Obstetrics Flashcards
Nutritional supplements in pregnancy
Folic acid 400mcg from conception to 12 weeks, reduce risk of neural tube defects. Higher dose if on AEDs
No need for routine iron supplementation
Advise to take vitamin D 10mcg daily, especially if darker skin or skin mostly covered.
Food and drink to avoid in pregnancy
Avoid alcohol. Dose response, so if cutting down should be supported.
Avoid unpasteurized milk, ripened soft cheese (camembert, brie, blue cheese), pate or undercooked meat, due to risk of listeriosis
Avoid raw or partially cooked eggs and meat (esp poultry), due to risk of salmonella
Booking appointment what happens
8-12 weeks
General infor re diet, alcohol, smoking, folic acid, vitamin D, antenatal classes
BP, urine dipstick, check BMI
Bloods: FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies, hep B, syphilis, HIV offer
Urine culture for asymptomatic bacteriuria
What scan happens at 20 weeks
Anomaly scan
Features of placental abruption not placenta praevia
shock out of keeping with visible loss
Pain constant
Tender, tense uterus
Normal lie and presentation
Fetal heart absent or distressed
Coagulation problems
Beware pre eclampsia, DIC, anuria
Features of placenta praevia not abruption
shock in proportion to visible loss
No pain
Uterus not tender
Lie and presentation may be abnormal
Fetal heart usual normal
Coagulation problems rare
Small bleeds before large
Hepatitis B and pregnancy
all pregnany women screened
babies born to infected mothers should have complete course of vaccination and hep B immunoglobulin (0.5ml within 12 hours of birth)
Hep B cannot be transmitted via breastfeeding
breastfeeding and antiepileptics
generally considered safe, apart from taking barbiturates
Stage 1 labour
from inset of true labour to when cervix is fully dilated
Stage 2 labour
From full dilation to delivery of fetus
Stage 3 labour
from delivery of fetus to when place ta and membranes have been completely delivered
Signs of labour
regular and painful uterine contracts
A show (shedding of mucous plug)
Rupture of membranes
Shortening and dilation of the cervix
Potential complications of post-term pregnancy
Neonatal: Reduced placental perfusion, oligohydramnios
Maternal: Incr rate of intervention incl forcepts and CS, incr rate of labour induction
What not to use for third stage if maternal hypertension
Ergometrine
Common drugs you can’t take during pregnancy
Aspirin - found in breast milk so Reye’s syndrome
Codeine as excreted
Lithium, can be transferred and cause enal and thyroid dysfunction
naproxen, possibly incr risk of bleeding and thrombocytopenia
Features of obstetric cholestasis
Pruritus, may be intense and typically worse on palms, soles abdomen
Clinically detectable jaundice only in 20%, but raised bilirubin in >90% of cases
Management of obstetric cholestasis
induction of labour at 37-38 weeks commonly occurs but isn’t really evidence based
Ursodeoxycholic acid widely used but evidence base limited
Results of quadruple test for Down’s syndrome
Alpha fetoprotein reduced
Unconjugated oestriol reduced
HCG increased
Inhibin A increased
Result of quadruple test for Edward’s syndrome
Alpha fetoprotein reduced
Unconjugated oestriol reduced
HCG reduced
Inhibin A normal
Results of quadruple test for neural tube defects
Alpha fetoprotein increased
Unconjugated oestriol norma’
HCG normal
Inhibin A normal
non invasive prenatal testing mechanism
analyses small DNA fragments circulating in blood of pregnant woman (cffDNA)
This is derived from placental cells, so is fetal tissue
early detection of chrompsomal abnormalities
Sensitivity and specificity are very high
anti epileptocs with adverse effects in pregnancy
Sodium valproate, phenytoin and phenobarbitone
Vaginal delivery with HIV?
Recommended if viral load is less than 50 copies/ml at 36 weeks
rhesus sensitisation
The process where RhD+ fetal RBCs enter maternal circulation where mother is RhD-. Fetomaternal haemorrhage can cause antibodies to form that can haemolyse fetal RBCs.
Potential events in pregnancy causing rhesus sensitisation
Ectopic pregnancy
Evacuation of retained products of conception
Vaginal bleeding >12wk if painful/heavy/persstent
Vaginal bleeding >12 wk
Chorionic villus sampling and amniocentesis
Antepartum haemorrhage
Abdo train
External cephalic version
Intra uterine
Post delivery
Consequences for fetus of RhD sensitisation
Oedema (hydrops fetalis, as liver focus on RBC production and falling albumin)
Jaundice, anaemia, hepatosplenomegaly
Heart failure
Kernicterus (excess bilirubin causes brain damage)
Pre-eclampsia classic triad
New onset hypertension (>140/90 after 20 wks)
Proteinuria
Oedema
Potential consequences of pre eclampsia
Eclampsia
Fetal IUGR and premature
Liver involvement
Haemorrhage (placental abruption, intra abdo/cerebral)
CardiAc failure
Features of severe pre eclampsia
Hypertension >160/110
Big proteiniria
Headache
Visual disturbance
RUQ/epigastric pain
Hyperreflexia
Low platelets, abnormal LFTs, or HELLP
High risk factors for preeclampsoa
hypertensive disease in prev pregnancy
CKD
autoimmune disease eg SLE or antiphospholipid
Type 1 or 2 DM
Chronic HTN
Moderate riSk factors for preeclampsia
first pregnancy
Age >39
BMI >35
FHx preeclampsiA
Multiple pregnancy
Who should take aspirin in preg
1+ high risk factors
2+ moderate risk factors
4 causes of PPH (Ts)
Tone (uterine atony in vast majority of cXds)
Trauma (eg tear)
Tissue (retained placenta)
Thrombin (clotting issuez)
ABCapproach for PPH
Two peripheral cannulae, 14 gauge
Lie woman flat
bloods including group and save
Commence warmed crystalloid
Classification of PPH
Blood loss >500ml after vaginal delivery.
Primary = within 24 he
Secondary = after
Risks for primary PPH
Prev PPH
Long labour
Pre eclampsia
Incr maternal age
polyhydramnios
Emergency CS
Multiple pregnancy
Macrosomia
Placenta praevia, accreta
Mechanical management of PPH
Palpate uterine fundus and rub to stimulate contractions
Catheterization to prevent bladder distension (and fluid balance watch)
Medical management of PPH
IV oxytocin (slow IV then IV)
Ergometrine slow IV or IM, unless history of HTN
Carboprost (called Hemobate) IM, unless history of asthma
Misoprostol sublingual
Surgical management of PPH
Intrauterine balloon tamponade
B lynch suture, ligation of uterine arteries or internal iliac
If severe and uncontrolled, may need lifesaving hysterectomy
Most appropriate anti depressant to start in breastfeeding women
sertraline or paroxetine.
As only present in tiny amounts in breast milk
Causes of increased nuchal translucency
Down’s syndrome
Congenital heart defects
Abdominal wall defects
Prevalence of preeclampsia
5% of pregnancies
Chronic hypertension
present at booking visit or before 20 weeks, can be primary or secondary aetiology
Gestational hypertension
new HTM (140/90) after 20 weeks without significant proteinuria
Preeclampsia definition
new HTN after 20 weeks with 1 or more of
Proteinuria (0.3g/24hrs = protein-creatinine ratio >30)
Other organ dysfunction (renal (creat >90), liver (ALT >40), neurological, haematological)
Uteroplacental dysfunction
pathophys of preeclampsia
poor placentation, then pulsatile high pressure flow, so oxidative stress to placenta. Then fetal growth restric.
OR late = placental capacity exceeded, then predominantly late onset PET, with little or no growth restriction
Fetal syndrome early pre eclampsia
incr uterine artery resistance
Abnormal umbilical artery Doppler flow
IUGR
stillbirth
Symptoms of imminent PET crisis
intense vascular headache
Epigastric pain, sudden onset, hepatic onset
Visual disturbances like migraine
Eclampsia
1/2500 pregnancies
Grand Mal confusions, PIH and new proteinuria
May occur before during or after labour and may or may not be heralded
HELPP syndrome
Haemolysis (jaundice, bruising)
Elevated Liver enzymes
Low Platelets
Acute and dangerous crisis of PET
Other crises of pre eclampsia
cortical blindness
Cerebral haemorrhage
Acute renal tubular necrosis
Acute renal cortical necrosis
Maternal death
Hepatic rupture
Hepatic infarction
Laryngeal oedema
Cardiac failure
Management of eclampsia
ABC approach
A position, suction, anesthetist
B(put O2 on)
C IV line, control BP
Parenteral MgSO4
Deliver
Preeclampsia approach in general
prevent in those with risk factors w aspirin prophylaxis
Detect symptomless cases by screening
Admit when condition becomes unstable
Deliver before becomes dangerous
High risk factors for PET - aspirin 75-150mg daily from 12 wks
HTN during pref pregnancy
CKD
AI disease, eg SLE, anti PPL
DM1/2
Chronic HTN
Moderate risk factors for PET (2 or more for aspirin from 12 aeeks)
first pregnancy
>40
Pregnancy interval >9 yrs
BMI >35
FH of PET
Multiple pregnancy
Examination findings with PET
oedema
Hyperreflexia
Clonus
Raised BP
Predicting preeclampsia I vestigation
sFLT-1:PIPGF ratio
Strong negative predictive value, but poor positive predictive value
ACE inhibitors in preg
Fetptoxic and contraindic
Renal impairment
FGR
Patent ductus arteriosus
Oligohydramnios -> poor lung development
First line med in preg for hypertension
labetalol (full beta blockers less associated with growth restriction)
Also methyldopa, but not at delivery due to assoc with post naral delivery
Nifedipine and alpha blockers
Diuretics but not thiazides
Long term effects PET
2x risk of CV complications in mother
Fetal – Barker hypothesis, incr HTN, stroke and Diabetes and CVD in later life
Chronic HTN approach in preg
give drug safe in pregnancy
Adequate control
Prefent superimposed preeclampsia
Consider other health promotion
SGA definition
smaller than 10th centile for gestatopm
IUGR definition
small compared to genetic determination, and compromised
Rate of stillbirth at 37 weeks and 43 weeks
0.37 to 2.12/1000
Antenatal fetal complications with multiple pregnancy
Incr risk of mortality (twins x6)
Incr risk of long term disability (twins 5x, triplets x18)
Miscarriafe more common, and also late miscarriage
Preterm labour: ~40% of twin and 80% of triplet pregnancies deliver before 36 weeks
Particular fomplicarkons of monochorionicity
Twin twin transfusion synfrome
occurs only in MCDA twins, in about 15%
Unequal blood distribution through vascular anastomoses of shared placenta
Donor twin is depleted, becomes anaemic, IUGR, and oligohydramnios
Recipient twin: Volume overloaded, polycythaemial caediac failure and massive polyhydramnios
Both twins at very high risk
Normally diagnosed between 16&24wks and should be managed with laser ablation of placental interface
Poor outcomes
Twin anaemic polycythaemia sequence
Marked Hb differences between MC twins, but without liquor changes of TTTS
Can follow incomplete laser ablation of TTTS
Twin reversed arterial perfusion
rare abnormality of MC twins. Abnormal, often acardiac twin is perfused by normal ‘pump’ twin which may then develop cardiac failure.
Co-twin death
if one twin dies in MC pair, drop in blood pressure allows rapid transfusion fro MN other twin. Resultant hypovolaemia causes death or neurological damage in approx 30% of cases
Survivor of dichorionic twin pregnancy nor ar risk because circulation not shared
Monoamniotic twins
placenta and also amniotic sad is shared, cords are entangled
In utero demise common because of this and shunting between twins’
Antenatal management of multiple pregnancies
Should be considered high risk and consultant led care.
Chorionicity needs to be checked in first trimester. Dichorionic-> lambda sign on USS = dividing nenbrNe between two placentae
MC twins need US every 2 weeks roughly
TTTS most commonly diagnosed between 16&24weeks
Delivery for multiple pregnancues
DC twins advised to delive at 37 weeks, MC at 36
Caesarean is indicated if the presenting twin is breech or transverse lie, with higher order multiples, if any antepartum complications
May need oxytocin to stimulate contractions after birth of first twin, and may need ECV if presentation not longitudinal - but avoid overstimulation and excessive haste is dangerous
Lots of CTG monitoring.
Movements of the babies head in labour
engagement in occipito transverse
Descent and flexion
Rotation 90 degrees to occipito anterior
Descent
Extension to deliver
Restitution and delivery of shoulders
Perineal trauma types and prevalence
perineum intact in about 1/3 of nulliparous women and 1/2 of multiparous
1st degree= minor damage to the fourchette
2nd degree and episiotomies = perineal muscle involved
3rd degree = involve anal mucosa- in approx 1% of deliveries
4th degree = anal mucosa
Average duration first stage of labour
8h nulliparous, 5h multiparous
First stage of labour whats occuring
uterus contracts every 2-3min
Latent <4cm and active 4-10cm phases
Cervxix dilates until widest part of head passes through
HeaD descends remaining flexed
90 degree rotation from occipito transverse to occipito anterior position
Amniotic membranes usually ruptured
2nd stage of labour whats occuring
contractions continue
Head descends and flexes duerhwr
Pushing when head reaches pelvic floor
Process of delicery
head extends as delivered over the perineum
Head restitutes, rotating back to transvers before shoulders delover
Third stage normal dueation
Normally up to 15 mins
Normal blood loss up to 500ml
Observation in normal labour
temp and blood pressure every 4 hours
Pulse every hour in 1st stage
Every 15 mins in second stage
Contraction frequency recorded every 30mins
Monitor with partogram - normal progress 1cm/hour
Slow progress of labour diagnosis
<2cm dilation in 4 hours
Augmentation options in labour
artificially rupture membranes and leave for 2 hours
If not oxytocin IV can be administered - less likely in multiparous labour and should consider size and position of fetal head
Common causes of failure to progress in labour
Powers: Inefficient uterine action
Passenger: Fetal size, disorders of rotation
Passage: Cephalo pelvic disproportion
Fetal distress scheme
- Intermittent auscultation of fetal heart. If abnormal, or meconium, or long or high risk labour proceed to
- Continuous CTG. If sustained bradycardia >5 min deliver. If abnormal on other criteria use simple measures to correct, if these fail proceed to
- Fetal blood sampling from scalp if abnormal
- Delivery by quickest route.
Indications for CTG
prelabour risk factors: Preeclampsia, IUGS, prev CS, induction of labour
In labour risks: Meconium, use of oxytocin, temp >38 degrees, using epidural
Pain relief in labour options
non medical - maintenance od mobility, water baths
Medical - Entonox, opiates, epidural
OEpidural advantages
pain free labour
Advisable on medical grounds if BP high ro abolish premature urge to push
Easily converted if complications
Epidural disadvantages
increased supervision
Maternal fever
Rwduced mobility
Increased instrumental delivery rate
Hypotension
Urinary retention
Need pushing direction - active second stage usually delayed by an hour
Contraindications to VBAC
Vertical uterine scar
Previous uterine rupture
Multiple previous CS
Success of VBAC
~75% successful vaginal delivery
Better outcomes if spontaneous labour, interpregnancy interval <2years, low she and BMI and previous elective CS
Risks of VBAC marwenal
lower maternal death
Uterine rupture 1/200
Blood transfusion 2%(1-2% repeat c section)
Fetal risks slightly higher
Prelabour term rupture of membranes
rupture after 37 weeks before onset of labour
60% start labour less than 24h later
Need CTG
Check for infection, lie and presentation. Avoid vaginal examination
Consider immediate induction
Advise induction and antibiotics if >18-24h duration
Indications for instrumental delivery
prolonged active second stage
Maternal exhaustion
Fetal distress in second stage
Head must be deeply engaged and at pr below level of ischial spines, cervic must be fully dilated. Bladder should be empty
Ventouse pros and cons
higher failure rate than instrumental
More fetal trauma
No difference in apgar scores
Less maternal trauma
Indications for emergency caesarean section
Prolonged first stage >12-16h, or earlier of was progressing before
Fetal distress
Indications for elective C section
Absolute indications: Placenta praevia, severe antenatal fetal compromise, uncorrectable abnormal like, previous vertical CS, gross pelvic deformity
Relative indications: Breech presentation, severe IUGR, twin pregnancy, diabetes mellitus and other medical probs, previous CS, older nulliparous patients.
Also if delivery before 34 weeks.
Complications of caesarean section
Haemorrhage
Uterine/wound sepsis
Thromboembolism
Anesthetic
Subsequent pregnancy risk increased
Rarely bladder or bowel damage
Shoulder dystocia prevalence and presentation
approx 1/200 deliveries
Normal downward tracitpm fails to deliver the shoulders after the head has been delivered
Delay in delivery -> possible brain injury or death, and possible damage to brachial plexus causing Erb’s palsy (permanent in ~10%)
Risks for shoulder dystocia
Large baby
Maternal diabetes
Previous shoulder dystocia
Obesity
Management of shoulder dystocia
Call for senior help
McRoberts manoeuvre: Legs hyperextended onto abdomen and suprapubic pressure applied (works in 90%)
If failed, episiotomy to put hand into vagina and rotate shoulders (Wood’s screw manoeuvre)
Last resort: Symphysiotomy
Or Caesarean, but by this time fetal damage normally irreversible
Cord prolapse what is
Umbilical cord descends below presenting part
Cord will then become compressed or spasm, and baby rapidly hypoxic
1/500 deliveries
Diagnosis usually at vaginal examination when fetal distress identified
risks for Cord prolapse
Preterm labour
Breech presentaiton
Polyhydramnios
Abnormal lie
Twin pregnancy
Management of cord prolapse
push up presenting part so not compressing cord
Give tocolytics eg tobutamine
If cord outside, keep warm and moist
Patient to go on all fours then prepare for delivery
Normally emergency CS
But instrumental vaginal is ok if cervix fully dilated and head is low
uterine rupture what happens
uterus can tear de novo or through old scar
Fetus comes our and uterus contracts down and bleeds from rupture site -> fetal hypoxia and massive internal maternal haemorrhage
Lower segment rupture less bd as nor so vascular
Neonatal mortality about 10%
1/5000 pregnancies, and 1/200 VBAC
Puerperium time period
6 weeks following delivery
Normal lochia
discharge from urweus. Blood stained for 4 weeks bur then yellow or white.
Internal os of cervix closed by 3 days
Physiology of lactation
dependent on prolacton and oxytocin, bur also drop in oestrogen and progesterone post birth
Milk ejection occurs in response ro nipple suckling
As much as 1L of milk per day can be produced, dependent on demand
Can be inhibited by emotional or physical stress
Colustrum (rich in far, proteins IgA and minerals) first 3 days then milk
Main challenges with breast feeding
insufficient milk, engorgement, mastitis, nipple trauma
Correct positioning of the baby helps with all of these
Advantages of breast geeding
protection against infant in neonate
Bonding
Protection against some gynae cancer for mother
Cannot give too much
Saves money
Not dependent on clean water
Postnatal contraception
lactation is insufficient
Should start 21 days post delkcert
Combined contracep suppresses breast feeding
Progesterone only pill or depot safe with breastfeeding
Or IUD can be inserted at wnd of 3rd stage or at 6 weeks.
Risks for PPH
Antepartum haemorrhage
Previous history
Previous CS
coagulation defect or anticoagulant therapy
Instrumental or CS
Retained placenra
Polyhydramnios
Multiple pregnancy
Many prev deliveries
Obesity
Prolonged and induced labour
Secondary PPH definition
Blood loss between 24h and 6 weeks post delivery
Due to endometritis with or without retained placental tossue, or rarely incidental gynae pathology/something else
Vaginal swab and FBC
Ultrasound mat identify retained products
Give Abx
If heavy bleeding continuing evacuate retained products
Postpartum pyrexia
Temp >38 ° in first 2 weeks post birth.
Infection most common: Enfometritis, wound, perineal, urinary infection, mastitis, chest infection
Treat w sepsis 6 and carefully examine for cause (eg offensive lochia and tender enlarged uterus)
DVT postnatal
0.5% women
Prophylaxis ID high risk with LMWH
Encoueage early mobility and hydration
Third day blues
50% women
Temporary emotional liability
Need reassurance and suppoet
PostnatL depression
10% of women
Identification difficult and poor
Support, psychotherapy and meds
Risk of suicide most with previous psychiatric issues
Frequently recurs in subsequent pregnancies
Postnatal psychosis
Affects 0.2% of women
Abrupt onset of psychotic symptoms, usually around 4th day but can be much later
More common in primigravid and family histort but hard to predicr
Blood tests at the booking antenatal visit
FBC for preexisting anaemia
AntiD antibodies
Glucose tolerance test planned for later in preg
Test for syphillis
Check rubella immunity
HIV and hrp B counselling and screening
Hb electrophoresis for at risk women eg of sickle cell and thalassaemia
Weight gain in pregnancy
10-15kg
Uterus and cervix changes in pregnancy
uterus weight incr from 50g to 1000g
Muscle hypertrophy increased blood flow and contractility
Cervix softens, may start to efface in third trimester
Blood physiological changes in pregnancy
blood volume incr by 50%
Red cell mass increases
Hemoglobin conc decreases, normal lower limit 110
WBC increases
cardiovascular system physiological changes in pregnancy
Cardiac output increases by 40%
Peripheral resistance decreases by 50%
Blood rpessure: Small mid pregnancy fall
Physiological respiratory changes in oregnancy
Tidal volume incr by 40%
Resp rate static
Itching in pregnancy
very normal
Sclera should be checked for jaundice and LFT and bile acids checked
Pelvic girdle pain
common and causing varying amount of discomfort in pubic and saxroiliac joints
Physio, corsets, analgesia and crutches may be used
Careful with leg abduction
Normally improves post delivery
Heartburn in pregnancy
affects 70% of women, and most marked in supine position
Give extra pillows, and antacids are fine. Ranitidine in severe cases.
Be aware PET can present with epigastric pain
Risks for downs syndrome
high maternal afge
Pregiously affected baby (risk is 1%)
Balanced parental translocation
Ultrasound indicators of down’s syndrome
thickened nuchal translucency
Some structural abnormalities
Absent or shortened nasal bone
Tricuspid regurgitation
Fetal growth restriction
Blood tests for Down’s syndrome
low PAPP-A
High beta HCG
low AFP
Low oestriol in 2nd trimester
High inhibin in 2nd trimester
High risk factors for PET
hypertensive disease during previous oregnancy
Chronic kidney disease
Autoimmune disease
Type 1 or 2 diabetes
Moderate risk factors for PET
nulliparous
Age 40 or above
Pregnancy interval >10 years
Booking BMI >35
Fhx PET
Multiple pregnancy
Antiphospholipid syndrome clinical criteria
Vascular thrombosis
1+ death of fetus >10 weeks
Pre eclampsia or IUGR requiring delivery <34 weeks
3+ fetal losses <10 weeks otherwise unexplained
Laboratory criteria for antiphospholipid syndrome
lupus anticoagulant or high anticardiolipin antibodies or anti beta2 glycoprotein I antibody
Major VTE risk factors
any previous VTE (unless single post surgery)
High risk thrombophilia
Low risk thrombophilia with family histrit
Managing major VTE risk
antenatal LMWH
Postnatal LMWH for 6 weeks
Intermediate VTE risk factors
BMI >40
Readmission or prolonged admission >3 days
Surgical procedure (except perineal repair)
Major medical comorbidity
C section
Management with intermediate VTE risks
consider LMWH antenatally
Postnatal: LMWH for 10 days
Minor risks for VTE
age >35
BMI >/=30
Parity 3 or more
Smoker
Elective C section
Family history VTE
low risk thrombophilia
Gross varicose veins
Current systemic infection
Immobility
Current pre eclampsia
Multiple pregnancy
Preterm delivery in this pregnancy (<37wks )
Stillbirth in this pregnancy
Operative delivery
Prolonged delivery >24hrs
PPH >1 L, or blood transfusion
ART
Management of minor VTE risks
if 3-4 risks, LMWH antenatally
If 2+ risks, LMWH for 10 days postnatally
DVT in pregnancy
0.1%
Usually left leg swelling and pain
Diagnosed with ultrasound or venogram
Anticoagulate with LMWH
PE in pregnancu
present: Collapse, chest pain, dyspnoea, tachycardia
CTPA or VQ scan
Anticoagulate with LMWH
High risk thrombophilias
antiphospholipid syndrome
Proteins S and C deficiency
Activated protein C resistance
Antithrombin III deficiency
Lower risk thrombophilias
factor V leiden heterozygosity
Prothrombin gene variant
Hyperhomocysteinaemia
Antiphospholipid Ab with no syndrome
Screening for GDM
GTT at 24-28 weeks if any family history DM, at risk ethnic group, BMI >30, previous large baby or stillbirth, persistent glycosuria or polyhydramnios
GTT after booking if prev. GDM
Complications of diabetes in pregnancy
maternal: Incr insulin requirements, hypoglycemia, worsening retinopathy, pre eclampsia, infections, operative delivery
Fetal: Congenital abnormalities, preterm labour, Macrosomia, birth trauma
Bishops score
assessment whether spontaneous labour is likely or not. Score above or equal 8 = likely and cervix is ripe and favouranle
Score <5, labour unlidkly to start without induction
Assesses cervical position, consistency, effacement, dilation, and fetal station
Features of congenital rubella syndrome
sensorineural deafness
Congenital cataracts
Congenital heart disease
Growth retaardatkon
Hepatosplenomegaly
Purpuric skin lesions
salt and pepper chorioretinitis
Microphthalmia
Cerebral palsy
Very high risk in first 8-10 weeks if infected
Suppressing lactation to stop breastfeeding
Stop lactation reflex -> stop suckling/expressing
Well supported bra and analgesia
Cabergoline is medication of choice if needef
If low lying placenta at 20 week scan….
rescan at 32 weeks
No limit to activity or intercourse unless bleeding
If still present at 32 weeks scan every 2 weeks, and if not budging at 36 then elective CS 37-38 weesk
Risks for placebtal abruption
Abruption previously
Blood pressure high
Ruptured membranes (premature or prolonged)
Uterine injury (trauma to abdo)
Polyhydramnios
Twins
Infection in uterus
Older age (>35)
Narcotic use
Prevalence of hyperemesis gravidarum
approx 1% of pregnancies
Although majority of women experience nausea during early stages of pregnancy
Risk factors for hyperemesis grafvidarum
increased levels of betaBCG: Multiple pregnancy, molar pregnancy
Nulliparity
Obesity
Family or personal history
Not smoking
Referral criteria for nausea and vomiting in pregnancy
continual n and v and unable to keep down liquids or oral antiemetics
Continual na and v with ketonuria and or weight loss >5% body weight despite oral antiemetics
Suspected or confirmed comorbidity - eg unable to tolerate oral antibiotics for uti
And lower threshold if condition like diabetes
Hyperemesis gravidarum triad
5% pre oregnancy weight loss
Dehydration
Electrolyte imbalance
Management of nausea and vomiting in pregnancy
rest and avoid triggers
Bland, plain food partic in morning
Ginger
P6 (wrist) acupuncture
Meds: Antihistamines (cyclizine or promethazine), phenothiazines (prochlorperazine), doxylamine/pyridoxine combinatjon
Second line medications for nausea and vomiting in pregnancy
Oral ondansetron (assic w small incr risk of cleft lip/palate when used in first trinestee)
Oral metoclopramide or domperidone. Risk of EPSEs so <5days use
May need admission for IV hydration
Complications of hyperemesis gravidarum
Acute kidney injury
Wernicke’s encephalopathy
Oesophagitis, Mallory Weiss tear
Venous thromboembolsim
Really severe and multiple admissions = small incr in preterm birth and low birth weight
