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Pregnancy Flashcards

(51 cards)

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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

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

Clinical features of placental abruption

Study These Flashcards
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’

Study These Flashcards
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

Study These Flashcards
A 
chronic HTN
gestational HTN
pre eclampsia
eclampsia
chronic HTN with superimposed pre eclampsia
25
gestational HTN - definition - risk factors - management (conservative vs medical)
>/=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
pre eclampsia definition and evidence of end organ damage
>/=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
risk factors for pre eclampsia
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
pre eclampsia pathophysiology
- 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
complications of pre eclampsia
maternal - eclampsia, renal and liver failure, HELLP, DIC, ICH, LVF, APO foetal - IUGR, hypoxia, placental abruption, death
30
pre eclampsia physical examination
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
investigations for pre eclampsia
bedside - urine dipstick, BP labs - urine PCR, FBC, UEC, LFT, uric acid, (+/- blood film, coagulation, fibrinogen, LDH) foetus - CTG, USS
32
management of pre eclampsia
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
indications to delivery in pre eclampsia
``` 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
types of mono and dizygotic twins and when they split
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
complications of twin pregnancies
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
management of multiple pregnancy antenatally - counsel - supplements - USS - screening
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
management of vaginal delivery for twins
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
post dates pregnancy - definition and complications
>42 weeks gestation ``` post maturity syndrome still birth macrosomia oligohydramnios foetal asphyxia from cord compressions foetal distress meconium aspiration ```
39
management of post dates pregnancy (41 week antenatal appointment)
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
SGA and IUGR definition and parameters used to assess size
<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
Risk factors for IUGR
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
Symmetrical vs asymmetrical growth plot
symmetrical: growth trajectory remains constant at the lower end of normal asymmetrical: growth trajectory crosses lines
43
Complications of IUGR/SGA
intrauterine - stillbirth labour - asphyxia (insufficient utero-placental perfusion in labour) postnatal - low BGL, polycythemia, respiratory distress
44
antenatal management of IUGR - maternal - Ix - Rx - delivery
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
LGA causes and complications
causes: large mum, African, GDM, obesity, congenital anomalies complications: shoulder dystocia, fractures, neonatal resp distress, MAS
46
Causes and risk factors for sepsis in pregnancy/labour/postnatal
causes: episiotomy, CS, PROM, septic abortion, chorioamnionitis, urosepsis, aspiration pneumonia RF - multiple VE during labour (>5) - CS - PROM - obstetric manoeuvres - multiple pregnancy
47
Chorioamnionitis mx
if pre viable age - TOP viable age - must deliver to protect mother Abx - ampicillin, gentamicin, metronidazole
48
Ddx for abdominal pain in pregnancy
<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
pathophysiology of rhesus disease of newborn
○ 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
risks of NSAIDs in pregnancy
premature closure of ductus arteriosus possible increase in miscarriage (inhibits prostaglandin) foetal renal impairment
51
MgSO4 dosing
4g over 15-30 minutes | 1g/hr after that for 24 hours

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