O&G Flashcards
A 30 year old woman in the third trimester of her first pregnancy develops an itchy, bumpy rash on her abdomen, with sparing of the periumbilical area. She is usually fit and well and has had an uneventful pregnancy so far. What is the most likely diagnosis?
Polymorphic eruption of pregnancy
Management of chickenpox exposure in pregnancy
If the pregnant woman <= 20 weeks gestation is not immune to varicella she should be given varicella-zoster immunoglobulin (VZIG) as soon as possible
If the pregnant woman > 20 weeks gestation is not immune to varicella then either VZIG or antivirals (aciclovir or valaciclovir) should be given days 7 to 14 after exposure
IVF pregnancies carry an increased risk of what affecting the placenta?
Placenta prevaia
6x higher risk
Gestational diabetes can be diagnosed by either a:
fasting glucose is >= 5.6 mmol/L, or
2-hour glucose level of >= 7.8 mmol/L
‘5678’
Risk factors of placental abruption
A for Abruption previously;
B for Blood pressure (i.e. hypertension or pre-eclampsia);
R for Ruptured membranes, either premature or prolonged;
U for Uterine injury (i.e. trauma to the abdomen);
P for Polyhydramnios;
T for Twins or multiple gestation;
I for Infection in the uterus, especially chorioamnionitis;
O for Older age (i.e. aged over 35 years old);
N for Narcotic use (i.e. cocaine and amphetamines, as well as smoking)
If ruptures may cause pseudomyxoma peritonei
mucinous cystadenoma - accumulation of mucinous material in the intraperitoneal space
If a semen sample is abnormal, a repeat test should be arranged when?
3 months
SSRIs of choice in breastfeeding women
Sertraline of paroxetine
What antibiotics should be given to all women with PPROM? (and how for how long)
10 days of oral erythromycin
Can mothers known to be HIV positive breast feed?
No!
All mothers known to be HIV positive, regardless of antiretroviral therapy, and infant PEP,
should be advised to exclusively formula feed from birth.
Ovarian cyst with intrauterine pregnancy. What do you do?
Reassure and leave the cyst alone.
In early pregnancy, ovarian cysts are usually physiological - known as a corpus luteum. They will usually resolve from the second trimester on wards.
Woman with GDM list the order of interventions and for how long.
2 weeks lifestyle modification
2 weeks of metformin
Finally: Short acting insulin - better post-prandial glucose control and is more flexible in terms of responding to the different day-to-day diets of a pregnant woman.
What can be used for facial hirsutism in PCOS?
topical eflornithine
What is the upper limit for the termination of a pregnancy?
24 weeks gestation
Hysterectomy how long is hospital stay and how long to stay off work?
1-4 days
6-8 weeks
What is the follow up to LLETZ?
6 months smear + HPV test
If normal back to 3 year follow up
Colposcopy for anything else (HPV positive)
What do the T and lambda sign show on USS?
T sign = MCDA
Lambda sign = DCDA
Woman gets headache 24hrs after delivery, elective cesarean, worse on sitting up and better lying down.
Post-dural tap headache
- Woman who has just given birth to 2 day old baby. Her 2 year old son gets chicken pox, women has antibodies. Goes to GP, what should be done?
Varicella zoster immunoglobulin to the baby
For the treatment of fibroids when can IUS be used as first line?
Uterine fibroid <3 cm
Not distorting the uterine cavity
Which is the best way to confirm ovulation?
Measure the progesterone level 7 days prior to expected next period = the time when it peaks. E.g day 21 progesterone
If your progesterone level is elevated within a certain range during the luteal phase, it likely means you are ovulating. If your progesterone level is not elevated, it can mean that you’re not ovulating.
> 30nmol/L
Useful in the investigation of infertility
What is the step wise approach to the management of overactive bladder?
Bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)
Bladder stabilising drugs: antimuscarinics are first-line
NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation)
Immediate release oxybutynin should, however, be avoided in ‘frail older women’. Mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patien
When can an IUD be fitted?
Anytime
It can also be fitted immediately after first or second-trimester abortion, and from 4 weeks postpartum
Pregnant woman exposed to chicken pox. What is the management?
Check for varicella IgG antibodies
<= 20 weeks gestation is not immune = varicella-zoster immunoglobulin (VZIG) ASAP
> 20 weeks gestation is not immune = VZIG or antivirals (aciclovir or valaciclovir) given days 7 to 14 after exposure
Combined oral contraceptive pill: 1 missed pill
If 1 pill is missed at any time in the cycle
Take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day
no additional contraceptive protection needed
Combined oral contraceptive pill: 2 or more missed pill
Week 1
Take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day
Use condoms or abstain from sex until she has taken pills for 7 days in a row
Emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1
Combined oral contraceptive pill: 2 or more missed pill
Week 2
Take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day
Use condoms or abstain from sex until she has taken pills for 7 days in a row
If pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception*
Combined oral contraceptive pill: 2 or more missed pill
Week 3
Take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day
Use condoms or abstain from sex until she has taken pills for 7 days in a row
if pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval
Woman pregnant receives an invitation for a cervical smear. What should be done?
Delay smear until 3 months post-partum
Woman on COCP presents with migraines with aura. How should you manage her?
Stop COCP and start POP
Women who have migraine with aura should stop the pill immediately - this is because the oestrogen component of the COCP can increase the risk of the women having an ischaemic stroke.
When should lochia be investigated?
If lochia persists beyond 6 weeks investigate with ultrasound scan
Woman with a little bit of pink post-coital bleeding on wiping. Smear is fine, ultrasound is clear. What is the next investigation?
Hysteroscopy with Biopsy
Lady who had a tear after delivering baby, a few days later has offensive discharge, no fever or other symptoms
Perineal wound breakdown/infection
What is the follow up for patients who have previously been treated for CIN?
CIN1, CIN2, or CIN3: 6 months after treatment test of cure with repeat cervical sample in the community
Dyskaryosis on colposcopy and biopsy showing CIN1 - no treatment. What is the management?
Repeat colposcopy and smear in 6 months
How is a endometrial biopsy performed? What are the indications for biopsy?
Pipelle biopsy
pre menopause = >10mm
post menopause = >4mm
What is the most common side effect of implantable contraceptives?
Irregular heavy bleeding
e.g nexplanon
What cancer are you at increased risk at with HRT?
depends on whether it is combined or oestrogen only:
‘oestrogen only’ increases risk of endometrial and breast cancer but mostly endometrial
‘combined’ increases risk of breast cancer = progesterone
How do you manage preterm premature rupture of membrane (PPROM)?
< 24 weeks: abortion
24-34 weeks: admit for 48 hours, steroids and abx (erythromycin)
> 34 weeks: steroids and abx and deliver
Signs of infection: deliver
What is the medical management for patients with PPH?
Syntocinon/oxytocin 40 units IV
Ergometrine IM *
Carboprost / Haemabate IM **
Misoprostol PR
tranexamic acid
- don’t give if worried about BP problems (eclampsia)
** don’t give to asthmatics; can cause exacerbation
misoprostol can cause diarrhoea
Foreign woman has come in and is pregnant. What vaccine should she be offered?
Pertussis (whooping cough)
HRT question for a menopausal woman with flushes, last period 10m ago. What do you give her?
Cyclical HRT
What’s the management for DVT risk in a pregnant woman after an elective Caesarean?
LMWH and Ted stockings
smear question she is 47 y/o. It was borderline dyskaryosis, HPV negative, what do you do?
Discharge to routine 3 years
Heavy periods in a girl not yet sexually active. What do you give her?
Tranexamic acid
*better than mefenamic acid in terms of reduction in menstrual blood loss
Woman with high BMI (28) who basically had stress incontinence. What’s the first line management?
pelvic floor exercises
weight loss only if BMI >30
Man with azoospermia – what is the most likely cause?
varcicocele
Woman who is exclusively breastfeeding for 6 weeks and wants contraception
LAM up to 6 months
What is Naegele’s rule?
Add 7 days subtract 3 months
What are the indications of a forceps delivery?
fetal distress in the second stage of labour
maternal distress in the second stage of labour
failure to progress in the second stage of labour
control of head in breech deliver
What is the treatment of PID?
intramuscular ceftriaxone + oral doxycycline + oral metronidazole
Bloating, raised CA125, next step?
pelvic USS
Smoker, which extra tests does she require in pregnancy
Serial growth scans
What signifies onset of active/ established labour?
Cervix reaches 4cm dilated
Amenorrhoea for 4 months – what is the best initial investigation?
check for pregnancy
Woman with signs of premature ovarian failure. What test would be best to confirm this diagnosis
FSH
Effect of taking Paroxetine during pregnancy on baby?
In first trimester: small risk of congenital heart defects. In third trimester: risk of persistent pulmonary hypertension of the newborn
Woman has pain before periods and has been subfertile, cyst found on ovary with a ground glass appearance on USS
Endometrioma
What is the treatment of a haemodynamically stable woman with placental abruption with no evidence of fetal distress?
> 37 weeks = induction of labour
<37 weeks = iv corticosteroids and admit for observation
HNPCC/Lynch syndrome is a strong risk factor for:
endometrial cancer
Nonpregnant women >18 with FGM what do you do?
No requirement to report to police unless a related child is at risk.
1) Offer surgical reversal - deinfibulation
2) Psychosexual counselling
45F. Wertheim’s hysterectomy. Last cervical smear 2 years ago. When next smear?
No more smears required = they remove the cervix
Lambda sign on USS. When do you deliver?
DCDA = 37 weeks
T sign on USS. When do you deliver?
MCDA = 36 weeks + course of steroids before
Describe the monitoring of mono/dichorionic twins?
Monochorionic twins: scan at 12, 16 and every 2 weeks until delivery
Dichorionic twins: scan at 12, 20 and every 4 weeks until delivery
Woman in stage 2 of labour, pushing for 30 minutes, head pressing against perineum, when CTG becomes pathological - what do you do next?
forceps delivery
Woman with fever, deep dyspareunia = PID
What is the treatment?
Fever therefore inpatient treatment
IV antibiotics = IV cefoxitin + IV doxycycline
When is anti-D given in rhesus negative mothers?
28, 34 weeks, delivery
at any sensitising event do a Kleihauer-Betke test
How many hours to fast before cesarean section?
6 hours
Baby born at term by c-section has RR of 170 at 4 hours. Uncomplicated pregnancy. Likely dx?
Transient tachypnoea of the Newborn
Girl was recently ill, now has a petechiael rash, low platelets, everything else normal.
ITP - self limiting
can use corticosteroids and IVIG
Rh negative, minor bleed at 9 weeks, resolves in 48 hours. What do you do?
Do nothing - don’t need to do anything cause less than 12 weeks.
Lady with ectopic wants to know how long after methotrexate tx you can/should wait to get pregnant?
6 months
Woman with low lying placenta on 20w scan, which has moved up but succenturiate lobe seen, what dx must you exclude?
Vasa praevia
multilobed placenta - the fetal blood vessels can run over the internal cervical os
Woman had a dating scan at 12 weeks, foetal CRL equivalent to 9 weeks foetus but no heart beat. Mx?
Rescan in 1 week
You have to rescan unless a second person confirms miscarriage
Preg woman at like 32w, OGTT at 28w was normal but now had glycosuria twice in preg, foetal parts difficult to palpate what would you do?
75g OGTT
Hyperemesis 1st hasn’t worked what do you do next?
prochlorpermazine
1st line: promethazine and cyclizine
- Pregnant woman has dysuria, frequency and urgency. Otherwise well. Mx plan?
send urine for MC&S and treat empirically with abx
- Woman with excessive vomiting, 10 weeks pregnant and BP 180/110 mmHg. Fundal height consistent with 16-week pregnancy. Dx?
Molar pregnancy - excessive uterine size for pregnancy
After a stillbirth, a woman is distressed, what drug would you give to stop breast milk production?
cabergoline
GDM:
1 hour post prandial
2 hour post prandial
Fasting
- 8
- 4
- 3
Please talk me systematically through the causes of oligomenorrhea
Hypothalamic - HH, hypothalamic lesion, Kallman’s
Pituitary - Prolactinoma, Sheehan’s
Ovarian - PCOS, POF, ovarian cyst
Uterine - fibroids, Asherman’s syndrome
Congenital - uterine malformation, imperforate hymen, chromosomal abnormality (Turner’s)
Physiological - pregnancy
Iatrogenic - progestogens, HRT, dopamine antagonists, mirena
PCOS criteria
Oligo/anovulation (> 2 years)
Clinical or biochemical features of hyperandrogenism
Polycystic ovaries on ultrasound (> 12 in one ovary measuring 2-9 mm in diameter)
What are the mechanisms of action for all forms of emergency contraception?
Copper Coil = Spermicide and prevents implantation
Levonorgestrel = Stops ovulations and inhibits implantation
Ulipristal = Progesterone receptor modulator – inhibits ovulation
Note: Levonorgestrel dose must be doubled in women over 70kg. Go for ulipristal instead.
When should contractions start after rupture of membranes?
within 24 hours
if not induction will be used
What do you understand by the term “endometriosis”?
Endometriosis is the presence and growth of tissue similar to the endometrium outside of the uterus. Most often, this growth occurs on the ovaries, fallopian tubes and organs around the uterus and ovaries. In rare cases it may occur in other parts of the body. May occur in 1-20% of all women (albeit asymptomatic in most). It is more common in nulliparous women.
What is the aetiology of endometriosis?
Poorly understood. Thought to be the result of retrograde menstruation. More distant foci may result from mechanical, lymphatic or blood-borne spread.
What are the typical symptoms of endometriosis?
Pelvic pain (can be frequent, chronic and severe)
Dysmenorrhoea affecting daily activities and quality of life
Deep dyspareunia or post coital pelvic pain
Cyclical GI sypmtoms e.g. dyschezia (painful defacation)
Cyclical urinary symptoms e.g. haematuria/dysuria
Infertility in association with any of the above
What would you expect to see on laparoscopy of endometriosis?
Active lesions are red vesicles or punctate marks on the peritoneum. White scars or brown spots (“powder burn”) represent less active endometriosis. Extensive adhesions and ovarian endometrioses (endometriosis cysts) indicate severe disease.
What is the prognosis of endometriosis?
Disease usually recurs after cessation of medical treatment
What are the differential diagnoses for endometriosis?
Endometriosis Adenomyosis Chronic pelvic inflammatory disease Chronic pelvic pain Cervical malignancy
What is the treatment of endometriosis?
Medical treatment of minimal and mild endometriosis diagnosed as the cause of infertility in women does not enhance fertility and should not be offered.
(Analgesia, Combined oral contraceptives (first line), Progestogens, GnRH +/- HRT, IUS)
Surgical
- Women with minimal or mild endometriosis who undergo laparoscopy (diagnosis) should be offered surgical ablation or resection of endometriosis plus laparoscopic adhesiolysis because this improves the chance of pregnancy.
- Women with ovarian endometriomas should be offered laparoscopic cystectomy because this improves the chance of pregnancy.
- With severe disease affecting the fallopian tubes, surgery may have limited benefit and IVF will be the best option.
How can endometriosis affect fertility?
Tubal adhesions Reduced ovarian reserve Fallopian tube dysfunction Poor implantation Dyspareunia may reduce the frequency of intercourse
Counsel a women with epilepsy on their antenatal care
EPILEPSY
Arrange an appointment with your neurologist to discuss medicines as this should be a specialist decision
Probable that he/she will switch you from sodium valproate to another medication. Sodium valproate is associated with a much higher chance of problems with development of the baby and so it is recommended to avoid this medication in pregnancy, especially during the first trimester.
As sodium valproate can lead to fetal malformations best to stay on the COCP until have switched to another medication
Unfortunately not much evidence or data on using any of the anti-epilepsy medications in pregnancy
HOWEVER, big risks to you and the fetus if you were to self discontinue any anti-epileptics so once on stable treatment recommended by neurologist, important to continue with this
Give you information about the UK Epilepsy and Pregnancy Register to join
Antenatally
Serial growth scans
More detailed anomaly scan
Perinatally
Most women with epilepsy have an uncomplicated labour and delivery and risk of seizures during labour is still very low
Adequate analgesia and appropriate care in labour should be provided to minimise risk factors for seizures such as insomnia, stress and dehydration.
Long-acting benzodiazepines such as clobazam can be considered if there is a very high risk of seizures in the peripartum period.
AED intake should be continued during labour. If this cannot be tolerated orally, a parenteral alternative should be administered.
Baby should receive 1mg IM Vit K
Postnatally
Mothers should be well supported in the postnatal period to ensure that triggers of seizure deterioration such as sleep deprivation, stress and pain are minimised
Counsel a woman who wants to get pregnant
May take a while for periods and all the hormones to normalise following coming off the COCP so just to be aware of that possible delay (up to a year)
Sexual health screen - we can arrange that either here at the GP or at a Sexual Health Clinic. You could go on NHS website and enter postcode and it tells you nearest one
Lifestyle
Well done for eating healthy - stay active and healthy diet
Stop smoking
Best to stop drinking altogether, and recommend your partner does the same to maximise chances of pregnancy
Try not to stress about getting pregnant - often makes this take longer and no evidence for measuring temperature and trying to work out when ovulating
Regular sex - every 2-3 days
Begin taking folic acid at HIGHER dose than normal - 5mg/day - I will prescribe that for you today
Come back and see us when you take a positive test
Can take up to 12 months of regular unprotected sex to conceive in healthy couples
To what extent can congenital abnormalities be minimised in WWE?
All WWE should be advised to take 5 mg/day of folic acid prior to conception and to continue the intake until at least the end of the first trimester to reduce the incidence of major congenital malformation.
Pre pregnancy folic acid 5mg/day may be helpful in reducing the risk of AED-related cognitive deficits. The lowest effective dose of the most appropriate AED should be used.
Exposure to sodium valproate and other AED polytherapy should be minimised by changing the medication prior to conception, as recommended by an epilepsy specialist after a careful evaluation of the potential risks and benefits.
What can precipitate a seizure in an epileptic?
Tiredness and lack of sleep, stress, alcohol, and not taking medication
Specific triggers - such as audio visual
How would you manage a OAB?
Conservative
Lifestyle: Advise that both caffeine and alcohol are bladder stimulants and are likely to worsen symptoms so should be minimised. Normal fluid intake per day but avoid drinks after about 7pm to limit nocturia
Bladder retraining for 6 weeks, involving a ‘drill’ restricting voiding to increasing intervals should be taught
Bladder diary
Medical
If lifestyle advice and bladder retraining fail then anticholinergic medication such as oxybutynin or tolterodine should be commenced. The associated side-effects include dry mouth, dry eyes and constipation. Elderly patients should receive mirabegron.
Define stress and urge incontinence
Due to weakness/damage to the pelvic floor, urethral sphincter weakness. Increase in intra-abdominal pressure affects bladder only as bladder neck has slipped below the pelvic floor, bladder pressure>urethral pressure -> voiding
Commonly idiopathic. Occasionally detrusor contractions in the presence of neuropathy (MS), urothelium overstimulation.
What is the management of prolonged first stage of labour?
Delay in 1st stage of labour = <1cm dilation over 2 hours
1st –> Membranes intact –> ARM (Artificial Rupture of the Membranes) –> review in 2 hours
2nd –> Membranes ruptured –> oxytocin:
• Increase every 15-30 mins until regular contractions
• Once regular contractions, review in 4 hours
What is the management of the prolonged second stage of labour?
In nulliparous women –> 3 hours (epidural) or 2 hours (no epidural)
In multiparous women –> 2 hours (epidural) and 1 hour (no epidural)
1st –> Membranes intact –> ARM (Artificial Rupture of the Membranes) –> review in 2 hours
2nd –> Membranes ruptured –> oxytocin:
Increase every 15-30 mins until regular contractions
Once regular contractions, review in 4 hours
A pregnant lady is started on LMWH. When should it be stopped again?
LMWH until 24 hours before delivery then start again post partum: 12 hours after CS and 6 hours after VD
What investigations would you do in a pregnant woman with a suspected DVT?
A-E approach - I would like to make a rapid assessment of the airway, breathing and circulation
Observations - HR, RR, BP, temp and saturations - all normal, HR slightly elevated at 95bpm
Examination - lower limb and respiratory
Imaging - compressive US (consider serial measurements - if ultrasound is negative and a high level of clinical suspicion exists, anticoagulant treatment should be discontinued but the ultrasound should be repeated on days 3 and 7); consider MRI venography if negative CUS - Confirms a clot found in the posterior tibial vein.
Bloods - FBC, coagulation screen, U&Es and LFTs (needed before starting anticoagulation therapy) NB: D-dimer raised in pregnancy anyway so not helpful.slightly raised WCC and CRP but otherwise normal, no clotting deficiencies found
What is the management of a DVT in a pregnant woman?
MDT approach - obstetrician, midwife, haematologist, GP (write letter)
Admit patient to antenatal ward, consult senior
If clinically suspect PE/DVT - treat immediately until dx excluded by objective testing, unless treatment strongly contraindicated
SC LMWH e.g. dalteparin 200 units/kg once daily
Preferred to IV/SC unfractionated heparin due to better efficacy and safety profile. Warfarin teratogenic (only suitable for women w mechanical heart valves)
Discontinue at least 24 hours prior to delivery
If high risk, switch to IV UFH and then stop 4-6 hours before delivery
After delivery restart LMWH
12 hours after CS
6 hours after VD
?US of baby
What investigations would you carry out in a pregnant women with signs of a PE?
ECG and CXR
If also have signs of DVT - CUS and if positive then no further ix necessary and treatment for VTE continues
If only have signs of PE and not DVT, then V/Q lung scan or CTPA performed
CTPA preferred over VQ if CXR is abnormal
Can repeat either scan if they are normal but clinical suspicion of PE remains
Women with suspected PE should be advised that, compared with CTPA, V/Q scanning may carry a slightly increased risk of childhood cancer but is associated with a lower risk of maternal breast cancer; in both situations, the absolute risk is very small
Counsel a woman with a DVT?
1 -Antenatal care
As we have admitted you, and started you on some blood thinning injections, this should get rid of the clot in your leg but you will have to continue these injections throughout the rest of your pregnancy until about 24 hours before delivery (if CS) to prevent another blood clot forming or when you start going into labour do not inject yourself with any more heparin.
We will arrange for you to see one of the midwives or nurses while you are in hospital who will be able to teach you and your partner how to administer these injections safely.
Compression stockings, hydration, mobilising as much as possible
You will now be seen by a consultant obstetrician at your antenatal appointments from now on, instead of a midwife
2 -Safety net
Give you a leaflet of the red flag symptoms of another clot - swelling, calf pain, tenderness
Possibility of clot spreading to one of the blood vessels in your lungs - SOB, chest pain, coughing up blood - then come straight back to hospital
3- Postnatal care
Once you have delivered your baby, you will need to be on the blood thinning medication for at least 6 weeks postnatally depending on what your risk is, this is decided by the medical team when you deliver.
Can choose what kind of blood thinning medication - either continue with LMWH injections or oral anticoagulant (warfarin) - need regular blood tests
Both safe to use during breastfeeding
4-Future pregnancies
Increased risk of future clots
Avoid COCP if you are considering contraception after this pregnancy
If you fall pregnant again please make sure you let your midwife and doctor know as this will affect how your antenatal care will be managed.
What do you do if you see a CTG showing a late deceleration?
Late Deceleration = PATHOLOGICAL –> do foetal blood sampling:
If foetal pH >7.2 –> normal –> continue monitoring
If foetal pH <7.2 –> foetal acidosis –> urgent delivery
Trace management
Trace Management –> get a review by an obstetrician Variable Deceleration
o Non-reassuring CTG:
(1) Left lateral position
(2) Stop oxytocin / consider tocolysis
• Exclude acute event (e.g. cord prolapse, uterine rupture)
• Correct underlying causes
• Give fluids (IV or oral)
(3) Digital foetal scalp stimulation (accelerates the heartbeat)
Pathological CTG:
(4) Foetal blood sampling (if not possible, expedite birth)
(5) EMCS
Causes of foetal tachycardia
> 160BPM
Maternal pyrexia
Chorioamnionitis
Hypoxia
Pre-maturity
