Name a type of headache that can mimic migraine during pregnancy
Cerebral venuos thrombosis
variable presentations; headache, focal neurological deficits, vomiting or seizures.
An important cause of symptoms that can overlap with those of migraine.
CT or MRI venography is used to make the diagnosis. When diagnosed, 6-12 months of therapeutic anticoagulation is required.
What anti-emetics can you use in pregnancy?
A lack of teratogenesis with; promethazine, cyclizine, chlorpromazine, prochlorperazine, metoclopramide and domperidone.
Ondansetron is a newer agent, and has been successful in cases of severe hyperemesis.
There is no evidence of teratogenesis with the use of H2 receptor blockers and proton pump inhibitors.
Foetus can "breathe" amniotic fluid into the lungs at what gestational age?
- this "breathing" is important for normal lung development (prevents pulmonary hypoplasia).
If membranes rupture, baby needs to be delivered quickly. WHY?
Risk of infection
Symptoms of Idiopathic intracranial hypertension
Tend to be gradually worsening and worse with position (bending over) or Valsalva manoeuvres.
Papilloedema and visual changes can also occur.
Management options in pregnancy include:
Regular lumbar puncture
What are the risks of warfarin in pregnancy?
>> chance of fetal intracranial haemorrhaging because warfarin cross the placenta.
Options: switch to LMWH (unless px is very high risk of thrombosis)
Eclampsia is when seizures occur;
usually preceded by hypertension, proteinuria, or the symptoms listed previously (pre-eclampsia symptoms)
What is Ergometrine used for in pregnancy?
(Acts on adrenergic, dopaminergic and 5-HT2 receptors)
Increases contraction of uterine smooth muscle
Postpartum to reduce bleeding
Risks: >> peripherial vascular resistance
(use Carboprost if Ergometrine ineffective)
What is Toxic shock syndrome? (TSS)
Toxic shock syndrome (TSS) is a multisystem inflammatory response to the presence of bacterial exotoxins.
Associated with tampon use in menstruating women and Group A streptococcal infections - the streptococcal toxic shock-like syndrome (STSS).
Management of gestational diabetes mellitus
regular growth scans
monitor for pre-eclampsia
delivery at 38-39 wks
What's the story with rubella (german measles) and pregnancy?
NO WOMAN should try to conceive unless the have had rubella, or been immunised.
Most dangerous in 1st trimester.
Can cause blindess, deafness, cardiac abnormalities, mental retardation.
Pre-eclampsia is a multisystem disorder related to inadequate placentation. The definition of the disorder is new onset hypertension and proteinuria which develop after 20 weeks of gestation.
If an egg is not fertilized, the corpus luteum eventually decays cand stops secreting progesterone.
What does it decay into?
a mass of fibrous scar tissue; corpus albicans
Mean gestational age of onset is 34 weeks
More common in first pregnancy and those with multiple pregnancies
Pruritic, urticarial papules and plaques most commonly on abdomen (but sparing umbilicus) and thighs
Rapid resolution after delivery
No fetal issues
Why is there an increased risk of aspiration with pregnant women? (esp. with general anaesthesia)
Reduced gastric motility, in combination with restriction of stomach expansion by the fetus results in gastro-oesophageal reflux, particularly in the third trimester.
Constipation common in pregnancy.
RBC and pregnancy - what happens?
Fall in haemoglobin concentration, haematocrit and red cell count (as expansion of plasma volume is greater than the increase in red cell mass)
No change in mean cell volume or mean cell haemoglobin concentration
2-3 fold increase in iron requirements
Iron deficiency anaemia is common and requires iron supplementation
What happens to platelets during pregnancy?
These fall progressively throughout gestation
5-10% of pregnant women have platelet count of 100-150 x109/L by term
Why to you sometimes get upper right upper side pain with pregnancy/ hypertension?
Cardiac output = stroke volume x heart rate
Cardiac output increases by about 40%, as a result of increased stroke volume and reduced systemic vascular resistance, in combination with an increased heart rate.
The cardiac output is greatest at 24 to 28 weeks of pregnancy. The heart is physiologically dilated and myocardial contractility is increased.
What is macrosomia?
The term "fetal macrosomia" is used to describe a newborn who's significantly larger than average
What;s the story with (during pregnancy):
Nitrofurantoin: Haemolytic anaemia in the neonate
Co-amoxiclav: Avoid in women at risk of preterm labour (20-36/40) - including risk of necrotising enterocolitis in neonate
Trimethoprim: Avoid in first trimester (folate antagonist)
What is PPCM?
Peripartum cardiomyopathy (PPCM) ; dilated cardiomyopathy
"deterioration in cardiac function presenting typically between the last month of pregnancy and up to six months postpartum. "
Decrease in left ventricular ejection fraction (EF) with associated congestive heart failure and an increased risk of arrhythmias, thromboembolism.
Legal requirements for termination before 24 weeks
- requires two doctors to sign -
For mothers <16 years : Fraser guidelines apply
If it reduces the risk to a woman's life;
If it reduces the risk to her physical or mental health;
If it reduces the risk to physical or mental health of her existing children;
If the baby is at substantial risk of being seriously mentally or physically handicapped.
Normal heart sounds in pregnancy
Normal findings in pregnancy include an ejection systolic murmur, a loud first heart sound, a third heart sound and ectopic beats.
What is the first line treatment of moderate 150/100 or severe hypertension 160/110 in pregnancy?
What is Gestational Trophoblastic Disease?
Def: A spectrum of histologially distinct diseases originating from the placenta.
a group of disorders which range from molar pregnancies to malignant conditions such as choriocarcinoma.
If there is any evidence of persistence of GTD the condition is referred to as gestational trophoblastic neoplasia (GTN).
Levels of hCG can be of diagnostic value, and ultrasound.
referral for follow-up to a trophoblastic screening centre
Do you need to investigate pruritus in pregnancy?
Liver function tests should be checked, particularly if it is mainly the palms and soles that are affected and/or it occurs in the third trimester.
These symptoms make obstetric cholestasis more likely.
Coagulation and pregnancy
Prothrombin time and activated partial thromboplastin time remain unchanged in pregnancy, so do not reflect the profound changes that result in a hypercoagulable state
Increased factors VIII, IX and X and fibrinogen, reduced fibrinolytic activity and a decrease in antithrombin and protein S all contribute
Pre-eclampsia- inadequate placentation; what's the worry?
Fetal growth restriction and/or intrauterine death can result from pre-eclampsia.
Placental abruption is also more common.
What are ossible causes of shortness of breath in a pregnant woman? (7)
- Pulmonary embolism
- Pulmonary oedema
what is scotoma
a partial loss of vision or blind spot in an otherwise normal visual field
When can the foetus perceive sound and light?
sound: 24-26 weeks
light: 28 weeks
Pregnancy-induced hypertension defined
development of hypertension in the absence of proteinuria or other features of pre-eclampsia.
Usually occurs after 20 weeks gestation and resolves within 6 weeks postpartum, (can remain elevated for up to 3 months postpartum).
What is hyperemesis gravidarum?
Hyperemesis gravidarum occurs in less than 1% and is when vomiting is severe enough to cause dehydration and biochemical derangement.
Immediate management of acute pulmonary oedema during pregnancy
Is glycosuria is diagnostic of diabetes mellitus in pregnancy?
No. Glucose loss during pregnancy is normal
Atopic eruption of pregnancy
Commonest pregnancy specific dermatosis, and is associated with atopy. It mainly occurs in the second or third trimester, more commonly in multiparous women. It is characterised by patches of intensely itchy papules which become excoriated. Treatment includes emollients, antihistamines and topical steroids.
How does pregnancy affect the thyroid gland?
50% more thyroid hormone is required to maintain circulating levels of free T4.
Maternal iodine requirements increase due to increased renal clearance.
Usual TFT tests in early pregnancy may suggest hyperthroidism. This is because HCG is structurally similar to TSH, thus early pregnancy causes >> T4 production and TSH suppression.
No limit on gestation time (for termination) if:
Risk to the mother's life.
Risk of grave, permanent injury to the mother's physical/mental health
Substantial risk that, if the child were born, it would have such physical or mental abnormalities as to be seriously handicapped.
Maternal diabetes and fetal health...
Poor glycaemic control in the first trimester is associated with an increased rate of congenital abnormalities (particularly neural tube defects and congenital heart disease) and miscarriage.
Studies have shown that the rate of congenital abnormalities increases as the HbA1c increases.
The risk of miscarriage is higher with co-existent renal disease or hypertension.
Define antepartum haemorrhage
bleeding from the birth canal after the 24th week of pregnancy.
[bleeding following the birth of the baby is postpartum haemorrhage.]
If pre-eclampsia is asymptomatically, what other investigation?
Uterine artery Doppler measurements can aid the identification of women at high risk of pre-eclampsia.
What factors affect drug availability during pregnancy?
Increased blood volume (50% increase by 34 weeks)
Increased clearance (> GFR 50% by 24 weeks)
- Increased hepatic metabolism
- decreased absorption
What are the common causes of maternal death during pregnancy?
medical complications rather than obstetric and include cardiac problems, neurological disease, sepsis and thromboembolism
SLE and pregnancy; what's the problem?
If there is renal involvement or if antiphospholipid antibodies are present,
there is an increased risk of miscarriage,
pre-eclampsia and preterm delivery.
signs and symptoms
Hypertension and proteinuria, and oedema
Can get swelling of feet, ankles, and hands
Symptoms such as headache, right upper quadrant/epigastric pain or transient visual disturbance can be reported
On examination, abnormalities such as right upper quadrant tenderness, hyper-reflexia or clonus may be present
The multi-system manifestations result from diffuse vascular endothelial dysfunction
What happens to BP in pregnancy?
Blood pressure decreases in first and second trimesters, but increases in the third. By term the blood pressure has returned to the pre-pregnancy level, but does not exceed this.
What happens to blood gases in pregnancy?
Increase in tidal volume (from 1st trimester onwards) causing increased PaO2 and decreased PaCO2
Compensatory respiratory alkalosis.
What is a post dural puncture headache?
After epidural; positional (worse on standing), and most frequently occur in the frontal and occipital regions. Symptoms such as neck stiffness, tinnitus, photophobia and nausea can be associated. They usually develop in the five days after the procedure.
Management is conservative (hydration, rest, oral analgesia) but occasionally an epidural blood patch is required.
How does the pulse change in pregnancy?
The pulse rate increases by 10-20 beats per minute early in pregnancy. A pulse rate of up to 105 beats per minute is regarded as normal in pregnancy.
On examination the pulse may be bounding or collapsing in nature.
What is placenta praevia?
Placenta praevia exists when the placenta is inserted wholly or in part into the lower segment of the uterus.
ultrasound diagnosis (transvaginal)
- Major, if the placenta covers the internal os of the cervix.
- Minor or partial, if the leading edge is in the lower segment but not covering the os.
What is one of the main causes of death in pre-eclampsia women?
(signs : headaches, visual disturbances, seizures)
List the DDs of pulmonary oedema in pregnancy
Non Cardiogenic (2)
- Undiagnosed congenital heart disease
- Peripartum cardiomyopathy
- Cardiac ischaemia
- Non cardiogenic
- Iatrogenic – medications such as corticosteroids, tocolytics, non-steroidal analgesia
How could toxic shock syndrome present?
- >> temperature. Can progress to life-threatening very quickly.
hypotension; suppressiong of myocardial contractility by the toxin.
- Very red mucosal surfaces; palms, soles of feel, tongue
weakness, myalgia, nausa, vomiting, diarrhoea
What are some risks factors for UTI in pregnancy?
use of systemic corticosteroids
history of UTI
Problem: untreated can lead to symptomatic UTI or pyelonephritis
ECG changes in pregnancy include:
Findings on a ECG performed during pregnancy that are not pathological include:
Small Q waves and inverted T waves in lead III
ST depression and T wave inversion inferiorly and laterally
Left shift of the axis
What skin/ hair changes happen in pregnancy?
- pruritus (without a rash - 20% occurence)
- hair loss (common between 4-20 wks)
- palmar erythema
- striae gravidarum
- spider naevi
Liver metabolism changes in pregnancy
Albumin – decreases, (increased blood volume)
Alkaline phosphatase – >> 2-4 fold, mostly as a result of the increasing production of placental alkaline phosphatase
- Heart beats at 4-5 weeks gestation
- After birth, change in PaO2 causes constriction of umbilical vessels, ductus arteriosus, foramen ovale, ductus venosus
New abdo pain in pregnancy. Always consider..
Appendicitis in pregnancy should be suspected when a pregnant woman complains of new abdominal pain
Does respiratory rate change with pregnancy?
Tidal volume increases up to 45%.
Functional residual capacity is reduced due to diaphramatic elevation (late pregnancy)
The symptoms and signs of this condition overlap with those of pre-eclampsia
Hypertension and/or proteinuria are not present in 100% of cases and are often mild
Blood tests may show haemolysis, elevated liver enzymes and low platelets
What's the story with chickenpox and pregnancy?
1:10 pregnant women with chickenpox develop pneumonia. 1:100 women die from this condition. Other serious infections possible.
Unborn baby: Small chance of developing Fetal Varicella Syndrome (FVS) that causes serious abnormalities. More common during 2nd trimester.
Most dangerous time for babies is within seven days before or after birth. iImmunoglobulins are given to the baby to stop this happening.
Babies can catch chickenpox before birth. Aciclovir can be prescribed by specialists.
Safe Antihypertensive treatment in pregnancy
What are alternatives to labetalol in pregnancy?
methyldopa and nifedipine
Glucose and pregnancy, what's the story?
Pregnancy is an insulin resistant state.
Hepatic glycogen stores are depleted in pregnancy, thus women can become ketotic quickly.
>> blood glucose associated with maternal age and family history of diabetes
NSAIDs and pregnancy?
exposure to NSAIDs after 30 weeks' gestation is associated with an increased risk of premature closure of the fetal ductus arteriosus
What anti-emetic meds could be used for acute attack of migraine?
Can occur any time in pregnancy, but usually in third trimester
Often occurs on abdomen (involving umbilicus), spreading to limbs, palms and soles
Associated with low birthweight, preterm delivery and stillbirth
Neonate can be affected by same eruption, which is mild and transient
Risk factors of PPCM
Pregnancy complicated by hypertension (pre-existing or pre-eclampsia)
Advanced maternal age
Developmental milestones of an embryo
What's the story with toxoplasmosis and pregnancy?
- Causes eye and brain damage during first trimester
- induces miscarriage later in pregnancy
(caused by eating undercooked meat, handling cat feces)
Why is glycaemic control difficult in first trimester?
nausea and vomiting
Increase in insulin sensitivity
Low glycogen stores; ketoacidosis common
Why is it important to treat asymptomatic UTI during pregnancy?
Mx: nitrites on urinalysis.
Asymptomatic bacteriuria should be treated as this can lead to symptomatic urinary tract infection or pyelonephritis.
This can be associated with low birth weight babies and preterm delivery.
What's the story; STi and pregnancy?
Syphilis, Genital Herpes, HIV?
- Syphilis; cannot be transmitted to fetus until 18th week, early tx prevents harm. Can can miscarriage.
- Genital herpes; Can cross placenta, most infections during birth (C.S. prevents infection)
- AIDS; ZDV reduces transmission by 70%, passed through placenta, whilst giving birth, or whilst breast-feeding.
Can you get AKI with pre-eclampsia?
Acute kidney injury (AKI) is a common consequence of pre-eclampsia.
This ranges from a mild increase in creatinine, to significant AKI requiring renal replacement therapy (rare)
An elevated serum urate concentration and oliguria can also be seen.
What antihypertensives cannot be used in pregnancy?
ACE inhibitors are teratogenic and fetotoxic.
Presentation of placenta praevia.
Painless bleeding (pain with 10% of cases) starting after the 28th week (although spotting may occur earlier) is usually the main sign:
25% risk of spontaneous labour in subsequent few days.
Suspect if: vaginal bleeding after 20 weeks of gestation, bleeding provoked by sexual intercourse.
Migration of the placenta can occur in 2nd and 3ed trimesters.
Future pregnosis of PPCM?
Left ventricular function does not recover in all affected women.
Further pregnancies can cause a recurrence of the cardiomyopathy, which can lead to significant left ventricular impairment, particularly if left ventricular function did not return to normal after the first affected pregnancy.
Which antihypertensives can be used in pregnancy?
Methyldopa - central action
- Nifedipine - CCB
- Labetalol - α- and β- receptors
What is the role of Misoprostol?
Increases contraction of uterine smooth muscle
Causes cervical effacement
Medical termination of pregnancy
What is RDS? (common in premature babies)
Respiratory Distress Syndrome
Tx: Corticosteroid therapy promotes surfactant production and decreases risk of RDS by 50%
NB> surfactant is made by type II pneumocytes.
What are striae gravidarum?
Stretch marks are caused by tearing of the dermis.
(resilient middle tissue layer that helps the skin retain its shape)
What does Pyelonephritis increase the chances of ?
Why give 400IU daily Vit D to pregnant women?
- Vit D is common during pregnancy and post partum causing transient osteoporosis of pregnancy.
- Vit D def causes fetal morbities; growth restriction, skeletal deformities, tooth and bone problems
Stages of labour (1-4)
1st stage : contractions 10-15 minutes apart, cervix dilated.
2nd stage: pushing and birth of baby
3rd stage: delivery of placenta
4th stage: postpartum
Syntometrine; role in labour?
Oxytocin/ergometrine (trade name Syntometrine) is an obstetric combination drug. oxytocin (produced by hypothalamus) and ergometrine (an alpha-adrenergic, dopaminergic and serotonin (5-HT2) receptor agonist.)
Both substances cause the uterus to contract.
Given just after the birth of the child to facilitate delivery of the placenta and to prevent postpartum hemorrhage[ by causing smooth muscle tissue in the blood vessel walls to narrow.
Retained placenta definition
Failure of the placents to deliver within 30 minutes
Definition - Primary haemorrhaging in pregnancy
Primary postpartum haemorrhage (PPH) is loss of blood estimated to be >500ml from the genital tract within 24 hours of delivery.
(this is the most common obstetric haemorrhage)
Minor PPH up to 1000ml
Major PPH over 1000ml
Definition - Secondary haemorrhaging in pregnancy
Secondary PPH abnormal bleeding from the genital tract, from 24 hours after delivey until six weeks postpartum.
What stage of labour does the placenta come away?
Postpartum haemorrhage defined
(incidence 5% of all deliveries)
a 10% drop in hemacrit from admission, or bleeding requiring blood transfusion
old definition: an estimated blood loss of > 500ml
NB> the AVERAGE blood losee after vaginal delivery is 500ml. Blood loss after c.s. averages 1000ml.
The causes of PPH have been described as the "four T's"
What's the most common cause of primary postpartum haemorrhaging?
followed by retained placenta
- Tone: uterine atony, distended bladder.
- Trauma: lacerations of the uterus, cervix, or vagina.
- Tissue: retained placenta or clots.
- Thrombin: pre-existing or acquired coagulopathy.
What is uterine atony?
Uterine atony is a loss of tone in the uterine musculature. Normally, contraction of the uterine muscles during labor compresses the blood vessels and reduces flow, thereby increasing the likelihood of coagulation and preventing hemorrhage.
Clinically, 75-80% of postpartum hemorrhages are due to uterine atony.
Treatment of uterine atony?
Bimanual uterine compression to stimulate contraction.
Ergometrine 0.5 mg slow IV or IM unless there is a history of hypertension
What are the most important causes of antepartum haemorrhage, (>50% of cases) (two)
Definition of antepartum haemorrhage
Antepartum haemorrhage is defined as any vaginal bleeding from the 24th week of gestation until delivery.
How does placenta praevia present?
incidental finding on ultrasound
Painless bleeding starting after the 28th week; Typically, it is sudden and profuse but usually does not last for long and so is only rarely life-threatening.
bleeding during intercourse
Facts about uterine inversion
(rare but serious obstetric complication)
- occurs in second stage of labour
Big risk factor - multiparity 6+
Postpartum haemorrhage, which occurs in 65-94% of cases and can be massive.
Lower abdominal pain (extreme), Sudden appearance of a vaginal mass.
"The sudden appearance of a large dark red mass accompanying the placenta is alarming."
Chronic cases are unusual and difficult to diagnose. They may present with spotting, discharge and low back pain.
What is Placenta accreta?
Placenta accreta: chorionic villi penetrate the decidua basalis to attach to the myometrium.
These are conditions where the placenta is morbidly attached to the uterine wall.
All are associated with retained placenta requiring surgical management and have high risk of massive postpartum haemorrhage.
What is Placental abruption?
May present with vaginal bleeding, abdominal pain (usually continuous), uterine contractions, shock or fetal distress.[
Abruption is the premature separation of a normally placed placenta before delivery of the fetus, with blood collecting between the placenta and the uterus.
It is one of the two most important causes of antepartum haemorrhage (the other being placenta praevia).
What is uterine rupture?
(rare but high mortality)
A catastropic event where a full-thickness tear develops, opening the uterus directly into the abdominal cavity.
Most occur during labour; however, uterine scars following earlier caesarean may rupture during the third trimester before any contractions occur.
keloid scars in the uterine wall from c.s. causes it to 'unzip'.