Antenatal problems Flashcards
what causes backache and sciatica in pregnancy
hormonal changes causing softening of ligaments
exacerbated by altered posture due to the weight of the uterus
the softening and weight on the uterus can lead to soft tissue pressuring on the sciatic nerve - sciatica
management of backache and sciatica in pregnancy
life-style - eg sleeping position
alternative therapies incl relaxation and massage
physiotherapy input - back care classes
simple analgesia - paracetamol and ibruprofen
what is symphysis pubis dysfunction
It describes pregnancy-associated pain, instability and dysfunction of the symphysis pubis joint and/or sacroiliac joint.
management of symphysis pubis dysfunction
physiotherapy advise and support
simple analgesia
limit abduction of the leg at delivery
C/S usually not indicated
when does haemorrhoids occur in pregnancy
tend to be in 3rd trimester
management of haemorrhoids in pregnancy
avoid constipation from early pregnancy which can inc pressure on the anus to cause haemorrhoids in later pregnancy
ice packs and digital reduction of prolapsed haemorrhoids
ibuprofen suppositories and topical agents for symptomatic relief
if thrombosed, may require surgical referral
how come pregnant ladies have a higher risk of constipation
progesterone - reduces smooth muscle tone, affecting bowel activity
often made worse by iron supplement
severity decreases with gestation
what are the management of the constipation in pregnancy
life-style modification - inc fruit, fibre and water intake
can take fibre supplements
osmotic laxatives (lactulose)
when is varicose vein worse in pregnancy
worse when inc with gestation
causes of varicose veins in pregnancy
due to progesterone relaxes vasculature + uterus mass reduce venous return
management of varicose veins in pregnancy
regular exercise
compression stockings
consider thromboprophylaxis if other risk factors are present
causes of GORD in pregnancy
progesterone relaxes the oesophagal sphincter allowing gastric reflux - worsen with inc intra-abdominal pressure from the growing foetus
worse as the gestation continue
causes of carpal tunnel syndrome
oedema compressing the median nerve in the wrist
usually, resolve after delivery
management of carpal tunnel syndrome
sleeping with hands over the side of the bed may help
wrist splints may be beneficial
surgical referral if neuro deficit
management of GORD in pregnancy
lifestyle modification - sleeping propped up, avoid spicy food
alginate preparations and simple antacids
if severe, H2 receptors antagonist (ranitidine)
what is morning sickness
N+V induced by hCG hormone but tends to better in 2nd trimester
when is morning sickness worst
first trimester due to the placental hCG still being produced
what can worsen morning sickness
multiple and molar pregnancies
management of morning sickness
lifestyle - ginger tea, eating small meals, inc fluid
acupuncture
anti-emetics - prochlorperazine, promethazine, metoclopramide (PPM)
what is hyperemesis gravidarum
excessive vomiting in pregnancy, so much so that the individuals is unable to maintain adequate hydration and endangers fluid, electrolyte and nutritional status
how common is hyperemesis gravidarum
rare - 1 in 1000
RF for hyperemesis gravidarum
multiple pregnancy eg twins
molar pregnancy
due to higher levels of hCG present
when is the peak onset of hyperemesis gravidarum
6-11 wks
symptoms of hyperemesis gravidarum
1st trimester of pregnancy N+V weight loss reduce oral intake muscle wasting dehydration liver tenderness
ptyalism (inability to swallow saliva) hypovolaemia electrolyte imbalance - ketones behaviours disorders due to electrolytes imbalance haematemesis due to Mallory-Weiss tears
IX for hyperemesis gravidarum
urinalysis - ketones
MSU - exclude UTI
U and Es - dec K+, dec Na+, metabolic hypochloremic alkalosis
LFT - inc transaminases, dec albumin
USS - to exclude multiple and molar pregnancies and confirm
treatment of hyperemesis gravidarum
exclude other causes - UTI or thyrotoxicosis
a small, little sip of water at first and small amount of carbohydrate
admit if not better
initially NBM then reintroduce later
IV fluid (hartman’s and NaCl), replace K+ if necessary
daily U and Es - to check renal functions
antiemetics - Promethazine or cyclizine first line then metoclopramide
nutritional support if required - Thiamine to prevent Wernicke’s encephalopathy
if anti-emetic not working - try corticosteroids eg hydrocortisone/prenisolone IV
acupuncture
complications of hyperemesis gravidarum
maternal risks - liver and renal failure, Wernicke’s encephalopathy
foetal risks - IUGR due to malnutrition, Wernicke’s encephalopathy (may lead to death)
what is the acronym SWAN in the contest of small for dates mean?
S - starved small –> IUGR
W- wrongly small –> wrong date
A - abnormal small –> chromosomal, structural, infection etc
N - normal small –> constitutional small
what is the definition of small for dates
foetus that has failed to achieve a specific biometiric or EFW by a specific gestational age
what measurement is the most accurate for foetal growth
Crown-Rump Length
what is the procedure for measuring foetal growth
CRL - between 8 and 13 weeks
subsequent foetal growth USS & plot on customised chart
what are some of the causes for large for dates
wrong date polyhydramnios - diabetes related, twins, foeal abnormality (unable to swallow) macrosomia - diabetes related multiple pregnancy presence of fibroids
definition of polyhydramnios
liquor volume increased > 10cm generally considered abnormal
aetiology of polyhydramnios
idiopathic
maternal disorders (maternal DM, renal failure)
twins
foetal anomaly (ipper GI obstructions or inability to swallow)
chest abnor
clinical features of polyhydramnios
maternal discomfort
large for dates
foetal part difficult to palpate
management of polyhydramnios
USS to diagnose
Maternal glucose tolerant test
if < 34 weeks and severe –> amnireduction or use NSAIDs to reduce foetal urine output
consider steroids if < 34 weeks if pre-term delivery is considered
how should a baby with polyhydramnios be delivered
vaginal unless persistent unstable lie or other obstetric indication
complications of polyhydramnios
6 Ps of polyhydramnios
1) placental abruption
2) pretty unstable lie
3) premature labour
4) prolapse of cord
5) PPH
6) perinatal mortality
when will a woman be able to notice foetal movement
18-20 weeks
When is the baby most active?
usually afternoon and evening
how long does a baby normally sleep for?
20-40 minutes, rarely longer than 90 minutes
what is the normal movement of a baby?
no such normal pattern for a baby, it is all individualized
the reduction/deviation from the normal pattern of a baby is what is the most worrying feature
what is the initial assessment of a pregnant woman for reduced foetal movement
lie down on the LHS for the next 2 hours and focus on the movement of the baby. if less than 10 separate episodes of movement –> should take action
you can also try to drink some cold water to wake the baby up
aetiology of reduced foetal movement
baby sleeping
anterior placenta and so less able to feel the baby movement
baby’s back is lying at the front of the uterus, you may feel fewer movements that if his back is lying alongside your own back
medications eg strong pain relief or sedatives
alcohol/smoking
foetal illness and distress
advice for women who think their babies might have reduced movement?
1) if by 24th week, you have never felt the movement of the baby, you should contact midwife for a check on the baby’s heartbeat.
2) if over 28 weeks, you must contact midwife/local maternity unit immediately. seek help immediately.
what is considered to be a prolonged pregnancy/postdate/post-term/post-maturity
exceeds 42 weeks from the first day of LMP
what is the chance of prolonged pregnancy if you had 1 x prev. prolonged pregnancy
30% (normally 3-10% chance if you never had one before)
what are the complications of prolonged pregnancy?
maternal - anxiety and psychological, inc interventions eg induction of labour/operative delivery (inc risk to genital tract trauma
foetal - inc perinatal mortality if after 42 weeks, intrapartum death 4x, early neonatal death 3x
other risks - meconium aspiration pneumonia and assisted ventilation, oligohydramnios, macrosomia/shoulder dystocia and foetal injury, cephalhaematoma. foetal distress in labour
neonatal period - hypothermia, hypoglycemia, polycythemia and growth restriction
management of prolonged pregnancy
1) confirm EDD
2) assess any other risks eg pre-eclampsia, DM, APH, IUGR
3) offer stretch and swap in 41 week
4) offer induction of labour at 41-42 weeks (reduce perinatal mortality)
what does PPROM stands for
preterm premature rupture of membrane
what is the most common cause of PPROM
overt infection (more common in earlier gestations)
clinical features of PPROM
vaginal loss?
gush of fluid?
trickle or dampness?
signs of chorioamnionitis - fever/malaise, abdo pain incl contractions, purulent/offensive vaginal discharge
maternal pyrexia
maternal tachycardia
uterine tenderness
foetal tachycardia
investigation of PPROM
put pad on before hospital arrival
Speculum examination not bimanual - confirmatory if pooled fluid in the posterior fornix/fluids running down the cervical canal.
FBC, CRP,
swabs (HVS, LVS)
MSU
CTG
USS for foetal presentation, EFW and liquor volume
management of P-PROM
if evidence of chorioamnionitis
- prepare for delivery - betamethasone 12 mg IM, deliver, board spectrum antibiotics cover (erythromycin 250mg QDS 10 days)
if no evidence of chorioamnionitis
- conservatively
- prophylactic ABx (erythroymcin 250mg QDS)
- inform SCBU and liaise with neonatologist
- discharge after 48 hours and review in day unit twice a week for bloods and vital obs
- induction from 34 weeks
which antibiotics should you not use in pregnancy
co-amoxiclav - inc NEC incidence
definition of PROM
membrane rupture after 37 weeks before the onset of labor
