Obstetrics Flashcards
Amniocentesis
Performed after 15 weeks
10 - 15ml of fluid
Risk of miscarriage 1% , 1: 56 in twin
Risk of severe sepsis < 1: 1000
Failure to obtain fluid
Maternal bowel injury
Fetal injury
Continued amniotic fluid leakage
Inadequate / uninterpretable results
ANTI-D
ANTI - DEPRESSANTS
a definite association between SSRI use and fetal malformation has not been confirmed.
There may be a small increase in the absolute risk of cardiovascular malformations.
Persistent pulmonary hypertension has been found to be more likely to affect newborns exposed to SSRIs after 20 weeks of gestation. Absolute risk is low (0.2–1.2% with SSRI exposure compared with 0.1–0.2%).
Transient neonatal withdrawal syndrome can affect infants exposed to SSRIs.
Her plans regarding breastfeeding.
Using medication in conjunction with a high-intensity psychological intervention (for example CBT).
Switching to a high-intensity psychological intervention (for example CBT) if she decides to stop taking medication.
Infants exposed to SSRIs via milk should be monitored for sedation, poor feeding and behavioural effects.
TWINS
MCDA 2 weekly from 16 weeks
DCDA 4 weekly from 20 weeks
MCDA deliver from 36 weeks
DCDA deliver from 37 weeks
triplets from 35 weeks
- if elective birth declined then offer weekly appointments with USS biophysical profile and fornightly growth scans
HERPES
Primary episode before 28 weeks 5/7 Aciclovir 400mh TDS.
From 28 weeks daily treatment until delivery and offer LSCS. Risk of transmission is 41%.
If women opt for vaginal delivery avoid FSE / FBS / ARM / OVD
Recurrent 0-3% risk of transmission
Can offer augmentation to reduce potential exposure to HSV
HIV positive and history of HSV offer acicolvir from 32 weeks to reduce the risk of transmission
Can recommend BF unless ulcers around nipples
HYPERTENSION
Aspirin 75mg / 150mg
- px hx HTN
- CKD
- SLE / APL
- DM 1 / II
- Chronic HTN
- First preg
- > 40 years
- Preg interval >10 years
- BMI > 35
- FH
- Multiple pregnancy
Growth scans in chronic HTN
Recurrence
- Pre-eclampsia 1: 6
- If severe 1 : 4 birth <34, 1: 2 birth <28
Haemophillia
X-linked
VIII - Haemophillia A
IX - Haemophillia B
XI deficiency - not X linked
Carriers are at increased bleeding risk with invasive proceedures / TOP / Misc / Delivery
Levels should be checked prior to proceedures
Factor VIII increases in pregnancy, IX no change.
Elligable for pre-implantation diagnosis
FFDNA analysis from 9 weeks
Offered CVS
3rd trimester amnio if not previously completed for male fetus to inform birth choices.
TXA
DDVAP
Recombinant factor VIII / XI
Offer LSCS if known affected male / severe haemophillia / unknown status.
Generally avoid invasive monitoring
EPILEPSY
30% increased sezure frequency
fewer the seziures in the 12 months prior to pregnancy lower likihood of increased seizures
Highest risk is peri-partum 1-2% in the 24 hours from delivery
Status - Lorazepam 0.1 mg/kg IV, diazepam 5-10mg IV,
Normal risk of congenital malformation (2-3%) if not on AEDs
AEDs increase risk 4-10%, Polytherapy 16.8%
5mg folic acid pre-conception and until 12 weeks
Serial scans for SGA
IUS / IUD FOR CONTRACEPTION
Encourage BF
AEDS
Sodium Valporate - NTDs, cognitive impairment, developmental delay. 10%
Lamotrigine and Carbamazepine least risk of malformation.
Lamotrigene levels can drop during pregnancy
ECV
Breech 3-4% of term babies
Recurrence 10%
Spontaneous version in primips 8% after 36 weeks
3% will revert back to breech after successful ECV
PRIMIP after 36 weeks, MULTIP after 37 higher chance of spontaneous version
Risk of Em.LSCS 0.5% - secondary to PVB
Anti-D and Kleihauer
Moxybustion between 33-35 weeks
DIABETES
Fasting BM 5-7 on waking , 4-7 before meals
Monthly HbA1c for preconception < 48 , >86 avoid pregnancy
Renal assessment for pre-conception.
Retinal assessment
Diagnose if
fasting BM >5.6 or 2 hour OGTT > 7.8
Pregnant women should
- fasting 5.3
- post meals < 7.8
Offer metformin if not meeting targets in 1-2 weeks with diet and exercise.
Clinic 1-2 weekly
Early GTT if previous GDM
Postnatal Fasting BM 6-13 weeks / > 13 weeks fasting bm or HbA1c
Annual HbA1c to all women with GDM
CHICKENPOX
Incubation period is 1-3 weeks.
Infectious 48 hours before the rash until crusted over
Live attenuated given in 2 doses 4-8 weeks apart, 4 weeks post-natal suitable in BF
Non-immune and exposed in pregnancy then VZIG can be offered up to 10 days post-exposure.
onset of rash give aciclovir 800mg TDS 7/7
Aim delivery 7 days from onset of rash to delivery
If delivery 1-4 weeks post infection up to 50% babies are infected and 23% develop clinical varicella.
If babies born to mothers with chickenpox 7 days pre / post delivery babies should be treated with VZIG prophylaxis with VZIG +/- ACICOLOVIR
Referred to FMU at 16-20 weeks / 5 weeks post infection
Can BF, if there are lesions over the nipple then can express until crusted over, EBM can be given to babies recieving tx with VZIG / Acicovir
VWD
Type 1 + 2 - autosomal dominant
Type 3 - autosomal recessive
In type 1 levels will rise during pregnancy and usually normalise by term
Pre-conception
- type of vWD and is responds to DDAVP
- genetic couselling
- pre-natal diagnosis (type 3)
- pregnancy implications
ANC
- joint with haematology
- VW screen in 1st / 3rd trimester
- anaesthetic assessment
- haemostatic correction before invasive testing
- APH, PPH and secondary PPH
- Likely to be iron deficient due to HMB
- Vaccination to hep A / B
Intrapartum
- TXA
- Avoid intervention in pregnancy
Postpartum
- Levels should be maintained 3 days post VD, 5 post LSCS
- TXA
- LMWH if VWF / VIII levels corrected
- COCP helps to reduce bleeding and increase VWF
Baby tested after 6 months
THYROID
Hypothyroid - only first trimester control affects fetal wellbeing.
with maternal iodine deficiency cretinism
Autoimmune thyrotoxicosis / Graves affects 2/1000
Can use beta blockers to control symptoms - control of symptoms outweighs risk of FGR.
Carbimazole / propylthiouracil both can cause agranulocytosis. PTU less likely to cross placenta.
Women with Graves disease or history of should have their antibodies tested and if positive look for signs of fetal thyrotoxicosis.
SICKLE CELL
- effect of cold / hypoxia / stress in sickle cell crisis
- anaemia may worsen increase crisis / ACS
- FGR
- Inheritance
- ECHO Pul hypertension
- Check for iron loading / need for chelation
- preimplantation testing
- partner screening
- Penicillin daily and Pneumocus + H. Influenzae vaccination.
- Folic acid
Hydroxycarbamide should be stopped 3/12 preconception
Growth scans
OBESITY
Higher risk of miscarriage / VTE / IOL / Labour dysfunction / PPH / GDM / LSCS.
Increased risk of still birth / prematurity / macrosomia / neonatal death / metabolic disorders
Weight loss between pregnancies reduces SB / PIH /PET
Increases success of VBAC
ANC
- folic acid 5mg 12/40
- Vit D
- Dietician
- If RF for PET 150mg aspirin from 12/40 - TERM
