Final O&G II Flashcards

Question

What are the risks to baby if they are LGA? [4]

Answer 1

**The risks to the baby include**: * **Birth injury** (Erbs palsy, clavicular fracture, fetal distress and hypoxia) * **Neonatal** **hypoglycaemia** * **Obesity** in **childhood and later life** * **Type 2 diabetes in adulthood**

Answer 2

**Check** **history** and **consider all risk factors for placental dysfunction** + measure **serum PAPP-A at 11-14 weeks: if < 0.4 placenta** may not have formed properly + **Doppler studies**

Answer 3

**Hypoxia --> acidemia --> CNS damage --> stillbirth:** * **Placental dysfunction** would be indicated by **abnormal uterine artery dopplers (UtA)** * Leads to **abnormal umbilical artery** * Leads to **brain sparing effect** - causing an **abnormal MCA Doppler** * Leads to **reduced cardiac compliance** and **abnormal venous doppler** * Leads to **fetal movements reduced** and **abnormal cCTG.** * Leads to still birth

Answer 4

**LGA**= **EFW>90th centile** or **EFW>4000g** **Macrosomia**= **EFW>4.500g**

Answer 5

**Beckwith Wiedemann** – macroglossia, exomphalos, organomegaly ## Footnote NB: comes up a couple of times in lecture

Answer 6

**Placental abruption is an obstetric emergency**: * Urgent involvement of a senior obstetrician, midwife and anaesthetist * 2 x grey cannula * Bloods include FBC, UE, LFT and coagulation studies * Crossmatch 4 units of blood * Fluid and blood resuscitation as required * CTG monitoring of the fetus * Close monitoring of the mother * **Active management of stage 3 labour** * **Corticosteroids** for baby between **24th and 34th weeks of getation** ## Footnote **NB**: It is important to consider concealed haemorrhage, where the vaginal bleeding may be disproportionate to the uterine bleeding.

Answer 7

Women with **antepartum** **haemorrhage** and **associated maternal and/or fetal compromise** are required to be **delivered immediately**. While **RCOG** **does** **not** **recommend** **premature delivery of fetus** in women with **less than 37 weeks of gestation** with **no fetal and maternal compromise**. **If gestational age** is **equal to or more than 37 weeks** and the **bleeding** presents as **spotting** or **mucus** streaks of blood, **active intervention is unlikely needed.** **Minor or major antepartum bleeding**, RCOG suggests **inducing** **labour** with the **aim of achieving vaginal delivery** to avoid serious complications related to placental abruption

Answer 8

**Diagnosed** **early** in pregnancy (e.g. at the 20-week anomaly scan): - Repeat scan at **32**. If still present.. - Repeat at **36** weeks gestation **Corticosteroids** are given **between 34 and 35 + 6 weeks** gestation to mature the fetal lungs, given the risk of preterm delivery. **Planned delivery** is considered between **36 and 37 weeks gestation**. It is **planned** **early** to **reduce the risk of spontaneous labour and bleeding** - **Planned cesarean section** is required with p**lacenta praevia and low-lying placenta** (< 20mm from the internal os).

Answer 9

**Normally**: - **umbilical** **cord** containing the **fetal vessels** (umbilical arteries and vein) **inserts directly into the central portion of the placenta**. - The fetal vessels are always **protected**, either by the **umbilical cord or by the placenta.** - The **umbilical cord contains Wharton’s jelly.** Wharton’s jelly is a layer of soft connective tissue that surrounds the blood vessels in the umbilical cord, offering protection. **Vasa praevia:** - Eccentric or marginal insertion of the umbilical cord. Get either: - **Velamentous cord insertion**: umbilical cord inserts into the chorioamniotic membranes rather than centrally into the placental mass. The blood vessels branch out from this point and travel within these membranes before reaching their connection with the placenta. OR - **Bilobed or succenturiate-lobed placentas**: variations in placental morphology where there's more than one lobe to a placenta. If a blood vessel connects two lobes across fetal membranes that traverse overlying cervical os, it can lead to vasa praevia.

Answer 10

**Ramified Vasa Praevia**: - Also known as **branching vasa praevia**, it involves **multiple small-calibre vessels crossing over the internal os**. **Funic Presentation Vasa Praevia:** - Characterised by a **single large vessel running over or near the internal os**, often associated with a **funic presentation of umbilical cord.**

Answer 11

**Painless PV Bleeding:** - Most common - Often sudden and can be heavy **Abnormal Fetal Heart Rate Patterns**: - Due to compromise in fetal blood supply - Most commonly bradycardia **Rupture of membranes**: - The membrane rupture exposes the unprotected vessels causing them to tear and bleed. **Fetal Anemia** - In cases where there has been chronic slow leakage from the vasa praevia, fetal anemia may occur due to gradual loss of fetal blood. **Fetal Distress or Death**: - If not promptly diagnosed and managed, vasa praevia can lead to severe fetal distress due to hypoxemia and even intrauterine death.

Answer 12

**Suspected vasa praevia**: hospital admission between 28-32w, antenatal steroids, elective CS between 35-37w **Undiagnosed vasa praevia**: emergency cat 1 CS and aggressive fetal resuscitation

Answer 13

If not above knee and presents with no other symptoms / signs - think **physiological dyspnea of pregnancy** If unilateral leg swelling - Think **VTE** If bilateral & hypertension (w/ proteinuira) - Think **pre-eclampsia** - also ask about **headache and visual changes** -

Answer 14

Risk of **Fetal varicella syndrome (FVS)**: - skin scarring - eye defects (microphthalmia) and cataracts - scars and significant skin changes located in **dermatomes** - **limb** **hypoplasia** - microcephaly - learning disabilities **Lecture notes:** - soft-tissue calcification * polyhydramnios, * limb defects and dermatomal skin scarring (due to fetal herpes zoster), * soft-tissue calcification * damage to the eyes and CNS. Neurological defects include cortical atrophy, microcephaly, limb paresis, spinal cord atrophy, encephalitis, seizures and Horner’s syndrome.

Answer 15

**severe neonatal varicella**: - if the mother develops rash **between 5 days before and 2 days** after birth there is a risk of neonatal varicella, which may be fatal to the newborn child in around 20% of cases

Answer 16

**oral aciclovir (or valaciclovir**) is now the first choice of **PEP** for **pregnant women at any stage of pregnancy** who are **exposed** to **chickenpox** - antivirals should be **given at day 7 to day 14 after exposure**, **NOT immediately** **Infection**: - consensus guidelines (Health Protection Authority and RCOG) suggest **oral aciclovir should** be given if the **pregnant women is ≥ 20 weeks and she presents within 24 hours of onset of the rash** - if the woman is **< 20 weeks the aciclovir should be 'considered with caution'** ## Footnote -Unknown exposure--> Antibodies test -NOT immune --> Oral aciclovir from day 7-14 after exposure -Aciclovir C.I? --> VZIG -Developed chickenpox--> Oral aciclovir if >20 weeks + present within 24 hours of onset of rash

Answer 17

**First 20 weeks** - but first **10 weeks poses highest risk** When **primary infection occurs before 12weeks’ gestation**, given the **risk of fetal infection and the risk of an infected fetus developing severe abnormalities**, it is reasonable to consider **termination** of **pregnancy** when appropriate

Answer 18

The features of congenital CMV are: * **'Blueberry muffin rash'** * **Petachial rash** * **Fetal growth restriction** * **Microcephaly** * **Hearing loss** - this is the key one to remember * **Vision loss** * **Learning disability** * **Seizures** ## Footnote **NB**: With approximately 40,000 infected children per year, **congenital CMV infection is the most common cause of congenital non-genetic hearing loss**

Answer 19

**Microcephaly** **Fetal growth restriction** Other intracranial abnormalities, such as **ventriculomegaly and cerebellar atrophy**

Answer 20

**Excess production can be due to increased foetal urination:** * **Maternal** **diabetes** **mellitus** * **Foetal** **renal disorders** * **Foetal** **anaemia** * **Twin-to-twin transfusion** syndrome **Insufficient removal can be due to reduced foetal swallowing**. Due to: [4] * **Oesophageal or duodenal atresia** * **Diaphragmatic** **hernia** * **Anencephaly** * **Chromosomal** **disorders**

Answer 21

**Maternal**: - **respiratory** **compromise** due to **increased pressure on the diaphragm** - **Increased risk of urinary tract infections** due to **increased pressure on the urinary system** - **Worsening** of other symptoms associated with pregnancy such as **gastro-oesophageal reflux, constipation, peripheral oedema and stretch marks** * **Increased incidence** of **caesarean section delivery**

Answer 22

* **Pre-term labour** and **delivery** * **Premature** **rupture** of **membranes** * **Placental** **abruption** * **Malpresentation** of the **foetus** (the foetus has more space to “move” within the uterus) * **Umbilical cord prolapse** (polyhydramnios can prevent the foetus from engaging with the pelvis, thus leaving room for the cord to prolapse out of the uterus before the presenting part)

Answer 23

The risk of congenital infection appears to vary according to the point in gestation at which primary infection occurs, **increasing from around 30% in the first trimester to 47% in the third trimester.** **While the risk of viral transmission is lower in early pregnancy**, the proportion of cases with a prenatal diagnosis of **severe fetal infection is higher when infection occurs in the first compared with the third trimester of pregnancy.**

Answer 24

The main sequelae of congenital toxoplasma infection involve the CNS and eyes, and typically include **microcephaly, hydrocephalus, ventriculomegaly and chorioretinitis**. These may lead to developmental delay, epilepsy and blindness.

Answer 25

**Spiramycin** (until the end of the pregnancy, in the absence of confirmed vertical transmission) **should be used to prevent vertical transmission after maternal toxoplasma infection during pregnancy** If **vertical transmission** is **confirmed**: - fetal infection should be treated by **spiramycin** **only for 1 week,** followed by **pyrimethamine** **plus** **sulfadiazine** **plus** **folinic** **acid** **throughout** the **pregnancy** and the **infant treated for 1further year.**

Answer 26

Fetal anaemia and fetal hydrops both visible on ultrasound. Anaemia can be assessed measuring at the **Peak Systolic on Middle Cerebral artery (raised MCA-PSV).**

Answer 27

Treatment should not be delayed. Management of the woman should be in line with her clinical condition and will usually involve the **use of oral** (or intravenous for disseminated HSV) **aciclovir** in **standard doses** (400 mg three times daily, usually for 5 days). **In the third trimester, treatment will usually continue with daily suppressive aciclovir 400 mg three times daily until delivery**. **Caesarean** **section** should be the **recommended mode of delivery** for all women developing **first episode genital herpes in the third trimester**, particularly those **developing symptoms within 6 weeks of expected delivery**, as the risk of neonatal transmission of HSV is very high at 41%

Answer 28

Delivery: * Risk of malpresentation / cord prolapse/ pre term labour * Aim **delivery** around **37 weeks** for **severe polyhydramnios** * **38-40 weeks** for **moderate** **polyhydramnios** * **Nasogastric tube postnatally** to ensure there is **no blockage in oesophgus/ tracheoesophageal fistula**

Answer 29

**Symptoms** typically start **2-3 hours** after starting **misoprostol** (second medication) * **Vaginal bleeding** - gestational age correlates to bleeding amount * **Heavy with clots** * Some **bleeding** up to **2-3 weeks** - normal * **Lower abdominal pain** - stronger than period pain **Bad period-like cramping pain** * Most **complete** within **6-8 hours**, almost all by **24 hours** Since telemedicine, EMA can be provided in many circumstances without the need for a scan

Answer 30

**Dilatation and evacuation (D&E)** Typically from **14-24 weeks** * **Cervical** **preparation** with **mifepristone** / **misoprostol (or both) / osmotic dilators** inserted into cervical os; absorb fluid and then dilate cervix * **Cervical dilation and removal of fetus and placenta using forceps and vacuum aspiration**

Answer 31

**Antibiotic prophylaxis** * Not required for early medical abortion * Surgical: **doxycycline 100mg bd for 3 days** (or Azithromycin 1g oral) **Anti-D** * Not required for early medical abortion * **Prophylactic anti-D for all Rh negative, non-sensitised women** undergoing surgical abortion * Administer within 72 hours of abortion

Final O&G II Flashcards

(55 cards)