obs Flashcards
when does a secondary PPH occur
500ml 24hrs-12 weeks post birth
when can you not give ergometrine IV in PPH
when there is hx of HTN (it can cause coronary artery spasm)
when can you not give carboprost IV in PPH
when there is a hx of asthma (as causes bronchospasm)
what happens if mum gets chicken pox in first 20 weeks of pregnancy
fetal varicella syndrome - problems with the eyes, limbs and microcephaly
what is the risk to mum with chicken pox in pregnancy
5x more likely to get pneumonitis, hepatitis, encephalitis
what is the risk if mum gets chicken pox around delivery
neonatal varicella syndrome
MX of chicken pox exposure in pregnancy
-check varicella antibodies
-If no immunity, give oral aciclovir 7-14 days post exposure.
-if rash is present, start aciclovir within 24 hours if more than 20 weeks pregnant
features of congenital rubella syndrome
sensorineural deafness, cataracts, CHD
Dx of rubella in pregnancy
IgM
Mx of rubella in preg
discuss with the health protection unit, offer MMR to non immune mothers after pregnancy
when are babies not at risk of congenital rubella syndrome
after 16 weeks
what does congenital CMV cause
growth restriction, microcephaly and hearing loss, blueberry muffin skin lesions
what does syphilis cause in babies
stillborn
complications of parvovirus in pregnancy
miscarriage, severe fetal anaemia –> hydrops fetalis from heart failure
Dx for parvovirus in pregnancy
IgM to parvovirus which tests for acute infection, IgG which detects long term immunity and rubella antibodies as a differential diagnosis
What does listeriosis come form
unpasteurised dairy products and processed meats
when does herpes present the highest risk to babies
in final 6 weeks –> need C section (cause neonatal herpes infection which can be localised or can disseminate)
in a mum who is known to have herpes, what should you consider?
prophylactic acyclovir from 36 weeks
if herpes is caught early on in the pregnancy, how is it treated
aciclovir
scoring for HG
PUQE
Mx of HG
1) promethazine / cyclizine
2) prochlorperazine (extrapyramidal SE)
3) ondansetron
Rf for HG
molar, multiple, nulliparity
Mx of molar pregnancy
evacuation of the uterus and then monitored hCG for 6 months (until it returns to normal), managed at a GTD centre
what is a choriocarcinoma
when moles metastasise, get systemic symptoms like coughing, chest pain and breathing difficulties
what contraception is available after birth
-POP can be started straight away
-COCP cannot be started for 21 days due to unacceptable VTE risk
-COCP contraindicated for 6 weeks if breastfeeding
-Ius/IUD can be put in in the 48 hours after birth or then after 4 weeks
-Lactational amenorrhea method —> effective for 6 months
taking sertraline in pregnancy gives a risk of what
withdrawal in baby (so must be monitored for 24 hours) and persistent pulmonary hypertension
how many women get PND
10% - normally start months 1-3, difficulty bonding, low mood, guilt
SSRI if severe PND
paroxetine / sertraline
complications of PND
recurrence and higher risk of lifetime depression
what class of drugs is firstline in morning sickness
antihistamines
if a woman has pre existing HTN in preg, what should happen to their meds?>
stop ACEi/ARB and start on labetolol ( also monitor for proteinuria)
what is pregnancy induced HTN
HTN occurring in the second half of preg, after 20 weeks
-no proteinuria or oedema which resolves after birth (treat with labetolol and monitor for weekly proteinuria)
cause for preeclampsia
abnormal placentation (impaired invasion of trophoblasts leading to shallow invasion of spiral arteries —> oxidative stress –> endothelial dysfunction)
-this causes increased permeability which causes oedema and proteinuria.
high risk factors of preeclampsia
pre existing HTN, CKD, DM, autoimmune conditions like SLE
moderate RF of preeclampsia
primi, BMI >35, molar, multiple preg, 10 year gap, first degree relative.
what risk reduction is started for women with 1 high risk factor or 2 moderate risk factors for pre eclampsia
aspirin 150mg daily from 12 weeks
signs of preeclampsia
HTN, oedema in peripheries, proteinuria, growth restriction, oligohydraminos, epigastric/RUQ pain, hyperreflexia
what Ix of you do for someone with preeclampsia
FBC
U+E
LFT coat profile
level of proteinuria by ACR (>300mg in 24 hours or 2++ on dip)
PlGF
Mx of preclampsia
-regular monitoring of mum and baby (CTG / doppler)(
-aspirin
-labetolol / nidefipine / methyldopa
-VTE prophylaxis
complications of preeclampsia for mum
ICH, stroke, pulmonary oedema, eclampsia , HELLP. DIC, placental abruption
complications of preeclampsia for baby
stillbirth, small baby, premature, placental abruption
RF of placental abruption
low BMI, cocaine, smoking, polyhydraminos, multiple pregnancy
Mx for placental abruption
Emergency - A_E
-bloods –> FBC, U+E, LFTs, clotting
-crossmatch
-CTG
-US to rule out praaevia
-anti D prophylaxis (kleihauer test)
-C section if distress
Rf for GDM
previous macrocosmic baby, FHx of DM, BMI > 30, black/Asian
what preconception counselling is done for someone known DM
-aim HbA1c < 6.5%
-BMI <27
-folic acid 5mg
-stop statin
-stop any oral glycaemias APART from metformin
-carry on with insulin
-managed in joint antenatal and diabetes clinic
for GDM patients, when should delivery occur
39-40+6 weeks
for preexisting DM, when should delivery occur
37-38+6 weeks
what is the post delivery MX of GDM
stop all Tx and re monitor HbA1c at 12 weeks
targets for GDM once starting Tx
fasting <5.3
1 hour post meal < 7.8
2 hours post meal <6.7
what 2 ways can preterm labour be prevented
1) vaginal progesterone (if cervix <25mm at 20 week US)
2) cervical cerclage
RF of preterm birth
previous preterm, PPROM, cervical trauma, smoking
what is it important not to do in PPROM (preterm premature rupture of membranes)
DV exam, do a sterile speculum exam instead to look for pooling of water (if unsure check PAMG and IGFBP1)
Mx of PPROM
admit - steroids, 10 days erythromycin, monitor temp for infection, expectant mx until 37 weeks
when do you suspect preterm labour with intact membranes
when there is regular and painful contractions and cervical dilation without rupture of membranes
Mx of preterm labour with intact membrane
1) speculum to look for cervica dilation
2) if < 30 weeks –> offer Tx
3) if > 30 weeks –> TV US to look at cervical length, if it is >15mm then labour is unlikely.
-if insure can check fetal fibronectin. (<50 = unlikely)
The MX:
-CTG
-tocolysis - nifedipine to stop contractions
-steroids
-mag sulphate
what is is important to never do in PROM
DV exam due to infection
contraindications to tocolysis
dilation >4cm, >34 weeks, chorioamnionitis, non reassuring CTG
what kind of insulin is GDM treated dwith
short acting
if a woman is unsure whether she has reduced FM, what should she be advised
lie on left side and concentrate on movements, should have 10 movements in 2 hr (after 28 weeks)
Ddx for RFM
fetal death, FGR, TORCH, positional change, sedate drugs, oligohydraminos or polyhydraminos
secondary PPH
24 hours - 12 weeks
how does uterus feel in atony
soft and boggy
RF for atony cause of PPH
advanced maternal age, polyhydraminos, multiple pregnancy, prolonged labour
what bacteria normally causes endometritis (most common cause of a secondaryPPH)
mixed gram - and +
when is the major haemorrhage protocol activated
> 1000ml
SE of oxytocin
hypotension, flushing, headache
complications of PPH
anaemia, hysterectomy, sheehan syndrome, PTSD
Dx of endometritis
vaginal swabs, urine cultures, do US to rule out RPOC
MX of endometritis
sepsis 6 if septic, otherwise broad spec Abx (prevented by prophylaxis abx in C section)
which part of pituitary gland undergoes avascular necrosis in PPH
anterior only (as this is supplied by the low pressure hypothalamohypohyseal system)
what happens in postpartum thyroiditis
hyperthyroid –>hypothyroid –> normal
RF of cord prolapse
breech, prem, ARM
what Abx is given for GBS prophylaxis
benzylpenicillin
RF for GBS infection
preterm, previous baby affected, high temperature, positive urine test, swab test for GBS, PROM
which race at risk of OC
Asian
IX for OC
LFT and bile acids, USS abdo, liver autoimmune screen
what monitoring is required in OC
LFT weekly and after 10 days post pregnancy
what vitamin needs to be replaced in OC
vitamin K
what happens in placenta accreta
the placenta attaches to the myometrium due to a defective decider basalis
what’s the different between placenta accrete, placenta increta and placenta percreta
placenta accreta –> attaches to myometrium but does not go through it
Placenta increta –> chorionic villas invaded the myometrium
Placenta percreta –> chorionic villi invade through the perimetrium
RF for placenta accreta
previous C section, placenta praaevia, previous PID, advanced age3
Mx of placenta accreta
-delivery at 35-36+6 weeks
-hysterectomy if not known until delivery
-expectant Mx (if known about and MRI has been done to look at invasion) –> have blood transfusions and ITU on standby
What is measured on a bishops score
-dilatation of cervix
-consistency of cervix
-cervical length (effacement)
-position of cervix
-station of presenting part
-max score 13
quadruple test screening results for DS increased likelihood
↓ AFP
↓ oestriol
↑ hCG
↑ inhibin A
causes of oligohydraminos
PROM, potter sequence, FGR, TORCH infections
IX for oligohydraminos
US, karyotyping
MX of oligohydraminos
serial fetal testing due to increased risk of fetal demise
apart from pulmonary hypoplasia, what are the other problems with oligohydraminos
limb deformities, cord compression
complications of polyhydraminos for mum
-worse pregnancy symptoms like reflux and SOB due to compression of the diaphragm
-PPH
causes of polyhydraminos
idiopathic, macrosomia, oesophageal atresia, muscular dystrophies
Mx of polyhydraminos
-not normally needed
-if symptoms vvv bad can do amnioreduction
-can use indomethacin - increase water retention and reduce fetal urine output
why is risk of VTE so high in preg
loss of anticoagulants, venous stasis, increase in clotting factors
when is VTE risk assessed
at booking and at any subsequent appointments
Rf for VTE
BMI>30, age >35, smoker, gross varicose veins, preterm birth, hyperemesis, ART
what do you do if you identify 4 RF for VTE
LMWH straight away until 6 weeks PP
-THIS IS ALSO IF ANY HX OF VTE IN MUM
what do you do if you identify 3RF for VTE in preg
LMWH from 28 weeks until 6 weeks PP
Ix for VTE in preg
venography with fetal shield (gold standard)
-doppler US is a good alternative
does anything need to be monitored in mum on LMWH
anti Xa
what side DVT is more common in preg
left sided 85%
what is chorioamnionitis
infection of fetal membranes and amniotic fluid (RF = PROM and GBS)
on SFH, when does a baby need a uterine artery doppler and serial growth scans (where head circumference, abdominal circumference, and femur length are measured)?
if on <10th centile
what is a large for dates baby
> 90th centile
what is a severe SGA
<3rd centile
what does it mean if a foetus has symmetrical IUGR vs asymmetrical
symmetrical –> intrinsic factors like chromosome abnormalities and infections
asymmetrical –> malnutrition / alcohol / placenta insufficiency
Investigations for fetal growth
vital signs, urine dip and BP (to check for preeclampsia), CTG, screen for infections and DP, biophysical profile (amniotic fluid measurements), karyotyping (by amniocentesis), detailed fetal anatomy scan
what is done every 3/4 weeks in IUGR
serial growth scan and umbilical artery doppler
what are worrying signs on umbilical artery doppler
-absent end diastolic flow
-reverse end diastolic flow
ANSWER IN EXAM WILL BE UMBILICAL ARTERY DOPPLER
uterine artery doppler (think more of a screening tool) shows worrying signs when, this can be done if someone has RF for IUGR as a screening tool firstline
pulsatility index >95th gentile and early diatonic notching
Causes for a large for dates baby
true causes - genetic syndrome like beckwith wiedemann / GDM / maternal obesity
other causes - large fibroids
Mx for large for dates babies
nothing!! induction not advised unless GDM
RF for uterine rupture
previous C section, induction, multiple preg
what causes symphysis pubic dysfunction (pain when walking/turning over in bed/climbing stairs)
separation of the pubic symphysis
what happens to mums respiration in pregnancy
increased minute ventilation (from increased TV not from increased RR)
-minute ventilation = TV x RR
what happens to the immune system in preg
mum does into immunosuppressed state so she does not attack the hemi-allogradt
what happens to the cardiovascular system in pregnancy
cardiac output increases by increasing stroke volume in early pregnancy and in later pregnancy HR increases
-get a procoagable state (loss of anticoagulants and increase in clotting factors)
-activation of RAAS to increase the circulating volume
what happens to the renal system in preg
eGFR goes up due to increase renal blood flow due to systemic vasodilation
-get reduced reabsorption of glucose in PCT so there is glycosuria
-get relaxation of smooth muscle so decrease in urine passage
what is a galactocele
a cystic lesion in the breast which causes a milky discharge and normally occurs when a woman stops breast feeding
causes for poor supply in breast feeding
maternal prolactin deficiency (Thyroid disorder, alcohol), mother perception, breast hypoplasia
what is raynauds disease of the nipple
intermittent soap pain which is present during / immediately after feeds which causes blanching
what are some issues with twin pregnancy
worse symptoms for mum (sickness, GORD), increased risk of preeclampsia, PPH, prematurity, poor growth, twin to twin transfusion
when can vaginal delivery be attempted with twins
if diamniotic and if the first twin is head down
what are some delivery points for twins
2 obstetricians / 2 midwives around
-offered/encourage to have epidural incase intervention needed
-CTG - with fetal scalp electrode attached to first baby
dizygotic twins are always diamnitoic, dichorionic, what are the options for monozygotic twins?
can have their own sacs/placentas but can also share
what happens in vasa praaevia
fetal blood vessels are not protected by the umbilical cord and run near the orifice
Mx of vasa praaevia
C section at 34-36 weeks
RF for vasa praaevia
IVF + multiple pregnancy
why is UTI common in preg
relaxation of smooth muscle (ureteral dilation), immunocompromised state, compression by gravid uterus
MX of UTIin preg
nitro for 7 days AND always send a urine culture and look for GBS
-in final trimester use amoxicillin / cefalexin
after lifestyle measures, what’s firstline for dyspepsia in pregnancy
antaacids and alginates
what is the blastocyst (embryology)
the trophoblast and the embryo blast in the second week with a cavity (blastocele)
what happens to the blastocyst
the trophoblast becomes the syncytiotrophoblast and the cytoplast and the embryo blast becomes the epiblast and the hypoblast
what happens in the third week of embryonic developing
gastrulation where the epiblast undergoes migration and invagination and becomes endoderm, mesoderm and ectoderm
the hypoblast becomes the embryonic membranes
what does the mesoderm become
connective tissue - cartilage / smooth muscle
how do the villi of the placenta form
the primary villi form form the cytotrophoblast, the secondary villli = mesenchymal core and the tertiary villi occur when blood vessels fill the mesenchymal core
when is placental development complete by
week 10
anaemia limits in pregnancy
first trimester <110, second and third <105, PP<100
consequences of anaemia in mum
tired, increased risk of permpartum blood loss, poor concentration
consequences of anaemia in foetus
preterm delivery, LBW, increased anaemia in first 3 months
preconception considerations for haemoglobinopathies
1) folic acid 5mg
2) worsening anaemia in preg
3) painful crisis
4) genetic counselling
5) check vaccination status
6) daily penicillin prophylaxis due to hyposplenism
7) risk of prematurity AND growth restriction
8) MX in haem/obstetric clinci
when should uterus return to non pregnant size
4 weeks
what hepatitis is likely to cause serious illness in preg
hep E (spread by feacal oral route, does NOT cause chronic illness or increased risk of hepatocellular carcinoma)
risks of obesity in preg
to mum: pre-eclampsia, GDM, VTE, problems in labour requiring intervention
to baby: more likely to be obese in life, more likely to be premature, big baby - complications for baby like nerve injuries
-need to take 5mg of folic acid
-need to have baby at a obstetric led hospital
stepwise MX of PPH
1) manual uterine rub and bimanual compression
2) IV oxytocin or IV ergometrine
3) IM carboprost
4) rectal misprostol
5) surgical intervention such as balloon tamponade / uterine artery ligation and last –> hysterectomy
where does toxoplasmosis come from
cat poo / undercooked meet –> causes chorioretinitis in eye and calcium deposits in brain
if women has pre-existing diabetes, when should delivery be done
37-38+6weeks
mx of pre-existing DM in preg
stop oral glycemic apart from metformin, start insulin, want BMI <27, manage in joint diabetes obstetrics clinic
Tx is resp depression occurs due to magnesium sulphate
calcium gluconate (note must continue magnesium sulphate until 24 hours after the last seizure)
apart from magnesium sulphate, whats another important TX for eclampsia
fluid restriction
Kleihauertest is needed for any sensitisation event over what gestation? to see if any additional anti D is needed
20 weeks
major RF for IUGR
+ minor
MAJOR
-pre-eclampsia
-kidney disease
-APS / SLE
-previous SGA or previous still birth
-cocaine use
-smoking
MINOR
low or high BMI
nulliparity
complications of SGA
neonatal hypoglycaemia, iatrgoenic prematurity due to expediting labour, NEC, stillbnirth
rhesus antibodies are what
IgG (these can cross the placenta)
signs of haemolytic disease of the newborn
jaundice in first 24hr of life, hepatosplenomegaly, hydrops fetalis,
