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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

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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

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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

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4
Q

What is suggestive of a large antepartum haemorrhage on abdo exam

A

Abdo feels ‘woody’ on palpation

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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
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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.

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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
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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
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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
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10
Q

Placental praevia

A

placenta is over the internal cervical os -> some vaginal bleeding

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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.

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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

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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)

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14
Q

Uterine rupture Px

A

Sudden PAIN + PV BLEEDING

Sudden STOP IN CONTRACTIONS and foetal distress on CTG

Hypotension, Tachycardia, possible collapse

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15
Q

gynae causes of antepartum bleeding

A

Cervical polyps/Cancer

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16
Q

Miscarriage

A

Early: spontaneous termination before 12wks gestation

Late = 12-24wks

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17
Q

Types of miscarriage

A
  • Missed miscarriage
  • Threatened
  • Inevitable
  • Incomplete
  • Complete (everything gone)
  • Anemryonic preg (sac present but no embryo)
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18
Q

Missed miscarriage + management

A
  • Uterus empty before 20 wks but cervical os is closed so any bleeding is contained -> asymp
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19
Q

Threatened miscarriage

A

Painless uterine bleeding but cervix is closed. Fetus is still alive at first.

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20
Q

Inevitable miscarriage

A

Heavy bleeding with clots and pain

Cervical os is open

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21
Q

Incomplete miscarriage

A

Pain and vaginal bleeding through open cervical os but not all products of conception have been expelled

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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
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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
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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))
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25
Q

Interventions for stage 1 labour

A

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

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26
Q

Stage 2 of labour

A

Full dilation to fetal delivery (~1 hour)

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27
Q

Stage 2 labour interventions

A
  • 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

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28
Q

Main complications associated with stage 2 of labour

A
  • Shoulder dystocia
  • cord prolapse
  • Breech presentation
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29
Q

Shoulder dystocia

A

Anterior shoulder gets stuck behind pubic symphesis after head already delivered.

Oft due to macrosomia from gestational diabetes.

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30
Q

Diagnosis of shoulder dystocia

A

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)
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31
Q

Mx of shoulder dystocia

A

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

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32
Q

First line manouver for shoulder dystocia

A
  • 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

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33
Q

2nd line manouvers for shoulder dystocia

A
  • 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

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34
Q

3rd line Mx for shoulder dystocia

A
  • 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
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35
Q

Complications of shoulder dystocia

A
  • 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

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36
Q

Umbilical cord prolapse

A

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)

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37
Q

Dx of cord prolapse

A

Suspect if CTG shows distress!

found with VE or speculum examination.

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38
Q

Mx of cord prolapse

A

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
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39
Q

Stage 3 of Labour

A

Post-fetal delivery; placental delivery

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40
Q

Interventions to stimulate stage 3 labour + when is it classed as delayed

A

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
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41
Q

Define Postpartum haemorrhage (PPH)

A
  • 500ml blood after vaginal
  • 1000ml blood after c-section

minor = <1000ml
major mod = 1000-2000 ml
major severe = >2000ml

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42
Q

Primary vs Secondary PPH

A
  • Primary PPH: bleeding within 24 hours of birth
  • Secondary PPH: from 24 hours to 12 weeks after birth
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43
Q

Causes of primary PPH

A

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

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44
Q

Mx of primary PPH

A
  • 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)
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45
Q

Mechanical treatment to stop PPH

A
  • Rub uterus (stimulate contraction)
  • Cathetarise (distended bladder stops uterus contraction)
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46
Q

Medical treatment of PPH

A
  • 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
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47
Q

Surgical treatment of PPH

A
  • 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)
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48
Q

Causes of secondary PPH

A

Endometritis +/- retained tissue

Rare: Gestational trophoblastic disease or gynae causes

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49
Q

Investigate secondary PPH with

A
  • USS (? anything in uterus)
  • Endocervical and high vaginal swabs for infection
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50
Q

Management of secondary PPH

A
  • Surgical evaluation of retained products of conception
  • Antibiotics for infection

if severe may need endoscopic exploration + histology

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51
Q

Gestational diabetes

A

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

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52
Q

RFx for gestational diabetes

A
  • 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
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53
Q

Screening for gestational diabetes

A

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

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54
Q

Signs indicative of gestational diabetes

A
  • Large for date fetus (/macroscomic)
  • Polyhydraminos (increased amniotic fluid)
  • Glucose on urine dip
  • Diabetes Sx (thirst, polyuria etc)
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55
Q

Management of gestational diabetes

A

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)

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56
Q

Glucose target levels for diabetes during preg

A
  • 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
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57
Q

Complications of gestational diabetes

A

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
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58
Q

Neonatal hypoglycaemia after gestational diabetes

A

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

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59
Q

Pre-eclampsia

A

Defined as: pregnancy-induced hypertension associated with organ damage, notably proteinuria but also other organ dysfunction or placental dysfunction

Characteristic:
- HTN
- proteinuria
- oedema

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59
Q

Pre-eclampsia pathophys

A

After 20wks gestation the spiral arteries of the placenta form abnormally causing high vascular resistance

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60
Q

Complications of pre-eclampsia

A
  • organ damage/failure
  • fetal growth restriction
  • seizures (eclampsia)
  • EARLY LABOUR
  • placental abruption
  • Death
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61
Q

pre-eclampsia vs gestational HTN vs eclampsia

A

Gestational HTN by itself has NO PROTEINURIA

Eclampsia is when seizures occur as a result of pre-eclampsia

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62
Q

RFx for pre-eclampsia

A

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

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63
Q

Pre-eclampsia prophylaxis

A

ASPIRIN

From 12 wks until birth if people have 1 high-ridk factor or 2/more moderate-risk factors

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64
Q

Sx of pre-eclampsia

A

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
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65
Q

How is proteinuria quantified

A
  • Urine protein:creatinine ratio (above 30mg/mmol is significant)
  • Urine albumin:creatinine ratio (above 8mg/mmol is significant)
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66
Q

Diagnosis of pre-clempsia

A

Test placental growth factor (protein which stimulates angiogenesis) levels once between 20-35 weeks
- LOW in pre-eclampsia

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67
Q

Pre-eclampsia screening

A

Every pregnant person is monitered every antenatal appointment

  • Blood pressure
  • Symptoms
  • Urine dipstick for proteinuria
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68
Q

management / investigations for gestational HTN (no proteinuria)

A
  • 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)
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69
Q

Pre-eclampsia initial management

A

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
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70
Q

Pre-eclampsia Tx

A

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

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71
Q

Treatment of eclampsia

A

IV magnesium sulphate + Emergancy section

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72
Q

HELLP syndrome

A

combination of features occuring from complications of pre-eclamsia/eclampsia

  • Haemolysis
  • Elevated Liver enzymes
  • Low Platelets
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73
Q

Main infections relevent to pregnancy

A
  • Herpes Simplex (can get verticle transmission through vesicles so c-section if attack within 6wks of delivery)
  • Group A strep
  • Group B strep
  • HIV
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74
Q

Group A strep in preg

A

Cause perinatal sepsis and chorioamnionitis

treat with IV Abx

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75
Q

Group B strep

A

Commensal in in birth canal -> neonatal sepsis

Treat with IV PENICILLIN if risk factors present

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76
Q

Risk factors for neonatal Strep B infection

A
  • previous infected child,
  • ROM >18hr
  • maternal fever in labour
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77
Q

Complications of HIV in preg

A
  • Inter-Uterine Growth Restriction (IUGR)
  • Still birth
  • Pre-eclampsia
  • Prematurity
  • Gestational DM
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78
Q

Prevention of vertical transmission of HIV in preg

A
  • Maternal ART (anti-retroviral therapy)
  • Elective C/S
  • Avoid breast feeding
  • Neonatal ART
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79
Q

Complications of gonorrhoea in preg

A
  • prematurity
  • early labour
  • perinatal mortality
  • VERTICAL TRANSMISSION leading to:
    • GONOCOCCAL CONJUNCTIVITIS - eye pain, redness + discharge
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80
Q

Management of gonorrhoea in preg

A
  • Prophyl antibiotics to prevent gonococcal conjunctivitis
  • otherwise same as usual - 1 dose IM CEFTRIAXONE 1g

Any infected babies urgent referral to prevent blindness

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81
Q

Preg women at higher risk of developing UTIs. What are the complications associated with UTI in preg?

A
  • PRETERM DELIVERY
  • Low birth weight
  • Pre-eclampsia

Other adverse preg outcomes

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82
Q

Management of UTI risk in preg

A

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)

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83
Q

Treatment of UTI in preg

A

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)
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84
Q

How can you seperate between monochorionic and dichorionic diamniotic twins on USS?

A
  • Dichorionic = lambda/twinpeak sign
  • Monochorionic = T sign (the chorion doesn’t peak, is flat)
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85
Q

Complications of multiple preg for mother

A
  • ANAEMIA
  • Polyhydramnios
  • Hypertension
  • Malpresentation (head not down in labour)
  • Spontaneous preterm birth
  • Instrumental delivery (ventouse or forceps used) or caesarean
  • Postpartum haemorrhage
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86
Q

Complications to baby in multiple pregnancy

A
  • Miscarriage
  • Stillbirth
  • Fetal growth restriction
  • Prematurity
  • Twin-twin transfusion syndrome
  • Twin anaemia polycythaemia sequence
  • Congenital abnormalities
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87
Q

Twin-Twin Transfusion Syndrome (TTTS)

A

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

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88
Q

Twin Anaemia Polycythemia Sequence

A

Similar to TTTS but less acute

One twin ANAEMIC, the other POLYCYTHEMIC

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89
Q

What is a partogram

A

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

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90
Q

What information is recorded on a partogram

A
  • 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
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91
Q

What is the aimed for uterine contraction frequency in labour

A

4-5 per 10 minutes

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92
Q

What factors determine the sucess of Stage 2 of labour

A

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)
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93
Q

Puerperium meaning

A

The period of ~6 wks after from placental delivary; when maternal reproductive organs return to non-preg condition + the initiation/suppression of lactation

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94
Q

Non-medical management of pain during labour

A
  • 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)
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95
Q

Options for Medical Mx of pain relief in labour

A
  • 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
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96
Q

Pain pathway in 1st vs 2nd stage of labour

A

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
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97
Q

Pros + Cons of Entenox

A

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

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98
Q

Diamorphine (/ Pethidine) functioning +

A
  • can give IM or SC
  • Take around 30 mins to work

SE:

  • Baby: SLEEPY, SLOW BREATHING, POOR FEEDING initially
  • Mum: SICKNESS + Sleepiness
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99
Q

Patient Controlled Analgesia pros + cons

A
  • 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
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100
Q

Epidural + CSE functioning

A
  • 1:10 may not work as well + need replacing
  • Take ~ 20 minutes to work
    • CSE = FASTER
  • Catheter + IV fluids
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101
Q

Risks/SE of Epidural / CSE

A
  • 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
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102
Q

Which method to use for fetal monitoring

A
  • INTERMITTENT AUSCULTATION if low risk
  • Continuous CTG if HIGH RISK
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103
Q

How to carry out intermittent auscultation

A

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
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104
Q

When to increase fetal monitoring

A
  • If increase in FHR of 20bpm or more since start of labour
  • Decelerations

Carry out a FULL CLINICAL REVIEW as well

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105
Q

What to do if concerned about FHR

A
  • Summon help
  • Advise continuous CTG monitoring
  • Transfer to CLC (consultant led care)
  • Return to IA if continous CTG is normal after 20 minutes
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106
Q

Categories of c-section

A
  • 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)
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107
Q

Variations that can be seen in CTGs

A
  • 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)
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108
Q

Physiology of puerperium

A
  • 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
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109
Q

Changes during involution of uterus + genital tract

A
  • 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
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110
Q

Diff stages of Lochia

A
  • 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

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111
Q

Prolactin response

A
  • 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

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112
Q

Oxytocin / Let-down reflex

A
  • 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

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113
Q

Benefits of breast feeding

A
  • 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
Q

Functions of LACTOFERRIN in milk

A
  • Regulates intestinal iron abdorption + iron delivery to cells
  • Protection against microbes + pathogens
    • Boosts immune system
  • Helps regulation of bone marrow function
115
Q

Sx which indicate mothers should report in puerperial period + the conditions associated with these presentations

A
  • 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
Q

What are the signs of sepsis

A

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
Q

Red Flag markers of severe sepsis

A
  • 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
Q

Red flags of mental health diorders in peurperium

A
  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
Q

Postpartum psychiatric conditions

A
  • 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
Q

Why may it be difficult to detect puerpural mental health disorders

A
  • 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
Q

Baby blues Sx

A
  • Mood swings
  • Low mood
  • Anxiety
  • Irritability
  • Tearfulness

Tend to be mild + self-resolve within 2 wks

Occurs in >50% of mothers

122
Q

Baby blues aet

A
  • 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
Q

Presentation of Postpartum depression (PPD)

A

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
Q

When is urgent specialist mental health referral needed for postpartum mental health disorders

A

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
Q

Postpartum depression (PPD) Epid

A

10% per year experience

126
Q

Risk factors for postpartum depression (PPD)

A
  • Low socioeconomic status
  • PHx/FHx of mental health disorders
  • Lack of social support
127
Q

PPD aet

A

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
Q

PPD Dx

A

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
Q

PPD Mx

A

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
Q

Postpartum psychosis/Puerpural psychosis epid

A
  • 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
Q

Postpartum psychosis Px

A

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
Q

postpartum depression vs psychosis

A

Depression has more insidious onset while pdychosis develops rapidly + obviously

Both either last longer than baby blues or require intervention (unlike baby blues)

133
Q

Postpartum psychosis Dx

A

Mainly clinical - Psych evaluation

Ix to exclude DDx e.g. thyroid, sepsis

134
Q

Postpartum psychosis Mx

A

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
Q

Postpartum psychosis prognosis

A

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
Q

SE of taking SSRIs during preg

A

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
Q

Baby blues Mx

A

Reassure; offer support through health visitors

Safty net - seek help if persisting for >2 wks or develop Sx of depression/psychosis

138
Q

Puerpural infection

A

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
Q

Sepsis Signs and Symps in postpartum period

A

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
Q

Postpartum Infected Endometritis aet

A

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
Q

Postpartum infected endometritis Dx

A

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
Q

Postpartum Infection Mx

A

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
Q

VTE in preg epid

A
  • 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
Q

RFx for VTE in preg

A

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
Q

VTE Px

A

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
Q

VTE Dx

A
  • 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
Q

How does a VQ scan work

A
  • 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
Q

VTE in preg Mx

A

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
Q

VTE prohylaxis in preg

A
  • 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
Q

Postpartum anaemia

A

Hb < 100 g/L

151
Q

Dx of postpartum anaemia

A

Take FBC if:

  • Postpartum haemorrhage >500 ml
  • C-SECTION
  • Antenatal anaemia
  • Sx of anaemia
152
Q

Anaemia in postpartum Tx

A

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
Q

When to consider iron infusion in postpartum

A
  • If poor adherence to oral
  • Can’t tolerate oral
  • Failure to respond to oral
  • Can’t absorb oral (e.g. IBD)
154
Q

When is an iron infusion for anaemia CONTRAINDICATED

A

During ACTIVE INFECTION
- bacteria feed on iron so iron infusion can cause proliferation + worse infection

155
Q

Anaemia in preg Definition

A
  1. 1st trimester = Hb < 110 g/L
  2. 2nd/3rd trimester = Hb < 105 g/L
  3. Postpartum = Hb < 100 g/L
156
Q

What often causes anaemia during preg + RFx aside from pre-existing conditions

A

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
Q

Anaemia screening during preg

A
  • recommended to screen everyone at 28 wks
  • additional screening at 20-28 wks if multi preg
158
Q

Anaemia in preg Mx

A

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
Q

What is the significance of rhesus states in preg

A
  • 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
Q

Rhesus incompatability Mx

A

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
Q

When is Kleihauer Test done

A

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
Q

What does Kleihaur Test involve

A
  • 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
Q

The postpartum period definition

A

typically say 6 WEEKS

However, when talking about perinatal mental health - this can be up to a year after birth

164
Q

Key factors of perinatal mental health Hx

A
  • PHx + psych Hx
  • DHx + substance use
  • FHx
  • Domestic / Sexual abuse
  • Patient Health Questionnaire-9 (PHQ-9)
165
Q

RFx for placenta accreta

A
  • Previous placenta accreta
  • Previous endometrial curettage
  • Previous C-SECTION
  • Multigravida (multiple previous preg)
  • Increased maternal age
  • Low-lying placenta / placenta previa
166
Q

Px of placenta accreta

A

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
Q

Placenta accreta Dx

A
  • USS
  • MRI may be used to assess depth + width
168
Q

PLacenta accreta Mx

A

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
Q

Management of premature labour

A
  • 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
Q

Premature rupture of membranes definiton

A

Rupture of membranes at least 1 hour before contractions start

171
Q

Prolonged premature rupture of membranes definition

A

Rupture of membranes >24 hrs before contractions start

172
Q

Preterm premature rupture of membranes definition

A

Rupture of membranes before 37 weeks gestation (relevant as it is likely to trigger premmie birth)

173
Q

Conditions associated with premature labour / ROM

A
  • 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
Q

DDx for premature labour / ROM

A
  • 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
Q

Investigation to dx PPROM and asses risk of pre-term delivery

A

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
Q

Risk factors for ectopic pregnancy

A
  • PID
  • Genital infection
  • Interuterine device in situ
  • Pelvic surgery
  • Endometriosis
  • If undergoing assisted reproduction
  • PMHx of ectopic
177
Q

Ectopic pregnancy Px

A
  • 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
Q

Ectopic pregnancy Ix

A
  • Pregnancy test to confirm actually pregnant
  • Transvaginal USS
179
Q

Ectopic pregnancy Mx

A

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
Q

Bishop score

A

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
Q

When is induction of labour indicated

A
  • 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
Q

When is induction of labour contraindicated

A
  • 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
Q

Which Ix may be involved in determining whether to indue labour

A
  • 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
Q

Methods of inducing labour

A
  • 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
Q

Polyhydramnios common presentation

A
  • Uterus feels tense / large for date
  • Fetal parts difficult to palpate
  • May be experiencing maternal / fetal complications
186
Q

Causes of polyhydramnios

A

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
Q

Maternal complications of polyhydramnios

A
  • 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
Q

Foetal complications of polyhydramnios

A
  • 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
Q

Polyhydramnios Mx

A
  • Mx managable underlying causes eg. maternal diabetes, pre-eclampsia
  • Amnio-reduction if severe
190
Q

Typical size of uterus in relation to gestational age

A
  • 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
Q

Which blood test is typically used to check for suspected menopause

192
Q

Amniotic fluid embolism definition and epidemiolofy

A

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
Q

Amniotic fluid embolism pathophys

A

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
Q

Amniotic fluid embolism Px

A
  • High resp rate
  • Tachycardia
  • Hypotension
  • Hypoxia
  • DIC potentially
195
Q

DDx for amniotic fluid embolism

A
  • 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
Q

Amniotic fluid embolism Ix

A

Clinical diagnosis - no specific tests

197
Q

Amniotic fluid embolism Mx

A
  • 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
Q

Placental abruption Sx

A
  • 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
Q

Placental abruption Mx

A

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
Q

How may group B strep infection in neonates and maternally present

A
  • Sepsis
  • Pneumonia
  • Meningitis

The mother may has uterine tenderness and pain (though oft asymp as group b strep is a vaginal commensal)

201
Q

Risk factors for neonatal group b strep infection

A
  • 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
Q

When are group B strep cultures / swabs taken in preg women

A

If there are risk factors or symptoms of infection present

Not routine;y done as colonisation status can change thorughout the pregnancy

203
Q

Prevention of neonatal group b strep infection

A

Prophylactic antibiotics - usually penicillins

  • IV Benzylpenicillin administered during LABOUR and DELIVERY

This is only done if risk factors present

204
Q

Features of neonatal HSV infection

A

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
Q

Mx of maternal HSV infection during preg

A

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
Q

HSV infection Ix in neonates

A
  • PCR
  • viral culture
  • Direct fluoroscent antibody testing
  • MRi if encephalitis / seizures
207
Q

Management of obstetric pain

A
  • 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
Q

Diagnostic findings of neonatal haemolysis

A
  • Pale / jaundiced
  • Yellow amniotic fluid
  • Hepatosplenomegaly
  • Hydrops fetalis (fluid collection subcutaneously / in serous cavities
    • baso foetal HF caused by the resulting anaemia)
209
Q

Examples of sensitisation events for haemolytic disease of the newborn

A
  • 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
Q

DDx for Haemolytic disease of the newborn

A
  • Spherocytosis
  • G6PD def
  • Thalessaemia
211
Q

Haemolytic disease of the newborn investigations

A
  • Direct Antiglobulin test (DAT)
  • USS to check for foetal oedema
  • LFTs to check for complication
212
Q

Haemotlytic Disease of the newborn Mx

A
  • 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
Q

Treatment for neonates with mothers who have active Hep B infection

A
  • HBV IgG

AND

  • HBV vaccination

Need BOTH within 24 hours of birth if mother has acute Hep B OR chronic Hep B

214
Q

Hyperemesis gravidarum definition

A

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
Q

DDx for severe vomiting during preg

A
  • 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
Q

Hyperemesis gravidarum Mx

A

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
Q

Complications of hyperemesis gravidarum

A
  • 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
Q

Indications for elective c-section

A
  • Abnromal presentation
  • Twin preg if first twin is not cephalic
  • MATERNAL HIV
  • Primary genital herpes in third semester
  • PLACENTA PRAEVIA
  • Anatomical reasons
219
Q

Breech presentation / malpresentation Mx

A
  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
Q

Breech presentation Ix

A

Detected on physical exam + US is confirmatory

221
Q

External Cephalic Version (ECV)

A

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
Q

Absolute contraindications for ECV

A
  • 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
Q

Relative contraindications for ECV

A
  • 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
Q

Which diabetes medications are not recommended in pregnancy

A
  • SGLT-2 inhibs
  • Gliclazide (sulfonylurea = risk of neonatal hypoglycaemia)
  • GLP-1 agonists (e.g. semaglutide, Exenatide) - risk of toxicity
225
Q

RFx / protective factors for hyperemesis gravidarum

A

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
Q

Referral criteria for nausea + vomiting in pregnancy

A
  • 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
Q

Why classify risk in pregnancy/labor and what categories of risk are there?

A
  • offer appropriate care
  • enable people to make choices
  • reduce variation in aspects of care

Classified as either:
- low risk
- increased/’high’ risk

228
Q

Medical conditions which might increase pregnancy risk

A
  • 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
Q

Key aspects of care in labour

A
  • 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
Q

What is involved in immediate postnatal care

A

Parent:

  • Mx postpartum hemorrhage
  • repair perineal trauma
  • bladder care

Baby:

  • resuscitation
  • monitoring temp, blood glucose etc
  • feeding
231
Q

What can change the parent’s risk during labour?

A
  • 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
Q

Things that can change baby’s risk during/after birth

A
  • presence of méconium
  • needing advanced neonatal resuscitation
233
Q

How do people decide where to birth?

A
  • risk assessment based advice from maternity team
  • preference for surroundings
  • accessibility
  • perception of risk
  • options during labour (possible relief, pool)
234
Q

Indications for c section

A
  • 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
Q

Serious risks of c sections

A

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
Q

Risks frequently associated with c sections

A
  • 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
Q

When is vaginal birth after cesarean contraindicated

A

Past uterine rupture OR classical c section scar

(70-75% without these problems can successfully vaginally deliver after one c section tho)

238
Q

When is it important to give anti d ig ASAP (defo within 72 hours)

A
  • 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
Q

Rfx for reduced fetal movements

A
  • 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
Q

Ix for reduced foetal movements

A

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
Q

Causes of premature labour

A

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
Q

Prophylactic tx for preterm labour and who is eligible for it

A

Given to people with PAST HISTORY of premmie OR CERVICAL LENGTH <25mm

  • Vaginal progesterone
  • cervical cerclage (AKA suture)
243
Q

DX and ix for preterm labour

A

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
Q

DX and ix for preterm labour

A

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
Q

Mx of pre-term labour

A
  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
Q

Mx of PPROM

A

PROPHYLACTIC ABX
- PO erythromycin for 10 days / until established labor

247
Q

Dfx of small for gestational age vs intrauterine growth restriction

A

SGA = Estimated weight lower than 10th centile

  • severe if EFW under 3rd centile

IUGR = PATHOLOGICAL resoning restricting full genetic growth potential

248
Q

How is foetal size measured

A
  • 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
Q

RFx for small for gestational age (SGA)

A

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
Q

Ix for Small for gestational age (SGA)

A
  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
Q

What is the significance of End-diastolic flow on umbilical artery doppler

A

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
Q

Mx of small for gestational age foetus

A
  • Monitor with serial UA dopplers
  • Deliver by C-section by 37 wks
253
Q

Placental insufficiency / placental dysfunction pathophys

A

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
Q

RFx for placental insufficiency

A
  • HTN / pre-eclampsia
  • SMOKING
  • Alcohol
  • DRUG USE (e.g. cocaine)
  • Primiparity
  • ADVANCED MATERNAL AGE (>35)
  • PHx of IUGR
  • ANTI-EPILEPTICS / ANTI-NEOPLASTICS
255
Q

Complications of placental insufficency

A
  • IUGR
  • PREMMIE
  • PRE-ECLAMPSIA (because of the increased placental resistance)
  • STILL BIRTH
256
Q

Dx of placental insufficiency

A
  • 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
Q

Placental insufficiency Tx

A

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
Q

Low birth weight Dfx

A
  • < 2500g (5 pounds 8 ounces)
  • <1500g (3 pounds, 5 ounces) = v low
259
Q

Complications of low birth weight

A

Increases risk of childhood mortality and morbidity + cognitive developmental problems

May cause further poor growth + Non-communicable diseases later in life

260
Q

GDM pathophys

A
  • 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
Q

Essential HTN vs Pregnancy Induced HTN (PIH) / pre-eclampsia

A

PIH / pre-eclampsia only develops AFTER 20 WKS gestation

262
Q

PIH / pre-eclampsia pathophys

A

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
Q

What is the criteria for urgent admission of severe pre-eclampsia

A
  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
Q

Complications of pre-eclampsia

A
  • Eclampsia
  • HELLP syndrome
  • Placental ABRUPTION
  • DIC
265
Q

Dfx of hypertension in preg

A

> = 140 systolic OR >= 90 diastolic

Severe = > 160/110 (either/or)

266
Q

Complications / risks of essential HTN during preg

A
  • Accelerated HTN in THIRD trimester
  • Superimposed pre-eclampsia
  • IUGR
  • placental ABRUPTION
  • PREMMIE / STILL BIRTH
267
Q

Mx of essential / chronic HTN in preg

A

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
Q

RFx for placenta praevia

A
  • PHX of placenta pravia
  • IVF preg
  • Past c-section
269
Q

Px of placenta praevia

A
  • oft picked up on scan
  • PAINLESS APH with SOFT, NON-TENDER uterus
270
Q

When are scans done if placenta praevia identified

A
  • 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
Q

Mx of placenta praevia / lowlying placenta

A
  • 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
Q

Mx of vasa praevia

A

If found antenatally:

  • STEROIDS at 32 wks + c-section (at ~34-36 wks)

If found during labour -> cat 1 c-section

273
Q

Mx of placenta accreta spectrum

A

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
Q

Placental abruption pathophys

A
  • 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
Q

Classification of placental abruption

A
  • Concealed - blood remains trapped between placenta + decidua so no PV bleed
  • Revealed
  • Mixed
276
Q

RFx for uterine rupture

A
  • Prev c-section / uterine surgery
  • Use of OXYTOCIN / Induction of labour
  • HIGH PARITY (muliple prev pregs)
  • Increased AGE
  • Raised BMI
278
Q

What are the complications of maternal varicella

A

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
Q

Mx of chickenpox exposure in preg (PEP - Post exposure prophylaxis)

A
  • if in doubt -> check for IgG ANTIBODIES
  • If confirmed:
    • ORAL ACICLOVIR 7-14 days post exposure (better results in clinical trials)
280
Q

Mx of chickenpox in preg

A
  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
Q

Mx of chickenpox in preg

A
  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
Q

Pathophysiology of DVT in preg

A

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
Q

Mx of DVT in preg

A

Warfarin contraindicated so SUB CUT LMWH (iv heparin is more likely to cause bleeding and thrombocytopenia)

Phase 3a (26 decks)

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