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Focused 1 > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

Factors which reduce vertical HIV transmission?

A

Reduce transmission from 30% to 2%
1. Maternal ART
2. Neonatal ART
3. C-section
4. Bottle feeding

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2
Q

HIV and mode of delivery?

A
  1. Vaginal delivery recommended if viral load <50 copies/ml at 36 weeks, otherwise C-section is recommended
  2. Zidovudine infusion should be started 4 hours before beginning C-section
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3
Q

Neonatal ART?

A
  1. Oral zidovudine if maternal vital load <50, otherwise triple ART should be used
  2. Therapy should be continued for 4-6 weeks
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4
Q

HIV and breastfeeding?

A

Should be advised not to

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5
Q

Rubella AKA?

A

German measles, caused by the togavirus

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6
Q

Rubella risk in pregnancy?

A
  1. In first 8-10 weeks risk of damage to fetus is as high as 90%
  2. Damage is rare after 16 weeks
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7
Q

Congenital rubella syndrome features?

A
  1. Sensorineural deafness
  2. Congenital cataracts
  3. CHD (PDA)
  4. Hepatosplenomegaly, growth retardation
  5. Purpuric skin lesions
  6. Salt and pepper chorioretinitis
  7. Microphthalmia
  8. Cerebral palsy
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8
Q

Rubella Dx?

A
  1. Suspected cases discussed immediately with HPU
  2. IgM raised in acute exposure
  3. Difficult to distinguish from Parvovirus B19 clinically so also check parvovirus B19 serology as there is a 30% risk of transplacental infection, with a 5-10% risk of fetal loss
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9
Q

Rubella Rx?

A
  1. Discuss with local HPU
  2. Rubella immunity no longer routinely checked at booking
  3. Non-immune mothers should be offered MMR vaccination in the post-natal period
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10
Q

Pregnancy anaemia screening times?

A
  1. Booking visit (8-10 weeks)
  2. 28 weeks
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11
Q

Pregnancy cut offs for oral iron therapy?

A
  1. 1st trimester = <110g/L
  2. 2nd/3rd = <105 g/L
  3. Postpartum = <100 g/L
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12
Q

Pregnancy anaemia Rx?

A

Oral ferrous sulfate or ferrous fumarate for 3m after correction to allow iron stores to be replenished

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13
Q

Pregnant women with GDM CBG targets?

A
  1. Fasting = 5.3mmol/L
  2. 1 hours postprandial = 7.8mmol/L
  3. 2 hours postprandial = 6.4mmol/L
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14
Q

Gestational diabetes (GDM) prevalence?

A

1/20 pregnancies

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15
Q

GDM RFs?

A
  1. BMI > 30
  2. Previous macrosomic baby weighing >4.5kg
  3. Previous GDM
  4. 1st degree relative with DM
  5. Family origin with high prevalence of diabetes
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16
Q

GDM screening?

A
  1. OGTT
  2. Women who’ve previously had GDM + OGTT ASAP after booking and at 24-48 if first test is normal. Early self-monitoring of blood glucose is an alternative to OGTTs
  3. Women with any RFs should be offered OGTT at 24-28 weeks
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17
Q

Diagnostic thresholds for GDM?

A
  1. Fasting glucose >5.6
  2. 2 hour glucose >7.8
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18
Q

GDM Rx?

A
  1. Joint diabetes and antenatal clinic in 1 week
  2. Taught about blood glucose self-monitoring
  3. Diet and exercise advice
  4. Medications
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19
Q

GDM Medications Rx?

A
  1. Fasting <7 = trial diet and exercise –> if not met within 1-2 weeks, metformin should be started
  2. If targets still not met insulin should be added
  3. GDM is Rx with short acting not long acting insulins
  4. If at time of diagnosis fasting glucose level is >7 insulin should be started
  5. If 6-6.9 and evidence of complications such as macrosomia or hydramnios, insulin should be offered
  6. Glibenclamide should only be offered for women who cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment
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20
Q

Pre-existing DM Rx?

A
  1. Weight loss for women with BMI > 27
  2. Stop oral hypoglycaemic agents apart from metformin and commence insulin
  3. Folic acid 5mg/day from pre-conception to 12 weeks gestation
  4. Detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts
  5. Tight glycaemic control reduces complication rates
  6. Treat retinopathy as can worsen during pregnancy
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21
Q

Folic acid deficiency causes?

A
  1. Phenytoin
  2. Methotrexate
  3. Pregnancy
  4. Alcohol excess
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22
Q

Consequences of folic acid deficiency?

A
  1. Macrocytic, megaloblastic anaemia
  2. Neural tube defects
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23
Q

Prevention of NTD during pregnancy?

A
  1. All women should take 400mcg folic acid until 12th week of pregnancy
  2. Women at higher risk should take 5mg from before conception until 12th week of pregnancy
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24
Q

Higher risk of NTDs?

A
  1. Either partner has NTD, previous NTD pregnancy, FHx NTD
  2. Antiepileptic drugs, coeliac diease, DM, thalassaemia trait
  3. Woman is obese
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25
Q

Bleeding in pregnancy classification?

A

1st, 2nd and 3rd trimester

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26
Q

1st trimester bleeding in pregnancy causes?

A
  1. Spontaneous abortion
  2. Ectopic pregnancy
  3. Hydatidiform mole
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27
Q

2nd trimester bleeding in pregnancy causes?

A
  1. Spontaneous abortion
  2. Placental abruption
  3. Hydatidiform mole
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28
Q

3rd trimester bleeding in pregnancy causes?

A
  1. Placental abruption
  2. Placenta Praevia
  3. Vasa Praevia
  4. Bloody show
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29
Q

Antepartum haemorrhage definition?

A

Bleeding after 24 weeks

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30
Q

Hydatidiform presentation?

A

Typically bleeding in first or early second trimester associated with exaggerated symptoms of pregnancy e.g. hyperemesis. The uterus may be large for dates and serum hCG is very high

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31
Q

Placental abruption presentation?

A

Constant lower abdominal pain and, woman may be more shocked than is expected by visible blood loss. Tender, tense uterus* with normal lie and presentation. Fetal heart may be distressed

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32
Q

Placenta praevia presentation?

A

Vaginal bleeding, no pain. Non-tender uterus* but lie and presentation may be abnormal

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33
Q

Vasa praevia presentation?

A

Rupture of membranes followed immediately by vaginal bleeding. Fetal bradycardia is classically seen

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34
Q

Why should vaginal examination not be performed in primary care for suspected antepartum haemorrhage?

A

Women with placenta praevia may haemorrhage

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35
Q

Types of C-section?

A
  1. LSCS = 99%
  2. Classic = longitudinal incision in upper segment of uterus
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36
Q

Category 1 C-section mushkies?

A
  1. Immediate threat to life of mother or baby
  2. Suspected uterine rupture, major placental abruption, cord prolapse, fetal hypoxia or persistent fetal bradycardua
  3. Delivery of baby should occur within 30 mins of making the decision
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37
Q

Category 2 C-section mushkies?

A
  1. Maternal or fetal compromise which is not immediately life-threatening
  2. Delivery of baby should occur within 75 minutes of making the decision
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38
Q

Category 3 C-section?

A

Delivery is required, but mother and baby are stable

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39
Q

Category 4 C-section?

A

Elective C-section

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40
Q

Serious maternal C-section risks?

A
  1. Emergency hysterectomy
  2. Need for further surgery at later date
  3. ITU admission
  4. VTE
  5. Bladder/ureteric injury
  6. Death (1/12,000)
  7. Future pregnancies = increased risk of uterine rupture, increased risk of antepartum stillbirth, increased risk in subsequent pregnancies of placenta praevia and accreta
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41
Q

Frequent maternal C-section risks?

A
  1. Persistent wound and abdominal discomfort for a few months
  2. Increased risk of repeat caesarian section when vaginal delivery attempted
  3. Readmission to hospital
  4. Haemorrhage
  5. Infection = wound, endometritis, UTI
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42
Q

Frequent fetal C-section risk?

A

Laceration, 1/2 in every 100

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43
Q

‘Other’ c-section complications?

A
  1. Prolonged ileus
  2. Subfertility: due to postoperative adhesions
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44
Q

Vaginal birth after Caesarian (VBAC)?

A
  1. Planned VBAC ok for pregnant women >37 weeks with a single previous C-section, 70-75% have a successful vaginal delivery
  2. C/I = previous uterine rupture or classical caesarian scar
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45
Q

Chickenpox exposure risk to mother?

A

5x greater risk of pneumonitis

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46
Q

Fetal varicella syndrome mushkies?

A
  1. Risk of FVS following exposure 1% before 20 weeks
  2. Small number occur between 20-28 weeks, none following 28 weeks
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47
Q

FVS features?

A
  1. Skin scarring
  2. Eye defects (microphthalmia)
  3. Limb hypoplasia
  4. Microcephaly
  5. Learning disabilities
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48
Q

Risk of shingles in infancy?

A

1-2% risk if maternal exposure in the 2nd or 3rd trimester

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49
Q

Neonatal varicella risk?

A

If mother develops rash between 5 days before and 2 days after birth there is a risk of neonatal varicella, which may be fatal to the newborn child in around 20% of cases

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50
Q

Chickenpox exposure in pregnancy Rx?

A
  1. Any doubt about previous chickenpox –> check for maternal varicella antibodies
  2. If <20 weeks and not immune should receive VZIG (effective up to 10 days post exposure)
  3. If >20 weeks not immune then VZIG or aciclovir given days 7-14 after exposure
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51
Q

Chickenpox in pregnancy Rx?

A
  1. Specialist advice sought
  2. Oral aciclovir if >20 weeks and presents within 24 hours of onset of rash
  3. <20 weeks aciclovir should be considered with caution
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52
Q

Antenatal care overall mushkies?

A
  1. 10 antenatal visits in 1st pregnancy if uncomplicated
  2. 7 antenatal visits in subsequent pregnancies if uncomplicated
  3. Women do not need to be seen by a consultant if the pregnancy is uncomplicated
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53
Q

Antenatal care times?

A
  1. 8 - 12 weeks = Booking visit, Booking bloods/urinw
  2. 10 - 13+6 weeks = Early scan to confirm dates, exclude multiple pregnancy
  3. 11- 13+6 weeks = Down’s syndrome screening including nuchal scan
  4. 16 weeks = Information on the anomaly and blood results. If Hb < 11g/dl consider iron. Routine care = BP and urine dipstick
  5. 18 - 20+6 weeks = anomaly scan
  6. 25 weeks = Only if primip, routine care of BP, urine dipstick, SFH
  7. 28 weeks = BP, urine dipstick, SFH, second screen for anaemia and atypical red cell alloantibodies, if Hb <10.5 consider iron, first dose of anti-D prophylaxis to Rh -ve women
  8. 31 weeks = only if primip, routine care
  9. 34 weeks = routine care, second dose of anti-D prophylaxis to Rh -ve women, information on labour and birth plan
  10. 36 weeks = routine care, check presentation and offer ECV if indicated, info on breastfeeding, Vitamin K, baby-blues
  11. 38 weeks = routine care
  12. 40 weeks = only if primip, routine care, discuss options for prolonged pregnancy
  13. 41 weeks = routine care, discuss labour plans and possibility of induction
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54
Q

Booking visit?

A
  1. General info = diet, alcohol, smoking, folic acid, Vitamin D, antenatal classes
  2. BP, urine dipstick, check BMI
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55
Q

Booking bloods/urine?

A
  1. FBC, blood group, RH, red cell alloantibodies, Haemoglobinopathies
  2. Hep B, syphilis
  3. HIV test offered to all women
  4. Urine culture to detect asymptomatic bacteriuria
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56
Q

When is anti-D prophylaxis given?

A

28 weeks and 34 weeks

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57
Q

When is presentation checked?

A

36 weeks

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58
Q

Most common cause of early-onset severe infection in neonatal period?

A

GBS

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59
Q

GBS mushkies?

A

It is thought around 20-40% of mothers have GBS present in their bowel flora and may therefore be thought of as ‘carriers’ of GBS. Infants may be exposed to maternal GBS during labour and subsequently develop potentially serious infections.

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60
Q

RFs for GBS infection?

A
  1. Prematurity
  2. PROM
  3. Previous sibling GBS infection
  4. Maternal pyrexia e.g. secondary to chorioamnionitis
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61
Q

GBS Rx?

A
  1. Dont offer universal screening, maternal request is not an indication
  2. GBS in prev. pregnancy –> risk is 50% for current pregnancy, offer intrapartum ABx prophylaxis (IAP) OR testing in late pregnancy and then antibiotics if still positive
  3. If having swabs for GBS should be offered at 35-37 weeks or 3-5 weeks prior to EDD
  4. IAP should be offered to women with a previous baby with GBS
  5. IAP should be offered to women in preterm labour regardless of GBS status
  6. Women with pyrexia during labour should be given IAP
  7. Benzylpenicillin is ABx of choice
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62
Q

Pre-eclampsia triad

A
  1. New-onset HTN
  2. Proteinuria
  3. Oedema
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63
Q

Pre-eclampsia definition?

A
  1. New-onset BP >140/90 after 20 weeks of pregnancy AND 1 or more of the following:
    a. Proteinuria
    b. Other organ involvement = renal (Cr > 90), liver, neurological, haematological, uteroplacental dysfunction
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64
Q

Pre-eclampsia consequences?

A
  1. Eclampsia
  2. Fetal = IUGR, prematurity
  3. Liver = elevated transaminases
  4. Haemorrhage: placental abruption, intra-abdominal, intra-cerebral
  5. Cardiac failure
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65
Q

Severe pre-eclampsia features?

A
  1. HTN > 160/110 and proteinuria ++/+++
  2. Headache, visual disturbance, papilloedema
  3. RUQ/epigastric pain, hyperreflexia
  4. Plt < 100, abnormal liver enzymes, HELLP
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66
Q

Pre-eclampsia moderate RFs?

A
  1. 1st pregnancy
  2. > 40 y/o
  3. Pregnancy interval >10 years
  4. BMI 35
  5. FHx Pre-eclampsia
  6. Multiple pregnancy
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67
Q

Pre-eclampsia high risk factors?

A
  1. HTN in prev. pregnancy
  2. CKD
  3. AI e.g. SLE/APS
  4. T1DM/T2DM
  5. Chronic HTN
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68
Q

Reducing risk of hypertensive disorders in pregnancy?

A
  1. Aspirin 75-150mg OD from 12wks until birth
    a. >=1 high risk factor
    v. >=2 moderate risk factors
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69
Q

Pre-eclampsia initial asessment?

A
  1. Emergency secondary care assessment for any woman in whom pre-eclampsia is suspected
  2. Women with BP >160/110 are likely to be admitted and observed
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70
Q

Pre-eclampsia further management?

A
  1. Oral labetalol 1st line (nifedifine may be used if asthmatic, hydralazine also)
  2. Delivery of baby is definitive management
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71
Q

Placental abruption vs. praevia distinguish?

A

Abruption = pain, praevia = no pain

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72
Q

Placental abruption definition?

A

Placental abruption describes separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space, occurs in 1/200.

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73
Q

Symphysis pubis dysfunction mushkies?

A
  1. Ligament laxity increases in response to hormonal changes of pregnancy
  2. Pain over the pubic symphysis with radiation to the groins and the medial aspects of the thighs. A waddling gait may be seen
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74
Q

Uterine rupture mushkies?

A
  1. Ruptures usually occur during labour but occur in third trimester
  2. Risk factors: previous caesarean section
  3. Presents with maternal shock, abdominal pain and vaginal bleeding to varying degree
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75
Q

Postpartum haemorrhage (PPH) definition?

A

Blood loss >500ml after vaginal delivery

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76
Q

PPH classification?

A
  1. Primary = Within 24h
  2. Secondary = 24h-6w
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77
Q

Secondary PPH causes?

A
  1. Retained placental tissue
  2. Endometritis
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78
Q

Primary PPH causes?

A

4 Ts
1. Tone = uterine atony, most common
2. Trauma = perineal tear
3. Tissue = retained placenta
4. Thrombin = clotting/bleeding disorder

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79
Q

Risk factors for Primary PPH?

A
  1. Previous PPH, prolonged labour, pre-eclampsia
  2. Age, Polyhdramnios
  3. Placenta praevia/accreta
  4. EMCS
  5. Macrosomia
  6. Nulliparity
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80
Q

Primary PPH Rx?

A
  1. Involve seniors immediately, ABC (2 x 14G peripheral cannulas, lie flat, bloods incl. G&S, commence warmed crystalloid infusion)
  2. Mechanical = rubbing up the fundus, catheterisation to prevent bladder distension and monitor UO
  3. Medical
  4. Surgical
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81
Q

Primary PPH Medical Rx?

A
  1. IV Oxytocin = slow IV injection followed by infusion
  2. Ergometrine slow IV or IM (Unless Hx of HTN)
  3. Carboprost IM (unless Hx of asthma)
  4. Intramyometrial carboprost
  5. Rectal misoprostol
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82
Q

Primary PPH Surgical Rx?

A
  1. Intrauterine balloon tamponade
  2. B-lynch suture
  3. Ligation of uterine/internal iliac arteries
  4. If severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life saving procedure
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83
Q

Medical C/I to breastfeeding?

A
  1. Galactosaemia
  2. Viral infections
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84
Q

Drug C/I to breastfeeding?

A
  1. Abx = ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
  2. Psychiatric = Lithium, BZDs, clozapine
  3. Aspirin, Amiodarone
  4. Carbimazole, cytototoxic drugs, methotrexate
  5. Sulfonylureas
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85
Q

Can warfarin be taken whilst breastfeeding?

A

Yes

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86
Q

Normal Fetal HR?

A

100-160

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87
Q

CTG baseline bradycardia?

A
  1. HR < 100
  2. Increased fetal vagal tone, maternal BB use
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88
Q

CTG baseline tachycardia?

A
  1. HR > 100
  2. Maternal pyrexia, chorioamnionitis, hypoxia, prematurity
89
Q

CTG loss of baseline variability?

A

1 .<5 beats/min
2. Prematurity/hypoxia

90
Q

CTG early deceleration?

A
  1. Deceleration of the heart rate which commences with the onset of a contraction and returns to normal on completion of the contraction
  2. Usually an innocuous feature and indicates head compression
91
Q

CTG late deceleration?

A
  1. Deceleration of the heart rate which lags the onset of a contraction and does not returns to normal until after 30 seconds following the end of the contraction
  2. Indicates fetal distress e.g. asphyxia or placental insufficiency
92
Q

CTG variable decelerations?

A
  1. Independent of contractions
  2. May indicate cord compression
93
Q

Postnatal depression scale?

A

Edinburgh scale

94
Q

Edinburgh Postnatal depression scale?

A
  1. 10 item questionnaire with maximum score of 20
  2. Indicates how mother has felt over previous week
  3. Score > 13 indicated depressive illness of varying severity
  4. Sensitivity and specificity > 90%
  5. Includes a question about self harm
95
Q

Postpartum mental health problems?

A
  1. Baby blues
  2. Postnatal depression
  3. Puerperal psychosis
96
Q

Baby blues mushkies?

A
  1. 60-70% women
  2. 3-7d after birth, more common in primips
  3. Anxious, tearful, irritable
  4. Rx = reassurance and support, health visitor has a key role
97
Q

Postnatal depression mushkies?

A
  1. 10%
  2. Start within a month, peaks at 3m, features similar to depression in other circumstances
  3. Rx = reassurance and support, CBT, SSRIs e.g. sertraline/paroxetine if symptoms severe
98
Q

Puerperal psychosis mushkies?

A
  1. 0.2% women
  2. First 2-3 weeks after birth, features include severe mood swings similar to bipolar and disordered perception e.g. auditory hallucinations
  3. Rx = admission to hospital, ideally mother and baby unit, 25-50% risk of recurrence following future pregnancies
99
Q

Induction of labour prevalence?

A

20%

100
Q

Induction of labour indications?

A
  1. Prolonged pregnancy e.g. 1-2 weeks after EDD
  2. Prelabour premature rupture of membranes, where labour does not start
  3. DM > 38 weeks
  4. Pre-eclampsia
  5. Rhesus incompatbility
101
Q

How to determine whether induction of labour will be required?

A

Bishop score

102
Q

Bishop score criterial?

A

Scoring = 0,1,2,3
1. Cervical position = posterior, intermediate, anterior
2. Cervical consistency = firm, intermediate, soft
3. Cervical effacement = 0-30%, 40-50%, 60-70%, 80%
4. Cervical dilation = <1cm, 1-2cm, 3-4cm, >5cm
5. Fetal station = -3, -2, -1/0, +1/+2
5. Fetal station

103
Q

Bishop score interpretation?

A
  1. <5 = unlikely to start without induction
  2. > =8 = cervix is ripe/favourable (high change of spontaneous labour/response to interventions made to induce labour)
104
Q

Induction of labour methods?

A
  1. Membrane sweep
  2. Vaginal Prostaglandin E2
  3. Maternal oxytocin infusion
  4. Amniotomy
  5. Cervical ripening balloon
105
Q

Membrane sweep mushkies?

A
  1. Involves the examining finger passing through the cervix to rotate against the wall of the uterus, to separate the chorionic membrane from the decidua
  2. Can be done by a midwife at the antenatal clinic. Nulliparous women are typically offered this at the 40- and 41-week antenatal visit, whereas parous women are offered it at the 41-week visit
  3. Membrane sweeping is regarded as an adjunct to induction of labour rather than an actual method of induction
  4. Prior to formal induction of labour, women should be offered a vaginal examination for membrane sweeping
106
Q

Preferred method for induction of labour?

A

Vaginal Prostaglandin E2

107
Q

Main complication of induction of labour?

A

Uterine hyperstimulation

108
Q

Uterine hyprestimulation mushkies?

A
  1. Refers to prolonged and frequent uterine contractions - sometimes called tachysystole
  2. Potential consequences = fetal hypoxaemia and acidemia, uterine rupture (rare)
  3. Rx = remove vaginal prostaglandins if possible and stopping the oxytocin infusion if one has been started. Tocolysis with terbutaline.
109
Q

Rhesus negative women receive anti-D when?

A

28 + 34 weeks

110
Q

What does intrapartum Abx entail?

A

IV benzylpenicillin ASAP after start of labour, then at 4 hourly intervals until delivery

111
Q

Woody uterus?

A

Placental abruption

112
Q

Placental abruption definition?

A

Placental abruption describes separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space, occurs in 1/200

113
Q

Placental abruption associated factors?

A
  1. Proteinuric HTN
  2. Cocaine use
  3. Multiparity
  4. Maternal trauma
  5. Increasing maternal age
114
Q

Placental abruption features?

A
  1. Shock out of keeping with visible loss
  2. Pain constant
  3. Tender, tense uterus
  4. Normal lie and presentation
  5. Foetal heartbeat = absent/distressed
  6. Coagulation problems
  7. Beware pre-eclampsia, DIC, anuria
115
Q

HELLP syndrome?

A

Severe form of pre-eclampsia whose features include: Haemolysis (H), elevated liver enzymes (EL), and low platelets (LP). A typical patient might present with malaise, nausea, vomiting, and headache. Hypertension with proteinuria is a common finding, as well as epigastric and/or upper abdominal pain.

116
Q

Intrahepatic cholestasis of pregnancy (AKA obstetric cholestasis) mushkies?

A
  1. 1% pregnancies, usually 3rd trimester, most common liver disease of pregnancy
  2. Features = pruritis often palms and soles, no rash, raised bilirubin
117
Q

Obstetric cholestasis Rx?

A
  1. UDCA for symptomatic relief
  2. Weekly LFTs
  3. Women typically induced at 37 weeks
118
Q

Obstetric cholestasis complications?

A

Increased rate of stillbirth

119
Q

Acute fatty liver of pregnancy features?

A
  1. Rare, usually 3rd trimester or in the period immediately following delivery
  2. Abdominal pain, N&V, headache, jaundice, hypoglycaemia, severe disease may result in pre-eclampsia
120
Q

AFLP Ix?

A

Raised ALT

121
Q

AFLP Rx?

A
  1. Supportive care
  2. Once stabilised, delivery is the definitive Rx
122
Q

Congenital rubella syndrome classical triad?

A
  1. Sensorineural deafness
  2. Eye abnormalities
  3. Congenital heart disease
123
Q

Toxoplasmosis features?

A
  1. Intracranial calcification
  2. Hydrocephalus
  3. Epilepsy
124
Q

Obesity in pregnancy management?

A
  1. 5mg folic acid until 12w
  2. OGTT at 24-28 weeks
  3. BMI >35 –> give birth in consultant-led obstetric unit
  4. BMI >40 –> antenatal consultation with obstetric anaesthetist and a plan made
125
Q

Placenta praevia definition?

A

Placenta lying wholly or partly in the lower uterine segment

126
Q

Placenta praevia epidemiology?

A
  1. 5% low-lying placenta at 16-20 weeks
  2. 0.5% at delivery
127
Q

Placenta praevia associated factors?

A
  1. Multiparity
  2. Multiple pregnancy
  3. Embryos are more likely to implant on a lower segment scar from previous CS
128
Q

Placenta praevia features?

A
  1. Shock in proportion to visible loss
  2. No pain, uterus not tender
  3. Lie and presentation may be normal
  4. Foetal heart usually normal
  5. Coagulation problems rare
  6. Small bleeds before large
129
Q

Placenta praevia Dx?

A
  1. Digital vaginal examination should not be performed before an ultrasound as it may provoke a severe haemorrhage
  2. Often picked up on 20 week routine abdominal US
  3. RCOG recommend the use of transvaginal ultrasound as it improves the accuracy of placental localisation and is considered safe
130
Q

Placenta praevia grading?

A
  1. I = placenta reaches lower segment but not the internal os
  2. II = placenta reaches internal os but doesn’t cover it
  3. III = placenta covers the internal os before dilation but not when dilated
  4. IV = placenta completely covers the internal os
131
Q

Normal pregnancy BP variations?

A
  1. Usually falls in 1st trimester (particuarly diastolic) and continues to fall until 20-24 weeks
  2. After this time the blood pressure usually increases to pre-pregnancy levels by term
132
Q

HTN in pregnancy definition?

A
  1. Systolic > 140 or Diastolic >90
  2. Or Increase in booking readings of >30 systolic or >15 diastolic
133
Q

3 types of HTN in pregnancy?

A
  1. Pre-existing HTN
  2. Pregnancy-induced HTN (PIH/GH)
  3. Pre-eclampsia
134
Q

Pre-existing HTN mushkies?

A
  1. A history of hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation
  2. No proteinuria, no oedema
  3. Occurs in 3-5% of pregnancies and is more common in older women
135
Q

PIH mushkies?

A
  1. HTN after 20 weeks
  2. No proteinuria, no oedema
  3. Occurs in around 5-7% of pregnancies
  4. Resolves following birth (typically after one month). Women with PIH are at increased risk of future pre-eclampsia or hypertension later in life
136
Q

Pre-eclampsia mushkies?

A
  1. Pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours)
  2. Oedema may occur but is now less commonly used as a criteria
  3. Occurs in around 5% of pregnancies
137
Q

Oligohydramnios definition?

A

<500ml at 32-36 weeks and an amniotic fluid index <5th percentile

138
Q

Oligohydramnios causes?

A
  1. PROM
  2. Fetal renal problems e.g. renal agenesis
  3. IUGR
  4. Post-term gestation
  5. Pre-eclampsia
139
Q

Minor breastfeeding problems?

A
  1. Nipple pain = may be caused by poor latch
  2. Blocked duct (‘milk bleb’) = causes nipple pain when breastfeeding. Breastfeeding should continue. Advice should be sought regarding the positioning of the baby. Breast massage may also be tried
  3. Nipple candidiasis = continue breastfeeding, miconazole cream for mum, nystatin suspension for baby
140
Q

Mastitis Rx?

A
  1. Rx if systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal or if culture indicates infection
  2. Breastfeeding or expressing should continue during treatment
  3. Flucloxacillin 110-14 days
  4. If untreated, may develop into breast abscess, generally requires I&D
141
Q

Breast engorgement mushkies?

A

It usually occurs in the first few days after the infant is born and almost always affects both breasts. The pain or discomfort is typically worse just before a feed. Milk tends to not flow well from an engorged breast and the infant may find it difficult to attach and suckle. Fever may be present but usually settles within 24 hours. The breasts may appear red. Complications include blocked milk ducts, mastitis and difficulties with breastfeeding and, subsequently, milk supply.
Although it may initially be painful, hand expression of milk may help relieve the discomfort of engorgement.

142
Q

Raynaud’s disease of the nipple?

A

In Raynaud’s disease of the nipple, pain is often intermittent and present during and immediately after feeding. Blanching of the nipple may be followed by cyanosis and/or erythema. Nipple pain resolves when nipples return to normal colour.

143
Q

Raynaud’s disease of the nipple Rx?

A
  1. Minimise exposure to cold, use of heat packs following a breastfeed, avoid caffeine and stop smoking
  2. If symptoms persist consider specialist referral for trial of oral nifedipine (off-license)
144
Q

Concerns about poor infant weight gain?

A

Around 1 in 10 breastfed babies lose more than the ‘cut-off’ 10% threshold in the first week of life. This should prompt consideration of the above breastfeeding problems. The infant should also be examined to look for any underlying problems. NICE recommends an ‘expert’ review of feeding if this occurs (e.g. midwife-led breastfeeding clinics) and monitoring of weight until weight gain is satisfactory

145
Q

Puerperal pyrexia definition?

A

Temperature >38 in first 14 days following delivery

146
Q

Puerperal pyrexia causes?

A
  1. Endometritis = most common cause
  2. UTI
  3. Wound infections = perineal tears + C-section
  4. Mastitis
  5. VTE
147
Q

Puerperal pyrexia Rx?

A

Admission for IV Abx (Clindamycin and gentamicin until afebrile for greater than 24 hours)

148
Q

How to remember diagnostic threshold for gestational diabetes?

A

5678
1. Fasting >= 5.6
2. 2 hour >= 7.8

149
Q

Vitamin D in pregnancy?

A

10mcg OD

150
Q

Perineal tear classification?

A

1st to 4th degree

151
Q

1st degree perineal tear?

A
  1. Superficial damage with no muscle involvement
  2. Do not require any repair
152
Q

2nd degree perineal tear?

A
  1. Injury to the perineal muscle, but not involving the anal sphincter
  2. Require suturing on the ward by a suitably experienced midwife or clinician
153
Q

3rd degree perineal tear?

A
  1. Injury to perineum involving the anal sphincter complex (external anal sphincter, EAS and internal anal sphincter, IAS)
  2. Require repair in theatre by a suitably trained clinican
    3a. <50% of EAS thickness torn
    3b. >50% of EAS thickness torn
    3c. IAS torn
154
Q

4th degree perineal tear?

A
  1. Injury to perineum involving the anal sphincter complex (EAS and IAS) and rectal mucosa
  2. Require repair in theatre by a suitably trained clinician
155
Q

Shoulder dystocia definition?

A

Inability to deliver the body of the fetus using gentle traction, the head having already been delivered. It usually occurs due to impaction of the anterior fetal shoulder on the maternal pubic symphysis. Shoulder dystocia is a cause of both maternal and fetal morbidity.

156
Q

Shoulder dystocia RFs?

A
  1. Fetal macrosomia (maternal DM)
  2. High maternal BMI
  3. DM
  4. Prolonged labour
157
Q

Shoulder dystocia Rx?

A
  1. Call senior help, McRoberts’ manoeuvre
  2. An episiotomy will not relieve the bony obstruction but is sometimes used to allow better access for internal manoeuvres. Symphysiotomy and the Zavanelli manoeuvre can cause significant maternal morbidity and are not first-line options.
158
Q

Shoulder dystocia complications?

A
  1. Maternal = PPH, perineal tears
  2. Fetal = brachial plexus injury, neonatal death
159
Q

Breech presentation definition?

A

In a breech presentation the caudal end of the fetus occupies the lower segment. Whilst around 25% of pregnancies at 28 weeks are breech it only occurs in 3% of babies near term. A frank breech is the most common presentation with the hips flexed and knees fully extended. A footling breech, where one or both feet come first with the bottom at a higher position, is rare but carries a higher perinatal morbidity

160
Q

Breech presentation RFs?

A
  1. Uterine malformations, fibroids
  2. Placenta praevia
  3. Polyhydramnios/oligohydramnius
  4. Fetal abnormality
  5. Prematurity
161
Q

Is cord prolapse more common in breech presentations?

A

Yes

162
Q

Breech presentation Rx?

A
  1. <36w = many will turn spontaneously
  2. 36w = ECV, success rate 60% (offer at 36w in nulliparous, 37w in multiparous)
  3. If still in breech then options include planned C-section or vaginal delivery
163
Q

Absolute contraindications to ECV?

A
  1. Where C-section required
  2. Antepartum haemorrhage within last 7 days
  3. Abnormal CTG
  4. Major uterine abnormality
  5. Ruptured membranes
  6. Multiple pregnancy
164
Q

When is Down’s syndrome screening including nuchal scan done?

A

11 - 13+6 weeks

165
Q

Which Down’s syndrome tests are offered between 15 and 20 weeks?

A

Triple and quadruple tests

166
Q

> 37w and showing signs of pre-eclampsia Rx?

A

Give birth within 24-48 hours

167
Q

Most important antigen of rhesus system?

A

D antigen

168
Q

Rhesus system mushkies?

A

1.15% are Rh -ve
2. If a Rh -ve mother delivers a Rh +ve child a leak of fetal red blood cells may occur
3. This causes anti-D IgG antibodies to form in mother
4. In later pregnancies these can cross placenta and cause haemolysis in fetus
5. This can also occur in the first pregnancy due to leaks

169
Q

Preventative Rx of rhesus negative pregnancy?

A
  1. D antibodies tested in all Rh -ve mothers at booking, give anti-D to non-sensitised Rh-ve mothers at 28 and 34 weeks
  2. Anti-D is prophylaxis = once sensitisation has occurred it is irreversible
  3. If event is in 2nd/3rd trimester give large dose of anti-D and perform Kleihauer test
170
Q

Kleihauer test?

A

Determines proportion of fetal RBCs present

171
Q

When should Anti-D Ig be given (within 72h but ideally ASAP)?

A
  1. Delivery of RH +ve infant, whether live or stillborn
  2. Any ToP
  3. Miscarriage if gestation > 12 weeks
  4. Surgically managed ectopic pregnancy
  5. ECV
  6. Antepartum haemorrhage
  7. Amniocentesis, CVS, fetal blood sampling
  8. Abdominal trauma
172
Q

Rhesus testing?

A
  1. All babies born to Rh -ve mother should have cord blood taken at delivery for FBC, blood group & direct Coombs test
  2. Coombs test: direct antiglobulin, will demonstrate antibodies on RBCs of baby
  3. Kleihauer test: add acid to maternal blood, fetal cells are resistant
173
Q

Rhesus affected foetus?

A
  1. Oedematous (hydrops fetalis)
  2. Jaundice, anaemia, hepatosplenomegaly
  3. HF
  4. Kernicterus
  5. Rx = transfusions, UV phototherapy
174
Q

When should delivery be offered for pre-eclampsia?

A

34 weeks (unless severe HTN remains refractory), after corticosteroids given

175
Q

When is second screen for anaemia and atypical red cell alloantibodies considered?

A

28 weeks

176
Q

SFH measurement?

A

Top of the pubic bone to the top of the uterus in cm

177
Q

SFH calculation?

A

After 20 weeks, gestation in weeks +/-2 cm

178
Q

Eclampsia Rx?

A

Magnesium sulphate

179
Q

Magnesium sulphate for eclampsia mushkies?

A
  1. Used to both prevent seizures in patients with severe pre-eclampsia and treat seizures once they develop
  2. Should be given once a decision to deliver has been made
  3. In eclampsia an IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour
  4. Treatment should continue for 24 hours after last seizure or delivery (around 40% of seizures occur post-partum)
180
Q

What needs to be monitored during MgSO4 Rx?

A
  1. UO, reflexes, RR and SPO2
  2. Respiratory depression an occur - calcium gluconate is the first-line treatment for magnesium sulphate induced respiratory depression
181
Q

Final eclampsia/pre-eclampsia Rx mushkie?

A

Fulid restriction to prevent overload

182
Q

Gestational trophoblastic disorder definition?

A

Describes a spectrum of disorders originating from the placental trophoblast:
1. Complete hydatidiform mole
2. Partial hydatidiform mole
3. Choriocarcinoma

183
Q

Complete hydatidiform mole definition?

A

Benign tumour of trophoblastic material. Occurs when an empty egg is fertilized by a single sperm that then duplicates its own DNA, hence the all 46 chromosomes are of paternal origin

184
Q

Complete hydatidiform mole features?

A
  1. Bleeding in 1st or early 2nd trimester
  2. Exaggerated symptoms of pregnancy - e.g. hyperemesis
  3. Uterus large for dates
  4. Very high hCG
  5. HTN and hyperthyroidism may be seen
185
Q

Complete hydatidiform mole Rx?

A
  1. Urgent referral to specialist centre - evacuation of the uterus is performed
  2. Effective contraception is recommended to avoid pregnancy in the next 12 months
186
Q

What % of complete hydatidiform moles go on to develop choriocarcinoma?

A

2-3%

187
Q

Partial hydatidiform mole?

A

A normal haploid egg may be fertilized by two sperms, or by one sperm with duplication of the paternal chromosomes. Therefore the DNA is both maternal and paternal in origin. Usually triploid - e.g. 69 XXX or 69 XXY. Fetal parts may be seen

188
Q

Fetal parts seen in what kind of hydatidiform mole?

A

Partial

189
Q

Chorioamniotis mushkies?

A

Chorioamnionitis (which can affect up to 5% of all pregnancies) is a potentially life-threatening condition to both mother and foetus and is therefore considered a medical emergency. It is usually the result of an ascending bacterial infection of the amniotic fluid / membranes / placenta. The major risk factor in this scenario is the preterm premature rupture of membranes (however, it can still occur when the membranes are still intact) which expose the normally sterile environment of the uterus to potential pathogens. Prompt delivery of the foetus (via cesarean section if necessary) and administration of intravenous antibiotics is widely considered the mainstay of initial treatment for this condition.

190
Q

UTI Rx in breastfeeding women?

A

Trimethoprim

191
Q

Diabetic maternal complications?

A
  1. Polyhydramnios
  2. Preterm labour
192
Q

Diabetic neonatal complications?

A
  1. Macrosome although SGA babies also possible
  2. Hypoglycaemia, hypomagnesaemia, hypocalcaemia
  3. RDS as surfactant production delayed
  4. Malformation rates infcrease
  5. Stillbirth
  6. Shoulder dystocia
193
Q

Preferred AEDs in pregnancy?

A
  1. Lamotrigine
  2. Carbamazepine
  3. Levetiracetam
194
Q

Phenytoin teratogenic effect?

A

Associated with cleft palate

195
Q

Aspirin in breastfeeding?

A

Contraindicated

196
Q

Episiotomy definition?

A

Incision in the posterior wall of the vagina and perineum that is performed in the second stage of labour to facilitate the passage of the fetus.

197
Q

Down’s combined test?

A
  1. Done between 11-13+6 weeks
  2. Nuchal translucency + serum bHCG + PAPPA-A
198
Q

Down’s syndrome combined test results?

A

Thickened nuchal translucency, raised HCG, reduced PAPP-A

199
Q

When is quadruple test offered?

A

Between 15 - 20 weeks

200
Q

Quadruple test?

A
  1. AFP
  2. Unconjugated oestriol
  3. HCG
  4. Inhibin A
201
Q

NTD Quadruple test results?

A

Raised AFP

202
Q

Down’s syndrome quadruple test result?

A
  1. AFP = low
  2. Unconjugated oestriol = low
  3. HCG = high
  4. Inhibin A = high
203
Q

Edward’s syndrome quadruple test result?

A

All low, Inhibin A normal

204
Q

Raised AFP?

A

NTD

205
Q

Combined and quadruple test results?

A
  1. Lower chance = 1 in 150 or more
  2. Higher chance = 1 in 150 or less
206
Q

NIPT?

A

Non-invasive prenatal testing

207
Q

NIPT mushkies?

A

If a woman has a ‘higher chance’ results she will be offered a second screening test (NIPT) or a diagnostic test (e.g. amniocentesis or chorionic villus sampling (CVS). Given the non-invasive nature of NIPT and extremely high sensitivity and specificity, it is likely this will be the preferred choice for the vast majority of women.

208
Q

NIPT further mushkies?

A
  1. Analyses small DNA fragments that circulate in the blood of a pregnant woman (cell free fetal DNA, cffDNA)
  2. cffDNA derives from placental cells and is usually identical to fetal DNA
  3. Analysis of cffDNA allows for the early detection of certain chromosomal abnormalities
  4. Sensitivity and specificity are very high for trisomy 21 (>99%) and similarly high for other chromosomal abnormalities
  5. Private companies (e.g. Harmony) offer NIPT screening from 10 weeks gestation
209
Q

Renal agenesis what type of amnios?

A

Oligohydramnios

210
Q

GBS isolated during antenatal treatment from high vaginal swab?

A

No immediate treatment, treat with intrapartum IV benzylpenicillin

211
Q

RhA and pregnancy?

A
  1. Early/poorly controlled RA should defer conception until more stable
  2. Symptoms tend to improve during pregnancy, but flare after delivery
  3. MTX needs to be stopped 6m before conception
  4. Leflunomide not safe
  5. Sulfasalazine and HCQ considered safe
  6. NSAIDs may be used until 32 weeks but after this time should be withdrawn due to the risk of early close of the ductus arteriosus
  7. Should be referred to obstetric anaesthetist due to risk of atlanto-axial subluxation
212
Q

Smoking and pregnancy risk?

A

Miscarriage, pre-term labour, stillbirth, IUGR, SIDS

213
Q

FAS features?

A
  1. Learning difficulties
  2. Characteristic facies: smooth philtrum, thin vermilion, small palpebral fissures, epicanthic folds, microcephaly
  3. IUGR and postnatal restricted growth
214
Q

Cannabis and pregnancy risk?

A

Similar to smoking risks due to tobacco content

215
Q

Cocaine and pregnancy risk?

A
  1. Maternal = HTN and pre-eclampsia, placental abruption
  2. Fetal = prematurity, neonatal abstinence syndrome
216
Q

Heroin and pregnancy risk?

A

Neonatal abstinence syndrome

217
Q

When is anomaly scan done?

A

18 - 20+6 weeks

218
Q

When are extra appts provided for primips?

A

25 weeks, 31 weeks, 40 weeks

219
Q

Premature labour Rx?

A

Tocolytics and steroids

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