General Obstetrics and Pregnancy Flashcards
What does the gestational age refer to?
Duration of pregnancy dated from first day of LMP which preceeds ovulation and fertilisation by about 2 weeks
What are the major functions of the placenta?
Maternal-foetal transfer of nutrients and oxygen
Clearance of foetal waste
Synthesis of proteins and hormones
Where does the exchange of substances occur between the mother and the foetus?
Across the placenta, where maternal blood surrounds the chorionic villus.
What are the side effects of smoking during pregnancy?
Increased risk of:
- Miscarriage
- Pre-term labour
- Stillbirth
- SUDI
- IUGR
What are the side-effects of alcohol in pregnancy?
Foetal alcohol syndrome Learning difficulties IUGR Post-natal restricted growth Microcephaly
Is occasional drinking or binge drinking worse for risk of foetal alcohol syndrome?
Binge drinking - it is a major risk factor for FAS.
What are the risks of taking cannabis during pregnancy?
Similar to smoking due to tobacco content.
Increased risk of IUGR, stillbirth, preterm labour, SUI, and miscarriage.
What are the risks to the mother of taking cocaine during pregnancy?
- Hypertension leading to pre-eclampsia
- Placental abruption
What are the risks to the foetus of taking cocaine during pregnancy?
Prematurity
Neonatal abstinence syndrome
What are the risks of taking heroin during pregnancy?
Neonatal abstinence syndrome - newborn withdrawal caused by in utero exposure to drugs of dependance.
What are the aims of preconceptual care?
To maximise maternal and foetal health during pregnancy, minimise the risks of pregnancy, and advise on appropriate steps for the mother to take.
What substances can a mother abuse during pregnancy?
Cigarettes/smoking
Alcohol
Illicit drugs e.g. cocaine, heroin, amphetamines, marijuana
What dose of folic acid should be prescribed for a woman planning a pregnancy, and how long for?
400 micrograms daily for at least one month pre-conception, and 3 months post.
What dose of folic acid should be prescribed for a high risk woman planning a pregnancy, and how long for?
5mg daily for at least one month pre- and 3 months post-conception.
Which women are in the high risk category for folic acid supplementation?
Epileptics
Obese women
Diabetic women
Women with PMH of neural tube defects
What is the first antenatal visit for?
To take the history from the mother and do early baseline observations for monitoring purposes throughout the pregnancy.
Also to give the mother advice about lifestyle and saftey-netting for the pregnancy.
They should be encouraged to ask any questions they might need/want to ask
What basic obs should be taken at the booking visit at the very minimum?
Maternal height and weight -> BMI
Maternal blood pressure
In an uncomplicated pregnancy, how many appointments should a nulliparous woman be given?
10
In an uncomplicated pregnancy, how many appointments should a parous woman be given?
7
What should be done at every antenatal appointment?
BP and urine sample for proteinuria
What are the risk factors for pre-eclampsia?
Previous history Nulliparous Multiple pregnancies Maternal age over 40 BMI over 35 Close FHx Pre-existing renal/cvs disease or diabetes
What is placental abruption?
Condition where part or all of the placenta become separated from the uterine wall prematurely.
What is the pathophysiology of placental abruption?
Rupture of the maternal vessels within the basal layer of endometrium. A haematoma forms which splits the placenta away from the endometrium. This compromises the placenta and causes foetal distress.
What are the 2 types of placental abruption?
Revealed - bleeding tracks downwards and drains through the cervix -> PV bleed.
Concealed - bleeding remains within uterus and forms a clot.
What are the major risk factors for placental abruption?
- Prev. placental abruption
- Pre-eclampsia/HTN
- Abnormal lie
- Polyhydramnios
- Abdo trauma
- Smoking/drug use
- Bleeding in first trimester
- Thrombophilias
- Multiple pregnancy
A woman who is 36 weeks pregnant presents with painful PV bleeding, pallor, distress, and generally feeling unwell. What re your differentials, and which is top and why?
- Placental abruption - painful PV blood loss with disproportionate symptoms of shock.
Placenta praevia
Marginal placental bleed
Vasa praevia
Uterine rupture
What history do you want to take from a woman with suspected placental abruption?
- Blood loss - how much and over what time period.
- Fresh or brown blood, any mucus
- Rupture of membranes?
- Reduced foetal movements
- Epigastric pain
- Risk factors
- Provoked? e.g. post-coital
A woman who is 36 weeks pregnant presents with painful PV bleeding, pallor, distress, and generally feeling unwell. How should this patient be managed?
ABCDE!!! She’s going into shock!
If a woman with suspected placental abruption is clinically stable, what should we examine for?
- Signs of shock (just incase)
- Tender abdomen
- “Woody” uterus
- Palpable contractions
- Lie and presentation of foetus
- CTG for foetal wellbeing
- External examination - avoid speculum until placenta praevia excluded, swabs for infection if bleeding minimal.
How should placental abruption be investigated?
Assess foetal and maternal wellbeing:
- Bloods - FBC, clotting, Rhesus status, G&S/crossmatch as appropriate, U&Es, LFTs (pre-eclampsia and HELLP eliminated)
- USS
- CTG if over 26 weeks gestation
How should placental abruption be managed?
ABCDE!!!
- Emergency delivery, usually by C section (unless delivery imminent or operative delivery achievable)
- Induction of labour if at term with no compromise of mother or foetus.
- Conservative if partial or marginal abruption with no maternal/foetal compromise
Always give anti-D within 72 hours if the mother is rhesus D negative
Define prolonged pregnancy.
Pregnancy which persists up to and beyond 42 weeks gestation.
What are the risk factors for prolonged pregnancy?
- Nulliparity
- Maternal age over 40
- Personal Hx of prolonged pregnancy
- High BMI
- FHx
What does prolonged pregnancy increase the risk of?
By how much?
Increased risk of stillbirth.
37/40 -> 1 in 1000
42/40 -> 3 in 1000
43/40 -> 6 in 1000
Why is the risk of stillbirth higher in prolonged pregnancy? What else does prolonged pregnancy increase the risk of?
Placental insufficiency and degradation
Foetal acidaemia
Meconium aspiration
Need for instrumental delivery or C-section.
What are the clinical features of prolonged gestation, aside from being past 42 weeks?
- Static growth
- Macrosomnia
- Oligohydramnios
- Reduced foetal movements
- Meconium
- Dry/flaky skin with reduced vernix
How do we manage prolonged pregnancy?
Delivery by 42 weeks by:
- Membrane sweeps from 40+0 nulliparous/41+0 parous
- Induction of Labour between 41 and 42 weeks
What do we do in prolonged pregnancy if the woman refuses induction of labour?
Twice weekly CTG monitoring and USS measuring amniotic fluid to check for foetal distress in case emergency c-section needed.
What happens in maternal isoimmunisation?
Mother’s immune system is sensitised to antigens on foetal erythrocytes resulting in the production of IgG antibodies.
What sensitising events can cause maternal isoimmunisation?
- Antepartum haemorrhage
- Abdominal trauma
- During delivery
When does maternal isoimmunisation tend to be a problem?
Rarely during primary exposure, but more commonly in subsequent exposures when maternal antibodies can cross the placenta and attack the foetal red blood cells.
What are the consequences of maternal isoimmunisation on the foetus?
Haemolysis -> foetal anaemia
What is the most common set of surface antigens capable of inducing maternal isoimmunisation?
Rhesus D when the mother is Rhesus negative and they have come into contact with rhesus positive foetal blood.
How can we prevent maternal isoimmunisation?
Administer Anti-D immunoglobulin which binds to RhD+ cells in maternal circulation so no immune response is stimulated.
When is anti-D Ig indicated?
Following a sensitising event to a RhD- woman:
- Invasive obstetric testing
- APH
- Ectopic
- External cephalic version
- Fall/abdo trauma
- Intrauterine death
- Miscarriage
- ToP
- Delivery
What blood tests should we do to determine rhesus status after a sensitivsing event?
Maternal blood group and antibody screen.
Foeto-maternal haemorrhage test (assess how much foetal blood has entered maternal circulation to determine how much anti-D should be given)
What is the minimum dose of anti-D that should be given to a mother following a sensitivsing event after 20 weeks gestation?
500 IU of anti-D Ig within 72 hours of event
What is the minimum dose of anti-D that should be given to a mother following a sensitivsing event before 12 weeks gestation?
250 IU anti-D within 72 hours of event
What is the minimum dose of anti-D that should be given to a mother following a sensitivsing event between 12 and 20 weeks gestation?
250 IU of anti-D
When do we check maternal blood group and do an antibody screen?
Booking visit and then again at 28 weeks.
When should prophylactic anti-D be given to a RhD- pregnant woman?
28 and 34 weeks gestation.
Define small for gestational age.
Infant with a birth weight below the 10th centile for its gestational age.
Sever = birth weight below 3rd centile.
Define foetal growth restriction.
When a pathological process has restricted the genetic growth potential of the foetus
What does low birth weight refer to?
Birth weight below 2.5kg
What can cause foetal growth restriction?
Placental insufficiency caused by low pre-birth weight, substance misuse, autoimmune disease, renal disease, diabetes, and chronic HTN.
Foetal factors such as chromosomal, structural, metabolic, or infective causes.
What are the risk factors for SGA?
Maternal age over 40 Smoking 11+ a day Previous SGA baby Parental SGA Previous stillbirth Cocaine use Daily vigorous exercise Maternal illness
How is SGA diagnosed?
USS then plot weight on customised growth chart.
Ratio of head circumference and abdominal circumference.
There is also often oligohydramnios as placental insufficiency can result in impaired renal function.
If SGA is suspected, how should we investigate?
- Detailed foetal anatomical survery
- Uterine artery Doppler
- Karyotyping
- Screening for infections
What can we do to prevent SGA in mothers with risk factors?
Modify risk factors - promote smoking cessation, optimise maternal disease, 75 mg aspirin from 16 weeks gestation if at risk of pre-eclampsia.
How is SGA monitored?
Uterine artery dopplers repeated every 14 days, unless abnormal.
Symohysis fundal height, CTG, amniotic fluid volume, and other measurments can also be used.
What are the indications for delivery with SGA according to UAD?
Under 37 weeks if absent/reverse end diastolic flow on Doppler. Deliver by C section.
By 37 weeks if abnormal UAD or MCA doppler
At 37 weeks if normal UAD
What are the neonatal complications of SGA?
Birth asphyxia Meconium aspiration Hypothermia Abnrmal blood sugars Polycythaemia Complications of prematurity
What are the long term complications of SGA?
Cerebral palsy T2DM Obesity HTN Precocious pubery Behavioural problems Depression Alzheimer's disease Increased risk of certain cancers
Define placenta praevia.
Obstetric condition in which the placenta is fully or partially attached to the lower uterine segment. Divided into major and minor.
What is the difference between major and minor placenta praevia?
Coverage of the cervical os - it is not covered in minor.
Why is placenta praevia a problem?
A low-lying placenta is more susceptible to haemorrhage, either from trauma or spontaneously.
Where should the placenta normally implant?
Usually the posterior uterine wall, always upper segment.
What is the main risk factor for placenta praevia, and why is it a risk factor?
Previous C section - the new placenta implants on the scar tissue.
What are the other risk factors for placenta praevia other than previous c section?
High parity Maternal age over 40 Multiple pregnancy PHx Hx of uterine infection Curettage of endometrium after miscarriage/termination
How might placenta praevia present?
- Picked up on antenatal scanning
- Antepartum haemorrhage
- Painless vaginal bleeding
What are the differentials for placenta praevia?
- Placental abruption
- Vasa praevia
- Uterine rupture
- Local genital causes of PV bleed
How should ?placenta praevia with antenatal haemorrhage be investigated?
ABCDE and resus if major bleed.
Bloods - FBC, clotting, rhesus test, G&S/Cross-match
Check for HELLP and pre-eclampsia
Assess foetal wellbeing (CTG)
USS for definitive diagnosis.
How should ?placenta praevia with antenatal haemorrhage be managed?
ABCDE!!!
C section at 38 weeks is safest mode of delivery, with anti-D administration within 72 hours if rhesus d negative.
If a woman is told she has placenta praevia at the 20 week scan, is that a definitive diagnosis?
No - as the foetus grows and the uterus stretches, the placenta can move upwards and no longer be in the lower segment. Keep an eye on this with subsequent scans to check progress. Diagnosis can be made if still in lower segment at 32-36 weeks (depending on if major or minor).
What is gestational diabetes?
Any degree of glucose intolerance with its onset during pregnancy, which usually resolves shortly after delivery.
Why does gestational occur?
Pregnancy hormones decreases fasting glucose levels, increases fat deposition, and increase appetite. Alongside that they cause increased insulin resistance. In women with GDM the body does not compensate enough by raising insulin production.
How is GDM diagnosed?
No set rules, but NICE recommends the woman has either:
- Fasting plasma glucose of 5.6 mmol/L or above
- Two-hour plasma glucose of 7.8 mmol/L or above
Is HbA1c used for diagnosis of GDM?
No
Why is gestational diabetes a problem?
Hyperglycaemia promotes large-for-dates babies, and there is increased risk of adverse foetal and maternal outcomes.
What are the increased foetal risks associated with GDM?
Increased birth weight Shoulder dystocia Birth injury Intensive neonatal care requirement Hyperbilirubinaemia
What are the increased maternal risks associated with GDM?
Preterm labour
Pre-eclampsia
Developing diabetes later in life
How common is GDM?
Quite - it occurs in 2-5% of pregnancies.
What non-modifiable factors increase the risk of GDM?
- Increasing age
- Asian/African-American/Hispanic/Latino/Pima Indians
What modifiable factors increase the risk of GDM?
- Smoking
- Inter-pregnancy weight gain
- Short interval between pregnancies
What obstetric history increases the risk of GDM?
- Previous macrosomia
- Previous unexplained stillbirth
What family history increases the risk of developing GDM?
-FHx of type 2 diabetes
Who should be offered screening for GDM?
BMI over 30 Previous baby over 4.5kg Previous GDM First degree relative with DM Ethnic background with high risk of DM
When does screening for GDM occur?
Offer at booking
Perform at 24-28 weeks
How might a pregnant woman who doesn’t have any risk factors for GDM be picked up?
On urinalysis at any antenatal appointment - glycosuria 2+ on one occasion or 1+ on mutiple occasions.
What test is used to diagnose GDM in women at risk?
Two-hour 75g oral glucose tolerance test
What is the main management principle for GDM?
Good glycaemic control
What are the steps to managing GDM?
- Self monitoring
- Dietary intervention
- Exercise therapy
- Insulin therapy if necessary
When are pregnant women with GDM advised to measure their blood glucose?
Fasting and one hour post-meal daily.
When are pregnant women with GDM on multiple daily insulin injections advised to measure their blood glucose?
Fasting pre-meal, one hour post meal, and bedtime glucose levels
What are the blood glucose targets for women with GDM?
Fasting glucose of 5.3
Glucose one hour after meal of 7.8 or 6.4 after 2 hours
What are the blood glucose targets for women with GDM on insulin?
Cap glucose should be above 4 mmol/L with the same upper limits
How many extra scans do women with GDM get?
20 week abnormality scan as well as scans at 28, 32 and 36 weeks.
What lifestyle modifications can help manage GDM?
- BMI under 27
- Diet advice
- 30 minutes of physical activity per day
What dietary advice is given to women with GDM?
- Eat 3 regular meals
- Eat starchy foods that release sugar slowly
- Lots of fruit and vag
- Avoid sugary foods and drinks
- Lots of lean protein e.g. fish
When are pregnant women with GDM on multiple daily insulin injections advised to measure their blood glucose?
Fasting pre-meal, one hour post meal, and bedtime glucose levels
What are the blood glucose targets for women with GDM?
Fasting glucose of 5.3
Glucose one hour after meal of 7.8 or 6.4 after 2 hours
When should a woman with GDM deliver?
No later than 40+6
Can offer induction of labour earlier if mother elects for it.
How many extra scans do women with GDM get?
20 week abnormality scan as well as scans at 28, 32 and 36 weeks.
What lifestyle modifications can help manage GDM?
- BMI under 27
- Diet advice
- 30 minutes of physical activity per day
What medications are used to control GDM if diet and exercise don’t work?
- Metformin
- Insulin
- Glibenclamide (if metformin not tolerated)
What long term effect does GDM have on the child?
More likely to be obese
When should a woman with GDM deliver?
No later than 40+6
How should management of GDM be continued after birth?
It shouldn’t - discontinue after birth, but advise lifestyle changes continued to reduce risk of T2DM and GDM in future
Screen for it in future pregnancies
What is the prognosis associated with GDM?
- Large baby
- Well controlled GDM reduces macrosomia, pre-eclampsia, and shoulder dystocia
- Women with GDM recover but 1 in 2 chance of recurrence in future pregnancy
What risks does a mother with diabetes face during pregnancy?
Increased risk of ketoacidosis, hypoglycaemia, and progression of microvascular complications
What long term effect does GDM have on the child?
More likely to be obese
What is the most common pre-existing medical disorder complicating pregnancy in the UK?
Diabetes
What are the maternal risks of having diabetes for pregnancy?
- Pre-eclampsia
- Preterm labour
- Miscarriage
- Diabetic retinopathy
What are the foetal risks of having diabetes for pregnancy?
- Stillbirth
- Congenital malformations
- Macrosomia
- Birth injury
- Perinatal mortality
- Postnatal hypoglycaemia
What risks does a mother with diabetes face during pregnancy?
Increased risk of ketoacidosis, hypoglycaemia, and progression of microvascular complications
What neonatal care is needed after a diabetic mother gives birth?
Admit to neonatal ICU if any complications occur.
Feed asap after birth then every 2-3 hours until pre-feed glucose levels are at least 2 mmol/L
What can be used as an adjuct to insulin in pre-conception period?
Metformin
Can a woman with diabetes continue her hypoglycaemic agents through pregnancy?
No - they hould be discontinued in favour of insulin and metformin.
How frequently should a woman with diabetes be seen by the diabetes care team?
Every 1-2 weeks
When should a woman with diabetes be advised to deliver?
Between 37+0 and 38+6 weeks by elective c-section or induction of labour
What neonatal care is needed after a diabetic mother gives birth?
Admit to neonatal ICU if any complications occur.
Feed asap after birth then every 2-3 hours until pre-feed glucose levels are at least 2 mmol/L
What symptoms are very common in early pregnancy?
Nausea and vomiting
Why might nausea occur in later pregnancy?
As a result of reflux oesophagitis
What is hyperemesis gravidarum?
Persistent and severe vomiting leading to fluid and electrolyte disturbance, marked ketonuria, nutritional deficiency and weight loss.
How common are N+V in pregnancy?
90% of pregnant women are affected to some degree.
When is N+V more common?
- First pregnancies
- Multiple pregnancies
- PMH of hyperemesis or motion sickness
- Molar pregnancy
- Younger women
- Obese women
What general advice can we give to mothers experiencing N+V in pregnancy?
- Rest
- Small frequent meals high in carbs and low in fat
- Avoid smells etc that trigger symptoms
- Ginger may help
- Eat a biscuit before getting up in the morning to settle stomach
If N+V in pregnancy starts after 12 weeks, is it more likely physiological or pathological?
Pathological or due to something other than pregnancy
What differentials are there for N+V in pregnancy?
- GI upset
- Cholecystitis
- Hepatitis
- Appendicitis
- Neurological e.g. migraine, RICP
- UTI
- Drugs (opioids, iron)
- Metabolic disturbance
- Other pregnancy pathology
When should N+V in pregnancy be investigated?
If there is another possible explanation, or if maternal or foetal wellbeing needs to be assessed.
When does N+V in pregnancy require treatment?
If the pt becomes dehydrated or hyperemesis gravidarum is suspected.
How should hyperemesis gravidarum be managed?
- Advice on diet and support
- Fluid and electrolye replacement
- Nutritional support
- Vitamin supplements
- Thromboprophylaxis
- Anti-emetics
- Corticosteroids in severe intractable cases
Which anti-emetics are recommendedfirts line for N+V in pregnancy?
Promethazine or cyclizine
What are the foetal complications of hyperemesis gravidarum?
Low birth weight
What is the prognosis for N+V in pregnancy?
It is good - no ahrm done to the baby, settles without complication as pregnancy progresses.
How common is hyperemesis gravidarum?
Not very - occurs in less than 1% of pregnancies
What are the clinical criteria for antiphospholipid syndrome?
- Vascular thrombosis
- Pregnancy morbidity (unexplained death of normal foetus from 10 weeks, preterm birth before 34 weeks, 3+ unexplained miscarriages before 10 weeks)
What are the lab criteria for antiphospholipid syndrome?
- Lupus anticoagulant present on 2+ occasions
- Anticardiolipin antibody present on 2+ occasions
- Anti-b2-glycoprotein 1 antidoby present
What are the foetal complications of hyperemesis gravidarum?
Low birth weight
What is antiphospholipid syndrome?
An autoimmune disorder characterised by arterial and venous thrombosis, adverse pregnancy outcomes, and raised antiphospholipid antibody levels.
How might antiphospholipid syndrome present in an already pregnant woman?
- Ischaemic stroke
- Recurrent pregnancy loss before 10 weeks
What are the clinical criteria for antiphospholipid syndrome?
- Vascular thrombosis
- Pregnancy morbidity (unexplained death of normal foetus from 10 weeks, preterm birth before 34 weeks, 3+ unexplained miscarriages)
What are the lab criteria for antiphospholipid syndrome?
- Lupus anticoagulant present on 2+ occasions
- Anticardiolipin antibody present on 2+ occasions
- Anti-b2-glycoprotein 1 antidoby present
What % of recurrent foetal loss is due to antiphospholipid syndrome?
About 15%
What other conditions are associated with antiphospholipid syndrome?
Other autoimmune disorders
How might antiphospholipid syndrome present in an already pregnant woman?
- Ischaemic stroke
- Recurrent pregnancy loss before 10 weeks
How should antiphospholipid syndrome be managed?
Prophylactic anticoagulation
- Switch to heparin when pregnant
- Add low dose aspirin in pregnancy
- Add post-partum thromboprophylaxis
What does antiphospholipid syndrome in pregnancy increase the risk of?
Cerebrovascular event or MI or PE
How does rubella present in adults?
Pink rash and lymphadenopathy, with mild constitutional symptoms and occasionally joint pain.
When does a rubella infection have a 90% chance of affecting a pregnancy?
If it occurs within the first 11 weeks.
After what gestation is a rubella infection not cause for concern?
After 20 weeks
When can a rubella infection in pregnancy cause increased risk of deafness in foetus?
Between 16 and 20 weeks
What can a congenital rubella infection do to a foetus?
Cause general learning disability, cataracts, deafness, heart defects, and IUGR. Inflammation of brain, liver, lungs and bone marrow can also occur.
How should rubella in pregnancy be managed?
Test for rubella and parvovirus if rash present. If infection present, discuss with patient with a view to terination if indicated and appropriate. Rubella is also a notifiable disease.
How should rubella in pregnancy be prevented?
Uptake of MMR vaccine in second year of life + preschool booster. Screen for susceptibility antenatally if at risk.
Why is chickenpox infection uncommon in pregnancy?
More than 90% of the population is varicella IgG antibody positive, so exposure may be common but active infection in the mother is not.
What are the consequences of chicken pox infection during pregnancy in the mother?
Greater morbidity - pneumonia in 10% of cases, and hepatitis and encephalitis.
What effects can congenital chickenpox infection before 20 weeks gestation do to a foetus?
There is no increased risk of miscarriage, but there is a risk of foetal varicella syndrome.
What are the characteristic of foetal varicella syndrome?
Skin scarring in a dermatomal distribution, microphthalmia, chorioretinitis, and cataracts, hypoplasia of limbs, and neurological abnormalities.
How does congenital chickenpox affect the foetus if the infection occurs in the second trimester (or 20-36 weeks)?
No adverse effects in foetus seen yet, but can present as shingles in first few years of life.
How does congenital chickenpox affect the foetus if the infection occurs after 36 weeks?
Up to 50% of babies are infected and 23% of these develop clinical varicella.
How should exposure to chickenpox in pregnancy be managed?
First establish if there is maternal immunity - this can be assumed if there is a hx of chickenpox or shingles. If not or any doubt, request varicella-zoster IgG antibody levels and liaise with local microbiology for advice.
What may be indicated if a mother has never developed chickenpox immunity but has been exposed during pregnancy?
Varicella-zoster Immunoglobulin but only in exposure, not in established infection!!!
How should established chickenpox infection in pregnancy be managed?
Specialist obstetric advice and conselling, monitor for complications, and admit if any worrying symptoms. If present within 24 hours of onset of rash, give oral aciclovir.
What is the most commonly congenitally acquired infection in infants?
CMV
How can CMV be transmitted?
Breast feeding, close contact, sexual activity, blood transfusion, and organ transplant.
What are the main abnormalities associated with congenital CMV infection?
Physical malformations and sensorineural hearing loss.
How many live births does CMV affect each year in the UK?
1800
How high is the risk of intrauterine transmission of CMV?
30-40%
How is congenital CMV diagnosed?
Amniocentesis at least 7 weeks after infection and past 21 weeks gestation.
How is congenital CMV monitored?
Extra ultrasounds to monitor for complications.
How does CMV affect a foetus?
IUGR, Low birth weight, Hepatosplenomegaly, Jaundice, Anaemia, hydrops and ascites, microcephaly, deafness, intracranial calcification, speech defects, psychomotor delay, visual impairment, general learning disability… basically everything. Often these become more apparent in later life.
How is CMV infection in pregnancy managed?
There is no effective therapy - best to avoid it. Prevention is the most important strategy.
What is the most effective way to prevent congenital CMV infection?
Hygiene measures - thorough washing of hands after nappy changing/feeding/wiping face/handling toys, don’t share utensils with young child, and avoid kissing child on or near mouth.
Why do we give pregnant women CMV negative blood if they need it?
Because CMV is highly teratogenic!!!!
How common is parvovirus B19 infection?
50-60% of adults have been infected at some point.
How does a parvovirus infection present?
Minor febrile illness with generalised rash similar to rubella, erythema infectiosum (slapped cheek disease), and arthropathy.
How should suspected parvovirus infection be investigated?
Parvovirus IgM and IgG with referral to specialist.
What are the consequences of parvovirus b19 infection during pregnancy?
Increased risk of intrauterine death, hydrops fetalis, and need for intrauterine transfusion for treatment of foetal anaemia.
How should a diagnosed case of parvovirus b19 infection during pregnancy be managed?
Serial ultrasounds and Doppler assessments. Intrauterine transfusion improves outcomes in hydrops foetalis.
Why has measles started to make a comeback in recent times?
Reduced vaccine uptake following adverse media coverage.
What are the clinical features of measles?
Disseminated maculopapular rash, coryza, conjunctivitis.
What complications can arise from measles infection?
Pneumonia, otitis media, and encephalitis.
What are the consequences of measles infection during pregnancy?
Increased maternal morbidity, intrauterine death, preterm labour. Rarely it can cause neonatal subacute sclerosing panencephalitis.
How should ?measles infection of pregnancy be investigated?
Measles IgG in absence of vaccination or immunity hx.
How can measles in pregnancy be managed? How good is this?
If no IgG for measles detected, human normal immunoglobulin can be given. This attenuates the illness but there isno evidence of protection against intrauterine death or preterm delivery.
What is toxoplasmosis and how does it spread?
Infection due to parasite Toxoplasma gondii from cats which are the definitive host.
How does toxoplasmosis infection present?
Often subclinical with vague features of illness (fatigue, headache, muscle ache, low-grade fever).
Which trimester is most affected by toxoplasmosis infection?
First trimester has the worst consequences, but thrid trimester has highest risk of transmission.
How can toxoplasmosis affect a foetus/neonate?
Systemic disease, neurological disease, or mild disease affecting eyes.
How is congenital toxoplasmosis infection managed?
Management by a specialist, with spiramycin for foetal prophylaxis, and regular ultrasounds. Specific abx are used to manage confirmed infection.
How can PID affect a foetus/neonate?
Increases risk of preterm delivery, and maternal and foetal morbidity. Ophthalmia neonatorum can also be transmitted which is potentially sight-threatening.
How should pregnant women with PID be managed?
Admit for IV abx.
Why is the management of PID in pregnancy quite difficult?
None of the evidence-based regimens have proven safety in pregnancy, so it’s about risk vs benefit for the individual drugs.
Which abx are considered safe for PID in pregnancy despite lack of evidence?
Cephalosporins e.g. ceftriaxone
Which abx/group of abx is contraindicated in the second and thrid trimesters?
Doxycycline (Tetracyclines) as it causes bone and tooth discolouration. Often it is used inadvertently in the first trimester, and no increased risk of malformation has been reported.
What does BASHH suggest for PID in pregnancy?
Follow local guidelines, but ceftriaxone + erythromycine +/- metronidazole is a good possibility.
What consequences can genital herpes infection in pregnancy have on a foetus/neonate?
Congenital herpes infection, neonatal herpes infection - congenitl is rare, but neonatal carries high risk of morbidity and mortality.
How does neonatal herpes infection present?
Eye, skin, and mouth lesionss, HSV encephalitis, or disseminated HSV with multisystem disease.
How should neonatal HSV infection be managed?
Antiviral treatent
How should neonatal HSV infection be prevented?
Oral or IV aciclovir in first or second trimester, or oral from 36 weeks and continue until delivery to prevent transmission. If a primary episode occurs at onset of labour, C-section should be recommended.
Which pregnant women are screened for HIV?
All of them
How does HIV work?
It affects T lymphocytes, macrophages, and monocytes with the CD4 receptor, wearing away at the immune system over many years until and AIDS-defining illness occurs.
Can HIV transmit from a mother to a baby?
Yes - it’s a big problem.
How can we reduce HIV transmission in pregnancy?
Maternal diagnosis and treatment with antiretrovirals, appropriate management of delivery, avoid breast feeding, and neonatal treatment with antiretrovirals and testing for HIV.
How should a woman with HIV deliver her baby?
It depends on the viral load - if the viral load is low, vaginal delivery is ok, but c-section is recommended if viral load is not low.
What is obstetric cholestasis?
Cholestasis occuring in pregnancy typically in the third trimester.
How does obstetric cholestasis present?
Intense pruritis particularly on palms and soles of feet without a skin rash, often in the third trimester. It is often worse at night.
What is obstetric cholestasis characterised by in terms of LFTs?
Abnormal, especially AST and ALT elevation, which resolve after delivery.
What are the risks of obstetric cholestasis?
Increased risk of foetal distress, intrauterine death, premature birth, and maternal morbidity due to intense itching and lack of sleep.
What are the risk factors for developing obstetric cholestasis?
PMHx or FHx of obstetric cholestasis, multiple pregnancy, gallstones, and Hepatitis C.
How should obstetric cholestasis be managed?
By a consultant-led team and deliver in a hospital. Monitor LFTs weekly until 10 days after delivery. Topical emollients can be used, but ursodeoxycholic acid is main management of pruritis. Induction from 37 weeks should be considered to reduce morbidity.
Who is involved in managing HIV in pregnancy?
HIV physician, obstetrician, paediatrician, and a specialist midwife.
How is a diagnosis of obstetric cholestasis made?
If no other cause is found for symptoms and LFT abnormalities, the diagnosis can be made.
When should obstetric cholestasis resolve by?
It should settle spontaneously following delivery, and LFTs should be back to normal by 10 days post-delivery.
What is malpresentation?
All presentations of the foetus other than the vertes.
What is malposition?
Abnormal positions of the vertex of the foetal head relative to the maternal pelvis.
How does the foetal head usually initially engage?
Occipito-anterior position (more commonly to the left that to the right)
Describe the occipito-anterior position.
The back of the foetal head is against the anterior wall of the pelvis.
What predisposes a foetus to malpresentation?
Prematurity, multiple pregnancy, uterine abnormalities e.g. fibroids, abnormal foetus, placenta praevia, and primiparity.
What is the most common malpresentation?
Breech presentation
