O Flashcards
Antenatal care
Ask in your history if their doctor has given them EXTRA folic acid to
demonstrate your knowledge of high risk NTD pregnancies.
• Check BMI, BP, risk factors for gestational diabetes and pre-eclampsia,
explore domestic violence risk, FGM and previous mental health Hx.
• At every appointment, you do: BP, BMI, Urine dip
PPROM
Risk Factors: smokers, STI, previous P-PROM, multiple pregnancy
• Explain need for admission
• Explain the risks of P-PROM (infection which can cause damage to the baby)
• Explain the risks of prematurity (and that you’d ideally like to keep the baby inside for as
long as possible, but this has to be balanced with the infection risk)
• Explain the importance of close monitoring (CTG, maternal observations)
• Explain the role of antenatal steroids
• Discuss the likelihood of delivery
Breech
PACES TIPS
• Risk Factors: uterine malformations, fibroids, placenta praevia, poly/oligohydramnios,
foetal anomaly (CNS malformations, chromosomal disorders), prematurity
• Explain what breech means
• Offer ECV and explain the risks (50% success rate, placental abruption, foetal distress
requiring an emergency C-section)
• Explain the benefits and risks of vaginal breech and C-section
o Vaginal: if successful, has the fewest complications, however, 40% risk of needing
an emergency C-section
o C-section: small reduction in perinatal mortality, implications on future pregnancy
(placenta praevia, VBAC, uterine rupture)
VBAC
Discuss options: elective repeat C-section (ERCS) or attempted vaginal birth after Csection (VBAC)
• Explain the risks of VBAC (uterine rupture risk of 1 in 200, success rate 70-75% remainder
require emergency CS)
• Explain the risks of ERCS (implications for future pregnancies
HIV in pregnancy
• Explain the need to be seen at a joint HIV physician and obstetric clinic every 1-2 weeks
• Explain the need to monitor viral load every 2-4 weeks, at 36 weeks and at delivery
• Stress the importance of good compliance with ART
• Discuss options for delivery (depending on viral load at 36 weeks gestation)
• Advise not to breastfeed
• Explain neonatal treatment with ART for 2-4 weeks and testing to confirm / deny HIV
transmission
Hepatitis B
• Antenatal
o Refer to hepatologist
pre-eclampsia
Risk Factors: previous hypertensive disease in pregnancy, multiple pregnancy, diabetes
mellitus, kidney disease, first pregnancy, obesity, over 35 or under 20 years, family history,
PCOS, IVF
• Adapt the counselling based on severity
• Explain that admission is needed (at least until BP can be controlled)
• Explain pre-eclampsia and the risks (early delivery, reduced placental function, IUGR, risks
to mother)
o Epidemiology: 2-3% of pregnancies
• Explain treatment (labetalol/nifedipine)
• Explain that BP will be monitored closely with regular blood tests (2/week) and foetal
surveillance (every 2 weeks)
• Explain that early delivery before 37 weeks may be necessary
• Risk of Recurrence: ~15%
• Note: risk of future CVS disease if a women has hypertension in current or previous
pregnancy (major adverse events, stroke, hypertension)
Gestational diabetes
• Risk Factors: age, FH of PMH, obesity, multiple pregnancy, Asian background
• Explain the diagnosis (diabetes that occurs in pregnancy because the body isn’t able to
produce enough insulin to meet the demands of carrying a baby)
• Estimated prevalence: 2-3%
• Explain the risks (MATERNAL: hypertensive disease, traumatic delivery, stillbirth; FOETAL:
macrosomia, neonatal hypoglycaemia, congenital abnormalities)
• Treatment options (diet/exercise, metformin, insulin) and the importance of good glycaemic
control
• Explain how to monitor blood glucose (using glucometer)
• Need to be seen at a joint diabetes and antenatal clinic within 1 week (and every 2 weeks
thereafter)
• Need to have ultrasound growth scans every 4 weeks from 28-36 weeks
• Explain that medication will be stopped after delivery but that they will be followed up to
check if glucose problem continue
obstetric cholestasis
Risk Factors: personal or family history of OC, history of liver disease, multiple pregnancy
• Explain diagnosis and risks (stillbirth and premature birth)
• Explain need for early delivery (37 weeks)
• Explain regular monitoring with weekly LFTs
• Advise paying close attention to foetal movements
• Symptomatic treatment with ursodeoxycholic acid and emollients (and maybe vitamin K)
• High recurrence rate (up to 90%)
Placenta Praevia
Risk Factors: previous placenta praevia, multiple pregnancy, previous C-section, smoking
and drug use, advanced maternal age
• Presenting with Asymptomatic Low-Lying / Placenta Praevia
o Explain the importance of the finding (increases risk of bleeding)
o Explain that 90% of placentas will move away from the os
o Rescan at 32 weeks and then go from there
o Advise to avoid having sex
• Presenting with Symptomatic Placenta Praevia (with bleeding)
o Admit until bleeding has stopped and for a further 48 hours
o Explain the importance of the finding and that the foetus needs to be monitored
o Explain that prompt delivery needs to be discussed (based on gestation)
o Explain the risks of delivery:
Major blood loss
May require a blood transfusion
May require a hysterectomy
DR C BRAVADO
DR – Define Risk
C – Contractions – frequency and regularity
BRA – Baseline Rate – calculated as the average heart rate over a period of 5-10mins (normal =
100 – 160 bpm)
• Tachycardia = maternal pyrexia, foetal infection, prematurity, foetal hypoxia, exogenous βagonists (e.g. salbutamol)
• Bradycardia = hypotension, maternal sedation, postmaturity, hypoxia, foetal distress due to placental abruption or uterine rupture
V – Variability – calculated as the heart rate variability over a period of 5-10mins, excluding decelerations and accelerations (normal = >5 bpm)
• Reduced variability = foetal sleep cycle (usually lasts <45 minutes preceded and followed by normal CTG trace), early gestation, drugs (e.g. opiates, BDZ), foetal hypoxia, foetal infection
A – Accelerations – defined as a rise from baseline heart rate of at least 15bpm lasting at least
15 seconds (normal = >2 accelerations on a 20-30mins CTG trace)
• Absent accelerations = foetal hypoxia
D – Decelerations – defined as a fall from baseline heart rate of at least 15bpm lasting at least
15 seconds (normal = no decelerations)
• Decelerations present = foetal hypoxia, umbilical cord compression
• 3 types of decelerations:
o Early – when deceleration occurs during a uterine contraction
Usually benign (uniform in depth, length and shape), due to a normal response
to head compression during labour 35
o Variable – where the time and shape of decelerations varies in relation to uterine
contraction Classically reflect cord compression
o Late – when decelerations occur during contractions and persist after the end of the contraction
Always abnormal, suggestive of foetal hypoxia.
O – Overall – each feature can be described as ‘reassuring’, ‘non-reassuring’ or ‘abnormal’
- define the CTG overall as: normal, suspicious or abnormal
reassuring CTG
BR: 110-160 Variability: 5-25 Decels: None or only early decelerations Variable decelerations with no concerning features occurring for <90mins
non-reassuring CTG
BR:
100-109
161-180
Variability: <5 for 30-
50mins
>25 for 15-
25mins
Decels:
Variable decelerations with no concerning
features occurring for >90mins
Variable decelerations with any concerning
features occurring in <50% of contractions for
>30mins
Variable decelerations with any concerning
features occurring in >50% of contractions for
<30mins
Late decelerations occurring for <30mins
Abnormal CTG
BR: <100 >180 Variability: <5 for >50mins >25 for >25mins Sinusoidal Decels: Variable decelerations with any concerning features occurring in >50% of contractions for >30mins Late decelerations occurring for >30mins Acute bradycardia Single prolonged deceleration lasting >3mins
