Babies 2 Flashcards
Risk factors for vaginal prolapse
Obesity Chronic cough Chronic constipation Post-menopausal (lack of oestrogen = weakens support structures) Connective tissue disorders
vaginal prolapse management
Conservative: pelvic floor exercises, minimise heavy lifting, lose weight, healthy diet, stop smoking
Medical: oestrogen cream (good if pt has atrophic vaginitis too. Strengthens epithelium), ring pessary
Surgery
Vaginal prolapse Ix
Bedside:
obs, abdominal examination, speculum, bimanual (rule out other causes)
ask pt to cough and see if it can be reduced digitally
-Weight and height to measure BMI
(examination often is sufficient)
Leavtor ani muscles
Puborectalis
Pubococcygeus
Iliococcygeus
Heavy menstrual bleeding Ix
Bedside: obs abdo exam - fibroids speculum - rule out intravaginal/cervical cause bimanual- fibroids Pregnancy test Bloods: FBC, iron TVUSS: Consider Ultrasound or outpatient hysteroscopy
Idiopathic heavy menstrual bleeding Rx
Wants to be get pregnant: Tranexamic acid
Does not want to get pregnant: LNG-IUS
+/- iron supplementation
- we dont think there is an obvious cause of bleeding
- however, I can see that this is clearly affecting your day to day life so there are things that we can give you to help you..
Gestational Diabetes cutoffs
o Fasting plasma glucose > 5.6 mmol/L
o 2-hour OGTT > 7.8 mmol/L
Gestational diabetes Rx
Explain diabetes and what it means
Counselling management AND complications for:
Maternal, Foetal, Labour
Maternal:
- will receive treatment (see below) (diet and lifestyle first line, dietician involvement possibly)
- care will be under consultant
- closely monitoring her blood glucose (see timings below)
- Greater risk of GDM and T2DM in the future
- will teach you how to monitor glucose at home.
- greater risk of pre eclampsia
- Regular blood glucose monitoring: fasting, pre-meal, 1 hour post-meal and at bedtime
Foetal:
- monitor baby, regular growth scans from 28 weeks every 4 weeks to look for size of foetus, amniotic fluid volume, umbilical doppler, placenta
- greater risk of macrosomia/traumatic delivery and neonatal hypoglycaemia
- CONTINUOUS monitoring during labour to look for foetal distress
Labour:
- WILL happen on labour ward since shes high risk
- could be offered elective caesarean at 39 weeks if macrosomic baby
- shoulder dystocia
- deliver by 40+6 weeks latest before baby gets too big/increased risk of stillbirth
- traumatic delivery
Long term/postnatal
- increased risk of gestational diabetes and T2DM in future
- Postnatal: newborn should be fed early and at frequent intervals, capillary glucose should be maintained > 2 mmol/L. Stop all medication (metformin and insulin) after delivery. This is because she will get massive hypo after since she’s also breastfeeding
- advise to encourage breastfeeding within 1st hour due to risk of neonatal hypoglycaemia.
- Follow-up the mother after birth to check whether diabetes has persisted
STEP 1: trial of lifestyle changes (for 1-2 weeks)
STEP 2: metformin (for 2 weeks more)
STEP 3: insulin (start straight away if fasting glucose >7)
target level of plasma glucose in pt with Gestational diabetes
Fasting plasma glucose < 5.3 mmol/L
2-hour post-meal < 6.4 mmol/L
In a woman with pre-existing diabetes, what is important to arrange at the first antenatal visit?
Digital retinal assessment
Renal function (creatinine, urinary albumin: creatinine ratio)
Measure HbA1c
why is macrosomia associated with stillbirth
large babies have nutritional demands > than the supply that can be offered by the placenta
Vaginal breech vs C section counselling
Benefits of vaginal breech: (hands off)
- if successful , has the fewest complications. However 40% risk of needing an emergency c section
Benefits of C section
- small reduction in perinatal mortality for baby
- immediate risks: wound infection
- implications on future pregnancy (VBAC, placenta praevia and uterine rupture)
ECV contraindications
Issues with the baby: - Abnormal CTG - Multiple pregnancy Issues with the membranes: - ruptured membranes Issues with the uterus: - Major uterine anomaly - Recent antepartum haemorrhage (last 7 days)
VBAC benefits and risks counselling and factors to consider
VBAC: (success rate approx 75%)
Benefits:
- avoid risk of surgery: infection, faster recovery, fewer scars, less blood loss
Risks:
- uterine rupture
- therefore may require emergency
Factors to consider:
- when was your last pregnancy? (<18 months since last pregnancy = higher risk)
- what type of c section scar do you have? (classical c section poses much higher risk of rupture and is a contraindication)
- any other previous surgeries on the uterus that may affect the uterus?
- any previous experience of vaginal deliveries before or after your c section?
HIV during pregnancy counselling
• Explain the need to be seen at a joint HIV physician and obstetric clinic every 1-2 weeks
• Explain the need to monitor viral load every 2-4 weeks, at 36 weeks and at delivery
• Stress the importance of good compliance with ART
• Discuss options for delivery (depending on viral load at 36 weeks gestation:
- <50 copies = vaginal delivery
- >50 copies = c section recommended
• Advise not to breastfeed
• Neonates are given ART within 4 hrs of birth and tests (PCR) will be done further down the line to check if baby has got HIV.
