Obstetrics Flashcards
1
Q
Categories CI to breatfeeding
A
- Drugs
- Infection
- Galactosaemia
2
Q
Drugs containdicated in breastfeeding
A
- Some antibiotics
- Lithium
- Benzodiazepines
- Aspirin
- Carbimazole
- Methotrexate
- Sulphonylureas
- Cytotoxic drugs
- Amiodarone
3
Q
Antibiotics contraindicated in breastfeeding
A
- Ciprofloxacin
- Tetracycline
- Chloramphenicol
- Sulphonamines
4
Q
Risk factors amniotic fluid embolism
A
- Increasing maternal age
- Induction
5
Q
Symptoms amniotic fluid embolism
A
Chills, shivering, sweating
Anxiety
Coughing
6
Q
Signs amniotic fluid embolism
A
Cyanosis
Hypotension
Bronchospasm
Tachycardia
Arrhythmia
MI
7
Q
Diagnosis amniotic fluid embolism
A
Diagnosis of exclusion - no definitive test
8
Q
Management amniotic fluid embolism
A
Supportive
9
Q
Vitamin D supps pregnancy
A
10microgram/day
10
Q
When is booking visit
A
8-12 weeks (ideally <10)
11
Q
Investigations done at booking
A
- FBC, blood group, rhesus, red cell alloantibodies, haemoglobinopathies
- Hep B, syphilis
HIV
Urine culture - detect asymptomatic bacteriuria
12
Q
Purpose of 11-13+6 weeks scan
A
- Confirm dates
- Exclude multiple pregnancy
- Down syndrome screening
13
Q
When to consider iron 16 week antental appt
A
Hb <11
14
Q
When is anomaly scan
A
18 - 20+6
15
Q
What is done at 28 week antenatal visit
A
Second screen for anaemia and atypical red cell alloantibodies
16
Q
When to consider iron 28 weeks
A
Hb <10.5
17
Q
When is presentation of baby checked antenatally
A
36 weeks - offer ECV if indicated
18
Q
When is anti-D prophylaxis given to rhesus neg women
A
28 weeks and 34 weeks
19
Q
Causes of first trimester bleeding
A
Spontaneous abortion
Ectopic pregnancy
Hydatidiform mole
20
Q
Causes of second trimester bleeding
A
Spontaneous abortion
Hydatidiform mole
Placental abruption
21
Q
Causes of third trimester bleeding
A
Bloody show
Placental abruption
Placenta praevia
Vasa praevia
22
Q
Features hydatidiform mole
A
- Bleeding in first or early second trimester
- Exaggerated symptoms of pregnancy, e.g. hyperem
- Uterus large for dates
- Serum hCG very high
23
Q
Features placental abruption
A
- Constant lower abdominal pain
- Shock out of proportion with visible blood loss
- Tender, tense uterus with normal lie and presentation
- Fetal heart may be distressed
24
Q
Features vasa praevia
A
Rupture of membranes followed immediately by vaginal bleeding
Fetal bradycardia classically seen
25
Treatment nipple candidiasis
Miconazole cream for mother
Nystatin suspension for baby
26
Indications for antibiotics mastitis
- Systemically unwell
- Nipple fissure present
- Symptoms do not improve after 12-24 hours of effective milk removal
- If culture indicates infection
27
First line antibiotic mastitis
Flucloxacillin
28
Complication mastitis
Breast abscess
29
Treatment breast abscess caused by mastitis
Usually needs I&D
30
Presentation breast engorgement
- Bilateral
- Worse just before a feed
- Milk doesn't flow well, infant find it difficult to latch and suckle
- Fever - usually settles within 24 hours
- Breasts may appear red
31
Complications engorgement
Blocked milk ducts
Mastitis
Difficulties with breastfeeding
32
Presentation Raynaud's disease of niple
- Pain often intermittent, present during and immediately after feeding
- Blanching of nipple → cyanosis and/or erythema
- Nipple pain resolves when nipples return to normal colour
33
Non-medical management of Raynaud's disease of nipple
- Minimising exposure to cold
- Use of heat packs following breastfeed
- Avoiding caffeine
- Stopping smoking
34
Medical management Raynaud's disease of nipple
Oral nifedipine
35
Suppression of lactation
- Stop suckling/expressing
- Supportive measures - well-supported bra, analgesia
- Cabergoline
36
Risk factors breech presentation
- Uterine malformations, fibroids
- Placenta praevia
- Polyhydraminos or oligohydraminos
- Fetal abnormality, e.g. CNS malformation, chromosomal disorders
- Prematurity
37
When should ECV be offered
36 weeks in nulliparous
37 weeks in multiparous
38
Absolute contraindications to ECV
- C-section required
- Antepartum haemorrhage in last 7 days
- Abnormal CTG
- Major uterine anomaly
- Ruptured membranes
- Multiple pregnancy
39
Why is C-section indicated in cervical cancer
Vaginal delivery can disseminate cancer cells
40
Timeframe emergency sections
Cat 1 - 30 mins
Cat 2 - 75 mins
41
Cause baseline bradycardia on CTG
- Increased fetal vagal tone
- Maternal beta blocker use
42
Cause baseline tachycardia on CTG
- Maternal pyrexia
- Chorioamnionitis
- Hypoxia
- Prematurity
43
Normal baseline variability CTG
>5 beats/min
44
Cause loss of baseline variability on CTG
Prematurity
Hypoxia
45
What is early decel
Decel of HR which commences with onset of contraction and returns to normal on completion of contraction
46
Cause early decel on CTG
Usually normal, indicates head compression
47
What is late decel
Decel of HR which lags the onset of contraction, does not return to normal 30 seconds after end of contraction
48
Cause late decel
Fetal distress, e.g. asphyxia, placental insufficiency
49
What is variable decel
Decels independent of contractions
50
Cause variable decel on CTG
Cord compression
51
Risk to mother of chickenpox in pregnancy
5x increase risk of pneumonitis
52
Risk of fetal varicella syndrome based on gestation
1% risk if exposed before 20 weeks
Very small number of cases 20-28 weeks
No cases following 28 weeks
53
Features fetal varicella syndrome
Skin scarring
Eye defects - microphthalmia
Limb hypoplasia
Microcephaly
Learning disbilities
54
Risk of shingles in infancy based on gestation at exposure
1-2% risk if maternal exposure in 2nd or 3rd trimester
55
When is there a risk of severe neonatal varicella
If mother develops rash 5 days before - 2 days after birth
56
First step in management of chickenpox exposure in pregnancy
If any doubt about previous chickenpox, urgent varicella antibodies in maternal blood
57
Management chickenpox exposure in pregnancy if not immune
Oral aciclovir (or valaciclovir) given at days 7-14 after exposure (not immediately)
58
Management of chickenpox in pregnancy
Specialist advice
Oral aciclovir given if pregnant women ≥20 weeks, and presents within 24 hours of rash. If <20 weeks, aciclovir 'considered with caution'
59
Components of combined test for Down's syndrome
- Nuchal translucency
- Serum b-hCG
- PAPP-A
60
Results of combined test suggesting DS
High HCG
Low PAPP-A
High nuchal translucency
61
What other conditions give similar results to DS on combined test
Edwards and Pataus (but hcg tends to be lower)
62
When is quadruple test for DS offered
15-20 weeks
63
Components of quadruple test for DS
- Alpha fetoprotein
- Unconjugated oestriol
- hCG
- Inhibin A
64
Results of quadruple test suggesting DS
- Alpha fetoprotein low
- Unconjugated oestriol low
- hCG high
- Inhibin A high
65
Quadruple test results DS vs Edwards
Inhibin A normal in Edwards
66
Cause of isolated raised alpha-fetoprotein on quad test
Neural tube defects
67
What to do if high risk on DS screening
Offer NIPT or diagnostic (amnio/CVS) - NIPT lower risk
68
Definition pre-eclampsia
New onset BP ≥140/90 after 20 weeks and one of;
- Proteinuria
- Other organ involvement, e.g. renal insufficiency, liver, neuro, haem, uteroplacental
69
Neurological complications of pre-E
- Eclampsia
- Altered mental status
- Blindness
- Stroke
- Clonus
- Severe headaches
- Persistent visual scotomata
70
Fetal complications pre-E
IUGR
Prematurity
71
Other comlications pre-E
Liver involvement - elevated transaminases
Haemorrhage - placental abruption, intra-abdominal, intra-cerebral
Cardiac failure
72
Features of severe pre-E
HTN >160/110
Proteinuria ++/+++
Headache
Visual disturbance
Papilloedema
RUQ/epigastric pain
Hyperreflexia
Plts <100/abnormal liver enzymes/HELLP
73
High risk factors pre-E
HTN in prev preg
CKD
Autoimmune disease, e.g. SLE, antiphospholipid
T1 or T2DM
Chronic HTN
74
Moderate risk factors pre-E
First preg
Age 40+
Preg interval >10 years
BMI ≥35 at booking
Family Hx
Multiple preg
75
Risk reduction of pre-E
Aspirin 75-150mg OD from 12 weeks if;
≥1 high risk factor
≥2 moderate risk factors
76
First line anti-HTN pre-E
Oral labetalol
77
Other anti-HTN options in pre-E
Nifedipine
Hydralazine
78
Treatment eclampsia
Magnesium - prevents seizures in severe pre-E and treats seizures in eclampsia
79
Dose magnesium in eclampsia
IV bolus 4g over 5-10 mins followed by infusion 1g/hour
80
Treatment resp depression caused by magnesium sulphate
Calcium gluconate
81
How long to continue magnesium in eclampsia
24 hours after last seizure or delivery
82
Least teratogenic anti-epileptic
Carbamazepine
83
Sodium valproate in preg associated with
Neural tube defects
84
Phenytoin in preg associated with
Cleft palate
Coag disorders - give mother vit K in last month of preg
85
Lamotrigine in preg
Studies so far suggest rate of congenital malformations low. Dose may need increasing in preg
86
Breastfeeding and anti-epileptic
Safe (except maybe barbiturates)
87
Causes folic acid deficiency
- Phenytoin
- Methotrexate
- Pregnancy
- Alcohol excess
88
Consequence of folic acid deficiency
- Macrocytic, megaloblastic anaemia
- Neural tube defects
89
Indications for 5mg folic acid
- Either partner had NTD, prev preg with NTD, or FHx NTD
- Anti-epileptic drugs
- Coeliac, diabetes, thalassaemia trait
- BMI ≥30
90
Risk factors gestational diabetes
BMI >30
Previous macrosomic baby ≥4.5kg
Previous gestational diabetes
First-degree relative with diabetes
Family origin with high prevalence of diabetes - South Asian, black Caribbean, Middle Eastern
91
When do do OGTT
- If previously had gestational diabetes, ASAP after booking at at 24-28 weeks if first test is normal
- If risk factors, 24-28 weeks
92
Alternative to OGTT for gestational diabetes
Self-monitoring of BM
93
Diagnostic threshold for gestational diabetes
Fasting glucose ≥5.6
2-hour glucose ≥7.8
94
First line management gestational diabetes with fasting glucose <7
Trial of diet and exercise
95
Second line management gestational diabetes with fasting glucose <7
If targets not met within 1-2 weeks of alterating diet/exercise, add metformin
96
Third line management gestational diabetes with fasting glucose <7
Add insulin (short acting)
97
When to start insulin immediately in gestational diabetes
- Fasting glucose ≥7
- Fasting glucose 6-6.9 and evidence of complications e.g. macrosomia, polyhydramnios
98
Alternative to metformin/insulin in gestational diabetes
Glibenclamide
Used if can't tolerate metformin, or don't meet targets with metformin but decline insulin
99
Management pre-existing diabetes in pregnancy
- Weight loss of BMI >27
- Stop oral hypoglycaemic agents, apart from metformin, and start insulin
- Folic acid 5mg/day
- Tight glycaemic control
- Treat retinopathy - can worsen in pregnancy
100
Glucose targets in gestational diabetes
Fasting 5.3
1 hour after meals 7.8
2 hours after meals 6.4
101
What is a complete hydatidiform mole
Benign tumour of trophoblastic material
102
Features complete hydatidiform mole
- Bleeding in first or early second trimester
- Exaggerated symptoms of pregnancy, e.g. hyperem
- Uterus large for dates
- Very high beta hCG
- Hypertension and hyperthyroidism
103
Management complete hydatidiform mole
Urgent referral to specialist centre for evacuation of the uterus
Effective contraception recommended to avoid pregnancy in next 12 months
104
Complication complete hydatidiform mole
1-2% develop choriocarcinoma
105
Management GBS in previous pregnancy
Offered intrapartum antibiotic prophylaxis or testing in late pregnancy → antibiotics if still positive
106
When to test for GBS if indicated
35-37 weeks, or 3-5 weeks prior to anticipated delivery date
107
When to offer intrapartum antibiotics (regardless of GBS status)
- Preterm labour
- Previous baby with early or late onset GBS disease
- Pyrexia during labour (>38)
108
Antibiotic GBS prophylaxis
Benzypenicillin
109
Factors reducing vertical transmission of HIV
- Maternal antiretroviral therapy
- C-section delivery
- Neonatal antiretroviral therapy
- Bottle feeding
110
Management of delivery in HIV
- Vaginal delivery if viral load less than 50 at 36 weeks, otherwise C-section
- Zidovudine infusion started 4 hours before beginning the C-section
111
Antiretroviral therapy for babies born to HIV positive mothers
Zidovudine orally if maternal viral load <50
Triple ART if viral load >50
Continue for 4-6 weeks
112
Breastfeeding and HIV
Advise not to breast feed
113
Definition hypertension in pregnancy
Systolic >140 or diastolic >90, or
Increase in booking readings >30 systolic or >15 diastolic
114
Management pre-existing hypertension in pregnancy
If taking ACEi or ARB, stop immediately and alternative anti-hypertensives started, whilst awaiting specialist review
115
First line anti-hypertensive in pregnancy
Labetalol
116
Alternative anti-hypertensives in pregnancy
Nifedipine
Hydralazine
117
Interpretation of Bishops score for induction
Score <5 = labour unlikely
Score ≥8 = cervix ripe, high change of spontaneous labour/interventions to induce labour
118
Methods of induction of labour
- Membrane sweep (adjunct, not true method)
- Vaginal prostaglandin (dinoprostone)
- Oral prostaglandin (misoprostol)
- Oxytocin infusion
- Amniotomy
- Cervical ripening balloon
119
Induction of labour method if Bishop score ≤6
Vaginal prostaglandins or oral misoprostol
120
When to consider mechanical methods (e.g. balloon catheter) for induction when Bishop ≤6
If woman higher risk of hyperstimulation or had previous C-section
121
Induction of labour method if Bishop score >6
Amniotomy and IV oxytocin infusion
122
Complications of induction of labour
Uterine hyperstimulation → fetal hypoxaemia and acidaemia, uterine rupture
123
Management uterine hyperstimulation caused by induction of labour
Removing vaginal prostaglandins if possible, stopping oxytocin infusion id one has been started
Consider tocolysisFe
124
Features intrahepatic cholestasis of pregnancy
- Pruritis, typically worse palms, soles, and abdomen
- Raised bilirubin - clinically detectable jaundice in 20%M
125
Management intrahepatic cholestatis of pregnancy
IOL 37-38 weeks
Ursodeoxycholic acid
Vit K supp
126
Complications intrahepatic cholestasis of pregnancy
Increased rate of stillbirth
127
Monitoring in labour
FHR every 15 mins
Contractions every 30 mins
Maternal pulse every 60 mins
Maternal BP and temp every 4 hours
VE every 4 hours to check progression
Maternal urine for ketones and protein every 4 hours
128
Stage 1 labour
From onset of true labour → cervical fully dilated
129
Stage 2 labour
Full dilation → delivery of fetus
130
Passive second stage labour
2nd stage but not pushing
131
Active second stage
Active process of maternal pushing
132
How long is too long second stage labour
1 hour - if longer, consider instrumental or section
133
Criteria oligohydraminos
Less than 500ml at 32-36 weeks
AFI <5th percentile
134
Causes oligohydraminos
PROM
Potter sequence (bilateral renal agenesis and pulmonary hypoplasia)
Intrauterine growth restriction
Post-term
Pre-eclampsia
135
What is first degree perineal tear
Superficial damage with no muscle involvement
136
Management first degree perineal tear
Do not require any repair
137
What is second degree perineal tear
Injury to perineal muscle, but not involving anal sphincter
138
Management second degree perineal tear
Suturing on ward by suitably experienced midwife or clinician
139
What is third degree perineal tear
Injury to perineum involving anal sphincter complex (external +/- internal anal sphincter)
140
What is 3a perineal tear
Less than 50% of external anal sphincter torn
141
What is 3b perineal tear
More than 50% of external anal sphincter torn
142
What is 3c perineal tear
Internal anal sphincter torn
143
Management third degree perineal tear
Require repair in theatre
144
What is fourth degree tear
Injury to perineum involving anal sphincter complex and rectal mucosa
145
Management fourth degree tear
Repair in theatre
146
Risk factors for perineal tears
- Primigravida
- Large babies
- Precipitant labour
- Shoulder dystocia
- Forceps delivery
147
What is placenta accreta
Attachment of the placenta to the myometrium, due to a defective decidua basalis
148
Risk factors placenta accreta
Previous C-section
Placenta praevia
149
Risk factors placenta praevia
- Multiparity
- Multiple pregnancy
- Previous C-section
150
Clinical features placenta praevia
- Shock in proportion to visible loss
- No pain
- Uterus not tender
- Lie and presentation may be abnormal
- Fetal heart usually normal
- Small bleeds before large
151
Diagnosis of placenta praevia
Transvaginal ultrasound - improves accuracy of placental localisation and is considered safe
152
What to avoid placenta praevia
Digital vaginal examination - may provoke severe haemorrhage
153
Grade I placenta praevia
Placenta reaches lower segment but not internal os
154
Grade II placenta praevia
Placenta reaches internal os but doesn't cover it
155
Grade III placenta praevia
Placenta covers internal os before dilation but not when dilated
156
Grade IV placenta praevia
Placenta completely covers internal os
157
Management low lying placenta at 20 week scan
Rescan at 32 weeks
No need to limit activity or intercourse unless bleed
158
Management low lying placenta at 32 weeks
Scan every 2 weeks, with final scan 36-37 to determine method of delivery
159
Management placenta praevia at 36-37 weeks
Elective section
If grade I, trial of vaginal delivery may be offered
160
Management of known placenta praevia woman going into labour
Emergency C-section
161
Management placenta praevia with bleeding
Admit
ABC approach to stabilise
If not able to stabilise, or if in labour/term reached → emergency C-section
162
Risk factors placental abruption
Proteinuric hypertension
Cocaine use
Multiparity
Maternal trauma
Increasing maternal age
163
Clinical features placental abruption
Shock out of keeping with visible loss
Pain constant
Tender, tense uterus
Normal lie and presentation
Fetal heart absent/distressed
164
Coag probelms abruption vs praevia
Coag problems more common in abruption, rare in praevia
165
Definition PPH
>500ml blood loss after delivery
166
What is primary PPH
Occurring within 24 hours
167
Causes primary PPH
- Tone (uterine atony) - vast majority
- Trauma, e.g. perineal tear
- Tissue (retained placenta)
- Thrombin, e.g. clotting/bleeding disorder
168
Fluids in PPH
Warmed crystalloid (until blood available)
169
Mechanical management PPH
- Palpate fundus and rub to stimulate contractions
- Catheterise (prevent bladder distention, monitor UO)
170
Medical management PPH
- IV oxytocin - slow IV injection → IV infusion
- Ergometrine - slow IV or IM
- Carboprost IM
- Misoprostol sublingual
171
CI ergometrine for PPH
History of hypertension
172
CI carboprost for PPH
History of asthma
173
First line surgical management PPH
Intrauterine balloon tamponade
174
Other surgical options PPH
B lynch suture
Ligation of uterine arteries or internal iliac arteries
175
Management severe, uncontrolled PPH
Hysterectomy
176
What is secondary PPH
Haemorrhage occurring 24 hours - 12 weeks
177
Cause secondary PPH
- Retained placental tissue
- Endometritis
178
Whats used to screen for postpartum depression
Edinburgh Postnatal Depression Scalente
179
Interpretation Edinburgh Postnatal Depression Scale
Score >13 indicates a depressive illness of varying severity
180
Features baby blues
- Typically 3-7 days after birth
- More common in primips
- Mothers anxious, tearful, irritable
181
Management baby blues
Reassurance and support
182
Timeline postnatal depression
Most cases start within a month and typically peaks at 3 months
183
Management postnatal depression
Reassurance and support
CBT
SSRIs if severe symptoms
184
SSRIs used in postnatal depression
Sertraline
Paroxetine
185
Timeline puerperal psychosis
Onset usually within the first 2-3 weeks following birth
186
Features puerperal psychosis
Severe swings in mood - similar to bipolar disorder
Disordered perception, e.g. auditory hallucinations
187
Management puerperal psychosis
Admission to hospital usually required, ideally mother and baby unit
188
Risk of recurrence puerperal psychosis in future pregnancies
25-50%
189
When is anaemia screening done in pregnancy
- Booking visit
- 28 weeks
190
Cut off iron treatment first trimester
<110
191
Cut off iron treatment second/third trimester
<105
192
Cut off iron treatment postpartum
<100
193
Management anaemia in pregnancy
Oral ferrous sulfate or ferrous fumurate
Treatment continued for 3 months after iron deficiency is corrected to allow iron stores to be replenished
194
Maternal complications diabetes
- Polyhydraminos
- Preterm labour
195
Neonatal complications diabetes
Macrosomia
Hypoglycaemia
RDS
Polycythaemia → jaundice
Congenital malformations
Stillbirth
Hypomagnesaemia
Hypocalcaemia
Shoulder dystocia
196
What congenital malformations at increased risk in diabetes
- Sacral agenesis
- CNS malformations
- CVS malformations, hypertrophic cardiomyopathy
197
Investigation suspected DVT in pregnancy
Compression duplex ultrasound
198
Investigation suspected PE in pregnancy
- ECG and CXR in all patients
- In women who also have symptoms and signs of DVT, compression duplex ultrasound, and if positive no further investigation needed
- If not, CT or V/Q scan
199
Risk of CTPA in pregnancy
Slightly increased lifetime risk of maternal breast cancer (breast tissue more sensitive to effects of radiation)
200
Risk V/Q scanning in pregnancy
Slightly increased risk of childhood cancer
201
When does acute fatty liver of pregnancy occur
Abdominal pain
Nausea and vomiting
Headache
Jaundice
Hypoglycaemia
202
LFTs in acute fatty liver of pregnancy
ALT elevated >500
203
Management acute fatty liver of pregnancy
Supportive care
Once stabilised, delivery is definitive management
204
What jaundice causing conditions may be exacerbated in pregnancy
Gilbert's
Dubin-Johnson
205
Maternal risks obesity in pregnancy
- Miscarriage
- VTE
- Gestational diabetes
- Pre-eclampsia
- Dysfunctional labour, induced labour
- Postpartum haemorrhage
- Wound infections
206
Fetal risks maternal obesity
- Congenital anomaly
- Prematurity
- Macrosomia
- Stillbirth
- Increased risk of developing obesity and metabolic disorders in childhood
- Neonatal death
207
Management obesity in pregnancy
- 5mg folic acid
- Screen for GD
Should not loose weight in pregnancy
208
Management BMI ≥35 in pregnancy
Should give birth consultant-led obstetric unit
209
Management BMI ≥40 in pregnancy
Antenatal consultation with obstetric anaesthetist and plan made
210
Risks of smoking in pregnancy
- Miscarriage
- Preterm labour
- Stillbirth
- IUGR
- Sudden unexpected death in infancy
211
Features fetal alcohol syndrome
- Learning difficulties
- Characteristic facies
- IUGR and postnatal restricted growth
212
Characteristic facies FAS
- Smooth philtrum
- Thin vermillion
- Small palpebral fissures
- Epicanthic folds
- Microcephaly
213
Maternal risks cocaine use during pregnancy
Hypertension in preg, inc pre-E
Placental abruption
214
Fetal risks cocaine use during preg
NAS
Prematurity
215
Fetal complications PROM
Prematurity
Infection
Pulmonary hypoplasia
216
Maternal complications PROM
Chorioamnionitis
217
How to confirm PROM
Sterile speculum to look for pooling of amniotic fluid in posterior vaginal vault.
If pooling of fluid not observed, test fluid for PAMG-1 or IGF-1
218
Management PROM
Admission
Regular observations to ensure chorioamnionitis not developing
Oral antibiotics
Antenatal corticosteroids
Consider delivery at 34 weeks
219
Antibiotic prophylaxis in PROM
Oral erythromycin for 10 days
220
Definition puerperal pyrexia
Temp >38 in first 14 days following delivery
221
Causes puerperal pyrexia
- Endometritis
- UTI
- Wound infections (perineal tears, C-section)
- Mastitis
- VTE
222
Management endometritis
Admission for IV antibiotics
223
IV antibiotics in endometritis
Clindamycin and gentamicin until afebrile for >24 hours
224
Investigations RFM if past 28 weeks
Handheld doppler initially
If no fetal heartbeat, immediate ultrasound
If fetal heartbeat, CTG for at least 20 minutes
If concern remains despite normal CTG, USS within 24 hours
225
Investigation RFM 24-28 weeks
Doppler to confirm fetal heartbeat
226
Investigation RFM under 24 weeks
If movements felt before, handheld doppler
227
Investigation never felt fetal movements at 24 weeks
Referral to FMU
228
Screening for women at risk of rhesus disease of newborn
Test for D antibodies in all rh -ve women at booking
229
Limitation of anti-D
Prophylaxis only - once sensitisation has occurred it is irreversible
230
Management sensitising event in rhesus -ve mother in 2nd/3rd trimester
Give large dose of anti-D
Perform Kleihauer test
231
Events requiring anti-D in Rh -ve mother
- Delivery of rh +ve infant, if live or stillborn
- Any termination of pregnancy
- Miscarriage if gestation >12 weeks
- Ectopic pregnancy managed surgically
- ECV
- Antepartum haemorrhage
- Amnio, CVS, fetal blood sampling
- Abdo trauma
232
Tests for all babies born to Rh -ve mother
Cord blood at delivery for FBC, blood group, and direct Coombs
233
Features rhesus disease of fetus
- Oedema (hydrops)
- Jaundice
- Anaemia
- Hepatosplenomegaly
- Kernicterus
- Treatment - transfusions, UV phototherapy
234
RA symptoms in pregnancy
Tend to improve, but only resolve in small minority
Patients tend to have flare in minority
235
RA drugs not safe in pregnancy
Methotrexate - needs to stop at least 6 months before conception
Leflunomide
236
RA drugs safe in pregnancy
Sulfasalazine
Hydroxychloroquine
Low-dose corticosteroids
NSAIDs until 32 weeks
237
Specialist input required RA in pregnancy
Need referring to obstetric anaesthetist due to risk of atlanto-axial subluxation
238
What gestation is rubella infection dangerous
Highest risk 8-10 weeks (90%)
Damage rare after 16 weeks
239
Features congenital rubella syndrome
- Sensorineural deafness
- Congenital cataracts
- Congenital heart disease
- Growth retardation
- Hepatosplenomegaly
- Purpuric skin lesions
- Salt and pepper chorioretinitis
- Micropthalmia
- CP
240
Investigation suspected exposure to rubella in pregnancy
IgM antibodies
241
Risk factors shoulder dystocia
- Fetal macrosomia
- High maternal BMI
- Diabetes mellitus
- Prolonged labour
242
First line management shoulder dystocia
McRoberts
243
Other management options shoulder dystocia
Symphysiotomy
Zavanelli manoeuvre
244
Normal symphysis fundal height
Gestation +/- 2cm
245
Complications mono mono twins
- Increased spontaneous miscarriage and perinatal mortality
- Increased malformations, IUGR, prematurity
- Twin to twin transfusion
246
Predisposing factors dizygotic twins
Previous twins
Family history
Increasing maternal age
Multigravida
Induced ovulation and IVF
Race
247
Antenatal complications twins
Polyhydraminos
Pregnancy induced hypertension
Anaemia
Antepartum haemorrhage
248
Fetal complications twins
Prematurity
Small for dates babies
Malformation
249
Labour complication twins
PPH
Malpresentation
Cord prolapse/entanglement
250
Risk factors cord prolapse
- Prematurity
- Multiparity
- Polyhydraminos
- Twin pregnancy
- Cephalopelvic disproportion
- Abnormal presentation
Around 50% occur at ARM
251
Features cord prolapse
Fetal HR abnormal
Cord palpable vaginally/visible beyond level of introitus
252
Immediate management cord prolapse
Presenting part may be pushed back into uterus
If cord past level of introitus, minimal handling and kept warm and moist to avoid vasospasm
'All fours' until prep for immediate C-section carried out
253
Mode of delivery cord prolapse
C-section
Instrumental possible if cervix dilated and head low
