Obstetrics Mx Flashcards
Diet and Exercise advice in GDM (4)
Self-monitoring of BG w/glucometer Diet - Refer ALL to dietician Exercise - 30mins walking/day until just breathless Target: Fasting BG - 5.3 but >4 to prevent hypoglycaemia 1hr BG - 7.8 or 2hr BG - 6.4
Neonatal side effects of VZV in pregnancy
<28 weeks: Congenital varicella syndrome (IUGR, microcephaly, limb hypoplasia, chorioretinitis)
28-36 weeks: Shingles (dermatomal distribution rash) in first few years of life
> 36 weeks: Neonatal chickenpox infection (especially if birth within 7 days of rash) and premature delivery
Mx of SGA
Screen infections: CMV, toxoplasmosis, syphilis
Umbilical artery doppler
Karyotyping may be offered
Steroids+deliver where there are neonatal facilities
Mx of retained product of conception
Elective curettage with antibiotic cover may be required.
Surgical measures should be undertaken if there is excessive
or continuing bleeding, irrespective of ultrasound findings.
Endometritis Mx
IV antibiotics if there are signs of severe sepsis.
If less systemically unwell – oral treatment may be sufficient
Endometritis risk factors
Caesarian Prolonged rupture of membranes Severe meconium staining in liquor Manual removal of placenta Extreme maternal ages Prolonged surgery Retained products of conception
Classification of pre-eclampsia
Mild: Proteinuria + mild/mod HTN
Moderate: Proteinuria + severe HTN + no Cx
Severe: Proteinuria + HTN <34 or maternal Cx
Mx of pre-eclampsia?
Mild: 6 hourly BP, don’t deliver before 34 weeks
Moderate/severe: Oral labetalol , nifedipine and hydralazine can also be used AVOID ACEi (teratogenic, reduced fetal urine output), ARB diuretic
MgSO4 to prevent/treat seizures
Pre-eclampsia questions (5)
Headache, vision Sudden swelling of hands/feet Abdo pain/tenderness Vomiting Bleeding
3 or more miscarriages Mx
Antiphospholipid syndrome antibody screen
Give asprin & LMWH
Karyotype both parentsGive donor or PGS of IVF
Pelvic USSGive IVF
Miscarriage Questions?
Colour, Clotting, Amount
Pain, Shoulder tip pain
RFs: Infection, trauma
PMH: DM, connective tissue disease, uterine abnormalities
Neonatal Tx if HIV in pregnancy
PO Zidovudine if viral load <50/ml
Triple ART if viral load >50/ml
Therapy continued for 4-6 weeks
Do NOT breastfeed
HIV in pregnancy Mx
Start ART 28-32 weeks and continued intrapartum
Zidovudine monotherapy: If viral load is <10,000/ml + if willing to deliver by prelabour caesarean section
HAART if viral load >10,000/ml
Vaginal if viral load <50
Zidovudine started 4 hours before Caesarian
Mx of miscarriage
Expectant (wait 2-6 weeks)
Medical: Misoprostol (prostaglandin) +/- mifepristone (anti-progesterone)
Surgery: Evacuation of retained products (ERCP) under anaesthetic
If RH -ve & >12 weeks OR medical/surgical: Give anti-D
VTE Mx
Graduated stockings for 2 years, elevate leg.
LMWH 1mg/kg BD for remainder of pregnancy. At least 6w postnatally
After delivery, choose to stay on LMWH or switch to warfarin.
Offer thrombophilia screening if strong personal or FH of VTE
PE Ix
- ECG, ABG
- Baseline investigations: FBC, coagulation screen, U&E, LFT
- Perform compression duplex ultrasound if DVT symptoms.
- CXR
CTPA or V/Q
PE Mx
- ABCDE, senior involvement
- Urgent CTPA
- IV unfractionated heparin until PE excluded. LMWH 1mg/kg BD for remainder of pregnancy. At least 6w postnatally.
- Graduated stocking and mobilisation
“When you go home you should continue injecting yourself daily with the medication we give”
Hyperemesis gravidarum Mx
Bland meals low in carbohydrates but high in protein, can try ginger.
PO cyclizine
Review in 1 week
Can switch to PO metoclopramide (max 5d)
Rehydrate if needed with 0.9% saline + KCL
Thiamine if needed
Serial growth scans if it continues into 2nd trimester
When to admit with hyperemesis gravidarum
Weight loss >5%, Ketonuria, Very dark urine (or no urination >8hrs) Inability to keep food or fluids down for 24hrs Symptoms of pre-eclampsia
GDM Mx
- Fasting glucose <7mmol/L, offer 2-week trial of diet and exercise. If targets of fasting<5.3mmol/L and 2hr glucose<6.4mmol/L are not met, offer metformin 500mg OD for 1w then 500mg BD for 1w then 500mg TDS.
• Fasting glucose >7mmol/L, offer rapid-acting insulin (aspart, lispro) ± metformin and lifestyle changes.
• Fasting glucose 6-6.9mmol/L, consider immediate insulin ± metformin and lifestyle changes. - If metformin is insufficient, offer insulin.
- Offer 75mg aspirin daily until delivery
GDM Ix
OGTT: 75g 2hr at booking and another at 24-28w if the first is negative and they have RFs. Offer review at diabetes antenatal clinic within 1w and contact GP.
• Fasting glucose> 5.6mmol/L
• 2hr glucose>7.8 mmol/L
GDM counselling
Diabetes-antenatal clinic every 2 weeks
Test fasting, pre-meal, 1hr post-meal and bedtime glucose
Advise on hypoglycaemia Sx
Offer retinal assessment immediately and at 28w
Recommend elective birth by induced labour or caesarean from 37 to 38+6.
Define pre-eclampsia
- 140/90mmHg on 2 occasions 4hrs apart after 20w
* 30 mg/mmol protein:creatinine ratio
Pre-eclampsia antenatal and postnatal Mx
US for foetal growth and umbilical artery doppler every 2-4 weeks
Measure FBC, LFT and U&E twice weekly
Initiate birth from 37 weeks
BP measured hourly intrapartum
Postnatal: measure BP 4 times a day, every 2 days up to 2 weeks after if on anti-hypertensives
Urine dip 6-8 weeks
GP follow up at 2 weeks
Pre-conception counselling if on antihypertensives
Lifestyle changes
• Discontinue ACEi and ARBs and offer alternative antihypertensives
HSV in pregnancy Mx
FIRST/SECOND TRIMESTER: acyclovir 400mg TDS 5d. Give acyclovir from 36w until delivery. Avoid vaginal delivery for 6w.
THIRD TRIMESTER: acyclovir 400mg TDS until delivery. Give IV if disseminated. Caesarean section indicated.
If vaginal delivery chosen, ROM and invasive procedures should be avoided. IV acyclovir intrapartum.
Prevention of Pre-term labour
has history of spontaneous preterm birth or cervical length <25mm
- Consider prophylactic vaginal progesterone between 16+0 and 24+0 until 34w.
- Consider prophylactic cervical cerclage between 16+0 and 24+0 with previous PPROM or cervical trauma.
- Consider rescue cerclage between 16+0 and 27+6 with dilated cervix and unruptured membranes.
• Do NOT offer rescue cerclage in infection, active PV bleed or uterine contractions.
Mx of preterm labour with rupture of membranes
- Sterile speculum.
- Measure IGF binding protein 1
- Prophylactic erythromycin 250mg QDS 10d or until labour
- Test CRP, WCC, CTG to diagnose intrauterine infection.
- Offer maternal steroid up to 33+6. Consider up to 35+6.
- Offer 4g IV magnesium sulphate bolus over 15 mins with IV infusion 1g/hr until birth or 24hrs at 24-29+6. Consider at 30-33+6. Monitor HR, BP, RR, UO.
- Consult senior obstetrician about fetal monitoring 23-25+6.
Mx of preterm labour with intact membranes
- Sterile speculum followed by digital examination.
- Offer nifedipine for 24+0 to 25+6. Consider up to 33+6.
- Under 29+6, manage as above.
- Over 30+0, consider TVUSS measurement of cervical length. If >15mm, consider discharge and safety netting. If <15mm, manage as above.
- Over 30+0 consider fetal fibronectin to support treatment if TVUSS is not available or acceptable
Contraindications to VBAC
- Previous uterine rupture
- Classical caesarean scar
- Absolute contraindications to vaginal birth that apply irrespective of scar eg major placenta praevia
Counselling for VBAC vs ERCS
- The advantages of VBAC are that if it is successful, you will have a shorter hospital stay and recovery. It also means that you have a good chance of successful future VBACs. However, there is a small risk of HIE to the baby during delivery and there is a 1 in 200 risk of uterine rupture. The absolute risk of birth-related death with VBAC is comparable to first time mums delivering vaginally.
- The advantages of ERCS are the smaller risk of HIE and the no risk of anal sphincter injury as you will not be pushing. There is no risk of uterine rupture but there is increased risk of placental problems and adhesion formation. ERCS also means that you are likely to require caesareans in future.
- If you choose to have a VBAC and don’t go into labour by 39w, your obstetrician will probably recommend a ERCS to minimise the risk of complications
