DRANZCOG/Obstetrics Flashcards

Question

Antenatal methods to protect against perineal morbidity

Answer 1

- Perineal massage 1-2x/week from 35/40 - Pelvic floor muscle training for women (Continence Foundation of Australia) Insufficient evidence to recommend raspberry leaf tea

Answer 2

No specific position or pushing technique recommended Warm compresses and perineal massage: lowers risk of 3rd and 4th degree tears During crowning: - minimise active pushing following crowning to ensure slower descent of head. - If rapid, consider counter pressure on foetal head if appropriate - maximise flexion to help reduce presenting diameter

Answer 3

Imminent perineal tear OR High risk of severe laceration: 1. Soft tissue dystocia 2. Foetal compromise indicating expedited delivery 3. Instrumental delivery (not always required for vacuum) 4. History of female genital mutilation 5. Past history of pelvic floor repair or third-degree tear

Answer 4

Vaginal mucosa Perineal skin Bulbocavernosus muscle Transverse perineal muscle

Answer 5

``` Appropriate analgesia (e.g. 1% lignocaine) Incision 3-5cm length from the fourchette ad 60-80 degree angle from midline (will become 45 degrees following delivery, loss of distension) ```

Answer 6

Repair if indicated Rectal NSAID unless PPH if torn If tear within close proximity of urethra, consider indwelling catheter

Answer 7

Cold packs (10-20 minute intervals) first 1-3 days PRN PO paracetamol and NSAID Urinary alkalinisers Avoid opioids Fibre rich, balance diet, adequate hydration ``` Support perineal wound when coughing or defecating Correct toileting position Avoid constipation Wash and pat dry post toileting Shower at least daily Check wound daily with hand mirror ``` Pelvic floor muscle training for women Avoid sitting/propped positions (dependent perineal oedema) Avoid increased intra-abdominal pressure for 6-12 weeks (e.g. straining, lifting etc.)

Answer 8

Sitz baths Perineal ultrasound for perineal pain or dyspareunia Topical anaesthetics Ray lamps Donut cushions (may lead to more dependent oedema) Herbal remedies e.g. arnica

Answer 9

Paired glands located in labia minor at 4 and 8 o'clock positions Approx 5mm in diameter Secrete mucus into 2.5cm ducts which emerge either side of vagina, inferior to the hymen

Answer 10

Nonspecific inflammation or trauma -> obstruction of opening of duct -> distension of gland or duct

Answer 11

Either secondary to infected cyst, or a primary gland infection Usually polymicrobial Rarely caused by STIs

Answer 12

2% of women of reproductive age will experience swelling of at least one Bartholin gland Typically in women 20-30y Rare in women >40y (malignancy should be considered)

Answer 13

Painless (unless very large) labial swelling, usually unilateral No signs of surrounding cellulitis Discharge if has spontaneously ruptured will be non-purulent

Answer 14

Acute painful unilateral labial swelling Dyspareunia Pain with walking and sitting Sudden relief of pain followed by discharge (suggests spontaneous rupture) Can occur spontaneously or on history of a painless cyst Very tender with surrounding erythema and oedema may have surrounding cellulitis Purulent discharge if spontaneously ruptured

Answer 15

Asymptomatic uncomplicated cyst: - Sitz baths 3x per day for several days (may induce resolution +/- rupture) Abscess: Incision and drainage +/- marsupialisation Antibiotics only required if significant surrounding cellulitis

Answer 16

Traditionally primary postpartum haemorrhage = blood loss >500mL in first 24h Minor: 500-1000mL major: >1000mL (moderate 1000-2000mL, severe >2000mL) note that some centres consider PPH as >600mL following NVD or >750mL following LSCS

Answer 17

2/3 of women who have PPH have no risk factors identified Background risk: - PPH in previous pregnancy - grand multiparity (4+) - Nulliparity - Advanced maternal age (>35y) - known coagulopathies or liver disease - obesity - previous LSCS Antenatal complications: - multiple pregnancy - antepartum haemorrhage (esp placental abruption or previa) - known placenta accreta - anaemia - pre-eclampsia - macrosomia ``` Intrapartum: - need for/use of oxytocics - prolonged labour (especially 2nd stage) Pyrexia in labour operative delivery Episiotomy Placental retention Shoulder dystocia ```

Answer 18

Tone (70%) Trauma (20%) Tissue (10%) Thrombin (<1%)

Answer 19

Uterine atony (e.g. physiological or prolonged 3rd stage) Over-distended uterus (polyhydramnios, multiple gestation, macrosomia) Uterine muscle exhaustion (rapid labour, prolonged labour, high parity, augmentation with oxytocin) Intra-amniotic infection (PROM >24h) Drug-induced (magnesium, nifedipine, salbutamol, GA) Functional or anatomical distortion of the uterus (fibroids, placenta praevia, uterine abnormalities, bladder distention)

Answer 20

Retained products Abnormal or adherent placenta Retained cotyledon or succenturiate lobe

Answer 21

``` Lacerations to cervix, vagina, perineum (precipitous labour, operative delivery) Uterine rupture (high parity, fundal placenta) Extensions/lacerations at LSCS (malposition, deep engagement) ```

Answer 22

Non-obstetric abnormalities (Haemophilia, vWd, hereditary coagulopathies, liver disease) Acquired in pregnancy (ITP, PET, DIC, IUFD, severe infection, abruption, AFE) Therapeutic anti-coagulation (e.g. clexane for VTE)

Answer 23

``` 15% (1000mL) RR: normal HR: <100 BP: Normal Mental state: anxious Urine output: normal ```

Answer 24

``` 15-30% (1300mL) RR: 20-30 HR: >100 BP: Normal/increased diastolic Mental status: anxious/confused ```

Answer 25

``` 30-40% (2000mL) RR: 30-40 HR: >120 BP: reduced systolic and diastolic Mental state: confused/agitated ```

Answer 26

``` >40% (2700mL) RR: >40 HR: >140 BP: decreased systolic and diastolic Mental state: lethargic Negligible urine output ```

Answer 27

- prevention of early onset GBS infection - women at risk of chorioamnionitis, or where infection is suspected (temp >38 on one occasion or >38.5 on two occasions) - women with cardiac lesions susceptible to infective endocarditis

Answer 28

1. Maternal HBV, HCV, HIV, HSV infection - minimise risk of vertical transmission to foetus 2. high and mobile presenting part

Answer 29

Flexion Rotation Descent of head

Answer 30

``` Antiphospholipid syndrome Previous history of PET Pre-existing diabetes Nulliparity Multiple pregnancy Family history of PET Obesity (BMI >30) Systolic BP >130 <20/40 Diastolic BP >80 <20 weeks Age >40y Overweight (BMI 25-29.9) Underlying renal disease Chronic autoimmune disease Inter-pregnancy interval >10y ```

Answer 31

Onset <32 weeks

Answer 32

``` Neurological Pulmonary Haematological Hepatic Renal Uteroplacental ```

Answer 33

Proteinuria >300mg/24h PR PCR >30 Creatinin >90 Oliguria <80mL/4h

Answer 34

Platelets <100 Haemolysis (shistocytes or red cell fragments on film, raised bilirubin, raised LDH >600, reduced haptoglobin) Disseminated intravascular coagulopathy

Answer 35

Increased transaminases | Severe epigastric and/or RUQ pain

Answer 36

``` Convulsions (=eclampsia) Hyperreflexia with sustained clonus Persistent, new headache Persistent visual disturbances (photopsia, scotomata, cortical blindness, posterior reversible encephalopathy syndrome, retinal vasospasm) Stroke ```

Answer 37

Pulmonary oedema

Answer 38

Fetal growth restriction

Answer 39

``` Aspirin 50-150mg daily from diagnosis of pregnancy (aim for <16 weeks - 37 weeks) Calcium supplementation (esp if high risk and low calcium intake diet) 1.5g/day from <20/40 until delivery ```

Answer 40

Urine PCR CBE (Hb, PLT) EUC Urate (not actually in diagnostic criteria) LFTs Coagulation studies (depending on severity of presentation) USS: foetal growth, AFI, umbilical artery doppler assessment

Answer 41

BP >/= 160/110 with proteinuria ``` OR BP 140/90-159/109 with at least ONE of the following - severe headache - visual disturbances - severe pain below ribs OR vomiting - papilloedema - clonus (3+ beats) - liver tenderness - HELLP syndrome - PLT <100 - abnormal liver enzymes ```

Answer 42

``` Methyldopa Labetalol Nifedipine XR Nifedipine IR Hydralazine ```

Answer 43

Nifedipine IR 10-20 mg repeated in 30 minutes if BP still above threshold Labetalol 200mg PO repeated in 30 minutes if not below threshold OR 20mg IV with repeat doses 40-80mg every 10 minutes until BP controlled (max 4 dose) Hydralazine f not controlled by nifedipine - 5mg IV bolus/5 minutes, repeated every 20 minutes until BP controlled (max 30mg)

Answer 44

Methyldopa 250-750mg every 8 hours Labetalol 100-400mg every 8 hours Nifedipine XR 30-60mg BD

Answer 45

Methyldopa: - depression - dry mouth - sedation - blurred vision Labetalol: - bradycardia (maternal and fetal) - bronchospasm - headache - nausea - scalp tingling ``` Nifedipine: - constipation - severe headache in first 24h - peripheral oedema tachycardia - flushing ``` Hydralazine: - flushing - headache - nausea - tachycardia

Answer 46

Labetalol: peak effect within 5 minutes of each dose Nifedpine IR: onset 30-45 minutes Hydralazine: onset of action 20 minutes (Methyldopa only used for sustained BP control, has slow onset over 24 hours)

Answer 47

Methyldopa: depression Labetalol: Asthma/COAD Nifedipine: Aortic stenosis Hydralazine:

Answer 48

1. Stabilise - control BP (labetalol, nifedipine IR or hydralazine) - MgSO4 loading + maintenance dose) 2. Monitor - vital signs - urine output/strict fluid balance - neurological status - clotting factors - fetal conditions (CTG) 3. Plan for labour/birth

Answer 49

Maternal: - >37/40 gestation - falling PLT count - intravascular haemolysis - HELLP syndrome - deteriorating LFTs - deterioration renal function - persistent neurological symptoms - persistent epigastric pain, nausea or vomiting with abnormal liver function - pulmonary oedema Fetal: - placental abruption - severe fetal growth restriction - non-reassuring fetal status

Answer 50

Thromboprophylaxis Monitoring of PLT at least daily (peripartum bleeding complications nor significantly increased until PLT <50) AND monitoring for intravascular haemolysis (CBE, blood film, LDH, haptoglobins)

Answer 51

``` Pre-eclampsia Gestational diabetes Gestational hypertension Antepartum haemorrhage Severe fetal growth restriction Neonatal morbidity ```

Answer 52

Pre-eclampsia | Gestational hypertension

Answer 53

``` Gestational diabetes PPROM Chorioamnionitis VTE Caesarean section Preterm birth ``` High rates of substance abuse, referral to child protective services, anticipation of traumatic delivery and frequent request of early delivery

Answer 54

Start inhalation 30-50 seconds prior to contraction

Answer 55

Start at 30% N2O, max of 70% N2O to prevent hypoxia

Answer 56

If used with oxygen (as always should be in labour): - nausea - vertigo - megaloblastic anaemia N2O alone: - increased maternal heart rate - respiratory depression

Answer 57

Inability to hold mouthpiece Impaired consciousness Impaired oxygenation (e.g. respiratory disease) Women who have received excessive amounts of other sedating medications Vitamin B12 deficiency (can cause megaloblastic anaemia) Recent ear surgery Hypersensitivity to N2O Any condition where air is trapped within a cavity and expansion may be dangerous (e.g. occluded middle ear, cysts, gross abdominal distension, maxillofacial injuries) Use >24h

Answer 58

(full history of woman and partner if possible - optimise any medical conditions) Imms: MMR, VZV, HBV Weight: reduce obesity BMI <30 ideal Nutrition: ?vegan/vego, assess and manage for nutritional deficiencies (B12, iron, VitD) Avoid excess caffeine (3-4 cup/day) CARD: cease all prior to conception. Aim for paternal smoking cessation pre-conception also Travel: avoid to areas particularly affected by Zika. mosquito and sexual protection if cannot avoid. Supplements: - Folic acid from 1/12 prior. 400mcg/day if low risk, 5mg/day if high risk (NTD hx, DM, AEDs, BMI >35, haemolytic anaemia) - Vit D if high risk group - B12 6mcg/day if vego/vegan or bariatric surgery - Calcium 1200mg/day if low dietary intake Iodine 150microg/day - iron if deficient, vego/vegan Genetic counselling: If high risk refer to geneticist, iff low risk, offer carrier screening e.g. Eugene (out of pocket currently)

Answer 59

``` 400 microg/day if low risk 5mg/day if high risk: - DM - personal or FHx of NTD - BMI >35 - AEDs - multiple pregnancy - haemolytic anaemia ```

Answer 60

6mcg/day if vegetarian/vegan/bariatric surgery

Answer 61

MMR VZV HBV

Answer 62

Pre-conception: - delayed conception by 2 months - 60% increased risk of female infertility - male infertility Obstetric: - Miscarriage - Preterm labour (2x) - placenta praevia (2x) - placental abruption (1.5x) - stillbirth (3x) - Ectopic (2.5x) - PPROM (2x) Fetal: - low birth weight (<2500g) (2x) - SGA (3x) - Birth defects (limbs, clubfoot, cleft palate, eye defects, GI defects) Postpartum: - less breastmilk production Child/adult: - SIDS (2.5x) - Behavioural issues (ADHD, CD, antisocial) - Respiratory disease (asthma, recurrent infection, reduced lung function) - Cognition (reduced academic performance) - T2DM - Obesity - HTN - Dyslipidaemia - Pyschiatric disorders early adulthood - Nicotine deopendence

Answer 63

1. Counselling and QuitLine referral 2. NRT (1st line is intermittent short acting forms, if patches required make sure are removed at bedtime 16h patches) Champix and Bupropion not evidenced to be safe or effective in pregnancy

Answer 64

``` IUGR Pre-term labour Placental abruption intrauterine passage of meconium Neonatal abstinence syndrome Foetal and neonatal death ``` Other associations: - inadequate antenatal care - poor nutrition - BBV exposure - overdose - financial hardship - unstable accommodation - pyschological instability

Answer 65

Methadone and buprenorphine both cross the placenta Methadone has been used for longer, more experience with it. >50% of exposed neonates will show signs of NAS Buprenorphine - only the mono therapy (without naloxone) is offered to pregnant women. Evidence suggests associated with fewer neonatal complications than methadone (less frequency, less severe NAS and less medication and admission durations) Concentrations in breastmilk are low, breastfeeding should be encouraged while on OST if no other contraindications

Answer 66

Develops within first 48-72 hours of birth - lasts from 1-several weeks depending on type of opioid use - difficulty feeding - central and autonomic hyperactivity - poor suckling - irritability - hyperactivity - sleep disturbances - high-pitched cry - seizures (in 5%)

Answer 67

``` Close monitoring in special care nursery for prolonged period Observation with standardised NAS scoring Oral morphine (dose and duration based on NAS scoring) ```

Answer 68

``` Miscarriage Stillbirth Low birth weight Premature birth Brain damage Birth defects Foetal alcohol spectrum disorders ```

Answer 69

``` Hyperactivity/inattention/impulsivity Aggression Impaired social interactions Antisocial personality traits Disrupted schooling Substance use disorders Mental health issues Employment/financial/independent living issues Criminal system contact ```

Answer 70

Safest not to use alcohol at all while breastfeeding Definitely no alcohol in first month postpartum and until BF established If chooses to drink after than, limit consumption as much as possible Avoid drinking immediately prior to breastfeeding Option to express prior to alcohol consumption

Answer 71

1. evidence of prenatal alcohol exposure 2. Growth deficiency (pre or post natal <10th centile) 3. Facial features (** = sentinel) - epicanthal folds - flat nasal bridge - short palpebral fissures** - upturned nose - smooth/flat philtrum** - thin upper lip ** 4. Neurological dysfunction - Structural: - -HC <10% - -structural brain abnormality on imaging - Neurological - -any neurological issues NOT due to postnatal event - Functional - -performance below expected for age

Answer 72

Risk of listeriosis: - pre-prepared salad vegies (e.g. salad bars) - raw, undercooked, chilled pre-cooked meats, pate and meat spreads - unpasteurised dairy, soft, semi-soft and surface-ripened cheeses Risk of salmonella - raw eggs/foods containing raw eggs Risk of mercury - shark/flake, marlin, broadbill/swordfish, catfish Risk of hepatitis A - frozen berries - bean sprouts Foods containing saturated fats, added salts and sugars

Answer 73

300g (3-6 cups coffee/tea per day)

Answer 74

750-1000mL above daily pre-pregnancy needs

Answer 75

``` Vitamin C (preterm birth, perinatal death, PPROM) Vitamin E (PPROM) Vitamin A (congenital malformation) ```

Answer 76

- Specifically designed programs can prevent pelvic girdle pain and reduce severity of back pain - Yoga associated with less stress, enhanced relationships, reduced back pain and less reported pain in labour - can prevent urinary incontinence - low-moderate intensity exercise is safe throughout pregnancy

Answer 77

Reduced immune system (increased risk of periodontal infections) Vomiting/reflux in pregnancy increases acidity -> enamel damage -> decay Frequent snacks/soft drinks and other cravings (often sweet) can increase risk of tooth decay

Answer 78

Rinse mouth with bicarb soda after vomiting Avoid tooth brushing directly after vomiting Use fluoridated mouthwash and toothpaste Small protein-rich non-cariogenic foods throughout the day Chew sugar-free gum (esp ones containing xylitol or CPP-ACP) after meals/sugar/acidic drinks

Answer 79

- family history of anaemia or haemoglobinopathy - MCV <80 OR MCH <27 Following ethnic backgrounds: - Southern European - African - Middle Eastern - Chinese - Indian subcontinent - Central and SE asian - Pacific Islander/Maori - South American - Caribbean - Northern WA/NT ATSI communities

Answer 80

FBE (for MCV+MCH) Ferritin (exclude Fe def) Hb electrophoresis DNA testing if indicated (microcytosis with normal iron and Hb electrophoresis and risk of disease)

Answer 81

High HbA2 (>3.5%) Normal HbA2 with low MCV and normal ferritin may be alpha thalassaemia

Answer 82

Requires DNA analysis for definitive diagnosis. Suggested with low MCV and normal Hb eletrophoresis + ferritin level

Answer 83

Progesterone - suppresses uterine contractility - systemic or functional withdrawal (due to reduced responsiveness due to inc. PR-A:PR-B intrauterine expression) leads to increased uterotonin production Prostaglandins: - stimulate contractions, cervical softening and rupture of membranes - synthesis is catalysed by COX-2 - increase the intrauterine PR-A:PR-B ratio-> feed forward mechanism

Answer 84

- more tolerable labour pains - lower use of pharmacological analgesia - lower augmentation rates - lower bleeding, reduced risk of PPH - shorter labour

Answer 85

the 6 weeks following delivery during which woman's physiology returns to pre-pregnancy state

Answer 86

Fundus at level of umbilicus immediately post delivery By day 5-7 halfway between umbilicus and pubic symphysis By 2 weeks not palpable By 6 weeks almost back to pre-pregnancy state

Answer 87

Contractions and reduction of size of myometrial muscle (Cause of after pains) Thrombosis and hyalinisation of blood vessels -> decidual shedding

Answer 88

Until day 5-6: lochia rubra Until day 10-12: lochia serosa (darker brown) Then becomes lochia alba (yellowish/white)

Answer 89

In non-lactating women usually by 10 weeks, can be as early as 4-6 weeks In lactating women highly variable Make sure to offer contraception from 4 weeks if sexually active

Answer 90

Most 1st/2nd and episiotomies will heal within 3 weeks

Answer 91

Keep dry and clean, clean from front to back Warm sitz baths Avoid constipation Advise to watch for excessive pain/PV discharge or malodourous discharge Abstinence for 6 weeks, advise may be some discomfort when resumes

Answer 92

Advise abstinence for 6 weeks if any tears If no tears, as soon as desired/comfortable Lactating women can have vaginal atrophy and may require topical oestrogen (after BF established) or lubrication

Answer 93

Regular diet ASAP Full ambulation ASAP Abdominal strength exercises after delivery pains have subsided (usually 1 day post NVD, 6 weeks post LSCS) - curl-ups while lying in bed (flexing knees and hips)

Answer 94

Massive diuresis can occur immediately post-partum due to withdrawal of oxytocin

Answer 95

Psyllium husk Docusate or Bisacodyl Should be given to all women with OASI injury postpartum, and to other women if BNO day 3 (or if otherwise desired)

Answer 96

If plans to BF:Hand expression in warm shower or pump between feeds, regular feed schedule, wear comfy nursing bra ``` If not wanting to BF: Supportive bra (avoid gravity), avoid nipple stimulation or manual expression, tight binding of breasts (e.g. with tight sports bra), cold packs and analgesia PRN ```

Answer 97

``` Transient depression is common in the first week - mood swings - irritability - anxiety - poor concentration - insomnia - crying spells Typically only mild and subsides by day 7-10 ```

Answer 98

- If depressive symptoms last >2 weeks post partum - if symptoms interfering with daily life - ANY suicidal or homicidal thoughts

Answer 99

Obstetric outcomes are improved by delaying conception until 18 months post delivery MUST delay conception at least 4 weeks post live vaccines Avoid combined oestrogen/progesterone contraceptives while lactation is being established

Answer 100

``` Aboriginal and Torres Strait Islander Women Younger women (especially <20y) Less educated women Obese women Lower socioeconomic status ```

Answer 101

- nutrients in perfect composition, bioavailability and readily absorbable state - active and passive immunity - improved visual acuity - improved psychomotor and cognitive development (higher IQ with longer durations of breastfeeding) Reduced risks of: - malocclusion - physiological reflux - pyloric stenosis - GI infections - respiratory illness - otitis media - urinary tract infections - meningitis - SIDS - NEC (in Prem babies) - Atopy (breastfeeding during time of antigen introduction facilitates development of tolerance) - Some childhood cancers - T1DM/T2DM - Coeliac diseae (if breastfeeding at time that gluten is introduced) - IBD - HTN, dyslipidaemia - obesity

Answer 102

- reduced risk of breast Ca - reduced risk of ovarian Ca - reduced risk of GDM women developing T2DM - Promotes uterine involution (less bleeding -> preservation of iron stores) - ?maybe helps return to pre-pregnancy weight

Answer 103

- importance of exclusive breastfeeding to 6 months and recommend breastfeeding to at least 12 months for nutritional and protective benefits - basic breastfeeding management - anticipatory guidance for coping with minor problems

Answer 104

- stressful delivery (due to reduced oxytocin release) - Caesarean delivery - Maternal T1DM (can delay lactation by 24h) - retained placental fragment (persistent progesterone release) - maternal obesity (higher levels of progesterone + attachment issues)

Answer 105

- Mum upright/semi-reclined with good back/feet/arm support - "C-hold" - if nipple erect, support outer area of breast, if flat/inverted should hold well behind areola from the bottom to shapebreast between thumb and index finger - Support infant behind shoulders, body flexed around mum, nose at level of nipple - Tease infant with underside of areola to encourage wide gape, then quickly bring INFANT to the BREAST - should be no clicking or sucking in of infants cheeks, slow even rhythm with deep jaw movements, pauses are normal - come off breast spontaneously

Answer 106

8-12 typically | Typically will establish pattern within first week

Answer 107

HIV infection (but discuss with specialist) Active TB Breast Ca treatment Breast syphilis Brucellosis Infant metabolic conditions requiring special formula (e.g. galactosaemia)

Answer 108

Ideally quit smoking during pregnancy and breastfeeding If unable to quit, reduced as much as possible COMPLETELY avoid smoking 60 minutes prior to feed (and during feed) Never smoke in same room as infant Champix and Zyban are not safe during pregnancy or lactation

Answer 109

- Content neonate after feed (though may cluster feed at certain period of each day) - time remaining on breast (should never be >60 mins) - passing urine at least 1x/day first few days (6+ times/day as volume increases) - transitional stools by 24-48h-> breastfed stools by day 3-4 - appropriate weight gain (averaged over 4 week period)

Answer 110

After maturation of alveoli of breasts due to prolactin, progesterone and human placental lactogen -> breast able to secrete small amounts of specific milk components (e.g. lactose) - complete by mid pregnancy Milk production is inhibited in late pregnancy by high progesterone levels

Answer 111

Rapid increase in milk production in the first 30-40h following delivery of placenta (due to progesterone withdrawal)

Answer 112

800mL/day AVERAGE

Answer 113

Sucking -> pulse of oxytocin from posterior pituitary -> contraction of myoepithelial cells surrounding alveoli -> milk ejected into ducts and lactiferous sinuses

Answer 114

- No symptoms at all - tingling/prickling/pins and needles sensation - sudden feeling of fullness - increase in skin temperature - feeling of wellbeing/relaxation - pain or nausea - dripping/leaking from other breast - intense thirst - uterine contractions + gush of lochia - slow sucking of infant (approx 1/sec)

Answer 115

- overall increased energy requirements - intake affects micronutrient composition of breastmilk only Vitamin D and iodine (150 microg/day supplementary) is recommended

Answer 116

Breastfeed as long as possible (ideally 2+ years) If not, then soy-based formula for the first 2 years AND dietary advice Likely will require supplements especially for iron and B12

Answer 117

From AROUND 6 months (4-6mo depending on infant signs) First introduce IRON-RICH foods (iron-enriched cereals, pureed meat/poultry/fish, cooked tofu and legumes) 6-8 mo: purees -> mashed -> minced -> chopped foods Ensure lumpy foods <9mo 8mo: finger foods 12mo: same foods as rest of family, continue iron-rich foods, small frequent servings of nutrient-dense foods

Answer 118

NOTHING other than breastmilk/formula first 6 months Cows milk: only with cereals etc <12mo, >24mo max of 500mL/day Water (after 12mo) Fruit juice, soft drinks, cordial should be avoided Tea, coffee, caffeinated drinks are unsuitable

Answer 119

Honey - do not give <12months due to risk of botulism Animal milks - FSCM ONLY with cereals/custards etc. in first 12 months - goat's milk NEVER GIVE TO A CHILD - unpasteurised milk NEVER GIVE - plant based milks (only acceptable is soy follow-on formula) - nutrient poor, high fat/salt/suagr foods (e.g cakes, biscuits, chips, lollies etc)

Answer 120

Bleeding into the space between the epicranial aponeurosis and the periosteum

Answer 121

Rupture of emissary veins (which connect dural sinusess to scalp veins) Most commonly after vacuum delivery

Answer 122

Life threatening haemorrhage - up to 250mL (50-75% of neonatal blood volume) can bleed into subgaleal space, with only a 1cm increase in scalp thickness

Answer 123

12-25% in infants admitted to NICU

Answer 124

- Instrumental delivery (esp vacuum) - nulliparous - 5 min apgar 7 or less - cup marks on sagittal suture - leadingedge of cup <3cm from anterior fontanelle - failed vacuum extraction (requiring forceps/LSCS) - high number of pulls/cup detachments/prolonged time from cup attachment to delivery

Answer 125

Insidious onset Localised signs: - vague generalised scalp swelling - laxity of scalp - then becomes fluctuant - ballotable lesion crossing suture lines - pitting oedema over scalp/preauricular/periorbital Generalised signs: - 5 minute apgar 7 or less without asphyxia - irritable cry or evidence of pain with handling - haemodynamic instability (later sign) (tachycardia, tachypnoea, poor activity, pallor, anaemia, coagulopathy, acidosis, death)

Answer 126

Can cross suture lines and midline | Size and firmness starts to reduce 1h post delivery

Answer 127

(bleeding between periosteum and underlying skull) more common after instrumental delivery Soft, fluctuant, localised swelling with well-defined outline Does NOT cross suturelines Canincrease in size over 12-24 hours

Answer 128

Promote neonatal IM vitamin K after instrumental delivery +++ Avoid vacuum when contraindicated Ensure correct placement of cup, correct traction, and abandonment if too many pulls/detachments/prolonged

Answer 129

Surveillance of different levels for all infants post instrumental delivery If higher risk (ie lots of pulls/detachments etc, more difficult extraction, incorrect cup placement) should have regular formal observations for 12 h, and cord gas + Hb and platelets at delivery

Answer 130

Immediately discuss with neonatologist Prompt evaluation, resuscitation and supportive treatment - restore circulating blood volume (IVT, blood products) - circulatory support - correct acidosis or coagulopathy Transfer to NICU

Answer 131

Low BGL <2.6mmol/L (note that intervention thresholds may differ according to clinical situation e.g. preterm deliveries or at risk babies intervention threshold is lower at 2.0 due to expected drop in BGL)

Answer 132

- nil by mouth - preterm birth - respiratory distress/TTN - LGA/macrosomia - IUGR - hypoxic-ischaemic events - systemic conditions e.g. infection - hypothermia (<36C) - inborn errors of metabolism - maternal medications (esp. beta blockers or valproate) - hyperinsulinaemia - maternal diabetes - congenital hyperinsulinaemic hypoglycaemia - iatrogenic hypoglycaemia

Answer 133

- disinterest in feeding for 8h or more from birth/last feed - hypothermia <36 - jitteriness

Answer 134

Screen all at risk neonates at 1 and 4h (SA PPG)

Answer 135

Mild- moderate: Neuro: irritability, jitters, tremors, hypotonia, lethargy, temperature instability, high-pitched cry Respiratory: tachypnoea CVS: tachycardia, diaphoresis Gastrointestinal: poor-feeding, vomiting SEVERE: Neuro: eye roll, seizures, altered conscious state Resp: hypoventilation, apnoea, cyanosis CVS: pallor

Answer 136

``` Serum glucose insulin Growth hormone Cortisol Ketone level (via UA or glucometer) ```

Answer 137

Check temp and manage as indicated Offer breastfeed/EBM or formula as soon as practical Alert medical team Recheck BGL in 30-60 min

Answer 138

BGL 1.5-2.5 (or 2.0): - offer feed - consider 10% glucose infusion at 60mL/day esp if respriatory distress - repeat in 30-60 min aiming for >2.5 if enteral or >3.5 in IV replacement <1.5 at any time (or baby with major illness <2.5) URGENT MANAGEMENT REQUIRED - IV 10% glucose bolus 2ml/kg + infusion 90mL/day - IM glucagon if IV access delayed - repeat BGL in 30 min - Aim for >3.5mmol by 30-60 min Advice from paediatric team

Answer 139

Set up for haemolysis - previous child with antibody mediated HDN - FHx G6PD deficiency or inherited red cell membrane/metabolic defects (hereditary spherocytosis, PKD etc.) - +ve maternal blood group antibody screen and +ve cord DAT to antibodies associated with HDN - visible jaundice of any degree within first 24h Weight loss >10%/poor feeding Gestation 35-38 weeks Unwell infant OR Confirmed/likely haemolysis - in utero haemolysis on basis of fetal anaemia + pos maternal antibody screen - rate of rise of SBR >5 without PTx or continued rise despite PTx - baby with bilirubin above exchange level

Answer 140

Anti-D Anti-C Anti-kell Others including Anti-A or -B are less likely to cause haemolysis

Answer 141

Daily clinical assessment for low risk babies prior to discharge - blanching of skin with finger tip in appropriate light OR - transcutaneous POC light reflectance meter higher risk babies requireblood bilirubin measurements

Answer 142

Extending below nipple line has high sensitivity for plasma levels >75th centile - therefore should be checked with bilimeter and/or SBR Clinical assessment is limited in dark skinned babies, therefore should be checked with bilimeter or blood level

Answer 143

Unaffected by gestation, postnatal age or skin pigmentation Underestimates total bilirubin level, especially at higher blood levels - therefore blood bilirubin should be checked if bilimeter result >75th%ile

Answer 144

Only validated in well babies without haemolysis | Therefore should only be used in well babies >38 weeks chart, and well babies 35-37+6 weeks

Answer 145

1. Rising bilirubin despite intensive PTx, approaching exchange line 2. anaemia with Hb <100, cardiac failure, or hydrops 3. Suspected kernicterus regardless of bilirubin level

Answer 146

>2 weeks in >35/40 gestation OR >3 weeks in <35/40 gestation Requires investigation, advise parents to present for medical review if any visible jaundice after 2 weeks, or if pale stools at any time

Answer 147

1. Review NNST results 2. Total and conjugated bilirubin 3. Free T4 4. Urine culture If above all normal and healthy breast fed baby, reassure that breast milk jaundice, and will resolve over 2-3 months

Answer 148

HEARING: AABR for neonatal screening rather than usual test if: - jaundice due to haemolytic disease - bili >350 in term baby - bili >250 in sick term, of a preterm >32/40 - all babies <32/40 or 1500g BW Should be performed as close to discharge from hospital as possible. If passes, no routine audiology f/up required ANAEMIA: - if confirmed haemolysis, close f/up over 4-6 weeks to watch for late anaemia - Most likely with Rh isoimmunisation - weekly CBE and reticulocyte - folic acid supp where continued haemolysis suspected - if unusual haemolysis, haem advice ENCEPHALOPATHY - if any symptoms/signs or who have been unwell with jaundice require long-term follow-up with paediatrician

Answer 149

1. CMV 2. Parvovirus 3. Rubella 4. Measles 5. Mumps 6. Varicella 7. HIV 8. Hepatitis A 9. Hepatitis B 10. Hepatitis C

Answer 150

``` Deafness Mental disability Hepatitis Pneumonitis Blindness ```

Answer 151

Transmitted through infectedblood, saliva, urine, breastmilk or through vertical transmission (in utero or intrapartum) or sexual contact

Answer 152

In primary infection - 50% | In reactivated disease: only 1% transmission rate

Answer 153

``` Microcephaly Ascites Hydrops fetalis Oligo or polyhydraminos Hepatomegaly Pseudomeconium ileus hydrocephalus IUGR pleural or pericardial effusion Intracranial calcification Abdominal calcification ```

Answer 154

50% transmission in PRIMARY infection - 10% of infants will be born symptomatic 90% of these infants will develop sequelae (10-30% mortality rate, 18% hearing loss, neurological conditions - microcephaly, intellectual impairment, seizures, chorioretinitis)

Answer 155

Maternal: CMV serology and repeat 2-4 weeks (if IgG -ve to positive OR rising then primary infection)

Answer 156

Supportive management of mother Check for fetal infection (amniocentesis for PCR/viral culture and serial USS) Counsel mother re: option to continue pregnancy v terminate Counsel re: risk of congenital CMV up to 4y following seroconversion (1% risk in 4th year)

Answer 157

Paeds at delivery for detailed examination Test: - ophthal examination - cranial USS ?hydrocephaly - CT brain - intracranial calcification, verntriculomegaly, cerebral atrophy Labs <3weeks: - CMV IgM serology - PCR for viral detection +/- viral culture (blood, urine, NPA) Consider ID input ?antivirals Paeds review every 3-6 months if asymptomatic, likely more if symptomatic depending on presentation

Answer 158

Fetal infection causes cytolysis leading to areas of focal necrosis and healing by fibrosis and calcification

Answer 159

Direct contact with respiratory secretions and hand-mouth contact Vertical transmission Most infectious from 1 week after exposure to before rash onset (likely not infectious after that)

Answer 160

30-40% subclinica Fever, myalgias and malaise which settle prior to rash onset (slapped cheek/reticular macular rash) Arthralgia or arthritis common adults, can develop few weeks after infeciton Can cause aplastic crisis in people with thalassaemia or sickle cell anaemia

Answer 161

Standard precautions Susceptible pregnant HCW avoid caring for women with known parvovirus Routine screening not recommended

Answer 162

``` Spontaenous miscarriage/stillbirth - 13% risk <20/40 - 0.5% risk >20/40 Hydrops fetalis - 3% risk if maternal infection 9-20/40 - on average 5 weeks after maternal infection ``` No evidence of congenital anomalies or long term sequelae for infant

Answer 163

Ascites Skin oedema Pleural and pericardial effusions Placental oedema

Answer 164

Check IgG and IgM - if IgG positive = immune, no further management - if IgG negative monitor in 2-4 weeks ?seroconversion If infection confirmed, serial USS every 1-2 weeks to assess for hydrops, if any signs, refer to MFM

Answer 165

up to 4% of pregnant women NOT immune VZV in pregnancy is complicated by pneumonia in 10% of cases 20-30% risk of transmission to neonate

Answer 166

- through airborne/respiratory droplets and direct contact with vesicle fluid - contagious from 2d before rash until all lesions crusted over (approx 1 week after onset)

Answer 167

0.5% risk in 1st trimester 1.4% risk in 2nd trimester Nil in 3rd trimester (but may be at risk of neonatal disease if around time of delivery)

Answer 168

``` Skin scarring Eye and limb abnormalities IUGR/LBW Prematurity Cortical atrophy, intellectual disability Decreased sphincter control Early death ```

Answer 169

If primary CHICKENPOX disease onset in mother >7 days before delivery, neonatal infection is mild (as maternal IgG is protective) If <7days before or 2 days after, risk of severe infection No risk if shingles infection - shingles in otherwise healthy pregnancy is not associated with intrauterine infection

Answer 170

Same household as someone with active varicella Direct face-to-face contact with a person with varicella for at least 5 minutes Same room for at least 1 hour

Answer 171

Preconceptual varicella serology+/- immunisation If <96h post exposure and seronegative, give zoster immunoglobulin and seek medical care immediately if develop chicken pox If >96h post exposure consider oral antivirals if >20 weeks, lung disease, immunocompromised or active smoker

Answer 172

Isolate If <24h since appearance of rash- oral antivirals If >24h since onset of rash: - no antivirals - monitor at home unless underlying lung disease, ISS, or active smoker (in which case monitor in hospital) Complicated varicella infection (respiratory, haemorrhagic o neurological symptoms, fever >6 days, newpox developing after 6 days) - 7-10 days aciclovir 10mg/kg for 7-10 days (iV then oral)

Answer 173

Maternal chickenpox >7 days before delivery: No interventions unless <28/40 or <1000g then IV aciclovir Maternal chickenpox <7 days before to 2 days after delivery: ZIG 200IU <24h after birth ideally (up to 72h) no isolation req, still breastfeed Maternal chicken pox 2-28 days after delivery (or other exposure when mumw as seronegative): Consider ZIG <96h Maternal shingles - no risk

Answer 174

Neonates: 200iu IM (1x vial) Adults: 600IU I (3 vials)

Answer 175

40-50% risk in women with primary infection + active lesions at time of vaginal delivery/ROM 1-3% risk if lesions associated with recurrent infection (thought HSV1 higher at 15%, HSV2 <0.01%)

Answer 176

Maternal PRIMARY infection Multiple lesions Premature delivery Premature rupture of membranes

Answer 177

If pre-existing: - consider suppressive antiviral therapy from 36/40 if multiple recurrent lesions or sooner if frequent symptomatic recurrences - careful speculum in early labour to check no active lesions If first episode in pregnancy: - obtain type specific HSV serology and PCR/culture from swab (if both positive for same type then likely recurrent infection) - if confirmed new primary <28 weeks, counsel as per pre-gestaional - if diagnosis >28/40, consider suppressive therapy from 36 weeks + caesarean delivery regardless of active lesions If first episode diagnosed during labour: - LSCS - HSV type specific PCR on genital swab

Answer 178

Asymptomatic low risk neonate (e.g. maternal seroconversion >6 weeks before birth) - normal postnatal care - at 24h post birth collect surface swabs (eye, throat, umbilicus and rectum) for HSV1/2 PCR - collect urine for HSV1/2 PCR - observe for signs of infection Asymptomatic high risk infant (i.e. maternal HSV close to birth or born through active HSV disease and no previous history of genital HSV) - paeds at birth, complete exam for signs of HSV - neonatal care unit - urine for HSV 1/2 PCR - CBE (?low PLT) - LFT - coags - HSV PCR on bloods - LP - commence IV aciclovir - surface swabs 24h after birth Symptomatic infant - Above tests - IV aciclovir 14-21 days - repeat LP after 7h if initially negative with signs of CNS disease - repeat LP near end of treatment completion to confirm clearance

Answer 179

Vesicular skin lesions, atypical pustular or bullous lesions (especially on presenting part) - ulcers involving buccal mucosa - corneal ulcer, conjunctivitis, keratitis - seizures - unexplained fever or sepsis with negative blood cultures, not responding to antibiotics - low PLT - elevated LFTs - DIC - respiratory distress 24h after birth

Answer 180

Asymptomatic in 25-50% May have: - low grade fever - transient erythematous rash - cephalocaudal spread with caudocephalic resolution within 3 days - arthritis and arthralgia (most commonly in women of child-bearing age) - neuro disorders, thrombocytopaenia (rare)

Answer 181

1 week before until 4 days after onset of rash

Answer 182

14-23 days

Answer 183

``` No effect on fetus Placental infection only Placental/fetal asymptomatic infection, but can affect organs IUFD/miscarriage Congenital rubella syndrome ```

Answer 184

- 90% of fetuses <8 weeks will be affected - 50-80% fetuses 8-12 weeks will be infected, half of these will have fetal defects - 12-16 weeks 30% fetuses infected, 10%overall risk of fetal defect (sensorineural deafness most likely) - >16 weeks fetal manifestations rare Maternal reinfection in immune women very low risk of fetal damage

Answer 185

Sensorineural deafness CNS dysfunction (intellectual impairment, developmental delay, microcephaly) Eye abnormalities (cataracts, retinopathy, glaucoma, strabismus, micropthalmos) Cardaic abnormalities (PDA, PA stenosis) IUGR, short stature Inflammatory lesions of brain, liver, lungs and bone marrow

Answer 186

Anyone with Rubella IgG <10 OR 10-20 if born in Australia or the Western world Should receive a second dose of MMR 4 weeks after the first **ensure to inform NOT to get pregnant within 28 days of vaccination

Answer 187

Test rubella specific IgG and IgM for any pregnany woman with contact with OR clinical features of rubella If both positive - possible recent infection, repeat test to confirm (4-fold increase in IgG titre is indicative of recent infection) If both negative - susceptible - repeat serology if <3 weeks since contact or <7 days since onset of illness - if no seroconversion, requires postnatal immunisation - if seroconversion occurs, then consistent with maternal infection IgG negative, IgM positive - possible recent infection - repeat - if no IgG seroconversion occurs may be false positive IgM (occurs especially in presence of rheumatoid factor) IgG positive, IgM negative - past infection or immunisation

Answer 188

Counsel regarding risks relevant to gestation - termination should be offered if infection occurs in first trimester - consider fetal testing if maternal infection in 2nd trimester (CVS may be appropriate in 1st trimester if couple are uncomfortable about termination based solely on risk of fetal infection) i. e. rubella PCR, culture and fetal IgM through CVS, amniocentesis or fetal blood sampling

Answer 189

Refer to HIV physician, sexual health physician and high risk obstetric consultant for discussion and screening Ensure CST up to date (within last 12 months)

Answer 190

Routine antenatal bloods+ serology for CMV, VZV, HSV, toxoplasmosis, cryptococcus, candida - CBE, CD4 count, lymphotcyte subsets - HIV viral load and resistance testing (unless already known) - baselineLFT, EUC, amylase, lactate, HLA B5701 Refer to tertiary centre for MDT management with HIV specialist, ID specialist and High risk/MFM obstetrician

Answer 191

If SROM, consider augmentation If PPROM 34-37 weeks, immediate delivery (with antibiotic and steroid cover) If <34 week PPROM- MDT discussion and planning If viral load undetectable at or after 36 weeks, can have vaginal delivery without intrapartum zidovudine If viral load <400 - intrapartum zidovudine and consider LSCS If viral load >400 intrapartum zidovudine and plan LSCS

Answer 192

>70% occurs in labour Risk increased by: - advanced maternal illness - high viral load - poor maternal immune status (e.g. low CD4 count) - ROM >4h before birth - Preterm birth - breastfeeding - procedures that may damage integrity of natural barriers (e.g. FSE, vigorous suctioning, injections through unwashed skin, invasive testing such as CVS)

Answer 193

Screening test with ELISA for HIV antibody -if positive, then confirmed with Western Blot (if indeterminate, discuss with reference lab + virologist)

Answer 194

If mother is HBeAg positive risk is 70-90% of developing HBV infection by 6 months (if does not have HBIG and postpartum Hep B immunisation) Risk with administering HBIG and Hep B reduces to 5-10% If acute HBV in 1st or 2nd trimester, risk of transmission to newborn 10%, if in 3rd trimester, risk approx 75%

Answer 195

HBsAg to ALL pregnant women - positive = infection with Hep B Can have false negatives though due to mutation in HBsAg therefore all women in HIGH RISK groups should also be screened with HBcAB

Answer 196

HBeAg (positivity indicates high infective status) HBeAb (positivity indicates lower risk of spreading HBV infection) HBcAb LFTs (and repeat at 28 weeks) CBE HBV viral load (repeat before 32 week gestation)

Answer 197

Refer to ID specialist and high risk obstetric unit. If high viral loads may be considered from approx 32 weeks (or 28) to reduced risk of perinatal transmission(not indicated if very low viral laod)

Answer 198

HBIG 100 units AND HBV vaccine given within 12 hours - skin should be cleaned prior to injection - continue with normal childhood HBV schedule Follow up at 8-12 months (2 months post completion of primary schedule) for HBsAg, HBsAb - if antigen positive, refer to paeds gastro or ID Breastfeeding encouraged

Answer 199

approximately 5% - transmission is 3-4 x more likely in event of co-infection with HIV

Answer 200

Clean skin with soap and water if visible blood OR with alcohol wipe prior to injections HBV vaccination within 12 hours of birth If co-infection with HBV, also requires 100IU of HBIG Test for HCV Ab at 18 months of age

Answer 201

Depends on gestation at maternal seroconversion 1st trimester - low risk of vertical transmission (5-15%) but high risk of abnormalities (60-80%) 2nd trimester - moderate risk vertical transmission (25-40%), low risk of congenital abnormalities (15-25%) 3rd trimester - 30-75% risk of vertical transmission (higher rates closer to term), 2-10% risk of abnormalities

Answer 202

- Chorioretinitis/retinal scarring - Hydrocephalus - Intracranial calcification - Mental retardation - Hepatosplenomegaly - Pneumonia - Thrombocytopaenia - Lymphadenopathy - Myocarditis

Answer 203

``` Most patients will be completely asymptomatic Potential symptoms in mild illness: - flu-like symptoms - malaise - myalgias - Swollen lymph glands ``` ``` Severe disease (more likely in immunocompormised) - ocular toxoplasmosis (blurred vision, photophobia, red eye, tearing) ```

Answer 204

Consider testing toxoplasmosis serology in pregnant women with acute symptoms (e.g. malaise, fever, lymphadenopathy) If IgG and IgM positive indicates POSSIBLE recent infection - IgM can remain positive for years - IgA, rising AigG and/or low IgG avidity are more specific for recent infection - if both are positive, repeat serology for IgM, IgA and/or IgG titre and avidity - if on repeat, High IgM, positive IgA and low IgG avidity consistent with recent toxoplasmos infection

Answer 205

Faecal-oral route - undercooked, contaminated meat (esp. pork, lamb or venison) or shellfish - contaminated water - accidental ingestion through contact with cat faeces (e.g. cleaning cat's litterbox, touching or ingesting anything that has come into contact with cat faeces, accidentally ingesting contaminated soil)

Answer 206

Further investigations to determine risk to fetus: - USS to detect abnormalities - amniocentesis for PCR/culture at 18-20 weeks or >4 weeks after maternal infection If both above are negative, consider pharmacological treatment if maternal infection is fairly certain In 1st trimester: counsel woman/partner re: termination if amniocentesis PCR is positive 2nd trimester: Counsel re: termination if USS abnormal Spiramycin, atavaquone or azithromycin if medication indicated (unknown efficacy) 3rd trimester (as above medical treatment, termination not advised)

Answer 207

Paeds at delivery Newborn assessment for congenital toxoplasmosis - ophthal examination and cerebral ultrasound required - placenta for histo/PCR - infant whole blood for PCR, serology for specific IgM and/or IgA, persistent IgG - infant CSF for PCR Majority of infected babies will be asymptomatic Manage with spiramycin oral syrup for first 12 months - repeat IgG at 6 months - regular paeds/ID review

Answer 208

*always obtain a dietary history from pregnant women with febrile, flu-like ilness, myalgia, headache or diarrhoea Often asymptmatic Can mimic pyelonephritis due to loin pain

Answer 209

In early pregnancy: fetal infection can cause miscarriage In 2nd and 3rd trimesters, if untreated maternal infection, associated with 40-50% fetal mortality (septicaemia, multi end organ damage, still birth, neonatal death) Neonatal infection: pneumonia, sepsis or meningitis Mortality rate 3-50%

Answer 210

Mild: PO amoxicillin Severe: IV amoxicillin + gentamicin (if penicillin allergy, consider bactrim PO or IV if >12/40)

Answer 211

Variable, but most commonly: - respiratory distress - rash - fever - jaundice - lethargy Suspicious findings include: - placental, cord, or post-pharyngeal granulomas - multiple small skin granulomas, papular or pustular skin rash - Meconium stained liquor <34 weeks - purulent conjunctivitis

Answer 212

1. Obstructed urinary flow -> stasis -> increased risk of asymptomatic bacteriuria becoming pyelo 2. Smooth muscle relaxation secondary progesterone -> reduced bladder and ureteral tone, dilatation of renal pelvices and ureters -> increased bladder volume, urinary stasis, residual volume and VUR 3. pregnancy-induced changes in urine pH, osmolality, glycosuria and aminoaciduria may facilitate bacterial growth

Answer 213

occurs in 5-10% of pregnancies 30% will develop acute pyelonephritis if untreated Associated with preterm birth, LBW Antibiotics associated with reduced preterm delivery and LBW infants

Answer 214

E coli >80% second most common is staphylococcus saprophyticus

Answer 215

Routine MSSU at booking Repeat after contaminated specimen History of recurrent infections outside of pregnancy Structural abnormality of the urinary tract

Answer 216

Risk begins at 6/40 and peaks 22-24/40

Answer 217

``` Low SES Sickle cell trait DM Neurogenic bladder retention History of previous UTIs Structural abnormality of urinary tract Renal stones ```

Answer 218

>100,000 bacteria/mL - <20 white cells (in AB) - if 2+ organisms usually contamination and should be repeated + clinical findings in acute cystitis

Answer 219

- 5 day course antibiotics (10-14 days for pyelo) - at least 48h IV if bacteraemia - increase fluid intake +/- IVT - monitor urine output - urinary alkalinisers are safe, but DO NOT USE WITH NITROFURANTOIN (will reduce efficacy) - only commence antibiotics for asymptomatic bacteriuria AFTER culture and sensitivities (not empirical based on UA)

Answer 220

Cephalexin 500mg BD for 5 days OR Nitrofurantoin 100mgBD for 5 days OR Augmentin DF BD for 5 days (only if <20/40) OR Trimethoprim 300mg daily for 5 days (only if>12/40)

Answer 221

1. cephalexin 500mg BD 5 days 2. nitrofurantoin 100mg BD 5 days (but don't use Ural) 3. trimethoprim 300mg daily for 5 days 4. ADF BD for 5 days

Answer 222

Only use if <20 weeks Associated with increased risk of necrotising enterocolitis, functional impairment and cerebral palsy, therefore only use inf no alternative

Answer 223

1. Cephalexin 500mg BD 5 days OR 2. Amoxicillin 500mg TDS for 5 days

Answer 224

Norfloxacin 400mg BD 5 days | Repeat MSSU 48h after treatment completed

Answer 225

``` Penicillin V 500mg BD 5 days OR cephalexin 500mg BD 5 days OR clindamycin 450mg TDS 5 days ``` (dependent on allergies) THESE WOMEN NEED GBS PROPHYLAXIS IN LABOUR

Answer 226

48h minimum IV antibiotics IVT+ monitor urine output Antipyretics PRN Monitor for preterm labour Amoxicillin 2g 6 hourly IV+ gentamicin 5mg/kg daily OR ceftriaxone 1g IV daily Step down to oral antibiotics after >24h apyrexia, clinically improving. Base on susceptibilities. (doses same as for UTI except cephalexin 500mg QID) and continue for 10 days

Answer 227

2+ documented separate episodes of CYSTITIS (not asymptomatic bacteriuria) OR Single episode pyelonephritis

Answer 228

Nitrofurantoin 50mg nocte (be careful using close to term) OR cephalexin 250mg nocte OR trimethoprim 150mg nocte (avoid 1st trimester or in women concerned about folate)

Answer 229

HIV positive mothers OR recent contact with infectious TB (e.g. household) Not otherwise performed as usually treatment would be deferred until 2-3 months postpartum in latent infection

Answer 230

``` Amphetamines: - cardiac malformations - ?other malformations such as cleft palate - IUGR (impaired placental function) Methamphetamines(ice/speed): - preterm labour - placental abruption ``` MDMA/Ecstasy: - little evidence of obstetric complications or teratogenicity, but likely confounding effect as multi-drug users Risk of neonatal abstinence syndrome with all, lower than risk with opioids. 50% will have some withdrawal but only 5% of infants will require treatment

Answer 231

Crosses the placenta - may cause withdrawal syndrome in neonates of heavy users Some evidence of association with IUGR

Answer 232

AFI >20cm (used to be 24cm) | OR Maximal vertical pool >8cm

Answer 233

Mostly produced by amniotic membrane covering placenta and cord >20 weeks also contribution by fetal kidneys

Answer 234

Same composition as maternal plasma for first half of pregnancy Then hypotonic compared to fetal and maternal plasma, with more urea and creatinine than plasma

Answer 235

Affects 1% of pregnancies

Answer 236

1. Impaired swallowing - anencephaly - CNS abnormalities - myotonic dystrophy - oesophageal atresia - tetralogy of fallot 2. Reduced absorption - gut atresias 3. increased production from fetal membranes - spina bifida - anencephaly 4. Excessive urination - cardiac overload (high output cardiac failure, fetal anaemia) 6. Increased placental area - multiple pregnancy - diabetes - placental tumour (rare)

Answer 237

Maternal: - overdistention -> PROM - pain - unstable lie - cord prolapse - abruption - PPH Fetal/neonatal: - associated fetal anomalies - asphyxia from cord prolapse - prematurity

Answer 238

- SFH large for dates - tense abdomen - difficulty palpating fetal parts - reduced fetal movements

Answer 239

USS (to confirm) - detect fetal structural anomalies Diagnostic amniocentesis Exclude treatable causes (fetal anaemia, cardiac failure)

Answer 240

Varies with gestational age, but generally: AFI <5cm Deepest pool (MVP) <2cm

Answer 241

MATERNAL: - PROM - poor placental diffusion - drug effect FETAL: - hypoxia - fetal anomalies (renal agenesis, renal dysplasia, urethral valve anomalies)

Answer 242

High risk pregnancy Fetal anomalies IUGR Fetal hypoxia (related to poor placental function) Early severe oligohydramnios associated with pulmonary hypoplasia and fixed deformities of flexion

Answer 243

- congenital malformations - pregnancy complications (macrosomia, IUGR, preterm birth, PET, shoulder dystocia, IUFD) - operative delivery or LSCS - Neonatal complications (hypoglycaemia, jaundice, respiratory distress)

Answer 244

Metformin Insulin All else have limited evidence and should be discontinued prior to pregnancy

Answer 245

- Discuss risks of poor glycaemic control in pregnancy - plan reviews with woman's GP, endocrinologist/physician, DNE - delay attempts of conception until BGL optimised (HbA1c <75, ideally <6.5% - change to pregnancy safe hypoglycaemics (metformin, insulin) - If T1DM, consider change to continuous subcut pump (refer to diabetes service) - folate 5mg daily for 6 weeks prior to conception

Answer 246

- refer to high risk clinic + DNE - aspiring 100mg nocte - weekly DNE monitoringofBGL - 2-4 weekly specialist appointments ADDIT investigations: - booking: HbA1c, TFTs, early morning spot urine ACR - UA for protein every visit - confirm dates with dating scan - consider early 16/40 morphology if appropriate - If HbA1c >10%, fetal echo at 20-22 weeks - Consider growth scans in third trimester BGL MONITORING: - change monitoring to include fasting+ 2h post-prandial measurements REFER: - ophthal - high risk clinic, obs med, endo, DNE

Answer 247

Should always occur <40+6 (but only if BGL within target, normal growth and AFI and otherwise uncomplicated pregnancy) Induction at 38+6 if: abnormal AFI, difficulty maintaining target BGL at 38/40, macrosomia or IUGR, HTN/PET developing IF birth likely <37+0, consider steroids for fetal lung maturity, admitfor additional glucose monitoring and increased insulin at direction of obs med/endocrine

Answer 248

Vaginal birth is safe if EFW <4kg - discuss risks of IOL and potential shoulder dystocia

Answer 249

CTG Consul with physician Avoid prolonged labour and water overload If ordered, give oxytocin with NORMAL SALINE (not Hartmann's) to prevent hyponatraemia Insulin infusion as per protocol, with hourly BGL monitoring

Answer 250

Continue pre-existing insulin regimen until labour is established, or no later than midnight on day of admission for IOL Continue metformin until labour established Hourly BGL (if >8 over 2h period and birth not imminent, to commence insulin infusion) Continuous CTG If giving oxytocin, give with normal saline Beware of risk of shoulder dystocia Cease dextrose/insulininfusionimmediately after birth

Answer 251

Paediatrician aware of birth Feed within 60 minutes (ideally BF) First BGL <1h of age Most babies need close observation in nursery for hypoglycaemia, polycythaemia, jaundice, hypocalcaemia, RDS

Answer 252

Send placenta for histopath Review hypoglycaemic therapy early (risk of hypos) Appropriate contraception Encourage breastfeeding for minimum 2 months Ensure appropriate hypoglycaemic agents for breastfeeding

Answer 253

Insulin (all forms) Metformin Glibenclamide and glipizide (NOT gliclazide or glimeprimide) NOT SAFE: - glitazones, acarbose, DDP-4 inhibitors (-gliptins), GLP1 antagonists and SGLT-2 inhibitors

Answer 254

Fasting <5 Postprandial (2h) <6.7 If 2 or more of the same reading is elevated in one week, step up in management

Answer 255

``` 75g glucose load Fast from food for at least 8h Drink glucose over 10-15 minutes Remain seated and non-smoking for duration of test Blood at fasting, 1h, and 2h ```

Answer 256

Gastric bypass surgery | gastric banding usually okay

Answer 257

In women who are at risk for OVERT diabetes in pregnancy (FBG >7 or 2h BGL >11) - previous hyperglycaemia (including in pregnancy) - maternal age >40y - ethnicity: Asian, Indian subcontinent, ATSI, Pacific islander, Maori, Middle eastern, non-white African - Family history of DM (1st degree relative with DM OR sister who had GDM) - pre-pregnancy or booking BMI >30 - Previous macrosomic baby (>4.5kg or >90th centile) - PCOS - Medicated with steroids or antipsychotics

Answer 258

90& occur in LEFT leg | >70% are iliofemoral (higher risk of embolisation than calf DVT)

Answer 259

LMWH 1mg/kg BD 3 months if uncomplicated distal DVT OR 6 months for PE or proximal DVT If therapy finished before end of pregnancy, prophylactic dose should continue until 6 weeks postpartum

Answer 260

LMWH - safe in breastfeeding Warfarin - safe in breastfeeding NOT SAFE IN PREGNANCY NOACs unsafe in pregnancy AND breastfeeding

Answer 261

Aspirin 100mg for 5-7 days + TEDS + analgesia | If not resolved, for enoxaparin 40mg for 7-10 days, if not resolved for ultrasound

Answer 262

Previous episodes in current pregnancy Length >20cm Previous personal or family history (1st degree) of DVT

Answer 263

0. 5-2/1,000 pregnancies affected - 25% are PE - 1 in 40 PE in pregnancy is fatal

Answer 264

5-10 fold increased risk antenatally | Further 15-25-fold increased risk postpartum

Answer 265

If on previous long-term anticoagulation (therapeutic dose LMWH) 2 or more previous VTE (prophylactic or intermediate dose LMWH) 1 previous unprovoked or oestrogen related VTE (prophylactic dose) 1 previous VTE provoked by non-oestrogen transient risk factor (surveillance)

Answer 266

If 1st degree relative with VTE NOT in setting of active malignancy - clinical vigilance or prophylactic LMWH if significant clinical risk factors

Answer 267

Protein C or S deficiency OR FVL heterozygote: clinical vigilance FVL homozygotes, prohrombin gene mutation homozygotes, double heterozygote FVL/PGM or antithrombin deficiency: clinical vigilance may be appropriate if no family history of VTE, if family history prophylactic LMWH at least

Answer 268

``` Bruising and pain at injection site Allergic skin reaction (rare) Thrombocytopaenia (HIT uncommon) Reversible osteoporosis Rise in ALT ```

Answer 269

History of HIT Actively bleeding High risk (e.g. placenta praevia) Delivery expected within 24h Intracranial haemorrhage or ischaemic stroke within past 4 weeks Uncontrolled hypertension (SBP>200 or DBP>120) Precautions: CrCl <30 PLT <80 Coagulopathy

Answer 270

Therapeutic LMWH - no regional analgesia for 24h Prophylactic LMWH- no regional analgesia for 12h No LMWH within 4h of spinal or removal of epidural

Answer 271

``` Inherited: PROGOACULANT factor abnormalities - FVL mutation (causes activated protein C resistance) - prothrombin gene mutation - plasminogen activator inhibitor ``` DEFICIENCIES of endogenous proteins in coagulation cascade: - Protein C deficiency - Protein S deficiency - Antithrombin deficiency ACQUIRED: - lupus anticoagulant - antiphospholipid antibodies - anticardiolipin antibodies MIXED inherited/acquired: - hyperhomocystinaemia

Answer 272

15% of Western populations are affected with inherited thrombophilia Inherited disposition can be identified in 60-70% of women presenting with DVT

Answer 273

- Strong family history of VTE in 1st and 2nd degree relatives (only check for inherited conditions) - recurrent (3+) first trimester miscarriages - Second trimester fetal loss - any previous history of VTE - stillbirth - Early onset PET <34 weeks - IUGR delivered <34 weeks

Answer 274

``` Lupus anticoagulant Protein C and S (Protein S should not be measured in pregnancy) Activated protein C resistance (APCR) Factor V leiden Prothrombin gene MTHFR homocysteine Anticardiolipin antibody ```

Answer 275

Refer to obs med/physician/obstetrician with expertise Arrange ongoing care in level 2-3 hospital Antenatal aspirin Increased feto-placental surveillance antenatally Consider if LMWH heparin necessary

Answer 276

Heterozygosity present in 20-40% of non-pregnancy people with VTE Homozygosity carries 80-fold increased risk for VTE Occurs in 5-15% of European populations (rare in Asian or African populations) Risk of VTE in pregnancy for FVL carriers is 0.2% (due to low prevalence in pregnancy overall)

Answer 277

``` Second and third trimester fetal loss Severe IUGR Abruption Severe early onset PET Preterm delivery Increased risk of pathological Doppler measurements ```

Answer 278

Screen with abnormal phenotype (Activated protein C resistance/APCR)

Answer 279

2-5% prevalence | More prevalent in Caucasian women

Answer 280

3-fold increased risk VTE ?PET (controversial association) IUGR Placental abruption

Answer 281

Protein S - there is a marked physiological decrease in pregnancy, therefore should not take until at least 8 weeks postpartum

Answer 282

PC: 0.3% PS: 0.1%

Answer 283

``` VTE Stillbirth Fetal loss (PS deficiency associated with recurrent loss) PET Abruption IUGR ```

Answer 284

Rarest of inherited thrombophilias but MOST thrombogenic- only thrombophilia that will ALWAYS require thromboprophylaxis in antenatal and postnatal period Prevalence 1 in 1,000-5,000

Answer 285

Autoimmune disorder defined by associated of vascular thrombosis and/or pregnancy morbidity with specified levels of antiphospholipid antibodies (either Lupus anticoagulant or anticardiolipin antibody)

Answer 286

Most common acquired thrombophilia in pregnancy Predominantly affects young women Prevalence in pregnancy approx 2%

Answer 287

ANF and ACA in women with history of: - early onset(<32w) PET and/or IUGR - fetal death - placental abruption

Answer 288

``` Recurrent early pregnancy loss (<10 weeks) PET Thrombosis Abruption IUGR preterm birth ```

Answer 289

Lupus anticoagulant detected on 2 or more occasions at least 6 weeks apart Anticardiolipin antibodies with moderate-high IgG or or IgM antibodies on 2 occasions at least 6 weeks apart

Answer 290

Aspirin 100mg/day - if history of late fetal loss or IUGR - early dating scan - close BP and UA surveillance - uterine artery dopplers at 20 and 24 weeks(if abnormal, consider 2-3 weekly scans) - 4 weekly scans to assess growth and AFI if uterine arteries normal - consider heparin

Answer 291

``` Deficiencies in Vit B12, folate, B6 GI malabsorption Renal disease Thyroid deficiency Smoking Coffee and alcohol consumption ```

Answer 292

- early onset PET - placental abruption - neural tube defects - stillbirth - IUGR - Vascular disease - recurrent VTE (if severe) - fetal loss

Answer 293

``` Avoidsmoking, alcohol, coffee Well balanced diet Folic acid Early dating scan + 12 weeks scan for neural tube defect Close PET surveillance Regular growth and wellbeing ultrasound ```

Answer 294

0.2% | 95% of these cases are due to Graves' disease

Answer 295

Refer to endocrinologist + obstetrician Anti-thyroid therapy (propothiouracil likely as less fetal effects) - on lowest maintenance dose to keep free T4 in high normal range - check T4 and TSH 6-weekly - monitor for fetal tachycardia Propanolol 40mg TDS if symptomatic

Answer 296

Preterm birth Perinatal mortality Fetal and neonatal thyrotoxicosis Risk of thyroid storm triggered by stressof infection, labour, or operative delivery (high risk of maternal and fetal morbidity and mortality)

Answer 297

Optimise T4 and TSH pre-conceptually Increase thyroxine by 30% immediately in first trimester (2 extra doses per week) Check TFT 4 weekly in T2, then 6-8 weekly Aim for TSH 0.5-2.5 Postpartum, return to pre-pregnancy dose and re-check 6-8 weeks postnatally

Answer 298

28 and 34 weeks

Answer 299

First trimester: - miscarriage - termination of pregnancy - ectopic pregnancy - Chorionic villus sampling Second & Third trimester: - Amniocentesis/cordocentesis - Fetal death - Abdominal trauma significant enough to cause fetomaternal haemorrhage - Antepartum haemorrhage - External cephalic version

Answer 300

Multiple pregnancy: 625IU Sensitising event <12 weeks: 250IU Sensitising event >12 weeks (or routine prophylaxis): 625IU

Answer 301

250IU:2.5mL fetal RBC 625IU: 6mL fetal RBC

Answer 302

Silent transplacental haemorrhages will lead to very small amounts (0.1mL) of fetal RBC accessing maternal circulation, this usually occurs after 28 weeks and especially around time of delivery

Answer 303

Discuss with MFM specialist Assess monthly until 28 weeks, then every 2weeks in 3rd trimester Non-invasive fetal genotyping (cell-free DNA) If significant rise, maternal anti-D titre >1/16, or history of Rh disease in previous pregnancy fetal monitoring with MCA PSV

Answer 304

- O group (or ABO identical with fetus) - leucodepleted - CMV negative - irradiated (to prevent graft v host disease) - Plasma reduced - <5 days old - Rh and Kell negative - Indirect antiglobulin test crossmatch compatible with mother's plasma

Answer 305

Increased renal blood flow (due to increased cardiac output), increasing GFR by up to 50% - fall in serum creatinine, urea, calcium and bicarbonate - tubular capacity to resorb glucose and protein is exceeded -> proteinuria + glycosuria Size of kidney increases due to increased blood flow (R>L due to dextrorotation of uterus) Dilatation of pelvicalyceal system R>L, up to 15-20mm, due to progesterone activity on relaxing smooth muscle Increased renin and aldosterone secretion -> sodium and water retention, fall in serum albumin and osmolality Increased EPO and vit D secretion

Answer 306

OGTT results: Fasting BGL 5.1-7 1h BGL 10-11 2h BGL 8.5- 11 (any one of these results = diagnosis) Below this range is normal Above this range is OVERT diabetes

Answer 307

PROM occurs in 10% of all pregnancies PPROM occurs in 2-3% of pregnancies, but is associated with 40% of preterm deliveries

Answer 308

- Past history of PPROM/preterm delivery - urogenital tract infection/colonisation - APH - cigarette smoking - past history of cervical surgery - amniocentesis in current pregnancy (PPROM in this setting associated with more favourable outcomes) - cervical length <25mm - positive fetal fibronectin - nutritional deficiencies - lean maternal body mass - multiple pregnancy - polyhydramnios

Answer 309

Maternal: - infection (chorio, endometritis, septicaemia) - increased risk of operative delivery and associated risks Fetal: - preterm delivery (most deliver within 1 week of PPROM) - associated neonatalmorbidities (HMD, IVH, periventricular leukomalacia, neurological sequelae, infection - sepsis, pneumonia, meningitis, NEC, retinopathy) - pulmonary hypoplasia - MSK/facial deformities - malpresentation - cord events incl. prolapse - placental abruption - perinatal mortality

Answer 310

``` HVS MCS LVS MCS GBS PCR +/- STI screen MSSU ``` USS: fetal growth, +/- dopplers, CRP + CBE daily for 3 days (then twice weekly if expectant management) If expectant management, weekly HVS MCS

Answer 311

Antibiotics: - prophylactic: IV benzylpenicillin 3g loading then 1.2g 4 hourly for 48 hours PLUS PO erythromycin 250mg QID for 10 days - if signs of chorio: amox 2g IV 6 hourly, gentamicin 5mg/kg IV daily, metronidazole 500mg IV BD (total 5 days treatment - can change to PO postnatal if afebrile) Tocolytics; - NEVER GIVE if signs of chorio - if contractions present but not in established labour, nifedipine can be given to prolong pregnancy for 4h while obtain steroid cover Corticosteroids - 11.4mg IM betamethasone in 2 doses 24h apart Magnesium sulphate: - if delivery anticipated within 24h, 24-30/40 gestation Aim to deliver >34/40 if GBS positive OR >36/40 if GBS negative However if any contraindicationsto expectant management (APH, fetal compromise, signs of chorioamnionitis, established labour), delivery when indicated

Answer 312

- CTG daily for first 3-6 days then twice per week unless indicated - CBE + CRP daily for 3 days then twice weekly - HVS swab weekly

Answer 313

- >50% of women who present in preterm labour will continue their pregnancy - occurs in 5-10% of all deliveries - prematurity is the cause for 75% perinatal deaths

Answer 314

- previous preterm birth - multiple pregnancy - polyhydramnios - urogenital tract infection - previous cervical surgery - uterine anomalies - periodontal disease - bleeding in 2nd trimester - extremes of age - smoking - low pre-pregnancy weight - pregnancies achieved through ART

Answer 315

No population based interventions, but following may be suitable in at risk women: - cervical length assessment at 20/40 (mean is 42mm, intervention considered if <25mm) - supplemental progesterone (Cxlength10-20mm) - Cervical cerclage (history of cervical incompetence, length <25mm at <24/40)

Answer 316

Should be undetectable from 22-35 weeks (>35 weeks less valuable) Must use STERILE water as lubricant - as intravaginal lubricants or disinfectants may interfere with antibody reaction and cause false negatives False positive can occur with blood or semen

Answer 317

Antibiotics- IV benzylpenicillin 3g loading, 1.2g 4hrly (only if active preterm labour, reduces maternal infection rate, no benefit to fetus) Tocolytics - if need to transfer to another unit/give time to cover with steroids Corticosteroids: if gestation age 23-34+6 and risk of imminent preterm birth or planned/expected within next 7 days Mode of Magnesium sulphate: 24-30/40 gestation for neuroprotection where birth is anticipated within 24h Mode of delivery: If breech and viable -> caesarean If cephalic, aim for vaginal If <26/40 multiple, caesarean Attendance of paeds/neonatologist at delivery. Dual vessel cord blood gas, sent placenta for histopath + swab

Answer 318

SGA: weight OR abdo circumference <10th percentile for GA IUGR: Evidence of growth restriction or arrest with EFW or birthweight<10th centile Low birthweight: <2500g Very low BW: <1500g Extremely low BW <1000g

Answer 319

5g/day 14-15/40 10g/day 20/40 30-35g/day 32-34/40 Growth rate decreases >34 weeks (growth rate lower in multiples than singletons)

Answer 320

``` Race Maternal size Female fetus Nulliparity History of baby with SGA Matrilineal tendency ```

Answer 321

MATERNAL: - multiple pregnancy - smoking, alcohol, amphetamines, cocaine - Low SES - DV - PET - previous stillbirth - obesity - Chronic HTN - Connective tissue disorders - Thrombophilias - diabetes - cardiac disorders - hypotension (<60mmHg diastolic) - respiratory disease e.g. severe asthma - anaemia - renal disease - medications (narcotics, chemo) - poor nutrition FETAL FACTORS: - fetal infection - malformations - chromosomal defects PLACENTAL FACTORS: - abruption - praevia - placentitis/vasculitis - chorioamnionitis - Placental cysts - decreased uteroplacental blood flow UTERINE FACTORS: - fibroids - morphological abnormalities (especially uterine septum)

Answer 322

CCPP acronym Constitutional Chromosomal Perinatal infections Placental insufficiency

Answer 323

Symmetric (20-30%) - all organs decreased proportionally - due to impairment of early fetal cellular hyperplasia Asymmetric (70-80%) - Relatively greater decrease in abdominal size (liver and subcut fat) than HC - due to fetal adaptation to hostile environment, redistribution of blood flow in favour of vital organs

Answer 324

70% | Healthy fetuses with no long term morbidity

Answer 325

``` Still birth Birth hypoxia Neonatal complications Impaired neurodevelopment T2DM and hypertension in long term ```

Answer 326

(20% of IUGR/SGA) Usually EARLY and SYMMETRICAL <5th%ile - aneuploidy - multiple deletions - gene mutations - placental mosaicism

Answer 327

(5% of IUGR due to infection) - CMV most common - rubella - toxoplasmosis - varicella - syphilis

Answer 328

Many causes, often recurrent | e.g. PET, abruption etc. manifestaitions

Answer 329

Non-genetic congenital abnormalities (2%) - hypoxaemia (e.g. cyanotic heart disease, severe anaemia) Multiple gestation - nutritional - complications e.g. twin-twin, PET Maternal factors - reduced placental blood flow (HTN, DM, collagen disease, lupus, obstetric causes) - smoking - toxins e.g. warfarin, AEDs

Answer 330

``` Smoking cessation Nutritional advice - well balanced - severe dietary restriction associated with LBW - low fasting BGL associated with LBW ```

Answer 331

AC is most sensitive SINGLE measurement (EFW also good) Serial RELATIONSHIP between HC and AC, along with AFI interpretation is most useful for identifying growth pattern - i.e. reduced AC growth with maintained HC growth, associated with oligohydramnios = IUGR ** oligohydramnios without an obvious cause is associated with high perinatal mortality

Answer 332

``` Bloods (if early <32/40): - Hb - ?thrombocytopaenia - TORCH screen If severe early IUGR, consider: - thrombophilia screen - karyotype ``` USS: - AC/HC/AFI - UA Doppler surveillance (if increased resistance, repeat in 2 weeks, if absent or reversed diastolic flow, admit and steroid load, usually needs delivery within days)

Answer 333

Usually reflects mild-moderate uteroplacental dysfunction Serial growth and AFI every 2 weeks

Answer 334

Depends on aetiology, severity and gestation If moderate: - consider IOL if cervix favourable >36/40 - delay until >37/40 if normal surveillance If significant: - Aim to delivery 34-36 weeks - if very preterm, delay until imminent signs of fetal compromise - delivery if>34/40 and AREDF - If IUGR and oligohydramnios >36 weeks, deliver **If associated with AREDF, almost always requires LSCS delivery

Answer 335

Routine iron supplement for all babies <2500g | - 2mg/kg/day from approx 8 weeks to 12 months of age

Answer 336

A: abdo palp (No fetal head palpable), address woman, analgesia, assistants B: bladder empty C: cervix check (fully, membranes ruptured) D: determine position, station and pelvic adequacy E: equipment- inspect vacuum cup, pump and tubing, check pressure. OR check correct forceps, blades match and lock F: FLEXION POINT- position cup 3cm anterior to posterior fontanelle and using Finger to clear maternal tissue FORCEPS: apply blades (left first) G: Gentle traction H: HALT - stop vacuum if no progress with 3 pulls, 3 pull offs or no significant progress after 20 minutes HANDLE ELEVATED: elevate forceps handles in axis of birth canal I: Incision - consider episiotomy J: Jaw - remove cup/forceps when jaw is reachable or delivery assured

Answer 337

Maternal: - inability to push - Prolonged 2nd stage (3h with epidural, 2h without) - Cardio or vascular conditions - neurological or muscular disease - significant vaginal bleeding Fetal: - suspected compromise - malposition with relative dystocia (e.g. OP/OT)

Answer 338

- operator inexperience - incompletely dilated cervix - unknown fetal position - unengaged head - malpresentation (e.g. face or brow) - suspected CPD - GA <36/40 (for vacuum only) (Relative:) - fetal predisposition to fracture e.g. OI - fetal bleeding disorder (e.g. haemophilia) - Maternal bloodborne virus

Answer 339

- analgesia - early removal of IDC (within 24h) - early mobilisation and hydration - deep breathing and coughing exercises +/- physio - diet as tolerated - debrief on birth and impact on future pregnancies - observe for postop complications (ileus, UTI, URTI, DVT, wound infection)

Answer 340

- evidence of intrauterine fetal pole (CRL) >6mm on TV scan with absent heartbeat - Gestation sac >15mm without fetal pole - successive scans of gestation sac <15mm fail to show change in size over 10-14 days - substantial tissue within uterus >15mm with a history of blood loss and possible passage of tissue (incomplete miscarriage) - Small fetal pole seen and bHCG is falling

Answer 341

- 70% will resolve spontaneously - contents <15mm likely to resolve spontaneously - 20% will need subsequent D&C especially if contents >15mm - Complete resolution may take weeks - less likely to be successful if there is an intact non-viable fetus and gestation sac Need review 7-10 days after diagnosis, consider repeat ultrasound if there were previously contents noted

Answer 342

Bleeding Infection Perforation (1 in 300) Asherman's syndrome (1:1000) - less likely with suction curette GA risks Small risk of repeat procedure in presence of ongoing bleeding

Answer 343

``` Tubal (95%) - Ampullary (55%) - Isthmic (25%) - fimbrial (17%) - Interstitial (2%) Other (5%) - Cervical - ovarian - peritoneal - C-section scar ```

Answer 344

in developed countries: Approx 1% of pregnancies are ectopic (1% of ART pregnancies are heterotopic, 1 in 30,000 spontaneous conceptions are heterotopic) - most common in 25-34yo - mortality rate in developed countries 0.2% - 10% recurrence risk after a single ectopic

Answer 345

- PID (7-fold increased incidence) - smoking (impairs tubal motility) - tubal surgery - previous ectopic pregnancy - POP, emergency pill, IUD (lower risk than those NOT on contraception, but higher risk than COCP users as progesterone reduces tubal mobility) - ART - endometriosis - Abnormal embryo

Answer 346

- inappropriately rising quant serum bHCG (though up to 1% will have hCG levels <25 therefore neg on UPT_ - no intrauterine sac seen with HCG levels suggestive that should be visible ultrasonographically (PUL, not confirmed ectopic) - fluid in pouch of douglas if ruptured, may have adnexal mass Laparoscopy - gold standard for diagnosis

Answer 347

TV scan: 1000-1500 | TA: 1800-2000

Answer 348

- Significant pain - Adnexal mass >35mm - fetal activity on USS - hCG 5000IU or higher - no availability for follow up of medical management - maternal preference or seeking permanent contraception - subsequent ectopic pregnancy in ipsilateral tube after previous medical management

Answer 349

- Salpingectomy (ideally laparoscopic, especially if haemodynamic compromise Salpingotomy - if other risk factors for infertility (i.e. already had other tube removed) - 5% risk of persistent ectopic, 20% risk of further treatment, higher rates of recurrent ectopic Local injection of MTX, KCl or prostaglandins - high risk of persisting

Answer 350

- haemodynamic instability - fetal cardiac activity - hCG >5000 - mass >35mm - no access to emergency facilities within 30 minutes of home - heterotopic pregnancy - immunodeficiency - free fluid in pelvis - sensitivity to MTX pre-existing liver, haematological, pulmonary or peptic ulcer disease

Answer 351

- Cease folate supplements - 50mg/m2 TBSA methotrexate single dose IM - Avoid UV light and high FODMAP foods to avoid side effects - paracetamol (+/- NSAIDs if safe)- can get separation pain approx day 3-4 - quant hCG on day 0(+baseline bloods), 4 and 7 - if fails to fall more than 15% between days 4 and 7, will need second dose - avoid pregnancy for 3 months Consider if anti-d required (all Rh negative women)

Answer 352

- lower serum hCG - slow-risking plateau or falling hCG prior to treatment - falling hCG by day 4

Answer 353

Delayed or absent puberty with an impaired sense of smell +/- colour blindness (Autosomal dominant condition, causing GnRH deficiency (hypothalamic hypogonadotrophic hypogonadism)

Answer 354

GnRH test - administer GnRH, if LH response is appropriate = hypothalamic failure - if absence of LH response = pituitary failure

Answer 355

PALM COEI N PALM = visually objective structural COEI = unrelated to structural anomalies N = not yet classified (e.g. AV malformations etc. ) Polyps Adenomyosis Leiomyoma (i.e. fibroids) Malignancy Coagulopathy Ovulatory disorders Endometrial Iatrogenic keep in mind women may have NON-uterine causes of vaginal bleeding (urethral, vulvar, vesical, vaginal, cervical and recto-anal)

Answer 356

Anti-D Anti-c Anti-kell ``` Anti-S Anti-s Anti-u Anti-dia Anti-Coa ```

Answer 357

Levels <1:32 are reasonable UNLESS - >2-fold increase in titre OR - Anti-kell antibodies (even low titres are at risk for HDFN)

Answer 358

``` Suppressed erythropoiesis PLUS haemolysis PLUS peripheral sequestration of red cells ```

Answer 359

4 weekly titres until 28 weeks, then every 2 weeks If titre >1:32 then needs weekly MCA PSV (through MFM department)

Answer 360

Vasovagal syncope Postural hypotension Haemorrhage (PPH, APH, Splenic artery aneurysm rupture, hepatic rupture) Thromboembolism Amniotic fluid embolism Epilepsy Eclampsia Intracranial haemorrhage Cardiac disease (MI, aortic dissection, cardiomyopathy, arrhythmia) Drug toxicity/overdose (MgSO4, Local anaesthetic, illicit drugs) Anaphylaxis

Answer 361

If there is no response after 4 minutes of correctly performed CPR in a woman >20 weeks

Answer 362

Can occur in any trimester Caused by changes in the normal relationship between the membranes, placenta and uterine wall -> disruption of the integrity of the uterine blood vessels amniotic fluid/debris is deposited in maternal lungs -> pulmonary vasoconstriction (?anaphylactic-type reaction)

Answer 363

Sudden collapse during labour/delivery or immediate postpartum associated with: - dyspnoea - pink frothy sputum - cyanosis - Cardiorespiratory failure - convulsions (10-20% of cases) HYPOTENSION HYPOXIA with respiratory failure DIC COMA OR SEIZURES

Answer 364

Onset almost immediately (within up to 20 mins max) of administering local anaesthetic - complain of metallic taste, tinnitus, confusion and disorientation - respiratory muscle paralysis and cardiac arrest may occur