Antepartum Care Flashcards
1
Q
Incidence of placenta praevia
A
1 in 200 pregnancies
2
Q
Resolution rate of placenta praevia at 32 weeks
A
90%
3
Q
Resolution rate of placenta praevia at 36 weeks
A
50%
4
Q
Cervical length of less than ________ predicts antepartum haemorrhage and emergency c/s
A
31mm
5
Q
Risk factors for placenta praevia
A
Smoking
ART
Caesarean birth
6
Q
Timing of steroids for placenta praevia
A
34+0 to 35+6
7
Q
Timing of delivery in placenta praevia
A
34+0 - 36+6 if vaginal bleeding/other risk factors
36+0 - 37+0 if uncomplicated
8
Q
Risk of bleeding by gestation with placenta praevia
A
4.7% by 35 weeks
15% by 36 weeks
30% by 37 weeks
59% by 38 weeks
9
Q
Risk of MOH requiring blood transfusion with placenta praevia c/s
A
12 x higher
10
Q
Risk factors for PAS
A
C/S
Previous uterine surgery
Placenta praevia
IVF
Maternal age
Bicornuate uterus
Adenomyosis
Submucous fibroids
Myotonic dystrophy
11
Q
Rate of PAS with praevia and 3 or more c/s
A
50-67%
12
Q
Proportion of PAS undiagnosed
A
1/3 to 2/3rds
13
Q
USS signs of PAS
A
Abnormal uterus-bladder interface
Abnormal vasculature on colour Doppler
Abnormal Placental lacunae vascularity
Increased vascularity of the placental bed
Loss of clear zone
Myometrial thinning
Placental bulge
Focal exophytic mass
Bridging vessels
14
Q
MRI signs of PAS
A
Abnormal uterine bulging
Dark intraplacental bands
Heterogenous signal intensity in placenta
Disorganised vasculature of placenta
Disruption of uteroplacental zone
15
Q
Gestation for delivery with PAS
A
35+0 to 36+0
16
Q
Risk of urinary tract injury during PAS surgery
A
16% of uterus preserved
57% with standard hysterectomy
17
Q
Risks of conservative management of PAS (placenta in situ)
A
Infection
Bleeding
Septic shock
Peritonitis
Uterine necrosis
Fistula
Pulmonary oedema
Acute renal failure
VTE
Injury to adjacent organs
18
Q
Emergency cerclage can be considered up from ______ to _____ gestation
A
16+0 to 27+6
19
Q
Risk of preterm birth with cervical length of <25mm and history of PTB
A
14%
20
Q
Indications for serial cervical length scans
A
Previous PTB/2nd trimester loss 16-34 weeks
Previous PPROM <34 weeks
Previous cerclage
Intrauterine adhesions
Known uterine variant
History of trachelectomy
21
Q
Indication for trans abdominal cerclage
A
Previous failed vaginal cerclage
22
Q
Risks of cervical cerclage
A
Cervical laceration
Bladder injury
Membrane rupture
Fistula formation
Removal under anaesthetic required if performed with bladder mobilisation
23
Q
Removal of cervical suture should be at
A
36+1 to 37+0 unless pt undergoing c/s
24
Q
History indicated cerclage
A
Singleton, 3 or more preterm births
Singleton, history of second trimester loss
25
Gestation at which you MUST remove cervical cerclage after PPROM
Less than 23 weeks
More than 34 weeks
26
Incidence of PPROM
3%
27
PPROM occurs in what percentage of PTB
30-40%
28
Median latency after PPROM
7 days
29
Management of PPROM
Delivery if septic
Erythromycin (penicillin if allergic) 10 days or established labour
Offer steroids between 24+0 to 33+6
Consider steroids 34+0 to 35+6
30
Benefit of abx in PPROM
Reduce babies born within 48 hours and within 7 days
Reduce risk of chorio
Reduces risk of neonatal infection, surfactant use, oxygen therapy and abnormal cerebral USS
31
Most helpful marker of chorioamnionitis
CRP (77% specificity)
32
Tocolysis in PPROM is not recommended because
Associated with lower APGAR scores (<7) and increased need for ventilatory support
Increased risk of chorio below 34 weeks
33
Timing of Delivery following PPROM
37+0
From 34+0 if GBS pos
34
MgSO4 for PPROM
Offer when Planned or established labour 24+0 to 29+6
Consider between 30+0 and 33+6
35
Average time to delivery after PPROM
8-10 days at 24+0 to 28+0
5 days at 31+0
May be sooner if there is oligo
36
Factors leading to worse outcomes for PPROM
Oligo
Non-cephalic presentation
Occurring <26+0
Consider hospital care
37
Benefits of antenatal steroids
Reduce NND
Reduce NEC
Reduce RDS
Reduce intraventricular haemorrhage
Reduce risk of infection in first 48 hours of life
Reduces risk of ITU admission/respiratory support
Reduce developmental delay
38
Optimal Timing of steroids
Greatest benefit with delivery within 48 hours of first dose
Benefit seen within 24 hours of delivery
Benefit for up to 7 days of giving
39
Dose and type of steroids
Dexamethasone phosphate 12mg 24 hours apart or 4 doses of 6mg given 12 hourly (better risk reduction for IVH)
Betamethasone phosphate/acetate mix - 12mg 24 hours apart
40
Gestations to give steroids
Offer between 24+0 to 34+6
Consider 35+0 to 36+6
Consider between 22+0 to 23+6
41
Harms of steroids
Affects maternal glycaemic control for 5 days
Neonatal hypoglycaemia
Reduced birth weight with repeat courses
Neurodevelopmental affects if baby born at term
42
Stillbirth rate
32 in 10, 000 (white)
72 in 10, 000 (black)
51 in 10, 000 (Asian)
43
Consider Prophylactic vaginal progesterone when
History of PTB up to 34+0/2nd trimester loss OR cervical length is <25mm on TV USS
44
Offer either cerclage or vaginal progesterone when
History of PTB/2nd trimester loss AND cervical length <25mm
45
Gestation to give vaginal progesterone
Start between 16+0 and 24+0
Continue until 34+0
46
Offer prophylactic cerclage when
History of cervical trauma OR
History of PPROM
AND cervical length <25mm
47
Contraindications for emergency cerclage
Uterine contractions
Active vaginal bleeding
Signs of infection
48
Diagnosis of PTB at 30+0 or more
15mm cervical length on TV USS (preferred)
OR
Fetal fibronectin >50
Treat for PTB if above tests not available
49
Tocolysis should be given at what gestation?
Consider between 24+0 and 26+0
Offer PTB between 26+0 and 33+6
50
Tocolysis medication
Nifedipine
Oxytocin receptor antagonists if nifedipine is contraindicated (atosiban)
Do not use betamimetics
51
Monitoring of FH in established PTB
Offer IA or CTG if no other risk factors
52
Fetal scalp electrode monitoring should not be used below _____ gestation
34+0
53
FBS should not be used below ______ gestation
34+0
54
Cord clamping technique in preterm babies
60 seconds
Hold baby below the level of the placenta
55
Incidence of PTB
7.3% of live births
56
Gestation for amniocentesis
15+0
Higher risk of low DNA quantity prior to 16+0
57
Risks of amniocentesis
Miscarriage 0.5%
Second sample required 6%
Blood stained sample 0.8%
Maternal cell contamination 1-2%
Rapid test failure 2%
Failed cell culture 0.5-1%
Severe infection
Fetal injury
Maternal visceral injury
58
Risks of CVS
Miscarriage 0.5%
Second sample required 6%
Confined placental mosaicism 2%
Failed cell culture 0.5-1%
Severe infection
Fetal injury
Maternal visceral injury
59
Gestation for CVS
10+0 minimum
Ideally after 11+0 to reduce technical difficulty
60
Pregnancy loss risk for CVS/amniocentesis in multiple pregnancy
1%
61
Risk of cross contamination in multiple pregnancy CVS
1%
62
Risks of 3rd trimester amniocentesis
10% risk cell culture failure
PTB 3-4%
More than one needle insertion 5%
Blood stained sample 5-10%
63
Amniocentesis/CVS considerations with blood borne viruses
Testing required prior to test
Ensure HIB viral load is undetectable
Ensure Hep B viral load is <6.99log10 copies/ml
No evidence for Hep C
64
Maternal mortality rates
11.66 per 100, 000 (white)
65
Definition of early FGR
Onset before 32+0
Fetal size or AC <3rd centile OR absent EDF
OR
<10th centile with uterine artery >95th or UA PI >95th centile
66
Static growth definition
No forward growth velocity in AC or EFW measured 14 days apart
67
Definition of late FGR
>32+0
AC/EFW <3rd centile
OR (2 of the following):
AC/EFW <10th centile
AC/EFW crossing 2 quartiles
Cerebroplacental ratio <5th centile or UA PI >95th centile
68
Definition of FGR in previous pregnancy
Previous baby <3rd centile
PET or FGR requiring birth <34+0
EFW <10th centile with evidence of placental dysfunction
69
Optimal time to start aspirin
11+0 to 16+6
70
Incidence of early onset FGR
0.3%
71
Timing of SFH measurement
First measurement between 26+0 and 28+6
No more than every 2 weeks, at each appointment
72
Method to determine EFW
Haddlock formula
73
Gestation for uterine artery Doppler
20+0 - 24+6
74
Fetal infection accounts for what percentage of SGA?
5%
75
Short femur length is associated with _____________
SGA and PTB
76
Early FGR coincides with maternal hypertension in ________ of cases
70%
77
Treatment for anaphylaxis
1:1000 adrenaline 500mcg IM (0.5ml)
78
Incidence of cardiac arrest in pregnancy
1 in 36000 pregnancies
79
Mortality rate of cardiac arrest
42%
80
Commonest cause of cardiac arrest in pregnancy
Anaesthetic (25%)
81
Commonest cause of maternal collapse
Vasovagal syncope
Epileptic seizures
82
MOH incidence
6 in 1000
83
Incidence of AFE
1.7 per 100, 000
84
Mortality rate with AFE
67 per 1000
85
Incidence of severe perioperative obstetric anaphylaxis
1-3.5 per 100, 000
86
Mortality rate from perioperative obstetric anaphylaxis
1%
87
Tryptase levels following anaphylaxis
After resuscitation has started
1-2 hours later
24 hours later
88
Aortocaval compression in pregnancy reduces CPR cardiac output by _____
From 30% to 10%
89
How to minimise aspiration pneumonitis risk? (Mendelsson syndrome)
Early intubation
Cricoid pressure
H1 anatagonists
Antacids
90
Left lateral tilt angle
15-30 degrees
91
Percentage cardiac output to placenta at term
10%
92
Aortacaval compression impairs venous return by ______
60%
93
Perimortem c/s should be done at ____ gestation and within ___ minutes of cardiac arrest
20+0
5 minutes
94
Fluid replacement in sepsis
30ml/kg within 3 hours
95
Target MAP in hypovolaemia
65mmHg
96
Intralipid infusion protocol
Bolus 15ml/kg over 1 minute then 15ml/kg/hr
Further bolus at 5 minute intervals if no return of circulation
Increase infusion to 30ml/kg/hr if needed
97
Maximum dose of intralipid
12ml/kg
98
Anaphylaxis treatment
1:1000 adrenaline 0.5ml IM
Repeat after 5 minutes
50 microgram IV bolus can be given by experienced Dr
99
Incidence of maternal cardiac arrest
2.78 per 100 000
100
Fetal survival after perimortem C/S
38%
101
Vasa praevia type 1 definition
Vessel connects to velamentous umbilical cord
102
Vasa praevia type 2 definition
Vessels connect placenta with succenturiate lobe
103
Vasa praevia prevalence
1 in 1200 to 1 in 5000
1 in 250 with IVF
104
Survival rates of vasa praevia when diagnosed antenatally with planned delivery
95%
105
Risk factors for vasa praevia
Velamentous cord insertion
Placenta praevia
Bilobed placenta
Succenturiate placental lobes
ART
106
What percentage of cases of vasa praevia resolve
20%
107
Rate of spontaneous version from breech to cephalic at term (primip)
8%
108
Rate of reversion to breech after ECV
3%
109
Factors associated with ECV success
Non-Engagement of breech
Palpable fetal head
Maternal weight <65kg
AFI >10
Tocolysis
Multiparous
110
Reason for c/s in labour after successful ECV
Slow progress
Fetal distress
111
When to perform ECV
37+0
Primips could have from 36 weeks
112
Rate of emergency c/s after ECV
1 in 200 within 24 hours
113
Indications for emergency c/s after failed ECV
Vaginal bleeding
Abnormal FH
114
Recurrence rate of breech presentation
9%
115
APH definitions
Spotting
Minor - <50ml and settled
Major - 50-1000ml with no sign of shock
Massive - >1000ml or sign of shock
116
Abruption incidence
Overall 0.5-1%
4.4% after 1
25% after 2
117
Severe abruption definition
Presence of:
(Maternal) shock, DIC, RBC requirement, hysterectomy, renal failure, death
(Fetal) IUD/NND, non-reassuring status, PTB, SGA
118
Risk factors for abruption
Previous
PET/essential HTN
FGR
PPROM
Old age
Multiparity
Smoking
Cocaine
Intrauterine infection
First trimester bleeding
Low BMI
ART
Abdominal trauma
Multiple pregnancy
Thrombophilia
Folic acid deficiency
119
Complications of abruption
Infection
Anaemia
Shock
DIC
AKI
Couvelere uterus
PPH
Ischaemia of distal organs (adrenal glands/pituitary)
Feto-maternal haemorrhage
Psychological sequalae
120
Risk of hysterectomy with placenta praevia + previous c/s
27 in 100
121
Extra peri-operative considerations for PAS
Ureteric stents
Iliac artery balloon insertion, fill after delivery for haemostasis
122
Risk of recurrence of uterine rupture
5%
123
Risk factors for uterine rupture
Previous c/s
Previous uterine surgery
Previous rupture
High parity
Induction/augmentation
Hyper stimulation
Mal presentation
Macrosomia
Uterine anomaly
Trauma
124
Uterine rupture causes CTG abnormalities in what percentage of cases
55-87%
125
Uterine rupture maternal mortality
17 per 100 000
126
Stage 1 DIC
Hypercoagulable state
Activation of clotting factors and development of microthrombi
Decreased clotting and increased platelet aggregation
127
Stage 2 DIC
Consumptive coagulants state
Increased consumption of platelets and clotting factors
Bleeding
Increased clotting
Decreased platelets
Decreased fibrinogen
128
Stage 3 DIC
Secondary fibrinolytic state
Formation of fibrin degradation products and plasmin
Marked bleeding
Increased thrombin time, decreased clot lysis time, increased fibrin degradation products
129
Prophylaxis of PPH
Correct DIC
Ensure euvolaemia with CVP 5-10mmHg
Synt
Rub up uterus
Keep patient warm
Re-assess DIC status
130
Iron requirement in pregnancy
2.5mg/day first trimester
6.66mg/day third trimester
131
Iron deficiency ferritin level
<30
132
B12 deficiency complications
PTB
Low birth weight
133
Maternal Complications of iron deficiency anaemia
PPH
Sepsis
PPD
Fatigue
Maternal death globally
134
Fetal complications of iron deficiency
Perinatal and neonatal mortality
SGA
PTB
Neurodevelopmental impairment
135
Oral iron replacement regime
Recheck Hb 2-3 weeks
Continue for 3 months or 6 weeks post partum
136
High dose folic acid for which women?
BMI >30
Taking AEDs
Previous affected pregnancy
Family history
T2DM and T1DM
Sickle cell disease
Thalassaemia
137
How is HbA2 measured
With HPLC test
138
HbA2 is _______ in sickle cell/thalassaemia carriers
Higher
139
Complications of thalassaemia
Hypersplenism
Delayed puberty
Hormone problems
Cardiomyopathy
Hepatitis, fibrosis, cirrhosis
Joint pains and osteoporosis
140
Chromosome deletion in alpha thalassaemia
16p
141
Alpha thalassaemia trait
2 abnormal alleles
Mild anaemia - hypochromic microcytic
142
Haemoglobin H disease
Unstable haemoglobins
Tetrameric gamma chains (Bart’s)
Tetrameric beta chains (H)
143
Blood film features of haemoglobin H disease
Microcytic hypochromic anaemia
Target cells
Heinz bodies (precipitated HbH)
144
Risk of cord prolapse with breech
1% footling breech (10% breech babies)
145
Contraindications to VBAC
Previous uterine rupture
Classical incision
Other absolute contraindications
146
Incidence of OASI after SVD
3.6% overall
Pri 5.4%
Multip 1.6%
147
Incidence of OASI after instrumental delivery
Pri 7.8%
Multip 4.8%
148
Repair of anorectal mucosa technique and suture
Continuous or interrupted
3-0 polyglactin
149
IAS repair technique and sutures
Repair separately from anorectal mucosa and EAS
Interrupted or mattress sutures, do not overlap
Use 3-0 PDS or 2-0 polyglactin
150
EAS repair technique and suture material
End to end for 3a and 3b
Can use overlapping for full thickness EAS tear
Use 3-0 PDS or 2-0 polyglactin
151
Prognosis of OASI
60-80% asymptomatic at 12 months
152
Mode of delivery after OASI
C/S if has symptoms after 1 year or abnormal endoanal ultrasound
153
Sub-occipito bregmatic diameter is
9.5cm
Flexed OA
154
Suboccipito-frontal diameter is
10cm
Incompletely flexed OA
155
Occipito-frontal diameter is
11.5cm
OP position
156
Submento-bregmatic diameter is
9.5cm
face presentation with head completely deflexed
157
Submento-vertical diameter is
11.5cm
Face presentation incompletely extended
158
Mento-vertical diameter is
13.5cm
Brow presentation
Cannot deliver vaginally
159
Risk of SGA with low PAPP-A
25%
160
BM targets in women with pre-existing diabetes
Fasting <5.3
1 hr Post prandial <7.8
2 hr post meal <6.4
Timing range >70% if using continuous monitoring
161
Best method to measure BM for pre-existing type 1 DM
Continuous glucose monitoring - reduces LGA, NNU admission and hypoglycaemia
Consider for type 2 when not meeting targets
162
Retinopathy screening timing
At booking
At 16-20 weeks of disease
28 weeks
No restrictions on treatment in pregnancy
163
Risk of type 2 diabetes after GDM
50% in 5 years
164
Offer insulin for GDM at diagnosis when
Fasting glucose >7
OR
Fasting 6-6.9 with fetal macrosomia or polyhydramnios
165
Start merformin/insulin for GDM after trial of diet when ____
Fasting BM > 5.3
BM >7.8 post meal
166
GDM timing of birth
Offer T+5 if uncomplicated
Deliver no later than T+6
167
HbA1c measurement for pre-existing DM
At booking and each trimester
168
Recommended delivery mode and timing after uterine transplant
37/40
Caesarean delivery
