Obs Flashcards
Oligohydraminos is often called Potter sequence - why
Pulmonary hypoplasia -> often leads to death
Oligohydraminos
Twisted skin (wrinkles)
Twisted face - often flattened face
Extremity - Eg club food
Renal agensis - this is usual cause or some kind of obstruction as the urine from fetus is what makes amniotic fluid
Booking visit
When does it occur?
What is the purpose / what happens?
8-12wks ideally <10
general information e.g. diet, alcohol, smoking, folic acid, vitamin D, antenatal classes
BP, urine dipstick, check BMI
Booking bloods/urine
FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies
hepatitis B, syphilis, rubella
HIV test is offered to all women
urine culture to detect asymptomatic bacteriuria
When does scan to confirm dates and exclude multiple pregnancy occur?
10-13 + 6 weeks
What happens at 16 weeks?
Information on the anomaly and the blood results. If Hb < 11 g/dl consider iron
Routine care: BP and urine dipstick
Who gets a 25 week scan and what does it involve? When else do they get one?
Primip
Routine care: BP, urine dipstick, symphysis-fundal height (SFH)
31 weeks
28 week scan purpose?
Routine care: BP, urine dipstick, SFH
Second screen for anaemia and atypical red cell alloantibodies. If Hb < 10.5 g/dl consider iron
First dose of anti-D prophylaxis to rhesus negative women
Purpose of 34 week ?
Routine care
Second dose of anti D if needed
Info on labour and birth plan
Mx of breach <36 weeks ? After 36wks ? If treatment fails?
if < 36 weeks: many fetuses will turn spontaneously
if still breech at 36 weeks NICE recommend external cephalic version (ECV)- this has a success rate of around 60%. The RCOG recommend ECV should be offered from 36 weeks in nulliparous women and from 37 weeks in multiparous women
if the baby is still breech then delivery options include planned caesarean section or vaginal delivery
A 19 year old woman who is 9 weeks into her first pregnancy is seen in the early pregnancy assessment unit with vaginal bleeding. Her ultrasound scan confirms a viable intrauterine pregnancy. However, the high vaginal swab has isolated group B streptococcus (GBS). How should she be managed?
Intrapartum IV benzylpenicillin
Interpret bishops scores for induction?
a score of < 5 indicates that labour is unlikely to start without induction
a score of > 9 indicates that labour will most likely commence spontaneously
What is placenta accreta? RF?
Placenta accreta describes the attachment of the placenta to the myometrium, due to a defective decidua basalis. As the placenta does not properly separate during labour there is a risk of post-partum haemorrhage.
Risk factors
previous caesarean section
placenta praevia
A 45-year-old woman presents at 10 weeks gestation for a routine check. She has a previous history of severe pre-eclampsia. Her BMI is 38 kg/m^2. Her blood pressure was 145/94 mmHg.
What treatment would you advise to reduce the risk of pre-eclampsia?
Aspirin
[Not labetalol as NICE don’t recommend antihypertensives for mild hypertension <150/100]
VBAC CIs?
previous classical caesarean scars, previous episodes of uterine rupture and patients with other contraindications to vaginal birth (e.g. placenta praevia).
Risks of Caesarian Serious maternal? Future pregnancies? Frequent maternal? Fetal?
Serious Maternal: emergency hysterectomy need for further surgery at a later date, including curettage (retained placental tissue) admission to intensive care unit thromboembolic disease bladder injury ureteric injury death (1 in 12,000)
Future pregos
Future pregnancies:
increased risk of uterine rupture during subsequent pregnancies/deliveries
increased risk of antepartum stillbirth
increased risk in subsequent pregnancies of placenta praevia and placenta accreta)
Maternal:
persistent wound and abdominal discomfort in the first few months after surgery
increased risk of repeat caesarean section when vaginal delivery attempted in subsequent pregnancies
readmission to hospital
haemorrhage
infection (wound, endometritis, UTI)
Fetal:
lacerations, one to two babies in every 100
Why is anti D prophylaxis not given to Rh negative women who have been sensitised?
By then it is too late and irreversible
What should happen to all babies born to Rh negative mothers?
all babies born to Rh -ve mother should have cord blood taken at delivery for FBC, blood group & direct Coombs test
Coombs test: direct antiglobulin, will demonstrate antibodies on RBCs of baby
Kleihauer test: add acid to maternal blood, fetal cells are resistant
Management of PPH
ABC
IV syntocinon (oxytocin) 10 units or IV ergometrine 500 micrograms
IM carboprost
other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure
What is the cause of secondary PPH ?
Retained placental tissue or endometritis
Causes of increased nuchal translucency (3)
Down’s syndrome
congenital heart defects
abdominal wall defects
Causes of hyperechogenic bowel?
cystic fibrosis
Down’s syndrome
cytomegalovirus infection
Most common benign ovarian tumour in <25?
Most common cause of ovarian enlargement In women of reproductive age?
Dermoid cyst
Follicular cyst
Most common cyst ? What usually happens to it?
Follicular
Regresses after several menstrual cycles
A 23-year-old woman who is 24 weeks pregnant presents to the emergency department with a 48-hour history of epigastric pain and severe headache, that has increased in severity. On examination, she has a heart rate of 110 beats/min, a respiratory rate of 21 /min, a temperature of 36.8ºC, mild pitting oedema of the ankles and brisk tendon reflexes.
Given the likely diagnosis of pre-eclampsia, which of the following is the most important sign to elicit? HR RR Oedema Temp Brisk. Tendon reflexes
Brisk reflexes are commonly associated with pre-eclampsia and are more specific than the other answers, which are general clinical signs.
Who should be given low dose asprin to prevent pre eclampsia?
High risk groups include:
hypertensive disease during previous pregnancies
chronic kidney disease
autoimmune disorders such as SLE or antiphospholipid syndrome
type 1 or 2 diabetes mellitus
A 33-year-old lady has developed a massive obstetric haemorrhage. A diagnosis of uterine atony is made. After initial stabilisation and general measures, what is the first-line medical management?
Syntocinon
Followed by ergometrine
List of drugs which must be avoided during breast feeding?
antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides psychiatric drugs: lithium, benzodiazepines aspirin carbimazole methotrexate sulphonylureas cytotoxic drugs amiodarone
Drugs which can be given while breast feeding
antibiotics: penicillins, cephalosporins, trimethoprim
endocrine: glucocorticoids (avoid high doses), levothyroxine*
epilepsy: sodium valproate, carbamazepine
asthma: salbutamol, theophyllines
psychiatric drugs: tricyclic antidepressants, antipsychotics**
hypertension: beta-blockers, hydralazine
anticoagulants: warfarin, heparin
digoxin
A 25-year-old present 8 weeks after her last menstrual period. She complains of severe nausea, vomiting and vaginal spotting. Pregnancy test was positive and transvaginal ultrasound showed an abnormally enlarged uterus.
Would you expect high or low ….BHCG, TSH, thyroxine ?
Diagnosis?
High BHCG, low TSH, high thyroxine
Molar pregnancy
Molar pregnancies are characterised by significantly high levels of beta hCG for gestational age, and are therefore used as a tumour marker of gestational trophoblastic disease. The biochemical structure of beta hCG is very similar to that of luteinizing hormone (LH), follicle-stimulating hormone (FSH), and thyroid-stimulating hormone (TSH). That being said, high levels of beta hCG can stimulate the thyroid gland to produce thyroxine (T4), and then triiodothyronine (T3). This can result in signs and symptoms of thyrotoxicosis. High levels of T4 and T3 have a negative feedback effect on the pituitary gland to stop secretion of TSH, causing and overall reduction in TSH levels.
Complete hydataform mole when? Features? Mx? Risk?
Empty egg fertilised by 1 sperm
Features
bleeding in first or early second trimester
exaggerated symptoms of pregnancy e.g. hyperemesis
uterus large for dates
very high serum levels of human chorionic gonadotropin (hCG)
hypertension and hyperthyroidism* may be seen
Management
urgent referral to specialist centre - evacuation of the uterus is performed
effective contraception is recommended to avoid pregnancy in the next 12 months
Around 2-3% go on to develop choriocarcinoma
Combined test? Triple test? Quadruple test?
the combined test is now standard: nuchal translucency measurement + serum B-HCG + pregnancy associated plasma protein A
alpha-fetoprotein, unconjugated oestriol, human chorionic gonadotrophin
**alpha-fetoprotein, unconjugated oestriol, human chorionic gonadotrophin and inhibin-A
What may happen if a mucinous cystadenoma ruptures ?
Pseudomyxoma peritonei
Most common epithelial cell tumour ?
Serous cystadenoma
Obstetric cholestasis is due to?
Features?
Risk?
Mx?
Bile salts elevated
pruritus - may be intense - typical worse palms, soles and abdomen
Risks
increased risk of premature birth
Management
induction of labour at 37 weeks is common practice but may not be evidence based
ursodeoxycholic acid - again widely used but evidence base not clear
vitamin K supplementation
A 30 year old type 2 diabetic presents to the diabetics clinic advising that she wishes to become pregnant. The patient normally has good glycaemic control and is currently being treated with metformin and gliclazide. What advice should you give her about potential changes to her medication during pregnancy?
Stay on metformin but stop gliclazide
RF for gestational diabetes?
BMI of > 30 kg/m²
previous macrosomic baby weighing 4.5 kg or above
previous gestational diabetes
first-degree relative with diabetes
family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
When do you screen for gestational diabetes? What if a patient has had Hx of gestational diabetes?
Thresholds for diabetes?
Oral glucose tolerance test at 24-28wks
Soon as possible after booking visit and at 24-28 weeks
fasting glucose is >= 5.6 mmol/l
2-hour glucose is >= 7.8 mmol/l
Mx of gestational diabetes (3)?
Mx if fasting glucose is <7mmol/L ?
What if glucose targets not met in 2 weeks?
Mx if fasting glucose >7mmol/L?
Seen in a joint diabtes and antenatal clinic within 1 week
Education on self monitoring Blood glucose
Diet and exercise advice
Trial of diet and exercise advice
- > metformin started if not effective
- > add insulin
Start insulin
What can be offered to women who cant tolerate metformin / fail glucose targets with metformin but decline insulin?
Glibenclamide
Mx of pre-existing diabetes in pregnancy ? What scan?
Weight loss
Stop all bar metformin and start insulin
Folic acid from pre-conception to 12 weeks gestation
Detailed anomaly scan at 20 weeks of heart
Manage retinopathy as can worsen during pregnancy
Glucose targets in pregnancy for diabetes ?
Time Target
Fasting 5.3 mmol/l
1 hour after meals 7.8 mmol/l, or:
2 hour after meals 6.4 mmol/l
What is associated with a decreased risk of hyperemesis?
smoking
Mx of hyperemesis?
1- Antihistamines Eg promethazine
Admission for IV hydration
Complications of hyperemesis?
Wernicke’s encephalopathy
Mallory-Weiss tear
central pontine myelinolysis
acute tubular necrosis
fetal: small for gestational age, pre-term birth
Usual point in pregnancy for hyperemesis?
usually 8-12 weeks but can be up to 20 weeks
Good source of folic acid?
Green leafy veg
Consequences of folic acid deficiency?
macrocytic, megaloblastic anaemia
neural tube defects
Mx of baby who is born to mother with Hep B? Breastfeeding?
Vaccination and HepB Ig at birth
further vaccination at 1-2months
Again at 6 months
Hep B cannot be transmitted via breast milk
Downs raised or low... AFP Oestriol HCG PAPP-A Nuchal translucency
Low alpha fetoprotein (AFP)
Low oestriol
High human chorionic gonadotrophin beta-subunit (-HCG)
Low pregnancy-associated
plasma protein A (PAPP-A)
Thickened nuchal translucency
High risk groups for pre-eclampsia?
hypertensive disease during previous pregnancies
chronic kidney disease
autoimmune disorders such as SLE or antiphospholipid syndrome
type 1 or 2 diabetes mellitus
Mx of PPH
ABC
IV syntocinon (oxytocin) 10 units or IV ergometrine 500 micrograms
IM carboprost
other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure
Who does twin-twin affect?
Treatment options?
After birth?
monozygotic twins who share a placenta
ndomethacin to reduce foetal urine output
Laser obliteration of placental vascular communications
Selective foetal reduction
Donor - Blood transfusion to treat anaemia
Recipient - exchange transfusion / heart failure medication
Associations withmonoamniotic monozygotic twins
increased spontaneous miscarriage, perinatal mortality rate
increased malformations, IUGR, prematurity
twin-to-twin transfusions: recipient is larger with polyhydramnios (do laser ablation of interconnecting vessels)
Twin complications
Antenatal?
Fetal?
Labour?
Antenatal complications polyhydramnios pregnancy induced hypertension anaemia antepartum haemorrhage
Fetal complications -
perinatal mortality (twins * 5, triplets * 10)
prematurity (mean twins = 37 weeks, triplets = 33)
light-for date babies
malformation (*3, especially monozygotic)
Labour complications
PPH increased (*2)
malpresentation
cord prolapse, entanglement
How does antenatal care change with twins?
When would you induce?
rest
ultrasound for diagnosis + monthly checks
additional iron + folate
more antenatal care (e.g. weekly > 30 weeks)
precautions at labour (e.g. 2 obstetricians present)
75% of twins deliver by 38 weeks, if longer most twins are induced at 38-40 wks
Features of acute fatty liver of pregnancy?
Ix?
Mx?
Abdo pain N+V headache jaundice hypoglycaemia
Investigations
ALT is typically elevated e.g. 500 u/l
Management
support care
once stabilised delivery is the definitive management
A 34-year old pregnant female at 12 weeks gestation presents with a two week history of severe nausea and vomiting. On examination the pulse is 110 beats/min and blood pressure 110/80 mmHg. It is also noted that the patient is experiencing diplopia and ataxia. Urinalysis demonstrates an increased specific gravity and 3+ ketones. A diagnosis of hyperemesis gravidarum is made. The patient responds suitably to fluid resuscitation with 0.9% saline. What other treatment should this patient receive?
IV vit B+C (Pabrinex)
[In this case the patient has presented with diplopia and ataxia suggestive of Wernicke’s encephalopathy. Therefore, supplementation of thiamine (Vitamin B1) with a vitamin B and C complex (e.g. Pabrinex) is indicated.]
What speed of fundal height would you expect after 24 weeks?
What stage would you expect the fundus to be palpable at the umbilicus?
xiphoid sternum?
What would you expect the head to be free on palpation?
1cm/week
20 weeks
36 weeks
Until 37 weeks
What does an increased level of fetal fibronectin indicate
possible the mother will go into early labour
What is risk of steroids (eg for fetal lung maturation) in diabetic mothers ? How would you manage?
Hypergycaemia
Hourly blood glucose measurements -> insulin as required
RF for group B strep infection
Premature
Prolonged ROM
Previous sibling GBS
Maternal pyrexia
Approximately how many mothers are thought to be carriers of GBS
20-40%
- in bowel which can then expose infants during labour
Who gets screened for GBS? When?
Who gets IV prophylaxis? What is it?
What to tell women who had positive for GBS in previous pregnancy ?
GBS in previous pregnancy - 35-37 weeks
Prev baby with GBS
Preterm labour
Pyrexia during labour
Benzylpenicillin
Risk in this one is around 50%
A 26-year-old primip school teacher has come to see you 4 days after contact with a child who had a vesicular rash on his head and trunk. She is currently 16 weeks pregnant and apart from some morning sickness, has felt completely well in herself. Blood tests reveal she is non immune to varicella zoster virus. What would be the next step in your management plan?
When is this given?
Single dose of varicella-zoster immunoglobulin
Effective up to 10 days post contact
Chicken pox exposure in pregnancy.
What is the risk to the mother?
Risk to fetus? At what gestation?
Features?
5x risk of pneumonitis
Fetal varicella syndrome
-risk of 1% if before 20 weeks
[none following 28 weeks]
-Skin scarring, eye defects, limb hypoplasia, microcephalic, learning difficuties
What happens if mother develops chicken pox rash during pregnancy? Risk if rash between 5days before or 2 days after birth?
Oral acyclovir within 24 hours
Risk of Neonatal varicella - fatal in 20%
1st line in women with no Hx of depression who have moderate to severe depression in preganancy or post natal period? 2nd line?
CBT
SSRI / TCA
What can be used to screen for post partum mental health issues ? What are the 3 increasing severities?
Edinburgh postnatal depression scale (Max 30 points)
‘Baby blues’
Post natal depression
Puerperal psychosis
When / who does baby blues tend to occur? Features? Mx?
60-70% of women - esp. Primip
3-7 days post birth
Anxious, tearful and irritable
Reassurance and support
-health visitor has key role
Time for usual onset of postnatal depression? Mx?
10% of women
Start around 1 month and peak at 3
Reassurance and support
CBT may be useful
- SSRIs Eg Sertraline and paroxetine
Onset of puerperal psychosis? Features? Mx? Recurrence risk?
0.2% of women
2-3 weeks following birth
Severe mood swings - similar to bipolar
-disordered perception Eg auditory hallucinations
Admission to hospital
20% in subsequent pregnancies
When are pregnant women screened for anaemia?
Booking visit
28 weeks
A 23-year-old woman presents at 20 weeks gestation of her second pregnancy. She is complaining of lower backache, fever and a slight vaginal loss of cloudy white viscous fluid. On examination she has a pyrexia of 38.2 centigrade and a pulse of 98 beats/minute. Routine examination of the patient's abdomen reveals that there is tenderness suprapubically. Speculum examination reveals a slightly open cervix and fluid draining. What is the most likely diagnosis? What is this? /Usual cause? Usual features? Why is it not a septic miscarriage ?
Chorioamnionitis
Inflammation of fetal amnion and chorion membranes
-usually due to ascending bacterial infection with a membrane rupture
Uterine tenderness, ROM with foul odour, maternal signs of infection
Lack of miscarriage sx - Heavy/prolonged bleeding and cramping
Mx of chorioamionitis ?
Prompt delivery - Via C section if needed
IV Abx
A woman who is 20 weeks pregnant presents for review She informs you that she has had a previous baby who has developed a Group B streptococcus infection shortly following delivery.
Mx?
Intrapartum Abx
[Maternal intravenous antibiotic prophylaxis should be offered to women with a previous baby with early- or late-onset GBS disease]
LFTs in intrahepatic cholestasis ? In acute fatty liver? What other fatty liver features to distinguish?
Cholestasis - High ALP + GGP, less rise in ALT
-jaundice, RUQ pain and steatorrhoea
Fatty - High ALT + AST, less rise in ALP
- raised WCC and maybe clotting abnormalities
- nausea, vomiting, jaundice and encephalopathy
A 24-year-old woman who is 18 weeks pregnant presents for review Earlier on in the morning she came into contact with a child who has chickenpox. She is unsure if she had the condition herself as a child. What is the most appropriate action?
Urgent check of varicella antibodies
Not immune -> varicella zoster immunoglobulin
Normal fetal HR? Cause of bradycardia? Tach?
100-160
Braddy- maternal b-blocker, Increased fetal Vagal tone
Tachy - maternal pyrexia, chorioamnionitis, hypoxia, premature
What counts as loss of baseline variability? Cause?
<5beats / min
Premature
Hypoxia
What is an early deceleration? Cause?
Deceleration of heart rate with contraction
- This is normal
- Due to fetal head compression
What is a late deceleration ? Cause/
Deceleration after 30 seconds
Fetal distress - Asphyxia / placental insufficiency
What is a variable deceleration? Cause?
Independent of contractions
Cord compression
What is lochia
Vaginal discharge contains blood mucous and uterine tissue for up to 6 weeks after birth
Usually starts red and changes to brown -> stops
A 33-year-old primigravida woman of 32 weeks gestation presents to the Emergency Department with premature rupture of membranes. There have been no complications of the pregnancy so far and the woman is normally fit and well. How is she best managed?
What if she does not progress into labour?
Admit
Prescribe steroids and Abx
[could be going into labour
Abx as risk of sepsis and post-natal infection Erythromycin advised ]
Managed at home with temp checked every 4-8 hours -> return if spike
Delivery considered at 34 weeks as risk of infection outweigh prematurity now lungs have had a chance to mature
Maternal / fetal complications of PPROM
Preterm prelabour rupture of membranes
F- Premature, infection, pulmonary hypoplasia
M- chorioamnionitis
Ix / Mx of PPROM?
Sterile speculum, nitrazine sticks (detect ph change)
US - show oligohydramnios
Admit Regular obs to check for chorioamnionitis Oral erythromycin for 10 days Corticosteroids Delivery considered at 34 weeks
Mastitis during breast feeding mx? Risk if untreated?
Fluclox for 10-14 days
Continue feeding
Breast abscess -> would need draining
Features of engorgement? Complications ?mx?
Breast pain in breast feeding women
Usually both breasts
Pain worst before a feed
Breasts may appear red
Blocked ducts, mastitis, difficulty feeding + poor milk flow
Hand expression of milk (may be initially painful)
What is the direct / indirect Coombs test?
Direct - looks for autoimmune haemolytic anaemia
Indirect - antenatally to detect antibodies in maternal blood that can cross the placenta -> haemolytic disease of newborn
Uterine inversion
What is it?
Mx?
Fundus of uterus protruding beyond the endometrial cavity after birth
ABCDE
Signs of shock -> fluids
Johnsons procedure - push the uterus up
Fail - O’Sullivans procedure -> warm saline into vagina
Prepare theatres for potential laparotomy
Breast feeding and anti-epileptic drugs
Safe with almost all
Pre eclampsia method of reducing blood pressure in labour?
Epidural
Mx of. Hyperemesis
antihistamines should be used first-line (BNF suggests promethazine as first-line)
ginger and P6 (wrist) acupressure: NICE Clinical Knowledge Summaries suggest these can be tried but there is little evidence of benefit
admission may be needed for IV hydration
Mx of woman with previous VTE in pregnancy?
LMWheparin throughout
Name 4 RFs for VTE
Age > 35 Body mass index > 30 Parity > 3 Smoker Gross varicose veins Current pre-eclampsia Immobility Family history of unprovoked VTE Low risk thrombophilia Multiple pregnancy IVF pregnancy
A 24-year-old female who is 10 weeks in to her first pregnancy presents for review. Her blood pressure today is 126/82 mmHg. What normally happens to blood pressure during pregnancy?
Falls in first half then rises to normal levels before term
ITP and pregnancy ?
Can be passed on to the fetus and so may need platelet transfusion
Woman with UTI who is breast feeding Abx?
Trimethoprim is safe in breast feeding
