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Phase 3a Tera Pyo Edition > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

What is gestational age? What do G and P refer to? What are the trimesters and when do foetal movements start

A

Gestational age is calculated from last menstrual period. EDD is 40 weeks gestation.

Gravida - number of pregnancies
Para/parity - number of deliveries after 24 weeks

First trimester - up to 12 weeks
Second trimester - 13-26 weeks
Third trimester - >27 weeks

Foetal movements start at 20 weeks

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2
Q

Hormonal changes in normal pregnancy

(Anterior pituitary hormones, TSH, HCG, Progesterone, Oestrogen)

Also give role of progesterone, and how does HCG rise

A

Anterior pituitary produces more prolactin, ACTH and melanocyte stimulating hormone.

Prolactin suppresses FSH and LH
ACTH increases cortisol and aldosterone (improvement in autoimmune conditions, increased susceptibility to diabetes)
MSH causes pigmentation of skin

TSH stays normal but T3/T4 rise

HCG rises, doubling every 48 hours until they plateau 8-12 weeks then gradually fall

Progesterone rises throughout pregnancy, maintaining pregnancy, preventing contractions and suppressing immunity to foetus. Corpus luteum produces for first 10 weeks, then placenta.

Oestrogen rises throughout, produced by placenta

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3
Q

What normally happens to blood pressure in pregnancy? What is defined as hypertension in pregnancy?

A

It falls during first trimester, and stays low until 20-24 weeks, then returns to normal.

HTN in pregnancy at >140 or >90 diastolic. OR increase of >30 or >15 diastolic

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4
Q

How is high risk of preeclampsia treated

A

75mg aspirin from 12 weeks gestation until birth

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5
Q

What should be done in a woman with HTN that becomes pregnant

A

If >140/90 before 20 weeks gestation, this is pre-existing HTN.

If taking ACEi or ARB, this should be stopped, and switched to alternative. Oral labetalol first line. (Nifedipine or hydralazine if asthmatic)

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6
Q

What is the difference between pre-eclampsia and pregnancy induced HTN

A

HTN (>140/90) in 2nd half (>20 weeks)

If symptomatic with proteinuria (>0.3g/24 hours) and/or oedema. this is pre-eclampsia.

if asymptomatic this is PIH (AKA Gestational hypertension). This resolves after birth, but increases risk of pre-eclampsia or HTN later in life.

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7
Q

Define pre-eclampsia

A

New >140/90 after 20 weeks gestation AND
- Proteinuria OR
- Other symptoms (oedema, renal insufficiency (Creatinine >90), etc)

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8
Q

Features of severe pre-eclampsia

A
  • > 160/110
  • Headaches and visual disturbance
  • Papilloedema
  • RUQ/Epigastric pain
  • Hyperreflexia
  • Reduced platelet count, abnormal liver enzymes or HELLP Syndrome
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9
Q

What can Pre-eclampsia cause, ti foetus, and to mother

A
  • Eclampsia
  • Foetal complications (intrauterine growth retardation, prematurity)
  • Liver disease
  • Haemorrhage (placental abruption, intra cerebral)
  • Cardiac failure
  • Neurological symptoms (stroke, altered mental status, blindness)
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10
Q

What are some high risk factors for pre-eclampsia

A
  • HTN, in previous pregnancy or chronic
  • CKD
  • SLE or Antiphospholipid syndrome
  • Diabetes
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11
Q

What are moderate risk factors for pre-eclampsia (>2 for prevention)

A
  • First pregnancy
  • > 40y
  • > 10y since last pregnancy
  • Obesity
  • Family history
  • Multiple pregnancy
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12
Q

If pre-eclampsia is found at 160/100 or higher, how should it be managed

A

Emergency secondary care assessment, admission and monitoring if >160/110

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13
Q

What is eclampsia

A

Development of seizures in association with pre-eclampsia

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14
Q

How is eclampsia managed

A

Magnesium sulphate.
- For prevention in severe pre-eclampsia and to treat seizures.
- IV bolus of 4g over 5-10 mins then 1g/hour infusion
- Monitor urine output, resp rate and O2 sats
- Until 24 hrs post last seizure or delivery

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15
Q

What should be monitored in patients with pre-eclampsia/Gestational HTN. What factor decreases in pre eclampsia

A

Urine dipstick, liver enzymes, FBC, renal profile weekly

Monitor foetal growth on scans

Platelet Growth Factor (PlGF) once between 20-35 weeks to rule out pre-eclampsia (PlGF is low in pre-eclampsia)

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16
Q

What is HELLP syndrome, how does it present, and how is it treated

A

Combination of features as a complication of pre-eclampsia

  • Haemolysis
  • Elevated Liver enzymes
  • Low Platelets

Nausea/vomiting, RUQ pain and lethargy

Treated with delivery of child

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17
Q

What is gestational diabetes

A

Diabetes complicates 1/20 pregnancies, majority of which is gestational diabetes - insulin resistance during pregnancy which resolves after birth.

Most commonly it causes larges for dates fetus and macrosomia, implications for delivery including shoulder dystocia.

Also puts woman at further risk of T2DM.

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18
Q

Risk factors for Gestational Diabetes

A

BMI>30
Previous gestational diabetes
Previous macrosomic baby >4.5kg
First degree relative with diabetes
Family origin (South Asia, black Caribbean and Middle East)

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19
Q

How is gestational diabetes screened for, and when is this offered

A

OGTT (fasting glucose, followed by 75g glucose drink. Blood sugar measured again after 2 hrs. Normal, fasting: <5.6mmol/L, 2hrs: <7.8 mmol/L (!5678!))

In those with previous this is offered at first antenatal appt, and repeated 24-28 weeks if normal.

If risk factors, 24-28 week test.

If features (large for dates fetus, polyhydroamnios, glucose on urine dip, then do test)

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20
Q

How should gestational diabetes be managed

A
  • Counselling, diet, exercise, and show how to take blood glucose.
  • If fasting <7, trial non medical.
  • If targets not met, add metformin
  • If still not met add insulin

If >7 add insulin

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21
Q

How should pre existing diabetes be managed in pregnancy? What non diabetic drug needs to be given?

A

Weight loss if BMI>27
Stop oral drugs except metformin, and start insulin
Folic acid 5mg/day until 12 weeks

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22
Q

Glucose self monitoring targets in pregnancy

A

Fasting 5.3
1 hr after meals 7.8
2 hr after meals 6.4

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23
Q

Define miscarriage

A

The spontaneous loss of pregnancy before 24 weeks gestation.

Most common in first trimester and usually present with vaginal bleeding +- lower abdominal pain.

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24
Q

What is the most common cause of miscarriage, and how many known pregnancies are affected by miscarriage

A

Chromosomal abnormalities in fetus are most common.

Affects 1 in 8 known pregnancies

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25
Q

Risk factors for miscarriage

A

Maternal age >35
History of miscarriage
Previous large cervical cone biopsy
Smoking, alcohol, obesity
Uncontrolled diabetes or thyroid disorders

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26
Q

Define these:
Missed miscarriage
Threatened miscarriage
Inevitable miscarriage
Incomplete miscarriage
Complete miscarriage
Anembryonic pregnancy

A

Missed - Fetus no longer alive, no symptoms of expulsion, before 20 weeks. Closed cervical os
Threatened - Painless vaginal bleeding but closed cervix and fetus alive (usually 6-9 weeks, can be anytime before 24wk)
Inevitable - Heavy painful bleeding with clots and open cervix
Incomplete - Conception products still in uterus. Pain and vaginal bleeding with open cervical os
Complete - Full miscarriage, no products of conception in uterus
Anembryonic - Gestational sac but no embryo

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27
Q

What is vaginal bleeding and symptoms caused by in miscarriage

A
  • Haemorrhage in decidua basalis leading to necrosis and inflammation
  • Ovum unable to continue developing causing uterine contractions and cervical dilation, causing loss of fetus and pregnancy tissue
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28
Q

What investigations are used to diagnose a miscarriage

A

Transvaginal ultrasound scan determines the viability and the location of the pregnancy.

If unable to determine, repeat in 7 days.

Serum bHCG can be done, decreases following miscarriage as produced by placenta. If ectopic, laparoscopy can be done.

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29
Q

Whats looked for in a transvaginal ultrasound in early pregnancy

A

Findings appear sequentially, and earlier features less relevant when later develop.

  • Mean gestational sac diameter
  • Fetal pole and crown-rump length
  • Fetal heartbeat

Fetal pole is expected once mean gestational sac diameter is >25mm. If GSD is >=25mm and no fetal pole, repeat in 1 week before confirming anembryonic pregnancy

If crown-rump<7mm and no heart beat, repeat in 7 days. If >7mm without heartbeat, repeat scan in 1 week and confirm non-viable pregnancy.

With fetal heartbeat, pregnancy viable. Expected once crown-rump length is 7mm.

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30
Q

What are the 3 ways miscarriage can be managed

A

Expectant: If no major risk factors (bleeding/infection etc), should be given 1-2 weeks to pass.
Medically: Misoprostol (prostaglandin analogue) causes strong myometrial contractions, expelling the contents of conception. Can be given vaginally or orally.
Surgical: vacuum aspiration (local anaesthetic/outpatient), surgical under general anaethetic

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31
Q

How is a missed miscarriage treated

A

Mifepristone (progesterone receptor antagonist - weakens attachment to endometrial wall + cervical softening and dilation + induction of contractions)

48 hours later give misoprostol unless already passed.

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32
Q

How is incomplete miscarriage managed

A

Single dose of misoprostol (vaginal, oral or sublingual).

May need vacuum suction too, as retained conception contents are an infection risk.

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33
Q

Differentials for miscarriage

A

Ectopic pregnancy - Pain unilateral, more severe and before bleeding. Darker blood and less heavy.

Molar pregnancy - Heavy and prolonged bleeding with clots and brown watery discharge. Uterus is large for date and exaggerated morning sickness

Ovarian torsion - Palpable mass with pelvic pain and may not bleed.

Fibroid degeneration - May have fever, more systemic, swelling

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34
Q

Complications of miscarriage

A
  • Incomplete miscarriage +- infection
  • Haemorrhagic shock due to blood loss
  • Depression/anxiety
  • Haemolytic disease of the newborn - Give anti-D immunoglobulin to rhesus-negative women who have had surgical intervention for miscarriage.
  • Increased risk of future miscarriage
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35
Q

What is post partum haemorrhage and what volumes of blood is it characterised by

A

Blood loss of >500ml after vaginal delivery, or >1000ml after C section. Can be primary or secondary

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36
Q

Causes of primary post partum haemorrhage

A

Within 24 hours.
4 Ts
- Tone (uterine atony - most common)
- Trauma (e.g. perineal tear)
- Tissue (retained placenta)
- Thrombin (Clotting/bleeding disorders)

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37
Q

Risk factors for Primary PPH

A

Previous PPH
Prolonged labour
Pre-eclampsia
Polyhydramnios
Emergency C Section
Macrosomia
Increased maternal age

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38
Q

Preventative measures for PPH

A

Treating antenatal anaemia
Giving birth with empty bladder
Active management of third stage (IM oxytocin)
IV tranexamic acid during C section in third stage in high risk patients.

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39
Q

Management of PPH (general, not necessarily addressing bleeding)

A

Medical emergency

Resuscitation with ABCDE
Lie flat, keep her warm.
Insert 2 14 gauge cannulae
Take bloods with group and save
Commence warmed crystalloid
Oxygen and blood transfusions.

Activate major haemorrhage protocol!

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40
Q

Management to stop bleeding in PPH

A

Mechanical: Palpate and rub uterine fundus to stimulate contractions. Catheterisation (bladder distension prevents uterine contraction)

Medical:
- IV Oxytocin, slow injection then infusion
- Ergometrine IV or IM (unless HTN) - Stimulates smooth muscle contraction
- Tranexamic acid (antifibrinolytic - prevents bleeding)
- Carboprost IM (unless asthmatic) - Prostaglandin analogue, stimulates uterine contraction
- Misoprostol

Surgical:
- Intrauterine balloon tamponade (Bakri)
- B-Lynch suture (suture around uterus to compress)
- Uterine artery litigation

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41
Q

What is secondary PPH, how is it investigated and treated

A

Bleeding from 24 hours to 12 weeks post partum.

Usually due to Retained Products of Conception (RPOC) or infection e.g. endometritis.

USS and/or endocervical or high vaginal swabs

Treated with surgery or Abx

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42
Q

When does labour normally occur and what are its stages

A

between 37 and 42 weeks

1 - Onset of labour (true contractions) until 10cm cervical dilatation
2 - 10cm cervical dilatation to delivery of the baby
3 - From delivery of baby to delivery of placenta

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43
Q

What happens during the first stage of labour

A

Cervical dilatation and effacement (thinning). The “show” (mucus plug that normally prevents bacteria from entering uterus) is passed, falling out and creating space for baby to pass through.

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44
Q

What are the 3 phases of the first stage of labour

A

Latent - 0 to 3cm dilatation. ~0.5cm/hour with irregular contractions
Active - 3 to 7cm dilatation. ~1cm/hour with regular contractions
Transition phase - 7 to 10cm dilatation. ~1cm per hour with regular strong contractions.

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45
Q

If a woman feels irregular, non labour contractions during pregnancy, what are these called and when do they normally happen.

A

Braxton-Hicks contractions.

Irregular uterus contractions usually during second or third trimester. Not true contractions, no indication of labour. Non progressive and irregular.

Staying hydrated and relaxing can help.

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46
Q

Give 4 signs of labour

A

Show (cervical mucus plug)
Rupture of membranes
Regular, painful contractions
Dilating cervix on examination

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47
Q

What prostaglandin can be used to induce labour

A

Prostaglandin E2 (dinoprostone)

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48
Q

What is the second stage of labour and how long should it last

A

From 10cm until delivery of baby

Passive 2nd stage - Delivery without pushing (normal)
Active - Active process of maternal pushing

It is less painful than stage 1 and should last 1 hour. If longer, consider Ventouse, forceps or C section.

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49
Q

What factors most dictate success of second stage

A

3 Ps

Power - Strength of uterine contractions

Passage - Size and shape of passageway and pelvis

Passenger (4 descriptive qualities of fetus)
- Size (especially head
- Attitude: Posture (how back is rounded, how head and limbs are flexed)
- Lie: Position of child in relation to mother’s body
- Presentation: Part of fetus closest to cervix

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50
Q

Explain the 4 descriptive qualities of the fetus in second stage, giving best and worst presentations.

And how should head position be

A

Size: Normal or small head. Macrosomia can cause difficulty passing through birth canal, causing complications like shoulder dystocia.

Attitude (posture): Well flexed head, rounded back and tucked in limbs best for delivery.

Lie (childs long axis compared to mother’s): Longitudinal best - fetus head or buttocks down, lining up wiht mother. Transverse not compatible with vaginal delivery needs C section.

Presentation (part of fetus closest to cervix): Cephalic (head first) best. Breech (legs first) or shoulder presentation may need c section.

Head position being occiptoanterior is best.

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51
Q

How should contractions occur in normal labour, how often should they occur and how long should they last

A

Regular, strong contractions - every 2-3 mins and lasting 60-90 seconds.

Weak, infrequent or uncoordinated contractions bad, may need oxytocin or c section

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52
Q

How should pelvis be ideally shaped in labour

A

Gynaecoid - round and spacious

Worst: Android - Narrow and heart shaped

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53
Q

What is the 3rd stage of labour, what are the benefits of a an active 3rd stage

A

Completed baby birth to placental delivery

Physiological - Maternal effort without medication or cord traction
Active management - IM Oxytocin and careful traction to umbilical cord help deliver placenta.

Active shortens 3rd stage and reduces risk of bleeding. Haemorrhage or >60min delay should prompt active management.

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54
Q

What are the 7 cardinal movements of labour

A

Engagement - Babys head enters pelvis
Descent - Downward movement through birth canal
Flexion - Babys head flexes, allowing smallest head diameter to present
Internal rotation - Babys head rotates to align with pelvis
Extension - As head passses under pubic bnoe, it extends up
External rotation (Restitution) - Baby’s head rotates back to align with shoulders
Expulsion - Shoulders and body delivered

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55
Q

How does the head of the baby enter and exit the pelvis

A

Enters occipito-lateral
Exits occipito-anterior

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56
Q

DEFINE
Prelabour rupture of membranes
Preterm prelabour rupture of membranes
Prolonged rupture of membranes

A

Prelabour - Amniotic sac ruptures before onset of labour
Preterm prelabour - Prior to labour and before 37 weeks
Prolonged - Rupture more than 18 hours before delivery

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57
Q

Define prematurity

A

Birth <37 weeks gestation. More premature = worse outcomes.

Non viable before 23 weeks.

Under 28 weeks: Extreme preterm
28-32: Very preterm
32-37: moderate preterm

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58
Q

What prophylaxis can be given for preterm labour

A

Vaginal progesterone. Offered to all women with cervical length of <25cm between 16 and 24 weeks gestation

Cervical cerclage. - Stitching cervix to keep it closed. Offered between 16-24 weeks with <25cm cervical length if previous premature birth or cervical trauma.

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59
Q

If there is cervical dilatation between 16 and 28 weeks, without rupture of membranes, what can be done?

A

“Rescue” Cervical cerclage (stitching cervix to keep it closed)

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60
Q

How can preterm prelabour rupture of the membranes be diagnosed

A

Sterile speculum examination showing pooling of amniotic fluid in the posterior vaginal vault.

If negative, test fluid for placental alpha microglobulin-1 protein (PAMG-1) or insulin-like growth factor binding protein 1

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61
Q

How should prelabour preterm rupture of membranes be managed

A

Prophylactic erythromycin 250mg 4xdaily for 10 days - prevent chorioamnionitis.

Antenatal corticosteroids to reduce risk of respiratory distress syndrome

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62
Q

How does preterm labour with intact membranes present

A

Regular painful contractions and cervical dilation without rupture of amniotic sac

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63
Q

How is preterm labour with intact membranes diagnosed

A

Less than 30 weeks, clinical diagnosis with speculum examination to assess cervical dilatation

> 30 weeks, Transvaginal ultrasound to assess cervical length. If <15mm, preterm labour management. If >15mm, unlikely to be preterm labour.

Fetal fibronectin is an alternative test: found in vagina during labour

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64
Q

Management of preterm labour

A

Tocolysis with nifedipine - stop uterine contractions between 24 and 34 weeks. Short term measure (<48 hours). Atosiban (oxytocin receptor blocker) is an alternative

Maternal corticosteroids (IM Betamethasone, 2 doses 24 hours apart) - reduce neonatal morbidity and mortality

Magnesium Sulfate IV to mother - helps protect fetal brain during premature delivery, reducing risk and severity of cerebral palsy.

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65
Q

What are signs of magnesium sulfate toxicity? How is it treated

A

Reduced resp rate
Reduced blood pressure
Absent reflexes

Treated with Calcium gluconate

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66
Q

What is ectopic pregnancy

A

Fertilised ovum implants outside uterine cavity, most commonly fallopian tubes. Other sites include ovary, cervix, abdominal cavity.

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67
Q

Risk factors for ectopic pregnancy

A
  • Fallopian tube abnormalities or damage (PID, surgery)
  • Previous ectopic
  • IUD and POP use
  • Endometriosis
  • Smoking
  • Fertility treatments
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68
Q

Typical presentation of ectopic pregnancy

A

Usually presents with 6-8 weeks of amenorrhoea with lower abdo pain and later, vaginal bleeding.

  • Lower abdo pain (caused by tubal spasms) usually constant and unilateral.
  • Recent amenorrhoea (6-8 weeks since last period) followed by vaginal bleeding (darker brown and lighter than normal period)
  • Peritoneal bleeding causes shoulder tip pain and pain on urination/defecation
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69
Q

Examination findings of ectopic pregnancy

A
  • Abdominal tenderness
  • Cervical excitation (cervical motion tenderness)
  • Adnexal mass (do not examine, risk of rupturing pregnancy)
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70
Q

Investigations of ectopic pregnancy

A

bHCG >1500

GOLD: Transvaginal ultrasound: gestational sac containing yolk sac or fetal pole.

Findings on TVUSS:
- blob/bagel/tubal ring sign (empty gestational sac)
- Empty uterus
- Fluid in the uterus (psuedogestational sac)

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71
Q

How does bhCG increase in:
- Intrauterine pregnancy
- Ectopic
- Miscarriage

Over 48 hours

A

Intrauterine: Increase of more than 63%
Ectopic: Increase of less than 63%
Miscarriage: Fall of >50%

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72
Q

How can ectopic pregnancy be managed

A

If pelvic pain/tenderness + positive pregnancy test, refer to early pregnancy assessment unit (EPAU).

Expectant - await natural termination
Medical - Methotrexate
Surgical - Salpingectomy

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73
Q

Criteria for expectant and medical management of ectopic pregnancy

A

Size <35mm
Unruptured
Asymptomatic
No fetal heartbeat
hCG <1000
48 hour monitoring

If: hCG >1500, but less than 5000, and if intrauterine pregnancy absence confirmed, methotrexate can be used.

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74
Q

When is surgical intervention indicated in ectopic pregnancy

A

Size >35mm
Can be ruptured
If significant pain
Visible fetal heartbeat
hCG >5000

Can be done if another intrauterine pregnancy
Done via laparoscopic salpingectomy

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75
Q

Why is treatment with methotrexate incompatible with another pregnancy. Give possible side effects of use

A

Methotrexate is given IM, and is teratogenic. Halts pregnancy and causes spontaneous termination.

Should not get pregnant for 3 months following treatment.

Common side effects:
- Vaginal bleeding
- Nausea/vomiting
- Abdo pain
- Stomatitis (inflammation in mouth)

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76
Q

What is placenta accreta spectrum

A

When the placenta implants deeper through endometrium to the myometrium or perimetrium (placenta percreta) due to a defective decidua basalis. As it does not properly separate, this can cause postpartum haemorrhage.

If chorionic villi invade into myometrium, placenta increta. If they simply attach to the myometrium instead of remaining in the decidua basalis, placenta accreta. (INvade = INcreta)

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77
Q

What can cause placenta accreta and what are its risk factors

A

Previous uterine surgery e.g. C section, curettage procedures.

  • Previous placenta accreta
  • Previous endometrial curettage procedures
  • Previous c section
  • Multigravida
  • Increased maternal age
  • Low lying placenta or placenta praevia
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78
Q

How does placenta accreta normally present

A

Usually no symptoms during pregnancy, but can be bleeding during third trimester. (antepartum haemorrhage)

May be diagnosed on routine antenatal ultrasounds or at birth, with difficulty delivering placenta.

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79
Q

What is the big worry with placenta accreta

A

Postpartum haemorrhage!

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80
Q

How is placenta accreta managed

A

Specialist MDT. Planned delivery between 35-37 weeks. Antenatal steroids given to mature fetal lungs and C section conducted.

Options during C section:
- Hysterectomy (recommended)
- Uterus preserving surgery
- Expectant management (carries significant bleeding and infection risk)

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81
Q

Main 3 causes of major and minor (spotting) antepartum bleeding

A

Major
- Placenta praevia
- Placental abruption
- Vasa praevia

Minor
- Cervical ectropion
- Infection
- Vaginal abrasion from sex or procedures

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82
Q

What is placenta praevia

A

When the placenta lies wholly or partly over the cervical os. Major cause of mortality and morbidity, and is indication for C section.

It is a worse version of a low lying placenta, as low lying placentas usually resolve upwards.

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83
Q

How is placenta praevia normally diagnosed

A

20 week anomaly scan (transvaginal USS) used to assess placenta position.

Usually asymptomatic but is a cause of 3rd trimester bleeding (antepartum haemorrhage), which can be major

NO Digital vaginal exam, as this could provoke major haemorrh, age.

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84
Q

Grading of placenta praevia

A

I - Reaches lower segment but not internal os
II - Reaches internal os but doesnt cover it
III - Covers internal os before dilation but not when dilated
IV (major) - Placenta completely covers internal os.

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85
Q

Risk factors for placenta praveia

A

Multiparity
Uterine scarring due to previous C section, uterine rupture, or endometriosis
Previous placenta praevia
Advanced maternal age

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86
Q

Management of placenta praevia

A
  • Repeat USS at 32 and 36 weeks.
  • Corticosteroids at 34 and 35+6 weeks to mature fetal lungs.
  • Planned C section between 36 and 37 weeks.
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87
Q

Complications of placenta praevia

A
  • Haemorrhage, either before. during or after delivery.
  • Preterm or low weight birth
  • Stillbirth
  • Emergency C section or hysterectomy may be indicated
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88
Q

What is placental abruption

A

When compromise of the vascular structures supporting the placenta separate from the wall of the uterus causing bleeding into the new space under attachment site. Causes a solid woody feeling abdomen

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89
Q

Risk factors for placental abruption

A

Preeclampsia
Cocaine use
Smoking
Maternal trauma
Multiparity
Increasing maternal age

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)

90
Q

Presentation of placental abruption

A
  • Sudden, severe, continuous abdominal pain
  • Tender, tense uterus
  • Vaginal bleeding (antenatal haemorrhage)
  • Characteristic “woody” abdomen on palpation suggests large bleed
  • Shock (tachycardia and hypotension) if severe bleeding
  • Absent fetal heart suggests fetal death
91
Q

How can an abruption remain concealed

A

If cervical os remains closed, or any bleeding occurs away from cervical os, containing blood.

92
Q

Management of placental abruption

A

Fetus alive <36 weeks
- If distressed: Immediate C section
- If not, observation and steroids

Fetus alive >36 weeks
- If distressed, immediate C section
- If not, normal delivery

If fetus is dead, induce delivery.

93
Q

Complications of fetal abruption

A

Maternal
- Hypovolaemic Shock
- PPH
- DIC
- Renal failure

Fetal
- Intrauterine growth restriction (IUGR)
- Hypoxia
- Death

94
Q

How is bleeding categorised in Placental abruption

A

Spotting (may not need intervention)
Minor - <50ml
Major 50-1000ml
Massive >1000ml

95
Q

What is vasa praevia

A

Rare condition where fetal blood vessels in chorioamniotic membranes cross the interal cervical os. Fetal membranes surround amniotic cavity and developing fetus.

Fetal vessels consist of 2 umbilical arteries and an umbilical vein.

96
Q

Pathophysiology of vasa praevia (including types)

A

Fetal vessels (2 umbilical arteries and umbilical vein) usually protected by umbilical cord (Wharton’s jelly) or by the placenta. 2 cases where they can become exposed:
- Velamentous umbilical cord - cord inserts into chorioamniotic membranes, and vessels travel unprotected through membranes before joining placenta. (TYPE 1)
- Accessory lobe of placenta - AKA a succenturiate lobe. When fetal vessels travel through chorioamniotic membranes between lobes. (TYPE 2)

In vasa praevia, the unprotected vessels travel through membranes and pass across the cervical os, becoming exposed and prone to bleeding. Especially during membrane rupture during labour, which can lead to fetal blood loss and death.

97
Q

Diagnosis of vasa praevia

A

May be diagnosed via USS in pregnancy, enabling planned C section.

May present with antepartum haemorrhage.
May be detected during labour, when pulsating vessels seen during dilation.
May be detected when dark red bleeding and fetal distress occur during labour - high mortality.

98
Q

Management of vasa praevia

A

Corticosteroids at 34 weeks
Elective C section 34-36 weeks

99
Q

What is cord prolapse and whats its most significant risk factor

A

Where the umbilical cord descends below presenting part of fetus into vagina after rupture of fetal membranes during delivery. If cord is compressed, can cause fetal hypoxia.

Most significant risk factor is an abnormal lie (Unstable, transverse or oblique). Being in an abnormal lie provides space for cord prolapse below presenting part.

100
Q

Diagnosis of cord prolapse

A

50% occur at artificial rupture of the membranes. Diagnosis made when fetal heart rate becomes abnormal and cord is palpable or visible vaginally.

101
Q

Management of cord prolapsee

A

Obstetric emergency

Push presenting part of baby back and keep cord warm and moist to prevent vasospasm.
Have mother go on all fours (knee-chest position) or in a left lateral lie to draw fetus away from pelvis and reduce compression.

Tocolytic medication (terbutaline) can minimise contractions while waiting for emergency C section

102
Q

What is rhesus disease?

A

Rhesus-D is an antigen found on blood cells. A rhesus positive mother won’t need treatment, but if rhesus negative, and her child is rhesus positive, this could be a problem;

If there is an event causing leakage, or when fetal and maternal blood is mixed during labour, the mother’s immune system can become sensitised to the rhesus D antigen, forming anti-D IgG antibodies.

In a second rhesus D positive pregnancy, these can cross the placenta and cause haemolysis of the fetal red blood cells. This is referred to as haemolytic disease of the newborn.

103
Q

How is rhesus disease prevented

A

Test for D antibodies in all Rh negative mothers at booking.

Giving anti-D to non-sensitised mothers at 28 and 34 weeks, and at birth, prevents sensitisation, as once sensitised this is irreversible.

Anti D should be given ASAP (<72hrs) if:
- Delivery of Rh +ve infant in Rh negative woman
- Any termination of pregnancy
- Miscarriage if >12 weeks gestation
- Ectopic pregnancy (unless managed with methotrexate)
- any situation where sensitisation may occur (amniocentesis procedures, antepartum haemorrhage, abdominal trauma)

104
Q

What test is performed at 20 weeks in rhesus negative women

A

Kleinhauer test
- after any sensitising event after 20 weeks, add acid to sample of mother’s blood. Fetal blood is naturally resistant to acid so they are protected against acidosis, keeping their haemoglobin, enabling a measurement of how much fetal blood is in the mother’s blood.

105
Q

What tests should be done on all babies born to a Rh -ve woman

A

FBC
Blood group
Direct coombs test (Demonstrate antibodies on baby’s RBCs)

106
Q

What are possible complications to a fetus in rhesus negative pregnancy

A
  • Oedematous (hydrops fetalis)
  • Jaundice, anaemia, hepatosplenomegaly
  • Heart failure
  • Kernicterus (newborn jaundice)

Treated with transfusions and UV phototherapy.

107
Q

What are some indications for induced labour?

A
  • Prolonged pregnancy (38/39 weeks)
  • Premature prelabour rupture of membranes where labour doesnt start
  • Maternal medical problems (diabetes >38 weeks, pre-eclampsia, obstetric cholestasis)
  • Intrauterine fetal death
108
Q

What score is used to figure out whether a labour may need to be induced

A

Bishop score

Looks at:
Cervical position (anterior best (+ 2))
Cervical consistency (soft best +2)
Cervical effacement (80% best +3, 60-70% +2)
Cervical dilation (>5cm best +3, 3-4 +2)
Fetal station (+1, +2 best (+3), -1,0 +2)

<5 indicates labour unlikely without induction
>8 indicates cervic is ripe and high chance of spontaneous labour, or response to induction

109
Q

Possible methods of labour induction

A
  • Membrane sweep - Finger passes through cervix to rotate against wall of uterus, to separate chorionic membrane from decidua. Adjunct to labour
  • Vaginal prostaglandin E2 (dinoprostone)
  • Oral prostaglandin E1 (misoprostol)
  • Maternal oxytocin infusion
  • Amniotomy (breaking of waters)
  • Cervical ripening balloon (passed through endocervical canal to dilate cervix)
110
Q

What are the NICE Guidelines for inducing labour

A

Bishop <6, Vaginal or oral prostaglandin (E2 dinoprostone or E1 misoprostol respectively)
- Balloon catheter if high hyperstimulation risk or previous caesarean
- Bishop >6, amniotomy and IV oxytocin.

111
Q

Complications of labour induction

A

Uterine hyperstimulation
- Prolonged and frequent uterine contractions (tachysystole)
- Can cause intermittent interruption of bood flow to child causing fetal hypoxemia and acidemia
- Can be treated by stopping prostaglandin or oxytocin, or with tocoloysis

112
Q

Why should VTE risk assessment be done in a pregnant woman

A

Pregnancy is a VTE risk

113
Q

How is VTE risk in pregnancy managed pharmacologically

A

Using LMWH (Warfarin and DOACs AVOIDED)

  • Woman with previous VTE high risk - needs LMWH throughout antenatal period
  • Woman with risk of VTE due to hospitalisation, surgery, comorbidities, thrombophilia, consider for treatment
114
Q

Risk factors for VTE, and their relation to treatment timings

A
  • Age >35
  • BMI>30
  • Parity >3 and multiple pregnancy
  • Smoker
  • Varicose veins
  • Preeclampsia
  • Immobility
  • Family history of unprovoked VTE
  • Low risk thrombophilia
  • IVF pregnancy

4 or more = immediate treatment until 6 weeks postnatal.
3 or more = LMWH from 28 weeks until 6 weeks postnatal

If DVT made before delivery, continue for 3 months after

115
Q

What is the current age of gestation abortion can be performed until, and what legal framework dictates this

A

24 weeks

(originally 28 weeks according to 1967 abortion act, 1990 Human Fertilisation and Embryology Act changed to 24)

116
Q

What are some cases where age of gestation can be ignored for abortion

A
  • To save woman’s life
  • Evidence of fetal abnormality (physical/mental handicap)
  • Risk of serious physical/mental injury to woman
117
Q

What must be done medico-legally in cases of an abortion and what must be given to women having an abortion after 10 weeks

A
  • 2 registered medical practitioners must sign document (1 if emergency)
  • Only a registered medical practitioner can perform an abortion (NHS or licensed premisis)

Give anti-D prophylaxis who are rhesus negative

118
Q

How can abortion be done medically

A

Mifepristone (anti-progesterone) followed 48 hours later by prostaglandins (e.g. oral misoprostol) to stimulate contractions
- “mimics a miscarriage”
- Takes hours to days to complete, unpredictable
- Pregnancy test 2 weeks later to confirm, measuring hCG

Can be done at home <10 weeks.

119
Q

How can abortion be done surgically

A

Vacuum aspiration, electric vacuum aspiration and dilatation and evacuation.
- Cervical priming with misoprostol or mifepristone before procedures
- After evacuation of uterine cavity, an intrauterine contraceptive can be used immediately.

120
Q

What are some complications of abortion

A

Vaginal bleeding and cramps intermittently for up to 2 weeks. Also:
- Bleeding
- Pain
- Infection
- Failure
- Damage to cervix, uterus, other structures

121
Q

When are women screened for anaemia in pregnancy, and what are the normal ranges during pregnancy

A

Booking clinic and at 28 weeks

Booking: >110g/L
28 weeks: >105g/L
Post partum: >100g/L

122
Q

What is a physiological cause of a reduced haemoglobin concentration in pregnancy

A

Plasma volume increases, reducing haemoglobin concentration

123
Q

What is the most common cause of Low MCV (mean cell voume) anaemia, as well as normal and high

A

Low - Iron
Normal - Physiological, due to plasma volume increase
High - B12/ferritin

124
Q

Treatment of iron deficiency anaemia in pregnancy

A

Iron replacement (ferrous sulphate 200mg 3 times daily)

(supplementary iron if not pregnant)

125
Q

Management of B12 deficiency in pregnancy

A

Test for pernicious anaemia (intrinsic factor antibodies)
- IM Hydroxycobalamin injections
- Oral Cyanocobalamin tablets

126
Q

Management of folate deficiency in pregnancy

A

All should be taking 400mcg per day folic acid anyway.

Start on folic acid 5mg daily

127
Q

Define obesity in pregnancy

A

BMI >30kg/m^2 at first antenatal visit

128
Q

Maternal risks with obesity in pregnancy

A
  • Miscarriage
  • VTE
  • Gestational Diabetes
  • Pre-eclampsia
  • Dysfunctional labour, induced labour
  • Postpartum haemorrhage
  • Wound infection
  • C section
129
Q

Fetal risks with obesity in pregnancy

A
  • Congenital abnormalities
  • Prematurity
  • Macrosomia
  • Stillbirth
  • Increased risk of obesity and metabolic disorders in childhood
  • Neonatal death
130
Q

Management of obesity in pregnancy

A
  • 5mg folic acid, rather than 400 mcg
  • Screening for gestational diabetes (OGTT) 24-28 weeks
  • BMI >35 = consultant led obstetric unit
  • > 40 = antenatal consultation with obstetric anaesthetist
131
Q

Define these terms in relation to a multiple pregnancy
- Monozygotic
- Dizygotic
- Monoamniotic
- Diamniotic
- Monochorionic
- Dichorionic

A
  • Monozygotic - Identical twins (one zygote)
  • Dizygotic - Non-identical twins (2 zygotes)
  • Monoamniotic - Single amniotic sac
  • Diamniotic - 2 amniotic sacs
  • Monochorionic - Single placenta
  • Dichorionic - 2 seperate placentas

Dichorionic, Diamniotic twin pregnancies have best outcomes, due to own nutrient supply.

132
Q

What can be done to diagnose a multiple pregnancy

A

Transvaginal USS
- Gestational age
- Number of placentas and amniotic sacs
- Risk of Down’s syndrome (as part of combined test)

133
Q

How do USS signs determine the type of twins

A

Dichorionic diamniotic have a membrane between twins
Lambda sign or twin peak sign (triangular appearance of space where membrane meets the chorion)

Monochorionic diamniotic have a membrane between twins with a T sign

Monochorionic monoamniotic twins have no membrane separating them.

134
Q

What are possible complications of a multiple pregnancy

A

Mother:
- Anaemia
- Polyhydramnios (excess amniotic fluid)
- HTN
- Spontaneous preterm birth
- Postpartum haemorrhage

Fetuses
- Miscarriage/stillbirth
- Fetal growth restriction
- Prematurity
- Twin-Twin transfusion syndrome
- Twin anaemia polycythaemia sequence
- Congenital abnormalities

135
Q

What is Twin-Twin Transfusion syndrome

A

Occurs when twins share a placenta.

When there is a connection of blood supplies from 2 fetuses, one fetus (recipient) may receive more blood, while donor fetus is starved.

The recipient can become overloaded, getting heart failure and polyhydramnios.

Donor has growth restriction, anaemia and oligohydramnios.

May need laser treatment to destroy the connection in blood supplies

136
Q

What is twin anaemia polycythaemia sequence

A

Similar to twin-twin transfusion syndrome but less acute. One develops anaemia and the other polycythaemia

137
Q

How must monoamniotic be delivered

A

Elective C section between 32 and 33+6 weeks

138
Q

How can diamnotic twins be delivered

A

Between 37 and 37+6 weeks
Vaginal possible if first baby has cephalic presentation
C Section may be needed for 2nd child

Elective C section if presenting twin is not cephalic presentation

139
Q

What is shoulder dystocia

A

When the anterior shoulder of the baby becomes stuck behind the pubic symphysis of the pelvis, after the head has been delivered.

Obstetric emergency

Often caused by macrosomias secondary to gestational diabetes

140
Q

Key risk factors for Shoulder Dystocia

A
  • Fetal macrosomia (which is often caused by maternal diabetes)
  • High maternal BMI
  • Diabetes
  • Prolonged labour
141
Q

How does shoulder dystocia present

A
  • Difficulty delivering the face and head, and obstruction in delivering the shoulders.
  • Failure of restitution (head remains facing down (occipito-anterior), and does not turn sideways as expected.
  • Turtle-neck sign (head delivered but retracts back in)
  • Pain to mother
142
Q

How is shoulder dystocia managed

A

Senior help (anaesthetist, paediatrician, obs)
- McRoberts’ manoeuvre (flexion and abduction of the maternal hips, bringing thighs to her abdomen. This increases anterior-posterior angle, by moving pubic symphysis out the way)
- Episiotomy can enlarge vaginal opening
- Pressure to anterior shoulder by pressing suprapubic region of maternal abdomen

  • Zavanelli manoeuvre involves pushing baby back in to do C section, but can cause maternal morbidity.
143
Q

Complications of shoulder dystocia

A

Maternal
- Postpartum haemorrhage
- Perineal tears

Fetal
- Fetal hypoxia (Subsuquent cerebral palsy)
- Brachial plexus injury and Erb’s palsy.

144
Q

How should Hypothyroid be managed in pregnancy

A

Untreated hypothyroid can lead to miscarriage, anaemia, small for gestational age child

Levo dose should be increased and titrated using TSH level.

145
Q

How should hypertension be managed in pregnnacy

A

Medication changes

ACEi, ARB and Thiazide diuretics can cause congenital abnormalities

Switch to Labetalol, CCB (nifedipine) or alpha blockers (doxazosin)

146
Q

How should epilepsy be managed in pregnancy

A

Take folic acid 5mg, prevent neural tube defects

Manage ideally with single drug. (levetiracetam, lamotrigine, carbamazepine best options)

Sodium valproate causes neural tube defects and developmental delay
Phenytoin causes cleft lip and palate

147
Q

Rheumatoid arthritis management in pregnancy

A
  • Methotrexate (teratogen, and causes miscarriage)

Hydroxycholorquine first line, safe for pregnancy.

Sulfasalazine and corticosteroids area also safe

148
Q

What is oligohydramnios and what are some of its causes

A

Reduced amniotic fluid

  • Premature rupture of membranes
  • Fetal renal abnormalities (agenesis, dysplasia, obstruction)
  • Post term gestation
  • Fetal growth restriction
  • Post term pregnancy
149
Q

What can oligohydramnios cause

A
  • Potter sequence (Reduced development of fetal lungs and bilateral renal hypoplasia)
  • Flattened facial features (wide set eyes, flat nose, receding chin, low set ears - caused by compression)
  • Clubbed feet and limb abnormalities
  • Wrinkly skin
150
Q

How is Oligohydramnios diagnosed

A

Ultrasound during second trimester

  • Usually advanced at diagnosis, and often results in stillbirth, or respiratory problems (pulmonary hypoplasia) so severe they’ll cause death.

Affects boys more

151
Q

How is oligohydramnios managed

A

If before term, monitoring with serial fetal testing. Therapeutic amniofusion may be used.

Delivery between 36-38 weeks

152
Q

What is post partum thyroiditis

A

Thyrotoxicosis or hypothyroidism, or both, within 12 months of delivery, in a women with previously no thyroid disease.

153
Q

How does post partum thyroiditis usually present

A

3 stages
- Thyrotoxicosis (3 months)
- Hypothyroid (3-6 months)
- Return to normal within a year

Anti-TPO found in 90% of patients

154
Q

Management of post partum thyroiditis

A
  • Thyrotoxic phase: Propanolol for symptom control (no thyroid drugs)
  • Hypothyroid phase: Thyroxine
155
Q

How is postpartum depression screened for

A

Edinburgh Postnatal Depression Scal
- 10 item questionnaire, maximum score 30
- Score >13 indicates depressive illness
- Indicates how mother has felt for last week

156
Q

Define baby blues vs postpartum depression vs postpartum psychosis in terms of their respective timings and epidemiology

A

Baby blues - Majority of women, in first week or so post birth

Postpartum depression - 1/10, peak 3 months after birth

Postpartum/puerperal psychosis - 1/1000, starting a few weeks post birth

157
Q

How does baby blues present and how is it treated

A

Mild symptoms, that last a few days and resolve entirely within a couple weeks.

  • Anxious/Low mood
  • Tearful
  • Irritable/mood swings

Treated with reassurance and support. No medical treatment

158
Q

How does postnatal depression present

A

Similar to depression (classic triad)
- Low mood
- Low energy
- Anhedonia (lack of pleasure in activities)

Symptoms usually start around 1 month and peak around 3 months post birth

Mild - Treated with support, self help and follow up
Moderate - CBT, talking therapy, Antidepressant medication
Severe - Psychiatry

159
Q

Medications used in postnatal depression

A
  • SSRI (Sertraline, paroxetine)
  • SNRI - Venlafaxine, duloxetine
  • Tricyclic antidepressant - amitriptyline
  • Monoamine oxidase inhibitor - Slegeline
160
Q

How does puerperal psychosis present and how is it treated

A
  • Delusions
  • Hallucinations
  • Depression
  • Mania
  • Confusion
  • Severe mood swings

Urgent assessment and admission to mother and baby unit.
(has a 25-50% chance of recurrence)

161
Q

What can SSRI use during pregnancy cause

A

Neonatal abstinence syndrome - poor feeding and irritability. Managed supportively

162
Q

What does varicella zoster virus (VZV)

A

Chickenpox as a primary infection. Shingles when the dormant virus reactivates in the dorsal root ganglion.

In pregnancy, there is a risk to both mother and fetus (AKA Fetal varicella syndrome)

163
Q

Presentation of chickenpox

A

Widespread erythematous raised vesicular blistering lesions, that usually start on the trunk or face and spread outwards over 2-5 days. Lesions eventually scab, and stop being contagious when they do.

164
Q

How infective is chickenpox

A

Highly contagious and spread through direct contact with lesions or infected droplets in cough or sneeze. Symptomatic 10 days-3 weeks after exposure.

165
Q

Complications of Chickenpox

A

Bacterial superinfection
Dehydration
Conjunctival lesions
Pneumonia
Encephalitis

The virus lays dormant in sensory dorsal root ganglion cells, and later reactivate as Shingles or Ramsay Hunt Syndrome

166
Q

What can happen if chicken pox exposure occurs in an unvaccinated pregnant woman before 20 weeks? What about between 20-28 weeks

A

<20 - low risk, unlikely to progress

20-28 - can cause congenital varicella syndrome (skin scarring, microcephaly, learning disabilities, eye defects, limb hypoplasia)

Treated with VZ immunoglobulins and aciclovir

167
Q

Management of VZV

A

Usually self limiting

Aciclovir if immunocompromised, over 14 and presenting within 24 hrs, or neonates at risk of complications.

168
Q

Management of VZV exposure in pregnancy

A

Exposure
1- check blood for VZV antibodies
2- IVIG varicella zoster immunoglobulins
3- Oral aciclovir main PEP (Post exposure prophylaxis) 7-14 days post exposure

169
Q

Management of Chicken pox in pregnancy

A

Oral aciclovir if >20 weeks and presents within 24 hours of onset

170
Q

What is breech presentation

A

Legs and bottom are presenting part of the fetus (upside down).

Complete breech - legs are fully flexed at the hips and knees
Incomplete breech - One leg flexed at hip and extended at knee.
Extended breech - AKA Frank breech - both legs flexed at hip and extended at knee
Footling breech - Foot presenting through cervix with leg extended.

171
Q

Management of breech

A

Breech before 36 weeks should turn spontaneously. External Cephalic Version can be used from 37 weeks to turn the fetus.

If ECV fails, can be vaginal or caesarean delivery.

If first baby in twins is breech, C Section is required

172
Q

Define Uterine rupture

A

Uterine rupture is a complication of labour in which the myometrium (muscle layer of uterus) ruptures.

With an incomplete rupture, or uterine dehiscence, the uterine serosa (perimetrium) remains intact. In a complete rupture, the serosa ruptures, causing the uterine contents to spill into the peritoneal cavity.

Causes significant bleeding and has high mortality and morbidity for mother and child

173
Q

Risk factors for uterine rupture

A
  • Previuos C section (scar becomes weak point)
  • Vaginal birth after C section
  • Previous uterine surgery
  • Increased BMI and age
  • Induction of labour and oxytocin use
  • High parity
174
Q

Presentation of Uterine rupture

A

Cessation of uterine contractions
Vaginal bleeding and abdominal pain
Shock (Hypotension, tachycardia, collapse)

175
Q

How is uterine rupture managed

A

Emergency C section, stop bleeding and repair or remove uterus (hysterectomy)

176
Q

What is Asherman’s syndrome

A

Formation of adhesions within the uterus. following damage to it.

Usually occurs after a dilatation and curettage procedure, e.g. when treating retained products of conception. Can also occur after uterine surgery or pelvic infection.

These adhesions bind uterine walls together, causing a physical obstruction and abnormalities in menstruation, infertility, and recurrent miscarriages

177
Q

Presentation of Asherman’s syndrome

A

Significantly lighter, but more painful periods
Secondary amenorrhoea (absent periods)

178
Q

How are intrauterine adhesions diagnosed

A
  • Hysteroscopy is gold standard, can involve dissection and treatment of adhesions
  • Hysterosalpingography - contrast injected into uterus
  • MRI
179
Q

What measurements are used on ultrasound to assess fetal size

A
  • Estimated Fetal Weight
  • Fetal abdominal circumference
180
Q

When is a fetus determined to be small for gestational age? What weight defines low birth weight?

A

<10th centile
<3rd centile = severe SGA

<2500g = low birth weight

181
Q

What information is used to plot a growth chart

A

Mother’s
- Ethnic Group
- Weight
- Height
- Parity

182
Q

What are causes of SGA

A
  • Constitutionally small (normal for family to be small, growing appropriately on growth chart)
  • Fetal Growth Restriction (pathology causing nutrient or oxygen delivery reduction)
183
Q

What are some placenta mediated causes of FGR

A
  • Pre eclampsia
  • Maternal smoking and alcohol
  • Anaemia
  • Infection
  • Malnutrition
  • Maternal health problems
184
Q

What are some signs of FGR

A
  • Reduced amniotic fluid volume
  • Abnormal doppler studies
  • Reduced fetal movements
  • Abnormal CTGs
185
Q

Complications of FGR

A
  • Fetal death/stillbirth
  • Birth asphyxia
  • Neonatal hypoglycaemia and hypothermia

Increased risk of:
- CVD, particularly HTN
- T2D
- Obesity
- Mood/behavioural problems

186
Q

What test is used to screen for Down’s syndrome

A

Combined test - HCG increased , PAPP-A (Pregnancy-Associated Plasma Protein A) reduced, thickened nuchal translucency.

Performed between 11-14 weeks. Trisomy 18 (Edwards) and 13 (Pataus) have similar results but lower hCG.

187
Q

What is the quadruple test

A

Offered later (15-20 weeks)
Alpha fetoprotein, Unconjugated oestriol, hCG, Inhibin A

Downs:
- AFP ↓
- Unconjugated Oestriol ↓
- hCG ↑
- Inhibin A ↑

Edwards:
- Everything ↓

Neural Tube Defects:
- AFP ↑

188
Q

How can combined and quadruple test results be assessed:

A

Lower or higher chance
Lower: <1 in 150
Higher: >1 in 150

If higher: offer second screening test (NIPT) or diagnostic test e.g. amniocentesis. NIPT (Non invasive prenatal screening test) is more specific and sensitive.

189
Q

What is Stillbirth

A

The death of a fetus after 24 weeks gestation, as a result of intrauterine fetal death. 1 in 200 pregnancies.

190
Q

Possible causes of stillbirth

A
  • Unexplained
  • Preeclampsia
  • Placental abruption
  • Vasa Praevia
  • Cord prolapse
  • Thyroid disease
191
Q

Prevention of stillbirth and 3 key symptoms to always ask during pregnancy

A

SGA or FGR - Monitor with serial growth scans.

Give aspirin for pre-eclampsia.

3 key symptoms:
- Reduced fetal movements
- Abdominal pain
- Vaginal bleeding

192
Q

How can stillbirth be diagnosed

A

Ultrasound to detect fetal heartbeat.

Kleihauer test if Rhesus-D negative, to check maternal blood mix. Anti-D prophylaxis dose depending on amount mixed.

Vaginal birth, either induced (mifepristone (anti-progesterone) or misoprostol (prostaglandin analogue))

193
Q

What are the main signs of fetal distress

A
  • Abnormal fetal heart rate
  • Meconium stained amniotic fluid (liquor)
  • Abnormal fetal scalp blood pH
  • Decreased movements
  • Umbilical cord prolapse
194
Q

What is neonatal hypoglycaemia

A

Transient hypoglycaemia is common in first hours post birth

If symptomatic or very low, admit to neonatal unit and start IV 10% dextrose

195
Q

what vaccines given to pregnant women

A

Influenza
Pertussis (from 16 weeks)

COVID also currently offered

196
Q

When after delivery is contraception required?

When can POP be started, when can COCP be started, when can IUD be reinserted.

A

After giving birth, require contraception after day 21.

POP - Can start anytime postpartum. After day 21, use additional contraception for 2 days. (small amount of progesterone enters breast milk but not harmful.)

COCP - Contraindicated if breastfeeding <6 weeks post partum (UKMEC4). UKMEC2 if breastfeeding 6wk-6months.
- DO NOT use in first 21 days due to increased VTE risk. After day 21 use additional contraception for 7 days

IUD - Within 48 hours of childbirth or after 4 weeks

197
Q

What are the risks of an inter-pregnancy interval of <12 months between birth and conceiving again

A
  • Preterm birth
  • Low birth weight
  • Small for gestational age
198
Q

What’s LAM

A

Lactational amenorrhoea method

Natural contraception, when a mother breastfeeds, it delays her periods.

3 criteria MUST be met:
- Exclusively breastfeeding
- No menstrual periods since delivery
- Babys age (less than 6 months)

LAM is over 98% effective. At 6 months, supplementary feeding starts, or cycle returns, so LAM becomes less reliable

199
Q

What is an elective C section and what are some indications

A

Planned delivery date, usually after 39 weeks. Done under Spinal Anaethetic

Indications
- Previous C section
- Symptomatic after previous perineal tear
- Placenta and vasa praevia
- Breech
- Multiple pregnancy
- Uncontrolled HIV
- Cervical cancer

200
Q

What are the 4 categories of emergency c section

A

1 - Immediate threat to life of baby or mother. Decision to delivery 30 mins
2 - Urgent but not imminent due to compromise of baby or mother. Decision to delivery 75 mins
3 - Delivery required but both baby and mother stable
4 - Elective, Chilling init

201
Q

What is the most commonly used procedure

A

transverse lower uterine segment skin incision
- Pfannenstiel: Curved incision 2 fingers width above symphysis
- Joel-Cohen incision: Straight incision slightly higher (recommended)

Blunt dissection used after this to seperate remaining layers, using fingers, blunt instruments, traction. Results in less bleeding, shorter procedure, less risk to baby

202
Q

Complications of C sections

A

Usually very safe and routine.

Surgical
- Bleeding
- Infection
- Pain
- VTE
- Damage to local structures (ureter, bladder, bowel, vessels)
- Ileus, adhesions, hernias

Postpartum
- PPH
- Wound infection
- Wound dehiscence
- Endometritis

Future pregnancy, increased risk of:
- Repeat C section
- Uterine rupture
- Placenta praevia
- Stillbirth

203
Q

Contraindications to vaginal birth after c section

A

Normally 75% successful

  • Previous uterine rupture
  • Classical caesarean scar (vertical)
  • Other contraindications (previous)
204
Q

How is VTE prevented in C section

A
  • Early mobilisation
  • Anti-embolism stockings, intermittent pneumatic compression of legs
  • LMWH
205
Q

What are the types of instrumental delivery, and what are their indications, and whats given with them

A

Ventouse suction cup + Forceps

  • Failure to progress (maternal exhaustion)
  • Fetal distress
  • Prolonged second stage
  • Malposition
  • Head in various positions

Single dose co amoxiclav given to reduce risk of maternal infection post delivery

206
Q

Risks to baby in instrumental delivery

A

Ventouse - Cephalohaematoma (swelling on newborn head, usually parietal, doesnt cross suture lines, resolves over months)

Forcep
- Facial nerve palsy (face, ear, taste, tear)
- Face: expression muscles
- Ear: nerve to stapedius
- Taste: Anterior two-thirds of the tongue
- Tear: Parasympathetic fibres to lacrimal glands, aka salivary glands

207
Q

Risks to mother in instrumental delivery

A

PPH
Episiotomy (cut between vagina-anus)
Perineal tears
Anal sphincter injury
Incontinence of bladder/bowel
Obturator or femoral nerve injury

Obturator - weakness of hip adduction and rotation, numbness of medial thigh
Femoral - Weakness of knee extension, loss of patella reflex, numbness of anterior thigh and medial lower leg

208
Q

What indicates either of the 2 instrumentals

A

Ventouse - head must be partially engaged in birth canal. Works for a slightly abnormal position, as vacuum cup can sometimes rotate head.

Forcep - Preferred when rotation necessary (occiput anterior, or transverse positions)

Forcep preferred for:
- Complex rotations
- Narrow pelvic outlet
- Preterm child

209
Q

What is polyhydramnios

A

Excessive amount of amniotic fluid

Amniotic fluid index (AFI) >25cm

OR

Single deepest pocket >8cm

210
Q

Causes of polyhydramnios

A

Maternal
- DM, Multiple pregnancy

Fetal
- Congenital abnormalities (anencephaly, GI tract obstruction (oesophageal atresia), fetal anaemia, infections

Idiopathic half the time

211
Q

How does polyhydramnios present

A
  • Rapid uterine growth
  • Maternal discomfort
  • Dyspnoea
  • Abdo pain
  • Peripheral oedema
  • May have reduced fetal movement due to excess fluid
212
Q

Hows polyhydramnios investigated

A
  • USS (measure AFI or Single deepest pocket)
  • Consider detailed anatomy scan and screen for gestational diabetes
  • Doppler for fetal anaemia for some reason
213
Q

How is Polyhydramnios treated

A

Treat underlying cause + amnioreduction if extremely severe

214
Q

Complications of Polyhydramnios

A

Preterm labour, preterm prelabour rupture of membranes PPROM, Malpresentations, Umbilical cord prolapse, PPH, placental abruption

215
Q

What is vasa praevia

A

Where fetal blood vessels run across or near internal cervical os, unprotected by umbilical cord or placental tissue

Caused by velamentous cord insertion and succenturiate lobe.

Associated with low lying placenta and multiple pregnancy

216
Q

How does vasa praevia present

A

Asymptomatic until membrane rupture. If vessels rupture, may present with painless, sudden vaginal bleeding during labour.

217
Q

How is vasa praevia diagnosed

A

Routine USS with colour doppler, 18-20 weeks.

If low lying placenta or accessory lobes identified during routine anomaly scan, colour doppler used to detect vasa praevia

218
Q

How is vasa praevia managed

A

Plan for C section 35-36 weeks.

219
Q

Complications of vasa praevia

A

Severe fetal blood loss if rupture, leading to distress, hypoxia, death.

Rapid exsanguination is major risk! (Losing so much blood body cant function)

220
Q
A

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