Obs PPQ Flashcards
Downs screening - combined + timing
high b-HCG, high nuchal translucency, low PAPP-a
between 11 - 13+6 weeks
Downs screening - quadruple + timing
low alpha-fetoprotein, low unconjugated oestriol, high human chorionic gonadotrophin and high inhibin A
When amniocentesis/cvs is offered
an antenatal screening test has suggested your baby may be born with a condition, such as Down’s syndrome, Edwards’ syndrome or Patau’s syndrome
you have had a previous pregnancy that was affected by a genetic condition
you have a family history of a genetic condition, such as sickle cell disease, thalassaemia, cystic fibrosis or muscular dystrophy
when is amniocentisis performed
Amniocentesis is usually carried out between the 15th and 20th weeks of pregnancy, but you can have it later if necessary.
What are the risks of amniocentesis/cvs?
One of the main risks associated with amniocentesis is miscarriage, which is the loss of the pregnancy in the first 23 weeks.
This is estimated to occur in up to 1 out of every 200 women who have amniocentesis.
There are also some other risks, such as infection or needing to have the procedure again because it was not possible to accurately test the first sample.
How + when CVS is performed
CVS is usually carried out between the 11th and 14th weeks of pregnancy, although it’s sometimes performed later than this if necessary.
During the test, a small sample of cells is removed from the placenta using 1 of 2 methods:
transabdominal CVS – a needle is inserted through your tummy (this is the most common method used)
transcervical CVS – a tube or small forceps (smooth metal instruments that look like tongs) are inserted through the cervix (the neck of the womb)
cvs/amniocentisis how does it feel
feels like a period cramp settles w pain killers more feels like pressure symptoms
A 33-year-old nulliparous woman is 29 weeks pregnant. She was referred to the
rapid access breast clinic for investigation of a solitary breast lump. Sadly, a biopsy
of this lump revealed a carcinoma. After much counselling from the oncologists
and her obstetricians a decision is reached on her further treatment. What option
below may be available to her?
A. Tamoxifen
B. Computed tomography (CT) of the abdomen-pelvis
C. Radiotherapy
D. Chemotherapy
E. Bone isoptope scan to look for metastases in order to stage the disease
This is difficult to answer as it depends on how aggressive the cancer is.
There may be a need for delivery but it would not be immediate as she
is only 29 weeks pregnant. You would give a course of betamethasone
in order to promote fetal lung maturity prior to delivery. Tamoxifen (A)
is not safe in pregnancy and breastfeeding because of the high risk of
teratogenicity. Radiotherapy (C) is contraindicated in pregnancy unless it
is as a life-saving option. All chemotherapy is potentially teratogenic in
the first trimester but may used in the mid- and third trimesters. Ideally
birth should be 2–3 weeks after the most recent chemotherapy session to
allow bone marrow regeneration. Bone isotope scans (E) and CT of the
abdomen and pelvis (B) are likely to provide insufficient clinical value to
warrant the high dose of radiation that the fetus would be exposed to.
The serum tests for infection that NICE recommend as an offer at booking
are
HIV Syphilis Hep B
Hep b care
If you have hepatitis B, you’ll receive specialist care throughout your pregnancy and after the baby is born.
Your partner and any other children you have should also be offered a test for infection, and vaccinations if needed.
To prevent the baby getting hepatitis B, they will need vaccinations at the following times:
within 24 hours of birth (with an injection of antibodies if required)
4 weeks
8 weeks
12 weeks
16 weeks
1 year, with a blood test to check if infection has been avoided
It’s very important that the baby has all 6 doses of the vaccine. The doses at 8, 12 and 16 weeks will be given as part of their routine infant immunisations.
Mx:
- Normal delivery
- Normal breastfeeding
4 Factors which reduce vertical transmission HIV (from 25-30% to 2%)
maternal antiretroviral therapy
mode of delivery (caesarean section)
neonatal antiretroviral therapy
infant feeding (bottle feeding)
hiv in pregnancy care
Mother with HIV must continue taking HAART
- Mother’s viral load measured every 2-4 weeks until 36 weeks
Delivery:
- vaginal delivery is recommended if viral load <50/mL at 36 weeks, - cord clamped asap and baby is bathed immediatly
- otherwise C-section (co-current Hep C is an indication for C-section)
Neonatal ART:
If mother’s viral load < 50copies/ml at birth → baby will receive monotherapy Zidovudine for 2-4 weeks
If mother’s viral load >50copies/ml or unknown → PEP & oral triple therapy for 2-4 weeks
Neonates often test +ve for HIV Abs through passive transfer of Abs from mother. Diagnosis of HIV requires PCR tests @ birth, discharge, 6w, 12w & 18 months
ONLY CONTRAINDICATION TO BREAST-FEEDING → give bromocriptine/cabergoline to supress milk
syphillis in pregnancy
If you have syphilis, you will need urgent referral to a specialist care team. Treatment is usually a course of antibiotics.
Your care team will also offer to test your partner to see if they need treatment as well so that you do not get reinfected.
Your baby may need to be examined and given antibiotics after birth.
syphilis manifestations + mmg
Manifestations: children born with congenital syphilis become symptomatic by 5 weeks
Early: Jaundice, HSM, snuffles, periostitis, mucocut lesions on palms+ soles
Late: Hutchinson’s teeth, saddle nose, bloody rhinitis, frontal bossing of skull, interstitial keratitis, rhagdes, saber shins
Rx – IM Benzylpenicillin STAT
Prelabour rupture of membranes (PROM). definition
the rupture of fetal membranes at least 1 hour prior to the onset of labour, at ≥37 weeks gestation.
It occurs in 10-15% of term pregnancies, and is associated with minimal risk to the mother and fetus due to the advanced gestation.
Preterm Prelabour rupture of membranes (PPROM). definition
the rupture of fetal membranes occurring at <37 weeks gestation.
It complicates ~2% of pregnancies and has higher rates of maternal and fetal complications. It is associated with 40% of preterm deliveries.
prom/pprom cause
1) Early activation of normal physiological processes – higher than normal levels of apoptotic markers and MMPs in the amniotic fluid.
2) Infection – inflammatory markers e.g. cytokines contribute to the weakening of fetal membranes. Approximately 1/3 of women with P-PROM have positive amniotic fluid cultures.
3) Genetic predisposition
prom/pprom risk factors
Smoking (especially < 28 weeks gestation).
Previous PROM/ pre-term delivery.
Vaginal bleeding during pregnancy.
Lower genital tract infection.
Invasive procedures e.g. amniocentesis.
Polyhydramnios.
Multiple pregnancy.
Cervical insufficiency.
prom/pprom inv
To confirm:
- a sterile speculum examination - to look forpooling of amniotic fluid in the posterior vaginal vault but digital examination should be avoided due to the risk of infection
- if pooling of fluid is not observed NICE recommend testing the fluid for placental alpha microglobulin-1 protein (PAMG-1) (e.g. AmniSure®) or insulin-like growth factor binding protein‑1
- ultrasound may also be useful to show oligohydramnios
prom/pprom differentials
Urinary incontinence.
Normal vaginal secretions of pregnancy.
Increased sweat/ moisture around perineum.
Increased cervical discharge (e.g. with infection).
Vesicovaginal vaginal fistula.
Loss of mucus plug.
Complications of PPROM
- fetal: prematurity, infection, pulmonary hypoplasia
- maternal: chorioamnionitis
pprom mmg
Management
admission
regular observations to ensure chorioamnionitis is not developing
oral erythromycin should be given for 10 days
antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome
delivery should be considered at 34 weeks of gestation - there is a trade-off between an increased risk of maternal chorioamnionitis with a decreased risk of respiratory distress syndrome as the pregnancy progresses
if close up follow is availble may discharge with 2 weekly check ups - advise patient to avoid sexual intercourse.
prom mmg
Monitor for signs of clinical chorioamnionitis.
Clindamycin/penicillin during labour if GBS isolated.
Watch and wait for 24 hours (60% of women go into labour naturally), or consider induction of labour.
IOL and delivery recommended if greater than 24 hours (but women can wait up to 96 hours – beyond this is their choice after counselling)
why not tocolytics in prom/pprom
- need intact membranes
name some tocolytics
4 MAIN TOCOLYTICS:
Ritodrine/Terbutaline (β-agonists)
Indomethacine (COX inhibitors)
Nifedipine (Ca2+ blocker)
Atosiban (competitive oxytocin antagonist)
THE ONLY OBJECTIVES OF TOCOLYSIS ARE TO:
GESTATION IS VERY PRETERM
ENSURE A COMPLETE COURSE OF ANTENATAL STEROIDS CAN BE GIVEN
ALLOW TIME FOR TRANSFER TO NICU
PREVENTION of preterm labour offered to + options
To women who have both:
A history of spontaneous preterm birth (up to 34+0 weeks) or mid-trimester loss (from 16+0w onwards) AND
Results of TVUSS between 16-24 weeks show cervical length less than 25mm
1) cerclage
2) vaginal progesterone
tocolytics contraindications
infection
prom/pprom
bleeding( unless tryna give enough time for steroids)
when is vaginal progesterone started
Start vaginal progesterone between 16-24 weeks and continue to 34 weeks
cerclage when + why
You might prefer cervical cerclage if there is Hx of P-PROM or cervical trauma:
Inserted between 12-14 weeks
Rescue cerclage up to 23 weeks
Removed by 37 weeks
Antenatal Corticosteroids roles + when given + how given + which one given + why
Given between 24 and 34+6 weeks
A Cochrane study unambiguously revealed that a single course of antenatal corticosteroids can reduce risk of:
Neonatal death
RDS
Intraventricular haemorrhage
Betamethasone is the most widely used steroid as it crosses the placenta, lacks mineralocorticoid activity and has weak immunosuppressive activity in the short term.
Dosing – 2x 12mg IM 12 or 24hrs apart
Benefit of steroids is 2-7 days after dose so use tocolytics to ensure course is completed
Anytime you give steroids to a patient with diabetes → give insulin to prevent DKA
mag- sulphate roles + when given + how given + which one given + why
Mothers given magnesium sulfate to prevent eclamptic seizures showed a reduction in rates of periventricular leukomalacia and cerebral palsy
Very useful in before preterm delivery (<30wks) – given IV
MONITOR: clinical signs of Mg toxicity every 4hrs
Recording pulse
BP
RR
Deep tendon reflexes → hyperreflexia
preterm labour rf
causes of Major neonatal morbidity:
Intraventricular haemorrhage Grades III/IV
Seizures – periventricular leukomalacia
Hypoxic-ischaemic encephalopathy
NEC stage II/III
Bronchopulmonary dysplasia
Persistent pulmonary hypertension
Peak 55% incidence @ 25 weeks then falls
causes of minor neonatal morbidity:
Hypotension requiring treatment
Intraventricular haemorrhage Grades I/II
NEC stage I
Respiratory distress syndrome
Hyperbilirubinaemia
Peak 81% incidence @ 31 weeks then falls
chorioamniotis pathogens
GBS, e-coli- anaerobes
chorioamniotis rf + s/s
Triad of maternal pyrexia, maternal tachycardia and fetal tachycardia
Major risk factor: PROM
S/S:
- Fever
- Abdominal pain
- Offensive vaginal discharge
- Evidence of preterm rupture of membranes
- Maternal and foetal tachycardia
- Pyrexia
- Uterine tenderness
chorioamniotis mmg
- Admit
- Arrange prompt delivery of the foetus (C-section if necessary)
IV intrapartum antibiotics (erythromycin and benzylpenicillin) - Consider TVUSS to assess cervical length and determine likelihood of birth within 48 hours
normal amniotic fluid index(afi)
5-25
polyhydramnios definiton
afi >25 = >95th centile, 2-3L fluid, deepest pool >8cm
polyhydramnios rf
RFs:
1) Failure of fetal swallowing – neuro or GI (Oesophageal or duodenal atresia, Diaphragmatic hernia, Anencephaly)
2) Congenital infections
3) Fetal polyuria ( Maternal diabetes mellitus, Foetal renal disorders, Foetal anaemia, Twin-to-twin transfusion syndrome
polyhydramnios pres
Presentation:
Uterus which feels tense or large for dates and it may be difficult to feel the foetal parts on palpation of the abdomen, increased fundal height
polyhydramnios mmg
MMG:
- Management of any underlying causes (e.g. in maternal diabetes)
- Amnio-reduction in severe cases (Needle aspiration)
- COX inhibitors to decrease foetal urine output
Consider induction of labour at 38-39 weeks
Complications of polyhydramnios
- Pregnancy induced hypertension
- Maternal urinary tract infection
- Premature delivery
- Postpartum haemorrhage - due to
overdistension of the uterus - Premature rupture of the membranes
- Cord prolapse
- Abnormal fetal presentation
- Low Apgar scores
- Intra-uterine death
- Neonatal death
- Placental abruption
- Caesarean section
oligohydramnios definiton
Amniotic fluid index < 5cm
oligohydramnios rf:
Reduced input fluid
- placental insufficiency, pre-eclampsia - results in IUGR
o Reduced output fluid
- structural pathology (AR PKD), medications (ACEi, NSAIDs), renal agenesis
o Lost fluid
- PROM, IUGR, post-term pregnancy carry, TTTS
o Chromosomal abnormalities
what does oligo hydramnions result in
potter sequence
what is potter sequence
Potter sequence occurs when renal issues in baby result in olgohydramnios resulting in foetal growth issues:
- Pulmonary hypoplasia
- Oligohydramnios
- Twisted skin , wrinkly skin
- Twisted face - flat face, wide spaced eyes + epicanthal folds, low set ears
- Extremity deformities - clubbed feet
- Renal agenesis,
oligohyrdraminos mmg
Depends on the underlying cause, the gestational age, and the presence of fetal distress. Options may include:
- Maternal rehydration: This may help to increase the amniotic fluid volume in mild cases of oligohydramnios.
- Amnioinfusion: This is the infusion of saline into the amniotic cavity to increase the volume of amniotic fluid.
- Delivery: In severe cases, or if the fetus is in distress, delivery may be the best option. This may be via induction of labour or caesarean section, depending on the clinical scenario.
poly/oligo hydramnios inv
Investigations:
amniotic fluid index
USS for diagnosis
Find underlying cause
foetal distress signs
what murmur is normal in pregnancy
soft systolic flow murmur is frequently audible on auscultation of
the praecordium due to dilatation across the tricuspid valve causing
mild regurgitant flow. Such a flow murmur is physiological and will
disappear after delivery.
PE in pregnancy mmg
-V/Q scan
- enoxaparin
fetal warfarin syndrome,
a constellation of symptoms comprising nasal hypoplasia,
vertebral calcinosis and brachydactyly. The risk of teratogenicity with
warfarin use in the mid- and third trimesters is reduced but evidence exists
to show a chance of cerebral malformations and ophthalmic disorders.
eclamptic fit mmg
Call for help, ABC, left lateral tilt, protect airway, prepare magnesium
