Obstetrics Flashcards
What are the risks of asymptomatic bacteriuria in pregnancy?
Increased risk of preterm delivery
Increased risk of pyelonephritis during pregnancy
How should asymptomatic bacteriuria be treated?
Immediate antibiotic prescription (nitrofurantoin, amoxicillin or cefalexin)
Which tests are done at the booking visit?
FBC
MSU
Blood group and antibody screen
Infection screen (Hep B, HIV, Syphilis)
When does gestational thrombocytopaenia tend to occur?
> 28 weeks
What should women with a history of GDM be offered in their pregnancy?
OGTT or random blood glucose in the 1st trimester
NOTE: helps identify pre-existing diabetes that has developed in the meantime
How should newborns born to women with hepatitis B be treated to reduce the risk of transmission?
Hepatitis B vaccine (at birth, 1 month and 6 months)
Hepatitis B immunoglobulin
NOTE: both should be given within 12 hours
Which parameters are used to date the pregnancy on ultrasound scan?
10-14 weeks = CRL
14-20 weeks = Head Circumference
What are the components of the combined test for Down syndrome?
Nuchal translucency
b-hCG
PAPP-A
What are the components of the quadruple test for Down syndrome?
b-hCG AFP Unconjugated oestriol Inhibin A NOTE: the triple test is a similar test that doesn't use inhibin A
What should be offered to women with a high risk of Down syndrome according to initial screening tests?
CVS (10-14 weeks)
Amniocentesis (15+ weeks)
cffDNA (only available privately)
NOTE: results take 48 hours
How often should SFH be measured?
Every antenatal appointment after 24 weeks
What should happen if there are concerns about foetal growth according to SFH measurements?
Organise an ultrasound
What is the NICE recommendation regarding vitamin D during pregnancy?
All pregnant and breastfeeding women should receive 10 µg vitamin D daily
When should an OGTT be performed in women with a high risk of GDM?
24-28 weeks
If previous history of GDM, this should be done at 16-18 weeks and a repeat at 24-28 weeks
What should be offered to women with a history of late pregnancy loss and a short cervix?
Prophylactic vaginal progesterone
Prophylactic cervical cerclage
How should PPROM be investigated?
Sterile speculum - pooling observed –> diagnose PPROM
No pooling –> test for IGF-like binding protein-1 and alpha-microglobulin-1 test
IMPORTANT: diagnostic tests should NOT be performed if the patient goes into labour
What antibiotic prophylaxis should be given to patients with PPROM?
Oral erythromycin 250 mg QDS for 10 days or until the woman is in established labour
Which women should be offered rescue cervical cerclage?
16-27 weeks with a dilated cervix and unruptured membranes
Do NOT perform if signs of infection, active vaginal bleeding or uterine contractions
Which investigations should be used to confirm a diagnosis of preterm labour?
If suspected preterm labour > 30 weeks
- Consider TVUSS to determine likelihood of birth within 48 hours (cervical length > 15 mm means it is unlikely)
- Consider fetal fibronectin (low concentration suggests it is unlikely)
IMPORTANT: if < 30 weeks and clinical assessment suggests preterm labour, treatment is necessary without further investigation
Which agent is most commonly used for tocolysis?
Nifedipine
If contraindicated: atosiban (oxytocin receptor antagonist)
Up to what gestation should maternal corticosteroids be considered in preterm labour?
36 weeks
Which agent is used for neuroprotection in preterm delivery?
IV magnesium sulphate 4 g over 15 mins (loading) and 1 g/hour until birth or for 24 hours
NOTE: this is used in women who are delivering at 24-34 weeks (most important for 24-30 weeks)
How is magnesium sulphate poisoning treated?
Calcium gluconate
Which parameters are measured in ultrasound biometry used to monitor foetal growth?
Biparietal diameter
Head circumference
Abdominal circumference
Femur length
How should IUGR babies be monitored?
Serial growth scans every 2 weeks
Doppler can be done 2 times per week (looks out for placental dysfunction leading to absent/reversal of blood flow in umbilical artery)
Advise monitoring foetal movements
ADMIT if reduced foetal movements
Which antihypertensives are associated with congenital abnormalities?
ACE inhibitors
ARBs
NOTE: these are not safe when breastfeeding (neither is amlodipine)
What level of urinary protein: creatinine ratio is considered significant?
> 30 ng/mmol
Which agent is used to treat gestational hypertension?
Oral labetalol
What should the target blood pressure be in gestational hypertension?
Systolic: < 150
Diastolic: 80-100
When should blood pressure be measured in a woman with gestational hypertension who has just given birth?
Daily for the first 2 days
Once on day 3 and 5
Continue the use of antihypertensives but consider reducing the dose as the BP falls < 140/90 (same applies for PET)
How often should blood pressure be measured in women who have been admitted for pre-eclampsia?
At least 4 times per day
Which other tests should you perform in a woman with pre-eclampsia?
FBC
U&E
LFTs
Foetal: USS, Doppler US, CTG
After how many weeks would you consider delivery for a woman with pre-eclampsia?
Within 24-48 hours for women with pre-eclampsia > 37 weeks
NOTE: this can be even earlier depending on the severity and response to treatment
How often should blood pressure be measured postnatally in a woman who has had pre-eclampsia?
At least 4/day whilst an inpatient
At least once on days 3 and 5
On alternate days thereafter if the results aren’t normal on days 3/5
NOTE: if blood pressure remains > 150/100, start an anti-hypertensive
When should methyldopa be stopped after birth?
Within 2 days after birth
When should further scans to assess the foetus be carried out in women with hypertensive disease in pregnancy?
28-30 weeks
Repeat at 32-34 weeks if severe pre-eclampsia
NOTE: CTG should be performed for any reported reduced foetal movements
What does magnesium sulphate toxicity cause and how is it treated?
Respiratory depression
Treatment: calcium gluconate
How long should magnesium sulphate be continued for in a woman with pre-eclampsia?
For 24 hours after the last seizure or until 24 hours after delivery
List some clinical features of severe pre-eclampsia?
Severe headache Visual disturbance Papilloedema Severe pain just below the ribs Liver tenderness Signs of clonus HELLP syndrome (platelet count falling below 100 x 109/L, abnormal liver enzymes)
What should be monitored whilst giving magnesium sulphate treatment?
Reflexes
Respiratory rate
Oxygen saturation
Urine output
ECG monitoring is required during and for 1 hour after loading dose
What is the recurrence rate of gestational hypertension?
16-47%
What is the recurrent rate of pre-eclampsia?
16%
What are the blood glucose targets for a patient with diabetes mellitus in pregnancy?
Fasting < 5.3 mmol/L
1-hour post-prandial < 7.8 mmol/L
2-hour post-prandial < 6.4 mmol/L
NOTE: if on insulin or glibenclamide, recommend maintaining BM > 4
How often should pregnant women with diabetes mellitus check their blood glucose?
7 times per day
How do insulin requirements change throughout pregnancy?
Insulin resistance changes through pregnancy so patients are likely to require an increase in the dose of metformin or insulin in the second half of pregnancy
Which extra screening tests/monitoring would be recommended for women with diabetes during pregnancy?
Renal and retinal screening
Serial ultrasound for foetal growth and amniotic fluid volume (every 4 weeks from 28-36 weeks)
Assessment of cardiac outflow tracts at 20-week anomaly scan
How should blood glucose be managed in a patient with T1DM or T2DM on insulin during labour?
Sliding scale or insulin and glucose
Aim for blood glucose 4-7 mmol/L
What are the risks that pregnancy carries in a woman with diabetes?
Blood glucose control is more important
Increased insulin requirements
Increased risk of hypoglycaemia
Risk of deterioration of pre-existing retinopathy and nephropathy
What are the risks of diabetes for a pregnancy?
Miscarriage Stillbirth Congenital malformation Macrosomia Pre-eclampsia Infection Operative delivery
Aside from blood glucose control, which other medications should be recommended for women with diabetes during pregnancy?
5 mg folate preconception until 12 weeks
75 mg aspirin from 12 weeks until delivery
Who should review a woman with a new diagnosis of GDM and when should this happen?
Joint diabetes and antenatal clinic within 1 week of diagnosis
Outline the management options for gestational diabetes mellitus.
1) diet and exercise (provided fasting BM < 7)
2) metformin (if step 1 ineffective after 1-2 weeks)
3) add insulin
If fasting BM > 7 –> insulin
If fasting BM 6-6.9 and evidence of complications (e.g. macrosomia) –> insulin
When should women with GDM check their blood glucose on a daily basis?
Fasting
Pre-meal
1-hour post-meal
Bedtime
When might HbA1c be used in pregnancy?
In all women with pre-existing diabetes at booking
At the time of diagnosis of GDM to identify undiagnosed T2DM
When should women with diabetes in pregnancy ideally deliver?
Offer elective birth between 37-39 weeks
How should a woman with GDM be followed-up postnatally?
Stop blood glucose lowering treatment immediately
If BM returns to normal:
- Offer lifestyle advice
- Offer fasting plasma glucose at 6-13 weeks (or HbA1c thereafter) to exclude diabetes
What is an alternative agent that can be used in diabetes in pregnancy is metformin is not tolerated?
Glibenclamide (sulphonylurea)
What are the steps in the management of a patient with hyperemesis gravidarum?
1st line: antihistamines (promethazine or cyclizine)
2nd line: ondansetron or metoclopramide
Alternative: P6 acupressure, ginger
If severe dehydration: admit for IV rehydration, thiamine supplementation and thromboprophylaxis
What antibiotic regime is recommended for UTI in pregnancy?
Nitrofurantoin 50 mg QDS for 7 days
2nd line: amoxicillin or cephalexin
What TSH level should pregnant women with hypothyroidism aim for?
< 4 mmol/L
What are the risks of suboptimal thyroid hormone replacement?
Developmental delay
Pregnancy loss
How should hyperthyroidism in pregnancy be treated?
Lowest possible dose of propylthiouracil (or carbimazole)
WARNING: risk of agranulocytosis
What are the risks of uncontrolled thyrotoxicosis in pregnancy?
Miscarriage
Preterm delivery
IUGR
What are the three criteria required to diagnose postpartum thyroiditis?
< 12 months of giving birth
Clinical manifestations of hypothyroidism
TFTs to support
NOTE: TPO antibodies present in 90%
How is post-partum thyroiditis managed?
Thyrotoxic phase: propanolol
Hypothyroid phase: thyroxine
What happens to the pituitary gland during pregnancy?
Enlarges by 50%
NOTE: dopamine agonists are usually stopped during pregnancy
What measures are taken in labour for a woman with heart disease?
Aim to wait for spontaneous labour
Epidural anaesthesia usually recommended (reduces pain-related stress/increase in CO)
Prophylactic antibiotics (if structural heart defect)
Use syntocinon judiciously
Consider instrumental delivery to keep second stage short
Avoid supine position
Which asthma drugs are safe to use in pregnancy?
ALL of them
Which medications that are commonly used in labour/delivery should be avoided in asthmatic patients?
Ergometrine
Prostaglandin F2a
Labetalol
What congenital abnormalities are associated with anti-epileptic drug use in pregnancy?
Neural tube defects
Facial clefts
Cardiac defects
Others: developmental delay, growth restriction
What is the dangerous consequence of a seizure during pregnancy?
Maternal and foetal hypoxia
How might the recommendations for delivery be different in a pregnant woman with epilepsy?
Recommend epidural analgesia because it reduces stressors that might precipitate an epileptic seizure
NOTE: women should also receive vitamin K in the last month of pregnancy if on phenytoin
Which antiepileptic is considered to carry the lowest risk of congenital malformations?
Lamotrigine
NOTE: breastfeeding is considered safe with antiepileptics
How are migraines managed in pregnancy?
Simple analgesia
Consider low-dose aspirin and beta-blockers to prevent attacks
NOTE: triptans are contraindicated
Which treatments can be used to increase platelet count in ITP in pregnancy?
Steroids
IVIG
NOTE: platelet count > 50 x 10^9/L is required for safe delivery, > 70 x 10^9 is necessary for epidurals
What are the risks associated with untreated coeliac disease in pregnancy?
Spontaneous miscarriage
IUGR
List some indications for high dose (5 mg) folic acid preconception to 12 weeks in pregnancy.
Diabetes mellitus Obesity Coeliac disease Thalassemia Sickle cell disease Epilepsy (i.e. antiepileptic drug use) Previous child with NTD HIV positive taking co-trimoxazole
Which investigations should be requested in suspected obstetric cholestasis?
LFTs
Bile acid
Coagulation screen (PT may be prolonged due to reduced vitamin K)
What are the main risks of obstetric cholestasis?
Prematurity
Stillbirth
Meconium passage
How should obstetric cholestasis be treated?
Advise wearing loose cotton clothes
Ursodeoxycholic acid
Vitamin K supplementation (if PT prolonged)
Topical emollients
Offer induction at 37 weeks
Offer weekly LFTs and twice weekly CTG (and close monitoring of foetal movements)
How long before getting pregnant should methotrexate be stopped?
3 months
Until what point in pregnancy can NSAIDs be used?
32 weeks
Outline the reassuring features of a CTG.
FHR/BRA: 110-160 bpm BV: 5-25 bpm Decelerations: absent or early Accelerations: 2 within 20 mins IMPORTANT: a CTG with each of these features is described as having ‘met criteria’
Outline the non-reassuring features of a CTG.
100-110 bpm or 161-180 bpm
BV: < 5 for 30-50 mins or > 25 for 15-25 mins
Variable decelerations with no concerning characteristics for > 90 mins
Variable decelerations with < 50% of contractions for > 30 mins
Variable decelerations with > 50% of contractions for < 30 mins
Late decelerations in > 50% of contractions for < 30 mins
Outline the pathological features of a CTG.
< 100 bpm or > 180 bpm
BV: < 5 for > 50 mins, > 25 for > 25 mins, sinusoidal
Variable decelerations with any concerning characteristics in > 50% of contractions for < 30 mins
Late decelerations for 30 mins
Acute bradycardia or a single prolonged deceleration lasting > 3 mins (terminal deceleration)
What is the difference between a suspicious and a pathological trace?
Suspicious: 1 non reassuring feature
Pathological: 2 non reassuring features OR 1 pathological feature
Which investigation can help confirm fetal distress after a suspicious CTG?
Foetal blood sampling
This is only done if the patient is at 8-9 cm and you want reassurance that you can continue
What are the features of congenital rubella syndrome?
o Sensorineural deafness o Congenital cataracts o Blindness o Encephalitis o Endocrine problems
Describe the relationship between the gestation at which a pregnant woman develops rubella and the risk to the foetus.
< 11 weeks = nearly 100% risk
> 20 weeks = no risk
< 16 weeks = offer termination of pregnancy
What advice would you give to Rubella IgG negative pregnant women?
Keep away from anyone that might have rubella
Offer MMR vaccine in the postnatal period
What are the consequences of syphilis in pregnancy?
o FGR o Foetal hydrops o Congenital syphilis (may cause long-term disability) o Stillbirth o Preterm birth o Neonatal death
How should syphilis in pregnancy be treated?
Benzathine penicillin (parenteral)
NOTE: if the woman is not treated during pregnancy, treat the child after delivery
What is the difference between non-treponemal and treponemal tests for syphilis?
Non-treponemal tests are non-specific screening tests that detect non-treponemal antibodies
Treponemal tests detect specific treponemal antibodies and are more specific
Name two non-treponemal tests.
Rapid plasma reagin (RPR)
Venereal disease research laboratory (VDRL)
Name two treponemal tests.
EIA
Treponema pallidum haemagglutination assay (TPHA)
NOTE: these are used in pregnancy
What is a Jarish-Herxheimer reaction?
Treatment results in the release of proinflammatory cytokines in response to dying organisms
Presents with symptoms and fever that develops 12-24 hours after treatment
What advice can you give a pregnant woman about avoiding toxoplasmosis?
Avoid eating raw/rare meat
Avoid handling cats and cat litter
How is a diagnosis of toxoplasmosis made?
Sabin Feldman dye test
Which test should be performed if an ultrasound suggests that there is a risk of congenital toxoplasmosis?
Amniocentesis and PCR of amniotic fluid for T. gondii
If toxoplasmosis is found to be the cause of the abnormal ultrasound, TOP should be offered
NOTE: treated with spiramycin
What are the clinical features of congenital toxoplasmosis?
Ventriculomegaly Microcephaly Chorioretinitis Cerebral calcification NOTE: most infants are asymptomatic at birth
Describe the relationships between the gestation at which the mother is exposed to toxoplasmosis and the risk of foetal damage.
1st trimester - most likely to cause severe foetal damage but the risk of transmission is low
3rd trimester - low risk of foetal damage but much higher transmission rates
Why is the detection of IgM antibodies not very useful for toxoplasmosis and CMV?
They persist for a long time so you don’t know when the patient was infected
How can IgM antibodies be used to confirm a diagnosis of CMV in a pregnant woman?
A new finding of anti-CMV IgM in a previously IgM-negative woman is suggestive of primary CMV infection
How can a diagnosis of CMV infection in pregnancy be confirmed?
Amniocentesis and PCR
If congenital CMV is detected, offer TOP
How can VZV immunity be confirmed?
Detection of VZV IgG
How should you treat non-immune pregnant women who have been exposed to chickenpox?
Before 20 weeks:
VZIG as soon as possible given up to 10 days after contact
Seek advice if rash develops
After 20 weeks:
Either VZIG OR acyclovir given 7-14 days after exposure
What are the maternal risks of VZV in pregnancy?
Increased risk of pneumonia, hepatitis and encephalitis
How is chickenpox in pregnancy managed?
Avoid contact with other pregnant women and infants
Oral aciclovir for 7 days should be prescribed if presenting within 24 hours of rash onset and > 20 weeks gestation (consider in patients < 20 weeks)
If hospitalised, keep in isolation
How should maternal chickenpox around the time of delivery be managed?
Significant risk to the newborn if within 4 weeks of delivery
Elective delivery should be avoided until 7 days after the onset of the rash (allow time for Abs to pass)
Arrange neonatal ophthalmic examination at birth
If birth within 7 days of maternal rash or the mother develops chickenpox within 7 days of delivery, give VZIG to the neonate
Neonatal infection should be treated with aciclovir
Monitor for signs of infection until 28 days after maternal infection onset
What are the main features of congenital varicella syndrome?
Skin scarring in a dermatomal distribution
Eye defects (microphthalmia, chorioretinitis, cataracts)
Hypoplasia of the limbs
Neurological abnormalities
What prenatal diagnosis techniques can be offered to a woman with chickenpox in pregnancy?
Refer to foetal medicine specialist at 16-20 weeks or 5 weeks after infection
Amniocentesis and VZV DNA PCR has a high NPV but low PPV
What is the main risk of parvovirus B19 infection in pregnancy?
Aplastic anaemia leading to hydrops fetalis and intrauterine death
May resolve spontaneously or may need intrauterine blood transfusion
At what point in pregnancy does parvovirus B19 infection pose the greatest risk to the foetus?
< 20 weeks
What are the risks of listeria in pregnancy?
Stillbirth
Late miscarriage
Early-onset sepsis
How is listeria treated?
IV antibiotics (ampicillin 2 g every 6 hours and erythromycin)
How should first-episode genital herpes in pregnancy be diagnosed and treated?
Refer to GUM
Viral culture and PCR
Aciclovir 400 mg TDS
How should women with primary herpes infection in the 3rd trimester be managed?
C-section should be recommended (especially if within 6 weeks of onset)
Give intrapartum IV aciclovir
How should recurrent episodes of herpes simplex infection in pregnancy be managed?
NOT an indication for C-section
Consider oral aciclovir from 36 weeks
Avoid invasive procedures if there are genital lesions
How would you manage a woman who is found to have GBS in her genital tract?
Intrapartum antibiotics (IV benzylpenicillin) as soon as possible after the onset of labour
Penicillin allergy: clindamycin
List some indications for GBS prophylaxis.
Intrapartum fever
PROM
Prematurity
Previous infant with GBS
Incidental detection of GBS in pregnancy
GBS bacteriuria
NOTE: women colonised with GBS who are having an elective C-section do NOT need GBS-specific antibiotic cover
Outline the management of the newborn with risk factors for early-onset GBS disease.
1 minor risk factor = remain in hospital for observation for 24 hours
2 or more minor risk factors = full septic screen AND IV penicillin + gentamicin
How should HIV be monitored in pregnancy?
CD4 at baseline and at delivery
Viral load every 2-4 weeks, at 36 weeks and after delivery
What interventions can be used to reduce the risk of transmission of HIV to the baby?
ART (antenatally and intrapartum in the mother, in the baby for 4-6 weeks)
Delivery by C-section if the viral load is high
Avoidance of breastfeeding
When would C-section be recommended for women with HIV in pregnancy?
Hepatitis C coinfection
High viral load > 50
What antiretroviral cover is recommended for pregnant women undergoing a planned C-section or presenting with SROM?
IV zidovudine (4 hours before C-section)
How are neonates born to mothers with HIV treated?
Clamp the cord ASAP
Bath the baby
Avoid breastfeeding
AZT aka zidovudine (oral or IV) for 4-6 weeks
How can HIV infection in the newborn be confirmed?
Direct viral amplification by PCR
Usually carried out at birth, 2 weeks, 6 weeks and 12 weeks
Last one at 18 months
How often should vaginal examination be performed in the first stage of labour?
Every 4 hours
When does the active phase of the 1st stage start?
When the cervix is 4 cm dilated and fully effaced
What counts as a prolonged second stage of labour?
Nulliparous > 2 hours since onset of active 2nd stage
Multiparous > 1 hour since onset of active 2nd stage
Allow an extra hour if they have epidural analgesia
What are some causes of obstructed labour?
Shoulder dystocia
Cephalopelvic disproportion
FGM
How should a prolonged second stage of labour be managed?
ARM if membranes are still intact Augmentation with oxytocin Ongoing obstetric review every 15-30 mins Continuous foetal monitoring (CTG) C-section
What is prolonged 3rd stage of labour?
If the placenta doesn’t come out within 30 mins
NOTE: usually comes out within 5-10 mins
Which management option for the 3rd stage of labour is recommended to all women?
Active management - controlled cord traction (reduces risk of PPH)
If parts of the placenta are retained, it will require manual removal under general anaesthetic
What is physiological management of the third stage?
The placenta is delivered by maternal effort and no uterotonic drugs
Associated with heavier bleeding
Active management should be considered if the placenta is not delivered after 60 mins or significant bleeding occurs
Outline the order in which interventions take place in the induction of labour.
1 - Propess (24 hours)
2 - Prostin if necessary (every 6 hours)
3 - ARM (perform VE afterwards to check for cord prolapse)
4 - Syntocinon
If fully dilated, instrumental delivery may be considered.
NOTE: membrane sweep may be attempted in the first instance
What is the definitive management option for placenta accreta?
Hysterectomy
What can cause increased nuchal translucency?
Down syndrome
Abdominal wall defects
Congenital cardiac defects
How is the Bishop score interpreted?
< 5 suggests that labour is unlikely to start without induction
How long can lochia go on for after birth?
6 weeks
What are the risks of smoking in pregnancy?
IUGR Miscarriage Preterm Stillbirth Sudden infant death
What are the characteristic features of foetal alcohol syndrome?
Learning difficulties
Facies: smooth philtrum, thin vemilion, small palpebral fissures
IUGR
Microcephaly
What is the definition of hyperemesis gravidarum?
5% pre-pregnancy weight loss
Dehydration
Electrolyte imbalance
What are the sepsis 6?
Oxygen IV fluids IV antibiotics Take blood cultures Take lactate Monitor urine output
Under what circumstance would you give a septic patient a fluid bolus and how much would you give?
If hypotensive and/or serum lactate > 4 mmol/L
Give 20 ml/kg bolus of crystalloid
Which investigations should be performed in a patient with an antepartum haemorrhage?
FBC
G&S and consider X-match
Kleihauer test (if RhD negative)
How should a stable patient with an antepartum haemorrhage be followed up?
Growth scan and umbilical artery Doppler every 2 weeks
Consultant-led antenatal care
Final USS at 36-37 weeks to determine mode of delivery
Which investigations should be performed in a patient presenting with suspected placenta praevia causing an antepartum haemorrhage?
TVUSS
CTG
Bloods - FBC, clotting studies, G&S and crossmatch
Do NOT do a bimanual
How long should a stable woman with an antepartum haemorrhage due to placenta praevia stay in hospital for?
Admit for 48 hours for observation
How should a patient with a low-lying placenta at the 20-week scan be followed-up?
Rescan at 32 weeks
If still low –> rescan at 36 weeks
If still low –> recommend elective C section (if < 2 cm from os)
What is major placenta praevia and how should it be managed?
Major = completely covering the os
Consider admission from 34 weeks
Which pharmacological agents can be used to minimise the risk of PPH?
IM oxytocin (10 iU) if vaginal
IM oxytocin (5 iU) if C-section
IM syntometrine if no hypertension and increased risk of PPH
Consider tranexamic acid
How is a minor PPH managed?
IV access Urgent venepuncture for: Group and screen FBC Coagulation screen, including fibrinogen Pulse, RR and BP every 15 mins Commence warmed crystalloid infusion
Outline the initial non-pharmacological steps in the management of major PPH.
ABC Lie flat 10-15 L/min oxygen 2 large bore cannulae Send blood for FBC, G&S and X-match Until blood is available infuse up to 3.5 L of warmed clear fluids Foley catheter Pharmacological/surgical management Transfuse (O negative and K negative blood, fibrinogen should be maintained > 2, FFP if bleeding continues, platelets if < 75)
Outline the pharmacological/surgical steps in the management of major PPH.
Step 1: IV/IM syntocinon or IM ergometrine or syntometrine
Step 2: IM carboprost (careful in asthmatics)
Step 3: Bakri balloon tamponade
Step 4: other surgical measures (e.g. B-lynch suture, hysterectomy)
EMERGENCY: bimanual compression
Outline the management of eclampsia.
Call for senior help
ABCDE
Magnesium sulphate - 4 g loading dose followed by infusion of 1 g/hour for 24 hours after delivery/last seizure
What are the consequences of magnesium sulphate overdose and what is the antidote?
Respiratory depression
Cardiac arrest
Antidote: 10 mL 10% calcium gluconate
Outline the management of cord prolapse.
Perform VE immediately
Call senior helps and prepare the operating theatre
Elevate the presenting part (or fill the bladder)
Consider tocolysis
Place mother on all fours
Performed CTG
Usually deliver by emergency C-section
List some risk factors for shoulder dystocia.
Macrosomia
High BMI
Diabetes mellitus
Prolonged labour
Outline the management of shoulder dystocia.
Call for senior help
McRobert’s manoeuvre
Suprapubic pressure
Consider episiotomy
Deliver posterior arm and shoulder or consider internal rotational manoeuvres (Rubin, Woods’ screw)
Change position to all fours
Consider symphysiotomy, cleidotomy or Zavanelli
Which investigation should be performed in a patient with a suspected DVT?
Compress duplex ultrasound
Which investigations should be performed in a patient with a suspected PE?
ECG
CXR
Compression duplex ultrasound (if DVT)
V/Q or CTPA
How should a DVT/PE during pregnancy be managed?
Therapeutic dose LMWH given daily in two divided doses according to the patient’s weight until 6 weeks postpartum (at least 3 months in total)
How should VTE in a collapsed patient be managed?
Unfractionated heparin
Thrombolysis
Thoracotomy and surgical embolectomy
Outline the management of uterine inversion.
ABCDE
Call for senior help, IV fluid resuscitation, insert urinary catheter, pain management
Attempt manual replacement
Attempt hydrostatic replacement (instilling 2-3 L of warm saline into the vagina)
Attempt surgical procedures (e.g. hysterectomy)
What causes puerperal pyrexia?
Endometritis (MOST COMMON) UTI Wound infection Mastitis VTE
Outline the management of puerperal pyrexia.
IV antibiotics (clindamycin and gentamicin) until afebrile for > 24 hours
NOTE: gentamicin should be avoided in pregnancy
What features of a pregnancy would suggest that it is safe to offer VBAC?
SIngleton
Cephalic presentation at 37+ weeks
Only one previous LSCS
Success rate: 70%
List some contraindications for VBAC.
Previous uterine rupture
Classical C-sections scar
Non-C-section contraindication (e.g. placenta praevia)
What are the risks of VBAC?
Uterine rupture
Instrumental delivery
Emergency C-section
Infant: stillbirth, transient respiratory morbidity
What are the benefits of elective repeat of C-section?
No risk of rupture
Can plan the recovery
What are the risks of elective repeat of C-section?
Longer recovery Risk of bladder/bowel injury (rare) Future placenta praevia/accrete Likely to need future LSCS Infant: transient respiratory morbidity
What are some important things to consider regarding the intrapartum management of VBAC?
Electronic foetal monitoring throughout
Induced or augmented labour has an increased risk of uterine rupture
Induction with mechanical methods (e.g. ARM) has a lower risk of scar rupture
From what gestation would you expect to be able to visualise the foetal heart beat?
6 weeks
How does hCG change in early pregnancy?
Double every 48 hours
List some causes of miscarriage.
Chromosomal abnormalities Medical/endocrine disorders Uterine abnormalities Infections Drugs/chemicals
How often should the following types of multiple pregnancies receive ultrasound scans?
MCDA
DCDA
MCDA: 2-weekly growth and Doppler scans from 16 weeks (refer to foetal medicine specialist)
DCDA: 4-weekly growth and Doppler scans from 20-36 weeks
List some maternal and foetal complications associated with multiple pregnancy.
Maternal: preterm delivery, traumatic birth, hypertension, hyperemesis gravidarum
Foetal: IUGR, TTTS, Down syndrome
How is IUGR in twin pregnancy monitored and what result would indicate IUGR?
Estimate foetal weight using > 2 biometric parameters at each scan from 20 weeks
Aim to repeat the scan at least every 4 weeks
Difference in size > 20/25% is IUGR
In a multiple pregnancy, the presence of which other risk factors would warrant the use of 75 mg aspirin from 12 weeks until term?
- First pregnancy
- 40+ years
- Pregnancy interval > 10 years
- BMI > 35 at first visit
- Family history of pre-eclampsia
At what point should elective delivery be offered to uncomplicated MCDA and DCDA twin pregnancies?
MCDA: from 36 weeks
DCDA: from 37 weeks
MCMA: C-section at 32-34 weeks
NOTE: increased risk of foetal death beyond 38 weeks
Which type of delivery is possible with twin pregnancy?
Vaginal if the 1st twin is in the cephalic position
5% risk of the second twin requiring C-section
How is TTTS managed?
Fetoscopic laser ablation if < 26 weeks
If > 26 weeks, delivery may be considered
Weekly ultrasound
Aim for delivery at 34-37 weeks
How should a breech presentation be managed?
< 36 weeks: many foetuses will turn spontaneously
> 36 weeks: ECV (36 weeks for nullip, 37 weeks for multip)
If ECV fails: planned C-section or planned vaginal delivery
List some contraindications for ECV.
Ruptured membranes Multiple pregnancy APH within the last 7 days Abnormal CTG Major uterine anomaly
C-section is required
Avoid inducing labour
What are the risks and benefits of planned C-section for breech presentation?
Risks: increased risk of immediate maternal complications, increased risk of complications in future pregnancy (e.g. placenta accreta)
Benefits: small reduction in perinatal mortality, planned vaginal delivery is associated with short-term complications in the baby (e.g. low Apgar scores)
How is an unstable lie managed?
If mechanical cause (e.g. placenta praevia) –> LSCS
Hospital admission is usually recommended from 37 weeks
Consider ECV, ARM or LSCS
How is mastitis managed?
Encourage continuation of breastfeeding
If systemically unwell, nipple fissures or symptoms not improving 12-24 hours after milk removal –> flucloxacillin 10-14 days
What are some causes of baseline tachycardia?
Maternal pyrexia
Chorioamnionitis
Hypoxia
Prematurity
List some causes of reduced baseline variability.
Prematurity
Hypoxia
Foetal sleep (up to 40 mins)
List some causes of late decelerations.
Asphyxia or placental insufficiency
What typically causes variable decelerations?
Cord compression
Outline a useful approach to interpreting CTGs.
DR C BRAVADO DR - define risk C - contractions BRA - baseline rate V - variability A - accelerations D - decelerations O - overall impression
What is considered a normal pattern of accelerations?
Rise in FHR of > 15 bpm lasting > 15 seconds
Should be 2 accelerations every 20 mins (usually with contractions and should occur with foetal movements)
What is a deceleration?
Reduction in FHR by at least 15 bpm lasting > 15 seconds
What is a terminal bradycardia and terminal deceleration?
Terminal Bradycardia: < 100 bpm for > 10 mins
Terminal Deceleration: FHR drops and does not recover for > 3 mins
These are indications for C-section
What are some non-reassuring features of a CTG?
100-110 bpm or 161-180 bpm
BV: < 5 for 30-50 mins or > 25 for 15-25 mins
Variable decelerations with no concerning characteristics for > 90 mins
Variable decelerations with < 50% of contractions for > 30 mins
Variable decelerations with > 50% of contractions for < 30 mins
Late decelerations in > 50% of contractions for < 30 mins
What are some abnormal features of a CTG?
< 100 bpm or > 180 bpm
BV: < 5 for > 50 mins, > 25 for > 25 mins, sinusoidal
Variable decelerations with any concerning characteristics in > 50% of contractions for < 30 mins
Late decelerations for 30 mins
Acute bradycardia or a single prolonged deceleration lasting > 3 mins (terminal deceleration)
What are the features of a normal intrapartum CTG?
FHR: 110-160 bpm BV: 5-25 bpm Decelerations: absent or early Accelerations: 2 within 20 mins IMPORTANT: a CTG with each of these features is described as having ‘met criteria’
What counts as a normal, suspicious and pathological CTG?
Normal: all features are reassuring
Suspicious: 1 non-reassuring + 2 reassuring
Abnormal: 1 abnormal feature OR 2 non-reassuring features
What is a combined deceleration and what causes it?
This is a deceleration within a deceleration
Usually due to overzealous use of syntocinon but can also be caused by infection and bleeding
How is a preterm CTG different from one that is done at term?
Higher baseline rate
Lower variability
Decelerations are less helpful
Recovery from decelerations should be rapid
Outline the degrees of perineal tears.
1st Degree: superficial damage with no muscle involvement
2nd Degree: injury to the perineal muscle, but not involving the anal sphincter
3rd Degree: injury to perineum involving the anal sphincter complex (EAS and IAS)
• 3a: < 50% of EAS
• 3b: > 50% of EAS
• 3c: IAS torn
4th Degree: injury to perineum involving the anal sphincter complex (EAS and IAS) and rectal mucosa
Outline the interpretation of the Edinburgh Postnatal Depression scale.
10-item questionnaire exploring how the mother is feeling
Maximum 30 points
> 13 suggests depressive illness
List some medications that are contraindicated with breastfeeding?
o Antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides o Psychiatric drugs: lithium, benzodiazepines o Aspirin o Carbimazole o Methotrexate o Sulphonylureas o Cytotoxic drugs o Amiodarone
What are some requirements for instrumental delivery?
o Fully dilated cervix
o OA position (OP delivery is possibly with Keilland forceps and ventouse)
o Ruptured membranes
o Cephalic presentation
o Engaged presenting part (NOT palpable abdominally)
o Pain relief
o Sphincter (bladder) empty (usually requires catheterisation)
Outline what is monitored during labour.
FHR monitored every 15 mins (or continuously via CTG)
Contractions every 30 mins
Maternal pulse rate every 1 hour
Maternal BP and temp every 4 hours
Vaginal examination every 4 hours to check progression of labour
Maternal urine for ketones and protein every 4 hours
Which women require a partogram?
All women in active labour
All women on syntocinon
Threatened premature labour with the use of atosiban
What do the alert line and the action line indicate in a partogram?
Alert line: when cervical dilatation is < 0.5 cm/hour (may require intervention (e.g. ARM))
Action line: 4 hours to the right of the alert line (requires urgent obstetric review)
What can cause slow progress in the 1st stage of labour?
Malposition
Epidural analgesia
How can a prolonged 1st stage of labour be managed?
ARM
Syntocinon (if there are inadequate contractions)
If they achieve full dilatation and enter the 2nd stage, instrumentation can be considered
What postnatal care advice would you offer a woman who has had a vaginal delivery?
Stitches - bath every day and gently pat dry
Using the toilet - drink lots of water and eat a healthy diet, peeing may be a bit painful and you may not poo for a few days
Haemorrhoids - very common but disappear after a few days
Lochia - quite heavy at first but disappears by about 6 weeks
Breasts - initially produces yellowish colostrum, may feel tight and tender
What postnatal care advice would you offer a woman who has had a C-section?
Average hospital stay: 3-4 days
Offer regular painkillers (avoid codeine) and encourage contact with the baby
Gently clean and dry the wound every day
Get stitches removed at 5-7 days
Caution with driving, exercising, heavy lifting and sex (should be fine after 6 weeks)
Avoid getting pregnant for 12-18 months
Which vaccines are recommended in pregnancy?
Influenza (at any gestation)
Pertussis (16-32 weeks)
How is secondary PPH managed?
High vaginal and endocervical swabs (endometritis) followed by appropriate antibiotic treatment (e.g. ceftriaxone and metronidazole)
TVUSS to exclude retained products of conception
Surgical evacuation of retained placental tissue
What are some contraindications for digital examination?
Placenta praevia
Prelabour rupture of membranes (and not in labour)
List some risks of obesity in pregnancy.
Antenatal: difficulty accurately assessing foetal growth, GDM, hypertensive disease, VTE
Intrapartum: difficulty with analgesia, difficulty monitoring labour, increased C-section rate
Postnatal: VTE, wound infection, PND
What are the WHO recommendations regarding breast feeding?
Initiate breastfeeding within 1 hour of birth
Exclusive breastfeeding for 6 months
Continue breastfeeding for at least 2 years
List some causes of IUGR.
Placental insufficiency Infection Hypertensive disease Chronic maternal disease Maternal drug use (e.g. smoking, alcohol)
How are antenatal corticosteroids given?
2 x 12 mg IM betamethasone 24 hours apart
Alternative: 4 x 6 mg IM dexamethasone 12 hours apart
NOTE: optimal benefit is seen 24 hours after starting treatment
List some causes of polyhydramnios.
Maternal diabetes mellitus Oesophageal or duodenal atresia Chromosomal abnormalities (e.g. Down, Edwards) Multiple pregnancy Anencephaly
List some causes of oligohydramnios.
PROM Potter sequence (renal agenesis) IUGR Post-term Intrauterine infection Polycystic kidneys
What is the normal range for the CRL at the dating scan?
45-84 mm
This will be from 11 - 13+6 weeks
List some abnormalities that can be seen on the foetal anomaly scan.
Spina bifida
Hydrocephalus
Skeletal abnormalities (e.g. achondroplasia)
Abdominal wall defects (e.g. gastroschisis)
Cleft lip/palate
Congenital cardiac abnormalities
What proportion of women have a low-lying placenta at the 20-week scan and how many of them will go on to have placenta praevia?
Low-lying placenta = 15-20%
Placenta praevia = 10% of those with a low-lying placenta
Which approaches are used to assess amniotic fluid volume by ultrasound?
Maximum vertical pool
Amniotic fluid index
NOTE: AFI < 5th centile for gestation is commonly defined as oligohydramnios and > 95th centile is polyhydramnios
What should be monitored in women with a history of midtrimester pregnancy loss?
TVUSS assessment of cervical length - regularly from 16 weeks
Which parameters are measured in a biophysical profile?
Foetal breathing movements (FBMs) Foetal gross body movement Foetal tone CTG Amniotic fluid volume
NOTE: a score of 2 for each is normal (8-10 overall is considered normal)
What does increased resistance in the foetal aorta suggest?
Foetal acidaemia
What does high resistance in the uterine artery suggest?
Pre-eclampsia
Placental abruption
When would cordocentesis be performed?
If foetal blood is needed (e.g. suspected severe foetal anaemia, thrombocytopaenia)
This can be performed from 20 weeks
What are the three main congenital uterine anomalies?
Subseptate/septate uterus
Bicornuate uterus
Uterus didelphys
List some predisposing factors for breech presentation.
Maternal: fibroids, congenital uterine anomaly, uterine surgery
Foetal/Placental: multiple pregnancy, prematurity, placenta praevia, oligo/polyhydramnios
What is the success rate of ECV?
50%
NOTE: ECV may be performed with the use of a tocolytic and FHR should be monitored before and after the procedure
What are some risks of ECV?
Placental abruption
PROM
Transplacental haemorrhage
Which manoeuvres may be used in a vaginal breech delivery?
Delivery of the legs: Pinard
Delivery of the shoulders: Loveset
Delivery of the head: Mauriceau-Smellie-Veit
What are the risks of post-term pregnancy?
Post-term > 42 weeks
Stillbirth
Perinatal death
Prolonged labour
C-section
On which chromosome are the Rhesus genes located?
Chromosome 1
Main Rhesus antigens = C, D and E (only D and c can caused haemolytic disease)
Outline the management of rhesus disease in a sensitised woman.
Anti-D wont make a difference
Close monitoring of antibody levels every 2-4 weeks
Regular MCA Doppler US
Treat by delivering or foetal blood transfusion
What is ‘shouldering’ on a CTG and what does it suggest?
Small rise in FHR before and after a deceleration
Shows that the foetus is coping well with the compression
What can cause a sinusoidal pattern?
Foetal anaemia/hypoxia
This requires delivery
NOTE: pseudosinusoidal traces are benign and uniform. They are less regular in shape and amplitude than sinusoidal traces. This can be due to thumb sucking
What are the different degrees of cranial moulding?
0 = sutures felt 1+ = bones are opposed 2+ = bones overlap but can go back into normal position 3+ = bones overlap and can't reset
What is uterine hyperstimulation?
Either a series of single contractions lasting 2 minutes or more OR a contraction frequency of five or more in 10 minutes
What should be offered to post-term women who decline IOL?
Twice-weekly CTG and USS
Outline the sequence of movements of the foetal head as it passes through the pelvis.
Descent - descent of the head into the pelvis
Engagement - < 2/5 of the head palpable abdominally
Flexion - head flexes to give the smallest diameter
Internal rotation - rotates from OT to OA
Extension - head extends as it reaches the perineum (crowns)
External rotation (restitution) - on delivery, the foetal head reverts to original OT position
Lateral flexion - needed for shoulders/trunk to be delivered
State the gestation at which the fertilised egg splits to give rise to MCMA, MCDA and DCDA twins.
MCMA: > 8 days
MCDA: 4-7 days
DCDA: <3 days
List some sensitising events that would require anti-D immunoglobulin.
Antepartum haemorrhage ECV Abdominal injury Invasive prenatal diagnosis (CVS, amniocentesis) Intrauterine procedures
Ideally should be given within 72 hours by IM injection
NOT needed < 12 weeks unless surgical management of ectopic, surgical TOP or molar pregnancy
When is anti-D routinely given to RhD-negative women?
28 weeks and 34 weeks (500 iU)
Another 500 iU will be given postpartum if the woman has given birth to an RhD-positive baby
What are the components of the Bishop score?
Dilation (<1, 1-2, 2-4, >4)
Consistency (firm, average, soft)
Length of cervix (>4, 2-4, 1-2, <1)
Position of cervix (posterior, mid/anterior)
Station of presenting part (-3, -2, -1 or 0, below spines)
What are the different grades of placenta praevia?
1 = encroaches on lower segment 2 = reaches internal os 3 = covers part of os (partial) 4 = completely covers the os (complete)
1 + 2 = minor
3 + 4 = major
Which bacteria cause chorioamnionitis?
E. coli
Streptococcus
E. faecalis
How should prelabour rupture of membrane be managed?
Immediate induction of labour
Expectant management (as 70% will spontaneously go into labour within 24 hours)
Antibiotic prophylaxis
NOTE: expectant management should not exceed 24 hours
What is the recurrence rate of HELLP?
20%
What biochemical change seen in acute fatty liver of pregnancy helps differentiate it from HELLP?
Hypoglycaemia
How is acute fatty liver of pregnancy managed?
Strict fluid balance
Correction of coagulopathy and electrolyte disturbance
Hasty delivery
How are the antihypertensives used in pregnancy administered?
Labetalol - oral or IV
Nifedipine - oral
Hydralazine - oral, IV or IM
When should you exercise caution with the use of antenatal corticosteroids?
Active septicaemia in the mother
Insulin-dependent diabetics (can lead to ketoacidosis)
What is the earliest gestation at which a ventouse can be used?
34 weeks
Before this, immaturity of the foetal head is associated with a risk of intracranial haemorrhage
Describe the features of congenital syphilis.
Poor feeding Runny nose (bloody) Rash Keratitis Deafness Frontal bossing Pregnancy: miscarriage, preterm, stillbirth
Describe how symphysis fundal height corresponds to gestational age.
It is 20 cm at 20 weeks
Then it should increase by 1 cm per week until 36 weeks
Should be measured at each antenatal appointment after 24 weeks
Which staging system is used for TTTS?
Quintero (goes from stage 1 to 5)
What is twin anaemia-polycythaemia sequence?
A rarer chronic form of TTTS where there is a large inter-twin difference in haemoglobin (likely due to small unidirectional arteriovenous anastomosis)
What are some risk factors for multiple pregnancy?
Age
Family history of multiple pregnancy
Assisted reproductive technology
Which manoeuvre can be performed to deliver the 2nd twin if they are lying abnormally?
External cephalic version
Internal podalic version
NOTE: these are only possible for twin 2
For twin 2, the membranes should be broken as late as possible
What is the effect of progesterone on myometrial activity?
Maintains uterine quiescence
Describe how oxytocin levels change at the onset of labour.
There is no change in the oxytocin levels, however, there is an increase in the sensitivity of the myometrium to oxytocin (due to increased expression of oxytocin receptors)
What is the main site of prostaglandin synthesis at labour?
Amnion
NOTE: myometrium is the main site of prostaglandin action and the chorion has enzymes responsible for prostaglandin metabolism
List some causes of preterm labour.
Cervical weakness
Infection (chorioamnionitis)
Uterine anomalies
Haemorrhage
What major consequence might chorioamnionitis have for the foetus?
Foetal brain damage (periventricular leukomalacia)
List some types of tocolytics.
Nifedipine
Atosiban
Beta-agonists (e.g. terbutaline, ritodrine)
Magnesium sulphate
NSAIDs (risk of premature PDA closure resulting in persistent pulmonary hypertension)
In which women should a choice of prophylactic vaginal cerclage or prophylactic vaginal progesterone be offered?
History of midtrimester (16-34 weeks) pregnancy loss
AND
TVUSS at 16-24 weeks showed cervical length < 25 mm
Which women should be offered prophylactic vaginal progesterone to prevent preterm labour?
NO history of spontaneous preterm birth/miscarriage
TVUSS at 16-24 weeks shows cervical length < 25 mm
Consider cerclage if previous PPROM or cervical trauma
Describe the use of nifedipine for tocolysis in preterm labour.
Consider nifedipine at 24-26 weeks
Offer nifedipine at 26-34 weeks
Can only be used if membranes are intact
NOTE: if nifedipine is contraindicated, use atosiban
When should magnesium sulphate be used in preterm delivery?
24-34 weeks
What proportion of women with gestational hypertension will go on to develop pre-eclampsia?
1/3
Define pre-eclampsia.
Hypertension of at least 140/90 mm Hg recorded on at least 2 separate occasions and at least 4 hours apart and in the presence of at least 300 mg protein in a 24-hr collection of urine, arising de novo after the 20th week of pregnancy in a previously normotensive woman and resolving completely by the 6th postpartum week
NOTE: or protein-creatinine ratio > 0.3 or > 30 mg/mmol
List some moderate risk factors for pre-eclampsia.
Moderate risk factors -> prescribe aspirin if 2 or more are present
First pregnancy Multiple pregnancy Family history of PET Age > 40 yrs BMI >35 > 10 year pregnancy interval
What lesion is seen within the kidneys in preeclampsia?
Glomeruloendotheliosis
Which antihypertensive medication is safe to use in pregnancy?
Labetalol (1st line)
Nifedipine
Methyldopa
NOTE: ACEi, ARB and chlorothiazide are associated with an increased risk of congenital abnormalities
List some indications for giving 75 mg aspirin OD to reduce the risk of pre-eclampsia from 12 weeks until conception.
(High risk factors - prescribe aspirin if 1 or more are present)
Hypertensive disease in previous pregnancy Chronic hypertension CKD Autoimmune disease (e.g. SLE, APLS) Diabetes mellitus
When should a woman with gestational hypertension ideally deliver?
If < 160/110 mm Hg, do NOT offer delivery until > 37 weeks
What proportion of Afro-Caribbean people have sickle cell trait?
1 in 10
Based on the combined test for Down Syndrome, what is considered a high chance result?
< 1 in 150
NOTE: a result will be provided for chance of Down syndrome, and another result for the chance of Edwards and Patau combined
What are some indications for immediate delivery in a IUGR pregnancy?
Abnormal CTG and reduced foetal movements
Reversal of end-diastolic flow
By what point postpartum would you expect all hypertensive diseases of pregnancy to have resolved?
6 weeks
When should growth scans be performed in a woman with chronic hypertension or high-risk of pre-eclampsia?
28-30 weeks
32-34 weeks
Perform CTG if abnormal movements are reported
Until what gestation should pre-eclampsia without complications be managed conservatively?
34 weeks
Conservative management involves weekly growth scan + Doppler
List some indications for urgent delivery in pre-eclampsia.
Uncontrollable BP
Rapidly worsening biochemistry/haematology
Eclampsia
Maternal symptoms
Foetal distress, severe IUGR, reduced UA EDF
What are some considerations for the intrapartum care of a woman with pre-eclampsia?
Continuous CTG monitoring
Encourage regional anaesthesia (helps control BP)
Avoid ergometrine
Monitor BP
Recommend operative birth if the hypertension is failing to respond to treatment
What MEWS score is associated with an increased risk of clinical deterioration?
5 or more
What are some risks of C-section?
Common: persistent wound/abdominal discomfort, increased risk of future C-section, infection
Uncommon: hysterectomy, uterine rupture in future pregnancy, placenta praevia/accreta in future pregnancy
What are the different categories of C-section?
1 - immediate threat to the life of the woman or foetus
2 - maternal or foetal compromise that is NOT immediately life-threatening
3 - no maternal or foetal compromise but needs early delivery
4 - delivery timed to suit woman or staff
How is chlamydia in pregnancy treated?
Erythromycin
Why should an ultrasound scan be performed at the time of diagnosis of GDM?
Exclude congenital anomaly
Assess foetal growth
Assess liquor volume
Which investigations would you consider in a pregnant women presenting with jaundice and itching?
LFTs Bile acids Clotting profile Liver screen (hepatitis serology and autoimmune antibodies) Liver USS FBC U&E
What measures can be taken to see whether a suspicious CTG trace will improve during labour?
Switch off syntocinon
Move to the left lateral position
What is a normal foetal pH?
> 7.25
If it goes < 7.2, immediate delivery would be indicated
7.20-7.25 is borderline so repeat after 30 mins
What is primary dysfunctional labour?
When the progress of labour is slow from the start
< 2 cm dilatation every 4 hours
Which screening tests are used for Down syndrome and when can they be used?
Combined Test: 10-14 weeks
Quadruple Test: 14-20 weeks
NOTE: beyond 20 weeks, a mid-pregnancy scan may be offered to look for physical abnormalities
When can cffDNA be performed?
10+ weeks
NOTE: it costs about £400-900 and has to be done privately
How long are tocolytics usually used for in preterm labour?
Up to 48 hours to allow time for steroids to work
What proportion of births occur after IOL?
20%
Success rate: 75-80%
What estimated foetal weight would require a C-section?
> 5 kg
What are some aspects of 3rd/4th degree perineal repair?
Repair in theatre
Antibiotic cover
Laxatives
What are the BUBBLE that you should check after delivery?
Breasts Uterus (and scar) Bowel Bladder Lochia Emotional/Episiotomy
List some indications for serial ultrasound scan.
Previous small baby Abnormal measurement on SFH Unable to measure SFH accurately Chronic medical condition High risk pregnancy
NOTE: growth scans should be at least 2 weeks apart
Describe the change in doppler results with placental failure.
First change: umbilical artery PI increases
This requires twice weekly Doppler/CTG
How should absent EDF be managed?
If > 32 weeks, daily monitoring and aim for delivery by 37 weeks
If < 32 weeks, ductus venosus is used to time delivery (if normal, deliver by 32 weeks; if abnormal then deliver immediately)
If CTG is abnormal at ANY POINT: C-section
How should reversed EDF be managed?
Urgent delivery
What are the main classes of haemorrhagic shock.
Class I: < 15%, normal HR/BP/RR, slightly anxious
Class II: 15-30%, mild tachycardia, normal BP, mild tachypnoea, anxious
Class III: 30-40%, moderate tachycardia, reduced BP, moderate tachypnoea
Class IV: >40%, severe tachycardia, reduced BP, severe tachypnoea
Which birth defects are more common in mothers with diabetes?
Cardiac defects
Brain and spine abnormalities (NTD)
Urinary and kidney
GI tract
Define ‘engagement’.
When the largest part of the foetal head enters the brim of the pelvis (usually in the OT position)
Which drugs used during labour can precipitate bronchoconstriction?
Ergometrine
Carboprost (prostaglandin F2a)
What are the consequences of hepatitis E infection in pregnancy?
Fulminant hepatic failure
Preterm delivery
IUGR
Stillbirth
Describe the appearance of polymorphic eruption of pregnancy.
Self-limiting pruritic disorder in the 3rd trimester
Often begins in the lower abdomen at striae and extends to the thighs and buttocks
Spares the umbilicus
Lesions usually become confluent
No impact on pregnancy
Describe the appearance of prurigo of pregnancy.
Common
Excoriated papules on extensor surfaces of limbs, abdomen and shoulders
Resolves after delivery
Describe the appearance of pruritic folliculitis of pregnancy.
Pruritic follicular eruption with papules and pustules mainly on the trunk
Looks like acne
Resolves within weeks of delivery
Where does toxoplasmosis come from?
Cat litter
Soil
Raw/undercooked meat
What are the average dimensions of the pelvic inlet, mid-pelvis and pelvic outlet?
Pelvic inlet: 13.5 x 11 (transverse diameter is biggest)
Midpelvis: 12 (reasonably round)
Pelvic outlet: 11 x 13.5 (AP diameter is biggest)
Describe the effects of progesterone in labour and describe how progesterone and oestrogen levels change at term.
Progesterone promotes uterine relaxation by suppressing prostaglandin production, inhibiting communication between myometrial cells and preventing oxytocin release
Oestrogen opposes the action of progesterone
Prior to labour, there is a decrease in PR and an increase in ER
NOTE: CRH production by the placenta also increases
How long does the 1st stage of labour usually last?
Latent Phase: 3-8 hours
Active Phase: 2-6 hours
How long does the 2nd stage of labour usually last?
Passive Phase: 1-2 hours
Active Phase: < 2 hours
How often should the FHR be assessed when using intermittent auscultation?
1st stage: every 15 mins
2nd stage: every 5 mins
How is AFI interpreted?
Normal: 8-18
Low (oligohydramnios): < 5-6
High (polyhydramnios): > 24
NOTE: a deepest pool > 8 cm is also considered polyhydramnios
