Passmed textbook - Obstetrics Flashcards
Breastfeeding - methods to suppress lactation
stop the lactation reflex i.e. stop suckling/expressing
supportive measures: well-supported bra and analgesia
cabergoline
Minor problems during breastfeeding
- Nipple pain - poor latch
- Blocked duct
Causes nipple pain when breastfeeding
Breastfeeding should continue
Give advice about the positioning of the bab
Breast massage - Nipple candidiasis
Treatment:
Miconazole cream for mother
Nystatin suspension for baby
Mastitis management
Affects 1 in 10 breasfeeding women
Treat if
- Systemically unwell
- Nipple fissure present
- symptoms do not improve after 12-24h of effective milk removal
- culture indicates infection
- Flucloxacillin for 10-14 days
- Breastfeeding/expressing should continue during the treatment
If mastits remains untreated –> breast abscess development –> incision + drainage
What is breast engorgement?
One of the causes of breast pain in breastfeeding women
Occurs in the first few days after birth
Almost always affects both breasts
Pain/Discomfort worse just before a feed
Fever - settles within 24h
Red breasts
Milk tends to not flow well from an engorged breast –> infant may find it difficult to attach + suckle
Complications of breast engorgement
Blocked milk ducts
Mastitis
Difficulties breastfeeding
Milk supply
Mx of breast engorgement
Hand expression of milk
Describe the symptoms of Raynaud’s disease of the nipple
- Intermittent pain
- Pain present during + immediately after feeding
- Blanching of nipple followed by cyanosis +/or erythema
- Nipple pain resolves when nipples return to normal colour
Management of Raynaud’s disease of the nipple
- Minimise exposure to the cold
- Use of heat packs following breastfeed
- Avoid caffeine
- Stop smoking
if symptoms persist
- refer to a specialist
- oral nifedipine
What is the cut-off weight loss for newborns in the first week of life?
10%
What might loss of more than the cut-off weight in newborns in the first week of life inidcate ?
Losing >10% of birth weight in the first week of life - consider referral to a midwife led breastfeeding clinic
-Should prompt consideration of breast feeding problems:
Poor latching Blocked duct Nipple candidiasis Mastitis Breast abscess Engorgement Raynaud's disease of the nipple
- Examine the infant to look for underlying problems
- Expert review of feeding (midwife-led breastfeeding clinics)
- Monitor wright until weight gain is satisfactory
Breastfeeding contra-indications (not drug-related)
- Galactosaemia*
- Viral infections
*Galactosaemia is an inherited metabolic disease caused by defects in galactose metabolism
Symptoms in babies start to show up within a few days after they begin to drink breast milk or formula with lactose – the milk sugar that contains galactose. They lose their appetite and starts vomiting.
Breastfeeding contra-indications (drug-related)
o Antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides o psychiatric drugs: lithium, benzodiazepines o HTN – ARBs, ACEi, amlodipine, statins o aspirin o carbimazole o methotrexate o sulfonylureas o cytotoxic drugs o amiodarone
Drugs allowed in women who are breastfeeding
o Antibiotics o Endocrine o Epilepsy o Asthma o Psychiatric drugs o Hypertension o Anticoagulants
The following drugs can be given to mothers who are breastfeeding:
o Antibiotics: penicillins, cephalosporins, trimethoprim
o Endocrine: glucocorticoids (avoid high doses), levothyroxine*
o Epilepsy: sodium valproate, carbamazepine
o Asthma: salbutamol, theophyllines
o Psychiatric drugs: tricyclic antidepressants, antipsychotics**
o Hypertension: beta-blockers, hydralazine
o Anticoagulants: warfarin, heparin
o Digoxin
*the BNF advises that the amount is too small to affect neonatal hypothyroidism screening
**clozapine should be avoided
Abdominal pain in early pregnancy causes
Ectopic pregnancy RF Damage to tubes (salpingitis, surgery) Previous ectopic IVF (3% of pregnancies are ectopic)
Typical hx: female with a hx of 6-8 weeks amenorrhoea who presents with lower abdominal pain + later develops vaginal bleeding
pain first symptoms constant unilateral due to tubal spasm
vaginal bleeding
less than a normal period
may be dark brown in colour
hx of recent amenorrhoea
typically 6-8 weeks from start of LMP
If longer (e.g. 10 weeks) - this suggests another cause e.g. inevitable abortion
peritoneal bleeding - shoulder tip pain + pain on defecation/urination
Miscarriage
Threatened
- painless vaginal bleeding <24 weeks, typically at 6-9 weeks
- cervical os is closed
- complicates up to 25% of all pregnanies
Missed/delayed miscarriage
- gestational sac with dead fetus before 20 weeks without the symptoms of expulsion
- light vaginal bleeding/discharge
- symptoms of pregnancy disappear
- if gestational sac >25mm + no embryonic/fetal part can be seen - described as “blighted ovum” or “anembryonic pregnancy”
Inevitable miscarriage
- Cervical os is open
- Heavy bleeding with clots and pain
Incomplete miscarriage
- not all products of conception have been expelled
Abdominal pain in late pregnancy causes
Labour
- regular tightening of the abdomen
- may be painful in later sages
Placental abruption
- separation of a normally sited placenta from the uterine wall
- maternal haemorrhage into the intervening space
- occurs in 1/200 pregnancies
- shock out of keeping with visible loss
- constant pain
- tense, tender, “woody” uterus
- normal lie + presentation
- fetal heart - absent/distressed
- coagulation problems
- beware pre-eclampsia, DIC, anuria
Symphysis pubis dysfunction
- Ligament laxity increases in response to hormonal changes of pregnancy
- pain over the pubic symphysis with radiation to the groins + the medial aspects of the thighs
- waddling gait
Pre-eclampsia/HELLP syndrome
- Associated with hypertension/proteinuria
- HELLP - haemolysis, elevated liver enzymes, low platelet count
- pain is typically epigastric or in the RUQ
Uterine rupture - Ruptures usually occur during labour but can also occur in the third trimester - RF Previous C-section - Maternal shock - Abdominal pain - Vaginal bleeding to varying degree
Abdominal pain at any point in pregnancy causes
Appendicitis
- Location of pain changes depending on gestation, moving up from the RLQ in the first trimester to the umbilicus in the second to the RUQ in the third
UTI
- Associated with an increased risk of pre-term delivery + IUGR
What is alpha-fetoprotein (AFP) and what does it mean if it’s increased vs decreased?
AFP is a protein produced by the developing fetus
Increased AFP
- Neural tube defects (meningocele, myelomeningocele, anencephaly)
- Abdominal wall defects (omphalocele, gastroschisis)
- Multiple pregnancy
Decreased AFP
- Down’s syndrome
- Trisomy 18 (Edward’s syndrome)
- Maternal DM
Define amniotic fluid embolism
Symptoms
Diagnosis
Management
When fetal cells/amniotic fluid enters the mother’s bloodstream and stimulates a reaction which results into
Chills, Shivering, Sweating, Anxiety, Coughing
Cyanosis, hypotension, bronchospasms, tachycardia, arrhythmia, MI
Diagnosis - clinical diagnosis of exclusion
Management -
critical care unit by a multidisciplinary team
Management is predominantly supportive
Aetiology/RF for amniotic fluid embolism
Maternal age
IOL
Lifestyle advice for antenatal care
Nutritional supplements
Alcohol
Smoking
Food-acquired infections
Work
Air travel during pregnancy
Prescribed medicines
OTC medicines
Complimentary therapies
Exercise in pregnancy
sexual intercourse
Nutritional supplements
o Pregnacare is what women take - multivitamins + minerals
- Folic acid 400mcg
o from conception until 12w
o reduces the risk of NTD
o certain women require higher doses - Vitamin D
o 10mcg per day
o particular care should be taken with higher risk women (those with darker skin or who cover their skin for cultural reasons, asian, obese, poor diet) - What should not be offered
o iron supplementation should not be offered routinely
o vitamin A might be teratogenic
Alcohol
- pregnant women should not drink
Smoking
- risks of smoking : low birthweight, preterm birth
- Nicotine replacement therapy may be used - women must have stopped smoking + risks/benefits need to be discussed
Varenicline or bupropion should not be offered to pregnant/breastfeeding women
Food-acquired infections
- Listeriosis - avoid unpasteurised milk, ripened soft cheeses, pate or undercooked meat
- Salmonella - avoid raw or partially cooked eggs and meat, esp. poultry
Work
- Inform women of their maternity rights + benefits
- conduct the health + safety executive if there are any concerns about possible occupational hazards during pregnancy
Air travel during pregnancy
- women >37 weeks with singleton pregnancy + no additional RF should avoid air travel
- women with uncomplicated, multiple pregnancies should avoid travel by air once >32 weeks
- increased risk of VTE
- Wear correctly fitted compression stockings
Prescribed medicines
- Avoid unless benefits outweigh risks
OTC medicines
- should be used as little as possible during pregnancy
Complimentary therapies
- should be used as little as possible during pregnancy
Exercise in pregnancy
- beginning or continuing moderate exercise is not associated with adverse outcomes
- high impact sports + scuba diving should be avoided
sexual intercourse
- not known to be associated with any adverse outcomes
Nausea and vomiting in pregnancy NVP mx
Natural remedies - ginger, acupuncture on the p6 point (by the wrist) are recommended by NICE
Antihistamines should be used as first-line
(promethazine as first line)
How many antenatal visits should take place in
the first pregnancy if uncomplicated
in subsequent pregnancies if uncomplicated
and who should see theses women
the first pregnancy if uncomplicated - 10 antenatal visits
in subsequent pregnancies if uncomplicated - 7 antenatal visits
women do not need to be seen by a consultant if the pregnancy is uncomplicated
Antenatal care timetable
8-12 weeks (ideally <10 weeks) 10-13+6 weeks 11-13+6 weeks 16 weeks 18-20+6 weeks
8-12 weeks (ideally <10 weeks)
o Booking visit
- general info e.g. diet, alcohol, smoking, folic acid, vitamin D
o BP, urine dipstick, check BMI
Booking bloods/urine
- FBC, blood group, rhesus status, red cell alloantibodies, haemorglobinopathies
- Hep B, syphillis
- HIV test
- urine culture to detect asymptomatic bacterituria
10-13+6 weeks
o to confirm dates
o to exclude multiple pregnancies
11-13+6 weeks
o DS screening incl. nuchal scan
16 weeks
o At every appointment, you do: BP, BMI, Urine dip
o Info on the anomaly
o Info on blood results
o if Hb <11g/dl consider iron
o Pertussis vaccine give now
o OGTT if Hx of previous gestational diabetes
18-20+6 weeks
o Anomaly scan
Antenatal care timetable
25 weeks 28 weeks 31 weeks 34 weeks 36 weeks 38 weeks 40 weeks 41 weeks
25, 31, 40w only if primip
25 weeks
o Only if primip
o Routine care: BP, urine dipstick, SFH (symphisis fundal height)
28 weeks
o Routine care: BP, urine, SFH
o Second screen for anaemia + atypical red cel alloantibodies
o If Hb <10.5 g/dl - consider iron
o First dose anti-D prophylaxis to rhesus -ve women
31 weeks
o Only if primip
o Routine care: BP, urine dipstick, SFH (symphisis fundal height)
34 weeks
o Routine care: BP, urine dipstick, SFH (symphisis fundal height)
o Second dose of anti-D prophylaxis to rhesus negative women
o Information on labour + birth plan
36 weeks
o Routine care: BP, urine dipstick, SFH (symphisis fundal height)
o Check presentation (offer ECV if indicated)
o Information on breast feeding, vitamin K, baby-blues
38 weeks
o Routine care: BP, urine dipstick, SFH (symphisis fundal height)
40 weeks
o Only if primip
o Routine care: BP, urine dipstick, SFH (symphisis fundal height)
o Discussion about options for prolonged pregnancy
41 weeks
o Routine care: BP, urine dipstick, SFH (symphisis fundal height)
o Discuss labour plans + possibility of induction
First dose of anti-D prophylaxis to rhesus -ve women
Second dose of anti-D prophylaxis to rhesus -ve women
First dose - 28 weeks
Second dose - 34 weeks
For which conditions should all pregnant women be offered screening for?
- Anaemia
- Bacteriuria
- Blood group, Rhesus status and anti-red cell antibodies
- Down’s syndrome
- Fetal anomalies
- Hepatitis B
- HIV
- Neural tube defects
- Risk factors for pre-eclampsia
- Syphilis
The following should be offered depending on the history:
Placenta praevia Psychiatric illness Sickle cell disease Tay-Sachs disease Thalassaemia
For which conditions should all pregnant women not be offered screening for?
Bacterial vaginosis Chlamydia Cytomegalovirus Fragile X Hepatitis C Group B Streptococcus Toxoplasmosis
Define antepartum haemorrhage
bleeding from the genital tract after 24 weeks pregnancy, prior to delivery of the fetus
How to distinguish placental abruption from placenta praevia
Placental abruption
- Shock out of keeping with visible loss (there might be a concealed haemorrhage)
- constant pain
- tender, tense, woody uterus
- normal life + presentation
- fetal heart - absent/distressed
- coagulation problems
- beware of pre-eclampsia, DIC, anuria
Placenta praevia
- shock in proportion to visible loss
- no pain
- uterus not tender
- lie + presentation may be abnormal
- fetal heart usually normal
- coagulation problems rare
- small bleeds before large
Vaginal examination (bimanual) should not be performed in primary care for suspected antepartum haemorrhage - women with placenta praevia may haemorrhage
Causes of bleeding during
the first trimester
the second trimester
the third trimester
first
- Miscarriage
- Ectopic
- Hydatidiform mole
second
- Miscarriage
- Hydatidiform mole
- Placental abruption
third
- Bloody show (labour or pre-term labour)
- Placental abruption
- Placenta praevia
- Vasa praevia
other causes
- STIs, cervical cancer, fibroids, polyps etc.
Describe vasa praevia
Rupture of membranes followed immediately by vaginal bleeding
Fetal bradycardia is classically seen
Hydatidiform mole symptoms + signs
Typically bleeding in first or early second trimester associated
Exaggerated symptoms of pregnancy e.g. hyperemesis
The uterus may be large for dates
Serum hCG is very high
Describe breech presentation
frank vs footling breech
The caudal end of the fetus occupies the lower segment
25% of pregnancies at 28 weeks are breech but it only occurs in 3% of babies near term
Frank breech
- most common presentation
- Hips flexed
- Knees fully extended
Footling breech
- One or both feet come first with the bottom at a higher position
- Rare but carries a higher perinatal morbidity
RF for breech presentation
- uterine malformations, fibroids
- placenta praevia
- polyhydramnios or oligohydramnios
- fetal abnormality (e.g. CNS malformation, chromosomal disorders)
- prematurity (due to increased incidence earlier in gestation)
What is more common in breech presentations?
Cord prolapse
Breech presentation management
if < 36 weeks: many fetuses will turn spontaneously
if still breech at 36 weeks
- External cephalic version (ECV)
Success rate of around 60%.
The RCOG recommend ECV should be offered from
36 weeks in nulliparous women
37 weeks in multiparous women
if the baby is still breech then delivery options include planned caesarean section or vaginal delivery
Absolute contraindications to ECV
- where caesarean delivery is required
- APH within the last 7 days
- abnormal CTG
- major uterine anomaly
- ruptured membranes
- multiple pregnancy
Which are the two types of C-sections?
Lower segment C-section
Classical C-section
- Longitudinal incision in the upper segment of the uterus
Indications for a C-section
- Cephalopelvic disproportion (absolute indication)
- placenta praevia grades 3/4
- pre-eclampsia
- post-maturity
- IUGR
- fetal distress in labour/prolapsed cord
- failure of labour to progress
- malpresentations: brow
https: //els-jbs-prod-cdn.jbs.elsevierhealth.com/cms/attachment/51ca00dd-455f-45c6-ba77-b45b242cda95/gr4_lrg.jpg - placental abruption: only if fetal distress; if dead deliver vaginally
- vaginal infection e.g. active herpes
- cervical cancer (disseminates cancer cells)
Frequent risks of a C-section
Maternal
o Persistent wound + abdominal discomfort in the first few months after surgery
o increased risk of repeat caesarean section when vaginal delivery attempted in subsequent pregnancies
o readmission to hospital
o haemorrhage
o infection (wound, endometritis, UTI)
o prolonged ileus
o subfertility: due to postoperative adhesions
Fetal:
o lacerations, one to two babies in every 100
Serous risks of a C-section
Maternal o emergency hysterectomy o need for further surgery at a later date, including curettage (retained placental tissue) o admission to intensive care unit o thromboembolic disease o bladder injury o ureteric injury o death (1 in 12,000)
Future pregnancies
o increased risk of uterine rupture during subsequent pregnancies/deliveries
o increased risk of antepartum stillbirth
o increased risk in subsequent pregnancies of placenta praevia and placenta accreta
VBAC (vaginal birth after C-section)
Success rate
Contraindications
Success rate = 70-75%
Contraindications
- Previous uterine rupture
- Classical caesarean scar
CTG cardiotocography - what does it record?
pressure change in the uterus using internal or external pressure transducers
records fetal heart rate + contractions
What is the normal fetal hear rate?
100-160 bpm
What things do you look at when interpreting a CTG?
DR C BRAVADO
DR - Define risk "low" or "high" C- contractions [frequency, duration] BR - baseline rate [brady/tachy/normal] A- Accelerations [present/absent] V - Variability [5-10 bpm] D - Decelerations [early/variable/late] O - Overall impression + management
Abnormalities in CTG
Describe + identify causes
Baseline bradycardia
Heart rate <100bpm
- Increased fetal vagal tone
- Maternal beta blocker use
Abnormalities in CTG
Describe + identify causes
Baseline tachycardia
Heart rate >160/min
- Maternal pyrexia
- Chorioamnionitis
- Hypoxia
- Prematurity
Abnormalities in CTG
Describe + identify causes
Loss of baseline variability
<5 beats/min
- Prematurity
- Hypoxia
Abnormalities in CTG
Describe + identify causes
Early deceleration
Deceleration of the heart rate which commences with the onset of a contraction + returns to normal on completion of the contraction
- Usually an innocuous feature
- Indicates head compression
Abnormalities in CTG
Describe + identify causes
Late deceleration
Deceleration of the heart rate which lags the onset of a contraction and does not return to normal until after 30 seconds following the end of the contraction
- Indicates fetal distress
- e.g. asphyxia or placental insufficiency
Abnormalities in CTG
Describe + identify causes
Variable decelerations
Independent of contractions
- May indicate cord compression
Chickenpox exposure in pregnancy
- What is it chickenpox caused by?
- What is Shingles caused by?
- Why is it risky during pregnancy?
Chickenpox - Caused by primary infection with the varicella-zoster virus
Shingles - caused by reactivation of dormant virus in dorsal root ganglion
Pregnancy
- fetal varicalla syndrome
- risk to both the mother + the fetus
What is the fetal varicalla syndrome (FVS)?
Risk + features
Risk of FVS following maternal varicella exposure is around 1% if occurs before 20 weeks gestation
Very small number of cases occurring between 20-28 weeks gestation
None following 28 weeks
features Skin scarring Eye defects (microphthalmia) Limb hypoplasia Microcephaly Learning disabilities
Chicken pox exposure in pregnancy
risk to mother
risk to fetus
risk to mother and fetus - fetal varicella syndrome
risk to mother
- 5 times greater risk of pneumonitis
risk to fetus
- shingles in infancy: 1-2% risk if maternal exposure in the second or third trimester
- severe neonatal varicella: if the mother develops rash between 5 days before and 2 days after birth there is a risk of neonatal varicella, which may be fatal to the newborn child in around 20% of cases
Management of chickenpox exposure in pregnancy
Management of chickenpox exposure in pregnancy, i.e. post-exposure prophylaxis (PEP)
- Maternal blood should be urgently checked for varicella antibodies (if in doubt about the mother previously having chickenpox)
- if the pregnant woman less than or 20 weeks gestation is not immune to varicella –> give varicella-zoster immunoglobulin (VZIG) asap
VZIG is effective up to 10 days post exposure - if the pregnant woman > 20 weeks gestation is not immune to varicella then
either VZIG or
antivirals (aciclovir or valaciclovir) should be given days 7 to 14 after exposure
Management of chickenpox in pregnancy
Specialist advice should be sought
Increased risk of serious chickenpox infection (i.e. maternal risk) and fetal varicella risk (i.e. fetal risk) balanced against theoretical concerns about the safety of aciclovir in pregnancy
Oral aciclovir
- if the woman is < 20 weeks the aciclovir should be ‘considered with caution’
- given if the pregnant women is ≥ 20 weeks and she presents within 24 hours of onset of the rash
Define chorioamnionitis
aetiology
major risk factor
management
- bacteria infect the chorion and amnion (the membranes that surround the fetus) and the amniotic fluid (in which the fetus floats)
- potentially life-threatening condition to both mother and foetus
- Considered a medical emergency
- Can affect up to 5% of all pregnancies
- Usually the result of an ascending bacterial infection of the amniotic fluid / membranes / placenta
Major risk factor –> is the preterm premature rupture of membranes –> exposure of the normally sterile environment of the uterus to potential pathogens
It can still occur when the membranes are still intact
Prompt delivery of the foetus (via cesarean section if necessary) + administration of IV abx
Define cord prolapse
What can happen if cord prolapse is left untreated?
Cord prolapse involves the umbilical cord descending ahead of the presenting part of the fetus
Occurs in 1/500 deliveries
Left untreated, this can lead to
- Compression of the cord or cord spasm –> fetal hypoxia –> irreversible damage or death
RF for cord prolapse
- prematurity
- multiparity
- polyhydramnios
- twin pregnancy
- cephalopelvic disproportion
- abnormal presentations e.g. Breech, transverse lie
- placenta praevia
- long umbilical cord
- high fetal station
Diagnosis of cord prolapse
The majority of cord prolapses occur at artificial rupture of the membranes
The diagnosis is usually made when the fetal heart rate becomes abnormal and the cord is palpable vaginally, or if the cord is visible beyond the level of the introitus
Management of cord prolapse
- Presenting part of the fetus may be pushed back into the uterus to avoid compression
- Tocolytics ro reduce compression and allow CS
If the cord is past the level of the introitus
• Should be kept warm + moist
• Should not be pushed back inside
• Patient is asked to go on ‘all fours’ until preparations for an immediate caesarian section have been carried out
• Immediate C-section
Usual first-line method of delivery
Instrumental vaginal delivery is possible if the cervx is fully dilated + the head is low
Antenatal testing for Down’s syndrome, trisomy 18, trisomy 13
Standard: combined test
- nuchal translucency measurement + serum B-HCG + pregnancy-associated plasma protein A (PAPP-A)
- should be done between 11 - 13+6 weeks
- Down’s syndrome = ↑ HCG, ↓ PAPP-A, thickened nuchal translucency
- Trisomy 18 (Edward syndrome) and 13 (Patau syndrome) give similar results but the PAPP-A tends to be lower
For women who book later in pregnancy:
• Triple or quadruple test should be offered between 15 - 20 weeks
• triple test: alpha-fetoprotein, unconjugated oestriol, human chorionic gonadotrophin
• quadruple test: alpha-fetoprotein, unconjugated oestriol, human chorionic gonadotrophin and inhibin-A
Define pre-eclampsia and eclampsia
Pre-eclampsia - a condition seen after 20 weeks gestation
pregnancy-induced hypertension
proteinuria
Eclampsia - The development of seizures in association pre-eclampsia
Magnesium sulphate in the treatment of severe pre-eclampsia or eclampsia
- Used to both prevent seizures in patients with severe pre-eclampsia and treat seizures once they develop
- Should be given once a decision to deliver has been made
Eclampsia
• IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour
• Treatment should continue for 24h after last seizure or delivery
• Monitor UO, reflexes, RR, O2 sat during treatment
Respiratory depression can occur
Management of magnesium sulphate induced respiratory depression
• Calcium gluconate
Other important aspects of treating severe pre-eclampsia/eclampsia include fluid restriction to avoid the potentially serious consequences of fluid overload
Management of epilepsy in pregnancy + SE of anti-epileptic medication
sodium valproate
carbamazepine
phenytoin
lamotrigine
- Folic acid 5mg per day well before pregnancy to minimise the risk of neural tube defects
- Aim for monotherapy
- No indication to monitor antiepileptic drug levels
- Pregnant women taking phenytoin are given vitamin K in the last month of pregnancy to prevent clotting disorders in the newborn
sodium valproate - NTD
carbamazepine - the least teratogenic of the older antiepileptics
phenytoin - cleft palate
lamotrigine - rate of congenital malformations may be low
Dose of lamotrigine may need to be increased in pregnancy
Breast feeding in epilepsy
Breast feeding is generally considered safe for mothers taking antiepileptics with the possible exception of the barbiturates
Use of sodium valproate in pregnancy
Significant risk of neurodevelopmental delay in children
Sodium valproate should not be used during pregnancy and in women of childbearing age unless clearly necessary
Women of childbearing age should not start treatment without specialist neurological or psychiatric advice
How to prevent neural tube defects (NTD) in pregnancy
- 400mcg of folic acid until the 12th week of pregnancy
- women at higher risk of conceiving a child with a NTD should take 5mg of folic acid from before conception until the 12th week of pregnancy
women are considered higher risk if any of the following apply: • either partner has a NTD • previous pregnancy affected by a NTD • family history of a NTD • antiepileptic drugs • coeliac disease • diabetes • thalassaemia trait • obesity ( [BMI] of 30 kg/m2 or more).
Causes and consequences of folic acid deficiency
Causes of folic acid deficiency: phenytoin methotrexate pregnancy alcohol excess
Consequences of folic acid deficiency:
macrocytic, megaloblastic anaemia
neural tube defects
What is the function of folic acid?
Folic acid is converted to tetrahydrofolate (THF). Green, leafy vegetables are a good source of folic acid.
Functions
THF plays a key role in the transfer of 1-carbon units (e.g. methyl, methylene, and formyl groups) to the essential substrates involved in the synthesis of DNA & RNA
Indications for a forceps delivery
- fetal distress in the second stage of labour
- maternal distress in the second stage of labour
- failure to progress in the second stage of labour
- control of head in breech deliver
Describe galactocele
How to differentiate galactocele from an abscess?
Typically occurs in women who have recently stopped breastfeeding
Due to occlusion of a lactiferous duct –> build up of milk creates a cystic lesion in the breast
The lesion can be differentiated from an abscess by the fact that a galactocele is usually painless, with no local or systemic signs of infection.
RF for gestational diabetes
- BMI of > 30 kg/m²
- previous macrosomic baby weighing 4.5 kg or above
- previous gestational diabetes
- first-degree relative with diabetes
- family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
Screening for gestational diabetes
Women who’ve previously had gestational diabetes: • • OGTT should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal
• Early self-monitoring of blood glucose is an alternative to the OGTTs
women with any of the other risk factors should be offered an OGTT at 24-28 weeks
