Obs Flashcards
1
Q
Preconception lifetstyle changes
A
- Reduce alcohol consumption
- Reduce/ maintain BMI (<30)
- Reduce/stop smoking
- Medication r/v if chronic condition
- Stop teratogenic meds
- High dose vit A
- Warfarin
- Lithium
- Sodium valproate
- Isotetrinoin (acne drug)
2
Q
Preconception supplementation
A
Folic acid 400mcg until end of 1st trimester
5mg if
- BMI >30
- FHx neural tube defect
- Prev preg - neural tube defect
- Diabetic
- Epileptic
3
Q
Diagnosis of pregnancy
A
HCG - human gonadotrophic hormone
detectable from around day 7-9 in blood and day 8-12 in urine
4
Q
Booking appointment
- When should it occur by?
- What is done during appt?
A
- 10 weeks
Comprehensive histories
- Medical
- Psychiatric
- Surgical
- O&G
- Social
Basics
- BMI
- BP
Bloods
- FBC
- G&S
- HIV
- Hep B
- Surface antigen
- Syphilis
Other Ix
- USS
Give info
- how the baby develops during pregnancy
- nutrition and diet
- exercise and pelvic floor exercises
- antenatal screening tests
- your antenatal care
- breastfeeding, including workshops
- antenatal education
- maternity benefits
- your options for where to have your baby
5
Q
What is checked for Hep B blood test?
A
Surface antigen
6
Q
Antenatal care timeline
A
8643, 5322
If pt has low risk/normal preg, will have midwife led care throughout.
8 to 12 weeks: booking appointment
8 to 14 weeks: dating scan
16 weeks: whooping cough
18 to 20 weeks: (20-week) scan for physical development of your baby
25 weeks*: Fundal height + BP + Proteinuria
28 weeks: Fundal height + BP + Proteinuria Fundal height + BP + Proteinuria
+ offer your first anti-D if rhesus negative + consider iron supplement if anaemic
31 weeks*: Fundal height + BP + Proteinuria
34 weeks: Fundal height + BP + Proteinuria + 2nd anti-D if rhesus neg
+ prep for labour & birth plan
36 weeks: Fundal height + BP + Proteinuria + foetal lie -> ECV offered if breech + Vit K and screening tests for newborn
+ prep for breastfeeding & newborn care incl bbblues+PND
38 weeks: Fundal height + BP + Proteinuria
+ discuss choices if preg >41 weeks
40 weeks*: Fundal height + BP + Proteinuria
41 weeks: Fundal height + BP + Proteinuria
+ offer membrane sweep + discuss induction of labour options
7
Q
How many antenatal appts?
A
If you’re expecting your first child, you’ll have up to 10 antenatal appointments.
If you have had a baby before, you’ll have around 7 appointments, but sometimes you may have more – for example, if you develop a medical condition.
Early in your pregnancy, your midwife or doctor will give you written information about how many appointments you’re likely to have and when they’ll happen.
8
Q
Which vaccines are routinely offered in pregnancy and when?
A
Whooping cough from 16 weeks + Influenza
9
Q
Combined screening test
1) When?
2) For which syndromes?
3) How?
A
1) Between 10 and 14 weeks (first trimester)
2) Down’s, Patau’s, Edward’s
3) Combined test: obtaining nuchal translucency, serum B-HCG, PAPP-A (Pregnancy Associated Plasma Protein-A)
10
Q
When is combined screening test not possible/doesnt work? And what is done alternatively?
A
Quadruple test, between 14 to 20 weeks pregnant.
11
Q
What screening test is performed if combined/quadruple test result is higher chance?
A
Non-Invasive Prenatal Testing (NIPT)
examines small fragments of DNA (cell free DNA (cfDNA) which are released from the placenta - can be done from 10weeks onwards; more sensitive
12
Q
Renal changes in pregnancy
A
cefalexin first line for UTI trx but check local guideline but used often bc safe throughout the trimesters
13
Q
GI changes in pregnancy
A
14
Q
Haem changes in pregnancy
A
Prophylactic clexane from 28 weeks when u do a screen of VTE risk
15
Q
Haemodynamic changes in pregnancy
A
increased blood volume is v diluted so u get associated NORMAl anaemia. Pregnant ppl usually have lower - normal BP than they usually do.
16
Q
Normal B-hCG blood levels
A
hCG levels usually consistently rise until around week 10–12 of your pregnancy, when the levels plateau or even decrease. This is the reason why pregnancy symptoms can be greater in the first trimester and ease off after this time for many women.
In early pregnancy, hCG levels usually double every two to three days.
17
Q
Causes of low B-hCG blood levels
A
- Gestational age miscalculation
- Miscarriage
- Ectopic pregnancy
18
Q
Malpresentation - breech
A
ECV - 36 weeks for first time mothers, 37 otherwise
19
Q
Malpresentation transverse
RF, Main risk, Mx
A
20
Q
Stages of labour
A
First stage (8-12h)
Latent phase
- Cervical effacement
- 0-3cm
- Start of regular, painful contractions
Active phase
- 4- 10cm (full dilation)
- Contractions are stronger and more frequent
Second stage (<3h)
- Baby moves down from uterus to vagina
- Baby is delivered
Third stage (1-60min)
- Delivery of placenta
21
Q
Causes of prolonged labour (by stage)
A
First stage
- Dysfunctional uterine activity
- Contractions aren’t strong enough
- Cephalopelvic disproportion
- Size of baby v size of pelvis
- Malpresentation
- Presenting in a diff way:(
Second stage
- Dysfunctional uterine activity
- Pelvic shape
- Resistant perineum
- not loosening for head delivery
Third stage
- Uterine atony
- Placenta abnormalities
- e.g., placenta accreta
22
Q
What is classed as prolonged labour for each stage?
A
- First stage: <1cm every 2h
- Second stage: >3h if nulliparous, >2h if parous
- Third stage: >30 mins if active, >60 mins if passive
23
Q
Induction of labour indications
A
- Post term (>42 weeks) -> Placental insufficiency
- Prelabour rupture of membranes
- T1/T2DM
- Gestational diabetes
- PET
- Obstetric cholestasis
24
Q
Induction and augmentation of labour methods
A
- Membrane sweep (antenatal clinic visits 39/40 onwards)
- Insert finger into vagina and through to cervix - sweep round to try detach membranes from inner wall of uterus and cervix -> cause release of hormones to progress labour
Bishop score 6 or less
- Balloon catheter
- Prostaglandin pessary (e.g., misoprostol)
Bishop score > 6
- Aritifical rupture of membranes (using amniohook)
- IV Syntocinon
25
Bishop score
assessment of ‘cervical ripeness' - assessed prior to and during induction.
**Score of ≥ 7** – cervix is ripe or ‘favourable’ – high chance of a response to interventions to induce labour (i.e. induction of labour is possible).
**Score of \<4** – labour unlikely to progress naturally and prostaglandin tablet/gel/pessary required
Failure of cervix to ripen despite use of prostaglandins may result in need for caesarean section.
Modifiers
+1 for e/:
Existence of pre-eclampsia
Each previous delivery
- 1 for e/:
Postdate/post-term pregnancy
Nulliparity
PPROM
26
What methods are used to assess foetal wellbeing in labour?
* CTG
* Intermittent auscultation (low risk women)
* Foetal blood sampling (used for assessing foetal hypoxia in presence of abnormal CTG)
27
Primary dysfunctional labour
Slow progress of labour from beginning, i.e. \<2cm increase cervical dilation in 4h.
Often caused by ineffective uterine action and deflexion of foetal head.
28
Secondary arrest of labour
Failure to progress when there was adequate/expected progress to begin with.
29
1. What are CTG accelerations?
2. What are CTG decelerations?
3. What are early decelrations?
4. What are late decelerations?
1. Accelerations = 15bpm \> baseline lasting \>15s
2. Decelerations = 15bpm \< baseline lasting \> 15s
3. Early deceleration = Deceleration starts when uterine contraction begins and ends when contraction finishes
4. Late deceleration = Deceleration starts at peak of uterine contraction and recovers after contraction ends
30
What can early decelerations indicate?
Foeta head compression
31
What can late decelerations indicate?
Foetal hypoxia
32
What can variable decelerations indicate?
Cord compression
33
Abnormal CTG Mx
**Conservative**
* Turn woman onto left lateral position (relieves aorto-caval compression)
* Turn off or down oxytocin infusion (ensure the uterus is not being hyperstimulated)
* Start IV fluids (ensure pt and foetus well hydrated)
If abnormal CTG persists, perform foetal blood sampling.
* If pH \>7.25:* Restart syntocinon and continue w labour
* If pH \<7.2:* Deliver immediately
34
Perineal tear classification
I: Vaginal mucosa and/or perineal skin injury
II: Perineal muscle torn
III: Perineal tear involving anal spincter complex
IIIa: \<50% external anal sphincter torn
IIIb: \>50& external anal sphincter torn
IIIc: both external and internal anal sphincter torn
IV: Injury to perineum involving anal sphincter complex and anal mucosa
35
Perineal tear RFs
* Forceps delivery
36
Perineal tear repair
3rd & 4th degree
* Repair in theatre
* Abx given in theatre
* Epidural, spinal or GA
Post-op care
* Analgesia
* Laxatives
* F/u w/ physio
37
Future method of deliveyr after a 3rd or 4th degree tear
If completely healed, able to opt for vaginal delivery
Suggested if 3rd/4th deg tear, future preg 7-10% having similar tear. RFs which incr likelihood: macrosomic baby, forceps delivery
38
VBAC
1. Success rate?
2. Risk of uterine scar rupture?
3. Interventions recommended as part of birth plan?
1. 72-75%
2. 0.5% / 1 in 200
3. Continuous CTG monitoring and IV access
39
VBAC risk of uterine scar rupture
0.5% / 1 in 200
40
Small for gestational age RFs and Mx
IOL bc we are worried placenta not working as well as it should
41
Large for gestational age
IOL bc worried fialure to progress bc baby tooo big to descend, or shoulder dystocia, or perineal tears
42
Reduced foetal movement Ix
AFI= amniotic fluid index (how much fluid is around bb)
43
Preterm labour
Regular contractions resulting in cervical dilation after week 20 and before week 37 of pregnancy
44
Preterm labour presentation
*\>20 and \< 37/40*
* Painful uterine contractions
* Cervical dilation
45
Preterm labour RFs
* Previous preterm labour
* Multiple pregnancy
* Polyhydramnios
* Antepartum haemorrhage
46
Preterm labour Ix
* CTG
* assess fetal wellbeing and to monitor uterine activity
* Foetal USS
* growth scan of the fetus will give an estimate of the fetal weight which is useful for the neonataologists to know
* FBC + CRP
* indicate if there is any subclinical infection causing the preterm labour
47
Preterm labour Mx
* Tocolysis
* relaxation of pregnant uterus
* Most common: Nifedipine (CCB) and Atosiban (oxytocin R antagonist)
* Steroid administration
* reduce incidence of respiratory distress syndrome by 50%
* considered between 24 and 36 weeks gestation
48
External Cephalic Version
Offered when babies are breech
* 36 weeks if nuliparous
* 37 weeks if multiparous
Approx 50% success rate
One of our specialist doctors encourages the baby to turn so that it's head down (‘cephalic presentation’), by pushing on the mother’s tummy whilst guided by ultrasound, which makes the baby do a forward or backward roll. Your baby’s heartbeat will be monitoried using a heart rate monitor (a ‘CTG’). You will be given some medicine (Terbutaline) by a small injection into your arm to relax the womb a little. This is safe for your baby and makes the ECV more likely to work.
This part only lasts a few minutes and you may experience some discomfort or pain whilst pressing on your tummy. You will be given the option to use gas and air (pain relief you breath in and out) to help with this but if you become too uncomfortable the doctor will stop.
49
Cord prolapse
Obstetric emergency - descent of umbilical cord through the cervix
50
Cord prolapse presentation
* Foetal bradycardia/deceleration
* Fullness in vagina
51
Cord prolapse RFs
* Breech
* Unstable lie
* position changes (consider admission if \>37 weeks)
* ARM (/recent SROM)
* Polyhydramnios
* Prematurity
52
Cord prolapse Mx
* Call for help + senior input
* Preparations made for immediate birth in theatre - immediate delivery EMCS
* To prevent vasospasm, minimal handling of loops of cord lying outside vagina
* To prevent cord compression, presenting part elevated either manually or by filling the urinary bladder (catheter if in situ filled w saline)
* Further prevent compression - left lateral position/knee chest position
* ±Tocolysis whilst awaiting theatre
53
Shoulder dystocia
Birth complication caused by one or both of the baby's shoulders getting stuck during delivery
54
Shoulder dystocia RFs
* Previous dystocia
* Macrosomia
* GDM/pre-existing diabetes
* Obesity (BMI\>30)
55
Shoulder dystocia Mx
1. STOP pushing + senior input
2. Flatten the bed
3. McRober's manouvre
* Moving to end of bed, lying on back, and hyperflexing legs towards abdomen
4. Suprapubic pressure
5. Episiotomy
6. Posterior arm delivery
7. Corkscrew manouvre
8. All fours position
9. Symphisotomy (divide pubic symphysis) / cleidotomy (forcibly breaking baby clavicle) / Zavanelli (push baby back into uterus and go for CS)
56
Shoulder dystocia Complx
Maternal
* Perineal trauma
* PPH
* Mental trauma from birth
Foetal
* Brachial plexus injury
* Erb's palsy
* Asymmetric moro reflex
* Fractured clavicle
* Hypoxic brian injury
57
3 Placental abnormalities
Placenta praevia
Placenta accreta, increta & percreta
Vasa praevia
58
Placental abnormalities shared presentation
Painless PV bleeding
May trigger preterm labour
59
Low lying placenta
Edge of placenta \<2cm from internal cervical os
(at 20 week scan)
60
Mx of low-lying placenta
Rescan at 32 weeks
-\> If \<2cm from cervical os
Rescan at 36 weeks
-\> If \<2cm from cervical os
Elective C-section
61
Placenta praevia
Placenta is overlying or enroaching on internal cervical os
(at 20 week scan)
62
Placenta praevia presentation
* Painless PV bleeding
* PCB
* Transverse lie of foetus (lower uterine segment occupied by placenta)
63
Placenta praevia RFs
* Multiple pregnancy
* Previous placenta praevia
* Multiparity
* Previous uterine surgery
* Smoking
* Older mothers
64
Placenta praevia Ix
* TV USS
* If painless bleeding post 13 weeks
* Further USS @ 37/40
* Assess location of placenta and determine delivery method
* Kleihauer test
* If RhD neg
* Determines how much foetal and maternal blood has mixed -\> how much anti-D antibodies need to be given
* CTG
* Growth scan & umbilical artery dopplers
* Every 2 weeks
## Footnote
**!Vaginal exam contradinidicated**
65
Placenta praevia Mx
*Bleeding with known placenta praevia:*
* Admit
* ABC approach (G&S, X match), resuscitation and stabilisation.
* If stabilisation is not achieved/foetal compromise, send for **emergency Caesarean Section**.
* **Corticosteroids** should be considered if between 24-34 weeks gestation and there is risk of preterm labour
*Placenta Praevia with no bleeding and not in labour:*
* Monitor with USS
* Give advice about pelvic rest (no penetrative sexual intercourse) and advise to go to hospital if there is significant vaginal bleeding
* For CS delivery 34-37weeks
NO VAGINAL EXAM
66
Placenta praevia Complx
* DIC
* Renal failure (due to hypovolaemia)
* PPH
67
Placenta accreta, increta and percreta
Acreta - placenta attaches to deeply into endometrium
Increta - placenta attaches into myometrium
Percreta - placenta attachment goes completely through uterine wall
68
Placenta accreta labour issues
Prolonged 3rd stage as placenta fixed onto myometrium
Placental material can be left in uterus -\> PPH
69
Placenta acreta/increta/percreta Ix
* Fetoprotein
* Raised circulating levels
* B-hCG
* Raised
* USS
* Diagnostic
70
Vasa praevia
Placental vessels (which usually travel in umbilical cord) are not protected by the umbilical cord or the placenta tissue, and travel over the internal cervical os/opening of birth canal --\> blood vessels are very fragile
71
Placental abruption
Premature separation of the placenta from the uterine wall
72
Placental abruption presentation
* Abdominal pain
* Vaginal bleeding (may be concealed bleed - blood pools between placenta and uterus)
* Hypovolaemic shock which is often disproportionate to the amount of vaginal bleeding visible
73
Placental abruption RFs
* HTN
* Smoking in pregnancy
* Substance misuse -\> cocaine
* Previous hx of abruption
* Multiple pregnancy
* Polyhydramnios
74
Placental abruption Ix
Abdo exam
* Tense, rigid abdomen
* Woody uterus
CTG
* Abnormal CTG due to reduced foetal movement
75
Placental abruption Mx
*If haemodynamically unstable*
* A to E approach
* 2 large bore cannulae
* Cross match 4units blood
* IV Hartmanns
* Admit to hospital
* Anti-D if rhesus D -
* Dexamethasone if \<37weeks
* If maternal and/or foetal compromise & \>30weeks*
* Caesarean section unless spontaneous vaginal delivery is imminent
* If at term and no maternal or foetal compromise*
* Induction of labour
* To avoid further bleeding
76
PPH Minor v Major
Minor 500-1000ml
Major \>1000ml
77
PPH Causes
4Ts
* **T**one (lack of) \*
* **T**rauma
* **T**issue (retention of placental tissue)
* **T**hrombin
\*Uterine atony most common cause
78
Management to minimise risk of PPH
Prophylactic uterotonics
* IM Oxytocin, or
* Low risk -\> SVD or CS
* IM Syntometrine
* High risk & no HTN
* + Tranexamic acid
* Adjunct to reduce blood loss
79
PPH Mx
* Obstetric major haemorrhage call
* Lie pt flat
* A to E
* 2 large bore cannulae
* VBG, FBC, G&S, clotting
* Oxygen
* Catheter
* Transfusion
Definitive
1. Bimanual compression
* Fist inserted into vagina and other hand compresses down over abdomen (uterus) to try to tamponade the bleed
2. IV syntocinon 5 IU
3. IV or IM ergometrine 0.5mg
4. Syntocin infusion
5. IM carboprost 0.25mg
Surgical
6. Bakri balloon tamponade
7. Brace suture
8. Internal iliac ligation
9. Hysterectomy
80
Gestational diabetes mellitus
Gestational diabetes is high blood sugar (glucose) that develops during pregnancy and usually disappears after giving birth. Usually occurs around 28 weeks.
81
GDM presentation
* Polyuria
* Dysuria
* Thirst
82
GDM RFs
* Previous GDM
* FHx DM
* High BMI
* Previous macrosomic baby (\>= 4.5kg)
* Ethnicity (afrocaribean/south east Asian)
* PCOS (low insulin state)
83
GDM Ix
Screening (at booking)
* Glycosuria
* Ask about RFs
If prev GDM, do OGTT at booking then if normal, again at 24-28/40
If glycosuria/other RF at booking, further testing between 24-28/40)
* Fasting plasma glucose
* 5.6 or above suggestive of GDM
* **Oral glucose tolerance test**
* 7.8 or above suggestive of GDM
* HbA1c
* Points towards pre-existing diabetes being more likely
* Urinary ketones
* Rule out possibility new presentation of T1DM and is v insulin deficient
84
GDM USS Ix indication
1. Exclude congenital abnormality - likelihood increased if patient had elevated plasma glucose concentrations earlier in pregnancy (pre-existing, even if undiagnosed Type 1 or Type 2 diabetes)
2. Establish fetal growth to assess growth rate from now on. Maternal hyperglycaemia is detected by foetus as glucose crosses the placenta. Foetus responds by increasing insulin secretion, as it does not have diabetes, and insulin can cause increased fetal growth which may make for obstetric difficulties.
3. Assessing liquor volume, as diabetes is common cause for polyhydramnios.
85
GDM Mx
**Fasting plasma glucose less than 7.0mmol/L**
Monitor glucose levels!
Lifestyle changes
* Diet
* Calorie-restricted
* Small, frequent meals
* Complex carbs (e.g., bread, rice, pasta, potatoes)
* Minimal simple sugars (e.g., sugar, sweets, jam, juice, cake, etc.)
* Exercise
If blood glucose targets not met in 1-2 weeks
* Metformin
**Fasting plasma gluocse 7.0mmol/L or above:**
* Insulin
* +/- Metformin
Stop medication post delivery.
* +*
* Joint endo + obstetrics care*
* Serial growth scans at 28, 32 and 36 weeks*
* Home testing*
* Induction of labour*
* Yearly HbA1C with GP*
86
GDM complx
Maternal
* Risk future T2DM and CVD
* Risk hypertensive disease in preg
* Increased risk of IOL/CS/intervention
Foetal
* Macrosomia
* Due to increase rate of foetal growth (from increased insulin)
* May make delivery more difficult -\> incr risk *shoulder dystocia*
* Neonatal hypoglycaemia
* Stillbirth
87
If a patient has GDM, what is their risk of developing T2DM further down the line?
50%
88
Group B Streptococcus + Mx
* Intrapartum abx
* Benzylpenicillin
* Vancomycin if penicillin allergy
89
Vomiting Ddx
* Hyperemesis gravidarum (less than 20 weeks)
* PET
* Molar pregnancy
* Infection
* GI problem
* Metabolic conditions
* Diabetic ketoacidosis, thyrotoxicosis
* Drug toxicity
90
Hyperemesis Gravidarum
Severe vomiting with onset before 20 weeks of gestation
+
* \>5% pre-pregnancy weight loss, or
* Dehydration, or
* Electrolyte imbalance
91
Hyperemesis gravidarum presentation
* Vomiting
* Nausea
* Weakness
* Reduced urine output
92
Hyperemesis gravidarum Ix
Bedside
* Obs (BP may be low)
* CRT (can be low)
* Mucous membranes (may be dry)
* Body weight
* PUQE score
* Risk stratisfy
Bloods
* U&Es
* TFTs
* HCG
* t3 and t4 agonist
93
Hyperemesis Gravidarum Mx
Admit to hospital/ MAS
Definitive
Antiemetics
1. Cyclizine/promethazine/chlorpromazine
2. Metoclopramide
3. Odansetron/Domperidone
4. Steroids (refractory)
Supportive
* IV fluids + KCl
* Excessive vom may cause hypoK
* IV Pabrinex
* Thiamine deficiency, caused by vomiting, can cause Wernicke's encephalopathy and result in foetal death
* VTE prophylaxis
* LMWH + TED (thromboembolytic) stockings
* Increased risk of VTE due to combination of pregnancy, immobility and dehydration
Alternative Mx
* Ginger
* P6 acupressure
94
What are the 2 biliary disease of pregnancy?
Obstetric cholestasis and acute fatty liver of pregnancy
95
Pruritis of palms and soles Ddx
* Obstetric cholestasis / intrahepatic cholestasis of pregnancy
* Acute fatty liver of pregnancy
* Autoimmune hepatitis
* Drug-induced hepatitis
* Viral hepatitis
* Extrahepatic obstruction from gallstones
96
Obstetric cholestasis presentation
* 3rd trimester
* Generalised itching/ pruritus - worst on palms and soles
* More severe w advancing gestation
* Can be so bad it prevents sleep - insomnia + malaise
* Relieved within 48h of delivery
+/-
* Anorexia
* Abdo discomfort
* Pale stools + dark urine
* Steatorrhoea
(Diagnosis of exclusion)
97
Obstetric cholestasis RFs
* Previous obstetric cholestasis
* Genetic traits
* Asian origin
* Pruritus on the COCP
98
Obstetric cholestasis Ix
Rule out other causes as OC is diagnosis of exclusion
* FBC
* Clotting profile
* Increased PTT (liver dysfunction reduces prothrombin production)
* U&Es
* LFTs (done weekly)
* Moderate rise transaminase
* **Increased serum total bile acid concentration**
* ALP may be raised beyond normal preg levels
* Mild/ no significant elevation of bilirubin
* Hepatitis serology
* Autoimmune antibodies
* Bile acids
* Liver USS
99
Obstetric cholestasis Mx
* Ursodeoxycholic acid
* Aim for delivery at 37-38weeks
* Allows adequate time for foetal development w/o unneccessarily prolonging risk of spontaneous death
* Antihistamine, e.g., chlorphenamine
* Reduce itch
100
Obstetric cholestasis complx
* **Preterm birth**
* Severe liver impairment
* Foetal macrosomia
* PPH
* Intrauterine death
101
Acute fatty liver of pregnancy presentation
Usually 3rd trimester
* Nausea/**vomiting**
* Abdominal pain
* Jaundice
102
Acute fatty liver of pregnancy Ix
* FBC
* Platelets low
* Kidney function
* eGFR low
* LFTs
* PT & APTT raised
* Bilirubin raised
* ALT & AST raised
103
Acute fatty liver of pregnancy Mx
ITU input
Blood products
Foetal monitoring
Prompt delivery
104
Acute fatty liver of pregnancy complx
DIC
Death
105
Ovarian hyperstimulation syndrome
Ovarian hyperstimulation syndrome is a complication of iatrogenic induction of ovulation.
The FSH used in IVF leads to many follicles maturing and enlarging. Once ovulation occurs from these follicles, each then becomes a corpus luteum. As a result there is an excessive production of oestrogen, progesterone, and local cytokines (e.g. vascular endothelial growth factor).
106
OHSS presentation
* Bloating/ distended abdomen + abdo discomfort
* Ovaries may enlarge to such an extent that they put pressure on surrounding structures --\> bloating + abdo discomf
* N+V
* Due to high [oestrogen]
* Weight gain
* Vascular endothelial growth factor causes blood vessels to leak --\> fluid retention
* Pt undergoing IVF
107
HTN in pregnancy 3 categories
* Essential/chronic HTN ( r a r e - pre existing HTN)
* Pregnancy induced HTN / gestational HTN
* Pre eclampsia
All require obstetric input
108
Pregnancy induced HTN / gestational HTN
* Occurs after 20/40 (anything before is essential HTN)
* BP \>140/90
* HTN w/o any end organ dysfunction
109
What should you check when taking BP?
Correct cuff size is used
110
Pregnancy induced HTN Mx
* Antihypertensives
* Offer induction of labour
111
Pre-eclampsia
High blood pressure and signs of damage to 1 or more organ system, commonly presenting as proteinuria. Can only be diagnosed from 20/40.
112
Pre-eclampsia presentation
Early syx
* High blood pressure
* Proteinuria
Further syx
* severe headaches
* visual disturbances, such as blurring or seeing flashing lights
* Oedema of the face and hands
* vomiting
* hyperreflexia, clonus
In baby/foetus
* Intrauterine growth restriction
* Caused by poor blood supply through placenta to baby --\> less oxygen and fewer nutrients received --\> affect development
113
Pre-eclampsia RFs
High
* Previous pre-eclampsia
* Chronic HTN
* CKD
* DM
Moderate
* Nulliparity
* Age \>40
* BMI\>35 at booking
* FH pre-eclampsia
* Multiple pregnancy
114
Pre-eclampsia Ix
Ix
Bedside
* Obs - BP
* Dipstick
* Send sample to lab if + protein for PCR (protein creatinine ratio \>30 is significant) or ACR (albumin creatinine ratio \>8 is significant)
* CTG
Bloods
* FBC
* U&E
* LFT
* ALT often abnormal
* Clotting/G&S
Imaging
* Abdo USS
* If earlier in preg
115
Pre-eclampsia Mx
* Admit if BP\>160/110
Monitoring in hospital
* BP
* Every 15- 30 mins
* Urine dip
* Bloods
* LFTs
* ALT rise
* Creatinine rise
* Platelets
* Look for drop (HELLP syndrome)
* USS
* Assess growth
* Assess amount of amniotic fluid
* Serial growth scans: 28, 32 and 36 weeks gestation
* CTG
Definitive
* Antihypertensives
* Labetalol (first line - NOT for asthmatics)
* Usually oral first line then IV if uncontrolled
* Can start with IV if very high BP
* Nifedipine (second line)
* Methyldopa (third line)
+ IV MgSulphate *if severe*
* Delivery at 37 or 38/40
* Consider early delivery if
* Inability to control BP
* SaO2 \<90%
* Deterioration in renal/liver function
* Deterioration in platelet count
* Placental abruption
116
When does pre-eclampsia tend to resolve by?
6 weeks post partum
117
Pre-eclampsia complications
Maternal
* Convulsions (eclampsia)
* HELLP syndrome (haemolysis elevated liver enzymes low platelets)
* RUQ pain!
* Placental abruption
Foetal
* IUGR
* Prematurity
* ARDS
* Foetal demise
118
Eclampsia Mx
Initial
* Left lateral position
* Reduce BP and reduce IVC pressure
* Secure airway
Definitive
* IV Magnesium Sulphate
119
Why are pregnant women at increased risk of VTEs?
Physiological changes in pregnancy make it so that blood loss is minimised when giving birth -\> shift towards pro clotting state
120
PE Ix
1. ECG
2. CXR
3. *If clinical evidence of DVT* compression duplex USS
Definitive
CTPA or VQ scan
(risk benefit analysis as radiation dose)
121
DVT Ix
Compression duplex USS
122
Mx of DVT and PE
**1. Low molecular weight heparin, e.g. Enoxaparin/clexane**
*Until end of pregnancy + at least 6 weeks post partum
+ at least 3/12 TOTAL treatment*
2. Routine measurement of peak anti-_Xa_ acitivity whilst on Cle**_Xa_**ne
Avoid warfarin and DOACs
123
Massive saddle embolus mx
Thrombolyse with IV Heparin
124
What is rhesus isoimmunisation?
Rhesus isoimmunisation can occur when a rhesus negative (RBCs don't have rhesus D antigens) mother has a baby which is rhesus positive (RBCs do have rhesus D antigens). If any foetal red blood cells enter the maternal circulation, the mother will form antibodies against them.
The maternal anti-D antibodies can cross the placenta in subsequent pregnancies and cause Rhesus Haemolytic Disease if the future baby is rhesus positive.
125
What type of antibodies are formed in rhesus isoimmunisation?
Initially mother forms **IgM** anti-D antibodies.
By subsequent pregnancies, immune response matures and mother forms **IgG** anti-D antibodies.
126
Who needs rhesus Anti D and when?
Rhesus -ve mothers at 28 weeks and as soon as possible after any sensitisation event. (Anti-D has no effect once sensitation has occurred - only prophylactic)
127
What are sensitisation events in rhesus isoimmunisation?
“Sensitisation” events are events which cause foetal blood to cross the placenta into the maternal circulation and thus these are indications for anti-D prophylaxis.
Examples of sensitisation events include:
* Abdominal trauma
* Blood transfusion
* Antepartum haemorrhage
* Amniocentesis/chorionic villus sampling
* Ectopic pregnancy (surgical)
* Termination of pregnancy
* Miscarriage \>12weeks
* External cephalic version
* Placental abruption
* Delivery (of RhD+ve infant)
128
How much rhesus anti D should be given after sensitisation event?
First trimester: 250IU
Second trimester: 250IU within 72h + Kleihauer test
Third trimester: 500IU within 72h+ Kleihauer test
(Kleihauer test tells you whether there is foetal blood in maternal circulation)
129
Complications of Rubella (perinatal infx)
* Sensorineural deafness
* Patent ductus arteriosus
* Cataracts
130
Rubella Mx
* No longer screened
* Bc of routine vax programmed
* If confirmed -\> foetal medicine unit for monitoring
* Offer TOP if \<16 weeks
131
Complications of syphilis (perinatal infection)
* Foetal growth restriction
* Congenital syphilis
* Preterm birth
* Stillbirth
132
Syphilis Mx
IM Benzathine Penicillin
133
Complications Varicella Zoster Virus (perinatal infection)
* Limb hyperplasia
* Cutaneous scarring
* FGR
134
VZV Mx
* Check varicella Ig
* If non immune -\> VZIg
* Up to 10 days from contact
* If presenting w rash and \>20week
* Aciclovir
* Foetal medicine referral
135
Complications of Herpes Simplex Virus (Perinatal infection)
* Skin-eye-mouth disease (SEM)
* Central nervous system disease
* Disseminated disease
136
HSV Mx
1st/2nd trimester -\> Aciclovir from 36/40
3rd trimester -\> aciclovir until delivery + CS
137
Complications of HIV (perinatal infection)
Vertical transmission
138
HIV Mx
* Check viral load every 2-4 weeks & at 36 weeks
* If viral load \<50copies/mL at 36 weeks, can consider vaginal delivery
* If \>50, CS
* ART for pt
* ART for neonate
* IV Zidovudine if CS
* Avoid breastfeeding
(Managed by specialists!)
139
HIV bb size
SGA
140
Complications of Hep B Infx (Perinatal Infection)
Vertical transmission
141
Hep B Mx
If mother has chronic infx, newborn to have:
* Vaccination + Hep B IG within 12h birth
* Vaccine at 1 month
* Vaccine at 6 months
* Test at 12 months
142
What does bacterial vaginosis increase risk of in pregnancy?
Preterm delivery and late miscarriage
143
Bipolar disorder in pregnancy
* If unstable even on Lithium (or alt), gradually switch to atypical antipsychotic
144
CI drugs during pregnancy
**Psych**
* Sodium valproate!
* Lithium
* congenital abnormalities, particularly Ebstein's anomaly, and an increased risk of miscarriage
* methotrexate
* warfarin
* NSAIDs - can impair closing of foramen ovale
145
CI drugs during breastfeeding
* Lithium
146
Contraception after giving birth
* Implant whenever
* POP whenever
* IUD or IUS within 48h, or from 4weeks onwards
* COCP from 6 weeks
* Avoid if breastfeeding
147
Sepsis 6
3 in
* O2 to keep sats \>94% (1)
* IV abx (3)
* Fluid challenge (4)
3 out
* Take blood cultures (2)
* Measure lactate (5)
* Measure UO (6)
148
Leading cause of maternal mortality UK
Sepsis
149
When would you deliver for twins?
37 weeks
150
What is lambda sign on USS indicative of?
Dichorionic twins
151
Twin-to-twin transfusion syndrome
Occurs in monochorionic twins - abnormal vessel connections within placenta resulting in imbalance of blood exchange between twins.
One twin, donor twin, gives away more blood than it receives - risk of malnourishment and organ failure. Therefore, its kidneys don’t have to filter as much fluid from the blood, and as a result, urination decreases. This affects development of the bladder and leads to low levels of amniotic fluid. (Oligohydramnios)
Other twin, receipient twin, receives too much blood and is susceptible to heart failure :( (Polyhydramnios)
152
Proteinuria w/o HTN Mx
* 1+ protein -\> MC&S + antibx
* 2+ protein -\> Same-day 2ndry care ref
153
UTI in pregnancy Mx
Asymptomatic:
Cefalexin
Symptomatic:
Nitrofurantoin
154
Postpartum endometritis presentation
* Bleeding
* Foul smelling vaginal d/c
* Pelvic/lower abdo pain
155
Reason for increased urinary frequency in first trimester?
Increased GFR
156
Reason for increased urinary frequency in third trimester?
Pressure from uterus pushing on bladder
157
Premature pre-term rupture of membrane
Rupturing before 37 weeks
158
PPROM RFs/Causes
* Infection
* Polyhydramnios
* Multiple pregnancy
* Smoking
* Low BMI
* Cervical weakness due to previous procedure, e.g., LLETZ (large loop excision of transformation zone)
159
PPROM Ix
* Sterile speculum examination
* WBC
* CRP
* CTG
160
PPROM Mx
* Erythromycin
* Give for 10 days, or until in established labour (whichever sooner)
* IM dexamethasone
* Between 24-33weeks (up to pre-36/40 can be considered)
* Mag sulphate
Expectant mx until 37+0 weeks
161
Mastitis Mx
* Analgesia
* NSAID/paracetamol
* Keep breast feeding (both)
If signs infx/abscess
* Abx
* PO Fluclox empirically
* Breast milk culture
* Keep breast feeding (both)
162
Lactational amenorrhoea contraception method
* Up to 98% effective for first 6 months
* Continuous exclusive breast feeding w gaps no more than 4h during day and 6h evening
163
What is gravidity?
total number of pregnancies, regardless of outcome
164
What is parity?
total number of pregnancies carried over the threshold of viability (24+0 in the UK)
165
How to calculate EDD?
1. First, determine the first day of your last menstrual period.
2. Next, count back 3 calendar months from that date.
3. Lastly, add 1 year and 7 days to that date.
166
Legal terms for TOP in GB
* Performed by **registered dr**
* Agreed on by **2 dr**
* (A)To occur **prior to 24weeks** if on grounds of risk, greater than if the pregnancy were terminated, of **injury to the physical or mental health of the pregnant woman or any existing children** of her family, OR
* (B)to prevent **grave permanent injury** to the physical or mental health of the **pregnant woman**, OR
* (C)involve risk to the **life of the pregnant woman**, greater than if the pregnancy were terminated, OR
* (D)substantial risk that if the child were born it would suffer from such **physical or mental abnormalities** as to be seriously handicapped
167
Chorionic villus sampling v Amniocentesis
1. When can each be done?
2. What does each consist of?
3. What are the risks?
1. CVS: 11/40 and 14/40; Amniocentesis: 15/40 and 20/4
2. CVS: removing and testing a small sample of cells from the placenta
Amniocentesis: removing and testing a small sample of cells from amniotic fluid
3. CVS: Miscarriage \<0.5% (Infection + Rhesus sensitisation)
Amniocentesis: Miscarriage \<0.5% (Infection + Rhesus sensitisation)
\*Misc risk for multiple preg is 1%
168
Pregnancy smoking risks
* SGA
* Miscarriage
* Stillbirth
* Heart defects
169
Smoking in preg Mx
* CO test (for all mothers) at booking
* Referral to smoking cessation specialists
If carry on smoking/2nd hand smoke
* Serial growth scans
170
What type of headache is common post-partum (24hr ish)?
Tension/migraine
| (Also post-dural headache if epidural)
171
Best method to predict preterm labour
fetal fibronectin testing
determines likelihood of birth within 48 hours if 30/40+
172
Additional antenatal test for pregnant women with history of drug use
Hepatitis C
173
What would use of NSAIDs in last trimester lead to?
Closure of patent ductus arteriosis (PDA)
174
How soon does period return postpartum?
1) If exclusively breast feeding
2) If partial/ bottle feeding
1) Approx 6 months
2) As early as 3 weeks
175
What could echogenic bowel (brighter than usual) on USS be indicative of?
Soft marker for trisomy 21
176
What are the 4 categories for CS?
Cat 1 (Emergency) - Immediate threat to life of woman/foetus
Cat 2 (Urgent) - Maternal/foetal compromise but not immediately life threatening
Cat 3 (Scheduled) - No maternal/foetal compromise but need early delivery
Cat 4 (Elective) - At a time to suit the woman/service
177
Probability of being permanently paralysed from epidural
less than 1 in 20,000
178
What is this presentation?
Polymorphic eruption of prgnancy
179
What drug would you give to stop breast milk production?
cabergoline
180
Amniotic fluid embolism
allergic-like reaction to the amniotic fluid that enters the mother's bloodstream
181
Amniotic fluid embolism presentation
* Agitated and odd behaviour
* SOB
* Sudden collapse
* Bleed from cannula site
* Hypotensive, tachy
* Low O2 sats oddly
182
What pregnancy condition is mum with CF at higher risk of?
GDM
183
Post-dural headache presentation
Worse on sitting up
184
Cerebral venous sinus thrombosis
occurs when a blood clot forms in the brain's venous sinuses, preventing blood from draining out
185
Cerebral venous thrombosis presentation
* Post partum severe headache
* Vision blurring
186
Cerebral venous thrombosis Ix
* CT head
* Rule out haemorrhage/ischaemic stroke
* MRI
* gold standard
187
Cerebral venous thrombosis Mx
* IV heparin (first line), then
* Catheter-guided local throombolysis
* 3-6/12 anticoag following
188
Insulin during delivery (for diabetics)
Sliding sale during labour - maintaining blood glucose between 4-7mmol.
189
What drug is used for active management of third stage of labour?
10IU of oxytocin (syntocinon)
190
Candida in pregnancy treatment
Topical antifungal preferably pessary - Intravaginal clotrimazole
191
What are absolute CIs to induction of labour
* Cephalopelvic disproportion
* Major placenta praevia
* Cord prolapse
* Transverse lie
* Active primary genital herpes
* Previous classical Caesarean section
(Basc same for vaginal delivery)
192
Relative CIs for induction of labour
* Breech presentation
* Triplet or higher order pregnancy
* Two or more previous low transverse caesarean sections
193
DVT/PE Ix
In A&E: ECG and CXR
If + signs of DVT -\> compression Duplex USS (if positive = start tx)
If –ve sx of DVT -\>OR V/Q
