What is an amniotic fluid embolism?
Amniotic fluid and foetal cells enter maternal circulation leading to cardiorespiratory collapse
How does the amniotic fluid embolism cause a maternal emergency?
Embolism --> anaphylactic reaction/ complement cascade
Complement --> pulmonary artery spasm
Pulmonary artery pressure and RVP increases
Myocardial and pulmonary capillaries are hypoxically damaged
What are the signs and symptoms of Amniotic fluid embolism?
Sudden onset of SOB and cyanosis
What would be seen on examination in amniotic fluid embolism?
What are some appropriate investigations to do in amniotic fluid embolism, and what would they show?
ABG (hypoxaemia, raised pCO2)
FBC (low Hb)
Clotting (DIC: low platelets, raised PT/APTT, decreased fibrinogen)
CXR (cardiomegaly?? Pulmonary oedema)
ECG (right heart strain, rhythm abnormalities)
How should amniotic fluid embolism be managed?
ABC and refer to ITU
Circulation: 2 large bore cannulae, fluid resus
Pharmacological: ionotropics, correct the coagulopathy (FFP, platelets etc) PPH management of uterine atony
Consider delivery +/- hysterectomy
What is the survival rate of amniotic fluid embolism?
What are the Hb values indicative of anaemia in each trimester?
1st TM: <110
2nd TM: <105
3rd TM: <105
What is the characteristic blood film appearance of iron deficiency anaemia, folate deficiency and B12 deficiency?
IDA: hypochromia, microcytes, pencil cells
Folate deficiency: megaloblastic picture: hypersegmented neutrophils, macrocytosis, thrombocytopaenia, leucopaenia
B12 deficiency: also megaloblastic - as above
What is the cause of IDA in pregnancy?
Increased use of iron and decreased intake/ absorption - may also be caused by blood loss/ haemolysis
What is the cause of folate/B12 deficiency during pregnancy?
Lack in diet can cause both folate and B12 deficiency
Folate deficiency may also be caused by increased demand/ drugs
Recall some B12-specific symptoms of anaemia
Glossitis, depression, psychosis/ dementia, paraesthesia, peripheral neuropathy
What is the dose of iron given in IDA?
100 -200mg OD
Recall some side effects of giving ferrous sulphate
Black stools, constipation, abdo pain
When should oral folic acid not be given?
If cause of anaemia is not known - as it could exacerbate symptoms in a B12 anaemia
What is the treatment for B12 deficiency?
When is asthma most likely to be exacerbated in pregnancy?
What is the cause of asthma in pregnancy?
Pregnancy itself can't cause it so it must have been present beforehand
What are the PEFR values that define severe and life-threatening asthma attacks?
Severe = 50-33%
Life-threatening = <33%
What are the appropriate investigations to do in asthma in pregnancy?
Peak flow, pulse oximetry, ABG, FBC (WCC infection?), CRP, UandEs, blood and sputum cultures, daily PEFR monitoring
How should chronic asthma be managed in pregnancy?
Continue medications throughout labour
Monitor foetal movements daily after 28 weeks
How should an acute asthma attack be managed in pregnancy?
High flow O2
Ipratropium 0.5mg QDS
Steroids (IV hydrocortisone/ PO prednisolone)
Summon senior help
What is the risk of oral corticosteroid use in first TM?
Cleft lip risk increased
What is the difference between the baby blues and post-natal depression?
Baby blues = mild, self-limiting low mood <2 weeks
PND = pervasive low mood in the PN period > 2 weeks
What is the perinatal period defined as?
Pregnancy + 1 year postpartum
Which class of drugs can increase risk of post natal depression?
What scoring system is used for post natal depression?
Edinburgh Post Natal Depression Scale
Recall 2 breast-feeding safe antidepressants
What is peripartum cardiomyopathy?
New-onset cardiomyopathy and heart failure usually within the last month of pregnancy to 5 months post-partum
What is the pathophysiology of peripartum cardiomyopathy?
40% rise in blood volume during pregnancy by 28w causing strain
Women with cardiac disease cannot increase CO --> uterine hypoperfusion --> increased pulmonary oedema
What classification system is used for cardiac disease in pregnancy?
Recall some cardiovascular system abnormalities that are normal in pregnancy
ESM 3rd heart sound
Peripheral oedema (more volume)
In which patients should anticoagulation be used during pregnancy, and what is an appropriate anticoagulant to use?
- Pulmonary HTN
- Artificial valves
- Increased risk of AF
Warfarin is teratogenic in 1st TM - so use LMWH instead
How can maternal cardiac disease be managed in labour?
Advise epidural to reduce pain-related cardiac strain
2nd stage can be kept short with elective forceps/ ventouse - reduces maternal effort for an increased cardiac output
Do a C-section where any effort is dangerous
Do not use ergometrine in 3rd stage (only syntocinon)
How does insulin resistance change throughout pregnancy?
How does pregnancy affect pre-existing diabetes?
Increase in insulin dose requirements in second half of pregnancy
Increased risk of severe hypoglycaemia
Risk of deterioration of any diabetic retinopathy/ nephropathy
How does diabetes affect pregnancy?
Increases risk of miscarriage
Risk of spina bifida
Risk of macrosomia
Also increases risk of: pre-eclampsia, still birth, infection
Recall the pre-conception checks in diabetes
1. Tight glucose control (HbA1c)
2. Renal testing (UandEs, creatinine)
3. BP checks
4. Retinal checks
5. Stop statins
6. Stop folic acid
What is the risk of poor glycaemic control to the baby during pregnancy?
It's teratogenic - can cause midline deformities like spina bifida
It can also cause the baby to be for large for dates
Why does diabetes increase still birth risk?
Placental damage by over-glycosylation of proteins means it may not be able to supply baby
What is the biggest risk to the neonate after the cord is cut when there is maternal DM?
Foetus has been producing high levels of insulin in utero because of high glucose load from mother, so when the cord is cut they keep producing lots of insulin which prediposes them to hypoglycaemia
Why does diabetes increase risk of macrosomia?
Excess maternal glucose --> foetus produces IGF-1 --> growth factor cause macrosomia
How often are antenatal diabetes clinics?
Every 2 weeks
What precaution should be taken when a diabetic mother requires antenatal steroids?
Insulin therapy is required to maintain normoglycaemia as steroids increase glucose release
What are the indications for testing for gestational diabetes in a pregnant woman?
Glycosuria on dipstick, previous GDM, any RF on clerking
What is the main investigation to do for GD?
2 hour 75g OGTT
What are the values that indicate diagnosis of GD?
5678 Fasting plasma glucose >5.6 2-hour OGTT >7.8
What should be the first thing you do if you diagnose GD?
Offer a review at a joint diabetes and antenatal clinic within 1 week
Recall the stepwise management of GD
1st line = changes in diet and exercise (CDE) - Only use this if fasting glucose is <7
2nd line - if targets are not met by 1st line in 2 weeks, still <7 fasting glucose = metformin as well as CDE (go straight to insulin if metformin contra-indicated)
3rd line (if >7 fasting glucose or 2nd line ineffective)
= CDE, metformin and insulin
Offer 3rd line straight away if fasting glucose is 7 or 6-6.9 with complications
4th line - consider glibenclamide
What should be done postnatally in mothers with GD?
Immediate discontinuation of blood-glucose lowering treatment GP should perform a fasting plasma glucose at 6-13w pp
What is by far the most common site of ectopic pregnancy?
Fallopian tubes - usually ampulla
Where is the site of ectopic pregnancy with highest chance of rupture?
What is the cause of ectopic pregnancy?
Tube damage due to infection (eg PID), endometriosis, previous tubal surgery, Depo-Provera injection
What are the signs and symptoms of ectopic pregnancy?
Abdo pain, diarrhoea, shoulder tip pain, back pain
Amenorrhoea with PV scanty blood
Dizziness if ruptured - with circulatory collapse
What will be seen on examination in ectopic pregnancy?
1. Abdomen - rebound tenderness, guarding 2. Vaginal - cervical excitation, adnexal tenderness + mass
What are the appropriate investigations for an ectopic?
Speculum + bimanual
Bloods: FBC, X match, clotting
What signs on TVUSS are indicative of ectopic pregnancy?
Tubal: 'blob' sign, 'bagel' sign
Cervical: 'barrel' cervix, negative sliding sign
How does a located ectopic appear?
Empty uterus, adnexal mass with GS and YS, free fluid in uterine cavity
What should be done in the case of a pregnancy of unknown location (PUL)?
Depends on increase in serum beta-hCG (taken at 0 and 48 hours)
1. >63% --> developing prenancy: rescan at 7-14 days
2. <63% --> review in EPAU <24 hours
3. <50% --> miscarriage --> expectant management
How should all early-pregnancy emergencies first be managed?
Call the on-call gynae
When should ectopics be managed expectantly?
Only permissable in stable, asymptomatic patient with falling levels of beta-hCG
What are the indications for medical management of an ectopic?
Normal LFT and UandEs
No blood in pouch of douglas
What is the medical management of ectopic?
ONCE IM methotrexate
What advice should be given following medical management of an ectopic?
Go home and come back for repeat blood tests (hCG)
No intercourse for 3 months
Don't drink alcohol
Avoid excessive sun exposure
Expect side effects of pain, nausea and diarrhoea
What are the indications for surgical management of ectopic pregnancy?
Ectopic with foetal heartbeat
Adnexal mass >35mm
What is the surgical management of ectopic pregnancy?
When can a salpingostomy be used to treat ectopic pregnancy?
If bleeding is minimal and occlusion is viable to be removed (eg at fimbriae) and the patient only has one viable tube left (as high future risk of ectopics)
What type of prophylaxis is required for surgical management of an ectopic?
What form of contraception should be avoided following a lap salpingectomy?
How should all seizures in second half of pregnancy be managed?
Immediate treatment for eclampsia until a definitive diagnosis is made
How should epilepsy medication be managed in pregnancy?
Minimum possible dose - levetiracetem and lamotrigene are safest agents
Reduce to monotherapy where possible
Explain risk of congenital malformation, as well as risk of recurrent seizures
Pre-conceptional folic acid 5mg, and vit K in last month of pregnancy
What congenital abnormalities are associated with anti-epileptic drugs?
Neural tube defects
Valporate is teratogenic
What is the main risk of phenytoin use in pregnancy?
Which anti-epileptic drugs are most appropriate in pregnancy?
Carbamazepine (least teratogenic of the old antiepileptics)
What extra source of support and advice could you refer someone to when counselling an epileptic expectant mother in PACES?
Invite to register to the UK Epilepsy and Pregnancy Register
What is a hyatidoform mole?
A benign tumour of the trophoblastic tissue
What is the aetiology of a hyatidoform mole?
Abnormal fertilisation leads to either a 'complete' mole (empty egg fertilised by 2 sperm) or a partial mole (normal egg fertilised by 2 sperm)
What are the signs and symptoms of a hyatidoform mole?
Painless PV bleeding (ie miscarriage)
Uterus larger than expected for GA
Often seen on USS before symptoms
What are appropriate investigations to do to diagnose hyatidoform mole?
Bloods: Beta-HcG grossly elevated
hCG shares an alpha subunit with TSH, therefore (due to negative feedback) there should be a low TSH and a high T4
Imaging: pelvic USS
- Complete mole: snowstorm/ 'cluster of grapes'
- Incomplete mole = foetal parts, no snowstorm/ cluster of grapes
How should hyatidoform mole be managed?
Urgent referral to a specialist centre
1st line = surgical: ERPC (evacuation of retained products of contraception) = suction curettage
Then: monitor serum BhCG, use methotrexate if rising/ stagnant levels, avoid pregnancy until 6 months of normal BhCG
What are the main complications of hyatidoform mole to be aware of?
May progress to malignancy (20% of complete moles, 2% of partial)
This would be either an invasive mole or a choriocarcinoma
How can the diagnosis of hyatidoform mole be explained in PACES?
When foetus doesn’t form properly, and a baby doesn’t develop, instead there is an irregular mass of pregnancy tissue
What is the main risk when gestational trophoblastic disease progresses to malignancy?
Rapid metastasis all over the shop
What are the forms of malignant gestational trophoblastic disease?
1. Invasive mole (Hyatidoform mole invades myometrium --> necrosis and haemorrhage)
2. Choriocarcinoma (cytoctrophoblast and synctiotrophoblast without formed chorionic villi invade myometrium)
3. Placental site trophoblastic tumour
Recall 4 things that choriocarcinoma might arise from
50% = molar pregnancy
22% = viable pregnancy
25% = miscarriage
3% = ectopic pregnancy
What are the signs and symptoms of malignant gestational trophoblastic disease?
Persistent PV bleeding
Lower abdo pain
Symptoms of mets to:
- Lung (haemoptysis, dyspnoea, pleuritic pain)
- Bladder/ bowel (haematuria/ PR bleeding)
On examination: excessive uterine size for GA
What are the appropriate investigations to do for malignant gestational trophoblastic disease?
Bloods: serum BhCG, FBC, LFT (mets)
Imaging: pelvic USS, CXR, CTP, MRI brain
How is malignant gestational trophoblastic disease managed?
Methotrexate, hysterectomy for placental site trophoblastic tumour
What % of women get hyperemesis gravidarum?
What % of pregnant women get emesis gravidarum?
What lifestyle factor is protective against hyperemesis gravidarum?
What factors increase risk of hyperemesis gravidarum?
Increased oestrogen (Nulliparity, obesity, multiple pregnancies)
Gestational trophoblastic disease (more BhCG)
What are the RCOG diagnostic criteria for hyperemesis gravidarum?
MUST HAVE ALL 3 OF:
>5% pre-pregnancy weight loss
When does hyperemesis gravidarum begin?
Between 4th and 7th gestational week
When does hyperemesis gravidarum peak?
When does hyperemesis gravidarum resolve?
By 20th week
What investigations should be done in hyperemesis gravidarum?
Body weight (for measuring dehydration)
Urine dipstick (to check ketones)
What scoring system is used to assess the severity of hyperemesis gravidarum, and what score means admission?
13 or above
How should hyperemesis gravidarum be managed?
Always VTE prophylaxis (LMWH) , IV saline with KCl and thiamine supplementation
1st line: antihistamines (eg IV promethazine/ cyclizine)
2nd line: antiemetics (eg IV ondansteron, metoclopramide, domperidone) Metoclopramide is 2nd line due to EPS 3rd line
What are the major possible maternal complications of hyperemesis gravidarum?
Acute renal tubular necrosis
What are the main risks to the foetus from hyperemesis gravidarum?
What BP is considered hypertensive, and what is the threshold for 'severe hypertension' during pregnancy?
Severe HTN: >160/110
When is HTN considered to be gestational, rather than chronic?
Appearing after 20 weeks
What are the features of pre-eclampsia?
New HTN present after 20 weeks
AND/OR Maternal organ dysfunction
What is HELLP syndrome?
Haemolysis, Elevated Liver enzymes, Low Platelets Severe form of pre-eclampsia
How is eclampsia defined?
1 or more seizures in someone with pre-eclampsia
How is decision to give aspirin for HTN in pregnancy (not pre-eclampsia, just HTN) guided?
Guided by presence of high/ moderate risk factors
Always give aspirin if 1 or more of the following is present:
- Previous pre-eclampsia
- AI disease
- Chronic HTN
Give aspirin if they have any two of:
- Age >40
- Pregnancy interval >10 years
- BMI >35
- Pos FHx
- Multiple pregnancy
What are the signs and symptoms of pre-eclampsia?
Can give: severe headache, visual disturbances, epigastric/ RUQ pain, vomiting, breathlessness, sudden swelling of face/ feet/ hands
What investigation is most useful in pre-eclampsia?
Urine dip (proteinuria) - if 1+ on dip or protein creatinine ratio quantification >30mg/mmol
How should pre-eclampsia be managed?
1st line: labetolol (100mg, BD) - contraindicated in asthma
2nd line: nifedipine
3rd line: methyldopa
How is eclampsia managed?
IV magnesium sulphate (it's a potent cerebral dialator)
What is the threshold for admission for gestational HTN?
Severe HTN (>160/110)
What is the target BP for those who have gestational HTN?
How should gestational HTN be managed?
1st line labetolol, 2nd line nifedipine
How often should mothers with gestational HTN be monitored, and what checks should be done?
BP measurement: weekly for moderate HTN, every 15-30 mins in severe HTN when mother is admitted
Dipstick: once or twice a week in moderate, daily whilst admitted FBC, LFT and
UandE once at presentation
What foetal monitoring should be done in mothers with HTN?
USS for foetal growth
Amniotic fluid assesment
Umbilical artery doppler
How does BP usually vary during pregnancy?
Tends to fall in first half of pregnancy before rising back to pre-pregnancy levels before term
How often are LFT, FBC and renal fx repeated in pre-eclampsia, eclampsia and gestational HTN?
Done twice a week in moderate pre-eclampsia or 3 times per week in eclampsia - only done once in gestational HTN
Describe the planning of birth timing in pre-eclampsia
If birth <34 weeks - offer antenatal steroids and MgSO4
If birth 34-36 weeks, continue surveillance unless delivery indicated in care plan
If birth >37 weeks, initiate birth within 24-48 hours
What should be monitored intrapartum in pre-eclampsia?
CTG (continuous) BP monitoring + continue antihypertensives
When should anticonvulsants be considered for women with pre-eclampsia?
1. Previous eclamptic fits
2. Birth planned in next 24 hours
3. Features of severe pre-eclampsia present
What are the features of severe pre-eclampsia?
Oligouria and severe HTN
Nausea and vomitimng
What is the first line anticonvulsant to use in eclampsia, and what is its reversing agent?
Calcium gluconate (10mls. 10%, over 10 mins)
Recall the MgSO4 dosing used to treat severe htn/pre-eclampsia/ eclampsia
Loading dose of 4g IV over 5 mins, followed by an infusion of 1g/hour for 24 hours
What are the discharge criteria following eclampsia?
No symptoms of pre-eclampsia
Blood test results stable/ improving
Recall some anti-hypertensives that are not recommended whilst breastfeeding
What drugs for HTN are safe when breastfeeding?
Labetolol, nifedipine, enalapril, captopril, atenolol
What is the aetiology of eclampsia?
Impaired trophoblastic invasion of spiral arteries --> high resistance flow --> poor placental perfusion --> release of factors from placenta into circulation --> factors cause symptoms
What is TORCH syndrome?
Toxoplasmosis, Other agents, Rubella, CMV, HSV
Cluster of symptoms caused by congenital infection with the above
Recall the 4 signs and symptoms of congenital toxoplasmosis
How should congenital toxoplasmosis be managed?
What pathogens come under the 'other' section of TORCH?
Syphillis, Parvovirus B19, hepatitis, VZV, HIV
What are the signs and symptoms of congenital syphilis?
Rash (soles and palms)
What condition does congenital parvovirus B19 cause?
Hydrops fetalis - causes heart failure
When does congenital HIV present?
What are the signs and symptoms of congenital rubella?
Cataracts (from chorioretinitis)
PDA heart defect
What are the signs and symptoms of congenital CMV?
Chorioretinitis --> cataracts
How should congenital CMV be managed?
What disease is caused by congenital HSV?
SEM (skin eyes mouth) disease/ disseminated disease
What other organisms can cause neonatal sepsis?
GBS. Listeria monocytogenes
How should congenital GBS be treated?
How should congenital listeria be managed?
What is the organism responsible for toxoplasmosis and how is it spread?
Protozoon toxoplasma gondii
Parasite excreted in cat faeces - transmission is faeco-oral route (from infected meat and cat faeces)
What are the maternal signs and symptoms of toxoplasmosis?
Often asymptomatic but may have fever, malaise, arthralgia
What are the signs and symptoms of congenital toxoplasmosis?
60% are asymptomatic but may develop deafness, low IQ and microcephaly
40% have classic '4 Cs of toxoplasmosis':
- intracranial Calcifications
What is the test for toxoplasmosis?
Sabin Feldman Dye test
How should toxoplasmosis be managed in pregnancy?
Prophylaxis: mother should avoid eating raw/ rare meat and handling cats/ cat litter
If +ve mother and -ve baby: spiramycin (prevents vertical transmission)
If +ve mother and +ve baby: pyrimethamine and sulfadiazine with prednisolone adjunct
What is the name, shape and gram status of the organism causing syphillis?
Treponema pallidum: gram neg spirochete
What are the symptoms of primary syphillis?
Painless chancres and local lymphadenopathy
What is the difference bwtween early and late latent syphillis?
Early = signs/symptoms <2 years, late = >2 years
What are the different types of tertiary syphillis?
Gummatous, cardiovascular and neurosyphilis
What is the most useful treponomal test?
How is syphillis treated?
Benzathine-penicillin OR doxycycline
Early: Benzathine-penicillin STAT or doxy BD 14/7
Late: Benzathine-penicillin IM once weekly 3/52 OR doxy BD 28/7
Neurosyphilis: Benzathine-penicillin IV 4-hourly, 14/7
Prednisolone used as an adjunct to avoid Jarish-Herxheimer reaction
For how long is parvovirus B19 infectious?
From 10 days prior to the rash to 1 day after the rash appears
How is parvovirus transmitted?
How does the parvovirus rash usually appear?
Slapped cheek' appearance
What symptoms are to be expected in an infant with parvovirus?
Coryzal symptoms + headache + rash
What is the risk of parvovirus in pregnancy?
Crosses placenta at 4-20w GA, destroying RBCs and --> hydrops foetalis (10% infant mortality)
How is hydrops fetalis managed?
If a baby is born to a HepB + mother, how should they be managed?
1. Vaccination - at birth, 1 month and 6 months
2. HBV IV Ig within 12 hours of birth
Is Hep B transmitted by breastfeeding?
How can Hep C infection be confirmed?
How should hep C be treated in pregnancy?
It shouldn't as it is contraindicated (ribavarin and interferon)
What is the danger of having Hep E in pregnancy?
If contracted in third TM can cause a severe reaction and a fulminant hepatitis
What should pregnant mothers avoid eating to avoid hep E?
Pork and shellfish
For how long is VZV infectious?
From 48 hours before rash until the vesicles crust over
How does congenital varicella syndrome appear?
In which period is VZV infection considered 'neonatal'?
Maternal infection 7 days before or after birth
How does neonatal VZV present?
Mild disease: pneumonua, disseminated skin lesions and visceral infections (ie hepatitis)
How should antenatal chickenpox be managed?
VZIg within 10 days of exposure (before 20/40 gestation)
Once symptoms have developed, VZIg cannot be given
If after 20/40 weeks gestation --> Aciclovir 800mgs QDS
What should be done if there is doubt about whether a mother has previously had VZV?
Maternal blood checked urgently for VZ Ig
What are the possible complications of delivery during viraemic period in varicella zoster infection?
Haematological: bleeding, DIC, thrombocytopaenia
VZV infection of new born
When should an HIV test be done antenatally?
Routinely in antenatal booking
How is HIV diagnosed in children?
Direct viral amplification by PCR carried out at birth, on discharge, at 6 , 12 and 18 weeks if mother is HIV+
How should maternal ARVs be managed during pregnancy?
Don't change them they're continual
How should the babies of HIV + mothers be treated?
First 2-4w of life: ARVs - zidovudine monotherapy
If viral load is undetectable or less than 50: vaginal delivery
If viral load >50 at 36 weeks: ELCS at 38 weeks
If viral load is detectable: intrapartum zidovudine
One of the only infections where avoidance of breastfeeding should be advised - offer cabergoline to suppress lactation
What are the S/S of rubella?
Coryzal symptoms + arthralgia + maculopapular rash
Soft palate lesions (NO koplik spots though)
Describe the spread of the rash in Rubella
Starts behind ears, spreads to head and neck and then to rest of body
At what point during gestation is there highest risk of congenital rubella syndrome?
<12 weeks GA
What are the features of congenital rubella syndrome?
Chorioretinitis, sensorineural hearing loss
At what point in gestation does maternal rubella become very low risk?
What investigations are appropriate for rubella?
USS for foetal abnormalities
How should maternal rubella be managed?
Rest, fluids and paracetamol (no treatment)
Offer TOP if <16w GA
What are the possible sites of latent CMV infection?
Dorsal root ganglion
At what stage of pregnancy is CMV most likely to transmit vertically?
Unlike other infections during pregnancy, CMV just as likely (30- 40%) to vertically transmit at any point
How does congenital CMV present?
90% are asymptomatic, although some will go on to develop sensorineural hearing loss
10% are symptomatic: Sensorineural hearing loss, pre-ventricular calcification, chorioretinitis, 'blueberry muffin rash'
What investigations are appropriate when a pregnant woman has CMV?
USS of foetus
How should maternal CMV be managed?
Do not treat, but if evidence of CNS damage to foetus --> offer TOP
Foetal USS every 2w following diagnosis
Can offer foetal MRI at 28wGA
How should congenital CMV be managed?
Which type of HSV is which?
HSV1 = oral, HSV2 = genital
What are the features of SEM disease?
Blistering vesicular rash, chorioretinitis
What are the possible presentations of congenital HSV infection?
1. CNS disease + SEM (seizures, lethargy, poor feeding + skin/eye/mouth disease)
2. Disseminated infection - encephalitis, CNS abnormalities
How is congenital HSV diagnosed?
Clinically + STI screen + PCR
How should congenital HSV infection be managed?
Acute infection --> Aciclovir Oral for mother, IV for child
When should a C section be done in maternal HSV?
If first episode <6 weeks prior to EDD
What antigen characterises the Group B Strep pathogen?
Group B Lancefield antigen
Is group B strep gram pos or neg?
Pos (cocci in chains)
What causes group B strep infection?
Commensal in vagina and rectum carried by 25% of women
What are the signs/symptoms of GBS?
Often asymptomatic until incidental finding
How should maternal group B strep be managed?
Intrapartum IV benzylpenicillin (or vancomycin if penicillin allergy) if pyrexial
In what situations would group B strep prophylaxis be given?
When there are RFs for an early-onset neonatal sepsis:
- intrapartum fever/ chorioamnionitis
- prolonged rupture of membranes (PROM)
- Pre-term birth
How should sepsis monitoring occur in neonates?
If 1 risk factor: remain in hospital for 24 hours for obs
If 2 or more risk factors, or one red flag, --> Abx + septic screen Sepsis
Abx in neonate: cefotaxime, amikacin, ampicillin
Red flags: seizure, resp distress, shock
What are the S/S of listeriosis?
Often asymptomatic or non-specific
How can listeriosis be diagnosed?
Isolation of organism from blood, vaginal swabs or placenta
How is listeriosis managed?
IV amoxicillin/ ampicillin
What is the prognosis for listeriosis?
Bad unless treated (then good)
What is a Braxton-Hicks contraction?
Painless contractions with no cervical change
Define the 3 stages of labour
1. Painful uterine contractions --> full (10cm) cervical dilatation 2. Starts with urge to push and ends with delivery of foetus 3. Delivery of placenta and foetal membranes
Up to how long should the 3rd stage of labour last ideally?
Up to 30 mins
What factors determine the progress of labour?
1. Power (contractions) 2. Passage (dimensions of pelvis) 3. Passenger (diameter of foetal head)
What is a possible complication of shoulder dystocia?
What is 'restitution'?
Bringing head in line with shoulders
Recall the management of shoulder dystocia
In LESS THAN 5 MINS:
1. Call for senior help and discourage pushing
2. McRobert's manoevre and suprapubic pressure
3. Evaluate for episiomtomy
4. Either Rubin's manoevre or Wood's Screw or deliver posterior arm
What is McRobert's manoevre?
Legs up to abdomen
What is Rubin's manoevre?
Push anterior shoulder towards baby's chest
What is Wood's Screw?
Rubin's + push posterior shoulder towards baby's back --> rotation
What score is used to decide how likely it is that a woman will go into labour imminently?
What is 'effacement'?
Reported as a %, measure of how thin the cervix is
What is the 'foetal station'?
Position of the baby's head relative to the ischial spines of the maternal pelvis
How should the 1st stage of labour be managed?
One-to-one midwifery care
Vaginal exams performed 4-hourly or as clinically-indicated
Ensurance of adequate: analgesia, antacids, hydration, light diet to provide ketosis
What is the normal progress of the first stage of labour?
1cm per hour
How should a delayed first stage of labour be managed?
1st - if membranes intact - ARM (artificial rupture of membranes) 2nd (if membranes ruptured) - oxytocin
What is the most common cause of primary dysfunctional labour?
Ineffective uterine action
When is the second stage of labour considered 'delayed'?
In nulliparous women: 3 hours with an epidural or 2 hours without
In multiparous women: 2 hours with epidural or 1 hour without
How should a delayed 2nd stage of labour be treated?
Same as delayed 1st stage with regards to ARM and oxytocin
What is 'crowning'?
When head no longer recedes between contractions
What does the midwife do as the baby crowns?
Flex the foetal head and guard the perineum
How should the woman be instructed once the head has crowned?
Discouraged from bearing down and should take rapid, shallow breaths
Recall the immediate care of the neonate
After clamping/ cutting of the umbilical cord, baby should have an apgar scre calculated at 1 min and at 5 mins
What apgar score is considered normal?
What does APGAR stand for?
Appearance, pulse, grimace, activity, respiration
How quickly should initiation of breastfeeding be encouraged?
Within 1 hour
What medication should be given to the baby whilst still in the delivery room?
What are the causes of PPH?
4 Ts: Tone (uterine atony) Tissue (retained products) Trauma (laceration) Thrombin (coagulopathy)
What is PPH?
Post Partum Haemorrhage
What is the normal duration of the 3rd stage of labour?
Describe the physiological management of the 3rd stage of labour
Associated with more bleeding (and therefore greater need for transfusions) than active management
Active Mx recommended if placenta undelivered within 60 mins or haemorrhage may occur
Describe the active management of the 3rd stage of labour
10 IU syntocinon (IM)/ ergometrine
Drug can be delivered after delivery of anterior shoulder or immediately after delivery (and before cord is clamped and cut)
Remove placenta using controlled cord traction
What are the signs of placental separation?
Gush of blood, cord lengthening, uterus rising, uterus becoming round
What should be done immediately following delivery of the placenta?
1. Inspection of placenta for missing cotyledone/ succenturiate lobe
2. Inspect vulva for tears
After how long of active management is it considered 'prolonged'?
Recall the options for induction of labour, from 1st to 5th line
1. Prior to formal induction: membrane sweeping - for nulliparous women = at 40-41 weeks - for multiparous women = at 41 weeks
2. Prepare the cervix --> prostaglandins (Prostin/ Propress; vaginal PGE2)
- this is the preferred formal method of induction, can be administered as a tablet, gel or pessary - max of 2 doses
- Risk of uterine hyperstimulation
3. Artificial Rupture of Membranes
- ARM = amniohook
- Should not be used first line
5. C section
At how many weeks is induction offered?
If induction is declined when it is indicated, what should be done?
Twice weekly USS and CTG
In what circumstances can labour be induced at maternal request?
Special circumstancs eg. If partner has to go away to serve in armed forces - only consider after 40 weeks
What should be done in the scenario of intrauterine foetal death?
If membranes are intact, offer an induction
If ruptured membranes/ infection/ bleeding - immediate induction with oral mifepristone, followed by prostin/ misoprostol
Recall 3 scenarios in which induction is not recommended
Breech/ transverse lie
Suspected foetal macrosomia
Recall 3 non-pharmacological methods of analgesia
Recall 4 pharmacological analgesics used in pregnancy, with their side effects
Entonox (nausea, light-headed, dry mouth)
Meperidine ('sleepy baby', low baby RR, constipation)
Morphine/ diamorphine ('sleepy baby', low baby RR, constipation)
Fentanyl ('sleepy baby', low baby RR, constipation)
Recall 2 surgical methods of analgesia
Lumbar epidural (bupivocaine, ropivacaine etc)
Combined lumbar-spinal epidural (fentanyl + bupivacaine)
What is a partogram, and what score is based on its results?
Records condition of mother, foetus and progress of labour
Used to calculate a Bishop's score
Define puerperal pyrexia
>38C in first 14 days following delivery
What is the most common cause of puerperal pyrexia?
How should puerperal pyrexia be managed?
Until fever has abated for >24 hours: - IV clindamycin AND IV gentamycin
What weight at term are macrosomic babies?
>4/4.5kg (definition varies)
What tools are used to diagnose LGA prenatally?
1st: symphisis-fundal height
2nd: abdominal circumference
3rd: estimated foetal weight
If in 90th/95th centile for GA = LGA
What investigations should be done if a baby seems LGA prenatally?
OGTT (gestational diabetes? This can cause LGA)
Bloods (serum beta-hCG, as molar pregnancy can cause polyhydramnios)
USS (liquor volume, biometry)
How should LGA be managed, if detected at 18-21 weeks?
How should LGA be managed, if detected at 24-36 weeks?
If acceleration of growth, arrange
USS for foetal biometry
How should LGA be managed, if detected at 36-40 weeks?
If SFH is in 90th centile, USS for foetal biometry
Care in labour + postnatally as per gestational diabetes at earlier gestation
Recall some complications of delivery in LGA
Hypoglycaemia in GDM
Respiratory distress syndrome (baby)
Intrauterine deformations eg matatarsus adductus, (hip subluxation)
<10th centile for GA
What are the biggest risk factors for SGA?
Previous stillbirth, APLS, renal disease
Others include: chromosomal abnormalities, infection, multiple pregnancy, placental insufficiency
How should SGA be investigated?
At booking assesment, note any minor or major RFs
If 1 major or 3 minor RFs, reassess at 20 weeks
At 20 weeks, if still at risk, consider:
- Minor risk: uterine artery doppler (if abnormal, serial USS from 26-28 weeks)
- Major risk: foetal size and umbilical artery doppler
What does USS biometry measure?
Biparietal diameter, head circumference, abdo circumference, femur length
How should SGA be managed?
Stop any smoking/ EtOH/ drugs
Low dose aspirin may have some role in preventing (not reversing) IUGR in high-risk pregnancies
Monitoring: SFH at booking and at antenatal appointment, confirm SGA with foetal biometry at 20 weeks, uterine artery doppler at 20-24 weeks
If abnormal, serial scans every week from 26w onwards
Indications for immediate delivery: abnormal CTG, reversal of end-diastolic flow
Delivery by 37 weeks is usually necessary
What are ths symptoms of obstetric cholestasis during pregnancy?
Pruritis, no rash
Recall some possible complications of obstetric cholestasis
PPH, foetal distress, meconium delivery, PTL, IVH
What does IVH stand for?
Where does the pruritis usually affect the worst in obstetric cholestasis, and at what point in the day?
Palms and soles
Recall some appropriate investigations in suspected obstetric cholestasis
Bile acids and LFTs
CTG (to check baby)
Coagulation screen (may be high if vit K deficient)
Fasting serum cholesterol (high)
Hep C serology (increased risk of OC in hep C)
How should obstetric cholestasis be managed?
Ursodeoxycholic acid (reduces itching and improves LFTs)
Vit K if deficient
How should mothers with obstetric cholestasis be monitored?
Weekly LFTs until delivery, two-weekly doppler and CTG until delivery
How should delivery be managed in mothers with obstetric cholestasis?
Offer induction at 37 weeks
What are the main possible complications of obstetric cholestasis?
1. Intrauterine death (due to intracranial haemorrhage)
2. PPH (due to low vit K)
Describe the epidemiology of Acute Fatty Liver of pregnancy
What is the aetiology of Acute Fatty Liver of pregnancy?
Probably a mitochondrial disorder affecting fatty acid oxidation
What is the main differential diagnosis in Acute Fatty Liver of pregnancy?
HELLP (haemolysis, elevated liver enzymes, low platelets)
Recall the S/S of AFL of pregnancy
Normally 3rd TM Nauea/ vomiting/ abdo pain Jaundice, bleeding, ascites, manifestations of coagulopathy 50% have proteinuric HTN
How can AFL of pregnancy be differentiated from OC?
Pruritis absent in AFL
What investigations are appropriate in AFL of pregnancy?
ALT typically very elevated
Low blood glucose
Elevated uric acid
USS to show fatty liver
How should AFL of pregnancy be managed?
Supportive care to stabilise
Once stabilised, delivery is the definitive management to prevent deterioration
What is the prognosis of AFL of pregnancy?
Maternal mortality of 10-20%, perinatal of 20-30%
What % of pregnancies are breech at term?
Recall some signs of breech delivery
Palpable head at fundus, soft breech in pelvis
Vaginal: soft presenting part, ischial tuberosities, anus or genitalia may be felt
Footling breech: foot felt or seen through cervix
What are the different types of breech presentation?
Recall some antenatal features of vaginal breech birth being high risk
Also Low EFW?!?!
How information should be given at term in breech presentation?
1. Offer ECV (exteral cephalic version) at 36w if nulliparous, 37w if multiparous:
- 50-60% success rate
- Foetal distress --> emergency CS
2. If ECV unsuccessful/ declined --> council risks for CS
What is the most dangerous form of breech delivery?
How should a breech delivery be managed?
'Hands off' approach (baby hopefully will deliver self - if handling - put thumbs on sacrum and fingers on ASIS - Pinard manoevre may be needed)
What is a Pinard manoevre?
Poke the baby in the popliteal fossa - this makes the bend their knees
How will you tell if the baby's head is stuck after the body is delivered in breech delilvery?
Winging of scapulae
How should a stuck head be managed in breech delivery?
Loveset's manoevre: rotate baby into transverse position and pull anterior arm down
If it stays stuck: perform Mauriceau-Smellie-Veit manoevre - you basically just haul them out resting baby on forearm and pulling head downwards
Recall 3 types of unstable lie
Transverse, face, brow
How should unstable lie be investigated?
USS to confirm the lie
How should unstable lie be managed?
If already in labour, CS
Transverse lie can be altered by ECV with 50% success rate
Brow lie should --> CS if persistent/ 2nd stage labour
Face:mentoposteroir --> CS, mentoanterior = SVD is oky
Loss of pregnancy at <20 weeks gestation
What is a 'threatened' miscarriage?
PV bleed with foetal heartbeat present: the cervical os must be closed
What is an incomplete miscarriage?
Passage of products of conception but uterus not empty on USS
What is a missed miscarriage?
USS diagnosis of miscarriage in absence of symptoms
What is recurrent miscarriage?
>3 consecutive miscarriages
No cause found in 50%
What is the most common cause of miscarriage?
Chromosomal abnormalities in the embryo (eg trisomy 16)
What causes must be considered in recurrent miscarriage?
Structural abnormalities (fibroids, bicornate/ septate uteri)
Medical conditions (diabetes, SLE)
Clotting abnormalities (eg FVL, ATIII deficiency, APLS)
What measure is used to date pregnancies <14 weeks?
CRL (crown rump length) using USS
What measure is used to date pregnancies >14 weeks?
Head circumference is the main one
What is needed to identify a IUP (rather than a PUL)?
Yolk sac and gestational sac
Recall the process of TVUSS dating of pregnancies
1st. Look for foetal heartbeat
2nd. Find foetal poles for CRL (crown rump length)
3rd. If not foetal pole, look for gestational sac
How would a miscarriage be identified on TVUSS?
Absence of foetal HR and CRL >7mm
Growth Sac > 25mm + no foetus
Also need 2 opinions - one USS alone is not enough
What happens if a TVUSS shows no FH and CRL <7mm?
PUV (pregnancy of unknown viability)
Repeat TVUSS in 7 days
What investigations should be done in recurrent miscarriage?
Cytogenic analysis of products of conception, pelvic USS, anti- phospholipid antibodies, screen for BV
Explain that cause is often never found
Recall the management of PV bleeding during pregnancy
If signs of an ectopic or severe bleeding: admit to surgeons
If more than 6w pregnant: GDR/EPU referral
If a viable pregnancy: go home and follow expectant management
If a complete miscarriage: council and go home
If <6w pregnant, expectant mx: no USS
How should miscarriage with retained products be managed?
1st line is expectant management for 7-14 days: if the bleeding/ pain settle, have a pregnancy test after 3 weeks.
Return if +ve.
If pain/ bleeding persist, go to follow up clinic in 4 weeks.
2nd line is medical or surgical management - depends on patient
Surgical: Suctioned RPC
How should thrombophilia/ anti-phospholipid syndrome be managed in pregnancy?
Low-dose aspirin and LMWH (clexane (enoxaparin))
What is the 'chorion' and 'amnion'?
Chorion = outermost foetal membrane
Amnion = membrane closely covering embryo
What % of monozygotic twins are dichorionic diamniotic - and what sign on USS shows this?
2 placenta and 2 amniotic sacs = 25%
What % of monozygotic twins are monochorionic diamniotic - and what sign on US is useful for identifying this?
75% - 1 shared placenta
What is lambda sign?
In dichorionic diamniotic twins, you can examine the junction between the inter-fetal membrane and the placenta, and there will be a triangular placental tissue projection into the base of the membrane
What is the T sign?
In monochorionic diamniotic twins, you can examine the junction between the inter-fetal membrane and the placenta, and there will be no placental tissue projection into the base of the membrane
How should multiple pregnancy be managed antenatally?
FBC at 20-24 weeks
BP (as increased risk of eclampsia)
GTT (Increased likelihood of diabetes)
TTTS monitoring/ growth scans - every 2w starting at 16w for shared placentas, every 4w starting at 20w for no shared placenta
Serial USS for foetal growths
How can a breech baby be turned in a multiple pregnancy when the other baby is cephalic?
Internal pedalic version
Recall some possible foetal complications of multiple pregnancy
Twin to twin transfusion syndrome (TTTS)
Recall 3 possble maternal complications to multiple pregnancy
Pre-eclampsia, hyperemesis gravidarum, GDM
In what type of pregnancy does TTTS occur?
What are the symptoms of TTTS?
Sudden increase in abdominal size, SOB
How should TTTS be managed?
If <26w, foetoscopic laser ablation of vascular anastomoses
If >26w, delivery
What is the pathogenesis of TTTS?
Direct arterial to venous flow in placenta
- Donor baby = SGA + oligohydramnios
- Recipient baby = LGA + polyhydramnios
What is the diagnostic criterion for TTTS?
>25% difference between EFW
What are the risks to the recipient baby in TTTS
More blood --> more cardiac strain --> hydrops fetalis
What BMI is classified as obesity?
What should be considered pre-delivery in obese mums?
Assess risk of giving birth vaginally and whether there needs to be induction/CS
How is oligohydramnios defined?
Deepest pool <2cm
Recall the risk factors for oligohydramnios
Reduced input fluid: placental insufficiency, pre-eclampsia
Reduced output fluid: structural pathology, medications
Lost fluid: ROM, IUGR, post-term pregnancy carry, TTTS
What are the signs and symptoms of oligohydramnios?
Hx of fluid leak PV
Abdo exam - decreased fundal height, foetal parts easily palpable
Speculum - assess for membrane rupture
What are the risk factors for polyhydramnios?
Any failure of foetal swallowing
What investigations are useful in polyhydramnios?
Liquor volume, foetal growth, UA doppler, exclude foetal abnormalities
Also exclude maternal DM
How should polyhydramnios be managed?
Antenatal foetal monitoring and DM monitoring
Amnioreduction - if gross reduction COX inhibition
Internal pedalic version - to decrease foetal urine output
What is placenta praevia?
Low-lying placenta = placental edge <2cm from internal os on TVUSS - placenta lies over internal os
After what GA can placenta praevia be diagnosed?
Recall 2 signs/symptoms of placenta praevia
Painless PV bleeding
Potential signs of shock
What is the first line investigation for diagnosis of placenta praevia?
What other investigations should be done in placenta praevia?
Kleihauer test/ Rhesus test
If mother RhD -ve --> Kleihauer test (check level of blood in maternal circulation).
Do not perform a bimanual
How should placenta praevia be managed when there is minimal bleeding?
Symptomatic management - if bleeding settles, they should be admitted for 48 hours for observation
How should a low-lying placenta at 20w scan be managed?
Rescan at 32w as only 10% go on to have a low-lying placenta later in pregnancy
If still present and grade I/II at 32 weeks, rescan at 36w --> if still low, recommend CS
If still present and grade III/IV, admit at 34w and CS 37 weeks USS at 36w to decid
How should PP be managed (with and without bleeding/ labour or no labour)?
No bleeding, no labour, preterm: Monitoring, possibly in hospital, steroids if pre term, anti-D if Rhesus negative
No bleeding, labour, preterm: Tocolytics (to prolong pregnancy and allow for transfer to experienced centre), corticosteroids, C-section if unsuccessful at stopping labour, anti-D if Rhesus negative
No bleeding, at term: Normally C-section after 35 weeks
Bleeding: Stabilise the mother haemodynamically. The secondary goal is to ensure foetal survival
- Not stabilized by resus: Emergency C-section
- Stabilised, not in labour: MDT discussion with seniors, corticosteroids if less than 34 weeks
- Stabilised, pre-term labour: Tocolytics (to prolong pregnancy and allow for transfer to experienced centre), corticosteroids, C-section if unsuccessful at stopping labour, anti-D if Rhesus negative
Stabilised at term or labour: Emergency C-section
What are the complications for the mother in PP?
Haemorrhage, antepartum haemorrhage and postpartum haemorrhage, DIC, hysterectomy
Recall the pathophysiology of vasa praevia
Foetal vessels course through membrane over the internal cervical os and below foetal presenting part, unprotected by placental tissue or umbilical cord. When baby descends they can rupture the vessels.
What is the difference between type 1 and 2 VP?
Type 1 = velamentous cord insertion in a single/ bilobed placenta
Type 2 = foetal vessels running between lobes of placenta with at least 1 accessory lobe
What is the haemorrhage of blood called when the vessels rupture in vasa praevia?
What are the signs and symptoms of VP?
ROM --> fresh PV bleeding + foetal bradychardia
What symptoms of vasa praevia are seen in the foetus?
HR abnormalities - decelerations, bradycardia, sinusoidal trace
What investigations should be done in suspected vasa praevia?
Kleihauer test: measures amount of foetal Hb in a mother's bloodstream
Hb electrophoresis: identify if foetal or maternal blood (takes a wee while)
How should vasa praevia be managed?
What are the complications of vasa praevia?
No major maternal risk but dangerous for foetus
Foetus loses relatively small amounts of blood, which can have major implications
Need to rapidly deliver and aggressively resuscitate including transfusion if necessary
What is placental abruption?
Separation of the placenta from the uterine wall before delivery (>24w, if <24w = miscarriage)
What is the pathophysiology of placental abruption?
As placenta separates, retroperitoneal bleeding results in further detachment
What are the signs and symptoms of placental abruption?
Constant abdo pain +/- PV bleeding, SUSTAINED contractions
OE: shock, speculum can show bleeding, abdomen reveals woody, tender uterus, vaginal exam (NOT IN PRAEVIA) shows cervical dilatation
How can placental abruption and placenta praevia be distingiushed clinically?
Need to distinguish so that you don't inappropriately do a vaginal exam on someone with placenta praevia
PP - bleed, no pain
Abruption = bleed and pain
How should mild placental abruption be managed?
If preterm and stable: conservative management with close monitoring
Admit for at least 48 hours or until bleeding stops
Anti-D Ig followed by Kleihauer test
How should severe placental abruption be managed?
2 x wide bore cannulae, fluids, blood transfusions, correct coagulopathies
FBC/X match/ Kleihauer test/ anti-D if needed, steroids
CTG if >27w, consider IOL if foetal compromise, TVUSS if query PP
What are the possible maternal complications of placental abruption?
- Haemorrhage (APH/PPH)
- Renal failure
- Couvelaire uterus (it goes rock solid because of blood that has extravasated into the myometrium and beneath the peritoneum)
What are the possible foetal complications of placental abruption?
Birth asphyxia, death
Blood loss >500 mls SVD or >1000mls at CS
What is a secondary PPH?
24 hours to 12w PP
What are the causes of PPH?
Tone (70%), Trauma (20%), Tissue (10%), Thrombin (1%)
Tone = Uterine atony
Tissue = related to placental products (membranes, cotyledon, succenturiate lobe)
Thrombin = coagulopathy (existing or acquired)
How can uterine atony be avoided?
Giving oxytocin with delivery of anterior shoulder or placenta
Recall 4 causes of secondary PPH
Abnormal involution of placental site
What are the signs and symptoms of primary PPH?
Abdomen will have atonic uterus above umbiloicus
Speculum: exclude trauma
Vaginal - evacuate clots from cervix
What classifies as a 'major PPH'?
>1000mls blood loss or signs of shock
How should PPH be managed?
If major - ring emergency buzzer
1. Bimanual compression (rub up a contraction if in theatre)
2. IM/IV Syntocinon (oxytocin)
3. IM Ergometrine (not in HTN/ asthmatics)
4. IM Carboprost
5. Balloon tamponade
6. B-lynch suture, ligate
What is placenta accreta?
Strong attachment of placenta - but not into the muscle wall
What is placenta increta?
Strong attahment of placenta into uterine wall
What is placenta percreta?
Strong attachent of placenta, through the uterine wall
What is the biggest risk factor for placenta accreta/increta/percreta?
Previous CS or uterine surgery
What investigations should be done in placenta accreta/increta/percreta?
MRI to assess depth of invasion
How should placenta accreta/increta/percreta be managed?
Managed delivery +/- caesarean hysterectomy
What is the difference between PROM and PPROM?
PROM = pre-labour rupture at TERM, PPROM = premature rupture
What is the cause of PROM?
Just physiological - but only affects <10% of women
What is the cause of PPROM?
Can be caused by weakening of membranes due to infective cause (often subclinical)
What are the signs and symptoms of (P)PROM?
Sudden gush of fluid leading to a constant trickle
What investigations should be done in (P)PROM?
DO NOT DO A BIMANUAL (like in PP)
1st: speculum: amniotic fluid pooling is diagnostic
- If >30w, contractions and os closed, TVUSS for cervical length
- If is >15mm it is unlikely to be a PTL
2nd: IGFBP-1/PAMG-1: these are suuuper sensitive so if a negative result, there is a v low chance of PROM
3rd: Foetal Fibronectin (FFN) may be present - positive in PROM
How should PPROM be managed?
Admission and expectant management until 37w
Do not offer tocolysis
Erythromycin and CS (24hours) and MgSO4 (if <30w)
Carefully monitor for chorioamnionitis
How should PROM be managed?
If clear liquor: expectant management for 24 hours, if >24 hours --> IOL
If meconium, induce labour asap
Define PTL, very PTL and extremely PTL
PTL = 32-37w GA
Very PTL = 28-32w GA
Extremely PTL = <28w GA
What is the biggest risk factor for PTL?
What is the biggest maternal lifestyle risk factor for PTL?
How should PTL be investigated?
Urine dip +/- MCandS if indicated
How should PTL be managed?
If membranes rupture --> PPROM management
If membranes not ruptured:
- Tocolysis (if less than 34w: 1st line is nifedipine, 2nd line is atosiban)
- 24 hours of corticosteroids
- MgSO4 if less than 30w
- Emergency 'rescue' cerclage
What is the indication for surgical management for PTL?
Exposed unruptured membranes
Give 3 contraindications of surgical management of PTL
Infection, bleeding, uterine contractions
What PTL prophylaxis be given?
Which women are offered prophylaxis for PTL?
If they have a hx of PTL and any of:
- cervical length <25mm
- >16w GA miscarriage
- Cervical length <25mm and hx of PPROM
- cervical trauma
What are the 'big four' complications of pre-term birth?
Respiratory distress syndrome
What % of the population are Rh negative?
Describe the process of Rhesus disease development
Rh neg mother has a Rh pos child
Sensitising event mixes blood (Simple SVD is not a sensitising event)
Mother develops IgM anti-Rh Abs
Mother delivers or miscarries child
Mother has a second Rh+ child --> Mother's IgG anti-Rh crosses the placenta
--> hydrops fetalis
Why does Rhesus disease never occur in first primoparous mothers?
IgM cannot cross the placenta - IgG (produced later) can
What test should be done in a known Rh neg mother?
cffDNA testing - tests for the child's Rh status
Recall the pathophysiology of hydrops fetalis in Rh disease
IgG anti-Rh Abs against foetal RBCs --> HDN = anaemia + high BR --> hydrops fetalis, foetal anaemia + kernicterus
What is the Kleiheur test?
It measures the amount of foetal Hb that passes into the mother's bloodstream
Recall the indication and management for routine anti-D prophylaxis
Indication: Rh neg mother
Management: Indirect antigobulin test at booking
Either 2 doses of 500IU at 28 + 34w, or 1 dose of 1500IU at 28w
Foetal cord bloods post-delivery and prophylaxis in 72 hours if baby pos with Kleiheur
Recall the prophylaxis protocol following a sensitising event
Needs to be done within 72 hours of the event
If <20w --> 250IU
If >20w --> 500IU
How can a baby be monitored when a mother has anti-D antibodies?
Middle cerebral artery dopplers
What are the 5 skin diseases of pregnancy?
Prurigo of pregnancy
Pruritis folliculitis A
Recall some physiological changes in the skin during pregnancy
Pre-existing conditions worsen
Spider naevi affecting face, arms and upper torso
Broad pink linear striae - striae gravidarum common over lower abdo + thighs
Hand and nipple eczema post-partum
What is pemphigoid gestationis?
Rare pruritic autoimmune bullous disorder
When does pemphioid gestationis present?
2nd or 3rd trimester
What are the signs and symptoms of pemphigoid gestationis?
Widespread clustered blisters, sparing face: usually begin on abdomen
How should pemphigoid gestationis be managed?
Potent topical steroids to relieve pruritis, oral prednisolone to stop new blisters forming
What does PUPPP stand for?
Pruritic Urticarial Papules and Plaques of Pregnancy
Where does Polymorphic Eruption of Pregnancy (PEP) tend to present?
Abdomen - umbilicus sparing - then extending to thigh/ buttock etc
When does Polymorphic Eruption of Pregnancy present?
3rd trimester/ immediately post-partum
How should Polymorphic Eruption of Pregnancy be managed?
Symptomatic management only
What % of normal pregnancies are affected by prurigo?
When does prurigo present?
Beginning in 3rd trimester and resolves upon delivery
What does prurigo look like?
Excoriated papules on extensor limbs, abdomen and shoulder
How should prurigo be managed?
Symptomatic treatment + topical steroids and emollients
Where does pruritis folliculitis affect?
Trunk, can involve limbs
When does pruritis folliculitis present?
2nd/3rd TM, may resolve on delivery
Describe the appearance of pruritis folliculitis
Apears like acne (consider a type of hormone-induced acne)
How should pruritis folliculitis be treated?
What are the main complications of maternal EtOH use at delivery?
Miscarriage, still birth, congenital abnormalities, LBW, SGA
What is the main area of development affected by maternal EtOH use?
How does smoking affect pregnancy?
Damages umbilical cord structure
Increased risk of ectopic/ placental abruption/ miscarriage
How does smoking affect the neonate?
How does smoking affect the baby in the longterm
Less likely to have a long term effect
How does cannabis affect pregnancy?
Increases NICU admission, as well as chance of LBW, SGA and PTL
How does maternal cannabis use affect child development?
Adverse consequences of growth of foetal and adolescent brains
Reduced attention and executive funtioning skills
Poor academic achievement
How does maternal cocaine use affect pregnancy?
Increases chance of PROM, PTL, LBW, SGA and placental abruption - due to vasospasm of uterine vessels
How does maternal opioid use affect pregnancy?
Can cause 3rd TM bleeding and SGA
How does maternal opioid use affect the neonate?
SIDS, toxaemia, microcephaly
What is the name of the withdrawl syndrome from opioids in babies?
Neonatal abstinence syndrome
Recall the presentation of neonatal opioid withdrawl
Irritability, hypertonia, seizures, emesis, respiratory distress
What investigation should be done in a suspected DVT?
What investigation should be done in a suspected PE?
CXR, duplex USS - if both neg then do CTPA (better than V/Q scan as delivers smalled dose to baby)
How should DVT be managed?
LMWH + elevate leg, apply graduated elastic stockings
How should PE be managed in the longterm?
LMWH until 6w post-partum or 3m total treatment - whichever is greater
How should minor PE be managed?
LMWH ie enoxaparin treatment dose
ECG + CXR --> If CXR is abnormal and clinical suspicion of PE --> CTPA
How should massive PE be managed?
1st line = unfractionated heparin 2nd line = thrombolytic therapy, thoracotomy or surgical embolectomty
How should unfractionated heparin be monitored?
When is central venous sinus thrombosis most common?
What are the signs and symptoms of central venous sinus thrombosis?
Headache and varying neurology
How should suspected central venous sinus thrombosis first be investgated?
How should central venous sinus thrombosis be managed?
IV unfractionated heparin --> thrombolysis --> 3-6m anticogulation
Recall 2 possible side effects of heparin
How should VTE at term be managed?
IV unfractionated heparin --> thrombolysis --> 3-6m anticogulation
How long before a planned delivery should LMWH be stopped?
24 hours prior to planned delivery
How long after the last LMWH dose can an epidural be given?
How long after the epidural catheter removal can LMWH be given again?
4 hours after
What drug is used to reverse IV unfractionated heparin?
By what route is clexane given?
How is VTE prevented in high-risk patients?
Prolonged use of LMWH and graduated elastic compression stockings
In women of extremes of weight, how should VTE prophylactic treatment be measured?
Anti Xa levels
What change in the thyroid fx is expected in pregnancy?
Fall in TSH and rise in T4 in 1st TM
How should pre-existing thyroid medication be managed during pregnancy?
Thyroxine should be increased by 25 nanograms, even if currently euthyroid - helps to mimic physiological rise in T4 in 1st TM
What thyroid disorder is associated with pregnancy?
What are the diagnostic criteria for post-partum thyroiditis?
- Less than 12 months since pt gave birth
- Clinical manifestations are suggestive of hypothyroidism
- TFTs alone (no need to measure TPO Ig)
Describe the progression of postpartum thyroiditis
Stage 1 = thyrotoxicosis
Stage 2 = hypothyroidism
Stage 3 = Euthyroid
What is the cause of postpartum thyroiditis?
It's autoimmune - anti-TPO is present in 90%
How should postpartum thyroiditis be managed?
Thyrotoxic phase = propranolol
Hypothyroid phase: thyroxine
How should hyperthyroidism during pregnancy be managed?
Treat medically - no surgery, at lowest possible dose
Propylthiouracil in 1st TM
Carbimazole in 2nd/3rd TM
What are the potential side effects of hyperthyroidism treatment on the foetus?
Foetal hypothyroidism - from high doses crossing the placenta
Agranulocytosis (do regular checks of maternal WCC)
How should mild hyperparathyroidism be managed in pregnancy?
Adequate hydration and low calcium diet
How should major hyperparathyroidism be managed in pregnancy?
Parathyroidectomy may be indicated for severe cases
What are the signs and symptoms of UTI/ bacteruria in pregnancy?
How frequently is urinalysis and urine MCandS during pregnancy?
Urinalysis at every antenatal visit
MSU sent at booking visit
What is the most likely causative organism in asymptomatic bacteriuria?
GBS (group B strep) - which is streptococcus agalactiae
How should asymptomatic bacteriuria be managed?
Nitrofurantoin - but AVOID AT TERM
How should symptomatic UTI in pregnancy be managed?
MCandS showing GBS --> Abx
Do MSU before Abx starts
7 days nitrofurantoin
Amox/ cephalexin is 2nd line
How should pyelonephritis be managed in pregnancy?
What common abx used in UTI is contraindicated in pregnancy?
Trimethoprim is contraindicated in 1st TM
Recall 4 generic complications of ERPC
Bleeding, infection, procedural failure, necessity to repeat
Recall 2 specific complications of ERPC
Intrauterine adhesions, perforation of uterus
What is ECV?
External Cephalic Version
External manipulation of foetus through maternal abdomen to achieve a cephalic presentation
What is the success rate of ECV?
When should ECV be offered?
If nulliparous - at 36 weeks
If multiparous - at 37 weeks
How can the success rate of ECV be improved?
Add tocolysis and beta agonists
Recall 3 drugs that can be used for tocolysis
Atosiban (oxytocin receptor antagonist)
Terbutaline (beta agonist so not in asthma)
What is the main contraindication for ECV?
What are the possible complications for ECV?
V low complication rate, but there may be procedural failure, placental abruption, uterine ruption
What is CTG?
Continuous monitoring of the foetal heart and uterine activity, used in labour
When is the booking appointment?
When is the anomaly scan?
How is a foetal doppler done?
Used to monitor foetal HR and should be placed over the anterior shoulder of foetus
How is foetal blood sampling done?
Blood withdrawn from umbilical vein
What is foetal blood sampling used for?
Determine if severe anaemia caused by Rh sensitisation
Recall a systemic method for interpreting CTGs
DR C BRAVADO:
DR = define risk - why are they on a CTG monitor? Previous CTGs?
C - contractions - normal is 5 contractions in 10 mins
BRA - baseline rate: 110-160bpm
V - variability: 5-25 bpm
A - accelerations: at least 2 every 15 mins
D - deceleratons: present? variable? Early? Late?
O - overall impression
What is an acceleration?
Rise in foetal HR of >15bpm lasting >15s
Occurs in response to foetal movements
What is a deceleration?
Drop of foetal HR of >15 bpm lasting >15 s
Late decelerations are much worse than early decelerations
Define the baseline values for foetal bradycardia and tachycardia
What counts as a loss of baseline variability, and what might cause it?
<5bpm (5-25 is normal)
May be caused by prematurity or hypoxia
What is an early deceleration?
Deceleration that commences with onset of contraction and returns to normal with completion of contraction
Recall one cause of early deceleration
Head compression (innocuous)
Generally not of concern
What is a late deceleration?
Lags the onset of a contraction and does not return to normal until after 30s following end of contraction
What is the cause of late decelerations?
Reduced uroplacental flow
What is the cause of variable decelerations?
Recall 2 indications for emergency CS that could be seen on CTG
Terminal braycardia: FHR <100bpm for more than 10 mins
Terminal deceleration: FHR drops and does not recover for more than 3 mins
Recall the FHR, BV, decelerations and accelerations that typify a normal CTG
Acc: 2 in 20 mins
Recall the FHR, BV, decelerations and accelerations that typify a 'non- reassuring' CTG
FHR: 100-110, 161-180
Late decelerations in >50% of contractions for >90 mins
- Alone for >90 mins
- With <50% of contractions for >30 mins
- With >50% of contractions for <30 mins
What characterises as a pathological CTG?
Late decelerations >30 mins
Loss of BV/ too much BV
Acute bradycardia/ a single prolonged deceleration lasting >3 mins
How should a sinusoidal rhythm seen on CTG be managed?
Immediate cat 1 emergency c section
If a CTG is borderline, what is the next test you should do and why?
Foetal blood sampling - check for acisosis, which is a LATE marker of reduced oxygen delivery
How many 'non-reassuring' features of CTG should there be for it to be considered pathological?
How does foetal head compression affect the CTG?
Causes a baroreceptor reflex that leads to a uniform deceleration
What should be the first course of action when a late deceleration is detected?
Immediate foetal blood sampling
How should a non-reassuring CTG be managed?
1. Left lateral position
2. Stop oxytocin and consider tocolysis - exclude an acute event (like cord prolapse or uterine rupture), correct any underlying causes and give fluids (IV/ oral)
3. Digital foetal scalp stimulation (this accelerates the HR)
Recall 4 indications for IUD
Recall 7 requirements for forceps delivery
Fully dilated cervix
Engaged presenting part
Sphincter (bladder) empty
What are the 4 categories of CS
Cat 1 = immediate threat to life of woman/ foetus
Cat 2 = immediate threat to life of woman/ foetus
Cat 3 = requires early delivery
Cat 4 - elective CS
What is the main complication risk with forceps delivery?
3rd degree perianal tears
Which type of instrumental delivery is more dangerous for the foetus?
What is the main risk of a prolonged ventouse delivery?
Haemorrhage in the newborn
What are the possible complications of ventouse delivery?
What is the main risk to the foetus from forceps deliveries?
Facial nerve palsies eg. Erb's palsy from shoulder dystocia
Recall 3 absolute contradicitions for vaginal birth after C section (VBAC)
Previous uterine rupture
Classical (vertical) C section scar
Other non-C section contraindications (eg maor placenta praevia)
Which has fewer complications: elective repeat CS or vaginal birth after CS?
What are the main benefits of elective repeat C section?
No risk of rupture
Able to plan recovery
What are the main risks of elective repeat CS?
Risk of bladder/ bowel injury (rare)
Placenta praevia/ accreta
Neonatal respiratory morbidity
After how many weeks should an elective repeat C section be performed?
After 39 weeks
What two forms of prophylactic treatment should all women getting a CS receive?
Recall the 3 points of aftercare for a C section scar
1. Keep it dry and get sutures taken out after 5 days
2. No heavy lifting for 6 weeks
3. No getting pregnant for 12-18 months
Describe the two options for surgical sterilisation
1. Hysteroscopic sterilisation - expanding springs inserted into tubal ostia via hysteroscope --> induce fibrosis
2. Tubal occlusion - occlude fallopian tubes with Filshie chips
What is a safer, quicker procedure for surgical contraception than sterilisation?
For how long after a sterilisation operation shoud women abstain from UPSI?
What should always be done before the sterilisation procedure?
For how long after sterilisation is effective contraception required?
If laparoscopic procedure: the next menstrual period
If hysteroscopic procedure: 3 months
What obstetric condition are women who have been sterilised at higher risk of?
Recall the indications for TOP under the Abortion Act
- [A] Continuation of pregnancy involves risk to pregnant woman greater than if pregnancy were terminated
- [B] Termination necessary to prevent grave permanent injury to physical/mental health of pregnant woman
- [C; majority] Pregnancy has not exceeded 24th week and continuance of the pregnancy would involve risk, greater than if pregnancy were terminated, of injury to the physical or mental health of the pregnant woman
- [D] Pregnancy has not exceeded its 24th week and continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the existing children of the family of the pregnant woman
- [E] There is substantial risk that if the child were born it would suffer from physical or mental abnormalities
- [EMERGENCY; F] To save the life of the pregnant woman; or
- [EMERGENCY; G] To prevent grave permanent injury to the physical or mental health of the pregnant woman
What is the % risk of infection from TOP?
What is required for a sign off of a TOP?
2 doctors unless an emergency
What must be done before a TOP?
Screen for chlamydia/ other STI if indicated
Assess VTE risk
Discuss future contraceptive needs (OCP/ IUD)
Check Rh status Bloods (eg haemaglobinopathy)
What is the max time between seeing a GP and having a TOP?
Less than 2 weeks
Recall the medical option for abortion at each stage of pregnancy
2 pills = 200mg mifepristone, then misoprostol (prostaglandin, 24-48 hours later)
0-9w: administer at home (bleeding for 2w after abortion)
9-24w: administer in clinic and repeat misopristol 3-hourly until expulsion
>22w: use feticide (intracardiac KCl injection)
Recall the surgical option for TOP
<14w: misoprostol (dilates) then ERPC (vacuum aspiration) + hCG level
>14w: misoprostol (dilates) then dilatation and curettage - under LA or GA
What are the booking tests done in pregnancy?
- Blood group and antibody screen
- Rhesus status and atypical antibodies
- Haemaglobinopathy screen if indicated
- Infection screen (Hep B, syphilis, HIV, rubella)
Recall a mnemonic to remember the causes of microcytic anaemia
Anaemia of chronic disease
What type of hepatitis is included within the 1st trimester infection screen?
Hep B and now (recently) C
What test can be used to predict risk of trisomy 13/18/21 follwing a result of increased nuchal translucency (but isn't yet funded by the NHS in most trusts)?
What is the expected B-hCG and PAPP-A in trisomy 21?
High B-hCG and low PAPP-A
When is the 'triple test' done and what does it involve?
AFP, PAPP-A, b-hCG
What does the anomaly scan look for?
Major congenital abnormalities
What supplementation is given to all women during pregnancy?
Folic acid 400micrograms (5mg in epilepsy/ BMI >30)
What breast changes should be expected at 12w, and why?
Nipples darken and breasts enlarge as this is highest oestrogen and human placental lactogen
What is hPL and what is its role?
Homologue to GH:
- Decreases insulin sensitivity
- Increases lipolysis to increase glucose availability for baby
- Decreases glucose utilisation
What is B-hCG a homologue to?
What steroid and dose is used antenatally?
2x12mg IM Betamethasone - given 24 hours apart
Alternative: 4 doses of 6mg IM dexamethosone 12 hours apart
What is a partogram?
Pictorial assessment of the progress of labour, allowing rapid identification of slow/ obstructed labour
Who needs a partogram?
All women in active labour (>4cm dilated, contracting >3 in 10)
All women on synctocinon
Threatened premature labour with the use of atosiban
What is the mechanism of action of atosiban?
Inhibits ocytocin and vasopressin
What are the components of a partogram?
Maternal HR every 30 mins
Contractions every 30 mins
Colour of liquor every 30 mins
Cervical dilation every 4 hours
BP and temp every 4 hours
What is the expected speed of cervical dilatation in a nulliparous vs a multiparous woman?
Nulliparous: 0.5cm/ hour
Parous: 0.5-1cm/ hour
What speed of labour on the partogram may suggest a prolonged labour?
What is the 'action line' on the partogram?
4 hours right of the alert line - if the cervical dilation crosses this then urgent obstetric review is needed
What is the first point of management in cord prolapse?
Summon senior help (and consider baby monitoring with CTG)
How can further cord prolapses be prevented?
Digital vaginal exam
Elevate the presenting part/ fill the bladder to reduce pressure
Avoid handling the cord as this causes cord spasm
IF CORD PAST INTROITUS, DON'T PUSH BACK IN
How should the mother be positioned in cord prolapse?
Either on all 4s or in left lateral position
Recall the definition of the 4 degrees of tear
1st degree = superficial damage with no muscle involvement
2nd degree = injury to perineal muscle, but no anal sphincter involvement
3rd degree = injury involves anal sphincter complex (3a = <50% of external anal sphincter involved, 3b = >50% of eas, 3c = involves interna sphincter)
4th degree = injury to perineum involving anal sphincter and rectal mu
What types of tear can be managed by the GP alone?
1st and 2nd degree
By how much does cardiac output input increase during pregnancy?
How much does stroke volume increase by in pregnancy?
By how much does tidal volume increase during preganancy?
How do kidneys change during pregnancy?
More aldosterone (fluid retention)
GFR increases in 1st TM
What are the expected haematological changes in pregnancy?
Increased VWF, F7 F8, fibrinogen
Decreased protein S