Obstetrics Flashcards
What are some other serious infxs in pregnancy?
HIV, CMV( cytomegalovirus), hep B, herpes simplex, listeriosis, rubella, parovirus B19, toxoplasmosis.
CMV: commonest viral infx, assc w/ congenital synromes in fetus.
Hx- asymptomatic, fever, malaise, fatigue
Assc: immunosupression, higjer socioeconomic class. Less likely to have childhood immunity.
-DNA virus (herpes family) - can be dormant & reactivated.
Inv- bloods- CMV IgM (current) IgG (immunity)
USS- fetal anomaly scan,
Others: amniocentisis for CMV PCR(polymesrase chain rct)
Manag: no tx to prevent transmission- offer termination if evidence of CNS damage.
Compl: ⬆️ risk of miscarriage and stillbirth, congenital- microcephaly, blindness, skin rash, hepatoslpenomegaly, pneumonitis, mental retardation.
prognosis- 90% babes who are symptomatic- later neuro- developmental sx.
Hep B - what happens?
Hx: fever, myalgia, nausea, vomiting, jaundice, abdo pain (70% asympt)
O/E- jaundice, hepatomegaly, RUQ tenderness.
Patho: double stranded DNA v- hepatic dysfuntion.
Bloods: HBsAg (infx), core antibody: anti-HBc IgM- acute infx)
Hep B e-markers( HBeAg- high infectivity) , LFTs.
Manag:
Deliver:C/S NOT indicated.
Postnatal: mothers can feed.
Neonate vaccine if mother HBsAg +ve- at birth, 1M & 2 M.
Neonate HBIG: within 48hrs delivery if acute infx in pregnancy, if
What happens in other infx?
HIV- routine HIV test at ANC booking (10weeks), regular viral load + CD4 count. Monitor for drug toxicity: FBC, U&Es, LFTs, lactate and blood glucose.
M: HAART- 3 antiretrovirals combined, reduce trasmission from28% to 2%.
Compl: SE of haart- pre-eclampsia, obstretric cholestasis, lactic acidosis, glicose intolerance, GDM.
Chickenpox,
Herpes simplex- HSV virus.,2% of pregnant women.
Type1- oral, type 2- genital - dormant in nerve ganglia- reactivated to form lesions. Inv- swabs for cultures
Listeriosis-listeria monocytogenes
Found in soil, decayed matter and animals, soft cheese, pate, unpasturised dairy products, unwashed salads.
Hx: diarrhoea, vomitting, nausea, fever, sore thoat- often asymptomatic.
Patho: gram +ve bacilli
Inv: microbiology: blood culture, amniotic fluid culture, placental culture- serological test not reliable
Manag- IV antibiotics- gentamicin.
Compl- septicaemia, (poor prognosis) pnaumonia, meningitis. ⬇️ progn.
Pregn: miscarriage, chorioamnionitis, fetal death.
Progn- good if treated
What happens in multiple pregnancy?
Pregn inv more than 1 fetus.
Aetiology: monozygous: division of fertilised egg
Dizigous- fertilisation of >1 ovum
Assc- ⬆️ maternal age, african, prx hx, FHx, ovulation
Twins.. Triplets..
Hx- 1st trimester- incidental on USS, hyperemesis- ⬆️b-HCG.
Later- large-for-dates, multiple fetal parts on abdo exam. + ⬆️ fundal height.
Patho: NA.
Inv- confirm by USS, nuchal translucency.
Manag- antenatal- serial USS for fetal growth, monitor FBC( ⬆️anaemia) BP (⬆️eclampsia) GTT( ⬆️ diabetes)
Vaginalmdelivery: only of first twin cephalic
C/S- recomended for delayed delivery of 2nd twin, fetal distress of either twin, not vertex presentation of 1st twin.
Complications: miscarriage, hyperemesis, pre-eclampsia, anaemia (⬆️ plasma vol and fetal iron requirments), PPH, APH, diabetes (⬆️ steroid load) ,operative delivery, postnatal depression
Fetal: prematurity, polyhyrdaminos, cong malformations, IUGR (intra uterine growth restrtiction)’ fetal death.
Twin twin transfusiom syndrome.
Prognosis-
Twin fetal mortality 4 times higher than singletons.
What happens in Group B streptococcal (GBS) infx?
Most common early onset
What are some causes of maternal mortality?
How could we prevent this?
PE Eclampsia Haemorrhage Infx Cardiac diseases
Real killers:cz many women die during preganacy and they didnt even want a pregnancy at the first place.
Poverty
Ignorance
Desires of men
Real solution: literacy, economic growth,
Equality of dialogue between sexes.
School-based sex education
- could work in conjuction with easy access to contraception.
In 2007 -England and Wales- 160 pregnancies terminated in those
Some obstetric definitions
Gravidity- number of pregnancies woman had at any stage
Parity-refers to viable pregnancies that were delivered beyond 28weeks gestation. I.e. Para 2+1 = has had 2 pregancies beyond 28weeks gestation and 1- which was terminated before 28 weeks.
Debate- stillbirth-24weeks- so dont knwo which one to use..
Twins.. Should the be gravida 1 or 2?
Length-40 weeks from LMP
Expected delivery date (EDD) = 1 year and 7 days after LMP - 3 months.
Revised rule- add 10 days- more reliable
What would a pre-pregnancy counselling involve?
Reduce weight if obese
Ensure rubella and chickenpox immune prior to pregnancy
Asses risk for thrombophylaxis
Others:
Optimal control of chronic disease( eg diabetes) before contraception.
+ hypothyroidism as fetus cannot make thyroxine until 12weeks.
🔹Stop teratogens + seek advise-lithium, HIV drugs(didanosine and efavirenze)
🔹Folate supplements(help DNA regeneration) to avoid neural tube defects(NTD)( fetus abnormalities)
🔸Provide expert info in those at ⬆️ risk- so pregnancy or ots avoidance is an informed choice and tests like CVS (11 weeks) or Amniocentesis (16weeks) are planned.
🔹Regional genetic services
Inrelevant ethnics take bloods for thalassaemia or sicke cell.
🔹Avoidance for infx: sperm washing if HIV +ve male and HIV-ve woman.
🔹If past/Fx for thromboembolism screen for thrombophilia.
🔶Diet: to avoid NTDs+ cleft lip- folate rich food and folic acid 0.4mg daily> 1 month pre-conception. - brussels,sprouts, asparagus, spinach, blackeye beans, avoid liver and vit A(vit A embryopathy) & caffeine.
Smoking: ⬇️ ovulations, abnormal sperm production,- less penetrating capacity, ⬆️ rates of miscarry x2, preterm baby and lighter-176g mean.
Placenta praevia and abbruption
Reduced reading ability in smokers child up to 11Y
17% of mothers stop before or in pregnancy. Should be 100%!!!!
Alcohol consumption:
High levels: alcohol fetal syndrome. Does cross placenta and may affect fetal brain. 1-2u not shown to affect.
Miscarriage risks are higher among drinkers.
NICE- 5u/session is especially harmfull!
Spontaneous miscarry
8.9% in 20-40Y women, 74.7% in >45Y
After 3 miscarriages risk of next pregnancy Failure is 44.6% for nullips aged 25-29 and 35.4% in parous women.
Whats vit A embryopathy?
Retinoic acid embryopathy
Assc w/ cardiovascular (ventricular septal, aortic arch , )external ear deformity, cleft palate, micrognathia and central nervous malformations
What is an individualised care plan for DM?
Many features to be addressed- individualised care plan helps.
Chance for mum to talk to all her carers- all must sign up.
By documenting plan, mum and dad and team members are frequently the most reliable making sure things happen if they know what is expected- to check if pregnancy is monitored as planned.
In case of diabetes:
Joint clinic- MDT- obstertrician, diabetes physician, diabetic specialist nurse, diabetes midwife and dietician.
Care plan- antenatal (ANC) period till 6 weeks postpartum.
Advice about:
🔹Aspirin 75mg/24h Unitl delivery to reduce pre-eclampsia risk.
Targets for glycaemic control: every 2 weeks contact diabetic team about her blood levels.
- up to 20% develop proliferative retinopathy- retinal digital screening w/ mydriasis asap when pregnancy confirmed- if not screened 12M before. After 1st ANC appt and again at 16-20 weeks if retinopathy seen in initial screem in pregnancy and 28w if not seen at initial.
🔹Renal screening schedule (for microalbuminuria and protein dipstick at 1st appnt if nor screened in px 12M. Refer to nephrologist of creatinine >120mmol/L or protein excretion >2g/day.
🔶Fetal surveillance: 4chamber and outflow tract echo at 20weeks
USS at 28,32,36 w for fetal growth and amniotic fluid depth
🔹Cardiotocogram- twice weekly from 38weeks if waits for spontaneous labour rather than induction or C/S offered at 38w.
🔸Plan for delivery: if comorbidity like neuropathy or obesity arrange anaethetic assesm at 36w.
🔹Diabetes care after delivery- return to pre-pregnancy regimne- glycaemic control
Look for macrosomia in USS.
🔹Neonate care:
Feed asap, them 2-4hrs after birth to prevent hypoglycaemia. Gige IV glucose to to baby if symptomatically hypoglycaemic. Do not discharge to community till >24hrs old, feeding well, and able to maintain blood glucose levels.m
🔹Contraception
🔹Follow-up care after discharge- GTT at 6w Postpartum + annually- see if still diabetic in GDM( gestational DM)
What are the main physiological changes happening in pregnancy?
♦️Hormonal changes:
🔹Progesterone (synthesised by corpus luteum till 35 days post conception days and by placenta after.
⬇️ smooth muscle excitability (uterus,gut,ureters)
⬆️ body temperature.
🔹Oestrogens-(90% oestriol)
⬆️ breast and nipple growth, water retention and protein synthesis.
🔹Maternal thyroid enlarges due to ivreased production of colloid.
🔸Pituitary secretion of prolactin rises throughout pregnancy.
🔹Maternal cortisol-output- is increased but unbound levels remain constant.
♦️Genital changes- 100g non-pregnant uterus weighs 1100g by term. Muscle hypertophy occurs up to 20w- after–> stretching.
The cervix may develop ectropion(erosion)
Late in pregnancy- cervical collagen reduces.
Vaginal discharge increases due to cervical ectopy, cell desuamation and ⬆️ mucus production from vasocongested vagina.
Haemodynamic changes-
Blood: 10w-32w when it is 3.8L. Red cell volume rises. 18% if iron not taken- ⬆️30% at term if supplements taken hence Hb falls due to dilution - “Physiological anaemia”-
WCC (mean 10.5x10*9/L ), platelets, ESR (up to x4), cholesterol, b-globulin and fibrinogen Raised.
⬇️: albumin and gamma globulin.
Cardiovascular:
CO ⬆️ from 5L to 6.5-7L/min in first 10 w by ⬆️ stroke vol (10%) and pulse rate (15beats per minute) . Peripheral resistance falls (hormonal changes) ⭐️BP particularly diastolic falls during 2nd semester and rises again to non-pregnant level by term.
⬆️ venous distensibility and ⬆️ venous pressure (due to any pelvic mass) varicose veins may form. vasodilatation and hypotemsion stimulate RAAS- Main BP regulator in pregnancy.
Aorto-caval compression -20w gravid uterus compresses IVC (and lesser extend aorta) in supine women- ⬇️ venous return.
“Supine hypotension” -⬇️ CO by 30-40% –> place woman at left lateral to relieve and restore CO.
What other changes might pregnancy bring?
- Ventilation ⬆️ by 40%- TIdal vol rises. Increased depth of breath- progesterone effect.
- 02 consumption ⬆️ only by 20%. Breathlessness common- maternal PCO2 set lower to allow fetus for CO2 unloading.
- Gut motility ⬇️–> constipation, delayed gastric emptying, lax cardiac sphincter–> heartburns.
- Renal size ⬆️ by 1cm during pregnancy.
- Frequency of micturion ⬆️ - glomerular filtration rate ⬆️ by 60%_ later from bladder pressure by fetal head.
- Skin pegmentation- linea nigra, nipples, chloasma- brown patches on face- spider navi, palmar erythema, striae are common.
- Hair shedding reduced in pregnancy but extra hairs shed in puerperium.
How do pregnancy tests work?
+ve from 9 days conception or 23/28 cycle until 20w of pregnancy. Remain +ve after 5 days of miscarriage/ fetal death. False +ve rare. 96% sensitivity-urinary ones. 100% sensitivity serum -b -hCG.
Detect b- subunit of human chorionic gonadotrophin in early morning urine, so are +ve in trophoblastic disease.
What happens in pregnancy abd obesity? BMI>30 at booking
Long fat shadow over babys adult life- w/ risk of Heart disease, DM, metabolic syndrome, some cancers eg breast and lung.
Also risk of macrosomia, meconium aspiration.
Diet during pregnancy- low wt gain-correlates with preterm babies and prone to postnatal probs.
Onese women more prone to vid D deficiency so give Vit D (+ African origin) supplements while pregnant and breastfeeding.
If BMI> 30 at booking- offer diabetes screening- oral glucose tolerance test at 24-28 weeks + RF offer heparin thrombophylaxis 7 days postnatally +RF TED stockings.
Mobilse all obese women early.
If BMI >30 and require C/S- give IV prophylactic antibiotics and if subcutaneous fat >2 cm thick suture seperately to avoid infx.
BMI>40- heparin prophylaxis and TED stockings 7 days postnatally whatever mode of delivery is.
What do we do in Antenatal care? (ANC)
Aims: detect any disease in mum, ameliorate discomforts of pregnancy, monitor and promote fetal wellbeing, prepare mums for birth, minotor BP!! Is thrombophylaxis or aspirin needed?
Who: Midwives on 12 week. BMI>35 need consultant care.
What happens in the 1st ANC visit?
Language interprteter if she needs one.
Avoid using rekatives(confidentiality issues)
Hx: cycle length, LMP, contraception, drugs, past hx, surgery to abdo/pelvis, fertility probs, outcomes and complications in past pregnancies.
FHx of DM, BP, fetal abn, twins? Any concurrent illness? FGM- has she been ‘cut’? If FHx or past hx of DVT or embolism- screen for thrombophilia.
Is GDM a risk?- 75g glucose tolerance test
Past mental illness? If serious schizophrenia or bipolar disorder- or past postnatal probs get antenatal assignment: managment plain in notes.
Is she poor? Eg gas/electricity cut off? Unmarried? Unsupported? Sunpbject tomdomestic violence? Substance abuser? “Healthy start vitamins for women- dolic acid + vits C+D.
Avoid pate and blue/soft cheese- listeria
Toxoplasmosis advice- avoid liver
Examination:
Check heart, lungs, BP, weight(BMI) + abdomen. Is cervical smear given? Varicose veins? Sensitevley ask if genital organ cut.
Tests:
Blood: Hb, group (Abs, if RD -ve), syphillis and rubella +- chickenpox serology, HBsAg HIV test, sickle cell if black, Hb electrophoresis and 25-hydroxyvit D if relevant.
MSU- protein, bacteria, arrange tests to exclude Downs. If foreign, CXR for TB at 14weeks.
12week early USS to establish dates (cz it calculates exact gestation time) exclude multiple pregnancies, aid w/ Downs testss and an 18-20 week anomaly scan.
Suggest: dental visit, relaxation classes, ask about probs and anxities.
Advice- stop smoking, alcohol, diet, upcorrect use of seatbelt-abore or below bump not over it + adequate rest. Ensure knowlEdge of social cecurity benefits- usual exercise and travel- ok- avpid malarious areas- check with airline. Intercourse okay if no vaginal bleeding.
