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Year 4 - 1. Reproductive Health > Group E - High-Risk Pregnancy and Obstetric Emergencies > Flashcards

Group E - High-Risk Pregnancy and Obstetric Emergencies Flashcards

1
Q

Outline the triad of clinical findings in pre-eclampsia

A
  1. Hypertension (> 140/90)
  2. Proteinuria
  3. Oedema
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2
Q

Briefly explain the suspected pathology of pre-eclampsia

A
  • Poor trophoblast invasion of the endometrium, leads to reduced quality and development of the spiral arteries and lacunae at around 20 weeks
  • This leads to high vascular resistance in the spiral arteries which causes oxidative stress
  • This leads to an inflammatory process and impaired endothelial function
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3
Q

List some risk factors for developing pre-eclampsia (aim to categorise into high and low risk)

A

High risk:
- Pre-existing HTN
- Previous pre-eclampsia in pregnancy
- Family history of pre-eclampsia
- Pre-existing renal disease
- Autoimmune condition
- Diabetes
- CKD

  • Large gap between pregnancies (>10yrs)
  • BMI > 35
  • Age > 40
  • First pregnancy
  • Twins / triplets or molar pregnancy
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4
Q

List some potential symptoms and signs of pre-eclampsia

A

Symptoms:
- Headache
- Visual disturbance
- Nausea & vomiting
- Abdominal pain
- Oedema
- Bleeding

Signs:
- HTN
- Papilloedema
- Proteinuria
- Non-dependant oedema
- Abnormal foetal doppler
- Oligohydramnios
- Hyperreflexia

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5
Q

List some investigations for pre-eclampsia

A

Maternal:
- Blood pressure
- Urinalysis (proteinuria)
- FBC (platelet count)
- LFTs (liver function)
- U&Es and eGFR (renal function)
- PCR / 24 hr collection (proteinuria)

Foetal:
- Regular ultrasound growth scans / foetal doppler / amniotic fluid volume measure
- CTG (foetal wellbeing)

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6
Q

Outline how you go about diagnosing pre-eclampsia

A

NEW onset of hypertension after 20 weeks, PLUS presence of 1 or more of the following:

  • Proteinuria
  • Renal insufficiency (raised creatinine)
  • Liver involvement (abnormal LFTs)
  • Neurological complications e.g. eclampsia, visual disturbance, severe headaches, altered mental status, stroke
  • Blood derangement e.g. thrombocytopenia or DIC
  • Placenta dysfunction e.g. fetal growth restriction, abnormal doppler
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7
Q

Outline the medication used in prophylaxis of preeclampsia for those at risk

A

Aspirin 150mg daily
From 12 weeks to 36 weeks

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8
Q

List some complications of pre-eclampsia
- Maternal
- Foetal

A

Maternal:
- Seizures
- Cerebral haemorrhage
- Renal failure
- Hepatic failure / rupture
- Pulmonary oedema
- DIC or thrombocytopenia

Foetal:
- Foetal growth restriction
- Foetal distress
- Premature delivery
- Stillbirth
- Oligohydraminos
- Placental abruption or infarct

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9
Q

List some complications of eclampsia
- Maternal
- Foetal

A

Maternal:
- HELLP syndrome
- DIC
- AKI
- ARDS
- Stroke (haemorrhage)
- Pernament neurological deficit / death

Foetal:
- Prematurity
- Intrauterine growth restriction (IUGR)
- Placental abruption
- Respiratory distress syndrome
- Foetal death

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10
Q

Outline the management of preeclampsia (not severe)

A
  • Labetalol (2nd line Nifedipine or Methyldopa)

Important to monitor mother and foetus closely for complications

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11
Q

Outline the management of severe preeclampsia

A
  • Labetalol
  • Magnesium infusion (prevent eclampsia)
  • Consider premature labour/delivery + steroids for lung development
  • Strict fluid balance
  • Consider HDU admission
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12
Q

Outline the emergency management of eclampsia

A

IV access
- Bolus 4g Magnesium sulphate
- Continuous infusion Magnesium sulphate
- Control hypertension (Labetalol)
- Strict fluid balance
- Consider HDU admission
- Plan for delivery by most appropriate route

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13
Q

Outline some aspects of postnatal care of preeclampsia patients

A
  • Anti-HTN for up to 6-12 weeks postnatally
  • Assess for VTE risk
  • Refer to postnatal hypertension clinic
  • Discussion of contraception and inform of implications for future pregnancy
  • Write to GP
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14
Q

Outline HELLP syndrome in terms of preeclampsia and 3 abnormalities seen in the bloods

A

HELLP syndrome is a combination of complications from preeclampsia/eclampsia
HELLP (Haemolysis, Elevated Liver enzymes, Low Platelets)

HELLP:
Haemolysis
Elevated Liver enzymes
Low Platelets

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15
Q

HELLP syndrome - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management

A

Pathophysiology:
- Complication associated with preeclampsia in pregnant women in the 3rd trimester
- However can also occur within 7 days of delivery
- Unknown specifically why it happens
- 3 changes of Haemolysis, Elevated Liver enzymes and Low Platelets

Presentation:
- Jaundice
- RUQ / abdominal pain
- Ascites / oedema
- Easy bruising, bleeding, petechiae
- N&V
- Fatigue
+ HTN, headache and proteinuria (preeclampsia)

Investigations:
- FBC and clotting profile (anaemia, low platelets)
- LFTs (elevated liver enzymes, raised bilirubin, low haptoglobin)
- Blood film (shows schistocytes)
- VBG (raised LDH)

Management:
Mainly supportive
- Deliver baby early (especially if > 34 weeks) with corticosteroids for surfactant and magnesium
- Blood transfusion
- Steroids e.g. Dexamethasone
- Antihypertensives

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16
Q

Outline some adverse pregnancy outcomes from hypergylcaemia

A
  • Increased rates of miscarriage
  • Increased rates of congenital abnormalities (mostly preconception hyperglycaemia)
  • Increased rates of macrosomia and associated shoulder dystocia
  • Preterm birth
  • Perinatal mortality
  • Preeclampsia
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17
Q

Name the hormone responsible for the diabetic state in pregnancy

A

HPL - human placental lactogen

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18
Q

List some congenital abnormalities associated with pre-conception hyperglycaemia, for the following systems:
- Cardiac
- Neuro
- MSK

A

Cardiac:
- VSD
-Tetralogy of Fallot
- Transposition of the great arteries
- Truncus arteriosus
- Persistent foetal circulation

Neuro:
- Spina bifida
- Anencephaly

MSK:
- Caudal regression / sacral agenesis (abnormal development of lower spine, associated with T1DM)

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19
Q

Outline the ideal HbA1C level and what level that it should strongly be advised to avoid pregnancy

A

Ideal is HbA1c < 6.5%

Avoid pregnancy if HbA1c > 10%

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20
Q

Outline some factors to consider in diabetic prenatal care, including additional medications to consider

A
  • Optimal diabetes control (HbA1c < 6.5%)
  • Weight loss if BMI > 27
  • Retinal assessment
  • Can continue on Metformin, but change other oral hypoglycemics to insulin therapy
  • VTE prophylaxis assessment

Additional medications:
- Aspirin 75mg from 12 weeks
- Increased folic acid 5mg daily, from 3 months prior to conception
- Stop any unsafe medications e.g. ACEi
- Add vit D if BMI > 35

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21
Q

Outline blood glucose level targets in pregnancy (pre-meal and 1 hr post-meal)

A

Pre-meal: < 5.3 mmol/L
1 hr post-meal: < 7.8 mmol/L

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22
Q

Outline recommended gestation for delivery of a diabetic pregnancy

A

Deliver at 37 - 38 (+6) weeks (induction of labour)
Or elective caesarean at 38-39 weeks

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23
Q

Outline some risk factors for developing gestational diabetes

A
  • GDM in a previous pregnancy
  • Previous macrosomic baby
  • Obesity (BMI > 30)
  • First degree relative with GDM
  • Ethnicity e.g. south asian or middle eastern
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24
Q

Outline the screening test used for those at risk of gestational diabetes and at what gestation it’s done

A

Screening test: oral glucose tolerance test (OGTT)
- Give 75ml glucose drink
- Measure glucose pre-drink and 2 hours post-drink

Done at:
- 26-28 weeks
- Earlier (16-18 weeks) if previous GDM or high risk factors

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25
Q

Outline briefly how GDM is managed and the additional monitoring required for diabetic pregnancy

A
  1. Lifestyle management (unless very high OGTT)
    - Weight loss
    - Increased exercise
    If fails, add:
    - Metformin 1st line (then add sulfonylureas or insulin)

Ultrasound scans
- Normal dating scan at 12 weeks (look for neural tube defects)
- Detailed scan at 20 weeks (look for cardiac abnormalities)
- Growth scans every 4 weeks, after 28 weeks (28, 32, 36, 40)

Joint antenatal diabetic clinic
- Every 1-2 weeks
- Discussion regarding delivery of baby

Retinal screen
- First test done in 1st trimester
- Re-test at 28 weeks

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26
Q

Outline the requires of post-natal GDM management

A
  • Stop all medications and blood glucose monitoring
  • Fasting blood glucose test at 6 weeks postpartum
  • HbA1c at 13 weeks
  • Lifestyle advice
  • Contraception and advice on future pregnancies
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27
Q

List some conditions that babies born to diabetic mothers are at risk of after birth

A
  • Hypoglycaemia
  • Polycythaemia
  • Jaundice
  • Congenital heart disease and cardiomyopathy
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28
Q

Briefly outline how pre-existing diabetes is managed in pregnancy including: medications, any screening and delivery aims

A
  • Should aim for very tight glucose control, especially before conception

Medications:
- Take 500mg of folic acid (rather than 400mg) from pre-conception until 12 weeks gestation
- Only Metformin and Insulin should be used, all other oral hypoglycaemics should be stopped

Screening:
- Retinopathy screening should be performed at 2 points: at booking and at 28 weeks

Delivery:
- Planned delivery is advised between 37-39 weeks (gestational diabetes up to 41 weeks)

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29
Q

What % of women with gestational diabetes go on to develop type 2 diabetes in the future?

A

50%

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30
Q

Outline the pathophysiology of obstetric cholestasis and how it presents

A
  • Caused by reduced outflow of bile acids from the liver (due to increased oestrogen and progesterone)
  • Leads to build up of bile acids in the blood
  • Usually presents after 28 weeks and resolves after delivery of the baby

Presentation:
- Intense itching of palms of hands / soles of feet
- Absence of a rash
- Jaundice
- Dark urine / pale stools
- Fatigue / malaise

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31
Q

List some investigations for suspected obstetric cholestasis

A
  • LFTs and bile acids
  • Viral screen (hepatitis)
  • Liver autoimmune screen
  • USS abdomen
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32
Q

Outline the risks of obstetric cholestasis
- Maternal
- Foetal

A

Maternal:
- Vitamin K deficiency (bleed risk - PPH)

Foetal:
- Increased risk of stillbirth / perinatal mortality
- Foetal distress / preterm labour
- Intracranial haemorrhage

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33
Q

Outline the management of obstetric cholestasis, including medications, advised delivery gestation and monitoring postpartum

A

Drug treatment for pruritus:
- Urso-deoxycholic acid
- Antihistamines e.g. Chlorphenamine
- Calamine lotion

+ Vitamin K for both mum & baby (minimise risk of bleeding)
+ Foetal surveillance

Baby should be delivered at normal delivery date, but with LFT tests 10 days after birth

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34
Q

List the reasons in pathophysiology why pregnancy women are at an increased risk of VTE

A
  • Hypercoagulable state
  • Increase in fibrinogen and factors 8, 9 and 10
  • Venous stasis in lower limbs and compression of veins
  • Trauma at pelvic veins at time of delivery
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35
Q

List some additional obstetric risk factors which increase the risk of VTE in pregnancy

A
  • Multiple pregnancy
  • Preeclampsia
  • Prolonged labour
  • Caesarean section
  • PPH haemorrhage > 1L
  • Preterm birth
  • Stillbirth
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36
Q

Outline which side is more likely for a DVT in pregnancy

A

Left side
- Venous drainage into left renal vein

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37
Q

Outline tests for suspected DVT in pregnancy

A

Compression duplex ultrasound

  • If ultrasound is negative and low level of clinical suspicion, anticoagulant treatment can
    be discontinued
  • If ultrasound is negative but high level of clinical suspicion, anticoagulant
    treatment should be discontinued but the ultrasound repeated on days 3 and 7
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38
Q

Outline tests for suspected PE in pregnancy

A
  • Blood tests: FBC, U&E, LFTs
  • ECG
  • Chest x-ray
  • Duplex USS for DVT (if confirmed, no further investigations = treat)

If chest x-ray normal = V/Q scan
If chest x-ray abnormal = CTPA

START LMWH before waiting for tests

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39
Q

Outline management for suspected VTE in pregnancy

A
  • Immediate full anticoagulation with LMWH, continue until 6 weeks postnatally
  • TED stocking / intermittent pneumatic compression
  • Advice on future pregnancies and generally e.g. risk of flying
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40
Q

List some antenatal factors that can increase the likelihood of preterm birth

A
  • Chorioamnionitis
  • Growth restriction (intrauterine)
  • Hypertension / preeclampsia
  • Gestational diabetes
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41
Q

Outline some consequences for the foetus if born preterm

A
  • Death
  • Respiratory distress syndrome
  • Sepsis
  • Chronic lung disease
  • Intraventricular haemorrhage
  • Necrotizing enterocolitis
  • Retinopathy

If < 28 weeks:
- Physical disability
- Learning disability
- Behavioural problems
- Visual / hearing problems

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42
Q

Outline the difference between SPROM, PROM and P-PROM in terms of rupture of membranes (ROM)

A

SPROM (spontaneous rupture of membranes)
- Self explanatory

PROM (pre-labour rupture of membranes)
- Rupture of membranes before the onset of labour

P-PROM (preterm pre-labour rupture of membranes)
- Rupture of membranes before the onset of labour AND before 37 weeks (preterm)

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43
Q

At what gestation is a baby considered premature and outline the 3 subcategories

A

Premature = born before 37 weeks

Extremely premature = < 28 weeks
Very premature = 28-32 weeks
Moderate-late premature = 32-37 weeks

The more premature the baby, the worse the outcomes

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44
Q

Suggest 2 methods that can be used to help prevent pre-term labour occurring (prophylaxis) and when they can be given

A
  1. Cervical cerclage (stitch)
    - Mechanical support to prevent cervix opening
    - Involves spinal or general anaesthetic
    - Removed prior to labour
  2. Vaginal progesterone pessary
    - Prevents remodelling of cervix and reduces myometrial activity

Between 16-24 weeks, if cervix < 25mm

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45
Q

Outline when a cervical cerclage may be used

A

Offered between 16-28 weeks
When there is cervical dilation WITHOUT rupture of membranes

Prevents progression and premature delivery

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46
Q

State the definition of P-PROM

A

Preterm - prelabour rupture of membranes (P-PROM)

Rupture of amniotic sac and release of amniotic fluid, before the onset of labour and before 37 weeks (preterm)

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47
Q

State the definition of PROM (prelabour rupture of membranes)

A

Prelabour rupture of membranes (PROM)

Rupture of amniotic sac and release of amniotic fluid, before the onset of labour after 37 weeks (at term)

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48
Q

Outline the risks to baby from P-PROM (preterm - prelabour rupture of membranes)

A
  • Prematurity
  • Chorioamnionitis and sepsis
  • Cord prolapse
  • Pulmonary hypoplasia (underdeveloped lungs)
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49
Q

State how P-PROM (preterm - prelabour rupture of membranes) is diagnosed

A

Mainly diagnosed by clinical history and speculum examination
(no digital vaginal exam)
- Would see pooling of amniotic fluid in the vagina

If there is doubt over the diagnosis:
- Actim-PROM (swab tests for amniotic insulin-like growth factors)

50
Q

Outline what symptoms may indicate PROM (prelabour rupture of membranes)

A
  • Foul-smelling or greenish amniotic fluid
  • Maternal fever
  • Reduced foetal movements
51
Q

Outline what symptoms may present for P-PROM (preterm - prelabour rupture of membranes)

A
  • Sudden gush of fluid
  • Steady leaking of fluid
  • Perception of urinary incontinence
  • Watery discharge
52
Q

Outline how P-PROM (preterm - prelabour rupture of membranes) can be managed

A

For women <37 weeks, whose membranes have ruptured…

  • Admission to hospital for observations (at least 2-3 days)
  • Inform NICU
  • Regular blood tests FBC and CRP for chorioamnionitis
  • Foetal monitoring
  • Steroids if < 34 weeks
  • Prophylactic Erythromycin for 10 days or until labour (whichever is soonest)

Aim to deliver at term (37 weeks) unless presence of group B strep (then 34 weeks)

53
Q

Outline how PROM (prelabour rupture of membranes) can be managed

A

Can offer 2 of following options, depending on patient choice:
1. Expectant management for up to 24 hours after the time of rupture of membranes
2. Immediate induction of labour (needed if there are any signs of infection)
**Those with HIV, Hep B/C, group B strep need to be induced immediately

Vaginal examinations should be kept to a minimum (risk of infection) - use CTG as alternative

+ observe after birth for 12 hours

54
Q

Define pre-term labour

A

Pre-term labour is when regular contractions and cervical dilation occur, before 37 weeks

(75% spontaneous, 25% elective)

55
Q

List some factors that increase the risk of preterm labour

A
  • Previous preterm delivery = most significant factor
  • Previous cervical surgery e.g. LLETZ procedure
  • Previous miscarriage
  • Multiple pregnancy
  • Asymptomatic bacteria
  • Bacterial vaginosis
  • Drug abuse / smoking
  • Extremes of age
56
Q

For those at risk of preterm labour, suggest what 2 aspects are monitored (more than normal)

A
  1. Transvaginal cervical length measurement
  2. High vaginal swabs for bacterial vaginosis
57
Q

Outline what 2 methods prophylaxis can be given to those with a shortened cervix between 16-24 weeks

A
  1. Cervical cerclage (stitch)
  2. Vaginal progesterone pessary
58
Q

Outline how preterm labour could present in terms of symptoms

A
  • Abdominal cramps / mild contractions
  • Mucus plug show
  • Sensation of pressure in the cervix/vagina
  • Lower back ache
59
Q

Outline what you would examine for a patient in suspected preterm labour

A

Abdomen:
- firmness
- tenderness
- foetal position

Measure contractions:
- frequency
- duration
- intensity

CTG for foetal heart rate

Speculum:
- observe dilation
- assess for blood, fluid or mucus

60
Q

Outline the investigations for suspected preterm labour

A

Transvaginal ultrasound of cervix length:
- < 15mm likely to be preterm labour = offer treatment
- > 15mm unlikely to be preterm labour = consider monitoring

If diagnosis uncertain, can do foetal fibronectin (not normally present) or Actim-partus

61
Q

Outline the management steps for preterm labour

A
  • Hospital admission and inform NICU
  • Rescue cerclage if < 28 weeks and no rupture of membrane
  • Nifedipine to slow contractions (max 48 hrs)
  • Provide corticosteroids if < 34 weeks
  • IV Magnesium Sulphate if < 34 weeks
62
Q

Outline why IV Magnesium Sulphate is given in preterm labour

A
  • Given as it helps to protect the foetal brain during premature delivery
  • Helps to reduce the risk of cerebral palsy
63
Q

Define postpartum haemorrhage (PPH) and outline the classifications for PPH (including the amounts)

A

Postpartum haemorrhage is blood loss after delivery of baby and placenta of over 500mL (vaginal) or 1000mL (caesarean)

Minor < 1000mL
Major > 1000mL
Moderate 100mL-2000mL
Severe > 2000mL

Primary PPH is within 24 hrs of birth
Secondary PPH is from 24 hrs of birth to 12 weeks after

64
Q

List 4 causes of postpartum haemorrhage

A

4Ts

Tone (uterine atony)
Trauma (perineal tear)
Tissue (retained products of conception)
Thrombin (bleeding disorder)

65
Q

List some causes of antepartum haemorrhage

A
  • Placental abruption
  • Placenta previa
  • Uterine rupture
  • Coagulopathy
66
Q

List some risk factors for postpartum haemorrhage

A

Pregnancy:
- Previous PPH
- Large baby
- Multiple pregnancy

Mother:
- Preeclampsia
- Obesity

Placenta:
- Placenta previa
- Retained placenta
- Placenta accreta

Labour:
- Failure to progress in 2nd stage
- Prolonged 3rd stage
- Perineal tear / episiotomy
- Instrumental delivery

67
Q

List some methods to reduce the risk of postpartum haemorrhage before and during birth

A
  • Treat anaemia during antenatal period
  • Empty bladder before birth
  • Active management in 3rd stage (Oxytocin)
  • Intravenous tranexamic acid
68
Q

Outline the emergency management steps for postpartum haemorrhage

A
  • IV access (2 large bore cannulas)
  • Take bloods: FBC, U&Es and clotting screen
  • Lie woman flat and keep warm
  • Group and cross match 4 units
  • Warmed IV fluids and blood products
  • Oxygen (regardless of sats)

If severe, may need to activate major haemorrhage protocol

69
Q

Outline some treatments to stop bleeding in postpartum haemorrhage

A

Mechanical:
- Rubbing the uterus
- Catheterise (empty bladder)

Medical:
- Oxytocin
- Ergometrine
- Carboprost
- Misoprostol
- Tranexamic acid

Surgical:
- Intrauterine balloon
- B-lynch suture
- Uterine artery ligation
- Hysterectomy last resort

70
Q

Outline some investigations to do with someone presenting with secondary postpartum haemorrhage, followed by the management for each cause

A

Ultrasound for retained products of conception
- Evacuate content surgically

Infection swabs (endocervical and high vaginal)
- Treat with antibiotics

71
Q

Outline the method of assessing CTG trace

A

Dr C BraVADO

Define Risk

Contractions

Baseline RAte

Variability
Accelerations
Decelerations
Overall impression

72
Q

Outline the 4 main abnormalities on a CTG trace

A
  1. Early decelerations
    - Dip and recovery of foetal HR, corresponds to contraction
    - Normal, caused by uterus stimulating vagus nerve
  2. Late decelerations
    - Gradual decreases in foetal HR, starting after contraction has begun
    - Concerning, caused by foetal hypoxia from excess uterine contractility, hypotension or hypoxia
  3. Variable decelerations
    - Sudden deceleration not associated with contractions
    - Concerning, but more reassuring if brief accelerations before/after
    - Caused by intermittent cord compression
  4. Prolonged decelerations
    - Prolonged decrease for 2-10 minutes (drop of more than 15bpm from baseline)
    - ALWAYS CONCERNING, caused by cord compression
73
Q

Outline the management options for breech presentation at 36 weeks onwards

A
  • External cephalic version (ECV) at 37 weeks
  • Choice of vaginal or elective c-section delivery (40% chance of needing emergency c-section with vaginal delivery)

If first twin breech, c-section suggested

74
Q

Outline which class of drugs can be used during external cephalic version (ECV) to improve success rate and give an example

A

Beta-2 receptor agonists
e.g. Terbutaline

75
Q

List some risks for the baby of breech delivery

A
  • Umbilical cord prolapse
  • Trauma during delivery e.g. broken bones
  • Birth asphyxia (delay in delivery)
  • Fetal head entrapment
  • Intracranial haemorrhage (rapid compression of head during delivery)
  • Premature rupture of membranes
76
Q

Outline the risks and benefits for vaginal delivery vs c-section in breech presentation

A

Overall, vaginal delivery is safer for the mother and c-section is safer for the baby

  • Vaginal breech birth increases the risk of low Apgar scores and serious short-term complications, but has not been shown to increase the risk of long-term morbidity
  • Elective c-section carries a small increase in immediate complications for the mother compared with vaginal birth, however the highest risk comes from emergency c-section (which occurs in 40% of vaginal births)
  • C-section carries a risk of complications in future pregnancy
77
Q

Outline the advantages and complications of VBAC (vaginal birth after c-section)

A

Advantages:
- Approx 75% success after 1 previous CS
- Avoids risks of surgery e.g. VTE, injury etc
- Faster recovery
- Higher chance of future uncomplicated vaginal births

Complications:
- Uterine scar rupture 1:200 (0.5%)
- 25% risk of conversion to emergency c-section
- Risks to baby slightly higher than c-section, but similar to risk in first time labour
- Increased risk of needing blood transfusion

78
Q

Outline some contraindications for VBAC

A
  • More than 2 previous c-sections
  • Previous uterine rupture
  • Previous upper segment incision to uterus
  • No other contraindications for vaginal birth
  • Home birth (must be in delivery suite)
79
Q

Outline the 3 main causes of cardiac arrest in pregnancy

A
  • Hypovolaemia secondary to haemorrhage
  • Pulmonary embolism
  • Sepsis (leading to metabolic acidosis and septic shock)
80
Q

Outline how CRP differs for pregnant women

A
  • Carry out CPR with a 15 degree tilt to the left
  • Early oxygen (higher requirements)
  • Early intubation (more difficult)
  • Aggressive fluid resuscitation

Delivery of baby if no response to CPR after 5 minutes

81
Q

Outline the first line management for maternal sepsis

A

SEPSIS 6 within 1 hour

Take:
- Blood cultures
- Urine output
- Hb and Lactate

Give:
- Oxygen
- Antibiotics
- Fluids

  • Regular observations with MEOW chart
  • Consider early delivery if perceived to benefit mother or baby (avoid spinal)
82
Q

Outline how foetal growth is assessed in the antenatal period

A

Conducted after 24 weeks gestation:
1. Palpation: either symphysis fundal height or just fundal height
2. Ultrasound (if high risk or known growth issues)
- Head circumference
- Abdominal circumference
- Femur length

83
Q

State the definition for small for dates/gestation and large for dates/gestation

A

Small for dates/gestation: below the 10th decile for their gestational age

Large for dates/gestation: above the 95th decile for their gestational age

84
Q

Outline some causes of small for dates/gestation

A

Normal small:
- Constitutionally small

Abnormal small:
- Chromosomal abnormalities / congenital malformation

Infected small:
- Infection during pregnancy

Starved small:
- Placental issues
- Smoking
- Multiple pregnancy

Wrong small:
- Dates are wrong!!

85
Q

Outline some risk factors for small for dates/gestation

A
  • Previous foetal growth restriction
  • Recurrent foetal loss
  • Previous unexplained stillbirth
  • 1st trimester bleeding
  • Smoking
  • Unexplained raised AFP
  • Extremes of age
  • Low BMI < 20
  • Hypertension / preeclampsia
  • Antiphospholipid syndrome / haemoglobinopathies
  • Renal disease
  • Infection during pregnancy
  • Domestic violence
86
Q

Outline some causes of large for dates/gestation

A

Maternal factors:
- Obesity / general large stature
- Diabetes
- Increased maternal age
- Multiparity

Foetal factors:
- Constitutional
- Male gender
- Overdue
- Genetic disorder e.g. Beckwith Wiedemann

87
Q

Outline some causes of oligohydramnios, as well as general management approach

A
  • Preterm rupture of membranes (P-PROM)
  • Placental insufficiency
  • Kidney problems e.g. renal agenesis or non-functioning kidneys
  • Obstructive uropathy
  • Genetic/chromosomal anomalies
  • Viral infections

Management depends on the cause e.g. P-PROM might require early delivery

88
Q

Outline some causes of polyhydramnios, as well as general management approach

A

Idiopathic in 50-60% cases

  • Macrosomia
  • Maternal diabetes (especially if poorly controlled)
    Potential underlying abnormalities:
  • Abnormal swallowing e.g. oesophageal atresia, CNS abnormalities
  • Duodenal atresia
  • Anaemia
  • Twin-to-twin transfusion syndrome
  • Increased lung secretions
  • Genetic or chromosomal abnormalities

Generally, no specific intervention is required

89
Q

Suggest a management plan for suspected abnormal foetal growth

A
  1. Establish cause
    - Check dates
    - Check for infections / maternal disease e.g. BP
    - Ultrasound, measure size and volume of fluid
    - Umbillical artery doppler
  2. Serial growth scans with regular ultrasound scans every 2-4 weeks
  3. Consider timing of delivery and mode of delivery
    - If UMA is normal, delay delivery until > 37 weeks
    - If UMA is abnormal, consider delivery > 34 weeks but before if abnormal CTG or other abnormalities
    - No benefit for c-section if large baby
90
Q

Outline the difference between the uterine artery doppler and umbilical artery doppler

A
  1. Uterine artery doppler
    - Used for screening at 20 weeks (not surveillance)
  2. Umbilical artery doppler
    - Used for surveillance for ‘small’ babies
91
Q

Outline some causes of increased symphysis fundal height in pregnancy

A
  • Uterine fibroids
  • Maternal obesity
  • Polyhydramnios
  • Pelvic mass
92
Q

Outline some risks associated with a large baby

A

Maternal risk:
- Prolonged labour
- PPH
- Trauma to genital tract
- Increased need for operative delivery

Foetal risk:
- Injury during birth e.g. Erb’s palsy
- Asphyxia
- Hypoglycemia post-birth
- Childhood obesity / metabolic syndrome

93
Q

Outline the risks associated with oligohydramnios

A

Poor prognosis if in second trimester

Linked to potential causes
- P-PROM increases chance of preterm delivery and pulmonary hypoplasia
- Foetal contractures (inability to move in-utero)

94
Q

Outline the risks associated with polyhydramnios

A

Increased perinatal mortality, due to:
1. Likely presence of an underlying abnormality / malformation
2. Increased incidence of preterm labour (due to over-distension of the uterus)

  • Malpresentation e.g. breech presentation, is more likely
  • Increased risk of postpartum haemorrhage
95
Q

List some causes of reduced foetal movements

A
  • Natural foetal sleep cycles / lack of concentration
  • Intrauterine death
  • Congenital fetal malformations e.g. neurological or musculoskeletal
  • Placental insufficiency = oligohydramnios or foetal growth restriction
  • Anterior placenta (< 28 weeks)
  • Maternal sedating drugs e.g. alcohol, benzodiazepines, opioids
  • Smoking
  • Foetal anaemia or hydrops fetalis
  • Fetomaternal haemorrhage
96
Q

Outline steps to be taken for a mother presenting with reduced foetal movements

A
  • Take a detailed history
  • Assess risk factors for Fetal Growth Restriction or Stillbirth
  • Record BP, HR, temperature and urinalysis
  • Abdominal palpation and measurement of symphysis fundal height
  • Fetal auscultation / CTG > 26 weeks
  • Consider umbilical artery Doppler
  • Ultrasound for growth
97
Q

Outline some potential causes of intrauterine death (stillbirth)

A

Unexplained (50%)
- Preeclampsia
- Placental issue: abruption or vasa praevia
- Cord prolapse / around neck
- Maternal disease: obstetric cholestasis / diabetes / thyroid
- Maternal infections e.g. rubella, parovirus
- Genetic abnormalities / malformations

98
Q

Outline how suspected intrauterine death is investigated and managed

A

Diagnosis: ultrasound scan, identify absence of foetal heartbeat

  • Rhesus-negative women require anti-D prophylaxis
  • Vaginal delivery is recommended unless contraindicated
  • Choice of expectant delivery or induction
  • Induction involves: oral Mifepristone and Misoprostol
  • Dopamine agonists e.g. Cabergoline can be used to suppress lactation after stillbirth
99
Q

Outline the maternal and foetal risks of multiple pregnancy, as well as risks relating to birth

A

Maternal risks:
- Anaemia
- Hypertension
- Polyhydramnios
- Spontaneous preterm delivery

Foetal risks:
- Miscarriage / stillbirth
- Prematurity / foetal growth restriction
- Twin/twin transfusion syndrome
- Congenital abnormalities

Birth risks:
- Malpresentation
- Instrumental delivery
- PPH

100
Q

Outline what additional monitoring is required in multiple pregnancies

A
  • FBC for anaemia (at booking, 20 weeks, 28 weeks)
  • Ultrasound scans (monochorionic = 2 weekly after 16 weeks, dichorionic = 4 weekly after 20 weeks)
101
Q

Outline the birth timing for the following twin combinations:
- Monochorionic monoamniotic
- Monochorionic diamniotic
- Dichorionic diamniotic

A

Monochorionic monoamniotic = between 32-34 weeks (require elective c-section)

Monochorionic diamniotic = between 36-37 weeks

Dichorionic diamniotic = between 37-38 weeks

102
Q

Outline how a retained placenta is managed

A
  • Provide adequate analgesia
  • Catheterise to empty bladder
  • Ensure Oxytocin has been given, if not already
  • Controlled cord traction whilst guarding the uterus
  • Encourage skin to skin / breastfeeding
  • Insert 2x large bore cannulas
  • Commence oxytocin infusion with IV fluids
  • If above doesn’t work, invasive manual removal of placenta (prophylactic antibiotics)
103
Q

How does pregnancy impact on asthma?

A
  • More likely to suffer from acid reflux
  • Attacks are more likely between 24-36 weeks (mainly viral infections and poor compliance with corticosteroids)
  • Most medications can be continued and used during breastfeeding
  • Poorly controlled asthma has been associated with: preterm delivery, intrauterine growth restriction and SGA
104
Q

Outline generally how asthma is managed during pregnancy

A

Women with well-controlled asthma, can remain under the community midwife
Worsening of their asthma symptoms can trigger a referral to the antenatal obstetric clinic

If severe, should managed by both a respiratory physician and obstetrician in the antenatal obstetric clinic

Non-medical:
- Trigger avoidance, smoking avoidance and treatment compliance
Medical:
- Inhaled corticosteroids, short or long-acting β2-agonists can be used
- Theophylline may cause irritability and apnoea in the neonate
- Oral corticosteroid use in the first trimester has shown a small increase in the risk of cleft lip or palate but should still be
prescribed when required, but used with caution

105
Q

Briefly outline how epilepsy is managed in pregnancy including: medications, any additional scans

A

Managed by obstetrician

Medications:
- Take 500mg of folic acid (rather than 400mg) from pre-conception until at least 12 weeks gestation
- Avoid sodium valproate and phenytoin
- Generally, Levetiracetam, Lamotrigine and Carbamazepine are considering safer
- Ideally, medications should be changed prior to conception and should be controlled by a single antiepileptic agent

Scans:
- Offered a foetal anomaly scan at 20 weeks

Baby offered a vitamin K injection at birth

106
Q

Which 2 anti-epileptic drugs should be avoided in pregnancy and what defects can they cause?

A
  1. Sodium valproate
    - Neural tube defects
    - Developmental delay
  2. Phenytoin
    - Cleft lip / palete
107
Q

Outline generally how cardiac disease is managed during pregnancy

A
  • Under joint care of obstetrician and cardiologist
  • Require pre-pregnancy counselling
  • Delivery generally before 40 weeks to prevent risk of emergency c-section and stillbirth
108
Q

Outline 3 complications of cardiac disease during pregnancy

A
  • Premature labour
  • Preeclampsia
  • PPH
109
Q

State some indications for an elective c-section (think maternal, foetal and placental)

A

Maternal:
- Maternal request
- Previous caesarean
- Poorly controlled HIV or primary genital herpes
- Maternal medical conditions e.g. cardiomyopathy
- Cervical cancer

Foetal:
- Breech presentation or other abnormal presentations
- Macrosomia (diabetes)
- Multiple pregnancy

Placental:
- Placenta praevia / vasa praevia

110
Q

Explain the 4 categories of emergency c-section (1-4), also include the timing for cat 1 and cat 2

A

Cat 1 = immediate threat to the life (mother or foetus)
- Within 30 minutes

Cat 2 = maternal or fetal compromise (not immediately life-threatening)
- Within 75 minutes

Cat 3 = no maternal or fetal compromise but needs early delivery

Cat 4 = elective

111
Q

State some risk factors for breech presentation

A
  • Previous breech presentation
  • Multiple pregnancy
  • Oligohydramnios / polyhydramnios
  • Uterine abnormalities e.g. fibroids
  • Placenta previa
  • Baby is preterm (not had time to turn)
112
Q

List some causes of itching during pregnancy (with and without rash)

A

With rash:
- Polymorphic eruption of pregnancy
- Atopic eruption of pregnancy
- Pemphigoid gestationis

Without rash:
- Obstetric cholestasis

113
Q

List some risk factors for obstetric cholestasis

A
  • Previous obstetric cholestasis
  • Family history of obstetric cholestasis
  • Multiple pregnancy
  • Increased maternal age
  • History of liver damage or disease e.g. hepatitis C
114
Q

Describe the following type of placental abnormalities

A

Placenta accreta = placenta adheres directly to superficial myometrium, but does not penetrate the thickness of the muscle

Placenta increta = villi invade into but not through the myometrium

Placenta percreta = villi invade through the full thickness of the myometrium to the serosa (invade too far) and may attach to other abdominal organs e.g. bladder or rectum

115
Q

Placental abruption - state the following:
- Pathophysiology
- Presentation
- Management

A

Pathophysiology:
- Premature separation of the placenta from the uterine wall
- Results in maternal haemorrhage

Presentation:
- Sudden severe abdominal pain
- ‘Woody’ hard uterus
- Uterine contractions
- Reduced foetal movements
+/- vaginal bleeding
+/- hypovolaemic shock

Investigations:
- CTG
- Ultrasound

Management:
- ABCDE approach
- If foetal or maternal compromise, emergency c-section
All cases: anti-D within 72 hours of the onset of bleeding if woman is rhesus D negative
- If NO foetal or maternal compromise and at term, consider induction of labour (avoid further bleeding)
- Can consider conservative management if no foetal or maternal compromise and not yet at term

116
Q

List some risk factors for placental abruption

A

Previous history of abruption
Advanced maternal age
Maternal trauma
Preeclampsia
Polyhydramnios
Substance abuse
Coagulation disorders

117
Q

Outline tocolysis drugs, including indications for their use

A

Medication which suppresses contractions during pregnancy to delay labor

Typically used in cases of preterm labor
- Aim to delay delivery by a few days,
- Usually to buy time for maternal steroids to work or allow transfer of the mother to the appropriate care unit

**Can only be used for a few days and should not be used for long term delay of delivery

118
Q

List 2 examples of tocolysis drugs

A

Nifedipine (Ca2+ channel antagonist) = first line
Terbutaline (beta-2-agonist)

119
Q

List some contraindications for the use of tocolysis drugs

A
  • After 34 weeks gestation
  • Cervical dilation > 4cm
  • Signs of infection (chorioamnionitis)
  • Abnormal foetal signs e.g. non-reassuring CTG, intrauterine death
  • Maternal factors such as pre-eclampsia, haemodynamic instability
  • Intrauterine growth restriction or placental insufficiency

+ drug-specific contraindications for Nifedipine e.g. heart failure, severe hypotension

120
Q

List some conditions indicating potential group B strep infection in a newborn

A
  • Sepsis
  • Pneumonia
  • Meningitis
121
Q

List some risk factors for neonatal GBS infection

A
  • Previous neonatal GBS infection
  • GBS in current / previous pregnancy
  • Preterm labour
  • Prolonged rupture of membranes
  • Intrapartum fever >38 degrees Celsius
  • Chorioamnionitis
122
Q

How is a group B strep positive mother managed?

A
  • Antibiotics during labour and delivery (reduce risk of neonatal infection)

Done if risk factors for GBS infection are present

Year 4 - 1. Reproductive Health (7 decks)

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