Flashcards

Question

Late antenatal complications associated w obesity

Answer 1

``` PET GDM VTE OSA Death Congenital abs (w DM) ```

Answer 2

``` IOL Assisted or operative del FTP PPH Shoulder dystocia Difficulties w foetal monitoring Anaesthetic complications ```

Answer 3

Cs scar healing and infection VTE Breast feeding difficulties

Answer 4

Transition usually lasts 4-5yrs Onset usually 40s to 50s Average last period 51 range 40-58. Menstrual changes - cycles may shorten or lengthen. Bleeding usually increases. Abrupt cessation in 10% Vasomotor symptoms - hot flushes. 80% women and severe in 10%. Up to 12yrs in 10% Vaginal dryness, atrophy --> dyspareunia, incontinence, prolapse, recurrent UTI Cognitive disturbance - irritability, anx/dep, difficulty concentrating, memory lapses Sleep disturbance Loss of libido

Answer 5

DM Thyroid disorders Pregnancy or other causes for secondary amenorrhea ``` Ix for ddx Lipid profile if other RF Pelvic US if atypical DEXA if early or other RF Cervical screening or mammograms if due ```

Answer 6

``` Don't forget, diet, lifestyle, smoking, exercise, wt loss. - modifiable RF for CVD. Pap smears and mammography Preventative and holistic health BENEFITS Most effective Rx for vasomotor sx. May be cardio protective for younger women Osteoporosis Sexual fxn May improve mood, sleep etc ``` ``` RISKS Thromboembolism Breast ca Endometrial ca w/out progesterone CVS w prolonged/ older use Stroke Gallbladder Migraine w aura Liver disease ``` Remember to Ix for abnormal bleeding

Answer 7

``` Spontaneous in 90% Iatrogenic Turners syndrome, fragile x, galactosaemia Ai esp thyroid CT or RT Any pelvic surg ```

Answer 8

``` Lethargy Poor feeding Hypertonia High pitched cry Seizures Coma ```

Answer 9

Always pathological Rhesus, ABO or other blood grp incompatibility Sepsis Rare - red cell abnormalities

Answer 10

Too high = 200-250 Cephalohaematoma or other bruising, cerebral haemorrhage Polycythemia Sepsis - UTI, hepatitis (conjugated >15%) Haemolysis Incr enterohepatic circulation - obstruction Physiologic breast milk jaundice / dehydration

Answer 11

``` Conjugated - TORCH - sepsis - idiopathic hepatitis - hbv Sepsis Resorption of bruising Gut obstruction Hypothyroidism Congenital malformations Haemolysis Breast milk jaundice ```

Answer 12

Take serum bili if early, widespread, otherwise unwell, Rh -ve and jaundiced, preterm and jaundiced General - hydration - FHx, feeding, irritability, skin changes, other obs, input/output, lethargy, hepatosplenomegaly, urine and stool changes ``` IX Assess for risk of sepsis FBC/film/retic count LFTs + conjugated DAT/Coombs tests Blood group + mothers ``` ``` Conjugated Septic screen TFT Coags G6PD if likely TORCH screen ``` PHOTOTHERAPY Temp 3-4hrly Recheck bili 12-24hrly and cease when >50 below threshold Demand feeding w input/output Daily wts Exchange if approaching threshold or Sx of acute encephalopathy

Answer 13

3-4% at 36-37/40 25% rate spontaneous version at term 6% reversion rate Assoc with preterm, multips, polyhydramnios, IUGR, uterine and congenital abnormalities

Answer 14

Vaginal breech assoc w 3x (5 - 1.6%) relative risk serious neonatal M&M at 6/12 No difference maternal No difference at 2yrs ``` Foetal complication 6% Serious complication 0.24% - abruption 0.1%, foetal distress, cord prolapse PV bleeding 3% Mortality 1/5000 ```

Answer 15

``` Macrosomia, IUGR Antepartum haemorrhage hx Hyperflexion/extension of head PET ROM Previous CS Foetal abnormalities severe Uterine anomalies Cord around neck Abnormal CTG ``` Success 40-60%

Answer 16

``` US prior to confirm lie - exclude footling/kneeling breech, placental location, uterine and foetal morphology, head position, EFW CTG ok Blood group/antiD Empty bladder US to exclude cord and conf position Perform w IV access CTG and US after Tocolysis if needed ```

Answer 17

Pregnancy Childhood Lactation Post menopausal

Answer 18

``` Hormonal therapy Hysterectomy/BSO CT/RT Pelvic irradiation Endometrial ablation Ashermans syndrome Other drugs - antipsychotics, metoclopramide, methyldopa ```

Answer 19

Remember to enquire about age of thelarche/adrenarche and maternal age of same INFANTILE Turners Hypothyroidism Gonadal dysgenesis - rarely Kallmanns syndrome MASCULINE Rare True haemaphrodite CAH NORMAL Androgen insensitivity Mullerian abnormalities

Answer 20

``` PCOS Obesity Prolactinomas Hypothalamic amenorrhoea Serious medical conditions Premature ovarian failure Ovarian causes - Ashermans ```

Answer 21

``` Thelarche/adrenarche and FHx of same Sx pregnancy Sx thyroid dysfxn Sx menopause Androgen related Sx Hx of periods if relevant and prev pregnancies MHx Meds - inc injections and devices SHx FHx ```

Answer 22

``` Wt, ht, waist, hips General appearance, stigmata of disease etc Thyroid and breast exam Abdo exam External genitalia Int exam only if appropriate ```

Answer 23

50% all conceptions 15-20% all recognised pregnancies 70% threatened mc will go on ``` Age Number of previous pregnancies and miscarriages Smoking Drinking Other illicit drug use Uterine anomalies Genetics Connect tissue abs Uncontrolled DM ```

Answer 24

Positive > 5 Becomes positive 9/7 post conception Min doubling in first trimester every 48hrs <2000 rpt in 48hrs and TVS at same time >2000 and nil seen on TVS - risk of ectopic - beware multiple pregnancy, fibroids. Rpt in 48-72hrs TVS and hCG Declining or plateauing - risk of no viable preg or ectopic. Follow to 0

Answer 25

``` Resusc IV access, bloods and IVT Analgesia Spec and removal of POC as necessary Expectant, medical or surgical Mx Anti-d Send tissue for histo Consider referral to social work etc ```

Answer 26

Failure of hCG rise over 48hrs if <2000 CRL >7 and no HB MSD >25mm and no embryo Absence of embryo with HB 2/52 after YS and no embryo or 11/7 after YS and present embryo

Answer 27

Most effective for incomplete - passage may take several weeks for intact sac Less infection Good if BF More days of bleeding and volume overall 10% require d&c Make f/u appt for 7-10 days Rpt hCG in 3/52 Serial US Consider surg if not passed in 7-10/7 Remind can change their mind and to return if bleeding, pain, infection

Answer 28

No difference between medical and expectant in completeness/infection or need for d&c Bleeding more and more prolonged that D&C SE miso - flushes, dizziness, fatigue, thermoregulatory changes, N/V/D May combine w mifepristone - May cause HTN - give 24-48hrs prior to miso and observe BP for 15min Give miso 800mcg PV day 1 and 2. Consider surg if no passage after 48hrs but may leave for 8/7. Bleeding May cont up to 3/52 May be in or outpt depending on gestation (9/40) AntiD Info on when to return RV day 8 regardless Oral analgesia and antiemetic Eval progress w clinical, hCG and US

Answer 29

Must be used if persistent heavy bleeding, infection, unstable, GTD Usually under GA May give mife 24-36hrs prior If >14/40 give miso 400mcg sl/po 4 hrs prior For all give same 2hrs prior RISKS GA Cervical trauma 1% Perforation 0.1% Mortality 0.6/1000 - lowest of all options EPC or or GP FU

Answer 30

``` Try to have both parents present Discuss memory creation Risk of dep/anx, precip psychotic disorder Refer to gynae anyone with recurrent loss No evidence for deferring next pregnancy Preconception counselling Lifestyle, diet, health Contraception Support services ```

Answer 31

1% couples w 0.33 chance. After 3 risk for next preg is 40% Idiopathic in 50% Age and lifestyle - smoking, obesity Chromosomal disorders - balanced translocations Endocrine - PCOS, thyroid, DM Thrombophilias - anti phospholipid disorders (15%) excess NK cells Structural - uterine abnormalities (5% with 50% able to carry pregnancy to term), fibroids, cervical incompetence Other - sperm fragmentation, incr maternal body temp

Answer 32

Caput seccundum - extra aponeurotic oedema caused by pressure on head during labour and del. benign, crosses suture lines Cephalhaematoma - caused by friction between periosteum and skull so therefore does not cross suture lines. Unlikely to be dangerous but can be cause of sig blood loss as well as resorption jaundice Subgaleal haemorrhage - separation of epicranial aponeurosis from periosteum. 0.6/1000 normal 4.6/1000 vacs. Insidious loss of significant amounts of blood. Crosses suture lines.

Answer 33

Suspect w APGARS < 7 at five minutes without sig asphyxia Pitting, ballotable, fluctuant swelling crossing suture lines Irritable to obtunded baby Puffy eyes, elevated/displaced ears

Answer 34

``` Sepsis - GBS Hyaline membrane disease Aspiration TTN Congenital abnormalities Pneumothorax OTHER Hypoglycaemia Hypothermia Anaemia Polycythemia Met acidosis ```

Answer 35

Maintain sats 92-96% Hood or incubator Monitor HR, resps and sats continuously FBC CRP BC CXR Proph ABX until infectious process excluded - amp + gent Monitor BSLs hourly until stable or 4hrs then four hrly Small regular feeds - tachypnoea >60-80 precludes oral feeds. Consider NG/OG Minimal handling Maintain body temp CPAP if persistent distress or req >30% oxygen Fluids 60ml/kg/day

Answer 36

``` Number pregnancy Prev preg probs Problems identified in preg - morph, RF for SGA etc, GDM Mode of del and indication for same Gestation Risk factors for sepsis - GBS positive without ABx - PROM - unwell mother - prev same Mec How is mother doing Mat Hx ```

Answer 37

``` Obs Appearance - congenital abs - body temp, skin colour WOB Cry Pulses Urine output Resp and cardiac exam Abdo - masses, empty abdo BGL ```

Answer 38

``` G/P Gestational age Complications to date Praevia? Blood group Prev bleeding MHx FM Pain/contractions Amount Consistency Clots? Triggers Colour Ongoing loss Weigh pads ```

Answer 39

``` Brief Hx inc gestational age and praevia, MHx, allergies, last ate Flat on side O2 support Two wide bore cannulas Urgent FBC, Coags, U&E, G&H, cross match at least 3 units IVT stat Cannula IDC 5min obs Foetal heart/CTG Prep for theatre ```

Answer 40

Hx as prev Foetal heart / CTG Gentle abdo palp - tenderness, tone, lie Spec/ bimanual if praevia excluded Bedside US for placental location and foetal well being and position Frequent obs

Answer 41

CYSTS Functional - 24%. Follicular or corpus luteum. Most will resolve in couple of cycles. < 2.5cm considered N and may be up to 10cm Benign masses - serous cystadenoma (20-25% malig and same bilat) or mucinous (5% bilateral and same malig), endometriomata, teratoma. Pregnancy related - theca lutein, corpus luteum Other - ectopic, PID, PCOS Malignant 6%

Answer 42

Ca 125 not required for all simple cysts LDH, AFP and hCG in all complex masses < 40yo - possible dermoid No malig features and < 3cm repro age or 1cm - no follow up Repro age and < 7cm follow up Haemorrhagic, endometrioma 6-12wks then yearly Mid size and dermoid yearly Surgical eval OCP not recommended. Remember to mention possibility of rupture/bleed and torsion

Answer 43

Hx - obtesteric Hx, MHx, FHx, Hx of infections in pregnancy, progress to date, ?first trimester screening - test for CMV and toxo +/- syphilus and malaria - screen for PET Confirm dates Confirm IUGR serially and tertiary morph if not completed Refer to tertiary centre if appropriate Foetal wellbeing - biophys + dopplers + AFI and CTG serially Mode of delivery Timing of delivery - explain will go to SCN/NICU if appropriate Communicate prognosis Introduce to neonatal care Prevention in next pregnancy

Answer 44

``` Must be focused at mother A consider C spine if obtunded B 10L C observe signs of peripheral perfusion, control obvious bleeding, flat, manually displace or tilt, cannula, IVT D neuro, GCS and pupils E keep warm CXR, pelvis and CT head/spine ```

Answer 45

Quick Hx - gestational age, problems, blood group, MHx, allergies, last ate Complete physical with catheter or breathing support if needed Obstetric - FH or CTG - abdo palp position, tenderness, contractions, fundal ht, visible bruising - spec cervix situation, membranes, bleeding - VE only when placental location known - urine for haematuria Bloods including Kleihauer US abdo/pelvis CT if indicated Consider antiD If >20/40 admit for observation - 4hr CTG - if concerning features more than basic CTG/FH every 4hrs - May discharge if no concerning features Think about shock, abruption, PTL

Answer 46

``` SGA/IUGR - start serial scans Oligohydramnios PPROM PTL PPH Anaemia LSCS ```

Answer 47

``` 2-5% pregnancies and 50% no cause found PLACENTAL Placenta praevia Marginal sinus rupture Vasa praevia ``` ``` LOCAL/GENITAL Ectropion Cervical dysplasia Cervicitis Vaginitis/trauma Cervical polyp Show Vulvovaginal varicosities PR/urinary source ```

Answer 48

``` Prolonged ROM FD Maternal pyrexia or unwell ness Obstetric procedures Preterm Hx GBS - early onset >80% GBS and important outside NICU setting w late onset (48hrs) ```

Answer 49

General - pallor, lethargy, jaundice, irritability, quiet, temperature days regulation, poor tolerance to handling Resp CVS tachycardia, episodic brady, hypotensive, poor perfusion - decr urine output GIT feeding, vomiting, diarrhoea, abdo distension Cutaneous petechiae, bruising, rash Neuro high pitched cry irritability, lethargy, seizures

Answer 50

``` Full Hx and exam looking for sources SCN w freq monitoring Resp and cardiac support if needed Incubator w light therapy if needed Fluid boluses for hypotension Unlikely to tolerate feeds so give fluid only or TPN if needed Minimal handling Neutral heating Bloods - glucose, FBC, U&E CRP, LFTs inc bili differential, cultures Urine unlikely in early CXR LP where suspicion high ```

Answer 51

Fully dilated OA with < 45 degrees rotation for non rotational. OP for vac ROM Cephalic Engaged. Nothing abdominally for low, 1/5 mid cavity. At spines or below, +2 for low, head on perineum for outlet Pain relief adequate Sphincter - bladder empty ``` Others Preferable >36/40 for vac Haemophilia Prone to fractures Hepatidities ```

Answer 52

``` VBAC Shorter stay Skin to skin Success average 75% down to 40%-90% 10-15% perineal damage Risk of rupture 0.5% Foetal mortality 2-3/10000 Hypoxic injury 1/2000 Resp distress 1% Endometritis 2.8% ``` LSCS Risk of anaesthetic Serious operative complications Post op complications - VTE, ileus, adhesions, wound infection Difficulty of successive operations Roughly double risk of resp complications - 2-3% at 39, 6% at 38 Incr risk praevia, percreta etc

Answer 53

``` BIRTH Events of birth How is baby Scars healing ok Any follow up from hospital needed Any concerns re health Lochia/ return to periods Breast feeding ``` PSYCHOLOGICAL How was the birth - any issues need discussing? Screening for dep - Sleeping, Mood, Affect, Activities. - consider Edinburg dep scale - exercise, psych, pharm Baby - content, sleeping, feeding, growth, responsive? ``` SOCIALLY Sleep Relationship w partner Social isolation Smoking - SIDS, childhood asthma ``` SEX and contraception Return to sex? PELVIC FLOOR EXAM Baby and mother as indicated

Answer 54

Failure to del foetal body 60s after del of head. Inlet problem. Usually accompanied by failure of restitution and turtle sign

Answer 55

H - call for help Assign someone to telling woman what is happening Tell not to push Head of bed flat, end of bed off and buttocks at edge Empty bladder/ balloon. IVC Paed at delivery E - evaluate for episiotomy L - legs. McRoberts. Hyperflexion and abduction of legs - try each manoeuvre for 30s. Apply axial pressure constant force P - suprapubic pressure E - entry manoeuvres - Rubin II apply pressure to top shoulder anteriorly to rotate - Woods screw - add pressure to bottom shoulder posteriorly - reverse Woods screw - anterior pressure on bottom shoulder R - removal of posterior arm R - roll onto all 4s and try again After - full neonatal review Maternal review - treat prophylactically for PPH, assess EBL and repair tears. Cord bloods Document Debrief Discuss risk of recurrence

Answer 56

Anoxia during dystocia Death Trauma - Erbs palsy - 9/10 resolved by 6/12. Physio referral. Neuro injury (usually Erbs) 1.6-2.9/1000. Weakness of abduction, ext rotation, supination. - fractures Recurrence 1-25%. Control of DM, timing so next not bigger, ? CS, experienced accoucher, in hospital, empty bladder in preparation. Avoid prolonged second stage and mid cavity instrumental

Answer 57

1. History - obstetric and gynae Hx, how long trying etc, consanguinity MHx FHx - inherited problems, chromosomal abs, birth defects, intellectual disability SHx - smoking etc, relationship issues, wt reduction, exercise, work Psych Hx Meds, allergies 2. Exam - chest, wt, abdo, pelvis if swabs/Pap smear indicated 3. Ix - FBC, TSH, rubella, blood group, CKD, TFT, carrier tests as needed, infectious serology, ferritin and electrophoresis if needed, +/-varicella. Vit D, Urinalysis 4. Advice - Diet and exercise - folate, iron, iodine, smoking, EtOH, any other drug use, appropriate wt gain etc, avoid hyperthermia Infectious diseases - rubella, varicella, toxo, listeria, salmonella, campylobacter, pasteurised milk Person specific advice Trisomy screening discussion Need for early US ? Need for genetic services Type of care plan

Answer 58

``` Life expectancy - close to normal Overwt/ obese Cardiac defects - 50%. Usually fully correctable Lower immune system Leukaemia Vision Ear infections DM Premature again GIT - ones or duodenal atresia, Hirschsprungs Intellectual disability ```

Answer 59

US for features 11+3-13+6 Bloods 10+6-13+6 - PAPP-A, BhCG FP 5%, sn 85-90% w 70% just US

Answer 60

Performed from 11/40 so results may be available for TOP by D&C US guided usually abdominally take preplacental tissue and send for FISH Sn 99% w 1% equiv and 0.1 FN 1% incr miscarriage rate

Answer 61

From 15/40 take abdo US guided sample of fluid around baby ~100% sn 0.5% additional mc rate Too late for D&C

Answer 62

Quadruple blood test - hCG, Inhibin, AFP, unconjugaged estrodial Perform 14-20 w best results 15-17 Sn 70% - 75% for Downs and NTD 95-100% when combined w morph. false positive 5%

Answer 63

Make sure dates are accurate and retake FHx Try to get partner in to discuss also Inform of results Provide written and paper info on invasive testing - do not book yet. Encourage to take time but make sure she is aware of time frame limitations Refer to genetic counsellor or other trained counsellor w/in few days Explain screening vs diagnostic Explain diagnosis of Downs Provide option of TOP Consider referral to foetal diagnostic unit for counselling or support groups for more info on child w Downs Consider referral to paed. All of this should happen after diagnosis Explain how care would be different from here on Reassure that this is not an infection/ disease and is no ones fault Acknowledge shock and emotional response Plans re ongoing support Normal karyotype - still at risk of pregnancy complications.

Answer 64

High risk 16, 18 Remember some cross coverage w vaccination Warts - 2, 6, 11

Answer 65

3% and 6 yrs

Answer 66

18yrs or 2 yrs sexually active whichever is later. Every 2yrs until 70 if no abs in 5yrs. May perform index smear after this.

Answer 67

This is a screening test not diagnostic that has found something that, if left a long time, might turn into a cancer. This is not a cancer Requires further Ix +/- minor surgery Majority of these changes resolve by themselves even high grade changes but we think on balance it's better to remove high grade changes and watch low grade ones unless they're persistent or there's something else going on LLETZ or cone biopsy w local or gen anaesthetic If trying for pregnancy wait until after treatment completed - treatment will take about 6/12 then wait for results of 6/12 check May cont taking the pill Consider Guardasil - six, eleven, sixteen and eighteen

Answer 68

``` Dysmenorrhea Menorrhagia Endometriosis Irreg cycles PCOS Ovarian ca 50% CRC 18-40% Endometrial ca 50% PID Endometriosis Fibroids PMS benign breast disease ```

Answer 69

Not pregnant and no sex in last 7/7 or coverage by other contraception or emergency contraception - if any risk return for pregnancy test as follow up - start in active section and cover w alt measure for 7/7 unless post TOP or post partum/ breast feeding exclusively Written and verbal information Inform as to what to do with missed pills, diarrhoea etc

Answer 70

May not be used w breast feeding, cardiovascular risk factors, severe, liver disease, migraine with aura, VTE risk, recent breast ca, smoker above 35yrs, active gallbladder disease Relative contraindications - Raynauds w lupus anticoagulant, SLE w antiphospholipid antibodies, poorly controlled DM User dependent No STI coverage Incr CVD Breast ca slightly inc ? Cervical ca Hepatic adenomas 2x VTE risk but this is much better than in puerperium

Answer 71

``` Quick start and rapid cycling counselling, when to use alt contraception STI screening Pap smears Safe relationship STI prevention Results mailed to her in 2-3/52 ```

Answer 72

``` Pregnancy Allergy to components Undiagnosed abnormal vaginal bleeding Breast ca in 5yrs Active severe liver disease Current DVT/PE - relative Liver enzyme inducing drugs ```

Answer 73

``` Safe MOA x3 most effective Lasts 5 yrs Not user dependent Decr pain and blood loss Easy to insert and remove Good for obese and those with RF Risk of PID the same - check before insertion just in case if at risk Hypooestrogenism not an issue Doesn't affect fertility ```

Answer 74

OGTT in pregnancy presumed onset in pregnancy fasting >5 or 2hr >8 Maternal risks - 50% in 20yrs dev DM w ocular, renal, CVD, peripheral neuropathy etc complications Labour dystocias ``` BABY Macrosomia - shoulder dystocia IUGR Jaundice RDS Electrolyte abnormalities Blood sugar regulation post birth Late - obesity, metabolic syndrome ```

Answer 75

``` Advice re diet and exercise Discussion of risks and new model of care and team based approach who she will be seeing Book in to see diabetic educator Discuss monitoring - fasting and 2x post prandials daily as a start Insulin Foetal monitoring Timing of delivery and mode of delivery Neonatal management Follow up ```

Answer 76

``` Usually starts ~28/40 Monitoring - no evidence for CTGs or dopplers. ?amnio for mec or foetal maturity. Twice wkly LFTs and bile acids. If soaring reconsider Dx Check 7/7 post del to check resolution Ursodeoxychoic acid - positive effects on mother, baby and itch Vit K if stentorrhoea or coag ab Antihistamines Del at 37/40 Low fat diet, loose cotton clothing Active third stage due to malabsorption of vit K Cont CTG Pruritis should resolve in 1-2/7 Recurrence 60-90% ```

Answer 77

NORMAL Ovulatory spotting Spotting before or after period - common w endometriosis Hormones - contraceptives, HRT, chemo agents ``` YOUNG STIs Ectropion Trauma Pregnancy and complications Endometriosis Cervical ca etc ``` ``` MIDDLE Polyps Trauma Cervical Px Fibroids Endometriosis Pregnancy ``` ``` OLD HRT Cervical Atrophy Trauma Polyps Endometrial hyperplasia or Ca Fibroids ``` OLD

Answer 78

``` History EXAM Abdo Ext genitalia Pap smear if due Swabs +/- pipelle Bimanual ``` ``` OTHER US PCB - colposcopy IMB - hysteroscopy E ```

Answer 79

``` Lifetime 2.5% ENDOMETRIAL Endometrioid Mucinous Clear cell Serous Squamous ``` Type 1 usually low grade and arise from hyperplasia. Oestrogen related Type 2 not related to obesity and poorer prognosis NOONEPITHELIAL

Answer 80

Age - 80% post menopausal w 5% under 40 Oestrogen excess esp unopposed across lifetime - obese, DM, HTN, nullip, tamoxifen Lynch syndrome (hereditary nonpolyposis colorectal cancer) - risk 45-60% w ovarian 10%. Colorectal 40% Hx of breast cancer Presentation w abnormal bleeding - 95%. 5-20% Ix for PMB will have it

Answer 81

``` Clock and light Blankets and heater Suction Air and oxygen connected and flowing w appropriate PEEP est Sats probe, stethoscope Laryngoscopes Review history ```

Answer 82

A - activity. Absent, flexing, active movement P - pulse. None, <100, >100 G - grimace. None, some flexion of extremities, active motion A - appearance. Blue, extremities blue, pink R - resp. None, slow and irreg, active cry Assess at 1 and 5min

Answer 83

Term, clear fluid, good breathing and tone - ROUTINE = warm and dry, clear airway if needed, watch respiratory effort and give supp O2 if needed. 1. Simple measures - warm and dry - neutral position - clear airway if needed - stimulate -- hr < 100 2. Provide air with PPV - 30/5mmH2O O2 monitoring commence 3. If HR <100 Turn to oxygen supp Ensure open airway, reduce leaks ensure chest rise and fall 4. If HR < 60 Add compressions 3:1 ratio and 100% O2 ``` 5. Drugs Venous access Adrenaline IV 10-30mcg/kg 0.1-0.3ml/kg --> if resuscitating a term baby draw up 1ml and use it all. consider volume expansion 10 ```

Answer 84

5-15% with 10% onset <34/40 1/4 severe 1:200 eclampsia without MgSO4 In developing countries second most common cause of still births and early neonatal death

Answer 85

``` BP greater than 160 or 110 Urine >3+ or 5g in 24hrs Oliguria <400ml in 24hrs Persistent headache or focal neuro General malaise Abdo pain or LFT changes Coag changes Falling plts Oligohydramnios, decr FM, abnormal dopplers or growth, abruption ```

Answer 86

``` MATERNAL non mod Primip Age >35 New partner PHx or FHx Collagen vascular disease Thrombophilias CKD Black ``` ``` MODIFIABLE Obesity GDM/DM PIH/ essential HTN Periodontal disease ``` ``` PREGNANCY ART Twins etc Triploidy Molar pregnancy ```

Answer 87

``` MATERNAL Daily WTU if not proteinuric Twice wkly bloods if stablish Q4h BPs Fluid balance ``` FOETAL Daily CTG as inpt or twice wkly Biophysical and biometry 2wkly

Answer 88

Location - outpt usually only for mild, well baby and remote from term Blood pressure - early usually methyldopa or SR nifedipine Foetal and maternal monitoring Steroids MgSO4 - severe PET with evidence of CNS abnormality - see next question Timing of delivery - Discussions with neonatal teams as relevant Mode of delivery Follow up - GP/ gynae follow up. Recurrence risk

Answer 89

1. DRABC - BLS - place in recovery, pelvic tilt, clear airway, responsiveness, oxygen, head down, rails up etc 2. Control seizures - MgSO4 - 4g loading dose then 2g per hr Further 2g loading over 5min with any further seizures Otherwise Diaz 5-10mg IV over 4-5min Regular obs inc patellar reflexes, RR and UO Continuous CTG Serum Mg if suspect OD Q5min BP IDC for strict fluid balance - minimise input Full exam inc chest exam Take basic bloods + Mg level Have calcium gluconate on hand for swift reversal if needed Therapeutic range 1.7 - 3.5 SE - flushing, nausea, thirst, headache, dizziness, pain or warmth in peripheries, slurred voice, weakness, blurred vision, drowsiness, resp depression, cardiac tox, ARF ``` 3. Control BP Cont CTG Aim for 130-140/90-100 Nifedipine 5-10mg PO and rpt after 30min OR 10-20mg and rpt after 45min Hydralazine 5-10mg IV slow 20min apart max 15mg ``` 4. Ix 5. Consider VTE prophylaxis 6. Deliver 44% occur postnatally 7. Follow up 4. Other Consider mode of del - MgSo4 conts until 24hrs after del or last seizure Place of care - HDU/ birth suite/ transfer

Answer 90

``` Place of care Blood pressure control - strict Multidisciplinary team Full maternal and foetal assessments Continuous CTG Fluid balance Ix bloods and urine Consider clexane ``` Reg bloods and involve haem, paeds etc as needed Mode and timing of delivery

Answer 91

``` Nonreassuring foetal status Severe IUGR >37/40 Eclampsia Acute pul oedema Uncontrollable HTN Det bloods persistent neuro Sx Persistent epigastric pain, N/V ```

Answer 92

``` Careful medical Hx to exclude other causes Gynae/ obs Hx esp dating and bleeding What is being tolerated and appetite Signs of dehydration Exclude mole and multiple pregnancy Exclude UTI, thyroid disease, liver disease and electrolyte derangement +/- amylase and AXR for obstruction Address concerns re viability ```

Answer 93

Fluid resuscitation and correction of electrolytes - NS rather than glucose first Antiemetics - maxalon - doxylamine - 1st generation antihistamine particularly good in combination w B6 (pyridoxine) - promethazine - prochlorperazine - both stemetil and phenergen assoc w EPSE in late pregnancy -- cat C - ondansetron - corticosteroids - ginger - as effective as B6. Feeding - May need NGT, TPN, slow introduction Advice re diet etc Other - thiamine, folic acid, other multivitamins GP follow up or consider dietician

Answer 94

6-12 12-24 6 1

Answer 95

``` 5 Ps - ask about the last 3 months, 6/12 and yr Partners Practices Protection from STIs Prevention of pregnancy Past Hx of STIs ``` Some other questions: Are you in a relationship Have you ever been paid or paid for sex in the last 12months Have you ever had tattoos, injected drugs, shared needles, been in gaol Remember to contact trace and mention this - do you want to contact or would you like help doing this? Some are ASx so need to be treated

Answer 96

1. Chlamydia (PCR on endocervical, self collected swab or first void urine) and HBV 2. Same + gonorrhoea as well 3. Chlamydia, HIV, syphilus, (HIV Ab, syphilus EIA) HBV 4. All above 5. All above 6. All plus HAV

Answer 97

Confidentiality statement excluding risk of self harm, homicide, suspicion of abuse STI risks - age of onset of sexual activity, age of partner, contraception, IVDU, sex work, body piercings/ tattoos, 5 Ps, remind of emergency contraception Home - where do you live, who lives with you, how long, pets, safety, weapons etc Education - where school, changed school, grade, favourite subjects, safety, grades, future plans Activities/ employment - what do you do for fun, do you have a best friend, clubs, teams, do you have a job and what is the environment life, eating habits Drugs - talk about friends first, use to relax, using alone, forget things while using, tell should cut down? Suicidality Sex - partners, screening for abuse, safe in relationship as well as practices etc Don't forget to screen for depression and STIs

Answer 98

``` Young age Social isolation Poor relationship with partner or single/ domestic violence Unemployed Unplanned pregnancy Prior anx/dep Recent stressful life events Dep in the father ```

Answer 99

``` Sleep Anhedonia Dysphoria Appetite Fatigue Agitation or anxiety Concentration Excessive guilt Suicidal ideation ``` Remember to screen for thoughts of harm to baby or self and ability to care for baby Ppp

Answer 100

Psycho education Lifestyle advice - rest, exercise, do things you enjoy, make a plan for the day Peer support Postnatal care Involve sig others Provide ongoing opportunities for further discussion Counselling or psych therapy

Answer 101

Assess risk of psychosis, risk to self or baby

Answer 102

``` Previous same ART Tubal factor infertility PID/ STI IUD in place Emergency contraception >40 yo BTL ```

Answer 103

Ix risk factors Good for haemodynamically unstable or peristent heavy bleeding Option for salpingostomy - 4-15% persistence Follow hCG to zero if ruptured or salpingostomy No data on interval between preg advise 3/12 after returns to zero if followed Recurrence 15% after one and 30% after two - early presentation to GP for hCG and US in early pregnancy

Answer 104

``` May be used for unusual locations HCG >500 TVS >3cm/foetal heart heard Ruptured or unstable Active bleeding LFTs abnormal or FBC off Renal disease Immunodeficiency Pul disease Peptic ulcer Heterotopic BF Non-compliance w follow up Allergy Geographic ```

Answer 105

95% success with hCG less than 5000 and 85%<10000 5-15% req surgical intervention Check hCG day 1, 4,7 and rpt if day 7 is <15% decline from day 4 Wkly to zero SE vomiting - Rx folate, bleeding

Answer 106

Only if low and falling hCG, mass <3cm and ASx Must be compliant Follow up hCG every 48-72hrs until <20 then weekly TVS to ensure resolution Represent w incr pain

Answer 107

``` Folate Stop smoking Exercise - 45 min on alternate days Wt loss / gain Avoid illicit drugs Appropriate EtOH Not suffic evidence re caffeine Med review re teratogenicity Refer directly to IVF if: >37 <42 Trying > 5yrs More than one factor in infertility Undergone sterilisation No children in current relationship ```

Answer 108

Group one - hypothalamic hypopit/ hypogonadotrophic hypogonadism - decr exercise and put on wt - pulsatile GnRH to induce ovulation - risk of hyperstim Group two - hypothal, pit, ovarian dysfxn - lose wt - clomifene citrate - anti oestrogen - risk of hyperstimulation - metformin Assisted conception - intrauterine insemination, gamete intrafallopian transfer, IVF, intracytoplasmic sperm injection

Answer 109

Varicocolectomy Assoc between erectile dysfxn, low testosterone levels and metabolic/CVD closely linked - consider exogenous testosterone Erectile problems - consider PDE5

Answer 110

Advise on how to maximise fertility and explain reversible causes of conception difficulties - 2-3/wk avoiding long absences, beh problems may need psych Unexplained have 35-50% pregnancy rate after 2yrs and 60-70 after 3 but very poor after this.

Answer 111

``` Admit and offer analgesia Administer steroids and start tocolysis Start prophylactic GBS cover Continuous CTG if appropriate age Consider mgSO4 if < 30/40 Determine presentation - if Cephalic usually can VD but if breech safest by LSCS Consider transfer Consider discussion with paeds ```

Answer 112

``` >34/40 Labour too advanced IUFD Lethal foetal anomalies Suspected foetal compromise Maternal BP <90 systolic Placental abruption Chorioamnionitis ```

Answer 113

Nifedipine 20mg PO max three doses 1/2 hr apart until contractions settle Maintenance 20mg every 6hrs for 48hrs

Answer 114

``` Prev same Low SES PPROM Multiple gestation Uterine anomalies Cervical incompetence Polyhydramnios Abruption PV bleeding Smoking Illicit drug use ```

Answer 115

Vitals Contraction pattern CTG WTU/ MCS Abdo palp for lie/ tenderness Spec - May perform amnisure or FFN (no sex or VE for 24hrs, ROM, bleeding, cerclage, lubricants, take from post fornix) HVS LVS VE if ROM excluded and definitely not long and closed Basic bloods TVUS where available or bedside US for foetal wellbeing where CTG not appropriate

Answer 116

``` Hypotension Flushing Headache Cardiac failure Tachycardia / palpitations Nausea Dizziness ```

Answer 117

Uncommon Exists in soil, dust, processed foods, water, meat and faeces. Usually ASx but may present with flu like illness and PTL Baby - mec with frequent Mc in early pregnancy or mortality 40-50% in later trimesters or mortality 3-50% live born Dietary HX but remember may be up to 70 days from ingestion Serology not useful consider BC, MCS, genital tract +/- amniocentesis Rx amp and gent w urgent del dependent on severity

Answer 118

``` 6/1000 w normal yearly seroconversion 2-3% Childcare workers 10% Parents w kids in childcare 20-30% 50% transmission risk to infant Ractivation <1% transmission ```

Answer 119

``` Exposed Symptomatic - usually a symptomatic. EBV like presentation Immunocompromised Exposure Abnormalities on routine antenatal US ```

Answer 120

PCR or direct fluorescent antibody on saliva, NPA or urine Serology looking for IgG (seroconversion), IgM (active disease) over time and CMV avidity Foetal risk assessment Future maternal care - risk of congenital CMV infection after primary remains elevated for up to 4yrs

Answer 121

Amnio for culture - if positive offer TOP If affected 90% ASx w 10% sequelae w 10% affected 90% sequelae. - mortality 10-30% - neuro microcephaly, seizures, chorioretinitis, retardation - sensory neural hearing loss *** big concern w ASx Serial growth / AFI / dopplers

Answer 122

1st and 2nd trimester 10% transmission 75% in late pregnancy w no role of HBIG in reducing transmission. Most transmission at time of del Baby - give HBIG and vax at birth followed by normal schedule at 2,4 and 12/12

Answer 123

If immunised check antiHB - if positive only give HBIG within 72hrs if high risk - if negative give HBIG ASAP if high risk as well as vaccine within 7/7 full course Adult exposure = 60-65% sub clinical infection and recover completely 20-25% acute hepatitis 5-10% carriers 5-10% chronic hepatitis

Answer 124

If eAg -VE risk of transmission 5-20%, if positive risk 70-90%. 90% infected infants become chronic carriers No evidence for avoiding breast feeding or LSCS Avoid invasive procedures Give HBIG and vax at birth + normal schedule Follow up serology in 12/12.

Answer 125

IVDU, abnormal LFTs, blood products before 1990. Organ Tx or haemodyalysis, incarceration, partner positive HCV ab by ELISA followed by HCV RNA PCR - if negative risk of transmission almost zero if positive proportional to load ~6% Test for HIV and HBV LFTs Give/check HAV vax Refer to hepatitis clinic Counselling

Answer 126

``` Counselling Refer to liver clinic No clear evidence for mode of del Breast feeding ok so long as no cracked or bleeding nipples Follow up anti HCV in baby at 18/12. ```

Answer 127

Goal is to distinguish primary from secondary infection Primary infection in 1st or 2nd trimester - obtain genital culture to distinguish type Seroconversion will occur riot to 30-34/40 Treat active infection acyclovir 400mg TDS 5/7 Advice - risk of shedding during birth 7% but risk of neonatal disease <3%. If no seroconversion risk is 3050%. Late infection >30/40 - CA preferable if SROm < hrs. Treat active infection and consider suppressive therapy Recurrent - re swab if close to term to avoid new serotype, treat if severe and consider repressive therapy Avoid invasive activities in labour Careful spec to exclude active lesions - LSCS Baby - low risk swabs for PCR, urine PCR and observe High risk same, FBC, LFT, serological PCR, commence acyclovir Hand hygiene and no kissing with active oral lesions

Answer 128

Overt recurrent lesion <1% Recurrent w normal appearance 0.02-3% Early seroconversion w normal appearance <3% Late 30-50% w normal appearance

Answer 129

HIV ELISA confirm w western blot Rpt in 4/52 if indeterminate or recent exposure Refer to ID and paeds LFTs, HCV, HBV, routine infective serology + CMV, HSV, toxoplasma and chlamydia

Answer 130

``` Refer to ID and paeds Risk grading Start ART at end of 1st trimester if not already on it Commence zidovudine at end of 1st trimester Clean eyes at time of del Collect cord blood for HIV Bath before injections Start ART ASAP ```

Answer 131

Ensure pt knows about confidentiality - de- identify samples tested, legal requirement for notification and procedures relating to contact tracing. Assess risk factors for transmission Previous testing Windows of testing and how tests performed Give results in person Discuss implcations of negative test and importance of safe sex etc Discuss options for medical treatment Risk reduction strategies Follow up support

Answer 132

``` Background yearly rate 3% seroconversion 60% child bearing women immune Exposure at home half infection if susceptible Childcare 20-30% -- 8-12% infection Community <20% ```

Answer 133

50% transmission to foetus First half 10% excessive foetal loss and 3% hydrops Second half 1/3 spontaneous resolution 1/3 death without IUT, 27% resolve w IUT, 6% death despite IUT <1% congenital abs - no change

Answer 134

``` Ix - IgG and IgM Work exclusion not recommended Refer to FDU US at 1-2/52 intervals for 6-12/52 If N no action if abnormal foetal blood sampling ```

Answer 135

``` Not recurrence not assoc w sig risk <5% Up to 8/40 risk 90-100 8-12 50% 12-20 20% >20 1% ``` Consider TOP in first trimester and testing in second trimester Congenital rubella growth retardation, eye, cardiac probs, rash, haematological abs, pneumonitis, osteitis Risk of late onset months or yrs later if PCR +ve but ASx

Answer 136

``` Most common - haemorrhage. PPH or APH Thromboembolism - most common cause of direct maternal death Amniotic fluid embolism Cardiac - arrhythmia, MI, aortic dissection, cardiomyopathy Sepsis Toxicity Eclampsia ICH Anaphylaxis ```

Answer 137

D danger call for help R response, L lateral tilt or manual displacement A airway, varies w responsiveness, clear airway if needed, early O2 supplementation. Early intubation as laryngeal masks less effective B breathing. Supplemental O2, bag and mask until intubation C circulation. Two wide bore cannula w aggressive approach to volume resuscitation In absence of breathing commence CPR immediately Abdo Use for concealed haemorrhage Same defibrillator energy as for nonpregnant D drugs. Same algorithm Perimortem CS if no response to correctly performed CPR at 4 minutes and achieved within 5 minutes - earlier brain damage Adrenaline 1mg after 2nd shock if shockable or immediately if not. Every second loop Amiodarone 300mg after 3rd shock After successful resuscitation re-evaluate ABCDE, 12 lead ECG Dd

Answer 138

2/3 of Oligo/anovulation Hypertestosteroneism - clinical or raised FAI or testosterone PCO on US Exclusion of other causes - CAH - androgen secreting tumours - Thyroid dysfxn - hyperprolactinaemia --> FAI, US, TFT, prolactin, FSH and LH follicular. Screen for metabolic things once confirmed

Answer 139

Features of hyperandrogenism gradual onset and often assoc w wt gain Absent or irreg periods Infertility or subfertility Psych - anx/dep, eating disorder Metabolic syndrome - obesity, dyslipidaemia, DM, Note PCO up to 70% in young women - not useful to US

Answer 140

Obesity - refer to lifestyle program, 5% wt loss can restore cycles! assist mental wellbeing and halve risk of DM and CVS - 150min/wk - address dep/ anx issues which may affect participation Irreg cycle - OCP w anti androgen properties - w irreg cycles give intermittent progesterone to induce withdrawal bleed and protect endometrium Hirsutism - beauty stuff, COCP, metformin, antiandrogens Infertility - aim for BMI < 30 - smoking - exercise - folate - if unsuccessful fertility referral esp if >35 - clomifene pregnancy rate 30-50% after six cycles - metformin alone or in combo - gonadotrophins - ovarian drilling - IVF Cardio metabolic - lifestyle, screen for eating disorders, lipid profile every 2 yrs, BP annually, GTT every 2yrs Emotional wellbeing

Answer 141

Suspect - risk factors, abnormal CTG - Brady or variables esp if following manipulation. Confirm - VE or spec depending on if in labour Help Vasospasm - minimise by avoiding excessive handling of external loops Avoid compression - presenting part elevated by manually lifting or by filling bladder w 500-750ml - knee to chest position or head down with L lateral tilt Consider tocolysis terbutaline 0.35mg subcut while preparing for CS If del imminent may consider replacing cord or assisted delivery Paed at delivery

Answer 142

Menstrual changes - full transition may take 4-5yrs - cycles may change abrupt cessation in 10% Vasomotor symptoms - usually upper body - affect 80% with 20% severe - May cont up to 12yrs Urinary/ vaginal - loss of trophic effect of oestrogen, dyspareunia, discomfort and dryness, recurrent UTI, incontinence - May not manifest until 5-10yrs after menopause Mood changes Loss of libido

Answer 143

DM Thyroid disorder Pregnancy ``` Acute sx management Manage complications Avoid risk factors for complications Preventative health care - lipids etc - Pap smear - mammogram - consider DEXA for early menopause or RF Exclude Ddx ```

Answer 144

Healthy lifestyle - smoking, EtOH, exercise, wt loss HRT - esp good at vasomotor sx, mood swings, vaginal and bladder sx - always contains oestrogen and progesterone if has uterus - some incr in risk of VTE etc - tibolone synthetic steroid w oestrogenic, androgenic and progestogenic actions - key indication is vasomotor sx adversely affecting QOL - May be used in peri menopause and menopause but not recommended for >60yrs - for early menopause continue until 50yrs

Answer 145

``` Pregnancy Abnormal vaginal bleeding undiagnosed VTE Active or recent angina or MI Suspected past or present breast ca Endometrial ca or other oestrogen dependent cancer Acute liver disease with abnormal LFTs Uncontrolled HTN Migraine - relative ```

Answer 146

Reduces number and severity of hot flushes Reduces fracture risk Vaginal dryness Sexual fxn May improve sleep, muscle aches and pains and QOL

Answer 147

``` Risk factors and contraindications Lifestyle to reduce risk of CVD Consider if really necessary Fracture risk Consider antidepressant Breast and cervix screening Abnormal vaginal bleeding ```

Answer 148

<40 1%= premature <45 5%= early ``` Spontaneous in 90% Heritable - Turners, fragile x, galactosaemia AI disease Oophrectomy CT/ RT Pelvic surgery due to supply disruption Secondary causes of amenorrhea are DDx ```

Answer 149

4/12 amenorrhoea FSH 2 samples over a couple of months >40 in absence of exogenous estrogen at least 1/12 Exclude secondary causes - prolactin, LH, TFT, pregnancy, DHEAS, FIA, SHBG, TVUS to slide obstruction to outflow or follicles, ET, ovarian volume Check thyroid, adrenal antibodies, fasting BGL, LFTs, B12 and intrinsic factor antibodies, FBC, ESR, ANA, RF Karyotype and fragile x assessment Fasting lipids DEXA

Answer 150

Assoc between red and poor foetal outcomes 55% stillbirths perceived red foetal movements 70% with will have normal outcome Plateau from 32/49 Av 31/hr w longest length between 50-75min

Answer 151

``` Multiple presentations Known FGR HTN Cholestasis DM Extremes of age Primip Smoking Placental insufficient Congenital malformations Obesity Indian Rhesus Trauma ```

Answer 152

If FH/ CTG N and movements felt with no risk factors If not or risk factors biometry and biophysical profile Consider IOL

Answer 153

``` Less efficient Painful Epidural and assisted del more likely - 15% instrumental and 22% em CS 2/3 will have VD Incr SCN admission Strain on BS ``` Decr perinatal mortality by half. 1/3000 at 37 3/3000 at 42 6/3000 at 43

Answer 154

``` Rv at 40/40 for RF and FM - stretch and sweep - stim cervix, incr pain and bleeding, incr spurious labour no change in infection AFI and CTG at 41+3 Plan for IOL at 42/40 Twice wkly CTg and AFT until del ```

Answer 155

``` Vaginal delivery Parity Age Childbirth injuries Uterine retroversion ``` ``` Less strong Obstetric RF FHx Straining Hysterectomy or continence surgeries CT disorders ```

Answer 156

``` VAGINAL Bulge Pressure Back ache in sacral area Need to splint/digitise Bleeding, discharge, infection ``` ``` RECTOCOELE Constipation Digitisation/splinting Incomplete defaecation Rectal urgency ``` ``` CYSTOCOELE Frequency esp day time Dysuria UTIs Incomplete emptying Obstructive symptoms Post micturition leakage Position dependent urination Urgency ``` SEX Laxity Dyspareunia

Answer 157

``` Abdo exam Neuro if required Stress w full bladder - try again with reduction of prolapse --> empty bladder and rectum External genitalia Sims in L lateral position Bimanual Rectal ``` Bladder diary TEst and treat for UTI

Answer 158

``` CONSERVATIVE UTI Physio - best for mild Without tuition most women will perform incorrectly Pressaries Wt loss Improving other medical conditions Reducing repetitive strain esp post op Vaginal oestrogens for vaginal comfort and urinary symptoms ``` SURGICAL Prior to op should formally assess urinary continence as well Vaginal hysterectomy w pedicle support to vaginal fault Anterior repair Posterior repair For women wanting fertility try pessary or sacrospinous hysteropexy

Answer 159

INFO 3-4% at term 25% revert after 36/40 ``` EXCLUDE CONGENITAL MALFORMATIONS. EXCLUDE CONTRAINDIACTIONS APH Multiple preg ROM Severe anomaly CS for other reasons Poor growth HTN/PET Uterine anomaly Cord around neck ``` ``` RISKS El LCSC compared to vaginal breech reduces short term neonatal morbidity and mortality 5-1.6% CS risks for mum No difference at 2yrs ECV v safe - mortality 1/5000, abruption 0.1%, complications 6.1% usually temporary CTG changes Bleeding 0.4 Reversion 3% Success 40-60% ``` ``` PRACTICE RV prev US US to confirm presentation and absence of Nuchal cord RV blood group Empty bladder CTG and obs before May use tocolysis ECV CTG and US to exclude prolapse Anti D ``` ``` CRITERIA FOR VAGINAL BREECH Clinical support Adequate pelvis No IUGR or macrosomia Not footling or kneeling Flexed head No prior CS No severe anomaly No foetal or mat compromise Cont FHR during labour ```

Answer 160

Give time away from post natal ward Give time with baby - memory books etc Help with funeral arrangements Social work/ psych Close GP follow up Baby Ix - prior US for morph, AFI, amnio for culture and chromosomes - after swabs, photos, external exam, postmortem, cord FBC, histo path Maternal check - full Hx and tree - check for PET, obs, extensive bloods. - thrombophilias, blood group, bleeds, DM, infection, cholestasis,thyroid, karyotype Birth - usually vaginal. Prepare for appearance, active 3rd stage Lactation suppression Contraception Early DC w outpt midwife support RV at 6/52 Preconception counselling and info on how nxt pregnancy will progress

Answer 161

``` Old maternal age Obesity or severe malnutrition Smoker/ cocaine / EtOH PET/HTN Renal disease or severe other disease Certain meds AI/ thrombophilias Low PAPP-A in early pregnancy Aneuploidy Malformations Infections Multiple gestation Anatomical Vascular ```

Answer 162

Confirm gestational age Check growth if time Assessment of wellbeing - minimum wkly biophysical, AFI, dopplers Exclude anomalies if not already done Hx of infection and test for CMV and Toxo as well as malaria and syphilus in risk areas Birth planning - mode of del, paed RV if <32/40, steroids Prognosis discussion - most morbidity due to gestational age, usually gain wt well Prevention - quit smoking, early detection of PET, control of DM

Answer 163

``` IMMEDIATE Morbidity assoc with vaginal birth Perinatal mortality Hypoglycaemia/ hypocalcaemia Feeding Breathing Temperature ``` ``` LATE Heart disease T2DM Stroke HTN Osteoporosis ```