Week 2 Flashcards

Question

**Complications of Hypertensive Disorders of Pregnancy** - 4 Fetal complications? - 12 Maternal complications?

Answer 1

**Fetal complications: occur due to insufficient placental perfusion.** 1. Fetal growth restriction 2. Preterm birth 3. Seizure-induced fetal hypoxia 4. Fetal death - Hypertension during pregnancy is the most common cause of placental abruption. - Ischemic stroke, cerebral hemorrhage, and ARDS are the most common causes of death in patients with preeclampsia.

Answer 2

The prognosis of hypertensive pregnancy disorders depends on the severity of the condition and the complications that occur. In the majority of cases, the conditions resolve within hours or days after delivery.

Answer 3

**Premature rupture of membranes (PROM)** - **Definition**: rupture of membranes occurring before onset of labor at term. - **Epidemiology**: between 5 and 10% of all deliveries - **Risk factors** 1. Ascending infection (common) 2. Cigarette smoking 3. Multiple pregnancy 4. Previous preterm delivery 5. Previous PROM

Answer 4

**Prolonged rupture of membranes** - **Definition**: Rupture of membranes that occurs > 18 hours before the onset of uterine contractions in term or preterm pregnancies - **Risk factors**: young maternal age, smoking, STDs, low socioeconomic status

Answer 5

**Management:** The management of PROM and PPROM depends on the gestational age and the presence of intraamniotic infection or nonreassuring fetal status. 1. Monitor for signs of intraamniotic infection (body temperature, uterine tenderness, WBC count). 2. Perform fetal heart rate monitoring to assess for nonreassuring fetal status. 3. Consider intrapartum risk factors and GBS screening and prophylaxis, depending on whether previous antenatal GBS screening has been performed. **Unstable patients** - Prompt delivery in: Patients with signs of intraamniotic infection, abruptio placentae, cord prolapse & Signs of fetal distress (nonreassuring fetal heart rate) - Additionally, collect cervical cultures and commence empiric antibiotic therapy ampicillin and gentamicin.

Answer 6

PROM occurs when the amniotic sac surrounding the baby breaks before the onset of labor. The management in this situation would focus on assessing the extent of the amniotic fluid loss, evaluating the well-being of the baby, and deciding on appropriate measures to ensure the best outcome for both the mother and the baby. Here's how healthcare professionals might proceed with the management:

Answer 7

Initial assessment of women presenting with term PROM should include confirmation of the diagnosis, confirmation of gestation, confirmation of presentation and assessment of maternal and fetal wellbeing. Where there is diagnostic uncertainty, a sterile speculum examination should be performed. If uncertainty remains regarding the diagnosis, tests for the presence of amniotic fluid proteins in vaginal fluid (e.g. Amnisure) may be used.

Answer 8

**Cervical insufficiency** - **Definition**: painless cervical dilation, in the absence of uterine contractions and/or labor, in the second trimester of pregnancy - **Aetiology**: Most cases are idiopathic. - **Risk factors** 1. Previous midtrimester pregnancy loss and/or preterm birth 2. Previous obstetric or gynecological trauma (e.g., termination of pregnancy, rapid delivery, multiple gestations, or cervical conization) 3. Short cervical length: transvaginal cervical length < 25 mm on ultrasound before 24 weeks' gestation 4. Cervical connective tissue weakness (e.g., Ehler-Danlos syndrome) 5. Diethylstilbestrol exposure

Answer 9

- In women with risk factors (i.e. previous preterm birth), serial cervical ultrasound monitoring between 16–24 weeks' gestation because the lower uterine segment is not well developed before 16th weeks' gestation, there is no benefit from performing ultrasound before this time. - A shortened cervical length alone is not sufficient to diagnose cervical insufficiency.

Answer 10

**Hemolytic disease of the fetus and newborn** = HDFN is a condition characterized by blood group incompatibility between the mother and fetus that leads to the destruction of fetal erythrocytes by maternal antibodies. **Rhesus incompatibility** = A hemolytic disease in which Rh antibodies from Rh-negative mothers transfer to an Rh-positive fetus or newborn and result in hemolysis; the severity of clinical presentation ranges from isolated mild anemia to marked anemia causing hydrops fetalis and stillbirth.

Answer 11

**ABO incompatibility - Pathophysiology** - Highest risk: mother with blood group O; newborn with blood group A or B - Maternal antibodies (anti-A and/or anti-B) against nonself antigens of the ABO system are present even if sensitization has not occurred , so fetal hemolysis may occur during the first pregnancy. - The presence of preexisting maternal antibodies anti-A and/or anti-B is possible in maternal blood groups O, A, and B. They are usually immunoglobulin M (IgM) antibodies (unable to cross the placenta) but may also be IgG antibodies (able to cross the placenta), which cause HDFN. - Combination of predominantly IgM antibodies and late expression of fetal ABO antigens reduces the chances of significant disease.

Answer 12

**Rh incompatibility - Pathophysiology** - In an Rh-negative mother and Rh-positive newborn: maternal exposure to fetal blood (fetomaternal hemorrhage) → production of maternal IgM antibodies against the Rh antigen → over time, seroconversion to Rh-IgG (able to cross the placenta) - In a subsequent pregnancy with an Rh-positive newborn: rapid production of maternal IgG anti-D antibodies to fetal RhD antigens → Rh-IgG agglutination of fetal RBCs with hemolytic anemia → risk of HDFN with possible hydrops fetalis

Answer 13

- ABO incompatibility usually has a significantly milder course of disease than Rh incompatibility. - Anemia may conceal cyanosis.

Answer 14

The diagnosis of HDFN requires evidence of hemolysis in the presence of fetomaternal blood incompatibility. **Postnatal diagnosis** - If the newborn has signs of hemolysis, conduct a Coombs test (either direct or indirect). - Rh incompatibility: positive - ABO incompatibility: weak positive or negative

Answer 15

About one woman in seven has a Rh(D) negative blood group, and if her baby has a blood group that is Rh(D) positive there is a small risk that during pregnancy the baby’s blood cells might stimulate an immune response in the mother’s blood (sensitisation). If this happens and a woman makes antibodies against the D-positive blood group, there is a risk that a baby could be affected in this or future pregnancy. Giving anti-D to a woman who has a Rh(D) negative blood group during, or in the days following pregnancy can reduce the risk of sensitisation, and of adverse consequences in this and future pregnancies.

Answer 16

**Potential sensitising events include:** 1. Ectopic pregnancy 2. Miscarriage 3. Termination of pregnancy 4. Ultrasound guided procedures including: − Chorionic villus sampling − Amniocentesis − Cordocentesis − Fetoscopy 5. Abdominal trauma that causes uterine activity and or abdominal pain 6. External cephalic version 7. Antepartum haemorrhage 8. Birth.

Answer 17

The administration of anti-D gamma globulin is given for Rh isoimmunization, which occurs when an Rh-negative mother is exposed to Rh-positive fetal blood. In this case, if the Direct Coombs test or other indicators show that the mother has developed antibodies against Rh-positive blood (Rh sensitization), anti-D gamma globulin is given to prevent the development of hemolytic disease of the fetus and newborn (HDFN) or erythroblastosis fetalis. The primary purpose of administering anti-D gamma globulin is to prevent the mother's immune system from producing Rh antibodies in response to the exposure to Rh-positive blood from the fetus. Anti-D gamma globulin contains Rh antibodies that bind to any Rh-positive fetal red blood cells that may have entered the mother's circulation. This process helps to clear these cells from the mother's bloodstream before her immune system can recognize them and mount an immune response.

Answer 18

The diagnosis of Rh isoimmunization is primarily based on the presence of Rh antibodies in the mother's blood and evidence of fetal anemia or complications on fetal assessment.

Answer 19

Rhesus (Rh) isoimmunization, also known as Rh disease or Rh incompatibility, occurs when an Rh-negative mother is exposed to Rh-positive fetal blood during pregnancy or childbirth. This exposure can lead to the development of Rh antibodies in the mother's blood, which can cross the placenta and attack the red blood cells of an Rh-positive fetus. The effects of isoimmunization on the fetus can be severe and potentially life-threatening.

Answer 20

To prevent Rh isoimmunization, Rh-negative pregnant women receive anti-D gamma globulin (Rh immune globulin) after specific events that may lead to fetal blood exposure to Rh-positive blood, such as during pregnancy-related bleeding, after delivery of an Rh-positive baby, or after certain invasive prenatal procedures. This preventive measure aims to prevent Rh sensitization and the subsequent development of Rh isoimmunization during subsequent pregnancies.

Answer 21

No, there is no need to check for antibodies if a woman is known to be Rh positive. The reason is that Rh antibodies are only produced in Rh-negative individuals who have been exposed to Rh-positive blood. When a woman is Rh positive, it means she has the Rh factor (antigen) on the surface of her red blood cells. If an Rh-positive woman becomes pregnant with an Rh-positive baby, there is no risk of Rh isoimmunization or the development of Rh antibodies. This is because there is no antigenic difference between the mother and the baby's red blood cells, so the mother's immune system does not recognize the baby's red blood cells as foreign and does not produce antibodies against them.

Answer 22

- Anaemia is defined by the WHO as a haemoglobin (Hb) <110 g/L at any stage of pregnancy and <100 g/L postpartum. - Physiological changes occur in the second trimester, increasing plasma volume alongside a smaller increase in red cell mass resulting in haemodilution – recognised as ‘physiological anaemia’. Therefore, a threshold of Hb <105 g/L in the second trimester is widely used throughout international guidelines in defining and directing management.

Answer 23

In this scenario, the 26-year-old woman at 16 weeks gestation with a hemoglobin level of 98g/L and a family history of Greek ancestry should undergo further investigations to determine the cause of her low hemoglobin. Certain genetic conditions, such as thalassemia, are more prevalent in individuals with Mediterranean ancestry, including Greek populations. Thalassemia is a group of inherited blood disorders that can lead to anemia.

Answer 24

In a normal obstetric population, screening for diabetes mellitus can be performed using various methods to identify women at risk of or already affected by gestational diabetes mellitus (GDM) or pre-existing diabetes.

Answer 25

The clinical risk factors for diabetes mellitus in pregnancy, particularly gestational diabetes mellitus (GDM), are factors that increase the likelihood of a pregnant woman developing diabetes during her pregnancy. Identifying these risk factors is crucial to implement early screening and appropriate management.

Answer 26

1. Lifestyle management 2. Self-monitoring of blood glucose 3. Pharmacological therapies - Metformin or insulin 4. Fetal surveillance & delivery planning 5. Follow-up post partum

Answer 27

Pregestational diabetes poses a greater risk of complications than gestational diabetes. Complications during the first trimester are more common in pregestational diabetes, while complications during the second and third trimesters are equally associated with pregestational and gestational diabetes.

Answer 28

**Diabetic fetopathy** - **Definition**: any anomaly in a fetus associated with maternal diabetes, caused by fetal hyperinsulinemia during gestation - **Onset**: second and third trimesters - **Pathophysiology**: maternal hyperglycemia → fetal hyperglycemia → stimulation of fetal pancreas → fetal hyperinsulinemia → ↑ metabolic rate, oxygen consumption, and fetal hypoxemia → metabolic, respiratory, and cardiovascular complications

Answer 29

- About half of Australian women with asthma find their asthma gets a bit worse during pregnancy, often between 17 and 36 weeks gestation. - The most important thing is that you do not stop taking your asthma medication – especially your preventer.

Answer 30

The likely diagnosis for the 18-year-old primigravida presenting at 24 weeks gestation with a temperature of 38°C and right loin pain for 12 hours is acute pyelonephritis. Acute pyelonephritis is a bacterial infection of the kidneys and is more common during pregnancy due to anatomical and hormonal changes that can impair the normal flow of urine and make pregnant women more susceptible to urinary tract infections. **Optimal Treatment:** The treatment for acute pyelonephritis in pregnancy typically involves hospital admission and intravenous antibiotics. The choice of antibiotics will depend on local antibiotic sensitivity patterns and should be safe for use during pregnancy. Commonly used antibiotics include penicillins, cephalosporins, or aminoglycosides. The duration of antibiotic therapy will depend on the severity of the infection and the response to treatment. Adequate hydration and pain relief may also be provided to manage symptoms.

Answer 31

Family history of VTE is significant if it occurs in a first degree relative (ie. parents or siblings).

Answer 32

1. Any woman who has been on antenatal anticoagulation (LMWH) for maternal thromboprophylaxis, regardless of mode of delivery: 6-12 weeks. 2. Any woman who has a personal history of a thromboembolic event, regardless of mode of delivery or whether they were on antenatal thromboprophylaxis: 6-12 weeks. 3. Women with clinical risk factors stratified according to table.

Answer 33

CTG = CardioTocoGraphy

Answer 34

**CTG Antepartum Use** 1. From 24 weeks onwards 2. High risk pregnancies – routine monitoring. Examples- Diabetes in Pregnancy, Fetal Growth Restriction, Hypertensive Disorders of Pregnancy 3. Emergency admissions: Examples- Reduced fetal movements, Antepartum haemorrhage, Rupture of membranes, trauma, infection

Answer 35

**Dr C BraVADO** - Dr : Define risk - C : Contractions - Bra : Baseline rate - V : Variability - A : Accelerations - D : Decelerations - O : Overall impression

Answer 36

- Normally 3-4 contractions in 10 mins each lasting 40-60 seconds every 2-3mins with relaxation of the uterus between contractions to allow for placental blood to be flushed with maternal blood and fetal oxygenation. - A CTG can only determine the frequency of the contractions but the Strength of contractions is felt clinically or with an intrauterine pressure transducer. - Hyperstimulation = tachysystole with an abnormal CTG

Answer 37

- Baseline rate: Is it normal, or is it bradycardia/tachycardia? - Is it the same as it was at the start of labour? - More important to look at the trend - Normal baseline FHR 110-160bpm - Bradycardia if FHR < 110 bpm for >5 minutes - Baseline fetal HR must be determined when there are no uterine contractions!

Answer 38

- Variability in HR once baseline has been defined - can vary 5-25 beats above or below baseline - Variability is the most important aspcet of CTG as it represents the SNS & PSNS balance in the fetal brainstem (Autonomic NS oxygenation)

Answer 39

- Acceleration = +15 beats above the baseline for >15 seconds more than 2 in a cycle

Answer 40

**Decelerations** - Considered “abnormal”, but may not always be concerning - Fall in FHR by 15 beats from baseline and lasting 15 seconds - There are four types and a good recording on the toco is required to differentiate between the four: 1. Early 2. Variable 3. Prolonged 4. Late

Answer 41

Some variables are more concerning than others - Consider: 1. A rising baseline or tachycardia? 2. Reducing variability? 3. Persistent deep or long variables? 4. A smooth post deceleration overshoot (NOT shouldering)? 5. Slow recovery?

Answer 42

Late decelarations = fetal hypoxia!

Answer 43

**SPECIAL PATTERNS on CTG** 1. **Sinusoidal**; reflective of severe anaemia in the fetus, and generally seen with a complaint of RFM (Reduced Fetal Movements) - THIS IS A COMPROMISED FETUS - This trace warrants immediate delivery - Sawtooth appearance 2. **Pseudosinusoidal**; looks sinusoidal, but the trace was normal before/is normal afterwards  Often attributed to thumb sucking!

Answer 44

GBS Positive - means she will need IV antibiotics during labour (either penicillin or clindamycin) Cervidil = a prostaglandin **CTG at admission** - variability normal - 2 accelerations in a 10 minute period - >15beats lasting more than 15 seconds - Normal CTG **CTG at decision for CS** - prolonged deceleration bordering on bradycardia - Outcome: Baby cried at birth, Normal cord gases

Answer 45

Bleeding = irritable uterus Mothers HR up and down = pain (pink) Fetal HR (red) going up during the bleed then it can no longer cope so it drops 2nd CTG - babys HR goes up to compensate but it drops and gets a bradycardia as it cant cope - goes up and down

Answer 46

**Early Pregnancy Complications - Clinical Approach** 1. History -dates, pain 2. Examination- abdo, speculum, bi-manual 3. Investigation- hb, group,BHCG, U/S, laparoscopy 4. Management- Anti-D, expectant Mx, evacuation of uterus, treatment of ectopic

Answer 47

**Complications of Suction D&C** 1. Infection 2. Retained products 3. Perforation of uterus 4. Wrong diagnosis - no products

Answer 48

**= Ensure the Blood pressure measurement is correct** - Seated and relaxed - Cuff size - Arm at heart level - Korotkoff V - First visit both arms - Average readings

Answer 49

- If newly diagnosed consider investigation for 2ry causes - Continue present medication if “safe” and monitor BP OR stop medication and monitor BP. Medicate if BP approaches 160/100 OR change current medication to “safer” medications and monitor BP - Consider low dose aspirin prophylaxis (must commence before 16 weeks) and calcium ± vitamin D supplementation

Answer 50

1. Alphamethyldopa- 250mg tds-750mg qid 2. Labetalol- 100mg tds-300mg qid (combined alpha & beta blocker - can worsen asthma) 3. Prazosin- 0.5mg qid- 2g 4 hourly 4. Beta blockers 5. Hydralazine 6. Nifedipine

Answer 51

BP ≥ 140/90 (x2) after 20 weeks with normal pre-pregnancy BP and > Pr/Cr ratio >30mg/mmol (≥ 2+ dipstick) or evidence multisystem dysfunction (renal, hepatic, neurological, hematological, IUGR)

Answer 52

In the nonpregnant state natural killer cells are a prominent immunological cell in the endometrium. Play a role in eliminating foreign cells, usually malignant cells or infectious agents. the NK cells secrete angiogenic growth factors and are thought to play an important role in implantation and may influence fertility. They surround the spiral arteries and interact with extravillous trophoblast cells to assist their migration into the spiral arteries, in which they cause dilatation by disruption of the elastin in the arterial wall. This process is impaired in the first trimester in pregnancies which go on to manifest with IUGR or preeclampsa.

Answer 53

1. Early onset vs late onset (prior to or after 34 weeks gestation). Ongoing debate re whether different diseases 2. Pure maternal (80-90% of cases) vs combined with IUGR (most of these early onset) 3. HELLP syndrome

Answer 54

1. Aspirin (nocte) 2. Pravastatin 3. Calcium supplementation 4. Mediteranean diet 5. Exercise 6. Limit weight gain

Answer 55

1. Headache 2. Visual disturbance 3. Epigastric/Right upper quadrant pain 4. Rapid weight gain/oedema

Answer 56

**Preeclampsia & Uric Acid** - Levels fall by 25% early pregnancy then Rise throughout gestation - Raised in preeclampsia- may be diagnostically useful - Some correlation of level with eclampsia, severe hypertension, fetal outcome but poor predictor - Hemolysis, polycythemia and renal disease may also cause elevated levels

Answer 57

1. Prophylaxis- low dose aspirin & calcium 2. Delivery! 3. Anti-hypertensive therapy 4. Convulsions- primary & secondary 5. HELLP syndrome monitoring 6. Volume management

Answer 58

1. Seizures 2. Cerebral haemorrhage 3. Cerebral oedema 4. Hepatic failure 5. Liver haematoma/ rupture 6. Ventricular dysfunction 7. Pulmonary oedema 8. Placental abruption 9. DIC 10. Renal failure

Answer 59

- Gestational age at 1st birth >37 weeks- 13% - Gestational age at 1st birth <28 weeks- 39% - Recurrence risk higher if obese

Answer 60

1. Make sure large cuff, not anxious, few more readings. Family history of hypertension and preeclampsia, diabetes. Examine for renal bruits, heart, bp each arm, urinalysis, msu, u and e, fasting glucose, fasting lipids, rubella status, vitamin D, renal ultrasound 2. Preeclampsia, severe hypertension, gestational diabetes, thromboembolism, preterm delivery. 3. Lose weight, exercise, mediteranean diet, aspirin, vit D and calcium supplementation if nec, limit weight gain during pregnancy. Commence alphamethyldopa or labetalol.

Answer 61

Aldomet or labetalol- chips trial. Lose as much weight as possible prior to pregnancy. Consider glucose tolerance test. Commence folic acid- commence aspirin when pregnant.