WOMENS HEALTH - obstetrics Flashcards
what is an ectopic pregnancy?
when a fertilised egg implants anywhere outside of the uterus
where is the most common site for ectopic pregnancy?
fallopian tubes
RFs for ectopic pregnancy
- previous ectopic
- tubal damage e.g. due to surgery
- hx of infertility
- endometriosis
- smoker
- > 35
- having the coil
when does ectopic pregnancy commonly present?
6-8 weeks gestation
presentation of an ectopic pregnancy
- missed period
- constant lower abdominal pain
- vaginal bleeding
- cervical motion tenderness (pain when moving cervix during bimanual)
investigations for an ectopic pregnancy
- first line = preg test
- transvaginal ultrasound scan (TVUS)
- investigation of choice
- may see… gestational sac containing sac/fetal pole/non specific mass in tube, empty uterus - +/- serum bHCG
- if high, would expect to see something in uterus, so if uterus is empty suggests pregnancy elsewhere
what level of serum bHCG is high an
> 1500
what is a pregnancy of unknown location (PUL)? what needs to be ruled out if this is the case?
= a positive pregnancy test but no evidence of pregnancy on US
need to rule out ectopic pregnancy
what change in hCG over 48h indicates:
a) intrauterine preg
b) ectopic preg
b) miscarriage
a) rise of more than 63%
b) rise of less than 63%
c) fall of more than 50%
when should women take folic acid during pregnancy? what dose?
It is recommended that women take folic acid 400mcg OD ideally 3 months before conception up to 12 weeks gestation
results from combined test chromosomal screening that indicate high risk of the baby having Down’s Syndrome
a) nuchal translucency
b) B-hCG
c) PAPP-A
- thickened nuchal translucency
- increased B-HCG
- reduced PAPP-A
what is perinatal depression?
encompasses depression occurring during (prenatal depression) and following (postpartum depression) childbirth
what are the most commonly used antidepressants in pregnancy? what do patients need to be cautious of?
SSRIs - can cross placenta into foetus so risks need to be balanced against tx benefit
what are the potential risks of SSRIs in:
a) first trimester
b) third trimester
c) neonates
a) congenital heart defects
b) persistent pulmonary HTN in the neonate
c) neonates can experience withdrawal sx (usually mild, not requiring tx)
which SSRI has the strongest link with congenital malformations when taken in the first trimester?
paroxetine
what is the diagnostic criteria triad for hyperemesis gravidarum?
- 5% pre-pregnancy weight loss
- dehydration
- electrolyte imbalance
criteria for conservative management of an ectopic pregnancy (6)
- FU needs to be possible
- ectopic needs to be unruptured
- adnexal mass <35mm
- no visible heartbeat
- no sig pain
- HCG level <1500 IU/l
criteria for medical management of an ectopic
- all same criteria as conservative PLUS
- HCG <5000
- confirmed absence of intrauterine pregnancy
what is the medical management of an ectopic pregnancy? what are the SEs?
- IM methotrexate
- vaginal bleeding, N&V, abdo pain, stomatitis
what is the 1st line surgical tx for an ectopic pregnancy?
laparoscopic salpingectomy - GA, key-hole surgery with removal of the fallopain tube
in which women with an ectopic pregnancy should laparoscopic salpingotomy, as opposed to salpingectomy, be performed?
women with increased risk of infertility due to damage to the other tube
criteria for surgical management of an ectopic pregnancy (4)
- pain
- adnexal mass >35mm
- visible heartbeat
- HCG >5000
4 causes of anaemia in pregnancy
- physiological!
- low Fe/B12/folate
- thalassemia
- sickle cell
risk factors for anaemia in pregnancy (2)
- multiple pregnancy
- poor dietary intake
pathophysiology of physiological anaemia in pregnancy
- plasma volume increases in pregnancy
- so reduction in haemoglobin concentration
- blood is diluted due to higher plasma vol
if not asymptomatic, how may a pregnant woman with anaemia present?
- SOB
- fatigue
- dizziness
- pallor
screening for anaemia in pregnancy
a) when?
b) what tests are done?
a) one screening at booking clinic, one at 28 weeks gestation
b) BLOODS
- haemoglobin conc
- MCV
what MCV result indicates:
a) Fe deficiency anaemia
b) physiological
c) B12/folate deficiency
a) low
b) normal
c) raised
what concentration of Hb is NORMAL/what are the thresholds for anaemia at
a) booking bloods
b) 28 weeks
c) post partum
a) >110g/l (< is threshold)
b) >105g/l
c) >100g/l
treatment of anaemia in pregnancy
a) women below thresholds
b) if low B12
c) if low folate
- iron - ferrous sulphate 200mg OD
- IM hydroxocobalamin or oral cyancobalamin
- folate - all pregnant women already taking 400mcg, BUT if folate deficiency take >5mg daily
management of thalassemia/sickle cell anaemia in pregnancy
specialist haematologist, 5mg folic acid, monitoring and transfusions
what screening tool is used to assess a woman’s mood postpartum? what score suggests possible postnatal depression?
Edinburgh Posnatal Depression Scale
10 Qs, total score of 30
> 10 suggests postnatal depression
define baby blues
a common condition causing anxiousness and tearfulness shortly after giving birth
when is baby blues common? when should it typically resolve?
3-7 days after birth
should resolve within 2 weeks
RF for baby blues
primips
management of baby blues
supportive - health worker has a key role
investigations for BV in pregnant women
- speculum (not indicated in non pregnant women)
- vaginal pH
- charcoal vaginal swab for microscopy
management of BV in pregnant women:
a) asymptomatic
b) symptomatic
a) discuss with obstetrician
b) oral metronidazole 400mg for 5-7 days
advice on reducing vaginal douching, using antiseptics/bubble baths
define antepartum haemorrhage
bleeding from/in genital tract, occurring from 24+0 weeks of pregnancy and prior to birth of the baby
causes of antepartum haemorrhage (5)
- vasa previa
- placenta previa
- rupture uterus
- placental abruption
- idiopathic
RFs for antepartum haemorrhage
abruption - preeclampsia, advanced maternal age, IVF, infection, non-vertex presentation, PROM, trauma, smoking drug misuse
praevia - previous c-section, previous termination, advanced maternal age, multiple pregnancy, smoking, IVF
presentation of antepartum haemorrhage (4)
- PV bleeding
- abdominal pain
- maternal cardiovascular compromise
- reduced foetal movement/abnormal CTG
assessment of antepartum haemorrhage if bleeding is:
a) ongoing and heavy
b) intermittent/into pad
a) emergency resus
b) assess location of placenta, foetal movements, abdominal/PV examination
management of antepartum haemorrhage
- DR ABCDE
- CTG
- IV access and bloods
- +/- fluids
- if expecting preterm delivery - steroids and MgSO4
- may need to expedite delivery
anti-D if mum is rhesus-negative
signs of a concealed antepartum haemorrhage
shock - clammy, pale, sweaty
NOT MUCH BLOOD LOSS
think - is amount of blood being lost fitting with the presentation?
what is cephalopelvic disproportion?
a mismatch between the size of the foetal head and the size of the maternal pelvis
causes of cephalopelvic disproportion (4)
- foetal macrosomia
- small mother e.g. young, petite
- pelvic malformations
- breech presentation
RFs for cephalopelvic disproportion (4)
- late due date
- gestational diabetes
- family hx of large babies
- previous trauma e.g. fractured pelvis
when will cephalopelvic disproportion present?
early labour stages - active stage
what is a sign of cephalopelvic disproportion?
fail to progress in labour
when is labour considered failing to progress?
a) if first birth
b) if previously given birth
what is a sign?
a) > 20 hours
b) >14 hours
slow/no thinning or dilatation of cervix
investigations for cephalopelvic disproportion
if labour is failing to progress…
1. abdominal exam
2. cervical exam
3. foetal monitoring with CTG
management for cephalopelvic disproportion
delivery of foetus ASAP
complications of cephalopelvic disproportion (2)
- foetal distress
- c-section
investigations for a UTI in pregnancy
- urine dipstick
- urine MSU and culture
- if suspect pyeloneph > renal USS
which medication for a UTI should be avoided in the FIRST trimester of pregnancy?
trimethoprim (think PRIM > PRIMARY for first trimester)
which medication for a UTI should be avoided in the THIRD trimester of pregnancy?
nitrofurantoin (think toin for trois > three)
lower UTI abx options for pregnant women (think what may be allowed depending on the gestation). how long should abx be taken for?
1st line = nitrofurantoin (but not in third trimester)
others = amoxicillin, cephalexin,
7 day course
upper UTI management for pregnant women
broad spectrum abx e.g. cefalexin or ciprofloxacin
what is asymptomatic bateriuria?
bacteria present in the urine without symptoms of infection
when is asymptomatic bacteriuria tested for in pregnant women? how is it done?
- at booking clinic and routinely throughout pregnancy
- urine sample sent to lab for microscopy, culture and sensitivities (MC&S)
what are the adverse outcomes associated with asymptomatic bacteriuria in pregnant women?
- upper and lower UTIs
- preterm delivery
- LBW
- pre-eclampsia
why is trimethoprim avoided in the first trimester of pregnancy?
it’s a folate antagonist - folate is important in early preg for normal development of foetus
trimethoprim in the first trimester can cause…
congenital malformations e.g. spina bifida
which antibiotic that treats chlamydia is contraindicated in pregnancy?
doxycycline
tx of chlamydia in pregnant women
azithromycin 1g orally for one day, then 500mg for two days
what is cord prolapse?
when the umbilical cord descends ahead of the presenting part of the foetus
an obstetric emergency
pathophysiology of cord prolapse - what happens to the foetus and why?
- exposure of cord to outside»_space; vasospasm
- reduces blood flow to foetus
- > > foetal hypoxia
RFs for cord prolapse (7)
- foetal malpresentation
- PROM
- polyhydramnios
- long umbilical cord
- multiparity
- multiple previous pregnancies
- ARTIFICIAL AMNIOTOMY (artificial ROM)
when is a diagnosis of cord prolapse made?
when foetal HR becomes abnormal AND umbilical cord is either:
- palpable vaginally
- visible beyond introitus (external vag opening)
investigations for cord prolapse (2)
- CTG (distress)
- vaginal/speculum exam (palpable/visible cord)
management steps for cord prolapse - what can be done to alleviate pressure on the cord? what positions can mum be put in? + definitive tx
- call 999/emergency buzzer
- can infuse saline into bladder (alleviates presenting part)
- positions of mum - trendelenburg (feet higher than head), left lateral (pillow under hip) or knee-chest position (all fours)
- constant foetal monitoring
- alleviate pressure on cord - push presenting part of foetus back
- IF cord past level of introitus > minimal handling, keep warm and moist (prevents vasospasm)
- transfer to theatre - definitive is emergency c-section
what medication can be given to a pregnant women with cord prolapse while waiting for delivery? why?
tocolytic meds e.g. terbutaline - minimises contractions
tx of gonorrhoea in pregnant women
ceftriaxone 1g IM injection (single dose)
define hypoactive uterus
dysfunction in the propulsive power of the uterus
signs and sx of hypoactive uterus plus
a) < what number of contractions in 10 minutes is worrying?
b) not strong enough to cause cervix to dilate beyond __cm
- abnormal labour pattern - prolonged delivery
- uterine contractions becoming weaker/inefficient/stopping
- < 2-3 contractions in 10 minute period
- cervix doesn’t dilate beyond 4cm
how is a hypoactive uterus monitored?
on partogram
what will be found on examination in a hypoactive uterus?
fundus won’t feel firm at height (acme) of contraction)
differential diagnosis for hypoactive uterus (2)
- malpresentation
- obstructed labour
stepwise management options for a hypoactive uterus
- supportive
- oxytocin infusion
- c-section
likely causes of antepartum haemorrhage in the 1st trimester (3)
- spontaneous abortion
- ectopic pregnancy
- hydatidiform mole
likely causes of antepartum haemorrhage in the 2nd trimester (3)
- spontaneous abortion
- hydatidiform mole
- placental abruption
likely causes of antepartum haemorrhage in the 3rd trimester
- bloody show
- placental abruption
- placenta praevia
- vasa praevia
6-8 weeks amenorrhoea with (unilateral) lower abdo pain and vaginal bleeding later. shoulder tip pain and cervical excitation
ectopic
bleeding in first/early second trimester associated with exaggerated sx of pregnancy e.g. hyperemesis. uterus may be large for dates.
hydatidiform mole
constant lower abdominal pain, may be in hypovolaemic shock despite not much blood. tender, tense uterus with normal lie and presentation. foetal heart may be distressed.
placental abruption
3rd trimester vaginal bleeding, no pain. non-tender uterus, lie and presentation may be abnormal.
placental praevia
3rd trimester - rupture of membranes followed immediately by vaginal bleeding. foetal bradycardia.
vasa praevia
which c-section scar is a contraindication for vaginal birth in the next pregnancy?
a classical vertical scar (as opposed to a vertical uterine incision)
which hormonal therapy is contraindicated in uncontrolled HTN?
oestrogen therapies e.g. COCP
what levels of hCG, TSH and thyroxine would be expected in a hydatidiform mole?
- high beta hCG
- low TSH
- high thyroxine
(hCG acts similarly to TSH, so stimulates thyroid gland to produce T3/4. this negatively feeds back on the pituitary to stop TSH secretion)
management of severe hyperemesis gravidarum in hospital
IV 0.9% saline with potassium (hypokalaemia common)
when should external cephalic version NOT be attempted?
if membranes have already ruptured in active labour
the COCP is contraindicated < how many weeks postpartum?
<6 weeks
management of pre-existing diabetes if patient becomes pregnant (6)
- weight loss if BMI <27
- stop oral hypoglycemics (apart from metformin) and commence insulin
- folic acid 5mg/day from pre-conception to 12w gestation
- detailed anomaly scan at 20w
- tight glycaemic control
- screen for retinopathy and neuropathy
impact of diabetes on pregnancy
- hyperglycemia»_space; foetal macrosomia
- vascular inflammation affects placental development»_space; preeclampsia, intrauterine foetal death
impact of pregnancy on pre-existing diabetes
- pregnancy = insulin resistant state !!! (as need slightly higher blood sugar to feed baby)
- so need for meds increases and higher risk of complications e.g. retinopathy etc
RFs for gestational diabetes (5)
- family hx of diabetes
- obesity (BMI >30)
- ethnicity (south Asian, Black, African-Caribbean, Middle Eastern)
- previous GDM
- previous macrosomic baby (>4.5kg)
- maternal age >40
GDM screening:
a) which women are screened?
b) when?
c) with what?
a) women with any of the 5 RFs
b) as soon as possible after booking appointment (if first test normal, test again at 24-28 weeks)
c) oral glucose tolerance test (OGTT) (measure fasting glucose, give sugary drink, re-measure in 2 hours)
diagnostic cut-offs for GDM
a) fasting glucose
b) 2 hour glucose
a) >5.6
b) > 7.8
remember 5678!
initial management for GDM if fasting plasma glucose <7
- referral to specialist joint antenatal + diabetes clinic (specialist midwives, obs, diabetes physician)
- trial of diet and exercise advice (avoid white bread/pasta/cake, replace with whole fibres, brown pasta etc. exercise!)
management of GDM <7mmol/l if glucose targets not met within 1-2 weeks of lifestyle trial
what if this does not work?
start metformin
if targets still not met, add insulin
what type of insulin is used in GDM?
short-acting (not long)
management of GDM if at time of diagnosis fasting glucose is >7
- referral to specialist joint preg/diabetes clinic
- start insulin!
birth timings for:
a) pre-existing diabetes
b) GDM
a) normally from 37-38+6 (aka before 39)
b) if uncomplicated, 39/40. if complicated e.g. growth concern, poor control then 37-38+6
when are women with GDM followed up? why?
13 weeks postnatal - to screen for development of T2DM
complications of GDM (4)
- macrosomia
- polyhydramnios
- CHD
- preeclampsia
definition of macrosomia
> 90th centile OR EBW >4.5kg
risks associated with macrosomia (2)
- shoulder dystocia
- operative birth
what is shoulder dystocia?
an obstetric emergency where the foetus’ anterior shoulder is impacted/stuck behind the mother’s pubic symphysis
foetal complications of shoulder dystocia (4)
- hypoxic ischaemic brain injury
- neonatal death
- nerve palsy (due to stretching of brachial plexus)
- fractures e.g. clavicle, humerus
maternal complications of shoulder dystocia (2)
- PPH
- perineal tears
which nerve palsy in the foetus is the most common in foetus’ with shoulder dystocia?
Erb’s palsy (paralysis of the arm)
management steps for shoulder dystocia (5)
- call for help
- legs in McRobert’s position (knees flexed up onto chest, hips abducted)
- evaluate for episiotomy
- abdominal pressure (pressure on tummy to try and push baby’s shoulders together)
- internal manoeuvres - deliver posterior arm/Woods screw (rotate baby)
what happens to diastolic BP in NORMAL pregnancy?
falls in first trimester by about 20-40mmHg
continues to fall until 20-24w gestation
then increases to pre-pregnancy levels by term
3 types of HTN in pregnancy
- chronic HTN
- pregnancy-induced HTN
- pre-eclampsia
definition of chronic HTN vs pregnancy-induced
chronic - pre-existing HTN OR HTN developing before 20 weeks gestation
pregnancy-induced - HTN after 20 weeks gestation
how is gestational HTN assessed? what is given to mum’s at risk?
- NICE criteria/Tommy’s
- aspirin 75-150mg OD
when is HTN screened in pregnancy? how?
at every antenatal contact mum gets BP check and urine dipped for proteinuria
if when screening HTN mum’s urine dipstick is +ve for protein, what further investigation is done?
protein-creatinine ratio
medical management for gestational HTN:
a) 1st line
b) if asthmatic
c) 3rd line
d) severe
a) labetalol
b) nifedipine
c) hydralazine/methyldopa
d) IV hydralazine/labetalol
labetalol for HTN in pregnancy
a) mechanism of action
b) contradindicated in…
c) SEs
a) beta-blocking and alpha-blocking activity
b) asthmatics
c) headache, oedema
target BP in pregnant women with HTN?
<135/85
monitoring of gestational HTN
a) if preeclampsia
b) if pregnancy induced
c) if chronic
a) monitor BP at least every 48h, don’t bother monitoring proteinuria
b) monitor BP once/twice weekly, with urine dip
c) depends on control, may be stable!
when does pregnancy-induced HTN typically resolve?
typically 1 month following birth
define pre-eclampsia
diagnostic criteria?
a multisystem inflammatory condition characterised/caused by placental insufficiency
new-onset BP >140/90 after 20 weeks of pregnancy, and 1 more of…
- proteinuria
- other organ involvement e.g. renal, liver, neuro
what defines proteinuria in preeclampsia?
0.3g/24hours
pathophysiology of preeclampsia
- remodelling of uterine arteries doesn’t happen (single lane country road > 18-lane super highway)
- baby not getting enough blood via placenta > sends out stress hormones
- these hormones enter the maternal circulation > inflammation
- maternal BP increases in response
- body-wide inflammation, implicating kidneys, liver, blood vessels, neuro
maternal impacts of preeclampsia (6)
- HTN
- haemolysis
- renal damage (proteinuria)
- placental abruption
- stroke
- seizures
feotal impacts of preeclampsia (4)
- growth probs
- preterm
- stillbirth
- placental abruption
signs and symptoms of preeclampsia (5)
- headache
- visual disturbance
- upper abdominal pain (hepatitis)
- oedema
- hyper-reflexia
screening for pre-eclampsia - what investigations and how is it quantified further if proteinuria is found?
- BP and urine dip at every antenatal contact
- if proteinuria»_space; do protein-creatinine ratio (PCR)
PCR cut-off for preeclampsia diagnosis
30mg/mmol
further investigations for preeclampsia for other complications
bloods - FBC, U&E, LFTs, clotting, placental growth factor ratio (PGFR)
growth scan
check reflexes
placental growth factor ratio (PGFR) is often … in preeclampsia
low
monitoring for pregnant women with preeclampsia
measure BP at least every 48h
management of a pregnant women presenting with BP >160/100mmHg
admit for observation
what can be given to prevent seizures in women with severe preeclampsia?
magnesium sulphate
what is eclampsia?
onset of seizures in a woman with preeclampsia
management steps for eclampsia
- IV magnesium sulphate and BP stabilisation
- c-section once mum is stable
when should magnesium sulphate tx be continued until in a pregnant women with eclampsia?
either 24 hours after last seizure or after delivery
tx of respiratory depression caused by magnesium sulphate in a woman with eclampsia
calcium gluconate
complications of preeclampsia
- foetal - intrauterine growth retardation, prematurity
- haemorrhage e.g. placental abruption, intra-abdominal or intra-cerebral
- cardiac failure
what is the most common cause of early-onset severe infection in the neonatal period?
group b streptococcus
RFs for GBS infection
- prematurity
- prolonged ROM
- previous sib with GBS infection
- prev baby with GBS infection
- previous GBS carrier
- maternal pyrexia (chorioamnionitis)
pathophysiology of how GBS can cause prematurity/how a neonate is exposed to GBS from the mother
- mum infected > bacteria ascends into uterus and infects chorion (chorioamnionitis)
- membranes more likely to damage and rupture before delivery time (premature/miscarriage)
- neonate is exposed during labour > commonly enters airway
when may GBS be incidentally found in the mother? if not found prior to birth, how does it present?
may be found incidentally on screening (but not all women screened)
if not found, may present in neonate as sepsis
how common is GBS in mothers?
v common - 20-40% of mums have GBS in bowel flora and are ‘carriers’ but will not cause probs
how is GBS screened for? who may get screened?
GBS swabs of vagina and rectum at 35-37 weeks or 3-5 weeks prior to expected delivery date
may be offered to women at high risk e.g. GBS in previous pregnancy
management of GBS in pregnancy
a) what preventative tx is given?
b) who to?
c) when?
a) intrapartum antibiotic prophylaxis (IAP) - benzylpenicillin
b)
- women who had GBS in prev pregnancy
- if pts prev baby had GBS
- preterm women
- pyrexia >38 during labour
c) given a couple of hours pre delivery
management of pregnant women who had GBS in previous pregnancy
- inform risk is 50% in this pregnancy
- offer IAP OR screening in late pregnancy
complications of GBS
- chorioamnionitis
- cystitis
- neonatal pneumonia/meningitis/sepsis
what is the general rule for when an instrumental delivery should be abandoned?
if no reasonable progress after 3 contractions and pulls with any instrument
pre-requisites for an instrumental delivery (8)
- fully dilated
- ruptured membranes
- cephalic presentation
- defined foetal position
- foetal head at least to level of ischial spines
- empty bladder
- adequate pain relief
- adequate maternal pelvis
what % of maternal births are instrumental?
10% (in UK)
maternal indications for an instrumental birth (3)
- failure to progress (>2 hours active pushing if nulliparous, >1 hour if multiparous)
- maternal exhaustion
- maternal medical condition limiting active pushing e.g. intracranial pathology, congenital heart disease, HTN
foetal indications for an instrumental (2)
- foetal compromise in second labour stage e.g. distress on CTG/abnormal blood sampling
- clinical concerns e.g. significant APH
absolute contraindications for an instrumental delivery (4) and (2) specifically for ventouse
- unengaged foetal head
- incompletely dilated cervix
- true cephalo-pelvic disproportion
- breech/face presentation
- preterm gestation (<34w) for ventouse
- high likelihood of foetal coagulation disorder (ventouse)
RFs for an instrumental delivery
epidural
relative contraindications for an instrumental delivery (3)
- severe non-reassuring foetal status
- delivery of second twin if head not quite engaged/cervix reformed
- umbilical cord prolapse
what is recommended after instrumental delivery to reduce risk of maternal infection?
single dose of co-amox
complications to mum if instrumental delivery (6)
- PPH
- episiotomy
- perianal tears
- injury to anal sphincter
- incontinence
- nerve injury (obturator, femoral)
key common complications to baby if
a) ventouse
b) forceps
a) cephalohematoma (collection of blood between skull and periosteum)
b) facial nerve palsy and bruising
rare complications to baby if instrumental delivery (4)
- subgaleal haemorrhage
- intracranial haemorrhage
- skull fracture
- spinal cord injury
define:
a) monozygotic
b) dizygotic
a) identical twins (single zygote)
b) non-identical twins (two different zygotes)
define:
a) monoamniotic
b) diamniotic
c) monochorionic
d) dichorionic
a) single amniotic sac
b) two separate amniotic sacs
c) share a single placenta
d) two separate placentas
what is the best outcome in a twin pregnancy?
diamniotic, dichorionic (both foetuses have own nutrient supply)
when is a multiple pregnancy usually diagnosed?
on booking scan (8-12 weeks)
management of multiple pregnancy: antenatal care
- specialist multiple preg obstetric team
- additional monitoring for anaemia (FBC) at
- booking
- 20 weeks
- 28 weeks - additional USS - monitor growth restriction, unequal growth and twin-twin transfusion syndrome
- 2 weekly scans from 16 weeks (monochorionic)
- 4 weekly scans from 20 weeks (dichorionic)
planned birth timings for
a) uncomplicated dichorionic twins
b) triplets
a) between 37 and 37+6
b) before 35+6
management of multiple pregnancy at delivery:
a) medications
b) if monoamniotic
c) if diamniotic
a) corticosteroids pre-birth (lung maturity)
b) elective c-section
c) vaginal delivery possible IF first baby has cephalic presentation
complications to mother of multiple pregnancy (8)
- anaemia
- hyperemesis gravidarum
- polyhydramnios
- HTN
- malpresentation
- spontaneous preterm birth
- instrumental delivery/c-section
- PPH
complications to feotus in multiple pregnancy (7)
- miscarriage
- stillbirth
- foetal growth restriction
- prematurity
- twin-twin transfusion syndrome
- twin anaemia polycythaemia sequence
- congenital abnormalities
what is placenta accreta spectrum?
the attachment/implantation of the placenta onto/through the myometrium (wall of uterus)
a defect in what causes placenta accreta spectrum?
decidua basalis (maternal part of placenta - specialised uterine lining (endometrium) that forms during preg)
RFs for placenta accreta spectrum (4)
- prev c-section
- prev endometrial curettage procedures (e.g. for miscarriage/abortion)
- multigravida
- placenta praevia
pathophysiology of placenta accreta spectrum
a) uterine wall layers (3)
b) normal placental attachment
b) pathology and why PPH can happen
a) endometrium - inner layer containing connective tissue, epithelial cells and vessels
myometrium - middle layer containing smooth muscle
perimetrium - outer layer, serous membrane
b) placenta normally only attaches to endometrium, allow a clean separation during third labour stage
c) placenta accreta - embeds into myometrium/beyond. during birth does not properly separate > PPH
placental accreta definitions
a) superficial placenta accreta
b) placenta accreta
c) placenta increta
d) placenta percreta
a) placenta only implants in surface of myometrium
b) attachment of placenta deeper, but not deep enough to penetrate muscle
c) placenta attaches deeply into myometrium
d) placenta invades past myometrium and perimetrium
presentation of placenta accreta spectrum - when does this typically occur?
- doesnt rlly cause sx during preg (some women can present with APH in 3rd trimester)
- at BIRTH: difficult to deliver placenta, may have PPH
when and how is placenta accreta ideally diagnosed?
antenatally, by USS - then can plan birth
investigation for assessing depth and width of invasion in placenta accreta spectrum
MRI
placenta accreta spectrum delivery management - IF known beforehand
- planned between 35 - 36+6 weeks
- antenatal steroids
- during c-section options are…
- hysterectomy (placenta remains in uterus - recommended)
- uterus preserving surgery
- expectant (leave placenta to be reabsorbed but risk of infection)
placenta accreta spectrum delivery management - IF not known beforehand
a) what if discovered when opening abdo for c-section?
b) what if discovered after delivery?
a) close-up, delay delivery until specialist services in place
b) hysterectomy recommended
placenta accreta spectrum - additional management at birth
risk of bleeds
- complex uterine surgery
- blood transfusions
- intensive care
causes of polyhydramnios (THINK overproduction and reduced swallowing)
- IDIOPATHIC
- overproduction
- maternal diabetes
- rhesus isoimmunisation - reduced foetal swallowing
- infection e.g. CMV, toxoplasmosis, parovirus
- congenital e.g. anencephaly, duodenal atresia
- genetic disease e.g. aneuploidy
causes of oligohydramnios (THINK increased fluid loss, decreased fluid production)
- increased fluid loss - rupture of membranes
- decreased fluid production
- foetal growth restriction
- maternal comorbidities
- placental abnormalities
- foetal urinary tract abnormalities e.g. renal agenesis
- maternal drug use
- post-term pregnancy
main RF for polyhydramnios
gestational diabetes
pathophys - production of amniotic fluid
- amniotic fluid in later preg = foetal urine
- foetus swallows and recycles this
- smaller volumes cross cell membranes and go into lungs
if any probs with this process >poly/oligo
signs & sx of polyhydramnios
if mild - no sig x
if severe - SOB, oedema of ankles and feet, abdo pain, contractions, enlarged uterus
signs & sx of oligohydramnios
- may be asymptomatic
- may present as fluid leakage (ROM)
- foetal parts hard to palpate
investigations for polyhydramnios - how is it normally disovered?
- normally found incidentally at routine appt (USS - extra fluid, uterus large for dates)
- OGTT to check for diabetes!
investigation for oligohydramnios
USS - uterus small for dates, amniotic fluid index <5cm
management of polyhydramnios
- if mild, don’t necessarily need management!
- management depends on cause e.g. control diabetes, treat infection
- may have checkups for rest of pregnancy
management of oligohydramnios
- monitor growth + fluid vol
- refer to foetal medicine
- may need early delivery
at what dates is induction recommended in mums with oligohydramnios?
36-38w
complications of polyhydramnios (severe) (6)
- prematurity
- breech birth
- PROM
- umbilical cord prolapse
- stillbirth
- PPH
complications of oligohydramnios
what if baby is <24w?
- congenital abnormalities e.g. urethral obstruction
- reduced growth
POORER prognosis if foetus <24w…
- limb deformities
- pulmonary hypoplasia
- preterm
- umbilical cord compression
- meconium aspiration
- c-section
what is placental abruption?
when part/all of the placenta separates from the wall of the uterus prematurely
results in maternal haemorrhaging into intervening space
aetiology of placental abruption
largely unknown but may occur by:
1. direct abdominal trauma
2. indirect trauma
3. cocaine use (causes vasospasm)
RFs for placental abruption - use ABRUPTION
A - abruption previously
B - blood pressure (HTN, preeclampsia)
R - ruptured membranes (premature, prolonged)
U - uterine injury e.g. trauma
P - polyhydramnios
T - twins/multiple gestation
I - infection e.g. chorioamnionitis
O - older age (>35)
N - narcotic use e.g. cocaine, amphetamines, smoking
two types of placental abruption
- revealed - bleeding tracks down from site of placenta separation > drains through cervix > vaginal bleeding
- concealed - bleeding remains in uterus, forms clot retroplacentally. bleeding not visible but can cause shock
pathophys of placental abruption
- rupture of maternal vessels within basal layer (bottom layer of epidermis) of endometrium
- blood accumulates
- splits placental attachment from basal layer
- detached portion of placenta cant function > foetal compromise
signs and symptoms of placental abruption
normally third trimester…
1. SUDDEN ONSET, SEVERE abdo pain (continuous)
2. woody abdomen on palpation
3. CTG abnormalities
4. if concealed - present with shock out of keeping with visible loss
1st line investigations for placental abruption
- haematology - FBC, clotting profile, group&save, cross match
- biochemistry - rule out pre-eclampsia and HELLP syndrome with U&Es and LFTs
- CTG (if foetus >26)
investigations for placental abruption once pt stable
USS
ddx for placental abruption (3)
- placenta praevia
- marginal placental bleed (wont be maternal/feotal compromise)
- vasa praevia
acute management of emergency placental abruption (if significant APH)
emergency c-section
ongoing management of placental abruption: when is emergency c-section indicated?
- if maternal and/or feotal compromise
- doesn’t matter if foetus is at term
ongoing management of placental abruption - when is induction/vaginal delivery indicated?
IF
1. haemorrhage at term WITHOUT maternal/foetal compromise
2. or foetus died
management of placental abruption - when is conservative (admit, observe, steroids) indicated?
- if partial/marginal abruptions not associated with maternal/foetal compromise
- OR if foetus is <36w and not distressed
management of placental abruption if mother is rhesus D -ve
given anti-D within 72h of onset of bleeding
complications of placental abruption
- hypovolemic shock
- intrauterine growth restriction
- preterm birth
- neuro impairment in infant
define placenta praevia
what are the 4 grades?
placenta lying wholly/partly in the lower uterine segment
I - placenta reaches lower uterine segment but not internal os
II - placenta reaches internal os but does not cover it
III - placenta covers internal os before dilation but not when dilated
IV (major) - placenta completely covers internal os
epidemiology of placental praevia - how common at 16-20 weeks vs at delivery?
5% will have low-lying placenta at 16-20 weeks, but incidence at delivery is only 0.5%
RFs for placenta praevia (6)
- multiparity
- multiple preg
- previous c-section (important)
- maternal age >40
- hx of uterine infection
- curettage to endometrium
when may placenta praevia cause a bleed?
(in general, more susceptible to haemorrhage, potentially due to defective attachment to uterine wall)
bleeding may be…
- spontaenous
- provoked e.g. during vag exam
- may be due to damage as presenting part of foetus moves downwards before labour!
presentation of placenta praevia
- PAINLESS vaginal bleeding in late preg
- shock in proportion to visible loss
- uterus non-tender
- lie/presentation may be abnormal
- foetal HB usually normal
what investigation/s should NOT be performed until an USS is done for placeta praevia?
digital vaginal/speculum exam (risk of bleed)
when would placenta praevia be incidentally picked up and how?
on routine 20 week USS scan
investigations for suspected placenta praevia if not picked up in pregnancy
- transvaginal ultrasound
- CTG (if >26w gestation)
ddx for placenta praevia (4)
- placental abruption (will be painful)
- vasa praevia
- uterine rupture
- infection
management of placenta praevia if acute significant APH
ABCDE and emergency c-section
management of placenta praevia if identified at 20-week scan:
a) minor (not over internal os)
b) major
a) repeat USS at 36w, placenta likely to have moved
b) repeat USS at 32w and plan for delivery - elective c-section between 36-37w
complications of placenta praevia
a) maternal
b) foetal
a) anaemia, placenta accreta spectrum, APH
b) preterm, IUGR, foetal death
medication to suppress lactation
cabergoline (dopamine receptor agonist - inhibits prolactin)
indications for high dose folic acid (5mg) in pregnancy (5)
- BMI >30
- maternal/paternal neural tube defects
- prev preg affected by NTD
- maternal anti-epileptic use
- diabetes mellitus
category 1 c-section
- immediate threat to mum/baby
- within 30 mins
- e.g. major placental abruption, cord prolapse, foetal hypoxia
category 2 c-section
- maternal/foetal compromise not immediately life-threatening
- within 75 minutes
category 3 c-section
- delivery is required but mum and baby are stable
- within 24h
- e.g. preterm, tiny baby, breech pres but mum doesn’t want breech vaginal
category 4 c-section
elective
what does a CTG measure?
feotal heartbeat and uterine contractions
after 28w gestation RFM and no heartbeat detected with handheld doppler - what investigation should be done?
immediate ultrasound
which meat should be avoided in preg? why?
cooked liver - high levels of vit A can be harmful
pregnant women should avoid air travel after how many weeks gestation if:
a) singleton
b) multiple preg
a) 37w
b) 32w
classification of perineal tears:
a) first degree
b) second degree
c) third degree
d) fourth degree
a) superficial damage with no muscle involvement, no repair needed
b) injury to perineal muscle but NOT involving anal sphincter - suturing on ward
c) injury to perineum involving the anal sphincter - repair in theatre
d) injury to perineum involving anal sphincter complex and rectal mucosa - repair in theatre
Bishop’s scoring - what is indicated by a score of…
a) <5
b) = or >8
a) labour is unlikely to start without induction
b) cervix is ripe - high chance of spontaneous labour
CTG findings:
a) foetal bradycardia
b) foetal tachycardia
a) <110bpm
b) >160bpm
pre-terminal CTG findings which indicate emergency c-section (2)
- terminal bradycardia - baseline foetal HR drops to <100bpm for more than 10 minutes
- terminal deceleration - HR drops and does not recover for more than 3 minutes
define primary and secondary PPH
primary - within 24h of delivery, >500ml blood loss
secondary - after 24h and up to 12w post delivery
what typically causes secondary PPH?
retained placental tissue/endometritis
minor vs major PPH
minor = 500ml-1L
major = >1L
causes of primary PPH (4)
the four Ts!!!
Tissue - placental not complete
Tone - uterine atony (most common)
Trauma - tears
Thrombin - clotting probs
RFs for PPH (8)
- macrosomia
- multi pregnancy
- first babies OR >4 babies
- precipitate/prolonged labour
- maternal pyrexia
- operative delivery
- shoulder dystocia
- previous PPH
initial management of a PPH
ACB
- two peripheral cannulae, 14 gauge
- lie woman flat
- bloods including group&save
- commence warmed crystalloid infusion
mechanical management options for PPH (2)
- palpate uterus fundus - stimulates contractions
- catheterise
medical management options for PPH (uterine atony)
- IV oxytocin
- IV/IM ergometrine
- IM carboprost
- tranexamic acid
contraindications to medical PPH managements:
a) ergometrine
b) carboprost
a) hx of HTN
b) asthmatics
1st line surgical PPH management if medical managements fail?
what if bleeding is severe and uncontrolled?
intrauterine balloon tamponade
hysterectomy
other surgical PPH managements (not 1st line)
- b-lynch suture
- ligation of uterine/internal iliac arteries
what is HELLP syndrome? what are the key features?
= severe form of pre-eclampsia
- haemolysis
- elevated liver enzymes
- low platelets
presents with malaise, nausea, vomiting and headache
what are the main stages of labour? (3)
stage 1 - onset of true labour to when cervix fully dilated
stage 2 - from full dilation to delivery of foetus
stage 3 - from delivery of foetus to placenta and membranes delivered
what are the phases of stage 1 labour?
latent phase - 0-3cm dilation, normally takes 6 hours, irregular contractions
active phase - 3-7cm dilation, normally 1cm/hr, regular contractions
transition phase - 7-10cm, strong and regular contractions
how long does the first stage of labour normally take in primigravida women?
10-16 hours
what are the passive and active stages of labour stage 2?
passive - in 2nd stage but absence of pushing
active - active process of maternal pushing
when is a delay considered in all labour stages?
stage 1 - if <2cm dilation in 4 hours or slowing of progress in multiparous women
stage 2 - active pushing lasting >2h in nulliparous women or >1 hour in multiparous
stage 3 - more than 30 mins with active management or more than 60 mins with physiological management
what is uterine rupture?
spontaneous full thickness/tear of the uterine muscle and overlying serosa
a rare complication typically occurring during labour
two types of uterine rupture
- incomplete - peritoneum overlying the uterus is intact. uterine contents remain within the uterus
- complete - peritoneum is also torn, and the uterine contents escape into the peritoneal cavity
pathophysiology of uterine rupture
complete division of all three layers of uterus:
1. endometrium (inner epithelial)
2. mymoetrium (smooth muscle)
3. perimetrium (serosal outer surface)
baby can slip out into abdomen
RFs for uterine rupture
generally those that make the uterus weaker…
1. PREV C-SECTION (classical (vertical) incisions)
2. previous uterine surgery
3. induction/augmentation of labour
4. obstruction of labour
5. multiple preg
6. multiparity
signs and symptoms of uterine rupture
DURING LABOUR…
1. sudden, severe abdo pain, persistent between contractions
2. may have shoulder-tip pain
3. may have bleeding
4. if sig haemorrhage - shock > tachycardia, hypotension
5. distressed foetus
what will show on examination of uterine rupture?
- regression of presenting part
- on abdo palpation > scar tenderness and palpable foetal parts
investigation for uterine rupture if suspicious pre-labour
use USS
investigation of uterine rupture in labour
CTG
- early indicators are change in foetal HR pattern, prolonged foetal bradycardia
ddx for uterine rupture
- placental abruption (pain, bleeding, woody abdomen)
- placental praevia (painless vag bleeding)
- vasa praevia (non-tender uterus)
emergency management of uterine rupture
- ABCDE
- call appropriate staff e.g. senior obs, midwives, anaesthetists
- may need to invoke Massive Obstetric Haemorrhage protocol
resus management of uterine rupture
- protect airway
- 15L 100% O2
- insert two large bore cannulas, take bloods
- give cross-matched bloods and fluids
- monitor GCS
surgical management of uterine rupture
- C-SECTION
- uterus either repaired or removed
define prelabour rupture of membranes (PROM)
amniotic sac has ruptured before the onset of labour (at >37w gestation)
define preterm prelabour rupture of membranes (P-PROM)
amniotic sac has ruptured before the onset of labour AND before 37w gestation
define prolonged rupture of membranes
amniotic sac ruptures >18h before delivery
define preterm labour with intact membranes
regular painful contractions and cervical dilation, without the rupture of the amniotic sac
define prematurity
what is
a) extreme preterm
b) very preterm
c) moderate to late preterm
defined before 37w gestation
a) under 28 weeks
b) 28-32 weeks
c) 32-37 weeks
from what preterm gestation is full resus offered?
> 24 weeks
RFs for prematurity/P-PROM
- smoking
- previous PROM/preterm
- vag bleeding during preg
- low genital tract infection
- invasive procedures e.g. amniocentesis
- polyhydramnios
- multiple preg
- cervical insufficiency
general presentation of ROM (3)
- “broken water” - painless popping, gush of fluid
- gradual leakage of watery fluid from vagina, damp underwear/pad
- change in colour/consistency of discharge
indications that the membranes have ruptured on speculum
- fluid draining from cervix
- pooling in posterior vaginal fornix
- lack of normal discharge
general investigations for premature labour/PROM/ROM (4)
- maternal hx
- speculum exam
- insulin-like growth factor-binding protein-1 (IGFBP-1)
- placental-alpha-microglobulin-1 (PAMG-1)
diagnostic investigation and finding for PROM/P-PROM
what if in doubt?
diagnostic = speculum - pooling of amniotic fluid in vagina
if in doubt, test IGFBP-1 and PAMG-1
investigation for preterm labour with intact membranes if <30 weeks
just need speculum examination - pooling of amniotic fluid in vagina
investigation for preterm labour with intact membranes if >30 weeks
- speculum (pooling of amniotic fluid)
- TVUSS to assess cervical length
a women >30 weeks gestation with suspected preterm labour with intact membranes comes in. speculum confirms this and a TVUSS is ordered. what should be done if on TVUSS the cervical length is…
a) <15mm
b) >15mm
a) management of preterm labour is offered
b) preterm labour unlikely, not managed as this
ddx for ROM/PROM/P-PROM
- urinary incontinence
- normal vaginal secretions of pregnancy
- increased discharge e.g. due to infection
prophylaxis of preterm labour IF
- cervical length <25mm
- 16-24w gestation
PROGESTERONE
- gel or pessary
- maintains preg by decreasing myometrium activity and preventing cervical remodelling
prophylaxis of preterm labour IF woman has
- cervical length <25mm
- 16-24w gestation
AND
- previous premature birth/cervical trauma e.g. colposcopy, cone biopsy
CERVICAL CERCLAGE (stitch in cervix to support and keep closed)
involves spinal/GA, removed when woman goes into labour or reaches term
management of P-PROM
a) medical
b) labour induction
a) prophylactic abx - erythromycin 250mg 4x daily for 10 days or until labour established
b) labour induced from 34w
general management options for preterm labour with intact membranes
- foetal monitoring CTG
- tocolysis with nifedipine (suppresses labour)
- maternal corticosteroids (if <35w) - IM betamethasone
- IV mag sulphate (if <34w)
- delayed cord clamping/cord milking
main complication of P-PROM
chorioamnionitis
most women who’s membranes have ruptured will progress into labour within…
24-48h
management of P-PROM if 24-33w
- do NOT induce labour
- prophylactic erythromycin
- corticosteroids
management of P-PROM if 33-36w
- prophylactic erythromycin
- corticosteroids if 34-34+6
- delivery
management of P-PROM if 36-37w
watch and wait for 24h OR consider induction of labour
delivery recommended
women can wait 24-96h if they want
complications of prematurity/P-PROM (5)
- chorioamnionitis
- neonatal death (premature, sepsis, pulmonary hypoplasia)
- placental abruption
- umbilical cord prolapse
- oligohydramnios
what is an amniotic fluid embolism?
foetal cells/amniotic fluid enters mothers bloodstream > results in embolic reaction
presentation of amniotic fluid embolism
- mostly DURING labour but can be during c-section and in immediate postpartum phase
- chills, shivering, sweating, anxiety, coughing
- cyanosis, hypotension, bronchospasm, tachycardia, arrythmia, MI
hospital tx of hyperemesis gravidarum
IV normal saline with added potassium
name 3 puerperal infections
- sepsis
- mastitis
- endometritis
management of sepsis post-pregnancy
SEPSIS 6 (BUFALO)
Blood cultures
Urine output
Fluids
Abx
Lactate
O2
most common organism associated with mastitis infection
s.aureus
management of simple mastitis
1st line = continue breastfeeding
analgesia, warm compresses
when are abx indicated for mastitis? (4)
- systemically unwell
- nipple fissure present
- sx don’t improve after 12-24h of effective milk removal
- culture shows infection
abx management for mastitis
oral flucloxacillin 10-14 days
(still continue breastfeeding/expressing)
aetiology/pathophy of endometritis
- infection introduced during/after labour and delivery
- process of delivery opens uterus to bacteria from vagina»_space; travel upward and infect endometrium
- caused by many different bacteria types
when does endometritis present?
from shortly after birth to several weeks postpartum
signs and symptoms of endometritis
- foul-smelling discharge/lochia
- bleeding that gets heavier/doesn’t improve
- lower abdo/pelvic pain
- fever
can»_space;> sepsis
what is lochia?
normal postpartum bleeding
investigations for endometritis
- vaginal swabs
- urine culture
- USS - rule out RPOC
prophylaxis for endometritis
abx given during c-section
management for endometritis if
a) mild, no signs of sepsis
b) septic
a) tx in community with oral broad-spec e.g. co-amoxiclav
b) admit to hospital, IV clindamycin and gentamicin until afebrile for >24h
when are pregnant women screened for syphilis? how?
blood test at booking appt with midwife (~10 weeks)
post-exposure management of chickenpox in pregnancy if
a) >20 weeks
b) <20 weeks
seek specialist advice…
a) oral acyclovir day 7-14 after exposure
b) with caution (advice)
management of post-partum thyroiditis
b-blockers e.g. propranolol
define vasa praevia
the foetal vessels run ahead of the presenting part of the baby and across the internal cervical os
type I vs type II vasa praevia
type I - foetal vessels exposed as velamentous umbilical cord (doesn’t insert into placenta directly but onto the foetal membranes)
type II - foetal vessels exposed as they travel to an accessory placental lobe
RFs for vasa praevia (3)
- low lying placenta
- IVF
- multiple pregnancy
sign of vasa praevia
a) antenatally
b) in labour
c) on exam
a) antepartum haemorrhage (painless)
b) dark red bleeding following ROM, foetal distress
c) pulsating foetal vessels seen in membranes through dilated cervix
when may vasa praevia be diagnosed?
antenatally on USS
management of vasa praevia
a) asymptomatic and diagnosed on antenatal USS
b) presenting with APH at birth
a) corticosteroids from 32 weeks, elective c-section booked for 34-36w
b) emergency c-section
which act created the legal framework for TOP? which reduced the legal limit of gestation age from 28 to 24w?
- 1967 abortion act
- 1990 human fertilisation and embryology act
criteria for abortion at
a) <24w
b) any time
a) if continuing pregnancy involves greater risk to physical/mental health of the woman or existing children
b) if necessary to save mums life/termination will prevent grave permanent injury/evidence of extreme foetal abnormality n
medical abortion (3 steps)
- oral mifepristone (anti-progesterone, halts pregnancy and relaxes cervix)
- 48h later, vaginal misoprostol (stimulates contractions)
- pregnancy test (multi-level) 2 weeks later
under what gestation can a medical abortion occur at home?
10 weeks
surgical abortion
a) prior to surgery
b) surgical options
a) meds used for cervical priming - misoprostol +/- mifepristone
b) options are…
- cervical dilatation and suction (up to 14w)
- cervical dilatation and evacuation using forceps (usually 14-24w)
causes of recurrent miscarriage (5)
- infection
- cervical incompetence
- uterine abnormalities e.g. fibroids, bicornate uterus
- parental chromosomal abnormality
- antiphospholipid abs
define
a) gravida
b) parity
a) the total number of pregnancies, regardless of pregnancy outcome
b) the number of pregnancies completed (births) over 24w gestation
a woman is currently 18 weeks pregnant. her obstetric hx includes 2 children who were born at 39 and 40 weeks, and a miscarriage at 14 weeks. what is her gravida and parity?
G4P2+1
calculating due date
use Naegele’s rule method - add 7 days to the first day of the LMP and then add 9 months
name the blood tests routinely offered during pregnancy (5)
- full blood count
- HIV, Hep B and syphilis testing
- blood group and rhesus status
- haem electrophoresis
- rubella
RFs for gestational diabetes (5)
- previous GD
- prev baby >4kg
- prev unexplained stillbirth
- 1st degree relative w diabetes
- BMI >30
complications in foetus if mum has gestational diabetes
- polyhydramnios
- preterm
- unexplained foetal death
- macrosomia
- shoulder dystocia/birth trauma
- congenital abnormalities e.g. CHD
when do these postpartum psych disorders typically present:
a) depression
b) psychosis
a) within first 3 months
b) first 2-3 weeks
future risk of postpartum psychosis if already had an episode
25-50%
RFs for postpartum depression
- previous PP depression
- previous mental health history e.g. depression
- poor social support
- relationship difficulties
- recent stressful events
what medical diagnosis should be considered in women presenting with depressive sx post-partum?
postpartum thyroiditis
