Obstetrics (Quesmed) Flashcards
When does the third stage of labour begin and end?
Begins at the delivery of the foetus and ends at the delivery of the placenta (it generally lasts between 30 minutes to an hour, or 5-10 minutes when Oxytocin is administered)
What are the 3 signs of Placental Separation and imminent Placental Delivery in the third stage of labour?
Gush of Blood
Lengthening of the Umbilical Cord
Ascension of the Uterus in the Abdomen
(Goes from -o to –0 (+ blood) basically)
How is the third stage of labour managed and what are the 2 possible complications?
It is managed manually by controlled cord traction
This must be gentle otherwise there is a risk of (2)
- Uterine Inversion
- Postpartum Haemorrhage
(Uterus turning upside down and dropping blood like a bucket)
When does Acute Fatty Liver of Pregnancy occur?
During the third trimester
What are 9 signs of Acute Fatty Liver of Pregnancy?
Disseminated Intravascular Coagulation
Oliguria
Nausea/ Vomiting
Tachycardia
Fever
Abdominal Pain (RUQ)
Malaise
Fatigue
Jaundice
What can Acute Fatty Liver of Pregnancy cause?
It can affect Foetal Acid-Base regulation due to Maternal Metabolic Acidosis secondary to damaged hepatocytes
This can affect Foetal Mortality
How is Acute Fatty Liver of Pregnancy managed?
Early Identification of the Disease, Delivery of the Foetus and Intensive Support Care
What is the Aetiology of Amniotic Fluid Embolism?
It is when Amniotic Fluid enters the Maternal Circulation
It occurs shortly after Labour
The fluid acts as an embolism and if this occurs in the lungs, it can cause a Pulmonary Embolism
It can also trigger an immune system reaction from the mother’s immune system which can lead to Disseminated Intravascular Coagulation
What are the 5 signs of Amniotic Fluid Embolism?
Hypotension
Tachycardia (Shock)
Hypoxia
High Respiratory Rate (Breathing Fast so Low O2)
Disseminated Intravascular Coagulation
What are the 4 differentials for Amniotic Fluid Embolism?
Septic Shock due to Infection
Anaphylactic Shock due to Drugs
Pulmonary Embolism (especially as Pregnancy is a Prothrombotic state)
Hypovolaemic Shock (Placental Abruption)
What is the 4 step management of Amniotic Fluid Embolism?
Transfer to Intensive Care
If the Embolism has occured before Delivery, then continuous foetal monitoring is necessary
Oxygen and Fluid Resuscitation
Correct any Coagulopathy-
- Fresh Frozen Plasma for Prolonged PT
- Cryoprecipitate for Low Fibrinogen
- Platelet Transfusion for Low Platelets
What is Antepartum Haemorrhage?
Bleeding occurring between 24 weeks of pregnancy and birth
What are the 9 differentials for Antepartum Haemorrhage?
Placental Abruption
Placental Praevia
Vasa Praevia
Malignancy or Trauma of the Genital Tract
Infection of the Genital Tract
Uterine Rupture
Inherited Bleeding Disorder
Gestational Trophoblastic Disease
Cervical Ectropion
What is the management of Antepartum Haemorrhage?
First assess the Haemodynamic status
If Haemodynamic Compromise is present due to there being a major Haemorrhage, then Resuscitation should be commenced
If there is no Haemodynamic Compromise, then a thorough clinical history, abdominal examination and speculum examination should be performed
(Digital Vaginal Examination should be avoided if there is a possibility of Placental Praevia)
All patients should be admitted to hospital for Observation
These 6 bloods should be taken-
- Group and Save, Crossmatch
- FBC
- Coagulation Screen
- U and Es
- LFTs
- Kleihauer Test in Rhesus Negative Women to determine the dose of Anti-D Immunoglobulin needed
Ultrasound may be required to eliminate Placental Praevia and Cardiotocography should be used to monitor the foetus
If there is a risk of Preterm Birth and the woman is between 24 and 34 weeks Gestation, Antenatal Corticosteroids should be offered to aid Foetal Lung Maturation
What is the management of Asymptomatic Bacteriuria in Pregnancy?
Asymptomatic Bacteriuria is when there is a positive urine culture without any of the symptoms of a UTI
It is managed with Antibiotics- NITROFURANTOIN or CEFALEXIN
Asymptomatic Bacteriuria has been shown to increase the risk of a Miscarriage and Preterm Labour
If a Group B Streptococcus has been identified, the mother must be prescribed Prophylactic Antibiotics to reduce the risk of Transmission to the Foetus during Labour
When are Obstetric Appointments booked and what are the 5 tests that are conducted at these appointments?
10 weeks prior to Gestation
- Height, Weight and BMI
- Urinalysis
- Blood Pressure
- Blood Tests for Bloodborne Diseases (HIV, Syphilis and Hepatitis B)
- Blood Tests for Sickle Cell Anaemia and Thalassaemia
Also Patient Histories are taken to identify risk to patient and foetus during pregnancy and labour
What are Branchial Cysts?
They are Embryological Remnants from the development of the Branchial arches which form parts of the Head and Neck
They manifest as Painless Cyst Masses which are ANTERIOR to the Sternocleidomastoid muscle and these become apparent in Late Childhood
What are the 3 Absolute Contraindications to Breastfeeding?
Mothers have-
- TB Infection
- Uncontrolled/ Unmonitored HIV
- Been taking harmful medication (Amiodarone)
What are the Indications for Extra Cephalic Version in Breech Presentation and how is it performed?
It is offered at 36 weeks for Breech Presentation for Primiparous Women or 37 weeks for Multiparous Women (they can afford to wait a week more cos they’ve had more experience)
What are the Indications for Extra Cephalic Version in Breech Presentation and how is it performed?
It is offered at 36 weeks for Breech Presentation for Primiparous Women or 37 weeks for Multiparous Women (they can afford to wait a week more cos they’ve had more experience)
ECV is a manual procedure that has a 50% success rate usually. It is usually carried under UltraSound Guidance.
The mother is given (3)
- Analgesia
- Tocolytics (medications that suppress Premature Labour)
- Anti-D Immunoglobulin (if required)
If ECV is unsuccessful, the options are either vaginal delivery or caesarean section
What are the 7 Absolute Contraindications and 7 Relative Contraindications to Extra Cephalic Version for Breech Presentation?
Otherwise Elective Caesarean Section should be performed
Absolute (Camp MnM)
- Caesarean Section is already indicated for other reasons
- Antepartum Haemorrhage has occured in the last 7 days
- Major Uterine Abnormality
- Placental Abruption or Placental Praevia
- Membranes have ruptured
- Non-reassuring Cardiotocograph
- Multiple Pregnancy (but may be considered for the delivery of the second twin)
Relative (Mump IOU)
- Major Foetal Abnormality
- Unstable Foetal Lie
- Maternal Obesity
- Pre-Eclampsia
-Intrauterine Growth Restriction with Abnormal Umbilical Artery Doppler Index
- Oligohydramnios
- Uterine Scarring from Previous Caesarean Section or Myomectomy
What is Chorioamnionitis and what are the 7 signs?
Infection of the Uterus Membranes
- Fever
- Abdominal Pain
- Pyrexia
- Uterine Tenderness
- Offensive Vaginal Discharge
- Preterm Rupture of Membranes
- Maternal and Foetal Tachycardia
What is the management of Chorioamnionitis?
Admission and Delivery
They require Intravenous Broad Spectrum Antibiotic Therapy as part of the Sepsis Six Protocol
What is Congenital Cytomegalovirus Infection and what are the 6 signs at birth and 3 Neurological signs?
(bear in mind, some babies have NO signs)
It is when CMV is vertically transmitted from mother to baby (bear in mind most of the population will have been infected with CMV at some point)
- Low birth weight
- Jaundice
- Microcephaly
- Seizures
- Pneumonia
- Petechial Rash
- Hearing Loss
- Visual Impairment
- Learning Disability
How is Congenital Cytomegalovirus Infection diagnosed?
Typically it is diagnosed Post-Natally- by testing the baby’s saliva, blood or urine
Antenatally, it can be detected on Ultrasound and confirmed by Amniocentesis. Routine screening for CMV antibodies in the mother is NOT recommended
When is the risk of developing Congenital Rubella Syndrome greatest in pregnancy?
The First Trimester of Pregnancy
What are the 4 main symptoms of Congenital Rubella Syndrome in babies and the 7 other symptoms?
Sensorineural Hearing Loss
Cataracts
Retinopathy
Congenital HEART Disease
(4 small/low things and 3 extra things)
Microcephaly
Micrognathia (small LOWER JAW)
Low Birth Weight
Developmental Delay and Learning Disability
HAEMATOLOGICAL abnormalities
BLUEBERRY MUFFIN rash
Organ Dysfunction
What is Congenital Toxoplasmosis?
It is caused by Toxoplasma gondii- found in Cat Faeces, Infected Meat and Soil
Most people who contract it are ASYMPTOMATIC or have MILD flu-like symptoms
It can also spread vertically to babies in the womb- Congenital Toxoplasmosis
What are the 4 signs of Congenital Toxoplasmosis? (seen later in life as babies are usually asymptomatic)
CNS Problems (Cerebral Palsy, Epilepsy and Hydrocephalus)
Learning Disabilities
Visual Impairment
Hearing Loss
What are the 4 things done to diagnose babies with Congenital Toxoplasmosis and the management for this?
Antenatal Ultrasound to look for Foetal Abnormalities)
Amniocentesis with PCR Testing
Maternal IgM testing to check for PREVIOUS exposure
Foetal Blood Test
SPIRAMYCIN is used to treat toxoplasmosis DURING pregnancy to reduce transmission to the baby
What are the 6 signs of Congenital Varicella Zoster in the babies?
Microcephaly
Low Birth Weight
Limb Hypoplasia
Learning Disabilities
Eye Defects
Skin Scarring
How is Congenital Varicella Zoster diagnosed and managed?
Diagnosis is clinical
Management
- if a non-immune pregnant woman comes into contact with someone infected with varicella zoster, Immunoglobulin can be given as prophylaxis
- Acyclovir is used as treatment if the maternal infection occurs. This should be given within 24 hours of the onset of the rash
- Neonate should be monitored and given IV Acyclovir as soon as they are born
What are the 2 main contraindications to Vaginal Examination during Pregnancy?
Undiagnosed Vaginal Bleeding- as may be Placenta Praevia and digital examination can provoke a haemorrhage
Preterm labour rupture of membranes without clear contractions- to Avoid the infection Ascending into the Uterus
What is Cord Prolapse and what are the 7 risk factors?
When the umbilical cord exits the cervix prior to the infant
LAMP HP
- Low Birth Weight
- Abnormal Lie
- Multiple Pregnancy/ Multiparity
- Prematurity
- High Head
- Polyhydramnios
What is the 5 step management of Cord Prolapse?
- Foetus should be delivered asap
- While preparing for delivery, further prolapse should be avoided by encouraging a “knees-to-chest” position
- Filling the bladder with 500ml warm saline can prevent further prolapse
- Avoid exposure and handling of the cord
- Tocolytics (Terbutaline)- to stop Uterine Contractions
What are the 4 foetal complications and 4 maternal complications of Diabetes in Pregnancy?
Foetal Complications
- Macrosomia (birthweight>4kg)- due to excess maternal blood glucose crossing the placenta and Increasing Foetal Insulin Production. This can increase the risk of (3) Shoulder Dystocia, Birth Injuries and Emergency Caesarean Section
- Pre-term Delivery- which may lead to Respiratory Distress Syndrome
- Hypoglycaemia in the baby shortly After Birth due to the high Insulin levels they have. They may have Hypoglycaemic Seizures on birth
- Increased risk of developing Type 2 Diabetes later in life
Maternal Complications
- Increased risk of Hypertension
- Increased risk of Pre-Eclampsia
- Increased risk of developing Type 2 Diabetes later in life
- Increased risk of Gestational Diabetes Mellitus (GDM) in future pregnancies
What are the 7 main complications of Down Syndrome?
Coeliac Disease
Hypothyroidism
Epilepsy
Alzheimer’s Disease
Tumours and Leukaemia
Cataracts
Hearing Loss
What are the features of Down Syndrome?
- Brachycephaly with Flat Occiput
- Epicanthal Folds and Upslanting Palpebral Fissures
- Brushfield Spots on the Iris
- Short Nose with a Low Nasal Bridge
- Small Ears that may be Low Set
- Protruding Tongue
- Down-turned Mouth with a Small Oral Cavity
- Extra Skin on the back of the baby’s Neck
- Small Hands with a Single Palmar Transverse Crease
- Saddle Toe Gap
- Hypotonia (Floppy Baby)
- Congenital Heart Disease (50% of Down Syndrome patients have this)
- Gross Motor Delay
- Language Delay
- Hearing Loss
- Autism Spectrum Disorder
- Constipation
What are the 3 Septal Defects that patients with Down Syndrome are likely to have (50% of them have one)?
Atrioventricular Septal Defects (AVSD)
Ventricular Septal Defects (VSD)
Patent Ductus Arteriosus (PDA)
What is the 4 step management of Down Syndrome?
Paediatric Assessment and Specialist Review for conditions associated with Down Syndrome (Congenital Heart Disease is the main risk)
General Counselling for Parents
Affected Children will require Interventional Treatments
Affected Children will need Personalised Education Plans and Social Support
What are the 3 parts of the Combined Test in Screening for Down Syndrome and when in Pregnancy is this test offered?
Nuchal Translucency using Ultrasound Scan
PAPP-A hormone (Level Reduced in pregnancy affected with Down Syndrome)
Beta-hCG (Raised in Pregnancy affected with Down Syndrome)
This test is carried out between 11 to 13 weeks of pregnancy in the First Trimester
If the mother attends for Down Syndrome Screening AFTER 13 weeks of gestation, what 3 tests are in the Triple Test offered and what additional test is offered for the Quadruple Test?
Triple Test-
- Beta HCG
- AFP (Reduced in pregnancy affected with Down Syndrome)
- uE3 (Reduced in pregnancy affected with Down Syndrome)
Additional Test-
- Inhibin-A Test (Raised in pregnancy affected with Down Syndrome)
The Down Syndrome Screening Tests only give us the risk of the foetus developing Down Syndrome, what 2 diagnostic tests will give the definitive answer?
Chorionic Villus Sampling
Amniocentesis
What are the 2 main features of Pre Eclampsia and 7 additional features?
Hypertension and Proteinuria
Severe Headache
Visual Disturbance
Drowsiness
Epigastric Pain
Nausea/ Vomiting
Hyperreflexia
Peripheral Oedema
What are the 6 risk factors for Pre Eclampsia?
Increased Maternal Age
Previous or Family History of Pre Eclampsia
Existing Disease (Hypertension, Diabetes, Renal Disease, Autoimmune Disease)
Multiple Pregnancy
Obesity
Nulliparity
What are the 4 maternal and 4 foetal complications of Pre Eclampsia?
Maternal Complications
- Eclampsia (Seizures due to Cerebrovascular Vasospasm)
- Organ Failure
- Disseminated Intravascular Coagulation
- HELLP Syndrome (Haemolysis, Elevated Liver Enzymes, Low Platelets)
Foetal Complications
- Intrauterine Growth Restriction
- Pre-term Delivery
- Placental Abruption
- Neonatal Hypoxia
What is the management of Pre Eclampsia?
Anti-Hypertensives (LABETALOL is first line)
MAGNESIUM SULPHATE can help prevent and treat Eclamptic Seizures
What are the 7 risk factors for an Ectopic Pregnancy?
- Pelvic Inflammatory Disease
- Genital Infection (like Gonorrhoea)
- Pelvic Surgery
- Having an Intrauterine Device
- Assisted Reproduction
- Previous Ectopic Pregnancy
- Endometriosis
What are the 6 signs of an Ectopic Pregnancy?
- Pelvic Pain (Unilateral to the side of the Ectopic)
- Shoulder Tip Pain (if the Ectopic bleeds, the blood can Irritate the diaphragm which is felt at the shoulder tip)
- Abnormal Vaginal bleeding (missed period or intermenstrual bleeding)
- Haemodynamic Instability caused by blood loss if the ectopic ruptures
- Abdominal examination may reveal Unilateral Tenderness
- Cervical Tenderness (Chandelier Sign) on Bimanual Examination
There are 3 management options for an Ectopic Pregnancy, what is the Conservative Pathway? (2)
If the patient has minimal/ no symptoms
Do repeat B-hCG tests and if the levels are not falling at a satisfactory rate, then active management is advised
What is the medical management of an Ectopic Pregnancy? (3)
One-off dose of Methotrexate
The criteria for Methotrexate treatment (3) (low hCG level, ability to attend follow up, adherence to avoiding pregnancy for a period following treatment)
If the initial dose does not work, then a second dose or surgical management may be necessary
What is the surgical management of an Ectopic Pregnancy?
4 Criteria for Surgical Management
- Significant amount of pain
- Adnexal mass of 35mm or more
- B-hCG levels are 5000IU or more
- Ultrasound identifies a foetal heartbeat
Surgical Management- Salpingectomy (fallopian tube containing the Ectopic Pregnancy is removed)- if they only have one Fallopian Tube and wish to remain fertile then a Salpingotomy can be done
The risk with Salpingotomy is that sometimes not all of the tissue is removed, so B-hCG measurements are done to make sure no trophoblastic tissue is left
Why is Epilepsy a risk during pregnancy?
Physiological changes during pregnancy can lower the seizure threshold and increase the frequency of fits. Prolonged fits are dangerous as they can increase the risk of Foetal Hypoxia
The mother’s use of Anti-Epileptic drugs increases the risk of the foetus developing Congenital Abnormalities such as Neural Tube Defects
So you need to find a middle ground between the risk of stopping anti-epileptic medication and the risk of a foetal abnormality although the risk of stopping anti-epileptic medication is generally considered the BIGGER THREAT
What is the Pre-Pregnancy Management of Epilepsy in Pregnancy? (5)
Neurology review should be started to assess the current Anti-Epilepsy Medication and they should aim for a Monotherapy, with the Lowest Effective Dose of Medication being used
CARBAMAZEPINE and LAMOTRIGINE are the safest anti-epileptic drugs to use in pregnancy. SODIUM VALPROATE should be AVOIDED as it carries the highest risk of congenital abnormalities
In general, women with a history of Epilepsy but no high risk of unprovoked seizures can be managed as Low Risk pregnancies. And all medications MAY be stopped if no fits have occurred for at least 2 years
Drug compliance must be emphasised and the woman should be advised to continue their medication through pregnancy
All of them need to take 5mg/day of Folic Acid pre-conceptually at least until the end of the first trimester. This is to minimise the risk of Neural Tube Defects and Folate Deficiency
What is the Antenatal Management of Epilepsy in Pregnancy? (7)
All pregnant women with Epilepsy should be under Joint Medical and Obstetric Care
Plasma Anti-epileptic Drug Levels should be monitored regularly, as levels are likely to decrease with increasing plasma volume during pregnancy
The foetus should be monitored throughout pregnancy for Abnormalities with Serial Growth and Anomaly Scans
Anti-epileptic Regimes may inhibit foetal Clotting Factor Production so Vitamin K therapy should be given from 36 weeks gestation
Pregnant women with epilepsy should be REASSURED that most will have an uncomplicated labour and delivery and that there are no specific differences in labour management compared to Non-epileptic women
If epileptic seizures do occur during labour, they should be terminated as quickly as possible with Benzodiazepines in order to avoid Maternal and Foetal Hypoxia
If a pregnant women with no previous diagnosis of epilepsy presents after the first trimester with seizures, the immediate management guidelines for Eclampsia should be followed until a definitive Neurological diagnosis can be made
What is the Postnatal management of Epilepsy in Pregnancy (2)?
It is generally safe to take Anti-Epileptic Drugs while Breastfeeding
The Anti-Epileptic doses should be reviewed after delivery to prevent post-partum toxicity as plasma levels return to normal
What are the maternal (4), foetal (3) and placental (2) factors that affect foetal growth?
Maternal Factors-
- Maternal BMI and Nutrition Status (poor weight gain during pregnancy)
- Co-morbidities such as (9) Diabetes, Anaemia, Hypertension, Infection, Sickle Cell Anaemia, Pulmonary or Cardiovascular Disease, Renal Disease and Coeliac Disease
- Cigarettes, Alcohol, Drugs
- Structural Uterine Malformations
Foetal Factors-
- Chromosomal Defects
- Multiple Pregnancy
- Vertically Transmitted Infection (CMV, Rubella, Toxoplasmosis)
Placental Factors-
- Utero-placental Insufficiency
- Pre-Eclampsia
When does the First Stage of Labour start and end and what are the 3 Steps in the First Stage of Labour?
Starts with the Regular Uterine Contractions and ends when there is complete Cervix Dilatation of 10cm
- Cervix Dilatation is 1cm every 2 hours in Primiparous Women and 1cm every hour in Multiparous Women
(Latent Phase- 0-3cm Cervix Dilatation, Active Phase- 3-10cm Cervical Dilation) - Signs include Regular Painful Contractions, Progressive Cervical Dilatation, Passage of Blood-Stained Mucus known as “show” and Rupture of Membranes
- Descent of the Foetal Head into Pelvis
What are the 3 risk factors for Genital Candidiasis?
Pregnancy, Antibiotic Use and Immunosuppression
What are the Symptoms and Examination findings in women for Genital Candidiasis? (8, 5)
Itching
White Curdy or Lumpy Discharge
Sour Milk Odour
Dysuria
Superficial Dyspareunia
Pruritus
Tenderness
Burning Sensation
Redness
Fissuring
Swelling
Intertrigo (redness caused by skin to skin rubbing)
Thick White Discharge
What are the Symptoms and Examination findings for Genital Candidiasis in men? (3, 1)
(Itchiness)
Soreness
Pruritus
Redness
Dry, Dull, Red, Glazed Plaques and Papules
What investigations should be ordered in Genital Candidiasis?
Investigations are not recommended if the history indicates acute, uncomplicated vulvovaginal candidiasis
Microscopy may show the presence of Blastospores, Pseudohyphae and Neutrophils
Culture is recommended for recurrent vulvovaginal candidiasis
How is Genital Candidiasis managed?
Managed with Antifungal Treatment-
- Oral (-azoles)- Fluconazole (generally FIRST LINE), Itraconazole
- Intravaginal- Clotrimazole Pessary
- Vulval- Topical Clotrimazole Cream
What are the 6 Risk Factors for developing Gestational Diabetes?
Middle-Eastern/ South-Asian and Afro-Caribbean
Previous Gestational Diabetes
Large Babies(>4.5 kg)
Previous Stillbirth or Perinatal Death
Maternal Obesity (BMI>30)
Family History of Diabetes in first degree relatives
What is the 3 step management of Gestational Diabetes?
Low Glycaemic Index Diet, plus Metformin and Insulin
Risk of Future Type 2 Diabetes can be addressed with Diet/ Lifestyle and Metformin
GDM tends to disappear as soon as the Placenta is delivered
What are the signs of Group B Streptococcus Infection?
Signs of Bacterial Infection in the Newborn- Pneumonia, Sepsis, Management
What are the 6 Risk Factors for Neonatal Group B Streptococcus Infection?
- Positive Group B Streptococcus culture in current or previous pregnancy
- Previous birth resulting in Neonatal Group B Streptococcus Infection
- Pre-term Labour
- Prolonged Rupture of Membranes
- Intrapartum Fever (>38 degrees Celsius)
- Chorioamnionitis
How is Group B Streptococcus Infection managed?
Intrapartum Antibiotic Prophylaxis to prevent GBS Infection in the newborn
Usually Penicillin- given intravenously
What is HELLP Syndrome and when does it manifest?
It consists of H- Haemolysis, EL- Elevated Liver Enzymes, LP- Low Platelets
HELLP manifests during the Third Trimester and is part of a spectrum of Hypertensive Disorders of Pregnancy such as Pre-Eclampsia
What are the 6 signs of HELLP Syndrome?
Peripheral Oedema
Headache
RUQ pain due to Liver Distension
Epigastric Pain
Nausea and Vomiting
Blurred Vision
What are the 3 Maternal and 3 Foetal Complications of HELLP Syndrome?
Maternal-
- Disseminated Intravascular Coagulation
- Organ Failure
- Placental Abruption
Foetal-
- Neonatal Hypoxia
- Intrauterine Growth Restriction
- Preterm Delivery
How is HELLP Syndrome managed?
The Definitive Treatment is Delivery of the Baby
Some mothers may require Blood Transfusions or Steroids during the pregnancy
What is the probability of HIV being passed from mother to baby?
25-40%, and 90% of these occur during delivery
What is the 5 step management of HIV and Pregnancy?
Start the mother on combination Antiretroviral Therapy (cART) as soon as the diagnosis is confirmed
If the mother’s viral load is LESS THAN 50, a normal vaginal delivery can be recommended, if it is MORE THAN 50, then elective Caesarean Section is recommended
The baby should have Post Exposure Prophylaxis (PEP) with either Zidovudine monotherapy or cART. The duration and type of therapy depends on the risk of transmission
In the UK, the safest way to feed these babies is with FORMULA MILK, not the mother’s milk
However, women with a low viral load on cART who choose not to breastfeed should be informed of the risk of transmission but supported to breastfeed if they wish alongside additional monitoring
What is the pathophysiology of Haemolytic Disease of the Newborn?
It is where a Rhesus Negative Mother becomes sensitised to the Rhesus Positive blood cells of the baby while in the uterus
What are Sensitisation Events in Haemolytic Disease of the Newborn?
AEI PAIRED
They are events where the Foetal Blood crosses the placenta into the Maternal Circulation and these are indications for Anti-D Prophylaxis
- Antepartum Haemorrhage
- External Cephalic Version
- Invasive Uterine Procedures like Amniocentesis and Chorionic Villus Sampling
- Placental Abruption
- Abdominal Trauma
- Intrauterine Death, Miscarriage, Termination
- Rhesus Positive Blood Transfusion to a Rhesus Negative Mother
- Ectopic Pregnancy
- Delivery (Normal, Instrumental or Caesarean Section)
What are the 6 Features of Haemolytic Disease of the Newborn?
- Yellow Coloured Amniotic Fluid due to Excess Bilirubin
- Jaundice and Kernicterus in the Neonate
- Foetal Anaemia caused by Skin Pallor
- Hydrops foetalis appearing as Foetal Oedema in at least 2 compartments- Pericardial Effusion, Pleural Effusion, Ascites) seen on Antenatal Ultrasound
- Severe Oedema if Hydrops Foetalis was present in utero
- Hepatomegaly or Splenomegaly
What are the 6 Features of Haemolytic Disease of the Newborn?
- Yellow Coloured Amniotic Fluid due to Excess Bilirubin
- Jaundice and Kernicterus in the Neonate
- Foetal Anaemia caused by Skin Pallor
- Hydrops foetalis appearing as Foetal Oedema in at least 2 compartments- Pericardial Effusion, Pleural Effusion, Ascites) seen on Antenatal Ultrasound
- Severe Oedema if Hydrops Foetalis was present in utero
- Hepatomegaly or Splenomegaly
What is the likelihood of vertical transmission of Hepatitis B from a mother who is positive for both HbsAg and HbeAg?
95% chance
The newborn should be given HBV IgG and HBV vaccination within 24 hours of delivery to reduce the risk- this procedure is 95% effective
What is Hyperemesis Gravidarum?
Severe vomiting with onset before 20 weeks of gestation
It is severe enough to require admission into hospital and is a diagnosis of Exclusion
What are the 5 differentials for vomiting during pregnancy?
- Infections such as (5) Gastroenteritis, Urinary Tract Infection, Hepatitis and Meningitis
- Gastrointestinal Problems- Appendicitis, Cholecystitis and Bowel Obstruction
- Metabolic Conditions- Diabetic Ketoacidosis and Thyrotoxicosis
- Drug Toxicity
- Molar Pregnancy- abnormally high levels of beta-hCG due to Gestational Trophoblastic Disease can cause severe nausea and vomiting
What is the 6 step management plan for Hyperemesis Gravidarum?
- Fluid Replacement Therapy
- Potassium Chloride (excessive vomiting causes Hypokalaemia)
- Antiemetic medication like CYCLIZINE (first line), Metoclopramide or Prochlorperazine. Ondansetron or Dompheridone may be used in severe cases
- Thiamine and Folic Acid to prevent development of Wernicke’s Encephalopathy
- Antacids to relieve Epigastric Pain
- Thromboembolic (TED) stockings and LMWH as there is an increased risk of VTE due to Pregnancy, Immobilisation and Dehydration
What are the 6 complications of Hyperemesis Gravidarum?
Psychological Sequelae- Depression, PTSD and Resentment towards the pregnancy
Gastrointestinal Problems- Mallory-Weiss Tear, Malnutrition and Anorexia
Dehydration related to Ketosis and VTE
Metabolic Disturbances such as Hyponatraemia, Wernicke’s Encephalopathy, Kidney Failure, Hypoglycaemia
If the condition is severe- the foetus may be affected by the Metabolic Disturbance
Foetal Complications include Low Birth Weight, Intrauterine Growth Restrictions and Premature Labour
How should pregnant women with Chronic and Gestational Hypertension be managed? (1, 4)
(WITHOUT PROTEINURIA)
Chronic Hypertension
- Stop all Antihypertensives and switch to pregnancy-safe alternatives such as Labetalol
Gestational Hypertension
- After 20 weeks of gestation and BP>150/100mmHg- give ORAL LABETALOL first line
- Mild Hypertension (140/90- 149/99) during pregnancy, then regular blood pressure monitoring should be carried out and no treatment is recommended
- If Labetalol is not tolerated then alternative medications can be used such as Methyldopa and Nifedipine
- For ALL WOMEN- regular blood pressure monitoring and URINALYSIS should be carrie dout
What are the features and causes of Hypothyroidism?
Peripheral Features (Snorlax is hairless with Thick Hide as an ability and probably doesn’t have sex much)
- Dry, thick skin
- Brittle hair
- Scanty secondary sexual hair
Head and Neck Features (Snorlax with small eyebrows)
- Macroglossia
- Puffy face
- Loss of lateral third of the eyebrow
- Goitre (depending on cause)
Cardiac Features (a Big Slow Heart- Snorlax)
- Bradycardia
- Cardiomegaly
Neurological Features (Snorlax is slow and imagine a Snorlax walking like a Spinda cos of the ataxia- plus with Carpal Tunnel)
- Carpal tunnel syndrome
- Slow relaxing reflexes
- Cerebellar ataxia
- Peripheral neuropathy
Auto-immune Causes (Remember Anti-TPO)
- Hashimoto’s thyroiditis
- Anti-TPO (thyroperoxidase): 90-95% of patients
- Anti-thyroglobulin: 35-60% of patients
- Anti-TSH receptor (blocking): 10% of patients
- Atrophic thyroiditis
- Autoimmune polyendocrine syndromes
Iatrogenic Causes
- Surgical
- Radioablation
- Radiation
Congenital Causes (TIP SHIP)
- Thyroid aplasia
- Infiltrative
- Pendred syndrome (defect in thyroxine synthesis)
- Sarcoid
- Haemochromatosis
- Iodine deficiency/Excess Related Causes
- Primary Autoimmune Hypothyroidism
Types of autoimmune thyroiditis include:
- Hashimoto’s thyroiditis
- Atrophic thyroiditis
- Autoimmune polyendocrine syndromes
What is the management of Hypothyroidism in Pregnancy?
Levothyroxine is First Line
(If patient is already on Levothyroxine, increase by 25mcg when they have a confirmed pregnancy even if they are in a Euthyroid State, as Free Thyroxine Increases in normal pregnancy until 12th week so this should be mimiced)- otherwise baby will have Neurodevelopmental Delay
2 main risks include Cardiac Arrhythmias and Osteoporosis
What are the 5 Indications and 8 Contraindications to the Induction of Labour?
Indications-
- Post-dates= >41 weeks Gestation
- Preterm prelabour Rupture of Membranes
- Intrauterine Foetal Death
- Abnormal CTG
- Maternal Conditions such as (3) Pre-Eclampsia, Diabetes and Cholestasis
Contraindications-
- Previous classical/ vertical incision during Caesarean Section
- Multiple Lower Uterine Segment Caesarean Sections
- Transmissible Infections (Herpes Simplex)
- Vasa Praevia
- Placenta Praevia
- Severe Foetal Compromise
- Malpresentations
- Cord Prolapse
What are the 4 methods of Inducing Labour?
Membrane Sweep (Gloved finger into os and separating the membranes from the cervix)
Vaginal Prostaglandins (PGE2)
Amniotomy- Artificial rupture of membranes
Balloon catheter
What is the Bishop Score used to assess?
How favourable the patient is as a candidate for induction of labour
A score of 9 or more means that the patient is likely to achieve a successful vaginal delivery and is a favourable candidate for labour induction
A lower score means they are less favourable
What is the indications for Foetal Blood Sampling and how is it done?
Indicated when there is a suspicious Cardiotocograph. It is used to confirm Foetal Hypoxia
The procedure involves making a small incision of the foetus scalp transvaginally. Blood is then collected and analysed for ACIDAEMIA
What are the 3 contraindications for FBS?
Prolonged DECELERATIONS on cardiotocography
Maternal Infection (HIV, Herpes Simplex)
Prematurity (<34 weeks)
In Foetal Blood Sampling, the results for pH and Lactate are divided into Normal, Borderline and Abnormal. What are the Borderline limits for pH and Lactate?
pH- 7.21- 7.24
Lactate- 4.2-4.8
What should be done if the Foetal Blood Sampling results are abnormal? (3)
Inform a senior obstetrician and the neonatal team
Talk to the woman and her birth companions about what is happening and take her preferences into account
Expedite the birth (speed it up)
What should be done if Foetal Blood Sampling results are borderline or normal?
Borderline + no accelerations in response to foetal scalp stimulation- take a second foetal blood sample no more than 30 minutes later
Normal + no accelerations in response to foetal scalp stimulation- take a second foetal blood sample no more than 1 hour later
How is Inversion of the Uterus managed?
Immediate Replacement of the Uterus is the best first step as the GREATER the DELAY in attempting this, the greater the likelihood of the manouevre failing
General Resuscitation should also be taken and Tocolytic drugs can be used to aid the Replacement of the Uterus process if a first attempt fails
What are the 3 causes of Iron Deficiency Anaemia?
Increased Loss (Menorrhagia, GI Bleeding, Hookworm)
Reduced Intake (Poor Diet)
Malabsorption (Coeliac Disease and Inflammatory Bowel Disease)
How is Iron Deficiency Anaemia diagnosed?
Symptoms (such as lethargy, tiredness, weakness, jaundice, heavy periods, change in bowel habits) and Hypochromic, Microcytic Red Cells
Total Iron Binding Capacity (TIBC)- high as the body mobilises Iron Stores to make up for the Iron Deficiency
Ferritin- low as available Iron Stores in the body are mobilised to counteract the Iron Deficiency
How is Iron Deficiency Anaemia managed?
Iron Deficiency can be treated with Ferrous Sulphate
Unexplained Iron Deficiency may require urgent investigation to rule out a new diagnosis of cancer
What is the Kleihauer Test?
It is used to measure the amount of Foetal Haemoglobin in the mother’s bloodstream
In Significant Sensitisation events, it can be used to determine the quantity of Rh-D antigen in the maternal circulation and guide the quantity of Anti-D needed to be given to prevent Sensitisation
- in mothers who are RhD negative with foetuses who are RhD positive- as they produce antibodies against RhD antigens
How is a RhD negative mother managed?
Anti-D antibodies can result in incompatibility and haemolysis in future pregnancies. To attenuate this risk, Anti-D antibodies are given to patients who have experienced a Sensitisation event
How is Listeria Monocytogenes transmitted?
Contracted from Contaminated Foods (commonly UNPASTEURISED DAIRY PRODUCTS and SOFT CHEESES)
When a pregnant mother is infected, the bacterium may be transmitted through the placenta or during delivery into the foetus
What are the 3 clinical features of Listeria Monocytogenes in Pregnancy (in the babies)?
And how is it managed?
Neonatal Sepsis
Meningitis
Respiratory Distress
Management-
- Antibiotic treatment involves AMPICILLIN and an AMINOGLYCOSIDE
- Pregnant women should be advised to avoid potentially contaminated food products
- And if there is a Febrile Illness, then Cultures for Listeria should be carried out
What are the facts about Lithium and Pregnancy?
Lithium should be avoided- specifically in the first Trimester of Pregnancy as it is Teratogenic
It can lead to Ebstein’s Anomaly and Miscarriage
How is Pregnancy at 41 weeks managed? (3)
There is a higher risk of complications at high gestational ages
At 41 weeks- a membrane sweep should be offered to the mother. A midwife or doctor inserts their finger into the cervical opening and SWEEPING to separate the amniotic membranes from the cervix
This separation causes the RELEASE OF PROSTAGLANDINS which may stimulate spontaneous labour
If this is unsuccessful, then the INDUCTION of LABOUR is offered. This involves the administration of PROSTAGLANDINS to stimulate contractions
If this is refused then FOETAL MONITORING is NEEDED
How is Pregnancy at 41 weeks managed? (3)
There is a higher risk of complications at high gestational ages
At 41 weeks- a membrane sweep should be offered to the mother. A midwife or doctor inserts their finger into the cervical opening and SWEEPING to separate the amniotic membranes from the cervix
This separation causes the RELEASE OF PROSTAGLANDINS which may stimulate spontaneous labour
If this is unsuccessful, then the INDUCTION of LABOUR is offered. This involves the administration of PROSTAGLANDINS to stimulate contractions
If this is refused then FOETAL MONITORING is NEEDED
What is Meconium?
It is the first faeces that is passed by the newborn- this is usually thick and dark green in colour
It may be expelled before birth in the amniotic fluid- which is known as “meconium stained liquor”
It is important that this is recognised as it may be a sign of Foetal Distress and Hypoxia (which causes Intestinal and Sphincter Relaxation
However this may be a NON-PATHOLOGICAL FINDING beyond 40 weeks of Gestation
The presence of Meconium in in the Amniotic Fluid may develop to Meconium Aspiration Syndrome
MAS is caused by the passage of meconium from the amniotic fluid into the lungs
This can cause blockage and inflammation in the airways and is associated with significant morbidity and mortality
What is Meconium Ileus and how is it presented?
The Meconium is thickened and causes obstruction of the bowel in the neonate. This is most commonly the early presentation of Cystic Fibrosis
It presents as Bilious Vomiting, a Distended Abdomen and a Failure to pass Meconium within the first 12-24 hours
This obstruction may Lead to-
- Bowel Perforation
- Peritonitis
- Mal-Rotation of the Bowel
- Intestinal Atresia (it didn’t develop properly)
What are the 5 signs of Meconium Aspiration Syndrome?
Meconium-stained liquor during Rupture of Membranes or at birth (greenish or yellowish appearance of amniotic fluid)
Green staining of infant’s skin, nail beds or umbilical cord
Signs of respiratory distress in the newborn (Increased Respiratory Rate, Grunting, Cyanosis, Noisy Breathing, Use of Accessory Muscles)
LIMP INFANT or low APGAR Score (done on infants after birth)
Crackles on Auscultation of Foetal Lungs
What are the 4 risk factors for Meconium Aspiration Syndrome?
Postdate Pregnancies (>40 weeks gestation)
Prolonged or Difficult Labour
Chorioamnionitis
Problems during pregnancy- Pre-Eclampsia, Hypertension, Oligohydramnios, Maternal Infection, Placental Insufficiency, Intrauterine Growth Restriction
How is Meconium Aspiration Syndrome managed?
Gentle Suctioning of mouth and nose should be carried out to remove any visible Meconium
Antibiotics should be given to reduce the Risk of Infection and the baby should be transferred to a Neonatal Intensive Care Unit for Oxygen Administration and Careful Monitoring
In SEVERE CASES- Artificial Ventilation may be required
What is the Dosing Regimen for Methotrexate?
Methotrexate always has a Once Weekly Dosing Regimen and only comes in the form of 2.5mg tablets
Generally patients start at a low dose and go up by 2.5mg every week until the disease is controlled or a maximum dose is reached
What are the 5 Side Effects and the Interactions of Methotrexate?
- Cytopenia- monitor their Full Blood Count and advice them to report suspected Infections and Bruising
- Hepatotoxicity- monitor Liver Function Tests. Mild Elevation is normal but discontinue Methotrexate if it rises to more than 3x the normal limit
- Renal Impairment- monitor Renal Function Tests
- Pulmonary Fibrosis- Take a baseline CXR- advice patient to report any Respiratory Symptoms- Dyspnoea and Dry Cough
- Teratogenicity- Advice use of contraception while on Methotrexate and 3 MONTHS AFTER USE- this is how long it takes Methotrexate to wash out (otherwise can lead to Cleft-Palate)- Low dose steroids can be given if a disease flare-up is experienced during this period of trying for a baby.
(O) METHOTREXATE impairs FOLATE METABOLISM so other ANTI-FOLATE DRUGS must be avoided, such as-
- Trimethoprim
- Permetrexed
- Proguan (Anti-malarial)
FOLIC ACID (5mg) has to be prescribed with METHOTREXATE and should be taken on a DIFFERENT DAY. Depending on the toxicity, Folic Acid should be taken 1-6 times a week
Remember “Methotrexate Mondays and Folate Fridays” to help remember to take them on different days and once a week!
What is the antidote for Methotrexate?
Folinic Acid (not Folic Acid)
Also can give (2)- Thymidine and Glucarpidase
What demographic of people are highest at risk of a Molar Pregnancy?
Those under 16 years old and over 45 years old
What are the 3 features of a Complete and Partial Mole?
Complete-
- One Sperm and an Empty Egg with no genetic material
- The sperm then replicates to give a normal number of chromosomes- so all the chromosomes are from the dad
- There is no foetal tissue present- just a proliferation of Swollen Chorionic Villi
Partial-
- Two Sperms and a Normal Egg
- Both paternal and maternal content is present
- There is variable evidence of foetal tissue present
What are the 5 features of a Molar Pregnancy?
Vaginal bleeding
Uterus is larger than expected for Gestational age- due to excessive growth of trophoblasts and retained blood
Nausea
Thyrotoxicosis (because hCG is closely related to TSH and can therefore activate its receptors)
Hyperemesis Gravidarum
What 2 investigations should be ordered if a Molar Pregnancy is suspected?
B-hCG levels are often much higher than would be expected in a Normal Pregnancy
Trans-vaginal Ultrasound is used which may show a SNOWSTORM APPEARANCE in a Complete Pregnancy
What is the management of a Molar Pregnancy?
Urgent referral to a specialist centre for treatment to reduce the timeframe for Potential Complications such as Choriocarcinoma or Invasion from developing
Molar pregnancies can not survive- so are managed with Suction Curettage to remove them from the Uterus
When fertility doesn’t need to be preserved, then a Hysterectomy can be performed
Surveillance is recommended
- Two weekly Serum and Urine hCG until the levels are Normal
- If a Partial Mole, a repeat hCG is done 4 weeks later- if normal, then the patient is discharged from surveillance
- In a Complete Mole, monthly repeat hCG samples are sent for at least 6 months
What is Naegele’s Rule used to calculate?
It is used to calculate the Estimated Due Date (EDD)- based on the first day of the woman’s Last Menstrual Period
You (Add One Year and Seven Days) to the first day of the Last Menstrual Period and (Subtract Three Months)
This may not be accurate with women with irregular or long cycles or those who have been using the Combined Oral Contraceptive Pill
This is an ESTIMATE
How can Neonatal Herpes Simplex Infection occur and what are the 7 signs of Neonatal Herpes Simplex Infection?
It can occur during delivery when the baby comes into contact with Primary Vesicles in the Maternal Genital Tract
Signs-
- Vesicular Lesions in the Eyes
- Vesicular Lesions in the Skin
- Vesicular Lesions in the Oral Mucosa
- Seizures
- Encephalitis
- Hepatitis
- Sepsis
Symptoms usually occur within the first 4 weeks of birth
How is Neonatal Herpes Simplex Infection managed?
Parenteral Acyclovir and Intensive Supportive Therapy for severe cases
An Elective Caesarean Section or Intrapartum IV Acyclovir may be advised if Active Primary Herpes Lesions are present in the mother at term or there has been a primary outbreak within 6 weeks of labour
What is the Pain Ladder in Pregnancy? (In order) (6)
NN SOEPG
Non Pharmacological Methods (TENS Stimulation, Hypnosis, Acupuncture, Massage, Heat, Exercise and Movement)
Nitrous Oxide (Entonox or “gas and air”)
Simple Analgesia (Paracetamol)
Opiate Analgesia (Oral Codeine Phosphate/ IV or IM Diamorphine)
Epidural Analgesia
Pudendal Nerve Block
Generally- NSAIDs are AVOIDED!!
What is Obstetric Cholestasis and what are the 5 signs of Obstetric Cholestasis?
It is the build up of bile acids occuring after 24 weeks of pregnancy
- Fatigue or Malaise
- Nausea/ Loss of Appetite
- Abdominal Pain- typically in the RUQ
- Rarely- Mild Maternal Jaundice- Dark Urine and Pale Stools
- Pruritus- Worse on Hands and Feet
How is Obstetric Cholestasis managed? (3)
Chlorphenamine to reduce the Itch
Vitamin K to reduce the risk of Haemorrhage
Early delivery to avoid Intrauterine Death
What is Oligohydramnios and what are the 6 causes of it?
CUPMAP
Lower than normal volume of amniotic fluid in the uterus
- Chromosomal Anomalies
- Uteroplacental Insufficiencies leading to Intrauterine Growth Restriction- could be due to maternal disease such as Hypertension, Pre Eclampsia, Maternal Smoking and Placental Abruption
- Premature Rupture of Membranes
- Maternal use of certain drugs (Prostaglandin Inhibitors or ACE Inhibitors)
- Abnormalities with the Foetal Urinary System (Amniotic Fluid is derived mainly from the the Foetal Urine). Examples include Renal Agenesis, Polycystic Kidneys or Urethral Obstruction
- Post-term Gestation
What are the 4 (5) complications of Oligohydramnios?
Reduced space around the foetus- Reduced Amniotic fluid for foetal lung growth and development
- Clubbed Feet
- Facial Deformity
- Congenital Hip Dysplasia
- Pulmonary Hypoplasia (due to underdeveloped lungs)
- Combination of all these symptoms is known as Potter Syndrome
What is Ovarian Hyperstimulation Syndrome?
a combination of Iatrogenic Induction of Ovulation and is an Exaggerated response to Hormonal Therapy
This can occur in IVF due to multiple follicles maturing and enlarging and becoming Corpus Luteums
This results in an excessive production of Oestrogen, Progesterone and local Cytokines (Vascular Endothelial Growth Factor)
What are the 2 (6) signs of Ovarian Hyperstimulation Syndrome?
Large Ovaries (Bloating and Abdominal Discomfort)
Vascular Endothelial Growth Factor causes blood vessels to leak-
- Weight Gain
- Oedema
- Ascites
- Pleural Effusion
What 2 investigations should be ordered if Ovarian Hyperstimulation Syndrome is suspected?
Bloods- Haemoconcentration and Organ Dysfunction
Chest Xray for Pleural Effusion
What is the management of Ovarian Hyperstimulation Syndrome?
Largely supportive- so things like Analgesia, Fluid Replacement, Drainage of Fluids (Ascites/ Pleural Effusion) but depends on severity so can be ITU Admission
These patients are at risk of VTE so make sure to give them Thromboprophylaxis
What are the (7) 6 signs of Pelvic Inflammatory Disease?
Bilateral Abdominal Pain
Discharge
Post Coital Bleeding
Adnexal Tenderness
Cervical Motion Tenderness on Bi-Manual Examination
Fever
(Fitz Hugh Curtiz Syndrome- RUQ pain secondary to Inflammation of the Liver Capsule- but LFTs are normal)
What 5 investigations should be conducted in Pelvic Inflammatory Disease is suspected?
Pelvic Examination
Pregnancy Test
Swabs for Gonorrhoea and Chlamydia
Bloods
Transvaginal Ultrasound
What is the management of Pelvic Inflammatory DIsease?
Ofloxacin and Metronidazole (or Ceftriaxone and Doxycycline and Metronidazole), and maybe Analgesia if needed
Patient should be reviewed within 4 weeks as well
ALL YOUNG, SEXUALLY ACTIVE women presenting with bilateral abdominal pain should be given treatment for Pelvic Inflammatory Disease
What are the 4 categories of Perineal Tears?
First Degree Tear- Limited to SUPERFICIAL Perineal Skin or Vaginal Mucosa only
Second Degree Tear- Tear extends to Perineal MUSCLES AND FASCIA, but the Anal Sphincter is Intact (an Episiotomy is a Second Degree Tear)
Third Degree Tear- (if the Sphincter is Torn but Mucosa is fine)
3a- Less than 50% of the thickness of the External Anal Sphincter is torn
3b- more than 50% of the thickness of the External Anal Sphincter is torn- but the INTERNAL ANAL SPHINCTER is Intact
3c- External and Internal Anal Sphincters are torn, but the ANAL MUCOSA is Intact
Fourth Degree Tear- Perineal Skin, Muscle and Anal Mucosa are torn
How are Perineal Tears managed?
First Degree- likely to heal on their own as long as minimal blood loss
Second Degree- Suturing is needed as the muscle is torn
Third and Fourth Degree- Surgical Repair needed under Local or General Anaesthetic- Patients should be given LAXATIVES to avoid Constipation
BROAD SPECTRUM ANTIBIOTICS should be given Post-Operatively
What is Placenta Accreta Spectrum and what are the 6 risk factors for this? (PAP DUP)
Abnormalities of Placental Abruption into the Uterine Wall
- Previous Caesarean Section
- Advanced Maternal Age
- Previous Termination of Pregnancy
- Dilatation and Curettage
- Uterine Structural Defects
- Placenta Praevia
What is Placenta Accreta Spectrum and what are the 6 risk factors for this? (PAP DUP)
Spectrum of Abnormalities of Placental Implantation into the Uterine Wall
- Previous Caesarean Section (as it can go into the cut)
- Advanced Maternal Age
- Previous Terminated Pregnancy
- Dilatation and Curettage
- Uterine Structural Defects
- Placenta Praevia
What are the 3 types of Placenta Accreta Spectrum?
THEY PRESENT WITH PAINLESS VAGINAL BLEEDING
Placenta Accreta- Adherence of the placenta directly to Superficial Myometrium but DOES NOT penetrate the thickness of the muscle
Placenta Increta- When the Villi invades INTO but NOT THROUGH the Myometrium
Placenta Percreta- When the Villi invades THROUGH the full thickness of the Myometrium into the Serosa. There is an increased risk of Uterine Rupture and risk of the placenta attaching onto other Abdominal Organs such as the Bladder or the Rectum
How is Placenta Accreta Spectrum diagnosed and managed?
It is diagnosed through Doppler Ultrasound and MRI- but can be difficult to diagnose Antenatally
There will also be High Levels of Fetoprotein and Beta- HCG
If Abnormal Placental Implantation is suspected, the safest management plan is a Caesarean Section and Hysterectomy
What is the main Complication of Placenta Accreta Spectrum?
Abnormal implantation of the Placenta can lead to an increased risk of Severe Post-partum Bleeding, Preterm Delivery and Uterine Rupture
What is Placenta Praevia and what are the signs?
When the Placenta is covering the Cervical OS
Painless Vaginal Bleeding- if this occurs after 24 weeks of pregnancy then Placenta Praevia should be Suspected
Mother may present with Shock if there is significant blood loss and Malpresentation of the foetus may be found on examination
What 2 investigations should be ordered if Placenta Praevia is suspected?
- If there is painless bleeding occurring after 13 weeks of Pregnancy or if there is Previous History of Uterine Incision, then Transvaginal Ultrasound should be used to exclude Placenta Praevia
- Further Ultrasound should be carried out at 37 weeks to reassess Placental Position
What is the 5 step management of Placenta Praevia?
Bleeding with UNKNOWN PLACENTA POSITION-
- ABC Approach, Resuscitation and Stabilisation
- If they are stable, then Urgent Ultrasound
- If the bleeding is not controlled, then Emergency Caesarean Section
Bleeding with KNOWN PLACENTA PRAEVIA-
- ABC Approach, Resuscitation and Stabilisation. If stabilisation is NOT ACHIEVED- then Emergency Caesarean Section
- Corticosteroids should be considered if 24-34 weeks of gestation and there is Risk of Preterm Labour (Corticosteroids and Tocolytics DELAY LABOUR)
In Labour- then Caesarean Section
Placenta Praevia with NO BLEEDING and NOT IN LABOUR-
- Monitor with Ultrasound Scans
- Give advice about Pelvic Rest (No Penetrative Sexual Intercourse) and advice to go to the hospital if there is significant Vaginal Bleeding
At TERM-
- If there is any degree of Placental Overlap at 35 weeks- aim for Elective C. Section at 37-38 weeks. Urgent C. Section if she goes into Labour
- When the Placental Edge is greater than 20mm from the Internal Cervical OS, women can be offered a Trial of Labour (if no bleeding and with Careful Intrapartum Monitoring). If Significant haemorrhage or foetal distress develops during trialled vaginal delivery, immediately take to the theatre for IMMEDIATE C SECTION
What is Placental Abruption and what are the 6 signs of Placental Abruption?
VW ARCH
It is the premature separation of the placenta from the uterine wall in pregnancy- this leads to a MATERNAL HAEMORRHAGE
Vaginal Bleeding (however in some cases the haemorrhage may be confined to the uterus)
“Woody” Hard Uterus
Abdominal Pain (Often Sudden and Severe)
Reduced Foetal Movement and Abnormal CTG
Contractions
Hypovolaemic shock which is often disproportionate to the amount of vaginal bleeding
What are the 7 Risk Factors for Placental Abruption?
Maternal Trauma (Assault, RTC)
Multiparity or Increased Maternal Ages
Pre Eclampsia or Hypertension
Polhydramnios
Previous History of Abruption
Substance Abuse during pregnancy (Smoking or Cocaine)
Existing Coagulation Disorders
Risk factors for ABRUPTION: Abruption before, Blood pressure high, Ruptured membranes, Uterine injury, Polyhydramnios, Twins/ multiple pregnancy, Infection, Older age (>35), Narcotics eg cocaine use
What is the 4 step management approach to Placental Abruption?
Any woman presenting with Antepartum Haemorrhage should be RESUSCITATED using an ABCDE approach. Do NOT Delay this
The management depends on the health of the foetus otherwise
- Emergency Delivery- Indicated in the presence of maternal or foetal compromise and this is usually done through CAESAREAN SECTION unless spontaneous delivery is IMMINENT or OPERATIVE VAGINAL BIRTH is achievable
- Even if an IN-UTERO foetal death has been diagnosed, a CAESAREAN SECTION may be needed if there is maternal compromise
- Induction of Labour- for HAEMORRHAGE at TERM and there is NO COMPROMISE
- Conservative Management- for some partial or marginal abruptions which are not associated with maternal or foetal compromise (depending on the gestation and the amount of bleeding)
- In ALL CASES- give Anti-D within 72 hours within the onset of bleeding if the woman is Rhesus Negative
What are the 8 causes of Polyhydramnios?
Excess Production due to Excess Foetal Urination
- Maternal Diabetes Mellitus
- Foetal Renal Disorders
- Foetal Anaemia
- Twin-to-Twin Transfusion Syndrome
Insufficient Removal-
- Diaphragmatic hernia
- Oesophageal or Duodenal Atresia
- Anencephaly
- Chromosomal Disorders
What are the signs of Polyhydramnios and how is it managed?
Uterus which feels tense or large for gestational date and it is difficult to feel the foetal parts on Palpation
It is managed by treating the cause (such as Maternal Diabetes Mellitus) and in severe cases- Amnio-Reduction
What are the 5 Maternal and 5 Foetal Complications of Polyhydramnios?
Maternal Complications-
- Maternal Respiratory Compromise due to pressure on Diaphragm
- Increased risk of UTIs due to increased pressure on Urinary System
- Worsening of other symptoms generally associated with Pregnancy- such as (4) Gastro-Oesophageal Reflux, Constipation, Peripheral Oedema and Stretch Marks
- Increased incidence of Caesarean Section Deliveries
- Increased risk of Amniotic Fluid Embolism (although this is rare)
Foetal Complications-
- Pre-term Labour and Delivery
- Premature Rupture of Membranes
- Placental Abruption
- Malpresentation of Foetus (foetus has more space to move within the uterus)
- Umbilical Cord Prolapse- Polyhydramnios can prevent the foetus from engaging with the pelvis so there will be more room for the Umbilical Cord to Prolapse
How long after delivery is Contraception not needed for?
The first 3 weeks
What are the 7 popular Post-partum Contraception methods and when can they be used?
Male and Female Condoms- Can be used anytime after delivery
Female Sterilisation- Can be performed at the time of CAESAREAN SECTION
Diaphragm- Women are advised to wait 6 WEEKS after delivery before relying on a DIAPHRAGM
Intrauterine Contraception (Copper Intrauterine Device and Levonorgestrel-releasing Intrauterine System)
- Can be inserted IMMEDIATELY AFTER delivery, up to 48 hours after delivery
- After 48 hours, insertion should be delayed until 28 days after childbirth
Progesterone-only Contraception- Can be started anytime after delivery
Combined Hormone Contraception- (like COCP, Patch or Vaginal Ring)
- Women who are not breastfeeding and have no additional risk factors for VTE should wait until 21 DAYS AFTER (Pre-Eclampsia and Post Partum Haemorrhage count as risk factors as well)
- Women who are breastfeeding should wait until 6 WEEKS AFTER childbirth before initiating CHC
Lactational Amenorrhoea- can be used if the woman is less than 6 months Post-Partum, Amenorrhoeic and Fully Breastfeeding
What are the risk factors for Postnatal VTE (4 or more of these would warrant Postnatal Thromboprophylaxis)
Previous VTE
Thrombophilia
Medical comorbidities (e.g. cancer, heart failure, systemic inflammatory conditions)
Age >35
BMI >30
Parity >3
Smoking
Multiple pregnancy
Pre-eclampsia
Caesarean section
Prolonged labour
Operative delivery
Preterm birth
Stillbirth
Postpartum haemorrhage >1000mL
Other surgical procedure carried out
Immobility
Systemic infection
What are the Clinical Features of Postpartum Depression?
Lowering of Mood/ Reduced Enjoyment in Activities and Reduced Energy Levels
Biological Symptoms of Depression may also be present- Poor appetite and Poor sleep- and it is important to differentiate between sleep that is disrupted due to the Baby Waking and sleep that is poor for other reasons
In Postpartum Depression, there may also be concerns from the mother about Bonding or Caring for her baby, and even Harming Herself or the Baby in Extreme cases
Unlike Baby Blues, which presents in the first TWO WEEKS and resolves on its own- Postpartum Depression rarely resolves on its own and needs to be treated to prevent Long-Term Depressive Disorder
How is Postpartum Depression Managed?
CBT or Interpersonal Therapy should be offered First Line- unless the Severity of the Depressive Episodes is High or there is a Risk, at which point the mother should be admitted to an Inpatient Mental Health Unit
What defines Postpartum Haemorrhage and what are the 4 causes? (4 Ts)
It is the lost of at least 500ml of blood within the first 24 hours after delivery (>1000ml is a MAJOR PPH)
- Tone- Most common cause of PPH is Uterine Atony- which is the failure of the uterus to contract after surgery
- Trauma- PPH may come after a birth canal injury or tear. This risk is increased in Instrumental Deliveries
- Tissue- Retained Placental or Foetal Tissue can lead to continued bleeding
- Thrombin- Coagulopathies can lead to continued bleeding due to failure of clotting
How is a Postpartum Haemorrhage managed?
Resuscitation (Cannulation and cross-matched blood) and then treatment to encourage uterine contraction- IV Oxytocin and Bimanual Uterine Compression
What is Pre-Eclampsia and what are its clinical features?
It is a placental condition affecting pregnant women commonly from 20 weeks of gestation
HYPERTENSION and PROTEINURIA
Other signs include- Peripheral Oedema, Severe Headache, Drowsiness, Visual Disturbances, Epigastric Pain, Nausea and Vomiting and Hyperreflexia
What are the 6 risk factors of Pre-Eclampsia?
IN MOPE
Increasing Maternal Age
Nulliparity
Multiple Pregnancy
Obesity
Previous History or Family History of pre-Eclampsia
Existing Disease (Hypertension, Diabetes- HIGH RISK FACTOR, Renal Disease, Autoimmune Disease)
What are the 4 Maternal ad 4 Foetal Complications of Pre-Eclampsia?
Maternal-
- HELLP Syndrome (Haemolysis, Elevated Liver enzymes, Low Platelets)
- Organ Failure
- Disseminated Intravascular Coagulation
- Eclampsia (Seizure due to Cerebrovascular Vasospasm)
Foetal-
- Intrauterine Growth Restriction
- Pre-term Delivery
- Placental Abruption
- Neonatal Hypoxia
How is Pre-Eclampsia Managed?
Labetalol is the first-line antihypertensive
Magnesium Sulphate is used as to prevent and treat Eclamptic Seizures
The delivery of the placenta is the only curative treatment choice
What blood tests should patients with Pre-Eclampsia need?
U&Es, FBC, Transaminase and Bilirubin 3 times a week
What is the Pre-Labour Rupture of Membranes at Term?
It is when the amniotic membranes rupture before the onset of labour after 37 weeks gestation
Most women with PROM at term will start spontaneous labour within the 24 hours after this occurs
The two main risks of PROM is Chorioamnionitis and Neonatal Infection
How should women with Pre-Labour Rupture of Membranes at Term? (3)
Women with PROM at Term should be assessed for any signs of Infection (Foul-smelling or Green Liquor, Maternal Fever and Reduced Foetal Movements)
The Foetal Heart should be monitored.
Digital Vaginal Examination should be avoided in the absence of labour as the membranes are ruptured so there is a risk of infecting
How should women with Pre-Labour Rupture of Membranes at Term? (3)
Women with PROM at Term should be assessed for any signs of Infection (Foul-smelling or Green Liquor, Maternal Fever and Reduced Foetal Movements)
The Foetal Heart should be monitored.
Digital Vaginal Examination should be avoided in the absence of labour
What is the management of Pre-Labour Rupture of Membranes at Term? (5)
If Labour does not commence-
If there are any signs of Infection-
If there are any signs of Foetal Compromise-
Following Delivery-
If this Occurs earlier with no issues-
If labour does not commence within 24 hours, Induction of Labour should be offered. If a woman does not choose to go through an induction, she should be MONITORED for her Temperature, Foetal Movements, Foetal Heart Rate and Vaginal Discharge and return if there are any abnormalities
If there are any signs of Infection- After taking bloods to CULTURE, immediate Induction of Labour should be commenced under consultant guidance and a BROAD SPECTRUM ANTIBIOTIC should be given
If there are any signs of Foetal Compromise, senior review is required to make a decision about whether Immediate Caesarean Section is needed
Following delivery, even if both mother and baby are Asymptomatic, the should be closely observed in hospital for 12 hours post-birth
If this Occurs earlier with no issues, give 2 doses of BETAMETHASONE 12mg IM 24 hours apart- Steroids are given to ADVANCE FOETAL LUNG MATURITY as they are likely to deliver Preterm
What are the 3 complications of Pre-Labour Rupture of Membranes at Term?
The Rupture of Amniotic Membranes can allow bacteria into the uterus- this can lead to Chorioamnionitis due to Ascending Infection
Increased risk of Preterm Birth and the Associated Complications of Preterm Birth (Respiratory Distress Syndrome, Necrotising Enterocolitis, Foetal Death)
Low levels of Amniotic Fluid due to PPROM can lead to Developmental Problems such as Pulmonary Hypoplasia, Facial and Limb Deformities (due to compression in the uterus) and Cord Prolapse
What are the 3 causes of a Pregnancy of Unknown Origin? (when a pregnancy test is positive but there is nothing on transvaginal ultrasound)
Early Viable/ Failing Intrauterine Pregnancy
Complete Miscarriage
Ectopic Pregnancy
What Investigations should be ordered in a suspected Pregnancy of Unknown Origin?
Serial serum Beta-hCGs 48 hours apart to give an indication of the Location and Prognosis of the Pregnancy
- If the levels fall, then it is suggested that the foetus will not develop or there has been a miscarriage
- If there is only a slight increase or a plateau in B-hCG, there may be an Ectopic Pregnancy
- A Normal Increase in B-hCG suggests the foetus is growing Normally but does not Exclude an Ectopic Pregnancy (in NORMAL PREGNANCY BETA hCG doubles every 48 hours and peaks at 8-10 weeks)
Transvaginal Ultrasound may show the location- but you may not see it in the early days of pregnancy- so it may be worth repeating this at a later date
What is Preterm Labour?
The onset of regular uterine contractions and cervical changes before 37 weeks gestation
Preterm Birth- is the delivery of a baby after 20 weeks gestation but BEFORE 37 weeks gestation
Prolonged Premature Rupture of Membranes is when the membranes rupture over 24 hours before the onset of labour
Pre-term Premature Rupture of Membranes is the rupture of membranes which occurs before 37 weeks
What Investigations should be ordered if Preterm Labour is suspected?
Foetal Fibronectin Test- assesses risk of Preterm Delivery after the onset of Preterm Labour
A negative Foetal Fibronectin Test means there is likely to be a low risk of delivery occurring within the next 1-2 weeks
What are the 5 risk factors for Pre-term Labour and Pre-term Delivery?
Conditions which may cause “Overstretching of the Uterus”- Multiple Pregnancy (commonly due to Assisted Conception) and Polyhydramnios
Conditions where Foetus is at risk- Pre-Eclampsia, Intrauterine Growth, Placental Abruption etc.
Problems with the Uterus or Cervix- Fibroids, Congenital Uterine Malformation, Short or Weak Cervix, Previous Uterine or Cervical Surgery
Infections such as Chorioamnionitis, Maternal or Neonatal Sepsis, Bacterial Vaginosis, Trichomoniasis, Group B Streptococcus, STI and UTI
Maternal Comorbidity (Hypertension, Diabetes, Renal Failure and Thyroid Disease)
What is the 5 step management of Preterm Labour?
Preterm Infants need to be delivered in a Neonatal Unit and NOT a standard Labour Ward
Corticosteroids should be given to Accelerate Foetal Lung Maturation (Betamethasone or Dexamethasone)
Intravenous Antibiotics should be given if there is an increased risk of Infection (Group B Streptococcus in current or previous pregnancy, presence of Maternal fever)
Penicillin is the ANTIBIOTIC of CHOICE if there is no allergy
Tocolytic agents may be considered to buy time for Administration of Corticosteroids, but risk of side effects and benefits should be weighed up
NIFEDIPINE is the recommended First Line Tocolytic- but can only buy a few days of time- not weeks
What are the 4 risk factors for Aspiration Pneumonia in Pregnant Women?
DRIV
Delayed Gastric Emptying
Relaxed Gastro-oesophageal Sphincter due to INCREASING CIRCULATING PROGESTERONE LEVELS
Increased Intragastric Pressure due to Gravid Uterus
Vigorous Abdominal Palpation or Disturbance during Examination, Labour or Caesarean Section
When are PPIs given in Obstetrics?
They are routinely given before a Caesarean Section to reduce Maternal Gastric Volume and Acidity
This reduces the risk of Aspiration of Gastric Contents during Surgery and Subsequent Aspiration Pneumonia
What are the 4 types of Rashes than can occur in Pregnancy?
(All apart from Obstetric Cholestasis are treated with Emollients and Topical Corticosteroids)
Polymorphic Eruption of Pregnancy- This occurs most frequently in the THIRD TRIMESTER and presents with Itchy Papules, typically first appearing on Striae Gravidarum, but may spread to the entire Abdomen, Thighs and Buttocks. It may progress to a Widespread Eczematous Rash with Fluid-filled Vesicles. PEP may be treated with Emollients and Topical Corticosteroids
Obstetric Cholestasis- Caused by Elevated Bile Acids. It can cause Pruritus which can develop into a rash. It is treated with URSODEOXYCHOLIC ACID, Emollients and Antihistamines
Atopic Eruption of Pregnancy- Presents similar to Eczema. Typical sites include the Face, Neck, Chest and Flexor Surfaces of the Upper Limbs. Treatment is with Emollients and Topical Corticosteroids
Pemphigoid Gestationis- Rare, Itchy Rash which forms around the UMBILICUS and can progress into Blisters. Management is with Emollients and Topical Corticosteroids. This condition is likely to flare up during pregnancy
At what week of Gestation are Non-sensitised Rhesus-negative mothers given Anti D?
28 weeks
What are the Sensitisation events that warrant Anti D in Rhesus Negative Mothers?
PAIRED AIE
Placental Abruption
Antepartum Haemorrhage
Intrauterine Death, Miscarriage or Termination
Rhesus Positive Blood Transfusion
Ectopic Pregnancy
Delivery (Normal, Instrumental or Caesarean Section)
Abdominal Trauma
Invasive Uterine Procedures (Amniocentesis, Chorionic Villus Sampling)
External Cephalic Version
What are the Risk Factors for Postpartum Haemorrhage?
PPH in Previous Pregnancy
BMI>35
Multiple Pregnancy
Parity>4
Placental Praevia/ Accreta
Placental Abruption
Pre-Eclampsia or Gestational Hypertension or Anaemia
Delivery via Caesarean Section
Induction of Labour
Instrumental Delivery
Prolonged Labour (>12 hours)
Macrosomia (>4kg baby)
Advanced Maternal Age
What are the 5 steps of the Second Stage of Labour?
FULL DILATATION- Then Foetus head is Flexed and Descends and Engages with the Pelvis
Foetus Internally rotates to face Outwards towards the Maternal Block
Foetus head Extends to deliver the head
Foetus Externally Rotates (Restitution) after delivery of the head so that Shoulders are in AP Position
The Anterior Shoulder is delivered first and the rest of the Foetus is Expelled
What is the common sign of the Second Stage of Labour and How long can it Last?
The Maternal Desire to Push
Can last between 20 minutes to 2 hours
What are the limits for Prolonged Second Stage?
In Nulliparous Women- >3 hours with Epidural, >2 hours without Epidural
In Multiparous Women- >2 hours with Epidural, >1 hour without Epidural
What is the management of a Prolonged Second Stage of Labour?
Instrumental Delivery
Caesarean Section in a Prolonged Second Stage increases Maternal Morbidity
What defines a Postpartum Haemorrhage as SECONDARY and what are the 5 common causes of it?
PACED
Excessive Vaginal Bleeding occurring between 24 hours and 12 weeks after Delivery
- Poor healing of Perineal Tear or Genital Tract Trauma
- Abnormal Involution of the Placental Site
- Choriocarcinoma
- Endometritis (bleeding occurs 2-10 days after delivery)- Often accompanied with OFFENSIVE DISCHARGE and may be due to RETAINED PLACENTAL TISSUE which leads to Uterus Atony
- Displacement of a Retained Blood Clot
What is Shoulder Dystocia?
After the head is delivered, the Anterior Shoulder becomes impacted behind the Maternal Pubic Symphysis
What are the 7 risk factors for Shoulder Dystocia?
and 2 additional risk factors I found on another website
- Fat, Short, Old, Diabetic Mother
Maternal Gestational Diabetes
Maternal Short Stature or Small Pelvis
Maternal Obesity
Advanced Maternal Age - Big, Fat, Delayed Baby
Macrosomia
Birthweight>4kg
Post-dates Pregnancy
ALSO PROLOGED SECOND STAGE of LABOUR and AUGMENTATION of LABOUR with OXYTOCIN
What are the 4 signs of Shoulder Dystocia?
RETRACTION of Foetal Head (Turtle-Neck Sign)
Difficult Delivery of Foetal Face or Chin
Failure of Restitution
Failure of Descent of the Foetal Shoulders following Delivery of Head
What is the Management of Shoulder Dystocia?
2 things to remember, 5 Manoeuvres, 2 things following Delivery
Immediately Call for Help
Do NOT APPLY FUNDAL PRESSURE as this may lead to Uterine Rupture and discourage maternal pushing as this may Exacerbate the Shoulder Impaction
- 5 APPROACHES in Order
1) McRoberts Manouevre-
= Hyperflexion and Abduction of Mother’s legs tightly to the Abdomen
= This may be accompanied with applied Suprapubic Pressure
= Routine Traction (as applied during normal delivery) in an Axial Direction- NOT Downward- should be applied to assess whether the shoulders have been released
2) All Fours Position (Gaskin’s Manoeuvre)
3) Internal Rotational Manoeuvres
= Rubin Manoeuvre II- Rotation of the Anterior Shoulder towards the Foetal Chest
= Woods’ Screw Manoeuvre- Anterior Shoulder is pushed towards the Foetal Chest and the Posterior Shoulder is pushed towards the Foetal Back
= Episiotomy will NOT RELIEVE Shoulder Dystocia as it is a Bony Obstruction, but may be indicated to allow space for the Internal Rotational Manoeuvres
4) Cleidotomy or Symphysiotomy (Division of the Foetal Clavicle or Maternal Symphysial Ligament)
5) Zavanelli Manoeuvre- Putting the Head back into the Canal and then Subsequent delivery Via Caesarean Section
Following Delivery-
- Mother should be examined and monitored for Postpartum Haemorrhage, Severe Perineal Tears and other Genital Tract Trauma
- Baby should be examined by Neonatologist for Injury- including Brachial Plexus Injury, Hypoxic Brain Damage, Humeral or Clavicular Fractures
What are the 4 indications for Speculum Examination?
To Assess-
- Cervical Dilatation (should not happen until around 38 weeks)
- Rupture of Membranes
- Antepartum Haemorrhage
- Vaginal Discharge
What are the 4 indications for Speculum Examination?
To Assess-
- Cervical Dilatation (should not happen until around 38 weeks)
- Rupture of Membranes
- Antepartum Haemorrhage
- Vaginal Discharge
What are the 3 main types of Neural Tube Defect?
Spina Bifida Occulta- Incomplete fusion of the vertebrae, but with No Herniation of the Spinal Cord- may only be visible as a SMALL TUFT OF HAIR
Meningocele- Incomplete fusion of the vertebrae, with Herniation of a Meningeal Sac filled with CSF, visible prominence usually covered in skin
Myelomeningocele- Incomplete fusion of the vertebrae with herniation of herniation of a Meningeal Sac containing CSF and Spinal Cord
- Usually accompanied by other defects such as Hydrocephaly or Chiari Malformation. Visible prominence at skin with Exposed Meninges
How can Spina Bifida be prevented?
All pregnant women, and those trying to conceive are recommended to take Folic Acid to decrease the risk of NTDs
- 400mcg/day from 3 months prior to Conception, until 12 weeks of gestation
- in women at higher risk (5) (like those with a child with an NTD, or mothers with Coeliac disease, Diabetes, Thalassaemia, Obesity or those on Antiepileptics) are recommended a higher dose of 5mg/day
How are NTDs diagnosed?
Prenatal scans or Ultrasound
What are the 5 Neurological and 3 Musculoskeletal signs of Spina Bifida and how is it managed (2)?
Neurological-
- Motor Deficits
- Sensory Deficits
- Neurogenic Bladder or Bowel
- Hydrocephalus
- Seizures
Musculoskeletal-
- Increased risk of Hip Subluxation
- Scoliosis
- Contractures (shortening and hardening of bones)
Management-
- Primary Neurosurgical Repair
- Orthopaedic Surgery
What are the 2 supplements recommended to take in Pregnancy?
All pregnant women, and those trying to conceive are recommended to take Folic Acid to decrease the risk of NTDs
- 400mcg/day from 3 months prior to Conception, until 12 weeks of gestation
- in women at higher risk (5) (like those with a child with an NTD, or mothers with Coeliac disease, Diabetes, Thalassaemia, Obesity or those on Antiepileptics) are recommended a higher dose of 5mg/day
Also Vitamin D- 10mcg (400IU) per day- shown to be beneficial in Foetal Bone Formation. Recommended in Pregnancy and Breastfeeding (1000IU recommended for obese women/ women who get reduced sunlight levels)
What are the 5 categories for requesting a Termination of Pregnancy? (only 4 on Quesmed)
A The pregnancy has not exceeded its 24th week of pregnancy and the continuation of the pregnancy would have greater risks that benefits to the physical and mental healths of the mother and her existing children
B The termination of the pregnancy is necessary to prevent permanent injury to the physical or mental health of the mother
C The continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy was terminated
D There is a substantial risk that the baby would suffer from mental and physical abnormalities to be seriously handicapped
What are the 2 steps of Medical and Surgical Termination of Pregnancy (2 each?
Medical Termination of Pregnancy
- Mifepristone, a Progesterone Antagonist blocks PROGESTERONE required for the continuation of pregnancy
- Misoprostol, a Prostaglandin Analogue. Causes SMOOTH MUSCLE CONTRACTIONs of Myometrium, resulting in expulsion of uterus contents (800mcg between 10+1 and 23+6 weeks of Pregnancy- 100mcg if after this as uterus becomes more sensitive)- followed by 400mcg every 3 hours
Surgical Termination of Pregnancy
- Suction Termination
- Dilatation and Evacuation/ Curettage (D&Cs)
What guidelines should be followed if the patient requesting termination of pregnancy is at an age where there is variation in the capacity to provide consent?
Fraser Guidelines
If patient experiences post-termination of pregnancy bleeding, what is the main differential and what should be investigated?
Retained products of Conception +/- Pelvic Inflammatory Disease
Check Inflammatory Markers, FBC and CRP and give INTRAVENOUS ANTIBIOTICS if high
If she is Pyrexial, she will need urgent Invasive Management- such as a Transvaginal Ultrasound
What should be done following a termination of pregnancy 4 and 5 weeks after it?
Beta HCG- to make sure the termination was complete it should decrease over time
What is the beginning and the end of the Third Stage of Labour and what are the 3 signs?
Delivery of Foetus- beginning
Delivery of Placenta and Foetal Membranes- end
Last 30 minutes to 1 hour, or 5-10 minutes with Oxytocin
- Gush of Blood
- Lengthening of Umbilical Cord
- Ascension of Uterus in the Abdomen
What is the management of the Third Stage of Labour?
Controlled Cord Traction
This must be gentle or else there is an increased risk of causing complications such as Uterine Inversion or Postpartum Haemorrhage
What is the use of Tocolytics and what are the 5 main Tocolytics used and what is first line?
NAITM
They are indicated in Preterm Labour to delay delivery by a few days- usually to buy time for Maternal Steroids to work or to allow the mother to be transferred to the appropriate unit
- Nifedipine (Calcium Channel Antagonist)
- Atosiban (Oxytocin Receptor Antagonist)
- Indomethacin (NSAID)
- Terbutaline (Beta-2-Antagonist)
- Magnesium Sulphate administered for its Neuroprotective Effects
ORAL NIFEDIPINE is FIRST LINE
It can only suppress by a FEW DAYS
What are the 6 contraindications to Tocolysis?
CCM ING
Chorioamnionitis
Cervical Dilatation greater than 4cm
Maternal Factors- Pre-Eclampsia, Ante-Partum Haemorrhage, Haemodynamic Instability
Intrauterine Growth Restriction or Placental Insufficiency
Non-reassuring Cardiotocograph, Fatal Foetal Anomaly or Intrauterine Death
Greater than 34 weeks Gestation
What are the features of Monozygotic and Dizygotic Twin Pregnancies?
Monozygotic Twins (One Egg and One Sperm)
- Dichorionic and Diamniotic (Two Different Sacs)
- Monochorionic and Diamniotic (One Outer Sac and Two Inner Sacs)
- Monochorionic and Monoamniotic (Same Sac)
- Monozygotic Twins are at risk of certain complications (like Twin-to-twin Transfusion Syndrome) and must be monitored more carefully
Dizygotic Twins (Two Different Eggs and Two Different Sperms)
- All of these are Dichorionic and Diamniotic and have Separate Placentas
-offer Elective Birth from 37 weeks onwards if Dichorionic Twins
- offer Elective Birth from 36 weeks onwards if Monochorionic Twins
2/3s of all twins are Dizygotic and 1/3 are Monozygotic
What is Twin-to-Twin Transfusion Syndrome and what are the risks and management?
It occurs due to the anastomoses of Umbilical Vessels between the two foetuses in the Placenta of Monochorionic Twins
Both Foetuses are at risk of developing Heart Failure and Hydrops (severe oedema in babies)
- Donor suffers High Output Cardiac Failure due to Anaemia
- Recipient suffers from Fluid Overload
Management- If Untreated, the mortality rate is high and the Donor is More Likely to Survive. Management is Laser Transection of the Blood Vessels in-utero
What are the 3 types of Foetal Presentations?
(4, 4, 3)
Cephalic
- Vertex (most common presentation)
- Brow
- Face
- Chin
Breech Presentations
- Frank- the Legs are extended up to the head, the Buttocks are the presenting part
- Complete- the Hips and Knees are Flexed- the Buttocks is presenting
- Incomplete- One or both Hips are extended and the Knee or Foot is the presenting part
- Footling (single/ double)- One or both Legs are extended and a Foot/Feet is the presenting part
Shoulder Presentations
- Arm is the leading Part
- Shoulder is the leading Part
- Trunk is the leading Part
What are the 2 Risks and 3 Contraindications to a Vaginal Birth after (previous) Caesarean Section?
Risks-
- Increased risk of Uterine Rupture (Scar Rupture) (Sudden Onset of Abdominal Pain and Loss of Contractions suggests this- Emergency surgery (C. Section/ Laparotomy) if this happens)
- Increased risk of requiring Caesarean Section (failed VBAC)
Contraindications-
- Classical (Vertical) Caesarean Section scar
- Previous history of Uterine Rupture
- usual contraindications to Vaginal Delivery- such as a Major Placenta Praevia
What is the purpose of giving Syntocinon (Oxytocin) in labour?
It is used to achieve Contractions of a Normal Rate, Duration and Intensity to facilitate labour
In the first stage of labour, they should be 3-5 per 10 minute period and should last 30-60 seconds
What medication inhibits Lactation?
Cabergoline
