Pregnancy & Labour Flashcards
1
Q
Screening tests play a key role in antenatal care. Define sensitivity and specificity, in relation to these tests.
A
Sensitivity = [true +] / [+ve + false -ve]. Identifies those with a disease Specificity = [true -] / [-ve + false +ve]. Identifies those without a disease.
2
Q
Describe the key investigations undertaken at the antenatal booking visit [5].
A
- histories: O&G, medical, surgical, allergies, psychiatric, family and social health
- physical health: height, weight, BP
- blood tests: Hb, ABO, Rh status, infection screen (syphilis, HIV, HBV, HCV)
- urinalysis (e.g., DM)
- ultrasound: estimates gestational age, detects major structural anomalies
3
Q
At what time is the antenatal booking visit normally undertaken?
A
8-12 weeks gestation
4
Q
Describe how gestational age is estimated until ultrasound is performed at the booking visit.
A
Naegele’s rule: LMP (last menstrual period) + 9 months and 7 days (280 days)
5
Q
What is placenta previa?
A
The placenta encroaches on the cervix at the anomaly scan; it does not move at the repeat scan 2 weeks later and requires Caeseran section
6
Q
Name and describe the three screenable trisomies in pregnancy, and describe how screening for these changes as first presentation changes with gestational age.
A
- trisomy 13 [Patau syndrome]; trisomy 18 [Edward syndrome]: both generally lethal, mosaics assc. with severe physical and mental disability
- trisomy 21: varies widely from mild to profound disability (structural defects in heart, duodenum, thyroid; increased rates of cancer, learning disability)
- all three may be screened for in the first trimester. only Down syndrome may be screened for in the second trimester
7
Q
Describe the non-invasive methods for genetic screening.
A
- nuchal thickness (on USS): increased thickness at the back of the foetal neck
- NIPT (non-invasive prenatal testing): assesses placental (foetal) DNA in maternal serum; >90% accuracy, although results affected by maternal BMI
8
Q
Describe the key differences in amniocentesis and chorionic villous sampling.
A
- amniocentesis: >15 weeks, risk of miscarriage <1%
- CVS: >12 weeks, risk of miscarriage 2%
9
Q
Describe how rhesus sensitisation works [4].
A
- Rh +ve father and Rh -ve mother produces a Rh +ve foetus
- Rh +ve foetus blood exchanged into maternal circulation
- this causes production of maternal antibodies, which remain lifelong
- second pregnancy with Rh +ve foetus will cause maternal antibodies to cross and attack foetus
10
Q
What are the risks of rhesus sensitisation in mother and foetus of opposite status?
A
May cause foetal hydrops and death
11
Q
Describe how rhesus problems are treated, both during pregnancy and in other O&G situations.
A
- early delivery; blood or intrauterine transfusion
- anti-D injections to prevent antigens forming in Rh -ve women given at 28w and after any sensitising event (TOP, APH, trauma etc.)
- after birth, cord blood is tested and anti-D is given if the baby is Rh +ve
12
Q
Define ‘small for gestational age’ and ‘foetal growth restriction’.
A
- SGA: birth weight <10th centile.
- abdominal circumference (AC) / estimated foetal weight (EFW) <3rd centile
- AC / EFW <10th centile, plus evidence of placental dysfunction
- FGR: failure to achieve genetic potential for growth, implying pathological restriction of genetic growth potential
13
Q
Describe the main causes of a SGA foetus [3].
A
- placental: infarct, abruption, hypertension
- foetal: infection (particularly rubella, CMV), congenital (e.g., absent kidneys), chromosomal abnormalities
- maternal: lifestyle, BMI, age, disease
14
Q
Describe the increased risks to the foetus and mother with an SGA foetus [3].
A
- stillbirth
- morbidity, GDM, PET
- mortality: hypoxia, hypoglycaemia, chronic asphyxia, hypothermia, polycythaemia, hyperbilirubinaemia, abnormal neurodevelopment
15
Q
Describe how foetal size is screened during pregnancy [4].
A
- SFH (symphysis-fundal height)
- performed from 24 weeks and plotted on a graph
- single SFH <10th centile / serial measurement crossing centile lines should be referred for USS
- SFH inaccuracies (BMI > 35, large fibroids, hydramnios) require USS use.
16
Q
Describe the risk factors for an SGA foetus [8].
A
[first quantifier indicates minor factor, second indicates major]
- age (>35, >40)
- nulliparity, IVF
- pregnancy interval <6 or >60 months
- BMI (<20/25-35, >35)
- smoking (<10/day, >11/day)
- previous SGA, parental SGA [major]
- non-O&G conditions: chronic HTN, DM w/ vascular disease, renal impairment, APLS
- O&G conditions: previous PET, heavy bleeds, large fibroids, uterine artery notching at 20wks
17
Q
Describe the management of an SGA foetus [4].
A
- aspirin 150mg for 12 weeks, steroids from 24-35+6wk, magnesium sulfate <32 wk
- genetic tests, infection screen, serial scans for growth, measurement of liquour volume, umbilical artery Doppler
- <3rd centile: delivery from 37 - 37+6 wk
- 3rd-10th centile: delivery at 39w
18
Q
Define LGA.
A
SFH >2cm for gestational age (e.g., 28cm at 24w is +4cm)
19
Q
What are the main causes of LGA? [5]
A
- foetal macrosomia
- polyhydramnios
- multiple pregnancy
- pre-existing diabetes
- GDM
20
Q
Define foetal macrosomia, describe associated risks and management.
A
- EFW >90th centile, AC >97th centile
- risks: anxiety, shoulder and labour dystocia, PPH
- Mx: exclude DM, reassure, offer options (conservative, IOL, C/S; latter is only option when weight >5kg)
21
Q
Regarding polyhydramnios, describe the:
- definition
- causes
- symptoms
- investigations
A
- excess amniotic fluid within the uterus; may be quantified as AFI >25cm or a deepest pool >8cm
- maternal (DM), foetal (anomlies, monochorionic twin pregnancy, hydrops, viral infection)
- abdominal discomfort, pre-labour rupture of membranes, preterm labour, cord-prolapse,, malpresentation, tense shiny abdomen
- OGTT, viral serology (parvovirus B19, toxo, CMV), serial USS survey
22
Q
Multiple pregnancy develops differently depending on at which stage the egg splits; describe the timeline [3].
A
- morula: forms DC/DA. Lambda sign on USS
- blastocyst: forms MC/DA. T sign on USS
- implanted blastocyst: forms MC/MA
[MC = monochorionic, DC = dichorionic, MA = monoamniotic, DA = diamniotic]
23
Q
Two risks of multiple pregnancy are single foetal death and selective growth restriction. Describe how these are managed.
A
- single foetal death: MRI on surviving foetal brain 4 weeks after IUD. perform MCA PSV for foetal anaemia
- selective growth restriction: selective reduction (early onset + abnormal Doppler)
24
Q
Describe TTTS (twin-to-twin transfusion syndrome) and its main complication, TAPS (twin anaemia polycythaemia sequence). [3]
A
- TTTS: donor twin perfuses recipient via artery-vein anastomoses
- treatment is via foetoscopic laser ablation
- TAPS is a complication of laser ablation. MCA PSV is used to monitor for anaemia
25
Describe the symptoms and management of multiple pregnancy.
- exaggerated symptoms (hyperemesis gravidarum), inc AFP, LGA uterus, increased foetal poles
- Mx: Fe, aspirin, folic acid; USS scanning 2.4 weekly.
- - deliver DCDA 37-38wk
- - delivery MCDA 36wk
26
Describe the management of diabetics who become pregnant [4].
- aim for HbA1C of 48 mmol/mol. avoid pregnancy if >86
- stop embryopathic drugs (e.g., ACE, statins)
- folic acid + aspirin
- deliver by 38+6
27
Regarding GDM, describe the:
- pathology
- risk factors
- investigations
- timing of delivery
- pregnancy is diabetogenic, and is a state of insulin resistance due to HPL and cortisol
- risks: previous GDM / LGA, obesity, FH, ethnic variation, polyhydramnios, glycosuria
- previous GDM: BP monitoring/OGTT. others: OGTT 24-28wk
- timing of delivery: insulin 38-39wk, metformin 39-40wk, diet alone 40-41wk
28
Describe the effects of pregnancy on drug pharmacokinetics / pharmacodynamics.
- kinetics (ADME):
- - absorption reduced by morning sickness
- - increased distribution with increased PV/fat stores
- - increased liver metabolism
- - increased elimination renally (due to increased GFR)
- no significant changes to dynamics; may be more prone to hypotension with anti-HTN drugs
29
Name the main classes of teratogenic drugs and their main effects on pregnancy.
- ACE/ARB: oligohydramnios, renal hypoplasia
- androgens: female foetus virilisation
- AEDs: cleft palate, facial abnormalities, neural tube defects
- carbimazole: hypothyroidism, bone growth abnormalities
- cytotoxics: multiple defects, abortion
- lithium: Ebstein's
- MTX: skeletal defects
- misoprostol: Moebius syndrome
- retinoids: ear, heart, skeletal defects
- thalidomide: phocomelia
- warfarin: limb, facial defects; risk of haemorrhage during delivery
30
Beta-blockers should not be used for the treatment of HTN, as they may inhibit foetal growth. When may they be used instead? [4]
- tachyarrhythmia
- mitral stenosis, possible aortic dissection
- migraine
- hyperthyroidism
31
Describe which drugs can be safely used for common conditions in pregnancy [4].
- N&V: cyclizine
- UTI: nitrofuratoin, cefalexin (trimethoprim in 3rd trimester)
- pain: paracetamol
- heartburn: antacids
32
Which chemical class of drugs are more likely to accumulate in breastmilk and which babies are they more likely to affect?
- small, lipophilic drugs more likely to accumulate in breastmilk
- few enter in sufficient quantities to cause problems
- foremilk (rich in protein) -> hindmilk (rich in fat and therefore fat-soluble drugs); those who suckle longer therefore more likely to be affected
33
Which drugs are particularly dangerous in breastfeeding? [5]
- phenobarbitone (affects suckling)
- amiodarone (hypothyroidism)
- cytotoxics
- BZDs (drowsiness)
- bromocriptine (suppresses lactation)
34
Describe the risks and management of obesity in pregnancy [4 + 4]
- risks split into following:
- - pre-pregnancy: menstrual disorder, subfertility, miscarriage, foetal anomaly
- - pregnancy: PET, GDM, VTE
- - labour: inc IOL, dysfunctional labour, operative delivery, haemorrhage, birth injury
- - post-labour: infection, red. breastfeeding, prolapse, incontinence
- handling risk assessment, assess risk of venous access and anaesthesia
- screen those with BMI >30 for GDM
- folic acid, aspirin, vitamin D
35
Why is VTE more common in the left leg (9:1)?
The gravid uterus compresses the left common iliac vein. Groin pain is an important feature to consider in these.
36
Describe the investigations and management of VTE in pregnancy [4].
- compression duplex USS, MRI venography
- pulmonary: V/Q, CTPA; V/Q preferred as no irritation to breast (and subsequent inc. risk of malignancy)
- use LMWH, as warfarin crosses the placenta and causes embryopathy
- neither heparin nor warfarin are contraindications to breastfeeding
37
Describe the presentation, risks, and management associated with intrahepatic cholestasis of pregnancy.
- pruritis (of soles, palms), dark urine, anorexia, steatorrhoea. inc. bile acids, GGTs, ALT, bili
- USS, viral serology, autoantibodies normal. biopsy, if performed (not indicated) would show centrilobar cholestasis
- risks: foetal distress, amniotic fluid meconium aspiration, IUD, preterm birth
- ursodeoxycholic acid 1-2g/daily; alternatives = piriton, aqueous menthol cream
38
What are the three categories of hypertension that may affect a pregnant woman?
- pre-existing (consider renal causes, Cushing's, Conn's, phaeochromocytoma)
- pregnancy-induced (resolves within 6/52 of delivery; no features of proteinuria/PET)
- pre-eclampsia and eclampsia
39
What are the main clinical features of pre-eclampsia (toxaemia - PET)? [4]
- cardinal 3: hypertension (!), ✨rapidly progressive✨ oedema, and proteinuria (>0.3g/24h)
- neuro: headache, blurring/flashing of vision, disorientation, hyperreflexia
- GI: N&V, E/RUQ pain
- O&G: SGA foetus, IUD
40
Describe the pathology of PET, and how timing of gestation may affect this [3].
- abnormal placental perfusion, due to endothelial dysfunction ('stiffness') causes ischaemia and an anti-angiogenic state
- early (<34wk), 12%: extensive villous/vascular lesions of the placenta, higher risks of complication
- late (>34wk), 88%: minimal placental lesions
41
Describe the risk factors and investigations associated with PET.
- risks: age >40, BMI >30, PMH, nulliparity, twins, previous PE, birth interval >10y, molar pregnancy
- 'standard' investigations: FBC, U&Es, LFTs, UPCR, coagulation screen
- maternal uterine artery Doppler: shows resistance of diastolic flow via 'notching'
42
Describe the medical management of PET [4].
- first line Tx: labetalol (a + b antagonist) or nifidepine (CCB); consider methyldopa (C/I in PMH depression)
- second line: hydralazine, doxazocin
- the only cure is delivery. indications for this include term gestational age, inability to control BP, rapidly deteriorating biochem/haem or crises
- at delivery, stabilise the mother and give her betamethasone for lung maturation of foetus
43
What is HELLP syndrome? [3]
- a crisis associated with PET
- Haemolysis, Elevated Liver enzymes, Low Platelets
- E/RUQ pain, N&V, jaundice, more common if multiparous
44
Name the crises associated with PET [7].
- eclampsia
- HELLP syndrome
- pulmonary oedema
- placental abruption
- cerebral haemorrhage, cortical blindness
- DIC
- AKI, hepatic rupture
45
Describe the purpose, parameters, and results of the Bishop's score.
- enables prediction of the likely outcome of induction of labour.
- five main parameters
- - dilatation (larger score with larger dilation)
- - effacement (larger score with larger %)
- - station (larger when positive)
- - colposcopy (larger score when soft)
- - cervix position (larger score when anterior)
- score <5: cervical ripening required
- score >5: strongly predictive of labour following induction
46
Name the methods of inducing labour.
- manual rupture of membranes (finger)
- artificial rupture of membranes (ARM) via amniotomy
- medical induction with syntocinon
- cervical ripening by prostaglandin E2 or balloon catheter
47
Describe the stages of labour.
- stage 1: regular contractions until cervical dilatation (early latent <4cm, active 4-10cm)
- stage 2: full dilatation to delivery of foetus
- - passive: full dilatation in absence of contractions
- - active: baby visible / persistent contractions
- stage 3: delivery of foetus to delivery of placenta and membranes; average 10min
48
Describe the active management of stage 3 labour.
- oxytocin or syntometrine
- bladder catheter
- deferred cord clamping
- controlled cord traction after signs of membrane seperation
- indications: excessive bleeding, failure to deliver placenta <1, maternal desire
49
Describe how the foetal head moves through the pelvis in labour [7].
- engagement: head is engaged at 3/5 (2/5 still in abdomen)
- descent: downward movement
- flexion: passively in descent due to shape of pelvis and soft tissue
- internal rotation: transverse to anterior, ROT --> ROA --> OA
- extension: reaches introitus, base of occiput in contact with inferior pubic symphysis
- external rotation: ROA --> ROT
- expulsion
50
Describe the options for analgesia in labout.
- narcotic (inc. remifentanil)
- inhalational (entonox)
- TENS, acupuncture, massage etc.
- epidural (complete relief in 95%)
- pudendal nerve block
- general anaesthetic
51
Describe the benefits of delayed cord clamping.
increased RBC flow, decreased anaemia, increased breastfeeding, increased Hct/Hb, increased BP/PV, decreased need for blood transfusion or oxygen
52
# Define the following terms.
- malpresentation
- breech presentation
- malposition
- malpresentation: anything other than the vertex presents
- breech: baby's buttocks, feet, or both come out first during birth; often determined by USS at end of gestation
- malposition: baby in OP/transverse position
53
Define failure to progress, give the main causes and complications.
- <2cm dilatation in 4hr
- causes by 3Ps:
- - power: inadequate contraction
- - passenger: big baby, malposition, cephalopelvic disproportion
- - passage: trauma, shape, disproportion
- maternal sepsis, PPH, fistula, asphyxia, neonatal sepsis, uterine rupture, AKI
54
Describe how low risk mothers are assessed for progress during labour.
intermittent auscultation every 15m 1st stage, and 5m 2nd stage, with USS doppler or Pinard stethoscope
55
Describe how a CTG should be interpreted.
DR C BRAVADO
- define risk (why on CTG)
- contractions (3-5 / 10min)
- baseline rate (110-160bpm)
- variability (>5bpm/10min)
- accelerations (>15 beats for 15s)
- deceleration
- overall impression
56
Describe the normal, non-reassuring, and abnormal findings on CTG.
normal / non-reassuring / abnormal
- HR: 100-160 / 161-180 / <100 or >180
- acceleration: >5 / <5 30-90m / <5 <90m
- deceleration: variable / late <30m <50% contractions / late > 30m, bradycardia, single deceleration >3m
57
Describe the management of non-reassuring and abnormal CTG.
- non-reassuring: foetal blood sampling, treat dehydration, hyperstimulation, hypotension, place in L lateral position, stop oxytocin, consider tocolysis
- abnormal: inform senior, category I C/S
58
Describe the findings of foetal blood gas analysis.
normal / borderline / abnormal
- lactate: <4.1 / 4.2-4.8 / >4.9
- pH: >7.25 / 7.2-7.25 / <7.2
- Mx: conservative / repeat CTG 30min / deliver C/S or forceps
59
Name and describe the three types of forceps.
- outlet (e.g. Wrigley's): when scalp is visible w/o separating labia, foetal skull reached pelvic floor
- low/mid-cavity (Neville-Barnes, Andersons, Simpsons): 1/5 palpable abdomen, station >+2 but not above spines
- rotational (Kielland's): in theatre with regional anaesthesia
60
Name the requirements for forceps delivery.
FORCEPS
- Fully dilated (>10cm)
- OA position
- Ruptured membranes
- Cephalic presentation
- Engaged presenting part
- Pain relief
- Sphincter (bladder) empty (by catheter)
61
Describe the complications of forceps delivery.
- mark on baby's face, brachial plexus injury, perineal trauma, psychological trauma, bowel/urinary symptoms
- rarer: neonatal trauma, ICH, facial nerve palsy
62
Describe the risk factors, complications, and management of shoulder dystocia.
- normally, the head is delivered in one contraction, followed by the shoulder in the next. Dystocia describes where the shoulder becomes stuck on the pubic symphysis
- risks: previous dystocia, macrosomia, DM, obesity, slow labour, IOL, operative vaginal delivery
- complications: hypoxia, brachial plexus injury, clavicle, humerus fracture, ICH, maternal PPH, genital tract trauma, pelvic injury
- HELPERR: call for Help, Evaluate, Legs, external suprapubic Pressure, Enter (via rotational manoeuvres), Remove posterior arm, Roll patient onto hands and knees
63
Define the difference types of postpartum haemorrhage (PPH) and give the four main causes.
- primary <24h after delivery, secondary 24h-6wk
- minor: SVD >500ml / OVD >750 / C/S >1000
- major: >1000ml or signs of cardiovascular collapse or ongoing bleeding
- 4Ts: tone (70%), trauma (20%), tissue (RPOC, 10%), thrombin (<1%, encephalopathy)
64
Describe the management of maternal haemorrhage (APH/PPH)
- ABCDE, O2 15l/min
- bloods: G&S, FBC, coag, fibrinogen, U&Es, LFTs, x-match 6 units
- warmed crystalloid (e.g. Hartmann's) + 0.9% saline
- uterine massage with bimanual compression
- syntocinon (bolus / infusion)
- ergometrine (+ antiemetic)
- carboprost, misoprostol
- balloon insertion, B-lynch sutures, embolisation, artery ligation, hysterectomy
65
Describe the classification of perineal tears.
- 1st: perineal skin only
- 2nd: perineal skin and levator ani
- 3a: <50% external anal sphincter
- 3b >50% external anal sphincter
- 3c: both external and internal sphincters
- 4th: involves anal epithelium / mucosa
66
What is an episiotomy?
Surgical cut with patient consent (unlike perineal tear), local anaesthetic given to pudendal nerve branches
67
Describe the management of perineal tears.
- repaired in theatre with regional anaesthesia, repair of mucosa, internal and external anal sphincters
- antibiotics, laxatives
- physiotherapy allowed pelvic-floor function
68
Describe the key features of chickenpox and foetal varicella syndrome.
- facial vesicular rash, spreading to the trunk and back
- foetal varicella syndrome: scarring, limb hypoplasia, congenital cataract, microphthalmia, CNS abnormalities
- blood test for IgG antibodies. if not immune, offer VZ Ig ASAP
- treat with aciclovir, paracetamol, fluids, light cotton clothes, and use calamine lotion
69
Describe the key features of rubella and congenital rubella syndrome.
- initially maculopapular rash on face, spreading to the trunk and back
- levels so low WHO declared eliminated in the UK due to MMR vaccine
- congenital rubella syndrome: sensorineural hearing loss, PDA, glaucoma / cataract
- check for rubella specific IgG/IgM <10 days exposure
- if not immune: TOP. immune: supportive treatment
70
Describe the key features of measles infection.
- blotchy rash on the forehead, Koplik spots in the mouth, runny nose and cough
- caused by paramyxovirus
- IUGR, microcephaly, miscarriage, stillbirth, preterm birth
71
Describe the key clinical features of CMV infection.
- hearing loss, visual impairment, blindness, learning difficulties, epilepsy
- most infected women have symptoms similar to mono (fever, malaise, myalgia, lymphadenopathy)
- jaundice, hepatospleno megaly, SGA, microcephaly
72
Describe the key features of slapped cheek syndrome.
- slapped cheek appearance, followed by a lacy rash sparing the palms and soles
- foetal infection: anaemia, heart failure, hydrops foetalis
- specific IgM -> MCA doppler for foetal anaemia
73
Describe the risks of foetal Zika, COVID-19, and influenza infection.
- Zika: microcephaly, birth defects, hearing/vision/mobility, seizures, developmental delay
- COVID: severe disease, ITU admission, death
- influenza: miscarriage, preterm labour if virulent
74
Describe the key features of listeriosis in pregnancy.
- caused by listeria monocytogenes, 10x more likely in pregnancy
- this is why pregnant women should avoid soft cheese (camembert, brie), unpasteurised milk, and deli food
- headache, diarrhoea, abdominal aches, nausea
- treated with ampicillin and gentamicin, or trimethoprim and sulfamethoxazole
75
Describe the key features of group B streptococcus infection.
- GBS is a common bacteria (20-40%). most have no problems, so no recommended screening programme
- if detected: benzylpenicillin / clindamycin and deliver <37wks
76
Describe the risk factors for maternal sepsis.
anaemia, PROM, long labour, assisted delivery, obesity, DM, cervical suture, RPOC, immunosuppression (esp. DMARDs, UC, cancer)
77
Describe the key infectious sources of sepsis and which symptoms they may present with.
- offensive PV loss - chorioamnionitis
- sore throat, cough - GBS, flu, CAP, COVID
- pain - endometritis, RPOC
- urinary frequency, dysuria - UTI, esp. with bladder catheter
- wound erythema - LSCS, episiotomy
- breast tenderness - mastitis
78
Describe the investigation and management of maternal sepsis.
- survival is directly related to early recognition and management
- swabs (HVS, throat, MSSU, wound, paired blood culture, sputum)
- ABCDE + sepsis 6 (give 3: O2, IV abx, fluid challenge) and (take 3: blood culture, lactate, urine)
- co-amoxiclav [+ gentamicin if severe] [+ clindamycin if sore throat]
79
Describe the key features of chorioamnionitis.
- 96% by ascending infection and polymicrobial (E coli, mycoplasma, anaerobes, GBS)
- risks: amniocentesis, CVS, prolonged ROM / labour, repeated digital examination, nulliparity, meconium stained liquor
- IOL / LSCS required if not in established labour
80
Quantify the blood loss of antepartum and postpartum haemorrhage.
- spotting (staining, streaking)
- minor <50ml
- major 50-1000ml, no signs of shock
- massive: >1000ml or signs of shock
81
Give the main features of placental abruption.
- separation of the placenta, normally implanted, partially or fully
- caused by vasospasm and arteriole rupture into the decidua, allowing blood to escape into the placenta
- severe continuous pain, backache, bleeding (unless concealed), maternal collapse, tender 'woody hard' uterus, Couvelaire (blue) uterus)
- risks: PET/HTN, trauma, drugs, thrombophilia, renal disease, polyhydramnios, PROM
82
Give the key features of placenta previa.
- placenta directly overlies cervical os (low-lying: <2cm from os)
- bright red painless bleeding, unprovoked (or after coitus), abnormal foetal presentation
- speculum exam may be helpful but vaginal exam should be avoided until previa excluded
- risks: previous C/S, age >40, multiparity, assisted contraception, multiple pregnancy, smoking, uterine scar, fibroid
83
Define the terms placenta accreta, increta, and percreta.
- accreta: morbidly adherent placenta to uterine wall
- increta: invades myometrium
- perceta: invades bladder from uterus
84
Give the key features of uterine rupture.
- full thickness of uterine opening (including serosa) prolapse; if the serosa is intact = dehiscence
- acute, constant pain, may be referred to shoulder tip, loss of contraction, acute abdomen, peritonism, IVD, acute foetal distress
- risks: surgery for fibroids, C/S, perforation etc.
85
Give the key features of vasa previa.
- type 1: velamentous umbilical cord
- type 2: multiple lobes (succentuate, accessory lobes)
- vessels rupture during labour or amniotomy. not screened for as this is so common
- symptoms: ARM, dark red bleeding, foetal bradycardia
86
Name the 5 main causes of maternal collapse.
5H's:
- head: eclampsia, epilepsy, CVA, vasovagal response
- heart: MI, arrhythmia, peripartum cardiomyopathy
- hypoxia: asthma, PE, pulmonary oedema, anaphylaxis
- haemorrhage: abruption, atony, trauma, rupture, inversion
- wHole body/hazards: hypoglycaemia, amniotic fluid embolism, sepsis, trauma, anaesthetic complications
87
Describe the pathology and key feature of amniotic fluid embolism.
- sudden acute resp distress, cardiovascular collapse, acute hypotension, acute hypoxia
- defect in membranes allows amniotic fluid to enter maternal circulation
88
Give the management of maternal collapse.
- anticipation with MEWS
- ABCDE and early help (999/2222)
- left tilt / manual displacement of uterus to avoid aortocaval compression, gravid uterus overlies IVC
- C/S after 3 min unsuccessful CPR
89
Define the postpartum period and describe the physiological changes that occur in this time.
- from the end of the 3rd stage of labour to 6 weeks
- the uterus involutes (returns to normal position) by day 10
- lochia becomes rubra, sera, then alba
- CO and PV returns to non-pregnant levels by the end of the first week
- dilatation of ureters occurs with decrease of GFR to normal over 3 months
90
Describe the risk factors conferring moderate and high risk for thromboembolism and the management.
- moderate: hospital admission, single VTE related to major surgery, high risk thrombophilia, medical co-morbidities, any surgery, OHSS in first term
- high risk: any previous VTE except a single event related to major surgery
- moderate: 10 days, high: 6 weeks prophlyactic LMWH
91
Describe the causes, history taking, and management of mastitis.
- s aureus, coagulase positive staph, anaerobes (smokers)
- duct ectasia, foreign objects (e.g. ring)
- MAIDS Hx: milk stasis, abscess (tender lump), inflammation (warmth, pain, swelling, firmness, erythema), discharge (purulent), systemic (fever, malaise, myalgia)
- flucloxacillin or augmentin; abscess: USS / aspiration
92
Describe the risk factors for perinatal mental illness, substance misuse, or suicide.
- young, single, lacks support, unplanned / unwanted, pre-existing Hx
- white, deprivation, known domestic violence, social work input
93
Describe the screening questions for perinatal psychiatry and the criteria for admission to a mother-baby psychiatric unit.
- screening: feeling depressed/down/hopeless? lost interest in things? feel like you need/want help?
- red flags/requires admission to mother-baby unit: rapidly changing mental state, suicidal ideation, significant feelings of estrangement or inadequacy as a mother, pervasive guilt, evidence of psychosis
94
Describe the key features of baby blues.
- affects 50-70%
- brief period of emotional instability: tearfulness, irritability, anxiety, poor sleep, confusion
- occurs 3-10days after birth; treated with support and reassurance
95
Describe the key features of puerperal psychosis.
- occurs <2wk delivery, in 0.1% of women
- disproportional mortality rate: 5% suicide, 4% infanticide
- sleep disturbance, confusion, irrational ideas, mania, delusion, hallucination, confusion
- it is an emergency requiring admission to a mother-baby unit; Mx with antidepressants, antipsychotics, mood stabilisers, and/or ECT
96
Describe the key features of postnatal depression.
- 1/3 of mothers suffer from postnatal depression; two peaks at 2-4wk and 10-14wk
- prevalence is 10% (same as non-pregnant); however, postnatal depression tends to be more severe
- tearfulness, irritability, anxiety, anhedonia, poor sleep, weight loss
- treated as non-pregnant depression
97
Describe the key risks of alcohol dependence in pregnancy.
- abstinence is best, but 2 units/week not shown to be detrimental
- foetal alcohol syndrome (FAS): facial deformities, low IQ, neurodevelopmental delay, epilepsy, hearing, heart, and kidney defects
- withdrawal
- Wernicke's encephalopathy
- Korsakoff's syndrome
98
Describe the key risks of drug dependency (esp. cocaine, amphetamine, ecstasy) in pregnancy, along with its management.
- can cause stroke and arrhythmia
- teratogenic
- PET, abruption, IUGR, preterm labour, miscarriage
- methadone, child protection, social services, smear Hx, breastfeeding, early IV access, postnatal contraception
99
Describe the use of SSRIs, TCAs, and antipsychotics in pregnancy.
- SSRIs generally safest: sertraline has least placental exposure, fluoxetine thought to be safest, peroxetine increased cardiac malformations
- rarer risks of SSRIs: PHN, low birth weight, increased early birth (by days), PPH
- TCAs may cause cardiac defects or cleft palate
- antipsychotics may cause GDM (esp. second gen.), decreased fertility due to reduced PRL release
100
Describe the breast changes that occur during pregnancy.
- 1st trimester: elongation and gland proliferation
- 2nd trimester: secretory alveoli differentiate
- 3rd trimester: maturation, development of extensive rER
