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
2
Q
Most common cause of stillbirth?
A
Idiopathic
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
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
5
Q
Placental causes of stillbirth?
A
Postmaturity
Abruption
Placenta praevia: significant blled
Cord prolaspe
6
Q
Other causes of stillbirth?
A
twins, social deprivation, increasing maternal age, smoking, previous CS, IVF, obesity
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
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
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
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
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
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
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
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
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
16
Q
Common chromosomal defect causing recurrent miscarriages?
A
Usually balanced reciprocal or Robertsonian translocation
17
Q
Common uterine defect causing recurrent miscarriages?
A
Cervical incompetence, polycystic ovary syndrome, adhesions etc.
18
Q
Common thrombophilia causing recurrent miscarriages?
A
Factor V leiden, prothrombin gene and protein C and S deficiency
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
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
21
Q
Treatments in recurrent miscarriage - thrombophilia?
A
LMWH (Enoxaparin)
22
Q
Treatments in recurrent miscarriage - bacterial vaginosis?
A
Treat infection
23
Q
Definition of miscarriage?
A
- Loss of a pregnancy before 24 weeks gestation
24
Q
Define early miscarriage?
A
- Early miscarriage, if it occurs before 13 weeks of gestation
25
Define late miscarriage?
- Late miscarriage, if it occurs between 13 and 24 weeks of gestation
26
How common are miscarriages?
- 15-20% of pregnancies miscarry, mostly in 1st trimester
| - Rate increases with maternal age
27
Definition of threatened miscarriage?
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
28
Definition of inevitable miscarriage?
o Bleeding is usually heavier.
o Although the fetus may still be alive, the cervical OS is open.
o Miscarriage is about to occur
29
Definition of incomplete miscarriage?
Some fetal parts have been passed, but the os is usually open.
30
Definition of complete miscarriage?
o All fetal tissue has been passed.
| o Bleeding has diminished, the uterus is no longer enlarged and the cervical os is closed.
31
Definition of septic miscarriage?
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
32
Definition of missed miscarriage?
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
33
Aetiology of isolated miscarriages?
- Isolated non-recurring chromosomal abnormalities – 60% of one off miscarriages
- Exercise, intercourse and emotional trauma DO NOT cause miscarriage
34
Symptoms and signs of miscarriage?
- 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
35
Investigations in miscarriage?
- Urine pregnancy test
- Blood hCG
- USS
- Bloods: FBC, Rh group, antiphospholipid antibodies, thrombophilia screening
- Blood culture
36
Initial management of early pregnancy bleeding? What about is haemodynamically unstable?
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
37
Management of uncertain viability of miscarriage?
o Arrange rescan in 10-14 days
38
Counselling in patient suffering a miscarriage?
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
39
Expectant management of non-viable miscarriages?
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
Medical management of miscarriage? When offered? Process?
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
Surgical management of miscarriage?
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
Complications of expectant miscarriage?
o Expectant leads to higher risk of incomplete miscarriage, need for surgical emptying or transfusion
43
Follow-up of patient with miscarriage?
- 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
Complications of miscarriage?
- 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
Counselling needed on grief for miscarriage?
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
Aetiology of mid-trimester miscarriage?
o May be due to mechanical causes (cervical weakness), uterine abnormalities, chronic maternal disease (DM, SLE), infection or no cause identified
47
Management of mid-trimester miscarriage?
o Cervical cerclage at 14 weeks of pregnancy – removed prior to labour
o Investigate to ensure any treatable cause is treated next time
48
Define VBAC?
o Woman gives birth vaginally, having had a C-section in the past
49
Success of VBAC?
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
Advantages of VBAC?
```
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
Disadvantages of VBAC?
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
Define FGM?
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
Most common areas for FGM?
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
How common is each type of FGM?
o 90% Types 1, 2 and 4
| o 10% Type 3
55
What is type 1 FGM?
o Type 1 – Partial or total removal of clitoris and/or prepuce (clitoridectomy)
56
What is type 2 FGM?
o Type 2 – Partial or total removal of clitoris and labia minora, with or without excision of labia majora
57
What is type 3 FGM?
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
What is type 4 FGM?
o Type 4 – Any other harmful procedures to female genitalia for non-medical purpose (pricking, piercing, cauterisation, incising and scraping)
59
Acute complications of FGM?
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
Long-term sequelae of FGM?
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
Management of FGM?
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
Maternal conditions in pregnancy - cardiac disease - how common?
- Affects <1% of pregnancies
63
Maternal conditions in pregnancy - cardiac disease - how common is IHD?
More common now women are giving birth later and later
| May have atypical symptoms
64
Maternal conditions in pregnancy - cardiac disease - Problems with pulmonary hypertension? Where do they need to managed?
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
Maternal conditions in pregnancy - cardiac disease - Congenital heart disease - most common and problems?
Most commonly PDA, ASD and VSD
If cyanotic and uncorrected, increased risk of IUGR
Refer for foetal echocardiography
66
Maternal conditions in pregnancy - cardiac disease - Marfans syndrome risks and management?
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
Maternal conditions in pregnancy - cardiac disease - Mitral stenosis monitoring/treatment?
Monitor with echo, aggressively treat AF (digoxin and BB safe), treat pulmonary oedema
68
Maternal conditions in pregnancy - cardiac disease - artificial heart valves treatment?
Warfarin throughout pregnancy, treatment-dose LMWH 6-12 weeks or LMWH throughout
69
Maternal conditions in pregnancy - cardiac disease - peripertum cardiomyopathy definition, referral?
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
Antenatal management of cardiac disease in pregnancy?
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
Labour of cardiac disease in pregnancy?
o Have O2 and drugs to treat cardiac failure ready
o Aim for vaginal delivery at term, may need LSCS
o Use oxytocin
72
Risks of sickle cell in pregnancy??
- Increased risk of painful crises, perinatal mortality, premature labour and foetal growth restriction
73
Preconception review and management for sickle cell disease?
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
Antenatal management of sickle cell disease in pregnancy? Management of hospital admission and sickle cell crisis?
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
Delivery management of sickle cell disease in pregnancy?
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
How common is transmission of HIV in pregnancy??
- Without intervention 15% babies acquire HIV
| o 2/3 vertical transmission during vaginal delivery and breastfeeding & membrane rupture >4h doubles risk
77
Antenatal care of HIV mother in pregnancy?
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
Management of premature labour in HIV mother?
o If >34 weeks – expedite delivery
| o If <34 weeks – steroids, erythromycin and take HAART, seek specialist advice
79
When to perform vaginal and LSCS delivery in HIV?
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
Postpartum care of HIV mother pregnancy:?
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
Hyperthyroidism in pregnancy is usually what? Associated with what? Management?
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
Hypothyroidism in pregnancy associated with? Management?
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
Post-partum thyroiditis features and management?
%, 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
Management of asymptomatic bacteriuria in pregnancy?
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
Management of pyelonephritis in pregnancy?
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
Management of chronic renal disease in pregnancy?
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
Management of AKI in pregnancy?
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
Management of rheumatoid arthritis in pregnancy?
o Usually alleviated by pregnancy
o DO NOT USE METHOTREXATE
o Sulfasalazine can be used
o NSAIDs used in 1st and 2nd trimesters
89
Management of SLE in pregnancy?
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
Features, investigations of antiphospholipid in pregnancy?
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
MAnagement of antiphospholipid in pregnancy?
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
Management of epilepsy in pregnancy?
- 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
When would you not perform a VE?
Pregnant women not in established labour
94
Monitoring in VBAC?
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
CI of VBAC?
Previous uterine rupture
Classical C-Section incision
Other CI for vaginal delivery
96
Indications of VBAC?
Singleton cephalic of 37 weeks with one VBAC
Need consultant review of 2 or more VBAC
