Obstetrics Flashcards
What is pre-eclampsia
A new high blood pressure in pregnancy with evidence of end-organ dysfunction (notably proteinuria)
What evidence of end-organ dysfunction may be present in pre-eclampsia ?
Proteinuria
Severe headache
Visual disturbance
Papilloedema
Clonus
Liver tenderness
Abnormal liver enzymes
Low platelet count
RF for pre-eclampsia
Pre-existing hypertension
Previous pre-eclampsia
Multiple pregnancy
First pregnancy
Family history
Obesity
Diabetes
Older age
Autoimmune conditions
What syndrome can occur as a complication of pre-eclampsia
HELLP syndrome (stands for Haemolysis, Elevated, Liver enzymes, Low, Platelets)
What is term?
37 weeks to 42 weeks
What is polyhydramnios
an abnormally large level of amniotic fluid - a amniotic fluid index above the 95th centile for gestational age
How is amniotic fluid produced?
It predominately comes from fetal urine output - fetus breathes and swallows fluid, then voids it from the bladder
What is the latent phase of labour
Anything up to 4cm dilated
Can last 2-3 days
irregular contractions
Describe the first stage of labour
cervix dilates from 4 to 10 cm
Stronger uterine contractions
Describe the second stage of labour
from full dilation to the birth of the fetus
describe the third stage of labour
from birth of the fetus to the expulsion of the placenta
Causes of polyhydramnios
-idiopathic 50-60%
-conditions preventing foetus from swallowing (oesophageal atresia, CNS abnormalities ect)
- duodenal atresia
- anaemia
-fetal hydrops
- increased lung secretions
- genetic and chromosomal abnormalities
- infections
-gestational diabetes
How is polyhydramnios diagnosed
USS- measure amniotic fluid index or the maximum pool depth
What is the role of oxytocin in labour
it onsets the contractions of the uterus
what are the role of prostaglandins in labour
they aid with cervical ripening
what is the role of oestrogen in labour
It surges at the start of labour to inhibit progesterone
This prepares the smooth muscles for labour
What is the role of prolactin after labour?
begins the production of milk in the mammary glands
What is cervical effacement
The thinning of the cervix - also called cervical ripening.
Normally it is 4cm long however thins for labour
What is the most common pelvis type in females
the gynaecoid pelvis
Risks of polyhydramnios
Cord prolapse
Malpresentations (more room to move around)
Post partum haemorrhage
How is polyhydramnios treated?
usually no intervention
Amnioreduction- not routinely used
indomethacin - enhances water retention and reduces fetal urine output
What is oligohydramnios
a low level of amniotic fluid during pregnancy- less than the 5th centile for gestational age
causes of oligohydramnios
preterm rupture of the membranes
placental insufficiency
renal agenesis (potter’s syndrome)
non-functional fetal kidneys
genetic/chromosomal abnormalities
How is oligohydramnios diagnosed?
USS- amniotic fluid index less than 5th centile or maximum pool depth less than 2cm
If rupture of membranes can test for the presence of amniotic fluid in vagina (IGFBP-1 and PAMG-1)
Why is delayed cord clamping important
Increases red blood cells, iron and stem cells that enter the baby - can aid the development for up to 6 months
What is placental abruption?
separation of the placenta from the uterine wall before delivery of the fetus
RF for placental abruption
smoking, trauma, cocaine use, hypertensive disorders, polyhydramnios, abnormal lie
What are the two types of placental abruption?
overt (blood escapes through the vagina) and concealed (blood remains behind the placenta)
Presentation of placental abruption
vaginal bleeding
abdominal pain
uterine contractions
utnerine tenderness- woody tense uterus on examination
signs of shock
Why might the level of haemodynamic shock appear out of proportion with the bleed in placental abruption
if it is a concealed abruption the blood will mainly be hidden
What antidepressants can be used during breastfeeding
sertraline and paroxetine
What is a Bishop score?
A score used to assess whether induction is needed
If < 5 labour is unlikely to start without induction
If >8 the cervix is ripe and there is a high chance of spontaneous delivery
Management of gestational diabetes if fasting glucose is >7
insulin +/- metformin
How long postpartum can the COCP be started if breastfeeding?
after at least 6 weeks postpartum
At what gestation can external cephalic version be attempted?
36 weeks primiparous and 37 weeks multiparous
Can lamotrigine be taken when breastfeeding?
yes
When should a progesterone blood test be taken to confirm ovulation?
7 days before next period is due
How soon after giving birth can the progesterone only pill be started
Immediately- in breastfeeding and non breastfeeding
When should rhesus D negative women receive anti D
at 28 and 34 weeks
How long after giving birth do women need to start birth control>
after 21 days
What conditions are screened for on antenatal testing
anaemia
bacteruiria
blood group
downs syndrome
detal anomalies
hep B
HIV
First line drug for vomiting in pregnancy
Promethazine
How soon after childbirth can the contraceptive implant be put in
Immediately
What is the most common cause of cord prolapse
Artificial amniotomy (artificial rupture of membranes)
What medication can be given to suppress lactation
Cabergoline
At what gestation should the oral glucose tolerance test be done in women
24-28 weeks
Over what BMI should the OGTT be done for gestational diabetes
Over 30
When should patients with pre-eclampsia be admitted
If BP is greater than 160 over 110
What is HELLP syndrome
Haemolysis, elevated liver enzymes and low platelet
How does fibroid degeneration present in pregnancy
Low grade fever, pain and vomiting
What antibiotic should be given to women with pyrexia during labour as GBS prophylaxis?
benzylpenicillin
What is the initial treatment of gestational diabetes if fasting glucose is less than 7
trial of diet and exercise
What cut off of iron is used to determine if iron supplementation should be given in the first trimester
110
Can aspirin be taken while breastfeeding
no- must be avoided
What should be given as prophylaxis to reduce the risk of pre-eclampsia
low dose aspirin
First step after chickenpox exposure during pregnancy
check maternal varicella antibodies
List some potentially sensitising events which would require anti-D prophylaxis
ectopic pregnancy
vaginal bleeding <12 weeks if heavy and painful
vaginal bleeding >12 weeks
chorionic villus sampling and amniocentesis
antepartum haemorrhage
abdominal trauma
external cephalic version
intra-uterine death
post delivery
When is prophylactic anti-D given
to any previously non-sensitised rhesus negative women between 38 and 34 weeks.
Medical treatment of postpartum haemorrhage secondary to uterine atony
oxytocin, ergometrine, carboprost or misoprostol
What health condition is a contraindication to using carboprost in postpartum haemorrhage
asthma
2nd line investigation for reduced fetal movements after 28 weeks if Doppler shoes no heart beat
immediate transabdominal USS
What is given to women who are established as high risk for pre-eclampsia
daily aspirin from 12 weeks gestation
Rf for hyperemesis gravidarum
multiple pregnancy
trophoblastic disease
nulliparity
obesity
family history
what is protective against hyperemesis gravidarum
smokign
When would admission be recommended for hyperemesis gravidarum
- can’t keep down liquids or oral antiemetics
- ketonuria and/or weight loss greater than 5% of pre-pregnancy weight loss despite oral antiemetics
- a confirmed or suspected comorbidity
What can be used to calculate the severity of hyperemesis gravidarum
the pregnancy - unique quantification of emesis score (PUQE)
Triad of hyperemesis gravidarum
5% pre-pregnancy weight loss
dehydration
electrolyte imbalance
first line medications for hyperemesis gravidarum
antihistamines- oral cylclizine or promethazine
phenothiazines- oral prochlorperazine or chlorpromazine
second line medications for hyperemesis gravidarum
oral ondansetron or oral metoclopramide or domperidone
what is a risk of oral ondansetron if used in the first trimester?
cleft lip/palate
For how long should oral metoclopramide be used and why?
for a maximum of 5 days
extrapyramidal side effects
Complications of hyperemesis gravidarum
AKI, wernicke’s, oesophagitis, VTE
How does a threatened miscarriage present
painless vaginal bleeding and a closed cervical os
If a woman has a past history of VTE what prophylaxis should she be given during pregnancy and from when
low molecular weight heparin immediately until 6 weeks postnatal
When does the booking visit occur
8-12 weeks
When is the nuchal scan done
11-13+6 weeks
when is the anomaly scan
18-20+6 weeks
What placental problem is increased in those who undergo IVF
placenta praevia
What are the components of the quadruple test for downs syndrome
AFP
oestriol
hCG
inhibin A
what results on the quadruple test would suggest increased risk of downs syndrome
low AFP
low oestriol
increased hCG
increased inhibin A
What are the components of the combined test for downs syndrome
nuchal translucency on USS
PAPP-A
hCG
what results on the combined test would suggest increased risk of downs syndrome
high hCG ,
low PAPP-A
increased nuchal translucency
when is the combined test performed
10-13+6 weeks
Treatment of chickenpox in a pregnant women if they present within 24 hours of rash developing
oral aciclovir
What is the first line proceedure that can be done in post partum haemorrhage before medication
uterine massage
If two pills are missed between days 8-14 of the cycle is emergency contraception required?
no - as long as there have been at least 7 days of correct usage
Rf of shoulder dystocia
fetal macrosomnia
high maternal BMI
diabetes mellitus
prolonged labour
What manoeuvre is used for shoulder dystocia
the McRoberts’ manoeuvre
what can be a neonatal complication of shoulder dystocia
brachial plexus injury- Erb’s palsy
What is sheehan’s syndrome
postpartum hypopituitarism
Occurs due to ischaemic necrosis of the pituitary gland due to hypovolaemic shock following birth
How quickly do category 2 caesareans need to occur?
within 75 mins
What antibiotic is used as GBS prophylaxis
benzylpenicillin
what haemoglobin level should be used as a cut off for iron supplementation in the postpartum period
100
first line surgical intervention for post partum ahemorrhage
intrauterine balloon tamponade
RF for ectopic pregnancy
previous ectopic
previous pelvic inflammatory disease
previous surgery of the fallopian tube
IUD/IUS
older age (>35)
smoking
IVF
Where might an ectopic pregnancy implant, and where is most common?
fallopian tube (most common)
ovary
cervix
abdomen
How does an ectopic pregnancy present
missed period
constant lower abdominal pain in right or left iliac fossa
vaginal bleeding
lower abdominal tenderness or pelvic tenderness
cervical motion tenderness
shoulder tip pain (if blood enters peritoneal cavity and irritates diaphragm)
At what gestation does an ectopic pregnancy typically present?
6-8 weeks
How is an ectopic pregnancy diagnosed?
hCG
Transvaginal USS
findings on transvaginal USS for ectopic pregnancy (4 signs that may be seen)
- gestational sac containing fetal pole or yolk sac in the fallopian tube
- adnexal mass moving separately from the ovary (sliding sign)
- non-specific mass in the tube (blob sign, bagel sign)
- empty uterus
How can the location of a pregnancy of unknown location be determiend
by following hCG levels
- an increase by 63% in 48 hours suggest intrauterine
- an increase of less than 63% indicates ectopic
- a decrease of more than 50% indicate misscarriage
What is a pregnancy of unknown location
when a woman has a positive pregnancy test but no evidence of pregnancy on USS
When would expectant management be used for ectopic pregnancies?
- if unruptured
- no visible heart rate
- asymptomatic
- hCG less than 1000
- adnexal mass less than 35mm
How is expectant management of an ectopic pregnancy monitored
Repeat hCG testing is performed on day 2,4 and 7.
If there is a continuous drop by at least 15% from the previous reading expectant management can be continued
what does medical management of an ectopic pregnancy consist of?
methotrexate
When can medical management of an ectopic pregnancy be used?
less than 35mm
unruptured
not in significant pain
no fetal HR
hCG less than 1500
When should surgical management of an ectopic pregnancy be used?
serum hCG 5000 or higher
adnexal mass greater than 35mm
foetal heartbeat is visible
patient is in significant pain
patient is haemodynamically unstable
what is the preferred surgical management of ectopic pregnancy?
salpinectomy (removal of tube)
What is the surgical management of ectopic pregnancy if there is damage to the other fallopian tube (e.g. PID, previous ectopic)
salpingotomy
What is a complication of salpingotomy and how is it monitored
retainment of products- serial serum hCG measurements taken
Explain cord prolapse
when the umbilical cord descends below the presenting part of the fetus, through the cervix and into the vagina
RF for cord prolapse
breech position
unstable lie
artificial rupture of the membranes
polyhydramnios
prematurity
long umbilical cord
multiple pregnancy
multiparity
What is the main risk factor for cord prolapse and why?
abnormal fetal lie (not cephalic)
this allows space for the umbilical cord to prolapse below the presenting part- something not possible in normal cephalic lie
Consequence of cord prolapse to the fetus
the presenting part compresses the cord leading to fetal hypoxia
additionally the cold atmosphere that the cord is exposed to leads to umbilical artery vasospasm
what percentage of cord prolapses occur after artificial rupture of the membranes
50%
when should cord prolapse be considered
when there is a non-reassuring fetal heart rate pattern and absent membranes
How is cord prolapse managed
- manually elevate the presenting part by lifting it off the cord by vaginal digital examination
- catheterise the bladder and insert 500ml of saline
- encourage patient into the left lateral position or the knee chest position (all fours)
- emergency caesarean
If delivery is not immediately available, what can be given to delay in cord prolapsy
tocolysis (e.g. terbutaline)- relaxes the uterus and stops contractions
What is placental abruption
separation of the placenta from the uterine wall before delivery
RF for placental abruption
smoking
cocaine use
trauma
hypertensive disorders
polyhydramnios
abnormal lie of the baby
Two types of placental abruption
overt (where the blood escapes through the vagina)
concealed (where the bleeding occurs behind the placenta )
Presentation of placental abruption
vaginal bleeding- painful
uterine contractions
woody tense uterus
How might shock associated with placental abruption present?
out of proportion from the bleeding (if concealed)
What is placental praevia
Where the placenta is fully or partially attached to the lower uterine segment - a placenta that is covering the os or within 2cm of it
RF of placental praevia
high parity
previous caesarean
maternal age >40
multiple pregnancy
history of uterine infection
curettage to the endometrium after miscarriage or termination
What is the different between minor and major placenta praevia
minor placental praevia does not cover the internal os whereas major does
How does placental praevia present
painless vaginal bleeding
If minor placenta praevia is identified at 20 weeks when should the scan be repeated
36 weeks- will have likely moved superiorly
if major placental praevia is located at 20 weeks when should the scan be repeated
32 weeks
What is uterine rupture
full thickness disruption of the uterine msucle and overlying serosa - typically occurs during labour
RF for uterine rupture
previous caesarean, previous uterine surgery, induction, obstruction of labour, multiple pregnancy, multiparity
What is a side effect of magnesium suphate that needs to be monitored
respiratroy rate- can cause respiratory depression
Also should monitor reflexes
What medication can be given to suppress lactation
cabergoline- a dopamine receptor agonist
How is a suspected PE in a pregnant women with a confirmed DVT managed
immediate low molecular weight heparin - investigate aftet
How soon after an abnormal semem sample should a repeat be taken?
3 months
Can lithium be used during breastfeeding?
no
What is lochia
the passage of blood, mucus and uterine tissue that occurs postpartum
When should lochia be investigated
if continued after 6 weeks
For what conditions are pregnant women screened for at their first booking appointment
HIV, syphilis and hepatitis B
If not breast feeding how soon after birth can the COCP be started?
21 days
What medication should patients with autoimmune conditions such as SLE and anti-phospholipid syndrome take during pregnancy
low dose aspirin from 12 weeks as high risk of pre-eclampsia
What is complication of IVF
ovarian hyperstimulation syndrome
How does ovarian hyperstimulation syndrome present?
lower abdominal pain
nausea and vomiting
abdo distention
ascites
hypotension
in severe scenarios = respiratory distress
Define primary post partum haemorrhage
loss of more than 500ml of blood from the genital tract within 24 hours of birth of the baby
What is primary post partum haemorrhage
haemorrhage within the first 24 hours after birth
what is secondary post partum haemorrhage
haemorrhage occuring if after 24 hours of birth to 12 weeks
Most common cause of secondary post-partum haemorrhage
endometritis
retained placental fragments
The 4 T’s of primary post partum haemorrhage
Tone- uterine atony
Trauma- perineal tear (RF= instrumental delivery, episiotomy, c-section)
Tissue- retained placenta
Thrombin - bleeding or clotting disorder
RF for post partum haemorrhage
- previous PPH
- prolonged labour
- pre-eclampsia
- increased maternal age
- polyhydramnia
- emergency caesarean
- instrumental delivery
- placental praevia and accreta
macrosomnia
What is uterine atony
where the uterus fails to contract adequately following labour
Management of postpartum haemorrhage when due to uterine atony
- uterine massage- bimanual compression to stimulate contraction
- uterotonics- medications to stimulate contraction (e.g syntocinon, carboprosy, ergometrine , misoprostol)
- surgical intervention- intrauterine balloon tamponade
Potential surgical management of post partum haemorrhage
intrauterine balloon tamponade
B-lynch suture
uterine artery ligation
hysterectomy
Investigations for secondary post partum haemorrhage
ultrasound scan
endocervical and high vaginal swabs
How can major post partum haemorrhage be prevented
- treat anaemia during pregnancy before delivery
- active management of the third stage using oxytocin IM)
- IV tranexamic acid during caesaran
Define major PPH
over 1000 ml of blood loss
mechanism of action of carboprost
prostaglandin analogue
what is vasa praevia
a condition where the fetal vessels are within the fetal membranes and travel across the internal cervical os
RF for vasa praevia
low lying placenta
IVF pregnancy
multiple pregnancy
Pathophysiology of vasa praevia
normally vessels run in umbilical cord which inserts directly into the placenta (so they are not exposed).
In vasa praevia either:
- the umbilicus inserts into the chorioamniotic membrenas and the vessels travel unprotected through the membranes to the placenta
or
- there is an accessory (succenturiate lobe) of the placenta and the vessels travel in the chorioamniotic membranes between the lobes
type 1 vasa praevia
also called a velamentous umbilical cord
- the umbilicus does not directly enter the placenta, instead it inserts into the chorioamniotic membranes and the foetal vessels run through these to the placenta
what is type 2 vasa praevia
there is an accessory (succenturiate) lobe of the placenta and the vessels travel in the chorioamniotic membranes between these lobes
How does vasa praevia present
typically presents as painless vaginal bleeding after rupture of the membranes
foetal bradycardia may also be present
management of vasa praevia
elective caesarean prior to rupture of the membranes- around 35 to 36 weeks
HOw does vasa praevia and placenta praevia differ
both have painless vaginal bleeding however placenta praevia wont happen with rupture of the membranes and will not have foetal bradycardia
when should women be admitted for pre-eclampsia
when BP >160/110
what drug is given to reverse magnesium sulphate induced respiratory depression
calcium gluconate
what hormone increase the chance of breast cancer
progesterone
How will a foetus present in placenta praevia
normally- should not have decelerations
What is a normal fetal HR
110-140
Can cooked liver be eaten in pregnancy and why?
no due to high levels of vitamin A
What investigation is used to explore suspected placenta praevia
transvaginal USS
what screening tool is used for postnatal depression
The Edinburgh scale
give an example of a tocolytic drug which can be given to delay labour
terbutaline
How long after a medical treatment of a miscarriage should a pregnancy test be performed
3 weeks
If a women is presenting with hypertension before 20 weeks gestation what is the liekly diagnosis
pre-existing hypertension (pregnancy related problems do not occur before 20 weeks)
how does an amniotic fluid embolism present
mainly occurs in labour
cyanosis, hypotension, chills, arrythmia, MI
What is the most common complication of termination of pregnancy?
infection - can happen in up to 10% of cases
indications for CAT 1
uterine rupture
placenta abruption
cord prolapse
fetal hypoxia
persistent foetal bradycardia
Treatment of women with PPROM
10 days erythromycin
risk of obstetric cholestasis
stillbirth
first line medical management of uterine atony
IV oxytocin
for how long does folic acid need to be taken in pregnancy
until the end of the first trimester
If a mother has had a previous child with early or late onset GBS disease what additional measures are needed in subsequent pregnancies?
intrapartum antibiotics
What conditions are included in gestational trophoblastic disorders
complete hydatidiform mole
partial hydatidiform mole
choriocarcinoma
what is a hydatidiform molr
a type of tumour that grows like a pregnancy in the uterus
What is a complete hydatidiform mole
Occurs when two sperm fertilise an ovum that contains no genetic material (an empty ovum). The sperm combine to create genetic material that begins to divide.
There will be no fetal material
what is an incomplete hydatidiform mole
occurs when two sperm fertilise an normal ovum containing some genetic material.
Creates a cell with three sets of genetic material which will dive and form some fetal parts
How does a hydatidiform mole present?
bleeding in the first or early second trimester
exaggerated symptoms of pregnancy- e.g. severe morning sickness
Enlarged uterus for dates
hypertension and hyperthyroidism
What will blood show in a molar pregnancy
very high serum hCG
Why can hyperthyroidism occur in molar pregnancy
hCG can mimic TSH leading to high T3 and T4
How is a molar pregnancy diagnosed?
very high serum hCG (often >100,000)
USS- shows snowstorm appearance
Diagnosis is confirmed on histological examination of the placenta
1st line treatment of molar pregnancy
suction evacuation of the uterus
What should women who have had a molar pregnancy be recommmended
contraception should be used for the next 12 months
Overview of treatment of a molar pregnancy
suction evacuation
contraception for 12 months
anti-D prophylaxis if rhesus negative
may need beta blockers +/- carbimazole for hyperthyroidism
may need antihypertensives for pre-eclampsia
Define miscarriage
spontaneous termination of a pregnancy before 24 weeks
what is the time frame of an early miscarriage
before 12 weeks
what is the timeframe of a late miscarriage
12 to 24 weeks
What is a missed miscarriage
the fetus is not alive but no symptoms have occured
what is a threatened miscarriage
vaginal bleeding with a closed cervix
what is a inevitable miscarriage
vaginal bleeding with an open cervix
what is an incomplete miscarriage
it is when a miscarriage has occured but there are remaining products of conception in the uterus
RF for miscarriage
advanced maternal age
previous miscarriage
previous large cervical cone biopsy
lifestyle factors (smoking, alcohol, obesity)
medical conditions (uncontrolled diabetes, thyroid problems)
How is a miscarriage diagnosed?
transvaginal USS
what 3 feature are looked at on an USS to determine miscarriage
mean gestational sac diameter
fetal pole and crown rump length
fetal heartbeat
At what crown rump length would you expect to see a fetal heartbeat
7mm
if a heartbeat is not present on USS but the fetal crown rump length is less than 7mm, what is the next action?
the USS should be repeated in a week
At what gestational sac diameter should a fetal pole be seen
25mm
What is the first line treatment of a miscarriage?
expectant management
describe expectant management of a miscarriage
7-14 days are allowed to see if the miscarriage spontanteously passes
this is confirmed on a urinary pregnancy test
When should expectant management be avoided in management of a miscarriage
when there is increased risk of bleeding- woman is late in first trimester, woman has a bleeding abnormality
When there is evidence of infection
When there is previous adverse/traumatic experiences with pregnancy
What is medical management of a miscarriage
misoprostol
what is medical management of a missed miscarriage
200mg mifepristone then 800mcg of misoprostol
how long after medical management of a miscarriage should a pregnancy test be done
3 weeks
What is surgical management of a miscarriage?
manual vacuum aspiration or electric vacuum aspiration
describe manual vacuum evacuation of a pregnancy q
local anaesthetic is used
a tube with a syringe attached is insterted into the uterus and the contents are aspirated
before what gestation can manual vacuum evacuation be done
before 10 weeks
what medication needs to be given to some women in surgical treatment of a miscarriage
anti-D prophylaxis
causes of recurrent miscarriage
anti-phospholipid syndrome
poorly controlled diabetes and thyroid disorders
PCOS
uterine abnormality - e.g. a uterine septum , large fibroids, bicornuate uterus
paternal chromosomal antibodies
smoking
cervical incompetence
what type of antibiotic is contradinicated in pregnancy (give some examples)
tetracyclines (doxycycline and lymecycline
what antiemetic can cause extrapyramidal side effects?
metoclopramide
before which gestation can termination of a pregnancy be done in the UK
24 weeks
what indications are legally required for abortion
- before 24 weeks
- continuation of the pregnancy would involve risk greater than if the pregnancy were terminated, or injury to the physical or mental health of the pregnant women or any existing child in their family
- the termination is necessary to prevent grave permanent injury to the physical and mental health of the pregnant women
- there is a substantial risk that if born the child would suffer from physical or mental abnormalities as to be seriously handicapped
what medications are take in medical abortion
mifepristone then 48 hours later misoprostol
before what gestation can medical management of an abortion be done at home
10 weeks
how soon after medical management of an abortion should hCG be checked
2 weeks after
what three surgical options are there for surgical abortion?
manual vacuum aspiration
electric vacuum aspiration
dilation and evacuation
how soon after an abortion can an IUD be inserted
immediately
indications for instrumental delivery
split into maternal and foetal factors
Maternal:
- inadequate progress (nulliparous should have delivery within 2 hours of pushing, multiparous should have delivery within 1 hour of pushing)
- maternal exhaustion
- maternal conditions where active pushing or prolonged exertion should be avoided (e.g. CHF)
Fetal:
- suspective fetal compromise as seen on CTG or abnormal fetal blood sample
- clincial concern such a antepartum haemorrhage
what prerequisites are required for instrumental delivery
fully dilated
ruptured membranes
cephalic presentation
defined fetal position
fetal head at least level with ischial spines
empty bladder
adequate pain relief
absolute contraindications for an instrumental delivery
-unengaged head of a singleton
-incompletely dilated cervix
-true cephalo-pelvic disproportion
- breech or face presentation
-preterm gestation of less than 34 weeks (for ventouse)
-High likelihood of fetal coagulation disorder (for ventouse)
what two methods of instrumental delivery are there?
ventouse
forceps
RF for anaemia in pregnancy
vegetarian
previous anaemia
carrying more than one baby
younger than 20
had 3 or more babies
having a second baby within a year
why is there physiological anaemia during pregnancy?
plasma volume increases with pregnancy which leads to a decrease in haemoglobin concentration
Why is it important that anaemia is treated in pregnancy?
to ensure there is a reasonable reserve if significant blood loss during delivery
When is anaemia checked in pregnancy
at booking appointment
at 28 weeks gestation
What should haemoglobin be at booking>
> 110
what should haemoglobin be at 28 weeks
> 105
What should haemoglobin be post partum
> 100
Management of iron deficiency in pregnant women
ferrous sulphate 200mg
complications of chlamydia in pregnancy
premature delivery
amnionitis
puerperal infection
Neonatal conjunctivits and pneumonia
how is chlamydia treated during pregnancy
erythromycin 500mg 4 times daily for 7 days
explain how ventouse delivery works
An instrument with a cup on the end is attached to the fetal head via a vacuum.
It is applied with its centre over the flexion point of the fetal skull and during contractions traction is applied to the cup
What types of ventouse are there?
electric pump attached to a silastic cup (only used in occipital-anterior position)
hand-held disposable devise called a kiwi (all positions)
RF for VTEs during pregnancy - when should treatment be started?
if 3 RF start prophylaxis at 28 weeks.
If 4 or more start prophylaxis in first trimester.
smoking
parity >3
ange >35
BMI >30
reduced mobility
multiple pregnancy
gross varicose veins
immobility
family history of VTE
thrombophilia
IVF
1st line investigation of a DVT
doppler USS
Gold standard investigation for a PE
CTPA
Why is D dimer not used in pregnancy
d dimer isnt helpful as it already elevates in fetus
What prophylaxis is given for DVT if recommended
low molecular weight heparin
for how long is LMWH continued after delivery
6 weeks
Is LMWH taken during labour
no it is temporarily stopped but then started immediately after
What are risk factors for placenta praevia
twin/multiple pregnancy
women with high parity
older women
scarred uterus (previous caesarean)
define antepartum haemorrhage
bleeding from the genital tract after 24 weeks gestation
what investigations would you do after
USS
FBC
clotting studies
group and save/ cross mathc
cardiotocography
RF for placental abruption
intrauterine growth restriction
previous abruption
maternal smoking
pre-eclampsia
hypertension
multiple pregnancy
what will clotting studies show after placental abruption
afibrinogenaemia- placental damage leads to release of thromboplastin into the circulation.
This causes disseminated intravascular coagulation and subsequent usage of blotting factors
what is vasa praevia
foetal blood vessels running in front of the placental part
at what gestation can you usually feel the uterus
12 weeks
what bloods are typically one at booking
haemoglobin or FBC
blood group and rhesus status
rubella immunity
syphillis serology
blood glucose level
HIV test
hepatitis B test
haemoglobin electophoresis for sickle cell
aside from downs syndrome what can cause raised nuchel thickness
cardiac abnormalities
results of triple test suggestive of downs syndrome
low AFP
low oestriol
raised hCG
what is fetal position
the positon of the head as it exits the birth canal
usually in occipito-anterior position, can also be occipito posterior and occipito transverse
what is the fetal presentation
the first part that enters the maternal pelvis (can be cephalic, breech, brow, shoulder)
What is the fetal lie
the relationship between the long axis of the fetus and the mother- can be longitudinal or breech
RF for breech presentation
prematurity
multiple pregnancy
uterine abnormality
placenta praevia
polyhydramnios
primiparity
When can external cephalic version be attempted
36 weeks for nulliparous, 37 weeks for multiparous
RF of ECV
platernal abruption
fetal distress
premature rupture of membranes
what different types of breech presentations are there
frank breech
footling breech
complete breech
management of breech presentation if ECV is unsuccessful
usually caesarean section-
absolute contraindications of external cephalic version
antepartum haemorrhage has occurred within the last 7 days
non-reassuring cardiotocograph
major uterine abnormality,
placental abruption or placental praevia
membranes have ruptured
multiple pregnancy
relative contraindications for ECV
intrauterine growth restriction with abnormal umbilical artery doppler
pre-eclampsia
maternal obesity
oligohydramnios
major foetal abnormalities
uterine scarring from previous caesarean section or myomectomy
what causes premature labour
not completely understood:
- uterine overdistention (twins, triplets, polyhydramnios )
- decidual haemorrhage
- cervical insufficiency (premature cervical ripening)
- infection and inflammation (present in 25-40%, ascending route or haematogenous, may be iatrogenic)
RF for premature labour
previous pre-term birth
multiple pregnancy
previous cervical surgery
uterine abnormalities
smoking
age
bacterial vaginosis
short cervix
primary prevention of premature labour
stopping smoking
avoiding multiple pregnancies (IVF)
Secondary prevention of premature labour
Cervical cerclage (a suture is placed to prevent dilation of the cervix)
Progesterone pessary
Tertiary prevention of premature labour
tocolysis (nifedipine)
antenatal corticosteroids
complications of preterm labour
sepsis
respiratory distress
nectotising eneterocolitis
vision and hearing abnormalities
cerebral palsy
What defines pre-term labour
the onset of regular uterine contractions and cervical changes before 37 weeks gestation
How can premature labour be confirmed
foetal fibronectin test (fFN test)
maternal risks of obesity in pregnancy
miscarriage
VTW
gestational diabetes mellitus
pre-eclampsia
dysfunctional labour
induced labour
postpartum haemorrhage
wound infection
fetal complications of obesity in labour
macrosomnia
prematurity
congenital anomalies
stillbirth
increased risk of metabolic disorders during childhood
neonatal death
management of pregnancy of women with BMI >35 (6)
consultant led care
may need serial growth scans as measurements are less likely to be accurate
5mg of folic acid rather than 400mcg
oral glucose tolerance test at 24-48 weeks
VTE assessment before and after birth
intrapartum antibiotics in caesareans due to increased risk of infection
RF for gestational diabetes
previous gestational diabetes
family history of gestational diabetes in first degree relative
previous macrosomnic baby
obesity >30
family origin with high diabetes prevalence
PCOS
maternal age >40
complications of gestational diabetes
fetal macrosomnia (>4kg)
shoulder dystocia
perinatal mortality
neonatal hypoglycaemia
what test is done at 24-28 weeks for gestational diabetes
oral glucose tolerance test (75g of glucose given and then blood glucose is measured 2 hours later)
what results of the OGTT and fasting blood glucose suggest gestational diabetes
fasting >5.6
2 hour >7.8
if a women has previously had gestational diabetes when should they be tested?
OGTT as soon as possible at booking, and then again at 24-28 weeks
first line treatment of gestational diabetes if fasting glucose <7
trial of diet and exercise
first line treatment of gestational diabetes if fasting glucose >7
insulin
how long should diet and exercsie changes be tried before starting further treatment for gestational diabets
1-2 weeks
management of gestational diabetes <7 where diet and exercise has failed
metformin
what should the fasting glucose target be in gestational diabetes
<5.3
what should the 1 hour post meal glucose target be in gestational diabetes
<7.8
what should the 2 hour post meal glucose target be in gestational diabetes
<6.4
what medication can be given to improve the success rate of external cephalic version
terbutaline- relaxes the uterine muscles
what is the management of molar pregnancies
suction curettage
in twin to twin tranfusion what is the risk to the recipient twin
hydrops fetalis and heart failure due to fluid overload
first line investigation when chorioamnionitis is suspected?
blood cultures
first line management of post partum haemorrhage if woman is hypovolaemic and shocked
insert large bore IV cannulae
group and save
cross match
coagulation studies
fluid resuscitation
what medication is routinely given to all women before caesarean
omeprazole
What classifies a baby as being small for gestational age?
below the 10th centile for gestational age
What two types of small for gestational age babies are there?
constitutionally small - those whose size is in keeping with the maternal and family size
Fetal growth restriction - small fetus due to pathology
What 2 types of fetal growth restriction are there?
placenta mediated and non-placenta mediated growth restriction
List some placenta mediated causes of fetal growth restriction
idiopathic
pre-eclampsia
maternal smoking
maternal alcohol
anaemia
malnutrition
infection
maternal health conditions
list some non-placenta-mediated causes of growth restriction
genetic abnormalities
structural abnormalities
fetal infections
errors of metabolism
What are some minor risk factors for fetal growth restriction
maternal age >35
smoker of 1-10 a day
nulliparity
BMI <20 or 25-34.9
IVF singleton
previous pre-eclampsia
pregnancy interval or <6 months of >60 months
low fruit intake during pregnancy
List some major risk factors for fetal growth restriction
maternal age >40
smoker >11/day
previous small for gestational age baby
maternal/paternal SGA
previous stillbirth
cocaine use
daily vigorous exercise
maternal disease
heavy bleeding
low PAPPA
what is the management of those at risk of fetal growth restriction
if low risk=
- monitoring with symphysis fundal height at every antenatal appointment from 24 weeks
- if SFH is found to be below 10th centile then book in for serial growth scans with umbilical artery doppler
If high risk =
- serial growth scans every 4 weeks
what are some short and long term complications of fetal growth restriction
short- stillbirth, birth asphyxia, neonatal hypothermia, neonatal hypoglycaemia
long- cardiovascular disease, T2DM, obesity, mood and behaviour problems
What is looked for on scans for fetal growth restriction
- estimated fetal weight and abdominal circumference
- umbilical artery pulsatility index
- amniotic fluid volume
If a women is diagnosed with fetal growth restriction what additional testing might be done?
- blood pressure and urine dipstick for pre-eclampsia
- uterine artery doppler scanning
- detailed fetal anomaly scan
- karyotyping
- testing for infections
If a pregnant women is symptomatic for a UTI how should it be managed?
- urine culture should always be sent
- 7 days antibiotic
first line is nitrifuratoin (except in third trimester)
second line is amoxicillin or cefalexin
How is asymptomatic bacteriuria managed in pregnant women?
immediate antibiotic prescription of either nitrofuratoin, amoxicillin or cefalexin
A urine culture should be sent after to test for cure
what is the risk of GBS infection in subsequent pregnancies?
50%
Who should be offered intrapartum antibiotic prophylaxis?
- women who have had previous GBS infection in pregnancy
- women who have had a baby with early or late onset GBS disease
- all women in preterm labour
- women with pyrexia during labour
what antibiotic is used as intrapartum prophylaxis for GBS
benzylpenicillin
what are some risk factors for GBS infection?
prematurity
prolonged rupture of the membranes
previous sibling with GBS
maternal pyrexia
how is gonorrhoea treated in pregnancy
a single dose of ceftriaxone (Same as in non-pregnant)
describe caput succedaneum
oedema of the scalp of the presenting part of the head in the baby
Crosses suture lines
Usually settles after a few days.
May be due to trauma of prolonged delivery or ventouse
describe cephalohaematoma
swelling of the newborns head several hours after delivery due to bleeding between the periosteum and skull
Most commonly in the parietal region and does not cross suture lines
can take 3 months to resolve
what might a baby with cephalohaematoma develop?
jaundice due to bruising
from what gestation would someone at risk start aspirin?
from 12 weeks gestation
aside from folic acid what should all pregnant women take?
vitamin A
what cut off of haemoglobin is used in the first and second trimester ?
110 in first
105 in second
