obstetrics Flashcards

1
Q

placenta accreta

A

placenta attaches to the myometrium

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2
Q

placenta increta

A

placenta invades into the myometrium

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3
Q

placenta percreta

A

placenta percolates through the perimetrium

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4
Q

what is the cut off for iron supplementation in the first trimester

A

<110g/L

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5
Q

what is the cut off for iron supplementation in the second/third trimester

A

<105g/L

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6
Q

what is the cut off for iron supplementation post partum

A

<100g/L

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7
Q

when are preg women screened for anaemia

A

the booking visit (often done at 8-10 weeks)
28 weeks

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8
Q

formal definition of pre-eclampsia

A

new-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of the following:
- proteinuria
- other organ involvement: e.g. renal insufficiency (creatinine ≥ 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction

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9
Q

high RFs for pre-eclampsia

A
  • hypertensive disease in a previous pregnancy
  • chronic kidney disease
  • autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
  • type 1 or type 2 diabetes
  • chronic hypertension
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10
Q

moderate RFs for pre-eclampsia

A
  • first pregnancy
  • age 40 years or older
  • pregnancy interval of more than 10 years
  • body mass index (BMI) of 35 kg/m² or more at first visit
  • family history of pre-eclampsia
  • multiple pregnancy
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11
Q

what to do it 1+ high Rfs or 2+ mod Rfs for pre-eclampsia

A

take aspirin 75-150mg (low dose) daily from 12 weeks gestation until the birth

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12
Q

first line for pre-eclampsia

A

oral labetalol
nifedipine if asthma

delivery is definitive

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13
Q

who to admit for pre-eclampsia

A

≥ 160/110 mmHg

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14
Q

causes of PPH

A

Tone (uterine atony): the vast majority of cases
Trauma (e.g. perineal tear)
Tissue (retained placenta)
Thrombin (e.g. clotting/bleeding disorder)

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15
Q

RFs primary PPH

A

previous PPH
prolonged labour
pre-eclampsia
increased maternal age
polyhydramnios
emergency Caesarean section
placenta praevia, placenta accreta
macrosomia
the effect of parity on the risk of PPH is complicated. It was previously thought multiparity was a risk factor but more modern studies suggest nulliparity is actually a risk factor

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16
Q

mx PPH

A

ABC approach
- two peripheral cannulae, 14 gauge
- lie the woman flat
- bloods including group and save
- commence warmed crystalloid infusion

mechanical
- palpate the uterine fundus and rub it to stimulate contractions (‘rubbing up the fundus’)
- catheterisation to prevent bladder distension and monitor urine output

medical
- IV oxytocin: slow IV injection followed by an IV infusion
- ergometrine slow IV or IM (unless there is a history of hypertension)
- carboprost IM (unless there is a history of asthma)
- misoprostol sublingual
- there is also interest in the role tranexamic acid may play in PPH

surgical:
- intrauterine balloon tamponade
- B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure

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17
Q

when is a baby dx w foetal macrosomia

A

birth weight >4kg

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18
Q

PPH def

A

blood loss of > 500 ml after a vaginal delivery and may be primary (within 24 hrs) or secondary.

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19
Q

erb’s palsy arm position

A

adduction and internal rotation of the arm, with pronation of the forearm.

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20
Q

RFs of shoulder dystocia

A

fetal macrosomia (hence association with maternal diabetes mellitus)
high maternal body mass index
diabetes mellitus
prolonged labour

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21
Q

mx shoulder dystocia

A

McRoberts’ manoeuvre (mums knees to abdo)- providing a posterior pelvic tilt
Pressure to anterior shoulder
Episiotomy
Rubins manoeuvre
Wood’s screw manoeuvre
Zavanelli manoeuvre

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22
Q

RFs for gestational diabetes

A

BMI of > 30 kg/m²
previous macrosomic baby weighing 4.5 kg or above
previous gestational diabetes
first-degree relative with diabetes
family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)

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23
Q

how to screen for gestational diabetes

A

OGTT

if had it previously: OGTT asap after booking + at 24-28 wks if 1st test is normal

any other RFs: OGTT at 24-28 wks

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24
Q

diagnostic thresholds for gestational diabetes

A

fasting glucose is >= 5.6 mmol/L
2-hour glucose is >= 7.8 mmol/L

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25
gest diabetes if the fasting plasma glucose level is < 7 mmol/l
trial of diet and exercise if glucose targets are not met within 1-2 weeks of altering diet/exercise metformin should be started if glucose targets are still not met insulin should be added to diet/exercise/metformin gestational diabetes is treated with short-acting, not long-acting, insulin
26
gest diabetes mx if the fasting glucose level is >= 7 mmol/l
start insulin
27
how to induce labour if bishop score
vaginal prostaglandins or oral misoprostol
28
how to induce labour if bishop score > 6
amniotomy and an intravenous oxytocin infusion
29
main comp of induction of labour
Uterine hyperstimulation
30
first-line treatment for magnesium sulphate induced respiratory depression
Calcium gluconate
31
what vaccines is a woman offered at 16-32 wks preg
pertussis and influenza
32
1st degree tear
limited to the superficial perineal skin or vaginal mucosa only
33
2nd degree tear
extends to perineal MUSCLES + fascia, but anal sphincter is in tact
34
3rd degree tear (a)
<50% thickness of EXTERNAL ANAL sphincter is torn
35
3rd degree tear (b)
>50% thickness of EXTERNAL ANAL sphincter is torn
36
3rd degree tear (c)
external + INTERNAL anal sphincters are torn
37
4th degree tear
perineal skin, muscle, anal sphincter + ANAL MUCOSA are torn
38
tx of vaginal tear
assess extent of the trauma 1. if minimal blood loss may not need anything 2. suture - experienced midwife 3 + 4. surgical repair by experienced clinician, sld take place in operating theatre under regional / general anaesthetic Broad spec abx + laxatives
39
what is lochia
passing vaginal discharge containing blood, mucus + uterine tissue which can continue for 6 weeks after childbirth
40
chickenpox exposure in pregnancy
check for varicella antibodies if doubt about prev infection <20 wks + not immune = varicella immunoglobulin asap > 20 wks + not immune = VXIG/antivirals given 7-14 days after exposure
41
mx of chickenpox in preg
> 20 wks + rash within 24 hrs presentation = oral aciclovir 800mg 5x/day 7 days
42
risk to fetus if mum gets chickenpox in preg
Fetal varicella syndrome (FVS) - skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning disabilities Shingles in infancy Severe neonatal varicella
43
what does the mum have greater risk of if she gets chickenpox in preg
5 times greater risk of pneumonitis
44
normal BP variations in preg
blood pressure usually falls in the first trimester (particularly the diastolic), and continues to fall until 20-24 weeks after this time the blood pressure usually increases to pre-pregnancy levels by term
45
what is HTN in preg defined as
systolic > 140 mmHg or diastolic > 90 mmHg or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic
46
gestational HTN
Hypertension occurring in the second half of pregnancy (i.e. after 20 weeks) No proteinuria, no oedema Occurs in around 5-7% of pregnancies Resolves after birth
47
mx gestational HTN /pre-existing in preg
1 = oral labetalol oral nifedipine (e.g. if asthmatic) and hydralazine
48
RFs for breech
uterine malformations, fibroids placenta praevia polyhydramnios or oligohydramnios fetal abnormality (e.g. CNS malformation, chromosomal disorders) prematurity (due to increased incidence earlier in gestation)
49
what is more common in breech
cord prolapse
50
mx breech
if < 36 weeks: many fetuses will turn spontaneously if still breech at 36 weeks = external cephalic version (ECV). Success rate = 60%. Offer from 36 weeks in nulliparous women and from 37 weeks in multiparous women Still breech = c sec?
51
absolute CIs to ECV
where caesarean delivery is required antepartum haemorrhage within the last 7 days abnormal cardiotocography major uterine anomaly ruptured membranes multiple pregnancy
52
CIs to VBAC
previous uterine rupture or classical caesarean scar (vertical) - offered a caesarean section at 37 weeks or more
53
Cat 1 c sec
an immediate threat to the life of the mother or baby delivery of the baby should occur within 30 minutes of making the decision
54
Cat 2 c sec
maternal or fetal compromise which is not immediately life-threatening delivery of the baby should occur within 75 minutes of making the decision
55
Cat 3 c sec
delivery is required, but mother and baby are stable
56
Cat 4 c sec
elective
57
some causes of folic acid deficiency
phenytoin methotrexate pregnancy alcohol excess
58
Consequences of folic acid deficiency
macrocytic, megaloblastic anaemia neural tube defects
59
how to take folic acid in preg
all women should take 400mcg of folic acid until the 12th week of pregnancy women at higher risk should take 5mg of folic acid from before conception until the 12th week of pregnancy - either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a FHx of a NTD - antiepileptic drugs, has coeliac disease, diabetes, or thalassaemia trait. - BMI > 30
60
what is intrahepatic cholestasis of pregnancy / Obstetric Cholestasis
reduced outflow of bile acids from the liver occurs in 1% of pregnant women usually dev after 28 wks, the result of increased oestrogen and progesterone levels more common in women of South Asian ethnicity increased risk of stillbirth
61
intrahepatic cholestasis of pregnancy / Obstetric Cholestasis presentation
3rd trim Itching (pruritis) - particularly affecting the palms of the hands and soles of the feet. Fatigue Dark urine Pale, greasy stools Jaundice No rash
62
intrahepatic cholestasis of pregnancy / Obstetric Cholestasis ix
Abnormal LFTs - mainly ALT, AST and GGT Raised bile acids (It is normal for ALP to increase in pregnancy as it is produced by the placenta)
63
intrahepatic cholestasis of pregnancy / Obstetric Cholestasis mx
Ursodeoxycholic acid Water-soluble vitamin K can be given if clotting (prothrombin time) is deranged Monitor of LFTs is required during pregnancy (weekly) and after delivery (after at least ten days) Planned delivery after 37 weeks
64
screening for down's syndrome the combined test when results
done between 11-13+6 wks ↑ HCG ↓ PAPP-A thickened nuchal translucency
65
screening for down's syndrome the quadrapule test when results
offered between 15 - 20 weeks ↓ AFP ↓ oestriol ↑ hCG ↑ Inhibin A
66
quadrapule test in Edward's syndrome
↓ AFP ↓ oestriol ↓ hCG ↔ Inhibin A
67
quadrapule test for neural tube defects
↑ AFP ↔ oestriol ↔ hCG ↔ Inhibin A
68
Results of combined or quadruple tests
Both the combined and quadruple tests return either a 'lower chance' or 'higher chance' result 'lower chance': 1 in 150 chance or more e.g. 1 in 300 'higher chance': 1 in 150 chance or less e.g. 1 in 100
69
what to do when a woman has higher chance of down syndrome results
offered a second screening test (Non-invasive prenatal screening test-NIPT, high sensitivity + specificity) or a diagnostic test (e.g. amniocentesis or chorionic villus sampling (CVS)
70
Causes of an increased nuchal translucency
Down's syndrome congenital heart defects abdominal wall defects
71
RFs for GBS infection
prematurity prolonged rupture of the membranes previous sibling GBS infection maternal pyrexia e.g. secondary to chorioamnionitis
72
who gets intrapartum abx (IAP) for GBS prev
women who've had GBS detected in a prev preg should be informed that their risk is 50% + offered intrapartum abx prophylaxis OR testing in late pregnancy and then abx if still positive women with a previous baby with early- or late-onset GBS disease women in preterm labour regardless of their GBS status women with a pyrexia during labour (>38ºC)
73
when would you swab for GBS
35-37 weeks or 3-5 weeks prior to the anticipated delivery date
74
abx for GBS proph
benzylpenicillin
75
when to refer to midwife-led breastfeeding clinic
If a breastfed baby loses > 10% of birth weight in the first week of life
76
indications for inductionof labour
prolonged pregnancy, e.g. 1-2 weeks after the estimated date of delivery prelabour premature rupture of the membranes, where labour does not start maternal medical problems - diabetic mother > 38 weeks - pre-eclampsia - obstetric cholestasis intrauterine fetal death
77
what does the bishop score mean
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
78
methods of induction
membrane sweep - Nulliparous women are typically offered this at the 40- and 41-week antenatal visit, whereas parous women are offered it at the 41-week visit vaginal prostaglandin E2 (PGE2) - dinoprostone oral prostaglandin E1 - misoprostol maternal oxytocin infusion amniotomy ('breaking of waters') cervical ripening balloon
79
guidelines for what type of induction to use
if the Bishop score is ≤ 6 - vaginal prostaglandins or oral misoprostol - mechanical methods such as a balloon catheter can be considered if the woman is at higher risk of hyperstimulation or has had a previous caesarean if the Bishop score is > 6 - amniotomy and an intravenous oxytocin infusion
80
comps of uterine hyperstimulation
intermittent interruption of blood flow to the intervillous space over time may result in fetal hypoxemia and acidemia uterine rupture (rare)
81
tx uterine hyperstimulation
removing the vaginal prostaglandins if possible and stopping the oxytocin infusion if one has been started consider tocolysis
82
can you breastfeed with antiepileptics
yes
83
risks of prematurity
increased mortality depends on the gestation respiratory distress syndrome intraventricular haemorrhage necrotizing enterocolitis chronic lung disease, hypothermia, feeding problems, infection, jaundice retinopathy of prematurity hearing problems
84
prematurity def
birth before 37 weeks gestation non-viable below 23 weeks gestation Under 28 weeks: extreme preterm 28 – 32 weeks: very preterm 32 – 37 weeks: moderate to late preterm
85
Prophylaxis of Preterm Labour
Vaginal Progesterone -offered to women with a cervical length less than 25mm on vaginal ultrasound between 16 and 24 weeks gestation. Cervical Cerclage - offered to women with a cervical length less than 25mm on vaginal ultrasound between 16 and 24 weeks gestation, who have had a previous premature birth or cervical trauma (e.g. colposcopy and cone biopsy) “Rescue” cervical cerclage may also be offered between 16 and 27 + 6 weeks when there is cervical dilatation without rupture of membranes, to prevent progression and premature delivery
86
Rupture of membranes dx
speculum examination revealing pooling of amniotic fluid in the vagina Insulin-like growth factor-binding protein-1 (IGFBP-1) is a protein present in high concentrations in amniotic fluid, which can be tested on vaginal fluid if there is doubt about rupture of membranes
87
tx premature rupture of membranes
Prophylactic antibiotics should be given to prevent the development of chorioamnionitis - erythromycin 250mg 4x daily for 10 days, or until labour is established if within ten days Induction of labour may be offered from 34 weeks to initiate the onset of labour.
88
dx Preterm Labour with Intact Membranes
< 30 wks = clinical assessment is enough to offer mx of preterm labour > 30 wks= a transvaginal ultrasound to assess cervical length. If < 15mm = mx. OR fetal fibronectin < 50 = not preterm labour
89
mc preterm labour
Fetal monitoring (CTG or intermittent auscultation) Tocolysis with nifedipine Maternal corticosteroids: can be offered before 35 weeks gestation to reduce neonatal morbidity and mortality (gets fetal lungs to dev) - two doses of intramuscular betamethasone, 24 hours apart IV magnesium sulphate: can be given before 34 weeks gestation within 24 hrs del and helps protect the baby’s brain - monitor mums of mg tox Delayed cord clamping or cord milking: can increase the circulating blood volume and haemoglobin in the baby at birth
90
key signs of magnesium toxicity
Reduced respiratory rate Reduced blood pressure Absent reflexes
91
what is placental abruption
when the placenta separates from the wall of the uterus during pregnancy signif cause APH
92
RFs placental abruption
Previous placental abruption Pre-eclampsia Bleeding early in pregnancy Trauma (consider domestic violence) Multiple pregnancy Fetal growth restriction Multigravida Increased maternal age Smoking Cocaine or amphetamine use
93
presentation placental abruption
Sudden onset severe abdominal pain that is continuous Vaginal bleeding (antepartum haemorrhage) Shock (hypotension and tachycardia) Abnormalities on the CTG indicating fetal distress Characteristic “woody” abdomen on palpation, suggesting a large haemorrhage
94
severity levels of APH
Spotting: spots of blood noticed on underwear Minor haemorrhage: < 50ml blood loss Major haemorrhage: 50 – 1000ml blood loss Massive haemorrhage: > 1000 ml blood loss, or signs of shock
95
what is a concealed abruption
where the cervical os remains closed, and any bleeding that occurs remains within the uterine cavity. The severity of bleeding can be significantly underestimated tender + hard uterus
96
mx placental abruption
Fetus alive and < 36 weeks - fetal distress: immediate caesarean - no fetal distress: observe closely, STEROIDS, no tocolysis, threshold to deliver depends on gestation Fetus alive and > 36 weeks - fetal distress: immediate caesarean - no fetal distress: deliver vaginally Fetus dead - induce vaginal delivery
97
causes of thyrotoxicosis in pregnancy
grave's disease is most common activation of the TSH receptor by HCG may also occur (transient gestational hyperthyroidism) HCG levels will fall in the second and third trimester
98
tx thyrotoxicosis in pregnancy
Propylthiouracil is used in the first trimester of pregnancy in place of carbimazole (as this may be assoc w risk of congenital abnormalities). At the beginning of the second trimester, the woman should be switched back to carbimazole (as propylthiouracil has risk of hepatic injury)
99
what is cord prolapse
when the umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina, after ROM danger of fetal hypoxia
100
RF for cord prolapse
abnormal lie after 37 weeks gestation (i.e. unstable, transverse or oblique)
101
when to suspect cord prolapse + dx
signs of fetal distress on CTG dx by vaginal exam speculum to confirm
102
mx cord prolapse
emergency c section keep cord warm + wet whilst waiting, minimal handing push presenting part up to prevent it from compressing the cord px lie in LEFT LATERAL position (w pillow under hip) or KNEE-CHEST position (on all fours) can use tocolytic meds
103
what abx to give after instrumental delivery
single dose of co-amoxiclav
104
indications for instrumental delivery
Failure to progress Fetal distress Maternal exhaustion Control of the head in various fetal positions
105
risks of instrumental delivery to mother
Postpartum haemorrhage Episiotomy Perineal tears Injury to the anal sphincter Incontinence of the bladder or bowel Nerve injury (obturator or femoral nerve)
106
risks of instrumental delivery to baby
Cephalohaematoma with ventouse Facial nerve palsy with forceps
107
what is cephalohaematoma
a collection of blood between the skull and the periosteum
108
poss nerve injuries to mother after instrumental delivery
Femoral nerve -> weakness of knee extension, loss of patellar reflex, numbness of anterior thigh Obturator nerve -> weakness of hip adduction + rotation, numbness of medial thigh
109
difference between complete + incomplete uterine rupture
incomplete - the uterine serosa (perimetrium) surrounding the uterus remains intact complete - the serosa ruptures along with the myometrium, and the contents of the uterus are released into the peritoneal cavity
110
RFs uterine rupture
prev c section is the main one - scar is pt of weakness Vaginal birth after caesarean (VBAC) Previous uterine surgery Increased BMI High parity Increased age Induction of labour Use of oxytocin to stimulate contractions
111
presentation of uterine rupture
acutely unwell mother and abnormal CTG Abdominal pain Vaginal bleeding Ceasing of uterine contractions Hypotension Tachycardia Collapse
112
mx uterine rupture
Resuscitation and transfusion may be required. Emergency caesarean section is necessary to remove the baby, stop any bleeding and repair or remove the uterus (hysterectomy).
113
what is an amniotic fluid embolism
rare but severe condition where the amniotic fluid passes into the mothers blood causing an immune reaction -> systemic illness usually occurs around labour + delivery
114
RFs amniotic fluid embolism
Increasing maternal age Induction of labour Caesarean section Multiple pregnancy
115
presentation amniotic fluid embolism
usually presents around the time of labour and delivery, can be postpartum. Similarly to sepsis, PE or anaphylaxis, with an acute onset of: SOB Hypoxia Hypotension Coagulopathy Haemorrhage Tachycardia Confusion Seizures Cardiac arrest
116
mx amniotic fluid embolism
emergency ABCDE Cardiopulmonary resuscitation and immediate caesarean section are required if cardiac arrest occurs.
117
what is placenta praevia
when the placenta is over the internal cervical os (so lower than presenting part of fetus)
118
Low-lying placenta
when the placenta is within 20mm of the internal cervical os
119
risks of having placenta praevia
Antepartum haemorrhage Emergency caesarean section Emergency hysterectomy Maternal anaemia and transfusions Preterm birth and low birth weight Stillbirth
120
RFs for placenta praevia
Previous caesarean sections Previous placenta praevia Older maternal age Maternal smoking Structural uterine abnormalities (e.g. fibroids) Assisted reproduction (e.g. IVF)
121
presentation placenta praevia
The 20-week anomaly scan is used to assess the position of the placenta and dx it Most asx May get painless vaginal bleeding in preg (usually after 36 wks)
122
what to do if placenta praevia dx early in preg (at 20 wk scan)
a repeat transvaginal ultrasound scan at: 32 weeks gestation 36 weeks gestation (if present on the 32-week scan, to guide decisions about delivery)
123
mx placenta praevia
Corticosteroids are given between 34 and 35 + 6 weeks gestation (due to risk of preterm del) Consider planned del between 34-35+6 wks - c section May use USS to guide procedure Emergency caesarean section may be required with premature labour or antenatal bleeding.
124
what is vasa praevia
where the fetal vessels (2 umbilical arteries + an umbilical vein) are within the fetal membranes (chorioamniotic membranes) and travel across the internal cervical os
125
what is a velamentous umbilical cord
where the umbilical cord inserts into the chorioamniotic membranes, and the fetal vessels travel unprotected through the membranes before joining the placenta (usually wld insert directly into placenta from umbilical cord + always be protected)
126
two types of vasa praevia:
Type I vasa praevia – the fetal vessels are exposed as a velamentous umbilical cord Type II vasa praevia – the fetal vessels are exposed as they travel to an accessory placental lobe
127
RFs vasa praevia
Low lying placenta IVF pregnancy Multiple pregnancy
128
presentation + dx vasa praevia
may be dx by USS in preg May present as APH May detect by vaginal exam in labour - pulsating fetal vessels are seen in the membranes through the dilated cervix May be detected during labour when fetal distress and dark-red bleeding occur following rupture of the membranes
129
mx vasa praevia
Corticosteroids, given from 32 weeks gestation to mature the fetal lungs Elective caesarean section, planned for 34 – 36 weeks gestation If APH -> emergency caesarean section After stillbirth or unexplained fetal compromise during delivery, the placenta is examined for evidence of vasa praevia as a possible cause.
130
causes of SGA
Constitutionally small, matching the mother and others in the family, and growing appropriately on the growth chart Fetal growth restriction (FGR), also known as intrauterine growth restriction (IUGR) - small due to a pathology reducing the amount of nutrients and oxygen being delivered to the fetus through the placenta
131
causes of placenta mediated growth restriction
conditions that affect the transfer of nutrients across the placenta: Idiopathic Pre-eclampsia Maternal smoking Maternal alcohol Anaemia Malnutrition Infection Maternal health conditions
132
cause of non-placenta medicated growth restriction
pathology of the fetus, such as: Genetic abnormalities Structural abnormalities Fetal infection Errors of metabolism
133
RFs SGA
Previous SGA baby Obesity Smoking Diabetes Existing hypertension Pre-eclampsia Older mother (over 35 years) Multiple pregnancy Low pregnancy‑associated plasma protein‑A (PAPPA) Antepartum haemorrhage Antiphospholipid syndrome
134
when is a baby large for gestational age (macrosomia)
when the weight of the newborn is more than 4.5kg at birth. an estimated fetal weight above the 90th centile during preg
135
causes of macrosomia
Constitutional Maternal diabetes Previous macrosomia Maternal obesity or rapid weight gain Overdue Male baby
136
ix for large for gestational age baby
Ultrasound to exclude polyhydramnios and estimate the fetal weight Oral glucose tolerance test for gestational diabetes
137
threatened miscarriage
mild bleeding fetus present cervical os closed
138
inevitable miscarriage
heavy bleeding + pain fetus present cervical os open
139
complete miscarriage
all products of conception expelled, empty uterus pain + bleeding cervical os usually closed
140
missed miscarriage
uterus still contains fetal tissue - no longer alive asx cervical os closed
141
what counts as a miscarriage
>7mm crown rump length + no cardiac activity wld repeat scan after 1 wk to confirm
142
when to refer for lack of fetal movement
if none by 24 wks (usually 18-20)
143
ix for miscarriage
transvaginal USS
144
mx miscarriage < 6 wks
expectant mx repeat preg test after 7-10 days
145
mx miscarriage > 6 wks
refer to EPAU if +ve preg test + bleeding USS to confirm location + viability - expectant mx offered 1st if no RFs for heavy bleeding/infection. 1–2 weeks to allow it to occur spontaneously. Preg test 3 wks after bleeding + pain settle. - medical mx MISOPROSTOL (prostaglandin analogue) vag or oral - surgical mx Manual vacuum aspiration under local anaesthetic as an outpatient Electric vacuum aspiration under general anaesthetic
146
monochorionic monoamniotic twins
share chorion, common amniotic cavity, single placenta rare splitting of zygote between 8-12 days after fertilisation
147
dichorionic diamniotic twins
2 placentas, 2 amniotic sacs division between 0-4 days have the best outcomes
148
monochorionic diamniotic twins
2 distinct amniotic cavities, shared chorion, shared placenta division between 4-8 days
149
iteterotropic pregnancy
presence of both an intrauterine + ectopic
150
dizygotic twins
non-identical (from two different zygotes)
151
Monozygotic twins
identical twins (from a single zygote)
152
risks to mum with twins
Anaemia Polyhydramnios Hypertension Malpresentation Spontaneous preterm birth Instrumental delivery or caesarean Postpartum haemorrhage
153
risk to babies w twins
Miscarriage Stillbirth Fetal growth restriction Prematurity Twin-twin transfusion syndrome Twin anaemia polycythaemia sequence Congenital abnormalities
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what is twin-twin transfusion syndrome
occurs when the fetuses share a placenta one fetus may get majority of BS (other fetus is called the donor + is starved of blood) the recipient can become fluid overloaded -> HF + polyhydramnios the donor has growth restriction, anaemia and oligohydramnios
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Twin anaemia polycythaemia sequence
One twin becomes anaemic whilst the other develops polycythaemia (raised haemoglobin)
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extra antenatal care for teins
additional monitoring for anaemia, with a full blood count at: Booking clinic 20 weeks gestation 28 weeks gestation Additional ultrasound scans are required in multiple pregnancy to monitor for fetal growth restriction, unequal growth and twin-twin transfusion syndrome: 2 weekly scans from 16 weeks for monochorionic twins 4 weekly scans from 20 weeks for dichorionic twins
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planned birth in twins
32 and 33 + 6 weeks for uncomplicated monochorionic monoamniotic twins 36 and 36 + 6 weeks for uncomplicated monochorionic diamniotic twins 37 and 37 + 6 weeks for uncomplicated dichorionic diamniotic twins Before 35 + 6 weeks for triplets
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Monoamniotic twins delivery
require elective caesarean section at between 32 and 33 + 6 weeks.
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what is oligohydramnios
reduced amniotic fluid less than 500ml at 32-36 weeks and an amniotic fluid index (AFI) < 5th percentile
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causes of oligohydramnios
premature rupture of membranes Potter sequence - bilateral renal agenesis + pulmonary hypoplasia intrauterine growth restriction post-term gestation pre-eclampsia
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causes of polyhydramnios
Excess production can be due to increased foetal urination: Maternal diabetes mellitus Foetal renal disorders Foetal anaemia Twin-to-twin transfusion syndrome Insufficient removal can be due to reduced foetal swallowing: Oesophageal or duodenal atresia Diaphragmatic hernia Anencephaly Chromosomal disorders
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Rhesus Incompatibility in Pregnancy
when a rhesus -ve mother has rhesus +ve baby, when baby's blood find a way into the mothers it will be seen as foreign causing her immune system to react + produce antibodies = sensitisation not a prob in 1st preg but will be in next as the mothers anti-D antibodies can attack another rhesus +ve preg -> haemolytic disease all mothers tested for rhesus status + anti-D antibodies at booking
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what are sensitisation events
those which carry risk of foetal blood crossing the placenta into maternal circulation + triggering the antibody formation APH signif abdo trauma ectopic preg miscarriage termination intrauterine death ECV invasive uterine procedures e.g. chorionic villus sampling/amniocentesis delivery of fetus
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when to give anti-D prophylaxis
sensitisation events (within 72 hrs) routinely given at 28 wks + at birth in rhesus -ve women
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what is the kleihauer Test
checks how much fetal blood has passed into the mother’s blood during a sensitisation event used after any sensitising event past 20 wks, to assess whether further doses of anti-D is required
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features of complete hydatidiform mole
vaginal bleeding uterus size greater than expected for gestational age abnormally high serum hCG ultrasound: 'snow storm' appearance of mixed echogenicity - no fetal parts present
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what is a complete hydatidiform mole
formation from a single sperm and an empty egg with no genetic material. The sperm replicates to provide a normal number of chromosomes, which are all paternal in origin. There is no foetal tissue present, only a proliferation of swollen chorionic villi.
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what is a partial hydatidiform mole
Formed from two sperm and a normal egg. Both paternal and maternal genetic material are present, and there is variable evidence of foetal parts.
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tx hydatidiform mole
suction curettage Bimonthly serum and urine hCG testing until levels are normal. In the case of a partial mole, a repeat hCG test is done 4 weeks later - if normal, the patient is discharged from surveillance. In a complete mole, monthly repeat hCG samples are sent for at least 6 months.
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dx criteria for hyperemesis gravidarum
5% pre-pregnancy weight loss dehydration electrolyte imbalance
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RFs hyperemesis gravidarum
increased levels of beta-hCG - multiple pregnancies - trophoblastic disease nulliparity obesity family or personal history of NVP (smoking assoc w decreased incidence)
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tx hyperemesis gravidarum
- rest and avoid triggers e.g. odours - bland, plain food, particularly in the morning ginger - P6 (wrist) acupressure first-line medications: - antihistamines: oral CYCLIZINE or PROMETHAZNE - phenothiazines: oral prochlorperazine or chlorpromazine second-line medications - oral ondansetron: ondansetron during the first trimester is associated with a small increased risk of the baby having a cleft lip/palate (discuss w the pregnant woman) - oral metoclopramide or domperidone: metoclopramide may cause extrapyramidal side effects (so do not use > 5 days) admission may be needed for IV hydration - normal saline with added potassium is used to rehydrate
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Referral criteria for nausea and vomiting in pregnancy
Continued N&V and is unable to keep down liquids or oral antiemetics Continued N&V with ketonuria and/or weight loss (greater than 5% of body weight), despite treatment with oral antiemetics A confirmed or suspected comorbidity (e.g. she is unable to tolerate oral antibiotics for a urinary tract infection) + lower threshold if coexisting condition e.g. DM that may be adversely affected by N&V
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when can you have IUS/IUD after birth
within 48 hours of childbirth or after 4 weeks
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when do you require contraception after birth
after 21 days
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POP after birth + breastfeeding?
anytime (after day 21 use additional contraception for the first 2 days) also fine when breastfeeding
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COCP after birth + breastfeeding?
CI (UKMEC 4) if breastfeeding < 6 wks pp UKMEC 2 - if breastfeeding 6 wks - 6 mths pp CI first 21 days due to increased VTE risk pp After day 21 need additional contraception first 7 days
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how effective is lactational amenorrhoea method (LAM) for contra + how to do it
is 98% effective providing the woman is fully breast-feeding (no supplementary feeds), amenorrhoeic and < 6 months post-partum
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risk of inter-pregnancy interval of less than 12 months between childbirth and conceiving again
increased risk of preterm birth, low birth weight and small for gestational age babies.