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.
Multiple pregnancy counselling
Most multiple pregnancies are completely healthy and normal. but complications are common
Maternal
- increased risk of Anaemia, pre-eclampsia and diabetes hence will be monitoring these
Foetal
- greater risk of prematurity (as they are delivered earlier than usual)
- will receive more frequent serial growth scans (every 2 weeks for monochorionic from 18wks and every 4 weeks for dichorionic from 24wks)
Labour
- aim to deliver at 37 weeks (or potentially earlier if MCMA) as there’s greater risk of stillbirth (sharing space and sharing placenta means there’s more problems)
Investigations for obstetric jaundice
Bedside: - obs - general inspection of patient for jaundice and excoriation marks - pregnant abdominal examination Bloods - FBC - U and Es - LFTs (WEEKLY) - Bilirubin - Clotting (prolonged due to reduced ADEK absorption due to cholestasis) Imaging - USS
Obstetric cholestasis management
NB in primary care: arrange same day referral to local maternity unit if you suspect obstetric cholestasis (so that bile acids can be measured and fetal wellbeing assessed)
Treat immediate symptoms of itching:
- Medical: ursodeoxycholic acid (reduce cholesterol absorption so less bile acid made)
- Lifestyle: emollients, loose fitting clothing
Maternal
- Consultant led care
- IM vitamin K
- wear loose clothing to help with itching.
- weekly LFTs
- Emollients may help
Foetal
- closely monitored
- pay close attention to foetal movements and come to triage if any problems
Labour
- deliver at 37 weeks (induce) to reduce risk of stillbirth. Offer continuous foetal monitoring at birth (really severe cases may require delivery earlier at 36wks)
- arrange appointment after delivery to follow up and make sure LFTs have returned to normal
IUGR counselling (after reading USS graphs)
Maternal:
- care under consultant
Foetal:
- scans will happen on a weekly basis to monitor growth and (growth scans every 2 wks, doppler scan weekly)
- CTG will also be done every week to monitor baby
Delivery:
- 37 wks but ultimately decision is consultant led
- IM steroids may be given if before 34 wks
Safety net:
FRAB = come back
How does amniotomy help with labour
it allows the foetal head to directly press on the cervix to dilate it
Prolonged labour Ix and management
Ix:
- CTG
- Bloods: FBC, Group and Save (preparation for delivery/theatre)
Rx;
- CTG to monitor foetal wellbeing
- ARM–> augmentation of labour via oxytocin infusion (syntocinon infusion) –> consider instrumental delivery –> c section if can’t
- regularly assess the cervical dilatation, foetal and maternal wellbeing throughout labour
When is ecv done in nullips vs multips
nullips = 36wks multips = 37wks
Bartholin’s cyst Rx
Blocked duct in vagina
Asymptomatic cyst = observation, warm compress and warm baths to encourage spontaneous rupture, simple analgesia
symptomatic cyst/abscess = marsupialisation or word catheter drainage + antibiotics
Word catheter:
- setting: outpatinets
- Anaesthesia: Local anaesthetic
- risks: infection, bleeding
- duration: 15- 30 mins
if pt >40 may need to send histology to rule out malignancy
- afterwards: pain relief, rest 1-2 days, warm baths (avoid bubble bath as that can irritate the wound)
- advise against tampons to reduce risk of infection
- sex: avoid due to infection risk
- safety net
Management of pre-existing diabetes who are now pregnant
- pre pregnancy optimisation before getting pregnant
- weight loss for women with BMI of > 27 kg/m^2
- stop oral hypoglycaemic agents, apart from metformin, and commence insulin
- folic acid 5 mg/day from pre-conception to 12 weeks gestation
- detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts
- tight glycaemic control reduces complication rates
- treat retinopathy as can worsen during pregnancy
labour:
- induce by 38+6 weeks
