Obs Flashcards
What is an amniotic fluid embolism?
It is an obstetric emergency in which amniotic fluid and foetal cells enter the maternal circulation = cardiorespiratory distress
What is the aetiology of amniotic fluid embolism?
- Embolism provokes an anaphylactic reaction or complement cascade –> pulmonary artery spasm –> increases pulmonary artery pressure and RVP –> hypoxic myocardial and pulmonary capillary damage –> LVF and death
What does post-mortem reveal in amniotic fluid embolism?
Foetal squames and debris in the maternal pulmonary circulation
What are the rick factors of amniotic fluid embolism?
- Increasing maternal age
- Placenta praevia/abruption
- Induction of labour (use of uterotonics)
- C-section
Signs and symptoms of amniotic fluid embolism?
- Sudden onset of SoB +/- cyanosis
- Seizures
- Bleeding (activation of coagulation cascade)/DIC
- Hypotension
What do you see on examination for amniotic fluid embolism?
- Tachypnoea
- Tachycardia
- Pulmonary Oedema
- Uterine atony (uterus failing to contract)
Investigations for amniotic fluid embolism?
ABG - hypoxaemia, raised PaCo2
FBC - low Hb
Clotting - low platelets, high PT/APPT, low fibrinogens, UE, X-match
CXR - cardiomegaly, pulmonary oedema
ECG - right heart strain, rhythm abnormalities
Management of amniotic fluid embolism?
Immediate –> ABC
- Airway - maintain potency
- Breathing - high flow O2 +/- intubation
- Circulation - 2 large bore cannulae, fluid resus
Pharmacological : - Ionotropics - Correct coagulopathy: FFP Platelets Cryopercipitate Transfuse if needed - Uterine atony --> PPH management
Consider delivery +/- hysterectomy
Complications of amniotic fluid embolism?
- Cardiac arrest
- Death
- DIC
- Seizures
- Uterine atony
- Haemorrhage
- Pulmonary oedema
- ARDS
- renal failure
What is the definition of anaemia in pregnancy?
Pregnant women with a mean value of Hb < 110 g/L (1st trimester)
- <110 g/L in 1st trimester
- < 105 g/L in 2nd/3rd trimester
- <100 g/L postpartum
- <70 g/L - URGENT REFERRAL
What are the different types of anaemia?
Iron deficiency:
- Blood loss, Inc use of decreased absorption, decreased intake, haemolysis
- Hypochromic microcytic anaemia and pencil cells
Folate deficiency:
- Green leafy vegetables –> lack increases neural tube defects - diet, demand, malabsorption, drugs
- Megaloblastic anaemia (hypersegmented neutrophils, macrocytosis, thrombocytopenia, leucopenia)
B12 deficiency:
- Vegan, poultry, dairy, eggs –> lack increases neural tube defects - diet, malabsorption
- Megaloblastic anaemia (hypersegmented neutrophils, macrocytosis, thrombocytopenia, leucopenia)
Risk factors of anaemia in pregnancy?
- Multiple pregnancy
- Loss of vomit due to morning sickness
- Anaemia before becoming pregnant
- 2 pregnancies close together
- Pregnancy teenager
- DIET (esp iron deficiency)
Signs and symptoms of anaemia in pregnancy?
- Tired of weak
- Trouble concentrating
- Dizziness
- Tachycardia/tachypnoea
- SOB
- Pale skin, lips, nails, conjunctiva
What is the B12 specific signs and symptoms of anaemia in pregnancy?
- Glossitis
- Depression
- Psychosis/dementia
- Paraesthesia
- Peripheral neuropathy
- Subacute combines degeneration = metabolic disorder of the spinal cord –> loss of proprioception/vibration –> full paralysis
Investigations of anaemia in pregnancy?
Screened of anaemia at booking and at 28 weeks
- FBC
- Blood film
- Haematinics/Iron studies
- Haematocrit
Management of anaemia in pregnancy?
Supplements –> Iron, B12 and folate (100-200mg OD iron)
- Oral ferrous sulfate (SE: black stool, constipation, abdo pain)
- Oral folic acid (if cause unknown, do not give as it can exacerbate B12 symptoms)
- IM hydroxycobalamin for B12 deficiency
Increase animal food in diet and advice:
Iron - green leafy vegetables, nuts, beans, seeds
B12 - meat and dairy
Folate - green leafy vegetable, nuts, yeast, liver
Intrapartum:
- Deliver in consultant-led unit
- IV access and group and screen on admission
- Active management in 3rd stage
- Active management of PPH
- Consider prophylactic syntocinon infusion
Complications of anaemia in pregnancy?
- Preterm or LBW baby
- Post-partum depression
- Child with developmental delays
- Spina bifida
What is asthma in pregnancy?
Chronic inflammatory airway disease characterised by variable reversible airway obstruction, a hyper-sensitive airway and bronchial inflammation (existing in pregnancy)
When does asthma in pregnancy most commonly occur?
24-36 weeks
What is the aetiology of asthma in pregnancy?
Must exist before pregnancy (allergic predisposition)
Signs and symptoms of asthma in pregnancy?
- Wheeze, breathlessness, cough - worse in the morning and at night
- Precipitating factors
- Atopic history
- Tachypnoea, use of accessory muscles, prolonged expiratory phase, polyphonic wheeze, hyperinflated chest
Severe attack:
- PEFR 33-50%, pulse <110, RR >25, inability to complete sentences
Life-threatening:
- PEFR <33%, silent chest, cyanosis, bradycardia, hypotension, confusion, coma
Investigations for asthma in pregnancy?
- Peak flow
- Pulse ox
- ABG
- FBC
- CRP
- U&Es
- Blood/sputum cultures
- PEFR monitoring (diary)
Management of asthma in pregnancy?
- Regular monitoring continued throughout labour –> bronchoconstrictors should be avoided
- Encourage smoking cessation and manage exacerbations aggressively
- Flu vaccine and monitor foetal movements daily after 28 weeks
What is the acute management of asthma in pregnancy?
- High flow oxygen, neb salbutamol 5mg, ipratropium 0.5mg QDS
- Steroid therapy (IV hydrocortisone 100mg, PO prednisolone 40-50mg 5-7 days)
- IV magnesium sulphate and summon senior help (Pco2 up)
- IV aninophylline
- ITU + intubation
Discharge when:
- PEFR >75% of pts best
- Diurnal variation <25%
- Stable on discharge meds for 24 hours
What is the chronic management of asthma?
1: SABA
2: SABA + ICS
3: SABA + ICS + LTRA (montelukast)
4: LABA + ICS + LTRA
5: LABA + increase ICS + LTRA
6: Theophylline LMRA
7: Oral CS
Complications of asthma in pregnancy?
Prolonged hypoxia - foetal growth restriction (FGR) and ultimately, foetal brain injury
- Oral CS use in first trimester can increase cleft palate risk
- Preterm birth, perinatal mortality
What is the definition of baby blues, post-natal depression and puerperal psychosis?
Baby blues - mild, self-limiting low mood in the post natal period
Post-partum depression - pervasive low mood in the post-natal period
Puerperal psychosis - acute onset of psychotic illness in the post-natal period
What is the aetiology of baby blues, post-natal depression and puerperal psychosis?
- Unclear
- Falling oestrogen, progesterone and cortisol postnatally
- Thyroid hormones dropping
Risk factors for baby blues, post-natal depression and puerperal psychosis?
- Past pysch history or previous PPD
- Primigravidity (postnatal blues)
- Antenatal or delivery complications (traumatic, incontinence, prematurity)
- Social isolation
- Anti-psychotics (esp risperidone) - dopamine inhibition and hyperprolactinaemia
What is perinatal depression?
- Depression through pregnancy + 1-year post-partum
Onset of baby blues, post-natal depression and puerperal psychosis?
Blues:
- Onset: 3-5 days postnatal and recover within 10-14 days
Depression:
- Last 2 weeks post-partum
- onset during pregnancy to 1 year post natal and recover within 4 weeks
Psychosis:
- Onset from 2-3 days post-partum to 1 year post-natal and recovers within 6-12 weeks
What are the signs and symptoms of baby blues, post-natal depression and puerperal psychosis?
Blues:
- emotional liability, irritability, poor sleep and concentration
- Insomnia, fatigue, anxiety, irritability, impaired concentration, tearfulness and labile mood
Depression:
- anaergia
- low mood
- anhedonia
Psychosis:
- delirium
- affective (depression or mania)
- schizophreniform
What are the investigations for baby blues, post-natal depression and puerperal psychosis?
- MSE and depression rating scales may be used
1st: Depression screening questions –> low mood, anhedonia
2nd: Edinburgh post natal depression scale (score >12 = likely depressive episode) - Safety net = confirm if she has had thought of self-harm, harm to others (baby), suicide and plans, delusions
Management of baby blues, post-natal depression and puerperal psychosis?
Blues - reassurance and support
Depression - severity dependant
- Breastfeeding safe antidepressants: setraline and paroxetine
Psychosis - psychiatric emergency –> inpatient admission
Complications of baby blues, post-natal depression and puerperal psychosis?
- Poor emotional attachment to child
- Suicide
- Long-term psychiatric morbidity
- Infanticide
What is cardiac disease in pregnancy?
Cardiomyopathies:
- Include peripartum cardiomyopathy (new-onset cardiomyopathy and heart failure usually within the last month of pregnancy to 5 months post-partum)
What is the pathophysiology of cardiac disease in pregnancy?
40% rise in blood volume during pregnancy causing strain and women with cardiac disease cannot increase cardiac output leading to uterine hypoperfusion and increase pulmonary oedema
Signs and symptoms of cardiac disease in pregnancy?
- Classified based on the NYHA classification
- Most women will remain well throughout pregnancy, normal cardiac response
- Ejection systolic murmur in 96%
- 3rd heart sound in 84%
- Forceful apex
- Peripheral oedema
Investigations of cardiac disease in pregnancy?
Echocardiogram is usually performed at booking and at 28 weeks
What is the management of cardiac disease in pregnancy?
Anticoagulation is essential in patients with congenital heart disease who have pulmonary hypertension or artificial valves and those at risk of AF
- LMWH is used as an alternative to warfarin as it is teratogenic if used in the first trimester
What are the foetal risks of maternal cardiac disease?
- Recurrence (congenital heart disease)
- Iatrogenic prematurity
- Maternal cyanosis (foetal hypoxia)
- FGR
- Effects of maternal drugs (teratogenesis, growth restriction, foetal loss)
What is the management of labour and delivery in a woman with cardiac disease in pregnancy?
- Aim to wait for spontaneous labour
- 2nd stage kept short with elective forceps or ventouse delivery –> reduce maternal effort and need for an increase Cardiac output (c-section for those where any effort is dangerous)
- Ergometrine may be dangerous (cause vasoconstriction, hypertension and heart failure) so active management of the 3rd stage is with syntocinon alone
- Induction may be considered in very-high risk women to ensure that delivery occurs at a predictable time with all personnel present
- Epidural usually recommended
- Risk of maternal hypotension
- Prophylactic antibiotics should be given to any woman with a structural heart defect
- Reduce the risk of bacterial endocarditis
- Post-partum haemorrhage is dangerous because it can lead to cardiovascular instability
- Avoid supine position - puts stress on the heart
What is diabetes mellitus in pregnancy?
Existing diabetes mellitus in a pregnant woman
Hypoglycaemia is more common in pregnancy and is very dangerous
- Insulin resistance increases throughout pregnancy (increase dose of metformin or insulin during pregnancy)
- Postnatally, insulin requirements return to normal levels, so insulin should be adjusted accordingly
What are the effects of pregnancy on diabetes?
- Nausea and vomiting
- Greater importance of tight glucose control
- Increase in insulin dose requirements in second half of pregnancy
- Increased risk of severe hypoglycaemia
- Risk of deterioration of any retinopathy
- Risk of deterioration of any nephropathy
What are the effects of diabetes on pregnancy?
- Increased risk of micarriage
- Risk of macrosomia
- Risk of of congenital malformation/spina bifida
- Increased risk of pre-eclampsia
- Increased risk of stillbirth
- Increased risk of infection
- Increased operative delivery rate
What are the pre-conception checks for diabetes in pregnancy?
- Glucose control must be tight (use a 4 hour delivery) –> test HbA1c for risk level, measure in the 2nd and 3rd trimester (greater risk if 48mmol/mol)
- Renal testing (U&Es and creatinine)
- BP checks
- Retina checks (retinopathy needs to be treated before pregnancy begins)
- Stop any statin use and start high dose folic acid (5mg, OD) until 12 weeks gestation
What is the preconception counselling for diabetes in pregnancy?
- Embryogenesis is affected by DM and so miscarriage risk is higher
- Poor glycaemic control is teratogenic and can cause midline deformities such as spina bifida
- Growth restriction possible (macrocosmic)
- Stillbirth risk (from baby outgrowing supply ability of the placenta)
- Polyhydroamnios (baby has osmotic diuresis –> cord prolapse and placental abruption)
- Hypoglycaemic risk for baby after cut cord as loss of glucose and high insulin levels
- Higher infection and DKA rate in pregnancy
Why does the baby become macrosomic in a diabetic pregnancy?
If the mother has high glucose, the glucose passes to the baby and the baby’s pancreas produces insulin (like IGF-1, a growth factor) and so the baby becomes macrosomic. (insulin and fragment are 2 things that cannot cross the placenta).
What is the blood glucose monitoring in pregnant woman?
Test fasting, pre-meal, 1 hour post meal and bedtime daily:
- Fasting target <5.3mmol/L
- 1 hour postprandial target <7.8mmol/L
What is the timeline for baby checks in women with diabetes?
12 weeks “booking” check
20 week “anomaly” scan
28w,32w,36w (4-weekly serial)
37+0weeks to 38+6weeks
Every 2 weeks –> joint antenatal-diabetes clinic
What is gestational diabetes?
- New-onset diabetes during pregnancy (usually disappears after birth, occurs 24-28w)
- Complications less than DM in pregnancy
What are the risk factors of gestational diabetes?
- BMI > 30 kg/m^2
- Previous baby weighing >4.5kg
- Asian
- FHx
- Previous GDM
Investigations for gestational diabetes?
Glycosuria on urine dipstick
- 2-hour 75g OGTT (immediate and HbA1c testing for previous DM)
Previous GDM
- 2-hour 75g OGTT (immediate –> if normal, again at 24-28w)
Any RF on clerking
- 2-hour 75g OGTT (24-28w)
What is the criteria for diagnosing gestational diabetes?
Fasting plasma glucose >5.6mmol/L
2-hour OGTT 7.8mmol/L
Management of gestational diabetes?
1st line:
- (only if blood glucose is <7mmol/L)
- changes to diet and exercise, CDE (2 week trial)
2nd line:
- if targets are not met by 1st line in 2 weeks and <7mmol/L
- metformin, CDE
- if metformin is contraindicated, then use insulin
3rd line:
- if 2nd line is ineffective or >7mmol/L
- Insulin, metformin, CDE
- Offer insulin alone straight away if glucose >7mmol/L or if fasting glucose is 6.0-6.9mmol/L with complications
4th line:
- consider glibenclamide
- in those that metformin does not work but they decline insulin on cannot tolerate metformin (se: decreased appetite, diarrhoea, abdo pain)
Medications contraindicated in gestational diabetes?
- Glicazide
- Liraglutide
What is the delivery method for gestational diabetes?
- Delivery: offer IOL or ELCS between 37+0w and 38+6w no later then 40+6w
- Monitor capillary glucose every hour during labour (maintain 4-7mmol/L)
- Discontinue blood glucose lowering treatment immediately after birth
What is the post partum management for gestational diabetes?
- GP should perform a fasting plasma glucose at 6-13 weeks post partum
- <6mmol/L –> low prob diabetes, need an annual test, moderate risk of developing T2DM
- 6.0-6.9mmol/L –> high risk of T2DM
- > 7mmol/L –> 50% chance of having/developing T2DM –> offer diagnostic test to confirm
What is the most common location of an ectopic pregnancy?
Ampulla of the fallopian tube
What is the site in an ectopic pregnancy with the highest risk of reupture?
Isthmus of the fallopian tube
What is the definition of an ectopic pregnancy?
Pregnancy outside the uterus
What is the aetiology of ectopic pregnancy?
Damaged tubes due to infection (PID), surgery or endometriosis:
- PID
- Previous ectopic
- Previous tubal surgery
- Pregnancy with IUD/IUS
- ICF
- Depo-Provera injection
What are the signs and symptoms of ectopic pregnancy?
- Abdo pain
- Amenorrhoea +/- PV bleeding (scanty dark blood)
- Diarrhoea, shoulder tip pain, back pain
- Dizziness (if rupture –> present with circulatory collapse)
What do you see on examination in an ectopic pregnancy?
- Abdomen - rebound tenderness +/- guarding
- Vaginal - cervical excitation, adnexal tenderness +/- mass
What are the investigations for ectopic pregnancy?
USS signs:
- Tubal: “bagel sign”, “blob sign”
- Cervical: “barrel cervix”, -ve sliding sign, below internal os
Pregnancy test –> speculum (inspect os) –> outcome:
(1) Located ectopic (empty uterus, adnexal mass with GS and YS, free fluid in uterine cavity)
(2) Pregnancy of unknown location (PUL) –> serial BHcG at 0 and 48 hours:
- increase serum BHcG >63% (inc 2x/48 hours) –> developing pregnancy, rescan in 7-14 days
- increase serum BHcG <63%, decrease serum BHcG <50% –> review in EPAU <24 hours
- decrease in serum BHcG >50% –> miscarriage and expectant management
- Bimanual and speculum
- Bloods - FBS, clotting and cross match
What is the expectant management of an ectopic pregnancy?
First thing on confirming an early-pregnancy-related emergency is to call the gynaecology on-call
Only permissible in stable, asymptomatic patient with failing levels of BHcG (tubal abortion)
- Size <30mm
- Unruptured
- Asymptomatic
- No foetal HR
- Serum hCG <200IU/L and declining
What is the medical management of an ectopic pregnancy?
x1 methotrexate injection can be done if:
- Stable
- Asymptomatic
- Normal LFTs/U&Es
- Serum hCG <3,000IU/L and declining
- No blood in pouch of douglas
- Ectopic <35mm/no FH detected
Expectations:
- Do not drink
- No interncourse for 3 months
- Avoid excessive sun exposure
- Go home and come back for repeat blood tests
SE: Pain, nausea and diarrhoea
What is the surgical management of an ectopic pregnancy?
Laparoscopic salpingectomy
Indications:
- significant pain
- ectopic with foetal HR
- Adnexal mass >35mm
- Serum hCG >5000 UL/l and declining
- Salpingostomy can be used in bleeding is minimal and occlusion is viable to be removed (ie fimbriae) and the patient only has only viable tube left (as a future ectopic risk)
- Anti-D prophylaxis required (no Kleihauer needed): No anti-d if sole medical management, threatened or complete miscarriage or PUL
- Copper IUD should not be used if you’ve had a laparoscopic salpingectomy
Complications of an ectopic pregnancy?
- Rupture
- Haemorrhage
- Death
- Tubal infertility
- Psychological sequelae
What is a gestational trophoblastic disease (hydatidiform mole)?
A benign tumour of the trophoblastic tissue
What is the aetiology of gestational trophoblastic disease (hydatidiform mole)?
Abnormal fertilisation leading to a ‘mole’ formation which is either:
- Complete = empty egg fertilised by 2 sperm (or 1 duplicate DNA) eg. 46 XX or 46 XY
- Partial = normal egg fertilised by 2 sperm (or 1 which duplicated DNA) eg 69 XXX or 69 XXY, one maternal and two paternal origin
Risk factors of gestational trophoblastic disease (hydatidiform mole)?
- Extremes of reproductive age
- Previous GTD
- Ethnicity (Japanese, asians, native american indian)
- Diet (low beta-carotene, low saturated fats)
What are the signs and symptoms of a gestational trophoblastic disease (hydatidiform mole)?
- Painless PV bleeding (ie. miscarriage)
- Hyperemesis (increased BHCG)
- Often seen on USS before symptoms
- Symptoms of hyperthyroid are rare (BHCG mimicking TSH)
- Uterus larger thane expected for GA
Investigations of gestational trophoblastic disease (hydatidiform mole)?
- Bloods: BHCG grossly elevated –> BHCG mimics TSH so low TSH and high T4
- Imagining: Pelvic US:
Complete: snowstorm/ cluster of grapes/ no foetal parts
Incomplete: no snowstorm/ cluster of grapes, foetal parts
What is the management of a gestational trophoblastic disease (hydatidiform mole)?
Urgent referral to specialist centre
1st line: Surgical –> ERPC - no contractions so disseminate it then monitoring.
Monitoring:
- serial HCG monitoring in a specialist centre –> methotrexate if rising or stagnant so avoid pregnancy until 6 months or normal levels
- Do not conceive until follow-up is complete (barrier and COCP)
- Avoid IUDs until hCG normalised
- If continues to rise then query choriocarcinoma
Complications of gestational trophoblastic disease (hydatidiform mole)?
Can progress to malignancy:
- Complete mole –> invasive mole =10%, choriocarcinoma=2.5%
- Partial mole –> choriocarcinoma=0%
- Recurrence risk of 1%
What is a gestational trophoblastic disease (malignancy)?
- A form of gestational trophoblastic disease associated with local invasion or metastasis
- Rapidly metastasising
What are the forms of gestational trophoblastic disease (malignancy)?
All metastasise widely - especially to lung, pelvic organs and the brain
- Invasive mole: hydatidiform mole with invasion of myometroum, necrosis and haemorrhage
- Choriocarcinoma: cytotrophoblast and syncytiotrophoblast without formed chorionic villi invade myometrium, rapidly metaststasise
- Placental site trophoblastic tumour: intermediate trophoblast infiltrate myometrium without causing destruction, contains GPL
What are the risk factors of gestational trophoblastic disease (malignancy)?
- Extremes of reproductive age
- Ethnicity (japanese, asian or native american indians)
- Previous gestational trophoblastic disease
- Diet - low beta-carotene, low saturated fats
What is the aetiology of gestational trophoblastic disease (malignancy)?
- Abnormal chromosomal material of placental tissue
- Invasive moles always follow hydatidiform mole
What do chociocarcinomas come from?
- Molar pregnancy (50%)
- Viable pregnancy (22%)
- Miscarriage (25%)
- Ectopic pregnancy (3%)
What are the signs and symptoms of gestational trophoblastic disease (malignancy)?
- Persistent PV bleeding, hyperemesis gravidarum, lower abdo pain
- Lung metastasis - haemoptysis, dyspnoea, pleuritic pain
- Bladder/bowel - haematuria, PR bleeding
O/E: excessive uterine size of gestation
What are the investigations of gestational trophoblastic disease (malignancy)?
- Bloods: serum BHCG (presistent raised or rising after ERPC), FBC, LFT(mets)
- Imaging - pelvic USS (snowstorm, vesicles or cysts), CXR, CT, CAP, MRI brain
What is the management of gestational trophoblastic disease (malignancy)?
- Manage in specialist centres - CX, sheffield, Dundee
- Chemotherapy - methotrexate, hysterectomy for placental site trophoblastic tumour
What are the complications of gestational trophoblastic disease (malignancy)?
- Metastasis
- Chemo side effects
What is the effect of epilepsy on pregnancy?
No consistent effect of pregnancy on epilepsy
10 fold increase in mortality amongst pregnancy with epilepsy
What are the investigations of epilepsy in pregnancy?
If there are seizures (1st presentation) in the 2nd half of the pregnancy not attributed to epilepsy –> immediate treatment for pre-eclampsia until a definitive diagnosis is made by a full neuro-assessment
What are the causes of seizures in pregnancy?
- Epilepsy
- CVA
- TTP
- Toxic overdose
- Eclampsia
- SOL - space occupying lesion
- Cerebral malaria or toxoplasmosis
- Drug/alcohol withdrawal
- Metabolic abnormalities
What is the management of seizures in pregnancy?
- Seizures should be controlling with the minimum dose possible for optimal anticonvulsant drug
- Delivery MODE and TIMING unaffected unless seizures are increasing in frequency (epidural recommended to reduce stressors that can illicit seizures)
- Encourage breastfeeding
What is the pre-pregnancy counselling for epilepsy in pregnancy?
- Alter medication according to seizure frequency
- Reduce monotherapy where possible
- Stress importance of compliance with medication
- Pre-conception folic acid 5mg and vitamin K in the last month of pregnancy
- Explain risk of congenital malformation
- Explain risk of recurrent seizures
What is complications of epilepsy in pregnancy?
Epilepsy has an increased risk of congenital abnormality cause by anti-convulsant medications (2-3x) with the use of severe AEDs further increase the risk of abnormalities associated with AED
- Neural tube defects
- Facial cleft
- Cardiac defects
- Other abnormalities: developmental delay, nail hypoplasia, IUGR and midface abnormalities
These complications can often be detected in anomaly scans.
Need to balance the risk of AEDs with the effect of seizures –> foetal and maternal hypoxia
What are the medications of AEDs and what are the abnormalities that can follow?
DO NOT GIVE:
- Sodium valproate –> neural tube defects
- Phenytoin –> cleft palate
CAN GIVE:
- Lamotrigine –> lowest rate of congenital malformations (and levetiracatem)
- Carbamazepine –> least teratogenic of the old AEDs
How many women get emesis gravidarum and how many get hyperemesis gravidarum?
80% of women get emesis gravidarum but only 1% get hyperemesis gravidarum
What are the risk factors of hyperemesis gravidarum?
- Nulliparity
- Multiple pregnancies
- Obesity
- Hyperthyroid
- Trophoblastic disease
- PHX of hyperemesis gravidarum
What is protective of hyperemesis gravidarum?
Smoking
What are the signs and symptoms of hyperemesis gravidarum?
RCOG diagnostic criteria to diagnose HG: (needs all 3)
- > 5% of pre-pregnancy weight loss
- Dehydration
- Electrolyte imbalance
Vomiting and inability to tolerate fluids and foods:
- Starts between 4-7th week
- Peaks at 9 weeks
- Resolves at 20 weeks
What other causes should you exclude with hyperemesis gravidarum?
- Abdo pain
- Urinary symptoms
- Infection
- Drugs
- Chronic H.pylori
What observations should you do for hyperemesis gravidarum?
- Basic obs: temperature, pulse, BP, O2 sats, RR, abdo exam
- Weight
- Signs of muscle wasting
- Signs of dehydration (if severe –> ketonuria and raised urea)
What are the investigations for hyperemesis gravidarum?
- Body weight
- Urine dipstick (check ketones)
- U&Es
- Obs
What form is used to determine the severity of hyperemesis gravidarum?
PUQE-24 from RCOG:
<6: Mild
7-12: Moderate
13-15: Severe
What is the admission for hyperemesis gravidarum?`
- Unable to keep down fluids/oral anti-emetics
- Ketonuria
- Weight loss >5%
- Co-morbidity (ie. diabetes)
Management: IV normal saline with KCL, thiamine (B12) supplementation
What is the management of mild and moderate NVP/HG treated in the community?
- If severe (PUQE >13) treat as inpatient
- If fails, treat as day case in ambulatory care
- 1st Line: antihistamines (IV promethazine, cyclizine, prochlorperazine, chlorperazine)
- 2nd line: antiemetics (IV ondansetron, metoclopromide (<5days), domperidone):
Reassess in 24 hours, metoclopromide in 2nd line due to chance for EPS, ondansetron is 2nd line due to unknown effects on pregnancy - 3rd line: steroids (IV hydrocortisone, BD, 100mg - convert to PO when capable)
- 4th line: alternative therapy (ginger and P6 acupuncture pressure)
What should you do if the patient is admitted for hyperemesis gravidarum due to dehydration?
- Give VTE prophylaxis (LWMH)
What is the prognosis of hyperemesis gravidarum?
Maternal (major= VTE, Wernicke’s, hypokalaemia, hyponatraemia)
- Dehydration
- Wernicke’s encephalopathy (B12 deficiency)
- Acute tubular necrosis (dehydration)
- Mallory-weiss tear
- Central pontine myelinolysis (rapid Na+ correction)
- VTE (from dehydration)
Foetal:
- IUGR
- PTL
- Termination
What is the definition of large for dates pregnancy?
Term to describe macrosomic babies (>4kg or >4.5kg the definition varies)
How many babies are large for dates pregnancy?
10%
What are the 3 tools used to diagnose large for dates pregnancy?
1st:
- Symphysis fundal height of >90/95th centile for gestational age
2nd:
- Abdominal circumference of >90/95th centile for gestational age
3rd:
- Estimated foetal weight of >90/95th centile for gestational age
What are the risk factors of large for dates pregnancy?
- High BMI
- Gestational or DM
- Molar pregnancy
- Multiparity
- Advanced maternal age
- Polyhydramnios
- Foetal macrosomia (>4kg in a term infant)
- Syndromes: Soto’s syndrome, Simpson-Golabi-Behemel, Beckwith-Wiedermann
What are the signs and symptoms of large for dates pregnancy?
On inspection: excessive distention for gestational age
Abdomen: Increased symphysis-fundal height, increased abdo circumference
What are the investigations for large for dates pregnancy?
- OGTT - for gestational diabetes
- Bloods - serum BHcG
- USS - liquor volume, biometry
- Genetic testing
Management of large for dates pregnancy?
Detected at 18-20 weeks –> repeat scan
Detected at 24-36 weeks –> if acceleration of growth, arrange USS for foetal biometry:
- if follows same path (no drop/rise growth), then reassure this is normal, arrange another routine scan
- Offer OGTT (GDM)
Detected at 36-40 weeks –> if SHF is >90th centile on routine measurements then USS for foetal biometry
- If EFW and AC on USS are >95th centile, return to routine care
- Perform OGTT (GDM)
- Care in labour + postnatally as per GDM dx at earlier gestation
What should be discussed in large for dates pregnancy?
Discuss risk for shoulder dystocia, nerve injuries, and prolonged labour
Offer C-section
What is the definition of obstetric cholestasis?
- Pruritus in pregnancy
- Resolves on delivery
- Associated with abnormal LFTs in the absence of other identifiable pathology (PPH - Vit K deficient, foetal distress, meconium delivery, PTL, IVH)
What is the cause of obstetric cholestasis?
- Likely genetic such as defect in membrane phospholipid
- Hormonal factors like oestrogen impairing sulphation
What are the risk factors of obstetric cholestasis?
- Previous OC
- FHx
- Ethnicity (south asian, chilean, bolivian)
- Multiple pregnancy
- prurits on COCP
What are the signs and symptoms of obstetric cholestasis?
- Pruritus with excoriations (palms and soles, worse at night)
- Raise billirubin and sometimes jaundice
- No rash
Investigations of obstetric cholestasis?
- Bile acids (raised)
- CTG (check baby)
- Fasting serum cholesterol (high)
- LFTs (raised billirubin)
- Coag screen (may be high if Vit K deficient)
- Hep C serology (increased risk of OC in hep C)
Complications of obstetric cholestasis at birth?
- Premature birth
- Intrauterine death (intracranial haemorrhage)
- Severe liver impairment
- PPH (due to low Vit K)
- Meconium passage
- Foetal distress
Management of obstetric cholestasis?
Symptomatic relief:
- Ursodeoxycholic acid: reduces itching and improves LFTS
- Vit K supplementation: if clotting impaired
- Sedating antihistamines (promethazine or chlorphenamine)
- Topical emollient and wear loose clothes: may help reduce itching
Antenatal monitoring:
- LFTs weekly until delivery
- Twice-weekly doppler and CTG until delivery
- Consultant led care
Delivery:
- Offer induction at 37 weeks
Postnatally (GP):
- Arrange follow-up, after delivery, to ensure that LFTs have returned to normal
What is the definition for small for dates pregnancy?
SGA= derived from birth weight, describes a baby with AC or EFW <10th centile for GA
EFW= estimated foetal weight AC= abdominal circumference GA= gestational age
What is IUGR?
Derived from growth rate, describes a baby with reduced growth rate and baby becomes SGA
All IUGR babies are SGA but not all SGA babies are IUGR
What are the risk factors for SGA or IUGR?
- Biggest RFs (maternal): previous birth > APLS > renal disease
- Foetal: chromosomal abnormalities (symmetrical IUGR), infection (CMV, rubella), multiple pregnancies
- Other: placental insufficiency (asymmetrical IUGR)
What are the risk factors for SGA or IUGR?
- Biggest RFs (maternal): previous birth > APLS > renal disease
- Foetal: chromosomal abnormalities (symmetrical IUGR), infection (CMV, rubella), multiple pregnancies
- Other: placental insufficiency (asymmetrical IUGR)
What are the investigations for SGA or IUGR?
Assess risk factors for booking
1st: if greater than 1 major risk factors or greater than 3 minor risk factors, reassess at 20 weeks
2nd: at 20 weeks, if still at risk then consider
- minor risk (>3 RFs): uterine artery doppler (20-24w) and if abnormal then serial USS from 26-28w
- major risk (<1 RFs): foetal size and umbilical artery doppler and serial USS from 26-28w
If SGA and IUGR, ultrasound biometry and umbilical artery doppler serial measurements every 2 weeks should be taken.
Screen for congenital infections
LOOK AT POSTER ON NOTES PAGE 40!
What is management of SGA and IUGR?
- Smoking, alcohol and drugs should be stopped
- Low-dose aspirin may have some role in preventing IUGR in high-risk pregnancies
Monitoring:
- 1st: SHF or risk status determined (at booking or any antenatal appointment)
- 2nd: confirm SGA with foetal biometry (20w)
- 3rd: Uterine artery doppler (20-24w)
Normal: repeat scans every 2 weeks from (20-24weeks onwards)
Abnormal: serial growth scans every week (26-28 weeks) and doppler ultrasound scans can be performed twice a week (umbilical artery flow)
SEE FLOW DIAGRAM PAGE 41
What is the delivery management of SGA and IUGR?
Indications for immediate delivery:
- Abnormal CTG (and reduced foetal movement)
- Reversal and end-diastolic flow
Delivery by 37 weeks is usually necessary but dependant on severity and gestation:
- Steroids should be given <36 weeks
- Consultant-led clinics and decision-making
What are the complications of SGA and IUGR?
- Stillbirth
- Birth asphyxia
- Neurodevelopmental delay
- PTL
- Meconium aspiration
- Intrapartum foetal distress
- Postnatal hypoglycaemia
- Risk TD2M and HTN in adult life
What is acute fatty liver disease?
- 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 mithochondrial disorder affective fatty acid and oxidation
What are the risk factors for acute fatty liver disease?
- Nulliparity
- Multiple pregnancies
- Obesity
- Male foetus
- Pre-eclampsia
What are the differentials of acute fatty liver disease?
- HELLP
- Haemolysis
- Elevated liver enzymes
- Low platelets
What are the signs and symptoms of acute fatty liver disease?
- Normally in 3rd trimester
- Nausea
- Vomitting
- Abdo pain
- Liver tenderness
- Jaundice
- Bleeding
- Ascites
- Manifestation of coagulopathy
- 50% have proteinuric hypertension
DIFFERENTIATE FROM CHOLESTATIS OF PREGNANCY BY PRURITIS
What are the investigations for acute fatty liver disease?
- LFTS (ALT is typically very elevated)
- ALP may be raised due to placental ALP (doesn’t always mean obstruction)
- Blood glucose is low
- Elevated uric acid (high)
- USS –> fatty liver (hypoechogenic)
What is the management of acute fatty liver disease?
- Supportive care and stabilisation
- Once stabilised, delivery is the definitive management to prevent deterioration
What are the complications of acute fatty liver disease?
Maternal:
- death
- haemorrhage (secondary to DIC)
- renal failure
- hepatic encephalopathy
- sepsis
- pancreatitis
Foetal:
- death
What is toxoplasmolosis in pregnancy?
- Protozoon Toxoplasma Gondii (parasite excreted in cat faeces, incubation period 5-23 days)
- Transmission is faeco-oral route (from infected meat and cat faeces)
- Increased risk of vertical transmission with increasing gestational age
- Risk of congenital toxoplasmosis reduced with increasing gestational age
What are the risk factors of toxoplasmolosis in pregnancy?
- Household cats
- Increased incidence in rural areas and in France
Signs and symptoms of toxoplasmolosis in pregnancy?
Mother:
- often asymptomatic
- fever, malaise, arthralgia
Child:
- 60% asymptomatic at birth, may develop deafness, low IQ, microcephaly
- 40% are symptomatic at birth.
CLASSIC TRIAD: (the 4 C’s)
- Chorlorentinitis
- Hydrocephalus (microcephaly)
- Intracranial calcifications “tram-like” (scattered throughout the brain unlike CMV, which is peri-ventricular)
- Convulsions
- Hepatosplenomegaly/jaundice
Investigations for toxoplasmolosis in pregnancy?
- Sabin Feldman Dye Test
- Bloods - IgM (active may persist for years), IgG (immunity)
- USS - foetal anomaly scan
- Other - amniocentesis and PCR to detect foetal infection (done if USS raises suspicion)
What is the management of toxoplasmolosis in pregnancy?
Mothers should avoid eating raw or rare meat and handling cats and cat litter
Toxoplasmosis PCR +ve in mother and -ve in baby:
- Spiramycin (3 week course, 2-3g/day)
- No vertical transmission
- Spiramycin prevents vertical transmission
Toxoplasmosis PCR +ve in mother and +ve in baby:
- Pyrimethamine + Sulfadlazine
- Treat baby for up to 1 year after delivery (if no TOP)
- Adjunct: Prednisolone
What is listeriosis?
- Gram +ve bacillus bacterium
- Listeria monocytogenes
What is the aetiology of listeriosis in pregnancy?
- Found in soil, decayed matter and animals
- Faecal-oral transmission (soft cheese, pate, unpasteurised dairy products, unwashed salads)
- Vertical (transplacental or during pregnancy)
What are the risk factors of listeriosis in pregnancy?
- Pregnancy and immunosuppression increases risk of infection
What are the symptoms and signs of listeriosis in pregnancy?
- Often asymptomatic and non specific
- Diarrhoea, vomiting, malaise, fever, sore throat, myalgia
- Meconium staining
What are the investigations of listeriosis in pregnancy?
- Isolation of the organism from blood, vaginal swabs or the placenta
What is the management of listeriosis in pregnancy?
- IV amoxicillin/ampicillin
What are the complications of listeriosis in pregnancy?
- General: septicaemia, pneumonia and meningitis
- Pregnancy: miscarriage, chorioamnionitis, PTL, foetal death
- Prognosis: good if treated or poor (sepsis, meningitis or neonatal infection)
What is Group B streptococcus in pregnancy?
- Gram postitive streptococcus characterised by presence of Group B Lancefield Antigen - Streptococcus agalactiae
- Gram +ve cocci in chains
- Most common cause of early onset infection in noenates <7 days old
What is the aetiology of Group B streptococcus in pregnancy?
- Commensal bacterium of vagina and rectum carried by 25% of women
- Majority of babies who come into contact are not affected
What are the investigations of Group B streptococcus in pregnancy?
- Often incidental
- There are no screening for it at the booking visit
- HVS or LVS
- Rectal swab
- MSU
What is the management of Group B streptococcus in pregnancy?
Antenatal discovery –> no prophylactic treatment as it does not reduce the likelihood of GBS colonisation at the time of delivery
Intrapartum treatment –> antibiotic prophylaxis treatment (reduce early onset symptoms in neonates)
1st line: IV benzylpenicillin
Pen-allergic: IV vancomycin (severe allergy) or cephalosporin (non-severe allergy)
What are the risk factors for early-onset neonatal sepsis/indications for GBS prophylaxis intrapartum?
- Intrapartum fever/ confirmed chorioamnionitis
- Prolonged rupture of membranes
- Pre-term birth <37 weeks
- Previous infant with GBS
- Maternal GBS bacteriuria/colonisation
What is involved in the monitoring of neonates in prior maternal prophylaxis with no fever in GBS?
- Mother has >4 hours prophylactic ABx before delivery –> neonate does not need monitoring
- Mother has <4 hours prophylactic ABx before delivery –> monitoring neonatal vital signs
What is involved in the sepsis monitoring in neonates for GBS?
Newborns with 1 risk factor: remain in hospital for at least 24 hours for observations
Newborns with >2 risk factors or one red flag: sepsis Abx + septic screen
- GOSH ABx in neonates = cefotaxime + amlkacin + ampicillin
What are the red flags in neonatal GBS?
- Signs of shock
- Need for mechanical ventilation in a term baby
- Seizures
- Resp distress starting <4 hours postpartum
- Intrapartum Abx for confirmed/suspected sepsis (not GBS)
When is IV antibiotic prophylaxis offer in pregnant mothers?
- With previous GBS baby
- In preterm labour regardless of GBS status
- With pyrexia during labour (>38 degrees)
When do pregnant women who need GBS testing go for their swabs?
- 35-37 weeks
- 3-5 weeks before edtimated delivery date
What is rubella in pregnancy?
- RNA virus with incubation period 6-12 days
- Infectious from 1 weeks prior or 5 days after onset of rash
What is the aetiology of rubella in pregnancy?
Transmission by aerosol route or vertical (transplacental)
What are the risk factors of rubella in pregnancy?
Non-immunity (increased rates in ethinic minorities)
What is the epidemiology of rubella in pregnancy?
RARE as 97% of women are vaccinated or immune in th eUK
What are the signs and symptoms of rubella in pregnancy?
- Coryzal symptoms (cold-like symptoms, fever, malaise), arthralgia and rash
- Soft palate lesions
- Lymphadenopathy
- Maculopapular rash (starting behind the ear, spreading to head and neck, then to rest of the body): called “german measles” because the rash mimics the measles rash and spreads in the same fashion
What is congenital rubella syndrome (CRS)?
PDA, chorioretinitis –> cataracts (blindness) –> SNHL
Infection <12 weeks GA:
- CRS, microcephaly
Infection 12-20 weeks GA:
- SNHL, chorioretinitis –> cataracts
Infection >20 weeks:
- low risk
What are the investigations rubella in pregnancy?
- Blood serology: IgG and IgM (active or 4x increase in IgG titre)
- PCR virus
- USS - foetal anomalities
Screening:
- Not routinely offered
- for women screened and rubella antibody not detected –> MMR after pregnancy (vaccine contraindicated in pregnancy because it is a live vaccine)
What is the management of rubella in pregnancy?
- Rest, fluids and paracetamol
- Offer TOP if <16weeks GA
- Refer to the foetal medicine unit and notify the Health Protection Unit –> notifiable condition
- Avoid work and pregnant women for 5 days after initial development of the rash
What are the complications of rubella in pregnancy?
Maternal - miscarriage, pneumonia, arthropathy, encephalitis, ITP
Foetal - detah, CSR (deafness, VSD, PDA, cataracts, CNS defects, IUGR, hepatosplenomegaly, thrombocytopenia, rash)
What is Hep B in pregnancy?
- Tested in all women
- Vertical transmission rate =20%, 90% of HBeAg
- Babies born to chronically infected mothers or mothers with acute Hep B during pregnancy should recieve:
- Vaccination given at birth, 1 month and 6 months –> serological test for HBV at 12 months
- HBV IVIG (0.5ml within 12 hours of birth)
- c section does not reduce vertical transmission
- Hep B not transmitted via breastfeeding
What is Hep C in pregnancy?
- Detect anti-HCV antibodies
- Confirm with PCR for the Virus
- Treatment contraindicated in pregnancy (ribavirin + inteferon)
What is Hep E in pregnancy?
- Causes severe reaction if contracted in the 3rd trimester - sometimes a fulminant hepatitis
- Pregnant mothers stay away from pork and shellfish
What is Parvovirus B19 in pregnancy?
- Erythema infectiosum (AKA fifth disease) caused by parovirus B19
- A small ssDNA virus
- Incubation period 4-20 days
- Infective from 10 days prior of rash until 1 day appearance of rash
When are pregnant mothers ar risk of transmitting Parvovirus B19 to the baby?
- High risk if vertically transmitted <20 weeks GA
- Low risk >20 weeks
What is the aetiology of Parvovirus B19 in pregnancy?
- Transmission by aerosol route or blood-bourne
- Common, immunity in adults by age 20
What are the signs and symptoms of Parvovirus B19 in pregnancy? Mother and noenate
In the young child/mother:
- Rash, malaise, fever, arthralgia, transient aplastic crisis
- Rash - commonly ‘slapped cheek’ appearance (erythema infectiosum)
- Infant - coryzol symptoms, headache, rash
In neonate/antepartum:
- B12 crosses the placenta at 4-20 weeks GA and destroys RBCs –> hrdrops fetalis –> 10% infant mortality
- Treat with intrauterine transfusions
- No other CNS damage if treatment with transfusions, many infants are completely fine
What are the investigations of Parvovirus B19 in pregnancy?
- If happens after 20 weeks, no investigations are needed as very low risk
- IgM and IgG –> if IgG -ve and IgM -ve, recheck in 1 month
- If IgM +ve then perform a serial USS
- USS –> foetal anomaly scan 4 weeks after onset of illness, then serial scans in 2 week internals until 30/40
- Rubella serology
What is the management of Parvovirus B19 in pregnancy?
- Maternal and infant –> self-limiting and clears up in 3 weeks
- Intrauterine –> blood transfusions in foetal hydrops
What are the complications of Parvovirus B19 in pregnancy?
- Miscarriage (15%)
- Foetal hydrops (3%)
What are the maternal risk factors of a breech delivery?
- Placental abnormalities (praevia, increta, percreta, accreta)
- Uterine abnormalities
- Grand multiparity (uterine laxity)
- Obstructed lower segments (fibroids, pelvic abnormalities)
What are the foetal risk factors of a breech delivery?
- Multiple gestation
- Prematurity
- Foetal Malformation
- Polyhydramnios
- Oligohydramnios
- Macrosomia
What are the signs and symptoms of a breech delivery?
Abdomen - palpable head at fundus, soft breech in pelvis
Vaginal - soft presenting part, ischial tuberosities, anus or genetalia may be felt
Footing breech - foot felt or seen through cervix
Investigations to prove breech position?
USS
What is the antenatal management of a breech position?
Features suggestive of vaginal breech birth being HIGH RISK:
- hyperextended neck
- high EFW
- low EFW
- Footing presentation
- Evidence of antenatal foetal compromise
What term information do you give a mother about a breech presentation of the baby?
- Offer ECV at 36 weeks (if foetal distress, emergency CS or go into labour)
If ECV unsuccessful/declines:
- council risks and benefits of vaginal delivery vs CS
Benefits of CS:
- small reduction in perinatal mortality
- planned vaginal birth increases the risk of low Apgar scores and short-term complications
Risk of CS:
- small increased risk of immediate complications for the mother (but risk is highest with emergency CS which is needed 40% of breech)
- Risk complications in future pregnancy (praevia, uterine rupture)
- Women near active second stage should not routinely be offered C-section
- Induction of labour is not recommended
- Use continuous CTG
What happens during breech delivery?
- Very dangerous if footing
- Hands off approach (ideally the baby will delivery itself - if handling needed, put thumbs on the sacrum and fingers on the asis of the baby)
- Pinard manoeuvre - poke them in the popliteal fossa which will make them bend their knee
- If the baby’s head gets stuck once the body has delivered, you will see winging of the scapulae
- Rotate the baby into the transverse position and pull the anterior arm down (Lovesets manoeuvre)
- If the second arm has not delivered, rotate the baby into opposite anterior position and pull other arm down
- If the head remains stuck, perform Mauricear-Smelle-Velt manouvre (rest the baby on your forearm and pull the head downwards and if this does not work, use forceps)
- Other considerations: G&S, X-match,, FBC, CTG, make sure theatre is ready
- Avoid induction if possible
When is EVC offered in breech women?
- Breech at 36 weeks and nulliparous
- Breech at 37 weeks and multiparous
What are the contraindications of EVC?
- C-section is required
- APH within last 7 days
- Abnormal CTG
- Major uterine anomaly
- Ruptured membranes
- Multiple pregnancy
What are the signs and symptoms of abnormal lie?
Transverse lie:
- Abdomen - no presenting part in pelvis, uterus appears wide, fundal health may be low
- Vaginal - no presenting part
Face:
- facial landmarks felt
Brow:
- supraorbital ridges or base of nose felt
What is the investigation for unstable lie?
USS to confirm
Can you deliver a baby in an unstable lie?
Impossible to deliver unless cephalic or breech. If in labour and in unstable lie, immediate CS
What is the management of unstable lie?
80% revert to longitudinal lie before labour.
Transverse lie:
- CS
- Increased risk of cord prolapses
Brow:
- If persistent or 2nd stage labour –> CS
Face:
- mentoposterior = CS
- mentoanterior = SVD ok
Compound (foetal arm along head):
- manage expectantly
What is a definition of a miscarriage?
Pregnancy loss <24 weeks
What is a threatened pregnancy?
PV blood with foetal heartbeat present
Cervical os must be closed
What is an inevitable pregnancy?
PV bleed with open cervical os
What is an incomplete miscarriage?
Passage of products of conception but uterus not empty on USS
What is a complete miscarriage?
Passage of products of conception, uterus on empty on USS
What is a missed miscarriage?
USS diagnosis of miscarriage in absence of symptoms
What is recurrent miscarriage?
More or = 3 consecutive miscarriage
- No cause found in 50%
What is the aetiology of miscarriage?
90% result from chromosomal abnormalities in the embryo - trisomy 16
What are the risk factors of miscarriage?
- increasing maternal age
- previous miscarriage
- chronic conditions
- uterus/cervix abnormalities
- alcohol
- illicit drugs
- underweight/obese
What are the signs and symptoms of miscarriage?
- PV bleeding (scanty, brownish red), cramping abdo pain, fever
- Speculum –> quantity and location of bleeding, os open or closed, can remove any products
- PV exam –> exclude ectopic (unilateral tenderness, cervical excitation, adnexal mass)
What are some of the reasons for recurrent miscarriages?
- Structural abnormalities (fibroids, bicornuate or septate uteri)
- Cervical incompetence (later miscarriage =>13 weeks)
- Medical conditions (renal, diabetes, SLA)
- Clotting abnormalities
What are the investigations of a miscarriage?
Pregnancy test –> speculum (inspect os) –> TVUSS (FH –> CRL,/foetal pole or GS/YS)
TVUSS:
Dating pregnancies using USS:
- CRL (end to end measure of the foetal pole) used to date pregnancies less then 14 weeks
- AC, HC, FL used to date pregnancies >14 weeks
Need yolk sac and gestational to be a viable IUP, otherwise PUL (pregnancy of unknown location)
Process of TVUSS:
1st: look for FH
2nd: foetal poles for CRL –> if no foetal pole looks for GS
If no FH and CRL >7mm –> miscarriage (cannot get miscarriage diagnosis on one USS alone, need second opinion)
If no FH and CRL <7mm –> Pregnancy of unknown viability (PUV) –> TVUSS in 7 days
If GS >25mm + no foetus –> miscarriage (cannot get miscarriage diagnosis on one USS alone, need second opinion)
If GS <25mm + no foetus –> Pregnancy of unknown viability (PUV) –> TVUSS in 7 days
Recurrent MC:
- cytogenic analysis of products of conception, pelvis USS (structural abnormalities), anti-phospholipid antibodies, anticardiolipin antibodies, screen for BV
- explain that the cause is often never found
Why can miscarriage sometimes cause bradycardia?
If a woman is having a miscarriage and the products of conception are coming through the cervix, the cervical excitation can cause parasympathetic stimulation and a bradycardia, even if there is a blood loss
What is the management of miscarriage >6 weeks?
GDR/EPAU referral:
Viable pregnancy:
- Go home and follow expectant management
Complete missed miscarriage:
- Council and go home
- Advise: menstruation will begin in 4-8 weeks, try for another when mentally ready
Miscarriage with retained products:
1st line: expectant management for 7-14 days
- if bleeding/pain settle –> pregnancy test after 3 weeks –> return if +ve
- If bleeding/pain persists or increases –> follow up clinic in 4 weeks
- Not appropriate if: infection, coagulopathy, late 1st trimester, previous traumatic experience
2nd line: Medical management
- Misoprostol (PO/PV)
- Advice: bleeding, pain, nausea
3rd line: Surgical management
- Manual vacummn aspiration (LA)
- Surgical ERPC (LA)
What is the management of miscarriage <6 weeks?
Expectant management (no USS, just sent them on their way)
- Do pregnancy test in 1 week
- Is positive result or symptoms persist –> follow up in clinic in 2 weeks
What needs to be given to a rhesus negative mother having a miscarriage?
Anti-RhD
BCSH guidelines:
- administer if mother rhesus -ve and >12 weeks GA
- for therapeutic termination, anti-D is given regardless of method and gestational age
NICE guideliens:
- administer if mother rhesus -ve and not soley managed medically
What should be given to recurrent miscarriage mums?
- Low dose aspirin and LMWH if thrombophillia identified (Anti-phospholipid syndrome/APLS)
What are the signs and symptoms of Anti-phospholipid syndrome/APLS?
- VTE
- Arterial thrombosis
- Thrombocytopenia
- RMC
- pre-eclampsia
What are the investigations of Anti-phospholipid syndrome/APLS?
Lupus anticoagulant AB +/- anti-cardiolipin AB
What is the management of Anti-phospholipid syndrome/APLS?
Acute –> warfarin + LMWH
Chronic –> DOAC
Pregnancy –> low dose aspirin + LMWH
What are the complications of ERPC?
- Haemorrhage/bleeding
- Cervical trauma
- Retained products of conception
- Psychological sequelae
- Infection
- uterine perforation
- Repeat ERPC
What are the risk factors of high risk pregnancies?
- Age <15 yo or >35 yo
- Height under 5 foot
- Uterine malformations
- Being single
- Illicit drugs
- Low socioeconomic status
- Hypothyroid
- Prepregnancy weight under 45kg or obese
- Incompetent cervix
- Small pelvis
- Smoker/alcohol
- No access to early prenatal care
- Previous obs hx for recurrent miscarriage
- Hyperthyroid
What to do for a high-risk pregnancy patients?
- refer to obstetrician led care
- continued surveillance for high risk patients = more frequent scans
- Offer high dose folate 5mg
- Offer low dose aspirin (75mg, OD) as prophylaxis for pre-eclampsia
Which women need high dose folate 5mg?
- Previous child with NTD
- Obesity
- Sickle cell
- Diabetes
- Taking anti-epileptic
- HIV positive taking co-trimoxazole
What is obesity in pregnancy?
BMI > 30 kg/m^2
What is the aetiology of obesity in pregnancy?
- Pre-existing obesity (poor diet, lack of exercise)
- Fluid retention (polyhydramnios, heart, kidney, liver failure)
What are the signs and symptoms of obesity in pregnancy?
- GDM
- Pre-eclampsia
- Infections
What are the investigations of obesity in pregnancy?
- BMI monitoring
- Bloods - FBC, LFT, UE, cholesterol, OGTT
- USS - liquor volume, foetal growth scans
What is the management of obesity in pregnancy?
Conservative - more exercise, better diet, Vit D
Labour planning - assess risk of giving birth via vaginal delivery and whether there needs to be induction/CS
Post-natal follow up - T2DM testing
What are the complications of obesity in pregnancy?
- GDM
- Pre-eclampsia
- Infections
- Overdue pregnancy
- Labour difficulties
- CS
- Miscarriage
Definition of hypertension?
BP 140/90 - 159/109 mmhg
Definition of severe hypertension
BP > 160/110 mmHg
Definition of chronic hypertension
Hypertension present before 20 weeks (assumed to have been present before pregnancy)
What is gestational hypertnesion?
New hypertension present after 20 weeks, without significant proteinuria
What is preeclampsia?
New hypertension present after 20 weeks, and >/=1 of:
- proteinuria (o.3g in 24 hours) AND/OR
- any maternal organ dysfunction
Renal: rising creatinine
Liver: Rising AST/ALT +/- epigastric pain
Neurological: Eclampsia, blind, stroke, clonus, severe headache, visual scotomata
Haem: Thrombocytopenia, DIC, hemolysis
Uteroplacental: IUGR, abnormal dopplers, stillbirth
What is HELLP syndrome?
Haemolysis, elevated liver enzymes, low platelets
SEVERE FORM OF PRE-ECLAMPSIA
What is Eclampsia
> /= 1 seizure in one with pre-eclampsia
What are the high risk factors for pre-eclampsia?
> /=1 aspirin 75mg OD from 12 weeks till end of pregnancy
- in previous pregnancy
- CKD
- Autoimmune disease (SLE, antiphospholipid)
- Diabetes 1 and 2
- Chronic hypertnesion
What are the moderate risk factors for pre-eclampsia?
> /=2 aspirin 75mg OD from 12 weeks till end of pregnancy
- primigravida
- > /= 40 years old
- BMI >/= 35
- FHx
- Multiple pregnancy
What are the signs and symptoms of pre-eclampsia?
Largely asymptomatic:
- severe headache
- vomitting
- breathlessness
- visual disturbances
- epigastric/RUQ pain
- sudden swelling
What are the investigations for pre-eclampsia?
- Urine dipstick (protein), if >/= 1 or more –> PCR quantification (>30mg/mmol = significant)
- DO NOT USE 24 hour urine collection
What is the management of pre-eclampsia?
Always: give healthy lifestyle advice, dip urine at every appt
High risk, Chronic hypertension:
- aspirin 75mg OD from 12 weeks till end of pregnancy
- NO ACEi or ARB
Pre-eclampsia therapy:
- 1st: Labetalol (100mg, BD) –> contraindicated in asthma
- 2nd: Nidefipine (cause tocolysis - use methyldopa at term)
- 3rd: Methyldopa (250mg, BD or TDS)
Eclampsia:
- IV Mag sulphate (potent cerebral vasodilator)
What are the next steps upon discovering moderate hypertension?
No admission:
- Target = 135/85 mmhg
Medications:
- 1st: Labetalol (100mg, BD) –> contraindicated in asthma
- 2nd: Nidefipine (cause tocolysis - use methyldopa at term)
- 3rd: Methyldopa (250mg, BD or TDS)
BP measurement:
- once a week
Dipstick:
- once a week
Blood test:
- FBC
- LFT
- renal function once at presentation
Admission test:
- CTG only if admitted with severe hypertension or indicated
- foetal heart ascultation (at every antenatal appt)
- USS for foetal growth
What are the next steps upon discovering severe hypertension?
Yes admission:
- Target = 135/85 mmhg
Medications:
- 1st: Labetalol (100mg, BD) –> contraindicated in asthma
- 2nd: Nidefipine (cause tocolysis - use methyldopa at term)
- 3rd: Methyldopa (250mg, BD or TDS)
BP measurement:
- every 15 to 30 mins until BP < 160/110 mmhg
Dipstick:
- daily whilst admitted
Blood test:
- FBC
- LFT
- renal function once at presentation
Admission test:
- CTG only if admitted with severe hypertension or indicated
- foetal heart auscultation (at every antenatal appt)
- USS for foetal growth
What is the ongoing pathway of antepartum and birth for moderate and severe hypertension?
Test on repeat assessment, every 2-4 weeks:
- USS for foetal growth
- amniotic fluid assessment
- umbilical artery doppler
- dipstick
- BP measurement
Once a week:
- FBC
- LFT
- renal function once at presentation
Care plan:
- Timing and nature of birth
- Indications for birth
- Timing of steroids if to be given
Birth timing:
- Aim to deliver after 37 weeks gestation, unless clinically indicated
What are the next steps upon discovering moderate pre-eclampsia?
Maybe admission if concerns:
- Target = 135/85 mmhg
Medications:
- 1st: Labetalol (100mg, BD) –> contraindicated in asthma
- 2nd: Nidefipine (cause tocolysis - use methyldopa at term)
- 3rd: Methyldopa (250mg, BD or TDS)
BP measurement:
- every 48 hours if not admitted
- 4 times a day if admitted
Dipstick:
- only repeat if indicated
Blood test (2 times a week):
- FBC
- LFT
- renal function
Admission test:
- CTG only if admitted with severe hypertension or indicated
- foetal heart ascultation (at every antenatal appt)
- USS for foetal growth
- amniotic fluid volume assessment
- umbilical artery doppler
What are the next steps upon discovering severe pre-eclampsia?
Yes admission:
- Target = 135/85 mmhg
Medications:
- 1st: Labetalol (100mg, BD) –> contraindicated in asthma
- 2nd: Nidefipine (cause tocolysis - use methyldopa at term)
- 3rd: Methyldopa (250mg, BD or TDS)
BP measurement:
- every 15 to 30 minutes until BP <160/110 mmhg
- 4 times a day as inpatient
Dipstick:
- only repeated if indicated
Blood test (3 times a week):
- FBC
- LFT
- renal function
Admission test:
- CTG only if admitted with severe hypertension or indicated
- foetal heart ascultation (at every antenatal appt)
- USS for foetal growth
- amniotic fluid volume assessment
- umbilical artery doppler
What is the ongoing pathway of antepartum and birth for moderate and severe pre-eclampsia?
Test on repeat assessment, every 2 weeks:
- CTG only if abnormal (abdo pain, PV bleeding, deterioration of mother, women report change in foetal movement)
- USS for foetal growth
- amniotic fluid assessment
- umbilical artery doppler
- dipstick (bilateral notching, increased pulsatility index predict PET development)
- BP measurement
2x a week if HTN 140/90 - 159/109 mmhg:
- FBC
- LFT
- renal function once at presentation
3x a week if admitted with HTN > 160/110 mmhg:
- FBC
- LFT
- renal function once at presentation
Care plan:
- Timing and nature of birth
- Indications for birth
- Timing of steroids if to be given
Birth timing (<34 weeks):
- continue surveillance unless delivery indicated (eg. uncontrollable BP, maternal/foetal distress, eclampsia).
- If delivery offer: 1) antenatal steroids, 2) MgSO4
Birth timing (34-36+6 weeks): - continue surveillance unless delivery indicated in care plan
Birth timing (>37 weeks): - Initiate birth within 24-48 hours
What is the ongoing pathway of intrapartum care for moderate and severe pre-eclampsia?
Intrapartum monitoring:
- CTG continuous
- BP monitoring + continue antihypertensives during labour:
1) 140/90 mmhg –> hourly measurements
2) > 160/110 mmhg –> measure every 15-30 minutes (until <160/110)
Delivery:
- epidural anaesthesia should help reduce BP
What is the critical setting management for severe hypertension, severe pre-eclampsia and eclampsia?
Consider anticonvulsants if:
1) Previous eclamptic fit
2) Birth planned in next 24 hours
3) Features of severe pre-eclampsia present (severe headaches, epigastric pain, oliguria, deteriorating biochemical tests, N&V, visual scotomata)
TREAT WITH:
1st) IV magnesium sulphate (continue 24 hours after last seizure/delivery)
- Reserving agent: Calcium gluconate (10ml, 10% over 10 mins)
Antihypertensives:
- 1st line: oral/IV labetalol
- 2nd line: oral nifedipine, IV hydralazine
Antenatal corticosteroids:
- if <34 weeks and birth planned in the next 7 days
AVOID ERGOMETRINE:
- use IM carboprost for PPH
What is the mag sulphate dosing in pre-eclampsia?
- Loading dose of 4mg IV over 5 mins, followed by infusion over 1g/hour for 24 hours
- Recurrent seizures should be treated with a further dose of 2-4g over 5 mins
- MONITOR: urine output, reflexes, resp rate, o2 sats, ECG
What is the postnatal inpatient monitoring for hypertension and pre-eclampsia?
Discharge criteria:
- no symptoms of pre-eclampsia
- Blood pressure <150/100mmhg (with or without treatment)
- blood test results are stable or improving
BP monitoring:
1) Inpatient = BP at least 4x a day
2) outpatient = BP every other day until target achieved then 1 time a week
Target achieved:
- wean down anti-HTN
BP < 130/80 mmhg:
- stop anti-HTN
What is the breastfeeding advice for hypertension and pre-eclampsia?
- Avoid diuretic treatment
Drugs NOT recommended:
- ARBs
- ACEi (except enalapril and captopril)
- Amlodipine
Drugs that are SAFE:
- labetalol
- nifedipine
- enalapril
- captopril
- atenolol
- metaprolol
What is the follow-up advice for hypertension and pre-eclampsia?
1 in 5 women will get some recurrence of HTN in any future pregnancies
What is the aetiology of pre-eclampsia?
Impaired trophoblastic invasion in spiral arteries:
1) Impaired invasion –> high resistance flow
2) Low flow –> poor perfusion of placenta
3) placenta releases factors into circulation
4) factors promote further systemic effects seen:
- peripheral vasoconstriction
- increased permeability –> oedema
- Glomerulonephritis –> proteinuria
- Endothelial damage –> platelet consumption
- Elevated liver enzymes (HELLP syndrome)
- Vasospasm, cerebal oedema –> eclampsia
What is the aetiology of HIV in pregnancy?
Present in vaginal fluid, semen, blood and breast milk. Transmission through sexual contact, BB and vertical:
- Less transmission through vaginal mucosa than through anal musoca
- decision to treat with PEP based on guidelines
What are the risk factors of HIV in pregnancy?
- Vertical risk if high viral load
- Low CD4 count
- Prolonged rupture of membranes (>4 hours)
- Breastfeeding
What are the signs and symptoms of HIV in pregnancy?
Aymptomatic:
- 1-4 weeks for seroconversion from primary infection
General S/S of HIV/AIDS:
- fever
- rash
- lethargy
- oral ulcers
- lymphadenopathy
- sore throat
Aids defining disease:
- PCP
- Kaposi sarcoma
- MAC - mycoplasma avarium complex
- oesophagal candidiasis
What are the investigations for HIV in pregnancy?
Routine HIV testing in antenatal booking:
- regular viral load
- CD4 count
Baseline indication tests:
- FBC
- U&E
- LFT
- lactate
- blood glucose
Neonates test positive for HIV antibodies due to passive transfer from mother:
- Diagnosis of HIV in the neonate requires direct viral amplification by PCR (carried out at birth, 6 weeks, 12 weeks and 18 weeks)
What is the monitoring management of HIV in pregnancy?
Monitoring:
- 2x CD4 counts (at baseline and at delivery)
- 8x viral load (measured every 2-4 weeks, at 36 weeks and after delivery)
The risk of vertical transmission is affected by maternal viral load, obstetric factors and infant feeding
What is the management of the mother with HIV in pregnancy?
ART:
- Maternal = continual, do not stop
- neonate = first 4-6 weeks of life for the baby
Delivery:
- undetectable (<50 copies/ml) at 36 weeks –> vaginal delivery
- detectable viral load (>50 copies/ml) at 36 weeks –> ECLS at 38 weeks
ECLS at 38 weeks if:
- HIV/HCV co infection
- > 50 HIV/ml
- zidovudine monotherapy
Avoide breastfeeding:
- offer cabergoline to women to suppress lactation
- free formula
Foetal blood sampling is contraindicated
Intrapartum zidovudine only if viral load is detectable
What is the management of the infant with HIV in pregnancy?
- Cord clamped as soon as possible and baby bathed immediately after birth
- Zidovudine (oral or IV) monotherapy for 4-6 weeks (low/medium risk - mother viral load <50 copies/ml)
- 4 week PEP combi (high risk)
- NO BREASTFEEDING
- give all immunisation including BCG (unless moderate-high risk of transmission)
- PCR HIV virions at 6 and 12 weeks (at least 2 and 8 weeks after stopping prophylaxis)
What is the aetiology of VZV in pregnancy?
Transmission is respiratory, 70% attach rate in susceptible individuals:
- Incubation 10-21 days, infectious 48 hours before rash until the vesicles crust over (about 5 days)
- transfer to baby can be transplacental, ascending vaginal or contact after delivery with lesions
What are the signs and symptoms of ZVZ in pregnancy?
Maternal chickenpox:
- risk of encephalitis, pneumonia and sepsis
- prodromal fever, malaise, myalgia
- generalised rash (macular –> popular –> vesicular)
Congenital varicella syndrome (maternal transmission 13-20w GA –> 2% risk):
- eyes (chorioretinitis –> cataracts)
- MSK (limb hypoplasia, cutaneous scarring)
- CNS (microcephaly)
- IUGR
Neonatal varicella infection (maternal infection 7 days before or after birth):
- mild disease
- penumonia
- disseminated skin lesions (–> purpura fulminans)
- Viseral Infections (ie. hepatitis)
What is the investigations of ZVZ in pregnancy?
Booking (check previous maternal exposure):
- NO previous exposure: avoid contact during pregnancy
- if contact contact medical services
- Contact defined as 15 mins or more in the same room or face-to-face contact
- If unsure, check immune status for VZV IgG before giving therapy
What is the management of antenatal VZV?
VZIG (within 10 days of exposure) before 20/40 GA:
- considered infectious for 21 days after exposure if they DON’T receive ZVIG
- considered infectious for 28 days after exposure if they DO receive ZVIG
- Once chickenpox symptoms have developed, ZVIG cannot be given
Aciclovir, 800mg QDS (from day 7-14 post-exposure) after 20/40 GA
Hospital admission (if these RFs are present: smoking, chronic lung disease, steroids or being in latter half of pregnancy): - nursed in isolation from babies and other pregnant mothers
Consider referral to foetal medicine specialist - at 16 to 20 weeks or 5 weeks after infection
What is the management of postpartum VZV?
- Neonatal ophthalmic exam should be organised at birth
- infant should be monitored for signs of infection until 28 days after the onset of maternal infection
- neonatal infection should be treated with aciclovir
What are the complications of VZV in pregnancy?
Delivery during the viraemic period may be extremely hazardous.
Risks:
- Bleeding
- DIC
- Varicella infection of the new born
- Hepatitis
- Thrombocytopenia
Low risk of non-immune pregnant women getting chickenpox from someone with shingles
What are the energy physiological changes of pregnancy?
14% increased demand:
- increased fat storage (4kg)
- less protein requirement
- Insulin sensitivity decreases (mother absorbs more glucose and more available for the baby)
What are the anatomical changes of pregnancy?
- Straie gravidarum (abdomen)
- Striae distansae (medial thigh)
- Linea Niagra
- Chloasma gravidarum (mask of pregnancy)
What are the cardiac changes of pregnancy?
- CO increased 50%
- SV increased 35% (more volume)
- Less peripheral resistance (progesterone)
- HR increase 15-25%
- LAD on CXR due to compensatory LVH
What are the cardiac changes of pregnancy?
- CO increased 50%
- SV increased 35% (more volume)
- Less peripheral resistance (progesterone)
- HR increase 15-25%
- LAD on CXR due to compensatory LVH
What are the resp changes of pregnancy?
- Tidal volume increased 30-50% (increased minute ventilation, feeling of breathlessness)
- FBC decreases
- RR does not change
What are the kidney changes of pregnancy?
- More aldosterone created (fluid retention)
- GFR increases (1st trimester)
- Albumin increases
What are the haem changes of pregnancy?
- Macrocytosis
- Neutrophillia
- Thrombocytopenia
- Dilutional anaemia
- Increased VWF, F7, F8, fibrinogen, PAI-1/2
- Decreased protein S
What are the endo changes of pregnancy?
- Biggest increase = oestriol
- Less increase = oestrone, oestrodiol
- LH, FHS suppressed
What is Naegle’s rule?
Add 9 months and 7 days (if cycle is >28 days, add the number of days above to the EDD)
eg. 25th August, 31 day cycles
- -> May 25th + 7 + 3 –> June 4th
What are the postpartum contraception?
No contraception required within 21 days postpartum
COCP:
- CONTRAINDICATED: <6 weeks post-partum + breastfeeding
- WARNING: 6w-6m postpartum + breastfeeding
- Not breastfeeding –> can start from day 21
- if starting >/= day 21, use barrier method for 7 days
POP:
- start any time
- starting >/= 21 days, 2 days of barrier method
IUD/IUS:
- 48 hours within childbirth
- 4 weeks after
Lactational:
- 98% effective
- Fully breastfeeding
- amenorrhoeic
- <6 months post-partum
What are the differentials of PV bleeding and abdo pain in 6 week pregnant woman?
- Ectropion
- Ectopic pregnancy
- Miscarriage
- Cervical polyp
- PID
- Cancer
What is Lochia?
- Need highly absorbant sanitary pads
- Avoid tampons in the first 6 weeks due to infection risk
- Eventually become brown and stop
- Normal process: Rubra (red) –> serosa (yellow) –> alba (white)
- Infection = offensive smell or greenish colour
- If persistent past 6 weeks then USS
What is the advice given to women post c-section?
- Avg stay is 3-4 days
- regular painkillers, encourage baby contact, encourage metabolism
- Wound: gently clean and dry everyday, wear loose cotton clothing, take painkillers, watch out for infection signs
- non-dissolvable stitches are taken out by midwife say 5-6
- scar fades over time
- stay mobile and return to normal activities
- caution to driving, exercising, heavy lifting, sex
- delay these activities till 6 weeks post delivery
Beta HcG in pregnancy?
- Normally doubles every 48 hours
- Ectopic –> doubles, but at a rate less than double every 48 hours
What are the differentials of PV bleeding and abdo pain in 32 week pregnant woman?
- Low lying placenta (placenta praevia after 32 weeks)
- Placental abruption
- Vasa praevia (placental vein blocks os and baby breaks it)
- Placenta accreta
- uterine rupture
- Preterm labour
What is placental praevia?
The placenta can implant on the anterior, posterior or fundus:
- if placenta adhered to the lower uterine segment, then it is preferred to as a “low-lying” placenta
- if placental remains until week 32, then it becomes placenta praevia
Management:
- depends on severity and foetal wellbeing
- c-section if emergency
What is placental abruption?
Massive blood loss, bleeding may not be overt (may be internal)
- pain from irritation and stretching of the myometrium
- sustained contractions (different from labour)
Risk factors:
- twin
- abdo trauma
- macrosomia
- cocaine use
- polyhydramnoos
- previous CS
What is pre-term labour?
Labour before 37 weeks:
- painful, regular contractions with cervical changes (effacement and dilatation) before 37 weeks
- if doesn’t have this can just be braxton hicks
- most common cause of preterm labour is infection
Management:
- NON-INFECTION: tocolytics and steroids until term
- INFECTION: tocolytics and steroids for at least 24 hours, review if contractions continue after stopping tocolytics, delivery after 24 hours if labour-like contractions begin again (as prolonged steroids in infection can be dangerous and so cannot be continually given)
What are the general landmarks of pregnancy?
- 12 weeks –> fundus at pelvic brim
- 20 weeks –> fundus at umbillicus
What is the management of cord prolapse?
1) Summon senior help (and consider baby monitoring with CTG):
- RFs: malpresentation, multiple pregnancies, polyhydramnios, placenta praevia, macrosomia
2) Prevent further cord compression –> perform digital vaginal exam
- Elevate presenting part or fill the bladder (reduces pressure on the prolapsed cord)
- Tocolytics (nifedipine - CCB), (atosiban - oxytocin receptor antagonist), (terbutaline - beta-agonist)
- Avoid handling the cord as it can cause cord spasms –> if past cord introitus, keep warm/moist and dont push back in
3) Place mother on:
- all fours
- left lateral position
- knee to chest position (baby will fall back into the uterus)
- Ideally have the head slightly declined
4) Deliver ASAP - ECS or expedited vaginal delivery
What are the 4 types of perineal tears?
1st: Superficial damage with no muscle involvement (vaginal mucosa)
2nd: injury to the perineal muscle, but not involving the anal sphincter (muscle/sc tissue)
3rd: injury to the perineum involving the anal sphincter complex (EAS and IAS)
- 3a: <50% of EAS
- 3b: >50% of EAS
- 3c: IAS torn
- EAS –> IAS
4th: Injury to the perineum involving the anal sphincter complex (EAS and IAS) and rectal mucosa
What is the management of perineal tears?
GP alone can manage 1st and 2nd degree teas
- repair undertaken in the operating theatre + antibiotics (broad spectrum)
- Post-op care: analgesia, laxatives, physiotherapy, gynae OP for incontinence review
Future pregnancies:
- Do not need prophylactic episiotomy
- measure anorectal manometry pressure to see if ELCS should be offered in future pregnancies
What antibiotics are contraindicated in pregnancy?
- Sulphonamides (NTDs)
- Chloramphenicol (grey baby)
- ciproflaxin
- tetracycline
- trimetophrim
What psychiatric meds are contraindicated in pregnancy?
- BDZ (cleft lip)
- Lithium (Ebsteins)
- Sodium valproate (NTDs)
- Cabamazepine (NTDs)
- Paroxetine (malformations)
What other medications are contraindicated in pregnancy?
- ACEi
- Methotroxate
- NSAIDs
- Glicazide - sulphonylureas
- Liraglutide - sulphonylureas
- Warfarin (1st and 3rd)
What antibiotics are contraindicated in breastfeeding?
- Sulphonamides (kernicterus)
- Chloramphenicol (BM toxic)
- ciproflaxin
- tetracycline
What psychiatric meds are contraindicated in breastfeeding?
- BDZ - resp depression
- Lithium
- Clozapine
What other medications are contraindicated in pregnancy?
- ACEi
- Sulphonylureas
- Aspirin
- Cytotoxic drugs
- Carbimazole, Fluconazole
- Amiodarone
What are the antiepileptic safe to use in pregnancy?
- Lamotrigine
- Carbamazepine
What can cause foetal hydantoin syndrome?
- Phenytoin/carbamazepine
Symptoms:
- IUGR
- Mental retardation
- Microcephaly
- Hypoplastic fingernails
- Cleft palate/lip
- Distal limb deformaties
What are the dosing for antenatal corticosteroids?
- 2x 12mg IM beclomethasone (given 24 hours apart)
- optional benefit is seen 24 hours after initiation of therapy and lasts for about 7 days
ALTERNATIVE:
- 4, 6mg IM dexamethasone 12 hours apart
What is a partogram?
Allows rapid identification of slow/obstructed labour
Who needs a partogram?
- All women in active labour (>4cm dilated, contracting >3 in 10)
- All women on syntocinon
- Threatened permature labour with the use of atosiban (inhibits oxytocin and vasopression)
What are the components of a partogram?
1) Maternal HR every 30 mins
2) Contractions every 30 mins
3) Cervicograph
4) BP and temperature - every 4 hours
5) Colour of liqour - every 30 mins
6) Abdominal descent
7) Cervical dilatation - every 4 hours (Nulliparous - 0.5cm/hour, parous - 0.5-1cm/hour)
What is the alert line on a partogram?
Line at 0.5cm/hour
- if plotted dilatation moves to the right of the alert line, this may suggest prolonged labour
What is the action line on a partogram?
4 hours right of the alert line and if the cervical dilation crosses this, urgent obstetric review is needed
What is slow progress in labour?
- May be due to malposition
- epidural analgesia can slow progress
What is the management of slow progress in labour?
- ARM (perform VE 2 hours later)
- Syntocinon if there are inadequate contractions
- Instruments –> may be used in some women if you don’t want them to push (eg hypertension)
What are the types of instrumental deliveries?
Ventouse:
- Same diameter for the mum, but can be distressing for the baby
Forceps:
- increases the diameter of the baby’s head but doesn’t upset the baby
What are the risk factors of UTI and bacteriuria in pregnancy?
Women are at increased risk from week 6 to 24 due to possible blockages
What are the signs and symptoms of UTI and bacteriuria in pregnancy?
- Pain or burning, frequency, urgency, blood or mucus in urine
- lower abdo pain
- dyspareunia, foul smelling urine
- signs of infection
What are the investigations of UTI and bacteriuria in pregnancy?
- Urinalysis performed at every antenatal visit
- Urine MC&S - MSU sent at booking visit as a screening test
1) Protein (renal disease, preeclampsia)
2) Persistent glycosuria (T1/2DM or GDM) - Nitrates (UTIs)
What is the management of asymptomatic bacteriuria in pregnancy?
- MC&S (GBS)
Immediate antibiotic treatment (7 days):
- Nitrofuratoin (AVOID AT TERM; 100mg , BD, 7days)
- Amoxicillin (500mg, TDS, 7 days)
- Cephalexin (500mg, BD, 7 days)
If GBS indentified:
- write in notes
- IV benzynpenicillin as will be needed intrapartum
What is the management of UTI in pregnancy?
No visible haematuria so MC&S (GBS)
- Advice and general care –> analgesia, avoid dehydration
- MSU before ABx starts
- Immediate antibiotic treatment (7 days)
1st:
- Nitrofuratoin (AVOID AT TERM; 100mg , BD, 7days)
2nd:
- Amoxicillin (500mg, TDS, 7 days)
- Cephalexin (500mg, BD, 7 days)
What is the management of pyelonephritis in pregnancy?
Cephalexin OR cefuroxime
What are the complications UTI and bacteriuria in pregnancy?
Asymptomatic bacteruia associated with:
- preterm delivery
- pyelonephritis during pregnancy –> LBW and early labour
- Good if treated early and well
- Trimethoprim is contraindicated in the first trimester
What is thyroid disease in pregnancy?
Fall in TSH and rise in Free T4 (free T4 will then fall with advancing gestation)
What is the screening for thyroid disease in pregnancy?
NEW, perform TFTs if:
- current thyroid disease
- 1st degree family history of thyroid disease
- Previous thyroid disease
- AI conditions (Coeliacs, T1/T2DM, GDM)
What is the risk of hypoparathyroidism in pregnancy?
- Increased risk of 2nd trimester miscarriage
- Foetal hypocalcaemia
- Neonatal rickets
What is the management of hypoparathyroidism in pregnancy?
- Vitamin D
- Oral calcium supplements
- Regular monitoring of calcium and albumin
What is the management of hyperparathyroidism in pregnancy?
- Parathyroidectomy may be indicated for severe cases
- Mild is managed with adequate hydration and low calcium count
What is the risk of hyperparathyroidism in pregnancy?
- Increased rates of miscarriage
- Preterm labour
- Intraterine death
- Noenatal tetany
What is the management of hyperthyroidism in pregnancy?
Treat medically (no surgery) at lowest acceptable dose:
- Propylthiouracil (1st trimester)
- Catbimazole (2nd and 3rd trimester)
What are the risks of hyperthyroidism in pregnancy?
- Foetal hypothyroid (from high dose crossing placenta - hence use low doses)
- 33% of women can actually stop treatment during pregnancy
- Does require readjustment postpartum to prevent relapse
- Agranulocytosis (do regular checks of maternal WCC)
- Radioactive iodine is CONTRAINDICATED (obliterates foetal thyroid)
- Risks of uncontrolled thyrotoxicosis –> increased risk of miscarriage, PTL and IUGR
- TSH-receptor stimulating antibodies can cross the placenta, so babies born to women with positive antibody titres should be reviewed by the neonate team
What is the management of hypothyroidism in pre-conception/pregnant women?
Beginning of pregnancy –> thyroxine increase by 25 ug, even if currently euthyroid
- repeat TFTs in 2 weeks and perform in each trimester to adjust dose is required
- this hopes to mimic the rise in thyroid hormone seen in normal pregnancy
Continue thyroid replacement therapy throughout pregnany:
- Aim for biochemical euthyroid (TSH <4mmol/L)
- Corrected hypothyroid has no influence on pregnancy outcome or complications
- Suboptimal replacement is associated with developmental delay and pregnancy loss
What is the diagnosis of hypothyroidism in postpartum women?
Diagnosed based on 3 criteria:
- patient is <12 months after giving birth
- clinical manifestations are suggestive of hypothyroidism
- thyroid function tests alone (no need to measure TPO antibodies)
What are the 3 stages of hypothyroid in postpartum women?
1) Thyrotoxicosis
2) Hypothyroidism
3) Euthyroid
- High recurrent rate
- TFTs measures every 2 months after stage 1
- Thyroid peroxidase antibodies in 90%
What is the management of hypothyroidism in post-partum women?
Thyrotoxic phase: propanolol
Hypothyroid phase: thyroxine
What is thromboembolism in pregnancy?
Any signs or symptoms suggestive of VTE:
- objective testing and treatment with LMWH (until diagnosis is excluded)
What is the aetiology of thromboembolism in pregnancy?
- Pregnancy tilts you into a pro-caogulative state, higher F7, F8, VWF, PAI-1, PAI-2, fibrinogen, less protein S
- Virchows triad: endothelial injury, hyper coagulable state and stasis
What are the signs and symptoms of thromboembolism in pregnancy?
DVT:
- red, hot, swollen tender calf, unilateral lower limb, oedema, erythema, tenderness, low grade pyrexia
PE:
- pleuritic chest pain, dyspnoea, cough, haemoptysis, tachycardia, tachypnoea, low-grade pyrexia, reduced O2 saturations, cardioresp collapse, chest signs (reduced air entry, crepitations), loud P2 sound
What are the investigations for thromboembolism in pregnancy?
DVT: duplex USS
PE: CTPA (higher breast dose) > V/Q (higher baby dose)
- General: ABG (hypoxia or hypercapnia), ECG (sinus tachy or S1Q3T3)
- Imaging: CXR, Duplex USS (if both negative, then do V/Q or CTPA)
- Bloods - before anticoag - FBC, UE, LFT, clotting
What is the immediate treatment DVT in pregnancy?
LMWH (SC, irreversible) + elevate leg and apply graduated elastic stocking
- monitor treatment with anti-Xa levels only in women with extremes of weight or if complicating factors such as renal or recurrent VTE
- Compression duplex ultrasound should be performed if there is a clinical suspicion of DVT
1) -ve and low clinical suspicion –> stop anticoags
2) -ve and high clinical suspicion –> stop antigoag and repeat USS on day 3 and 7
If unfractionated heparin given (IV, adjustable, protamine reversible)
What is the treatment of a minor PE in pregnancy?
- LMWH (SC, BD, 1mg/kg ie. enoxaparin)
- ECG + CXR (if CXR abnormal and clinical suspicion of PE –> CTPA better than V/Q scan)
1) If DVT suspected alongside PE –> compression duplex USS
2) If no DVT suspected alongside PE –> VQ scan or CTPA
VQ has a higher risk of childhood cancer
CTPA has a higher risk of maternal breast cancer but the absolute risk if very small
- Alternative or repeat testing if VQ scan and CTPA normal, but clinical suspicion of PE remains
- Anticoag treatment should be continued until PE is definitively excluded
What is the treatment of a massive PE in pregnancy?
1st line = IV unfractionated heparin (monitor with APTT)
2nd line = thrombolytic therapy, thoractomy or surgical embolectomy
What is the immediate treatment of central venous sinus thrombosis pregnancy?
Most common in post-partum:
- saggital sinus most commonly
- S/S: headache and varying neurology
- IX: MRI (CT may be first to exclude stroke etc)
- Tx: IV unfractionated heparin –> thrombolysis –> 3-6m anticoag
What is the maintenance treatment of VTE in pregnancy?
- Subcutaneous LMWH until at least 6 weeks postnatally and until >/=3 months of treatment
1) Breastfeeding is fine
2) 2nd line = oral anticoags (require routine INR monitoring)
SEs: heparin-induced thrombocytopenia, heparin allergy
What is the delivery for thromboembolism in pregnancy?
- If VTE at term –> IV unfractionated heparin
- If on LMWH maintenance treatment –> no inject any more if they go into labour
(If delivery is planned, LMWH should be discontinued 24 hours before)
Anesthetics:
- epidural not given until at >24 hours after last dose of LMWH
- LMWH not to be given until 4 hours after the epidural catheter has been removed
What is the reversal agent for unfractionated heparin IV?
protamine sulphate
What is the reversal agent for LWMH SC?
Irreversible (Stop 24 hours before delivery)
What is the reversal agent for warfarin?
FFP/ prothrombin complex concentrates
What is the prevention management of VTE in at-risk patients in pregnancy?
Prevention at 12w booking visit:
- Prolonged use of LMWH (>12 weeks)
- Graduated elastic compression stocking
LMWH + stocking will be based on:
- From 12w until 10 days to 6 weeks postpartum (>/= 4 risk factors, VTE event)
- From 28w until 10 days post-partum (3 risk factors)
- Conservative (<3 risk factors)
How do you monitor the treatment of VTE treatment in pregnant woman?
With anti-Xa levels only in women of extreme weights or if complicating factors
What are the social problems of substance use in pregnancy?
- Housing, crime, child in care/abuse
- Malnutrition (Iron, vit B,C)
- Co-exsistent addictions (alcohol and smoking)
- Risk of viral infections (HIV, Hep B)
What is the risk of alcohol substance use in pregnancy?
More cognitive and behavioural abnormalities:
- miscarraige, stillbirth, infant mortality, congetinal abnormalities, LBW, preterm delivery, SGA
- Foetal alcohol spectrum disorder with later neurodevelopmental abnormalities
- Prenatal drinking associated with long-term effects - cognitive/behavioural change, adverse language outcomes
- Executive functioning defects, psychosocial consequences in adulthood
What is the risk of cannabis substance use in pregnancy?
- Preterm labour, LBW, SGA, increased NICU admission
Prenatal cannabis use linked to:
- adverse consequences of growth of foetal and adolescent brains
- reduced attention and executive functioning skills
- poor academic achievement
- behavioural problems
What is the risk of cocaine substance use in pregnancy?
- PROM
- Preterm birth
- Placental abruption
- LWB, SGA
What is the risk of amphetamine substance use in pregnancy?
Similar to cocaine:
- SGA
- LBW
- foetal loss
- developmental and behavioural defects
- preeclampsia
- gestational HTN
- intrauterine foetal death
What is the risk of opiods substance use in pregnancy?
- Greater risk of LBW
- Toxaemia
- microcephaly
- resp prblems
- mortality
- behavioural problems
- 3rd trimester bleeding
- growth deficiency
- SIDS
What is neonatal abstinence syndrome (NAS)?
Opiate exposure in utero triggers postnatal withdrawal syndrome
- 45-90% of infants to opioids in utero (methadone, buprenorphine)
- NAS = substantial neonatal morbidity + increased healthcare utilisation
Presentation:
- irritability
- feeding difficulties
- tremors
- loose stools
- emesis
- hypertonia
- seizures
- resp distress
What is pemphigoid gestationis?
Rare pruritic AI bullous disorder:
- presents in later 2nd or 3rd trimerster
SS:
- lesions begin on abdomen 50% of the time –> widespread culstered blisters, sparing face
M:
- relive pruritus and stop new blister formation
- use potent topical steroids or oral prednisolone
What is polymorphic eruption of pregnancy (PEP)?
Self limiting pruritic inflammatory disorder
- AKA: pruritic urticarial papules and plaques of pregnancy (PUPPP) - umbilical sparing rash
- present in 3rd trimester or immediately post-partum
SS:
- begin on lower abdoment, involving pregnancy stria –> extend to thigh, buttocks, legs, arms, sparing umbillicus and rarely involves face, hands, feet
- can sometimes resemble erythroderma
M:
- symptomatic treatment
C:
- preterm delivery and SGA births
- no increase in pregnancy loss
- recurs in most subsequent pregnancies
What is atopic eczema in pregnancy?
Common pruritic condition affecting up to 5% of the pop
SS:
- causes commenest pregnancy rash
M:
- emollients
- bath additives
What is pruritis folliculitis?
Pruritic follicular eruption with papules and pustules affecting trunk and can involve limbs (2nd or 3rd trimester, resolve a week after delivery)
SS:
- acne (considered a type of hormone induced acne)
M:
- topical steroids
What is prurigo of pregnancy?
Common pruritic disorder
(affects 20% of normal pregnancies, do LFTs to exclude obstetric cholestasis, starts 3rd trimester of pregnancy, resolve after delivery, no effect on mother or baby)
SS:
- present as excoriated papules on extensor limbs, abdo, shoulder
M:
- symptomatic treatment + topical steroids and emollients
What are the common changes in the physiology during pregnancy affecting the skin?
- Pre-exsisting conditions (acne flares up in 3rd trimester - oral or topical erythromycin, retinoids contraindicated)
- increased pigmentation (face, areola, abdo midline) common
- Spider naevi affecting face, arms upper torse,
- Broad pink linear striae - striae gravidarum common over lower abdo and thighs
- Hand and nipple eczema common post-partum
- psoriasis - topical steroids, methotrexate contraindicated
What are the risk factors if rhesus disease in pregnancy?
- Previous pregnancy with insufficient anti-D prophylaxis
- Previous blood transfusion
What is the process of rhesus disease development?
1) Rh -ve mother has a rh +ve mother
2) sensitising event inxes blood (simple SVD is not a sensitising event)
3) mother develops IgM anti-Rh Abs (IgM do not affect 1st baby as IgM cannot cross the placenta)
4) Mother delivers or miscarries child
5) Time passes and mother develops IgG anti-Rh Abs
6) Mother has a 2nd Rh +ve child –> mother IgG anti-RH crosses the placenta –> hydrops fetalis
cffDNA testing can test for the child’s Rh status which reduce the need for anti-D
Anti-A, Anti-B = IgM
Anti-RhD, Anti-duffy, Anti-kidd = IgG
What is the pathophysiology of hydrops fetalis?
IgG anti-Rh ABs against foetal RBCs –> HDN = anaemia + high BR –> hydrops fetalis (foetal HF associated with fluid accumulation - ascites, pericardial effusion), foetal anaemia, kernicterus
What are the possible sensitising events of rhesus disease?
PSE = potentially sensitising events
- Amniocentesis, CVS
- ECV
- Ectopic pregnancy
- Intrauterine (transfusion, surgery)
- Intra-operative cell salvage
- APH/PV bleed in pregnancy (>12 weeks, prolonged and <12 weeks)
- Abdo trauma (T3: 26-37 weeks)
- Spontaneous miscarriage
- Therapeutic miscarriage (any GA, any method)
- IUD and stillbirth/TOP/molar pregnancy
What is the delivery method of rhesus disease?
If baby is found to be Rh +ve at birth, all mothers to receive 500IU <72 hours for all methods of delivery
What are the investigations for rhesus disease?
- Father status
- Mothers anti-RhD levels (higher=worse)
- Baby status (cffDNA testing)
- Kleiheur test (only >20w)
What is the routine antenatal anti-D prophylaxis?
- Indirect antiglobulin testing at booking
EITHER:
- 2 doses of 500IU at 28 or 34 weeks
- 1 dose of 1500IU at 28 weeks
Foetal cord bloods post-delivery and prophylaxis in 72 hurs (500IU anti-D) if baby +ve with kleihaur
Kleihauer = determines need for more anti-D
Coombs Test/ Antiglobulin test:
- Direct AT = ABs on RBCs
- Indirect AT = ABs in serum (eg. mother Anti-D)
What is the anti-D prophylaxis after sensitising events?
<72 hours of event –> Kleihauer-Bekte (+125 IU IM / 1mL foetal blood)
1) 250 IU <20 weeks (baby Rh +ve cells in mothers circulation coated in exogenous anti-D)
2) 500 IU >20 weeks (which is removed by reticuloendothelial system prior to any sensatisation)
What is done if the mother is found RhD -ve and has antibodies at booking?
Monitor titres and if they peak above a level, monitor baby using Middle Cerebral Artery (MCA) dopplers weekly
- if baby affected, consider IU transfusion
What to do if there is continuous bleeding in a Rh-ve woman?
Anti-D every 6 weeks with Kleihauer every 2 weeks (adjust anti-D if needed)
When is cffDNA done?
cell-free foetal DNA testing at 12 weeks can determine baby Rh status
What are the complications of rhesus disease in pregnancy?
- Hydrops fetalis
- IUD
- neonatal kernicterus
What is pre-term labour?
PTL = 32-37w GA
very PTL = 28-32 w
Extremely PTL = <28 w
What is the aetiology of PTL?
- Infection
- Uterine abnormalities
- Cervical procedures
- Overdistention of the uterus (polyhydramnios, multiple pregnancies)
What are the risk factors for PTL?
- Previous:
1) PTL/PROM/PPROM
2) Miscarriage between 16-24 weeks
3) Cervical biopsy - Infection
- Structural (uterine abnormalities, pre-eclampsia)
- Mechanical (fibroids, polyhydramnios, multiple pregnancies, APH - concealed)
- Social lifestyle (smoking, high BMI, drugs, extreme ages, ethinicity)
What are the investigations for PTL?
In addition to main investigations
- CTG monitor
- Urine dip +/- MC&S (if indicated)
What is the management of PTL?
Note: may be in PTL without having ruptured membranes
1) Ruptured membranes –> PPROM guidance and treat as PPROM
2) Non-ruptured membranes (if membranes rupture, treat as per PPROM):
Medications:
- Tocolysis = 34 weeks, 1st: nifedipine, 2nd: Atosiban
- Corticosteroids = 34 weeks for 24 hours (can induce DKA in diabetics so co-administer with insulin)
- MgSo4 = 30 weeks, labour or planned birth <24 hours
Surgical: emergency “rescue” cerciage
- Indication = if 16-18 weeks, dilated cervix, exposed unruptured membranes
- Contraindications = infection, bleeding, uterine contractions
Prophylactic vaginal progesterone (16-24w) / cervical cerciage:
- History of PTL (<34 weeks) AND cervical length <25mm
- History of >16w miscariagge AND cervical length <25mm
- Cervical length <25mm AND history of PPROM
- Cervical length <25mm and cervical trauma
What are the complications of PTL?
Pre-term birth complications:
1) RDS = resp distress syndrome –> Oxygen –> complication: retinopathy of prematurity
2) Necrotising Enterocolitis
3) Intraventricular Haemorrhage
4) Periventricular Leukomalacia
Sepsis
What is PROM?
TERM = Pre-labour rupture of membranes
- Spontaneous rupture of membranes before onset of labour at term (>37 weeks)
- Occurs in = 10% of women
- Cause = natural physiological (EG. Braxton Hicks contractions + cervical ripening –> weakening of membranes)
What is PPROM?
PRE-TERM (24+0 to 36+6 week) = Pre-term pre-labour rupture of membranes
- Spontaneous rupture of membranes before onset of labour in pregnancy (24+0 to 36+6 week)
- Can be caused by weakening of membranes due to infective cause (often subclinical)
- Occurs in 2% of pregnancies
What are the signs and symptoms of PROM/PPROM?
- Sudden gush of fluids PV –> constant trickle
- Contractions (regular & painful = PTL; not braxton hicks)
- General exams –> assess for signs of infection (tachycardia, fever)
What are the investigations for PROM/PPROM?
Do no offer bimanual as it increases risk of infection:
1st) Speculum exam (amniotic fluid pooling is diagnostic of PPROM/PROM):
- Os (open or closed)
- Pooling (diagnostic of PROM/PPROM, if none test for IGFBP-1 or PAMG-1)
- DO NOT USE KY jelly - will complicated FFN results, only perform if ROM not evident
If >30w contractions (PTL) and Os closed –> TVUSS for cervical length:
- <15mm –> likely to be in preterm labour
- > 15mm –> unlikely to be preterm labour
2nd) IGFBP-1 or PAMG-1 (these are very sensitive, so if a -ve result, low chance of PPROM)
3rd) FFN (from gestational sac) may be present:
- <24 weeks (FFN glue is liquid, detectable)
- 24-34w (FFN dried, NOT detectable)
- >34w (contractions stimulate released of FFN, detectable and +ve in PROM)
What do you not offer Digital exams in pregnant woman?
- Placenta praevia
- PROM/PPROM (SROM)
When do you not perform diagnostic tests for PPROM?
If labour is established (ie. bulging membranes, abdo pain) in a woman reporting signs/symptoms suggestive of PPROM –> admit to labour ward
What is the management of pre-labour rupture of membrane (PROM)?
Depends on gross amniotic fluid examined on speculum:
Clear liqour:
- 0-24hours = expectant management (60% of women will labour within 24 hours)
- > 24 hours: IOL (4 hourly temperature and 24 hours foetal monitoring, augment with prostaglandin or oxytocin infusion)
Meconium: INDUCE LABOUR ASAP
What are the complications of PROM?
Increased risk of ascending infection
What is the risk factors of pre-labour pre-term rupture of membranes?
- APH
- Previous PROM/PTL
- Smoking
- Trauma
- Uterine abnormalities
- Multiple pregnancy
- UTI
- Cervical incompetence
- Polyhydramnios
What is the management of PPROM?
ADMISSION + expectant management until 37 weeks (if no complications)
Medications:
- Do not offer tocolytics
- Erythromycin (= 37 weeks for 10 days until in established labour)
- Corticosteroids (= 34 weeks for 24 hours, can induce DKA in diabetics so co-administer with insulin)
- MgS04 (=30 weeks AND labour OR planned birth <24 hours)
Chorioamnionitis: (need to carefully monitor)
- Clinical assessment
- Bloods (CRP and WCC)
- CTG (monitor foetal HR)
What are the complications of PPROM?
Maternal - sepsis, cord abruption
Foetal - chorioamnionitis, cord prolapse, PTL, pulmonary hypoplasia, limb contractures, death
Increased perinatal mortality due to sepsis, permaturity and pulmonary hypoplasia
What is PPH?
Blood loss >500ml SVD or >1000ml at CS
- Primary PPH = within 24 hours
- Secondary PPH = 24 hours of 12 weeks
What causes PPH?
Tone (70%), Trauma (20%), Tissue (10%), Thrombin (1%)
Tone - Uterine atony
- Avoid by giving oxytocin with delivery of anterior shoulder or placenta
- Occurs within first 24 hours due to (overdistended uterus, uterine muscle exhaustion, uterine anatomy abnormal, intra-amniotic infection)
Tissue - retained placental products (membranes, cotyledon, succenturiate lobe):
- Retained blood clots in atonic uterus
- Gestational trophoblastic neoplasia
- Abnormal placentation - accreta/increta/percrea
Trauma - laceration - vagina, cervix, uterus:
- Episiotomy
- Haematoma
- Uterine rupture
- Uterine inversion
Thrombin - coagulopathy - existing or acquired:
- most commonly identified prior or delivery - low platelets increase risk
- includes haemophilia, DIC, aspirin use, ITP, TTP, VWD
- Therapeutic anti-coagulation
What are the causes of secondary PPH?
- Endometriosis
- Retained products
- Abnormal involution of placental site
- Trophoblastic disease
What are the signs and symptoms of primary PPH?
1) General - shock (tachycardia, hypotension), signs of anaemia
2) Abdomen - atonic uterus (above umbilicus)
3) Speculum - exclude trauma (perineal/vaginal/cervical)
4) Vaginal - evacuate clots from cervix (inhibits contraction)
What are the signs and symptoms of secondary PPH?
1) Abdomen - tender uterus
2) Speculum - assess bleeding, is the cervical os open
3) Vaginal - uterine tenderness
What is minor PPH?
- 500-1000mL blood loss and no signs of shock
What is major PPH?
> 1,000mgl blood loss or signs of shock
What is the management of major PPH?
Ring emergency buzzer
What is the stepwise management of PPH?
Bimanual compressuon (rub up a contraction, if in theatre)
Step 1: IM/IV syntocinon (oxytocin) 10U
- uterine hyperstimulation –> give tocolytics
Step 2: IM ergometrine/syntometrine (not in HTN, not in asthmatics)
Step 3: IM Carboprost (not in asthmatics)
Step 4: Balloon tamponade (ie. Bakri Balloon)
Step 5: B-lynch sutures –> ligate arteries –> interventioanl radiology
Step 6: Hysterectomy
What are the complications of PPH?
- Death
- Hysterectomy
- VTE
- renal failure
- DIC
- Sheehans syndrome
What is placenta accreta?
Strong attchment of placental, not into the muscle wall
What is placenta increta?
Placental into uterine muscle wall
What is placenta percreta?
Placenta thought the uterine wall
What are the risk factors of accreta/increta/percreta?
- History in previous pregnancy
- Previous CS/uterine surgery
- endometrial cutterage
What are the investigations for accreta/increta/percreta?
- TVUSS
- MRI (assess depth of invasion)
What is the management of accreta/increta/percreta?
- Managed delivery (35 - 36+6 w) +/- cesarean hysterectomy (ie. for precreta)
What is placental abruption?
Seperation of the placenta from the uterine wall before delivery (>24 weeks; if <24w then miscarriage)
Pathology: as placenta seperates, retroperitoneal bleeding results in further detachment
Haemorrhage may be concealed (20%) or revealed (80%)
Occurs in 1-2% of all pregnancies
What is the aetiology of Placental abruption (APH)?
Idiopathic of may occur secondary to raised pressure on maternal side or mechanical trauma
What are the risk factors of Placental abruption (APH)?
- HTN
- Abdo trauma
- Previous APH
- Smoking, cocaine
- PPROM
- Polyhydramnios
What are the signs and symptoms of placental abruption?
- Constant abdo pain +/- PV bleeding, sustained contractions
On exam:
- General: Shock
- Speculum: Assess bleeding
- Abdomen: Hypertonic “woody” tender uterus
- Vaginal exam (not in praevia): Cervical dilatation
What are the investigations for Placental abruption (APH)?
- Bloods: FBC, clotting, U&E, crossmatch
- USS: exclude praevia, abruption unlikely to be present unless large
What is the management of mild Placental abruption (APH)?
If preterm and stable: conservative management with close monitoring –> IOL at term
- admit for at least 48 hours of until bleeding stops
- Anti-D Ig followed by Kheihauer test
What is the management of severe Placental abruption (APH)?
ABC, emergency CS, 2x wide bore cannulae, fluids, blood transfusion, correct coagulopathies
- FBC, G&S, crossmatch, Kleihauer test (and anti-D if needed), steroids (between 24-34+6w)
- CTG (if >27 weeks), consider IOL if foetal compromise, TVUSS (query placental praevia)
What are the complications of Placental abruption (APH)?
Maternal - haemorrhage (APH,PPH), DIC, renal failure, “Couvelaire Uterus” (extravasation of blood into myometrium and beneath the peritoneum –> very hard uterus)
Foetal - birth asphyxia, death
What is the pathophysiology of Vasa Praevia?
- Foetal vessels course through membrane over the internal cervical os and below foetal presenting part, unprotected by placental tissue or umbilical cord –> when baby descends, they can rupture the vessels
What is type 1 Vasa Praevia?
Velamentous cord insertion in a single or bilobed placenta
What is type 2 Vasa Praevia?
Foetal vessels running between lobes of a placenta with 1 or more accessory lobes
What is Benckaiser’s haemorrhage?
The haemorrhage of blood when the vessels are ruptured
What are the risk factors of Vasa Praevia?
- Foetal anomaly (bilobed placental or succenturiate lobes) - foetal vessels run through the membranes joining seperate lobes together
- History of low-lying placenta in 2nd trimester
- Multiple pregnancies
- IVF
What are the signs and symptoms of Vasa Praevia?
- Typical picture = ROM –> fresh PV bleeding + foetal bradycardia (after membranes rupture, the veins alone can’t hold the weight of the baby –> bleeding)
- Foetal HR abnormalities - decelerations, bradycardia, sinosoidal trace, foetal demise
O/E: you can palpate the vessels in the membranes, amnioscopre can directly visualise this
What are the investigations of Vasa Praevia?
- Kleihauer test (measures amount of foetal Hb in a mother’s blood stream)
- Haemoglobin electrophoresis - identify if foetal or maternal blood (takes a long time)
- Doppler US
What is the management of Vasa Praevia?
CS
What are the complications of Vasa Praevia?
- No major maternal risk but dangeroud for the foetus
- Foetus –> the loss of relatively small amounts of blood can have major implications for the foetus = rapid delivery + aggressive resuscitation including use of blood transfusion if required are essnetial
What is the prognosis of Vasa Praevia?
Foetal mortality if presenting with haemorrhage is 60% but if identified antenatally its 3%
What is oligohydramnios?
Decreased volume of amniotic fluid, <5th centile, deepest pool <2cm
What are the risk factors for oligohydramnios?
- Reduce input fluid: placental insufficiency, pre-eclampsia
- Reduced output fluid: structural pathology (AR PKD), medications (ACEi, NSAIDS)
- Lost fluid: ROM, IUGR, port-term pregnancy carry, TTTS
- Chromosomal abnormalities
What are the signs and symptoms of oligohydramnios?
- History of fluid leak PV, rupture of membranes - commonly asymptomatic
- Abdo exam - decreased fundal height, foetal parts easily palpable
- Speculum - assess for membrane rupture if appropriate
What are the investigations for oligohydramnios?
- USS: liqour volume, foetal abnormalities
- CTG: foetal wellbeing
What is the management of oligohydramnios?
- Term: delivery if appropriate, IOL if no CI
- Pre-term: monitor serial USS for growth, liqour volume, dopplers, regular CTGs, delivery if further abnormalities arise (note: amniofusion has very a limited role of effect)
What are the complications of oligohydramnios?
- Labour: increased incidence of CTG abnormalities, meconium liqour, emergency CS
- Neonate: pulmonary hyperplasia, limb deformities
What is the prognosis of oligohydramnios?
Increase perinatal mortality rates with early onset oligohydramnios
What is polyhydramnios?
AFI >90th centile, 2-3 L fluid, deepst fool >8cm
What are the risk factors of polyhydramnios?
- Failure of foetal swallowing –> neurological –> neurology, chromosomal abnormalities
- Congenital infections –> GIT –> duodenal atresia, oesophagal atresia
- Foetal polyuria –> maternal diabetes, TTTS
What are the signs and symptoms of polyhydramnios?
- Symptoms of underlying cause
- Abdo: increased fundal height, impalpable foetal parts, tense abdo
What are the investigations of polyhydramnios?
- Liqour volume, foetal growth, umbilical artery dopplers, exclude foetal abnormalities
- Other: exclude maternal diabetes
What is the management of polyhydramnios?
- Antenatal monitoring of foetus, ensure diabetes control, paeds present at delivery
- Amnioreduction (if gross polyhydramnios –> discomfort)
- COX inhibitors to decreased foetal urine output
What are the complications of polyhydramnios?
- PTL, malpresentation, placental abruption, cord prolapse, PPH, increased risk of CS
What is the prognosis of polyhydramnios?
Increased perinatal morbidity and mortality, related to PTL/congenital
What happens during labour?
Painful uterine contractions leading to effacement and dilation of the cervix (normal length = 4cm)
- 2/5th palpable or below is defined as engagement
- if someone is just dilating due to cervical insufficiency, you can perform cervical cerciage
What are braxton-hicks contractions?
Painless and no cervical change
What is the 1st stage of labour?
Painful uterine contractions –> full (10cm) cervical dilatation
Latent phase = begins with painful, irregular contractions, dilation up to 4cm
Established / active = regular painful contractions, >/= 4cm
What is the 2nd stage of labour?
Starts with the urge to push and ends with delivery of foetus
- Passive stage: no pushing
- Active stage: pushing
Analgesia (1,2,3 and analgesia = +1 hour):
- In nulliparous women –> 3 hours (epidural) or 2 hours (no epidural)
- In multiparous women –> 2 hours (epidural) or 1 hour (no epidural)
What is the 3rd stage of labour?
Delivery of placenta and foetal membranes:
- can last as long as 30 mins
Where is the pelvic inlet the widest?
Transverse
Where is the pelvic outlet the widest?
Anterior-posterior
What is the progress of labour determined by?
Power - contractions
Passage - dimensions of pelvis
Passenger - diameter of foetal head
What does restitution mean?
Bringing head in line with shoulders
What are the risk factors of shoulder dystocia?
- Macrosonia
- High maternal BMI
- BM
- Prolonged labour
What are the signs and symptoms of shoulder dystocia?
- Difficult face/chin delivery
- Turtling head (retracing)
- failure of restitution
- failure of shoulder decent
What is the complications of shoulder dystocia?
Erb’s palsy
What is the management of shoulder dystocia?
Should all take less than 5 mins to perform:
1) Call for senior help + discourage pushing
2) McRoberts manoeuvre (legs up to abdomen) and suprapubic pressure
3) Evaluate for episiotomy
4) Either (depends on user experience / classical indication):
- Rubins manoeuvre (push anterior shoulder towards baby’s chest)
- Woods screw (Rubins + push posterior shoulder towards baby’s back –> rotation)
- Delivery posterior arm (then rotate 180 and deliver the other arm)
5) Change position to all fours and repeat the above manoeuvres
6) Symphysiotomy, cleidotomy (divide clavicles) or Zavanelli (reversal of normal delivery movement)
What is Bishops score?
A score used to see how likely one is to go into labour
What are the components of the Bishop score?
Effacement=(also called shortening or thinning) is reported as a percentation from 0% (normal length of cervix) to 100% or complete (paper thin cervix)
Position=the position of the foetal head relative to the maternal head and pelvis
Station=position of the baby’s head relative to the ischial spines of the maternal pelvis. If the head is level with the spines, the score is 0; however, above or below them can modify the score
Consistency=of the cervix
Dilatation=how dilated the cervix is
What does different bishop scores mean?
<3 = IOL unlikely to be successful
=5 = IOL with PV postaglandin gel (should start labour or ripen cervix)
6-8 = ARM (amniotomy +/- oxytocin infusion if labour does no begin)
> /=9 = labour likely to be spontaneous
What is the summary management of 1st stage of labour?
- One to one midwife
- VE performed 4-hourly or as clinically indicated
- Progress of labour in monitored using a partogram with timely intervention if abnormal
- Ensure adequate:
1) Analgesia +/- antacids
2) Hydration and light diet to prevent ketosis (which can impair uterine contractility)
What is the normal progress of labour?
0.5cm every 1 hour (a well flexed head will speed this up)
What is the delayed progress of labour?
<1cm every 2 hours (a well flexed head will speed this up)
What is the management of the latent 1st phase of labour?
Mobilise and managed away from labour suite:
- this stage is generally silent as the cervix gradually effaces over a period of days/weeks
- intervention should be avoided where possible
- Standing upright may encourage progress of labour (so mobility should be encouraged)
What is the management of delayed 1st stage of labour?
<1cm every 2 hours (intervention should not be started so soon)
1) 1st –> membranes intact –> ARM –> review in 2 hours
2) 2nd –> membranes ruptured –> oxytocin:
- increase every 15-30 mins until regular contractions
- once regular contractions review in 4 hours
What are the types of delayed labour?
- Primary dysfunctional labour = <2cm dilation in 2 hours, never progressed properly (most commonly due to ineffective uterine action)
- Secondary arrest of labour = progressed well and then stopped
- Prolonged latent phase = prolonged latent
- Cervical dystocia = rare; cervix doesn’t dilate properly
What is the management of 2nd stage of labour?
- First sign of the 2nd stage = urge to push (with 10cm dilation)
- full dilation of the cervix confirmed by VE (if head not visible)
- women should be discouraged from lying supine or semi-supine
- use of regional anaesthesia (epidural or spinal) may interfere with the normal urge to push - meaning that the 2nd stage is more often diagnosed on routine scheduled VE
What is the definition of prolonged/delayed second stage of labour?
From the start of active 2nd stage:
- in nulliparous women –> 3 hours (epidural) or 2 hours (non-epidural)
- In multiparous women –> 2 hours (epidural) and 1 hour (no epidural)
1) 1st –> membranes inatct –> ARM –> review in 2 hours
2) 2nd –> membranes ruptured –> oxytocin: - increase every 15-30 mins until regular contractions
- once regular contractions review in 4 hours
What is the delivery in 2nd stage of labour?
- Watch the perineum –> between contractions, elastic tone of the perineal muscles will push the head back into the pelvic cavity –> when head no longer recedes between contractions = crowning (delivery is imminent)
- As crowning occurs, the hands of the midwife are used to flex the foetal head and guard the perineum
- once the head has crowned, the woman should be discouraged from bearing down by telling her to take rapid, shallow breaths
What is the immediate care of the neonate after deliivery?
- baby will usually take first breath within seconds
- no need for immediate clamping
- after clamping and cutting cord, baby should have an APGAR score calculated at 1 min and at 5 mins
- head should be kept dependant to allow mucus in resp tract to drain
- immediate skin to skin contact between mother and baby will help bonding and promote release of oxytocin
What is the APGAR score?
1 min and at 5 mins of delivery (and every 5 mins if condition remains poor)
- >7 is normal
A = appearance P = pulse G = grimace A = activity R = resp
What should be done in the first hour of life?
- baby should be covered and dried with a warm blanket or towel
- initiation of breastfeeding should be encouraged within the first hour of life
- routine measurements of HC, birthweight and temp should be measured after this hour
- first dose of baby’s vit K should be given in delivery room (in 24 hours)
What are the 4 causes of PPH?
Tone (uterine atony, 70%)
Trauma (laceration, 20%)
Tissue (retained products, 10%)
Thrombin (coagulopathy, 1%)
What is the management of 3rd stage of labour?
- Normally takes 5-10 mins (expulsion of placenta and foetal membranes)
- Active or physiological
What is the active management of the 3rd stage of labour?
1) 10 IU oxytocin (IM) / ergometrine (only oxytocin if hypertensive)
- after birth of the anterior shoulder
- immediately after delivery (and before the cord is clamped and cut)
2) clamp the cord between 1-5 mins
3) use controlled cord traction to remove the placenta –> signs of placental separation:
- gush of blood
- cord lengthening
- uterus rises
- uterus becomes round
- uterine inversion is a rare complication
- in 2% of cases, placenta will not be expelled by this method
- if no bleeding occurs, another attempt should be made after 10 mins
What is the post-delivery management of the 3rd stage?
1) Inspect placenta for:
- missing cotyledons
- succenturiate lobe
2) vulva inspected for tears
If retained –> EUA + MORP (manual removal of placental tissue)
What is prolonged 3rd stage of labour?
Active management: >30 mins
Physiological management: >60 mins –> move to active management
What is prolonged 3rd stage of labour?
Active management: >30 mins
Physiological management: >60 mins –> move to active management
What is the 1st step in the induction of labour?
Membrane sweeping:
- offered prior to formal induction (not part of induction of labour) –> repeat if labour not starting
- nulliparous (offer at 40-41 weeks)
- multiparous (offer at 41 weeks)
What is the 2nd step in the induction of labour?
Prepare the cervix –> prostaglandics (Prostin or Propress; Vaginal protaglandin E2)
- preferred formal method of induction
- can be administered as a tablet, gel or pessary
Tablet/gel: 1 dose followed by a second dose after 6 hours (ONLY MAX 2 DOSES)
Pessary: 1 dose over 24 hours
RISK: uterine hyperstimulation
In case of IUD: misoprotol and mefipristone may be used
What is the 3rd step in the induction of labour?
ARM
- amniohook
- should not be used first line
What is the 4th step in the induction of labour?
syntocinon
What is the 5th step in the induction of labour?
C-section
What are the indications of inducing labour?
1) Prevention of prolonged pregnancy
- offer from 41 weeks
- if declines –> twice weekly USS and CTG
2) Maternal request
- in exceptional circumstances (ie. partner has to go away for armed service)
- Considered at or after 40 weeks
3) IUD
- if membranes intact –> offer induction
- if ruptures of membranes, infection or bleeding –> immediate induction
- induction regimen: oral mifepristone, followed by prostin or misopristol
4) previous C-section
- use prostin/propress
- increases risk of uterine rupture and need for a 2nd C section
5) PPROM
- avoid induction before 34 weeks unless other indications
- if inducting after 34 weeks, use prostin/propess but beware infection risk
6) Breech/transverse lie
- Induction NOT recommended
- Consider if C-section and ECV declined/unsuccessfu
7) IUGR
- Induction NOT recommended
- If severe foetal growth restriction –> C-section
8) Suspected foetal macrosomia
- Induction not recommended
What Non-pharmacological analgesia can be used in labour?
- TENS
- Breathing techniques
- Massage
What pharmacological analgesia can be used in labour?
- Entonox (50% NO in O2) –> nausea, light headed, dry mouth
- meperidine (pethidine, IM, 1mg/kg) –> sleepy baby, low baby, RR, constipation
- Morphine (0.1-0.15mg/kg) or diamorphine (IM 5-7.5mg) –> sleepy baby, low baby, RR, constipation
- Fentanyl PCA (20ug bolun with 5 mins lockout –>sleepy baby, low baby, RR, constipation
What surgical analgesia can be used in labour?
Slow labour, increased instrumental risl:
- Lumbar epidural - bupivacine, ropivacine, levobupivacine, chloroprocaine
- Combine lumbar spinal-epidural - fentanyl 10-25 mcg +/- bupivacaine 2.5mg
What does a partogram do in labour?
- Record condition of mother, condition of foetus and progress of labour
- Can be used to calculate a Bishop’s score (collects all necessary pieces of data)
What are obs emergencies?
- Sepsis
- Placenta accreta
- Eclampsia
- Shoulder dystocia
- Uterine rupture
- APH or PPH
- Vasa praevia
- Amniotic fluid embolism
- DVT/PE
- Puerperal pyrexia
- Placental praevia
- Prolonged 3rd stage
- Collapse cord
- Uterine inversion
What is Puerperal pyrexia?
> 38 degress in the first 14 days following delivery
What are the causes of Puerperal pyrexia?
- Endometriosis (a big one)
- UTI
- VTE
- Wound infection (tear, CA)
- Mastitis
What is the management of Puerperal pyrexia?
Until fever has abated for >/= 24 hours
- IV Clindamycin AND
- IV gentamicin
What is the aetiology of syphilis?
A systemic infection caused by gram-ve spirochete (Treponema Pallidum)
- sexual contact
- blood-bourne
- vertical
What is the risk factors for syphilis?
- Young (< 29 years)
- African American
- Use of illicit drugs
- infection with other STIs
- sex worker
What are the signs and symptoms of primary syphilis?
- 3-4 weeks - painless chancres +/- local lymphadenopathy
- resolves in 3-8 weeks
What are the signs and symptoms of secondary syphilis?
- 4-10 weeks after chancre - only 25% get symptoms
- rough papulonodular rash (hands, feet, trunk)
- Uveitis
- Condylomata Lata
- Lymphadenopathy + systemic symptoms
- Resolves in 2-12 weeks
What are the signs and symptoms of latent syphilis?
- No symptoms, detected on routine tests
- Early latent (< 2 years after infection - exposure to OR symptoms of the 1st/2nd S/S in <2 years)
- Late latent (> 2 years after infection - exposure to OR symptoms of the 1st/2nd S/S in >2 years)
What are the signs and symptoms of tertiary syphilis?
- 1 to 20 years - affects 1/3rd of untreated illness
- Gummatous syphilis/15% (erosive skin and bone lesions)
- Cardio syphilis/10% (aortitis, aortic regurge (early diastolic crescendo), heart failure)
- Neurosyphilis - types (n.b tabes dorsalis affects the dorsal columns):
1) Meningovascular (5-10 years) –> ischaemia, insomnia, emotionally labile
2) General paresis (10-25 years) –> dementia
3) Tabes dorsalis (15-20 years) –> sensory problems, lighting pains, absent reflexes
What are the investigations for syphilis?
- Microbiology - dark ground (from chancre with dark-field illuminations), PCR
- Serology - routine antenatal screening offered to all pregnant women –> detects treponemal antibodies (Takes 3 months for syphilis to become positive in serology)
- Neurosyphilis –> CT/MRI head, LP (raised WCC, raised protein), TPPA >1:320
What are the non-treponemal test for syphilis?
Non-treponemal tests - high false-positive rate due to cross-reactivity (ie. with EBV)
- PRP (rapid plasmin reagin), dilutional ratios –> how many dilutions to lose the reagins
- VDRL (venereal disease research lab) test
What are the treponemal test for syphilis?
1) EIA - very sensitive and specific (if positive, likely to have syphilis)
2) TPHA/TPPA (treponema palladium hemagglutinin assay)
3) FTA-ABS (fluorescent treponemal antibody absorption)
What is the management of early syphilis?
1st, 2nd and early latent
- Benzathine-Pen (IM, STAT) OR
- Doxycycline (BD, 14/7)
What is the management of latent syphilis?
Late latent and 3rd
- Benzathine-Pen (IM, OW, 3/52) OR
- Doxycycline (BD, 28/7)
What is the management of neurosyphilis?
- Benzathine-Pen (IV, 4-hourly, 14/7) OR
- Doxycycline (BD, 28/7)
- Prednisolone (OD, 3/7) started 24 hours before treatment to avoid Jarish-Herxheimer reaction
- Jarish-Herxheimer reaction = release of proinflammatory cytokines in response to dying organism
- S/S: 24 hours of febrile myalgia - rare/serious consequences - admit mother >22 weeks when treating
What is the follow up for syphilis?
- Partner notification
- repeat bloods at 3/12 (4-fold drop in RPR)
What are the complications of syphilis in pregnancy?
Congenital syphilis (PTL, still birth, miscarriage):
- Rash on soles of feet and hands
- Blood rhinitis
- Hepatosplenomegaly
- Glomerulonephritis
- “Hutchinson’s teeth” (small, widely spaces, notches)
- Frontal bossing of skull, saddle-nose deformity
- “Saber’s shins” (anterior bowling of shins)
- “Clutton’s joints” (symmetrical knee swelling)
What is HSV?
- DNA virus
- Two types 1 (oral>genital) and 2 (genital>oral)
- Spread to neonate - through direct contact with infected maternal secretions (transplacental possible), risk of neonatal transmission at vaginal delivery is 41% with primary lesions or 2% with recurrent lesions
What is the aetiology of HSV?
- Physical/sexual contact
- vertical
What are the risk factors of HSV?
- Unprotected sex
- immunosuppression
- Other STI
What is the epidemiology of HSV?
- 2% of pregnant women
What are the maternal signs and symptoms of HSV?
- Asymptomatic
- Oral herpes
- Genital herpes (dysuria, frequency)
- Disseminated herpes (encephalitis, hepatitis, disseminated skin lesions)
What are the neonatal signs and symptoms of HSV?
1 per 60,000 live births –> SEM, CNS +/- SEM or disseminated infection
1) Skin, eye and mouth (SEM) disease (45%)
- blistering vesicular rash
- chorioretinitis
2) CNS disease +/- SEM (30%)
- seizures
- lethargy
- irritability
- poor feeding
- temperature instability
- bulging fontanella
3) Disseminated infection involving multiple organs (25%)
- encephalitis (60-70%)
- CNS (60-70%)
- hepatitis
- penumonitis
- No skin lesions (>20%)
- DOC
What are the investigations of HSV?
- Clinical diagnosis +/- STI screen
- PCR virus
What is the management of HSV?
Acute infection –> aciclovir (400mg, TDS)
Maternal:
- <26 weeks primary infection –> oral aciclovir, 36 weeks until delivery
- > 26 weeks primary infection –> oral aciclovir until delivery
Neonate:
- IV aciclovir to child (14d if SEM disease –> 21d if CNS or disseminated)
What is the delivery management of primary HSV infection?
- 1st episode >/= 6 weeks prior to EDD –> SVD
- 1st episode = 6 weeks prior to EDD –> CS (perform HSV (type-specific) antibody testing
What is the management of HSV if the woman chooses vaginal delivery?
- Rupture of membranes and invasive procedures should be avoided
- IV aciclovir given intrapartum to the mother and the neonate
- Avoid invasive procedures in labour (ie. forceps) –> increase risk of neonatal HSV
What is the management of delivery in recurrent episodes of HSV?
SVD only (only 2% risk of transmission if recurrent, due to maternal IgG)
- daily supressive aciclovir 400mg TDS from 36 weeks gestation
- avoid invasive procedures during labour if genital lesions (ie. foetal scalp electrodes)
What are the complications of HSV in pregnancy?
Prognosis –> neonatal mortality from 2% (local disease) to 50% (disseminated disease)
What are the types of HHV and the site for infection?
- HHV1, HHV2, (HSV1 and 2)
- HHV 3 (VZV) - dorsal root ganglion
- HHV 4 (EBV) - B cells
- HHV 5 (CMV) - monocytes
- HHV 6 (roseolovirus)
- HHV 7 (roseolovirus)
- HHV 8 (Kaposi sarcoma-associated HV)
What is the aetiology of CMV?
Most common congenital infection
- sexual contact, blood-bourne, bodily fluid (saliva, urine), vertical
What are the risk factors of CMV?
- higher socioeconomic class (no childhood immunity), immunosupression
What is the epidemiology of CMV?
- 50% immunity in pregnant women
- 1% seronegative will contract CMV anetenatally
What are the signs and symptoms of CMV in the mother?
Chorioretinitis is more common in congenital toxoplasmosis
- Often asymptomatic (or non-specific: fever, malaise, fatigue)
- May have lymphadenopathy
- 3-40% vertical transmission (any stage of pregnancy)
What are the signs and symptoms of CMV in the child?
Throughout life;
90% (birth) –> asymptomatic
- 10% develop sensorineural hearing loss
10% (birth) –> congenital CMV
- 65% have sensorineural hearing loss
- peri-ventricular calcification
- Chrorioretinitis –> cataracts
- Jaundice +/- blueberry muffin rash
- IUGR
- Microcephaly
- Hepatosplenomegaly
What are the investigations of CMV?
Prenatal diagnosis –> PCR of virus (>21w GA)
Postnatal diagnosis –> PCR of virus (<21 day neonatare, +ve result beyond this will not confirm congenital CMV)
Maternal serology - seroconversion (2 samples: IgM -ve to IgM +ve) or low-avidity IgG
- IgM can presist for months, so a single IgM value alone is insufficient to diagnose CMV primary infection and the raised IgM has to be new finding in previous IgM -ve at booking
USS of foetus
Amniocentesis PCR - 6-9 weeks after primary infection
What is the maternal management of CMV?
- No treatment
- TOP if evidence of CNS damage
What is the child management of CMV?
- Ganciclovir (IV)/ Valganciclovir (oral) for 6m + audiology follow-up + opthalmology follow-up
What are the complications of CMV?
- Increased risk of miscarriage and still birth
- Congenital CMV (IUGR, microcephaly, periventricular calcifications, blindness, sensorineural deafness, hepatosplenomegaly, skin rash, pneumonitis, mental retardation)
What is the prognosis of CMV in pregnancy?
Rare of transmission to foetus is 40%, 10% of these develop congenital syndrome
- 90% babies symptomatic at birth will later have neurodevelopmental problems
