Obstetrics Flashcards

1
Q

Physiological changes in pregnancy

A

See notes

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2
Q

Ectopic pregnancy

A

Implantation of fertilised ovum outside uterine cavity

Commonly - ampulla, isthmus of fallopian tube

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3
Q

Ectopic RFs

A

Tube damage - PID, surgery
Previous ectopic
endometriosis
IUS/D
POP
IVF

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4
Q

Ectopic Px

A
  • Lower abdo pain
  • 6-8wks amenorrhoea
  • PV bleed later
  • Brown PV discharge
  • Pregnancy sx - breast tenderness
  • Cervical motion tenderness
  • adnexal mass maybe - don’t examine for - risk of rupture
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5
Q

Ectopic DDx

A

Miscarriage, ovarian cyst, PID, UTI, abdo ddx

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6
Q

Ectopic Ix

A

urine pregnancy test

Urinalysis - eg UTI - r/o DDx

Pelvic USS - ?intrauterine pregnancy

TVUS - if nothing seen on pelvic

No pregnancy on US + pregnancy test +ve = pregnancy unknown location -> take serum bHCG
- if bhCG >1500 - ectopic until proven otherwise
- bhCG <1500 - rpt in 48hrs (doubles if viable, halves if miscarriage)

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7
Q

Ectopic Mx

A

If Rh-, give anti-D

Medical
<35mm, unruptured, no pain, no heartbeat, hCG <1500
- IM methotrexate
Contraception for 3-6mo after as methotrexate teratogenic
Follow up required

Surgical
>35mm, may be ruptured, pain, heartbeat, hCG>5000
- Salpingectomy - if no infertility RFs
- Salpingotomy - if contralateral tube damaged

Conservative
Not 1st line
Stable pts, rupture unlikely, no pain, low bHCG, <35mm
Monitor bHCG to ensure fall

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8
Q

Miscarriage

A

Loss of pregnancy <24wks gestation

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9
Q

Miscarriage RFs

A

> 30-35yo
Previous miscarriage
Obesity
smoking
chromosomal abnormalities, uterine abnormalities
aPL syndrome
coagulopathies

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10
Q

Miscarriage types

A

Threatened
PV bleed, ?painless, os closed, viable

Inevitable
heavy bleed + clots + pain, os opened, non/viable, likely to progress to incomplete

Incomplete
not all POC expelled, pain, PV bleed, OS open, expectant / medical / surgical mx

complete
Hx of bleed, passing clots, pain, now settled, no POC in uterus + proof of prev pregnancy (eg scan), os closed

missed
gestational sac contains dead fetus, no expulsion, light PV bleed / discharge, os closed, no fetal heartbeat on USS

Septic
infected POC, fever, rigors, cervical motion tenderness, discharge/pain, increased WCC/CRP, features of in/complete
medical/surgical mx, IV abx, fluids

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11
Q

Miscarriage Px

A

PV bleed +/- clots, POC
Haemodynamically unstable
Tender abdo / pain / cramp
POC in cervical canal
Uterine tenderness / adnexal masses

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12
Q

Miscarriage Ix

A

Urine pregnancy test -> see in EPAU

Bloods - maybe serial serum bHCG (drop if miscarriage, rise if ectopic)
FBC, G+S, rhesus, triple swabs + CRP if fever

TVUS
Measure crown rump length (CRL) - estimate gestation
- <7mm, no fetal heart - rpt scan 7d, then confirm dx if no change
- >7mm + no HB - 2nd opinion before dx

Measure mean sac diameter - if growing alone -> anembryonic pregnancy
- <25mm + no fetal pole - 2nd scan 7d before dx
- >25mm + no fetal pole - 2nd opinion then dx

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13
Q

Miscarriage Mx

A

Anti-D if needed

Preventing miscarriage
- R/o ectopic
- vaginal pessary progesterone, take until 16wks
- only if PV bleed, threatened miscarriage + hx of miscarriage

Conservative / expectant
- POC pass naturally, remain at home, but unpredictable
- Rpt scan 2wks, pregnancy test 3wks
- Not if heavy bleed / tissue >50mm
- Medical / surgical after 2wks if no change

Medical
- Vaginal misoprostol (prostaglandin E) - stimulate cervical ripening + myometrial contractions - 2nd dose if not passed by 48hrs
- can be at home if <9wks, <40mm
- pregnancy test 3wks, further dose if still +ve

Surgical
- <12wks, manual vacuum aspiration - LA
- Evacuation of retained products of conception (ERPC) - GA - blind suction, risk of uterine perf
- give misoprostol before (soften cervix)
- for unstable pts, infected tissue, molar pregnancy

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14
Q

Recurrent miscarriage

A

> 3 consecutive miscarriages

Causes
aPL syndrome, DM, thyroid, PCOS, uterine abnormalities, cervical weakness, chromosome abnormalities, smoking, infections, thrombophilias

Ix
aPL ABs, thrombophilia screen
Karyotyping
Pelvic USS - anatomy

Mx
Tx cause
Refer to recurrent miscarriage clinic / geneticist

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15
Q

Termination of pregnancy (TOP)

A

Elective end to pregnancy

2 registered medical practitioners must agree, <24wks gestation, carry out in NHS approved premise

Can perform at any time during pregnancy if:
- woman’s life at risk
- prevents grave injury to physical / mental health of woman
- substantial risk child would suffer physical / mental abnormalities

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16
Q

TOP Mx

A

Medical
Mifepristone - antiprogesterone, halts pregnancy
Misoprostol - prostaglandin, softens cervix, stimulates contraction

Surgical
- Under LA / GA
- Dilate cervix, suction if <14wks, forceps evacuation if 14-24wks

Post-abortion
Urine pregnancy test 3wks after to confirm complete

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17
Q

Hyperemesis gravidarum (HG)

A

Persistent severe vomiting during pregnancy

Starts wk4-7, settle by 20wks, from increase in bHCG

leads to >5% pre-pregnancy wt loss, dehydration, electrolyte imbalances

RFs
First pregnancy, previous HG, raised BMI, multiple pregnancy, molar pregnancy (raised beta-hCG)

Smoking associated with decreased risk

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18
Q

HG Ix / assessment

A

Triad of 5% pre-pregnancy weight loss, dehydration, electrolyte imbalace is reccomended for diagnosis of HG

H/E - dehydration sx

PUQE score for severity

Measure weight

Urine dip - 1+ ketones, MSU sample

Bloods - FBC, U/E, LFT, amylase, TFTs, ABG

USS fetus - doppler

Referral criteria:

Continued N+V and is unable to keep down liquids or oral antiemetics

Continued N+V with ketonuria and/or weight loss (greater than 5% body weight), despite treatment with oral antiemetics

A confirmed or suspected comorbidity

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19
Q

HG Mx

A

Oral fluids, diet advice, oral antiemetics

Admit if severe - IV fluids, IV antiemetics, thiamine, KCl if needed

1st line - cyclizine, prochlorperazine, promethazine, chlorpromazine

2nd line - metoclopramide (5d max - EPSEs), domperidone, ondansetron (1st trim cleft lip/palate risk)

3rd line - IV hydrocortisone, PO prednisolone

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20
Q

Molar pregnancy

A

pregnancy related tumours (premalignant) from placental trophoblast

includes complete hydatidiform mole, partial hydatidiform mole, choriocarcinoma

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21
Q

Complete hydatidiform mole

A

Benign tumour of trophoblastic material - empty egg fertilised by single sperm, then duplicates itself

Px
- bleeding in 1/2nd trim
- exaggerated sx of pregnancy - eg HG
- uterus large for dates
- high serum bHCG
- HTN, hyperthyroid (hCG mimics TSH)

Ix
USS - snowstorm appearance

Mx
surgical evacuation
contraception - avoid pregnancy for 12mo

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22
Q

Partial hydatidiform mole

A

Normal egg fertilised by 2 sperms, or one sperm with duplicate chromosomes

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23
Q

Choriocarcinoma

A

Cancer of trophoblastic cells of placenta

Mets to lungs

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24
Q

Antenatal care timetable

A
  • 10 visits in 1st pregnancy, 7 visits later on
  • 1st trim start ->12wks
  • 2nd trim 13->26wks
  • 3rd trim 27->term
  • Whooping cough vaccine >16wks, flu when available

<10wks - booking, baseline assessment, plan pregnancy
10-14wks - Dating scan - CRL, multiple pregnancy
11-14wks - Down’s screening (increased nuchal thickness, increased bHCG, low PAPPA)
16wks - antenatal appt - results, discussion etc
18-21wks - anomaly scan
24-28wks - OGTT
25,28,31,34,36,38,40,41,42 - other appts

Screening offered for:
anaemia, bacturia, group + Rh, Down’s, fetal abnormalities, hep B, HIV, neural tube defects, RFs for pre-eclampsia, syphilis

No screening for BV, chlamydia, CMV, fragile X, hep C, GBS, toxoplasmosis

Lifestyle advice
400mcg folic acid from before conception -> 12wks (5mg in epileptics, obesity), take vit D, not too much vit A, don’t smoke, avoid certain foods……

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25
Pre-eclampsia
Hypertensive disorder - placental disease Triad of -> new HTN, proteinuria, oedema Issue w/ spiral arteries - high resistance, low flow circulation
26
Pre-eclampsia RFs
Moderate nulliparity >40yo >35BMI FHx pregnancy interval >10yrs multiple pregnancy High Chronic HTN HTN / pre-eclampsia / eclampsia in previous pregnancy CKD DM autoimmune (SLE, aPL etc)
27
Pre-eclampsia Px
Asym Headache, visual disturbance, epigastric pain (hepatic capsule distension / infarction) Sudden oedema Hyperreflexia Papilloedema
28
Pre-eclampsia Dx
New onset BP >140/90 >20wks and 1 of: - proteinuria - other organ involvement - eg renal (raised creat), liver, neuro, haem...)
29
Pre-eclampsia DDx
Essential HTN (HTN <20wks) Pregnancy induced HTN (PIN) - w/o proteinuria Eclampsia - seizure
30
Pre-eclampsia Ix
Urine dip + 24hr collection - protein +++ BP FBC (low Hb + platelets) U/E (high urea + creat) LFTs (raised ALT, AST) Raised PlGF - placental growth factor
31
Pre-eclampsia Mx
Labetalol / nifedipine (if asthmatic) / methyldopa Mg during labour + 24hrs after >37wks - initiate birth 34-37wks -> deliver if cannot control BP, reduced sats, deterioration, neuro sx, placental abruption (give steroids) <34wks - monitor unless indications as above, give Mg + steroids
32
Pre-eclampsia prophylaxis
aspirin 75mg OD for women with 1 high RF or >2 moderate 12wks -> birth
33
Eclampsia
1+ seizure + pre-eclampsia
34
Eclampsia Px
New onset tonic clonic seizure Pre-eclampsia (new HTN, proteinuria, >20wks) Headache, hyperreflexia, N+V, oedema, RUQ pain +/- jaundice, visual disturbance, reduced GCS
35
Eclampsia Ix
Fundoscopy - papilloedema Bloods - FBC, U/E, LFTs, coag, BM Abdo USS + CTG - monitor fetus CT head
36
Eclampsia Mx
A-E, left lateral position MgSO4 - 4g prophylaxis - 4g with first seizure - 1g/hr maintenance - 2g bolus with recurrent seizures - Too high -> hyperreflexia, resp depression Labetalol + hydralazine C-section
37
Oligohydramnios
reduced amniotic fluid Amniotic fluid index (AFI) <5th %tile
38
Oligohydramnios causes
PROM Fetal renal agenesis (fetus swallows fluid, excreted in urine normally) IUGR pre-eclampsia, placental insufficiency (blood to fetal brain rather than kidneys - reduced UO)
39
Oligohydramnios Px
may have sx of leaking fluid, damp all the time
40
Oligohydramnios Ix
Fundo-symphysis height Speculum - pool of fluid in vagina USS - liquor volume, fetus kidneys, measure size Bedside tests for proteins if ?PROM
41
Oligohydramnios Mx
ROM - labour likely in 24-48hrs - if preterm - steroids + IOL Placental insufficiency - baby likely to be prem - monitor with scans, doppler for umbilical artery
42
Polyhydramnios
increased amniotic fluid >95%tile
43
Polyhydramnios causes
idiopathic 50% fetus cannot swallow - oesophageal atresia, CNS abnormalities Duodenal atresia - double bubble sign on US anaemia fetal hydrops macrosomia - big babies produce more urine lithium maternal diabetes
44
Polyhydramnios Px
mum can present SOB
45
Polyhydramnios assessment
Tense uterus on palpation USS - liquor volume, fetal size OGTT for mum
46
Polyhydramnios Mx
Nothing in most Amnioreduction if severe - but risk of infection / abruption Indomethacin - enhance water retention, reduce fetal UO, but not >32wks (premature PDA closure) Examine baby before 1st feed - eg TOF, oesophageal atresia
47
Breech presentation
Fetus presents buttocks / feet first Complete - flexed at hips/knees Frank - flexed at hips, extended at knees (most common) Footling - one / both legs extended at hip - foot is presenting part RFs Multiparity, uterine malformations, fibroids, placenta praevia, prematurity, macrosomia, polyhydramnios, twin pregnancy
48
Breech px Ix
Examination USS
49
Breech px Mx
External cephalic version - at 36wks, 50% success - CIs - c-section needed, APH, membrane rupture, multiple pregnancy, previous c-section C-section - elective Vaginal breech birth - CI - footling
50
Fetal lie
Fetus against mother long axis
51
Fetal presentation
fetal part that enters maternal pelvis
52
Fetal position
Position of head as it exist birth canal OA / OP
53
Placenta praevia
placenta fully / partially attached to lower uterine segment Leads to APH (wk24-term) Minor - low placenta, doesn't cover os Major - lies over internal os RFs prev c section, high parity, >40yo, multiple pregnancy, previous praevia
54
Placenta praevia Px
Antepartum haemorrhage (APH) - painless, spotting/massive bleed Pain if in labour Shock in keeping with visible loss VE -> risk of bleed (do not do)
55
Placental praevia Ix
Bloods CTG USS - at 20wks, can do TVUS - minor - rpt at 36wks - major - rpt at 32wks, plan delivery
56
Placenta praevia Mx
C-section
57
Placental abruption
Placenta separates from uterine wall prematurely -> APH, possible fetal compromise Revealed - bleed drains through cervix Concealed - bleed remains in uterus, clot forms retroplacentally
58
Placental abruption Px
APH Pain Woody / tense uterus Shock out of keeping with visible loss
59
Placenta abruption Ix
Bloods CTG USS
60
Placental abruption Mx
A-E Fetal distress - emergency c-section No distress - <36wks observe, steroids - >36wks ?vaginal delivery, IOL
61
Gestational diabetes mellitus (GDM)
Glucose intolerance / insulin resistance in pregnancy Body can't produce enough insulin to meet demands, progressive insulin resistance, higher vol needed for normal blood glucose level RFs BMI>30, Asian, previous, FHx, PCOS, prev macrosomia Leads to macrosomia, organomegaly...
62
GDM Px
Asym polyuria, polydipsia, fatigue
63
GDM Ix
OGTT - measure fasting glucose, drink 75g glucose, rpt plasma glucose in 2hrs - >5.6 fasting / >7.8 on repeat (2 hour)- dx - at booking, 24-28wks, at any point if 2+ glycosuria
64
GDM Mx
Diet / exercise if <7 Metformin if not met within 1-2 weeks Insulin (straight away if fasting >7)/ not reacted to metformin Short acting insulin for treatment Offer insulin if 6-6.9 If pre-existing DM Weight loss, stop drugs apart from metformin, start insulin, folic acid 5mg preconception ->12wks
65
Obstetric cholestasis
Aka intrahepatic cholestasis of pregnancy Cause unsure Px 3rd trim, pruritis (palms, soles, abdo), jaundice (20%), nausea, anorexia, fatigue, RUQ pain, dark urine, pale stools DDx HG, pre-eclampsia, HELLP Ix LFTs - raised bilirubin, high PTT? Mx Monitor LFTs weekly IOL at 37-38wks Risk of prem birth Ursodeoxycholic acid Vit K supplements
66
Anaemia in pregnancy
Low Hb <110 in 1st trim, <105 in 2/3rd trim, <100 post-partum Check at booking, 28wks Px Dizzy, fatigue, SOB, asym, pallor, koilonychia, angular cheilitis Ix FBC, serum ferritin (not routine), B12/folate Mx Iron supplements, folate if needed
67
Antiphospholipid (aPL) syndrome
Autoimmune - ABs target phospholipid binding proteins -> thrombosis, miscarriage
68
aPL Px
Stroke, DVT Miscarriage IUGR Pre-eclampsia livedo reticularis renal impairment Libmann-Sacks endocarditis Thrombocytopenia
69
aPL Ix
Anticardolipin AB Lupus anticoagulant AB Anti-B2-glycoprotein I AB
70
aPL Mx
LMWH, continue >6wks post partum Low dose aspirin 75mg
71
VTE in pregnancy
Pregnancy is RF - assess risk at booking, any further admission RFs >35yo, >30BMI, parity >3, smoker, varicose veins, FHx, multiple pregnancy, IVF, low-risk thrombophilia Px DVT / PE Ix Doppler first - if positive, avoid scanning chest ECG, CXR, CTPA if necessary Mx LMWH - >4 RFs - start immediately -> 6wks postnatal - 3 RFs - 28wks -> 6wks postnatal - DVT at delivery - continue for >3mo
72
Fetal varicella syndrome (FVS)
1% risk if mum exposed <20wks, less 20-28wks, none >28wks Skin scarring, eye defects, limb hypoplasia, microcephaly, LDs Also shingles in infancy Severe neonatal varicella - if mother develops rash 5d before birth -> 2d after - tx - VZIg +/- acyclovir
73
Mx of chickenpox exposure in pregnancy
If mum had chickenpox, no tx If doubt mum had chickenpox - check VZV ABs - if none: - <20wks - give VZIg asap - effective <10d post-exposure - >20wks - acyclovir 7-14d post exposure New guidance seems to be oral aciclovir given at 7-14 days post exposure, not immediately for all stages of pregnancy
74
Mx of chickenpox in pregnancy
>20wks - oral acyclovir <24hrs of rash <20wks, consider acyclovir with caution Serial USS - for abnormalities
75
GBS colonisation
infant exposed in labour Streptococci - G+ chain - Strep agalactiae RFs prem, prolonged ROM, prev sibling GBS infection, maternal pyrexia
76
GBS Px
May manifest as chorioamnionitis, endometritis neonatal sepsis UTI
77
GBS Ix
not routinely screened for Swabs - rectum + vagina At 35-37wks, or 3-5wks before delivery date
78
GBS Mx
IV benpen throughout labour if: - +ve swabs, GBS UTI this pregnancy, previous GBS baby, labour fever, <37wks labour, >18hrs ROM Abx not needed in c-section If ROM >37wks, GBS+ve -> IOL - reduce time fetus exposed If previous GBS infection - offer intrapartum abx prophylaxis - test in late pregnancy, more abx if still +ve
79
Hep B in pregnancy
Offer screening Vaccine + Ig to babies born to +ve mums No breastfeeding transmission C-section doesn't really reduce vertical transmission
80
HIV and pregnancy
Offer screening 4 factors to reduce vertical transmission Maternal antiretrovirals C-section Neonatal antiretrovirals Bottle feeding - spread by breastfeeding
81
CMV infection pregnancy
Herpes virus 5, 1/3 transmitted vertically, 5% cause damage Px Flu-like sx Fever, splenomegaly, impaired liver function Ix Viral serology for CMV IgM, IgG Mx - refer to fetal medicine - Maternal - no tx if immunocompetent - Dx fetus - amniocentesis, PCR, >21wks - Offer TOP if infected - If no TOP - serial USSs for congenital CMV (IUGR, HSM, low platelets, jaundice, microencephaly)
82
Parvovirus B19 in pregnancy
Slapped cheek syndrome Resp droplet / blood spread Px Asym, symmetrical arthralgia Children URTI, flu, erythema infectiosum (slapped cheek) Ix Viral serology - IgM, IgG Mx Refer to fetal medicine Mum self-limiting Risk of fetal hydrops - fluid accumulation, severe anaemia - intrauterine transfusion if found
83
Rubella infection in pregnancy
Not screened, vaccines, but infection in pregnancy serious for fetus, airborne droplet spread Px asym malaise, headache, coryza, lymphadenopathy, fine maculopapular rash Ix IgM, IgG Mx - refer to fetal medicine, inform public health - mother - self-limiting - <12wks - likely defects - TOP - 12-20wks - amniocentesis + PCR to confirm - then TOP / US surveillance - >20wks - no action Fetal rubella syndrome Sensorineural deafness, congenital cataracts, congenital heart disease, reduced growth, HMS....
84
Listeria in pregnancy
G+, causes listeriosis - more likely in pregnant women From unpasteurised milk, processed meats, blue cheese Px asym, flu, pneumonia, meningoencephalitis Miscarriage, intrauterine death (IUD), severe neonatal infection
85
Congenital toxoplasmosis
Parasite infection - from faeces of cat which is host Triad of: intracranial calcification hydrocephalus chorioretinitis
86
Obesity in pregnancy
increased risk of cx - miscarriage, VTE, GDM, pre-eclampsia, PPH.... Risks to fetus - prematurity, macrosomia, stillbirth.... Mx Don't reduce weight by diet whilst pregnant 5mg folic acid OGTT screen
87
Placenta accreta spectrum
attachment of placenta to myometrium - past endometrium - due to defective decidua basalis Placenta does not separate properly during labour -> PPH risk RFs Previous c section, placenta praevia Types Accreta - attached to myometrium Increta - invade into myometrium Percreta - invade through perimetrium Px APH in 3rd trim May dx on antenatal US scans PPH Mx Planned delivery 35-37wks to reduce risk of spontaneous delivery Antenatal steroids Several options - Hysterectomy - Resect part of myometrium - preserve uterus - Leave placenta in - reabsorbed over time - bleeding / infection risk
88
HTN in pregnancy
>140/90, or increase above booking readings >30/15 Pre-existing HTN No proteinuria / oedema Stop ACEi, ARB, thiazides Target BP 135/85 Labetalol / nifedipine 75mg aspirin 12wks->term Pregnancy induced HTN (PIH) >20wks, no proteinuria / oedema resolves 1mo after birth Test for PlGF - r/o pre-eclampsia Labetalol / nifedipine Pre-eclampsia PIH + proteinuria, maybe oedema
89
HELLP syndrome
Haemolysis, Elevated Liver enzymes, Low Platelets Px N+V, RUQ pain, lethargy Ix Bloods - as above Mx deliver baby
90
Chorioamnionitis
Ascending bacterial infection of amniotic fluid / membranes / placenta RFs - PPROM (can occur without) Mx - deliver fetus, c-section if needed, IV abx
91
Hypothyroidism in pregnancy
Untreated --> miscarriage, anaemia, SGA, pre-eclampsia Increase levothyroxine dose (crosses placenta during pregnancy) - titrate based on TSH
92
Epilepsy in pregnancy
Folic acid 5mg from before conception Pregnancy - worse seizure control - avoid valproate (neural tube defects) Levetiracetam, lamotrigine, carbamazepine - safer
93
RA in pregnancy
Should be well controlled for 3-6mo before becoming pregnant Methotrexate teratogenic 1st line - hydroxychloroquine Sulfasalazine safe Corticosteroids for flare ups
94
Medications in pregnancy
NSAIDs Block prostaglandins (which keep PDA open) - avoid, esp in 3rd trim BBs IUGR, low BM/HR in neonate ACEi/ARBs teratogenic Opiates withdrawal sx Warfarin teratogenic valproate neural tube defects lithium Ebstein's anomaly monitor levels every 4wks, then weekly from 36wks Avoid in breastfeeding SSRIs Balance +/-s 1st trim - congenital heart defects 3rd trim - pulm HTN Isotretinoin related to vit A, highly teratogenic
95
UTI in pregnancy
Pregnant women more at risk increased risk of preterm, SGA, pre-eclampsia Test at booking for asymptomatic bacteriuria - higher risk of developing UTI - dip + MC+S E coli, Klebsiella commonly.... Mx Nitrofurantoin (avoid 3rd trim - neonatal haemolysis) Amoxicillin, after sensitivities known Cefalexin Avoid trimethoprim 1st trim - spina bifida
96
Vasa praevia
Fetal vessels (2x arteries, 1x vein) normally in umbilical cord, but are in fetal membranes + travel across internal cervical os - prone to bleeding Px Dx by US APH Fetal distress Bleed after ROM Mx Steroids from 32wks Elective c-section at 34-36wks APH - emergency c-section
97
Multiple pregnancy
Zygote - mono/dizygotic Amniotic sac - mono/diamniotic Placenta - mono/dichorionic Diamniotic, dichorionic twins best outcomes - each fetus has own blood supply Dx Booking US scan - dichorionic, diamniotic - membrane between - lambda / twin peak sign - monochorionic, diamniotic - T sign - monochorionic, monoamniotic - no membrane Mx FBC (anaemia), regular scans, plan birth for earlier Steroids, elective c-section, can do vaginal
98
Twin-twin transfusion syndrome
Fetuses share placenta, one gets all blood, other starved Recipient - fluid overload, HF, polyhydramnios Donor - IUGR, anaemia, oligohydramnios Tx at tertiary centre - laser tx to destroy connection between blood vessels
99
Twin anaemia polycythaemia sequence
Similar to transfusion syndrome, less acute One twin anaemia, other polycythaemic
100
Reduced fetal movts
Can be fetal distress - reduced O2 consumption due to chronic hypoxia - risk of stillbirth, IUGR, placental insufficiency Fetus felt more and more 18/20wks->32wks, defo by 24wks RFs - posture, distraction, meds, fetal position, placental position, small fetus Ix Handheld doppler USS if no fetal HB >28wks CTG if HB >28wks - 30 mins monitoring If no movts by 24wks - refer to maternal fetal medicine unit
101
Rhesus incompatibility patho
If mum RhD-, and child RhD+ - if fetal blood enters maternal circulation, RhD Ag recognised as foreign - mum produces ABs (sensitised) to RhD Ag In later pregnancies, ABs then destroy RBCs in fetus (haemolytic disease of newborn) Give anti-D prophylaxis to RhD- women - destroys RhD Ags from fetus in maternal bloodstream - prevent sensitisation occurring
102
Rhesus incompatibility Maternal Mx
Take ABO group + RhD typing at booking, rpt at 28wks Routine anti-D given: 28wks 34wks Sensitisation - give anti-D <72hrs APH, amniocentesis, abdo trauma, at birth of Rh+ infant, TOP, miscarriage >12wks, ectopic, ECV >20wks (I think 2nd/3rd trimester)+ sensitisation event - perform Kleinhauer test - see how much fetal blood in maternal bloodstream - see if further anti-D needed - add acid, mum's cells die, fetal RBCs survive
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Rhesus incompatibility baby Mx
When baby born - take cord blood - FBC, group and DAT (direct antiglobulin test) -Coombs - if shows ABs on RBC of baby - haemolysis Affected fetus: Hydrops fetalis, jaundice, anaemia, HSM, HF, kernicterus Mx - transfusions, UV phototherapy
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Small for gestational age (SGA)
<10th centile, birth weight <2.5kg Assess size by estimated weight / abdo circumference SGA causes - constitutional, IUGR SGA RFs - previous SGA, obesity smoking, DM, HTN, pre-eclampsia, >35yo, multiple pregnancy IUGR causes - placenta mediated - idiopathic, pre-eclampsia, smoking, anaemia... - fetus mediated - genetic, infection.... IUGR other signs oligohydramnios, abnormal dopplers, reduced fetal movt, abnormal CTGs Monitoring US, SFH, scan uterine artery doppler, amniotic fluid levels.... Mx Stop smoking, early delivery if concern with growth, test for infection
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Large for gestational age (LGA)
macrosomia, >4.5kg, >90th centile Causes Constitutional, GDM, prev, maternal obesity, overdue, male Risks To mother - shoulder dystocia, failure to progress, perineal tears, instrumental delivery, PPH, uterine rupture To baby - birth injury, neonatal hypoglycaemia, obesity, T2DM Ix USS - r/o polyhydramnios OGTT Mx Deliver in hospital, c-section if needed
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Acute fatty liver of pregnancy
Rare cx in 3rd trim / after birth - rapid accumulation of fat in liver - from impaired processing of fatty acids in placenta Px abdo pain, N+V, headache, jaundice, hypoglycaemia, ascites, pre-eclampsia Ix Raised ALT, AST, bilirubin, WCC deranged clotting, low platelets DDx HELLP - more common Mx deliver baby mx acute liver failure consider liver transplant
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Stillbirth
Birth of dead fetus >24wks - from intrauterine fetal death (IUFD) Causes unexplained, various cx - pre-eclampsia, abruption, vasa praevia.... Prevention Regular scans, stop smoking report reduced fetal movts, abdo pain, vaginal bleeding Ix USS - visualise fetal HB Mx Vaginal birth, unless c-section indicated Induce labour Dopamine agonist (cabergoline) - suppress lactation Testing for cause - genetic, post-mortem, XR/MRI, infection tests
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Signs of labour
Show - mucus plug Rupture of membranes Regular, painful contractions Dilating cervix
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Stages of labour
FIRST STAGE - Onset of contractions -> 10cm dilatation - <4cm latent phase, >4cm established phase - Latent phase - 0-3cm, 0.5cm/hr, irregular contractions - Active phase - 3-7cm, 1cm/hr, regular cont. - Transition phase - 7-10cm, 1cm/hr, strong + regular cont. SECOND STAGE - 10cm -> delivery of baby THIRD STAGE - delivery of placenta
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Braxton-Hicks contractions
irregular contractions of uterus, 2/3rd trim - temporary, not labour
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Monitoring in labour
FHR/15mins / continuously on CTG Contractions/30mins Maternal HR/60mins Maternal BP, temp/4hrs VE/4hrs
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Lochia
PV discharge, blood, mucus, uterine tissue- for 6wks after birth
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Cardiotocography - DR C BRaVADO
Define Risk - CTG Indications - sepsis, maternal tachy, meconium, pre-eclampsia, induction of labour, labour delay.... Contractions - No of cont./10mins - Too few - not progressing - Too many - uterine hyperstimulation - risk of fetal compromise Baseline HR - 110-160 reassuring - Brady - increased vagal tone, BBs - Tachy - maternal fever, hypoxia, prem, Variability - 5-25 normal - loss of this - prem, hypoxia Acceleration - good sign - occurs with contractions Decelerations - Early - dip with contraction - fine (vagal) - Late - after cont - hypoxia - variable - intermittent cord compression - hypoxia - prolonged - 2-10mins - concern Features are reassuring, non-reassuring, abnormal CTG categories - normal, suspicious, pathological, need for urgent intervention Mx - escalate - reposition mother, IV fluids if low BP - fetal scalp stimulation - should see acceleration in response - fetal scalp blood sampling - eg acidosis - deliver baby - instruments / emergency c-section Fetal bradycardia - 3 mins - call for help - 6 mins - move to theatre - 9 mins - prepare for delivery - 12 mins - deliver baby (by 15 mins)
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Drugs in labour
Oxytocin - syntocinon - Produced in hypothalamus, secreted by pos pit. - Ripens cervix, stimulates contractions, role in lactation in breastfeeding - Used for - induction, progression, improve contraction frequency / strength, prevent PPH Ergometrine - Stimulates smooth muscle contraction - Delivery of placenta, prevent PPH - only after delivery of baby - S/Es - HTN, D+V, angina. Avoid in eclampsia / HTN Syntometrine - Combination of oxytocin + ergometrine Nifedipine - CCB - first line for tocolysis in preterm labour Atosiban - Oxytocin receptor antagonist - For tocolysis, eg premature labour, when nifedipine contraindicated Prostaglandins - dinoprostone (prostaglandin E2) - Induction of labour - stimulate contractions, ripen cervix - Pessaries, tablets, gel - (Lower BP - vasodilation, NSAIDs inhibit this action - increase BP - avoid in pregnancy) Misoprostol - Prostaglandin analogue - Medical mx in miscarriage, IOL in IUFD - used alongside mifepristone Mifepristone - Anti-progesterone, halts pregnancy, ripens cervix, stimulates contractions - Used with misoprostol for abortions, IOL in IUFD Carboprost - Synthetic prostaglandin analogue, stimulates uterine contraction - Given IM in PPH, where ergometrine and oxytocin have been inadequate - Avoid in asthma Terbutaline - B2 agonist - suppresses uterus smooth muscle contractions - used for tocolysis in uterine hyperstimulation TXA - Antifibrinolytic, binds to plasminogen, prevents it converting into plasmin (which dissolves fibrin in clots), reduces bleeding - PPH
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Failure to progress
Labour not progressing at satisfactory rate - increased risk to fetus and mother - more likely in first labour Causes Power - contractions Passenger - baby size, presentation Passage - pelvis etc Psyche - motivation Delay definitions 1st stage - <2cm dilatation 4hrs / slowing if multiparous 2nd stage - 2hrs pushing if 1st baby, 1hr if multiparous 3rd stage - >30mins with active mx, >60mins physiological Mx - ARM - amniotomy - oxytocin infusion - instrumental delivery - c-section
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Pain relief in labour
Paracetamol, codeine, entenox IM pethidine / diamorphine - opioids, make mum drowsy, can cause resp depression in neonate PCA - remifentanil - anaesthetic support - naloxone + atropine on standby Epidural - catheter in epidural (outside dura) space - inject levobupivacaine + fentanyl - S/Es - headache, hypotension, weak legs, nerve damage, prolonged 2nd stage, likely instrumental delivery Spinal - in CSF, subarachnoid Combined spinal + epidural (CSE)
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Instrumental delivery
- After 3 pulls, abandon - Give single dose co-amox Indications - inadequate progress, maternal exhaustion, ?fetal compromise, clinical concern (eg APH) Need to be - fully dilated, ROM, cephalic px, empty bladder, adequate pain relief... Ventouse - vacuum cup on baby head - less painful, less maternal injury - cephalohaematoma, fetal retinal haemorrhage Forceps - lower fetal cx risk, higher maternal risk - 3/4th degree tears - facial nerve palsy to baby Maternal injuries Femoral Obturator
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Perineal tears
1st degree - superficial, no muscle, no repair 2nd degree - perineal muscle, suture on ward 3rd degree - perineum + anal sphincter - external/internal - theatre repair - 3a - <50% EAS thickness torn - 3b - >50% EAS torn - 3c - IAS torn 4th degree - Perineum, EAS/IAS + rectal mucosa - theatre repair Give PR diclofenac + abx Episiotomy - cut perineum, use LA, cut 45 degrees diagonally Perineal massage - reduce tear risk, massage from 34wks on, warm towels during delivery
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Mx of 3rd stage
Physiological Deliver placenta by maternal effort Active IM oxytocin helps uterus contract Careful traction of umbilical cord, suprapubic pressure Reduces bleeding risk N+V S/E
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Premature labour
SROM - spontaneous ROM PROM - prelabour rupture of membranes - rupture >1hr before labour onset, >37wks PPROM - preterm PROM - <37wks - cx Prematurity - birth <37wks, non-viable <23wks
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Prophylaxis of preterm labour
Offer to women with cervix length <25mm, 16-24wks Vaginal progesterone - Gel / pessary - maintain pregnancy Cervical cerclage - put stitch into cervix (under GA / spinal) - Rescue cerclage - 26-28wks, cervical dilatation, w/o ROM
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PROM / PPROM
Fetal membranes normally weaken in time for labour, but may rupture early due to - early activation of normal processes, infection, genetics RFs - smoking, previous PROM / prem, PV bleed in pregnancy, infection, amniocentesis, polyhydramnios, multiple pregnancy
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PROM / PPROM Px
Broken waters - painless pop + gush, may be gradual Lack of normal discharge (washed away) Pooling in posterior fornix - speculum
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PROM / PPROM Ix
Actim-PROM - swab for IGFBP-1 - high in amniotic fluid Amnisure - for PAMG-1 High vaginal swab - GBS
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PROM / PPROM Mx
Majority go into labour in 24-48hrs Penicillin / clindamycin if GBS >36wks - w+w for 24hrs - IOL >24hrs 34-36wks - prophylactic erythromycin (10d course / until labour) - corticosteroids - IOL + delivery 24-33wks - erythromycin, steroids - expectant until 34 wks - avoid sex
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Preterm labour + intact membranes
Regular painful contractions, cervical dilation, no ROM Dx - speculum - dilatation seen - <30wks clinical assessment only to offer Mx of preterm labour, >30wks offer TVUS assess - <15mm offer mx, >15mm preterm labour unlikely - fetal fibronectin - in vagina Mx - CTG - Tocolytics - nifedipine - <35wks - dexamethasone - <34wks MgSO4 - prevent CP
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Induction of labour (IOL)
Start labour artificially Indications - Prolonged gestation - P/PROM - maternal health problems - HTN, preclampsia - IUGR - IUFD Contraindications - same as vaginal birth CIs - if prev c-section - can only induce if consultant says
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Methods of IOL
Vaginal prostaglandins - prostaglandin E2 - ripen cervix, role in uterus contraction - tablet, gel, pessary Amniotomy - amnihook - rupture membranes artificially - add IV oxytocin - increase contractions Cervical ripening balloon (CRB) - insert into cervix, gently inflate Membrane sweep - insert gloved finger through cervix, rotate against fetal membranes If IUFD - mifepristone + misoprostol
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IOL monitoring
Bishop Score - assess cervical ripeness, likelihood of need of IOL - considers dilatation, length, station (relative to ischial spine), consistency, position - >_8 - cervix ripe, high chance response to IOL / spontaneous - <5 - IOL likely needed CTG - continuous - fetal scalp electrode (FSE) alternative
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IOL Cx
Failure, cord prolapse, infection Uterine hyperstimulation - contractions too long / frequent - fetal distress - give terbutaline (tocolytic)
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C-section + indications
99% lower segment c-section, classic was longitudinal in upper segment Indications - placenta praevia, pre-eclampsia, IUGR/fetal distress, failure to progress, breech, abruption, infection (eg herpes), cervical cancer, previous 3/4th
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C-section categories
Cat 1 - 30 mins, immediate threat to life of mother/baby Cat 2 - 75 mins - maternal / fetal compromise - not immediately life-threatening Cat 3 - delivery required, mother + baby stable Cat 4 - elective c-section, >39wks to reduce TTN
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C-section risks
Serious Emergency hysterectomy, further surgery, ICU, VTE, bladder/ureter injury, death, future uterine rupture, placenta praevia/accreta Frequent Persistent abdo pain, rpt c-section, haemorrhage, infection, fetal laceration
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C-section procedure
- Send FBC, group and save - Prescribe ranitidine (H2 receptor antagonist) +/- metoclopramide - reduce vomit / aspiration risk - Calculate VTE risk score - Stockings, LMWH - Epidural / spinal / general anaesthetic - Left lateral position - Skin incision - Sharp / blunt dissection through layers - skin, camper fascia, scarpa fascia, rectus sheath, rectus muscle, abdominal peritoneum (parietal) - Visceral peritoneum cut, pushed down to reflect bladder - Uterine incision made below, baby delivered - Oxytocin 5 units given IV to aid delivery of placenta - Everything closed
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Vaginal birth after c-section (VBAC)
Most appropriate method >37wks with 1 previous c-section 70-75% successful Mx deliver in hospital continuous CTG Avoid induction / augmentation CIs uterine rupture, classical caesarean scar
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Shoulder dystocia
anterior shoulder stuck on pubic symphysis in delivery leads to fetal hypoxia, risk of brachial plexus injury (less commonly posterior shoulder on sacral promontory)
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Shoulder dystocia RFs
Pre-labour Previous, macrosomia, DM, BMI>30, IOL Intrapartum prolonged 1st/2nd stage labour, secondary arrest, IV oxytocin augmentation, instrumentation
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Shoulder dystocia Px
- Difficulty delivering head/chin - failure of restitution - remains OA, doesn't turn to look to side - Turtle head sign - fetal head retracts
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Shoulder dystocia Mx
Call for help, stop pushing, routine axial traction, ?episiotomy 1st line - McRoberts - knees to chest - suprapubic pressure 2nd line - posterior arm - insert hand + grab - internal rotation - pressure on shoulders to rotate baby 180 degrees - roll onto all 4s, repeat Further - cleidotomy - fracture baby clavicle - symphysiotomy - cut pubic symphysis - Zavenelli - return fetal head to pelvis, deliver via c-section Post-delivery - active mx 3rd stage - PR - exclude 3/4th tear - debrief parents, - physiotherapy / paediatric review
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Amniotic fluid embolism (AFE)
rare cause of maternal collapse fetal / amniotic fluid enters mother's bloodstream, stimulates reaction
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AFE Px
- majority in labour / c-section / post-partum - chills, shivering, sweating, anxiety, coughing - cyanosis, hypoxia, resp arrest, hypotension, shock, seizure, MI, DIC
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AFE Ix
- Dx of exclusion - post-mortem - fetal squamous cells + debris in pulmonary vasculature - bloods, ECG, CXR
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AFE Mx
A-E Anaesthetics, haem, ICU
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Umbilical cord prolapse
Cord descends through cervix with / before presenting part of fetus Fetal hypoxia from occlusion of cord / vasospasm from cold Overt / complete - cord past presenting part Occult / incomplete - alongside presenting part RFs - ARM, prem, multiparity.....
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Cord prolapse Px
Non-reassuring fetal HR Examine to confirm May have PV bleed
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Cord prolapse Mx
Avoid handling cord (keep warm + wet) - reduce vasospasm Manually elevate presenting part of fetus Fill bladder with 500ml warm normal saline Knee/chest position / left lateral position Tocolysis - terbutaline Deliver via c-section If fully dilated / vaginal imminent - encourage pushing / instrumental delivery
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Uterine rupture
Full thickness tear of uterine muscle / serosa - typically occurs during labour Incomplete - peritoneum intact, remains within uterus Complete - peritoneum torn, uterine contents escape RFs prev c-section / uterine surgery, IOL, obstructed labour
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Uterine rupture Px
- sudden severe abdo pain, constant - shoulder tip pain (diaphragmatic irritation) - PV bleed - shock - fetal distress - contractions stop
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Uterine rupture ddx
Abruption - abdo pain +/- PV bleed - woody/tense uterus on palpation Placenta praevia - painless PV bleed Vasa praevia - ruptured membranes, painless PV bleed, fetal bradycardia
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Uterine rupture Ix
CTG Catheter - look for haematuria USS
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Uterine rupture Mx
A-E Blood resus C-section to deliver, repair uterus or remove
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Primary PPH
>500ml PV bleed <24hrs delivery Minor - 500-1000 Major - >1000
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Primary PPH causes
Tone Uterus fails to contract properly Tissue retention of placental tissue, prevents contraction Trauma from instrument, episiotomy, c-section Thrombin coagulopathies vascular (placental abruption, HTN, pre-eclampsia)
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Primary PPH Px
PV bleed Haemorrhagic shock Dizzy, SOB, palpitations...
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Primary PPH Ix
Bloods - FBC, G+S, crossmatch 4-6 units, coag, U/E, LFTs, gas
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Primary PPH Mx
A-E MHP Atony - Bimanual compression, insert catheter - Oxytocin (syntocinon), ergometrine (avoid in HTN), carboprost, misoprostol - Surgery - intrauterine balloon tamponade, B-lynch suture, artery ligation, hysterectomy Trauma - surgical repair Tissue - IV oxytocin - surgery for evac Thrombin - correct Active mx of 3rd stage to prevent
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Secondary PPH
PV bleed 24hrs->12wks post-partum Causes - endometritis, retained placental tissue
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Secondary PPH Px
Excessive PV bleed, spotting 10% massive haemorrhage If infection - fever, rigors, lower abdo pain, foul smelling lochia
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Secondary PPH Ix
Bloods, inc cultures Pelvic USS - retained tissue
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Secondary PPH Mx
Abx - Ampicillin (clindamycin if pen allergic) + metronidazole - Add gentamicin if endomyometritis / sepsis Uterotonics - eg oxytocin, prostaglandins Surgery - if bleeding heavily, eg balloon catheter
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Uterine inversion
uterus turns insure out, fundus drops down through uterine cavity Complete - through to introitus
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Uterine inversion Px
PPH Maternal shock / collapse Palpate on VE See uterus at introitus
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Uterine inversion Mx
Johnson manoeuvre - push back up with hand, oxytocin to stimulate contraction Hydrostatic - fill vagina with fluid, tight seal needed Surgery - laparotomy
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Routine post-natal care
6wk check - GP, general stuff Menstruation - Lochia to begin - breastfeeding -> more oxytocin -> more bleeding - lactational amenorrhoea - absence of periods with breastfeeding - bottlefeeding - periods begin 3wks after birth Contraception - fertility returns 21d after birth - lactational amenorrhoea 98% effective as contraception up to 6mo post partum - POP + implant safe for breastfeeding - if breastfeeding, avoid cOCP until >6wks - coil - insert <48hrs >4wks after birth
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Baby blues
60-70%, 3-7d after birth, more common in primips Px mood swings, low mood, anxiety, irritable, tearful Mx reassure, support health visitor important sx resolve <2wks
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Post-natal depression
10%, start <1mo, peak at 3mo Px depression sx - low mood, anhedonia, low energy.... Ix Edinburgh Postnatal Depression Scale - >10/30 suggests dx Mx CBT Sertraline, paroxetine
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Puerperal psychosis
0.2%, <2-3wks birth Px mood swings - depression / mania Hallucinations, delusions confusion, thought disorder Mx Admit to mother + baby unit CBT Antidepressants, antipsychotics, mood stabilisers, ECT if needed 25-50% recurrence
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Endometritis
infection of endometrium, more common in c-sections Px foul smelling discharge bleed, abdo / pelvic pain, fever, sepsis can be weeks later Ix Vaginal swabs, urine culture, US to r/o POC Mx Sepsis - clindamycin + gent Oral coamox if more well
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Retained POC
pregnancy related tissue (eg placenta, fetal membrane) remains in uterus after delivery Can happen after miscarriage / TOP Px PV bleed, unresolving Abnormal PV discharge Lower abdo / pelvic pain Fever - infection Ix US Mx ERPC - evacuation of retained POC - under GA
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Post-partum anaemia
Hb<100 post-partum Often PPH Mx FBC <100, start oral iron <90, iron infusion - but risk of reaction, also active infection is CI <70/80 - blood transfusion
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Mastitis
Inflammation of breast tissue +/- infection, common cx of breastfeeding - S aureus risk of abscess development Px Breast pain, tender, unilateral Warm, red, inflamed Nipple discharge, fever Mx continue breastfeeding, heatpacks / analgesia No improvement - fluclox / erythromycin Milk -> MC+S Fluconazole for candida
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Post-partum thyroiditis
Changes to thyroid function in first year Stages thyrotoxicosis <3mo hypothyroid 3-6mo function normal <1yr Px thyrotoxicosis - anxiety, irritable, sweating, heat, tachycardia, wt loss, fatigue, diarrhoea hypothyroid - wt gain, fatigue, dry skin, coarse hair, hair loss, low mood, fluid retention, heavy periods, constipation Ix - TFTs Thyrotoxicosis - raised T3/4, low TSH Hypothyroid - low T3/4, raised TSH Mx TFTs every 6-8wks Propranolol for thyrotoxicosis Levothyroxine for hypothyroid Annual monitoring after resolution
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Sheehan's syndrome
Rare cx of PPH - drop in BV -> avascular necrosis of pituitary gland Only ant pit - TSH, ACTH, FSH, LH, GH, prolactin (oxytocin, ADH not affected) Px reduced lactation amenorrhoea adrenal insufficiency / crisis, hypothyroid Mx Endo referral Oestrogen, progesterone Hydrocortisone Levothyroxine GH
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Puerperal infection
T>38 <14 after birth Causes endometritis, UTI, wound infection, mastitis, VTE Px Fever >38, rigors, low abdo pain, foul PV discharge Mx Endometritis - IV abx - clindamycin + gent Tx cause
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Injectable contraceptives?
Depo provera- given IM every 12 weeks Inhibits ovulation. Also thickens cervical mucus Cannot be reversed, fertility return can take up to 12 months Adverse effects- Irregular bleeding Weight gain Osteoporosis risk CI- Current breast cancer UKMEC 4
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COCP missed pill advice?
If 1 pill missed at any time in the cycle- take the last pill even if it means taking two pills in one day and continue taking pills daily, one each day, no additional contraception needed If 2+ missed pills Take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily Use condoms or abstain until taken pills for 7 days in a row If pills are missed in week 1- emergency contraception should be considered if she had unprotected sex in pill free interval or in week 1 Week 2- no need for emergency contraception after 7 days of pill Week 3- finish pills in current pack and start a new pack the next day, omitting the pill free interval
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Postpartum contraception
After giving birth, women require contraception after day 21 Progestogen-only pill POP Can start at any time postpartum After day 21 addition contraception should be used for first 2 days COCP- UKMEC 4 if breastfeeding <6 weks post partum UKMEC 2- if breast feeding 6weeks-6months postpartim May reduce breast milk prodcution Not used in first 21 days due to increased VTE risk Additional contraception for first 7 days IUD or IUS can be inserted within 48 hours of childbirth or after 4 weeks Lactational amenorrhoea method (LAM)- 98% effective providing women is fully breast feeding, amenorrhoeic and <6 months post partum
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UKMEC 4 for COCP?
More than 35 years old and smoking more than 15 cigarettes/day Migraine with aura History of thromboembolic disease or thrombogenic mutation History of stroke or ischaemic heart disease breast feeding < 6 weeks post-partum Uncontrolled hypertension Current breast cancer Major surgery with prolonged immobilisation Positive antiphospholipid antibodies (e.g. in SLE)
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Prematurity risks?
Increased mortality depends on gestation Respiratory distress syndrome Necrotizing enterocolitis Intraventricular haemorrhage Hypothermia, infection, jaundice, chronic lung disease Retinopathy of prematurity- cause of visual impairment in premature before 32 weeks Hearing probelms