Antenatal Complications Flashcards
What to do first is presenting complaint of reduced fetal movements?
check for foetal heartbeat with foetal USS doppler, then do SFH and CTG
When to offer IOL in RFM?
OFFER IOL IF RECURRENT RF, AFTER 36+8 WEEKS AS ASX WITH STILLBIRTH
When to discuss IOL in RFM?
Single episode of RFM post 38 weeks
2 main causes of abdominal pain in pregnancy
Threatened preterm labour
Uterine rupture
How does threatened preterm labour present?
Contraction/period-like pain
coming in waves
uterine origin
What to do first if suspecting threatened preterm labour?
Abdo and speculum exam
What would be seen on examination in threatened preterm labour?
Dilated, bulging membrane
Dilated, bulging membrane on examination
Preterm labour
RFs for threatened preterm labour
anything that weaken the uterus
Gow does uterine rupture present?
Contraction/period-like pain
continuous
may feel head free in abdomen
What may be seen on CTG in uterine rupture?
Pathological
RFs for uterine rupture
Precious uterine surgeries
Multiple pregnancy
Previous CS
Age
Obstetric Intervention
Clinical features of uterine rupture
Rapid deterioration during labour (associated with significant haemodynamic instability)
Acute abdominal pain followed by features of shock and intra-abdominal haemorrhage.
Uterine scar tenderness (over suprapubic area)
Abnormal CTG trace or absent fetal heart rate
Cessation of uterine contractions
Vaginal bleeding - This may not always be apparent as bleeding can be concealed
Types of uterine rupture
Incomplete or complete
When to admit in uterine rupture?
scar tenderness
Management of uterine rupture
OBSTETRIC EMERGENCY
Emergency CS
Resuscitation
If unable to control the bleeding, a hysterectomy or internal iliac ligation will be performed
PACES: Counselling of patient for uterine rupture
need for emergency caesarean section , possibility of laparotomy, sterilization after the repair of scar
Complications of uterine rupture
If the patient survives, late sequels are intestinal obstruction, repeat rupture of uterus
Differentials for vaginal leaking during pregnancy
Urine
Liquor
Discharge
What is most common cause of discharge in pregnancy?
Thrusy
What is used to manage thrush in pregnancy?
Only treat if symptomatic –> clotrimazole pessary and cream
Do you use oral thrush management in pregnancy?
No, use clotrimazole pessary and cream
what to check if complaint of dizziness in pregnancy?
Hb,ferritin
What to check if complaints of SOB in pregnancy
Anaemia
Rule out PE/cardiac cause
NB: may be physiological
What is done if suspicious of PE in pregnancy?
CTPA
What to check if complaint of palpitations in pregnancy?
Bloods - Hb, electrolytes, TFTs
What diagnosis to consider if itching in pregnancy? How to manage?
Obstetric cholestasis
Manage with IOL at 39 weeks and ursdeoxycholic acid for Sx
Bleeding in pregnancy <24 weeks
Threatened miscarriage
Bleeding in pregnancy >24 weeks
Antepartum haemorrhage
Causes of antepartum haemorrhage
Placental
Placenta praevia
Placental abruption
Vasa praevia
Local
Cervicitis
Cervical ectropion
Vaginal trauma
Vaginal infection
NB: bleeding can come from any part of genital tract
Most likely cause if painful antenatal bleeding
PLACENTA
MOST IMPORTANT DRUG TO GIVE IF ANTENATAL BLEEDING
ANTI-D IF RHESUS NEGATIVE
What is placenta praevia?
Placenta attaches low in the uterus and covers the cervix
How does placenta praevia present?
painless, bright red bleeding at around 32 weeks
Complications of placental praevia
maternal haemorrhage and foetal IUGR
How to diagnose placenta praevia?
Abdominal exam: soft and non-tender uterus, abnormal foetal position
Transvaginal ultrasound: confirms diagnosis, measures distance between placenta and os
Management of placenta praevia
What is placental abruption?
Placenta separates from the uterus prematurely
RFs for placental abruption
prior abruptions, pre-eclampsia and smoking crack
What can abruption feel like to the woman?
Continous contractions
Types of abruption and what they can result in
Abruption caused by arterial bleeding (majority) results in sudden, severe symptoms like DIC and severe haemorrhage
Abruption caused by venous bleeding is more likely to cause oligohydramnios and IUGR
What type of abruption is more likely to result in sudden, severe symptoms like DIC and severe haemorrhage?
Arterial bleeding (majority)
What are the majority of abruptions due to?
Arterial bleeding
What is an abruption that leads to oligohydramnios and IUGR
likely to be due to?
Venous bleeding
What is a concealed abruption
No blood seen but signs of placental abruption
How to diagnose placental abruption?
Abdominal exam: woody, tender and enlarged uterus
Transvaginal ultrasound: NOT diagnostic, but used to rule out praevia
Abruption is a diagnosis of exclusion –> can be diagnosed on clinical suspicion alone, even if no blood seen,
Painless vaginal bleeding
Praevia
Painful vaginal bleeding
Abruptuion
Woody, tender and enlarged uterus on abdo exam
Abruption
What would be seen on abdo exam of placental abruption?
woody, tender and enlarged uterus
What condition to rule out before diagnosis of abruption?
Transvaginal ultrasound: NOT diagnostic, but used to rule out praevia
Is abruption a diagnosis of exclusion?
Yes, can be diagnosed on clinical suspicion alone, even if no blood seen,
Management of placental abruption
Who to prioritise in placental abruption?
Mum –> if pathological –> transfer to LW/theatre
When is admission needed in placental abruption?
If bleeding seen
What is pre-eclampsia defined as?
New-onset of hypertension with proteinuria after 20 weeks’ gestation.
What is chronic hypertension defined as?
high BP diagnosed <20 weeks
What is gestational hypertension defined as?
new high BP diagnosed >20 weeks WITHOUT PROTEINURIA
NB: If proteinuria too –> pre-eclampsia
Features of pre-eclampsia
headaches, oedema, right UQ pain, visual disturbance, low platelets
What can untreated pre-eclampsia lead to?
eclampsia (seizures)
RFs for pre-eclampsia
Moderate risk factors: 1st pregnancy, multiple pregnancy, family history, age > 40, BMI > 35, > 10 year pregnancy interval
High risk factors: hypertensive disease in previous pregnancy, chronic hypertension, CKD, autoimmune disease, diabetes
NOTE: To reduce risk of pre-eclampsia, give aspirin from 12 weeks onwards if 2 or more moderate RFs present OR 1 or more high RFs present
When is aspirin given to prevent risk of pre-eclampsia?
12 weeks onwards if 2 or more moderate RFs present OR 1 or more high RFs present
NOTE: Moderate risk factors: 1st pregnancy, multiple pregnancy, family history, age > 40, BMI > 35, > 10 year pregnancy interval
High risk factors: hypertensive disease in previous pregnancy, chronic hypertension, CKD, autoimmune disease, diabetes
Hypertensive drugs in pregnancy
Labetalol - alpha and beta blocker, oral or IV
Nifedipine – calcium channel blocker, oral
Methyldopa – alpha 2 agonist, oral or IV
Hydralazine – direct acting smooth muscle relaxant and vasodilator, oral IM or IV
1st line hypertensive in pregnancy
Labetalol
Who is labetalol contraindicated in?
Asthmatics –> give Nifedipine
2nd line hypertensive in pregnancy
Nifedipine
Mnemonic for pre-eclampsia management
Labetalol → Largely Used, Lung disease caution (asthma)
Nifedipine → Narrow airways (asthma) friendly
Magnesium Sulfate → Seizure Prevention and neuroprotection
BP medication if asthmatic
Nifedipine
Pre-eclampsia management
How often to monitor BP in hospital for pre-eclampsia?
4 times a day
Why monitor bbloods in pre-eclampsia?
worsening haematology/biochemistry with features of HELPP syndrome would be an indication for delivery
W
When to offer antenatal steroids?
Offer antenatal steroids if delivery is anticipated before 34 weeks’ gestation
What drug to avoid in pre-eclampsia?
Ergometrine
Indications for urgent delivery in pre-eclampsia
Uncontrollable Blood Pressure
Rapidly Worsening Biochemistry/Haematology (e.g. HELLP syndrome)
Eclampsia
Foetal Distress, Severe IUGR or Reduced Umbilical Artery End-Diastolic Flow
Is eclampsia an obstetric emergency?
Yes, call 2222 and say obstetric emergency
What position to place patient in if eclamptic?
Left lateral
NOTE: GIVE OXYGEN
What is eclampsia?
Onset of seizures or coma in the context of pre-eclampsia.
Management of Eclampsia
Summon senior help immediately
Secure the airway
Early ITU and neonatal team input
Magnesium Sulphate
Loading Dose: 4 g over 5-10 mins
Maintenance Dose: 1 g/hour until 24 hours after delivery
Monitor deep tendon reflexes, respiratory rate and oxygen saturation (to be able to identify magnesium toxicity)
Antidote for magnesium toxicity: 10 mL 10% calcium gluconate (slow IV infusion)
Discuss Delivery
Urgent delivery recommended
Administer steroids if deemed necessary
Strict fluid balance monitoring (at risk of pulmonary oedema)
Treat High Blood Pressure
1st Line: IV Labetalol
2nd Line: PO Nifedipine or Methyldopa
3rd Line: IV Hydralazine
What to do immediately in eclampsia management?
Summon senior help, secure airway
How to give Magnesium Sulphate in eclampsia?
Loading Dose: 4 g over 5-10 mins
Maintenance Dose: 1 g/hour until 24 hours after delivery
What to monitor when giving magnesium sulphate in pregnancy?
Monitor deep tendon reflexes, respiratory rate and oxygen saturation (to be able to identify magnesium toxicity)
Antidote for magnesium sulphate toxicity
Antidote for magnesium toxicity: 10 mL 10% calcium gluconate (slow IV infusion)
When is delivery recommended in eclampsia?
Urgently
What hypertensives should be avoided in pregnancy?
WARNING: ACE Inhibitors and ARBs are associated with an increased risk of congenital malformations
Thiazide diuretics should be avoided as they are associated with an increased risk of neonatal electrolyte abnormalities, jaundice and thrombocytopaenia
What is pre-existing diabetes defined as?
diabetes diagnosed <20 weeks
What is gestation diabetes defined as?
new diabetes diagnosed >20 weeks
How does diabetes present?
Classic diabetes symptoms of polyuria, polydipsia, fatigue etc.
How is diabetes diagnosed?
Diagnosis using either fasting blood glucose or OGTT
Rule of 5,6,7,8: fasting glucose > 5.6 or OGTT > 7.8
What diagnostic test is used for pateints with risk factors?
2-hour 75 g Oral Glucose Tolerance Test (at 24-28 weeks)
Recommended to patients with risk factors
Diagnostic: > 7.8 mmol/L
What diagnostic test is used for pateints without risk factors?
Urine Dipstick
Glycosuria is usually how GDM is diagnosed in patients without risk factors
What effect does pregnancy have on diabetes?
Increased insulin requirements
Increased risk of hypos
Deterioration of existing complications like retinopathy and nephropathy
What effects does pregnancy have on diabets?
Miscarriage and stillbirth
Macrosomia and congenital malformations
Pre-eclampsia, infections
Complicated birth, shoulder dystocia
GDM management
Management of GDM
1st Line (provided fast blood glucose < 7 mmol/L): Changes in diet and exercise
Caveats
If fasting blood glucose is > 7 mmol/L at the time of diagnosis, commence insulin therapy straight away
If fasting blood glucose is 6.0-6.9 mmol/L with complications (e.g. macromsomia) then consider commencing insulin treatment
2nd Line (if targets not met by diet and exercise after 1-2 weeks): Metformin
3rd Line: Add Insulin
When to offer insulin straightaway in GDM?
Fasting glucose > 7 OR 6 – 6.9 with evidence of complications
1st line management in GDM with fasting glucose <7 without complications
Diet and exercise 1–2-week trial
Followed by Metformin and Insulin
What can be offered if metformin can’t be tolerated?
If metformin can’t be tolerated, an alternative is glibenclamide
How many times to check BM’s per day in GDM?
BMs should be checked 7 times per day: fasting, pre-meal, 1-hour post-meal, bedtime
Target GM’s in GDM
Fasting < 5.3
1-hour post-prandial < 7.8
2-hour post-prandial < 6.4
When is USS monitoring offered in GDM
Offer ultrasound monitoring of foetal growth and amniotic fluid volume every 4 weeks from 28-36 weeks
Offer appointments at diabetes clinic every 2 weeks
Maternal complications of GDM
Postpartum haemorrhage
Prolonged labour
Increased rates of assisted or instrumental delivery
Foetal complications of GDM
Stillbirth
Neonatal hypoglycaemia
Macrosomia
Shoulder dystocia
Definition of HELLP syndrome
Acronym for Haemolysis, Elevated Liver enzymes and Low Platelets.
What is HELLP syndrome associated with?
pre-eclampsia
Clinical features of HELLP syndrome
Right upper quadrant pain
Oedema
Blurred vision
Nausea and vomiting
Headache
Bleeding
Seizures (rare)
Investigations for HELLP syndrome
Bedside
Blood Pressure
Urine Dipstick (check for proteinuria)
Bloods
Full blood count (evidence of haemolysis and thrombocytopaenia)
LFT
Coagulation Screen
Management of HELLP syndrome
Best supportive care with fluids and blood products
Treatment involves prompt delivery of the baby
Which pregnant women should be screened for HIV? Why?
All pregnant women should be offered HIV screening
This is because measures can be taken (e.g. commencing antiretrovirals and suppressing viral load) that can decrease the risk of vertical transmission of HIV
How is HIV monitored during pregnancy? How often?
CD4 count should be measured at baseline and at delivery
Viral load should be checked every 2-4 weeks, at 36 weeks and after delivery
When should viral load be monitored in pregnancy for HIV?
Viral load should be checked every 2-4 weeks, at 36 weeks and after delivery
What does the mode of delivery depend on in HIV in pregnancy?
For women with a plasma viral load of <50 HIV RNA copies/mL at 36 weeks, and in the absence of obstetric contraindications, planned vaginal delivery should be supported.
For women with a plasma viral load of 50–399 HIV RNA copies/mL at 36 weeks, pre-labour CS (PLCS) should be considered, taking into account the actual viral load, the trajectory of the viral load, length of time on treatment, adherence issues, obstetric factors and the woman’s views.
Where the viral load is ≥400 HIV RNA copies/mL at 36 weeks, PLCS is recommended.
What is the mode of delivery for women with a plasma viral load of <50 HIV RNA copies/mL at 36 weeks, and in the absence of obstetric contraindications?
planned vaginal delivery should be supported.
What is the mode of delivery for omen with a plasma viral load of 50–399 HIV RNA copies/mL at 36 weeks?
pre-labour CS (PLCS) should be considered
What is the mode of delivery when the viral load is ≥400 HIV RNA copies/mL at 36 weeks?
pre-labour CS (PLCS) is reccomended
How to reduce the risk of vertical transmission in HIV in pregnancy?
Antiretroviral Therapy
Delivery by Elective C-Section (if the mother has a high viral load at the time of delivery)
Planned vaginal delivery is possible if the viral load is < 50 copies/mL at 36 weeks’ gestation
Avoidance of breastfeeding
What intervention can be done to reduce the risk of vertical transmission in HIV in pregnancy if mother has a high viral load at time of delivery?
Delivery by Elective C-Section (if the mother has a high viral load at the time of delivery)
Planned vaginal delivery is possible if the viral load is < 50 copies/mL at 36 weeks’ gestation
Should you breastfeed in HIV in pregnancy?
NO, breastfeeding should be avoided
What should patients with a high or unknown viral load of HIV in pregnancy receive? When should they receive it?
Patients with a high or unknown viral load should receive IV Zidovudine if undergoing a planned C-section or presenting with spontaneous rupture of membranes
Who should receive IV Zidovudine in pregnancy?
Patients with a high or unknown viral load should receive IV Zidovudine if undergoing a planned C-section or presenting with spontaneous rupture of membranes
How are infants managed when mother has HIV in pregnancy?
Clamp cord as soon as possible after birth
Advise women NOT to breastfeed
All infants should receive zidovudine for the first 4-6 weeks after birth
Infants can only be diagnosed with HIV by PCR carried out at birth, upon discharge, at 6 weeks and 12 weeks
What should infants receive postnatally if mother has HIV?
All infants should receive zidovudine for the first 4-6 weeks after birth
How long should IV Zidovudine be given for after birth if mother has HIV?
4-6 weeks
When can infants be diagnosed with HIV?
Infants can only be diagnosed with HIV by PCR carried out at birth, upon discharge, at 6 weeks and 12 weeks
What is used to diagnose infants with HIV?
PCR
What is hyperemesis gravidarum defined as?
Severe nausea and vomiting associated with pregnancy and characterised by dehydration, electrolyte imbalance and more than 5% pre-pregnancy weight loss.
Diagnostic criteria for hyperemesis gravidarum
dehydration, electrolyte imbalance and more than 5% pre-pregnancy weight loss.
What condition can cause hyperemesis gravidarum? Why?
molar pregnancies produce extremely high levels of hCG and, hence, are strongly associated with hyperemesis gravidarum
RFs for hyperemesis gravidarum
Previous hyperemesis gravidarum
Multiple pregnancy
Primiparous
Clinical features of hyperemesis gravidarum
Nause and vomiting
Dehydration
What score is used to calculate severity in hyperemesis gravidarum?
PUQE
Investigations for hyperemesis gravidarum
Bedside
Body Weight
Urine Dipstick (likely to be positive for ketones)
Bloods
U&E (check electrolyte derangement)
Bone Profile
Magnesium
TFTs (high circulating levels of hCG can cause thyrotoxicosis)
Imaging & Other
Ultrasound Scan (can be used to explore possible diagnosis of gestational trophoblastic disease)
What can high circulating levels of HCG cause?
Thyrotoxicosis
Why might you do an US scan in hyperemesis gravidarum?
Ultrasound Scan (can be used to explore possible diagnosis of gestational trophoblastic disease)
Pharmacological management of hyperemesis gravidarum
First-Line: Antihistamines (Cyclizine, Promethazine, Chlorpromazine), Prochlorperazine
Second-Line: Domperidone, Metoclopramide, Ondansetron
Third-Line: IV Hydrocortisone or Oral Prednisolone (if tolerated)
1st line pharmacological management for hyperemesis gravidarum
First-Line: Antihistamines (Cyclizine, Promethazine, Chlorpromazine), Prochlorperazine
Followed by: Second-Line: Domperidone, Metoclopramide, Ondansetron
Third-Line: IV Hydrocortisone or Oral Prednisolone (if tolerated)
2nd line management for hyperemesis gravidarum
Second-Line: Domperidone, Metoclopramide, Ondansetron
Preceded by: First-Line: Antihistamines (Cyclizine, Promethazine, Chlorpromazine), Prochlorperazine
Followed by: Third-Line: IV Hydrocortisone or Oral Prednisolone (if tolerated)
What should be offered to all patients with hyperemesis gravidarum?
IV Fluids (including potassium)
Thiamine Supplementation
Thromboprophylaxis
What are patients with hyperemesis gravidarum at risk of?
VTE
What is Obstetric cholestasis defined as?
Liver disorder associated with pregnancy characterised by non-obstructive cholestasis.
RFs for obstetric cholestasis
Personal or family history of intrahepatic cholestasis of pregnancy
Maternal age
Pre-existing gallstones
Risks of Obstetric cholestasis
Premature Birth
Stillbirth
Clinical features of obstetric cholestasis
Pruritus (often affecting the palms and soles of the feet)
Right upper quadrant discomfort
Jaundice
Excoriation marks
Nausea
Investigations for obstetric cholestasis
Bloods
LFTs
Bile Acids
Clotting Screen
Imaging & Other
Ultrasound Abdomen
Medical management of obstetric cholestasis
Ursodeoxycholic Acid (reduces itching and improves LFTs)
Chlorphenamine (to reduce itching)
Vitamin K Supplementation (if PT is prolonged)
Topical Emollients
How is delivery managed in obstetric cholestasis?
IOL at 38-39 weeks
Why is IOL offered in obstetric cholestasis?
Increased risk of stillburth
What should be monitored during obstetric cholestasis?
Advise monitoring foetal movements
Weekly LFTs
Twice-Weekly Ultrasound Doppler and CTG until delivery
What is large for gestational age defined as?
Infants who weight more than 4 kg at birth or are above the 90th centile on measures of growth during pregnancy.
Another word for LGA
Macrosomia
RFS for LGA
Maternal diabetes (includes gestational diabetes mellitus)
Previous large for gestational age baby
Obesity
Post-term delivery
Complications of LGA
Prolonged labour
Perineal tears
Uterine rupture
Instrumental delivery
Neonatal hypoglycaemia
Shoulder dystocia
Postpartum haemorrhage
Clinical features for LGA
Noted on antenatal assessments of symphysis fundal height and ultrasound scans measuring foetal growth
May be noted at delivery due to failure to progress
When may LGA babies be noticed?
Noted on antenatal assessments of symphysis fundal height and ultrasound scans measuring foetal growth
May be noted at delivery due to failure to progress
Investigations for LGA
Ultrasound
Oral Glucose Tolerance Test (screen for gestational diabetes)
Management of LGA
Management of modifiable risk factors (e.g. good glycaemic control)
May require C-section if labour fails to progress adequately
Offer elective C-section if estimated foetal weight is over 4.5 kg
When may you offer ELCS in LGA?
Offer elective C-section if estimated foetal weight is over 4.5 kg
What may be required if labour fails to progress adequately in LGA?
May require C-section if labour fails to progress adequately
What is small for gestational age defined as?
Defined as below the 10th centile for their gestational age on measures of growth (foetal abdominal circumference and foetal weight).
Another name for SGA
Microsomia
Causes of SGA
Constitutionally small (based on genetics and ethnic backgrounds)
Intrauterine Growth Restriction
Causes of intrauterine growth restriction
Placenta Mediated
Maternal smoking or alcohol use
Anaemia
Malnutrition
Pre-eclampsia
Non-Placenta Mediated
Prenatal infection
Inborn errors of metabolism
Structural abnormalities
Placenta mediated causes of IUGR (leads to SGA)
Maternal smoking or alcohol use
Anaemia
Malnutrition
Pre-eclampsia
Non-placenta mediated causes of IUGR (leads to SGA)
Prenatal infection
Inborn errors of metabolism
Structural abnormalities
RFs for SGA
Maternal Age
Previous SGA
IVF
Obesity
Chronic Disease in the Mother (e.g. hypertension)
Multiple Pregnancy
Clinical features of SGA
Noted on antenatal assessments of symphysis fundal height and ultrasound scans measuring foetal growth
When may SGA be noted?
Noted on antenatal assessments of symphysis fundal height and ultrasound scans measuring foetal growth
Management of SGA
Treatment of modifiable risk factors (e.g. smoking cessation, management of hypertension)
Serial growth scans for high risk pregnancies
May need to consider induction of labour following MDT discussion (i.e. including involvement of the neonatal team)
What may need to be carried out in high risk SGA pregnancies?
Serial growth scans
Risks of SGA pregnancies
Stillbirth
Neonatal Hypoglycaemia
Neonatal Hypothermia
Long-Term Complications for Child: Increased risk of cardiovascular disease, type 2 diabetes mellitus and obesity
Long term risks for SGA children
Increased risk of cardiovascular disease, type 2 diabetes mellitus and obesity
What changes in glucose metabolism are seen during pregnancy?
Pregnancy is associated with an increase in insulin resistance and glucose tolerance
What will happen to patient’s insulin/metformin dose during pregnancy?
Insulin resistance increases during the pregnancy, so the patient’s dose of metformin or insulin will need to be up-titrated in the second half of the pregnancy
What scans need to be offered in GDM?
A foetal anomaly scan should be offered at 19-20 weeks with assessment of cardiac outflow tracts
Serial growth scans (every 2-4 weeks) should be carried out from 28-36 weeks (check for macrosomia and polyhydramnios)
What are you looking for on serial growth scans in GDM between 29-36 weeks?
macrosomia and polyhydramnios
How should delivery be planned in GDM?
In the absence of complications, aim to achieve vaginal delivery between 38-39 weeks’ gestation
Patients on insulin should be started on a variable-rate insulin infusion upon the onset of labour (maintaining glucose levels between 4-7 mmol/L)
Insulin requirements should return to pre-pregnancy levels after delivery
Management of intrapartum sepsis
What is CTG done for in intrapartum sepsis?
CTG to assess for foetal distress and how urgently the baby needs to be delivered
Sources of sepsis in pregnancy
UTI / pylonephritis
Chorioamnionitis / endometritis
Mastitis
What is the threshold for admission in intrapartum sepsis?
Low threshold for admission and IV antibiotics – can deteriorate quickly
Management of sepsis follows what protocol
sepsis 6
Who defines reduced fetal movements?
mother
What is reduced fetal movements?
reduction in the frequency or intensity of foetal movements perceived by the mother.
What should patients be advised to do if they have RFM after 28 weeks?
they should be advised to lie on their left side and focus on foetal movements for 2 hours - if they do not feel 10 or more discrete movements in 2 hours, they should contact their midwife or maternity unit immediately.
After lying on their left side and focusing on fetal movements for 2 hours, how many discrete movements should they have felt?
10
if they do not feel 10 or more discrete movements in 2 hours, they should contact their midwife or maternity unit immediately.
RFs for RFM
Anterior placenta
Alcohol intake
Benzodiazepine use
Obesity
Small for Gestational Age
Assessment of RFM in less than 24 weeks gestation
Confirm the presence of a foetal heartbeat by auscultation with a Doppler handheld device
If foetal movements have NOT been felt by 24 weeks’ gestation, refer to a specialist foetal medicine centre
When should fetal movements have been felt by? What should you do if they haven’t?
24 weeks
If foetal movements have NOT been felt by 24 weeks’ gestation, refer to a specialist foetal medicine centre
Assessment of RFM in foetus of 24-28 weeks gestation
Confirm the presence of a foetal heartbeat by auscultation with a Doppler handheld device
Assessment of RFM in foetus more than 28 weeks gestation
Confirm the presence of a foetal heartbeat by auscultation with a Doppler handheld device
Once foetal viability is confirmed, arrange CTG
Consider ultrasound scan if perception of reduced foetal movements persists despite a normal CTG or if there are additional risk factors for FGR or stillbirth
Offer induction of labour if recurrent episodes of reduced foetal movement or if foetal movements are reduced at term
1st line investigation for foetus of all ages presenting with RFM
Confirm the presence of a foetal heartbeat by auscultation with a Doppler handheld device
After what gestation is CTG typically used?
28 weeks
In a foetus more than 28 weeks gestation presenting with RFM, what is used after confirmation of foetal viability with an USS doppler?
CTG
RFs for VTE in pregnancy
Previous VTE
1st degree relative
>35
Parity
Investigations for VTE in pregnancy
’Walking’ / exertional HR and saturations
ECG
US doppler LL
CTPA (+/- CXR)
MRV
How is VTE treated in pregnancy?
LMWH throughout pregnancy, at least 3 months post- partum
Haematology follow up 3 months post partum
How long should LMWH be carried on for in pregnancy?
3 months post partum
How can placenta praevia be categorised?
Minor (Grade I/II) ‘close to’ os
Major (Grade III/IV) ‘covering’ os
What are 50% of APH due to?
Praevia
What should you NOT do if suspecting praevia?
Vaginal exam
Grading of placenta praevia
I - placenta reaches lower segment but not the internal os
II - placenta reaches internal os but doesn’t cover it
III - placenta covers the internal os before dilation but not when dilated
IV (‘major’) - placenta completely covers the internal os
When is placenta praevia often picked up?
20 week scan
What to do if placenta is ‘low’ on 20 week scan?
follow up scan at 32 weeks, and then again at 36 weeks if still low.
What to do if placenta is <2cm from os at term?
Elective CS
Management of fetus if alive and <36 weeks in abruption
fetal distress: immediate caesarean
no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation
Management of fetus if alive and >36 weeks
fetal distress: immediate caesarean
no fetal distress: deliver vaginally
Sudden onset constant abdominal pain, with PVB in a pregnant women
Placental abruption
What is vasa praevia?
When the fetal vessels run in membranes below the presenting part
What does vasa praecia present with?
MASSIVE PPH
What happens to reflexes in pre-eclampsia?
increased
