Lecture week 4-RNH Flashcards
What is the 1st thing you should do when reading the OSCE stem and KFP
KNOW YOUR ROLE
e.g I am an RMO….part of the ….. team, can I have a chat to you until my consultant is coming….
When asking about CST, what other questions should be asked
Were there any abnormal reports/reading that came back from those tests?
Naegele rule for EDD
Add seven days to the first day of your LMP and then subtract three months.
MDT for GDM women
You must state MDT
- Diabetic educator
- Dietician
- Physiotherapist
- GP
You must take care of mother’s microvascular and macrovascular complications–> ophthalmology review is a must–> retinal haemorrhages
Why is GDM mother more likely to get an infection
Immunosuppressed
GDM
- definition
- risk factors
- effects on the mother, fetus and pregnancy
- screening guidelines–> what are the values
- monitoring
- labour
Look at the guidelines
Advice for GDM postpartum-3 points
6 weeks review of OGTT
Breastfeeding should be encouraged as it will help with managing the blood sugars
Interpregnancy interval
Pathophysiology of HTN in pregnancy
The placenta fails to invade properly to the level of the spiral arterioles leading to a high resistance placenta
This causes the release of vasculoendothelial substances from the placenta that causes multi-organ problems for the mother
The hormonal consequences result in generalised vasoconstriction. At the same time, endothelial cell damage causes interstitial leakage through which blood constituents, including platelets and fibrinogen, are deposited subendothelially
What are the 3 features of Mg toxicity
what should be done then?
Monitor urine output, tendon reflex and respiratory rate for R depression
o Urine output < 80 mL in 4 hours
o Deep tendon reflexes are absent or
o Respiratory rate < 12 breaths/minute
Serum magnesium level can be checked
Stop the infusion and start them on calcium gluconate
MgSO4 doses
-apparently we need to know doses?
Loading dose Magnesium Sulfate
• 4 g IV over 20 minutes via controlled
infusion device
Maintenance dose Magnesium Sulfate
• 1 g per hour IV via controlled infusion
device for 24 hours after birth
MgSO4 is also used in the fetus for what and before when
Neuroprotection before 30 weeks, prematurity
One sentence for each: stages of labour 1st stage 2nd stage 3rd stage 4th stage
1- 0-4cm and then 4cm to fully dilated
2- 10 cm to delivery
3- Delivery of the placenta, 30-60, 60 min max
4-2-4 hours after delivery, need to monitor(even in a healthy mother with no complications during pregnancy)
Mechanisms of labour
Floating Descent and flexion internal rotation complete internal rotation The complete extension(head is popping out) restitution(external rotation) Delivery of anterior shoulder Delivery of posterior shoulder
Maternal collapse-4H and 4Ts
4H Hypovolemia Hypoxia Hypo/hyperkalaemia Hypothermia
MDT
Major transfusion protocol if needed
Maternal collapse-4Ts
Thromboembolism
Toxicity
Tension pneumothorax
Tamponade
What are some risk factors for cord prolapse
1) Multiparity/Multiple pregnancies
2) Prematurity/PPROM
3) Malpresntations
4) Polyhydramnios
What are the 2 types of cord prolapse
Concealed and revealed
Management of cord prolapse
DO NOT ATTEMPT TO REPLACE THE CORD
Displace the presenting part with the hand
If IDC in, full quickly with 500 ml of saline
CAT1 summoned
Can tocoylse if OT delayed
Cord prolapse vs cord presentation
Rupture of the membrane is the difference
Risk factors for shoulder dystocia
Previous history Obesity(BMI>30) DM Macrosomia>4.5kg IOL Prolonged 1st or 2nd stage of labour Assisted vaginal delivery
Risk factors for shoulder dystocia
and what is the HELPERR
Previous history Obesity(BMI>30) DM Macrosomia>4.5kg IOL Prolonged 1st or 2nd stage of labour Assisted vaginal delivery
3 complications for each shoulder dystocia
Look at slides- lecture week 4
Cord prolapse or presentation, what shouldn’t you do
PUT IT BACK
induce vasospasm, cut off blood to the fetus–> death
IX at your first antenatal visit
1) Blood group and antibody screen
2) FBC
3) Rubella
4) Syphilis
4) STI screen- chlamydia, HIV and Hep B and C
5) Urea, creatinine, uric acid
6) MSU
7) CST
8) Random blood glucose
9) USS dating scan
AT 26 week visit
FBC Antibody screen Syphilis Hep C OGTT
At 34 weeks visit
FBC
Antibody screen
During an Obs OSCE state some of the things you will ask the mother
GA
Foetal movements
Uterine bleeding/leakage/cramping
BP, Weight, Fundal height, foetal lie, FHR
When can nuchal translucency be done
Nuchal Translucency
11 ———–13 +6
When can CVS be done
CVS—> 11-13wk
When can Aminocentesis be done
16-18wk
Which vital sign is really important in these antenatal visits
BP
What should be recommended for women with high BP in early antenatal visit
Low dose aspirin
The woman is 25 years old, should Down syndrome screening be discussed with her
Yes, it should be. Maternal age is irrelevant for having a baby with Down syndrome. Maternal age is a risk factor just like any other condition
CFTS- how much? private? public?
How good
Medicare-funded if high risk, if not it’s private
90%
NIPT
99.5-99.9 sensitive 400$ Harmony test private SCREENING
The test is done after 10 weeks and is more than 99% accurate for Down syndrome
Trisomies 21, 18, 13; sex chromosome conditions*( sex conditions its upto the patient)
What is the risk of miscarriage with these screening a diagnostic test
The screening test is non-invasive hence no risk of miscarriage
However CVS(1 IN 100) and amino(1 in 200)
Frequency of Down syndrome
1 in 1000 births worldwide
Why are we doing antenatal screening
Down syndrome-trisomy 21 Edwards syndrome (trisomy 18) Patau syndrome (trisomy 13) Neural tube defects(spinal cord defects)
What will these screening tests tell the patient
vs diagnostic test
Screening tests: These do not give you a definitive answer, but let you know if your baby is at increased risk of Down syndrome. Screening tests do not harm the mother or baby.
Diagnostics test: These are very accurate, giving you a definitive answer. Diagnostic tests are usually offered to women whose babies are at increased risk, based on the result of the screening tests. A diagnostic test can increase your risk of having a miscarriage, so they aren’t routinely offered to all women.
Second-trimester screening involves
The second trimester ‘quadruple test’ involves a different formula based on demographic information and the maternal serum levels of four markers; alpha-feto protein, human chorionic gonadotrophin, unconjugated estriol and inhibin
Doctor, I know my screening test are high risk can I not have the diagnostic test
You don’t have to undergo any tests if you don’t want to. If you have a screening test that shows your baby is at increased risk of Down syndrome, you don’t have to proceed to the diagnostic test.
There are 3 types of screening test for Down syndrome:
1) the combined first-trimester screening
2) the non-invasive prenatal testing (NIPT)
3) and second-trimester maternal serum screening.
What are prenatal screening tests? what are they looking for
chromosomal conditions (Down syndrome, and Patau syndrome) neural tube defects (spina bifida or anencephaly) birth defects (congenital heart or kidney conditions)
If it a down syndrome station, what questions must you ask the mother
Any known genetic conditions among close family members (refer to ‘Family history’).
History of intellectual disability (ID), multiple pregnancy loss, stillbirth, children with congenital abnormalities.
MUST ASK ABOUT INCEST–>
Consanguinity (‘Is there any chance that a relative of yours might be related to someone in your partner’s family?’).
Pre-pregnancy and pregnancy folic acid intake.
Information about carrier screening (ideally pre-conception or early in first trimester).
CFTS includes
Nuchal translucency
pregnancy-associated plasma protein-A (PAPP-A)
ß-subunit of human chorionic gonadotrophin (ß-hCG)
Trisomies 21, 18, 13; structural anomalies
Second-trimester screening includes
Estriol
beta-HCG
alphafetoprotein
inhibin A
Trisomies 21 and 18; neural tube defects
CFTS- when is the blood test and when is the USS for neck thickness to be done doc
• Screening blood–Free BhCG, Papp A
(after 10wk , 3-5 days before nuchal scan)
• Nuchal Translucency (11-13 +6)
INVASIVE DIAGNOSTIC TESTING is done should be given
** Anti-D for ALL RhD-ve women
Non-viable pregnancy diagnostic criteria (based on transvaginal USS)
- MSD ≥25mm but NO foetus present
2. Foetus with CRL ≥7mm but NO foetal heart movements (≥30 seconds)
5 MUST ask symptoms of ectopic
1) Amenorrhea
2) PV bleeding
3) Shoulder tip pain
4) Symptoms of pregnancy
5) Signs of shock–> syncope, dizziness and fatigue
Most common risk factors for ectopic
PID
What USS sign is seen with ectopics
Ring of fire/Tubal ring sign
What is the cut off for ectopics should you remember
> 2000 IU/L
Indications for anti-D before 1wk-12+6 GA
For women w/
1) Miscarriage
2) Termination of Pregnancy
3) Ectopic
4) Chorionic Villous Sampling
5) Molar Pregnancy
What are the indications for anti-D after 13 weeks
- CVS, Amniocentesis
- Abdo trauma,
- APH- revealed or concealed
- ECV,
- Miscarriage or Termination of pregnancy
Tenderness or acute abdomen, ‘woody’ feel of uterus -
Placental abruption
Which APH is concerning? why?
Placental abruption
DDX for placental abruption-4
PTL Placenta Praevia Chorioamnionitis Acute Appendicits Acute Pyelo UTI
The biggest maternal complication with Placental abruption
DIC
Maternal- DIC or renal failure, PPH,
Foetal – prematurity, foetal distress, low birth weight or stillbirth
Ruptured uterus, what is the clinical presentation
Tachycardia, signs of shock, sudden SOB,
- Constant abdo pain, shoulder tip pain, uterine/suprapubic tenderness
haematuria
- Frank haematuria, abnormal vaginal bleeding,
Indication for fetal fibronectin test
fFN number to be positive
Indication:
symptomatic women – 22+0 – 36+0 AND
intact membranes AND
≤3cm dilation of cervix
Contraindicated: dilated >3cm, +ve ROM, cervical cerclage +ve
fFN >50ng/ml +ve
4 management steps of PTL
1) Tocolysis
2) Antibiotics if indicated
3) Corticosteroids
4) MgSO4
Tell me the principles of corticosteroid use and PTL
- whats the dose
- when to use it
Indication: viable IUP in woman w/increased risk of PTB before 35+0 (bw 24-3%+0)
1st dose – betamethasone 11.4mg IM
2nd dose: betamethasone 11.4mg (24 hours after 1st dose or 12 hours if not enough time)
Tell me the principles of MgS04 use and PTL
- when to use it
- why?
MgSO4 – neuroprotection: Give shortly before birth (4-6 hours before delivery)
- 24+0 – 30+0 GA
PROM and PPROM, what would you like to know in the history about the discharge from the mother-5
Vaginal Loss
- amount
- colour
- consistency
- odour
- bleeding
- meconium
PROM management is based on
1) GA
2) Signs of Labour
3) Signs of Infection
4) Foetal lie/presentation
5) foetal wellbeing
6) GBS status
Outline the management for PROM
1) Routine Abs: Oral Erythromycin – 250mg QID for 10 days
2) Prematurity
- corticosteroids b/f 35+0
- MgS04 b/f 30+0
- Intrapartum Abx prophylaxis
3) 4 hourly: temp, foetal activity, uterine activity, vaginal discharge
4) Supportive cares – contact specialist, psychosocial support–> MDT, MDT, MDT
5) Advise patient re:
Risk of chord prolapse
Risk of infection – regular pad changes, shower not baths
** Tocolysis is patient-specific e.g. patient PPROM + contracting in the rural setting
What advice do you need to tell the patient been discharged after evaluation from PROM
Advise patient re:
Risk of chord prolapse
Risk of infection – regular pad changes, shower not bath
MDT involvement
Personal hygiene—change sanitary pad four hourly (or more frequently), wiping front to
back after toileting, showering in preference to baths
o Self-monitoring temperature daily and vaginal loss with each pad change
o Avoiding tampon use, vaginal creams/medications, vaginal intercourse, swimming/baths
o Attending all review appointments
How long do we need to give ABx for PPROM
Erythromycin 250 mg oral 6 hourly for 10 days
What is the difference between primary and secondary PPH
Primary PPH: within 24 hours of delivery
Secondary PPH: 24 hours to 6 weeks post-partum
PET what is it
Formerly called toxemia, preeclampsia
pre-eclamptic toxaemia
What drug is contraindicated in uterine atony in PPH
Ergometrine:
- Contraindicated for retained placenta
- PET
- severe/persistent sepsis
- renal, hepatic or cardiac disease
what can be given is: - IV oxytocin
- Can also give oxytocin/0.9% saline infusion
What are the complications of PPH-7
- Hypovolaemic Shock
- Renal Failure
- Hepatic failure
- DIC
- ARDS
- Sheehan Syndrome: post-partum hypopituitarism due to blood loss and shock-related necrosis
- Death
Tell me the difference between three main causes of vagintis/discharge
Trichomoniasis
Candidiasis
BV
Why BV screening so important
Increase risk of PTL and PROM
BV is not a STI so ask this in your PTL patient and also ask about GBS and stuff
A post-menopausal woman comes with an endometrial thickness of >5cm. What is the treatment algorithms
Pipelle—> D/C (blind biopsy)—> Hysteroscopy guided D/C(Definitive biopsy– cause it viewed)
Basically do for ongoing AUB or inadequate sample.
This is the step-up
What is the change of PCOS Rotterdam criteria in 2019
USG: >20 subscapular follicular cysts in each ovary
and/ or 10m3 in ovarian volume
This criterion is NOT RECOMMENDED in adolescents
6 MUST know contraindications for OCP
1) Gross obesity
2) Cerebrovascular disease
3) Any ischemic heart disease
4) Any liver disease
5) previous DVT–> thrombophilias
6) breast or gynaecological cancer
CST algorithm
CST–> HPV 16/18 detected–> colp
–> HPV 16/18 not detected but other strain detected–> Reflex cytology–> then if indicated colp
Colposcopy does either of the 2 treatment options
Ablation/excision
Biopsy–> follow up
Maternal short term risk of GDM
Preeclampsia Recurrent GDM Induced labour Increased risk of T2 diabetes Operative birth Cardiovascular disease Hydramnios Post-partum haemorrhage Infection
Maternal long term risk of GDM
Recurrent GDM
Increased risk of T2 diabetes
Cardiovascular disease
Neonates short term risk of GDM
Respiratory distress Jaundice Hypoglycaemia Premature birth Hypocalcaemia Polycythaemia Increased newborn weight and adiposity Macrosomia/associated risks
Neonatal long term risk of GDM
Impaired glucose tolerance
Type 2 diabetes
Obesity
GDM mothers should be registered under
NDSS
-diabetic educator
What are the indications for insulin therapy in GDM
- Hyperglycaemia above BGL targets
- Suboptimal BGLs with Metformin
- Maternal preference
- Metformin not tolerated
- Fetal macrosomia
Causes of pathological jaundice(Within the 1st 24 hours)- 3 causes
• Haemolysis–bruising, haemorrhage, isoimmunisation • Decreased conjugation of bilirubin– congenital hypothyroidism • Decreased excretion of bilirubin–biliary atresia, cystic fibrosis
Exchange transfusion why for jaundice baby
-what are the indications
Medical emergency–perform in NICU
Indications
• TSB continues to rise despite phototherapy
• Baby shows signs of acute bilirubin encephalopathy
4 risk factors for jaundice- what the neonatalologist said
1) sepsis
2) haemolysis
3) acidosis
4) asphyxia
The most common cause of glomerulonephritis in children
PSGN
due to GAS infection
