Obstetrics Flashcards
when can nausea and vomiting in pregnancy be diagnosed?
simple NVP in pregnancy can only be diagnosed before 16 weeks.
if a woman presents with severe n+v post 16 weeks, alternative causes must be considered (although the nausea and vomiting itself can last longer than 16 weeks)
how common in NVP in pregnancy?
NVP is very common and can affect 90% of pregnant women. Cases tend to peak at week around week 9 and most cases have resolved by week 20.
what are some complications of HG/NVP in pregnancy?
electrolyte imbalance
wernickes encephalopathy - if thiamine deficient due to poor nutritional status
dehydration
oesphagitis/barretts oesophagus
constipation
increased risk of thromboembolism
reduced fetal growth
inability to tolerate important medications for other conditions i.e. epilepsy, thryoid
what should be taken as part of the hx when assessing HG?
current gestation
px hx of HG / complications during pregnancy
assess for any other sx - abdo pain/dysuria/constipation/fever - any suggestion of alternative pathology
check regular medications
relevant px surgical hx
calculate PUQE score
what should be taken as part of the examination of patient with HG?
current weight
assess for dehydration
assess neurological signs - ensure no wernickes encephalopathy - signs typically confusion, nystagmus, ataxia
abdominal examination
what investigations should be carried out in HG?
urine dip + MSU
ketones
VBG
bloods - FBC, U+E, CRP, amylase, calcium, phosphate, LFT’s + thyroid if refractory
TVUSS - if not done yet in this pregnancy (i.e. <12 weeks) to ensure in utero pregnancy and not trophoblastic disease or multiple pregnancy
what are the indications for inpatient management of HG?
continued n+v with inability to tolerate oral antiemetics
continued n+v with clinical signs of dehydration on examination/obs/bloods
alternative dx i.e. UTI exacerbating sx
high risk w/ comorbidities i.e. epilepsy , diabetes, HIV, mental health disorder
what is first line antiemetic treatment of HG?
Xonvea 20/20mg ON (can increase to 10/10mg OM and lunchtime if needed)
Cyclizine 50mg TDS PO/IV/IM
Prochlorperazine 5-10mg PO 6-10 hourly / 12.5mg 8 hourly IV/IM
Promethazine
Chlorpromazine
what is the second line antiemetic treatment of HG?
metoclopramide 10mg TDS PRN
Domperidone
Ondansetront
what is the third line treatment of HG?
prednisolone 40-50mg - gradually tapered by 5-10mg per week until maintenance dose established where sx well controlled
what are some issues with metoclopramide?
extra-pyramidal side effects with prolonged use
what are some issues with domeperidone?
women should be made aware there is a slight increase in risk of fetal orofacial clefting if used in the first trimester - this should be balanced with untreated HG risk
what other medications should be given in patients with HG?
omeprazole 20mg - reduce risk of GORD BD
thiamine 100mg TDS PO
pabrinex I+II - if 2nd admission with HG or still not tolerating food after 48 hours - only needs to be given once a week
enoxaparin if inpatient - has higher risk of thromboembolism
what IVF regimen should be prescribed to woman who are reviewed in ED/EPU with HG and do not need admission?
usually 1L 0.9% NaCL + 20mmol KCL over 2 hours
PLUS IV/IM antiemetic
what IVF regimen should be prescribed to women with HG that require admission as inpatient?
1L 0.9% Normal saline over 1 hour
1L 0.9% Normal saline over 2 hours
1L 0.9% Normal saline + 20 mmol Potassium Chloride over 4 hours x 2
1L 0.9% Normal saline + 20 mmol Potassium Chloride over 6 hours x 2
U&Es should be reviewed daily in all women requiring IV Fluids.
Women not eating must have 60-80 mmol IV Potassium Chloride per day
what are the normal antenatal appointments for a primip mother?
booking appt at 10 weeks
10 subsequent appointments - 3x during second trimester (14-16weeks, 25 week, 28 weeks)
6x during third trimester (31, 34, 36, 38, 40, 41 if not given birth)
what are the normal antenatal appointments for a mother who is having her second baby?
booking appt 10 weeks
6 appts after this - 14-16, 28, 34, 36, 38 and 41 weeks.
what is done at the booking appointment?
full detailed hx - px pregnancy, medical, complications etc.
booking height and weight , calculate BMI
urine dip - glucose / protein
blood pressure
what are some complications of placental disorders/pre-eclampsia/eclampsia?
late miscarriage
early delivery
foetal growth restriction
pre-term rupture of membranes
what is pre-eclampsia?
pre-ecamplsia is the precursor to eclampsia and means a condition during which there is new onset or worsening of existing hypertension with proteinuria after 20 weeks gestation.
what is the pathophysiology of pre-eclampsia?
pathophysiology is not well understood
it is thought that there is development of an abnormal placenta. the spiral arteries are narrowed, causing less blood to reach the placenta. Poorly perfused placenta leads to the release of pro-inflammatory proteins, which causes narrowing of blood vessels throughout the body. This causes proteinuria (damage to the kidneys), blurred vision (damage to vessels in the eye), HTN, and liver derrangment (damage to vessels of the liver).
what is eclampsia?
eclampsia is the progression of pre-eclampsia, with the development of unexplained generalised seizures in patients with pre-eclampsia.
what are the complications of pre-eclampsia?
risk of placental abruption
restricted fetal growth
pulmonary edema
acute kidney injury
liver rupture
eclampsia
HELLP syndrome
what is placental abruption?
separation of the placenta from the uterus wall early - from 20 weeks onwards - obstetric emergency.
what is the criteria for diagnosis of pre-eclampsia?
New onset after 20 weeks gestation of 1) hypertension plus 2) new unexplained proteinuria (> 300 mg/24 hours or a urine protein/creatinine ratio of ≥ 0.3) and/or signs of end-organ damage
what are some symptoms of pre-eclampsia?
Severe headache.
Problems with vision, such as blurring or flashing before the eyes.
Severe pain just below the ribs.
Vomiting.
Sudden swelling of the face, hands or feet
what is gestational hypertension?
New-onset hypertension at > 20 weeks gestation without proteinuria or other signs of end-organ damage; it resolves by 12 weeks (usually by 6 weeks) postpartum
why are patients with gestational hypertension offered aspirin?
it reduces the risk of development of pre-eclampsia and increases blood flow through the placenta
how long should women with gestational HTN take aspirin?
recommended from 12 weeks until birth
what are the main high risk factors for pre-eclampsia?
One of the following high risk factors:
A history of hypertensive disease during a previous pregnancy.
Chronic kidney disease.
Autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome.
Type 1 or type 2 diabetes.
Chronic hypertension
what are the main moderate risk factors for pre-eclampsia?
first pregnancy
over 40 years
Pregnancy interval of more than 10 years.
Body mass index (BMI) of 35 kg/m2 or greater at the first visit.
Family history of pre-eclampsia.
Multiple pregnancy.
why is RUQ pain an indicator of pre-eclampsia?
sign of HELLP syndrome
HELLP syndrome is a severe variant of pre-eclampsia
what is first line antihypertensives for gestational hypertension?
labetalol 100mg BD (contraindicated if currently has asthma, less effective in afro-Caribbean community).
Nifedipine MR 10mg BD - may cause headache and flushing - first line in afro-caribbean population.
Increase the agent to maximum dose before adding another
what is the second line antihypertensive for gestational hypertension?
Nifedipine MR 10mg BD - may cause headache and flushing
Methyldopa 250mg TDS
doxazosin 1mg OD - 8mg OD
which antihypertensive agents must be stopped during pregnancy and why?
ACE-I / ARB - due to fetal toxicity - causing renal failure, oligiohydramnios, and still birth
what is the target blood pressure whilst on antihypertensive treatment in pregnancy?
BP < 135/85
what antihypertensives can be offered postnatally?
labetalol / nifedipine - continue if short term use or woman prefers to cont antenatal medications.
Enalapril 5mg (can increase to 20mg) or amlodipine up to 10mg - if longer term antihypertensive needed
can add in atenolol if needed as third agent
when should blood pressure be monitored in postnatal period, in a woman who has had gestational hypertension?
Blood pressure should be monitored:
* Daily Day 1 and 2.
* At least once between Day 3 and Day 5
* 2 days after any change of antihypertension medication
* On day of discharge from community midwife care
which antihypertensive should be stopped after delivery?
methyldopa should be stopped within 2 days of delivery as it is increases the risk of depression
should switch to an alternative
which is the first line antihypertensive postnatally for a woman who is breastfeeding?
Enalapril should be offered first-line, with appropriate monitoring of maternal renal function and maternal serum potassium.
which is the first line antihypertensive agent for afro-caribbean women postnatally?
If the woman is of black African or Caribbean family origin, first-line treatment with nifedipine (or amlodipine if the woman has previously used this sucessfully) should be considered.
what should be done if a womans blood pressure is not controlled on one agent postnatally?
If blood pressure is not controlled with a single medicine, a combination of nifedipine (or amlodipine) and enalapril can be considered. If this combination is not tolerated or is ineffective, it may be appropriate to either add atenolol or labetalol to the combination treatment or swap one of the medicines being used for atenolol or labetalol.
when should a patient with gestational diabetes be reviewed postnatally by the GP?
2 weeks after discharge from the hospital - either GP or secondary services
again at 6-8 week postnatal check up
management of pre-eclampsia presenting at > 37 weeks?
induction of labour
management of pre-eclampsia presenting at 34 weeks to 36 + 6 days?
Continue surveillance unless there are indications for planned early birth
Consider IV MgSO4 + course of antenatal corticosteroids
what are some indications for planned early delivery in patients with pre-eclampsia?
inability to control maternal blood pressure despite using 3 or more classes of antihypertensives in appropriate doses
maternal pulse oximetry less than 90%
progressive deterioration in liver function, renal function, haemolysis, or platelet count
ongoing neurological features, such as severe intractable headache, repeated visual scotomata, or eclampsia
placental abruption
reversed end-diastolic flow in the umbilical artery doppler velocimetry, a non-reassuring cardiotocograph, or stillbirth.
when should bloods be done for monitoring in a patient with pre-eclampsia after delivery?
measure platelet count, transaminases and serum creatinine 48 to 72 hours after birth or step-down
do not repeat platelet count, transaminases or serum creatinine measurements if results are normal at 48 to 72 hours
when should urine dip be repeated in patient with pre-eclampsia who has delivered?
at 6-8 week GP postnatal check - if still positive, to have further repeat and review at 3 months and if remains positive/decline in renal funciton - refer to renal team in line with CKD guidelines
define gestational diabetes?
any degree of glucose intolerance with onset during pregnancy and resolving shortly after delivery.
what is the diagnostic criteria for gestational diabetes?
Fasting plasma glucose level of 5.6 mmol/L or above; or
Two-hour plasma glucose level of 7.8 mmol/L or above.
what are the risk factors of gestational diabetes?
advancing age > 40 years
previous GDM
high BMI
smoking
px macrosomia
px stillbirth
short time interval between pregnancy
rapid weight change between pregnancy
FHx of T2DM
certian ethnicities - Asian, African Americans, Hispanic/Latino Americans and Pima Indians
who is screened at 24-28 weeks for gestational diabetes?
those screened early at 10 weeks with normal OGTT
any of the RF-
BMI > 30
previous macrosomic baby > 4.5kg
Family origin with high prevelance of diabetes
Family history of diabetes (first degree relative with diabetes)
Polycystic ovarian syndrome
Women taking antipsychotic medication
Previous IUD / stillbirth
when are women screened for gestational diabetes if they have had previous gestational diabetes?
at booking 10 weeks
who is screened for gestational diabetes?
BMI >30 kg/m2.
Previous macrosomic baby ≥4.5 kg or above.
Previous GDM.
First-degree relative with diabetes.
Family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern).
what determines the management of gestational diabetes?
fasting glucose level -
if between 5.6 - 7 - lifestyle measures and metformin generally
if > 7 - likely will need insulin
what is the management of patients with fasting blood glucose of 5.6 - 7 with gestational diabetes at test?
Start with dietary and lifestyle changes.
If diet and exercise measures are unsuccessful, then the first line treatment is metformin. If
metformin is contraindicated or unacceptable then offer insulin.
what is the management of patients with fasting blood glucose of > 7 at diagnosis with gestational diabetes?
Offer immediate treatment with insulin, with or without metformin, as well as changes in diet and
exercise
management of gestational diabetes postnatally?
Normal diet
Stop medication (metformin and/or insulin) and regular CBG testing immediately after
delivery
Monitor CBG for 24-48 hours prior to and one hour post meal
If CBG >11 , repeat in 1 hour and if remains high escalate to SpR
how should women with gestational diabetes be followed up in the community?
repeat OGTT or HbA1c at 13 weeks - to monitor as increased risk of T2DM
hba1c annually after this
what are the type of miscarriage?
Threatened, Inevitable, Complete, and Missed.
what is threatened miscarriage?
any patient with bleeding + positive pregnancy test
internal os closed
what is inevitable miscarriage?
patient who is bleeding, positive pregnancy test, internal os open
what is complete miscarriage?
A Complete miscarriage is defined as anybody who has presented with bleeding, positive pregnancy test and
evidence of an intrauterine pregnancy with either physical evidence of complete removal of
Products of Conception (POC) or scan evidence of an empty uterus following the above.
what is missed miscarriage?
positive pregnancy test
however USS - no evidence of products of conception or non-viable/fetal death
no bleeding/sx to indicate miscarriage
what are the risk factors for miscarriage?
Small GS diameter in proportion to CRL
Oligohydramnios
Bradycardic embryo (< 90 bpm).
Discrepancy between scan and menstrual dates of > 10 days
what is the management of a threatened miscarriage?
Expectant - if stable, wait and offer a repeat scan in 7 days if bleeding lasting more than 14 days. If bleeding stops, continue routine care.
In women who are bleeding and have had px miscarriage, offer micronized progesterone 400mg BD for 16 weeks.
what is the expectant management of a missed/incomplete miscarriage?
expectant - repeat scan after 14 days if no bleeding on presentation or has persistent/increasing bleeding. If pain/bleeding resolves in 7-14 days, NICE recommends repeat urine pregnancy test after 3 weeks, and return to EPU if positive for further assessment.
who should not be offered expectant management of missed/incomplete miscarriage?
people who have had previous poor experience
those at the highest risk of excessive bleeding i.e. people who refuse blood transfusion, or have coagulopathies
signs of infection
what is the surgical management of missed/incomplete miscarriage?
elective SMM - under general anaesthetic or
MVA under local anaesthetic
what is the medical management of miscarriage?
Mifepristone 200mg orally
48 hours later stat dose of misoprostol 800mcg vaginal or oral (generally vaginal preferred as less side effects - inserted into posterior fornix)
what is mifepristone?
antiprogestogenic steroid
how does mifepristone work?
blocks progesterone, and causes vessel contraction within the uterus, sensitising the myometrium to prostaglandin induced contractions and ripens the cervix
what is misoprostol?
synthetic prostaglandin analogue
how does misoprostol work?
causes prostaglandin to bind to the uterine wall - causing contractions and expulsion of the contents of the uterus
who is eligible for MVA?
Those with fetal demise up to ten weeks of gestation estimated by ultrasound scan
measurements with Crown-rump length [CRL] up to 30 mm.
Those with retained products of conception after spontaneous miscarriage of up to 5cm
(mean diameter) on USS
Retained products of conception following surgical termination of pregnancy, SMM or
OMMM - those with small RPOC who are symptomatic may be offered MVA.
what is the definition of recurrent miscarriage?
three or more miscarriages consecutively. this affects around 1% of couples trying to conceive.
when is testing for cytogenetics of the fetus indicated in miscarriage?
if the patient fulfils the criteria for recurrent miscarriage
Should a couple wish to investigate the miscarriage/s without the above definition (i.e. at 2nd
consecutive miscarriage or 3rd miscarriage but non-consecutive), then they will need to self-fund
for this, and make their own arrangements for interpretation of the test results by arranging a
private gynaecology consultation
when is expectant management of ectopic pregnancy offered
clinically stable and pain free
ectopic less than 35mm with no visible FHR
good social support
able to return for serial hcge
when is beta hcg repeated for patients with expectant management of ectopic pregnancy?
repeated on day 2,4,7
if beta hcg drops by more than 15% from previous value, then repeat weekly until < 20
what is the medical management of ectopic pregnancy?
methotrexate single dose
what are the side effects of methotrexate?
Nausea, vomiting, mouth & lip ulcers
Skin rash, sensitivity to light
Colicky abdominal pain (75%) - can be aggravated by gas producing foods such as leeks,
cabbage etc. which should be avoided
Liver & and bone marrow function may become abnormal and this may require inpatient
monitoring
what nutritional supplements are indicated during pregnancy?
vitamin D 10 micrograms (400 units) per day
Folic acid 400 micrograms per day for first 12 weeks
which vitamin should be avoided in pregnancy?
vitamin A - teratogenic
what dietary advice should be given in pregnancy?
avoid foods that may contain Listeria such as soft mould ripened cheeses (camembert, brie, blue veined cheese), unpasturized milk or cheese and pate
avoid raw and uncooked meats i.e. sushi, salami, oysters
avoid liver and liver products as these may contain high levels of vitamin A
avoid fish containing high doses of mercury i.e. limit tuna to no more than 4 medium sized cans per week
caffeine should be limited to 200mg per day (i.e. 2 cups of instant coffee)
what advice should be given to pregnant women regarding exercise?
moderate exercise may be continued or started during pregnancy - these should reflect pre-pregnancy levels and include strength training
Vigorous activity is not recommended for previously inactive women
avoid sports that risk abdominal trauma or scuba diving
what is toxoplasmosis?
infection with the parasite toxoplasma gondii which can cause still birth, miscarriage, intracranial abnormality, and developmental delay
how can toxoplasmosis be acquried?
eating undercooked meat , unwashed vegetables, cat litter, contct with lambs/sheep and mother to child transmission
how can women who are pregnant avoid toxoplasmosis infection?
Wash her hands before handling food.
Thoroughly wash all fruit and vegetables, including ready-prepared salads, before eating.
Thoroughly cook raw meats and ready-prepared chilled meals.
Wear gloves and thoroughly wash hands after handling soil and gardening.
Avoid cat faeces in cat litter or in soil.
Avoid lambing or milking ewes and contact with newborn lambs.
what advice should be given to a pregnant woman regarding air travel?
no evidence that air travel is harmful for healthy women with an uncomplicated pregnancy
some airlines may ask for letter from midwife or doctor after 27 weeks gestation confirming expected delivery date and that the pregnancy is uncomplicated
most will not allow women > 37 weeks to fly
should avoid areas with zika / malaria
what advice should be given to a pregnant woman regarding car travel?
Advise the woman to always wear her seatbelt with the diagonal strap across her body between her breasts and with the lap belt over her upper thighs. The straps should lie above and below the bump, and not over it.
what is the healthy start scheme?
The Healthy Start Scheme is a government scheme that aims to improve the health of pregnant women and families with children aged under 4 years. It is available in England, Wales, and Northern Ireland and provides:
Free vouchers or payments every 4 weeks that can be spent on cow’s milk, fresh, frozen, or tinned fruit and vegetables, infant formula milk, and fresh, dried, and tinned pulses.
Free Healthy Start vitamins.
what is the legal maternity pay?
26 weeks of ordinary maternity leave and 26 weeks of additional maternity leave, making 1 year in total (if they work for an employer).
Maternity leave may be taken no matter how long the woman has been with an employer, how many hours she works, or how much she is paid.
She may be entitled to take some of this leave as Shared Parental Leave. A woman is not legally permitted to return to employment in the 2 weeks following childbirth (or 4 weeks if they work in a factory).
Also have the right for paid time off to attend appointments/classes if recommended by doctor or midwife.
how many scans are offered during uncomplicated pregnancy?
2 scans
Dating scan - 11+2 to 14+1 weeks - to determine gestational age, detect multipregnancy, confirm viability, provide a component of the screening for Downs/edwards/pataus syndrome
Fetal anomaly scan - 18+0 to 20+6 weeks - to locate the placenta, assess amniotic fluid and identify 11 specified conditions
when might additional USS be offered in pregnancy?
There are concerns with the progress of the pregnancy for example if symphysis–fundal height is small or large for gestational age.
Breech presentation is suspected (after 36+0 weeks).
A complication of pregnancy develops.
what differential diagnosis for breast pain during pregnancy?
mastitis
breast engorgement
raynauds disease of the nipple
blocked duct
galactocele - milk retention cyst
what are the symptoms of breast engorgement?
breast pain typically starting within the first few days of birth
bilateral
before feed
whole breast is often oedematous and erythematous
nipple may be stretched and flat in appearance
may leak
what is the management of breast engorgement?
hand express small amounts
apply cold ice packs
ibu/para
supportive bra
refer to breastfeeding team
symptoms of mastitis?
breast pain
worse on one side
fever
malaise
tender red hard area of breast, usually in wedge shaped distribution
management of mastitis in breastfeeding woman?
flucloxacillin 500mg QDS for 10-14 days
advise to continue to breastfeed
seek immediate medical attention if no improvement after 48 hours of abx or worsening at any point
what is some good breastfeeding advice?
Make sure the infant is attached to the breast correctly.
Feed on demand, both in terms of frequency and duration.
Avoid missed feeds, especially when the infant starts to sleep through the night.
Finish the first breast before offering the other.
Breastfeed exclusively for 4–6 months, if possible.
Avoid the use of a dummy, which may result in poor attachment to the breast.
For future pregnancies, start to breastfeed within an hour of delivery, if possible.
how to treat mastitis that has not improved with flucloxacillin but woman does not need admission?
send a sample of breast milk for microscopy, culture, and antibiotic sensitivity (if this has not already been done)
Prescribe a second-line antibiotic, co-amoxiclav 500/125 mg three times a day, for 10–14 days; review this choice when breast milk culture results become available. Seek specialist advice if the woman is allergic to penicillin.
what is the management of non-lactational mastitis?
Prescribe co-amoxiclav 500/125 mg three times a day for 10–14 days.
If the woman is allergic to penicillin, prescribe a combination of erythromycin (250–500 mg four times a day) or clarithromycin (500 mg twice a day) plus metronidazole (400 mg three times a day) for 10–14 days.
what is raynauds disease of the nipple?
vasospasm of the vessels int he breast and nipple
what are the symptoms of raynauds 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.
what is the management of raynauds disease of the nipple?
Options of treatment for Raynaud’s disease of the nipple include advice on minimising exposure to cold, use of heat packs following a breastfeed, avoiding caffeine and stopping smoking. If symptoms persist consider specialist referral for a trial of oral nifedipine (off-license).
what is a galactocele?
blockage of the milk ducts within the nipple
how does galactocele present?
smooth, round, painless breast swelling which causes milky discharge when pressed
what re the differentials for nipple pain in breast feeding women?
physiological milk let-down pain
nipple damage
blocked duct
nipple infection
skin conditions such as dermatitis
raynauds
what is the criteria for diagnosis of GDM?
fasting glucose > 5.6
2 hour glucose level > 7.8
“5678”
what causes unilateral nipple pain for breast feeding woman, with a small 1mm white spot visible on nipple with some localised tenderness?
blocked duct - milk bleb
what are the risks of gestational diabetes to the mother?
polyhydramnios - due to excessive urination by the fetus
the excessive fluid
preterm labour - largely due to polyhydramnios
what are the risks to the foetus of gestational diabetes?
macrosomia (although diabetes may also cause small for gestational age babies)
hypoglycaemia (secondary to beta cell hyperplasia)
respiratory distress syndrome: surfactant production is delayed
polycythaemia: therefore more neonatal jaundice
malformation rates increase 3-4 fold e.g. sacral agenesis, CNS and
CVS malformations (hypertrophic cardiomyopathy)
stillbirth
hypomagnesaemia
hypocalcaemia
shoulder dystocia (may cause Erb’s palsy)
what dose of folic acid should women who are on epileptics and trying to conceive recieve?
folic acid 5mg
which women should receive a higher dose of 5mg folic acid during pregnancy?
either parents has NTD
family hx NTD
px pregnancy with NTD
women taking anti-epileptic medication
women with diabetes
obese BMI > 30
sickle cell disease
thalassemia trait or thalassaemia
management of chickenpox exposure in pregnancy?
if there is any doubt about the mother previously having chicken pox - maternal blood should be urgently checked for varicella antibodies
oral aciclovir at day 7-14 after exposure
management of chickenpox in pregnancy?
oral aciclovir if > 20 weeks
if < 20 weeks, oral aciclovir should be considered with caution
which is the SSRI of choice in breastfeeding women?
sertraline
paroxetine
how many women are affected by postanatal depression ?
around 10%
when is the peak of postnatal depression?
3 months post birth
management of postnatal depression?
reassurance and support
CBT
sertraline or paroxetine
what are the symptoms of “baby blues”
typically 3-7 days after birth
anxious
tearful
irritable
which screening tool is used to detect postanatal depression?
Edinburgh postnatal depression scale - 10 item questionnaire with max score of 30
what are differentials of jaundice in pregnancy?
viral hepatitis - most commonly hep B
intrahepatic cholestasis
pre-eclampsia - HELLP
acute fatty liver of pregnancy
HG
which type of hepatitis is the most common cause of acute viral hepatitis in pregnancy?
hepatitis B
how is hepatitis B transmitted?
blood to blood transmission / contact
vaginal / anal intercourse
needle injuries
vertical transmission from mother to child
when is hep B screening offered in pregnancy?
routine screening offered ideally within the booking visit
how is hepatitis B managed in pregnancy?
babies born to mothers who are chronically infected with hepatitis B or to mothers who’ve had acute hepatitis B during pregnancy should receive a complete course of vaccination + hepatitis B immunoglobulin
features of idiopathic cholestasis of pregnancy?
pruritis of palms and soles
no rash
raised bilirubin
what is idiopathic cholestasis of pregnancy?
impaired liver function secondary to high levels of oestrogen, causing increase in bile acids which deposit in the skin tissues causing pruritis. Occurs in late pregnancy when oestrogen is highest.
blood results for idiopathic cholestasis of pregnancy?
raised ALP
raised bilirubin
management of idiopathic cholestasis of pregnancy?
anthistamines
ursodeoxycholic acid - symptom relief
weekly LFT’s
usually induced at 37 weeks
feautres of acute fatty liver in pregnancy?
abdo pain
nausea and vomiting
headache
jaundice
hypoglycaemia
severe disease can result in pre-eclampsia
pathophysiology of acute fatty liver in pregnancy?
impaired ability of liver to metabolise fat due to deficiency of LCHAD enzyme, leading to the accumulation and build up of fatty acids in the liver
what does HELLP stand for?
haemolysis, elevated liver enzymes (due to liver damage), low platelets
what causes HELLP syndrome?
the exact cause is not fully understood, however it is believed to result from abnormal development of the placenta during pregnancy leading to vascular dysfunction and endothelial injury
what are some complications of HELLP syndrome?
liver rupture, kidney failure
preterm birth
distress
what is puerpural pyrexia?
fever > 38, in the first 14 days after giving birth
what is the management of puerpural pyrexia?
needs urgent admission to hospital - will need IV abx
what are the most common causes of puerpural pyrexia?
endometritis: most common cause
urinary tract infection
wound infections (perineal tears + caesarean section)
mastitis
venous thromboembolism
what is postpartum thyroiditis?
autoimmune condition where thyroxide peroxidase antibodies are produced, causing inflammation of the thyroid, presenting within 1 year of giving birth
how does postpartum thyroiditis present?
three stages -
thyrotoxicosis - ususally mild symptoms, palpitations/sweating/heat intolerance/irritability
hypothyroid - more symptomatic - usually constipation, fatigue, dry skin
resolution
how is postpartum thyroiditis investigated?
thyroid function tests
management of postpartum thyroiditis in thyrotoxicosis phase?
If initial TFTs show a thyrotoxic pattern:
Refer to an endocrinology specialist, the urgency depending on clinical judgement, to differentiate suspected PPT from Graves’ disease and to advise on ongoing management. See the CKS topic on Hyperthyroidism for more information.
Check TFTs 4–8 weeks after resolution of the thyrotoxic phase, to screen for the hypothyroid phase (or sooner if symptoms develop).
management of postpartum thyroiditis in hypothyroid phase?
discuss with endocrinologist whether there is a need to commence medication
Generally -
Symptomatic women, women who are breastfeeding, and those planning another pregnancy should be treated with LT4.
Untreated asymptomatic women who are not planning a pregnancy should be reassessed in 4–8 weeks, and if the TSH remains above the reference range, a specialist may start treatment with LT4.
Untreated asymptomatic women should have their TFTs checked every 4–8 weeks until thyroid function normalizes.
Once stabilised - TFT every year.
what are the risk factors for GBS infection?
prematurity
prolonged rupture of the membranes
previous sibling GBS infection
maternal pyrexia e.g. secondary to chorioamnionitis
who should be offered intrapartum antibiotics?
anyone in preterm labour
anyone who has had previous baby with early or late onset GBS +ve infection
women with pyrexia during labour > 38C
women who have had previous positive GBS swab should be offered but not mandatory
what antibiotic is used to treat GBS intrapartum?
IV benpen
what mode of delivery is recommended for HIV positive women?
vaginal delivery if CDC < 50
if > 50 -> CS
what is the intrapartum management of HIV positive woman?
Zidovudine infusion started 4 hours prior to CS
woman start of antivirals when first booked if not already
what is the neonatal management of newborn to HIV positive mother?
zidovudine is usually administered orally to the neonate if maternal viral load is <50 copies/ml.
Otherwise triple ART should be used. Therapy should be continued for 4-6 weeks.
why should aspirin be avoided in breastfeeding?
can cause Reyes syndrome in neonate
what is placental abruption?
separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space
how does placental abruption present?
shock out of keeping with visible loss
pain constant
tender, tense uterus
normal lie and presentation
fetal heart: absent/distressed
coagulation problems
beware pre-eclampsia, DIC, anuria
who is at risk of placental abruption?
proteinuric hypertension
cocaine use
multiparity
maternal trauma
increasing maternal age
what are the differential diagnosis for PV bleeding during the first trimester?
Spontaneous abortion
Ectopic pregnancy
Hydatidiform mole
what are the differential diagnosis for PV bleeding during the second trimester?
Spontaneous abortion
Hydatidiform mole
Placental abruption
what are the differential diagnosis for PV bleeding during the third trimester?
Bloody show
Placental abruption
Placenta praevia
Vasa praevia
what is placenta praevia?
placenta lying wholly or partly in the lower segment of the womb
what is vasa praevia?
exposed blood vessels of the umbilical cord are found at the cervix
what is the effect of epilepsy during pregnancy?
significant increase in neurodevelopmental conditions - 1-3% of babies born to mothers with epilepsy suffer neurodeveopmental effects which rises to 3-5% of those who are on medications
what defect is phenytoin associated with?
cleft palate
which is the least teratogenic epileptic medication?
lamotrigine + carbamazapine
which antiepileptic is most highly associated with neural tube defects?
sodium valproate
which classes of antibiotics should be avoided in breastfeeding?
ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
name some medications that should be avoided in breastfeeding?
aspirin
amiodarone
methotrexate
carbimazole
sulfonylureas
cytotoxic drugs
what is the pathophysiology of rhesus disease in pregnancy?
The D antigen is the most important antigen of the rhesus system
around 15% of mothers are rhesus negative (Rh -ve)
if a Rh -ve mother delivers a Rh +ve child a leak of fetal red blood cells may occur
this causes anti-D IgG antibodies to form in mother
so in later pregnancies these can cross placenta and cause haemolysis in fetus
this can also occur in the first pregnancy due to leaks.
how is rhesus disease managed in pregnancy?
all women are tested at booking for anti D antibodies
if a woman is anti-D negative and non-sensitised (i,e, not produced any antibodies to D positive) then should be given single dose of anti D immunoglobulin to try neutralise any RhD positive antigens that may have entered the mother’s blood during pregnancy. This will prevent antibody formation. If the antigens have been neutralised, the mother’s blood won’t produce antibodies.
what is the current downs syndrome testing offered antenatally?
Nuchal translucency + B-HCG + pregnancy associated plasma protein A - known as the combined test
The combined test includes an ultrasound scan to measure nuchal translucency (the fluid at the back of the baby’s neck) and blood tests to measure levels of beta-human chorionic gonadotropin (B-HCG) and pregnancy associated plasma protein A (PAPP-A). This test is usually performed between 10 weeks 0 days and 13 weeks 6 days of pregnancy.
when is the anomaly scan performed?
18 - 20+6 weeks
when is the first and second screening of haemoglobinopathies?
booking - 8-12 weeks
28 weeks
what are the benefits of breast feeding?
protects against breast Ca and ovarian Ca
protects against T1DM
bonding with baby
reduces risks of eczema/hayfever/asthma
reduces incidences of ear/resp/GI infections
reduces incidence of sudden infant death syndrome
which conditions are associated with increased nuchal translucency?
downs syndrome
congenital heart defects
abdominal wall defects
which conditions are associated with hyperepogenic bowel?
cystic fibrosis
Down’s syndrome
cytomegalovirus infection
when should hba1c be offered to mothers postnatally who have had gestational diabetes?
after 3 months
what is a complete hydatidiform mole?
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
how does a hydatidiform mole present?
excessive vomiting
painless PV bleed
high HCG levels
can have symptoms that mimic thyrotoxicosis - secondary to the HCG levels
uterus is large for dates
in what situations should anti D be administered to a rhesus D non-sensitised woman?
delivery of a Rh +ve infant, whether live or stillborn
any termination of pregnancy
miscarriage if gestation is > 12 weeks
ectopic pregnancy (if managed surgically, if managed medically with methotrexate anti-D is not required)
external cephalic version
antepartum haemorrhage
amniocentesis, chorionic villus sampling, fetal blood sampling
abdominal trauma
what are the risks associated with rubella infection in pregnancy?
maternal infection in non-immune women can cause serious complications such as miscarriage, stillbirth, severe birth defects - congenital rubella syndrome
what are clinical features suggestive of rubella infection?
rash - typically face and neck then spreads down the body - maculopapular
lymphadenopathy
arthritis
arthralgia
low grade fever
headache , malaise , nausea - generalised symptoms
what advice should be given to non-pregnant people with rubella?
no tx - viral infection
supportive - para/ibu, regular fluids , rest
stay away from work or school for at least 5 days after initial development of symptoms and avoid contact with pregnant women
what gestation does congenital rubella syndrome affect?
up until 20 weeks - after this there is no ducmented risk of congenital rubella syndrome
16-20 weeks - low risk of deafness
11-16 weeks - 10-20% risk of deafness
8-10 weeks - 90% risk of deafness + multiple other congenital risks
how is rubella diagnosed?
must be confirmed through serology testing - not based on clinical symptoms alone
management if rubella confirmed in woman < 20 weeks gestation?
refer urgently to obestrics for genetic consultation, risk assessment and further management
contact local health protection team wihtin 3 days
no effecgive treatments to prevent CRS - human IgG is not recommended routinely for post exposure
what are some long term effects of congenital CMV infection?
small birth weight
micropcephaly
seizures
hearing difficulties
vision difficulties
problems with liver and spleen
Is CMV routinely tested for in pregnancy?
CMV is not routinely tested for - as most babies are not affected
can CMV be passed on through breast milk?
yes
how is a neonate managed if suspected to have CMV infection?
if appear to have symptomatic central nervous system congenital CMV infection - antiviral medication (IV valganciclovir), admission and will likely need regular monitoring for next 5 years
risk factors for developing group B strep?
prematurity
prolonged rupture of the membranes
previous sibling GBS infection
maternal pyrexia e.g. secondary to chorioamnionitis
how common is group B infection?
thought to be present in the gut flora of 20-40% of mothers - they are thought to be carriers
what causes slapped cheek disease?
parvovirus b19
what is parvovirus b19?
slapped cheek and fifth disease - very common virus usually infects paediatric population, causing rash and generalised symptoms of malaise, fatigue, arthalgia, nausea
what are the clinical features of parvovirus b19 in children?
1-2 week history of prodromal symptoms - low grade fever, headache, coryzal symptoms, abdo pain, pharyngitis
Then develops maculopapular rash usually on the face - spreads to the torso - lacy reticular appearance
then symmetrical polyarthropathy - small joints of the hands, knees, ankles, wrists
what are the symptoms of parvovirus b19 in adults?
more difficult to diagnose , many are asymptomatic
can have prodromal symptoms
polyarthropathy
may have race rash but also may be absent
how to manage suspected parvovirus b19 in a pregnant woman?
It is not usually necessary to stay off work if symptoms are controlled, as the infection is no longer contagious by the time the rash or arthropathy develops.
If the woman has not been fully immunized against rubella or got a documented history of previous rubella infection, it may be sensible to avoid contact with other pregnant women while any rash is present, until her rubella status is known.
take bloods for parvovirus b19 + rubella
how to manage confirmed parovirus b19 infection in pregnancy?
urgent referral to specialist in foetal medicine - for ongoing management and mointoring
arrange urgent FBC + reticulocyte count
if any suspect of anaemia or maternal pre-eclampsia like syndrome - urgent obstetric admission
management of primary HSV infection in mother in first and second trimester?
Initial treatment – 400mg orally, three times a day (TDS) for 5 days (or intravenous
for disseminated HSV)
Additional treatment – 400mg TDS from 36 weeks gestation. This reduces the risk of HSV lesions at term and the need for an elective caesarean section.
Note 0 this should always be discussed and commenced by the obstetrics team as the use of aciclovir is off license
management of primary HSV infection in third trimester?
A caesarean section at 39 weeks should be the recommended mode of delivery for all
women who develop a primary infection in the 3rd trimester.
Treatment is Aciclovir 400mg TDS until delivery.
management of primary HSV infection symptoms during labour?
Recommend elective CS
If the woman opts for a vaginal delivery or if a vaginal delivery is unavoidable:
* Intra-venous Aciclovir – 5mg/Kg should be given to the woman 8 hourly
which hepatitis strain is tested for in pregnancy and when?
hep B - tested at booking
risks of hep B infection during pregnancy?
what does the screening for hepatitis involve in pregnancy?
at booking appt -serological testing for presence of hepatitis B surface antigen (HBsAg). If positive, further serological and molecular testing is required to determine infectivity status.
how should women with hepatitis B positive be managed in pregnancy?
risk assessed to see if high risk of vertical transmisison or have liver cirrhosis
if they are -
Tenofovir disoproxil (TD) is currently the preferred choice of antiviral
therapy for treatment of hepatitis B during pregnancy
is breast feeding contraindicated in hep B positive mothers?
no - breastfeeding is recommended!
what medications must be avoided after 20 weeks gestation?
ibuprofen!!
NSAIDs of any kind must be avoided as it can cause premature closure of the ductus arteriosus
management of migraine in pregnancy?
ensure not due to any other reason - i.e. headache in pre-eclampsia
first line - paracetamol
can use ibu < 20 weeks
sumatriptan
metoclopramide/prochlorperazine for n+v
usually will need referral
low threshold for referral to secondary care - as migraine increases the risk of other serious causes of headache and treatment options are limtied
which antiepileptic medications are considered to have the lowest risk of major congenital malformations?
lamotrigine
levetiracetam
how many women with epilepsy will have an increase in their seizure frequency during pregnancy?
approx 30% - usually on lamotrogine
what are some causes of increased seizure activity in women with epilepsy who are pregnant?
non-compliance with medication – this needs careful exploration and explanation
sleep deprivation
alteration in antiepileptic drug pharmacokinetics particularly increased drug clearance
(lamotrigine)
what advice should be given to women postnatally who have epilepsy?
Advise feeding whilst sitting
* Advise WWE against co-sleeping with baby.
* Bathing of baby using a sponge down method rather placing the baby in a bath.
* Change the baby on the floor
* Babies should be carried up the stairs in a carrycot.
* Consider a pushchair with automatic brake
what are examples of enzyme inducing AED’s?
carbamazepine
phenobarbitone
phenytoin
topiramate
primidone
what methods of contraception are contraindicated in women taking enzyme inducing AED’s?
COCP, POP, transdermal patches, vaginal ring and implants = must be used with barrier contraception in addition
what emergency contraception can be used in women taking enzyme inducing AED’s?
copper IUD insertion
levonelle and ella one - efficacy is reduced
antibiotic of choice for UTI in pregnancy?
first line - nitrofurantoin 100mg MR BD for 7 days - but NOT IN THIRD TRIMESTER
second line - amoxicillin 500mg TDS for 7 days OR cefalexin 500mg BD
how should a pregnant women with confirmed UTI be followed up?
review choice of abx once mc+s results back
arrange for repeat urine mc+s to be sent once abx completed to ensure resolution
what is sickle cell disease?
Sickle cell disease is a genetic blood disorder caused by a mutation in the gene encoding the beta-globin chain of hemoglobin. The mutation leads to the production of hemoglobin S (HbS) instead of the normal hemoglobin A. Under low oxygen conditions, HbS molecules aggregate and form long, rigid rods, causing red blood cells to adopt an abnormal, crescent or “sickle” shape.
These sickle-shaped cells are less flexible and can get trapped in small blood vessels, leading to blockages (vaso-occlusion), which reduces blood flow and causes pain crises (sickle cell pain episodes). The impaired blood flow also leads to tissue ischemia and organ damage over time.
Additionally, sickled red blood cells have a shortened lifespan (10-20 days vs. the normal 120 days), leading to chronic hemolytic anemia.
what are the key clinical features of sickle cell disease?
painful vaso-occlusive crisis
splenic sequestration
haemolytic anaemia
increased risk of infection - due to splenic dysfunction
what are the risks of passing on sickle cell to a child?
Two carriers (HbAS) have a 25% chance of having a child with SCD (HbSS).
One parent with SCD (HbSS) and one carrier (HbAS) have a 50% chance of having a child with SCD.
when is sickle cell screened for in pregnancy?
at booking appointment
when is sickle cell screened for neonatally?
new born spot screening programme - usually when aged 5 days
what antibiotic prophylaxis and immunisation should be offered to a women with sickle cell disease in pregnancy?
penicillin prophylaxis - due to high risk of infections
should have h. influenza type B and Men C vaccine as a single dose
what vitamins should be given prenatally in women with sickle cell?
folic acid 5mg
should also consider aspirin - usually led by obstetrics team
what medication should be stopped 3 months prior to conception for a woman with sickle cell?
hydroxycarbamide
ACE-I / ARB
what are some acute complications of SCD?
ACS
stroke
acute anaemia
acute pain
what contraceptives are appropriate for use in women with sickle cell disease?
Progesterone containing contraceptives are first line
oestrogen containing are second line
what is the pathophysiology of thalaessmia?
Hemoglobin is composed of four protein chains: two alpha globin chains and two beta globin chains. Thalassemia occurs when there is a mutation or deletion in the genes responsible for producing these chains.
Alpha Thalassemia: The alpha-globin gene is affected, leading to a reduced or absent production of alpha globin chains.
Beta Thalassemia: The beta-globin gene is affected, leading to reduced or absent production of beta globin chains.
I
neffective erythropoiesis → Premature destruction of red blood cells in the bone marrow
Hemolysis → Destruction of fragile red blood cells in the spleen and liver
Compensatory extramedullary hematopoiesis → Organ enlargement (splenomegaly, hepatomegaly)
Iron overload → Deposits in vital organs, leading to organ damage
Bone deformities → Due to increased bone marrow expansion
Endocrine abnormalities → Due to iron overload and chronic anemia
what are the different types of beta thalassemia?
Beta thalassemia minor (trait): One gene is affected, usually causing mild anemia.
Beta thalassemia intermedia: Two genes are affected but the disease is less severe than the major form.
Beta thalassemia major (also called Cooley’s anemia): Both genes are severely affected, leading to a more serious form of anemia that requires regular blood transfusions for survival.
what complications are more common in multipregnancies?
premature labour
pre-eclampsia
gestational hypertension
gestational diabetes
placental abruption
foetal growth restriction
how many placentas do fraternal twins have?
two
how many placentas do identical twins have?
70% - 1
30% - 2
what is the main risk of identical twins with one placenta?
They may develop a condition called twin-twin-transfusion-syndrome (TTTS). This is the consequence of vascular communications at the placenta level between the twins. Due to these communications, the twins may share their blood. When this happens — if nothing is done — there is a 90% risk that the twins will die in-utero. In-utero procedures are performed to decrease the fetal death risk for the twins.
Twin-anaemia-polycythemia sequence - one twin becomes anaemic when the other becomes polcythemic
selective IUGR - one twin grows well an the other does not
