Postnatal and Neonatal Care Flashcards
What is the recommended dose of acyclovir to be administered to neonates at high risk of vertical transmission of herpes simplex?
a. 2mg/kg
b. 5mg/kg
c. 10mg/kg
d. 20mg/kg
e. 35mg/kg
D - 20mg/kg
Infants born to mothers with recent or active primary genital HSV infection require active management with IV anti-viral medication at birth. The dose is higher per kg than in adults – 20mg/kg 8 hourly.
Which of the following is NOT routinely recommended for systemically well infants delivered vaginally to mothers with a history of primary HSV <6 weeks antenatally?
a. Lumbar puncture
b. Skin swabs
c. Breastfeeding
d. IV acyclovir 8 hourly
e. Rectal and oropharyngeal swabs
A - Lumbar puncture
Active investigation and management for potential neonatal HSV infection is recommended in babies born vaginally to mothers with a history of primary genital HSV in the third trimester or <6 weeks pre-delivery including IV acyclovir and rectal, skin, oropharyngeal and conjunctival swabs. Breastfeeding is recommended unless the mother has herpetic lesions around the nipples. There is not indication for routine lumbar puncture in the initial investigation of a well neonate.
What percentage of neonatal HSV is though to be acquired postnatally?
a. 5%
b. 10%
c. 25%
d. 35%
e. 50%
C - 25%
Up to 25% of neonatal HSV is thought to be as a result of postnatal contact with the virus – often via an infected relative of the mother. Those with coldsores should not kiss the baby.
A neonate born to a mother with undetected primary HSV 4 weeks prior to vaginal delivery presents with disease which appears to be localised to the skin alone. With appropriate antiviral treatment, what is the likelihood of long-term neurological morbidity?
a. <2%
b. 4%
c. 8%
d. 12%
e. 15%
A - <2%
The prognosis is neonatal herpes infection depends largely on the systems involved – infants with localised skin/eye or mouth infection alone have the best prognosis – with appropriate treatment, neurological or ocular morbidity is <2%. Such presentation accounts for ~30% of all neonatal herpes infection.
An infant is readmitted from home after a normal vaginal delivery 2 weeks ago with suspected localised CND HSV disease. What are the approximate rates of mortality and long-term neurological impairment associated with such a presentation?
a. Mort. 2% Neuro. 20%
b. Mort. 5% Neuro. 33%
c. Mort 6% Neuro. 70%
d. Mort 10% Neuro. 50%
e. Mort 30% Neuro. 85%
C - Mortality 6%; Neurological Impairment 70%
70% of neonatal herpes infections involve disseminated or localised CNS disease which both carry a considerably worse prognosis than isolated skin disease. In localised CNS disease, mortality is around 6% and neurological morbidity (which may well be lifelong) 70%.
An infant is readmitted following vaginal delivery with apparent disseminated HSV infection. What are the respective rates of mortality and long term neurological impairment in this group?
a. Mort. 5% Neuro 33%
b. Mort. 30% Neuro. 80%
c. Mort. 30% Neuro. 17%
d. Mort. 50% Neuro 50%
e. Mort 70% Neuro. 33%
C - Morality 30%; Neurological Impairment 17%
Disseminated neonatal herpes infection unsurprisingly carries the poorest prognosis – 30% morality and 17% long term neurological sequelae. Poorer outcomes in these groups are in part attributed to the fact that symptom onset if often more delayed (~10 days to 4 weeks postnatal typically) meaning further time may elapse before a diagnosis is reached.
Which of the following is reported transiently amongst infants born to mothers taking acyclovir in pregnancy?
a. Raised liver enzymes
b. Low platelets
c. Neutropenia
d. Hypocalcaemia
e. Hypophosphataemia
C - Neutropenia
Mothers taking acyclovir as prophylaxis against active lesions at delivery can be reassured that while the drug is not licensed for use in pregnancy, it is not known to be harmful – a transient neonatal neutropenia has been reported in some though with no long term adverse effects.
What is the approximate incidence of EOGBS disease of the newborn in the UK?
a. 0.1 in 1000
b. 0.5 in 1000
c. 1 in 1000
d. 2.5 in 1000
e. 3 in 1000
B - 0.5 in 1000
The incidence of EOGBS infection in the UK was 0.57/1000 in 2015 representing a considerable increase since the previous survey in 2000. This equated to 517 cases nationwide in one year.
How soon following birth must GBS infection occur to be considered ‘early onset’?
a. 24 hours
b. 3 days
c. 7 days
d. 14 days
e. 6 weeks
C - 7 days
To differentiate it from late-onset GBS, EOGBS is defined as infection occurring within the first 7 days of life. This sad, over 90% of affected infants will display clinical signs or symptoms within 12 hours.
What is the case-fatality rate amongst infants affected by EOGBS disease?
a. 1%
b. 5%
c. 10%
d. 20%
e. 35%
B - 5%
While rates of GBS appear to have risen somewhat in recent years, the mortality associated with the condition have fallen drastically from ~10% in 2000 to ~5% in 2015. This is considerably greater for preterm infants (20-30%) than term (2-3%)
What proportion of babies affected by EOGBS disease are born prematurely?
a. 1/10
b. 1/8
c. 1/5
d. 1/3
e. 1/2
C - 1/5
22% of infants who developed EOGBS in the 2015 survey were delivered preterm – equivalent to around 1/5. The mortality associated with EOGBS infection in preterms is tenfold higher than term – 20-30% vs. 2-3%.
What is the incidence of EOGBS in the newborn where the mother develops a temperature >38C in labour?
a. 1 in 400
b. 1 in 200
c. 1 in 150
d. 1 in 100
e. 1 in 50
B - 1 in 200
Maternal pyrexia >38C in labour increases the risk of EOGBS in the neonate and antibiotics given for this should also cover GBS. The risk is estimated to be approximately 1 in 200
A primigravida is booked for midwifery led care in this pregnancy and attends the birthing unit in spontaneous labour at 38/40. On review of her record, the midwife notes that she tested positive for GBS during an admission with suspected, though unconfirmed, membrane rupture at 32/40. She explains to the patient that antibiotic prophylaxis is recommended though the patient declines. How long after birth in such cases should the baby be closely monitored as an inpatient for signs of EOGBS infection?
a. 6 hours
b. 12 hours
c. 24 hours
d. 48 hours
e. 72 hours
B - 12 hours
Infants deemed to be at risk of GBS infection where antibiotic prophylaxis has not been given in labour, should be monitored at birth, 1 hour, 2 hours then 2 hourly thereafter for signs suggestive of GBS infection. Where the mother has received adequate antibiotic prophylaxis (i.e. >4 hours), no additional monitoring is necessary. The exception is mothers with a previously affected baby – these infants should be monitored for 12 hours regardless.
A Para 2 with a history of GBS carriage in a previous pregnancy (the baby was not affected) receives IAP in labour this time around. Antibiotics were commenced when she attended delivery suit at 01:00 and she delivered by SVD some 9 hours later at 10:00. How long after birth should be the baby be closely monitored as an inpatient for signs of EOGBS infection?
a. No monitoring required
b. 4 hours
c. 6 hours
d. 12 hours
e. 24 hours
A - No monitoring required
Infants deemed to be at risk of GBS infection where antibiotic prophylaxis has not been given in labour, should be monitored at birth, 1 hour, 2 hours then 2 hourly thereafter for signs suggestive of GBS infection. Where the mother has received adequate antibiotic prophylaxis (i.e. >4 hours), no additional monitoring is necessary. The exception is mothers with a previously affected baby – these infants should be monitored for 12 hours regardless.
A Para 1 undergoes induction of labour at term for anxiety after her first child died of GBS infection at 3 days of life. She is treated appropriately and promptly with IV IAP in labour and after a 6 hour labour, delivers by SVD. How long after birth should the baby be closely monitored as an inpatient for evidence of EOGBS?
a. No monitoring necessary
b. Hourly until 6 hours
c. 2 hourly for 24 hours
d. 4 hourly for 48 hours
e. At 1 hour, 2 hours and 2 hourly thereafter for 12 hours
E - At 1 hour, 2 hours and 2 hourly thereafter until 12 hours
Infants deemed to be at risk of GBS infection where antibiotic prophylaxis has not been given in labour, should be monitored at birth, 1 hour, 2 hours then 2 hourly thereafter for signs suggestive of GBS infection. Where the mother has received adequate antibiotic prophylaxis (i.e. >4 hours), no additional monitoring is necessary. The exception is mothers with a previously affected baby – these infants should be monitored for 12 hours regardless.
What antibiotic regimen is advised for babies who display symptoms/signs of EOGBS infection after birth?
a. Benzylpenicillin monotherapy
b. Benzylpenicillin/Vancomycin
c. Gentamicin monotherapy
d. Benzylpenicillin/Gentamicin
e. Vancomycin monotherapy
D - Benzylpenicillin/Gentamicin
Babies who display signs suggestive of EOGBS infection should receive both Benzylpenicillin and Gentamicin.
What is the relative risk of developing VTE in the post-partum, compared with the ante-partum period?
a. 2x
b. 5x
c. 10x
d. 15x
e. 20x
B - 5x
The risk of VTE is increased 4-6 times in pregnancy when compared with non-pregnant controls. This is an worthwhile consideration when we think how much emphasis is put on considerably smaller increases in risk of VTE on certain contraceptives. The risk is further increased considerably in the post-natal period – around 20 times greater than outwith pregnancy or, put another way, around 5 times greater than antenatally. For this reason, the threshold for prophylactic LMWH is considerably less in the post-natal period.
How long after administration of a spinal anaesthetic or siting of an epidural catheter might LMWH safely be administered in at-risk patients?
a. 2 hours
b. 4 hours
c. 6 hours
d. 12 hours
e. 18 hours
B - 4 hours
LMWH should not be given for a minimum of 4 hours following a spinal anaesthetic or removal of an epidural catheter. Where regional anaesthetic has NOT been used, the first dose of LMWH should be given as soon as possible after delivery providing there is no PPH, as pregnancy associated pro-thrombotic changes are maximal immediately following delivery.
How long after a dose of prophylactic LMWH might an epidural catheter safely be removed?
a. 4 hours
b. 6 hours
c. 8 hours
d. 12 hours
e. 24 hours
D - 12 hours
An epidural catheter should not be removed less than 12 hours from the last administration of LMWH.
A patient on antenatal LMWH prophylaxis for a history of VTE requires a return-to-theatre on day 3 after she develops a large haematoma within her caesarean section scar. What is the incidence of wound haematoma after LSCS in women on prophylactic LMWH?
a. 0.5%
b. 2%
c. 5%
d. 7.5%
e. 10%
B - 2%
Evidence for an increased risk of bleeding amongst patients on LMWH is controversial – some studies suggestive of an increased risk of PPH which is not supported by others. The risk of wound haematoma after caesarean section amongst those on prophylactic LMWH is increased at ~2%.
You see a patient on the postnatal ward round who has been on LMWH since developing a DVT in the left calf at 35/40. She is struggling with administering daily heparin injections and enquires about the option of switching to an oral preparation. How long after delivery is it appropriate to switch from LMWH to warfarin?
a. 24 hours
b. 48 hours
c. 5 days
d. 7 days
e. 10 days
C - 5 days
Women should be offered a choice of either LMWH or oral anticoagulants for postnatal therapy though should be advised of the need for regular blood tests for monitoring of warfarin levels, especially during the initial 10 days of treatment. Warfarin should be avoided until day 5 post-partum or long in women at increased risk of PPH.
- How long after switching to warfarin postnatally, should LMWH be continued in patients who develop VTE in pregnancy?
a. LMWH can be stopped immediately on commencing warfarin
b. 3 days
c. 7 days
d. Until INR >2 for 24 hours
e. Until INR >2.5 for 24 hours
D - Until INR >2 for 24 hours
INR should be checked on day 2 of warfarin treatment and subsequent doses titrated to keep INR between 2 and 3 – heparin should be continued until INR is >2 for at least 24 hours. Both warfarin and LMWH are safe in breastfeeding.
- Which of the following risk profiles most accurately reflects the safety of varying thromboprophylaxis agents in breastfeeding mothers?
LMWH Warfarin NOACS
a. Safe Safe Safe
b. Safe Not safe Safe
c. Safe Safe Not safe
d. Not safe Safe Not safe
e. Safe Not safe Not safe
C - LMWH and warfarin safe; NOACs not safe
Neither unfractioned nor low-molecular weight heparin nor warfarin are contraindicated in breastfeeding. Small amounts of heparin may be present in breast milk although as neither form is orally active, this is of little consequence. Warfarin in 99% bound to serum proteins and does not pass into breast milk to any measurable degree. NOACs may be considered in women who are not breastfeeding but data on safety in those who are is severely limited/lacking altogether and they should be avoided.
A patient has a spontaneous vaginal delivery following diagnosis of an IUFD at 36/40. What would you offer to suppress lactation as a first line agent?
a. Domperidone 250mg BD for 7 days
b. Bromocriptine 2.5mg BD for 14 days
c. Cabergoline 1mg stat dose
d. Prolactin 32mg stat dose
e. Bromocriptine 5mg stat dose
C - Cabergoline 1mg stat dose
Women should be advised that dopamine agonists successfully suppress lactation in a very high proportion of women and are very well tolerated. Cabergoline at a single stat dose of 1mg is equally effective though simpler to use than Bromocriptine which must be taken twice daily for 14 days. Dopamine agonists are contraindicated in women with pre-eclampsia or hypertension.