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Obs 4 Flashcards

1
Q

Define large for gestational age (LGA)

A

A neonate who, at birth, weighs at or above the 90th percentile for gestational age

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2
Q

Define foetal macrosomia

A

Babies with birth weight >4,000 g

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3
Q

What are the tools to diagnose LGA prenatally?

A
  • SFH: Greater than 90th centile for gestational age (top of fundus to top of symphysis pubis)
  • AC: >95th centile for gestational age
  • EFW: >90th centile on customised growth chart or over 4000g on USS
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4
Q

What are the RFs for LGA?

A
  • High BMI
  • Foetal macrosomia (>4kg in a term infant)
  • Gestational or DM
  • Syndromes: Beckwith-Wiedemann, Simpson-Golabi-Behemel, Soto’s syndrome
  • Molar pregnancy
  • Polyhydramnios
  • Multiparity
  • Advanced maternal age
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5
Q

What are the S/S of LGA?

A
  • On inspection > excessive distension for gestational age
  • Abdomen > increased SFH, increased abdominal circumference
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6
Q

What are the investigations for LGA?

A
  • OGTT – for gestational diabetes
  • Bloods – serum βHCG
  • USS – liquor volume, biometry
  • Genetic testing
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7
Q

What is the management for LGA?

A

At every antenatal appointment after 26 weeks, measure SFH:
If greater than expected on two or more occasions, or there is a significant increase in growth on one occasion, offer a growth scan at the hospital (check baby’s growth, AF volume and blood flow through the placenta)

Serial SFH plots show linear growth pattern >90th centile with no other concerns:

  • Reassure this is normal, arrange another routine scan
  • Refer to ANC by 37wks if EFW projects to be >4000g at 40wks

Serial SFH plots show accelerated growth at <36wks:

  • Refer for USS
  • If EFW >90th centile, refer for OGTT
  • If normal OGTT, organise 1 week of BM testing
  • If not diabetic, refer to consultant ANC by 37wks
  • Offer IOL between 37-40wks if predicted to be >4000g at 40wks

Serial SFH plots show accelerated growth at >36wks:

  • Refer for USS
  • If EFW >90th centile, offer home BM monitoring for 1wk
  • If not diabetic, refer to consultant ANC by 37wks
  • Offer IOL between 37-40wks if predicted to be >4000g at 40wks
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8
Q

What are the complications of LGA?

A

Baby:

  • Shoulder dystocia - Brachial plexus injury
  • Fractures
  • Stillbirth
  • HIE
  • Hypoglycaemia in GDM
  • Increased mortality

Mother:

  • 3rd/4th degree tears
  • Prolonged labour
  • PPH

Prognosis > early planning/care > no difference in outcomes for LGA compared to normal

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9
Q

Define small for gestational age (SGA)

A

Babies with a birth weight below the 10th percentile for their GA

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10
Q

Define IUGR

A

Derived from growth rate:
Describes a baby with a reduced growth rate (baby becomes SGA)

All IUGR babies are SGA but not all SGA babies are IUGR

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11
Q

What are the RFs for SGA?

A

Maternal:

  • Previous SGA baby
  • Previous stillbirth
  • Maternal disease - CKD , chronic HTN, APLS
  • Placental insufficiency (asymmetrical IUGR)

Foetal:

  • Chromosomal abnormalities (symmetrical IUGR)
  • Infection (CMV, rubella)
  • Multiple pregnancy
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12
Q

What are the investigations for SGA?

A

1st: SFH or risk status determined

  • At booking or any antenatal appointment
  • ≥1 major RF or ≥3 minor RFs
  • Reassess at 20 weeks

2nd: confirm SGA with foetal biometry (20w)

  • Biparietal diameter, HC, AC, FL

3rd: uterine artery doppler (20-24w)

  • Normal = repeat scans every 2 weeks (from 20-24w onwards)
  • Abnormal = Serial USS growth scans every week (from 26-28w onwards), Doppler USS can be performed twice a week (umbilical artery flow)

+Screen for congenital infections

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13
Q

What is the management of SGA?

A

General:

  • Smoking, alcohol and drugs should be stopped
  • Low-dose aspirin may have some role in preventing (not reversing) IUGR in high-risk pregnancies

Delivery:
Indications for IMMEDIATE DELIVERY:

  • Abnormal CTG (and reduced foetal movements)
  • Reversal of end-diastolic flow

Delivery by 37 weeks is usually necessary > dependent on severity and gestation:

  • Steroids should be given <36 weeks
  • Consultant-led clinics and decision-making
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14
Q

What are the complications of SGA?

A
  • Stillbirth
  • PTL
  • Intrapartum foetal distress
  • Birth asphyxia
  • Meconium aspiration
  • Postnatal hypoglycaemia
  • Neurodevelopmental delay
  • Risk T2DM and HTN in adult life

Prognosis > increased perinatal morbidity and mortality, increased neurodevelopmental delay if onset <26/40

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15
Q

What is obstetric cholestasis?

A

Pruritus in pregnancy, resolves on delivery, associated with abnormal liver function in the absence of other identifiable pathology

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16
Q

What is the aetiology of obstetric cholestasis?

A

Likely genetic (defect in membrane phospholipid) and hormonal (oestrogen impairing sulphation) factors

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17
Q

What are the RFs for obstetric cholestasis?

A
  • Previous OC
  • FHx
  • ethnicity (South Asia, Chilean, Bolivian)
  • multiple pregnancy
  • pruritis on COCP
  • Affects ~1% of pregnancies in the 2nd half of pregnancy
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18
Q

What are the S/S of obstetric cholestasis?

A
  • Pruritus with excoriations (palms and soles; worst at night)
  • Raised bilirubin (and jaundice in 20%)
  • No rash
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19
Q

What are the investigations for obstetric cholestasis?

A
  • Bile acids (raised)
  • LFTs (raised bilirubin / liver enzymes) - repeat weekly

Consider:

  • Coagulation screen (may be high if vitamin K deficient)
  • FBC
  • Hepatitis C serology (increased risk of OC in hepatitis C)
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20
Q

What is the management of obstetric cholestasis?

A

Symptomatic relief:

  • Ursodeoxycholic Acid – reduces itching and improves LFTs
  • Vitamin K supplementation (if clotting impaired)
  • Sedating antihistamines (chlorphenamine or promethazine)
  • Topical emollient and wear loose cotton clothes (may help reduce itching)

Antenatal Monitoring:

  • Weekly LFTs until delivery
  • Twice-weekly Doppler and CTG until delivery
  • Consultant-led care

Delivery:

  • Offer induction of labour at 37 weeks

Postnatally (with GP):

  • Arrange follow-up, after delivery, to ensure that LFTs have returned to normal
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21
Q

What are the complications of obstetric cholestasis?

A

Baby:

  • Stillbirth
  • Premature birth
  • Meconium aspiration
  • Foetal distress

Mother:

  • PPH (due to low vitamin K)
  • Severe liver impairment
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22
Q

What is acute fatty liver of pregnancy?

A

Rare pregnancy associated disorder characterised by fatty infiltration of the liver

  • Accumulation of microvesicular fat in hepatocytes, periportal sparing, small yellow liver on gross examination
  • Likely mitochondrial disorder affecting fatty acid oxidation
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23
Q

What are the RFs for acute fatty liver of pregnancy?

A
  • Nulliparity
  • multiple pregnancies
  • Obesity
  • male foetus
  • pre-eclampsia
24
Q

What are the S/S of acute fatty liver of pregnancy?

A
  • Normally 3rd trimester
  • Nausea, vomiting, abdominal pain / liver tenderness, jaundice, bleeding, ascites, manifestations of coagulopathy
  • 50% have proteinuric hypertension

Differentiate from cholestasis of pregnancy by pruritis

25
Q

What are the investigations of acute fatty liver of pregnancy?

A
  • LFTs (ALT is typically very elevated) - ALP may be raised due to placental ALP
  • FBC (low plts in HELLP)
  • Blood glucose (low)
  • Elevated URIC ACID (high)
  • USS - fatty liver (hypoechogenic)
26
Q

What is the management of acute fatty liver of pregnancy?

A
  • Emergency - treat as liver failure
  • Supportive care > stabilisation
  • Once stabilised, delivery is the definitive management to prevent deterioration
27
Q

What are the complications of acute fatty liver of pregnancy?

A
  • Maternal – death, haemorrhage (secondary to DIC), renal failure, hepatic encephalopathy, sepsis, pancreatitis
  • Foetal – death

> Prognosis: Maternal mortality 10-20%, perinatal mortality 20-30%

28
Q

What are the RFs for breech presentation?

A

Maternal:

  • Placental abnormalities (praevia, increta, percreta, accreta)
  • Uterine abnormalities
  • Grand multiparity (> uterine laxity)
  • Obstructed lower segments (i.e. fibroids, pelvic abnormalities)

Foetal:

  • Multiple gestation
  • Prematurity
  • Foetal malformation
  • Polyhydramnios, oligohydramnios
  • Macrosomia
29
Q

What are the S/S of breech presentation?

A
  • Abdomen – palpable head at fundus, soft breech in pelvis
  • Vaginal – soft presenting part, ischial tuberosities, anus or genitalia may be felt
  • Footling breech – foot felt or seen through cervix
30
Q

What are the 3 types of breech presentation?

A
  • Frank breech = hips flexed & knees extended, feet next to head
  • Complete breech = both hips flexed & both knees flexed, legs crossed
  • Footling breech = one or both hips not completely flexed, foot presenting
31
Q

What are the investigations for breech presentation?

A

USS to confirm

32
Q

What is the management of breech presentation?

A

Offer External Cephalic Version (ECV)

  • Involves applying external pressure and firmly pushing or palpating the mother’s abdomen to coerce the fetus to somersault (either forwards or backwards) into a cephalic position in order to allow normal vaginal birth
  • Give tocolytic agents (e.g. salbutamol, terbutaline)
  • CTG and USS should be performed before and after
  • If ECV is successful, pregnancy care should continue as usual for any cephalic presentation (50% success rate)
  • If foetal distress - emergency CS
  • Advise risks/benefits - very low risk

Unsuccessful/declined ECV with persistent breech:

  • ELCS or breech vaginal delivery

Council risks and benefits of vaginal delivery vs ELCS

  • Benefits of ELCS: Reduces perinatal and neonatal mortality - cord prolapse, head getting stuck, avoid emergency CS
  • Risks of ELCS: Small increased risk of immediate maternal complications (but risk is highest with emergency CS which is needed in 40% of vaginal breech birth), risk of complications in future pregnancy (PE, infection, bleeding, damage to bladder/bowel)

>37wks gestation and in labour:

  • C-section

> Induction of labour is not recommended (augmentation of slow progress with oxytocin considered)

33
Q

What are contraindications for ECV?

A
  • C-section is required
  • APH within last 7 days
  • Abnormal CTG
  • Major uterine anomaly
  • Ruptured membranes
  • Multiple pregnancy
34
Q

Describe the management of breech vaginal delivery

A
  1. ‘Hands off’ approach (ideally baby will deliver itself, legs often deliver spontaneously)
  2. If legs don’t deliver - Pinard manoeuvre (apply pressure in popliteal fossa, causes flexion of the knees, helps delver legs
  3. Place thumbs on the sacrum and fingers on the ASIS of the baby - let baby come down until you see the scapula
  4. Lovset’s manoeuvre - rotate the baby 90°, place finger in antecubital fossa of anterior arm and deliver anterior arm - rotate baby into opposite anterior position and deliver other arm
  5. If baby’s head gets stuck once body has delivered, you will see winging of the scapulae - Mauriceau-Smellie-Veit manoeuvre (rest baby on your forearm, maintain head flexion, and pull the head downwards and deliver in a J shape)
  6. If this doesn’t work, use forceps

Other considerations: G&S, X-match, FBC, CTG, make sure theatre is ready

35
Q

What features are suggestive of vaginal breech birth being HIGH RISK?

A
  • Hyperextended neck
  • High or low EFW
  • Footling presentation
  • Evidence of antenatal foetal compromise
36
Q

What are the S/S of transverse lie?

A
  • Abdomen – no presenting part in pelvis, uterus appears wide, fundal height may be low
  • Vaginal – no presenting part
  • Face – facial landmarks felt
  • Brow – supraorbital ridges or base of nose felt
37
Q

What are the investigations for unstable lie?

A

USS to confirm lie

38
Q

What is the management of unstable lie?

A

Transverse lie:

  • Before 36 weeks gestation: no management required. The patient should be informed that most foetuses will spontaneously move into longitudinal lie during pregnancy.
  • After 36 weeks gestation: the patient must have an appointment with the obstetric medical antenatal team to discuss management options:
  • ECV (50% success)
  • ELCS

Other:

  • Brow: If persistent or 2nd stage labour = CS
  • Face: Mentoposterior = CS, Mentoanterior = SVD
  • Compound (foetal arm along head) = Manage expectantly
39
Q

Define miscarriage

A

Pregnancy loss <24 weeks gestation

  • 1 in 5 pregnancies
  • (PV bleeding >24w is APH)
40
Q

What are the different types of miscarriage?

A

Threatened: An ongoing pregnancy with vaginal bleeding

  • PV bleeding with FH present
  • Typically occurs at 6-9 weeks
  • Cervical os closed

Inevitable: A non-viable pregnancy in which bleeding has begun and the cervical os is open, but pregnancy tissue remains in the uterus

  • Heavy PV bleeding with clots / pain
  • Cervical os open

Incomplete: Not all products of conception have been expelled

  • Passage of products of conception but uterus not empty on USS
  • Pain and vaginal bleeding
  • Cervical os is open

Complete:

  • Passage of products of conception, uterus empty on USS

Missed: Gestational sac which contains a dead foetus before 20 weeks without the symptoms of expulsion

  • USS dx of miscarriage in absence of symptoms
  • Mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear
  • Pain not usually a feature
  • Cervical os is closed
  • When gestational sac >25mm and no embryonic/foetal part can be seen it is sometimes described as a ‘blighted ovum’ or ‘anembryonic pregnancy’
41
Q

Describe recurrent miscarriage (RMC)

A
  • ≥3 consecutive miscarriages
  • No cause found in 50%
  • RFs: advancing maternal age, previous miscarriage
  • Prognosis for future successful pregnancy is 75%
42
Q

What is the aetiology of a miscarriage?

A

90% result from chromosomal abnormalities in the embryo – trisomy 16

43
Q

What are the RFs for miscarriage?

A
  • Increasing maternal age
  • Previous miscarriage (more than 95% occur in 1st trimester)
  • Chronic conditions
  • Uterine/cervix abnormalities
  • Smoking, alcohol, illicit drugs
  • Underweight/obese
44
Q

What are the causes of RMC?

A
  • Structural abnormalities (fibroids, congenital uterine abnormality - bicornuate or septate uterus)
  • Cervical incompetence (later miscarriages = >13w)
  • Medical conditions (renal, diabetes, SLE)
  • Clotting abnormalities (FV-L, AT-III deficiency, APLS)
45
Q

What are the S/S of a miscarriage?

A
  • PV bleeding (scanty, brownish/red), cramping abdominal pain, fever
  • Speculum > quantity and location of bleeding, os open/closed, can remove any products
  • PV exam > exclude ectopic (unilateral tenderness, cervical excitation, adnexal mass)
  • General – assess for signs of shock, pyrexia
46
Q

What are the investigations for a miscarriage?

A

TVUSS:
Miscarriage diagnosed if:

  • No FH + CRL >7mm
  • GS >25mm + no visible yolk sack or foetal pole

Repeat USS no less than 7d later to confirm diagnosis

> If no FH and CRL <7mm = PUV (Pregnancy of Unknown Viability) > TVUSS in 7 days

N.B. cannot be diagnosed as miscarriage on 1 USS alone > get 2nd opinion / re-scan

47
Q

How are pregnancies dated using USS?

A
  • CRL (end-to-end measure of foetal pole) used to date pregnancies <14 weeks
  • N.B. a foetal pole may not be seen until 9 weeks
  • AC, HC, FL used to date pregnancies >14 weeks
  • Need yolk sac and gestational sac to be a viable IUP; otherwise PUL
48
Q

What are the investigations for RMC?

A
  • Cytogenic analysis of products of conception
  • Pelvic USS (structural abnormalities)
  • Anti-phospholipid antibodies
  • Anticardiolipin antibodies
  • Screen for BV
  • > explain that the cause is often never found
49
Q

What is the management of a threatened miscarriage?

A

ABC approach, stabilise the patient and replace lost volume

Analgesia plus counselling

  • Paracetamol (avoid NSAIDs)
  • Provide patient information leaflet
  • Pregnancies that continue require closer follow-up and targeted foetal surveillance
  • Many women who experience spontaneous vaginal bleeding in the first half of pregnancy have uneventful pregnancies thereafter
  • Offer vaginal progesterone to women with an intrauterine pregnancy confirmed by a scan, if they have vaginal bleeding and have previously had a miscarriage
  • continue progesterone until 16 completed weeks of pregnancy
50
Q

What is the management of an inevitable / missed / incomplete miscarriage?

A

1st line = Expectant Management for 7-14 days:
Women given info on what to expect/advice

  • If bleeding/pain settle = pregnancy test in 3 weeks > return if +ve
  • If bleeding/pain persist/increasing/not started = repeat scan done
  • Plus analgesia and counselling

2nd line = Medical management:
If expectant management not appropriate / ongoing sx after 14 days / patient choice

  • Misoprostol (PO or PV)
  • Advise: bleeding, pain, nausea
  • Plus analgesia and counselling
  • Pregnancy test in 3 weeks > return if it is positive

2nd line = Surgical management:
If products of conception retained despite medical treatment / ongoing symptoms after 14 days of expectant management

  • Manual vacuum aspiration under local anaesthetic, OR
  • Surgical management under a general anaesthetic.
  • Consider abx prophylaxis
  • Anti-D IG offered to all rhesus-negative women who have had a surgical procedure to manage a miscarriage.
51
Q

When is expectant management not appropriate for a miscarriage?

A

If the woman:

  • Is at increased risk of haemorrhage (e.g. pregnancy is in late first trimester)
  • Has had a previous adverse and/or traumatic experience associated with pregnancy
  • Is at increased risk from the effects of haemorrhage (coagulopathy or is unable to have a blood transfusion)
  • Has an infection.
52
Q

What is the management of a complete miscarriage?

A
  • Analgesia and counselling
  • Consider anti-D
53
Q

What is the management of RMC?

A
  • Low-dose aspirin
  • LMWH if thrombophilia identified (APLS)
  • High dose folate from when the woman is trying for another pregnancy – 5mg
54
Q

Describe APLS

A

Disorder of the immune system that causes an increased risk of blood clots

  • S/S: VTE, arterial thrombosis, thrombocytopenia, RMC, pre-eclampsia
  • Assess for features of SLE
  • Ix: lupus anticoagulant AB ± anti-cardioliptin AB
  • Mx:
    Acute = warfarin + LMWH
    Chronic = DOAC
    Pregnancy = low-dose aspirin + LMWH
55
Q

What are the complications of an ERPC?

A
  • Haemorrhage/bleeding
  • Infection
  • Cervical trauma
  • Uterine perforation
  • Retained products of conception
  • Repeat ERPC
  • Psychological sequelae
56
Q

What is the prognosis of a miscarriage?

A

Most patients go on to have successful pregnancies:

  • 1 miscarriage = 85% chance next will be successful
  • 2 miscarriages = 75% chance next will be successful
  • 3 miscarriages (RMC) = 60% chance next will be successful

O&G (17 decks)

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