Obstetrics Flashcards
Why is foetal monitoring important?
Identify a baby at risk of dying in utero
How might you monitor a foetus?
Pinard stethoscope
Hand held doppler - intermittent auscultation for low risk mothers
Cardiotocography for high risk mothers - continuous - measures FHR and uterine contractions
What might you see on abnormal CTG?
FHR variability
Accelerations/decelerations - early/variable/late
How can you get the true beat-to-beat FHR? When can you obtain it?
Fetal ECG
Only in labour (is invasive) when cervix is >2cm dilated
A fetal magneto cardiogram is a non invasive high resolution device that can accurately analyse the foetal heart. Problems with it?
Expensive and big
Shield environment
Skilled technician
Analgesia used in labour?
Simple - paracetamol/codeine
Opioids (IM/IV morphine, diamorphine, pethidine)
Entonox - half O2 and N2O
Epidural
Where an epidural be administered?
L3/4 space - Tuffier’s line at level of iliac crest
Epidural space - between dura and vertebral body
When to administer epidural? When not to (C/I)
Maternal request
maternal disease
Augmented labour - multiple births, induced, instrumental/operative labour likely
Not: maternal refusal, allergy, local infection
Why is epidural good?
Superior analgesia, maternal satisfaction
What sort of anaesthesia might you use for a caesarean section?
Spinal or general but prefer spinal
When might you administer GA for C section?
Imminent threat to mother/foetus
C/I to regional
Maternal preference
A 28 year old lady is 27 weeks pregnant (24+) presents with vaginal bleeding. What is this referred to as? What might cause it?
Antepartum haemorrhage - bleeding from genital tract after 24 weeks pregnancy, prior to delivery of fetus
Placental abruption, placenta praevi
Ectropion of cervix (trauma to cervical columnar cells causes bleeding)
A 30 year old is 32 weeks pregnant and has a 3 week hx of intermitant painless bleeds, which have become more frequent and heavier over time. Examination is normal apart from that the foetus lying transverse(/breech). Likely dx? Cause?
Placenta praevi - placenta implanted in lower segment of uterus - can be in lower segment (types I-II) or partially (III) or completely covering os (IV).
Aetiology unknown - twins, previous hx, C-section scar
Thought that in early pregnancy the upper part of uterus grows faster. Usually a praevi corrects itself - lower segment grows and placenta ‘moves upwards’
Complications of praevi?
Low lying placenta obstructs engagement of head
Placenta accrete - placenta implants into deeper endometrium/myometrium eg previous C section scar
Placenta percreta - placenta penetrates through uterine wall into surrounding abdominal structures eg bladder
Ix of suspected praevi?
NEVER DO VAGINAL EXAM - can provoke massive bleeding
USS - if <2cm from os after 32 weeks - like to be praevi at term
3D doppler USS to determine if accreta
Assess fetal/maternal well-being - CTG/FBC/clotting
Management of praevi?
Anti-D of Rh -ve
IV access, cross match
Nurse in left lateral position
If asymptomatic - delay birth til 37 weeks
If <34wks - steroids
Elective C section at 37-38 weeks by most senior person (Lower segment - LSCS) - if grade III/IV. Vaginal delivery if grade I
Prepare for haemorrhage - compression w/ Rusch balloon or hysterectomy
A 35 week pregnant lady has a 1 day hx of painful bleeding. O/E she is tachycardic, hypotensive, and has a tender, tense, woody hard uterus. Fetal heart beat seems abnormal. Lie is normal.
Placental abruption - part/all of placenta separates before the delivery of foetus Causes: autoimmune disease IUGR Pre-eclampsia - proteinuric hypertension Multiparity maternal trauma, smoking/cocaine use hx of abruptions Bleeding due to separation. Pain due to uterine contractions
Investigations of placental abruption?
CTG - establish fetal wellbeing (decelerations)
USS - r/o praevi
Bloods: FBC, U&E, coagulation, cross match
Rx of placental abruption?
Assessment/resuscitation: IV fluids
Nurse in left lateral position
Steroids (<34 wks)
Blood transfusion
Opiate analgesia
Anti-D if Rh -ve
Delivery: Emergency C section if fetal ditress
Labour w/ amniotomy if no fetal ditress and gestation >37wks
If <37 weeks and no distress - D/C but now high risk
Apart from praevia and abrption, name some others causes of antepartum haemorrhage
Undermined origin
Uterine rupture - sudden stop in contraction and fetal distress
Vasa praevi - fetal blood vessels run in membrane infront of presenting part - fetal distress - brisk painless bleeding at ROM
Gynae (cervical carcinoma/polyps)
Define a post partum haemorrhage
> 500mL blood loss <24h after delivery
or 1000mL after C section
Describe the causes of PPH
Tone - uterine atony in prolonged labour or retained placenta
Trauma - injury to birth canal eg w/ instrumental delivery - vaginal tear/cervical tear
Tissue - retained placenta/fetus - partial separation - blood accumulates in uterus
Thrombin - rare coagulopathy or consumption coagulopathy - DIC/shock as coagualtio factors used up in labour
RF: large baby, rapid progression, oxytocin can increase BP
How can PPH be prevented?
Use of oxytocin in 3rd stage of labour
Management of PPH?
IV access
Nurse flat
Remove placenta if bleeding or not expelled after 60mins
Uterine cause - IV oxytocin to contract uterus
Uterine atony - prostaglandin F2a into myometrium
Examine uterine cavity for retained fragments/cervix/vagina for tears
Surgery - Rusch balloon if bleeding from placental bed
Uterine artery embolization, hystrerectomy as last resort, brace suture
What is secondary PPH? How might it present?
Excessive blood loss between 24h and 6 weeks after delivery.
Tender uterus, os open
Causes of secondary PPH?
Endometritis, gynae pathology, gestational trophoblastic disease
Dx and Rx of secondary PPH?
Vaginal swabs, FBC, USS, biopsy and histology - r/o gestational trophoblastic disease
Abx
If heavy bleeding - ERPC
What are the cardiovascular changes in pregnancy?
Increase in plasma vol, CO, stroke vol, heart rate
Decrease in serum albumin con/colloid oncotic P
Venous return interfered with -> ankle oedema, varicose veins
Increase in coagulation factors and fibrinogen
Compression of inferior vena cava by uterus (aorto-caval compression) –> supine hypotension
What are the GI cahnages in pregnancy?
Biochemical:
N&V
Delayed gastric emptying
Prolonged small bowel transit time
GORD
Biochem: Ca requirement increase - transported to placenta. Serum Ca & phosphate fall, gut absorption increases (increased 1,25-DiOH vit D
Renal change in pregnancy?
Increase renal blood flow
Increased GFR
Salt & water reabsorption reabsorption increased by elevated sex steroid hormones
Urinary protein loss
Hepatic changes in pregnancy?
changes in oxidative liver enzymes eg cytochrome P450
Normal hepatic flow
ALP rises, albumin falls
Pulmonary changes in pregnancy?
Increase in tidal vol and minute ventilation
What does hCG do? What secretes
Signals presence of blastocyst and prevents breakdown of corpus luteum - synthesises progestins until placeta forms
Trophoblast cells of blastocyst secretes around day 6-7
Significance of progestins?
Myometrial quiescence - prevents contracting too early
Prepares uterus for implantation
(mifepristone will terminate)
Placenta continues to produce progesterones until baby delivered
Significant of oestrogens?
Change in cardiovascular system
fetal wellbeing
Increase breast growth
Pituitary to secrete prolactin
Hormones in milk production?
Prolactin - production
Oxytocin - ejection
Why is the fetus not rejected?
Extra-villus trophoblast has modified self-non self markers - HLA-G/E
Synctiotrophoblast unlikely to stimulate maternal response
What is the window of implantation?
Day 20-24 in cycle
What does the placenta form after implantation? What facilitates it?
Floating and anchoring villi
By fetal cytotrophoblasts in hypoxic conditions
Describe the uteroplacental circulation. Failure of spiral arteries causes?
Spiral arteries supply placental bed - become tortuous, dilated and les elastic by trophoblast invasion - failure causes pre-eclampsia, IUGR
Maternal blood through intervillous space
Fetal blood –> chorionic plate –> basal plate –> uterine vein
Describe fetoplacental circualtion
1 umbilical vein from placenta –> IVC in fetus and circulated and 2 umbilical arteries carry deoxygenatwed blood from fetus to placenta
Matrnal and fetal blood streams flow side by side in opposite directions
What is the function of the placenta?
Anchor fetus
Gaseous and nutrient exchange
Endocrine organ - hCG, oestrogens and progesterone
Barrier of infection of blood bourne diseases but syphilis, parvovirus, hep B/c, cytomegalovirus cross and infect fetus
Significance of progesterone
Decrease smooth muscle contractility
Raise body temp
Skin changes in pregnancy?
Linea nigra
Striae
Chloasma - brown pigmentation of skin
Palmar erythema
What is in stage 1 of labour?
From onset to full cervical dilation
Latent phase - 0-3cm
Active phase - 3-10cm, 1cm/hr
Possible interventions at stage 1 of labour?
Membrane sweep
Prostaglandin pessary
Oxytocin
What is engagement?
When head accommodates 2 fingers (2/5) above pubic symphysis
What are the mechanical factors of labour?
The power - uterine contraction - pulls cervix up (effacement)
The pelvis/planes (11x11cm)
The passenger - oblong head w/ bones not fused - fontanelles and sutures
What is attitude?
Degree of flexion if head - ideal is maximal flexion
What is presentation?
Part of foetus that occupies lower segment ie cephalic/breech
What is presenting part?
Lowest part of fetus palpable on vaginal exam (cephalic = vertex) but smaller degree of flexion –> face/brow
How is the fetus positioned usually? How might it be and what would this mean?
Occiput-anterior (face down)
Could be occiput-posterior - difficulty
Occipito-transverse - non rotation and needs assistance
Describe what marks the initiating of labour
Involunatry contractions of uterine smooth muscle in 3rd trimester - Braxton Hick contractiosn
Fetal prostaglandin production and oxytocin release
Labour = painful regular contractions - effacement/dilatation of cervix & shortening
Show- shedding of mucous plug
Rupture of membranes
What is cervical ripening/effacement?
When normal tubular cervix drawn up into lower segment until it is flat
Accompanied by show - mucus plug and release of membranes
How does the fetus and hormones stimulate a positive feedback throughout labour?
Fetus pushes down –> pressure on cervix
Prostaglandin released as muscles stretched –> release of oxytocin
Elevates Ca conc –> higher contractility
Describe the 2nd stage of labour
From full dilation to delivery of fetus
1 hr
Passive stage: full dilation until head reaches pelvic floor
Active stage: mother pushing, bearing down
Why might the second stage of labour be delayed?
Brow/face/shoulder presentation
Transverse/OP/OT position
Describe 3rd stage of labour
From deliver of foetus to delivery of placenta & membranes
Active - oxytocin, cord clamping after 1 minute, cord traction
Physiological - clamp cord after pulsations stops
Uterine muscles contract and compress blood vessels
Blood loss <500mL
Prolonged if >30 mins active, >60 mins physiological
How is the progress of labour monitored?
FHR monitored every 15 mins or continuous by CTG
Contractiosn assessed every 30mins
Partogram - dilation of cervix, descent of head
Laert/action lines - indicates slow progress
Maternal pulse rate assessed every 60 min
Maternal BP & temp checked 4hourly
VE (vaginal exam) offered every 4 hours
offered
Urine checked for ketones & protein every 4 hours
Common causes of failure to progress?
Insufficient uterine action
Hyperactive uterine action - excessively strong contractions
Inefficient uterine action in nulliparous women
Malpresentation
Small pelvis
Rx of Insufficent uterine power?
Augmentation - amniotomy then oxytocin
Rx for hyperactive uterine action?
If no abruption - tocolytic eg IV/SC salbutamol
If fetal distress - emergency LSCS
Rx for inefficient uterine action in nulliparous women?
1st stage: artificial membrane sweep, IV oxtocin (no full dilation by 2 hrs)
If not FD by 12-16 hrs - C section
Poor descent in 2nd stage: oxytocin
If 2nd stage lasting longer than 1 hr: episiotomy (head pushing on perineum)
If fetal distress in 2nd stage/maternal distress –> traction w/ ventouse/Kielland’s forceps
Which malpresentation would you use instrumental delivery?
OP/OT
Which malpresentation would you have a LSCS?
Brow/Face
What are the indications for induction of labour?
Prolonged pregnancy (>12 days) ?IUGR Pre term membrane rupture Pre-eclampsia Medical disease - HTN/diabetes >38 weeks
How is labour induced?
Cervical sweep to strip membranes
IV prostaglandin
Amniotomy w/ amnihook (breaking waters)
Oxytocin infusion if labour not started in 2 hrs
Define the lie of the foetus?
The relationship of the foetus to the long axis of the uterus
Cause of abnormal lie/malpresentation?
More room to move - polyhydramnios
Structural abnormailites eg uterine/foetus/twins
Conditions preventing engagement eg praevi/tumours
Complications of malpresentions?
No labour
Uterine rupture - fetus/mother at risk
Cord prolapse
Head is in flank. What lie?
Transverse
Head is in iliac fossa. What lie?
Oblique
Management of malpresentation?
After 37 wks: USS for cause
C section
External cephalic version is option
Pregnant lady with upper abdo discomfort. O/E head is ballottable at fundus and USS confirms. What lie? Management?
Breech External cephalic conversion CTG anti-D given to Rh -ve C section if ECV fails
In an antenatal clinic, a 31 year old pregnant lady present with drowsiness, some visual disturbances and N&V. She is hypertensive and has some oedema in hr ankles. She has some epigastric tenderness. Urine dip stick shows proteinuria. Likely dx and cause?
Pre-eclampsia - disease of placenta - characterised by pregnancy-indiced hypertension & proteinuria (>0.3g/24hr)
Aetiology: hypertensive in a previous pregnancy
nullipairty
Obesity
Extremes if maternal age
Microvascular disease - HTN, renal disease, diabetes, autoimmune disease eg antiphospholipid syndrome/SLE
CKD
High BMI
Multiple pregnancy
Family hx
Describe stage 1 of pre-eclampsia
Incomplete trophoblastic invasion into spiral arterioles and atherosis of spiral artery –> reduced spiral artery/uteroplacental blood flow –> ishaemic placenta –> inflammatory response
Describe stage 2 of pre-eclampsia
Endothelial damage from inflammation. causes:
Increased vascular permeability –> oedema/proteinuria
Vasoconstriction –> HTN, eclampsia, liver damage
Clotting abnormality
Classification of pre-eclampsia?
Mild: Proteinuria and HTN
Moderate: Proteinuria and severe HTN. No complications
Severe: Proteinuria, HTN <34 wks. Maternal complications
What are the complications of pre-eclampsia in mothers?
Eclampsia: tonic clonic seizure from cerebral vasospasm
Cerebrovascular haemorrhage
Placental abruption, intra abdo haemorrhage
HELLP syndrome (Haemolysis - dark urine, Elevated liver enzymes, Low Platelet count)
Renal failure
Pulmonary oedema
Cardiac failure
Fetal complications of pre-eclampsia?
IUGR –> preterm delivery
Risk of placental abruption
Ix for pre-eclampsia?
Urinalysis: proteinuria and protein:creatinine ratio of >30mg/nmol Bloods: elevated uric acid/Hb Fall in platelets (HELLP) Deranged LFTs USS for foetus Umbilical artery Doppler at 23 weeks If abnormal - CTG BP
How is pre-eclampsia prevented?
75mg aspirin before 16 wks
Management of pre-eclampsia?
Antihypertensives - PO labetalol (if severe - IV labetalol, PO nifedipine)
Mg sulphate (esp is eclampsia/HELLP)
Steroids - promote fetal pulmonary maturity if moderate/severe
Delivery by 37 weeks if mild but 34-36 weeks in moderate/severe
If fetal distress <34 weeks - C section
Long term management of pre-eclampsia
BP monitoring
If a woman wants to get pregnant but has a medical condition, what should you tell her?
Optimise disease control Safe drug therapy Agree care plan - MDT Advise risks Contraception
Ante-partum management of medical condition?
Obstetrician w/ expertise in medical problems and physician w/ expertise in pregnancy + nurse/midwife specialist
Risk of anaemia in pregnancy and rx?
Low birth weight
B12 injections
Screened at booking visit (8-10 weeks) & ar 28 weeks
Hb cut offs for oral iron: <11 at booking visit, <10.5 at 28 weeks
Management of CVD in pregnancy?
Echo
Anticoagualtion if prothetic valves
Pregnant lady in third trimester presents with pruritus on palms & soles, raised bilirubin. LFTs are deranged. Dx? Risk? Management?
Obstetric intrahepatic cholestasis Stillbirth/premature labour Rx: ursodeoxycholic acid, vitamin K if prolonged clotting Monitor LFTs Induce at 37 weeks
Risks of maternal hyperthyroidism? Management?
Maternal: thyroid crisis w/ cardiac failure
Fetal: thyrotoxicosis from anti-TSH
Rx: Propylthiouracil
Risk and Rx of hypothyroidism?
Early fetal loss and impaired neurodevelopment
Rx: adequate replacement w/ levothyroxine in 1st trimester
Risks of renal disease in pregnancy?
Pre-eclampsia
IUGR
Premature delivery
Severe HTN
Risks of epilepsy in pregnancy? Rx?
Sudden Unexplained Death in Epilepsy (SUDEP - esp if not taking anticonvulsants
If on valproate - teratogenic - spina bifida, phenytoin - cleft palate
Rx: Preconception: high dose folic acid
Screen for fetal abnormalities
AED mnonotherapy
Levitiracetem (Keppra) to control seizures or lamotrigine
Why might a pregnant woman get a DVT/PE? Ix? Rx?
Haematological changes - increased clotting factors: VII, VIII, X & fibrinogen, decrease in protein S
Uterus compresses IVC -> venous stasis in legs
(hypercoagulable state)
Ix: DVT - Doppler USS, PE: VQ scan or CTPA
RX: LMWH SC
Why would you not give warfarin in pregnancy?
Crosses placenta and causes fetal abnormalities and intracranial bleeding
What is gestational diabetes?
carbohydrate intolerance diagnosed in pregnancy
Fasting glucose >7.0mmol/L or >7.8 2hr after 75g glucose load
RF for gestational diabetes?
History of gestational diabetes Previous large (macrosomic) foetus FHx - 1st degree relative High BMI (>30) Glycosuria Family origin - south Asian, black Caribbean, middle eastern
Why do pregnant women develop diabtetes?
Decreased glucose tolerance
Kidneys excrete glucose at lower threshold
Fetal complications of gestational diabtetes?
Cardiac/neural tube defects
Preterm labour - lung prematurity
Macrosomnia and large fetus –> risk of shoulder dystocia
Featl distress
Maternal complications of gestational diabetes?
DKA hypoglycaemia HTN and pre-eclampsia C section diabetic retinopathy/nephropathy
Management of pre existing diabetes in pregnancy?
Antenatal consultant led w/ MDT, education, weight kiss if BMI > 27
Check: renal function, BP, retinae
Stop oral hypoglycaemic agents (apart from metformin)
Folic acid - from preconception to 12 weeks
labetalol if antihypertensive needed
Monitor glucose levels (keep <6mmol/L), HbA1c <48
Fetus: normal scans, echocardiography
Aspirin after 12 weeks
(prevent pre-eclampsia)
Detailed anomaly scan at 20 weeks (esp heart chambers)
Delivery at 39 weeks - offer C section
Management of gestational diabetes
Ix: OGTT at booking & 24 weeks if previous history/risk factors.
Ix: Fasting glucose >5.6, 2 hour glucose >7.8
Mx: Joint diabetes & antenatal clinic
Diet advice
Monitor glucose levels
Metformin if glucose not in range after 1-2 weeks
Then add Insulin if high fasting glucose (>7) or if still not being controlled
If plasma level between 6-6.9: offer insulin (evidence if polyhydramnios & macrosomnia)
Glibenclamide if cannot tolerate metformin
Postnatal: discontinue insulin, GTT at 3 mo
Risks and management of herpes simplex in pregnancy?
Vertical transmission if vesicales present
If within 6 weeks of delivery - C/S
Risks of Group A Streptococcus and rx?
Perinatal sepsis, chorioamnionitis
Rx: IV Abx
Concern of Step B infection in pregnancy? Treatment?
It is a commensal in birth canal - causing early onset neonatal sepsis
Treat risk factors if previously infected child, maternal fever in labour (give IV penicillin)
Risks of HIV in pregnancy and treatment?
Risks: IUGR, still birth, pre-eclampsia, prematurity (risk of gestational DM)
Rx: All pregnant women screened for HIV
prevent vertical transmission, maternal/neonatal ART
Elective C/S with zidovudine infusion
Vaginal delivery if viral load <50 at 36 weeks
PO zidovudine to neonate if maternal viral load was > 50
Avoid breast feeding
How would maternal parvovirus B19 affect the neonate?
Aplastic anaemia
How would maternal toxoplasmosis affect the neonate?
LD, convuslions, visual defects
How would maternal Rubella affect the neonate?
Cardiac defects, sensorineural deafness, visual defects (congenital cataracts, ‘salt & pepper’ choroidoretinitis, purpuric skin lesions, micophthalmia), cerebral palsy
Dx: check IgM for togavirus & parvovirus B19 (similar)
Rx: If no immunity deomstrated - stay away from people with rubella, offer MMR vaccine post natal period
How would maternal CMV affect the neonate?
IUGR, neurological damage, pneumonia
Describe the routine USS in pregnant
8-14 weeks - dating, pregnancy site, multiple pregnancy?
18-21 weeks - anomaly scan
When would there be a detailed cardiac scan?
Increased risk of defects: DM, hx of congenital disease, chromosomal abnormalities
How is Down’s syndrome screened for? (And T13/18)
Combined test - nuchal translucency and PaPP-A and b-hCG (11-14 weeks)
Quadruple test - B-hCG, AFP, Inhibin-A, free estriol 3 (after 14 weeks)
How is Down’s diagnosed in pregnancy?
Amniocentesis - from 14 weeks
Chorionic villus sampling 11-15 weeks
Risk of CVS?
Slightly higher rate of miscarriage
A 18 year old sexually active girl presents with vaginal bleeding, hyperemesis, pelvic pain , large uterusand high B-hCG. Likely dx? Types?
Gestational trophoblastic disease
Often beign hydatiform moles - benign tumour tumour of trophoblastic material. Empty egg fertilized by single sperm and it duplicates on its own - ie all 46 chrms from paternal
Can be partial - triploid (2x sperm, 1 oocyte - ie 69 XXY)
Complete - Haploid (1 x sperm, empty oocyte)
Invasive - locally/metastatic
Mx: urgent referral specialist centre - evacuation of uterus, effective contraception to avoid pregnancy in next 12 months
Risks of gestational trophoblastic disease and management?
Metastatic choriocarcinoma - often to lung
ERPC
Serial B-hCG (check if removed as mole continue to produce B-hCG)
If invasive - assess risk, chemo/radiotherapy
Risk of alcoholism in pregnancy?
Fetal alcohol syndrome
Risk of tobacco in pregnancy?
Miscarriage
Prematurity
prelabour rupture of membranes
Abruption and praevi
Risk of cocaine use in pregnancy?
Placental abruption
Pregnant lady has UTI. Rx and why?
Nitrofurantoin as trimethoprim is folate antagonist (so may cause defects eg spina bifida in foetus)
Some drugs to NOT USE in pregnancy?>
Statins Warfarin Methotrexate Valproate Hormones
What is low for birthweight?
Under 2.5kg
Define small for dates
10% below 10th centile
What is intrauterine growth restriction
Implies compromise - growth slowed and take sinto account constitutional factors
Why might there be IUGR?
Constitutional - low maternal weight/height, nullipairty
Pre-eclampsia - high resistance in spiral arteries - poor perfusion
Multiple pregnancy
Smoking/drug use
Infection
Maternal obesity/diabetes
Fetal adaptions to IUGR? Complications?
Reduced fetal movements Oligohydramnios Cerebal palsy Preterm delivery Cardiac defects
Investigations for IUGR?
Hx - previous birthweights, complications
Exam: serial symphysis fundal heights. If SF height >2cm less gestation (wks) - do serial USS
End diastolic flow Doppler US - if present = good perfusion
Amniocentesis (infection test)
CTG of fetal distress
Management of IUGR?
Review in antenatal clinic
High resistance Doppler - see abnormal flow
Term: Labour induction and C section
Preterm: If >36wk - CTG and induce, <36 weeks - repeat twice weekly
Severe abnormality: <34 weeks - steroids, daily CTG, fetal Doppler
>34 weeks - CTG, LSCS delivery
What is macrosomnia?
Weught over 90th centile
Causes for macrosomia?
Gestational diabetes –> insulin release –> fetal pancreatic islet cell hyperplasia –> hyperinsulinaemia and fat deposition
Complications of macrosomnia?
Polyhydramnios
Shoulder dystocia due to increased fat around shoulders
Fetal distress in labour and death
Post partum hypoglycaemia and hyperbilirubinaemia
How should a macrosomnic foetus be monitored?
Usual scans
Echo for cardiac defects
GTT
Management of macrosomnia
Control diabetes
Delivery at 39 wks
C section if fetus >4kg
During labour - glucose levels maintained using sliding scale of insulin and dextrose
Risk for neonate if macrosomnic? Advice?
Hypoglycaemia, resp distress
Breastfeed
A premature infant is born before?
37 weeks
259 days afterLMP
245 days after conception
A LBW infant is?
<2500g at birth
VLBW: <1500g
ELBW: <1000g
Complications of prematurity?
Developmental delay Visual impairment Chronic lung disease Hypothermia, feeding probslems, infection, jaundice respiratory distress syndrome Cerebral palsy Retinopathy of newborn, hearing problems
How could survival rates be improved in prematurity?
Antenatal steroids Artificial surfactant Ventilation Nutrition Abx
Risk factors for prematurity?
Preterm labour/PROM, amnionitis Medical disorders Multiple pregnancy APH UTI
How is prematurity diagnosed?
Persistent uterine activity and cervical dilation/effacement
How can prematurity be assessed?
Screen asyptomatic high risk women
Qualitative fetal fibronectin test - may indicate disruption of attachment of membranes to decidua
Management of prematurity?
IM/Pessary progesterones
Tocolysis/steroids
Decide best route of delivery
Plan w/ neonatologists
What is the puerperium?
Delivery to placenta to 6 weeks following birth
What si the post natal period?
No less than 10 days after birth where a midwife attends upon a woman and baby. This may be longer if the midwife deems it necessary
Common causes of maternal death after childbirth?
VTE/thrombosis
Influenza
Sepsis, DIC and mutli-organ failure
Suicide
What is maternal death?
Death of woman during puerperium through causes related to, or aggravated by the pregnancy or its management
What is direct maternal death?
Death relating from obstetric complications of pregnancy, labour or puerperium
What is indirect maternal death?
Death resulting from pre-existing disease/disease that developed in pregnancy but not a result of obstetric causes
Mother of recently born infant feels exhausted, unable to cope, overwhelming anxiety, is tearful for no reason, reduced appetite, struggles to bond with the baby. What is likely diagnosis and how should it be assessed?
Post natal depression
Psych hx
physical wellbeing - weight, smoking, health problems
Alcohol/drug misuse
Woman’s attitude towards pregnancy and any probloems
mother-baby relationship
RF for postnatal depression?
Past/present mental health problems
Poor social support/isolation
Family history of mental health conditions
Domestic/childhood abuse
Factors that may impede detection of post natal depression?
Fear of treatment Fear of children being taken away Stigma of mental health Cultural lack of recognition Denial of problem
Pregnant woman experiencing regular contractions with meconium stained pad. Significance?
Likely to be breech
Additional tests in pregnancy?
Glucose tolerance test - 24-28 weeks
Infection screen - syphilis, hep B, HIV by 10 weeks
