general obs Flashcards
AMA
Risks Fetal miscarriage ectopic Chromosomal and structural abnormalities IUGR PTB perinatal mortality baseline risk 1:1000 if over 40 2:1000 Maternal Maternal morbidity including hypertensive disorders and GDM obstetric intervention intrapartum abnormal placentae
Management
Aspirin for SGA prevention
Risk discussion
Obstetric led care
Offer chromosomal screening
BP and urine dip every visit
anatomy scan 18-20 weeks with uterine artery dopplers
GTT 24-28 weeks
Serial growth scans 28/32/36
Auckland guideline IOL for 40 + at 40 weeks
CEFM for over 42 year olds without other complications
Post partum
Contraception
high BMI
Definition Overweight BMI 25-29.9 Obese BMI >30 Risks Antental: Miscarriage GDM Fetal congenital abnormalities (NTDs) Stillbirth PET VTE OSA Preterm birth Maternal death Intrapartum IOL, prolonged labour and failure to progress Instrumental delivery Failed instrumental delivery Shoulder dystocia Caesarean section Difficulties with FHR monitoring PPH Peripartum death Anaesthetic risks Difficulty with labour analgesia GA Difficulty maintaining adequate airway, failed intubation
Increased need for ICU post-operatively
Post-partum
Delayed wound healing and infection
VTE
Greater likelihood of needing support with breastfeeding
Postnatal depression
Long-term neonatal consequences including neonatal body composition, infant weight gain and obesity
Management
Antenatal
Diet and exercise
Advice to lose weight pre-pregnancy and continue with healthy diet and exercise in pregnancy
Dietician review (especially if post-bariatric surgery)
Folic acid 5mg and iodine 150mcg
Consider aspirin
Advise weight gain as per NZ guidelines:
BMI 25-29.9: 7-11kg
Obese: 5-9kg
Offer psychological support if appropriate
Obstetric consultation in pregnancy
Early OGTT with repeat if necessary
Tertiary anatomy scan
Influenza and pertussis vaccines (major morbidity associated with H1N1)
Growth USS every 2-4 weeks from 24 weeks
Anaesthetic consultation for obese women
Advise IOL by 40/40
Intrapartum
IV access in labour
Anaesthetic consultation
Continuous CTG monitoring, consider FSE
Low threshold for instrumental in theatre
Inform OT if weight >120kg to ensure adequate staffing
Active 3rd stage management
Postnatal Consider thromboprophylaxis Offer breastfeeding support Screen for post-natal depression Recommend weight loss Arrange appropriate contraception
RFM
DFM is also strongly linked to adverse perinatal outcomes such as neurodevelopmental disability, infection, feto-maternal haemorrhage (FMH), emergency delivery, umbilical cord complications, small for gestational age (SGA) and fetal growth restriction (FGR)
All pregnant women should be routinely provided with verbal and written information regarding normal fetal movements during the antenatal period. and this should be emphasized every visit
Women with a concern about decreased fetal movements should be advised to contact their health care provider immediately.
assessment ASAP at least within 2 hours Assess for other risks of SB Symphysis fundal height CTG USS review previous Ix Kleihaurer
Still birth
PMR 11/1000
8/1000 fetal deaths and 3/1000 neonatal deaths
However in approximately 20-30% of stillbirths, a cause is never identified.
Talk to both parents
offer a support person
culturally competent
Comprehensive maternal (medical, social, family) and pregnancy history
Kleihauer-Betke test/Flow cytometry for fetal to maternal haemorrhage
External examination of the baby performed by the attending clinician
Clinical photographs of the baby
Autopsy
Detailed macroscopic examination of the placenta and cord
Placental histopathology
Cytogenetics (Chromosomal microarray (CMA) or karyotype if CMA is not available).
The rest are targeted
VTE personal or FHx - APLS
Sx cholestasis - LFT and bile salts
LGA - HBA1c
SGA - TORCH APLS and HBA1c
Placenta abruption APLS
NAIT
Dx mum HLA bb
with +ve HLA 1a antibodies
Test father
HLA1a
This is a condition when you create anti platelet antibodies that can cross the placenta and cause fetal thrombocytopenia
This can affect the first pregnancy
Risk depends on how severely previous pregnancies were affected
Severity of fetal/ neonatal consequence is a spectrum from petechiae to intracranial haemorrhage, venticulomegly GI or pulmonary haemorrhage and fetal or neonatal death
Management paternal screening Amnio to confirm fetal genotype (option) IVIG depending on previously affected pregnancy Can perform cordiocentesis 8 weeks after IVIG started to assess response (risk may outweigh benefit) USS to screen for ICH All offered ELLSCS at 37-38 weeks recurrence 70-90% 30% worse
vbac
Involve the woman in joint decision making about MOD
Counselling around MOD should start after the primary caesarean. Give advise on how to alter risk factors
Advise 12 months interpregnancy interval and optimising BMI
Review operative record from prev LSCS
Document a plan if labours spontanously before LSCS date
Success depends on Indication for previous LSCS, any prev VB, co existing abnormality, maternal BMI over 30, macrosomia, short stature, number of caesareans IOL, AMA
BMI increases risk of rupture and decreases success
VBAC Benefits less morbidity avoid major surgery and onging caesareans in the future earlier mobilisation and discharge patient gratification
Risks
uterine rupture 1/200 perinatal death 0.5/1000
Increased perinatal loss compared with elective 39 week LSCS - rupture and prolonged pregnancy 1.8/1000
HIE risk 0.7/1000
Increased risk if rupture of hysterectomy, GU injury blood transfusion
INcreased morbidity of EmLSCS (complications 13% vs 7 %)
Pelvic floor trauma
ELLSCS
Benefits
avoid late stillbirth
Reduced perinatal morbidity and mortality (HIE)
Risks Surgical risk ERCS increases the risk of serious complications for future pregnancies risk of respiratory neonatal morbidity Lower breast feeding initiation
Intrapartum In hospital with access to NICU and theatre epidural as desired CEFM continuous MW support clear oral fluids only IVL Hb and G+H 2 hourly VEs from 7 cm
