ICSM Year 5 Obstetrics Flashcards
What is an amniotic fluid embolism?
Amniotic fluid + foetal cells enter maternal circulation leading to cardiorespiratory collapse
How does the amniotic fluid embolism cause a maternal emergency?
Embolism –> anaphylactic reaction/ complement cascade
Complement –> pulmonary artery spasm
Pulmonary artery pressure + RVP increases
Myocardial + pulmonary capillaries are hypoxically damaged
LVF failure
Death
What are 4 signs and symptoms of Amniotic fluid embolism?
Sudden onset of SOB + cyanosis
Seizures
DIC
Hypotension
What would be seen on examination in amniotic fluid embolism?
Tachypnoea
Tachycardia
Pulmonary oedema
Uterine atony
What are some appropriate investigations to do in amniotic fluid embolism, and what would they show?
ABG (hypoxaemia, raised pCO2)
FBC (low Hb)
Clotting (DIC: low platelets, raised PT/APTT, decreased fibrinogen)
CROSS MATCH
CXR (cardiomegaly?? Pulmonary oedema)
ECG (right heart strain, rhythm abnormalities)
How should amniotic fluid embolism be managed?
ABC and refer to ITU
Circulation: 2 large bore cannulae, fluid resus
Pharmacological: ionotropics, correct the coagulopathy (FFP, platelets etc) PPH management of uterine atony
Consider delivery +/- hysterectomy
What is the survival rate of amniotic fluid embolism?
75%
What are the Hb values indicative of anaemia in each trimester?
1st TM: <110
2nd TM: <105
3rd TM: <105
Postpartum: <100
What is the characteristic blood film appearance of iron deficiency anaemia, folate deficiency and B12 deficiency?
IDA: hypochromia, microcytes, pencil cells
Folate deficiency: megaloblastic picture: hypersegmented neutrophils, macrocytosis, thrombocytopaenia, leucopaenia
B12 deficiency: also megaloblastic - as above
What is the cause of IDA in pregnancy?
Increased use of iron and decreased intake/ absorption - may also be caused by blood loss/ haemolysis
What is the cause of folate/B12 deficiency during pregnancy?
Lack in diet can cause both folate and B12 deficiency
Folate deficiency may also be caused by increased demand/ drugs
Recall some B12-specific symptoms of anaemia
Glossitis, depression, psychosis/ dementia, paraesthesia, peripheral neuropathy
What is the dose of iron given in IDA?
100 -200mg OD
Recall some side effects of giving ferrous sulphate
Black stools, constipation, abdo pain
When should oral folic acid not be given?
If cause of anaemia is not known - as it could exacerbate symptoms in a B12 anaemia
What is the treatment for B12 deficiency?
IM hydroxycobalamin
When is asthma most likely to be exacerbated in pregnancy?
24-36 weeks
What is the cause of asthma in pregnancy?
Pregnancy itself can’t cause it so it must have been present beforehand
What are the PEFR values that define severe and life-threatening asthma attacks?
Severe = 50-33%
Life-threatening = <33%
What are the appropriate investigations to do in asthma in pregnancy?
Peak flow, pulse oximetry, ABG, FBC (WCC infection?), CRP, UandEs, blood and sputum cultures, daily PEFR monitoring
How should chronic asthma be managed in pregnancy?
Continue medications throughout labour
Avoid bronchoconstrictors
Monitor foetal movements daily after 28 weeks
How should an acute asthma attack be managed in pregnancy?
High flow O2
Nebulised salbutamol
Ipratropium 0.5mg QDS
Steroids (IV hydrocortisone/ PO prednisolone)
IV magnesium
Summon senior help
What is the risk of oral corticosteroid use in first TM?
Cleft lip risk increased
What is the difference between the baby blues and post-natal depression?
Baby blues = mild, self-limiting low mood <2 weeks
PND = pervasive low mood in the PN period > 2 weeks
What is the perinatal period defined as?
Pregnancy + 1 year postpartum
Which class of drugs can increase risk of post natal depression?
Antipsychotics (ironically)
What scoring system is used for post natal depression?
Edinburgh Post Natal Depression Scale
Recall 2 breast-feeding safe antidepressants
Sertraline
Paroxetine
What is peripartum cardiomyopathy?
New-onset cardiomyopathy and heart failure usually within the last month of pregnancy to 5 months post-partum
What is the pathophysiology of peripartum cardiomyopathy?
40% rise in blood volume during pregnancy by 28w causing strain
Women with cardiac disease cannot increase CO –> uterine hypoperfusion –> increased pulmonary oedema
What classification system is used for cardiac disease in pregnancy?
NYHA classification
Recall some cardiovascular system abnormalities that are normal in pregnancy
ESM 3rd heart sound
Peripheral oedema (more volume)
In which patients should anticoagulation be used during pregnancy, and what is an appropriate anticoagulant to use?
Patients with:
- CHD
- Pulmonary HTN
- Artificial valves
- Increased risk of AF
Warfarin is teratogenic in 1st TM - so use LMWH instead
How can maternal cardiac disease be managed in labour?
Advise epidural to reduce pain-related cardiac strain
2nd stage can be kept short with elective forceps/ ventouse - reduces maternal effort for an increased cardiac output
Do a C-section where any effort is dangerous
Do not use ergometrine in 3rd stage (only syntocinon)
How does insulin resistance change throughout pregnancy?
Increases throughout
How does pregnancy affect pre-existing diabetes?
Increase in insulin dose requirements in second half of pregnancy
Increased risk of severe hypoglycaemia
Risk of deterioration of any diabetic retinopathy/ nephropathy
How does diabetes affect pregnancy?
Increases risk of miscarriage
Risk of spina bifida
Risk of macrosomia
Also increases risk of: pre-eclampsia, still birth, infection
Recall the pre-conception checks in diabetes
- Tight glucose control (HbA1c)
- Renal testing (UandEs, creatinine)
- BP checks
- Retinal checks
- Stop statins
- Stop folic acid
What is the risk of poor glycaemic control to the baby during pregnancy?
It’s teratogenic - can cause midline deformities like spina bifida
It can also cause the baby to be for large for dates
Why does diabetes increase still birth risk?
Placental damage by over-glycosylation of proteins means it may not be able to supply baby
What is the biggest risk to the neonate after the cord is cut when there is maternal DM?
Hypoglycaemia
Foetus has been producing high levels of insulin in utero because of high glucose load from mother, so when the cord is cut they keep producing lots of insulin which prediposes them to hypoglycaemia
Why does diabetes increase risk of macrosomia?
Excess maternal glucose –> foetus produces IGF-1 –> growth factor cause macrosomia
How often are antenatal diabetes clinics?
Every 2 weeks
What precaution should be taken when a diabetic mother requires antenatal steroids?
Insulin therapy is required to maintain normoglycaemia as steroids increase glucose release
What are the indications for testing for gestational diabetes in a pregnant woman?
Glycosuria on dipstick, previous GDM, any RF on clerking
What is the main investigation to do for GD?
2 hour 75g OGTT
What are the values that indicate diagnosis of GD?
5678 Fasting plasma glucose >5.6 2-hour OGTT >7.8
What should be the first thing you do if you diagnose GD?
Offer a review at a joint diabetes and antenatal clinic within 1 week
Recall the stepwise management of GD
1st line = changes in diet and exercise (CDE) - Only use this if fasting glucose is <7
2nd line - if targets are not met by 1st line in 2 weeks, still <7 fasting glucose = metformin as well as CDE (go straight to insulin if metformin contra-indicated)
3rd line (if >7 fasting glucose or 2nd line ineffective)
= CDE, metformin and insulin
Offer 3rd line straight away if fasting glucose is 7 or 6-6.9 with complications
4th line - consider glibenclamide
What should be done postnatally in mothers with GD?
Immediate discontinuation of blood-glucose lowering treatment GP should perform a fasting plasma glucose at 6-13w pp
What is by far the most common site of ectopic pregnancy?
Fallopian tubes - usually ampulla
Where is the site of ectopic pregnancy with highest chance of rupture?
Isthmus
What is the cause of ectopic pregnancy?
Tube damage due to infection (eg PID), endometriosis, previous tubal surgery, Depo-Provera injection
What are the signs and symptoms of ectopic pregnancy?
Abdo pain, diarrhoea, shoulder tip pain, back pain
Amenorrhoea with PV scanty blood
Dizziness if ruptured - with circulatory collapse
What will be seen on examination in ectopic pregnancy?
- Abdomen - rebound tenderness, guarding 2. Vaginal - cervical excitation, adnexal tenderness + mass
What are the appropriate investigations for an ectopic?
Pregnancy test
Speculum + bimanual
TVUSS
Bloods: FBC, X match, clotting
What signs on TVUSS are indicative of ectopic pregnancy?
Tubal: ‘blob’ sign, ‘bagel’ sign
Cervical: ‘barrel’ cervix, negative sliding sign
How does a located ectopic appear?
Empty uterus, adnexal mass with GS and YS, free fluid in uterine cavity
What should be done in the case of a pregnancy of unknown location (PUL)?
Depends on increase in serum beta-hCG (taken at 0 and 48 hours)
- >63% –> developing prenancy: rescan at 7-14 days
- <63% –> review in EPAU <24 hours
- <50% –> miscarriage –> expectant management
How should all early-pregnancy emergencies first be managed?
Call the on-call gynae
When should ectopics be managed expectantly?
Only permissable in stable, asymptomatic patient with falling levels of beta-hCG
What are the indications for medical management of an ectopic?
Stable
Normal LFT and UandEs
Beta-hCG <3000
Ectopic <35mm
No blood in pouch of douglas
What is the medical management of ectopic?
ONCE IM methotrexate
What advice should be given following medical management of an ectopic?
Go home and come back for repeat blood tests (hCG)
No intercourse for 3 months
Don’t drink alcohol
Avoid excessive sun exposure
Expect side effects of pain, nausea and diarrhoea
What are the indications for surgical management of ectopic pregnancy?
Significant pain
Ectopic with foetal heartbeat
Adnexal mass >35mm
beta-hCG >5000
What is the surgical management of ectopic pregnancy?
Laparoscopic salpingectomy
When can a salpingostomy be used to treat ectopic pregnancy?
If bleeding is minimal and occlusion is viable to be removed (eg at fimbriae) and the patient only has one viable tube left (as high future risk of ectopics)
What type of prophylaxis is required for surgical management of an ectopic?
Anti-D prophylaxis
What form of contraception should be avoided following a lap salpingectomy?
Copper IUD
How should all seizures in second half of pregnancy be managed?
Immediate treatment for eclampsia until a definitive diagnosis is made
How should epilepsy medication be managed in pregnancy?
Minimum possible dose - levetiracetem and lamotrigene are safest agents
Reduce to monotherapy where possible
Explain risk of congenital malformation, as well as risk of recurrent seizures
Pre-conceptional folic acid 5mg, and vit K in last month of pregnancy
What congenital abnormalities are associated with anti-epileptic drugs?
Neural tube defects
Facial clefts
Cardiac defects
Valporate is teratogenic
What is the main risk of phenytoin use in pregnancy?
Cleft palate
Which anti-epileptic drugs are most appropriate in pregnancy?
Lamotrigine
Levetiracetem
Carbamazepine (least teratogenic of the old antiepileptics)
What extra source of support and advice could you refer someone to when counselling an epileptic expectant mother in PACES?
Invite to register to the UK Epilepsy and Pregnancy Register
What is a hyatidoform mole?
A benign tumour of the trophoblastic tissue
What is the aetiology of a hyatidoform mole?
Abnormal fertilisation leads to either a ‘complete’ mole (empty egg fertilised by 2 sperm) or a partial mole (normal egg fertilised by 2 sperm)
What are the signs and symptoms of a hyatidoform mole?
Painless PV bleeding (ie miscarriage)
Uterus larger than expected for GA
Hyperemesis
Often seen on USS before symptoms
What are appropriate investigations to do to diagnose hyatidoform mole?
Bloods: Beta-HcG grossly elevated
hCG shares an alpha subunit with TSH, therefore (due to negative feedback) there should be a low TSH and a high T4
Imaging: pelvic USS
- Complete mole: snowstorm/ ‘cluster of grapes’
- Incomplete mole = foetal parts, no snowstorm/ cluster of grapes
How should hyatidoform mole be managed?
Urgent referral to a specialist centre
1st line = surgical: ERPC (evacuation of retained products of contraception) = suction curettage
Then: monitor serum BhCG, use methotrexate if rising/ stagnant levels, avoid pregnancy until 6 months of normal BhCG
What are the main complications of hyatidoform mole to be aware of?
May progress to malignancy (20% of complete moles, 2% of partial)
This would be either an invasive mole or a choriocarcinoma
How can the diagnosis of hyatidoform mole be explained in PACES?
When foetus doesn’t form properly, and a baby doesn’t develop, instead there is an irregular mass of pregnancy tissue
What is the main risk when gestational trophoblastic disease progresses to malignancy?
Rapid metastasis all over the shop
What are the forms of malignant gestational trophoblastic disease?
- Invasive mole (Hyatidoform mole invades myometrium –> necrosis and haemorrhage)
- Choriocarcinoma (cytoctrophoblast and synctiotrophoblast without formed chorionic villi invade myometrium)
- Placental site trophoblastic tumour
Recall 4 things that choriocarcinoma might arise from
50% = molar pregnancy
22% = viable pregnancy
25% = miscarriage
3% = ectopic pregnancy
What are the signs and symptoms of malignant gestational trophoblastic disease?
Persistent PV bleeding
Hyperemesis gravidarum
Lower abdo pain
Symptoms of mets to:
- Lung (haemoptysis, dyspnoea, pleuritic pain)
- Bladder/ bowel (haematuria/ PR bleeding)
On examination: excessive uterine size for GA
What are the appropriate investigations to do for malignant gestational trophoblastic disease?
Bloods: serum BhCG, FBC, LFT (mets)
Imaging: pelvic USS, CXR, CTP, MRI brain
How is malignant gestational trophoblastic disease managed?
Methotrexate, hysterectomy for placental site trophoblastic tumour
What % of women get hyperemesis gravidarum?
1%
What % of pregnant women get emesis gravidarum?
80%
What lifestyle factor is protective against hyperemesis gravidarum?
Smoking
What factors increase risk of hyperemesis gravidarum?
Increased oestrogen (Nulliparity, obesity, multiple pregnancies)
Hyperthyroid
Gestational trophoblastic disease (more BhCG)
What are the RCOG diagnostic criteria for hyperemesis gravidarum?
MUST HAVE ALL 3 OF:
>5% pre-pregnancy weight loss
Dehydration
Electrolyte imbalance
When does hyperemesis gravidarum begin?
Between 4th and 7th gestational week
When does hyperemesis gravidarum peak?
Week 9
When does hyperemesis gravidarum resolve?
By 20th week
What investigations should be done in hyperemesis gravidarum?
Body weight (for measuring dehydration)
Urine dipstick (to check ketones)
UandE
Basic obs
What scoring system is used to assess the severity of hyperemesis gravidarum, and what score means admission?
PUQE-24
13 or above
How should hyperemesis gravidarum be managed?
Always VTE prophylaxis (LMWH) , IV saline with KCl and thiamine supplementation
1st line: antihistamines (eg IV promethazine/ cyclizine)
2nd line: antiemetics (eg IV ondansteron, metoclopramide, domperidone) Metoclopramide is 2nd line due to EPS 3rd line
What are the major possible maternal complications of hyperemesis gravidarum?
VTE
Wernicke’s
Hypokalaemia
Hyponatraemia
Acute renal tubular necrosis
Mallory-Weiss tear
What are the main risks to the foetus from hyperemesis gravidarum?
IUGR
Pre-term labour
Termination
What BP is considered hypertensive, and what is the threshold for ‘severe hypertension’ during pregnancy?
HTN: 140/90
Severe HTN: >160/110
When is HTN considered to be gestational, rather than chronic?
Appearing after 20 weeks
What are the features of pre-eclampsia?
New HTN present after 20 weeks
Proteinuria
AND/OR Maternal organ dysfunction
What is HELLP syndrome?
Haemolysis, Elevated Liver enzymes, Low Platelets Severe form of pre-eclampsia
How is eclampsia defined?
1 or more seizures in someone with pre-eclampsia
How is decision to give aspirin for HTN in pregnancy (not pre-eclampsia, just HTN) guided?
Guided by presence of high/ moderate risk factors
Always give aspirin if 1 or more of the following is present:
- Previous pre-eclampsia
- CKD
- AI disease
- DM
- Chronic HTN
Give aspirin if they have any two of:
- Primigravidity
- Age >40
- Pregnancy interval >10 years
- BMI >35
- Pos FHx
- Multiple pregnancy
What are the signs and symptoms of pre-eclampsia?
Often asymptomatic
Can give: severe headache, visual disturbances, epigastric/ RUQ pain, vomiting, breathlessness, sudden swelling of face/ feet/ hands
What investigation is most useful in pre-eclampsia?
Urine dip (proteinuria) - if 1+ on dip or protein creatinine ratio quantification >30mg/mmol
How should pre-eclampsia be managed?
1st line: labetolol (100mg, BD) - contraindicated in asthma
2nd line: nifedipine
3rd line: methyldopa
How is eclampsia managed?
IV magnesium sulphate (it’s a potent cerebral dialator)
What is the threshold for admission for gestational HTN?
Severe HTN (>160/110)
What is the target BP for those who have gestational HTN?
135/85
How should gestational HTN be managed?
1st line labetolol, 2nd line nifedipine
How often should mothers with gestational HTN be monitored, and what checks should be done?
BP measurement: weekly for moderate HTN, every 15-30 mins in severe HTN when mother is admitted
Dipstick: once or twice a week in moderate, daily whilst admitted FBC, LFT and
UandE once at presentation
What foetal monitoring should be done in mothers with HTN?
USS for foetal growth
Amniotic fluid assesment
Umbilical artery doppler
How does BP usually vary during pregnancy?
Tends to fall in first half of pregnancy before rising back to pre-pregnancy levels before term
How often are LFT, FBC and renal fx repeated in pre-eclampsia, eclampsia and gestational HTN?
Done twice a week in moderate pre-eclampsia or 3 times per week in eclampsia - only done once in gestational HTN
Describe the planning of birth timing in pre-eclampsia
If birth <34 weeks - offer antenatal steroids and MgSO4
If birth 34-36 weeks, continue surveillance unless delivery indicated in care plan
If birth >37 weeks, initiate birth within 24-48 hours
What should be monitored intrapartum in pre-eclampsia?
CTG (continuous) BP monitoring + continue antihypertensives
When should anticonvulsants be considered for women with pre-eclampsia?
- Previous eclamptic fits
- Birth planned in next 24 hours
- Features of severe pre-eclampsia present
What are the features of severe pre-eclampsia?
Severe headaches
Epigastric pain
Visual scotomata
Oligouria and severe HTN
Nausea and vomitimng
Deteriorating biochemistry
What is the first line anticonvulsant to use in eclampsia, and what is its reversing agent?
IV MgSO4
Calcium gluconate (10mls. 10%, over 10 mins)
Recall the MgSO4 dosing used to treat severe htn/pre-eclampsia/ eclampsia
Loading dose of 4g IV over 5 mins, followed by an infusion of 1g/hour for 24 hours
What are the discharge criteria following eclampsia?
No symptoms of pre-eclampsia
BP <150/110
Blood test results stable/ improving
Recall some anti-hypertensives that are not recommended whilst breastfeeding
ARBs
ACE inhibitors
Amlodipine
What drugs for HTN are safe when breastfeeding?
Labetolol, nifedipine, enalapril, captopril, atenolol
What is the aetiology of eclampsia?
Impaired trophoblastic invasion of spiral arteries –> high resistance flow –> poor placental perfusion –> release of factors from placenta into circulation –> factors cause symptoms
What is TORCH syndrome?
Toxoplasmosis, Other agents, Rubella, CMV, HSV
Cluster of symptoms caused by congenital infection with the above
Recall the 4 signs and symptoms of congenital toxoplasmosis
Chorioretinitis
Hydrocephalus
Convulsions
Intracranial calcifications
How should congenital toxoplasmosis be managed?
Pyrimethamine
What pathogens come under the ‘other’ section of TORCH?
Syphillis, Parvovirus B19, hepatitis, VZV, HIV
What are the signs and symptoms of congenital syphilis?
Rash (soles and palms)
Bloody rhinitis
Nose deformity
Saber shins
Hutchinson’s teeth
Clutton’s joints
What condition does congenital parvovirus B19 cause?
Hydrops fetalis - causes heart failure
When does congenital HIV present?
6 months
What are the signs and symptoms of congenital rubella?
Cataracts (from chorioretinitis)
PDA heart defect
Microcephaly
What are the signs and symptoms of congenital CMV?
Chorioretinitis –> cataracts
Intracranial calcifications
Microcephaly
Hepatosplenomegally
Jaundice
Purpura/ petichiae
How should congenital CMV be managed?
Ganciclovir
What disease is caused by congenital HSV?
SEM (skin eyes mouth) disease/ disseminated disease
What other organisms can cause neonatal sepsis?
GBS. Listeria monocytogenes
How should congenital GBS be treated?
Benzylpenicillin
How should congenital listeria be managed?
Amoxicillin/ ampicillin
What is the organism responsible for toxoplasmosis and how is it spread?
Protozoon toxoplasma gondii
Parasite excreted in cat faeces - transmission is faeco-oral route (from infected meat and cat faeces)
What are the maternal signs and symptoms of toxoplasmosis?
Often asymptomatic but may have fever, malaise, arthralgia
What are the signs and symptoms of congenital toxoplasmosis?
60% are asymptomatic but may develop deafness, low IQ and microcephaly
40% have classic ‘4 Cs of toxoplasmosis’:
- Chorioretinitis
- hydroCephalus
- intracranial Calcifications
- Convulsions
What is the test for toxoplasmosis?
Sabin Feldman Dye test
How should toxoplasmosis be managed in pregnancy?
Prophylaxis: mother should avoid eating raw/ rare meat and handling cats/ cat litter
If +ve mother and -ve baby: spiramycin (prevents vertical transmission)
If +ve mother and +ve baby: pyrimethamine and sulfadiazine with prednisolone adjunct
What is the name, shape and gram status of the organism causing syphillis?
Treponema pallidum: gram neg spirochete
What are the symptoms of primary syphillis?
Painless chancres and local lymphadenopathy
What is the difference bwtween early and late latent syphillis?
Early = signs/symptoms <2 years, late = >2 years
What are the different types of tertiary syphillis?
Gummatous, cardiovascular and neurosyphilis
What is the most useful treponomal test?
EIA
How is syphillis treated?
Benzathine-penicillin OR doxycycline
Early: Benzathine-penicillin STAT or doxy BD 14/7
Late: Benzathine-penicillin IM once weekly 3/52 OR doxy BD 28/7
Neurosyphilis: Benzathine-penicillin IV 4-hourly, 14/7
Prednisolone used as an adjunct to avoid Jarish-Herxheimer reaction
For how long is parvovirus B19 infectious?
From 10 days prior to the rash to 1 day after the rash appears
How is parvovirus transmitted?
Aerosol/ blood-borne
How does the parvovirus rash usually appear?
Slapped cheek’ appearance
What symptoms are to be expected in an infant with parvovirus?
Coryzal symptoms + headache + rash
What is the risk of parvovirus in pregnancy?
Crosses placenta at 4-20w GA, destroying RBCs and –> hydrops foetalis (10% infant mortality)
How is hydrops fetalis managed?
Blood transfusion
If a baby is born to a HepB + mother, how should they be managed?
- Vaccination - at birth, 1 month and 6 months
- HBV IV Ig within 12 hours of birth
Is Hep B transmitted by breastfeeding?
No
How can Hep C infection be confirmed?
PCR
How should hep C be treated in pregnancy?
It shouldn’t as it is contraindicated (ribavarin and interferon)
What is the danger of having Hep E in pregnancy?
If contracted in third TM can cause a severe reaction and a fulminant hepatitis
What should pregnant mothers avoid eating to avoid hep E?
Pork and shellfish
For how long is VZV infectious?
From 48 hours before rash until the vesicles crust over
How does congenital varicella syndrome appear?
Chorioretinitis
Cutaneous scarring
Microcephaly
IUGR
In which period is VZV infection considered ‘neonatal’?
Maternal infection 7 days before or after birth
How does neonatal VZV present?
Mild disease: pneumonua, disseminated skin lesions and visceral infections (ie hepatitis)
How should antenatal chickenpox be managed?
VZIg within 10 days of exposure (before 20/40 gestation)
Once symptoms have developed, VZIg cannot be given
If after 20/40 weeks gestation –> Aciclovir 800mgs QDS
What should be done if there is doubt about whether a mother has previously had VZV?
Maternal blood checked urgently for VZ Ig
What are the possible complications of delivery during viraemic period in varicella zoster infection?
Haematological: bleeding, DIC, thrombocytopaenia
Hepatitis
VZV infection of new born
When should an HIV test be done antenatally?
Routinely in antenatal booking
How is HIV diagnosed in children?
Direct viral amplification by PCR carried out at birth, on discharge, at 6 , 12 and 18 weeks if mother is HIV+
How should maternal ARVs be managed during pregnancy?
Don’t change them they’re continual
How should the babies of HIV + mothers be treated?
First 2-4w of life: ARVs - zidovudine monotherapy
If viral load is undetectable or less than 50: vaginal delivery
If viral load >50 at 36 weeks: ELCS at 38 weeks
If viral load is detectable: intrapartum zidovudine
One of the only infections where avoidance of breastfeeding should be advised - offer cabergoline to suppress lactation
What are the S/S of rubella?
Coryzal symptoms + arthralgia + maculopapular rash
Soft palate lesions (NO koplik spots though)
Describe the spread of the rash in Rubella
Starts behind ears, spreads to head and neck and then to rest of body
At what point during gestation is there highest risk of congenital rubella syndrome?
<12 weeks GA
What are the features of congenital rubella syndrome?
Chorioretinitis, sensorineural hearing loss
At what point in gestation does maternal rubella become very low risk?
20 weeks
What investigations are appropriate for rubella?
Blood serology
USS for foetal abnormalities
How should maternal rubella be managed?
Rest, fluids and paracetamol (no treatment)
Offer TOP if <16w GA
What are the possible sites of latent CMV infection?
Dorsal root ganglion
B cells
Monocytes
At what stage of pregnancy is CMV most likely to transmit vertically?
Unlike other infections during pregnancy, CMV just as likely (30- 40%) to vertically transmit at any point
How does congenital CMV present?
90% are asymptomatic, although some will go on to develop sensorineural hearing loss
10% are symptomatic: Sensorineural hearing loss, pre-ventricular calcification, chorioretinitis, ‘blueberry muffin rash’
What investigations are appropriate when a pregnant woman has CMV?
Maternal serology
USS of foetus
Amniocentesis
PCR
How should maternal CMV be managed?
Do not treat, but if evidence of CNS damage to foetus –> offer TOP
Foetal USS every 2w following diagnosis
Can offer foetal MRI at 28wGA
How should congenital CMV be managed?
IV ganciclovir
Audiology follow-up
Ophthalmology follow-up
Which type of HSV is which?
HSV1 = oral, HSV2 = genital
What are the features of SEM disease?
Blistering vesicular rash, chorioretinitis
What are the possible presentations of congenital HSV infection?
- CNS disease + SEM (seizures, lethargy, poor feeding + skin/eye/mouth disease)
- Disseminated infection - encephalitis, CNS abnormalities
How is congenital HSV diagnosed?
Clinically + STI screen + PCR
How should congenital HSV infection be managed?
Acute infection –> Aciclovir Oral for mother, IV for child
When should a C section be done in maternal HSV?
If first episode <6 weeks prior to EDD
What antigen characterises the Group B Strep pathogen?
Group B Lancefield antigen
Is group B strep gram pos or neg?
Pos (cocci in chains)
What causes group B strep infection?
Commensal in vagina and rectum carried by 25% of women
What are the signs/symptoms of GBS?
Often asymptomatic until incidental finding
How should maternal group B strep be managed?
Intrapartum IV benzylpenicillin (or vancomycin if penicillin allergy) if pyrexial
In what situations would group B strep prophylaxis be given?
When there are RFs for an early-onset neonatal sepsis:
- intrapartum fever/ chorioamnionitis
- prolonged rupture of membranes (PROM)
- Pre-term birth
How should sepsis monitoring occur in neonates?
If 1 risk factor: remain in hospital for 24 hours for obs
If 2 or more risk factors, or one red flag, –> Abx + septic screen Sepsis
Abx in neonate: cefotaxime, amikacin, ampicillin
Red flags: seizure, resp distress, shock
What are the S/S of listeriosis?
Often asymptomatic or non-specific
How can listeriosis be diagnosed?
Isolation of organism from blood, vaginal swabs or placenta
How is listeriosis managed?
IV amoxicillin/ ampicillin
What is the prognosis for listeriosis?
Bad unless treated (then good)
What is a Braxton-Hicks contraction?
Painless contractions with no cervical change
Define the 3 stages of labour
- Painful uterine contractions –> full (10cm) cervical dilatation 2. Starts with urge to push and ends with delivery of foetus 3. Delivery of placenta and foetal membranes
Up to how long should the 3rd stage of labour last ideally?
Up to 30 mins
What factors determine the progress of labour?
- Power (contractions) 2. Passage (dimensions of pelvis) 3. Passenger (diameter of foetal head)
What is a possible complication of shoulder dystocia?
Erb’s palsy
What is ‘restitution’?
Bringing head in line with shoulders
Recall the management of shoulder dystocia
In LESS THAN 5 MINS:
- Call for senior help and discourage pushing
- McRobert’s manoevre and suprapubic pressure
- Evaluate for episiomtomy
- Either Rubin’s manoevre or Wood’s Screw or deliver posterior arm
What is McRobert’s manoevre?
Legs up to abdomen
What is Rubin’s manoevre?
Push anterior shoulder towards baby’s chest
What is Wood’s Screw?
Rubin’s + push posterior shoulder towards baby’s back –> rotation
What score is used to decide how likely it is that a woman will go into labour imminently?
Bishop’s score
What is ‘effacement’?
Reported as a %, measure of how thin the cervix is
What is the ‘foetal station’?
Position of the baby’s head relative to the ischial spines of the maternal pelvis
How should the 1st stage of labour be managed?
One-to-one midwifery care
Vaginal exams performed 4-hourly or as clinically-indicated
Ensurance of adequate: analgesia, antacids, hydration, light diet to provide ketosis
What is the normal progress of the first stage of labour?
1cm per hour
How should a delayed first stage of labour be managed?
1st - if membranes intact - ARM (artificial rupture of membranes) 2nd (if membranes ruptured) - oxytocin
What is the most common cause of primary dysfunctional labour?
Ineffective uterine action
When is the second stage of labour considered ‘delayed’?
In nulliparous women: 3 hours with an epidural or 2 hours without
In multiparous women: 2 hours with epidural or 1 hour without