Group E - High-Risk Pregnancy and Obstetric Emergencies Flashcards
1
Q
Outline the triad of clinical findings in pre-eclampsia
A
- Hypertension (> 140/90)
- Proteinuria
- Oedema
2
Q
Briefly explain the suspected pathology of pre-eclampsia
A
- Poor trophoblast invasion of the endometrium, leads to reduced quality and development of the spiral arteries and lacunae at around 20 weeks
- This leads to high vascular resistance in the spiral arteries which causes oxidative stress
- This leads to an inflammatory process and impaired endothelial function
3
Q
List some risk factors for developing pre-eclampsia (aim to categorise into high and low risk)
A
High risk:
- Pre-existing HTN
- Previous pre-eclampsia in pregnancy
- Family history of pre-eclampsia
- Pre-existing renal disease e.g. CKD
- Autoimmune condition
- Diabetes
Lower risk:
- Large gap between pregnancies (>10yrs)
- BMI > 35
- Age > 40
- First pregnancy
- Twins / triplets or molar pregnancy
4
Q
List some potential symptoms and signs of pre-eclampsia
A
Symptoms:
- Headache
- Visual disturbance
- Nausea & vomiting
- Abdominal pain
- Oedema
- Bleeding
Signs:
- HTN
- Papilloedema
- Proteinuria
- Non-dependant oedema
- Abnormal foetal doppler
- Oligohydramnios
- Hyperreflexia
5
Q
List some investigations for pre-eclampsia
A
Maternal:
- Blood pressure
- Urinalysis (proteinuria)
- FBC (platelet count)
- LFTs (liver function)
- U&Es and eGFR (renal function)
- PCR / 24 hr collection (proteinuria)
Foetal:
- Regular ultrasound growth scans / foetal doppler / amniotic fluid volume measure
- CTG (foetal wellbeing)
6
Q
Outline how you go about diagnosing pre-eclampsia
A
NEW onset of hypertension after 20 weeks, PLUS presence of 1 or more of the following:
- Proteinuria
- Renal insufficiency (raised creatinine)
- Liver involvement (abnormal LFTs)
- Neurological complications e.g. eclampsia, visual disturbance, severe headaches, altered mental status, stroke
- Blood derangement e.g. thrombocytopenia or DIC
- Placenta dysfunction e.g. fetal growth restriction, abnormal doppler
7
Q
Outline the medication used in prophylaxis of preeclampsia for those at risk
A
Aspirin 150mg daily
From 12 weeks to 36 weeks
8
Q
List some complications of pre-eclampsia
- Maternal
- Foetal
A
Maternal:
- Seizures
- Cerebral haemorrhage
- Renal failure
- Hepatic failure / rupture
- Pulmonary oedema
- DIC or thrombocytopenia
Foetal:
- Foetal growth restriction
- Foetal distress
- Premature delivery
- Stillbirth
- Oligohydraminos
- Placental abruption or infarct
9
Q
List some complications of eclampsia
- Maternal
- Foetal
A
Maternal:
- HELLP syndrome
- DIC
- AKI
- ARDS
- Stroke (haemorrhage)
- Pernament neurological deficit / death
Foetal:
- Prematurity
- Intrauterine growth restriction (IUGR)
- Placental abruption
- Respiratory distress syndrome
- Foetal death
10
Q
Outline the management of preeclampsia (not severe)
A
- Labetalol (2nd line Nifedipine or Methyldopa)
Important to monitor mother and foetus closely for complications
11
Q
Outline the management of severe preeclampsia
A
- IV Labetalol
- Magnesium infusion (prevent eclampsia)
- Consider premature labour/delivery + steroids for lung development
- Strict fluid balance
- Consider HDU admission
12
Q
Outline the emergency management of eclampsia
A
IV access
- Bolus 4g Magnesium sulphate
- Continuous infusion Magnesium sulphate
- Control hypertension (Labetalol)
- Strict fluid balance
- Consider HDU admission
- Plan for delivery by most appropriate route
13
Q
Outline some aspects of postnatal care of preeclampsia patients
A
- Anti-HTN for up to 6-12 weeks postnatally
- Assess for VTE risk
- Refer to postnatal hypertension clinic
- Discussion of contraception and inform of implications for future pregnancy
- Write to GP
14
Q
Outline HELLP syndrome in terms of preeclampsia and 3 abnormalities seen in the bloods
A
HELLP syndrome is a combination of complications from preeclampsia/eclampsia
HELLP (Haemolysis, Elevated Liver enzymes, Low Platelets)
HELLP:
Haemolysis
Elevated Liver enzymes
Low Platelets
15
Q
HELLP syndrome - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
A
Pathophysiology:
- Complication associated with preeclampsia in pregnant women in the 3rd trimester
- However can also occur within 7 days of delivery
- Unknown specifically why it happens
- 3 changes of Haemolysis, Elevated Liver enzymes and Low Platelets
Presentation:
- Jaundice
- RUQ / abdominal pain
- Ascites / oedema
- Easy bruising, bleeding, petechiae
- N&V
- Fatigue
+ HTN, headache and proteinuria (preeclampsia)
Investigations:
- FBC and clotting profile (anaemia, low platelets)
- LFTs (elevated liver enzymes, raised bilirubin, low haptoglobin)
- Blood film (shows schistocytes)
- VBG (raised LDH)
Management:
Mainly supportive
- Deliver baby early (especially if > 34 weeks) with corticosteroids for surfactant and magnesium
- Blood transfusion
- Steroids e.g. Dexamethasone
- Antihypertensives
16
Q
Outline some adverse pregnancy outcomes from hypergylcaemia
A
- Increased rates of miscarriage
- Increased rates of congenital abnormalities (mostly preconception hyperglycaemia)
- Increased rates of macrosomia and associated shoulder dystocia
- Preterm birth
- Perinatal mortality
- Preeclampsia
17
Q
Name the hormone responsible for the diabetic state in pregnancy
A
HPL - human placental lactogen
18
Q
List some congenital abnormalities associated with pre-conception hyperglycaemia, for the following systems:
- Cardiac
- Neuro
- MSK
A
Cardiac:
- VSD
-Tetralogy of Fallot
- Transposition of the great arteries
- Truncus arteriosus
- Persistent foetal circulation
Neuro:
- Spina bifida
- Anencephaly
MSK:
- Caudal regression / sacral agenesis (abnormal development of lower spine, associated with T1DM)
19
Q
Outline the ideal HbA1C level and what level that it should strongly be advised to avoid pregnancy
A
Ideal is HbA1c < 6.5%
Avoid pregnancy if HbA1c > 10%
20
Q
Outline some factors to consider in diabetic prenatal care, including additional medications to consider
A
- Optimal diabetes control (HbA1c < 6.5%)
- Weight loss if BMI > 27
- Retinal assessment
- Can continue on Metformin, but change other oral hypoglycemics to insulin therapy
- VTE prophylaxis assessment
Additional medications:
- Aspirin 75mg from 12 weeks
- Increased folic acid 5mg daily, from 3 months prior to conception
- Stop any unsafe medications e.g. ACEi
- Add vit D if BMI > 35
21
Q
Outline blood glucose level targets in pregnancy (pre-meal and 1 hr post-meal)
A
Pre-meal: < 5.3 mmol/L
1 hr post-meal: < 7.8 mmol/L
22
Q
Outline recommended gestation for delivery of a diabetic pregnancy
A
Deliver at 37 - 38 (+6) weeks (induction of labour)
Or elective caesarean at 38-39 weeks
23
Q
Outline some risk factors for developing gestational diabetes
A
- GDM in a previous pregnancy
- Previous macrosomic baby
- Obesity (BMI> 30)
- First degree relative with GDM
- Ethnicity e.g. south asian or middle eastern
24
Q
Outline the screening test used for those at risk of gestational diabetes and at what gestation it’s done
A
Screening test: oral glucose tolerance test (OGTT)
- Give 75ml glucose drink
- Measure glucose pre-drink and 2 hours post-drink
Done at:
- 26-28 weeks (i.e 6-7 months)
- Earlier (16-18 weeks i.e. 4-5 months) if previous GDM or high risk factors
25
Outline briefly how GDM is managed and the additional monitoring required for diabetic pregnancy
1. Lifestyle management (unless very high OGTT)
- Weight loss
- Increased exercise
If fails, add:
- Metformin 1st line (then add sulfonylureas or insulin)
Ultrasound scans
- Normal dating scan at 12 weeks (look for neural tube defects)
- Detailed scan at 20 weeks (look for cardiac abnormalities)
- Growth scans every 4 weeks, after 28 weeks (28, 32, 36, 40)
Joint antenatal diabetic clinic
- Every 1-2 weeks
- Discussion regarding delivery of baby
Retinal screen
- First test done in 1st trimester
- Re-test at 28 weeks
26
Outline the requirements of post-natal GDM management (maternal perspective)
- Stop all medications and blood glucose monitoring
- Fasting blood glucose test at 6 weeks postpartum
- HbA1c at 13 weeks
- Lifestyle advice
- Contraception and advice on future pregnancies
27
Outline the management of new onset gestational diabetes (depending on OGTT results)
Confirmation of diabetes (5,6,7,8)
- Fasting glucose > 5.6mmol
- Random glucose > 7.8mmol
First line:
- Lifestyle measures (unless fasting glucose > 7mmol)
If no improvement from lifestyle measures, start
- Metformin
- If fasting glucose > 7mmol, start Insulin
28
List some conditions that babies born to diabetic mothers are at risk of after birth
- Hypoglycaemia
- Polycythaemia
- Premature birth and respiratory distress syndrome
- Jaundice
- Congenital heart disease and cardiomyopathy
Long term:
- Risk of diabetes later on in life
29
Briefly outline how pre-existing diabetes is managed in pregnancy including: medications, any screening and delivery aims
- Should aim for very tight glucose control, especially before conception
Medications:
- Take 5mg of folic acid (rather than 400micrograms) from pre-conception until 12 weeks gestation
- Only Metformin and Insulin should be used, all other oral hypoglycaemics should be stopped
Screening:
- Retinopathy screening should be performed at 2 points: at booking and at 28 weeks
Delivery:
- Planned delivery is advised between 37-39 weeks (gestational diabetes up to 41 weeks)
30
What % of women with gestational diabetes go on to develop type 2 diabetes in the future?
50%
31
Outline the pathophysiology of obstetric cholestasis and how it presents
- Caused by reduced outflow of bile acids from the liver (due to increased oestrogen and progesterone)
- Leads to build up of bile acids in the blood
- Usually presents after 28 weeks and resolves after delivery of the baby
Presentation:
- Intense itching of palms of hands / soles of feet
- Absence of a rash
- Jaundice
- Dark urine / pale stools
- Fatigue / malaise
32
List some investigations for suspected obstetric cholestasis
- LFTs and bile acids
- Viral screen (hepatitis)
- Liver autoimmune screen
- USS abdomen
33
Outline the risks of obstetric cholestasis
- Maternal
- Foetal
Maternal:
- Vitamin K deficiency (bleed risk - PPH)
Foetal:
- Increased risk of stillbirth / perinatal mortality
- Foetal distress / preterm labour
- Intracranial haemorrhage
34
Outline the management of obstetric cholestasis, including medications, advised delivery gestation and monitoring postpartum
Drug treatment for pruritus:
- Urso-deoxycholic acid
- Antihistamines e.g. Chlorphenamine
- Calamine lotion
+ Vitamin K for both mum & baby (minimise risk of bleeding)
+ Foetal surveillance
Baby should be delivered at normal delivery date, but with LFT tests 10 days after birth
35
List the reasons in pathophysiology why pregnancy women are at an increased risk of VTE
- Hypercoagulable state
- Increase in fibrinogen and factors 8, 9 and 10
- Venous stasis in lower limbs and compression of veins
- Trauma at pelvic veins at time of delivery
36
List some additional obstetric risk factors which increase the risk of VTE in pregnancy
- Multiple pregnancy
- Preeclampsia
- Prolonged labour
- Caesarean section
- PPH haemorrhage > 1L
- Preterm birth
- Stillbirth
37
Outline which side is more likely for a DVT in pregnancy
Left side
- Venous drainage into left renal vein
38
Outline tests for suspected DVT in pregnancy
Compression duplex ultrasound
- If ultrasound is negative and low level of clinical suspicion, anticoagulant treatment can
be discontinued
- If ultrasound is negative but high level of clinical suspicion, anticoagulant
treatment should be discontinued but the ultrasound repeated on days 3 and 7
39
Outline tests for suspected PE in pregnancy
- Blood tests: FBC, U&E, LFTs
- ECG
- Chest x-ray
- Duplex USS for DVT (if confirmed, no further investigations = treat)
If chest x-ray normal = V/Q scan
If chest x-ray abnormal = CTPA
*START LMWH before waiting for tests*
40
Outline management for suspected VTE in pregnancy
- Immediate full anticoagulation with LMWH, continue until 6 weeks postnatally
- TED stocking / intermittent pneumatic compression
- Advice on future pregnancies and generally e.g. risk of flying
41
List some antenatal factors that can increase the likelihood of preterm birth
- Chorioamnionitis
- Growth restriction (intrauterine)
- Hypertension / preeclampsia
- Gestational diabetes
42
Outline some consequences for the foetus if born preterm
- Death
- Respiratory distress syndrome
- Sepsis
- Chronic lung disease
- Intraventricular haemorrhage
- Necrotizing enterocolitis
- Retinopathy
If < 28 weeks:
- Physical disability
- Learning disability
- Behavioural problems
- Visual / hearing problems
43
Outline the difference between SPROM, PROM and P-PROM in terms of rupture of membranes (ROM)
SPROM (spontaneous rupture of membranes)
- Self explanatory
PROM (pre-labour rupture of membranes)
- Rupture of membranes before the onset of labour
P-PROM (preterm pre-labour rupture of membranes)
- Rupture of membranes before the onset of labour AND before 37 weeks (preterm)
44
At what gestation is a baby considered premature and outline the 3 subcategories
Premature = born before 37 weeks
Extremely premature = < 28 weeks
Very premature = 28-32 weeks
Moderate-late premature = 32-37 weeks
The more premature the baby, the worse the outcomes
45
Suggest 2 methods that can be used to help prevent pre-term labour occurring (prophylaxis) and when they can be given
1. Cervical cerclage (stitch)
- Mechanical support to prevent cervix opening
- Involves spinal or general anaesthetic
- Removed prior to labour
2. Vaginal progesterone pessary
- Prevents remodelling of cervix and reduces myometrial activity
Between 16-24 weeks, if cervix < 25mm
46
Outline when a cervical cerclage may be used
Offered between 16-28 weeks
When there is cervical dilation WITHOUT rupture of membranes
Prevents progression and premature delivery
47
State the definition of P-PROM
Preterm - prelabour rupture of membranes (P-PROM)
Rupture of amniotic sac and release of amniotic fluid, before the onset of labour and before 37 weeks (preterm)
48
State the definition of PROM (prelabour rupture of membranes)
Prelabour rupture of membranes (PROM)
Rupture of amniotic sac and release of amniotic fluid, before the onset of labour after 37 weeks (at term)
49
Outline the risks to baby from P-PROM (preterm - prelabour rupture of membranes)
- Prematurity
- Chorioamnionitis and sepsis
- Cord prolapse
- Pulmonary hypoplasia (underdeveloped lungs)
50
State how P-PROM (preterm - prelabour rupture of membranes) is diagnosed
Mainly diagnosed by clinical history and speculum examination
(no digital vaginal exam)
- Would see pooling of amniotic fluid in the vagina
If there is doubt over the diagnosis:
- Actim-PROM (swab tests for amniotic insulin-like growth factors)
51
Outline what symptoms may indicate PROM (prelabour rupture of membranes)
- Foul-smelling or greenish amniotic fluid
- Maternal fever
- Reduced foetal movements
52
Outline what symptoms may present for P-PROM (preterm - prelabour rupture of membranes)
- Sudden gush of fluid
- Steady leaking of fluid
- Perception of urinary incontinence
- Watery discharge
53
Outline how P-PROM (preterm - prelabour rupture of membranes) can be managed
For women <37 weeks, whose membranes have ruptured...
- Admission to hospital for observations (at least 2-3 days)
- Inform NICU
- Regular blood tests FBC and CRP for chorioamnionitis
- Foetal monitoring
- Steroids if < 34 weeks
- Prophylactic Erythromycin for 10 days or until labour (whichever is soonest)
Aim to deliver at term (37 weeks) unless presence of group B strep (then 34 weeks)
54
Outline how PROM (prelabour rupture of membranes) can be managed
Can offer 2 of following options, depending on patient choice:
1. Expectant management for up to 24 hours after the time of rupture of membranes
2. Immediate induction of labour (needed if there are any signs of infection)
**Those with HIV, Hep B/C, group B strep need to be induced immediately
Vaginal examinations should be kept to a minimum (risk of infection) - use CTG as alternative
+ observe after birth for 12 hours
55
Define pre-term labour
Pre-term labour is when regular contractions and cervical dilation occur, before 37 weeks
(75% spontaneous, 25% elective)
56
List some factors that increase the risk of preterm labour
- Previous preterm delivery = most significant factor
- Previous cervical surgery e.g. LLETZ procedure
- Previous miscarriage
- Multiple pregnancy
- Asymptomatic bacteria
- Bacterial vaginosis
- Drug abuse / smoking
- Extremes of age
57
For those at risk of preterm labour, suggest what 2 aspects are monitored (more than normal)
1. Transvaginal cervical length measurement
2. High vaginal swabs for bacterial vaginosis
58
Outline what 2 methods prophylaxis can be given to those with a shortened cervix between 16-24 weeks
1. Cervical cerclage (stitch)
2. Vaginal progesterone pessary
59
Outline how preterm labour could present in terms of symptoms
- Abdominal cramps / mild contractions
- Mucus plug show
- Sensation of pressure in the cervix/vagina
- Lower back ache
60
Outline what you would examine for a patient in suspected preterm labour
Abdomen:
- firmness
- tenderness
- foetal position
Measure contractions:
- frequency
- duration
- intensity
CTG for foetal heart rate
Speculum:
- observe dilation
- assess for blood, fluid or mucus
61
Outline the investigations for suspected preterm labour
Transvaginal ultrasound of cervix length:
- < 15mm likely to be preterm labour = offer treatment
- > 15mm unlikely to be preterm labour = consider monitoring
If diagnosis uncertain, can do foetal fibronectin (not normally present) or Actim-partus
62
Outline the management steps for preterm labour
- Hospital admission and inform NICU
- Rescue cerclage if < 28 weeks and no rupture of membrane
- Nifedipine to slow contractions (max 48 hrs)
- Provide corticosteroids if < 34 weeks
- IV Magnesium Sulphate if < 34 weeks
63
Outline why IV Magnesium Sulphate is given in preterm labour
- Given as it helps to protect the foetal brain during premature delivery
- Helps to reduce the risk of cerebral palsy
64
Define postpartum haemorrhage (PPH) and outline the classifications for PPH (including the amounts)
Postpartum haemorrhage is blood loss after delivery of baby and placenta of over 500mL (vaginal) or 1000mL (caesarean)
Minor < 1000mL
Major > 1000mL
Moderate 1000mL-2000mL
Severe > 2000mL
Primary PPH is within 24 hrs of birth
Secondary PPH is from 24 hrs of birth to 12 weeks after
65
List 4 causes of postpartum haemorrhage
4Ts
Tone (uterine atony)
Trauma (perineal tear)
Tissue (retained products of conception)
Thrombin (bleeding disorder)
66
List some causes of antepartum haemorrhage
- Trauma
- Placental abruption
- Placenta previa
- Uterine rupture
- Coagulopathy
67
List some risk factors for postpartum haemorrhage
Pregnancy:
- Previous PPH
- Large baby
- Multiple pregnancy
Mother:
- Preeclampsia
- Obesity
Placenta:
- Placenta previa
- Retained placenta
- Placenta accreta
Labour:
- Failure to progress in 2nd stage
- Prolonged 3rd stage
- Perineal tear / episiotomy
- Instrumental delivery
68
List some methods to reduce the risk of postpartum haemorrhage before and during birth
- Treat anaemia during antenatal period
- Empty bladder before birth
- Active management in 3rd stage (Oxytocin)
- Intravenous tranexamic acid
69
Outline the emergency management steps for postpartum haemorrhage
- IV access (2 large bore cannulas)
- Take bloods: FBC, U&Es and clotting screen
- Lie woman flat and keep warm
- Group and cross match 4 units
- Warmed IV fluids and blood products
- Oxygen (regardless of sats)
If severe, may need to activate major haemorrhage protocol
70
Outline some treatments to stop bleeding in postpartum haemorrhage
Mechanical:
- Rubbing the uterus
- Catheterise (empty bladder)
Medical:
- Oxytocin
- Ergometrine
- Carboprost
- Misoprostol
- Tranexamic acid
Surgical:
- Intrauterine balloon
- B-lynch suture
- Uterine artery ligation
- Hysterectomy *last resort*
71
Outline some investigations to do with someone presenting with secondary postpartum haemorrhage, followed by the management for each cause
Ultrasound for retained products of conception
- Evacuate content surgically
Infection swabs (endocervical and high vaginal)
- Treat with antibiotics
72
Outline the method of assessing CTG trace
Dr C BraVADO
Define Risk
Contractions
Baseline RAte
Variability
Accelerations
Decelerations
Overall impression
73
Outline the 4 main abnormalities on a CTG trace
1. Early decelerations
- Dip and recovery of foetal HR, corresponds to contraction
- Normal, caused by uterus stimulating vagus nerve
2. Late decelerations
- Gradual decreases in foetal HR, starting after contraction has begun
- Concerning, caused by foetal hypoxia from excess uterine contractility, hypotension or hypoxia
3. Variable decelerations
- Sudden deceleration not associated with contractions
- Concerning, but more reassuring if brief accelerations before/after
- Caused by intermittent cord compression
4. Prolonged decelerations
- Prolonged decrease for 2-10 minutes (drop of more than 15bpm from baseline)
- ALWAYS CONCERNING, caused by cord compression
74
Outline the management options for breech presentation at 36 weeks onwards
- External cephalic version (ECV) at 37 weeks
- Choice of vaginal or elective c-section delivery (40% chance of needing emergency c-section with vaginal delivery)
If first twin breech, c-section suggested
75
Outline which class of drugs can be used during external cephalic version (ECV) to improve success rate and give an example
Beta-2 receptor agonists
e.g. Terbutaline
76
List some risks for the baby of breech delivery
- Umbilical cord prolapse
- Trauma during delivery e.g. broken bones
- Birth asphyxia (delay in delivery)
- Fetal head entrapment
- Intracranial haemorrhage (rapid compression of head during delivery)
- Premature rupture of membranes
77
Outline the risks and benefits for vaginal delivery vs c-section in breech presentation
Overall, vaginal delivery is safer for the mother and c-section is safer for the baby
- Vaginal breech birth increases the risk of low Apgar scores and serious short-term complications, but has not been shown to increase the risk of long-term morbidity
- Elective c-section carries a small increase in immediate complications for the mother compared with vaginal birth, however the highest risk comes from emergency c-section (which occurs in 40% of vaginal births)
- C-section carries a risk of complications in future pregnancy
78
Outline the advantages and complications of VBAC (vaginal birth after c-section)
Advantages:
- Approx 75% success after 1 previous CS
- Avoids risks of surgery e.g. VTE, injury etc
- Faster recovery
- Higher chance of future uncomplicated vaginal births
Complications:
- Uterine scar rupture 1:200 (0.5%)
- 25% risk of conversion to emergency c-section
- Risks to baby slightly higher than c-section, but similar to risk in first time labour
- Increased risk of needing blood transfusion
79
Outline some contraindications for VBAC
- More than 2 previous c-sections
- Previous uterine rupture
- Previous upper segment incision to uterus
- No other contraindications for vaginal birth
- Home birth (must be in delivery suite)
80
Outline the 3 main causes of cardiac arrest in pregnancy
- Hypovolaemia secondary to haemorrhage
- Pulmonary embolism
- Sepsis (leading to metabolic acidosis and septic shock)
81
Outline how CRP differs for pregnant women
- Carry out CPR with a 15 degree tilt to the left
- Early oxygen (higher requirements)
- Early intubation (more difficult)
- Aggressive fluid resuscitation
**Delivery of baby if no response to CPR after 5 minutes**
82
Outline the first line management for maternal sepsis
SEPSIS 6 within 1 hour
Take:
- Blood cultures
- Urine output
- Hb and Lactate
Give:
- Oxygen
- Antibiotics
- Fluids
- Regular observations with MEOW chart
- Consider early delivery if perceived to benefit mother or baby
**Avoid spinal anaesthetic in c-section if sepsis - use of general anaesthetic instead**
83
Outline how foetal growth is assessed in the antenatal period
Conducted after 24 weeks gestation:
1. Palpation: either symphysis fundal height or just fundal height
2. Ultrasound (if high risk or known growth issues)
- Head circumference
- Abdominal circumference
- Femur length
84
State the definition for small for dates/gestation and large for dates/gestation
Small for dates/gestation: below the 10th decile for their gestational age
Large for dates/gestation: above the 95th decile for their gestational age
85
Outline some causes of small for dates/gestation
Normal small:
- Constitutionally small
Abnormal small:
- Chromosomal abnormalities / congenital malformation
Infected small:
- Infection during pregnancy
Starved small:
- Placental issues
- Smoking
- Multiple pregnancy
Wrong small:
- Dates are wrong!!
86
Outline some risk factors for small for dates/gestation
- Previous foetal growth restriction
- Recurrent foetal loss
- Previous unexplained stillbirth
- 1st trimester bleeding
- Smoking
- Unexplained raised AFP
- Extremes of age
- Low BMI < 20
- Hypertension / preeclampsia
- Antiphospholipid syndrome / haemoglobinopathies
- Renal disease
- Infection during pregnancy
- Domestic violence
87
Outline some causes of large for dates/gestation
Maternal factors:
- Obesity / general large stature
- Diabetes
- Increased maternal age
- Multiparity
Foetal factors:
- Constitutional
- Male gender
- Overdue
- Genetic disorder e.g. Beckwith Wiedemann
88
Outline some causes of oligohydramnios, as well as general management approach
- Preterm rupture of membranes (P-PROM)
- Placental insufficiency
- Kidney problems e.g. renal agenesis or non-functioning kidneys
- Obstructive uropathy
- Genetic/chromosomal anomalies
- Viral infections
Management depends on the cause e.g. P-PROM might require early delivery
89
Outline some causes of polyhydramnios, as well as general management approach
Idiopathic in 50-60% cases
- Macrosomia
- Maternal diabetes (especially if poorly controlled)
Potential underlying abnormalities:
- Abnormal swallowing e.g. oesophageal atresia, CNS abnormalities
- Duodenal atresia
- Anaemia
- Twin-to-twin transfusion syndrome
- Increased lung secretions
- Genetic or chromosomal abnormalities
Generally, no specific intervention is required
90
Suggest a management plan for suspected abnormal foetal growth
1. Establish cause
- Check dates
- Check for infections / maternal disease e.g. BP
- Ultrasound, measure size and volume of fluid
- Umbillical artery doppler
2. Serial growth scans with regular ultrasound scans every 2-4 weeks
3. Consider timing of delivery and mode of delivery
- If UMA is normal, delay delivery until > 37 weeks
- If UMA is abnormal, consider delivery > 34 weeks but before if abnormal CTG or other abnormalities
- No benefit for c-section if large baby
91
Outline the difference between the uterine artery doppler and umbilical artery doppler
1. Uterine artery doppler
- Used for screening at 20 weeks (not surveillance)
2. Umbilical artery doppler
- Used for surveillance for 'small' babies
92
Outline some causes of increased symphysis fundal height in pregnancy
- Uterine fibroids
- Maternal obesity
- Polyhydramnios
- Pelvic mass
93
Outline some risks associated with a large baby
Maternal risk:
- Prolonged labour
- PPH
- Trauma to genital tract
- Increased need for operative delivery
Foetal risk:
- Injury during birth e.g. Erb's palsy
- Asphyxia
- Hypoglycemia post-birth
- Childhood obesity / metabolic syndrome
94
Outline the risks associated with oligohydramnios
Poor prognosis if in second trimester
Linked to potential causes
- P-PROM increases chance of preterm delivery and pulmonary hypoplasia
- Foetal contractures (inability to move in-utero)
95
Outline the risks associated with polyhydramnios
Increased perinatal mortality, due to:
1. Likely presence of an underlying abnormality / malformation
2. Increased incidence of preterm labour (due to over-distension of the uterus)
- Malpresentation e.g. breech presentation, is more likely
- Increased risk of postpartum haemorrhage
96
List some causes of reduced foetal movements
- Natural foetal sleep cycles / lack of concentration
- Intrauterine death
- Congenital fetal malformations e.g. neurological or musculoskeletal
- Placental insufficiency = oligohydramnios or foetal growth restriction
- Anterior placenta (< 28 weeks)
- Maternal sedating drugs e.g. alcohol, benzodiazepines, opioids
- Smoking
- Foetal anaemia or hydrops fetalis
- Fetomaternal haemorrhage
97
Outline steps to be taken for a mother presenting with reduced foetal movements
- Take a detailed history
- Assess risk factors for Fetal Growth Restriction or Stillbirth
- Record BP, HR, temperature and urinalysis
- Abdominal palpation and measurement of symphysis fundal height
- Fetal auscultation / CTG > 26 weeks
- Consider umbilical artery Doppler
- Ultrasound for growth
98
Outline some potential causes of intrauterine death (stillbirth)
Unexplained (50%)
- Preeclampsia
- Placental issue: abruption or vasa praevia
- Cord prolapse / around neck
- Maternal disease: obstetric cholestasis / diabetes / thyroid
- Maternal infections e.g. rubella, parovirus
- Genetic abnormalities / malformations
99
Outline how suspected intrauterine death is investigated and managed
Diagnosis: ultrasound scan, identify absence of foetal heartbeat
- Rhesus-negative women require anti-D prophylaxis
- Vaginal delivery is recommended unless contraindicated
- Choice of expectant delivery or induction
- Induction involves: oral Mifepristone and Misoprostol
- Dopamine agonists e.g. Cabergoline can be used to suppress lactation after stillbirth
100
Outline the maternal and foetal risks of multiple pregnancy, as well as risks relating to birth
Maternal risks:
- Anaemia
- Hypertension
- Polyhydramnios
- Spontaneous preterm delivery
Foetal risks:
- Miscarriage / stillbirth
- Prematurity / foetal growth restriction
- Twin/twin transfusion syndrome
- Congenital abnormalities
Birth risks:
- Malpresentation
- Instrumental delivery
- PPH
101
Outline what additional monitoring is required in multiple pregnancies
- FBC for anaemia (at booking, 20 weeks, 28 weeks)
- Ultrasound scans (monochorionic = 2 weekly after 16 weeks, dichorionic = 4 weekly after 20 weeks)
102
Outline the birth timing for the following twin combinations:
- Monochorionic monoamniotic
- Monochorionic diamniotic
- Dichorionic diamniotic
Monochorionic monoamniotic = between 32-34 weeks (require elective c-section)
Monochorionic diamniotic = between 36-37 weeks
Dichorionic diamniotic = between 37-38 weeks
103
Outline how a retained placenta is managed
- Provide adequate analgesia
- Catheterise to empty bladder
- Ensure Oxytocin has been given, if not already
- Controlled cord traction whilst guarding the uterus
- Encourage skin to skin / breastfeeding
- Insert 2x large bore cannulas
- Commence oxytocin infusion with IV fluids
- If above doesn't work, invasive manual removal of placenta (prophylactic antibiotics)
104
How does pregnancy impact on asthma?
- More likely to suffer from acid reflux
- Attacks are more likely between 24-36 weeks (mainly viral infections and poor compliance with corticosteroids)
- Most medications can be continued and used during breastfeeding
- Poorly controlled asthma has been associated with: preterm delivery, intrauterine growth restriction and SGA
105
Outline generally how asthma is managed during pregnancy
Women with well-controlled asthma, can remain under the community midwife
Worsening of their asthma symptoms can trigger a referral to the antenatal obstetric clinic
If severe, should managed by both a respiratory physician and obstetrician in the antenatal obstetric clinic
Non-medical:
- Trigger avoidance, smoking avoidance and treatment compliance
Medical:
- Inhaled corticosteroids, short or long-acting β2-agonists can be used
- Theophylline may cause irritability and apnoea in the neonate
- Oral corticosteroid use in the first trimester has shown a small increase in the risk of cleft lip or palate but should still be
prescribed when required, but used with caution
106
Briefly outline how epilepsy is managed in pregnancy including: medications, any additional scans
Managed by obstetrician
Medications:
- Take 500mg of folic acid (rather than 400mg) from pre-conception until at least 12 weeks gestation
- Avoid sodium valproate and phenytoin
- Generally, Levetiracetam, Lamotrigine and Carbamazepine are considering safer
- Ideally, medications should be changed prior to conception and should be controlled by a single antiepileptic agent
Scans:
- Offered a foetal anomaly scan at 20 weeks
Baby offered a vitamin K injection at birth
107
Which 2 anti-epileptic drugs should be avoided in pregnancy and what defects can they cause?
1. Sodium valproate
- Neural tube defects
- Developmental delay
2. Phenytoin
- Cleft lip / palete
108
Outline generally how cardiac disease is managed during pregnancy
- Under joint care of obstetrician and cardiologist
- Require pre-pregnancy counselling
- Delivery generally before 40 weeks to prevent risk of emergency c-section and stillbirth
109
Outline 3 complications of cardiac disease during pregnancy
- Premature labour
- Preeclampsia
- PPH
110
State some indications for an elective c-section (think maternal, foetal and placental)
Maternal:
- Maternal request
- Previous caesarean
- Poorly controlled HIV or primary genital herpes
- Maternal medical conditions e.g. cardiomyopathy
- Cervical cancer
Foetal:
- Breech presentation or other abnormal presentations
- Macrosomia (diabetes)
- Multiple pregnancy
Placental:
- Placenta praevia / vasa praevia
111
Explain the 4 categories of emergency c-section (1-4), also include the timing for cat 1 and cat 2
Cat 1 = immediate threat to the life (mother or foetus)
- Within 30 minutes
Cat 2 = maternal or fetal compromise (not immediately life-threatening)
- Within 75 minutes
Cat 3 = no maternal or fetal compromise but needs early delivery
Cat 4 = elective
112
State some risk factors for breech presentation
- Previous breech presentation
- Multiple pregnancy
- Oligohydramnios / polyhydramnios
- Uterine abnormalities e.g. fibroids
- Placenta previa
- Baby is preterm (not had time to turn)
113
List some causes of itching during pregnancy (with and without rash)
With rash:
- Any non-pregnancy related rashes!
- Polymorphic eruption of pregnancy (intensely itchy red rash around abdomen)
- Atopic eruption of pregnancy (eczema in pregnancy)
- Pemphigoid gestationis (itchy urticaria type rash, autoimmune disease)
Without rash:
- Obstetric cholestasis (build up of bile acids)
114
List some risk factors for obstetric cholestasis
- Previous obstetric cholestasis
- Family history of obstetric cholestasis
- Older age
- Pre-existing liver damage or disease e.g. hepatitis C
- Multiple pregnancy
115
Describe the following type of placental abnormalities
Placenta accreta = placenta adheres directly to superficial myometrium, but does not penetrate the thickness of the muscle
Placenta increta = villi invade into but not through the myometrium
Placenta percreta = villi invade through the full thickness of the myometrium to the serosa (invade too far) and may attach to other abdominal organs e.g. bladder or rectum
116
Placental abruption - state the following:
- Pathophysiology
- Presentation
- Management
Pathophysiology:
- Premature separation of the placenta from the uterine wall
- Results in maternal haemorrhage
Presentation:
- Sudden severe abdominal pain
- 'Woody' hard uterus
- Uterine contractions
- Reduced foetal movements
+/- vaginal bleeding
+/- hypovolaemic shock
Investigations:
- CTG
- Ultrasound
Management:
- ABCDE approach
- If foetal or maternal compromise, emergency c-section
All cases: anti-D within 72 hours of the onset of bleeding if woman is rhesus D negative
- If NO foetal or maternal compromise and at term, consider induction of labour (avoid further bleeding)
- Can consider conservative management if no foetal or maternal compromise and not yet at term
117
List some risk factors for placental abruption
Mostly due to the poor formation of placental vessels - most commonly due to chronic processes e.g. HTN, smoking
- Previous history of abruption
- Advanced maternal age
- **Maternal trauma**
- Preeclampsia
- Polyhydramnios
- Smoking
- Substance abuse e.g. cocaine use
- Coagulation disorders
118
Outline tocolysis drugs, including indications for their use
Medication which suppresses contractions during pregnancy to delay labor
Typically used in cases of preterm labor
- Aim to delay delivery by a few days,
- Usually to buy time for maternal steroids to work or allow transfer of the mother to the appropriate care unit
**Can only be used for a few days and should not be used for long term delay of delivery
119
List 2 examples of tocolysis drugs
Nifedipine (Ca2+ channel antagonist) = first line
Terbutaline (beta-2-agonist)
120
List some contraindications for the use of tocolysis drugs
- After 34 weeks gestation
- Cervical dilation > 4cm
- Signs of infection (chorioamnionitis)
- Abnormal foetal signs e.g. non-reassuring CTG, intrauterine death
- Maternal factors such as pre-eclampsia, haemodynamic instability
- Intrauterine growth restriction or placental insufficiency
+ drug-specific contraindications for Nifedipine e.g. heart failure, severe hypotension
121
List some conditions indicating potential group B strep infection in a newborn
- Sepsis
- Pneumonia
- Meningitis
122
List some risk factors for neonatal GBS infection
- Previous neonatal GBS infection
- GBS in current / previous pregnancy
- Preterm labour
- Prolonged rupture of membranes
- Intrapartum fever >38 degrees Celsius
- Chorioamnionitis
123
How is a group B strep positive mother managed?
- Antibiotics during labour and delivery (reduce risk of neonatal infection)
Done if risk factors for GBS infection are present
124
State the pathophysiology, main risk factor, presentation and management of cord prolapse
Occurs when the umbilical cord drops below the presenting part of the foetus (into the vagina)
Signs of foetal distress
Main risk factor = abnormal lie e.g. breech, transverse
Suspect when abnormal CTG and signs of foetal distress, diagnosed on vaginal examination
Management
- Category 1 c-section
- Apply physical pressure pushing against the presenting part to relieve the pressure
- Woman on all fours to use gravity to release pressure
- Use of tocolysis medication e.g. Terbutaline
125
Placenta praevia - state the pathophysiology, presentation, investigations and management
Pathophysiology:
- Incorrect implantation of the placenta, further down in the uterus leading to the placenta sitting further down than the foetus
- Must be sitting over the cervical os for it to be placenta praevia (otherwise it's a 'low lying placenta')
Presentation:
- Painless vaginal bleeding (usually after 36 weeks)
- Otherwise generally symptomless
Investigations:
- Usually diagnosed on 20 week USS
- CTG if baby > 20 weeks
Management:
- Repeat USS at 32 & 36 weeks to check position
- Planned c-section at 36-37 weeks (reduce risk of sponatneous labour)
- Consider emergency c-section if large blood loss or premature labour
126
Vasa praevia - state the pathophysiology, presentation, investigations and management
Pathophysiology:
-Placental blood vessels sit over the cervical os
-Placental blood vessels sit over the cervical os (2 x umbilical arteries & 1 umbilical vein)
Presentation:
- Painless vaginal bleeding (usually after 36 weeks)
Investigations:
- May be detected on vaginal examination, felt as pulsating mass over the cervical os
- Abdominal USS
- CTG if baby > 20 weeks
Management:
Very high foetal mortality even with emergency c-section :(
- Planned c-section at 34-36 weeks (reduce risk of sponatneous labour)
- Consider emergency c-section if large blood loss or premature labour
127
State the presentation of sepsis in pregnancy
- Pyrexia / hypothermia
- Tachycardia
- Tachypnoea
- Hypotension
- Hypoxia
- Poor urine output
- Reduced conscious level
128
List some risk factors for placenta praevia
- Previous c-section
- Previous placenta praevia
- Uterine abnormalties e.g. fibroids
- Increased age
- Smoking
- Assited reproductive techniques
