GOSH Flashcards
Definition of menstrual cycle >32 weeks?
if <23 days?
oligomenorrhea (infrequent)
polymenorrhoea (frequent)
heavy menstrual bleeding definition?
interferes with life socially, mentally, or physically
what measurement determines growth:
10-13(+9days) weeks?
14-20 weeks?
Why are growth scans NOT done later than 20 weeks? (1)
- crown-rump measurement (10-14wks)
- head circuference (14-20wks)
- scans >20 weeks for growth are inaccurate as the growth rates vary
growth scans more accurate than calculating based on LMP as actual time of ovulation in cycle may vary more than previously thought.
When is expected due date first decided? (1)
why is it important? (2)
- at booking visit
- important for assessing later growth of foetus
- reduces risk of premature elective deliveries or induction
In addition to the usual social history, what else should you ask in pregnancy? (3)
DOMESTIC ABUSE
ASD OHA DOT
Occupation:
- stable income?
- is she still working? for how long is she planning to work?
Housing:
- single or has partner
- no lift and lots of stairs
In obstetric history, why is it important to ask about LMP and regularity of cycle? (2)
- for dating
- very long cycles can = polycystic ovarian syndrome = insulin resistance and higher risk of gestational diabetes
IVF increases risk of… what in the mother?
pre eclampsia
Important things to ask for in family history of pregnant women?
- pre eclampisa
- diabetes
- serious psychiatric disorders (puerperal psychosis)
- VTE or blood clotting
- congenital abnormalities
Does a +ve HIV test affect insurance?
- if +ve, may need to go under specialist insure and propraly expect higher premiums
- existing insurance NOT affected by +ve result
What to do before testing for HIV? (2)
who to call before telling HIV +ve result? (1)
- explain why doing test
- get two methods of contact
- phone local HIV service for advice
- arrange urgent review to inform patient
- give results at start of consultation
<18 risk assessment?
- age he started having sex
- number lifetime partners
- age of partners
- where does he meet them?
- can he say no to sex?
- can he negotiate condom use?
- does he feel safe?
- any domestic violence/abuse?
- is he known to CAHMS/ social worker?
- where does he live?
- education?
- what support network does he have?
- self harm?
- anyone give him gifts or money for sex?
- anyone taken sexual photos/videos of him?
BE AWARE OF PHOTOS/VIDEOS
HIV:
what is risk of transmitting HIV if on treatment? (1)
what are the caveats? (2)
they can NOT transmit HIV to partner as long as…
(1) viral load undetectable for at least 6 months
(2) on going excellent adherence required
undetectable=untransmittable
HIV:
what to do if a partner of HIV +ve lady attends clinic with chlamydia? (2)
- treat chlamydia
- routine screen for other STIs (including HIV)
CANNOT disclose HIV status
- discuss in MDT
- ensure shes compliant with ARVs
- explain to her: HIV disclosure, criminalisation, PEPSE, PrEP, U=U (undetectable=untrasmissable)
Barriers to healthcare for trans people? (6)
- discimination
- fear of being misgendered
- segregated waiting areas
- lack of cultural competence by health care providers
- health system barriers e.g. inappropriate electronic records/ forms/ lab references/ clinic facilities
- socioeconomic barriers: transportation/housing/ mental health
How to be inclusive in sexual history taking? (1)
- explain WHY you’re asking things: i.e. “need to know what type of sex you’re having so we test the correct sites”
Contraindications to breastfeeding? (3)
are opioids allowed? (1)
- certain drugs
- galactosaemia(is a rare genetic metabolic disorder that affects an individual’s ability to metabolize the sugar galactose properly.)
- viral infections
- dihydrocodeine is safe to take when breastfeeding but codeine is not due to the risk of ultra rapid metabolism
Shoulder dystocia:
what to do?
What manouver you should use for shoulder dystocia? (1)
what is it? (1)
- HELPERR Call for Help with SOAPS (senior Obstetrician, Anaesthetist, Paediatrician, Midwives and a scribe and basically anyone free) Episiotomy Legs in McRoberts suprapubic Pressure Enter hands for rotation Remove post. arm out of the way Roll mum onto hands and feet
- McRobert’s manoeuvre
- supine with both hips fully flexed and abducted
it increases the mobility at the sacroiliac joints aiding rotation of the pelvis and allowing the release of the fetal shoulder. It is very important that additional help is called as the first step following recognition of shoulder dystocia.
most common cause of PPH? (1)
treatment 1st line? (1)
uterine atony
syntocinon followed by 0.5 mg of ergometrine
PPH
Management of PPH uterine atony?
Don’t forget HAEMOSTASIS!
Help (call for help)
ABC (assess and resuscitate - insert two 14G cannulas)
Establish aetiology and ensure availability of blood and uterotonics
Massage uterus
Oxytocin (syntocinon) - ergometrine - carboprost - misoprostol
Shift to theatre
Tamponade test (intrauterine balloon tamponade)
Apply compression sutures (B-Lynch sutures)
Systematic pelvic devascularisation
Interventional radiology/internal iliac or uterine artery ligation
Subtotal/total hysterectomy
remember primary PPH= <24 hours
secondary= 24hours -12 weeks due to retained placental tissue or endometritis
Gestational diabetes: glucose aims fasting? (1) 1 hour after meals? (1) 2 hours after meals? (1) management? (6)
- 5.4 mmol/l
- 7.8 mmol/l
- 6.4 mmol/l
- joint diabetes and antenatal clinic
- diet/exericse
- educate on monitoring glucose
- <7 mmol/l= exercise trial, then give metformin
- if >7mmol/l, start insulin
- if the plasma glucose level is between 6-6.9 mmol/l, and there is evidence of complications such as macrosomia or hydramnios, insulin should be offered
Baby blues:
treatment? (1)
- reassure and explain
RFM:
how to investigate? (3)
when should fetal movements be felt by? (1)
- Doppler to confirm fetal heartbeat IF NO HEARTBEAT= - immediate ultrasound IF HEARTBEAT= - CTG for at least 20 minutes to monitor HR to exclude fetal compromise
- 24 weeks
If fetal movements have not yet been felt by 24 weeks, onward referral should be made to a maternal fetal medicine unit.
Folic acid:
dose in all pregnancies? (1)
dose in increased risk? (1)
how long to take it for?
- 400 micrograms per day whilst trying to conceive and until 12th week
- FHx of NTD/ PMHx/ BMI 30/ use antiepileptic durgs/ coeliac disease/ diabetes/ thalassemia= dose 5 milligrams
DOCTor N.T.D Diabetes Obesity Coeliac Thassalaemia traits
or
NTD
Exercise in pregnancy:
advice? (3)
- aim to maintain fitness, not reach peak fitness
- walking, swimming, etc
- pelvic floor exercises during pregnancy and after birth reduce risk of urinary/foecal incontinence
- avoid contact sports
- if coexisting medical conditions may need more taoilored programme
- strength exercises good for preventing back pain
Diet advice in pregnancy? (3)
- 5 fruit/veg a day
- dont eat for two
- base meals on starchy foods, wholegrain where possible
- avoid surgar, foods high in fat and sugar, fizy drinks
- alcohol and smoking =NO!
Pregnancy and obesity: maternal complications antenatal (4) intrapartum (4) postnatal (3)
- difficulty assessing growth and anatomy of foteus
- increased GDM
- HTN
- VTE
- difficulty with analgeisa (spinal/epidural)
- difficulty monitoring labour
- increased instrumental delivery rate
- increased caesarean section rate
- VTE
- wound breakdown and infection
- postnatal depression
Pregnancy and obesity: foetal complications antenatal (4) intrapartum (4) postnatal (3)
- congenital malformations (NTD!!–> give FOLIC ACID 5mg once daily in first 12 weeks)
- macrosomia and associated complications
- fetal growth resitrcitons and assocaited complications
- misscarriage
- stillbirth
- shoulder dystocia
- risk of obesity and diabetets later in life
Breastfeeding recommendations (3)
- EBF 6 months
- breastfeding up to 2 years
- breastfeeding within 1 hour
Options for delivery? (3)
- home birth ~2%
(can’t have epidural and more adverse outcomes) - midwife units/ birth centres
- hospital birth centre
no difference between adverse outcomes risk in birth centres/ hospital births for mothers with no risk factors. If risk factors asked to go to hospital anyway.
Booking visit:
what is done?
- BMI
- exercise advice
- diet advice
- ASD advice
- antenatal urine test (MSU)
- blood pressure
- options for delivery
- breastfeeding
- BP
- booking tests for lots of things!: FBC, Blood group (R-), haemoglobinopathy, infection, dating and first trimester screening
Urinalalysis in pregnancy:
what to check for? (3)
- protein –> eclampsia
- glycosuria –> diabetes/GDM
- nitrites (UTIs)
if nitrites detected on dipstick then send for MSU to microscopy, culture and sensitivity to detect asymptomatic bateria
FBC in pregnancy:
anaaemia definitions in each timester? (3)
what else to look at if aneamic? (1)
1- < 110g/l
2- <105g/l
3- <100g/l
MCV to identify if iron/ folate/ B12
give trial of oral iron
Platelets in pregnancy:
when does it drop? (1)
what conditions might low platelets indicate?
de-novo immune thromocytopaenic purpura
- gestational thrombocytopenia (a fall in platelet count in pregnanct) rarely presents in first trimesters and is commonly detected beyond 28 wks
- HELLP
- haemolysis
–> if platelets low in first trimester then get haematology involved
Rhesus -ve:
when are anti-D immunoglobulins given? (3)
- 28 weeks
- 34 weeks
- post birth once cord checked and baby confirmed R+ve
Thalassaemia: dominant/recessive? (1) what is it? (1) risk factors? (1) severity levels? (2) how do you assess risk in pregnany, i.e. what tests? (2)
- recessive
- Hb abnormal as result of mutations in the genes that code for Hb
- Southeast Asia/ India/ Middle east
ALPHA THALASSAEMIA
- severity depends on how many chains are mutated out of the possible 4
- 1=asymptomatic, 2= mild, 3= regulat blood tranfusions, 4= intrauterine death
BETA THALASSAEMIA
- only 2 possible beta genes
- major (2: blood transfusions) vs minor (1)
- give questionaire
- FBC results
- -> if high risk refer to fetal medicine unit to discuss option of invasive confirmatory testing
Sickle cell anemia:
which ethnic group?
Africans
75mg aspirin is offered to women at risk of pre-eclampsia. What risk factors maek someone..
high risk? (4)
low risk? (6)
- HTN in this pregnancy or previous ones
- CKD
- autoimmune disease: SLE/ antiphospholipid
- any diabetes
- primiparity
- > 40years
- pregnanct interval >10 years
- > =35 BMI
- FHx pre-eclampsia
- multifetal pregnancy
Vitamin D in pregnancy:
what to advise?
take if when pregnant and breastfeeding
10yg daily
don’t bother testing for it as tests expensive
When a foetal abnormality is identified on US dating scan, what do you do?
refer to foetal mediicne specialsits for advice on prognosis/management/ further tests
make sure you inform women the limitations fo routien US scanning- it doesnt pick up all abnormalitie
CTG:
how is it taken?
- left lateral position or semi-recumbent position to avoid compression of vena cava
- two transduers placed on mothers abdomen, each other a belt, one measures the contractions other measures the foetal heartbeat
- recording for 30 mins at least
- mother presses for any foetal movements she feels
Why rubella no longer routinely tested?
MMR vaccine - v low rates in the UK so deemed not worth it!
Fetal HR:
how does it change over pregnancy? (1)
over what time period is needed to determine baseline fetal HR? (1)
- falls with advancing gestational age as a result of parasympathetic tone (max 160 bpm normal)
- 5-10 minutes
Normal baseline variability?
> 10 bpm
Causes of preterm labour: main groups? (3) which is the most common? (1) causes of preterm labour (PTL)? (8) how can you manage polyhydraminos? (1)
1- maternal/fetal problems causing induction
2- preterm labour (50%)- MOST COMMON
3- PPROM
- cervical weakness e.g PMHx cervical surgery
- infection of fetal membranes (chorioaminoitis) –> PPROM and PTL
- multiple pregnancy
- polyhydraminos
- uterine mullerian anomalies (abnormal uterus)
- haemorrhage/ placental abruption
- stress (fetal or maternal!): increased incidence on poor mothers/single/anxiety/Africa/ surgery (e.g.appendectomy)
- amino-drainage, but this may increase the risk of PTL and/or PPROM
- indomethacin (an NSAID) may be used to reduce fetal urine production but may result in premature closure of ductus arteriosis
They are all interlinked - ascending infection can cause cervical weakness
What role does the cervix have in preventing infection? (1)
Other than through the cervix, where else can infection come from? (2)
mucous plug has bacteriocidal properties
physical barrier between outside world
although it is possible for infection to come up through a normal cervix!
- transplacental
- invasive procedures
Note: abnormal vaginal flora (bacterial vaginosis) is common in PPROM and PTL, with a greater risk the earlier gestation is identified
Chorioaminonitis:
complications? (2)
- preterm labour
- PPROM
- fetal brain injury: since intrauterine infection drives fetal inflammatory response, involving proinflammatory cytokinaemia
- vasculitis of the umbilical cord and/or vessels of the chorionic plate
Multiple Pregnancies:
Only two complications multiple pregnancies DON’T cause? (2)
what’s the BIGGEST risk? (1)
what does preterm birth increase the risk of in multiple pregnancy? (1)
- post term labour
- macrosomia
EVERYTHING else they increase the risk of!
all preterm babies and end up in NICU
- cerebral palsy, 6-7 * increased risk in twins
Placental abruption:
what percentage? (1)
what does outcome depend on? (1)
- 1%
- gestational age when it occurs (same as with PPROM)
- pre-eclampsia
- HTN
- previous abruption
- traume
- smoking
-cocaine
-mutiple pregnancy
-polyhydraminos
-thrombophilias-
advanced materla age - PPROM
if >50% of the placenta abrupts –> fetal death
Preterm labour: how to test for it? (1) what to do if positive or negative result? (2) why use tocolytics? (2) first and second line tocolytics? (1)
70% of women who present with threatened PTL do not deliver on that admission!
- test fetal fibronectin (fFN), a glycoprtoein found in cerviocvaginal fluid, amniotic fluid and placental tissue
NEGATIVE
- high specificity–> if negative fFN then can send home
POSITIVE
- tocolytics and steroid for fetal lung maturation
- delay birth until steroids had change to work
- transfer to area with a NICU
1st line= CCB (nifedipine)
2nd line= OTR antagonist (atosiban)
Prostglandin inhibitors also very effective
delay delivery by 48 hours, improve outcomes
Types of tocolytics?
- beta-sympathomimetics
- magnesium sulphate (reduced cerebral palsy)
- NSAIDs (indomethacin)
- Calcium channel blockers
- oxytocin receptor antagonists
Indomethacin:
patent ductus arterosis closure –> persistent pulmonary hypertension
–> monitor it and stop immediately if you notice it
these dont improve neonatal outcomes, they just buy TIME for steroids to work/to be moved
Preterm:
when do you administer antibiotics? (1)
don’t give to preterm labour if membranes in tact–> NO BENEFIT
give erythromycin if PPROM (10 days)
Preterm:
why give steroids? (3)
what is given? (2)
- reduce respiratory distress syndrome
- reduce intraventricular haemorrhage
IM betamethasone * 2, 12 hours apart
crosses the placental barrier
PPROM: when in pregnancy are outcomes worst? (1) main organ underdeveloped? (1) how is PPROM diagnosed? (2) what does delivery need to weigh up? (2)
early it happens, worse it is!
- pulmonary hypoplasia if <24 weeks
- history
- pool of liquor in the vagina on speculum examination
- risk of prematuriy
- risk of materal/foetal infection
in general: conservative until 34 weeks, unless chorioamnioitis then immediate induction if after 37 weeks
PPROM:
conservatie management involves…? (5)
what are you checking for? (1)
what do you NOT give? (1)
Regular moniroting of
- temperature
- maternal HR
- CTG
- maternal biochemitry (to see CRP and white cell count)
- lower genital tract swabs
SIGNS OF INFECTION (CHORIOAMINONITIS)
don’t give tocolytics in PPROM!!
as increased risk of infection
Prediction of preterm delivery:
what two things are key? (2)
who are these not useful in? and why? (1)
two main interventions to reduce preterm? (2)
problem with prevention methods? (1)
primiparous women as rely on past obestric history
- POHx: previous PTD (4* risk)/ miscarriage
- cervical length measured by transvaginal US (Short Cervix): cervical surgery
- progesterone (limited evidence on effectiveness)
- cervical cerclage: stitch done 12-24 weeks
- NEW= arabin pesary but evidence shows no benefit at the moment
late miscarriage
Problem: 85% of preterm delivery occurs in low-risk women, its hard to predict
could transvaginal US all women and give progesterone to the ones with small cervix’s but this hasn’t proven to be cost-effective
Cervical clerclage:
who is it given to? (1)
when? (1)
how are sutures put in? (1)
small group of carefully slected patients - PMHx of 3+ late misscarriages or PTD
- after 12-14 weeks to avoid problems of early pregnancy loss
- non-absorbable tape used –> have to remove it
- transabdominal
- transvaginal
a cervical suture placed vaginally can usually be removed without recourse to regional anesthesia (transabdominal ones did if transvaginal has failed in the past!)
Pre eclampsia: commonly associated with? (1) Percentage of pregnancy that get preeclampsia? (1) gestational hypertension definition? (1) and risk? (1) risk of chronic HTN? (1)
- FGR
3%
- gestationalHTN arises in 2nd half of pregnancy
gestational hypertension itself doesn’t actually worsen outcomes, it just increases the risk of pre-eclampsia (1/3 go on to get pre-eclampsia) - if HTN in first half of pregnancy = chronic HTN –> maority have essential HTN but need to be explored for 2ndary
- chronic HTN = high-risk it inself (can be hidden by the physiological fall in BP in the first trimester due to peripheral vasodilation)
Preeclampsia definition?
- HTN at least 140/90
- recorded on 2 separate occasions
- at least 4 hours apart
- presence of 300mg protein in a 24-hour collection of urine
- after 20th week pregnancy
- previously normotensive woman
- resolving completely by sixth postpartum week
How does preeclampsia link to number of pregnancies?
- first pregnancy
- FHx pre-eclampsia (mum or sister)
- 10 years+ since last baby
- > 40years old
- BMI >35
- multiple pregnancy
- pre-existing HTN
- booking proteinuria
- diabetes
- renal disease
- antiphospholipid antibodies
- highest risk with first pregnancy (mum getting used to the fetal products)
- risk increase if next child is with a new partner!
Obstetric emergencies:
remember we can’t prevent all instances but we can identify risk factors, have appropriate support present in anticipation
Warning score used in obstetrics?
MEOWS
Modified Early Obstetric Warning System
Obstetric Sepsis:
risk factors? (10)
- ruptured membranes
- immunocompromised patients
- immunosuppressed
- obesity
- diabetes
- minority ethnic group orihin
- anaemia
- strep B infection
- vaginal discharge
- previous pelvic infection
- cervical cervlage
- group A strep
- UTI
Sepsis:
management of hypotension?
if hypotension or serum lactate >=4mmok/l, deliver initial minimum 20ml/kg of crystalloid
if no response–> vasopressors for hypotension to maintain MAP at >=65 mmHg
involve microbiologist or infectious disease physician early particularly if she doesn’t respond to ABx
Severe sepsis? (4)
- HR >100
- RR>20
Temo >38 or <36
WCC >17*10^9 or <4
What does the followig ABx cover: co-amoxyclav? metronidazole? clindamycin? gentamicin?
- gram +ve and anaerobe, NOT MRSA, Pseudomonas or extended spectrum B-lactamase
- anaerobic
- strep and staphylococci including MRSA
- gram -ve against coliforms and Psudomonas
Why is placental abruption blood loss unrelated to the amount of blood lost? (1)
what does abdomen feel like on exam? (1)
blood is hidden inside if the placenta is at the top
tense, rigid abdomen
may show fetal distress
how to prevent placenta abruption on a public health level? (1)
non-clinically induced C section
Of placenta previa/abruption, which is more dangerous for:
mother? (1)
fetus? (1)
- praevia= mother
- abruption= fetus
vasa previa= not dangerous for mother but dangerous for baby
major obstetric haemorrhage? (1)
> 2,500ml
or requiring blood transfusion >=5 units red cells
Prevention of PPH? (2)
Commonest cause of PPH? (1)
- iron supplements if low Hb
- prophylactic use of oxytocin
- uterine atony
What Hb do you give blood transfusion in haemorrhage?
DO NOT DELAY based on Hb result
TREAT THE PATIENT not the result
–> ongoing bleeding –> treat
young women will compensate extremely well.. hypotension only occurs after 2,000ml loss ! can get minimal signs up o 1,000ml
- consider blood products before coagulation indicies deteriorate if a women is likely to develop coagulopathy
Placenta acreata:
what is it? (1)
what to consent for just incase? (4)
placenta grows too deeply into the uterine wall
consent for:
- blood transfusion
- interventional radiology
- leaving placenta in situ
- hysterectomy
what to give women with preeclampsia who are high risk of eclampsia? (1)
risk factors? (5)
IV magnesium sulphate
remember all patients at risk though!
- black
- Hx diabetes
- <20
- primigravidy
- prenatal care
Backache in pregnancy:
What causes backache in pregnancy? (2)
advice? (4)
- hormone-induced laxicity of spinal ligaments
- a shifting in the centre of gravity as the uterus grows
- additional weight gain
–> exadurated LUMBAR LORDOSIS
- advice correct posture
- avoid heavy lifting (kids)
- avoid high heels
- regular physio
- simple analgesia
don’t need to know this off by heart
What is symphysis pubis dysfunction?
excurciatinly painful - symphysis pubis joint becomes ‘loose’ -> two halves of pelvis rub up on one another when walking/moving
Carpel tunnel syndrome:
why increased in pregnancy? (1)
increased soft tissue swelling
- median nerve compressed
- tingling thumb and forefinger
- -> analgesia
- -> splinting
- -> surgical decompression rarely performed in pregnancy as it will probably resolve after
Conspitation in pregnancy:
causes? (3)
management? (2)
hormonal plus mechanical plus iron tables
- reassure and advice regarding high-fibre diet
- if necessary, mild laxatives like lactulose can be used
Hyperemesis gravidarum:
when most common? (1)
complications? (4)
treatment? (4)
NOT ALWAYS IN MORNING
- first trimester
- severe, intractable N&V in 0.3-2%
1- imbalance of electrolytes
2- 5% weight loss
3-
- preterm
- low birthweight
- WEirnikes encephalopathy
- oesophageal trauma/ Mallory Weiss tear
- fluid
- electrolyte replacement
- thiamine supplementation
- antiemetic: phenothiazine
GORD:
are H2 receptor antagonists or PPIs safe in pregnancy?
all safe !!
Obstetric cholestasis: prevalnece? when in pregnancy? (1) symptoms? (2) complications? treatment? (1) management of birth? (1)
- 7%
- second half of pregnancy
- abnormal LFTs
- pruritis
fetal risks
- preterm birth
- fetal death
for mum:
- intense puritis
- sleep
- ursodeoxycholic acid (UDCA)
- delivery at 37 weeks
Why are varicose veins formed in pregnancy?
- relaxant affect of vessels of progesterone and weight of uterus on inferior vena cava
- support stockings
- dont stand for long periods
- simple analgesia
- if bleeds then elevate and give direct pressure
- thrombophlebitis may occur if large, morecommon after delivery
Oedema in pregnancy:
whats normal and whats concerning? (1)
what to check for? (2)
- generalized oedema = CONCERNING
(preeclampsia, or more rarely cardiac problem or nephrotic syndrome)
oedema in extremities= common due to soft tissue swelling and increased capillary permeability (mainly lower limb)
–> check BP and urine
common ‘minor’ disorders in pregnancy?
itching urinary incontinece nose bleeds thrush headache fainting breast soreness tired altered taste sensation insomnia leg cramps
Fibroid in pregnancy:
why a problem? (1)
what is red degeneration? (1)
may ENLARGE in pregnancy –> may obstruct labour
Red degeneration:
if becomes ischaemic –> acute pain + vomiting
if these symptoms are severe it may precipitate uterine contractions, causing miscarriage and preterm labour
–> analgesics, fluids
do ultrasound to distinguish from large ovarian cyst
(TV in first trimester, TA in 2nd/3rd)
Retroversion of uterus:
complications? (1)
in most the uterus flips itself. if it doesn’t it fulls up the entire pelvic cavity
–> pulls urethra and bladder up –> urinary retention and pain
uterine abnormalitis are caused by abnormal embryonic fusion of..
the mullerian ducts
Ovarian cysts in pregnancy:
when to do surgery? (1)
why do surgery in pregnancy?! (3)
late 2nd or 3rd timester so if baby problem could deliver the baby
may:
- undergo torsion
- acute abdo pain
resulting distress–> misscarriage/ preterm
UTI in pregnancy:
how to investigate? (1)
MSU, and microscopy w sensitivities
if strong suspicion- start ABx straight away
drink fluids
analgesia (paracetamol)
most common cause direct death in UK in pregnancy?
what factors are changed?(4)
VTE
pregnancy is hypercoagulable state due to altered thrombotic and fibrinolytic system
- factor VIII, IX, X and fibrin levels
- reduction in protein S and antithrombin (AT) III concentrations
further exacerbated by gravid uterus on IVC pressure and immobility in pregnancy
more than 50% of women with pregnanct-related VTE have a thrombophilia!!! –> SCREEN all with history ofthrombotic events
most common acquired thrombophilia? (1)
antiphospholipid syndrome (APS) lupus anticoagulant with or without anticardiolipin antibodies
recurrent miscarriage and/or thrombosis
How long to wear DVT stockings for following a DVT?
2 years following DVT
Woman with strng VTE history or family history?
SCREEN for thrombophilias
~15% of the population!!
Alcohol and drugs in pregnancy:
who to involve?
MDT meeting
psychiatric/addiction assessment
social workers
consider nutrition, BBVs
Smoking:
advice on how much they can smoke? (3)
what complications are they at risk of? (3)
TRY NOTHING
but cut down as much as possible, the less the better
5 ciagrettes a day has a discernible obstetric effect on birthweight (lowbirthweight and placental abruption)
- perinatal mortality
- low birth weight
- placental abruption
–> COuncil at booking visit
biggest risk of breech presentation? (1)
when to offer C section? (1)
cord prolapse
36-37 weeks as want to avoid labour with breech (but it does happen!)
EVC:
what to give before EVC?
tocolytic (nifedipine) as imrpves the sucess rate
anti-D if rhesus negative
Vaginal bleeding in pregnancy:
pre -24 weeks? (1)
post -24 weeks? (1)
early misscarriage
antepartum haemorrhage
APH: 1% placenta previa 1% placental abruption 1% other causes e.g. vasa previa/ cervicx problems (infection/carcinoma) or vaginal (infection/trauma)
Rhesus disease: prevalence? (1) what does it cause if blood mixed? (1) what pregnancy does it not occur in? (1) what does the immunization do? (1)
15%
and about 2/3 of these will have a R +ve baby
over 40 types of antigens in the rhesus system but only d and c cause problems (and D much more common!)
(D negative is homozygous recessive inheritance!)
haemolytic disease of the fetus and newborn (HDFN)
for this to happen, fetal blood must go to maternal circulation, mix, cause immune response, and maternal antibodies cross plaaacenta back
doesn’t occur in first pregnancy as first response weak and only produces IgM that dont cross the placenta, but after that its a risk
mops up circulating rhesus-positive cells before immune response excited in mum
(should be given within 72 hours but max 10 days some protection may still be had)
dose depends on size of haemorrhage and gestation (use Kleihauer test to see how much to give !)
What is a Kleihaeur test? (1)
Kleihauer test is a test to determine if there has been and the size of foeto-maternal haemorrhage (FMH) FMH estimation is is performed to ensure that pregnant women who have undergone potentially sensitising events are given adequate quantities of anti-D.
When do you give anti-D in first trimester? (1)
why not often? (1)
when is it given routinely in pregnancy (what dates)? (2)
fetal circulating blood volume so low
- ectopic pregnancy
- molar pregnancy
- therapeutic termination of pregnancy
- LOTS of abdo bleeding
- 28 and 34 weeks
Rhesus negative mum:
what to test for when baby is delivered? (3)
if father is rhesus negative, what is the likelihood the baby is +ve/-ve?
cord for: - FBC - blood group - indirect Coombs test (as incompatibility may cause anaemia in fetus)
if both parents negative then BABY IS NEGATIVE
Rhesus disease gets worse in successive pregnancies
ABO incompatibility:
why does nobody talk about it? (1)
mother blood group O and baby A or B
anti-B or anti-A present
–> fetal aneamia/hamolysis
generally less of a problem as only causes mild haemolytic disease as most anti-A and anti-B are IgMs that don’t cross the placenta
may –> unexplained jaundice
VTE prophylaxis if…
previous VTE? (1)
multiple risk factors? (1)
single risk factor? (1)
- 6 weeks VTE prophylaxis
- early mobilization and hydration
- LMWH 10 days
Two most common invasive tests? (2)
when do you do it? (1)
who to get involved in decision? (1)
reasons for doing a prenatal invasive test? (3)
what must you test for before invasive testing?(1)
amniocentesis
chorion villus sampling (CVS)
check karyotpe of the fetus and diagnose single gene disorders
- to identify thalassaemia or CF
- Genetics Department
must contribution to an OPTION otherwise no point doing it:
- continue (but prepare for birth of baby with serious condition)
- influence decision to terminate
- terminate
complete consent form as formal record that the discussion has taken place
- BBV (HIV/ Hepatitis)
- if these tests are declinedthen have to explain to women there may be vertical transmission
Chronic villus sampling: what does it sample? (1) when it is done? (1) what is done before? (1) two types? (2)
SAMPLE OF DEVELOPING PLACENTA
- <10 weeks
- US before to confirm: viable pregnancy, if multiple, localise the placenta and determine if transabdominal or transcervical approach more appropriate
transabdominal (more common but cant be done if placenta low on posterior wall of uterus
can get a delay in getting results (over a week)
trasvaginal
2% risk of miscarriage on top of ordinary risk
Aminocentesis:
what does it sample? (1)
advantage of CVS over aminocentesis? (2)
AMNIOTIC FLUID
CVS performed earlier where surgical termination possible and at a stage before women needs to dislose pregnancy to family and friends and employers, and CVS sample size of cells is bigger, but >15 weeks of gestation its dangerous
Cordocentesis:
performed when? (2)
- severe fetal anaemia
- thrombocytopenia
needle into umbilical cord where it is fixed by the placenta
performed from ~20 weeks gestation
Downs syndrome:
how is prenatal screening done- ie what two tests? (2)
what to do if booking visit in 2nd trimstester? (1)
- US scan for nuchaltranslucencey and crown-rump length
(11-14 week)
+ - blood test between 10-14 for hCG and pregnancy associated plasma protein-A (PAPP-A) in maternal blood
look at risk of age of mother and these test to decide if they want to go for invasive testing
quadruple test (hCG, AFP, unconjugated oestriol and inihibin A) - 14-20 weeks
EXPLAIN TO WOMEN ITS JJUST SCREENING AND NOT DIAGNOSTIC - IF +VE 10% WILL BE NORMAL –> diagnostic tests
Results for Downs syndrome: AFP= reduced b-hCG= raisefd PAPP-A= reduced unconjugated oestroiol= reduced inhibin-A= raised thicker NT for gestational age
Invasive testing: which is.. 1. under US guidance 2. can be done at 9weeks 3. used to diagnosed spina bifida 4. diagnose single gene disorders 5. diagnose fetal anaemia 6. performed at 11 weeks
- both CVS and aminocentesis (to reduce complcaitons
- neither (early aminocentesis <15 weeks = miscarriage risk), early CVS (<11 weeks = limb defects).
- neither (need US)
- both , usually using PCR analysis
- cordocentesis
- CVS
CVS = early aminocenetiss = alte
What is FGR? (1)
complications? (3)
failed to reach GROWTH POTENTIAL
not all FGR are SGA, not all SGA are FGR!!
- more likely to suffer hypoxia/asphyxia and be stillborn or have sign of hypoxic-ischaemic encephalopathy (HIE), including seizures, and multiorgan damage
- neonatal hypothermia
- hypoglycaemia
- infection
- necrotizing enterocolitis
- cerebal palsy
- chronic disease (CVD, diabetes, HRN)
–> if SGA you must think, are they ‘small and healthy’ or ‘small and unhealthy?
What mechanism maternal diabetes cause macrosomia?
fetal hyperinsulinemia
What does HTN cause in terms of fetal growth?
placental abruption and FGR (the placenta is basically rubbish so baby can't grow properly!)
Placenta:
functions? (4)
- prevent movement of fetus without causing limb contracture
- permit adhesions between fetus and amnopn
- protect fetus from mechanical injury
- permit fetal lung developments; absence of amniotic fluid in second trimester —> pulmonary hypoplasia
Premature infant risks on: fetal growth? (1) cardiovascular? (1) respiratory(1) fetal blood? immune system? alimentary system? liver/gall bladder? kidney? CNS?
- deficient glycogen stores in liver –> risk of hypoglycaemia compounded by higher glucose requirements in preterm
- patent ductus arteriosis –> pulmonary congestion, worsened lung disease, decreased blood to brain/GI track (Close with prosglandin synthetase inhibitor e.g. indomethacin or surgical ligation)
- RDS/apnoea
- anaemia of prematurity (due to reduced erythropoiesis, decreased iron stores)
- susceptible to infection
- hypothermia (incubator)
- nectrotizing enterocoloitis –> necrosis due to reduced blood flow, hypotension, hypoxia, infection and feeding problems
- jaundice (hyperbilurinaemia) secondary to liver immaturity and shorter half life of red blood cells –> PHOTOTHERAPY as risk of bilirubin encepahhalopahty
- dehydration/electrolyte discutances because of immature kidneys (hyperK+, HypoNa+, metabolic acidosis)
- periventricular and intraventricular hemorrhages from bleeding from the immature rich capillary bed of the lining ventricules
Chlamydia sequelae?
Reiter’s syndrome (reactive arthritis) and Fitz-Hugh Curtis syndrome (also known as perihepatitis [inflammation of the lining of the liver])
fibrosis and scaring of tubes–>
- tubal-factor infertility
- increased ectopics
- PID in 10-20% of untreated
Antenatal care aims during..
timester 1 (2)
timester 2? (1)
timestter 3? (2)
where are problems of timester 1 dealt? (1)
when does booking visit occur? (1)
what maternal well-being checks are carried out throughout pregnancy? (3)
what fetal wellbeing checks are carried out? (4)
what do extra growth scans check? (3)
when is presentation checked? (1)
- define if high or low risk pregnancy
- date the pregnancy and confirm viability
- screen for chromosomal or structural abnormality in the fetus
- ensure continued maternal and fetal wellbeing
- prepare for delivery
Early Pregnancy Unit
- 8-10 weeks for booking (i.e. after fetal heartbeat at 6 weeks)
- questioning
- BP measurement
- urinanalysis
- SFH measurement
- ask mum about fetal movements
- Rheus status
- optional extra CTG monitoring or growth scans
1 Growth (abdominal circumferene and femur length) 2 Biophysical profile (including fetal tone, movements and amniotic fluid volume) 3 Umblical dopplers ( to check blood flow to fetus, uterine dopplers can be done to check blood flow to the placenta)
- check presentationfrom 36 weeks onwards
What is the effect of fetal attitude on the presenting diameter? (4)
how do you work out wich way baby is? (1)
which way is the pelvis widest…
pelvic inlet? (1)
pelvic outlet? (1)
WELL FELXED= 9.5cm
suboccipito-bregmatic
LESS WELL FLEXED=11.5
occipito-frontal
EXTENDED (BROW PRESENTATION)=13.0cm
occipito-mental
HYPERTEXTENDED (FACE PRESENTATION)=9.5cm
submento-bregmatic
feel the sutures and fontanelles on baby head to see attitude and position, they mould to help baby get out
pelvis is widest TRANSVERSE than AP diameter in pelvic inlet
but
pelvic outlet
AP wider than transverse
–> head enters pelvis transverse then twists to deliver AP
(the shape of pelvis and pelvic muscles are shaped to aid this!)
pelvic diameters increase during labour due to pelvic ligament laxicity
Diagnosis of labour (1)
hormonal changes assocaited with it?
normal length first and second labour? (2)
regulat strong painful contractions resulting in cervical changes
NOT rupture of menbranes of mucus plug lost– these can occur a few days before! your body starts preparing..
decrreased progesterone receptors (progesterone stops oxytocin release, suppresses prostglandin productio and inhibits communicaiton between myometrial cells)
and increased oestrogen–> prostglandins, increased calcium influx into cells
CRH produced by the placenta to increase action of prostaglandis and oxytocin on myometrial contractility
FIRST= 8 hours SECOND = 5 hours
epidural does increases which stage of labour?
how long is this stage normally?
2nd stage (the active 2nd stage) no more than 3 hours
engagement:
how much should you be able to feel? (1)
occipitoanterior position, what happens? (2)
what does extension/’crowning’ reduce the risk of? (1)
if > fingers (2/5) then it is not yet engaged
in OA, itnernatl rotation can occur to roate baby round, alternatively it can be delivered OA (face to pubis)
associated with extension of fetal head and increased diameter
can –> obstructed labour needing instrumental or caesarean section
reduces risk of perineal trauma
Rupture of membranes:
what to note? (3)
what to record for women in labour? (3)
- meconium
- blood?
- scanty ? how much fluid (bad sign if scanty_
indicates fetal compromise
every hour:
pulse
every four hours:
temp
BP
vaginal exam
frequency of contractions: every 30 mins
test urine for ketones and protein
once in second stage perform hourly vaginal exam and BP and pulse
cetheterise if epidural
Purpose of the contractions not being continuous? (1)
why babys pH drop when distressed? (1)
how long to listen to HR with doppler? (1)
how long to do CTG for? (1)
allow fetal blood flow
lactic acid and hydrogen ions due to anaerobic respiration as no oxygen!!!
bight green meconium= baby distressed- baby should poo AFTER birth!
1 minute
repeat every 15minute during first stage and every 5 minutes in second stage
20 mins CTG
can women eat/drink durign labour? (1)
yes, eat little bits and stay hydrated
- give IV if not drinking and risk of ketosis which can cause problems with contractions
- be careful if on opioids as vomit
how long after full dialteion should baby be delivered? (1)
where is an episostomy cut? (1)
which births often need these? (1)
4 hours
mediolateral direction (to ensure doesnt tear down to rectum)
operative births (ventouse or forcepts) or to hasten delivery if suspected fetal compromise egg.. fetla bradycardia
Apgar score calculated when? (1)
what else is done shortly after birth? (4)
after 1min of birth
then every 5 mintues
measure temp, birth weight and head circumfernece within the hour
skin to skin
breat feeding 1 hour
first dose of vit K
wrist label for identification and examnation for abnormaliites
Active management of 3rdstage? (3)
complication? (1)
10 IU oxytocin injection as anterior shoulder delivered
early clamping and cutting of the umbilical cord
controlled cord traction
uterine inversion if the left hand doesn’t hold the uterus properly and if excessive traction used on the cord in absence of complete separation from and a uterine contraction
Uterine involution: after birth? (1) when is it no longer palpable?(1) causes of delayed involution? (5) what happens to the os? (1)
- under umbilicus
- by 2 weeks no longer palpable
linked to oxytocin (released when breastfeeding) –> accelerated
if delayed and no other signs/symptoms then don’t worry
delayed could be due to: infection - full bladder - full rectum - retained productsof conception - fibroids - broad ligament hematoma - artefact
after 1st week, increasingly difficult to pass 1 finger
can remain open permanently
assessment of postnatal cervix important to check for retained products
Describe the lochia: for first few days? (1) first week? (1) after a month? (1) what is unusual? and what does this indicate? (1)
red in first few days
changes to pink
then by the second week serous
then scanty yellow-white discharge that lasts a month
persistent red lochia suggests delayed involution, associated with infection/ retained placental tissue
Perineal pain after episiotomy:
management for mum? (4)
what to avoid?
NSAIDS paracetamol lignocaine gel crushed ice keep clean with daily shper
avoid opiates as constipation
Secondary postpartum haemorrhage:
when does it occur? (1)
two commonest causeS? (2)
symptoms of each
- 24 hours post birth to 14 days
- endometiris
(discharge, low grade fever, pungent lochia, uterine tenderness) - retined product of conception
(crampy abdo pain, uterus larger than appropriate,e ox open, Hx prolonged third stage, passage of bits of placental tissue)
Main differential for postpartum depression
HYPOTHROIDISM
caused by postpartum thyroditis!
Breas engorgement:
when does it occur? (1)
what must you check?
management? (6)
- 2/3rd day postpartum
- can result in puerperal fever up to 39oC in around 15% –> check no other signs of infection
- cabbage leave
- ice bags
- electric breast pump
- firm support
-bimanual expression
(but getting baby to get milk is the most effective!)
Mastitis: what is it? (1) common organism? (1) management (2) main complication? (1)
blocked duct –» pressure and inflammagtory response
breast red and oedematous
flu-like symptoms andtachycardia and pyrexai
s. aureus
- massage of breast and analgesia
if worsens… then take sample of milk for microbiological culture and give flucloxacillin whilst awaiting sensitivity
Continue breastfeeding during this - breast abscess
- -> surgical incision and drainage
why wait 4-8 weeks to put inIUD after baby? (1)
risk of what is increased? (1)
waiting for uterine involution
increased risk of uterine perforation in breastfeeding mothers
perinatal death
> 24 weeks (stillbirth) or death within 7 days gestation
when can you start combined contraceptives postnatally?
6 weeks postnatally due to VTE risk
