Obstetrics Flashcards
When are children competent to consent?
When they can understand the nature and consequences of treatment
4 reasons why you can breech confidentiality for children
too immature to understand/ consent (see Frazer guidelines)
force or threat of force dangerous to health
drugs/ alcohol used to influence them
known to police as having abusive relationships with children/young people
How old is a child when they are presumed competent to consent to treatment
16-18 years
When can a child refuse treatment
If they are over 18
What happens if a competent child refuses treatment
A parent/court might allow management in their best interest
What is the difference between the frazer guidelines and gillick competence?
Frazer guidelines: If under 16 for contraceptives
Gillick competence: General issues around consent
5 points for frazer guidelines
understand advice cannot inform parents dangerous to their health unless they get contraception have sex anyway in their best interest
What 3 acts are used for consent in people with learning difficulties?
learning disability, sex and the law (2005)
sexual offences act (2003)
mental capacity act
What do people with learning difficulties need in order to consent to sex ?
They need capacity to know the mechanisms and the consequences of sex
What would you do if a patient came to you after a rape
Refer to sexual assault referral centre (SARC) where a forensic physician does Hx and examination
Checks for pregnancy, HIV, Hep B, suicidal ideation and safeguarding
how can you assess the quality of NHS services
Number of processes (referral/smears) and Outcome (mortality/morbidity, STI, unplanned pregnancy)
4 issues with NHS services
societal (less services), cultural (language, modesty), economic (access), political (e.g. law regarding abortion)
4 sexual health services
GP
Family planning clinics (STI, unplanned pregnancy)
Pharmacies
SARC
3 GU services
GUM clinic
GP
A&E
2 gynae services
Gynaecologist
GP
4 midwife/obstetric services
Hospital Antenatal services Community midwife GP Early assessment unit
Define stillbirth
A baby delivered after 24 weeks with no signs of life
1/200
Defineneonatal death
Death of a LIVE BORN infant within 28 days (3/1000)
Define early neonatal health
Within 7 days
Define post-neonatal death
From 28 days to 1 year (1/1000)
Define stillbirth rate
Number of stillbirths per 1000
4/1000
Define perinatal mortality rate
Number of stillbirths + early neonatal deaths per 1000 total
(7/1000)
Define infant mortality rate
Number of deaths in first year per 1000 live births (4/1000)
Define maternal mortality rate
Within 42 days of TOP/whilst pregnant
9/100,000
What recent campaign has reduced infant mortality rate in the UK
Sleep campaign
8 risk factors for stillbirth in the UK
Foetal growth restriction (biggest cause)
Congenital abnormality
Multiple birth
Maternal age (<25 or >40), ethnicity (black/Asian have 50% increased risk), poverty, substances, obstetric complications.
5 causes of stillbirth in the UK
4 causes worldwide
1 key fact about worldwide stillbirths
- 92% occur before onset of labour
- 54% are unexplained
- 25% due to asphyxia/ trauma e.g. cord prolapse/ abruption
- 15% due to congenital abnormalities
- 10% due to infections
Worldwide, 50% of deaths occur during labour, maternal infections inc malaria, syph and HIV, post term pregnancy and poorly controlled maternal health conditions e.g. NTH, DM
(most are preventable)
4 biggest causes of neonatal death in the UK and 1 worldwide
- prematurity is biggest killer (resp. disorders followed by neurological disorders)
- congenital abnormalities (heart, NTD, etc)
- obstetric complications e.g. shoulder dystocia
- infections
Globally, majority are due to infections
What global percentage of stillbirths occur in low/middle income countries
98%
75% in ssa
8 strategies for prevention of stillbirth in the UK
Vit D, folate and iron
Stop smoking (SIDS/ neonatal breathing difficulties), alcohol, medication
Certain foods (raw meat, soft chesses, liver)
Screen for diseases
Breastfeeding
CTG training
5 ways to reduce perinatal deaths
- thermal protection, dry the goddam baby
- hygiene
- breastfeeding
- assessment
- prevention (vit K, Hep B and BCG if necessary)
First down syndrome screening
11-14 weeks
Combined test
Increased nuchal BHCG; low PAPP-A
Second down syndrome screening
15-20 weeks
Quadruple test
High inhibin A and BHCG, low AFP and low unconjugated oestriol
What happens if there is a low and high chance of downs syndrome
and what are the cut offs?
1/150 is cut off
Go for amniocentesis
2 benefits of screening for downs syndrome
Allows the parents to prepare and plan
Gives them an informed choice if they want to terminate
3 arguments against screening for downs syndrome
Risk of false positive and negatives
Spontaneous abortion with diagnostic testing (1%)
Suggesting Down’s syndrome life is less important
When should you seek fertility help
After 1 year of trying (6 months if over 35 years)
First line for infertility
Lifestyle change
Epidemiology of fertility
Affects 1/7 couples
84% should conceive within 1 year
5 causes of infertility and %
30% male factor 20% ovulation failure 15% tubal damage 20% unexplained 15% other
Investigations for infertility
Semen analysis
Serum progesterone 7 days prior to next period
Oestrogen
FSH/LH
Medication used for infertility where the cause is known
Clomifene (SERM, increases HPG axis)
How long do you wait after investigations before IVF is considered
1 year
How many cycles of Intrauterine Insemination (IUI)?
3 criteria
Up to 6 cycles
If unable to have vaginal intercourse (e.g. disability)
Condition that means need help to conceive (e.g. STI)
Same sex relationship
How many cycles of IVF if below 43 years
Up to 3 cycles on the NHS if:
Below 43 years and 2 years of trying with 12 cycles of artificial insemination
Between 23 and 39 AND there is a fertility problem OR infertile for more than 3 years
Does any previous self-funded count towards 3 funded by NHS
Yes
How many cycles of IVF if aged 40-42 years
1 cycle of IVF if after 2 years of regular sex or 12 cycles of insemination
- never had IVF
- no evidence of fertility problems
- risks have been discussed
2 lifestyle criteria for IVF
Non smoking
Healthy BMI
Epidemiology of assisted reproduction
2% of all babies in the UK
25% success rate
What are the 5 stages of IVF?
Ovarian hyperstimulation Oocyte recovery Insemination Embryo culture and transfer Luteal phase support
What happens during ovarian hyperstimulation?
GnRH agonist given to cause pituitary downregulation to prevent premature ovulation (increased then decreased oestrogen)
jMG, LH, FAH and hCG to stimulate folliculogenesis
When does oocyte recovery occur?
34-36 hours after hCG infections
US for transvaginal oocyte recovery
Percentage of sperm which fertilise during insemination
Put sperm in petri dish with oocytes
50-70% fertilise
What happens during embryo culture and transfer
Fertilised oocytes examined, selected and inserted into the uterus
What happens during luteal phase support
Progesterone supplementation to support the pregnancy until 10 weeks (when placenta begins to make progesterone)
What is intrauterine insemination (IUI)
Separate healthy sperm and inject them into the uterus
Benefits and drawbacks of IUI
Good for male infertility
If you can’t have sex, same sex or HIV
Cheaper
Worse outcomes
What happens during intracytoplasmic sperm injection (ICSI)
Same as IVF but sperm are INJECTED into oocytes instead of left to mix in a petri dish
2 indications for ICSI
Indicated when quality of sperm is poor/low sperm count or when pregnancy has failed in the past
What happens during pre-implantation genetic diagnosis (PIGD)
Single cell removed from the blastocyst and screened for diseases
3 things people can donate
Who uses it?
Ethics?
Oocyte, Sperm or Embryo
Same-sex
Ethics of anonymity
When would you use surrogacy
When the mother can no-longer carry the foetus
Legality of surrogacy
Surrogate is the legal mother and cannot hand over legal responsibility until 6w postnatal
6 risks of IVF to mother
ectopic, OVHS, multiple gestation GD, anaemia, pre-eclampsia, miscarriage
3 risks of IVF to the foetus
Prematurity (and consequences), IUGR, Miscarriage
What does the court/adoption agency consider in regards to the child’s welfare in subfertility
Effect on child on not being a member or original family
Harm (children’s act 1989) child has suffered or is at risk of suffering
In adoption, child’s religious, racial, cultural and linguistic background
3 arguments for IVF
Procreative autonomy: respect patient choices, minimalize state interference
Infertility can affect mental health
Welfare interest of future child
2 arguments against IVF
Embryos have moral status (destruction of embryos)
Harm to those conceive (OHSS, multiple, ectopics)
Positive and Negative right of IVF
- Positive rights: no obligation to provide parents with means to have children
- Negative right: obligation not to interfere with peoples decision to have children
What does the HFEA Act 1990 State?
no treatment unless welfare of child has been taken into account (including need for a father)
- changed to 2008 to remove father and just supportive parenting
Epidemiology of TOP
30% of pregnancies terminated
92% before 13 weeks
What does the Abortion Act (1990) state about the foetus?
Foetus holds no legal status until birth
When was the abortion act amended from 28 weeks to 24 weeks
1990
2 laws regarding medical practitioners in termination
Done by a medical practitioner in NHS hospital or licenced premise
Two medical practitioners signs HSA1 agree unless it is an emergency (HSA2)
5 key points for TOP
A: continuing pregnancy involves greater risk of life to pregnant women than if terminated
B: Termination is necessary to prevent permanent injury to physical/mental health of mum
C: pregnancy < 24w and continuing pregnancy means greater risk than if terminated to physical/mental of pregnant woman
D: < 24w and continuing pregnancy means greater risk to physical/mental heath of existing children of pregnant woman
E: if child was born it would suffer physical or mental abnormalities > seriously handicapped.
i. e. > 24w, threatens mums life, permanent injury to mum, child has serious handicap (A,B,E)
i. e. < 24w risk>benefit of preg vs TOP to physical/mental health of mum or her children (C,D)
?
When can you continue with a TOP in under 16 year olds
If Gillick competent AND
- Girl understands all aspects and implications
- Cant persuade her to tell her parents/ allow us to tell them
- Physical/mental health is likely to suffer unless they receive treatment
- In the best interest of the young person to receive treatment without parents
3 routes to get an abortion
Contact advisor e.g. British pregnancy advisory service (BPAS), Marie Stopes
GP for referral to abortion service
Visit contraception clinic/ family planning clinic/ sexual health clinic/ Gum for referral
Length of time from initial appointment to abortion
2 weeks
Can a doctor refuse
Yes, unless it is an emergency
They need to refer quickly to another person
5 things to do prior to TOP
Screen for STO Discuss contraception Check smear Give ABX prophylaxis Give Anti-D if needed after procedure
What infection can you get?
Post-operative salpingitis
TOP procedure if less than 9 weeks
use mifepristone (anti-progesterone – cervix easier to open) followed by misoprostol (prostaglandins) 48h later to stimulate uterine contractions
TOP procedure if less than 13 weeks
Misoprostol 3h before surgery – reduce cervical trauma
Surgical dilation and suction of uterine contents
TOP if more than 15 weeks
Surgical dilation and evacuation of uterine contents or late medical abortion (mini-labour)
TOP procedure if more than 22 weeks
Feticide is performed by using KCL in umbilical vein or foetal heart.
4 complications of TOP
Infection (10%)
Cervical trauma (1%)
Failed TOP (1%)
Haemorrhage 1/1000)
6 arguments for TOP
- respects mothers autonomy
- prevents harm to mothers health
- prevents harm to foetus’ health
- may be due to crime e.g. rape
- may not be able to cope with a child
- more backstreet abortions
4 arguments against TOP
- Pro-life: ends life of fetus with moral status of a person (their rights)
- religions reasons
- abortions for Down’s syndrome – suggest they have a lower moral status than other children
- subjects more parents to unnecessary procedures.
What are the four types of FGM?
Type 1: patrial/total removal of clitoris
Type 2: Removal of clitoris and labia minora
Type 3: Narrowing vaginal oriface by cutting labina minora/majora
Type 4: All other harmful procedures
?Where is FGM most common and why?
Africa, Middle East, Malaysia, Indoesia
Preservation of virginity, promoting hygiene, cultural norms and religion
Consequences of FGM for girl
Infection, pain, dyspareunia, self-harm, depression
Suspect FGM
Illegal
Call police
