Antenatal Care Flashcards
Risk of miscarriage following Amnio or CVS for:
1. Singleton
2. Twin
- Singleton - 0.5%
- Twin 1%
When is:
1. CVS performed?
2. Amnio performed?
- CVS 11+0 - 13+6
- Amnio from 15+0
Risks associated with Amnio?
- Second sample/rpt procedure - 6%
- Blood stained sample - 0.8%
- Maternal cell contamination - 1-2%
- Rapid test failure - 2%
- Failed cell culture - 0.5-1%
- Severe infection/fetal injury / maternal visceral injury - rare
Risks associated with CVS?
- Second sample/rpt procedure - 6%
- Confined placental mosaicism - <2%
- Maternal cell contamination - 1-2%
- Rapid test failure - 2%
- Failed cell culture - 0.5-1%
- Severe infection / fetal injury / maternal visceral injury - rare
Chickenpox:
1. Incubation period?
2. Infectious period?
- Incubation period: 1-3 weeks
- Infectious period: 48 hours before the rash appears and continues to be infectious until vesicles crust over (usually 5 days)
Treatment of chickenpox in Pregnancy?
- If non immune pregnant woman has significant exposure, she should be offered VZIG as soon as possible (effective when given up to 10 days after contact).
- Oral Aciclovir should be given:
- Within 24 hours of onset of rash
- If over 20/40
- IV Aciclovir should be given to women with severe chickenpox
If maternal chicken pox happened in last 4 weeks of pregnancy:
1. What is the plan for delivery?
2. % of babies infected?
3. % of babies that develop clinical varicella?
- Avoid planned delivery for 7 days to allow for passive transfer of antibodies
- 50% of babies are infected
- Approx 23% will develop clinical varicella
For babies born to mothers who have had chickenpox within the period 7 days before to 7 days after delivery - the neonate will need VZIG with or without Aciclovir ASAP.
No need to test neonate in these circumstances.
Chickenpox infection < 28/40 management?
- 1% chance of FVS
- Refer to FMU at 16-20 weeks or 5 weeks after infection
- Amniocentesis to detect varicella DNA may be considered
What are the three subgroups of neonatal herpes?
What is the mortality and morbidity of each subgroup?
- Disease localised to skin/eye/mouth
- 30% of neonatal herpes infections
- <2% morbidity with appropriate Rx - Local CNS disease (encephalitis)
- 70% of infections
- 6% mortality
- 70% neurological abnormality - Disseminated infection with multi organ involvement
- 70% infections combined with local CNS disease
- 30% mortality from disseminated infection
- 17% long term neurological sequelae
60% will present without skin/eye/mouth infection.
Present late - typically 10 days to 4 weeks
Neonatal Herpes:
1. HSV 1
2. HSV 2
HSV 1: 50%
HSV 2: 50%
TTTS complicates what % of Monochorionic Pregnancies?
15%
Incidence if TAPS (twin anaemia-polycythaemia sequence) after laser ablation?
13%
(2% uncomplicated monochorionic twins)
TTTS (Quintero Staging)
Associated with 15% Monochorionic Twins.
I - significant discordance in amniotic fluid volume. This is defined as: oligo with DVP < 2cm in donor sac and Poly in the recipient sac (DVP > 8cm before 20/40 and >10cm after 20/40). Donor bladder visible and normal Doppler.
II - Bladder of the donor twin not visible and severe oligo due to anuria. Doppler studies not critically abnormal.
III - Doppler studies are critically abnormal in either the donor or recipient.
IV - Ascites, pericardial effusion, scalp oedema or overt hydrops present usually in the recipient.
V - One or both babies have died (not amenable to therapy)
TAPS (twin anaemia- polycythaemia sequence)
1. Incidence
2. Definition
2% uncomplicated Monochorionic pregnancies
Up to 13% post laser ablation
Signs of fetal anaemia in the donor and polycythaemia in the recipient without significant oligo/poly being present.
Donor has increased MCA PSV (> 1.5 MoM) and recipient has decreased MCA PSV (< 1.0 MoM)
Selective Growth Restriction Monochorionic Twins
- Incidence
- Define
- Growth discordance > 20%
- Approx 10-15% monochorionic twins
I - growth discordance but positive diastolic velocities in both fetal and umbilical arteries.
II - Growth discordance with absent or reversed end diastolic velocities in one or both fetuses.
III - growth discordance with cyclical UA diastolic waveforms (iAREDV)
Risk of congenital CMV with primary infection during Pregnancy?
30-40%
Risk of congenital infection with recurrent CMV?
1-2%
Risk of congenital infection with recurrent CMV?
1-2%
Incubation period for CMV?
3-12 weeks
Diagnosis of fetal CMV is by Amniocentesis.
Amnio should not be performed for at least 6 weeks after maternal infection and not until 21/40.
List features of congenital CMV
- Sensorineural hearing loss
- Visual impairment
- Microcephaly
- Low birth weight
- Seizures
- Cerebral palsy
- Hepatosplenomegaly with jaundice
- Thrombocytopenia with petechial rash
In women who develop chickenpox within the 4 weeks prior to delivery, what is the risk of varicella infection of the newborn?
50% of babies are infected.
23% of babies develop clinical varicella.
High risk factors for antenatal Aspirin?
Moderate risk factors for antenatal Aspirin?
High Risk Factors:
1. Hypertensive disease during a previous pregnancy
2. CKD
3. Autoimmune disease such as SLE or APLS
4. Type 1 or Type 2 DM
5. Chronic HTN
Moderate Risk Factor:
1. Primip
2. Age > 40
3. Inter pregnancy interval > 10 years
4. BMI > 35
5. FHx PET
6. Multiple Pregnancy
Risk of renal transplant injury at LSCS?
1.5%
Consider midline skin incision to reduce risk of trauma to allograft.
Risk of cephalhaematoma with vacuum?
1-12%
Risk of facial or scalp lacerations with instrumental delivery? (Vacuum and Forceps)
10%
Risk of retinal haemorrhage with instrumental delivery?
17-38%
Monochorionic twin pregnancy with single twin demise.
1. Risks?
2. Investigations?
- Neurological abnormality 26%
Death 15% - Fetal MRI of brain 4/52 after co-twin demise
MCMA twins comprise what % of monochorionic twin pregnancies?
1%
They carry a very high risk of perinatal loss, most commonly before 24/40.
Selective growth restriction in monochorionic twin pregnancies.
- % cases
- Staging
Growth discordance of > 20%.
Approx 10-15% monochorionic twins.
Staging:
I - growth discordance but +ve EDF in both fetal UA.
II - growth discordance with absent or reversed EDF in one or both fetuses.
III - growth discordance with cyclical UA diastolic waveforms (+ve followed by absent then reversed EDF in a cyclical pattern over several minutes).
Lambda and T sign
- Monochorionic - T sign (inter twin membrane that inserts into the placenta at a perpendicular plane)
- Dichorionic - lambda sign (adjacent pelvic masses forming a lambda sign as placental tissue is present where the thick inter twin membrane inserts onto the placenta)
Recurrence rate of TTTS following fetoscopic laser ablation?
Up to 14%
Likely due to missed anastamoses at the time of initial laser treatment.
% of women that are GBS carriers?
20-40%
Incidence of early onset GBS?
0.57/1000
Of these:
1. 22% born prematurely
- 35% had 1 or more of the following RFs (prev baby affected by GBS, GBS bacteruria, vaginal swab pos for GBS or mat T > 38C in labour)
Intrapartum pyrexia and risk of EOGBS?
5.3/1000
(Compared to background risk of 0.6/1000)
Risk of EOGBS in preterm infants?
What % of women deliver pre term?
- 2.3/1000
(Mortality rate from infection is increased at preterm gestation (20-30% vs 2-3% at term)
- 8.2%
Incidence of EOGBS without risk factors?
0.2/1000 cases.
Main reason for transfer to an obstetric unit from home/birth unit?
- Delay in 1st or 2nd stage
(32% from home, 37% birth unit) - Meconium
(12.2% from home/Birth unit)
IOL for fetal macrosomia vs expectant management
Benefit:
1. Lower rates of SD vs expectant management
Risks:
2. Increased 3rd/4th degree tears
Same:
1. Perinatal death
2. Brachial plexus injury
3. Need for EmLSCS
Low risk primip wanting home birth - risks of babies born with serious medical problems vs hospital/MLU?
Home: 9/1000
Hosp/MLU: 5/1000
75%: Neonatal encephalopathy and Meconium aspiration syndrome
13%: Intrapartum SB or death of baby in first week of life
4%: # humerus/clavicle
Pre-Labour Rupture of Membranes:
1. Risk of infection
2. Chance of spont labour within 24h
- Risk of serious neonatal infection 1% rather than 0.5% for women with intact membranes
- 60% of women with pre labour rupture of membranes will go into labour within 24 hours
Maternal cardiac arrest.
1. Incidence
2. Case fatality rate
3. Leading cause
- 1/36,000
- 42% case fatality rate
- 25% secondary to anaesthesia (100% survival from this)
Amniotic Fluid Embolism:
1. Incidence
2. Survival
3. Perinatal Mortality
- Incidence: 1.7/100,000
- 81% survival (2014)
- Perinatal mortality: 67/1000 births
MOH Incidence?
6/1000
Anaphylaxis
1. Incidence
2. Mortality
- 1-3.5/100,000
- 1% mortality rate
Mast cell tryptase levels 1-2 hours after onset of symptoms.
Risk of dural puncture headache following spinal anaesthetic?
1/500
Risk of temporary nerve damage following epidural anaesthesia?
1/1000
Risk of significant hypotension following epidural?
1/50
Risk of epidural providing inadequate pain relief in labour ?
Risk of epidural providing inadequate pain relief for caesarean section necessitating GA?
- 1/8 ineffective pain relief in labour
- 1/20 inadequate analgesia for C/S
Risk of dural puncture headache?
1. Epidural
2. Spinal
- 1/100 epidural
- 1/500 spinal
Risk of nerve damage (numb patch on leg or foot, or weak leg) following epidural/spinal.
- Temporary
- Permanent
- 1/1000 temporary
- 1/13000 permanent
Risk of:
1. Epidural abscess
2. Epidural haematoma
- Epidural abscess: 1/50,000
- Epidural haematoma: 1/170,000
IUD - Mife/Miso regime
Mifepristone 200mg followed 24-48hrs later by:
- 100mcg Miso 6 hourly before 26+6
- 25-50mcg 4 Miso 4 hourly at 27+0 or more, up to 24 hours
Risk of haemorrhage > 500ml with:
- Active management of 3rd stage?
- Physiological 3rd stage?
- 68/1000 with active management
- 188/1000 with physiological 3rd stage
Risk of haemorrhage > 1000ml
- Active management
- Physiological management
- 13/1000 active management
- 29/1000 physiological management
Need for blood transfusion:
- Active management 3rd stage
- Physiological management
- 13/1000
- 35/1000
Need for further uterotonics in 3rd stage:
- Active Management
- Physiological 3rd stage
- Active mgmt: 47/1000
- Physiological: 247/1000
3rd stage management- what were similar outcomes for both active and physiological management ?
- Retained placenta > 1hr or need for MROP
- Antibiotics for bleeding
- Satisfied with 3rd stage management
- Felt in control during labour
Nausea and vomiting in 3rd stage with:
- Active management
- Physiological management
- 100/1000
- 50/1000
Management of 3rd stage - risk of PP anaemia Hb < 90.
- Active management
- Physiological management
- 30/1000
- 60/1000
When should PET bloods be re checked after delivery for women with PET?
48-72 hrs
Do not repeat again if results are normal.
Thrombophilias and risk of PET
- Hyperhomocystinaemia
- Anticardiolipin antibodies and prothrombin heterozygosity
- Methylenetetrahydrofolate reductase gene mutation (MTHFR)
(Antithrombin III, Protein S and Protein C deficiencies, lupus anticoagulants are not associated with PET).
IVF and first trimester screening - discuss.
- PAPP-A
- HCG
- MSuE3 (maternal serum conjugated estradiol)
- Falsely low PAPP-A
- Elevated free HCG leading to false Pos Downs Syndrome screening results
- MSuE3 levels are lower
- in IVF pregnancies, the rate of false positive results in 2x as high as in normal controls in the mid trimester.
- PAPP-A was significantly lower in IVF pregnancies compared to spontaneously conceived pregnancies.
- ICSI was associated with a significantly decreased PAPP-A and an increased false positive rate.
IVF pregnancies have significantly lower PAPP-A levels supporting the need to appropriately adjust the cFTS algorithm for IVF conceptions.
- Maternal serum levels of free HCG are elevated in IVF pregnancies causing a high false positive rate on screening for DS.
- MSuE3 levels are lower in IVF pregnancies.
When compared to euploid pregnancies at 11-13 weeks, how are maternal PAPP-A levels affected with Down Syndrome?
Reduced by 50%!
Free HCG is about twice as high.
T13 is associated with what anomalies?
- Holprosencephaly
- Micro-Opthalmia
- Anopthalmia or cyclopia
- Cleft lip and palate
- Clenched fist
- Single palmar crease/scalp defects
- Post axial (little finger side) polydactyly
- Cardiac defects (VSD, PDA, dextrocardia)
- Abnormal genitalia
- Renal defects
- 10% survive beyond the first year; severe developmental delay