Pregnancy Flashcards
1
Q
Molar pregnancy has what appearance on ultrasound?
A
Snow storm appearance
2
Q
What marker is used in pregnancy tests?
A
- beta HCG
- human chorionic gonadotrohpin
3
Q
Name causes of bleeding in pregnancy
A
- implantation bleeding
- sub-chorionic haematoma
- cervical causes; infection, malignancy, polyp
- vaginal causes; infection, malignancy
- unrelated; haematuria, PR bleeding etc
- miscarriage
- ectopic
4
Q
Describe symptoms of miscarriage
A
- positive urine pregnancy test
- bleeding primary symptoms (> cramping), varied amount
- period type cramps
- passed products may be brought in
- cervical shock symptoms
5
Q
What are cervical shock symptoms and how are they managed?
A
- cramps
- nausea and vomiting
- sweating
- fainting
- resolves if product removed from cervix
- resuscitation with IV infusion, uterotonics maybe required
6
Q
What are the causes of miscarriage
A
- embryonic abnormality
- immune cause; antiphospholipid syndrome
- infections; cytomegalovirus, rubella, toxoplasmosis, listeria
- severe emotional upsets, stress
- iatrogenic loss
- associations; heavy smoking, cocaine, alcohol misuse
- uncontrolled diabetes
7
Q
Describe the pathophysiology of miscarraige
A
- unclear
- bleeding from placental bed or chorion causing hypoxia and villous / placental dysfunction
- this causes embryonic demise
8
Q
What are the different classifications of miscarriage?
A
- threatened miscarriage (risk to pregnancy)
- inevitable miscarriage (pregnancy can’t be saved)
- incomplete miscarriage (part of pregnancy is lost already)
- complete miscarriage (all of pregnancy is lost, uterus is empty)
- early foetal demise or non-continuing pregnancy
- anembryonic pregnancy; no foetus, empty sac
9
Q
Describe the management of miscarriage
A
- assessing and ensuring haemodynamic stability
- investigations; FBC, group and save, serum hCG, ultrasound, histology
- realistic but sensitive discussion
- discharge or admit
- treatment; conservative, medical, manual vacuum aspiration
- anti-D administration if surgical intervention is needed
- emotional support
10
Q
Recurrent miscarriage is defined as what?
A
3 or more pregnancy losses
11
Q
Name the common sites of ectopic pregnancy
A
- fallopian tube
- interstitial
- isthmic
- ampullary
- fimbrial
12
Q
Describe the presentation of ectopic pregancy
A
- pain
- dizziness
- collapse
- shoulder tip pain
- shortness of breath
- pallor
- haemodynamic instability
- signs of peritonism
- guarding and tenderness
13
Q
Name investigations for ectopic pregnancy
A
- FBC
- group and save
- beta HCG
- USS (transvaginal is the gold standard); empty uterus / pseudo sac, +/- mass in adenexa, free fluid pouch of douglas
14
Q
Describe the management of ectopic pregnancy
A
- ABCDE
- surgical management (if patient acutely unwell); laparoscopic salpingectomy or salpingotomy
- medical management (if stable); methotrexate 1 or 2 doses as protocol
- conservative management
15
Q
Describe the presentation of pregnancy of unknown location
A
- amenorrhoea
- abdominal pain
- no evidence of pregnancy in uterus, fallopian tube, cervix, csection scar or abdominal cavity
- level of hCG confirming a pregnancy circumstnace
16
Q
Describe the management of pregnancy of unknown location
A
- follow up with progesterone levels
- medically with methotrexate if no deterioration clinically
17
Q
Describe possible issues of presentation for molar pregnancy
A
- hyperemesis, hyperthyroidism, early onset pre-eclampsia
- varied bleeding and occasional history of passage of ‘grape like’ tissue
- fundus > dates on abdominal palpation
- rare cases; shortness of breath (due to embolisation to lungs) or seizures (metastasis to brain)
- USS can diagnose ‘snow storm appearance’
18
Q
Describe the management of molar pregnancy
A
- surgical procedure (uterine evacuation) and tissue sent for histology to ascertain type
- in higher gestation where foetus is present in partial mole medical management can be undertaken
- registration and follow up with molar pregnancy services
- 3 centres in UK; london, sheffield, dundee
19
Q
What is implantation bleeding?
A
- occurs when the fertilised egg implants in the endometrial lining
- timing is about 10 days post-ovulation
- bleeding is light / brownish and self limiting
- soon signs of pregnancy emerge
- occasionally mistaken as period (2 weeks post ovulation, heavier, bright red like a normal period usually)
- watchful waiting and being aware of entity
- usually settles and pregnancy continues
20
Q
What is a chorionic haematoma?
A
Pooling of blood between endometrium and the embryo due to separation; sub-chorionic
21
Q
Describe symptoms of chorionic haematoma
A
- bleeding
- cramping
- threatened miscarriage
- large haematomas may be a source of infection, irritability (causing cramping) and miscarriage
22
Q
How is bacterial vaginosis treated in pregnancy?
A
- metronidazole 400mg twice daily for 7 days
- avoid alcohol during medication
- option of vaginal gel
23
Q
How is chlamydia treated during pregnancy?
A
- erythromycin, amoxicillin
- test of cure 3 weeks late
- liaise with sexual health, include partner tracing
24
Q
What is hyperemesis gravidarum?
A
- vomiting in the first trimester common, limited and mild
- starts as early as around time of missed period
- if excessive, protracted, altering quality of life it is called hyperemesis gravidarum
25
Hyperemesis gravidarum can have what effects?
- dehydration
- ketosis
- electrolyte and nutritional disbalance
- weight loss
- altered liver function (up to 50%)
- signs of malnutrition
- emotional instability, anxiety
- severe cases can cause mental health issues
26
What are the principles of management of hyperemesis gravidarum?
- rehydration IV, electrolyte replacement
- parenteral antiemetic
- nutritional supplement
- vitamin supplement; thiamine / pabrinex
- NG feeding, total parenteral nutrition
- steroid use in recurrent, severe cases
- thromboprophylaxis
27
Name medications used in the treatment of hyperemesis gravidarum
- antimetics
- first line; cyclizine (50mg orally, IM or IV 8 hourly), prochlorperazine (12.5mg IM/IV 8 hourly or 5-10mg orally 8 hourly)
- second line; metoclopramide 5-10mg IM 8 hourly
- thiamine supplement 50mg TDS / pabrinex IV
- H2 receptor blocker (ranitidine) and PPI (omperazole) safe for use in pregnancy
- steroid; oral prednisolone 40mg/ day in divided doses, tapered per effect over weeks
28
The fertilised ovum progressively divides and differentiates into what?
A blastocyst as it moves from site of fertilisation in the upper oviduct to the site of implantation in the uterus
29
What occurs 3-5 days after fertilisation?
Transport of blastocyst into the uterus
30
What occurs 5-8 days after fertilisation?
Blastocyst attaches to lining of uterus
31
What do the two parts of the blastocyst go on to develop?
- inner cells develop into embryo
| - outer cells burrow into uterine wall and become placenta
32
What happens when the blastocyst adheres to the endometrial lining?
- cords of trophoblastic cells being to penetrate the endothelium (achieves implantation)
- advancing cords of trophoblastic cells tunnel deeper into endometrium, carving out a hole for the blastocyst
- the boundaries between cells in the advancing trophoblastic tissue disintegrate
33
The placenta is derived from what?
Both trophoblast and decidual tissue
34
Describe placental development
- trophoblast cells (chorion) differentiate into multinucleate cells (syncytiotrophoblasts) which invade decidue and break down capillaries to form cavities filled with maternal blood
- developing embryo sends capillaries to form palcental villi
- no direct contact between foetal and maternal blood, thin layer of tissue
35
Describe the early nutrition provisions for the embryo
- invasion of the trophoblastic cells into the decidua
- HCG signals the corpus luteum to continue secreting progesterone
- progesterone stimulates decidual cells to concentrate glycogen, proteins and lipids
36
The oxygen supply of the foetus with oxygen is facilitated by what three factors?
- foetal Hb; increased ability to carry O2
- higher Hb concentration in foetal blood
- bohr effect; foetal Hb can carry more oxygen in low PCO2 than in high PCO2
37
How does the placenta transport nutrients and waste products?
- water diffuses along its osmotic gradient
- electrolytes follow H20 (iron and Ca2+ only go from mother to child)
- glucose, passes via simplified transport
- free diffusion of fatty acids
- diffusion of waste products
38
Name examples of drugs that can cross the placenta
- thalidomide, carbamazepine, coumarins, tetracycline
| - alcohol, nicotine, heroin, cocaine, caffeine
39
Human chorionic gonadotrophin (HCG) has what effects?
- prevents involution of corpus luteum (which in turn stimulates progesterone, oestrogen)
- effect on the testes of male foetus; development of sex organs
40
Human placental lactogen has what effects?
- produced from week 5 of pregnancy
- growth hormone like effects, protein tissue formation
- decreases insulin sensitivity in mother; more glucose for the foetus
- involved in breast development
41
Progesterone has what effects?
- development of decidual cells
- decreases uterus contractility
- preparation for lactation
42
Oestrogens have what effect?
- enlargement of uterus
- breast development
- relaxation of ligaments
43
Increase in cardiac output in pregnancy is due to what?
The demands of the uteroplacental circulation
44
Why does the cardiac output depend on body position in pregnancy?
The uterus can compress the vena cava
45
Describe the cardiovascular changes during pregnancy
- increased cardiac output
- heart rate increased
- bp drops during 2nd trimester, rises in 3rd trimester
- multiple pregnancy; CO increases more, BP drops more
- increased plasma volume
- increased stroke volume
- decreased peripheral vascular resistance
46
Describe the haematological changes during pregnancy
- plasma volume increases proportionally with cardiac output
- erythropoesis increases
- Hb is decreased by dilution
- iron requires increases; meaning iron supplements are needed
47
What is the definition of anaemia in pregnancy?
- first trimester Hb <110g/L
| - 2nd and 3rd trimester Hb <105g/L
48
Describe the respiratory changes during pregnancy
- occur partly due to progesterone increase and partly because enlarging uterus interferes with lung function
- lower CO2 levels
- O2 consumption increases to meet metabolic needs
- RR increases, tidal and minute volume increases
49
Describe the urinary system changes during pregnancy
- GFR and renal plasma flow increases (up to 30-50%; peaks at 16-24 weeks)
- increased re-absorption of ions and water; placental steroids, aldosterone
- slight increase of urine formation
50
What is the average weight gain during pregnancy?
11kg
51
What occurs during the mothers anabolic phase?
- normal or increased sensitivity to insulin
- lower plasmatic glucose level
- lipogenesis, glycogen stores increases
- growth of breasts, uterus, weight gain
52
What occurs during the mothers catabolic phase?
- accelerated starvation
- maternal insulin resistance
- increased transport of nutrients through placental membrane
- lipolysis
53
What are the hormonal changes towards the end of pregnancy?
- uterus becomes progressively more excitable
- oestrogen:progesterone ratio alters increasing excitability; progesterone inhibits contractility while oestrogen increases contractility
- prostaglandins produced by placenta, myometrium, decidua and membranes
- oxytocin (from maternal posterior pituitary gland); increases contractions and excitability
54
Cervical stretching during labour causes what to be released?
Oxytocin
55
What are the three stages of labour?
- 1st stage; cervical dilation (8-24 hours)
- 2nd stage; passage of the foetus through birth canal (few min to 120 mins)
- 3rd stage; expulsion of placenta
56
What hormones are involved in producing and releasing milk?
- oestrogen; growth of ductile system
- progesterone; development of lobule alveolar system
- both of these inhibit milk production, at birth sudden drop in E and P
- prolactin stimulates milk production
- oxytocin; mild let down reflex
57
What are the folic acid recommendations?
- 400mcg folic acid pre-conception and first trimester
| - 5mg in some cases (obese, diabetics, antiepileptics, FH)
58
What are the vitamin D recommendations?
- Throughout pregnancy and continuation if breast feeding
| - 10 mcg/day
59
What foods should be avoided in pregnancy?
- soft cheese
- undercooked meat, cured meats, game
- tuna
- raw / partially cooked eggs
- pate
- liver
- vitamin and fish oil supplements
60
What is the commonest cause of iatrogenic prematurity?
Pre-eclampsia
61
What is the definition of hypertension in pregnancy?
- >140/90 mmHg on 2 occasions
- >160/110 mmHg once
- (>30/15 mmHg compared to first trimester BP)
62
What are the risks of having pre-existing hypertension during pregnancy?
- pre-eclampsia 2x risk
- foetal growth restriction
- placental abruption
63
Describe pregnancy induced hypertension
- second half of pregnancy
- resolves within 6 weeks of delivery
- no proteinuria or other features of pre-eclampsia -
- rate of recurrence is high
64
What is the triad of features of pre-eclampsia?
- hypertension
- proteinuria (>0.3g/24h or uPCR>0.3)
- oedema
- rarely all three so absence does not exclude diagnosis
65
What is pre-eclampsia?
- a pregnancy specific multi-system disorder with unpredictable, variable and widespread manifestations
- women may be asymptomatic at the first time of their presentation
- diffuse vascular endothelial dysfunction, widespread circulatory disturbance
66
What is the time scale for early and late pre-eclampsia?
- early pre eclampsia <34 weeks
| - late pre-eclampsia >34 weeks
67
Describe the pathogenesis of pre-eclampsia
- stage 1; abnormal placental perfusion, placental ischaemia
- stage 2; maternal syndrome, an anti-angiogenic state associated with endothelial dysfunction
68
What is HELLP syndrome?
- associated with pre-eclampsia
- haemolysis
- elevated liver enzymes
- low platelets
69
What liver features can occur with pre-eclampsia?
- epigastric / right upper quadrant pain
- abnormal liver enzymes
- hepatic capsule rupture
- HELLP syndrome
70
Name symptoms of pre-eclampsia
- headache
- visual disturbance
- epigastric / RUQ pain
- nausea / vomiting
- rapidly progressive oedema
- considerable variation in timing, progression and order of symptoms
71
Name signs of pre-eclampsia
- hypertension
- proteinuria
- oedema
- abdominal tenderness
- disorientation
- small for gestational age (SGA) foetus
- intra-uterine foetal death
- hyper-reflexia / involuntary movements / clonus
72
Name investigations for pre-eclampsia
- urea and electrolytes
- serum urate
- liver function tests
- FBC
- coagulation screen
- urine-protein creatinine ratio
- cardiotocography
- ultrasound; foetal assessment
73
Name risk factors for pre-eclampsia
- maternal age >40
- maternal BMI >30
- family history
- first pregnancy
- multiple pregnancy
- previous PE
- birth interval >10 years
- molar pregnancy
- pre-existing renal disease,
- pre-existing hypertension -
- diabetes all forms
- connective tissue disease
- thrombophilias
74
What is the mode of action of aspirin?
- inhibits cyclo-oxygenase
| - prevents TXA2 synthesis
75
What is low dose aspirin used for in pregnancy?
- prevention of pre-eclampsia
- used for high risk women renal, DM etc
- commence before 16 weeks
- 150mg dose
76
How can pre-eclampsia be predicted on ultrasound?
- maternal uterine artery doppler
- at 20-24 weeks
- notching of the artery is a sign
77
What drugs can be used to treat hypertension in pregnancy?
- methyldopa (centrally acting alpha agonist)
- labetalol (alpha and beta antagonist)
- nifedipine SR (Ca2+ channel antagonist)
- hydralazine and doxazocin 2nd line
78
How is the foetus monitored during admission for pre-eclampsia?
- foetal movements
- CTG daily
- ultrasound; biometry, amniotic fluid index, umbilical artery doppler
79
What are the indications for birth with a pre-eclamptic mother?
- term gestation
- inability to control BP
- rapidly deteriorating biochemistry / haematology
- eclampsia
- other crisis
- foetal compromise
80
Name crises in pre-eclampsia
- eclampsia
- HELLP syndrome
- pulmonary oedema
- placental abruption
- cerebral haemorrhage
- cortical blindness
- DIC
- acute renal failure
- hepatic rupture
81
What is eclampsia?
- tonic clonic (grand mal) seizure occuring with features of pre-eclampsia
- associated with ischaemia / vasospasm
82
What antihypertensives can be IV in pre-eclampsia?
- IV labetalol
| - IV hydralazine
83
What is the seizure treatment / prophylaxis of eclampsia?
Magnesium sulphate
- loading dose; 4g IV over 5 minutes
- maintenance dose; IV infusion 1g/h
- if further seizures administer 2g Mg SO4
- if persistent seizures consider diazepam 10mg IV
84
What drug should be avoided in labour and birth in patients with pre-eclampsia?
Ergometrine
also caution with IV fluids
85
What is large for dates?
Symphyseal-fundal height >2cm larger than expected for gestational age
86
What are the causes of large for dates?
- wrong dates
- foetal macrosomia
- polyhydramnios
- diabetes
- multiple pregnancy
- obesity
87
How is foetal macrosomia diagnosed?
USS EFW >90th centile
88
What are the risks of foetal macrosomia?
- clinical and maternal anxiety
- labour dystocia (failure to progress in labour)
- shoulder dystocia; more with diabetes
- PPH
89
Describe the management of foetal macosomia
- exclude diabetes
- reassure
- conservative vs IOL vs C/S delivery
- in EFW >/= 5kg offer c/section
90
What is polyhydramnios?
- excess amniotic fluid
- amniotic fluid index (AFI >25cm)
- deepest pool >8cm
91
Name causes of polyhydramnios
```
maternal
- diabetes
foetal
- anomaly; GI atresia, cardiac, tumours
- monochorionic twin pregnancy
- hydrops foetalis; Rh isoimmunisation
- viral infection (erythrovirus B19, toxoplasmosis, CMV)
- idiopathic
```
92
Name clinical features of polyhydramnios
```
Symptoms;
- abdominal discomfort
- pre labour rupture of membranes
- preterm labour
- cord prolapse
Signs;
- LFD
- malpresentation
- tense shiny abdomen
- inability to feel foetal parts
```
93
Name investigation for polyhydramnios
- oral glucose tolerance test (OGTT)
- serology; toxoplasmosis, CMV, parvovirus
- antibody screen
- USS; foetal survey, lips, stomach
94
Describe management of polyhydramnios
- patient information; complications
- serial USS; growth, LV, presentation
- IOL by 40 weeks
- labour; risk of malpresentation, cord prolapse, preterm labour, PPH, neonatal examination
95
What are the different forms of twins?
Zygosity;
- monozygotic; splitting of a single fertilised egg
- dizygotic; fertilised of 2 ova by 2 spermatozoa
Chorionicity
- 1 or 2 placentas
- dizygotic; always DCDA
- monozygotic; dichorionic diamniotic (DCDA), monochorionic, diamniotic (MCDA), monochorionic monoamniotic (MCMA), conjoined
96
How can chorionicity be determined on USS?
- dichorionic diamniotic has a lambda sign
| - monochorionic diamniotic has a T sign
97
What complications can occur in monochorionic twins?
- single foetal death
- selective growth restriction
- twin to twin transfusion syndrome
- twin anaemia-polycythaemia sequence
- abnormal dopplers
98
What is twin to twin transfusion syndrome?
- syndrome with artery-vein anastomoses
- donor twin perfuses the recipient twin
- olidohydramnios-polyhydramnios
99
What is management and complications of twin to twin transfusion syndrome?
- before 26/40; fetoscopic laser ablation
- >26/40; amnioreduction / septostomy
- deliver 34-36/40
- complications; mortality >90% with no treatment
100
Describes the timings of delivery in multiple pregnancy
- DCDA twins deliver 37-38 weeks
- MCDA twins deliver after 36+0 weeks with steroids
- MCMA caesarean section
101
What are the effects of pregnancy on diabetes?
- increases insulin requirements
- N and V can precipitate DKA
- ketosis more common
- diabetic retinopathy worsens especially after rapid control of diabetes
- diabetic neuropathy can worsen
102
What is small for gestational age?
- Infant born with birth weight below 10th centile
| - abdominal circumference or estimated foetal weight below 10th centile by ultrasound san
103
What is foetal growth restriction?
- failure to achieve genetic potential for growth, implies pathological restriction of genetic growth potential
- AC or EFW below 3rd centile or
- AC or EFW below 10th centile and evidence of placental dysfunction
104
Name causes of small for gestational age
```
Placental
- infarcts
- abruption
- often secondary to Htx
Maternal;
- smoking, alcohol, drugs
- height and weight
- age
- maternal disease
Foetal;
- infection (rubella, CMV, toxoplasmosa)
- congenital anomalies
- chromosomal abnormalities e.g. downs syndrome
```
105
How is small for gestational age diagnosed?
- ultrasound measurement of AC and calculation of EFW
- measurements plotted on centile chart
- various charts available
- some customised for maternal factors
- intergrowth 21st used in NHS tayside
106
Name major risk factors for SGA
- maternal age >40
- smoker
- paternal or maternal SGA
- cocaine use
- daily vigorous exercise
- previous SGA
- previous stillbirth
- chronic hypertension
- diabetes with vascular disease
- renal impairment
- APS
- low PAPP-A
- foetal echogenic bowel
- bmi >35
- known large fibroids
107
What is the management plan once small for gestational age is recognised?
- serial scans with umbilical doppler and liquor volume as a minimum (reduced liquor is a sign of foetal distress)
- 150mg aspirin at night from 12 weeks in women with risk factors for pre-eclampsia or uterine artery notching at anomaly scan
108
What should the flow of blood be in the umbilical artery?
- should always be forward flow even in maternal diastole
| - this can be measured using doppler
109
When is magnesium sulphate offered before delivery?
- 4 hours before delivery if no foetal compromise
- offer if below 32 weeks gestation
- can protect somewhat from cerebral palsy
110
Describe warfarin and its effects on pregnancy
- crosses the placenta and is teratogenic
- warfarin embryopathy; midface hypoplasia, stippled chondral calcification, short proximal limbs, short phalanges, scoliosis
- risk seems to be dose dependent (>5mg/day)
- convert to LMWH by 6 weeks
111
Describe post-natal anticoagulation
- neither heparin nor warfarin are contraindications to breastfeeding
- commence warfarin on 5th day post partum
- anticoagulant therapy should be continued until at least 6 weeks post-natal and until at least 3 months post partum
112
What is obstetric cholestasis?
- disease of pregnancy, a diagnosis of exclusion
- sever pruritus (excoriations but no rash), particularly palms and soles in second half pregnancy
- very rare; dark urine, anorexia and steatorrhoea
- LFTs deranged
- recovers within 2 weeks postnatal
- investigated by liver USS, viral serology and liver autoantibodies
113
The booking visit occurs when?
Generally 8-12 weeks
114
What occurs during the booking visit?
- history
- height, weight, BP
- bloods; Hb, ABO, rhesus status and antibodies, syphilis, HIV, hep b and c, urinalysis
- ultrasound; usually secondary app. confirm viability, single or multiple pregnancy, estimate gestational age, detect any major structural anomalies, offer trisomy screening
115
What can be used to estimate gestational age in first trimester and in second trimester?
On scan
- 1st trimester; crown rump length
- 2nd trimester; head circumference
116
What usually occurs during normal antenatal appointments?
- history; physical and mental health, foetal movements
- examination; BP and urinalysis, symphysis and fundal height, lie and presentation, engagement of presenting part, foetal heart auscultation
117
What is placenta praevia?
- When the placenta is low lying in the uterus and covers all or part of the cervix
- if placenta is low at anomaly scan then rescan at 32 weeks
- sometimes a transvaginal scan is needed for placental site
118
What trisomy can be screened for in pregnancy?
- downs syndrome; T21
- edwards syndrome T18
- pataus syndrome T13
119
How is trisomy risk assessed in the first trimester?
- measure of skin thickness behind foetal neck using ultrasound (nuchal thickness)
- measured at 11-13+6 weeks
- combined with HCG and PAPP-A
- a value of <3.5mm would be considered normal when the CRL is between 45 and 84 mm
120
How is trisomy risk assessed in the second trimester?
- blood sample at 15-20 weeks
| - assay of HCG and AFP, unconjugated oestradiol, inhibin A
121
Describe NIPT
- cell free foetal DNA testing, non-invasive prenatal testing
- it detects foetal DNA fragments in a sample taken from the mother
- detectable from about 10 weeks of pregnancy
- screening test only, NOT diagnostic
122
Name diagnostic tests for trisomy
```
Amniocentesis
- usually performed after 15 weeks
Chorionic villus sampling;
- sample of placenta
- usually performed after 12 weeks
```
123
Where should fundal height be at 20 weeks and at 36 weeks?
- at 20 weeks around the umbilicus
| - at 36 weeks up to ziphisternum
124
Who should take 150mg of aspirin daily from 12 weeks until birth of baby?
- first pregnancy
- age 40 or older
- pregnancy interval more than 10 years
- BMI >35
- Fhx of pre-eclampsia
- multiple pregnancy
125
At the 20 week anomaly scan, what is looked at?
- cleft
- heart
- NTD
- limb defects
- placental site
- diaphragmatic hernia
- abdominal wall defects
- lung abnormalities
- brain abnormalities
- urinary tract abnormalities
126
What kinds of drugs can cross the placenta?
- most drugs
- except large molecular weight drugs e.g. heparin
- small, lipid soluble drugs cross more quickly
127
How are pharmacokinetics affected in pregnancy?
- absorption may be affected by morning sickness
- increased plasma volume and fat stores, volume of distribution increases
- decreased protein binding, increased free drug
- increased liver metabolism of some drugs
- elimination of renally excreted drugs increases, increased GFR
128
When is the period of greatest teratogenic risk?
4th to 11th week
129
Name examples of teratogenic drugs
- ACE inhibitors, ARBs
- androgens
- antiepileptics; valporate, phenytoin
- cytotoxics
- lithium
- methotrexate
- retinoids
- warfarin
130
What drug is safest for use in pregnancy for nausea and vomiting?
Cyclizine
131
What drug is safest for use in pregnancy for UTI?
- nitrofuratonin
- cefalexin
- 3rd trimester; trimethroprim
132
What drug is safest for use in pregnancy for pain?
Paracetamol
133
What drug is safest for use in pregnancy for heartburn?
Antacids
134
What antiepileptic drugs is particularly associated with cleft lip and palate?
Phenytoin
135
Define labour
Labour is a physiological process during which the foetus, membranes, umbilical cord and placenta are expelled from the uterus
136
How is labour initiated naturally?
- uncertain
- changed in the oestrogen/ progesterone ratio
- foetal adrenals and pituitary hormones may control the timing of the onset of labour
- myometrial stretch increases excitability of myometrial fibres
- mechanical stretch of cervix and stripping of foetal membranes
- fergusons reflex
137
What is fergusons reflex?
Neuroendocrine reflex in which the foetal distension of cervix stimulated oxytocin production when the stimulates more cervical contractions - positive feedback system
138
What hormone makes the uterus contract?
Oestrogen
| also promotes prostaglandin production
139
What hormone initiates and sustains contractions?
Oxytocin
| acts on decidual tissue to promote prostaglandin release
140
What is the function of liquor?
Nurtures and protects foetus and facilitates movement
141
What is cervical tissue composed of?
- collagen tissue mainly types 1,2,3 and 4
- smooth muscle
- elastin
- held together by connective tissue ground substance
142
What occurs in cervical ripening?
- decrease in collagen fibre alignment
- decrease in collagen fibre strength
- decrease in tensile strength of the cervical matrix
- increase in cervical decorin (dematan sulphate proteoglycan 2)
- excess of cervical decorin near term is capable of initiating a decorin-collagen interaction that leads to collagen fibrin disruption and decreased cervical tensile strength
143
Describe the bishops score
- score of the likelihood of a woman going into labour
| - equal weight is given to five elements; position, consistency, effacement, dilatation, stating in pelvis
144
A bishops score of 4 or less indicates what?
- unfavourable cervix
| - requires ripening
145
What are the two parts of the first stage of labour?
- latent phase
| - active phase
146
Describe the latent phase of the first stage of labour
- mild irregular uterine contractions
- cervix shortens and softens
- duration variable
- may last few days
- up to 3cm
147
Describe the active phase of the first stage of labour
- 4cms onto full dilatation
- slow decent of the presenting part
- contractions progressively become more rhythmic and stronger
- painful
- normal progress is assessed at 1-2cms per hour
- analgesia, mobility and parity increase variability
148
When does the start of the second stage of labour occur?
When the cervix is fully dilated 10cms
149
When is the second stage of labour classed as prolonged?
- in nulliparous woman is considered prolonged if it exceeds 3 hours if there is regional anaesthesia, or 2 hours without
- in multiparous women, the second stage is considered prolonged if it exceeds 2 hours with regional analgesia or 1 hour without
150
What is the third stage of labour?
Delivery of the baby to expulsion of the placenta and foetal membranes
151
How long does the third stage of labour take and what managment is required is this does not progress?
- average duration 10 minutes but can be 3 minutes or longer
- after 1 hour presentation made for surgical removal either by regional analgesia or under GA
- active management; use of oxytoxic drugs and controlled cord traction is preferred for lowering risk of post partum haemorrhage
152
What are braxton hicks contractions?
- tightening of the uterine muscles, thought to aid the body to prepare for birth
- can start 6 weeks into pregnancy but more usually felt in the third trimester
- irregular, do not increase in frequency or change in activity
153
What are the three key factors during labour?
- power; uterine contraction - passage; maternal pelvis
| - passenger; foetus
154
How do contractions occur?
- pacemaker; region of tubal ostia, wave spreads in a downward direction
- synchronisation of contractions waves from both ostia
- polarity; upper segment contracts and retracts, lower segment and cervix stretch, dilate and relax
- normal contractions have a fundal dominance with a regular pattern and an adequate 'resting tone'
155
Describe the different types of pelvis
- anthropoid pelvis; there is an oval shaped inlet with large anterior-posterior diameter with comparatively smaller transverse diameter
- gynaecoid pelvis; most suitable shape, western
- android pelvis; android shaped pelvis has triangular or heart shaped inlet and is narrower from the front
156
What is the normal way for baby to lie for labour?
- longitudinal / cephalic presentation
- presenting part; vertex
- position; occipito-anterior, head engages occipito-transverse
- flexed head
157
Name the different analgesia options for birth
- paracetamol / co-codamol
- TENS
- entonox
- diamorphine
- epidural
- remifentanyl
- combined spinal / epidural
158
What is a partogram?
A graphic record of key data (both maternal and foetal) contained on one sheet, used to assess the progress of labour i.e. cervical dilatation, foetal heart rate
159
Name the 7 cardinal movements of labour
- engagement
- decent
- flexion
- internal rotation
- crowning and extension
- restitution and external rotation (head adopts optimal position for shoulder)
- expulsion, anterior shoulder first
160
Describe engagement of the head
- the foetal head is engaged when the widest
diameter of the foetal head has entered the brim of the pelvis
- this is also described as 3/5 of the foetal head having entered the pelvis and 2/5 still felt abdominally
161
What needs to be observed during descent of the head?
- abdominal fifths
- maternal discomfort and feeling of pressure
- frontal synciput and occipital eminences
- vaginal examinations for cervical assessment, should be carried out approx 4 hourly in normal labour
162
Describe the extension cardinal movement
- occurs once the foetus has reached the level of the interoitus, bringing the base of occiput in contact to the inferior margin at the symphysis pubis
163
What is crowning?
- appearance of a large segment of foetal head at the introitus
- labia are stretched to full capacity
- largest diameter of foetal head is encircled by the vulval ring
- burning and stinging feeling for the mother
- care of the perineum at birth is vital to reduce trauma
- delivery of head should be managed carefully and slowly with hands guiding but not leading the exit at crowing to prevent rapid extension of tissues and perineal tearing
164
Name the signs of third stage of labour
- uterus contracts, hardens and rises
- umbilical cord lengthens permanently
- frequently a gush of blood variable in amount
- placenta and membranes appear at introitus
165
Describe placental separation
- plane of separation; spongy layer of decidua basalis
- mechanics; shearing force
- inelastic placenta reduces surface area on the placental bed due to the sustained contraction of the uterus
- method of separation; matthew duncan, most common type of separation
166
What is a normal level of blood loss during normal labour?
Less than 500mls
167
Homeostasis is achieved physiologically after birth how?
- tonic contraction; lattice pattern of uterine muscle strangulates the blood vessels
- thrombosis of the torn vessel ends; pregnancy is a hyper-coaguable state
- myo tamponade opposition of the anterior / posterior walls
168
What is the puerperium?
Period of repair and recovery, return of tissues to non-pregnant state
169
Describe the changes to vaginal discharge following labour
- vaginal discharge containing blood, mucus and endometrial castings
- rubra (fresh red); 3-4 days
- serosa (brownish red, watery); 4-14 days
- alba (yellow); 10-20 days
- bloodstained discharge lasts for about 10-14 days following birth
170
Describe the uterine changes in the peurperium
- uterine involution
- weight reduces from around 1000gm to 50-100gms
- fundal height; umbilicus to within pelvis in 2 weeks
- endometrium regenerates by end of a week (except the placental site)
- regression but never back to pre-pregnancy state; cervix, vagina and perineum
171
What is lactation initiated by?
Placental expulsion and a decrease in oesrrgoen and progesterone
172
What is the vertex?
Bounded by the anterior and posterior fontanelles and the parietal eminences
173
What are the three forms of breech?
- complete breech; legs folded at the level of the babys bottom
- footling breech; one or both feet point down so the legs would emerge first
- frank breech; legs point up with feet at the babys head so the bottom emerges first
174
Describe brow presentation
- occurs with more extreme flexion (14cm)
| - will not pass through the pelvis
175
Describe face presentation
- unusual
| - narrower diameter, chin under symphysis pubis, face will deliver via flexion over the perineum
176
What is the aetiology of labour pain?
Compression of para-cervical nerves / myometrial hypoxia
177
Does epidural anaesthesia impair uterine activity?
No - may inhibit progress during stage 2
178
What drugs are usually given during epidural anaesthesia?
- levobuprivacaine
| - +/- opiate
179
Name the complications of epidural anaesthesia
- hypotension
- dural puncture
- headache
- high block
- atonic bladder
180
What is the most common reason for caesarean sections?
Failure to progress
181
Name risks of obstructed labour risks
- sepsis
- uterine rupture (particularly common in first time labours)
- obstructed AKI
- postpartum haemorrhage
- fistula formation
- foetal asphyxia
- neonatal sepssi
182
How is progress in labour assessed?
- cervical dilatation
- descent of presenting part
- signs of obstruction; moulding, caput anuria (swelling of foetal scalp), haematuria, vulval oedema
183
When is doppler auscultation of the foetal heart carried out during labour?
- stage 1; during and after a contraction, every 15 minutes
- stage 2; at least every 5 minutes during and after a contraction for 1 whole minute and check mat pulse at every 15 mins
184
What occurs during intra-partum foetal assessment?
- doppler auscultation of foetal heart
- electronic foetal monitoring cardiotocograph (CTG)
- colour of amniotic fluid
185
Name risk factors for foetal hypoxia
- small foetus
- preterm / post dates
- antepartum haemorrhage
- hypertension / pre-eclampsia
- diabetes
- meconium
- epidural analgesia
- VBAC
- PROM >24 hrs
- sepsis (temp >38c)
- induction / augmentation of labour
186
What should be assessed and documented when reviewing a CTG?
- baseline foetal heart rate
- baseline variability
- presence or absence of decelerations
- presence of accelerations
- CTG should be classified as; normal /suspicious / pathological
187
Hypoxia development during labour is characterised by what?
- loss of accelerations
- repetitive deeper and wider decelerations
- rising foetal baseline heart rate
- loss of variability
188
Describe the management of abnormal CTG
- change maternal position
- IV fluids
- stop syntocinon
- scalp stimulation
- consider tocolysis; terbutaline 250 mcg s/c
- maternal assessment; pulse /BP / abdomen / VE
- consider foetal blood sampling
- operative delivery (category 1 delivery)
189
Describe the results and actions of foetal blood sampling
- scalp pH >7.25 = normal
- scalp pH 7.2-7.25 = borderline, repeat in 30 min
- scalp pH <7.2 = abnormal, deliver
190
What are the main indications for caesarean section?
- previous CS
- foetal distress
- failure to progress in labour
- breech presentation
- maternal request
191
Define post partum haemorrhage
- >500mls in the first 24 hours
- SVD >500ml
- operative vaginal delivery >750ml
- CS >1000ml
- major PPH >1000ml
192
What are the 4 Ts of PPH causes?
- tone; uterine atony
- trauma; perineal tears, cervical tears
- tissue; placenta, fragment of placenta
- thrombin; coagulation problems
193
Describe the general management of PPH
- ABCDE
- large bore IV access, 2 point
- FBC, coagulation screen, group and save, crossmatch, LFTs, kidney function
- warmed fluids
- anaesthetic staff required
- utertotonics
- intrauterine balloon, brace sutures, interventional radiology, hysterectomy
194
What is the order in which to give uterotonics?
1st; oxytocin - bolus injection IV or IM, then maintained as IV
2nd; ergomectrin - IV or IM, can cause nausea and cannot be used in hypertensive patients
3rd; carboprost - prostaglandin, IM into womans thigh or directly into wall at womb at caesarean, can be given every 15 minutes for up to 8 doses
4th; misoprostol - PR in these situations, takes some time to work
195
What is an intrauterine balloon?
- first line after drug failure of PPH
- saline filled balloon that sits inside uterus and compresses from inside and out
- can be very effective but not always the easiest thing to site
- women needs to be under anaesthetic as painful
196
Describe brace sutures
- to stop PPH
- wrap around uterus to compress it
- only if abdomen is open e.g. c section or laparotomy (b link sutures)
197
Name risk factors for shoulder dystocia
- antenatal; previous shoulder dystocia, foetal macrosomia, BMI >30, short stature
- intrapartum; slow 1st and or 2nd stage labour, induction of labour, instrumental delivery
198
Name complications of shoulder dystocia
- foetal; hypoxia, brachial plexus injury fracture of clavicle / humerus, intracranial haemorrhage, death
- maternal; PPH, genital tract trauma, pelvic injuries
199
Describe the management of shoulder dystocia
- helperr
- call for help
- evaluate for episiotomy
- leg; mcroberts manoeuver
- external pressure; suprapubic
- enter; rotational maeouvres
- remove the posterior arm - roll the patient to her hands and knees
200
Name risk factors for postpartum sepsis
- anaemia
- prolonged rupture of membranes
- long labour
- assisted delivery
- raised BMI
- diabetes
201
Name sources of postpartum sepsis
- uterus (endometritis)
- skin / wound
- urine
- breasts
- chest
- other
202
What is the sepsis six?
- give O2 to keep SATS above 94%
- take blood cultures
- give IV antibiotics
- give a fluid challenge
- measure lactate
- measure urine output
203
What are the side effects for the mother and foetus of epidural anaesthesia?
- large doses during delivery can cause neonatal respiratory depression, hypotonia and brady cardiac
- dizziness, hypertension, hypotension, nausea, paraesthesia, urinary retention, vomiting
204
What are the 5Hs of maternal collapse?
- head; eclampsia, epilepsy, cerebrovascular accident, vasovagal response
- heart; MI, arrythmias, peripartum cardiomyopathy
- hypoxia; asthma, PE, pulmonary oedema, anaphylaxis
- haemorrhage; abruption, atony, trauma, uterine rupture, uterine inversion, rupture aneurysm
- whole body and hazards; hypoglycaemia, amniotic fluid, embolism, septicaemia, trauma, anaesthetic complications, drug overdose
205
How is aortocaval compression relieved?
- displace uterus to relieve pressure on aorta and vena cava and improve venous return to the heart - keep mother supine and apply left manual uterine displacement or 30 degree tilt if on theatre table
206
What drug is given in magnesium toxicity?
1g calcium gluconate
207
What is given in local anaesthetic toxicity?
1.5ml 20% intralipid
208
Describe amniotic fluid embolism
- not predictable or preventable, usually in labour
- amniotic fluid enters maternal circulation - collpase +/- arrest
- acute presentation; profound foetal distress, sudden respiratory distress, seizure and DIC
- treatment is supportive in ITU
209
Describe cord prolapse
- obstetric emergency
- associated with malpresentation, pre term labour, 2nd twin, artificial membrane rupture
- direct compression and cord spasm = decrease flow, hypoxia, death
- immediate delivery (CS or forceps)
- tocolytic and maternal positions to relieve pressure for transfer
210
What are the signs of shoulder dystocia?
- slow delivery of the head, face and chain
- turtle sing; the delivered head becomes tightly pulled back against the perineum and there is difficulty delivering the chin
- head bobbing; when the head consistently retracts back between contraction during the active second stage
211
What is the triad of rubella?
- microcephaly
- cataract
- patent ductus arteriosus
212
What is rubella?
- rubella is a viral infection
- transmitted by direct contact / respiratory droplet exposure
- fever, rash, lymphadenopathy and polyarthritis
- maternal infection can cause miscarriage, still birth and birth defects
213
Rubella infection at different stages of pregnancy can what effects?
- <8-10 weeks of gestation; 90% chance of CRS / multiple defects
- 11-20 weeks; 10-20% risk of CRS / single defects
- 16-20 weeks; low chance of deafness
214
Describe managment of rubella
- rubella specific IgG antibody can be detected after infection or vaccination
- blood IgM should be done within 10 days of exposure
- supportive treatment, avoid contact with other pregnant women
215
What is measles?
- caused by paramyxovirus
- highly contagious
- fever, white spots inside the mouth, runny nose, cough, red eyed and rash
- non teratogenic
- however high fever can cause problems
216
What is chickenpox?
- VZV is a DNA of the herpes family
- transmission mainly via droplets
- fever, malaise and vesicular rash
- primary infection in pregnancy is rare
217
Describe chickenpox treatment in pregnancy
- establish the significance of the contact / susceptibility of the patient
- check to VZV immunity
- offer VZIG within 10 days of exposure
- patients should avoid contact with other pregnant women
- aciclovir should be considered if 20+ weeks (800mg five times a day for 7 days)
218
Chickenpox infection at different stages of pregnancy can what effects?
- 7-28 weeks; foetal varicella syndrome
- 4 week before delivery; neonatal chicken pox
- 7 days prior to delivery; neonatal chicken with septicaemia and increase mortality
219
What are the features of congenital varicella syndrome?
- hypoplasia of limbs
- psychomotor retardation
- IUGR
- chorioretinal scarring
- cataracts
- microcephaly
- cutaneous screening
220
What can CMV cause in pregnancy?
- miscarriage
- stillbirth
- IUGR
- microcephaly
- intracranial calcifications
- hepatosplenomegaly
- thrombocytopenia
- chorioretinitis
- mental retardation
- deafness
221
Describe treatment of CMV during pregnancy
- antiviral drugs; valacyclovir
| - hyper immune globulin
222
What are the effects of zika virus on pregnancy?
- microcephaly
- brain defects
- problems with hearing and vision
- joints with limited range of motion
- seizures / too much muscle tone, restricting body movement
- swallowing abnormalities
- possible development delay
223
Describe labour options for mothers HIV
- elective C/S reduces risk of transmission by 50%
- avoidance of breast feeding reduces transmission risk to <1%
- zidovudine infusion commenced 4 hours prior to C/S
- women who have a viral load of <50 copies / ml (if on HAART) can consider vaginal delivery
224
What toxoplamosis?
- toxoplasmosis gondii
- raw or uncooked meat / infected cat faeces
- trans placental transmission
225
What are the effects of toxoplasmosis on pregnancy?
- hydrocephalus
- chorioretinitis
- cerebral calcifications
- microcephaly
- mental retardation
226
What the treatment of toxoplasmosis?
- pyrimethamine; 25mg orally and oral sulfadiazine 1gram QDS
- pyrimethamine is not given in the first trimester
- leucovrin is added to minimise toxicity
- spiramycin can be used as an alternative
227
What is listerosis?
- listeria monocytogenes (LM) is an intracellular gram positive bacillus
- found in soil and vegetation
228
Describe treatment and prevention of listerosis in pregnancy
```
Treatment;
- ampicillin + gentamicin
- trimethroprim and sulfamethoxazole
Prevention;
- not to drink or take unpasteuised milk, soft cheese, refrigerated smoked seafood (salmon, trout, cod)
```
229
Name signs and symptoms of maternal infection
- offensive PV loss
- sore throat
- rash
- abdominal pain
- urinary frequency, dysuria
- productive cough
- wound erythema, purulent discharge
- breast erythema, tenderness
230
Describe the management of suspected sepsis
- sepsis 6 bundle
- cultures
- IV co-amoxiclav within the 'golden hour' +/- gentamicin depending severity and clindamycin if sore throat (GAS)
- clindamycin + gentamicin if penicillin allergic
- tazocin, clindamycin + gentamicin if septic shock
231
Describe chorioamnionitis
- inflammation of the aminochorionic (foetal) membrane of the placenta, typically in response to microbial invasion
- 96% caused by ascending infection
- usually polymicrobial from e coli, mycoplasma, anaerobes and group b strep
- signs and symptoms; include offensive PV loss, foetal CTG concerns, maternal pyrexia and abdominal pain
- risks of neonatal sepsis, morbidity and mortality is not recognised and treated
232
What is endometritis?
Infection of uterine lining following delivery of miscarriage
233
What is the presentation and treatment of endometritis?
- typically present with abdominal pain, abnormal PV bleeding, offensive PV loss
- treatment co-amoxiclav +/- surgical evacuation of uterus if significant RPOC
- co-trimoxazole +/- metronidazole if penicillin allergic
234
What is the presentation and treatment of epidural abscesses?
- presents with back pain or fever and potential deficit as it progresses
- treatment with IV antibiotics +/- surgical decompression if no response or neurological concerns
- vancomycin, metronidazole and cefotaxime to cover MRSA, anaerobes and gram -ve bacteria
235
Define antepartum haemorrhage
- bleeding from the genital tract after 24 weeks gestation and before the end of the second stage of labour
- bleeding from or into the genital tract, occuring from 24+0 weeks of pregnancy and prior to the birth of the baby
236
What are the commonest causes of antepartum hamorrhage?
- placental abruption
| - placental praevia
237
What is placental abruption?
- separation of a normally implanted placenta
- partially or totally before the foetus
- a clinical diagnosis
238
Describe the pathophysiology of placental abruption
- vasospasm followed by uterine rupture into the decidua
- blood escapes into the amniotic sac or further under the placenta and into myometrium
- causes tonic contraction and interrupts placental circulation which causes hypoxia
- results in couvelaire uterus
239
Name risk factors for placental abruption
- 70% unknown
- pre eclampsia / htx
- trauma
- smoking / cocaine / amphetamine
- medical thrombophilias / renal disease / diabetes
- polyhydramnios
- multiple pregnancy
- preterm PROM
- abnormal placenta
- previous abruption
240
Name symptoms of placental abruption
- severe abdominal pain; continuous, labour is intermittent pain with contractions
- backache with posterior placenta
- bleeding (may be concealed)
- preterm labour
- may present with maternal collapse
241
Name signs of placental abruption
- unwell distressed patient
- signs may inconsistent with revealed blood
- uterus LFD or normal
- uterine tenderness
- woody hard uterus
- foetal parts difficult to identify
- may be in preterm labour (with heavy show)
- foetal heart rate; bradycardic / absent
- CTG show irritable uterus
242
Describe management of placental abruption
- ABCDE
- assess and deliver the baby
- manage the complications
- 2 large bore IV access
- blood; FBC, clotting, LFT, U&E, x match, 4-6 units RBC
- IV fluids
- catheterise
- assess foetal heart
243
What is placenta praevia?
- when the placenta lies directly over the internal os
- after 16/40 the term low lying placenta should be used when the placental edge is less than 20mm from the internal os on transabdominal or transvaginal scanning
244
What is the lower segment of the uterus?
Anatomical
- the part of the uterus below the utero-vesical peritoneal pouch superiorly and the internal os inferiorly
- thinner and contains less muscle fibres than upper segment
Physiological
- the part of the uterus which does not contract in labour but passively dilates
Metric
- the part of the uterus which is about 7cm from the level of the internal os
245
Name risk factors for placenta praevia
- previous c section
- previous termination of pregnancy
- advanced maternal age >40
- multiparity
- assisted conception
- multiple pregnancy
- smoking
- deficient endometrium due to presence or history of; uterine scar, endometritis, manual removal of placenta, D+C, submucous fibroid
246
Name symptoms of placenta praevia
- painless bleeding >24 weeks
- usually unprovoked but coitus can trigger it
- bleeding can be minor e.g spotting or it can be severe
- foetal movements usually present
247
Name signs of placenta praevia
- patients condition directly proportional to amount of observed bleeding
- uterus soft, non tender
- presenting high part
- malpresentations; breech, transverse, oblique
- CTG usually normal
- DO NOT PERFORM VAGINAL EXAMINATION, speculum examination may be useful when performed by specialist
248
Describe diagnosis of placenta praevia
- check anomaly scan
- confirm by transvaginal ultrasound
- MRI for excluding placenta accreta
249
Describe management of placenta praevia
- ABCDE
- assess babys condition; steroids 24-35+6 weeks, MgSO4 if <32 weeks
- anti d is rhesus negative
- conservative management if stable and observe in hospital for at least 24 hours
250
Describe delivery planning in placenta praevia
- c section if placenta covers os or <2cm from cervical os
| - vaginal delivery if placenta >2cm from os and no malpresentation
251
Define placenta accreta
A morbidly adherent placenta - abnormally adherent to the uterine wall
252
What are the different forms of placenta accreta?
- increta = invading myometrium
| - percreta = penetrating uterus to bladder
253
Define uterine rupture
- full thickness opening of uterus
- including serosa
- if serosa is intact - dehiscence
254
Name risk factors for uterine rupture
- previous c section / uterine surgery
- multiparity and use of prostaglandins / syntocinon increase risk
- obstructed labour
255
Name symptoms of uterine rupture
- severe abdominal pain
- shoulder tip pain
- maternal collapse
- PV bleeding
256
Name signs of uterine rupture
- intra partum loss of contractions
- acute abdomen
- PP rises
- loss of uterine contractions
- peritonism
- foetal distress / IUD
257
Describe management of uterine rupture
- urgent resuscitation and surgical managment
- 2 large bore IV access
- FBC, clotting, LFTs, U&E, kleihauer (if Rh neg)
- x match 4-6 units RBC
- may need major haemorrhage protocol
- IV fluids or transfuse
258
Define vasa praevia
Unprotected foetal vessels transverse the membranes below the presenting part over the internal cervical os - will rupture during labour or at amniotomy
259
Describe the diagnosis of vasa praevia
- ultrasound TA and TV with doppler
| - clinical; ARM and sudden dark red bleeding and foetal bradycardia / death
260
What are the two types of vasa praevia?
- type 1; when the vessel is connected to a velamentous umbilical cord
- type 2; when it connects the placenta with a succenturiate or accessory lobe
261
Name risk factors for vasa praevia
- placental anomalies such as a bilobed placenta or succenturiate lobes where the foetal vessels run through the membranes joining the separate lobes together
- a history of low lying placenta in the second trimester
- multiple pregnancy
- in vitro fertilisation
262
Describe the management of vasa praevia
- steroids from 32 weeks
- consider inpatient management if risks of preterm birth
- deliver by elective c section before labour (34-36 weeks)
- APH from vasa praevia; emergency c section
- placenta for histology
263
What are the two forms of PPH?
- primary PPH; within 24 hours of delivery
| - secondary PPH; >24-6 weeks post delivery
264
How is bleeding stopped in PPH?
- uterine massage, bimanual compression
- expel clots
- 5 units IV syntocinon stat
- 40 units syntocinon in 500ml hartmanns 125 ml/h
- foleys catheter
- 500 mcg ergometrine IV (not if hypertensive)
- carboprost / haemabate (PGF 2 alpha) 250mcg IM every 15 mins, max 8 doses
- misoprostol 800mcg PR
- tranexamic acid 1.5 IV
265
Describe 'baby blues'
- 50% of women
- brief period of emotional instability
- tearful, irritable, anxiety and poor sleep, confusion
- day 3-10 and self limiting
- support and reassurance
266
Describe puerperal psychosis
- usually presents within 2 weeks of delivery
- early symptoms are sleep disturbance and confusion, irrational ideas
- mania, delusions, hallucinations, confusion
- emergency and needs admission to mother baby unit
- antidepressants, antipsychotics, mood stabilisers and ECT
267
Describe postnatal depression
- 10% women, 1/3 lasts a year or more
- tearfulness, irritable, anxiety, lack of enjoyment and poor sleep, weight loss, can present as concerns re baby
- onset 2-6 weeks postnatally
- mild to moderate; self help, counselling
- moderate to severe; psychotherapy and antidepressants, admission?
268
What are the recommendations for use of antidepressants in pregnancy?
- sertaline 1st line
- lots of options
- no need to change from drug used previously
269
What are the recommendations for use of antipsychotics in pregnancy?
- olanzapine, quetiapine best evidence but others appear to be ok
- avoid clozapine (risk of agranulocytosis in infant)
270
What are the recommendation for use of mood stabilisers in pregnancy?
- antipsychotics
- avoid lithium (secreted into breast milk)
- valporate associated with neonatal development problems
271
When is the postpartum period / puerperium?
From the end of 3rd stage of labour until 6 weeks
272
Describe the repair of 3rd and 4th degree tears
- repair in theatre
- regional anaesthesia
- repair of anal mucosa
- rapid or internal and external anal sphincter
- antibiotics
- laxative
- physiotherapy
- postnatal follow up
273
Name common causative bacteria of endometritis / pelvic infection
- group B streptococcus
- staphylococcus
- e coli
- anaerobes
- basically vaginal commensals as mucus plug is lost during labour to prevent ascending infection
274
Name the causes and managment of urinary retention following labour
```
Causes
- pain
- vaginal trauma
Management
- catheterise
- treat any underlying cause
- trial without catheter after 48 hours
- avoid bladder overdistention
```
275
How can a fistula occur following labour?
- by prolonged obstructed labour (>24hrs)
- tissue compressed between the babys head and pubic symphysis, avascular necrosis occurs
- in some cases the rectum is also damaged
276
What problems can occur with lactation?
- cracked / sore nipples
- breast engorgement
- mastitis
- breast abscess
277
Describe mastitis
- occurs at any time in a breast feeding mother
- staph infection most common
- presents with fever and breast tenderness (often localised)
- continue with breast feeding
- oral or IV antibiotics (flucloxacillin)
- may progress to breast abscess
278
Define stress urinary incontinence
Complaint of involuntary loss of urine on effort or physical exertion including sporting activities, on sneezing or coughing
279
Define urgency urinary incontinence
Complaint of involuntary loss of urine associated with urgency
280
Define overactive bladder syndrome
Urinary urgency, usually accompanied by increased daytime frequency and or nocturia, with urinary incontinence (OAB-wet) or without (OAB-dry), in the absence of urinary tract infection or other detectable disease
281
Describe the pathophysiology of stress urinary incontinence
- occurs when intravesical pressure exceeds urethral closing pressure
- urethral hypermobility (impaired pelvic floor support)
- intrinsic sphincter deficiency (denervation or weakness of sphincter mechanism)
282
Name baseline investigations for overactive bladder
- urinalysis and culture
- frequency / volume chart
- ultrasound; post void residual, pelvic mass, assess kidneys
- cystoscopy
- urodynamics
283
Describe conservative management of urinary incontinence
- fluid management
- weight management
- bladder retraining
284
Describe medical management of overactive bladder
- vaginal oestrogen
- anti-cholinergics (tolertodine , solifenacin)
- beta 3 adrenoreceptor agonist (mirabegron)
- desmopressin (nocturia)
285
Describe surgical management of overactive bladder
- botox
- percutaneous posterior tibial nerve stimulation (after MDT and failed botox)
- augmentation cystoplasty (last resort)
286
Describe the management of stress urinary incontinence
- conservative; lifestyle (weight), pelvic floor muscle training, incontinence ring
- medical; vaginal oestrogen, duloxetine (last line)
- surgical; bulking agents, fascial slings, colposuspension
287
Describe bulkamid
- a synthetic substance is injected into the walls of the urethra to increase its size and allow it to remain closed under pressure
- stays permanently but may need repeated
- local anaesthetic but GA or spinal option
- minimal complications; burning sensation when peeing
- average 55% success at 5 years
288
Describe fascial slings
- a sling is made using the rectus sheath and placed behind the urethra to support it
- open surgery
- 75% success at 5 years
- 10% will need to self catheterise post op
289
Describe colposuspension
- lifting up the tissue around the neck of the bladder, and suspending it to the ileopectineal ligament using non-absorbable synthetic stitches
- open or laparoscopic
- 70% success rate at 5 years
- 10% will need to self catheterise post op
290
How might pelvic floor dysfunction present?
- incontinence of bladder / bowel
- difficulty with bowel emptying
- pelvic organ prolapse
- vulvodynia or other male / female pelvic pain
291
Describe the modified oxford scale for pelvic floors
- grade 0- no detectable contraction, ICS absent
- grade 1 - flicker, ICS weak
- grade 2 - weak contraction, ICS weak
- grade 3 - moderation contraction - ICS normal
- grade 4 - good contraction, ICS normal
- grade 5 - strong contraction against maximal resistance, ICS strong
292
Describe the umbilical cord
- umbilical cord connects the foetus to the placenta
- contains 3 blood vessels; one vein which carries oxygenated blood to the baby, 2 arteries which carry deoxygenated blood back to the placenta
293
Name the three shunts of foetal circulation
- ducuts venosus
- foramen ovale
- ductus arteriosus
294
Describe the circulatory changes at birth
- pulmonary vascular resistance drops (baby breathes)
- systemic vascular resistance rises (cord clamped / cut)
- oxygen tension rises
- circulating prostaglandins drop
- duct constricts
- foramen ovale closes
295
Describe thermoregulation of the foetus in utero
- mum responsible for thermoregulation
- lots of brown fat laid down between scapulae and around internal organs in 3rd trimester
- less in growth restricted or preterm infants
296
Describe thermoregulation of the baby after delivery
- main source of heat production is non shivering thermogenesis, heat produced by breakdown of stored brown adipose tissue in response to catecholamines (not efficient in the first 12 hours of life)
- peripheral vasoconstriction
- no shivering
297
How is glucose homeostasis maintained in utero?
- in utero glucose comes via placenta
- during the 3rd trimester they accumulate stores of glycogen to use for glucose production after they are born
- created in liver and muscle
298
How is glucose homeostasis maintained after delivery?
- interruption of glucose supply from placenta
- very little oral intake of milk
- drop in insulin, increase in glucagon
- mobilisation of hepatic glycogen stores for gluconeogenesis
- ability to use ketones and lactate as brain fuel
299
Describe the pathophysiology persistent pulmonary hypertension of the newborn
- generally happens when the pulmonary resistance does not drop for some reason (hypoxia, acidosis, cold stress, disease, sepsis)
- as the pressure in the pulmonary circulation is high, pressure in RA stays higher than the left and blof continues to flow throguh foramen ovale
- as resistance is high, blood continues to flow from pulmonary trunk to aorta via ductus arteriosus
- again meaning baby is passing deoxygenated blood to systemic circulation
300
Describe the clinical features of persistent pulmonary hypertension of the newborn
- usually very unwell
- the body parts supplied by the aorta before the duct (right arm and head and neck) will have higher oxygen saturations than the post ductal areas
- measuring pre and post ductal oxygen saturations with a sats probe on the right hand and one on a foot helps to aid diagnosis
- baby will be cyanosed
301
Describe the management of persistent pulmonary hypertension of the new born
- ventilation
- oxygen
- nitric oxide
- sedation
- inotropes
- ECLS
302
What are the two main ultrasound techniques used?
- transabdominal; using a standard general abdominal US transducer
- transvaginal; using a dedicated endocavity high frequency transducer
303
What are the features of colostrum?
- high levels of immunoglobulins particularly lactoferrin
- strong anti-inflammatory effect
- stimulates gut growth
- acts as a laxative
- high in Na and Kcl
- initiates acidic pH environemnt
