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Year 3- placement > Obstetric core conditions 3 > Flashcards

Obstetric core conditions 3 Flashcards

1
Q

Risks of prematurity

A
  • Increased mortality depends on the gestation
  • Respiratory distress syndrome
  • Intraventricular haemorrhage
  • Necrotizing enterocolitis
  • Chronic lung disease, hypothermia, feeding problems, infection, jaundice
  • Retinopathy of prematurity: important cause of visual impairment in babies born before 32 weeks gestation
  • Hearing problems
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2
Q

Complications of PPROM

A
  • Fetal: prematurity, infection, pulmonary hypoplasia
  • Maternal: chorioamnionitis

2% of pregnancies but 40% of preterm deliveries

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3
Q

Investigation of PPROM

A

A sterile speculum examination should be performed (to look for pooling of amniotic fluid in the posterior vaginal vault) but digital examination should be avoided due to the risk of infection. Ultrasound may also be useful to show oligohydramnios

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4
Q

Management of PPROM

A
  1. Admission
  2. Regular observations to ensure chorioamnionitis is not developing
  3. Oral erythromycin should be given for 10 days
  4. Antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome
  5. Delivery should be considered at 34 weeks of gestation - there is a trade-off between increased risk of maternal chorioamnionitis with a decreased risk of respiratory distress syndrome as the pregnancy progresses
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5
Q

Categories of preterm baby

A

Preterm baby: birth prior to 37 weeks

  1. Extremely preterm <28 weeks
  2. Very preterm= 28 – 31+6 weeks
  3. Moderate to late preterm= 32 – 36+6 weeks
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6
Q

Risk factors for a preterm baby

A
  1. Multiple pregnancy
  2. Cone biopsy/LLETZ
  3. Obstetric cholestasis
  4. Pre-eclampsia
  5. Diabetes
  6. Antiphospholipid syndrome
  7. Uterine abnormality
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7
Q

Planned preterm babys

A

In 25% of preterm births, the delivery is planned (IOL / CS) due to maternal or fetal complications, for example pre-eclampsia, fetal growth restriction, chorioamnionitis, or PPROM (preterm premature rupture of membranes).

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8
Q

Preterm delivery prophylaxis

A
  1. If a women has had a previous preterm delivery/ mid-trimester loss, cervical loss shortening- vaginal progesterone or cervical cerclage
  2. At risk of preterm delivery- corticosteroids aid fetal lung maturity (between 24-34+6 weeks if vaginal delivery, up to 38+6 in CS). Other pharmacological agents include magnesium sulfate for neuroprotection and nifedipine for tocolysis.
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9
Q

Medication in P-PROM

A

Offer women with P-PROM oral erythromycin 250 mg 4 times a day for a maximum of 10 days or until the woman is in established labour (whichever is sooner)

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10
Q

Diagnosis of P-PROM

A
  1. Speculum examination shows pooling of amniotic fluid in the vagina
  2. If in doubt: IGFBP-1 and PAMG-1 in the vaginal fluid prove P-PROM
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11
Q

Preterm labour with intact membranes

A
  1. Involves regular painful contractions and cervical dilation without rupture of the amniotic sac
  2. Less than 30 weeks gestation, clinical assessment alone is enough to offer management of preterm labour.
  3. More than 30 weeks gestation, a transvaginal ultrasound can be used to assess the cervical length. When the cervical length on ultrasound is less than 15mm, management of preterm labour can be offered. A cervical length of more than 15mm indicates preterm labour is unlikely.
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12
Q

Fetal Fibronectin

A

A result of less than 50 ng/ml is considered negative, and indicates that preterm labour is unlikely.

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13
Q

Management of preterm labour

A
  • Fetal monitoring (CTG or intermittent auscultation)
  • Tocolysis with nifedipine: nifedipine is a calcium channel blocker that suppresses labour
  • Maternal corticosteroids: can be offered before 35 weeks gestation
  • IV magnesium sulphate: can be given before 34 weeks gestation and helps protect the baby’s brain
  • Delayed cord clamping or cord milking: can increase the circulating blood volume and haemoglobin in the baby at birth
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14
Q

Reduced fetal movement

A

Movement first perceived between 18-20 weeks of gestation. Reduced or absent movement could signal death. Fetal movements are usually absent during fetal ‘sleep’ cycles; these occur throughout the day and usually last 20-40 minutes, rarely exceeding 90 minutes in a healthy fetus.

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15
Q

Reduced fetal movement- examination

A
  1. SFH- to assess fetal size
  2. Auscultation of the fetal heart using a handheld doppler
  3. CTG- if the women is over 28 weeks gestational age
  4. Ultrasound- if there is reduced movement even after normal CTG
  5. If no fetal movement has been felt by 24 weeks gestation- referral to a specialist fetal medicine centre to investigate for neuromuscular conditions
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16
Q

Risk factors for reduced fetal movements

A
  • Posture- being more prominent during lying down and less when sitting and standing
  • Distraction
  • Placental position- Patient with anterior placentas prior to 28 weeks gestation may have lesser awareness of fetal movements
  • Medication- Both alcohol and sedative medications like opiates or benzodiazepines can temporarily cause reduced fetal movements
  • Fetal position- Anterior fetal position means movements are less noticeable
  • Body habitus- Obese patients are less likely to feel prominent fetal movements
  • Amniotic fluid volume- Both oligohydramnios and polyhydramnios can cause reduction in fetal movements
  • Fetal size- Up to 29% of women presenting with RFM have a SGA fetus
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17
Q

Definition of reduced fetal movements

A

Less than 10 movements within 2 hours in pregnancies past 28 weeks gestation. Usually based just on maternal perception though can be objectively assessed with a hand held Doppler or ultrasonography

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18
Q

Reduced fetal movement- investigations

A
  • Initially, handheld Doppler should be used to confirm fetal heartbeat.
  • If no fetal heartbeat detectable, immediate ultrasound should be offered.
  • If fetal heartbeat present, CTG should be used for at least 20 minutes to monitor fetal heart rate which can assist in excluding fetal compromise.
  • If concern remains, despite normal CTG, urgent (within 24 hours) ultrasound can be used.
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19
Q

SGA and FGR

A

Small for gestational age (SGA): birth weight less than the 10th centile
Fetal growth restriction (FGR): a pathological restriction of genetic growth potential. Different to SGA.

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20
Q

Causes for SGA fetus’s are divided into 3 categories

A
  1. Normal (constitutionally) small
  2. Non-placenta mediated growth restriction – structural / chromosomal anomaly, inborn errors of metabolism, fetal infections
  3. Placenta medicated growth restriction – cigarette smoking, severe anaemia, pre-eclampsia, diabetes, hypertension
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21
Q

Management of SGA in pregnancy

A
  1. Women who have risk factors for developing a SGA fetus should be referred for consultant-led care and have serial scans measuring fetal size and umbilical artery doppler from 26-38 weeks.
  2. Timing of delivery is individualised on a case to case basis depending on growth trajectory, severity of SGA and umbilical artery doppler, however delivery should be considered from 37 weeks if they have a normal doppler, and before this with an abnormal doppler.
    FGR and IUGR are used synonymously
22
Q

Different types of IUGR

A
  1. Asymmetrical IUGR: disproportionate growth restriction, greater decrease in foetal body and limbs compared to head circumference. Due to placental insufficiency. Oxygen and nutrients are directed towards vital foetal organs (brain and heart) bypassing other organs (e.g. foetal liver, muscle and fat tissue). This affects the foetus later in gestation.
  2. Symmetrical IUGR: proportional growth restriction in all parts of the foetus, due to intrinsic factors like genetic abnormalities and intrauterine infections. Affects the foetus early in gestation.
23
Q

Maternal risk factors for IUGR

A
  1. Maternal medical conditions: pre-existing diabetes mellitus, chronic hypertension, gestational hypertension, pre-eclampsia, systemic lupus erythematosus, antiphospholipid syndrome, sickle cell disease, severe anaemia, anorexia nervosa
  2. Substance use: tobacco, alcohol, cocaine, or narcotics
  3. Exposure to teratogenic drugs: ACE-inhibitors, warfarin, carbamazepine, phenytoin, cyclophosphamide or valproic acid
  4. Previous pregnancy with IUGR
24
Q

Placental risk factors for IUGR

A
  1. Placental insufficiency caused by maternal conditions (e.g. chronic hypertension, diabetes mellitus, sickle cell disease or anorexia nervosa) or pregnancy-related conditions (e.g. Rh- incompatibility or pre-eclampsia)
  2. Placenta praevia or placental abruption
  3. Umbilical artery thrombosis or infarction
  4. Uterine abnormalities (e.g. fibroids)
  5. Multiple gestation
25
Q

IUGR- clinical findings

A
  • Symphysial-fundal height (SFH) is decreased compared to gestational age (at least 3cm less than gestational age in weeks)
  • Foetus is small for gestational age
  • Foetal movements are reduced or absent
26
Q

IUGR- Bedside investigation’s

A
  • Maternal vital signs (basic observations): blood pressure, heart rate, respiratory rate, oxygen saturation, temperature
  • Urine dipstick
  • Cardiotocography (CTG): to assess foetal compromise. It may show late decelerations of the foetal heart rate and foetal bradycardia in IUGR
27
Q

IUGR- Imaging

A
  • Serial ultrasound scans: to assess foetal biometry and estimated foetal weight which are plotted on a customised growth chart
  • Umbilical artery doppler: reduced or reversed diastolic flow
  • Biophysical profile: A BPP score of <4 indicates need for delivery
28
Q

Prevention of IUGR

A

Consider administration of low dose aspirin prior to 16 weeks of gestation. Smoking cessation and treating underlying cause

29
Q

Complications of IUGR

A
  • Preterm labour and delivery, Stillbirth
  • Perinatal asphyxia
  • Necrotising enterocolitis
  • Cognitive delay and behavioural issues
  • Adult-onset diseases (e.g. diabetes mellitus, obesity, coronary artery disease, hypertension)
  • Motor and neurological disabilities
30
Q

LGA= large for gestational age

A
  • Estimated weight over the 90th centile for gestational age. Macrosmia
  • Risk factors: high BMI (>35), diabetes, previous LGA, family history. Male babies are more likely to be LGA
  • Can be diagnosed on serial growth scans, or through SFH measurements over the 90th centile, which should prompt an urgent growth scan to more accurately estimate fetal weight. An oral glucose tolerance test (OGTT) should also be offered to test for gestational diabetes.
  • LGA fetuses have a higher rate of shoulder dystocia, perineal tear and requirement of instrumental delivery.
31
Q

Breech presentation

A

A longitudinal fetal lie with the fetal buttocks presenting at the maternal pelvis and the head towards the fundus of the uterus

32
Q

Types of breech position

A
  1. Extended breech (sometimes referred to as ‘frank’ - 70% of breech presentations): both legs are extended with feet by head; presenting part is the buttocks
  2. Flexed breech(or ‘complete’- 15%): legs are flexed at the knees so that both buttocks and feet are presenting
  3. Footling breech (15%): one leg is flexed with the foot presenting below the buttocks, and the other leg is extended.
33
Q

Risk factors for breech positioning

A

Previous breech presentation, uterine abnormalities (i.e. fibroids, bicornuate uterus), placenta previa, fetal abnormalities and multiple gestation.

34
Q

ECV

A

ECV is the manipulation of the fetus, through the maternal abdomen, into a cephalic (head down) presentation. Usually a tocolytic (such as terbutaline) is given to relax the uterine muscles during the procedure and ultrasound guidance is used.

35
Q

Management of breech position

A
  1. if < 36 weeks: many fetuses will turn spontaneously
  2. if still breech at 36 weeks NICE recommend external cephalic version (ECV)- The RCOG recommend ECV should be offered from 36 weeks in nulliparous women and from 37 weeks in multiparous women
  3. if the baby is still breech then delivery options include planned caesarean section or vaginal delivery. Complications are more common in vaginal delivery
36
Q

Absolute contraindications to ECV

A
  1. where caesarean delivery is required
  2. antepartum haemorrhage within the last 7 days
  3. abnormal cardiotocography
  4. major uterine anomaly
  5. ruptured membranes
  6. multiple pregnancy
37
Q

Breech position- clinical findings

A

1.Longitudinal lie
2. Head palpated at the fundus
3. Irregular mass over pelvis (feet, legs and buttocks)
4. Fetal heart auscultated higher on the maternal abdomen
5. Palpation of feet or sacrum at the cervical os during vaginal examination

38
Q

Fetal complications of breech position include

A
  • Developmental dysplasia of the hip (DDH)
  • Cord prolapse
  • Fetal head entrapment
  • Birth asphyxia
  • Intracranial haemorrhage
  • Perinatal mortality
39
Q

Unstable lie

A

Definition: fetal position changing frequently

Patients with an unstable or transverse lie may be admitted to hospital from 37 weeks (due to higher risk of cord prolapse) and considered for a caesarean section.

40
Q

Cause of an unstable lie

A
  • polyhydramnios
  • prematurity
  • subseptate uterus
  • pelvic tumours such as fibroids and ovarian cysts
  • Placenta praevi
41
Q

Management of an unstable lie

A
  • Increased risk of cord prolapse
  • Refer for ECV
42
Q

Foetal lie- definition and classification

A

‘Foetal lie’ is the term which refers to the long axis of the foetus relative to the longitudinal axis of the uterus.

The 3 types of lie are:
1. longitudinal lie (99.7% of foetuses at term)
2. transverse lie (<0.3% of foetuses at term)
3. oblique (<0.1% of foetuses at term)

43
Q

Transverse lie

A

Transverse lie is an abnormal foetal presentation whereby the foetal longitudinal axis lies perpendicular to the long axis of the uterus. In real terms, this means the foetal head is on the lateral side of the pelvis and the buttocks are opposite. When in transverse lie, the foetus can be either ‘scapulo-anterior’ (most common) where the foetus faces towards the mother’s back or ‘scapulo-posterior’ where the foetus faces towards the mothers front.

44
Q

Risk factors for a transverse lie

A
  1. Most commonly occurs in women who have had previous pregnancies
  2. Fibroids and other pelvic tumours
  3. Pregnant with twins or triplets
  4. Prematurity
  5. Polyhydramnios
  6. Foetal abnormalities
45
Q

Complications of a transverse lie

A
  • Pre-term rupture membranes (PROM)
  • Cord-prolapse (20%)
  • If allowed to progress to vaginal delivery, compound presentation may occur. This is extremely rare in the UK.
    The breech baby lies vertically, the transverse lie baby lies horizontally.
46
Q

What should high risk pregnancies be offered

A

CTG monitoring of the heart rate, done from 4cm dilation it is continuously monitored

47
Q

Assessing a CTG

A
  • Contractions= How many in 10 minutes? Strength? Duration? (Aim for 4:10 if using synthetic oxytocin)
  • Baseline rate= Normal Baseline rate for full term pregnancy = 110-160bpm.
  • Variability= The amplitude of the beat-to-beat fluctuation of the fetal heart rate around the baseline. Should be 5-25bpm.
  • Acceleration= An increase in the baseline fetal heart rate of greater than 15 bpm for greater than 15 seconds. The presence of accelerations is reassuring – they’re often associated with fetal movements. The absence of accelerations in an otherwise normal trace is an ambiguous finding.
  • Decelerations= A decrease in the baseline fetal heart rate of greater than 15 bpm for greater than 15 seconds.
  • Based on the features: Normal, Suspicious and Pathological.
48
Q

Indications for the induction of labour

A
  • Prolonged pregnancy, e.g. 1-2 weeks after the estimated date of delivery
  • Prelabour premature rupture of the membranes, where labour does not start
  • Diabetic mother > 38 weeks
  • Pre-eclampsia
  • Rhesus incompatibility
49
Q

Bishops score

A
  • A score of < 5 indicates that labour is unlikely to start without induction
  • A score of ≥ 8 indicates that the cervix is ripe, or ‘favourable’ - there is a high chance of spontaneous labour, or response to interventions made to induce labour
50
Q

Methods of inducing labour

A
  • Membrane sweep
  • Vaginal prostaglandins: preferred method for inducing labour
  • Maternal oxytocin infusions
  • Amniotomy- breaking off waters
  • Cervical ripening balloon- passed through the endocervical canal and inflated to dilate the cervix

Year 3- placement (34 decks)

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