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PHASE 3A > WOMENS HEALTH - obstetrics > Flashcards

WOMENS HEALTH - obstetrics Flashcards

1
Q

what is an ectopic pregnancy?

A

when a fertilised egg implants anywhere outside of the uterus

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2
Q

where is the most common site for ectopic pregnancy?

A

fallopian tubes

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3
Q

RFs for ectopic pregnancy

A
  • previous ectopic
  • tubal damage e.g. due to surgery
  • hx of infertility
  • endometriosis
  • smoker
  • > 35
  • having the coil
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4
Q

when does ectopic pregnancy commonly present?

A

6-8 weeks gestation

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5
Q

presentation of an ectopic pregnancy

A
  • missed period
  • constant lower abdominal pain
  • vaginal bleeding
  • cervical motion tenderness (pain when moving cervix during bimanual)
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6
Q

investigations for an ectopic pregnancy

A
  1. first line = preg test
  2. transvaginal ultrasound scan (TVUS)
    - investigation of choice
    - may see… gestational sac containing sac/fetal pole/non specific mass in tube, empty uterus
  3. +/- serum bHCG
    - if high, would expect to see something in uterus, so if uterus is empty suggests pregnancy elsewhere
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7
Q

what level of serum bHCG is high an

A

> 1500

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8
Q

what is a pregnancy of unknown location (PUL)? what needs to be ruled out if this is the case?

A

= a positive pregnancy test but no evidence of pregnancy on US

need to rule out ectopic pregnancy

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9
Q

what change in hCG over 48h indicates:
a) intrauterine preg
b) ectopic preg
b) miscarriage

A

a) rise of more than 63%
b) rise of less than 63%
c) fall of more than 50%

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10
Q

when should women take folic acid during pregnancy? what dose?

A

It is recommended that women take folic acid 400mcg OD ideally 3 months before conception up to 12 weeks gestation

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11
Q

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

A
  1. thickened nuchal translucency
  2. increased B-HCG
  3. reduced PAPP-A
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12
Q

what is perinatal depression?

A

encompasses depression occurring during (prenatal depression) and following (postpartum depression) childbirth

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13
Q

what are the most commonly used antidepressants in pregnancy? what do patients need to be cautious of?

A

SSRIs - can cross placenta into foetus so risks need to be balanced against tx benefit

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14
Q

what are the potential risks of SSRIs in:

a) first trimester

b) third trimester

c) neonates

A

a) congenital heart defects

b) persistent pulmonary HTN in the neonate

c) neonates can experience withdrawal sx (usually mild, not requiring tx)

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15
Q

which SSRI has the strongest link with congenital malformations when taken in the first trimester?

A

paroxetine

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16
Q

what is the diagnostic criteria triad for hyperemesis gravidarum?

A
  1. 5% pre-pregnancy weight loss
  2. dehydration
  3. electrolyte imbalance
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17
Q

criteria for conservative management of an ectopic pregnancy (6)

A
  1. FU needs to be possible
  2. ectopic needs to be unruptured
  3. adnexal mass <35mm
  4. no visible heartbeat
  5. no sig pain
  6. HCG level <1500 IU/l
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18
Q

criteria for medical management of an ectopic

A
  1. all same criteria as conservative PLUS
  2. HCG <5000
  3. confirmed absence of intrauterine pregnancy
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19
Q

what is the medical management of an ectopic pregnancy? what are the SEs?

A
  • IM methotrexate
  • vaginal bleeding, N&V, abdo pain, stomatitis
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20
Q

what is the 1st line surgical tx for an ectopic pregnancy?

A

laparoscopic salpingectomy - GA, key-hole surgery with removal of the fallopain tube

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21
Q

in which women with an ectopic pregnancy should laparoscopic salpingotomy, as opposed to salpingectomy, be performed?

A

women with increased risk of infertility due to damage to the other tube

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22
Q

criteria for surgical management of an ectopic pregnancy (4)

A
  1. pain
  2. adnexal mass >35mm
  3. visible heartbeat
  4. HCG >5000
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23
Q

4 causes of anaemia in pregnancy

A
  1. physiological!
  2. low Fe/B12/folate
  3. thalassemia
  4. sickle cell
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24
Q

risk factors for anaemia in pregnancy (2)

A
  1. multiple pregnancy
  2. poor dietary intake
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25
Q

pathophysiology of physiological anaemia in pregnancy

A
  • plasma volume increases in pregnancy
  • so reduction in haemoglobin concentration
  • blood is diluted due to higher plasma vol
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26
Q

if not asymptomatic, how may a pregnant woman with anaemia present?

A
  • SOB
  • fatigue
  • dizziness
  • pallor
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27
Q

screening for anaemia in pregnancy
a) when?
b) what tests are done?

A

a) one screening at booking clinic, one at 28 weeks gestation

b) BLOODS
- haemoglobin conc
- MCV

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28
Q

what MCV result indicates:
a) Fe deficiency anaemia
b) physiological
c) B12/folate deficiency

A

a) low
b) normal
c) raised

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29
Q

what concentration of Hb is NORMAL/what are the thresholds for anaemia at
a) booking bloods
b) 28 weeks
c) post partum

A

a) >110g/l (< is threshold)
b) >105g/l
c) >100g/l

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30
Q

treatment of anaemia in pregnancy
a) women below thresholds
b) if low B12
c) if low folate

A
  1. iron - ferrous sulphate 200mg OD
  2. IM hydroxocobalamin or oral cyancobalamin
  3. folate - all pregnant women already taking 400mcg, BUT if folate deficiency take >5mg daily
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31
Q

management of thalassemia/sickle cell anaemia in pregnancy

A

specialist haematologist, 5mg folic acid, monitoring and transfusions

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32
Q

what screening tool is used to assess a woman’s mood postpartum? what score suggests possible postnatal depression?

A

Edinburgh Posnatal Depression Scale
10 Qs, total score of 30
> 10 suggests postnatal depression

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33
Q

define baby blues

A

a common condition causing anxiousness and tearfulness shortly after giving birth

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34
Q

when is baby blues common? when should it typically resolve?

A

3-7 days after birth
should resolve within 2 weeks

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35
Q

RF for baby blues

A

primips

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36
Q

management of baby blues

A

supportive - health worker has a key role

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37
Q

investigations for BV in pregnant women

A
  • speculum (not indicated in non pregnant women)
  • vaginal pH
  • charcoal vaginal swab for microscopy
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38
Q

management of BV in pregnant women:
a) asymptomatic
b) symptomatic

A

a) discuss with obstetrician
b) oral metronidazole 400mg for 5-7 days
advice on reducing vaginal douching, using antiseptics/bubble baths

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39
Q

define antepartum haemorrhage

A

bleeding from/in genital tract, occurring from 24+0 weeks of pregnancy and prior to birth of the baby

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40
Q

causes of antepartum haemorrhage (5)

A
  1. vasa previa
  2. placenta previa
  3. rupture uterus
  4. placental abruption
  5. idiopathic
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41
Q

RFs for antepartum haemorrhage

A

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

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42
Q

presentation of antepartum haemorrhage (4)

A
  1. PV bleeding
  2. abdominal pain
  3. maternal cardiovascular compromise
  4. reduced foetal movement/abnormal CTG
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43
Q

assessment of antepartum haemorrhage if bleeding is:
a) ongoing and heavy
b) intermittent/into pad

A

a) emergency resus
b) assess location of placenta, foetal movements, abdominal/PV examination

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44
Q

management of antepartum haemorrhage

A
  1. DR ABCDE
  2. CTG
  3. IV access and bloods
  4. +/- fluids
  5. if expecting preterm delivery - steroids and MgSO4
  6. may need to expedite delivery

anti-D if mum is rhesus-negative

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45
Q

signs of a concealed antepartum haemorrhage

A

shock - clammy, pale, sweaty
NOT MUCH BLOOD LOSS

think - is amount of blood being lost fitting with the presentation?

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46
Q

what is cephalopelvic disproportion?

A

a mismatch between the size of the foetal head and the size of the maternal pelvis

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47
Q

causes of cephalopelvic disproportion (4)

A
  1. foetal macrosomia
  2. small mother e.g. young, petite
  3. pelvic malformations
  4. breech presentation
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48
Q

RFs for cephalopelvic disproportion (4)

A
  1. late due date
  2. gestational diabetes
  3. family hx of large babies
  4. previous trauma e.g. fractured pelvis
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49
Q

when will cephalopelvic disproportion present?

A

early labour stages - active stage

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50
Q

what is a sign of cephalopelvic disproportion?

A

fail to progress in labour

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51
Q

when is labour considered failing to progress?
a) if first birth
b) if previously given birth
what is a sign?

A

a) > 20 hours
b) >14 hours

slow/no thinning or dilatation of cervix

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52
Q

investigations for cephalopelvic disproportion

A

if labour is failing to progress…
1. abdominal exam
2. cervical exam
3. foetal monitoring with CTG

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53
Q

management for cephalopelvic disproportion

A

delivery of foetus ASAP

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54
Q

complications of cephalopelvic disproportion (2)

A
  1. foetal distress
  2. c-section
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55
Q

investigations for a UTI in pregnancy

A
  1. urine dipstick
  2. urine MSU and culture
  3. if suspect pyeloneph > renal USS
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56
Q

which medication for a UTI should be avoided in the FIRST trimester of pregnancy?

A

trimethoprim (think PRIM > PRIMARY for first trimester)

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57
Q

which medication for a UTI should be avoided in the THIRD trimester of pregnancy?

A

nitrofurantoin (think toin for trois > three)

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58
Q

lower UTI abx options for pregnant women (think what may be allowed depending on the gestation). how long should abx be taken for?

A

1st line = nitrofurantoin (but not in third trimester)

others = amoxicillin, cephalexin,

7 day course

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59
Q

upper UTI management for pregnant women

A

broad spectrum abx e.g. cefalexin or ciprofloxacin

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60
Q

what is asymptomatic bateriuria?

A

bacteria present in the urine without symptoms of infection

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61
Q

when is asymptomatic bacteriuria tested for in pregnant women? how is it done?

A
  • at booking clinic and routinely throughout pregnancy
  • urine sample sent to lab for microscopy, culture and sensitivities (MC&S)
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62
Q

what are the adverse outcomes associated with asymptomatic bacteriuria in pregnant women?

A
  • upper and lower UTIs
  • preterm delivery
  • LBW
  • pre-eclampsia
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63
Q

why is trimethoprim avoided in the first trimester of pregnancy?

A

it’s a folate antagonist - folate is important in early preg for normal development of foetus

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64
Q

trimethoprim in the first trimester can cause…

A

congenital malformations e.g. spina bifida

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65
Q

which antibiotic that treats chlamydia is contraindicated in pregnancy?

A

doxycycline

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66
Q

tx of chlamydia in pregnant women

A

azithromycin 1g orally for one day, then 500mg for two days

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67
Q

what is cord prolapse?

A

when the umbilical cord descends ahead of the presenting part of the foetus

an obstetric emergency

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68
Q

pathophysiology of cord prolapse - what happens to the foetus and why?

A
  • exposure of cord to outside&raquo_space; vasospasm
  • reduces blood flow to foetus
  • > > foetal hypoxia
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69
Q

RFs for cord prolapse (6)

A
  1. foetal malpresentation
  2. PROM
  3. polyhydramnios
  4. long umbilical cord
  5. multiparity
  6. multiple previous pregnancies
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70
Q

when is a diagnosis of cord prolapse made?

A

when foetal HR becomes abnormal AND umbilical cord is either:
- palpable vaginally
- visible beyond introitus (external vag opening)

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71
Q

investigations for cord prolapse (2)

A
  1. CTG (distress)
  2. vaginal/speculum exam (palpable/visible cord)
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72
Q

management steps for cord prolapse - what can be done to alleviate pressure on the cord? what positions can mum be put in? + definitive tx

A
  1. call 999/emergency buzzer
  2. can infuse saline into bladder (alleviates presenting part)
  3. positions of mum - trendelenburg (feet higher than head), left lateral (pillow under hip) or knee-chest position (all fours)
  4. constant foetal monitoring
  5. alleviate pressure on cord - push presenting part of foetus back
  6. IF cord past level of introitus > minimal handling, keep warm and moist (prevents vasospasm)
  7. transfer to theatre - definitive is emergency c-section
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73
Q

what medication can be given to a pregnant women with cord prolapse while waiting for delivery? why?

A

tocolytic meds e.g. terbutaline - minimises contractions

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74
Q

tx of gonorrhoea in pregnant women

A

ceftriaxone 1g IM injection (single dose)

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75
Q

define hypoactive uterus

A

dysfunction in the propulsive power of the uterus

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76
Q

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

A
  1. abnormal labour pattern - prolonged delivery
  2. uterine contractions becoming weaker/inefficient/stopping
  3. < 2-3 contractions in 10 minute period
  4. cervix doesn’t dilate beyond 4cm
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77
Q

how is a hypoactive uterus monitored?

A

on partogram

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78
Q

what will be found on examination in a hypoactive uterus?

A

fundus won’t feel firm at height (acme) of contraction)

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79
Q

differential diagnosis for hypoactive uterus (2)

A
  1. malpresentation
  2. obstructed labour
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80
Q

stepwise management options for a hypoactive uterus

A
  1. supportive
  2. oxytocin infusion
  3. c-section
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81
Q

likely causes of antepartum haemorrhage in the 1st trimester (3)

A
  1. spontaneous abortion
  2. ectopic pregnancy
  3. hydatidiform mole
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82
Q

likely causes of antepartum haemorrhage in the 2nd trimester (3)

A
  1. spontaneous abortion
  2. hydatidiform mole
  3. placental abruption
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83
Q

likely causes of antepartum haemorrhage in the 3rd trimester

A
  1. bloody show
  2. placental abruption
  3. placenta praevia
  4. vasa praevia
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84
Q

6-8 weeks amenorrhoea with (unilateral) lower abdo pain and vaginal bleeding later. shoulder tip pain and cervical excitation

A

ectopic

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85
Q

bleeding in first/early second trimester associated with exaggerated sx of pregnancy e.g. hyperemesis. uterus may be large for dates.

A

hydatidiform mole

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86
Q

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.

A

placental abruption

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87
Q

3rd trimester vaginal bleeding, no pain. non-tender uterus, lie and presentation may be abnormal.

A

placental praevia

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88
Q

3rd trimester - rupture of membranes followed immediately by vaginal bleeding. foetal bradycardia.

A

vasa praevia

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89
Q

which c-section scar is a contraindication for vaginal birth in the next pregnancy?

A

a classical vertical scar (as opposed to a vertical uterine incision)

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90
Q

which hormonal therapy is contraindicated in uncontrolled HTN?

A

oestrogen therapies e.g. COCP

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91
Q

what levels of hCG, TSH and thyroxine would be expected in a hydatidiform mole?

A
  • 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)

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92
Q

management of severe hyperemesis gravidarum in hospital

A

IV 0.9% saline with potassium (hypokalaemia common)

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93
Q

when should external cephalic version NOT be attempted?

A

if membranes have already ruptured in active labour

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94
Q

the COCP is contraindicated < how many weeks postpartum?

A

<6 weeks

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95
Q

management of pre-existing diabetes if patient becomes pregnant (6)

A
  1. weight loss if BMI <27
  2. stop oral hypoglycemics (apart from metformin) and commence insulin
  3. folic acid 5mg/day from pre-conception to 12w gestation
  4. detailed anomaly scan at 20w
  5. tight glycaemic control
  6. screen for retinopathy and neuropathy
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96
Q

impact of diabetes on pregnancy

A
  1. hyperglycemia&raquo_space; foetal macrosomia
  2. vascular inflammation affects placental development&raquo_space; preeclampsia, intrauterine foetal death
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97
Q

impact of pregnancy on pre-existing diabetes

A
  1. pregnancy = insulin resistant state !!! (as need slightly higher blood sugar to feed baby)
  2. so need for meds increases and higher risk of complications e.g. retinopathy etc
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98
Q

RFs for gestational diabetes (5)

A
  1. family hx of diabetes
  2. obesity (BMI >30)
  3. ethnicity (south Asian, Black, African-Caribbean, Middle Eastern)
  4. previous GDM
  5. previous macrosomic baby (>4.5kg)
  6. maternal age >40
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99
Q

GDM screening:
a) which women are screened?
b) when?
c) with what?

A

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)

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100
Q

diagnostic cut-offs for GDM
a) fasting glucose
b) 2 hour glucose

A

a) >5.6
b) > 7.8

remember 5678!

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101
Q

initial management for GDM if fasting plasma glucose <7

A
  1. referral to specialist joint antenatal + diabetes clinic (specialist midwives, obs, diabetes physician)
  2. trial of diet and exercise advice (avoid white bread/pasta/cake, replace with whole fibres, brown pasta etc. exercise!)
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102
Q

management of GDM <7mmol/l if glucose targets not met within 1-2 weeks of lifestyle trial

what if this does not work?

A

start metformin

if targets still not met, add insulin

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103
Q

what type of insulin is used in GDM?

A

short-acting (not long)

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104
Q

management of GDM if at time of diagnosis fasting glucose is >7

A
  1. referral to specialist joint preg/diabetes clinic
  2. start insulin!
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105
Q

birth timings for:
a) pre-existing diabetes
b) GDM

A

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

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106
Q

when are women with GDM followed up? why?

A

13 weeks postnatal - to screen for development of T2DM

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107
Q

complications of GDM (4)

A
  1. macrosomia
  2. polyhydramnios
  3. CHD
  4. preeclampsia
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108
Q

definition of macrosomia

A

> 90th centile OR EBW >4.5kg

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109
Q

risks associated with macrosomia (2)

A
  1. shoulder dystocia
  2. operative birth
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110
Q

what is shoulder dystocia?

A

an obstetric emergency where the foetus’ anterior shoulder is impacted/stuck behind the mother’s pubic symphysis

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111
Q

foetal complications of shoulder dystocia (4)

A
  1. hypoxic ischaemic brain injury
  2. neonatal death
  3. nerve palsy (due to stretching of brachial plexus)
  4. fractures e.g. clavicle, humerus
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112
Q

maternal complications of shoulder dystocia (2)

A
  1. PPH
  2. perineal tears
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113
Q

which nerve palsy in the foetus is the most common in foetus’ with shoulder dystocia?

A

Erb’s palsy (paralysis of the arm)

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114
Q

management steps for shoulder dystocia (5)

A
  1. call for help
  2. legs in McRobert’s position (knees flexed up onto chest, hips abducted)
  3. evaluate for episiotomy
  4. abdominal pressure (pressure on tummy to try and push baby’s shoulders together)
  5. internal manoeuvres - deliver posterior arm/Woods screw (rotate baby)
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115
Q

what happens to diastolic BP in NORMAL pregnancy?

A

falls in first trimester by about 20-40mmHg
continues to fall until 20-24w gestation

then increases to pre-pregnancy levels by term

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116
Q

3 types of HTN in pregnancy

A
  1. chronic HTN
  2. pregnancy-induced HTN
  3. pre-eclampsia
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117
Q

definition of chronic HTN vs pregnancy-induced

A

chronic - pre-existing HTN OR HTN developing before 20 weeks gestation

pregnancy-induced - HTN after 20 weeks gestation

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118
Q

how is gestational HTN assessed? what is given to mum’s at risk?

A
  • NICE criteria/Tommy’s
  • aspirin 75-150mg OD
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119
Q

when is HTN screened in pregnancy? how?

A

at every antenatal contact mum gets BP check and urine dipped for proteinuria

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120
Q

if when screening HTN mum’s urine dipstick is +ve for protein, what further investigation is done?

A

protein-creatinine ratio

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121
Q

medical management for gestational HTN:
a) 1st line
b) if asthmatic
c) 3rd line
d) severe

A

a) labetalol
b) nifedipine
c) hydralazine/methyldopa
d) IV hydralazine/labetalol

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122
Q

labetalol for HTN in pregnancy
a) mechanism of action
b) contradindicated in…
c) SEs

A

a) beta-blocking and alpha-blocking activity
b) asthmatics
c) headache, oedema

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123
Q

target BP in pregnant women with HTN?

A

<135/85

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124
Q

monitoring of gestational HTN
a) if preeclampsia
b) if pregnancy induced
c) if chronic

A

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!

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125
Q

when does pregnancy-induced HTN typically resolve?

A

typically 1 month following birth

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126
Q

define pre-eclampsia

diagnostic criteria?

A

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

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127
Q

what defines proteinuria in preeclampsia?

A

0.3g/24hours

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128
Q

pathophysiology of preeclampsia

A
  1. remodelling of uterine arteries doesn’t happen (single lane country road > 18-lane super highway)
  2. baby not getting enough blood via placenta > sends out stress hormones
  3. these hormones enter the maternal circulation > inflammation
  4. maternal BP increases in response
  5. body-wide inflammation, implicating kidneys, liver, blood vessels, neuro
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129
Q

maternal impacts of preeclampsia (6)

A
  1. HTN
  2. haemolysis
  3. renal damage (proteinuria)
  4. peri-hepatitis
  5. stroke
  6. seizures
130
Q

feotal impacts of preeclampsia (4)

A
  1. growth probs
  2. preterm
  3. stillbirth
  4. placental abruption
131
Q

signs and symptoms of preeclampsia (5)

A
  1. headache
  2. visual disturbance
  3. upper abdominal pain (hepatitis)
  4. oedema
  5. hyper-reflexia
132
Q

screening for pre-eclampsia - what investigations and how is it quantified further if proteinuria is found?

A
  • BP and urine dip at every antenatal contact
  • if proteinuria&raquo_space; do protein-creatinine ratio (PCR)
133
Q

PCR cut-off for preeclampsia diagnosis

A

30mg/mmol

134
Q

further investigations for preeclampsia for other complications

A

bloods - FBC, U&E, LFTs, clotting, placental growth factor ratio (PGFR)

growth scan

135
Q

placental growth factor ratio (PGFR) is often … in preeclampsia

A

low

136
Q

monitoring for pregnant women with preeclampsia

A

measure BP at least every 48h

137
Q

management of a pregnant women presenting with BP >160/100mmHg

A

admit for observation

138
Q

what can be given to prevent seizures in women with severe preeclampsia?

A

magnesium sulphate

139
Q

what is eclampsia?

A

onset of seizures in a woman with preeclampsia

140
Q

management steps for eclampsia

A
  1. IV magnesium sulphate and BP stabilisation
  2. c-section once mum is stable
141
Q

when should magnesium sulphate tx be continued until in a pregnant women with eclampsia?

A

either 24 hours after last seizure or after delivery

142
Q

tx of respiratory depression caused by magnesium sulphate in a woman with eclampsia

A

calcium gluconate

143
Q

complications of preeclampsia

A
  1. foetal - intrauterine growth retardation, prematurity
  2. haemorrhage e.g. placental abruption, intra-abdominal or intra-cerebral
  3. cardiac failure
144
Q

what is the most common cause of early-onset severe infection in the neonatal period?

A

group b streptococcus

145
Q

RFs for GBS infection

A
  1. prematurity
  2. prolonged ROM
  3. previous sib with GBS infection
  4. prev baby with GBS infection
  5. previous GBS carrier
  6. maternal pyrexia (chorioamnionitis)
146
Q

pathophysiology of how GBS can cause prematurity/how a neonate is exposed to GBS from the mother

A
  1. mum infected > bacteria ascends into uterus and infects chorion (chorioamnionitis)
  2. membranes more likely to damage and rupture before delivery time (premature/miscarriage)
  3. neonate is exposed during labour > commonly enters airway
147
Q

when may GBS be incidentally found in the mother? if not found prior to birth, how does it present?

A

may be found incidentally on screening (but not all women screened)

if not found, may present in neonate as sepsis

148
Q

how common is GBS in mothers?

A

v common - 20-40% of mums have GBS in bowel flora and are ‘carriers’ but will not cause probs

149
Q

how is GBS screened for? who may get screened?

A

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

150
Q

management of GBS in pregnancy
a) what preventative tx is given?
b) who to?
c) when?

A

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

151
Q

management of pregnant women who had GBS in previous pregnancy

A
  1. inform risk is 50% in this pregnancy
  2. offer IAP OR screening in late pregnancy
152
Q

complications of GBS

A
  1. chorioamnionitis
  2. cystitis
  3. neonatal pneumonia/meningitis/sepsis
153
Q

what is the general rule for when an instrumental delivery should be abandoned?

A

if no reasonable progress after 3 contractions and pulls with any instrument

154
Q

pre-requisites for an instrumental delivery (8)

A
  1. fully dilated
  2. ruptured membranes
  3. cephalic presentation
  4. defined foetal position
  5. foetal head at least to level of ischial spines
  6. empty bladder
  7. adequate pain relief
  8. adequate maternal pelvis
155
Q

what % of maternal births are instrumental?

A

10% (in UK)

156
Q

maternal indications for an instrumental birth (3)

A
  1. failure to progress (>2 hours active pushing if nulliparous, >1 hour if multiparous)
  2. maternal exhaustion
  3. maternal medical condition limiting active pushing e.g. intracranial pathology, congenital heart disease, HTN
157
Q

foetal indications for an instrumental (2)

A
  1. foetal compromise in second labour stage e.g. distress on CTG/abnormal blood sampling
  2. clinical concerns e.g. significant APH
158
Q

absolute contraindications for an instrumental delivery (4) and (2) specifically for ventouse

A
  1. unengaged foetal head
  2. incompletely dilated cervix
  3. true cephalo-pelvic disproportion
  4. breech/face presentation
  5. preterm gestation (<34w) for ventouse
  6. high likelihood of foetal coagulation disorder (ventouse)
159
Q

RFs for an instrumental delivery

A

epidural

160
Q

relative contraindications for an instrumental delivery (3)

A
  1. severe non-reassuring foetal status
  2. delivery of second twin if head not quite engaged/cervix reformed
  3. umbilical cord prolapse
161
Q

what is recommended after instrumental delivery to reduce risk of maternal infection?

A

single dose of co-amox

162
Q

complications to mum if instrumental delivery (6)

A
  1. PPH
  2. episiotomy
  3. perianal tears
  4. injury to anal sphincter
  5. incontinence
  6. nerve injury (obturator, femoral)
163
Q

key common complications to baby if
a) ventouse
b) forceps

A

a) cephalohematoma (collection of blood between skull and periosteum)

b) facial nerve palsy and bruising

164
Q

rare complications to baby if instrumental delivery (4)

A
  1. subgaleal haemorrhage
  2. intracranial haemorrhage
  3. skull fracture
  4. spinal cord injury
165
Q

define:
a) monozygotic
b) dizygotic

A

a) identical twins (single zygote)
b) non-identical twins (two different zygotes)

166
Q

define:
a) monoamniotic
b) diamniotic
c) monochorionic
d) dichorionic

A

a) single amniotic sac
b) two separate amniotic sacs
c) share a single placenta
d) two separate placentas

167
Q

what is the best outcome in a twin pregnancy?

A

diamniotic, dichorionic (both foetuses have own nutrient supply)

168
Q

when is a multiple pregnancy usually diagnosed?

A

on booking scan (8-12 weeks)

169
Q

management of multiple pregnancy: antenatal care

A
  1. specialist multiple preg obstetric team
  2. additional monitoring for anaemia (FBC) at
    - booking
    - 20 weeks
    - 28 weeks
  3. 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)
170
Q

planned birth timings for
a) uncomplicated dichorionic twins
b) triplets

A

a) between 37 and 37+6
b) before 35+6

171
Q

management of multiple pregnancy at delivery:
a) medications
b) if monoamniotic
c) if diamniotic

A

a) corticosteroids pre-birth (lung maturity)

b) elective c-section

c) vaginal delivery possible IF first baby has cephalic presentation

172
Q

complications to mother of multiple pregnancy (8)

A
  1. anaemia
  2. hyperemesis gravidarum
  3. polyhydramnios
  4. HTN
  5. malpresentation
  6. spontaneous preterm birth
  7. instrumental delivery/c-section
  8. PPH
173
Q

complications to feotus in multiple pregnancy (7)

A
  1. miscarriage
  2. stillbirth
  3. foetal growth restriction
  4. prematurity
  5. twin-twin transfusion syndrome
  6. twin anaemia polycythaemia sequence
  7. congenital abnormalities
174
Q

what is placenta accreta spectrum?

A

the attachment/implantation of the placenta through and past the myometrium (wall of uterus)

175
Q

a defect in what causes placenta accreta spectrum?

A

decidua basalis (maternal part of placenta - specialised uterine lining (endometrium) that forms during preg)

176
Q

RFs for placenta accreta spectrum (4)

A
  1. prev c-section
  2. prev endometrial curettage procedures (e.g. for miscarriage/abortion)
  3. multigravida
  4. placenta praevia
177
Q

pathophysiology of placenta accreta spectrum
a) uterine wall layers (3)
b) normal placental attachment
b) pathology and why PPH can happen

A

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

178
Q

placental accreta definitions
a) superficial placenta accreta
b) placenta accreta
c) placenta increta
d) placenta percreta

A

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

179
Q

presentation of placenta accreta spectrum - when does this typically occur?

A
  • doesnt rlly cause sx during preg (some women can present with APH in 3rd trimester)
  • at BIRTH: difficult to deliver placenta, may have PPH
180
Q

when and how is placenta accreta ideally diagnosed?

A

antenatally, by USS - then can plan birth

181
Q

investigation for assessing depth and width of invasion in placenta accreta spectrum

A

MRI

182
Q

placenta accreta spectrum delivery management - IF known beforehand

A
  1. planned between 35 - 36+6 weeks
  2. antenatal steroids
  3. during c-section options are…
    - hysterectomy (placenta remains in uterus - recommended)
    - uterus preserving surgery
    - expectant (leave placenta to be reabsorbed but risk of infection)
183
Q

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

a) close-up, delay delivery until specialist services in place
b) hysterectomy recommended

184
Q

placenta accreta spectrum - additional management at birth

A

risk of bleeds
- complex uterine surgery
- blood transfusions
- intensive care

185
Q

causes of polyhydramnios (THINK overproduction and reduced swallowing)

A
  1. IDIOPATHIC
  2. overproduction
    - maternal diabetes
    - rhesus isoimmunisation
  3. reduced foetal swallowing
    - infection e.g. CMV, toxoplasmosis, parovirus
    - congenital e.g. anencephaly, duodenal atresia
    - genetic disease e.g. aneuploidy
186
Q

causes of oligohydramnios (THINK increased fluid loss, decreased fluid production)

A
  1. increased fluid loss - rupture of membranes
  2. decreased fluid production
    - foetal growth restriction
    - maternal comorbidities
    - placental abnormalities
    - foetal urinary tract abnormalities e.g. renal agenesis
    - maternal drug use
    - post-term pregnancy
187
Q

main RF for polyhydramnios

A

gestational diabetes

188
Q

pathophys - production of amniotic fluid

A
  • 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

189
Q

signs & sx of polyhydramnios

A

if mild - no sig x

if severe - SOB, oedema of ankles and feet, abdo pain, contractions, enlarged uterus

190
Q

signs & sx of oligohydramnios

A
  • may be asymptomatic
  • may present as fluid leakage (ROM)
  • foetal parts hard to palpate
191
Q

investigations for polyhydramnios - how is it normally disovered?

A
  • normally found incidentally at routine appt (USS - extra fluid, uterus large for dates)
  • OGTT to check for diabetes!
192
Q

investigation for oligohydramnios

A

USS - uterus small for dates, amniotic fluid index <5cm

193
Q

management of polyhydramnios

A
  • if mild, don’t necessarily need management!
  • management depends on cause e.g. control diabetes, treat infection
  • may have checkups for rest of pregnancy
194
Q

management of oligohydramnios

A
  • monitor growth + fluid vol
  • refer to foetal medicine
  • may need early delivery
195
Q

at what dates is induction recommended in mums with oligohydramnios?

A

36-38w

196
Q

complications of polyhydramnios (severe) (6)

A
  1. prematurity
  2. breech birth
  3. PROM
  4. umbilical cord prolapse
  5. stillbirth
  6. PPH
197
Q

complications of oligohydramnios

what if baby is <24w?

A
  1. congenital abnormalities e.g. urethral obstruction
  2. reduced growth

POORER prognosis if foetus <24w…
- limb deformities
- pulmonary hypoplasia
- preterm
- umbilical cord compression
- meconium aspiration
- c-section

198
Q

what is placental abruption?

A

when part/all of the placenta separates from the wall of the uterus prematurely

results in maternal haemorrhaging into intervening space

199
Q

aetiology of placental abruption

A

largely unknown but may occur by:
1. direct abdominal trauma
2. indirect trauma
3. cocaine use (causes vasospasm)

200
Q

RFs for placental abruption - use ABRUPTION

A

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

201
Q

two types of placental abruption

A
  1. revealed - bleeding tracks down from site of placenta separation > drains through cervix > vaginal bleeding
  2. concealed - bleeding remains in uterus, forms clot retroplacentally. bleeding not visible but can cause shock
202
Q

pathophys of placental abruption

A
  1. rupture of maternal vessels within basal layer (bottom layer of epidermis) of endometrium
  2. blood accumulates
  3. splits placental attachment from basal layer
  4. detached portion of placenta cant function > foetal compromise
203
Q

signs and symptoms of placental abruption

A

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

204
Q

1st line investigations for placental abruption

A
  1. haematology - FBC, clotting profile, group&save, cross match
  2. biochemistry - rule out pre-eclampsia and HELLP syndrome with U&Es and LFTs
  3. CTG (if foetus >26)
205
Q

investigations for placental abruption once pt stable

A

USS

206
Q

ddx for placental abruption (3)

A
  1. placenta praevia
  2. marginal placental bleed (wont be maternal/feotal compromise)
  3. vasa praevia
207
Q

acute management of emergency placental abruption (if significant APH)

A

emergency c-section

208
Q

ongoing management of placental abruption: when is emergency c-section indicated?

A
  • if maternal and/or feotal compromise
  • doesn’t matter if foetus is at term
209
Q

ongoing management of placental abruption - when is induction/vaginal delivery indicated?

A

IF
1. haemorrhage at term WITHOUT maternal/foetal compromise
2. or foetus died

210
Q

management of placental abruption - when is conservative (admit, observe, steroids) indicated?

A
  1. if partial/marginal abruptions not associated with maternal/foetal compromise
  2. OR if foetus is <36w and not distressed
211
Q

management of placental abruption if mother is rhesus D -ve

A

given anti-D within 72h of onset of bleeding

212
Q

complications of placental abruption

A
  1. hypovolemic shock
  2. intrauterine growth restriction
  3. preterm birth
  4. neuro impairment in infant
213
Q

define placenta praevia
what are the 4 grades?

A

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

214
Q

epidemiology of placental praevia - how common at 16-20 weeks vs at delivery?

A

5% will have low-lying placenta at 16-20 weeks, but incidence at delivery is only 0.5%

215
Q

RFs for placenta praevia (6)

A
  1. multiparity
  2. multiple preg
  3. previous c-section (important)
  4. maternal age >40
  5. hx of uterine infection
  6. curettage to endometrium
216
Q

when may placenta praevia cause a bleed?

A

(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!

217
Q

presentation of placenta praevia

A
  • PAINLESS vaginal bleeding in late preg
  • shock in proportion to visible loss
  • uterus non-tender
  • lie/presentation may be abnormal
  • foetal HB usually normal
218
Q

what investigation/s should NOT be performed until an USS is done for placeta praevia?

A

digital vaginal/speculum exam (risk of bleed)

219
Q

when would placenta praevia be incidentally picked up and how?

A

on routine 20 week USS scan

220
Q

investigations for suspected placenta praevia if not picked up in pregnancy

A
  • transvaginal ultrasound
  • CTG (if >26w gestation)
221
Q

ddx for placenta praevia (4)

A
  1. placental abruption (will be painful)
  2. vasa praevia
  3. uterine rupture
  4. infection
222
Q

management of placenta praevia if acute significant APH

A

ABCDE and emergency c-section

223
Q

management of placenta praevia if identified at 20-week scan:
a) minor (not over internal os)
b) major

A

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

224
Q

complications of placenta praevia
a) maternal
b) foetal

A

a) anaemia, placenta accreta spectrum, APH

b) preterm, IUGR, foetal death

225
Q

medication to suppress lactation

A

cabergoline (dopamine receptor agonist - inhibits prolactin)

226
Q

indications for high dose folic acid (5mg) in pregnancy (5)

A
  1. BMI >30
  2. maternal/paternal neural tube defects
  3. prev preg affected by NTD
  4. maternal anti-epileptic use
  5. diabetes mellitus
227
Q

category 1 c-section

A
  • immediate threat to mum/baby
  • within 30 mins
  • e.g. major placental abruption, cord prolapse, foetal hypoxia
228
Q

category 2 c-section

A
  • maternal/foetal compromise not immediately life-threatening
  • within 75 minutes
229
Q

category 3 c-section

A
  • 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
230
Q

category 4 c-section

A

elective

231
Q

what does a CTG measure?

A

feotal heartbeat and uterine contractions

232
Q

after 28w gestation RFM and no heartbeat detected with handheld doppler - what investigation should be done?

A

immediate ultrasound

233
Q

which meat should be avoided in preg? why?

A

cooked liver - high levels of vit A can be harmful

234
Q

pregnant women should avoid air travel after how many weeks gestation if:
a) singleton
b) multiple preg

A

a) 37w
b) 32w

235
Q

classification of perineal tears:

a) first degree
b) second degree
c) third degree
d) fourth degree

A

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

236
Q

Bishop’s scoring - what is indicated by a score of…
a) <5
b) = or >8

A

a) labour is unlikely to start without induction

b) cervix is ripe - high chance of spontaneous labour

237
Q

CTG findings:
a) foetal bradycardia
b) foetal tachycardia

A

a) <110bpm
b) >160bpm

238
Q

pre-terminal CTG findings which indicate emergency c-section (2)

A
  1. terminal bradycardia - baseline foetal HR drops to <100bpm for more than 10 minutes
  2. terminal deceleration - HR drops and does not recover for more than 3 minutes
239
Q

define primary and secondary PPH

A

primary - within 24h of delivery, >500ml blood loss

secondary - after 24h and up to 12w post delivery

240
Q

what typically causes secondary PPH?

A

retained placental tissue/endometritis

241
Q

minor vs major PPH

A

minor = 500ml-1L

major = >1L

242
Q

causes of primary PPH (4)

A

the four Ts!!!

Tissue - placental not complete
Tone - uterine atony (most common)
Trauma - tears
Thrombin - clotting probs

243
Q

RFs for PPH (8)

A
  1. macrosomia
  2. multi pregnancy
  3. first babies OR >4 babies
  4. precipitate/prolonged labour
  5. maternal pyrexia
  6. operative delivery
  7. shoulder dystocia
  8. previous PPH
244
Q

initial management of a PPH

A

ACB
- two peripheral cannulae, 14 gauge
- lie woman flat
- bloods including group&save
- commence warmed crystalloid infusion

245
Q

mechanical management options for PPH (2)

A
  1. palpate uterus fundus - stimulates contractions
  2. catheterise
246
Q

medical management options for PPH (uterine atony)

A
  • IV oxytocin
  • IV/IM ergometrine
  • IM carboprost
  • tranexamic acid
247
Q

contraindications to medical PPH managements:
a) ergometrine
b) carboprost

A

a) hx of HTN
b) asthmatics

248
Q

1st line surgical PPH management if medical managements fail?

what if bleeding is severe and uncontrolled?

A

intrauterine balloon tamponade

hysterectomy

249
Q

other surgical PPH managements (not 1st line)

A
  • b-lynch suture
  • ligation of uterine/internal iliac arteries
250
Q

what is HELLP syndrome? what are the key features?

A

= severe form of pre-eclampsia

  • haemolysis
  • elevated liver enzymes
  • low platelets

presents with malaise, nausea, vomiting and headache

251
Q

what are the main stages of labour? (3)

A

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

252
Q

what are the phases of stage 1 labour?

A

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

253
Q

how long does the first stage of labour normally take in primigravida women?

A

10-16 hours

254
Q

what are the passive and active stages of labour stage 2?

A

passive - in 2nd stage but absence of pushing

active - active process of maternal pushing

255
Q

when is a delay considered in all labour stages?

A

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

256
Q

what is uterine rupture?

A

spontaneous full thickness/tear of the uterine muscle and overlying serosa

a rare complication typically occurring during labour

257
Q

two types of uterine rupture

A
  1. incomplete - peritoneum overlying the uterus is intact. uterine contents remain within the uterus
  2. complete - peritoneum is also torn, and the uterine contents escape into the peritoneal cavity
258
Q

pathophysiology of uterine rupture

A

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

259
Q

RFs for uterine rupture

A

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

260
Q

signs and symptoms of uterine rupture

A

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

261
Q

what will show on examination of uterine rupture?

A
  • regression of presenting part
  • on abdo palpation > scar tenderness and palpable foetal parts
262
Q

investigation for uterine rupture if suspicious pre-labour

A

use USS

263
Q

investigation of uterine rupture in labour

A

CTG
- early indicators are change in foetal HR pattern, prolonged foetal bradycardia

264
Q

ddx for uterine rupture

A
  1. placental abruption (pain, bleeding, woody abdomen)
  2. placental praevia (painless vag bleeding)
  3. vasa praevia (non-tender uterus)
265
Q

emergency management of uterine rupture

A
  1. ABCDE
  2. call appropriate staff e.g. senior obs, midwives, anaesthetists
  3. may need to invoke Massive Obstetric Haemorrhage protocol
266
Q

resus management of uterine rupture

A
  1. protect airway
  2. 15L 100% O2
  3. insert two large bore cannulas, take bloods
  4. give cross-matched bloods and fluids
  5. monitor GCS
267
Q

surgical management of uterine rupture

A
  • C-SECTION
  • uterus either repaired or removed
268
Q

define prelabour rupture of membranes (PROM)

A

amniotic sac has ruptured before the onset of labour (at >37w gestation)

269
Q

define preterm prelabour rupture of membranes (P-PROM)

A

amniotic sac has ruptured before the onset of labour AND before 37w gestation

270
Q

define prolonged rupture of membranes

A

amniotic sac ruptures >18h before delivery

271
Q

define preterm labour with intact membranes

A

regular painful contractions and cervical dilation, without the rupture of the amniotic sac

272
Q

define prematurity

what is
a) extreme preterm
b) very preterm
c) moderate to late preterm

A

defined before 37w gestation

a) under 28 weeks
b) 28-32 weeks
c) 32-37 weeks

273
Q

from what preterm gestation is full resus offered?

A

> 24 weeks

274
Q

RFs for prematurity/P-PROM

A
  1. smoking
  2. previous PROM/preterm
  3. vag bleeding during preg
  4. low genital tract infection
  5. invasive procedures e.g. amniocentesis
  6. polyhydramnios
  7. multiple preg
  8. cervical insufficiency
275
Q

general presentation of ROM (3)

A
  1. “broken water” - painless popping, gush of fluid
  2. gradual leakage of watery fluid from vagina, damp underwear/pad
  3. change in colour/consistency of discharge
276
Q

indications that the membranes have ruptured on speculum

A
  1. fluid draining from cervix
  2. pooling in posterior vaginal fornix
  3. lack of normal discharge
277
Q

general investigations for premature labour/PROM/ROM (4)

A
  1. maternal hx
  2. speculum exam
  3. insulin-like growth factor-binding protein-1 (IGFBP-1)
  4. placental-alpha-microglobulin-1 (PAMG-1)
278
Q

diagnostic investigation and finding for PROM/P-PROM

what if in doubt?

A

diagnostic = speculum - pooling of amniotic fluid in vagina

if in doubt, test IGFBP-1 and PAMG-1

279
Q

investigation for preterm labour with intact membranes if <30 weeks

A

just need speculum examination - pooling of amniotic fluid in vagina

280
Q

investigation for preterm labour with intact membranes if >30 weeks

A
  1. speculum (pooling of amniotic fluid)
  2. TVUSS to assess cervical length
281
Q

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

a) management of preterm labour is offered

b) preterm labour unlikely, not managed as this

282
Q

ddx for ROM/PROM/P-PROM

A
  1. urinary incontinence
  2. normal vaginal secretions of pregnancy
  3. increased discharge e.g. due to infection
283
Q

prophylaxis of preterm labour IF
- cervical length <25mm
- 16-24w gestation

A

PROGESTERONE
- gel or pessary
- maintains preg by decreasing myometrium activity and preventing cervical remodelling

284
Q

prophylaxis of preterm labour IF woman has
- cervical length <25mm
- 16-24w gestation
AND
- previous premature birth/cervical trauma e.g. colposcopy, cone biopsy

A

CERVICAL CERCLAGE (stitch in cervix to support and keep closed)

involves spinal/GA, removed when woman goes into labour or reaches term

285
Q

management of P-PROM
a) medical
b) labour induction

A

a) prophylactic abx - erythromycin 250mg 4x daily for 10 days or until labour established

b) labour induced from 34w

286
Q

general management options for preterm labour with intact membranes

A
  1. foetal monitoring CTG
  2. tocolysis with nifedipine (suppresses labour)
  3. maternal corticosteroids (if <35w) - IM betamethasone
  4. IV mag sulphate (if <34w)
  5. delayed cord clamping/cord milking
287
Q

main complication of P-PROM

A

chorioamnionitis

288
Q

most women who’s membranes have ruptured will progress into labour within…

A

24-48h

289
Q

management of P-PROM if 24-33w

A
  • do NOT induce labour
  • prophylactic erythromycin
  • corticosteroids
290
Q

management of P-PROM if 33-36w

A
  • prophylactic erythromycin
  • corticosteroids if 34-34+6
  • delivery
291
Q

management of P-PROM if 36-37w

A

watch and wait for 24h OR consider induction of labour

delivery recommended

women can wait 24-96h if they want

292
Q

complications of prematurity/P-PROM (5)

A
  1. chorioamnionitis
  2. neonatal death (premature, sepsis, pulmonary hypoplasia)
  3. placental abruption
  4. umbilical cord prolapse
  5. oligohydramnios
293
Q

what is an amniotic fluid embolism?

A

foetal cells/amniotic fluid enters mothers bloodstream > results in embolic reaction

294
Q

presentation of amniotic fluid embolism

A
  1. mostly DURING labour but can be during c-section and in immediate postpartum phase
  2. chills, shivering, sweating, anxiety, coughing
  3. cyanosis, hypotension, bronchospasm, tachycardia, arrythmia, MI
295
Q

hospital tx of hyperemesis gravidarum

A

IV normal saline with added potassium

296
Q

name 3 puerperal infections

A
  1. sepsis
  2. mastitis
  3. endometritis
297
Q

management of sepsis post-pregnancy

A

SEPSIS 6 (BUFALO)

Blood cultures
Urine output
Fluids
Abx
Lactate
O2

298
Q

most common organism associated with mastitis infection

A

s.aureus

299
Q

management of simple mastitis

A

1st line = continue breastfeeding

analgesia, warm compresses

300
Q

when are abx indicated for mastitis? (4)

A
  1. systemically unwell
  2. nipple fissure present
  3. sx don’t improve after 12-24h of effective milk removal
  4. culture shows infection
301
Q

abx management for mastitis

A

oral flucloxacillin 10-14 days

(still continue breastfeeding/expressing)

302
Q

aetiology/pathophy of endometritis

A
  1. infection introduced during/after labour and delivery
  2. process of delivery opens uterus to bacteria from vagina&raquo_space; travel upward and infect endometrium
  3. caused by many different bacteria types
303
Q

when does endometritis present?

A

from shortly after birth to several weeks postpartum

304
Q

signs and symptoms of endometritis

A
  1. foul-smelling discharge/lochia
  2. bleeding that gets heavier/doesn’t improve
  3. lower abdo/pelvic pain
  4. fever

can&raquo_space;> sepsis

305
Q

what is lochia?

A

normal postpartum bleeding

306
Q

investigations for endometritis

A
  1. vaginal swabs
  2. urine culture
  3. USS - rule out RPOC
307
Q

prophylaxis for endometritis

A

abx given during c-section

308
Q

management for endometritis if
a) mild, no signs of sepsis
b) septic

A

a) tx in community with oral broad-spec e.g. co-amoxiclav

b) admit to hospital, IV clindamycin and gentamicin until afebrile for >24h

309
Q

when are pregnant women screened for syphilis? how?

A

blood test at booking appt with midwife (~10 weeks)

310
Q

post-exposure management of chickenpox in pregnancy if
a) >20 weeks
b) <20 weeks

A

seek specialist advice…

a) oral acyclovir day 7-14 after exposure
b) with caution (advice)

311
Q

management of post-partum thyroiditis

A

b-blockers e.g. propranolol

312
Q

define vasa praevia

A

the foetal vessels run ahead of the presenting part of the baby and across the internal cervical os

313
Q

type I vs type II vasa praevia

A

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

314
Q

RFs for vasa praevia (3)

A
  1. low lying placenta
  2. IVF
  3. multiple pregnancy
315
Q

sign of vasa praevia
a) antenatally
b) in labour
c) on exam

A

a) antepartum haemorrhage (painless)
b) dark red bleeding following ROM, foetal distress
c) pulsating foetal vessels seen in membranes through dilated cervix

316
Q

when may vasa praevia be diagnosed?

A

antenatally on USS

317
Q

management of vasa praevia

a) asymptomatic and diagnosed on antenatal USS
b) presenting with APH at birth

A

a) corticosteroids from 32 weeks, elective c-section booked for 34-36w

b) emergency c-section

318
Q

which act created the legal framework for TOP? which reduced the legal limit of gestation age from 28 to 24w?

A
  • 1967 abortion act
  • 1990 human fertilisation and embryology act
319
Q

criteria for abortion at
a) <24w
b) any time

A

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

320
Q

medical abortion (3 steps)

A
  1. oral mifepristone (anti-progesterone, halts pregnancy and relaxes cervix)
  2. 48h later, vaginal misoprostol (stimulates contractions)
  3. pregnancy test (multi-level) 2 weeks later
321
Q

under what gestation can a medical abortion occur at home?

A

10 weeks

322
Q

surgical abortion

a) prior to surgery
b) surgical options

A

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)

PHASE 3A (18 decks)

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