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
Diagnostic thresholds for gestational diabetes
Gestational diabetes is diagnosed if either:
fasting glucose is >= 5.6 mmol/L
2-hour glucose is >= 7.8 mmol/L
Management of gestational diabetes
Management of gestational diabetes
• newly diagnosed women should be seen in a joint diabetes and antenatal clinic within a week
• women should be taught about self-monitoring of blood glucose
• advice about diet (including eating foods with a low glycaemic index) and exercise should be given
• Fasting plasma glucose level is < 7 mmol/l
o Trial of diet and exercise - 1st line
o Start metformin - 2nd line
If glucose targets are not met within 1-2 weeks of altering diet/exercise
o Add insulin - 3rd line
If glucose targets are still not met
Gestational diabetes is treated with short-acting, not long-acting, insulin
• Fasting glucose level is >= 7 mmol/l
o Start insulin
• Plasma glucose level is between 6-6.9 mmol/l + evidence of complications (e.g. macrosomia, hydramnios)
Insulin should be offered
o Glibenclamide should only be offered for women who cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment
Targets for self monitoring of pregnant women (pre-existing and gestational diabetes)
Fasting - 5.3 mmol/l
1 hour after meals - 7.8 mmol/l
2 hour after meals - 6.4 mmol/l
Management of pre-existing diabetes in pregnancy
- Weight loss for women with BMI of > 27 kg/m^2
- Folic acid 5 mg/day from pre-conception to 12 weeks gestation
- Stop oral hypoglycaemic agents, apart from metformin
- Commence insulin
- Detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts
- tight glycaemic control reduces complication rates
- treat retinopathy as can worsen during pregnancy
Pathophysiology of gestational thrombocytopenia
-Common condition in pregnancy
Resuls from
- Dilution
- Decreased production of platelets
- Increased destruction of platelets (increased work of maternal spleen –> mild sequestration)
What is ITP (immune thrombocytopenia)?
- Autoimmune condition
- Associated with acute purpuric episodes in children
- Chronic relapsing course may be seen more frequently in women
How to differentiate gestational thrombocytopenia from immune thrombocytopenia
Gestational thrombocytopenia
- Platelet count continues to fall as the pregnancy progresses (not a reliable sign)
- Does not affect neonates
ITP
- If the patient becomes dangerously thrombocytopenic - treat with steroids + dx ITP
- Pregnant women found to have low plt during booking vist or those with a previous dx of ITP –> tested for serum antiplatelet antibodies for confirmation
- Can affect neonates if maternal antibodies cross the placenta
Depending on the degree of thrombocytopenia in the newborn - plt transfusions may be indicated
Serial plt counts performed to see whether there is an inherited thrombocytopenia
What is gestational trophoblastic disease?
Describes a spectrum of disorders originating from the placental trophoblast:
complete hydatidiform mole
partial hydatidiform mole
choriocarcinoma
What is a complete hydatidiform mole?
Benign tumour of trophoblastic material.
Occurs when an empty egg is fertilized by a single sperm that then duplicates its own DNA, hence the all 46 chromosomes are of paternal origin
Less commonly an empty ovum is fertilised by 2 sperms
What is a partial hydatidiform mole?
In a partial mole a normal haploid egg may be fertilized by two sperms, or by one sperm with duplication of the paternal chromosomes. Therefore the DNA is both maternal and paternal in origin. Usually triploid - e.g. 69 XXX or 69 XXY. Fetal parts may be seen
Features of a complete hydatidiform mole
Features
- bleeding in first or early second trimester
- exaggerated symptoms of pregnancy e.g. hyperemesis
- uterus large for dates
- very high serum hCG
- hyperthyroidism (hGC can mimic TSH)
- hypertension
Management of a complete hydatidiform mole
- urgent referral to specialist centre
- evacuation of the uterus is performed
- effective contraception is recommended to avoid pregnancy in the next 12 months
Around 2-3% go on to develop choriocarcinoma
What is Group B streptococcus?
- most common cause of early-onset severe infection in the neonatal period
- around 20-40% of mothers have GBS present in their bowel flora –> ‘carriers’ of GBS
- Infants may be exposed to maternal GBS during labour –> can develop potentially serious infections
RF for GBS (group B strep) infection
- prematurity
- prolonged rupture of the membranes
- previous sibling GBS
- infection
- maternal pyrexia e.g. secondary to chorioamnionitis
Management of GBS (group B strep)
- universal screening for GBS should not be offered to all women
- maternal request is not an indication for screening
Swabs for GBS
o Should be offered at 35-37 weeks or 3-5 weeks prior to the anticipated delivery date
• women who’ve had GBS detected in a previous pregnancy
o risk of maternal GBS carriage in this pregnancy is 50%
o Should be offered intrapartum antibiotic prophylaxis (IAP) OR testing in late pregnancy and then antibiotics if still positive
IAP
o Women with a previous baby with early- or late-onset GBS disease
o Women in preterm labour regardless of their GBS status
o Women with a pyrexia during labour (>38ºC)
o Benzylpenicillin is the antibiotic of choice for GBS prophylaxis
If it is isolated during the antenatal period, it does not require treatment immediately, as it will not reduce the likelihood of colonisation at delivery.
In which circumstances is IAP (intrapartum antibiotic prophylaxis) given and which is the abx of choice for GBS prophylaxis?
o Women with a previous baby with early- or late-onset GBS disease
o Women in preterm labour regardless of their GBS status
o Women with a pyrexia during labour (>38ºC)
o Benzylpenicillin is the antibiotic of choice for GBS prophylaxis
Features, investigations and treatment of HELLP syndrome
Features
nausea & vomiting
right upper quadrant pain
lethargy
Investigations
bloods:
Hemolysis
Low Platelet
Treatment
delivery of the baby
When does HELLP develop?
Late stages of pregnancy
What relationship does HELLP and pre-eclampsia have?
Significant overlap with severe pre-eclampsia in terms of the features
Some patients present with no prior history so many specialists consider it a separate entity in its own right
Around 10-20% of patients with severe preeclampsia will go on to develop HELLP
Hepatitis B and pregnancy
1) Who is offered screening?
2) How should a baby born to a chronically infected mother/mother who have had acute hep B during pregnancy be manages?
3) Can Hep B be transmitted via breastfeeding?
1) all pregnant women are offered screening for hepatitis B
2) Babies should receive a complete course of vaccination + hepatitis B immunoglobulin
3) hepatitis B cannot be transmitted via breastfeeding (in contrast to HIV)
How can vertical transmission of HIV be reduced during delivery?
- Screening
o HIV screening should be offered to all pregnant women - Maternal antiretroviral therapy
o all pregnant women should be offered antiretroviral therapy regardless of whether they were taking it previously - Mode of delivery
o Vaginal delivery
<50copies/ml at 36w
o C-section - zidovudine infusion should be started 4h before beginning the C-section - Neonatal antiretroviral therapy
o Zidovudine - administered orally to neonate if maternal viral load is <50copies/ml
o Triple ART - 4-6/52 - Bottle feeding instead of breastfeeding
hCG (human chorionic gonadotrophin)
- Where is it produced from?
- What is its main role?
- How do levels change throughout pregnancy?
- When do hcg levels peak in pregnancy?
- produced by the embryo and later by the placental trophoblast
- Its main role is to prevent the disintegration of the corpus luteum
- hCG levels double approximately every 48 hours in the first few weeks of pregnancy
- levels peak at around 8-10 weeks gestation
Which are the women at high risk of developing pre-eclampsia and how should they be managed?
o hypertensive disease during previous pregnancies
o CKD
o AI disorders e.g. SLE, APL
o T1DM/T2DM
Management
aspirin 75mg od from 12 weeks until the birth of the baby
What happens to the blood pressure of the mother during a normal pregnancy?
o blood pressure usually falls in the first trimester (particularly the diastolic), and continues to fall until 20-24 weeks
o after this time the blood pressure usually increases to pre-pregnancy levels by term
Define hypertension in pregnancy
systolic > 140 mmHg or diastolic > 90 mmHg
or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic
After establishing that the patient is hypertensive they should be categorised into one of the following groups
- Pre-existing HTN o Hx of HTN before pregnancy or elevated BP >140/90mmHg before 20 weeks gestation o No proteinuria, no oedema o Occurs in 3-5% of pregnancies o More common in older women
- Gestational HTN/Pregnancy induced HTN (PIH)
o elevated BP >140/90mmHg after 20 weeks gestation
o No proteinuria, no oedema
o Occurs in 5-7% of pregnancies
o Resolves following birth - typically after 1 month
o Women with PIH –> increased risk of future pre-eclampsia or HTN later in life - Pre-eclampsia
o PIH in association with proteinuria (>0.3g/24h) or Other maternal organ dysfunction
Renal insufficiency (Cr > 90micromol/L, >1.02mg/100ml)
Liver involvement ( transaminases – ALT or AST > 40IU/L) with or without RUQ or epigastric abdominal pain
Neurological complications (eclampsia, altered mental status, blindness, stroke, clonus, severe headaches, persistent visual scotomata)
Haematological complications (thrombocytopenia (plt < 150.000/microleter), DIC, or haemolysis)
Uteroplacental dysfunction e.g. IUGR, abnormal umbilical artery doppler waveform analysis, stillbirth
o Occurs in around 5% of pregnancies
Indications for induction of labour (IOL)
o prolonged pregnancy, e.g. 1-2 weeks after the estimated date of delivery
o prelabour premature rupture of the membranes, where labour does not start
o diabetic mother > 38 weeks
o pre-eclampsia
o rhesus incompatibility
Which score is used to decide whether induction of labour IOL will be required? + describe its components + interpretation
Bishop score
Cervical position
0 - Posterior
1 - Intermediate
2 - Anterior
Cervical consistency
0 - Firm
1 - intermediate
2 - Soft
Cervical effacement 0 - 0-30% 1 - 40-50% 2 - 60-70% 3 - 80%
Cervical dilation 0 - <1cm 1 - 1-2cm 2 - 3-4cm 3 - >5cm
Fetal station 0 - -3 1 - -2 2 - -1,0 3 - +1, +2
<5 - labour is unlikely to start without induction
≥ 8 - cervix is ripe or favourable - high chance of spontaneous labour, or response to interventions made to induce labour
How can you induce labour (induction of labour, IOL)
o Membrane sweep
Examining finger passing through the cervix to rotate against the wall of the uterus –> separates the chorionic membrane form the decidua
Can be done by the midwife in the AN clinic
Nulliparous women - offered this at 40 - 41 weeks
Parous women - offered this at 41 weeks
Regarded as an adjunct to IOL rather than an actual method of induction –> prior to formal IOL women should be offered a vaginal examination for membrane sweeping
o Vaginal prostaglandin E2 (PGE2)
Preferred method of IOL unless there are specific clinical reasons for not using it
o Maternal oxytocin infusion
o Amniotomy (breaking of waters)
o Cervical ripening balloon
Passed through the endocervical canal - gently inflated to dilate the cervix
Main complication of IOL + management
Main complication of IOL –> uterine hyperstimulation
Uterine hyperstimulation –> prolonged + frequent uterine contractions - sometimes called tachysystole
potential consequences
- intermittent interruption of blood flow to the intervillous space over time –> fetal hypoxemia and acidemia
- uterine rupture (rare)
management
- removing the vaginal prostaglandins if possible
- stopping the oxytocin infusion
- tocolysis with terbutaline
Describe the features of intrahepatic cholestasis of pregnancy (obstetric cholestasis)
Features
o pruritus - may be intense - typical worse palms, soles and abdomen clinically detectable o jaundice (20% of patients) o raised bilirubin (> 90% of cases)
Which risk does intrahepatic cholestasis of pregnancy (obstetric cholestasis) increase?
What is the risk of recurrence of intrahepatic cholestasis of pregnancy in subsequent pregnancies?
Associated with an increased risk of premature birth
recurrence - 45-90% in subsequent pregnancies
management of intrahepatic cholestasis of pregnancy (obstetric cholestasis)
o IOL 37-38 weeks (common practice but may not be evidence based)
o ursodeoxycholic acid - widely used but evidence base not clear
o vitamin K supplementation
Define labour
the onset of regular and painful contractions associated with cervical dilation + descent of the presenting part
Signs of labour
o regular and painful uterine contractions
o a show (shedding of mucous plug)
o shortening and dilation of the cervix
o rupture of the membranes (not always)
The three stages of labour
stage 1: from the onset of true labour to when the cervix is fully dilated
stage 2: from full dilation to delivery of the fetus
stage 3: from delivery of fetus to when the placenta and membranes have been completely delivered
Monitoring in labour
o FHR monitored every 15min (or continuously via CTG)
o Contractions assessed every 30min
o Maternal pulse rate assessed every 60min
Every 4 hours
o Maternal BP and temp
o Vaginal examination to check progression of labour
o Maternal urine should be checked for ketones and protein
Latent phase vs active phase of labour in stage 1
Latent phase
- 0-3 cm dilation
- Normally takes 6 hours (0.5cm/hr)
Active phase
- 3-10 cm dilation
- Normally 1cm/hr
How does the head enter the pelvis and how it it normally delivered?
Head enters pelvis in occipito-lateral position
The head normally delivers in an occipito-anterior position
Passive second stage vs active second stage
Passive second stage - 2nd stage but in the absence of pushing
Active second stage - active process of maternal pushing
Labour stage 2
- how painful is it compared to stage 1?
- how long does it normally last?
- What should be done if that stage takes longer than anticipated?
- what might be necessary following crowning?
- How does the fetus respond to the second stage of labour?
- less painful than 1st (pushing masks pain)
- lasts approximately 1 hours
- if longer than 1 hour (can be left longer if epidural) consider Ventouse extraction, forceps delivery or caesarean section
- episiotomy may be necessary following crowning
- associated with transient fetal bradycardia
What is lochia?
Lochia may be defined as the vaginal discharge containing blood mucous and uterine tissue which may continue for 6 weeks after childbirth
Define oligohydramnios and least causes
o Reduced amniotic fluid
o <500ml at 32-36 weeks
o AFI (amniotic fluid index) <5th percentile
o Maximum vertical pocket (MVP) <2 cm from late mid-trimester
Causes
- PROM
- Fetal renal problems e.g. renal agenesis
- IUGR
- PET
- Post-term gestation
Classification of perineal tears
o first degree: superficial damage with no muscle involvement
o second degree: injury to the perineal muscle, but not involving the anal sphincter
o third degree: injury to perineum involving the anal sphincter complex (external anal sphincter, EAS and internal anal sphincter, IAS):
o 3a: less than 50% of EAS thickness torn
o 3b: more than 50% of EAS thickness torn
o 3c: IAS torn
o fourth degree: injury to perineum involving the anal sphincter complex (EAS and IAS) and rectal mucosa
RF for perineal tears
o primigravida o large babies o precipitant labour o shoulder dystocia o forceps delivery
Types of placenta accreta
Depend on the degree of invasion
accreta: chorionic villi attach to the myometrium, rather than being restricted within the decidua basalis
increta: chorionic villi invade into the myometrium
percreta: chorionic villi invade through the perimetrium
RF for placenta accreta
previous caesarean section
placenta praevia
Risk associated with placenta accreta
As the placenta does not properly separate during labour there is a risk of post-partum haemorrhage
Describe placenta accreta
Attachment of the placenta to the myometrium, due to a defective decidua basalis
Grading of placenta praevia
I - placenta reaches lower segment but not the internal os
II - placenta reaches internal os but doesn’t cover it
III - placenta covers the internal os before dilation but not when dilated
IV (‘major’) - placenta completely covers the internal os
Define placenta praevia + list the associated factors + epidemiology
Placenta praevia describes a placenta lying wholly or partly in the lower uterine segment
multiparity
multiple pregnancy
embryos are more likely to implant on a lower segment scar from previous caesarean section
5% will have low-lying placenta when scanned at 16-20 weeks gestation
incidence at delivery is only 0.5%, therefore most placentas rise away from cervix
Clinical features of placenta praevia
o shock in proportion to visible loss o no pain o uterus not tender o lie and presentation may be abnormal o fetal heart usually normal o coagulation problems rare o small bleeds before large
Ix for placenta praevia
o often picked up on the routine 20 week abdominal ultrasound
o use of transvaginal ultrasound improves the accuracy of placental localisation and is considered safe
Next steps if low-lying placenta at 20 week scan
o rescan at 34 weeks
o if present at 34w + grade I/II scan every 2 w
o final US at 36-37w to determine the mode of delivery
I - trial of vaginal delivery may be offered
III/IV - ELCS at 37-38 w
o if woman with known placenta praevia goes into labour prior to ELCS –> EMCS to reduce risk of PPH
Management of placenta praevia with bleeding
o admit
o ABC approach to stabilise the woman
o if not able to stabilise → emergency caesarean section
o if in labour or term reached → emergency caesarean section
Define placental abruption
separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space
occurs in approximately 1/200 pregnancies
Clinical features of placental abruption
o shock out of keeping with visible loss o pain constant o tender, tense uterus o normal lie and presentation o fetal heart: absent/distressed coagulation problems o beware pre-eclampsia, DIC, anuria
RF for placental abruption
o proteinuric hypertension o cocaine use o multiparity o maternal trauma o increasing maternal age
Management of placental abruption
Fetus alive and < 36 weeks
Fetus alive and > 36 weeks
Fetus dead
Fetus alive and < 36 weeks
o fetal distress: immediate caesarean
o no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation
Fetus alive and > 36 weeks
o fetal distress: immediate caesarean
o no fetal distress: deliver vaginally
Fetus dead
o induce vaginal delivery
Complications of placental abruption + prognosis
Maternal o shock o DIC o renal failure o PPH
Fetal
o IUGR
o hypoxia
o death
Prognosis
o associated with high perinatal mortality rate
o responsible for 15% of perinatal deaths
Screening for post-natal depression
Edinburgh Postnatal depression scale
- 10 item questionnaire
- Max score of 30
- Indicates how the mother has felt over the previous week
- > 13 - depressive illness of varying severity
- > 90% sensitivity +specificity
- incl. qs about self-harm
PHQ-9 score
- Nine item depression scale of the patient health questionnaire
- Items of the PHQ-9 are based directly on the nine diagnostic criteria for major depressive disorder in the DSM-IV
0-4 - none 5-9 - mild 10-14 - moderate 15-19 - moderately severe 20-27 - severe
Baby blues vs postnatal depression vs puerperal psychosis
Baby blues
o Seen in around 60-70% of women
o Typically seen on day 3, peak at 5th day, subside within 10 days
o more common in primips
o Mothers are characteristically anxious, tearful and irritable, poor concentration
o Reassurance and support, the health visitor has a key role
Postnatal depression
o Affects around 10% of women
o Most cases start within a month and typically peaks at 3 months
o Features are similar to depression seen in other circumstances
o Fears about baby’s health, maternal deficiencies, martial tensions incl. loss of sexual interest
o As with the baby blues reassurance and support are important
o CBT may be beneficial
o SSRIs such as sertraline and paroxetine may be used if symptoms are severe - whilst they are secreted in breast milk it is not thought to be harmful to the infant
o paroxetine - the low milk/plasma ratio
o fluoxetine is best avoided - long half-life
Puerperal psychosis
o Affects approximately 0.2% of women
o Onset usually within the first 2-3 weeks following birth
o Can take form of manic depression or schizophrenia
o Severe swings in mood (similar to bipolar disorder)
o Disordered perception (e.g. auditory hallucinations)
o There might be high suicidal drive
o Admission to hospital is usually required
o There is around a 25-50% risk of recurrence following future pregnancies
Post-partum thyroidits - the three stages
- Thyrotoxicosis
- Hypothyroidism
- Normal thyroid function (but high recurrence rate in future pregnancies)
Thyroid peroxidase antibodies are found in 90% of patients
Management of post-partum thyroiditis
Thyrotoxic phase is not usually treated with anti-thyroid drugs as the thyroid is not overactive
o Propylthiouracil
Present in breast milk but this does not preclude breast-feeding as long as neonatal development is closely monitored and the lowest effective dose is used. Amount in milk probably too small to affect infant; high doses may affect neonatal thyroid function
Carbimazole (CMZ)
Present in breast milk but this does not preclude breast-feeding as long as neonatal development is closely monitored and the lowest effective dose is used. Amount in milk may be sufficient to affect neonatal thyroid function therefore lowest effective dose should be used.
Propranolol used for symptom control
Hypothyroid phase is usually treated with thyroxine
What is considered post-term pregnancy?
pregnancy extended to or beyond 42 weeks
Complications/consequences of post-term pregnancy
Neonatal
- Reduced placental perfusion
- Oligohydramnios
Maternal
- Increased rates of intervention incl. forceps + C-section
- Increased rates of IOL
Organisms causing early onset within 72h) vs late onset neonatal sepsis
Early onset (within 72h) GBS, Streptococcus agalactiae
Late onset
Staphylococcus epidermis
Gestational diabetes - what kind of insulin is required?
o Gestational diabetes is treated wish short-acting + not long-acting insulin Long-acting insulin is not preferred in pregnancy as it may be associated with adverse birth outcomes. Equally, it may lead to maternal hypoglycaemia. Short-acting alone gives better post-prandial glucose control and is more flexible in terms of responding to the different day-to-day diets of a pregnant woman.
Which is the earliest date of ovulation after giving birth?
Day 28 post party,
When is contraception required post partum and why?
Contraception is not required before day 21 postpartum. As sperm can survive in the vagina for up to 7 days, and the earliest date of ovulation after giving birth is 28 days postpartum, no contraception is needed until day 21
SSRIs of choice in breastfeeding women
Sertraline
Fluoxetine
To resent in tiny amounts in breast milk
What happen to blood pressure during pregnancy?
Falls in first half of pregnancy
Continues to fall until 20-24 weeks
After this time the bop usually increases to prepregnancy levels by term
What happens to the GFR in pregnancy?
30% rises in GFR because of the increase CO (5L/min before pregnancy, 6.5L/min during pregnancyj.
Therefore a normal creatinine in pregnancy is a sign of kidney failure
Lactational mastitis - indication for antibiotics
Infected nipple fissure
Symptoms do not improve or worsen after 12-24h despite effective milk removal
Positive bacterial culture
Flucloxacillin 500mcg 14/7
Erythromycin if penicillin allergic
Down Syndrome - combined test - levels of blood markers
PAPP-A low
Bhcg raised
Down Syndrome - quadriple test - levels of blood markers
AFP low
Unconjugated oestradiol low
Bhcg raised
Inhibit A raised
Why is oral fluconazole contraindicated in pregnancy?
Associated with congenital anomalies
Downs syndrome findings
alpha fetoprotein (AFP) oestriol HCG PAPP-A nuchal translucency Inhibin A
Low alpha fetoprotein (AFP)
Low oestriol
High human chorionic gonadotrophin beta-subunit (-HCG)
Low pregnancy-associated plasma protein A (PAPP-A)
Thickened nuchal translucency
High inhibin A
“All serum tests are low inDS excpet thenones that are HIM(hcg, inhibin A)”
Congenital rubella symptoms + signs
Congenital cataracts Sensorineural deafness (indicated by the milky opacities and lack of response to the hearing screen respectively)
The risk of damage to the foetus increases the earlier in the pregnancy infection occurs, with 90% being affected if infected in the first 8-10 weeks
Miscarriage Congenital heart defects (usually a patent ductus arteriosus) Purpuric 'blueberry muffin' skin lesions Intellectual disability Hepatosplenomegaly
Congenital toxoplasmosis symptoms + signs
Congenital toxoplasmosis tends to be asymptomatic, and pregnant women are classically exposed to the parasite through cat litter rather than person-to-person transmission
When signs and symptoms are present, they typically include
cerebral calcification,
chorioretinitis
hydrocephalus
Toxoplasmosis- remembers by the 4Cs:
- Convulsions
- Chorioretinitis
- Calcifications
- Cephaly (anencephaly, hydrocephalus)
Congenital syphillis symptoms + signs
which bacterium causes syphillis?
Treponema pallidum is the bacterium that causes syphilis
Congenital syphilis tends to present 2-6 weeks after birth
Blunted upper incisor teeth (Hutchinson’s teeth),
rhagades
saber shins
saddle nose
keratitis
deafness
It does not tend to cause cataracts in neonates
Congenital zika virus symptoms + signs
microcephaly
central nervous system abnormalities
Congenital varicella symptoms + signs
skin scarring
microphthalmia
limb hypoplasia
intellectual disability
Mx of Streptococcus agalactiae UTI
Streptococcus agalactiae = group B streptococcus (GBS)
This woman should receive oral antibiotics immediately to treat her urine infection
She would then be offered IV benzylpenicillin as soon as she presents in labour
Following the first dose, she would receive further IV benzylpenicillin doses 4 hourly until delivery
Women who test positive for GBS on urine cultures or vaginal swabs in pregnancy are offered intrapartum IV antibiotics due to the high risk of neonatal sepsis. If positive urine culture this also requires antenatal antibiotics. Vaginal swabs positive for GBS do not require antenatal treatment, only intrapartum.
Describe Ebstein’s anomaly
Associated with taking lithium during pregnancy
pan-systolic murmur
Cardiac echocardiogram
- low insertion of the tricuspid valve
- large right atrium
- small right ventricle
- associated tricuspid incompetence
Ebstein’s anomaly - ‘atrialisation’ of the right ventricle
Ebstein’s anomaly results in low insertion of the tricuspid valve resulting in a large right atrium and small right ventricle causing tricuspid incompetence.
Cyanotic heart defects
1 - Truncus Arteriosus (pulm + aorta connect into 1)
2 - Transposition (2 great arteries are swapped)
3 - Tricuspid atresia (3 cusps)
4 - Tet Fal (4 aspects)
5 - Total Anomalous Pulmonary Venous Return (5 words)
CoA becomes cyanotic if the PDA closes
Risk factor (RF) for GBS md
GBS + Urine mx
GBS -urine +RF mx
Risk factor (RF) for GBS = either offer intrapartum IV penicillin OR offer swab test @ 35-37 weeks or 3-5 weeks before expected delivery date
GBS + Urine = intrapartum IV penecillin & tx immediately
GBS -urine +RF = intrapartum IV penecillin
What do we mean when we refer to biophysical profile?
An ultrasound detecting fetal heart rate, breathing, movement, tone; and amniotic fluid volume
It is an evaluation of fetal wellbeing at a given point in time and is often used to assess the need for rapid induction of labor
Combined test
Triple test
Quadriple test
Combined screening is now standard and comprises an ultrasound scan to assess nuchal translucency; and serum testing to measure levels of β-human chorionic gonadotropin (β-hCG) and pregnancy-associated plasma protein A (PAPP-A).
α-fetoprotein, unconjugated oestriol and β-hCG comprises the triple test conducted between 15-20 weeks gestation to assess for Down’s syndrome. Either the triple test or the quadruple test (see below) are often offered when women have missed the window for combined antenatal screening.
α-fetoprotein, unconjugated oestriol, β-hCG and inhibin-A comprise the quadruple test, which maybe conducted between 15-20 weeks gestation to assess for Down’s syndrome.
What is the Kleihauer test and how does it work?
- The Kleihauer is used after a sensitising event to see if fetomaternal haemorrhage has occurred
add acid to maternal blood which removes adult hemoglobin, fetal cells are resistant so % of fetal to maternal cells can be calculated’.
Direct vs indirect coombs test
Direct Coombs test: direct antiglobulin, will demonstrate antibodies on RBCs of baby
An indirect Coombs is a screening test that is carried out at booking/28/34 weeks to establish if the mother already has Rh Abs present.
Physiological changes in pregnancy
Maternal circulation volume and cardiac output is increased in pregnancy, and this is NORMAL. The resulting signs include ejection systolic murmur (due to increased cardiac output), a forceful apex beat (increased cardiac output), peripheral oedema (due to increased venous volume and backpressure), and a third heart sound (due to increased vascular volume).
Despite all these changes, a physiological pregnancy should never result in enough pulmonary oedema, as this would be detrimental to the health of the mother and foetus.
> 20w + has developed chickenpox during pregnancy
Women who develop chickenpox during pregnancy should be treated with oral aciclovir 800mg 5 times a day for 7 days if >20 weeks pregnant.
The RCOG advises that only women who develop severe infection and are at high risk of complicated chickenpox should be referred to hospital for IV aciclovir. Patients should be hospitalised if they develop chest or CNS symptoms, a dense hemorrhagic rash, or are immunocompromised.
Repair of tears after labour - where and who
Small first degree tears can be Left to heal on their own
Trained midwife can repair deep first second degree tears and episiotomies in labour suite
Third and fourth degree tears need to be repaired in an operating theatre by a doctor eithe uner local or generalised anaesthesia
Which anti-epileptics are known to have the smallest effect on the developing fetus?
Lamotrigine
Carbamazepine
Levetiracetam
What do you administer in a cord prolaspe whilst waiting for a cs to prevent complications?
Tocolytics - terbutaline
Upper limit of bhcg in pregnancy + when
300,000 mIU/ml is approximately the upper limit of expected βhCG in an intrauterine pregnancy during weeks 9-12.
Which presentation has the greatest mortality and morbdity?
Footling presentation at delivery
Difference between combined and quadruple test
is worth noting that, unlike the combined screen, the quadruple screen only screens for Down’s syndrome and is less accurate.
Amniocentesis/ CVS indications
abnormal findings at the time of the 12-week scan
high-risk trisomy screening test results
a previous pregnancy/baby with a genetic condition
maternal/paternal family history of another genetic condition (e.g. sickle cell disease, thalassaemia major or cystic fibrosis)
GDM
Changing metformin to modified-release metformin can be helpful in patients who
Changing metformin to modified-release metformin can be helpful in patients who do not tolerate metformin due to side-effects such as gastrointestinal upset, but would not have a role in improving glycaemic control in this patient.
Infants with cystic fibrosis at 1 to 2 weeks of age show increased levels of IRT in the plasma in the neonatal heal-prick test
CI to nitrofurantoin for pregnant women
Nitrofurantoin should not be used near term due to the risk of neonatal haemolysis.
When can you start the COCP PP?
can start cocp from D21 post partum if not breastfeeding
first 21 days - increased risk of DVT
COCP might slightly reduce breast milk production
GDM dx vs targets
Dx
o Fasting plasma glucose level >5.6 mmol/L
o 2-h plasma glucose level (OGTT) >7.8 mmol/L
Targets CBG o Fasting glucose <5.3 mmol/L o 1h after meal <7.8 mmol/L o 2h after meal <6.4mmol/L
Which abx is contraindicated during the third trimester and why
Nitrofurantoin can safely be prescribed in the first and second trimester, though is contraindicated in the third trimester due to increased risk of neonatal haemolysis
BV in pregnancy mx
Treatment should be offered to all pregnant woman who are symptomatic. This consists of oral metronidazole 400mg twice daily for 5-7 days (2grams stat dose is not recommended in pregnancy).
Treatment is considered on a individual basis for pregnant woman with BV who are asymptomatic. This is because evidence suggests that identification and treatment of asymptomatic pregnant women does not lower the risk of preterm births.
Kidney changes in pregnancy
he correct answer is trace glycosuria. Glomerular filtration rate (GFR) increases during pregnancy, which causes a physiological reduction in creatinine levels. In accordance with this, trace glycosuria is often seen due to reduced levels of tubular reabsorption of freely filtered glucose due to greater flow rate through the tubules.
Booking appointment things
4 3 2 1
4 blood (FBC, rhesus, blood group, alloantibodies)
3 virus (hepB, HIV, syphilis) rubella no more
2 UTI (dipstick, culture)
1 full physical examination (breast, BMI, BP)
Examples of tocolytics
Indomethacin and salbutamol can be used as tocolytics.
placental abruption RF
A for Abruption previously;
B for Blood pressure (i.e. hypertension or pre-eclampsia);
R for Ruptured membranes, either premature or prolonged;
U for Uterine injury (i.e. trauma to the abdomen- C-section);
P for Polyhydramnios;
T for Twins or multiple gestation/multiparity;
I for Infection in the uterus, especially chorioamnionitis;
O for Older age (i.e. aged over 35 years old);
N for Narcotic use (i.e. cocaine and amphetamines, as well as smoking)
Hb targets for
non-pregnant women
early pregnancy (1 trimester)
later pregnancy (2-3 trimester)
after childbirth
115 for non-pregnant women, 110 in early pregnancy, 105 in later pregnancy, and 100 after childbirth.
