Antenatal care Flashcards

Question

What are the features of fetal alcohol syndrome?

Answer 1

* Microchephaly (small head) * Thin upper lip * Smooth flat philtrum (the midline groove in upper lip) * Short palpebral fissure (short horizontal distance from one side of the eye to the other) * Behavioural difficulties * Hearing and vision problems * Cerebral palsy

Answer 2

* Fetal growth restriction * Misscarriage * Stillbirth * Preterm labour and delivery * Placental abruption * Pre-eclampsia * Cleft lip or palete * Sudden infant death syndrome (SIDS)

Answer 3

Ok in uncomplicated pregnancy up to: * 37 weeks in a single pregnancy * 32 weeks in a twin pregnancy

Answer 4

**28 weeks gestation**

Answer 5

Midwife Occurs by 10+0 weeks gestation

Answer 6

* Ask the woman about: * PMH, obstetric hx, fhx * Mental health problems * Current and recent medicines, including OTC medicines, health supplements, herbal remedies * Allergies * Occupations- any risks/ concerns * Family and home situation * People involved in care of baby- partner or others * Contact details for partner and next of kin * Factors such as nutrition & diet, physical activity, smoking and tobacco use, alcohol consumption, recreational drug use * Other points of discussion * What to expect at different stages of the pregnancy * Plans for birth * Screening tests (e.g. Downs) * Antenatal classes * Breastfeeding classes

Answer 7

* Blood group * Antibodies and rhesus D status * FBC- for anaemia * Screening for **thalassaemia** (all women) and **sickle cell disease** (those at risk)- forward planning * Offered screening for infectious diseases- antibodies for HIV, hep B, syphilis - vertical transmission * Screening for Down's can only be done from 11 weeks

Answer 8

* The woman's height and weight- calculate BMI * Blood tests- FBC, blood group, rhesus D status * Offer infectious disease scfreening * Urine dip for protein and bacteria * Blood pressure

Answer 9

3 step method: 1. First determine the first day of last menstrual period 2. Then count back 3 months from that date 3. Then add 1 year and 7 days to that date This gives you an estimated date of delivery

Answer 10

* **Rhesus negative** (book anti-D prophylaxis) * **Gestational diabetes** (book oral glucose tolerance test) * **Fetal growth restriction** (book additional growth scans) * **Venous thromboembolism** (provide prophylactic LMWH if high risk) * **Pre-eclampsia** (provide aspirin if high risk)

Answer 11

**Trisomy 21** * Down's syndrome is caused by 3 copies of chromosome 21

Answer 12

To establish whether more invasive testing is needed

Answer 13

Using: - **Measurements** from the fetus using ultrasound - Mother's **age** - Mother's **blood results**

Answer 14

**Nural translucency** - thickness of the back of the neck of the fetus (greater than 6mm indicates Down's)

Answer 15

Combined test * Ultrasound * Nuchal translucency- \>6mm can be caused by Down's * Maternal blood tests-the following results indicates a greater risk of Down's: 1. ↑ βHCG 2. ↓ PAPP-A

Answer 16

Maternal blood tests- triple test (1-3) or quadruple test (all 4) the following results indicates a greater risk of Down's: 1. ↑ βHCG 2. ↓ AFP 3. ↓ oestriol 4. ↑ inhibin-A

Answer 17

A risk score - if it is greater than 1 in 150 (occuring in 5% of women) then the woman is offered **amniocentesis** or **chorionic villus sampling**

Answer 18

Ultrasound-guided **biopsy** of the **placental** tissue (used earlier in pregnancy - before 15 weeks) Risks * Miscarriage- 1% * Inadequate sample- may need to be carried out again/ do amniocentesis instead * Infection- 0.1% * Rhesus sensitisation- if mother is RhD negative but baby is Rhpositive then sensititisation can occur- baby's blood enters mother's bloodstream and mother produces antibodies * Anti-D immunoglobulin injection can be given to avoid sensitisation

Answer 19

**Ultrasound-guided aspiration** of **amniotic fluid** using a needle and syringe - used later in pregnancy when there is enough amniotic fluid to make a sample Risks- higher if carried out before 15 weeks, so amniocentesis only done after 15 weeks Most common time is 15-18 weeks * Miscarriage- 1% * Discomfort (uterien cramping) * Vaginal bleeding- 2% * Maternal rhesus sensitisation in susceptible pregnancies * Amnionitis * Failure of cell culture if performed \<12 weeks gestation * Anxiety for parents

Answer 20

New test for detecting fetal abnormalities - involves a simple blood test from the mother. Contains fragments of **DNA from the fetus** which can be tested. Used as an alternative to invasive testing (CVS and amniocentesis)

Answer 21

* Hypothyroidism can cause- * Miscarriage * Anaemia * SGA * Pre-eclampsia * Thyrotoxicosis can cause- * Fetal loss * Maternal heart failure * Premature labour

Answer 22

**Hypothyroidism:** Levothyroxine (T4) * Can cross placenta and provide thyroid hormone to the fetus * Hence dose needs to be increased by 30-50% (25-50mcg) * Treatment is based on the TSH level, aiming for low-normal TSH **Thyrotoxicosis** (commonly caused by Graves'): Propylthiouracil / Carbimazole * Carbimazole can cause congenital abnormalities, so PTU is used in the 1st trimester * Can switch back to carbimazole in the 2nd trimester

Answer 23

Essential hypertension The following medications need to be stopped * ACE inhibitors * Angiotensin receptor blockers (e.g. losartan) * Thiazide and thiazide-like diuretics (e.g.indapamide) They may cause congenital abnormalities The target BP is 135/85

Answer 24

* **Labetalol** (a beta-blocker - although other beta blockers may have adverse effects) * Not suitable to DM pts (hypos) * **CCB**s (e.g. nifedipine) * Alpha-blockers (e.g. doxazosin)

Answer 25

5mg daily to reduce the risk of **neural tube defects**

Answer 26

* Additional stress * Lack of sleep * Hormonal changes * Altered medication regimes

Answer 27

No, only the risk of physical injury

Answer 28

* Levetiracetam * Iamotrigine * Carbamazepine

Answer 29

* **Sodium valporate** (causes neural tube defects and developmental delay) * **Phenytoin** (causes cleft lip and palete)

Answer 30

* Programme to prevent pregnancy in epileptic patients on sodium valporate (due to it's teratogenic effects)

Answer 31

**3 months**

Answer 32

Improve but may flare up after delivery

Answer 33

**Methotrexate** (teratogenic, causing miscarriage and congenital abnormalities)

Answer 34

* **Hydroxychloroquine** (often the first-line choice) * **Sulfasalazine** (safe during pregnancy) * Corticosteroids may be used during flare-ups

Answer 35

* Maintaining ductus arteriosus in fetus * During delivery, soften cervix * Stimulate uterine contractions both during delivery and pregnancy

Answer 36

Avoided in the **third trimester** as they can cause **premature closure of the ductus arteriosus** in the fetus. They can also **delay labour**.

Answer 37

* Hypertension * Cardiac conditions * Migraine

Answer 38

* **Fetal growth restriction** * **Hypoglycaemia** in the neonate * **Bradycardia** in the neonate

Answer 39

* In the fetus, they affect the kidneys causing reduced production of urine (and therefore amniotic fluid) * Hypoclavaria (incomplete formation of the skull bones) * Oligohydraminos (reduced amniotic fluid) * Miscarriage or fetal death * Hypocalvaria (incomplete formation of the skull bones) * Renal failure in the neonate * Hypotension in the neonate

Answer 40

**Withdrawal symptoms** in the neonate after birth, called **neonatal abstinence syndrome** which presents between 3 - 72 hours after birth with **irritability**, **tachypnoea** (fast breathing), **high temperatures** and **poor feeding** Treatment is usually initiated if: * Feeding becomes a problem and tube feeding is required; * There is profuse vomiting or watery diarrhoea; * The baby remains very unsettled after two consecutive feeds despite gentle swaddling and the use of a pacifier. Treatment involves weaning the baby from the drug on which it is dependent- morphine can be given

Answer 41

No **Teratogenic**; crosses the placenta, causes: * Fetal loss * Congenital malformations, particularily craniofacial problems * Bleeding during pregnancy, PPH, fetal harmorrhage and intracranial bleeding

Answer 42

* Neural tube defects * Developmental delay Prevent programme to ensure it is avoided

Answer 43

Mood stabilising agent for patients with bipolar disorder, mania, recurrent depression.

Answer 44

**Avoided** in pregnant women or those **planning pregnancy** unless other options (i.e. antipsychotics) have failed

Answer 45

It's linked with **congenital cardiac abnormalities** * Ebstein's anomaly * Characterised by low insertion of the tricuspid valve resulting in a large RA and small R ventricle * Clinical features: cyanosis, prominent 'a' wave in the distended jugular venous pulse, hepatomegaly, tricupsid regurgitation, RBBB

Answer 46

Monitored closely (every 4 weeks, then weekly from 36 weeks) it also **enters breast milk** so should be **avoided in breastfeeding**

Answer 47

- **Congenital heart defects** - **Paroxetine** has stronger link with **congenital malformation**

Answer 48

**Persistent pulmonary hypertension**

Answer 49

**Withdrawal symptoms** usually only mild and **not requiring medical management**

Answer 50

**Retinoid** medication (relating to **vitamin A**) which is used to treat **severe acne** - should be prescribed and monitored by a specialist dermatologist

Answer 51

Highly **teratogenic** causing **miscarriage** and **congenital defects**. Women need very reliable contraception before, during and for one month after taking isotretinoin.

Answer 52

**German measles** * Rash — typically starts on the face and neck before spreading down the body and becoming generalized — the rash is pink or light red, maculopapular and usually present for 3–5 days. * Lymphadenopathy (most often suboccipital, postauricular, and cervical) — may precede rash and last for 2 weeks after the rash resolves. * Arthritis and arthralgia — more common in adult women. * Non-specific symptoms such as low-grade fever, headache, malaise, nausea, mild upper respiratory tract symptoms and non-purulent conjunctivitis.

Answer 53

Maternal infection with **rubella virus** during the first 20 weeks of pregnancy The risk is highest before 10 weeks

Answer 54

* Women **planning on becomming pregnant** should ensure that they have **had the MMR vaccine,** if in doubt they can be **tested** for **rubella immunity** if they do not have **antibodies** to rubella they can be **vaccinated** with two doses of the MMR **three months** apart * Pregnant women shouldn't have the vaccine as it is a live vaccine * Non-immune women should be offered the vaccine after birth

Answer 55

* Congenital **deafness** * Congenital **cataracts** * Congenital **heart disease** (PDA and pulmonary stenosis) * **Learning difficulty**

Answer 56

* Varicella zoster virus (VZV) * Causes more severe cases in the mother, such as **varucella pneumonitis**, **hepatitis** or **encephalitis** * Fetal varicella syndrome * Severe **neonatal varicella infection** (if infected around delivery)

Answer 57

**IgG** levels for **VZV** can be tested, if positive then indicated immunity

Answer 58

Treated with **IV varicella immunoglobulins** as prohylaxis against developing chickenpox, given within 10 days of exposure

Answer 59

Treament with **oral aciclovir** if presenting within 24 hours and more than 20 weeks gestation

Answer 60

Occurs in around 1% of chickenpox cases with infection in the first 28 weeks of gestation. Features include: * Fetal **growth restriction** * Microcephaly, hydrocephalus and learning difficulty * Scars and **significant skin changes** located in **specific dermatomes** * Limb **hypoplasia** (underdeveloped limbs) * Cataracts and **inflammation** in the eye (**chorioretinitis**)

Answer 61

**Gram positive**

Answer 62

**Listeriosis**

Answer 63

**Asymptomatic** or **flu-like illness** or less commonly **pneumonia** or **meningoencephalitis**

Answer 64

High rate of **miscarriage** or **fetal death** it can also cause **severe neonatal infection**

Answer 65

**Unpasteurised dairy products** **Processed meats** Contaminated food Advise *avoid blue cheese and other **high risk** fods and practice good **food hygiene***

Answer 66

Via infected saliva or urine of asymptomatic children

Answer 67

- Fetal growth restriction - Microcephaly - Hearing loss - Vision loss - Learning disability - Seizures

Answer 68

Caused by **infection during pregnancy** with the **toxoplasma gondii** parasite

Answer 69

By **contamination** with **faeces** from a cat that is a **host** of the parasite

Answer 70

1. Intracranial calcification 2. Hydrocephalus 3. Chorioretinitis (inflammation of the choroid and the retina in the eye)

Answer 71

**Fifth disease**, **slapped cheek syndrome** and **erythema infectiosum**.

Answer 72

* **Initally** with **non-specific** viral symptoms * **After 2-5 days** the rash appears quite rapidly as a **diffuse bright red rash on both cheeks** as though they have "**slapped cheeks**" * **A few days later** a **reticular** mildly erythmatous rash affecting the trunk and limbs appears which can be **raised and itchy** * Illness is self-limiting and the rash and symptoms usually fade over 1-2 weeks

Answer 73

* **7-10 days before the rash appears** (not infectious once the rash has appeared) * They are not infectious once the rash appears

Answer 74

15 minutes in the **same room** or face-to-face contact with someone that **has the virus**

Answer 75

Typically worse in 1st and 2nd trimesters * **Miscarriage** or fetal death * Severe **fetal anaemia** * ****Casued by parvovirus infection of erythroid progenitor cells in the fetal bone marrow & liver * The infection causes them to produce faulty RBCs * Leads to anaemia * Which can lead to HF * **Hydrops fetalis** (fetal heart failure) * Maternal **pre-eclampsia**-like syndrome * Mirror syndrome * Triad of hydrops fetalis, placental oedema, and oedema in mother, hypertension & proteinuria

Answer 76

Infection of the **erythroid progenitor cells** in the fetal **bone marrow** and **liver** (the cells which produce red blood cells) Producing **faulty red blood cells** which have a shorter life span - less red blood cells results in anaemia, this anaemia leads to heart failure, referred to as **hydrops fetalis**.

Answer 77

**Rare complication** of severe fetal heart failure (**hydrops fetalis**) involving a triad of: 1. Hydrops fetalis 2. Placental oedema 3. Oedema in the mother

Answer 78

* **IgM** to **parvovirus** which tests for **acute infection** within the past 4 weeks * **IgG** to **parvovirus** which tests for **long term immunity** to the virus after a previous infection * **Rubella** antibodies (as a differential diagnosis)

Answer 79

Supportive **Referral** to **fetal medicine** to monitor for complications and malformations

Answer 80

By host **Aedes mosquitos** in aread of the world where the virus is **prevalent** Also spread by **sex** with someone infected

Answer 81

No symptoms, minimal symptoms or mild flu-like illness

Answer 82

* Microcephaly * Fetal growth restrictions * Other intracranial abnormalities such as **ventriculomegaly** and **cerebellar atrophy**

Answer 83

* Viral PCR * Antibodies to the zika virus

Answer 84

Referred to **fetal medicine** for close monitoring of the pregnacy There is **no treatment** for the virus

Answer 85

No additional treatment needed during pregnancy

Answer 86

* Blood from the baby will find a way into the mothers blood stream e.g. during childbirth, the **baby**'s **RBCs** display the **rhesus-D antigen** which the **mother's immune system will recognise as foreign** and produce antibodies to the **rhesus-D antigen** - the mother has then become **sensitised** to rhesus-D antigens * This won't cause problems during the 1st pregnancy * During subsequent pregnancies the mother's anti-rhesus-D antibodies can cross the placenta into the fetus. * If the fetus is rhesus-D positive, these antibodies attach themselves to the RBC of the fetus and cause the immune system of the fetus to attack them, causing the destruction of the RBC = haemolytic disease of the newborn

Answer 87

**Prevention of sensitisation** - involves giving prophylactic **intramuscular** **anti-D** injections to rhesus-D negative women (there is no way to reverse the sensitisation process once it has occured) 1. Offered once at 28 weeks gestation 2. Offered at birth 3. Also offered any other events where sensitisation may occur- eg antepartum haemorrhage, amniocentesis procedures, abdominal trauma Given within 72 hrs of a sensititisation event

Answer 88

**Attaches** itself to the **rhesus-D antigens** on the **fetal red blood cells in the mothers circulation** causing them to be destroyed - thus **preventing** the **mother's immune system** recognising the antigen and creating it's own antibodies to the antigen - acts as a prevention of sensitisation

Answer 89

**Within** **72 hours**

Answer 90

Test to **check how much fetal blood** has passed into the mother's during a sensitisation event Done at 20 weeks To determine whether further doses of anti-D are required

Answer 91

Involves **adding acid to a sample of the mother's blood** fetal haemoglobing is more resistant to acid (so they are protected against the acidosis that occurs around childbirth) **Fetal haemoglobin** persists in response to the added acid whilst the mothers Hb is destroyed - number of cells still containing the haemoglobin (remaining fetal cells) can then be calculated

Answer 92

Fetus which measures **below the 10th** centile for their **gestational age**

Answer 93

- **Estimated fetal weight** (EFW) - **Fetal abdominal circumference** (AC)

Answer 94

Mother's: - Ethnic group - Weight - Height - Parity

Answer 95

**Below the 3rd centile** for their gestational age

Answer 96

Birth weight less than 2500g (5.5 Ib)

Answer 97

1. **Constitutionally small** (matching the mother and other's in the family) - growing appropriately on the growth chart 2. **Fetal growth restriction** also known as **intrauterine growth restriction-** fetus not growing as expected due to a pathology reducing the amount of nutrients & O2 being delivered to fetus via placenta

Answer 98

**Placenta mediated** growth restriction- conditions which affect the transfer of nutrients across the placenta: * Idiopathic * Pre-eclampsia * Maternal smoking * Maternal alcohol * Anaemia * Malnutrition * Infection * Maternal health conditions **Non-placenta mediated growth restriction**, where the baby is small due to a genetic or structural abnormality * Genetic abnormalities * Structural abnormalities * Fetal infection * Errors of metabolism

Answer 99

* Small for Gestational Age (SGA) * Reduced amniotic fluid volume * Abnormal Doppler studies * Reduced fetal movements * Abnormal CTGs

Answer 100

* Fetal **death or stillbirth** * **Birth asphyxia-**when a baby's brain and other organs do not get enough oxygen and nutrients before, during or right after birth * **Neonatal hypothermia** * **Neonatal hypoglycaemia**

Answer 101

* Cardiovascular disease, particularly hypertension * Type 2 diabetes * Obesity * Mood and behavioural problems

Answer 102

Previous SGA baby Obesity Smoking **Diabetes** **Existing hypertension** **Pre-eclampsia** **Older mother** (over 35 years) **Multiple pregnancy** **Low** pregnancy‑associated plasma protein‑A (**PAPPA**) **Antepartum haemorrhage** **Antiphospholipid syndrome**

Answer 103

**Estimated fetal weight** (EFW) and abdominal circumference (**AC**) to **determine the growth velocity** **Umbilical arterial pulsatility index** (UA-PI) to measure flow through the umbilical artery **Amniotic fluid volume**

Answer 104

**Identifying those at risk** of SGA * Woman with a major risk factors- USS measurement of fetal size & assessment of wellbeing with umbilical artery doppler from 26-28 weeks * 3 or more minor risk factors- uterine artery Doppler at 20-24 weeks gestation **Aspirin** is given to those at risk of **pre-eclampsia** Treating **modifiable risk factors** (e.g. **stop smoking**) **Serial growth scans** to monitor growth **Early delivery** where growth is static, or there are other concerns

Answer 105

* Blood pressure and urine dipstick for pre-eclampsia * Uterine artery doppler scanning * Detailed fetal anatomy scan by fetal medicine * Karyotyping for chromosomal abnormalities * Testing for infections (e.g. toxoplasmosis, cytomegalovirus, syphilis and malaria)

Answer 106

Growth is static on the charts or abnormal doppler results ## Footnote **Reducing the risk of stillbirth**

Answer 107

**Corticosteroids** particulary when delivered by C-Section These help the unborn baby's lungs to develop more quickly

Answer 108

\>4.5kg at birth (weight above 90th centile in pregnancy) (9.92 Ib)

Answer 109

* Constitutional * Maternal diabetes * Previous macrosomia * Maternal obesity or rapid weight gain * Overdue * Male baby

Answer 110

**Failure to progress** Perineal **tears** **Instrumental delivery** or caesarean Postpartum **haemorrhage** **Uterine rupture** (rare)

Answer 111

* Shoulder dystocia is a complication of vaginal cephalic delivery * It entails the inability to deliver the body of the fetus using gentle traction, the head having already been delivered * It usually occurs due to impaction of the anterior fetal shoulder on the maternal pubic symphysis * Shoulder dystocia is a cause of both maternal and fetal morbidity * Key risk factors * Fetal macrosomia * High maternal BMI * DM * Prolonged labour

Answer 112

* Shoulder dystocia * Birth injury (Erbs palsy, clavicular fracture, fetal distress and hypoxia) * Neonatal hypoglycaemia * Obesity in childhood and later life * Type 2 diabetes in adulthood

Answer 113

**Ultrasound to exclude polyhydramnios** and estimate the fetal weight **Oral glucose tolerance test** for gestational diabetes

Answer 114

**Delivery on a consultant lead unit** Delivery by an **experienced midwife or obstetrician** **Access to an obstetrician** and **theatre** if required **Active management of the third stage** (delivery of the placenta) **Early decision for caesarean section** if required Paediatrician attending the birth Senior help should be called as soon as shoulder dystocia is identified and McRoberts' manoeuvre should be performed: * This manoeuvre entails flexion and abduction of the maternal hips, bringing the mother's thighs towards her abdomen * This rotation increases the relative anterior-posterior angle of the pelvis and often facilitates a successful delivery An episiotomy will not relieve the bony obstruction but is sometimes used to allow better access for internal manoeuvres.

Answer 115

Pregnancy with **more than one fetus**

Answer 116

**Diamniotic, dichorionic** - each fetus has their own nutrient supply (2 separate amniotic sacs and 2 placentas)

Answer 117

Booking ultrasound scan; USS to determine: - Gestational age - Number of placentas (**chorionicity**) and **amnionicity** - Risk of **Down's syndrome** (as part of the combined test)

Answer 118

**Dichorionic diamniotic** twins have a **membrane between the twins**, with a lambda sign or twin peak sign **Monochorionic diamniotic** twins have a **membrane between the twins, with a T sign** **Monochorionic monoamniotic** twins have **no membrane** separating the twins

Answer 119

The triangular appearance, where the **membrane** **between** the **twins** meets the **chorion** as the chorion blends **partially into the membrane**, indicating a **dichorionic twin pregnancy** (2 separate placentas) Its absence does not confidently exclude dichroionicity

Answer 120

Where the membrane between the twins abruptly meets the chorion giving a T appearance - indicating a **monochorionic twin pregnancy** (single placenta)

Answer 121

* Anaemia * Polyhydramnios * Hypertension * Malpresentation * Spontaneous preterm birth * Instrumental delivery or caesarean * Postpartum haemorrhage

Answer 122

* Miscarriage * Stillbirth * Fetal growth restriction * Prematurity * Twin-twin transfusion syndrome * Twin anaemia polycythaemia sequence * Congenital abnormalities

Answer 123

When **fetuses share a placenta** called **feto-fetal transfusion syndrome** in pregnancies with **more than two fetuses** **One fetus** (the recipient) may receive the majority of the blood from the placenta whilst the other (the donor) is starved of blood **Recipent** = Heart failure and polyhydraminos **Donor** = Growth restriction, anaemia and oligohydraminos Discrepancy between the size of the fetuses

Answer 124

Referred to a tertiary specialist fetal medicine centre **Laser treatment** may be used to destroy the connection between the two blood supplies

Answer 125

Similar to twin-twin transfusion syndrome but **less acute**, one twin becomes **anaemic** whilst the **other develops polycythaemia** (raised Hb)

Answer 126

**Anaemia** with an **FBC** at **booking clinic**, **20 weeks** gestation and **28 weeks gestation** Additional USS to monitor for FGR, unequal growth and twin-twin transfusion syndrome- 2 weekly scans from 16 weeks for monochorionic twins and 4 weekly scans from 20 weeks for dichorionic twins Planned birth is also offered

Answer 127

**32 and 33 + 6 weeks** for **uncomplicated mono**chorionic **mono**amniotic twins **36 and 36 + 6 weeks** for **uncomplicated mono**chorionic **diamniotic** twins **37 and 37 + 6 weeks** for **uncomplicated dichorionic diamniotic twins** **Before 35 + 6 weeks** for triplets

Answer 128

**Elective C-Section** at between 32 and 33+6 weeks

Answer 129

Between 37 and 37 + 6 weeks * Vaginal delivery is possible when the first baby has a cephalic presentation (head first) * Caesarean section may be required for the second baby after successful birth of the first baby * Elective caesarean is advised when the presenting twin is not cephalic presentation

Answer 130

**Increased risk of** **preterm** delivery, also increased risk of low birth weight and pre-eclampsia

Answer 131

**Bacteria present in the urine** without symptoms of infection (increases risk of UTI in pregnancy)

Answer 132

At booking and **routinely throughout pregnancy** involving **sending urine sample** to the lab for **microscopy, culture and sensitivites** (MC&S)

Answer 133

* Dysuria (pain, stinging or burning when passing urine) * Suprapubic pain or discomfort * Increased frequency of urination * Urgency * Incontinence * Haematuria

Answer 134

* Fever (more prominent than in lower urinary tract infections) * Loin, suprapubic or back pain (this may be bilateral or unilateral) * Looking and feeling generally unwell * Vomiting * Loss of appetite * Haematuria * Renal angle tenderness on examination

Answer 135

* Nitrites produced by gram-negative bacteria (such as E. Coli) a breakdown produce of nitrates - a normal waste product in the urine * Leukocytes refer to WBCs (normally a small number anyway in the urine) - dipstick tests for leukocyte esterase which gives an indication to the number of leukocytes in the urine

Answer 136

**Nitrites**

Answer 137

**Escherichia coli** (gram negative, anaerobic, rod-shaped bacteria which is part of the normal lower intestinal micobiome - found in faeces normally) **Klebsiella pneumoniae** (gram negative anaerobic rod) **Enterococcus** Pseudomonas aeruginosa Staphylococcus saprophyticus Candida albicans (fungal)

Answer 138

7 days of abx: * **Nitrofurantoin** (avoid in the third trimester- risk of neonatal haemolysis) * **Amoxicillin** (only after sensitivities are known) * **Cefalexin**

Answer 139

Not to be used in **first trimester** as it works as a **folate antagonist** - folate is important in early pregnancy for the **normal development of the fetus** Can cause **congenital malformations** particularly **neural tube defects** (i.e. **spina bifida**) Not known to be harmful later in pregnancy but is generally avoided

Answer 140

Usually twice during pregnancy: * **Booking** clinic * **28 weeks** gestation

Answer 141

**Plasma volume increases** Causes a **reduction** in the **Hb concentration-** blood is diluted

Answer 142

So the woman has **reasonable reserves** in case there is significant blood loss during delivery

Answer 143

Often anaemia in pregnancy is **asymptomatic**, symptoms include: - SoB - Fatigue - Dizziness - Pallor

Answer 144

* Booking bloods = \> 110 g/l * 28 weeks gestation = \> 105 g/l * Post partum = \> 100 g/l

Answer 145

**Low MCV** may indicate **iron deficiency** **Normal MCV** may indicate a **physiological anaemia due to the increased plasma volume** of pregnancy **Raised MCV** may indicate **B12 or folate deficiency**

Answer 146

**Thalassaemia** (all women) **Sickle cell disease** (women at higher risk)

Answer 147

**Iron** = iron replacement (e.g. **ferrous sulphate** 200mg three times daily) also for if they just have low ferritin **B12** = tested for **pernicious anaemia** (checking for **intrinsic factor antibodies,** advice from a haematologist RE treatment but **includes**: Intramuscular hydroxocobalamin injections, Oral cyanocobalamin tablets **Folate** = 5mg daily if folate deficient (should already be on 400mcg daily) **Thalassaemia and sickle cell anaemia** = women with haemoglobinopathy will be managed jointly with a specialist haematologist - require **high dose folic acid** (5mg), close monitoring and transfusions when required

Answer 148

Pregnancy is a **hyper-coagulable state** * Fibrin generation is increased * Fibrinolytic activity is reduced * Coagulation factors increase- II, VII, VIII, X

Answer 149

**Postpartum** period

Answer 150

* Smoking * Parity ≥ 3 * Age \> 35 years * BMI \> 30 * **Reduced mobility** * **Multiple pregnancy** * **Pre-eclampsia** * Gross **varicose veins** * **Immobility** * **Family history of VTE** * **Thrombophilia** * **IVF** pregnancy

Answer 151

**28 weeks** if there are **three risk factors** **First trimester** if there are **four or more of these risk factors**

Answer 152

**Hospital admission** **Surgical** procedures **Previous VTE** **Medical conditions such as cancer** or arthritis **High-risk thrombophilias** **Ovarian hyperstimulation syndrome**

Answer 153

At **booking** and again **after birth** (additionally if admitted to hospital, undergo a procedure or develop significant immobility)

Answer 154

Low molecular weight heparin (e.g. enoxaparin, dalteparin and tinzaparin) * As soon as possible (1st trimester) in very high risk * From 28 weeks in high risk * Temporariyl stopped when woman goes into labour, can be started immediately after delivery except with PPH, spinal anaesthesia and epidurals * Continued throughout the antenatal period and for 6 weeks postnatally

Answer 155

Mechanical prophylaxis: - Intermittent pneumatic compression - Antiembolic compression stockings

Answer 156

**Unilateral:** **Calf** or leg **swelling** **Dilated** superficial **veins** **Tenderness to the calf** (particularly over the deep veins) **Oedema** **Colour changes** to the leg

Answer 157

Measure the circumference of the calf 10cm below the **tibial tuberosity** **More than 3cm difference** between calves is significant

Answer 158

Shortness of breath **Cough** with or without blood (**haemoptysis**) **Pleuritic** chest **pain** **Hypoxia** **Tachycardia** (this can be difficult to distinguish from the normal physiological changes in pregnancy) **Raised respiratory** rate Low-grade **fever** **Haemodynamic instability** causing **hypotension**

Answer 159

Doppler ultrasound (repeated on day 3 and 7 in patients with a high index of suspicion for DVT)

Answer 160

Definitive diagnosis: CTPA or VW scan Also require chest X-ray and ECG

Answer 161

**CT pulmonary angiogram** **Ventilation-perfusion scan** (VQ scan)

Answer 162

Chest CT with **IV contrast** which highlights the **pulmonary arteries** to **demonstrate any blood clots** (helpful as it provides info about alternative diagnoses such as pneumonia or malignancy)

Answer 163

Involves using **radioactive isotopes** and a **gamma camera** to compare the ventilation with the perfusion of the lungs First the **isotopes are inhaled to fill the lungs** and a picture is taken to demonstate ventilation Next a **contrast containing isotopes is injected** and a picture is taken to demonstrate perfusion In a PE, the area of lung tissue will be **ventilated** but **not perfused**

Answer 164

**CTPA** is the test for choice for patients **with an abnormal chest xray** **CTPA** carries a **higher risk of breast cance**r for the mother (minimal absolute risk) **VQ** scan carriers a **higher risk of childhood cancer** for the fetus (minimal absolute risk)

Answer 165

No as the **treatment for DVT and PE are the same**

Answer 166

No as pregnancy is a cause of raised D-Dimers

Answer 167

LMWH e.g. enoxaparin, dalteparin and tinzaparin, dose is based on the **woman's weight** at the **booking clinic** or **from early pregnancy** * Should be started immeditately even before confirming the diagnosis * Treatment can be stopped when Ix exclude the diagnosis * When diagnosis is confirmed, LMWH is continued for remainder of pregnancy + 6 weeks post partum - option to switch to DOAC or warfarin after delivery

Answer 168

**Unfractionated heparin** **Thrombolysis** **Surgical** embolectomy

Answer 169

* New onset hypertension: \>140/90 after 20 weeks of pregnancy * And end organ dysfunction- proteinuria or other organ dysfunction eg renal insufficiency

Answer 170

* Recurrent 1st/2nd trimester losses * Fetal growth restriction (FGR) * Early onset pre-eclampsia * Spontaneous pre-term labour * Pre-term premature rupture of the membranes

Answer 171

After 20 weeks gestation, when the **spiral arteries** of the placenta form abnormally leading to a **high vascular resistance** in these vessels

Answer 172

* Maternal organ damage * FGR * Seizures (eclampsia) * Early labour * Death * Cerebral haemorrhage * Renal failure * Placental abruption * HELLP syndrome

Answer 173

1. Hypertension 2. Proteinuria 3. Oedema

Answer 174

When **seizures** occur as a result of pre-eclampsia

Answer 175

*_Pathophysiology is poorly understood, by simplified:_* - When the blastocyst implants on the endometrium , the outermost later called the syncytiotrophoblast grows into the endometrium forming finger-like projections called chorionic villi, these villi contain fetal blood vessels - Trophoblast invasion of the endometrium sends signals to the spiral arteries in that area of the endometrium, reducing their vascular resistance making them more fragile, blood flow to these areas increases and eventually they break down forming pools of blood called lacunae - Maternal blood flows from the uterine arteries into the lacunae and back out through the uterine veins- these form at around 20 weeks gestation - When the process of forming lacunae is inadequate then the woman can develop pre-eclampsia - Pre-eclampsia is caused by high vascular resistance in the spiral arteries and poor perfusion of the placenta causing oxidative stress in the placenta and the release of inflammatory chemicals into the systemic circulation leadind to a systemic inflammation and impaired endothelial function in the blood vessels

Answer 176

* Pre-existing hypertension * Previous hypertension in pregnancy * Existing autoimmune conditions (e.g. systemic lupus erythematosus) * Diabetes * Chronic kidney disease

Answer 177

* Older than 40 * BMI \> 35 * More than 10 years since previous pregnancy * Multiple pregnancy * First pregnancy * Family history of pre-eclampsia

Answer 178

Women with **one high-risk factor** or **more than one moderate risk factor** from 12 weeks gestation until birth

Answer 179

**Headache** **Visual disturbance** or blurriness **Nausea and vomiting** **Upper abdominal or epigastric pain** (this is due to liver swelling) **Oedema** **Reduced urine output** Brisk reflexes

Answer 180

Systolic blood pressure above **140 mmHg** Diastolic blood pressure above **90 mmHg** PLUS **Proteinuria** (1+ or more on urine dipstick) **Organ dysfunction** (e.g. **raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia**) **Placental dysfunction** (e.g. f**etal growth restriction or abnormal Doppler studies**)

Answer 181

**Urine albumin:creatinine ratio** (above 30mg/mmol is significant) **Urine protein:creatinine ratio** (above 8mg/mmol is significant)

Answer 182

Recommended for use on one occasion during pregnancy in women suspected of having pre-eclampsia **Placental growth factor** is a protein released by the placenta which functions to stimulate the development of new blood vessels. In pre-eclampsia the levels of PIGF are low NICE recommends using PIGF between 20 and 35 weeks gestation to **rule out pre-eclampsia**

Answer 183

Blood pressure Symptoms Urine dipstick for proteinuria

Answer 184

Treating to **aim** for a blood pressure below **135/85** mmHg **Admission** for women with a blood pressure **above 160/110 mmHg** **Urine dipstick testing at least weekly** **Monitoring of blood tests weekly** (full blood count, liver enzymes and renal profile) **Monitoring fetal growth** by serial growth scans **PlGF** testing on **one occasion**

Answer 185

Outpatient mx * Appropriate if: * BP \< 160 systolic and \<110 diastolic and can be controlled * No or low proteinuria * Asymptomatic * Difficult to distinguish from gestational htn * Warn about development of symptoms * 1-2 weekly review of BP and urine * Weekly review of bloods * Monitoring fetal growth 2 weekly Mild-moderate pre-eclampsia * BP \<160 systolic and \<110 diastolic with significant proteinuria and no maternal complications * Once significant proteinuria occurs, admission is advised * ≥2+ protein * \>300mg proteinuria/24h * A split protein:creatinine ratio can be a useful screening test for proteinuria—check with your lab for their normal values, but in general \>30 equates to \>300mg proteinuria/24h. * 4 hourly BP * 24 hour urine collection for protein * Daily urinalysis * Daily fetal assessment with CTG * Regular blood tests every 2-3 days unless signs/ symptoms worsen * Regular USS Severe pre-eclampsia mx * Defined as the occurrence of BP ≥160 systolic or ≥110 diastolic in the presence of significant proteinuria (≥1g/24h or≥2+ on dipstick), or if maternal complications occur. * Senior obstetric, anaesthetic, and midwifery staff should be informed and involved in the management of a woman with severe pre-eclampsia * The only treatment is delivery, but this can sometimes be delayed with intensive monitoring if \<34wks * Pre-eclampsia often worsens for 24h after delivery Management * Labetalol is first line * Offer nifedipine if labetalol not suitable * Offer methyldopa if nidepine and labetalol both not suitable * Strict fluid balance- consider catheter * CTG monitoring of fetus until condition status * USS fetus, assess if IUGR, assess condition using fetal and umbilical artery doppler * If \<34 weeks give steroids

Answer 186

**Labetolol is first-line** as an antihypertensive **Nifedipine** (modified-release) is commonly used second-line **Methyldopa is used third-line** (**needs to be stopped within two days of birth**) **Intravenous hydralazine** may be used as an antihypertensive in critical care in **severe pre-eclampsia or eclampsia** **IV magnesium sulphate** is given **during labour and in the 24 hours afterward**s to **prevent seizures** **Fluid restriction is used during labour** in severe pre-eclampsia or eclampsia, to avoid fluid overload

Answer 187

Blood pressure cannot be controlled or complications occur Indications for immediate delivery * Worsening thrombocytopaenia or coagulopathy. * Worsening liver or renal function. * Severe maternal symptoms, especially epigastric pain with abnormal LFTs. * HELLP syndrome or eclampsia. * Fetal reasons such as abnormal CTG or reversed umbilical artery end diastolic flow.

Answer 188

**Enalapril** (first-line) **Nifedipine or amlodipine** (first-line in black African or Caribbean patients) **Labetolol or atenolol** (third-line)

Answer 189

The seizures associated with pre-eclampsia **IV magnesium sulphate** is used to help manage the seizures * IV bolus 4g over 5-10 mins * Followed by IV infusion 1g/hour * Monitor UO, reflexes, RR, O2 sats * Respiratory depression can occur- calcium gluconate is first-line for magnesium sulphate induced respiratory depression

Answer 190

Combination of features with occur as a complication of pre-eclampsia: **H**aemolysis **E**levated **L**iver enzymes **L**ow Platelets

Answer 191

Diabetes triggered by birth, caused by reduced insulin sensitivity during pregnancy and resolves after birth

Answer 192

Large for dates fetus and macrosomia leading to shoulder dystocia Long term risk- women are at a higher risk of developing type 2 diabetes after pregnancy

Answer 193

**Oral glucose tolerance test** at **24-28 weeks gestation** Used for pts with risk factors for gestational diabete and also when there are features suggestive of gestational diabetes such as * Large for dates fetus * Polyhydramnios * Glucose on urine dipstick

Answer 194

**Previous gestational diabetes** Previous **macrosomic** baby (≥ 4.5kg) **BMI \> 30** **Ethnic origin** (black Caribbean, Middle Eastern and South Asian) **Family history of diabetes** (first-degree relative)

Answer 195

Performed **in the morning** after a fast (they can drink plain water) Patient **drinks** a **75g** **glucose** drink at the start of the test Blood **sugar level** is measured before the sugar drink (**fasting)** and then at **2 hours**

Answer 196

Fasting: \< 5.6 mmol/l At 2 hours: \< 7.8 mmol/l (5, 6, 7, 8)

Answer 197

**Fasting glucose less than 7 mmol/l:** trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin **Fasting glucose above 7 mmol/l**: start insulin ± metformin **Fasting glucose above 6 mmol/l plus macrosomia** (or other complications): start insulin ± metformin

Answer 198

**Glibenclamide** (a sulfonylurea)

Answer 199

* **Fasting:** 5.3 mmol/l * **1 hour post-meal:** 7.8 mmol/l * **2 hours post-meal:** 6.4 mmol/l * **Avoiding levels of 4 mmol/l or below**

Answer 200

They should take **5mg folic acid from preconception until 12 weeks gestation**

Answer 201

Using metformin and insulin (other oral diabetic medications should be stopped)

Answer 202

Shortly after booking and at 28 weeks gestation in pregnancy Involves **referral** to an **ophthalmologist** to check for **diabetic retinopathy**

Answer 203

Planned delivery between 37 and 38 + 6 weeks

Answer 204

Up to 40+6

Answer 205

**Sliding-scale insulin regime** A dextrose and insulin infusion is titrated to blood sugar levels according to the local protocol. Also considered for women with **poorly controlled blood sugars** with gestational or type 2 diabetes

Answer 206

Immediately after birth with follow up testing for their fasting glucose at least 6 weeks after

Answer 207

Lower their insulin dose and be wary of **hypoglycaemia** in the postnatal period - insulin sensitivity will increase after birth and with breast feeding

Answer 208

* Neonatal hypoglycaemia * Polycythaemia (raised haemoglobin) * Jaundice (raised bilirubin) * Congenital heart disease * Cardiomyopathy

Answer 209

**Neonatal hypoglycaemia** - babies have been accustomed to a large supply of glucose during the pregnancy Neonates need close monitoring for this with regular blood glucose checks and **frequent feeds** aiming to **maintain thier blood sugar** above 2 mmol/l and if it falls they may need **IV dextrose** or **nasogastric feeding**

Answer 210

**Reduced outflow of bile acids** from the liver - resolving after delivery of the baby Result of Increased oestrogen and progesterone levels

Answer 211

South asian ethnicity

Answer 212

* Itching (pruritis) on the palms of the hands and soles of the feet * Fatigue * Dark urine * Pale, greasy stools * Jaundice (indicating obstruction of the common bile duct) More acute cholecystitis- * Signs of systemic infection (fever, tachycardia) * N&V * Murphy's sign positive * Colicky epigastric/ RUQ pain

Answer 213

No rash, if this is present then an alternative diagnosis should be considered e.g. **polymorphic eruption of pregnancy** pr **pemphigoid gestationis**

Answer 214

* Obstetric chilestasis * Gallstones * Acute Fatty liver * Autoimmune hepatitis

Answer 215

**LFTs** (deranged ALT, AST and GGT) (WCC and alkaline phosphatase are ↑ in pregnancy; a rise of ALP with normal LFTs may be ALP production from placenta) ↑ Bilirubin (identify patients with concomitant biliary tree obstruction) **Bile acids** (raised) USS biliary tract (may demonstate calculi or a dilated biliary tree)

Answer 216

* **Ursodeoxycholic acid** - improves LFTs, bile acids and symptoms * Emollients (i.e. calamine lotion) to soothe the skin * Antihistamines (e.g. chlorphenamine) can help sleeping (but does not improve itching) * Vit K supplementation if clotting (prothrombin time) is deranged * Monitor LFTs during pregnancy weekly and for 10 days after pregnancy to ensure condition doesn't woren & resolves after birth * induction of labour at 37-38 weeks is common practice but may not be evidence based

Answer 217

Rare condition which occurs in the **third trimester of pregnancy** with **rapid accumulation of fat** within the liver cells (**hepatocytes**) causing **acute hepatitis** High risk of **liver failure** and **mortality** for both the mother and fetus

Answer 218

Impaired processing of **fatty acids** in the **placenta** result of a genetric condition in the fetus which impairs fatty acid metabolism Most common cause is **long-chain 3-hydroxyacyl-CoA dehydrogenase** (**LCHAD**) deficiency in the fetus which is an **autosomal recessive** condition The **LCHAD** enzyme is important in **fatty acid oxidation** breaking down fatty acids to be used as fuel **Fatty acids then enter maternal circulation** and accumulate in the liver causing **inflammation and failure**

Answer 219

Vague symptoms associated with hepatitis: General **malaise and fatigue** **Nausea** and **vomiting** **Jaundice** **Abdominal pain** **Anorexia** (lack of appetite) **Ascites** **Headache** **Hypoglycaemia** **Severe disease may result in pre-eclampsia**

Answer 220

* Elevated ALT and AST (liver enzymes) * Raised bilirubin * Raised WBC * Deranged clotting (raised prothrombin time and INR) * Low platelets

Answer 221

**Obstetric emergency** which requires prompt admission and delivery of the baby - most patients recover after delivery

Answer 222

**Acute liver failure** - consider liver transplant

Answer 223

Itchy rash which tends to **start in the 3rd trimester** * Also known as **pruritic and urticarial papulaes and plaques of pregnancy** * Usually **begins of abdomen** and particularly assocuated with **stretch marks** (striae) Characterised by: * Urticarial papules (raised itchy lumps) * Wheals (raised itchy areas of skin) * Plaques (larger inflamed areas of skin)

Answer 224

* Polymorphic eruption of pregnancy * Pruritic condition associated with 3rd trimester * Lesions often appear in abdominal striae first * Periumbilical area often spared * Atopic eruption of pregnancy * Commonest skin disorder found in pregnancy * Eczemaotus, itchy, red rash * No specific treatment required * Pemphigoid gestationis * Pruritis blistering lesions * Often peri-umbilical reigon, later spreads to trunk, back, buttocks and arms * Usually 2nd and 3rd trimester * Oral corticosteroids usually required * Melasma * Increased pigmentation to patches of skin on the face, symmetrical and flat, on sun-exposed areas * Pyogenic granuloma * Sites: head, neck, upper trunk, hands * Lesions in oral mucosa during pregnancy * Initially small red/ brown spot, rapidly progresses within days to weeks forming raised, red brown lesions which are spherical in shape, lesions may bleed profusely or ulcerate * Resolve spontaneously post-partum

Answer 225

Control the symptoms: **Topical emollients** **Topical steroids** **Oral antihistamines** **Oral steroids** may be used in severe cases

Answer 226

**E-type or eczema type** with eczematous inflamed, red and itchy skin, inside of elbows and knees, face and chest **P-type or prurigo-type** intesely itchy papules (spots) typically affecting the abdomen, back and limbs

Answer 227

**Topical emollients** **Topical steroids** **Phototherapy with ultraviolet light** (UVB) may be used in severe cases **Oral steroids** may be used in severe cases

Answer 228

**Increased pigmentation** to patched of the skin on the face - usually symmetrical and flat, affecting sun-exposed areas

Answer 229

**Increased female sex hormones** associated with pregnancy Also occurs with the COCP and HRT Associated also with **sun exposure, contraceptive pill and HRT**

Answer 230

No active management if the appearance is acceptable to the woman, otherwise: **Avoiding sun exposure** and using suncream **Makeup** (camouflage) **Skin lightening cream** (e.g. hydroquinone or retinoid creams), **although not in pregnancy** and only under specialist care **Procedures such as chemical peels** or laser treatment (not usually on the NHS)

Answer 231

**Benign** rapidly growing tumour of capillaries

Answer 232

Discrete lump with a red / dark appearace **Occuring more often in pregnancy** can also be associated with hormonal contraceptives, minor trauma or infection

Answer 233

Rapidly growing lump which develops **over days** up to 1-2cm in size (but can be larger) Often occur on the **fingers** or on the upper chest, back, neck or head. **May cause profuse bleeding and ulceration if injured**

Answer 234

Usually resolve in pregnancy without any further treatment after delivery Treatment is with **surgical removal** with **histology** to confirm the diagnosis

Answer 235

Rare **autoimmune skin condition** in pregnancy **Autoantibodies** are created with **damage the connection** between the **epidermis and dermis** creating a space with can fill with fluid, resulting in large fluid-filled blisters (bullae)

Answer 236

**Itchy, red, papular or blistering rash** around the umbilicus that then spreads to other parts of the body - **over weeks** large **fluid filled blisters form**

Answer 237

Rash usually resolves without treatment after delivery, **blisters heal without scarring**, treatment can be: **Topical emollients** **Topical steroids** **Oral steroids** may be required in severe cases **Immunosuppressants** may be required where steroids are inadequate **Antibiotics** may be necessary if infection occurs

Answer 238

**Fetal growth restriction** **Preterm** delivery **Blistering rash after delivery** (as the maternal antibodies pass to the baby)

Answer 239

The palcenta is attached in the **lower portion of the uterus,** lower than presenting part of fetus * Over the internal cervical os Low lying placenta = the placenta is within 20mm of the cervical os

Answer 240

Cervical ectropion Infection Vaginal abrasions from intercourse

Answer 241

* Antepartum haemorrhage * Emergency caesarean section * Emergency hysterectomy * Maternal anaemia and transfusions * Preterm birth and low birth weight * Stillbirth

Answer 242

**Minor praevia, or grade I** – the placenta is in the lower uterus but not reaching the internal cervical os **Marginal praevia, or grade II** – the placenta is reaching, but not covering, the internal cervical os **Partial praevia, or grade III** – the placenta is partially covering the internal cervical os **Complete praevia, or grade IV** – the placenta is completely covering the internal cervical os

Answer 243

**Previous caesarean sections** **Previous placenta praevia** **Older** maternal **age** Maternal **smoking** Structural uterine abnormalities (e.g. **fibroids**) Assisted reproduction (e.g. **IVF**)

Answer 244

20 week anomaly scan

Answer 245

Usually asymptomatic **Painless vaginal bleeding** (around 36 weeks) Malpresentation of fetus Normal uterine tone- unlike abruption- fetal parts easy to palpate

Answer 246

When antepartum haemorrhage of any type occurs, suspect placenta praevia, admit to hospital * IV access * Fluid resuscitation * Take bloods for FBC and cross match * CTG to determine fetal status * Cause for bleeding sought from USS * Up to 50% no cause may be seen * Emergency C-Section required with premature labout or antenatal bleeding * Anti D immunoglobulin if Rh negative mother Conservative mx of placenta praevia where there is non-life-threatening bleeding and pre-term lady * Keep in hospital with cross-matched blood until fetal maturity is adequate * Oral iron or iron infusion where necessary to maintain adequate Hb * Repeat scans at 32 weeks and 36 weeks gestation (if present on the 32-week scan, to guide decisions about delivery) * Corticosteroids given between 34 and 35+6 gestation to mature the fetal lungs * Planned delivery between 36 and 37 weeeks to reduce the risk of spontaneous labour and bleeding * Planned C-Section is required with placenta praevia and low-lying placenta * Ultrasound around the time of procedure to locate placenta

Answer 247

**Haemorrhage** before, during and after delivery

Answer 248

* Emergency caesarean section * Blood transfusions * Intrauterine balloon tamponade * Uterine artery occlusion * Emergency hysterectomy

Answer 249

Condition where the **fetal vessels** are within the **fetal membranes** (chorioamniotic membranes- surround amniotic cavity & developing fetus) and travel across the **internal cervical os** The fetal vessels = 2 umbilical arteries and single umbilical vein The fetal vessels are places over the internal cervical os, before the fetus - exposed, outside the protection of the umbilical cord or placenta - prone to bleeding, particularly when the membranes are ruptured during labour and at birth

Answer 250

**Type I vasa praevia** – the fetal vessels are exposed as a velamentous umbilical cord **Type II vasa praevia** – the fetal vessels are exposed as they travel to an accessory placental lobe

Answer 251

**Low lying placenta** **IVF** pregnancy **Multiple pregnancy**

Answer 252

**Maybe** diagnosed **by ultrasound during pregnancy** (allowing planned C-Section to reduce risk of haemorrhage) **Antepartum haemorrhage** with **bleeding during 2nd or 3rd trimester** of pregnancy **Maybe** detected on **vaginal examintation during labour** when pulsatiling vessels are seen in the membranes **Maybe** detected during labour when **fetal distress** and **dark-red bleeding occur following rupture of the membranes** carries a very high fetal mortality

Answer 253

For asymptomatic patients: - **Corticosteroids** from week 32 gestation - **Elective c-section** planned for 34 to 36 weeks gestation In **antepartum haemorrhage**: - **Emergency C-Section** is required to deliver fetus

Answer 254

When the placenta separates from the walls of the uterus during pregnancy (site of attachment can bleed extensively after the placenta separates - significant cause of antepartum haemorrhage)

Answer 255

Previous placental abruption Pre-eclampsia **Bleeding early** in pregnancy **Trauma** (consider domestic violence) **Multiple pregnancy** **Fetal growth restriction** **Multigravida** **Increased maternal age** **Smoking** **Cocaine or amphetamine use**

Answer 256

**Sudden onset severe abdominal pain** that is continuous **Vaginal bleeding** (antepartum haemorrhage) **Shock** (hypotension and tachycardia) **Abnormalities on the CTG** indicating fetal distress Characteristic **“woody” abdomen on palpation**, suggesting a large haemorrhage *Unlike placenta praevia, placental abruption presents with pain, vaginal bleeding of variable amounts and increased uterine activity.*

Answer 257

**Spotting**: spots of blood noticed on underwear **Minor haemorrhage:** less than 50ml blood loss **Major haemorrhage**: 50 – 1000ml blood loss **Massive haemorrhage:** more than 1000 ml blood loss, or signs of shock

Answer 258

**Cervical os remains closed**, and **any bleeding that occurs remains within the uterine cavity**. The **severity** of bleeding can be **significantly underestimated** with concealed haemorrhage.

Answer 259

Where blood loss is observed via the vagina

Answer 260

No reliable test, clinical diagnosis

Answer 261

**Obstetric emergency** - urgency depends on the amount of fetal separation, extent of bleedin, haemodynamic stability of the mother and condition of the fetus (important to consider **concealed haemorrhage** where vaginal bleeding may be disproportionate to uterine bleeding)

Answer 262

* Urgent involvement of a senior obstetrician, midwife and anaesthetist * 2 x grey cannula * Bloods include FBC, UE, LFT and coagulation studies * Crossmatch 4 units of blood * Fluid and blood resuscitation as required * CTG monitoring of the fetus * Close monitoring of the mother Fetus alive and \< 36 weeks * fetal distress: immediate caesarean * no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation Fetus alive and \> 36 weeks * fetal distress: immediate caesarean * no fetal distress: deliver vaginally Fetus dead * induce vaginal delivery

Answer 263

**Ultrasound** to **exclude placenta praevia** as a cause for antepartum haemorrhage (not good for diagnosing abruption) **Antenatal steroids** between 24 and 34 + 6 weeks gestation **Rhesus-D negative women** require **anti-D prophylaxis** when bleeding occurs - a **Kleihauer test** is used to quantify how much fetal blood is mixed with maternal blood to determine dose **Emergency C-Section** if mother is **unstable** or there is **fetal** distress **Increased risk** of **postpartum haemorrhage** after delivery in women with placental abruption - **active management of the third stage is recommended**

Answer 264

When the **placenta implants deeper**, through and past the endometrium - then difficult to separate the placenta after delivery of the baby

Answer 265

**Endometrium**, the inner layer that **contains connective tissue** (stroma), **epithelial cells and blood vessels** **Myometrium**, the **middle layer that contains smooth muscle** **Perimetrium**, the **outer layer, which is a serous membrane** similar to the peritoneum (also known as serosa)

Answer 266

The **endometrium**

Answer 267

Past the endometrium **into the myometrium and beyond**

Answer 268

**Previous uterine surgery** e.g. C-Section or curettage procedure

Answer 269

Difficult for the placenta to separate suring delivery, leading to **extensive bleeding** (post-partum haemorrhage)

Answer 270

**Superficial placenta accreta** is where the placenta implants in the surface of the myometrium, but not beyond **Placenta increta** is where the placenta attaches deeply into the myometrium **Placenta percreta** is where the placenta invades past the myometrium and perimetrium, potentially reaching other organs such as the bladder

Answer 271

**Previous placenta accreta** **Previous endometrial curettage procedures** (e.g. for miscarriage or abortion) **Previous caesarean section** **Multigravida** **Increased maternal age** **Low-lying placenta** or placenta praevia

Answer 272

Doesnt usually cause symptoms in pregnancy Can present with **antepartum haemorrhage** in the **third trimester** May be diagnosed on **antenatal ultrasound scans** with particular attention fiven to women with previous placenta accreta or caesarean during scanning May be diagnosed at birth when it is **difficult to deliver the placenta**

Answer 273

Antenatally by ultrasound - allowing planning for birth

Answer 274

**MRI scans**

Answer 275

May need additional management at birth due to the risk of bleeding: **Complex uterine surgery** Blood **transfusions** **Intensive care** for the mother **Neonatal intensive care**

Answer 276

**Between 35 to 36+6 weeks** gestation to reduce the risk of spontaneous labour and delivery (antenatal steroids given to mature the fetal lungs before delivery)

Answer 277

**Hysterectomy with the placenta remaining in the uterus** (recommended) **Uterus preserving surgery,** with resection of part of the myometrium along with the placenta **Expectant management,** leaving the placenta in place to be reabsorbed over time

Answer 278

- During an **elective C-section** the abdo can be closed and delayed whilst services are put in place - If discovered after delivery of baby then a **hysterectomy** is recommended

Answer 279

Presenting part of the fetus is the **legs and bottom**

Answer 280

**Less than 5% of pregnancies by 37 weeks gestation**

Answer 281

**Complete breech**, where the legs are fully flexed at the hips and knees **Incomplete breech,** with one leg flexed at the hip and extended at the knee **Extended breech**, also known as frank breech, with both legs flexed at the hip and extended at the knee **Footling breech**, with a foot is presenting through the cervix with the leg extended

Answer 282

**Before 36 weeks** often turn spontaneously **After 37 weeks** external cephalic version can be used to attempt to turn the fetus If this fails then women are given a choice between vaginal delivery and elective CS * VD needs to involve senior midwives and access to emergency theatres if CS required * When the first baby in a twin pregnancy is breech CS is required

Answer 283

**Tocolysis** to relax the uterus: subcutaneous terbutaline- A **beta-agonist** similar to salbutamol (**reduces the contractility of the myometrium**)

Answer 284

Birth of a dead fetus after 24 weeks gestation (result of **intrauterine fetal death**) occurs in approx 1 in 200 pregnancies

Answer 285

Unexplained (around 50%) Pre-eclampsia **Placental abruption** **Vasa praevia** **Cord prolapse** or wrapped around the fetal neck **Obstetric cholestasis** **Diabetes** **Thyroid disease** **Infections**, such as rubella, parvovirus and listeria **Genetic abnormalities** or congenital malformations

Answer 286

**Fetal growth restriction** **Smoking** **Alcohol** **Increased maternal age** **Maternal obesity** **Twins** Sleeping on the back (as opposed to either side)

Answer 287

**Risk assesment for SGA / FGR** is performed on all pregnant women Those at risk have **serial growth scans** (maybe planned early delivery when the growth is static or other concerns) **Risk assessment for pre-eclampsia** and given aspirin **Modifiable risk factors for stillbirth** are treated e.g. stopping smoking, avoiding alcohol, effective control for diabetes **Sleeping on the side** is recommended

Answer 288

**Reduced fetal movements** **Abdo pain** **Vaginal bleeding**

Answer 289

**Ultrasound scan** to **visualise the fetal heatbeat** Passive fetal movements are still possible so a repeat scan is offered to confirm situation

Answer 290

**Vaginal birth is first line** (choice of induction of labour or expectant management - provided there is no sepsis, pre-eclampsia or haemorrhage) **Expectant managment** needs close monitoring - condition of fetus will deteriorate with time **Induction of laboue** involves use of **oral mifepristone** (anti-progesterone) and vaginal or oral misoprostol (**prostaglandin analogue**) **Dopamine agonists** (e.g. **cabergoline**) can be used to **suppress lactation** after stillbirth

Answer 291

With **parental consent**, testing is carried our after stillbirth: **Genetic testing of the fetus** and placenta **Postmortem examination of the fetus (including xrays)** **Testing for maternal and fetal infection** **Testing the mother for conditions** associated with stillbirth, such as diabetes, thyroid disease and thrombophilia

Answer 292

1. **Thrombosis** (i.e. PE or MI) 2. Tension **pneumothorax** 3. **Toxins** 4. **Tamponade** (cardiac) 1. **Hypoxia** 2. **Hypovolaemia** 3. **Hypothermia** 4. **Hyperkalaemia, hypoglycaemia**, and other metabolic abnormalities

Answer 293

Eclampsia Intracranial haemorrhage **Obstetric haemorrhage** **Pulmonary embolism** **Sepsis leading to metabolic acidosis and septic shock**

Answer 294

**Ectopic pregnancy** (early pregnancy) **Placental abruption** (including concealed haemorrhage) **Placenta praevia** **Placenta accreta** **Uterine rupture**

Answer 295

Pregnant woman lies on her back - the mass of the uterus compresses the **IVC and aorta** (compression on the IVC is most significant as it lowers cardiac output leading to hypotension) can **lead to cardiac arrest**

Answer 296

Place the pt in the left lateral position, lying on her left side

Answer 297

**Aortocaval compression** **Increased oxygen requirements** **Splinting of the diaphragm** by the pregnant abdomen **Difficulty with intubation** **Increased risk of aspiration** **Ongoing obstetric haemorrhage**

Answer 298

**A 15 degree tilt to the left side** for CPR, to relieve compression of the inferior vena cava and aorta **Early intubation to protect the airway** **Early supplementary oxygen** **Aggressive fluid resuscitation** (caution in pre-eclampsia) **Delivery of the baby after 4 minutes**, and within 5 minutes of starting CPR

Answer 299

There is **no response after 4 minutes** to CPR when performed correctly **CPR continues for more than 4 minutes** in a woman more than 20 weeks gestation

Answer 300

Within **5 minutes of starting CPR** - performed at the site of the arrest e.g. A&E resus or on the ward

Answer 301

**Improves survival of the mother** improving the venous return to the heart, improving cardiac output and reducing oxygen consumption - also helps with ventilation and chest compressions (also increases the chances of the baby surviving, although this is secondary to the survival of the mother)

Answer 302

* Increased vascularity * Hypertrophy of cervical glands producing the appearance of a cervical erosion; an increase in mucous secretory tissue in the cervix during pregnancy leads to a thick mucus discharge and the development of an antibacterial plug of mucus in the cervix * Reduced collagen in the cervix in the third trimester and the accumulation of glycosaminoglycans and water, leading to the characteristic changes of cervical ripening * The lower section shortens as the upper section expands, while during labour there is further stretching and dilatation of the cervix

Answer 303

* Polyhydramnios is the presence of too much amniotic fluid in the uterus. * Polyhydramnios may present with a uterus which feels tense or large for dates and it may be difficult to feel the foetal parts on palpation of the abdomen. In many cases of polyhydramnios there is no identifiable cause.

Answer 304

Causes of polyhydramnios can be due to excessive production of amniotic fluid or insufficient removal of amniotic fluid. Excess production can be due to increased foetal urination: * Maternal diabetes mellitus * Foetal renal disorders * Foetal anaemia * Twin-to-twin transfusion syndrome Insufficient removal can be due to reduced foetal swallowing: * Oesophageal or duodenal atresia * Diaphragmatic hernia * Anencephaly * Chromosomal disorders

Answer 305

Complications of polyhydramnios can be divided into maternal and foetal. Maternal complications * Maternal respiratory compromise due to increased pressure on the diaphragm * Increased risk of urinary tract infections due to increased pressure on the urinary system * Worsening of other symptoms associated with pregnancy such as gastro-oesophageal reflux, constipation, peripheral oedema and stretch marks * Increased incidence of caesarean section delivery * Increased risk of amniotic fluid embolism (although this is rare) Foetal complications * Pre-term labour and delivery * Premature rupture of membranes * Placental abruption * Malpresentation of the foetus (the foetus has more space to “move” within the uterus) * Umbilical cord prolapse (polyhydramnios can prevent the foetus from engaging with the pelvis, thus leaving room for the cord to prolapse out of the uterus before the presenting part) Management * Treatment includes management of any underlying causes (e.g. in maternal diabetes) and amnio-reduction in severe cases.

Answer 306

U&E, FBC, transaminases and bilirubin three times per week to anticipate if a pt will develop HELLP syndrome

Answer 307

WHO definition- haemorrhage from vagina after 24 weeks gestation The factors that cause antepartum haemorrhage may be present before 20 weeks, but the distinction between a threatened miscarriage and an antepartum haemorrhage is based on whether the fetus is considered potentially viable at the time of the bleed

Answer 308

Gestational hypertension is characterized by the **new onset of hypertension without any features of pre-eclampsia after 20 weeks of pregnancy** or **within the first 24 hours postpartum**. Although by definition the blood pressure should return to normal by 12 weeks after pregnancy; it usually returns to normal **within 10 days** after delivery.

Answer 309

Vaginal bleeding may be due to: * haemorrhage from the placental site and uterus: placenta praevia, placental abruption, uterine rupture * lesions of the lower genital tract: heavy show/onset of labour (bleed from cervical epithelium), cervical ectropion/carcinoma, cervicitis, polyps, vulval varices, trauma and infection * bleeding from fetal vessels, including vasa praevia (very rare)

Answer 310

* Gestational age * Placental location * Uterine anomalies * Multiple pregnancy * Neurological impairment of the fetal limbs

Answer 311

400mcg daily from before pregnancy till 12 weeks Take 5mg if any of the following apply: * BMI \> 30 * Sickle cell disease * Diabetes * Thalassemia trait * Personal/ family hx of neural tube defects (NTD) * Coeliac disease * On AEDs

Answer 312

24 weeks gestation

Answer 313

* Posture * There can be positional changes in fetal movement awareness, generally being more prominent during lying down and less when sitting and standing * Distraction * Awareness of fetal movements can be distractable, and if a woman is busy or concentrating on something else, these can be less prominent * Placental position * Patient with anterior placentas prior to 28 weeks gestation may have lesser awareness of fetal movements * Medication * Both alcohol and sedative medications like opiates or benzodiazepines can temporarily cause reduced fetal movements * Fetal position * Anterior fetal position means movements are less noticeable * Body habitus * Obese patients are less likely to feel prominent fetal movements * Amniotic fluid volume * Both oligohydramnios and polyhydramnios can cause reduction in fetal movements * Fetal size * Up to 29% of women presenting with RFM have a SGA fetus

Answer 314

Hyperemesis gravidarum is believed to occur due to rapidly rising levels of human chorionic gonadotropin (HCG) and oestrogen. Any condition which increases these hormone levels (or is associated with higher hormone levels) will lead to an increased risk of hyperemesis. Smoking is considered to be anti-oestrogenic and has been found to decrease the risk of hyperemesis gravidarum.

Answer 315

* Shock * DIC- Disseminated intravascular coagulation * Renal failure * PPH

Answer 316

IUGR Hypoxia Premature birth Death