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Year 5 > Repro 2 > Flashcards

Repro 2 Flashcards

1
Q

Cord prolapse

A

when the umbilical cord descends through the cervix and into the vagina after rupture of the fetal membranes. Its ahead of the presenting part of the foetus. Danger of the cord getting compressed resulting in fetal hypoxia

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2
Q

Cord prolapse risk factors

A
  • Abnormal lie after 37 weeks gestation i.e. unstable transverse or oblique
  • Multiparity, prematurity
  • Polyhydramnios
  • Artificial rupture of membranes
  • External cephalic version, stabilising induction of labour= over 50% of cord prolapses have an iatrogenic cause
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3
Q

Cord prolapse diagnosis

A
  • Umbilical cord prolapse should be suspected where there are signs of fetal distress on the CTG (bradycardia, abnormal fetal heart rate).
  • US to confirm the diagnosis
  • Sudden onset of symptoms post rupture of membrane
  • A prolapsed umbilical cord can be diagnosed by vaginal examination.
  • Speculum examination to confirm the diagnosis.
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4
Q

Cord prolapse management

A
  • Emergency caesarean section if not immediate vaginal delivery
  • Cord should be kept warm and wet, minimal handling whilst waiting for delivery
  • If the baby is compressing the cord it can be pushed upwards
  • The women can lie in the left lateral position i.e. Trendelenburg position (pillow under hip) or the knee chest position (on all fours)
  • Give mum high flow oxygen via a non re-breathe mask
  • Tocolytic medication i.e. terbutaline can minimise contractions
  • Filling the bladder i.e. inserting a catheter and filling the bladder with 500ml of normal saline. Bladder should be emptied prior to C-section

Medical emergency= will develop vasospasm and fetal hypoxia

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5
Q

Pregnancy depression and anxiety

A
  1. 12-13%, includes generalised anxiety disorder, OCD and phobias
  2. Al pregnant women are screened via a questionnaire for anxiety and depression: at booking and at 28 weeks and should be asked at every patient contact
  3. Refer for perinatal mental health support if fulfils criteria for referral i.e. red flags- previous/high risk of suicides, attempt or self harm, previous admission under psychiatric services, previous psychosis of any kind, bipolar
  4. Sertraline (SSRI) often first line or citalopram (very small risks of Persistent pulmonary hypertension)
  5. Risks of not treating – high cortisol levels in mum of unknown risk to baby, assoc with poor bonding and effect on other children, deteriorating mood.
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6
Q

Pregnancy psychotic disorders

A
  1. Include bipolar disorder, schizophrenia, schizoaffective disorder and psychotic depression
  2. Preconception counselling – plan regarding their medication & risks in pregnancy and postpartum period
  3. Require referral to perinatal mental health team
  4. High risk of relapse and postpartum psychosis (50% recurrence)
  5. May need prophylactic admission to Mother and Baby units (MBU)
  6. Medication should not be stopped or changed without PMHT involvement
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7
Q

Pregnancy drug and alcohol misuse

A
  • Refer to a specialist substance misuse service for advice and treatment
  • Assisted alcohol withdrawal and detoxification of opioids (or supportive on methadone/subutex) should be in collaboration with specialist mental health services and preferably as in-patients. Generally do not attempt to reduce opioid substitutes – less risk of seeking additional supplementation if stable.
  • Consultant led care, specialised support. Ongoing toxicology screening
  • Fetal growth is monitored by ultrasound scans. Neonates will need monitoring for withdrawal
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8
Q

Pregnancy eating disorders

A
  1. Changes in body shape can be difficult, or reignite previous problems
  2. Prevalence of anorexia nervosa and bulimia nervosa is lower in pregnant women
  3. Prevalence of binge eating disorder is higher in pregnant women
  4. Psychological interventions include focussed family therapy (FT) and eating disorder CBT (CBT-ED).
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9
Q

Maternal mental health: medication

A
  1. Emphasis on maintaining good maternal mental health. The lowest dose that keeps them well
  2. Sodium valproate should be avoided
  3. Shouldn’t stop medication without discussion
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10
Q

Postnatal blues ‘baby blues’

A
  1. Common condition (50-80% of women).
  2. Symptoms include tearfulness, anxiety and irritability
  3. usually starts on day 3-4 postnatally and last for up to 10 days.
  4. self-limiting, requires reassurance and monitoring.
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11
Q

Postnatal depression (PND)

A
  1. Common condition (10-15% of women) in the first year after childbirth.
  2. In 30% symptoms commence in the antenatal period. Most cases start within a month of birth and peak at 3 months
  3. Women with a prior history of major depression and a family history of PND are at high risk. Risk of recurrence in future pregnancies
  4. Cognitive behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine may be used if symptoms are severe - whilst they are secreted in breast milk it is not harmful to the infant
  5. Treatment of severe PND includes anti-psychotics, mood stabilisers and occasionally ECT
  6. Can be diagnosed with the Edinburgh postnatal depression scale
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12
Q

Postpartum (puerperal) psychosis)

A
  • Rare (1-2 in 1000) women who have given birth.
  • High risk of bipolar or FH of postpartum psychosis. Can occur with no previous psychiatric history.
  • Symptoms can vary ,usually a mix of psychosis, depression and mania: excited or elated, severely depressed, rapid mood changes. Confused or disorientated
  • Features include severe swings in mood (similar to bipolar disorder) and disordered perception i.e. auditory hallucinations
  • Usually present in the first 2 weeks following delivery.
  • Majority of the women have delusional ideas of their baby (ie, that it is at risk, or somehow evil).
  • Psychiatric emergency and requires assessment by a trained psychiatrist.
  • Treatment of the acute episode requires in-patient admission to a mother and baby unit and anti psychotics, anti depressants and/or mood stabilisers.
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13
Q

Pregnancy PTSD

A
  1. ~4% of all women who have given birth suffer from PTSD
  2. Trauma is subjective – how the patient perceives experience, not necessarily what happened that causes the symptoms.
  3. Partners can also suffer from PTSD related to birth trauma.
  4. Symptoms include re-experiencing the trauma, avoidance of any reminders of the trauma, negative cognitions and mood and hyper vigilance. Impacts on ability to bond with baby and parent, as well as other relationships.
  5. It is important to differentiate PTSD from depression as treatment for both conditions are different.
  6. Treatment includes psychological interventions, varying from a debrief/birth reflections, to EMDR or CBT. Antidepressants - SSRI’s Can be used in conjunction
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14
Q

Gestational diabetes

A

Glucose intolerance first diagnosed in the second/ third trimester of pregnancy. Diagnosis earlier can be type 2 diabetes/ MODY which has previously not been recognised. GDM can have an increased risk of developing T2DM later. May be asymptomatic or have thirst/polyuria.

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15
Q

Gestational diabetes risk factors

A
  • Obesity (BMI ≥30)
  • Family history (1st degree relatives)
  • Previous GDM
  • Ethnicity
  • Previous unexplained SB / NND
  • Previous 4.5kg baby
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16
Q

Gestational diabetes: screening/diagnosis

A
  • OGTT 24-28/40 (plus at booking if previous GDM)
  • Home blood glucose monitoring from 16/40
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17
Q

Gestational diabetes: postnatal screening

A
  • Fasting blood glucose at 6-13weeks
  • Or HBA1C after 13 weeks
  • Annually thereafter
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18
Q

When is gestational diabetes diagnosed

A
  • Fasting glucose >5.6mmol/L
  • 2-hour glucose ( or OGTT) >7.8mmol/L
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19
Q

Management of gestational diabetes

A
  • If fasting glucose levels are <7mmol/L. A trial of diet and exercise is offered. If glucose targets are not met within 1-2 weeks of diet/exercise, metformin should be started. If still not met short acting insulin should be added
  • If at the time of diagnosis the fasting glucose level is >= 7 mmol/l insulin should be started with or without metformin
  • If the plasma glucose level is between 6-6.9 mmol/l, and there is evidence of complications such as macrosomia or hydramnios, insulin should be offered
  • Glibenclamide should only be offered for women who cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment
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20
Q

Management of pre-existing diabetes

A
  • weight loss for women with BMI of > 27 kg/m^2
  • stop oral hypoglycaemic agents, apart from metformin, and commence insulin
  • folic acid 5 mg/day from pre-conception to 12 weeks gestation
  • detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts
  • tight glycaemic control reduces complication rates
  • Retinopathy screening shortly after booking and at 28 weeks gestation
  • treat retinopathy as can worsen during pregnancy
  • Planned delivery between 37-38+6. (woman with gestational diabetes can give birth up to 40+6)
  • T1D: sliding scale insulin regime during labour. Dextrose and insulin infusion titrated to blood sugar levels
21
Q

Gestational diabetes: foetal complications

A
  • Macrosmia (birthweight >4kg)
  • Sacral agenesis
  • Prematurity
  • Neonatal hypoglycaemia
  • Long term: increased risk of developing T2DM later in life
22
Q

Gestational diabetes blood sugar target

A
  • Fasting: 5.3 mmol/l
  • 1 hour post-meal: 7.8 mmol/l
  • 2 hours post-meal: 6.4 mmol/l
  • Avoiding levels of 4 mmol/l or below
23
Q

Diagnosing pre-eclampsia

A
  • New onset of hypertension >140/90 at >20 weeks of pregnancy and one of:
    1. urine PCR (protein/creatinine ratio) of ≥30 mg/mmol
    2. maternal organ dysfunction (renal, hepatic, neurological or haematological abnormalities)
    3. Uteroplacental insufficiency (Stillbirth, FGR or abnormal umbilical artery Doppler waveform)
  • Severe Hypertension is blood pressure >160/110
24
Q

Pre-eclampsia triad

A

Pre-eclampsia describes the emergence of high blood pressure during pregnancy that may be a precursor to a woman developing eclampsia and other complications. It is classically a triad of 3 things:

  • new-onset hypertension
  • proteinuria
  • oedema
25
Q

Pre-eclampsia definition

A
  • condition seen after 20 weeks gestation
  • pregnancy-induced hypertension
  • proteinuria
  • Investigations: BP measurement, urinalysis, blood tests
26
Q

Potential complications of pre-eclampsia

A
  1. Eclampsia- other neurological complications like altered mental status, blindness, stroke, clonus, severe headache or persistent visual scotoma
  2. Fetal complications: intrauterine growth retardation, prematurity
  3. Liver involvement (elevated transaminases)
  4. Haemorrhage: placental abruption, intra-abdominal, intra-cerebral
  5. DIC, HELLP syndrome
  6. Cardiac failure
  7. Neonatal: IUGR, pre-term delivery, placental abruption, Neonatal hypoxia
27
Q

Features of severe pre-eclampsia

A
  1. hypertension: typically > 160/110 mmHg and proteinuria as above
  2. proteinuria: dipstick ++/+++
  3. headache, peripheral oedema, drowsiness
  4. visual disturbance
  5. papilloedema
  6. RUQ/epigastric pain
  7. hyperreflexia
  8. platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome
28
Q

Management: pre-eclampsia

A
  1. Asprin is used for prophylaxis against the development of pre-eclampsia. Given from 12 weeks untill birth in women with one high risk factors or >2 moderate risk factors
  2. Women with blood pressure 160/110mmHg are likely to be admitted and observed
  3. Oral labetalol is first line, Nifedipine and hydralazine may be used
  4. Delivery of the baby is the definitive treatment
29
Q

Eclampsia

A
  • Onset of seizures in woman with pre-eclampsia
  • Generalised tonic clonic
  • Magnesium sulphate (IV) is used for both prophylaxis and treatment of eclamptic seizures
30
Q

Eclampsia: treatment

A
  1. Magnesium sulphate- in severe pre-eclampsia and eclampsia. In eclampsia an IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour
  2. Urine output, reflexes, respiratory rate and oxygen saturations should be monitored during treatment
  3. Respiratory depression can occur: calcium gluconate is the first-line treatment for magnesium sulphate induced respiratory depression
  4. Treatment should continue for 24 hours after last seizure or delivery (around 40% of seizures occur post-partum)
  5. Fluid restriction to avoid fluid overload
31
Q

Pre-eclampsia:Antihypertensive treatment

A
  • Recommended antihypertensive drugs in pregnancy: Labetalol (oral or IV), Nifedipine, Methyldopa, Hydrallazine (IV)
  • Postnatal antihypertensive choice includes ACE inhibitors (Enalapril) are recommended as first line agent postnatally. Labetalol or nifedipine may be continued from antenatal treatment
  • BP targets: Antenatally: 135/85; Postnatally: 140/90
32
Q

Pre-eclampsia: timing of delivery

A

In cases of well controlled hypertension with no maternal and fetal concerns delivery is recommended at 37 weeks or earlier depending on the clinical situation. Where delivery is indicated prior to 36 weeks a course of antenatal steroids should be considered

33
Q

HELLP syndrome

A
  1. 10-20% of patients with severe pre-eclampsia will go on to develop HELLP, don’t have to have pre-eclampsia to get it
  2. Features: nausea and vomiting, right upper quadrant pain, lethargy, headache, peripheral oedema, blurred vision
  3. Investigations: bloods (haemolysis, elevated liver enzymes and low platelet), coagulation to look for DIC and US for liver abnormalities
  4. Treatment: delivery of the baby, maybe a blood transfusion for anaemia or steroids for lung maturation
  5. Acronym: Haemolysis, elevated liver enzymes and a low platelet count
34
Q

Ectopic pregnancy

A

Pregnancy outside the uterine cavity

35
Q

Ectopic pregnancy; site of implantation

A
  1. In the fallopian tube (fimbriae, ampullary, isthmus, interstitial). 97% are tubal, more dangerous if in the isthmus. Trothoblasts invade the tubal wall producing bleeding and may dislodge the embryo
  2. In the ovary
  3. In the abdominal cavity
  4. In the cervical canal
36
Q

Ectopic pregnancy- natural history

A

most common are absorption and tubal abortion

  • tubal abortion
  • tubal absorption: if the tube does not rupture, the blood and embryo may be shed or converted into a tubal mole and absorbed
  • tubal rupture
37
Q

Ectopic pregnancy- risk factors

A
  • Previous ectopic pregnancy, Endometriosis
  • History of PID
  • Previous procedure on fallopian tube
  • Previous pelvic surgery, IVF
  • Uterine fibroid Abnormal uterine anatomy
  • Intra uterine devise does not increase risk but if failed more chances of ectopic pregnancy
38
Q

Ectopic pregnancy- clinical presentation

A
  1. Vaginal bleeding- less the normal period, dark brown
  2. Lower abdominal pain, unilaterally initially, back or pelvic pain
  3. Shoulder pain
  4. Synocopal attacks (hemoperitoneum)
  5. Symptoms of hypovolaemic shock; Haemodynamic instability
  6. History of recent amenorrhoea: 6-8 weeks, from the start of last period
  7. Pregnancy symptoms i.e. breast tenderness
39
Q

Ectopic pregnancy- examination findings

A
  1. Abdominal tenderness
  2. Cervical excitation also known as cervical motion tenderness (chandelier sign) on bimanual examination
  3. Adnexal mass: don’t examine for adnexal mass as increased risk of rupturing the pregnancy
40
Q

Ectopic pregnancy: Expectant management

A
  1. Size <35mm
  2. Unruptured
  3. Asymptomatic
  4. No fetal heartbeat
  5. hCG <1,000 IU/L
  6. Compatible if another intrauterine pregnancy
  7. Closely monitor the patient over 48 hours and if B-hcg levels rise again or symptoms manifest, intervention is performed
41
Q

Ectopic pregnancy: medical management

A
  1. Size <35mm
  2. Unruptured
  3. No significant pain
  4. No fetal heartbeat
  5. hCG <1,500IU/L
  6. Not suitable if intrauterine pregnancy
  7. Medical management involves giving the patient a one off dose of methotrexate and can only be done if the patient is willing to attend follow up and avoid pregnancy for 3 months.
42
Q

Ectopic pregnancy criteria for surgical management

A
  1. Size >35mm
  2. Can be ruptured
  3. Patient unable to attend follow up
  4. Pain, haemodynamicly unstable
  5. Visible fetal heartbeat
  6. hCG >5,000 IU/L
  7. Compatible with another intrauterine pregnancy
  8. Where medical management has failed
43
Q

Ectopic pregnancy: different types of surgical management

A
  1. Surgical management can involve salpingectomy of salpingotomy. Salpingectomy is first line for women with no other risk factors for infertility
  2. Salpingotomy should be considered for women with risk factors for infertility such as contralateral tube damage. Will need serial b-hCG measurements afterwards. Around 1 in 5 women who undergo a salpingotomy require further treatment (methotrexate and/or salpingectomy).
  3. Offer anti-D immunoglobulins go all rhesus negative women
44
Q

Ectopic pregnancy: choosing between medical and surgical management

A
  • These women are offered a choice or either methotrexate or surgical management
  • Have a serum hCG level between 1500 IU/L and 5000 IU/L
  • Are able to return for follow up
  • Have no significant pain
  • Have an unruptured ectopic pregnancy with an adnexal mass smaller than 35 mm with no visible heartbeat.
  • Have no intrauterine pregnancy (confirmed on an ultrasound scan).
45
Q

Signs ectopic pregancy

A
  1. Hypotension, tachycardia. Generally pale
  2. Increased CRT
  3. Abdominal palpitation: uterus not enlarged on palpitation, tenderness, guarding
  4. Per speculum: os closed, may be minimal bleeding
  5. Bimanual examination of uterus: cervical excitation, uterus not enlarged, possible adnexal mass
46
Q

Ectopic pregnancy invetigations

A
  1. Positive urine pregnancy test
  2. Transvaginal ultrasound: empty uterus. Presence of free fluid especially in the pouch of Douglas, Gestation sac in adnexa. May see a non-specific mass i.e. ‘blob sign’ or ‘bagel sign’.
  3. Blood beta hCG: if beta hCG is greater than 1,500 mIU per ml but the transvaginal ultrasonography does not show an intrauterine gestational sac, ectopic pregnancy should be suspected. Suboptimal rise or rise less than 66% is highly suggestive of an ectopic pregnancy
  4. Diagnostic laparoscopy
47
Q

Ectopic pregnancy complications

A
  • Tubal rupture: severe intraperitoneal haemorrhage between 6-10 weeks gestation. Sudden severe abdominal pain, sign of hypovolaemic shock. Need prompt surgical intervention
  • Haemoperitoneum: bleeding in the peritoneal cavity causing haemodynamic instability and shock
48
Q

Pregnancy of unknown location

A

A pregnancy of unknown location (PUL) is when the woman has a positive pregnancy test and there is no evidence of pregnancy on the ultrasound scan. An ectopic pregnancy cannot be excluded.

49
Q

PUL investigations

A
  • The serum hGC level is repeated after 48 hours, to measure the change from baseline.
  • A rise of more than 63% after 48 hours is likely to indicate an intrauterine pregnancy. A repeat ultrasound scan is required after 1 – 2 weeks to confirm. A pregnancy should be visible on US once the hCG level is above 1500 IU / l.
  • A rise of less than 63% after 48 hours may indicate an ectopic pregnancy. When this happens the patient needs close monitoring and review.
  • A fall of more than 50% is likely to indicate a miscarriage. A urine pregnancy test should be performed after 2 weeks to confirm the miscarriage is complete.

Year 5 (24 decks)

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