Passmedicine - Obstetrics Flashcards
What are the risks associated with prematurity?
Increased mortality (depends on gestation)
IRDS
Intraventricular hemorrhage
Necrotising enterocolitis
Chronic lung disease, hypothermia, feeding problems, infection, jaundice
Retinopathy of newborn, hearing problems
If a women is in premature labour but at an early stage what two medications should you give her?
Steroids - helps foetal lung maturation
Tocolytics - may stop premature labour
What is a first degree perineal tear?
Superficial damage with no muscle involvement (vaginal mucosa only)
What is a second degree perineal tear?
Injury to the perineal muscle but not involving the anal sphincter
What is a third degree perineal tear?
Injury to perineum involving the anal sphincter complex (external and internal anal sphincter)
What is a 3a degree perineal tear?
<50% of EAS thickness torn
What is a 3b degree perineal tear?
> 50% EAS thickness torn
What is a 3c degree perineal tear?
IAS torn
What is a fourth degree perineal tear?
Injury to perineum involving the anal sphincter complex + rectal mucosa
What are risk factors for perineal tears?
Primigravida Large babies Precipitant labour Shoulder dystocia Forceps delivery
What are the three stages of post-partum thyroiditis?
- Thyrotoxicosis
- Hypothyroidism
- Normal thyroid function (recurrence rate high in future pregnancies)
What kind of antibodies are found in 90% of patients with post-partum thyroiditis?
TPO
How is post-partum thyroiditis managed?
Thyrotoxic phase - don’t use ATD as thyroid is not overaction, propanolol for symptom control
Hypothyroid phase - thyroxine
Post-partum thyroiditis is based upon clinical manifestations and ____ alone?
Thyroid function tests
What 3 criteria is post-partum thyroiditis definitively diagnosed using?
- Patient is within 12 m of giving birth
- Clinical manifestations are suggestive of hypothyroidism
- Thyroid function tests support diagnosis
Define pre-eclampsia
Condition after 20 wees gestation characterised by pregnancy induced hypertension + proteinuria (>0.3g/24h)
What is the classic triad of pre-eclampsia?
Pregnancy induced:
HTN
Proteinuria
Oedema (not included in definition)
What does pre-eclampsia predispose to?
Foetal: prematurity, intrauterine growth retardation
Eclampsia
Haemorrhage: placental abruption, intra-abdominal, intra-cerebral
Cardiac organ failure
Multi-organ failure
What are high risk factors for pre-eclampsia?
Hypertensive disease is another pregnancy
CKD
Autoimmune disease, e.g. SLE, antiphospholipid syndrome
T1/T2DM
Chronic HTN
What are moderate risk factors for pre-eclampsia?
First pregnancy Age 40+ Pregnancy interval of >10 years BMI of 35+ at first visit FH pre-eclampsia Multiple pregnancy
What are the features of severe pre-eclampsia?
HTN: >170/110mmHg Proteinuria: dipstick ++/+++ Headache Visual disturbances Papilloedema RUQ/epigastric pain Hyperreflexia Platelet count <100x10^6/l, abnormal liver enzymes or HELLP syndrome
When should you treat someone’s BP in pre-eclampsia?
BP >160/110mmHg recommended but many treat when it is under this
What is used to treat pre-eclampsia?
1st line: oral labetaolol
Alts: nifedipine, hydralazine
What is the definitive management of pre-eclampsia?
Delivery of the baby
What may help reduced BP during labour if a women has pre-eclampsia?
Epidural anaesthesia
Should women continue to take their anti-epileptic medication throughout their pregnancy?
Usually as the risks of uncontrolled epilepsy during pregnancy generally outweigh risks of meds to the foetus
What drug should women with epilepsy who are trying for a baby be advised to take?
Folic acid 5mg per day
minimise risk of neural tube defects
What are the key points for women taking anti-epileptics whilst pregnant?
Aim for monotherapy
No need to monitor AED levels
What congenital malformation is sodium valproate associated with?
Neural tube defects
What congenital malformation is carbamazepine associated with?
Actually considered one of the least teratogenic
What congenital malformation is phenytoin associated with?
Cleft palate
What congenital malformation is lamotrigine associated with?
Also considered to have low rates of congenital malformations
Can you breastfeed whilst on AEDs?
Yes, apart from barbituates
Pregnant women taking phenytoin should be given what drug in the last month of pregnancy and why?
Vitamin K to prevent clotting disorders in the newborn
In which group of people should sodium valproate not be used?
Pregnant women or women of childbearing age
What should be the first line AED for a women of child bearing age?
Lamotrigine
How is the SV affected by pregnancy?
Goes up by 30%
How is the HR affected by pregnancy?
Goes up by 15%
How is the CO affected by pregnancy?
Goes up by 40%
How is BP affected by pregnancy?
Systolic unchanged
Diastolic reduced in 1st and 2nd trimester, returns to normal by term
Apart from those already mentioned, what other physiological changes occur to the CV system during pregnancy?
Enlarged uterus may interfere with venous return –> ankle oedema, supine hypotension, varicose veins
What physiological changes occur to the respiratory system during pregnancy?
Pulmonary ventilation and tidal volume increases
Why might pregnant women find warm conditions uncomfortable?
BMR increases (due to increased thyroxine and adrenocortical hormones)
Why might pregnant women find themselves being more breathless?
Oxygen requirements increase by 20% so over breathing can lead to fall in pCO2
Elevation of diaphragm
How is the maternal blood volume affected by pregnancy?
Goes up by 30%
NB - red cells increased by 20% but plasma increases by 50% so Hb falls
How is coagulation affected by pregnancy?
Low grade increase in coagulant activity
Rise in fibrinogen and factors VII, VIII, X
Fibrinolytic activity is decreased
How is coagulation activity increased in pregnancy?
To prepare for delivery
Changes in maternal coagulation put a pregnant mother at risk of what?
TE
How is platelet count affected by pregnant?
Falls
What happens to ESR, WCC and CRP in pregnancy?
ESR and WCC is raised
Why is GFR increased in pregnancy?
As blood flow increases
What elevates salt and water resorption in pregnancy?
Elevated sex steroid levels
What is excreted more in urine when you are pregnant?
Protein
What element is needed more during pregnancy?
Ca (esp. 3rd trimester and continues into lactation)
How is more calcium absorbed?
Increased 1, 25 dihydroxy vit D
How is hepatic blood flow affected by pregnancy?
Remains unchanged
What liver enzyme is raised in pregnancy?
ALP
How is albumin level affected by pregnancy?
Falls
How does the uterus change in pregnancy?
100g –> 1100g
Hyperplasia –> hypertrophy later
Increase in cervical ectropion + discharge
What may a retroverted uterus lead to in pregnancy?
Retention (at 12-16w) this usually self corrects
What are Braxton-Hicks contractions?
Non-painful practice contractions in late pregnancy (>30w)
What signs are features of increased CO and blood volume in pregnancy?
Ejection systolic murmur
Third heart sound
What organism is responsible for most early-onset severe infection in the neonatal period?
Group B strep
Why might mothers be described as carriers of GBS?
They have GBS in their bowel/vaginal flora and can expose their newborn to it during labour
What are risk factors for GBS infection?
Prematurity
PROM
Prev. sibling GBS infection
Maternal pyrexia, e.g. secondary to chorioamniotiis
Is universal screening for GBS offered to all women?
No
And mothers cannot request it
What is the risk of maternal carriage of GBS of someone who has had GBS detected in a previous pregnancy?
50%
For those who’ve had GBS in a previous pregnancy, what action should be taken when having another child?
Intra-partum antibiotics
OR
Testing in late pregnancy
If women are being offered swabs for GBS when should this be done?
35-37 weeks or 3-5w prior to anticipated delivery date
Who should be offered GBS prophylaxis?
A women with a previous baby with GBS disease
OR
Any women in preterm labour
OR
Women with pyrexia (>38) during pregnancy
What antibiotic is used for intra-partum prophylaxis for GBS? When should it be givne?
Benzylpenicillin
At start of labour and 4hrly intervals thereafter
What infections are GBS associated with?
Chorioamnionitis
Neonatal sepsis
Define foetal lie
Long axis of foetus relative to the longitudinal axis of the uterus
What are the three types of lie?
Longitudinal (99.7% foetuses at term)
Transverse lie
Oblique lie
What has a higher incidence: oblique or transverse lie?
Transverse
How does the management for oblique and transverse lie differ?
Same management for both
Define transverse lie
Foetal longitudinal axis lies peripendicular to the long axis of the uterus
What are the two types of transverse lie?
Scapulo-anterior: foetus faces mother’s back
Scapulo-posterior: foetus faces mother’s front
When is transverse lie actually quite common?
Early gestation (most have moved to longitudinal lie bby 32w)
What are risk factors for transverse lie?
Those who have had previous pregnancies Fibroids/other pelvic tumours Pregnant with twins/triplets Prematurity Polyhydramnios Foetal abnormalities
When is abnormal foetal lie picked up?
Routine antenatal appointments by abdominal ex
US will show foetal lie
What are complications of transverse lie?
PROM
Cord-prolapse
Compound presentation
How is transverse lie managed?
<36w: nothing, most will move into longitudinal lie spontaneously
36w: appt to discuss options
What are the two options for managing transverse lie >36w?
External cephalic version
elective c-section (if pt opts for it or failed ECV)
When can ECV be done up until?
Early labour (before rupture of membranes)
What are contraindications to doing ECV?
Maternal rupture within last 7 days Multiple pregnancy Major uterine abnormality Abnormal CTG Where c-section is required
What is the success rate of ECV?
50%
What is the decision to perform C-section over ECV based on?
Risks to mother/foetus Preference of pt Pts previous pregnancies Co-morbidities Pts ability to access obstetric care rapidly
How many antenatal visits is required for a first pregnancy if uncomplicated?
10
How many antenatal visits is required for a subsequent pregnancy if uncomplicated?
7
When is the booking visit? What happens here?
8-12 weeks
General info re diet, alcohol, smoking, folic acid, vit D, antenatal classes
BP, urine dipstick, check BMI
Booking bloods/urine
What tests are done as part of the booking bloods/urine?
FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies
Hep B, syphillis, rubella
HIV
Urine culture to detect asymptomatic bacteriuria
What is done as part of antenatal care at 10-13+6 weeks?
Early scan to confirm dates, exclude multiple pregnancy
What is done as part of antenatal care at 11-13+6 weeks?
Down’s syndrome screening, incl. nuchal scan
What is done as part of antenatal care at 16 weeks?
Info on the anomaly + blood results
If Hb <11g/dl consider iron
Routine care - BP + urine dipstick
What is done as part of antenatal care at 18-20+6 weeks?
Anomaly scan
What is done as part of the antenatal care at 25 weeks (if primip)?
BP, urine dipstick, symphysis-fundal height
What is done as part of antenatal care at 28 weeks?
BP, urine dipstick, SFH
Second screen for anaemia, atypical red cell alloantibodies
If Hb <10.5g/dl, consider iron
First dose anti-D to rh-ve women
What is done as part of the antenatal care at 31 weeks (if primip)?
Routine care - BP, dipstick…
What is done as part of the antenatal care at 34 weeks?
Routine care
Second dose anti-D
Info on labour and birth plan
What is done as part of the antenatal care at 36 weeks?
Routine care
Check presentation + offer ECV if indicated
Info on breast feeding, vit K, baby blues
What is done as part of the antenatal care at 38 weeks?
Routine care
What is done as part of the antenatal care at 40 weeks (if primip)?
Routine care
Discussion about prolonged pregnancy
What is done as part of the antenatal care at 41 weeks?
Routine care
Discuss labour plans, possibility of induction
Define placenta praevia
A placenta lying wholly/partly in the lower uterine segment
What factors are associated with placenta praevia?
Multiparity
Multiple pregnancy
Embyros are more likely to implant on a lower segment scar from a previous c-section
What are the clinical features of placenta praevia?
Shock in proportion to visible loss No pain Uterus not tender Lie + presentation may be abnormal (e.g. high presenting part) Small bleeds before large
Where is placenta praevia often picked up?
20w scan
What is the best imaging technique to see placenta praevia?
TVUS
What is a grade I placenta praevia?
Placenta reaches lower segment but not the internal os
What is a grade II placenta praevia?
Placenta reaches internal os but doesn’t cover it
What is a grade III placenta praevia?
Placenta covers internal os before dilatation but not when dilated
What is a grade IV placenta praevia?
Placenta completely covers the internal os
What is the key clinical feature in placenta praevia?
Painless PV bleeding after 24 weeks
What tool is used to screen for PND?
Edinbrugh postnatal depression scale
What is the max score on the edinbrugh scale?
30
What does the edinbrugh scale indicate?
How the mother has felt over the last week
Includes a q about self harm
What score on the edinbrugh scale would indicate a ‘depressive illness of varying severity’?
> 13
How common is baby blues?
Affects 60-70% women
When does baby blues tend to happen?
Usually 3-7 days after birth
In who is baby blues most common?
Primps
What are features of baby blues?
Anxiety, tearfulness, irritability
How common is PND?
10%
When do most cases of PND start?
Within a month but typically peaks at 3 months
What are the features of PND?
Similar to depression
How common is puerperal psychosis?
0.2% of women
When does puerperal psychosis tend to occur?
2-3w after birth
What are features of puerperal psychosis?
Severe swings in mood (similar to bipolar) Disordered perception (eg. auditory hallucinations)
How is baby blues managed?
Reassurance
Support
Health visitor has a key role
How is PND managed?
Reassurance, support
CBT
SSRIs, e.g. sertraline, paroxetine if symptoms severe
Why are sertraline + paroxetine used for PND?
They are secreted in breastmilk but are not thought to be harmful to the infant
How is puerperal psychosis managed?
Admission
What is the risk of recurrence of puerperal psychosis in future pregnancies?
20%
Define post partum haemorrhage
Loss of 500ml + blood from genital tract
What are the two types of PPH
Primary
Secondary
What is a primary PPH
PPH occuring in first 24h after birth
What accounts for 90% cases of PPH?
Uterine atony
What are other causes of PPH?
4Ts - Tissue Trauma Tone Thrombin
(e.g. genital trauma, clotting factor problems)
What are risk factors for a primary PPH?
Previous PPH Prolonged labour Pre-eclampsia Increased maternal age Polyhydramnios Emergency C-section Placenta praevia, placenta accreta Macrosomnia Ritodrine
What is ritodrine?
A beta-2 adrenergic receptor agonist used for tocolysis
How is primary PPH managed?
ABC, incl. 2 peripheral cannulae (14G)
1. Bimanual uterien compression to manually stimulate contractions
2. IV syntocinon (oxytocin) 10 units or IV ergometrine 500microg
3. IM carboprost
4. intramyometrial carboprost
5. Rectal misoprostol
If these fail - consider surgical options
What are surgical options for managing primary PPH?
1st line: intrauterine balloon tamponade (if uterine atony)
Other options: B-lynch suture, ligation of the uterine arteries or internal iliac arteries
V. severe, uncontrolled: hysterectomy may be lifesaving
Define secondary PPH
PPH occuring 24h-12w after birth
What tends to be the cause of secondary PPH?
Retained placental tissue or endometritis
What things are associated with uterine atony?
Overdistension (e.g. due to multiple gestation, macrosomnia, polyhydramnios)
What virus is responsible for chicken pox?
Varicella zoster virus
What causes shingles?
Reactivation of dormant VZV in the dorsal root ganglion
If a mother is exposed to VZV during pregnancy for the first time what is the foetus at risk of?
Foetal varicella syndrome
Shingles in infancy (if exposed in third trimester)
Severe neonatal varicella which may be fatal
If a mother is exposed to VZV during pregnancy for the first time what she more at risk of?
5x greater risk of pneumonitis
What are features of foetal varicella syndrome?
Skin scarring, eye defects (microphthalmia, limb hypoplasia, microcephaly, learning disabilities
How should pregnant lady exposure to varicella be managed?
If any doubt about VZV status - check maternal blood for varicella Abs
If not immune give VZIG ASAP
How should you manage a pregnant lady with chicken pox?
Oral aciclovir if they present within 24h of rash onset
Up to how many days post-exposure if VZIG effective?
10 days
Can the varicella vaccine be given during pregnancy?
No as it is a live vaccine
What can cause nipple pain whilst breast feeding?
A poor latch
Blocked duct - nipple pain when breast feeding, continue breastfeeding, seek advice re positioning of baby, breast massage
nipple candidiasis
How should nipple candidiasis while breastfeeding be managed?
Miconazole cream for mother
Nystatin suspension for baby
How common is mastitis?
Affects 1 in 10 breastfeeding women
When should you treat mastitis?
If systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24h of effective milk removal or if culture indicates infection
What is the first line antibiotic for mastitis?
Flucloxacillin 10-14 days
erythromycin if penicillin allergic
Should you continue to breastfeeding if you have mastitis?
Yes
Continue through treated
What may develop as a result of untreated mastitis?
Breast abscess
How are breast abscesses managed?
Incision and drainage
What are the feature of breast engorgement?
Breast pain a few days after birth affecting both breasts
Usually worse just before a feed
Milk doesn’t flow well and infant may find it hard to attach and suckle
Fever may be present but tends to settle after 24h
Breasts may appear red
What are complications of breast engorgement?
Blocked milk ducts
Masitis
Difficulties breastfeeding
What may help the discomfort of engorgement?
Although initially painful hand expression of milk may help
What happens in Raynaud’s disease of the nipple?
Intermittent nipple pain, usually present during + immediately after feeding
Blanching of nipple may –> cyanosis +/or erythema
Nipple pain resolves when nipples return to normal colour
What is the management of Raynaud’s disease of the nipple?
Advice re minimising cold Use heat packs following breastfeeding Avoid caffeine Stop smoking If persistent - refer to specialist to try oral nifedipine
What are contraindications to breast feeding?
Galactosaemia
Viral infections (e.g. HIV)
Drugs
List drugs that should be avoided when breastfeeding
Antibiotics (ciprofloxacin, tetracycline, chloramphenicol, sulphonamides) Psychiatric drugs: lithium, benzos, clozapine Aspirin Carbimazole Methotrexate SUs Cytotoxic drugs Amiodarone
Define olgiohydramnios
Reduced amniotic fluid (less than 500ml at 32-36 weeks + an amniotic fluid index <5th percentile)
What are causes of olgiohydramnios?
PROM Foetal renal problems, e.g. renal agenesis IUGR Post-term gestation Pre-eclampsia
How can pre-eclampsia cause oligohydamnios?
Hypoperfusion of placenta
What factors would mean a pregnant lady is at high risk of VTE?
Previous VTE
What should be done if a pregnant lady is considered at high risk of VTE?
LMWH prophylaxis throughout antenatal period
What factors would mean a pregnant lady is at intermediate risk of VTE?
Hopsitalisation or surgery
Co-morbidities
Thrombophilia
What should be done if a pregnant lady is considered at intermediate risk of VTE?
Consider antenatal prophylactic LMWH
What are risk factors for VTE during pregnancy?
Age >35 BMI >30 Parity >3 Smoker Gross varicose veins Current pre-eclampsia Immobility FH of unprovoked VTE Low risk thrombophilia Multiple pregnancy IVF pregnancy
How many risk factors for VTE in pregnancy warrants treatment with LMWH?
4+
How long should women be given LMWH for if they are pregnant and at risk of VTE?
Until 6 weeks postnatal
Unless diagnosis of DVT is made before shortly before delivery then continue for at least 3 months
What is shoulder dystocia?
Inability to delivery the body of the foetus using genital traction after delivery of the head
What are complications of shoulder dsytocia?
PPH
Perineal tears
Brachial plexus injury
Neonatal death
What are risk factors for shoulder dystocia?
Foetal macrosomnia
High maternal BMI
DM
Prolonged labour
What tends to cause shoulder dystocia?
Impaction of the anterior foetal shoulder on the maternal pubic symphysis
How is shoulder dystocia managed?
Call additional help
McRobert’s manoeuvre
What does McRobert’s manoeuvre entail?
Flexion + abduction of the maternal hips, bringing the mother’s thighs towards her abdomen
What is intrahepatic cholestasis of pregnancy associated with?
Increased risk of premature birth and still birth
What are features of intrahepatic cholestasis of pregnancy?
Pruritus (typically worse on palms, soles + abdomen)
Jaundice in 20%
Raised bilirubin, GGT, ALP
RUQ pain, steathorrhoea
How is intrahepatic cholestasis of pregnancy managed?
Induction of labour at 37w
Ursodeoxycholic acid
Wkly LFTs
Vit K supplementation
What should be given to babies born to mothers who are chronically infected with Hep B or have had an acute Hep B infection during pregnancy?
Complete course of vaccination + hep B Ig
Can hep B be transmitted via breastfeeding?
No
Define antepartum haemorrhage
Bleeding after 24 weeks
What are reasons for 1st trimester bleeding?
Spontaneous abortion
Ectopic pregnancy
Hydatidform mole
What are reasons for 2nd trimester bleeding?
Spontaneous abortion
Hydatidiform mole
Placental abruption
What are reasons for 3rd trimester bleeding?
Bloody show
Placental abruption
Placenta praevia
Vasa praevia
Along with pregnancy related causes of bleeding during pregnancy what other things should you rule out?
STIs
Cervical polyps etc.
How does hydatidiform mole tend to present?
Bleeding in 1st/2nd trimester associated with exaggerated symptoms of pregnancy, e.g. hyperemesis
Uterus large for dates
Serum bHCG v. high
How does vasa praevia tend to present?
Rupture of membranes followed by immediate vaginal bleeding
Foetal bradycardia
What is vasa praevia?
Foetal blood vessels cross or run near the internal orifice of the uterus
Vessels can become compromised when the membranes rupture
What are foetal complications of premature rupture of the membranes?
Prematurity
Infection
Pulmonary hypoplasia
What are maternal comlications of PROM?
Chorioamnionitis
What investigations may be useful in PROM? What investigation should be avoided?
Sterile speculum examination
Nitrazine sticks (detect changes in pH)
US to show oligohydramnios
DO NOT do digital ex due to infection risk
What is the management of PROM?
Admission Regular obs to ensure chorioamnionitis doesn't develop Oral erythromycin 10d Antenatal corticosteroids to reduce IRDS Delivery considered at 34w
Up until what week of gestation can catching VZV for the first time lead to foetal varicella syndrome?
20
Define labour
Onset of regular + painful contractions associated with cervical dilatation + descent of the presenting part
What are signs of labour?
Regular + painful uterine contractions
A show
Rupture of the membranes
Shortening + dilatation of the cervix
What is a show?
Shedding of the mucous plug
How stages of labour are there?
3
What is the first stage of labour?
Onset of true labour to when cervix is fully dilated
What is the second stage of labour?
From full dilatation to delivery of the foetus
What is the third stage of labour?
From delivery of foetus to when the placenta membranes have been completely delivered
What monitoring is done during labour?
FHR Contractions Maternal pulse rate Maternal BP and temp VE Maternal uterine
How often should FHR be assessed during labour?
Every 15m
OR
Continuously via CTG
How often should contractions be assessed during labour?
Every 30 minutes
How often should maternal pulse rate be assessed during labour?
Every hour
How often should maternal BP and temperature be checked during labour?
Every 4h
How often should VE be done during labour?
Every 4h to check progression of labour
How often should maternal urine be checked for ketones and protein during labour?
Every 4h
What are the cons of having an epidural during labour?
It is associated with a prolonged labour + increased operative vaginal delivery
What would CI an epidural?
Coagulopathy
What is folic acid converted to the in the body?
Tetrahydrofolate
What are good dietary sources of folate?
Green, leafy vegetables
What is the function of tetrahydrofolate (THF)?
Plays key role in transfer of 1-carbon units (e.g. methyl, methylene + formyl groups) to the essential substrates involved in the synthesis of DNA and RNA
What can cause folate deficiency?
Phenytoin
Methotrexate
Pregnancy
Alcohol xs
What kind of anaemia do you get with a folate deficiency?
Macrocytic, megaloblastic
What are consequences to the foetus during pregnancy if the mother has a folate deficiency?
Neural tube defects
What is the recommendation for pregnant women taking folate when they are not deemed to be at risk of their child having a NTD?
400mg of folic acid until 12th week of pregnancy
What is the recommendation for pregnant women taking folate when they are deemed to be at higher risk of their child having a NTD?
5mg folic acid from before conception until 12th week of pregnancy
What factors would make a women high risk of having a child with a NTD?
Partner has NTD, they have had prev. pregnancy affected by a NTD, FH NTD
She is on AEDs or has coeliac disease, diabetes, thalassaemia trait
BM 30+
What are the two types of twins?
Dizygotic
Monozygotic
What is a dizygotic twin?
Non-identical, develop from two separate ova that were fertilised at the same time
What is a monozygotic twin?
Identical, developed from single ovum which has divided to form two embyros
What type of twin is more common?
Dizygotic (80% of twins)
What are monoamniotic monozygotic twins more at risk of?
Increased spontaneous miscarriage and perinatal mortality
Increased malformations, IUGR, prematurity
Twin to twin transfusions
What factors predispose to having dizygotic twins?
Previous twins FH Increasing maternal age Multigravida Induced ovulation, IVF Race, e.g. afrocaribbean
What antenatal complications are associated with twins?
Polyhydramnios
Pregnancy induced HTN
Anaemia
Antepartum haemorrhage
What are foetal complications associated with twins?
Prematurity
Light for date babies
Malformation
What labour complications are associated with twins?
PPH (x2 increased risk)
Malpresentation
Cord prolapse, entanglement
What additional things should be done during a twin pregnancy?
Additional iron + folate
Precautions at labour, e.. 2 obstetricians present
What is twin to twin transfusion syndrome?
Two foetuses share the same placenta, so blood can flow between the twins
One foetus (donor) recieves a lesser share of the blood flow than the other twin (recipient)
Recipient may become fluid overloaded and the donor becomes anaemia
(one has polyhydramnios + the other oligohydramnios etc.)
Can be fatal to one or both foetuses
What causes twin to twin transfusion syndrome?
Abnormalities in the network of placental blood vessels
What factors will reduce the vertical transmission of HIV?
Maternal ART
C-section
Neonatal ART
Bottle feeding
When might you do a vaginal delivery in an HIV positive woman?
If viral load <50 copies/ml at 36w
What medication is given prior to having a c-section in HIV +ve women?
Zidovudine infusion (start 4h before c-section)
What ART is given to the neonates of HIV +ve women?
If maternal viral load <50copies/ml - oral zidovudine
Otherwise triple ART for 4-6 wees
What are the two types of C-section?
Lower segment C-section
Classic C-section (longitudinal incision upper segment of uterus)
What type of c-section is most commonly done?
Lower segment c-section (99%)
What are indications for c-section?
Absolute - placenta praevia (grade 3/4)/cephalopelvic disproportion
Relative - Pre-eclampsia Post-maturity IUGR Foetal distress in labour/prolapse cord Failure of labour to progress Malpresentations (brow) Placental abruption (only if foetal distress, if dead, delivery vaginally) Vaginal infection, e.g. active herpes Cervical cancer
Why should a women with cervical cancer deliver via c-section?
Vaginal delivery disseminates cancer cells
What are some serious maternal complications of c-section?
Emergency hysterectomy Need for further surgery at later date (incl. curettage) Admission to ITU TE dx Bladder injury Ureteric injury Prolonged ileus Death
What are some serious complications for future pregnancies of c-section?
Increased risk of uterine rupture in subsequent pregnancies/deliveries
Increased risk of antepartum stillbirth
Increased risk in subsequent pregnancies of placenta praevia + accreta
Subfertility
What are some common complications of c-section for the mother?
Persistent wound + abdominal discomfort in 1st few months after
Increased risk of repeat c-section when vaginal delivery attempted in subsequent pregnancies
Readmission to hospital
Haemorrhage
Infection (wound, endometritis, UTI)
What is a common complication of c-section to the foetus?
Lacerations
What are contraindications to having a vaginal birth after caesarean?
Previous uterine rupture
Classical caesarean scar
What layers do you go through when performing a lower segment C-section?
Skin Superficial fascia Deep fascia Anterior rectus sheath Rectus abdominis muscle (incision of linea alba and muscle pushed aside) Transversalis fascia Extraperitoneal connective tissue Peritoneum Uterus
What happens the serum urea and creatinine and the urinary protein loss in pregnancy normally?
Decreased serum urea and creatinine (increased perfusion to kidneys in pregnancy)
Increased urine protein loss
What is the bishop score used for?
To help assess whether induction of labour will be required
What are the 5 components of the bishop score?
Cervical position Cervical consistency Cervical effacement Cervical dilatation Foetal station
How do you score 0-2 on the bishop score for cervical position?
0 - posterior
1 - intermediate
2 - anterior
How do you score 0-2 on the bishop score for cervical consistency?
0 - firm
1 - intermediate
2 - soft
How do you score 0-3 on the bishop score for cervical effacement?
0 - 0-30%
1 - 40-50%
2 - 60-70%
3 - 80%
How do you score 0-3 on the bishop score for cervical dilatation?
0 - <1cm
1 - 1-2cm
2 - 3-4cm
3 - >5cm
How do you score 0-2 on the bishop score for foetal station?
0 - -3
1 - -2
2 - -1, 0
3 - +1, +2
What score on the bishop score indicates that labour is unlikely to start without induction?
<5
What score on the bishop score indicates that labour is likely to start spontaneously?
> 9
What techniques can be used to suppress lactation?
Stop lactation reflex - stop suckling/expressing
Supportive measures - analgesia, well supported bra
Cabergoline
What is cabergoline? How does it work to suppress lactation?
Dopamine receptor agonist which inhibits prolactin production –> suppression of lactation
Define lochia
Vaginal discharge containing blood, mucous and uterine tissue
How long can lochia continue for after birth?
6 weeks
What advice can you give to people re lochia?
If it begins to smell badly, its volume increases or it doesn’t stop seek medical attention
Where is hCG produced?
By embyro then later by placental trophoblast
What is the main action of hCG?
Prevent disintegration of the corpus luteum to maintain the production of progesterone
How often do hCG levels double in the first few weeks of pregnancy?
Double every 48h
When do levels of hCG peak?
Around 8-10 weeks gestation
What hormone forms the basis of many of the pregnancy home testing kits?
bhCG
When can hCG be detected in the maternal blood after conception?
8 days
Define breech presentation
Caudal end of foetus occupies the lower segment
What is the most common type of breech presentation?
Frank breech (hips flexed + knees fully extended)
What is the other type of breech (not frank)?
Footling breech (1 or both feet come first with the bottom at a higher position)
This is rarer with higher perinatal morbidity
What are RFs for breech presentation?
Uterine malformations, fibroids
Placental praevia
Polyhydramnios or oligohydramnios
Foetal abnormality (e.g. CNS malformation, chromosomal disorders)
Prematurity (due to increased incidence earlier in gestation)
What complication is more common in breech presentations?
Cord prolapse
How do you manage breech presentation <36w?
Many will turn spontaneously
How do you manage breech presentation at 36w?
ECV
offer at 36w in nulliparous women and 37w in multiparous
If ECV fails to fix a breech presentation what are the options?
Planned c-section or vaginal delivery
must inform women that planned c-section carried reduced perinatal mortality
How can non-infectious mastitis become infected?
Accumulation of milk in breast tissue –> inflammatory response (non-infectious mastitis) with inadequate milk removal predisposes to bacterial growth (infectious mastitis)
How does infectious mastitis tend to present?
Painful breast Fever Malaise Tender, red, swollen and hard area Usually in wedge shaped distribution
How do you define a major PPH and a minor PPH?
Minor 500-1000ml
Major >1000ml
If you find a low lying placenta at the 16-20w scan what should you do?
Rescan at 34 weeks
No need to limit activity/intercourse unless they bleed
If you rescan someone who had a low lying placenta at 16-20w scan at 34 weeks and it is still low lying what should you do?
If grade I/II then scan every 2 weeks
If high presenting part/abnormal lie at 37w –> c-section
How should you manage a placenta praevia with bleeding?
Admit
Treat shock
Cross match blood
Final US 36-37w to determine method of selivery
C-section for grades III/IV between 37-38 weeks
If grade I - vaginal delivery
What is the normal foetal heart rate?
Varies between 100-160bpm
With regards to CTG:
Define baseline bradycardia
HR <100bpm
With regards to CTG:
Define baseline tachycardia
HR >160bpm
With regards to CTG:
What can cause baseline bradycardia?
Increased foetal vagal tone
Maternal Bblocker use
With regards to CTG:
What can cause baseline tachycardia?
Maternal pyrexia
Chorioamnionitis
Hypoxia
Prematurity
With regards to CTG:
Define loss of baseline variability
<5 beats/min variation
With regards to CTG:
What can cause loss of baseline variability?
Foetus is asleep (most common reason for short episodes (<40m)) Prematurity Hypoxia (foetal acidosis) Use of maternal drugs, e.g. benzos, opioids, methyldopa
With regards to CTG:
Define early deceleration
Deceleration of HR which commences with the onset of contraction + returns to normal on completion of contraction
With regards to CTG:
What does an early deceleration usually mean?
Usually harmless feature
Indicates head compression
With regards to CTG:
Define late deceleration
Deceleration of HR which lags the onset of a contraction + does not return to normal until 30s following the end of the contraction
With regards to CTG:
What does a late deceleration indicate?
Foetal distress, e.g. asphyxia or placental insufficiency
Want to delivery asap
With regards to CTG:
Define variable decelerations
Independent of contractions
With regards to CTG:
What can variable deceleration indicate?
Cord compression
Supplementation of which vitamin may be teratogenic in pregnancy?
Vit A
Should avoid foods rich in this too, e.g. liver
What vitamin should pregnant women be advised to supplement?
Vit D
What is the alcohol limit during pregnancy?
Avoid all together
What are the risks of smoking during pregnancy?
Low birthweight Preterm birth Increased risk miscarriage IUGR Increased risk of sudden unexpected death in infancy
What can be offered to pregnant women to help them stop smoking?
NRT
DO NOT offer varenicline or bupropion to pregnant/breastfeeding woman
What two food acquired infections should pregnant women be advised to take extra care to avoid?
Listeriosis
Salmonella
What kinds of products might you catch listeriosis from?
Unpasteurised milk
Ripened soft cheeses (e.g. Brie, Camembert)
Pate
Undercooked meat
What kinds of products might you catch salmonella from?
Raw/partially cooked eggs and meat (esp poultry)
At what gestation should women be advised to avoid air travel?
> 37w if uncomplicated singleton pregnancy
>32 if uncomplicated multiple pregnancy
Why are pregnant women advised not to fly after a certain gestation?
Risk of VTE
How may women who have to travel by air while pregnant reduce their risk of getting a VTE?
Compression stockings
What advice should you give to pregnant women re. taking prescribed medications?
Avoid unless benefits outweigh risks
What advice should you give to pregnant women re. taking OTC medications?
Use as little as possible
What advice should you give to pregnant women re. using complimentary therpies?
Avoid as much as possible
No evidence of their safety/effectiveness during pregnancy
Should women be advised to continue/begin exercise during pregnancy?
Yes - moderate exercise is not associated with adverse outcomes
What spots should be avoided in pregnancy?
High impact sports where there is a risk of abdominal trauma
Scuba diving
Should you advise women to stop having sex during pregnancy?
Sex is not associated with adverse outcomes
What factors put someone at risk of getting gestational HTN?
HTN dx during prev. pregnancies
CKD
Autoimmune dx, e.g. SLE, antiphospholipid syndrome
T1/T2 DM
Define HTN in pregnancy
Systolic >140 OR diastolic >90mmHg
Or increase above booking readings of >30mmHg systolic or >15mmHg diastolic
What are the 3 groups of hypertensive diseases in pregnancy?
Pre-existing HTN
Gestational HTN
Pre-eclampsia
How can you tell if a pregnant women has pre-existing HTN?
Hx HTN before pregnancy/before 20 weeks gestation + BP >140/90
No proteinuria/oedema
Define gestational HTN
HTN (>140/90) occurring after 20 weeks gestation
With NO oedema/proteinuria
Does gestational HTN tend to resolve after giving birth?
Yes
What are women with gestational HTN more at risk of in later life?
Future pre-eclampsia/HTN
Define pre-eclampsia
Pregnancy induced HTN with proteinuria (>0.3g/24h)
In what % of pregnancies does pre-eclampsia occur?
5%
Define mild gestational HTN
140-149/90-99mmHg
Define moderate gestational HTN
150-159/100-109mmHg
Define severe gestational HTN
> 160/110mmHg
How is gestational HTN managed?
Oral labetalol
Alts: nifedipine, methylopa
What condition CIs the use of methyldopa?
Depression
What is a first degree perineal tear?
Superficial damage with no muscle involvement
What is a second degree perineal tear?
Injury to the perineal muscle but not involving the anal sphincter
What is a third degree perineal tear?
Injury to perineum involving the anal sphincter complex
What is a 3a perineal tear?
Less than 50% EAS thickness torn
What is a 3b perineal tear?
More than 50% EAS thickness torn
What is a 3c perineal tear?
IAS torn
What is a fourth degree perineal tear?
Injury to perineum involving anal sphincter complex and rectal mucosa
What are RFs for perineal tears?
Primigravida Large babies Precipitant labour Shoulder dystocia Forceps delivery
What are the three types of diabetes that can be present during pregnancy?
T1
T2
Gestational DM
What are RFs for gestational DM?
BMI >30 Previous macrosomic baby weighing 4.5kg+ Prev. gestational DM 1st degree relative with DM FH with high prevalence DM (e.g. South Asian, black caribbean)
What screening should be done for gestational DM in those who have previously had gestational DM?
OGTT after booking and at 24-28w if first test is normal
OR can do early self-monitoring of blood glucose
What screening should be done for gestational DM in those with any other RF for gestational DM?
OFTT at 24-28w
How can you diagnose gestational DM?
If either:
Fasting BG >=5.6mmol/l
2h BG >=7.8mmol/l
Women who are newly diagnosed with gestational diabetes should be seen within what clinic within 1 week?
Joint diabetes + antenatal clinic
What should advice should women receive when they are diagnosed with gestational DM?
How to self monitor BG
Diet
Exercise
How is gestational DM managed?
If fasting G <7: trial diet + exercise
If glucose targets not met within 1-2w - start metformin
If glucose targets still not met - add insulin
If fasting GB >= 7 at time of diagnosis - start insulin
In which situations might you give insulin to treat gestational DM if fasting BG is not >=7?
If fasting BG 6-6.9 + evidence of complications (e.g. macrosomia, hydramnios)
What drug can be offered for women who cannot tolerate metformin/fail to meet glucose targets with metformin but refuse insulin?
Glibenclamide
How do you manage pr-existing DM in pregnancy?
Wt loss if BMI >27
Stop oral hypoglycaemics, apart from metformin + start insulin
Folic acid 5mg from before conception till 12w
Aspirin 75mg/d from 12w to birth
Detailed anomaly scan at 20w (4 chamber view of heart + outflow tracts)
Tight glycaemic control
What can worsen for diabetics during pregnancy?
Retinopathy
Why do you give aspirin to pregnant diabetics?
Reduce risk of getting pre-eclampsia
What are the targets for fasting BG for those with gestational DM/pre-existing DM?
5.3mmol/l
What are the targets for 1 hour post meal BG for those with gestational DM/pre-existing DM?
7.8mmol/
What are the targets for 2 hour post meal BG for those with gestational DM/pre-existing DM?
6.4mmol/l
What is the only oral hypoglycaemic that should be used whilst breastfeeding?
Metformin
During what part of the pregnancy is it most common to get acute fatty liver of pregnancy?
3rd trimester or period following delivery
What are the clinical features of acute fatty liver of pregnancy?
Abdominal pain NV Headache Jaundice Hypoglycaemia Severe disease may --> pre-eclampsia Raised ALT
How do you manage acute fatty liver of pregnancy?
Supportive care
Delivery once stabilised is definitive management
What are the features of HELLP syndrome?
Haemolysis
Elevated liver enzymes
Low platelets
What is the WHO definition of a post-term pregnancy?
Pregnancy extending to or beyond 42 weeks
What are potential complications of a post-term pregnancy to the unborn child?
Reduced placental perfusion
Oligohydramnios
What are potential complications/consequences of a post-term pregnancy to the mother?
Increased rates of intervention incl. forceps + c-section
Increased rate of labour induction
What causes gestational thrombocytopenia?
Dilution, decreased production + increased destruction of platelets
Why is there increased destruction of platelets in gestational thrombocytopenia?
Increased work of the maternal spleen leading to mild sequestration
How can you distinguish between ITP and gestational thrombocytopenia?
If platelets continue to fall during pregnancy - more likely GT
If dangerously thrombocytopenia assumed ITP and given steroids
At booking if platelets low/prev. ITP diagnosis -> test serum antiplatelet antibodies to confirm
Which of gestational thrombocytopenia and ITP affect the newborn?
ITP - as maternal antibodies cross the placenta
How should a neonate born to a mother with ITP be treated differently?
Depends on degree of thrombocytopenia but may req. platelet transfusion
Serial platelet counts should be done to see if it is an inherited thrombocytopenia
What sort of delivery should be avoided in a mother with ITP as it may provoked a haemorrhage/cephalohaematoma in the newborn?
Prolonged ventouse delivery
What may be given to help with the itch in intrahepatic cholestasis of pregnancy but does not improve outcomes?
Antihistamines
Topical menthol emollients
What drug should be used first line for nausea and vomiting during pregnancy?
Antihistamines, promethazine is first line
What natural remedies are recommended by NICE for nausea and vomiting during pregnancy?
Ginger and acupuncture on the p6 point
How much vitamin D should pregnant/breast feeding women take every day?
10 microg
Which steroid is given in PROM to reduce risk of IRDS?
Dexamethasone (corticosteroid)
Define cord prolapse
Umbilical cord descends ahead of the presenting part of the foetus
What does untreated cord prolapse lead to?
Compression of cord
Cord spasm
–> foetal hypoxia and eventually death
What are risk factors for cord prolapse?
Prematurity Multiparity Polyhydramnios Twin pregnancy Cephalopelvic disporpotion Abnormal presentations, e.g. Breech, transverse lie Placenta praevia Long umbilical cord High foetal station
When do the majority of cord prolapses occur?
At artificial rupture of the membranes
How do you manage cord prolapse?
Push presenting part of foetus back in to avoid compression
Tocolytics
If cord is passed level of introitus keep warm + moist but do not push back inside
Pt on all 4s
Immediate c-section (although instrumental vaginal delivery may be possible if cervix fully dilated)
What is an amniotic fluid embolism?
Foetal cells/amniotic fluid enters the mothers bloodstream + stimulates a reaction
What are RFs for amniotic fluid embolism?
Maternal age
Induction of labour
When do the majority of cases of amniotic fluid embolism occur?
In labour
What are symptoms of amniotic fluid embolism?
Chills, shivering, sweating, anxiety, coughing
What are signs of amniotic fluid embolism?
Cyanosis, hypotension, bronchospasms, tachycardia, arrhythmia, MI
How do you diagnose amniotic fluid embolism?
Diagnosis of exclusion - no specific tests
How is amniotic fluid embolism managed?
Supportively (in critical care unit)
Define placental abruption
Separation of a normally sited placenta from the uterine wall –> maternal haemorrhage into the intervening space
What are associated factors with placental abruption?
Proteinuric hypertension
Multiparity
Maternal trauma
Increasing maternal age
What are clinical features of placental abruption?
Shock out of keeping with visible loss Constant pain Tender, tense uterus Normal lie and presentation Absent/distress foetal heart
How often should patients with T1DM measure their BG?
Daily fasting, pre-meal, 1h post meal, bed times
What is drinking alcohol in pregnancy associated with?
Foetal alcohol syndrome
What are the features of foetal alcohol syndrome?
Learning difficulties
Characteristic facies - smooth philtrum, thin vermilion, small palpebral fissures
IUGR + post-natal restricted growth
Microcephaly
What is one of the biggest risk factors for foetal alcohol syndrome?
Binge drinking
What are risks to the mother if she uses cocaine during pregnancy?
HTN in pregnancy, incl. pre-eclampsia
Placental abruption
What are risks to the foetus is the mother is using cocaine during the pregnancy?
Prematurity
Neonatal abstinence syndrome
What are the consequences of maternal heroine use during pregnancy?
Neonatal abstinence syndrome
What antibiotic should be avoided for treating UTIs in the first trimester?
Avoid trimethoprim (teratogenic) Use nitrofuratoin (avoid in full term due to risk of neonatal haemolysis)
List ALL (18) of the conditions that should be offered to be screened for during pregnancy
Anaemia Bacteriuria Blood group, Rh status, anti-red cell Abs Down's Fetal anomalies Hep B HIV NTDs Risk factors for pre-eclampsia Rubella immunity Syphillis
\+ depending on if hx is suggestive - Placenta praevia Psychiatric illness Sickle cell disease Tay-Sachs disease Thalassaemia
What can occur if a Rh-ve women has a Rh +ve child?
Foetal RBCs may leak into maternal blood flow during birth
–> anti-D IgG antibodies to form in mother
In later pregnancies can cross placenta + cause haemolysis in foetus
When is anti-D given to non-sensitised Rh-ve pregnancy women?
28 and 34 weeks
If a women who is Rh -ve has a sensitising event in the 2nd or 3rd trimester what action should be taken?
Give large dose anti-D and perform Kleihauer test
What does Kleihauer test determine?
Proportion of foetal RBCs present
In which situations does anti-D Ig need to be given ASAP (and what is the time window it must be given in?)?
Within 72h
- Delivery of Rh+ve infant (live or stillborn)
- Any TOP
- Miscarriage >12w
- Ectopic pregnancy (only if surgical management)
- ECV
- Antepartum haemorrhage
- Amniocentesis, CVS, foetal blood sampling
- Abdominal trauma
What should all babies born to Rh-ve mothers have done at birth?
Have blood taken from cord for FBC, blood group and direct coombs test
What does coombs test do?
Direct antiglobulin test - will demonstrate Abs on the surface of the RBCs of the baby
How does Kleihauers test work?
Add acid to maternal blood, foetal cells are resistant
How might a foetus in a Rh -ve sensitised women be affected?
Oedematous (hydrops fetalis as liver devoted to RBC production, albumin falls)
Jaundice, anaemia, hepatosplenomegaly
Heart failure
Kernicterus
How can you treat a foetus in a Rh -ve sensitised women that has been affected?
Transfusions
UV phototherapy
How might you distinguish between intrahepatic cholestasis of pregnancy and acute fatty liver of pregnancy clinically?
Cholestasis: severe pruritus
Fatty liver: non-specific symptoms (e.g. fever, malaise, jaundice)
When does baby blues tend to subside by?
10 days
What are symptoms women get with baby blues?
Tearfulness, irritability, anxiety about the baby, poor concentration
What are symptoms women get with PND?
Usual features of depression, fears about baby’s health, maternal deficiencies, martial tensions incl. loss of sexual interest
When does puerperal psychosis tend to occur?
Within first 2 weeks
What are the two forms of puerperal psychosis?
Manic depression
Schizophrenia
Who does galactocele tend to occur in?
Women who have recently stopped breastfeeding
What is a galactocele caused by?
Blocked lactiferous duct
What is a galactocele?
Build up of milk creating a cystic lesion in the breast
How can you differentiate a galactocele from an abscess?
Galactocele usually painless with no local/systemic features of infection
What causes rubella?
Togavirus
If a women contracts rubella whilst pregnant what is the risk to the foetus?
Congenital rubella syndrome
How long are people with rubella infectious?
From 7 days before symptoms appear to 4 days after onset of rash
At what gestation is there the highest risk of the foetus getting congenital rubella syndrome if the mother contracts rubella?
First 8-10 weeks
Rare after 16w
What are the features of congenital rubella syndrome?
Sensorineural deafness Congenital cataracts Congenital heart disease, e.g. PDA Growth retardation Hepatosplenomegaly Purpuric skin lesions Salt and pepper chorioretinitis Microphthalmia Cerebral palsy
What infection is very similar to rubella and you must check the serology for if a pregnant women presents with this? Why must you do this?
Parovirus B19
Risk of transplacental infection and foetal loss
Suspected cases of rubella in pregnancy should be discussed with who?
The local health protection unit
Is rubella immunity checked at booking?
No
Can you give the MMR vaccine to a non-immune woman during pregnancy?
No!!
Offer in postnatal period
What is the management of a non-immune to rubella pregnant woman?
Just have to advise to keep away from infected people
After ____ weeks gestation, the fundal height should increase by __cm per week.
24
1
What may be a reason for the fundal height increasing by more than expected per week after 24w?
Unknown multipregnancy
Baby is big for dates
Define induction of labour
Process of labour is started artifically
What are indications for induction of labour?
Prolonged pregnancy (>12d after EDD)
Prelabour PROM where labour does not start
Diabetic mother >38w
Rh incompatability
What are methods of inducing labour?
Membrane sweep
Intravaginal prostaglandins
Breaking of waters
Oxytocin
What do intravaginal prostaglandins do?
Ripen the cervix and induce labour
What produces alpha feto-protein?
The developing uterus
What things may cause increased AFP in a pregnant lady?
NTDs (meningocele, myelomeingocele, anencephaly)
Abdominal wall defects (omphalocele, gastroschisis)
Multiple pregnancy
What things may cause decreased AFP in a pregnant lady?
Down’s syndrome
Trisomy 18
Maternal DM or obesity
Define placenta accreta
Attachment of the placenta to the myometrium due to a defective decidua basalis
What is the big risk with placenta accreta and why?
PPH as the placenta does not separately properly during labour
What are RFs for placenta accreta?
Prev. c-section
Placenta praevia
What are the 3 types of placenta accreta?
Accreta: choronic villi attach to myometrium rather than being restricted within the decidua basalis
Increta: choronic villi invade into myometrium
Percreta: choronic villi invade through perimetrium
What are gestational trophoblastic disorders?
Spectrum of disorders originating from the placental trophoblast
What are the gestational trophoblastic disorders?
Complete hydatidiform mole
Partial hyatidiform mole
Choriocarcinoma
What is a complete hydatidiform mole?
Benign tumour of trophoblastic material
What causes a complete hydatidiform mole?
Empty egg is fertilised by single sperm that duplicates its own DNA –> 46 paternal chromosomes
What are the clinical features of a complete hydatidiform mole?
Bleeding in 1st/2nd trimester Exaggerated symptosm of pregnancy, e.g. hyperemesis Uterus large for dates V. high levels bHCG HTN and hyperthyroidism may be seen
How is a complete hydatidiform mole managed?
Evacuation of uterus
What recommendation should be given to women who have had evacuation of the uterus for a complete hydatidiform mole?
Use contraception to avoid pregnancy in the next year
2-3% of complete hydatidiform moles go on to develop what?
Choriocarcinoma
What happens to cause a partial mole?
Normal haploid egg fertilised by two sperms/one sperm with duplication of parental chromosomes
DNA is maternal + paternal
Usually triploid
Foetal parts may be seen
Why is hyperthyroidism seen in a complete hydatidiform mole?
hCG can mimic TSH
What should women at moderate/high risk from pre-eclampsia take?
75mg aspirin daily from 12w gestation until birth
What are indications for a forceps delivery?
Foetal or maternal distress in the 2nd stage of labour
Failure to progress in 2nd stage of labour
Control of head in breech delivery
Prophylactic use in medical conditions, e.g. CV dx, HTN
What are the requirements for a forceps delivery?
FORCEPS = Fully dilated cervix OA position preferable Ruptured membranes Cephalic presentation Engaged presenting part Pain relief Sphincter (bladder) empty - usually req. catheterisation
Define engaged
Head at or below ischial spines
What are the 2 second stages of labour?
Passive second stage - 2nd stage in absence of pushing
Active second stage - active process of maternal pushing
Which of the two stages of the second stage of labour is more painful?
1st (pushing masks pain)
How long does the second stage of labour usually take? What can you do it if it is taking longer?
1h
Consider ventouse extraction, forceps delivery or c-section
What is a typical history of retained products post-c-section?
Pain, heavy vaginal bleeding
Boggy poorly contracted uterus
Offensive discharge may indicate products have become infected
How do you manage retained products?
Urgent ex under anaesthesia to remoe products
Define eclampsia
Development of seizures in associated with pre-eclampsia
What drug is used to prevent seizures in those with severe pre-eclampsia and treat seizures once they occur?
Magnesium sulphate
When should mg sulphate be given for severe pre-eclampsia?
Once a decision to delivery ahs been made
How should mg sulphate be given for eclampsia?
IV bolus 4g over 5-10m then infusion of 1g/h
What parameters should be measured during treatment with mg sulphate?
Urine output
Reflexes
RR
O2 sats
as resp. depression can occur
How do you treat resp. depression due to mg sulphate treatment?
Calcium gluconate
When should treatment with mg sulphate be continued until?
Until 24h after last seizure or delivery
What are features of eclampsia?
Seizures
Abdominal pain
NV
Visual disturbance
Hyperreflexia
Define puerperal pyrexia
Temperature >38C in the first 14d after delivery
What is the most common cause of puerperal pyrexia?
Endometritis
What are other causes of puerperal pyrexia?
UTI
Wound infections (perineal tears, c-section)
Mastitis
VTE
How should endometritis be managed?
Refer to hospital for IV antibiotics (clindamycin + gentamicin until afebrile for >24h)
What tests are done for Down’s syndrome in antenatal screening?
Combined test: nuchal translucency measurement (USS), serial bHCG (raised)+ pregnancy associated plasma protein A (low)
When should the combined test for Down’s screenig be done?
Between 11 - 13 + 6 weeks
NB if women book later in pregnancy either triple/quadruple test should be offered between 15 and 20weeks
What is involved in the triple assessment?
AFP (low), unconjugated oestriol (low), hCG (high)
What is involved in the quadruple assessment?
AFP, unconjugated oestriol, hCG, inhibin A (high)
What women are at increased risk of NTDs and should be advised to take 5mg dose of folic acid?
Prev. child with NTD DM Women on antiepileptic Obese (BMI >30) HIV +ve taking co-trimoxazole Sickle cell Coeliac disease Thalassaemia trait
When is the neural tube formed during the embyro’s development?
In the first 28 days
What is foetal fibronectin?
Protein released from the gestational sac
High levels related with early labour
Is active management of the third stage of labour recommended? Why or why not?
Yes to reduce PPH
How long does active management of the third stage of labour take?
30 mins
What does active management of the third stage of labour involve?
Uterotonic drugs (oxytocin) Deferred clamping + cutting of cord (between 1 min to 5 min after delivery) Controlled cord traction after signs of placental separation
List things that warrant continuous CTG use during labour:
Suspected chorioamnionitis/sepsis/temp 38+
Severe HTN 160/110mmHg or above
Oxytocin use
Presence of significant meconium
Fresh vaginal bleeding that develops during labour
What could fresh vaginal bleeding be a sign of during labour?
Placental rupture
Placenta praevia
Apart from mg sulphate what is another important aspect of treating severe pre-eclampsia/eclampsia?
Fluid restriction to avoid serious consequences of fluid overload
Where is the pain typically in HELLP syndrome/pre-eclampsia?
Epigastric or RUQ
When do uteruses tend to rupture?
During labour (may occur in 3rd trimester)
What are RFs for uterine rupture?
Prev. c-section
How does uterine rupture tend to present?
Maternal shock
Abdominal pain
Vaginal bleeding
What causes symphysis pubis dysfunction?
Ligament laxity increased in response to hormonal changes of pregnancy
How does symphysis pubis dysfunction tend to present?
Pain over pubic symphysis with radiation to groins and medial aspect of thighs
May see waddling gait
What is UTI in pregnancy associated with an increased risk of?
Pre-term delivery
IUGR
What causes RUQ in pre-eclampsia?
Stretching of liver capsule
If a women presents in labour with is found to be pre-eclamptic, how do you manage her?
IV labetalol (alt: oral nifedipine/hydralazine) Diastolic BP target of 80-100mmHg and systolic <150mmHg
Why do you have to have a high index of suspicion for chorioamnionitis?
Can be life-threatening to foetus and mother
What causes chorioamnionitis?
Ascending bacterial infection of amniotic fluid –> membranes –> placenta
What is a major RF for chorioamnionitis?
PROM
How is chorioamnionitis managed?
Prompt delivery of foetus
IV antibiotics
How does chorioamnionitis tend to present?
Uterine tenderness
Foul smelling discharge
Maternal fever, tachycardia, neutrophilia
Baseline foetal tachycardia
How do RA symptoms tend to change during pregnancy?
Improve during
Flare after delivery
Is methotrexate safe in pregnancy?
No - stop 6m before conception in MEN and WOMEN
What RA drugs are considered safe during pregnancy?
Sulfasalazine
Hydroxychloroquine
Low dose corticosteroids
NSAIDs until the 32w
Why should NSAIDs not be used by pregnant women after 32w gestation?
Due to risk of early closure of DA
Why should pregnant pts with RA be referred to an obstetric anaesthetist?
Risk of alanto-axial subluxation
Why must methotrexate be stopped prior to conception?
Teratogen - craniofacial defects, spine and rib defects, defects of digits
Can cause abortions
What additional measure can help the effectiveness of the McRobert’s manoeuvre?
Suprapubic pressure
If lochia persists beyond ___ weeks, what investigation should be done?
6 weeks
USS
May indicate retained products of conception
What is the puerperium?
Period of 6w post childbirth in which the women’s reproductive organs return to normal
What does a CTG measure?
Foetal HR and uterine contractions
If a newborn has only 1 minor RF for early onset sepsis how should they be manaed?
Remain in hospital for at least 24h with regular obs
2+ RFs or 1 red flag for early onset sepsis should be managed with?
Empirical benzylpenicillin and gentamicin + a full septic screen
What are red flags for early onset sepsis?
Suspected/confirmed infection in another baby in case of multiple pregnancy
Parenteral antibx treatment given to women for confirmed/suspected invasive bacterial infection at time of labour or 24h before/after the birth
Resp distress starting >4h after birth
Seizures
Need for mechanical ventilation in term baby
Signs of shock
What is Sheehan’s syndrome?
Complication of severe PPH where pituitary gland undergoes ischaemic necrosis –> hypopituitarism
What is the most common clinical feature of Sheehan’s syndrome?
Lack of post-partum milk production + amenorrhoea following delivery
How do you diagnose Sheehan’s syndrome?
Inadequate prolactin and gonadotrophin stimulation tests in pts with hx severe PPH
Define station
Term used to describe the head in relation to the level of the ischial spines
What does station of 0 mean?
Head is directly at the level of the ischial spines
What does station of -2 mean?
Head is 2cm above ischial spine
What does station of +2 mean?
Head is 2cm below ischial spine
In relation to rhesus disease:
What does sensitisation mean?
Process whereby foetal red cells (Rh +ve) enter the maternal circulation where the mother is Rh -ve this causes antibodies to form int he maternal circulation that can haemolyse foetal RBCs
Why are NOACs CI in pregnancy?
Can cause placental haemorrhage + subsequent foetal prematurity/loss
Why is warfarin CI in pregnancy?
Warfarin embyropathy if taken from weeks 6-13
(Nasal flattening –> severe mid face flattening and short limbs)
Exposure in 2nd/3rd trimester –> inc. risk of foetal haemorrhage
What is the management of a late deceleration on CTG?
Foetal blood sampling
If foetus acidosis consider urgent delivery
What is false labour?
(Irregular) contractions every 20m occurring in last 4 weeks of pregnancy
At what two gestations are women screened for anaemia during pregnancy?
Booking visit
28 weeks
What is the cut of for anaemia at the booking visit?
<11g/dl
What is the cut of for anaemia at the 28 week visit?
<10.5g/dl
What are the cut offs for anaemia in
a) the 1st trimester
b) the 2nd trimester
c) the 3rd trimester?
a) <110g/l
b) <105g/l
c) <100g/l
How should you manage anaemia in pregnancy?
Oral iron supplements
Only investigate if no rise in Hb after 2w
How should suspected DVT be investigated in pregnant women?
Compression duplex USS
How should suspected PE be investigated in pregnant women?
ECG, CXR
If also sx/sx DVT –> compression duplex USS –> shows DVT treat for VTE and no further Ix req.
Consider V/Q or CTPA
What is a con of using CTPA in pregnancy?
Pregnancy makes breasts particularly sensitive to radiation so increases lifetime risk of breast cancer
What is a con of using V/Q scan in pregnancy?
Slightly increased risk of childhood cancer
Can you use d-dimer in pregnancy?
No as it is often raised in pregnancy anyway
How should PE/DVT be treated in pregnancy?
LMWH
How do you carry out the woodscrew manoeuvre?
Put hand in vagina and rotate foetus 180 degrees to try and dislodge anterior shoulder from pubic symphysis
What is normal variability on CTG?
Between 5 and 25bpm
How is placenta accreta definitively managed?
Hysterectomy with placenta left in situ
attempts to remove only the placenta can lead to haemorrhage
What is GBS also known as?
Streptococcus agalacticae
What is the symphysis fundal height?
From top of pubic bone to top of uterus in cm
What should the SFH match?
The no of weeks in gestation +/-2cm
What are causes of increased nuchal translucency?
Down’s syndrome
Congenital heart defects
Abdominal wall defects
What are causes of hyperechogenic bowel on US in pregnancy?
Cystic fibrosis
Down’s syndrome
CMV
What are predisposing factors for aortic dissection in pregnancy?
HTN
Congenital heart disease
Marfan’s syndrome
What are the majority of aortic dissections during pregnancy?
Type A dissections
How does aortic dissection present?
Sudden tearing chest pain
Hypertensive
Aortic regurg murmur
