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
