Deck 1 Flashcards
What is the prevalence of 3rd or 4th degree tears in a primiparous woman during a forceps delivery?
8-12%
What is the overall prevalence of 3rd or 4th degree tears?
2.9%
What is the prevalence of 3rd or 4th degree tears in a primiparous woman during a ventouse delivery
4-8%
What is the prevalence of 3rd or 4th degree tears in a multiparous woman
1.7
What is the prevalence of 3rd or 4th degree tears in a nulliparous woman
6.1%
What is the prevalence of vulval-vaginal tears in a ventouse delivery
10%
What is the prevalence of vulval-vaginal tears in a forceps delivery
20%
What is the stillbirth rate at 39 weeks gestation?
Rate 3.9:1000
It is common 1:200
What are X-linked recessive disorders (11)
Becker's & Duchene's muscular dystrophy Fabry's "Fatty" & Hunter's "Sugary" disease Fragile "X" Haemophilias A & B Red-Green colour blindness Ocular albinism Testicular Feminisation syndrome Wiskott-Aldrich's syndrome (eczema-thrombocytopenia-ID)
If mom has an X-linked recessive disorder
100% sons will inherit the disorder
100% daughters will be carriers
If mom is a carrier for an X-linked recessive disorder
50% sons will have the disorder
50% daughters will be carriers
If dad has an X-linked recessive disorder
0% son affected
100% daughters carriers
What are X-linked dominant disorders (3)
Vit D-resistant rickets: Hypophosphatemic rickets, bones become painfully soft and bend easily, symptoms usually begin in early childhood
IP: rash from infancy
Rett’s: repetitive hand movements
If mom has an X-linked dominant disorder
50% daughters & sons will inherit the allele and disease
If dad has an X-linked dominant disorder
0% sons affected
100% daughters
What are Y-linked disorders?
Hairy ears
What are common autosomal dominant disorders (12)
Huntington's Neuro-Fibromatosis, Marfan's & Ehlors-Danlos Tuberous sclerosis Achondroplasia Myotonic dystrophy Adult PCKD Gilbert’s von Hippel-Lindau von Willebrand BRCA1/2
What is the pattern of inheritance for autosomal dominant disorders in one parent?
Each child has a 50% chance of inheriting the disorder Affects males & females equally Vertical inheritance Delayed onset New mutations occur in older fathers Variable expression/reduced penetrance
What are common autosomal recessive disorders?
TS, SC, CF [Tay-Sachs, Sickle Cell, Cystic Fibrosis {1:25}]
B-thal
CAH
Wilson’s, hemochromatosis
What is the pattern of inheritance for autosomal recessive disorder carrier for both parents?
1/4 (25%) homozygous diseased child
1/4 (25%) homozygous normal child
1/2 (50%) heterozygous/carrier child
At 18w, what are the chances of Parvovirus fetal infection?
25% (>15-20w)
At 8w, what are the chances of Parvovirus fetal infection?
15% (5-15w)
At 28w, what are the chances of Parvovirus fetal infection?
70% (>21w-term)
Before 20w, what are the complications of Parvovirus fetal infection?
IUD (5-10% fetal loss rate)
Hydrops (3-10%) with 50% IUD
What is the failure rate of the filshie clip resulting in pregnancies?
2-5 in 1000 (at 10 years)
What is the detection rate (sensitivity) of the Quad test for Trisomy 21?
70-75%
What is the false positive rate of the Quad test for Trisomy 21?
5%
What is the detection rate (sensitivity) of the triple test for Trisomy 21?
65-70%%
What is the false positive rate of the triple test for Trisomy 21?
5%
What is the detection rate (sensitivity) of the Doub test for Trisomy 21?
60-65%
What is the false positive rate of the doub test for Trisomy 21?
5%
What is the detection rate (sensitivity) of the combined test for Trisomy 21?
90%
What is the false positive rate of the combined test for Trisomy 21?
5%
What is the detection rate (sensitivity) of the cfDNA test for Trisomy 21?
99%
What is the false positive rate of the cfDNA test for Trisomy 21?
0.1%
For the normal female bladder, the first sensation of bladder filling occurs at:
150-200mL
For the normal female bladder, the strong desire to void occurs at:
400-600mL
For the normal female bladder, the normal flow rate (Qmax) is
> 15ml/s
Pves=
Pdet+Pabd
For the normal female bladder, the normal refill flow rate is:
60-80mL/min
What is the incidence of nerve injury in Gyn surgeries?
1.1-1.9% of all cases
What are the causative factors of peri-operative nerve injury? (5)
Patient mal-position Improper placement of self-retining retractors Hematoma formation Entrapment Transaction
Most common nerve injuries:
Femoral Obturator Sciatic- common peroneal, tibial Ilio-hypogastric Ilio-inguinal Pudendal Lateral cutaneous Genitofemoral
Nerve injury in Gynae surgeries with both motor and sensory function:
Femoral (L2-4)
Obturator (L2-4)
Sciatica (L4-S3), common peroneal, tibial
Nerve injury in Gynae surgeries with only motor function:
Ilio-hypogastric T12-L1 Ilioinguinal T12-L1 Genito-femoral L1-2 Lateral cutaneous L2-3 Pudendal S2-3
Name the nerve injury associated with the clinical presentation of “inability to climb stairs”
Femoral L2-4
Sensory: ant/med thigh, med calf
Motor: Hip flex/add, knee ext
Name the nerve injury associated with the clinical presentation of “minor ambulatory problems”
Obturator L2-4
Sensory: upper medial thigh
Motor: thigh adduction
Name the nerve injury associated with the clinical presentation of “Sciatica”
Sciatica L4-S3
Sensory: Below knee exc medial foot
Motor: Hip ext, knee flex
Name the nerve injury associated with the clinical presentation of “foot drop”
Common peroneal nerve L4-S3
Sensory: lateral calf, dorsum
Motor: dorsiflex & eversion
*brace at fibular neck
Name the nerve injury associated with the clinical presentation of “foot cavus deformity”
Tibial nerve L4-S3
Sensory: Toes, plantar
Motor: plantarflex & inversion
Name the nerve injury associated with the clinical presentation of “sharp, burning radiating pain from incision to mons, labia or thigh”
Iliohypogastric T12-L1
Sensory: mons, lateral labia, upper inner thigh
Name the nerve injury associated with the clinical presentation of “sharp, radiating pain from incision to mons, labia, inner thing AND groin & symphysis”
Ilioinguinal T12-L1
Sensory: groin, symphysis
Name the nerve injury associated with the clinical presentation of “meralgia parasthetica, pain/parasthesia AP-lat thigh”
Lateral cutaneous nerve L2-3
Sensory: AP/lat thigh
Name the nerve injury associated with the clinical presentation of “pain/parasthesia labia, fem triangle”
Genito-femoral L1-2
Sensory: labia, fem triangle
Name the nerve injury associated with the clinical presentation of “claw hand”
Ulnar C8-T1
Sensory: Medial 1 1/2 fingers
Motor: small muscles of hand
“Klumpke’s Palsy” C8-T1
Sensory: medial arm, forearm, hand, medial 2 fingers
Motor: intrinsic hand muscles
Name the nerve injury associated with a brace placed too laterally in Trendelenburg during scope-surgery
Klumpke’s palsy, loss of small muscle function
Name the nerve injury associated with the clinical presentation of “wrist drop”
Radial nerve C5-T1
Sensory: dorsal tips of latera 3 1/2 fingers
Motor: wrist and finger ext
Name the nerve injury associated with the clinical presentation of “waiter’s tip”
“Erb’s Palsy”
Sensory: none
Motor: Abd shoulder, flex elbow, supination
Name the surgeries during which the obturator nerve can be injured
Retroperitoneal surgeries: endometriosis excision, TOT, Paravaginal defect repairs
Sensory loss in the upper medial thigh and motor weakness in hip adductors or “some abulatory problems” after TOT is indicative of which nerve injury?
Obturator
“Footdrop” is indicative of which nerve injury, and what is the mechanism of injury?
Common peroneal nerve, from compression of the posterolateral aspect of the fibular neck in hyperflexion of thighs (improper lithotomy)
Pain that worsens on sitting at the glutes, perineum and vulval region is indicative of which nerve injury? And occurs after which gynae surgery?
Pudendal nerve injury during sacrospinous fixation
What is the risk of stress incontinence in a caesarean?
4% (8% in VD)
What is the risk fetal injury of in a caesarean?
2%
What is the risk of blood transfusions in a caesarean?
1.7%
What is the risk of ICU admission in a caesarean?
9:1000
What is the risk of hysterectomy in a caesarean?
7-8:1000
What is the risk of further surgery in a caesarean?
5:1000
What is the risk of bladder injury in a caesarean?
1:1000
What is the risk of VTE in a caesarean?
4-16:10 000
What is the risk of ureteric injury in a caesarean?
1: 10 000
What is the risk of death in a caesarean?
1 : 12 000
What is the future risk of IUD in a caesarean?
1-4 :1000
What is the future risk of uterine rupture in a caesarean?
2-7:1000
What is the future risk of PP/PAS in a caesarean?
4-8:1000
What SSRI (antidepressant) is contraindicated in pregnancy and why?
Paroxetine (Paxil), due to associated cardiac defects.
Which SNRI (Antidepressant) is used in treatment-resistant disorders and what further monitoring is required?
Venlafaxine (Effexor), requires close BP monitoring throughout pregnancy.
What are the potential risks of antidepressant therapy in pregnancy?
Birth defects, mainly cardiac (1-2%)
IUGR
LBW
Low AS
What is the risk of pulmonary HTN associated with antidepressant therapy in pregnancy?
6-12:1000 (vs 1-2:1000 Gen Pop)
Slightly reduced neonatal withdrawal from antidepressants is associated with which antidepressant and why?
Fluoxetine (Prozac). Due to its long half-life.
Which antipsychotics are recommended in pregnancy by the UKTIS?
Olanzapine
Quetiapine
Which antipsychotic is not recommended in pregnancy in association with an increased risk of cardiac malformations?
Risperidone (30%)
What vitamin level is reduced in second-generation atypical antipsychotics usage and what is the treatment?
Folate. Consider PPC use of 5mg/day
What are the side effects of olanzapine and quetiapine in pregnancy, and how to manage/follow up?
Weight gain, GDM.
GTT 24-28w even without other risk factors.
Which mood stabilisers are considered safer in pregnancy?
Olanzapine, quetiapine and aripiprazole
What advice should be given to a pregnant woman regarding lithium?
Lithium should be avoided if possible, especially in the first trimester, and where possible prescribing stopped before conception.
What is the possible risk of lithium usage in pregnancy?
Congenital malformations, notably Ebstein’s anomaly 20x more likely.
How should lithium cessation/continuation in pregnancy be done?
Cessation should be done over 4 weeks.
If unwell, a switch to another antipsychotic drug can be done or Lithium restarted in the second trimester (IF not BF).
How should lithium cessation/continuation in pregnancy be monitored?
4-weekly serum levels until 36w
[aim lower therapeutic level]
weekly from 36w until delivery
within 24h after (hospital)birth
Which mood stabiliser is absolutely contraindicated in pregnancy and why?
Sodium valproate (Epilim) There is a high risk of NTD (100-200:10000 from 6:10000) and affects intellectual development in children up to 30% (Valproate syndrome)
Whats are the malformations associated with the mood stabiliser Carbamazepine use in pregnancy?
NTD (20-50:10000 vs 6:10000)
other major GI and cardiac malformations
Whats are the malformations associated with the mood stabiliser Lamotrigine use in pregnancy?
Risk of oral cleft (9:1000)
Whats is the recommendation for benzo use in pregnancy ie, Diazepam (valium), Alprazolam (Xanax) or Lorazepam (Ativan)?
Short term, for extreme anxiety or agitation.
Whats are the risks of benzo usage in pregnancy?
Cleft palate and other malformations
Premature deliveries
Floppy baby syndrome and neonatal withdrawal is possible
Whats is the rate of depression and anxiety during pregnancy?
12% experience depression
13% experience anxiety
What is the percentage of women affected by anxiety and depression in the first year following childbirth?
15-20%
What is the occurrence of postpartum psychosis?
1-2:1000
What disorder predisposes women to postpartum psychosis?
Bipolar 1 disorder
What is the management for a PUQE score of 3-12?
Antiemetics in community care
Lifestyle and dietary changes
What is the management for a PUQE score of >= 13?
- No complications
- Not refractory to antiemetics
Ambulatory/Daycare monitoring until no ketonuria
- IVF NS + K
- antiemetics
- Thiamine
What is the management for any PUQE with complications or failed daycare management?
Inpatient management:
- IVF NS + K
- antiemetics
- Thiamine
- Thromboprophylaxis
- MDT
- Consider steroids
What are the diagnostic criteria for HG?
> 5% weight loss
Dehydration
Electrolyte imbalance
In the first 12w, what is the risk of Rubella fetal infection?
8-9:10 (85%)
From 13-16w, what is the risk of Rubella fetal infection?
1:2 (50%)
End of the second trimester onwards, what is the risk of Rubella fetal infection?
1:4 (25%)
How do we determine adequate Rubella vaccination?
2 POS antibody tests, or
2 DOC doses vaccine administration, or
1 of each.
In which case: reassure.
If Rubella-specific IgG is not detected, but IgM is detected, what is the next course of action?
Obtain further serum and consider further testing.
Diagnose and advise as per results
If Rubella-specific IgG and IgM are not detected, what is the next course of action?
The patient is susceptible to rubella. Further serum for testing is required [IgG & IgM] x1/12 OR if illness develops.
What are the common methods of analgesia in labour for women with epilepsy?
TENS, Entonox and RA (epi, spinal, combined)
Diamorphne is in preference to Pethidine.
What are the anaesthetic agents to avoid in GA for women with epilepsy?
Pethidine and ketamine (which are known to lower seizure threshold) and sevoflurane (may have epileptogenic potential).
What is the prevalence of epilepsy in pregnancy?
0.5-1%
How many infants are born to WWE annually in the UK?
2500 infants.
How many of WWE are in the reproductive group?
1/3
What is the risk of maternal mortality in WWE compared to non-WWE?
10x
In the 2020 MBRRACE-UK Report, how many SUDEPs occurred between 2016-18?
29 (13%)- double that of the preceding 3 years
Which types of seizures put a mother at the highest risk for SUDEP?
Uncontrolled tonic-clonic seizures
Which types of seizures put a mother at high risk for tonic-clonic seizures?
Worsening absence seizures
What is the background risk of major congenital malformations in WWE not exposed to AEDS?
2.9% (=gen pop)
Among AEDS, which have the least risk of congenital malformation?
Lamotrigine (2% <300mg/day)
Carbamazepine (3.4% <400mg/day)
Monotherapy at lower doses.
Whats are the major malformations associated with AEDs?
NTDS, cardiac, urinary tract and skeletal, cleft palate
Whats are the major malformations associated with sodium valproate?
NTD, facial clefts & hypospadias
Whats are the major malformations associated with phenobarbital?
Cardiac lesions
Whats are the major malformations associated with phenytoin?
Cardiac lesions and cleft palate
Whats are the major malformations associated with carbamazepine?
Cleft palate
What is the risk of major congenital malformations in WWE exposed to AEDS?
- 7% for sodium valproate
16. 8% for AED polypharmacy
What is the risk for recurrence in congenital malformation in a previous child with malformations?
16.8%
What are the possible adverse effect on long term neurodevelopment associated with in-utero exposure to sodium valproate
Lower IQ, increased rates of autism.
What should WWE be informed regarding seizure deterioration in pregnancy?
2/3 (67%) do not experience a seizure in pregnancy.
What is the most important factor in assessing the risk of seizure deterioration?
The seizure-free period, whereby 74-92% of women who were seizure-free for at least 9mo-1yr prior to pregnancy remained seizure-free.
What is the rate of pregnant women with idiopathic generalised epilepsies remaining seizure-free?
74%
What is the rate of pregnant women with focal epilepsies remaining seizure-free?
60%
What is the rate of WWE self-discontinuing medication in pregnancy?
4/26 (15%)
What is the detection rate for NTD in WWE utilising maternal AFP & USG?
94-100%
Levels of lamotrigine are known to fall by up to how many % in pregnancy?
70%
What are the factors to consider in ordering AED levels?
Suspicion of non-adherence, toxicity and intractable seizures.
What are the adverse effects of AEDs in pregnancy?
Depression, anxiety and neuropsychiatric ssx
When would WWE on AED require PMH team referral?
If/when there are concerns regarding cognitive function (memory & attention) in combo with mood disturbances.
In comparing WWE and WWxE, what is the difference between GDM or PND?
No difference
In comparing WWE exposed to AED vs non-exposure, there are higher odds for:
IOL, FGR & PPH
In comparing WWE exposed to AED vs non-exposure, there is no difference in odds for:
HTN disorders, CS, misc, APH, PTL, IUD.
In comparing WWE exposed to AED, polytherapy vs monotherapy is associated with:
Increased cs rates
What are precipitants for seizures that need to be regularly assessed?
Fasting, sleep deprivation and stress.
What seizures put a woman at high risk for SUDEP?
Unwitnessed seizures, especially nocturnal seizures.
What are fetuses exposed to AEDs at risk for and how is monitoring done?
SGA, and serial growth scans should be offered from 28 weeks.
Is there a role for routine antepartum CTG monitoring in WWE?
No.
How do AEDs affect Vit K in newborns?
They competitively inhibit precursors of clotting factors and affect fetal microsomal enzymes that degrade vit K, thereby increasing the risk of HDNB.
Which AEDs require 1mg of IM Vit K administration in newborns?
Carbamazepine, oxcarbazepine, eslicarbazepine Phenytoin Phenobarbital Primidone (enzyme inducers)
What is the optimal timing and mode for WWE based on seizure control?
Most women will have uncomplicated labour and delivery.
However, an elective LSCS may be required in a proportion of women with significant deterioration of seizures which are recurrent and prolonged and at risk of status.
What is the management of non-epileptic attack disorder?
MDT with psychiatric or psychological services.
What is the dosage of antenatal corticosteroids required in pregnant WWE on enzyme-inducing AEDS?
Administer as per routine dose.
What is the risk of seizure in labour for WWE?
Low, at 1-2% of WWE in labour and a further 1-2% within 24h of delivery.
What are the complications of seizures in labour?
Maternal hypoxia (due to apnoea) and fetal hypoxia and acidosis secondary to uterine hypertonus.
How should women at high risk for seizures be managed?
Prophylactic clobazam (long-acting benzo)
What is the potential risk of clobazam?
Neonatal respiratory depression.
Outwith of pregnancy, what is the drug of choice for status epileptcus?
IV Lorazepam 0.1mg/kg (4mg then further after 10-15mins), or
IV Diazepam 5-10mg slow bolus, or
PR Diazepam 10-20mg then repeat 15 mins later, or
Buccal Midazolam 10mg
Seizures uncontrolled by benzos should be treated with:
Phenytoin (10-15mg/k, adult dosage 1000mg) or fosphenytoin.
During an epileptic episode in labour, when should delivery be considered?
If the fetal heart rate has not recovered in 5 minutes, or seizures are recurrent.
Where should WWE deliver?
Consultant-led facilities with one-to-one MW care, maternal and NRP.
WWE in labour, there needs to be special monitoring with regards to:
Over-breathing, poor pain control, dehydration and omission of AED.
When is the maximal period of seizure exacerbation?
3 days peripartum, with generalised and partial seizures.
The risk is higher in women who seized in the past month.
When should AEDs be reviewed post-delivery?
If the dose was increased in pregnancy, review in 10 days.
What are the ssx of AEDs toxicity?
Drowsiness, diplopia or unsteadiness.
Fetal accumulation is mildly increased for which AEDs?
Levetiracetam, gabapentin and sodium valproate.
Which AEDs have minimal BM transfer?
Sodium valproate, carbamazepine and phenytoin.
What are the effects of BF while on AEDs?
Affected psychomotor function but no effect on cognitive function.
(Option: alternate BF with bottle feed)
Postnatal observation should be:
In a single room with the continual observation by a carer, partner or nursing staff.
What strategyy specific to myoclonic jerks should be undertaken?
Alcohol avoidance
What are the PPD rates in WWE?
29% vs 11%
What are the risk factors for PPD in WWE?
Multiparity and polypharmacy.
What are the non-enzyme inducing AEDS?
Sodium valproate, levetiracetam,
Gabapentin, viGABtrin, tiaGABine, preGABalin.
What are the contraception options offered in WWE on enzyme inducer AEDs?
Copper IUCS, Mirena, IM Depo
What are the EC options offered in WWE on enzyme inducer AEDs?
IUCD
Which AEDS and Contraception combination is associated with a potential increase in seizures?
Lamotrigine and estrogen-containing pills.
What is the failure rate of WWE on enzyme-inducing AEDs?
3x (3.1 per 100 woman years)
How does Topiramate interact with COCP with NE and EEand at which concentrations?
<200mg/day: no interaction
200-800mg/day: modestly increase the clearance.
WWE on AEDs inducers who choose COCP should:
increase the estrogen component to 50-70mcg.
What type of data are gender and race?
Qualitative, nominal. [Variables with no inherent order, ranking or sequence]
What type of data are blood types and performance?
Qualitative, ordinal [Variables with an ordered series]
What type of data are pass/fail and yes/no?
Qualitative binary [Variables with only 2 options]
What type of data is the number of parts in a USG machine?
Quantitative discrete [based on counts]
What type of data is length, size width etc…
Quantitative continuous {on a continuum or on a scale]
Blood spotting and satellite lesions in young?
Candida
Blood spotting and satellite lesions in old?
Malignant melanoma (pigmented)
What is the implication of anti-TNF in pregnancy?
Infection is a particular risk, which may present typically or atypically.
What is the implication of anti-TNF on the fetus?
While there is no evidence of teratogenicity, these drugs cross the placenta and neonatal cord drug levels may exceed maternal levels.
Therefore, anti TNF should be discontinued by 30-32 weeks to avoid significant neonatal levels.
What is the implication of anti-TNF exposure beyond the recommended duration on neonatal vaccination schedule?
Live attenuated vaccines should not be given for 6 months.
What is the implication of anti-TNF in breastfeeding?
It does not cross into breast milk
With regards to IBS, what is the rate of diagnosis under 35years?
50% under 35 years old
With regards to IBD, how many women conceive after the diagnosis?
25% of women with IBD will conceive for the first time after diagnosis.
In stable IBD, what is the risk of flare-ups in pregnancy?
30%
In patients with active IBD at conception, what is the rate of persistent flare-ups in pregnancy?
2/3
In patients with active IBD at conception, what is the relative risk of active disease in pregnancy?
2x
With regards to IBD, what is the effect of pregnancy long-term?
Pregnancy seems to lower risk of relapse however its its influence on stenosis and resection rate is inconsistent.
With regards to IBD, what factors affect fertility?
Active disease and previous extensive abdominal surgery.
What are the causes of subfertility in IBD?
Pelvic adhesions causing tubal occlusion, ovarian dysfunction related to nutritional deficiencies/chronic illness and dyspareunia due to perianal illness/pelvic disease.
With regards to IBD, how does active disease at conception affect pregnancy?
Higher rates of miscarriages, preterm births and SGAs.
With regards to IBD and women with previous bowel surgery, how does pregnancy affect them?
Stretching of the abdominal wall may lead to peristomal cracking and bleeding; rarely would women develop IO.
With regards to IBD, what are the criteria for diagnosis?
There is an emphasis on clinical features (abdominal pain, stool frequency and rectal bleed) as pregnancy alters HB-conc, ESR and serum albumin.
CRP is valuable in assessing disease activity (level unchanged by pregancy)
Fecal Calprotein: ddx IBD & non-inflammatory, ie- irritable bowel syndrome and other non-inflammatory conditions in non-pregnant. **neutrophil breakdown, and doesn’t ddx infectious & non-infectious.
With regards to IBD in pregnancy, what are the imaging modalities used?
USG, which could be limited in advanced pregnancy.
With regards to IBD in pregnancy, when is MRI used?
Without contrast in 2nd & 3rd trimester, for complex cases, where USG has been inconclusive.
With regards to IBD in pregnancy, what are the indications for AXR?
It is used in specific scenarios, i.e.- colonic dilation in acute colitis.
With regards to IBD in pregnancy, what are the concerns re CT abd?
It is avoided if possible due to fetal radiation concerns.
With regards to IBD in pregnancy, are endoscopes safe?
Where absolutely necessary, gastroscopy, sigmoidoscopy and colonoscopy are considered safe in pregnancy and should be undertaken by an experienced examiner according to the clinical setting.
With regards to IBD, what PPC advise should be given regarding pharmacological treatment(s)?
MTX and mycophenolate should be stopped and replaced by appropriate alternatives 3 months prior pregnancy.
With regards to IBD, what PPC advise should be given regarding smoking?
Women should be encouraged and advised to stop smoking, as in addition to its deleterious effect on pregnancy, it is an independent risk factor for IBS activity & relapse, esp UC.
With regards to IBD in pregnancy, what are the well documented outcomes with regards to nutritional support and diet?
Poor maternal weight gain and fetal growth restriction have been well-documented and specific nutritional deficiencies corrected.
With regards to IBD in pregnancy, what are the principles of medical treatment?
With the exception of MTX and mycophenolate, IBS medications have not been shown to cause significant fetal outcomes.
With regards to IBD treatment in pregnancy, what is the safety in pregnancy and breast feeding and pertinent things to note for mesalazine/sulfasalazine therapy?
Possible in both pregnancy (up to 3g/day) and BF.
- Doesn’t significantly increase rates of miscarriages, congenital defects, LBW, IUDS, PTL.
- avoid doses >3mg OD d/t risk of fetal nephrotoxicity
- With Sulfasalazine use: supplement with folate 5mg OD, and watch out for kernicterus.
- Watch out for neonatal bloody diarrhoea in Mesalazine use.
With regards to IBD treatment in pregnancy, what are the safety in pregnancy and breastfeeding and pertinent things to note for Metronidazole therapy?
Possible in both pregnancy and BF
Maybe use a short course in perianal disease and as initial treatment for CD flare.
With regards to IBD treatment in pregnancy, what are the safety in pregnancy and breastfeeding and pertinent things to note for in steroid therapy?
Possible in both pregnancy and BF and achieves rapid disease remission however, it is associated with:
Maternal HTN, GDM, SGA, PTL, PPROM,
Fetal cleft lip & palate (early pregnancy use) &
Neonatal adrenal suppression syndrome.
Peri-partum stress dose is required in regimes >5mg/day >4w
Hydrocortisone is preferred, there is limited data in budesonide use.
With regards to IBD treatment in pregnancy, what is the safety in pregnancy and breast feeding and pertinent things to note for Thiopurine therapy?
Possible in pregnancy (teratogenesis in animal studies) & BF.
Aza preferred to mercapto
With regards to IBD treatment in pregnancy, what is the safety in pregnancy and breast feeding and pertinent things to note for in calcineurin inhibitors (tacrolimus & ciclosporin)
Possible in pregnancy and BF.
Use limited to fulminant colitis and rescue therapy in steroid-refractory UC.
Possible associations with LBW & PTB.
With regards to IBD treatment in pregnancy, what is the safety in pregnancy and breast feeding and pertinent things to note for with biologics treatment?
Possible in pregnancy and BF.
No increase in infections, although they may present typically and atypically.
Possible link with PTB, LBW & SGAs.
Discontinue use by early T3 and avoid neonatal live vaccine administration until level undetectable (6mo)
With regards to IBD treatment in pregnancy, what is the safety in pregnancy and breast feeding and pertinent things to note for mycophenelate?
Avoid in pregnancy and BF. It is associated with multiple congenital abnormalities and fetal losses.
With regards to IBD treatment in pregnancy, what is the safety in pregnancy and breast feeding and pertinent things to note for MTX?
Contraindicated in both pregnancy and BF. To seek medical advice if conception occurs on MTX or within 3mo of cessation to discuss options including TOP
With regards to IBD treatment in pregnancy, what is the safety in pregnancy and breast feeding and pertinent things to note for fluoroquinolones therapy?
Avoided in pregnancy and breastfeeding due to their association with bone and cartilage damage in animal studies.
With regards to IBD treatment in pregnancy, what is the mechanism of action for Sulfasalazine?
It interferes with folate synthesis by inhibiting dihydrofolate reductase.
With regards to steroid treatment in pregnancy, which are the options and their readiness for placenta metabolism?
Prednisolone (hydrocortisone)- more efficiently metabolised by the placenta thus reducing fetal exposure
Dexa & Betha: less efficiently metabolised by the placenta thus increasing fetal exposure.
PO Budesonide: Limited data, however possible reduced maternal side effects.
With regards to IBD treatment in pregnancy, what is the mechanism of action for immune modulators like calcineurin and tacrolimus?
They inhibit IL-2 & IL-3 production, thereby inhibiting chemotaxis of neutrophils and inducing the apoptosis of T-cells.
With regards to IBD treatment in pregnancy, how are infliximab and adalimumab transferred across the placenta?
With the help of an Fc receptor neonatal molecule responsible for the mother-fetal IgG transfer.
With regards to IBD treatment in pregnancy, how does certolizumab differ from infliximab and adalimumab?
It is an F-ab fragment, not the whole IgG.
With regards to IBD treatment in pregnancy, what are the indications for surgery?
OPHAT
- Obstruction
- Perforation
- Haemorrhage
- Abscess
- Toxic megacolon
With regards to IBD in pregnancy, when is fetal growth surveillance indicated?
Women with active IBD and those on steroids & calcineurin.
With regards to labour and delivery in women with IBD, what are the considerations in vaginal delivery?
To avoid episiotomy where possible as it can trigger perianal disease.
With regards to labour and delivery in women with IBD, what are the considerations in operative delivery?
ELLSCS is indicated in women with active perianal or rectal disease, after restorative proctocolectomy with ileo-anal pouch, and for obstetric reasons.
With regards to women with IBD, what are the considerations for IOL?
IOL is for obsteric indications, unless the disease remains active near term or when optimal treatment cannot be provided because of pregnancy.
With regards to the postpartum period in women with IBD, what are the considerations?
Flare ups are common especially in women with UC, hence contact with IBD and Gastro treams are advisable for treatment optimisation at this time.
It is good practice to ensure f/up appointment upon discharge.
With regards to breastfeeding in women with IBD, what are the considerations for treatment?
Most medications are considered safe in pregancy. There is a higher risk of disease relapse with medication cessation in the postpatum period.
With regards to postpartum analgesia in women with IBD, what are the considerations?
NSAIDS can excerbate IBD in some.
Opiods can cause constipation and exacerbate conditions with significant perianal disease, hence osmotic laxatives should be co-prescribed.
What is the most likely diagnosis in a woman who complains of long-standing vulval pain, felt at the introitus, at penetration during intercourse, or tampon insertion?
Localized provoked vulvodynia (vestibulodynia)
What is the most likely diagnosis in a woman whose vulval pain is elicited by gentle application of a q-tip to the introitus or around the clitoris?
Localized provoked vulvodynia (vestibulodynia)
What is the treatment for localized provoked vulvodynia (vestibulodynia)?
Emolient soap, LA ointment 5% or gel 2% (15-20mins prior)
What is the treatment for localized unprovoked vulvodynia (vestibulodynia)?
Emolient soap
TCA: Amitriptyline, from 10mg to 100mg OD
Gabapentin or pregabalin
alt: LA ointment 5% or gel 2%
A baby delivered with no signs of life after 23+6 weeks of pregnancy is known as?
A stillbirth
When is early fetal loss defined?
A first-trimester miscarriage
When is late fetal loss defined?
A second-trimester loss
What is early neonatal death?
The death of a baby occurring within 7 days after birth, irrespective the gestation.
With regards to GBD carriage, which ethnic group has the highest rate of carriage?
Black African ancestry
With regards to GBD carriage, which ethnic group has the lowest rate of carriage?
South Asian ancestry
What is the rate of adult GBS colonization?
20-40% of adults.
What is the incidence of EOGBS disease?
0.57/1000 births
WHats are the risk factors for EOGBS? (4)
Previous baby with EOGBS, GBS bacteriuria, +VS GBS, T 38' or more intrapartum/chorio, Prem birth Prolonged LL
With regards to antenatal care and GBS screening, is universal screening recommended and why?
No.
- Many women carry the bacteria, however, the majority of babies are born safely without developing an infection.
- Screening late in pregnancy cannot accurately predict which babies will develop EOGBS.
- No screening is entirely accurate.
- Many of the babies severely affected are born prematurely, before the suggested time for screening.
- Giving all GBS carriers IAP would mean a large number and may increase the adverse outcomes to mother & baby.
With regards to GBS testing, how many who test positive remain positive at delivery; conversely, how many who test negative remain negative at delivery?
POS @ 35-37w: 17-25% NEG at delivery
NEG @ 35-37w: 5-7% POS at delivery
What is the likelihood of maternal GBS carriage in this pregnancy if GBS was detected in the previous, what are her options, and what are her risks of EOGBS?
50% recurrent carriage and EOBGS risk of 1:700-800
The patient may be offered IAP or bacte-testing in late pregnancy.
POS: 1:400 risk EOGBS
NEG: 1:5000 risk
How should antenatal GBS bacteriuria be managed and why?
Offer IAP
In the presence of a UTI (1 mil cfu/ml), appropriate treatment should be offered and IAP offered.
GBS bacteriuria is associated with higher risks of chorio & nnt sepsis, however, it is not possible to accurately quantify these risks.
How should antenatal GBS isolated from a VS/RS be managed and why?
Treatment is not indicated, as it does not reduce the likelihood of GBS colonisation a ToD. IAP should be offered.
How should GBS carriage influence IOL methods?
It should not. There is no evidence to suggest that different IOL methods increase the risk of EOGBS.
Membrane sweeping is not contraindicated.
IV IAP should be commenced once established labour is diagnosed.
How should GBS carriage influence an EL CS?
GBS-specific antibiotic prophylaxis is not indicated in the absence of labour and intact membranes.
They should receive broad-spec as per NICE CS guidance.
How should GBS carriage influence an EL CS in the presence of ROM?
IAP offered and schedule CAT2/3
How should confirmed-GBS carriage influence a woman at term in labour(with/without ROM)?
IAP and IOL should be offered ASAP.
How should a negative or unknown GBS carriage influence term labour(with/without ROM)?
Offer IOL or expectant up to 24H
>24H, IOL is appropriate
What is the risk of EOBGS associated with intrapartum pyrexia and what is the management?
The risk is 5.2:1000 (vs 0.6:1000 background)
Broad spec antibiotics should be offered: IV Amoxicillin 2g QID or IV Cefuroxime 1.5g TDS)
What is the proportion of women who deliver prematurely?
8.2%
What is the risk of EOGBS in women who deliver prematurely?
2.3 : 1000
Compared to term babies, what is the risk of GBS infection and the risk of mortality rates in premature infants?
Higher.
20-30% (2-3% term)
With regards to GBS carriage in pregnancy, what are the considerations with water birth?
Evidence suggests that there are no contraindications to water birth if IAP has been offered.
