Obs Flashcards
1
Q
Common physiological changes in preg
A
- Cardio: heart function and plasma volume increase; But the inferior vena cava gets compressed
- Circulation: decreased albumin and osmotic pressure (risk of oedema)
- Lungs: increased tidal volume
- GI: N+V; delayed gastric emptying, prolonged small bowel transit time; GI reflux
Also: changes in oxidative enzymes in liver; Increased GFR in kidneys
2
Q
Types of antepartum haemorrhage
A
- Placental Abruption
- Placental Previa
- Onset of labour
Rare:
- Vasa Previa
- Uterine rupture
Can also be from DOMESTIC VIOLENCE. But 50% of time cause = unkown
Small could be: cervical ectropion
3
Q
Placental abruption
A
Sudden detachment of placenta from uterine wall causing bleeding (usually comes out through vagina) and continuous severe abdo pain
- can cause hypovolemic shock
- can see CTG (cardiotocography) changes: shows fetal distress
4
Q
What is suggestive of a large antepartum haemorrhage on abdo exam
A
Abdo feels ‘woody’ on palpation
5
Q
Stages of severity of antepartum haemorrhage
A
- Spotting: spots of blood noticed on underwear
- Minor haemorrhage: less than 50ml blood loss
- Major haemorrhage: 50 – 1000 ml blood loss
- Massive haemorrhage: more than 1000 ml blood loss, or signs of shock
6
Q
Dx of Antepartum haemorrhage
A
Diagnosed via clinical presentation.
Be aware of CONCELED HAEMORRHAGE where cervical os remains closed so vaginal bleeding is disproportionate to uterine bleeding.
7
Q
Acute Mx of major/massive antepartum haemorrhage
A
- Urgent involvement of a senior obstetrician, midwife and anaesthetist + admit to hopsital
- 2 x grey cannula
- Bloods include FBC, UE, LFT and coagulation studies
- Crossmatch/Group and save 4 units of blood
- Fluid and blood resuscitation as required
- CTG monitoring of the fetus
- Close monitoring of the mother
8
Q
Non-acute management of antepartum haemorrhage
A
- USS to exclude placenta praevia
- Antenatal steroids at 24-34+6 wks gestation (matures fetal lungs incase preterm)
-
If parent = Rhesus-D -ve -> need anti-D prophylaxis
- dose determined via Kleihauer test
- Group + save
- CTG for foetal monitoring
- If unstable -> emergency c-section
- FBC, U+E, Group + save
- Active management of third stage for postpartum haemorrhage
9
Q
RFx for placental abruption
A
- PMHx of abruption
- PRE-ECLAMPSIA
- TRAUMA
- Multiple pregnancy; bleeding early in preg
- Fetal growth restriction
- Multigravida
- Increased maternal age
- Smoking
- Cocaine or amphetamine use
10
Q
Placental praevia
A
placenta is over the internal cervical os -> some vaginal bleeding
11
Q
Placental abruption vs praevia
A
Abruption is painful and there is fetal distress. Patients may be shocked.
Praevia is painless but increases in severity and frequency over time. Fetus is often breech/transverse. Don’t do vaginal exam.
12
Q
Types of placental abnormalities (placenta accreta spectrum)
A
- Superficial placenta Accreta (grows into surface of myometrium so doesn’t deteach post-partum)
- Placenta Increta (deeply into myometrium - through to serosa / perimetrium)
- Percreta (goes all the way through wall - can potentially grow into other organs e.g. bladder)
Caused by abnormal decidualisation from defective endometrial-myometrial interface - usually due to scars
13
Q
Vasa previa
A
Malformation of umbilical vessels resulting in them running through PLACENTAL membrane instead of umbilical cord AND passing on/near internal cervical os (uncommon)
Px as - brisk PAINLESS bleeding on rupture of amniotic membrane with FOETAL DISTRESS
- typically haemorrhage triggered by dilatation of cervical os / movement of presenting part
These vessels can rupture without a ROM too which leads to the foetus bleeding out + intrauterine haemorrhage
Picked up antenatally on USS OR as bleed post SROM (check with VE - can feel vessels)
14
Q
Uterine rupture Px
A
Sudden PAIN + PV BLEEDING
Sudden STOP IN CONTRACTIONS and foetal distress on CTG
Hypotension, Tachycardia, possible collapse
15
Q
gynae causes of antepartum bleeding
A
Cervical polyps/Cancer
16
Q
Miscarriage
A
Early: spontaneous termination before 12wks gestation
Late = 12-24wks
17
Q
Types of miscarriage
A
- Missed miscarriage
- Threatened
- Inevitable
- Incomplete
- Complete (everything gone)
- Anemryonic preg (sac present but no embryo)
18
Q
Missed miscarriage + management
A
- Uterus empty before 20 wks but cervical os is closed so any bleeding is contained -> asymp
19
Q
Threatened miscarriage
A
Painless uterine bleeding but cervix is closed. Fetus is still alive at first.
20
Q
Inevitable miscarriage
A
Heavy bleeding with clots and pain
Cervical os is open
21
Q
Incomplete miscarriage
A
Pain and vaginal bleeding through open cervical os but not all products of conception have been expelled
22
Q
Dx of miscarriage
A
- fetal heartbeat should be present if crown-rump length bigger than 7mm
- if no heartbeat repeat after week to confirm
- fetal POLE should be present is gestational sac mean diameter >= 25mm
- if not; repeat after 1 wk to confirm anembryonic preg
23
Q
Mx of miscarriage
A
- <6 wks = only expectant if no complications (just wait for it to happen) + preg test after 7-10 days to confirm
- > 6wks = referr to early preg assessment service (EPAU)
- USS to confirm
- Expectant +/- pain relief/anti-emetic if no risk factors
- Medical management = MISOPROSTOL (prostaglandin analogue) -> binds to prostaglandin receptors in cervix, softens it and stimulates uterine contractions
- Surgical: Manual vacuum aspiration (local anaesthetic, outpatient); Electric vac asp (general anaesth) - typically for incomplete
- need to give anti-D prophylaxis if resus -ve
24
Q
What happens in stage 1 of labour
A
From onset till full dilation - 3 phases:
- Latent phase = 0-3/4cm (0.5 cm/hr + irregular)
-
Active = 3/4-7cm or till 10cm (1cm/hr + regular + stronger at end)
(- Transition phase = 7-10cm (1cm/hr + strong + regular))
25
Interventions for stage 1 labour
**Membrane sweep** (seperate sac from uterus) – can be done in community
**Prostaglandin pessary** – done as inpatient
Amniotomy (break sac) – not routine
Oxytocin – offered for delayed first stage
26
Stage 2 of labour
Full dilation to fetal delivery (~1 hour)
27
Stage 2 labour interventions
- Changing positions
- Oxytocin (stimulates uterine contractions if weak)
- Instrumental delivery:
- Ventouse (vacuum cup)
- Forceps
- Epiostomy (cutting perineum)
- C-section
- Classical C-section (rarely done as it involves upper part of uterus and contraindicates future vaginal delivery)
Analgesia just in general
28
Main complications associated with stage 2 of labour
- Shoulder dystocia
- cord prolapse
- Breech presentation
29
Shoulder dystocia
Anterior shoulder gets stuck behind pubic symphesis after head already delivered.
Oft due to macrosomia from gestational diabetes.
30
Diagnosis of shoulder dystocia
Clinical - can present with:
- Difficulty in delivery of the fetal head or chin.
- Failure of restitution - baby doesn't turn to side
- Turtle neck sign - head delivered but then retracts back in (head still visible)
31
Mx of shoulder dystocia
It is an obs emergancy so get senior obs, midwife and peads
Get mum to stop pushing; only use axial (upward) traction on baby (pushing down can cause bracial plexus damage and pushing in can cause uterine rupture)
Consider episiotomy to increase space + reduce risk of tearing
32
First line manouver for shoulder dystocia
- **McRoberts** (hyperflex hip - knees up and out) -> **posterior pelvic tilt** lifting pubic symphysis + stop pushing
- **Suprapubic pressure** (sustained or rocking) - dislodge baby from behind pubic symphysis
Over 90% success
33
2nd line manouvers for shoulder dystocia
- **Posterior arm** (Rubins) – insert hand posteriorly into sacral hollow and grasp posterior arm to deliver.
- **Internal rotation** (“Wood's screw manoeuvre”) – apply pressure simultaneously in front of one shoulder and behind the other to move baby 180 degrees or into an oblique position.
Repeat with patient on all 4s if not working
34
3rd line Mx for shoulder dystocia
- Cleidotomy – fracturing the fetal clavicle.
- Symphysiotomy – cutting the pubic symphysis.
- Zavenelli – returning the fetal head to the pelvis for delivery of the baby via caesarean section
35
Complications of shoulder dystocia
- Fetal hypoxia (and subsequent cerebral palsy)
- **Brachial plexus injury and Erb’s palsy (arm paralysis)**; clavicle fracture
- Perineal tears (can extend into anal muscle/lining)
- Postpartum haemorrhage
More likely to get again in future
36
Umbilical cord prolapse
Umbilical cord falls out beneath presenting part of fetus after membrane rupture. Presenting part can compress cord -> fetal hypoxia and distress.
Typically happens when fetus in abnormal lie (enough room for card if head is down)
37
Dx of cord prolapse
Suspect if CTG shows distress!
found with VE or speculum examination.
38
Mx of cord prolapse
Is an obs emergancy -> c-section
Don't push cord back in; minimal handling (can cause vasospasm); keep it warm and wet
- Push up presenting part if compressing
- Lie in left lateral position with + pillow under hip OR on all fours (relieves pressure)
- Can give **Tocolytic meds (terbutaline)** - minimises contractions
39
Stage 3 of Labour
Post-fetal delivery; placental delivery
40
Interventions to stimulate stage 3 labour + when is it classed as delayed
Active:
- **IM oxytocin**
- clamp cord after 1 min
- **controlled cord traction** (pulling)
Physiological - clamp cord after pulsation stops
**>30 mins with Active Mx** OR **>60 mins with Physiological** = **prolonged**
- need to do VE with analgesia + consider manual removal
41
Define Postpartum haemorrhage (PPH)
- 500ml blood after vaginal
- 1000ml blood after c-section
minor = <1000ml
major mod = 1000-2000 ml
major severe = >2000ml
42
Primary vs Secondary PPH
- Primary PPH: bleeding **within 24 hours** of birth
- Secondary PPH: from **24 hours to 12 weeks** after birth
43
Causes of primary PPH
Four Ts:
– Tone (uterine atony = utermine muscles don't contract enough to clamp blood vessels - main cause)
- Trauma (e.g. perineal tear)
– Tissue (retained placenta)
– Thrombin (bleeding disorder)
Rare: cervical/high vaginal tear or uterine rupture
44
Mx of primary PPH
- ABCDE
- Lie flat
- 2x large cannulas
- Bloods + clotting screen
- Group + save/crossmatch 4 units
- IVfluids/blood as required
- OXYGEN
- Fresh frozen plasma (if clotting abnormal/still needing more blood)
45
Mechanical treatment to stop PPH
- Rub uterus (stimulate contraction)
- Cathetarise (distended bladder stops uterus contraction)
46
Medical treatment of PPH
- **Oxytocin** (slow injection followed by continuous infusion)
- Ergometrine (intravenous or intramuscular) - stimulates smooth muscle contraction (contraindicated in hypertension)
- Carboprost/PGF2a (intramuscular) - stimulates uterine contraction (caution in asthma)
- Misoprostol (sublingual)
- **Tranexamic acid** (intravenous) - antifibrinolytic
47
Surgical treatment of PPH
- **Intrauterine balloon tamponade** – inflatable balloon into the uterus to press against the bleeding
- **B-Lynch suture** – putting a suture around the uterus to compress it
- Uterine artery ligation (one or more arteries) – reduce the blood flow
- Hysterectomy (last resort)
48
Causes of secondary PPH
Endometritis +/- retained tissue
Rare: Gestational trophoblastic disease or gynae causes
49
Investigate secondary PPH with
- USS (? anything in uterus)
- Endocervical and high vaginal swabs for infection
50
Management of secondary PPH
- Surgical evaluation of retained products of conception
- Antibiotics for infection
if severe may need endoscopic exploration + histology
51
Gestational diabetes
Diabetes cuased by REDUCED INSULIN SENSITIVITY during pregnancy
- typically resolves after birth
Defined as glucose intolerance with fasting blood glucose >= 5.6 mmol/L or 2-hr plasma glucose >= 7.8 mmol/L on a 75g Oral Glucose Tolerance Test
52
RFx for gestational diabetes
- PHx of gestational diabetes
- BMI > 30 (obesity)
- Ethnicity (black caribbean, middle eastern and south asian)
- FHx of diabetes in 1st degree relatives
- Previous macrosomic baby
- Maternal Hx of stillbirth / perinatal death
53
Screening for gestational diabetes
Oral glucose tolerance test
- drink 75g glucose in morning (no food before)
- Blood sugar measured before and 2 HOURS after
Normal max values:
- 5.6 mmol/l fasting
- 7.8 mmol/l at 2 hours
(5-6-7-8)
Used if any ONE of RFx or Signs are present
- routine screening is done between 24-28 wks
- if Sx (glycosuria) then test then itself
For people without RFx -> Just screen based on URINALYSIS at ANC
54
Signs indicative of gestational diabetes
- Large for date fetus (/macroscomic)
- Polyhydraminos (increased amniotic fluid)
- Glucose on urine dip
- Diabetes Sx (thirst, polyuria etc)
55
Management of gestational diabetes
Inform + explain. **USS every 4 weeks at 28, 32, 36 wks** (check fetal growth + aminotic fluid). Monitor blood **glucose 4 times a day**.
- Fasting glucose **<7**: **diet + exercise for 2 wks**. Continue if working, otherwise progress to metformin, then insulin.
- **Fasting glucose > 7** mmol/l: **start insulin** ± metformin
- Fasting glucose above 6 mmol/l plus macrosomia (or other complications): start insulin ± metformin
*Can also give **glibenclaminde** (sulphonylurea) if not tolerating others (other diabetes meds can be teratogenic) but risk of neonatal hypoglycaemia*
Carry on glucose testing postpartum to ensure the GDM resolves (can develop T2DM)
56
Glucose target levels for diabetes during preg
- Fasting: 5.3 mmol/l
- 1 hour post-meal: 7.8 mmol/l
- 2 hours post-meal: 6.4 mmol/l
- Avoiding levels of 4 mmol/l or below
57
Complications of gestational diabetes
Foetal
- **Macrosomia** +/- shoulder dystocia
- **Neonatal hypoglycaemia**
- **Childhood obesity**
- Polycythaemia (raised haem specifically)
- Jaundice (raised bilirubin)
- Congenital heart disease
- Cardiomyopathy
- Premmie delivery
- Increased risk of sacral agenesis
- Long term risk of baby developing **T2DM / METABOLIC SYNDROME in later life**
Maternal
- Increased risk of **HTN** / Pre-eclampsia
- Future risk of developing GDM in subsequent preg
- **60% get T2DM**
- Increased CVD risk
58
Neonatal hypoglycaemia after gestational diabetes
Caused due to babies being accoustomed to high levels of sugar in blood - struggle to maintain with oral feeding after birth
Need to be closely monitored
Give **IV dextrose or nasogastric feeding** if blood sugar **<2 mmol/l or Sx** - otherwise monitor + feed
59
Pre-eclampsia
Defined as: pregnancy-induced hypertension associated with organ damage, notably **proteinuria** but also **other organ dysfunction** or **placental dysfunction**
Characteristic:
- **HTN**
- **proteinuria**
- **oedema**
59
Pre-eclampsia pathophys
After 20wks gestation the **spiral arteries** of the placenta form abnormally causing **high vascular resistance**
60
Complications of pre-eclampsia
- organ damage/failure
- fetal growth restriction
- seizures (eclampsia)
- EARLY LABOUR
- placental abruption
- Death
61
pre-eclampsia vs gestational HTN vs eclampsia
Gestational HTN by itself has NO PROTEINURIA
Eclampsia is when seizures occur as a result of pre-eclampsia
62
RFx for pre-eclampsia
High
- **HTN**
- **PMHx**
- Autoimmune (e.g. SLE)
- **DIABETES**
- **CKD**
Moderate
- AGE: >40 years old
- Nulliparity (never given birth before)
- >10 yrs since last preg
- Multiple pregnancy
- **Obesity**
- FHx
Previous vascular disease
63
Pre-eclampsia prophylaxis
ASPIRIN
From 12 wks until birth if people have 1 high-ridk factor or 2/more moderate-risk factors
64
Sx of pre-eclampsia
Symptoms are caused by the complications (HTN comps baso)
Can be asymp
- **Headache**
- **Visual** disturbance or blurriness
- **Upper abdominal pain** (due to liver swelling)
- Nausea and vomiting
- Oedema
- Reduced urine output
- **Brisk reflexes**
- Reduced foetal movements
65
How is proteinuria quantified
- **Urine protein:creatinine ratio** (above 30mg/mmol is significant)
- **Urine albumin:creatinine ratio** (**above 8mg/mmol** is significant)
66
Diagnosis of pre-clempsia
Test **placental growth factor** (protein which stimulates angiogenesis) levels once between 20-35 weeks
- **LOW in pre-eclampsia**
67
Pre-eclampsia screening
Every pregnant person is monitered every antenatal appointment
- Blood pressure
- Symptoms
- Urine dipstick for proteinuria
68
management / investigations for gestational HTN (no proteinuria)
- Regular BP READINGS
- Treating to aim for a blood pressure below 135/85 mmHg
- Admission for women with a blood pressure **above 160/110 mmHg**
- **Urine dipstick** testing at least weekly (2+ = pre-eclampsia)
- **sFLT : PLGF ratio** (placental growth factor) testing ONCE (**>85 = diagnostic**)
Additionally:
- Weekly BLOODS (full blood count, liver enzymes and renal profile)
- Monitoring fetal growth by SERIAL GROWTH SCANS
- SERIAL UA DOPPLER
- CTG:
- on Dx
- if pain
- PV bleed
- Sx deterioration
- reduced foetal movements
- Foetal HR (offer at every appointment - aka 2 weekly)
69
Pre-eclampsia initial management
Similar to gestational HTN BUT:
- Scoring systems are used to determine whether to admit the woman (fullPIERS or PREP‑S)
- **Blood pressure monitored at least every 48 hours**
- *Urine dipstick testing is not routinely necessary (the diagnosis is already made)*
- **Ultrasound monitoring of the fetus, amniotic fluid and dopplers is performed two weekly**
- + bloods to check for organ dysfunction
- CTG as required (aka if on ward with something concerning)
- Check FHR
70
Pre-eclampsia Tx
**Prevention = 75mg ASPIRIN OD from 12wks**
1. **Labetolol**
2. **Nifedipine** (modified-release)
3. **Methyldopa** (needs to be stopped within two days of birth)
Consider induction / c-section at 37 wks
- ***Severe ICU care = Intravenous hydralazine***
- **IV magnesium sulphate** - during labour and in the 24 hours afterwards to prevent seizures
- Fluid restriction - during labour in severe pre-eclampsia or eclampsia, to avoid fluid overload
NB: **switch to Enalapril (1st line)** (or Nifedipine/amlodipine 2nd) after birth
71
Treatment of eclampsia
IV magnesium sulphate + Emergancy section
72
HELLP syndrome
combination of features occuring from complications of pre-eclamsia/eclampsia
- **H**aemolysis
- **E**levated **L**iver enzymes
- **L**ow **P**latelets
73
Main infections relevent to pregnancy
- Herpes Simplex (can get verticle transmission through vesicles so c-section if attack within 6wks of delivery)
- Group A strep
- Group B strep
- HIV
74
Group A strep in preg
Cause perinatal sepsis and chorioamnionitis
treat with IV Abx
75
Group B strep
Commensal in in birth canal -> neonatal sepsis
Treat with IV PENICILLIN if risk factors present
76
Risk factors for neonatal Strep B infection
- previous infected child,
- **ROM >18hr**
- maternal fever in labour
77
Complications of HIV in preg
- Inter-Uterine Growth Restriction (IUGR)
- Still birth
- Pre-eclampsia
- Prematurity
- Gestational DM
78
Prevention of vertical transmission of HIV in preg
- Maternal ART (anti-retroviral therapy)
- Elective C/S
- Avoid breast feeding
- Neonatal ART
79
Complications of gonorrhoea in preg
- prematurity
- early labour
- perinatal mortality
- VERTICAL TRANSMISSION leading to:
- GONOCOCCAL CONJUNCTIVITIS - eye pain, redness + discharge
80
Management of gonorrhoea in preg
- Prophyl antibiotics to prevent gonococcal conjunctivitis
- otherwise same as usual - **1 dose IM CEFTRIAXONE 1g**
Any infected babies urgent referral to prevent blindness
81
Preg women at higher risk of developing UTIs. What are the complications associated with UTI in preg?
- PRETERM DELIVERY
- Low birth weight
- Pre-eclampsia
Other adverse preg outcomes
82
Management of UTI risk in preg
Preg women tested for ASYMP BACTERIURIA at booking + routinely:
**MSU -> MS+C **
(don't usually test if asyp but must do in preg because of risk of complications)
83
Treatment of UTI in preg
**Needs 7 days as it is complicated**
- Nitrofurantoin (NOT IN 3RD TRIMESTER -> *neonatal haemolysis*)
- Amoxicillin (only if sensitivites known)
- Cefalexin
- Trimethoprim (NOT IN 1ST TRIMESTER - folate antagonist -> *neural tube defects*)
84
How can you seperate between monochorionic and dichorionic diamniotic twins on USS?
- Dichorionic = lambda/twinpeak sign
- Monochorionic = T sign (the chorion doesn't peak, is flat)
85
Complications of multiple preg for mother
- **ANAEMIA**
- **Polyhydramnios**
- Hypertension
- Malpresentation (head not down in labour)
- Spontaneous preterm birth
- Instrumental delivery (ventouse or forceps used) or caesarean
- Postpartum haemorrhage
86
Complications to baby in multiple pregnancy
- **Miscarriage**
- Stillbirth
- **Fetal growth restriction**
- **Prematurity**
- Twin-twin transfusion syndrome
- Twin anaemia polycythaemia sequence
- Congenital abnormalities
87
Twin-Twin Transfusion Syndrome (TTTS)
Occurs in some monochorionic diamniotic pregs
One fetus (recipient) recieves the majority of the blood while the other (donor) is starved.
Recepient - FLUID OVERLOAD -> HF and POLYHYDRAMNIOS
Donor - GROWTH RESTRICTION, ANAEMIA, OLIGOHYDROAMNIOS
Connection between blood supplies can be destroyed with laser treatment if severe
88
Twin Anaemia Polycythemia Sequence
Similar to TTTS but less acute
One twin ANAEMIC, the other POLYCYTHEMIC
89
What is a partogram
A compositie graphical record of key data from both fetus and parent, USED DURING 1st stage of LABOUR, all on the same sheet of paper; all against time on the x-axis
90
What information is recorded on a partogram
- **CERVICAL DILATION (vaginal exam every 4 hours)**
- **DESCENT of FETAL HEAD** (in relation to **ischial spines** on maternal pelvis)
- Vitals:
- Maternal pulse, BP, urine output + TEMP
- Fetal Heartrate, colour of amniotic fluid, moulding of fetal skull
- **FREQUENCY OF CONTRACTIONS** (measured in contractions / 10 mins)
- State of MEMBRANES + ?MECONIUM STAINED LIQUOR (when baby opens bowels before waters burst)
- RECORDS OF ANY DRUGS + FLUIDS GIVEN
If labour is too slow, will cross 'Alert' and then 'Action' lines:
- Consider Amniotomy (artificially rupture membranes - uncommon)
- Escelated to Obstetrics/senior decision makers + take action
- Threshold for taking action may be lower if something abnormal with measurements
91
What is the aimed for uterine contraction frequency in labour
4-5 per 10 minutes
92
What factors determine the sucess of Stage 2 of labour
the 3 P's:
- Power (strength of contract)
- Passenger:
- Size of fetus
- Attitude i.e POSTURE
- Lie - Longitudinal, Transverse or Oblique
- Presentation
- Passage (size + shape of passageway/pelvis)
93
Puerperium meaning
The period of ~6 wks after from placental delivary; when maternal reproductive organs return to non-preg condition + the initiation/suppression of lactation
94
Non-medical management of pain during labour
- Education of what to expect + Good Support
- Relaxed environement
- Change position as required to stay comfortable
- Controlled BREATHING
- Potentially water births (ineligible if needing regular monitoring/pre-eclampsia)
- Potentially TENS machine (Transcutaneuos Electirical Nerve Stimulation) at start of labour (stimulates endorphins + can reduce need for opioids for 5 hrs after)
95
Options for Medical Mx of pain relief in labour
- Simple analgesia (NOT NSAIDS)
- Gas + Air (Entenox) = **50% NO + 50% O2** (ONLY SHORT TERM)
- IM Pethidine OR Diamorphine
- Patient controlled analgesia (REMIFENTANIL = short-acting opiate)
- EPIDURAL
- Levobupivacaine
- Bupivacaine
- Fentanyl
96
Pain pathway in 1st vs 2nd stage of labour
1st stage:
- Pain from lower UTERINE + CERVIAL change
- VISCERAL AFFERENT nerve fibres
- **T10 - L1** Segments
2nd stage:
- Distension of PELVIC FLOOR, VAGINA + PERINEUM
- SOMATIC nerve fibres, PELVIC SPLANCHNIC + PUDENDAL nerve
- **S2 - S4**
97
Pros + Cons of Entenox
Pros
- Works immediately
Cons:
- Lightheaded, Nausea, Sleepiness, Tiring, Drys mouth
- Have to take deep breaths at start of contraction so Too distracting to use while pushing
98
Diamorphine (/ Pethidine) functioning +
- can give IM or SC
- Take around 30 mins to work
SE:
- Baby: SLEEPY, SLOW BREATHING, POOR FEEDING initially
- Mum: SICKNESS + Sleepiness
99
Patient Controlled Analgesia pros + cons
- Useful for those for whom neuroaxial anaesthesis is Contranindicated e.g. Clotting disorder, spinal abnormalities etc
- Works within 30 SECONDS
- Oft used alongside entox
Cons:
- Gotta press button for each contraction
- Not as effective in 2nd stage
- Wears of after a few minutes
- Baby - may be slow to breath
- Mum - Sickness, sleepiness, slow breathing/bradycardia, O2 may be needed via nasal cannula
100
Epidural + CSE functioning
- 1:10 may not work as well + need replacing
- Take ~ **20 minutes** to work
- CSE = FASTER
- Catheter + IV fluids
101
Risks/SE of Epidural / CSE
- Low BP (but this is known + easily treatable)
- **Severe Headache; worse on sitting up + in bright light** if needle punctures dura (typically due to CSF leaking out)
-> treat with Epidural Blood Patch + caffine drinks
- Nerve damage / severe nerve injury
- **need to do urgent anaesthetic review if they get motor weakness**
- Spinal / Epidural Abscess
- Meningitis
- Spinal Haematoma
- Increased probability of instrumental delivery
102
Which method to use for fetal monitoring
- INTERMITTENT AUSCULTATION if low risk
- Continuous CTG if HIGH RISK
103
How to carry out intermittent auscultation
in 1st stage:
- Palpate for at least 1 min immediately after palpated contraction
- Repeat every 15 mins
- Record any acels/decels
- Palpate maternal pulse every 1hr to ensure the FHR being heard is diff
In stage 2:
- 1 minute every 5 MINUTES after a contraction
104
When to increase fetal monitoring
- If increase in FHR of **20bpm or more** since start of labour
- Decelerations
Carry out a FULL CLINICAL REVIEW as well
105
What to do if concerned about FHR
- Summon help
- Advise continuous CTG monitoring
- Transfer to CLC (consultant led care)
- Return to IA if continous CTG is normal after 20 minutes
106
Categories of c-section
- Cat 1
- Deliver within 30 MINUITES of making decision
- Cat 2
- Deliver within 75 MINUTES (e.g. in labour but FAILURE TO PROGRESS)
- Cat 3
- Delvier within 24 HOURS (e.g. induced labour but not progressing enough)
- Cat 4
- elective (plan months in advance)
107
Variations that can be seen in CTGs
- Variable = norm (baby should be able to push up HR when required)
- Reduced variability (loss of accelerations - could be due to baby tiring OR sleeping)
- Increased variability
- Sinosoidal (risk of FETAL COMPROMISE if had prev abnormal CTGs)
- Variable decels (tiring if antenatal - in labour could be due to cord/skull compression)
- Late decelerations (tiring fetus)
108
Physiology of puerperium
- Endocrine changes
- Decrease in placental hormones (human placental lactogen, hcg, oestrogen + progesterone)
- Increased prolactin
- Involution of uterus + genital tract
- Muscle ischaemia, autolysis + phagocytosis
- Decidua shedding as LOCHIA
- Breast
- Lactogenesis / Lactation supression
109
Changes during involution of uterus + genital tract
- Should be able to feel hard muscle layer at umbilical level just after birth
- Height should decrease by ~1cm per day
- Returns to pelvis by day 10
- Continues for ~6wks
- Cervix internal os should be closed by 2nd weeks
- external os may remain dilated up to permanently
110
Diff stages of Lochia
- Rubra = day 0-4
- Blood + cervical discharge od Decidua (fetal membrane, vernix + meconium)
- Serosa = day 4-10 (pinky)
- Cervial mucus + exudate
- Fetal membrane; microbes; WCC
- Lochia Alba = day 10-28:
- Cholesterol + fat; Epithelial cells
- Microbes + Leukocytes
- Mucus
At no point should it smell offensive -> infection
111
Prolactin response
- Baby suckles / is in contact with nipple
- sensory impulse sent from nipple to brain
- prolactin secreted by **ANTERIOR PIT GLAND** -> blood -> breasts
- **LACTOCYTES** produce milk
More is secreted at night; Levels peak after feed to get milk for next feed
Supresses ovulation if exclusively breastfeeding - for 6 MONTHS
112
Oxytocin / Let-down reflex
- Suckling
- Sensory impulse to brain
- oxytocin secreted by **POSTERIOR pit gland**
- **MYO-EPITHELIAL CELLS** contract + EXPEL milk
Stimulated by sight, sound + smell of baby -> gets conditioned to release as soon as triggered by baby over time
Works BEFORE + DURING feeding to get milk flowing
Hindered by ANXIETY, STRESS, PAIN + DOUBT
113
Benefits of breast feeding
- Breastfeeding for 6 months - reduces risk of breast cancer in future
- and suppresses ovulation (only if exclusively breast feeding)
- Reduces risk of allergies + atopy; diabetes in kids
- Reduces incidence of acute conditions:
- GI disease
- resp disease
- otitis media
- NECROTISING ENTEROCOLITIS
114
Functions of LACTOFERRIN in milk
- Regulates intestinal iron abdorption + iron delivery to cells
- Protection against microbes + pathogens
- Boosts immune system
- Helps regulation of bone marrow function
115
Sx which indicate mothers should report in puerperial period + the conditions associated with these presentations
- Sudden/profuse blood loss; peristent increased blood loss; Faint, dizzy, palps/tachycardia
- PPH; Retained placental tissue; endometritis
- Abdo, pelvic or perineal pain; fever; shiverinng; offensive smelling vaginal discharge
- INFECTION
- Persistent/severe headache
- HTN
- PRE-ECLAMPSIA
- Postdural-puncture headache
- Migraine, Intracranial pathology
- Infection
- Leg swelling/tenderness esp if unilateral; SOB or chest pain
- VTE or cardiac problems
116
What are the signs of sepsis
Remember: 3 Teas WHITE with SUGAR
- TEMP: **>38** or **<36**
- TACHYcardia: **HR > 90 bpm**
- Tachypnoea: **RR > 20 bpm**
- WCC: **>12** or **<4** x10^9/L
- HYPERGLYCAEMIA: **>7.7 mmol**
AND evidence of organ dysfunction
117
Red Flag markers of severe sepsis
- BP: <90mmHg systolic OR >40mmHg drop from norm
- HR >130 bpm
- RR > 25/min
- **O2 sats < 90%**
- **Urine output <30 ml/hr**
- Lactate > 2mmol/L
Do sepsis 6/BUFALO within 1 HR if ANY ONE of these markers present
118
Red flags of mental health diorders in peurperium
1. Recent significant CHANGE IN MENTAL STATE or NEW Sx
2. NEW THOUGHTS or acts of VIOLENT SELF HARM/SUICIDE
3. NEW + PERSISTENT expressions of INCOMPETENCY as mother or ESTRANGEMENT FROM BABY
119
Postpartum psychiatric conditions
- Depression
- Puerperal psychosis
- PTSD
Baby blues (low mood + irritability for ~1wk post birth) is very common and is not clinically concerning unless it develops into depression or psychosis
120
Why may it be difficult to detect puerpural mental health disorders
- Fear of Tx
- Fear of baby being taken
- Just coping day to day
- Stigma of mental illness / Cultural underecognition
- Belief that health wrkers are not interested
- Denial by parent / family
- LACK OF RECOGNITION OF SERIOUSNESS by health care professional
121
Baby blues Sx
- Mood swings
- Low mood
- Anxiety
- Irritability
- Tearfulness
Tend to be mild + self-resolve within 2 wks
Occurs in >50% of mothers
122
Baby blues aet
- Significant hormonal changes
- Recovery from birth
- Fatigue and sleep deprivation
- The responsibility of caring for the neonate
- Establishing feeding
- All the other changes and events around this time
123
Presentation of Postpartum depression (PPD)
Can present up to 12 months after birth
Classic triad:
1. Low mood
2. Lethargy
3. ANHEDONIA
+ Bio Sx e.g. poor appetite; disrupted sleep (not caused by baby)
May include more baby related stuff e.g.:
- negative cognitions about motherhood and coping skills
- anxiety about baby
- illness; being unable to care adequately; fear they may harm baby
- hopelessness about the future
124
When is urgent specialist mental health referral needed for postpartum mental health disorders
Any of following
- Severely depressed
- Risk of self-harm / suicide
- Evidence of self-neglect
- Manic features / behaviour OR previous definite/possible Dx of bipolar (or any other severe mental illness)
- PSYCHOTIC FEATURES
- Consider if FHx of severe mental illness / suicide
- ESTRANGEMENT FROM INFANT
esp if severe enough to be concerned about baby's wellbeing
125
Postpartum depression (PPD) Epid
10% per year experience
126
Risk factors for postpartum depression (PPD)
- Low socioeconomic status
- PHx/FHx of mental health disorders
- Lack of social support
127
PPD aet
Bio factors:
- Hormonal fluctuations
- Immunoinflammatory processes
- Genetic predisposition
Psych:
- PHx/FHx
- Neurotic personality
- Stress + unrealistic expectations of motherhood
Social:
- Lack of support
- Relationship issues
- Life stressors
- Low socioecon
128
PPD Dx
Needs to last at least 2 weeks (to differentiate from baby blues)
- Edinburgh Postnatal Depression Scale (evaluates intensity of Sx over past wk)
- 10 Qs
- score of 10/30 or more = postnatal depression
- Psych Hx
- Complete physical examination + lab Ix to rule out DDx
- e.g. hypothyroid, anaemia
- esp if atypical Sx or not responding to Tx
129
PPD Mx
Mild:
- More support + follow-up with GP
- Self-help
Moderate:
- CBT or Interpersonal Therapy (IPT)
- SSRIs if more severe/risk identified - avoid where possible if breastfeeding BUT TOTALLY FINE DURING PREG
- Paroxetine + SERTRALINE more safe
Severe:
- Specialist Perinatal psych services input + rarely inpatient mother + baby unit care (or just on psych ward)
130
Postpartum psychosis/Puerpural psychosis epid
- 1-2 in 1000 women experience (rare)
- More likely if PHx of severe mental illness/postpartum psychosis OR FHx of postpartum psychosis
**MORE COMMON IN PEOPLE WITH: Schizophrenia / BIpolar**
131
Postpartum psychosis Px
Typically starts within days/weeks of delivery + can develop within hours
- Hallucinations and/or Delusions (esp paranoia)
- Depression and/or Mania
- Confusion
- Thought disorder
- Sleep disturbance
132
postpartum depression vs psychosis
Depression has more insidious onset while pdychosis develops rapidly + obviously
Both either last longer than baby blues or require intervention (unlike baby blues)
133
Postpartum psychosis Dx
Mainly clinical - Psych evaluation
Ix to exclude DDx e.g. thyroid, sepsis
134
Postpartum psychosis Mx
Urgent assessment + input from perinatal psych specialists
- Admission to mother + baby unit if needed
- CBT
- Meds
- SSRIs - paroxetine + sertraline safer if breastfeeding
- Antipsychotics - OLANZAPINE + QUETIAPINE safe in breastfeeding
- DON'T GIVE LITHIUM or SODIUM VALPROATE during PREG
- Mood stabiliser
- careful if breastfeeding
- Potentially Electroconvulsive therapy (ECT)
Additionally: **50% risk of recurrence so close monitoring in future pregs**
135
Postpartum psychosis prognosis
Pretty good overall
Typically:
- severe Sx for 2 - 12 wks
- full recovery after 6 - 12 months
Earlier Dx seems to reduce long term difficulties
136
SE of taking SSRIs during preg
neonatal abstinence syndrome (also known as **neonatal adaptation syndrome**)
- Presents in the first few days after birth with symptoms like irritability and poor feeding
Monitor + offer supportive Mx
137
Baby blues Mx
Reassure; offer support through health visitors
Safty net - seek help if persisting for >2 wks or develop Sx of depression/psychosis
138
Puerpural infection
Infection within **14 days** postpartum period. Temp >38 degrees
Usually presents with ENDOMETRITIS.
- need to **REFER TO HOSP FOR IV ABX (Clindamycin + gentamicin until afebrile for > 24hrs)**
- think RETAINED PRODUCTS OF CONCEPTION
In vaginal delivary, the uterus is opened so vaginal flora can ASCEND and infect.
- More likely after c-section
Other causes:
- UTI
- **Wound infections**
- Mastitis
- consider fever may be due to VTE
139
Sepsis Signs and Symps in postpartum period
Symps:
- Fever / Rigors
- Diarrhoea / Vomiting (sign of early toxic shock)
- RASH (maculopapular = strep; puprura fulminans = early toxic shock)
- Abdo / Pelvic pain
- Offensive vaginal discharge (anaerobe infection; serosanguinous = strep)
- Productive cough
- Urinary Sx
Signs:
- New onset altered mental state
- TEMP >38 or <36
- HR >130 bpm
- RR >20
- BM >7.7mmol/L (in non-diabetics)
- WCC >12 / <4 x10^9/L
- HYPOXIA
- HYPOTENSION
- Oligouria (< 0.5 ml/kg/hr for at least 2 hrs even with enough fluid input)
- Failure to respond to Tx
140
Postpartum Infected Endometritis aet
Any common bacteria from vaginal tract / entering through skin break in c-section
Also any organisms causing STIs
The wound left behind by placenta is at risk of infection
141
Postpartum infected endometritis Dx
Clinical picture can inform if infected
- Vaginal swabs + Urine MS+C to identify organisms
Consider US to identify retained products of conception but not diagnostic
Straight to sepsis 6 if septic (Bloods, Urine, Fluids, Abx, Lactate, O2)
142
Postpartum Infection Mx
Prophylactic Abx before C-section
If septic -> hosp admission + sepsis 6 (BUFALO):
- CLINDAMYCIN + GENTAMICIN = recommended BROAD SPECTRUM IV ANTIBIOTICS combo
Non-septic -> oral Abx in community
- Co-amox is common broad spec choice but need to test sensitivites to figure out best Tx
143
VTE in preg epid
- the cause of 1/3 of maternal deaths
- More common in postpartum period (possibly because people stop taking the meds because the danger is over)
144
RFx for VTE in preg
Pre-existing:
- Thrombophilia (e.g. Antiphospholipid syndrome, factor V Leiden etc)
- Medical co-morbs e.g. CANCER
- Age >35
- OBESITY (BMI > 30)
- Parity > 3 (at least 3 past kids)
- SMOKING
- VARICOSE VEINS
- FHx
Obs factors:
- Multiple preg
- PRE_ECLAMPSIA
- C-SECTION
- Prolonged labour
- Stillbirth
- Prem birth
- Postpartum Haemorrhage
Transient:
- Surgery
- Dehydration
- Ovarian hyperstimulation syndrome
- Admission / Immobility
- SYSTEMIC INFECTION
- Long distance travel
145
VTE Px
Usually unilateral - esp on LEFT LEG in preg
- calf/leg swelling
- Dilated superficial veins
- Tenderness (esp over deep veins)
- Colour changes
PE:
- SOB
- Cough +/- blood
- Pleuritic chest pain
- Hypoxia
- Tachycardia
- High RR
- Low-grade fever
- Potentially hypotension
146
VTE Dx
- Bloods: FBC, U+E, LFTs, COAG
- D-dimer already raised in preg so unhelpful (can't use WELLs score in preg)
- COMPRESSION DUPLEX USS (can repeat after 1wk if first time is inconclusive)
- For PE:
- ECG + CXR
- CTPA or V/Q scan
- CTPA is best choice if abnormal CXR
- CTPA has a minimal breast cancer risk for mum
- V/Q (ventilation perfusion) scan has increased risk of childhood cancer in baby
If presenting with both DVT + PE -> do doppler USS first and treat if positive as Tx is same for both and want to avoid radiation where possible
147
How does a VQ scan work
- Radioisotpes inhaled into lungs (Ventilation)
- Contrast isotope injected (Perfusion)
- Take pic of both with gamma camera + compare
- should be a deficit in perfusion if PE, but normal ventilation
148
VTE in preg Mx
**SC LMWH** - enoxaparin, dalteparin, tinzaparin
- based on weight recorded at booking clinic/early preg
- start IMMEDIATELY before Dx confirmed if suspected but delay in Dx
- Continue for 6 WEEKS POSTNATAL or 3 MONTHS TOTAL (whichever is longer)
- Can change to oral e.g warfarin or DOAC after birth but can't use before delivery as warferin = teratogenic
- Make sure to do risk assessment before stopping
Experienced MDT Mx if presenting with massive PE + haemodynamic compromise
- Unfractioned heparin
- Thrombolysis
- Surgical embolectomy
Consider IV unfractioned heparin if VTE at term.
DISCONTINUE BEFORE INDUCTION / C-SECTION
149
VTE prohylaxis in preg
- Assess risk based on RFx
- Offer thromboprophylaxis if:
- >=4 RFx till 2nd trimester
- >= 3 RFx in 3rd trimester
- >= 2 RFx in postpartum period
- Continue thrombolysis till 6 wks after birth or for 3 months total
- Consider 10-day course if had a C-section
150
Postpartum anaemia
**Hb < 100 g/L**
151
Dx of postpartum anaemia
**Take FBC if:**
- **Postpartum haemorrhage >500 ml**
- C-SECTION
- Antenatal anaemia
- Sx of anaemia
152
Anaemia in postpartum Tx
Varies slightly with local guidelines
- Hb under 100 g/L - ORAL IRON
- Hb under 90 g/L - IRON INFUSION + ORAL IRON
- iron infusion = risk of allergic/anaphylactic reactions
- Hb under 70 g/L - BLOOD TRANSFUSION
153
When to consider iron infusion in postpartum
- If poor adherence to oral
- Can't tolerate oral
- Failure to respond to oral
- Can't absorb oral (e.g. IBD)
154
When is an iron infusion for anaemia CONTRAINDICATED
During **ACTIVE INFECTION**
- bacteria feed on iron so iron infusion can cause proliferation + worse infection
155
Anaemia in preg Definition
1. 1st trimester = Hb < 110 g/L
2. 2nd/3rd trimester = Hb < 105 g/L
3. Postpartum = Hb < 100 g/L
156
What often causes anaemia during preg + RFx aside from pre-existing conditions
Plasma volume increases disproportionately to RBcs in preg -> HAEMODILUTION EFFECT - predisposes to anaemia
RFx other than pre-existing conditions:
- Increasing maternal age
- Low socioeconomic status
- Poor diet
- PHx of anaemia during preg
157
Anaemia screening during preg
- recommended to screen everyone at 28 wks
- additional screening at 20-28 wks if multi preg
158
Anaemia in preg Mx
Assuming it's not macrocytic on MCV - probs iron def
-> trial oral iron (100-200mg) - if they resposnd to it this is diagnostic
- FERROUS SULPHATE / FERROUS FUMARATE
-> Ferinject (infusion) if poor compliance/malabs
- If folate def -> usually 5mg folate once - thrice daily depending on how much is required
- Beta thalessaemia -> Folate supps + blood transfusions
- Aim = Hb 80 g/L during preg; 100 g/L at delivery
- Sickle cell - folate + iron supps
CONTINUE FOR 3 MONTHS AFTER IRON CORRECTED TO ALLOW STORES TO REPLENISH
159
What is the significance of rhesus states in preg
- Rhesus antigens are found on RBCs (seperate from ABO groups)
- Can be Rhesus D +ve or -ve
- If the mum is rhesus D -ve and baby is rhesus D +ve - when baby's antigens get into mum's blood -> causes an immune reaction as mum recognises it as foreign and makes ANTIBODIES
- Becomes sensitised at this point
- If they have another +ve baby - the antibodies in the mum's blood can get into baby + attach to baby's RBCs
- Baby's immune system attacks their own RBCs -> haemolysis -> HAEMOLYTIC DISEASE OF THE NEWBORN
160
Rhesus incompatability Mx
Prevention is main as can't reverse sensitisation process once it has occured!
- IM ANTI-D to rhesus-D -ve women
- attaches to rhesus-D antigens on the FETAL RBCs in mum's circulation and destroys them
- prevents mum from making her own antibodies -> prevents sensitisation
Given at:
- 28 wks
- Birth (IF baby is rhesus +ve)
- At any other point where sensitisation can occur
- Antepartum haemorrhage
- Amniocentesis procedures
- Abdo trauma
Has to be given 72 HOURS of sensitisation event
161
When is Kleihauer Test done
Done after 20 weeks gestation
- Checks how much fetal blood has passed into mum's blood during rhesus-D sensitisation event
- Assesses if more anti-D is needed
162
What does Kleihaur Test involve
- take bloods from mum
- add acid
- destroys only mum's cells as fetal Hb is more resistant to acid as acidosis occurs during childbirth
- Number of cells left is calculated
163
The postpartum period definition
typically say 6 WEEKS
However, when talking about perinatal mental health - this can be up to a year after birth
164
Key factors of perinatal mental health Hx
- PHx + psych Hx
- DHx + substance use
- FHx
- Domestic / Sexual abuse
- Patient Health Questionnaire-9 (PHQ-9)
165
RFx for placenta accreta
- Previous placenta accreta
- Previous endometrial curettage
- Previous C-SECTION
- Multigravida (multiple previous preg)
- Increased maternal age
- Low-lying placenta / placenta previa
166
Px of placenta accreta
Usually asymp until unable to deliver placenta + SIGNIFICANT POSTPARTUM HAEMORRHAGE
- Can get antepartum haemorrhage in third trimester
- Can see on antenatal US - esp close attention if have RFx
167
Placenta accreta Dx
- USS
- MRI may be used to assess depth + width
168
PLacenta accreta Mx
Specialist MDT Mx - may require:
- Complex uterine surgery
- Blood transfusions
- ICU for mum
- Neonatal intensive care
Plan deliver between 35 - 36+6 weeks gestation to reduce risk of spontanteous labour
- Antenatal STEROIDS for FETAL LUNGS
- can consider:
- Hysterectomy
- Uterus preserving surgery
- Expectant management (leaving placenta in place to be reabsorbed over time)
- Significant risk of bleeding + infection
169
Management of premature labour
- corticoSTEROIDS (promotes fetal lung maturity)
- consider TOCOLYTICS (inhibit uterine contractions to prolong preg)
- NIFEDIPINE (dihydropyridine - usually used for anti HTN/angina so main SE = hypotension)
+ IV antibiotics if infection risk (penicillin best if no allergy)
170
Premature rupture of membranes definiton
Rupture of membranes at least 1 hour before contractions start
171
Prolonged premature rupture of membranes definition
Rupture of membranes >24 hrs before contractions start
172
Preterm premature rupture of membranes definition
Rupture of membranes before 37 weeks gestation (relevant as it is likely to trigger premmie birth)
173
Conditions associated with premature labour / ROM
- Overstretching of uterus (e.g. mutipregnancy + polyhydramnios)
- Foetal risk conditions
- Pre-ecalmpsia
- Interuterine growth restriction
- Placental abruption
- Uterus / cervical problems
- Fibroids
- Congenital uterine malformation
- Short / weak cervix / cervical incompetence
- Previous uterine / cervical SURGERY
- INFECTIONS
- Chorioamnionitis
- Maternal / neonatal sepsis
- Bacterial vaginosis
- Trichomoniasis
- Group B Strep
- STIs
- Recurrent UTIs
- Maternal co-morbs
- HTN
- DM
- Renal failure
- Thyroid disease
174
DDx for premature labour / ROM
- Braxton Hicks contractions (irregular, painless contractions with no cervical dilation / effacement (cervix stretches + gets thinner))
- UTI (suprapubic pain + can sometimes get contractions)
- Placental abruption (vaginal bleeding, abdo pain + hypertonic uterus (uterus doesn't relax between contractions))
- **Uterine rupture** (SEVERE abdo pain, vaginal bleeding, abnormal fetal heartrate + CEASSATION of contractions)
175
Investigation to dx PPROM and asses risk of pre-term delivery
Foetal fibronectin test (fFN test) - protein in vaginal fluid
If -ve = low risk of delivery occuring in next 7-14 days
Speculum examination (check for pooling)
Can do igf-1 or placental alpha microglobulin test to confirm dx
176
Risk factors for ectopic pregnancy
- PID
- Genital infection
- Interuterine device in situ
- Pelvic surgery
- Endometriosis
- If undergoing assisted reproduction
- PMHx of ectopic
177
Ectopic pregnancy Px
- Pelvic pain (may be more so to one side depending on where the ectopic is) +/- tenderness on palpation
- Shoulder tip pain (caused by bleeding from the ectopic causing diaphragmatic irritiation)
- Abnormal vaginal bleeding (missed period OR intermenstrual)
- Haemodynamic instability if the ectopic ruptures
Cervical tenderness (chandelier sign) on bimanual palpation
178
Ectopic pregnancy Ix
- Pregnancy test to confirm actually pregnant
- Transvaginal USS
179
Ectopic pregnancy Mx
3 options - non-of them are viable
Conservative:
- Only done if individual has minimal/no Sx
- Need close follow up with repeat B-hCG tests
- if they don't reduce by themselves, need to move onto active management
Medical:
- METHOTREXATE
- Criteria =
- low hCG levels
- patient can attend a follow up
- patient will adhere to avoiding pregnancy for some time after Tx
- Normally only give ONE DOSE but can give 2 if first doesn't work OR just move onto surgical Mx
Surgical:
- Recommended when:
- patient unable to attend follow-up
- ectopic is advanced
- haemodynamically unstable
- Usually SALPINGECTOMY tho sometimes a less efficient SALPINGOTOMY is done to preserve fertility
- If salpingOTOMy done - need to do serial serum B-hCG to make sure no trophoblastic tissue left in fallopian tube
180
Bishop score
Used to predict how likely it is for spontaneous labour to occur
- **6 or less** = suggests induction with **PROSTAGLANDIN E2 or OSMOTIC DILATOR** needed
- **>6** = can do **ARM +/- OXYTOCIN**
181
When is induction of labour indicated
- Post-dates (>41 weeks gestation)
- Preterm / term prelabour rupture of membranes (after 24hrs expectant Mx)
- Interuterine foetal DEATH
- Abnormal CTG (fetus at risk of dying)
- MAternal conditions like pre-eclampsia, diabetes, cholestasis
- maternal request
- Foetal conditions like IUGR,
182
When is induction of labour contraindicated
- Any previous classical c-sections OR multiple lower uterine segment c-sections
- Transmissible infections (e.g. herpes simplex)
- Placenta previa (blocking cervix)
- Malpresentation (anything aside from the head at cervical os)
- SEVERE foetal compromise
- Cord prolapse
- Vasa previa (fetal blood vessels not in the placenta overlying/near to cervical os)
Basically anything that would cause complications for the foetus if they try to push it out naturally or if the fetus is at risk of imminently dying
183
Which Ix may be involved in determining whether to indue labour
- Bishop scoring system + consider indicative and CI factors
- USS
- confirm gestational age,
- foetal position
- placental location
- Bloods:
- Check maternal health status (pre-clampsia, diabetes, infections)
184
Methods of inducing labour
- Membrane sweep (insert gloved finger into external os, separating membranes from cervix)
- Vaginal prostaglandins / prostaglandin pessary (PGE2) - Ripens cervix + induces contractions
- Amniotomy (artificial rupture of membranes)
- Balloon catheter (inserted into cervix to mechanically dilate)
185
Polyhydramnios common presentation
- Uterus feels tense / large for date
- Fetal parts difficult to palpate
- May be experiencing maternal / fetal complications
186
Causes of polyhydramnios
Excess production of fluid - e.g. due to increased foetal urination:
- Maternal DM
- Foetal renal disorders
- Foetal anaemia
- Twin-twin tranfusion syndrome
Insufficient removal e.g. due to reduced foetal swallowing:
- Oesophagela / duodenal atresia
- Diaphrgamatic hernia (/ other compressive airway lesions)
- Anencephaly (/ other structural CNS anaomaly)
- Chromosomal disorders (e.g. DOWN's)
Placental tumours
~ half of cases are idiopathic
187
Maternal complications of polyhydramnios
- Resp compromise due to increased pressure on diaphragm
- Increased risk of UTIs due to increased pressure on urinary system
- Worsening of other preg associated Sx e.g. GORD, constipation, peripheral oedema, stretchmarks
- Increased incidence of c-section
- Increased risk of amniotic fluid embolism (rare)
Baso more pressure on surrounding structure = worse preg Sx
188
Foetal complications of polyhydramnios
- Premmie labour / delivery
- Prem ROM
- Placental abruptions
- Malpresentation (more space to rotate around)
- Umbilical cord prolapse (can prevent foetus from engaging with pelvis -> leaves room for cord to prolapse out -> can cause cord compression)
189
Polyhydramnios Mx
- Mx managable underlying causes eg. maternal diabetes, pre-eclampsia
- Amnio-reduction if severe
190
Typical size of uterus in relation to gestational age
- 1-11 wks ~ lemon sized
- 12 wks ~ large orange (this is typically when it becomes palpable on abdo exam)
- 12-20 wks ~papaya
- between 18-20wks fundal height is measured
- typically corresponds with number of weeks preg e.g. 32 cm = ~32wks
- Reaches umbilicus ~ 20-22 wks
- watermelon size in 3rd trimester (typically stops at ~ 36-38 wks reaching up to the xiphisternum)
191
Which blood test is typically used to check for suspected menopause
FSH
192
Amniotic fluid embolism definition and epidemiolofy
Life threatening condition when amniotic fluid / other debris enters mother's circulation
Rare but significant cause of mortality / morbidity
**Most likely to occur during / shortly after labour**
193
Amniotic fluid embolism pathophys
Amniotic fluid / debris enters maternal circulation and causes embolism similar to in PE
The fluid also triggers an **inflam response** within mothers immune system -> **can cause DIC**
194
Amniotic fluid embolism Px
- High resp rate
- Tachycardia
- **Hypotension**
- **Hypoxia**
- DIC potentially
195
DDx for amniotic fluid embolism
- Septic shock: Fever, increased heart rate, confusion
- Anaphylactic shock: Rash, swelling, shortness of breath, low blood pressure
- Pulmonary embolism: Chest pain, shortness of breath, irregular heartbeat
- Hypovolaemic shock (e.g. due to placental abruption): Rapid heartbeat, cold and sweaty skin, irregular heart rhythm
196
Amniotic fluid embolism Ix
Clinical diagnosis - no specific tests
197
Amniotic fluid embolism Mx
- 15L O2 non-rebreath + call anaesthetics
- Move to ITU
- FLUID RESUSCITATION
- Continuous foetal monitoring if baby bot yet delivered
- Correct any coagulopathy
- fresh frozen plasma fro prolonged PT
- cryoprecipitate for low fibrinogen
- Platelet transfusion for low platelets
198
Placental abruption Sx
- Abdominal pain (oft sudden + severe)
- "woody" hard uterus
- Contractions
- Vaginal bleeding (tho sometimes blood remains concealed within uterus)
- Reduced foetal movements + abnormal CTG
- Hypovolemic shock (oft disproportinate to how much vaginal bleeding is visible)
199
Placental abruption Mx
Urgent A-E resuscitation as with any significant antepartum haemorrhage
Further Mx depends on foetal health:
- Emergancy delivery - if maternal / foetal compromise
- Might need to c-section out a stillborn baby if there is maternal compromise
- Induction of labour if at term with no compromise (mainly done to avoid further bleeding)
- Conservative management - for some partial / marginal abruptions with no compromise (depending on gestation + amount of bleeding)
**Always give Anti-D within 72 hours of onset of bleeding if mother is rhesus D negative**
200
How may group B strep infection in neonates and maternally present
- Sepsis
- Pneumonia
- Meningitis
The mother may has uterine tenderness and pain (though oft asymp as group b strep is a vaginal commensal)
201
Risk factors for neonatal group b strep infection
- Positive GBS culture in current or previous pregnancy
- Previous birth resulting in neonatal GBS infection
- Pre-term labour
- Prolonged rupture of membranes
- Intrapartum fever >38 degrees Celsius
- Chorioamnionitis
202
When are group B strep cultures / swabs taken in preg women
If there are risk factors or symptoms of infection present
Not routine;y done as colonisation status can change thorughout the pregnancy
203
Prevention of neonatal group b strep infection
Prophylactic antibiotics - usually penicillins
- IV Benzylpenicillin administered during LABOUR and DELIVERY
This is only done if risk factors present
204
Features of neonatal HSV infection
Local
- vesicles on skin
- Eye involvement (conjunctivitis?)
- Oral mucosa involvement without internal organ involvement
Disseminated
- Seizures
- Encephalitis
- Hepatitis
- Sepsis
Typically presents in 1st week post birth but can be up to 4 weeks later
205
Mx of maternal HSV infection during preg
Aciclovir + offer elective c-section
Typically only done if active herpes lesions present at term or if there has been a primary outbreak within 6 wks of labour
206
HSV infection Ix in neonates
- PCR
- viral culture
- Direct fluoroscent antibody testing
- MRi if encephalitis / seizures
207
Management of obstetric pain
- Non-pharm e.g. exercise, heat therapy, TENs (transcutaneous electrical nerve) stimulation, acupuncture, hypnosis, massage
- Entonox (Nitrous Oxide and O2 in 1:1)
- Simple analgesia (e.g. paracetamol)
- Opiate analgesia (e.g. codeine phosphate, IV/IM diamorphine)
- affects foetal HR + neonatal RR
- Epidural analgesia
- Pudendal nerve block
NSAIDs avoided in third trimester due to increased risk of constriction of ductus arteriosus and renal dysfunction
208
Diagnostic findings of neonatal haemolysis
- Pale / jaundiced
- Yellow amniotic fluid
- Hepatosplenomegaly
- Hydrops fetalis (fluid collection subcutaneously / in serous cavities
- baso foetal HF caused by the resulting anaemia)
209
Examples of sensitisation events for haemolytic disease of the newborn
- Antepartum haemorrhage
- Placental abruption
- Abdominal trauma
- External cephalic version
- Invasive uterine procedures e.g. chorionic villus sampling
- Rhesus positive blood transfusion
- Intrauterine death, misscariage + termination
- Ectopic pregnancy
- Delivery
These are things that allow foetal blood to cross the placenta into maternal circulation
210
DDx for Haemolytic disease of the newborn
- Spherocytosis
- G6PD def
- Thalessaemia
211
Haemolytic disease of the newborn investigations
- Direct Antiglobulin test (DAT)
- USS to check for foetal oedema
- LFTs to check for complication
212
Haemotlytic Disease of the newborn Mx
- Interuterine transfusions if severe foetal anaemia
- Early delivery if condition severe
- Postnatal management with phototherapy / exchange transfusion (for high bilirubin from haemolysis)
- Immunoglobulins for the neonate to prevent further haemolysis
- Regular follow up to assess for developmental issues
213
Treatment for neonates with mothers who have active Hep B infection
- HBV IgG
AND
- HBV vaccination
Need BOTH **within 24 hours of birth** if mother has acute Hep B OR chronic Hep B
214
Hyperemesis gravidarum definition
Severe nausea and vomiting **BEFORE 20 weeks gestation**
Leads to the triad of weight loss, dehydration and electrolyte disturbance
Key findings include:
- **Ketonuria** (from starvation state)
- Weight loss of up to **5% of overall pre-pregnancy weight**
- Signs of hypokalaemia on ECG and metabolic acidosis from the ketosis, later in presentation
Oft a diagnosis of exclusion
215
DDx for severe vomiting during preg
- Infections (GI, UTI, hepatitis, meningitis)
- Other GI problems (appendicitis, cholecystitis, bowel obstruction)
- Metabolic conditions (DKA, thyrotoxicosis)
- Drug toxicity
- Molar preg
- the gestational trophoblastic disease causes abnormally high beta-hCG which can cause severe N+V
- Hyperemesis grvidarum
216
Hyperemesis gravidarum Mx
Mainly supportive
- Simple:
- rest + avoid triggers
- bland / plain food, esp in morning
- ginger
- wrist acupressure
- Antacids to relieve gastric discomfort
- 1st line meds:
- Cyclizine (anti-histamine/emetic)
- Prochlorperazine (phenothiazine - technically an antipsychotic)
- 2nd line meds:
- Ondansetron (during 1st rimester = increased risk of cleft lip/palate)
- Metoclopromide (NOT FOR >5 DAYS - can cause extrapyramidal SE)
- Domperidone
- If hosp admission required:
- Fluid replacement therapy
- Normal saline with added POTASSIUM for hypokalaemia
- Thiamine + folate supps to prevent Wernicke's encephelopathy
- TED stockings + LMWH to reduce increased risk of VTE (combination of preg, immobility + dehydration)
217
Complications of hyperemesis gravidarum
- GI (Mallory-Weiss tear, malnutrition, anorexia)
- Dehydration -> ketosis + VTE; AKI
- Metabolic distrubances (hyponatraemia, Wernickes, Kidney failure, hypoglycaemia)
- Psychological sequelae (depression, PTSD, resentment towards pregnancy)
- Rarely foetal complications (Low birth weight, intrauterine growth restriction, premature labour)
218
Indications for elective c-section
- Abnromal presentation
- Twin preg if first twin is not cephalic
- MATERNAL HIV
- **Primary genital herpes** in **third semester**
- PLACENTA PRAEVIA
- Anatomical reasons
219
Breech presentation / malpresentation Mx
1. External Cephalic Version
- at 36 weeks if nulliparous
- at 37 weeks if multiparous
2. Consider elective c-section
Often many babies will transition to a cephalic position by term
220
Breech presentation Ix
Detected on physical exam + US is confirmatory
221
External Cephalic Version (ECV)
Experienced physician attempts to turn baby using hands on abdomen
- 50% success rate
Mother is given analgesia, tocolytics (to prevent contractions), + anti-D Ig if needed
222
Absolute contraindications for ECV
- C-section indicated for other reason
- Antepartum haemorrhage in last 7 days
- Non-reassuring cardiotocograph
- Major uterine abnormality
- Placental abruption
- Placenta praevia (will need c-section anyways)
- Membranes have ruptures
- Multiple preg (tho can do ECV to deliver the last child by itself)
223
Relative contraindications for ECV
- Intrauterine growth restriction WITH abnormal umbilical artery Doppler index
- Pre-eclampsia
- Maternal obesity
- Oligohydramnios
- Major foetal abnormalities
- Uterine scarring from previous c-section or myomectomy
224
Which diabetes medications are not recommended in pregnancy
- SGLT-2 inhibs
- Gliclazide (sulfonylurea = risk of neonatal hypoglycaemia)
- GLP-1 agonists (e.g. semaglutide, Exenatide) - risk of toxicity
225
RFx / protective factors for hyperemesis gravidarum
Anything that raises hCG
- Multiple preg
- TROPHOBLAsTIC DISEASE
- Obesity or being underweight
- Primagravida (as it is body's first experience of rising hCG)
- **PMHx / FHx**
- Hyperthyroid (due to hCG interacting with TSH receptors and exacerbating hyperthyroidism)
***Smoking is associated with DECREASED incidence***
226
Referral criteria for nausea + vomiting in pregnancy
- Continued N+V - unable to keep down liquids + antiemetics
- Continued N+V with KETONURIA and/or WEIGHT LOSS >5% of pre-preg bodyweight - DESPITE Tx with oral antiemetics
- Confirmed / suspected comorb (e.g. UTI but unable to tolerate oral ABx)
227
Why classify risk in pregnancy/labor and what categories of risk are there?
- offer appropriate care
- enable people to make choices
- reduce variation in aspects of care
Classified as either:
- low risk
- increased/'high' risk
228
Medical conditions which might increase pregnancy risk
- Cardio resp
- heart disease
- asthma
- Haem
- bleeding disorders
- Endo
- diabetes
- long term steroid use
- obesity
- Infection
- chorioamnionitis
- Immune reaction
- renal
- aki / ckd
- neuro
- epilepsy
- sub arach haemorrhage / av malformation
- gi
- psych
- obs
- intrapartum haemorrhage
- breech presentation
- small for gestational age
- large for gestational age
- no antenatal care
- prev c-section
- labor after 42 weeks
229
Key aspects of care in labour
- 1:1 care
- maternal comfort and hygiene
- maternal monitoring
- assessment of progress in labour
- foetal monitoring
- birth
Closer monitoring of these aspects in Obstetrics unit
230
What is involved in immediate postnatal care
Parent:
- Mx postpartum hemorrhage
- repair perineal trauma
- bladder care
Baby:
- resuscitation
- monitoring temp, blood glucose etc
- feeding
231
What can change the parent's risk during labour?
- raised HR / bp +/- proteinuria
- pyrxia: 38 once or 37.5 at least twice
- vaginal blood loss (more than just bloody show)
- ROM >24 hrs
- additional pain/ needing extra pain relief
232
Things that can change baby's risk during/after birth
- presence of méconium
- needing advanced neonatal resuscitation
233
How do people decide where to birth?
- risk assessment based advice from maternity team
- preference for surroundings
- accessibility
- perception of risk
- options during labour (possible relief, pool)
234
Indications for c section
- absolute cephalopelvic disproportion
- placenta praevia 3/4
Also:
- pre eclampsia
- post maturity
- intrauterine growth restriction
- fetal distress during labour / prolapsed cord
- failure of labor to progress
- brow/face malpresentation
- placental ABRUPTION with LIVE DISTRESSED foetus (vaginal is fine if dead)
- active vaginal infection (eg herpes)
- cervical cancer (vaginal birth would cause dissemination of cancer cells)
235
Serious risks of c sections
Maternal:
- may need emergency hysterectomy
- need further surgery later e.g curettage to remove retained placental tissue
- ITU admission
- VTE/DVT
- Bladder injury
- Ureteric injury
- Death (1/12 000)
Future preg:
- increased risk of uterine rupture
- increased risk of still birth
- increased risk of placenta praevia / accreta
236
Risks frequently associated with c sections
- persistent wound/abdo discomfort for first few months
- increased risk of c section being needed for future preg
- readmission
- Haemorrhage
- infection (endometritis and UTIs as well as wound)
Fetus may get lacerations (1-2 / 100)
237
When is vaginal birth after cesarean contraindicated
Past uterine rupture OR classical c section scar
(70-75% without these problems can successfully vaginally deliver after one c section tho)
238
When is it important to give anti d ig ASAP (defo within 72 hours)
- delivery of rhesus +ve child
- miscarriage post 12 wks
- termination of any preg
- surgical management of ectopic
- antepartum haemorrhage
- amniocentesis, chorionic villus sampling, fetal blood sampling
- abdo Trauma
- external cephalic version
239
Rfx for reduced fetal movements
- posture of mother (less noticeable on sitting or standing)
- distractibility of mother
- alcohol and sedatives
- anterior placental position
- anterior foetal position
- raised or lowered amniotic fluid volume
- raised body mass
- foetal size low
240
Ix for reduced foetal movements
After 28 wks:
- handheld Doppler to confirm heartbeat (if no heartbeat then urgent uss)
- ctg for 20 mins
- if not reassured -> urgent uss including abdo circumference / estimated foetal weight AND amniotic fluid volume measurement
Between 24-28 wks = handheld Doppler
Less than 24 wks but previously had movements = handheld Doppler
No movements by 24 weeks = refer to foetal maternal medicine
241
Causes of premature labour
Inflammatory reactions that release PROSTAGLANDINS
1. Intrauterine INFECTION
- inflam mediators trigger
2. Placental ISCHAEMIA / Abruption
- thrombin activation triggers uterine contraction
3. Uterine STRETCH
- myometrial stretch induces:
- gap junction formation
- increases oxytocin receptors, prostaglandins and inflammatory cytokinesis
4. Foetal / maternal STRESS
- activates hypophyseal-pituitary-adrenal axis causing most ACTH release
242
Prophylactic tx for preterm labour and who is eligible for it
Given to people with PAST HISTORY of premmie OR CERVICAL LENGTH <25mm
- Vaginal progesterone
- cervical cerclage (AKA suture)
243
DX and ix for preterm labour
Usual Hx, abdo exam, Vaginal exam + observations
Analgesia if needed
- Speculum to assess for PPROM
- Vaginal USS can check cervical length and dilation
- OR FOETAL FIBRONECTIN testing (vaginal swab)
244
DX and ix for preterm labour
Usual Hx, abdo exam, Vaginal exam + observations
Analgesia if needed
- Speculum to assess for PPROM
- Vaginal USS can check cervical length and dilation
- OR FOETAL FIBRONECTIN testing (vaginal swab)
245
Mx of pre-term labour
1. STEROIDS - betamethasone or Dex - 2 doses 24 hrs apart (If <=34 wks for lung maturation)
2. MgSO4 for neural protection (defo <=30 wks but can give till 34wks)
3. TOCOLYSIS (Suppression) aka NIFEDIPINE if <=34 wks
4. Mx and monitoring of labour
246
Mx of PPROM
PROPHYLACTIC ABX
- PO erythromycin for **10 days / until established labor**
247
Dfx of small for gestational age vs intrauterine growth restriction
SGA = Estimated weight lower than **10th centile**
- severe if **EFW under 3rd centile**
IUGR = PATHOLOGICAL resoning restricting full genetic growth potential
248
How is foetal size measured
- **Symphyseal fundal height** (measure regularly from 24 wks onwards)
- On **scan**
- Foetal ABDO CIRCUMFERENCE
- Foetal FEMUR length
- Foetal HEAD CIRCUMFERENCE / biparietal diameter
- LIQUOR volume / amniotic fluid index
249
RFx for small for gestational age (SGA)
Major:
1. MATERNAL **AGE >40**
2. **SMOKING**
3. **COCAINE** use during preg
4. Daily VIGOROUS **EXERCISE**
5. **PMHx** - SGA or STILL BIRTH
6. Maternal or Paternal SGA
7. Chronic **HTN**
8. Diabetes with **VASCULAR DISEASE**
9. **Renal** Impairment
10. **Antiphospholipid** syndrome
- Pre-eclampsia
- **UNEXPLAINED APH**
- LOW MATERNAL WEIGHT GAIN
Minor:
- Nulliparity
- Prev pre-eclampsia
Basically things that impair O2 supply / blood supply / nutrition to baby + PMhx
250
Ix for Small for gestational age (SGA)
1. Routine monitoring
1. Measure **SYMPHYSIAL FUNDAL HEIGHT** (adjusted to maternal weight, height, ethnicity and parity)
2. USS
2. **Serial USS + UMBILICAL ARTERY DOPPLER** IF any SINGLE MAJOR RFx present -> from **26-28 wks**
3. If any ONE symphasis fundal height BELOW 10TH centile / growth is SLOWING / STATIC -> SERIAL USS + UMBILICAL ARTERY DOPPLER
251
What is the significance of End-diastolic flow on umbilical artery doppler
If EDF is Slowing or REVERSED -> means INCREASED PLACENTAL RESISTANCE as foetal blood is not able to flow out
- implies PLACENTAL COMPROMISE
- Predictive of SGA
252
Mx of small for gestational age foetus
- Monitor with serial UA dopplers
- Deliver by **C-section by 37 wks**
253
Placental insufficiency / placental dysfunction pathophys
Can be caused by anything that reduces the blood flow to the placenta
**Hypoxaemia** also activates coagulation factors and promotes the deposition of fibrin (through endothelial activation) further minimising nutrient transfer
Also occurs in **abruption** as less of the placenta is attached to the wall (and can get lots of blood loss obvs)
Lateralisation of placenta (attaching to one side vs being central) can also lead to imbalance of blood flow + poorer nutrition of foetus
254
RFx for placental insufficiency
- **HTN** / pre-eclampsia
- SMOKING
- Alcohol
- **DRUG USE** (e.g. cocaine)
- Primiparity
- **ADVANCED MATERNAL AGE (>35)**
- **PHx** of IUGR
- ANTI-EPILEPTICS / ANTI-NEOPLASTICS
255
Complications of placental insufficency
- IUGR
- PREMMIE
- PRE-ECLAMPSIA (because of the increased placental resistance)
- STILL BIRTH
256
Dx of placental insufficiency
- Hx + abdo exam
- DOPPLER USS (e.g. Uterine artery + check end-diastolic flow) + serial (every 2 wks) UA artery doppler to monitor
- MRI if USS can't pick up v. well -> shows if any arteries lost signal + can show haemorrhages / infarctions in soft tissues
257
Placental insufficiency Tx
**Delivering baby** is best -> can only do after 34 wks
**< 34 wks:**
- LOW DOSE ASPIRIN + ANTIOXIDANTS e.g. VIT C+E (improves mild insufficiency)
- HEPARIN can stimulate angiogenesis in placenta + reduces inflam / coag / apoptosis
258
Low birth weight Dfx
- < 2500g (5 pounds 8 ounces)
- <1500g (3 pounds, 5 ounces) = v low
259
Complications of low birth weight
Increases risk of childhood mortality and morbidity + cognitive developmental problems
May cause further poor growth + Non-communicable diseases later in life
260
GDM pathophys
- In preg - maternal peripheral insulin resistance increases to increase glucose available for baby
- Increased lipolysis + gluconeogenesis
- Normally get hypertrophy / hyperplasia of BETA-cells thus meaning more insulin should be produced + maintaining maternal glucose homeostasis
- In GDM -> BETA-CELL DYSFUNCTION -> too much insluin resistance with not enough compensatory insulin
261
Essential HTN vs Pregnancy Induced HTN (PIH) / pre-eclampsia
PIH / pre-eclampsia only develops AFTER 20 WKS gestation
262
PIH / pre-eclampsia pathophys
Systemic reaction to abnormally invasive placenta
1. spiral arteries don't remodel right
- placental hypoperfusion -> IUGR
2. Oxidative stress
3. Trophoblasts release inflam cytokines + sFLT
4. systemic inflam response + reduced blood to maternal organs (disrupted endothelium)
- similar to hypovolemic shock
- Seizures from cerebral vasospasm
5. Impaired renal + reduced GFR + raised sFLT -> HTN
6. further glomerular disruption -> Proteinuria
263
What is the criteria for urgent admission of severe pre-eclampsia
1. Systolic BP >160mmHg (**raised BP**)
2. Severe headaches, visual SCOTOMATA, N+V, OLIGURIA, PULM OEDEMA (significant organ dysfunction) (**symptoms**)
3. Rising CREATININE, raised LIVER EZYMES, ThromboCYTOPENIA (liver / kidney failure) (**abnormal bloods**)
264
Complications of pre-eclampsia
- Eclampsia
- HELLP syndrome
- Placental ABRUPTION
- DIC
265
Dfx of hypertension in preg
>= 140 systolic OR >= 90 diastolic
Severe = > 160/110 (either/or)
266
Complications / risks of essential HTN during preg
- Accelerated HTN in THIRD trimester
- Superimposed pre-eclampsia
- **IUGR**
- placental **ABRUPTION**
- PREMMIE / STILL BIRTH
267
Mx of essential / chronic HTN in preg
Continue prev Tx if safe to do so
- ACE-I typically not used in preg as can be teratogenic in 2nd / 3rd trimesters
Otherwise:
- Labetolol 1st
- Nifedipine 2nd
- Methyldopa 3rd*
Do PlGF between 20-35 wks to check for superimposed pre-eclampsia
Additional ANC based on need:
- weekly if poorly controlled
- 2-4 wks if well controlled
Medical review 6-8 wks post-natal
***** needs to be stopped within 2 days of birth
268
RFx for placenta praevia
- PHX of placenta pravia
- IVF preg
- Past c-section
269
Px of placenta praevia
- oft picked up on scan
- PAINLESS APH with SOFT, NON-TENDER uterus
270
When are scans done if placenta praevia identified
- usually picked up on 20 week anatomy scan
- re-check at 32 wks
- re-check at 36 wks
If only identified when Sx -> just do TV USS at the time
271
Mx of placenta praevia / lowlying placenta
- Conservative Mx with scans at 32 + 36 weeks to see if placenta has moved up (oft moves up as lower pole stretches later in preg)
- 1 course of ORAL STEROIDS between 34-36 wks
- Deliver w/ C-section at 36-37 wks
- Can try to labour normally if placenta only within 10-20cm of os
272
Mx of vasa praevia
If found antenatally:
- **STEROIDS at 32 wks** + c-section (at ~34-36 wks)
If found during labour -> cat 1 c-section
273
Mx of placenta accreta spectrum
Checked on routine scans -> further screening as needed
- Additional USS screening done in ppl with low-lying placentas w/ PHx of C-section
Elective section at 35-37 wks
- Will need HYSTERECTOMY if anything worse than mild accreta as difficult to safely remove deeply embbeded placenta
274
Placental abruption pathophys
- chronic processes (e.g. thrombosis, infection) cause HYPOPERFUSION + INFARCTION of placenta -> SHALLOW invasion of trophoblasts into decidua
- Acute trigger (e.g. mechanical force) -> separation
- Separation causes RUPTURE of maternal DECIDUAL vessels -> haematoma can form
Normally when placenta detaches, uterus contracts which stems bleeding -> can't du this whilst foetus inside
275
Classification of placental abruption
- Concealed - blood remains trapped between placenta + decidua so no PV bleed
- Revealed
- Mixed
276
RFx for uterine rupture
- Prev c-section / uterine surgery
- Use of OXYTOCIN / Induction of labour
- HIGH PARITY (muliple prev pregs)
- Increased AGE
- Raised BMI
277
278
What are the complications of maternal varicella
Maternal
- 5x risk of pneumonitis
Foetal
- foetal varicella syndrome
- 1% in first trimester
- rare between 20-28 and baso none after 28 wks
- SCARRING, EYE DEFECTS (Microphthalmia), LIMB hypoplasia, microCEPHALY, LEARNING DISABILITIES
- Shingles in infancy (from exposure during 2nd / 3rd trimester)
- Severe neonatal varicella (typically happens if mum gets rash from 5 days before birth / 2 days after
279
Mx of chickenpox exposure in preg (PEP - Post exposure prophylaxis)
- if in doubt -> check for IgG ANTIBODIES
- If confirmed:
- ORAL ACICLOVIR **7-14 days post exposure** (better results in clinical trials)
280
Mx of chickenpox in preg
1. ORAL ACICLOVIR if >=20 wks and presents within 24 hours of rash onset
- be cautious about aciclovir in <20 wks
2. IV aciclovir only if v severe
281
Mx of chickenpox in preg
1. ORAL ACICLOVIR if >=20 wks and presents within 24 hours of rash onset
- be cautious about aciclovir in <20 wks
2. IV aciclovir only if v severe
282
Pathophysiology of DVT in preg
Pregnancy is a hypercoagulable state:
- increase in factors 7, 8, 10, and fibrinogen
- decrease in protein S
- uterus presses on IVC causing VENOUS STASIS
Most DVT happens in last trimester
283
Mx of DVT in preg
Warfarin contraindicated so SUB CUT LMWH (iv heparin is more likely to cause bleeding and thrombocytopenia)
