Obstetrics Flashcards

Question

Describe the pathophysiology of pre-eclampsia?

Answer 1

* Endothelial cell damage in the placenta in association with an exaggerated maternal inflammatory response (due to incomplete trophoblastic invasion of spiral arterioles) causes ischaemia, which leads to vasospasm, increased capillary permeability and clotting dysfunction * This leads to increased vascular resistance (hypertension), increased vascular permeability (proteinuria), reduced placental blood flow (IUGR) and reduced cerebral perfusion (eclampsia)

Answer 2

* nulliparity * preeclampsia in a previous pregnancy * age \>40 yr or \<18 yr * FHx of preeclampsia * chronic HTN * chronic renal disease * antiphospholipid antibody syndrome or inherited thrombophilia * vascular or connective tissue disease * DM (pre-gestational and gestational) * high BMI * hydrops fetalis * unexplained fetal growth restriction * abruptio placentae * there is a potential for further deterioration to severe preeclampsia * the adverse conditions are many and include both maternal and fetal issues

Answer 3

* Small placenta – looks like a cupcake * Serial slices show cream-white areas of infarction which involve more than 25% of the placental parenchyma * Retroplacental haematomas are more common

Answer 4

* Lack of conversion in decidual vessels * Aggregates of foamy macrophages * Fibrinoid necrosis-atherosis in decidual arteries * Coagulative necrosis in areas of infarction * Accelerated maturation in some villi * Occasional nucleated RBCs

Answer 5

* Bloods: * FBC and peripheral smear: microangiopathic haemolytic anaemia (HELLP), schistocytes on peripheral smear, thrombocytopaenia\<100,000, haemoconcentration in severe cases * LDH * LFT: transaminase levels elevated from hepatocellular injury and in HELLP syndrome * INR and aPTT * UEC: serum creatinine levels elevated due to decreased intravascular volume and decreased GFR * Urine (dip ± 24 h collection or protein/creatinine ratio) * Uric acid: hyperuricaemia one of the earliest lab manifestations, serial levels indicate progression * Imaging: * US: to assess foetal well-being and evaulate IUGR * If US is abnormal: umbilical artery Doppler and cardiotocography to evaluate foetal well-being

Answer 6

* RUQ pain * headache * visual disturbances

Answer 7

* History: * usually asymptomatic * headache, drowsiness, visual disturbances, nausea/vomiting or epigastric pain may occur at a late stage * Examination: * HTN usually the first sign * oedema (massive, not postural, or of sudden onset) * epigastric tenderness * urine dipstick (1+ possibly significant, ≥2+ likely significant)

Answer 8

* Without proteinuria and mild/moderate hypertension – managed as outpatients, BP and urinalysis repeated twice weekly and U/S performed every 2-4wk unless foetal compromise * Severe hypertension or proteinuria – admit to hospital * Drugs * Anti-hypertensives if BP\>150/100mmHg – labetalol (1st), methyldopa, nifedipine, hydralazine * Magnesium sulphate – used for treatment and, if severe, prevention of eclampsia * Steroids – used to promote foetal pulmonary maturity if gestation \<34wk * Timing of delivery – mild pre-eclampsia required delivery by 37wk, moderate of severe preeclampsia requires delivery if gestation exceeds 34-36wk, clinical deterioration prompts delivery * Conduct of delivery – caesarean section if before 34wk, induction after 34wk * Post-natal care – usually takes at least 24h for condition to improve post-delivery, so monitor bloods (FBC, LFT, EUC) and fluid balance, treatment for BP may be required for several weeks.

Answer 9

* Maternal: * Eclampsia * Cerebrovascular accident (CVA) * Haemolysis, elevated liver enzymes and low platelet count (HELLP) * Disseminated intravascular coagulation (DIC) * Liver failure * Renal failure * Pulmonary oedema * Foetal: * Intrauterine growth restriction (IUGR) * Pre-term birth * Placental abruption * Hypoxia

Answer 10

the occurrence of one or more generalized convulsions and/or coma in the setting of preeclampsia and in the absence of other neurologic conditions

Answer 11

* eclampsia is a clinical diagnosis * typically tonic-clonic and lasting 60-75 s * one of the signs of an impending seizure is hyperreflexia * symptoms that may occur before the seizure include persistent frontal or occipital headache, blurred vision, photophobia, right upper quadrant or epigastric pain, and altered mental status * in up to one third of cases, there is no proteinuria or blood pressure is \<140/90 mmHg prior to the seizure * In general, women with typical eclamptic seizures who do not have focal neurologic deficits or prolonged coma do not require diagnostic evaluation including imaging

Answer 12

* ABCs * roll patient into LLDP * supplemental O₂ via face mask to treat hypoxemia due to hypoventilation during convulsive episode * aggressive antihypertensive therapy for sustained diastolic pressures ≥105 mmHg or systolic blood pressures ≥160 mmHg with hydralazine or labetalol * prevention of recurrent convulsions: to prevent further seizures and the possible complications of repeated seizure activity (e.g. rhabdomyolysis, metabolic acidosis, aspiration pneumonitis, etc.) * MgSO4 is now the drug of choice, with previously used agents including diazepam and phenytoin * the definitive treatment of eclampsia is DELIVERY, irrespective of gestational age, to reduce the risk of maternal morbidity and mortality from complications of the disease * mode of delivery is dependent on clinical situation and fetal-maternal condition

Answer 13

* Flushing * Hyporeflexia * Somnolence * Respiratory and cardiac depression * Weakness * Note: Increased risk of toxicity with concurrent calcium channel blocker use or renal disease * Rx: * Stop MgSO4 * Calcium gluconate 10% in 10 mL IV

Answer 14

* affects 50-90% of pregnant women * often limited to T1 but may persist

Answer 15

* rule out other causes of N/V * weigh frequently, assess level of hydration, test urine for ketones * non-pharmacological * Avoid mixing fluids and solids, frequent small meals * stop prenatal vitamins (folic acid must continue until \>12 wk) * increase sleep/rest * ginger (maximum 1,000 mg/d) * acupuncture, acupressure * pharmacological * first line: Diclectin® (10 mg doxylamine succinate with vitamin B6) 4 tablets PO daily to maximum of 8 tablets * if no improvement, try dimenhydrinate (50-100 mg q4-6h PO), followed by hydroxyzine, pyridoxine, phenothiazine, or metoclopramide * vitamin B6 lollipops * if patient dehydrated, assess fluid replacement needs and resuscitate accordingly * severe/refractory: * consider homecare with IV fluids and parenteral anti-emetics, hospitalization

Answer 16

* intractable N/V, usually presents in T1 then diminishes; occasionally persists throughout pregnancy * affects ~1% of pregnancies

Answer 17

* Infections: UTI, hepatitis, meningitis, gastroenteritis * GI: appendicitis, cholecystitis, pancreatitis, fatty liver, peptic ulcer, SBO * metabolic: thyrotoxicosis, Addison’s, DKA, hyperparathyroidism * drugs * gestational trophoblastic disease (molar pregnancy, choriocarcinoma)

Answer 18

* rule out systemic causes: GI inflammation, pyelonephritis, thyrotoxicosis * rule out obstetrical causes: multiple gestation, GTN, HELLP syndrome * FBC, UEC LFTs * urinalysis * US

Answer 19

* thiamine supplementation may be indicated * non-pharmacological (see Nausea and Vomiting) * pharmacological options * Diclectin® (for dosage, see Nausea and Vomiting) * Dimenhydrinate can be safely used as an adjunct to Diclectin® (1 suppository bid or 25 mg PO qid) * other adjuncts: hydroxyzine, pyridoxine, phenothiazine, metoclopramide * also consider: ondansetron or methylprednisolone * if severe: admit to hospital, NPO initially then small frequent meals, correct hypovolemia, electrolyte disturbance, and ketosis, TPN (if very severe) to reverse catabolic state

Answer 20

* maternal * dehydration, electrolyte and acid-base disturbances * Mallory-Weiss tear * Wernicke’s encephalopathy, if protracted course * death * fetal: usually none, IUGR is 15x more common in women losing \>5% of pre-pregnancy weight

Answer 21

* usually around 24-28 wk GA * anti-insulin factors produced by placenta and high maternal cortisol levels create increased peripheral insulin resistance → higher fasting glucose → leading to GDM and/or exacerbating pre-existing DM

Answer 22

Preconception * pre-plan and refer to high-risk clinic * optimize glycemic control * counsel patient re: potential risks and complications * evaluate for diabetic retinopathy, neuropathy, CAD Pregnancy * if already on oral medication, generally switch to insulin therapy * continuing glyburide or metformin controversial * teratogenicity unknown for other oral anti-hyperglycemics * tight glycemic control * insulin dosage may need to be adjusted in type 2 due to increased demand and increased insulin resistance * monitor as for normal pregnancy plus initial 24 h urine protein and creatinine clearance, retinal exam, HbA1c * HbA1c: \>140% of pre-pregnancy value associated with increased risk of spontaneous abortion and congenital malformations * increased fetal surveillance (BPP, NST), consider fetal ECHO to look for cardiac abnormalities Labor * timing of delivery depends on fetal and maternal health and risk factors (i.e. must consider size of baby, lung maturity, maternal blood glucose, and blood pressure control) * can wait for spontaneous labor if blood glucose well-controlled and BPP normal * induce by 40 wk * type of delivery * increased risk of cephalopelvic disproportion (CPD) and shoulder dystocia with babies \>4,000 g (8.8 lbs) * elective C/S for predicted birthweight \>4,500 g (9.9 lbs) (controversial) * monitoring * during labor monitor blood glucose q1h with patient on insulin and dextrose drip * aim for blood glucose between 60-120 mg/dL to reduce the risk of neonatal hypoglycemia Postpartum * insulin requirements dramatically drop with expulsion of placenta (source of insulin antagonists) * no insulin is required for 48-72 h postpartum in most type 1 DM * monitor glucose q6h, restart insulin at two-thirds of pre-pregnancy dosage when glucose \>144 mg/dL

Answer 23

* Age \>25 yr * Obesity * Ethnicity (Aboriginal, Hispanic, Asian, African) * FHx of DM * Previous history of GDM * Previous child with birthweight \>4.0 kg * Polycystic ovarian syndrome * Current use of glucocorticoids * Essential HTN or pregnancy-related HTN

Answer 24

* first line is management through diet modification and increased physical activity * initiate insulin therapy if glycemic targets not achieved within 2 wk of lifestyle modification alone. Common regime: * short acting insulin before meals PRN * medium acting insulin at bedtime if fasting BG are elevated * glycemic targets (PG = plasma glucose): FPG ≤5.0 mmol/L, 1h PG ≤7.4 mmol/LL, 2h PG ≤6.7 mmol/L * Oral agents: metformin and glibenclamide have not been approved for use in pregnancy in Australia * stop insulin and diabetic diet postpartum * follow-up with 75 g OGTT 6 -12 weeks postpartum

Answer 25

* Obstetric * HTN/preeclampsia (especially if pre-existing nephropathy/proteinuria): insulin resistance is implicated in etiology of HTN * Polyhydramnios: maternal hyperglycemia leads to fetal hyperglycemia, which leads to fetal polyuria (a major source of amniotic fluid). * Diabetic Emergencies * Hypoglycemia * Ketoacidosis * Diabetic coma * End-Organ Involvement or Deterioration (occur in T1DM and T2DM, not in GDM) * Retinopathy * Nephropathy * Other * Pyelonephritis/UTI: glucosuria provides a culture medium for E. coli and other bacteria * Increased incidence of spontaneous abortion (in T1DM and T2DM, not in GDM): related to pre-conception glycemic control

Answer 26

* Growth Abnormalities * Macrosomia: maternal hyperglycemia leads to fetal hyperinsulinism resulting in accelerated anabolism * IUGR: due to placental vascular insufficiency * Delayed Organ Maturity * Fetal lung immaturity: hyperglycemia interferes with surfactant synthesis (respiratory distress syndrome) * Congenital Anomalies (occur in T1DM and T2DM, not in GDM) * 2-7x increased risk of congenital heart disease, neural tube defect, GU (cystic kidneys), GI (anal and duodenal atresia), and MSK (sacral agenesis) anomalies due to hyperglycemia * Note: Pregnancies complicated by GDM do not manifest an increased risk of congenital anomalies because GDM develops after the critical period of organogenesis (in T1) * Labor and Delivery * Preterm labor/prematurity: most commonly in patients with HTN/preeclampsia * Preterm labor is associated with poor glycemic control but the exact mechanism is unknown * Increased incidence of stillbirth * Birth trauma: due to macrosomia, can lead to difficult vaginal delivery and shoulder dystocia

Answer 27

* Hypoglycemia: due to pancreatic hyperplasia and excess insulin secretion in the neonate * Hyperbilirubinemia and jaundice: due to prematurity and polycythemia * Hypocalcemia: exact pathophysiology not understood, may be related to functional hypoparathyroidism * Polycythemia: hyperglycemia stimulates fetal erythropoietin production

Answer 28

* Infant weight \>90th percentile for a particular gestational age or \>4,000g * Clinical presentation * Mother: obese, excessive weight gain during pregnancy, uterus large for dates, Leopold manoeuvres may give appreciation of foetal size * Foetus: as per definition * Significance * Mother: increased risk of birth canal lacerations, risk of caesarean delivery and associated risks * Foetus: cephalopelvic disproportion (baby’s head or body too large to fit through mother’s pelvis), birth trauma (shoulder dystocia, foetal bone fracture, brachial plexua injuries), increased risk of perinatal mortality * Neonate: hypoglycaemia, haematologic disturbances, electrolyte disturbances

Answer 29

* Excess of amniotic fluid in the amniotic sac, typically diagnosed with the amniotic fluid index (AFI) \>24cm * Clinical presentation * Mother: increased abdominal size out of proportion for weight gain and dates, uterus large for dates, shiny skin with striae (in severe), dyspnoea, chest heaviness * Foetus: difficulty palpating foetal parts and hearing foetal heart rate * Significance * Mother: pressure from over-distended uterus (dyspnoea, oedema, hydronephrosis) * Foetus: cord prolapse, placental abruption, mal-presentation, preterm labour, uterine dysfunction and post-partum haemorrhage, 2-5 fold increase in risk of perinatal mortality

Answer 30

* Affects 1% of pregnant women, most due to Hashimoto’s thyroiditis or thyroid surgery in areas where iodine deficiency is not an issue * Ix: thyroid function test (TFT), in pregnancy it is normal for TSH to be below classic lower limit of normal, free T₄ tends to increase in 1st trimester and then decrease later in pregnancy * Rx replacement with thyroxine, TSH monitored 6-weekly * Implications for foetus/neonate: untreated disease is rare as anovulation is usual but is associated with a high perinatal mortality; even subclinical hypothyroidism associated with miscarriage, preterm delivery and intellectual impairment in childhood

Answer 31

* Affects 0.4% of pregnant women, usually due to Grave’s disease and gestational thyrotoxicosis * Ix: thyroid function test (TFT) * Rx: * Propylthiouracil (PTU) treatment of choice in pre-natal period or 1st trimester, may be switched to carbimazole after this time, both safe in breastfeeding * Poorly controlled disease risks a thyroid storm, usually near or at delivery * Implications for foetus/neonate: symptoms of hyperthyroidism including congestive heart failure, inadequately treated disease increases peri-natal mortality, PTU can cause neonatal hypothyroidism

Answer 32

* Usual risk: previous VTE, age \>35, obesity, infection, bedrest/immobility, shock/dehydration, thrombophilias. * Specific for pregnancy: * Hypercoagulability: * Increased factors: II, V, VII, VIII, IX, X, XII, fibrinogen * Increased platelet aggregation * Decreased protein S, tPA, factors XI, XIII * Stasis: * Increased resistance to activated protein C * Antithrombin can be normal or reduced * Increased venous distensibility * Decreased venous tone 50% decrease in venous flow in lower extremity by T3 * Uterus is mechanical impediment to venous return * Endothelial: * Vascular damage at delivery (C/S or SVD) * Uterine instrumentation * Peripartum pelvic surgery

Answer 33

* Hypercoagulable state * Stasis * Endothelial damage

Answer 34

* duplex venous Doppler sonography for DVT * CXR and V/Q scan or spiral CT for PE

Answer 35

* before initiating treatment, obtain a baseline FBC and aPTT * warfarin is contraindicated during pregnancy * unfractionated heparin * bolus of 5,000 IU followed by an infusion of ~30,000 IU/24h * measure aPTT 6 h after the bolus * maintain aPTT at a therapeutic level (1.5-2x normal) * repeat q24h once therapeutic * heparin-induced thrombocytopenia (HIT) uncommon (3%) but serious complication * LMWH can also be used in pregnancy * compression stockings * poor evidence to support a recommendation for or against avoidance of prolonged sitting * VTE prophylaxis * women on long-term anticoagulation: full therapeutic anticoagulation throughout pregnancy and for 6-12 wk postpartum * women with a non-active PMHx of VTE: unfractionated heparin regimens suggested * routine VTE prophylaxis * insufficient evidence in pregnancy to recommend routine use of LMWH * current prophylaxis regimens for acquired thrombophilias (e.g. APS syndrome) include low dose Aspirin® in conjunction with prophylactic heparin

Answer 36

* WHO defines anaemia as Hb \<110g/L in pregnancy and Hb \<100g/L postpartum; it is recognised that during the 2nd trimester of pregnancy, Hb concentrations diminish by approximately 5g/L * WHO estimates that 12% of pregnant women in Australia have anaemia, with iron deficiency the most common cause, and megaloblastic anaemia second more common (folate more common than B12)

Answer 37

* Increased risk of pre-term delivery, low birth weight, stillbirth and newborn death * Pregnancy demands * Physiological iron requirements at 3 times high in pregnancy than they are in menstruating women, with increasing demand as pregnancy advances * ~600mg of elemental iron is required to the increase in red cell mass during pregnancy and a further 300mg for the foetus, RDI of iron for the latter half of pregnancy is 30mg * Routine administration of iron is not recommended due to lack of evidence of outcomes * Investigations * FBC should be assessed at booking and 28wk, and those anaemic should have serum ferritin checked and offered a trial of therapeutic iron * Hb can by normocytic and normochromic in early stages, otherwise microcytic and hypochromic * Treatment * All women should have counselling regarding diet in pregnancy including details of iron rich food sources and factors that may inhibit (tannins in tea/coffee, calcium) or promote iron absorption (vitamin C, haem iron) * In iron deficiency anaemia the oral dose should be 100-200mg of elemental iron daily, replacement should continue for 3m or until 6wk postpartum

Answer 38

* Pregnancy demands * Folate and its co-factor vitamin B₁₂ are required for DNA synthesis and cell division * During pregnancy, requirements are increased approximately 5-10 fold and stores may be exhausted if increased folate intake does not occur * B₁₂ deficiency may result in irreversible neurological damage to the breastfed infant * Vegetarians and vegans should be supplemented with vitamin B12 in pregnancy and lactation, the RDI is 6 µg/d * Investigations * FBC at booking and 28wk, will likely see megaloblastic anaemia (increased MCV) if deficiency, but if combined with iron deficiency may present as normocytic * Treatment * If folate deficiency supplemental folate given at 5mg per day and continued through pregnancy * If B₁₂ deficiency consult a haematologist/physician for advice regarding IM vitamin B12 injections * Foods high in folic acid include lightly cooked or raw green vegetables and fish; foods high in B₁₂ include shellfish, liver, fish, crab, fortified soy products and cereals, red meat, dairy, eggs

Answer 39

* Aymptomatic bacteriuria * Affects 5% of women, but in pregnancy is more likely (20%) to lead to pyelonephritis * Management * The urine should be cultured at the booking visit, and asymptomatic bacteriuria treated * Subsequently, culture is performed if nitrites are detected on routine analysis * Pyelonphritis – affects 1-2% of women, causing loin pain, rigors, vomiting and fever, and requires treatment with IV antibiotics * E. coli accounts for 75% and is often resistant to amoxicillin

Answer 40

* Occurs when extra fluid accumulates in two or more areas of the foetus * Causes * Immune: due to anaemia and haemolysis as a result of antibodies including rhesus disease * Non-immune * Chromosomal abnormalities e.g. trisomy 21 * Structural abnormalities e.g. pleural effusions * Cardiac abnormalities or arrhythmias * Anaemia causing cardiac failure e.g. parvovirus, haemorrhage or foetal α-thalassaemia major * Twin-twin transfusion syndrome in chorionic twins causes hydrops in severe cases

Answer 41

* U/S assessment, including echocardiography and assessment of the middle cerebral artery * Maternal blood taken for Kleihauer test and parvovirus, CMV and toxoplasmosis IgM testing * Foetal blood sampling performed if anaemia is suspected * Foetal blood sampling or amniocentesis performed for karytotyping

Answer 42

* Treatment or prognosis depends on the cause – cure only possible where anaemia (transfusion) or compression by fluid collection such as pleural effusions (vesicoamnitoic shunting) have caused hydrops

Answer 43

* Definition – antibodies (Ab) produced against a specific RBC antigen (Ag) as a result of antigenic stimulation with RBC of another individual * Pathophysiology * Blood groups – blood classified according to its ABO and rhesus genotype, the immune system of those that are rhesus negative (and do not express D antigen) will recognise the D antigen as foreign if they are exposed to it * Sensitisation * Small amounts of foetal blood cross the placenta and enter maternal circulation during sensitising events, and if the foetus is rhesus positive and mother rhesus negative, the mother will mount an immune response (sensitisation) creating anti-D antibodies * Potentially sensitising events – incompatible blood transfusions, previous foetal-maternal transplacental haemorrhage (e.g. ectopic pregnancy), invasive procedures in pregnancy (e.g. pre-natal diagnosis, cerclage, D&C), any type of abortion, labour and delivery * Haemolysis * Immunity is permanent, and if the mother’s immune system is again exposed to the antigen (e.g. a subsequent pregnancy), large numbers of antibodies are rapidly created * These antibodies can cross the placenta and bind to foetal RBS, which are then destroyed in the foetal reticuloendothelial system * This can cause haemolytic anaemia and ultimately death (rhesus haemolytic disease)

Answer 44

* Antenatal * Check all women for antibodies at booking and 28wk * Anti-D should be given to all women who are rhesus negative at 28wk, which will reduce the rate of isoimmunisation in a first pregnancy from 1.5% to 0.2% * Anti-D also given to such women within 72h (up to 10d) of any sensitising event * Postnatal * Neonate’s blood groups is checked and if rhesus positive, anti-D given to the mother within 72h of delivery * A Kelihauer test, to assess the number of foetal cells in the maternal circulation, is also performed within 2h or birth to detect occasional larger foeto-maternal haemorrhages that require larger doses of anti-D to ‘mop up’

Answer 45

* Mild disease – neonatal jaundice only * Moderate – sufficiency haemolysis to cause neonatal anaemia (haemolytic disease of the newborn) * Severe – in utero anaemia, cardiac failure, ascites, oedema (hydrops) and foetal death

Answer 46

* Definition – delivery between 24 and 37 weeks’ gestation, risks greatest before 34wk * Complications * Neonatal – occupancy in NICU, perinatal mortality, cerebral palsy, chronic lung disease, blindness, minor disability, less developed immune system (note that preterm infants are more at risk for infection because of this, but also because many have interventions that make them vulnerable) * Maternal – caesarean section more common, if infection associated with pre-term labour can caused severe maternal illness

Answer 47

* idiopathic (most common) * maternal: * infection (recurrent pyelonephritis, untreated bacteriuria, chorioamnionitis) * genital infection (bacterial vaginosis is associated with a 2-fold increase in relative risk of preterm birth) * HTN, DM, chronic illness * mechanical factors: previous obstetric, gynecological, and abdominal surgeries * socio-environmental (poor nutrition, smoking, drugs, alcohol, stress) * maternal-fetal: * PPROM (common) * polyhydramnios * placenta previa * placental abruption * placental insufficiency * fetal: multiple gestation, congenital abnormalities of fetus, fetal hydrops * uterine: incompetent cervix, excessive enlargement (hydramnios), malformations (leiomyomas, septate uterus)

Answer 48

* Assess foetal state – cardiotocography (CTG) and ultrasound * Assess the likelihood of delivery * If cervix is uneffaced, foetal fibronectin assay – negative result means delivery unlikely * Transvaginal scanning (TVS) of cervical length – \>15mm means delivery unlikely * Look for infection – vaginal swabs should be taken, CRP usually high, steroids will cause WCC to rise

Answer 49

* Initial * transfer to appropriate facility if stable * hydration (NS at 150 mL/h) * bed rest in LLDP * sedation (morphine) * avoid repeated pelvic exams (increased infection risk) * U/S examination of fetus (GA, BPP, position, placenta location, estimated fetal weight) * prophylactic antibiotics; controversial but may help delay delivery, important to consider if PPROM * Suppression of Labor – Tocolysis * does not inhibit preterm labor completely, but may buy time (used for \<48 h) to allow for betamethasone valerate (Celestone®) and/or transfer to appropriate center for care of the premature infant * requirements (all must be satisfied) * preterm labor * live, immature fetus, intact membranes, cervical dilatation of \<4cm * absence of maternal or fetal contraindications * contraindications * maternal: bleeding (placenta previa or abruption), maternal disease (HTN, DM, heart disease), preeclampsia or eclampsia, chorioamnionitis * foetal: erythroblastosis fetalis, severe congenital anomalies, foetal distress/demise, IUGR, multiple gestation (relative) * Enhancement of Foetal Pulmonary Maturity * betamethasone or dexamethasone * 28-34 wk GA: reduces incidence of RDS * 24-28 wk GA: reduces severity of RDS, overall mortality, and rate of IVH * specific maternal contraindications: active TB

Answer 50

* PROM or amniorrhexis: rupture of membranes prior to labor at any GA * prolonged ROM: \>24 h elapsed between rupture of membranes and onset of labor * preterm ROM: ROM occurring before 37 wk gestation (associated with PTL) * PPROM: rupture of membranes before 37 wk AND prior to onset of labor

Answer 51

Same as pre-term labour * idiopathic (most common) * maternal: infection (recurrent pyelonephritis, untreated bacteriuria, chorioamnionitis), genital infection (bacterial vaginosis is associated with a 2-fold increase in relative risk of preterm birth), HTN, DM, chronic illness, mechanical factors, previous obstetric, gynecological, and abdominal surgeries, socio-environmental (poor nutrition, smoking, drugs, alcohol, stress) * maternal-fetal: PPROM (common), polyhydramnios, placenta previa, placental abruption, or placental insufficiency * fetal: multiple gestation, congenital abnormalities of fetus, fetal hydrops * uterine: incompetent cervix, excessive enlargement (hydramnios), malformations (leiomyomas, septate uterus)

Answer 52

* U/S: can show reduced liquor, but volume can also be normal as foetal urine production continues * To look for infection: high vaginal swab (HVS), FBS and CRP taken; in doubtful cases amniocentesis with gram staining and culture occasionally used * Foetal well-being: assessed by CTG, persistent foetal tachycardia is suggestive of infection

Answer 53

* admit for expectant management and monitor vitals q4h, daily BPP and WBC count * avoid introducing infection with examinations (do NOT do a bimanual exam) * cultures (cervix for GC, lower vagina for GBS) * assess fetal lung maturity by L/S ratio of amniotic fluid * consider administration of betamethasone valerate (Celestone®) to accelerate maturity if \<32 wk and no evidence of infection * consider tocolysis for 48 h to permit administration of steroids if PPROM induces labor * if not in labor or labor not indicated, consider antibiotics (controversial) * studies show broad spectrum coverage increases the time to onset of labor from PROM by 5-7 d with no increase in maternal or neonatal morbidity or mortality * deliver urgently if evidence of foetal distress and/or chorioamnionitis

Answer 54

* Without chorioamnionitis * amoxy/ampicillin 2 g IV, 6-hourly for 48 hours, followed by amoxycillin 250 mg orally, 8-hourly for a total of 7 days (IV + oral) * PLUS erythromycin 250 mg orally, 6-hourly for 7 days * With chorioamnionitis * Mild to moderate: amoxycillin+clavulanate 875+125 mg orally, 12-hourly for 14 days * PLUS doxycycline 100 mg orally, 12-hourly for 14 days. * Severe infection: amoxy/ampicillin 2 g IV, 6-hourly * PLUS gentamicin IV; * PLUS metronidazole 500 mg IV, 12-hourly.

Answer 55

* varies with gestational age * 90% of women with PROM at 28-34 wk GA go into spontaneous labor within 1 wk * 50% of women with PROM at \<26 wk GA go into spontaneous labor within 1 wk * complications: cord prolapse, intrauterine infection (chorioamnionitis), premature delivery, limb contracture

Answer 56

* The head is oblong in transverse section * Its bones are not yet fused and, on vaginal examination, spaces between them are palpable as sutures and fontanelles * The anterior fontanelle (bregma) lies above the forehead, the posterior fontanelle (occiput) lies on the back of the top of the head * The head can be compressed in the pelvis because the sutures allow the bones to come together and even overlap slights (moulding)

Answer 57

* The bony pelvis * Inlet – transverse diameter is about 13cm, wider than the 11cm antero-posterior (AP) diameter * Mid-cavity – almost round as the transverse and AP diameters are similar * Outlet – AP diameter (12.5cm) is greater than the transverse diameter (11cm) * Ischial spines – palpable vaginally in the lateral wall of the round mid-pelvis * The soft tissues * Cervical dilatation is a prerequisite for delivery and is dependent on contractions, the pressure of the foetal head on the cervix and the ability of the cervix to soften and allow distention * The soft tissues of the vagina and perineum need to be overcome in the second stage

Answer 58

* true labor: regular, painful contractions of increasing intensity associated with progressive dilatation and effacement of cervix and descent of presenting part, or progression of station * preterm (\>20 to \<36+6 wk GA) * term (37-41+6 wk GA) * postterm (\>42 wk GA) * false labor: Braxton-Hicks contractions * irregular contractions, with unchanged intensity and long intervals, occur throughout pregnancy and not associated with any dilatation, effacement, or descent * often relieved by rest or sedation

Answer 59

* latent phase * uterine contractions typically infrequent and irregular * slow cervical dilatation (usually to 3-4 cm) and effacement * active phase * rapid cervical dilatation to full dilatation (nulliparous ~1.2 cm/h, multiparous ~1.5 cm/h) * phase of maximum slope on cervical dilatation curve * painful, regular contractions q2-3min, lasting 45-60 s * contractions strongest at fundus, weakest at lower segment

Answer 60

* from full dilatation to delivery of the baby * mother feels a desire to bear down and push with each contraction * women may choose a comfortable position that enhances pushing efforts and delivery * upright (semi-sitting, squatting) and LLDP are supported in the literature * progress measured by descent

Answer 61

* separation and expulsion of the placenta * can last up to 30 min before intervention indicated * start oxytocin IV drip, or give 10 U IM or 5 mg IV push after delivery of anterior shoulder in anticipation of placental delivery, otherwise give after delivery of placenta * routine oxytocin administration in third stage of labor can reduce the risk of PPH by \>40%

Answer 62

* first postpartum hour * monitor vital signs and bleeding * repair lacerations * ensure uterus is contracted (palpate uterus and monitor uterine bleeding) * inspect placenta for completeness and umbilical cord for presence of 2 arteries and 1 vein * 3rd and 4th stages of labor most dangerous to the mother (i.e. hemorrhage)

Answer 63

* _pain or anxiety leads to high endogenous catecholamines, which produce a direct inhibitory effect on uterine contractility_ __Non-Pharmacologic Pain Relief Techniques * reduction of painful stimuli * maternal movement, position change, counter-pressure, abdominal compression * activation of peripheral sensory receptors * superficial heat and cold * immersion in water during labor * touch and massage, acupuncture, and acupressure * TENS * intradermal injection of sterile water * aromatherapy * enhancement of descending inhibitory pathways * attention focusing and distraction * hypnosis * music and audio analgesia * biofeedback * Pharmacologic Methods (see Anesthesia, A24) * nitrous oxide (e.g. self-administered Entonox®) * narcotics (usually combined with anti-emetic) * pudendal nerve block * perineal infiltration with local anesthetic * regional anesthesia (epidural block, combined spinal-epidural, spinal)

Answer 64

* A partogram or partograph is a composite graphical record of key data (maternal and fetal) during labour entered against time on a single sheet of paper. Relevant measurements might include statistics such as cervical dilation, fetal heart rate, duration of labour and vital signs. * It is intended to provide an accurate record of the progress in labour, so that any delay or deviation from normal may be detected quickly and treated accordingly. However, a Cochrane review came to the conclusion that there is insufficient evidence to recommend partograms in standard labour management and care.

Answer 65

1. Atrioventricular septal defect 2. Ventricular septal defect 3. Patent ductus arteriosus 4. Tetralogy of Fallot, and 5. Atrial septal defect.

Answer 66

* Power (leading cause): contractions (hypotonic, incoordinate), inadequate maternal explusive efforts * Passenger: fetal position, attitude, size, anomalies (hydrocephalus) * Passage: pelvic structure (CPD), maternal soft tissue factors (tumors, full bladder or rectum, vaginal septum) * Psyche: hormones released in response to stress may contribute to dystocia; psychological and physiological stress should be evaluated as part of the management once dystocia has been diagnosed

Answer 67

* Amniotomy * artificial rupture of membranes (amniotomy) to stimulate prostaglandin synthesis and secretion; may try this as initial measure if cervix is dilated * amniotomy plus intravenous oxytocin: more women delivered vaginally at 24 h than amniotomy alone (relative risk = 0.03) and had fewer instrumental vaginal deliveries (relative risk = 5.5) * Oxytocin * oxytocin: 10 U in 1L NS, run at 0.5-2 mU/min IV increasing by 1-2 mU/min q20-60min to a max of 36-48 mU/min * reduces rate of unsuccessful vaginal deliveries within 24 h when used alone (8.3% vs. 54%, RR 0.16) * ideal dosing regime of oxytocin is not known * current recommendations: use the minimum dose to achieve active labor and increase q30min as needed * reassessment should occur once a dose of 20 mU/min is reached * potential complications * hyperstimulation/tetanic contraction (may cause fetal distress or rupture of uterus) * uterine muscle fatigue, uterine atony (may result in PPH) * vasopressin-like action causing anti-diuresis

Answer 68

* use of medications or other means to soften, efface, and dilate the cervix to increase likelihood of induction success * ripening of an unfavorable cervix (Bishop score \<6) is warranted prior to induction of labor

Answer 69

* intravaginal prostaglandin PGE2 gel: long and closed cervix * recommended dosing interval of prostaglandin gel is every 6 to 12 h up to 3 doses * intravaginal PGE2: long and closed cervix, may use if ROM * continuous release, can be removed if needed * controlled release PGE2 * Foley catheter placement to mechanically dilate the cervix

Answer 70

* Foetal distress and hypoxia * Foetal infection * Meconium aspiration * Foetal trauma * Foetal blood loss

Answer 71

* Used to record progress in dilatation of the cervix (± descent of the head) as assessed on vaginal examination, and is plotted against time * The usual minimum rate of dilatation is 1cm/h – ‘alert’ and ‘action’ lines on the partogram indicate slow progress, so aids identification abnormal progress * Records each hour – foetal heart rate, liquor colour, cervical dilatation, descent of the head, BP, pulse, temperature, urine (protein, acetone, volume), oxytocin and any other drugs/fluid given

Answer 72

* Reduction of painful stimuli: maternal movement, position change, counter-pressure, abdominal compression * Activation of peripheral sensory receptors: Superficial heat and cold, immersion in water during labour, touch and massage, acupuncture and acupressure, TENS, intradermal injection of sterile water, aromatherapy * Enhancement of descending inhibitory pathways: Attention focussing and distraction, hypnosis, music and audio analgesia, biofeedback

Answer 73

* Nitrous oxide (e.g. self-administered Entonox) * Narcotics – usually combined with anti-emetic * Pudendal nerve block * Perineal infiltration with local anaesthetic * Regional anaesthesia – epidural block, CSE, spinal

Answer 74

* Aim – to shorten the length of labour * Principles * Early diagnosis of labour2-ho * urly vaginal examinations * Augmentation – Early correction of slow progress * Artificially rupturing the membranes (ARM or amniotomy) * If this fails to further cervical dilatation in 1-2h, artificial oxytocin is administered IV and will usually increase cervical dilatation within 4h * Caesarean section by 12h if delivery is not imminent

Answer 75

* Pre-term – 20wk to 36+6wk gestation * Term – 37wk to 41+6wk gestation * Post-term (also known as post-dates, post-mature, overdue) – more than 42wk gestation * Risks of reduced placental perfusion, oligohydramnios, meconium aspiration

Answer 76

* To estimate the expected date of delivery (EDD), subtract 3m from the date of last menstrual period (LMP), add 7 days and 1 year * If a cycle is more or less than 28d, the EDD will be later and needs to be adjusted

Answer 77

* Foetal: high-risk situations such as prolonged pregnancy, suspected IUGR or compromise, antepartum haemorrhage, poor obstetric history and pre-labour term rupture of the membranes * Materno-foetal indications: pre-eclampsia and maternal disease such as diabetes * Maternal indications: social reasons and in utero death

Answer 78

* fetal * atypical or abnormal fetal heart rate tracing * consider if second stage is prolonged as this may be due to poor contractions or failure of fetal head to rotate * maternal * need to avoid voluntary expulsive effort (e.g. cardiac/cerebrovascular disease) * exhaustion, lack of cooperation, and excessive analgesia may impair pushing effort

Answer 79

* Forceps: * Maternal: anaesthesia risk, lacerations, injury to bladder, uterus, or bone, pelvic nerve damage, PPH, infections * Fetal: fractures, facial nerve palsy, trauma to face/scalp, intracerebral haemorrhage, cephalohaematoma, cord compression * Vacuum: * Increased incidence of cephalohaematoma and retinal haemorrhages compared to forceps * Subgaleal hemorrhage, subaponeurotic haemorrhage, soft tissue trauma

Answer 80

* maternal: obstruction, active herpetic lesion on vulva, invasive cervical cancer, previous uterine surgery, underlying maternal illness (eclampsia, HELLP syndrome, heart disease) * maternal-fetal: failure to progress, placental abruption or previa, vasa previa * faetal: abnormal faetal heart tracing, malpresentation, cord prolapse, certain congenital anomalies

Answer 81

* skin * transverse (i.e. Pfannensteil) * decreased exposure and slower entry * improved strength and cosmesis * vertical midline * rapid peritoneal entry and increased exposure * Increased dehiscence * uterine * low transverse (most common): in noncontractile segment * decreased chance for rupture in subsequent pregnancies * low vertical * used for very preterm infants, poorly developed maternal lower uterine segment * classical (rare): in thick, contractile segment * used for transverse lie, faetal anomaly, \>2 fetuses, lower segment adhesions, obstructing fibroid, morbidly obese patients

Answer 82

* anesthesia * hemorrhage (average blood loss ~1,000 cc) * infection (UTI, wound, endometritis) * single dose prophylactic antibiotic should be used (e.g. cefazolin 1-2g) * injury to surrounding structures (bowel, bladder, ureter, uterus) * thromboembolism * increased recovery time/hospital stay * maternal mortality (\<0.1%)

Answer 83

* Above the arcuate line: external oblique, internal oblique, rectus abdominis, internal oblique, transversus abdominis * Below the arcuate line: external oblique, internal oblique, transversus abdominis, rectus abdominis

Answer 84

* Vaginal birth after cesarean (VBAC) - trial of labour after cesarean. * recommended after previous low transverse incision * success rate varies with indication for previous C/S (generally 60-80%) * risk of uterine rupture (\<1% with low transverse incision) * Contraindications * previous classical, inverted T, or unknown uterine incision, or complete transection of uterus (6% risk of rupture) * history of hysterotomy or previous uterine rupture * multiple gestation * non-vertex presentation or placenta previa * inadequate facilities or personnel for emergency C/S

Answer 85

* incidence of twins is 1/80 and triplets 1/6,400 in North America * 2/3 of twins are dizygotic (fraternal) * risk factors for dizygotic twins: IVF, increased maternal age, newly discontinued OCP, ethnicity (e.g. certain African regions) * monozygous twinning occurs at a constant rate worldwide (1/250) * determine zygosity by number of placentas, thickness of membranes, sex, blood type

Answer 86

* Maternal: * Hyperemesis gravidarum * GDM * Gestational HTN * Anemia * Increased physiological stress on all * systems * Increased compressive symptoms * C/S * Uteroplacental: * Increased PROM/PTL * Polyhydramnios * Placenta previa * Placental abruption * PPH (uterine atony) * Umbilical cord prolapse * Cord anomalies (velamentous insertion, 2 vessel cord) * Faetal: * Prematurity\* * IUGR * Malpresentation * Congenital anomalies * Twin-twin transfusion * Increased perinatal morbidity and mortality * Twin interlocking * (twin A breech, twin B vertex) * Single fetal demise

Answer 87

* U/S determination of chorionicity must be done within first trimester (ideally 8-12 wk GA) * increased antenatal surveillance * serial U/S q2-3wk from 28 wk GA to assess growth (uncomplicated diamniotic dichorionitic) * increased frequency of ultrasounds in monochorionic diamniotic and monochorionic monoamniotic twins * Doppler flow studies weekly if discordant fetal growth (\>30%) BPP as needed * may attempt vaginal delivery if twin A presents as vertex, otherwise C/S (40-50% of all twin deliveries, 15% of cases have twin A delivered vaginally and twin B delivered by C/S) * mode of delivery depends on fetal weight, GA, presentation

Answer 88

* Monozygotic twins – originate from the fertilisation and subsequent division of one egg * Dichorionic and diamniotic (DCDA) – one chorion and one placenta (amnion) * Fertilised egg splits in the first 3 days after fertilisation * Risk if pregnancy extends past 38-39wk * Monochorionic diamniotic (MCDA) – split occurs at days between days 4 and 8 * Considered high-risk due to 3-5 fold increase in perinatal morbidity and mortality compared to DCDA pregnancies, risk of sudden unexpected stillbirth between 5-10% after 32wk * Twin to twin transfusion syndrome (TTTS) complicates about 15%, with discordant IUGR complicating an additional 25% * Monochorionic monoamniotic (MCMA) – split occurs after the 8th day post-fertilisation * At high risk of foetal death and neonatal morbidity, secondary to umbilical cord entanglement, prematurity, and congenital anomalies, risk of sudden stillbirth as with MCDA * Conjoined twins – division 13 days or later (extremely rare) * Dizygotic twins – originate from the fertilisation and development of two eggs, are always DCDA

Answer 89

Abnormal location of the placenta near, partially, or completely over the internal cervical os

Answer 90

* bloody show (shedding of cervical mucous plug) – most common etiology in T3 * placenta previa * abruptio placentae – most common pathological etiology in T3 * vasa previa * cervical lesion (cervicitis, polyp, ectropion, cervical cancer) * uterine rupture * other: bleeding from bowel or bladder, placenta accreta, abnormal coagulation

Answer 91

* How much bleeding? * Are there contractions/cramping/pain? * Description? Colour, clotting, etc.

Answer 92

Premature separation of a normally implanted placenta after 20 wk GA

Answer 93

* **PAINLESS** bright red vaginal bleeding (recurrent), may be minimized and cease spontaneously, but can become catastrophic * mean onset of bleeding is 30 wk GA, but onset depends on degree of previa * physical exam * uterus soft and non-tender * presenting fetal part high or displaced * FHR usually normal * shock/anemia correspond to degree of apparent blood loss * complications * foetal * perinatal mortality low but still higher than with a normal pregnancy * prematurity (bleeding often dictates early C/S) * intrauterine hypoxia (acute or IUGR) * foetal malpresentation * PPROM * risk of fetal blood loss from placenta, especially if incised during C/S * maternal * \<1% maternal mortality * haemorrhage and hypovolemic shock, anemia, acute renal failure, pituitary necrosis (Sheehan syndrome) * placenta accreta – especially if previous uterine surgery, anterior placenta previa * hysterectomy

Answer 94

* transvaginal U/S is more accurate than transabdominal U/S at diagnosing placenta previa at any gestational age * if the placenta lies between 20 mm of overlap and 20 mm away from the internal os after 26 wk regular transvaginal ultrasounds should be repeated at regular intervals – continued change in the placental location is likely

Answer 95

* goal: keep pregnancy intrauterine until the risk of delivery \< risk of continuing pregnancy * stabilize and monitor * maternal stabilisation: large bore IV with hydration, O₂ for hypotensive patients * maternal monitoring: vitals, urine output, blood loss, blood work (haematocrit, CBC, INR/ PTT, platelets, fibrinogen, FDP, type and cross match) * electronic fetal monitoring * U/S assessment: when fetal and maternal condition permit, determine fetal viability, gestational age, and placental status/position * Rhogam® if mother is Rh negative * Kleihauer-Betke test to determine extent of fetomaternal transfusion so that appropriate dose of Rhogam® can be given * GA \<37 wk and minimal bleeding: expectant management * admit to hospital * limited physical activity, no douches, enemas, or sexual intercourse * consider corticosteroids for fetal lung maturity * delivery when fetus is mature or hemorrhage dictates * GA ≥37 wk, profuse bleeding, or L/S ratio is \>2:1 – deliver by C/S

Answer 96

* total (fetal death inevitable) vs. partial * external/revealed/apparent: blood dissects downward toward cervix * internal/concealed (20%): blood dissects upward toward fetus * most are mixed

Answer 97

Placental abruption

Answer 98

* **PAINFUL** (80%) vaginal bleeding (bleeding not always present if abruption is concealed), uterine tenderness, uterine contractions * pain: sudden onset, constant, localized to lower back and uterus * shock/anemia out of proportion to apparent blood loss * ± fetal distress, fetal demise (15% present with demise), bloody amniotic fluid (fetal presentation typically normal) * ± coagulopathy

Answer 99

* foetal complications: perinatal mortality 25-60%, prematurity, intrauterine hypoxia * maternal complications: \<1% maternal mortality, DIC (in 20% of abruptions), acute renal failure, anaemia, haemorrhagic shock, pituitary necrosis (Sheehan syndrome), amniotic fluid embolus

Answer 100

clinical diagnosis, U/S not sensitive for diagnosing abruption (sensitivity = 15%)

Answer 101

* maternal stabilization: large bore IV with hydration, O2 for hypotensive patients * maternal monitoring: vitals, urine output, blood loss, blood work (haematocrit, FBC, PTT/PT, platelets, fibrinogen, FDP, group and hold) * Electronic Foetal Monitoring * blood products on hand (red cells, platelets, cryoprecipitate) because of DIC risk * Rhogam® if Rh negative * Kleihauer-Betke test may confirm abruption * mild abruption * GA \<37 wk: use serial Hct to assess concealed bleeding, deliver when foetus is mature or when haemorrhage dictates * GA ≥37 wk: stabilize and deliver * moderate to severe abruption * hydrate and restore blood loss and correct coagulation defect if present * vaginal delivery if no contraindication and no evidence of foetal or maternal distress OR foetal demise * C/S if live foetus and foetal or maternal distress develops with fluid/blood replacement, labor fails to progress or if vaginal delivery otherwise contraindicated

Answer 102

* Primary: loss of 500mL of blood after vaginal delivery or 1,000mL after Caesarean within first 24h. * Secondary: excessive blood loss from the genital tract occurring more than 24 hours to 6 weeks after delivery.

Answer 103

* Risk factors: * antepartum bleeding * use of Syntocinon (Oxytocin) in labour * prolonged labour, instrumental delivery * uterine abnormalities e.g. fibroids, placenta praevia, previous PPH, sepsis * Mitigation: * Antepartum checks on Hb (and Fe supplementation if required) * IV line * group and hold * fluid management during labour * active management of third stage * fundal massage * check placenta for completeness * check perineum and vagina for trauma

Answer 104

* Tone * uterine atony * most common cause of PPH * avoid by giving oxytocin with delivery of the anterior shoulder or placenta * occurs within first 24 h * due to * labor (prolonged, precipitous, induced, augmented) * uterus (infection, over-distention) * placenta (abruption, previa) * maternal factors (grand multiparity, gestational HTN) * halothane anesthesia * Tissue * retained placental products * retained blood clots in an atonic uterus * gestational trophoblastic neoplasia * Trauma * laceration (vagina, cervix, uterus), episiotomy, hematoma (vaginal, vulvar, retroperitoneal), uterine rupture, uterine inversion * Thrombin * coagulopathy * most identified prior to delivery (low platelets increases risk) * includes hemophilia, DIC, Aspirin® use, ITP, TTP, vWD (most common) * therapeutic anti-coagulation

Answer 105

* assess degree of blood loss and shock by clinical exam * explore uterus and lower genital tract for evidence of tone, tissue, or trauma * Bloods: * FBC, coags, INR/APTT, group and hold

Answer 106

* ABCs * 2 large bore IVs and crystalloids * FBC, coagulation profile, cross and type 4 units pRBCs * treat underlying cause

Answer 107

* Tone: * oxytocin * ergotamine * misoprostol (side effect: pyrexia) * Prostol * Thrombin: * Tranexamic acid - antifibrinolytic * Replacement of platelets and clotting factors

Answer 108

* bimanual compression: elevate the uterus and massage through patient’s abdomen * uterine packing (mesh with antibiotic treatment) * Bakri Balloon for tamponade: may slow hemorrhage enough to allow time for correction of coagulopathy or for preparation of an OR

Answer 109

* Used for intractable PPH * D&C (beware of vigorous scraping which can lead to Asherman’s syndrome) * embolisation of uterine artery or internal iliac artery by interventional radiologist * laparotomy with bilateral ligation of uterine artery (may be effective), internal iliac artery (not proven), ovarian artery, or hypogastric artery * hysterectomy last option with angiographic embolisation if post-hysterectomy bleeding

Answer 110

* Malpresentation – any presentation other than a vertex presentation (top of the head first) * Cephalic presentation (head first) – sinciput (forehead), brow (eyebrows), face, chin * Breech (buttocks or feet first) – complete breech, footling breech, frank breech * Shoulder presentation – arm, shoulder, trunk

Answer 111

* Diagnosis – only important from 37wk or if the patient is in labour * History – upper abdominal discomfort * Exam – head normally palpable and ballotable at the fundus * Investigation – U/S confirms the diagnosis, helps detection of other abnormalities and ensures prerequisites for external cephalic version (ECV) are met.

Answer 112

* External cephalic version (ECV) * From 37wk, an attempt made to turn the baby to a cephalic presentation, success rate is about 50% and about 3% will turn back * Technique – under U/S guidance (and using tocometry if required), with both hands on the pelvis, the breech is disengaged from the pelvis, pushed upwards and to the side, and rotation in the form of a forward somersault is attempted; CTG performed straight after * Contraindication – not performed if the foetus is compromised, if vaginal delivery is contradicted anyway, multiple pregnancy, ruptured membranes, recent antepartum haemorrhage * Caesarean section * If ECV is failed or in contraindicated, or if breech presentation was missed * Some women still wish to deliver vaginally, breech presentation is often diagnosed in late labour only, and second twins often present as breech, and in these circumstances vaginal breech delivery is still appropriate * Vaginal breech birth * Intrapartum – pushing not encouraged until the buttocks visible, CTG advised, epidural common * In about 30% there is slow cervical dilatation – in these cases perform Caesarean section * Breech delivery * The foetus delivers with maternal effort as far as the umbilicus * The legs can be flexed out of the vagina, whilst the back is kept anterior, and once the scapula is visible the arms are hooked down by a finger over the shoulder * Mauriceau-Smellie-Veit manoeuvre – Once the back of the head is visible, the operator supports the entire weight of the foetus on one palm, with their finger in its mouth to guide the head over the perineum and maintain flexion, and the other hand against the occiput

Answer 113

* maternal: obesity, DM, multiparity * foetal: prolonged gestation, macrosomia * labour * prolonged 2nd stage * instrumental midpelvic delivery

Answer 114

* impaction of anterior shoulder of foetus against symphysis pubis after foetal head has been delivered * life threatening emergency

Answer 115

* Maternal: perineal injury, may result in PPH * Foetal: brachial plexus injury (e.g. Erb’s palsy which is permanent in 50%), fracture (clavicle, humerus, cervical spine), hypoxia (can be lethal)

Answer 116

* “turtle sign”: head delivered but retracts against inferior portion of pubic symphysis

Answer 117

* goal: to displace anterior shoulder from behind symphysis pubis; follow a stepwise approach of maneuvers until goal achieved * Position the mother’s legs in full flexion, hyperextended onto the abdomen (McRobert’s manoeuvre) * Applying suprapubic pressure in addition to McRobert’s manoeuvre works in 90% of cases * If the above fails, internal manoeuvres are required, necessitating episiotomy * Pressure behind the anterior shoulder, which can be combined with pressure on the anterior part of the posterior shoulder (Wood’s screw manoeuvre) * If this fails the posterior arm is grasped and the hand is brought down, the trunk should follow * other options * cleidotomy (deliberate fracture of neonatal clavicle) * Zavanelli maneuver: replacement of foetus into uterine cavity and emergent C/S * symphysiotomy

Answer 118

Around 1 in 10 women will have shoulder dystocia again in the future

Answer 119

* prematurity/PROM * foetal malpresentation (~50% of cases) * low-lying placenta * polyhydramnios * multiple gestation * cephalopelvic disproportion (CPD)

Answer 120

* Visible or palpable cord * Foetal heart rate changes – variable decelerations, bradycardia or both

Answer 121

Cause cord compression between presenting part and pelvis, baby will become rapidly hypoxic

Answer 122

* O₂ to mother, monitor foetal heart * Presenting part prevented from compressing the cord – pushed into the vagina by a digit, or tocolytics such as terbutaline are given * Keep cord warm and moist by replacing it into the vagina ± applying warm saline soaks * Position mother on all fours while preparation for delivery undertaken * Mode of delivery: Emergency Caesarean usually, instrumental delivery if the cervix fully dilated and the head is low

Answer 123

* Retained products of conception * Infection (often secondary to retained products) * Lacerations, including episiotomy * Others (rare): Blood dyscrasias, Trophoblastic disease, Carcinoma of the cervix, Submucous fibroids (causing subinvolution), Placental site subinvolution

Answer 124

* can cause profound vasovagal response with vasodilation and hypovolaemic shock * may be disproportionate to maternal blood loss

Answer 125

* Bed rest and intravenous antibiotic therapy are the mainstays of treatment. * Curettage is not performed routinely (risk of uterine perforation or Asherman's Syndrome). Evidence of retained products is suggested by subinvolution of the uterus, an open cervical os or a poor response to conservative management. * Oxytocics (eg: oral Ergometrine) have almost no part in the management. * If vaginal bleeding continues following curettage for secondary postpartum haemorrhage, then consider the need for a pelvic trans-vaginal ultrasound scan

Answer 126

* Immediately the placenta has separated, the uterus contracts and the fibres of the myometrium occlude the blood vessels that formerly supplied the placenta * Uterine size reduces over 6wk, within 10d the uterus is no longer palpable abdominally * The internal os of the cervix is closed by 3d * Lochia (discharge from the uterus) may be blood-stained for 4wk, but is thereafter yellow or white

Answer 127

* Cardiac output and plasma volume decrease to prepregnant levels within a week * BP will return back to normal (if increased) and oedema will reduce within 6wk

Answer 128

* Suckling is the major stimulus for milk letdown, but the reflex can be conditioned * Impulse recognition (e.g. cry or sight of an infant) results in episodic oxytocin release from the posterior pituitary, resulting in milk ejection * Suckling reflects also affects the activity of the GnRH pulse generator, inhibiting gonadotropin release and thus ovulation does not typically occur; menstruation usually delayed by lactation (to ~3-6m), but occurs at about 6w if not lactating

Answer 129

* Breastfeeding problems * Inadequate milk, breast engorgement, nipple pain, mastitis, inverted nipples, maternal medications * Bladder dysfunction * Pelvic floor prolapse can occur after vaginal delivery * Stress or urge urinary incontinence common * Increased risk with instrumental delivery or prolonged second stage * Puerperal pain * “After pains” common in first 3 d due to uterine contractions

Answer 130

* General – Mother and baby should not be separated, early mobilisation is encouraged * Daily monitoring – uterine involution and the lochia, BP, temperature, pulse, any perineal wound, careful fluid balance check should prevent retention if a woman has had an epidural * Investigations – FBC, iron prescribed if appropriate, usually in conjunction with laxatives * Analgesia – may be required for perineal pain (pelvic floor exercises can also help) * Midwife/doctor – whoever attended the delivery should visit the patient and discus the delivery (particularly if there has been an intervention) and the woman can ask questions about the labour * Discharge * Dependent on the mother’s wishes, the child may need to stay longer * Complete the blue book and give to woman with explanation, advise when baby vaccinations due * Advice on contraception given prior * GP should be alerted of any complications, and a postnatal plan for follow up for any psychiatric issues of pregnancy should be drawn up

Answer 131

* Enhancement of mother-child bonding * Protection of baby against common health problems – middle-ear infections, GIT infections, urinary infections, respiratory infections and asthma, some childhood cancers, diarrhoeal diseases, juvenile diabetes, childhood obesity, allergies, eczema, SIDS * Health benefits for the mother – reduces the risk of breast cancer, ovarian cancer and osteoporosis; quicker return of uterus to pre-pregnancy size * Cost benefits * Breastmilk is sterile * Convenience and accessibility

Answer 132

fever ≥38°C in the first 14d postpartum, except the first day

Answer 133

* **B**reast: engorgement, mastitis * **W**ind: atelectasis, pneumonia * **W**ater: UTI * **W**ound: episiotomy, C/S site infection * **W**alking: DVT, thrombophlebitis * **W**omb: endometritis

Answer 134

* Endometritis – infection of the uterine myometrium and paraetrium * Clinical features – fever, chills, abdominal pain, uterine tenderness, foul-smelling discharge or lochia * Investigations – blood and genital cultures * Surgical prophylaxis – use cephazolin within the 60min before surgical incision * Management – depends on infection severity; oral antibiotics if well, IV with hospitalisation in moderate to severe cases (amoxy/ampicillin plus gentamycin plus metronidazole).

Answer 135

* Mastitis – inflammation of mammary glands * Clinical features – fever, chills, myalgias, erythema, warmth, swelling, breast tenderness * Prevention – milk stasis implicated, treat with moist heat, massage, fluids, rest, proper positioning of the infant during nursing, nursing or manual expression of milk, analgesics * Management – Early treatment with antibiotics to prevent abscess formation; use di/flucoxacillin

Answer 136

* Lacerations: * first degree: involves skin and vaginal mucosa but not underlying fascia and muscle * second degree: involves fascia and muscles of the perineal body but not the anal sphincter * third degree: involves the anal sphincter but does not extend through it * fourth degree: extends through the anal sphincter into the rectal mucosa * Episiotomy: * Incision in the perineal body at the time of delivery, essentially a controlled second decree laceration * Current evidence suggests letting perineum tear and then repair as needed * Indications – to relieve obstruction of the unyielding perineum, instrumental delivery * Complications – infection, haematoma, extension, fistula formation, incontinence

Answer 137

* First and second degree tears – suture under local anaesthetic to increase healing and reduce pain * Third and fourth degree tears * Sphincter repaired under epidural or spinal anaesthesia in an operating theatre for visualisation and asepsis * Antiobiotics, laxatives and analgesia given, usually physiotherapy assessment * Sequelae – incontinence of flatus or urgency, occasionally frank incontinence, if ongoing incontinence problem vaginal birth in the future may make this worse (consider Caesarean)

Answer 138

* Transient period of mild depression, mood instability, anxiety, decreased concentration, increased concern over own health and health of baby – considered to be normal emotions in the puerperium * Occurs in 50-80% of mothers; begins 2-4d postpartum, usually lasts 38hr, can last up to 10d * Does not require psychotropic medication, self-limiting (should resolve by 2wk) * Patient at increased risk of developing postpartum depression

Answer 139

**DSM-V Criteria, Specifier for Major Depressive Episode with Peripartum Onset** * This specifier can be applied to the current, or, if full criteria are not currently met for a major depressive episode, most recent episode of major depression if onset of mood symptoms occurs during pregnancy or in the 4 weeks following delivery

Answer 140

* Previous history of a mood disorder (postpartum or otherwise) * Psychosocial factors – stressful life events, unemployment, marital conflict, lack of social support, unwanted pregnancy, colicky or sick infant

Answer 141

* Antenatal Risk Questionnaire (ANRQ) – to assess risk of PPD, components include: * past mental health history * past history of physical * sexual or emotional abuse * current level of supports * anxiety and obsessionality levels * stressors in the last year (including bereavement, separation etc.)

Answer 142

* Psychotherapy (CBT or IPT) * Short-term safety of maternal SSRIs for breastfeeding infants established, long-term effects unknown * If depression severe, consider ECT

Answer 143

* Child – increased risk of cognitive delay, insecure attachment, behavioural disorders * Treatment of mother improves outcome for child at 8m through increased mother-child interaction

Answer 144

* Miscarriage – when a foetus is born with no signs of life before 24wk gestation * Stillbirth – when a foetus is delivered after 24wk completed gestation showing no signs of life * Neonatal death – death occurring within 28d of delivery

Answer 145

* The sum of stillbirths and early neonatal deaths per 1,000 total births * Has declined from \>50.0 in the 1930s to 7.5 per 1,000 in 2008 * The lowest rates are found in Scandinavia and the highest found in Bangladesh and Central Africa

Answer 146

* unknown (20%) * preterm delivery (most common) * IUGR (\>10%) * antepartum haemorrhage (~10%) * intrapartum still birth (9%) * major congenital abnormalities (10% of still births and 25% of neonatal mortality) * pre-eclampsia * infection

Answer 147

* Maternal death – death during pregnancy, or within 42d of its cessation, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes * Late maternal death – death related to pregnancy or management, 42d – 1y after birth * Direct death – result from obstetric complications of the pregnancy * Indirect death – result from previous or new disease, which was aggravated by pregnancy * Incidental death – would have happened irrespective of the pregnancy

Answer 148

* ~11.4 per 100,000 pregnancies in the UK (2006-2008) * Deaths in less developed countries far higher, around 500 per 10,000 pregnancies in parts of Africa

Answer 149

* infection * thromboembolism * hypertensive disorders * cardiac disease * ectopic pregnancy and abortion * haemorrhage * neurological disease * psychiatric disease and suicide

Answer 150

* Maternal drugs such as carbimazole, iodine containing compounds * Pendred's syndrome (associated with bilateral hearing loss and goitre) * Maternal Graves' disease due to the passage of thyroid-stimulating hormone receptor antibodies across the placenta which will cause thyroid enlargement.