Womens health - antenatal care Flashcards
(239 cards)
1
Q
What is considered term?
A
37-42 weeks
2
Q
What are the subcategories of preterm deliveries (3)?
A
- Moderately preterm = 32-37
- Very preterm = 28-32
- Extremely preterm = <28
3
Q
How is the number of times a woman has been pregnant and the number of births she has given birth denoted?
A
- Gravida = number of pregnancies
- Parity = number of pregnancies carried to viable gestational age (24 weeks)
4
Q
How are twins denoted in Gravida and parity?
A
Classed as one birth - so a woman with one pair of twins delivered at 39 weeks would be G1P1
5
Q
What is the terminology for first pregnancy, multiple deliveries, never birthed, first delivery?
A
- First pregnancy = pimigravida
- Multiple deliveries (2 or more) = multiparous
- Never birthed = nulliparous
- First delivery = primiparous
6
Q
What are the functions of the placenta (5)?
A
- Excretion
- Nutrition
- Circulation (HbF has high O2 affinity)
- Immunity
- Hormonal
7
Q
What hormones does the placenta produce during pregnancy (4)?
A
- Progesterone
- Ostrogen
- BhCG (beta human chorionic gonadtotropin)
- hPL (human placental lactogen)
8
Q
What does BhCG and hPL do in pregnancy (2)?
A
- BhCG - stimulates the production of progesterone
- hPL - regulates metabolism + stimulates breast development (prepares for lactation)
9
Q
When does the foetus begin producing surfactant and when is a sufficient amount of surfactant produced by the foetus?
A
- Begin at 24 weeks
- Sufficient amount by 34 weeks
10
Q
When should steroids be given to the mother until during pregnancy if she is going to give birth?
A
Up to 37 weeks
11
Q
What is often given to a preterm baby if they are premature?
A
Surfactant
12
Q
What can be given to mother to protect the baby from cerebral palsy?
A
MgSO4
13
Q
When is MgSO4 given until in pregnancy?
A
Until 34 weeks
14
Q
What are some changes to the maternal body that happen during pregnancy (8)?
A
- Increased cardiac output
- Decreased BP in first 2 trimesters
- Dysmotility –> constipation + GORD
- Decreased immune response (so don’t attack baby)
- Poor glycemic control –> GDM
- Increased renal excretion
- Hormonal changes
- Skin changes
15
Q
What hormonal changes happen in pregnancy (6)?
A
Raised:
* Progesterone
* Oestrogen
* Prolactin
* T3/4
* BhCG
* ALP
also ESR/ CRP
16
Q
What are some skin changes that happen during pregnancy (3)?
A
- Linea nigra (dark line on stomach)
- Striae gravidarum (stretch marks)
- Polymorphic eruptions of pregnancy (red rash on abdomen)
17
Q
How is gestational age determined?
A
- Before dating scan = first day of last menstrual period
- After dating scan = CRL
18
Q
When is each trimester between?
A
- 1st = 0-12
- 2nd = 13-26
- 3rd = 27+
19
Q
When should pregnant women be refered to foetal medicine if they not have felt movements?
A
24 weeks
20
Q
How many appointments are given to pregnant women?
A
- 8 for parous
- 11 for nulliparous
21
Q
What are the key appointments (4)?
A
- Before 10 + 0 = Booking
- 10 - 14 weeks = Dating
- 18 - 21 = Anomoly
- 16, 25, 28, 31, 34, 36, 38, 40, 41 = Antenatal appointments
22
Q
What happens at the booking visit (6)?
A
- BMI
- Screening offered
- BP
- Urinalysis
- Assess risk scores
- Vaccines offered
23
Q
What happens at dating scan (2)?
A
- Gestational age calculated (crown rump length)
- Multiple pregnancies identified
24
Q
What happens at anomaly scan (2)?
A
- Anatomical anomalies identified (e.g. CHD, NTD, gastroschisis, omphelocele)
- Placenta position identified
25
What happens at general antenatal appointments (4)?
* Urinalysis
* BP
* Symphyseal-fundal height (SFH)
* Foetal presentation (after 36 weeks)
26
What risks are assessed at booking visit (5)?
* GDM
* Pre-eclampsia
* Foetal Growth Restriction
* VTE
* FGM (female genital mutilation)
27
What vaccines are given (2)?
* Whooping cough (pertussis) - from **16** weeks
* Influenza - seasonal (autumn + winter)
28
What are the 3 elements of pregnancy screening at the booking and dating appointment?
* Infectious diseases
* Sickle cell and thalassaemia
* Genetic abnormalities
29
What 3 infectious diseases are screened for at the booking appointment?
* HIV
* Syphilis
* Hep B
30
What genetic abnormalities are screened for in pregnancy (3)?
* Downs syndrome (T21)
* Edwards syndrome (T18)
* Patau's syndrome (T13)
31
What test is used to screen for genetic abnormalities between 11 and 14 weeks?
Combined test
32
What test is used to screen for downs syndrome after 14 weeks?
Quadruple test
33
What are the parameters of the combined test (4)?
* Maternal age
* Beta-hCG
* PAPP - A (pregnancy associated plasma protein - A)
* Nuchal translucency (on USS)
34
What results are suggestive of genetic disorders in the triple test (3)?
Low PAPP-A + high NT
AND
* High B-hCG = downs syndrome
* Low B-hCG = T18,13
35
How are genetic abnormalities identified as high risk further screened for (3)?
* Nothing
* Non-invasive prenatal testing (mum's blood DNA tested)
* Chorionic villus sampling (11-14 weeks)/ amniocentesis (15+)
36
What is in the quadruple test for downs syndrome?
* BhCG (raised)
* AFP - alpha fetoprotein (low)
* E3 (low)
* Inhibin A (raised)
37
What additional appointments/ tests are sometimes offered to those in pregnancy (4)?
* **OGTT** at 24 - 28 weeks
* **Anti-D injections** at 28, 34 weeks
* **USS** at 32 if placenta praevia
* **Growth scans** if high risk of FGR
38
What additional things are pregnant mothers advised about general advice/ lifestyle advice (6)?
* Take folic acid 400mcg from before pregnancy --> 12 weeks
* Vitamin D
* Stop smoking + drinking
* Healthy eating (low vitamin A - teratogenic)
* Avoid unpasteurised milk, soft cheeses, avoid undercooked meat + eggs (due to risks of salmonella and listeriosis)
* No flying after 37 weeks (32 weeks if multiple pregnancy)
39
What medications are important to know about avoiding in pregnancy (10)?
* NSAIDs
* Beta blockers
* ACE-i + ARBs
* Opiates
* Warfarin
* Sodium valproate
* Lithium
* SSRIs
* Isoretinoin (retinoids)
* Amiodarone
40
What effects can NSAIDs have on pregnancy (2)?
* Premature closure of PDA
* Delay labour
41
What effects can beta blockers have on pregnancy (3)?
* FGR
* Hypoglycaemia in the neonate
* Bradycardia in neonate
*be aware of this for labetalol*
42
What effects can ACE-i + ARBs have in pregnancy (2)?
* Oligohydramnios (low amniotic fluid)
* Hypocalvaria (incomplete formation of skull bones)
43
What effect can opiates have in pregnancy?
Neonatal abstinence syndrome
44
What effects can warfarin have during pregnancy (3)?
* Miscarriage
* Congenital malformations
* Bleeding during pregnancy/ delivery
45
What effects can sodium valproate have during pregnancy (2)?
* Neural tube defects
* Developmental delay
46
What effect does lithium have during pregnancy?
Ebsteins anomaly
47
What is ebsteins anomaly?
Tricuspid valve set lower on right side of heart
48
What effects can SSRIs have on pregnancy (3)?
* CHD
* Persistent pulmonary hypertension (in neonate)
* Withdrawal in neonate
49
What effects can isotretinoin have in pregnancy?
Highly teratogenic + congenital defects e.g. NTDs
50
What are the common conditions involving the placenta in pregnancy (4)?
* Low lying placenta
* Vasa praevia
* Placenta accreta
* Placental abruption
51
What is placenta praevia?
Placenta covering internal os
52
What is a low lying placenta?
Placenta within 20mm of internal os, but NOT covering
53
What are the grades of a low lying placenta/ placenta praevia (4)?
1. Within 20mm of internal os
2. Touching/ reaches internal os
3. Partially covering internal os
4. Fully covering internal os
54
Why does placenta praevia cause bleeding?
Bastocyst implants into lower uterus --> trauma (e.g. cervical dilation in labour) causes bleeding, can also be spontaneous
55
What are some risk factors for placenta praevia (6)?
* Previous caesarean
* Previous placenta praevia
* IVF
* Older age
* Smoking
* Multiple pregnancy
56
What can be the presentation of placenta praevia (2)?
* **Painless** PV bleeding (antepartum haemorrhage)
* Non-tender uterus
*quite common, usually no symptoms however*
57
How is placenta praevia diagnosed?
Identified at anomaly scan at 18-21 weeks
58
How is placenta praevia monitored?
32 and 36 week follow up scans
59
What is important not to do on a woman with placenta praevia?
Don't give PV exam
60
How is placenta praevia managed (2)?
* Corticosteroids given at 34-36 weeks to mature foetal lungs
* C-section 36-37 weeks
*can consider vaginal delivery if grade 1*
61
What are some complications of placenta praevia (3)?
* Preterm
* Maternal shock --> death
* Morbidly adhered placenta (placenta accreta)
62
What is vasa praevia?
Malformation of foetal vessels --> run through placental membranes instead of umbilical cord
63
How does vasa previa typically present?
Rupture of membranes followed by vaginal bleeding and foetal distress (bradycardia)
64
What are the 2 types of vasa praevia?
* Type 1 = foetal vessels connected to placenta corsing over internal os (velamentous)
* Type 2 = placenta connect to accessory (succenturiate) lobe of placenta via internal os
65
What protects the blood vessels in umbilical cord?
Wharton's jelly
66
How is vasa praevia sometimes detected?
Ultrasound antenatal scans
67
What are some risk factors for vasa praevia (3)?
* Low lying placenta
* IVF
* Multiple pregnancy
68
What might be found on vaginal examination of those with vasa praevia?
**Pulsating vessels**
69
How is vasa praevia managed (2)?
* Corticosteroids from 32 weeks
* C-section 34-36 weeks
70
What is placenta accreta?
The placenta implants deeper through the endometrium
71
What are the 3 types of abnormally invasive placenta?
* Superficial placenta accreta
* Placenta increta
* Placenta percreta
72
What are the different extents of invasion of the placenta (3)?
* Accreta = **surface** of myometrium
* Increta = **deeply** in myometrium
* Percreta = past myometrium and perimetrium (serosa) reaching other internal organs
73
What are some risk factors for placenta accreta (5)?
* Previous c-section/ uterine surgery
* Previous accreta
* Low lying placenta
* Increased age
* Multigravida
74
How is placenta accreta diagnosed?
Routine USS (loss of retroplacental zone)
*Women with previous acreeta are screened*
75
How is placenta accreta managed (4)?
* Hysterectomy (recommended)
* Uterus preserving surgery (myometrium resected with placenta)
* Expectant management (very risky)
* Group + save + transfusions if needed!!
76
What are some complications of placenta accreta (3)?
* Preterm
* Severe haemorrhage (PPH)
* Infection of uterus (if no hysterectomy)
77
What is placental abruption?
Premature separation of the placenta from the decidua
78
What are some risk factors for placental abruption (5)?
* Previous abruption
* Pre-eclampsia
* Abdominal trauma
* Smoking
* Cocaine
79
What are the types of placental abruption (3)?
* **Concealed** - blood remains behind placenta
* **Revealed** - blood escapes from behind placenta = PV bleed
* **Mixed** - clot forms behind placenta
80
What is the presentation of placental abruption (4)?
* Antepartum haemorrhage (dark red blood)
* Sudden abdo pain
* 'Woody' hard contracted uterus
* Shock
81
How is placental abruption diagnosed?
Clinical diagnosis
*USS not very helpful*
82
How is placental abruption managed if massive blood loss (5)?
* 2 x grey cannula
* FBC, U&E, LFT, coagulation studies
* Group + save
* Fluid/ blood resuscitation
* Monitor CTG
* C-section
83
What are some complications of placental abruption (3)?
* DIC
* Prematurity
* Maternal/ foetal death
84
What is antepartum haemorrhage?
PV bleeding after 24 weeks gestation but before labour
85
What are the most common causes of antepartum haemorrhage (4)?
* **Placenta praevia** = MC
* **Placental abruption** = second MC
* Vasa praevia
* Cervical causes (e.g. cervicitis, polyps)
86
What are the different severities of antepartum haemorrhage?
* Minor < 50ml
* Major 50 - 1000ml
* Massive > 1000ml
87
How is antepartum haemorrhage investigated (4)?
* FBC + Group & save
* Kleinbauer test (foetal Hb in mother peripheral blood)
* USS
* CTG
88
What is defined as small for gestational age (SGA)?
Being below the 10th percentile
89
What is severe SGA?
Being below 3rd percentile
90
How is foetal size assessed (3)?
* Estimated foetal weight
* Foetal abdominal circumference
* Symphyseal fundal height
91
What two categories can the causes of SGA be divided into?
* Constitutionally small (mother/ father is small)
* Foetal growth restriction
92
What are the two categories of foetal growth restriction?
* Placenta mediated growth restriction
* Non- placenta mediated growth restriction (due to genetic/ structural abnormality)
93
What causes placenta mediated growth restriction (6)?
* Idiopathic
* Pre-eclampsia
* Smoking/ alcohol
* Anaemia
* Malnutrition
* Infection
94
What causes non-placenta mediated growth restriction (3)?
* Genetic abnormalities
* Structural abnormalities
* Foetal infection
95
What are some signs/ symptoms of foetal growth restriction (5)?
* Reduced foetal movements
* Abnormal CTG
* Abnormal doppler (decreased blood flow)
* Reduced amniotic fluid volume
* Reduced SFH
96
What are some complications of FGR (4)?
* Foetal death
* Obesity
* T2DM
* Cardiovascular disease
97
What are some risk factors for SGA (10)?
* Previous SGA
* Obesity
* Smoking
* Diabetes
* Previous hypertension
* Pre-eclampsia
* Older age
* Multiple pregnancy
* APL syndrome
* Antepartum haemorrhage
98
What scenarios require serial growth scans and umbilical artery doppler (3)?
* Three or more minor risk factors
* 1 or more major risk factor
* Issues measuring SFH
99
What investigations are sometimes done for SGA (4)?
* BP + urine dip
* Uterine artery doppler
* Anatomy scan by foetal medicine
* Infection screening (CMV/ toxoplasmosis)
100
How is SGA managed if the growth is static?
Early delivery with c-section
101
What is large for gestational age known as?
Macrosomia
102
What is classed as being large for gestational age?
Above 90th percentile (4.5 kg at birth)
103
What are some causes of large for gestational age (4)?
* Idiopathic/ constitutional
* GDM
* Polyhydramnios
* Post term (not really large of gestational age though - as they are late)
104
How should a foetus large for gestational age be investigated (2)?
* Serial USS
* OGTT (24-28 weeks)
105
What are some complications of large for gestational age (3)?
* Perineal tears
* **Shoulder dystocia**/ obstructed labour
* PPH
106
What is too much amniotic fluid known as?
POLYHYDRAMNIOS (1% of women)
107
What is too little amniotic fluid known as?
OLIGOHYDRAMNIOS (6% of women)
108
What are the criteria for poly/oligohydramnios (2)?
* Polyhydramnios = AFI > 25cm (>2000ml)
* Oligohydramnios = AFI < 5cm (<300ml)
*AFI = amniotic fluid index*
109
What are some causes of polyhydramnios (4)?
* GDM
* Oesophageal/ duodenal atresia
* Torch infections
* Idiopathic
110
What are some examination findings in those with polyhydramnios (3)?
* Increased SFH height
* Exaggerated foetal movements
* Lack of foetal heartbeat
111
What are some complications of polyhydramnios (5)?
* Cord prolapse
* Placental abruption
* PPH
* Prematurity
* Increased UTIs
112
What are some causes of oligohydramnios (3)?
* PPROM (preterm premature rupture of membranes)
* Pre-eclampsia/ uteroplacental insufficiency
* Foetal renal issues
113
What are some examination findings of those with oligohydramnios (3)?
* Reduced SFH height
* Reduced foetal movements
* Easily identifiable foetal boney prominences
114
What are some complications of oligohydramnios (4)?
* **Potters sequence** = foetal deformities/ ugly baby
* Prolonged labour + foetal distress
* IUGR
* Skeletal deformities
115
What is pregnancy induced hypertension?
New onset hypertension developing after 20 weeks gestation
116
What is pre-eclampsia?
New onset hypertension and end organ dysfunction (e.g.proeteinuria) after 20 weeks gestation
117
What causes pre-eclampsia/ PIH?
Increased resistance in the spiral arteries due to systemic reaction to invasion of the placenta
118
What is the presentation of PIH?
Usually asymptomatic - can have hypertension sx e.g. headaches, blurred vision
119
What is the presentation of pre-eclampsia (8)?
* Headache
* Visual changes
* N+V
* Abdo pain
* Oedema
* Oliguria (low urine)
* Reduced foetal movement
* Brisk reflexes
120
What are some major risk factors for pre-eclampsia (5)?
* Pre-existing hypertension
* Previous hypertension in pregnancy
* Autoimmune conditions (aPL/SLE)
* Diabetes
* CKD
121
What are the moderate risk factors for pre-eclampsia (6)?
* Older than 40
* BMI > 35
* 10 years since last pregnancy
* Multiple pregnancy
* First pregnancy
* Family history
122
What would be considered high risk for developing pre-eclampsia?
2 moderate risk factors OR 1 major risk factor
123
How is pre-eclampsia diagnosed?
* **Hypertension**
+ (one of)
* Proteinuria
* Organ dysfunction (raised creatinine, LFTs, seizures, thrombocytopenia, haemolytic anaemia)
* Placental dysfunction (FGR, abnormal dopplers)
124
What is used as prophylaxis against pre-eclampsia?
**Aspirin**
From 12 weeks
125
When is aspirin given to prevent pre-eclampsia?
From 12 weeks until birth
126
How is pre-eclampsia treated (3)?
1. Labetalol
2. Nifedipine
3. Methyldopa
127
What is an important contraindication to labetalol?
Asthma (start on nifedipine instead)
128
How is pre-eclampsia treated after birth (3)?
1. Enalapril (ACE-i)
2. Nifedipine (CCB)
3. Labetolol/ atenolol
129
What are some complications of pre-eclampsia (4)?
* **Eclampsia**
* **HELLP syndrome**
* DIC
* Placental abruption
130
What is eclampsia?
Seizures associated with pre-eclampsia
131
How is eclampsia managed (2)?
* IV MgSO4
* Deliver
132
What is HELLP syndrome?
Syndrome of:
* **H**aemolysis
* **E**levated **L**FTs
* **L**ow **p**latelets
133
How is HELP syndrome managed?
Delivery baby ASAP after 34 weeks
134
How is pre-existing hypertension managed in pregnancy?
Stop current medications (e.g. **ramipril**, ARBs and diuretics) --> **labetalol**
135
How is pre
136
What is obstetric cholestasis?
Reduced outflow of bile acids from the liver causing a build up in the blood
137
When does obstetric cholestasis occur?
3rd trimester
138
Where do the bile acids commonly deposit in obstetric cholestasis (2)?
* Skin
* Placenta
139
What are the risks with placental bile acid deposition?
Raised foetal bile acid levels --> foetal arrhythmia/ cardiomyopathy
140
What does obstetric cholestasis increase the risk of?
Still birth!!!
141
What is the presentation of obstetric cholestasis (3)?
* **Pruritis** (hands + soles of feet) - at night
* Excoriation marks
* Jaundice
142
How is obstetric cholestasis investigated (2)?
* LFTs (raised)
* Bile acids (raised)
143
What is important to exclude when investigating obstetric cholestasis (3)?
* Gallstones
* Acute fatty liver
* Autoimmune/ viral hepatitis
144
What LFT is commonly raised in pregnancy and why?
ALP due to its production by the **placenta**
145
How is obstetric cholestasis treated (3)?
* Ursodeoxycholic acid
* Antihistamines (chlorphenamine - for sleep)
* Emollients
* Elective c-section (37-38 weeks) - if severe bile acid/LFT levels
146
What is acute fatty liver of pregnancy?
Rapid accumulation of fat within the liver cells causing acute hepatitis
147
When does acute fatty liver of pregnancy typically occur?
3rd trimester
148
What is the underlying cause of most cases of acute fatty liver of pregnancy?
LCHAD deficiency in the foetus (auto recessive) --> deficiency in fatty acid metabolism --> builds up in maternal liver (this is exacerbated by mother having 1 copy of defective LCHAD gene)
149
What are the signs/ symptoms of acute fatty liver of pregnancy (5)?
* RUQ pain
* N+V
* Ascites
* Jaundice
* General unwell feeling
*patient often very unwell*
150
What are the blood findings in acute fatty liver of pregnancy (3)?
* Deranged LFTs
* Raised bilirubin
* Deranged clotting/ low platelets
151
What is a much more common differential of acute fatty liver of pregnancy (from the blood test results)?
HELP syndrome
152
How is acute fatty liver of pregnancy managed?
* A-E
* **DELIVER**
153
What is gestational diabetes?
Chronic hyperglycaemia and insulin resistance during pregnancy
154
What causes hyperglycaemia in gestational diabetes?
* Placenta hormones stimulate peripheral insulin resistance in normal pregnancy
* Hypertrophy and hyperplasia of pancreatic beta cells occurs in normal pregnancy
* Failure of these mechanisms --> GDM
155
What are the risk factors for GDM (7)?
* BMI > 30
* Previous GDM
* Macrosomia (large growth of baby)
* Family history of DM/ GDM
* Ethnicity (asian, black Caribbean)
* PCOS
* Pre-eclampsia/ hypertension
156
How is GDM diagnosed?
OGTT (fasting glucose, 75 g carb drink, then 2 hours later RPG)
157
Who is given an OGTT in pregnancy and when (2)?
* Women with a risk factor screened 24-28 weeks
* Women with glycosuria/ polyhydramnios
*women with history of GDM screened at booking as well*
158
What are the diagnostic criteria for GDM?
* Fasting plasma glucose > **5.6** mmol/L *OR*
* 2 hour glucose > **7.8** mmol/L
*5678*
159
How is GDM managed?
1. 2 week trial of lifestyle changes
2. Metformin
3. Insulin
4. Extra growth scans
*FPG > 7.0 **or** FPG > 6.0 + macrosomia --> start insulin immediately +/- metformin*
160
What are some complications of GDM (5)?
* Polyhydramnios
* Macrosomia --> shoulder dystocia
* Childhood obesity
* **Neonatal hypoglycaemia** (high glucose levels in pregnancy causes high insulin levels in foetus)
* Pre-eclampsia
161
How is GDM managed at the end of pregnancy?
All medications are stopped and a review takes place with GP in 6 - 13 weeks
162
How is T2DM managed in pregnancy (3)?
* Metformin and insulin given **ONLY**
* Retinopathy screening
* Planned delivery 37-39 weeks
163
How is T1DM managed during pregnancy?
Insulin (BG closely monitored during labour)
164
What are the blood glucose targets during pregnancy (2)?
* < 5.3 FPG
* < 6.4 OGTT (2 hour)
165
What are some congenital defects of pre-existing diabetes (2)?
* CHD (especially TGA)
* NTD
166
What is haemolytic disease of the foetus and newborn?
A condition whereby the mother develops antibodies against antigens on the the RBC of the foetus after a prior sensitisation event
167
What blood types are needed for rhesus disease to occur?
* Rh -ve mother
* Rh +ve foetus
168
What is the pathophysiology of rhesus disease?
Rh -ve mother develops antibodies against +ve foetus in first pregnancy --> second pregnancy T2 hypersensitivity reaction occurs --> IgG cross placenta --> RhD IgG --> foetal distress in-utero
169
How should Rh -ve mothers be managed to prevent sensitisation to Rh +ve foetus?
They should be given anti-D (IM) at various points during pregnancy
170
When should anti-D be given to Rh -ve pregnant mothers (4)?
* **28 weeks pregnant**
* 34 weeks pregnant
* Birth
* After a sensitisation event
171
What are examples of sensitisation events in the context of rhesus incompatibility (4)?
* Antepartum haemorrhage
* Amniocentesis
* Abdo trauma
* TOP/ miscarriage
172
What test can be done to assess amount of foetal blood that has entered to maternal circulation?
Kleihauer test
173
What does kleinhauser test involve?
Mothers peripheral blood taken --> tested for foetal Hb
174
What test can be used to assess whether the mother has developed antibodies against antigens of RBCs not in her blood?
(Indirect) coombs test
175
What are the signs/ symptoms of a newborn with haemolytic disease of the newborn (3)?
* Hydrops foetal is (severe oedema of newborn)
* Jaundice
* Yellowing of amniotic fluid
176
What is a multiple pregnancy?
Pregnancy with more than 1 foetus
177
What percentage of pregnancies are multiple pregnancies?
3%
178
What are identical/ non-identical twins known as?
* **Monozygotic** - one egg splits
* **Dizygotic** - two eggs released
179
What are the different types of twin pregnancies (3)?
* Dichorionic diamniotic
* Monochorionic diamniotic
* Monochorionic monoamniotic
*chorionic = placenta; amniotic = amniotic sac*
180
What are some risk factors for multiple pregnancies (2)?
* IVF
* fHx
181
What are the signs seen on USS that suggest different types of multiple pregnancies (2)?
* Di-di = lambda sign
* Mono-di = T sign
182
How should multiple pregnancies be managed prior to birth (3)?
* Monochorionic = 2 weekly scans from 16 weeks
* Dichorionic = 4 weekly scans from 20 weeks
* FBC at booking, 20 weeks and 28 weeks
183
How should the birth of multiple pregnancies be managed (3)?
* Monochorionic = 36 weeks
* Dichorionic = 37 weeks
* Triplets < 36 weeks
184
Can a vaginal delivery be done for multiple pregnancies?
If the first baby has a cephalic presentation it can be delivered vaginally, otherwise c-section required
185
What are some complications of multiple pregnancies (8)?
* **Twin to twin transfusion**
* Prematurity
* Maternal anaemia
* Congenital abnormalities (conjoined twins)
* Low birth weight
* Pre-eclampsia
* PPH
* Twin anaemia polycythaemia sequence
186
What is twin to twin transfusion?
Blood supply to one twin is high whilst the other is starved of blood
187
What does twin to twin transfusion result in for both twins (2)?
* Recipient of blood = fluid overload (heart failure + polyhydramnios)
* Donor of blood = growth restriction + oligohydramnios
*discrepancy in the size of both twins*
188
What are two possible symptoms for the mother of twin to twin transfusion?
* Sudden increases in size of abdomen
* Breathlessness
189
How can twin to twin transfusion be treated if severe?
Laser treatment to destroy connection between two twins
190
What is twin anaemia polycythaemia sequence?
Less acute version of twin to twin transfusion resulting in anaemia in one twin and polycythaemia in the other.
191
When should foetal movements be felt by?
24 weeks
*most start by 20 weeks*
192
How should reduced foetal movements be investigated (3)?
* 1st = handheld doppler (establish foetal heartbeat)
* If no heartbeat heard --> immediate USS
* If heartbeat heard --> CTG
193
What are some important chronic conditions to know about the management of during pregnancy (5)?
* Diabetes (already covered)
* Hypertension (already covered)
* Hypothyroidism + hyperthyroidism
* Epilepsy
* Rheumatoid arthritis
194
What are some complications of hypothyroidism during pregnancy (4)?
* Miscarriage
* Small for gestational age
* Anaemia
* Pre-eclampsia
195
How should hypothyroidism be managed during pregnancy?
Titrate levothyroxine dose up by 30-50%
*TSH can be measured to monitor*
196
How should hyperthyroidism be managed during pregnancy (2)?
* **Propylthiouracil**
* Propanolol (sx control)
197
What epilepsy medications are safe during pregnancy (3)?
* Lamotrigine
* Carbamazepine
* Levetiracetam
198
What are some side effects of sodium valproate during pregnancy (2)?
* Neural tube defects
* Developmental delay
199
What is one side effect of phenytoin during pregnancy?
Cleft lip/ pallate
200
Which drugs are safe to take during pregnancy for rheumatoid arthritis (3)?
* **Hydroxychloroquine** = first
* Sulfasalazine
* Steroids
201
What medications should not be taken during pregnancy for rheumatoid arthritis and why (2)?
* Ibruprofen - premature closure of ductus arteriosus
* Methotrexate - can cause miscarriage and congenital abnormalities
202
When are women screened for anaemia during pregnancy (2)?
FBC at **booking** and **28 weeks**
203
What levels of Hb are normal during pregnancy (3)?
* 1st trimester > 110
* 2nd + 3rd trimester > 105
* postpartum > 100
204
What additional test can be done for women who are anaemic during pregnancy?
MCV
205
What are the most likely causes of anaemia if the MCV is low, normal and high?
* Low = iron deficiency
* Normal = physiological anaemia (due to increased blood volume during pregnancy)
* High = vitamin b12/ folate deficiency
206
What conditions can be exacerbated during pregnancy and cause anaemia (2)?
* Sickle cell
* Thalassaemias
207
What are some complications of obesity during pregnancy (8)?
* Miscarriage
* Congenital defects
* Macrosomia
* GDM
* PPH
* Pre-eclampsia
* Stillbirth
* Increased risk of obesity + metabolic disorders in child
208
How should obesity be managed during pregnancy (4)?
* High dose folic acid
* OGTT at 24-28 weeks
* Consultant led care
* You should not try to loose weight **during** pregnancy
209
Why is VTE risk increased during pregnancy?
Pregnancy causes a hyper-coagulable state
210
What are some risk factors for VTE during pregnancy (13)?
* Smoking
* **Surgery**
* **Cancer**
* Parity 3 or more
* Age >35
* BMI > 30
* Reduced mobility
* Multiple pregnancy
* Family history/ **past history**
* Pre-eclampsia
* Immobility
* IVF
* Thrombophilia
211
When should VTE risk assessments be done during pregnancy (2)?
* Booking
* After birth
212
When should VTE prophylaxis be started in pregnancy (2)?
* 1st trimester if 4 risk factors
* 28 weeks if 3 risk factors
*stopped 6 weeks postpartum*
213
What should be used as VTE prophylaxis during pregnancy?
LMWH (e.g. dalteparin)
214
How should DVT/ PE be investigated in pregnancy (3)?
* Doppler USS (DVT)
* CXR (PE)
* ECG (PE)
215
How should PE be investigated in pregnancy if CXR and ECG inconclusive?
CTPA or VQ scan
216
How should DVT/ PE be managed during pregnancy?
LMWH until 6 weeks postpartum
*if DVT seen on doppler, no need to investigate for PE as same treatment required*
217
What is an amniotic fluid embolism?
When foetal cells or amniotic fluid enters the mothers blood stream
218
When do the majority of amniotic fluid embolisms happen?
During labour
*can also occur during c-section or postpartum*
219
What are the signs/ symptoms of amniotic fluid embolism (5)?
* Shock
* SOB
* Shivering
* Sweating
* Coughing
220
What advice should be given about folic acid to women planning on becoming pregnant?
Before pregnancy (ideally 3 months) --> 12 weeks gestation
221
What is the standard dose of folic acid taken during pregnancy?
400 mcg
222
What is the higher dose of folic acid taken during pregnancy?
5 mg
223
What are some reasons for taking a higher dose of folic acid (6)?
* fHx or PMH
* Antiepileptic drugs
* Coeliacs
* Diabetes
* Thalassaemia trait
* Obese (BMI>30)
*excess alcohol + methotrexate can cause folic acid deficiency as well*
224
What is a good dietary source of folic acid?
Green leafy vegetables
225
What is the function of folic acid?
Key role in synthesis of DNA/RNA
226
What effect can low folic acid have during pregnancy (2)?
* Neural tube defects
* Macrocytic, megaloblastic anaemia
227
What infection presents a greater risk during pregnancy and is relatively common?
UTI (+pyelonephritis)
228
How are women screened for UTIs during pregnancy?
Urine samples are sent at booking and through pregnancy for MC&S
229
What indicates a UTI on a urine dip?
* Nitrites = most specific
* Leukocytes
* Blood
230
What are the most common causes of UTI (6)?
* **E. coli** = mc
* **Klebsiella pneumoniae**
* Enterococcus
* Pseudomonas aeruginosa
* Staph saprophyticus
* Candida
231
What antibiotics are used for UTIs during pregnancy (4)?
* Cefalexin
* Nitrofurantoin (not in 3rd trimester)
* Trimethoprim (not in first trimester)
* Amoxicillin
232
Why can't nitrofurantoin and trimethoprim be used in 3rd and 1st trimester respectively (2)?
* Nitrofurantoin = risk of neonatal haemolysis
* Trimethoprim = folate antagonist (NTD)
233
What are some risks associated with UTI during pregnancy (2)?
* IUGR
* Prematurity
234
What should all pregnant women be offered screening for (10)?
* Anaemia
* Bacteriuria
* Blood group + rhesus status
* Down's, Edwards, Pataus
* Fetal anomalies
* Hep B
* HIV
* NTDs
* Syphilis
* Pre-eclampsia risk factors
*can screen for SCD, thalassaemia + others in some women*
235
What are some important infections to know about during pregnancy (7)?
* VZV
* HSV
* Gonorrhoea
* GBS
* Chlamydia
* Syphilis
* Bacterial vaginosis
* Trichomonas vaginalis
236
How should VZV be managed during pregnancy (2)?
* Check VZ Igs (if exposed)
* If >20 weeks = Aciclovir (d7-14 or within 24 hours of rash)
237
How is HSV managed during pregnancy (2)?
* Aciclovir
* C-section (if ulcers present OR contracted in 3rd trimester)
*risk of neonatal HSV*
238
How should bacterial vaginosis be managed during pregnancy?
Metronidazole
*does not usually need treatment outside of pregnancy*
239
How is GBS treated during pregnancy?
IV benzylpenicilin (during labour)
*if woman has previous GBS then swab + test; if woman has fever during labour then treat*
