1
Q
What proportion of chronic HTN is essential?
A
90%
2
Q
When does BP in pregnancy nadir?
A
17-24 weeks
3
Q
What are the renal and cardiac secondary causes of chronic HTN?
A
renal failure result from:
chronic glomerulonephritis
polycystic kidneys
nephrotic or nephritic syndrome
reflux nephropathy
diabetic nephropathy
aortic coarctation
renovascular hypertension (renal artery stenosis)
4
Q
What are the endocrine disorders which can cause chronic HTN?
A
T2DM
cushings
conns
acromegaly
phaechromocytoma
hyper or hypothyroidism
phaeocrhomocytoma
OSA
hyperaldosteronism
Hyperparathyroidism
5
Q
What is the ISSHP definition of PET?
A
Gestational hypertension (>140/90) plus one or more of the following new-onset conditions at or after 20 weeks of gestation:
4. Proteinuria
5. Maternal organ dysfunction
a. AKI, Cr>90
b. Liver derangement, ALT or AST >40
c. Neurological complications: eclampsia, altered mental status, blindness, stroke, clonus, severe headaches, persistent visual scotoma
d. Haematological complications: plts<150, DIC or haemolysis
6. Uteroplacental dysfunction: IUGR, raised UAPI or stillbirth
6
Q
What is the etiology of PET?
A
- failure of trophoblast differentiation and invasio. failes to destroy muscularis layer of spiral arterioles
- maternal factors (obesity, diet) causing widespread endothelial dysfunction and HTN
- Systemic inflammation -exaggerated leukocytosis, extensive platelet activation and enhanced complement activation
7
Q
If you have a family history of PET what is a Para 0 increased risk?
A
2-5 x
8
Q
What is the imbalance of angiogenesis in PET?
A
placental hypoxia resulting from the impaired trophoblast invasion results in an imbalance between pro-angiogenic and anti-angiogenic factors due to the excessive secretion of anti-angiogenic factors, such as sFlt-1, and a reduction in the release of the pro-angiogenic factors vascular endothelial growth factor and placental growth factor
9
Q
Describe how endothelial dysfunction contributes to PET?
A
all of the clinical features of pre-eclampsia can be explained as clinical responses to generalised endothelial dysfunction (e.g. hypertension results from disturbed endothelial control of vascular tone, proteinuria and oedema are caused by increased vascular permeability, and coagulopathy is the result of abnormal endothelial expression of procoagulants).
10
Q
What are the risk factors for developing PET?
A
- Primigravida
- Long inter-pregnancy interval
- > 40 years age (RR 1.96)
- Previous PET (RR 7.19)
- Pre-pregnancy obesity (RR 2.47)
- Donated eggs (30% risk of PET), embryo donation or donor insemination
- Diabetes (RR 3.56)
- Pre-existing hypertension (RR 1.38)
- Family history (RR 2.90)
- APLS (RR 9.72)
Bilateral uterine artery notching at 20/40 = 20% will develop PET
11
Q
What are the long term risks for a mother with PET?
A
hypertension, MI, major cardiovascular events, heart failure, stroke and death
12
Q
What are the long term risks for the offspring of PET pregnancies
A
increased risk of hypertension and stroke
13
Q
What is the diagnostic criteria for eclampsia?
A
SOMANZ the occurrence of one or more seizures in association with the syndrome of PET
convulsion (not attributable to other cerebral condition) during pregnancy or within 10 days PP with at least two features within 24 hours:
HTN
proteinuria
thrombocytopenia
ALT/AST >42
14
Q
How common is eclampsia?
A
1 in 2000 or 1-2% of women with PET
15
Q
Who often do eclamptic seizures occur ante/intra/post partum?
A
40/20/40
16
Q
When is uterine artery pressures the best at predicting risk of severe PET?
A
high risk women with elevated PI
In low risk women there is insufficient evidence for it’s predictive ability as a test
17
Q
What did the aspre trial show?
A
A reduction in delivery from PET prior to 37 weeks with 150mg aspirin. 4.3 –> 1.6%
18
Q
When should you order coags in PET?
A
if LFTs abnormal
19
Q
Describe recommended fetal monitoring in pre eclampsia
A
- Give prophylactic steroids if the duration of gestation is less than 34 weeks
- Perform an ultrasound assessment of fetal weight on initial presentation and repeat fortnightly
- Doppler ultrasonographic assessment of umbilical blood-flow velocity if there is evidence of growth restriction
- Regular CTG
- Ultrasonography at least twice weekly for liquor volume
Multidisciplinary approach regarding timing and mode of delivery
20
Q
What is the recommended fluid in take in PET intrapartum and PN?
A
1ml/kg/hour of booking weight max 80ml/hr
21
Q
What is the recommended screening for PET?
A
- Women should be screened for signs of hypertension using blood pressure checks and urinalysis
○ monthly before 30
○ fortnightly from 30-36 weeks
○ weekly after 36 - educated about the signs and symptoms
- Epigastric pain in the second half of pregnancy should be considered to be the result of pre-eclampsia until proven otherwise
If there is elevated BP ± proteinuria, refer for admission or monitoring in antenatal day unit
22
Q
What pregnancy complications are related to essential HTN in pregnancy?
A
- Superimposed PET (risk 20-25%)
- Placental abruption
- IUGR
- Intracranial haemorrhage
Maternal heart failure
PTB 28%, low BW 17%, SGA, perinatal death
If severe HTN DBP >110 PET risk 46%!
23
Q
What investigations should be done to investigate ess HTN?
A
- Serum urea, creatinine, electrolytes & uric acid
- Autoantibody screen
- Complement studies - looking at complement mediated renal disease eg SLE, membranoproliferative glomerulonephritis
- PCR
- Renal ultrasound scan
ECG & ECHO
24
Q
If you have PET what is the likelihood for the next pregnancy?
A
you have a risk of recurrence but usually less severe and presents 2-3 weeks later
25
If you have severe or early onset PET what should you screen for?
APLS
Maybe:
hyperhomocysteinuria, factor V leiden, protein S/C/antithrombin deficiency
26
What is the criteria for severe PET?
severe HTN and proteinuria
OR
mil-mod plus
○ Symptoms of severe headache
○ Problems with vision
○ Severe epigastric pain or vomiting
○ Papilloedema
○ >3 beats clonus
○ Liver tenderness
○ HELLP syndrome
○ Plts <100
ALT/AST >70
27
Timing and mode of delivery in PET?
○ <34/40 - try to stabilise mother to allow for steroid administration, most likely by CS
○ 34-37/40 - timing dependent on maternal & fetal condition, IOL reasonable if good chance of success
37-40/40 - IOL offered to women with PET, IOL at this gestation not shown to increase delivery by CS and reduced major maternal morbidity (HYPITAT study)
28
What is the aim of blood pressure management in labour?
SBP <150 DBP 80-100
29
What are the contraindications for labetalol?
severe asthma
caution with cardiac disease
30
What are the signs of MgSO4 toxicity/
absent deep tendon reflexes, slurred speech, double vision, RR <12, U/O <30ml/hr, hypotension
31
What can you give in MgSO4 toxicity?
10ml of 10% calcium gluconate in 100ml of saline over 10 minutes (more rapidly if cardiac or respiratory arrest)
32
What is the dose of MgSO4 to give and what if has another seizure?
Loading dose 4g over 10-20 minutes, then infusion 1g/hour until 24 hours after last seizure or birth, whatever is later.
Recurrent seizures: reload with 2g over 5 minutes and consider increase in infusion to 2g/hour
do not give more than 8g an hour
33
When should you stop MgSO4 based on UO?
If <20ml/hr. 97% is excreted in the urine
34
What are Beta Blockers associated with in pregnancy if longterm use?
FGR
35
Which drug is associated with development of non-specific auto-antibodies that may precipitate consumption of maternal red cells by the spleen ?
methyldopa
36
What is the ABCDEF in severe PET management?
Airway
Breathing
Circulation: pulse, BP at intervals of 5mins to 1 hour depending on severity, can use automated but manual at least hourly, IV access
Disability: mini neuro, check drug chart, examine pupils, AVPU scale, measure blood glucose
Exposure/environment: head-to-toe examination, including assessment of reflexes
Further management: hourly fluid balance, consider MgSO4, consider delivery
37
What are the causes of hyponatremia in PET?
1. Natural Na reduction due to increased GFR and haemodilution in pregnancy
2. PET causes increased ADH due to intravascular depletion
3. Labour - oxytocin in similar to ADH and has similar effect, sweating, stress, pain and haemorrhage causes ADH secretion.
other drugs - insulin, antidepressant, diuretics, AEDs, omeprazole
38
What is the time frame of BP measurement for PET? SOMANZ
>/140 SBP or >/90 DBP 3 consecutive readings 2 minutes apart then confirmed at least 4 hours later
RANZCOG and ISSHP just have the 4 hours
39
What are the other diagnostic criteria for PET. HTN + one of:
As per SOMANZ
* Renal involvement: PCR >30, Cr>90
* Liver involvement: raised serum transaminases in the absence of alternative diagnoses
* Haematological involvement
* Thrombocytopenia
* Haemolysis: decreased haptoglobin +/- fragmented red cells, elevated LDH
* DIC
* Neurological involvement: eclampsia, cerebral irritability, cerebrovascular accident
* Pulmonary oedema
Placental dysfunction: IUGR, sFlt-1/PlGF
40
What is the criteria for resolution for GHTN?
3/12 PP
41
How does aspirin work in PET prophylaxis?
1. TXA2 reduction --> improved TXA2/PLGF ratio --> improved UtPI by reducing platelet aggregation and inhibiting vasoconstriction.
2. Generates aspirin triggered lipoxins --> upregulates IL-10 and NO and downregulates TNF-alpha --> anti inflammatory
42
What is the ideal dose of aspirin prophylaxis?
150mg, not associated with neonatal harm
43
What effect does aspirin have in reducing pregnancy risks if started before 16 weeks?
* PET 0.67
* Early onset PET 0.29
* Preterm birth 0.51
Small for gestation 0.52
44
What have the universal aspirin studies shown?
reduced risk of preterm birth, increased risk of PPH, no effect on PET although did not look at early onset vs late onset
45
What is the MOA for calcium in pregnancy, reducing PET?
Hypothesised that low calcium stimulates PTH or renin release -> increase in vascular smooth muscle intracellular calcium -> vasoconstriction -> elevation in BP
calcium lowers resistance index in uterine and umbilical arteries -> improving uteroplacental blood flow
46
Who should get calcium for PET prevention?
women who have low dietary calcium <1g/day
47
What is the evidence for calcium in preventing PET?
17 RCTs show women with low dietary calcium ONLY
reduction in PET RR 0.4 PIH 0.53 PTB 0.85
48
What is the evidence for exercise and PET/PIH prevention?
2-2.5 hours moderate intensity exercise /week RR 0.63 (same as aspirin from early in pregnancy) includes stretching, aerobic and resistance
49
What is the evidence for vitamin D in pregnancy for PET prevention?
3 RCTs 176, all different preparations, improvement in PET PTB SGA, not recommended because of ? safety data
50
What is the urine lab result you can use as an alternative to urine PCR if not available?
urine albumin creatinine ratio 8g/mmol or more
51
What is the utility of slft/PLGF?
It has a high NPV so good at ruling PET out at 1 (99.3%) and 4 weeks (94.3%)
It has a low PPV (not diagnostic 36%)
The sFlt-1/PlGF ratio should be used as an adjunct to clinical assessment. The use of the ratio should not replace clinical assessment and management decisions should not be made based on the ratio alone.
It shouldn't be used to diagnose PET, severity or decide of timing of birth.
It may be helpful in reducing admission for ? PET by 34-39%
52
What does PLGF do?
induces non-branching angiogenesis leading to low-resistance placental vascular network
53
When does PLGF peak?
26-30 weeks
54
What should be the target BP for chronic HTN and gest HTN and why?
<135/85
shown to reduce severe HTN, PET and PTB
55
What is first line for essHTN?
any of methyldopa, nifedipine, labtealol
56
What BP indicates severe PET and what is it associated with?
repeatedly over 160/110
haemorrhagic stroke, death, eclampsia, and placental abruption.
57
What does the evidence show improves acute severe HTN in PET best?
immediate release nifedipine reduces BP faster than IV labetalol or hydralazine and needed fewer doses.
IV diazoxide
58
Is there a difference with how fast IV labetalol or hydralazine work?
no
59
When should you give MgSO4 for neuroprotection?
Always <30 weeks between 30-34 consider with informed shared decision making
60
What do they think is the MOA eclampsia?
glutamate (amino acid and NT) activates NMDA receptors
61
how does MgSO4 work?
inhibits NMDA receptors
cerebral vasodilation
reduces cerebral edema by acting on endothelium
62
What is the increase in VTE risk PP for PET?
4 x
hypoalbuminemia 5 x
63
Why should you avoid NSAID use in PET post partum?
can increase BP, only use if short term, inpatient and not other alternatives
64
what long term risks should you discuss with women with PET for future health?
* 4x higher risk developing chronic hypertension
* 2-4x higher risk T2DM
* 4-8x higher risk chronic kidney disease
* 2x higher risk heart disease
* 2x higher risk stroke
* 2/3 women will die from cardiac disease
65
When should you see your doctor after you have had PET?
one week
6 weeks
3-6 months
annually
66
What should be done at the 6 weeks check up after PET?
screen for depression
check medication adherence
check BP
NSAID avoidance where able
67
What should be done at the annual review for PET in primary care?
BP, weight, lipid and glycaemic profile, urine protein analysis
Discuss future pregnancies: importance of pre-conception care and early preeclampsia prophylactic intervention (i.e. aspirin, regular exercise, dietary +/- supplemental calcium)
Explain future cardiovascular, metabolic and renal risk factors
68
What should be done at the 3-6 month PET check with GP?
BP check - 24 hour where possible
if BP>130/80 or on meds should look for secondary causes of HTN
encourage a healthy lifestyle
check bloods and urine have normalised
metabolic screen - cholesterol, FBG, BMI
discuss future pregnancies
discuss contraception
discuss risks for future helath
69
What is the definition of FGM?
partial or full removal of the external female genitalia or other injury to the female genitalia for non medical reasons
70
What types of FGM are there?
Type I - removal of clitoris
Type II - removal of clitoris and labia minora +/- majora
Type III - narrowing of vaginal orifice creating a seal by cutting labia and apposing them +/- clitoral excision
Type IV - other harmful procedures eg piercing
71
Who should be offered deinfibulation and when?
women with type III FGM
Can be intrapartum or antenatal
consider location of birth, and home, woman's preference and surgeon's experience.
72
How should you counsel women about deinfibulation?
They will have increased vaginal discharge, faster micturition and expected labial appearance
there is a lack of evidence of benefit for clitoral reconstruction
73
What health complications can occur with FGM type III?
UTI, dyspareunia, dysuria
74
What outcomes are improved with infundibulation?
PPH and CS rates likley OASI rates
75
What is the PSANZ <32 weeks FGR criteria?
AC or EFW <3%
OR
UAPI with AEDF
OR
AC/EFW <10% plus UtA >95% or UAPI >95%
76
What is the PSANZ FGR criteria >32 weeks?
AC or EFW <3%
OR
AC/EFW <10% plus UtA >95% or UAPI >95% or CPR <5% or AC/EFW crossing >2 quartiles on growth centiles
77
WHat is PSANZ definition of slowing of fetal growth?
crossing 50%
78
What is the most common placental histology abnormality after FGR?
maternal vascular malperfusion (poor early placentaion and infarction)
79
What are the placental histology findings associated with FGR?
* Most commonly maternal vascular malperfusion (early placentation and infarction)
* Chronic intervillositis
* Villitis
Massive perivillous fibrin deposition (maternal floor infarction)
80
What ist the care postpartum of FGR neontes?
* Take cord gases
* Need maintenance of oxygen, temperature, BSLs
* Local feeding guidelines of nutrition and feeding
* Consider preterm conditions affected FGR neonates eg NEC, neurological complications, infection, lung disease
81
What are the major risk factors for SGA/FGR in NZ guideline?
Age >39 and nullip
smoking>16 weeks >10/day
recreational drug use
previous FGR pregnancy
previous HTN in pregnancy
previous still birth
chronic HTN
Diabetes with vascular disease
renal impairment
APLS
Heavy PVB <20 weeks
PET of PIH
APH or abruption
82
What are the risk factors for early onset FGR in NZ guideline?
previous FGR<32 weeks , previous HTN in pregnancy with birth <34 weeks , previous still birth, chronic HTN, renal impairment, APLS
83
What are the minor risk factors for SGA and FGR in NZ guideline?
nullip
Age >39 and multip
smoking 1-10/day
short IPI <6 months or long > 60 motnhs
ART
BMI >30 of <18.5
placenta praevia
low gestational weight gain
need three to indicate growth scans
84
If you have unreliable funsal height measurement what is the guidance?
two USS:
one at 30-32 weeks
one at 36-38 weeks
85
What is the reccomendation if one or more major risk factor for FGR (NZ)?
start LDA
monthly growth from 28-30 weeks
86
What is the recommendation if risk factors for early FGR (NZ)?
Growth scans from 24-26 weeks until birth
PLUS Uterine A dopp 20-24 weeks
87
If three or more minor risk factors for SGA/FGR?
Consider growth at 30-32 weeks and 36-38 weeks
88
What is low risk and what should growth monitoring be?
<3 minor and no major risk factors
SFH from 26-28 weeks until birth, plotted on a customised growth chart
89
What are the risks for preterm FGR infants?
* Necrotising enterocolitis
* Low Apgar score
* HIE
* Need for respiratory support
* Chronic lung disease
* Retinopathy of prematurity
* Prolonged NICU admission
Higher mortality
90
What are the risks of FGR neonates?
* Hypoglycaemia
* Hypocalcaemia
* Hypothermia
* Polycythaemia
* Hyperbilirubinaemia
* Failure to thrive
* Learning difficulties
* Short stature
* Cerebral palsy & developmental delay
* Barker's hypothesis:
90
What is Barkers Hypothesis?
undernourished in-utero -> longstanding changes -> increased risk cardiovascular disease later in life
91
Why do we do Uterine artery dopplers from 20-24 weeks?
at this time they should under go transformation from high to low resistance vessels.
if they don't it may be due to inadequate trophoblastic invasion of the spiral arteries --> maternal vascular malperfusion
92
What does the meta analysis looking at use of UAPI vs no doppler or CTG find?
Use of UAPI associated with reduction in perinatal deaths, fewer IOL, fewer CS, no difference in operative vaginal deliveries, no difference in Apgar scores
93
What organs are prioritised in FGR?
liver, heart, brain, adrenals (largest)
94
What organs have blood diverted from them in FGR?
lung, gut, kidneys, placenta
95
What is the NZ definition of early onset FGR <32 weeks?
Early onset <32/40: EFW or AC <3rd or UAPI with AREDV or EFW/AC <10th + one of: raised UAPI or UtA >95th or bilateral notching
96
What is the NZ definition of late onset FGR >32 weeks?
EFW/AC <3rd or two of: EFW/AC <10th, slowing of growth ( >30 centiles at >28/40), any of UAPI>95th, CPR<5th, UtA>95th or bilateral notching
97
From when should MCA be measured to calculate CPR?
32 weeks
98
What can you advise women to reduce risk factors for FGR?
Healthy BMI
smoking smoking and recreational drugs
folic acid supplementation from one month prior (may help prevent FGR)
Healthy diet
regular moderate exercise
99
When should you organise a growth scan for a low risk woman?
SFH <10% or drops 30%
or if SFH unreliable (eg fibroids, BMI>35, polyhydramnios)
100
What should be referred to MFM when IUGR?
early onset FGR, especially <28 weeks
FGR with polyhydramnios or fetal malformation
101
When should we test for congenital infection in FGR? and what should we test?
early onset or severe
consider CMV IgG and IgM
if non immune to rubella test IgG and IgM
syphilis EIA
toxoplasmosis IgG and IgM
102
If FGR is based of abnormal CPR what should be considered?
repeat in 24-48 hours to reduce risk of false result
103
What is the threshold for STV being abnormal 26-28+6?
<2.6ms
104
What is the threshold for STV being abnormal 29-31+6?
<3.0 ms
105
What is the management for isolated SGA?
* SGA without FGR is EFW 3-10th centile with normal dopplers and normal growth
* Growth & dopplers every two weeks
* Clinical review every two weeks
* From 37/40
* Weekly clinical review
* Weekly USS for fluid & dopplers
* Recommend birth at 40/40, not earlier than 39/40 if spontaneous labour has not occurred
Increase surveillance if oligohydramnios, poor interval growth or suspected PET
106
What is the recomended management for early onset FGR?
* Weekly fluid & doppler + CTG
USS growth 2 weekly
107
What is the recomended management for early onset FGR with AEDF and REDF?
* Admit as an inpatient
* Twice daily cCTG and clinical review
* USS UA, DV and AFI 2-3 times per week
* Timing of birth
* AEDF: 32-34 weeks by CS
REDF: 30-32 weeks by CS
108
What is the management for late onset FGR?
* USS for dopplers & fluid 2x/week
* Clinical review & CTG 3x/week
* USS for growth 2 weekly
Birth by 38/40, not earlier than 37/40
109
How long should FGR babies be monitored for after delivery?
12-24 hours
110
Which babies should have their placentas sent to histology from SGA/FGR guideline?
all FGR and if possible SGA
111
What are the criteria called which is used for placenta pathologies with FGR? What does it describe?
Ansterdam workshop consensus criteria. Standardised guidelines for describing placenta patholggies
maternal vascular malperfusion (MVM), fetal vascular malperfusion (FVM), chronic villitis of unknown etiology (VUE), and acute chorioamnionitis (ACA).
112
What increased risks do Mmothers have long term after having an FGR baby?
HTN and high cholesterol. annual screening
113
What are criteria for delivery before 32 weeks for FGR?
AEDF >32-34 weeks
REDF 30-32 weeks
absent of reverse DV a wave
reduced STV
abnormal FHR - repetitive unprovoked decels
maternal deterioration
if you deliver, deliver by CS
114
If growth normalises from SGA how long until you can transfer back to routine care?
if growth and dopplers normal for at least a month
115
When do you stop doing DV?
34+0 as you are guided by UAPI eg Absent or reversed and it is unlikely to show severe abnormalities
116
What SOMANZ risk factors are high risk for PET?
Previous HTN in pregnancy
CKD
multifetal gestation
chronic HTN
T1 or T2DM
auto immune disorder
Only need one then offer prevention
117
What are the SOMANZ moderate risk fatcors for developing PET?
AMA >40
obesity BMI >35
nulliparity
FHX PET
IPI 10 years +
ART
SBP >130 or DBP >80
need two and offer prevention
118
What is the criteria for chronic HTN?
high BP confirmed prior to conception or up to 20 weeks
119
What are the NZ guideline criteria for PET diagnosis that are different to SOMANZ?
1. Renal insufficiency: UO<80ml over 4 hours
2. Liver involvement: AST/ALT >2x/normal, RUQ or epigastric pain
3. Neurological complications: hyperreflexia + clonus, severe headache with persistent visual scotoma, altered mental status,
4. Haematological complications: platelets <100,
3. Uteroplacental dysfunction: abruption
120
What is the NZ guideline criteria for Severe PET?
* BP >160/110 despite antihypertensive treatment
* Deteriorating clinical condition: worsening of diagnostic features (LFTs, Cr, plts), pulmonary oedema
* HELLP
Eclampsia
121
What is ueterine incarceration?
uterus trapped between the sacral promontory and the pubic symphysis during pregnancy
122
What are the risk factors for uterine incarceration?
- Multigestation
- Retroflexion
- Adhesions - PID, endo, surgery
- Uterine anomaly
- Deep sacral concavity
- Ovarian cysts
- Prior incarceration
Fibroids (fundal or posterior)
123
How does uterine incarcertaion usually present?
- 14-16 weeks typically
- Pain
- Urinary difficulties
- Pressure
- GI symptoms
Exam - very anterior cervix, unable to feel fundus.
124
What is inverted polarity in uterine inversion?
Where the fundus is below the anterior uterus which is cephalad and strecting above the stuck fundus
125
What USS findings do you get in uterine incarceration?
- Elongated cervix pulled anterior between bladder and pregnancy
- Fundus in scarum
- Bladder displaced superiorly and is anterior to uterus
Beware, locating placental location can be difficult in regard to cervix.
126
What are the complications associated with incarcerated uterus?
- Urinary - retention, bladder rupture, ureteric obstruction, infection
- Obstetric - impacted vascular flow to uterus, T2 loss, FGR
- Vascular - VTE from compression
GI - rectal ischemia
127
When should you try to reduce uterine incarceration and why?
14-20 weeks
most likely to be successful
prior to 14 weeks can self resolve
128
What are the ways to reduce uterine incarceration?
passive, manual, uss probe, vaginal balloon, laparoscopic reduction
129
How do you do a manual reduction of a uterine incarc?
with sedation or GA, empty bladder, lithotomy, fingertips to apply to posterior fornix, can apply ring forcep to cervix to give counter traction. Finger in Rectum can be trialled. If unsuccessful can try again in one week.
130
What is the cut off for mild polyhydramnios?
DVP 9-11cm AFI 25-30cm
131
What is the cut off for moderate polyhydramnios?
AFI 30-35cm and DVP 12-15cm
132
What adverse outcomes are associated with poly for mum?
- PPH
- Discomfort - dyspnoea, pain, UA
- Malposition
- Cord prolapse
- Abruption after ROM
- CS - fetal indication
PTL, PPROM
133
What adverse events are associated with poly for fetus?
NICU
high BW
congenital or neurological anomaly
134
What is the worst prognosis for poly when associated with?
SGA
135
What investigations should be done for polyhydramnios?
- Detailed anatomy scan - cleft palate, tracheo esophageal fistula, cardiac defects - refer to FMM
- OGTT
- If anaemia:
○ Immunological causes - blood group, rhesis factor, red cell antibodies
○ Kleihauer
○ Parvovirus
○ Haemaglobinopathy
TORCH screen is not indicated unless abnormal scan
136
What is labour management for poly?
- If moderate to severe - CTG and NICU involvement
- Only ARM in controlled environment
- Aware of abruption with ROM
- Confirm presentation and no cord prolapse
Active 3rd stage
137
What are the causes of polyhydramnios?
- Congenital anomaly - causing poor fetal swallowing or malabsorption. Eg atresia
- Diabetes
- Infection - parvovirus, CMV, toxo, syphilis.
- Fetal anaemia - increased CO increases renal blood flow.
- Drugs - lithium
- Multiple gestation
Maternal hypercalcemia
138
How often is a cause for poly found in moderate to severe?
91%
139
What is the first dose of IV labetalol, peak time of effect? when can you repeat it?
20mg, 10 minutes, repeat in 10 minutes
140
What is the first dose of hydralazine's and peak time of action? when can you repeat it?
5-10mg, 10-80 minutes, repeat in 20 minutes
141
What is the first dose of immediate release nifeidpines, when is peak time of action? when can you repeat it?
10mg, 30-45 mins and can repeat 30-45 minutes
142
How often should you check BP and PCR with PIH?
weekly
143
How often should you test bloods in PET and when should you check coags?
twice weekly.
when LFTs are abnormal
144
In severe PET who often should you check BP and bloods?
hourly BP
daily bloods
145
Post partum for PET how often should BP be checked after discharge?
within 24 hours and weekly after
146
For women with HTN what should be done at Pre conception and booking?
change ACE
assess PET risk factors
start calcium
start aspirin 12-16 weeks
refer to obs
educate about PET symptoms.
147
What should be the goal for BP management in ess HTN?
maintain at pre pregnancy BP or below
148
What are the signs of symptoms of PET?
severe HA
retrosternal pressure or pain
SOB
visual changes
epigatsric pain
N+V
hyperreflexia
sudden swelling
149
What is the goal BP for PET antenatally as per NZ guideline?
140-160 and 90-100
150
What is the acceptable BP monitoring frequency for PET overnight?
8 hours
151
In severe PET what are we aiming for BP target?
<140/100
152
What is recommended monitoring during MgSO4?
during bolus - q5mins BP
Maintenence - 30mins HR BP, RR, O2
UO - hourly aiming >100ml in 4 hours
continuous CTG
reflexes hourly
153
What is the recommended fluid restriction in severe PET?
replace birth losses then 85ml/hr total
154
What antihypertensive causes profound hypotension with MgSO4?
nifedipine
155
What side effects do peopel get from MgSO4?
flushing, N+V, headaches, drowsiness
156
What would warrant stopping MgSO4?
UO <100ml/4hours RR <12/min absent reflexes
157
When should you check Mg levels?
UO<100ml/4 hours or creat >100
158
What signs indicate magnesium toxicity
loss of tendon reflexes, hypotonia, arrythmia and cardiac arrest, hypoventilation, slurred speech, confusion
159
What should you do in MgSO4 toxicity?
call for help
stop infusion
apply oxygen 8-12L/min
check vitals
give 10% calcium gluconate 10ml IV slow
check electrolytes, Mg and creat
160
What is the typical concentration of MgSO4 given IV?
20%
161
What are the indications for delivery in PET?
>37 weeks
unable to control HTN
deteriorating bloods
persistent neurological sytmpoms
persistent EG pain, vomiting and abnormal LFTs, pulmnary edema
abruption
severe IUGR
non reassuring CTG
162
NZ PET guidelines say consider CS prior to what gestation because IOL less likely to be successful and disease more severe
28 weeks
163
What should you do postpartum for severe PET women?
monitor for at least 72 hours
continue strict fluid balance
monitor until all obs and bloods are normal
BF safe benefits out weight risks
VTE consideration
debreif events
discuss long term metabolic risks and next pregnancy
164
What proportion of PIH will develop PET?
25%
165
What is the PIERS model?
a calculation tool to predice the likelihood of severe adverse maternal outcome
looks at GA, chest pain, O2, plts, AST, creatinine
166
In Women who have an abnormal Ut Artery doppler when should they commence growth scans?
24 weeks
167
When is caffeine associated with increased risk fo SGA?
more than 300mg/day in the 3rd trimester.
Recommended 200mg/day max
168
When low PAPP A is found how does this effect recommended growth screening advice>
offer growth surveillance, low PAPP A increased risk of FGR
low <0.4
169
What mid timester USS findings should prompt UtA doppler?
2VC
echogenic bowel
EFW <10%
170
If women are unwell eg with COVID when should you offfer a growth scan?
within 14 days
171
What does universal growth scans achieve?
it increases detection of SGA but doesn't improve outcomes
172
GTG - when uterine artery doppler is normal what is the reccomendation for USS growth scan timing?
32 weeks, monthly
173
When a fetal growth disorder is diagnosed what should be done?
discussion about fetal movements +/- CTG
BP and poteinuria
174
When should IUGR be investigated further?
other structural abnormalities, anatomically normal fetuses <23 weeks especially if UtA normal consider invasive diagnostic testing (microarray or exome sequencing if multisystem anomalies or isolated short bones)
CMV testing and toxo if severe SGA
consider zika and malaria in severe SGA in high risk groups
175
How often are infection responsible for severe SGA?
5%
176
What patients with FGR should be advised to have a CS?
A or REDF UAPI
abnormal STV on CTG
177
When should you initiate CFM in FGR IOL?
from the onset of uterine contractions
178
What post natal investigations and prepregnancy counselling should be done for FGR?
placental histology
postnatal counselling - consider investigations and discuss histo
discuss prevention - smoking, aspirin
179
When can you consider the use of loop diuretics with PET?
short term use, postpartum where clinically indicated eg pulmonary edema, fluid overload.
180
At every post partum review after PET what should be discussed?
screen for depression
counsel on the risk of condition in subsequent pregnancies and the importance of medical optimisation pre conception, contraception (where appropriate) and risk minimisation strategies (aspirin)
181
What are the classifications of hypertensive disorders of pregnancy?
* PET
* Gestational hypertension
* Superimposed PET
* Chronic HTN
* White coat hypertension
Masked hypertension - diagnosed on ambulatory monitoring
182
Why is uric acid no longer reccomended for PET screen?
it is not an independent predictor for adverse maternal or perinatal outcomes
183
What should you consider testing for in women with early onset PET <34 weeks?
SLE, APLS, renal disease, rarely phaeo
184
Why has the evidence on aspirin been contradictory?
varying doses, inconsistent definitions of high risk women, difference in when it was started
185
When aspirin is commenced prior to 16 weeks it is shown to effect rates of?
abruption, neonatal intracerebal haemorrhage, PPH, APH needing admission, spotting or bleeding
186
If aspirin is started after 16 weeks is there benefit?
not statistically significant
187
SOMANZ reports aspirin <16 weeks reduces risk of?
PTB, PET, early onset PET, SGA
188
When does SOMANZ recommend cessation of aspirin?
between 34 weeks and birth
189
What kind of drug is methyldopa?
alpha blocker
190
What is the reccomended dose of methyldopa? What are the CI
250-750mg PO TDS to QID
CI - depression, anxiety, PND
191
What is the reccomended dose of Labetalol? What are the CI and what is it's MOA
100-400mg TDS to QID
CI asthma of chronic airway limitation
alpha and beta blocker
works 30-120 minutes
192
What is the reccomended dose of nifedipine? What are the CI
20-60mg SR BD
CI AS, may cause peripheral oedema
193
Why is hydralazine not given first line?
may cause headache, tachycardia, if given first line without concurrent alpha, beta or calcium blockade
194
When is ambulatory BP monitoring useful?
White coat HTN and poor pregnancy outcomes without cause looking for ?masked HTN
195
Persistent HTN >160/110 is associated with what outcomes?
stroke, eclampsia, death, abruption
196
What should you do for refractory HTN to IV boluses?
Infusion of labetalol (20-160mg/hr) or hydralazine (10-20mg/hr)
consider MgSO4
197
What are the benefits of steroids
reduce the risk of perinatal death, neonatal death, RDS, IVH, developmental delay, APGARs <7 5 mins, surfactant used, systemic infection in first 48 hours, infection while in NICU, NEC
198
What should you do in the event of an eclamptic seizure?
ABCs
2 IV lines
left lateral
start MgSO4 4g loading and 1g/hr until 24 hours from birth or last seizure
if seizure is prolonged consider diazepam or midazolam IV
aim to reduce BP <160/110
Airway support
urgent transfer
199
When do you reduce the dose in MgSO4?
renal impairment 50%
200
What is a toxic level of MgSO4? when do you measure it?
if signs of toxicity or renal impairment. >3.5mmol/L
201
What is the RANZCOG definition of suspected macrosomia?
AC or EFW equal to or more than the 95 centile for gestation
202
What are the risk factors for macrosomia?
* Previous LGA
* Age >30 years
* Post dates
* Excessive weight gain during pregnancy
* Diabetes - pre existing or gestational
* Obesity
* High parity
* Male fetus
Race
203
What is the utility of USS in LGA?
It is good at ruling it out but not at ruling it in
USS sensitivity for estimating a fetus >4000g is sensitivity of 56% and specificity of 92% but this reduces as the fetal weight increases
204
What are the maternal risks of fetal macrosomia?
* PPH RR 3.1
* CS - slowed labour progress, if fetus is >4500g the risk doubles
* Chorio RR 2.4
3rd and 4th degree tears RR 1.7
205
What are the fetal risks of macrosomia?
* SD OR 7.1
* Injury - brachial plexus injury (erb-duchenne paralysis) 18-20x risk 80-90% resolve within a year, clavicle # 10x risk. Permanent injury is more common in babies with birth weights 4500g
* Neonatal hypoglycemia
* Low apgar scores 5 minutes
* NICU admission
Obesity, overweight, metabolic syndrome
206
What is RANZCOGs recomendation about CS for macrosomia?
offer if EFW >4500 and diabetes or >5000g and no diabetes
207
What is the recommendation of LGA and instrumental?
The decision should be made by an experienced clinician and consideration to be done in OT and dystocia of labour and macrosomia and instrumental are shown to sigificantly increase SD risk.
208
What can be done to reduce your risk of macrosomia in future pregnancies?
good glycemic control
regular exercise in pregnancy
pre pregnancy bariatric surgery in class II and III obesity
209
What exam and investigations should be considered in HTN?
Examination - renal bruits, radial femoral delay, urine analysis (protein and haematuria)
Investigations - creatinine, electrolytes, Ca, urine catecholamines
210
What are the 3 most common causes of death in PET?
intracerebral haemorrhage
multi organ failure
RDS
211
What are the 'crises in PET'?
eclampsia, HELLP, renal failure, hepatic rupture, cortical blindness, Cerebral haemorrhage, pulmonary oedema, transient LV dysfunction
212
PRES is associated with which symptoms?
headache, seizure, vision loss, confusion
seen on MRI
213
Catherine describes PET as a two stage process, what is stage 1?
Trophoblastic invasion is abnormal then the invading placenta is unable to optimise it's blood supply from the uterine vessels. The spiral arteries (uterine) in the placental bed do not undergo normal vascular remodelling and so do not become high capacity, low pressure vessels.
Overall you have relative utero placental ischaemia - whether due to underlying microvascular disease or under perfusion of large placenta eg diabetes
214
Catherine describes PET as a two stage process, what is stage 2?
1. Normal pregnancy metabolic disturbance and systemic inflammatory response exaggerated - increased triglycerides and cytokine release causing endothelial dysfunction
2. Endothelial cell activation causes increased capillary permeability and increased cell adhesion molecules and prothrombotic factors. Decreased prostcylclin and increased TXA 2 synthesis causes increased platelet activation, vasoconstriction from increased vascular tone (HTN).
This causes widespread microvascular damage and dysfunction
215
What are the angiogenic and anti angiogenic factors involved in PET?
angiogenic - PLGF, VEGF, transforming growth factor
anti - soluble FLT 1, soluble endoglin (released by placenta)
216
When and who should be screened for preterm pre eclampsia?
all women between 11-14 weeks
217
What is included in the fetal medicine foundation algorithm?
combination of prior risk factors (maternal & medical history) with mean arterial pressure, uterine artery pulsatility index, PAPP-A and PlGF
218
What is the minimum input needed for the fetal medicine foundation algorithm?
BP and clinical history
219
When should uterine A doppler be measured for the FMF algorithm?
11+0-13+6
220
What cut off from the FMF algorithm should initiate prophylaxis?
1 in 100.
screen positive rate of 10%
221
When and what dose of aspirin is recommended by RANZCOG for preventing PET?
at least 100mg and before 16 weeks
222
What % of pregnancies are complicated by PET?
3%
223
What proportion of pregnancies have PET diagnosed <34 weeks?
0.4%
224
What % of pregnancies have PET diagnosed <37 weeks?
0.7%
225
What is the increased risk of PET in maori?
50%
226
Who is the FMF calculator validated for use on?
11+0 to 14+1
227
What do studies show the FMF algorithm and aspirin use <16 weeks show for early onset PET diagnosed or resulting in birth<32-34 weeks?
most likely reduces the risk OR 0.38
228
What do studies show the FMF algorithm and aspirin use <16 weeks show for preterm PET diagnosed or resulting in birth<37 weeks?
May reduce OR 0.61
229
What do studies show the FMF algorithm and aspirin use <16 weeks show for still birth?
May reduce OR 0.71
230
What do studies show the FMF algorithm and aspirin use <16 weeks show for term PET prevention?
little or no effect
231
what is the CRL expected at 11+0-13+6?
45-84mm
232
What is the fetal medicine foundation alogorithm used for? can it be used for twins?
predicting preterm PET (not term)
twins - yes but not as quality evidence to support
233
Why does RANZCOG recommended at least 100mg of aspirin for PET prevention?
the largest study ASPRE showed benefit with 150mg
This isn't available in NZ aus
it apperas there is a dose response but no studies comparing 100 with 150
234
What does the cochrane review on aspirin for PET and PTB prevention show?
may reduce PET RR 0.83
most likely reduces PTB RR 0.87
235
What does the cochrane reveiw show for aspirin for PET and. PTB prevention and adverse outcomes?
no difference in severe maternal morbidity, APH, placental abruption, PPH, neonatal IVH
236
What did the US preventative services task force systematic review for aspirin and PET and PTB show?
looked at aspirin doses >100mg and found
PET RR 0.74
PTB RR 0.68
these dropped further when <16 weeks
PET RR 0.68
PTB 0.49
237
What does the RANZCOG prevention of PET guideline say about high dose calcium?
>1g per day reduces
PET RR 0.22
PTB RR 0.45
but this has since been disproven
238
What is echogenic bowel and independent risk factor for?
SGA and IUFD
239
Who is SFH inaccurate in and thus should have USS?
BMI >35, fibroids, polyhydramnios, abnormal fetal lie
240
What change in AC after 30 weeks indicated IUGR?
<5mm
241
What testing should be offered for very early onset IUGR?
karyotype <23 weeks 19% abnormal
serological screening for toxy, syphilis, CMV, malaria
242
What stage in pregnancy is the uterine A doppler most helpful in predicting adverse outcomes?
T2. in T3 limited accuracy
243
smoking cessation by what point in pregnancy reduces the SGA risk to baseline?
15
244
In a high risk population what has UAPI been shown to change?
less perinatal deaths
less IOL and CS
same operative vaginal births and APGARs
245
what labour outcomes is AFI <5cm associated with?
apgars less than 7 at 5 minutes
CS
246
What SGA fetuses does the MCA doppler have the most use?
term SGA fetus with a normal UAPI, use to time delivery
247
What labour outcomes is an abn MCA doppler associated with?
emCS, acidosis, NICU admission
248
What does a should a DV be taken?
In a preterm fetus where the UAPI is abnormal to time delivery
249
What does the DV reflect?
atrial pressure volume changes in the cardiac cycle
250
What fetal change causes an abnormal DV?
increased after and preload, and end diastolic pressure due to acidemia/hypoxia and increased adrenergic drive
251
What is the rate of still birth in aus/nz?
0.24%
252
What is the prevalence of early FGR <32 weeks?
0.5-1%
253
what is the prevalence of late FGR >32 weeks
5-10%
254
When do you start SFH?
24 weeks
255
What does post pates IOL reduce the risks of?
CS, perinatal death, mec aspiration, 5 minute apgar less than 7
256
Babies born prior to 39 weeks are at increased risks of what?
mortality
serious morbidity - NICU, respiratory complications, hypoglycemia
childhood - CP and special education needs
257
What does the cochrane review of post dates induction show?
IOL reduces
perinatal death
CS
NICU admission and apgars <7 5 min
no difference IN PPH, perineal trauma or LOS
258
Ellen's flashcards
flashcards
Decks in class (27)
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Week 419
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Week 585
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Autoimmune medications and pregnancy11
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Landmark trials to date13
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week 371
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Week 13381
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GONC 1395
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Week 261
