Antenatal care and early pregnancy Flashcards

1
Q

What is the definition of small for gestational age and of fetal small for gestational age?

A

SGA: infant with birth weight <10th centile for gestational age (severe= <3rd centile)
Fetal SGA: estimated fetal weight or abdominal circumference <10th centile (again, severe= <3rd centile)

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2
Q

What is the definition of fetal growth restriction?

A

Then a pathological process has restricted genetic growth potential. This can present with features of fetal compromise including reduced liquor volume (LV) or abnormal doppler studies. Likelyhood of FGR is higher in sevre SGA fetus.

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3
Q

What does ‘constitutionally small’ mean?

A
  • small size at all stages but growth following centiles
  • no pathology is present
  • contributing factors are ethnicity, sex and parental height
  • accounts for 50-70% of SGA fetus
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4
Q

How do placenta mediated growth restrictions tend to present and what can cause them?

A
  • initially the growth is normal but growth slows in utero
  • low pre pregnancy weight, substance abuse, autoimmune disease, renal disease, diabetes and chronic hypertension can cause
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5
Q

What can cause a non placenta mediated growth restriction?

A

fetal factors such as chromosomal or structural anomaly, an error in metabolism or fetal infection (usually CMV)

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6
Q

Give 5 risk factors for SGA?

A
  • maternal age >40
  • smoker >11 a day
  • previous SGA baby
  • maternal/ parental SGA
  • previous still birth
  • cocaine use
  • daily vigorous exercise
  • maternal disease eg chronic htn, renal impairment, diabetes, vascular disease
  • low maternal BMI
  • heavy bleeding
  • pregnancy interval <6 months or >60 months
  • low pregnancy associated plasma protein (a hormone produced by the placenta)
  • if 3 minor RFs or 1 major RF present refer tor uterine artery doppler
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7
Q

What investigations may be appropriate for fetus with small gestational age?

A
  • detailed fetal anatomical survey
  • uterine artery doppler
  • karyotyping
  • screening for infections such as congential cytomegalovirus, toxoplasmosis, syphilis, malaria
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8
Q

How should fetal SGA be managed?

A
  • modify RFs to help prevent SGA
  • uterine doppler ultrasound should be primary surviellance tool, if normal repeat every 14 days, if abnormal repeat more frequently or consider delivery
  • if delivery is <37 weeks due to absent/ reverse end diastolic flow on doppler then give single course of antenatal do steroids and c section
  • if UAD normal then can offer normal induction at 37 weeks
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9
Q

State 4 complications of SGA?

A
  • neonatal complications: stillbirth, birth asphyxia, meconium aspiration, hypothermia, polycythaemia, retinopathy or prematurity, pulmonary haemorrhage, NEC
  • long term: cerebral palsy, T2DM, lbesity, HTN, behaviour problems, precocious puberty, depression, alzheimers, cancer (breast, lung, colon, ovarian, blood)
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10
Q

What is large for gestational age?

A

weight, length or head circumferance in >90th percentile for gestational age
- high birth weight is >4000g (macrosomia)

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11
Q

What is the definition of low, very low and extremely low birth weight?

A

LBW: <2500g
VLBW: <1500g
ELBW: <1000g

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12
Q

When does symmetrical IUGR present and what causes it?

A
  • 20-30% of IUGR
  • Early onset, <32weeks gestation
  • causes by things affecting all stages of growth eg genetic disorders and TORCH infections
  • While constitutionally SGA fetuses are symmetrically small in their size, they growth hasnt been restricted per se so do not come under IUGR
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13
Q

When does asymmetrical IUGR present and what causes it?

A
  • 70-80% IUGR
  • later onset >32 weeks
  • chronic hypoxia eg due to placental insufficiency, smoking etc
  • malnutrition
  • HTN
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14
Q

What risks are involved with LGA foetus’?

A
  • shoulder dystocia
  • hypoglycaemia
  • metatarsus adductus
  • hip subluxation
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15
Q

What can cause LGA?

A
  • poorly controlled gestational diabetes
  • genetics: large parent= large baby
  • increased maternal age
  • obesity
  • genetic disorders- beckwith weideman
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16
Q

How may LGA be managed?

A
  • due to increased risk shoulder dytocia, induction of labour usually offered when EFW 4kg
  • better to avoid situation so manage RFs
  • c section of LGA + maternal diabetes
  • can manage as normal pregnancy unless polyhydramnios
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17
Q

What is RBC isoimmunisation?

A
  • production of antibodies in the mum in response to isoantigen on the foetuses erythrocyte
  • Commonest example is when a rhesus -ve mum has a rhesus +ve baby
  • it occurs when the fetal cells enter the maternal circulation via a sensitiseing event eg antepartum haemorrhage, abdo trauma or during delivery.
  • there is rarely any problems during the primary exposure
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18
Q

What disease may occur due to RBC isoimmunisation?

A

haemolytic disease of the newborn (mum gives baby her antibodies to its own RBCs)

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19
Q

When are anti D immunoglobulins indicated? (9)

A

In rhesus D negative women, anti D immunoglobulins should be considered following any sensitising event:
- invasive obstetric testing (eg amniocentesis of Chorionic villus sampling)
- antepartum haemorrhage
- ectopic pregnancy
- external cephalic version
- fall or abdo trauma
- intauterine deaht
- miscarriage
- termination of pregnancy
- delivery (normal, instrumental or c section)
The immunoglobulins prevent isoimmunisation during sensitising events.

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20
Q

How should sensitising events at <12 weeks (ectopic pregnancy, molar pregnancy, termination or heavy uterine bleeding) and 12-20 weeks gestation (any sensitising event) be managed?

A
  • maternal blood group and anti body screen (to confirm RhD- and no anti D antibodies already present)
  • 250 IU anti D within 72 hrs of event
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21
Q

What is a feto- maternal harmorrhage test?

A

also known as the Kleihauer test, this assesses how much fetal blood has entered the maternal circulation. If there has been a sensitising event after 20 weeks gestation, this test is used to determine how much anti-D immunoglobulin should be administered

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22
Q

How should sensitising events at >20 weeks gestation be managed? (inc after delivery)

A
  • maternal blood group and antibody screen
  • if after delivery also do rhesus status of baby
  • feto- maternal haemorrhage test (if after delivery, this test is only done if baby rh+ve and mum rh-ve)
  • 500 IU within 72 hrs of event, dose can be increased depening on size of FMH
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23
Q

Describe the RBC isoimmunisation screening and prophylaxis programme in the uk

A
  • all pregnancy woman have maternal blood group (ABO and RhD typing) at booking visit (8- 12 weeks gestation) and again at 28 weeks
  • any women found to be RhD- should be offered routine antenatal anti- D prophylaxis (500IU) at 28 and 34 weeks, some centres give a larger dose at 34 weeks.
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24
Q

Define prematurity

A

any baby born before 37 weeks from the first day of the last menstrual period.
Very prem: 28-32 weeks, extreme prem: <28weeks

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25
Q

What are the main probelms prem babies face immediatly?

A
  • hypothermia (little subcut fat, less able to shiver, high SA:BW)
  • hypoglycaemia, esp if SGA and hypocalcaemia
  • respiratory distress
  • neonatal jaundice
  • infection and NEC risk increases
  • intraventricular brain haemorrhage risk higher
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26
Q

What may cause premature birth?

A
  • infections
  • cervical incompetence (through past cervical surgery, or childbirth etc)
  • multiple pregnancies
  • pre eclampsia (planned)
  • kidney disease (planned)
  • growth restriction (planned)
  • bleeding after 24 weeks is a RF
  • Water breaking too early- unknown why, may be due to smoking, weak cervix, infection, vaginal bleeding
  • antiphospholipid antibody syndrmoe
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27
Q

How can high risk of prem birth be managed?

A
  • increased monitoring with transvaginal USS for cervical shortening or funnelling every 2 weeks from 14-28 weeks
  • progesterone pessary/ injections if previous Prem birth or cervix length <25mm
  • cervical stitch (cerclage stitch) or vaginal stitch if history of preterm birth AND cervic length of <25mm
  • fetal fibronectin test- predicts chance of going into labour within next couple of weeks
  • steroid injection and and magnesium sulphate before delivery
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28
Q

What is prolonged pregnancy?

A

pregnancies which persist longer than 42 weeks gestation

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29
Q

What RFs are associated with prolonged pregnancy?

A
  • nulliparity (never having completed a pregnancy beyond 20 weeks)
  • maternal age >40
  • previous prolonged pregnancy
  • high BMI
  • FHx prolonged pregnancy
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30
Q

What complications are associated with prolonged pregnancy?

A
  • exponential increase in the risk of still birth
  • increased potential for placental insufficiency causing fetal acidaemia and meconium aspiration in labour
  • increased risk of need for c section
  • neonatal hypoglyacemia due to reduced oxygen and nutrient transfer from placental degradation, depleting glycogen stores
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31
Q

When should a fetus be dated?

A

between 11 and 13+6 weeks gestation, as they rarely show signs of being constitutionally large or small until later stage of gestation

32
Q

how should prolonged pregnancy be managed?

A
  • membrane sweeps offered from 40 weeks in nulliparous and 41 weeks in parous women
  • induction of labour offered between 41 and 42 weeks gestation
  • women who decline induction are offered twice weekly CTG monitoring with USS and amniotic fluid measurement in an attempt to identify fetal distress or other serious complication to mother or child and emergency c section may be needed
33
Q

Define miscarriage?

A

loss of pregnancy at less than 24 weeks gestation. Early miscarriages are in the first trimester (12-13 weeks) and are more common than late (13-24 weeks). They are relatively common and occur in 20-25% of pregnancies.

34
Q

Give 5 RFs for miscarriage?

A
  • maternal age >35 (largely due to increase in chromosomal abnormalities)
  • previous miscarriage
  • obesity, smoking, alcohol, caffeine
  • chromosomal abnormalities (maternal or paternal)
  • uterine abnormalities (eg septate, adhesions or fibroids)
  • previous uterine surgery
  • antiphospholipid syndrome
  • coaguloathies
  • STIs
  • endocrine dysfunction: PCOS, diabetes, thryoid
35
Q

Describe the clinical features of miscarriage

A
  • main presenting symptom is vaginal bleeding- may be passing clots or products of conception
  • a significant number are found incidentally on USS
  • if excessive bleeding may lead to haemodynamic instability- dizziness, pallor, SOB
  • suprapubic cramping pain often common
  • distended abdomen and localised areas of tenderness
36
Q

give 3 differentials for miscarriage

A
  • ectopic pregnancy
  • hydatidiform mole
  • cervical/ uterine malignancy
  • implant bleed
  • cervical ectropian
37
Q

How should suspected miscarriage (

+ve urine pregnancy test + vaginal bleeding +/- pain) be investigated?

A
  • sent to early pregnancy assessment unit
  • transvaginal USS to detect fetal cardiac activity if 5/6 weeks
  • if Crown- rump length <7mm and no heart sound detected, conclusive diagnosis cannot be made and repeat scan in at least 7 days is required
  • if fetal pole not visible, mean sac diameter can be used- if >25 mm diagnosis of failed pregnancy can be made, if <25mm, repeat needed in 10-14 days
  • serum b- HCG can be used if USS not immediately available, serial bHCG measurements are useful in assessing possibility of ectopic pregnancy
  • FBC, blood group, triple swabs and CRP as also indicated in bleeding women
38
Q

How are miscarriages managed?

A
  • anti D prophylaxis if rhD-ve and >12 weeks or require surgical intervention.
  • Conservative approach is to let products of conception to pass naturally, can remain at home but timing unpredictable and heavy bleeding and pain can occur, f/u pregnancy test in 3 weeks
  • medical option is to give vaginal misprostol (prostaglandin analogue) to stimulate cervical ripening and myometrial contractions, f/u pregnancy test in 3 weeks
  • surgical options involve manual vacuum aspiration with local anaesthetic or evacuation of retained products of conception under general, these generally used if haemodynamically unstable or infection
39
Q

What is a ‘threated pregnancy’ and how are they managed?

A
  • mild bleeding +/- pain, cervix closed and viable on transvaginal USS
  • admit if heavy bleeding, if not reassure and send back to GP/ midwife
  • if >12 weeks and rhD-ve, give anti D
40
Q

What are ‘inevitable’ miscarriages?

A
  • heavy bleeding
  • clots
  • pain
  • open cervix
  • internal os open
  • fetus may be viable or non viable
  • offer conservative/ medical/ surgical management
41
Q

What are incomplete and complete miscarrigaes?

A
  • incomplete: retained POC with A/P diametr >15mm and proof there was an intrauterine pregnancy
  • complete: No POC on uss, endometrium that is <15mm diameter and proof there was a previous intrauterine pregnancy
42
Q

What is a septic miscarriage?

A
  • infected POC: fever, rigors, uterine tenderness, bleeding/ discharge
  • leucocytosis
  • raised CRP
  • features of complete/ incomplete miscarriage
43
Q

What is a missed miscarriage?

A

the fetus is dead but retained. Also described as early fetal demise, empty sac or blighted ovum.The uterus is small for dates. A pregnancy test can remain positive for several days or even weeks in some cases. It presents with a history of threatened miscarriage and persistent, dark-brown discharge. Early pregnancy symptoms may have decreased or gone

44
Q

What do increasing and decreasing bHCG tests suggest? (tests should be done 48hrs apart)

A

> 63% increase after 48 hrs suggests ongoing pregnancy

>50% decrease suggests pregnancy unlikley to continue

45
Q

How should pt who is less than 6 weeks pregnant and bleeding but not in pain be managed?

A
  • expectant/ conservative management
  • advise her to repeat the pregnancy test after 7-10 days
  • if -ve then the pregnancy has miscarried
  • if +ve refer to EPAU or out of hrs gynae
46
Q

When should woman with recurrent miscarriages be refer for investigations?

A
  • 3 or more consecutive miscarriages before 10 weeks gestation
  • one of more morphological normal fetus loss after 10 weeks gestation
47
Q

How may recurrent miscarriages be investigated?

A
  • antiphospholipid antibodies
  • genetic abnormalities in both partners
  • fetal genetic abnormalities if fetal tissue available
  • pelvic USS for uterine abnormalities and PCOS
  • blood tests, HbA1c and clotting/ thrombophilia screen
  • STI tests (rare cause)
48
Q

How may miscarriage rates be reduced in those with thrombophilias and antiphospholipid syndrome?

A

thrombophilias: heparin therapy during pregnancy
antiphospholipid: low dose aspirin plus heparin

49
Q

What is the most common site for an ectopic pregnancy?

A
  • the ampulla and the isthmus of the fallopian tubes

- less commonly it may be in the ovaries, cervix or peritoneal cavity

50
Q

State 5 RFs for ectopic pregnancy

A
  • previous ectopic
  • PID (due to the adhesions)
  • endometriosis (again, adhesions)
  • getting pregnant while on contraception (IUD/IUS, progesterone oral or inplant (due to fallopian tube dysmotility) or tubal ligation)
  • pelvic surgery- esp tubal surgery/ reversal of sterilisation
  • assisted reproduction eg IVF
51
Q

Describe the clinical features of an ectopic pregnancy

A
  • PAIN- lower abdo/ pelvic
  • with or without vaginal bleeding- this is due to uterine breakdown due to suboptimal bHCG, bleeding from rupture is intraabdominal
  • hx of amenorrhoea
  • shoulder tip pain- irritation of diaphragm by blood in peritoneal cavity
  • vaginal discharge - brown colour classically akin to prune juice, due to decidua breaking down
  • abdo tenderness, cervical motion tenderness
  • if ruputre: haemodynamically unstable with signs of peritonitis, vag exam= fullness in pouch of douglas
52
Q

How should a suspected ectopic pregnancy be investigated?

A
  • pregnancy test (urine bHCG) is initial investigation
  • if +ve then pelvic USS
  • can try transvaginal USS if no intrauterine pregnancy seen on transabdo
  • if cant see one on USS but bHCG +ve then its a pregnancy of unknown location: very early intrauterine, miscarriage or ectopic
  • if this is the case, do serum bHCG
  • if >1500, this is ectopic until proven otherwise and diagnostic laproscopy should be offered
  • if <1500 and stable, do it again 48 hrs, later, if viable pregnancy it shouldve doubled, if miscarriage the bHCG shouldve halved
  • if not doubled or halved, ectopic cannot be excluded and they need laproscopy
  • also investigate for differentials eg urinalysis for UTI
53
Q

How should an ectopic pregnancy be managed?

A
  • admit all to hospital
  • A-E resus of unstable
  • conservative management (give 24 gynae access) if stable, well controlled pain, size <3cm, bHCG <1500m unruptured and no visible heartbeat.
  • medical (IM methotrexat) if <3.5cm, bHCG <5000, no symptoms/ free fluid monitor serum bHCG to ensure its declining and give 2nd dose if not.
  • Surgical management if severe pain, serum bHCG >1500, adnexal mass >35 mm and/ or fetal heartbeat on USS: laparoscopic salpinectomy if tubal, however if damage to contralateral tube from infection or whatever they can do a salpingotomy to remove the ectopic but you can still have kids- however need to monitor bHCG after if you have this cos change they might not get it all
  • anti D if rhd-ve and surgical
  • very few people can have conservative approach- stable pts with low bHCG which is falling
54
Q

What is gestational trophoblastic disease?

A

A group of pregnancy related tumours. 2 main groups:

  • premalignant conditions eg partial molar pregnancy or complete molar pregnancy
  • malignant conditions eg invasive mole, choriocarcinoma- these are rarer
55
Q

What is a complete and a partial molar pregnancy?

A
  • partial: where a ovum of 23 chromosomes is fertilised by two sperm so its got 69 chromosomes (triploidy)- this may coexist with a viable fetus
  • complete: where an ovum with no chromosomes is fertilised by one sperm which duplicates into two sperm leading to 46 chromosomes of paternal origin
56
Q

how do molar pregnancies tend to present?

A
  • vaginal bleeding and abdo pain in early pregnancy
  • O/E the uterus can be larger than expected for gestation and of a soft boggy consistency
  • later symptoms inc hyperemesis, hyperthroidism and anaemia
57
Q

How should suspected gestational trophoblastic disease be investigated?

A
  • blood bHCG: markedly elevated at diagnosis and used in monitoring
  • USS: complete mole has granular or snowstorm appearance with central heterogenous mass
  • histology of products of conception post treatment
58
Q

how are molar pregnancies and other GTDs managed?

A
  • all need registering with GTD centre for follow up and monitoring
  • molar pregnancies should be removed by suction curettage or medical evacuation if mole is of greater gestation with fetal development
  • all need anti D prophylaxis if rhD-ve
  • chemo may be needed after evac if bHCG doesnt fall
  • chemo +/- surgery is mainstay of treatment for other GTDs
59
Q

What is placental abrpution?

A
  • where part of all of the placenta separates from the wall of the uterus prematurely
  • it is an important cause of antepartum haemorrhage (vag bleeding from week 24 until delivery)
60
Q

Describe the pathophysiology of placental abruption

A
  • rupture in maternal vessels within the basal layer of the endometrium
  • blood accumulates and splits the placental attachment from the basal layer
  • the detached portion cannot function leading to rapid fetal compromise
  • 2 types: revealed (bleeding tracks down from site of separation and drains through the cervix- vag bleed) and concealed (bleeding remains in uterus and typically forms a clot retroplacentally, bleeding can be severe enough to cause systemic shock)
61
Q

give 4 RFs for placental abruption

A
  • previous placental abruption (most important)
  • pre eclampsia and other hypertensive disorders
  • abnormal lie of baby
  • polyhydramnios
  • abdo trauma
  • smoking or other drug use
  • bleeding in first trimester, esp if haematoma is seen inside uterus on first trimester scan
  • underlying thrombophilias
  • multiple pregnancy
62
Q

Describe the clinical features of placental abruption?

A
  • painful (sudden onset and continious) vaginal bleeding (may not have this), after 24 weeks of pregnancy
  • decreased fetal movement and HR
  • bleed is bright red or dark
  • if in labour: pain between contractions
  • o/e: uterus may be woody (tense all the time) and tender on palpation
63
Q

how should antepartum haemorrhage be assessed?

A
  • hx: pain? how much blood and when start? fresh or old brown blood? mixed w/ mucus? could waters have broken? post coital or not? abdo pain? fetal movement? RFs? praevia on scan?
  • O/E: general for signs of shock, tender abdo? uterus feel? contractions? lie of foetus? CTG? USS? cusco speculum exam (avoid until placenta previa ruled out), triple genital swabs to exclude infection if bleeding minimal
64
Q

Other then abruption, what could cause antenatal harmorrhage? (5)

A
  • placenta praevia
  • marginal placental bleed (not enough to cause maternal or fetal compromise
  • vasa praevia (fetal blood vessles run near internal os, characterised by: minor vaginal bleed when ruptures membranes + fetal compromise)
  • uterine rupture: full thickness disruption of uterine muscle and overlying serosa, usually occurs in labour w/ previous c section or uterine surgery
  • local benign causes eg polyps, ectropian, infections
65
Q

how should placental abruption be investigated?

A
  • bloods:fbc, clotting, kleihauer test if RhD-ve, g+s, xmatch, u+e, lft
  • cardiotocograph (CTG) to assess fetal wellbeing
  • USS should not be used to exclude abruption but can be used to confirm it
66
Q

How should placental abruption be managed?

A
  • A-E resus if significant blood loss
  • depends on health of fetus:
  • emergency delivery if maternal or fetal compromise
  • induction of labour: for haemorrhage at term without maternal or fetal compromise
  • conservative management: for partial or marginal abruption not associated with maternal or fetal compromise (dependant on gestation and amount of bleeding
  • give anti D if woman rhD neg
67
Q

what is placenta praevia?

A

where the placenta is fully or partially attached to the lower uterine segment, it is an important cause of antepartum haemorrhage

68
Q

What is the difference between a major and minor placenta praevia and what may cause them to bleed?

A

Minor: placenta low but doesnt cover internal os
Major: placenta lies over internal os
- more susceptible to haemorrhage, possibly due to defective attachment to uterine wall
- bleeding may be spontaneous
- bleeding may be provoked by mild trauma eg a vaginal examination or as the fetus moves into the lower uterine segment in prep for labout

69
Q

Give 3 RFs for placenta praevia

A
  • previous c section is biggest rf
  • high parity
  • maternal age >40
  • multiple pregnancies
  • previous placenta praevia
  • history of uterine infections
  • curettage to endometrium after miscarriage or termination
70
Q

How does placenta praevia present?

A
  • painless vaginal bleeding- varies from spotting to massive haemorrhage
  • there may however be pain if the pt is in labour
  • examination may reveal RFs pertinent to placenta praevia- eg c section scar or multiple pregnancy. the uterus is not tender on palpation
71
Q

How is placenta praevia definitively diagnosed?

A
  • ultrasound scan- short distance between lower edge of placenta and internal os
  • remember todo CTG to assess fetal wellbeing
72
Q

How is placenta praevia managed?

A
  • A- E and resus if unstable
  • usually identified in asymptomatic pt in 20 week scan: minor needs repeat scan at 36 weeks as likely to have moved superiorly, major (or within 4 cm of os) needs scan at 32 weeks and plan for delivery to be made at this time
  • C section is safest mode of delivery and done electively at 37 weeks
73
Q

How is hyperemesis gravidarum managaed?

A
  • rehydration: not with dextrose as can cause wernickers encephalopathy
  • thiamine replacement (iv then oral)
  • K+ replacement if hypokalaemia
  • po antiemetics (antihistamines eg cylizine/ promethazine 1st line then metoclopramide, ondansetron, domperidone 2nd)
  • thromboprophylaxis if v dehydrated
  • steroids if severe
  • NG/ PEG feeding if very severe
  • termination if cant get vomiting under control
74
Q

What characterises hyperemesis gravidarum?

A
  • ketosis
  • severe dehydration
  • marked wieight loss
  • blood derrangements
  • nutritional deficiency
  • complications of the above
75
Q

How many visits should a woman have for a standard 1st and 2nd pregnancy (no complications, low risk)?

A

9 1st preggers, 7 for 2nd

76
Q

What tests are offered for downs if present before and after 14 weeks?

A

The ‘combined test’ (nuchal translucency, beta-human chorionic gonadotrophin, pregnancy associated plasma protein-A) should be offered to screen for Down’s syndrome between 11 and 13 weeks 6 days. For women who book later in pregnancy triple (AFP, hCG, uE3) or quadruple (+ inhibin A) test should be offered between 15 and 20 weeks gestation

77
Q

When should steroid injections and magnesium sulphate be used before birth?

A
  • steroids give if to be born vaginally before 37 weeks or 39 weeks before c section, for 24-48 hrs
  • magnesium sulphate should be given if giving birth before 34 weeks