Obstetrics - Management Flashcards

Question

Pre-eclampsia Medications and indications Anticonvulsants (+reversing agent) Anthypertensives CS for fetal lung maturation Antihypertenives in the postnatal period

Answer 1

• Anticonvulsants – Magnesium sulfate o If woman has previously had an eclamptic fit o For women with severe pre-eclampsia in a critical care setting if birth is planned within 24h o If 1 or more of the following features of severe pre-eclampsia are present  Ongoing or recurring severe headaches  Visual scotomata  N or V  Epigastric pain  Oliguria + severe HTN  Progressive deterioration in lab tests (raised Cr or LFTs, low plt count) o 1st line – IV magnesium sulfate  Continue 24h after last seizure/delivery  Loading dose of 4g IV over 5 mins, followed by infusion of 1g/hour for 24h  Recurrent seizures - further dose of 2-4g over 5 mins  Monitor: UO, reflexes, RR, O2 sats, ECG o Reversing agent – Calcium gluconate  10ml, 10% over 10 minutes • Antihypertensives o 1st line – Labetalol (PO or IV) – contraindicated in asthma o 2nd line – Nifedipine (PO) – causes tocolysis (use methyldopa at term) o 2nd line – Hydralazine (IV) o NICE: 3rd line for chronic HTN/gestational HTN/pre-eclampsia – methyldopa • Corticosteroids for fetal lung maturation o bn 24+0 and 34+6 weeks + at risk of preterm birth  24mg in 2 doses (12mg each, separated by 12 hours) o If early birth is considered likely within 7 days in women with pre-eclampsia • Antihypertensives in the postnatal period o Enalapril o Monitor maternal renal function + maternal serum potassium o If black African/Caribbean  nifedipine or amlodipine o If BP not well controlled with a single medicine  combination of enalapril + nifedipine or amlodipine o If combination is not tolerated/ineffective – add atenolol or labetalol to the combination treatment or swap 1 of the medicines already used for atenolol or labetalol o Avoid diuretics or ARBs

Answer 2

RCOG – the management of amniotic fluid embolism is supportive rather than specific as there is not proven effective therapy • Resuscitation o High flow O2 – most pt will require endotracheal intubation  Signs and symptoms of adequate oxygen delivery + tissue perfusion should be continuously monitored o Fluids to maintain BP o If haemodynamically unstable – consider pulmonary artery catheterisation o If arrhythmias develop – standard treatment o If she arrests – CPR o If she does not respond to CPR – perimortem Caesarean delivery  Within 5 minutes or asap after cardiac arrest  During this time, can also trigger the full protocol for a massive haemorrhage • Pharmacological o Inotropic support o Early, aggressive treatment of coagulopathy should be considered in the presence of bleeding gums or haematuria  FFP – if APTT >1.5x normal  Cryoprecipitate – if fibrinogen <1g/L  Platelets – if plt count <50x10^9/L  Up to 1 L of FFP + 10U of cryoprecipitate (2 packs) may be given empirically in the presence of massive haemorrhage while awaiting results of coagulation studies o Aggressive treatment of uterine atony (look at management of PPH)  Oxytocics  Ergometrine  Prostaglandins  Packing, bimanual uterine compression, catheterisation, tamponade, Rusch balloons o CO measurement – ensure fluid overload does not occur  Fluid overload will exacerbate pulmonary oedema + increase the risk of ARDS • Surgical o Delivery o Hysterectomy if bleeding cannot be controlled – should not be delayed until the woman is in extremis o Uterine artery embolization • Of those who die, 25% die within the first hour and most of the remainder by 9h after presentation o Palliative care may be initiated concurrently with resuscitation

Answer 3

pre-existing diabetes in pregnancy - 37+0 to 38+6 weeks - Induction of labour or C-section Gestational diabetes - 40+6 weeks - Induction of labour or C-section

Answer 4

• Aim for the same capillary plasma glucose target ranges as recommended for all people with T1DM o HbA1c <48 mmol/mol (6.5%) o Fasting plasma glucose 5-7mmol/l on waking and o Plasma glucose level 4-7 mmol/l before meals at other times of the day * If HbA1c >86 mmol/mol (10%) - do not get pregnant * Women with BMI >27 kh/m2 should be offered advice on how to lose weight * Retinal assessment should be offered at the first pre-conception appointment + then every year if no retinopathy is found • Assessment of diabetic nephropathy before and during pregnancy o Refer if – creatinine >120μmol/l or eGFR <45ml/min/1.73m2 * 5mg folic acid daily until 12 weeks of gestation to reduce the risk of neural tube defects * If antihypertensives are needed – methyldopa. Labetalol + nifedipine can also be used * Benefits of breast-feeding – improved glucose control, easier weight loss

Answer 5

Medication for diabetes and diabetic complications before and during pregnancy • All other hypoglycaemic agents should be discontinued before pregnancy except metformin + insulin • Substitute glucose lowering agents with insulin o Isophane insulin (NPH insulin) – first choice for long-acting insulin during pregnancy o Consider continuing treatment with long-acting insulin analogues (insulin detemir or insulin glargine) in women with diabetes who have established good blood glucose control before pregnancy o Rapid-acting insulin analogues (aspart and lispro) do not seem to affect pregnancy or the health of the fetus or newborn baby adversely – they are actually associated with fewer episodes of hypoglycaemia, a reduction is postprandial glucose excursions and an improvement in overall glycaemic control compared with regular human insulin o Continuous SC insulin infusion (insulin pump therapy) may be appropriate for pregnant women who have difficulty achieving glycaemic control with multiple daily injections of insulin without significant disabling hypoglycaemia o If high glucose after meals – need more short acting o If high fasting glucose – need more long-acting o All women treated with insulin during pregnancy should be aware of the risks of hypoglycaemia, particularly in the first trimester + should be advised to always carry a fast-acting form of glucose (dextrose tablets, glucose containing drink) + pregnant women with T1DM should also be prescribed glucagon • Metformin o Used as an adjunct or alternative to insulin o Likely benefits from improved glycaemic control outweigh the potential for harm • Since insulin resistance increases throughout pregnancy, advice patients to increase their dose of metformin or insulin during the 2nd half of the pregnancy • Should be stopped before conception or as soon as pregnancy is confirmed o ACEi o ARB o Statins

Answer 6

• Arrange contact with joint diabetes + obstetric clinic  Women with diabetes should be seen every 1-2 weeks during pregnancy by the diabetes care team • Other medication o Folic acid 5mg until 12w o Aspirin from 12w Glycaemic control + monitoring • T1DM & T2DM + GDM who are on a multiple daily insulin injection regimen – need to test their fasting, pre-meal + 1h post-meal + bedtime blood glucose levels • T2DM + GDM who manage their diabetes with exercise changes along or oral therapy or single-dose intermediate-acting or long-acting insulin – test their fasting and 1h post meal blood glucose • Target blood glucose levels o Fasting glucose <5.3 mmol/L o 1h after meal <7.8 mmol/L o 2h after meal <6.4mmol/L • HbA1c o Measure in 2nd and 3rd trimester to assess the level of risk for the pregnancy o Do not use HbA1c levels routinely to assess a woman’s blood glucose control in the 2nd and 3rd trimesters of pregnancy o The level of risk for the pregnancy for women with pre-existing diabetes increases with an HbA1c level >48mmol/mol (6.5%) • Insulin treatment + risks of hypoglycaemia o Isophane insulin (NPH insulin) – first choice for long-acting insulin during pregnancy o Consider continuing treatment with long-acting insulin analogues (insulin detemir or insulin glargine) in women with diabetes who have established good blood glucose control before pregnancy o Rapid-acting insulin analogues (aspart + lispro) for pregnant women with diabetes o Can also offer SC insulin infusion (CSII - continuous SC insulin infusion) during pregnancy if adequate blood glucose control is not obtained by multiple daily injections of insulin without significant disabling hypoglycaemia o If high glucose after meals – need more short acting o If high fasting glucose – need more long-acting o always carry a fast-acting form of glucose (dextrose tablets, glucose containing drink) + pregnant women with T1DM should also be prescribed glucagon • Intermittently scanned CGM (isCGM) and continuous glucose monitoring (CGM) o Offer CGM to all pregnant women with T1DM o Offer isCGM to pregnant women with T1DM who are unable to use continuous glucose monitoring or express a clear preference to it o Consider CGM for pregnant women who are on insulin therapy but do not have T1DM if  They have problematic severe hypoglycaemia (+/- impaired awareness of hypoglycaemia)  They have unstable glucose levels that are causing concern despite efforts to optimise glycaemic control • Retinal assessment during pregnancy o Retinal assessment by digital imaging with mydriasis using tropicamide during their first antenatal clinic appointment unless they had a retinal assessment in the previous 3 months o Repeat retinal assessment at 28 weeks o If diabetic retinopathy is present, assess again at 16-20 weeks o If diabetic retinopathy is diagnosed during pregnancy - ophthalmological follow-up for at least 6 months after the birth of the baby o Retinopathy needs to be treated before pregnancy begins o Advise women with diabetes who are planning a pregnancy to defer rapid optimisation of blood glucose control until after they have had retinal assessment and treatment o Diabetic retinopathy should not be considered a contraindication to rapid optimisation of blood glucose control in women who present with a high HbA1c in early pregnancy • Pre-eclampsia o High risk of pre-eclampsia (includes women with T1DM + T2DM) – take 75mg of aspirin daily from 12 weeks until the birth of the baby • Detecting congenital malformations o USS anomaly scan incl. examination of the fetal heart at 20 weeks (4 chambers, outflow tracts, 3 vessels) • Monitoring fetal growth + well-being o Offer US monitoring for fetal growth and amniotic fluid volume every 4 weeks from 28-36 weeks o If there is risk of fetal growth restriction – routine monitoring of fetal wellbeing before 38 weeks (fetal umbilical artery doppler recording, fetal heart rate recording, biophysical profile testing)

Answer 7

• Pre-term labour o Not contraindicated o Steroids increase glucose release - If antenatal corticosteroids are needed additional insulin therapy is required to maintain normoglycaemia (often requires admission) • Blood glucose during labour + birth o Monitor every hour during labour + birth o T1DM + T2DM - For women on insulin, consider sliding scale insulin and glucose should be commenced in labour  Aim for blood glucose levels between 4-7 mmol/l o Consider IV dextrose + insulin infusion from the onset of established labour if difficult to maintain capillary blood glucose within that range • Timing and mode of birth o Timing – between 37+0 weeks and 38+6 weeks o Consider delivery before this in the presence of foetal/maternal complications o IOL or CS • Anaesthesia o Anaesthetic assessment in the third trimester of pregnancy o If GA for birth, monitor blood glucose every 30 mins from induction of GA until after the baby is born and the woman is fully conscious

Answer 8

• Should only be admitted to NICU if there is a specific complication – hypoglycaemia, respiratory distress, signs of cardiac decompensation, neonatal encephalopathy, signs of polycythaemia, need IVF/tube feeding, jaundice requiring intense phototherapy + frequent monitoring of bilirubinaemia, born before 34 weeks • Babies should feed asap after birth o Within 30 mins o Then every 2-3h until re-feed glucose levels are at least 2 mmol/L • Only use additional measures (tube feeding, IV dextrose if) o Capillary plasma glucose <2.0 mmol/L on 2 consecutive readings o Abnormal clinical signs o Baby will not feed orally • Blood glucose testing o Carried out routinely in babies of women with diabetes at 2-4 hours after birth to exclude neonatal hypoglycaemia ``` • Signs of hypoglycaemia in babies + management o Abnormal muscle tone o Level of consciousness o Fits o Apnoea o Rx – IV dextrose ``` • If signs of heart disease/cardiomyopathy – echo • Babies discharged o At least 24 hours old o Maintaining blood glucose levels o Feeding well

Answer 9

• Adjust insulin + metformin doses back to those of pre-pregnancy immediately after birth • Women with insulin-treated pre-existing diabetes o Should reduce their insulin immediately after birth + monitor their blood glucose levels carefully to establish their appropriate dose o Are at an increased risk of hypoglycaemia in the postnatal period, especially when breast-feeding – provide advice to have meal or snack available before or during feeds • Women with pre-existing T2DM who are breast-feeding o Can continue to take metformin + glibenclamide immediately after birth o Should avoid other oral blood glucose-lowering agents while breastfeeding • Women with diabetes who are breastfeeding o Should continue to avoid any medicines for the treatment of diabetes complications that were discontinued for safety reasons in the pre-conception period mal

Answer 10

All women should take 400mcg folic acid until the 12th week of pregnancy

Answer 11

High dose folic acid (5mg) needed in women at higher risk of conceiving a child with NTD: ``` Pregnant obese women (BMI >30 kg/m2) Previous pregnancy with NTD (neural tube defects) FHx of NTD Either partner has NTD Use of anti-epileptic drugs Coeliac disease Diabetes Thalassaemia trait ``` In these cases 5mg of folic acid should be taken from before conception until the 12th week of pregnancy • Sickle cell disease, thalassaemia trait, thalassaemia – take 5mg throughout pregnancy ``` Causes of folic acid deficiency • Phenytoin • Methotrexate • Pregnancy • Alcohol excess ```

Answer 12

• When women are dx with GDM offer review with the joint diabetes + AN clinic within 1 week If fasting plasma glucose <7 mmol/L at diagnosis • Lifestyle modifications – 1st line o Body loss for women with BMI >27kg/m2 o Diet o Physical activity – at last 30 mins per day • Metformin – 2nd line o If blood glucose targets are not met with diet and exercise changes within 1-2 weeks • Insulin – 3rd line o If metformin is contraindicated/unacceptable (SE – decreased appetite, diarrhoea, abdominal pain) o If blood glucose targets are not met with diet and exercise + metformin, offer insulin as well • Glibenclamide – 4th line o For women in whom blood glucose targets are not achieved with metformin but who decline insulin therapy or who cannot tolerate metformin • Contraindications o Gliclazide o Liraglutide

Answer 13

If fasting plasma glucose >7 mmol/L at diagnosis OR fasting plasma glucose 6-6.9 mmol/L with complications (e.g. macrosomia, hydramnios) • Immediate treatment with insulin +/- metformin and • Changes in diet and exercise

Answer 14

• Use the same capillary plasma glucose target levels for women with GDM as for women with pre-existing diabetes • Targets for capillary plasma glucose o Fasting glucose <5.3 mmol/L o 1h after meal <7.8 mmol/L o 2h after meal <6.4mmol/L o If women with GDM are on insulin or glibenclamide – should maintain their capillary plasma glucose level >4 mmol/L

Answer 15

Glycaemic control + monitoring • T1DM & T2DM + GDM who are on a multiple daily insulin injection regimen – need to test their fasting, pre-meal + 1h post-meal + bedtime blood glucose levels • T2DM + GDM who manage their diabetes with exercise changes along or oral therapy or single-dose intermediate-acting or long-acting insulin – test their fasting and 1h post meal blood glucose

Answer 16

No later than 40+6 weeks

Answer 17

o Should stop blood glucose-lowering therapy immediately after birth o Offer a fasting plasma glucose test 6-13 weeks after birth to exclude diabetes  Fasting plasma glucose level <6.0 mmol/L or HbA1c <39mmol/mol (5.7%)– low probability of having diabetes at the moment, moderate probability of developing T2DM they will need an annual test to check that their blood glucose levels are normal  Fasting plasma glucose 6.0mmol/l-6.9 mmol/l or HbA1c 39-47 mmol/mol (5.7%-6.4%) – high risk of developing T2DM  Fasting plasma glucose >7.0mmol/l or HbA1c >48 mmol/mol (6.5%) – (likely to) have T2DM (50%) + offer a test to confirm this o Offer an annual HbA1c test to women with gestational diabetes who have a negative postnatal test for diabetes o Offer women with gestational diabetes  early self-monitoring of blood glucose  an OGTT in future pregnancies  Offer a subsequent OGTT (24-28 weeks) if the first OGTT results in early pregnancy are normal • (2h OGTT asap after booking + 2h OGTT at 24-28 weeks if first OGTT is normal)

Answer 18

• Admit as an emergency Conservative (expectant) management: • Pregnancy of <6 weeks gestation who are bleeding but not in pain and do not have RF (e.g. previous ectopic pregnancy) (NICE) or • USS dx of ectopic pregnancy + a decreasing βhCG level initially less than 1500 iu/l (RCOG) or • Clinically stable and pain free women (NICE) or • Have a tubal ectopic pregnancy measuring <35mm with no visible heartbeat on TVUSS (NICE) or • Have serum hcg levels of <1000IU/L (NICE) or • Are able to return for follow up (NICE) • If expectant management - Repeat hCG levels o Performed for women with a tubal ectopic pregnancy being managed expectantly on days 2, 4, 7 after the original test  If hcg levels drop by >15% from the previous value on days 2, 4 and 7 - repeat weekly until a negative result (<20 IU/L) is obtained or  If hcg levels do not fall by 15%/stay the same/rise from the previous value - seek senior advise to help decide further management

Answer 19

``` Referral to hospital for urgent assessment via the early pregnancy assessment service or on-call gynaecologist out of hours • Pain + abdominal tenderness • Pelvic tenderness • Cervical motion tenderness • Vaginal bleeding ```

Answer 20

• Admit as an emergency ``` Medical management • Single dose methotrexate o First line in women who are able to return for follow-up and who have the following  No significant pain  Unruptured ectopic pregnancy with adnexal mass <35mm + no visible heartbeat  No intrauterine pregnancy seen on USS  Serum hCG <1500 IU/L • Consider if bhcg <5000iu/l ``` o SE – abdominal pain, N+V, reversible impaired liver function o Avoid  Conceiving 3/12 after methotrexate – Contraception should be used for 3-6 months - methotrexate is teratogenic  Sexual intercourse during treatment  Alcohol and prolonged exposure to sunlight o Need for follow up • Blood tests • Day 1 – BHCG, U+Es, LFTs, FBC, blood group • Days 4+7 – Repeat bhcg levels • If drop >15% between days 4 + 7  1 bhcg per week until negative (hcg <15iu/l) [RCOG] • If no fall by >15%  repeat TVUS (exclude ectopic fetal cardiac activity + presence of hemoperitoneum), consider second dose of methotrexate if still fulfils criteria for medical management

Answer 21

``` Surgical management • Offered to those who cannot return for follow-up after methotrexate or to those who have an ectopic pregnancy and any of the following o Significant pain o Adnexal mass >35mm o Fetal heartbeat visible on scan o Serum hCG level >5000 IU/L ``` • Laparoscopic approach is preferable to an open approach o No RF for infertility (presence of a healthy contralateral tube) - Salpingectomy  Urine pregnancy test at 3/52 o RF for infertility (previous ectopic pregnancy, contralateral tubal damage, previous abdominal surgery, previous PID) - Salpingotomy  Salpingotomy - risk of persistent trophoblast - need for serum β-hCG level follow up • 1 serum hcg measurement 7 days after surgery, then 1 serum hcg measurement per week until a negative result is obtained  Salpingectomy - urine pregnancy test after 3 weeks – further assessment if is positive  Up to 1 in 5 women may need further treatment – methotrexate +/or salpingectomy  Copper IUD should not be used if you’ve had a laparoscopic salpingectomy • Anti- rhesus D prophylaxis(250iU) o Offered to all women who have surgical removal of an ectopic pregnancy or where bleeding is repeated, heavy or associated with abdominal pain o No Kleihauer needed  Kleihauer test checks level of foetal blood in maternal circulation o Do not offer anti-rhesus D prophylaxis to women who  Receive solely medical treatment for their ectopic pregnancy or miscarriage or  Threatened/complete miscarriage or  PUL

Answer 22

Offer the choice of either methotrexate or surgical management: • Women with an ectopic pregnancy who have a serum hCG of >1500 IU/L but <5000 IU/L and • Who are able to return for follow up and • Have no significant pain and • Have an unruptured ectopic pregnancy with an adnexal mass <35mm with no visible heartbeat and • No intrauterine pregnancy (as confirmed on an USS) o If women choose methotrexate - their chance of needing further intervention is increased - they may need to be urgently admitted if their condition deteriorates

Answer 23

Symptomatic + asymptomatic women with low-lying placenta or placenta praevia • Single course of antenatal CS therapy recommended between 34+0 week and 35+6 weeks of gestation * Appropriate prior to 34+0 weeks of gestation in women at higher risk of preterm birth * Prevention and treatment of anaemia during the antenatal period * Do not have penetrative intercourse • Placental edge <20mm from the os o Need for C-section, especially if it is posterior or thick o If head has engaged at the time of planned C-section review with TVS again as the lower segment continues to develop after 36 weeks • Manage woman as if she has placenta accreta if all of the following apply o Anterior placenta reaching the os o Previous C-section

Answer 24

Asymptomatic women • Rescan at 32 weeks o If still low lying/praevia – rescan at 36 weeks * If uncomplicated low lying/praevia at 36 weeks – delivery should be considered between 36+0 and 37+0 weeks of gestation * Counselling re. risks of preterm delivery and obstetric haemorrhage * Avoid sex * If home-based care - close proximity to the hospital, constant presence of a companion, fully informed consent from the woman

Answer 25

* Make sure that the cause is clearly local vaginal bleeding * Exclude cervical carcinoma (smear hx, direct visualisation of the cervix) * Symptomatic management * If bleeding settles, admit 48h for observation

Answer 26

• Tailor antenatal care incl. hospitalisation to individual woman’s needs + social circumstances o No penetrative intercourse o Encouraged to stay in hospital from 34 weeks • If hospital admission o Assess RF for VTE – balance risk of developing a VTE against the risk of bleeding from a placenta praevia or a low lying placenta • If home-based care - close proximity to the hospital, constant presence of a companion, fully informed consent from the woman o Woman should attend hospital immediately if she experiences any bleeding, contractions, pain (incl. vague suprapubic period-like aches) • Delivery through a C-section o Women presenting with placenta previa or low-lying placenta + a hx of vaginal bleeding or other associated RF for preterm delivery - Late preterm (34+0 to 36+6 weeks of gestation) delivery should be considered • Tocolysis o May be considered for 48h to facilitate administration of antenatal corticosteroids o If delivery is indicated based on maternal/fetal concerns, tocolysis should not be used in an attempt to prolong gestation

Answer 27

``` Investigations: • Do not perform a vaginal examination o Do not perform a bimanual o Speculum ok to assess bleeding o This may start torrential bleeding in the presence of placenta praevia ``` • Assess blood loss + cross-match for possible transfusion o FBC, G+S, consider crossmath o Kleihauer test • Continuous foetal monitoring • Scans o CTG if >27 weeks o Umbilical artery dopplers every 2 weeks o Growth scan • Admit pt until bleeding has stopped (+keep them in for 48h to observe) o ABC – IV access + fluids o Resuscitation – mother is priority * Anti-D immunoglobulin if Rh -ve and Kleihauer test * IOL if early foetal compromise • Appropriate surgical intervention may be required o Severe bleeding/mother haemodynamically unstable/evidence of foetal distress - deliver baby urgently whatever its gestational age o if bleeding during delivery + pharmacological measures fail to control haemorrhage - initiate intrauterine tamponade +/or surgical haemostatic techniques incl. interventional radiological techniques o Consider hysterectomy in severe cases if conservative medical + surgical interventions prove ineffective • If immediate delivery is not likely (mother haemodynamically stable, no evidence of foetal distress) o Admit until bleeding has stopped + for a further 48h for observation o Maternal steroids – to promote fetal lung development + reduce the risk of respiratory distress syndrome + intraventricular haemorrhage o Rescan at 36 weeks - If still low-lying placenta – recommend elective CS at 36+0-37+0 weeks gestation

Answer 28

• High risk of placenta accreta in women with placenta praevia who have previously had a c-section • Dx o Antenatal imaging techniques – e.g. grey scale/colour flow Doppler, 3D ultrasonography o Can help raise the suspicion of a morbidly adherent placenta o Should be considered in any situation where any part of the placenta lies under the previous C-section scar, even if not praevia o Definitive dx can only be made at surgery • Care bundle for suspected placenta accreta (6 elements of good care) o Consultant obstetrician planned + directly supervising delivery o Consultant anaesthetist planned + directly supervising anaesthetic at delivery o Blood and blood products available on site o MDT involvement in pre-operative planning o Discussion + consent incl. possible interventions e.g. hysterectomy, leaving the placenta in place o Locally available level 2 critical care bed • Uterus should be opened at a site distant from the placenta, delivering the baby without disrupting the placenta o Then – conservative mx of the placenta or hysterectomy if accreta is confirmed

Answer 29

* Women presenting with placenta previa or low-lying placenta + a hx of vaginal bleeding or other associated RF for preterm delivery - Late preterm (34+0 to 36+6 weeks of gestation) delivery should be considered * If uncomplicated placenta praevia - delivery should be considered between 36+0 and 37+0 weeks of gestation * Third trimester asymptomatic low-lying placenta - consider the distance between the placental edge + the fetal head position relative to the leading edge of the placenta on TVS * Grade I - can delivery vaginally * Grade III + IV - C-section * Consultant obstetrician + consultant anaesthetist should be present within the delivery or theatre suite when the surgery is occurring * Consider vertical skin and/or uterine incisions when the fetus is in transverse lie to avoid the placenta, particularly below 28 weeks of gestation

Answer 30

• Confirmed vasa praevia in the third trimester o Elective C-section prior to the rupture of membranes o Prophylactic hospitalisation form 30-32 weeks of gestation in women with confirmed vasa praevia should be individualised and based on a combination of factors, incl. multiple pregnancy, antenatal bleeding and threatened premature labour • Bleeding vasa praevia o Emergency C-section o Neonatal resuscitation (incl. the use of blood transfusion) o Delivery should not be delayed while trying to confirm the diagnosis (fetal exsanguination can occur rapidly, high perinatal mortality) • After birth o Placental pathological examination to confirm the diagnosis  In particular where stillbirth has occurred or where there has been acute fetal compromise during delivery

Answer 31

* Stop tobacco/cocaine/amphetamine misuse * If vaginal bleeding -stop taking anticoagulant medication + go to hospital • Mild – if preterm + stable – conservative management with close monitoring – IOL at term o Admit for at least 48h or until bleeding stops o Anti-D Ig

Answer 32

• ABC, emergency CS, 3x wide bore cannulae, fluids, blood transfusions, correct coagulopathies o FBC, G+S, crossmatch, Kleihauer test (and anti-D if needed), clotting screen, steroids (between 24-34+6w) o CTG (if >27w), consider IOL if fetal compromise, TVUSS (?placenta praevia) • Resuscitate mother – ABCD o Evaluate circulation  IV access, FBC, coagulation screen, U+E, Kleihauer test, crossmatch 4 units  Position in left lateral position tilted + keep the woman warm  Principles of fluid replacement + administration of blood products are the same for APH as they are for PPH  Fluid – Until blood is available, infuse up to 2L of warmed crystalloid Hartmann’s solution +/or 1-2L of colloid as rapidly as required  Blood-product replacement – With continuous massive haemorrhage + whilst awaiting coagulation studies + haematology advice - give up to 4 units of FFP (1l) and 10 units (2 packs) of cryoprecipitate empirically  Blood transfusion - Measure central venous pressure (CVP) + adjust transfusion accordingly  Antifibrinolytics o Asses fetus and decide on delivery  If fetus is alive – C-section or artificial rupture of the amniotic membranes – monitor the fetus + switch to Caesarean if fetal distress develops  If fetus is dead + haemorrhage is controlled – vaginal delivery  If fetus is dead + abruption is massive – C-section to control haemorrhage  If bleeding has settled + delivery is not imminent – maternal steroids to promote fetal lung development + reduce the risk of RDS and intraventricular haemorrhage * CTG once mother is stable or resuscitation has commenced, to aid decision making on the mode of delivery * Anti-D ig * Admit for at least 48h or until bleeding stops • If bleeding settles, consider discharging home with weekly serial growth scans until term o Placental abruption + abnormal CTG or mother is haemodynamically unstable - delivery (irrespective of gestation) o Antenatal Corticosteroids to women between 24+0 and 34+6 weeks of gestation at risk of preterm birth  24mg in 2 doses (12mg each, separated by 12 hours)  If mum is haemodynamically unstable, we wont have enough time to give steroids • Preterm pregnancy o Placental abruption + normal CTG (no evidence of foetal distress) and mother haemodynamically stable - conservative (expectant) management  >37 w - IOL  <37 w - steroids + admit to antenatal ward for close monitoring * If a woman presents with spotting and has a PHx of IUD resulting from placental abruption - hospitalisation * APH – Consider using ergometrine-oxytocin for the third stage of labour (to reduce the risk of PPH)

Answer 33

Hospitalisation

Answer 34

* Metformin is safe * Exenatide, liraglutide, sitagliptin to be avoided * Sulfonylureas (gliclazide) – to be avoided – risk of neonatal hypoglycaemia

Answer 35

• Lamotrigine has been increasingly prescribed in pregnancy • Once an unplanned pregnancy has been discovered it is usually too late for changes to be made to the epilepsy treatment regimen o The risk of harm to the mother + fetus from convulsive seizures outweighs the risk of continued therapy • Sodium valproate o Should never be used for epilepsy in women with childbearing potential unless there is no effective treatment available o Women on valproate with unplanned pregnancy  refer urgently to a specialist but continue treatment until they are seen • Need to balance risk of AEDs with the effect of seizures  foetal + maternal hypoxia ``` • If treatment with AEDs must continue throughout pregnancy o Monotherapy o Lowest effective dose o Preferred AEDs – lamotrigine o Contraindicated – sodium valproate ``` • Folic acid o 5mg per day before any possibility of pregnancy + throughout the first trimester o To reduce the risk of neural tube defects, major congenital malformation and AED-related cognitive deficits

Answer 36

• Anticonvulsants that induce liver enzymes (phenytoin, barbiturates, primidone, topiramate, carbamazepine, oxacarbazepine) o Depot medroxyprogesterone acetate o IUCD o LNG-IUS o Barrier methods o Natural family planning methods o NOT recommended: POP, progestogen implant

Answer 37

• Oestrogen-based contraceptive o Can result in a sig. reduction of lamotrigine levels o Can lead to loss of seizure control o Women taking lamotrigine monotherapy and oestrogen-containing contraceptives should be informed of the potential  in seizures due to fall in the levels of lamotrigine

Answer 38

• Possibility of status epilepticus + SUDEP should be discussed with all women + girls who plan to stop AED therapy o Status epilepticus = convulsive seizure that continues for a prolonged period of time (longer than 5 minutes), or convulsive seizures that occur one after the other with no recovery between.

Answer 39

o Sodium valproate – neural tube defects – NO o Phenytoin – cleft palate – NO o Lamotrigine + levetiracetam – lowest rate of congenital malformations – YES o Carbamazepine – least teratogenic of the old antiepileptics

Answer 40

assess for eclampsia before changing anti-epileptic treatment

Answer 41

• Delivery mode + timing unaffected unless seizures are increasing in frequency

Answer 42

* Women should deliver in a centre with adequate facilities for maternal + neonatal resuscitation * The risk of seizures in labour is low * Risk of tonic-clonic seizure during the labour and the 24h after birth is low • During labour o Should continue to take their AEDs  If this cannot be tolerated orally  parenteral alternative o Adequate analgesia + appropriate care in labour to minimise RF for seizures e.g. insomnia, stress, dehydration  Pain relief in labour should be prioritised in WWE  TENS (transcutaneous electrical nerve stimulation), NO + O2 (Entonox), regional anaesthesia  Diamorphine should be used in preference to pethidine  Pethidine should be used with caution in WWE for analgesia in labour o Long-acting benzodiazepines e.g. clobazam can be considered if there is a very high risk of seizures in the peripartum period o IV access in case of seizure  IV benzodiazepine (e.g. lorazepam, diazepam) – recommended to terminate any seizures  Seizures should be terminated asap to avoid maternal + fetal hypoxia + acidosis o If BZD used to terminate seizure  loss of baseline variability of the fetal heart rate tracing can be expected for approx. 1h o Continuous CTG  Recommended in women at high risk of a seizure in labour  Following an intrapartum seizure (GTC seizures are associated with hypoxia) • To be avoided o Birthing pools o Hyperventilation + maternal exhaustion

Answer 43

• All babies born to WWE taking enzyme-inducing AEDs o Should be offered 1mg of IM vitamin K o To prevent haemorrhagic disease of the newborn

Answer 44

• Overall chance of seizures during + immediately after delivery is low but relatively higher than during pregnancy • AEs should be continued postnatally o If doses have been increased during pregnancy  Medication requirement is likely to fall in the puerperium Toxicity may occur - review within 10 days of delivery • Withdrawal effects in the newborn may occur with some AEDs – esp. BZD, phenobarbital • Breastfeeding o Encourage breastfeeding o Breastfeeding for most women taking AEDs  generally safe, should be encouraged o Drowsiness in breast-fed babies  primidone, phenobarbital, benzodiazepines * Risk of postpartum seizures, particularly in the setting of sleep deprivation, stress, pain * Juvenile myoclonic epilepsy in mother– myoclonic jerks tend to be more frequent in the early morning, often around the time of infant waking * Restart contraception

Answer 45

o Change or feed the baby on the floor o Avoid baby slings o Minimise climbing of stairs o Avoid bathing the baby when alone

Answer 46

• Once treatment is completed, check for resolution o After taking abx pregnant women will have another urine culture done to make sure the bacteria were killed o If culture is negative  screen for re-infection periodically until they give birth

Answer 47

Send urine for MCS Start abx immediately Change abx according to susceptibility when results of MCS are back - using a narrow-spectrum abx wherever possible • Adverse effects of abx – diarrhoea + nausea • Safety netting – Seek medical help if abx are taken and o Symptoms worsen rapidly or significantly at any time or o Symptoms do not start to improve within 48h of taking the abx or o Person becomes systemically unwell • Refer if they have any symptoms or signs suggesting a more serious illness or condition e.g. sepsis

Answer 48

* Drink plenty of fluids – at least 8 glasses of water per day * Avoid alcohol, citrus juices, spicy food, caffeinated drinks which can irritate the bladder * Don’t douche * Wipe front to back after bowel movement * Urinate shortly after having sex * Cranberry products

Answer 49

• Confirm with a repeat sample • Offer an immediate antibiotic but send MSU before starting – choose from o Nitrofurantoin  If eGFR >45ml/min  100mg modified-release BD 7/7  Avoid at term – may produce neonatal haemolysis o Amoxicillin  Only if culture results available + susceptible  500mg TDS 7/7 o Cefalexin  500mg BD 7/7 • Duration – 7 day course • If GBS bacteriuria identified o Write in notes – Ensure antenatal services are made aware o In addition to the treatment at the time of dx, IAP (intrapartum abx prophylaxis) will be required – IV benzylpenicillin intrapartum • Advise women to seek urgent medical review if any symptoms develop

Answer 50

o Trimethoprim  Contraindicated in pregnancy  Folate antagonist  teratogenic risk in the first trimester  Can sometimes be used in pregnancy when given with folic acid 5mg daily in the first trimester  Safe in breastfeeding women

Answer 51

• Immediate prescription of abx but send MSU before starting o Nitrofurantoin  First line  Usual dose – 100mg modified-release BD 7/7  If eGFR >45ml/min  Not recommended at term pregnancy  may produce neonatal haemolysis o Second line:  Amoxicillin – 500mg TDS for 7/7 • Recommended only if culture results are available + bacteria are susceptible (high resistance rates)  Cefalexin – 500mg BD for 7/7  Second line at usual doses • if lower UTI symptoms do not improve on a 1st-choice abx taken for at least 48h • if first-choice abx are not suitable

Answer 52

• Cephalexin o First-choice oral abx o 500mg BD/TDS for 7-10/7 o Severe infections – 1g-1.5g TDS/QDS • Cefuroxime o First line IV abx o If vomiting, unable to take oral abx or severely unwell o 750mg – 1.5g TDS/QDS • Refer to specialist for advice

Answer 53

• Untreated hyperthyroidism in women lighter, irregular periods, difficulty conceiving • After treatment o If woman has had recent radioactive iodine treatment  advise her to avoid becoming pregnancy for at least 6 months after the treatment o Planning a pregnancy – blood test to check thyroid function o If TFTs are not within the euthyroid range  Advise delaying conception + using correct contraception until thyroid function has normalised o Not planning a pregnancy – contraception during + after treatment (normal fertility can return extremely quickly) • Advise woman to seek immediate medical advice if pregnancy is suspected or confirmed • Referral to an endocrinologist specialist o Check serum TSH, FT4 (free thyroxine levels) o Consider checking TPOAb status (thyroid peroxidase antibody) * Offer advice of sources of information and support * Radioactive iodine is contraindicated in people who are pregnant/trying to become pregnant within the next 4-6 months - obliterates the fetal thyroid, risk of inducing fetal hypothyroidism

Answer 54

• Urgent specialist referral o Check TSH, FT4, FT3 for all women o TRAbs

Answer 55

• Pregnancy increases thyroid hormone requirements o Women often require lower doses of antithyroid drugs during pregnancy o 1/3 women are able to stop treatment altogether during pregnancy o Grave’s disease tends to enter remission as pregnancy proceeds  doses can usually be reduced or withdrawn in the 3rd trimester • Many women with mild hyperthyroidism during pregnancy are not treated o Mild hyperthyroidism is managed with adequate hydration + low calcium diet

Answer 56

o Propylthiouracil o Women on carbimazole (CMZ) should change to propylthiouracil (PTU)  PTU may cross the placenta less readily than (CMZ)  CMZ has been associated with teratogenic defects  Thiamazole + carbimazole are associated with more common + severe birth defects than propylthiouracil  If CMZ is the only choice use that – risks of untreated maternal hyperthyroidism outweigh those of potential teratogenicity o “Block and replace” should not be used in pregnancy • Medications to continue in labour

Answer 57

o Can cross the placenta and affect fetal thyroid function o Have been associated with birth defects o Lowest possible dose of antithyroid drugs should be used

Answer 58

``` o Skin rash 7-12% o Agranulocytosis 0.1-0.5% o Severe liver damage o Fetal hypothyroidism  From high doses crossing the placenta – use low doses ```

Answer 59

o Propranolol  Associated with neonatal hypoglycaemia, apnoea, bradycardia, IUGR  Use should be minimised  Fetal growth should be closely monitored o Labetalol o CCB – discouraged as their effects on the fetus are not known o Uses of BB beyond a few weeks may adversely affect the fetus – not advised o Beta blockers contraindicated if there is a hx of – asthma, bradycardia, heart block

Answer 60

• Untreated/undertreated hypothyroidism in women longer or heavier periods  anaemia or periods may stop completely • Check TFTs before conception o If TFTs are not within the euthyroid range  Advise delaying conception + using correct contraception until the woman is stabilised on levothyroxine (LT4) treatment o Experts recommend that if you are on LT4, TSH level should ideally be kept in the lower half of the reference range(<2.5 mU/l) before + during pregnancy   risk of miscarriage * Inform that there is likely to be an increased demand for LT4 during pregnancy * Her LT4 dose must be adjusted asap in pregnancy to reduce the risk of obstetric + neonatal complications * Advise woman to seek immediate medical advice if pregnancy is suspected or confirmed * Offer advice of sources of information and support

Answer 61

• Check TFTs immediately once pregnancy is confirmed o Interpret results using a pregnancy-related reference range o Discuss urgently with an endocrinologist regarding initiation/changes to dosage of LT4 + TFT monitoring while waiting for specialist review

Answer 62

• Levothyroxine • It may be necessary to increase the dose of levothyroxine in the first trimester of pregnancy o By 25-30% o dose should be increased by approx. 25-50 mcg daily or LT4 dose should be doubled on 2 days of the week even if currently euthyroid  To provide sufficient supply of thyroid hormones to the baby o Repeat TFTs in 4 weeks + perform in each trimester, make adjustments if necessary • Continue thyroid replacement therapy throughout pregnancy o Aim for biochemical euthyroid (TSH <4mmol/L) o TSH + T4 levels are checked every 8 weeks * Dose adjusted in small increments to normalise TSH * Long half-life of levothyroxine (1 week) – TSH should be measured 4-6 weeks after initiation of therapy or dosage change

Answer 63

o Nephrotic syndrome o Malabsorption (e.g. coeliac disease) o Concomitant use of iron/cholestyramine/calcium/sucralfate/anticonvulsants (e.g. phenytoin, phenobarbital, carbamazepine), rifampin, sertraline o Gaviscon o Iron/calcium/Gaviscon – should be taken several hours before or after the LT4  these can alter the absorption of levothyroxine

Answer 64

* For many women following delivery, the LT4 dose should be reduced to pre-pregnancy levels * TFTs monitoring at 6-8 weeks postnatal check with GP * Breastfeeding – safe when on LT4 * In the UK, all babies have a heel-prick blood test to screen for hypothyroidism shortly after birth * Treatment can be started very quickly if baby needs LT3 * Hypothyroidism is rare in newborn babies in the UK

Answer 65

• TFTs after delivery o Mother – six weeks, 3 months o Neonate – 6hours, few days later (neonate will have metabolised any maternal antithyroid drugs by this time) • Check TSH, FT4 levels 6-8 weeks postpartum (post-natal check), particularly if the woman has any of the following o Goitre o Sx of thyroiditis o Hx of postpartum thyroiditis or positive TPOAbs o Hx of autoimmune thyroid disease e.g. Graves’ disease * For many women following delivery, the LT4 dose should be reduced to pre-pregnancy levels * Serum TSH should be checked after 6 weeks * Once stable, TSH should be measured at least annually * 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

Answer 66

• Breastfeeding o Antithyroid drugs at low-moderate doses are thought to be safe during breastfeeding o Usually taken in smaller doses over 2-3x/day following a feed o If higher doses are required  blood test to check whether baby’s thyroid is being affected o Mothers with Grave’s disease who are not taking antithyroid drugs  can safely breastfeed

Answer 67

• Three stages – thyrotoxicosis  hypothyroidism  euthyroid o Refer to an endocrinologist specialist to differentiate between suspected PPT from Grave’s disease • Check TFTs 4-8 weeks after resolution of the thyrotoxic phase to screen for the hypothyroid phase – or sooner if symptoms develop o Thyrotoxic phase – propranolol (ant-thyroid drugs are not used) o Hypothyroid phase – thyroxine Hypothyroidism phase o If it persists, may need to take LT4 tablets  most women are able to stop taking these tablets after 6-12 months o Around 1/3 of women develop permanent hypothyroidism  need LT4 for the long term o Symptomatic women who are breastfeeding + those planning another pregnancy  treated with LT4 o Untreated asymptomatic women who are not planning a pregnancy  reassessment in 4-8 weeks  if TSH remains above the reference range  consider starting treatment with LT4 o Untreated asymptomatic women  check TFTs every 4-8 weeks until thyroid function normalises

Answer 68

o Annual TFT monitoring for all women with a history of postpartum thyroiditis which has been resolved o TFTs before next conception to ensure that hypothyroidism hasn’t developed * 50% risk that you develop a recurrence of PPT in subsequent pregnancies * Offer advice on source of information and support

Answer 69

o ACEi, ARBs, thiazide diuretics, statins, warfarin

Answer 70

• Arrange contact with joint cardiac + obstetric clinic o Every 2-4 weeks until 24w gestation + weekly thereafter • Monitoring o Maternal echo at booking + repeat at 28 weeks o Specialist foetal cardiac scan at 22 weeks • Anticoagulation – LMWH SC o Patients with congenital heart disease who have pulmonary HTN or artificial valves o Those at risk of AF • Vasodilators (hydralazine, nitrates, amlodipine) – to  afterload in the presence of ventricular dysfunction

Answer 71

• In most cases – wait for spontaneous labour o 2nd stage kept short with elective forceps or ventouse delivery -  maternal effort + need for an increased CO o 3rd stage – active management with syntocinon alone  Syntocinon is a vasodilator  introduce it slowly  Avoid ergometrine – dangerous (vasoconstriction, hypotension, HF) • C-section for those where any effort is dangerous • IOL in very high-risk women to ensure that delivery occurs at a predictable time with all the personnel present o Epidural – to reduce pain-related cardiac strain o Risk of maternal hypotension • Prophylactic abx for all women with structural heart defects o  risk of bacterial endocarditis • PPH dangerous  can lead to cardiovascular instability

Answer 72

• Monitoring o Transfer to HDU for close monitoring for first 12-28h o Arrange obstetric + cardiac F/U

Answer 73

* Echocardiogram at booking and at 28 weeks * Anticoagulation may be necessary * Avoid IOL if possible * Use prophylactic antibiotics * Ensure fluid balance * Avoid supine position * Discuss regional/epidural anaesthesia * Keep the second stage short * Use syntocinon judiciously

Answer 74

o Pulmonary oedema – salt restriction, diuretics o Vasodilators (hydralazine, nitrates, amlodipine) – to  afterload in the presence of ventricular dysfunction o If at high risk of thromboembolism – anticoagulation o Post-partum  ACEi (not given antenatally  fetotoxic) o Time of delivery should be dictated by obstetric considerations

Answer 75

* LFTs + bile acid levels – weekly until delivery * Doppler + CTG – twice weekly until delivery * Women with persistent pruritus + normal biochemistry should have LFTs (+bile acid levels) repeated every 1-2 weeks (until pruritus resolves) • Postnatal resolution of pruritus + abnormal LFTs should be confirmed o Postnatally, LFTs should be deferred for at least 10 days

Answer 76

• Women should be booked in under consultant-led team-based care and give birth in a hospital unit • Conservative o Wear cool, loose, cotton clothing o Soak in a cool bath o Apply ice packs for short periods in affected areas o Advise paying close attention to fetal movements • Ursodeoxycholic acid (UDCA) o Mainstay of medical management o Improves pruritus + liver function o But lack of robust data concerning protection against stillbirth + safety to the fetus or neonate • Antihistamines (e.g. chlorphenamine) o Improve sleep o No impact on pruritus • Vitamin K o If prothrombin time is prolonged/ if there is steatorrhoea o Water soluble vitamin K (menadiol sodium phosphate) in doses of 5-10mg daily o Avoid vitamin K late in pregnancy + labour – risk of neonatal haemolytic anaemia, hyperbilirubinaemia, kernicterus

Answer 77

• Induction at 37+0 weeks o Aim to deliver no later than 40 weeks o Perinatal + maternal morbidity increase from 37 weeks of gestation onwards o Advise to delivery in labour ward, with continuous CTG monitoring • Offer continuous fetal monitoring in labour

Answer 78

* Postnatally, LFTs should be deferred for at least 10 days | * Measure LFTs at the 6-week PN check to ensure resolution

Answer 79

• Supportive care  stabilisation o Admit to ITU o Continuous maternal and fetal monitoring o Correct coagulopathy, electrolytes, hypoglycaemia • Consider early delivery o As soon as maternal condition is stable or o As soon as possible if maternal condition deteriorating o Delivery is the definitive management to prevent deterioration

Answer 80

• Most effective treatment of HELLP – prompt delivery o Delivery of fetus after 34 weeks of gestation if multisystem disease is present o If fetus <34 weeks + delivery can be deferred – give CS to promote fetal lung maturation * Magnesium sulfate * Transfusion of RBC, plt, FFP and cryoprecipitate or fibrinogen as indicated clinically by blood and coagulation tests • Postpartum HELLP syndrome – treated with plasma exchange * BP control is essential * If severe liver damage  transplantation * There is no proven treatment or prophylaxis for HELLP syndrome

Answer 81

• Routine iron replacement in pregnancy is not recommended in the UK o If given routinely, iron supplementation causes iron overload leading to haemochromatosis, placental insufficiency o Dietary advice  Iron – green leafy vegetables, nuts, beans, seeds  Folate – green leafy vegetables, nuts, yeast, liver  B12 – meat and dairy o Oral iron supplements (repletion through diet alone is not possible)  Ferrous iron salts – oral ferrous sulphate  40-80mg every morning  Check Hb at 2-3 weeks to ensure adequate response  Advice – on an empty stomach with water or a source of vitamin C, other multivitamins + antacids or iron-rich food with substances which inhibit its absorption (e.g. tea, coffee, or foods rich in calcium) should not be taken at the same time  SE – black stools, constipation, abdominal pain  Once Hb is in the normal range • Replacement to continue for 3 months and • At least 6 weeks post-partum to replenish iron stores

Answer 82

 IV access + group and save on admission  Women with Fe deficiency anaemia + Hb <100g/l should delivery in an obstetrician led unit + should have active management of the third stage of labour • Active management: 1) uterotonic, 2) early cord clamping, 3) CCT (controlled cord traction) + counterpressure on the uterus to deliver placenta  Active management of PPH  Consider prophylactic syntocinon infusion

Answer 83

 Check Hb 48h after delivery in • Women with blood loss >500ml • Women with uncorrected anaemia detected in the antenatal period • Women with symptoms of anaemia postnatally  if Hb <100 g/l 48h after delivery • Offer oral elemental iron 40-80 mg PO for at least 3/12

Answer 84

o Anaemia is severe (Hb <70 g/l) and/or o Associated with significant symptoms or advanced gestation (>34 weeks) or o If the Hb is failing to respond after 2-3 weeks of oral iron correctly taken

Answer 85

o Offer TOP if presence of B2 thalassaemia major ``` o Women with known thalassaemia  Specialist antenatal care  High dose folate (5mg per day)  Frequent USS  Regular Hb monitoring  Transfusions ```

Answer 86

 High dose folate (5mg per day)  FBC routinely checked 20, 28, 32 weeks  Transfusion considered if – Hb falls <60 g/L or if there is a fall of 20g/L from baseline  Iron supplements not needed unless serum iron + ferritin levels are reduced  Use of regular prophylactic transfusions not recommended  Prophylactic abx through pregnancy + afterwards

Answer 87

o While on heparin  UFH – aPTT 6h after the loading dose + then daily, plt count monitoring performed every 2-3/52 from days 4-14 until heparin is stopped  LMWH – Consider monitor Anti-Xa activity if weight <50kg or >90kg or with other complicating factors (e.g. renal impairment, recurrent VTE)

Answer 88

 Dehydration + immobilisation should be avoided throughout pregnancy * If signs/ sx of VTE or PE  LMWH until dx excluded by testing * Massive life-threatening PE  Echo/CTPA within 1h, IV UFH (1), thrombolysis (2) • Previous VTE  LMWH from start o Previous VTE related to surgery + no other RF  start from 28w o Unprovoked/ idiopathic/ oestrogen related VTE or other RF (FHx in 1st relative, thrombophilia)  LMWH from start • After VTE/PE  SC LMWH for remainder of pregnancy + for at least 6w PP until 3m of treatment in total • Recurrent VTE  LMWH, stop warfarin o If receiving long-term anticoagulation with warfarin can be converted from LMWH to warfarin PP when risk of haemorrhage is reduced (5–7 days after delivery) * Antithrombin deficiency/ APL/ recurrent VTE  high dose LMWH from start + for 6w PP * Hyperemesis  LMWH, discontinue when hyperemesis resolves * OHSS  LMWH in 1st trimester * IVF + 3 RF  start LMWH in 1st trimester * VTE at term  IV UFH

Answer 89

PP • Offer LMWH SC or warfarin PO Warfarin • Avoid warfarin until at least the 5th day PP • Need for regular blood tests when monitoring warfarin, particularly in the first 10 days of treatment (INR) • Target INR – 2-3 LMWH • After delivery – first dose asap if no PPH + regional anaesthesia not used • Heparin should be continued until the INR is >2.0 for at least 24h ``` • 10d LMWH if o Intermediate risk o BMI >40kg/m2 o EMCS o ELCS + additional RF ``` ``` • 6w LMWH if o High risk women o Previous VTE o FHx in 1st relative + thrombophilia o Antithrombin deficiency/ APL/ recurrent VTE ``` • Birth/ Miscarriage/ TOP  consider if risk of VTE > risk of bleeding, 7d

Answer 90

 In women who are likely to be immobilised or have significantly reduced mobility  Should continue until the woman is sufficiently mobile or discharged from the hospital  For women travelling long-distance for >4h  Prior VTE (combined with LMWH)  Hospitalised women with contra-indication to LMWH  Post C- section (combined with LMWH)  First line – intermittent pneumatic compression  Second line – anti-embolism stockings

Answer 91

 Should be considered for LMWH during hospital admission  Should start LMWH 4- hours after the event  Should continue for a minimum of 7 days

Answer 92

o Should be commenced in clinically suspected DVT or PE until the dx is excluded by objective testing, unless treatment is strongly contraindicated o Should be given in doses titrated against the woman’s booking or early pregnancy weight o Does not require monitoring  Consider monitor Anti-Xa activity if weight <50kg or >90kg or with other complicating factors (e.g. renal impairment, recurrent VTE)

Answer 93

o Baseline blood tests o Elevate leg + Elastic graduated compression stockings o Empirical treatment with LMWH until the dx is excluded by objective testing o Compression duplex US  Negative US • + low level of clinical suspicion – anticoagulant treatment can be discontinued • + high level of clinical suspicion – anticoagulant treatment should be discontinued + US should be repeated on days 3 + 7

Answer 94

o Baseline blood tests o LMWH o ECG + o CXR  If CXR is normal/ if DVT suspected alongside PE – compression duplex Doppler • If compression ultrasonography confirms the presence of DVT, no further investigation is necessary + treatment for VTE should continue i.e. not need to scan for PE if DVT already confirmed on scan  If CXR is abnormal + there is high clinical suspicion of PE/ if no DVT suspected alongside PE – CTPA > V/Q  If CXR or compression duplex Doppler is negative – CTPA or V/Q  V/Q or CTPA normal but clinical suspicion of PE remains • Alternative or repeat testing • Continue anticoagulant treatment until PE is definitely excluded

Answer 95

o Team – senior physicians, obstetricians, radiologists o Echo or CTPA within 1h of presentation should be arranged  If massive PE is confirmed or in extreme circumstances prior to confirmation – immediate thrombolysis should be considered o Women should be managed on an individual basis  1st line – IV UFH (monitor with APTT)  2nd line – Thrombolytic therapy, or thoracotomy + surgical embolectomy

Answer 96

o Most common in post-partum o Sagittal sinus most commonly o Headache + varying neurology o MRI (CT may be first to exclude stroke) o IV UFH  Thrombolysis  3-6m anticoagulation

Answer 97

o Therapeutic doses of SC LMWH should be employed during the remainder of the pregnancy + for at least 6 weeks PN until at least 3 months of treatment has been given in total o Alternative anticoagulant (heparinoid, danaparoid sodium or fondaparinux) if – HIT (heparin induced thrombocytopenia) or heparin allergy o Vitamin K antagonists (e.g. warfarin) – should not be used for antenatal VTE treatment – adverse effects on fetus (teratogenic, can cause placental abruption, can cause fatal/neonatal haemorrhage) o LMWH – does not need monitoring, anti-Xa only needs monitoring at the extremes of weight (<50kg or >90kg) o UFH – monitor the platelet count at least every other day for the first 14 days or until the treatment is stopped o If unable to tolerate heparin (LMWH or UFH) or danaparoid – consider use of newer anticoagulants (fondaparinux, argatroban, r-hirudin)

Answer 98

o IV UFH o If woman is on LMWH maintenance therapy – should not inject any further heparin once she is in established labour o If ELCS or IOL – LMWH maintenance therapy should be discontinued 24h prior to planned delivery o Regional anaesthetic or analgesic techniques – should not be undertaken until at least 24h after the last dose of therapeutic LMWH o LMHW – should not be given for 4 hours after the use of spinal anaesthesia or after the epidural catheter has been removed  The epidural catheter should not be removed within 12h of the most recent injection o Patients will be managed with IV UFH throughout this time

Answer 99

o Therapeutic anticoagulant therapy should be continued for the duration of the pregnancy + for at least 6 weeks PN + until at least 3 months of treatment has been given in total – reduces the risk of post-thrombotic syndrome o Before discontinuing treatment, the continuing risk of thrombosis should be assessed o Offer women a choice of LMWH or oral anticoagulant for PN therapy o PP warfarin should be avoided until at least the 5th day + for longer in women at  risk of PPH  Need for regular blood tests for monitoring of warfarin, particularly during the first 10 days of treatment  Aim for an INR between 2 and 3  Continue heparin treatment until there have been 2 successive readings of an INR >2 o Neither heparin (LMWH, UFH) nor warfarin is contraindicated in breastfeeding – they are detectable in breast milk but they are all safe for use during breast-feeding – warfarin metabolites are inactive + heparin is not absorbed through the GIT • PN review o Perform thrombophilia testing once anticoagulant therapy has been discontinued only if it is considered that the results would influence the woman’s future management

Answer 100

o Post-thrombotic syndrome – a condition that can happen to people who have had a DVT of the leg – chronic extremity swelling, chronic pain, unspecific discomfort of the extremity, diffuse aching, heaviness/tiredness/cramping of the extremity, post-thrombotic pigmentation, bluish dscoloration of toes/fingers, foot/hand or diffusely of leg/arm, formation of varicose veins, stasis ulcer, atrophie blanche, dermatoliposclerosis o Prolonged use of LMWH (>12 weeks) – associated with a significantly  chance of developing post-thrombotic syndrome o DVT – graduated elastic compression stockings should be worn on the affected leg to reduce pain + swelling (but the role of compression stockings in the prevention of post-thrombotic syndrome is unclear)

Answer 101

o Limb or life-threatening embolus – surgical embolectomy or thrombus fragmentation may be attempted o Heparin does not cross the placental barrier o Heparin has to be parenterally administered o UFH administration – aPTT measurement should be taken 6h after the loading dose + then daily

Answer 102

o UFH – protamine sulphate o LMWH (SC) – irreversible (stop 24h before delivery) o Warfarin – FFP/ prothrombin complex concentrates

Answer 103

Known bleeding disorder Active AN or PP bleeding Women considered at increased risk of major haemorrhage (e.g. placenta praevia) thrombocytopenia (plt count <75 x10^9/L) Acute stroke in previous 4 weeks (haemorrhagic or ischaemia) Severe renal disease (GFR <30ml/min/1.73m2) Severe liver disease (PTT above normal range or known varices) Uncontrolled HTN (SBP >200 mmHg OR >120mmHg DBP)

Answer 104

• Admit to antenatal ward • Offer prophylactic antibiotics • Intense clinical surveillance for signs of chorioamnionitis • Clear liquor o 0-24 hour = expectant management  60% of women will labour within 24h  You may follow expectant management for up to 24h o >24 hours = IOL  4-hourly temperature and 24h foetal monitoring  Augment with PG or oxytocin infusion  Risk of chorioamnionitis with term PROM has been reported to be <10% and to increase to 40% after 24h of PROM o Monitor neonate for at least 12 hours after delivery – when the risk of infection is greatest • Meconium o Induce labour ASAP

Answer 105

• Urgent referral if o P-PROM is suspected o Ascending infection is suspected – maternal or fetal tachycardia, temperature, abdominal tenderness • Admit to antenatal ward for the first 48h o Intense clinical surveillance o Then managed at home if low risk of cord prolapse + normal inflammatory markers o Lack of consensus whether intense clinical surveillance is best inpatient or outpatient o Within imperial NHS trust, best practice is to admit until 28 week after which 2-3x/week outpatient monitoring until delivery • Intense clinical surveillance for signs of chorioamnionitis o At hospital  Mother – obs for maternal tachycardia or pyrexia, uterine tenderness, offensive vaginal discharge, leukocytosis, or  CRP  Fetus – CTG – fetal tachycardia (>160 bpm) o At home – 2ice daily to 4-8 hourly temperatures – infection requires hospital admission • Prophylactic antibiotic administration o Prophylactic antibiotics for P-PROM – reduced complications due to preterm delivery and postnatal infection o 1st line = Erythromycin 250 mg QDS <37 w for 10/7 or until labour is established if this is sooner o 2nd line = Penicillin or clindamycin for 10/7 or until labour is established if this is sooner  if GBS is isolated from a swab or if erythromycin is contra-indicated o Co-amoxiclav should not be used for prophylaxis in P-PROM – increases the risk of necrotising enterocolitis in the neonate o Intrapartum antibiotic prophylaxis may be given for women in premature labour if  Pre-labour rupture of membranes  Suspected/confirmed intrapartum rupture of membranes lasting >18 hours • Antenatal steroids • Magnesium sulfate o If in established labour or have a planned preterm birth within 24 hours – IV Magnesium sulfate should be offered between 24+0 and 29+6 weeks of gestation o Reduces cerebral palsy + motor dysfunction in the offspring o The benefit is greatest before 30+0 weeks of gestation o Should also be considered if preterm birth is anticipated between 30+0 and 33+6 weeks • Do not offer tocolysis * Offer additional emotional support during pregnancy + postnatally * In a subsequent pregnancy following PPROM, women should be cared for by an obstetrician with an interest in preterm birth

Answer 106

o Betamethasone two doses of 12mg IM 12-24h apart o Dexamethasone four doses of 6mg IM 12h apart o The medications are most effective from 2-7 days after the first dose o Between 24+0 and 33+6 weeks o Can be considered between 34+0 and 35+6 weeks of gestation o Significant reduction in rates of neonatal death, RDS, intraventricular haemorrhage o WCC will rise 24h following administration of CS + should return to baseline 3 days following administration o Corticosteroids induce DKA in diabetics so co-administer with insulin

Answer 107

• Delivery o If PPROM after 24+0 weeks + no contraindications to continuing the pregnancy  Expectant management until 37+0 weeks in cases without overt signs of infection o Chorioamnionitis can cause neurological damage in the fetus  once it is evident  delivery o Delivery advised if lung maturity is confirmed or clinical evidence of infection appears o Consider delivery at 34 weeks o If pregnancy continues over 36 weeks – increased risk of chorioamnionitis but reduced risk of respiratory problems for the neonate o Recommendation – women with PROM at term should not exceed 96 hours following membrane rupture o Neonatologists should be informed when the diagnosis of PPROM is confirmed and delivery is anticipated o Women with PPROM should have the opportunity to meet with a neonatologist antenatally to discuss their baby’s care

Answer 108

• Intravaginal progesterone + cervical cerclage • Cervical length <25mm on TVUS between 16+0 and 34+0 weeks o Women with previous preterm birth or pregnancy loss between 16+0 and 34+0 weeks  intravaginal progesterone or cervical cerclage o Women with no hx of preterm birth or pregnancy loss  intravaginal progesterone o Women with history of P-PROM in previous pregnancy or a history of cervical trauma  cervical cerclage

Answer 109

* Based on gestational age * Planed birth in an obstetric unit is recommended * Severe oligohydramnios – transfer to a tertiary referral centre * Treatment of maternal dehydration with PO or IV rehydration – has been shown to increase the AFV by 30% Amnioinfusion • NaCl or Ringer’s lactate is infused under US guidance via a needle inserted through the uterine wall • Can also be undertaken during labour transcervically via an intrauterine catheter o The RCOG does not recommend this for women with PROM Vesico-amniotic shunts • Fetal obstructive uropathy – Vesico-amniotic shunt may be used to divert fetal urine to the amniotic fluid cavity • Pulmonary function cannot be guaranteed with restoration of the AVF

Answer 110

* Expectant management * Ongoing antepartum surveillance (incl. assessment of fetal growth, dopplers, regular CTGs, follow-up monitoring of AFV) * Continuous fetal heart rate monitoring during labour

Answer 111

* Delivery is often the most appropriate management * With reassuring fetal testing, delivery may be safely delayed on the basis of the parity, GA, inducibility of the mother’s cervix and the severity of the oligohydramnios

Answer 112

• Insufficient evidence to support IOL

Answer 113

• Mx undertaken under secondary care – no guidelines or large studies to guide management decisions • Identified causes are treated as appropriate o Fetal hydrops anaemia – intravascular transfusion o GDM – tight glycaemic control • Mild polyhydramnios – monitored + treated conservatively • Preterm labour is common (overdistension of uterus) o Regular antenatal checks o Inspection of the uterus o Serial USS to monitor AFI + fetal growth o Give antenatal steroids if preterm delivery is imminent or considered • IOL if fetal distress develops • Prostaglandin synthetase inhibitors (e.g. indomethacin, sulindac) o Reduces renal blood flow o Reduces renal urination o Used usually for a maximum of 48 hours o Not used in twin-to-twin syndrome or after 32 weeks o Main risk: fetal ductus arteriosus constriction (the risk increases with gestation) • Amnioreduction o Drainage of amniotic fluid under US guidance o Used in cases where indomethacin is contraindicated, in severe polyhydramnios or in patients who are symptomatic o More commonly used in twin-to-twin transfusion syndrome o Serial procedures may be required • Laser ablation of connecting placental vessels o For polyhydramnios associated with twin-to-twin syndrome • (Alistair – COX inhibitors to decrease fetal urine output)

Answer 114

• Urgent referral to specialist care team (GU physician) • Refer to GUM clinic (for appropriate contact tracing) • Primary/secondary/early latent syphilis – IM benzathine benzylpenicillin stat • Tertiary/late latent syphilis – IM benzathine benzylpenicillin (once weekly, for 3 weeks) • If penicillin allergic – desensitise (oral or IV) + treat with penicillin (BMJ) or doxycycline (specialties guide) • Abx (patient.info) o 1st + 2nd trimester –IM benzathine penicillin stat o 3rd trimester – 2 doses benzathine penicillin one week apart • Partner, all siblings, any sexual partner to be screened for syphilis

Answer 115

o If the woman is not treated during pregnancy, treat the baby immediately after delivery o If stable/rising RPR/VDRL titres – child should be evaluated + treated o Confirmed proven/highly probable/possible congenital syphilis  IV aq benzylpenicillin or  IM procaine benzylpenicillin o Congenital syphilis less likely  IM benzathine benzylpenicillin o If allergic to penicillin – desensitisation + post-desensitisation penicillin as above

Answer 116

• Prevention – no licensed vaccine, preventive measures are not available • Conservative mx of mother o Rest + drink fluids o Paracetamol • Information + support o NHS leaflet o Not necessary to stay off work – infection is no longer contagious by the time the rash or arthropathy develops o If not fully immunised against rubella/no previous documented rubella infection – avoid contact with other pregnant women If B19V infection is confirmed in a pregnant woman following laboratory ix • Urgent referral to a specialist in fetal medicine o To be seen within 4w of the onset of symptoms • Specialist fetal monitoring (USS may start around 4 weeks after the onset of symptoms or estimated time of seroconversion) o Serial USS + Doppler assessment – to detect fetal anaemia, heart failure, hydrops fetalis o Hydrops fetalis presentation on US – ascites, thickening + enlargement of the fetal heart

Answer 117

• If suspected fetal hydrops/evidence of fetal anaemia o B19V viral DNA detection in amniotic fluid o Expectant management  Spontaneous resolution in 50% with no long term sequalae o In utero transfusion  Fetal blood sampling + intrauterine red blood cell transfusion – may reduce fetal mortality rate  Always offer if infection occurs in the first 20w of pregnancy (where risk of fetal loss is high = 10%)  Allows for complete recovery p • Admission if suspected acute complications in pregnancy o Urgent FBC + reticulocyte count • Emergency admission if o Sx of severe or aplastic anaemia – SOB, lightheadedness, lethargy, confusion o Maternal pre-eclampsia like syndrome • Information o Transfer to the fetus is unlikely – if it occurs, effective specialist treatment options available o Specialist fetal monitoring will be arranged

Answer 118

o Antenatal treatment not recommended for GBS cultured from a vaginal or rectal swab o During labour  IAP  Benzylpenicillin [once commenced, treatment should be given regularly until delivery]  Known/suspected penicillin allergy  cephalosporin (if not a severe allergy to penicillin)  Severe allergy to penicillin  vancomycin o IAP  Benzylpenicillin 3g as soon after the onset of labour  1.5g 4-hourly thereafter until delivery

Answer 119

o positive test for GBS in late pregnancy (incidentally or by intentional testing) o previous baby with early- or late-onset GBS disease o GBS bacteriuria during the current pregnancy • Women with GBS UTI (growth >10^5 cfu/ml) during pregnancy should receive appropriate treatment at the time of diagnosis as well as IAP NICE: Offer antibiotics during labour to women who: * are in pre-term labour or * have group B streptococcal colonisation, bacteriuria or infection during the current pregnancy or * have had group B streptococcal colonisation, bacteriuria or infection in a previous pregnancy, and have not had a negative test for group B streptococcus by enrichment culture or PCR on a rectovaginal swab samples collected between 35 and 37 weeks' gestation or 3-5 weeks before the anticipated delivery date in the current pregnancy or * have had a previous baby with an invasive group B streptococcal infection or * have a clinical diagnosis of chorioamnionitis.

Answer 120

• Abx prophylaxis specific for GBS is not required for women undergoing ELCS in the absence of labour and with intact membranes o However all women having CS are offered abx at the time of operation

Answer 121

o IAP or | o ECM testing for GBS between 35 and 37 weeks of pregnancy with IAP if test is positive

Answer 122

o Known GBS carriers  IAP + IOL asap | o Carrier status negative/unknown  IOL or expectant management up to 24h and then IOL

Answer 123

• If women with known GBS colonisation decline IAP – baby should be monitored closely for 12h after birth + discouraged from seeking very early discharged from the maternity hospital

Answer 124

• PROM known/unknown GBS carrier o Bacteriological testing for GBS carriage not recommended o IAP should be given once labour is confirmed or induced irrespective of GBS status o Evidence of colonisation in the current pregnancy/in previous pregnancies  <34+0 weeks  risks of PTL outweigh risks of perinatal infection  >34+0 weeks  offer immediate birth by IOL or CS

Answer 125

if you are pregnant and get shingles there is no danger to your pregnancy or baby

Answer 126

• Uncertain/ no previous history of chickenpox who come from tropical/subtropical countries who have been exposed to infection  blood test to determine VZV immunity or non-immunity

Answer 127

• Varicella vaccination pre-pregnancy or postpartum o Should be considered for women who are seronegative for varicella-zoster virus immunoglobulin G (VZV IgG) o If vaccinated postpartum still safe to breastfeed • Women who have no had chickenpox/are known to be seronegative for chickenpox o Advise to avoid contact with chickenpox + shingles during pregnancy o Inform HCP of a potential exposure without delay

Answer 128

• If the mother had previously had chickenpox – no need to do anything • If there is any doubt about the mother previously having chickenpox – maternal blood checked urgently for varicella antibodies before giving therapy o Antibodies present – no further action o No antibodies present – at risk of developing chickenpox - VZIG • Varicella-zoster immunoglobulin (VZIG) o Best to have it within 4 days of coming into contact with the virus o Effective when given up to 10 days after contact (in the case of continuous exposures, this is defined as 10 days from the appearance of the rash in the index case) o <20 weeks + not immune to varicella – VZIG asap o >20 weeks + not immune to varicella – VZIG or Antivirals (acyclovir (800 mg QDS) or valacyclovir) should be given days 7-14 after exposure o Once chickenpox symptoms have developed, VZIG cannot be given • Managed as potentially infectious o from 8-21 days after exposure if they do not receive VZIG o from 8-28 days after exposure if they receive VZIG • A second dose of VZIG may be required if a further exposure is reported and 3 weeks have elapsed since the last dose • Daily reviews

Answer 129

• Women who have had exposure to shingles (regardless of whether or not they have received VZIG) should be asked to notify their doctor or midwife if a rash develops o A pregnant woman who develops a chickenpox rash should be isolated form other pregnant women when she attends GP/hospital o Women should avoid contact with potentially susceptible individuals e.g. other pregnant women and neonates until the lesions have crusted over – usually about 5 days after the onset of the rash • Symptomatic treatment + hygiene – to prevent secondary bacterial infection of the lesions

Answer 130

• Seek specialist advice • Oral acyclovir (800mg 5/day for 7 days) o <20 +0 w  consider oral acyclovir (seek specialist advice) o >20 +0 w  give If they present within 24h of the onset of the rash o Not licensed for use in pregnancy  risk and benefits of use should be discussed with the woman o Does not cure chickenpox but makes it less severe • IV acyclovir o Severe chickenpox • VZIG o No therapeutic benefit once chickenpox has developed o Should not be used in pregnant women who have developed a chickenpox rash • If mum develops chickenpox within 7 days before or after the birth of the baby o Baby can be given VZIG o Newborn babies who develop chickenpox despite being given VZIG may be treated with antiviral medicines by specialists in the hospital • Hospital admission o Team – obstetrician or fetal medicine specialist, virologist, neonatologist o Contact the doctor immediately if she develops respiratory symptoms or any other deterioration in her condition o Symptoms or signs of severe chickenpox  Severe spots (severe rash), bleeding rash, chest/breathing problems, drowsiness, vomiting, APH o Woman at high risk of severe/complicated chickenpox even in the absence of concerning symptoms or signs (lung disease, smoker, treatment with immunosuppressants (e.g. steroids), being in the latter half of pregnancy) o Women hospitalised with varicella – should be nursed in isolation from babies, potentially susceptible women or non-immune staff • Referral to a fetal medicine specialist o At 16-20 weeks or 5 weeks after infection – discussion + detailed US examination – to look for signs of fetal varicella syndrome

Answer 131

o Epidural/spinal anaesthesia  a site free of cutaneous lesions should be chosen for needle placement o A neonatologist should be informed of the birth of all babies born to women who have developed chickenpox at any gestation during pregnancy o Biggest risk of neonatal varicella if maternal infection occurs +/- 7 days of birth o If infection occurs within the last 4 weeks of pregnancy  delay delivery until 7 days after the onset of rash – allow time for passive transfer of antibodies

Answer 132

o Neonatal VZIG if  Birth occurs <7 days onset of maternal rash  Mother develops chickenpox <7 days of delivery o ^Infant monitored for signs of infection until 28 days after the onset of maternal infection o No vaccination o Neonatal ophthalmic examination should be organised after birth o Neonatal infection treated with aciclovir o Women with chickenpox should breastfeed if they wish to and are well enough to do so • Varicella vaccination can be offered postpartum for women who are found to be non-immune to VZV. It is contraindicated in pregnancy, as it is a live vaccine.

Answer 133

* Haemodynamic instability * IUP * BF * Unable to comply with follow up * Chronic liver disease, active pulmonary disease, peptic ulcer disease, immunodeficiency, pre-existing blood dyscrasia * Known sensitivity to methotrexate

Answer 134

• Avoid conceiving at least 3m after methotrexate – contraception should be used for 3-6m or do not have sex

Answer 135

NICE 250IU • To all women who have surgical removal of an ectopic pregnancy or where bleeding is repeated, heavy or associated with abdominal pain – not offered if medical mx of ectopic • No Kleihauer test needed (checks level of fetal blood in maternal circulation) ``` BCSH 500IU anti-D Ig within 72h • If <12w + surgically managed ectopic • If 12-20w + surgically or medically managed ectopic OR continuous uterine bleeding • >20w – for any PSE ```

Answer 136

``` • Most common o Abdominal pain/discomfort – Excessive flatulence + bloating due to intestinal gas formation o Transient mild elevation in LFTs o Stomatitis (inflamed + sore mouth) • Other adverse effects o Marrow suppression o Pulmonary fibrosis o Nonspecific pneumonitis o Liver cirrhosis o Renal failure o Gastric ulceration ```

Answer 137

``` • Where o EPAU o On-call gynaecologist if out of hours • When o Pain + abdominal tenderness o Pelvic tenderness o Cervical motion tenderness o Vaginal bleeding ```

Answer 138

• Conservative measures based on assessment of the most likely cause o Encourage woman to mobilise or adopt an alternative position (left lateral position, avoid being supine) o Offer IVF if woman is hypotensive o Reduce contraction frequency by stopping oxytocin or offering a tocolytic drug (terbutaline 0.25mg) • Inform a senior midwife or an obstetrician whenever conservative measures are implemented

Answer 139

All features are reassuring • Continue CTG (unless it was started because of concerns arising from intermittent auscultation and there are no ongoing risk factors) and usual care

Answer 140

1 non-reassuring feature AND 2 reassuring features * Inform an obstetrician or a senior midwife * Correct any underlying causes e.g. hypotension, uterine hyperstimulation * Perform a full set of maternal observations * Start >1 conservative measures

Answer 141

1 abnormal feature OR 2 non-reassuring features • Obtain a review by an obstetrician and a senior midwife • Exclude acute events (e.g. cord prolapse, suspected placental abruption or suspected uterine rupture) • Correct any underlying causes e.g. hypotension or uterine hyperstimulation • Start >1 conservative measures • If the CTG is still pathological after implementing conservative measures: – obtain a further review by an obstetrician and a senior midwife – offer digital fetal scalp stimulation + document outcome – If digital fetal scalp stimulation leads to an acceleration in the FHR baby is healthy • If CTG is still pathological after fetal scalp stimulation – consider fetal blood sampling – consider expediting the birth – take the woman's preferences into account

Answer 142

Acute bradycardia or Single prolonged deceleration for >3min * Urgently seek obstetric help * If there has been an acute event (eg. cord prolapse, suspected placental abruption or suspected uterine rupture)  expedite the birth * Correct any underlying causes e.g. hypotension or uterine hyperstimulation * Start >1 conservative measures * Make preparations for an urgent birth * Expedite the birth if the acute bradycardia persists for 9 minutes * If the fetal heart rate recovers at any time up to 9 minutes, reassess any decision to expedite the birth, in discussion with the woman

Answer 143

pH Normal >7.25 Borderline 7.21 – 7.24 Abnormal <7.20 Lactate Normal <4.1 mmol/l Borderline 4.2-4.8 mmol/l Abnormal >4.9 mmol/l • If fetal blood sampling is normal + CTG trace remains pathological o Repeat FBS in 1h • If fetal blood sampling is borderline o Repeat FBS in 30 mins • If fetal blood sampling result is abnormal o Inform a senior obstetrician + the neonatal team o Talk to the woman + her birth companion about what is happening + take her preferences into account o Expedite the birth

Answer 144

* cord prolapse is an obstetric emergency * Call for senior help • Prepare immediately for theatre • If cord is out of the introitus o Avoid handling the cord – can cause cord vasospasm o Keep warm and moist o Do not force back inside • Prevent further cord compression o Elevate presenting part – manually or by filling the urinary bladder • retrofilling the bladder with 500-700ml of saline may be helpful as it gently elevates the presenting part o Reposition mother until preparations for an immediate caesarian section have been carried out  All 4s  Left lateral position with head down • tocolytics may be used to reduce uterine contractions * Expedite delivery by quickest route possible * although caesarian section is the usual first-line method of delivery, an instrumental vaginal delivery is possible if the cervix is fully dilated and the head is low.

Answer 145

• Discharge when o PEFR >75% of patients best o Diurnal variation <25% o Stable on discharge mets for 24h

Answer 146

• 1) SABA o SABA used as required in all steps, unless using MART o Consider moving up the stages if using >3 doses/week * 2) SABA + low dose ICS * 3) SABA + low dose ICS + long-acting LABA • 4) SABA + o Medium dose ICS + LABA or o LTRA o If no response to LABA, consider stopping LABA ``` • 5) 4) + o High dose ICS + LABA or o + LRTA If not already trialled or o Add tiotropium or o Add theophylline ``` • 6) oral steroids o Patients requiring frequent or continuous use of oral corticosteroids should be under the care of a specialist asthma service

Answer 147

Signs • Increasing symptoms • PEF >50-75% best or predicted • No features of acute asthma Mx • High dose inhaled SABA using a pressurised metered-dose inhaler + spacer • Oral prednisolone • +/- nebulised ipratropium bromide if poor response to SABA

Answer 148

Any of the following * PEF 33-50% best or predicted * RR >25/min * HR >110/min * Inability to complete sentences • High dose inhaled SABA through an oxygen-driven nebuliser +/- nebulised ipratropium bromide o Aim for SpO2 between 94-98% • Oral prednisolone • Consider a single IV single dose of magnesium sulfate

Answer 149

Any one of the following in a patient with severe asthma * PEF <33% best or predicted * SpO2 <92% * PaO2 <8kPa * PaCO2 4.6-6.0kPa * Silent chest * Cyanosis * Poor respiratory effort * Exhaustion * Arrythmia * Hypotension * Altered conscious level • High dose inhaled SABA through an oxygen-driven nebuliser +/- nebulised ipratropium bromide o Aim for SpO2 between 94-98% o ICU • Oral prednisolone or IV hydrocortisone or IM methylprednisolone • IV aminophylline

Answer 150

• Raised PaCO2 and/or need for mechanical ventilation with raised inflation pressures * Need for mechanical ventilation with raised inflation pressures * IV hydrocortisone or IM methylprednisolone if unable to take PO prednisolone * IV aminophylline

Answer 151

Antenatal • Conservative – re-educate on inhaler technique, smoking cessation etc • Medical – continue pre-existing asthma treatment regimen as normal Acute asthma • Give drug therapy as for non-pregnant patients incl. systemic steroids + magnesium sulphate • Delivery high-flow oxygen immediately to maintain saturation 94-98% Acute severe asthma • Emergency – should be treated vigorously in hospital • Continuous foetal monitoring • Early referral to critical care physicians During labour • Advise women o Acute asthma attack is rare in labour o Women should continue their usual asthma medications in labour • Avoid use of ergometrine (bronchoconstrictor) • If acute asthma attack – C-section • If anaesthesia is required o Regional blockade is preferrable to GA (risk of bronchospasm with certain inhaled anaesthetic agents) • Women receiving steroid tablets at a dose > 7.5mg prednisolone/day for >2 weeks prior to delivery should receive parenteral hydrocortisone 100mg 6-8 hourly during labour • Prostaglandin F2a – used with extreme caution in women with asthma – risk of inducing bronchoconstriction Post-partum • Encourage women to breastfeed • Use asthma medications as normal during lactation, in line with manufacturer’s recommendations

Answer 152

 Evaluated at birth for clinical indicators of neonatal infection  Have their vitals signs (general wellbeing, HR, T, breathing, feeding) checked at 0, 1, 2 hours  Then 2hourly until 12 hours

Answer 153

o Babies with clinical signs of EOGBS – IV benzylpenicillin every 12h for 14/7 + gentamicin for 5/7 within an hour of the decision to treat  Treatment will be stopped if there is no sign of infection after at least 36h and all the tests are negative

Answer 154

 1 RF – reman in hospital for at least 24h for observations  >2 RF or one red flag – sepsis abx + septic screen (Blood cultures, CRP, LP) • GOSH abx in neonate <72h – cefotaxime + amikacin + ampicillin

Answer 155

 follow recommendations 1.4.1 to 1.4.8 on investigations before starting antibiotics, and  start antibiotic treatment according to recommendations 1.5.1 to 1.6.7, and  do not wait for the test results before starting antibiotics

Answer 156

 whether it is safe to withhold antibiotics, and  whether the baby's vital signs and clinical condition need to be monitored. If monitoring is needed, continue for at least 12 hours using a newborn early warning system

Answer 157

• Prevention – Simple hygiene-based measures – handwashing after contact with urine or saliva, and avoiding sharing utensils, drinks or food with young children (young children usually get CMV in nursery) • No prenatal treatment available o Currently no treatment for CMV in pregnancy o Antiviral medicine used to treat (congenital CMV after birth, immunosuppressed patients, post SCT patients) • Prenatal dx of CMV infection or evidence of symptomatic fetal infection on US discuss the options o Continuation of pregnancy with expectant management  refer to fetal medicine specialist for regular fetal surveillance  Fetal US examination every 2-3 weeks form dx until delivery  Cerebral MRI at 28-32 weeks o TOP

Answer 158

• Antiviral therapy of children with symptomatic CNS congenital CMV infection o Effective at reducing the risk of long-term disabilities (SNHL, developmental impairment) o Should be offered to families with affected newborn infants o Neonates with symptoms at birth  valganciclovir (PO) /ganciclovir (IV) commenced within the firs 4 weeks of life, for 6/12 o Follow-up evaluation to detect sequelae  Audiology follow up  Ophthalmology follow up  Babies born with congenital CMV may have tests to check their kidneys, liver, brain, eyes and hearing, and regular follow-up appointments until they're around age 5

Answer 159

• Peer support • Women already taking ART and or PCP prophylaxis before pregnancy should not discontinue their medication • Arrange contact with joint HIV physician and obstetric clinic every 1-2 weeks • HIV woman + not already on cART o Start cART during pregnancy – all women should have commenced cART by week 24 o Continue lifelong treatment

Answer 160

o Start on tenofovir DR or abacavir + emtricitabine or lamivudine o Third agent – efavirenz or atazanavir  Alternatives for the 3rd agent – rilpivirine (25mg OD), raltegravir (400 mg BD), darunavir (600/100 mg BD)  Dolutegravir – may be considered from 6w gestation  Tenofovir alafenamide – may be prescribed after the first trimester  If high baseline viral load (>100,000 HIV RNA copies/ml) + cART is failing to suppress the virus – consider an integrase inhibitor-based regimen as the third agent o Zidovudine monotherapy (250mg BD PO + IV started 4 hours before beginning CS + continuing until the umbilical cord has been clamped) between 20-28 weeks – not recommended, should only be used in women declining cART with a viral load <10,000 HIV RNA copies/ml + willing to have a CS o For women who present late + are not on treatment (>28 weeks)  Viral load unknown or >100,000 HIV RNA copies/ml  3 or 4 drug regimen that includes raltegravir 400mg BD or dolutegravir 50mg OD o For women who present in labour at term + are not on treatment  Nevirapine 200mg stat and  Zidovudine 300mg PO + lamivudine 150mg BD and  Raltegrvir 400 mg BD and  Zidovudine IV for the duration of labour o For women who present in PTL + are not on treatment  If the infant is unlikely to be able to absorb PO meds – addition of double dose tenofovir DF o PCP prophylaxis depends on CD4 count

Answer 161

• Dolutegravir o Evidence of causing NTD o High dose folic acid 5mg OD  Women taking dolutegravir who are trying to conceive or in the first trimester of pregnancy (<12 weeks gestation) • Women on regimens that do not contain dolutegravir should take the standard recommended dose of folic acid 400μg OD

Answer 162

o If on cART – decision re. MOD to be made after review of the plasma viral load results at 36 weeks  <50 HIV RNA copies/ml at 36w + in the absence of obstetric contraindications  SVD or VBAC • Obstetric management should follow the same guideline as for HIV -ve population, apart from duration of ruptured membranes • Use of fetal scalp electrodes and fetal blood sampling should be avoided  >50 at 36w  PLCS  Risk of placental transmission with PLCS for women >50 copies/ml is half that of SVD – below 50 copies/ml there is no difference o CS  Indicated for prevention of vertical transmission  bn 38-39w • Women taking ART who have plasma viral load >50 copies/ml • Women taking ZDV monotherapy as an alternative to ART  Only for obstetric indications (viral load <50 HIV RNA copies/ml)  after 39w (usual obstetric considerations apply) • Reduces the risk of transient tachypnoea of the newborn o Waterbirth if viral load <50 HIV RNA copies/ml • Cord clamped asap and baby bathed immediately after birth

Answer 163

o Pre-labour SROM  Delivery within 24h o <50 HIV RNA copies/ml  immediate IOL or augmentation, low threshold for treatment of IP pyrexia, aim for delivery within 24 o >50 HIV RNA copies/ml  immediate CS o >34w SROM mx same as that of term SROM except – women at 34-37w will require GBS prophylaxis o <34 weeks SROM  IM CS, optimise viral load, MDT about timing + MOD

Answer 164

o Recommended when – Viral load >1000 HIV RNA copies/mL who present in labour or with SROM or who are admitted for PLCS o Recommended when – Untreated women in whom the current viral load is not known presenting in labour or with SROM o Considered when – women on cART + plasma HIV viral load 50-1000 HIV RNA copies/ml

Answer 165

o Encourage to continue cART post-delivery  Stopping cART after delivery is not recommended o If they choose to stop cART  a further resistance test is recommended to ensure that mutations are not missed with revision during the off-treatment period o Review within 4-6 weeks PP o Assess mental health + refer appropriately o Discuss contraception – ART may be changed to optimise a woman’s contraception o Cervical cytology – scheduled 3 months post-delivery o Test partner + other children

Answer 166

o Breastfeeding increases MTCT by approx. 15% o Safest way  formula milk (women should be provided with free formula feed to minimise vertical transmission of HIV) o Offer cabergoline to suppress lactation o If woman virologically suppressed on cART + good adherence + wants to BF  support her, inform about low risk of transmission of HIV through BF + requirement for extra maternal and infant clinical monitoring  Review mum + baby monthly in clinic for HIV viral load testing during and for 2 months after stopping BF • In developing countries where CS is unavailable + there is no alternative to BF  offer ART to pregnant HIV infected women (duration of treatment depends on CD4 count) + OD nevirapine from birth to 6w for infants

Answer 167

* Cord clamped asap and baby bathed immediately after birth * Neonatal PEP – commenced asap after birth, at least within 4 hours * Zidovudine monotherapy – oral or IV • Very low risk o 2/52 zidovudine monotherapy if  Woman has been on cART for >10 weeks and  2 documented maternal HIV viral loads <50 HIV RNA copies/mL during pregnancy at least 4 weeks apart and  Maternal HIV viral load <50 HIV RNA copies/Ml at or after 36 weeks • Low risk o 4/52 zidovudine monotherapy  If criteria for very low risk not fulfilled but maternal HIV viral load <50 HIV RNA copies/Ml at or after 36 weeks  If premature infant (<34 weeks) but most recent maternal HIV vial load is <50 HIV RNA copies/ml • High risk o Combination PEP (HIV-1 zidovudine, lamivudine, nevirapine, HIV 2 zidovudine, lamivudine, raltegravir) if  Maternal HIV viral load known/likely to be >50 HIV RNA copies/ml on day of birth, if uncertainty about recent maternal adherence, if vira load is not known * Zidovudine monotherapy still recommended in very low or low risk even if mother is resistant to zidovudine * Infant PEP should not be started unless significant subsequent exposure e.g. maternal viral load detectable during breastfeeding • Pneumocystis pneumonia (PCP) prophylaxis o Co-trimoxazole prophylaxis recommended form 4 weeks of age if HIV PCR screening is positive at any stage or if the infant is confirmed to be diagnosed with HIV o Should only be stopped if HIV infection is subsequently exclude • If infants diagnosed with HIV during infant monitoring after birth o Cotrimoxazole prophylaxis from 4 weeks of age o Refer urgently to a specialist centre for mx of HIV o Feedback to the obstetric unit where the infant was born to allow ix of any avoidable factors in transmission

Answer 168

Prevention • Pregnant women o should avoid contact with wild and domestic animals o should avoid consumption of soft cheeses, delicatessen meats, pates, spreads, refrigerated smoked seafood and salad bar cold salads, unpasteurised milked, unpasteurised soft cheese, undercooked food o food should always be adequately cooked or thoroughly reheated • Healthy adults + older children – symptomatic management • Pregnant women or severe infection o IV amoxicillin + ampicillin 16 every 6/24 for 14/7 • Invasive Listeriosis (meningitis or septicaemia) o IV amoxicillin/ampicillin + gentamicin for 21 days (gentamicin may be stopped after 7 days) o In pregnancy gentamicin should be avoided – IV amoxicillin/ampicillin o 2nd line for listerial meningoencephalitis – co-trimoxazole IV • If listeriosis is a clinical possibility (e.g. acute pyogenic meningitis) + the organism is unknown – IV amoxicillin/ampicillin should always be part of the regimen • If patient is allergic to amoxicillin or ampicillin – erythromycin • Immunocompromised – longer courses required • Listeria spp. are resistant to cephalosporins

Answer 169

Prevention • Avoid eating raw or undercooked meat, or cured meats like salami or parma ham • Do not have unpasteurised goats’ milk or any products made from it • wash your hands before preparing food and eating • wash hands, knives and chopping boards thoroughly after preparing raw meat • wash fruit and vegetables thoroughly to get rid of any traces of soil • Avoid handling cats and cat litter • wear gloves while emptying cat litter trays and empty them every day • Wear gloves and wash hands when gardening or handling soil • You cannot catch toxoplasmosis from stroking a cat, having a cat as a pet or from coming into contact with someone who’s got it Toxoplasmosis in the mother • Spiramycin (3-week course of 2-3g OD) o Prevents vertical transmission Toxoplasmosis in the fetus • Sulfadiazine + Pyrimethamine o Continuation of pregnancy with more aggressive abx treatment • Treat baby for up to 1 year after delivery (if no TOP) • Adjunct can be prednisolone Toxoplasmosis in the newborn • Symptomatic o Pyrimethamine + Sulfadiazine + Folinic acid  Continue all 3 for 1 year o Monitor LFTs and FBCs ever 4-6 weeks • Asymptomatic with positive serology o No definitive guidelines present – treatment is controversial o Discuss individual cases with infection and virology specialists • Ophthalmology and audiology assessment recommended

Answer 170

• Booking appointment – ask mother if they have ever had or if their partner had ever had genital herpes • If male has HSV but female is asymptomatic – important to not transmit the infection in pregnancy o Condom use throughout pregnancy o Do not have sex during a recurrence and in the last 6 weeks of pregnancy o If oral lesions evident – discuss risk of HSV-1 infection during urogenital contact o Avoid multiple sexual partners during pregnancy • Reduction in the number of sexual partners, use of condoms, avoidance of sex with someone who has active genital herpes or active oral herpes (although viral shedding and transmission also occur from asymptomatic infections) • Antiviral drugs may reduce transmission to partners – they are thought to reduce symptomatic and asymptomatic viral shedding by 80-90% Prevention of PN transmission • Careful had hygiene – the mother and all those with herpetic lesions • Those with oral herpetic lesions (cold sores) should not kiss the neonate • In about ¼ of cases, infection is acquired PN from somebody other than the mother • Staff or relative with an active oral HSV lesion or herpetic whitlow who come in contact with the neonate  risk of potential transmission  should avoid direct contact between the lesion + the neonate

Answer 171

• Refer to a genitourinary medicine physician (GUM clinic) + inform an obstetrician • Oral/ IV if disseminated HSV acyclovir (400mg TDS, 5/7) o Reduction in the duration and severity of symptoms o Decrease in the duration of viral shedding o Associated with transient neonatal neutropenia but no clinically significant adverse maternal or neonatal effects • Following 1st or 2nd trimester acquisition  daily suppressive acyclovir 400mg TDS from 36w until delivery o Reduces HSV lesions at term + hence the need for delivery by CS o Reduces asymptomatic viral shedding • Symptomatic relief o Paracetamol o Topical lidocaine 2% gel • Expectant management, SVD (assuming there are no active lesions or symptoms at term)

Answer 172

• Oral/ IV if disseminated HSV acyclovir (400mg TDS daily, 5/7) • Daily suppressive acyclovir 400mg TDS until delivery • CS recommended o For all women developing first episode genital herpes in the third trimester, o Particularly for those developing symptoms within 6 weeks of expected delivery • If woman chooses vaginal delivery o IV acyclovir to mum IP (5mg/kg every 8/24) o IV acyclovir to the neonate (20MG/KG every 8/24) o invasive procedures should be avoided (e.g. application of fetal scalp electrodes, fetal blood sampling, artificial rupture of membranes and/or instrumental deliveries)

Answer 173

• Supportive therapy o Majority of recurrent episodes of genital herpes are short-lasting and resolve within 7-10 days without antiviral treatment o Saline bathing o Analgesia with standard doses of paracetamol (1-2 500mg tablets up to 4 times in 24h) • Daily suppressive acyclovir 400mg TDS from 36w until delivery o Reduces viral shedding and recurrence at delivery • Vaginal delivery is safe • Avoid artificial rupture of membranes and invasive procedures during labour if there are genital lesions

Answer 174

• Type specific HSV antibody testing can help distinguish between primary/recurrent infection, however it may take 2-3 weeks for the result of the test to become available • Therefore an initial plan of delivery should be based on the assumption that all first episode lesions are primary genital herpes • Onset of labour  careful vulval inspection to look for HSV lesions • Primary episode genital herpes lesions at the time of delivery or within 6 weeks of the EDD: o CS  SVD should be avoided if possible o If SVD  IV acyclovir to mum IP (5mg/kg every 8/24)  IV acyclovir to the neonate (20MG/KG every 8/24)  invasive procedures should be avoided (e.g. application of fetal scalp electrodes, fetal blood sampling, artificial rupture of membranes and/or instrumental deliveries) • Recurrent genital herpes lesions o Offer SVD o Reassure that the risk of transmitting the infection to her baby is very small, even if she does have active lesions at delivery o Can consider CS but weigh the risk of CS to the mother and future pregnancies against the small risk of neonatal transmission of HSV with recurrent disease (0-3% with vaginal delivery) o Invasive procedures increase the risk of neonatal HSV transmission however there is a small background risk of transmission and therefore these invasive procedures are unlikely to be clinically significant so they may be used if required

Answer 175

• Primary infection o Limited evidence o If initial conservative management  mother to receive IV acyclovir 5mg/kg every 8h o Prophylactic CS o If delivery is indicated within 6 weeks of the primary infection  Delivery by CS • Recurrent infection o <34 w  expectant management + PO acyclovir 400mg TDS daily o >34 w  RCOG PPROM guidelines + AN CS

Answer 176

• Primary HSV infection  follow recommendations for all women with primary genital HSV infection • Recurrent HSV infection o HIV ab +ve  daily suppressive acyclovir 400mg TDS from 32w o No evidence to recommend daily suppressive treatment of HSV for HIV ab +ve women who are HSV-1 or -2 seropositive but have no hx of genital herpes

Answer 177

• Inform the neonatal team • If baby born by CS in mothers with primary HSV infection in 3rd trimester o At low risk of vertical HSV transmission o Liaise with the neonatal team o Conservative management (no swabs, no active treatment, normal postnatal care, neonatal examination at 24h of age, discharge if well and feeding established) o Educate parents regarding good hand hygiene o Parents to seek medical help if they have concerns about baby – look for – skin, eye, mucous membrane lesions, lethargy/irritability, poor feeding • If baby born by SVD in mothers with a primary HSV infection within the previous 6 weeks o At high risk of vertical HSV transmission o If baby is well  Swabs of – skin, conjunctiva, oropharynx and rectum for HS PCR  Empirical treatment – IV acyclovir (20mg/kg every 8/24) until evidence of active infection is ruled out  BF recommended unless mum has herpetic lesions around the nipples (acyclovir is excreted in breast milk but there is no evidence of harm)  Parents should be warned to report any early signs of infection – poor feeding, lethargy, fever or any suspicious lesions o If baby is unwell  Swabs of – skin, conjunctiva, oropharynx and rectum for HS PCR  LP performed even if CNS features are not present  IV acyclovir (20mg/kg every 8/24) until evidence of active infection is ruled out • If baby born to mothers with recurrent HSV infection in pregnancy +/- active lesins at delivery o At low risk of vertical transmission  Maternal IgG will be protective in the baby o Liaise with the neonatal team o Conservative management (no swabs, no active treatment, normal postnatal care, neonatal examination at 24h of age, discharge if well and feeding established) o Educate parents regarding good hand hygiene o Parents to seek medical help if they have concerns about baby – look for – skin, eye, mucous membrane lesions, lethargy/irritability, poor feeding • Concerns regarding the neonate (clinical evidence of sepsis, poor feeding) o Liaise with the neonatal team o Consider bacterial sepsis, HSV infection o Surface swabs and blood – HSV culture, PCR o IV acyclovir (20mg/kg every 8h) while awaiting cultures o Further mx by the neonatal team • Alistair o IV acyclovir 14days if SEM, 21days if CNS or disseminated

Answer 178

• If the baby is Rh D -ve there is no need for anti-D prophylaxis at 28 (+/- 34) weeks – HDN cannot occur Prevention • Routine antenatal anti-D prophylaxis (RAADP) in the third trimester o Given to all rhesus-negative women who have not already been sensitised as prophylaxis against small amounts of FMH that can occur in the absence of observable sensitising events (1% of pregnancies have no obvious sensitising events yet RhD negative mothers become sensitised)  Anti-D Ig should be given to RhD-negative women with non-anti-D antibodies  If immune anti-D is detected, prophylaxis is no longer necessary  Usually administered by community midwives or at antenatal clinics o The use of RAADP is in addition to the administration of anti-D Ig following potentially sensitising events  Its use in either indication is not affected by prior use in the other o 2 doses of anti-D Ig of 500 IU at 28 + 34 week or o 2 doses of anti-D Ig of 1000-1650 IU at 28 + 34 week or o 1 dose of 1500IU at 28 weeks or o 1 dose of 1500 IU between 28- and 30-weeks gestation • Antenatal anti-d prophylaxis also indicated for other sensitising events if the mother is RhD -ve and is not sensitised o E.g. abortion, miscarriage, amniocentesis, CVS, ECV, ectopic pregnancy, abdominal trauma + all the other RF, stillbirth or IUD o Dose should be given within 72 hours of occurrence • If mother is RhD-ve and has antibodies at booking – monitor titres and if they peak above a level*  Monitor baby using middle cerebral artery (MCA) dopplers weekly  if baby affected, consider IU transfusion • Discussion + liaison with the transfusion laboratory to determine whether anti-D antibodies are immune or passive in women who have previously received anti-D prophylaxis • If continuous bleeding – anti-D every 6 weeks with Kleihauer every 2 weeks (adjust anti-D if needed)

Answer 179

• If the fetus carries the corresponding antigen for a maternal antibody which is capable of causing fetal anaemia + if antibody levels/titres rise beyond a certain level (see referral criteria) o Pregnancy should be monitored weekly by US – specifically assessing the fetal MCA PSV • Pregnant women with red cell antibodies at high risk of requiring a blood transfusion (placenta praevia, sickle cell disease etc) o Should have a cross-match sample taken at least every week • Referral to a fetal medicine specialist o When there are rising antibody levels/titres o *A level/titre above a specific threshold  Anti-D >4 iu/ml • Anti-D level >4 iu/ml but <15 iuml – moderate risk of HDFN • Anti-D level >15 uml – can cause severe HDFN  Anti-c >7.5 iu/ml • Anti-C level >7.5 iu/ml but <20 iuml – moderate risk of HDFN • Anti-C level >20 uml – can cause severe HDFN  Anti-K antibodies – once detected  Anti-E at low titres • Potentiates the severity of fetal anaemia due to anti-c antibodies o US features suggestive of fetal anaemia  If the middle cerebral artery peak systolic velocities (MCA PSV) rises above the 1.5 multiple of the median (MoM) threshold or if there are other signs of fetal anaemia  ^Referral to a fetal medicine specialist for consideration of invasive treatment o Hx of unexplained severe neonatal jaundice / neonatal anaemia requiring transfusion or exchange transfusion  to exclude HDFN as the cause

Answer 180

• Intra-uterine transfusion o Should be performed only in fetal medicine units o Group O-packed cells crossmatched with maternal blood  Should be group O or ABO identical with the fetus + negative for the antigen’s corresponding to the maternal red cell antibodies o As soon as the blood samples confirm anaemia/ elevated MCA flow or amniotic bilirubin levels / hydrops fetalis o Best done at 18 weeks o Samples can be taken at 16 weeks if necessary o IV transfusion under US guidance via the umbilical vein > intraperitoneal route  Intraperitoneal route – more difficult in a hydropic fetus, causes more complications o Further transfusions – should be dictated by serial Doppler scans o Transfusion carries a 2% risk of fetal loss • Selective modulation of the maternal immune system • IP o Continuous electronic fetal monitoring during labour of women with red cell antibodies that can cause fetal anaemia

Answer 181

• Anticipated between 37-38 weeks following successful transfusions • If complications arise – consider delivery at 32 w • When severe HDFN is anticipated o Birth should be attended by a paediatrician trained in neonatal resuscitation o Fresh O- blood should be immediately available

Answer 182

Neonatal mx • Resuscitation if preterm, anaemic, hydropic • Observations o Regular clinical assessment of its neurobehavioral state o Observation for the development of jaundice and/or anaemia o Regular assessment of Hb + bilirubin o Regular feeding to protect against dehydration (can increase the severity of jaundice) o Hearing screen o If bilirubin levels rise rapidly or above interventional threshold  phototherapy +/or exchange transfusion may be required o Pregnancies complicated by red cell alloimmunisation with minimal or no risk of fetal or neonatal anaemia require no specific treatment • Normal Hb + bilirubin levels (50%)  monitor for onset of late anaemia at 6-8 w o Consider folate supplementation to protect against late anaemis • Moderate disease (25%)  may require transfusion o Significant hyperbilirubinemia  phototherapy to avoid kernicterus • Severe disease (25%)  stillborn or have hydrops fetalis • When severe HDFN is anticipated o Baby  immediate resuscitation, supportive treatment (temperature stabilisation), exchange transfusion o Further top-up blood transfusions and phototherapy may be needed o Early administration of IVIG in babies with severe haemolytic disease  reduces haemolysis, peak bilirubin levels + the need for exchange transfusion • Phototherapy o Do not delay if baby though to clinically have significant jaundice o Transcutaneous bilirubin measurement can be taken to confirm/if unsure • IVIG o Only for immune haemolysis • Exchange transfusion indicated if o Bilirubin rapidly rising (>8-10 μmol/hr) despite adequate phototherapy o Severe hyperbilirubinemia insufficiently responsive to phototherapy and supportive cre o Significant anaemia (Hb <100 g/l) • Neonate transfusion – blood should be o ABO compatible with the neonate and the mother (to avoid ABO HDFN from the woman’s anti-A or anti-B antibodies present) o RhD -ve (or RhD identical with neonate) o K -ve o Negative for the corresponding antigen to which the woman has an antibody o Cross-match compatible with the woman’s blood sample

Answer 183

• Post-partum o If a woman has clinically significant antibodies – cord samples should be taken for a DAT (direct antiglobulin test), Hb and bilirubin levels  ABO + Rh D typing on cord blood  Baby confirmed to be D+  all D-ve previously non-sensitised women should be offered at least 500 IU of anti-D immunoglobulin within 72hours of delivery to prevent sensitisation o Kleihauer test  Check maternal samples for FMH  Give additional dose guided by FMH results • If maternal transfusion is required o Red cell components of the same ABO group + RhD type that are K negative and CMV negative • Future pregnancies o Hx of pregnancy/infant affected by HDFN  refer for early assessment to a fetal medicine specialist o Counsel on recurrence of HDN in subsequent pregnancies

Answer 184

• Diet lifestyle and nutritional supplements o Same advice as in routine antenatal care o Higher incidence of anaemia in women with a multiple pregnancy compared to a singleton pregnancy • Antenatal care o Obstetric led antenatal care o MDT  Specialised obstetricians, specialist midwives + sonographers  Enhanced team for referrals – perinatal mental health professional, Women’s health physiotherapist, infant feeding specialist  Dietician  Team should offer information + emotional support as well as advice on * AN + PN MH + wellbeing * AN nutrition * Risks, symptoms signs of PTL * Potential need for CS for fetal lung maturation but no benefit in using untargeted (routine) administration of CS * Likely timing of birth + possible modes of birth * Breastfeeding ``` • Parenting o A tertiary-level fetal medicine centre referral is indicated for  Monochorionic monoamniotic twins  Monochorionic monoamniotic triplets  Monochorionic diamniotic triplets  Dichorionic diamniotic triplets  Asymmetrical fetal growth  Fetal anomaly  Death of one fetus  FFTS  TAPS ```

Answer 185

• Do not offer screening in the first trimester • Offer diagnostic monitoring to women with monochorionic twin or triplet pregnancy • Start monitoring at 16 w o Monitor every 2 weeks with US until birth • Measurements o DVP depths of amniotic fluid on either side of the amniotic membrane o Difference in DVP depth of >4cm = concerning o Also a >25% difference in EFW is concordant with IUGR which is a sign of FFTS • Difference in DVP depth of >4cm o Monitor every 7 days o Include doppler assessment of the umbilical artery flow for each baby • Referral o To a tertiary level fetal medicine centre  Diagnosis of feto-fetal transfusion syndrome  Amniotic sac of 1 baby has a DVP depth of <2cm and  The amniotic sac of another baby has a DVP depth of • >8cm before 20+0 weeks of pregnancy or • >10cm from 20+0 weeks of pregnancy o To her named specialised obstetrician Concerning findings  Amniotic sac of 1 baby has a normal DVP depth and  The amniotic sac of another baby has a DVP depth of • <2cm or • >8cm • First line management of TTTS o <26 weeks  Fetoscopic laser alation of vascular anastomoses  Laser surgery of inter-twin vascular placenta anastomoses where the syndrome develops o >26 weeks  delivery o Other options – serial amnioreduction (old treatment), septostomy, selective feticide

Answer 186

• Weekly US monitoring for TAPS using MCA-PSV (middle cerebral artery peak systolic velocity) from 16 weeks of pregnancy o To women whose pregnancies are complicated by  Feto-fetal transfusion syndrome that has been treated by fetoscopic laser therapy or  Selective fetal growth restriction (= EFW discordance of >25% and an EFW of any of the babies below the 10th centile for GA) • US MCA-PSV measurements to help detect advanced-stage TAPS o For women with monochorionic pregnancy presenting with  CV compromise (e.g. fetal hydrops or cardiomegaly) or  Unexplained isolated polyhydramnios or  Abnormal umbilical artery o Seek management advice immediately from a tertiary level fetal medicine specialist

Answer 187

Timing of elective delivery (Planned birth from xx weeks does not appear to be associated with an increased risk of serious neonatal adverse outcomes) - Continuing the pregnancy beyond xx weeks increases the risk of fetal death Dichorionic diamniotic twin pregnancy 37+0 - 37+6 Monochorionic diamniotic twin pregnancy 36+0 (After AN corticosteroids) - 36+6 Monochorionic monoamniotic twin pregnancy 32+0 - 33+6 weeks (After AN corticosteroids, These babies will usually need to be admitted to the NCU and have an increased risk of respiratory problems) Trichorionic triamniotic or dichorionic triamniotic triplet pregnancy 35+0 (After AN corticosteroids) - 35+6 o If women decline planned birth at the timing recommended  Fortnightly fetal growth scans  Weekly appointments with the specialist obstetrician – at each appointment • Offer an USS • Perform assessments of amniotic fluid level • Doppler of the umbilical artery flow for each baby

Answer 188

o The risk per pregnancy in monochorionic pregnancies and for each baby in dichorionic and trichorionic pregnancies should be calculated • Referral after screening o If women have a risk of >1:150 – higher chance of DS, Edward’s syndrome or Patau’s syndrome o Refer to a fetal medicine specialist in a tertiary-level fetal medicine centre • Selective termination o If desired after one fetus is detected as abnormal o Must be accurately targeted o Selective termination in monochorionic pregnancies particularly risks co-twin sequalae

Answer 189

Fetal growth restriction monitoring • Do not offer screening in the first trimester • Do not use abdominal palpation or symphysis-fundal height measurements to monitor for fetal growth restriction EFW calculations • Calculate and document EFW (estimated fetal weight) discordance for dichorionic twins o (EFW larger fetus – EFW smaller fetus) / EFW larger fetus • Calculate and document EFW (estimated fetal weight) discordance for trichorionic triplets o (EFW largest fetus – EFW smaller fetus) / EFW largest fetus o (EFW largest fetus – EFW middle fetus) / EFW largest fetus First trimester Dichorionic twin + trichorionic triplet pregnancies • From 24 weeks onwards o At each USS offer diagnostic monitoring for fetal weight discordance using >2 biometric parameters + amniotic fluid levels  To assess amniotic fluid levels – measure the deepest vertical pocket (DVP) on either side of the amniotic membrane o Continue monitoring for fetal weight discordance at intervals that do not exceed  28 days for women with a dichorionic twin pregnancy  14 days for women with a trichorionic triplet pregnancy Monochorionic pregnancies ****Monochorionic triplet pregnancy includes dichorionic or monochorionic triplets • From 16 weeks onwards o At each USS offer diagnostic monitoring for fetal weight discordance using >2 biometric parameters + amniotic fluid levels  To assess amniotic fluid levels – measure the deepest vertical pocket (DVP) on either side of the amniotic membrane o Continue monitoring for fetal weight discordance at intervals that should not exceed 14 days Second and third trimester for monochorionic pregnancies, dichorionic twin + trichorionic triplet pregnancies • Increase diagnostic monitoring to at least weekly • Include doppler assessment of the umbilical artery flow for each baby if o There is an EFW discordance of >20% and/or o The EFW of any of the babies is <10th centile for GA • Refer to a tertiary level fetal medicine centre if – selective growth restriction = o EFW discordance of >25% and o The EFW of any of the babies is <10th centile for GA This is a clinically important indicator of selective growth restriction • Management – Selective growth restriction/disconcordant IUGR o Selective reduction may be an option if it is early o Surveillance scans every 2 weeks o Abnormal doppler waveforms = indication for delivery

Answer 190

= includes monochorionic twins and dichorionic and monochorionic triplets • Offer women simultaneous monitoring for o Feto-fetal transfusion syndrome + FGR + TAPS (advanced-stage twin anaemia polycythaemia sequence) o The relative likelihood changes with advancing gestation but these can occur at any GA • Offered at every US assessment to monitor for all complications of monochorionicity

Answer 191

o Twin pregnancy – diamniotic (dichorionic or monochorionic)  women giving birth after 32 weeks • >1/3 who plan SVD go on to have a CS • Almost all of women who plan to have a CS have one, but a few women have vaginal birth before CS • A small number of women who plan SVD will need an EMCS to deliver the 2nd twin after SVD of the first twin  SVD + CS are both safe choices if all of the following apply • Pregnancy remains uncomplicated + has progressed >32 weeks • No obstetric contraindications • First baby is in a cephalic presentation • No significant size discordance between the twins  Offer CS • If the first twin is not cephalic at the time of planned birth • To women in established PTL between 26-32 weeks if first twin is not cephalic  Suspected, diagnosed or established PTL <26 weeks – offer an individualised assessment for the mode of birth  Aim for interval time between twin 1 and 2 <30 mins  Informa of small 4% risk of second twin requiring CS  Vaginal delivery is safe if the first twin is in the cephalic position and the second is in breech o Twin pregnancy – monochorionic monoamniotic  CS • At the time of planned birth (bn 32+0 and 33+6 weeks) or • After any complication is diagnosed in her pregnancy requiring earlier delivery or • If she is in established PTL + GA suggest there is a reasonable chance of survival of babies (unless the 1st twin is close to SVD + a senior obstetrician advises continuing to vaginal birth) o Triplet pregnancy  CS • At the time of planned birth (35 weeks) or • After any complication is diagnosed in her pregnancy requiring earlier delivery or • If she is in established PTL + GA suggest there is a reasonable chance of survival of babies o Immediately after the first baby is born  Determine the position of the second fetus by vaginal examination  If longitudinal, once the presenting part is engaged (after a couple of contractions) rupture the second amniotic sac + proceed to delivery  Transverse/breech  external cephalic or internal podalic version • If successful (confirm by vaginal examination) – rupture the second amniotic sac when the fetal head is engaged • If unsuccessful – C-section  Contractions can reduce after the birth of the first fetus – if they do not quickly return set up an IV oxytocin infusion  The second twin will usually deliver within 20-45 minutes of the first twin  If there are difficulties with the delivery of the 2nd twin or if bradycardia develops  vacuum extraction (in cephalic position) or breech extraction can be used to expedite delivery without necessarily resorting to C-section

Answer 192

• Management o Do not offer physiological management o Offer active management  Associated with a lower risk of PPH +/or blood transfusion  SVD  10 IU IM oxytocin (Syntometrine or Syntocunon) immediately after the birth of the last baby + before the cord is clamped and cut  CS  5 IU IV oxytocin immediately after the birth of the last baby + before the cord is clamped and cut o If woman has >1 RF (in addition to a multiple pregnancy) – consider active management of third stage with additional uterotonics

Answer 193

o Portable USS when established labour starts  To confirm which twin is which  To confirm the presentation of each twin  To locate the fetal hearts o Continuous CTG to women who are in established labour + >26 weeks pregnant  Do not offer intermittent auscultation  For women 23+0 and 25+6 – discuss with a senior obstetrician about how to monitor the fetal HR  Use dual channel CTG monitors to allow simultaneous monitoring of both fetal hearts  Document on the CTG which CTG belongs to which baby  Monitor the maternal pulse electronically + display it simultaneously on the same CTG trace

Answer 194

o Major RF  Referred for serial US measurement of fetal size + assessment of wellbeing with UMBILICAL artery doppler  From 26-28 w o >=3 minor risk factors  Refer for UTERINE artery doppler at 20-24 w

Answer 195

• Abnormal UTERINE artery doppler at 20-24 weeks o Defined as increased pulsatility index [PI] >95th centile and/or notching o Referred for serial US measurement of fetal size + assessment of wellbeing with UMBILICAL artery doppler o From 26-28 w ---- • Normal UTERINE artery doppler at 20-24 weeks o Do not require serial measurement of fetal size + serial assessment of wellbeing o Unless they develop specific pregnancy complications e.g. APH, or HTN o During third trimester  scan for fetal size + umbilical artery Doppler

Answer 196

``` Indications o High risk of SGA fetus/neonate (A)  Based on hx, biochemistry, uterine artery doppler  1 major RF  >3 minor RF + abnormal uterine artery ``` o SFH (B)  Single measurement <10th customised centile +/or serial measurements indicative of FGR or  Inaccurate SFH ((o Monitoring fetuses with high risk of SGA – these patients will be needing serial growth scans + UA dopplers irrespective of whether their growth scans will be abnormal or not o SFH – screening fetuses with suspicious SFH to determine if they are at risk of SGA or not – some of these patients might have normal AC/EFW or growth velocity and therefore not need serial growth scans or UA dopplers))

Answer 197

o Monitoring fetuses with high risk of SGA – these patients will be needing serial growth scans + UA dopplers irrespective of whether their growth scans will be abnormal or not o SFH – screening fetuses with suspicious SFH to determine if they are at risk of SGA or not – some of these patients might have normal AC/EFW or growth velocity and therefore not need serial growth scans or UA dopplers* o Measurement of the AC or EFW o SGA fetus = AC or EFW <10th centile o Growth velocity = 2 measurements of AC or EFW 3 w apart  *if AC/EFW <10th centile or evidence of reduced growth velocity • serial assessment of fetal size • UMBILICAL artery Doppler o Use of customised fetal weight reference o Severe SGA is identified at the 18-20 week scan  for a detailed fetal anatomical survey and uterine artery Doppler by a fetal medicine specialist o Specialties guide – serial growth scans every 2 weeks

Answer 198

o Should be the primary surveillance tool in the SGA fetus o SGA + normal umbilical artery Doppler flow indices – repeat surveillance every 2 weeks (AC, EFW, UA Doppler, MCA Doppler after 32 weeks) ----- o SGA + abnormal umbilical artery Doppler flow indices (increased pulsatility or resistance index >2 SDs above mean for GA) + delivery is not indicated – repeat surveillance  End-diastolic velocities present • Weekly – AC + EFW (=serial growth scans) • Twice weekly – umbilical artery doppler  Absent/reversed end-diastolic frequencies (AREDV) • Weekly – AC + EFW (=serial growth scans) • Daily – UA doppler, DV doppler, cCTG o Severely SGA fetus – more frequent surveillance

Answer 199

o Patients who require umbilical artery doppler  AC/EFW <10th centile or there is evidence of reduced growth velocity – decide on findings of umbilical artery doppler which monitoring is needed  1 major RF – UA doppler from 26-28 weeks  >3 minor RF + abnormal UTERINE artery – UMBILICAL artery doppler from 26-28 weeks o Patients who require serial US growth scans  If SFH is inaccurate (BMI >35, large fibroids, polyhydramnios)  1 major RF  >3 minor RF + abnormal uterine artery  if AC/EFW <10th centile or there is evidence of reduced growth velocity o Patients who require US measurement of fetal size  Single SFH <10th centile or serial measurements demonstrating slow/static growth by crossing centiles

Answer 200

A refer for US measurement of fetal size B serial assessment of fetal size using US

Answer 201

o Single course of AN CS to accelerate fetal lung maturation  If delivery is being considered between 24+0 and 35+6 weeks of gestation o Preterm SGA + absent or reversed end-diastolic velocity (AREDV) in umbilical artery doppler 32w  deliver when DV (ductus venous) doppler becomes abnormal or umbilical vein pulsations appear  Deliver provided that the fetus is considered viable(>24 weeks + EFW >500g) and after completion of steroids  Even when DV doppler is normal  delivery recommended by 32+0w  delivery should be considered between 30-32 w o Abnormal MCA doppler – delivery no later than 37+0w o SGA fetus detected >32 weeks + Abnormal umbilical artery Doppler – delivery no later than 37+0w o SGA fetus detected >32 weeks + normal umbilical artery Doppler – offer delivery at 37+0 weeks, involve a senior obstetrician in determining the timing and mode of birth of these pregnancies

Answer 202

o SGA fetus with umbilical artery AREDV  CS  IOL or spontaneous delivery – rated of intrapartum FHR decelerations necessitating CS = 75-90% o SGA fetus with normal umbilical artery Doppler or abnormal umbilical artery PI but end-diastolic velocities present  IOL  Rates of EMCS are increased • 15% for fetuses with AC or EFW <10th centile • Higher rates in those with serial AC or EFW measurements suggestive of FGR  Continuous FHR monitoring is recommended from the onset of uterine contractions o Spontaneous labour with SGA fetus  early admission in order to instigate FHR monitoring o Continuous electronic fetal monitoring should be offered o There is currently no evidence to support immediate delivery

Answer 203

o Abnormal CTG (and reduced fetal movements) o Abnormal umbilical artery doppler waveform (reversal of end-diastolic flow) - when DV (ductus venous) doppler becomes abnormal or umbilical vein pulsations appear

Answer 204

``` Placental failure = increased pulsatility index (this should be a low resistance pathway) ``` absent or reversed end diastolic flow = emergencies

Answer 205

``` • External cephalic version o Offered to all women o Nulliparous  36 weeks o Multiparous  37 weeks o Success rate = 50% ``` • C-section o If ECV is unsuccessful/contraindicated/declined o Recommended for a twin pregnancy of the presenting twin is breech  But routine C-section for breech presentation of the second twin is not recommended o not recommended for breech presentation in spontaneous pre-term labour o recommended for preterm breech presentation where delivery is planned due to maternal and/or fetal compromise o Benefits of CS  ELCS leads to a small reduction in perinatal mortality (0.5/1000) and early neonatal morbidity compared to vaginal breech delivery (2/1000) due to • Avoidance of stillbirth after 39 weeks of gestation • Avoidance of intrapartum risks and the risks of vaginal breech birth 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  planned vaginal birth increases risk of low apgar scores and short-term complications o risks of a CS  Small increase in immediate complications for the mother compared with planned vaginal birth • Maternal complications are least with successful vaginal birth • ELCS carries a higher risk • EMCS carries the highest risk – needed in approx. 40% of women planning a vaginal breech birth  Increases the risk of complications in future pregnancies • Risk of opting for VBAC • Increased risk of complications at repeated caesarean section – uterine rupture, placenta praevia (1.5-6 times higher than after a SVD) • Increased risk of an abnormally invasive placenta (?placenta acreeta)  Small increase in the risk of still birth for subsequent babies • Association, this may not be casual  Assess women based on their individual risk profile, reproductive intentions etc. o Risk of perinatal mortality with a CS – 0.5/1000 after 39+0 weeks • Vaginal breech delivery o Woman’s choice o Maternal complications are least with successful vaginal birth (ELCS carries a higher risk)

Answer 206

 Considerations – G+S, X-match, FBC, CTG, make sure theatre is ready • Empty bladder  Passive second stage to allow the descent of the breech to the perineum prior to active pushing • If breech is not visible within 2h of passive second stage  CS • If involuntary pushing occurs earlier, encouragement of maternal effort should not start until the breech is visible  Position – semirecumbent or in all-fours  Delivery of buttocks • Most important advice - Hand off the breech! • Traction on the baby during delivery  can cause the fetal head to extend  gets trapped • Tactile stimulation of the fetus may result in reflex extension of the arms or head • If handling is needed, put thumbs on sacrum and fingers on ASIS – not on soft tissues • Fetal sacrum/back needs to be maintained anteriorly – can be done by holding the fetal pelvis  Delivery of legs and lower body • If legs are flexed  will be delivered spontaneously • If legs are extended  Pinard’s manoeuvre o Poke the baby in the popliteal fossa to make them bend their knees  Delivery of shoulders • If the baby gets stuck once the body has delivered  winging of the scapulae • Lovset’s manoevre – rotate the body into the transverse position and pull the anterior arm down to deliver the shoulder o With thumbs on the infant's sacrum, take hold of the hips and pelvis with the other fingers. o Turn the infant 90° (back to the left or to the right), to bring the anterior shoulder underneath the symphysis and engage the arm. Deliver the anterior arm. o Then do a 180° counter-rotation (back to the right or to the left); this engages the posterior arm, which is then delivered.  Delivery of head • Mauriceau-Smellie-Veit (MSV) manoeuvre – deliver head by flexion – rest baby on your forearm and pull the head downwards • If MSV fails  forceps • A vaginal breech delivery cannot be expedited w forceps until its final stages

Answer 207

``` • External cephalic version o Offered to all women o Nulliparous  36 weeks o Multiparous  37 weeks o Success rate = 50% o Risks  Placental abruption  Foetal distress requiring an EMCS ``` o Contraindications  Multiple pregnancy  Recent APH (last 7 days)  Ruptured membranes  Abnormal CTG  Uterine abnormalities  Previous CS  Where CS is required irrespective of ECV outcome o If unsuccessful/declined  counsel about risks and benefits of vaginal breech delivery vs ELCS o Long-term health of the baby is not influenced by how the baby is born

Answer 208

 Management depends on a) stage of labour, b) whether factors associated with increased complications are found, c) availability of appropriate clinical expertise, d) informed consent  Women near or in active second stage of labour should not be routinely offered CS  Where time + circumstances permit, the position of the fetal neck + legs + the fetal weight should be estimated using US + the woman counselled as with planned vaginal breech birth

Answer 209

 IOL not recommended  Slow progress • Augmentation of slow progress with oxytocin – only considered if the contraction frequency is low (<4 in 10) + in the presence of epidural analgesia • Otherwise if progress is slow – consider CS  Epidural • Might increase the risk of a CS • Vaginal breech birth is usually easer if a mother is able to bear down effectively  an epidural may interfere with this  Continuous CTG/electronic fetal monitoring (EFM) – can lead to improved neonatal outcomes • If declines – intermittent auscultation as with cephalic fetus with conversion to EFM if any abnormality is detected  Birth in a hospital with facilities for immediate CS recommended (labour ward)

Answer 210

o Absolute contraindication  Footling presentation – feet and legs can slip through a non-fully dilated cervix and the shoulders or head become trapped

Answer 211

 Normal size foetus  Multiparity  Positive mental attitude of woman

Answer 212

```  Hyperextended neck on US  High estimated fetal weight (>3.8kg)  Low estimated fetal weight (<10th centile)  Footlong presentation  Evidence of antenatal fetal compromise ```

Answer 213

o Lack of tone or colour o Delay o Extended arms or extended neck o Poor fetal condition o Delay of >5 mins from delivery of buttocks to head o Delay of >3 mins from the umbilicus to head  If progress is slow • CS or • Oxytocin if epidural + contracting <4 in 10 • A vaginal breech delivery cannot be expedited w forceps until its final stages

Answer 214

Transverse lie • Vaginal delivery is impossible • Requires a C-section o Unless it converts/is converted in late pregnancy o Surgeon might be able to rotate the fetus through the wall of the uterus once the abdominal wall has been opened o Otherwise, a transverse uterine incision is needed to gain access to a fetal pole • ECV with 50% success

Answer 215

``` • Mento-anterior position (chin anterior)  Vaginal delivery with delivery by flexion o If adequate pelvic size o Risk of CS being required o Long labour • Mento-posterior (chin posterior)  CS ```

Answer 216

Unstable lie • Consider ECV or ELCS Brow position • CS Shoulder • CS

Answer 217

* 90% of malpositions spontaneously rotate to OA as labour progresses * If the head does not rotate  operative vaginal delivery with Kielland’s forceps to manually rotate the fetal head * CS

Answer 218

* OP results in long labour  close maternal and fetal monitoring * Epidural recommended * Adequate fluids given to mother * Discourage push before full dilation * If head comes into a face-to-pubis position  vaginal delivery is possible (as long as there is reasonable pelvic size) * Otherwise  forceps or CS may be required

Answer 219

• Alternatives for delivery o Manual rotation of fetal head using Kielland’s forceps o Delivery using vacuum extraction  Inappropriate if there is fetal acidosis  risk of cerebral haemorrhage o Some centres prefer to manage by CS without trial of forceps • There must be provision for a failure of forceps delivery to be changed immediately to C section o Trial of forceps is often performed in theatre

Answer 220

* Either partner as NTD, they have a previous pregnancy affected by NTD or they have a family history of NTD * The woman is taking antiepileptic drugs * The woman has coeliac disease, diabetes or the thalassaemia trait * The woman is obese (BMI >30kg/2) * HIV positive taking co-trimoxazole * The woman is taking dolutegravir for HIV (HIV women on regimens that do not contain dolutegravir should take the standard dose of folic acid 400μg OD) * Women on trimethoprim

Answer 221

Tailored monitoring and clinical review during the IP period  Hourly monitoring of fluid input + output, BP, pulse, RR, O2 sats.  ECG + pulse oximetry  Continuous intra-arterial BP monitoring  CO monitoring with non-invasive techniques or serial echo by trained staff

Answer 222

o Women on LMWH  Women must not have had a prophylactic dose LMWH for 12 hours or a therapeutic dose LMWH for 24 hours  After siting an epidural/spinal or removing an epidural catheter, wait 4hours before administering a further dose of LMWH  Do not administer therapeutic dose LMWH while an epidural is in place

Answer 223

• Prostaglandins o Do not offer prostaglandin F2 alpha (carboprost) – risk of bronchospasm o Consider prostaglandin E1 or prostaglandin E2 as options for IOL – no evidence that they worsen asthma o Consider prostaglandin E1 for treating PPH – no evidence that they worsen asthma

Answer 224

IV hydrocortisone during labour SVD - when in established first stage ELCS or EMCS - when starting anaesthesia

Answer 225

 >80 x109/L – treat the woman as healthy for the purpose of considering regional analgesia and anaesthesia  50-80 x109/L – before considering regional analgesia/anaesthesia take into account – clinical hx, woman’s preferences, anaesthetic expertise  <50 x109/L – avoid regional analgesia + anaesthesia under most circumstances

Answer 226

o To reduce the risk of bleeding for the baby  Inform neonatal team of imminent birth of baby at risk  Do not carry out fetal blood sampling  Do not use ventouse  Use fetal scalp electrodes / mid-cavity or rotational forceps with caution  A CS may not protect the baby from bleeding  Measure the plt count in the umbilical cord blood at birth

Answer 227

``` • Monitoring o Every 1 hour  Pulse  BP in the second stage of labour  Temperature  Level of consciousness (AVPU = alert, voice, pain, unresponsive) ``` o Every 4 hours  BP (if not in the second stage of labour)  RR  O2 sats o Record urine output

Answer 228

``` • Continuous or at least every 30 mins o Pulse o BP o RR o O2 sat ``` • Every 30 minutes o Level of consciousness (AVPU = alert, voice, pain, unresponsive) • Every 1 hour o Temperature o Urine output if catheterised • Record urine output

Answer 229

• Management o Signs of shock – resuscitation  IV fluids urgently  FBC + Xmatch  Seek senior help  Mx may also include • Triggering the major haemorrhage protocol • Taking blood for clotting studies and blood gases • Use of amniotomy or oxytocin • Expediting birth o Hx – associated symptoms, pain , concerns, previous uterine surgery o Check scans for placental position o Assess volume of blood loss + characteristics of blood – colour, presence of clots or amniotic fluid o Physical examination – vital sings, abdominal examination, speculum examination, vaginal examination after excluding placenta praevia, fetal heart auscultation o Start continuous CTG o Take blood sample to determine FBC + blood group o Stable – establish venous access, maternal + fetal monitoring ``` • Maternal monitoring o At least hourly  Pulse  BP in the second stage of labour  Level of consciousness (AVPU = alert, voice, pain, unresponsive)  Urine output if catheterised o At least 4-hourly  BP (if not in the second stage of labour)  RR  Temperature  O2 sas o Record urine output ```

Answer 230

``` • Take a full medical, psychological and social history o Try to find out why there has been no care during pregnancy o Ask the woman who, if anyone, she would like to support her as her birth companion(s) during labour o Explore vulnerability or safeguarding concerns  young maternal age  maternal mental health  maternal learning disability  maternal substance misuse  domestic or sexual abuse  homelessness  human trafficking  undocumented migrant status  female genital mutilation  the woman or family members being known to children's services or social services • assess baby o viability o presentation o estimate GA o possibility of multiple pregnancy o placental site • offer tests for o Anaemia FBC o Haemoglobinopathies o Blood group + rhesus D status o Atypical red cell alloantibodies o Random blood glucose o Asymptomatic bacteriuria o HIV, HBV, syphillis • Give her information about IP care at her first contact • Provide obstetric led intrapartum care • Follow guidance for healthy women and babies if no medical conditions/obstetric complications are identified • If there are safeguarding concerns – refer to safeguarding services ```

Answer 231

• Offer continuous CTG

Answer 232

Pulse Every 1 h BP Every 4h Every 1h in second stage Temp Ever 4h Monitor UO

Answer 233

• IOL o Should be offered to women with healthy pregnancy after 41 weeks o Between 41+0 and 42+0 to avoid the risk of post-term pregnancy, primarily increased IUD o Associated with a decrease in both the risk of CS + meconium-stained amniotic fluid • If woman reduces to have an induction o Increased monitoring – Biweekly CTG + US estimation of maximum amniotic pool depth

Answer 234

pre-pregnancy counselling • Conservative management – more exercise, better diet, vitamin D supplementation • optimise their weight before pregnancy • BMI >30 kg/m2 should be seen for pre-pregnancy counselling o Give information and advice about the risks of obesity during pregnancy + childbirth o Support women to lose weight before conception and between pregnancies • Women with a BMI >30 kg/m2 wishing to become pregnant o 5mg folic acid OD starting ta least 1 month before conception + continuing during the first trimester of pregnancy ``` benefits of weight loss • Weight loss between pregnancies o Reduces the risk of  Stillbirth  Hypertensive complications  Fetal macrosomia o Increases the chances of  Successful VBAC ``` Risks  Increased risk of GDM, PET, fetal macrosomia  Poor US visualisation of the baby + consequent difficulties in fetal surveillance and screening for anomalies  AN screening for chromosomal anomalies less effective  Maternal obesity is associates with a physiological delay in lactogenesis, lower rate of BF, earlier cessation of BF + earlier introduction of solids  Potential difficulty for intrapartum fetal monitoring, anaesthesia and CS  maternal obesity is associated with an increased incidence of - IOL - Augmentation of labour - IP CS o + how they may be minimised  Increased level of maternal and fetal monitoring  Senior obstetric and anaesthetic involvement  Antenatal anaesthetic assessment  Need to prioritise the safety of the mother at all times o Screened for GDM (maternal obesity is a RF_ o VTE assessment and thromboprophylaxis  Therapeutic doses of LMWH + extremes of weight <50kg or >90kg – routine measurement of peak anti-Xa activity o Screening for MH problems

Answer 235

* If it’s difficult to obtain nuchal translucency (NT) measurements transabdominally consider use of TVUS * Those with unsuccessful first trimester screening (the combined test) should be offered second trimester screening with serum markers (the quadruple test)

Answer 236

o Antenatal monitoring  BMI >35kg/m2 – serial assessment of fetal size using US (more likely to have inaccurate SFH)  If external palpation is technically difficult or impossible to asses fetal presentation  US o IOL at term – may reduce the chance of a CS o If macrosomia is suspected – IOL (Reduction in the risk of shoulder dystocia + fetal fractures) o Active management of the third stage should be recommended to reduce the risk of PPH  FHR monitoring can be a challenge – use fetal scalp electrode or US assessment of the fetal heart if necessary • CS o BMI >30kg/m2 – increased risk of wound infection during CS – should receive prophylactic abx at the time of surgery • VBAC o Obesity is a RF for unsuccessful VBAC o Class III obesity – increased rates of uterine rupture during trial of labour, increased rates of neonatal injury

Answer 237

o Aspirin 150 mg OD from 12 weeks until birth of baby o If at high risk of pre-eclampsia (>1 high risk factors) or if >2 moderate RF BMI >=35kg/m2 is already 1 moderate RF ``` • High RF o HTN disease during previous pregnancy o CKD o Autoimmune disease e.g. SLE or antiphospholipid syndrome o T1 or T2DM o Chronic HTN ``` ``` • Moderate RF o First pregnancy o Pregnancy interval of >10 years o >40 y/o o BMI >35kg/m2 at first visit o FHx of pre-eclampsia o Multiple-fetal pregnancy ``` o NICE – women who have had PET should be advised to achieve and keep a BMI within the healthy range (18.5-24.9 kg/m2) before their next pregnancy

Answer 238

o Aspirin 150 mg OD from 12 weeks until birth of baby o If at high risk of pre-eclampsia (>1 high risk factors) or if >2 moderate RF BMI >=35kg/m2 is already 1 moderate RF ``` • High RF o HTN disease during previous pregnancy o CKD o Autoimmune disease e.g. SLE or antiphospholipid syndrome o T1 or T2DM o Chronic HTN ``` ``` • Moderate RF o First pregnancy o Pregnancy interval of >10 years o >40 y/o o BMI >35kg/m2 at first visit o FHx of pre-eclampsia o Multiple-fetal pregnancy ``` o NICE – women who have had PET should be advised to achieve and keep a BMI within the healthy range (18.5-24.9 kg/m2) before their next pregnancy

Answer 239

• You have 5 minutes • Push red emergency button – call senior and neonatal help • 1st line • All mothers – do not push (risk of Erb’s palsy), lay woman flat, axial traction (push baby towards you, not downwards), 30s • External manoeuvres o McRoberts – hyper-flexion and abduction of the maternal hips, bring thighs to the abdomen  Try to deliver the baby – palms covering baby’s ear and pull – never pull from the neck  Increases AP diameter of pelvis  Success 90%  Low rate of complications o Rubin maneuver – Suprapubic pressure  Locate back of baby and apply pressure by interlocking hands like you are doing CPR (apply pressure over the posterior aspect of the anterior fetal shoulder)  Continuous pressure (30s), rocking (pulses, 30s)  Reduced fetal bisacromial diameter  Rotates anterior shoulder to the oblique direction to disimpact • Internal manoeuvres – 2nd line – performed while maintaining downward traction o Assess for an episiotomy if this will make the internal manoeuvres easier o Sacral hollow o Rubin II manoeuvre/reverse woodscrew manoeuvre – two fingers placed behind anterior shoulder + apply downward pressure o Wood’s screw manoeuvre – apply pressure on the anterior aspect of the posterior shoulder to aid rotation – two fingers placed in front of posterior shoulder + apply upward pressure  Two fingers by anterior shoulder  Two fingers by posterior shoulder  Rubin II manoeuvre – rotate counter-clockwise for 30-60s  Wood-screw manoeuvre – rotate clockwise for 30-60s o Deliver Posterior arm – try to take out of the uterus baby’s posterior arm by pulling it from the antecubital fossa  Reduces the diameter of the shoulders by the width of the am  Associated with humeral fractures  Rotate 180 and deliver other arm o All fours  Repeat above manoeuvres • 3rd line o Cleidotomy – surgical division of the clavicle or bending with a finger  Break baby’s clavicle  Preferred to symphysiotomy as babys bone will heal much quicker and wont leave lasting problems o Symphysiotomy – dividing the anterior fibres of the symphyseal ligament o Zavanelli’s – vaginal replacement of the head (2nd pic)  Last resort when other methods have failed  Reversal of normal delivery movemens  Fetal head is manually return to its pre-restitution position and then slowly replaced in the vagina + then into the uterus by steady upward pressure against the head  Delivery is then accomplished by C-section  Uterine relaxant may be required to carry out this procedure  Usually done when the baby has passed away • Note!: do not perform fundal pressure (risk of uterine rupture) or encourage continued maternal pushing

Answer 240

• Dry baby • Stimulate baby – 30s • Wrap baby to keep it warm • Make sure that you can see the chest • Assess baby in terms of o Tone o Colour o Breathing o Heart rate • (if there is meconium you can suction it, meconium can increase risk of developing cerebral palsy) • Ensure the head is in a neutral position o If it’s either extended/flexed the airway will close • Deliver 5 inflation breaths o Each should be 3 seconds long o Can do a jaw thrust o Observe for chest wall movement o If the chest wall is not moving, consider advanced airway techniques e.g. gadelle airway o If the chest wall has risen, assess again for tone, colour, breathing, heart rate • HR o <60 + chest wall is rising  continue 1s ventilation breaths for 30s o Asses baby again o If HR still <60/not improving  move on to chest compressions • Chest compressions o 1 finger below the internipple line at a rate of 3 chest compressions: 1 breath o After 30s reassess the HR o If HR is improving  continue ventilation breaths at a rate of 30 per minute o If HR <60/not improving  continue CPR  At this stage consider whether the baby will need drugs e.g. adrenaline (given through the umbilical cord and more specifically the umbilical vein) o If no signs of life/breathing for 20 minutes  stop the resuscitation, baby is dead