En of sem 2026 MID2102

Hepatic changes in pregnancy

Decreased tone and mobility

tendency to retain bile salts

increased glycogen storage

altered production of liver enzymes

enlarging uterus that places pressure on gall bladder

Lupus and pregnancy

Infertility can result from SLE's regimen

Women with serious SLE should be counseled against pregnancy (decreased platelets and WBCs increase risks)

risks - stillbirth, IUGR, PTB, neonatal lupus, PET, thormbosis

Multidisciplinary team rheumatologist

Recommendation for postdates

IOL at 41 weeks

OR

Monitoring: CTG, amniotic fluid, Biophysical profile (NST, US assessment of FM, tone, breathing and quantification of amniotic fluid)

Diagnosis of hypertension in pregnancy

Systolic BP ≥ 140 and or diastolic BP ≥90

Severe - Systolic BP ≥160 and/or diastolic BP ≥110

≥170 sBP with or without 110 dBP is a medical emergency

Diagnosis of Chronic hypertension

Preconception or prior to 20 weeks

either with no cause (primary) or associated with an underlying condition

Diagnosis of white coat hypertension

elevated BP in a clinical setting & a normal BP at other times

earlier than 20 weeks

Diagnosis of masked hypertension

Normal BP in a clinical setting and an elevated BP at other times

Diagnosis of gestational hypertension

New onset after 20 weeks without features of pre-eclampsia

Diagnosis of preeclampsia

Hypertension and involvement of one or more other organ systems and/or the fetus

Diagnosis of transient gestational hypertension

Hypertension that is detected in the clinical setting but settles after repeated readings

Diagnosis of superimposed preeclampsia

features of preeclampsia superimposed on either pre-existing hypertension or renal disease

Hypertension risks

Postpartum hemorrhage

Cerebral injury

placental abruption

heart attack or stroke

low birth weight

fetal death

preterm birth

Respiratory distress

Management of hypertension in pregnancy

Control BP - antihypertensives (Labetalol, nifedipine)

Urinalysis

more USS

Delivery - mode determined by obstetric indications

Postpartum - BP may be unstable & require additional therapy

Monitor for the development of PET

organ involvement and symptom in Preeclampsia

Renal - proteinuria

Liver - NV

Neurological - Blurred visoin headaches

Haematological - low platelets

Pulmonary oedema

features of placental dysfunction- IUGR

maternal complications of preeclampsia

placenta abruption

organ damage

haemostatic disorder & major haemorrhage

Stroke or cerebral bleeding

seizures

death

CVD later in life

Fetal complications of preeclampsia

low birth weight

preterm birth

death

CVD later in life

Cause of preeclampsia - Stage 1

Abnormal placentation & trophoblast invasion into maternal vessels

Abnormal spiral artery remodelling (they are either too small or blocked which caused placental hypoxia and oxidative stress)

Cause of preeclampsia - Stage 2 Hypertension

Increased response to vasoactive substances (Angiotensin Il )

Reduced production of endothelial vasodilators eg prostacyclin, NO,

EDRF production

Release of procoagulants, mitogens, vasoconstrictors

Increased levels of markers of endothelial cell injury

Fibronectin, Factor Vlll antigen, thrombomodulin

Cause of preeclampsia - Stage 2 systemic inflammatory response

Activation of neutrophiles, monocytes, lymphocytes

Increase TN\- a, 116, IL8

Metabolic adaptations associated with systemic inflammatory response include acute phase response, oxidative stress, hyperlipidaemia, insulin resistance

Asprin for preeclampsia

150mg, prior to 16 weeks, preventative for preeclampsia

Drugs to avoid in preeclampsia

Diuretics

NSAIDS

ACEI/ARB

HELLP syndrome

hemolysis, elevated liver enzymes, low platelets

VARIANT OF SEVERE PRE-ECLAMPSIA

Magnesium sulfate may be indicated

risk factors for preeclampsia

First pregnancy

Previous PE

>10 years since last baby

Maternal age >40 years old

Body mass index >35 kg/m2

Family sister of PE (mother or sister)

Multiple pregnancy

Underlying medical conditions: pre-existing hypertension, renal disease or diabetes

Presence of antiphospholipid antibodies

Renal system

Includes the kidneys, bladder, ureters and urethras

Responsible for blood filtration and reabsorption of required substances and elimination of wastes through urine. BP regulation

renal changes in pregnancy

Kidney size increases.

GFR, renal plasma flow, Cr clearance increase. Ureters elongated, displaced, and compressed by uterus.

Decreased bladder capacity. (INcreased urination)

Increased UTI susceptibility

UTI in pregnancy

Can be asymptomatic or symptomatic

Can become more serious pyelonephritis

Increased risk for preterm birth

Chronic kidney disease in pregnancy

Can worsen Kidney damage/ reduced renal function

Risks of preterm birth, IUGR, preeclampsia, deteriorating renal function

multidisciplinary care

Monitor fetal growth, hypertensions, regular kidney function tests

GI changes in pregnancy

Gums appear red/swollen and bleed easier caused by elevated estrogen levels,

nausea/vomiting, constipation, reflux, diarrhea common in pregnancy

Hormones cause smooth muscle relaxtion, reducing motility and gatsic emptying

increases appetite

more absorption of essiential nutrients

Reflux GERD in pregnancy

stomach acid or bile irritates the food pipe lining

very common especially later in gestation

heartburn caused by reduced tone of esophageal sphincter caused by progesterone

Nausea and vomiting in pregnancy

•80-85% experience nausea and vomiting in first 12 weeks

stomach has decreased tone and motility

delayed gastric emptying

Advice for NVP

•Eat frequent small meals a day that include carbohydrate

•Avoid fatty and spicy foods

•Drink plenty of fluids

•Ginger can offer some relief

Metoclopramide, ondansetron, doxylamine etc if needed

hyperemesis gravidarum

severe nausea and vomiting in pregnancy that can cause severe dehydration in the mother and fetus

Can cause dehydration and malnutrition

IV treatment of fluids may be needed

•1% experience severe nausea

Continues past 20 weeks

Intrahepatic cholestasis of pregnancy

Most common liver disease of pregnancy

marked pruritis

elevated total bile acids and or LFTs

Stasis of bile acids in teh gall bladder,

Treatment for ICP

Ursodeoxycholic acid (UDCA) Provides cytoprotection against the hepatotoxic effects of the hydrophobic bile acids and improves hepatobiliary bile acid transport

ICP birth outcomes

associated with increased rates of preterm birth, meconium-stained amniotic fluid, RDS, prolonged admission to the neonatal unit, and stillbirth

Treatment for GERD

-Lifestyle changes → small frequent meals, eat upright, eat slowly, avoid spicy/v acidic foods Antacids -Acid lowering drugs → H2 blockers, PPI, antacids Further investigations

Haematological changes in pregnancy

Increased blood volume, Red cell mass, white blood cells

Physiological anemia (Dilution affect)

increased iron and folate requirements

hypercoagulable state

Anemia

a deficiency of red blood cells

causes for anemia

-blood loss

-decreased production of RBCs or haemoglobin

-destruction of RBCs

Iron deficiency

Thrombocytopenia

low platelet count

can be gestational

just keep a close eye on levels before birth

Autoimmune disorders in pregnancy

Might decrease symptoms in pregnancy due to anti-inflammatory state

Monitor symptoms, continue usual treatment

systemic lupus erythematosus

chronic autoimmune inflammatory disease of collagen in skin, joints, and internal organs

term pregnancy

pregnancy from 37 weeks to 42 weeks

prolonged pregnancy

over 42 weeks

Prolonged Pregnancy Risks

-Placenta ages - delivering oxygen and nutrients to the fetus less efficiently

-The fetus may lose weight

-stillbirth

-Meconium may be expelled and aspirated

-Low blood glucose levels in the fetus

- >4000g birth weight

PPH

Normal gestation of birth multips

50% by 40+3

75% by 41

Ways to stimulate labor

•upright position (gravity helps)

•Intercourse

•nipple stimulation

walking

how does spontaneous labour start

Prostaglandins and oxytocin increase at term - more gap junctions too. Ca crosses gap junctions causing coordinated uterine contraction

CRH increases estrogen and cortisol causing more receptors in teh uterus for P and O

Increase in estrogen in relation to progesterone also helps initiate labour

Induction of labour

Is the planned initiation of labor prior to the onset of spontaneous labor

induction of labor indications

Fetal compromise (intrauterine growth restriction, Rh incompatibility)

PROM

Post term pregnancy

Infection

GDM, preelcmapsia

Hypertension associated with pregnancy

Maternal medical conditions

Fetal death

risks of induction of labour

- Operative birth

- Tachysystole

- Chorioamnionitis

- Cord prolapse

- PPH

- Failed induction

Bishop score

Determines maternal readiness for labor by evaluating whether the cervix is favorable by rating cervical dilation, effacement, consistency, position, and station

cervical ripening methods

- chemical agents (prostaglandins)

- mechanical and physical methods (Balloon)

Prostaglandin Gel

softens the cervix when applied before labor induction; woman is placed on bed rest for 1-2 hours and monitored for uterine contractions

Midwives Role in CVD in pregnancy

Primary clinician across the continuum of pregnancy care

Discuss symptoms

Facilitate risk assessment, detection, referral and consultation

Collaborate with multidisciplinary colleagues caring for high-risk women in pregnancy

Normal Cardiorespiratory Changes in Pregnancy

BP falls 10 mmHg by 20/40 and then returns to baseline T3

Pulse rate increases by 10-20 BPM and can be bounding or collapsing — average HR 91 BPM at 34 weeks ( Range 68-115)

Peripheral oedema

Cardiac output increases 50%

Blood volume increases by 50%, plamsa 100ml, 500 RBC

ECG changes: 15-20 degree left axis deviation, Transient ST segment and T wave changes, Q wave (small) and inverted T wave lead Ill

attenuated Q wave in AVF, Inverted T wave in VI, V2 and occasionally V3 and SVT and ventricular extrasystoles are common.

Haemodynamic changes related to labour and delivery

Cardiac output increases

BP increases during each contraction

Uterine blood flow 700mls/min at term

How much does CO increase in labour and then postpartum

15% early labour; 25% active phase; 50% pushing

Immediately postpartum CO increases up to 80% - due to auto transfusion 500ml blood from uterine involution and Release of IVC compression from uterus

By how much does BP increase in labour

Systolic 10-15% Diastolic 10-15%

how does supine body position influence the cardiovascular system in pregnancy

2nd & 3rd trimester uterus compresses the Inferior Vena Cava(lVC) & reduces venous return

Results in decreased CO and increased HR compared to lateral position

Can cause maternal hypotension

Associated increased HR, decreased pulse pressure & symptoms of autonomic

activation

May result in reduced placental perfusion with no reassuring CTG

Signs and symptoms of normal pregnancy mimic cardiorespiratory disease

Shortness of Breath

Palpitations

Peripheral oedema

Dizziness

Easy fatigability, decreased exercise capacity

Increased heart rate

Why does looking an amniotic fluid help monitor health of baby

With diminished placental function selective perfusion of the brain and heart and reduced perfusion of other systems including the kidneys takes place

Reducing fetal urine

Dating pregnancies

Naegle's Rule

USS dating scan 10-13 weeks

Have a margin of error and can be a few days off

Naegele's Rule

add 7 days to LMP, subtract 3 months, add 1 year

Normal gestation of birth Primparous

50% by 40+5

75% by 41+2

balloon catheter

silicone double-balloon catheter used for mechanical dilation of the cervical canal prior to labor induction

artificial rupture of membranes ARM

Bag of waters is broken using a hooked instrument in an attempt to induce or speed up labor. This is often carried out in conjunction with a drip of a synthetic hormone (SYNTOCININ) into the arm to stimulate contractions.

Syntocinon infusion for induction

Synthetic oxytocin that causes uterine contractions

Start at 1ml/h, 2, 4, 8, 12ml/hr

CTG monitoring needed

30 unites in 500ml

Trauma

emotional or physical response to a life-threatening or harmful event or circumstances, with lasting adverse affects

Birth trauma

ANY FORM OF TRAUMA THAT HAS OCCURED AS A RESULT OF A BIRTH EXPERIENCE

Believes her baby or herself is in danger

Depends on how a woman perceives her birth

Feel helpless, out of control, abandoned, disrespected

How does birth trauma PTSD manifest

Nightmares

sleep disturbances

dwelling on experience

avoidance

irritability, hyperarousal

interrupted baby bonding

How to interact with a woman with birth trauma

Listen

no judgement

acknowledge feelings

take seriously

Importance of self-care

referral potentially

focus on informed choice and shared decision making

Consent is key

Explaining what recommend care is and what you are doing

"What do you want from me?"

"Thank you for trusting me"

Trauma informed care

an approach to treatment that acknowledges the role that trauma can have on the mental health of individuals

Flexible and focuses on safety, trust, choice, collaboration and empowerment

Edinburgh Postnatal Depression Scale (EPDS)

Screening test used to identify depression during pregnancy or in the postpartum period

Above 13 means referral

EPDS Q10

Harm/suicide

I see you have ticked yes for Q10 Can you tell me more about this?

Importance of documentation

Documented treatment and safety plan and thoughts about required care

anxiety

The condition of feeling stressed or worried about what may happen more than the average person

Stress

the body's reaction to any type of perceived threat

Stress biochemical

Triggers SNS and adrenal line and cortisol release

this increases HR, RR, muscle contract and mind sharpens

stress and anxiety effect on unborn baby

SGA

PTB

LBW

negative birth experiences (Birth trauma)

exacerbate placental issues

affect babys brain devlopment

Identify risks of mental health decline

Warning signs

Psychosocial stressors

Mental state exam

See how changes over pregnancy

baby blues

Mild depressive symptoms, anxiety irritability, mood swings, tearfulness, increased sensitivity, fatigue

Usually peak at days 4 and 5 and resolve by day 10

80% of mother experience

Postpartum Depression

a mood disorder characterized by feelings of sadness and the loss of pleasure in normal activities that can occur within a year after giving birth. lasts longer than 2 weeks

Postpartum Depression symptoms

Fatigue

Irritability

Loss of appetite

Sleep disturbances

Low mood

withdrawal

Concern about inability to care for infant

Bipolar

A mood disorder in which the person alternates between the hopelessness and lethargy of depression and the overexcited state of mania.

Can get worse in pregnancy and postpartum

medications might be changed

Schizophrenia

a psychological disorder characterized by delusions, hallucinations, disorganized speech, and/or diminished, inappropriate emotional expression.

Increased risk of postpartum psychosis

What third stage uteronic for those with hypertension

syntocinin

not syntometrine or ergometrine

Magnesium sulfate for preelcmapsia

anticonvulsant 4g loading, 1g maintenance

What are predisposing factors to Post Traumatic Stress Disorder (PTSD) following Birth Trauma?

Having prior trauma

prior PTSD

fear of birth

history of psychiatric disorders

Anxiety

What are precipitating factors to Post Traumatic Stress Disorder (PTSD) following Birth Trauma?

Instrumental/ operative birth

long labour

out of control

extensive blood loss

Negative neonatal outcomes

Subjective

Four sub themes to the perfect storm of trauma

Bring the baggage to birth - preexisting health

trauma by 1000 cuts - accumulation of negative experiences

Thrown in the pressure cooker - lack of sleep, parenting, trauma, recovery

trying to work it out - healing, seeking support, reflection, validation

Midwives role

debriefing

infomed choice

building trusting relationships

supportive

idneity risk factors

recognise trauma coming - hey this is whats heppening, lets focus on this thing right ot

taking symptoms seriouly

sleep, excersie

BF - help with bonding

Antiphospholipid syndrome

Blood becomes sticky

Low does aspirin, multidisciplinary team, clexane

risks

miscarriage, pre-eclampsia, placental abruption, IUGR, PTB

Asymptomatic UTI

Increases low birthweight

Mid stream urine sample recommended in ecah trimester

Increased risk if you have Hx of recurrent UTI, diabetes or an abnormal urinary tract

5 day antibiotic course

Symptomatic UTI

ant biotic, discoloured, cloudy urine, temperature

oral antibiotic therapy

severe cases - IVABS

Diagnosed by MSU

Acute pyelonephritis

INfection of ranal pelvis that can spred into kidney tissue

Symptoms - UTI, backache, tenderness, fatigue, fever, malise, rigors, NV, dehydration,

Complications of Acute pyelonephritis

Endotoxic shock

chronic renal infection

renal failure

IUGR

Preterm birth

Managemenet of Acute pyelonephritis

MSU

blood specimen

IV fluids'

IVABS

real function tests

OBS

Management of preelcmpsia

Urinalysis regularly

USS and CTG twice weekly

early delivery

Fluid management in birth - Catheter

MgSO4 if signs of eclampsia (Central nervous dysfunction)

Eclampsia