Obstetrics Flashcards
1
Q
what is classed as premature labour?
A
when pregnancy occurs between 24 and 37 weeks gestation.
2
Q
what are the risk factors for preterm birth?
A
previous premature labour previous cervical trauma previous induced abortion maternal infection multifetal pregnancies short cervical length positive fetal fibronectin test preterm premature rupture of membranes short interpregnancy interval extremes of maternal age maternal medical disease (renal failure, DM, thyroid disease) pregnancy complications - preeclampsia or IUGR
3
Q
what is normal labour?
A
Spontaneous in onset, low-risk at the start of labour and remaining so throughout labour and delivery. The infant is born spontaneously in the vertex position between 37 and 42 completed weeks of pregnancy. After birth, mother and infant are in good condition’
4
Q
what is a normal birth ?
A
Birth without induction of labour, spinal or epidural analgesia, general anaesthesia, forceps or ventouse delivery, caesarean section or episiotomy
5
Q
what is the latent phase of labour?
A
when there is irregular contractions, the show a mucoid plug
- can last from 6 hours to 2-3 days
cervix is effacing and thinning
encouraged to stay at home
6
Q
what are the three stages of labour?
A
the first stage - commences with the onset of labour and terminates when the cervix has reached full dilatation and is no longer palpable
second stage - the stage of expulsion begins with full dilatation of the cervix and ends with expulsion of the fetus
third stage or the placental stage - expulsion of the placenta
7
Q
what is labour defined as?
A
Labour may be defined as the onset of regular and painful contractions associated with cervical dilation and descent of the presenting part
8
Q
what are the signs of labour?
A
- regular and painful uterine contractions
- a show (shedding of mucous plug)
- rupture of the membranes (not always)
- shortening and dilation of the cervix
9
Q
what monitoring would you perform during labour?
A
- FHR monitored every 15min (or continuously via CTG)
- Contractions assessed every 30min
- Maternal pulse rate assessed every 60min
- Maternal BP and temp should be checked every 4 hours
- VE should be offered every 4 hours to check progression of labour
- Maternal urine should be checked for ketones and protein every 4 hours
10
Q
what is latent and active labour?
A
latent phase = 0-3 cm dilation, normally takes 6 hours
active phase = 3-10 cm dilation, normally 1cm/hr
11
Q
what mechanical factors determine the progress of labour?
A
the degree of of force expelling the foetus
the dimensions of the pelvis and resistence of soft tissue
the diameter of the fetal head
12
Q
once labour is established how often do contractions occur and what happens during a contraction?
A
the uterus contacts for 45-60 seconds about every 2-4 minutes
during the contraction the cervix is pulled up (effacement) and caused dilatation, aided by the pressure of the head as the uterus pushes the head down into the pelvis
13
Q
what are the movements of the head in labour?
A
every darn fool in egypt eats raw egss
engagement descent flexion internal rotation extension external rotation expulsion
14
Q
what is a braxton hicks contraction?
A
involuntary contractions of uterine smooth muscle that occur through the third trimester
15
Q
what is effacement of the cervix?
A
when the normally tubular cervix is drawn up into the lower segment until it is flat
16
Q
what observations should be performed during labour?
A
FHR monitored every 15min (or continuously via CTG)
Contractions assessed every 30min
Maternal pulse rate assessed every 60min
Maternal BP and temp should be checked every 4 hours
VE should be offered every 4 hours to check progression of labour
Maternal urine should be checked for ketones and protein every 4 hours
17
Q
what can be done to help quicken
labour progress?
A
amniotomy and then artificial oxytocin
*if full dilatation is not not imminent within 12-16 hours, usually a c-section is performed
18
Q
what factors determine how easily the head fits through the pelvis?
A
attitude: extension/flexion - vertex presentation (well flexed is ideal) the less flexed and more extended makes it harder for head to pass
position - rotation - usually delivered with occiput anterior (other rotations included occipito posterior, occipito-transverse, brow presentation or face presentation)
size of the head
19
Q
what can cause damage to the fetus during labour?
A
fetal hypoxia - commonly describes as distress
infection/inflammation in labour - e.g. group b streptococcus
meconium aspiration leading to chemical pneumonitis
trauma is rarely spontaneous and is more commonly due to obstetric interventions e.g. forceps
fetal blood loss
20
Q
how is hypoxia diagnosed in the fetus during labour?
A
pH of <7.2 in the fetal scalp blood indicates significant hypoxia
it is actually only when the pH is below 7 that neurological damage is considerably more common
colour of the liquor - if it is meconium stained - more risk of fetal distress as it could aspirate the meconium - closer monitoring with CTG is needed
fetal HR auscultation - the distressed fetus will show abnormal heart rate patterns
CTG
fetal ECG monitoring
21
Q
what can cause acute hypoxia of the fetus during labour?
A
placental abruption
hypertonic uterine states and the use of oxytocin
prolapse of the umbilical cord
maternal hypotension
22
Q
what can be done to help the mother during labour?
A
entonox - equal mix of NO and O2
systemic opiates - pethidine and Meptid are widely used as IM injections
epidural - administered between L3-4 or L4-5. (can make labour pain free)
23
Q
how often is the fetal heart rate listened to and whe is a CTG required?
A
every 15 minutes for 1 minute following a contraction
if the pregnancy is high risk or meconium is seen or if there is a maternal fever then a CTG should be started
in the second stage of labour - FHR should be measure every contraction
24
Q
what are the observations of the mother in the first and second stage of labour?
A
fist stage - every 30 minutes measure contraction frequency, every hour - pulse, every four hours - BP, temp, vaginal exam
Second stage - every 15 mins - pulse
25
what is administered in the third stage of labour?
active management of the third stage
ergometrine and oxytocin
this will reduce risk of postpartum haemorrhage
26
what are the classifications of perineal trauma from delivery?
first degree - injury to skin only
second degree - involves perineal muscles but not anal sphincter
third degree - involves anal sphincter complex
fourth degree - involves anal sphincter and anal epithelium
27
what are the disadvantages, complications and contraindications of an epidural?
disadvantages: increased supervision, maternal fever, reduced mobility, increased instrumental delivery rate, hypotension, urinary retention
complications: spinal tap, total spinal analgesia, local anaesthetic toxicity
Contraindications: severe sepsis, coagulopathy, active neuronal disease, hypovolaemia, severe spinal abnormalities, severe cardiac outflow obstruction
28
what are the complications of premature birth?
```
ICU needed
perinatal mortality
cerebral palsy
chronic lung disease
blindness
```
29
what is periventricular leukomalacia?
Periventricular leukomalacia (PVL) is a type of brain injury that is most common in babies born too soon (premature) or at low birthweight. The white matter (leuko) surrounding the ventricles of the brain (periventricular) is deprived of blood and oxygen leading to softening (malacia). The white matter is responsible for transmitting messages from nerve cells in the brain so damage to the white matter can cause problems with movement and other body functions.
30
what are some of the mechanisms for preterm labour?
the castle model
- 'too many defenders' - multiple pregnancy (excess liquor, polyhydramnios has the same effect)
- ' the defenders give up' - spontaneous preterm labour is more common where the fetus is at risk e.g. preeclampsia and IUGR or if there is an infection
- 'the castle design is poor' - uterine abnormalities
- ' the castle wall is weak' - cervical invcompetence
- 'the enemy knock down the wall' infection
31
how is preterm labour prevented?
preterm labour prevention is really only aimed at those who are high risk - the strategies should begin by 12 weeks
- cervical cerclage - insertion of sutures into the cervix to strengthen and keep it closed
- progesterone supplememntation
- screen and treat STI's, UTIs, BV
- treat polyhydramnios - by needle aspiration
32
when can cervical cerclage be used?
it can be done elective at 12-14 weeks
or the cervix can be scanned regularly and when there is significant shortening it can be sutured
finally it can be used as a rescue suture - can prevent delivery when the cervix is widely dilated
33
what test can be used to assess whether birth in the next week is likely?
fetal fibronectin assay (present in cervical secretions )
| positive = birth likely in the next 7 days
34
in which women is steroids prescribed to ?
given to women between 23 and 34 weeks
*in woman presenting with only contractions, they can be restricted to those who are fibronectin positive or have a short cervix
35
why are steroid prescribed?
they reduce perinatal morbidity and mortality by promoting pulmonary maturity
36
what is tocolysis?
nifedipine or oxytocin receptor antagonists (e.g. atosiban)
| tocolytics are given to suppress premature labour by suppressing uterine contraction
37
why are tocolytics given?
they are given to allow steroids time to act, or to allow time for transfer to a unit with neonatal intensive care facilities
* should only be given for a max of 24 hours
38
what can be given as a neuroprotective for the neonate?
magnesium sulphate
given <12 hours prior to anticipated or planned preterm delivery
a single dose of 4g by slow IV injection is used prior to delivery between 23 and 34 weeks
39
what are the two classifications of premature rupture of membranes?
premature rupture of membranes (PROM) - the rupture of fetal membranes at least 1 hour prior to onset of labour >/ 37 weeks' gestation. It occurs in 10-15% of term pregnancies and is associated with minimal risk
Preterm premature rupture of membranes (P-PROM) - the rupture of fetal membranes occurring less than 37 weeks gestation.
40
what can lead to PROM and P-PROM?
early activation of the normal physiological process - higher than normal level of apoptotic markers and MMPs in the amniotic fluid
Infection - inflammatory markers contribute to the weakening of the fetal membranes
genetic predisposition
41
what are the risk factors for PROM/P-PROM?
```
often none identifiable
smoking (especially <28 weeks gestation)
previous PROM/preterm delivery
vagiunal bleeding during pregnancy
lower genital tract infection
invasive procedure - amniocentesis
polyhydramnios
multiple pregnancy
cervical insufficiency
```
42
what are the clinical features of PROM?
- women experiences a painless popping sensation - followed by a gush of watery fluid leaking from the vagina
- symptoms can be more non-specific, such as gradual leakage of watery fluid from the vagina and damp underwear, or a change in colour or consistency of vaginal discharge
43
what are the complications of P-PROM?
preterm delivery is the main complication - follows within 48 hours in 50% of cases
infection of the fetus or placenta (chorioamnionitis) or cord (funisitis)
rarely there may be prolapse of the umbilical cord
44
how would you diagnose PROM?
usually from maternal hisory and positive exam findings
digital exam should be avoided
take high vaginal swab to check for infection
point of care tests - actim-PROM
45
what antibiotic is contraindicated in prevention infection in PROM?
amoxicillin/Co-amoxiclav is contraindicated, as the neonate is more prone to necrotising enterocolitis (NEC)
46
how do you manage P-PROM?
the woman should be admitted for 48 hours and be given steroids
>36 weeks - monitor signs of clinical chorioamnionitis. If there is evidence of group B streptococcus - give clindamycin/penicillin. induction of labour is recommended if greater than 24 hours.
34-36 weeks - monitor for signs of clinical chorioamnionitis, and advise to avoid sexual intercourse. Prophylactic erythromycin should be given, corticosteroids should be given.
IOL and delivery often recommended
24-33 weeks - monitor for signs of clinical chorioamnionitis and advise patients to avoid sexual intercourse
Prophylactic erythromycin
47
what are the indications for induction of labour?
- prolonged pregnancy, e.g. > 12 days after estimated date of delivery
- prelabour premature rupture of the membranes, where labour does not start
- diabetic mother > 38 weeks
- rhesus incompatibility
- pre-eclampsia
- suspected growth restrictions
48
how can labour be induced?
- intravaginal prostaglandins
- cervical sweep
- breaking of water amd oxytocin
49
what are the contraindications for induction of labour?
acute fetal compromise
abnormal lie
placenta praevia
pelvic obstruction
50
what score can be used to predict if induction of labour will be required?
BISHOP score
```
cervical position (0=posterior, 1=intermediate, 2=anterior)
cervical consistency (0=firm, 1=intermediate, 2= soft)
```
Cervical effacement (0-30%=0, 40-50%=1, 60-70%=2, 80%=3)
cervical dilation (<1cm=0, 1-2cm=1, 3-4cm=2, >5cm=3)
fetal station (-3=0, -2=1, -1/0=2, +1+2=3)
score <5 indicates that labour is unlikely to start without induction
a score >9 indicated that labour will most likely commonce spontaneously
51
what is the definition of a spontaneous miscarriage?
when the fetus dies or delivers dead before 24 completed weeks of pregnancy
52
when do the majority of miscarriages occur by?
the majority occur before 12 weeks
53
what percentage of pregnancies miscarry?
15%
54
what are the different types of miscarriage?
threatened miscarriage: there is bleeding but the fetus is still alive, the uterus is the size from the dates and the cervical os is closed. Only 25% will go on to miscarry
inevitable miscarriage: bleeding is usually heavier. although the fetus may still be alive the cervical os is open and miscarriage is about to occur
incomplete miscarriage: not all products of conception have been expelled, pain and vaginal bleeding,
cervical os is open
complete miscarriage - all fetal tissue has been passed. Bleeding has diminished, the uterus is not longer enlarged and the cervical os is closed
septic miscarriage - the contents of the the uterus are infected, causing endometriosis. Vaginal loss is usually offensive, the uterus is tender, but a fever can be absent .
Missed miscarriage - a gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion
mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear. Pain is not usually a feature
cervical os is closed
when the gestational sac is > 25 mm and no embryonic/fetal part can be seen it is sometimes described as a 'blighted ovum' or 'anembryonic pregnancy'
55
what symptoms would make you want to exclude and ectopic pregnancy?
pain
hypotension
tachycardia
anaemia
56
what are some causes of miscarriage?
embryonic factors - (embryonic disease, disorder or damage, chromosomal abnormalities, embryonic malformations)
maternal factors (maternal genital tract dysfunction or systemic illness, exposure to high doses of toxic agents)
57
what is the definition of recurrent miscarriage?
The spontaneous loss of ≥3 consecutive pregnancies before 20-24 completed weeks (gestation depends on country) is regarded as recurrent miscarriage.
58
what are some risk factors for miscarriage?
```
older age
uterine malformation
bacterial vaginosis
thrombophilia
chromosomal abnormality
previous miscarriage
infertility/assisted conception
NSAIDs
caffeine
alcohol
DM
```
59
what investigations would you perform for suspected miscarriage?
pregnancy test
FB
serum beta hCG titres
transvaginal USS
60
what are the classifications of miscarriage in terms of time?
```
Biochemical pregnancy loss:
Typical gestation <6 weeks
No fetal activity ever detected
Pregnancy not located on ultrasound
Beta hCG levels are high and then fall.
```
Early pregnancy loss:
Gestation typically 6 to 8 weeks
No fetal activity ever detected
Empty sac or large sac with minimal structures without fetal heart activity
Beta hCG levels show an initial rise and then fall.
Late pregnancy loss:
Typical gestation >12 weeks
Loss of fetal heart activity
Crown to rump length and fetal heart activity previously identified.
61
how do you manage a miscarriage?
*antiD is given to all woman who are rhesus negative if the miscarriage is treated surgically or medically or if there is bleeding after 12 weeks
Expectant management:
First line and involves waiting for 7-14 days for the miscarriage to complete spontaneously
Medical management:
Give the patient vaginal misoprostol. Advise them to contact the doctor if the bleeding hasn't started in 24 hours. Should be given with antiemetics and pain relief. Often preferred if there is a higher risk of haemorrhage (late first trimester or coagulopathies), evidence of infection or previous adverse experiences.
Surgical management:
May involve manual vacuum aspiration under local anaesthetic as an outpatient or surgical management in theatre under general anaesthetic (previously referred to as ERPC).
62
what are some causes of recurrent miscarriage?
antiphospholipid syndrome
endocrine disorders - poorly controlled DM, thread disease or PCOS
uterine abnormalities e.g. uterine septum
parental chromosomal abnormalities
smoking
63
how can you manage antiphospholipid syndrome to prevent recurrent miscarriage?
aspirin and low dose molecular weight heparin
64
why does glucose tolerance decrease during pregnancy?
during pregnancy resistance to insulin action increases
** in most pregnancies, pancreatic beta cells are able to compensate for increased insulin demands
65
what is gestational diabetes?
traditionally it has been defined as any degree of glucose intolerance with onset or first recognition during pregnancy
66
what factors can increase the risk of gestational diabetes?
age - due to age-related decreased pancreatic beta-cell reserve
obesity - leads to increased insulin resistance
smoking
PCOS - associated with insulin resistance and obesity
fam history of T2DM
previous GDM
67
what are the clinical features of gestational diabetes?
Most woman with borderline pancreatic reserve will be asymptomatic and will show no signs of Gestational diabetes.
If present, the clinical features tend to be the same as other forms of diabetes. – polyuria, polydipsia and fatigue.
68
what are the fetal complications of gestational diabetes?
glucose crosses placenta but insulin does not -fetus will therefore increase its own insulin levels to compensate - excess insulin can cause
- macrosomia
- organomnegaly
- eryhtropoiesis (results in polycythaemia)
- polyhydramnios
- increases rate of preterm delivery
- risk of hypoglycaemia at birth
- decreased surfactant production - risk of tachypnoea
69
who is screened for gestational diabetes?
those who have previously had gestational diabetes and those who have any of the other risk factors should be screened at 24-28 weeks with an oral glucose tolerance test
70
what are the fasting a 2 hour glucose levels for GDM to be diagnosed?
fasting - glucose level of >5.6mmol/L
a 2 hour plasma glucose level >7.8mmol/L
71
how is gestational diabetes managed?
1st line - lifestyle (diet and exercise and glucose monitoring)
2nd line - insulin therapy - for those with uncontrolled dietary therapy or marked initial hyperglycaemia
additional growth scans at 28,32 and 36 weeks
aim to deliver at 37 to 38 weeks
72
what is the post natal care for gestation diabetes?
* All anti-diabetic medication should be sopped immediately after delivery
* The blood glucose levels should be measured before discharge to check it has returned to normal
* Around 6-13 weeks post-partum, a fasting glucose test is recommended.
* Yearly tests should be offered due to increased risk of developing diabetes in the future.
73
what is pre-eclampsia?
a hypertensive syndrome that occurs in pregnant women after 20 weeks of gestation associated with proteinuria. and often oedema
74
how is pre-eclampsia diagnosed?
BP >140mmHg systolic and/or 90mmHg diastolic in a previously normotensive women
*at least 2 measurements should be made at least 4 hours apart
75
when is pre-eclampsia considered severe?
BP >160mmHg systolic and/or >110mmHg diastolic
76
what is eclampsia?
the occurrence of epileptiform seizures
77
why does pre-eclampsia occur?
there is abnormal placental development - narrow fibrous placental arteries = hypoperfused placenta which will proteins which regulate angiogenic balance which somehow this leads to a systemic maternal response - vasoconstriction, capillary leaking, and salt retention which lead to hypertension
78
what are the complications of pre-eclampsia?
MATERNAL: eclampsia, CVA, HELLP (hemolysis, elevated liver enzymes and low platelet count), DIC, liver failure, renal failure, pulmonary oedema.
FETAL: IUGR, preterm birth, placental abruption, hypoxia
can cause fetal and maternal death.
79
what are the risk factors for pre-eclampsia?
```
first pregnancy
pre-eclampsia in a previous pregnancy
fam history of pre-eclampsia
BMI>30
maternal age >35
multiple pregnancy
chronic hypertension
autoimmune disease
PCOS
```
80
what are the symptoms/features of pre-eclampsia?
```
high BP
proteinuria on dipstick
headache
visual disturbance
papiloedema
RUQ pain - cardinal sign of severe pre-eclampsia
hyperreflexia
```
81
what can be given for the prevention of pre-eclampsia?
low dose aspirin before 16 weeks can significantly reduce the risk of pre-eclampsia
high dose VD with calcium may also be effective
82
how is mild/moderate (less than 140/90) pre-eclampsia managed?
managed as an outpatient - close monitoring - BP and urinalysis repeated twice weekly and USS every 2-4 weeks.
83
how is BP>160/110 in pre-eclampsia managed?
hospital admission when there is severe hypertension and where there is proteinuria
treat with antihypertensives - first line is labetalol second line is nifedipine or hydralazine
84
what additional drug can be used in severe pre-eclampsia and to prevent eclampsia?
magnesium sulphate
85
when should babies be delivered from mothers with pre-eclampsia?
if the patient is stable (absence of seizure and controlled hypertension) a conservative approach is usually taken and the decision to deliver is based on the gestational age.
if less than 32 weeks prolonging the pregnany will be beneficial to the fetus
method for delivery depends on gestational age - less than 32 weeks c-section should be used
dexamathasone should be admistered if delivering before 34 weeks to mature the lungs
86
how is pre-eclampsia managed post delivery?
close monitoring of fluid balance ad the main risk to mother is fluid overload - fluid restriction regimen
control of hypertension and seizures needs to be continued after delivery untul recovery is apparent
87
what is gestational hypertension?
usually asymptomatic - BP >140/90 in the absence of proteinuria - in a usually normotensive woman
again labetalol is first line
88
what anit hypertensives are contraindicated in pregnancy?
ACE inhibitors
89
what are some causes of antepartum haemorrhage?
placental abruption
placenta praevia
uterine rupture
90
what is placental praevia?
it is defined as the placenta overlying the cervical os
| so the placenta is lying wholly or partly in the lower uterine segment
91
what are the three types of abnromally adherent placentas?
placenta accreta (attachment to the myometrium rather than being restricted within the decidua basalis)
Placenta increta (where the chorionic villi invade into the myometrium)
placenta percreta (where the chronionic villi invade through the myometrium and sometimes adjoining tissue
all of these will have the same management decisions for primary care givers
92
what are the classifications of placenta praevia?
complete (placenta cover entire internal cevical os)
partial (placenta covers a portion of the internal cervical os)
marginal (edge of plaenta lies within 2cm of the internal cervical os)
low lying
93
what are the risk factors for placenta praevia?
```
uterine scarring (most commonly due to prior c-section)
infertility treatments
prior placenta praevia
age>35
multiple previous pregnancies
smoking
previosu miscarriage/abortion
```
94
how would a placenta praevia present?
typically present in the second or third trimester as painless vaginal bleeding - which may be light, moderate or heavy
95
what is vasa praevia ?
fetal blood vessels overlying cervical os
no major maternal risk but major fetal risk
membrane rupture leads to major fetal haemorrhage
mortaility =60%
96
what investigations are performed for placenta praevia?
often picked up on the routine 20 week scan
RCOG reccomend the use of TV USS - helps accuracy of placenta localisaiton
97
how should placenta praevia be managed?
if there is bleeding:
stabilisation - give corticosteroids if less than 34 weeks and antiD if rhesus negative
if not stable - emergency c-section
if in labour and pre-term give tocolytics and steroids
if term and labour - emergency c-section
elective c section at 38-39 weeks
if no bleeding and >2mm from edge of os then normal labour can be offered
98
how are abnormal adherent placentas managed?
arrange elective c-section at 36-37 weeks
| have descussions and consent for possible interventions - hysterectomy, leaving placenta in place, cell salvage)
99
what is placental abruption?
the premature separation of a normally located placenta from the uterine wall that occurs before delivery
100
what are the different types of placental abruption?
revealed - when abruption occurs close to the margain and blood escapes through the vagina
concealed - when the abruption occurs in the middle and there is a concealed haemorrhage behind the placenta with no evidence of vaginal bleeding
101
what are the risk factors for placental abruption ?
```
chronic hypertension
pre-eclampsia
smoking
cocain use
trauma
chorioamnionitis
uterine malformation
prior placental abruption
oligohydramnios
```
102
what are clinical features of placental abruption?
```
vaginal bleeding
abdominal pain
uterine contraction
tender uterus
woody-hard, tense uterus
fetal distress
there may be maternal shock out portion to bleed
```
103
what are the complications of placental abruption?
```
hypovolaemic shock
DIC
IUGR
neurological impairment in the infant
preterm birth
perinatal death
```
104
what investigations would you perform for plaental abruption?
fetal monitoring - abnormalities in the tracing that suggest abruption
Hb and Hct
coagulation studies
USS
105
how do you manage a placental abruption?
1st line: stabilise the mother and monitor mother and fetus
give antiD in rhesus negative women
if >34 weeks and stable - vaginal delivery - give oxytocin and amniotomy
if unstable - urgent c section
if less than 34 weeks - corticosteroids and tocolytic (nifedipine or magnesium sulphate) to give time for lungs to mature
small abruptions may be managed conservatively large abruptions need resuscitation and delivery
106
what are the complications after antipartum haemorrhage?
```
premature labour/delivery
blood transfusion
acute tubular necrosis (+/- renal failure)
DIC
PPH
ITU admission
ARDS
fetal morbidity
```
107
what are the two types of post partum haemorrhage?
Primary - within 24 hours of deliver, blood loss gretaer than 500mls
secondary - after 24 hours and up to 1 weeks post delivery
minor (500-1000mls)
major (>1000mls)
108
what are the causes of post partum haemorrhage?
The four T's
tissue (retained placenta - ensure the placenta complete - manual removal of the placenta)
Tone (ensure uterus is contacted - uterotonics)
Trauma - look for tears - repair them
Thrombin - check clotting
109
what are the risk factors for post-partum haemorrhage?
```
big baby
nulliparity
grand multiparity (more than 5 births)
multiple pregnancy
precipitate or prolonged labour
maternal pyrexia
operative delivery - c section or instrumental delivery
shoulder dystocia
previous PPH
prolonged labour
```
110
what is a massive PPH defined as?
blood loss more than 1500mls
111
what can be used to reduce risk of PPH?
the use of oxytocin in the third stage of labour
| or ergometrine
112
how is PPH managed?
suppor and restoration of blood volume and treatment of any developing coagulopathy and cessation of blood loss.
to treat coagulopathy - FFP should be given and cryoprecipitate may be requires
if uterine atony persists prostaglandins is injected into the myometrium
113
what are the risk factors for maternal sepsis?
Obesity
Diabetes
Impaired immunity/ immunosuppressant medication
Anaemia
Vaginal discharge
History of pelvic infection
History of group B Strep infection
Amniocentesis and other invasive procedures
Cervical cerclage
Prolonged spontaneous rupture of membranes
Group A Strep infection in close contacts / family members
114
what are signs and symptoms of maternal sepsis?
```
Pyrexia
Hypothermia
Tachycardia
Tachypnoea
Hypoxia
Hypotension
Oliguria
Impaired consciousness
Failure to respond to treatment
```
115
how should you treat maternal sepsis?
```
First hour SEPSIS SIX BUNDLE
1) O2 as required to achieve SpO2 over 94%
2) Take blood cultures
3) Commence IV antibiotics
4) Commence IV fluid resuscitation
5) Take blood for Hb, lactate (+glucose)
6) Measure hourly urine output
Ongoing multidisciplinary care: obstetrician, anaesthetist, critical care, microbiologist, etc
```
116
what is the dosage of magnesium sulphate given to women eclampsia?
IV MgSo4 4gms given over 5 minutes, followed by an infusion of 1 g/hour maintained for 24 hours
117
what is cord prolapse?
Cord prolapse involves the umbilical cord descending ahead of the presenting part of the fetus.
118
what happens if a cord prolapse is left untreated?
the cord will become compressed or go into spasm and the baby will become hypoxic which can eventually cause irreversible damage or death
119
what are the risk factors for cord prolapse?
```
premature labour
multi-parity
polyhydramnios
twin pregnancy
cephalopelvic disproportion
abnormal lie - breech, transverse lie
placenta praevia
long umbilical cord
```
the majority of cord prolapses occur at artificial rupture of the membranes
120
how is a cord prolapse managed?
initially the presenting part must be prevented from compressing the cord - it is pushed up by the examining finger. Tocolytics such as terbutaline may be given.
if the cord is past the level of the introitus, it should be kept warm and moist but should not be pushed back inside.
the patients is then asked to go on all fours, whilst preparing for an immediate c-section - if the head is low and the cervix is dilated then an instrumental delivery may be performed
prom treatment means that fetal mortality is rare
121
what is shoulder dystocia?
Shoulder dystocia is a complication of vaginal cephalic delivery. It entails inability to deliver the body of the fetus using gentle traction, the head having already been delivered
122
what are complications of shoulder dystocia?
Erbs palsy ( paralysis of the arm caused by injury to the upper group of the arm's main nerves, specifically the severing of the upper trunk C5–C6 nerves)
it can cause both maternal and fetal morbidity
it is associated with postpartum haemorrhage and perineal tears
123
what are the risk factors for shoulder dystocia ?
```
fetal macrosomia
high maternal body mass index
DM
prolonged labour
previous shoulder dystocia
```
124
what manoeuvre should be performed to relieve shoulder dystocia?
McRoberts' manoeuvre
125
why is an episostomy used sometimes in should dystocia?
An episiotomy will not relieve the bony obstruction but is sometimes used to allow better access for internal manoeuvres. Symphysiotomy and the Zavanelli manoeuvre can cause significant maternal morbidity and are not first-line options
126
what are the chances of twins being pre-term
50%
127
what are the different types of twins?
dizygotic
| monozygotic
128
what are dizygotic twins and what increase chance of them?
- Fertilisation of two eggs by two different sperm
- Two babies with a different genetic makeup
- Women with dizygotic twins have ↑ FSH and LH
- Multiple ovulation due to increased FSH
- fertility drugs
- dietary (Yoruba tribe Nigeria - they eat food rich in FSH)
- assisted conception techniques
129
what are monozygotic twins?
```
20% of twins; worldwide 3.5/1000 births
Fertilisation of one egg by one sperm
Same sex and genetically identical
Occur due to oxygen lack as a result of delayed implantation
Unrelated to hereditary factors
```
130
what is the relationship between zygosity and chorionicity?
Zygosity refers to whether twins are monozygotic (identical) or dizygotic (non- identical)
Chorionicity refers to placentation: monochorionic (one placenta) dichorionic (two placentas)
131
what time of devisions lead to which types of twins ?
<4 days - dichorionic diamniotic
4-8 days - monochrorionic diamniotic
8-13 days monochorionic monamniotic
>13 days - conjoined twins
132
what are the risk of perinatal mortality associated with twins?
Perinatal mortality for twins 6 times increased above that for singletons
perinatal mortality for monochorionic twins further increases 3-4 times above DC twins
primarily due to twin to twin transfusion syndrome
Early diagnosis and surveillance will increase potential for treatment intervention.
133
what are the risks of twins?
```
miscarriage
perinatal death
UUGR
Preterm delivery <32 weeks
major defects
```
134
what are complications associated with inter-twin vascular anastomoses
```
Twin to twin transfusion syndrome
TAPS – Twin anaemia/polycythaemia
sequence
Selective fetal growth restriction (sFGR)
TRAP – Twin reversed arterial perfusion
```
135
what is twin to twin transfusion syndrome?
5% MCDA twins (1 in 1600)
Placental vascular anastomoses which allow communication of the two feto-placental circulations in 96%
Superficial anastomoses: AAA 66% and VVA 20%
Deep anastomoses AVA 90% - cotyledon receives blood
from one twin and drains venous blood to the other
Presence of AVA and absence of AAA lead to TTTS
136
what is TAPS?
- marked haemoglobin differences between MC twins
137
what is twin reversed arterial perfusion sequence? (TRAP)
• 1% of MC twins
• Lack of cardiac structure in
one fetus (a cardiac twin)
• Perfused by structurally normal co-twin (pump twin)
• Single superficial artery- artery anastomosis through which arterial blood flows in a retrograde manner
138
what are the maternal complications of multiple pregnancies?
all obstetric risks are exaggerated
GDM and Pre-eclampsia are more frequent
anaemia is common
139
what are the fetal complications of multiple pregnancy?
greater mortality and long term handicap risk
preterm delivery
IUGR
miscarriage
140
what are the complications of monochorionicity?
Twin to twin transfusion syndrome (TTTS)
Twin anaemia polycthaemia sequence (TAPS_
Twins reversed arterial perfusion (TRAP)
IUGR
141
what are the intrapartum complications of twin pregnancy??
malpresentation
fetal distress is more common
PPH is more common
142
how is twin pregnancy managed?
the pregnancy should be considered high risk - care should be consultant led
Iron and folic acid supplementation
low dose aspirin should prescribed to prevent pre-eclampsia
Early USS (Tsign or lambda sign) - screening for chromosomal abnormalities is offered as usual
identification of risk of prterm
identification of IUGR
timing of delivery: 37 weeks
143
what are the signs on USS of twins?
```
monochorionic:
T sign
single placental mass
very thin dividing membrane
composed of two amniotic layers
```
dichorionic:
ambda sign
Optimal gestation 10 -14 weeks
Difficult to see with advanced gestation
Disappears by 20 weeks in 7% of DC twins
144
how should monochorionic twins be managed?
USS surveillance from 12 weeks
| US every 2 weeks until 24 weeks and then every 2-3 weeks after that
145
how should twins be delivered?
C-section does not improve outcomes if the presenting twin is cephalic
Csection is indicated if the first fetus is breech or transverse lie
146
at what gestation should twins be delivered?
```
37 weeks (DC twins)
36 weeks (MC twins)
```
147
what increases risk of dizygotic twins?
```
previous twins
family history
increasing maternal age
multigravida
induced ovulation and in-vitro fertilisation
race e.g. Afro-Caribbean
```
148
what infections can cause miscarriage?
```
chlamydiosis ( transmission by inhalation - farm animals, can cause still birth or abortion)
Listeria monocytogenes (from animals or contaminated food, mild flu like symptoms, may cause abortion or premature birth)
```
149
what infections can affect the unborn child?
```
rubella
chicken pox
Parvo virus
CMV
Zika virus
Syphilis
Toxoplasmosis
```
150
when and what are the risk of CMV during pregnancy?
Primary CMV in first trimester risk of transplacental infection is about 40%
Of these 5-15% are symptomatic at birth. Multiple manifestations including microcephaly, other neurological abnormalities, growth restriction mental retardation.
Of these 20-30% will die and 80% survivors have serious disabilities.
Of those with no symptoms at birth 5-15% will go on to develop serious sequelae including hearing loss, visual impairment & pschyomotor delay.
By third trimester risk of transmission is higher but risk of fetal injury is very low.
Secondary infection in the mother - low risk to fetus
Most commonly acquired from own or other children eg child care workers
151
what problems can rubella cause if caught <13 weeks?
severe foetal damage in up to 90% of cases
Cataracts & other eye defects
Deafness
Cardiac anomalies
Microcephaly
Growth retardation
Inflammatory lesions of brain, liver, lungs, bone marrow.
152
what problems can occur if rubella is caught after 13 weeks?
mainly associated with hearing impairment
153
what is parvo virus B19?
what are problems of it during pregnancy?
slapped cheek
Droplet spread
Infects rapidly dividing cells
Characteristic rash in children
Adults often asymptomatic
50 – 60% adults immune
Diagnosis as with CMV following reported contact or when symptoms identified in the fetus on scan
Attacks red blood cells -> fetal anaemia
Infection in the first 20 weeks may result in miscarriage/ intrauterine death (9% risk)
OR hydrops fetalis (about 3%)
Not associated with fetal anomaly, but may rarely.
Consequences usually occur 3 – 5 weeks after maternal infection.
Intrauterine transfusion after 20 weeks
154
what problems can zika virus cause?
CNS abnormalities
155
what are the risks of chicken pox to mothers
Excess morbidity associated with infection in adults including pneumonia, hepatitis , encephalitis and occasionally mortality.
Up to 10% of pregnant women with C Pox will get pneumonia
Increased risk in later pregnancy, smokers, h/o chronic lung disease or immunosuppression
156
what are the risks of chickenpox to fetus?
Risk of anomally before 20 weeks.
Fetal Varicella Syndrome has been described where C. Pox has occurred between 3 and 28 weeks of pregnancy.
Risk is thought to be about 2% between 13 to 20 weeks gestation, probably only around 0.5 – 1 % in first trimester
Very rare after 20 weeks
Immunoglobulin for non-immune mother following contact
157
what are the risk of transmission of toxoplasmosis to fetus and what are the problems when it is transferred?
Half maternal infections transmitted to fetus. Risk of transmission greatest in late pregnancy but minimal risk to fetus. Risk of severe consequences greatest in early pregnancy.
Chorioretinitis, intracranial calcifications hydrocephalus
90% asymptomatic at birth. May go on to develop symptoms later in life
Treat mother (antibiotics) reduce risk of infection in fetus
158
what is syphilis
| what are the risks of transmission and risk to fetus?
Sexually transmitted – spirochete -treponema pallidum
Primary lesion
Secondary – rash systemic infection
Latent phase
Congenital syphilis results from untreated syphilis in pregnancy.
Risk of transmission declines as maternal infection progresses. 10% in late latent syphilis (>2yrs ); ~100% if primary.
Late miscarriage, hydrops, low birth weight. Untreated can result in physical and neurological impairment.
All women offered screening at booking in each pregnancy
Treated with penicillin
Baby followed up and screened for infection.
159
how can HIV be transmitted and what interventions can be performed to reduce risk of transmission
HIV can be transmitted to fetus during pregnancy; greatest risk in third trimester
Also transmitted at delivery and through breast feeding
Rate of transmission 15-20% without breast feeding
Risk increases by about 14% with breast feeding
Risk of transmission closely associated with maternal viral load
Reducing the viral load (VL) in the mother
Minimising the contact with maternal body fluids at birth (no invasive procedures, occasionally caesarian section (high VL)
Treating baby prophylactically
Avoiding breast feeding – but an option with ART & regular testing
can reduce the risk to less than 1%
all woman are offered screening
160
what is the leading cause of serious neonatal infection?
group B streptococcus
| fetus usually infected during labour after rupture of membranes
161
what are risks of group B Streptococcus?
can result in sepsis, pneumonia and meningitis
1 in 19 cases will be fatal
1 in 14 leads to long term disability?
162
what can be offered to mothers colonised with group B strept
- intrapartum intravenous antibiotics can be offered, usually penicillin. This has been shown to significantly reduce the risk of early onset disease in the new-born, but not late onset disease (occurring after 7 days of age)
163
what are the baby blues?
Typically seen 3-7 days following birth and is more common in primips.
Mothers are characteristically anxious, tearful and irritable.
164
how are the baby blue managed?
Reassurance and support, the health visitor has a key role.
165
what is post-natal depression?
Most cases start within a month and typically peaks at 3 months.
Features are similar to depression seen in other circumstances.
166
how is post-natal depression managed?
As with the baby blues reassurance and support are important.
CBT. SSRIs such as sertraline and paroxetine, only if sx are severe.
167
what is puerperal psychosis?
Onset usually within the first 2-3 weeks following birth.
Features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations).
168
how is puerperal psychosis managed?
Admit to hospital.
20% risk of recurrence.
169
what is an incomplete uterine rupture?
Surgical scar separating but the visceral peritoneum staying intact. It is usually asymptomatic and does not require emergency surgery.
170
what are the two types of complete uterine rupture?
traumatic - Incorrect use of oxytocic agent
Poorly conducted attempt at vaginal delivery
spontameous - Most pts have Hx of CS/ trauma that could have caused damage
Multiparity may lead to weakened uterus.
171
how would uterine rupture present?
uterine rupture is an important cause of abdo pain in late pregnancy and occasionally during labour
```
Maternal shock
Severe abdo pain
Vaginal bleeding to varying degree
Chest / shoulder tip pain and sudden SOB
CTG abnormalities
```
172
how is uterine rupture managed?
Urgent surgical delivery!
| Future pregnancies: if pt has had a prev uterine rupture, vaginal birth after caesarean (VBAC) is CI’d.
173
what is an amniotic fluid embolization?
When fetal cells/ amniotic fluid enters the mother’s bloodstream → stimulates a massive immune reaction. Aetiology not understood.
174
what are the phases of amniotic fluid embolisaiton?>
1. Pulmonary embolism → direct blockage, anaphylactic reaction → hypoxia and acute RDS
2. Hemorrhagic phase → activation of complement pathways → DIC. this is often fatal.
175
how would amniotic fluid embolisaiton present?
similar to PE or acute collapse
tachypnoea, tachycardira, hypotension, severe bleeding, cardiac arrest, SOB, palps, dizziness, confusion, seizures, cough, LOC
176
how would you manage amniotic fluid embolisaition?
ABCDE
Maintain O2: 100% supplemental O2 via mechanical ventilation
Maintain perfusion: fluid replacement, inotropic drugs
Correct coagulopathy: discuss w/ on-call haematologist. May need to give blood products
Delivery. Perimortem CS should be considered. It will improve fetal and maternal survival.
177
what are the three main causes of a retained placenta?
Uterine atony - most common
Trapped placenta - placenta detached but unable to deliver due to closed os
Placenta accreta/ percreta - more common w/ prev. CS.
178
what are the complications of retained placneta?
PPH (occurs 24hrs - 12 wks after birth)
Genital tract infection
Uterine inversion → emergency as can cause acute neurogenic shock, w/ profound bradycardia and hypotension.
179
how would you manage retained placenta?
Call for help
Assess blood loss
Administer IM syntocinon - increases uterine tone and may help with delivery.
Ensure bladder empty (full bladder can contribute to retention).
Manual removal of the placenta in theatre
180
what is the antibiotic of choice for GBS prophylaxis in pregnancy?
benzylpenicillin
it should be offered to women in preterm labour
also in prolonged rupture of membranes
pyrexia in labour
