Obstetrics - General Flashcards

Question

Vasa praevia complications, prognosis and ddx

Answer 1

Complications • No major maternal risk but dangerous for the foetus o Foetus – loss of relatively small amounts of blood can have major implications for the foetus = rapid delivery + aggressive resuscitation incl. use of blood transfusion if required Prognosis • Foetal mortality if presenting with haemorrhage is 60% but if identified antenatally it’s 3% DDx • Placental abruption o Will present with pain o It is maternal blood, therefore mum is in danger

Answer 2

the haemorrhage of blood when the vessels n vasa previa are ruptured

Answer 3

``` Complications • Foetal o Fetal anaemia, fetal compromise o Fetus exposed to severe hypoxia and acidaemia o Abnormalities of the fetal HR pattern  If fetal heart rate cannot be heard on auscultation, then USS should be performed to exclude IUD o Birth asphyxia o IUD ``` ``` • Maternal o Coagulopathy o DIC o Hypovolaemic shock o Renal failure o Catastrophic haemorrhage associated with postpartum DIC o Haemorrhage (APH, PPH) ``` • Labour – blood transfusion Prognosis • Maternal – 0.5% mortality in severe abruption • Foetal – 3.3% mortality in severe abruption

Answer 4

DDx • Labour o Placental abruption should be considered when the pain is continuous o Labour should be considered if the pain is intermittent • Placenta praevia o In placenta praevia the uterus is soft + non-tender, bleeding + no pain o In placental abruption the uterus is tense (woody) + tender, bleeding + pain

Answer 5

• The premature separation of a normally placed placenta before delivery of the fetus with blood collecting between the placenta and the uterus before delivery (>24 weeks) o If <24 weeks – miscarriage * As placenta separates, retroperitoneal bleeding results in further detachment * One of the most important causes of antepartum haemorrhage (APH) (the other being placenta praevia) Concealed (20% of cases) – haemorrhage is confined within the uterine cavity and is the more severe form. The amount of blood lost is easily underestimated Revealed (80)% - where blood drains through the cervix, usually with incomplete placental detachment and fewer associated problems Marginal haemorrhage – painless bleed and clot located along the margin of the placenta with no distortion of its shape. It is usually due to the rupture of a marginal sinus. Women should be admitted for observation and fetal monitoring

Answer 6

• 70% occur in low-risk pregnancy Maternal • Previous abruption – the most predictive RF • Previous C-section • Intrauterine infections • Pre-eclampsia • Hypertension • Thrombophilia e.g. FV leiden • Advanced maternal age, low BMI • Trauma – road traffic accident, domestic violence, iatrogenic (e.g. ECV) • Smoking, cocaine or amphetamine use during pregnancy [MCQ] • Pregnancy following assisted reproductive techniques, PPROM Fetal • Non-vertex presentations • Threatened miscarriage earlier in current pregnancy, fetal growth restriction • Multiple pregnancy, Multiparity, polyhydramnios,

Answer 7

o The causes of APH include:  Placenta praevia  Placental abruption  Local causes e.g. bleeding form the vulva, vagina, cervix

Answer 8

Following APH from placental abruption or unexplained APH Pregnancy should be classified as “high risk” and antenatal care should be consultant led Serial USS for fetal growth should be performed

Answer 9

* Epilepsy * Eclampsia * Encephalitis or meningitis * Cerebral malaria or toxoplasmosis * CVA * TTP * SOL * Toxic overdose * Drug/alcohol withdrawal * Metabolic abnormalities (e.g. hypoglycaemia)

Answer 10

o Prenatal screening + its implications o Risks of self-discontinuation of AEDs – stress importance of compliance with medication o Effects of seizures + AEDs on the fetus + on pregnancy, breastfeeding and contraception o Explain risk of congenital malformations o Explain risk from recurrent seizures o Explain importance of pre-conceptional + antenatal folic acid 5mg • Although they are likely to have healthy pregnancies, their risk of complications during pregnancy + labour is higher than for women + girls without epilepsy

Answer 11

Generalised tonic clonic seizure o Fetus at relatively higher risk of harm o Level of risk may depend on seizure frequency o Miscarriage o Trauma related to falls o Fetal hypoxia and acidosis * Status epilepticus  High mortality rate for mother + fetus * Focal, absence, myoclonic seizures  no evidence that they affect the pregnancy or developing fetus adversely unless the mother falls and sustains an injury

Answer 12

``` o Hyperemesis gravidarum o Gestational hypertension o Mild pre-eclampsia o Vaginal bleeding o Anaemia ```

Answer 13

o Premature labour o Failure to progress o Increased rate of caesarean sections o Generalised seizures occurring during labour  fetal bradycardia

Answer 14

• Increased risk of seizures in children of parents with epilepsy but the probability that the child will be affected is generally low – this will also depend on the family history

Answer 15

o 3-4% risk of developing congenital defects o 1-2% in non-epileptic mothers * most mothers have normal healthy babies + the risk of congenital malformations is low if they are not exposed to AEDs in the periconception period * Increased risk of congenital abnormality caused by AEDs (2-3x increase) • The likelihood of a woman who is taking AEDs having a baby with no malformations  90%

Answer 16

o Especially if used during the first trimester | o Especially if the patient takes two or more AEDs

Answer 17

o Neural tube defects o Facial clefts o Cardiac defects o Other abnormalities – developmental delay, nail hypoplasia, IUGR, midface abnormalities can often be detected in anomaly scans

Answer 18

o Associated with the highest risk of major + minor congenital malformations o In particular neural tube defects o Long-term neurodevelopmental effects o Associated with an increased likelihood of difficulty with adaptive functioning o Associated with ADHD

Answer 19

``` o Phenytoin o Primidone o Phenobarbital o Lamotrigine o Carbamazepine ``` o In utero exposure to carbamazepine + lamotrigine  does not appear to adversely affect neurodevelopment of the offspring o Levetiracetam + phenytoin  limited evidence • Topiramate increased risk of cleft palate if taken in the first trimester

Answer 20

* Children exposed to valproate have more distinctive facial features * Bustle + distinctive facial phenotype is also seen in children exposed to carbamazepine * Tall/broad forehead * Trigonocephaly – premature fusion of the metopic suture, leading to a triangular-shaped forehead * Medial deficiency of eyebrows * Infraorbital grooves * Epicanthic folds * Broad nasal bridge * Anteverted nose * Abnormal philtrum * Thin upper lip * Everted lower lip * Micrognathia * Dysplastic ears * Hypoplastic digits * Arachnodactyly * Clinodactyly * Flat feet * Hypoplastic nails https://slidetodoc.com/presentation_image_h/35f5d23857fe74075ddf5ba8f697d9de/image-33.jpg

Answer 21

``` confirm dx fertility obtaining optimal seizure control risk of withdrawal from AEDs 9SUDEP, status epilepticus) drug regimen (withdrawal + substitution) folic acid supplementation 5mg per day teratogenic effect of AEDs effect of pregnancy on seizure control effect of epilepsy on fetus risk of child developing epilepsy ```

Answer 22

pain control during labour importance of taking medication into hospital post natal exhaustion and seizure frequency BF + AEDs looking after the child

Answer 23

o Presence of significant levels of bacteria (>10^5 colony forming units/ml) in the urine in a person without signs or symptoms

Answer 24

RF for pyelonephritis, premature delivery, LBW Screening takes place <10w MC+S

Answer 25

o Infection can progress upward  acute urethritis, acute cystitis, acute pyelonephritis o Adverse pregnancy outcomes if woman ends up developing kidney infection  LBW, preterm labour o Pyelonephritis (up to 45% of pregnant women with untreated asymptomatic bacteriuria will develop pyelonephritis)

Answer 26

* Preterm labour * Severe infection * ARDS * Sepsis * Aneamia * Long-term infection

Answer 27

* Pregnancy increases thyroid hormone requirements * Required dose for levothyroxine may increase • Physiological changes during pregnancy – these reverse postnatally o Total T4 + T3 increase o Free T4 + T3 remain within the normal range o TSH doesn’t change o Usual for the thyroid gland to hypertrophy in normal pregnancy o Increased thyroid gland vascularity o Increase in TBG + albumin due to increased hepatic synthesis o Thyroid gland will need to produce 50% more thyroid hormone during pregnancy to maintain a euthyroid state o Free T4 will then fall with advancing gestation

Answer 28

• Associated with hyperemesis gravidarum • Can arise from high levels of hcg which stimulate the TSH receptor  resolves as hCG falls o May occur in molar pregnancy • Patients are not usually thyrotoxic – antithyroid drugs don’t help

Answer 29

Can cross the placenta – if current or previous hx of Graves’ disease  Can cause temporary hyperthyroidism in the baby during pregnancy and after birth  This is treatable – can be treated during pregnancy and after birth  This blood test can help predict whether the baby will be affected in this way  Normal values <130% (by measuring thyroid-stimulating immunoglobulins) of basal activity  If levels of antibodies are high baby to be reviewed by neonatology team  monitor baby closely (seral ultrasonography)  Re-measure TRAb in the third trimester • If TRAb remains high at 36 w  neonate needs to have TFTs performed at birth + then repeated a few days later  Associated with an  risk of fetal/neonatal morbidity + mortality if it is unrecognised and untreated incidence of fetal/neonatal hyperthyrodisim is 1-5% in all women with active/PMHx of Grave’s hyperthyroidis)

Answer 30

• Abnormal TSH level within the first 12 months post-partum in the absence of a toxic thyroid nodule or thyroxin receptor antibodies * Temporary inflammatory thyroid disorder * Occurs following 5-10% of pregnancies * ESR is normal * Women with T1DM + women with thyroglobulin or thyroid peroxidase autoantibodies are at higher risk of these conditions * Usually shows up in the mother within 6-12 months after birth • Diagnosed based on 3 criteria o Patient is <12 months after giving birth o Clinical manifestations suggestive of hypothyroidism o TFTs alone – no need to measure TPO antibodies • Three stages – thyrotoxicosis  hypothyroidism  euthyroid

Answer 31

``` Hypothyroidism complications o  risk of 2nd trimester miscarriage o Foetal hypocalcaemia o Neonatal rickets o Management – vitamin D, oral calcium supplements, regular monitoring of calcium + albumin ``` • Overt hypothyroidism  increased risk of infertility + subfertility • Must be avoided during pregnancy to avert adverse effects on the fetus o Suboptimal replacement is associated with developmental delay + pregnancy loss * Corrected hypothyroidism has no influence on pregnancy outcome or complications * Main complication of levothyroxine treatment  over-replacement of thyroid hormone  increased risk of osteoporosis and AF ``` • Sub-clinical hypothyroidism or the presence of thyroid antibodies   risk of complications in pregnancy o PET o Gestational HTN o LBW o GDM o Pre-term delivery o Perinatal mortality o Recurrent miscarriage o Fetal neurological maldevelopment ``` • Presence of TPO (thyroid peroxidase) antibodies – indicate a degree of thyroid autoimmunity - increased risk of having a miscarriage/gestational thyroid dysfunction/predisposition to PPT

Answer 32

• Antithyroid drugs o Slight increased risk of baby having developmental abnormalities  some patients choose to have definitive treatment for Graves’ disease with radioactive iodine or surgery to allow them to have a pregnancy without needing to take antithyroid drugs o High dose  underactive thyroid in baby  goitre o Do not stop taking antithyroid drugs before speaking to a doctor  greater risk to the pregnancy from an untreated overactive thyroid gland than from taking antithyroid medication

Answer 33

* Negative impact of mild maternal thyrotoxicosis on the IQ of the offspring * Relapse rate after a full course of therapy = 50-70% * It is possible to discontinue treatment with antithyroid drugs in 20-30% of women in the last trimester of pregnancy * Small risk of birth defects if carbimazole is taken in pregnancy * Increased risk of miscarriage in the early stages if your hypothyroidism is not under control

Answer 34

``` • Untreated overt hypothyroidism in pregnancy Maternal o Miscarriage o Anaemia o PET o Placental abruption o PPH o Congestive HF o Megacolon o Adrenal crisis o Organic psychosis o Myxoedema coma o Hyponatremia due to SIADH ``` ``` Fetal o Stillbirth o Adverse neonatal outcomes  Preterm delivery  LBW  Neonatal respiratory distress  Congenital abnormalities  Congenital hypothyroidism  Impaired fetal neurocognitive development ```

Answer 35

``` o Miscarriage o Pregnancy-induced HTN o PET o Maternal heart failure o Thyroid storm o Preterm delivery o IUGR o LBW o Fetal death o Fetal goitre o Fetal hydrops and heart failure o Fetal or neonatal thyrotoxicosis  In women with Grave’s disease  May occur as a result of TRAbs (thyroid-stimulating hormone receptor antibodies) crossing the placenta + stimulating the fetal thyroid  Incidence of fetal/neonatal hyperthyroidism is 1-5% in all women with active/PMHx of Grave’s hyperthyroidism  Associated with an  risk of fetal/neonatal morbidity + mortality if it is unrecognised and untreated • Subclinical hyperthyroidism  GDM ```

Answer 36

• Fetal + neonatal hyperthyroidism o 1-5% in all women with active/PMHx of Grave’s hyperthyroidism o Associated with an  risk of fetal/neonatal morbidity + mortality if it is unrecognised and untreated • For women who have previously had Graves’ disease (but not had thyroid surgery or radioiodine)  may relapse at any stage but the risk rises after giving birth + remains high for up to a year • PPT -> 50% risk that you develop a recurrence of PPT in subsequent pregnancies

Answer 37

``` • Ejection systolic murmur o In 96% (more CO) o Can be normal in pregnancy esp. systolic murmur at the 2nd L ICS or along the sternal border which radiates. May occur at any stage in pregnancy + may come and go • 3rd heart sound o In 84% (more CO) • Forceful apex (more CO) • Peripheral oedema (more volume) ```

Answer 38

* New onset cardiomyopathy + HF * Can present one month before-five months after delivery * Viral myositis * RF – old age, greater parity, black race, multiple gestations

Answer 39

• Impaired flow of bile from the liver/ Flow is reduced or blocked – this causes a build-up of bile acids in the body can be due to a functional impairment of the hepatocytes in the secretion of bile and/or due to an obstruction at any level of the excretory pathway of the bile

Answer 40

* Past history of obstetric cholestasis – tends to recur in a more severe form in 45-90% of subsequent pregnancies * Family history of obstetric cholestasis e.g. mother * Multiple pregnancy * Pruritis on COCP * Ethnicity (south Asia, Chilean, Bolivian) * Presence of gallstones * Hepatitis C

Answer 41

* Increased incidence of premature birth * Increased likelihood of meconium passage, fetal distress, delivery by C-section, PPH * In a hospital setting, the current additional risk of stillbirth above that of the general population has not been determined but is likely to be small * IUD – intracranial haemorrhage

Answer 42

• Condition should settle spontaneously following delivery • Follow-up should be long enough to ensure normalisation of LFTs – reasonable to check LFTs at the 6 week PN check o If not improvement at 6 months – further specialist input is required • Significant risk of recurrence (45-90%) • Increased risk of adverse fetal outcome

Answer 43

• Pregnancy associated disorder characterised by fatty infiltration of the liver * Rare condition – prevalence 0.005-0.01% * Tends to occur late in pregnancy • May be associated with a mutant gene producing a defect in mitochondrial fatty acid oxidation o Infants born to mothers with AFLP should be screened for defects in this system

Answer 44

• Maternal o Life-threatening condition o Can progress to acute liver failure within 1-2 weeks o Haemorrhage, renal failure, hepatic encephalopathy, sepsis, pancreatitis • Fetal – death

Answer 45

Condition usually resolves after delivery with complete recovery o No reports of spontaneous remission of AFL prior to delivery of the infant • Maternal mortality 10-20% • Perinatal mortality (still birth + early neonatal death (death of a live newborn <7 days)) 20-30%

Answer 46

• Obstetric cholestasis o Obstetric cholestasis patients have pruritus • Pre-eclampsia (PET) o AST in acute fatty liver disease – mean elevation of 300 unis/L o AST in PET – 60 units/L • HELLP o AST in HELLP – 150 units/L

Answer 47

``` Acute fatty liver of pregnancy Hyperemesis gravidarum Acute viral hepatitis (most common cause of jaundice in pregnancy) cholelithiasis in pregnancy choric liver disease HELLP syndrome Autoimmune hepatitis ```

Answer 48

• All liver diseases occurring during pregnancy can lead to increased maternal and fetal morbidity and mortality

Answer 49

``` Maternal • DIC 5-56% • AKI 7-46% • Placental abruption 9-20% • Eclampsia 4-9% • Severe ascites 4-11% • Cerebral oedema 1-8% • Pulmonary oedema 3-10% • Death 1-25% ```

Answer 50

``` Fetal • Perinatal death – 7-34% • IUGR – 38-61% • Preterm delivery – 70% • Neonatal thrombocytopenia – 15-38% ```

Answer 51

• In pregnant women anaemia is defined as Hb <110 g/L throughout pregnancy o Hb <110g/L – adequate in the first trimester o Hb <105 g/L – adequate in the second and third trimesters o Hb <70g/L – urgent referral • Postpartum – anaemia is Hb <100g/L

Answer 52

``` • Iron deficiency anaemia accounts for the majority of cases of anaemia – low MCV o Nutritional deficiency, blood loss, decreased absorption, haemolysis, increased use, low iron stores resulting from previous pregnancy or previous heavy menstrual loss o Hypochromic microcytic anaemia, o Pencil cells • Less common causes of anaemia in pregnancy o Folic acid deficiency  Green leafy vegetables  Lack increases neural tube defects  Diet, demand, malabsorption, drugs  Megaloblastic anaemia • Macrocytosis • Hypersegmented neutrophils • Leucopaenia • Thrombocytopenia o Vitamin B deficiency  Vegans, poultry, dairy, eggs  Lack increases neural tube defects  Diet, malabsorption  Megaloblastic anaemia • Macrocytosis • Hypersegmented neutrophils • Leucopaenia • Thrombocytopenia o Sickle cell disease o Beta thalassaemia o Haemoglobin sickle-C (HbSC), hereditary spherocytosis (chronic haemolysis), leukaemia, paroxysmal nocturnal haemoglobinuria o GI bleeding, coeliac disease, parasitic diseases (e.g. hookworm, schistosomiasis) ```

Answer 53

• Haemoglobin in normal pregnancy o Physiological reduction in Hb concentration occurs which does not represent anaemia o Increased in red cell mass + plasma volume o Plasma volume increase > red cell mass increase  haemodilution  fall in HCT from 40% to 33% on average o This does not represent anaemia – Hb resulting from haemodilution is approx. 115 g/L o Slight increase in MCV (by approx.. 4 femtolitres) • Serum ferritin concentration in normal pregnancy o In women with adequate iron stores at conception, serum ferritin concentration initially rises followed by a progressive fall by 32 weeks to about 50% pre-pregnancy levels o This is due to haemodilution + mobilisation of iron o Levels increase again mildly in the third trimester • Requirements in pregnancy o Physiological requirements for iron in pregnancy are 3x higher than in non-pregnant menstruating women o Iron requirement increases as pregnancy advances

Answer 54

* Previous anaemia * Multiparity >P3 * Multiple pregnancy * Interpregnancy interval <1y * Poor dietary habits * Vegans/vegetarians * Teenagers * Recent history of clinically significant bleeding

Answer 55

 Spontaneous abortion – up to 25%  Perinatal mortality – 15% • Associated with preterm delivery + low birth weight (30% <2500g)  Stillbirth – 8-10% • Thorough antenatal fetal testing is required to assess growth, incl. US of the umbilical artery  Sickle cell crisis, stroke, PE  Frequent UTIs – common + require prompt treatment  Pregnancy associated hypertension

Answer 56

• Iron deficiency anaemia associated with o Increased risk of maternal morbidity and mortality o Increased risk of perinatal morbidity and mortality o Has important implications for the future neuro-development of the infant • Women with anaemia in pregnancy o Maternal death o Fetal death o Premature delivery o LBW o HF o Babies have subsequent developmental problems o Poor work/capacity performance o Susceptibility to infection

Answer 57

* Venous stasis * Maternal age >35 years * Multiparity * Gestation <36 weeks * Instrument-assisted or C-section * Haemorrhage * Pre-eclampsia * Prolonged labour

Answer 58

• Women with suspected PE should be advised that o V/Q scanning may carry a slightly increased childhood cancer o CTPA is associated with a higher risk of maternal breast cancer o Absolute risk of both is very small • Management with heparin o HIT – heparin induced thrombocytopenia  Usually happens 5 days – 2 weeks after the first dose of heparin  Can cause DVT or PE o Heparin allergy o Heparin induced osteoporosis

Answer 59

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Answer 60

* DVT – muscle strain, ruptured Baker’s cyst, cellulitis superficial thrombophlebitis, rupture plantaris tendon, trauma * PE – chest infection, intra-abdominal bleed (look for abdominal signs, shoulder tip pain from diaphragmatic irritation, low JVP)

Answer 61

Preterm prematre rupture of membranes • Rupture of membranes prior to the onset of labour <37 weeks

Answer 62

Premature rupture of membranes • Rupture of membranes occurring prior to the onset of labour >37 weeks (absence of any uterine activity)

Answer 63

• Smoking • Previous preterm delivery/PPROM • Multiple pregnancy/polyhydramnios • Vaginal bleeding – at any time during the pregnancy • Trauma • Uterine abnormalities/cervical incompetence • Lower genital tract infection o UTI o STI • Previous P-PROM • Around 1/3 of women with P-PROM have positive amniotic fluid cultures

Answer 64

• 3 main causes of neonatal morality associated with P-PROM o Prematurity o Sepsis o Pulmonary hypoplasia ``` • Fetal o Chorioamnionitis o Umbilical cord prolapse o Limb contractures o Death ``` • Maternal o Sepsis o Placental abruption o Increased incidence of retained placenta + primary + secondary PPH

Answer 65

* Amniotic fluid volume (AFV) <500ml at 32-36 weeks of gestation * Maximum vertical pocket (MVP) <2 cm from late mid-trimester * Amniotic fluid index (AFI) <5cm or <5th percentile from late mid-trimester

Answer 66

• Second half of pregnancy o Excretion of urine by the fetus is the major source of amniotic fluid production o Fluid secreted by the fetal respiratory tract o In the first half of pregnancy – fetal skin  This becomes keratinised at 22-25 weeks of gestation, significantly reducing transfer o In the last half of gestation – fetal swallowing

Answer 67

``` • The mother’s fluid balance has a major effect on the AFV o Increased maternal fluid intake has been shown to increase the AFV in women with oligohydramnios • Secondary to either o An excess loss of fluid o Decrease in fetal urine production/excretion • Fetal causes o Chromosomal factors o Congenital factors o IUGR o Post-term pregnancy o PROM o Fetal demise • Placental causes o Abruption o Uteroplacental insufficiency o Twin-to-twin transfusion syndrome (TTTS) (monochorionic twins) • Maternal causes o Maternal dehydration o Hypertension o Pre-eclampsia o Diabetes (either pre-existing or gestational diabetes) o Chronic hypoxia o ROM o Post-pregnancy carry • Drug induced causes o Indometacin o ACEi o NSAIDs • Idiopathic ```

Answer 68

• ROM • Congenital absence of functional renal tissue or obstructive uropathy o Conditions that prevent the formation of urine or entry of urine into the amniotic sac o Fetal urinary tract malformations (incl. renal agenesis, cystic dysplasia, ureteral atresia) • Decreased renal perfusion leading to reduced urine production o As a sequela of hypoxaemia-induced redistribution of fetal cardiac output o In growth-restricted fetuses, chronic hypoxia results in shunting of fetal blood away from the kidneys to more vital organs o Anuria and oliguria lead to oligohydramnios • Post-term gestation o Cause of decreased AFV in post-term pregnancies is unknown o The decreased deficiency of placental function has been proposed as a case – this has not been confirmed histologically o reduced fetal renal blood flow + reduced fetal urine production have been demonstrated >42 weeks in pregnancies involving oligohydramnios

Answer 69

``` • There is an association between oligohydramnios + IUGR + increased perinatal mortality • Fetus o Pulmonary hypoplasia o Fetal compression syndrome o Amniotic band syndrome o  risk of fetal infection (by the presence of prolonged ROM) • Labour o  incidence of CTG abnormalities o Meconium liquor o Emergency CS ```

Answer 70

• The earlier in pregnancy that oligohydramnios occurs, the poorer the prognosis • Fetal mortality in the second trimester is a result of o Major congenital malformations o Pulmonary hypoplasia Secondary to PROM before 22 weeks of gestation • Mid-trimester PROM o Leads to pulmonary hypoplasia  The inspiration of amniotic fluid at regular intervals is probably needed for terminal alveolar development o Fetal compression syndrome o Amniotic band syndrome • IUGR secondary to o Decreased fetal blood volume  renal blood flow  fetal urine output

Answer 71

* Abnormally large volume of amniotic fluid * AFI >95th centile * 2-3L fluid * Deepest pool >8cm

Answer 72

• Physiologically, the volume of fluid increases with gestation to a maximum at 36-37 weeks • Purpose of the amniotic fluid o Protects the fetus from trauma and infection o Allows lung development o Facilitates the development and movement of the limb + other skeletal parts • Mechanisms affecting the amniotic fluid volume o Fetal swallowing  By term, the fetus swallows 210-760ml of amniotic fluid per day  Polyhydramnios – Conditions which cause a problem with swallowing– atresia of the UGIT, fetal hypoxia, neuromuscular disorders, brain abnormalities o Fetal urination  By term, urinary output is 700-900ml/day  Main source of amniotic fluid in the second half of pregnancy – there is almost no amniotic fluid in cases of renal agenesis or fetal urinary tract obstruction  Fetus regulates amniotic volume as it responds to changes by adjusting the amount of urination  Polyhydramnios – increases in fetal urination e.g. fetal anaemia => subsequent  cardiac output o Secretions of fetal lung fluid + fetal oral and nasal cavities o Absorption via intramembranous and transmembranous pathways  This includes movement of fluid between the fetal blood + placenta  And across intrauterine membranes such as the amnion and chorion

Answer 73

• Idiopathic – most common Fetal factors • Fetal macrosomia • Fetal anaemia (1-11% of cases) • Hydrops fetalis (excessive fluid in >1 fetal compartment e.g. the pleural space or abdominal space – common in rhesus haemolytic disease) • Foetal polyuria – maternal diabetes, twin to twin transfusion syndrome • Chromosomal abnormalities • Congenital anomalies and genetic disorders (8-24%)– anomalies may be isolated or due to a genetic disorder o Oesophageal or duodenal atresia o CV defects o Microcephaly or anencephaly o Neural tube defects o Renal defects (incl. Bartter’s syndrome – a rare inherited defect in the LoH of the renal tube) • Genetic disorders o Trisomy 21, 18, 13 o Pena-Shokeir syndrome (contractures of the joints (arthrogryposis), growth problems, underdeveloped lungs, facial deformities) o Beckwith-Wiedemann syndrome (overgrowth disorder) Maternal factors • Maternal DM (5-26%) • Increasing maternal age • Multiple pregnancy (8-10%) • Congenital infections (e.g. toxoplasmosis, parvovirus, rubella, CMV) • Maternal substance abuse • Maternal metabolic abnormalities e.g. hypercalcaemia

Answer 74

``` • Pregnancy o Higher incidence of preterm labour + delivery o Higher incidence of C-section o PROM o Placental abruption o Malpresentation o PPH o Cord prolapse • Maternal o Increased Risk of UTI (Increased pressure on urinary tract) o Increased dyspnoea (Increased pressure on diaphragm) o Risk of hypertension during pregnancy • Fetus o Low birth weight o Low Apgar scores o Fetal death o Neonatal mortality ```

Answer 75

• The more severe the polyhydramnios, the more likely the chance of finding an underlying cause o 17% of pregnancies with mild polyhydramnios have a significant associated problem o 91% of pregnancies with moderate-to-severe polyhydramnios have a significant associated problem • Poor prognosis is associated with the more severe fetal or placental malformations o The severity of the prognosis is dependent on the severity of the abnormality

Answer 76

• Primary syphilis – solitary painless genital ulcer (chancre) in the anogenital or cervix area • Secondary syphilis – appear 4-8w after primary syphilis infection • Latent syphilis – positive serology in the absence of clinical features o Early latent syphilis – acquired <1y (CDC) or <2y (WHO) previously o Late latent syphilis – acquired >1y (CDC) or >2y (WHO) previously • Tertiary syphilis – if syphilis remains untreated – chronic, end organ complications many years after initial infection

Answer 77

• Caused by Treponema pallidum - coiled spirochaete bacterium with a corkscrew appearance + motility

Answer 78

• Miscarriage (25%) • PTL/LBW (13%) • Stillbirth (10%) • If untreated  congenital syphilis • Jarisch - Herxheimer reaction o Reaction to treatment, common in early syphilis o Acute febrile illness with headache, myalgia, chills, rigors o Resolves within 24h o Occurs in up to 44% of pregnant women with syphilis- Might cause fetal distress, premature labour, stillbirth o Rx – antipyretics, reassurance

Answer 79

• Infectious period | o 7-10 days before the rash develops, until 1 day after the rash appears

Answer 80

* Schoolchildren | * Household exposure > Occupational exposure

Answer 81

• Usually occur 3-5 weeks after onset of maternal infection • Infection in the first 20 w  IUD (9%) • 9-20 weeks gestation  hydrops fetalis (3% of cases, 50% of these die) • After 20w  rarely associated with developmental hydrops or fetal loss (<1%) • Permanent congenital abnormality and/or congenital anaemia • Non-immune hydrops fetalis o Infection of fetal erythroid progenitor cells in the BM + liver  anaemia, hypoalbuminaemia, HF, hydrops fetalis o There may be associated hepatitis + myocarditis in the fetus o Can cause fetal loss in about 50% cases if left untreated o Spontaneous resolution in 50% with no long term sequalae • Fetal death o Spontaneously or as a consequence of hydrops fetalis o 5-10% - overall fetal loss rate for those with maternal infection o Usually occurs in the second trimester, rare in the first trimester • Maternal pre-eclampsia-like syndrome (“mirror syndrome” – maternal sins reflect those present in the fetus) o Rare, typically presents late in pregnancy o Maternal peripheral oedema, HTN, proteinuria, anaemia during conservative management of hydrops fetalis

Answer 82

* Hepatitis B * HIV * Syphilis

Answer 83

* HHV-1, HHV-2 (HSV 1 and 2) * HHV-3 (VZV) * HHV-4 (EBV) * HHV-5 (CMV) * HHV-6 (Roseolovirus) * HHV-7 (Roseolovirus) * HHV-8 (Kaposi’s sarcoma-associated HIV)

Answer 84

* Gram +ve streptococcus characterised by presence of Group B Lancefield antigen (streptococcus agalactiae) * Gram +ve cocci in chains * Most common cause of early onset infection in neonates <7d old • Commensal bacterium of vaginal and rectum

Answer 85

Early-onset GBS (EOGBS) • Most babies who develop GBS infection become unwell in the first week of life, usually within the first 12h after birth Late onset GBS • Affects babies between 7 days and 3 months after birth o Infection in babies older than 1 month – very uncommon o Very rare after the age of 3 months • Less common than EOGBS

Answer 86

* GBS is carried in the vagina and bowel of about 30% of women in the UK * The likelihood of maternal GBS carriage in pregnancy is 50% * If GBS was found in a previous pregnancy but baby unaffected, then there is a 50% chance that the mother will be carrying GBS in any future pregnancy * Up to 1/3 of GBS infections in babies are late onset * GBS is the most common cause of severe infection in newborn babies * It is the most common cause of meningitis in babies <3 months * In the UK, about 1 in 2,000 newborn babies are diagnosed with EOGBS * Majority of babies who come into contact are not affected (some become colonised, minority become ill)

Answer 87

• Can rarely cause serious infections in babies incl. sepsis, pneumonia, meningitis, osteomyelitis, septic arthritis

Answer 88

• Delay in treating baby can be very serious or even fatal o 1 in 20 babies die o 1 in 14 survivors will have a long-term disability • IAP reduce the risk of EOGBS from 1 in 400 to 1 in 4000 • The chance the baby will develop infection after 12h is very low and neither the mother nor the baby will need abx after this time unless they become unwell • If you’ve had a baby affected with GBS there is an increased risk that any future baby will also be affected • In average in the UK, every month o 43 babies develop EOGBS o 38 babies make full recovery o 3 babies survive with long-term physical or mental disabilities o 2 babies die from their EOGBS

Answer 89

* Chickenpox is infectious from 2 days before the spots first appear until they have all crusted over  this is commonly about 5 days after the spots appear * Shingles is infectious from when the rash appears until all the affected areas have crusts on them

Answer 90

• Most pregnant women who have chickenpox recover fully and their babies are fine Maternal • Likely to make full recovery however serious complications occur in a small number of cases • Pneumonia (5x greater, 10%, death in 1% of these 10%) • Hepatitis • Encephalitis + ataxia (uncommon but very serious) • Death • Other – myocarditis, glomerulonephritis, appendicitis, pancreatitis, arthritis, inflammation of various parts of the eye, hepatitis, bleeding, DIC, thrombocytopenia

Answer 91

• Maternal infection occurs in the last 4 weeks of pregnancy – significant risk of varicella infection of the newborn o Delay delivery until 7 days after the onset of the rash • Risk of spontaneous miscarriage does not appear to be increased if chickenpox occurs in the first trimester • FVS (fetal varicella syndrome) – if the pregnant woman develops varicella or shows serological conversion in the first 28 weeks of pregnancy o <12 weeks – 1 in 200 chance of FVS o 13-20 weeks – 1 in 50 chance of FVS o Small number of cases between 20-28 weeks, none following 28 weeks o Features of FVS – skin scarring, eye defects (microphthalmia, chorioretinitis  cataracts), limb hypoplasia, microcephaly, learning disabilities, IUGR • Severe neonatal varicella – (VZV intra-/post-partum) o If the mother develops a rash between 5 days before and 2 days after birth (or within 7 days before or after giving birth) o Mild disease, disseminated skin lesions (purpura fulminans), pneumonia, visceral infections (i.e. hepatitis) o May be fatal to the newborn child in around 20% of cases • Shingles in infancy o 1-2% risk if maternal exposure in the 2nd or 3rd trimester o If the baby catches the chickenpox from the mother before they are born VZIG – might prevent chickenpox from developing or make it a much less serious infection if it does develop

Answer 92

• Invasive fetal procedures o Intrauterine transfusion/surgery/insertion of shunts/laser o Intra-operative cell salvage • Medical intervention o Chorionic villus sampling o Amniocentesis o ECV • Gynae o Ectopic pregnancy o TOP (any method, any GA), IUD, stillbirth, molar pregnancy o Miscarriage, Threatened miscarriage o Evacuation of molar pregnancy • APH/PV bleed in pregnancy (>12w, prolonged and <12w) • Abdominal trauma (sharp/blunt, open/closed) • Placental trauma • Previous blood transfusion (rare if in UK) • Delivery o Traumatic deliveries o Sickle cell disease o CS o Instrumental o Normal delivery of a Rh+Ve baby • Over 99% have an FMH of <4ml at deliver – Large FMH RF o Traumatic deliveries incl. C-section o Manual removal of the placenta o Stillbirths + IUD o Abdominal trauma during the 3rd trimester (26-37w)

Answer 93

DR - define risk -- high or low risk pregnancy C - contractions (in labour should be 4-5 in 10, 1 big square = 1 min) • Number of contractions in a 10-minute period (no. of contractions within 10 big squares) • How long do they last? • How strong are they? (assess using palpation – height of the wave does not correlate with strength of contraction BR - Baseline HR - Normal FHR = 110-160 Variability = normal variability 5-25 bpm3 • Calculated by assessing how much the peaks and troughs of the FHR deviate from the baseline rate (in bpm), excluding accelerations + decelerations Accelerations - abrupt increase in baseline FHR >15 bpm for >15s, reassuring • Normal = >2 accelerations on a 20-30 mins CTG trace Decelerations - abrupt decrease in baseline FHR >15 bpm for >15s, Normal = no decelerations Overall impression

Answer 94

* Normal CTG = all features are reassuring * Suspicious CTG = 1 non-reassuring feature + 2 reassuring features * Pathological CTG = 1 abnormal feature or >2 features are non-reassuring features * Need for urgent intervention CTG = acute bradycardia or a single prolonged deceleration for >3 mins

Answer 95

• When describing decelerations in FHR specify o their timing in relation to the peaks of the contractions o the duration of the individual decelerations o whether or not the fetal heart rate returns to baseline o how long they have been present for o whether they occur with over 50% of contractions o the presence or absence of a biphasic (W) shape o the presence or absence of shouldering o the presence or absence of reduced variability within the deceleration

Answer 96

``` o >60s o Reduced baseline variability within the decelerating o Failure to return to baseline o Biphasic W shape o No shouldering ```

Answer 97

``` • 4 types of decelerations o Early decelerations – physiological o Late decelerations o Variable decelerations o Prolonged decelerations ```

Answer 98

``` o Reassuring  5-25 bpm o Non-reassuring  <5bpm form between 30-50 mins  >25 bpm for 15-25 mins o Abnormal  <5bpm for >50min  >25 bpm >25min  Sinusoidal ```

Answer 99

FHR 110-160 Baseline variability 5-25 Decelerations • None or early • Variable decelerations with no concerning characteristics for <90 mins

Answer 100

FHR 100-109 Or 161-180 Baseline variability <5 for 30-50min Or >25 for 15-25 min Decelerations • Variable decelerations with no concerning characteristics for >90 mins • Variable decelerations with any concerning characteristics in <50% of contractions >30 mins • Variable decelerations with any concerning characteristics in >50% of contractions for <30 mins • Late decelerations in >50% of contractions for <30 minutes, with no maternal or fetal clinical risk factors such as vaginal bleeding or significant meconium

Answer 101

FHR <100 >180 ``` Baseline variability <5 for >50min Or >25 for >25min Or sinusoidal ``` Decelerations • Variable decelerations with any concerning characteristics in >50% of contractions for 30 minutes (or less if any maternal or fetal clinical risk factors) • Late decelerations for 30 minutes (or less if any maternal or fetal clinical risk factors) • Acute bradycardia • Single prolonged deceleration lasting >3 mins

Answer 102

* Physiological + non-pathological (uniform in depth, length, shape) * Start when the uterine contraction begins + recover when the uterine contraction stops * Due to increased fetal intracranial pressure causing increased vagal tone * https://geekymedics.com/wp-content/uploads/2011/05/CTG-Early-Decelerations-3-770x433.jpg

Answer 103

• Begin at the peak of the uterine contraction + recover after the contraction ends • Decelerations occur during the contractions + persist after the end of the contraction • Indicates that there is insufficient blood flow to the uterus + the placenta • Blood flow to the fetus is significantly reduced  fetal hypoxia + acidosis • Caused by contractions in the presence of hypoxia – they will occur with each contraction + the fetus is already hypoxic • https://geekymedics.com/wp-content/uploads/2011/05/CTG-Late-Decelerations-2-770x433.jpg

Answer 104

• Rapid fall in baseline FHR with a variable recovery phase • Variable in their duration, may not have any relationship to uterine contractions • • Most often seen during labour + in patient’s with oligohydramnios • Usually caused by umbilical cord compression • Shoulders of deceleration = acceleration before + after variable deceleration o Indicate that fetus is not yet hypoxic + is adjusting to reduced blood flow o Variable decelerations without the shoulders are more worrying – suggests that the fetus is becoming hypoxic • Variable decelerations can sometimes resolve if the mother changes position • Presence of persistent variable decelerations indicates the need for close monitoring • Concerning characteristics of variable decelerations o >60s o Reduced baseline variability within the decelerating o Failure to return to baseline o Biphasic W shape o No shouldering https://geekymedics.com/wp-content/uploads/2011/05/CTG-Variable-Decelerations-2.jpg

Answer 105

• Deceleration that lasts >2 mins • Non-reassuring = 2-3 minutes • Abnormal = >3 mins• https://geekymedics.com/wp-content/uploads/2011/05/CTG-Prolonged-Deceleration-770x433.jpg

Answer 106

What is the most common cause of variable decelerations on CTG during labour? • Usually caused by umbilical cord compression o Umbilical vein occluded first  acceleration in FHR o Then umbilical artery is occluded  causes a subsequent rapid deceleration o Pressure on the cord is reduced  another acceleration occurs  baseline then returns

Answer 107

• Always abnormal • Suggest fetal hypoxia • Late decelerations indicate that there is insufficient blood flow to the uterus + placenta • As a result, blood flow to the fetus is significantly reduced, causing fetal hypoxia + acidosis • Causes of reduced uteroplacental blood flow o Maternal hypotension o PET o Uterine hyperstimulation

Answer 108

``` • Rare, very concerning • Associate with high rates of fetal morbidity + mortality • Characteristic o Smooth, regular, wave-like pattern o Frequency of around 2-5 cycles/min o Stable baseline rate of 120-160bpm o No beat to beat variability • Indicates o Severe fetal hypoxia o Severe fetal anaemia (Hb <50gm/L2) o Fetal/maternal haemorrhage ```

Answer 109

• Hypoxic stress o FHR is controlled by the ANS + SNS – in response to hypoxic stress, the fetus reduces its HR to preserve myocardial oxygenation + perfusion • Deceleration = the reduction in HR to reduce myocardial demand

Answer 110

• Fetal sleeping o Most common cause o Shouldn’t last >40 mins o Preceded and followed by a normal CTG trace o Heart rate decreases with quiet sleep – baby shouldn’t be tachycardic • Fetal hypoxia • Fetal infecition • Fetal acidosis (due to hypoxia) o More likely if late decelerations are also present • Fetal tachycardia • Drugs o Opiates, BDZ, methyldopa, MgSO4 • Prematurity o Variability is reduced at earlier gestation (<28w)

Answer 111

* >5 in 10 contractions * Fetal heart rate abnormalities * Uterine contractions reduce blood flow to the placenta thus reducing fetal oxygenation * A period of 60-90s is required between contractions to allow fetal oxygenation to recover to fetal norms

Answer 112

• IOL PG / oxytocin • Abnormal auscultation or CTG • Oxytocin augmentation • Regional analgesia e.g. epidural or spinal, paracervical block o Following a decision to insert an epidural block, a CTG should be commenced to establish baseline features prior to the block’s insertion • Abnormal vaginal bleeding in labour • Maternal pyrexia > 38°C • Meconium or blood stained liquor • Absent liquor following amniotomy • Active first stage of labour >12 hours (i.e. after diagnosis of labour) • Active second stage (i.e. pushing) >1 hour where birth is not imminent • Preterm labour less than 37 completed weeks • Tachysystole (more than 5 active labour contractions in 10 minutes, without fetal heart rate changes) • Uterine hypertonus (contractions lasting more than 2 minutes or occurring within 60s of each other, without fetal heart rate changes) • Uterine hyperstimulation (tachysystole/hypertonus with fetal heart rate changes)

Answer 113

``` • Maternal medical illness o GFM, HTN, asthma o Maternal age >42 • Obstetric complications • Maternal o Multiple gestation o Post-date gestation (>42w) o Previous CS o APH o PET • Fetal o IUGR o Oligohydramnios/ polyhydramnios o RFM o Preterm o Breech o PROM o Prolonged rupture of membranes (>24h) o Congenital malformations o Meconium stained liquor • Intrapartum o IOL w PG/ Oxytocin o Oxytocin induction/augmentation of labour o Abnormal auscultation or CTG o Epidural anaesthesia o Maternal pyrexia • Antenatal RF o Absence of prenatal care o Abnormal AN CTG o Abnormal doppler umbilical artery velocimetry o Abnormalities of maternal serum screening associated with an  risk of poor perinatal outcomes e.g. low PAPP-A <0.4MoM o Smoking o Drug abuse ```

Answer 114

* Prolonged cord compression * Cord prolapse * Epidural + spinal anaesthesia * Maternal seizures * Maternal sedation * Rapid fetal descent * Hypotension * Post-maturity * Hypoxia * Fetal distress due to placental abruption or uterine rupture

Answer 115

* Every hour or more frequently if there are concerns | * Do not make any decision about a woman’s care in labour on the basis of CTG findings alone

Answer 116

• Fetal heart rate • Uterine contractions • Mostly used in the third trimester to monitor fetal well-being + allow early detection of fetal distress • Two transducers o One records the FHR using US o One monitors the uterine contractions measuring the tension of the maternal abdominal wall (indirect indication of intrauterine pressure) * Determine indication for fetal monitoring * Discuss fetal monitoring with the woman and obtain permission to commence * Perform abdominal examination to determine lie and presentation * Give the woman the opportunity to empty her bladder * The woman should be in an upright or lateral position (not supine) * Check the accurate date and time has been set on the CTG machine, and paper speed is set at 1cm per minute * Label CTGs the mother’s name, UR number and date / time of commencement * Maternal HR must be recorded on the CTG at commencement of the CTG in order to differentiate between maternal and fetal heart rates

Answer 117

Which feature on a CTG might indicate severe hypoxia? • Severe prolonged bradycardia (<80 bpm for >3m) Which situations commonly cause a lower baseline fetal heart rate (100-120bpm)? • Postdate gestation • Occiput posterior or transverse presentations

Answer 118

A multigravida is a woman who has been pregnant at least once before the current pregnancy A multipara is a woman who has previously given birth to live babies at least twice before now.

Answer 119

* Graphical record of key maternal + fetal data during labour entered against time on a singe piece of paper * Intended to provide an accurate record of the progress in labour, so that any delay or deviation from normal may be detected quickly + treated accordingly * Tool for monitoring maternal + fetal wellbeing during the active phase of labour + a decision making aid when abnormalities are detected

Answer 120

• Hours + Time o Hours = the number of hours since you began monitoring the labour o Time = time on the clock o Recorded at an interval of 1 hour o Start recording on the partograph when the labour is in active first stage (>4cm) • Initially + Every 30 mins o Contractions per 10 mins  Assess strength + duration through palpatin o FHR (counted for 1 full minute)  Recorded every 30mins in the first stage of labour (if every count is within the normal range) + every 5 minutes in the second stage  Each square for the FHR on the partograph represents 30 mins o Maternal Pulse • Initially + Every 2 hours o Maternal temperature • Initially + Every 4 hours o Liquor (record the colour, if the membranes have ruptured) o Moulding (the extent to which the bones of the fetal skull are overlapping each other as the baby’s head is forced down the birth canal) o Cervical dilation (as determined by vaginal examination, might need more frequent monitoring in multigravida/multipara mother) o Descent of head (by measuring the station of the fetal head or by palpating the abdomen) o Degree of moulding or caput o Maternal BP • Oxytocin (conc. + dose) / drugs given and IVF • Temperature • Urinalysis – protein + acetone + volume

Answer 121

Alert line • Starts at 4cm of cervical dilation + ends 10cm (point of expected full dilation) at a rate of 1cm per hour • If the marks recording cervical dilation cross over the alert line, this indicates that cervical dilation is proceeding too slowly – less than 1cm per hour • Refer woman to hospital/ move to labour ward Action line • 4 hours to the R of the alert line • If the dilation curve crosses this line, decisions must be made – augmentation of labour, artificial rupture of membranes CS etc o CS if fetal distress/ obstructed labour o Augmentation with IV oxytocin if there are no contraindications Between alert + action lines • Transfer to a hospital with facilities for a CS o Unless almost fully dilated o Observe labour progress for short period before transfer • Continue routine observations • ARM may be performed if membranes are still intact

Answer 122

• Slow rate of cervical dilation o Cervical dilation mark crosses alert line on partograph + is now on the R of the alert line • +3 moulding of fetal skull with poor progress of labour  indicates labour obstruction • FHR <100/min or >160/min for >10min • Meconium-stained liquor (even if N FHR) unless labour is progressing fast o M1 in latent first stage of labour o M2 in early active stage of labour o M3 in any stage of labour Latent phase (<4cm dilation) >8h

Answer 123

G • A rate of dilation of the cervix that keeps it on or to the L of the alert line – 1cm/h cervical dilation • Evidence of fetal descent coinciding with cervical dilation - 1cm descent in 4 hours • Contractions which show a steady increase in duration + number in 10 mins • 1cm per hour • Often quicker in multigravida mothers

Answer 124

``` • First stage o Latent – cervical dilation up to 4cm  At least 2 in 10 contractions, each lasting >20s o Active – cervical dilation from 4cm to 10cm  1cm dilation every 1h  1cm descent in 4h  At least 3 in 10 contractions, each lasting >40s  Nullips – 8-12h  Multiparous – 5h • Second stage o 4-5 in 10 contractions o Nullips – <3h o Multiparous – <2h • Third stage o Active mx – within 30 mins o Physiological mx – up to 1h for separation to occur, only takes a few mins to push it out ```

Answer 125

``` • I = intact membranes • If membranes have ruptured o A = absent o C = clear liquor o B = blood stained o M = meconium-stained  M1 – lightly stained  M2 – little bit thick  M3 – very thick liquor, like soup ```

Answer 126

Abdominal examination • It should be assessed by abdominal examination immediately before doing a vaginal examination, using the rule of fifth to assess engagement • When 2/5 or less of fetal head is felt above the level of symphysis pubis, this means that the head is engaged, and by vaginal examination, the lowest part of vertex has passed or is at the level of ischial spines Vaginal examination * Assess station through vaginal examination * By reference to the position of the presenting part of the fetal skill relative to the ischial spines in the mother’s pelvic brim * At station +3 the baby’s head is crowining – visible at the vaginal opening even between contractions, the cervix should be fully dilated at this point

Answer 127

• When >50% of the presenting part (usually the head) has descended into the pelvis

Answer 128

* Crowning means that the presenting part of the baby’s head remains visible between contractions * This indicates that the cervix is fully dilated

Answer 129

* The 5 separate bones of the fetal skull are joined together by sutures which are quite flexible during birth, and there are also 2 larger soft areas called fontanels * Movement in the sutures + fontanels allows the skull bones to overlap each other to some extent as the head is forced down the birth canal by the contractions of the uterus

Answer 130

* The extent of overlapping of fetal skull bones * Usually disappears within 1-3d after the birth * 0 – bones are separated and the sutures can be felt easily * +1 moulding – sutures apposed – adjacent skull bones are touching each other but are not overlapping * +2 moulding – sutures overlapped but reducible – bones overlapping but can be separated easily with pressure by your finger * +3 moulding – sutures overlapped but not reducible – bones overlapping but cannot be separated easily with pressure by your finger

Answer 131

* If found along with poor progress of labour, may indicate that the labour is at increased risk of becoming obstructed * Red flag, needs urgent intervention

Answer 132

• Parietal bones which are joined by the sagittal suture + have the anterior + posterior fontanels to the front + back

Answer 133

* Swelling in baby’s skill in the area that was pressed against the cervix during labour + delivery * Common

Answer 134

* Pulse – every 30mins * T – every 2h * BP – every 4h * Urine output – every time it is passed * Vital signs (HR, BB, RR, T), blood loss, uterine retraction * Bn Hr 0 + Hr 2 – every 15/30 mins * Bn Hr 2 + Hr 4 – every hour * Verify that the woman drinks + urinates

Answer 135

• CTG • Partogram o FHR 100-160 (except for slight changes lasting <10mins) o Moulding of not more than +2 o Clear or only lightly stained liquor (C or M1) (if membranes have ruptured)  Lightly stained amniotic fluid may not necessarily indicate fetal distress unless it is accompanied by persistent FHR deviations outside the normal range o Moulding • Suspect fetal distress if persistent (>10mins) fetal bradycardia or tachycardia • One you detect any FHR abnormality count it more frequently + refer quickly if it persists for >10mins • Count every 5 mins if the liquor contains thick green or black meconium

Answer 136

• Placental blood flow to the fetus is compromised • Commonly occurs when there is o HTN disorder in pregnancy o Maternal anaemia o Hypovolaemia due to blood loss or body fluid through V+D o Maternal hypoxia due to hear/lung disease or living in a very high altitude o Aged placenta o Oligohydramnios – can prevent the fetus from moving easily the umbilical cord may become compressed against the uterine wall by the baby’s body o Cord compression either due to prolapse or entanglement around the baby’s neck o Placental abruption

Answer 137

* Macrosomic baby * Weak contractions * Epidural * Malposition * Malpresentatio * Cephalo-pelvic disproportion (incl. small pelvis) * Cephalo-pelvic disproportion (incl. small pelvis) * Malpresentation * Malprosition

Answer 138

* Sepsis * Stillbirth * PPH * Uterine rupture * Maternal death

Answer 139

• Risks of complications are small in those with well-controlled asthma • Maternal o Pre-eclampsia o C-section o GDM o Complicate labour • Foetal o Premature birth o Low birth weight o Cleft lip or palate – oral CS use in first trimester increases this risk o Prolonged hypoxia – FGR, foetal brain injury • Prognosis o Severity of asthma remans stable in 1/3, worsens in another 1/3, improves in 1/3

Answer 140

* Hepatitis B * HIV * Syphilis

Answer 141

Maculopapular rash/ Non-vesicular • Measles • Rubella • Parvovirus B19 Vesicular rash • Chicken pox • Shingles

Answer 142

o 8-10w – 90% risk of congenital rubella syndrome(CRS) + a high likelihood of multiple defects, microcephaly, miscarriage (20%) o 12-20w - sensorineural hearing loss, chorioretinitis  cataracts  11-16w – 10-20% risk of CRS, with single defects being most common  16-20w – low chance of deafness occurring o >20 weeks – no published care reports of CRS

Answer 143

``` Maternal • Miscarriage • Pneumonia • Arthropathy • Encephalitis • ITP ``` • Maternal o Usually a mild, self-limiting viral infection o May cause first-trimester miscarriage

Answer 144

Fetal • Death • Congenital rubella syndrome Transient o IUGR o Thrombocytopenic purpura (25% - blueberry skin), haemolytic anaemia, hepatosplenomegaly, jaundice o Radiolucent bone disease (20%) o Meningoencephalitis (25%) +/- neurological sequelae Developmental o Sensorineural deafness (80%, variable, unilateral or bilateral) o General learning disability (55%) o Insulin-dependent diabetes (20% - immune-related but often delayed to adolescence or adulthood) o Late onset disease at 3-12 months – rash, diarrhoea, pneumonitis – high mortality Permanent o Congenital heart disease (patent ductus arteriosus or peripheral pulmonary artery stenosis) o Eye defects – cataracts, congenital glaucoma, pigmentary retinopathy (50% “salt and pepper”), severe myopia, microphthalmia , chorioretinitis, blindness o Microcephaly • TORCH viruses (toxoplasmosis, rubella, CMV, herpes simplex) have the following common features o Preterm delivery o LBW o Anaemia o Thrombocytopenia o Hepatitis with jaundice + hepatosplenomegaly • Microcephaly, mental handicap, seizures, failure to thrive

Answer 145

o AN Transplacental route o IP During labour and delivery through contact with cervicovaginal secretions and blood o PN through breast milk * Infection earlier in the pregnancy is associated with greater risk of more severe harm to the fetus/neonate * Risk of vertical transmission increases with gestation

Answer 146

• Increased risk of miscarriage + still birth • Most common sequalae o Sensorineural hearing loss o Mental retardation o Cerebral palsy • Other complications of congenital CMV o IUGT, microcephaly periventricular calcifications, blindness, hepatosplenomegaly, skin rash, pneumonitis • Cytomegalic inclusion disease complications o Moderate to severe LD o Neurological abnormalities o Hearing loss * Babies born with cytomegalic inclusion disease – poor prognosis * Rate of transmission to fetus 40% - 10% will develop congenital syndrome * In about 10-20% of cases, F/U shows neurological damage * Significant morbidity especially in infants who are symptomatic in the neonatal period – 90% will later have neurodevelopmental problems * Main sonographic prognostic indicator  fetal cerebral anomalies

Answer 147

• Found in soil, decayed matter and animals • Infection may be foodborne or from direct contact with animals (faeco-oral transmission) o Soft cheese and meat-based pate o Raw foods incl. vegetables, uncooked meats, processed foods o Eating cooked food that has been refrigerated and recooked • Spread from mother to fetus can occur in utero (transplancental) or during birth (vertical transmission)

Answer 148

• In immunocompromised patients – severe illness, severe sepsis, meningitis, encephalitis • Listeriosis in pregnancy o Miscarriage or stillbirth o Premature delivery o Chorioamnionitis o Severe illness in a newborn child • Infants who survive listeriosis o May have long-term neurological damage and delayed development • Most cases of listeriosis in healthy adults + children  mild and of short duration with complete recovery • Invasive infection – fatality can be as high as 30% in specific high risk populations e.g. elderly, immunocompromised, fetuses, newborns o Listeriosis in pregnancy  Around ½ of infected infants at or near term will die • Good if treated • Poor – sepsis, meningitis or neonatal infection – mortality of 50%, 70%, 80%

Answer 149

• Miscarriage • Fetal anomalies • Choroidoretinitis • (any condition with chorioretinitis can progress to cataracts (it’s just rubella is most commonly associated) o Rubella o Toxoplasmosis o CMV o VZV o HS • The risk of maternal-fetal transmission increases as the pregnancy proceeds but the consequences become less severe • Mother – if there are symptoms they normally get better on their own within about 6 weeks • Once you’ve had toxoplasmosis you cant catch it again

Answer 150

Consider the dx in any infant in the first weeks of life who develops vesicles, seizures or sepsis • Neonatal herpes – refers to infection acquired around the time of birth - classified into 3 subgroups o Disease localised to skin, eye and/or mouth (30%) o Local CNS disease (encephalitis alone) (70%) o Disseminated infection with multiple organ involvement • Appear 2 days – 6 weeks after delivery • Nonspecific signs + no mucocutaneous involvement • Rarely a hx of maternal infection • Congenital herpes – refers to infection acquired in utero (very rare) Congenital HSV infection – if lesions appear within 48h of brith, congenital infection is the cause • Rare but more likely in mothers who have disseminated herpes infection • IU transmission is greatest during the first half of the pregnancy • Most congenital herpes infections are due to HSV-2 • Can cause miscarriage, stillbirth, microcephaly, hydrocephalus, chorioretinitis, vesicular skin lesions • High perinatal mortality (50%)

Answer 151

* Greatest risk of neonatal infection  third trimester primary presentation – viral shedding may persist + the baby is likely to be born before the development of protective maternal antibodies * Infants born to women who have not completed HSV seroconversion during pregnancy (i.e. infants born before the development of protective maternal antibodies) (most commonly in third trimester, within 6 weeks of delivery)  highest risk * Primary genital infection with lesions present at the time of delivery + delivery is SVD risk of neonatal transmission of HSV is 41% * Recurrent herpes  Risk of neonatal herpes with vaginal delivery  0-3%

Answer 152

actors associated with transmission o The type of maternal infection (primary or recurrent)  Risks are greatest when a woman acquires primary genital herpes in the third trimester (particularly within 6 weeks of delivery) – viral shedding may persist + the baby is likely to be born before the development of protective maternal antibodies  Recurrent herpes • Associated with a very low risk of neonatal herpes • But recurrent herpes at the time of delivery (commonly asymptomatic or unrecognized) may cause the localised forms of neonatal herpes – both skin, eye and mouth infection and local CNS disease o The presence of transplacental maternal neutralising antibodies  Transplacentally acquired HSV antibodies do not prevent herpes virus spreading to the brain of the neonate o The duration of rupture of membranes before delivery o The use of fetal scalp electrodes o The mode of delivery • I

Answer 153

• Primary genital herpes in the first trimester  No evidence of an increased risk of spontaneous miscarriage or congenital abnormalities • Primary genital herpes acquisition in the third trimester  Some evidence of increased perinatal morbidity (PTL, LBW) together with stillbirth • Recurrent herpes o No increased risk of PTL, PPROM, FGR o Incidence of congenital abnormalities is not increased • Genital herpes infection in mum – can last up to 4 weeks if not treated • Disease localised to the skin, eye or mouth alone o Best prognosis o With appropriate antiviral treatment, neurological and/or ocular morbidity is <2% • Local CNS disease o 6% mortality o Neurological morbidity is 70% (may be lifelong) • Disseminated disease o Have the worst prognosis o 30% mortality with appropriate antiretroviral treatment o 17% have long-term neurological sequelae o More common in preterm infants, occurs almost exclusively as a result of primary infection in the mother • The poor outcomes of disseminated and local CNS disease have been attributed to delays between symptoms onset and treatment • Congenital herpes o Skin, eyes, CNS o FGR or IUD o Can cause miscarriage, stillbirth, microcephaly, hydrocephalus, chorioretinitis, vesicular skin lesions o High perinatal mortality (50%) • Women with recurrent herpes o Risk of neonatal herpes is low, even if lesions are present at the time of delivery (0-3%) o No increased incidence of congenital abnormalities

Answer 154

Anaemia Kernicterus o If rate of red cell destruction > red cell rate of production = fetal anaemia  If severe  heart failure, fluid retention, swelling (hydrops) – hydrops fetalis  Red cell break breakdown = bilirubin release • Not a problem during fetal life as it is cleared by the placenta • At birth – immature neonatal liver is not capable of handling a high bilirubin load  severe neonatal jaundice • High levels of jaundice if untreated  permanent brain damage (kernicterus) (because of deposition of bilirubin in certain areas of the neonatal brain) • This can lead to neurodevelopmental problems  cerebral palsy, deafness, motor and speech delay

Answer 155

• The anti-D immunoglobulin administered neutralises the fetal RhD antigen in the maternal circulation o Mechanism – baby Rh +ve cells in mother’s circulation coated in exogenous anti-D which is removed by reticuloendothelial system prior to any sensitisation

Answer 156

• Alloimmunization/Sensitization during first/second/subsequent pregnancy o Results in large amounts of anti-D antibodies being produced in subsequent pregnancies o Risk increases with each gestation o The risk of sensitisation is greatest in the first pregnancy and decreases with each subsequent pregnancy o Once sensitisation has occurred it is irreversible • Failed prophylaxis • Invasive fetal procedures o Intrauterine transfusion/surgery/insertion of shunts/laser o Intra-operative cell salvage • Medical intervention (chorionic villus sampling, amniocentesis, ECV) • Gynae o Ectopic pregnancy o TOP, IUD, stillbirth, molar pregnancy o Therapeutic TOP(any GA, any method) o Threatened miscarriage o Spontaneous miscarriage o Evacuation of molar pregnancy • APH/PV bleed in pregnancy (>12w, prolonged and <12w) • Placental trauma • Previous blood transfusion (rare if in UK) • Delivery o Traumatic deliveries o Sickle cell disease o CS o Instrumental o Normal delivery of a Rh+Ve baby • Over 99% have an FMH of <4ml at deliver – Large FMH RF o Traumatic deliveries incl. C-section o Manual removal of the placenta o Stillbirths + IUD o Abdominal trauma during the 3rd trimester (26-37w) o Multiple pregnancies (at delivery) o Unexplained hydrops fetalis

Answer 157

• Maternal o No long-term adverse health consequences associated with the presence of red cell antibodies o Anti-D  Small risk of localised or generalised allergic reaction  Transmission of blood-borne infections • Extracted form donor blood + carefully screened for transmissible infection but there is always a small risk

Answer 158

• Fetal o Consequence of Rh disease is severe fetal anaemia which can result to hydrops fetalis (collection of fluid in serous compartments) and death o Infants may experience anaemia persisting for a few weeks following birth o Some infants may develop late anaemia which is usually due to hyporegenerative anaemia o Kernicterus (bilirubin encephalopathy) – extrapyramidal, auditory, visual abnormalities, cognitive deficit) o Graft vs host disease o Infections o Metabolic abnormalities • Neonates o Exchange transfusion – portal vein thrombosis, portal hypertension o Kernicterus (permanent brain damage from large amounts of bilirubin) – neurodevelopmental problems cerebra palsy, deafness, motor and speech delay – phototherapy and exchange transfusion

Answer 159

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Answer 160

Amnionicity • Number of amnions (inner membranes) that surround babies in a multiple pregnancy • 1 amnion – all babies share an amniotic sac Chorionicity • Number of chorionic (outer) membranes that surround babies in a multiple pregnancy • Monochorionic twin pregnancies + monochorionic or dichorionic triplet pregnancies – carry higher risks because babies share a placenta ``` Monochorionic twin or triplet pregnancy = a pregnancy in which any of the babies share a placenta and a chorionic (outer) membrane This includes monochorionic twins and dichorionic or monochorionic triplets ``` ****Monochorionic triplet pregnancy includes dichorionic or monochorionic triplets In dizygotic multiple pregnancies each fetus has its own placenta, amnion and chorion In monozygotic multiple pregnancies, this depends on the timing of the division of the ovum

Answer 161

* Previous multiple pregnancy * Family history (maternal side) * Increasing maternal age (>45 are most likely to have a multiple birth) * Racial origin (more common in West Africa, less common in Japan) * Assisted reproductive techniques (ART) – might implant 2 ovuums

Answer 162

• Complication of monochorionic multiple pregnancies (monochorionic twins and monochorionic or dichorionic triplets) arising from shared placental circulation • Pathogenesis o When blood moves from one baby to another o Donor = baby that loses blood / SGA / oligohydramnios o Recipient = baby that receives blood / LGA / polyhydramnios o Disproportionate blood supply between the fetuses leads to unequal levels of amniotic fluid between each fetus + usually leads to death of the undersupplied twin and without treatment, usually death or a range of birth defects or disabilities in for a surviving twin (underdeveloped/damaged/missing limbs/digits/organs, cerebral palsy) o Sometimes, one fetus dies and forms a mummified fetus papyraceous or is reabsorbed (“the disappearing twin” syndrome) o Risk to recipient baby > donor baby – more blood – more cardiac strain – hydrops fetalis • Symptoms o Sudden abdomen size increase, SOB

Answer 163

* Complication affecting monochorionic twin or triplet pregnancies * Chronic form of feto-fetal transfusion caused by the joining for fine blood vessels connecting the fetal circulations of the placenta * Occurs without the differences in levels of amniotic fluids between the fetuses (polyhydramnios and oligohydramnios) that is usually seen in FFTS * Donor – at risk of progressive blood loss (anaemia) * Recipient – at risk of successively increasing blood count (polycythaemia)

Answer 164

• Hypertension o At each AN appointment – measure BP + test urine for proteinuria o (If at high risk of pre-eclampsia (>1 high risk factors) or if >2 moderate RF) - aspirin o If there is presence of >2 RF for hypertension (multiple fetal pregnancy is already a moderate RF so you only need 1 more high or moderate RF for hypertension to prescribe aspirin)  Low dose aspirin (75-150mg) daily from 12 weeks until birth o High risk factors  HTN disease during previous pregnancy  CKD  Autoimmune disease e.g. SLE or antiphospholipid syndrome  T1 or T2DM  Chronic HTN o Moderate RF  First pregnancy  Pregnancy interval of >10 years  >40 y/o  BMI >35kg/m2 at first visit  FHx of pre-eclampsia  Multiple-fetal pregnancy • Anaemia o Higher incidence in women with a multiple pregnancy o FBC at 2 at booking + 20 + 24 + 28 to identify need for early supplementation with iron or folic acid • Indications for referral to a tertiary level fetal medicine centre o Pregnancies with a shared amnion o Pregnancies complicated by any of the following  Fetal weight discordance (>25%) and an EFW of any of the babies <10th centile for GA  Fetal anomaly (structural or chromosomal0  Discordant fetal death  Feto-fetal transfusion syndrome  TRAP – twin reverse arterial perfusion sequence  Conjoined twins or triplets  Suspected TAPS

Answer 165

=increased o  likelihood of these conditions in triple pregnancy o Different options for screening o  false positive rate of screening tests in triplet pregnancy o  likelihood of being offered invasive testing o  likelihood of complications of invasive testing o The physical risk + psychological implications in the short and long-term relating to selective fetal reduction o Calculate the chance for each fetus

Answer 166

Primary prevention • Limiting the number of embryos transferred in IVF • Close counselling/monitoring of those using ovulation-induction therapies • HFEA – has criteria for single embryo transfer o If the woman does not fulfil them, a maximum of 2 embryos can be transferred per cycle Secondary prevention • Multifetal pregnancy reduction (MFPR) o Not acceptable to all – particularly those with a past hx of infertility o Preformed early in pregnancy – usually between 9-12 weeks o TA or TV US-guided injection of KCl into the heart of selected fetuses – heart stops and fetus dies o Generally the fetal material is reabsorbed into the woman’s body o Usual practice is to reduce higher-order pregnancies to a twin pregnancy, although some favour reduction to a singleton pregnancy o Risks  Miscarriage of remaining fetuses  Emotional consequences to parents  Infections

Answer 167

o Stillbirth  Singletons 5 per 1,000  Twins – 12.3 per 1,000  Triplets 31.1 per 1,000 o IUD  For dizygotic twins, the other twin will be fine  For monochorionic monozygotic twins this can be bad  BP will drop in the surviving twins’ placenta  neurological damage in the surviving twin in 25% o PTL   neonatal mortality rate   chance of long-term morbidity (neurodevelopmental delay, chronic lung disease) o FFTS  Most common in monochorionic twins  Also occurs in monochorionic or dichorionic triplets  Accounts for 20% of the stillbirths in multiple pregnancy o  risk of umbilical cord entanglement – mainly in monochorionic monoamniotic twin pregnancies o IUGR  And discordant IUGR – when one baby is SGA + the other normal or LGA  Monitored with EFW discordance (not SFH)  difference in size >25% - indicator of IUGR o Congenital abnormalities • Language and speech delay, more general cognitive delay or motor problems, behavioural problems and difficulty in parent-child interactions all appear to be more common in multiple birth children  Risk higher in monozygotic twins (2X)  In dizygous twins the risk is close to that in singleton pregnancy o DS  Greater absolute risk as same risk per baby so increased total risk

Answer 168

o Miscarriage o Anaemia, thrombocytopenia o Pre-eclampsia  More risk of abnormal vasculature development  Always check at every antenatal appointment – BP, urine dip for protein  Follow normal pre-eclampsia pathways o APH, PPH (stretched uterus) o Operative delivery o Severity of symptoms of pregnancy – N, V SOB, heartburn o Hyperemesis gravidarum (more bHCG) o GDM (more placental lactogen and placental steroids so more likely to tip into diabetes) o Polyhydramnios o Postnatal illness o Death (maternal mortality is 2.5x higher for twin pregnancy than singleton pregnancy) • Risks to the fetus/baby – increased risk of

Answer 169

• Multiple pregnancies should be monitored for IUGR + FFTS

Answer 170

• An infant born with a birth weight <10th centile

Answer 171

• LBW = birth weight <2500 g

Answer 172

• Fetal growth restriction (FGR) is not synonymous with SGA o FGR implies a pathological restriction of the genetic growth potential  FGR fetuses may manifest evidence of fetal compromise – abnormal Doppler studies, reduced liquor volume  Clinical definition and applies to neonates born with clinical features of malnutrition and IUGR, irrespective of their birth weight percentile o SGA is not always pathological, but it can be  Used in neonates whose birth weight is <10th percentile for that GA or 2 S.D. below the population norms on the growth charts  The definition considers only the birth weight without any consideration of the in-utero growth and physical characteristics at birth • Some growth restricted fetuses are SGA • A baby may not be SGA (birth weight >10th percentile) but still be considered IUGR if they have features of in-utero growth restriction and malnutrition at the time of birth • A baby may be SGA (birth weight <10th percentile) but not considered IUGR (no features of malnutrition) o The likelihood of FGR is higher in severe SGA infants

Answer 173

o Normal (constitutionally) small  Babies whose growth at all GAs has been low  They are SGA but otherwise healthy  50-70% constitutionally small – fetal growth appropriate for maternal size and ethnicity o Non-placenta mediated growth restriction  E.g. structural or chromosomal anomaly, inborn errors of metabolism, fetal infection  Symmetrical o Placenta mediated growth restriction  Growth is normal in the early part of pregnancy but slows in utero by at least 2 measurements (normally from US assessments)  Due to IUGR  Newborn baby has a wasted appearance with little SC fat + a greater risk of complications  Asymmetrical (head circumference is spared, AC smaller than it should be)  Serial growth scans needed every 2 weeks  Doppler USS 2ice a week  risk of fetal death

Answer 174

``` • Maternal factors can affect placental transfer of nutrients o Low pre-pregnancy weight o Under nutrition o Substance abuse o Severe anaemia • Medical conditions can affect placental implantation and vasculature and hence transfer o Pre-eclampsia o Autoimmune disease o Thrombophilia o Renal disease o Diabetes o Essential hypertension ``` • Fetal o Chromosomal abnormalities (symmetrical IUGR) o Infection (CMV, toxoplasmosis, syphilis, malaria) • Other o Placental insufficiency (any conditions that result from malfunctioning of the placenta – includes pre-eclampsia) (asymmetrical IUGR) ``` Major • Age >40 • Smoker >11 cigarettes per day • Cocaine • Daily vigorous exercise • Previous SGA baby • Previous stillbirth • Maternal SGA • Paternal SGA • Chronic hypertension • Severe pregnancy induced hypertension • Diabetes with vascular disease • Renal impairment • APL syndrome • Threatened miscarriage – heavy bleeding similar to menses • Unexplained APH • Low maternal weight gain • PAPP-A <0.415 MoM • Fetal Echogenic bowel o Has been shown to be independently associated with an SGA neonate and fetal demise ``` ``` Minor • Age >35 • Nulliparity • BMI <20 or >25 • Smoker 1-10 cigarettes per day • IVF singleton pregnancy • Low fruit intake pre-pregnancy • Pre-eclampsia • Mild pregnancy induced hypertension • Placental abruption • Pregnancy interval <6 months or >60 months • Caffeine >300 mg/day in third trimester ```

Answer 175

* The relationship between the long axis of the fetus and the mother * Longitudinal, transverse, oblique Unstable lie = where the presentation of the fetus changes between transverse/oblique/breech and back

Answer 176

* The fetal part that first enters the maternal pelvis * Cephalic vertex, breech, shoulder, face, brow Malpresentations = all presentations of the fetus other than vertex (brow, face, shoulder, breech, variable lie) Variable lie = when the head is completely unengaged and floating (seen mostly in cases of severe polyhydramnios and prematurity)

Answer 177

* The position of the fetal head as it exits he birth canal * Occipito-anterior, occipito-osterior, occipito-transvrse Malposition = abnormal position of the vertex of the fetal head relative to the maternal pelvis

Answer 178

Vertex = head is flexed and the occiput leads the face

Answer 179

Denominator = the bony landmark on the presenting part used to denote position Vertex = occiput Face = mentum (chin) Breech = sacrum

Answer 180

Attitude = relation of different parts of the fetus to one another

Answer 181

``` • Maternal factors o Abnormalities of the uterus e.g. fibroids o Obstructed lower segments (fibroids, pelvic abnormalities) o Uterine malformations o Partial septate uterus o Multiparity (uterine laxity) o Multiple pregnancy • Fetal factors o Prematurity o Fetal anomaly (CNS malformations, chromosomal disorders) o Macrosomia • Pregnancy factors o Placenta praevia o Poly/oligohydramnios ```

Answer 182

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Answer 183

Multiparity Uterine malformations (e.g. septate uterus) Fibroids Placenta praevia ``` prematurity macrosomia polyhydramnios twin pregnancy abnormality ```

Answer 184

• Complete (flexed) breech o Both legs are flexed at the hips and the knees • Frank (extended breech) o Both legs are flexed at the hips and extended at the knee o Most common type of breech presentation • Incomplete/Footling breech o One or both legs extended at the hip o Foot is the presenting part o Can become footling breech

Answer 185

Brow position • Fetal head stays between full extension and full flexion • The biggest diameter (mento-vertex) presents • Occurs in 0.14% of deliveries • Usually only diagnosed when labour is well established • Anterior fontanelle and supra-orbital ridges or base of nose are palpable on vaginal examination

Answer 186

Occipito-posterior position • Most common malposition • Head initially engages normally but then the occiput rotates posteriorly rather than anteriorly • Results from o Poorly flexed vertex o Weak uterine contractions which may not push the head down into the pelvis with sufficient strength to produce correct rotation o Flat sacrum • Anterior fontanelle felt anteriorly (4 radiating sutures) • Posterior fontanelle palpated posteriorly (3 radiating sutures) Occipito-transverse position • Head initially engages correctly but fails to rotate + remains in a transverse position

Answer 187

o Woman’s choice o Maternal complications are least with successful vaginal birth (ELCS carries a higher risk) o 40% risk of needing an EMCS  EMCS carries the highest risk out of planned vaginal breech or ELCS

Answer 188

o Risks  Low Apgar scores  Serious short-term complications • fetal head entrapment o due to delivery of the trunk through an incompletely dilated cervix – occurs in up to 14% of vaginal deliveries o incisions in the cervix (vaginal birth) or vertical uterine incision extension (C-section) may be used • birth asphyxia – usually secondary to delay in delivery • Birth trauma • intracranial haemorrhage – as a result of rapid compression of the head during delivery  Has not been shown to increase the risk of long-term morbidity o Risk of perinatal mortality with a planned breech vaginal delivery – 2/1000  Compares to approx. 1/1000 with planned cephalic birth

Answer 189

• Major complication  cord prolapse (= the umbilical cord drops down below the presenting part of the baby and becomes compressed as the head enters the pelvis – likely to be better tolerated by a fetus that is not hypoxic) o Incomplete or footling breech  15-18% risk of cord prolapse o Complete breech  4-6% risk of cord prolapse o Frank breech  0.5% risk of cord prolapse • higher perinatal mortality and morbidity due to o premature rupture of membranes o fetal head entrapment o birth asphyxia – usually secondary to delay in delivery o Birth trauma o intracranial haemorrhage – as a result of rapid compression of the head during delivery o increased incidence of congenital malformations • term babes presenting by the breech have worse outcomes than cephalic ones, irrespective of the mode of delivery • Perinatal morbidity and mortality is higher in cases of planned vaginal breech birth compared to CS in term babies • Breech presentation is associated with an  risk of developmental dysplasia of the hip  USS of the hips should be performed in all babies who were breech at 36 weeks irrespective of their presentation at delivery or mode of delivery • Breech presentation has a significant recurrence risk • Look at risks/complications of each mode of delivery for breech presentation

Answer 190

Transverse lie | • Associated with a risk of cord prolapse of up to 20%

Answer 191

``` • Pregnant women who have a medical condition or complications in their current or previous pregnancy • Women who have had no antenatal care • Includes women with o Existing medical conditions o Heart disease o Asthma o Long-term systemic steroids o Bleeding disorders o SAH or arteriovenous malformation of the brain o AKI or CKD o Obesity o Obstetric complications or no antenatal care o Pyrexia o Sepsis o IPH o Breech presentation in labour o Small for gestation age baby o Large for gestational age baby o No antenatal care o Previous CS o Labour after 42 weeks of pregnancy ```

Answer 192

* Age <15yo or >35yo * Pre-pregnancy weight under 45kg or obese * Height under 5 ft (1.5m) * Incompetent cervix * Uterine malformations * Small pelvis * Being single * Smoker or alcohol * Illicit drugs * No access to early prenatal care * Low socioeconomic status * Previous obs hx for recurrent miscarriages * Hypothyroid * Hyperthyroid

Answer 193

• Pregnancy which progresses beyond 42 weeks

Answer 194

• Risks associated with continuing pregnancy beyond 41+0 weeks: o increased likelihood of CS o increased likelihood of the baby needing admission to NICU o increased likelihood of stillbirth + neonatal death ``` Maternal risks • Obstructed labour • Perineal damage • Instrumental vaginal delivery • CS • PPH • Infection ``` ``` • Fetal risks due to o Utero-placental insufficiency o Meconium aspiration o Intrauterine infection • Increased risk of stillbirth + neonatal death • Increased risk of death in the first year of life • Meconium aspiration • Macrosomia + larger babies – prolonged labour, cephalo-pelvic disproportion, shoulder dystocia, birth injury (brachial plexus damage, cerebral palsy) • Neonatal acidaemia • Low 5 minute Apgar scores • Neonatal encephalopathy • Neonatal seizures • IUGR due to placental insufficiency ``` ``` IOL before uterus or cervix are in a favourable state • Need for CS • Prolonged labour • PPH • Traumatic delivery ```

Answer 195

* Previous post-term pregnancies * Primigravity * High maternal BMI * Genetic factors * Advanced maternal age

Answer 196

BM > 30 kg/m2

Answer 197

``` • Maternal o High maternal BMI o DM o GDM o Short stature o Multiparity • Fetal o Macrosomia o Post-term gestation • Labour o Prolonged 2nd stage of labour • Previous hx of shoulder dystocia • Previous large infant ```