Antenatal care Flashcards
What should women be informed about the additional risk of miscarriage following amniocentesis or CVS?
It is likely to be below 0.5%
What is the earliest gestation amniocentesis should be performed?
15 weeks gestation
What is the earliest gestation CVS should be performed?
10 weeks gestation
What should women be informed about the additional miscarriage risk for twin pregnancy following amniocentesis or CVS?
The additional risk is around 1%
What gestation is CVS usually performed between?
11+0 and 13+6 weeks gestation
1-2% of all CVS results will be affected by which confounding complication?
Confined placental mosaicism
RCOG recommends those trained in CVS and Amniocentesis should carry out how many of these procedure per year as a minimum to maintain skills?
20
Aside from miscarriage, what other risk is increased if amniocentesis is carried out prior to 15 weeks gestation?
Talipes equinovarus
What risks are increased with CVS before 10 weeks?
Oromandibular and limb defects
What complication is increased when amniocentesis is carried out in the third trimester?
Culture failure
Corticosteroids should be offered to women between which gestations when imminent preterm birth is anticipated?
24+0 - 34+6 weeks
What are the two potential harmful side effects of antenatal corticosteroids for the neonate?
Neonatal hypoglycaemia and developmental delay
What is the number needed to treat to prevent 1 neonatal death by giving antenatal corticosteroids between 22-34+6 weeks gestation?
38.5
How should women with multiple pregnancy be counselled about the use of antenatal corticosteroids?
In line with the guidance for singleton pregnancy, however they should be advised of the uncertainties around their use in multiple pregnancy
What is the median latency of delivery after PPROM ?
7 days
What is the change in blood oxygen saturation during a flight at cruising altitude?
SpO2 reduced by 10%
What does the evidence show about risk of adverse pregnancy events with air travel?
There is no good data to suggest an increase in preterm labour, PPROM or abruption
What advice should be given to women about the maximum gestation to fly at?
36 weeks if no complications
32 weeks if any risk factors for preterm birth
Which conditions are absolute contraindications to air flight?
Anaemia with Hb <75
Recent haemorrhage
Otitis media or sinusitis
Serious cardiac or respiratory disease
Recent sickle cell crisis
Recent GI surgery
A fracture
What advice should be given to pregnant women about antimalarial therapy?
Anti-malarials are safe in pregnancy
Which travel vaccines should be avoided in pregnant women?
Live vaccines such as the Yellow Fever vaccine
What percentage of babies born in the UK weigh more than 4,000g?
10%
What is the Number Needed to Treat to prevent 1 fracture by using IOL in LGA?
60
Antepartum haemorrhage is defined as vaginal bleeding after what gestation?
24 weeks
APH complicates what percentage of all pregnancies?
3-5%
What is the definition of minor APH?
Blood loss less than 50mls which has settled
What is the definition of major APH?
Blood loss of 50-1,000mls with no signs of clinical shock
What is the definition of massive APH?
Blood loss greater than 1,000mls and or signs of clinical shock
What is the incidence of recurrent placental abruption?
4.4%
What is the relative risk of placental abruption for women who have first trimester bleeding with an intrauterine haematoma?
Relative Risk 5.6
What is the recurrence rate of placental abruption in women who have had two previous pregnancies complicated by abruption?
19-25%
Approximately what percentage of placental abruptions happen in “low risk” women?
70%
What should be avoided in placenta praevia?
Vaginal and rectal examinations
Penetrative sexual intercourse
What neonatal outcomes are associated with unexplained APH?
Increased risk of preterm birth
Increased rates of IOL
Increased neonatal admission
Increased rates of neonatal hyperbilirubinaema
Decreased birth weight
What should be considered in cases of APH associated with rupture of membranes?
Vasa praevia
What investigation should be performed for Rhesus negative women presenting with APH?
Kleihauer
What is the sensitivity of ultrasound in identifying placental abruption?
24%
Antenatal corticosteroids are associated with a reduction in the risk of… (3)
- Neonatal death
- Respiratory distress syndrome
- Intraventricular haemorrhage
How should antenatal care be changed in a low risk woman with APH from placental abruption or unexplained cause?
- The pregnancy should be reclassified as high risk
- Serial fetal growth scans should be performed
What action should be considered in active APH after 37 weeks?
IOL should be considered to avoid the risk of placental abruption
What advice should be given about fetal monitoring for women with APH?
Women with one episode of minor APH with no subsequent concerns about maternal or fetal wellbeing could have intermittent auscultation
Women with major or recurrent minor APH and those women with suspected abruption should have CEFM
What postnatal plan should be put in place for women with APH?
Recommend active management of the third stage
How should anti-D be managed in Rh negative women with APH after 20 weeks?
500 units Anti-D should be given followed by Kleihauer - if >4mls leak then further anti-D is indicated
Serum lactate above which threshold is indicative of tissue hypoperfusion?
> =4mmol/l
What are the two most common pathogens identified in pregnant women dying of sepsis?
Group A Strep and E.coli
What are the drawbacks of using Co-Amoxiclav to treat maternal sepsis?
- Does not cover MRSA or Pseudomonas
- May cause necrotising enterocolitis in the neonate
When should haemoglobin be rechecked after initiating treatment for anaemia?
After 2 weeks
When should pregnant women be screened for anaemia?
At booking and at 28 weeks
Women with multiple pregnancy should have an additional FBC at 20-24 weeks
How often should women at high risk of needing blood transfusion (e.g. placenta praevia/accreta) have Group and Screen samples sent?
At least weekly
What dose of Anti-D should be given to Rhesus negative women who receive autologous cell salvage blood?
1,500 units
How often should FFP be transfused during major obstetric haemorrhage?
1 unit FFP should be transfused for every 6 units of Red Blood Cells
When is Cryoprecipitate indicated in major obstetric haemorrhage?
- Give the first dose of 2 5-unit pools early
- Give subsequent Cryoprecipitate to keep Fibrinogen levels above 1.5g/l
What platelet level should trigger platelet infusion in major obstetric haemorrhage?
75 x 10^9
What percentage of direct maternal deaths in the UK is caused by haemorrhage?
10%
Which vitamin are obese women at high risk of being deficient in?
Vitamin D
Above what BMI should women have a review for anaesthetic assessment in pregnancy?
> 40
What is the guidance on assessment for GDM in women with obesity?
All women with BMI >30 should have a GTT
Above what BMI should serial growth scans be offered due to reduced utility of SFH?
> 35
Above what depth of subcutaneous fat should women have the subcutaneous tissue space closed at Caesarean section?
2cm
What are the BMI thresholds for class I, II and III obesity?
Class I 30-34.99
Class II 35-39.99
Class III >40.00
What are pregnant women with obesity at increased risk of during pregnancy? (12 in total)
- Miscarriage
- GDM
- Pre-eclampsia
- VTE
- Induced labour
- dysfunctional or prolonged labour
- Caesarean section
- anaesthetic complications
- PPH
- Wound infections
- mortality
- Delayed initiation of breastfeeding
Weight loss between pregnancies reduces which risks?
Stillbirth
Hypertensive complications
Macrosomia
Which congenital malformation can arise in babies born to mothers who use Topiramate in pregnancy?
Cleft lip and palette
What is the relative risk of pre-eclampsia in overweight, obese and severely obese women?
1.7
2.93
4.14
(Obese women are 3-4 times more likely to get pre-eclampsia)
What did the FaSTER trial demonstrate with relation to maternal obesity?
Lower sensitivity and higher false negative rate when screening for aneuploidy with ultrasound
What percentage of obese primparous women will have a vaginal birth following IOL?
60%
how many antenatal appointments should low risk nulliparous and parous women have respectively?
Nulliparous women should have 10 antenatal appointments
Parous women should have 7 antenatal appointments
What advice should women be given about sleeping position after 28 weeks?
Women should be advised to avoid sleeping on their back after 28 weeks as this may increase the risk of stillbirth
What advice should be given to women regarding caffeine intake in pregnancy?
Caffeine intake should be limited to 200mg per day to reduce risks of low birth weight in the baby
Constipation affects up to what percentage of pregnancies?
38%
What are the ROME III diagnostic criteria for constipation?
- At least 2 of:
a. straining for >25% of defecations
b. Lumpy or hard stools in at least 25% of defecations
c. Sensation of incomplete emptying for at least 25% of defecations
d. Sensation of anorectal obstruction/blockage for at least 25% of defecations
e. Manual maneouvres to facilitate at least 25% of defecations
- Loose stools are rarely present without the use of laxatives
- Insufficient criteria for irritable bowel syndrome
Which promotility hormone is inhibited by increasing levels of progesterone in pregnancy, leading to constipation?
Motilin
What is the role of the RAAS system in constipation?
Increased RAAS results in sodium and water reabsorption from the gut, reducing stool water content
What is the treatment of choice for chronic constipation in pregnancy?
Polythylene glycol (PEG, an osmotic laxative)
*Movicol is a polymer of PEG
Which laxatives should be avoided in the third trimester and why?
Stimulant laxatives should be avoided as they have been shown to cause uterine contractions
Why should Docusate sodium be avoided in pregnancy?
It can cause neonatal hypomagnesaemia
Which medication can be used in moderate to severe constipation associated with IBS-C and works by increasing c-GMP to decrease visceral pain?
Linaclotide
How does ECV affect the outcome of labour?
Women should be informed that following successful ECV, there is a slightly increased rate of instrumental birth or Caesarean section compared to spontaneous cephalic labour
When should ECV be offered?
- Typically from 37 weeks
- ECV can be offered to nulliparous women from 36 weeks
How does 1 previous Caesarean affect risks of ECV?
The risks of ECV following 1 previous Caesarean are not increased compared to the unscarred uterus
What can be given to improve the success rate of ECV?
Use of tocolysis with betamimetics (Terbutaline) improves the success rate of ECV
Breech presentation complicates what proportion of term deliveries?
3-4%
What is the risk of emergency Caesarean within 24 hours of ECV?
0.5%
How does the risk of fetal mortality compare between vaginal breech, elective Caesarean and vaginal cephalic birth
- Vaginal breech - 2/1,000
- Caesarean - 0.5/1,000
- Vaginal cephalic - 1/1,000
What is the rate of emergency Caesarean section in women planning vaginal breech birth?
40%
Which factors increase the risks of vaginal breech birth (5)
- Hyperextended neck on ultrasound
- EFW >3.8Kg
- EFW <10th centile
- Footling presentation
- Evidence of antenatal fetal compromise
Are induction and augmentation appropriate in vaginal breech birth?
- IOL is not recommended for vaginal breech birth
- Augmentation of slow progress should only be considered if contraction frequency is low in the presence of epidural anaesthesia
How should a first twin in breech position be delivered?
Planned Caesarean section is recommended where the leading twin is breech
How should a second twin in breech position be delivered?
Routine Caesarean section for breech presentation of the second twin is not recommended
What advice should be given about the Varicella vaccine and breastfeeding?
It is safe to breastfeed following Varicella vaccination
How should pregnant women without previous exposure to chickenpox be managed following an exposure to chickenpox or shingles?
She should have a blood test to determine VZV immunity
How should a women not immune to VZV be managed if she has had a significant exposure?
She should have PEP with Aciclovir from day 7 to day 14 post exposure
When is VZIG effective following contact with Chickenpox or shingles?
Up to 10 days following exposure
For what timespan should non-immune pregnant women who have been exposed to chickenpox be considered as potentially infectious?
From day 8-28 if they received VZIG or day 8-21 if they do not receive VZIG
How soon after PEP with Aciclovir or VZIG can another course be prescribed if there is repeat exposure?
Aciclovir can be repeated after 7 days
VZIG can be repeated after 3 weeks
What are the maternal risks of Varicella?
Increased risk of pneumonia, hepatitis and encephalitis
What advice should women with chickenpox be given about avoiding susceptible individuals?
Avoid susceptible individuals until the lesions have crusted over (usually around 5 days)
When should Aciclovir be prescribed for women with Chickenpox?
Within 24 hours of the onset of rash and if they are 20 weeks gestation or beyond
What is the advice about VZIG for women with chickenpox?
VZIG has no therapeutic benefit once the rash has developed
What fetal investigation should be offered for a pregnant woman who develops chicken pox and when should this happen?
Refer to fetal medicine for detailed ultrasound at 16-20 weeks or 5 weeks after infection
Amniocentesis has a good negative predictive value for fetal damage secondary to chickenpox and so should be offered
How should pregnant women be managed following a chickenpox infection in the last 4 weeks of pregnancy?
Avoid planned delivery for at least 7 days following the onset of maternal rash
Inform a neonatologist of all babies born to mothers with chickenpox
What are the characteristics of fetal varicella syndrome?
Skin scarring in a dermatomal distribution
eye defects
Hypoplasia of the limbs
Neurological abnormalities
(can happen following maternal infection up to 28 weeks)
What are the high risk factors for pre-eclampsia?
Previous hypertensive disease in pregnancy
Chronic kidney disease
Autoimmune disease such as SLE or antiphospholipid syndrome
Type 1 or Type 2 diabetes
Chronic hypertension
What are the moderate risk factors for pre-eclampsia?
Nulliparity
Age >=40
Pregnancy interval >10 years
BMI 35 or more at booking
FH pre-eclampsia
Multiple pregnancy
What is the diagnostic threshold for pre-eclampsia using albumin-creatinine ratio
8mg/mmol
What is the range of gestational ages for PLGF testing?
20-36+6 weeks
How often should women with chronic hypertension be seen in ANC?
Weekly if hypertension is poorly controlled
Every 2-4 weeks if hypertension is well controlled
How should BP be monitored postnatally in women with chronic hypertension?
Daily for the first 2 days
At least once between days 3 to 5
Review of antihypertensives at 2 weeks
How often should women with gestational hypertension have BP measured?
Once or twice a week until BP is 135/85 or less
How often should women with severe gestational hypertension have their BP meausred?
Every 15 to 30 minutes until BP is <160/110
How often should urine dip be performed for protein in women with gestational hypertension?
Once to twice per week
How often should urine dip be performed for protein in women with severe gestational hypertension?
Daily while admitted
How often should PET bloods be performed in women with gestational hypertension?
Weekly
How often should fetal growth assessment be performed in women with gestational hypertension?
Every 2-4 weeks
How often should blood pressure be monitored for women with pre-eclampsia?
Every 48 hours as outpatient
At least 4 times daily whilst admitted to hospital
How often should women with pre-eclampsia have their bloods tested?
Twice weekly
3 times per week if severe hypertension
How often should women with pre-eclampsia have fetal growth monitored?
Every 2 weeks
What are the sequelae of pre-eclampsia which should prompt delivery prior to 37 weeks?
Poor BP control despite 3 agents
SpO2 <90%
Progressive deterioration in LFT, renal function or platelet count
Ongoing neurological features
Placental abruption
Reversed end-diastolic flow
What is the name for the thin, continuous fibrinoid layer between anchoring villi and uterine decidual cells?
Nitabuch’s membrane
What is the role of Methotrexate in PAS?
There is no role for Methotrexate in PAS in treatment of retained placental tissue as there are no rapidly dividing cells in the third trimester placenta
What are the clinical criteria for diagnosis of FIGO grade 1 placenta accreta?
No separation with synthetic oxytocin or gentle cord traction
Attempts at manual removal result in heavy bleeding from placental site requiring mechanical or surgical procedures
At laparotomy or caesarean, there is no obvious distension over the placental bed, no neo-vascularity and no placental tissue seen invading through placental surface
What are the clinical criteria for FIGO grade 2 PAS?
Abnormal macroscopic findings over the placental bed such as bluish/purple colouring or distension
Significant amounts of hypervascularity
No placental tissue seen invading through the placental surface
Dimple sign: gentle cord traction results in the uterus being pulled inwards without separation of the placenta
What are the clinical criteria for FIGO grade 3a PAS?
Abnormal macroscopic findings on uterine serosal surface and placental tissue seen invading through the surface of the uterus
No invasion into any other organ - a clear surgical plane can be seen between the bladder and the uterus
What are the clinical criteria for FIGO grade 3b PAS?
Placental villi are seen to be invading into the bladder but no other organs
A clear surgical plane cannot be seen between the bladder and the uterus
Which ultrasonographic features of PAS have been seen in 98% of low-risk pregnancies with normal placentas?
Lacunae
Sub-placental hypervascularity
Irregular bladder wall
Which ultrasonographic features of PAS are rarely seen unless there is PAS or UD?
Placental bulge
Bridging vessels
A myometrium <1mm thick
Loss of the retroplacental clear zone
What is the risk of PAS in a woman with placenta praevia and 1 prior Caesarean?
3%
What is the risk of PAS in a woman with placenta praevia and 2 prior Caesareans?
11%
What is the risk of PAS in a woman with placenta praevia and 3 prior Caesareans?
40%
What is the risk of PAS in a woman with placenta praevia and 4 prior Caesareans?
61%
What was the overall maternal death rate in 2020-2022?
13.56 per 100,000
What was the leading direct cause of maternal death in the most recent MBBRACE report?
Venous Thromboembolism
How much higher are the odds of VTE in pregnant women with cancer?
7 times increased
What is the success rate of planned VBAC?
72-75%
What is the success rate of planned VBAC for women with a previous vaginal birth?
85-90%
What are the changes in risk for induction/augmentation of labour in a woman pursuing a VBAC?
Women having IOL with VBAC have:
2-3 fold increase in risk of uterine rupture
1.5 times increased risk of Caesarean delivery
How do risk rates for VBAC differ in a preterm woman?
Similar rates of successful VBAC but lower rate of uterine rupture in preterm
(i.e. prematurity is not a contraindication to VBAC)
What is the risk of repeat uterine rupture for women labouring following previous uterine rupture?
5%
What percentage of women who plan elective repeat Caesarean will labour before 39 weeks?
10%
What thresholds should be used for diagnosis of anaemia in the first, second/third, and postpartum periods?
110 first trimester
105 second/third trimester
100 postpartum
Group and screen samples used for transfusion in pregnancy should be no more than how old?
72 hours
Cell salvage should be used when blood loss is expected to be above what % of circulating volume?
20%
What is the lifetime risk of breast cancer in the UK?
1 in 9
What percentage of breast cancer cases are diagnosed prior to age 45?
15%
What is the 5 year survival of breast cancer in women aged under 50?
80%
How does diagnosis of breast cancer differ in pregnant women?
They should have biopsy for histology, not cytology in pregnancy
What investigations are used for staging of breast cancer in pregnancy if necessary?
Chest xray
Liver ultrasound
Which chemotherapeutic agents used in breast cancer are safe in pregnancy?
Anthracyclines (Doxorubicin or Epirubicin)
When should chemotherapy for breast cancer be used?
From second trimester onwards
What advice should be given about use of Tamoxifen and Herceptin (Trastuzumab) for breast cancer in pregnancy?
They should not be used in pregnancy
Birth should be aimed at least how long after administration of chemotherapy?
2-3 weeks
What advice should be given about breastfeeding following Tamoxifen or Herceptin use?
Women taking Tamoxifen or Herceptin should not breastfeed
How long prior to conceiving should women stop Tamoxifen?
At least 3 months
Women with PPROM either in established labour or expected to have preterm birth within 24 hours should be offered MgSO4 up to what gestation?
29+6 weeks
PPROM complicates roughly what percentage of pregnancies?
3%
PPROM is associated with roughly what percentage of preterm births? (range)
30-40%
What is the median latency from PPROM to birth?
7 days
What typically happens to WCC following administration of antenatal corticosteroids?
WCC rises 24 hours after steroids and typically returns to normal after 3 days
What is the alternative antibiotic of choice in PPROM for a woman who cannot have Erythromycin?
Penicillin
What is the relative risk of chorioamnionitis when antibiotics are given in PPROM compared to no antibiotics?
RR 0.66
(i.e. a third reduction in rates of chorioamnionitis)
What is the effect of antibiotics on the latent period following PPROM
29% reduction in labour within 48 hours
21% reduction in labour within 1 week
What is the effect of corticosteroids on Respiratory Distress Syndrome following PPROM?
Antenatal corticosteroids reduce the rate of RDS following PPROM by 19%
What is the effect of corticosteroids on Intraventricular haemorrhage following PPROM?
Antenatal corticosteroids reduce the rate of intraventricular haemorrhage by 51%
When should MgSO4 be given in the context of PPROM?
Magnesium sulfate should be offered to women in established preterm labour or when birth is expected withing 24 hours between 24 and 29+6 weeks gestation
Why is tocolysis not recommended in PPROM?
It increases the risk of chorioamnionitis without improving neonatal outcomes
Hospital based care following PPROM should be offered to women with all three of which factors?
PPROM <26 weeks gestation
Non-cephalic presentation
Oligohydramnios
What percentage of women who have PPROM will go on to have PTSD postnatally?
17%
At what gestation should women having PPROM after 24 weeks be planned to birth in the absence of GBS?
37 weeks
What is the odds ratio of recurrent PPROM?
8.7
i.e. women with PPROM are 8 times more likely to have PPROM again in subsequent a pregnancy
Weight loss between pregnancies reduces the risks of which complications?
Stillbirth
Hypertensive complications
Fetal macrosomia
Which medication should obese women (BMI >30) be advised to take in early pregnancy?
Folic acid 5mg til 12 weeks
What additional screening do women with BMI >30 require?
OGTT
BMI > what threshold is a moderate risk factor for pre-eclampsia?
35
Women with BMI over what should have serial growth scans?
35
Women with >= what depth of subcutaneous fat should have suturing of the subcutaneous tissue space?
2cm
How long should women be advised to wait after bariatric surgery before trying to conceive?
12-18 months
What percentage of the antenatal population are obese?
21%
How much more likely are women with obesity to develop gestational diabetes?
Women with obesity are 3 times more likely to develop gestational diabetes
How much more likely are women with obesity to have a pulmonary embolism than healthy weight women?
Women with obesity are 15 times more likely to have a pulmonary embolism
What percentage of obese women will have a successful VBAC?
54.6%
At what gestation should a history-indicated cervical cerclage be placed? (answer is a range)
11-14 weeks gestation
What are the indications for history-indicated cerclage?
Women with singleton pregnancy with a history of 3 or more previous preterm births/second trimester losses
What is the role of cervical cerclage in women with incidentally-identified cervical shortening?
Women should not be offered cervical cerclage for incidental cervical shortening in the absence of other risk factors for preterm birth
When is cervical cerclage indicated in the context of ultrasound-identified cervical shortening?
When there is a history of one or more previous preterm births/second trimester losses
What percentage of women with a history of previous preterm birth or second trimester pregnancy loss will reach 34 weeks gestation if they maintain a cervical length >25mm til 24 weeks gestation?
90%
Which are the high risk factors for preterm birth?
Previous preterm birth or second trimester loss beyond 16 weeks
Previous PPROM <34 weeks
Previous use of cerclage
Known uterine variant
Intrauterine adhesions
History of trachelectomy
How should women at high risk for preterm birth be monitored?
Review by preterm birth specialist by 12 weeks
Cervical length scanning every 2-4 weeks from 16-24 weeks gestation
What are the intermediate risk factors for preterm birth?
Previous Caesarean section at full dilatation
LLETZ >1cm depth
more than one LLETZ
cone biopsy
How should women at intermediate risk for preterm birth be monitored?
Offer single cervical length scan between 18-22 weeks gestation
What is the median delay in preterm birth in women who have rescue cervical cerclage performed?
34 days
What are the contraindications to insertion of cervical cerclage?
Active preterm labour
Clinical evidence of chorioamnionitis
Continuing vaginal bleeding
PPROM
Evidence of fetal compromise
Lethal fetal defect
Fetal death
What advice should be given on bed rest and abstinence from sexual intercourse for women who have had cervical cerclage?
Bed rest and abstinence from sexual intercourse should not be routinely recommended for women with cervical cerclage
When should cervical cerclage be electively removed?
Between 36+1 and 37+0 weeks gestation
How is labour managed for women with abdominally-sited cervical cerclage?
All women with abdominal cervical cerclage require Caesarean section
Which legal framework covers the law surrounding FGM in England?
The Female Genital Mutilation Act 2003
FGM must be reported to the police within what timeframe of its being identified?
1 month
What is the role of clitoral reconstruction surgery in the context of FGM?
It should not be performed as there is high complication rate with inadequate results
What additional antenatal screening assessment should be offered to women with FGM?
Hepatitis C serology
Partial or total removal of the clitoris or prepuce constitutes which type of FGM?
type 1
Partial or total removal of the clitoris and the labia minora, with or without removal of the labia majora constitutes which type of FGM?
Type 2
Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or labia majora with or without excision of the clitoris constitutes which type of FGM?
Type 3
How many women and girls in England and Wales are thought to have had FGM?
137.000
Which infections are more common in women who have had FGM? (2 of them)
Bacterial vaginosis
HSV2
How should FGM be recorded?
FGM should be recorded in the HSCIC database in a non-anonymised fashion
The type of FGM should be recorded
Genital piercings must be included
What percentage of neonatal HSV infections occur at the time of birth?
85%
What percentage of neonatal HSV infections occur in utero
5%
What is the mortality of neonatal HSV with CNS involvement, when antivirals are given?
15%
What percentage of neonatal HSV infections will present with disseminated disease?
33%
What is the mortality of disseminated neonatal HSV infection, when antivirals are given?
66%
What is the overall mortality of neonatal HSV infection?
24%
When is the most high risk time for neonatal HSV infection?
When there is primary infection in the third trimester within 6 weeks of delivery
When should antiviral prophylaxis be started for most mothers with genital herpes?
32 weeks
When should antiviral prophylaxis be started for mothers with genital herpes with risk factors for preterm birth?
22 weeks
What is the workup of a pregnant woman presenting with suspected disseminated HSV infection?
Send samples for urgent HSV PCR and HSV IgG
Commence high dose IV Valaciclovir 10mg/Kg TDS
Inform neonatal team
What treatment should be given for uncomplicated primary genital herpes simplex infection in pregnancy?
Aciclovir 400mg TDS 5 days
or
Valaciclovir 500mg BD 5 days
How should mode of birth be decided in women with primary HSV infection in pregnancy before the 3rd trimester?
Vaginal birth can be considered if infection occurs at least 6 weeks prior to birth
How should mode of birth be decided in women with primary HSV infection in pregnancy in the 3rd trimester?
They should be counselled to have Caesarean section
What is the chance of neonatal herpes infection in a baby born to a mother with recurrent herpes lesions at the time of vaginal birth?
0-3%
How should episodes of recurrent genital herpes presenting in pregnancy be managed?
Supportive management with analgesia and topical lidocaine is appropriate for most
What is the risk of perinatal mortality with planned breech vaginal birth?
2/1,000
What is the risk of perinatal mortality with planned cephalic birth?
1/1,000
What is the risk of perinatal mortality with planned Caesarean birth after 39 weeks?
0.5/1,000
What percentage of women planning a vaginal breech birth will need emergency Caesarean?
40%
What are the contraindications to planning a breech vaginal birth?
- Hyperextended neck on ultrasound
- EFW >3.8Kg
- SGA or FGR
- Footling presentation
- Evidence of antenatal compromise
When is induction or augmentation appropriate in the context of vaginal breech birth?
- IOL should be avoided with breech presentation
- Augmentation with Oxytocin should only be considered with lack of contractions in the context of an epidural
How should mode of birth be managed with preterm breech presentation?
Routine Caesarean section for breech presentation in preterm labour should not be recommended
How should mode of birth with breech presentation of the first twin be managed?
Planned Caesarean section is recommended for twin pregnancy where the leading twin is breech
What percentage of pregnancies involve breech presentation at term?
3-4%
Breech presentation at term is not diagnosed til labour in what percentage of cases?
25%
What time frames should be used to identify delay in the active second stage with breech presentation?
> 5 minute from buttocks to head
3 minutes from umbilicus to head
Head entrapment with delivery of the fetal trunk through an incompletely dilated cervix occurs in what percentage of preterm breech deliveries?
14%
What percentage of twin labours involve non-cephalic presentation of the second twin?
40%
Identification of chorionicity on ultrasound is best performed at what gestation?
Prior to 14 weeks
What is the ultrasound screening regime for monochorionic twin pregnancies?
- Ultrasound every 2 weeks from 16 weeks gestation
- MCA dopplers at every scan from 20 weeks
What difference in fetal liquor volumes by DVP should be concerning for TTTS?
> 4cm differential in the second or thrid trimester
What EFW discordance in monochorionic twin pregnancy should be concerning?
> =20%
What system should be used to stage TTTS?
The Quintero system
A unit acting as a tertiary referral centre for fetoscopic laser ablation should perform a minimum of how many procedures per year?
15
When should birth occur for monochorionic twin pregnancies with treated TTTS?
36 weeks
What is the risk of death to the surviving twin following IUD of the other in monochorionic pregnancy?
15%
What is the risk of neurological abnormality to the surviving twin following IUD of the other in monochorionic pregnancy/
26%
At what gestation should birth of MCMA twins be planned?
32-34 weeks gestation
