Conditions and assessments Flashcards
APH-
Assessment, referral + mgmt
APH : any PV bleed from 20wks (before onset of labour)
Assess
1) obs - assess harmodynamic stability
2) EBL (some may be concealed)
3) locate placenta (rule out placenta praevia)
4) palpitation- tender, tone, lie, contractions, movements, SF
measurement
5) CTG
Referral- Consult
Mgmt
1) stabilise woman- lay flat, Iv fluids, blood transfusion
2) site IV and take bloods (CBC, kleihaier, G+S, coag bloods)
3) do speculum
Pre eclampsia Assessment
Assessment
BP
-to confirm hypertension (140/90 x 2 consecutive >4hrs apart)
Bloods
(gold- LfT, renal), (purple- platelets)
MSU- PCR (>30)
Ask about neurological, RUQ or epi gastric pain
Consider utero placental insufficiency (Placental abruption, IUGR)
Confirm PE
Hypertension + 1 other sign
Referral- transfer
Mgmt
Stabilise BP (Labetalol, nifidipine, methyldopa)- conservative mgmt and monitor until term
If BP unstable- mag sulphate, expedite birth (give steroids <35wks, mag sulphate <30wks)
Assessment for reduced Fetal movement
When do you do the assessment
Gestation >28 wks
Asap (don’t delay)
Primary assessment
- measure fundal height and plot on customised chart
- Maternal obs
-CTG monitoring
- screen for stillbirth risk (previous still birth, diabetes, FGR, age, hypertension)
If there are risk factors or Recurrent RFM
Referral- consult
Growth scan+ dopplers + AFI
PTL
Definition, assessment, referral, mgmt
Definition-
Painful cx + cervical change before 37 weeks
Assessment
Maternal Obs (infection?)
Auscultation (CTG> 28 wks)
Palpation- position, contractions
Bloods - Fetal fibronectin (24-36 wks), CBC, CRP
MSU- UTI
Speculum- VAginal assessment, SROm?, bleeding, amnisure, partisure, swabs
VE- maybe (not absolutely contraindicate)
Referral
>34wks- Consult
<34 wks- Transfer
Notify NIcU
Mgmt
<24wks- rescue cerclage?
Tocolysis? (<34wks gestation, safe to delay)
Steroids (24-35wks, 2 doses, 24hrs apart)
Mag sulphate (<30wks)
AB’s (GBS prophylactic- unless CS and membranes intact)
PROM
Definition / Assessment, mgmt
Definition
rupture of membranes prior to established labour
>37 wks
(70% women labour spontaneously by 24hrs)
MW role
*MW should assess all women to check maternal + fetal wellbeing (can be at home)
Assessment
* GBS risk factors (bacteriuria, previous GBS infected bbay, fever, GBS+ swab not ruled out by GBS- swab)
* liquor- colour, volume, smell
* obs (temp+ FHR)
* Palpation (tender?)
* Speculum (if unsure SROM)
* VE Contraindicated! (chorioamnionitis)
* FHR / movements / presentation
Mgmt + Referrals
moderate / thick Meconium - Consult (IOL)
Fever - Consult–> broad spctrum AB’s + IOL + NICu notified
If GBS risk factors –> consult - IOL + AB prophylactic
Clear liquor /n o fever / no GBS risk factors
* await labour
* COnsult <24hrs - recommend commence IOL / GBS prophylactic AB’s
Post birth
- if <2 doses AB’s given, 24hr obs on baby
- Monitor baby for GBS infection (RDS/ fever / signs of sepsis)
Meconium liquor (thick / moderate)
Risks / Mgmt / referrals
Risks
* mec may indicate baby is hypoxic
* baby may breathe in mec (mec aspiration syndrome) - interferes with nomral breathing- can lead to RDS/ infection / pneumothorax / persistent pulmonary hypertension
usually term babies
Mgmt
Consult (thick / moderate only)
CTG, IOL / prepare to suction non-vigours infant (not routine)
monitor baby for RDS, may develop into mec aspiration syndrome
Cord prolapse
definition/
definition
when loop of cord is alongside (occult- can’t be felt via VE) or past (overt- can be felt via VE) presenting part + membranes are rupture
Emergency- perinatal morbidity / mortality
Physiology
- cord presentation (umbilical cord sits between leading part and internal os, with membranes intact]
- when waters break, there is risk of cord prolapsing through cervix into vagina
- risk of fetal hypoxia with fetal weight on cord
**Risk factors **
ill-fitting presenting part ( malpresentation (e.g. footling breech) / unengaged / poorly applied )
ARM with unengaged presenting part- esp in presence of polyhydramnios
vaginal manipulation of fetus
external cephalic version
preterm
polyhydramnios
second twin
SIGNS
Difficult to predict impending cord prolapse (i.e. presentation)
abnormal FHR- early decels then prolonged decel/ bradycardia
**Referral- Emergency
**
mgmt
always check FHR before / after amniotomy + SROM
advise women with known risk of cord prolapse (e.g. malpresentation) to go to hospital if ROM
call for help
knees to chest / exaggerated SIMs
stop oxytocin (if running)
elevate presenting part (digitally or bladder filling)
Don’t touch cord (causes vasospasm)
Expedite birth (Vaginal if possible / caesarean - consider tocolysis)
Venous Thromboembolism
Physiology/ risks/ assessment /referrals/ prevention
**Physiology
**maternal body is “hypercoagulable” during pregnancy (esp end of pregnancy)
creates risk:
1) DVT- blood clots (thrombus) forms in deep veins
2) PE- thrombus can travel (embolus) to lungs and block blood to lungs
**Risk factors **
factors stopping circulation (C section / lack of mobilising)
smoking
>35 years
>
PPH >1L
Forceps
previous venous thromboembolism (CONSULT)
Assessment
1) DVT-
[ MW needs to distinguish DVT from normal oedema +/ varicose veins]
SIGNS-
* Calf pain (crampy / sore) “homan’s sign” (flex knee, forcibly dorsiflex ankle (pain should appear behind knee)
* swelling (in affected limb) (varicose vein is bulging/ bluish vein)
* change of colour
* warmth on affected area
2) pulmonary embolism
chest pain, shortness of breath
referral
suspected DVT- Transfer
Pulmonary Embolism- Emergency
prevention
early ambulation
anti-coagulant (clexane 40 mg)
mobilising
compression socks
hydration
avoid combined oral contraceptive
Uterine Rupture
what is it / Risks / Risk factors / Signs / management
what is it
trauma to uterus
- “incomplete” partial separation (Dehiscence) / windows - fetus/ placenta / cord is retained in placenta
- “complete rupture- tear through uterine serosa, fetus spills into cavity
Risk
fetal morbidity / haemorrhage
risk factors
uterine scar (e.g. C section)
IOL / augmentation
Classical scar / recent / complicated scar
poor wound healing
condition causing overdistension of uterus (macrosomia/ hydramnios/ multiples / choriocarcinoma)
obstructed labour
signs
abdo pain between contractions
prolonged fetal bradycardia
sudden cessation of contractions
PV bleeding / haematuria
maternal tachycardia / hypotension
shoulder tip pain / chest pain
SOB
Management
1) Maternal resus
2) CS
3) uterine rapair or hysterectomy
Transient tachyapnoea of NB
physiology/ signs / Refer/ mgmt
what is it
temporary condition
caused by excess fluid in lungs at birth and / or mild surfactant deficiency- so neonate has increased WOB
usually <34wks (but can be >35wks)
**Risk factors
CS without labour
Signs
respiratory distress ( tachyapnoea, grunting, nasal flaring, inward drawing of ribs)
Refer-
consult - persistent tachypnoea
Transfer (pallor / cyanosis/ persistent grunting)
Management
should spontaneously resolve 24-48hrs
may be treated with oxygen + AB’s
miscarriage
Definition / Types /
definition
<20 wks / <400g (after that, it is stillbirth)
**Types **
1) threatened
* bleeding - usually self limiting (may be trophoblastic implantation)
* lower abdo / back pain
* increased risk of miscarriage / PTL / IUGR
2) inevitable / imminent
* PV bleeding persists
* cervical dilation or ROM
* on scan - non-viable embryo or empty sac
* maybe contractions / cramping
complete
* passed POC
* Pain + bleeding usually subside
* USS confirms
* hCG values gradually fall
incomplete (* have not passed POC)
*bleeding + pain may persist
D&C required
more likely 6-14 wks
*bleeding heavy +cervix remains open (increased infection risk)
septic bleeding
Hx recent pregnancy
pyrexia / malaise / abdo pain /++ PV dx (prulent) and bleeding
investigations
serum hcG 48-72hr intervals
Respiratory distress syndrome
what is it/ risks / signs / Referral / management
what is it
neonatal condition- usually preterm
caused by inadequate surfactant production (most surfactant produced after 30wks(
– surface tension in lungs is too high—> air sacs collapse on expiration —> increased WOB–> hypoxic / increased CO2
–> baby becomes fatigued, apnoic / hypoxic
**signs **
Respiratory distress (tachyapnoic/ grunting/ diminished breath sounds/ inward drawing of ribs / nasal flaring/ cyanosis)
**Referral ** Transfer
Megaloblastic anaemia
what is it, Signs (lab results) / mgmt
what is it- abnormally Large RBCs, caused by B12+ Folate deficiency
signs- Normal ferritin, low Hb
mgmt-
B12 + folate supplement
haemolytic anaemia
what is it / referral
low Hb due to breakdown of RBC’s (eg Sickle Cell / HELLP /PE)
Referral- Transfer
Hyperemesis gravidarum
what is it, cause, mgmt
debilitiating and can lead to severe medical complications (most common indication for early hospital admission)
symptoms usually start at 6wks, 90% women improve by 20wks
more common with multiple gestation /molar pregnancy
characteristics
* persistent vomiting leading to fluid / electrolyte depletion
(small PU voids), marked ketonuria,
nutritional deficiency
rapid weight loss
Cause:
unknown / multifactorial
hormonal- hcg
gastric issues
ANS changes
nutritional deficiencies
psychological
high thyroxine
Assessment
Rule out pyleonephritis / molar pregnancy
obs- tachycardic / hypotensive /hypovolaemic / acidotic and ketonuric- hospital admission
mgmt goals
allegiate nausea / vomiting
correct dehydration + electrolyte abnormality
prevent further weight loss
provide emotional support
first line treatment- rest / diet / lifestyle
medication- ginger, antihistamines, pyridoxine (b6), metoclopramide, ondansetron (not T1)
prolonged first stage
definition / mgmt / referral
Definition:
* Primip: <2cm dilation / 4hrly VE
* multip: slowing of progress
* consider other signs of progress
mgmt
* positions / environment / bladder/ hydration + FLuids
referral: Consult
prolonged 2nd stage
definition / mgmt / referral
definition
- >2hrs primip
- >1hr multip
mgmt
* VE to (position / station/ attitude)
* position
* hydration
* bladder
* augmentation
* transfer from home
referral - COnsult
obstetric cholestasis
what is it, risks, signs, assessment, management
what is it
high bile acids build up- contribute to fetal demise
risks
fetal- preterm birth / stillbirth / mec amniotic fluid / NICU
mum - sleep depression, increased risk GDM + PE
assessments
* pruiritis hands and feet (absence of skin rash)
* pale clay poo
* dark urine
* family hx
* abnormal Lft, bilirubin, bile salts
–> viral screen + PET screen
liver USS
Referral- Transfer
management
* manage pruiritis
* expedite birth (based on Lft)
* Review LFT’s 3wks post partum
* beware risk of recurrence with future pregnancy / use of oestrogen based contraceptive
Principles of bladder care
**labour
**PU 4hrly (with catheter if needed)
epidural- IDC, deflate IDC in 2nd stage (replace post birth)
instrumental- ensure bladder is empty
postnatal
*woman without IDC-
* void <6hrs, * 2 PU >200ml, * check bladder feels empty / flow + vol normal
woman with IDC
* keep IDC >6rs after epidural removed (confirm woman is mobilising )
* 1st void <6hrs after IDC removed, 2 voids >200ml
Rhesus negative women
what is the issue, risks (events), management, side effects
issue
some women have Rh Neg blood group- means they don’t have do Rh antigen on RBC’s.
most people DO have Rh antigen.
if maternal and (Rh pos) fetal blood mix, mum creates antibodies that “attack” fetal cells
Risks ( isoimmunising events)
* trauma (Car accident)
* ectopic pregnancy
* miscarriage >12wks (Anti D not required before then)
* stillbirth
* Amniocentesis / CVS
* APH
* Forceps
Management
**Antenatally **
- - 625 IU Anti D prophylaxis 28 + 34 wks
- Anti D for isoimmunising event (within 72hrs) (as well as prophylactic)
- <12 wkS 250 IU (only if there is repeated pain)
12-20 wks- 250 IU (No Kleihauer)
>20wks- request Kleihauer - use this to determine additional dose req)
Postnatal
- <12 wkS 250 IU (only if there is repeated pain)
- Confirm baby’s blood type + Coombs
- if baby is Pos- give mum 625 IU prophylactically
side effects
some women have Severe hypersensitivity (incl. anaphylaxis) - (agonist- adrenaline)
women with bleeding disorders should have Anti D IV / SC
Placental abruption
risk factors, presentation
Risk factors
previous abruption
sudden reduction in size of overdistended uterus
Prolonged ROM
chorioamnionitis
PE / hypertension
IUGR
substance abuse / smoking
trauma
advanced maternal age
grand multip
thrombophilia
ECV
Vasa praevia
risk factors, presentation
risk factors
low lying placenta, succenturiate lobe / bipartite placenta, valementous insertion
presentation
PV blood loss after ROM
No maternal shock
acute fetal compromise (bradycardia / sinusoid CTG)
palpable vessel with VE
VBAC
Referral, Risk factors for requiring CS (during TOL), contraindiations
Signs of uterine rupture
Referral- consult
**
risk factors-**
BMI>30, induction, no previous vaginal birth, previous CS was for labour dystocia
contraindications-
classical CS, short time between births, previous uterine rupture, multiple CS’s
sign of uterine rupture
abnormal CTG
abdo pain - persisting between contractions
chest / shoulder tip pain / shortness of breath
scar tenderness
bleeding (PV/ haematuria)
contractions stop
maternal tachycardia / hypotension / shock
loss of station of presenting part
Diabetes - Type 1 + Type 2
BGL’s in pregnancy physiology of DM, Risks, Referral, management
physiology
DMT1- pancreas doesn’t make insulin, so BGL’s too high - requires exogenous insulin
autoimmune response
DMT2- body is less sensitive to insulin, and produces less
**BGL’s in pregnancy
**pregnancy hormone hPL reduces insulin sensitivity, so harder to maintain stable BGL’s
Risks
* maternal- hyperglycaemia –>retinopathy, nephropathy, ketoacidosis, cadiavascular disease)
* fetal- Still birth, fetal abnormalities, LGA, Preterm labour + birth, IUGR
Referral- Transfer
management
folic acid (5mg (higher)
diet + lifestyle
metformin
insulin therapy
emergency plan for ketoacidosis
Obstetric clinic monitor BGL’s / adjust insulin + diet
colostrum harvesting
postpartum- insulin levels should return quickly
Gestational Diabetes
definition, physiology, risks, risk factors, MW role + screening, Referrals, mgmt
definition
* hyperglycaemia first recognised in pregnancy (can be any type of DM, first picked up in pregnancy)
* usually disappears after birth (but increased risk of DM T2 in later life)
physiology
from 20 wks, Hpl increases insulin resistance, can cause BGL’s to increase
risk
macrosomia, hypertensive disorders (PIH, PE), Miscarriage, polyhydramnios, UTI’s, PTL, thrush
Risk factors
family hx diabetes
age / BMI
ethnicity
Previous macrosomia / stillbirth
PCOs
MW role + Screening
responsibility to: “inform women that obesity is leading to increaed incidence of diabetes, and offer screening”
HbA1C<40
Urinalysis
26-28wks OGTT / Polycose
If high risk (e.g. HbA1C 40-50, then have OGTT at 24-28wks)
**Referrals
**diet / metformin- consult
insulin- transfer
Mgmt
Antenatally- Diet / metformin/ insulin
intrapartum-
Postnatal- AN treatment should be discontinued
Hypoglycaemia of NB
what is it / risk factors/ signs + symptoms, management
**What is it
BGLs < 2.6mmol
associated with brain injury / death
**
Risk factors
Preterm (<37wks)
SGA (<9th) / LGA (>98th)
Maternal DM
Hypothermia
severe fetal distress
asymmetric growth with fetal distress and / or mec
unwell
sepsis
Signs / symptoms
- may be asymptomatic or symptomatic
- General signs- poor feeding / sleepiness /irritability –> require xx feeding / monitor temp
- Further signs- jittery / tachynopea/ hypothermia
- Urgent review - BGL <2.0, cyanosis, seizures, apnoea, floppy
**Management for babies at risk
- feed asap after birth, THEN 3hourly –> - consider EBM /colostrum / PDM / formula if (?)milk transfer 2hour post feed- BGL >2.6?
- check BGL 3-4hrs post birth (prefeed)–> 2.6?. If <2.6, repeat 3hourly until 3 consecutive readings >2.6
- if 1st BGL <2.6, consult NICU and give dextrose, then recheck 30mins later
- if BGL <2.0 or 2nd BGL (After dextrose) is <2.6- transfer
External cephalic version
indication
**what is it
**procedure in which fetus is rotated from non-cephalic presentation by manipulating mum’s tummy
40-64% success rate
process
offer 35-36wks (primip), 36-37wks (multip)
have terbutaline prior to procedure
offer 625IU anti-d to Rh Neg women
**
complications**
transient fetal distress
abnormal CTG
bleeding PV
abruption
emergency CS
fetal death
contraindications
-anything that contraindicates vaginal birth (placenta pravia / previous classical CS)
- placental abruption
- abnormal CTG
-severe uterine / fetal anomaly
- severe oligohydramnios
- ROM
- multiple pregnancy (except for birth of 2nd twin)
**complications
**- SGA baby (with normal dopplers)
- PE
- Oligohydramnios
- major fetal anomalies / uterine surgery
- APH within last 7 days
GBS
what is GBS + risks / risk factors / risk based approach / signs of GBS infection (maternal + neonatal)
What is it
- ‘normal’ transient bacteria in vagina - usually harmless. cannot be eradicated with AB’s
- can cause infection in woman’s genital tract (UTI’s) , placenta or amniotic fluid–> miscarriage / stillbirth/ sepsis/ meningitis
- can be transmitted to baby vaginally and cause neonatal GBS infection (up to 3mths)
**neonatal GBS infection types
**- early onset (<7 days)- 70% Symptomatic at birth, 95% symptomatic <24hrs
- late onset (up to 3mths)
**Mgmt
1) screen women for signs of GBS infection
**Signs of GBS infection (maternal)
pyrexia (37.8)
tachycardia
chills / malaoise
fetal tachycardia
purulent liquor /PV discharge
uterine tenderness
laucocytosis
2) asses risk factors for GBS during pregnancy
- GBS pos swab (unless GBS neg swab >37wks)
-GBS bacteriuria
-previous baby infected with GBS
- ROM >24hrs (unless GBS neg swab >37wks)
-intrapartum fever (>38 degrees)
preterm
mgmt
- incidental GBS finding - don’t bother treating. reswab at 37wks
- GBS bacteruria /UTI- treat with braod spectrum AB’s, adn then use intrapartum prophylaxis
-Anyone with risk factors- narrow spectrum Prophylactic AB’s (and IOL if PROM>24hrs) regardless of ROM
4) women with clinical signs infection- immediate IOL + broad spectrum AB’s
note- prelabour elective / emergency CS do not require prophylaxis
Signs of neonatal GBS infection
RDS (grunting / breathing issues)
signs of sepsis
temp instability
seizures/ stiff /limp
fever
Chorioamnionitis
clinical signs / referrals/mgmt
signs
* pyrexia (≥38) “maternal fever”
+ 2 or more
-abdo tenderness
-PV discharge / liquor
-maternal / fetal tachycardia
(ROM not necessary_
referral- consult
mgmt- broad spectrum AB’s, fetal monitoring
Sepsis (maternal)
what is it / risk factors / signs/ referral /mgmt
aka septicaemia
**what is it*
** an abnormal immune response to an infection you already have (typically bacterial(GBS E Coli, Group A, also viral (influenza, Herpes, CMG, Varicella)
life threatening- immune system starts attacking organs / other tissues **
**Risk factors
**- impaired immune system
- GDM
- obesity
- has had invasive procedure (C section / forceps, RPOC / Cathether / PROM)
- Contact with people with Group A strep
- ongoing / smelly PV loss / wound infection
- fetal tachycardia / non-reassuring CTG
Signs
[Sepsis can be challenging to identify early as symptoms may be subtle / mimic pregnancy]
Don’t exclude sepsis if temp is normal/low (paracetamol may be masking sepsis)
Slurred speech /confusion
Temperature - extreme high / low
tachyapnoic
tachycardic (maybe maternal or FHR)
hypotensive (systolic)- clammy + sweaty
new onset / pain
Genital tract sepsis may also- ++ / offensive PV dx, diarrhoea, nausea/ vomiting
Refer
TRANSFER
Management
Give 3 (oxygen, fluid challenge, IV antibiotics)
Take 3 (bloods + cultures, lactate, urine output, swabs )
consider 2 (birth or ROC / thromboprophylaxis (risk of DVT/ PE)
Sepsis (neonatal)
Signs
same as adult (temperature extremes, tachycardic, hypotensive)
but also (RDS, bradycardic, cyanotic episides, poor feeding, lethargy irritable, unstable BGL’s abdominal distension unexplained jaundice, umbilical flare)
PPH
definition, risk factors, assessments, referrals, mgmt
definition:
*excessive bleeding after birth–> haemodynamic instability
>500ml + continuing (Vaginal birth)
Primary bleeding- first 24hrs Postpartum
secondary bleeding- 24-6 wks post partum
Risk factors
hx previous PPH
LGA
Placenta praevia / accreta
Hypertensive disorders
obesity
high parity
bleeding disorders
IOL/ AUgmentation
long 1st /2nd stage
Fast labour
instrumental / CS / Retained placenta/ lacerations
**Causes **
uterine atony - shoulder dystocia, long labour,
arterial bleeding (forceps, episiotomy)
retained products
thrombosis- thrombocytopaenia, clotting disorder
Assessments
feeling unwell / lightheaded / fainting
pallor / cold peripheries
tachy or bradycardic / hypotensive
confused / agitated
referrals
>500ml with ongoing loss - Consult
ongoing uncontrollable bleeding - Emergency
**
Mgmt
- Deliver placenta
- rub fundus (helps uterus contract)
- baby to breast
- uterotonic
- empty bladder
Obs (BP/ HR) / EBL
Take bloods (CBC + G&H) + site IV line
Call for help
Give oxygen / lie flat
Put up fluids
** Stop bleeding
*** - Uterotonic (Synotocin 10 IU (1ml) / Syntometrine 1ml (5 IU syntocin +500mg ergometrine)/ oxytocin infusion (40 IU / 500ml)
* - TXA
* misoprostil / carboprost
Check perineum for retained products / bleeding vessel
send coag bloods away
Woman complains of heartburn
physiology
pressure from uterus (late pregnancy)
relaxing of oesophageal sphincter
food is in stomach for longer (due to reduced peristalsis / gastric secretion)
Symptoms-
burning / pain in chest
feeling full /heavy / bloated
assessment
confirm it’s not PE (check BP / Other possible signs)
start with dietary changes (avoid spicy / greasy food, acidic products, carbonated drinks)
what is Brandt
Andrews manoeuvre
CCT
describe intrapartum care for twins
basic interventions/ birth of 2nd twin / 3rd stage)
basic care
continuous monitoring / OB present/
birth of 2nd twin
- continously monitor T2 FHR
- check lie (cephalic), presentation, position - consider ECV?
- ensure labour is progressing? augment if not.
3rd stage**
- don’t give ecbolic until T2 born**
- once ecobolic given, CCT to both cords simultaneusly
**- don’t take cord bloods until after T2 born
**- be prepared for PPH
Chronic hypertension
risks + mgmt
risks- PE / SGA
Mgmt-
* commence aspirin + Ca 12-16wks-36wks
* discontinue ACE inhibitors in pregnancy –> keep BP stable with labetalol, nifidipine
* Monthly scans from 28-30wks ( SGA guideline)
* monitor BP AN /Intrapartum / postpartum
*
Describe the types of twins
physiology/ risk factors / timing of separation?
**Dizygotic (fraternal)
**2 ovum released. 2 sperm fertilise. 2 zygotes implant.
may share a placenta, but unlikely to have issues with vessels
DCDA - 2 Chorion +2 AMNION
share ~50% genetic material (same as non-identical siblings)- 50% same sex, 50% different
causes- IVF, maternal age (release more ovum naturally), familial
Monozygotic (identical)
1 ovum + 1 sperm = 1 zygote. zygote then separates to form 2 identical zygote. share 90% DNA- physically + psychologically very similar.
may share placenta / chorion/ amnion
- ~30% DCDA - separate placenta. split before 3 days (before placenta has formed)
- MCDA - share placenta +chorion, but separate amnion (3-9 days- before amnion formed)
- MCMA- share amnion (9-12 days)
- conjoined- >12 days
Stable Pre-eclampsia
**“controlled” hypertension (staying < 160/110)
no severe features
unstable Pre eclampsia
definition
management/ referrals
timing of birth
**definition
**severe hypertension (>160/110)
worsening signs /symptoms / bloods
HELLP
mgmt
Transfer of care
consider mag sulphae (to prevent seizure)
birth recommended >34wks
What is HELLP
definition
mgmt
**Definition
Form of extreme pre-eclampsia
Diagnosed 1 or more characteristic :Haemolytic anaemia, elevated liver enzymes, low platelets (<100)
risks-hepatic, haemotological, cardiac, pulmonary (respiraotry), CNS, renal
management
referral- Emergency
Expedite birth (any gestation)- ideally have mag sulphate (<30wks) + corticosteroids (24-34+6 wks)
Eclampsia
definition
management / Referral
**definition
**severe form of pre-eclampsia
when can it occur -before/during / after
seizures are self limiting/ not caused by pre-existing condition / no persistent neurological features
management / rx
Transfer
Airway/ breathing /circulation
Antihypertensive
start mag sulphate
birth at any age (ideally wait to have corticosteorids (<34+6) + mag sulphate (of <30wks )
What is criteria for “slowing of fetal growth”
From 28 wks onwards, there is a >30 centile decline in EFW or AC
What are major risk factors for SGA (incl. early onset)
what is recommended mgmt
Major risk factors:
**maternal demographics
*** nulliparous >40years
* Smoking >10 cigarettes (After 16wks)
* drug use
pregnancy hx
previous SGA/ FGR (risk of early onset)
Previous hypertensive disorder (risk of early onset)
prev stillbirth
medical hx [ALL have RISK of early onset)
chronic hypertension
diabetes with vascular disease
renal impairment
antiphospholipid syndrome
current pregnancy risk
heavy bleeding >20wks
PE / gestational hypertension
APH / placental abruption
Recommended management
- monthly growth scans in 3rd trimester (from 28-30wks)
- for early onset risks - doppler study at 20-24wks + monthly scans from 24-26wks
what are minor risk factors for SGA/ FGR
what is mgmt
MATERNAL DEMOGRAPHIC
* Nulliparity
* multip >40years
* smoking 1-10 cigaretts
medical hx
ART conception
BMI>30 / <18.5
**Pregnancy hx
Short (<6mths) / Long (>5 years)
current pregnancy risk
placenta praevia
Low gestational weight gain
management
>3 minor risks:
growth scans @ 28-30 wks + 36-38wks
Herpes
- What is it
- very common chronic viral infection - “intermittant reactivation”
- genital + oral
- first episode is most severe, recurrent episodes may be milder
- symptoms may be non-specific - most women don’t have ‘classical symptoms. woman may be receiving treatment for other genital conditions (UTI/ thrush)
- need clinical diagnosis (lab test)-
- risks
if there is ‘outbreak’ (visible lesion / promodal symptoms) during vaginal birth, can be transmitted to baby (esp high risk if it’s first outbreak)
–consider C section
if no lesion/ promodal symptoms- can labour - risk of transmission very low
management
* if lesions in pregnancy-CONSULT/ take aciclovar from 36 wks to reduce viral load
* If lesions intrapartum- CONSULT, consider CS
* CONTRAINDCATED - Scalp electrodes / instrumental birth
Neonatal HSV
- rare / potentially fatal
- symptoms are non-specific- any baby with skin vesicles should be referred
Molar pregnancy
what is it
after ‘silent’ miscarraige- placental tissue abnormally/ rapidly grows –> cancer
- Complete-
- when egg without maternal dna is fertilised= no embryo /normal placental tissue.
- placenta continues to grow, produce hcG (woman feels pregnant)
- looks like graps
Partial
* 2 sperm fertilise 1 ovum (69 chromosomes) –> fetus dies
* pv bleeding / absence of FHR
symptoms
- uterine enlargement
- dark brown PV loss
- signs of hyperthyroidism (from hCG)
- Early PET (before 20wks)
Assessment
- monitor serum hCG until not detectable
- don’t get pregnant during this phase
mmo
Maternal age >35
risks
Is there a referral?
risks
fertility / miscarriage
GDM/ G hypertension
Ca section
Multiples
referral
none
Describe the types of twins
physiology/ risk factors / timing of separation?
**Dizygotic (fraternal)
**2 ovum released. 2 sperm fertilise. 2 zygotes implant.
may share a placenta, but unlikely to have issues with vessels
DCDA - 2 Chorion +2 AMNION
share ~50% genetic material (same as non-identical siblings)- 50% same sex, 50% different
causes- IVF, maternal age (release more ovum naturally), familial
Monozygotic (identical)
1 ovum + 1 sperm = 1 zygote. zygote then separates to form 2 identical zygote. share 90% DNA- physically + psychologically very similar.
may share placenta / chorion/ amnion
- ~30% DCDA - separate placenta. split before 3 days (before placenta has formed)
- MCDA - share placenta +chorion, but separate amnion (3-9 days- before amnion formed)
- MCMA- share amnion (9-12 days)
- conjoined- >12 days
Explain risks of multiples
maternal
- HG
- GDM
- PE / GIH
- Anaemia
-
fetus
- congenital abnormalities
- malpresentation
- IUGR/ SGA
L&B
preterm labour / birth
PROM/ PPROM
malpresentation (breech)
PPH
Cord accidents
birth asphyxia (twin 2)
placental abruption (Esp after T1 Born)
placenta praevia
What is twin to twin transfusion syndrome?
which type of twins are affected
condition in which blood from one twin is transfused to other twin, via blood vessels in shared placenta
affects MZ twins (~15%)
what is definition of secondary PPH
Signs?
definition:
abnormal / excessive bleeding from uterus
>24hrs - 12wks post partum
Cause
Retained placenta–> infection / preventing involution
Signs / symptoms
sudden / profuse blood loss OR persistent increased blood loss
faintness / dizzy
low BP
Tachycardia
What is PN monitoring for women that have PE/ PIH?
Daily BP for 7 days
weekly
Assessing lower segment CS wound infection
what are types
signs of infection
seroma (sterile accumulation of serum beneath skin incision- should be treated conservatively)
superficial infection
deep wound infection
Signs of infection (red, hot, tender)
mgmt- take swab and consult (but no official guidelines)
Hypertension
bP >= 140 and / 90
Consecutively, >4hrs apart
Chronic hypertension
definition
referral
Hypertension <20wks
referral- consult
Gestational hypertension
definition
referral
definition
* Hypertension >20wks
* No other PE symptoms
* bP normalises <3mths postpartum
referral- Consult
mgmt
- regularly monitor BP / screen urine for proteinuria- - do PE bloods / MSU if BP/ protein increase
-(SGA guideline)- monthly growth scans from 28-30 wks
Pre-eclampsia
Definition, risk factors, mgmt, referral,
**DEFINITION
**hypertension (pre-existing or gestational)
+ 1 or more new conditions
- proteinurea (PRC>30)
- Renal (creatinine (>90)
- Liver (bloods) or RUQ / epigastric
- Neurological (headache /visual / hyperreflexic with clonus, seizures, stroke)
- haemotological (thrombocytopaenia (<100), haemolysis)
-placental insufficiency (placental abruption / IUGR)
**risk factors
personal / family hx
first baby / new dad / 10 years since last baby / multiples
medical hx (Chronic hypertension, DM, antiphospholipid ABs, renal
>40 years, high BMI
>
**
Referral- Transfer
Management
- stabilise BP (labetalol /nifidipine/ methydopa) - 160-100
- Monthly USS
- Consider timing of birth (expectant if <37 wks )
Stable Pre-eclampsia
**“controlled” hypertension (staying < 160/110)
no severe features
unstable Pre eclampsia
definition
management/ referrals
timing of birth
**definition
**severe hypertension (>160/110)
worsening signs /symptoms / bloods
HELLP
mgmt
Transfer of care
consider mag sulphae (to prevent seizure)
birth recommended >34wks
What is HELLP
definition
mgmt
**Definition
Form of extreme pre-eclampsia
Diagnosed 1 or more characteristic :Haemolytic anaemia, elevated liver enzymes, low platelets (<100)
risks-hepatic, haemotological, cardiac, pulmonary (respiraotry), CNS, renal
management
referral- Emergency
Expedite birth (any gestation)- ideally have mag sulphate (<30wks) + corticosteroids (24-34+6 wks)
Eclampsia
definition
management / Referral
**definition
**severe form of pre-eclampsia
when can it occur -before/during / after
seizures are self limiting/ not caused by pre-existing condition / no persistent neurological features
management / rx
Transfer
Airway/ breathing /circulation
Antihypertensive
start mag sulphate
birth at any age (ideally wait to have corticosteorids (<34+6) + mag sulphate (of <30wks )
“EARLY onset FGR”
definition
criteria
risk factors
management (referral)
<32 Wks gestation
Either:
EFW / AC <3rd centile
UA absent/ reversed end diastolic flow
EFW / AC <10TH Centile AND abnormal dopplers
Management for women at risk
Consult Referral
What is criteria for “slowing of fetal growth”
From 28 wks onwards, there is a >30 centile decline in EFW or AC
what is definition of SGA
what is referral +Mgmt
EFW or birthweight <10th centile
REFERRAL - Consult (EFW/Birthweight between 3rd-10th centile (and normal dopplers)
Mgmt
-increase USS+ dopplers (fortnightly until 36+6. then weekly_
recommend birth at 40wks
late onset FGR
what is definition / criteria / referrals
Diagnosed after 32wks gestation
- EFW/ AC <3rd centile
OR 2 or more - EFW/ AC <10th centile (“SGA”)
- Slowing of fetal growth (EFW/AC <30 centiles from 28wks onwards)
- abnormal doppler
Mgmt: Referral
Anaemia
definition
Causes
Signs of deficiency
Referrals
Hb <110 T1/ 105 (T2+T3)
Causes
* iron deficiency anaemia : low ferritin (>30) (CRP<5) (note start treating when just ID)
signs- tiredness / breathless / dizzy/ cold / headaches/ tachycardic
risks- premature labour, SGA, fatigue, depression
mgmt- 100mg elemental iron
**CONSULT if hb <90 / not responding to treatment
*Megaloblastic anaemia
- caused by deficiency of B12 / folate
*Haemolytic anaemia - Transfer
RBC’s are destroyed faster than they are made (usually autoimmune condition)
*Sickle cell - Transfer
*Thalassaemia - Transfer
What are major risk factors for SGA (incl. early onset)
what is recommended mgmt
Major risk factors:
**maternal demographics
*** nulliparous >40years
* Smoking >10 cigarettes (After 16wks)
* drug use
pregnancy hx
previous SGA/ FGR (risk of early onset)
Previous hypertensive disorder (risk of early onset)
prev stillbirth
medical hx [ALL have RISK of early onset)
chronic hypertension
diabetes with vascular disease
renal impairment
antiphospholipid syndrome
current pregnancy risk
heavy bleeding >20wks
PE / gestational hypertension
APH / placental abruption
Recommended management
- monthly growth scans in 3rd trimester (from 28-30wks)
- for early onset risks - doppler study at 20-24wks + monthly scans from 24-26wks
What is management for women with low risk FGR
fortnightly measurements of Fundal height from 26-28 WKS, plot on customised GROW chart
refer for scan if
-Fundal height <10th centile
- 30centile decline
what are minor risk factors for SGA/ FGR
what is mgmt
MATERNAL DEMOGRAPHIC
* Nulliparity
* multip >40years
* smoking 1-10 cigaretts
medical hx
ART conception
BMI>30 / <18.5
**Pregnancy hx
Short (<6mths) / Long (>5 years)
current pregnancy risk
placenta praevia
Low gestational weight gain
management
>3 minor risks:
growth scans @ 28-30 wks + 36-38wks
What is referral for FGR (<3rd centile/ risk of birth <28wks /<1kg)
Transfer
what is ‘large for gestational age”
what is referral
EFW and AC >90th centile AND no diabetes
Referral- consult
what is definition of “fetal growth restriction” after birth
Mgmt
Referrals
customised BW <3rd centile
OR:
customised BW is 3-10th centile
AND 2+
* BMI/ length/ skin z zcore <1.3
* baby was diagnosed with “FGR” antenatally
* evidence of placental insufficiency
Referral- consult
Mgmt
- hypoglycaemia
-
Herpes
- What is it
- very common chronic viral infection - “intermittant reactivation”
- genital + oral
- first episode is most severe, recurrent episodes may be milder
- symptoms may be non-specific - most women don’t have ‘classical symptoms. woman may be receiving treatment for other genital conditions (UTI/ thrush)
- need clinical diagnosis (lab test)-
- risks
if there is ‘outbreak’ (visible lesion / promodal symptoms) during vaginal birth, can be transmitted to baby (esp high risk if it’s first outbreak)
–consider C section
if no lesion/ promodal symptoms- can labour - risk of transmission very low
management
* if lesions in pregnancy-CONSULT/ take aciclovar from 36 wks to reduce viral load
* If lesions intrapartum- CONSULT, consider CS
* CONTRAINDCATED - Scalp electrodes / instrumental birth
Neonatal HSV
- rare / potentially fatal
- symptoms are non-specific- any baby with skin vesicles should be referred
mmo
Maternal age >35
risks
Is there a referral?
risks
fertility / miscarriage
GDM/ G hypertension
Ca section
Multiples
referral
none
what is atelectasis
partial inflation of lungs
what are ‘locked twins’
T1- breech
T2- Cephalic
risk of obstructed labour
what is referral for twins
TRANSFER
What is criteria/ referral for suspected chorioamnionitis
Fetal tachycardia, maternal
pyrexia, offensive liquor
CONSULT
3rd /4th degree perineal trauma
TRANSFER
Cervical laceration
TRANSFER
Vaginal laceration- complex
CONSULT
VULVAL / VAGINAL Haematoma
TRANSFER
Referral for PET
Transfer
What referral for Previous PPH >1L
Consult
What referral for previous obstetric/ sphincter injury
3/4th tear (with/ without symptoms)- consult
What is MSS1, when do we screen?
MSS1 ( Trimester 1 (<14wks)
Screening to test for chance of T18 (edwards), T13 (patau), T21
involves
- blood test (Serum) 9- 13+6
- - Scan- fluid at back of baby’s neck: 11-13+6
> 1/300 –> refer
what is sickle cell anaemia / referral
point mutation / familial
RBC’s become mischapen and break down/ die early = haemolysis
referral- transfer
what is thalassaemia/ referral
inherited blood disorder
when body has less Hb + fewer RBC’s
what is thrombocytopenia / referral?
<100?
Transfer
what is thromboembolism / rx?
previous DVT / PE
Consult
What is criteria to send MSU
Dipstick has proteinuria of ≥+1
ECV
process
criteria
success factors
process
- scan to confirm presentation + placenta location
- give terbutaline (tocolytic) to relax uterus
from 37 wks
only singleton babies
not engaged / normal liquor
ALWAYS give anti-D prophylactically if mum is Rh neg
contraindications
anything that prevents normal vaginal birth (maternal / fetal compromise / placenta praevia )
multiple gestation
oligohydramnios
Risks (very rare)
- abnormal FHR (usually transient)
PV bleeding
placental aburption
emergency CS
perinatal mortality
what is assessment of early bleeding in pregnancy
1) assess woman’s haemodynamic stability
(women may experience significant blood loss before showing signs of shock)
2) if no signs of shock present, can continue assessment in community
- ask about risk factors for ectopic pregnancy (chlamydia, IUD, STI, pelvic infection)
- take serum hCG every 48-72hrs - if these are falling, usually indicates non-viable pregnancy (but doesn’t rule out ectopic pregnancy or molar pregnancy)
- scan
what are signs of schock
hypotension
tachycardia
clammy skin
confusion
pallor
faint
vomiting
ectopic pregnancy
what is it
signs
risk factors
mgmt
what is it
when blastocyst implants outside uterus (usually fallopian tubes)
pregnancy continues as normal, until blastocyst becomes too big and it ruptures /dies
risk of internal bleeding
signs
(usually women report non-specific vague symptoms, so watch for early signs, as bleeding can quickly become torrential)
early
1) lower abdominal pain
2) immediately prior to rupture- increasing abdo pain, rigidity, rebound tenderness, shoulder tip pain
-mass on one side of uterus
3) bleeding
4) shock
risk factors
hx of ectopic pregnancy
hx tubal surgery /infection
infertility
IVF
surgery
IUD use
assessment-
- always consider possibility of ectopic pregnancy with women that have abdo pain
- watch for early signs
- Transvaginal scan + lab studies ( hcg increases, but more slowly than normal)
mgmt
if ectopic pregnancy suspected + signs of haemodynamic stability- resus as required (fluids) + transfer
what is low lying implantation ectopic pregnancy
when blastocyst implants in cervical mucus + caesarean scar
risk- multiple CS births
cervical polyps
- indicators
benign tumour- usually harmless. remove after pregnancy
can cause bleeding in pregnancy
appear as bright red, fleshy protrusions that extend out from cervical canal
