Obs pass med Flashcards
what is puerperal pyrexia?
A temperature of > 38ºC in the first 14 days following delivery
What is the most common cause of puerperal pyrexia?
Endometritis
other causes include: UTI, wound infections, mastitis, venous thromboembolism
What is the management of puerperal pyrexia?
If endometritis is suspected the patient should be referred to hospital for IV (clindamycin and gentamicin until afebrile for greater than 24 hours)
what medications are suitable for breastfeeding women (antidepressant)?
sertraline and paroxetine are the SSRIs of choice
What are the two main risk factors for placenta acretta?
-Previous C section
-Placenta previa
What is oligohydraminous?
-Reduced amniotic fluid
-Less than 500ml between 32-36 weeks and an amniotic fluid index <5th percentile
What are the causes of oligohydraminous?
-Premature rupture of membranes
-Potter sequence (bilateral renal agenesis + pulmonary hypoplasia)
-IUGR
-Post-term gestation
-Pre-eclampsia
Why folic acid important to take in pregnancy?
protects against neural tube defects - which are caused by folic acid deficiency
How should “high risk” women take folic acid?
5mg of folic acid before conception until 12th week pregnancy
What is recommended with folic acid to all women in pregnancy?
400 mg of folic acid until 12 weeks
When are women considered “high risk” for having a baby with neural tube deftect?
-Fhx NTD
-Taking antiepileptic drugs
-Coeliac disease
-Diabetes
-Thalassemia triat
-Obese BMI>30kg
Why does shoulder dystocia occur?
Due to impaction of anterior fetal shoulder on maternal pubic symphysis - occurs after the head has been delivered
What are the risk factors of shoulder dystocia?
-Fetal macrosomia (hence association with MDM)
-High BMI
-Prolonged labour
-DM
How should shoulder dystocia be managed once idenifted?
-Senior help
-Episiotomy (allows better access for internal manoeuvres)
-McRoberts’ manoeuvre
What is McRoberts’ manoeuvre?
Flexion and abduction of maternal hips - it increases the relative anterior-posterior angle of the pelvis
What are the complications of shoulder dystocia?
-Maternal: PPH and perineal tears
-Fetal: Brachial plexus injury and neonatal death
What are symptoms of placental abruption?
Vaginal bleeding with pain and discomfort
What are risk factors for placental abruption?
-Chronic hypertension
-Smoking
-Cocaine use
-Abdominal trauma
What investigation should be done if placental abbruption?
NOTE: these are performed to investigate the extent and consequence of the arupbtion
-Blood test - FBC (Hb), group and save, Kleihauer in RhD - women, this is to gauge the dose of anti D
-Ultrasound can be used to diagnose placenta praevia but does not exclude abruption
-CTG to see if the there is fetal distress
What weeks are corticosteriods useful ?
24- 34+6 - if at risk of preterm birth
What are antenatal corticosteroids associated with?
Significant reduction in rates of neonatal death, RDS, intraventricular haemorrhage
What is the management of placental abruption if fetus alive and <36 weeks?
Fetal distress: immediate C section
No fetal distress: Admit observe closely, administer corticosteroids, no tocolysis, threshold to deliver depneds on gestation
What is the management of placental abruption if fetus alive and >36 weeks?
Fetal distress: Immediate C section
No fetal distress: deliver vaginally
How to manage placental abruption if fetus dead?
Induce vaginal delivery
What are the maternal complication of placental abruption?
-Shock
-DIC
-Renal failure
-PPH
What are the fetal complication of placental abruption?
-IUGR
-Hypoxia
-Death
What is the prognosis of placental abruption?
-Associated with high perinatal mortality rate
-Responseible for 15% of perinatal deaths
What are the high risk factors for developing pre-eclmapsia?
-Hypertensive disease in pregnancy
-CKD
-Autoimmune diseases, such as lupus
-Chronic hypertension
-Type 1 or 2 diabetes
What are the moderate risk factors for developing pre-eclampsia?
-First pregnancy
-Age >40
-Pregnancy internal >10 years
-BMI >35 at first vist
-Multiple pregnancy
What should women with either > 2 moderate factors or >1 high factors take?
75-150mg aspirin
What is the classical triad of pre-eclampsia?
-New-onset hypertension
-Proteinuria
-Oedema
What is the definition of pre-eclampsia?
-Newonset blood pressure > 140/90 mmHg after 20 weeks AND 1 or more of :
-Proteinuria
-Other organ involvement (renal, liver, neurological, uteroplacental dysfunction)
What are features of severe pre-eclampsia?
-Hypertension: typically > 160/110 mmHg and Proteinuria
-Proteinuria: dipstick ++/+++
-Headache
-Visual disturbance
-Papilloedema
-RUQ/epigastric pain
-Hyperreflexia
-Platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome
What are the complications of pre-eclampsia?
-Eclampsia
-Fetal complications: Intrauterine growth retardation, prematurity
-Liver involvement (elevated transaminases)
-Haemorrhage (placental abruption)
-Cardiac failure
What is the initial management of pre-eclampsia?
-NICE recommend arranging emergency secondary care assessment for any woman in whom pre-eclampsia is suspected
-Women with blood pressure ≥ 160/110 mmHg are likely to be admitted and observed
What is the further management of pre-eclampsia?
-Oral labetalol 1st line, nifedipine if asthmatic
-Delivery of baby is most important and defintive management
What is the first line Abx for mastitis?
-Flucloxacillin 10-14 days - as the most common organism is staphylococcus aureus
-Erythromycin can also be used
If a women is breastfeeding and they have mastitis what should they do?
Continue breastfeeding
What is the first line conservative management of lactation mastitis?
-Analgesia and encouraging effective milk removal to prevent further milk stasis
What is the main cause of lactation mastitis?
Milk stasis, due to overproduction or insufficient removal
Air travel during pregnancy?
> 37 weeks with singleton pregnancy avoid air travel
32 weeks multiple pregnancy
-This is due to the increased risk of venous thromboembolism
What Erbs palsy?
Damage to the upper brachial plexus - resulting in a characteristic pattern of adduction and internal rotation of the arm - with protonation of the forearm
- commonly called the waiter’s tip
What is Klumpke’s palsy?
It occurs due toi damage of the lower brachial plexus and commonly affects nerves innervating muscles of the hand
What is placenta accreta?
Attachment of placenta to the myometrium, due to defective decidua basalis
What is the main risk of placenta accreta?
PPH - as the placenta does not separate properly during labour
What are the risk factors of placenta accreta?
-Previous C section
-Placenta previa
What are the three types of placenta accreta?
-Accreta: chorionic villi attach to the myometrium, rather than being restricted within the decidua basalis
-Increta: Chorionic villi invade into the myometrium
-Percreta: Chorionic villi invade through the perimetrium
How often should pregnant patients with T1DM test their blood glucose levels?
-Multiple times
(Daily fasting, pre-meal, 1 hour post meal, bedtime)
What should be discussed with patient that have intrahepatic cholestasis of pregnancy?
Induction of labour 37-38 weeks as there is a risk of still birth
When is a nuchal scan performed?
11- 13 weeks
What are the causes of increased nuchal translucency on USS?
-Down syndrome
-Congentital heart defects
-Abdominal wall defects
What is the threshold of blood pressure where you woould admit a women?
> 160/110
What is the screening tool used for post natal depression?
-Edinburgh postnatal depression scale
-10 question max score 30
->13 indicates a depressive illness of varying severity
-Screens for self harm questions
How to manage a visible umbilical cord during labour?
- This is an umbilical cord prolapse
-Manual elevation of the presenting part back into the uterus to avoid compression
-If cord past level of introitus minimal handling, keep wet and warm to avoid vasospasm
-Patient asked ot go on all fours (or left lateral position as an alternative) - C section prepared
-Tocolytics can be used to reduce uterine contractions
-Filling bladder may be helpful as it gentle elevates presenting part
What is galactocele?
-When a build up of milk creates a cystic lesion in the breast
-Occurs in women who have recently stopped breastfeeding
-is due to occlusion of a lactiferous duct
-is usually painless, with no local or systemic signs (how to differentiate from an abscess)
When is GDM diagnosed?
-Fasting glucose >5.6mmol/L
-2-hour gluocse >7.8mmmol/L
Remember (5678)
In GDM if fasting glucose <7 what should be management?
-A 2 weeks trial of diet and exercise
-If not met within 1-2 weeks start metformin
-If still not met then short acting insulin is added
If at time of diagnosis fasting glucose>7mmol/L then what is the management of GDM?
Short acting insulin should be added
(this is because at 6-6.9mmol/l complications such as macrosomia and hydramnios occur)
What is the treatment for pregnant women that cannot tolerate metformin or fail to meet glucose targets with metformin and decline insulin?
Glibenclamide
What are the risk factors for umbilical cord proplapse?
-Prematurity
-Multipartity
-Polyhydramnios
-Multiple pregnancy
-Cephalopelvic disproportion
-Abnormal presentation (breech , transverse lie)
When do 50% of cord prolapses occur
at artificial rupture of membranes - cord visible beyond level of introitus
When is vaginal delivery possible with a umbilical cord prolapse?
-An instrumental vaginal delivery is possible if the cervix is fully dilates and the head is low
-NOTE- C section is first line
What is the main complication of umbilical cord prolapse?
-Compression of the cord or cord spasm which can lead to fetal hypoxia, irreversible damage or death
How common in umbilical cord prolpase?
1/500 deliveries
What is the main complication of induction of labour?
Uterine hyperstimulation
What is the BISHOP score?
It is used to assess whether the induction of labour will be required
-Score <5 indicates labour is unlikely to start without induction
-Score >8 indicates cervix is ripe and high chance of spontaneous labour
What are the 5 factors assessed with the BISHOP score?
-Cervical position
-Cervical consistency
-Cervical effacement
-Cervical dilation
-Fetal station
Draw the bishop score table
Smoking cessation in pregnancy?
-Discuss risk of smoking: low birth weight and premature
-NRT but discuss risks/benfits
-Do not give varenicline or bupropion to pregnant or breastfeeding women
What is PPROM and how common is it?
Premature prelabour rupture of membranes - occurs in 2% pregnancy but is associated with around 40% of preterm deliveries
How to confirm PPROM?
-A sterile speculum examination - look for pooling of amniotic fluid in posterior vaginal vault
How to confirm PPROM if no pooling is observed with speculum examination?
Test fluid for PAMG-1 (placental alpha microglobulin 1) or IGFBP-1 (insulin-like growth factor binding protein 1)
Why should a digital examination be avoided when investigated PPROM?
Risk of infection
How does PPROM present?
-Feeling gush/leak of fluid from vagina
WHat medications cause folic acid deficiency?
Phenytoin
Methotrexate
Hwo results at combined sreening test at 12 weeks would suggest Down’s syndrome?
-Increased HCG, Decreased PAPP-A and a thickned nuchal translucency
What is the management for a suspected PE in a pregnant women with a confirmed DVT?
Treat with LMWH and then investigate to rule out
What is the complication of PE in pregnancy?
-Hypoxia to foetus and mother
-Potentila cardiac arrest
What is the investigation of choice for women with a suspected DVT?
Compression duplex US
Investigation for patients with suspected PE?
-ECG and CXR in all patients
-If signs and symptoms of DVT the compression duplex US
-If confirms presence of DVT, no further investigation is needed and treatment for VTE should continue
-The decision to perform a V/Q or CPTA should be taken at local level after discussionw ith patient and radiologist
CPTA vs V/Q scanning in pregnancy?
-CPTA slightly increased lifetime risk of maternal breast cancer (1/200) as pregnancy makes breast tissue particularly sensitive to effects of radiation
-V/Q scanning increased risk of childhood cancer 1/50,000)
Why is the use of D-dimer limited in the investigation of thromboembolism in pregnanyc?
it is often already raised in pregnancy
What is the treatment for women who develop chickenpox >20 weeks and presnets within 24hours of onset of the rash ?
oral aciclovir
When is zoster immunoglobulin given?
To a pregnancy women exposed to chicken pox in first 20 weeks of pregnancy
What is the preferred method of induction of labour after membrane sweep when Bishops score <6?
Vagianal prostaglandins or oral misoprostol
What type of pregnancy does twin-to-wtin transfusion syndrome occur?
In a monochorionic pregnancy where the two fetuses share a single placenta
Why does twin-to twin transfusion syndrome occur?
-As two fetus share one placenta, blood can flow between the twins
-One is the donor and receives a lesser share of the placental blood flow than the recipient
-It occurs due to abnormalities in the network of placental blood vessels
What may happen to the the recipient and donor in twin to twin transfusion syndrome?
Donor - may become anemic (oligohydramnios)
Recipient - Fluid overload (polyhydramnios)
What maternal symptoms may the mother experience and should be specifically asked to report if pregnant with monochorionic twins?
-Any sudden increase in size of abdomen
-Breathlessness - this may be result of polyhydramnios affecting recipient twin
How to manage a women taking an ACE inhibitor or ARB for pre-exisitng hypertension?
Stop immediately and started on labetalol
What vitamin is recommended for all pregnant women?
Vitamin D 10mg
What is an alternative name for group B streptococcus (GBS)?
Steptococcus agalactiae
What is the most common cause of early onset severe infection in neonatal period?
-Group B streptococcus (GBS)
-Inafnts may be exposed to maternal GBS during labour and develop a serious infection (neonatal spesis)
How many mothers are thought to be carrier of GBS?
20-40 %
-Found in bowel flora
What are the risk factors for GBS infection?
-Prematurity
-Prolonged rupture of membranes
-PRevious sibling with GBS infection
-Maternal pyrexia e.g. sec ondary to chorioamnionitis
If a woman has had a previous GBS detected in a previous pregnancy what is the management?
-Inform that the risk of carriage in this pregnancy is 50%
-Offer intrapartum antibiotic prophylaxis (IAP)
or
-Test later on in the pregnancy to see with GBS positive
When should swabs for GBS testing be carried out?
-35-37 weeks
or
-3-5 weeks before delivery
When should intrapartum antibiotic prophylaxis be offered?
-If previous baby had early or late onset GBS disease
-Women in pre-term labour (regardless of GBS status)
-Women with pyrexia (>38)
What is the Abx of choice for GBS prophylaxis?
Benzylpenicillin
What layers are cut through in C-section?
1.Superficial fascia
2.Deep fascia
3.Anterior rectus sheath
4.Rectus abdominis muscle (not cut, rather pushed laterally following incision of the linea alba)
4.Transversalis fascia
5.Extraperitoneal connective tissue
6.Peritoneum
7.Uterus
What is the standard screening test for Down’s syndrome?
The combined test
-Trisomy 21 is suggested by: ↑ HCG, ↓ PAPP-A, thickened nuchal translucency
NOTE - trisomy 18 (Edward syndrome) and 13 (Patau syndrome) give similar results but the hCG tends to lower
When is the combined test done?
11-13+6 weeks
What is does the quadruple test look at?
-Alpha fetoprotein
-Unconjugated oestriol
-Human chorionic gonadotropin
-Inhibin A
How do you interpret the results of the quadruple tests?
What are the two screening tests for Down’s syndrome?
-Combined test and quadruple test
What to the results of the combined or quadruple tests show?
-“lower chance” 1 in 150 or more
-“high chance” 1 in 150 or less
If a woman has a ‘higher chance’ result then what will she be offered?
-A non-invasive prenatal screening test (NIPT) or
-Diagnostic test (amniocentesis or chorionic villus sampling)
NOTE: most women chose NIPT as it is non0invasive and has high sensitivity and specificity
When is chorionic villous sampling carried out as a diagnostic tests?
11-13+6 weeks
When is amniocentesis performed as a diagnostic test?
From 15 weeks
What risk of miscarriage do CVS and amniocentesis carry?
CVS -1-2%
Amniocentesis - 0.5-1%
What is the SSRI of choice in breastfeeding women?
-Sertraline
-Paroxetine
What is the screening test for GDM?
Oral glucose tolerance test
When should OGTT be performed if previous GDM?
-As soon as possible after booking
-24-28 weeks if first test is normal
What do NICE advise as an alternative to OGTT?
Early self monitoring of blood glucose
If a women has a risk factors for GDM when should OGTT be performed?
24-28 weeks
What are the risk factors for GDM?
-BMI >30kg/m
-Previous macrosomic baby weighing 4.5kg or above
-Previous GDM
-First degree relative with diabetes
-Family origin with high prevalence of diabetes (south asian, black caribbean and middle eastern)
What analgesic is absolutely contraindicated in breastfeeding?
-Aspirin
-It is associated with Reye’s syndrome which can cause liver and brain damage
What can be used to help with nausea and vomiting during pregnancy?
-NICE reccomend ginger and acupuncture on the “p6” point (by wirst)
-Antihistamine sshould be used 1st line (BNF - promethazine)
What are the baby blues?
-Seen in 60-70% of women
-Seen 3-7 days following birth and is more common in primips
-Symptoms:>
What is the incubation period of rubella?
-14-21 days
-Individuals are infectious from 7 days before symptoms appear to 4 days after the onset of the rash
When is the foetus most at risk of rubella infection?
-8-10 weeks damage to fetes is as high as 90%
-Damage is rare after 16 weeks
What are the features of congenital rubella syndrome?
-Sensorineural deafness
-Congenital cataracts
-Congenital heart disease (PDA)
-Growth retardation
-Hepatosplenomegaly
-Purpuric skin lesions
-Salt and pepper choriortinitis (type of posterior uveitis)
-Micophthalmia
-Cerebral palsy
Diagnosing rubella?
-IgM antibodies are raised in women recently exposed to the virus
NOTE: it is very difficult to distinguish between parvovirus and B19 serology so must check provirus B19 serology and there is a 30% risk of transplacental infection and 5-10% risk of fatal loss
When should non-immune mothers be offered the vaccine ?
Post natal period
What is the difference between primary postpartum haemorrhage and secondary?
-Primary occurs within 24 hours after delivery
-Secondary occurs between 24hours - 6 weeks and is typically due to retained placental tissue or endometritis
What are the causes of primary PPH (the 4Ts)
-Tone (uterine aony) - majority of cases
-Trauma (perineal tear)
-Tissue (retained placenta)
-Thrombin (clotting/bleeding disorder)
What are the risk factors of PPH?
-Previous PPH
-Prolonged labour
-Pre-eclampsia
-Increased maternal age
-Polyhydraminos
-Emergency C-section
-Placenta praevia, placenta accreta
-Macrosomia
What is the 1st step in management of PPH?
PPH is life threatening emergency - senior members of staff should be involved immediately
What is required in the ABC approach of PPh?
-Two large boree cannula - 14 gauge
-Lie women flat
-Bloods with group and save
-Commence warm crysalloid infusion
What is the mec h
