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
2
Q
HIV and mode of delivery?
A
- Vaginal delivery recommended if viral load <50 copies/ml at 36 weeks, otherwise C-section is recommended
- Zidovudine infusion should be started 4 hours before beginning C-section
3
Q
Neonatal ART?
A
- Oral zidovudine if maternal vital load <50, otherwise triple ART should be used
- Therapy should be continued for 4-6 weeks
4
Q
HIV and breastfeeding?
A
Should be advised not to
5
Q
Rubella AKA?
A
German measles, caused by the togavirus
6
Q
Rubella risk in pregnancy?
A
- In first 8-10 weeks risk of damage to fetus is as high as 90%
- Damage is rare after 16 weeks
7
Q
Congenital rubella syndrome features?
A
- Sensorineural deafness
- Congenital cataracts
- CHD (PDA)
- Hepatosplenomegaly, growth retardation
- Purpuric skin lesions
- Salt and pepper chorioretinitis
- Microphthalmia
- Cerebral palsy
8
Q
Rubella Dx?
A
- Suspected cases discussed immediately with HPU
- IgM raised in acute exposure
- 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
9
Q
Rubella Rx?
A
- Discuss with local HPU
- Rubella immunity no longer routinely checked at booking
- Non-immune mothers should be offered MMR vaccination in the post-natal period
10
Q
Pregnancy anaemia screening times?
A
- Booking visit (8-10 weeks)
- 28 weeks
11
Q
Pregnancy cut offs for oral iron therapy?
A
- 1st trimester = <110g/L
- 2nd/3rd = <105 g/L
- Postpartum = <100 g/L
12
Q
Pregnancy anaemia Rx?
A
Oral ferrous sulfate or ferrous fumarate for 3m after correction to allow iron stores to be replenished
13
Q
Pregnant women with GDM CBG targets?
A
- Fasting = 5.3mmol/L
- 1 hours postprandial = 7.8mmol/L
- 2 hours postprandial = 6.4mmol/L
14
Q
Gestational diabetes (GDM) prevalence?
A
1/20 pregnancies
15
Q
GDM RFs?
A
- BMI > 30
- Previous macrosomic baby weighing >4.5kg
- Previous GDM
- 1st degree relative with DM
- Family origin with high prevalence of diabetes
16
Q
GDM screening?
A
- OGTT
- 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
- Women with any RFs should be offered OGTT at 24-28 weeks
17
Q
Diagnostic thresholds for GDM?
A
- Fasting glucose >5.6
- 2 hour glucose >7.8
18
Q
GDM Rx?
A
- Joint diabetes and antenatal clinic in 1 week
- Taught about blood glucose self-monitoring
- Diet and exercise advice
- Medications
19
Q
GDM Medications Rx?
A
- Fasting <7 = trial diet and exercise –> if not met within 1-2 weeks, metformin should be started
- If targets still not met insulin should be added
- GDM is Rx with short acting not long acting insulins
- If at time of diagnosis fasting glucose level is >7 insulin should be started
- If 6-6.9 and evidence of complications such as macrosomia or hydramnios, insulin should be offered
- 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
20
Q
Pre-existing DM Rx?
A
- Weight loss for women with BMI > 27
- Stop oral hypoglycaemic agents apart from metformin and commence insulin
- Folic acid 5mg/day from pre-conception to 12 weeks gestation
- Detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts
- Tight glycaemic control reduces complication rates
- Treat retinopathy as can worsen during pregnancy
21
Q
Folic acid deficiency causes?
A
- Phenytoin
- Methotrexate
- Pregnancy
- Alcohol excess
22
Q
Consequences of folic acid deficiency?
A
- Macrocytic, megaloblastic anaemia
- Neural tube defects
23
Q
Prevention of NTD during pregnancy?
A
- All women should take 400mcg folic acid until 12th week of pregnancy
- Women at higher risk should take 5mg from before conception until 12th week of pregnancy
24
Q
Higher risk of NTDs?
A
- Either partner has NTD, previous NTD pregnancy, FHx NTD
- Antiepileptic drugs, coeliac diease, DM, thalassaemia trait
- Woman is obese
25
Bleeding in pregnancy classification?
1st, 2nd and 3rd trimester
26
1st trimester bleeding in pregnancy causes?
1. Spontaneous abortion
2. Ectopic pregnancy
3. Hydatidiform mole
27
2nd trimester bleeding in pregnancy causes?
1. Spontaneous abortion
2. Placental abruption
3. Hydatidiform mole
28
3rd trimester bleeding in pregnancy causes?
1. Placental abruption
2. Placenta Praevia
3. Vasa Praevia
4. Bloody show
29
Antepartum haemorrhage definition?
Bleeding after 24 weeks
30
Hydatidiform presentation?
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
31
Placental abruption presentation?
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
32
Placenta praevia presentation?
Vaginal bleeding, no pain. Non-tender uterus* but lie and presentation may be abnormal
33
Vasa praevia presentation?
Rupture of membranes followed immediately by vaginal bleeding. Fetal bradycardia is classically seen
34
Why should vaginal examination not be performed in primary care for suspected antepartum haemorrhage?
Women with placenta praevia may haemorrhage
35
Types of C-section?
1. LSCS = 99%
2. Classic = longitudinal incision in upper segment of uterus
36
Category 1 C-section mushkies?
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
37
Category 2 C-section mushkies?
1. Maternal or fetal compromise which is not immediately life-threatening
2. Delivery of baby should occur within 75 minutes of making the decision
38
Category 3 C-section?
Delivery is required, but mother and baby are stable
39
Category 4 C-section?
Elective C-section
40
Serious maternal C-section risks?
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
41
Frequent maternal C-section risks?
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
42
Frequent fetal C-section risk?
Laceration, 1/2 in every 100
43
'Other' c-section complications?
1. Prolonged ileus
2. Subfertility: due to postoperative adhesions
44
Vaginal birth after Caesarian (VBAC)?
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
45
Chickenpox exposure risk to mother?
5x greater risk of pneumonitis
46
Fetal varicella syndrome mushkies?
1. Risk of FVS following exposure 1% before 20 weeks
2. Small number occur between 20-28 weeks, none following 28 weeks
47
FVS features?
1. Skin scarring
2. Eye defects (microphthalmia)
3. Limb hypoplasia
4. Microcephaly
5. Learning disabilities
48
Risk of shingles in infancy?
1-2% risk if maternal exposure in the 2nd or 3rd trimester
49
Neonatal varicella risk?
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
50
Chickenpox exposure in pregnancy Rx?
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
51
Chickenpox in pregnancy Rx?
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
52
Antenatal care overall mushkies?
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
53
Antenatal care times?
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
54
Booking visit?
1. General info = diet, alcohol, smoking, folic acid, Vitamin D, antenatal classes
2. BP, urine dipstick, check BMI
55
Booking bloods/urine?
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
56
When is anti-D prophylaxis given?
28 weeks and 34 weeks
57
When is presentation checked?
36 weeks
58
Most common cause of early-onset severe infection in neonatal period?
GBS
59
GBS mushkies?
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.
60
RFs for GBS infection?
1. Prematurity
2. PROM
3. Previous sibling GBS infection
4. Maternal pyrexia e.g. secondary to chorioamnionitis
61
GBS Rx?
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
62
Pre-eclampsia triad
1. New-onset HTN
2. Proteinuria
3. Oedema
63
Pre-eclampsia definition?
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
64
Pre-eclampsia consequences?
1. Eclampsia
2. Fetal = IUGR, prematurity
3. Liver = elevated transaminases
4. Haemorrhage: placental abruption, intra-abdominal, intra-cerebral
5. Cardiac failure
65
Severe pre-eclampsia features?
1. HTN > 160/110 and proteinuria ++/+++
2. Headache, visual disturbance, papilloedema
3. RUQ/epigastric pain, hyperreflexia
4. Plt < 100, abnormal liver enzymes, HELLP
66
Pre-eclampsia moderate RFs?
1. 1st pregnancy
2. > 40 y/o
3. Pregnancy interval >10 years
4. BMI 35
5. FHx Pre-eclampsia
6. Multiple pregnancy
67
Pre-eclampsia high risk factors?
1. HTN in prev. pregnancy
2. CKD
3. AI e.g. SLE/APS
4. T1DM/T2DM
5. Chronic HTN
68
Reducing risk of hypertensive disorders in pregnancy?
1. Aspirin 75-150mg OD from 12wks until birth
a. >=1 high risk factor
v. >=2 moderate risk factors
69
Pre-eclampsia initial asessment?
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
70
Pre-eclampsia further management?
1. Oral labetalol 1st line (nifedifine may be used if asthmatic, hydralazine also)
2. Delivery of baby is definitive management
71
Placental abruption vs. praevia distinguish?
Abruption = pain, praevia = no pain
72
Placental abruption definition?
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.
73
Symphysis pubis dysfunction mushkies?
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
74
Uterine rupture mushkies?
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
75
Postpartum haemorrhage (PPH) definition?
Blood loss >500ml after vaginal delivery
76
PPH classification?
1. Primary = Within 24h
2. Secondary = 24h-6w
77
Secondary PPH causes?
1. Retained placental tissue
2. Endometritis
78
Primary PPH causes?
4 Ts
1. Tone = uterine atony, most common
2. Trauma = perineal tear
3. Tissue = retained placenta
4. Thrombin = clotting/bleeding disorder
79
Risk factors for Primary PPH?
1. Previous PPH, prolonged labour, pre-eclampsia
2. Age, Polyhdramnios
3. Placenta praevia/accreta
4. EMCS
5. Macrosomia
6. Nulliparity
80
Primary PPH Rx?
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
81
Primary PPH Medical Rx?
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
82
Primary PPH Surgical Rx?
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
83
Medical C/I to breastfeeding?
1. Galactosaemia
2. Viral infections
84
Drug C/I to breastfeeding?
1. Abx = ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
2. Psychiatric = Lithium, BZDs, clozapine
3. Aspirin, Amiodarone
4. Carbimazole, cytototoxic drugs, methotrexate
5. Sulfonylureas
85
Can warfarin be taken whilst breastfeeding?
Yes
86
Normal Fetal HR?
100-160
87
CTG baseline bradycardia?
1. HR < 100
2. Increased fetal vagal tone, maternal BB use
88
CTG baseline tachycardia?
1. HR > 100
2. Maternal pyrexia, chorioamnionitis, hypoxia, prematurity
89
CTG loss of baseline variability?
1 .<5 beats/min
2. Prematurity/hypoxia
90
CTG early deceleration?
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
CTG late deceleration?
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
CTG variable decelerations?
1. Independent of contractions
2. May indicate cord compression
93
Postnatal depression scale?
Edinburgh scale
94
Edinburgh Postnatal depression scale?
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
Postpartum mental health problems?
1. Baby blues
2. Postnatal depression
3. Puerperal psychosis
96
Baby blues mushkies?
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
Postnatal depression mushkies?
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
Puerperal psychosis mushkies?
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
Induction of labour prevalence?
20%
100
Induction of labour indications?
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
How to determine whether induction of labour will be required?
Bishop score
102
Bishop score criterial?
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
Bishop score interpretation?
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
Induction of labour methods?
1. Membrane sweep
2. Vaginal Prostaglandin E2
3. Maternal oxytocin infusion
4. Amniotomy
5. Cervical ripening balloon
105
Membrane sweep mushkies?
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
Preferred method for induction of labour?
Vaginal Prostaglandin E2
107
Main complication of induction of labour?
Uterine hyperstimulation
108
Uterine hyprestimulation mushkies?
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
Rhesus negative women receive anti-D when?
28 + 34 weeks
110
What does intrapartum Abx entail?
IV benzylpenicillin ASAP after start of labour, then at 4 hourly intervals until delivery
111
Woody uterus?
Placental abruption
112
Placental abruption definition?
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
Placental abruption associated factors?
1. Proteinuric HTN
2. Cocaine use
3. Multiparity
4. Maternal trauma
5. Increasing maternal age
114
Placental abruption features?
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
HELLP syndrome?
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
Intrahepatic cholestasis of pregnancy (AKA obstetric cholestasis) mushkies?
1. 1% pregnancies, usually 3rd trimester, most common liver disease of pregnancy
2. Features = pruritis often palms and soles, no rash, raised bilirubin
117
Obstetric cholestasis Rx?
1. UDCA for symptomatic relief
2. Weekly LFTs
3. Women typically induced at 37 weeks
118
Obstetric cholestasis complications?
Increased rate of stillbirth
119
Acute fatty liver of pregnancy features?
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
AFLP Ix?
Raised ALT
121
AFLP Rx?
1. Supportive care
2. Once stabilised, delivery is the definitive Rx
122
Congenital rubella syndrome classical triad?
1. Sensorineural deafness
2. Eye abnormalities
3. Congenital heart disease
123
Toxoplasmosis features?
1. Intracranial calcification
2. Hydrocephalus
3. Epilepsy
124
Obesity in pregnancy management?
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
Placenta praevia definition?
Placenta lying wholly or partly in the lower uterine segment
126
Placenta praevia epidemiology?
1. 5% low-lying placenta at 16-20 weeks
2. 0.5% at delivery
127
Placenta praevia associated factors?
1. Multiparity
2. Multiple pregnancy
3. Embryos are more likely to implant on a lower segment scar from previous CS
128
Placenta praevia features?
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
Placenta praevia Dx?
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
Placenta praevia grading?
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
Normal pregnancy BP variations?
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
HTN in pregnancy definition?
1. Systolic > 140 or Diastolic >90
2. Or Increase in booking readings of >30 systolic or >15 diastolic
133
3 types of HTN in pregnancy?
1. Pre-existing HTN
2. Pregnancy-induced HTN (PIH/GH)
3. Pre-eclampsia
134
Pre-existing HTN mushkies?
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
PIH mushkies?
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
Pre-eclampsia mushkies?
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
Oligohydramnios definition?
<500ml at 32-36 weeks and an amniotic fluid index <5th percentile
138
Oligohydramnios causes?
1. PROM
2. Fetal renal problems e.g. renal agenesis
3. IUGR
4. Post-term gestation
5. Pre-eclampsia
139
Minor breastfeeding problems?
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
Mastitis Rx?
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
Breast engorgement mushkies?
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
Raynaud's disease of the nipple?
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
Raynaud's disease of the nipple Rx?
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
Concerns about poor infant weight gain?
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
Puerperal pyrexia definition?
Temperature >38 in first 14 days following delivery
146
Puerperal pyrexia causes?
1. Endometritis = most common cause
2. UTI
3. Wound infections = perineal tears + C-section
4. Mastitis
5. VTE
147
Puerperal pyrexia Rx?
Admission for IV Abx (Clindamycin and gentamicin until afebrile for greater than 24 hours)
148
How to remember diagnostic threshold for gestational diabetes?
5678
1. Fasting >= 5.6
2. 2 hour >= 7.8
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Vitamin D in pregnancy?
10mcg OD
150
Perineal tear classification?
1st to 4th degree
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1st degree perineal tear?
1. Superficial damage with no muscle involvement
2. Do not require any repair
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2nd degree perineal tear?
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
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3rd degree perineal tear?
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
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4th degree perineal tear?
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
Shoulder dystocia definition?
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
Shoulder dystocia RFs?
1. Fetal macrosomia (maternal DM)
2. High maternal BMI
3. DM
4. Prolonged labour
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Shoulder dystocia Rx?
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
Shoulder dystocia complications?
1. Maternal = PPH, perineal tears
2. Fetal = brachial plexus injury, neonatal death
159
Breech presentation definition?
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
Breech presentation RFs?
1. Uterine malformations, fibroids
2. Placenta praevia
3. Polyhydramnios/oligohydramnius
4. Fetal abnormality
5. Prematurity
161
Is cord prolapse more common in breech presentations?
Yes
162
Breech presentation Rx?
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
Absolute contraindications to ECV?
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
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When is Down's syndrome screening including nuchal scan done?
11 - 13+6 weeks
165
Which Down's syndrome tests are offered between 15 and 20 weeks?
Triple and quadruple tests
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>37w and showing signs of pre-eclampsia Rx?
Give birth within 24-48 hours
167
Most important antigen of rhesus system?
D antigen
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Rhesus system mushkies?
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
Preventative Rx of rhesus negative pregnancy?
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
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Kleihauer test?
Determines proportion of fetal RBCs present
171
When should Anti-D Ig be given (within 72h but ideally ASAP)?
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
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Rhesus testing?
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
Rhesus affected foetus?
1. Oedematous (hydrops fetalis)
2. Jaundice, anaemia, hepatosplenomegaly
3. HF
4. Kernicterus
5. Rx = transfusions, UV phototherapy
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When should delivery be offered for pre-eclampsia?
34 weeks (unless severe HTN remains refractory), after corticosteroids given
175
When is second screen for anaemia and atypical red cell alloantibodies considered?
28 weeks
176
SFH measurement?
Top of the pubic bone to the top of the uterus in cm
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SFH calculation?
After 20 weeks, gestation in weeks +/-2 cm
178
Eclampsia Rx?
Magnesium sulphate
179
Magnesium sulphate for eclampsia mushkies?
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
What needs to be monitored during MgSO4 Rx?
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
Final eclampsia/pre-eclampsia Rx mushkie?
Fulid restriction to prevent overload
182
Gestational trophoblastic disorder definition?
Describes a spectrum of disorders originating from the placental trophoblast:
1. Complete hydatidiform mole
2. Partial hydatidiform mole
3. Choriocarcinoma
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Complete hydatidiform mole definition?
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
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Complete hydatidiform mole features?
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
Complete hydatidiform mole Rx?
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
What % of complete hydatidiform moles go on to develop choriocarcinoma?
2-3%
187
Partial hydatidiform mole?
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
Fetal parts seen in what kind of hydatidiform mole?
Partial
189
Chorioamniotis mushkies?
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
UTI Rx in breastfeeding women?
Trimethoprim
191
Diabetic maternal complications?
1. Polyhydramnios
2. Preterm labour
192
Diabetic neonatal complications?
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
Preferred AEDs in pregnancy?
1. Lamotrigine
2. Carbamazepine
3. Levetiracetam
194
Phenytoin teratogenic effect?
Associated with cleft palate
195
Aspirin in breastfeeding?
Contraindicated
196
Episiotomy definition?
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
Down's combined test?
1. Done between 11-13+6 weeks
2. Nuchal translucency + serum bHCG + PAPPA-A
198
Down's syndrome combined test results?
Thickened nuchal translucency, raised HCG, reduced PAPP-A
199
When is quadruple test offered?
Between 15 - 20 weeks
200
Quadruple test?
1. AFP
2. Unconjugated oestriol
3. HCG
4. Inhibin A
201
NTD Quadruple test results?
Raised AFP
202
Down's syndrome quadruple test result?
1. AFP = low
2. Unconjugated oestriol = low
3. HCG = high
4. Inhibin A = high
203
Edward's syndrome quadruple test result?
All low, Inhibin A normal
204
Raised AFP?
NTD
205
Combined and quadruple test results?
1. Lower chance = 1 in 150 or more
2. Higher chance = 1 in 150 or less
206
NIPT?
Non-invasive prenatal testing
207
NIPT mushkies?
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
NIPT further mushkies?
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
Renal agenesis what type of amnios?
Oligohydramnios
210
GBS isolated during antenatal treatment from high vaginal swab?
No immediate treatment, treat with intrapartum IV benzylpenicillin
211
RhA and pregnancy?
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
Smoking and pregnancy risk?
Miscarriage, pre-term labour, stillbirth, IUGR, SIDS
213
FAS features?
1. Learning difficulties
2. Characteristic facies: smooth philtrum, thin vermilion, small palpebral fissures, epicanthic folds, microcephaly
3. IUGR and postnatal restricted growth
214
Cannabis and pregnancy risk?
Similar to smoking risks due to tobacco content
215
Cocaine and pregnancy risk?
1. Maternal = HTN and pre-eclampsia, placental abruption
2. Fetal = prematurity, neonatal abstinence syndrome
216
Heroin and pregnancy risk?
Neonatal abstinence syndrome
217
When is anomaly scan done?
18 - 20+6 weeks
218
When are extra appts provided for primips?
25 weeks, 31 weeks, 40 weeks
219
Premature labour Rx?
Tocolytics and steroids
