Obstetrics/Post-natal/neonatal and Fertility Flashcards
Lifestyle impacts on a women’s fertility?
(7)
Stress
Excessive exercise
Alcohol
Smoking
Toxin/chemical exposure
caffiene intake
Illicit drug use
Causes for infertility in women?
(9)
Endometriosis
Autoimmune conditions such as thyroiditis
Uterine fibroids
premature ovarian failure
PCOS
Age > 35
Chemo/radiotherapy
Fallopian tube damage/ovarian surgery
Obesity
Investigations to order for female infertility?
(8)
- Day 2-4 FSH
- Day 2-4 LH
- AMH
- TV U/S for oocyte count +/- structural abnormalities
- Makers for PCOS such as FAI
- Prolactin
- TSH
- Day 2-4 E2
With lactational mastitis what are some measures that can be used?
(4)
- increased breastfeeding from the affected breast
and
gently expressing milk from the affected breast may prevent progression and resolve infection without antibiotics.
- Heat packs should be applied to left the breast prior to feeding to aid with drainage
And
Cold packs should be applied to the left breast after feeding for comfort
- Paracetamol 1gram oral, 4-6 hourly
- Gentle massage the affected breast during feeding to aid with drainage
When would you consider antibiotic treatment for mastitis and what would you use?
- If systemic symptoms
- If other symptoms (local) do not resolve in 24-48 hours with increased expression/breastfeeding
use
Di/Flucloxacillin 500mg, oral, QID, 5 days, if not quite resolved then 10 days
How do you calculate the LMP?
Add 40 weeks to the date of the LAST menstrual period. based on a 28 day period
If periods are longer then add the extra days
If periods are shorter then subtract the extra days.
When is the dating U/S best ordered?
8-9 weeks Gestation and only if unsure about LMP
What conditions to check in the past medical history in the first antenatal consult?
(Extensive list)
Thyroid Disease
Previous GD or T2 or T1 DM
Alcohol use
Tobacco use
High Blood Pressure
Kidney disease
Heart disease
GI disorders
Asthma
DVT/VTE
Gyne or incontinence issues
Epilepsy
Psychiatric history
What are appropriate tests in the first antenatal visit?
(7+3)
Opportunistic CST
FBC
Blood group and antibody
Infectious screen: Rubella, syphilis, hep B, hep C, HIV,
STI screen especially chlamydia if under 25*
Tests for trichomonas or mycoplasma if symptomatic*
Quantitative bHCG
MSSU
Vitamin D
OGGT- if they meet the screening criteria*
*= Not for everyone
What 2 main supplements should be recommended in the prenatal or antenatal consult?
Folic acid 500micrograms daily
If overweight/obese then 5mg
Iodine supplementation 150mg daily
Beside for recommending folic acid and iodine what other vitamin/minerals can you screen for or educate about in the antenatal visit?
Vitamin D
Iron (if deficiency)
Calcium
B12
List 4 main foods to avoid in pregnancy?
Soft cheeses (listeria)
Raw or partially cooked eggs or meat (salmonella and campylobacter)
Liver products (vitamin A toxicity)
Raw shellfish (listeria)
What main lifestyle topics should you cover in the antenatal consult?
Think SNAP WAS
(6)
Diet- healthy
Foods to avoid
Smoking STOP
Alcohol NONE
Exercise
Weight management, weight loss is not an appropriate goal.
When is screening for genetic/chromosomal abnormalities best done? and what is offered?
11-13 weeks
Option one
Combined first trimester screening
Screens for trisomies 13, 18, 21
Levels of PAPP-A
Also involves nuchal translucency
- is rebatable
Option two
NIPT
Also screens for trisomies 13, 18, 21 BUT also a host of other genetic issues
- not rebatable
What if screens on either the combined first trimester screening or NIPT come back positive? what is the diagnostic next step?
Ideally a CVS or amniocentesis
Amniocentesis is actually SLIGHTLY less risk, but has to wait until after 14-15 weeks, which might limit decision making time
One definition of hypertension in pregnancy is a BP of > 140/90, but another more useful measure might be a raise of __ ___ systolic or __ ___ diastolic from _____ or _____ previous blood pressure.
(a raise of 30 /15 is defined is hypertension in pregnancy)
> 30 systolic or > 15 diastolic from preconception or baseline readings
The definition of preeclampsia is ________ associated with ____ _______ damage or failure most commonly seen as ________
Hypertension
organ system
Proteinuria
What organ systems are involved in pre-eclampsia?
Kidney (proteinuria)
Liver (RUQ pain, abnormal tests)
Haematological
platelets <100000 IU
Neurological –? seizures (eclampsia)
Pulmonary oedema
Fetal growth restricion
What tool can you use to asses pre or post natal depression?
Edinburugh Post Natal depression Scale
Safest Anti-depressant to use in pregnancy if warranted?
Sertraline, primarily because it has all the data
Differntials for antenatal bleeding?
Ectopic pregnancy
Miscarriage
Threatened miscarriage
Cervical ectropion
Cervical polyp
Uterine infection
Gestational trophoblastic disease
What are important points of examination when presented with antenatal bleeding?
(3)
- Haemodynamic stability to determine urgency
- Speculum exam
-Determine amount of bleeding
-Determine products of conception
-Determine if there are lesions - Bimanual exam
–> size of uterus e.g. if large then GTD
–> Cervical motion tenderness can be PID, ectopic or peritonitis
Tests for antenatal bleeding
(3)
- Group and save
- TVUS
- Beta HCG to track rate of increase or decrease
What are three management options to consider for patients if suspecting their antenatal bleeding is a miscarriage?
(3)
- Expectant management.
Advise of pain, Advise of blood loss, follow up in 1 week, Educate and arrange how to seek medical attention - Medical
Needs to be given in monitored facility using misoprostol - Surgical
D&C - best if haemodynamic instability
What is gestational diabetes?
Glucose intolerance that is diagnosed in pregnancy. Usually tested at 24-28 weeks gestation
In a mother with Gestational diabetes what are some complications for the baby?
(6)
macrosomnia
Fetal death
Shoulder dystocia
Nerve palsy
Hypoglycaemia
Respiratory distress
What are the cut offs that diagnose GD
List some of the higher risk groups, in terms of development of Gestational diabetes, that would dictate screening for it within the first trimester?
(8)
Previous GD
Previously elevated BGL
BMI > 30
First degree relative with T2DM
PCOS
Medications : antipsychotics, corticosteroids
Maternal age > 40
Ethnicity: asian, Indian subcontinent, ATSI, Pacific islander, Maori, Middle eastern, non-white African.
Medications that can be used for gestational diabetes?
Which medications are not ideal to use?
- Metformin - no harm to mother or fetus reported
- Insulin can be used safely
Not ideal for use in pregnancy:
SGLT2i, GLPRA have not been studied enough
Sulfonylureas- being an insulin secretagogue that crosses the placenta can lead to increased birth weight and concerns about infant pancreas, but in saying this, it is used overseas.
After a mother with gestational diabetes gives birth when
- Can they Stop medication (for GD)
- Should they be screened for T2DM
- Have follow up regarding Diabetes
- Stop straight away
- Test for diabetes 6 weeks to 3 months later
- 1-2 yearly follow up for development of T2DM
In 9 steps outline the major areas to check in the 6 week baby check?
- Concerns from the mother )+ immunisations
- Interaction assessment (between mother/father and child in the room)
- Measurements (growth chart length, weight, HC)
- Observations (jaundice? cyanosed? abnormal features? work of breathing? does baby look at follow the examiner?)
- Neurological and eye exam
- Mouth exam (cleft palate, bifid uvula)
- Abdominal exam (organomegaly)
- Cardio-resp exam (auscultate heart, chest, check femoral pulses)
- Hip exam
What are 6 key areas of a 6 week baby check on neurological and eye signs? and 1 area not as useful, that we tend to do alot?
- Does baby track the examiner
- Is there a red reflex
- Are limbs moving spontaneously
- Does baby prefer one side to use over another
- Is there a certain posture the baby adopts: decerebrate, decorticate.
- Hold in a ventral position to check for spinal defects
- Eliciting primitive reflexes isn’t that useful. eg. babinskis or clasping.
What is the Barlow test?
The fetus is dependent on placental transfer of maternal T4.
The fetus then makes t3 from that maternal T4.
What important role does thyroid hormone have to play in a developing fetus?
Particularly important for neurological development.
Most notably, Haddow et al demonstrated children born to mothers with untreated overt hypothyroidism had an intelligence quotient (IQ) seven points lower at age 7–9 years compared to children born to euthyroid mothers
What are the thyroid references ranges in pregnancy compared to normal?
The TSH is usually lower in pregnancy than normal states. And the range changes as per trimester.
What is the recommended IODINE intake during
a. pregnancy
b. breastfeeding
a. 250ug/day
b. 270ug/day
If needing thyroxine during pregnancy, which is safe, effective and urgent if a patient is hypothyroid in pregnancy, what supplements need to be taken separately to avoid poor absorption of iodine?
Calcium
Iron
Both can reduce thyroxine absorption and should be taken separately.
How much extra thyroxine (as a percentage) should pregnant patients take if they ALREADY had hypothyroidism prior to pregnancy?
about a 30% increase
Subclinical hypothyroidism as evidenced by a _(a)__ _(b)__ is associated with ___(c)___.
And women with multiple __(c)___ should definitely be screened with a _(b)__ and __(d)__
a.high
b.TSH
c. Miscarriage/s
d. anti-TPO (TPOab)
Poorly controlled maternal hyperthyroidism increases the risk of pregnancy complications, such as
(3)
miscarriage
low birth weight
premature birth