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Pregnancy problems Flashcards

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1
Q

Ectopic pregnancy RF

A

Assisted conception

Hx of PID

Endometriosis

Tubal surgery

Previous ectopic (recurrence is 10-20%)

Higher maternal age

Smoking

IUCD POP - if pregnant, more likely to be ectopic

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2
Q

S+S Ectopic

A

Amenorrhoea, pain, bleeding (small amounts, often brown), shoulder tip pain, cervical excitation, adnexal tenderness

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3
Q

Ectopic investigations

A

TVUSS

Serum hCG - should double in 48 hours. Suboptimal rise = ectopic Laparoscopy = gold standard

Serum progesterone is helpful to see if pregnancy is failing (<20 = failing)

hCG >1500 should be seen with TVUSS if viable intrauterine

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4
Q

Management of ectopic (circumstances for each) + risk of death

A

Expectant = if stable AND: asymptomatic, hCG <1500, no fetal cardiac activity, can come into hospital easily

Medical = methotrexate IM - measure hCG at day 4 and day 7. Choice is given if gCG 1500-5000

Another dose given if hCG decrease is <15% on days 4-7.

Use reliable contraception for 3 months.

Side effects: conjunctivitis, stomatitis, GI upset. Give anti-D

Surgical (if there is fetal heart activity, pain, hCG >5000, adnexal mass >35mm) = salpingostomy if rupture has not occurred.

Salpingectomy if there is a rupture

Risk of death 1:2000

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5
Q

Molar pregnancy aetiology + types

A

Abnormal overgrowth of placenta Hyatidiform mole = overgrowth is benign.

Partial mole = part develops normally, due to 2 sperm entering egg. May be a developing fetus but has genetic abnormalities

Complete = whole placenta is abnormal, no developing fetus. Due to 1 sperm entering egg but only half genetic material present.

Appears as snowstorm on USS, with hydropic villi + large theca lutein cysts

Choriocarcinoma = placenta becomes malignant

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6
Q

Molar pregnancy RF

A

>40 or <15 y/o

Previous molar pregnancy (10% risk of recurrence)

Ethnicity: higher in east Asia

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7
Q

S+S Molar pregnancy

A

Irregular first trimester bleeding

Uterus large for dates

Pain from theca lutein cysts due to ovarian hyperstimulation (due to increased hCG)

Exaggerated pregnancy symptoms = hyperemesis, hyperthyroidism, early pre-eclampsia

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8
Q

Molar pregnancy investigations + management (+ follow up)

A

USS - snowstorm appearance, large lutein cysts

High hCG. Must be taken every 14 days

SURGICAL EVAC

Once levels normal, test urine every month for hCG

Do not become pregnant til normal for 6 months

If abnormal levels after surgical evac, methotrexate + folinic acid are given

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9
Q

How does BP change in pregnancy

A

Decreases in early pregnancy until 24 weeks due decrease in vascular volume

Increases after 24 weeks due to increase in stroke volume

Decreases after delivery but may peak again 3-4 days postpartum

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10
Q

Existing HTN in pregnancy - what are you at risk of, management of HTN

A

At risk of: pre-eclampsia, IUGR, placental abruption, stroke

Stop ACEi + ARBs

Use Ca ch blockers or B blockers

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11
Q

Pre-eclampsia pathology + diagnosis

A

HTN + proteinuria

Blood vessel endothelial cell damage - exaggerated maternal inflammatory response

Vasospasm, increased capillary permeability + clotting dysfunction

Increases vascular resistance, permeability + reduced placental blood flow

140/90 + >300mg protein in 24hr collection or PCR >30

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12
Q

Pre-eclampsia risk factors

A

Previous pre-e

Extremes of age

Fam hx

Obesity

Primip

Twins

Fetal hydrops

Hyatidiform mole

HTN, DM, thrombophilias

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13
Q

Pre-eclampsia complications for mother + fetus

A

Mother: eclampsia, CVAs, liver/ renal failure, HELLP, DIC, pulmonary oedema

Fetal: IUGR, morbidity, placental abruption, pre-term birth, hypoxia

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14
Q

Pre-eclampsia blood results

A

High Hb

Low platelets

Prolonged PT + APTT

Abnormal LFTs

Increased urea + creatinine

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15
Q

Pre-eclampsia treatment

A

Magnesium sulphate to prevent eclampsia

Labetalol to reduce BP

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16
Q

Indications for immediate delivery in pre-eclampsia

A

Worsening thrombocytopaenia - beware - this means epidural CI

Worsening liver/ renal function

Severe maternal symptoms

Fetal distress HELLP/ eclampsia

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17
Q

Effect of diabetes on pregnancy

A

Hyperglycaemia in fetus - high insulin through B cell hyperplasia

Insulin acts as growth promoter - macrosomia, organomegaly + erythropoesis

Fetal polyuria = polyhydraminos

Neonatal hypoglycaemia after birth

Surfactant deficiency due to reduced production of pulmonary phospholipids = respiratory distress syndrome

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18
Q

Effect of pregnancy on diabetes

A

Ketoacidosis (associated with hyperemesis, infection, steroids + tocolytics)

Retinopathy, nephropathy = increased risk

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19
Q

Complications of diabetes in pregnancy (maternal, fetal, neonatal)

A

Maternal: UTI, candidiasis, HTN, pre-eclampsia, obstructed labour, retinopathy + nephropathy

Fetal: Miscarriage, preterm labour, polyhydraminos, macrosomia, IUGR

Neonatal: jaundice, hypoglycaemia, hypocalcaemia, hypothermia, shoulder dystocia, Erb’s palsy, respiratory distress syndrome

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20
Q

Glycaemic control in pregnancy

A

Continue insulin until in established labour then convert to sliding scale

Hyperglycaemia may occur with steroid use

Insulin requirements fall after delivery of placenta

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21
Q

Treatment of constipation, thrush + epilepsy in pregnancy

A

Constipation = laxatives but avoid stimulants

Thrush = imidazole/ clotrimazole

Epilepsy = lamotrigine - avoid sodium valproate

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22
Q

Treatment of chorioamnionitis, UTI, endometritis + resp infections

A

Chorioamnionitis = cefuroxime + metronidazole

UTI = trimethoprim (not 1st trimester) or nitrofurantoin (not 3rd trimester)

Resp infection = penicillins/ macrolides

Endometritis = co-amoxiclav

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23
Q

Risk factors for gestational DM

Study These Flashcards
A

Fam hx

Obesity

Previous large baby

Previous stillbirth

PCOS

Polyhydraminos

24
Q

GDM S+S

Study These Flashcards
A

Recurrent infections

Glycosuria

Large for dates

25
Diagnosis of GDM
Oral glucose tolerance test at 26 weeks \>7.8 after 2 hours If previous GDM, do OGTT at 16 weeks
26
Complications of GDM
Macrosomia - shoulder dystocia CS Pre-eclampsia NTD
27
Rhesus disease pathology
Mendelian inheritance Fetal cells cross into maternal circulation Mothers exposed to foreign antigen mount immune response (sensitisation) - initially IgM so current pregnancy not at risk Re-exposure in subsequent pregnancy causes memory B cells to produce IgG which crosses placenta IgG binds to fetal red cells which are then destroyed in reticuloendothelial system Causes haemolytic anaemia = fetal hydrops, high output cardiac failure Haemolysis can cause jaundice from increase bilirubin levels If fetus is Rhesus +ve, and mother is -ve, mother will create anti-D antibodies
28
Sensitising events
Termination or miscarriage Ectopic Vaginal bleeding \>12 weeks or heavy bleeding ECV Trauma Amniocentesis/ CVS Intrauterine death Delivery
29
Management of rhesus
Check for Ab at booking Anti D given at 28 weeks + within 72 hours of any sensitising event Given after delivery if baby is +ve
30
Small for dates - causes, RF, diagnosis
Constitutional: low maternal height/ weight, nulliparity, femal fetus RF: fibroids, polyhydraminos, IVF Diagnose with CRL at 8-10 weeks and biparietal diameter at 16-20 weeks Serial USS + umbilical artery Doppler to diagnose IUGR
31
Large for dates - causes, risk to the fetus
Causes: maternal diabetes Risks to fetus: hypoglycaemia after birth, respiratory disease, shoulder dystocia (damage to brachial plexus - Erb's + Klumpky's palsy)
32
What is MacRoberts position?
To aid with shoulder dystocia
33
IUGR - what is it, diagnosis, risks to fetus
Growth normal initially then slows Reversed/ absent end diastolic flow or increased pulsatile index = IUGR Mortality is higher, CP risk is higher More likely to meconium aspirate, necrotising enterocolitis, hypoglycaemia and hypocalcaemia
34
Causes of IUGR (maternal, placental, fetal)
Maternal: maternal disease, substance abuse, poor nutrition, low SES Placental: pre-eclampsia, placenta accreta, infarction, placenta praevia, tumours, abnormal cord insertion Fetal: genetic abnormalities, congenital infection, multiple pregnancy
35
IUGR management
Steroids before birth for fetal lung maturation Absent end diastolic flow = admit for steroids + daily CTG
36
Dizygotic twins - how common, pathology
2 separate ova being fertilised by 2 different sperm Dichorionic + diamniotic (DCDA) 75% multiple pregnancies
37
Monozygotic twins pathology
Division of a single embryo \<3 days = DCDA 4-7 days = MCDA 8-12 days = MCMA Genetically identical
38
RF for multiple pregnancy
Previous or fam hx Increasing maternal age Assisted reproduction
39
Fetal risks associated with multiples
Risk of miscarriage NTD, cardiac abnormalities + gastrointestinal atresia IUGR Preterm labour Risk of mortality, disability, CP
40
Maternal risks with multiples
Hyperemesis, anaemia, pre-eclampsia, GDM, HTN, polyhydraminos, placenta praevia, APH + PPH
41
Twin to twin transfusion syndrome - pathology, effect on donor + recipient. Management
Affects monochorionic twins Caused by abherrant vascular anastamoses within the placenta - blood from donor twin is transferred to recipient Effect on donor: hypovolaemic, anaemic, oligohydraminos, growth restriction Effect on recipient: hypervolaemic, large bladder, polyhydraminos, fetal hydrops Monochorionic twins scanned every fortnight from 12 weeks. Laser ablation or placental anastomoses, selective feticide by cord occlusion or septostomy
42
Intrauterine death of a twin - effect on pregnancy (other fetus + mother)
Dichorionic = loss in first trimester - no issue. Loss in 2nd or 3rd precipitates labour Monochorionic = due to shared circulation, death occurs in the other twin Increased risk of DIC in mother
43
Intrapartum risks for twins
Malpresentation Fetal hypoxia Cord prolapse PPH Cord entanglement (MCMA) Head entrapment
44
Selective termination - how, when, risks
When 1 twin has an abnormality. Injection of KCl in DC twins. In monochorionic = cord must be occluded Risk of miscarriage Can occur up to 34 weeks
45
Risk of anti-convulsants in pregnancy
Phenytoin + carbamazepine cause fetal hydantoin syndrome: IUGR, microcephaly, cleft lip, hypoplastic fingernails + distal limb deformities
46
Management of existing thyroid disease in pregnancy
Hypothyroidism = increase thyroxine by 25mg due to physiological increase in T4 until 12 wks (which doesn't occur in hypothyroidism)
47
Most common site for ectopic pregnancy
Ampulla then isthmus
48
Complications of ectopic pregnancy
Rupture + internal bleeding
49
Why is an ectopic pregnancy in the uterine horn worrying?
Can reach 10-14 weeks gestation before rupture
50
How are women managed in pregnancy if they've had a previous molar?
Serum hCG measured at 6 + 10 weeks postpartum due to risk of choriocarcinoma
51
S+S pre-eclampsia
Frontal headache, visual disturbances, RUQ pain, N+V, rapid oedema (face), hyperreflexia + clonus
52
USS findings for multiples
Widely separated sacs = dichorionic. Membrane insertion showing lambda sign = dichorionic. Absence of lambda sign \<14 weeks = monochorionic
53
What is the most common cause of recurrent miscarriage + how to manage?
Antiphospholipid ab = likely cause of recurrent miscarriage = treat with aspirin + LMWH
54
What reduces the risk of pre-eclampsia?
Smoking
55
When would you give aspirin in a subsequent pregnancy?
If severe pre-eclampsia requiring delivery before 34 weeks
56
What are the indications for 5mg folic acid?
Previous NTD Diabetes Sickle cell On anti-epileptic treatment

OBGYN (18 decks)

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