillbirth, APH, PPH, PTL, PPROM

specific
twin-twin transfusion syndrome 
malpresentation 
asphyxiation of twin 2
cord entanglement
PPH
36
Q

management of multiple pregnancy antenatally

  • counsel
  • supplements
  • USS
  • screening
A

counsel - increased risk of complications, c section delivery recommended
antenatal care - high risk clinic at hospital, USS every 4 weeks from 24 weeks
prenatal screening - bHCG, PAPP-A and NIPT less accurate
supplements - folate 5mg (not 0.5mg as usual), iodine, +/- B12/folate, +/- iron

37
Q

management of vaginal delivery for twins

A

only done if first twin is cephalic presentation

IV access
epidural recommended
monitoring: CTG, vitals, scalp electrode, USS

delivery:
deliver 1st
immediate IV oxytocin after first delivery
leave membranes intact for second until head descended in pelvis OR ruled out cord prolapse
if CTG abnormal - forceps delivery

38
Q

post dates pregnancy - definition and complications

A

> 42 weeks gestation

post maturity syndrome 
still birth
macrosomia
oligohydramnios 
foetal asphyxia from cord compressions 
foetal distress 
meconium aspiration
39
Q

management of post dates pregnancy (41 week antenatal appointment)

A

41 week antenatal appointment
assess pregnancy - hx, foetal movements, passage of blood/fluid, vitals, abdo palp
CTG and USS
book IOL for 41+3

if declined IOL - frequent CTG and AFI monitoring until delivery

40
Q

SGA and IUGR definition and parameters used to assess size

A

<10th percentile
SGA - may or may not be pathological
IUGR - pathological cause

head circumference
abdominal circumference
foetal length

1st trimester; CRL
3rd trimester; biparietal diameter, HC, abdominal circumference

41
Q

Risk factors for IUGR

A

maternal: small parents, Asian, extremes of age (<18, >35), previous SGA baby, malnutrition, smoking, substance abuse, HTN, PET, anaemia, chronic disease
foetal: chromosomal abnormalities, multiple pregnancy, intrauterine infection, congenital anomalies
placenta: smoking, twin to twin transfusion syndrome, abruption, accreta, infarction, low placental weight or SA

42
Q

Symmetrical vs asymmetrical growth plot

A

symmetrical: growth trajectory remains constant at the lower end of normal
asymmetrical: growth trajectory crosses lines

43
Q

Complications of IUGR/SGA

A

intrauterine - stillbirth

labour - asphyxia (insufficient utero-placental perfusion in labour)

postnatal - low BGL, polycythemia, respiratory distress

44
Q

antenatal management of IUGR

  • maternal
  • Ix
  • Rx
  • delivery
A

maternal - assess for pre eclampsia, screen for infection

ix

  • offer amniocentesis
  • USS and foetal doppler
  • CTG

Rx

  • refer maternal foetal medicine
  • low dose aspirin
  • prednisone if <34 weeks

delivery

  • depends on results
  • early delivery if poor placental flow, growth stops, abnormal AFI
45
Q

LGA causes and complications

A

causes: large mum, African, GDM, obesity, congenital anomalies
complications: shoulder dystocia, fractures, neonatal resp distress, MAS

46
Q

Causes and risk factors for sepsis in pregnancy/labour/postnatal

A

causes: episiotomy, CS, PROM, septic abortion, chorioamnionitis, urosepsis, aspiration pneumonia

RF

  • multiple VE during labour (>5)
  • CS
  • PROM
  • obstetric manoeuvres
  • multiple pregnancy
47
Q

Chorioamnionitis mx

A

if pre viable age - TOP

viable age - must deliver to protect mother

Abx - ampicillin, gentamicin, metronidazole

48
Q

Ddx for abdominal pain in pregnancy

A

<24 weeks: round ligament strain, ectopic, miscarriage, septic abortion, ruptured CL cyst

> 24 weeks: braxtonhicks, PTL, labour, placental abruption, chorioamnionitis, pre eclampsia

pregnancy related: UTI, cholestasis, GORD

other: PUD, appendicitis, renal calculi, AAA, aortic dissection

49
Q

pathophysiology of rhesus disease of newborn

A

○ Rh -ve mother & Rh +ve foetus –> sensitisation occurs –> mother forms Rh antibodies after exposure to Rh+ blood (usually occurs subsequently to exposure in a first pregnancy) –> in subsequent pregnancies Rh antibodies cross the placenta and bind to foetal RBCs –> haemolysis

Sensitisation events - normal delivery, miscarriage, termination, ectopic, abdominal trauma, antepartum haemorrhage

50
Q

risks of NSAIDs in pregnancy

A

premature closure of ductus arteriosus

possible increase in miscarriage (inhibits prostaglandin)

foetal renal impairment

51
Q

MgSO4 dosing

A

4g over 15-30 minutes

1g/hr after that for 24 hours

RNH (9 decks)

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