Obstetrics Flashcards
hyperemesis gravidum clinical features
raised bHCG, 8-12/40 (may persist up to 20/40), 5% pre-pregnancy weight loss, dehydration, electrolyte imbalance
hyperemesis gravidum associations
multiple pregnancies, trophoblastic DZ, hyperthyroidism, nulliparity, obesity
mamagement of hyperemesis gravidum
- antihistamines (promethazine), cyclizine, 2. ondansetron, metoclopramide admission may be required for IV fluids
complications of hyperemesis gravidum
Wernike’s encephalopathy, Mallory-Weiss tear, central pontine myelinolysis, ATN, SGA, preterm birth
raised bHCG, 8-12/40 (may persist up to 20/40), 5% pre-pregnancy weight loss, dehydration, electrolyte imbalance
hyperemesis gravidum
multiple pregnancies, trophoblastic DZ, hyperthyroidism, nulliparity, obesity are associations with
hyperemesis gravidum
- antihistamines (promethazine), cyclizine, 2. ondansetron, metoclopramide admission may be required for IV fluids management of
hyperemesis gravidum
Wernike’s encephalopathy, Mallory-Weiss tear, central pontine myelinolysis, ATN, SGA, preterm birth complications of
hyperemesis gravidum
antenatal assessment aims
detect + manage pre-existing maternal conditions that may affect pregnancy outcome, prevent/detect maternal complications, prevent/detect foetal complications, detect congenital foetal abnormalities, plan delivery, educate/advise RE lifestyle
time of booking visit
10-12/40
booking visit Hx
age, obstetrics Hx (preterm, SGA, stillbirth, ante/post-partum haemorrhage, congenital abnormalities, Rh DZ, preeclampsia, GDM), LMP, gynae Hx (fertility, Sx), smear Hx, PMH (HTN, DM, AI DZ, Hbopathy, thromboembolic DZ, CVS/renal DZ, depression), DH, FH (DM, HTN, thromboembolic DZ, AI DZ, preeclampsia), SH (smoking, EtOH, drug abuse, domestic violence)
booking visit O/E
health, nutritional status, BMI, BP, abdo exam, foetal HR
booking visit investigations
TAUS (crown-rump l to date, multiple pregnancies, nuchal translucency), FBC, anti-D, OGTT (at risk females), syphillis, rubella immunity, HIV, hep B, Hb electrophoresis, urine culture
which trimesteris it best to generally avoid medications
first
1st trimester
1-12/40
2nd trimester
13-27/40
3rd trimester
28/40-birth
folic acid
0.4mg/d until >12/40
0.4mg/d until >12/40
folic acid supplementation
vitamin D
10ug/d if BMI >30 or sunlight deprived areas
10ug/d if BMI >30
vitamin D supplementation
EtOH in pregnancy
avoid, esp in first 12/40, limit to 1U/d
foods to avoid during pregnancy
unpasturised milk, soft/blue cheese, pate, uncooked/partially cooked ready prepared meals
pregnant women should sleep
in the L lateral position
anomaly scan
18-21/40, detects structural foetal abnormalities, sex determination
number/frequency of midwife visits
10 for nulliparous, 7 for multiparous women at increasing f as the pregnancy progresses
10 for nulliparous, 7 for multiparous women at increasing f as the pregnancy progresses
number/f of midwive visits
25/40 midwife visit
exclude early onset preeclampsia
28/40 midwife visit
FH measurement, FBC, anti-D, OGTT if indicated
SGA definition
weight of foetus < 10/100th for its gestation
SGA DD
wrong dates, small foetus (consistently small, still progressing along its own projectile), placental insufficiency (HTN, proteinuria, extremes of age), IUGR (smoking/drug abuse), maternal DM, prolonged pregnancy, multiple pregnancy, ch abnormalities/inborn errors of metabolism, ethnic groups, small parents, infection (CMV)
SGA vs IUGR
SGA is when the foetus’ weight falls below the 10/100th, IUGR is when the trajectory of the foetal growth has slowed suggesting foetal compromise + is more worrying (stillbirth risk) than SGA alone if growth continuing at a constant rate
stages of labour
1st stage: initiation to full dilatation (10cm), latent (slow dilatation to 3cm, several hours) + active phase (1-2cm/h progression)
2nd stage: 10cm to delivery of the foetus, passive (until head reaches pelvic floor, desire to push) + active stages (active pushing 20-40 mins)
3rd stage: foetus to delivery of the placenta (15 mins)
three “ “‘s of labour
“P”’s: power, passenger, passage
power
uterune contractions, painful, regular, leading to effacement (then dilatation) of the cervix
passage
pelvis: inlet transverse d = 13cm, outlet AP d = 13cm
station: position of the head in relation to the ischial spines + is below the level of the spines and - is above
passenger
unfused scull bones, vertex (sagital suture) = -/- the ant (bregma) + post (occipus) fontanelle
presentation
the part of the foetus that occupies the lower segment/pelvis e.g. cepalic/breech
presenting part
lowest part of the foetus palpable on VE e.g. vertex, brow, face
position of the head
describes the rotation e.g. OT, OP, OA
attitude of the head
describes the degree of flexion e.g. vertex, brow, face
the part of the foetus that occupies the lower segment/pelvis e.g. cepalic/breech
presentation
lowest part of the foetus palpable on VE e.g. vertex, brow, face
presenting part
describes the rotation e.g. OT, OP, OA
position of the head
describes the degree of flexion e.g. vertex, brow, face
attitude of the head
Braxton-Hicks contractions
felt throughout the 3rd trimester, involuntary uterine smooth m contractions
felt throughout the 3rd trimester, involuntary uterine smooth m contractions
Braxton-Hicks contractions
show
pink/white mucus plug, usually happend once the cervix is effaced + followed by the rupture of the menbranes
pink/white mucus plug, usually happend once the cervix is effaced + followed by the rupture of the menbranes
show
observations during labour
temp, HR, BP, foetal HR
pyrexia in labour
> 37.5’c, increased risk of neonatal illness, vaginal swabs, blood, urine cultures, consider IV ABx + antipyretics
partogram
used to assess progression of cervical dilatation
used to assess progression of cervical dilatation
partogram
ARM
used when there is failure of cervical dilatation progression
1st line when there is failure of cervical dilatation progression
ARM
2nd line when there is failure of cervical dilatation progression
IV oxytocin, required foetal montoring
IV oxytocin
when ARM has failed to progress cervical dilatation after 1-2hrs
3rd line when there is failure of cervical dilatation progression
consider c/s
foetal HR monitoring during labour
every 15 min, after a contraction, auscultate for 60 sec
VE every
2-4hrs
medical initiation of the 3rd stage of labour
IM oxytocin
most common position of head at delivery
OA
common abnormality of rotation leading to position of heat at delivery
OP
IoL
- sweep 2. prostglandins pessary 3. oxytocin 4. amniotomy
maternal collapse DD
ectopic pregnancy, major placental abruption, scar rupture in pregnancy post-c/s, amniotic fluid embolism, eclampsia, severe preeclampsia, uterine rupture, epilepsy, hypoxia, PPH, APH (haemorrhage is most common cause), cardiac DZ, spinal/LA toxicity, PE, placenta praevia, atonic uterus, retained placenta, laceration
management of maternal collapse
call for help (SOAP - semior midwife, obstetrician, anaethetist, paediatrician/porter), ABCDE apporach, supportive, rescusitation, fluid therapy, O2, FBC, clotting, x-match, U+Es, LFTs, transfusion, FFP
uterine rupture risk factors
deep myomectomy (fibroid remouval), c/s, congenitally abnormal uterus, abnormal lie/presentation, hyperstimulation of the uterus
retained placenta definition
3rd stage of labout >30 mins
retained placenta risk factors
congenital uterine malformations
APH definition
bleeding from genital tract after 24/40
causes of APH
idiopathic, placental abruption, placenta praevia, ruptured vasa praevia, uterine rupture, bleeding of gynae origin
ruptured vasa praevia
foetal blood vessels run in membranes infront of presenting part (rare), rupture leads to APH
ruptured vasa praevia presentation
painless, moderate vaginal bleeding at amniotomy/spontaneous membrane rupture, severe foetal distress (c/s often not quick enough to save foetus)
PPH management
call for help (SOAP senior midwife, obstetrician, anaethetist, porter), ABCED approach, massive haemorrhage call, give blood, FFP, compress uterus bimanually, FBC, U+E, clotting, x-match
PPH causes
uterine atony, retained placental parts, perineal/vaginal trauma/tears, cervical laceration (rare, associated with instrumental deliveries), uterine rupture, coagulopathy, episiotomy
1’ PPH definition
loss of >500mL of blood <24h post-delivery, or >1000mL post-c/s
the problem with retained placental parts
means that the uterus can’t contract properly
uterine atony is more common in
prolonged labout, grand multips, overdistension of the uterus (polyhydramnios, multiple foetus’), fibroids
PPH risk factors
previous PPH, previous c/s, coagulation defect, anticoagulation therapy, instrumental delivery, c/s, retained placenta, APH, polyhydramnios, multiple pregnancies, grand multips, uterine malformation, fibroids, prolonged/induced labour
PPH prevention
oxytocin in the 3rd stage of labour, as effective as ergometrin which causes V + CI in HTN
2’ PPH definition
excessive blood loss, 24h-6/52 post-delivery
2’ PPH cause
endometritis with/w/o retained placenta tissue
2’ PPH management
ABCDE approach, FBC, swabs, US, ERPC, ABx
itching in pregnancy investigations
check sclera for jaundice, LFT, bile acids
itching in pregnancy DD
vaginitis, intrahepatic cholestsis
intrahepatic cholestasis
itch w/o rash, abnormal LFTs, raised bile acids, FH, recurrent, increased risk of sudden stillbirth + preterm delivery
intrahepatic cholestasis management
give vitamin K from 36/40 becuase of increased tendancy to haemorrhage, ursodeoxycholic acid relieves itching, IoL at 38/40, follow up at 6/52 to ensure LFTs have returned to N
preeclampsia HPC questions
headache, visual disturbances, flashing lights, drowsiness, EG pain, N+V, facial/hands/pretibial swelling, seizures, HTN, DM, FH of preeclampsia
general obstetrics history questions
weight change, appetite, fevers, rigors, seizures, results of scans/checks so far in pregnancy, previous pregnancies, smear, FM
is paracetamol safe in pregnancy
yes
is ibuprofen safe in pregnancy
no, NSAIDs not recommended in pregnancy
GDM glucose values
> 11.1
GDM ‘impaired glucose tolerance’ values
between 7.9-11.1
GDM management
lifestyle changes: diet + exercise, medication, regular BM checking (3x/d pre + postprandial), >f antenatal checks, DM specialist team, IoL at 38-39/40
risks of uncontrolled blood glucose during pregnancy
macrosomia, sholder dystocia, foetal hypoglycaemia (paediatricians to check BM regularly + present at birth), jaundice, breathing difficulties
GDM Hx questions
polyuria, polydipsia, previous miscarriages, FH (DM + GDM)
APH questions
colour, V, pain, previous bleeding in this/previous pregnancy, duration, outcome, precipitating factors (intercourse, straining, Sx), placental position on scans, blood group, Rh status, pregnancy-related problems to date, previous pregnancies, previous APH/PPH, FH (bleeding disorder)
post-partum low mood DD
baby blues, postnatal depression, postpartum thyroiditis, BPAD
postpartum thyroiditis prevalence
5-10%
postpartum thyroiditis risk factors
antithyroid Abs, T1DM
postpartum thyroiditis course
3/12 postpartum transient + subclinical hyperthyroidism, followed by 4/12 of hypothyroidism (permanent in 20%)
baby blues
third d post partum, 10% prevalence
tool for scoring PND
EPDS Edinburgh postnatal depression scale
risk factors for PND
social/emotional isolation, previous Hx, pregnancy complicaitons
management of PND
social support, psychotherapy, antidepressants
PND recurrence in subsequent pregnancies
70%
puerperal aka
postpartum period
postpartum period aka
puerperal
post partum period duration
immediately after birth to 6/52 later
physiological change that happens during the puerperium
mothers body returns to its prepregnant state
mothers body returns to its prepregnant state during
the puerperium
lochia
discharge from uterus post partum, may be blood stained for 4/52, then yellow/white
discharge from uterus post partum
lochia
postpartum pyrexia
genital tract sepsis, chest infection, mastitis, perineal infection, would infection
endometritis causes in pregnancy
retained tissue, septic miscarriage
common causes of polyhydramnios
DM, GDM, foetal abnormality (upper GI obstructions, inability to swallow, chest abnormalities, MD), idiopathic, maternal renal failure, twins,
clinical features of polyhydramnios
maternal distress, large for dates, taut uterus, foetal parts difficult to palpate
complications of polyhydramnios
preterm labour, maternal discomfort, abnormal lie, malpresentation
management of polyhydramnios
amnioreducion, foetal surveillance, NSAIDs
increased nuchal translucency indicated
Down S, congenital heart defects, abdo wall defects
causes of hyperechogenic bowel
cf, Down S, CMV infection
pulmonary hypoplasia + congenital diaphragmatic hernia
occur alongside each other rather than as a sequence of events
causes of pulmonary hypoplasia
oligohydramnios (decreases size of intrathoracic cavity, preventing foetal L growth), congenital diaphragmatic hernia
pulmonary hypoplasia is
underdeveloped L in newborn infants
placenta praevia association
twins, high pariety, age, scarred uterus
placental praevia is when
the placenta is implanted in the lower segment of the uterus
low lying placentas at
20/40, most appear to move up as the pregnancy progresses, due to formaion of the lower segment of the uterus in the 3rd trimester
classification of placenta praevia
marginal = placent in lower segment, not over os major = placenta completely/partially covering os
complications of placenta praevia
obstructs head engagement, causes transverse lie, haemorrhage (A/PPH), placenta accreta, placenta percreta
placenta accreta
when the placenta invades the myometrium, v high risk of PPH necessitating hysterectomy
placenta percreta
when the placenta penetrates through the uterine myometrium into surrounding structures e.g. bladder (often at the site of a previous c/s scar), may necessitate hysterectomy
placenta praevia presentation
intermittant painless bleeds, increasing f + intensity, incidental on US (some women experience no bleeding)
placenta praevia O/E
breech presentation, transverse lie, high unengaged head
examination never to perform in a pregnant wonam who’s bleeding
VE, unless placenta praevia is excluded
placenta praevia investigations
TV/TAUS, 3D power US (if suspect placenta accreta), CTG, FBC, clotting, x-match
if low lying placenta detected at 20/40 scan
repeat at 32/40
placenta praevia management
admit (all women with bleeding), praevia on US amy warrent hositalisation until delivery, steroids if <34/40, elective c/s at 39/40 (earlier is bleeding is severe)
why intraoperative/PPH so common with placenta praevia
because the lower segmentdoesn’t contract well after delivery
twins, high pariety, age, scarred uterus increase the risk of
placenta praevia
the placenta is implanted in the lower segment of the uterus
placenta praevia
obstructs head engagement, causes transverse lie, haemorrhage (A/PPH), placenta accreta, placenta percreta are complications of
placenta praevia
when the placenta invades the myometrium, v high risk of PPH necessitating hysterectomy
placenta accreta
when the placenta penetrates through the uterine myometrium into surrounding structures e.g. bladder (often at the site of a previous c/s scar), may necessitate hysterectomy
placenta percreta
intermittant painless bleeds, increasing f + intensity, incidental on US (some women experience no bleeding) describes the presentation of
placenta praevia
breech presentation, transverse lie, high unengaged head O/E may suggest
placenta praevia
never do a VE on a pregnant woman when
she’s bleeding
placenta praevia vs placental abruption
PP: shock consistent with external loss, painless, red, ?profuse bleeding, abnormal lie, high head, foetal HR N, low placenta
PA: shock inconsistent with external loss, severe pain, absent/dark blood, tenderness, hard uterus, N lie/engagement, foetal HR ?dead/distressed, US N
placental abruption is when
part/all pf the placenta separates from the uterine wall before the delivery of the foetus
complications of placental abruption
foetal death, haemorrhage, DIC, renal failure
risk factors for placental abruption
IUGR, preeclampsia, preexisting HTN, AI DZ, smoking, cocaine, previous placental abruption, multiple pregnancies, high pariety, trauma, rupture of membranes in polyhydramnios
placental abruption presentation
painful bleeding, constant, dark blood
concealed abruption
pain alone w/o PV bleeding
placental abruption O/E
tachycardia, low BP, tender uterus, contracting, woody uterus (severe cases)
placental abruption investigations
clincal diagnosis, CTG, tocograph, US (exclude praevia), regular FBC, regular clotting, x-match, catheterise + monitor UO, regular U+Es, central v P monitoring (severe cases)
features of major placental abruption
maternal collapse, coagulopathy, foetal distress/demise, woody hard uterus, poor UO/renal failure
placental abruption management
hospitalise, IV fluids, steroids (if gestation <34/40), analgesia, anti-D (if necessary), blood transfusion (if necessary)
delivery in placental abruption
stabilise mother first
foetal distress: emergency c/s
no foetal distress >37/40: IoL with amniotomy
no foetal distress <37/40: steroids (<34/40), close monitoring
foetus is dead: coagulopathy likely, blood products, IoL
part/all pf the placenta separates from the uterine wall before the delivery of the foetus
placental abruption
foetal death, haemorrhage, DIC, renal failure are complications of
placental abruption
IUGR, preeclampsia, preexisting HTN, AI DZ, smoking, cocaine, previous placental abruption, multiple pregnancies, high pariety, trauma, rupture of membranes in polyhydramnios are risk factors for
placental abruption
painful bleeding, constant, dark blood
placental abruption
tachycardia, low BP, tender uterus, contracting, woody uterus (severe cases)
placental abruption
pain alone w/o PV bleeding
concealed placental abruption
pregnancy induced HTN
BP >140/90 after 20/40
causes of pregnancy induced HTN
preeclampsia, transient HTN
preeclampsia is definied as
HTN + proteinuria (>0.3g/24h) +/- oedema
eclampsia
occurrence of epileptiform/grand mal seizures in pregnancy
pregnancy induced HTN aka
gestational HTN
preexisting HTN in pregnancy
BP >140/90 <20/40 or already on antiHTN medication
1’ vs 2’ preexisting HTN in pregnancy
2’ = as a result of renal/other DZ
physiological consequences of preeclampsia
increased vascular R leads to HTN, increased vascular permeability leads to proteinuria, reduced placental blood flow leads to IUGR, reduced cerebral perfusion leads to eclampsia
in early stage preeclampsia what sign can be absent
proteinuria (a relatively late sign)
preeclampsia risk factors
nulliparity, previous preeclampsia, FH, long interpregnancy interval, obesity, old maternal age, chronic HTN, DM, twins, AI DZ, renal DZ, obesity
HTN in pregnancy classification
mild = >140/90 moderate = >150/100 severe = >160/110
preeclampsia classification
mild = proteinuria + HTN <160/110 moderate = proteinuria + HTN >160/110 w/o maternal complications severe = proteinuria + any HTN + <34/40 or maternal complications
preeclampsia investigations
urine dipstick (2+), protein creatinine ratio (30mg/nmol), 24h urine collection (>0.3g/24h), exclude infection, FBC, U+E, LFT, clotting, US
HELLP S
haemolysis (dark urine, raised LDH, anaemia), elevated liver EZ (EG pain, liver failure, abnormal clotting), low platelets
preeclampsia O/E
HTN, oedema (massive, not postural, sudden onset), EG tenderness (impending complications)
complications of preeclampsia
eclampsia, cerebrovascular haemorrhage, HELLP, DIC, liver failure, renal failure, pulmonary oedema, IUGR, preterm birth, placental abruption, hypoxia
any complication of preeclampsia warrents
delivery
complications of eclampsia
hypoxia, death
prophylaxis against eclampsia
Mg sulphate
prophylaxis in at risk women for preeclampsia
aspirin 75mg before 16/40
management of new onset mild/moderate HTN in pregnancy w/o proteinuria
OP management, BP + urinalysis twice weekly, US 2-4 weekly
criteria for admission in preeclampsia/suspected preeclampsia
symptoms, proteinuria (2+ dipstick, 30mg/nmol PCR, 0.3g/24h), BP >160/110, suspected foetal compromise
give antihypertensive at what BP
150/100, give urgently if >160/110, target BP <140/90
antihypertensives in preeclampsia
labetalol, nifedipine
effect of antihypertensives in preeclampsia
don’t change the course of the DZ but increase safety for the mother
non antihypertensive medications in preeclampsia
Mg sulphate
mechanism of action of Mg sulphate
increase cerebral perfusion to minimise seizure risk
symptoms of Mg sulphate toxicity
loss of plantar reflexes, respiratory depression, hypotension
gestational HTN delivery management, w/o foetal compromise
regular monitoring, IoL at 40/40 if required antihypertensive medication
mild preeclampsia + delivery
IoL by 37/40
moderate/severe preeclampsia + delivery
if gestation >34-36/40: IoL
if <34/40: inPT managment, steroids, deterioration will prompt c/s
severe preeclampsia with complications/ foetal distress + delivery
deliver now
postnatal care of preeclampsia
LFT, FBC, U+E, fluid balance, UO, BP
a really accurate way to measue BP
CVP central venous P
risk factors for preexisting HTN in pregnancy
obesity, increased maternal age, COCP induced HTN, FH
women with pregnancy induced HTN are at greater risk of
developiong HTN in later life
antihypertensives not to use in pregnancy
ACEi (teratogenic)
BP >140/90 after 20/40
pregnancy induced HTN
HTN + proteinuria (>0.3g/24h) +/- oedema defines
preeclampsia
occurrence of epileptiform/grand mal seizures in pregnancy
eclampsia
gestational HTN aka
pregnancy-induced HTN
BP >140/90 <20/40 or already on antiHTN medication
preexisting HTN in pregnancy
nulliparity, previous preeclampsia, FH, long interpregnancy interval, obesity, old maternal age, chronic HTN, DM, twins, AI DZ, renal DZ, obesity are riskfactors for
preeclampsia
HTN, oedema (massive, not postural, sudden onset), EG tenderness (impending complications) O/E suggests
preeclampsia
eclampsia, cerebrovascular haemorrhage, HELLP, DIC, liver failure, renal failure, pulmonary oedema, IUGR, preterm birth, placental abruption, hypoxia are complications of
preeclampsia
Mg sulphate is used as
prophylaxis against eclampsia
aspirin 75mg before 16/40 is used as
prophylaxis in women at risk of preeclampsia
labetalol, nifedipine are
antihypertensives used in pregnancy
medication that increase cerebral perfusion to minimise seizure risk
Mg sulphate
loss of plantar reflexes, respiratory depression, hypotension are symptoms of
Mg sulphate toxicity
obesity, increased maternal age, COCP induced HTN, FH are risk factors for
preexisting HTN in pregnancy
can you use ACEi in pregnancy
no - teratogenic
amniotic fluid embolism
when liquor enters the maternal circulation, extremely rare
consequence of an amniotic fluid embolism
anaphylaxis, sudden SOB, hypoxia, hypotension, seizures, cardiac arrest, acute HF, DIC, pulmonary oedema, ARDS
risk factors for amniotic fluid embolism
maternal age, IoL, strong contractions in the presence of polyhydramnios
prevention of amniotic fluid embolism
impossible
management of amniotic fluid embolism
rescuscitation, supportive treatment, O2, fluids, blood, FFP, transfer to ITU
amniotic fluid embolism investigations
FBC, clotting, U+E, x-match
when liquor enters the maternal circulation, extremely rare
amniotic fluid embolism
anaphylaxis, sudden SOB, hypoxia, hypotension, seizures, cardiac arrest, acute HF, DIC, pulmonary oedema, ARDS are consequences of
amniotic fluid embolism
maternal age, IoL, strong contractions in the presence of polyhydramnios are risk factors for
amniotic fluid embolism
effect of epidural anaesthesia on BP
reduced
clinical features of HELLP S
HTN, V, abdo pain
HTN, V, abdo pain are clinical features of
HELLP S
Mg sulphate dose in eclampsia
IV 4g bolus over 5-10mins, followed by 1g/h infusion
preexisting DM in pregnancy management
women may require > insulin/similar to maintain their blood glucose levels
GDM glucose levels
> 7 fasting
>7.8 2hrs post OGTT
foetal complications of GDM/DM during pregnancy
congenital abnormalities (neural tube, cardiac), preterm, reduced foetal L maturity, increased birthweight, polyhydramnios, shoulder dystocia, birth trauma, foetal compromise, foetal distress, sudden foetal death
maternal complications of GDM/DM during pregnancy
increased insulin requirements, hypoglycaemia, DKA, UTI, wound/endometrial infection post partum, HTM, preeclampsia, worsening of IHD, c/s/instrumental > likely, DM nephropathy, DM retinopathy
investiagations in GDM/DM in pregnancy
foetal ECHO, US to monitor foetal growth + liquor V, U+E, fundoscopy
management of GDM/DM in pregnancy
preconceptual diabetic control, aspirin 75mgfrom 12/40, diet, exercise, home monitoring, metformin, insulin, OGTT at 3/12 post delivery
delivery + GDM/DM in pregnancy
should be by 39/40
c/s is indicated in GDM/DM when
birth weight is predicted >4kg
screening for GDM
screen at 28/40: previous large baby (>4.5kg), unexplained still birth, 1st degree relative with DM, BMI >30, South Asian, Black Carribean, Middle Eastern origin, PCOS
screen at 18/40: previous GDM
risk factors for GDM
personal Hx of GDM, previous >4.5kg foetus, previous unexplained stillbirth, 1st degree relative with DM, BMI >30, racial origin, polyhydramnios, persistent glycosuria
congenital abnormalities (neural tube, cardiac), preterm, reduced foetal L maturity, increased birthweight, polyhydramnios, shoulder dystocia, birth trauma, foetal compromise, foetal distress, sudden foetal death
foetal complications of GDM/DM in pregnancy
increased insulin requirements, hypoglycaemia, DKA, UTI, wound/endometrial infection post partum, HTM, preeclampsia, worsening of IHD, c/s/instrumental > likely, DM nephropathy, DM retinopathy
maternal complications of GDM/DM in pregnancy
personal Hx of GDM, previous >4.5kg foetus, previous unexplained stillbirth, 1st degree relative with DM, BMI >30, racial origin, polyhydramnios, persistent glycosuria are risk factors for
GDM
molar pregnancy is a types of
trophoblastic DZ
presentation of a molar pregnancy
vaginal bleeding, large for dates uterus, hyperemesis, hyperthyroidism
shoulder dystocia is associated with
PPH, perineal tears, brachial plexus injury, neonatal death
risk factors for shoulder dystocia
foetal macrosomia, high maternal BMI, DM, prolonged labour
vaginal bleeding, large for dates uterus, hyperemesis, hyperthyroidism may suggest
molar pregnancy
foetal macrosomia, high maternal BMI, DM, prolonged labour are risk factors for
shoulder dystocia
intrahepatic cholestasis of pregnancy is characterised by
itch w/o rash, abnormal LFTs
intrahepatic cholestasis is caused by
abnormal sensitivity to the cholestatic effects of oestrogens
complications of intrahepatic cholestasis
stillbirth, preterm
intrahepatic cholestasis management
vit K 10mg/d from 36/40, ursodeoxycholic acid (UDCA) relieves itch, IoL at 38/40, follow up 6/52 post partum
itch w/o rash, abnormal LFTs indicated
intrahepatic cholestasis
ectopic pregnancies
fertilised egg implants outside of the uterus, most commonly the fallopial tubes
risk factors for ectopic pregnancy
PID, assisted conception, Sx, previous ectopic, smoking, IUD
ectopic pregnancy presentaion
scanty dark vaginal bleeding, lower abdo pain, syncope, shoulder tip pain, amenorrhoea
ectopic pregnancy O/E
abdo tenderness, rebound tenderness, cervical excitation, adenexal tenderness, tachycardia, hypotension
ectopic pregnancy investigations
urine pregnancy test, TVUS, serum B-hCG (repeat in 48h)
ectopic pregnancy management
NBM, FBC, x-match, TVUS, laproscopy (esp if HD unstable/heartbeat, salpingectomy), IV access, methotrexate (no cardiac activity), serial B-hCG
PID, assisted conception, Sx, previous ectopic, smoking, IUD are all risk factors for
ectopic pregnancy
scanty dark vaginal bleeding, lower abdo pain, syncope, shoulder tip pain, amenorrhoea
ectopic pregnancy
abdo tenderness, rebound tenderness, cervical excitation, adenexal tenderness, tachycardia, hypotension O/E may indicate
ectopic pregnancy
threatened miscarriage
there is bleeding by the foetus is still alive, the uterus is the correct size for dates, os is closed
% with a threatened miscarriage that go on to miscarry
25%
miscarriage definition
foetus dies/delivers <24/40
ineviatable miscarriage
heavy bleeding, foetus alive, os open, miscarriage is about to occur
incomplete miscarriage
some foetal parts have passed, os open
complete miscarriage
all foetal tissue passed, bleeding reduced, uterus no longer enlarged, os closed
septic miscarriage
contents of uterus are infected, causing endometritis, offensive vaginal loss, tender uterus
missed miscarriage
foetus undeveloped/died in utero, not recognised until US/bleeding occurs, uterus is smaller than expected for dates, os closed
myths that don’t really cause miscarriages
exercise, stress, emotional trauma
miscarriage investigations
early pregnancy assessment unit, TVUS, B-hCG, FBC, anti-D
recurrent miscarriage definition
3+ miscarriages in succession
management of recurrent miscarriages
counselling, US monitoring, aspirin + low dose LMWH (in anti-PL S), karyotyping (ch)
recurrent miscarriage risk factors
anti-PL S, ch abnormalities, uterine abnormalities, cervical incompetence, obesity, smoking, PCOS, excess caffeine, high maternal age, poorly controlled DM, thyroid DZ
there is bleeding by the foetus is still alive, the uterus is the correct size for dates, os is closed
threatened miscarriage
heavy bleeding, foetus alive, os open, miscarriage is about to occur
ineviatable miscarriage
some foetal parts have passed, os open
incomplete miscarriage
all foetal tissue passed, bleeding reduced, uterus no longer enlarged, os closed
complete miscarriage
contents of uterus are infected, causing endometritis, offensive vaginal loss, tender uterus
septic miscarriage
foetus undeveloped/died in utero, not recognised until US/bleeding occurs, uterus is smaller than expected for dates, os closed
missed miscarriage
anti-PL S, ch abnormalities, uterine abnormalities, cervical incompetence, obesity, smoking, PCOS, excess caffeine, high maternal age are risk factors for
miscarriage
risks of twin pregnancies
preterm labour, miscarriage, congenital abnormalities, IUGR, GDM, hyperemesis, preeclampsia, anaemia
delivery of twins
most likely c/s due to mal presentaion, if 1st baby = cephalic can do vaginal, IoL at 38-39/40
risks of vaginal delivery with twins
risk of cord prolapse/breech presentation with 2nd twin), PPH
breech presentation
try ECV, elective c/s at 38/40
ECV CI
fibroids, low placenta, APH, premature ROM
`% success rate of ECV
50%
breech presentation risks in vaginal delivery
cord prolapse
