cOGText: Antenatal care Flashcards
(132 cards)
1
Q
- what should be given in the preconceptual period to reduce risk of neural tube defects?
- which individuals will need to continue taking folic acid, 5mg daily from 12 weeks?
- T/F: Iron supplementation is not offered routinely.
- Women can be given 10mg of vitamin __ supplements during the pregnancy to be continued when breastfeeding.
- They are encouraged to maintain a balanced diet with only an extra ___ calories in the last trimester.
A
- Folic acid 400mcg from before conception - 12 weeks gestation
- those with diabetes, on anti-epileptic meds, BMI>30, previous pregnancy affected by a neural tube defect, PMH (inc partner) of neural tube defect
- true
- D
- 250-300
2
Q
how are the demographics of pregnant women changing?
A
- having children later in life.
- increase in same-sex marriages - increased use of assisted conception.
- advances in healthcare - now common for women with serious medical conditions to conceive
- 50% of women of child-bearing age in the UK are either overweight or obese.
3
Q
what is the safe limit on alcohol consumption in pregnant women?
A
there is no safe limit because of the risk of fetal alcohol syndrome (learning and behavioural problems, poor growth and facial abnormalities)
4
Q
- Why are women advised to avoid smoking during pregnancy?
- What can be used to help her stop?
A
- may affect the fetus’ development leading to increased risk of miscarriage, low birth weight and prematurity.
- Nicotine replacement therapy (patches, gum, lozenges). NB: bupropion and varenicline are contraindicated in pregnancy and breastfeeding.
5
Q
Effect of cocaine, amphetamines and ecstasy in pregnancy?
A
- Maternal: hypertensive disorders including pre-eclampsia, placental abruption, death via stroke and arrhythmias.
- Fetal: prematurity, neonatal abstinence syndrome , teratogenicity, IUGR, pre-term labour, miscarriage, developmental delay, Sudden Infant Death Syndrome (SIDS), withdrawal
6
Q
Effect of opiates e.g. Heroin in pregnancy?
A
Risk of neonatal abstinence syndrome, IUGR, SIDS, stillbirth and maternal deaths.
7
Q
Effect of Cannabis consumption in pregnancy?
A
- Cognitive deficits
- miscarriage
- fetal growth restriction
8
Q
Effect of nicotine in pregnancy?
A
- Increased risk of miscarriage
- Increased risk of pre-term labour and intra-uterine growth retardation (IUGR)
- Increased risk of still-birth, SIDS (sudden infant death syndrome)
- Increased risk of sudden unexpected death in infancy
9
Q
Effect of alcohol consumption in pregnancy?
A
- Fetal alcohol syndrome (characteristic faces – smooth philtrum, thin vermillion, small palpebral fissures)
- IUGR and postnatal restricted growth
- Learning difficulties
- Risk of miscarriage
- Withdrawal
- Wernicke’s encephalopathy and Korsakoff’s syndrome
- Microcephaly
10
Q
Important points to consider in the Management of substance abuse in antenatal care?
A
- Consider methadone programme – to avoid chaotic lifestyle
- Child protection and social work referral
- Smear screening programme
- Breastfeeding education
- Labour plan regarding analgesia and labour ward delivery
- Early IV access
- Postnatal contraception plan – start as soon as possible after birth so in place when woman is discharged from hospital.
11
Q
Can HIV+ women in the UK breastfeed?
A
- women who test +ve for HIV are encouraged to formula feed.
- breastfeeding can be supported in women with low titre levels who understand the transmission risk
12
Q
at how many weeks if the ‘booking visit’ carried out (the first appointment a woman will get once she finds out she’s pregnanct
A
ideally at 10-12 weeks by a community midwife (refer to obstetrician if any risk factors identified)
13
Q
Which information is gathered and which tests are conducted in a booking visit? (10-12 weeks)
A
- A history: inc. medical, drug, social and family history. Date of last menstrual period, whether the pregnancy was planned and ethnicity of parents [to identify risk factors for developing haemoglobinopathies like sickle cell anaemia or beta thalassemia].
- Obstetric history: previous pregnancy, mode of delivery, previous miscarriages/ terminations.
- Tests: mother’s blood group, Hb, screened for haemoglobinopathies and infections e.g. HIV/AIDs, syphilis, hepatitis B and C.
14
Q
screening for which genetic abnormality is offered at the booking scan?
A
Down syndrome screening (DSS) - 50% of babies born with Down syndrome will have a normal anomaly scan.
15
Q
What is screened for at the 20 week scan (anomaly scan)?
A
Structural abnormalities (using ultrasound) and placentation site
16
Q
Screening for Down’s syndrome
- The first stage of testing is done at 11+0 and 13+6 weeks gestation and is called the ____ test.
- It involves a ___ test and an ____ scan.
- What does the USS look at?
- As the size of the nuchal translucency increases, the chances of a chromosomal abnormality _____.
- what is the blood test?
- In fetus with Down’s syndrome, PAPP-A and aFP is LOW/HIGH, while beta-hCG and nuchal translucency will be DECREASED/INCREASED.
- The second stage of testing is done at 15-16 weeks gestation and involves quadruple test, i.e. which tests?
A
- combined
- blood, ultrasound
- nuchal translucency - assesses the amount of fluid collecting within the nape of the fetal neck. (Normal: ≤ 3.5mm)
- increases
- Triple test: serum pregnancy-associated plasma protein A (PAPP-A), alpha fetoprotein (aFP) and beta-hCG.
- low, increased
- blood levels of aFP, inhibin, oestriol and total hCG.
17
Q
Booking visit
- carried out when?
- what maternal assessent is undertaken?
- what fetal assessment is undertaken?
A
- 10 - 14 weeks
- medical, surgical, drug, obstetric, family and social history to identify additional care needs. Discuss mental health. Measure BP Blood tests (FBC, blood group, rhesus status, check for infection [HIV, hepatitis C, B, syphilis) and haemoglobinapathies (thalasseamias, sickle cell disease)). Check immunity against chicken pox, rubella etc
- Dating scan - Ultrasound scan to check for viability, determine gestation using fetal pole measurements, intrauterine pregnancy, number of pregnancies. Nuchal translucency will also be assessed as part of the Down Syndrome screening (DSS)
18
Q
16 week scan
- what information is discussed
- maternal assessment?
3.
A
- Results from the screening tests discussed
- BP and urinalysis (for protein)
19
Q
18-20 weeks scan
what fetal assessment is undertaken?
A
USS for structural fetal anomalies (anomaly scan) e.g. cleft palate, heart anomalies, limb defects, CNS defects, renal abnormalities. Placental site position visualised to aid in delivery
20
Q
24weeks scan
- which vaccine should be discussed
- maternal test?
A
- Whooping cough (offered between 28-32 weeks)
- Offer Random glucose to check for gestational diabetes. Anti-D if rhesus negative
21
Q
Routinely, uncomplicated nulliparous women will often have __ appointments while multiparous women will have __ appointments with their midwife.
A
10
7
Women with complex risk factors/conditions will require more
22
Q
Women with pre-existing diabetes or those with new onset gestational diabetes are offered extra surveillance to monitor fetal growth and amniotic fluid volume as there is an increased risk of what complications?
A
- stillbirth, congenital malformations and polyhydramnios
23
Q
- The Rhesus blood group system is used to classify antigens on the surface of which cells?
- Why is it important to test for this in pregnant women?
- why will it not affect the baby in her first pregnancy?
A
- RBCs, one of which is the D antigen (if they have the antigen = rhesus positive)
- Individuals who are rhesus negative can set up an immune response to blood cells that have the Rh D antigen leading to haemolytic transfusion reactions and haemolytic disease of the newborn in future pregnancies.
- When irst exposed, they form IgM Abs which are too big to cross the placenta and harm the current fetus. However, in future pregnancies, the body forms IgG Abs which are smaller and can cross the placenta to harm the fetus
24
Q
what treatment is delivered in cases of suspected rhesus isoimmunisation?
A
Anti-D used as prophylaxis - works by removing the rhesus positive blood cells from mother’s circulation before antibodies are formed.
25
1. anti-D is only given to which group of mothers?
2. To have maximal effect, it should be given within __ hours of the sensitising event or after birth.
3. what is a 'sensitising event'?
4. A single dose of anti-D lasts approximately 6 weeks so for cases where there is repetitive sensitising events a ____ test can be done - what is the point of this?
5. Prophylactic anti-D is given at __ weeks gestation in rhesus negative mothers to cover “silent sensitising events” and is given regardless of whether there have been other sensitising events.
1. Rhesus -ve mothers who may have been exposed to a sensitising event.
2. 72
3. one where there has been feto-maternal blood transfusion e.g. Placental abruptionl, abdominal traum (e.g. RTA), intra-uterine surgery/transfusion, TOP, delivery (in rhesus-D + baby), amniocentesis or CVS
4. Kleihauer; to check the right dose for each sensitising event by quantifying fetal RBCs in mother’s blood.
5. 28
26
1. what are the 2 main diagnostic tests for fetal abnormalities and when are they done?
2. They both carry a risk of what?
3. Another risk of CVS is ___ \_\_\_ \_\_\_
1. chorionic villus sampling (CVS): 11-14 weeks. amniocentesis: \>15weeks
2. miscarriage risk (2% of chorionic villus sampling and 1% for amniocentesis)
3. amniotic fluid embolism.
27
Risk factors for multiple pregnancy?
* Assisted conception e.g. clomid, IVF
* Family history (maternal)
* Increased maternal age
* Increased parity
* Tall women \> short women
28
Zygosity vs Chorionicity?
* Monozygotic = splitting of a single fertilised egg. Dizygotic = fertlisation of 2 ova by 2 sperm
* Dichorionic = two placentas (always DCDA). Monochorionic = one placenta (can be MCMA or MCDA depending on timing of ovum splitting)
29
1. how is chorionicity determined?
2. when is this done?
3. why is this so important to monitor?
1. by ultrasound using the shape and thickness of the membrane
2. more reliably done at the booking scan (11-14weeks).
3. monochorionic/monozygous twins are at higher risk of pregnancy complications and require 2 weekly USS to pick up the early signs of TTTS
30
Symptoms and signs of multiple pregnancy?
* Exaggerated pregnancy symptoms e.g. excessive sickness/hyperemesis gravidarum
* High AFP (alpha fetoprotein)
* Large for dates uterus
* Multiple fetal poles
31
Fetal complications of multiple pregnancy?
* Congenital anomalies
* Intrauterine deaths and higher perinatal mortality
* Pre-term birth
* Growth restrictions – both/discordant
* Cerebral palsy
* Twin to twin transfusion (only in monochorionic pregnancies) - oligohydramnios and polyhydramnios.
32
Maternal complications of multiple pregnancy?
* Hyperemesis gravidarum
* Anaemia
* Pre-eclampsia
* Gestational diabetes
* Antepartum haemorrhage – abruption, placenta praevia
* Preterm labour (50%)
* Caesarean section
33
**Antenatal management of multiple pregnancy:**
1. Women with confirmed multiple pregnancy receive consultant led care and attend antenatal clinic every __ weeks for monochorionic pregnancies and every __ weeks for dichorionic pregnancies.
2. Women are given __ and __ \_\_ supplementation, low-dose ____ to try to prevent hypertensive disorders.
3. Ultrasound scans are done from 16th week of gestation every 2 weeks where the deep vertical pool, bladder and umbilical artery are assessed
4. Anomaly scan is done at 18-20 weeks.
1. 2, 4
2. iron and folic acid, aspirin
34
**Twin-Twin Transfusion Syndrome (TTTS)**
1. What is this?
2. risks to the fetuses?
3. treatment if \<26 weeks?
4. if \>26 weeks?
1. A condition where there is disproportionate blood supply to fetuses in monochorionic pregnancies.
2. Because monochorionic twins share a placenta, anastomoses in the blood supply may not be balanced causing blood from the “donor” twin to flow to the “recipient” twin. Donor twin = decreased blood volum, affects growth and development (decreased urine output, anaemia and oligohydramnios). Recipient twin = increased blood volume (increased urinary output, polyhydramnios, polycythaemia and eventually heart failure)
3. fetoscopic laser ablation - can lead to twin anaemia-polycythaemia sequence.
4. amnioreduction/septostomy with aim to deliver at 34-36weeks (but may require preterm delivery).
5.
35
what option is offered to reduce risk in
1. conjoined twins
2. higher order births
1. offered tOP
2. offered selective reduction
36
Mode of Delivery for
1. triplets? (or more)
2. MCMA
3. Twins, if twin one is cephalic
Overall much greater risk of C-section in twins (approx 50%)
1. C-section
2. C-section at 32-34 weeks due to the higher risk for cord entanglement
3. can aim for vaginal delivery but may opt for a c-section – maternal choice.
37
Labour for multiple pregnancies
1. Suggest ____ analgesia because can be used to facilitate operative delivery
2. fetal monitoring: continuous use of ___ for both, possibly use a fetal scalp electrode.
3. ____ administered after twin 1 to maintain contractions and aid delivery
4. Intertwin delivery time aimed for \<\_\_\_\_
5. Risk of PPH - active __ stage
1. epidural
2. CTG
3. Syntocinon
4. 30min
5. 3rd
38
name 3 different types of breech presentation
39
**Breech presentation**
1. Mode of delivery?
2. risks associated with vaginal delviery?
3. NB: non-cephalic presentation is normal up to \_\_weeks gestation
4. what is external cephalic version (ECV)?
5. what is the most risky form of breech presentation? what is the associated risk?
1. maternal choice - can either be vaginally/external cephalic version or elective c-section.
2. malpresentation can lead to the baby getting stuck, fetal hypoxia and trauma to the baby.
3. 36
4. involves attempting to manually turn the fetus into a cephalic presentation (50% success rate)
5. Footling - risk of cord prolapse (can obstruct fetal blood flow, is an obstetric emergency)
40
**Term pregnancy**
1. Between __ and __ weeks gestation.
2. Any pregnancy lasting longer than this is termed a ____ pregnancy.
3. risks associated with this?
4. Women are monitored every 2 weeks to assess the fetus wellbeing and offered induction of labour between __ and __ weeks gestation to avoid risks of prolonged pregnancy
1. 37-42
2. prolonged
3. increased risk of stillbirth, meconium aspiration for the fetus leading to respiratory distress.
4. 41-42
41
1. what is the mainstay imaging used to assess pregnancy?
2. In early pregnancy, it is used for assessment of what?
3. In 2nd trimester, it is used to look what?
4. In the 3rd trimester, it is used for what?
1. ultrasound - no ionising radiation to the fetus.
2. viability, to determine if intrauterine or ectopic, date pregnancy using crown-rump length (CRL), determine chorionicity, offer DSS [Down syndrome screening] using nuchal translucency
3. for fetal anomalies, determine placental site and screen the maternal uterine artery resistance.
4. to monitor fetal growth, look for fetal hypoxia and anaemia (only done to assess at risk pregnancies)
42
The ____ artery increases its resistance in fetal hypoxia and the ___ \_\_\_ artery decreases its resistance.
umbilical
middle cerebral (MCA) - will show an increase peak systolic volume in fetuses with anaemia.
43
\_\_\_\_ (imaging modality) can also be used safely in pregnant women and is sometimes used to assess placental site, assess fetal anomalies or look for maternal pelvic pathology.
MRI
44
1. An uncomplicated pregnancy receives how many ultrasound scans?
2. High risk pregnancies are screened for fetal ____ using ultrasound
3. Women with high risk red cell antibody levels are screened for fetal \_\_\_\_
4. Low risk pregnancies have the fetal growth monitored by what measurement?
1. 2 - booking (12weeks) and anomaly (20weeks) scans.
2. growth
3. anaemia
4. symphseal fundal height. If s too large or small for gestation they are referred for a growth scan.
45
1. which ethnicities have a higher risk of dying in pregnancy
2. Age \> ___ is another risk factor
3. T/F: Deprivation and poor medical/pregnancy care are risk factors.
4. What is the leading direct cause of maternal mortality.
5. ____ causes are the most common indirect cause of maternal mortality.
6. ____ is the leading cause in the first year post-delivery.
1. Black and Asian women
2. 40
3. true
4. VTE
5. Cardiac
6. Suicide
46
WHO definition of stillbirth?
a baby born with no signs of life at or after 28 weeks' gestation.
47
Major causes of stillbirth?
* labour complications
* Post-term pregnancy
* Maternal infections e.g. malaria, HIV
* Maternal disorders e.g. diabetes, hypertension
* Fetal growth restrictions
* Congenital abnormalities
48
# Define:
1. Neonatal mortality
2. Early neonatal mortality
3. Late neonatal mortality
1. death of a live-born baby within the first 28 days of life
2. death of a live-born baby within the first seven days of life.
3. death after 7 days until before 28 days.
49
1. What is gestational hypertension (aka idiopathic hypertension)
2. Hypertension in pregnancy in usually defined as: systolic \> __ mmHg or diastolic \> __ mmHg or an increase above booking readings of \> __ mmHg systolic or \> __ mmHg diastolic
3. Pre-eclampsia is a condition seen after __ weeks gestation characterised by pregnancy induced ____ together with \_\_\_\_\_
1. develops \>20 weeks gestation but does not involve proteinuria or oedema.
2. 140, 90, 30, 15
3. 20, hypertension, proteinuria (\>0.3g /24hours).
50
Pre-eclampsia increases the risk of...?
* Fetal prematurity and intrauterine growth retardation
* Eclampsia
* Haemorrhage due to placental abruption
* Cardiac failure, Stroke, VTE
* DIC (Disseminated Intravascular coagulopathy) and HELLP (Haemolysis, Elevated Liver enzymes and low platelets)
* Pulmonary oedema
* Multi-organ failure e.g. liver failure/rarely rupture, kidney failure
51
Investigations for preecalampsia?
* BP
* Urinalysis (will show proteins)
* Haemoglobin, Platelets, U&Es, LFTs, coagulation screen, urate
52
Risk factors for preeclampsia?
* Hypertensive disorder in previous pregnancy
* Chronic kidney disease
* Autoimmune disease such as SLE or antiphospholipid syndrome
* type 1 or 2 diabetes
* Chronic hypertension
* First pregnancy
* Age 40 years or older
* Pregnancy interval of more than 10 years
* BMI of 35kg/m2 or more at first visit
* Family history of pre-eclampsia
* Multiple pregnancy
53
Features of severe pre-eclampsia?
* Hypertension (typically \>170/100mmHg) + proteinuria
* Headache (cerebral oedema)
* Visual disturbance
* Papilloedema
* Right upper quadrant/epigastric pain
* Sudden onset oedema
* Hyperreflexia, clonus
* Platelets \<100 x106 /L, abnormal liver enzymes or HELLP syndrome
54
what is HELLP syndrome?
* hemolysis (H)
* elevated liver enzymes (EL)
* low platelet count (LP)
55
If pre-eclampsia is not controlled it can develop into eclampsia which is characterised by what symptom?
grand mal seizures.
56
managemen of pre-existing hypertension in pregnancy?
Switch from teratogenic ACE-inhibitors to either
* labetalol
* nifedipine
* methyldopa
57
management of pregnancy induced hypertension (if below 20 weeks gestation)
Antihypertensives like
* labetalol
* nifedipine
* methyldopa
* hydralazine
58
management of pre-eclampsia (after 20 weeks gestation)
Antihypertensives like labetalol, nifedipine, methyldopa, hydralazine (same as pregnancy induced HTN \<20w)
IV magnesium sulphate (If severe, used to reduce the chance of eclampsia)
59
The definitive treatment for pre-eclampsia?
delivery of the baby
60
Often mothers with pre-eclampsia are given IM steroids
1. why?
2. which ones?
3. IV steroids also decrease the risk of what else?
1. in order to encourage fetal lung maturation if gestation \<34weeks (\<38 if c-section) \> aims to speed up the production of surfactant within the fetus’ lungs and avoid acute respiratory distress syndrome.
2. betamethasone or dexamethasone
3. Neonatal death, Intraventricular haemorrhage, Necrotising enterocolitis, Intensive care admission and need for respiratory effort, Systemic infections.
61
Eclampsia management?
IV Magnesium sulphate and urgent delivery by fasteST method (usually C-section, unless fully dilated)
62
Secondary prevention in women with history of pre-eclampsia or risk factors for pre-eclampsia?
* Low dose aspirin started at 12 weeks gestation
* Increased surveillance for signs and symptoms of PET
63
**Gestational diabets mellitus (GDM)**
1. What ees it?
2. risk factors?
3. signs?
4. Pregnancy is a diabetogenic state due to the influence of ____ hormones which lead to a relative ____ deficiency/resistance.
1. carbohydrate intolerance resulting in hyperglycaemia of variable severity with onset or first recognition during pregnancy
2. Previous GDM, Obesity (BMI ≥30), FH (first degree relative), Ethnicity (SE Asian, Middle Eastern, black Caribbean), Previous big baby
3. Polyhydramnios, Glycosuria
4. placental, insulin
64
consequences of diabetes in pregnancy?
* Overgrowth of insulin sensitive tissues and macrosomia
* Shoulder dystocia and vaginal trauma (increased risk and of assisted delivery via forceps/ c-section)
* Hypoxaemic state in utero - higher risk of stillbirth
* Short term metabolic complications – fetal hypoglycaemia post-delivery
* Fetal metabolic reprogramming leading to increase long term risk of obesity, insulin resistance and diabetes + cardiovascular disease
65
Complications of diabetes in pregnancy (both pre-existing and gestational)?
* Pre-eclampsia
* Neonatal hypoglycaemia, obesity, cardiovascular disease
* Macrosomia, obstructed labour, operative delivery, vaginal trauma, 3rd degree tears.
* Shoulder dystocia
66
Complications specific to pre-existing diabetes?
* Congenital anomalies – increased risk of NTD and cardiac anomalies.
* Miscarriage (\<24weeks)
* Intrauterine death (\>24weeks)
67
Diabetes in pregnancy
1. aim for a HBA1C of \_\_mmol/mol prior conception
2. Avoid pregnancy if HBA1C above __ mmol/mol
3. Stop any embryopathic medication e.g. ...
4. Give high Dose Folic Acid \_\_mg (3 months before conception to __ weeks of pregnancy)
5. Low dose ___ from 12 weeks
6. Fetal anomaly scan at ___ weeks
7. Regular eye checks for \_\_\_\_\_
8. Safety advice about diabetes & hypoglycaemia – higher risk of ____ events with tighter control and pregnancy demands.
9. Consider ___ \_\_\_ monitoring
10. Growth scans 4 weekly from ___ weeks
11. Type 1: Deliver at __ weeks (earlier if complications present) and counsel about shoulder dystocia. Offer CS if EFW \>4.5kg
12. Gestational diabetes - If on metformin: deliver at ____ weeks, if diabetes controlled by diet alone – deliver at 40-41 weeks, if on insulin: deliver at \_\_weeks.
1. 48
2. 86
3. ACE inhibitors, cholesterol lowering agents
4. 5, 12
5. aspirin
6. 18-20
7. retinopathy
8. hypoglycaemic
9. continuous glucose
10. 28
11. 38
12. 39-40
13. 38
68
1. screening tests for gestational diabetes?
2. Risk of recurrence if previous gestational diabetes?
3. Diagnostic values for gestational diabetes?
4.
1. Assess risk factors at booking visit
Blood glucose monitoring
OGTT in 1st trimester (if normal repeat at 24-28weeks)
Oral glucose tolerance test at 24-28weeks
2. recurrence risk of \>50%
3. Fasting \>=5.1 mmol/l
2 hour \>=8.5 mmol/l
69
1. Pregnant women diagnosed with any form of diabetes need to monitor their blood glucose at least ___ times a day
2. Targets are : Fasting: ?
3. 1 hr post meal?
1. 4 (premeal times, 1hr post-meal and before bed)
2. 3.5 -5.5 mmol/l
3. \<7.8mmol/l
70
1. Which medications can be used if exercise and diet fail to control blood glucose?
2. Pros and cons of oral hypoglycaemic agents compared to insulin?
1. Metformin, Insulin - does not cross the placenta but there’s a risk of maternal hypoglycaemia
2. pros: avoids hypoglycaemia associated with insulin, less weight gain, less education needed to ensure safe/effective administration. cons: they cross the placenta.
71
1. Women with GDM have an increased risk of developing type __ diabetes postnatally
2. Fasting BG is measured __ weeks postnatally (OGTT at 6weeks if results suggest T2DM)
3. Women also require screening how often for diabetes by GP.
1. 2
2. 6-8
3. annual
72
what is PPROM?
Preterm prelabour rupture of membranes
* 5-7% of labours occur \<37weeks.
* breakage of amniotic sac before the onset of labour
73
causes of PRROM?
* Infection (may weaken the tensile strength of the fetal membranes)
* Cervical incompetence
* Over-distension of uterus (multiple pregnancy or polyhydramnios)
* Vascular causes – placental abruption
74
risk factors for PPROM?
* Previous pre-term labour (20% risk after 1 previous episode, 40% risk after 2 episodes)
* Multiple pregnancy
* Smoking
* Uterine anomalies
* Parity (=0 or \>5)
* Ethnicity
* Poor socio-economic status
* Drugs (especially cocaine)
75
Consequences of PPROM? (to neonate and mum)
* Neonate: mortality and morbidity (ass. with prematurity, sepsis and pulmonary hypoplasia) - depends on gestation
* Maternal: chorioamnionitis
*
76
WHO definition of:
1. Extremely preterm?
2. Very preterm?
3. Moderate to late preterm?
1. Extremely preterm – before 28 weeks
2. Very preterm – from 28 weeks – 32 weeks
3. Moderate to late preterm – from 32 weeks to 37 weeks
77
survival of preterm infants?
* \<22 weeks = close to 0
* 22 weeks ≈ 10%
* 24 weeks ≈ 60%
* 27 weeks ≈ 89%
* 31 weeks ≈ 95%
* 34 weeks is equivalent to a baby born at full term
78
how to diagnose PPROM?
* sterile speculum exam - pooling of blood in posterior vaginal fornix.
* in some cases USS may demonstrate oligohydramnios
* NB: avoid PV exam because of the risk of infection, unless there is suspicion the woman may be in labour (micro-organisms may be transferred from the vagina into the cervix, causing an infection, prostaglandin release leading to preterm labour)
79
Management of PPROM?
* Monitor for chorioamnionitis (maternal pyrexia, tachycardia, leucocytosis, uterine tenderness, offensive vaginal discharge and fetal tachycardia)
* **Abx**: to preventing ascending infections leading to chorioamnionitis
* **Tocolytics:** nifedipine first line (if contraindicated, oxytocin receptor antagonists such as atosiban can be offered)
* **Maternal steroids:** to encourage maturation of the fetal lungs to assist in adaption to extrauterine life once delivered.
* **Magnesium sulphate:** for neuroprotection of the foetus
* CTG
* FBS (only \>34 weeks)
80
1. What is often the first choice Abx in PPROM to prevent ascending infections leading to chorioamnionitis
2. Why should co-amoxiclav be avoided?
* Erythromycin (250mg PO every 6 hours for 10 days)
* as it causes necrotising enterocolitis in the neonate
81
when administering Magnesium sulphate in PPROM, what should you beware and monitor for?
clinical signs of magnesium toxicity at least every 4 hrs by recording pulse, BP, RR and deep tendon reflexes.
82
1. Who does Rhesus isoimmunisation occur in?
2. Describe what it means
3. what is it a problem?
4. when a pregnant woman is identified as having antibodies, what screening is initiated?
5. If the baby appears anaemic, specialist centres will perform what investigation?
6. When the anaemia is extremely severe, the fetus can experience heart failure and develop what condition?
7. Management if this occurs \>32 weeks?
1. Rhesus D -ve mothers who have a rhesus +ve fetus.
2. The mother forms antibodies (large IgM in first pregnancy and then smaller IgG in subsequent pregnancies) to the fetus’ red blood cells during sensitising events where there is mixing of fetal and maternal blood.
3. RBC Abs created by the mother pass through the placenta and attack fetal red cells causing fetal anaemia.
4. the antibody titres are checked regularly - if high, the baby is screened for fetal anaemia by checking the middle cerebral artery-peak velocity pressure (MCA-PSV)
5. FBS and in utero transfusion via the umbilical vein under ultrasound guidance.
6. Hydrops fetalis: abnormal accumulation of fluid in 2 or more compartments \> ascites, pleural effusion, skin oedema, pericardial effusion. Late and poor sign of fetal anaemia and if untreated could result in death.
7. fetus will be delivered for ex-utero transfusion.
83
what is antepartum haemorrhage?
bleeding from the genital tract \>24 weeks and before the end of the second stage of labour
84
Causes of antepartum haemorrhage:
* **Placenta:** Placenta praevia/ abruption
* **Uterus:** Uterine rupture, preterm labour
* **Local:** cervical ectropion, polyps, infection, cervical cancer
* **Vessels:** Vasa praevia
85
DDx of APH?
* heavy show (of mucus and blood)
* cystitis or haemorrhoids
* thorough history needed to arrive at diagnosis
86
Is important to quantify blood loss in APH:
1. Spotting
2. Minor haemorrhage
3. Major haemorrhage
4. Massive haemorrhage
1. Staining, streaking or blood spotting noted on underwear or sanitary protection
2. \<500ml (settled)
3. 500-1000ml with no signs of clinical shock
4. \>1000ml and/or signs of clinical shock.
87
**Placenta praevia?**
1. definition?
2. If an earlier scan (18-20w) showed a low-lying placenta (encroaching or covering the cervix), another scan is done at __ weeks to check if the placenta has moved with the growth of the uterus. If this scan is unclear, what other scan should be offered?
3. typical presentation?
4. risk factors?
1. placenta either covering the internal cervical os or within 2cm of the cervical os.
2. 32, transvaginal scan
3. bright red painless vaginal bleeding. Can be a cause of abnormal fetal presentation
4. Age, previous c-section, Previous placenta praevia
88
**Placental abruption**
1. what ees eet?
2. diagnosed how?
3. typical presentation?
4. Other potential presenting symptoms?
1. separation of a normally implanted placenta either partially or totally before birth of the fetus.
2. clinical diagnosis
3. painful vaginal bleeding (can be painless/ concealed i.e. no vaginal bleeding as blood is concealed behind the placenta). Tender, tense uterus (woody hard uterus).
4. May have clinical shock that's out of proportion with the amount of visible blood (concealed PA). Severe, continuous abdo pain, backache with posterior placenta,
preterm labour, maternal collapse.
89
1. What is the cause of placental abruption though to be?
2. This causes tonic ____ and interrupts placental circulation which causes \_\_\_\_\_
3. This results in a Couvelaire uterus – what is this?
1. Vasospasm followed by arteriole rupture into the decidua; blood escapes into the amniotic sac or further under the placenta and into myometrium.
2. contraction, hypoxia
3. blood between muscle fibres so the uterus appears blue and doesn’t contract well, increasing risk of PPH
90
Consequences of placental abruption?
* Intrauterine death and fetal hypoxia
* High risk of primary PPH
* massive bleeding \> DIC (widespread clotting and bleeding from cannula sites, low BP, multi-organ failure, with a risk of death if not recognised and treated in time)
91
Risk factors for placental abruption?
* pre-eclampsia/hypertension
* trauma
* smoking/cocaine/amphetamine
* medical thrombophilia/renal disease/diabetes
* polyhydramnios
* Abnormal placenta
* Previous abruption (recurrence is 10%)
* multiple pregnancy, preterm rupture of membranes.
92
Signs of placental abruption?
* **General**: unwell distressed patient, may be inconsistent with revealed blood
* **Uterus**: large for dates or normal, tenderness, woody, hard, irritable uterus on CTG (zigzag pattern or few contractions, fetal tachycardia, loss of variability or decelerations)
* **Fetus**: fetal parts difficult to identify, HR may be absent (intrauterine death) or bradycardic
93
Management of placental abruption?
* Resuscitate mother (mum comes first over baby)
* Urgent c-section and replacing blood products (RBC, platelets, fibrinogen) as well as fetal resuscitation if necessary
* Manage complications (anti-D in Rh-D negative women)
94
1. What is vasa praevia?
2. how does it present?
1. fetal blood vessels in the membranes overlying or close to the internal cervical os.
2. Most commonly: membranes are ruptured followed by small amount of dark vaginal bleeding accompanied by acute fetal bradycardia and decelerations (significant fetal mortality risk)
3. Doesn't carry maternal risk unlike placenta praevia (because it's fetal blood loss)
95
How is vasa praevia
1. screened for?
2. diagnosed?
3. to avoid this high mortality presentation, its important to check what before amniotomy?
4. In the case of accidental bleeding, an urgent ____ is required.
1. Not screened for (very common)
2. Ultrasound TA and TV with doppler. Clinical diagnosis: ARM and sudden dark red bleeding, fetal bradycardia and death (mortality ≈ 60%)
3. Imfeel for pulsations or any cord-like structures before an amniotomy. Also important to check the fetal head is presenting and engaged before inducing labour or ARM.
4. c-section
96
2 types of vasa praevia?
* Type 1 : vessel connected to velamentous umbilical cord
* Type 2: when it connects to the placenta with a succenturiate or accessory lobe
97
Risk factors for placenta praevia?
* Placental abnormalities (bilobed placenta or succenturiate lobes - fetal vessels run though the membranes joining separate lobes together)
* Hx of low-lying placenta in 2nd trimester
* Multiple pregnancy
* IVF
98
Management of placenta praevia?
1. if detected antenatally
2. if presents with ruptued vasa praevia during labour
3. It is crucial to tell paediatrics if this is a likely diagnosis?
4. Placenta can be sent for ____ to confirm diagnosis.
1. Steroids at 32 weeks. Consider inpatient management if risks of preterm birth (32-34 weeks). Deliver by elective c-section before labour (34-36 weeks)
2. Emergency c-section and neonatal resuscitation (blood transfusion if needed)
3. so blood transfusions for baby is initiated early.
4. histology
99
**Uterine rupture**
1. Risk factors?
2. It can occur spontaneously generally due to what?
3. Diagnosis?
4. what monitoring equipment may be useful?
5. T/F: is associated with a very high fetal mortality
6. Treatment?
7. It can result in a _____ (surgical op) depending on the extent of the uterine rupture or may involve repairing the uterus.
1. previous uterine surgery which breached the uterine cavity (c-sections, myomectomy for fibroid removal, previous perforation), multiparity, obstructed labour
2. Overstimulation following excessive use of syntocinon or prostaglandins during induction.
3. clinical diagnosis – acute constant abdominal pain even when the uterus is relaxed, may refer to shoulder tip. Sudden maternal collapse with or without vaginal bleeding. Fetal parts will be felt easily as fetus may be in intra-abdominal cavity out with the womb.
4. CTG - showing acute fetal distress
5. true
6. urgent c-section and fetal resuscitation
7. hysterectomy
100
**Chicken pox**
1. Presents how?
2. T/F: primary infection in pregnancy is rare
3. Maternal complications?
4. Fetal complications if mother develops infection before 28weeks?
5. T/F: Neonatal (within 7 days of life) varicella is life-threatening
1. prodrome of fever and malaise, followed by itchy whole body vesicular skin rash, including the palms, soles and mucous membranes.
2. True - but the effects on the fetus and mother can be hugely detrimental
3. Increased risk of pneumonia, encephalitis and hepatitis
4. Fetal varicella syndrome (congenital malformations e.g. cutaneous scarring, limb hypoplasia and deformities, congenital cataracts, microphthalmia and CNS abnormalities).
5. True - 30% of infants will die.
101
**Chicken pox in pregnancy**
1. If maternal infection occurs in the last 4 weeks of a woman’s pregnancy, there is significant risk of what? How should this risk be managed?
2. T/F: pregnant women who've never had chicken pox or been in contact with a source should let health professionals (obstetrician, midwife GP) know.
3. What test can be conducted to check immunity to the virus?
4. If a pregnant woman is not immune to varicella zoster virus and has had significant exposure, what should she be offered?
5. Oral ____ should be prescribed in women who present within 24hours of the rash developing and who are over 20weeks gestation
6. Symptomatic relief is also important. Offer what?
7. Women who develop chickenpox in pregnancy should be assessed by a fetal medicine specialist __ \_\_ after the infection as this is the optimal time lag for the detection of fetal abnormalities.
8. Infections during pregnancy becomes relevant once the pregnant woman has had sufficient exposure to an infected person. This involves spending __ \_\_ or more, face-to-face contact or contact in the setting of a large open ward.
1. varicella infection of the newborn - planned delivery should normally be avoided for at least 7 days after the onset of maternal rash to allow for the passive transfer of Abs from mother to child.
2. True
3. A blood test to check IgG antibodies to varicella zoster virus
4. varicella-zoster immunoglobulins (VZIG) as post-exposure prophylaxis asap- effective within 10days of exposure.
5. aciclovir (IV if severe)
6. paracetamol, soothing moisturisers or calamine lotion and advise to ensure adequate fluid intake, wear light cotton clothing and avoid contact with susceptible groups (elderly, other seronegative pregnant women, neonates, children) until the lesions have crusted.
7. 5 weeks
8. 15 minutes
102
1. T/F: cytomegalovirus is a very dangerous infection
2. why is it dangerous in pregnancy?
3. Infants born to mothers with primary infection have a risk of congenital infection of \_\_\_\_%
4. How does the risk of congenital infection vary throughout gestation?
5. T/F: CMV infection in pregnancy can only be due to primary infection
6. T/F: Majority of women who acquire CMV infection for the first time will remain asymptomatic
7. In those fetuses who are identified as having congenital CMV infection – severe cerebral ultrasound abnormalities (e.g. microcephaly, ventriculomegaly, white matter abnormalities and cavitations, intracerebral haemorrhage, delayed cortical development) – what should be offered?
8. Clinical features of congenital CMV infection?
1. common in children but dangerous during pregnancy if the mother has never had CMV infection before.
2. can cause hearing loss, visual impairment/ blindness, mild - severe learning difficulties and epilepsy in an infected fetus.
3. 30-40
4. increases from 30% if primary infection occurs first trimester to 47% in the 3rd trimester.
5. false - either primary infection or by reactivation of a previous CMV infection with a different strain of the virus.
6. true - only a minority have fever, malaise, myalgia, cervical lymphadenopathy
7. TOP
8. jaundice, petechial rash, hepatosplenomegaly, microcephaly and infants born SGA
103
**Parvovirus B19 (slapped cheek syndrome)**
1. Parvovirus is a ___ virus most common in the paediatric population.
2. The incubation period lasts from 4-20 days. When is the infectious period?
3. Woman should be explained that she remains infectious until 1 day after the rash develops and she should contact who?
4. Why?
5. Confirmed case \> referral to specialist within 4 weeks to assess for complications. Risks associated with Parvovirus B19 fetal infection?
6. signs and symptoms of infection in adults?
7. What is hydrops fetalis?
1. DNA
2. starts about 7-10 days before the rash develops to 1 day before the rash develops
3. any pregnant women to whom she was exposed and advise them to contact their own GP.
4. Infection with parvovirus B19 can be transmitted to the fetus and can lead to significant fetal morbidity and mortality.
5. severe anaemia, heart failure and hydrops fetalis (higher risk if infection occurs \<20weeks)
6. lacy rash on trunk, back and limbs (may also be asymptomatic)
7. accumulation of fluid in at least 2 fetal compartments, mortality of 50%
104
**Rubella**
1. rubella virus (German measles) is a(n) virus causing a flu-like illness associated with poly\_\_\_\_ and a facial ____ rash that spreads to the limbs and trunk.
2. Women who are not immune to rubella and contract this within the first trimester are at risk of what?
3. A baby born following an intrauterine infection with rubella is at risk of developing what?
4. T/F: Rubella infection levels in the UK are so low they are defined as eliminated
5. The decision to end screening for rubella susceptibility in pregnancy has been made possible by what?
6. T/F: a reassuring fetal ultrasound can rule out congenital rubella
1. RNA, polyarthritis, vesicular
2. miscarriage
3. congenital rubella syndrome of the newborn: SN hearing loss, congenital heart disease (most commonly PDA) and ocular issues e.g. congenital glaucoma and cataracts.
4. true - according to WHO
5. high vaccination levels achieved through the MMR immunisation programme
6. false - does **NOT,** but intra-uterine growth retardation, microcephaly, heart defect and brain abnormalities may be seen.
105
**HIV**
1. Can HIV+ women deliver vaginally?
2. What is recommended for women who are HIV+ and did not previously need medication?
3. Does the baby need tested?
4. What are the rules regarding breastfeeding?
5. What about in developing countries?
1. if viral load \<50copies/ml - otherwise, c-section is protective to the baby.
2. Should commence combined ART in the 2nd trimester by the 24th week and continue this lifelong.
3. Yes - at birth and at regular intervals for up to 2 years.
4. formula milk is safest way, however mothers can choose to breastfeed their babies in certain situations: undetectable viral load and mother taking ART; Exclusive breastfeeding for first 6 months, not mixing with formula or cow’s milk; Avoid breastfeeding the baby at high risk times i.e. mastitis, cracked nipples, detectable viral load or D&V in both mother and baby.
5. WHO advises they breastfeed as there may be no suitable alternative (formula milk not available/ too expensive/ hygiene concerns)
106
**Thromboembolic disease in pregnancy**
1. There is \_\_X increase in risk of VTE in pregnancy
2. Risk higher in the puerperium or antenatal period?
3. T/F: VTE/DVT is the leading cause of maternal death
4. Why is the risk so increased?
5. Symptoms of DVT?
6. There should be a low threshold for investigation of DVT. What Ix is done?
7. If iliac vein thrombosis is suspected and if patient complains has a whole swollen leg and back pain, consider what Ix?
8. symptoms and signs of PE?
9. diagnosis of PE?
1. 4-6
2. 5x higher in the puerperium - influences choice of contraception that can be given
3. true
4. Pregnancy is a hyper-coaguable state which fulfils all of Virchow’s triad: Hypercoagulability, Venous stasis, Vascular damage
5. Painful swollen/ oedematous leg. Increased leg temp, tenderness
6. Do a compression duplex ultrasound - if normal but clinical suspicion remains high, repeat in one week to exclude an extending thrombosis and give therapeutic dose of LMWH.
7. MRI venography
8. Dyspnoea, Chest pain, Faintness, Collapse, Haemoptysis, Raised JVP, Focal signs in the chest, Symptoms and signs associated with DVT.
9. Weigh up risk and benefits of doing either CTPA or V/Q scan (risk of undiagnosed PE is greater than risk to mother or baby from scan)
107
**Thromboembolic disease in pregnancy**
1. T/F: both UFH and LMWH cross the placenta
2. Are heparins secreted in breast milk?
3. LMWHs are the agents of choice for antenatal thromboprophylaxis and why?
4. T/F: treatment should be commenced until an objective diagnosis of VTE is confirmed
5. Acute massive PE in pregnancy or the puerperium may present as a collapsed shocked woman - should be treated as a matter of urgency. Preferred initial treatment in this situation and why?
6. When might thrombolysis be considered?
7. IV ___ should be started promptly after thrombolysis and this can be converted to ____ once stability is achieved.
8. For those on anticoagulants, delivery planning involves a balance between which two risks?
9. T/F: the use of novel oral anticoagulants such as rivaroxaban, dabigabtran are becoming more popular in pregnancy
1. false - neither cross the placenta
2. no
3. LMWH (because of a better side-effect profile and once daily dosing for thromboprophylaxis - at least as effective and safer than UFH)
4. false - should be commenced on clinical suspicion
5. UFH due to its rapid onset of action and dose adjustment can be performed if thrombolytic therapy is administered.
6. pts with life-threatening PE and haemodynamic compromise.
7. UFH, LMWH
8. Risk of PPH and risk of progressive/ recurrent VTE
9. false - not recommended in pregnancy/ breastfeeding
108
**Warfarin**
1. Does this cross the placenta?
2. Features of warfarin embryopathy?
3. T/F: the risk appears to be dose-dependent
4. Women who are already on warfarin or any other anticoagulant need to convert to LMWH by __ weeks gestation
5. T/F: heparin and warfarin are contraindications to breastfeeding.
6. Anticoagulant therapy should be continued until at least 6 weeks post-natally and until 3 months post-partum??
1. yes - and is teratogenic.
2. Midface hypoplasia; Stippled chondral calcification; Short proximal limbs; Short phalanges; Scoliosis
3. True - more than 5mg/day
4. 6
5. false - neither are (commence warfarin day 5 post-natally)
6. postnatal vs postpartum??
109
2 causes of a small baby?
* Preterm
* Small for gestational age (Intrauterine growth restriction due to pathology or constitutionally small)
110
1. what is 'pre-term delivery'?
2. define extreme, very and moderate preterm
1. Delivery before 37weeks gestation
2. Extreme preterm : 24-28 weeks
Very preterm : 28-32weeks
Moderate to late preterm : 32-37 weeks
111
what are some causes of preterm birth?
* Over-distention i.e. multiple pregnancy, polyhydramnios
* Cervical incompetence
* Vascular e.g. placental abruption
* Intercurrent illness e.g. pyelonephritis, appendicitis, pneumonia
* Infection
* Idiopathic
112
Risk factors for preterm birth?
* **The pregnancy:** Multiple pregnancy, Parity (either nulliparity or grand multiparity), Uterine anomalies
* **The woman:** Age, Ethnicity, Poor socio-economic status, Smoking, Drugs (especially cocaine), Low BMI (\<20), Previous preterm labour
113
Why are babies born pre-term?
* 25% planned caesarean section - severe pre-eclampsia, kidney disease or poor fetal development
* 20% PROM
* 25% emergency event like placental abruption, infection, eclampsia
* 30% cause unknown.
114
where will a small for gestational age fetus be on the centiles?
EFW or abdominal circumference \<10th centile in both population and customised centiles
115
defined 'low birth weight'
\<2.5kg (regardless of gestation)
116
IUGR is due to failure to achieve growth potential. Can be symmetrical or asymmetrical.
1. what is symmetrical IUGR?
2. causes?
3. what is asymmetrical IUGR?
4. causes?
1. fetus’ head and abdomen are small.
2. chromosomal abnormalities, TORCH [toxoplasmosis, others like syphilis, varicella-zoster, parvovirus B19, rubella, cytomegalovirus and herpes] infections.
3. Often due to placental defects where the head is large compared to the small abdomen as there is preservation of brain development over other organs.
4. pre-eclampsia, malnutrition, chronic hypoxia.
117
minor risk factors for SGA?
* Maternal age \>35 years
* IVF pregnancy
* Nulliparity
* BMI \<20
* BMI 25-34.9
* Smoker 1-10 cigarettes/day
* Low fruit pre-pregnancy
* Previous pre-eclampsia
* Pregnancy interval \<6 months
* Pregnancy interval \>60 months
118
Major risk factors for SGA?
* Maternal age \>40 years
* **Current pregnancy:**
* Heavy bleeding in pregnancy. Known large fibroids
* **Maternal PMH:** Previous SGA baby, Previous stillbirth, Maternal SGA, Chronic hypertension, Diabetes with vascular disease, Renal impairment, Antiphospholipid syndrome, BMI \>35
* **Maternal FH:** husband (paternal) SGA
* **Maternal SH:** Smoker \>11 cigarettes/day, Cocaine use, Daily vigorous exercise
* **Maternal Ix:** Low PAPP-A, Fetal echogenic bowel
119
1. what investigations should women with a single major risk factor for SGA be reffered for?
2. What about women with 3 minor risk factors?
1. serial US measurement of fetal size and assessment with umbilical artery doppler from 26-28weeks gestation.
2. should be referred for uterine artery doppler at 20-24weeks gestation.
120
Screening for SGA during antenatal care:
1. All women get measurement of __ \_\_ __ from 24weeks
2. Growth scans are done if single measurement below \_\_th centile on customised chart
3. Serial measurements in SG suggest _____ growth
1. symphyseal-fundal height
2. 10
3. slow/static
121
**Diagnosis of SGA:**
1. measurement of fetal ___ \_\_\_
2. Combined with ____ circumference +/- ____ length to give estimated __ \_\_
3. Additional information - ____ volume or _____ fluid index and doppler scans of the umbilical artery
1. abdominal circumference
2. head, femur, fetal weight
3. liquour, amniotic
122
What is a large for dates fetus?
* estimated fetal weight \>90th centile.
* symphyseal-fundal height will be \>2cm for the gestational age.
123
causes of a large for dates fetus?
* Polyhydramnios
* Multiple pregnancy
* Macrosomia secondary to gestational diabetes
* Occasionally - wrong dates in late bookers, vulnerable women or women who have recently moved from abroad.
124
What risks are associated with a large for dates fetus?
* Clinician and maternal anxiety
* Shoulder dystocia
* PPH
125
What is polyhydramnios?
excess of amniotic fluid: amniotic fluid index (AFI) \>25cm and the deepest vertical pool \>8cm.
126
causes of polyhydramnios?
* Diabetes
* Anomaly - GI atresia, cardiac deformities
* Monchorionic twin pregnancy
* Hydrops fetalis -Rhesus isoimmunisation
* Viral infection (erythrovirus B19, toxoplasmosis)
* idiopathic
127
Symptoms of polyhydramnios?
* Abdominal discomfort
* Prelabour rupture of membranes
* Preterm labour
* Cord prolapse
128
Signs of polyhydramnios?
* Large for dates
* Malpresentation
* Shiny, tense abdomen
* Inability to feel fetal parts
129
\_\_\_\_\_ is first line for management of hypertensive disorders in pregnancy.
\_\_\_\_ is second line and used when labetalol is contraindicated for example in \_\_\_\_.
labetalol
Nifedipine
asthmatics
130
name some indications for continuous CTG monitoring in pregnancy
* suspected chorioamnionitis or sepsis, or temp ≥38°C
* severe hypertension ≥160/110 mmHg
* oxytocin use
* the presence of significant meconium
* fresh vaginal bleeding that develops in labour
131
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