Obstetrics Flashcards
Congenital Rubella Syndeome
When at risk?
Features (9)
Risk
in first 8-10 weeks risk of damage to fetus is as high as 90%
damage is rare after 16 weeks
sensorineural deafness congenital cataracts congenital heart disease (e.g. patent ductus arteriosus) growth retardation hepatosplenomegaly purpuric skin lesions 'salt and pepper' chorioretinitis microphthalmia cerebral palsy
Management of Rubella exposure in pregnancy (4)
suspected cases of rubella in pregnancy should be discussed with the local Health Protection Unit
if a woman is however tested at any point and no immunity is demonstrated they should be advised to keep away from people who might have rubella
non-immune mothers should be offered the MMR vaccination in the post-natal period
MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant
Hypertension in pregnancy - causes (3)
Pre-existing hypertension - A history of hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation
Pregnancy-induced hypertension - hypertension occurring after 20 weeks of pregnancy. no proteinuria or oedema. increased risk of pre-eclampsia in future pregnancies.
Pre-eclampsia - hypertension with proteinuria at 20 weeks of pregnancy or later.
Types of breech presentation
Frank breech - most common, hips flexed and knees fully extended.
Footling breech - one or both feet come first with the bottom at a higher position, rare but higher perinatal morbidity
Risk factors for breech presentation (5)
uterine malformations, fibroids
placenta praevia
polyhydramnios or oligohydramnios
fetal abnormality (e.g. CNS malformation, chromosomal disorders)
prematurity (due to increased incidence earlier in gestation)
Mx of Breech presentation
if still breech at 36 weeks = external cephalic version (ECV) at 36 weeks in nulliparous women and from 37 weeks in multiparous women
if the baby is still breech then delivery options include planned caesarean section or vaginal delivery
contraindications to ECV (6)
where caesarean delivery is required antepartum haemorrhage within the last 7 days abnormal cardiotocography major uterine anomaly ruptured membranes multiple pregnancy
Suppressing lactation
stop the lactation reflex i.e. stop suckling/expressing
supportive measures: well-supported bra and analgesia
cabergoline is the medication of choice if required
Management of HIV in pregnancy
All mothers:
- ARVT, advise against breastfeeding.
Viral load less than 50:
- vaginal delivery
- treat infant with zidovudine for 4 to 6 weeks
Viral load over 50
- C-section with zidovudine infusion prior
- treat infant with ARVT for 4 to 6 weeks
Resus negative women Mx
anti-D at 28 + 34 weeks
What is HELPP Syndrome?
A severe form of pre-eclampsia whose features include: Haemolysis (H)
Elevated liver enzymes (EL)
Low platelets (LP). Present with malaise, nausea, vomiting, and headache. Hypertension with proteinuria is a common finding, as well as epigastric and/or upper abdominal pain.
Shoulder dystocia manoueveures and Mx
1: McRoberts position - hyperflex the mother’s legs onto her abdomen and apply suprapubic pressure
2: Rubin manoeuvre - press on the fetal posterior shoulder
3: Woodscrew manoeuvre - putting a hand in the vagina and rotating the foetus 180 degrees
repeat these manoeuvres with the mother on all-fours
failing this, push the head back in and emergency c-section
What is Sheehan’s syndrome?
Sheehan’s syndrome is a complication of severe postpartum haemorrhage (PPH) in which the pituitary gland undergoes ischaemic necrosis which can manifest as hypopituitarism. The most common physical sign of Sheehan’s syndrome is a lack of postpartum milk production and amenorrhoea following delivery.
What is cord prolapse
umbilical cord descending ahead of the presenting part of the fetus
Mx of cord prolapse
The presenting part of the fetus may be pushed back into the uterus to avoid compression.
Tocolytics may be used.
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 patient is asked to go on ‘all fours’ until preparations for an immediate caesarian section have been carried out.
VTE Risk factors in pregnancy
Age > 35 Body mass index > 30 Parity > 3 Smoker Gross varicose veins Current pre-eclampsia Immobility Family history of unprovoked VTE Low risk thrombophilia Multiple pregnancy IVF pregnancy
VTE prophylaxis in pregnancy
Four or more risk factors warrants immediate treatment with low molecular weight heparin continued until six weeks postnatal. If a woman has three risk factors low molecular weight heparin should be initiated from 28 weeks and continued until six weeks postnatal.
VTE Mx in pregnancy
LMWH
In women with extremes of body weight or complicating factors e.g. renal impairment monitor anti-Xa activity
Drugs to avoid during breast feeding
antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides psychiatric drugs: lithium, benzodiazepines aspirin carbimazole methotrexate sulfonylureas cytotoxic drugs amiodarone
Mx of PPROM
- admission
- regular observations to ensure chorioamnionitis is not developing
- oral erythromycin should be given for 10 days
- antenatal corticosteroids to reduce the risk of respiratory distress syndrome
- delivery should be considered from 34 weeks of gestation
Presentation of amniotic fluid embolisation
majority occur in labour , though they can occur in caesarean section and after delivery in the immediate postpartum.
Sudden deterioration
Symptoms include: chills, shivering, sweating, anxiety and coughing.
Signs include: cyanosis, hypotension, bronchospasms, tachycardia. arrhythmia and myocardial infarction.
Mx of Amniotic fluid embolisation
Critical care unit by a multidisciplinary team, management is predominantly supportive
tool for assessing PND
Edinburgh Postnatal Depression Scale
Mx of chicken-pox exposure in pregnancy
check immunity with Varicellar Zoster Antibody
if not immune give VZ immunoglobulin
Stages of post-partum thyroiditis
Three stages
- Thyrotoxicosis
- Hypothyroidism
- Normal thyroid function (but high recurrence rate in future pregnancies)
Mx of post-partum thyroiditis
the thyrotoxic phase is not usually treated with anti-thyroid drugs but Propranolol is typically used for symptom control
the hypothyroid phase is usually treated with thyroxine
Antenatal Care timetable
8-12 - booking visit and bloods 10-13+6 - early scan - confirm dates, exclude multiple pregnancies, nuchal scan if past 11 weeks 18-20+6 - anomaly scan 25 primip routine care 28 routine care +anti D 31 routine care 34 routine care +anti D 38 routine care 40 primip/ 41 if not routine care and discuss options for prolonged pregnancy
Mx of Eclampsia
magnesium sulphate first-line
What is Lochia?
When and how to investigate?
Lochia is the passage of blood, mucus and uterine tissue that occurs during the puerperium*. This should be expected to cease after 4-6 weeks.
Continued vaginal discharge beyond this time is an indication for ultrasound to investigate the possibility of retained products of conception.
