Antenatal care Flashcards
What is gestational age?
duration of the pregnancy starting from the date of the last menstrual period
What is gravida?
total number of pregnancies a woman has had
What is primigravida?
patient that is pregnant for the first time
What is multigravida?
patient that is pregnancy for at least the second time
What is para?
number of times the woman has given birth after 24 weeks gestation, regardless of whether the foetus was alive or stillborn
What does nuliparous mean?
patient that has never given birth after 24 weeks gestation
What does primiparous mean?
patient that has given birth after 24 weeks gestation once before
What does multiparous mean?
patient that has given birth after 24 weeks gestation two or more times
When is the first trimester?
start of pregnancy until 12 weeks gestation
When is the second trimester?
13-26 weeks gestation
When is the third trimester?
27 weeks gestation to birth
When do foetal movements start?
20 weeks
When is the booking clinic?
before 10 weeks
What happens at the booking clinic?
baseline assessment
plan the pregnancy
When is the dating scan?
10 - 13+6
What happens at the dating scan?
accurate gestational age is calculated from the crown rump length
multiple pregnancies are identified
When is the anomaly scan?
18 - 20+6
When are antenatal appointments?
weeks:
16
25
28
31
34
36
38
40
41
42
When is the oral glucose tolerance test carried out in people at risk of gestational diabetes?
24-28 weeks
and at booking if previous gestational diabetes
When are anti-D injections administered to rhesus negative pregnant people?
28-34 weeks
What vaccines are offered to all pregnant people?
whooping cough (pertussis) from 16 weeks gestation
influenza (Flu) in autumn or winter
What supplements should pregnant people take?
folic acid 400mcg from before pregnancy to 12 weeks (reduces neural tube defects)
vitamin D
What vitamin supplement should pregnant people avoid?
vitamin A (teratogenic at high doses)
What foods should pregnant people avoid?
liver or pate (high in vitamin A)
unpasteurised diary or blue cheese (risk of listeriosis)
undercooked or raw poultry (risk of salmonella)
What are the effects of alcohol in pregnancy?
miscarriage
small for dates
preterm delivery
foetal alcohol syndrome
What are the features of foetal alcohol syndrome?
microcephaly (small head)
thin upper lip
smooth flat philtrum (groove between the nose and upper lip)
short palpebral fissure (short horizontal distance from one side of the eye to the other)
learning disability
behavioural difficulties
hearing and vision problems
cerebral palsy
What does smoking during pregnancy increase the risk of?
foetal growth restriction
miscarriage
stillbirth
preterm labour and delivery
placental abruption
pre-eclampsia
cleft lip or palate
sudden infant death syndrome (SIDS)
What are the recommendations around flying in pregnancy?
safe in uncomplicated healthy pregnancies up to:
37 weeks in a single pregnancy
32 weeks in a twin pregnancy
What forms the antenatal screening programme for Down’s syndrome?
11-14 weeks = combined test
14-20 weeks = triple test
14-20 weeks = quadruple test
What is involved in the combined screening test for Down’s syndrome?
US to measure nuchal translucency (thickness of the back of the neck)
maternal blood tests:
beta-HCG
pregnancy-associated plasma protein-A (PAPA)
What is involved in the triple screening test for Down’s syndrome?
maternal blood tests:
beta-HCG
alpha-fetoprotein (AFP)
serum oestriol
What is involved in the quadruple screening test for Down’s syndrome?
triple test plus maternal blood testing for inhibin-A
When is antenatal testing for Down’s syndrome offered?
risk of Down’s greater than 1 in 150 (occurs in around 5% of tested pregnant people)
What are the antenatal tests for Down’s syndrome?
before 15 weeks = chorionic villus sampling (US-guided biopsy of the placental tissue)
after 15 weeks = amniocentesis (US guided aspiration of amniotic fluid using a needle and syringe)
non-invasive prenatal testing (not definitive but less invasive)
How is hypothyroidism managed during pregnancy?
increased levothyroxine dose
aim for a low-normal TSH level
What hypertension medications should be stopped during pregnancy as they cause congenital abnormalities?
ACE inhibitors (e.g. ramipril)
ARBs (e.g. losartan)
thiazide and thiazide-like diuretics (e.g. indapamide)
What medications can be used to manage hypertension during pregnancy?
labetalol (other beta-blockers may have adverse effects)
CCBs (e.g. nifedipine)
alpha-blockers (e.g. doxazosin)
What anti-epileptic drugs are safe in pregnancy?
levetiracetam
lamotrigine
carbamazepine
What anti-epileptic drugs should be avoided in pregnancy and why?
sodium valproate - causes neural tube defects and developmental delay
phenytoin - causes cleft lip and palate
What DMARDs are safe during pregnancy?
hydroxychloroquine (first-line)
sulfasalazine
What DMARD should be avoided during pregnancy?
methotrexate
Why should NSAIDs be avoided during pregnancy unless absolutely necessary?
premature closure of the ductus arteriosus in the fetus
delay labour
(block prostaglandins - maintain the ductus arteriosus, soften the cervix, stimulate uterine contractions)
What can use of beta blockers during pregnancy cause?
foetal growth restriction
hypoglycaemia in the neonate
bradycardia in the neonate
What can the use of ACE inhibitors and ARBs in pregnancy cause?
oligohydraminos (reduced amniotic fluid)
miscarriage or foetal death
hypocalvaria (incomplete formation of the skull bones)
renal failure in the neonate
hypotension in the neonate
What can the use of opiates during pregnancy cause?
neonatal abstinence syndrome
What is the presentation of neonatal abstinence syndrome?
3-72 hours after birth with:
irritability
tachypnoea
high temperatures
poor feeding
What can the use of warfarin during pregnancy cause?
foetal loss
congenital malformations - particularly craniofacial problems
bleeding during pregnancy, postpartum haemorrhage, foetal haemorrhage, intracranial bleeding
Why should lithium be avoided during pregnancy unless other options have failed?
congenital cardiac abnormalities - particularly Ebstein’s (tricuspid valve is set lower on the right side of the heart, causing a bigger right atrium and a smaller right ventricle)
What are the potential risk of SSRIs during pregnancy?
first-trimester = congenital heart defects, paroxetine has a stronger link with congenital malformations
third-trimester = persistent pulmonary hypertension in the neonate
neonates can experience withdrawal (usually mild)
What causes congenital rubella syndrome?
maternal infection with the rubella virus during the first 20 weeks of pregnancy
What are the features of congenital rubella syndrome?
congenital deafness
congenital cataracts
congenital heart disease
learning disability
Why is chickenpox dangerous in pregnancy?
more severe in the mother (e.g. varicella pneumonitis, hepatitis, encephalitis)
foetal varicella syndrome
severe neonatal varicella infection (if infected around delivery)
What is done when a pregnant person is exposed to chickenpox?
check blood for antibodies
if non-immune = IV varicella immunoglobulins within 10 days of exposure
What is the treatment of chickenpox during pregnancy?
oral aciclovir within 24 hours of onset of rash in a patient that is more than 20 weeks gestation
What are the features of congenital varicella syndrome?
foetal growth restriction
microcephaly, hydrocephalus and learning disabilities
scars and significant skin changes located in specific dermatomes
limb hypoplasia (underdeveloped limbs)
cataracts and inflammation in the eye (chorioretinitis)
What can listeriosis in a pregnant person cause?
miscarriage
foetal death
severe neonatal infection
What are the features of congenital CMV?
foetal growth restriction
microcephaly
hearing loss
vision loss
learning disability
seizures
How is toxoplasmosis spread?
faeces from a cat that is a host of the parasite Toxoplasma gondii
What are the features of congenital toxoplasmosis?
classic triad of:
intracranial calcification
hydrocephalus
chorioretinitis (inflammation of the choroid and retina in the eye)
What are the complications of parvovirus B19 infection during pregnancy?
miscarriage or foetal death
severe foetal anaemia
hydrops fetalis (foetal heart failure)
maternal pre-eclampsia-like syndrome
How is the Zika virus spread?
Aedes mosquitos
sex with someone infected with the virus
What are the features of congenital Zika syndrome?
microcephaly
foetal growth restriction
other intracranial abnormalities such as ventriculomegaly and cerebellar atrophy
What can happen if a rhesus-D negative person becomes pregnant with a rhesus positive child?
likely at some point, that the blood from the baby will cross into the mother’s bloodstream
mother’s immune system will recognise the rhesus-D antigen as foreign and produce antibodies to it - mother has become sensitised to rhesus-D antigens
during subsequent pregnancies, the mother’s anti-rhesus-D antibodies can cross the placenta
if the foetus is rhesus-D positive, this can result in haemolytic disease of the newborn
When are anti-D injections given to rhesus-D negative pregnant patients?
routinely at:
28 weeks gestation
birth - if the baby’s blood group is found to be rhesus-positive
within 72 hours of a sensitisation event - e.g. antepartum haemorrhage, amniocentesis procedures, abdominal trauma
What is the Kleihauer test used for?
assess how much foetal blood has passed into the mother’s blood during a sensitisation event after 20 weeks
used to assess whether further doses of anti-D is required
How is the Kleihauer test performed?
adding acid to a sample of the mother’s blood
foetal haemoglobin is naturally more resistant to acid
foetal haemoglobin persists in response to the added acid, whilst the mother’s haemoglobin is destroyed
number of cells still containing haemoglobin (remaining foetal cells) can then be calculated
What is the definition of small for gestational age?
foetus measures below the 10th centile for their gestational age
What are the two US measurements used to assess foetal size?
estimated foetal weight (EFW)
foetal abdominal circumference (AC)
What is the defined as severe small for gestational age?
below the 3rd centile for their gestational age
What is low birth weight defined as?
birth weight of less than 2500g
What are the two categories of causes of small for gestational age?
constitutionally small (matching the mother and others in the family and growing appropriately on the growth chart)
foetal growth restriction/intrauterine growth restriction
What are the two categories of causes of foetal growth restriction?
placenta mediated growth restriction
non-placenta mediated growth restriction
What are the causes of placenta mediated growth restriction?
idiopathic
pre-eclampsia
maternal smoking
maternal alcohol
anaemia
malnutrition
infection
maternal health conditions
What are the causes of non-placenta medicated growth restriction?
genetic abnormalities
structural abnormalities
foetal infection
errors of metabolism
What signs may indicate foetal growth restriction other than the foetus being SGA?
reduced amniotic fluid volume
abnormal doppler studies
reduced foetal movements
abnormal CTGs
What are the short term complications of foetal growth restriction?
foetal death or stillbirth
birth asphyxia
neonatal hypothermia
neonatal hypoglycaemia
What are the long term complications of foetal growth restriction?
increased risk of:
cardiovascular disease, particularly hypertension
T2DM
obesity
mood and behavioural problems
What are the risk factors for small for gestational age?
previous SGA baby
obesity
smoking
diabetes
existing hypertension
pre-eclampsia
older mother (>35 years)
multiple pregnancy
low pregnancy-associated plasma protein-A (PAPPA)
antepartum haemorrhage
antiphospholipid syndrome
What is the management of pregnant people at low risk of SGA?
monitoring of symphysis fundal height at every antenatal appointment from 24 weeks onwards
What is the criteria for a pregnant person to have serial growth scans with umbilical artery doppler?
three or more minor risk factors
one or more major risk factors
issues with measuring the symphysis fundal height (e.g. large fibroids, BMI>35)
symphysis fundal height <10th centile
What is the management of pregnant people with SGA?
monitored closely with serial US measuring:
estimated foetal weight and abdominal circumference to determine growth velocity
umbilical arterial pulsatility index
amniotic fluid volume
treat modifiable risk factors (E.g. smoking)
early delivery where growth is static or there are other concerns
identify underlying cause:
blood pressure and urine dipstick for pre-eclampsia
uterine artery doppler scanning
detailed foetal anatomy scan by foetal medicine
karyotyping for chromosomal abnormalities
testing for infections
What is defined as being large for gestational age/macrosomia?
estimated foetal weight >90th centile
What is a high birthweight?
> 4500g
What are the causes of macrosomia?
constitutional
maternal diabetes
previous macrosomia
maternal obesity or rapid weight gain
overdue
male baby
What are the risks to the mother of macrosomia?
shoulder dystocia
failure to progress
perineal tears
instrumental delivery or caesarean
postpartum haemorrhage
uterine rupture (rare)
What are the risks to the foetus of macrosomia?
birth injury
neonatal hypoglycaemia
obesity in childhood and later life
T2DM in adulthood
What investigations are done in macrosomia?
US to exclude polyhydramnios and estimate the foetal weight
oral glucose tolerance test for gestational diabetes
How can the risks surrounding delivery in macrosomia be reduced?
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
early decision for caesarean section if required
paediatrician attending the birth
What is monozygotic?
identical twins from a single zygote
What is dizygotic?
non-identical twins from two different zygotes
What is monoamniotic?
single amniotic sac
What is diamniotic?
two separate amniotic sacs
What is monochorionic?
share a single placenta
What is dichorionic?
two separate placentas
What type of twin pregnancy has the best outcome?
diamniotic, dichorionic (each foetus has their own nutrient supply)
How can the type of twin pregnancy be determined on US?
dichorionic diamniotic twins = membrane between the twins with a lambda sign or twin peak sign
monochorionic diamniotic twins = membrane between the twins with a T sign
monochorionic monoamniotic twins = no membrane
What are the risks to the pregnant person with a twin pregnancy?
anaemia
polyhydramnios
hypertension
malpresentation
spontaneous preterm birth
instrumental delivery or caesarean
postpartum haemorrhage
What are the risks to the foetuses and neonates of a twin pregnancy?
miscarriage
stillbirth
foetal growth restriction
prematurity
twin-twin transfusion syndrome
twin anaemia polycythaemia sequence
congenital abnormalities
What is the pathophysiology of twin-twin transfusion syndrome?
foetuses share a placenta and there is a connection between the blood supplies of the foetuses
one foetus (the recipient) may receive the majority of the blood while the other foetus (the donor) is starved of blood
What are the complications of twin-twin transfusion syndrome?
recipient = fluid overloaded - heart failure, polyhydramnios
donor = growth restriction, anaemia, oligohydramnios
What is the management of twin-twin transfusion syndrome?
referred to a tertiary specialist foetal medicine centre
What is twin anaemia polycythaemia sequence?
similar to twin-twin transfusion syndrome but less acute
one twin becomes anaemic whilst the other develops polycythaemia (raised haemoglobin)
What additional US scans are required in twin pregnancy?
monochorionic = 2 weekly scans from 16 weeks
dichorionic = 4 weekly scans from 20 weeks
When is planned birth offered for twin pregnancies?
uncomplicated monochorionic monoamniotic twins = 32-33+6 weeks
uncomplicated monochorionic diamniotic twins = 36-36+6 weeks
uncomplicated dichorionic diamniotic twins = 37-37+6 weeks
triplets = before 35+6 weeks
(waiting beyond these dates is associated with an increased risk of foetal death, corticosteroids given before delivery to help mature the lungs)
How are twin pregnancies delivered?
monoamniotic twins = elective caesarean section
diamniotic twins:
vaginal delivery is possible when the first baby has a cephalic presentation
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
What can UTIs increase the risk of in pregnant people?
pre-term delivery
low birth weight
pre-eclampsia
What is the management of UTIs during pregnancy?
7 days of antibiotics
antibiotic options:
nitrofurantoin (avoid in the third trimester - risk of neonatal haemolysis)
amoxicillin (only after sensitivities are known)
cefalexin
(avoid trimethoprim as it is a folate antagonist)
What are the risk factors for VTE during pregnancy?
smoking
parity ≥3
age >35
BMI >30
reduced mobility
multiple pregnancy
pre-eclampsia
gross varicose veins
immobility
FMHx of VTE
thrombophilia
IVF pregnancy
When should prophylaxis for VTE in pregnancy start?
28 weeks if there are three risk factors
first trimester if there are four or more risk factors
hospital admission
surgical procedures
previous VTE
medical conditions such as cancer or arthritis
high-risk thrombophilias
ovarian hyperstimulation syndrome
What are the options for VTE prophylaxis during pregnancy?
LMWH (e.g. enoxaparin, dalteparin, tinzaparin) unless contraindicated
contraindications to LMWH consider mechanical prophylaxis:
intermittent pneumatic compression
anti-embolic compression stockings
When does pre-eclampsia occur?
after 20 weeks gestation
What are the features of pre-eclampsia?
triad of:
hypertension
proteinuria
oedema
What is chronic hypertension?
high blood pressure that exists before 20 weeks gestation and is longstanding
What is pregnancy-induced/gestational hypertension?
hypertension occurring after 20 weeks gestation without proteinuria
What is pre-eclampsia?
pregnancy-induced hypertension associated with organ damage, notably proteinuria
What is eclampsia?
seizures occurring as a result of pre-eclampsia
What is the pathophysiology of pre-eclampsia?
process of forming lacunae is inadequate
high vascular resistance in the spiral arteries and poor perfusion of the placenta
causes oxidative stress in the placenta and release of inflammatory chemicals into the systemic circulation
leads to systemic inflammation and impaired endothelial function in the blood vessels
What are the high-risk factors for pre-eclampsia?
pre-existing hypertension
previous hypertension in pregnancy
existing autoimmune conditions
diabetes
CKD
What are the moderate-risk factors for pre-eclampsia?
older than 40
BMI >35
more than 10 years since previous pregnancy
multiple pregnancy
first pregnancy
FMHx of pre-eclampsia
What are the symptoms of pre-eclampsia?
headache
visual disturbance or blurriness
nausea and vomiting
upper abdominal or epigastric pain (due to liver swelling)
oedema
reduced urine output
brisk reflexes
How is pre-eclampsia diagnosed?
systolic BP >140 OR diastolic BP >90
PLUS any of:
proteinuria (1+ or more on urine dipstick)
organ dysfunction (e.g. raised creatinine, elevated liver enzymes, thrombocytopenia, haemolytic anaemia)
placental dysfunction (e.g. foetal growth restriction or abnormal Doppler studies)
What pregnant people are given aspirin as prophylaxis against the development of pre-eclampsia?
single high-risk factor
two or more moderate risk factors
What is the management of gestational hypertension?
aim for BP <135/85
admit if BP >160/110
weekly urine dipstick
monitoring of blood tests weekly - FBC, LFTs, renal profile
monitoring foetal growth by serial growth scans
placental growth factor (PIGF) testing between 20-35 weeks gestation to rule out pre-eclampsia (low levels in pre-eclampsia)
What is the management of pre-eclampsia?
scoring system to determine need for admission - fullPIERS or PREP-S
48hrly blood pressure
two weekly US
medical management:
1st line = labetolol
2nd line = modified release nifedipine
3rd line = methyldopa (needs to be stopped within 2 days of birth)
severe = IV hydralazine
during labour and 24 hrs afterwards = IV magnesium sulfate (to prevent seizures)
What is the treatment of pre-eclampsia post birth?
BP monitoring - will return to normal once placenta is removed
medical:
first line = enalapril
second line or first line in black African or Caribbean patients = nifedipine or amlodipine
3rd line = labetolol or atenolol
What is used to manage seizures associated with eclampsia?
IV magnesium sulfate
What is HELLP syndrome?
complication of pre-eclampsia
What are the features of HELLP syndrome?
Haemolysis
Elevated Liver enzymes
Low Platelets
What are the risks of gestational diabetes?
large for dates foetus/macrosomia - increased risk of shoulder dystocia
higher risk of developing T2DM after pregnancy
What are the risk factors that warrant testing for gestational diabetes?
previous gestational diabetes
previous macrosomic baby (>4.5kg)
BMI >30
ethnic origin
FMHx of diabetes (first degree relative)
large for dates foetus
polyhydramnios (increased amniotic fluid)
glucose on urine dipstick
What are the normal results of an oral glucose tolerance test in pregnancy?
fasting <5.6 mmol/l
at 2 hours <7.8 mmol/l
(5-6-7-8)
What is the initial management of gestational diabetes?
fasting glucose <7:
1st line = 1-2 week trial of diet and exercise
2nd line = metformin
3rd line = insulin
fasting glucose >7 = insulin +/- metformin
fasting glucose >6 + macrosomia or other complications = insulin +/- metformin
glibenclamide is an option for women who decline insulin or cannot tolerate metformin
What are the target blood sugar levels for diabetes during pregnancy?
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
When should retinopathy screening in patients with diabetes be performed during pregnancy?
booking
28 weeks gestation
When should patients with pre-existing diabetes deliver their baby?
37-38+6 weeks
What are the risks to the baby of a patient with diabetes?
neonatal hypoglycaemia
polycythaemia (raised haemoglobin)
jaundice (raised bilirubin)
congenital heart disease
cardiomyopathy
When does obstetric cholestasis usually develop?
after 28 weeks
What patients is obstetric cholestasis most common in?
South Asian
What is the main risk of obstetric cholestasis?
increased risk of stillbirth
What is the presentation of obstetric cholestasis?
main symptom = pruritis - particularly of the palms and soles
other symptoms = fatigue, dark urine, pale, greasy stools, jaundice
What are the differential diagnoses of obstetric cholestasis?
gallstones
acute fatty liver
autoimmune hepatitis
viral hepatitis
What is the management of obstetric cholestasis?
ursodexoycholic acid
symptoms of itching = emollients
water-soluble vitamin K if prothrombin time deranged
weekly LFT monitoring
When does acute fatty liver of pregnancy occur?
third trimester
What is the pathophysiology of acute fatty liver of pregnancy?
impaired processing of fatty acids in the placenta
fatty acids enter the maternal circulation and accummulate in the liver
What is the pathophysiology of acute fatty liver of pregnancy?
impaired processing of fatty acids in the placenta
fatty acids enter the maternal circulation and accumulate in the liver
What causes acute fatty liver of pregnancy?
genetic condition in the foetus - most commonly LCHAD deficiency (autosomal recessive)
What is the presentation of acute fatty liver of pregnancy?
general malaise and fatigue
nausea and vomiting
jaundice
abdominal pain
anorexia
ascites
What is the management of acute fatty liver of pregnancy?
obstetric emergency - prompt admission and delivery of baby
When does polymorphic eruption of pregnancy occur?
third trimester
Where does polymorphic eruption of pregnancy typically begin?
abdomen - particularly associated with stretch marks (striae)
When does atopic eruption of pregnancy typically occur?
first and second timester
When does atopic eruption of pregnancy typically occur?
first and second trimester
What are the two types of atopic eruption of pregnancy?
E-type/eczema type = eczematous, inflamed, red and itchy skin, typically affecting the insides of the elbows, back of the knees, neck, face and chest
P-type/prurigo type = intensely itchy papules affecting the abdomen, back and limbs
What are the symptoms of melasma?
increased pigmentation to patches of sun-exposed skin
What can cause melasma?
pregnancy
COCP
HRT
thyroid disease
What is the management of melasma?
avoiding sun exposure and using suncream
makeup
When does pemphigoid gestationis occur?
second or third trimester
What is the presentation of pemphigoid gestationis?
itchy red papular or blistering rash around the umbilicus that then spreads to other parts of the body
over several weeks, large, fluid-filled blisters form
What is a low-lying placenta?
placenta is within 20mm of the internal cervical os
What is placenta praevia?
placenta is over the internal cervical os
What are the risks associated with placenta praevia?
antepartum haemorrhage
emergency C section
emergency hysterectomy
maternal anaemia and transfusions
preterm birth and low birth weight
stillbirth
What are the risk factors for placenta praevia?
previous C section
previous placenta praevia
older maternal age
maternal smoking
structural uterine abnormalities (e.g. fibroids)
assisted reproduction (e.g. IVF)
When is placenta praevia diagnosed?
20 week anomaly scan
What are the symptoms of placenta praevia?
asymptomatic
may present with painless vaginal bleeding (antepartum haemorrhage) late in pregnancy (after 36 weeks(
What is the management of a low-lying placenta or placenta praevia?
repeat transvaginal US at 32 weeks and 36 weeks
corticosteroids between 34-35+6 weeks to mature foetal lungs due to the risk of preterm delivery
planned delivery between 36-37 weeks via elective C section
What is vasa praevia?
foetal vessels travel across the internal cervical os
What are the two causes of vasa praevia?
type 1 = foetal vessels are exposed as a velamentous umbilical cord
type 2 = foetal vessels are exposed as the travel to an accessory placental lobe
What are the risk factors for vasa praevia?
low lying placenta
IVF pregnancy
multiple pregnancy
How can vasa praevia be diagnosed?
US during pregnancy
antepartum haemorrhage
vaginal examination during labour - pulsating foetal vessels are seen in the membranes through the dilated cervix
foetal distress and dark-red bleeding following rupture of the membranes
What is the management of vasa praevia?
corticosteroids from 32 weeks to mature the foetal lungs
elective C section planned for 34-36 weeks gestation
What are the risk factors for placental abruption?
previous placental abruption
pre-eclampsia
bleeding early in pregnancy
trauma (consider domestic violence)
multiple pregnancy
foetal growth restriction
multigravida
increased maternal age
smoking
cocaine or amphetamine use
What is the presentation of placental abruption?
sudden onset severe abdominal pain in third trimester
vaginal bleeding (antepartum haemorrhage)
shock (hypotension and tachycardia)
CTG abnormalities indicating foetal distress
woody abdomen on palpation
What are the causes of antepartum haemorrhage?
placenta praevia
placental abruption
vasa praevia
How is the severity of an antepartum haemorrhage defined?
spotting = spots of blood noticed on underwear
minor haemorrhage = <50ml blood loss
major haemorrhage = 50-1000ml blood loss
massive haemorrhage = >1000ml blood loss or signs of shock
What is a concealed placental abruption?
cervical os remains closed so blood remains within the uterine cavity
What are the risk factors for placenta accreta?
previous placenta accreta
previous endometrial curettage procedures (e.g. for miscarriage or abortion)
previous C section
multigravida
increased maternal age
low-lying placenta or placenta praevia
What are the management options for placenta praevi during a C section?
hysterectomy (recommended)
uterus preserving surgery
expectant management (leaving the placenta in place to be reabsorbed over time)
What is a complete breech presentation?
legs are fully flexed at the hips and knees
What is an incomplete breech presentation?
one leg flexed at the hip and extended at the knee
What is an extended/frank breech presentation?
both legs flexed at the hip and extended at the knee
What is a footling breech presentation?
foot presenting through the cervix with the leg extended
What is the management of breech presentation?
<36 weeks = no intervention as they often turn spontaneously
37 weeks = external cephalic version
choice of elective C section or vaginal delivery with access to emergency theatre
What is used to relax the uterus for ECV?
subcutaneous terbutaline (beta-agonist)
What is a stillbirth?
birth of a dead foetus after 24 weeks gestation
What are the causes of stillbirth?
unexplained (50%)
pre-eclampsia
placental abruption
vasa praevia
cord prolapse or wrapped around the foetal neck
obstetric cholestasis
diabetes
thyroid disease
infections - e.g. rubella, parvovirus, listeria
genetic or congenital abnormalities
What factors increase the risk of stillbirth?
foetal growth restriction
smoking
alcohol
increased maternal age
maternal obesity
twins
sleeping on the back
What are the key symptoms of an intrauterine foetal death?
reduced foetal movements
abdominal pain
vaginal bleeding
How is an intrauterine foetal death diagnosed?
US to visual foetal heartbeat
What is the management of intra-uterine foetal death?
1st line = vaginal birth - induction or expectant management
dopamine agonists (e.g. cabergoline) to suppress lactation
testing to determine cause
What are the three major causes of cardiac arrest in pregnancy?
obstetric haemorrhage
PE
sepsis
What are the causes of a massive obstetric haemorrhage?
ectopic pregnancy
placental abruption (may be concealed)
placenta praevia
placenta accreta
uterine rupture
Why should a pregnant person be positioned in the left lateral position?
prevent the uterus from compressing the IVC and preventing venous return to the heart (aotrocaval compression)
What factors make resuscitation more complicated in pregnancy?
aortocaval compression
increased oxygen requirements
splinting of the diaphragm by the pregnant abdomen
difficulty with intubation
increased risk of aspiration
ongoing obstetric haemorrhage
What are the key differences with resuscitation in pregnancy?
15 degree tilt to the left side for CPR (relive aortocaval compression)
early supplementary oxygen and intubation
aggressive fluid resuscitation (caution in pre-eclampsia)
delivery of the baby via immediate C section after 4 minutes and within 5 minutes of starting CPR - improves maternal survival
What women should take 5mg of folic acid instead of 400mcg?
either partner has a neural tube defect
previous pregnancy affected by a neural tube defect
FMHx of neural tube defect
woman is taking antiepileptic drugs
woman has coeliac disease, diabetes or thalassaemia trait
woman is obese (BMI >30)
What are the causes of oligohydraminos?
premature rupture of membranes
Potter sequence (bilateral renal agenesis + pulmonary hypoplasia)
intrauterine growth restriction
post-term gestation
pre-eclampsia
What are the causes of increased nuchal translucency on US in pregnancy?
Down’s syndrome
congenital heart defects
abdominal wall defects
What are the causes of hyperechogenic bowel on US in pregnancy?
cystic fibrosis
Down’s syndrome
CMV infection
When should pregnant people receive oral iron?
first trimester = Hb <110
second/third trimester = Hb <105
postpartum = Hb <100
What should be monitored during treatment with magnesium sulphate?
urine output
reflexes
respiratory rate
oxygen saturations
What is the treatment for magnesium sulphate induced respiratory depression?
calcium gluconate
What are the physiological blood pressure changes in a normal pregnancy?
blood pressure falls in the first trimester (particularly the diastolic) and continues to fall until 20-24 weeks
after this time, the blood pressure usually increases to pre-pregnancy levels by term
What are the results of the quadruple test in Down’s syndrome?
low AFP
low unconjugated oestriol
high HCG
high inhibin A
What are the results of the quadruple test in Edward’s syndrome?
low AFP
low unconjugated oestriol
low HCG
normal inhibin A
What are the results of the quadruple test in neural tube defects?
high AFP
normal unconjugated oestriol
normal HCG
normal inhibin A
What is the most common cause of early onset severe infection in the neonatal period?
group B Strep
(20-40% of mothers have GBS in their bowel flora and infants may be exposed to it during labour)
What are the risk factors for neonatal GBS infection?
prematurity
prolonged rupture of membranes
previous sibling GBS infection
maternal pyrexia
When should GBS be tested for?
35-37 weeks or 3-5 weeks prior to anticipated delivery
Who is offered testing for GBS?
women who’ve had GBS detected in a previous pregnancy
What women get intrapartum antibiotic prophylaxis for GBS?
tested positive
previous baby had GBS (and women wasn’t tested this pregnancy)
preterm labour regardless of their GBS status
pyrexia during labour regardless of GBS status
What is used for GBS prophylaxis?
benzylpenicillin
What are the glucose targets for diabetes during pregnancy?
fasting = 5.3 mmol/l
1 hr after meals = 7.8 mmol/l
2 hrs after meals = 6.4 mmol/l
How does the location of appendicitis pain change during pregnancy?
first trimester = RLQ
second = umbilicus
third = RUQ
What are the investigations for reduced foetal movements?
initial = handheld Doppler to confirm foetal heartbeat
if no foetal heartbeat = US
if foetal heartbeat = CTG for at least 20 minutes
What is placenta accreta?
chorionic villi attach to the myometrium, rather than being restricted within the decidua basalis
What is placenta increta?
chorionic villi invade into the myometrium
What is placenta percreta?
chorionic villi invade through the perimetrium
What is the management of migraine during pregnancy?
1st line = paracetamol
2nd line = NSAIDs in the first and second trimester
Why is gestational thrombocytopenia relatively common?
combination of dilution, decreased production and increased destruction of platelets
What are the differentials for bleeding in the first trimester?
spontaneous abortion
ectopic pregnancy
hydatidiform mole
non-pregnancy causes - e.g. STIs, cervical polyps
What are the differentials for bleeding in the second trimester?
spontaneous abortion
hydatidiform mole
placental abruption
non-pregnancy causes - e.g. STIs, cervical polyps
What are the differentials for bleeding in the third trimester?
bloody show
placental abruption
placenta praevia
vasa praevia
non-pregnancy causes - e.g. STIs, cervical polyps
What is gastroschisis?
congenital defect in the anterior abdominal wall just lateral to the umbilical cord
What is the management of gastroschisis?
vaginal delivery may be attempted
newborns should go to theatre asap after delivery
What is exomphalos/omphalocoele?
abdominal contents protrude through the anterior abdominal wall but are covered in an amniotic sac formed by amniotic membrane and peritoneum
What is exomphalos/omphalocoele associated with?
Beckwith-Wiedemann syndrome
Down’s syndrome
cardiac and kidney malformations
What is the management of exomphalos/omphalocoele?
C section to reduce the risk of sac rupture
staged repair
