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Phase 3a > obs 2 > Flashcards

obs 2 Flashcards

1
Q

what is polyhydramnios?

A

when there is increased amniotic fluid

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2
Q

what are the causes of polyhydramnios?

A

increase in fetal urine production (maternal diabetes, TTTS, fetal hydrops)

Fetal inability to swallow or absorb amniotic fluid (GI obstruction e.g. duodenal atresia, trachea-oesophageal fistula, fetal neurological or muscular abnormalities, idiopathic)

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3
Q

what are the complications of polyhydramnios?

A

preterm delivery
complications of the cause - e.g. duodenal atresia is associated with trisomy 21
malpresentation at delivery because of increase room for fetus
maternal discomfort because of abdominal distension

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4
Q

what investigations would you perform for polyhydramnios?

A

exclude maternal diabetes with a GTT

USS for examination of fetus

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5
Q

how should you manage polyhydramnios?

A

if severe (AFI>40) -> amnioreduction or NSAIDs
if there is a fetal abnormality refer to a fetal medicine centre
TTTS - laser ablation of placental anastomoses
if preterm assess risk of delivery with cervical scan and or fibronectin assay and consider steroids
if unstable or transverse lie at term admit to hospital

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6
Q

what is oligohydramnios?

A

when amniotic fluid volume is reduced

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7
Q

what are the causes of oligohydramnios?

A 
PPROM
IUGR
leakage of amniotic fluid - SROM
fetal renal failure or abnormalities 
post-dates pregnancy 
obstruction to fetal renal output
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8
Q

what are the complications of oligohydramnios?

A

lung hypoplasia if occurs <22 weeks
limb abnormalities e.g. clubbed foot
oligohydramnios before 22 weeks has a very poor prognosis

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9
Q

how do you manage oligohydramnios?

A

If SROM at 34-36 weeks - induce labour unless CS indicated for another reason

If SROM before 34-36 weeks: give prophylactic erythromycin, monitor for signs of infection, daily CTG, consider induction by 34-36 weeks

If IUGR: manage according to umbilical artery doppler and CTG

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10
Q

what are the principal functions of the placenta?

A

to anchor the fetus and establish fetoplacental unit
to act as an organ gaseous exchange
endocrine organ to bring the needed changes in pregnancy
transfer substances to the fetus
barrier against infection

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11
Q

what is breech presentation

A

the lie is longitudinal and the head is found in the fundus

the caudal end of the fetus occupies the lower segment

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12
Q

what are the three types of breech?

A

extended breech (frank breech 70%) - both legs extended with fee by head, presenting part is the buttock

Flexed breeches (15%)
- legs flexed at knees so that both buttocks and feet are presenting

footling breeches (15%) - on leg flexed one leg extended

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13
Q

what are the risk factors/causes for breech presentation ?

A

most often idiopathic
is often associated with pre term delivery
previous breech presentation
uterine abnormalities
placenta praevia and obstruction to the pelvis
fetal abnormalities
multiple pregnancies

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14
Q

what are the consequences of breech presentation?

A

fetal complications - there is an increased risk of hypoxia and trauma in labour, there is an association with congenital abnormalities

cord prolapse is more common in breech presentations

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15
Q

what is the diagnosis of breech presentation ?

A

if diagnosed before 36 weeks It is not important unless in labour

breech presentation is commonly diagnosed before labour

on examination the lie is longitudinal and the head can be palpate at the fundus
the presenting part is not hard
the fetal heart is heard best high up on the uterus

USS can confirm the diagnosis

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16
Q

what can be used to change the presentation from breech to cephalic?

A

external cephalic version - manually turning a breech or transverse presentation into a cephalic one

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17
Q

after external cephalic version?

A

after the attempt, CTG is performed and anti-D given if the mother is rhesus -ve

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18
Q

what are some contraindications to external cephalic version?

A
  • if a C-section is already indicated
  • APH
  • fetal compromise
  • oligohydramnios
  • rhesus isoimmunization
  • pre-eclampsia

relative contraindications - one previous c section, fetal abnormality, maternal hypertension

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19
Q

other than breech presentation what are the other types?

A

transverse or oblique occurs when the axis of the uterus - common before term but uncommon after 37 weeks

unstable lie occurs when the lie is still changing, usually several times a day and may be transverse or longitudinal lie, and cephalic or breech presentation

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20
Q

how do you manage an abnormal lie?

A

admission to hospital at 37 weeks is usually recommended with unstable lie that that a c section can be carried out if labour starts or membranes rupture

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21
Q

why is there increased risk of anaemia in pregnancy?

A

because normal pregnancy has 2-3 fold increase in iron requirements and 10-20 fold increase in folate requirements in pregnancy

plasma volume expansion (50%) greater than red cell mass - this leads to physiological dilution with decreased Hb and haematocrit

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22
Q

what is the most common cause of anaemia in pregnancy?

A

iron deficiency anaemia

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23
Q

how should iron deficiency anaemia be treated?

A

oral iron supplementation - if not tolerated parenteral iron

*in situations such as multiple pregnancy with high risk then prophylactic iron should be given

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24
Q

what are risk factors for folate deficiency anaemia in pregnancy?

A

poor nutritional status
haematological problems with rapid turnover of blood cells e.g. haemolytic anaemia and haemoglobinopathies
drug interaction with folate metabolism e.g. antiepileptics

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25
why is folic acid given pre-conception?
also given in early pregnancy | given to reduce risk of neural tube defect
26
who should be given high dose folic acid?
``` high dose = 5mg those on anticonvulsants a previous child with neural tube defects with demonstrated deficiency with diabetes with a BMI >35 with sickle cell disease ```
27
what ae the risks of sickle cell disease in pregnancy?
crisis are more common during pregnancy increased risk of pre-eclampsia increase risk of delivery by c section secondary to fetal distres
28
what are the fetal risk of sickle cell disease during pregnancy~?
miscarriage IUGR prematurity still birth
29
how should sickle cell disease be managed during pregnancy?
MDT care with obstetrician and haematologist pre pregnancy counselling should involve screening of the partner stop iron-chelating agents before pregnancy screen for urine infection during each visit regular assessment of fetal growth
30
what is obstetric cholestasis?
Intrahepatic cholestasis of pregnancy (ICP) is a pruritic condition during pregnancy caused by impaired bile flow allowing bile salts to be deposited in the skin and the placenta
31
what are the risk factors for obstetric cholestasis?
previous history of intrahepatic cholestasis of pregnancy hep c fam history age >35 years
32
what are the symptoms of obstetric cholestasis?
pruritus of the trunk and limbs sparing the face, without the presence of a rash anorexia and malaise epigastric discomfort, steatorrhoea and dark urine
33
what are the complications of obstetric cholestasis?
maternal risks - vitamin K deficiency = PPH risk fetal risks - preterm labour, still birth, resp distress syndrome in pre-term infants due to insufficient levels of surfactant
34
what investigation would you perform to diagnose obstetric cholestasis?
bile acids and LFTs should be sent for all woman itching without a rash coagulation profile fasting serum, cholesterol hep c virology
35
how do you manage obstetric cholestasis?
antihistamine (hydroxyzine) for symptomatic relief cholestyramine plus vitamin K ursodeoxycholic acid (improves itching and liver function)
36
what makes UTI more common in pregnancy?
dilatation of upper renal tract and urinary stasis
37
what are the risk factors for UTI in pregnancy?
``` previous infections renal stones DM immunosuppression polycystic kidneys congenital anomalies of renal tract neuropathic bladder ```
38
what are the symptoms of cystitis and pyelonephritis in pregnancy?
cystitis: urinary frequency, urgency, dysuria, haematuria, proteinuria and suprapubic pain pyelonephritis - fever, rigors, vomiting, loin and abdominal pain
39
what investigations should you perform for UTI?
urinalysis (nitrites and leukocytes) MSU bloods - cultures, FBC, U&E, CRP in a pyrexial patient renal USS
40
how should UTI in pregnancy be treated?
oral Abx are recommended in asymptomatic bacteria and cystitis to prevent pre term labour and pyelonephritis pyelonephritis should be treated with IV Abx until pyrexia and vomiting stops
41
what is the duration of treatment for UTI in pregnancy ?
NICE recommends 7 day course in all cases of bacteriuria may require longer if pyeloniphritis
42
what antibiotics should be used in UTI in pregnancy?
amoxicillin cephalosporin gentamicin - however needs monitoring Trimethoprim should be avoided in first trimester - folate antagonist Nitrofurantoin - avoid in 3rd trimester as risk of haemolytic anaemia in the neonate with G6PD deficiency sulphonamides - avoid in 3rd trimester as risk of kernicterus in the neonate due to displacement of protein binding to bilirubin
43
what antibiotics are contraindicated in pregnancy?
tetracyclines - causes staining of teeth and problems with skeletal development Ciprofloxacin - causes skeletal problems
44
what are the differential diagnosis for a first seizure during pregnancy?
eclampsia epilepsy infection (meningitis, encephalitis, abscess) metabolic (drug/alcohol, drug toxicity, hypoglycaemia, electrolyte imbalance) severe hypoxia space-occupying lesion vascular
45
what are the fetal risks of epilepsy during pregnancy?
congenita abnormalities risks of anticonvulsant therapy - teratogenicity, neonatal withdrawal, VK deficiency, developmental delay and behavioural problems
46
what are the main teratogenic risks of commonly used anticonvulsants?
valproate - neural tube defect, GU abnormalities, cardiac abnormalities, facial clefts, neurodevelopmental delay carbamazepine - neural tube defects, cardiac anomalies, facial clefts Phenytoin - facial clefts, cardiac anomalies
47
what screening would you perform for pregnant woman on anticonvulsants?
prenatal screening - alpha fetoprotein (neural tube defects) - detailed anomaly scan (facial clefts and cardiac abnormalities)
48
what is the postnatal care for women with epilepsy?
neonatal vitamin K to decrease the risk of haemorrhagic disease of new-born
49
what is antiphospholipid antibody syndrome?
Antiphospholipid syndrome is an acquired disorder characterised by a predisposition to both venous and arterial thromboses, recurrent fetal loss and thrombocytopenia.
50
what are the maternal risk s of antiphospholipid antibody syndrome?
placenta abruption and pre-eclampsia
51
what are the fetal risks of antiphospholipid antibody syndrome?
early and late miscarriage in utero death IUGR
52
how should antiphospholipid antibody syndrome be managed in pregnancy?
if no previous thrombosis or pregnancy loss - no treatment of aspirin previous thrombosis - aspirin and LMWH
53
what are the effects of diabetes on pregnancy?
maternal hyperglycaemia leads to fetal hyperglycaemia fetal hyperglycaemia leads to hyperinsulinemia insulin acts aa growth promotor this leads to macrosomia, organomegaly increased erythropoiesis and fetal polyuria (polyhydramnios) neonatal hypoglycaemia due to removal of mothers glucose at birth
54
what are the maternal complications of diabetes in pregnancy?
``` UTI recurrent vulvovaginal candidiasis pregnancy induced hypertension/pre-eclampsia obstructed labour operative deliveries increase retinopathy increased nephropathy cardiac disease ```
55
what are the fetal complication of diabetes during pregnancy?
``` miscarriage congenital abnormalities (neural tube defects, microcephaly, cardiac abnormalities, sacral agenesis, renal abnormalities) preterm labour polyhydramnios macrosomia IUGR unexplained IUD ```
56
what are the neonatal abnormalities of diabetes in pregnancy?
``` polycythaemia jaundice hypoglycaemia hypocalcaemia hypomagnesaemia hypothermia cardiomegaly birth trauma RDS ```
57
what is puerperal pyrexia?
Puerperal pyrexia may be defined as a temperature of > 38ºC in the first 14 days following delivery.
58
what are some causes of puerperal pyrexia?
``` endometritis - most common cause UTI wound infections mastitis/breast abbcess venous thromboembolism ```
59
what could increase the risks of endometritis?
``` c section prelabour ROM intrapartum chorioamnionitis prolonged labour multiple pelvic examinations internal fetal monitoring anaemia ```
60
what investigations would you perform for puerperal pyrexia?
``` FBC blood cultures MSU swabs from cervix wound swabs throat swabs sputum culture and CXR ```
61
how should puerperal pyrexia be managed?
analgesics and NSAIDS wound care in cases of wound infection ABx if endometritis is suspected - the patient should be referred to the hospital and receive IV Abx (clindamycin and gentamycin)
62
what are the fetal complications of shoulder dystocia?
``` hypoxia and neurological injury (cerebral palsy) brachial plexus palsy fracture of clavicle or humerus intracranial haemorrhage cervical spine injury rarely, fetal death ```
63
how should you treat uterine atony?
IV ergometrine start oxytocin infusion if bleeding still persists then give misoprostol if still continues give carboprost IM into thigh or directly into myometrium
64
why does pregnancy increase the risk of VTE?
because there is venous stasis in the lower limbs possible trauma to the pelvic veins at the time of delivery changes in the coagulation system
65
what are the risk factors for VTE in pregnancy?
``` previous VTE thrombophilia age>35 years obesity parity >3 gross varicose veins paraplegia sickle cell disease fam history of unprovoked VTE multiple pregnancy ``` new onset/transient risk factors - OHHS, hyperemesis, dehydration, long haul travel, severe infection, immobility (>4days bed rest), pre-eclampsia, prolonged labour
66
how are VTE prevented in pregnancy?
LMWH is the gent of choice should be given immediately if there are four or more risk factors and it should be continued until 6 weeks postnatal if they have 3 risk factors it should be started at 28 weeks gestation
67
what are the symptoms/signs of a DVT?
``` leg pain or discomfort swelling tenderness pyrexia erythema, increased skin temp and oedema lower abdominal pain elevated WBC ```
68
what are the symptoms/signs of a PE?
``` dyspnoea collapse chest pain haemoptysis faintness raised JVP focal signs in chest symptoms and signs associated with DVT ```
69
how would you investigate VTE?
``` thrombophilia screen FBC U&E LFTs coagulation screen ``` compression duplex USS If PE suspected - ECG, CXR, ABG, ventilation perfusion lung scanning, CT/MRI *D-Dimer - not used in pregnancy as often gives a false positive, however if it is low then it would usually rule out VTE
70
what considerations should be taken if a women is on LMWH during labour/delivery?
once she is in labour she is advised not to inject further heparin avoid epidural haematoma - regional anaesthesia should be avoided until 12 hours after the last dose, LMWH should not be given until 4 hours after epidural catheter has been removed. there is an increased risk of wound haematoma following C-section there is a higher risk of haemorrhage
71
what should women who are at risk of haemorrhage be put on for VTE?
unfractional heparin - has a shorter half life and is completely reversed with protamine sulphate

Phase 3a (41 decks)

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