Obstetrics Flashcards
1
Q
What is ectopic pregnancy
A
a pregnancy is implanted outside the uterus
2
Q
What is the most common site of ectopic pregnancy
A
fallopian tube
3
Q
Where can an ectopic pregnancy implant
A
fallopian tube (cornual region), ovary, cervix or abdomen
4
Q
What are risk factors for ectopic pregnancy
A
Previous ectopic pregnancy
Previous pelvic inflammatory disease
Previous surgery to the fallopian tubes
Intrauterine devices (coils)
Older age
Smoking
5
Q
what are classical features of ectopic pregnancy
A
- Missed period
- Constant lower abdominal pain in the right or left iliac fossa
- Vaginal bleeding
- Cervical motion tenderness (pain when moving the cervix during a bimanual examination)
6
Q
When does ectopic pregnancy typically present
A
6-8 weeks gestation
7
Q
What is the investigation of choice for ectopic pregnany
A
A transvaginal ultrasound scan
8
Q
How does ectopic pregnancy appear on ultrasound examination
A
gestational sac containing a yolk sac or fetal pole may be seen in a fallopian tub
9
Q
What is “blob sign”, “bagel sign” or “tubal ring sign” on transvaginal ultrasound
A
a non-specific mass containing an empty gestational sac
10
Q
How is ectopic pregnancy differentiated from corpus luteum
A
A mass representing a tubal ectopic pregnancy moves separately to the ovary
a corpus luteum will move with the ovary
11
Q
What features on ultrasound beside a mass with or without gestational sac may also indicated ectopic pregnancy
A
An empty uterus
Fluid in the uterus, which may be mistaken as a gestational sac (“pseudogestational sac”)
12
Q
what is a pregnancy of unknown location (PUL)
A
woman has a positive pregnancy test and there is no evidence of pregnancy on the ultrasound scan
ectopic pregnancy cannot be excluded follow up needed
13
Q
What hormone can be tracked to help monitor pregnancy of unknown location
A
Serum human chorionic gonadotropin (hCG)
measured again after 48 hours to measure change from baseline
14
Q
How much should hCG change every 48 hours in an intrauterine pregnancy
A
double
This will not be the case in a miscarriage or ectopic pregnancy.
15
Q
What produces hCG
A
developing syncytiotrophoblast
16
Q
hCG rises more than 63% in 48 hours what does this indicate
A
intrauterine pregnancy
17
Q
hCG rises less than 63% in 48 hours what does this indicate
A
ectopic pregnancy
18
Q
hCG falls more than 50% in 48 hours what does this indicate
A
miscarriage
19
Q
At what hCG should pregnancy be visible on ultrasound
A
above 1500 IU / l.
20
Q
what test should be performed on all women with abdominal or pelvic pain that might be cuased by ectopic pregnancy
A
pregnancy test
21
Q
Where should women with pelvic pain or tenderness and a positive pregnancy test be referred to
A
early pregnancy assessment unit (EPAU) or gynaecology service
22
Q
How are ectopic pregnancies managed
A
All ectopic pregnancies need to be terminated. An ectopic pregnancy is not a viable pregnancy.
23
Q
What are the three options for terminating an ectopic pregnancy
A
- Expectant management (awaiting natural termination)
- Medical management (methotrexate)
- Surgical management (salpingectomy or salpingotomy)
24
Q
What criteria need to be met for expectant management in ectopic pregnancy
A
Follow up needs to be possible to ensure successful termination
The ectopic needs to be unruptured
Adnexal mass < 35mm
No visible heartbeat
No significant pain
HCG level < 1500 IU / l
25
What criteria need to be met for methotrexate management in ectopic pregnancy
the same as expectant management, except:
No heartbeat
HCG level must be < 5000 IU / l / hCG <1,500IU/L
Confirmed absence of intrauterine pregnancy on ultrasound
26
How is ectopic pregnancy management with methotrexate provided
an intramuscular injection into a buttock
27
what is ectopic pregnancy methotrexate management
highly teratogenic
halts the progress of the pregnancy and results in spontaneous termination.
28
What advise is given to women who have methotrexate management for ectopic pregnancy
advised not to get pregnant for 3 months following treatment.
This is because the harmful effects of methotrexate on pregnancy can last this long.
29
What are side effects of methotrexate for mother
Vaginal bleeding
Nausea and vomiting
Abdominal pain
Stomatitis (inflammation of the mouth)
30
What is the criteria surgical ectopic pregnancy management
Pain
Adnexal mass > 35mm
Visible heartbeat
HCG levels > 5000 IU / l
Most patients with an ectopic pregnancy will require surgical management.
31
What are the two surgical options for ectopic pregnancy
Laparoscopic salpingectomy
Laparoscopic salpingotomy
32
what is Laparoscopic salpingectomy
removal of the affected fallopian tube, along with the ectopic pregnancy inside the tube.
33
What is the 1st line treatment for ectopic pregnancy
Laparoscopic salpingectomy
34
what is Laparoscopic salpingotomy
A cut is made in the fallopian tube, the ectopic pregnancy is removed, and the tube is closed.
35
Which surgical option has an increased risk of failure to remove the ectopic pregnancy
salpingotomy
1 in 5 women having salpingotomy may need further treatment with methotrexate or salpingectomy.
36
What prophylaxis is given to women having surgical management of ectopic pregnancy.
Anti-rhesus D prophylaxis is given to rhesus negative women
37
What are risk factors for ectopic pregnancy
Previous ectopic pregnancy
Pelvic inflammatory disease
Endometriosis
IUD
tubal ligation
pelvic surgery
embryo transfer
38
does an IUD increase the risk of ectopic pregnancy
The use of contraception actually reduces the rate of pregnancy. However, if there is failure of the contraception types below, the pregnancy is more likely to be ectopic.
39
What is a complication of untreated ectopic pregnancy
fallopian tube rupture
40
What is a miscarriage
spontaneous termination of a pregnanc
41
When is early miscarriage
before 12 weeks
42
When is late miscarriage
between 12 and 24 weeks gestation.
43
What is missed miscarriage
the fetus is no longer alive, but no symptoms have occurred
44
What is a threatened miscarriage
vaginal bleeding with a closed cervix and a fetus that is alive
45
What is a inevitable miscarriage
vaginal bleeding with an open cervix
46
what is an incomplete miscarriage
retained products of conception remain in the uterus after the miscarriage
47
what is a complete miscarriage
a full miscarriage has occurred, and there are no products of conception left in the uterus
48
what an anembryonic pregnancy
a gestational sac is present but contains no embryo
49
What is the investigation of choice for diagnosing a miscarriage
transvaginal ultrasound scan
50
What are the three key features on ultrasound for diagnosing miscarriage
Mean gestational sac diameter
Fetal pole and crown-rump length
Fetal heartbeat
51
When is a pregnancy considered viable
When a fetal heartbeat is visible
52
When is fetal heartbeat expected
once the crown-rump length is 7mm or more
53
What is procedure when crown-rump length is less than 7mm, without a fetal heartbeat
can is repeated after at least one week to ensure a heartbeat develops
54
What is procedure when crown-rump length of 7mm or more, without a fetal heartbeat
scan is repeated after one week before confirming a non-viable pregnancy.
55
When is a fetal pole expected
once the mean gestational sac diameter is 25mm or more
56
what is procedure when there is a a mean gestational sac diameter of 25mm or more, without a fetal pole
the scan is repeated after one week before confirming an anembryonic pregnancy.
57
What is management for less than 6 week gestation miscarriage
managed expectantly
awaiting the miscarriage without investigations or treatment.
58
When can a miscarriage be confirmed
after a repeat urine pregnancy test after 7 – 10 days, and if negative, a miscarriage can be confirmed.
59
What is management for miscarriage more than 6 weeks gestation
referral to an early pregnancy assessment service (EPAU)
Ultrasound to confirm location and viability
60
What symptoms indicate miscarriage
positive pregnancy test + bleeding
61
What are three options of managing a miscarriage
Expectant management (do nothing and await a spontaneous miscarriage)
Medical management (Oral mifepristone followed by vaginal misoprostol)
Surgical management
62
When is expectant management offered first line for miscarriage
women without risk factors for heavy bleeding or infection
1 – 2 weeks are given to allow the miscarriage to occur spontaneously
repeat urine pregnancy test after 3 weeks
63
What is medical management for miscarriage
Oral mifepristone followed by vaginal misoprostol 48hrs later
64
how does mifepristone work
weakening of attachment to the endometrial wall + cervical softening and dilation
65
what is mifepristone
progesterone receptor antagonist
66
What is Misoprostol and how does it work in miscarriage
prostaglandin analogue, meaning it binds to prostaglandin receptors and activates them
Prostaglandins soften the cervix and stimulate uterine contractions.
67
How is misoprostol given
as vaginal suppository or an oral dose.
68
what are key side effects of misoprostol
Heavier bleeding
Pain
Vomiting
Diarrhoea
69
What are the two options of surgical management of miscarriage
Manual vacuum aspiration under local anaesthetic as an outpatient
Electric vacuum aspiration under general anaesthetic
70
what is manual vacuum aspiration
tube attached to syringe inserted through cervix into uterus and contents are aspirated
women must be under 10 weeks gestation
71
what is Medical management of an incomplete miscarriage
vaginal misoprostol alone
72
what is electric vacuum aspiration
traditional, under GA
cervix is widened using dilators and the products of conception are removed through the cervix using an electric-powered vacuum
73
what is classed as recurrent miscarriage
three or more consecutive miscarriages.
74
when are investigations for recurrent micarriage started
Three or more first-trimester miscarriages
One or more second-trimester miscarriages
75
What are the causes of recurrent miscarriages
Idiopathic (particularly in older women)
** Antiphospholipid syndrome **
Hereditary thrombophilias
Uterine abnormalities
Genetic factors in parents (e.g. balanced translocations in parental chromosomes)
Chronic histiocytic intervillositis
Other chronic diseases such as diabetes, untreated thyroid disease and systemic lupus erythematosus (SLE)
76
When should Antiphospholipid syndrome be considered in a patient presenting with recurrent miscarriages
past history of deep vein thrombosis
test for antiphospholipid antibodies, and treatment is with aspirin and LMWH.
77
What investigations should be arranged for recurrent miscarriages
Antiphospholipid antibodies
Testing for hereditary thrombophilias
Pelvic ultrasound
Genetic testing of the products of conception from the third or future miscarriages
Genetic testing on parents
78
What legal acts outline framework for abortion
1967 Abortion Act.
1990 Human Fertilisation and Embryology Act
79
What is the criteria for an abortion
before 24 weeks if continuing the pregnancy involves greater risk to the physical or mental health of woman and exisiting children
anytime time during pregnancy if continuing the pregnancy presents risk to life of woman, prevents permanent injury to woman, the child is incompatible w life
80
What are legal requirements for an abortion
- Two registered medical practitioners must sign to agree abortion is indicated
- It must be carried out by a registered medical practitioner in an NHS hospital or approved premise
81
How can abortion services be accessed
self-referral or by GP, GUM or family planning clinic
82
What does a medical abortion involve
involves two treatments:
- Mifepristone (anti-progestogen)
- Misoprostol (prostaglandin analogue) 1 – 2 day later
83
How does Mifepristone end pregnancy
anti-progestogen medication that blocks the action of progesterone
weakening of attachment to the endometrial wall + cervical softening and dilation
84
How does Misoprostol end pregnancy
prostaglandin analogue, meaning it binds to prostaglandin receptors and activates them. Prostaglandins soften the cervix and stimulate uterine contractions. From 10 weeks gestation, additional misoprostol doses (e.g. every 3 hours) are required until expulsion.
85
Who should receive prophylaxis in abortion treatment
Rhesus negative women given anti-D prophylaxis
medical and surgical
86
what are the two options for surgical abortion
- Cervical dilatation and suction of the contents of the uterus (usually up to 14 weeks)
- Cervical dilatation and evacuation using forceps (between 14 and 24 weeks)
87
before a surgical abortion what medications are given and why
misoprostol, mifepristone or osmotic dilators
for cervical priming - softening and dilating the cervix
88
How long after abortion is a pregnancy test taken
3 weeks after the abortion to confirm it is complete
89
What are complications of abortion
Bleeding
Pain
Infection
Failure of the abortion (pregnancy continues)
Damage to the cervix, uterus or other structures
90
what is placenta praevia
placenta laying in the lower proportion of the uterus lower than the presenting part of the fetus
"going before"
91
what does low lying placenta refer to
when the placenta is within 20mm of the internal cervical os
92
when is the term placenta praevia only used
used only when the placenta is over the internal cervical os
93
what are the three causes of antepartum haemorrhage.
placenta praevia
placental abruption
vasa praevia
94
what are causes of spotting or minor bleeding in pregnancy
cervical ectropion
infection
vaginal abrasions from intercourse or procedures.
95
What are risk/complications associated with having placenta praevia
Antepartum haemorrhage
Emergency caesarean section
Emergency hysterectomy
Maternal anaemia and transfusions
Preterm birth and low birth weight
Stillbirth
96
What is grade 1 placenta praevia
Minor praevia, or grade I
- the placenta is in the lower uterus but not reaching the internal cervical os
97
What is grade 2 placenta praevia
Marginal praevia, or grade II
– the placenta is reaching, but not covering, the internal cervical os
98
What is grade 3 placenta praevia
Partial praevia, or grade III
– the placenta is partially covering the internal cervical os
99
What is grade 4 placenta praevia
Complete praevia, or grade IV
– the placenta is completely covering the internal cervical os
100
What are the risk factors for developing placenta praevia
**Previous caesarean sections**
Previous placenta praevia
Older maternal age
Maternal smoking
Structural uterine abnormalities (e.g. fibroids)
Assisted reproduction (e.g. IVF)
101
How is placenta praevia diagnoses
the 20-week anomaly scan is used to assess the position of the placenta and diagnose placenta praevia.
102
how does placenta praevia present
- mostly asymptomatic
- may present with painless vaginal bleeding in pregnancy (antepartum haemorrhage).
- Bleeding usually occurs later in pregnancy (around or after 36 weeks).
103
How is placenta praevia managed
recommends a repeat transvaginal ultrasound scan at:
- 32 weeks gestation
- 36 weeks gestation (if present on the 32-week scan, to guide decisions about delivery)
- Corticosteroids given at 34 and 35 + 6 weeks gestation to mature the fetal lungs, given the risk of preterm delivery.
- planned early delivery at 36 and 37 weeks gestation
- c section safest delivery option
104
What is the major complication of placenta praevia
haemorrhage before, during and after delivery
105
What is the management for haemorrhage before, during and after delivery.
ABC
Blood transfusions
warmed crystalloid infusion
Emergency caesarean section
rubbing up the fundus
IV oxytocin
Intrauterine balloon tamponade - 1st line
Uterine artery occlusion
Emergency hysterectomy
106
What is vasa praevia
fetal vessels are exposed, outside the protection of the umbilical cord or the placenta.
the fetal vessels travel through the chorioamniotic membranes, and pass across the internal cervical os (the inner opening of the cervix). These exposed vessels are prone to bleeding,
107
where are the fetal membranes
surround the amniotic cavity and developing fetus.
108
what comprises the fetal vessels
two umbilical arteries and single umbilical vein.
109
What is the normal anatomy of fetal vessels
umbilical cord containing the fetal vessels (umbilical arteries and vein) inserts directly into the placenta
always protected, either by the umbilical cord or by the placenta
110
What is Whartons Jelly
comprises umbilical cord
layer of soft connective tissue that surrounds the blood vessels in the umbilical cord, offering protection
111
What are two types of vasa praevia
Type 1 vasa praevia -Velamentous umbilical cord - fetal vessels travel unprotected through membranes before joining placenta
Type II vasa praevia - An accessory lobe of the placenta - bilobed placenta and vessels exposed as they travel between lobes
112
What are the complications of vasa praevia
prone to bleeding, particularly when the membranes are ruptured during labour and at birth.
this can lead to dramatic fetal blood loss and death.
113
What are the risk factors for vasa praevia
Low lying placenta
IVF pregnancy
Multiple pregnancy
114
How does vasa praevia present
usually presents with painless, sudden vaginal bleeding after the rupture of membranes and rapid foetal deterioration.
115
how is vasa praevia diagnosed
- ultrasound
- vaginal examination during labour, pulsating fetal vessels are seen in the membranes through the dilated cervix
- fetal distress and dark-red bleeding occur following rupture of the membranes.
116
how does vasa praevia present
antepartum haemorrhage, with bleeding during the second or third trimester of pregnancy.
117
What is outcome for vasa pravia when haemorrhage occurs
very high fetal mortality, even with emergency caesarean section.
118
How is vasa praevia managed
Corticosteroids, given from 28 weeks gestation to mature the fetal lungs
Elective caesarean section, planned for 34 – 36 weeks gestation
119
What is placenta abruption
when the placenta separates from the wall of the uterus during pregnancy
site of attachment can bleed extensively after the placenta separates.
significant cause of antepartum haemorrhage
120
What are risk factors for placenta abruption
* A for Abruption previously;
* B for Blood pressure (i.e. hypertension or pre-eclampsia);
* R for Ruptured membranes, either premature or prolonged;
* U for Uterine injury (i.e. trauma to the abdomen);
* P for Polyhydramnios;
* T for Twins or multiple gestation;
* I for Infection in the uterus, especially chorioamnionitis;
* O for Older age (i.e. aged over 35 years old);
* N for Narcotic use (i.e. cocaine and amphetamines, as well as smoking)
121
How does placenta abruption present
- Sudden onset severe abdominal pain that is continuous
- Vaginal bleeding (antepartum haemorrhage)
- Shock (hypotension and tachycardia)
- Abnormalities on the CTG indicating fetal distress
- tender and tense uterus
122
how is the severity of antepartum haemorrhage classified
- Spotting: spots of blood noticed on underwear
- Minor PPH – under 1000ml blood loss
- Major PPH – over 1000ml blood losss
- Major: Moderate PPH – 1000 – 2000ml blood loss
- Major: Severe PPH – over 2000ml blood loss
123
What is a concealed abruption
where the cervical os remains closed, and any bleeding that occurs remains within the uterine cavity.
The severity of bleeding can be significantly underestimated with concealed haemorrhage.
124
What is a revealed abruption
blood loss is observed via the vagina.
125
how is placenta abruption diagnosed
- clinical diagnosis based on presentation
obstetric emergency
- Ultrasound can be useful in excluding placenta praevia
126
What does the urgency of placenta abruption depend on
- depends on the amount of placental separation
- extent of bleeding
- haemodynamic stability of the mother and condition of the fetus.
127
how is placenta abruption managed if Fetus alive and < 36 weeks
fetal distress: immediate caesarean
no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation
128
how is placenta abruption managed if Fetus alive and > 36 weeks
fetal distress: immediate caesarean
no fetal distress: deliver vaginally
129
What are complications of placental abruption to the mother
shock
DIC
renal failure
PPH
130
What are complications of placental abruption to the baby
IUGR
hypoxia
death
131
what is the prognosis of placenta abruption
associated with high perinatal mortality rate
responsible for 15% of perinatal deaths
132
what is a kleihauer test
quantify how much fetal blood is mixed with the maternal blood, to determine the dose of anti-D that is required
133
what is placenta accreta
when the placenta implants deeper, through and past the endometrium eg myometrium
134
what does placenta accreta result in
Results in delayed separation and/or placental retention as well as postpartum hemorrhage
135
Where does the placenta usually attach to
endometrium
allows the placenta to separate cleanly during the third stage of labour, after delivery of the baby.
136
What are risk factors for developing placenta accreta
Previous placenta accreta
Previous endometrial curettage procedures (e.g. for miscarriage or abortion)
Previous caesarean section
Multigravida
Increased maternal age
Low-lying placenta or placenta praevia
137
How does placenta accreta present
typically asymptomatic
can present with bleeding (antepartum haemorrhage) in the third trimester.
138
How is placenta accreta diagnosed/investigated
antenatal ultrasound scans
MRI to assess depth and width of invasion
may be diagnosed at birth, when it becomes difficult to deliver the placenta
139
What additional management should be given to women with placenta accreta before birth
Complex uterine surgery
Blood transfusions
Intensive care for the mother
Neonatal intensive care
140
What are management options for placenta accreta during caesarean
- Hysterectomy with the placenta remaining in the uterus (recommended)
- Uterus preserving surgery, with resection of part of the myometrium along with the placenta
- Expectant management, leaving the placenta in place to be reabsorbed over tim
141
When is a hysterectomy recommended for placenta accreta
If placenta accreta is discovered after delivery of the baby
142
What is superficial placenta accreta
where the placenta implants in the surface of the myometrium, but not beyond
143
what is placenta increta
the placenta attaches deeply into the myometrium
144
what is placenta percreta
the placenta invades past the myometrium and perimetrium, potentially reaching other organs such as the bladder
145
what is cord prolapse
when the umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina, after rupture of the fetal membranes
146
What is the danger associated with cord prolapse
significant danger of the presenting part compressing the cord, resulting in fetal hypoxia.
147
What is the most significant risk factor for developing cord prolapse
fetus in abnormal lie after 37 weeks gestation (i.e. unstable, transverse or oblique).
Being in an abnormal lie provides space for the cord to prolapse below the presenting part.
In a cephalic lie, the head typically descends into the pelvis, without room for the cord to descend.
148
How is cord prolapse investigated
suspected where there are signs of fetal distress on the CTG.
diagnosed by vaginal examination.
Speculum examination can be used to confirm
149
how is cord prolapse managed
Emergency caesarean section
* can push the baby back into uterus
* cord should be kept warm and wet and have minimal handling whilst waiting for delivery to prevent vasospams
* tocolytics to prevent contrations
* fill the bladder
* mother on all fours
150
what medication can be used to minimise contractions whilst waiting for c section
Tocolytic medication (e.g. terbutaline)\
β2-adrenergic agonist - smooth muscle
151
How is cord prolapse managed when the baby is compressing the cord
the presenting part of fetus can be pushed upwards to prevent it compressing the cord.
The woman can lie in the left lateral position (with a pillow under the hip) or on all fours, using gravity to draw the fetus away from the pelvis and reduce compression on the cord.
+ Tocolytic medication
152
What is Postpartum haemorrhage
bleeding after delivery of the baby and placenta
153
What amount of blood loss is required to have Postpartum haemorrhage
500ml after a vaginal delivery
1000ml after a caesarean section
154
What is minor PPH
under 1000ml blood loss
155
what is major PPH
over 1000ml blood loss
Major PPH can be further sub-classified as:
moderate
severe
156
What is moderate PPH
1000 – 2000ml blood loss
157
what is severe PPH
over 2000ml blood loss
158
What is primary PPH
bleeding within 24 hours of birth
159
what is secondary PPH
from 24 hours to 12 weeks after birth
160
What are the causes of PPH
T – Tone (uterine atony – the most common cause)
T – Trauma (e.g. perineal tear)
T – Tissue (retained placenta)
T – Thrombin (bleeding disorder)
161
What are risk factors for PPH
Previous PPH
Multiple pregnancy
Obesity
Large baby
Failure to progress in the second stage of labour
Prolonged third stage
Pre-eclampsia
Placenta accreta
Retained placenta
Instrumental delivery
General anaesthesia
Episiotomy or perineal tear
162
What preventative measures can be taken to reduce risk and consequence of PPH
* Treating anaemia during the antenatal period
* Giving birth with an empty bladder
* Active management of the third stage (IM oxytocin)
* Intravenous tranexamic acid can be used during caesarean section
163
What team of specialists would be involved in a PPH
senior midwives, obstetricians, anaesthetics, haematologists, blood bank staff and porters.
164
How would a PPH patient be stablized
Resuscitation with an ABCDE approach
Lie the woman flat, keep her warm and communicate with her and the partner
Insert two large-bore cannulas
Bloods for FBC, U&E and clotting screen
Group and cross match 4 units
Warmed IV fluid and blood resuscitation as required
Oxygen (regardless of saturations)
Fresh frozen plasma is used where there are clotting abnormalities or after 4 units of blood transfusion
165
How much blood is given in a major haemorrhage protocol.
4 units of crossmatched or O negative blood.
166
What is the mechanical treatment for to stop bleeding in PPH
* Rubbing the uterus through the abdomen to stimulates a uterine contraction
* Catheterisation
167
What are the medical options to stop bleeding in PPH
- Oxytocin (IV)
- Ergometrine (IV or IM)
- Carboprost (IM)
- Misoprostol (sublingual)
- Tranexamic acid (IV) i
168
what does oxytocin do
induce labor, strengthen uterine contractions during labor, contract uterine muscle after delivery of the placenta, and control postpartum hemorrhage.
169
what is Ergometrine
stimulates smooth muscle contraction
CI in hypertension
170
what is Carboprost
prostaglandin analogue and stimulates uterine contraction
(caution in asthma)
171
what is Misoprostol
prostaglandin analogue and stimulates uterine contraction
172
what is Tranexamic acid
antifibrinolytic that reduces bleeding
173
how much oxytocin is given in PPH
40 units in 500 mls.
174
what are surgical treatment options for PPH
- Intrauterine balloon tamponade – inserting an inflatable balloon into the uterus to press against the bleeding
- B-Lynch suture – putting a suture around the uterus to compress it
- Uterine artery ligation – ligation of one or more of the arteries supplying the uterus to reduce the blood flow
- Hysterectomy is the “last resort” but will stop the bleeding and may save the woman’s life
175
What are causes of secondary PPH
retained products of conception (RPOC) or infection (i.e. endometritis).
176
how is secondary PPH investigated
Ultrasound for retained products of conception
Endocervical and high vaginal swabs for infection
177
how is secondary PPH managed
Surgical evaluation of retained products of conception
Antibiotics for infection
178
What is instrumental delivery
vaginal delivery assisted by either a ventouse suction cup or forceps
~ 10% of births in UK
179
what medication is given after instrumental delivery
A single dose of co-amoxiclav
180
What are indications of instrumental delivery
* Failure to progress
* Fetal distress
* Maternal exhaustion
* Control of the head in various fetal positions
* epidural is in place for analgesia.
181
What does having instrumental delivery increase the risk to the MOTHER of
Postpartum haemorrhage
Episiotomy
Perineal tears
Injury to the anal sphincter
Incontinence of the bladder or bowel
Nerve injury (obturator or femoral nerve)
182
What does having instrumental delivery increase the risk to the BABY of
Cephalohaematoma with ventouse
Facial nerve palsy with forceps
183
what is cephalohaematoma
collection of blood between the skull and the periosteum.
does NOT cross suture lines resolves in couple months
184
what nerves of the mother are at most risk in instrumental delivery
Femoral nerve
Obturator nerve
185
What are femoral nerve injury symptoms
weakness of knee extension, loss of the patella reflex and numbness of the anterior thigh and medial lower leg.
186
What are obturator nerve injury symptoms
weakness of hip adduction and rotation, and numbness of the medial thigh.
187
level of what haemoglobin is defined as first, second trimester and postpartum anaemia
1st - less than 110 g/l
2nd - less than 105 g/l
Postpartum - less than 100 g/l.
188
what is anaemia
deficiency of haemoglobin (Hb) in the blood
189
When are women screened for anaemia in pregnancy
Booking clinic
28 weeks gestation
190
what happens to plasma volume in pregnancy
plasma volume increases. This results in a reduction in the haemoglobin concentration. The blood is diluted due to the higher plasma volume.
191
why is it important to treat anaemia during pregnancy
so that the woman has reasonable reserves, in case there is significant blood loss during delivery.
192
what are symptoms of anaemia
Shortness of breath
Fatigue
Dizziness
Pallor
193
What may low MCV anaemia indicate
- iron deficiency
- Thalassaemia
- Sideroblastic anaemia
194
What may normal MCV anaemia indicate
- physiological anaemia due to the increased plasma volume of pregnancy
- Anaemia of chronic disease
- Marrow infiltration
- Haemolytic anaemia
- Chronic kidney disease
195
What may raised MCV with anaemia indicate
B12 or folate deficiency
- Alcohol consumption
- Recticulocytosis
- Hypothyroidism
196
What screening tests are pregnant women offered at booking clinic
haemoglobinopathy screening
thalassaemia (all women)
sickle cell disease (women at higher risk).
197
What additional investigation may be performed to establish cause of anaemia
Ferritin
B12
Folate
198
What investigations can be ordered for women suspected with anaemia
FBC - haemoglobin level and MCV
199
how is iron anaemia managed
iron replacement (e.g. ferrous sulphate 200mg three times daily)
200
how is b12 anaemia managed
- tested for pernicious anaemia --> checking for intrinsic factor antibodies
- Intramuscular hydroxocobalamin injections
- Oral cyanocobalamin tablets
201
how is folate anaemia managed
All women should already be taking folic acid 400mcg per day.
Women with folate deficiency are started on folic acid 5mg daily.
202
what is pre eclampsia
new high blood pressure (hypertension) in pregnancy with end-organ dysfunction,
203
what causes preeclampsia
abnormal formation of spiral arteries, leading to a high vascular resistance in these vessels and poor perfusion of the placenta
204
When does pre eclampsia occur
new-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy
205
What is preeclampsia triad
Hypertension
Proteinuria
Oedema
206
Without treatment what are outcomes of preeclampsia
maternal organ damage
fetal growth restriction
eclampsia -> seizures
early labour
maternal and fetal mortality
207
What is chronic hypertension
high blood pressure that exists before 20 weeks gestation and is longstanding.
This is not caused by dysfunction in the placenta and is not classed as pre-eclampsia.
208
What is pregnancy induced hypertension or gestational hypertension
hypertension occurring after 20 weeks gestation, WITHOUT proteinuria.
209
what is eclampsia
when seizures occur as a result of pre-eclampsia.
210
what should be monitored in eclampsia management
urine output, reflexes, respiratory rate and oxygen saturations
211
what are high risk factors for pre eclampsia
Pre-existing hypertension
Previous hypertension in pregnancy
Existing autoimmune conditions (e.g. systemic lupus erythematosus)
Diabetes
Chronic kidney disease
212
what are moderate risk factors for pre eclampsia
Older than 40
BMI > 35
More than 10 years since previous pregnancy
Multiple pregnancy
First pregnancy
Family history of pre-eclampsia
213
When are women offered aspirin as prophylaxis against pre eclampsia
from 12 weeks gestation until birth if they have
- one high-risk factor
- or more than one moderate-risk factors.
214
What are symptoms of pre eclampsia
Headache
Visual disturbance or blurriness
Nausea and vomiting
Upper abdominal or epigastric pain (this is due to liver swelling)
Oedema
Reduced urine output
Brisk reflexes
215
How is pre eclampsia diagnosed
Systolic blood pressure above 140 mmHg
Diastolic blood pressure above 90 mmHg
PLUS
proteinuria
organ dysfunction
placental dysfunction
216
What are investigational signs of organ dysfunction
* raised creatinine
* elevated liver enzymes
* seizures
* thrombocytopenia
* haemolytic anaemia
217
what are signs of placental dysfunction
fetal growth restriction or abnormal Doppler studies
218
How can proteinuria be quantified
- Urine protein:creatinine ratio (above 30mg/mmol is significant)
- Urine albumin:creatinine ratio (above 8mg/mmol is significant)
219
What is placental growth factor
protein released by the placenta that functions to stimulate the development of new blood vessels.
Low in pre eclampsia
used btwn 20 and 35 week
220
how is pre eclampsia monitored
Blood pressure
Symptoms
Urine dipstick for proteinuria
assessed at every antenatal appointment
221
What is the general management of pre eclampsia / gestational hypertension
- Treating to aim for a blood pressure below 135/85 mmHg
- BP monitored at least every 48hrs
- Admission for women with a blood pressure above 160/110 mmHg
- ultrasound monitoring of fetus, amniotic fluid every 2 weeks
- Monitoring of blood tests weekly (full blood count, liver enzymes and renal profile)
- Monitoring fetal growth by serial growth scans
- PlGF testing on one occasion
222
what scoring system is used to determine to admit women with pre eclampsia
fullPIERS or PREP‑S
223
what is the 1st line medical management of pre eclampsia
Labetolol - anti hypertensive
Beta blocker
224
what is the 2nd line medical management of pre eclampsia
Nifedipine
CCB if have asthma
225
what is the 3rd line medical management of pre eclampsia
Methyldopa
alpha agonist
226
What common anti hypertenive is CI in pregnancy
ACE-inhibitors are contra-indicated in pregnancy due to their association with congenital abnormalities.
227
What the medical management during labour for pre eclampsia
- IV magnesium sulphate is given during labour and in the 24 hours afterwards to prevent seizures
- Fluid restriction is used during labour in severe pre-eclampsia or eclampsia, to avoid fluid overload
228
what is the medical management in critical care in severe pr eclampsia and eclampsia
IV hydralazine
229
What is medical management for pre eclampsia after delivery (1st, 2nd and 3rd line)
- Enalapril (first-line)
- Nifedipine or amlodipine (first-line in black African or Caribbean patients)
- Labetolol or atenolol (third-line)
230
What are the features of the complication that occur as a result of pre eclampsia and eclampsia
Haemolysis
Elevated Liver enzymes
Low Platelets
231
What is rhesus
various types of rhesus antigens on the surface of red blood cells
232
What rhesus antigen does rhesus-negative refer to
Rhesus D antigen
233
What rhesus antigen requires treatment
When a woman that is rhesus-D negative becomes pregnant
234
What is Rhesus Incompatibility in Pregnancy
- rhesus-D negative woman with rhesus-D positive baby
- blood from the baby will find a way into the mother’s bloodstream.
- baby’s red blood cells display the rhesus-D antigen
- the mother’s immune system will recognise this rhesus-D antigen as foreign, and produce antibodies to the rhesus-D antigen.
- The mother has then become sensitised to rhesus-D antigens.
- During subsequent pregnancies, the mother’s anti-rhesus-D antibodies can cross the placenta into the fetus.
- If that fetus is rhesus-D positive, these antibodies attach themselves to the red blood cells of the fetus and causes the immune system of the fetus to attack them, causing the destruction of the red blood cells (haemolysis)
235
what is haemolytic disease of the newborn.
red blood cell destruction caused by antibodies from the mother
236
how is Rhesus Incompatibility in Pregnancy managed
Prevention of sensitisation - IM anti-D injection to pregnant woman
237
how do anti-D injection work
attaching itself to the rhesus-D antigens on the fetal red blood cells in the mothers circulation, causing them to be destroyed.
prevents the mother’s immune system recognising the antigen and creating it’s own antibodies to the antigen
238
When are anti D injections given routinely
28 & 34 weeks gestation
Birth (if the baby’s blood group is found to be rhesus-positive)
239
At what points where sensitisation could occur should anti D injections be given
Antepartum haemorrhage
Amniocentesis procedures
Abdominal trauma
240
how does a kleihauer test work
- Adding acid to a sample of the mother’s blood.
- Fetal haemoglobin is naturally more resistant to acid, so that they are protected against the acidosis that occurs around childbirth.
- Therefore, fetal haemoglobin persists in response to the added acid, while the mothers haemoglobin is destroyed.
- The number of cells still containing haemoglobin (the remaining fetal cells) can then be calculated.
241
what is Small for gestational age
a fetus that measures below the 10th centile for their gestational age.
242
what two measurements on ultrasound are used to assess fetal size
Estimated fetal weight (EFW)
Fetal abdominal circumference (AC)
243
what factors into customised growth charts for a fetus
mothers:
Ethnic group
Weight
Height
Parity
244
what is severe SGA
when the fetus is below the 3rd centile for their gestational age
245
what is low birth weight
defined as a birth weight of less than 2500g.
246
what are two categories of causes for SGA
Constitutionally small, matching the mother and others in the family, and growing appropriately on the growth chart
Fetal growth restriction (FGR), also known as intrauterine growth restriction (IUGR)
247
what are causes of fetal growth restriction
- Placenta mediated growth restriction
- Non-placenta mediated growth restriction, where the baby is small due to a genetic or structural abnormality
248
what are causes of placenta mediated growth restriction
Idiopathic
Pre-eclampsia
Maternal smoking
Maternal alcohol
Anaemia
Malnutrition
Infection
Maternal health conditions
249
what are causes of Non-placenta medicated growth restriction
Genetic abnormalities
Structural abnormalities
Fetal infection
Errors of metabolism
250
what are signs of fetal growth restriction
Reduced amniotic fluid volume
Abnormal Doppler studies
Reduced fetal movements
Abnormal CTGs
251
What are short term complications of fetal growth restriction
Fetal death or stillbirth
Birth asphyxia
Neonatal hypothermia
Neonatal hypoglycaemia
252
What are long term complications of fetal growth restriction
Cardiovascular disease, particularly hypertension
Type 2 diabetes
Obesity
Mood and behavioural problems
253
What are risk factors of small for gestational age babies
Previous SGA baby
Obesity
Smoking
Diabetes
Existing hypertension
Pre-eclampsia
Older mother (over 35 years)
Multiple pregnancy
Low pregnancy‑associated plasma protein‑A (PAPPA)
Antepartum haemorrhage
Antiphospholipid syndrome
254
How are low risk women monitored for small for gestational age
- monitoring of the symphysis fundal height (SFH) at every antenatal appointment from 24 weeks onwards to identify potential SGA
- If the symphysis fundal height is less than the 10th centile, women are booked for serial growth scans with umbilical artery doppler.
255
when are women booked for serial growth scans with umbilical artery doppler
- Three or more minor risk factors
- One or more major risk factors
- Issues with measuring the symphysis fundal height (e.g. large fibroids or BMI > 35)
256
what is measured in women at risk or with SGA serial ultrasound scans
- Estimated fetal weight (EFW) and abdominal circumference (AC) to determine the growth velocity
- Umbilical arterial pulsatility index (UA-PI) to measure flow through the umbilical artery
- Amniotic fluid volume
257
what are the critical management steps of SGA
- Identifying those at risk of SGA
- Aspirin is given to those at risk of pre-eclampsia
- Treating modifiable risk factors (e.g. stop smoking)
- Serial growth scans to monitor growth
- Early delivery where growth is static, or there are other concerns
258
what investigations can be ordered to identify the underlying cause of SGA
- Blood pressure and urine dipstick for pre-eclampsia
- Uterine artery doppler scanning
- Detailed fetal anatomy scan by fetal medicine
- Karyotyping for chromosomal abnormalities
- Testing for infections (e.g. toxoplasmosis, cytomegalovirus, syphilis and malaria)
259
what is large for gestational age
weight of the newborn is more than 4.5kg at birth.
During pregnancy, an estimated fetal weight above the 90th centile is considered large for gestational age.
260
what are causes of macrosomia
Constitutional
***Gestational diabetes***
Previous macrosomia
Maternal obesity or rapid weight gain
Overdue
Male baby
261
what are risks to the mother of LGA
***Shoulder dystocia***
Failure to progress
Perineal tears
Instrumental delivery or caesarean
Postpartum haemorrhage
Uterine rupture (rare)
262
what are risks to the baby of LGA
- Birth injury (Erbs palsy, clavicular fracture, fetal distress and hypoxia)
- Neonatal hypoglycaemia
- Obesity in childhood and later life
- Type 2 diabetes in adulthood
263
What are investigation used for LGA
- Ultrasound to exclude polyhydramnios and estimate the fetal weight
- Oral glucose tolerance test for gestational diabetes
264
How can risks associated with LGA delivery be mitigated
* Delivery on a consultant lead unit
* Delivery by an experienced midwife or obstetrician
* Access to an obstetrician and theatre if required
* Active management of the third stage (delivery of the placenta)
* Early decision for caesarean section if required
* Paediatrician attending the birth
265
what is chorionicity
Number of placentas
266
what is amnionicity
number of amniotic sacs
267
what ultrasound sign is shown in Dichorionic diamniotic
lambda sign or twin peak sign
268
what ultrasound sign is shown in Monochorionic diamniotic
twins have a membrane between the twins, with a T sign
269
what type of multiple pregnancy has best outcomes
diamniotic, dichorionic twin pregnancies, as each fetus has their own nutrient supply.
270
What are risks to mother in multiple pregnancy
Anaemia
Polyhydramnios
Hypertension
Malpresentation
Spontaneous preterm birth
Instrumental delivery or caesarean
Postpartum haemorrhage
271
What are risks to baby in multiple pregnancy
Miscarriage
Stillbirth
Fetal growth restriction
Prematurity
Twin-twin transfusion syndrome
Twin anaemia polycythaemia sequence
Congenital abnormalities
272
what is Twin-Twin Transfusion Syndrome
occurs when the fetuses share a placenta
one fetus (the recipient) may receive the majority of the blood from the placenta, while the other fetus (the donor) is starved of blood.
273
What is the risk to the recipient in Twin-Twin Transfusion Syndrome
fluid overloaded, with heart failure and polyhydramnios.
274
What is the risk to the donor in Twin-Twin Transfusion Syndrome
growth restriction, anaemia and oligohydramnios
275
What is the management in severe Twin-Twin Transfusion Syndrome
laser treatment may be used to destroy the connection between the two blood supplies.
276
What is Twin Anaemia Polycythaemia Sequence
similar to twin-twin transfusion syndrome, but less acute.
One twin becomes anaemic
The other develops polycythaemia (raised haemoglobin).
277
Women with multiple pregnancies require additional monitoring for what
anaemia, with a full blood count
Additional ultrasound scans
278
What are ultrasounds used to monitor in twin pregnancies
fetal growth restriction, unequal growth and twin-twin transfusion syndrome:
279
how often are twin pregnancies scanned
2 weekly scans from 16 weeks for monochorionic twins
4 weekly scans from 20 weeks for dichorionic twins
280
When are women with twin pregnancies tested for anaemia
Booking clinic
20 weeks gestation
28 weeks gestation
281
when is planned birth offered for uncomplicated monochorionic monoamniotic twins
32 and 33 + 6 weeks
282
when is planned birth offered for uncomplicated monochorionic diamniotic twins
36 and 36 + 6 weeks
283
when is planned birth offered for uncomplicated dichorionic diamniotic twins
37 and 37 + 6 weeks
284
when is planned birth offered for triplets
Before 35 + 6 weeks
285
What type of twins requires elective caesarean section
Monoamniotic twins
286
how are Diamniotic twins delivered
- Vaginal delivery is possible when the first baby has a cephalic presentation (head first)
- Caesarean section may be required for the second baby after successful birth of the first baby
- Elective caesarean is advised when the presenting twin is not cephalic presentation
287
What is Oligohydramnios
low level of amniotic fluid during pregnancy
amniotic fluid index that is below the 5th centile or less than 500ml at 32-36
288
What can cause oligohydramnios
- Preterm prelabour rupture of membranes
- Placental insufficiency
- Renal agenesis (known as Potter’s syndrome)
- Non-functioning fetal kidneys, e.g. bilateral multicystic dysplastic kidneys
- Obstructive uropathy
- Genetic/chromosomal anomalies
- Viral infections (although may also cause polyhydramnios)
289
how does Placental insufficiency cause oligohydramnios
resulting in the blood flow being redistributed to the fetal brain rather than the abdomen and kidneys. This causes poor urine output.
290
how is oligohydramnios diagnosed
ultrasound examination
amniotic fluid index (AFI) *MC
or maximum pool depth (MPD).
291
how is amniotic fluid index calculated
by measuring maximum cord-free vertical pocket of fluid in four quadrants of the uterus and adding them together.
292
what proteins in amniotic fluid suggest membrane rupture
IGFBP-1 (insulin-like growth factor binding protein-1) or PAMG-1 (placental alpha-microglobulin-1)
293
how is Ruptured Membranes cause of oligohydramnios managed
* admission
* regular observations to ensure chorioamnionitis is not developing
* oral erythromycin should be given for 10 days
* antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome
* delivery should be considered at 34 weeks of gestation
294
what factors when timing delivery in placental insufficiency oligohydramnios
- Rate of fetal growth
- Umbilical artery and middle cerebral artery Doppler scans
- Cardiotocography (baby HR - assess distress)
295
what is Polyhydramnios
abnormally large level of amniotic fluid during pregnancy.
amniotic fluid index that is above the 95th centile for gestational age.
296
what comprised amniotic fluid
fetal urine output, with small contributions from the placenta and some fetal secretions
297
How much does amniotic fluid change over pregnancy
increases until 33 weeks then
plateaus from 33-38 then
declines
approx 500mls at delivery
298
What causes Polyhydramnios
- MC - idiopathic
- condition that prevents the fetus from swallowing
- Duodenal atresia
- Anaemia
- Twin-to-twin transfusion syndrome
- Maternal diabetes
299
how is Polyhydramnios diagnosed
US Scan
- Amniotic fluid index
- Maximum pool depth
300
how is Polyhydramnios managed
No medical intervention is required in the majority of women
- aminoreduction - risky due to infection and placental abruption risk
- Indomethacin (enhance water retention)
301
What is gestational diabetes
any degree of glucose intolerance with onset or first recognition during pregnancy
1 in 5 pregnancies
fasting glucose is >= 5.6 mmol/L
2-hour glucose is >= 7.8 mmol/L
302
What are risk factors for gestational diabetes
- BMI >30
- Asian ethnicity
- Previous gestational diabetes
- 1st degree relative with diabetes
- Polycystic ovarian syndrome
- Previous macrosomic baby (>4.5kg)
303
what is the pathophysiology of gestational diabetes
- body unable to respond to the increased insulin requirements, resulting in transient hyperglycaemia
304
what happens to insulin function in pregnancy
progressive insulin resistance
a higher volume of insulin is needed in response to a normal level of blood glucose.
On average, insulin requirements rise by 30% during pregnancy.
305
what are the symptoms of gestational diabetes
if present, polyuria, polydipsia and fatigue.
306
what are the fetal complications of gestational diabetes
- Macrosomia
- Organomegaly (<3)
- neonatal hypoglycaemia
- polycythaemia (high # RBC)
- Polyhydramnios
- pre term delivery
307
What is the main investigation for gestational diabetes
oral glucose tolerance test (OGTT)
308
When is OGTT offered in pregnancy
booking
24-28 weeks if present RF
any point of glycosuria
309
What level of fasting glucose and 2hr post glucose is required for GD diagnoses
Fasting glucose > 5.6mmol/L
2hrs postprandial glucose > 7.8mmol/L
(5 – 6 – 7 – 8)
310
What is the medical management of GD if Fasting glucose less than 7 mmol/l
trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin if metformin not sufficient
311
What is the medical management of GD if Fasting glucose above 7 mmol/l
start insulin
312
What is the medical management of GD if Fasting glucose between 6-6.9 mmol/l, and there is evidence of complication
insulin
313
What is the medical management of GD for women who decline insulin or cannot tolerate metformin.
Glibenclamide (a sulfonylurea)
314
when should additional growth scans be done for GD
28, 32 and 36 weeks
315
what is postnatal care for GD for mother
- All anti-diabetic medication should be stopped immediately after delivery
- blood glucose should be measured before discharge
- fasting glucose test @ 6-13 weeks postpartum
316
what percent of mothers with GD will go on to develop diabetes
50%
317
What screening during pregnancy for women with existing diabetes.
retinopathy screening
318
What is the post natal care for babies born to mothers with GD
close monitoring for neonatal hypoglycaemia, with regular blood glucose checks and frequent feeds
319
how are hypoglycaemic newborns managed
asymptomatic
* encourage normal feeding (breast or bottle)
* monitor blood glucose
symptomatic or very low blood glucose
* admit to the neonatal unit
* intravenous infusion of 10% dextrose
320
What is uterine rupture
rupture of myometrium in labor
321
What is the difference between incomplete and complete uterine rupture
incomplete = uterine serosa (perimetrium) surrounding the uterus remains intact.
complete = serosa ruptures along with the myometrium, and the contents of the uterus are released into the peritoneal cavity.
322
what are risk factors of uterine rupture
** previous caesarean section **
Previous uterine surgery
Increased BMI
High parity
Increased age
Induction of labour
Use of oxytocin to stimulate contractions
323
How does uterine rupture present
acutely unwell mother and abnormal CTG
- Ceasing of uterine contractions
- Abdominal pain
- Vaginal bleeding
- Hypotension
- Tachycardia
- Collapse
324
how is uterine rupture managed
obstetric emergency.
Resuscitation and transfusion may be required.
Emergency caesarean section
stop any bleeding and repair or remove the uterus (hysterectomy).
325
How common is baby blues and when is its incidence
seen in the majority of women in the first week or so after birth
326
How common is postnatal depression and when is its incidence
low mood in the postnatal period.
seen in about one in ten women, with a peak around three months after birth
327
How common is puerpal psychosis and when is its incidence
seen in about one in a thousand women, starting a few weeks after birth
328
What are symptoms of baby blues
Mood swings
Low mood
Anxiety
Irritability
Tearfulness
329
what are causes of baby blues
Significant hormonal changes
Recovery from birth
Fatigue and sleep deprivation
The responsibility of caring for the neonate
Establishing feeding
All the other changes and events around this time
330
What is triad of postnatal depression presentation
Low mood
Anhedonia (lack of pleasure in activities)
Low energy
331
how long should symptoms last to be diagnosed with post natal depression
2 weeks
332
What is a screening tool for post natal depression
Edinburgh Postnatal Depression Scale
score >10/30 --> postnatal depression
333
How does puerperal psychosis present
Delusions
Hallucinations
Depression
Mania
Confusion
Thought disorder
334
how is puerperal psychosis treated
Admission to the mother and baby unit
Cognitive behavioural therapy
Medications (antidepressants, antipsychotics or mood stabilisers)
Electroconvulsive therapy (ECT)
335
what is a complication of a mother taking SSRI during pregnancy
3rd trimester = persistent pulmonary hypertension
1st trimester= small increased chance of congenital heart defects
336
what is SSRI of choice in breastfeeding women
Sertraline or paroxetine
337
where are women with existing mental health concerns before or during pregnancy are referred to
perinatal mental health services for advice and specialist input
338
what are types of fetal lie
Longitudinal, transverse or oblique
long axis relative
339
what are types of fetal presentations
fetal part that first enters the maternal pelvis.
cephalic vertex
breech
shoulder
brow
340
what are types of fetal head positions
position of the fetal head as it exits the birth canal.
occipito-anterior
occipito-posterior
occipito-transverse
341
what are RF for abnormal fetal lie, malpresentation and malposition
- Prematurity
- Multiple pregnancy
- Uterine abnormalities (e.g fibroids, partial septate uterus)
- Fetal abnormalities
- Placenta praevia
- Primiparity
342
how is abnormal fetal lie managed
external cephalic version (ECV) - manipulation of the fetus to a cephalic presentation
50-60% success rate
343
what is chickenpox caused by
varicella zoster virus (VZV).
344
what can varicella zoster in pregnancy lead to
- More severe cases in the mother, such as varicella pneumonitis, hepatitis or encephalitis
- Fetal varicella syndrome
- Severe neonatal varicella infection (if infected around delivery)
345
How are mothers tested for immunity to chickenpox
IgG levels for VZV can be teste
positive = immunity
346
How are not immune women exposed to chickenpox managed
IV varicella immunoglobulins prophylaxis
within 10 days
347
what are features of Congenital varicella syndrome
in 1% of cases
- Fetal growth restriction
- Microcephaly, hydrocephalus and learning disability
- Scars and significant skin changes located in specific dermatomes
- Limb hypoplasia (underdeveloped limbs)
- Cataracts and inflammation in the eye (chorioretinitis)
348
chickenpox infection in first XX weeks of pregnancy can lead to Congenital varicella syndrome
in the first 28 weeks of gestationn
349
What is lower urinary tract infection
infection in the bladder, causing cystitis (inflammation of the bladder)
350
what is Upper urinary tract infection
infection up to the kidneys, called pyelonephritis.
351
what are complications of UTI in pregnancy
preterm delivery
low birthweight
preeclampsia
352
What is Asymptomatic bacteriuria
bacteria present in the urine, without symptoms of infection.
higher risk of UTI
353
How does Lower urinary tract infections present
Dysuria (pain, stinging or burning when passing urine)
Suprapubic pain or discomfort
Increased frequency of urination
Urgency
Incontinence
Haematuria
354
how does Pyelonephritis present
Fever (more prominent than in lower urinary tract infections)
Loin, suprapubic or back pain (this may be bilateral or unilateral)
Haematuria
Renal angle tenderness on examination
355
What 2 substance is indicative of UTI on dipstick
nitrites
leukocytes
356
What are infective causes of UTI
Escherichia coli (E. coli).
Klebsiella pneumoniae
Enterococcus
Pseudomonas aeruginosa
357
How are UTIs in pregnancy managed
7 days of Abx
Nitrofurantoin (avoid in the third trimester)
Amoxicillin (only after sensitivities are known)
Cefalexin
358
What Abx should be AVOIDED in 1st trimester
Trimethoprim - folate antagonist
359
What Abx should be AVOIDED in 3rd trimester
Nitrofurantoin - neonatal haemolysis
360
what is Venous thromboembolism
blood clots (thrombosis) developing in the circulation
361
what causes thrombosis
* stagnation of blood
* epithelial injury
* hyper-coagulable states, such as pregnancy.
362
what is a pulmonary embolism
thrombosis can mobilise (embolisation) from the deep veins and travel to the lungs, where it becomes lodged in the pulmonary arteries.
363
what is DVT
When a thrombosis develops in the venous circulation
364
What are pre-existing RF for VTE in pregnancy
- Age >35 years
- BMI >30 kg/m2
- Parity >3
- Smoking
- Paraplegia
365
What are obstetric RF for VTE in pregnancy
- Multiple pregnancy
- Pre-eclampsia
- caesarean section
- Prolonged labour
- PPH
366
What are transient RF for VTE in pregnancy
- Dehydration
- Ovarian hyperstimulation syndrome
- Admission or immobility
- Systemic infection
- Long distance travel
367
When is it advised to start prophylaxis for VTE in pregnancy
28 weeks if there are three risk factors
First trimester if there are four or more of these risk factors
or
- Hospital admission
- Surgical procedures
- Previous VTE
- Medical conditions such as cancer or arthritis
- High-risk thrombophilias
- Ovarian hyperstimulation syndrome
368
What is prophylaxis for VTE in pregnancy
low molecular weight heparin (LMWH) eg enoxaparin, dalteparin and tinzaparin.
369
when is prophylaxis for VTE in pregnancy be stopped
when the woman goes into labour
370
what are the Mechanical prophylaxis options for VTE in pregnancy
- Intermittent pneumatic compression with equipment that inflates and deflates to massage the legs
- Anti-embolic compression stockings
371
How does DVT present
unilateral
- Calf or leg swelling
- Dilated superficial veins
- Tenderness to the calf (particularly over the deep veins)
- Oedema
- Colour changes to the leg
>3cm change in calves is significant
372
How does PE present
- sudden onset shortness of breath
- Cough with or without blood (haemoptysis)
- Pleuritic chest pain
- Hypoxia
- Tachycardia
- Tachypnoea
- Low-grade fever
- Haemodynamic instability causing hypotension
373
What is investigation of choice for suspected DVT
Doppler ultrasound
374
What bloods can be preformed for suspected DVT or PE
FBC, U&Es, LFTs and a coagulation screen
375
What is investigation of choice for suspected PE
Chest xray
ECG
376
What is the investigation of choice for a definitive diagnosis for DVT/PE
- CT pulmonary angiogram (CTPA)
- or ventilation-perfusion (VQ) scan.
377
When is CTPA the preferred choice investigation for VTE in pregnancy
CTPA is the test for choice for patients with an abnormal chest xray
378
What does CTPA have a higher risk of
higher risk of breast cancer for the mother (minimal absolute risk)
379
What does VQ scan have a higher risk of
higher risk of childhood cancer for the fetus (minimal absolute risk)
380
Why is wells score not validated in pregnancy
D-dimers are not helpful in pregnant patients, as pregnancy is a cause of a raised D-dimer.
381
how is VTE in pregnancy managed
low molecular weight heparin (LMWH).
started immediately before confirming diagnosis
382
Give an example of a LMWH
enoxaparin, dalteparin and tinzaparin.
383
What is LMWH does based on
weight at booking clinic
384
how long should LMWH be continued when used for VTE prophylaxis in pregnancy
LMWH is continued for the remained of pregnancy, plus six weeks postnatally, or three months in total (whichever is longer).
385
what are treatment options for women with a massive PE and haemodynamic compromise in pregnancy
- Unfractionated heparin
- Thrombolysis
- Surgical embolectomy
386
How many maternal deaths if VTE responsible for
in UK approximately 1/3 of maternal deaths
387
What is an alternative to LMWH in pregnancy
rivaroxaban
388
why should Warfarin not be used in pregnancy
teratogenic
and can lead to foetal loss through haemorrhage.
389
what is Group B streptococcus
gram positive cocci, which typically grow in chains.
390
What can Group B streptococcus infection cause in neonate
sepsis, pneumonia, or meningitis
5% mortality rate
391
what are the RF for colonisation with GBS in neonate
- GBS infection in a previous baby
- Prematurity <37 weeks
- Rupture of membranes >24 hours before delivery
- Pyrexia during labour
- Positive test for GBS in the mother
- Mother diagnosed with a UTI found to be GBS during pregnancy
392
What are clinical feature of maternal GBS that leads to infection
UTI - frequency urgency dysuria
Chorioamnioitis - fever lower abdo pain, foul discharge
Endometritis - fever lower abdo pain, foul discharge
393
How is GBS investigated
swabs, cultured, PCR
394
what are neonatal symptoms of GBS infection
pyrexia, cyanosis, difficulty breathing and feeding, and floppiness.
395
How is GBS infection prevented
- High dose IV penicillins (benzylpenicillin)
- cefuroxime or clindamycin in penicillin-allergic patients
throughout labour
396
when is Abx indicated in GBS
GBS positive swabs
A UTI caused by GBS during this pregnancy
Previous baby with GBS infection.
Pyrexia during labour
Labour onset <37 weeks
Rupture of membranes >18 hours
397
what is management of a woman who has rupture of membranes in a woman of >37 weeks gestation known to be GBS positive
induced immediately
398
what is the 1st stage of labour
Dilation stage -> involves cervical effacement and dilatation facilitated by uterine contractions.
399
what is the 2nd stage of labour
The expulsion stage commences when cervix is fully dilated until delivery of the baby
400
what is the 3rd stage of labour
placental stage concludes with placental expulsion.
401
what is bishops score
used to help assess whether induction of labour will be required
402
what does a bishops score of <5 indicate
labour is unlikely to start without induction
403
what does a bishops score of ≥8 indicate
cervix is ripe, or 'favourable' - there is a high chance of spontaneous labour, or response to interventions made to induce labour
404
how is labor induced if bishops score is ≤6
* vaginal prostaglandins or oral misoprostol
* mechanical methods such as a balloon catheter can be considered if the woman is at higher risk of hyperstimulation or has had a previous caesarean
405
how is labor induced if bishops score is >6
* amniotomy and an intravenous oxytocin infusion
406
what is inadequate progress in the active phase of 1st stage of labour
cervical dilatation less than 2 cm over 4 hours, or no change in cervical dilatation over 4 hours despite adequate uterine contractions.
407
what is inadequate progress in the latent phase of 1st stage of labour
exceeds 20 hours in nulliparous women or 14 hours in multiparous women.
408
What RF indicate 5mg of folic acid
* Previous child with NTD
* Diabetes mellitus
* Women on antiepileptic
* Obese (body mass index >30kg/m²)
* HIV +ve taking co-trimoxazole
* Sickle cell
409
What are categories of C section and their time frame
1 = within 30 mins
2 = within 75 mins
3 = needed but stable
4 = elective
410
What medication are CI in breastfeeding
L - Lithium
A - Aspirin
M - Methotrexate
B - Benzodiazepines
A - Amiodarone
S - Sulphonylureas
T - Tetracycline
4'Cs - Carbimazole, Ciprofloxacin, Chloramphenicol, Cytotoxics
LAMBAST + 4C's
411
When should women with hyperemesis gravidarum be admitted
* Continued nausea and vomiting with ketonuria and/or weight loss (greater than 5% of body weight), despite treatment with oral antiemetics
* unable to keep down liquids or oral antiemetics
412
What is the management of hyperemesis gravidarum
first-line medications
* antihistamines: oral cyclizine or promethazine
second-line medications
* oral ondansetron
* oral metoclopramide -> no more than 5 days
413
who is at increased risk of hyperemesis gravidarum
* multiple pregnancies
* trophoblastic disease
* nulliparity
* obesity
* family or personal history of NVP
