random Flashcards
Why cant you give nitrofurantoin to pregnanct women in their 3rd trimester?
what are the alternative Abs for treating a UTI?
It increases the risk of haemolytic anaemia in the baby
Amoxicillin or ceftriaxone
why is ibruprofen contraindicated in pregnancy?
crosses the placenta and increases the risk of kidney problems in baby
Lithium risks to the baby
Ebsteins anomaly
congenital heart defect where the tricuspid valve is in the wrong place resulting in abnormally large RA and small RV
Which anti-epileptics are CI in pregnancy and why
sodium valporate and carbamazepine
teratogenic and can result in spina bifida
what are the risks of taking SSRIs in pregnancy
1st trimester -> congenital heart defects
3rd trimester -> inc risk of persistent pulmonary hypertension in the newborn
UKMEC3 scenarios
> 35 and smokes <15/day
wheelchair bound/ immobility
BMI >35
FHx of VTE in 1st degree relatives <45
current gallstones
carrier of BRCA1/2 gene
controlled HPTN
UKMEC4 scenarios
> 35 and smokes >15/day
uncontrolled HPTN
history of breast cancer
history of VTE
History of stroke or IHD
migraine with aura
breastfeeding and postpartum <6weeks
positive antiphospholipid antobodies
major surgery
Drugs considered safe in breastfeeding
Antibiotics: penicillins, trimethoprim, cephalosporins
anti-epileptics: sodium valporate, carbamazepine
anti-depressants: TCAs
antipsychotics
glucocorticoids
thyroxine
asthma: salbutamol, theophyllines
b-blockers
warfarin/heparin
Drugs contraindicated in breastfeeding
antibiotics: chloramphenicol, ciprofloxacin, sulphonamides, tetracycline
Lithium
benzodiazapines
aspirin
carbimazole
methotrexate
sulphonyureas
amiodarone
risks to mother and fetus in epilepsy during pregnancy
mother:
increased plasma volume may mean lesser effect of medications and inc risk of seizures
lowered seizure threshold with excessive tiredness and hyperemesis
fetus:
increased risk of congenital abnormalities with anti-epileptic drugs. risk increases with multiple meds
esp valporate and carbamazepine
risk of fetal hypoxia in prolonged seizures
management of epilepsy in pregnancy
- MDT management with obstetrician and neurologist
- aim for a single drug regime with wither lamotragine or phenytoin
-5mg folic acid preconception-12weeks to minimise neural tube defects
-monitor of drug plasma levels
-detailed anomaly scan and fetal echo at 18-20 weeks for cardiac abnormalities
-serial growth scans every 4 weeks from 28-36wks gestation
-vitamin K at 36 weeks and IM to baby at birth as anticonvulsants can inhibit clotting factor production
-anticonvulsant medication deemed safe in breast feeding
counselling:
- advise to take medication as risk of fetal hypoxia if have a prologed fit
- if last fit was >2yrs then could consider stopping medication
- advise to take showers over baths to reduce risk of drowning if have a fit
Exposure to chicken pox when pregnant
if mother has had chickenpox in the past then she is ok
if cant remember then test for VZ Ig
if non-immune:
<20 weeks, >20wks and NO rash –> VZIG (effective for up to 10days post contact)
- avoid contact with other pregnant women and neonates for 4 weeks
> 20 weeks presenting with a rash –> oral acyclovir (800mg 5 a day for 7 days)
avoid contact with other pregnant women and neonates until all the lesions have crusted over
-arrange referral to fetal medicine specialist
-post natal neonatal ophthalmic examination
-if infection occurs at term, planned delivery should be delayed until 7 days post clearance of lesions (allows passive transfer of Abs to fetus)
conselling about obesity in pregnancy
Preconception:
-Lifestyle/diet and exercise advice
-5mg folic acid –>12wks
risks of obesity in pregnancy:
maternal:
- increased risk of GDM (2-3 fold) (OGTT offered at 24-28wks)
- increased risk of VTE (9fold)(consider prophylactic LMWH during pregnancy and after)
- increased risk of gestational HPTN (2-3 fold)
- inc risk of PPH (2fold)
-vitamin D deficiency –> supplementation
fetal:
- congenital abnormality (60% inc risk) eg NTD
- prematurity (20% inc risk)
- macrosomia and shoulder dystocia (3fold)
- stillbirth (2fold)
advice:
- hospital birth
- encourage vaginal birth but advise on possible complications and risk of EMCS
- weight loss throughout pregnancy
managament for GDM
diagnosis
fasting>5.6, 2hr post OGTT >7.8
- joint antenatal and diabetes clinic 1 week after diagnosis and then every 2 weeks
-self BM measurements before and after each meal. aim for <5.6 preprandial and <7.8 post prandial
1st line (fasting <7mmol) - lifestyle changes
2nd line (targets not met 2 weeks after lifestyle changes) - metformin
3rd line (targets not met with lifestyle and metformin)
- insulin
NB: if fasting glucose >7 at diagnosis offer insulin straight away
birth no later than 40+6wks
drugs CI in pregnancy
ACEi, ARBs, thiazides, ibruprofen
High and moderate risk RFs in pre-eclampsia
HIGH RISK
previous pregnancy with pre eclampsia or HPTN
pre-existing maternal conditions (HPTN, DM, SLE, renal disease)
MODERATE RISK
primigravid
age >40
pregnancy interval >10 years
BMI >35
FH of pre-eclampsia
multiple pregnancy
when to offer aspirin in pregnancy
pre-eclampsia prophylaxis:
1 high risk RF or 2 moderate risk RF
Offer from12/40 GA until delivery
75-150mg OD
when to admit someone with high BP
severe HPTN >160/100
symptoms- eg. headache, dizziness, changes in vision, abdo pain
reduced fetal movements
abnormal bloods- deranged LFTs, U&Es, low Plts, anaemia
Management of someone admitted to the ward with signs of pre-eclampsia
MONITOR
- BP every 30 mins
- urine dip daily
- bloods (FBC, U&Es, LFTs)
- CTG
MEDICATION
- IV labetelol
- steroids if <34 weeks
- severe PET: MgSO4 –> delivery within 24hrs
DELIVERY
-aim for 37weeks
- maternal choice of delivery but advise on labour ward
- conitinuous BP 4x day for at least 24hrs
- 1-2day BP for 2 weeks post discharge
first degree tear
Tear limited to the superficial perineal skin or vaginal mucosa only
second degree tear
Tear extends to perineal muscles and fascia, but the anal sphincter is intact (episiotomy is anatomically classified as second degree)
Stitch on ward by midwife
third degree tear
3a: extends to perineal muscles, fascia and less than 50% of the anal sphincter
3b: extends through the perineal muscles, fascia and more than 50% of the anal sphincter- but the internal sphincter remains intact
3c: Extends through the perineal muscles, fascia and the external and internal anal sphincter. The anal mucosa is intact
repair in theatre by reg
Fourth degree tear
Perineal skin, muscle, anal sphincter and anal mucosa are torn
Management of toxoplasmosis in pregnancy
PREVENT: avoid contact with cats/ kittens, raw meat, wash hands after touching soil
INVESTIGATIONS
infection suspected send maternal blood sample to specialised toxoplasmosis lab
if +ve then amniocentesis >14wks
TREATMENT
refer to fetal medicine unit for USS every 2 weeks
mother- spiromycin (2-3g OD for 3 weeks)
baby- sulfadiazine, pyrimethamine, folonic acid for 1 year
management of Rubella in pregnancy
not routinely screened for in the UK anymore
RF- unvaccinated mother
INVESTIGATIONS
serum IgM- active infection
serum IgG- previous immunity
TREATMENT
Refer to fetal medicine unit for 1-2weekly monitoring
Management of CMV in pregnancy
INVESTIGATIONS
serology, signs of CMV infection on USS
TREATMENT
Refer to fetal medicine for regular check ups
no prenatal treatment available
valganciclovir PO 8g OD to baby at birth for 6 months
management of HIV in pregnancy
Routinely screened for at booking
INVESTIGATIONS
(if known positive) Viral load and CD4 count every 2-4 weeks
F/U every 1-2 weeks
MANAGEMENT
joint HIV and obstetrician care
maternal ART ASAP
PEP to baby immediately at birth- zidovudine for 2-4 weeks
AT DELIVERY
viral load <50copies/mL- vaginal delivery ok
>50copies/mL- C/S advised
NO BREASTFEEDING
Management of HSV in preganancy
painful genital ulcer- high risk when first occurrence
INVESTIGATIONS
swab of ulcer for PCR
TREATMENT
1st-2nd trim- 400mg aciclovir TDS for 5 days + 400mg OD from 36wks- delivery –> vaginal okay
3rd trim- 400mg aciclovir TDS until delivery –> C/S advised
if vaginal give IV aciclovir intrapartum and to baby
management of HBV in pregnancy
joint ID/hepatologist and obstetrician care
maternal tenofovir
baby at birth - HBIg within 24hrs + HB vaccine at birth, 4 weeks and 12 months
management of listeriosis in pregnancy
admission to hospital
IV amoxicillin 2g every 6 hours for 14days
Managament of a UTI in pregnancy
asymptomatic or symptomatic - 50mg nitro QDS for 7 days
not resolved after 48hrs or near term:
amoxicillin 500mg TDS for 7 days or cefalexin 500mg BD for 7 days
management of syphilis in pregnancy
Refer to GUM
IM benzylpenicillin BD for 14 days
Complications of toxoplasmosis infection in pregnancy
In vitro
IUGR
intracranial calcification
hydrocephalus or microcephalus
birth
CHD
blindness -chorioretinitis
neurological defects
complications of CMV infection in pregnancy
At birth:
hepatitis
hepatosplenomegaly
microcephaly
SGA
Long term
sensory neural hearing loss
neurological disabilities
complications of rubella infection in pregnancy
infection <12wks- discuss TOP as severe congenital defects likely
12-20- some form of defect likely
>20wks- unlikely
at delivery:
microcephaly
cataracts
CHD: PDA, VSD, PS
sensory neural hearing loss
long term:
learning disabilities
DM
thyroiditis
complications of listeria monocytogens infection in pregnancy
paralysis
seizures
cerebral palsy
learning difficulties
blindness
CHD
renal problems
complications of VZV infection in pregnancy
maternal:
pneumonitis
encephalitis
hepatitis
death (rare)
baby:
complications of parvovirus B19 infection in pregnancy
hydrops fetalis
complications of syphilis in pregnancy
Hutchinson teeth, blindness, deafness, rashes
describe the antenatal screening for downs
Who would it be offered to?
- offered to all women
- high risk: increased age, FHx
- includes screen for pataus and edwards
- all free on NHS
When would it be offered
NIPT- (private:7-10 weeks, NHS: offered if higher risk after integrated test)- maternal blood
1. 10-13 weeks: combined test- looks at the chance of having T21/18/13. maternal age, bHCG, PAPP-A and NT (>3.5)
(CRL needs to be between 45-84mm to be eligible)
- 15-20: Quadruple screen
InhibinA, BHCG, UE3, AFP - Integrated test- combines the results of the combined and quadruple test
((NB: smoking can affect the results, the quadruple test has a higher false positive result than the combined and the intesgrated has the lowest false positive result)
- CVS- 11-14wks
- Amnioscentesis 15-20
interpretation of the results
Obesity in pregnancy managament
BMI >35
- OGTT at 24-28 weeks
- Vitamin D 10mg OD
- 5g folic acid preconception -12 weeks
- anaestetic review
- higher risk of marosomia, GDM, dystocfia, PPH
- post-natal thromboprophylaxis
physiological changes in pregnancy
- marked increase in fibrinogen
- increase in fVII,X and XII
- stroke volume increases by 30
- plasma volume increases disproportionately to red cell mass resulting in relative anaemia
- rise in AFP
- soft systolic flow murmur due to dilation across tricuspid valve
effects of warfarin in pregnancy
teratogenic
most in 1st trim but also CI in 2nd and 3rd
1st
vertebral calcinosis
nasal hypoplasia
brachydactyly
later
cerebral deformities
eye problems
Mx of PE in pregnancy
Ix:
ECG, CXR
FBC, U&Es, clotting screen, LFTs
USS of leg if DVT suspected
V/Q scan or CTPA
80mg enoxaparin (LMWH) BD
cut off for normal protein creatinine ratio
<30
when should a fetal pole and heart beat be detected on USS
6 weeks
causes of secondary amenorrhoea
Pregnancy
thyroid disorders
anorexia/ low BMI
hyperprolactinaemia (prolactinoma, dopamine antagonist drugs)
PCOS
POI
sheehans syndrome
Causes of primary amenorrhoea
Turners
hypogonadism
hypopituitarism
low BMI
CAH
Investigations for amenorrhoea
primary-
examine genitalia, sex hormones, height and weight, karyotyping
secondary
urine pregnancy test
TFTs
Prolactin
LH/FSH
androgens
medication review
MRI brain
when should anti-D injections be given in the antenatal period?
weeks 28 and 34
and any sensitising event such as trauma, antenatal bleed, amnioscentesis, CVS, ECV, delivery
types of breech and how common is it
20% babies breech at 28 weeks. by term most of these move to cephalic spontaneously and only 3% are left as breech.
flexed (complete)
- both legs flexed at the hip and knees and baby apears to be ‘crossed legged’
extended (frank)
- both legs flexed at the hips and extended at the knees (so legs are straight up)
- most common
footling
- one or both legs extended at the hip so the foot is presenting first
- most dangerous to deliver
Management of breech at >37
counselling
Understand the mothers wishes. is she very keen for a vaginal delivery or C/S
ECV
- try to move the position of the baby from the outside of abdomen
- give anti-D to Rh-ve mothers
- approx 50% success rate (slightly less if first baby, more if not)
risks: fetal distress, placental abruption –> emergency C/S 1/200 chance
- Contraindications: ruptured membranes, multiple pregnancy(except for second twin), placenta praevia, PV bleed, footling breech
breech vaginal delivery - must be in hospital
4/10 will need an EMCS
- hands off approach
- continuous CTG
- risk of fetal hypoxia/ distress
RFs for breech and complications
- polyhydramnios/ oligohydramnios
- obstructive fibroids
- low lying placenta
- multiparity
complications
- chord prolapse
differentials for menorrhagia
dysfunctional uterine bleeding
fibroids
adenomyosis
endometriosis (more dysmenorrhoea than menorrhagia)
bleeding disorders
hypothyroidism
obesitty
indications for taking 5mg folate preconception-12weeks
anti-epileptic drugs
BMI >30
coeliac
diabetes
thalassaemia traits
what are the different types/ severities of spina bifida
Spina bifida occulta
Incomplete fusion of the vertebrae, but with no herniation of the spinal cord
May be visible only as a small tuft of hair overlying the site
Meningocele
Incomplete fusion of the vertebrae, with herniation of a meningeal sac containing CSF
Visible prominence at the site, but usually covered by skin
Myelomeningocele
Incomplete fusion of the vertebrae with herniation of herniation of a meningeal sac containing CSF and spinal cord.
Usually accompanied by other defects such as hydrocephaly or Chiari malformation
Visible prominence at the site, with exposed meninges
causes of polyhydramnios
GDM/ DM
fetal renal problems
oesophageal atresia
twin twin transfusion syndrome
diaphragmatic hernia
chromosomal abnromalities
complications of polyhydramnios
maternal
increased risk of needing C/S
increased pressure so hightened sx eg. GORD, urinary sx, stretch marks
respiratory distress
fetal
chord prolapse
breech/ unstable lie
PROM
Preterm labour
abruption
features of a partogram and when is it used
In active stage of first stage of labour (>6cm dilated)
Time
Temp
BP
Urine (K, G, P, B) - all every 4 hrs
HR- maternal (every 30mins) and fetal
Contractions (check every hr, measure no of contractions in 10 minutes)
Dilation- PV exam every 4 hrs aiming for 1cm/hr in prim, 2cm/hr in multiparous. failure to progress if half that rate
Station- in relation to ischial spine
Liquor- blood stained: abruption, clear: SROM, meconium stained
Position- of anterior fontanelle
Moulding- of fontanelles
Caput
Drugs given
Oxytocin rate
reassuring CTG features
Baseline rate- 110-160bpm
variability - 5-25bpm
accelerations inc in HR by >15bpm for >15seconds
decels- non or early
non-reassuring CTG features
baseline rate 100-109bpm or 161-180bpm
variability <5bpm for 30-50mins or >25bpm for 15-25 mins
variable decelerations with shoulder accelerations
prolonged decels for 3-5minutes
pathological CTG
baseline rate <100 or >180
variability <5bpm for >50mins or >25bpm for >25mins
variable decels with no shouldering
prolonged decels for >5mins
failure to return to BRa
sinosoidal
biphasic W shape
causes of fetal tachycardia
hypoxia
hyperthyroidism
chorioamnionitis
fetal/maternal anaemia
causes of fetal bradycardia
prolonged cord compression
cord prolapse
hypothyrodism
epidural/ spinal anaesthesia
maternal seizure
100-120 could be normal for post dates
causes of reduced variability
fetal sleeping (no longer than 40mins)
acidosis
fetal tachycardia
drugs- opiates, benzos, MgSo4
prematuriy
congenital heart disease
mechanism of early decelerations
uterine contracture causes increased ICP in fetus leading to increase vagal tone which lowers the HR
causes of variable decelerations
oligohydramnios
umbilical cord compression
causes of late decelerations
maternal hypotension
PET
uterine hyperstimulation
causes of sinosoidal rhythm
severe fetal hypoxia
severe fetal anaemia
feta/ maternal haemorrhage
why is hypotension an absolute CI to epidural?
the epidural will cause peripheral vasodilation and worsen pre existing hypotension
most anaethesists will pre load pt with 1L IV fluids before giving epidural
absolute contraindications for epidural anaesthesia in pregnancy
maternal refusal
allergies to anaesthetic agents
sytemic infection
skin infection by epidural site
bleeding disorders
platelet cout <80000
uncontrolled hypotension
relative CI to epidural
HOCM
aortic stenosis
mitral stenosis
where does the pudendal nerve arise from and what are the branches of the pudendal nerve and what do they innovate
S2,3 and 4
perineal nerve -> perineal muscles and perineal skin
inferior anal nerve –> external anal sphincter, perianal skin
dorsal nerve of the clitorus –> urethral sphincter
physiology of fetal circulation after birth
occlusion of the umbilical vessels –> reduces venous return back to the right side of the heart –> reduces right sided arterial pressure –> closure of foramen ovale.
As the fetus starts to breath the pulmonary circulation pressure lowers –> right ventricular output increases
The pulmonary artery vasodilates to allow the new low pressure right sided system to develop
increased flow through pulmonary system leads to more venous return to the left side of the heart –> increased pressure on left side of heart –> closure of the ductus arteriosus
difference between urge and stress incontinence
urge- detrusor overactivity and bladder oversensitivity causes leakage of urine
stress- increased abdo floor pressure vs decreased pelvic pressure causes leakage of urine on coughing/ laughing/ sneezing/ heavy lifting
investigations for incontinence
- abdo/ pelvic exam
- speculum/ bimanual
- kegel test
- urine dip and MSU
- bladder diary for 3 days (noting exactly when it happens and any triggers)
- bladder scan- post void residual volume
- referral to urodynamics
management of urge incontinence
- lifestyle changes
- avoid caffeine
- lose weight if BMI >30
modify fluid intake - bladder retraining exercises (minimum 6 weeks)
- anticholinergics
- eg. oxybutynin (not in >80/ frail), tolterodine, mirabegron
management of stress incontinence
- lifestye changes
- avoid caffeine - pelvic floor exercises (refer to physiotherapy)
- 8 contractions, 3x a day for a minimum of 3 months - surgical
- colposuspension
- autologous rectal facia sling
Pathophysiology of PMS
symptoms occuring in the luteal phase of menstrual cycle casued by high progesterone
eg. mood swings, bloating, tearfullness, irritability, breast tenderness, abdo pain
(all progesterone problems)
management of PMS
- psychosocial
- exercise
- sleep hygiene
- CBT
- vit B6 - bio
- COCP
- mirena coil
- SSRIs eg. citalopram
- oestrodiol patches
- GnRH analogue + HRT - surgical
-hysterectomy
Management of PCOS
weight loss
metformin
COCP
trying to conceive
wt loss +/- metformin
clomifene
sensitising events in Rh- woman requiring anti D
vaginal bleeding <12 weeks if heavy, painful or persistent
PV bleeding >12 weeks
ruptured ectopic pregnancy
TOP
ERPC
amniocentesis or CVS
antenatal haemorrhage
ECV
intra uterine death
post delivery
at 28 and 34 weeks
abdominal trauma
dose of MgSO4 to be given in eclampsia
IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour
what is important to monitor when giving MgSO4
reflexes
respiratory rate
O2 sats
if resp depression occurs then calcium gluconate is the Rx
layers to cut through during a C/S from skin to uterus
Superficial fascia
Deep fascia
Anterior rectus sheath
Rectus abdominis muscle (not cut, rather pushed laterally following incision of the linea alba)
Transversalis fascia
Extraperitoneal connective tissue
Peritoneum
Uterus
rokitasnky’s protuberance is associated with which ovarian tumour?
mature teratoma
causes of increased nuchal translucency
Downs
CHD
abdominal wall defects
causes of hyperechogenic bowel
cystic fibrosis
downs
CMV infection
what should be measured in someone with suspected DVT/ PE started on LMWH in extremes of body weight (<50kg or >90kg)?
anti-Xa activity
what test is used to detect presence of fetal blood in maternal circulation and how does it work?
Kleihaur test
adds acid to maternal blood sample- fetal blood is resistant
management of RFM >28 weeks
- hand held doppler
- if no HB detected then immediate USS
- include: abdo circumference, amniotic fluid volume and estimated fetal weight - if HB present then CTG for 20 mins
if no fetal movements established after 24 weeks then referral to maternal fetal medicine unit
70% of episodes of RFM will be isolated and result in normal uncomplicated pregnancy
factors associated with increased risk of miscarriage
Increased maternal age
Smoking in pregnancy
Consuming alcohol
Recreational drug use
High caffeine intake
Obesity
Infections and food poisoning
Health conditions, e.g. thyroid problems, severe hypertension, uncontrolled diabetes
Medicines, such as ibuprofen, methotrexate and retinoids
Unusual shape or structure of womb
Cervical incompetence
normal lab findings in pregnancy
reduced urea
reduced creatinine
increased urinary proteins
dilutional anaemia
thrombocytopenia
neutrophilia
hypercoaguable
raised D-dimer
missed pill rules
COCP
1 missed pill- take ASAP and no further action required
2 missed pill- take last one missed ASAP and barrier contraception until 7 days of consecutive pills
UPSI in days 1-7 pack -> emergency contraception
in days 8-14 -> no emergency contraception required
days 15-21 -> continue rest of pack then go straight onto new pack omitting pill free week
POP
traditional- <3hrs late take ASAP and no further action, >3hrs take ASAP and barrier for 48hrs
desogestrel (carazette)
<12hrs late take ASAP and no further action
>12 hrs take ASAP and barrier for 48hrs
2 missed pills- take one and barrier for 48hrs
Drugs/ scenarios a pt is on that would make the COCP non favourable
drug inducing drugs eg. rifampicin, carbamazepine as will lower the effectiveness of the pill
lamotragine- as COCP reduces the effectiveness and will lower the seizure threshold
women who have had bariatric ssurgery as effectiveness is reduced as less absorption
positives and negatives of the depo-provera injection
positives:
- induces amenorrhoea so useful in pts with painful/ heavy periods
- reduces pain in sickle cell crisis
negatives:
- small risk of wt gain
- can cause irregular periods
- can cause mood swings
- small risk of reduced bone density
- delayed return to fertility up to 1 year
dose release of progesterone with the implant
60/70mcg/ day –> year 3 25mcg/day
risks and benefits of inplanon
benefits
- reversible
- good for painful periods
- can induce amenorrhoea
- little/ no risk of VTE
- good for obese, smokers, VTE RFs
- nexplanon is radioopaque
risks
- can cause irregular bleeding
-
late injection rules
up to 14 weeks
14 weeks +1 late –> 7 days barrier
if UPSI –> emergency contraception + 7 days barrier
NB: not ella one
positives and negatives of copper IUD
positives:
- non hormonal
- very effective contraception
- lasts 5 years
- not affected by any other medication
negatives:
- cause heavier, more painful periods
- irregular bleeding
positives and negatives of copper IUS
positives:
- makes periods lighter, less painful or stop altogether
- very effective
- lasts 5 years (mirena)
- protective over endometrial cancer
negatives:
- some reports of acne, breast pain, headache (but lesser extent to systemic progesterone)
- can cause irregular bleeding
- can cause functional cysts
risk of expulsion, PID and perforation for IUD/IUSS
expulsion 1in 20
PID 1 in 100 up to 4-6 weeks post insertion
perforation 1 in 1000
