Group D - Normal pregnancy, labour and puerperium Flashcards

Question

Outline 2 supplements that should be taken during pregnancy

Answer 1

1. Folic acid 400mg (standard) from before pregnancy to 12 weeks - 500mg if high risk e.g. diabetic 2. Vitamin D **Avoid vitamin A supplements - teratogenic at high doses**

Answer 2

- Foetal alcohol syndrome - Preterm delivery - Small for dates - Miscarriage

Answer 3

- Foetal growth restriction - Preterm delivery - Small for dates - Miscarriage - Placental abruption - Preeclampsia - Sudden infant death syndrome (SIDS) - Cleft lip / palette

Answer 4

Uncomplicated, nulliparous: 7 appointments Uncomplicated parous: 10 appointments (more if had children before)

Answer 5

Pregnancy past 41 weeks: - Offer a membrane sweep - Offer induction of labour (after 41 weeks), if declined then regular CTG and USS monitoring Breech presentation at term: - Offer external cephalic version (after 37 weeks if no contraindications) High risk for VTE: - Offer LMWH prophylaxis High risk for preeclampsia: - Offer Aspirin from 12 weeks onwards, until 36 weeks Suspected foetal growth restriction: - Serial growth scans

Answer 6

1. Booking bloods at < 10 weeks Range: > 110 g/l 2. At 28 weeks Range: > 105 g/l

Answer 7

Iron replacement - ferrous sulphate 200mg tds - If not tolerated or discovered late, may require a IV iron - Further tests should be undertaken if there is no rise at 2 weeks - Multiple pregnancy should have an additional FBC at 20–24 weeks If folate deficiency, give 500mg folic acid (rather than 400mg) Specialist haematological management if haemoglobinopathy e.g. sickle cell

Answer 8

Investigations are usually not necessary 1st line: lifestyle advice e.g. eat smaller meals, avoid spicy food 2nd line: medication - antacids and alginates e.g. Gaviscon - H2 receptor antagonists or PPIs only used if symptoms are severe

Answer 9

Pathophysiology: - Caused by the pelvic joints moving unevenly Symptoms: - Pelvic pain (pubic, lower back, hips, groin, thighs or knees) - Clicking or grinding in pelvic area - Pain made worse by movement Investigations: - Physiotherapy diagnosis Management: - Lifestyle modification to e.g. changing position frequently, equal weight on both legs and avoiding exacerbation e.g. heavy lifting - Conservative e.g. exercises, hot baths - Analgesia - Crutches or wheelchair - Can still have a natural birth

Answer 10

Latent phase (0cm to 3cm): 0.5cm per hour (max 6 hours) Active phase (3-10cm): 1cm per hour (max 7 hours)

Answer 11

Either: - Less than 2cm dilation in 4 hours - Or a slowing of progress in multiparous women

Answer 12

- More than 2 hours for nulliparous women - More than 1 hour for multiparous women

Answer 13

> 60 minutes with natural (physiological) management > 30 minutes with active management

Answer 14

- Previous failure to progress in previous pregnancy - Epidural - PROM - Induced labour with medications such as oxytocin - Macrosomia e.g. from diabetes or LGA

Answer 15

1st stage: - Hourly maternal observations - Intermittent auscultation for 1 minute immediately after a contraction, at least once every 15 minutes 2nd stage: - Intermittent auscultation for 1 minute immediately after a contraction, at least once every 5 minutes Move to CTG monitoring if any concerns If CTG is normal after 20 minutes, can return to normal monitoring

Answer 16

- Previous caesarean scar or uterine rupture - Pre-existing diabetes - Preeclampsia / hypertension - Sepsis / chorioamnionitis - Any vaginal blood loss - SGA / foetal growth restriction - Oligohydramnios / polyhydramnios - RFM 24 hours prior to labour - Epidural - Use of oxytocin - Maternal tachycardia - Delay in labour - Disproportionate maternal pain - Significant meconium

Answer 17

- Over due date e.g. 41 and 42 weeks gestation - Premature rupture of membranes (after 24 hours if > 37 weeks, less than this = difficult decision) - Foetal growth restriction - Maternal issues e.g. preeclampsia / obstetric cholestasis / existing diabetes - Intrauterine foetal death

Answer 18

- Placental issues e.g. placenta praevia or vasa previa - Cord prolapse - Poor baby positioning e.g. transverse or cephalopelvic disproportion - Active genital herpes

Answer 19

Membrane sweep (not considered full induction) but used > 40 weeks - Induces natural release of prostaglandins 1. Vaginal prostaglandins (tablet, gel or pessary) - Ripen cervix and smooth muscle uterine contractions 2. AmniHook +/- Oxytocin infusion - Process releases prostaglandins - Only used when cervix is 'ripe' - Oral Mifepristone if intrauterine death

Answer 20

- First time birth / nulliparity - Large babies (>4kg) - Instrumental delivery - Shoulder dystocia - Occipito-posterior position - Asian ethnicity

Answer 21

1st degree: limited to area where labia minora meet, superficial skin only 2nd degree: tear involving superficial skin AND perineal muscles (not anal sphincter) 3rd degree: anal sphincter (but not rectal mucosa) 4th degree: anal sphincter AND rectal mucosa

Answer 22

1st degree: generally, no sutures required 2nd degree: sutures can be done in delivery room 3rd degree and 4th degree: sutures in theatre Additional measures: - Broad-spectrum antibiotics - Laxatives - Physiotherapy (incontinence) - Follow up

Answer 23

Short term: - Pain - Infection - Bleeding / haematoma - Wound dehiscence Long term: - Incontinence (urinary or faecal) or altered bowel habits - Sexual dysfunction / dyspareunia - Psychological impact/ mental health

Answer 24

Maternal benefits: - Reduced risk: T2DM, hypertension and heart disease - Reduced rates breast cancer and ovarian cancer - Triggers oxytocin release, helps contraction of uterus and reduce blood loss - Burns calories Foetal benefits: - Contains full requirements for baby - Easier to digest so less GI symptoms e.g. gas - Reduce risk of short term and long term health problems e.g. gastroenteritis, asthma and obesity - Reduced risk of SIDS (sudden infant death syndrome)

Answer 25

No - avoided (especially in 3rd trimester) NSAIDs block prostaglandin production, which is responsible for maintaining the ductus arteriosus and induction of labour Risk: - premature closure of ductus arteriosus - delay labour

Answer 26

Only Labetalol - other beta blockers are avoided Risk: - foetal growth restriction / SGA - hypoglyacemia in neonate - bradycardia in neonate

Answer 27

No - avoided Block renin-angiotensin system and can cross the placenta Mainly affect the kidneys and reduce the production of amniotic fluid Risks: - Oligohydramnios - Hypocalvaria (incomplete formation skull bones) - Renal failure in neonate - Hypotension in neonate - Miscarriage or foetal death

Answer 28

Generally avoided - Can lead to withdrawal symptoms in the neonate after birth = 'neonatal abstinence syndrome' (NAS) - Presents 3-72 hours after birth, as irritability, tachypnoea, high temp and poor feeding

Answer 29

No - teratogenic!! Crosses the placenta, risk of: - Congenital malformation - Foetal loss - Increased risk of bleeding (PPH, intracranial bleeding and foetal haemorrhage)

Answer 30

No - avoided Linked with congenital cardiac abnormalities, especially Ebstein's anomaly Also avoided in breastfeeding, can enter breastmilk and is toxic to infant

Answer 31

Situation dependant - generally avoided but used if the risk of depression is great Risks: 1st trimester: congenital heart defects 3rd trimester: pulmonary hypertension in neonate Neonates can also experience withdrawal symptoms

Answer 32

No - highly teratogenic!! Avoided completely in pregnancy and need to be on very reliable contraception

Answer 33

Rubella can lead to congenital rubella syndrome, caused by maternal infection with rubella virus Occurs during the first 20 weeks of pregnancy (risk highest before 10 weeks)

Answer 34

- Deafness (sensorineural) - Congenital cataracts / retinopathy - Congenital heart disease (PDA and pulmonary stenosis) + microcephaly + low birthweight + organ dysfunction

Answer 35

Mothers should be vaccinated with MMR vaccine prior to trying to conceive (can't have the live MMR vaccine during pregnancy) If unsure of status, should be tested for antibodies - if no antibodies, vaccinated with 2 doses 3 months apart

Answer 36

Most cases of cytomegalovirus (CMV) don't cause issues However, risk of congenital cytomegalovirus Features: - Hearing loss - Vision loss - Learning disability - Foetal growth restriction - Microcephaly - Seizures

Answer 37

- Anaemia caused by infection of foetal bone marrow and liver, leading to faulty production of RBCs with shorter lifespan - This severe anaemia can lead to heart failure (Hydrops fetalis) - Rarely, a maternal preeclampsia like syndrome can occur from the foetal heart failure = triad of Hydrops fetalis, maternal oedema and placental oedema

Answer 38

- General supportive management - Referral to foetal medicine to monitor for complications and malformations of foetus

Answer 39

9/10 women are immune to chickenpox. If unsure, can test for antibodies to chickenpox If not immune: injection of varicella zoster immune globulin (VZIG) during pregnancy as prophylaxis - can be given within 10 days of contact with chickenpox (ineffective if rash already appeared) - human blood product that strengthens the immune system for a short time - can make the infection milder and shorter in duration

Answer 40

More severe disease in the mother, leading to: - Hepatitis - Pneumonia - Encephalitis Foetal varicella syndrome Neonatal infection with chickenpox

Answer 41

Before 28 weeks: - Baby unlikely to be affected - However small risk of foetal varicella syndrome - Requires referral to a fetal medicine specialist for ultrasound scans Between 28 - 36 weeks: - Virus stays in your baby’s body but does not cause symptoms - May cause shingles in the first few years After 36 weeks: - Greatest risk of chickenpox - If baby born within 7 days of chickenpox rash chickenpox within the first week after birth = give Aciclovir and Varicella-zoster immune globulin (VZIG)

Answer 42

- Microcephaly / hydrocephalus / learning disability - Foetal growth restriction - Scars and skin changes in specific dermatomes - Limb hypoplasia - Chorioretinitis

Answer 43

If immune: no management required If not immune and contact has occured: - Varicella zoster immunoglobulin (VZIG) within 10 days of contact (but ineffective if rash already appeared) If symptomatic: - Oral Acyclovir if > 20 weeks - When baby is born, IV Acyclovir + close monitoring Referral to foetal medicine to monitor for complications and malformations of foetus

Answer 44

Pregnant women are more likely to develop more severe symptoms Management: supportive therapy and admission if unwell: - IV fluids - Paracetamol - Analgesia - Thromboprophylaxis Oseltamivir asap (within 48 hours) for 5 days

Answer 45

Syphilis can readily cross the placenta to the baby Increased risk of: - Premature birth - Foetal growth restriction - Stillbirth - Miscarriage Risk of congenital syphilis (give Benzylpenicillin after birth) If positive, management: - Single dose of Benzylpenicillin - Referral to foetal medicine for regular checks from 26 weeks onwards

Answer 46

2/3rds = asymptomatic at birth However will develop signs within 5 weeks - Jaundice - Rash - Anaemia - Generalised lymphadenopathy - Hepatosplenomegaly - Skeletal abnormalities Can also have latent presentation, up to 2 years after birth

Answer 47

Zika virus can be spread through mosquitoes or through sex Risk of congenital zika syndrome if virus contracted during pregnancy: - Microcephaly - Foetal growth restriction - Intracranial abnormalities e.g. cerebellar atrophy

Answer 48

Unfortunately no cure/treatment for the virus - only supportive treatment If uncertain about infection, test for virus with viral PCR / antibody test - May then require ultrasound scans for monitoring

Answer 49

- All women should be on antiretroviral therapy indefinitely, starting from 2nd trimester onwards (decrease risk of teratogenicity) - Should be screened for other STIs Mode of delivery / management: All based on viral load at 36 weeks! All women recommended to have birth at medical facility Viral load < 50 - Vaginal birth acceptable Viral load > 50 - Pre-labour c-section recommended (38-39 weeks) - If spontaneous rupture of membranes, immediate c-section recommended (rather than waiting usual 24 hours) - If high, give IV Zidovudine infusion during labour Breastfeeding: - Not currently recommended in UK due to low risk of transmission, formula recommended - If woman decides to breastfeed, mother and baby should be reviewed monthly for HIV RNA viral load testing during and for 2 months after stopping breastfeeding

Answer 50

Very low risk - 2 weeks Zidovudine Low risk - 4 weeks Zidovudine High risk - combination post-exposure prophylaxis (PEP) within 4 hours

Answer 51

Increased risk of severe illness if pregnant and COVID-19, especially after 28 weeks (3rd trimester) Risk: - Maternal ICU admission - Stillbirth - Premature birth Evidence that COVID-19 itself doesn't have an impact on the development in-utero Management of pregnant women with COVID-19 should be the same as for non-pregnant women - If COVID positive during labour, advised for obstetric led unit - Advised to have COVID vaccine prior to or during any stage of pregnancy

Answer 52

Rhesus status is based on whether or not rhesus-D antigens are present on maternal RBCs Rhesus positive = rhesus-D antigens present Rhesus negative = rhesus-D antigens are absent Only issue is rhesus negative - rhesus positive isn't an issue 1st pregnancy - potential for sensitisation (if foetus is rhesus positive and mother is negative) Subsequent pregnancies - if sensitisation has occurred (now rhesus positive) and the foetus is rhesus positive = antibodies cross placenta and attack rhesus-D RBCs End result: haemolytic disease of newborn

Answer 53

Prevention of sensitisation is the mainstay of management - Intramuscular anti-D injections to rhesus-D negative women - Given within 72 hours of any event where the mum might become sensitised Anti-D immunoglobulins attacks the rhesus-D antigens on the surface of foetal RBCs that have made their way into the maternal bloodstream - Prevents mother from becoming sensitised to foetal rhesus-D positive RBCs

Answer 54

- Miscarriage > 12 weeks - Abdominal trauma - Antepartum haemorrhage - Birth - External cephalic version (ECV) - Amniocentesis

Answer 55

1. 28 weeks 2. At birth

Answer 56

Kleinhauer test - Detects how much foetal blood has passed into the mother's blood during a sensitisation event - Only used after 20 weeks - Helps suggest whether further doses of anti-D injections are required

Answer 57

- Vaginal bleeding - Abdominal pain (can reported to be worse than the pain of a usual period) - Tissue loss (loss of foetus)

Answer 58

Idiopathic! The cause is often idiopathic. Known causes can be split into: Foetal causes: - Genetic disorder - Abnormal foetal development Maternal pathology: - Cervical incompetence - Uterine abnormality - Antiphospholipid syndrome - Poorly controlled diabetes or thyroid disease - PCOS

Answer 59

Both can present with pain and vaginal bleeding However in ectopic pregnancy, pain is often the dominant symptom and occurs first If vaginal bleeding does occur it is minor in ectopic pregnancy, in comparison to a miscarriage

Answer 60

Skin Subcutaneous fat Rectus sheath Rectus abdominus muscle Peritoneum Uterine myometrium Amniotic sac