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OBSTETRICS TO DO Flashcards

1
Q

ECTOPIC PREGNANCY
Where is the most common site for an ectopic?
What is the most common site for a ruptured ectopic?

A
  • Ampulla
  • Isthmus
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2
Q

ECTOPIC PREGNANCY
What is expectant management?
What are the indications?
What indicates that it has worked?

A
  • Effectively do nothing
  • Clinically stable (no Sx), ectopic <35mm, no heartbeat, serum hCG <1000IU/L (consider up to 1500) + able to return for follow up
  • Serum hCG days 2, 4 + 7 (drop ≥15% then repeat weekly until negative)
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3
Q

ECTOPIC PREGNANCY
What is medical management?
What are the indications?
What indicates that it has worked?

A
  • Single dose IM 50mg/m^2 methotrexate
  • No significant pain, unruptured ectopic <35mm, no heartbeat, serum hCG <1500 (consider up to 5000IU/L) + able to return for follow up
  • hCG levels at days 4 + 7 then weekly, <15% fall = ?another dose
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4
Q

ECTOPIC PREGNANCY
What are the requirements for methotrexate management?
What are some side effects?

A
  • Satisfactory liver + renal functions
  • Teratogenic so effective contraception for 3m
  • Conjunctivitis, diarrhoea, abdo pain + stomatitis
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5
Q

MISCARRIAGE
What are some other causes of miscarriage?

A
  • PCOS
  • TORCH infections
  • Iatrogenic (amniocentesis, CVS)
  • Smoking, substance abuse
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6
Q

MISCARRIAGE
What are some causes of recurrent miscarriage?

A
  • Antiphospholipid syndrome
  • Hereditary thrombophilias (Factor V leiden deficiency, factor II prothrombin gene mutation, protein C/S deficiency)
  • Uterine abnormalities (uterine septate, fibroids)
  • Poor controlled chronic conditions (DM, thyroid, SLE)
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7
Q

MISCARRIAGE
What are the investigations for recurrent miscarriage?

A

≥3 1st trimester, ≥1 in 2nd –
- Lupus anticoagulant, anti-cardiolipin + phospholipid antibodies
- Thrombophilia screen
- Pelvic USS for structural issues
- Cytogenic analysis of POC after 3rd miscarriage
- Parental blood for karyotyping

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8
Q

TERMINATING PREGNANCY
What is the legal framework for terminating pregnancies?

A
  • 1967 Abortion Act (+ 1990 amendment which reduced gestation from 28 to 24w)
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9
Q

ANTENATAL SCREENING
What results indicate higher risk for…

i) nuchal translucency?
ii) beta-hCG?
iii) PAPP-A?

What else is taken into account?

A

i) >6mm
ii) Higher result
iii) Lower result

  • Maternal age, USS crown rump length, detection rate 85%
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10
Q

ANTENATAL SCREENING
What results indicate higher risk for…
i) beta-HCG?
ii) AFP?
iii) oestriol?
iv) inhibin?

A

i) Higher result
ii) Lower result
iii) Lower result
iv) Higher result

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11
Q

ANTENATAL SCREENING
What risk score would warrant further invasive tests?
What are those tests?

A
  • > 1:150 = screen +ve
  • Amniocentesis
  • Chorionic villus sampling (CVS)
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12
Q

PLACENTAL ABRUPTION
What are the major risk factors for placental abruption?
What are some other risk factors?

A
  • IUGR, pre-eclampsia or pre-existing HTN, maternal smoking + previous abruption
  • Cocaine use, multiple pregnancy or high parity, trauma
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13
Q

ADHERED PLACENTA
What are some risk factors for a morbidly adhered placenta?

A
  • Previous c-sections (placenta attaches to site)
  • Myomectomy
  • Surgical TOP
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14
Q

VASA PRAEVIA
What are some risk factors for vasa praevia?

A
  • Placenta praevia
  • Multiple pregnancy
  • IVF pregnancy
  • Bilobed placentas
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15
Q

PRE-ECLAMPSIA
How can pre-eclampsia be classified?

A
  • Mild-mod = pre-eclampsia without severe HTN (<160/110) and NO Sx, biochemical or haematological impairment
  • Severe = pre-eclampsia w/ severe HTN ± Sx ± biochem ± haem impairment
  • Early <34w, late >34w
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16
Q

PRE-ECLAMPSIA
What is the normal physiology of the placenta?

A
  • Spiral arteries dilate + develop into large utero-placental arteries, supplying lots of blood to the endometrium > placenta + foetus
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17
Q

PRE-ECLAMPSIA
What is the pathophysiology of pre-eclampsia?

A
  • Spiral arteries do not remodel + dilate but become fibrous so utero-placental arteries deliver less blood > placental ischaemia
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18
Q

PRE-ECLAMPSIA
What is the result of placental ischaemia?

A
  • Pro-inflammatory protein + thromboplastin release leads to endothelial damage > vasoconstriction, clotting dysfunction + increased vascular permeability
  • Ultimately leads to poor renal perfusion > RAAS activation > HTN, proteinuria ± oedema > pre-eclampsia + eclampsia (if continues)
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19
Q

PRE-ECLAMPSIA

What are the…

i) high risk
ii) moderate risk

factors for pre-eclampsia?

A

i) Pre-existing HTN, previous pre-eclampsia, CKD, autoimmune (SLE, T1DM)
ii) Nulliparity, multiple pregnancy, >10y pregnancy interval, FHx, >40y, BMI >35kg/m^2

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20
Q

PRE-ECLAMPSIA
What are the 2 main causes of symptoms in pre-eclampsia?

A
  • Local areas of vasospasm leading to hypoperfusion
  • Oedema due to increased vascular permeability + hypoproteinaemia
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21
Q

PRE-ECLAMPSIA
What symptoms are caused by local areas of vasospasm and what area is affected?

A

Renal = glomerular damage (low GFR) –
- Oliguria + proteinuria
Retinal –
- Visual disturbances (blurred, flashing lights, scotoma)
Liver = injury + swelling stretches liver capsule –
- RUQ or epigastric pain

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22
Q

PRE-ECLAMPSIA
What are the signs of pre-eclampsia?

A
  • Raised BP + proteinuria are hallmarks
  • Rapid weight gain, RUQ tenderness
  • Ankle clonus (brisk reflexes normal in pregnancy but not clonus)
  • Papilloedema if severe
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23
Q

PRE-ECLAMPSIA
What blood investigations would you do in pre-eclampsia?

A
  • FBC with platelets (thrombocytopenia)
  • Serum uric acid levels (raised due to renal issues)
  • LFTs (elevated liver enzymes ALT + AST)
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24
Q

PRE-ECLAMPSIA
What other investigations could you perform in pre-eclampsia?

A
  • Proteinuria on dipstick (++ or +++ is severe)
  • Protein:Creatinine ratio (PCR) ≥30ng/nmol = significant proteinuria
  • Accurate dating + USS to assess foetal growth
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25
PRE-ECLAMPSIA What are the 2 big complications of pre-eclampsia?
- Eclampsia - HELLP syndrome
26
PRE-ECLAMPSIA What is the criteria for outpatient management of pre-eclampsia? What care is given?
- BP <160/110, no or low proteinuria (≤+, <0.3g/24h) + no symptoms - Weekly review of bloods, twice weekly mother + foetal evaluation (HBPM + urine) - Any changes > hospital
27
IUGR What are the two types of IUGR?
- Symmetrical = entire body is proportionately small, tends to be seen in early onset IUGR, TORCH + chromosomal abnormalities - Asymmetrical = undernourished foetus that is compensating by directing most of its energy to maintain growth of vital organs like brain + heart
28
IUGR What might be seen in asymmetrical IUGR?
Head-sparing effect – - Normal head size but small abdominal circumference + thin limbs - Mostly secondary to placental insufficiency
29
IUGR What is low birth weight?
- Baby born with a weight <2.5kg (regardless of gestational age)
30
IUGR What are the 3 broad categories causing IUGR?
- Placental insufficiency (most common cause) - Maternal factors - Foetal factors
31
IUGR What are some placental causes of IUGR?
- Abnormal trophoblast invasion (pre-eclampsia, placenta accreta) - Infarction, abruption, location (praevia)
32
IUGR What are some maternal causes of IUGR?
- Chronic disease (HTN, cardiac, CKD) - Substance abuse (cocaine, alcohol) smoking, previous SGA baby - Autoimmune - Low socioeconomic status - >40
33
IUGR What are some complications of IUGR?
- Hypoglycaemia - Risk of necrotising enterocolitis - Neonatal jaundice - Hypothermia - Respiratory issues - Long-term sequelae include T2DM, HTN, obesity, behavioural problems, CP
34
IUGR What causes... i) hypoglycaemia? ii) necrotising enterocolitis? iii) neonatal jaundice?
i) Blood directed away from liver>brain so glycogen stores don't develop adequately ii) Reduced blood to bowel iii) Compensatory polycythaemia for reduced oxygen supply from mother if reduced placental perfusion
35
IUGR What causes... i) hypothermia? ii) respiratory problems?
i) No fat stores developed so cannot thermoregulate, large surface area ii) Kidney hypoperfusion > decreased urine output > oligohydramnios > inadequate lung development
36
IUGR What are the investigations for IUGR?
- BP + urine dipstick (?pre-eclampsia) - Karyotyping (?foetal) - Infection screen, TORCH (?infection)
37
IUGR When would you be concerned about IUGR? What would you do?
- SFH < 10th centile, slow or static growth or crossing centiles - Refer for serial growth scans (USS) every 2w, umbilical artery doppler + amniotic fluid volume - MCA doppler performed after 32w
38
OLIGOHYDRAMNIOS What are some causes of oligohydramnios?
- PROM or SROM - Renal agenesis (Potter's syndrome) or non-functional kidneys - Placental insufficiency (pre-eclampsia, post-term gestation) as blood redistributed to brain so reduced urine output - Genetic anomalies - Obstructive uropathy
39
POLYHYDRAMNIOS What are the causes of polyhydramnios?
- Increased foetal urine production (maternal DM), twin-twin transfusion, foetal hydrops - Foetal inability to swallow/absorb amniotic fluid (GI tract obstruction e.g. duodenal atresia, foetal neuro/muscular issues)
40
RHESUS DISEASE What is the pathophysiology of rhesus disease in the first pregnancy?
- Rh-ve woman exposed to Rh+ve foetal blood, her immune system recognises as foreign + produce antibodies against rhesus D (sensitisation) - Usually no issues in 1st pregnancy as IgM produced that cannot cross placenta
41
RHESUS DISEASE What is the pathophysiology of rhesus disease in subsequent pregnancies?
- Memory cells produce IgG which can cross placenta so if Rh+ve foetus will attack leading to haemolysis (haemolytic disease of newborn) with jaundice + hydrops fetalis (abnormal accumulation of fluid)
42
GESTATIONAL DIABETES What are some anti-insulin hormones produced by the placenta?
- Main one is human placental lactogen (hPL) - Also glucagon + cortisol
43
OBSTETRIC CHOLESTASIS Why can clotting be deranged in obstetric cholestasis?
- Bile acids important for fat soluble vitamin absorption like vitamin K
44
OBSTETRIC CHOLESTASIS What are the complications of obstetric cholestasis?
- Maternal = vitamin K deficiency (may lead to PPH) - Foetal = stillbirth (#1), increased risk of prematurity (often iatrogenic)
45
INFECTIONS + PREGNANCY What are the risks of Varicella zoster?
- Maternal risk = 5x greater risk of pneumonitis - Foetal varicella syndrome = skin scarring, microphthalmia, limb hypoplasia, microcephaly + learning difficulties
46
ANAEMIA + PREGNANCY What are the complications of iron deficiency anaemia? How is it managed?
- LBW + preterm delivery - Ferrous sulfate 200mg TDS - If not anaemic but low ferritin indicating iron stores then start them on it - Vitamin C can increase absorption of iron
47
ANAEMIA + PREGNANCY What is the management of macrocytic anaemias?
- Pernicious = IM hydroxocobalamin - B12 deficiency = B12 tablets (cyanocobalamin) - Folate = increased from 400mcg to 5mg/day to reduce NTD.
48
PROM What are some risk factors for (P)PROM?
- Previous PROM/preterm - Smoking - Polyhydramnios - Amniocentesis
49
STAGES OF LABOUR What are 7 important hormones in labour?
- Prostaglandins - Oxytocin - Oestrogen - Beta-endorphins - Adrenaline - Prolactin - Relaxin
50
STAGES OF LABOUR What is the first stage of labour? How is it further divided?
- From onset of labour (true contractions) until the cervix is fully dilated - Latent phase = from 0–3cm dilation - Active phase = from 3–10cm
51
STAGES OF LABOUR What is the difference between latent and active phase of the first stage of labour?
- Latent: cervix begins to efface, irregular contractions, 'show', can last 2–3d (usually 6h) - Active: stronger, more regular contractions (4:10), cervix continues effacing
52
STAGES OF LABOUR What is the second stage of labour? How is it further divided?
- From full dilation to delivery of the foetus - Passive stage: complete dilation but no pushing (often 1 hour) - Active stage: maternal pushing until delivery
53
STAGES OF LABOUR What is considered a delay in the active second stage of labour? What does success depend on?
- >2h in nulliparous, 1h in multiparous - 3Ps (power, passenger + passage [?Psyche of mum])
54
STAGES OF LABOUR What are the parts of the APGAR score?
Activity – absent 0, flexed arms + legs 1, active 2 Pulse – absent 0, <100bpm 1, >100bpm 2 Grimace – floppy 0, minimal response to stimulation 1, prompt response to stimulation 2 Appearance – blue 0, blue extremities 1, pink 2 Respiration – absent 0, slow + irregular 1, vigorous cry 2
55
STAGES OF LABOUR What are the 6 cardinal movements of labour?
- Engagement + descent - Flexion - Internal rotation - Extension (crowning) - Restitution/external rotation - Expulsion
56
STAGES OF LABOUR What is engagement?
- Passage of presenting part into pelvic inlet - Entire head felt = 5/5ths palpable aka not engaged - Unable to feel head = 0/5ths palpable aka fully engaged - Foetus is engaged when >50% of presenting part descended into pelvis
57
STAGES OF LABOUR What is descent? How can descent be described? What is descent encouraged by?
- Downward passage of presenting part through bony pelvis - Position of baby's head (cm) in relation to mother's ischial spines - Increased abdo muscle tone and increased frequency + strength of contractions
58
STAGES OF LABOUR How can descent of the baby be described?
In relation to ischial spines in cm – - –5 = baby high up at around the pelvic inlet - 0 = head at ischial spines (engaged) - +5 = foetal head descended further out
59
STAGES OF LABOUR What position is the foetal head during engagement and descent?
- Occiput transverse
60
STAGES OF LABOUR What is flexion?
- Uterine contractions exert pressure down foetal spine towards occiput + cause neck flexion, allowing circumference of foetal head to reduce
61
STAGES OF LABOUR What is internal rotation? Why does it occur?
- Foetus passively internally rotates from OT to OA/OP to allow shoulders to negotiate pelvic inlet - Pelvic inlet widest diameter is transverse (side-side)
62
STAGES OF LABOUR What is extension?
- Foetal occiput slips beneath suprapubic arch allowing head to extend + foetal head is born, usually facing maternal back (occiput anterior)
63
STAGES OF LABOUR What is restitution?
- Shoulders only now negotiating pelvic outlet so head externally rotates to face mother's L/R medial thigh so shoulders can pass - Pelvic outlet widest diameter is A-P (front-back)
64
STAGES OF LABOUR What is expulsion? How may this be assisted?
- Ultimately ends with delivery of foetus - Gentle downwards traction > deliver shoulder below suprapubic arch - Gentle upwards traction > deliver posterior shoulder (caution with excessive force as may cause brachial plexus damage)
65
FAILURE TO PROGRESS What are the 2 types of abnormal progression in labour?
- Slow from beginning (primary dysfunctional labour) – may be insufficient uterine contractions - Sudden slowing of labour (secondary arrest) – may be cephalopelvic disproportion
66
FAILURE TO PROGRESS What are the components of the Bishop score?
- Cervical dilation – <1cm (0), 1-2 (1), 3-4 (2), >5cm (3) - Cervical consistency – firm (0), intermediate (1), soft (2) - Cervical effacement – <30% (0), 40-50 (1), 60-70 (2), 80% (3) - Cervical position – posterior (0), intermediate (1), anterior (2) - Foetal station – –3 (0), -2 (1), -1/0 (2), ≥1 (3)
67
BREECH What are the 3 types of breech presentation?
- Extended (Frank) = most common, hips flexed, both legs extended with feet by head, buttocks presenting - Flexed (Complete) = hips + knees flexed so buttocks + feet presenting (Cannonballing) - Footling = one leg flexed, one extended, foot hanging through cervix
68
CTG How do you interpret a CTG?
Dr C Bravado – - Dr = define risk (high risk = continuous - C = contractions (bottom trace shows frequency) - Bra = baseline rate - V = variability - A = accelerations - D = decelerations - O = overall assessment
69
CTG What might different foetal baseline rates tell you?
- >160 may be maternal pyrexia, prematurity, chorioamnionitis - <110 may be maternal beta-blockers, increased foetal vagal tone
70
CTG What are decelerations? What are the 3 types and their causes?
- Fall in baseline HR by 15 for ≥15s - Early = peak of contraction corresponds with trough of depression (head compression from uterine contraction = normal) - Late = deceleration after contraction (hypoxia = placental insufficiency, asphyxia) - Variable = vary in shape + timing (cord compression)
71
CTG What are the pros of CTGs?
- Allows long-term monitoring - Can pick up on foetal distress - Can be on constantly to identify any slight changes
72
CTG What are the cons of CTGs?
- No improvement in perinatal outcomes in low-risk pregnancies - Foetal exposure to USS ionisation - Ambulatory monitoring may not be possible - Doesn't give true beat to beat FHR monitoring or morphological Ax of heart
73
FOETAL ECG What is an alternative to scalp ECG?
- Abdominal foetal ECG - Can be used ambulatory at home but only for high risk, morphological analysis possible + non-invasive
74
SHOULDER DYSTOCIA What are the 3 rotational manoeuvres?
- Rubin II = pressure on post. aspect of ant. shoulder to help deliver under symphysis pubis - Woods' screw = Rubin II + pressure on ant. aspect of post. shoulder - Reverse woods' screw = pressure on ant. aspect of ant. shoulder + post. aspect of post. shoulder in opposite way
75
INSTRUMENTAL DELIVERY What are the main risks of ventouse delivery?
- Cephalohaematoma = collection of blood between periosteum + skull from damaged blood vessels, does not cross suture lines, presents hours after - Caput Succedaneum = Crosses Sutures, diffuse oedema outside periosteum due to pressure to a specific area of scalp, resolve in few days, conehead present at birth
76
C-SECTION What are the different categories of c-section?
- 1 = immediate threat to life of mother/baby. Decision>delivery time = 30m - 2 = not imminent threat to life but c-section required urgently due to compromise. Decision>Delivery time = 75m - 3 = c-section required but both stable - 4 = elective section
77
C-SECTION What two types of anaesthesia can be used in c-sections? What else is given in c-sections?
- General - Regional block (spinal) - H2 receptor antagonists or PPIs, prophylactic Abx, oxytocin (PPH), LMWH for VTE prophylaxis
78
PAIN RELIEF What are some important notes about single shot opioids?
- Lipid soluble so crosses placenta rapidly - Diamorphine 2x as potent as morphine so faster onset - Pethidine metabolites can cause seizures so avoid in epileptics
79
PAIN RELIEF What are some side effects from opioids?
- Foetal = resp depression, diminishes breast seeking + feeding behaviour - Maternal = euphoria + dysphoria, N+V, can prolong 1st + 2nd stages, resp depression + pruritus
80
PAIN RELIEF What 4 regimes can be given for regional techniques?
- Intermittent = high conc LA, labour intensive, periods of inadequate analgesia + haemodynamic instability - Continuous = low dose LA + opioid, less labour intensive, constant analgesia + haemodynamic stability - Continuous + bolus = greater maternal satisfaction - CSE = rapid onset, high satisfaction, reduced LA dose
81
PAIN RELIEF What medications can be given epidurally?
- LA like bupivacaine - Opioids like fentanyl, diamoprhine
82
PAIN RELIEF What sequential effects do regional techniques have?
- Autonomic (vasodilation = reduced MAP) - Sensory (analgesia) - Motor (motor blockade) + fever
83
PAIN RELIEF What are the indications for regional techniques?
- Maternal request - HTN/pre-eclampsia - Cardiac disease - Induced labour - Multiple births - Instrumental/op delivery likely
84
PAIN RELIEF What are some complications of regional techniques?
- Potential for spinal cord damage - Hypotension + bradycardia - Haematoma/abscess at injection site - Anaphylaxis if allergic - Post-dural puncture headache
85
PERINEAL TEARS How are third degree tears further classified?
- 3A = <50% of external anal sphincter thickness torn - 3B = >50% of EAS thickness torn - 3C = EAS + internal anal sphincter torn
86
PPH What are the risk factors for PPH?
- Before birth = previous PPH, APH, twins/triplets, pre-eclampsia, obesity, polyhydramnios - Labour = prolonged, c-section, perineal tear or episiotomy, macrosomia
87
MENTAL HEALTH What are some red flags in terms of maternal mental health?
- Recent change in mental state or new Sx - New thoughts or acts of violence/self-harm - New + persistent feelings of incompetency as mother or estrangement from baby
88
MENTAL HEALTH Why can mental health disorders be difficult to detect in the puerperium?
- Fear of treatment - Fear of children being removed - Cultural lack of recognition - Denial - Stigma
89
HYPEREMESIS What are some associations of hyperemesis gravidarum?
- nulliparity, - hyperthyroid, - obesity, - decreased in smokers
90
HYPEREMESIS How is severity assessed?
Pregnancy-Unique Quantification of Emesis (PUQE) – - <7 mild, - 7-12 mod, - >12 severe
91
OBSTETRIC CHOLESTASIS What are some associations?
- Asian women, thought to be due to increased oestrogen + progesterone levels
92
ANAEMIA + PREGNANCY What are some causes?
Physiological, Fe deficiency (increased demand), B12 or folate deficiency
93
ANAEMIA + PREGNANCY What are some risk factors?
Menorrhagia, malaria, hookworm, twins, poor diet
94
STAGES OF LABOUR How quickly are women expected to dilate during the active phase?
- Primis = 0.5cm/h, - multiparous = 1cm/h
95
UTERINE RUPTURE What are the two types?
- Incomplete = peritoneal lining surrounding uterus intact - Complete = peritoneal lining ruptures so uterine contents released into peritoneal cavity
96
PPH What are the secondary causes of PPH?
Secondary most common cause is retained placental tissue, endometritis
97
HELLP what other condition is HELLP associated with?
- 10% have antiphospholipid syndrome
98
HELLP what are the risk factors for HELLP?
➢ White ethnicity ➢ Maternal age >35 yrs. ➢ Obesity ➢ Chronic hypertension ➢ DM ➢ Autoimmune disorders ➢ Abnormal placentation and multiple gestation ➢ Previous pregnancy with preeclampsia
99
SICKLE CELL DISEASE IN PREGNANCY what are the risks of sickle cell disease during pregnancy?
* Crises are more common during pregnancy * Increased risk of pre-eclampsia * Increased risk of delivery by CS due to fetal distress
100
SICKLE CELL DISEASE IN PREGNANCY what are the foetal risks in sickle cell disease?
- miscarriage - IUGR - prematurity - stillbirth
101
SICKLE CELL DISEASE IN PREGNANCY what is the management?
- Pre-Pregnancy counselling - Stop iron chelating agents before pregnancy - Give folic acid and penicillin prophylaxis for hypersplenism - Screen for UTI infections each visit - Crisis Treatment: Analgesics, oxygen, hydration, and antibiotics if infection is suspected - Regular foetal monitoring - Aim for vaginal delivery
102
FOETAL HYDROPS what are the different types?
immune and non-immune
103
FOETAL HYDROPS what is the pathophysiology?
an imbalance of interstitial fluid production and inadequate lymphatic return. This can result from congestive heart failure, obstructed lymphatic flow, or decreased plasma osmotic pressure.
104
FOETAL HYDROPS what are the causes of immune foetal hydrops?
results from blood group incompatibility between the mother and the fetus causing fetal anaemia. THIS IS RHESUS DISEASE OF THE NEWBORN**
105
FOETAL HYDROPS what are the causes of non-immune foetal hydrops
- severe anaemia (parvovirus B19, thalassaemia, G6PD) - cardiac abnormalities - chromosomal abnormalities (trisomies 13, 18 and 21) - genetic conditions - other infections (toxoplasmosis, rubella, CMV, varicella) - structural abnormalities (CCAM, diaphragmatic hernia) - twin-to-twin transfusion syndrome - chorioangioma
106
FOETAL HYDROPS what is the management?
depends on the cause - anaemia = in-utero blood transfusion - pleural effusions/CCAM = shunt - twin-to-twin transfusion syndrome = laser photocoagulation of placental anastomoses - cardiac arrhythmias = maternal digoxin + flecanide
107
LOW BIRTH WEIGHT what are the risk factors for low birth weight?
➢ Low socioeconomic ➢ History of abuse ➢ Age (<15 or >35) ➢ Race (black, ethnic minorities...)
108
LOW BIRTH WEIGHT what are the causes of low birth weight?
➢ Preterm birth (before 37 weeks gestation) ➢ Genetics (could be chromosomal abnormalities...) ➢ Uteroplacental insufficiency ➢ Multiple pregnancy ➢ Substance abuse (smoking, drinking alcohol, illicit drug) causing IUGR ➢ Chronic conditions and infections (hypertension, rubella, CMV, syphilis, toxoplasmosis, BV...) ➢ Medications (sodium valproate, ramipril, warfarin...)
109
LOW BIRTH WEIGHT what are the consequences of a low birth weight?
➢ Feeding struggles ➢ Respiratory distress syndrome ➢ Jaundice ➢ Infections ➢ PDA ➢ Intraventricular hemorrhage ➢ Retinopathy of prematurity, and hearing problems ➢ Intellectual and developmental disabilities ➢ Diabetes ➢ High blood pressure ➢ Heart disease ➢ Obesity
110
LOW BIRTH WEIGHT what is the management?
➢ IV fluids or gavage feeding ➢ Light therapy ➢ Supplemental surfactant or oxygen ➢ Surgery or medications (ROP or PDA), and for intraventricular hemorrhage ➢ Kangaroo care (skin to skin contact) ➢ Primary prevention: Avoid drinking, smoking and unhealthy diet during pregnancy. Get the flu vaccine
111
UTEROPLACENTAL INSUFFICIENCY what are the causes of uteroplacental insufficiency?
➢Abnormal trophoblast invasion: ▪ Pre-eclampsia ▪ Placenta accreta ➢ Abruption ➢ Infarction ➢ Placenta previa ➢ Tumor: chorioangiomas ➢ Abnormal umbilical cord or cord insertion (i.e., two vessel cord) ➢ Maternal diabetes ➢ Maternal hypertension ➢ Anemia ➢ Smoking ➢ Drug abuse (cocaine, heroin, methamphetamine) ➢ Antiphospholipid syndrome ➢ Renal disease ➢ Advanced age
112
UTEROPLACENTAL INSUFFICIENCY what are the investigations?
➢ USS ➢ Maternal alpha fetoprotein levels ➢ CTG
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PUERPERAL INFECTION what are the non-genital causes?
1. Breast causes (mastitis, abscess) 2. UTI (i.e., from catheter, hypotonic bladder, KEEPS bacteria) 3. Thrombophlebitis (high risk of DVT and PE) 4. Respiratory complications (mainly women with CS; due to atelectasis, aspiration, or bacterial pneumonia) – hence the need for prophylactic antibiotics before CS! 5. Abdominal wound infection
114
PUERPERAL INFECTION what is the management?
➢ Supportive (analgesics/NSAIDS, wound care, ice packs...) ➢ Antibiotics (for endometritis – IV clindamycin and gentamicin until >24hrs afebrile) ➢ Surgical (drain abscess, secondary repair of wound, drainage of hematomas...)
115
OBSTRUCTED LABOUR What are the different types of causes of obstructed labour?
- Power (most common) - Passage - Passenger - Psyche (maternal exhaustion in second stage)
116
CHLAMYDIA IN PREGNANCY what are the risks of chlamydia infection during pregnancy?
- preterm labour - PROM - low birth weight - infection during delivery (conjunctivitis and pneumonia)
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CHLAMYDIA IN PREGNANCY what is the management?
- azithromycin 1g OD followed by 500mg orally OD for 2 days - erythromycin 500mg QD for 7 days - amoxicillin 500mg TD for 7 days
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GONORRHOEA IN PREGNANCY what are the risks?
- miscarriage - premature birth - low birth weight - PROM - chorioamnionitis - eye infection in newborn
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GONORRHOEA IN PREGNANCY? what is the management?
500mg ceftriaxone IM single dose
120
SYPHILIS IN PREGNANCY what are the risks?
congenital syphilis - premature births - still births - multi-organ problems to brain, eyes, heart, skin, teeth and bones
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SYPHILIS IN PREGNANCY what is the management?
penicillin
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TRICH VAGINALIS IN PREGNANCY what are the risks?
- PROM - preterm births - low birth weight - female newborns can acquire infection during birth
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TRICH VAGINALIS IN PREGNANCY what is the management?
metronidazole
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UTIs IN PREGNANCY what are the treatments?
* Oral antibiotics - Asymptomatic bacteriuria: 3 days - Cystitis 7 days
125
UTIs IN PREGNANCY what is the management of pyelonephritis?
antibiotics (IV) for 10-14 days - Pyelonephritis needs IV antibiotics until pyrexia settles and vomiting stops. IV fluids and antipyretics too.
126
UTIs IN PREGNANCY which antibiotics should be avoided in first trimester and why?
trimethoprim it is a folate antagonist so can reduce folate levels
127
UTIs IN PREGNANCY which antibiotics should be avoided in the third trimester and why?
- nitrofurantoin - risk of haemolytic anaemia in newborn with G6PD - sulfonamides - risk of kernicterus in newborn due to displacement of protein binding of bilirubin
128
UTIs IN PREGNANCY which antibiotics are contraindicated in pregnancy?
- tetracyclines - cause permanent staining of teeth and problems with skeletal development - ciprofloxacin - causes skeletal problems
129
CEPHALOPELVIC DISPROPORTION what can increase the risk?
- flat (platypelloid) pelvic opening - heart-shaped (android) pelvis

A TO REVISE - PHASE 3A (16 decks)

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