Obs notes Flashcards
What do primordial follicles contain?
The primary oocyte
What are oocytes?
Germ cells that undergo meiosis to become the mature ovuum ready for fertilisation
What produces b-hCG?
synciotrophoblast
Around what day does implantation occur?
8-10
What week does the fetal heart form and begin to beat?
Around 6 weeks
What week have all major organs began to develop?
8 weeks
What later of the fertilised egg implants into the uterus (and which part?)
The synciotrophoblast implants into the endometrium via finger like projections (chorionic villi)
What are the 5 functions of the placenta?
Respiration, nutrition, excretion, endocrine, immunity
What is the placenta’s role in respiration?
Source of oxygen for the fetus. Fetal haemoglobin has a high affinity for O2, so draws O2 away from the mother across the placental membrane
When do hCG levels plateau?
Around 10 weeks gestation
What is the job of hCG?
Maintains the corpus luteum until the placenta can take over the production of oestrogen and progesterone
What hormones does the placenta produce?
Oestrogen and progesterone
What is the function of the oestrogen being produced by the placenta?
- softens tissues and makes them more flexible
- allows the muscles and ligaments of the uterus and pelvis to expand
- helps cervix become soft and ready for birth
- enlarges and prepares breasts
What is the primary role of progesterone in pregnancy?
To maintain the pregnancy
By what week does the placenta take over progesterone production
Around 5 weeks
How does progesterone maintain the pregnancy?
- relaxation of the uterine muscles (prevents contractions and labour)
- maintains endometrium
What effects does the rise in progesterone have on other parts of the body than the uterus?
- relaxes the lower oesophageal sphincter and causes heartburn
- relaxes the bowel (constipation)
- blood vessels (hypotension, headaches, skin flushing)
- raises body temp by ~1 degree celsius
How does gas exchange occur in terms of the umbilical vessels?
x2 umbilical arteries leave the fetus (deoxygenated), and x1 umbilical vein comes back in (oxygenated). Exchange occurs across the placenta, specifically lacunae
What cardiovascular changes occur in pregnancy?
- increased blood volume
- increased plasma volume
- increased cardiac output (increased stroke volume + heart rate)
- decreased peripheral vascular resistance
- decreased blood pressure in early/middle pregnancy
- varicose veins
- peripheral vasodilation
How does cardiac output, HR and stroke volume change in pregnancy?
Increases
Why might there be ankle oedema and varicose veins in pregnancy?
Enlarged uterus may interfere with venous return
How do tidal volume and respiratory rate change in pregnancy?
Increase
What hormone causes increased tidal volume?
Progesterone
Why might their be some dyspnoea in pregnancy?
Pulmonary ventilation increased by 40%, but oxygen requirements only rise by 20%. Therefore, over breathing can lead to a fall in pCO2 and give a sense of dyspnoea. Can be worsened by elevated diaphragm
What changes occur to the blood in pregnancy?
Increase in coagulant activity, RBC volume increases (plasma more than RBC, so Hb falls), WCC and ESR rise, platelets fall
What occurs to Hb in pregnancy?
Falls, due to plasma increasing more than RBC. Leads to anaemia
Why are pregnant women more at risk of DVT + PE?
Clotting factors such as fibrinogen and factor VII, VIII and X increase in pregnancy, making women hyper-coagulable.
How does ALP change in pregnant women?
Increase a lot due to secretion by the placenta
How does GFR change in pregnancy?
Increases 30-60%
Why is there sometimes trace glycosuria in pregnancy?
Due to increased GFR and reduction in tubular reabsorption of filtered glucose
Is there proteinuria in pregnancy?
Yes
How does changes in hormones affect salt and water retention in pregnancy?
More steroid hormones such as aldosterone, leads to more salt and water retention
How does calcium levels change in pregnancy?
Requirements increase, but so does gut absorption, so levels remain stable
Does hepatic blood flow change?
No
What happens to albumin levels in pregnancy?
Fall
How does the uterus change in size in pregnancy?
Gains a 1kg. Hyperplasia occurs
What are Braxton Hicks? When do they occur?
Non painful ‘practice contractions’, from around 30 weeks
Why might linear nigra occur in pregnancy?
There may be increased skin pigmentation due to increased melanocyte stimulating hormone (alongside ACTH)
What skin changes might be seen in pregnancy?
- striae gravidarum (stretch marks of abdomen)
- general itchiness
- spider naevi
- palmar erythema
What hormones change in pregnancy?
More ACTH, more prolactin, more melanocyte stimulate hormone
What does ACTH rise in pregnancy cause?
Increased cortisol and aldosterone
Why does prolactin rise in pregnancy?
To suppress FSH and LH
What occurs to TSH, T3 and T4 levels in pregnancy?
TSH remains normal, T3 and T4 rise
How might vaginal discharge change in pregnancy?
Increased oestrogen may cause cervical ectropion and increased cervical discharge. Oestrogen also causes hypertrophy of the vaginal muscles and increased vaginal discharge. The changes in the vagina prepare it for delivery, however they make bacterial and candidal infection (thrush) more common.
What do prostaglandins do to the cervix?
Cause breakdown of collagen, allowing dilating and effacing
How many stages of labour are there?
3
What is the first stage of labour?
True contractions until 10cm cervical dilatation
What is the 2nd stage of labour?
10cm cervical dilatation to delivery of the baby
What is the 3rd stage of labour?
Delivery of the baby to delivery of the placenta
What are signs of labour?
Regular and painful uterine contractions, a show (shedding of mucous plug), rupture of membranes, shortening and dilation of the cervix
How often is FHR monitored?
Every 15 mins, or constantly via CTG
How often are contractions assessed in labour?
Every 30 mins
How often is maternal BP and temp checked in labour?
Every 4 hours
How often should a vaginal examination be done in labour?
4 hours
How often should maternal urine be checked for ketones and proteins in labour?
Every 4 hours
How often should maternal pulse rate be assessed in labour?
Every 60 mins
What can be used to induce labour?
Prostaglandin E2 (pessaries can be used)
When does cervical dilation and effacement occur?
In the first stage of labour
What is ‘the show’ and what is its funciton?
Mucus plug in the cervix, prevents bacteria from entering the uterus in pregnancy
How long does stage 1 labour last typically in a primigravida?
10-16 hours
What are the two stages of the first stage of labour?
Latent and active phase
What is the latent phase of labour, and how long should it last?
0-3cm dilation, around 6 hours
What is the active phase of labour, and how long should it last?
3-10cm, normally 1cm/hour
What position should the head enter the pelvis?
Occipito-lateral position
What is the 3 P’s of the second stage of labour?
Power, passenger and passage
How long should the 2nd stage of labour last?
around an hour: if longer consider ventouse/forceps/c-section
What can happen to the baby’s heartrate in the second stage of labour?
Can have transient fetal bradycardia
What does power refer to in the second stage of labour?
Strength of uterine contractions
What does passage refer to in the second stage of labour?
Size and shape of the passageway, mainly the pelvis
What are the 4 qualities of the fetus that can affect the second stage of labour?
Size (particularly head!), attitude, lie, presentation
What are the possible presentations of the fetus?
Cephalic, shoulder, breech
What are the 7 cardinal movements of labour?
Engagement, descent, flexion, internal rotation, extension, restitution and external rotation, expulsion
How is descent measured in labour?
Obstetricians describe the position of the baby’s head in relation to the mother’s ischial spines during the descent phase. Descent is measured in centimetres, from -5 to +5. 0= at level of ischial spines (‘engaged’)
What is physiological management of the third stage of labour?
When the placenta is delivered by maternal effort without medications or cord traction
What requires active management of the third stage of labour?
Haemorrhage, or more than 60 minute delay
What is active management of the third stage of labour?
IM oxytocin to help uterus contract and expel the placenta. Careful traction is applied to the umbilical cord.
What is the definition of gravida vs para?
- gravida: total number of pregnancies
- para: number of times the woman has given birth after 24 weeks (alive or dead)
When does pregnancy technically begin?
From the day of the last menstrual period
When is first trimester?
start of pregnancy to 12 weeks
When is second trimester?
From 13 weeks to 26 weeks
When is second trimester?
27 weeks until birth
When do fetal movements start?
Around 20 weeks
When should a booking clinic happen in pregnancy?
Before 10 weeks
When does the dating scan happen?
Between 10 and 13+6 weeks
What happens at the dating scan?
Accurate gestational age calculated (crown rump length), and multiple pregnancies identified
When should their be antenatal appointments?
16, 25, 28, 31, 36, 38, 40, 41, 42
When does the anomaly scan occur?
Between 18 and 20 + 6 weeks
When is the oral glucose tolerance test for women at risk of gestational diabetes done?
Between 24 and 28 weeks
When are anti-D injections given to rhesus negative women?
Between 28 and 34 wrrks
Who is offered serial growth scans?
Women at risk of fetal growth restriction
When is fetal presentation assessment done?
From 36 weeks onwards
What vaccines are offered to all pregnant women?
Whooping cough and influenza
What vitamins/supplements are recommended and what vitamin should be avoided?
Take folic acid (400mcg) up to 12 weeks, take vitamin D supplements. Avoid vitamin A supplements
Why should vitamin A be avoided in pregnancy?
Teratogenic at high doses
What amounts of alcohol are safe in pregnancy?
No amount is safe
What are the risks of alcohol in early pregnancy?
Miscarriage, small for dates, preterm delivery, fetal alcohol syndrome
What are the features of fetal alcohol syndrome?
Microcephaly, smooth flat philtrum, short palpebral fissure (short distance from one eye to the other), learning disability, behavioural issues, hearing and vision problems, cerebral palsy, thin upper lip
What is the risk of smoking in pregnancy?
Miscarriage, increased risk of preterm labour, increased risk of stillbirth, IUGR, increased risk of sudden unexpected death in infancy
What bloods are booked at the booking clinic (the first midwife appointment)?
Blood group, antibodies, Rhesus D status, FBC for anaemia, screening for thalassaemia + SCD (women at risk)
How many antenatal visits are recommended in the first pregnancy vs subsequent if uncomplicated?
10 and 7
When should iron be started in pregnancy?
Hb <11g/dl
What natural remedies are offered for nausea and vomiting in pregnancy?
Ginger and acupuncture on the p6 point (by the wrist)
What does the combined test for Down’s syndrome test?
Ultrasound and maternal blood tests. Looks at nuchal translucency, and in bloods b-HCG and PAPPA
What levels of b-HCG can indicate downs syndrome?
High result = greater risk
How do levels of PAPPA indicate downs syndrome?
Low result= greater risk
When is the combined test offered?
between 11 and 14 weeks
What is involved in the triple test?
bHCG, AFP, serum oestriol
What levels of AFP and serum oestriol indicate a higher risk of downs?
Lower levels
When is the triple test done?
between 14 and 20 weeks
What is assessed in the quadruple test?
bHCG, AFP, serum oestriol, inhibin A
What levels of inhibin A can indicate risk of downs?
Increased
When is antenatal testing for Down’s offered?
If risk greater than 1 in 150
What antentatal testing for Down’s is done earlier in pregnancy?
CVS (up to 15 weeks)
What is CVS?
Ultrasound guided biopsy of the placenta
What is amniocentesis?
Ultrasound guided aspiration of amniotic fluid
What other disorders are checked for alongside downs?
Edwards (18) and Pataus (13)
What is NIPT?
Non invasive prenatal screening test, which is a blood test from the mother which checks fetal DNA. High sensitivity and specificity
What should be done to dose of levothyroxine in pregnancy?
Increase the dose, as it can cross the placenta and provide thyroid hormone to the developing fetus
How can hypothyroidism affect the fetus?
Miscarriage, anaemia, SGA, pre-eclampsia
What HTN medications should be stopped in pregnancy?
ACE-I, ARBs, thiazide
How much folic acid should women with epilepsy take?
5mg (compared to 400mcg in everyone else)
What can sodium valproate cause in pregnancy?
Neural tube defects, developmental delay
What can phenytoin cause in pregancy?
Cleft lip and palate
Are NSAIDs allowed in pregnancy?
Generally avoided, especially in 3rd trimester, as they can cause premature closure of ductus ateriosus
Why are NSAIDs avoided in pregnancy?
Work by blocking prostaglandins, which maintain the ductus arteriosus, soften the cervix and stimulate uterine contractions at the time of delivery
Even though beta blockers are used in pregnancy, what can they cause?
Fetal growth restriction, hypoglycaemia, bradycardia
Why should ACE-I and ARBs be avoided in pregnancy?
They cross the placenta, and can affect the fetus’ kidneys, and reduce production of urine (oligohydramnios). Can also cause incomplete formation of skull bones
What is neonatal abstinence syndrome?
When babys are going through drug withdrawal after birth
When does neonatal abstinence syndrome occur?
3-72 hours after birth
What are the symptoms of neonatal abstinence syndrome?
Irritability, tachypnoea, high temperature and poor feeding
Can warfarin be used in pregnancy?
No: can cause fetal loss, congenital malformation
What abnormality is Lithium associated with in pregnancy?
Ebstein’s anomaly: the tricuspid valve is set lower on the right side of the heart, causing a bigger right atrium
What acne medication is highly teratogenic?
Isotretinoin
What are the first trimester risks of SSRIs?
Congenital heart defects
What SSRI particularly has risks in the first trimester?
Paroxetine
What can SSRIs in the third trimester be associated with?
Persistent pulmonary hypertension
What are features of congenital rubella syndrome?
Deafness, bilateral cataracts, congenital heart disease, growth issues, purpuric skin lesions, small head, cerebral palsy
If someone is diagnosed with rubella in pregnancy, what (holistic/legal) management is required?
Discuss with local health protection unit
Can MMR vaccines be administered to women known to be pregnant?
No
What increased risks are there to the mother if she encounters chicken pox in pregnancy?
Higher risk of pneumonitis
What is congenital varicella syndrome?
Features: FGR, microcephaly, hydrocephalus, scars and skin changes in specific dermatomes, underdeveloped limbs, cataracts and inflammation in the eye
Can the varicella vaccine be given in pregnancy?
Yes: can check IgG levels to confirm if this is needed (or if planning to go to Tokyo…)
What is the treatment for women who are not immune against chickenpox and exposure?
Give IV varicella immunoglobulins, and if the rash starts give oral aciclovir (if >20 weeks)
When can oral aciclovir be given to women who have chickenpox in pregnancy?
> 20 weeks, and if she presents within 24 hours of rash onset
What causes Listeria, and thus what should be avoided in pregnancy?
Listeria is typically transmitted by unpasteurised dairy products, processed meats and contaminated foods. Pregnant women are advised to avoid high-risk foods (e.g. blue cheese) and practice good food hygiene.
Why is listeria dangerous in pregnancy?
Listeriosis in pregnant women has a high rate of miscarriage or fetal death. It can also cause severe neonatal infection.
What are the features of congenital CMV?
Growth retardation, pinpoint petechial blueberry muffin skin lesions, microcephaly, deafness, seizures
What is the triad of congenital toxoplasmosis?
Intracranial calcification, hydrocephalus, chorioretinitis
What are complications of parvob19 in pregnancy?
Miscarriage, fetal death, severe anaemia, hydrops fetalis, maternal pre-eclampsia
Why does parvovirus B19 infection cause fetal anaemia?
Infection of the erythroid progenitor cells occurs in the fetal bone marrow and liver. This causes less erythropoiesis. This can lead to hydrops fetalis
What is maternal pre-eclampsia like syndrome?
Rare complication of severe fetal heart failure (hydrops fetalis). Triad of hydrops fetalis, placental oedema, and oedema in the mother
What causes rhesus disease?
When a woman is rhesus D negative, there is a chance her baby is Rhesus D positive. The babys blood will enter the mothers bloodstream at some point, and be recognised as foreign. Antibodies will be produced. This is sensitisaton. When the next exposure occurs (eg, next pregnancy), the antibodies can cross the placenta into the fetus, and attack the fetus’ RBCs (causing haemolysis)
When should anti D immunoglobulin be given?
- delivery of Rh+ve infant
- any termination of pregnancy
- miscarriage if gestation >12 weeks
- ectopic pregnancy that is managed surgically
- antepartum haemorrhage
- amniocentesis, CVS, fetal blood sampling
- abdominal trauma
How does anti-D medication work?
The anti-D medication works by attaching itself to the rhesus-D antigens on the fetal red blood cells in the mothers circulation, causing them to be destroyed. This prevents the mother’s immune system recognising the antigen and creating it’s own antibodies to the antigen.
If a rhesus D sensitisation event occurs in 2nd/3rd trimester, what must be done?
Dose of anti-D and perform Kleihauer test (determines proportion of fetal RBC present in mother’s blood)
What are the symptoms of rhesus disease if it affects the baby?
- oedematous (hydrops fetalis, as liver devoted to RBC production so albumin production falls)
- jaundice
- anaemia
- hepatosplenomegaly
- heart failure
- kernicterus
How is fetal size assessed on ultrasound?
Estimated fetal weight and fetal abdominal circumference
What is the definition of severe small for gestation age?
<3rd centile
What is low birth weight definition?
<2500g
What are the two categories of SGA?
Constitutionally small (matches mother + family, growing appropriately on growth chart) and fetal growth restriction
What is fetal growth restriction?
When there is a small fetus due to a pathology reducing the amount of nutrients and oxygen being delivered to the fetus through the placenta
What are the two categories of fetal growth restriction?
Placental mediated growth restriction and non-placenta mediated growth resitrction
What are causes of placenta mediated growth resitrction?
Idiopathic, pre-eclampsia, maternal smoking, maternal alcohol, anaemia, malnutrition, infection, malnutrition, infection, maternal health conditions
What are non placenta mediated growth restriction?
Genetic abnormalities, structural abnormalities, fetal infection, errors of metabolism
What are signs other than SGA that there is fetal growth restriction?
Abnormal doppler studies, reduced fetal movements, abnormal CTGs, reduced amniotic fluid volume
What are short term complications of fetal growth restriction?
Fetal death or stillbirth, birth asphyxia, neonatal hypothermia, neonatal hypoglycaemia
What are the long term complications of fetal growth restriction?
Cardiovascular disease (particularly HTN), T2DM, obesity, mood and behavioural problems
What are risk factors for SGA?
Previous SGA baby, obesity, smoking, diabetes, existing HTN, pre-eclampsia, older mother (other 35), multiple pregnancy, antepartum haemorrhage, antiphospholipid syndrome
When are women assessed for risk factors for SGA?
Booking clinic
What growth monitoring is done for women at low risk of SGA/IUGR?
Symphisis fundal height at every antenatal appointment from 24 weeks. If this <10th centile, they are booked for serial growth scans with umbilical artery doppler
When are women booked for serial growth scans with umbilical artery doppler?
3 or more minor risk factors (RCOG green-top guidelines), 1 or more major risk factor, issue with measuring the symphysis fundal height
When might there be issues with measuring the symphisis fundal height?
Large fibroids or BMI >35
What is measured for women at risk of SGA via serial US/doppler?
- estimated fetal weight and abdominal circumference to determine growth velocity
- umbilical artery pulsality index
- amniotic fluid volume
What investigations are done if a fetus is identified as SGA?
- blood pressure and urine dipstick for pre-eclampsia
- uterine artery doppler scanning
- detailed fetal anomaly scan by fetal medicine
- karyotyping
- test for infection
What definitive management may be done if growth is static on birth charts?
Early delivery to reduce risk of stillbirth
What is the definition of macrosomia?
> 4.5kg at birth
What centile is defined as large for gestational age?
> 90th centile
What are causes of macrosomia?
Constitutional, maternal diabetes, previous macrosomia, maternal obesity or rapid weight gain, overdue, male baby
What are risks to the mother of a macrosomic baby?
Shoulder dystocia, failure to progress, perineal tears, instrumental delivery or caesarean, post partum haemorrhage, uterine rupture
What are risks to the baby of being macrosomic?
Birth injury (Erbs palsy, clavicular fracture, fetal distress, hypoxia), neonatal hypoglycaemia, obesity in childhood and later life, T2DM in adulthood
What are investigations for a large for gestational age baby?
Ultrasound to exclude polyhydramnios and estimate fetal weight, and oral glucose tolerance test for gestational diabetes
What is monochorionic vs dichorionic twins?
One placenta vs two placentas
What sort of multiple pregnancies have the best outcomes?
Diamniotic, dichorionic twin pregnancies (each fetus has their own nutrient supply)
When is multiple pregnancy identified?
Booking ultrasound scan. Can also determine the number of placentas and amniotic sacs at this stage
How are dichorionic diamniotic twins identified on ultrasound scan?
Membrane between the twins with a lambda sign (or twin peak sign)
How are monochorionic diamniotic twins identified on ultrasound?
Have a membrane between the twins with a T sign
What are the risks to the mother in a multiple pregnancy?
Anaemia, polyhydramnios, HTN, malpresentation, spontaenous preterm birth, instrumental delivery/c-section, PPH
What are the risks to the fetuses and neonates in multiple pregnancies?
Miscarriage, stillbirth, fetal growth restriction, prematurity, twin-twin transfusion syndrome, congenital abnormalities
What is twin-twin transfusion syndrome?
When fetuses share a placenta, so there is a connection between the blood supplies of the two fetuses. One fetus recieves more blood, and can become overloaded with heart failure and polyhydramnios. The other has growth restriction, anaemia and oligohydramnios
What is the management of twin-twin transfusion syndrome?
Referral to tertiary specialist fetal medicine centre
What additional blood test is required in twin pregnancy, and why/when?
FBC for anaemia. At booking clinic, 20 weeks, 28 weeks
What additional scans are done in twin pregnancies?
- 2 weekly scans from 16 weeks for monochorionic twins
- 4 weekly scans from 20 weeks for dichorionic twins
When is term for triplets?
Before 35+6
When is term for uncomplicated di di twins?
Between 37 and 37+6
When is term for uncomplicated monochorionic diamniotic twins?
Between 36 and 36+6
When is term for mono mono twins?
Between 32 and 33+6 weeks, c-section
When can there be vaginal delivery in twins?
If diamniotic and the first twin is in a cephalic position
What is a major risk factor of UTI in pregnancy?
Preterm delivery
When are women tested for asymptomatic bacteria in UTI?
Booking clinic
What is seen on urine dipstick of UTI?
- nitrites (produced by E.coli)
- leukocytes (less accurate than leukocytes)
What is the most common causes of UTI?
E.coli, Klebsiella pneuomoniae, enterococcus, pseudomonas aeruginosa
What is the management of UTI in pregnancy?
Nitrofurantoin (until 3rd trimester), amoxicillin, cefalexin
When does nitrofurantoin need to be avoided in pregnancy?
3rd trimester: risk of neonatal haemolysis
Why is trimethoprim avoided in the first trimester of pregnancy?
Folate antagonist: can lead to congenital malformations, neural tube defects
When are women routinely screened for anaemia in pregnancy?
Booking clinic and 28 weeks
What is the presentation of anaemia in pregnancy?
Shortness of breath, fatigue, dizziness, pallor
What are risk factors for VTE in pregnancy?
Smoking, parity >3, age >35, BMI >30, reduced mobility, multiple pregnancy, preeclampsia, gross varicose veins, immobility, family Hx of VTE, thrombophilia, IVF pregnancy
When should VTE prophylaxis be started?
- 28 weeks if 3 or more risk factors
- first trimester if four or more risk factors
What is prophylaxis of VTE in pregnancy?
LMWH (dalteparin, enoxaparin)
When is VTE prophylaxis stopped in pregnancy?
6 weeks post natally, though temporarily stopped when the woman goes into labour
What can be considered in women with C/I to LMWH?
Intermittent pneumatic compression, anti embolic compression stockings
How do DVTs present?
Calf or leg swelling, dilated superficial veins, tenderness to the calf (particularly over deep veins), oedema, colour changes to the leg
Where should leg swelling be examined in queried DVT, and what result is significant?
10cm below the tibial tuberosity. More than 3cm difference is significant
What score is used to calculate risk of DVT?
Wells. 2 points or more =DVT likely, 1 or less = unlikely
What is the management of likely DVT?
- doppler leg ultrasound within 4 hours
- d-dimer
What is the first line management of DVT?
Apixaban or rivaroxaban (DOAC), even in patients with cancer
How long should all patients with a DVT recieve anticoagulation?
At least 3 months. If unprovoked, 6 months total
What are the features of PE?
Chest pain (pleuritic), dyspnoea, haemoptysis, tachycardia, tachypnoea. Chest clear on examination
If a woman is pregnant and has potential DVT but a negative doppler, what is the management?
Repeat on days 3 and 7
What should be done for women with queried PE?
Immediate ECG and CXR
What can be done to diagnosed PE in pregnancy?
CTPA or ventilation perfusion scan
Can you use the wells score in pregnant women?
No: not validated
Do you check d-dimer in pregnant women?
No: will always be raised
Do pregnant women with a confirmed DVT on ultrasound and queried PE, need to be investigated for the PE?
No: treatment is the same
What is the management of DVT/PE in pregnancy?
LMWH (dalteparin)
When should LMWH be started in suspected DVT/PE?
IMMEDIATELY: can be stopped when excluded
If a woman has confirmed VTE event in pregnancy, how long should they have LMWH for?
LMWH is continued for the remained of pregnancy, plus six weeks postnatally, or three months in total (whichever is longer). There is an option to switch to oral anticoagulation (e.g. warfarin or a DOAC) after delivery
Can DOACs be taken in pregnancy?
No: switch to LMWH
What triad is observed in pre eclampsia?
New onset HTN, proteinuria, oedema
What is the definition of pre-eclampsia?
New onset blood pressure > 140/90 after 20 weeks of pregnancy, and 1 or more of proteinuria or other organ involvement
What causes pre-eclampsia?
Spiral arteries of the placenta and the lacunae form abnormally, leading to high vascular resistance.There is also poor perfusion in the placenta, leading to oxidative stress. This releases inflammatory chemicals into the systemic circulation leading to systemic inflammation and impaired endothelial function
If a woman has hypertension before she is pregnant, and then when pregnant technically fits the BP range for pre eclampsia, does this count?
No: this is chronic hypertension
What is the name for hypertension in pregnancy that occurs after 20 weeks with no proteinuria?
Pregnancy induced hypertension
What is eclampsia?
When seizures occur as a result of pre-eclampsia
What are high risk factors for pre-eclampsia?
Pre existing HTN, previous HTN in pregnancy, existing autoimmune conditions, diabetes, chronic kidney disease
What are moderate risk factors for pre-eclampsia?
Older than 40, high BMI, more than 10 years since previous pregnancy, multiple pregnancy, first pregnancy, FHx of pre-eclampsia
What is the prophylaxis for pre-eclampsia and when is it offered?
Aspiring: offered from 12 weeks if one high risk factor or more than one moderate risk factor
What are the symptoms of pre-eclampsia?
Headache, visual disturbance or blurriness, N+V, upper abdo/epigastric pain (due to liver swelling), oedema, reduced urine output, brisk reflexes
How can proteinuria be quantified in pre-eclampsia?
High urine protein:creatinine ratio, or high urine albumin:creatinine ratio
What blood test can be done to investigate pre-eclampsia?
Placental growth factor: it is low in pre-eclampsia
How are all women routinely monitored at antenatal appointments for pre-eclampsia?
Blood pressure, symptoms, urine dipstick
What blood pressure should indicate admission in pregnancy?
Above 160/110 mmHg
What is the blood pressure goal in gestational hypertension in pregnancy?
Below 135/85mmHg
What scoring systems can be used to decide whether to admit a woman with pre-eclampsia?
fullPIERS or PREP-S
How often should fetal ultrasound be done in women with pre-eclampsia?
Every 2 weeks
What is first line management of pre-eclampsia?
Labetalol
What is second line management of pre-eclampsia?
Nifedipine
What is third line management of pre-eclampsia?
Methyldopa
What is used in the management of severe pre-eclampsia or eclampsia?
IV hydralazine (vasodilator)
What is given during labour and the 24 hours after if a woman has diagnosed pre-eclampsia?
IV magnesium sulphate
What should be given to any woman having a premature birth?
Corticosteroids, to help mature fetal lungs
What is the definitive treatment of pre-eclampsia?
Giving birth
What is first line management for pre-eclampsia after giving birth?
Enalapril
What is HELLP syndrome?
Combination of features that occur as a complication of pre-eclampsia and eclampsia. It is Haemolysis, Elevated Liver enzymes, Low Platelets
What are the presenting symptoms of HELLP syndrome?
N+V, right upper quadrant pain, lethargy
What is a s/e of magneisum sulfate that should always be managed?
Respiratory depression: calcium gluconate is first line
What must be monitored after given IV magnesium sulfate in pregnancy?
Urine output, reflexes, RR and oxygen sats
What is the most common medical disorder complicating pregnancy?
Hypertension
When is oral glucose tolerance test done during pregnancy, and who for?
Anyone with risk factors, done at 24-28 weeks, or anyone with previous gestational diabetes (do asap)
What are risk factors for gestational diabetes?
BMI >30 kg/m2, previous macrosomic baby (>4.5kg), previous gestational diabetes, first degree relative with diabetes, family origin with high prevalence of diabetes
What are the diagnostic thresholds for gestational diabetes?
Fasting glucose >= 5.6 mmol/L, and 2-hour glucose is >=7.8 mmol/L (5678)
How is a OGTT performed?
Perform in the morning after a fast. Patient drinks 75g glucose drink. Blood sugar is taken before drinking the sugar drink and at 2 hours
Who should women with gestational diabetes be under the care of?
Join diabetes and antenatal clinic
What is the fasting plasma glucose level that is a cutoff for insulin treatment of gestational diabetes?
<7 mmol/L
What is the management for women with gestational diabetes with fasting glucose <7mmol/l
Trial diet and exercise. If targets not met in 1-2 weeks start metformin, and if still not met add short acting insulin
What is the management of gestational diabetes with fasting glucose >7 mmol/l
Insulin started
What is the management of pre-existing diabetes in pregnancy?
Weight loss if >27 BMI, folic acid 5mg/day, stop oral hypoglycaemia agents except metformin and start insulin, detailed anomaly scan at 20 weeks, treat retinopathy promptly
What are the most significant immediate complications of gestational diabetes?
Large for date fetus and macrosomia
What additional screening should be done for women with diabetes during pregnancy?
Retinopathy: referral to an ophthalmologist to check
When should women with pre-existing diabetes give birth?
Between 37-38+6
What insulin regime is considered during labour for women with type 1 diabetes?
Sliding scale insulin regime
What is a risk for women with existing diabetes after birth?
Hypoglycaemia
What are risks for babies of mothers with diabetes?
Neonatal hypoglycaemia, polycythaemia, jaundice, congenital heart disease, cardiomyopathy
What is the figure that defines neonatal hypoglycaemia?
<2.6mmol/L
What levels can you expect of glucose after birth in a baby?
Transient hypoglycaemia in first few hours is common
What can cause persistent/severe hypoglycaemia in the neonate?
Preterm birth, maternal diabetes, IUGR, hypothermia, neonatal sepsis, inborn errors of metabolism
What are features of neonate hypoglycaemia?
Autonomic (jitteriness, irritable, tachypnoea, pallor), neuroglycopenic (poor feeding/suckling, weak cry, drowsy, hypotonia), apnoea, hypothermia
What is the management of asymptomatic neonatal hypoglycaemia?
Encourage normal feeding, monitor blood glucose
What is the management of symptomatic or very low blood glucose in the neonate?
Admit to the neonatal unit, and IV infusion of 10% dextrose
What is baby blues?
Seen in the majority of women in the first week of birth
What is the peak incidence of post natal depression?
3 months after birth
What are symptoms of baby blues?
Mood swings, low mood, anxiety, irritability, tearfulness
What is the management of baby blues?
Nothing, usually resolve
What is the presentation of postnatal depression?
The same as outside of pregnancy: low mood, anhedonia, low energy
What scale is used to assess postnatal depression?
Edinburgh postnatal depression scale
What is the treatment for post natal depression
Sertraline and paroxetine
What management is needed in puerperal psychosis?
Admission to the mother and baby unit
What is a potential complication of puerperal psychosis?
Recurrence: 25%
How long is the puerperium?
6 weeks
What is the pathophysiology of obstetric cholestasis?
Reduced outflow of bile acids from the liver
When does obstetric cholestasis typically develop?
Later in pregnancy, after 28 weeks
What is thought to cause obstetric cholestatis?
Increased oestrogen and progesterone levels
What are bile acids a product of?
Break down of cholesterol
What causes pruritis in obstetric cholestasis?
Build up of bile acids in the blood
What complication is obstetric cholestasis associated with?
Stillbirth
What are the features of obstetric cholestasis?
Pruritis (particularly palms of the hands and soles of the feet), fatigue, dark urine, pale greasy stools, jaundice, NO RASH
What investigations should be done for women with queried obstetric cholestasis?
LFTs and bile acids checked
What is found on investigation of obstetric cholestasis?
Abnormal liver function tests (mainly ALT, AST and GGT), and raised bile acids
Why is a rise in ALP alone not enough to diagnose obstetric cholestasis?
Increases in pregnancy anyway, as it is produced by the placenta
What is first line treatment of obstetric cholestasis?
Ursodeoxycholic acid. Sometimes may plan delivery at 37 weeks
When does acute fatty liver of pregnancy tend to occur?
In the third trimester
What is the pathophysiology of acute fatty liver of pregnancy?
Results from impaired processing of fatty acids in the placenta, due to a recessive genetic condition in the fetus. Fatty acids enter the maternal circulation and accumulate in the liver. This can lead to inflammation and liver failure in the mother
What deficiency can cause acute fatty liver of pregnancy?
Long chain 3-hydroxyacyl CoA dehydrogenase (LCHAD) deficiency in the fetus, which is recessive, so the mother will also have a copy
What is the presentation of acute fatty liver of pregnancy?
General malaise and fatigue, N+V, jaundice, abdominal pain, anorexia, ascites, headache, hypoglycaemia
What is seen on investigation of acute fatty liver of pregnancy?
Deranged liver enzymes, raised bilirubin, raised WBC count, deranged clotting, low platelets
What is the management of acute fatty liver of pregnancy?
Obstetric emergency, and requires delivery of the baby
What is placenta praevia?
Where the placenta is attached in the lower portion of the uterus, lower than the presenting part of the fetus. It is over the internal cervical os
What is the definition of a low lying placenta?
When the placenta is within 20mm of the internal cervical os (but not over it)
What risks are associated with placenta praevia?
Antepartum haemorrhage, emergency c-section, emergency hysterectomy, maternal anaemia and transfusions, preterm birth and low birth weight, stillbirth
What is grade 1 placenta praevia?
placenta reaches the lower segment but not the internal os
What is grade 2 placenta praevia?
placenta reaches the internal os but doesn’t cover it
What is grade 3 placenta praevia?
Placenta covers the internal os before dilation but not when dilated
What is grade 4 placenta praevia?
Placenta completely covers the internal os
What are risk factors for placenta praevia?
Previous c-section, previous placenta praevia, older maternal age, maternal smoking, structural uterine abnormalities (fibroids), assisted reproducton, multiple pregnancy
When is placenta praevia diagnosed and how?
20 week ultrasound anomaly scan. Can do transvaginal
What is the clinical features of placenta praevia?
Painless bleeding, uterus not tender, fetal heart usually normal
What must not be done in placenta praevia?
Digital vaginal examination: may provoke severe haemorrhage
What is the next step in women diagnosed with placenta praevia at the 20 week scan?
Repeat transvaginal scan at 32 weeks, and then 36 weeks to determine method of delivery
What is the delivery management of placenta praevia/low lying placenta?
Planned c-section at 36-37 weeks. This reduces the risk of spontanous labour and bleeding
What is the management for a woman with known placenta praevia who goes into premature labour?
Emergency c-section due to the risk of PPH
What is the management of placenta praevia that is bleeding?
ADMIT + ABC. If unable to stabilise or in labour: emergency c-section
What is placenta accreta?
When the placenta implants deeper, past the endometrium, which makes it difficult to deliver
What are the three layers of the uterine wall?
Endometrium, myometrium, perimetrium
What are risk factors for placenta accreta?
Previous placenta accreta, previous endometrial curettage, previous c-section, multigravida, increased maternal age, low lying placenta or praevia
What is possible complication of placenta accreta?
Post partum haemorrhage due to the deep implantation making it hard for the placenta to separate in delivery
What is placenta increta?
When the placenta attaches deeply into the myometrium
What is placenta percreta?
Where the placenta invades past the myometrium and perimetrium, potentially reaching other organs such as the bladder
What is the presentation of placenta accreta?
Typically doesn’t present. May have bleeding in the third trimester
When might placenta accreta be diagnosed?
Antenatal ultrasound, or at birth when difficult to delivery placenta
What imaging can be used to assess the depth and width of the invasion of placenta accreta?
MRI scans
What management may be required in placenta accreta during the third stage of labour?
Complex uterine surgery, blood transfusions, intensive care for mother
When is delivery planned in placenta accreta?
Between 35 and 37 weeks
What options are recommended in c-section for the management of placenta accreta?
Hysterectomy with the placenta remaining in the uterus, uterus preserving surgery, or expectant management
What is expectant management in placenta accreta?
Leaving the placenta in place to be reabsorbed over time: risks relating to bleeding and infection
What is the recommendation for if placenta accreta is found when there is an elective c-section?
Abdomen closed and delivery delayed whilst specialist services put in place.
What is vasa praevia?
Where the fetal vessels are within the fetal membranes and travel occur the internal cervical os. They aren’t within the umbilical cord the whole way
What do the fetal vessels consist of?
Two umbilical arteries and a single umbilical vein
What is a velamentous umbilical cord?
A type of vasa praevia: the umbilical cord inserts into the chorioamniotic membranes and the fetal vessels travel unprotected through the membanes being joining the placenta
What is a succenturiate lobe?
An accessory lobe of the placenta
What is the risk of unprotected fetal vessels in vasa praevia?
Fetal vessels are exposed, and can lead to dramatic fetal blood loss and death
What are the two types of vasa praevia?
Type 1: the fetal vessels are exposed as a velamentous umbilical cord. Type 2: the fetal vessels are exposed as they travel to an accessory placental lobe
What are risk factors for vasa praevia?
Low lying placenta, IVF pregnancy, multiple pregnancy
When is vasa praevia diagnosed?
Ideally in ultrasound, though not always. May be diagnosed after a antepartum haemorrhage. May be diagnosed after vaginal examination during labour when pulsating fetal vessels are seen in the membranes. Or,it may be detected during labour when fetal distress and dark-red bleeding occur following rupture of the membranes
How will vasa praevia present if it is not diagnosed before rupture of membranes?
Fetal distress and dark red bleeding
What is the management of asymptomatic women with vasa praevia?
Give corticosteroids from 32 weeks, and elective c-section planning
What is there a high risk of in vasa praevia?
Stillbirth or unexplained fetal death
What is placental abruption?
Where the placenta separates from the wall of the uterus during pregnancy, which can cause significant bleeding
What are risk factors for placental abruption?
Previous placental abruption, pre-eclampsia, bleeding in early pregnancy, trauma (especially domestic violence), multiple pregnancy, fetal uterine growth restriction, smoking, increased maternal age, cocaine use
What is the typical presentation of placental abruption?
Sudden onset severe abdominal pain that is continous, vaginal bleeding, shock (hypotension + tachycardia) out of proportion to visible loss, abnormalities on CTG, woody abdomen
What is the definition of antepartum haemorrhage?
Bleeding from the genital tract after 24 weeks (anything before =miscarriage)
What can cause bleeding in the first trimester?
Molar pregnancy, ectopic pregnancy, spontaneous abortion
What can cause bleeding in the 2nd trimester?
Spontaenous abortion, hydatidiform mole, placental abruption
What can cause bleeding in the 3rd trimester?
Bloody show, placental abruption, placenta praevia, vasa praevia
What are the definitions for severity of antepartum haemorrhage?
Minor: less than 50ml, major: 50-1000ml, major: >1000ml
What is concealed abruption?
Concealed abruption is where the cervical os remains closed, and any bleeding that occurs remains within the uterine cavity. The severity of bleeding can be significantly underestimated with concealed haemorrhage.
How is placental abruption diagnosed?
Clinically: no reliable tests, ultrasound is not very good
What are the initial steps for management of large antepartum haemorrhage?
- urgent involvement of senior obstetrician, midwife, anaesthetist
- 2x grey cannula
- crossmatch 4 units of blood
- fluid and blood resus as required
- ctg monitoring fetus
What is breech presentation?
When the presenting part of the fetus is the legs and bottom
What are the 4 types of breech?
- complete breech: legs fulled flexed at hips and knees
- incomplete breech: one leg flexed at hip and extended at knee
- extended breech: both legs flexed at hip and extended at knee
- footling breech: one foot presenting through the cervix with leg extended
What is the most common breech presentation?
Frank breech (extended breech)
What are risk factors for breech presentation?
- uterine malformations such as fibroids
- placenta praevia
- polyhydramnios or olgiohydramnios
- fetal abnormality
- prematurity
Up to what point do many babys in breech position turn spontaenouslt?
36 weeks
What is first line management for breech presentation?
External cephalic version at 37 weeks to attempt to turn the fetus
What is the management for breech if external cephalic version fails?
Mother can chose between vaginal delivery and elective c-section. If vaginal, need to be in consultant led care with access to emergency theatre
What are women given for external cephalic version?
Tocolysis: this relaxes the uterus. Subcutaneous terbutaline is given, which is a beta agonist and reduces the contractility of the myometrium
What test is required if external cephalic version is done?
Kleihauer test, and give anti-D prophylaxis if needed
What is a potential complication of breech presentation?
Cord prolapse
What are absolute C/I to external cephalic version?
- where c-section is required
- antepartum haemorrhage in the last 7 days
- abnormal cardiotocography
- major uterine anomaly
- ruptured membranes
- multiple pregnancy
What is the management of placental abruption if <36 weeks?
- fetal distress: c-section
- no fetal distress: observe closely, no tocolysis, steroids
What is symphysis fundal height?
The symphysis-fundal height (SFH) is measured from the top of the pubic bone to the top of the uterus in centimetres. After 20 weeks should match the gestational age in weeks to within 2cm
What is oligohydramnios?
Reduced amniotic fluid. Definition ~ <500ml at 32-36 weeks
What can cause oligohydramnios?
Premature rupture of membranes, potter sequence (renal agenesis), intrauterine growth restriction, post term gestation, pre-eclampsia
What can cause polyhydramnios?
- excess production due to increased foetal urination: maternal DM, foetal renal disorders, foetal anaemia
- insufficient removal due to reduced fetal swallowing: oesophageal or duodenal atresia, diaphragmatic hernia, chromosomal disorders
What are potential maternal complications of polyhydramnios?
Increased respiratory compromise, increased UTIs, increased risk of amniotic fluid embolism
What are potential foetal complications of polyhydramnios?
Pre term labour and delivery, premature rupture of membranes, placental abruption, malpresentation, umbilical cord prolapse
What are possible causes of stillbirth?
Unexplained, pre-eclampsia, placental abruption, vasa praevia, cord prolapse or wrapped around fetal neck, obstetric cholestasis, diabetes, thyroid disease, infections, genetic abnormalities
What are factors that increase the risk of stillbirth?
Fetal growth restriction, smoking, alcohol, increased maternal age, maternal obesity, twins, sleeping on the back
What can be done to prevent stillbirths?
- aspirin for pre-eclampsia risk reduction
- lifestyle modification
- serial growth scans for those with/at risk of small for gestational age
What three symptoms are red flag in pregnancy?
Reduced fetal movement, abdominal pain, vaginal bleeding
How is intrauterine fetal death diagnosed?
Ultrasound scan
What is first line for most women after intra uterine fetal death?
Vaginal birth; can be induced or expectant management
What can be given to induce labour?
- mifepristine (anti progestogen)
- misoprostol (stimulate uterine contractions)
What can be given to suppress lactation after stillbirth?
Dopamine agonists such as cabergoline
What are the causes of cardiac arrest (in all general adults)?
4Ts and 4Hs
Thrombosis, tension pneumothorax, toxins, tamponade
Hypoxia, hypothermia, hypovolaemia, hyperkalaemia/hypoglycaemia
What are the three major causes of cardiac arrest in pregnancy?
Obstetric haemorrhage, PE, sepsis leading to metabolic acidosis and septic shock
What is aortocaval compression in pregnancy?
When the mass of the uterus compresses the inferior vena cava and aorta. Compressing the IVC can lead to reduced cardiac output + hypotension
What is the management of acute aortocaval compression?
Place the woman in left lateral position
What position should CPR be done in pregnant women?
15 degree tilt to the left side
When should immediate c-section be done in a pregnant woman in cardiac arrest?
No response after 4 minutes of CPR. Aim to deliver baby and placenta within 5 minutes of CPR commencing
What is the reason for immediate delivery in cardiac arrest in a pregnant woman?
To improve the survival of the mother: it improves cardiac output and reduces oxygen consumption
How is latent first stage of labour differentiated from established first stage of labour?
- Latent: painful contractions, changes to the cervix, effacement and dilation up to 4cm
- Established: regular painful contractions, dilation of more than 4cm
What is the latent phase at labour, and what rate should it progress?
0-3cm, at around 0.5cm/hr
What is the active phase of labour, and what rate should it progress?
3-7cm, at around 1cm/hr
What is the transition phase of labour, and what rate should it progress?
7-10cm, around 1cm/hour
What is premature labour?
Before 37 weeks gestation
How can preterm labour be prevented?
Vaginal progesterone, cervical cerclage
When is vaginal progesterone given in regards to preterm labour?
In women with cervical length of less than 25mm on vaginal ultrasound between 16 and 24 weeks
When is cervical cerclage done?
For prevention of premature labour in women with previous premature labour, or cervical trauma (eg, colposcopy/cone biopsy). If cervical length <25mm on TVUS between 16 and 24 weeks gestation
When is rescue cervical cerclage done?
Between 16 and 28 weeks if there is cervical dilatation without rupture of membranes
How is premature prelabour rupture of membranes diagnosed?
Speculum examination reveals pooling of amniotic fluid in vagina
What tests can be done if there is doubt about preterm prelabour rupture of membranes?
Insulin like growth factor binding protein 1: this is a protein present in high concentrations in amniotic fluid, so can test fluid for this
What management should be offered in P-PROM?
Prophylactic abx; erythromycin four times daily for 10 days, of until labour established. Given corticosteroids for RDS. Labour may be induced from 34 weeks
How is potential pre term labour with intact membranes diagnosed?
- <30 weeks: clinically
- > 30 weeks: TVUS to assess ultrasound. Diagnose if cervical length <15mm
What test can be done for diagnosis of preterm labour with intact membranes?
Fetal fibronectin: if >50ng/ml likely
What is fetal fibronectin?
It is the glue between the chorion and uterus
What are management options for preterm labour?
- fetal monitoring
- tocolysis with nifedipine
- maternal cortorticosteroids
- IV magnesium sulphate
- delayed cord clamping
What is tocolysis?
Stopping uterine contractions
What is used for tocolysis in premature labour?
Nifedipine (CCB)
When is tocolysis offered in pregnancy?
Between 24 and 34 weeks
Why is IV magneisum sulfate given in premature labour?
Helps protect the fetal brain during premature delivery, can reduce cerebraly palsy
What must be monitored if magneisum sulfate has been given due to prematurity?
Magnesium toxicity: reduced resp rate, reduced blood pressure, absent reflexes
What is risk factors of prematurity?
- RDS
- intraventricular haemorrhage
- necrotising enterocolitis
- chronic lung disease, hypothermia, feeding problems
- retinopathy of prematurity
- hearing problems
What is retinopathy of prematurity?
Visual impairment in babys born before 32 weeks gestation
What is cardiotocography used for?
Used to measure the fetal heart rate and contractions of the uterus
How is cardiotocography performed?
Two transducers are placed on the abdomen to get the CTG readout: one above the fetal heart for fetal heartbeat, one near the fundus for contractions
How do the two transducers work in CTG?
- fetal heart: doppler ultrasound
- fundus: uses ultrasound to measure tension in the uterine wall, indicating uterine contraction
What are the indications for continous CTG monitoring?
Sepsis, maternal tachycardia (>120 BPM), significant meconium, pre-eclampsia, fresh antepartum haemorrhage, delay in labour, use of oxytocin, disproportionate maternal pain
What 5 things should be looked for on a CTG?
Contractions, baseline rate, variability, accelerations, decelerations
When should accelerations be seen in CTG?
Alongside contractions of the uterus
What are worrying signs when considering the contractions on CTG?
Too many: uterine hyperstimulation
- too few: not progressing
What is reassuring baseline rate and variability?
Baseline: 110-160
Variability: 5-25
What is abnormal baseline rate and variability?
Baseline: <100 or >180
Variability: <5 for 50 mins, or >25 for 25 mins
Why are decelerations a concerning find on CTG?
The fetal heart rate is slowing to conserve oxygen for vital organs
What are the 4 types of decelerations?
Early, late, variable, prolonged
What are early decelerations?
Gradual dips and recoveries in HR in time with contractions. Normal and not pathological. Caused by compression of vagus nerve in head of fetus, slowing HR
What are late decelrations?
Late decelerations are gradual falls in heart rate that starts after the uterine contraction has already begun. There is a delay between the uterine contraction and the deceleration. The lowest point of the declaration occurs after the peak of the contraction.
What can cause late decelerations?
Hypoxia in the fetus: excessive uterine contractions, maternal hypotension, maternal hypoxia
What are variable decelerations?
Abrupt decelerations that may be unrelated to contractions, and a fall of more than 15 bpm from baseline. Last less than 2 minutes, lowest point in 30seconds
What are reassuring signs with variable decelerations?
‘Shoulders’: accelerations either side of the decelerations
What are the features of prolonged decelerations?
2-10 minutes, drop more than 15bpm
What causes prolonged decelerations?
Compression of the umbilical cord and fetal hypoxia. Very abnormal and concerning
What is the most concerning form of decelerations?
prolonged
What are the four categories of CTG?
Normal, suspicious, pathological, need for urgent intervention
What means a CTG requires urgent intervention?
Acute bradycardia, or prolonged decelerations of more than 3 mins
When is fetal scalp stimulation done?
If decelerations, can do this as an acceleration in response is reassuring
What is the rule of 3’s for fetal bradycardia?
3 mins: call for help, 6 mins: move to theatre, 9 mins: prepare for delivery, 12 mins: deliver the baby, 15 mins: done
What is sinusoidal CTG?
Pattern of CTG that can indicate severe fetal compromise. Can be associated with severe fetal anaemia, eg after a haemorrhage
What can cause baseline bradycardia (CTG)?
Increased fetal vagal tone, maternal beta-blocker use
What can cause baseline tachycardia (CTG)?
Maternal pyrexia, chorioamnionitis, hypoxia, prematurity
Why are infusions of oxytocin used in labour?
Induce labour, progress labour, improve frequency and strength of contractions, prevent or treat PPH
What are the roles of oxytocin in labour?
Stimulates ripening of the cervix and contractions of the uterus
When might ergometrine be used in labour?
In the third stage of labour, and post partum to prevent and treat PPH. Only used AFTER delivery
How does ergometrine work in pregnancy?
Stimulates smooth muscle contraction both in uterus and blood vessels
What is syntometrine and when is it used?
Combination drug of both oxytocin and ergometrine, can be used for PPH
Why are prostaglandins given in pregnancy?
To induce labour (dinoprostone, prostaglandin E2), due to cervical ripening
Why are NSAIDs avoided in pregnancy?
Prostaglandins act as vasodilators, and lower blood pressure. NSAIDs such as ibuprofen and naproxen inhibit the action of prostaglandins. As a result, NSAIDs can increase blood pressure. NSAIDs are generally avoided in pregnancy, and also after delivery in women with raised blood pressure
What is misoprostol?
Prostaglandin analogue; activates prostaglandin receptors. Ripens cervix + contractions
How does mifepristone work?
Anti-progesterone; halts pregnancy, ripens cervix, stimulates contraction
Why is nifedipine used in pregnancy?
Reduces smooth muscle contraction in blood vessels and the uterus. Reduces blood pressure + tocolysis
When is terbutaline used?
Reduces contractions in uterine hyperstimulation
How does carboprost work?
Carboprost is a synthetic prostaglandin analogue, meaning it binds to prostaglandin receptors. It stimulates uterine contraction
When is carboprost C/I?
Patients with severe asthma, can cause life threatening exacerbation
When is carboprost given?
In PPH when ergometrine and oxytocin have been inadequate
How does TXA work?
Anti-fibrinolytic. Stops fibrin dissolving in clots, so reduces bleeding.
What is failure to progress?
When labour is not developing at a good rate
When is there delayed first stage of labour?
Less than 2cm cervical dilatation in 4 hours
How are uterine contractions measured?
Per 10 minutes
What is a partogram?
Way of measuring/monitoring progress in the 1st stage of labour
What is measured on a partogram?
Cervical dilatation, descent of fetal head, maternal pulse + blood pressure + temp + urine output, frequency of contractions, fetal heart rate, membrane status, frequency of contractions, drugs and fluids
What are the two lines on a partogram? What do they show?
Alert and action: shows if cervical dilation taking too long
What occurs if the alert line is crossed on a partogram?
Indicates amniotomy
What is indicated if the action line is crossed on a partogram?
Escalate to obstetric led care
What indicates failure to progress in 2nd stage of labour?
- nulliparous: 2 hours
- multiparous: 1 hour
What is the active management of 3rd labour?
IM oxytocin and controlled cord traction
What is first line to stimulate contractions in labour?
Oxytocin
How many contractions should be aimed for in 10 mins?
4-5 per 10 mins
When is induction of labour offered (gestatational dates)?
Between 41 and 42 weeks gestation
What are indications for induction of labour?
Prelabour rupture of membranes, fetal growth restriction, pre-eclampsia, obstetric cholestasis, existing diabetes, intrauterine fetal death
What is the bishop score?
Used to determine whether to induce labour
What is measured in the bishop score?
Fetal station, cervical position, cervical dilatation, cervical effacement, cervical consistency
What Bishop score predicts a successful induction of labour?
8
What Bishop score indicates that labour is unlikely to start without induction?
<5
What is first line for induction of labour?
Membrane sweep done in antenatal clinic. Separate the chorionic membrane from decidua
What is done after membrane sweep for induction of labour?
Vaginal prostaglandin E2
What is done if vaginal prostaglandins fail or are contraindicated in induction of labour?
Cervical ripening balloon
What is final line Induction of labour?
Artifical rupture of membranes with oxytocin infusion
What is done to induce labour where intrauterine fetal death has occured?
Oral mifepristone plus misoprostol
What is the management option if labour is unable to be induced?
Elective c-section
What is a possible complication of induction of labour with vaginal prostaglandins?
Uterine hyperstimulation
What are the common criteria for uterine hyperstimulation?
Contractions lasting longer than 2 minutes, and mroe than 5 contractions in 10 minutes
What is the treatment for uterine hyperstimulation?
Tocolysis with terbutaline, and removal vaginal prostaglandins
What are potential complications of uterine hyperstimulation?
Fetal compromise with hypoxia and acidosis, emergency c-section, uterine rupture
What is lochia?
Vaginal discharge containing blood, mucous, and uterine tissue that may continue 6 weeks after childbirth
Why might fetal scalp sampling be done in labour?
Measure capillary blood pH to determine if the baby is hypoxic
What does a low pH fetal scalp blood indicate?
Indicates that the baby is hypoxic (if pH is <7.2)
What simple analgesia is used in labour?
Paracetamol, and sometimes add codeine
What simple analgesia is avoided in childbirth?
NSAIDs
What is used for short term pain relief in labour?
Gas and air (50% NO, 50% oxygen)
What opioids may be given in childbirth?
IM pethidine and diamorphine
What patient controlled pain relief may be offered?
IV remifentanil, which is a short acting opiate medication
What medications are kept readily available if patient controlled analgesia is being used?
Naloxone for respiratory depression, atropine for bradycardia
Where is an epidural inserted?
Into the epidural space, which is outside the dura mater
What anaesthetic options are used for epidural?
Levobupivacaine or bupivacaine, usually mixed with fentanyl
What are possible AEs of epidural?
Headache after insertion, hypotension, motor weakness in legs, nerve damage, prolonged second stage, increased probability of instrumental delivery
If a woman has an epidural and has significant motor weakness, what may have occurred?
Catheter may be incorrectly sited in the SAH space
What is umbilical cord prolapse?
Where the umbilical cord descends below the presenting part of the fetus, after the membranes have rupture
What are risk factors for cord prolapse?
Prematurity, multiparity, polyhydramnios, twin pregnancy, cephalopelvic disproportion, abnormal presentation
What is the most significant risk factor for umbilical cord prolapse?
Abnormal lie
What is the most significant complication of umbilical cord prolapse?
Presenting part may compress the cord, leading to fetal hypoxia
How is umbilical cord prolapse diagnosed?
If there is fetal distress on CTG. Can be diagnosed by vaginal examination
What can be done immediately after umbilical cord prolapse for acute temporary management?
Push the presenting part of the fetus back into the uterus to avoid compression
What is the definitive management of cord prolapse?
C-section
What should be done to the cord whilst waiting for further management in cord prolapse?
Kept warm, wet, and have minimal handling
What management should be done in cord prolapse whilst waiting for c-section?
- woman lie in left lateral position or knee-chest position
- tocolytic medication such as terbutaline can minimise contractions
- retrofilling the bladder
What is shoulder dystocia?
When the anterior shoulder of the baby becomes stuck behind the pubis symphysis of the pelvis after delivery of the head
What are risk factors for shoulder dystocia?
Fetal macrosomia, high maternal body mass index, diabetes mellitus, prolonged labour
What is the turtle neck sign in labour?
Seen in shoulder dystocia: the head is delivered and then retracts into vagina
What is failure of restitution in labour?
Where the face remains downwards and doesn’t turn sideways as expected
What manouever should be performed in shoulder dystocia?
McRoberts: bringing knees towards the abdomen. Also Rubins (hand into the vagina to put pressure on the posterior aspect of the baby’s anterior shoulder) and Wood’s screw (trys to rotate the baby)
Where can pressure be applied that may help shoulder dystocia?
On the anterior shoulder (suprapubic region of abdomen)
What intervention may be done in shoulder dystocia?
- episiotomy (enlarge vaginal opening)
What is the zavanelli manoeuvre?
Zavanelli manoeuver involves pushing the baby’s head back into the vagina so that the baby can be delivered by emergency caesarean section.
What are the potential complications of shoulder dystocia?
Maternal: PPH, perineal tears. Baby: death, brachial plexus injury (Erb’s palsy), cerebral palsy
What is an instrumental delivery?
Vagina delivery assisted by either a ventouse suction cup or forceps
What medication is given after instrumental delivery to reduce risk of infection?
Co-amoxiclav
What are indications of instrumental delivery?
Failure to progress, fetal distress, maternal exhausation
What factor increases the risk for instrumental delivery?
Epidural
What are the risks of instrumental delivery?
Post partum haemorrhage, episiotomy, perineal tears, injury to anal sphincter, incontinence of bladder or bowel, nerve injury
What is there a risk (to the baby) of with ventouse delivery?
Cephalohaematoma
What is there a risk of (to the baby) with forcep delivery?
Facial nerve palsy
What is a cephalohaematoma?
Swelling on a newborns head, typically in the parietal region, and doesn’t cross suture lines
What nerves may be injured in a instrumental delivery (in the mother)?
Femoral nerve, obturator nerve
What is seen if the femoral nerve in the mother is damaged in instrumental delivery?
Weakness of knee extension, loss of patella reflex, numbness of anterior thigh and medial lower leg
What is seen if the obturator nerve in the mother is damaged in instrumental delivery?
Weakness of hip adduction and rotation, numbness of medial thigh
What are risk factors for perineal tears?
First baby, large baby, shoulder dystocia, asian ethnicity, instrumental deliverys
What is a first degree perineal tear + what is the management?
Superficial damage with no muscle involvement. Doesn’t require any repair
What is a first degree perineal tear + what is the management?
Injury to the perineal muscle, but not the anal sphincter. Sutured on the ward
What is a third degree tear + what is the management?
Including the anal sphincter, but not the rectal mucosa. Requires repair in theatre
What is the classification of third degree perineal tears?
3a: less than 50% external anal sphincter torn
3b: more than 50% external anal sphincter torn
3a: internal anal sphincter torn
What is a fourth degree perineal tear + how is it repaired?
Tear that includes the rectal mucosa. Repaired in theatre
What is offered for future pregnancies in women with third or fourth degree perineal tears?
Elective C-section
What are potential complications of perineal tears?
Pain, infection, bleeding, wound dehiscence, urinary incontinence, anal incontinence, fistula between the vagina and bowel, dyspareunia
What is an episiotomy and when is it done?
When a cut is made in the perineum before the baby is delivered, under anticipation of needing more room. It is done downwards and laterally.
What can reduced the risk of perineal tear?
Perineal massage, done from 34 weeks onwards
What is delayed cord clamping?
When there is a delay of a few minutes between the delivery of the baby and the clamping of the cord to allow blood flow to the baby
How is controlled cord traction in the third stage of labour?
Pulling the cord while applying counter pressure to help deliver the placenta
What is done after the placenta is delivered?
It is examined to ensure it is complete and no tissue remains in the uterus
What blood volume must be lost to be classified as a post partum haemorrhage?
500ml after vaginal delivery and 1000ml after a C-section
What is a major and minor PPH?
- Major: >1000ml
- Minor: <1000ml
What is a severe PPH?
> 2000ml
What is a primary PPH?
Bleeding within 24 hours of birth
What is a secondary PPH?
24 hours- 12 weeks
What are the four T’s of PPH?
Tone, trauma, tissue, thrombin
What is the most common cause of PPH?
Tone (uterine atony)
What are risk factors for PPH?
Previous PPH, multiple pregnancy, obesity, large baby, failure to progress in the second stage of labour, prolonged third stage, pre-eclampsia, placenta accreta, retained placenta, instrumental delivery, general anaesthesia, episiotomy or perineal tear
What generally causes secondary PPH?
Retained placenta or endometritis
What are preventative measures for PPH?
Treating anaemia during antenatal period, giving birth with empty bladder, active management of third stage, IV TXA in C-section in third stage
What is the ABC approach to PPH?
Lie the woman flat, keep her warm and communicate with her and her partner. Insert two large bore cannulas. Bloods for FBC, U+E, clotting. Group and match 4 units, warmed IV fluid and blood resus as required. Given oxygen regardless of saturations, and fresh frozen plasma can be used where there are clotting abnormalities
What are the mechanical treatments for PPH?
Rubbing the uterus to stimulate contraction, catheterisation (bladder distension reduces contractions)
What is the medical treatment of PPH?
IV oxytocin (slow injection then infusion, 40 units in 500mls), ergometrine (IV or IM), carboprost (IM), misoprostol (sublinguinal), TXA
When is ergometrine C/I?
In patients with HTN
When is carboprost C/I?
In patients with asthma
What are the surgical options for managing PPH?
- intrauterine balloon tamponade
- B-lynch suture (suture around uterus)
- uterine artery ligation
- hysterectomy
What are investigations for secondary PPH?
Ultrasound for retained productions of conception, and endocervical and high vaginal swabs for infection
What anaesthetic is elective caesarean done under?
Generally a spinal anaesthetic
What are indications for elective c-section?
Previous c-section, symptomatic after a previous significant perineal tear, placenta praevia, vasa praevia, breech presentation, multiple pregnancy, uncontrolled HIV infection, cervical cancer
What is a category 1 c-section?
Immediate threat to the life of the mother or baby. Decision to delivery time is 30 minutes
What is a category 2 c-section?
Not an imminent threat to life, but c-section is urgently required. Decision to delivery times is 75 minutes
What is a category 3 c-section?
Delivery required but mother and baby stable
What is a category 4 c-section?
Elective c-section
What is the most common c-section type?
Transverse lower uterine segment incisions
What is a vertical incision c-section and why would it be done?
Vertical incision down the middle of the abdomen. May be done if very premature or anterior placenta praevia
What method is used dissect in c-section and why?
Blunt dissection. Results in less bleeding, shorter operating times, and less risk of injury to the baby
What are the layers of the abdomen that have to be dissected in a c-section?
Skin, subcutaneous tissue, fascia/rectus sheath, rectus abdominis muscles, peritoneum, vesicouterine peritoneum, uterus, amniotic sac
What is the benefit of spinal anaesthesia in c-seciton?
Safe, few complications, fast recovery
What measures are taken during c-section to reduce risks of complications?
- H2 receptor antagonists or PPI before the procedure
- prophylactic antibiotics
- oxytocin to reduce PPH
- VTE prophylaxis with LMWH
Why might H2 receptor antagonists or PPIs be given before c-section?
There is a risk of aspiration pneumonitis during caesarean section, caused by acid reflux and aspiration during the prolonged period lying flat.
What are potential complications in the postpartum period that might be caused by c-section?
PPH, wound infection, wound dehiscence, endometritis
What are potential complications to the local structures/abdominal organs that might be caused by c-section?
Ureter/bladder/bowel/blood vessel damage. Can also have ileus, adhesions, hernias
What are increased risks on future pregnancies after a c-section?
Increased risk of repeat c-section, uterine rupture, placenta praevia, stillbirth
What are the risks on the newborn with a c-section?
Risk of lacerations, and increased incidence of transient tachypnoea of the newborn
When is a v-bac an appropriate method of delivery?
For pregnant women at >37 weeks gestation with a single previous c-section
What are contraindications to V-bac?
Previous uterine rupture, classical caesarean scar (vertical)
What are two key causes of sepsis in pregnancy?
Chorioamnionitis, UTIs
What is septic shock?
When arterial blood pressure drops and results in organ hypo-perfusion
What is chorioamnionitis?
Infection of the chorioamniotic membranes and amniotic fluid
What causes chorioamnionitis?
Caused by a large variety of bacteria, including gram positive, negative and anaerobes
What is a major risk factor for chorioamnionitis?
P-PROM
What is the mainstay of treatment in chorioamnionitis?
Prompt delivery of the foetus, administration of IV abx
What chart is used to identify sepsis in pregnant women?
MEOWS: maternal earlyobstetric warning system
What are the non-specific signs of sepsis?
Fever, tachycardia, raised resp rate, reduced oxygen saturations, low blood pressure, altered consciousness, reduced urine output, raised WBC on FBC, fetal compromise on CTG
What are signs and symptoms related to chorioamnionitis?
Abdominal pain, uterine tenderness, vaginal discharge, signs of sepsis
What investigations should be done in suspected sepsis?
FBC, U+Es (assess kidney function and AKI), LFTs, CRP, clotting (DIC), blood cultures, blood gas (lactate, pH, glucose)
What anaesthesia is used for women with maternal sepsis in c-section?
General anaesthesia: spinal is avoided
What are examples of sepsis antibiotic management?
Piperacillin + tazobacatam + gentamicin, or amoxicillin + clindamycin + gentamycin
What is sepsis six?
Blood lactate, blood cultures, urine output, oxygen, empirical broad spectrum abx, IV fluids
What is amniotic fluid embolism?
Where fetal cells/amniotic fluid enters the mothers bloodstream and triggers an immune reaction from the mother
What are risk factors for amniotic fluid embolus?
Increased maternal age, induction of labour, c-section, multiple pregnancy
What is the presentation of amniotic fluid embolism?
Usually presents around the time of labour + delivery, can be post partum. Shortness of breath, hypoxia, hypotension, coagulopathy, haemorrhage, tachycardia, confusion, seizures, cardiac arrest
What is the management of amniotic fluid embolus?
Largely supportive. Requires input of MDT: medical emergency. ABCDE. May need CPR and immediate c-section if cardiac arrest occurs
What is uterine rupture?
Where the muscle layer of the uterus (myometrium) ruptures
What is the difference between incomplete and complete uterine rupture?
Incomplete: uterine serosa (perimetrium) surrounding the uterus remains intact
Complete: serosa ruptures with the myometrium, contents of the uterus released into the peritoneal cavity
What is the main risk factor for uterine rupture and why?
The main risk factor for uterine rupture is a previous caesarean section. The scar on the uterus becomes a point of weakness, and may rupture with excessive pressure (e.g. excessive stimulation by oxytocin)
What are possible risk factors for uterine rupture?
VBAC, previous uterine surgery, increased BMI, high parity, increased age, induction of labour, use of oxytocin to stimulate contractions
What is the presentation of uterine rupture?
Acutely unwell mother and abnormal CTG. Abdominal pain, vaginal bleeding, ceasing of uterine contractions, hypotension, tachycardia, collapse
What is the management of uterine rupture?
Resuscitation and tranfusions, and emergency c-section
What is uterine inversion?
Where the fundus of the uterus drops down through the uterine cavity and cervix, turning the uterus inside out
What can cause uterine inversion?
Pulling too hard on the umbilical cord during active management of the third stage of labour
How does uterine inversion typically present?
If complete, will be seen. If incomplete, may be felt with manual examination. Typically presents with large PPH, and maternal shock or collapse
What manouevre can be used to treat uterine inversion, and how does this work?
Johnson manoeuvre: using a hand to push the fundus back up into the abdomen and to the correct position. Hold for several minutes, can give a drug such as oxytocin to trigger uterine contraction
What is second line management of uterine inversion after Johnson manoeuvre?
Hydrostatic methods: fill the vagina with fluid to inflate the uterus back into the normal position
What is done 6 weeks after the birth of a baby?
6 week postnatal appointment, and 6 week newbould check
How long will bleeding (lochia) take to settle after childbirth?
Around 6 weeks
What should be avoided whilst lochia is being produced?
Tampons: risk of infection
Why might there be more bleeding during breastfeeding?
Breastfeeding releases oxytocin, which can cause uterine contraction and lead to more bleeding
What is lactational amenorrhoea?
When a woman who is breastfeeding doesn’t have periods whilst breastfeeding. There is a reduction in GnRH and LH/FSH
When is contraception required after childbirth?
21 days after
How long is lactational amenorrhoea effective contraception and what is required?
98% effective up to 6 months, but women must be fully breast feeding and amenorrhoeic
What contraception is considered safe in breast feeding?
Progestogen only pill and implant
When can COCP be started after childbirth in women who are breast feeding?
6 weeks
When can the IUD or IUS be inserted after childbirth?
Within 48 hours or after 4 weeks
What is endometritis?
Inflammation of the endometrium, typically caused by infection
What is a major risk factor for endometritis, and what can be done to prevent it?
C-section, and prophylactic abx are given after c-section to reduce risk of infection
How does endometritis typically present?
Foul discharge or lochia, bleeding getting heavier/not improving, lower abdominal or pelvic pain, fever, sepsis
What investigations should be done for endometritis?
Vaginal swabs (including chlamydia and gonorrhoea if RF), urine culture, sensitivities, ultrasound (rule out retained products of conception)
How is mild endometritis treated (with no signs of sepsis)
Broad spectrum: co-amoxiclav
What is a RF for retained products of conception?
Placenta accreta
What is the presentation of retained products of conception?
Vaginal bleeding not improving, abnormal vaginal discharge, lower abdominal or pelvic pain, fever
How is retained products of conception diagnosed?
Ultrasound
What is the management of retained products of conception?
Surgical removal: D+C
What are two possible complications of retained products of conception management?
D+C can lead to endometritis and Asherman’s syndrome
Why can asherman’s occur after D+C for retained products of conception?
Endometrial curettage can damage the basal layer of the endometrium. Can heal in a way that there is scar tissue and adhesions
When is a FBC indicated the day after delivery?
If there has been a PPH >500ml, c-section, antenatal anaemia, symptoms of anaemia
What hb should be aimed for post natally?
> 100
What is the management of Hb <100g/l post natally?
Oral iron
What is the management of Hb <90 g/l postnatally?
Iron infusion
What is the management of Hb <70g/l postnatally?
Blood transfusion in addition to oral iron
What is a contraindication to iron infusion?
Active infection (pathogens can feed off iron: this is why anaemia can be a sign of inflammation)
When does candida of the nipple occur? what can it cause?
After a course of abx, can lead to recurrent mastitis
How can candida of the nipple present?
Sore nipples bilaterally (particularly after feeding), nipple tenderness and itching, cracked/flaky or shiney areola, symptoms in the baby (oral or candidal nappy rash)
What is treatment for candida of the nipple?
Both mother and baby: mother is topical miconazole 2% after each breastfeed, for the baby miconazole gel or nystatin
What are the three stages of postpartum thyroiditis?
Thyrotoxicosis, hypothyroidism, normal thyroid function
What is post partum thyroiditis?
Changes in thyroid function within 12 months of delivery
What is the pathophysiology of PP thyroiditis?
- pregnancy has an immunosuppressant effect on the body
- exaggerated rebound effect, with increased immune system activity and expression of antibodies
- includes thyroid peroxidase antibodies
When are thyroid function tests done after delivery?
6-8 weeks
What is typical treatment of thyrotoxicosis in PP thyroiditis?
Symptomatic control (propanolol)
What is the typical treatment of hypothyroidism in PP thyroiditis?
Levothyroxine
What is sheehan’s syndrome?
Complication of PPH, where low blood volume leads to avascular necrosis of the pituitary gland. Ischaemia and cell death occurs
What part of the pituitary is affected by Sheehans?
Anterior
Why is only the anterior pituitary affected by Sheehans?
anterior pituitary gets its blood supply from a low-pressure system ( hypothalamo-hypophyseal portal system). This is susceptible to rapid drops in blood pressure. The posterior pituitary gets a good blood supply from various arteries, and is not susceptible to ischaemia when there is a drop in BP
What hormones does Sheehans release?
TSH, ACTH, FSH, LH, GH, prolactin
How does Sheehans present?
Due to lack of hormones. Can include amenorrhoea (low FSH and LH), reduced lactation (low prolactin), adrenal insufficiency and crisis (low ACTH), hypothyroidism with low thyroid hormones (lack of TSH)
What is the management of Sheehans?
Hormone replacement by a specialist: eg, oestrogen, progesterone, hydrocortisone, levothyroxine, growth hormone
What can cause abdominal pain in early pregnancy?
Ectopic pregnancy, miscarriage
What are causes of abdominal pain in late pregnancy?
Labour, placental abruption, symphysis pubis dysfunction, pre-eclampsia/HELLP syndrome, uterine rupture
What is symphysis pubis dysfunction?
Ligament laxity increases in hormonal change in pregnancy
What is the presentation of symphysis pubis dysfunction?
Pain over pubic symphysis with radiation to groins + medial thighs. Waddling gait
What should be done if a baby loses >10% of birthweight in the first week of life?
Expert review: eg, midwife breastfeeding clinic
What are major contraindications to breastfeeding?
Viral infections (mostly HIV) and galactosaemia
Is sodium valproate safe in breast feeding?
Yes
Are antipsychotics safe in breast feeding?
Yes; except clozapine
What antibiotics should be avoided when breast feeding?
Ciprofloxacin, tetracycline, sulphonamides
What antibiotics are safe in breast feeding?
Penicillins, cephalosporins, trimethoprim
What is the medication used for suppressing lactation if required?
Cabergoline
What antiepileptics should be avoided in pregnancy?
Phenytoin (cleft lip), sodium valproate (neural tube defects)
What can cause folic acid deficiency?
Methotrexate, phenytoin, pregnancy, alcohol excess
Who should take 5mg of folic acid rather than just 400mcg?
FHx of neural tube defects, antiepileptic drugs, hx of coeliac or diabetes, obesity (>30 BMI)
How can a galactocele be differentiated from an abscess?
Galactocele is painless, no signs of infection
What is the most common cause of early onset infection in the neonatal period? (and thus sepsis)
GBS
What are risk factors for GBS infection?
Prematurity, prolonged rupture of membranes, previous sibling with GBS infection, maternal pyrexia
Should all women be screened for GBS?
No
If a woman has had GBS in a previous pregnancy, what is her risk in her next one?
50%
What is the management for women who have had GBS in a previous pregnancy?
Offer intrapartum abx prophylaxis or testing in late pregnancy + abx if positive then
If women are being swabbed for GBS, when should this be done?
35-37 weeks, or 3-5 weeks before delivery date
What is the prophylaxis of choice for GBS?
BenPen
Which women should always be offered GBS prophylaxis?
- pyrexia in labour
- preterm labour (regardless of status)
- a baby with previous early or late onset GBS disease
What are the 3 types of foetal lie?
Longitudinal, transverse, oblique
What are risk factors for transverse lie?
Multiparous, fibroids, pregnant with twins or triplets, prematurity, polyhydramnios, foetal abnormalities
What is the possible complications of transverse lie?
PROM, cord prolapse
What is the management of transverse lie?
The same as breech (ECV at 37 weeks, etc).
What is puerperal pyrexia defined as?
Temperature of more than 38 degrees in the first 14 days following delivery
What are possible causes of puerperal pyrexia?
Endometritis, UTI, wound infections, mastitis, VTE
When should fetal movements be established by?
24 weeks
At what point does fetal movements tend to plateau?
32 weeks
What is the first line investigation for a mother reporting reduced fetal movements?
Handheld doppler for fetal heartbeat. If heartbeat felt, then CTG used for 20 mins
What is the next management for a woman with reduced fetal movements reported, and no heartbeat on doppler?
Immediate ultrasound
What are maternal risks of obesity during pregnancy?
Miscarriage, VTE, gestational diabetes, pre-eclampsia, dysfunction labour + induction, PPH, wound infections, C-section
What is the fetal risks of obese mother?
Congenital anomaly, prematurity, macrosomia, stillbirth, neonatal death
What is the BMI cut off for giving birth in a consultant led unit?
> 35 BMI
Can hep B be transmitted by breast feeding?
No (in contrast to HIV)
What is the management for a baby born to a mother who is hepB positive?
Complete course of vaccination and hep B immunoglobulin
When is vaginal delivery recommended in HIV?
If the viral load is less than 50 copies/ml at 36 weeks
What HIV prophylaxis should be used in birth for HIV mothers?
IV zidovudine, also give to neonate
What investigation should be done for all women with queried PE?
DVT + PE
What increased risk does CTPA hold for a mother if done during pregnancy?
Risk of maternal breast cancer because pregnancy makes breast tissue sensitive to radiation effects
What is cephalopelvic disproportion?
When the head is too large for the baby
What are causes of cephalopelvic disproportion?
Large baby, abnormal position of baby, small pelvis, abnormal shape to pelvis, abnormality of the genital tract
What can cephalopelvic disproportion lead to?
Obstructed labour
