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MSRA Content > Antenatal Obstetrics 4 > Flashcards

Antenatal Obstetrics 4 Flashcards

1
Q

What is stillbirth? How common?

A

o Babies born dead after 24 weeks gestation

o 1 in 200 total births

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2
Q

Most common cause of stillbirth?

A

Idiopathic

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3
Q

Maternal causes of stillbirth?

A 
Diabetes (pre-existing and gestational)
Pre-eclampsia
Sepsis
Obstetirc cholestasis
Acute fatty liver
Thrombophilias (e.g. Protein C and protein S resistance, factor V leiden mutation, antithrombin II deficiency
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4
Q

Foetal causes of stillbirth?

A 
Infection: Toxoplasma, Listeria, Syphilis, parvovirus
Chromosomal abnormality
Structural abnormality
Rhesus disease leading to severe anaemia
TTTS
IUGR
Alloimmune thombocytopaenia
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5
Q

Placental causes of stillbirth?

A

Postmaturity
Abruption
Placenta praevia: significant blled
Cord prolaspe

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6
Q

Other causes of stillbirth?

A

twins, social deprivation, increasing maternal age, smoking, previous CS, IVF, obesity

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7
Q

Diagnosis of stillbirth?

A 
	Absent foetal movements
	No foetal heart sounds
	Absent foetal heart beat on US (diagnostic)
•	Can repeat US if mother requests
o	Foetus looks macerated
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8
Q

Immediate management of stillbirth? When to advice delivery and how? Management of those not induced?

A

 If Rh negative – give Anti-D
 Kleihauer to diagnose foetomaternal haemorrhage
 Ix – Temp, BP, urine, clotting screen
 Advise delivery if pre-eclampsia, abruption, sepsis, coagulopathy, membrane rupture
• Induced using – mifepristone oral, prostaglandin vaginally and may need oxytocin
 If not induced by 48h, check coagulopathy twice weekly
 Some women choose to continue the pregnancy - >90% will spontaneously labour within 3 weeks

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9
Q

Management of stillbirth during labour?

A

 Good analgesia
 Wrap baby up and offer to present to mother
 Photographs, lock of hair and palm print given
 May need VTE prophylaxis

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10
Q

Practical steps following stillbirth?

A

 Follow-up
 Refer for genetic counselling if appropriate
 Certificate of Stillbirth required
 Bereavement counselling (SANDS)
 Mother may be prescribed cabergoline to suppress lactation

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11
Q

Maternal tests performed to establish cause of stillbirth?

A

• Kleihauer, FBC, U&E, CRP, LFT, TFT, HbA1c, glucose, blood culture, viral screen (TORCH, etc), thrombophilia screen, antibodies, MSU, urine for cocaine, cervical swabs

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12
Q

Foetal tests performed to establish cause of stillbirth?

A

• Foetal and placental swabs, cord blood
• Post mortem
o If denied – MRI, cytogenetics, small volumes of tissue for metabolic studies

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13
Q

Define recurrent pregnancy loss? Risk factors?

A

• Three or more miscarriages occurring in succession before 24 weeks gestation (1% of couples).
• Risk Factors for future pregnancies
o Number of miscarriages
o Maternal age

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14
Q

Aetiology of recurrent misscarriages?

A 
Antiphospholipid antibodies
o	Chromosomal defects (4% of couples) 
Uterine abnormalities are common with late miscarriage
o	Thrombophilia
Bacterial vaginosis
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15
Q

What is antiphospholipid antibodies defined as?

A

 Defined as presence of antibodies on 2 occasions plus 3 or more consecutive miscarriages <10 weeks, 1 foetal loss 10 weeks or older or 1 or more births of normal foetus >34/40 with severe pre-eclampsia or growth restriction

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16
Q

Common chromosomal defect causing recurrent miscarriages?

A

 Usually balanced reciprocal or Robertsonian translocation

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17
Q

Common uterine defect causing recurrent miscarriages?

A

 Cervical incompetence, polycystic ovary syndrome, adhesions etc.

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18
Q

Common thrombophilia causing recurrent miscarriages?

A

 Factor V leiden, prothrombin gene and protein C and S deficiency

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19
Q

Investigations in recurrent miscarriages?

A

o Referral to specialist recurrent miscarriage clinic
o Tests for:
 Antiphospholipid antibodies (positive if 2 tests +ve, 12 weeks apart)
 Thrombophilia screening
 Pelvic US to assess uterus
 Karyotype foetal products
• If abnormal chromosome – karyotype parental blood
 High cervical swab for bacterial vaginosis

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20
Q

Treatments in recurrent miscarriage - antiphospholipid syndrome?

A

 Aspirin 75mg PO from day of positive pregnancy test

 Enoxaparin 40mg SC as soon as foetal heart seen

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21
Q

Treatments in recurrent miscarriage - thrombophilia?

A

 LMWH (Enoxaparin)

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22
Q

Treatments in recurrent miscarriage - bacterial vaginosis?

A

 Treat infection

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23
Q

Definition of miscarriage?

A
  • Loss of a pregnancy before 24 weeks gestation
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24
Q

Define early miscarriage?

A
  • Early miscarriage, if it occurs before 13 weeks of gestation
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25
Q

Define late miscarriage?

A
  • Late miscarriage, if it occurs between 13 and 24 weeks of gestation
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26
Q

How common are miscarriages?

A
  • 15-20% of pregnancies miscarry, mostly in 1st trimester

- Rate increases with maternal age

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27
Q

Definition of threatened miscarriage?

A

o There is bleeding but the foetus still alive, the uterus is the size expected from the dates and the OS is closed.
o Only 25% will go on to miscarry

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28
Q

Definition of inevitable miscarriage?

A

o Bleeding is usually heavier.
o Although the fetus may still be alive, the cervical OS is open.
o Miscarriage is about to occur

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29
Q

Definition of incomplete miscarriage?

A

Some fetal parts have been passed, but the os is usually open.

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30
Q

Definition of complete miscarriage?

A

o All fetal tissue has been passed.

o Bleeding has diminished, the uterus is no longer enlarged and the cervical os is closed.

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31
Q

Definition of septic miscarriage?

A

o The contents of the uterus are infected causing endometritis.
o Vaginal loss is offensive and the uterus is tender.
o A fever can be absent.
o If pelvic infection occurs there is abdominal pain and peritonism

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32
Q

Definition of missed miscarriage?

A

o The fetus has not developed or died in utero, but this is not recognised until bleeding occurs or USS is performed
o The uterus is smaller than expected for dates and the OS is closed

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33
Q

Aetiology of isolated miscarriages?

A
  • Isolated non-recurring chromosomal abnormalities – 60% of one off miscarriages
  • Exercise, intercourse and emotional trauma DO NOT cause miscarriage
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34
Q

Symptoms and signs of miscarriage?

A
  • Bleeding PV in first 24 weeks
  • Pain
  • Enquire about: nausea, vomiting, dizziness, fainting, shoulder tip pain, urinary symptoms, passage of tissue
  • Need to assess state of os and uterine size
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35
Q

Investigations in miscarriage?

A
  • Urine pregnancy test
  • Blood hCG
  • USS
  • Bloods: FBC, Rh group, antiphospholipid antibodies, thrombophilia screening
  • Blood culture
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36
Q

Initial management of early pregnancy bleeding? What about is haemodynamically unstable?

A

o If >6 weeks and no pain, tenderness, cerical motion tenderness – refer for EPAU services
o If <6 weeks and no pain – repeat pregnancy test in 7 days, if positive then refer to EPAU
o If unacceptable pain or bleeding – surgical management of miscarriage
 Evacuation of retained products of conception (ERPC)
o Immediate admission if haemodynamically unstable
 IV fluids
 If bleeding profuse – ergometrine 0.5mg IM
 If there is a fever, swabs for bacterial culture are taken and IV abx are given

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37
Q

Management of uncertain viability of miscarriage?

A

o Arrange rescan in 10-14 days

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38
Q

Counselling in patient suffering a miscarriage?

A

o Patients should be told that the miscarriage was not the result of anything they did/didn’t do.
o There is a likelihood of bleeding, but foetal tissue usually absorbed
o Reassurance of the high chance of successful further pregnancies is important.
o Referral to support group may be useful.
o Miscarriage is common → further investigation is reserved for women who have had three miscarriages

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39
Q

Expectant management of non-viable miscarriages?

A

o Expectant management (wait for miscarriage to pass naturally without intervention)

 Offer for 7-14 days when confirmed miscarriage
 Offer rescan in 2 weeks to ensure complete if no significant bleeding or increasing bleeding/pain
 Repeat pregnancy test at 3 weeks later and return if positive

40
Q

Medical management of miscarriage? When offered? Process?

A

 Offered when failed expectant treatment
 Give analgesia and anti-emetic
 Misoprostol either orally/vaginally
 Bleeding should start within 24 hours and may continue for 3 weeks
 80-90% successful in <9 weeks gestation
 Pregnancy test after 3 weeks and return if positive

41
Q

Surgical management of miscarriage?

A

 If heavy or persistent bleeding > 2 weeks, infected retained tissue or patient choice
 Manual vacuum aspiration under LA in clinic OR Suction evacuation under GA in theatre
o Anti-D immunoglobulin given to all surgical patients

42
Q

Complications of expectant miscarriage?

A

o Expectant leads to higher risk of incomplete miscarriage, need for surgical emptying or transfusion

43
Q

Follow-up of patient with miscarriage?

A
  • Cancel routine antenatal appointments
  • Discuss questions patients have
  • Avoid sex until symptoms of miscarriage settled completely
  • Menstruation expected to resume within 4-8 weeks of miscarriage and ovulation will occur before that
  • Provide leaflet
44
Q

Complications of miscarriage?

A
  • Heavy vaginal bleeding.
  • Infection (can lead to endotoxic shock, hypotension, renal failure, ARDS, and DIC)
  • Surgical → Asherman’s syndrome (adhesions in the uterus) or perforated uterus, infection, haemorrhage, cervical tears, intra-abdominal trauma
45
Q

Counselling needed on grief for miscarriage?

A

o Patients should be told that the miscarriage was not the result of anything they did/didn’t do.
o Reassurance of the high chance of successful further pregnancies is important.
o Referral to support group may be useful.
o Miscarriage is common → further investigation is reserved for women who have had three miscarriages

46
Q

Aetiology of mid-trimester miscarriage?

A

o May be due to mechanical causes (cervical weakness), uterine abnormalities, chronic maternal disease (DM, SLE), infection or no cause identified

47
Q

Management of mid-trimester miscarriage?

A

o Cervical cerclage at 14 weeks of pregnancy – removed prior to labour
o Investigate to ensure any treatable cause is treated next time

48
Q

Define VBAC?

A

o Woman gives birth vaginally, having had a C-section in the past

49
Q

Success of VBAC?

A

o After 1 C-section, ¾ of women with straightforward pregnancy who go into labour give birth vaginally
o Successful vaginal birth more likely if:
 Previous vaginal birth (8-9/10 will be success)
 Labour starting naturally
 BMI<30 at booking

50
Q

Advantages of VBAC?

A 
o	If success vaginal birth:
	Greater chance of future vaginal births
	Recovery quicker, drive sooner
	Stay in hospital may be shorter
	Avoid operative risks
	Less respiratory problems in neonate
51
Q

Disadvantages of VBAC?

A

o May need Emergency LSCS (25/100)
o Higher risk of:
 Needing for blood transfusion compared to planned C-section
 Uterine rupture (2-3x increase risk)
 Emergency C-section higher risk of foetal death and brain injury
 May need Ventouse or forceps delivery
 More likely to tear muscle that controls anus (third- or fourth-degree tear)

52
Q

Define FGM?

A

o Removal or partial removal of external female genitalia or injury to other internal female genital organs
o Illegal in UK under 2003 FGM Act and recognised form of child abuse

53
Q

Most common areas for FGM?

A

o Traditionally practiced in Africa, but some parts of India and Indonesia
o In UK most affected women come from:
 Somalia, Sudan, Kenya, Eritrea, Ethiopia, Yemen, Mali, Guinea, Egypt

54
Q

How common is each type of FGM?

A

o 90% Types 1, 2 and 4

o 10% Type 3

55
Q

What is type 1 FGM?

A

o Type 1 – Partial or total removal of clitoris and/or prepuce (clitoridectomy)

56
Q

What is type 2 FGM?

A

o Type 2 – Partial or total removal of clitoris and labia minora, with or without excision of labia majora

57
Q

What is type 3 FGM?

A

o Type 3 – Narrowing of vaginal orifice with creation of a covering seal by cutting and appositioning of labia minora/labia majora, with or without excision of clitoris (infibulation)

58
Q

What is type 4 FGM?

A

o Type 4 – Any other harmful procedures to female genitalia for non-medical purpose (pricking, piercing, cauterisation, incising and scraping)

59
Q

Acute complications of FGM?

A

o Death, blood loss, sepsis, pain, urinary retention, tetanus, hepatitis and HIV
o Often unhygienic – by traditional circumciser, usually no anaesthesia and shared blades

60
Q

Long-term sequelae of FGM?

A

o Aparenunia, superficial dyspareunia, anorgasmia, sexual dysfunction, chronic pain, keyloid scare, UTI, subfertility, HIV, emotional trauma
o Fear of childbirth, risk of CS, postpartum haemorrhage, episiotomy, vaginal lacerations

61
Q

Management of FGM?

A

o Should report and safeguarding issue
o De-fibulation may be performed before marriage, electively at 20 weeks gestation or in 1st stage of labour
o If not correct antenatally – manage in unit with emergency obstetric care and get expert advice
o Offer epidural
o Repair – control bleeding (Re-infibulation is ILLEGAL)

62
Q

Maternal conditions in pregnancy - cardiac disease - how common?

A
  • Affects <1% of pregnancies
63
Q

Maternal conditions in pregnancy - cardiac disease - how common is IHD?

A

 More common now women are giving birth later and later

 May have atypical symptoms

64
Q

Maternal conditions in pregnancy - cardiac disease - Problems with pulmonary hypertension? Where do they need to managed?

A

 Mortality rate of 25-40% in pregnancy
 Due to lung disease, connective tissue disease, primary, veno-occlusive and Eisenmenger syndrome
 Advise against pregnancy and offer ToP
 Manage pregnancy in tertiary centre

65
Q

Maternal conditions in pregnancy - cardiac disease - Congenital heart disease - most common and problems?

A

 Most commonly PDA, ASD and VSD
 If cyanotic and uncorrected, increased risk of IUGR
 Refer for foetal echocardiography

66
Q

Maternal conditions in pregnancy - cardiac disease - Marfans syndrome risks and management?

A

 Autosomal dominant with 80% cardiac involvement with mitral valve prolapse and/or aortic root dilatation
 Risk of aortic rupture and dissection
 Offer root replacement pre-pregnancy and LSCS if root >4.5cm

67
Q

Maternal conditions in pregnancy - cardiac disease - Mitral stenosis monitoring/treatment?

A

 Monitor with echo, aggressively treat AF (digoxin and BB safe), treat pulmonary oedema

68
Q

Maternal conditions in pregnancy - cardiac disease - artificial heart valves treatment?

A

 Warfarin throughout pregnancy, treatment-dose LMWH 6-12 weeks or LMWH throughout

69
Q

Maternal conditions in pregnancy - cardiac disease - peripertum cardiomyopathy definition, referral?

A

 Heart failure without known cause and no previous heart disease
 Onset 1 month pre- and 5 months post-partum
 Diagnosis by echo
 Manage – elective delivery, anticoagulants, treatment for HF and may need LV assist devices

70
Q

Antenatal management of cardiac disease in pregnancy?

A

o Regular cardiology/obstetric combined clinic visits
 Prevent anaemia, obesity and smoking
 Treat hypertension
 Exclude pulmonary oedema and arrhythmias at each visit
 Refer for Echo
o HF needs admission

71
Q

Labour of cardiac disease in pregnancy?

A

o Have O2 and drugs to treat cardiac failure ready
o Aim for vaginal delivery at term, may need LSCS
o Use oxytocin

72
Q

Risks of sickle cell in pregnancy??

A
  • Increased risk of painful crises, perinatal mortality, premature labour and foetal growth restriction
73
Q

Preconception review and management for sickle cell disease?

A

o Annual review, sickle specialist review
 Screen for red cell antibodies& check partners carrier status
 Echocardiogram
 BP, urinalysis, U&E, LFT, Retinal screening
 Daily penicillin/erythromycin
 Vaccines up to date
o Stop ACE and hydroxycarbamide >3 months preconception
o 5mg Folic Acid daily throughout pregnancy

74
Q

Antenatal management of sickle cell disease in pregnancy? Management of hospital admission and sickle cell crisis?

A

o Manage specialist MD team or high-risk protocols
 growth scan 4-weekly from 24 weeks
o From 12 weeks – daily aspirin 75mg
o Admit with crises – IV opioids, nasal O2, fluids

75
Q

Delivery management of sickle cell disease in pregnancy?

A

o Delivery 38-40 weeks at specialist hospital
o Continuous foetal monitoring and maternal O2 sats
o 7 days LMWH post-vaginal delivery, 6 weeks if CS
o Progestogenic contraception 1st choice

76
Q

How common is transmission of HIV in pregnancy??

A
  • Without intervention 15% babies acquire HIV

o 2/3 vertical transmission during vaginal delivery and breastfeeding & membrane rupture >4h doubles risk

77
Q

Antenatal care of HIV mother in pregnancy?

A

o MDT care with HIV physician
 HIV tests & genital infection screen at booking and 28 weeks (can do rapid labour tests)
 Check Hep B&C, VZV, measles, toxoplasmosis antibodies
 Offer vaccines to HepB, pneumococcal and influenza
o Continue HAART, if not on – give 24 weeks
o If on co-trimoxazole (P.jirovecii prophylaxis), offer folic acid 5mg daily

78
Q

Management of premature labour in HIV mother?

A

o If >34 weeks – expedite delivery

o If <34 weeks – steroids, erythromycin and take HAART, seek specialist advice

79
Q

When to perform vaginal and LSCS delivery in HIV?

A

o Vaginal Delivery
 If viral load <50 (<400 if on HAART), continue HAART in labour
 Avoid FBS, amniotomy
 Low cavity forceps preferred
o Elective CS
 38 weeks if on zidovudine monotherapy/HAART/high viral load/Hep C/not on HAART
 If viral load <50 and CS needed – 39+ weeks

80
Q

Postpartum care of HIV mother pregnancy:?

A

o Avoid breast-feeding
o Cabergoline 1mg PO within 24h (suppresses lactation)
o Neonates within 4h:
 Zidovudine BD for 4 weeks and HAART if high risk (untreated mother/viral load >50)
 Co-trimoxazole PCP prophylaxis
o Tested at day 1, 6 weeks, 12 weeks for HIV with confirmation at 18 months
o Contraception – IUD, condoms, depot suitable

81
Q

Hyperthyroidism in pregnancy is usually what? Associated with what? Management?

A

o Usually Graves’ disease
o Associated with infertility, foetal loss and malformations
o Transient exacerbations may occur in 1st trimester and postpartum
o Carbimazole and propylthiouracil (PTU mostly)
 Monitor levels and TFTs
o Partial thyroidectomy can be done in 2nd trimester if dysphagia/malignancy/large goitre

82
Q

Hypothyroidism in pregnancy associated with? Management?

A

o Untreated associated with infertility, oligomenorrhoea or menorrhagia, stillbirth, miscarriage, anaemia, pre-eclampsia and IUGR
o Reduced IQ and neurodevelopmental delay
o Optimise T4 preconception and each trimester
o Replace with levothyroxine

83
Q

Post-partum thyroiditis features and management?

A

%, hyperthyroidism followed by hypothyroidism
o Hyperthyroidism – usually self-limiting but may need BB
o Monitor hypothyroid for 6 months and treat if symptomatic – withdraw at 12 months to see if long-term treatment needed
o Associated with postpartum depression

84
Q

Management of asymptomatic bacteriuria in pregnancy?

A

o If present on MSU – cefalexin 500mg PO TDS given
 Avoid trimethoprim in 1st trimester and nitrofurantoin in 3rd trimester
o Check MSU on each visit
o Treat cystitis as per asymptomatic bacteriuria

85
Q

Management of pyelonephritis in pregnancy?

A

o More common due to dilatation of upper renal tract in pregnancy
o Blood and urine cultures needed
o IV Cefuroxime, if sepsis consider stat dose of gentamicin
o If for at least 24 hours and oral 2-3 weeks
o Check MSU and renal function regularly

86
Q

Management of chronic renal disease in pregnancy?

A

o Risks of miscarriage, pre-eclampsia, IUGR, preterm delivery
o Avoid pregnancy if severe renal disease as expect further deterioration
o Outcome poor if on dialysis

87
Q

Management of AKI in pregnancy?

A

o Causes – Sepsis, HELLP, hypovolaemia, volume contraction, NSAIDs
o Monitor urine output and fluid balance carefully, U&E
o Aim>30ml/hr
o Specialist advice needed about diuretics and dialysis

88
Q

Management of rheumatoid arthritis in pregnancy?

A

o Usually alleviated by pregnancy
o DO NOT USE METHOTREXATE
o Sulfasalazine can be used
o NSAIDs used in 1st and 2nd trimesters

89
Q

Management of SLE in pregnancy?

A

o Exacerbations common, most moderate and involve skin
o Planned pregnancy needs 6 months stable disease with azathioprine and hydroxychloroquine
o Aspirin 75mg given throughout pregnancy
o Prone to pre-eclampsia
 Hydralazine and methyldopa can be used for pre-eclampsia
o If needing prednisolone >7.5mg daily 2 weeks before delivery, IV hydrocortisone used in labour

90
Q

Features, investigations of antiphospholipid in pregnancy?

A

o Antiphospholipid antibodies (lupus anticoagulant +/- anticardiolipin antibodies on 2 tests taken 8 weeks apart) present
o Often baby dies due to 1st trimester loss or placental thrombosis
o Need regular foetal Doppler and US for growth from 20 weeks

91
Q

MAnagement of antiphospholipid in pregnancy?

A

o Aspirin 75mg OD and Enoxaparin 40mg SC/24h from when foetal heart identified (6 weeks)
o Postpartum – use heparin or warfarin as thrombosis risk high

92
Q

Management of epilepsy in pregnancy?

A
  • MDT management
  • Folic acid 5mg
  • Foetal risks – NTD, orofacial cleft, CHD, foetal anticonvulsant syndrome
  • Anticonvulsants 1st line - Lamotrigine, leviteracetam
  • AVOID SODIUM VALPROATE
  • AED dose may need increasing
  • Oral Vit K in last 4 weeks of pregnancy
93
Q

When would you not perform a VE?

A

Pregnant women not in established labour

94
Q

Monitoring in VBAC?

A

EFM

Deliver in a unit where there is immediate access to CS and on-site blood transfusion.

With induction of labour, increased risk of uterine rupture if oxytocin infusion or prostaglandin infusion used

95
Q

CI of VBAC?

A

Previous uterine rupture
Classical C-Section incision
Other CI for vaginal delivery

96
Q

Indications of VBAC?

A

Singleton cephalic of 37 weeks with one VBAC

Need consultant review of 2 or more VBAC

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