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Pregnancy Flashcards

1
Q

What are neural tube defects?

A

When the neural tube (forming the early brain and spine) doesn’t close properly

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2
Q

When do neural tube defects occur?

A

Early in the pregnancy, often before a woman knows she is pregnant.

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3
Q

What are the 2 most common NTDs?

A

Spina bifida and Anencephaly

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4
Q

What is spina bifida?

A

An NTD which causes physical and intellectual disabilities that vary in severity depending on the size and location of the opening of the spine, and whether the spinal cord and nerves are affected

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5
Q

What is anencephaly?

A

A NTD where the upper part of the neural tube does not close all the way, resulting in the baby being born without parts of the skull and brain. Usually, the baby will die shortly after birth.

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6
Q

What makes a couple higher risk of NTD?

A

A previous pregnancy being affected by NTD
Family or personal history of NTD
Woman taking anti-epileptocs
Woman having diabetes, sickle cell anaemia, or thalassaemia.
The woman being obese (BMI >30)

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7
Q

What role does folate play in pregnancy?

A

Folate is an essential water soluble B vitamin which serves as a cofactor in cell division. Deficiency can affect expression of neural tube closure-related genes and impair growth and replication within the foetus.

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8
Q

Name 5 foods high in folate?

A

Leafy greens
Fruits
Beans
Meat
Cerals

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9
Q

How should women take folic acid supplements for pregnancy?

A

Women should take folic acid daily before conception and until the 12th week.
Low risk: 400mcg
High risk: 5mg

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10
Q

When does nausea and vomiting occur throughout pregnancy?

A

Begins 4-7th week
Peaks between 9-16th week
Resolves before 16-20th week

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11
Q

When does it mean if nausea and vomiting in pregnancy begins after 11 weeks?

A

Likely not morning sickness, due to another cause.

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12
Q

What is some lifestyle advice for morning sickness?

A

Rest - tiredness makes nausea worse.
Avoid trigger foods/smells.
Eat dry toast or plain biscuit or similar before getting out of bef.
Eat small, frequent, protein-rich meals.
Sip water little and often.
Cold foods tend to be better tolerated if nausea is smell-related.
Ginger supplements, teas, or foods may reduce symptoms.
Try acupressure bracelets.

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13
Q

What are some first line pharmacological options for morning sickness?

A

Xonvea
Chlorpromazine
Cyclizine
Prochlorperazine
Promethazine

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14
Q

What is Xonvea?

A

The only medicine specifically licensed in the UK for nausea and vomiting. Contains doxylamine/pyridoxine.

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15
Q

What is doxylamine?

A

A H1 receptor antagonist (1st generation antihistamine)

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16
Q

What is chlorpromazine?

A

A phenothiazine anti-emetic which blocks histamine H1, dopamine D2, and muscarinic M1 receptors in the vomiting centre.

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17
Q

What is cyclizine?

A

Antihistamine and anti-emetic which blocks histamine H1 and has anti-muscarinic effects at the chemoreceptor trigger zone of the vomiting centre.

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18
Q

How does metoclopramide work?

A

Inhibits dopamine and serotonin in the chemoreceptor trigger zone.

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19
Q

What is prochlorperazine?

A

A phenothiazine anti-emetic which inhibits dopaminergic receptors.

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20
Q

What is promethazine?

A

An antihistamine and anti-emetic which inhibits histaminic, muscarinic, and dopaminergic receptors in the vomiting centre.

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21
Q

How does ondansetron work?

A

Inhibits serotonin/5HT3 receptors.

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22
Q

Which anti-emetics are not recommended in the 3rd trimester and why?

A

Chlorpromazine, Prochlorperazine - EPSE’s and withdrawal.

Cyclizine, Promethazine - paradoxical excitability and tremor

Metoclopramide - EPSEs

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23
Q

How long should metoclopramide be used for?

A

Not recommended for use over 5 days due to EPSEs

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24
Q

Should ondansetron be used in pregnancy?

A

Not licensed but used for severe nausea and vomiting. Associated with increased risk of cleft lip/palate during first trimester.

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25
Q

What can be used in moderate-severe nausea and vomiting in pregnancy?

A

IV fluids
Acupressure
Oral prednisolone 40-50mg (BP monitor and diabetes screen)

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26
Q

What is very severe morning sickness known as?

A

Hyperemesis gravidarum

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27
Q

What is hyperemesis gravidarum?

A

Prolonged, persistent, and severe nausea and vomiting unrelated to causes other than pregnancy.

28
Q

What are some adverse effects of hyperemesis gravidarum?

A

Weight loss (5% of pre-pregnancy weight)
Dehydration
Electrolyte Imbalance

Often requires hospital treatment.

29
Q

What is gestational diabetes?

A

Diabetes which develops during pregnancy due to hormones produced by the placenta which block the ability to use insulin effectively. It usually disappears after pregnancy.

30
Q

What are some symptoms of diabetes/gestational diabetes?

A

Thirst
Polyuria
Dry mouth
Blurred vision
Thrush
Fatigue

31
Q

Which individuals are at higher risk of gestational diabetes?

A

BMI >30
Previous macrosomic baby weight 4.5kg+
Previous gestational diabetes
First-degree relative with diabetes
Asian, black, Afro-caribbean

32
Q

How is gestational diabetes diagnosed?

A

At 24-28 weeks, a 75g 2-hour oral glucose tolerance test (OGTT) is performed. The woman fasts for around 10-12 hours, then consume a drink containing 75g of sugar. After 2 hours of resting, a blood sample is taken and glucose is measured.
If plasma glucose is 7.8mmol/L or above, diagnose gestational diabetes.

33
Q

What can untreated gestational diabetes lead to?

A

Foetal macrosomia - birthweight >4kg
Trauma during birth
Induction of labour and/or C-section
Neonatal hypoglycaemia
Perinatal death

34
Q

What should the capillary plasma glucose of a gestational diabetic be?

A

Fasting: 5.3mmol/L or lower
1-hour post-meal: 7.8mmol/L or lower
2-hour post-meal: 6.4mmol/L

If taking insulin, ensure above 4mmol/L.

35
Q

When should a patient measure blood glucose if their gestational diabetes is managed by diet and exercise only?

A

Fasting
1-hour post-meal

36
Q

When should a patient measure blood glucose if their gestational diabetes is managed by oral therapy such as metformin?

A

Fasting
1-hour post-meal

37
Q

When should a patient measure blood glucose if their gestational diabetes is managed by single-dose intermediate/long-acting insulin?

A

Fasting
1-hour post meal

38
Q

When should a patient measure blood glucose if their gestational diabetes is managed by a multiple daily insulin regimen?

A

Fasting
Pre-meal
1-hour post meal
Bedtime

39
Q

What is some lifestyle advice for gestational diabetes?

A

Self-monitor blood glucose according to treatment plan.
Maintain a healthy diet.
Switch from high to low glycaemic foods
Exercise regularly e.g., walk for 30 mins after meal
Carry fast-acting glucose if taking insulin.

40
Q

How should gestational diabetes be managed?

A

Fasting blood glucose <7mmol/L at diagnosis:
1. Diet and exercise changes alone for at least 1-2 weeks.
2. + Metformin
3. + Insulin

Fasting blood glucose 7mmol/L+ at diagnosis, or 6mmol/L+ with complications:
1. Diet and exercise changes alone + Insulin
2. + Metformin

41
Q

What type of insulin is bets during pregnancy?

A

Rapid-acting insulin analogues (aspart and lispro to be used before meals) have advantages over soluble human insulin during pregnancy. Intermediate-acting insulin (insulatard or Humulin I) may also be used.

42
Q

What are some common symptoms of DVT?

A

Unliateral localised throbbing pain that occurs when walking or bearing weight.
Unilateral calf swelling or of the entire leg.
Tenderness
Skin changes e.g., oedema, redness, warmth
Vein distension.

43
Q

Who is more at risk of DVT?

A

History of DVT
Cancer
>60
Obesity
Male
Heart failure
Varicose veins
Smoking
Recent surgery, hospitilisation, or trauma
Significant immbolity
Prolonged travel >4 hours
Hormone treatment e.g., COC, HRT
Pregnancy

44
Q

What should be done to assess suspected DVT?

A

If pregnant or within 6-weeks post partum, refer for same day assessment and management.

Otherwise:
1. Measure circumference of both legs 10cm below the knee and compare. A difference of >3cm increases the probability of DVT.
Also assess for oedema and dilated collateral superficial veins on the affected side.
2. Peform 2-level DVT Wells score to assess likelihood of DVT.

45
Q

What do 2-level DVT Wells score warrant?

A

Score of 2 or more:
o Offer ultrasound scan with results within 4 hours if possible. If not possible:
 Offer D-dimer test
Then:
 Interim therapeutic anticoagulation and a proximal leg vein ultrasound scan with results within 24 hours.

Score of <2:
o Offer D-dimer test with results available within 4 hours (if not offer interim therapeutic anticoagulation while awaiting result).
 If positive, offer proximal leg vein ultrasound scan with results within 4 hours (if not, interim therapeutic anticoagulation and scan with result within 24 hours).
 If negative, stop any interim anticoagulation and consider an alternative diagnosis.

46
Q

What must be measured before starting interim therapeutic anticoagulation for DVT?

A

FBC
Renal and hepatic function
Prothombin time
Activated partial thromboplastin time

47
Q

What is given for interim therapeutic anticoagulation?

A

Apixaban or Rivaroxaban
or (if not suitable)
LMWH for 5+ days followed by dabigatran or edoxaban
or LMWH with warfarin for 5+ days

48
Q

What is given following acute treatment for DVT?

A

Maintenance oral anticoagulation with DOAC or warfarin for at least 3 months.

49
Q

What is the mechanism of action of DOACs?

A

Intervene directly in the coagulation cascade by inhibiting clotting factors such as factor Xa and thrombin, thus preventing formation of a clot.

50
Q

What is the mechanism of action of Warfarin?

A

Vitamin K antagonist. Prevents the production of vitamin-K dependent clotting factors by blocking epoxide reductase complex in the liver, thus inhibiting vitamin K activation.

51
Q

What is INR?

A

measure of how much longer it takes the blood to clot.

52
Q

What is the ideal INR?

A

2-3

53
Q

What can be done to reverse an INR which is too high?

A

Give patient vitamin K.

54
Q

What are some common side effects of warfarin?

A

Bleeding, bruising, heavier/longer periods, rash, and mild hair loss.

55
Q

What are some red flag side effects of warfarin?

A

Blood in urine/vomit/sputum/stools, extremely large/dark or unexplained bruises, uncontrolled bleeding, jaundice, skin necrosis.

56
Q

How should a patient be switched from warfarin to a DOAC?

A

Stop warfarin and take INR. DOAC can be started when INR is less than 2.

57
Q

How should a patient be switched from a DOAC to warfarin?

A

Start warfarin and continue DOAC for 2 days measuring INR. When INR is in range, stop DOAC.

58
Q

Why is D-dimer tested for DVT?

A

The formation of thrombus is normally followed by immediate fibrinolytic response, resulting in generation of plasmin which causes release of fibrin degradation products, predominantly containing D-dimer, into the circulation. A negative d-dimer therefore implies that thrombosis is not occurring.

59
Q

What can D-dimer test determine?

A

D-dimer tests have relatively high sensitivity, but low specificity (false-positives are common), so while a negative D-dimer may be useful for excluding DVT, a positive D-dimer is not diagnostic and just mandates further testing.
Other causes of a positive D-dimer test include:
Liver disease
Inflammation
Malignancy
Pregnancy
Trauma
Recent surgery

60
Q

How would a suspected VTE in pregnancy be dealt with?

A

Refer for objective testing and should be treated with LMWH until the diagnosis is excluded unless treatment is strongly contraindicated.
The usual tests to assess risk of DVT in primary care are not accurate as the use of 2-level Wells score is not supported and D-dimer will be inaccurate (positive in pregnancy regardless of DVT).

61
Q

What causes a UTI?

A

When bacteria colonize the urethra and invade the urinary epithelium cells, causing irritation and inflammation

62
Q

What are the 2 types of UTI?

A
  • Lower urinary tract – inflammation of the bladder (cystitis) and urethra (urethritis). The infection can ascend the urinary tract and lead to an upper UTI.
  • Upper urinary tract – infection of the proximal part of the ureters (pyelitis) or the proximal part of the ureters and the kidneys (pyelonephritis).
63
Q

What complications can upper UTIs cause?

A

Upper UTIs can cause renal scarring, abscess, or failure, and urosepsis.

64
Q

What are some common symptoms of UTIs?

A

Dyrsuria - burning, stinging, itching during urination.
Nocturia - frequent urge to urinate at night
Changes in urine appearance or odour.

65
Q

How is UTI diagnosed in pregnancy?

A

Urine dipstick + mid-stream urine (MSU) sample for culture

66
Q

How should a UTI be managed in pregnancy?

A
  1. Nitrofurantoin 100mg MR bd for 7 days.
  2. If no improvement after 48 hours or 1st line contraindicated or not tolerated:
    Cefalexin 500mg bd for 7 days
    Or
    Amoxicillin 500mg tds for 7 days (only if urine culture shows susceptibility)
67
Q
A

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