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MK SR INDEX CASES REPRODUCTIVE CARE > Normal Pregnancy > Flashcards

Normal Pregnancy Flashcards

1
Q

What constitute Low Risk Midwifery led care during pregnancy?

A
  • Booking appointment – before 12+6 weeks gestation
  • Dating Scan – 12 weeks gestation
  • 16 week appointment
  • 20 week gestation – anomaly scan
  • 25 week gestation – nulliparous
  • 28 week gestation – start fundal height measurement
  • 31 week gestation
  • 34 week gestation
  • 36 week gestation
  • 38 week gestation
  • 40 week gestation – primips only – offer membrane sweep
  • 41 week gestation – offer membrane sweep and consider planning induction of labour
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2
Q

Antenatal growth scans - how are scans differentiated from fundal height measurements?

A

X fundal height measurement

o scan measurement

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3
Q

High Risk ANC pathway: Maternal characteristics

A 
BMI > 30 kg/m2
BMI<18 KG/m2
Smoking
Age> 40
Teenage mothers
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4
Q

High Risk ANC pathway: Past medical History

A
  • Cardiac disease
  • Renal Disease
  • Endocrine disease, Diabetes
  • HIV
  • Hematological disease
  • Autoimmune disorders
  • Epilepsy requiring treatment
  • Severe asthma
  • Recreational drugs
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5
Q

High Risk ANC pathway: Obstetrics Issues

A
  • Recurrent miscarriage
  • Preterm birth
  • Eclampsia, preeclampsia
  • HELLP
  • RH isoimmunization
  • Significant blood group antibodies
  • APH, PPH on 2 occasions
  • > 6 pregnancies
  • Stillbirth/neonatal death
  • SGA < 5TH centile
  • LFGA < 5 th centile
  • Birth weight <2.5 kg,>4.5 kg
  • Fetal congenital anomaly: structural, chromosomes
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6
Q

widest diameter of pelvis

A

inlet - transverse is widest

outlet - anterior posterior is widest

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7
Q

Shape of fontanelles on infant

A
  • Anterior fontanelle-bregma (diamond)
  • Posterior fontanelle- Occiput (triangle)
  • Area between the two- vertex
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8
Q

Mechanical Factors of labour- 3 Ps

A
  • Power ( force expelling fetus: uterine contractions)

* Passage : Pelvic dimensions, Soft tissue resistance • Passenger ( diameters of fetal head)

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9
Q

Important factors on Power in mechanism of labour

A
  • In established labour contraction for 45-60 seonds every 2-4 minutes.
  • This leads to cervical effacement and dilatation aided by pressure of head
  • Poor contractions common in nulliparous and induced labours but rare in multiparous.
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10
Q

Mechanism of labour: Passage Bony pelvis

A

3 planes
• Inlet: Transverse 13cm wider that AP 11 cm
• Mid-cavity: Round ( Transverse and AP similar)
• Outlet : AP AP 12.5 > Transverse 11 cm
• Ischial spine is the palpable landmark to assess descent
• Station 0 : Head at level of spines.

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11
Q

Mechanism of labour: Passage: Soft tissue

A
  • Cervix: Dilatation depends on contractions, Pressure of fetal head on cervix
  • Vagina ( tear, episiotomy)
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12
Q

Mechanism of labour steps

A

Engagement – Head enters the pelvis in occipito transverse postion

Descent of flexed head

at ischael spines internal rotation to AP

delivery by extension of head

shoulders turn to AP

Restitution - Head rotates back to 90 degrees to the same position in which it entered the inlet to enable delivery of shoulders

delivery by lateral flexion

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13
Q

Mechanism of labour: Passenger factors

A
  • Presentation: Cephalic/Breech ( part of the fetus that occupies the lower segment)
  • Presenting part: Lowest part of fetus palpable on vaginal examination
  • Attitude of head describes the degree of flexion- vertex/brow/face
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14
Q

Fetal skull - what is Atitude of fetus

A

Attitude is degree of flexion of the head on the neck.

Maximum flextion- vertex presentation

  • Vertex: Presenting diameter 9.5 cm
  • Brow: 90 degree extension Presenting diameter 13 CM • Face: further 30 degree extension
  • Extension makes the fetal presenting diameter larger
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15
Q

Movements of the head in labour

A
  • Engagement ( head enters pelvis) in occipito-transverse as it is oblong and transverse diameter of pelvis is longer
  • Descentandflexion
  • Internal Rotation 90 degrees to occipito-anterior OA
  • Descent
  • Extension to deliver
  • Restitution and delivery of shoulders
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16
Q

Signs of placental separation

A

gush fresh blood

cord lengthening

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17
Q

First stage of labour

A

Average 8 hours nulliparous, 5hours multiparous Latent ,4m, active 4-10 cm
Cervix dilates
Head remains flexed during descent
90 degree rotation from OT to OA

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18
Q

Second stage of labour

A

Contractions continue, Full dilatation to delivery Head descends, flexes and rotation completed
Pushing starts when head reaches levator ani (active second stage)

Delivery: Head extends as it delivers over the perineum
Head restitutes, rotating back to transverse before shoulders deliver.

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19
Q

Third stage of labour

A

average 15 minutes, Placenta delivered by controlled cord traction to prevent uterine inversion

Physiological management or 
Active management (to reduce blood loss in women at risk of PPH - overstretched uterus such as twins, polyhydramnos)
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20
Q

How long is postnatal period?

A

up to 6 weeks

still at risk of DVT, PE, eclampsia, infection

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21
Q

Lochia

A

discharge from the uterus may be blood stained for 4

weeks later on it is yellow or white

22
Q

Cardiovascular changes in puerperium

A
  • BP usually normal in 6 weeks

* Cardiac output and plasma volume returns prepregnant level with in a week

23
Q

Postnatal review history

A
  • Privacy
  • Mother and baby should be together
  • Early mobilization
  • Check blood loss
  • Pain
  • Bladder –passing urine
  • Bowel – opened or not
  • Lochia
  • Diet
  • Mobility
  • Breast feeding/bottle feeding/both
  • Mood-normal/low/elevated
  • Postnatal debrief about delivery events
  • Fasting blood sugar in 6 weeks for gestational diabetics
24
Q

Postnatal review-examination

A
  • Vitals
  • Abdominal palpation- uterus
  • Examine calves-DVT
  • Episiotomy /caesarean scar
  • Risk score all women according to RCOG guidelines for risk for DVT and start appropriate prophylactic treatment
  • Breast for mastitis
  • Chest/throat
  • Uterine tenderness
  • LSCS wound
  • Look for signs of DVT • Dip urine
  • Take vaginal swab
  • Lochia-foul smelling • Perineal wound
25
Q

Postnatal Advise

A
  • Contraception advise • Perineal care
  • Pelvic floor exercises Post
LSCS-
• Wound care
• No heavy lifting for 6 weeks
• Future pregnancies-VBAC
• Driving as per insurer terms
• Delay pregnancy for at least 12months
26
Q

Postnatal review: Women with third/forth degree perineal tears

A
  • Perineal care/hygiene
  • Laxatives
  • Antibiotics
  • Analgesia
  • Review in 6 weeks
27
Q

Colostrum

A

yellow fluid containing fat laden cells, proteins including immunoglobulin A and minerals – passed first 3 days

28
Q

Advantages of breast feeding

A
  • Protection against infection
  • Bonding
  • Protect mother against cancer
  • Cost saving
  • Combined pills supress lactation/ hence progesterone only pill is safer
29
Q

Lactation is dependent on which hormones?

A
  • Prolactin from anterior pituitary stimulates milk secretion
  • Oxytocin from posterior pituitary stimulates ejection in response to suckling
30
Q

Approach to Postpartum pyrexia

A
  • Maternal fever ≥38°C in the first 14 days • Genital tract sepsis
  • Group A streptococcus, Staphylococcus, E. Coli. • Urinary tract infection (10%)
  • Chest infection/pharyngitis
  • Infection at IV (intravenous) sites
  • Mastitis
  • Perineal infection
  • Wound infection after LSCS
  • Infection of epidural site
  • Deep Vein thrombosis –low grade pyrexia
31
Q

Definition of Postpartum pyrexia

A

Maternal fever ≥38°C in the first 14 days

32
Q

Postnatal Red flag’ signs and symptoms

A
  • pyrexia more than 38°C
  • sustained tachycardia more than 90 beats/minute
  • breathlessness (respiratory rate more than 20 breaths/minute; a serious symptom)
  • abdominal or chest pain
  • diarrhoea and/or vomiting
  • uterine or renal angle pain and tenderness
  • woman is generally unwell or seems unduly anxious or distressed.
33
Q

Common organisms –puerperal sepsis

A
  • GAS, also known as - Group A Streptococcus pyogenes • Escherichia coli
  • Staphylococcus aureus
  • Streptococcus pneumoniae
  • methicillin-resistant S. aureus(MRSA), • Clostridium septicum
  • Morganella morganii
34
Q

Managing Hypotension Bacterial Sepsis following Pregnancy

A
  • In the event of hypotension and/or a serum lactate greater than 4 mmol/l: Deliver an initial minimum 20 ml/kg of crystalloid
  • Apply vasopressors for hypotension In the event of persistent hypotension despite fluid resuscitation (septic shock) and/or serum lactate greater than 4 mmol/l:
  • Achieve a central venous pressure of ≥8 mmHg
35
Q

Antibiotics for Bacterial Sepsis following Pregnancy

A
  • Co-amoxiclav
  • Metronidazole
  • Gentamycin
  • Clindamycin
  • Tazocin (Piperacillin/Tazobactam)
  • Discuss with microbiology consultant on call about treatment
36
Q

Postnatal Psychiatric problems

A
  • Postnatal blues -50%- need support and reassurance
  • Postnatal depression affects -10% of women
  • Puerperal psychosis- 0.2% of women, around 4th day
37
Q

Postnatal Urinary problems

A

Retention of urine- is common after delivery
• Bladder scan to check for residual urine
• Cather for 24 hrs
Urinary infection in 10%
Incontinence in 20% women
Usually improve with pelvic floor exercise
Vaginal haematoma –severe pain and needs drainage under general anaesthesia
Constipation in 20% women Incontinence of faeces in 4% , transient

38
Q

what is the NIPT test?

A

Maternal Blood test
• Diagnostic test: NIPT -free fetal DNA 99% accurate Results take > 1 week & expensive , not routine now
• NIPT used as near 100% sensitivity • Positive NIPT-needs invasive testing
Free fetal DNA

39
Q

outline Ultrasound as a diagnostic test in pregnancy

A
  • Anomaly scan ~ 20 weeks
  • 25% identified earlier
  • Cardiac – may remain undiagnosed even at 20 weeks • Some develop later gestation
40
Q

Outline Amniocentesis

A
  • Removal of amniotic fluid using fine gauge ultrasound needle under US guidance
  • Performed after 15 weeks
  • Used of chromosomal abnormalities, infections(CMV, Toxo)
  • Inherited disorders(Sickle cell, thallasemia & CF)
  • 1% chance of miscarriage
41
Q

Outline Chorionic villus sampling

A
  • Biopsy of trophoblast by fine needle through cervix or abdomen from 11 weeks
  • Higher risk of miscarriage
  • Earlier identification of abnormalities • Can offer TOP
42
Q

How are samples from amnio and CV sampling tested?

A

• FISH(Fluorescence insitu hybridization) & PCR –result <48 hrs • Karyotyping-inspection of chromosomes by looking through
microscope
• Microarray-CGH-Comparative genomic hybridization techniques-closer or magnified inspection of chromosomes- smaller deletions or abnormalities

43
Q

What is PGD (Pre-implantation genetic diagnosis)?

A
  • Requires IVF
  • Selection before implantation
  • Expensive
  • Ethical dilemmas
  • Used in X linked ,trisomies & AD /AR conditions
44
Q

What is Down syndrome due to?

A
  • Trisomy 21

* Most common Non disjunction or balanced translocation(6%) • Features: mental handicap, facies, 50% cardiac disease

45
Q

Risk factors for Down syndrome

A
  • Maternal age
  • Previous affected baby
  • Balanced parental translocation
  • Thick NT
  • Structural abnormalities
  • Absent or short nasal bone#
  • Tricuspid regurgitation
  • Severe FGR
  • Low PAPP-A, High HcG, Low AFP, low estriol ,high inhibin
46
Q

Screening for chromosomal abnormalities

A
  • All pregnant women offered
  • DS 75% sensitivity , 3% False positive
  • 1 in < 150 high risk
  • NIPT 1 in <1000
  • Combined test: Maternal age , NT ,PAPPa & hcG
  • Performance enhanced by presence or absence of nasal bone & TR
47
Q

What is the rate of Structural abnormalities-CNS screened for in pregnancy?

A
  • 1 in 200 pregnancies
  • Spina bifida , anencephaly, ventriculomegaly
  • Preconception folic acid 400mcg reduces NTD risk • Recurrence in 1 inn 10 pregnancies
  • Higher dose 5mg reduces recurrence
48
Q

What risk factors are there for fatal Cardiac defects

A

• 1% pregnancies
Cardiac defects
• Common in maternal diabetes, congenital cardiac defects, on antiepileptic drugs ,previous offspring affected 3%,other chromosomal defects & structural abnormalities
• 50% can be associated with high NT
• Less than 1/3 diagnosed prenatally
• Most are non lethal/Correctable after birth
• Arrthymias can be treated in-utero –Flecainide /Digoxin

49
Q

List types of chest defects screened for in pregnancy

A
  • Diaphragmatic hernia- herniation of abdominal contents into chest-60% with isolated defects survive
  • In-utero tracheal occlusion FETO
  • Pleural effusions-in-utero shunting useful
  • Congenitalcysticadenomatousmalformation(CCAM)-many regress and prognosis usually good
50
Q

What sign is there to indicate Gastrointestinal defects of the foetus?

A

• Oesophageal atresia & Tracheo-oesophageal fistula: • Polyhydramnios present, stomach small

51
Q

What condition is the ‘double bubble’ sign on ct a sign of?

A

Duodenal atresia

• Classic “double bubble” sign , dilated upper duodenum- associated with Down syndrome

52
Q

What test results would be expected in a trisomy 21 (Down’s syndrome) pregnancy?

A

Low alpha fetoprotein (AFP)
Low oestriol
High human chorionic gonadotrophin beta-subunit (-HCG)
Low pregnancy-associated plasma protein A (PAPP-A)
Thickened nuchal translucency

MK SR INDEX CASES REPRODUCTIVE CARE (23 decks)

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