peer teaching oct 2018 Flashcards
what is the first line treatment for pre-eclampsia?
oral labetalol (beta blocker)
what are is the second and subsequent treatment of pre-eclampsia?
steroid is <34 wks
nifedipine (calcium channel blocker) or hydralazine (vasodilator)
the definitive treatment is the delivery of placenta–> mild by 37 wks. moderate/severe by 34 weeks
describe the changes in blood pressure during pregnancy?
- the blood pressure drops in the 1st trimester until 20/24 wks.
then the blood pressure increases to pre-pregnancy.
what is the new onset of hypertension in pregnancy defined?
> 140/90 mmHg
or an increase of > 30 systolic or >15 diastolic after 20 wks gestation
what are the high risk factors of developing pre-eclampsia?
previous hypertensive disease in previous pregnency
chronic kidney disease
autoimmune disease–> SLE or antiphospholipid syndrome
type 1 or 2 diabetes mellitus
what medication should women at risk of pre-eclampisa take?
daily aspirin from 12th wk until delivery (75 mg)
what are the moderate risk facotrs for developing pre-eclampisa?
first pregnency
aged 40 or older
pregnency interval over 10 years
BMI > 35
family history if pre-eclampsia
multiple pregnency
what is HELLP syndrome in pre-clampsia?
haemolysis
elevated liver emzymes
low platelets
what other conditions does re-clampsia predispose yout to?
DIC cerebrovasculat haemorrhage placental abruption renal failure eclampisa
what is eclampsia?
development of seizure in association with pre-eclapsia.
how to manage eclampsia?
Mg Sulfate. used to bith treat and prevent
causes of sepsis in neonates <48 hrs since birth? (early onset)
micro-organisms from the birth canal–> group B streptococcus
causes of sepsis in neonates >48 hrs? (late onset)
hospital acquired–> staph.aureus, or staph epidermidis
what are the risk factors of sepsis in neonates?
prematurity
prolonged rupture of the membranes
previous GBS infection
maternal pyrexia
what is the treatment for GBS ?
benzylpencillin
what arre the common causes of infection in pregnency ?(all are teratogenic)
Christ
C= CMV, visual hearing, mental development
H=Herpes zoster, rare
R=rubella, deafness, cardiac arrest, eye, mental development. befroe 16wk can offer termination
S=syphilis, miscarriage, congenital disease or still birth
T= toxoplasmosis, mental retardation, insual, hydrocephalus
what is cause of painless bleeding in pregnancy?
placenta praevia
what is the cause of paiful bleeding in pregnency?
placental abruption
what is placental praevia?
where the placenta is wholly or partially lying in the lower uterine segment
what are the causes of APM? (antpartum haemorrhage)
placenta praevia
placental abruption
vasa praevia
uterine rupture
what is the classification used in placenta praevia?
marginal (typeI-II)= in lower segment but not over the Os
major (type III-IV)= partially or completely covering the Os
what’s the presentation of placental praevia?
incidental USS
painless vaginal bleeding
abnormal breech
what is the magagement of placental praevia?
anti D is rhesus -ve
steroids <34 wks
deliver C/S
what is placental abruption
when all or part of the placenta separates before the delivery
what are the risk factors for placental abruption?
IUGR
pre-eclampsia
smoking
previous abruption
what is the presentation of placental abruption?
painful bleeding
ternder and tense uterus
Management of placental abruption?
ABCDE
anti-D is < 34 wks and not fetal distress
C/S if fetal distress
if no fetal distress and >37 wk induction of labout with amniotomy
what is the cause of pain in placenta abruption?
bloode behind placenta and in the myometrium.
what is vasa praevia?
when fetal blood vessel runs in the membranes before presenting part
when the membrane ruptures the vessel ruptures too
whats the presentation of vasa praevia?
painless viginal bleed
what are the 4 stages of fetal passage throught eh birth canal?
engagement, head enters the pelvis in occipital transverse position (OT)
desecent and flexion,
rotation
extention and deliver
restitiution
what are the factors determing the progree thoughout labour?
3Ps
Power–> force in expelling the fetus
Passage–> the dimensions of the pelvis and the resistance of the soft tissue
Passenger–> the diameter of the fetal head
what are the 3 stages of labour?
stage 1–> from the start of labour to full cevical dilation (10cm)
stage 2–> from full cervical dilation to the delivery of foetus
stage 3–> from foetus deliver to the placenta delivery
whats the cause of a lack of power in labour?
inefficient uterine contraction
common in nullips and induced labour
how to magage a lack of power in labour?
1st stage:
Nullip - Strengthening the powers artificially (augmentation) - artificial rupture of membranes (amniotomy, if this fails to progress further cervical dilatation in 1-2h, give oxytocin IV. If still not progressed within 12-16h, C/S.
Multip- exclude malpresentation before giving oxytocin
Passive 2nd stage:
Nullip - oxytocin, delay pushing by 2h
Active 2nd stage: if >1h, if head against perineum = episiotomy, if not = ventouse/forceps delivery
cause of problem with passage in labour?
cephalo-pelvic disproportion=pelvic too small to let the head through.
it is often a retrospect diagnosis in the abscence of malposition and malrepresentation
abnormal pelciv archiecture due to rickets, osteomalacia.
pelciv mass= fibroid or ovarian tumor
what is malposition?
Malpositions are abnormal positions of the vertex of the fetal head (with the occiput as the reference point) relative to the maternal pelvis
what is malrepresentation?
Malpresentations are all presentations of the fetus other than vertex.
what are the problems with passenger in labour?
occiput posterior (OP)= longer labour and more pain. use augmentation and rotation to turn to OA.
Occiput transverse (OT)= incomplete normal rotation, use ventouse
Brow presentation= extension of fetal head creating a large diameter. can palpate anterior fontanelle and supraorbital ridges–> C/S
Face presentation= complete extension of the head. Mouth, nose and eyes are palpable. if mento-anterior vaginal birth is possible.
for mento-posterior–> C/S
hydrocephaulus
what is bishop score?
method to rate the readiness of the cervix for induction of labor
interpretation of bishop score?
a score of < 5 indicates that labour is unlikely to start without induction
a score of > 9 indicates that labour will most likely commence spontaneously
Scores between 5 and 9 require additional consideration and professional judgement for clinical management.
whats the method to induce labour?
Vaginal prostaglandins are best method in nulliparous and most multiparous women
Oxytocin is after SROM or 2h after amniotomy
Surgical method (amniotomy) comes after less invasive method.
Amniotomy involves rupturing membranes with an amnihook.
what are the first line and subsequent methods of labour induction?
at all stages–> monitor with CTG
1) Membrane sweep
Pass finger through cervix and “strip” between the membranes and the lower segment of the uterus.
2) Vaginal prostaglandin gel
2mg inserted into the posterior vaginal fornix.
Give one dose and if it does not increase the cervical ripeness, you can try another dose 6h later. >2 doses are not helpful.
2)Amniotomy ± oxytocin
Rupture membranes with amnihook, if not progressed then start oxytocin infusion 2h after.
Can use oxytocin alone if SROM occurred.
complications from induced labour?
Higher risk delivery - using instrumental or C/S risk is higher
Hyperstimulation of uterine activity → causes fetal distress and uterine rupture
Umbilical cord can prolapse at amniotomy
PPH
Intrapartum and postpartum infection
Prematurity from incorrect gestation or by design
what is CTG used for?
Cardiotocography (CTG) is a technical means of recording the fetal heartbeat and the uterine contractions during pregnancy
CTG abnormality(prolonged and late decelerations) and palpable umnilical cors is an indication of what?
This scenario describes cord prolapse, which is causing cord compression and hence showing variable decelerations on the CTG.
what is the initial management of cord prolapse?
‘To prevent cord compression, it is recommended that the presenting part be elevated either manually or by filling the urinary bladder
what is terbutaline used in labour?
Terbutaline is a medication used to delay preterm labor. It is in a class of drugs called betamimetics, which help prevent and slow contractions of the uterus.
what are obstetric emergencies?
Shoulder dystocia Cord prolapse Uterine rupture Amniotic fluid embolism Retained placenta
what is shoulder dystocia?
=complication of vaginal delivery. Inability to deliver the body of the fetus, having already delivered the head. Usually due to impaction of anterior fetal shoulder on maternal pubic symphysis.
what are the complications of shoulder dystocia to the mother?
Postpartum haemorrhage (PPH), Perineal tears, urethral and bladder injuries
what are the complications of shoulder dystocia to the fetus?
Brachial plexus injury (Erb palsy; C5-7), hypoxia, hypoxic ischaemic encephalopathy and death
how to treat shoulder dystocia?
Call for help!
McRoberts’ manoeuvre. Bring mother’s thighs towards her abdomen (flexion and abduction of the hips) → increases the relative anterior-posterior angle of the pelvis
Apply suprapubic pressure
Internal manoeuvres (+/- episiotomy)
what is cord proplapse?
Umbilical cord descends ahead of the presenting part of the fetus
what is the risk of cord prolapse?
compression of cord or cord spasm → fetal hypoxia → irreversible damage (e.g. cerebral palsy) or death
what are the types of cord prolapse?
Occult (cord alongside the presenting part of fetus)
Overt (cord past presenting part)
whats the presentation of cord prolapse?
Mother usually asymptomatic/ report prolapse if the cord is outside the vagina.
Fetus commonly present with bradycardia (but could be any other CTG abnormality).
what is the disgnosis of cord prolapse?
Vaginal examination → is cord visible beyond the level of the introitus (vaginal opening)? Is cord palpable vaginally?
CTG
whats the management of cord prolapse?
Definitive Mx: deliver baby ASAP!
Urgent CS usually used
Instrumental vaginal delivery possible if fully dilated and will provide fastest delivery
Call for help! Need obstetrician, anaesthetist, neonatologist, and additional midwives
Try not to handle the cord (as much as possible). Handling can → vasospasm.
But until then…
If cord before the level of introitus → Presenting part of cord pushed back to avoid compression
If cord past level of introitus → keep warm and moist
Tocolytics (reduce contractions, and therefore cord compression)
cord prolapse risk factors?
The key with this question is thinking about things which make is less likely that the fetuses head will be engaged with the pelvis. If the head isn’t engaged, the cord is more likely to prolapse!
1)Raised liquor volume - True. (aka polyhydramnios).
Increases the space for the fetus to move, making it less likely to engage with the pelvis.
Polyhydramnios also increases risk of premature rupture of membranes. If this occurs the fetus won’t be engaged.
2)Multiple pregnancy - true
Multiple pregnancies mean the uterus is distended, and the positioning of the fetuses may result in poor engagement.
During vaginal delivery of twins, the greatest risk of cord prolapse comes after the delivery of the 1st twin. This is because the second twin may be lying in any position.
3)Low lying placenta - true (aka placenta praevia)
prevents head from engaging, and if placenta is not over the os, the cord could prolapse when the cervix dilates
4)Prematurity → the presenting part is rarely engaged until labour and is more likely to present breech
Breech → fetuses may not be engaged properly in the pelvis
Abnormal lie → presenting part is not in the pelvis
what is uterien rupture?
Important cause of abdo pain in late pregnancy (3rd trimester), usually .
risk factors for uterine rupture?
prev CS (v. rare in unscarred uteruses)
presentation of uterine rupture?
Maternal shock Severe abdo pain Vaginal bleeding to varying degree Chest / shoulder tip pain and sudden SOB CTG abnormalities
maganement of uterine rupture?
Urgent surgical delivery!
Future pregnancies: if pt has had a prev uterine rupture, vaginal birth after caesarean (VBAC) is CI’d.
what is amniotic fluid embolism?
When fetal cells/ amniotic fluid enters the mother’s bloodstream → stimulates a massive immune reaction. Aetiology not understood
what are the phases of amniotic fluid embolism?
Pulmonary embolism → direct blockage, anaphylactic reaction → hypoxia and acute RDS
Hemorrhagic phase → activation of complement pathways → DIC. this is often fatal.
signs and symtoms of amniotic fluid embolism?
presents similiar to PE
Signs: tachypnoea, tachycardia, hypotension, coagulation/ severe bleeding, cyanosis, cardiac arrest, hypoxia, resp arrest
Symptoms: SOB, palpitations, dizziness, confusion, seizures, cough, pul oedema, loss of consciousness
what is the management of amniotic flid embolism?
ABCDE
Maintain O2: 100% supplemental O2 via mechanical ventilation
Maintain perfusion: fluid replacement, inotropic drugs
Correct coagulopathy: discuss w/ on-call haematologist. May need to give blood products
Delivery. Perimortem CS should be considered. It will improve fetal and maternal survival.
what is the diagnosis of retained placenta?
Physiological Mx → if placenta not delivered w/in 60 mins of the baby Active Mx (synthetic oxytocin + controlled cord contraction) → if placenta not delivered w/in 30 mins of the baby
what is the cause of retained placenta?
Uterine atony - most common
Trapped placenta - placenta detached but unable to deliver due to closed os
Placenta accreta/ percreta - more common w/ prev. CS.
complications of retained placenta?
PPH (occurs 24hrs - 12 wks after birth)
Genital tract infection
Uterine inversion → emergency as can cause acute neurogenic shock, w/ profound bradycardia and hypotension
management of placenta retainment?
Call for help
Assess blood loss
Administer IM syntocinon - increases uterine tone and may help with delivery.
Ensure bladder empty (full bladder can contribute to retention).
Manual removal of the placenta in theatre
what is fetal distress?
signs before and during childbirth indicating that the fetus is not well. Fetal distress is an uncommon complication of labor.
Hypoxia that might result in fetal death or damage if not reversed or fetus delivered urgently. pH in the fetal scalp of <7.20 = sig hypoxia
what is a meaure of fetal distress?
CTG, fetal blood sampling, fetal ECG
what is CTG monitoring?
DR Brvado
DR – define risk - Other risk factors?
C – Contractions per 10 mins - Hyper stimulation > 5 in 10 mins
BR – Baseline rate – 110 – 160 is normal
V – Variability – variation should be >5 beats per minute
A – Accelerations - accelerations in fetal heart rate with movement or contractions are reassuring
D – Decelerations – Early (with contractions, usually benign) , Variable (? Cord compression), Late (persist after contractions, suggest fetal hypoxia)
O – Overall assessment – if normal CTG it’s reassuring, false positive is high for abnormal patterns
syntocinon is the 1st line treatment of what?
Uterine atony is the most common cause of primary postpartum haemorrhage (PPH). RCOG guidance: This states that first-line management should be 5U of IV Syntocinon (oxytocin), followed by 0.5 mg of ergometrine.
what si primary postnatal haemorrhage?
occurs within 24h
Loss of >500ml blood <24h of delivery or >1000ml after C/S
Causes
Uterine atony (most common cause!) → enlarged uterus
Genital trauma
Vaginal: Bleeding from a perineal tear or episiotomy or high vaginal tear
Cervical: Associated with precipitate labour and instrumental delivery
Retained placenta
Coagulopathy
what is secondary haemorrhage?
occurs between 24h and 12 weeks following delivery. Due to retained placenta or endometritis.
Excessive blood loss occurring between 24h and 6 weeks after delivery
Causes
Endometritis, retained placental tissue, gestational trophoblastic disease
Uterus is enlarged/tender with an open internal cervical os
Mx
Antibiotics
Evacuation of retained products of conception (heavy bleeding)
what are the risk factors for PPH?
previous PPH prolonged labour pre-eclampsia increased maternal age polyhydramnios emergency Caesarean section placenta praevia, placenta accreta macrosomia ritodrine (a beta-2 adrenergic receptor agonist used for tocolysis)
what is the management of parimary PPH
ABC
1st line - IV syntocinon (oxytocin) 10 units or IV ergometrine 500 micrograms
IM carboprost
Remove retained placenta manually if there is bleeding or if not expelled within 60 mins of delivery
Other options include: B-Lynch suture, uterine or internal iliac artery embolisation
If severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure
Which creening tools is most appropriate to detect postnatal depression?
Edinburgh Scale
what is baby blue?
presentation=Typically seen 3-7 days following birth and is more common in primips.
Mothers are characteristically anxious, tearful and irritable.
mx=Reassurance and support, the health visitor has a key role.
what is postnatal depression?
px=Most cases start within a month and typically peaks at 3 months.
Features are similar to depression seen in other circumstances.
Mx=As with the baby blues reassurance and support are important.
CBT. SSRIs such as sertraline and paroxetine, only if sx are severe.
what is Puerperal psychosis?
Px=Onset usually within the first 2-3 weeks following birth.
Features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations).
Mx=Admit to hospital.
20% risk of recurrence.
