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
