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Flashcards in Complications Exam Deck (350):
0

What is the gestation of a prolonged pregnancy?

42 weeks or beyond

1

Name 8 possible reasons for a prolonged pregnancy

- Inaccuracy of dating
- Malpresentation
- Malposition
- Cephalopelvic disproportion
- Hereditary and ethnic origin
- Seasonal variations
- Congenital abnormalities
- Maternal stress, anxieties and fears

2

List 8 potential maternal complications of a prolonged pregnancy

- Anxiety and fear
- Macrosomic fetus
- Cephalopelvic disproportion
- Shoulder dystocia
- Perineal, vaginal and cervical trauma
- PPH
- Increased risk of LUSCS
- Chorioamnionitis

3

List 8 potential fetal complications of a prolonged pregnancy

- Post maturity
- Macrosomia
- Fetal distress
- Birth asphyxia
- Shoulder dystocia (neurological and orthopaedic trauma)
- Increased risk of neonatal seizures
- Hypoglycaemia
- Stillbirth / perinatal death

4

If a mother wishes to avoid induction, what type of management can be offered?

Expectant management

5

What is expectant management of prolonged pregnancy?

If no obvious complications with the mother or baby and the mother wishes to avoid induction then fetal surveillance should be offered from 41 weeks. This includes:
- Fetal kick chart
- Non stress test (CTG)
- Amniotic fluid measurement
- Biophysical profile

6

What is an induction of labour?

It involves the stimulation of contractions prior to the onset of spontaneous labour.

7

List 8 indications (reasons) for the induction of labour

- Prolonged pregnancy
- Obstetric or medical complications
- Poor obstetric history
- Fetal wellbeing
- Prolonged rupture of membranes
- Unstable lie
- Maternal request
- Intrauterine death

8

List 8 contraindications (reasons not to) for induction of labour

- Placenta praevia
- Malpresentation
- Cord presentation / prolapse
- Cephalopelvic disproportion
- Severe fetal compromise
- Active genital herpes
- Previous LUSCS
- Maternal condition

9

How is the best method of induction determined?

The cervix is assessed using the modified Bishop's score

10

List the 5 factors that are assessed using the Bishop's score

- Dilatation (cm)
- Length of cervix (cm)
- Station (cm)
- Consistency of cervix
- Position of cervix

11

List 10 natural methods of induction

- Sexual intercourse
- Clitoral stimulation
- Nipple stimulation
- Pineapple
- Reflexology
- Castor oil
- Raspberry leaf tea
- Exercise
- Homeopathy
- Membrane sweep

12

What is the medical method of induction?

The use of oxytocic drugs which cause the uterus to contract

13

What are the three types of oxytocic drugs and what effect do they have?

- Propess (synthetic prostaglandin E2 in pessary form) - causes cervical ripening
- Prostin (synthetic prostaglandin E2 & F2 in gel form) - causes cervical ripening and uterine contractions
- Synthetic oxytocin (administered IV) - stimulates uterine contraction

14

What is the NHS Forth Valley protocol for the induction of labour on a woman with intact membranes?

On a nulliparous woman with a Bishop score of:
- 4 or less = Propess pessary 10mg for 24 hours

- 7 or less = Prostaglandin E2 gel 1mg. Review and repeat every 6 hours with a maximum of 3 doses in 24 hours

15

What is the NHS Forth Valley protocol for the induction of labour on a woman with ruptured membranes?

Add 30 IU of Syntocinon to a 500ml infusion bag of normal saline and give via an infusion pump with a non-return valve.
Dose should start at 1ml/hour and increase every 30 minutes dependant upon uterine activity and fetal and maternal wellbeing

16

What should be undertaken following the induction process?

Continuous fetal monitoring for 30-60 minutes while the woman remains recumbent to maximise the effectiveness of the prostaglandins

17

List 7 potential risks involved with induction of labour

- Hyperstimulation / hypercontractability
- Uterine rupture
- Increased sensitivity to pain
- Pyrexia
- Vasodilation and hypotension
- Inflammation
- Gastro-intestinal disturbance

18

What 3 medications can be given to counteract contractions if an adverse reaction occurs?

Salbutamol, ritodrine or terbutaline

19

What is the surgical method of induction and what two things should be done at the time of the procedure?

Amniotomy or artificial rupture of the membranes.
Documentation of amount and colour of liquor is vital!
Fetal heart should be auscultated before and after procedure.

20

What effect does syntocinon have on endogenous oxytocin production?

It does not suppress the production

21

What is the half life of syntocinon?

Approximately 15 minutes

22

How long can the syntocinon regime continue if labour does not establish?

5 hours

23

In what 4 circumstances should the explicit approval of the consultant be given before the use of syntocinon?

- Multiple pregnancy
- Malpresentation
- Previous LUSCS or other uterine scar
- Grandmultiparity

24

List 12 potential side effects of the use of syntocinon

- Overstimulation
- Contraction of umbilical blood vessels
- Constriction / Dilatation of blood vessels
- Nausea
- Trauma
- Uterine rupture
- PPH
- Placental abruption
- DIC (disseminated intravascular coagulation)
- Amniotic fluid embolism
- Fetal hypoxia
- Neonatal jaundice

25

List 5 points in the midwifery management of induction

- Full informed discussion with woman prior to procedure
- Gain consent
- Ensure suitability for induction
- Appropriate method of induction used and administered
- Continuously monitor wellbeing of fetus and mother throughout

26

When can disordered uterine action occur and what is it attributed to?

It can occur at any stage in labour and is attributed to an abnormal pattern in uterine contractability

27

What can disordered uterine action result in?

Slow or rapid progress in labour

28

What is the most common cause of prolonged labour in primigravid women?

Inefficient uterine activity

29

In what type of women, is over efficient uterine activity most common?

Multiparous women

30

What is tonic uterine action?

A rare condition in which the uterus increases powerful contractions to overcome an obstruction, eventually becoming one long contraction

31

What are the 5 steps in the management of tonic uterine action?

- Administer oxygen
- Lay woman on left lateral
- Summon emergency help
- If using oxytocics - STOP
- Immediate delivery to prevent uterine rupture

32

What is a complete or true uterine rupture?

Involves the full thickness of the uterine wall and pelvic peritoneum

33

What is an incomplete uterine rupture?

Involves the myometrium but NOT the pelvic peritoneum

34

List 6 signs that a uterine rupture may have occurred

- Sudden sharp abdominal pain followed by cessation of contractions
- Abdominal tenderness
- Fetal distress (usually bradycardia)
- Vaginal bleeding
- Maternal collapse
- Haematuria (blood in the urine)

35

List 10 points in the midwifery management of a ruptured uterus

- Press emergency buzzer
- Call for senior obstetrician and anaesthetist and possibly paediatrician
- Maintain airway with facial oxygen
- Assess pulse and blood pressure
- Obtain IV access
- Full blood count and clotting screen, cross match 6 units of blood
- Give IV Hartmann's solution and blood transfusion as necessary
- Give CPR if necessary
- Set up continuous CTG and apply fetal scalp electrode
- Obtain consent for laparotomy and possible hysterectomy under general anaesthetic

36

List 6 points in the midwifery after care following a ruptured uterus

- Closely monitor for PPH
- IV oxytocin
- Debrief woman and her partner
- Risk assess for PTSD
- Advise on counselling services
- Advise on bereavement support if applicable

37

List 4 contributing factors to a prolonged labour

- Inaccurate estimation of time labour started
- Maternal distress, tiredness, exhaustion
- Full bladder or rectum
- Early rupture of membranes

38

List 5 possible causes of a prolonged labour

- Inefficient uterine action
- Cephalopelvic disproportion
- Posterior position of occiput
- Malpresentation of fetus
- Macrosomia

39

List 7 points to consider for the midwifery management of prolonged labour

- Informed choice and communication with woman
- Continuous assessment of maternal and fetal condition
- Ensure effective pain management
- Psychological support
- Amniotomy if membranes are intact
- Augmentation with oxytocin
- Closely monitor contractions if augmentation

40

What is cephalopelvic disproportion?

Any condition where the presenting diameters of the fetal head are larger than the diameter of the maternal pelvis.

41

List 5 maternal indications of possible cephalopelvic disproportion

- Bone conditions such as rickets
- Spinal deformities such as scoliosis
- Pelvic trauma and fractures which may have altered the pelvis
- Previous obstetric conditions such as prolonged labour or LUSCS
- Short stature of the woman

42

What is a trial of labour and what is its purpose?

The purpose is to ascertain whether contractions will allow the fetal head to engage and descend to allow for a vaginal delivery.
The woman is taken to an operating theatre to allow her to labour in a safe environment where obstetric management is readily available if required.

43

List 5 possible causes of an obstructed labour

- Cephalopelvic disproportion
- Deep transverse arrest
- Malpresentation
- Lower segment fibroids
- Fetal hydrocephaly

44

List 4 maternal symptoms of an obstructed labour

- Dehydration
- Ketosis
- Pyrexia
- Tachycardia

45

What is the fetal indication of an obstructed labour?

The fetus will become bradycardic

46

What is Bandl's ring?

During obstructed labour, the upper segment of the uterus becomes thicker while the lower segment becomes thinner. The difference between the segments is seen obliquely across the abdomen which is known as Bandl's ring.

47

List 3 things that can help prevent a woman from requiring an operative delivery

- Continuous support during labour from a birth partner or midwife
- Remaining in upright, lateral positions
- Avoiding epidurals, or delayed pushing in 2nd stage if an epidural has been given

48

List 3 maternal indications of an operative delivery

- Distress or exhaustion
- To spare the mother effort where medically significant conditions occur such as cardiopulmonary issues or pre-eclampsia
- Dural tap (a specific severe headache caused by any injection in to the spine)

49

List 3 fetal indications of an operative delivery

- Fetal distress
- Breech delivery (forceps)
- Malposition

50

List 8 contraindications for an operative delivery

- Unengaged head (more than 1/5 palpable abdominally)
- Undefined position
- Brow presentation
- Suspected or actual cephalopelvic disproportion
- Fetal macrosomia
- Intra-uterine death
- Prematurity (less than 34 weeks)
- Inexperienced operator

51

List 7 prerequisites for an operative delivery

- Head less than 1/5 palpable
- Vertex presenting
- Cervix fully dilated
- Membranes ruptured
- Exact position of head determined
- No cephalopelvic disproportion
- Resuscitation available

52

List 6 things to consider for the preparation of the woman for an operative delivery

- Clear explanation given
- Informed consent
- Appropriate analgesia
- Bladder emptied
- Explanation of episiotomy
- Continuous reassurance

53

List 2 signs that an operative delivery should be stopped

- Where there is no evidence of progressive descent with each pull
- Where delivery is not imminent after 3 pulls

54

List 5 potential maternal complications from an operative delivery

- Trauma to the bladder, urethra, vagina, cervix or uterus
- Urinary retention
- Back and joint pain
- PPH
- Psychological distress

55

List 5 fetal complications that may occur from an operative delivery

- Scalp trauma
- Cephalhaematoma
- Facial nerve damage
- Cerebral bleeding
- Shoulder dystocia

56

List 6 things for the midwife to do and be aware of during an operative delivery

- Support the woman and her partner
- Support the operator
- Remember analgesia
- Keep accurate records
- Paediatrician aware if necessary
- Core staff aware

57

List 9 things the midwife should do following an operative delivery

- Suturing if required
- Pain relief
- Skin to skin contact and feeding
- Bladder care
- Care of the baby
- Thromboprophylaxis
- Physiotherapy offered
- Accurate documentation
- Detailed handover - SBAR

58

Which type of operative delivery increases the risk of maternal trauma and which increases the risk of neonatal trauma?

Forceps - maternal
Ventouse - neonatal

59

List 4 indications for a ventouse delivery

- Cervix not necessarily fully dilated
- Fetal head below spines
- Position must be known
- Not used in face presentation

60

List 3 contraindications for a ventouse delivery

- Fetus should not have suspected or actual bleeding disorders
- Not used if repeated FBS has been carried out
- Not used if gestation is less than 34 weeks and with caution between 34-36 weeks

61

List 3 potential complications that may occur with a ventouse delivery

- Chignon (large caput)
- Scalp trauma
- Maternal trauma if position of cup encroaches on vaginal wall

62

What is anaemia?

The reduction in the oxygen-carrying capacity of the blood which may be due to:
- A reduction in the number of red blood cells
- A low concentration of haemoglobin
- A combination of both

63

List 4 maternal signs and symptoms of anaemia

- Dyspnoea (laboured breathing)
- Fainting fatigue
- Tachycardia
- Palpitations

64

List 2 fetal signs and symptoms of anaemia

- Intrauterine hypoxia
- Growth restriction

65

List 4 types of anaemia

- Iron deficiency anaemia
- Folic acid deficiency
- Hereditary haemoglobinopathies (sickle cell anaemia and thalassaemia)
- Anaemia due to blood loss

66

What is the cause of iron deficiency anaemia?

Blood plasma volume increases during pregnancy which lowers haemoglobin ratio.

67

In what 4 types of women is folic acid anaemia most common?

- Undernourished women
- Multiple pregnancy
- Women on anticoagulants
- Women who drink and/or smoke heavily

68

In what 3 ethnic origins are haemoglobinopathies most common?

- African
- Asian
- Mediteranean

69

List 5 outcomes on mum and baby that may occur due to low haemoglobin levels

- Increased risk of haemorrhage
- Sepsis
- Low birth weight
- Maternal mortality
- Perinatal mortality

70

How are haemoglobin levels assessed?

By taking a full blood count

71

In relation to anaemia, what information does a full blood count NOT provide?

The cause of the anaemia

72

Where in the body should iron be more easily absorbed during pregnancy?

The small intestine

73

What effect does low haemoglobin have on oxygen uptake and how does it affect the fetus and placenta?

Causes poor uptake of oxygen by the red blood cells therefore poor oxygen delivery to the placenta and fetus

74

How and when does the fetus obtain iron across the placenta?

From around 30 weeks gestation, the fetus obtains iron from transferrin in the maternal blood

75

What is the normal reference range of haemoglobin levels in pregnant women?

110 - 150 g/l (grams per litre)

76

A fall in levels of what, will indicate iron deficiency anaemia before a fall in haemoglobin levels?

Serum ferritin (iron stores)

77

What can be assessed to confirm iron deficiency anaemia if haemoglobin levels are low?

Serum ferritin concentration

78

Why should a urine sample also be taken if assessing serum ferritin levels?

To rule out a UTI (serum ferritin levels may be artificially high if an infection is present)

79

What is the usual treatment and amount required for iron deficiency anaemia?

Oral iron preparation such as ferrous salts.
60-120mg of iron required daily

80

What should women be advised to drink with iron medication and why?
And what should they be advised to avoid around the time they take the medication?

Orange juice to maximise absorption.
Caffeine should be avoided as it prevents iron from being absorbed

81

In relation to anaemia, what is folic acid necessary for?

Red cell proliferation and DNA synthesis

82

What is the only way to confirm folic acid deficiency?

A bone marrow biopsy

83

Is folate or folic acid more easily absorbed?

Folic acid

84

What 3 things in a full blood count will be low if a woman has folic acid anaemia?

- Platelet count
- White cell count
- Serum folic acid

85

What is the dosage of folic acid required to treat folic acid anaemia?

5-15mg

86

What is the preventative dosage of folic acid?

300 - 500 micrograms

87

What are the two most common haemoglobinopathies?

Sickle cell disease and thalassaemias

88

What is haemoglobinopathy?

Inherited genes produce abnormal proteins in normal haemoglobin preventing efficient uptake, delivery and release of oxygen in to the tissues

89

What 4 types of ill health can a haemoglobinopathy cause?

- Anaemia
- Hypoxia (oxygen deficiency in the tissue)
- Tissue damage
- Haemolysis (the destruction of red blood cells)

90

What is a sickle cell crisis?

When the sickle shaped cells block capillaries which creates pain and can cause tissue death within the affected organs

91

Where does sickle cell vascular occlusion usually occur?

This usually occurs in the brain and kidneys but the placental bed may also be affected during pregnancy

92

Is the sickle cell shape permanent?

No, most red blood cells regain their shape following reoxygenation and rehydration

93

What are the 2 potential fetal complications of sickle cell disease?

- Fetal growth restriction
- Low birth weight

94

What are the 4 potential maternal complications of sickle cell disease?

- Pre-term labour
- Postpartum infections
- Anaemia
- Proteinuric hypertension

95

What are the 6 principles of treatment of sickle cell disease in pregnancy?

- Anaemia may be prevented with prophylactic use of iron and folic acid
- Blood transfusion if haemoglobin is extremely low
- Avoidance of infection
- Avoidance of cold and stress
- In labour, keep hydrated with IV therapy, prophylactic antibiotics and use oxygen if necessary
- If crisis occurs, give pain relief

96

What is thalassaemia and what does it cause?

A reduction in the synthesis of globin chains.
This causes severe anaemia.

97

List 4 clinical signs and symptoms of thalassaemia

- The spleen may be enlarged due to increased haemolysis
- Severe anaemia
- Fetal haemoglobin levels always raised
- Bone growth may be stunted in young children due to hyperplasia

98

What kind of care should be provided to women with thalassaemia?

They should be provided with specialised care by an obstetrician and haematologist

99

List 4 effects that thalassaemia may have on the fetus

- More likely to inherit haemoglobin disorders
- Birth anomalies
- Pre-term birth
- Growth restriction

100

What is asthma?

A chronic inflammatory disease of the airways which is characterised by intermittent episodes of wheezing, shortness of breath, tight chest and cough

101

List 7 common triggers of asthma "flare ups"

- Smoking
- Allergens
- Exercise
- Pollution
- Drugs
- Food and drink
- Hormonal (pre-menstrual conditions and pregnancy)

102

What are the 2 main causes of asthma deaths?

- Poor patient education / presenting late for treatment
- Underestimation by healthcare professionals of the severity of the symptoms

103

What are the 3 main aims of asthma management?

- Control of symptoms
- Prevention of exacerbation
- Achievement of the best pulmonary function for the patient with minimal side effects

104

List 3 risks for asthmatic women in pregnancy

- Low birth weight neonates
- Preterm delivery
- Preeclampsia

105

What asthma medications are suitable for use during pregnancy?

Most first line treatments

106

What causes a small reduction in lung capacity after the 5th month of pregnancy?

The uterus is expanding which causes the diaphragm to rise and the transverse diameter of the chest increases

107

What 6 mortality factors can asthma in pregnancy result in?

- Increased perinatal morbidity and mortality
- Pregnancy induced hypertension
- Placental abruption
- Preterm labour and birth
- Increased risk of Caesarean section
- Increased risk of low birth weight baby

108

What effect does uncontrolled asthma have on the fetus?

The fetus is developing in an increasingly hypoxic environment where there is decreased umbilical blood flow due to increased pulmonary and vascular resistance

109

What effect can pregnancy have on asthma sufferers?

1/3 will have worsening symptoms
1/3 will have no change
1/3 will have an improvement in symptoms

110

What might be required during labour, for women who have been on oral steroids?

Hydrocortisone

111

Which 3 labour drugs may cause bronchoconstriction?

- Ergometrine
- Syntometrine
- Prostaglandins

112

Is entonox considered safe for use by asthmatics?

Yes

113

Which drug should be used for active management of the third stage of labour for an asthmatic woman?

Syntocinon

114

Are standard asthma medications safe to use whilst breastfeeding?

Yes

115

What is the definition of hypertension in pregnancy?

A systolic blood pressure of 140mmHg or greater and/or a diastolic blood pressure of 90mmHg or greater

116

If hypertension is diagnosed early in pregnancy, what type is it more likely to be?

Pre-existing chronic hypertension

117

What is chronic hypertension?

Hypertension that exists before pregnancy

118

Why is chronic hypertension not usually diagnosed until pregnancy?

Infrequent medical encounters prior to pregnancy

119

What happens to blood pressure in the first trimester of pregnancy?

Blood pressure falls

120

Why does blood pressure fall in the first trimester of pregnancy?

Vasodilation causes a decrease in systemic vascular resistance

121

Why should a 6 week postnatal check for a woman diagnosed with hypertension during pregnancy, involve a blood pressure check?

To confirm whether hypertension is Pregnancy Induced Hypertension (PIH) or Chronic Hypertension (CHT)

122

List 4 potential complications of chronic hypertension in pregnancy

- Fetal growth restriction
- Placental abruption
- Severe hypertension
- Superimposed Pre-Eclampsia

123

Why can hypertension cause fetal growth restriction?

Hypertension can cause poor placentation which prevents the fetus from receiving enough nutrients

124

What is acute severe hypertension?

Blood pressure of 160/110mmHg or greater

125

What 4 other symptoms (as well as hypertension) are indicative of pre-eclampsia?

- Proteinuria
- Severe headaches
- Visual disturbances
- Epigastric pain

126

What are the 3 main pregnancy issues for women with hypertension?

- Treatment of hypertension
- Screening for pre-eclampsia
- Screening for fetal growth restriction

127

What are the 3 medications used to treat hypertension in pregnancy?

- Labetalol
- Nifedipine
- Methyldopa

128

What 4 checks should be undertaken at every antenatal appointment for a woman with hypertension?

- Fundal height measurement
- Blood pressure
- Urinalysis
- Ask about symptoms of pre-eclampsia

129

List 6 points to consider during labour of a woman with hypertension

- Labour usually induced from 37 weeks
- NICE and RCOG recommend continuous fetal monitoring
- Consider an epidural to aid BP control
- Hourly BP
- Do not routinely limit length of 2nd stage unless severe hypertension
- Avoidance of Syntometrine or Ergometrine for third stage

130

List 5 points to consider in the postnatal period for a woman with hypertension

- Continue antenatal anti hypertensives
- No known adverse effects of Labetalol or Nifedipine on breastfed babies
- Offer obstetric review at 6-8 weeks
- Target BP less than 140/90mmHg
- Daily BP check

131

What is pre-eclampsia?

A pregnancy specific syndrome characterised by variable degrees of placental dysfunction with maternal responses including:
- Systemic inflammation
- Development of new hypertension
- Proteinuria

132

What is the only cure for pre-eclampsia?

Delivery of the baby

133

When can pre-eclampsia manifest?

At any time during the antenatal, intrapartum and postnatal periods

134

List the 5 risk factors for pre-eclampsia

- Extremes of maternal age
- Primiparity
- Chronic hypertension
- Family history
- Previous pre-eclampsia

135

List 4 fetal complications of pre-eclampsia

- Growth restriction
- Prematurity
- Placental abruption
- Intrauterine death

136

List 7 maternal complications of pre-eclampsia

- Renal and liver failure
- Intracerebral bleeds
- Eclampsia
- HELLP Syndrome
- DIC (Disseminated Intravascular Coagulation)
- Liver rupture
- Death

137

What medication is advised for women with two moderate or one high risk factor of pre-eclampsia and from what gestation?

Aspirin (75mg once daily) from 12 weeks gestation

138

List 4 points to consider in the antenatal period for pre-eclampsia

- Risk factor assessment at booking
- Individualised plan if risk factors present
- Referral to daycare if BP greater than 140/90 and proteinuria
- Detailed fetal assessment should be undertaken at the time of diagnosis

139

At what blood pressure should antihypertensive medication be given if pre-eclamptic and what should be used?

BP over 150/100
Oral Labetalol

140

What 3 blood tests should be taken regularly from a woman with pre-eclampsia, and how often?

- FBC (Full blood count)
- U and E (Urea and Electrolytes)
- LFT (Liver Function Test)

2-3 times a week

141

When would corticosteroids be given to a woman diagnosed with pre-eclampsia?

If she was less than 34 weeks at the time of diagnosis

142

What prophylactic treatment should be considered for a woman diagnosed with pre-eclampsia?

TED stockings and enoxaparin

143

If a woman arrives at hospital with pre-eclampsia, what 4 things should be checked as part of her initial care?

- Check reflexes
- Obtain BP profile
- Urinalysis
- Bloods (FBC, Group and Save, UandE, Creatine, Urates, LFT, clotting screen)

144

Following initial checks (reflexes, BP etc) what 6 steps should then be taken if a woman presents at hospital with pre-eclampsia?

- Insert a 16g venflon and begin Hartmann's solution at 85mls/hour
- Monitor urine output
- Offer epidural if high platelet count
- Begin continuous electronic fetal monitoring
- Inform consultant obstetrician
- Inform consultant anaesthetist

145

What 2 maternal risks may increase with anaemia in pregnancy?

- Increased risk of infection
- Increased risk of antepartum/postpartum haemorrhage

146

What do sufferers of thalassaemia require on a regular basis?

Regular blood transfusions but not replacement iron

147

Once the consultant obstetrician and anaesthetists have been informed, what are the next 2 steps to be undertaken if a woman presents at hospital with pre-eclampsia?

- Assess fetal wellbeing: growth, amniotic fluid volume
- Decide whether to deliver or manage conservatively

148

What delivery plans would be put in place for the following:
- Severe pre-eclampsia
- Mild/Moderate pre-eclampsia at term
- Mild/Moderate pre eclampsia preterm

- Severe -- Deliver regardless of gestational age
- Mild/Moderate at term -- Deliver
- Mild/Moderate preterm -- May be managed conservatively

149

If delivery is imminent in a woman with pre-eclampsia, what medication and dose should be given immediately and then how regularly after that?

Ranitidine 150mg
Then the same dose every 6 hours until delivery

150

If a woman presents at hospital with pre-eclampsia at less than 34 weeks gestation, what prophylactic medication should be given and why?

Betamethasone to develop lung maturity of the fetus before birth

151

What 2 oxytocic drugs should be avoided in the third stage for a woman with pre-eclampsia and why?

Syntometrine and ergometrine as they may increase blood pressure

152

What type of fetal monitoring should be undertaken during the labour of a woman with pre-eclampsia?

Continuous fetal monitoring

153

How often should a pre-eclamptic woman's blood pressure be checked during labour?

Hourly

154

How often should a pre-eclamptic woman's blood pressure be checked following delivery?

Hourly for first 4 hours
4 hourly for next 12 hours
8 hourly for next 48 hours

155

For how long following delivery, should a pre-eclamptic woman's blood pressure be checked?

Until anti-hypertensive medication is stopped so usually beyond the 10 days postnatal

156

With what blood pressure will anti hypertensive medication usually be stopped?

130/80mmHg

157

What type of review should the pre-eclamptic woman be referred to at 6-8 weeks postnatal?

A medical review

158

What are the 2 definite and 9 other possible symptoms of severe pre-eclampsia?

- Definite- BP 160/110 on two or more occasions
- Definite- Significant proteinuria
- Severe headache
- Visual disturbances
- Epigastric pain possibly with vomiting
- Liver tenderness
- Clonus (involuntary rhythmic muscular contractions)
- Papilloedema (optic disc swelling)
- Low platelet count
- Abnormal liver function
- HELLP syndrome

159

What can severe pre-eclampsia lead to?

Eclampsia

160

What is eclampsia?

The occurrence of one or more generalised convulsions on the background of pre-eclampsia

161

List 7 things to do if a woman begins to convulse

- Maintain the airway
- Turn the patient on to left lateral
- Administer facial oxygen (at least 10L/min)
- Insert and IV line
- Arrest convulsions with a loading dose of magnesium sulfate
- Prevent further fits with a maintenance dose of magnesium sulfate solution
- Treat hypertension

162

What is the loading dose of magnesium sulfate?

4mg

163

What is the maintenance dose of magnesium sulfate?

1g / hour

164

In the case of eclampsia, what 4 things should be reviewed hourly and what should their values be?

- Respiratory rate should be greater than 12 breaths a minute
- Urine output greater than 20mls an hour
- Knee or forearm jerk is present on reflex test
- O2 saturations should be greater than or equal to 95%

165

How long should the maintenance dose of magnesium sulfate be continued for?

For 24 hours after the last seizure

166

What are the 6 possible side effects of magnesium sulfate?

- Double vision
- Slurred speech
- Respiratory depression
- Loss of tendon reflexes
- Cardiac arrhythmia
- Cardiac arrest

167

In what circumstances should magnesium sulfate be stopped sooner than 24 hours after a seizure?

If reflexes or respirations are depressed or if urine output is less than 10mls/hour

168

When does type 1 diabetes usually present?

In childhood or early adulthood

169

What causes type 1 diabetes?

The autoimmune destruction of the insulin-producing beta cells of the pancreatic islets leading to a severe lack of insulin

170

Is type 1 diabetes inherited or pathological?

Inherited

171

What happens to the body without insulin?

It breaks down fat and muscle for energy sources which can lead to diabetic ketoacidosis

172

What is diabetic ketoacidosis?

The bloodstream becomes acidic and the body becomes seriously dehydrated

173

In type 1 diabetes, what happens to ingested glucose?

It stays in the bloodstream and does not get used as energy

174

What are the 7 symptoms of hyperglycaemia (type 1 diabetes)?

- Thirst
- Polydipsia (excessive thirst)
- Polyuria (excessive urination)
- Polyphagia (increased appetite)
- Weight loss
- Fatigue
- Blurred vision

175

What is the target blood glucose level for type 1 diabetics in pregnancy, before and after meals?

3.5 - 5.9 mmol/L before meals
Under 7.8 mmol/L one hour after eating

176

What is the usual treatment for type 1 diabetics?

Subcutaneous insulin injections

177

What 5 points of pre-conception advice should be given to diabetic women?

- Establish good glycemic control before conception
- Advice should be given on diet and exercise for women with a BMI over 27
- Folic acid should be advised until 12 weeks gestation
- Individualised blood glucose targets to be agreed
- Women should be offered retinal assessment at their first appointment and annually thereafter if no retinopathy is found

178

When should diabetics check blood glucose levels during pregnancy?

Before meals
1 hour after meals
Before going to bed

179

How often should fetal growth and liquor volumes be assessed during pregnancy of a woman with diabetes and from what gestation?

Every 4 weeks from 28-36 weeks gestation

180

How often should pregnant diabetics see the diabetic care team?

Every 1-2 weeks

181

What should be offered to pregnant diabetic women from 38 weeks?

Induction or section

182

How often should blood glucose be monitored during the labour of a diabetic?

Hourly

183

What type of infusion should be considered for diabetics at the onset of established labour?

Dextrose and insulin infusion

184

Where should women with diabetes be advised to give birth and why?

In hospitals where advanced neonatal resuscitation skills are available 24 hours a day

185

List 5 points to consider in the postnatal management of women with diabetes

- Blood glucose testing should be carried out on the baby at 2-4 hours after birth
- The baby should not be transferred to community care until at least 24 hours and feeding well
- Insulin should be reduced immediately after birth and blood glucose monitored to establish dose
- Women are at increased risk of hypoglycaemia especially if breastfeeding so advise a meal or snack before or during feeds
- Women should be referred back to routine diabetic care arrangements

186

When does type 2 diabetes usually present?

In late middle age or later life

187

What are the 2 metabolic defects that characterise type 2 diabetes?

- Insulin resistance
- Impaired insulin secretion

188

List 6 potential pregnancy complications for a type 2 diabetic

- Miscarriage
- Congenital malformations
- IUGR
- Macrosomia
- Polyhydramnios
- Intrauterine fetal death

189

What are the 3 stages of treatment for a type 2 diabetic?

- Lifestyle modification (diet and exercise)
- Oral medication such as Metformin
- Insulin injections

190

What is gestational diabetes?

Diabetes that develops in pregnancy due to transient, pregnancy induced glucose intolerance

191

Why does glucose tolerance change during pregnancy?

Fasting blood glucose levels fall and post meal glucose levels rise.
From week 20, increasing levels of placental hormones are responsible for increasing maternal insulin resistance

192

List 5 risk factors for gestational diabetes

- BMI over 30
- Previous macrosomic baby
- Previous gestational diabetes
- Family history of diabetes
- Family origin with a high history of diabetes: South Asian, Black Caribbean and Middle Eastern

193

List 6 potential complications of diabetes for the fetus

- Polyhydramnios
- Macrosomia
- Hepatomegaly
- Polycythaemia (high red blood cell count)
- Intrauterine death
- Neonatal hypoglycaemia

194

From what gestation will the onset of gestational diabetes occur?

After 12 weeks

195

What and where is the thyroid gland?

An endocrine gland located in the front of the neck, just below the Adam's apple

196

What 2 hormones does the thyroid gland excrete in to the blood?

- Thyroxine (T4)
- Triiodothyronine (T3)

197

What do the two thyroid hormones influence?

The metabolism of the body's cells

198

What happens if the thyroid gland excretes too much of the hormones?

The body's cells work too fast and hyperthyroidism develops

199

What happens if the thyroid gland secretes too little of the thyroid hormones?

The body's cells slow down and hypothyroidism develops

200

How is the thyroid gland controlled?

It uses negative feedback

201

Which gland detects the levels of thyroid hormone in the blood?

The pituitary gland

202

What does the pituitary gland secrete if thyroid hormone levels drop below normal?

Thyroid Stimulating Hormone (TSH)

203

What does the pituitary gland do if thyroid hormone levels rise above normal?

Stops secreting Thyroid Stimulating Hormone

204

What happens to levels of Thyroid Stimulating Hormone in early pregnancy?

They reduce

205

What effect does Human Chorionic Gonadotrophin have on the thyroid?

A weak thyroid stimulating effect causing thyroxine to increase and TSH to drop

206

What effects does pregnancy have on basal metabolic rate, from 4 months?

Increases it by 25%

207

What other organ-specific autoimmune disease can hypothyroidism sometimes occur with?

Type 1 diabetes

208

List 10 symptoms of hypothyroidism

- Weight gain
- Cold intolerance
- Dry skin
- Lethargy
- Cognitive impairment
- Menorrhagia
- Constipation
- Alopecia
- Bradycardia
- Hoarsness

209

How do you confirm hyper and hypothyroidism?

With a thyroid function blood test

210

List 2 maternal and 2 fetal pregnancy associated complications of hypothyroidism

Maternal
- Reduced fertility
- PIH

Fetal
- Low birth weight
- Psychomotor retardation

211

What is the treatment for hypothyroidism?

Oral thyroxine - dose sufficient to restore TSH to normal range

212

How often should thyroid hormone levels be checked during pregnancy?

4-6 weekly

213

Are there any specific issue to be aware of in labour for a woman with hypothyroidism?

No

214

List 4 points to consider in the postnatal management of hypothyroidism

- Reduce thyroxine to pre-pregnancy dose
- Check thyroid hormone levels 6 weeks postnatally
- Arrange paediatric review of the baby
- Neonatal screening test to be performed promptly with maternal condition documented on the request form

215

List 8 symptoms of hyperthyroidism

- Heat intolerance
- Insomnia
- Tremor
- Sweating
- Diarrhoea
- Weight loss despite good appetite
- Agitation
- Tachycardia

216

What can make diagnosis of hyperthyroidism difficult in pregnancy?

Several of the symptoms occur in normal pregnancy

217

What is Graves' disease?

An autoimmune condition in which thyrotoxicosis is caused by auto-antibodies attaching to the thyroid stimulating hormone receptor

218

List 4 indications for an LUSCS

- Morbidly adherent placenta
- Mother-to-child transmission of HIV
- Maternal request
- Urgent fetal or maternal complication eg uterine rupture

219

List 8 potential complications of an LUSCS

- Haemorrhage
- Infection
- Thromboembolism
- Damage to bladder and uterus
- Abdominal adhesions
- Anaesthetic complications
- Maternal dissatisfaction
- Neonatal complication

220

How long does an epidural take to take effect?

15-20 minutes

221

How long can an epidural last?

Can sometimes last days

222

How dense is the block from an epidural?

The density can vary from person to person

223

How quickly does a spinal block take effect?

Very rapidly

224

How dense is the block from a spinal?

Very dense

225

List 8 problems which may arise with a Caesarean section?

- Unexpectedly high block
- Loss of consciousness
- Respiratory depression
- Anaphylaxis
- Aspiration of gastric contents
- Difficult/failed intubation
- Hypoxia
- Post-op respiratory problems

226

List 6 pros of a spinal LUSCS

- Instantaneous result
- Only small amounts cross the placenta
- Lasts 2-3 hours
- Good if patient has spinal stenosis
- Results in less mother and baby morbidity
- Partner can be present at birth

227

List 2 pros of an LUSCS done under GA

- Quick, pain free and effective
- Appropriate in emergencies

228

List 3 cons of a spinal during LUSCS

- Cannot be given to women with low BP or bleeding conditions
- Not very long lasting
- Uncomfortable for women during the spinal procedure

229

List 6 cons for using GA during an LUSCS

- Mum misses the birth and skin to skin
- Nausea and vomiting
- Shivering
- Memory loss
- Hypoxia
- Respiratory depression on baby

230

What is sepsis?

When the body's immune system goes in to overdrive following an infection setting off a series of reactions including widespread inflammation, swelling and blood clotting

231

List 8 signs and symptoms of sepsis

- Pyrexia
- Chills and shivering
- Tachycardia
- Tachypnoea
- Dizzyness, nausea and vomiting
- Diarrhoea
- Confusion or disorientation
- Cold, clammy and pale or mottled skin

232

What is group A strep?

A bacterium commonly found in the throat and on the skin

233

List 6 illnesses that are caused by group A strep

- Necrotising fascilitis
- Streptococcal toxic shock syndrome
- Acute pharyngitis
- Impetigo
- Scarlet fever
- Rheumatic fever

234

How is group A strep spread?

By direct person to person contact.
Can also enter the body through a cut or laceration such as perineal or abdominal wounds

235

List 3 signs and symptoms of a strep A throat infection

- Fever
- Sore throat
- Swollen glands

236

What can a strep A skin infection cause?

Red weeping sores

237

What can strep A pelvic infections cause?

- Diarrhoea
- Abdominal pain

238

How quickly will symptoms of a group A strep infection appear?

Within 1-3 days

239

What is the definition of IUGR and what are the 2 classifications?

When a fetus does not meet its growth potential
Classifications:
- Symmetrical
- Asymmetrical

240

What is symmetrical growth restriction?

When growth, particularly of the head, is impaired early in pregnancy.
It is less common than asymmetrical growth restriction but more concerning. This fetus is more likely to have neurological complications

241

What is asymmetrical growth restriction?

Fetus tends to have appropriate head growth until late in pregnancy. Most often associated with PIH.
Restriction of weight followed by length.
The head continues to grow at a normal rate.

242

List 9 potential causes of IUGR

- Maternal illness
- Substance abuse
- Lower socio-economic class
- Viral infection
- Congenital abnormality
- High blood pressure
- Kidney disease
- Poor nutrition
- Smoking

243

How is gestational age measured antenatally?

Using a measurement taken during a 12 week ultrasound

244

How is gestational age assessed postnatally?

Using the Dubowitz scale and centile charts

245

What is the definition of a low birth weight baby?

One that is born under 2.5kg

246

What is the definition of a very low birth weight baby?

One born under 1.5kg

247

What is the definition of an extremely low birth weight baby?

One born at less than 1kg

248

What is the definition of a preterm baby?

One born at less than 37 completed weeks of gestation

249

List 8 possible causes of preterm birth

- Pre-eclampsia
- Essential hypertension
- APH
- Placenta praevia
- Maternal substance abuse
- Multiple pregnancy
- Polyhydramnios
- Congenital abnormalities

250

List 4 things that low birth weight babies may have difficulty with

- Breathing
- Temperature regulation
- Infection
- Nutrition

251

List 6 potential complications of prematurity

- Necrotising enterocolitis
- Vitamin K deficiency bleeding
- Anaemia
- Cerebral haemorrhage
- Birth asphyxia
- Infection

252

List 6 physiological cardiac changes that occur in pregnancy

- Increase in circulatory blood volume
- Increase in cardiac output
- Increase in stroke volume
- Increase in resting oxygen consumption
- Big decrease in peripheral vascular resistance
- Increase in resting heart rate

253

List 4 points to consider in the antenatal management of women with cardiac disease

- Referral to joint care of consultant obstetrician, anaesthetist, cardiologist and possibly paediatrician
- Plan for management of delivery (possible early delivery if more severe cardiac problems)
- Some medications may affect fetal development so regular growth scans required
- Support with thromboprophylaxis administration

254

List 8 points to consider in the management of a woman with cardiac disease in labour

- Minimise cardiovascular stress
- Possible induction. Oxytocin in low doses
- Monitor and document observations which may include ECGs
- Continuous fetal monitoring
- Maintain pain relief after conferring with anaesthetist
- Refer slow progress promptly
- TED stockings
- Avoid ergometrine and syntometrine in third stage

255

List 6 points to consider in the postnatal care of a woman with cardiac disease

- Continue to monitor and document observations
- Plan care and support the mother in caring for her health and the baby's
- Advice in avoiding stress and anxiety
- Avoiding exertion
- Provide contraception advice
- Major changes in cardiac output and plasma volumes continue up to 2 weeks postnatally. Ongoing surveillance required

256

What is epilepsy?

A common neurological condition causing recurrent seizures

257

What is a seizure in epilepsy caused by?

A sudden burst of excess electrical activity in the brain causing a temporary disruption in the normal message passing between brain cells

258

What are the 2 categories of seizures in epilepsy?

- Partial
- Generalised

259

List 7 signs of a simple partial seizure

- Remains conscious
- Experiences an aura
- Deja vu
- Pins and needles
- Muscles in arms and legs become stiff
- Flushed face or goes pale
- Sweating

260

List 6 signs of a complex partial seizure

- Change in awareness, loses memory of the event
- Rubbing of hands
- Smacking of lips
- Picking at clothes
- Fiddling with objects
- Making random noises

261

List the 5 types of generalised seizures in epilepsy

- Absence
- Myoclonic
- Tonic
- Tonic clonic
- Atonic

262

Describe an absence seizure

Staring and blinking, daydreaming. Mainly affects children

263

Describe a Myoclonic seizure

Brief muscle jerking or one or both arms or legs. Lasts a fraction of a second. Remains conscious

264

Describe a tonic seizure

All muscles of the body contract causing falling but no convulsions. Lasts less than 20 seconds

265

Describe a tonic clonic seizure

Most common. There are two stages.
First stage the whole body contracts
Second stage the arms and legs twitch
Usually lasts 1-2 minutes

266

Describe an Atonic seizure

All muscle tone lost briefly
Fall limply to the ground so head injury is likely

267

List 8 potential seizure triggers in epilepsy

- Stress/Anxiety
- Lack of sleep
- Lack of food
- Excess alcohol or illegal drugs
- Missing a dose of anti-epileptic medication
- Flickering lights
- Illnesses causing a high temperature
- Hormonal changes with menstrual cycle

268

List 5 points to consider in the antenatal management of a woman with epilepsy

- Care should be shared between obstetrician, midwife and neurologist
- Detailed booking history with emphasis on current drug therapy
- Advocate importance and compliance with drug therapy and refer to medical staff if increase or change in seizures
- Advise against unattended bathing
- Ascertain expectations of birth - discuss realistic plans

269

List 8 points to consider in the management of an epileptic woman in labour

- Delivery should be in a consultant led unit with maternal and neonatal resuscitation nearby
- Do not leave alone
- Use of birthing pool contraindicated
- Ensure continuation of drug therapy
- If seizure free, treat as any other labouring woman
- Limit stress and anxiety and ensure hydration
- Avoid exhaustion
- Adhere to unit policy for management of epilepsy

270

List 4 points to consider in the postnatal management of a woman with epilepsy

- Vitamin K 1mg IM to babies at birth, whose mothers are taking enzyme inducing AEDs
- Breastfeeding should be encouraged
- Observe neonate closely and report promptly to paediatrician if any concerns
- Advise parents about simple safety precautions

271

List 7 points of safety advice that can be given to a parent with epilepsy

- Share care of the baby at night to avoid exhaustion
- When feeding the baby, sit safely with a back rest
- Consider feeding on the floor
- Dress and change the baby on the floor
- Carry baby up and down stairs in a car seat
- Bath the baby when support is available
- Use a buggy/pram with brakes that initiate when the handle is released

272

List the 3 temporary structures in the fetal circulation

- Ductus venosus
- Foramen ovale
- Ductus arteriosus

273

At what gestation does the blood begin to circulate in the fetal body

3 weeks

274

What is a teratogen?

Any agent that can disturb the development of a fetus

275

List 3 possible sources of teratogen

- Maternal infection
- Maternal illness
- Maternal substance ingestion

276

List 4 types of fetal heart disease

- Acyanotic
- Cyanotic
- Cardiac arrhythmias
- Acquired heart disease such as rheumatic heart disease

277

List 4 signs of congenital heart disease in neonates

- Rapid breathing
- Fatigue
- Cyanosis (blue tinge to skin, lips and fingernails)
- Poor blood circulation

278

List 5 ways in which neonatal heart failure will present

- Tachypnoea
- Tachycardia
- Shock
- Hepatomegaly
- Possible murmur

279

What is the best indicator of cyanosis in a newborn?

The oral mucosa/tongue

280

Is cyanosis associated with respiratory or cardiac problems?

Both

281

List 3 possible causes of cyanosis

- Desaturation of systemic arterial blood
- Infection
- Blood bypasses the lungs due to an obstruction

282

List 5 steps to undertake if you suspect a baby has congenital heart disease

- History taking
- Inspection
- Examination
- Auscultation
- Palpation

283

List 7 points to consider in the history taking of a newborn with suspected heart disease

- How old?
- Term/pre-term?
- Type of delivery?
- PROM?
- Maternal history? Illness etc
- Maternal drugs in history?
- Family history?

284

List 9 things to consider when inspecting and examining the newborn for suspected heart disease

- Dysmorphic features?
- Feeding difficulties?
- Poor colour/ mottling?
- Dyspnoea - chest recession or grunting?
- Restlessness?
- Lethargy?
- Sweating or clammy?
- Cyanosis?
- Tachypnoea?

285

List 6 points to consider when auscultating and palpating a neonate for suspected cardiac disease

- Abnormal cardiac rate and rhythm
- Murmer
- Poorly palpable or absent peripheral pulses
- Poor femoral pulses
- Hepatomegaly
- Poor capillary return time

286

What is a heart murmer?

When blood flows turbulently through the heart, creating a sound. Normal blood flow is silent

287

What happens to fetal blood glucose levels at birth and why?

There is a fall in glucose concentration as the baby no longer has a constant supply of glucose from the placenta

288

What 4 reactions increase due to endocrine changes at birth? (In relation to fetal hypoglycaemia)

- Glycogenolysis
- Gluconeogenesis
- Ketogenesis
- Lipolysis

289

In relation to fetal hypoglycaemia, what 3 factors may cause problems following the birth?

- A lack of glycogen stores
- Excessive insulin production
- When infants are sick and have a poor supply of energy

290

How is neonatal hypoglycaemia usually diagnosed?

Blood glucose concentration or clinical signs.
Sometimes a combination of both

291

List 8 symptoms of fetal hypoglycaemia

- Lethargy
- Poor feeding
- Seizures
- Decreased consciousness level
- Cyanosis
- Apnoea
- Poor tone
- Jitteriness

292

How are healthy neonates able to cope with low blood glucose concentrations?

By using alternative fuels such as ketones, lactate or fatty acids

293

Why are breastfed infants more likely to have low blood glucose concentrations?

Due to the low energy content of breastmilk in the first few postnatal days

294

What alternative fuel do breastfed babies usually have higher concentrations of?

Ketones

295

What 5 types of infants are at risk of hypoglycaemia and why?

- Pre term infants (low glycogen stores - can't mobilise glucose quickly)
- Growth restricted (low glycogen stores - can't mobilise glucose quickly)
- Infants of diabetic mothers (excess of insulin)
- Sick term infants (low substrate stores and poor feeding)
- Infants with inborn errors of metabolism

296

List 4 steps to preventing hypoglycaemia in at risk babies

- Adequate temperature control
- Early feeding (within the first hour)
- Frequent feeding (every 3 hours or less)
- Blood glucose check immediately before the second feed and then 4-6 hourly

297

What 2 types of infant does hyperglycaemia usually occur in?

- Very pre-term babies (before 32 weeks gestation)
- Very low birth weight babies (less than 1.5kg)

298

List 4 adverse outcomes associated with fetal hyperglycaemia

- Increased risk of death
- Increased risk of infection
- Increased risk of eye problems
- Increased risk of bleeding in to the brain

299

What percentage of body weight should the normal infant lose following birth?

10%

300

What is an inborn error of metabolism?

When enzyme deficiencies in metabolic pathways lead to an accumulation of substrate, causing toxicity

301

Are babies affected in utero by inborn errors of metabolism and why?

No because the placenta acts as dialysis

302

List 7 tests that can be done to help diagnose inborn errors of metabolism in the neonate

- Full blood count
- Creatinine, urea and electrolytes
- Liver enzymes
- Blood gas
- Blood glucose
- Urine ketones
- Coagulation tests

303

What 5 disorders does the blood spot screening test for?

- Phenylketonuria
- Congenital hypothyroidism
- Cystic fibrosis
- MCADD
- Sickle cell disease

304

What is jaundice?

A yellow discolouration of the skin and sclera (the white of the eyeball) caused by raised levels of bilirubin in the blood

305

When does physiological jaundice usually appear?

About 48 hours after birth

306

What 3 things can cause pathological jaundice?

- Increased haemolysis
- Metabolic and endocrine disorders
- Infection

307

What happens to ageing, immature or malformed red blood cells?

They are removed from circulation and broken down in the liver, spleen and macrophages.
They are the usually conjugated and then excreted

308

What are the 3 components that haemoglobin is broken down in to?

- Haem (converted to unconjugated bilirubin)
- Globin (broken down to amino acids)
- Iron (stored in the body or used for new red blood cells)

309

Why is unconjugated bilirubin not easily excreted?

It's not water soluble

310

How is unconjugated bilirubin transported to the liver?

By being bound to albumin

311

What happens to free bilirubin, not attached to albumin?

It gets deposited in the fatty or nerve tissues (skin or brain)

312

What can brain deposits of bilirubin cause?

Kernicterus (bilirubin toxicity)

313

What are the 4 early signs of kernicterus?

- Lethargy
- Changes in muscle tone
- High pitched cry
- Irritability

314

What happens to unconjugated bilirubin in the liver?

It is unbound from albumin and combined with glucose and glucuronic acid.
Conjugation occurs in the presence of oxygen and an enzyme

315

How is conjugated bilirubin excreted?

Via the biliary system in to the small intestine.
Normal bacteria then change it in urobilinogen
This is then oxidised in to urobilin and excreted mainly in the faeces

316

What causes physiological jaundice in neonates?

A temporary discrepancy between red cell breakdown and their ability to transport, conjugate and excrete the resulting bilirubin

317

What causes an increase in unconjugated bilirubin at birth?

The breaking down of the large red cell mass

318

List 5 ways in which breastfeeding helps reduce hyperbilirubinaemia

- Supplies glucose to the liver
- Increases bowel motility
- In turn this helps increase albumin binding capacity
- Increases enzyme production for conjugation
- Decreases enterohepatic reabsorption

319

When does pathological jaundice usually appear?

Within 24 hours of birth

320

When does rhesus disease begin to affect the baby?

In utero

321

What 4 things do babies with rhesus disease usually present with at birth?

- Anaemic
- Hydropic
- Jaundiced
- Hepatosplenomegaly

322

List 3 points to consider in the antenatal care of a woman who is rhesus negative

- Women are screened throughout pregnancy to monitor any increase in antibodies
- Any sensitising events such as PV bleeding or abdominal trauma require prophylactic anti-d within 72 hours
- NHS Forth Valley give a routine prophylactic dose between 28-30 weeks gestation

323

What are the 3 treatment options for jaundice in neonates?

- Phototherapy
- Blood exchange
- Drug treatments

324

How does phototherapy treat jaundice?

It detoxifies the bilirubin in to a water soluble form which can be excreted by the kidney

325

List 6 points to consider when treating neonatal jaundice with phototherapy

- Ensure infant is adequately hydrated
- Baby can come out of phototherapy for feeding to reinforce parental bonding
- Eye shield to prevent retinal damage
- Baby should be naked and nursed in a heated cot
- SBR to be repeated every 6-24 hours depending on initial level
- Ensure effective communication with parents to help the, understand the need for phototherapy

326

What is hyperemesis gravidarum?

An extreme form of nausea and vomiting in pregnancy.
Usually defined as the occurrence of 3 or more episodes of vomiting per day with significant maternal weight loss and ketonuria

327

List 5 signs and symptoms of hyperemesis gravidarum

- Weight loss
- Tachycardia
- Low BP
- Nausea and vomiting
- Abdominal pain

328

What are the 5 risk factors for hyperemesis gravidarum?

- Maternal age
- Obesity
- Primiparous
- Female fetus
- Multiple pregnancy

329

What is the treatment for hyperemesis gravidarum?

IV rehydration and anti-emetic injection

330

What is Intrahepatic Cholestasis of Pregnancy?

The disruption and reduction of bile products from the liver and its flow to the intestine

331

When does cholestasis usually occur from?

From 28 weeks gestation but has been seen as early as 20 weeks

332

List 3 risk factors for cholestasis

- Family history of cholestasis
- Advanced maternal age
- Multiple pregnancy

333

List 5 signs and symptoms of cholestasis

- Pruritis (itching) mainly on hands and feet
- UTIs
- Pale stools
- Nausea
- Rarely severe jaundice

334

List the 5 fetal complications associated with cholestasis

- Prematurity
- Meconium stained liquor
- Asphyxia
- Respiratory distress syndrome
- Intrauterine death

335

List 5 points to consider in the antenatal management of a woman with cholestasis

- Treatment of symptoms such as creams to reduce itching
- Oral vitamin k to reduce risk of PPH
- Ensure woman monitors fetal movements closely
- Twice weekly CTG
- Possible pre-term delivery

336

List 3 points to consider in the management of a woman with cholestasis in labour

- Continuous CTG
- Timing of induction should be individualised
- Active management of third stage highly recommended due to risk of PPH

337

List 3 points to consider in the postnatal management of a woman with cholestasis

- Ensure pruritis returns to normal
- Check LFTs have returned to normal on day 3 and then 6 week check up
- Advise mother on risk of recurrence on subsequent pregnancies

338

What are the components in a blood test that confirms HELLP syndrome?

- Haemolysis
- Elevated liver enzymes
- Low platelets

339

What other pregnancy condition has similar signs and symptoms to HELLP syndrome and what effect does this have?

Pre-eclampsia - can often lead to misdiagnosis

340

What are the 3 risk factors for HELLP syndrome?

- Advanced maternal age
- Multiparity
- Caucasian origin

341

List 5 potential complications of HELLP syndrome

- DIC
- Placental abruption
- Acute renal failure
- Pulmonary oedema
- Liver haematoma and rupture

342

List 7 points to consider in the management of HELLP syndrome

- Referral to senior obstetricians care
- Assess and monitor fetal wellbeing and growth
- HDU care by experience midwifery staff in labour
- Accurate fluid balance in labour
- Continuous support to woman and her partner
- HDU care usually 24-48 hours postnatally
- Regular BP and symptoms check until bloods normalise

343

When does acute fatty liver of pregnancy usually present?

From 30 weeks gestation

344

List 3 risk factors for acute fatty liver syndrome

- Primiparity
- Multiple pregnancy
- Raised maternal BMI

345

List 10 signs and symptoms of acute fatty liver syndrome

- Nausea and vomiting
- Right upper quadrant abdominal pain
- Fever
- Pruritis
- Tiredness
- Headache
- Jaundice
- Flu like symptoms
- Hypoglycaemia
- Liver failure

346

List 7 potential complications of acute fatty liver syndrome

- Renal and hepatic failure
- Adult respiratory distress syndrome
- Pancreatitis
- Hypoglycaemia
- Infection and sepsis
- Haemorrhage
- Stillbirth

347

List 3 points to consider in the antenatal management of a woman with acute fatty liver syndrome

- Alternative diagnosis such as HELLP to be excluded through biochemical analysis
- Admit to consultant let unit with NNU ASAP following diagnosis
- Observe for signs of DIC and hypoglycaemia

348

List 6 points to consider in the management of a woman with acute fatty liver syndrome in labour

- Once diagnosis is made, delivery should be expedited
- Birth should be induced or operative depending on fetal and maternal wellbeing
- If induced, close observations of maternal and fetal condition
- Be alert for meconium stained liquor and fetal distress
- Careful fluid balance to prevent pulmonary and cerebral oedema
- Avoid episiotomy

349

List 6 points to consider in the postnatal management of a woman with acute fatty liver syndrome

- PN care should be carried out in a critical care unit
- Condition should improve after 48 hours
- Postnatal wound infection is common so observation is important
- Closely observe lochia as PPH is common
- Provide support and communication between parents, HDU and NNU
- Inform parents of the genetic risk of recurrence