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Pregnancy Flashcards

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1
Q

What is the definition of small for gestational age

A

Birth weight <10th centile for gestational age

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2
Q

What is severe SGA

A

Birth weight <3rd centile

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3
Q

What are the measurements used to calculate size for gestational age

A

Estimated fetal weight

Abdominal circumference

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4
Q

What would be classed as a low birth weight

A

<2500g

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5
Q

What is fetal growth restriction

A

Pathological process restricting genetic growth potential

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6
Q

How does fetal growth restriction present

A

Fetal compromise

  • Reduced liquor volume
  • Abnormal doppler
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7
Q

What does normal (constitutionally) small mean

A

Small size at every stage

Following along for their own centile

No pathology present

Due to ethnicity, sex, parental height

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8
Q

What is placenta-mediated growth restriction

A

Normal growth initially

Growth slows in utero

Common cause of fetal growth restriction

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9
Q

What are the maternal factors that can cause placenta-mediated growth restriction

A

Low pre-pregnancy weight

Substance abuse

Autoimmune disease

Renal disease

Diabetes

Chronic hypertension

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10
Q

What is non-placenta mediated growth restriction

A

Growth affected by fetal factors

  • Chromosomal abnormalities
  • Structural anomalies
  • Metabolic errors
  • Fetal infection
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11
Q

When are risk factors for small for gestational age assessed

A

Booking

20 week scan

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12
Q

What are the minor risk factors for small for gestational age

A

Age >35

Smoking 1-10 per day

Nulliparity

BMI <20 or 25-35

IVF singleton

Previous pre-eclampsia

Pregnancy interval <6 or >60 months

Low fruit intake pre-pregnancy

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13
Q

What are the major risk factors for small for gestational age

A

Age >40

Smoking >11 per day

Previous SGA baby

Maternal/paternal SGA

Previous stillbirth

Cocaine use

Daily vigorous exercise

Maternal chronic disease

Heavy bleeding

Low PAPP-A

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14
Q

How is small for gestational age diagnosed

A

Ultrasound

Values plotted on customised centile chart

Measure head circumference and abdominal circumference

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15
Q

What does the head to abdominal circumference ratio tell us

A

Symmetrically small
- More likely to be constitutionally small

Asymmetrically small
- More likely to be placental insufficiency

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16
Q

What would be seen on doppler for small for gestational age

A

‘Brain-sparing’ effect

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17
Q

What investigations are used to assess for small for gestational age

A

Ultrasound

Detailed fetal anatomical survey

Uterine artery doppler

Karyotyping

Screening for infections (cytomegalovirus, toxoplasmosis, syphilis, malaria…)

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18
Q

What can be done to prevent small for gestational age babies

A

Smoking cessation

Optimise maternal health

If high risk of pre-eclampsia, start aspirin

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19
Q

What surveillance is needed as part of the management of small for gestational age

A

Uterine artery doppler every 14 days

Symphysis fundal height

Middle cerebral artery doppler

Ductus venosus doppler

CTG

Amniotic fluid volume

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20
Q

When would you decide to deliver small for gestational age babies

A

If considering delivery before 35 weeks, give antenatal steroids

Before 37 weeks, C-section

After 37 weeks, offer induction

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21
Q

What are the complications associated with small for gestational age babies

A

Increased risk of stillbirth

Neonatal complications: birth asphyxia, meconium aspiration, hypothermia, hyper/hypoglycaemia…

Long-term complications: cerebral palsy, T2DM, obesity, HTN, precocious puberty…

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22
Q

When do pregnant women have maternal blood group and antibody tests

A

Booking (8-12 weeks)

28 weeks

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23
Q

When are RhD- women routinely given anti-D prophylaxis

A

28 and 34 weeks

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24
Q

What are some ‘sensitisation events’ that can cause RBC isoimmunisation

A

Antepartum haemorrhage

Abdominal trauma

Delivery

Invasive obstetric testing

Ectopic pregnancy

External cephalic version

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25
How do anti-D immunoglobulins work
Bind RhD+ cells in maternal circulation Prevent mounting of an immune response Intrauterine death/miscarriage Termination of pregnancy
26
What blood tests should be done following a sensitisation event for RBC isoimmunisation
Maternal blood group and antibody screen Feto-maternal haemorrhage test (Kleihauer test) - Assesses how much fetal blood has entered maternal circulation Check Rhesus status of baby after delivery
27
How long post-partum should anti-D be given
72 hours
28
What is a prolonged pregnancy
Pregnancy that goes beyond 42 weeks 5-10% of pregnancies
29
What are the risk factors for prolonged pregnancy
Nulliparity Age >40 Previous prolonged pregnancy Obesity Family history
30
What are the complications associated with prolonged pregnancy
Significant increase in stillbirths Increased chance of placental insufficiency Placental degradation
31
What are the clinical features of prolonged pregnancy
Static growth Potential macrosomia Oligohydramnios Reduced fetal movements Presence of meconium Dry/flaky skin (reduced vernix)
32
What is the main differential diagnosis for prolonged pregnancy
Inaccurate dating
33
What is the management for prolonged pregnancy
Deliver by 42 weeks to reduce risk of stillbirth Membrane sweep (from 40 in nulliparous, from 41 in multiparous) Induction of labour
34
If a mother declines induction in prolonged pregnancy, how should she be monitored
Twice weekly CTG monitoring USS with amniotic fluid measurement Look out for fetal distress
35
What is miscarriage
Loss of pregnancy at <24 weeks Early miscarriage: 12-13 weeks Late miscarriage: 13-24 weeks
36
Roughly how many pregnancies end in miscarriage
20-25%
37
What are the risk factors for miscarriage
Age >35 Previous miscarriage Obesity Chromosomal abnormalities Smoking Uterine anomalies Previous uterine surgery Anti-phospholipid syndrome Coagulopathies
38
How might a woman with a miscarriage present
Vaginal bleeding (may pass products of conception) Suprapubic cramping pain Many found incidentally
39
What might you see on speculum examination of a woman with a miscarriage
Abnormal diameter of cervix Products of conception in cervical canal Localised bleeding
40
What are the differential diagnoses for miscarriage
Ectopic pregnancy Hydatidiform mole Cervical/uterine malignancy
41
What investigations are needed in miscarriage
Transvaginal ultrasound Mean sac diameter (>25mm = failed pregnancy, <25mm = repeat scan in 10-14 days) Bloods (beta-HCG, FBC, CRP...)
42
What is the management of miscarriage in RhD- women
If >12 weeks, need anti-D prophylaxis If surgical management, need anti-D regardless of gestational age
43
What is the conservative management of miscarriage
Allow for products of conception to pass naturally Can stay at home, no side effects... Unpredictable timing, heavy bleeding, pain... Follow up scan in 2 weeks or pregnancy test in 3 weeks Contraindications: infection, high risk haemorrhage, haemodynamic instability
44
What is the medical management of miscarriage
Vaginal misoprostol (prostaglandin analogue) Stimulates cervical ripening and myometrial contraction Give mifepristone 24-48 hours before admission Follow up pregnancy test in 3 weeks
45
What is the surgical management of miscarriage
Manual vacuum aspiration with local anaesthetic if <12 weeks Or evacuate retained products of conception under GA Definitive indications: haemodynamic instability, infected tissue, gestational trophoblastic disease
46
What is recurrent miscarriage
3 or more consecutive pregnancies that end in miscarriage before 24 weeks
47
What can cause recurrent miscarriage
Antiphospholipid syndrome (15% of women with recurrent miscarriage) Chromosomal abnormalities Diabetes Thyroid disease PCOS Anatomical abnormalities Infection Inherited thrombophilias
48
What are the risk factors for recurrent miscarriage
Advanced maternal age Number of previous miscarriages Smoking Heavy alcohol
49
What investigations are needed for recurrent miscarriages
Blood tests (antiphospholipid antibodies, inherited thrombophilia screen) Karyotyping Pelvic USS
50
What is the management for recurrent miscarriage
Refer to specialist clinic Genetic abnormalities - Genetic counselling/familial chromosomal studies - Other reproductive options Anatomical abnormalities - Cervical cerclage (suture cervix closed), serial cervical sonographic surveillance Thrombophlias and antiphospholipid syndrome - Heparin therapy throughout pregnancy
51
What are the most common sites of implantation in ectopic pregnancy
Ampulla or isthmus of fallopian tube
52
What are the rare sites of implantation of ectopic pregnancy
Ovary, cervix, peritoneal cavity
53
What is an ectopic pregnancy
Pregnancy implanted outside uterine cavity
54
What are the risk factors for an ectopic pregnancy
Previous ectopic pregnancy PID Endometriosis Coil POP Pelvic surgery Assisted reproduction
55
How may a woman with an ectopic pregnancy present
Pain Vaginal bleeding Shoulder tip pain Brown vaginal discharge Abdominal tenderness
56
What would you find on vaginal examination of a woman with an ectopic pregnancy
Cervical excitation Adnexal tenderness Fullness in pouch of Douglas (if ruptured)
57
What are the differential diagnoses for an ectopic pregnancy
Miscarriage Ovarian cyst haemorrhage/torsion/rupture Acute PID UTI Appendicitis Diverticulitis
58
What investigations are needed for an ectopic pregnancy
Pregnancy test Pelvic/transvaginal USS b-HCG - >1500 and no pregnancy seen, ectopic until proven otherwise - <1500, redo in 48 hours (double in pregnancy, half in miscarriage)
59
What is the medical management for ectopic pregnancy
IM methotrexate (anti-folate cytotoxic agent) Monitor b-HCG to make sure that it is declining Indications: b-HCG <1500, unruptured, no visible heartbeat
60
What is the surgical management for ectopic pregnancy
Tubal ectopics: laparoscopic salpingectomy If have damage to contralateral tube, try salpingostomy (preserve tube) Indications: severe pain, b-HCG >5000, adnexal mass >34 mm, visible heartbeat
61
What is the conservative management for ectopic pregnancy
Watchful waiting Only if rupture is very unlikely Monitor b-HCG every 48 hours
62
What are the complications of ectopic pregnancy
Rupture Hypovolaemic shock
63
What is gestational trophoblastic disease
Group of pregnancy-related tumours Can be pre-malignant (more common) or malignant
64
What are some examples of pre-malignant gestational trophoblastic disease
Partial molar pregnancy Complete molar pregnancy
65
What are some examples of malignant gestational trophoblastic disease
Invasive mole Choriocarcinoma Placental trophoblastic site tumour Epithelioid trophoblastic tumour
66
What is a molar pregnancy
A gestational trophoblastic disease Abnormality in chromosomal number during fertilisation Partial = 69 chromosomes Complete = 46 chromosomes Usually benign but can become malignant
67
What is a choriocarcinoma
A gestational trophoblastic disease Malignancy of trophoblastic cells of placenta Often co-exists with molar pregnancy Metastasises to lung
68
What is a placental site trophoblastic tumour
A gestational trophoblastic disease Malignancy of intermediate trophoblasts (anchor placenta to uterus)
69
What is an epithelioid trophoblastic tumour
A gestational trophoblastic disease Malignancy of trophoblastic placental cells Mimics a squamous cell carcinoma
70
What are the risk factors for gestational trophoblastic disease
Age <20 or >35 Previous gestational trophoblastic disease Previous miscarriage Oral contraceptive use
71
What are the clinical features of a molar pregnancy
Vaginal bleeding and abdominal pain early in pregnancy Large, soft, boggy uterus
72
If gestational trophoblastic disease goes undiagnosed, what might the mother develop
Hyperemesis (higher b-HCG) Hyperthyroidism (gestational thyrotoxicosis due to b-HCG) Anaemia
73
What investigations are needed for gestational trophoblastic disease
Urine/blood b-HCG Ultrasound (complete mole = granular/snowstorm appearance) Histological examination of products of conception (post-treatment for molar pregnancy) If suspect metastases, staging CT/MRI
74
What is the management of gestational trophoblastic disease
Register patient with GTD centre for follow up and monitoring of future pregnancies Molar pregnancy - Suction curette - Medical evacuation - May need chemotherapy
75
What is placental abruption
Part/all of placenta separates from uterine wall prematurely Important cause of antepartum haemorrhage
76
What is the pathophysiology of placental abruption
Rupture of maternal vessels in basal layer of endometrium Blood accumulation splits placenta from uterine wall Detached bit of placenta unable to function - get fetal compromise
77
What are the 2 main types of placental abruption
Revealed - Blood drains through cervix, get PV bleeding Concealed - Blood stays in uterus, get a retroplacental clot
78
What are the risk factors for placental abruption
Placental abruption in previous pregnancy Pre-eclampsia Abnormal lie Polyhydramnios Abdominal trauma Smoking Drug use Bleeding in 1st trimester Underlying thrombophilia Multiple pregnancy
79
What are the clinical features of placental abruption
Painful vaginal bleeding Woody uterus Pain on abdominal examination
80
What are the differential diagnoses for placental abruption
Placenta praevia Marginal placental bleeding (small abruption, not big enough to cause compromise) Vasa praevia Uterine rupture Polyps/carcinoma/cervical ectropion Candida/bacterial vaginosis, chlamydia
81
What investigations are needed for placental abruption
Bloods Assess fetal wellbeing (if >26 weeks, use CTG) Ultrasound
82
What is the management of placental abruption
ABCDE Emergency delivery (if have compromise) Induction of labour (at term, everyone stable) Conservative management (partial abruption) Anti-D within 72 hours of onset of bleeding for RhD- women
83
What is placenta praevia
Placenta fully/partially attached to lower uterine segment Important cause of antepartum haemorrhage Placenta may be damaged by presenting part of baby
84
What are the 2 main types of placenta praevia
Minor - Placenta low, but not covering internal os Major - Placenta lying over internal os
85
Placentas in what position are most susceptible to haemorrhage
Low-lying placentas
86
What are the risk factors for placenta praevia
Previous C-section High parity Age >40 Multiple pregnancy Previous placenta praevia History of uterine infection Curette of endometrium (after miscarriage/termination)
87
What are the clinical features of placenta praevia
Painless vaginal bleeding Not tender on palpation
88
What are the differential diagnoses of placenta praevia
Placental abruption Vasa praevia Uterine rupture Polyps/carcinoma/cervical ectropion Candida/bacterial vaginosis/chlamydia
89
How does vasa praevia present
Vaginal bleeding Rupture of membranes Fetal compromise
90
What are the investigations needed for placenta praevia
Bloods Assess fetal wellbeing (if >26 weeks, use CTG) Ultrasound scan
91
What is the management of placenta praevia
ABCDE Minor - repeat scan an 36 weeks, placenta likely to have moved Major - repeat scan at 32 weeks and make plan for delivery (Initial scan at 20 weeks) Confirmed placenta praevia - C-section at 38 weeks Anti-D within 72 hours of bleeding for RhD- women
92
What is a breech presentation
When fetus presents with buttocks or feet first 20% breech at 28 weeks, but most move to have cephalic presentation
93
What are the 3 different types of breech presentation
Complete (flexed) Frank (extended) Footling
94
What is a complete (flexed) breech
Both legs flexed at knees and hips In a 'cross-legged' position
95
What is a frank (extended) breech
Both legs flexed at hip, extended at knees Most common type of breech
96
What is a footling breech
One or both legs extended at hip Foot presents first
97
What are the uterine risk factors for breech presentation
Multiparity Uterine malformation (septate uterus...) Fibroids Placenta praevia
98
What are the fetal risk factors for breech presentation
Prematurity Macrosomia Polyhydramnios Twins Anencephaly
99
When does a diagnosis of breech presentation become significant
32-35 weeks
100
What is found on clinical examination in breech presentations
Round head at upper end of uterus Irregular mass at pelvis Fetal heart auscultated in abdomen
101
How many breech presentations are spotted at labour
20% Significant fetal distress (meconium-stained liquor) Sacrum/foot coming through cervix
102
What are the differential diagnoses for breech presentation
Oblique lie Transverse lie Unstable lie
103
What investigations are needed in breech presentations
Ultrasound
104
What are the methods of management for breech presentations
External cephalic version C-section Vaginal breech delivery
105
What is external cephalic version
Manipulation of fetus to cephalic presentation through maternal abdomen Aim to attempt vaginal delivery 40% success in primips, 60% success in multips
106
What are the complications of external cephalic version
Fetal heart rate abnormalities (most revert back to normal) Placental abruption May need emergency C-section
107
What are the contraindications for external cephalic version
Recent antepartum haemorrhage Ruptured membranes Uterine abnormalities Previous C-section
108
What is a vaginal breech delivery
For those that choose to deliver vaginally, or present in advanced labour Contraindicated in footling breech No traction applied (head can expand and get stuck) Can use specific manoeuvres if baby gets stuck, may need forceps
109
What are the complications of breech presentations
Cord prolapse Fetal head entrapment Premature rupture of membranes Birth asphyxia (if have delay in delivery) Intracranial haemorrhage (rapid compression of head)
110
What does the lie of a fetus describe
Relationship between long axis of fetus and maternal pelvis Longitudinal, transverse, or oblique
111
What does the presentation of a fetus describe
Fetal part that first enters maternal pelvis Cephalic, breech, shoulder, face, or brow
112
What does the position of a fetus describe
Position of fetal head as it exits birth canal Head usually emerges in occipito-anterior position
113
What are the risk factors for abnormal fetal lie/presentation/position
Prematurity Multiple pregnancies Uterine abnormalities Fetal abnormalities Placenta praevia Primiparity
114
What investigations are needed for abnormal fetal lie/presentation/position
Ultrasound
115
What is the management for abnormal fetal lie
External cephalic version At 36-38 weeks
116
What is the management for malpresentation
Breech - Attempt ECV - Vaginal breech/C-section Brow - C-section Face - Chin anterior = vaginal, chin posterior = C-section Shoulder - C-section
117
What is the management for malposition
90% revert to occipito-anterior position as labour progresses If head does not rotate, can physically rotate/use operative vaginal delivery C-section may be needed
118
What is oligohydramnios
Low levels of amniotic fluid Below 5th centile for gestational age
119
What happens to the level of amniotic fluid as a pregnancy progresses
Increases until 33 weeks Plateaus from 33-38 weeks Decreases after 38 weeks Around 500ml at term Mostly fetal urine output
120
What can cause oligohydramnios
Preterm premature rupture of membranes Placental insufficiency Renal agenesis (Potter's syndrome) Non-functioning fetal kidney Obstetric uropathy Genetic/chromosomal abnormalities Viral infections
121
How is oligohydramnios diagnosed
Ultrasound Amniotic fluid index - Measures maximum pockets of fluids in 4 quadrants and adds them together Maximum pool depth - Vertical measurement of the area
122
What is the management of oligohydramnios due to ruptured membranes
Labour likely to commence in 24-48 hours If <37 weeks, steroids, induce, antibiotics
123
What is the management of oligohydramnios due to placental insufficiency
Deliver at 36-37 weeks
124
What is the prognosis for oligohydramnios
In second trimester, poor prognosis (PROM, prematurity, pulmonary hypoplasia) Disability (not able to move muscles as much in utero)
125
What is polyhydramnios
Abnormally large amounts of amniotic fluid Above 95th centile
126
What are the causes of polyhydramnios
Idiopathic (60% cases) Conditions stopping fetus swallowing (oesophageal atresia, CNS abnormalities, muscular dystrophy...) Duodenal atresia ('double bubble' sign on USS) Anaemia Fetal hydrops Twin-to-twin transfusion syndrome Increased lung secretions Genetic/chromosomal abnormalities Maternal diabetes Maternal ingestion of lithium Macrosomia
127
How is polyhydramnios diagnosed
Ultrasound Amniotic fluid infex - Measures maximum pockets of fluids in 4 quadrants and adds them together Maximum pool depth - Vertical measurement of the area
128
How is polyhydramnios managed
Usually need no intervention Amnioreduction Indomethacin (enhances water retention, reduces fetal urine output, not to be used past 32 weeks) If idiopathic, need paeds review before 1st feed
129
What are the complications of polyhydramnios
High perinatal mortality Increased rates of malpresentation Cord prolapse PROM PPH
130
What is pre-eclampsia
A hypertensive disorder of pregnancy A placental disease (due to poor placental perfusion) Can lead to life-threatening maternal/fetal compromise
131
What is the pathophysiology of pre-eclampsia
Incomplete remodelling of spiral arteries High resistance, low-flow uteroplacental circulation Get high blood pressure, hypoxia, and oxidative stress
132
What are the moderate risk factors for pre-eclampsia
Nulliparity Age >40 BMI > 35 Family history Pregnancy interval >10 years Multiple pregnancy
133
What are the high risk factors for pre-eclampsia
Chronic hypertension HTN/pre-eclampsia/eclampsia in previous pregnancy Pre-existing CKD Diabetes Autoimmune disease
134
What is the prophylactic treatment for pre-eclampsia
For those with 1 high or 2 moderate risk factors 75 mg aspirin daily From 12 weeks to birth
135
What are the 3 criteria of pre-eclampsia
Hypertension (>140 or >90 on 2+ occasions) Significant proteinuria >20 weeks gestation
136
What are the symptoms of pre-eclampsia
Most asymptomatic Headaches (frontal) Visual disturbances Epigastric pain Sudden onset non-dependent oedema Hyper-reflexia
137
What are the 3 classifications of pre-eclampsia
Mild - 140/90 - 149/99 Moderate 150/100-159/109 Severe >160/110 or >140/90 with proteinuria and symptoms
138
When is the prognosis of pre-eclampsia poorest
Onset before 34 weeks
139
What are the maternal complications of pre-eclampsia
HELPP syndrome (haemolysis, elevated liver enzymes, low platelets) Eclampsia AKI DIC Adult respiratory distress syndrome Post-partum hypertension Cerebrovascular haemorrhage Death
140
What are the fetal complications of pre-eclampsia
Prematurity Intrauterine growth restriction Placental abruption Intrauterine fetal death
141
What are the differential diagnoses of pre-eclampsia
Essential hypertension (<20 weeks) Pregnancy-induced hypertension (>20 weeks, but no proteinuria) Eclampsia (pre-eclampsia with seizures)
142
What investigations are needed in pre-eclampsia
Blood pressure Urine dip Monitoring for signs of organ damage (U&Es, LFTs...)
143
What is the management for pre-eclampsia
Monitor maternal and fetal wellbeing VTE prophylaxis (LMWH) Antihypertensives Delivery (definitive cure) Post-natal care
144
What anti-hypertensives are used in pre-eclampsia
Labetalol - First line - Beta blocker Nifedipine - CCB Methyldopa - Alpha agonist ACE inhibitors contraindicated (linked to congenital abnormalities)
145
What post-natal care is needed for pre-eclampsia
Monitor mother for 24 hours post-partum - Risk of eclamptic seizures - Considered 'safe' after 5 days Monitor blood pressure - First 2 days post-partum - Once between day 3-5 - Reassess need for antihypertensives
146
What is hyperemesis gravidarum
Persistent and severe vomiting during pregnancy Leads to weight loss, dehydration, and electrolyte imbalance
147
What are the normal patterns of nausea and vomiting in pregnancy
Starts at 4-7 weeks Peaks in 9th week Settles by 20 weeks Due to b-HCG stimulating chemoreceptor trigger zone in brain
148
What is the diagnostic criteria for hyperemesis gravidarum
Prolonged and severe vomiting >5% pre-pregnancy weight loss Dehydration Electrolyte imbalance
149
What are the risk factors for hyperemesis gravidarum
First pregnancy Previous hyperemesis gravidarum High BMI Multiple pregnancy Hydatidiform mole
150
What scoring system is used for hyperemesis gravidarum
Pregnancy-unique quantification of emesis (PUQE) - Up to 6 = mild - 7-12 = moderate - 13-15 = severe
151
What are the differential diagnoses for hyperemesis gravidarum
Gastroenteritis Cholecystitis Hepatitis Pancreatitis Peptic ulcer UTI/pyelonephritis Drug-induced
152
What investigations are needed for hyperemesis gravidarum
Weight Urine dip, MSU Bloods Glucose Ultrasound
153
What is the management of hyperemesis gravidarum
Mild managed in community, moderate managed in ambulatory daycare, severe managed as inpatient IV rehydration H2 receptor antagonist/PPI - For reflux, oesophagitis or gastritis Thiamine - Prevents Wernicke's encephalopathy in prolonged vomiting Thromboprophylaxis Antiemetics
154
What are the recommended antiemetics for hyperemesis gravidarum
First line - Cyclizine, prochlorperazine, promethazine, chlorpromazine Second line - Metoclopramide, domperidone, ondansetron Third line - IV hydrocortisone
155
What is gestational diabetes
Any degree of glucose intolerance with onset or first recognition during pregnancy Increasing in incidence
156
What happens to insulin resistance during pregnancy
Increases Those with poor pancreatic reserve can not deal with increased demand
157
What are the risk factors for gestational diabetes
BMI >30 Asian Previous gestational diabetes 1st degree relative with diabetes PCOS Previous macrosomic baby
158
What are the clinical features of gestational diabetes
Mostly asymptomatic Polyuria Polydipsia Fatigue
159
What are the fetal complications of gestational diabetes
Macrosomia Organomegaly Erythropoiesis Increased rates of pre-term delivery Reduced surfactant production
160
What happens to babies of mothers with gestational diabetes after birth
Fetal insulin levels stay high No longer getting glucose from mother Risk of hypoglycaemia Need to ensure regular feeding
161
What are the investigations needed for gestational diabetes
Oral glucose tolerance test - Diagnostic criteria: fasting >5.6, 2hrs postprandial >7.8 Offered at - Booking - 24-28 weeks (if have risk factors) - Any point in pregnancy if have glycosuria
162
What is the management for gestational diabetes
Lifestyle advice Measure capillary glucose 4 times per day Medical management Additional growth scans (at 28, 32 and 36 weeks) Aim to deliver at 37-38 weeks if on treatment Post-natal care
163
What is the medical management for gestational diabetes
Metformin Insulin - If fasting >7 - If abdominal circumference >95th centile Gibenclamide - If metformin not tolerated and insulin refused
164
What post-natal care is needed in gestational diabetes
Stop all anti-diabetic medication immediately after delivery Do fasting glucose test at 6-13 weeks post-partum Yearly screen for diabetes
165
What is cytomegalovirus
Member of herpesvirus family Most common virus transmitted to fetus during pregnancy Highest risk in first trimester
166
What are the clinical features of cytomegalovirus in pregnancy
Mostly asymptomatic Mild flu-like symptoms Fever Splenomegaly Impaired liver function
167
What investigations are needed if maternal cytomegalovirus infection is suspected
Viral serology for CMV specific IgM and IgG
168
What is the management of cytomegalovirus in pregnancy
Refer to fetal medicine specialist Maternal - No treatment for immunocompetent women Fetal - Diagnosis via amniocentesis and PCR - Test done after 21 weeks - Termination of pregnancy offered (chances of malformations and congenital CMV)
169
What are the congenital cytomegalovirus effects on the baby
Intrauterine growth restriction Hepatosplenomegaly Thrombocytopenia purpura Jaundice Microcephaly Chorioretinitis 20-30% mortality If born without symptoms, 15% chance that they will soon develop: sensorineural hearing loss, psychomotor developmental delay, visual impairment
170
What are the risk factors for GBS infection of the neonate
GBS infection in previous baby <37 weeks Rupture of membranes >24 hours before delivery Pyrexia during labour Positive test for GBS in mother Mother diagnosed with UTI due to GBS in pregnancy
171
What are the maternal symptoms of GBS infection
UTI Chorioamnionitis Endometritis
172
What are the symptoms of neonatal GBS infection
Pyrexia Cyanosis Difficulty breathing and feeding Floppiness
173
What investigations are needed to detect GBS in the mother
Swab (first in vagina, then in rectum) Urine culture (if have UTI)
174
What is done to prevent GBS infection of the newborn
High dose IV penicillin (benzylpenicillin) throughout labour for women with: - GBS +ve swab - UTI due to GBS in pregnancy - Previous baby with GBS infection - Pyrexia during labour - Labour at <37 weeks - Rupture of membranes >18 hours
175
What is Parvovirus B19
Mild, self-limiting infection in adults Can cause spontaneous miscarriage and intrauterine death
176
What are the symptoms of parvovirus B19 infection
Asymptomatic in adults In children: URTI, malaise, headaches, low grade fever, erythema infectiosum (slapped cheek syndrome)
177
What investigations are needed for parvovirus B19 infection
Viral serology (IgM and IgG antibodies)
178
What is the management of parvovirus B19 infection in pregnancy
Refer to fetal medicine specialist Maternal - No need for treatment - Consider antipyrexials and analgesia Fetal - Risk of fetal hydrops (abnormal accumulation of fluid in fetal compartments) - Serial USS and doppler (start 4 weeks post-infection, every 1-2 weeks until 30 weeks) If evidence of fetal hydrops, refer to tertiary care for intrauterine erythrocyte transfusion
179
What are the symptoms of fetal hydrops
Ascites Subcutaneous oedema Pleural effusion Pericardial effusion Scalp oedema Polyhydramnios Severe anaemia
180
What are the signs and symptoms of Rubella infection
Often asymptomatic Malaise, headaches, coryza, lymphadenopathy, diffuse fine maculopapular rash Incubation 14-21 days
181
What investigations are needed in Rubella infection
ELISA to look for IgG and IgM antibodies
182
What is the maternal management for Rubella
Refer to fetal medicine specialist Antipyrexials
183
What is the fetal management for Rubella
Risk of transmission decreases with increasing age <12 weeks - High likelihood of defects - Consider termination of pregnancy 12-20 weeks - Consider termination of pregnancy - Serial ultrasound surveillance >20 weeks - No action needed
184
What is congenital Rubella syndrome
Neonatal manifestation of Rubella virus during pregnancy Present at birth: Sensorineural hearing loss, pulmonary stenosis, patent ductus arteriosus, ventricular septal defect, retinopathy, congenital cataracts, learning disability, microencephaly, thrombocytopenia Late onset: diabetes, thyroiditis, growth hormone abnormalities, behaviour disorders
185
What are the clinical features of Varicella zoster infection
Primary infection - Fever, malaise, purpuric maculopapular rash Incubation 10-21 days Associated with maternal: - Pneumonia, hepatitis, encephalitis, mortality
186
What investigations are needed for Varicella zoster infection
Clinical diagnosis PCR IgG and IgM testing
187
What is the management of Varicella zoster in pregnancy
Enquire about previous exposure If no previous infection, IgG test needed If not immune - Give varicella zoster immunoglobulin within 10 days of contact Maternal chicken pox - Aciclovir within 24 hours of rash appearing - Refer to fetal medicine specialist - Serial USS from 5 weeks post-infection Varicella vaccination not recommended during pregnancy
188
What are the complications of Varicella zoster infection
Varicella of the newborn - Significant risk if mother infected in last 4 weeks of pregnancy - Treat with varicella zoster immunoglobulin and aciclovir Fetal varicella syndrome - Reactivation of virus in utero as herpes zoster - Only if mother infected at <20 weeks - Skin scarring, eye defects, hypoplasia of limbs, neurological abnormalities
189
What are the thresholds for diagnosing anaemia in pregnancy
1st trimester <100 2nd/3rd trimester <105 Postpartum <100
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What are the risk factors for anaemia in pregnancy
Haemoglobinopathies (thalassaemia, sickle cell disease) Increased maternal age Low socioeconomic status Anaemia during previous pregnancy
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What are the clinical features of anaemia in pregnancy
Dizziness Fatigue Dyspnoea Pallor Koilonychia Angular cheilitis
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What investigations are needed for anaemia in pregnancy
FBC Haemoglobinopathy screen Women screened at booking and at 28 weeks
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What is the management for anaemia during pregnancy
Iron deficiency anaemia - Oral iron (repeat bloods in 2 weeks) - Parenteral iron infusion Other causes - Folate supplements - Blood transfusion
194
What is antiphospholipid syndrome
Autoimmune condition where antibodies are targeted against phospholipid-binding protein Linked with adverse pregnancy outcomes Major cause of recurrent miscarriage
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What are the signs and symptoms of antiphospholipid syndrome
Thrombosis formation (ischaemic stroke, DVT...) Recurrent pregnancy loss
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What are the complications of antiphospholipid syndrome
Pre-eclampsia Intrauterine growth restriction Livedo reticularis (blue pattern on skin) Valvular heart disease Renal impairment Thrombocytopenia
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What is catastrophic antiphospholipid syndrome
Rare complication Acute formation of microthrombosis Infarction of multiple organs
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What are the investigations for antiphospholipid syndrome
Needed in all women with - Recurrent miscarriage - Atypical vascular thrombosis - Recurrent thromboses Bloods - Anticardiolipin - Lupus antibodies Anti-B2-glycoprotein 1
199
What is the management for antiphospholipid syndrome
Presentation with recurrent pregnancy loss - LMWH and low does aspirin throughout future pregnancies Presentation with previous pre-eclampsia or intrauterine growth restriction - Low dose aspirin throughout future pregnancies Presentation with VTE - Long-term anticoagulation with warfarin
200
What are the obstetric risk factors for VTE
Multiple pregnancy Pre-eclampsia C-section Prolonged labour Stillbirth Pre-term birth PPH
201
What investigations are needed for VTE in pregnancy
Basic bloods Compression duplex USS ECG and CXR CTPA or V/Q scan Do not measure D-dimer (normally raised in pregnancy)
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What is the management for VTE in pregnancy
LMWH - Start at suspicion Confirmed VTE - Maintain anticoagulation throughout pregnancy and to 6-12 weeks post-partum Do not use warfarin (teratogenic)

Obs and gynae (6 decks)

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