Obstetrics Flashcards
1st Trimester
1-12 weeks
2nd Trimester
13-26/27 weeks
3rd trimester
28-40 weeks
Baseline foetal heart rate (FHR)
110- 160 bpm
Baseline FHR variability
Normal: 6-25 bpm
Reduced: 3-5 bpm
Absent: < 3bpm
Increased (salutatory): > 25 bpm
FHR accelerations
Transient increase in FHR of 15 bpm lasting 15 sec
FHR decelerations
transient episodes of decreased FHR below baseline more than 15 bpm for at least 15 sec
- often pathological
Types of FHR decelerations
Early
Variable
Prolonged
Late
Early FHR decelerations
- benign & physiological
- 4-8cm cervical dilation
- mirror contraction
Variable FHR decelerations
- repetitive/intermittent
- in association with other non-reassuring/abnormal features are pathological
Late FHR decelerations
- uniform, repetitive decrease
- slow onset at mid to end of contraction
- caused in the presence of hypoxia (foetus already hypoxic)
- decelerations less than 5-15 bpm
Reassuring CTG findings
- baseline FHR 110- 160
- No late or variable FHR decelerations
- Moderate FHR variability (6-25 bpm)
- age-appropriate FHR accelerations
Abnormal CTG findings any
ANY OF THE FOLLOWING
- Baseline FHR <100 bpm or >170 bpm
- Absent variability < 3 bpm
- Prolonged decelerations for > 3 bpm OR late OR complicated variables
Abnormal CTG findings >2
AT LEAST 2 OF THE FOLLOWING:
- Baseline FHR between 100-109 bpm
- Baseline FHR between 160 -170 bpm
- FHR variability is reduced (3-5 bpm for > 40 mins)
- Variable decelerations without complicating features
Abnormal CTG, what’s the next step
- Stop syntocinon (give blood to baby)
- foetal scalp sampling unless contraindicated (lactate high, pH low) give C-sec
CTG high risk vs low risk
High risk: mandatory obstetrical intervention
Low risk: limited value, and can lead to unnecessary obstetrical intervention
Pregnancy screening test
Before conception: Rubella
10-12 weeks: Chorionic villus sampling (CVS) Rh negative women need Rh D immunoglobulin (anti-D)
15-17 weeks: Maternal serum screening (alpha fetoprotein, estriol, and beta-HCG ) for Down syndrome
16-18 weeks: Amniocentesis
18-20 weeks: Ultrasound for identification of physical abnormalities (NTD)
First antenatal visit time frame
Within 10 weeks
Antenatal screening protocol
- every four weeks until 28 weeks
- every two weeks until 36 weeks
- every week until 40 weeks or delivery
Spina bifida investigation
US of foetal spine at 16-18 weeks
Tenderness of the right lower part of the uterus indicates
Indications to use ant-D
-Spontaneous abortion.
-External cephalic version.
-Significant closed intra-abdominal trauma.
-Termination of pregnancy.
-Chorionic Villus Sampling.
-Ectopic pregnancy.
-Threatened abortion after 12 weeks of gestation
Doppler studies result
- increase in end-diastolic flow velocity relative to peak systolic velocity
- S/D ratio to decreases with advancing gestation
Increase in S/D ratio is associated with
- increased resistance in the placental vascular bed
- can be noted in pr-eclampsia or festal growth retardation
- Nicotine and maternal smoking increase S/D ratio
Teenage pregnancy complication
- maternal poor weight gain
- premature delivery
- low birth weight
- increased risk of pregnancy-induced hypertension
- increased risk of violence
Rectus sheath haematoma causes
- anticoagulation therapy
- severe cough
- pregnancy
- previous or recent abdominal surgery
- abdominal trauma
- chronic kidney disease
- steroid/immunosuppressive therapy
- vigorous uncoordinated rectus muscle contraction
Features of Placental abruption
- PAINFUL vaginal bleeding or without bleeding (concealed bleeding)
- uterine tenderness
- foetal compromise on CTG
Features of Placenta previa
- painless vaginal bleeding (low in comparison to other forms)
- with or without uterine tenderness (AMC handbook)
- foetal compromise on CTG (can also be without AMC handbook)
- tender rigid abdomen
Vasa previa feature
Carries minimal maternal risk but has serious fetal risk
- no bleeding when ROM
∗ Causes fresh painless vaginal bleeding when membranes rupture just before labour starts
∗ Can be detected by transvaginal ultrasound
∗ If detected early, c – c-section will be done between 34 to 37 weeks
Trying for pregnancy after miscarriage/abortion
Wait one menstrual period after abortion
pregnant women with Myasthenia Gravis with pre-eclampsia
magnesium sulphate is contraindicated. as it impairs already slowed nerve muscle connections
Platelet count that is considered safe in pregnancy
50000/mm3
Safe platelets count for regional anaesthesia
70000-100000/mm3
Causes of thrombocytopenia in pregnancy
- Gestational/incidental thrombocytopenia (most common)
- Acute fatty liver
- HELLP syndrome
- Pre-eclampsia
- Eclampsia
HELLP Syndrome stands for
H- haemolysis
EL -elevated liver enzyme levels
LP -low platelet levels
HELLP Syndrome features
- average between 32-34 weeks
- postpartum in up to 30% of cases
- right upper quadrant pain or epigastric pain
- nausea, vomiting, and malaise
- hypertension 80%
- low level proteinuria 5-15%
- AST/ALT elevated secondary to liver dysfunction
- High blood urea and creatinine with acute renal failure
- bilirubin level is increased secondary to haemolysis
Pre-eclampsia dx
> 20 weeks + Hypertension (1st symptom) + end-organ damage such as ankle and facial edema or placental insufficiency
- proteinuria (2nd symptom) after 20 weeks
-headache, dizziness and abdominal pain just below the ribs.
Severe pre-eclampsia dx
BP > 160/110mmHg + proteinuria
Pre-eclampsia ddx
gestational hypertension
acute fatty liver
Proteinuria in pre-eclampsia
> 300g protein in 24hr urine
protein to creatinine ratio
Used to diagnose pre-eclampsia
- >30mmol
Risk of pre-eclampsia
- Previous eclampsia [7x]
- Chronic hypertension [5]
- Pre-existing diabetes [4x]
- Multiple pregnancy (twin) [3x]
- Autoimmune disease (SLE, antiphospholipid syndrome) [3x]
- Nulliparity [3x]
- 1st degree family history [3x}
- Age >40 [2x]
- Pre-existing kidney disease [2x]
- BMI > 30 [2x]
- Prolonged interpregnancy interval
gestational hypertension features
> 20 weeks
- without pre-eclampsia features
- resolves within 3 months after delivery
- good prognosis
gestational hypertension investigation
monitor to exclude development of pre-eclampsia
- if BP >140/90: start antihypertensives
- aim to maintain BP at 110-140/80-90
Symphyseal fundal height
gestational age +- 2
- if low check for pre-eclampsia
Medication for hypertension
Moderate:
- Methyldopa
- labetalol/atenolol
- Nifedipine
Severe:
- IV Hydralazine 5mg bolus every 20 min
Methyldopa in postpartum period
- Cease as it can increase risk of postpartum depression
- Switch to enalapril
- Add nifedipine if above don’t work (acts very quickly)
Criteria for gestational thrombocytopenia
- mild/asymptomatic thrombocytopenia
- no past hx (unless previous pregnancy)
- no foetal thrombocytopenia association
- spontaneous resolution upon delivery
Obstetric cholestasis features
- late second and early third trimester of pregnancy
- pruritus and rash on the palms of the feet worse at night
- increased serum bile acids and other liver function tests.
- jaundice uncommon but could be present
- 40% of recurring in subsequent pregnancies
Obstetric cholestasis investigation
weekly LFT
- increased ALP
- mildly increased AST/ALT & bilirubin
Monitor foetus
- deliver if distressed
Obstetric cholestasis prognosis
- usually clears up rapidly after delivery
- often recurs in future pregnancies or using OCP (which are contraindicated)
Obstetric cholestasis treatment
- relieve bile acids with ursodeoxycholic acids
- antihistamine/emollients
Obstetric cholestasis complications
- foetal distress/death
- preterm delivery
- meconium ingestion
- meconium aspiration syndrome
Acute fatty liver features
Life threatening
- Late 3rd trimester/ early postpartum period (35-36 weeks)
- 1 in 10000 pregnancies
- mortality rate 50%
- Jaundice prevalent
Acute fatty liver causes
disordered fatty acid metabolism by mitochondria in mother
- due to LCHAD enzyme deficiency
- hepatotoxic agents given to mother
Acute fatty liver complications
- ascites
- pancreatitis
- liver encephalopathy
- disseminated intravascular coagulation (DIC)
Acute fatty liver of pregnancy (AFLP) is a rare but serious condition that occurs in the third trimester of pregnancy, where fat accumulates in the liver cells, leading to liver dysfunction. Here’s why it can cause these complications in simple terms:
- What It Is: Ascites is the buildup of fluid in the abdomen.
- Why It Happens: In AFLP, the liver is damaged and can’t produce enough proteins like albumin, which normally helps keep fluid inside blood vessels. Without enough albumin, fluid leaks out into the abdomen, causing ascites.
- What It Is: Pancreatitis is inflammation of the pancreas.
- Why It Happens: The liver and pancreas are closely connected in the digestive process. When the liver is severely damaged in AFLP, it can disrupt normal digestion and lead to the inflammation of the pancreas, causing pancreatitis.
- What It Is: Liver encephalopathy is brain dysfunction caused by severe liver disease.
- Why It Happens: The liver usually filters toxins from the blood. In AFLP, the liver’s ability to do this is impaired, so toxins build up in the blood and eventually affect the brain, leading to confusion, drowsiness, or even coma.
- What It Is: DIC is a serious condition where blood clots form throughout the body’s small blood vessels.
- Why It Happens: In AFLP, the liver can’t produce enough of the proteins needed for normal blood clotting. This can trigger widespread clotting (using up clotting factors), followed by excessive bleeding because the clotting system becomes exhausted.
- Ascites happens because a damaged liver can’t keep fluid in the blood vessels, leading to fluid buildup in the abdomen.
- Pancreatitis can occur as liver damage disrupts normal digestive processes, causing inflammation in the pancreas.
- Liver encephalopathy occurs when a failing liver can’t filter toxins from the blood, leading to brain dysfunction.
- DIC is a severe clotting disorder triggered by the liver’s inability to properly manage blood clotting, leading to both excessive clotting and bleeding.
These complications arise because the liver is crucial for many bodily functions, and when it’s damaged, multiple systems can be affected, leading to serious health problems.
Acute fatty liver dx
Liver failure
-increased AST + ALT (200)
- increased bilirubin
- ALP normal
Acute fatty liver investigation
Liver biopsy confirms dx
Acute fatty liver management
- DRABCD
- Admission to ICU
- Termination of pregnancy (lifesaving for both mother and baby)
- prevent/treat DIC
- may require liver transplant
Foetal
Uterine hyperstimulation
more than 5 active labour contractions in 10 minutes (tachysystole)
- contractions lasting more than 2 mins/ occurring within 60 secs of each other (hypertonus)
Umbilical cord prolapse
- Variable decelerations
- persistent foetal bradycardia
- prolonged decelerations for over 1 minute
Umbilical cord prolapse
-PPROM.
-Polyhydramnios
-Breech presentation.
-Multiparity.
-Multiple gestations.
-GDM increasing the risk of polyhydramnios, fetal
malpresentation, premature rupture of membrane.
Hypertension in pregnancy
- primary pulmonary hypertension is a contraindication
- increases the risk of pre-eclampsia
- increases the risk of foetal growth restriction
- Daily intake of 1000mg of calcium to reduce incidence of hypertensive disorders and preterm labour
Varicella Zoster (Chickenpox)
- Check mothers IgG status for antibodies:
positive = no further action needed
negative = within first 96 hours, give immunoglobulin (VZIG)
Varicella Zoster (Chickenpox) screening
1st trimester if no prior/uncertain history
Varicella prophylaxis
Acyclovir (1st line) valaciclovir:
-2nd half of pregnancy
- underlying history of lung disease
- smoker
- immunocompromised
Varicella management IgM+
without complications:
- Rash < 24 hours - give oral antivirals (acyclovir)
Rash >24 hours - no treatment is required.
With complications /
immunocompromised:
- Intravenous acyclovir
Varicella management in a px that is infected/ symptomatic about to deliver
Chicken pox
### If Symptoms Appear More Than 7 Days Before Delivery:
- No special treatment: The baby does not need VZIG (a protective shot).
- No isolation needed: The baby does not need to be separated from others.
- Breastfeeding encouraged: The mother should continue breastfeeding as usual.
- VZIG for the Baby: The baby should receive a shot of VZIG (200 IU) right after birth to help protect against chickenpox. Ideally, this should be done within the first 24 hours but can be given up to 72 hours after birth.
- Early Discharge: Full-term babies should be discharged from the hospital as soon as possible.
- No isolation needed: The baby does not need to be isolated.
- Breastfeeding encouraged: The mother should continue breastfeeding as usual.
-
VZIG for Certain Babies:
- If the baby was born before 28 weeks gestation or weighs less than 1000 grams, they should receive VZIG within 96 hours of exposure, but it can be given up to 10 days after the mother develops a rash.
- If the mother has never had chickenpox or doesn’t have immunity, the baby should get VZIG if exposed between 2 and 28 days after birth.
- Early Discharge: Full-term babies should be discharged from the hospital as soon as possible.
- No isolation needed: The baby does not need to be isolated.
- Breastfeeding encouraged: The mother should continue breastfeeding as usual.
- The need for VZIG and other measures depends on when the mother shows symptoms in relation to delivery.
- Isolation is generally not required, and breastfeeding is always encouraged.
Presentation of the symptoms >7 days before delivery:
- No VZIG required.
- No isolation required.
- Encourage breastfeeding
Maternal chickenpox 7 days before to 2 days after birth:
- Give newborn VZIG 200 1U bone vial)
intramuscularly (IM) immediately after birth.
VZIG should be given as soon as possible within
the first 24 hours of birth but may be given up
to 72 hours.
- Discharge term neonates as soon as possible.
- No isolation required.
- Encourage breastfeeding.
Maternal chickenpox > 2 to 28 days after birth:
- If neonate < 28 weeks gestation or 1000 g birth
weight, give VZIG (preferably within 96 hours
but can be given up to 10 days post-maternal
rash.
- Due to the increased risk of severe varicella in
newborns of seronegative women (if the mother
has no personal history of infection with VZV),
give VZIG to neonates exposed to varicella
between 2 to 28 days of age.
- Discharge term neonates as soon as possible.
- No isolation required.
- Encourage breastfeeding.
Vaccines that are contraindicated in pregnancy
- Varicella Zoster (chicken pox)
- Rubella
- Measles
Pertussis DPTa
- can give vaccine
- usually recommended at 28 weeks
Effects of oxytocin
- uterine stimulation
- antidiuretic
- mammary gland stimulation
- labor induction
Foods that should be avoided during pregancy
- Dairy: soft cheese, soft serve ice cream, unpasteurised
- Smoked salmon, trout
Eating soft cheese/salmon increases the risk of
Listeriosis
(meningitis, meningoencephalitis)
PROM vs PPROM
PROM
- <37 weeks
Preterm Pre-Rupture of Membranes (PPROM)
- Rupture of foetal membranes before labour at any gestational age
- 50% progression into labour with 24 hrs
- 80% in 7 days
- preterm delivery
- presence of liquor flow from the cervical os
- pooling of liquor flow in the posterior vaginal fornix
- Neonatal complications
-intrauterine infections (chorioamnionitis)
NOTE: DON’T DO vaginal swabs due to high risk of infections
Preterm Pre-Rupture of Membranes (PPROM) ddx
- fluid loss
- ## urinary incontinence
PPROM risks
- cord prolapse
- preterm labour
- placental abruption
- chorioamnionitis
- foetal pulmonary hypoplasia/ other features of prematurity
- limb positioning defects
- perinatal mortality
Preterm Pre-Rupture (PPROM) of Membranes management
-admit to hospital
- < 34 week + 6 days: corticosteroids (IM betamethasone) to decrease neonatal complications
- oral erythromycin or IV prophylactic antibiotics 48hrs (amoxicillin) to prevent chorioamnionitis
-
- Baby born < 34 weeks would need to be monitored in the NICU (tertiary hospital)
- weekly bloods + CRP + vaginal swabs
Foetal fibronectin (fFN)
- absence is best negative predictor of PTD.
negative test means preterm labour within the next 7 days would be unlikely.
criteria:
- Intact foetal membranes
- Cervical dilation less than 3 cm
- Gestational age of between 22 +0d - 34+6d
weeks
Preterm labour criteria
< 36 + 6 weeks
Preterm labour dx
- history two or more miscarriages occurring after the 12th weeks gestation, usually starting with painless leaking of amniotic fluid
- The easy passage of a size 9 cervical dilator through the internal os of the cervix when the woman is not pregnant, and the absence of a ‘snap’ on its
withdrawal - cervical length of less than 25mm or cervical
funnelling >40% prior to 24 weeks gestation
Preterm labour causes
- idiopathic 40%
- cervical incompetence
- multiple pregnancy
- polyhydramnios
- uterus abnormalities, septum
- infections: GBS, measles, SMV, UTI
- DM
- haemorrhage: pre-eclampsia
Labour induction indications
- pre-eclampsia
- IVF
- IUGR
- Cephalic presentation
Contraindications of labour
- Signs of chorioamnionitis
- antepartum haemorrhage
- request of mother
- neonatal jeopardy
Features of Inefficient or incoordinate labour
- Usually no moulding of the foetal head
- +/- caput formation of foetal head
- usually absent cervical oedema
- tachycardia
- Can be above or below IS
- Usually < 1 finger breadths of head palpable above the pelvic brim when the lowest point of the head is at the IS
Features of obstructed labour
- ++ moulding of foetal head
- ++ caput formation on foetal head
- anterior lip cervical oedema
- ++ progressive foetal tachycardia
- just at or above the ischial spines (IS)
> 2 finger breadths of head palpable above the pelvic brim when the lowest point of the head is at the IS
These signs suggest that the baby is having difficulty moving down through the birth canal during labor. Here’s what each point means in simple terms:
-
++ Moulding of the Fetal Head:
- The baby’s head is being squeezed tightly as it tries to fit through the mother’s pelvis. The skull bones overlap more than usual.
-
++ Caput Formation on the Fetal Head:
- A swelling (caput) forms on the baby’s head due to pressure during labor. This is a soft bump on the top of the baby’s head.
-
Anterior Lip Cervical Edema:
- Part of the cervix (the opening of the uterus) is swollen. This can happen if the baby’s head is pushing against it before the cervix is fully dilated.
-
++ Progressive Fetal Tachycardia:
- The baby’s heart rate is getting faster than normal, which can be a sign of distress.
-
Just at or Above the Ischial Spines (IS):
- The baby’s head is either at or just above a specific point in the pelvis called the ischial spines. This means the baby hasn’t moved down very far during labor.
-
> 2 Finger Breadths of Head Palpable Above the Pelvic Brim When the Lowest Point of the Head is at the IS:
- Even though the baby’s head is at the ischial spines, you can still feel a good portion of the head (more than 2 finger widths) above the pelvic brim. This suggests the baby’s head hasn’t descended properly into the pelvis.
These signs indicate that the baby is having a tough time moving down into the birth canal, possibly due to the head not fitting well through the mother’s pelvis. This situation might require closer monitoring or intervention to ensure the baby and mother stay safe during labor.
Features of chorioamnionitis
- increased WBC (>15x 10^9/L)
-Maternal tachycardia >100 bpm - foetal tachycardia > 160 bpm
- uterine tenderness
- offensive vaginal discharge
- CRP > 40
Tocolysis contraindication
- chorioamnionitis (absolute)
Measles (MMR) during pregnancy
- Notifiable disease therefore contact tracing
- Immunoglobulin is used as prophylactic only, not for established
- symptomatic treatment
Measles incubation period
10-14 days
Measles symptoms
- fever
- malaise
- cough
- coryza
- conjunctivitis
- white spots surrounded by red ring in the buccal mucosa (Koplik’s)
- maculopapular rash 2-4 days after initial symptoms
- infection periods start 2 days after rash onset, 4 days after eruption
Measles complications in children
- Otitis media 7%
- Bronchopneumonia 6%
- acute encephalitis 2-10/10000
Measles complications in mother
- preterm labour
- spontaneous abortion
- foetal/neonatal loss
- maternal mortality
Complications in the Fetus
1. Congenital Measles: Though rare, the virus can cross the placenta and infect the fetus, leading to congenital infection. 2. Preterm Birth: Due to complications like pneumonia and systemic infection in the mother. 3. Low Birth Weight: Associated with preterm birth and maternal infection. 4. Stillbirth: Severe cases of measles can lead to fetal death.
Placental abruption
- separation of placenta from uterus
- 3rd trimester bleeding
- foetal morbidity and mortality
- MVA
Placental abruption symptoms
- vaginal bleeding 80%
- Abdominal/back pain 70%
- uterine tenderness 70%
- abnormal uterine contractions - 35%
- idiopathic premature labour - 25%
- foetal death 15%
-hypofibriogemia
Placental abruption with no foetal heart sounds, what to do next
foetus is dead.
Commence amniotomy as it’ll induce spontaneous labour
Rubella in pregnancy
- check serology (IgM and IgG) (IgG titer of = >than 10 IU/ml)
- Rubella infection in the first trimester (<8 weeks) causes severe foetal anomalies 85%
- If infected termination is recommended
rubella symptoms
- usually asymptomatic 25- 50% cases
- low grade fever
- transient erythematous rash
- post- auricular/ sub-occipital nodes lymphadenopathy
Maculopapular rash on the face and spreads to trunk and extremities (resolves within 3 days)
Rubella infection during pregnancy
- <8 weeks 85% foetal infection (congenital rubella syndrome)
- 8< - <12: 50 - 80% infected 65 -85 clinically infected
- 13 -16 weeks 30% infected, 1/3 have sensorineural deafness
- 16 -19 weeks: 10% infected, clinical features rare
- > 19 weeks: no apparent risk
Rubella vaccinated before pregnancy
Reassure if not exposed to Rubella
Rubella abnormalites
- CNS dysfunction 10 25% (intellectual impairment developmental delay, microcephaly)
- eye 10 -25% (cataracts, retinopathy, glaucoma)
- sensorineural deafness 60-75%
cardiac 10-20% (PDA wide pulse pressure, PA stenosis, ) - intrauterine growth restriction, short stature
- inflammatory lesions (brain, liver, lungs, bone marrow
Hyperemesis gravidarum
- nausea and vomiting at 5-6 weeks of gestation, peaking at 9 weeks
-Weight loss (more than 5% of weight)
-Ketosis - urine analysis to check for hydration status
School exclusion
Measles: 5 days
Mumps: 9 days
Rubella: 5 days
Incarcerated uterus
- pregnant uterus entrapped in the pelvis by subpromontary sacrum
- retroverted uterus?
Episiotomy haematoma management
- < 3cm conservative management
- > 3cm surgical excision/exploration
Most serious cause of Hyperemesis gravidarum
- Hypokalemia
- On ECG: such as inverted T waves and prolonged QT and PR intervals
Pregnancy-Unique Quantification of Emesis (PUQE-24) score 4-6
- Ginger 250mg orally, 4 times/day
Pyridoxine (Vit B6) 10-25mg 3-4 times/day
Pregnancy-Unique Quantification of Emesis (PUQE-24) score 7 -12
Cyclizine 12.5-50mg oral 3/d
Promethazine 10-25mg oral 3/day
Prochlorperazine 5-10mg oral 3-4/day
Metoclopramide 10mg oral/IV/IM
Domperidone 10mg 3/day
Ondesatron 4-8mg oral/IV
Pregnancy-Unique Quantification of Emesis (PUQE-24) score > 13
Hydrocortisone IV 100mg 2/day
Prednisolone 40-50mg oral 1/day
Hyperemesis gravidarum excessive vomiting may lead to the
following
- Hyponatremia - caused by vomiting and Gl loss
- Hypokalemia - caused by vomiting and Gl loss
- Hypochloremic alkalosis - caused by vomiting
and GI loss - Ketosis - resulting from decreased oral intake,
starvation and dehydration - Abnormal liver enzymes (ALT>AST)
- Increased serum amylase and lipase
- Vitamin deficiency in pregnancy (very rare)
Hyperemesis gravidarum mx
1st line: metoclopramide
2nd line: Ondansetron if metoclopramide doesn’t’ work
3rd: steroids (prednisolone) last resort
Placenta previa management
management depends on gestation duration:
- < 37 weeks even with large amounts of bleeding can be safely monitored
- > 37 weeks with bleeding delivery through C section
Hyperthyroidism in Pregnancy
- Check TSH and free T4
foetus: - foetal tachycardia
- small gestational size
- premature/stillborn
- Graves
- if px
Hyperthyroidism medication
- radioactive iodine therapy if patient is not pregnant (postpone pregnancy for 6 months)
- PTU if already pregnant
- Don’t give carbimazole in first trimester as if causes scalp defects
Imminent eclampsia dx
-BP > 160mm/hg on 2 occasions 6 hours apart
- Proteinuria of > 5g
- cerebral/visual disturbances drowsiness, droopy eyelids
- pulmonary oedema
Eclampsia dx
-seizures
Eclampsia management
IV diazepam with Magnesium sulphate (phenytoin teratogenic)
Features of magnesium sulphate toxicity
- respiratory rate < 12 breaths/minute
- urine output < 100mLs in 4 hours (renal insufficiency)
- loss of patellar reflexes; further seizures occur
- Muscle paralysis and respiratory difficulty at >7.5 mmol/L
- cardiac arrest at levels greater than >12 mmol/L
magnesium sulphate toxicity treatment
serum magnesium level is >3.5mmol/L, cease infusion and consult with obstetrician
foetal growth restriction causes
- intrauterine restriction
- Maternal hypertension (SLE, lupus nephritis) - Congenital
- Trisomy 21, 18, 13 Turner’s - Infections
– Cytomegalovirus (CMV) /intrauterine infection - Maternal
- smoking, alcohol, phenytoin
Most common viral cause of birth defects
CMV
Features of CMV
- maternal primary infection often asymptomatic
- IgG seropositive up to 50% of pregnant women
- Transplacental foetal infection is 50% with primary infection
CMV symptoms
- retardation
- microcephaly
- seizures
- hearing deficits
- chorioretinitis
- optic atrophy
- brain architectural changes
CMV dx
combination of
foetal ultrasound, amniocentesis + /- foetal serology
definite diagnosis of foetal infection is by
amniocentesis
CMV serology protocol
IgM-ve/IgG-ve: No CMV infection/susceptible
IgM-ve/IgG+ve: repeat serology after 2 weeks
IgM+ve/IgG+ve: Test immediately/repeat testing
- low: recent primary infection
- intermediate: not sure if primary
- high: past infection
Anaemia in pregnancy
< 100g/L
Secondary postpartum haemorrhage
24 hours - 12 weeks
- bright red haemorrhage
- fever
- Scant lochia bright red, brown red
- retained products of conception (RPOC)
endometritis ddx: look for bleeding colour
Postpartum endometritis risk factors
-C Section delivery (most common)
- Young maternal age.
-Multiple digital cervical examinations.
-Prolonged rupture of membranes.
-Retention of placental products.
-Prolonged labour.
-Chorioamnionitis
Folic acid deficiency cause
- Neural Tube Defects (NTD)
Phenytoin in pregancy
- Phenytoin is teratogenic
- Enzyme inducer
Folic acid during pregnancy
- 0.5mg recommended dose
- 1 month before conception to 3 months after
- 5 mg unless:
- family history of NTD
- Enzyme inducing medication (epileptic)
- BMI > 35
– Pre-pregnancy diabetes
– Risk of malabsorption syndrome
– A family history of congenital heart disease
– Multiple pregnancy
Uterine rupture features
- foetal bradycardia
- previous uterine surgery (C -section)
- constant abdominal pain
- intraabdominal haemorrhage signs
- little vaginal bleeding (usually concealed)
- maternal tachycardia/hypotension
- uterine contraction cessation
-foetal loss of station - uterine tenderness
Uterine rupture Dx
Laparotomy
Uterine rupture Ddx
- uterine atony
- amniotic fluid embolism
Transverse lie/breech indicates
- high parity
- pendulous abdomen
- placenta previa
- polyhydramnios
-pelvic inlet contracture/ foetal macrosomia - uterine abnormalities (fibroids, bicornuate uterus)
- foetal abnormalities (neck/sacrum tumours, hydrocephaly, abdominal distension)
- distended maternal bladder
- poorly formed lower segment
- more premature (wrong date)
- undiagnosed twins
- preterm delivery
Transverse lie/breech investigation
US
Transverse lie/breech management
If placenta previa excluded
- Cephalic version is < 36
- C section if >37 weeks or in labour
Fundal height
height correlates to gestational age (weeks) with > 2cm discrepancy
< gestational age:
- dating errors
- foetal growth restriction (3rd trimester)
- reduction in liquor volume (3rd trimester)
- oligohydramnios
- traverse/oblique lie
- small gestational age
- late ovulation (if px ceased OCP: 2 weeks 50%, 6 weeks 90%, 12 months 1%)
> gestational age:
-dating errors
- large gestational age
- polyhydramnios
- molar pregnancy
Fundal height location
- 12 weeks: palpable above the pubis
- 20 weeks: level of umbilicus
Fundal height not matching gestational age, next step?
US to check for dating error as wells as polyhydramnios, multiple gestation
Placenta Previa grading
I: placenta is lower segment, but lower edge doesn’t reach internal os
II: lower edge reaches internal os but doesn’t cover it
III: placenta partially covers internal is
IV: completely covers internal os
GDM antenatal screening
Routine OGTT at 24-28 weeks
If risk index > 2 OGTT at 14 weeks
GDM criteria
a fasting plasma level: > 5.5mmol/L
1hr: 10.1mmol/L
2 hours after a 75g OGTT: 8.5mmol/L
Placenta Previa < 37 weeks managment
if routine exam at 18 weeks shows low lying placenta, then another US should be done at 32-34 weeks
- Vital signs, IV if needed
- uterine tenderness
- US
- Anti-D (RhoGAM) (mum is Rh- but foetus Rh+)
Gestational diabetes (GDM) postpartum screening
- 30% in the next 10 years
- 50% risk of type 2 DM within 20 years
diagnosed should have - 75g OGTT 6 -12 weeks postpartum
HbA1c every 3 months during pregnancy - FBS and/or HbA1C 3 yearly
Gestational diabetes (GDM) antepartum screening
Consult risk index to assess px score:
If < 2: 75g OGTT 24-28 weeks
if >2: 75g OGTT at 14 weeks (earlier if px can tolerate it)
Gestational diabetes (GDM) screening risk index
BMI: 25-35 = 1
BMI: > 35 = 2
Ethnicity: not white = 1
Previous GDM = 2
Previous elevated blood glucose = 2
Maternal age > 40 years = 2
Family hx: 1st degree relative or sister = 2
Previous macrosomia = 2
Previous perinatal loss = 2
PCOS = 2
Medications (corticosteroids, antipsychotics) = 2
DM in px planning to conceive
aim to achieve a target HbA1c value less than 6-7%
GDM diet control delivery plan
if well controlled, continue to 40 weeks
GDM medicated control delivery plan
if good control: 38-39 weeks (try for 39 weeks onwards)
If poorly controlled: induce at 38 weeks
Epstein-Barr (EBV) in pregnancy
- 2-7 weeks incubation
- doesn’t transmit to foetus
- Infectious mononucleosis
- 3-3.4% susceptible
- 50% infected develop clinical disease
- recurrent infection can cause shortened pregnancy and low birth weight
- only need to deal with px if symptoms arise
EBV features
- fever
- sore throat
- cervical/ post auricular lymphadenopathy
- characteristic increases in monocytes and lymphocytes
- hepatosplenomegaly
-hepatic transaminase increase
EBV management
Symptomatic treatment
- Antibiotics in bacterial URTI
Drug associated patent ductus arteriosus
-NSAID’s
NSAID’s in pregnancy
- USED WITH CAUTION
- not more than 48 hours
-PDA
-delayed labour and birth - oligohydramnios via decreased foetal GFR
treatment of hyperemesis graviudarum
codeine and metoclopramide correct
Round ligament pain
- 2nd trimester
-RLQ pain - aggravated by moving
- all vital signs normal
Features of threatened abortion
- closed cervical os
- absent history of passing foetal tissue
- uterine size is the expected size
Features of inevitable abortion
- open cervical os
- bulging of membranes of the os < 20 weeks
- uterine size is smaller than the expected size
Features of incomplete abortion
- open cervical os
- bulging of membranes of the os >10 weeks
- uterine size is smaller than the expected size
Features of complete abortion
- closed cervical os
- passing of foetal tissue
- uterine size is smaller than the expected size
Features of septic abortion
- uterine infection during any time
- vaginal bleeding
-cramping pain - fever
- purulent cervical discharge
Features of missed abortion
- Closed cervical os
- No spotting or bleeding (no foetal tissue passed)
- Ultrasound scans diagnosis of a non-viable IUP (empty sac)
- uterine size is smaller than the expected size
Spontaneous abortion risk factors
- age > 35
- previous miscarriages
- antiphospholipid syndrome 15%
- parenteral chromosomal derangements
- embryonic chromosomal abnormalities
- congenital uterine malformations
-cervical weakness - DM, thyroid disease
- Immune factors
- Infections
_ inherited thrombophilic defects - caffeine, smoking, alcohol
-uterine adhesions
Most common method of abortion in Aus
4 to 9 weeks: mifepristone and misoprostol
6 to 14 weeks: D&C
Legal for up to 24 weeks
> 16weeks: get 2nd opinion and if ok then D&C
Most accurate estimation of gestational age
Transvaginal US at 8 weeks
Vaginal bleeding in 2nd trimester
- cervical insufficiency or labour
- placenta previa
-placental abruption - uterine rupture
- vasa previa
Features of cervical insufficiency
Sx usually persisting for several days or weeks:
- increased pelvic pressure (similar to labour discomfort)
- premenstrual-like cramping
- backache
- increased vaginal discharge
- seen between 14-20 weeks
- soft effaced cervix, with minimal dilation
- advanced clinical
- uterine size is the expected size
presentation
- more than 4 cm dilated and more
than 80% effaced
Risk factors of cervical insufficiency
-Congenital disorders of collagen synthesis (Ehlers-Danlos syndrome).
-Prior cone biopsies.
-Prior deep cervical lacerations, usually secondary to vaginal or C section.
-Müllerian duct defects (e.g., bicornuate or septate uterus).
-More than three prior foetal losses during the 2nd trimester
Vaginal bleeding in 1st trimester
- ectopic pregnancy
- occurs in 20-30% of all pregnancies
- significantly increases the risk of preterm birth by 28-31 weeks
Vaginal bleeding 3rd trimester
- Placental abruption
- Placenta Previa
Vaginal bleeding postpartum
Bleeding 2 weeks postpartum is normal
bleeding 2 weeks indicate placental site subinvolution
- retention of small placental fragments
(estimate blood loss and then perform a pelvic examination top check for uterine subinvolutionor tenderness)
Spider veins in pregnancy
- angiomas
- common findings during pregnancy
- hyperestrogenemia
- resolve spontaneously after delivery
C section risk in Mother
- Increased risk of maternal mortality
- thromboembolism
- haemorrhage
- infection
- incidental surgical injuries
- more postpartum pain
- adhesions
- hospital readmission
-infertility/sub infertility - uterine rupture
-abnormal plancetation
C section risk in foetus
- neonatal death
- reparatory problems
- asthma
- iatrogenic prematurity
- trauma (laceration)
- breastfeeding failure
Risk of asthma in foetus
- C section
- Smoking
- avoidance of house dust mite or pet allergens
- Probiotic dietary supplements, vitamin A, D or E supplements, or fish oil
Maternal Vitamin D deficiency
- Hypocalcaemia in newborn.
– Rickets later in life.
– Defective tooth enamel.
– Small for gestational due to effect on skeletal growth
– Foetal convulsions or seizures due to hypocalcaemia.
Pituitary apoplexy features
- sudden haemorrhage
- excruciating headache
- diplopia ( oculomotor nerve)
- life threatening hypotension
- Fall in ACTH, sortisol
Pituitary apoplexy inverstigation
- CT/MRI (MRI for pregnancy)
Anticoagulation in pregnancy
- both warfarin and heparin safe to use for breastfeeding mothers
Medications safe for breastfeeding
- Beta blockers: Propranolol, labetalol and metoprolol
- Anticoagulation: Warfarin and Heparin
3rd trimester use of anticoagulants
- Both warfarin and heparin can be given to the mother.
- Heparin doesn’t cross the placenta
- Heparin is preferred due to the quick reversal by protamine sulphate, compared to warfarin, especially if labour occurs
Antenatal thromboembolism management
LMWH enoxaparin is treatment of choice
Below knee: 3 months
Above knee: 6 months
Postpartum: 6 weeks
Warfarin during pregnancy
CONTRAINDICATION
- crosses placenta
1st trimester:
foetal warfarin syndrome:
6-12 weeks’ gestation
- nasal hypoplasia
- short fingers. Hypoplastic nails
- calcified epiphyses (chondrodysplasia)
- intellectual disability
- low birth weight
2nd trimester (>12 weeks):
- microcephaly
- hydrocephalus
- corpus callosum agenesis
- Dandy walker malformation
- mental retardation
-optic atrophy, peter anomaly, microphthalmia
- blindness
3rd trimester DVT patient on LMWH protocol
Switch to unfractionated heparin (UFH) at 36 weeks to avoid epidural haematoma
Pregnancy and DVT
Pregnancy is hypercoagulable state due to
- drop in C and S proteins
- increased procoagulant factor V and VII
- antithrombin
- more common in left leg (85%) due to left iliac vein compression
antiphospholipid antibody syndrome criteria
1 or > 1 foetal losses beyond 10 weeks of gestation
antiphospholipid antibody syndrome treatment
- low-dose aspirin (50 to 100 mg per day)
- Low dose prophylactic LMWH
Pulmonary hypertension (PH)
- Contraindicated for pregnancy
- maternal death 30-56%
- most dangerous at peripartum period and
immediate postpartum period (2 months) - C section preferred
Pulmonary embolism (PE) investigation in pregnancy
- CTPA 1st-2nd trimester (uses less radiation than VQ, therefore safer during pregnancy)
- Ventilation perfusion 3rd trimester scan (to rule out PE)
hypothyroidism in pregnancy
- thyroid gland increases by 15%
- increased T3 and T4
- Free T3 and T4 unchanged
- increases demand of thyroxine by 25-30%
-TSH should be monitored every 8 to 10 weeks during pregnancy
Here’s a simplified overview of hypothyroidism in pregnancy:
-
Thyroid Changes:
- During pregnancy, the thyroid gland grows by about 15% to meet the increased demands of the body.
-
Hormone Levels:
- Total T3 and T4: These thyroid hormones increase during pregnancy.
- Free T3 and T4: These levels (the active form of the hormones) usually stay the same, even though the total levels go up.
-
Increased Demand for Thyroxine:
- Pregnancy increases the body’s need for thyroxine (a key thyroid hormone) by about 25-30%. This means that women with hypothyroidism might need a higher dose of thyroid medication during pregnancy.
-
Monitoring TSH:
- Thyroid-stimulating hormone (TSH) should be checked every 8 to 10 weeks throughout pregnancy to ensure the thyroid hormone levels are well-managed. This helps keep both the mother and baby healthy.
These points highlight how pregnancy affects thyroid function and the importance of monitoring and adjusting treatment for hypothyroidism to support a healthy pregnancy.
medications safe for hypothyroidism
levothyroxine
What is elevated during 3rd trimester
- prolactin
- alkaline phosphatase
- iron binding capacity
- cortisol
Iron deficiency anaemia (IDA) in pregnancy
- 18% of pregnant women
- screened at 1st trimester and at 28 weeks
- 1000–1200 mg iron is required
- serum ferritin test investigation of choice
- microsomia
Iron deficiency anaemia (IDA) in pregnancy complications
- increases the risk of preterm delivery
- increases the risk of microsomia or low birth weight
Iron deficiency anaemia (IDA) in pregnancy treatment
- routine supplementation not recommended
- oral iron 20mg/day first line
- IV iron at 2nd & 3rd trimester
Toxoplasma transmission
- unwashed fruits and vegetables
- untreated water
- raw meat
- cat litter
Rh -ve woman and anti-D indications
1st trimester:
Chorionic Villus Sampling;
Miscarriage;
Abortion (medical after 10 weeks of gestation or surgical)
Ectopic pregnancy.
Molar pregnancy
- blood transfusion
Second and third trimester: (basic dose 625 IU)
Obstetric haemorrhage;
Amniocentesis or other invasive foetal intervention;
External cephalic version of a breech presentation, whether successful
or not
Abdominal trauma, or any other suspected intra-uterine bleeding or sensitising event.
Abortion
Molar pegnancy
What type of twins will get blood to blood transfusion
monochorionic
Antepartum haemorrhage
- placenta previa
- vase previa
- placental abruption
- cervical previa (cancer
Postpartum haemorrhage blood loss
vaginal 500ml - balloon, uterine ligation, hysterectomy
C sec 1L
Postpartum haemorrhage causes
tone
trauma
tissue
thrombin
- Uterine atony (most common) 70%
- Genital Tract trauma/laceration 20%
- Retained products of conception/invasive placenta 10%
- Coagulation abnormalities <1%
Postpartum haemorrhage management
- atony: fundal massage + oxytocin
maintained placenta - exploration under anaesthesia to remove
laceration - repair
if unstable:
DRABCD
oxygen
blood match
Postpartum haemorrhage predisposing factors
- Antepartum haemorrhage (especially placental abruption and placenta praevia)
- Postpartum haemorrhage with a previous pregnancy
- Known placenta accreta
- Multiple pregnancy
- Coagulopathies
Most common cause of postpartum haemorrhage requiring
hysterectomy?
Placenta accreta due to deep invasion to the uterine wall not the myometrium
Hysterectomy reasons
Placenta accreta
Gas gangrene (clostridia 5-10%)
haemolysis
renal failure
Postpartum depression risk
20%
When to discontinue epileptic medication
- seizure free at least 2 years
- no epileptic activity on EEG
- no neurological finding
Lithium in pregnancy
- Cause of Ebstein anomaly
- in cases of severe bipolar disorder, lithium may outweigh the risks
- Lithium use during the first trimester of pregnancy has been reported to be associated with foetal cardiovascular
anomalies (e.g. Ebstein’s anomaly) and midfacial and other defects.
Risk of developing Ebstein’s anomaly on patients on lithium?
approximately 1 in 1000 to 2000
compared with 1 in 20000 in the general population.
If patient continues to use lithium during pregnancy, what should be investigated?
an ultrasound and echocardiogram should be performed at 16-20weeks gestation to exclude foetal anomalies, especially cardiac anomalies
In relation to lithium dosage during pregnancy, what should be done in each trimester?
1st trimester: keep same dose as before pregnancy but heavily monitor foetus by US at 16-20 weeks.
2nd trimester: continue same lithium dosage.
3rd trimester: decrease lithium dosage by 25% to avoid floppy baby syndrome due to neonatal toxicity.
After delivery immediately increase lithium dosage due to
increased risk of relapse in postpartum period.
Sodium Valproate in pregnancy
1st trimester: decrease dose to prevent neural tube defects
2nd semester: continue decreased dosage through to 3rd semester
3rd trimester: increase the dosage to prevent seizures
Which SSRI is contraindicated in pregnancy
Paroxetine
HIV screening
- First antenatal visit
Risk of HIV transmission to foetus
20-30%
Perinatal HIV transmission interventions
- assess mother’s viral load:
- if viral load >1000 copies/mL/unknown then intrapartum zidovudine and elective C section
- If mother hasn’t taken antiretroviral therapy (including only intrapartum) add lamivudine plus nevirapine to zidovudine
- if viral load <1000 copies/mL then no retroviral therapy needed, allow for vaginal delivery
- peripartum intravenous zidovudine
- Elective C section
- Bottle feeding
Intervention decreases risk to <2%
Herpes (HSV) during pregnancy
- Usually asymptomatic 75%
- acyclovir before delivery recommended
- Foetal infection risk significantly higher in primary infection
- Presence of lesions on the genital (vulva, cervix) require immediate C section
- <30 weeks, risk of shedding during normal birth is 7% with an overall risk of <3% for neonatal HSV
Which heart disease can lead to significant complication during pregnancy
Mitral stenosis secondary to pulmonary hypertension
Postpartum fever
38.7 for the first 24 hours, > 38 after 10 days post.
Depends fever onset and uterine tenderness:
- endometritis= uterine tenderness with/o lochia
- UTI: 1-2 postpartum and urinary symptoms (dysuria)
- Wound infection: 4-5 days
- Septic thrombophlebitis: 5-6 days
- breast engorgement: 7-21 days
-atelectasis: 1st 24 hours
Postpartum fever management
Amoxicillin + metronidazole + gentamycin
IF CI: vancomycin
Most common pathogen of septic shock
Escherichia coli
Smoking complications during pregnancy
Obstetric
- abortion/miscarriage
- placental abruption
- placenta previa
-preterm birth < 37 weeks
pre-eclampsia
-PROM
-ectopic pregnancy
- Still birth
foetal
- low birth weight -
- Intrauterine growth restriction
- birth defects
Childhood/adult
- SIDS
- developmental delay
- Type 2 DM
- Obesity
- hypertension
- decreased HDL
Foetal alcohol syndrome (FAS)
- Small teeth/faulty enamel
Hypertensive medication in pregnancy
Most are contraindicated
- ACE inhibitors
-ARB’s
-Diuretics (1st sem teratogenic, 2-3 sem foetal renal dysfunctions, oligohydramnios, skull hypoplasia)
- Beta blockers (foetal bradycardia, growth restriction)
recommendation: Methyldopa, if contraindicated due to other reasons then hydralazine or labetalol
acute antihypertensive therapy in pregnancy
- Intravenous labetalol unless in patients with bradycardia (ie, <60/min)
- Intravenous hydralazine if bradycardia is present
- Oral nifedipine unless px nausea/vomiting
Tocolysis contraindications
- Gestation > 34 weeks or <24 weeks
- Labor is too advanced - advanced cervical
dilation (>4cm) - Chorioamnionitis
- In utero foetal death
- Abnormal CTG suggesting non-reassuring foetal
Status - Lethal foetal anomalies
- Intrauterine foetal demise
- Suspected foetal compromise
- Significant antepartum haemorrhage, such as
placental abruption/ active vaginal bleeding - Suspected intrauterine infections (e.g.
chorioamnionitis) - Maternal hypotension
- Haemorrhage with hemodynamic instability
- Pregnancy-induced hypertension/ eclampsia/
- pre-eclampsia
- Placenta previa
- Placental insufficiency
- Intrauterine growth retardation
– Congestive cardiac failure.
– Diabetes mellitus - Severe pre-eclampsia
- Maternal allergy to specific tocolytic agents, or
where tocolytics are contraindicated due to
specific co-morbidities (e.g. beta agonists should
not be given in case of cardiac disease)
Tocolysis medication
1st choice: nifedipine
2nd: salbutamol and terbutaline
3rd: Ato Sibam (oxytocin antagonist)
Salbutamol contraindication
HFMI
– Hyperthyroidism.
– Foetal cardiac disease.
– Maternal cardiac disease.
– Insulin-dependent diabetes mellitus
Salbutamol side effects
– Hyperglycaemia.
– Hypokalaemia.
– The maternal tachycardia.
– Pulmonary oedema.
– Hypotension.
– Tremors
Tocolysis in px with mitral stenosis
Ato Sibam (oxytocin antagonist) —> CHECHK this info
- Magnesium sulphate (stabilises cardiac membrane & also decreases uterine contractions)
trauma px monitoring
- Minimum 24 hrs
look for:
-Regular uterine contractions
-Vaginal bleeding
- non-reassuring foetal heart rate tracing
- Abdominal/uterine pain
- Significant trauma to the abdomen
Cervical cerclage indication
History: 12-14 weeks
- Two or more second trimester pregnancy
losses
- Each loss earlier than the previous pregnancy
Ultrasound: 14-26 weeks
- progressive cervical shortening on serial ultrasounds
- external os is closed
Rescue:
- Cervix dilated > 2 cm no perceived uterine contractions
- > 50 % Premature cervical effacement
- Increased pelvic pressure
-Heavy mucoid vaginal discharge / bulging membranes through the cervical os
Breech presentation factors
Maternal:
Nulliparity
Previous breech birth
Uterine (anatomical) anomaly
Placental abnormalities (previa, cornual)
Oligohydramnios
Polyhydramnios
Multiple pregnancy
Grand multiparity
Foetal:
- Extended foetal legs
- Short umbilical cord
- Early gestation
- Foetal abnormality
- Poor foetal growth
Breech presentation contraindications
- Cord presentation
- Any presentation other than frank or complete
-breech with a flexed or neutral head attitude - Clinically inadequate maternal pelvis
- Foetal anomaly incompatible with vaginal delivery
- The foetal weight less than 2500g or over 3800g
Types of breech presentation
- Frank breech: The foetal hips are flexed, and the
knees extended. - Complete breech: The foetus seems to be sitting
with hips and knees flexed. - Footling breech: One or both legs are
completely extended and present before the
buttocks. - Kneeling breech: The baby is in a kneeling
position, with one or both legs extended at the
hips and flexed at the knees.
Breech presentation management
- external cephalic version if not at term < 36 weeks
- if in labour and/or >37 weeks: elective C-sec
Don’t allow for vaginal delivery
Pregnancy supplementation
-folic acid (0.5-5mg depending on situation)
- 150mcg iodine throughout pregnancy
Breastfeeding contraindication
Breast abscess
HIV
Stroke in pregnancy
Usually SAH
CT (cover the uterus)
Ectopic pregnancy (EP) features
-most common exam finding: Marked rebound tenderness in the suprapubic region
with only little or absent guarding
- cervical motion tenderness
- PID major predisposing factor
Glucosuria in pregnancy
- Common
- increased GFR
- decreased tubular reabsorption of filtered glucose
- Common in 1/6 women
Features of parvovirus
also known as fifth disease or slapped cheek syndrome
- fetal parvovirus syndrome.
Hydrops fetalis features
abnormal accumulation of
fluid in 2 or more foetal compartments including:
- ascites
-pleural effusion
- pericardial effusion
- skin oedema
Hydrops fetalis causes
-Haemolytic disease of the newborn
-Severe anaemia.
-Chromosomal abnormalities.
-Congenital heart disease.
Effects of tobacco smoking during pregnancy include:
-Premature birth,
-Placental abruption (double the risk for smokers who consume more than 20 cigarettes a day)
-Spontaneous abortion.
-Low birth weight.
-Stillbirth.
-Placenta praevia
parvovirus screening
IgM- IgG- - mother not immune, infection possible = repeat serology in 2 weeks
IgM+ IgG-: infection established = foetal monitoring 1- 2 weeks for next 6-12 weeks
IgM+ IgG+: infection established = foetal monitoring 1- 2 weeks for next 6-12 weeks
IgM- IgG+: mother immune = reassurance
GBS sepsis risk factors
- Maternal fever more than or equal to 38°C
either intrapartum or within 24 hours of giving birth - Group-B streptococcus bacteriuria and colonization in current pregnancy
- Rupture of membranes prior to birth for more than 18 hours
-Preterm labour (less than 37 weeks) - Previous GBS related early onset sepsis
asymptomatic bacteriuria treatment
- first-line: cephalexin 500mg orally, 12 hourly for
10 days (category A) - Second-line: nitrofurantoin 50mg orally, 6 hourly for 10 days (category A)
Trimethoprim 300 mg oral daily for 5 days **(avoid 1st trimester due to folic acid deficeiency) - Third-line: amoxicillin + clavulanate 500+125mg
orally, 12-hourly for 10 days (category B1) - Augmentin if px allergic to penicillin
asymptomatic bacteriuria complication
- acute pyelonephritis 50%
- acute cystitis 30%
asymptomatic bacteriuria pathogen
Escherichia coli 80%
Staphylococcus Saprophyticus 5-10%
asymptomatic bacteriuria treatment indication
Pregnant women
Elderly
Types of episiotomy
1st degree: tear involves the vaginal mucosa or perineal skin only
2nd degree: underlying subcutaneous tissue is also involved
3rd degree: rectal sphincter is affected
4th degree: extends into the rectal mucosa
GBS treatment
IF vaginal discharge but no urinary symptoms: no treatment necessary
Vaginal discharge WITH urinary symptoms: IV penicillin (clinda if CI) 5-7 days
- Consult with Obstetrician
- Commence parental treatment in labour and IM (penicillin) injection to the baby after delivery is sign of infection
Asymptomatic bacteriuria vs GBS
Asymptomatic bacteriuria doesn’t present with vaginal discharge as well as no urinary symptoms.
Treatment cephalexin
GBS comes with vaginal discharge with/o urinary symptoms
GBS screening
35-37 weeks
Hepatitis B (HBV)
what do to viral load - late pregnancy
amniocentesis better
- HBsAg-positive with high viral load should be offered antiviral therapy during late pregnancy to
reduce viral load before delivery - amniocentesis is probably safer than CVS
- Universal screening for Hepatitis B is recommended for all pregnant women,
regardless of previous testing or vaccination
Hepatitis C (HCV) in pregnancy
- **PCR test for HCV RNA **
- liver function tests (LFT) for concomitant HIV
- transmission rate to foetus is 5%
- co-infection with HIV, transmission rate increases to
25%. (avoid foetal blood sampling/foetal scalp electrode) - Infant HCV screening at 12-18months
- Ribavirin teratogenic
HCV contraindications
- C section
- amniocentesis
- FBS
- amniotomy
Down syndrome screening
1st trimester: Reduced pregnancy-associated plasma protein A (PAPP-A)
2nd trimester: Increased Inhibin A + increased free Beta HCG, decreased AFP + decreased unconjugated estriol (60-75% sensitivity)
Tiple test common. Quadruple if indicated
2nd trimester:
Free bhCG increased
AFP decreased
Unconjugated estriol decreased
70-75% sensitivity
Most accurate test for Down syndrome
Amniocentesis at 16 weeks
Worst drug for pregnancy
Cocaine:
most severe neurological defects
Increased ICH
most important single warning sign of diminishing blood volume within the first four hours postpartum?
Tachycardia
risk of unplanned pregnancy
– Rural or remote residents.
– Sexual abuse survivors.
– Early age at first sexual intercourse.
– Aboriginal and Torren Street islander.
– Disrupted home and family life.
– Teenage mothers.
– Inconsistent use of contraceptives
Planned home birth hospital transfer
delayed first/2nd delivery
Causes of Oligohydramnios
- Prolonged pregnancy
- Pre-eclampsia
- Congenital infections (CMV, toxoplasmosis)
- Placental insufficiency
Complications of oligohydramnios
- foetal kidneys congenital
abnormalities
-genitourinary tract (renal agenesis or obstruction)
Causes of Polyhydramnios
- GDM
chlamydial urethritis treatment
Azithromycin 1 g oral
Obesity in pregnancy
1- Gestational diabetes (GDM)
2- Pre-eclampsia
3- Sleep apnoea
4- Macrosomia (increased baby weight > 4kg)
Thyrotoxicosis in pregnancy
- US to differentiate between “hot” and “cold” nodule
- FNAC after for all cold nodules to establish a
histopathological diagnosis
Meconium stainied liquor
greenish fluid
Meconium-stained liquor indicates
Foetal respiratory distress
Meconium-stained liquor management
- CTG remains normal then spontaneous vaginal delivery
- minor abnormality (early deceleration) on CTG then foetal scalp blood sampling to see blood pH and or lactate level
Shoulder dystocia features
- occurs when breadth of the shoulders diameter exceeds the diameter of the pelvic inlet
- brachial plexus
palsies including Erb’s palsy (waiter step) (C5-C6 compression) - McRoberts manoeuvre ( hyperflexing the mother’s legs tightly to her abdomen) is employed
- If manoeuvre fails, apply pressure on the lower
abdomen (suprapubic pressure), and delivered head is also gently pulled. Useful in about 42% of cases.
Shoulder dystocia MANAGEMENT mnemonic
Shoulder dystocia risk factors
- Maternal DM
- foetal macrosomia
- Oxytocin augmentation
- epidural anaesthesia
Ascaris lumbricoid (Roundworm) treatment in pregnancy
- confirmed by eggs in faeces
- may develop respiratory tract symptoms
- gastrointestinal symptoms
- Pyrantel pamoate 11mg/kg single dose
benzimidazoles absolutely
contraindicated
Contraindications for baby discharge
- excessive weight loss >10%
-excessive weight loss - suspected domestic violence
- court order
Which presentation always requires C section
Face presentation
Most common cause of C section in Aus
previous C sec
Gestational trophoblastic disease complications
– Uterine infection.
– Haemorrhagic shock.
– Sepsis.
– Pre-eclampsia.
– Metastasis to the lungs/breast
Gestational trophoblastic disease features
- Hydatidiform mole may be complete with no fetal tissue or incomplete with some fetal tissue
- vaginal bleeding in early pregnancy (“grape like debris”)
- Uterus is large for date
- hyperemesis gravidarum
- hyperthyroidism
- high Beta-hCG
- ultrasound shows “typical snow-storm appearance”
Types of Gestational trophoblastic disease (GTD)
- Hydatidiform Moles (HM)
- Complete HM.
- Partial HM.
- Gestational Trophoblastic Neoplasia (GTN)
- Invasive moles.
- Choriocarcinomas.
- Placental-site trophoblastic tumors (PSTT; very rare)
Gestational trophoblastic disease treatment
- suction & curettage
- Consider hysterectomy if patient has completed family
Contraindications to vaginal delivery
-Cord presentation.
-Foetal growth retardation or macrosomia.
-Any presentation is other than frank or complete breech.
-Clinically inadequate pelvis.
-Extension of the foetal head.
-The foetal anomaly is incompatible with vaginal delivery
Contraindication to influenza
- Previous influenza allergy
- Egg allergy
Post maturity labour
> 42 weeks
- induce labour
Syphilis in pregnancy
- Treponema pallidum
- spontaneous miscarriage or stillbirth
- 2 serological tests:
treponemal tests
non-treponemal tests
-routine testing at first
antenatal contact - Prenatal screening tests offered as a choice
HPV during pregnancy
- screening done after delivery if urgent can done immediately?
- vaccination done after delivery
Rheumatoid arthritis in pregnacy
- can improve in
75% of the cases and can get worse in 25% - methotrexate and leflunomide contraindicated (folic congenital disabilities)
- methotrexate can be switched to sulfasalazine
Methadone in pregnancy
- Safe at even high doses, can be given during breastfeeding
Epilepsy in pregnancy
- 30% increase in seizures/relapse (level of anti-epileptic drugs falls in pregnancy)
Epileptic that has the highest rate of congenital malformations
Sodium Valproate/Valproic acid
Induction of labour gestation in dication
- Wait for spontaneous vagina delivery at 41st week
- After 41 weeks, induce labour
Dizziness, light-headedness,
and syncope at very late stage of gestation
significant arterial hypotension resulting from inferior vena cava
compression (supine hypotensive syndrome or inferior vena cava
syndrome)
Dead foetus in peripartum management
- If mother asymptomatic: oxytocin and amniotomy
- if symptomatic: C section
Normal weight gain during pregnancy
<18.5 kg/m : 12.7-18 kg
18.5-24.9 kg/m : 11.4-15.9 kg
25-29.9 kg/m : 6.8-11.4 kg
≥30 kg/m : 5-9 kg
Postcoital bleeding during pregnancy
- cardinal symptom of cervical cancer
red and inflamed appearance of the cervix (cervical ectropion) - HPV and liquid based cytology test
Dizygotic twins
- dichorionic and diamniotic placenta regardless of the
sex of the foetuses - placentas of dizygotic twins may be totally separated or
intimately fused
Monozygotic twins
- are always of the same sex but may be
monochorionic or dichorionic depending upon when the separation of the twins occurred - 20% to 30% have dichorionic placentation
Sheehan syndrome pathogenesis in pregnancy
- Obstetric haemorrhage complicated by hypotension
- Postpartum pituitary infarction
Sheehan syndrome features in pregnancy
Lactation failure (low prolactin)
Amenorrhea, hot flashes, vaginal atrophy (low FSH, LH)
Fatigue, bradycardia (low TSH)
Anorexia, weight loss, hypotension (low ACTH)
Decreased lean body mass (low growth hormone)
epidural anaesthesia side effects
- hypotension (Vasodilation and venous pooling)
- bradycardia
- respiratory difficulty
- Leakage of CSF (no hypotension)
HPV treatment in prenancy
asymptomatic: no treatment needed
symptomatic: large lesions with cryotherapy or keratolytics such as trichloracetic acid (TCA) or bichloracetic acid (BCA)
bilateral absence of the vas deferens
- cystic fibrosis
- sweat chloride test for confirmation
- for conception/fertility, sperm can be aspirated from the epididymis
Which of the following age group of the children is at the highest risk of a serious infection?
Less than three months old:
- sepsis,
- meningitis
- pneumonia
Most likely cause of occipito-posterior (OP) position in labour
Incoordinate uterine action
other causes:
- prolonged labour
- intrauterine infection
- increased analgesia required
- obstructed labour
Most common adverse effect of oxytocin
foetal distress
Most common cause of foetal distress
Incoordinate uterine action resulting in occipito-posterior (OP) position in labour
occipito-posterior (OP) position in labour features
11cm (vs normal 9.5 cm)
- CTG monitoring recommended
even more common if oxytocin & epidural were used (CTG mandatory)
associated with poor quality uterine contraction
- if this is excluded, cephalopelvic disproportion
incoordinate uterine action almost always occurs (AMC Handbook)
occipito-posterior (OP) position in labour management
Stimulate labour:
- amniotomy
- oxytocin
Epidural (often necessary)
C-sec (in case of obstructed labour/foetal distress)
Causes of dyspareunia
Dyspareunia is genital pain during or after sexual intercourse.
atrophic vaginal epithelium
- low oestrogen level due to high prolactin level
Premature delivery risks
Positive foetal fibronectin test
Previous premature delivery
Increased uterine size
- foetal macrosomia
- polyhydramnios
- multiple pregnancies
shortened cervix
- <1.5cm in length
Opened cervix
- open internal os
bacterial vaginosis only if
- in case of increased cervical length
- open cervix
Multiple pregancies complications
- IUGR
- monochorionic twins twin to twin transfusion
