Obs and Gynae Flashcards
(265 cards)
1
Q
Mean age for menopause
A
51
2
Q
Premature menopause is defined before what age? and how common?
A
41
1/100
3
Q
What is menopause/casues it’s symptoms?
A
Loss of production of estradiol and progesterone by ovaries
4
Q
Is estrogen still produced after menopause?
A
Yes, by ovaries and bone, blood vessels, brain
5
Q
How is menopause defined?
A
Cessation of menses for 12 months. Given retrospective diagnosis
6
Q
Symptoms of menopause are…
A
variable from woman to woman
7
Q
Short term consequences of menopause
A
vasomotor symptoms (hot flashes, palpitations, migrain) CNS menopausal syndrome (mood swings, irritability, sleep disturbance, libido depression, fatigue)
8
Q
Long term consequences menopause
A
Genital tract atrophy CVD Osteoporosis Effect on skin, teeth, liver, eyes ?brain function, Alzheimers
9
Q
Osteoporosis is diagnosed with
A
Bone densinometry <2.5
10
Q
RFs for osteoporosis
A
Fhx, smoking, alcohol, low BMI, steroids, low calcium, low exercise, liver disease, arthritis, hyperthyroid, renal
11
Q
Mx for osteoporosis
A
Non-medical= exercise, diet Medical= bisphosphonates, calcium, vit D, HRT
12
Q
SE’s bsiphosphonates
A
GI side effects
13
Q
What % of women whave symptoms of menopause
A
80%
14
Q
Pathophys of hot flashes?
A
Unknown
15
Q
Why add progesterone in HRT?
A
To prevent “unopposed” oestrogen–>endometrial proliferation, adenocarcinoma
16
Q
Consequences of menopause are all related to low … level?
A
estrogen
17
Q
Advantages of HRT
A
Relieves symptoms, improves bone density
18
Q
Disadvantages of HRT
A
increase breast cancer (only proven in estrogen-progesterone combo HRT- small increase too), increase in CHD for older HRT users, increase stroke, VTE
MAIN: unwanted bleeding (progesterone) leading to unneccessary investigations
19
Q
Contraindications for HRT
A
Thromboembolic disease, oestrogen dependent carcinoma, undiagnosed vaginal bleeding
Relative CIs= CHD risks (eg HTN, DM), benign breast disease
20
Q
Counselling about HRT important points
A
Relieves symptoms Decrease fracture risk Increase risk for other things Alternatives Should only use short term
21
Q
Alternatives to HRT
A
Tibolone- synthetic steroid with weak oestrogen, progesterone and androgenic action- improves symptoms and decreases fracture but no data on risks of breast/endometrial cancer etc
22
Q
Other non-hormonal medications to decrease hot flashes?
A
gabapentin, SSRI, clonidine
23
Q
What is the MSAFP screening for?
A
Risk of neural tube defect
24
Q
MSAFP >… or … percentile associated with
A
2.2, 97th, open neural tube/abdo wall defect, multiple gestation, fetal demise, incorrect dates
25
What type of test is MSAFP?
biochemical
26
2 factors that influence background risk of chromosomal abnormality?
Maternal age, gestation at testing
27
Maternal age increases risk of chromosomal abnormality...
exponentially
28
Risk of any chromosomal defect in birth in WA?
5-7 per 1000 live births
29
Risk of Down's specifically in WA?
2-3 per 1000 live births
30
Increase in gestational age at testing decreases risk of triploidy at 14 weeks to...
ZERO!
31
Relative risk of Down's syndrome decreases to what % in third trimester?
60% (not as much as most, but still more likely not to have if pregnancy has progressed that far)
32
Obstetric cholestasis affects ~ how many women?
1%
33
3 features of obstetric cholestasis
Pruritis without rash
Increased serum bile acids
Abnormal LFTs
34
What is maternal serum screening?
Serum concentrations of alpha-fetoprotein, estriol and hCG at 15-18 weeks gestation to stratify women in to low and high risk for trisomy 21
35
General patterns of MSAFP, hCG and estriol in trisomy 21 babies
MSAFP= 25% lower
hCG= twice normal
Estriol= 25% lower
Lvels reflect functional immaturity of placenta
36
What is done in a first trimester screen?
Nuchal translucency, free b-hCG, PAPP-A
37
What does nuchal translucency assess?
Aneuploidy screen, association with some chromosomal and fetal structural anomlaies
38
Detection rate of Down's in FTS?
80-90% using combination of tests and maternal age to stratify risk
39
Free b-hCG should... with gestational age, but if not suspect...
decrease, Down's
40
PAPP-A normally... with gestation, but if not suspect...
increases, Down's
41
What is PAPP-A and function
Plasma protein in placenta that has immunologic and angiogenesis function
42
Very low PAPP-A associated with...
IUGR, still birth, abruption
43
At what level of risk do you do furthe testing to diagnose Down's
<1:300. If greater than 1:300 routine care
44
How do you definitely diagnose Down's?
Karyotyping via amniocentesis
45
False positive rate of FTS for Down's?
3.9%
46
Complications of amniocentesis
PPROM, Resp distress, postural deformity, fetal trauma, alloimmunisation
47
What weeks to do karyotyping?
15-17
48
Fetal loss rate of amniocentesis?
.5-1%
49
Mid-trimester ultrasound can...
accurately estimate gestational age, identify multiple pregnancy, congenital anomalies, placental location, review uterus and adnexae
50
Limitations of mid-trimester ultrasound
Greatly limited by tester (training), maternal obesity and fetal position
Can detect uncertain things (low lying placenta rates for example 5%, but .5% at 37weeks)
Deficit not tyet manifest (late defects, IUGR)
51
Future of pregnancy screening...
non-invasive prenatal testing via fetal cell-free DNA (simple blood test!!!-->currently issues that need ironing out though)
52
Why give anti-D to rhesus negative pregnant women. Explain rationale as well
To prevent haemolytic disease of new born. In rhesus negative women who have rhesus positive baby, if they are exposed (sensitised) to fetal blood cells, they will create rhesus negative antibodies (sensitisation). These can cross placenta in future pregnancies and cause HDN
53
When to give anti-D
28 weeks and booster at 34
54
Why give anti-D at 28 weeks?
most sensitisation events occur after this
55
Sensitisation events in pregnancy for Rh-ve women
Delivery, ECV, C-section, amniocentesis, ectopic, miscarraige, idiopathic
56
Is sensitisation common in Rh-ve women?
NO. about 13%, but still prevents alot of fetal deaths/extremely ill babies
57
When else to give anti-D apart from routine?
After sensitisation events in early pregnancy
58
What is the kelihauer test?
Detects presence of fetal blood passing in to maternal circulation
59
What is the coombs test?
confirms haemolytic anaemia, for IgG antibodies that may have passed through placenta and caused HDN
60
How does ABO haemolytic disease differ from Rh-D HDN?
Less common, occur in mostly in first born baby. About 1/5 of pregnancies have incompatibiltiy but symptoms do not develop in vast majority
61
Clinical features of obstetric cholestasis
Itching, in particular hands and feet, raised SBAs and LFTs
62
Risks of cholestasis and management
Mx is to deliver baby (recommended at 38 weeks when lungs are mature).
Fetal risk: fatal distress, meconium ingestion/aspiration, stillbirth
Maternal: debilitating itch, PROM, deranged clotting (needs VitK)
63
Theories on pathophys of obstetric cholestasis
Hormonal and genetic. Mainly occurs in 3rd trimester (hormones are highest). Higher incidence in twin and triplet pregnancies (higher hormones). ICP resolves quickly when placental hormone production ceases. High dose estrogen OCP increased ICP
64
Rx Cholestasis
Ursodeoxycholic Acid
65
At what week gestation can you hear fetal heart?
Week 5-6
66
Why induce labor?
Risks of continuing pregnancy for maternal-fetal wellbeing outweigh risks of delivery
67
Indications for induction
Post dates (1 week or more)
Maternal health condition eg PE, GDM, Chole
PROM-->without resultant labour in 24 hours
Chorio or high risk of chorio
Placental dysfunction
Slowing baby growth, baby health condition requiring treatment (polyhydramnios)
Woman lives far from medical service
Psychosocial
Fetal macrosomia
Intrauterine fetal death (mifepristone + miso)
68
What pain relief options are offerred during induction?
Same as spont labor
69
What is augmented labor?
Labour that starts spontaneously but fails to progress because of weak/ineffective contractions. Can be helped with some induction methods
70
Methods of induction
Mechanical- stretch and sweep, foleys, AROM
| Medical- Oxytocin, prostaglandins
71
How do prostaglandins work in induction?
Soften cervix and dilate it via gel/pessary overnight
72
What to always do pre-induction to determine approach?
Pelvic exam to get Bishops score on state of cervix
73
Bishops score >? favours induction
5
74
How does stretch and sweep work?
Separation of amniotic membrane from cervix can dilate and soften it by increasing bodies prostaglandin levels naturally
75
How does syntocin work to induce labour?
Mimics bodies own oxytocin which is sent from hypothalamus and posterior pituitary to cause uterine contractions
76
How does foleys work?
Constant pressure against cervix causes dilation and softening
77
General risks of induction...
Failure--> C-section
Those who are induced are more likely to need C-section than natural labour (except post-dates women)
Increases risk of uterine rupture in VBAC patients-->haemorrhage, hysterectomy, amniotic fluid emoblus to mother
78
Risks of prostaglandin/oxytocin induction
Uterine overstimulation-->fetal distress
79
Risk of stretch and sweep?
Bleeding, infection (infrequent)
80
ARM increases risk of...
Infection, cord prolapse (C-section), lengthy labour (if ARM to early for cervix)
81
Risk of foleys...
infection, bleeding
82
2 stages of labour induction
cervical ripening, uterine contractions
83
Which cells secrete what to allow remodelling of cervix?
Infiltrative macrophages, fibroblasts
| Collagenase, elastase (break collagen, elastin down)
84
What is the main mediators of cervical ripening thought to be?
Prostaglandins (PGE2!), NO, Progesterone
| also (PGF2a, MMP2, MMP9)
85
What % of women having IOL deliver vaginally?
<2/3
86
What happens to collagen in cervix as term approaches?
Infiltration of hyaluronic acid that causes increase water molecules intercallating between collagen fibres as well as increased collagenase to break down collagen. Decreases allignment and fibre strength
87
How does NO cause cervical ripening?
Unsure. But levels are high at onset of labour and decrease during labour
88
What week should all women be offerred stretch and sweep and why?
Post 37 weeks in practice (guidelines say 41)--> prevent induction of labour and post-dates
89
SEs of stretch and sweep
Vaginal spotting, mild abdo cramp
90
Maternal contraindication to IOL
Previous transmural uterine surgery, >2 C-sections, unexplained maternal pyrexia, regular contractions, active herpes
91
Fetal contraindications to IOL
Malpresentations (eg face, brow, breech), cord prolapse, severe fetal growth restriction
92
Placental contraindications to IOL
Placenta previa, vasa previa
93
What position should cervix be in for favourable labour (Bishops score)
Anterior
94
5 parts of Bishops score
position, consistency, dilatation and effacement of cervix. Station of presenting part
95
Recommended timing for IOL?
41-42 weeks. BUT no evidence to say stillbirth is reduced at this time, so up to woman still.
96
Mx if woman opts to go >42 weeks
twice weekly CTG and Ultrasound of max amniotic fluid pool depth
97
What is main danger of mechanical methods of induction with low lying placenta?
Ante-partum haemorrhage
98
Mechanical method disadvantage for IOL
Patient discomfort, less efficacy
99
Advantages of mechanical method IOL
lower risk of fetal heart rate abnormality, low risk of hyper stimulation
100
Does chorio rate increase for mechanical IOL?
NO- not unless already PROM
101
HOw does mifepristone work?
Anti-progesterone, anti-glucocorticoid
102
What drug increases rate of uterine rupture for induction in VBAC patients?
Misoprostol
103
Risk of uterine rupture for VBAC?
74 in 100000
104
Evidence for PGE2 increasing uterine rupture for VBAC?
inconclusive
105
risk factors for cord prolapse in ARM
polyhydramnios, high presenting head
106
due to fact evidence is inconclusive about risks of IOL for C-sections, most important thing to do is...
assess each case on its merits. Cervical ripeness, threshold for fetal distress and use of fetal monitoring are all factors that will affect eventual outcome
107
Why might an oxytocin infusion give drowsiness, headache and lethargy?
Hyponatremia- similar structure to ADH and can cross react with ADH receptor
108
Indications to use CTG in IOL?
```
Mec stained liquor
Abnormal fetal heart
Maternal pyrexia
Unexplained fresh bleeding developing in labour
Use of oxytocin
Maternal request
```
109
Correlation between fetal fibronectin and time to delivery?
positive, also predictive of successful induction
110
Best way of predicting vaginal delivery in IOL cervical dilatation vs FFN vs sonographic measure cervical length
cervical dilatation and Bishops!
111
VBAC compared to ERCS increases risk of... BUT...
perinatal morbidity/mortality, maternal morbidity. BUT overall risk is extremely low for both, therefore mother's choice and VBAC is seen relatively safe
112
VBAC success rates
70%
113
Risk of uterine scar rupture
.5%
114
Prevalence of placenta previa?
.5%
115
Ceasarean risk and placenta previa/accreta
1,2,>3= 1%,2%,5% for PP
| .3%, .6%, 2.4% for PA
116
Risk of placenta accreta?
Haemorrhage!!! Severe cause maternal mortality
117
Risk of uterine rupture for VBAC vs ERCS
50 per 10,000 for VBAC
| 2 per 10,000 for ERCS
118
Types of non-pharm analgesia in labour?
Hydrotherapy, acupunture, intradermal water blocks, continuous labour support, positional change
119
Types of pharm analgesia in labour?
NOS gas, opioids (pethidine, morphine, fentanyl IV, oral, PCEA), epidural
120
What is gold standard for analgesia in labour
Epidural
121
How NO works as analgesic in labour?
Not sure, but thought to increase inhibitory pain pathways in brain
122
Advantages of NO for analgesia
Rapid onset and rapid elimination therefore minimal side effects. Cheap, no monitoring, no effect on uterine contractions (therefore doesn't alter progress). No effect on fetus (APGAR unchanged)
123
SEs of NO analgesia
drowsiness, dizziness, N+V (1/3 women)
| unconsciousness (but extremely rare due to demand valve
124
When given with pethidine there is a danger of...
oxygen desaturation
125
Main disadvantage of NO is...
efficacy in later labour
126
Peak onset of effect after inhalation is... therefore...
50 seconds. Therefore need to anticipate contraction for best effect
127
Advantages of opioids
Cheap, easily available and efficacious (although some studies have shown non-pharm to be more efficacious!!)
128
Greatest concern with opioids
Fetal respiratory depression
129
New better opioids for analgesia in labour. Why?
Fentanyl. shorter half life, therefore less side effects.
130
Drugs used for epidural
bupivicaine + fentanyl
131
Contraindications to epidural
thrombocytopenia, overlying skin infection, raised ICP
132
Risks of epidural
```
incomplete block (1 in 8), failure (1 in 20), headache (1 in 100)
rare: nerve damage, epidural abscess, meningitis, haematoma, paralysis
```
133
Ceasarean rates and intstrumental rates for epidural
Ceasar not increased. Instrumental increased
134
Best approach to analgesia is...
multimodal
135
Side effects of epidural
inhibition of symp outflow and decrease catecholamines= vasodilation and hypotension in up to 80% (good for pre-eclampsia!)
136
Pain during first stage of labour is mediated by?
t10-L1 (visceral innervation of myometrium)
137
Pain during second and third stage also added mediation by...
Somatic fibres (perineal stretch) of S2-S4
138
risks of no pain control in labour
increased catecholamines in stress result in tacky, hypertension and increase cardiac output (can cause heart failure in those at risk)
decrease gastric emptying, increasing risk of aspiration in event of emergency GA
139
pain relief satisfaction with epidural reported rate is
95%
140
Prolonged pregnancy defined as lasting longer than...
42 weeks
141
Incidence of prolonged pregnancy
5-10%
142
main cause of "prolonged pregnancy"
innaccurate dates
143
Risk of recurrence of prolonged pregnancy
20%
144
Risk factors for prolonged pregnancy
previous prolonged, primib, Fhx, male fetus, fetal abnormality, maternal obesity
145
Fetal risks of prolonged pregnancy 2 categories
Decreased uteroplacental function= oligohydramnios, reduced growth, passage of meconium (aspiration), STILLBIRTH
Normal placental function: trauma during birth, shoulder dystocia, neuro injury
146
Maternal risks of prolonged pregnancy
Macrosomic fetus (perineal damage), cephalopelvic disproportion, labour dystocia, C-section required, chorio, PPH
147
Diagnostic criteria for PCOS
Need 2 of 3
Oligo/anovulation
Clinical or biochemical evidence of excess androgens
Polycystic ovaries
148
Signs of hyperandrogenisms
Acne, hirsuitism, alopecia
149
Characteristics of ovaries in PCOS
Increased stroma and multiple subcapsular follicles (12 or more 2-9mm in one ovary) and increased ovarian volume
150
Prevalence of PCOS
5-7%
151
What % of women with oligomenorrhoea have PCOS?
90
152
Of women with PCOS what % are hirsute, obese
70%
| 50%
153
Describe genetic basis for PCOS
Suggestion of autosomal dominance from family cluster studies with strong environmental influences on genetic susceptibility (eg obesity--> increased insulin resistance)
154
What % of women with PCOS are insulin resistant?
50% of lean women! Much greater for obese!
155
Treatment options for hirsuitism?
OCP to reduce free testosterone
| anti-androgens (CPA, flutamide, spironolactone)
156
3 Effects of insulin on sex hormones
Decreased hepatic SHBG production
Increased ovarian androgen production via increased IGF-1
Increased ovarian LH receptor expression
157
Treatment for fertility issues in PCOS
Mainly due to chronic anovulation
Use clomiphene to induce ovulation (works in 80%)
FSH will induce ovulation in 80% of remaining
Ovarian drilling found to be as effective as FSH in resistant patients
158
Risk of using clomiphene to induce ovulation?
INcrease risk for multiple pregnancy x5
159
Advice for fertility in woman with PCOS?
Lose weight! Improves ovulation and insulin sensitivity.
| Low fat diet and exercise
160
Insulin resistance causes what long term complications for PCOS women?
7.5 times risk of MI
| 10x incidence of carotid plaques
161
Weight loss of just 5% results in what improvements for PCOS women
INcreased ovulation, improved spontaenous pregnancy rate, reduction in miscarraige, longterm benefits to patient, improved psychological measures
162
What % of women with PCOS miscarry?
44%
163
When PCOS women do conceive there is increased risk of?
All pregnancy related complications
164
Management of substance abuse patient in pregnancy revolves around a ... team involving... with the aim being...
Multidisciplinary
Specialist midwife, GP, Social services, mental health and drug services, police
Compliance with and access to antenatal care
165
Problems associated with substance misuse in pregnancy can be broken into 5 categories...
physical- injecting related problems, BBVs, overdose, injury
psychological- life dominated by drugs, chronic anxiety, sleep disorders, memory, stress, depression
Social- family break up, poverty, unemployment
Financial
Legal
166
Are abstinence and detoxification priority of substance abuse patient in pregnancy?
NO!
167
What % of female IV drug users report needle sharing (usually with sexual partner)?
25%
168
What is the evidence behind substance misuse in pregnancy effect on fetus and why?
Scarce! Complex nature of cases make them difficult to follow long term, plus the fact it is so hard to separate effect of drugs alone from other usual co-existing environmental factors (eg smoking, drinking, poor nutrition, stress, violence, poverty)
169
What is the main effect of tobacco on fetus?
IUGR
170
High alcohol consumption in pregnancy has been shown to result in...
```
lower birthweight
physical anomalies (e.g. fetal alcohol syndrome)
```
171
Cocaine has been shown to cause what physiological effect in pregnancy that results in IUGR, miscarraige, preterm labor and placental abruption?
Vasoconstriction
172
Negative associations between cocaine and physical growth, development and language skills??
NO- no proof in studies
173
Heroin withdrawl can cause...
smooth muscle spasm and risk preterm labor
174
Do opiates cause poor mental or psychomotor development of infant long term?
No evidence
175
What drug is given to treat opiate addiciton in pregnancy?
Methadone- once daily with slow weaning to gestation
| Buprenorphine also starting to be used
176
What is more important than complete drug absitnence in pregnancy?
Drug stability and achievable goals
177
HCV prevalence in IVDU?
Up to 50% in some areas
178
Vertical transmission of HCV unlikely unless...
viremic
179
If syphillis is left untreated transmission to fetus is at a rate of...
70-100%
180
Rx Syphillis
Penicillin (erythro if allergic)
181
STI testing protocol in drug abusers?
Same as normal. Except repeat in 3rd trimester in case re-infected (esp sex workers)
182
Intrapartum issues for IVDU?
IV access can be difficult
| Opioid addiction/use of buprenorphine/methadone can make opioid analgesia less effective
183
What is NAS?
Neonatal abstinence syndrome- CNS hyperirritability, GI dysfunction, resp distress and vague autonomic symptoms
184
Mx for NAS
Non-pharmacological- mother encouraged to swaddle, parent, feed and nuture infant to settle it
185
Medical conditions that may present similarly to NAS are...
hypoglycaemia, CNS haemorrhage, infection
186
Alcohol recommendations in pregnancy
1-2 units, once or twice a week
187
FAS is said to be the ... cause of non-genetic mental disability in the Western world and the only one that is ... preventable
greatest
| 100%
188
Fetal alcohol spectrum disorder sequelae
```
Growth restriction
Facial anomalies (flat philtrum, long upper lip, mid face hypoplasia)
CNS anomalies (microcephaly, agenesis of corpus callosum, cerbellar hypoplasia)
Neurodevelopmental abnormalities (reduced IQ, behavioral problems)
```
189
Should heavy drinkers be advised to stop drinking straight away in pregnancy?
NO- withdrawl can threaten life of fetus and cause tachycardia, hypertension and seizures in mother. Slow withdrawl in inpatient setting is recommended
190
Alcohol effect on breast feeding
Not stored in breast milk but its levels parallel in the maternal blood. Encourage breast feeding still but alcohol may disrupt lactation and milk supplies
191
Approx % of RhD-ve women and % of babies that are RhD pos born to RhD-ve women
15%, 10% (of all births!!!)
192
Can ABO blood group incompatibility cause HDN?
Yes but disease is usually mild
193
How does HDN come about...?
Fetal positive antigen RBCs cross placenta to mother and immune response occurs to foreign antigen (mother has no antibodies to RhD). This is called sensitization event. Then in future pregnancies, if baby is RhD+ve these antibodies in maternal blood can re-cross placenta and cause haemolysis (initially antibodies are IgM in sensitisation so can't cross placenta)
194
Events to increase risk of fetal-maternal haemorrhage (increasing risk of sensitisation)
```
Traumatic delivery eg C-section
Manual placental removal
Stillbriths and intrauterine deaths
Abdo trauma in 3rd trimester
Twins
Unexplained hydrops fetalis
```
195
Signs of hydrops on ultrasound?
Polyhydramnios (Increased AFI), fluid around babies body (eg ascites)
196
Severity of HDN ranges from...
mild jaundice to intrauterine death
197
Mx of HDN...
depends on severity of disease. In mild can use phototherapy. In severe need transfusion
198
Features of severe HDN
Hydrops: oedema, hepatosplenomegaly, ascites, pleural and pericardial effusion
199
How to prevent rhesus isoimmunisation
Screen and give anti-D to mothers who are Rh-ve
200
How does giving anti-D work?
Binds to fetal antigen positive cells in maternal blood to prevent sensitisation event
201
Dosage of anti-D for RhD-ve women
| Mx post-partum
500IU at 28 and 34 weeks plus within 72 hours postpartum.
PLUS 500IU for any possible sensitising event
Must determine amount of feto-maternal haemorrhage and adjust anti-D accordingly
202
Sensitising events requiring anti-D prophylaxis
```
Invasive testing eg amniocentesis, chorion villus smapling
Ante-partum haemorrhage
ECV
Closed abdo injury
Intrauterine death or miscarraige
```
203
Other events to give Anti-D for...
Ectopic, therapeutic termination, spontaneous miscarraige >12 weeks
204
In pregnancy there is a shift from... immunity to... immunity opening women up to... infections
cell mediated, humoral, intracellular pathogens (eg listeria, influenza, varicella)
205
UTIs more common in pregnancy because of...
progesterone and compression by gravid uterus
| also higher urinary glucose and pH facillitates bacterial growth
206
Resp infections more severe in pregnancy due to...
diaphragmatic elevation decreases secretion clearance.
increased oxygen demand, reduced tolerance to hypoxia
Gastric acid aspiration more common too
207
WOmen at high risk of HIV should be tested...
At booking AND 3rd trimester
208
Infections to screen for in early pregnancy
Hep B, HIV, rubella, syphilis
| Urine MCS
209
Abx safe in pregnancy
Penicillins, cephalosporins, macrolides
210
Tetracyclines can cause... in pregnancy
fulmninant maternal hepatitis
211
Gentamicin and vancomycin can cause...
fetal ototoxicity/nephrotoxicity
212
PPROM causes what % of preterm deliveries
40%
213
Prophylactic Abx of choice in PROM
erythromycin
214
Diagnosis of chorioamnionitis suggested by...
fever late in pregnancy, uterine tenderness, offensive vaginal discharge, fetal tachycardia
215
Consequences of chorio for neonate
Neonatal sepsis-->pneumonia, meningitis
216
If chorio is suspected what is definitive Mx
Deliver the baby!
217
Main causes Endometritis?
polymicrobial (serious when GAS, GBS)
218
What % of feveres in women who have just delivered are endometritis?
30%
219
Rx for chorio for baby?
Ampicillin and gentamicin (broad spec)
220
Asymptomatic bacteruria occurs in what % pregnant women
4-7%
221
ASB develops into symptomatic UTI in what%
20-40%
222
UTI in pregnancy is 75-90% which bug and use what Rx?
E.Coli, cephalosporin
223
Cystitis and pyelonephritis occur in what % pregnancies
2% (each)
224
WHich kidney most affected by pyelonephritis in pregnancy and why?
Right.
| Dextro-rotation of the uterus causes compression of right ureter and ascending infection
225
Mx of pyelonephritis post Abx/discharge?
Follow up monthly urine cultures
226
Fetal effects of untreated pyelonephritis?
Preterm delivery, low birth weight
227
Varicella is more... in pregnancy
severe (35% mortality vs 11% non-preg)
228
Progression of varicella to penumonia in pregnancy is...%
10-20%
229
Classical CXR for varicella pneumonia
bilateral miliary nodular shadowing with later pulmonary calcification
230
Risk of vertical transmission of HBV
95% if e-antigen and B-surface antigen positive
231
Risk of HCV vertical transmission. risk of transmission increased to ... if with HIV
6%, 15%
232
Screening is carried out routinely for which hepatitis in pregnancy?
Hep B
233
Rx Hep B
IgG
234
Important DDx in pregnancy rash
Rubella, parvovirus, varicella, measles, enterovirus, EBV
235
Enteroviruses (eg coxsackie and echo) cause what in mothers/neonates?
Myocarditis, meningitis--> multisystem life threatening complications
236
Measles causes what in pregnancy
intrauterine death and preterm delivery (not congenital infection)
237
What drug to avoid in TB treatment of pregnant women for fetal 8th nerve damage association?
Streptomycin
238
Malaria is much more... in pregnancy. causes increased...
severe
| maternal mortality, severe anaemia, preterm birth, miscarraige, stillbirth
239
Parvovirus is associated with fetal...
hydrops
240
2nd most common cause of mental retardation after Downs?
Fetal CMV infection
241
Congenital syphillis can result in...
polyhydramnios, hepatomegaly, osteochondritis, purpura, late interstitial keratitis
242
Mx of obese women in pregnancy general principles
1) GET HEALTHY BEFORE FALLING PREGNANT!-->get the BMI measure
2) advise them of increased risk of medical complications for themselves (CVS, pulmonary, HTN, PE, Gestational diabetes)
3) Diet and exercise advice during pregnancy
4) Anatomy scan at possibly later date
5) advise fetus at risk of congenital abnormalities
6) Increased risk of C-section
7) Increased risk VTE- consider prophylaxis
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Obesity in pregnancy increases risk of...
Spontaneous abortion
Hypertension in pregnancy (PE, HELLP)
Gestational Diabetes, Macrosomic child
C-section with increased blood loss, increased op time, increased post op wound infection and endometritis, increased risk for vertical skin incision
Increased decision to delivery interval
Unexplained stillbirth (decreased perception fetal movement, hyperlipidaemia, hypoxia due to apnoea
244
Difficulties in assessing obese women include...
Ultrasound at all stages
Fetal monitoring in labour
Uterine monitoring in labour
245
General success of VBAC vs obese VBAC
80%
| 50-70% (heavier is much worse, 13% for >136kg)
246
Anaesthetic difficulties in obese women
```
Difficult intubation
Difficult epidural (multiple attempts)
```
247
Incidence VTE normal vs obese
0.6% vs 2.5%
248
Rx VTE prophylaxis >30BMI
Clexane 3-5 days post partum
| consider ante-natally for extreme obese
249
Overall message about obesity in pregnancy...
Get fit before getting pregnant!! Preventative medicine is best
250
Define ante-partum haemorrhage?
Any bleeding from genital tract after 20th week but before birth
251
Causes of APH?
Placenta praevia (31%)
Placental abruption (22%)
Labor, show, ruptured vasa praevia, marginal sinus bleed
Local lesions of cervix/vagina
Causes outside genital tract- varicosities, haemorrhoids
252
Define placental abruption?
Premature separation of placenta from uterus
253
Define placenta praevia
Placenta lies partly or wholly in lower uterine segment
254
What are the types of placenta praevia in stages?
```
Minor
Stage 1- doesn't reach os
Stage 2- extends to but doesn't cover os
Major
Stage 3- partially covers os
Stage 4- complete praevia (covers os)
```
255
What % have a low lying placenta on 20Wk US?
5%
256
Of those with low lying placenta at 20wks, what % will have normal implantation at >30wks and then at term?
90%
| 99.5%
257
How close to os does PP have to be to require C-section
2cm
258
Risk factors for placental abruption
PP POSTIT
```
Pre-ecalmpsia
Placental insufficiency
Previous Hx
Overdistention (twins, polyhydram)
Smoking and substance absue
Trauma
Increasing age and parity
Maternal thrombophilia
```
259
Risk factors for placenta praevia
CUP TAPSID
```
Previous C-section
Previous uterine instrumentation
Previous PP Hx
Twins
Increasing age, parity
Smoking, drugs (cocaine)
IVF procedures
```
260
Differences in clinical presentation of abruption and praevia?
Abruption- may have no PV bleed (or little), often sudden onset abdo pain with constant pain between contractions, tender to palpate and hypertonic uterus
Praevia- Soft, non-tender abdo with unrpovoked bright painless bleeding
261
Why can you get no bleeding clinically in placental abruption?
It can be "concealed" in the pocket between the placental and uterine wall and therefore not drip out of vagina
262
First part of investigating an APH?
Ultrasound! Placental location, fetal wellbeing and presentation.
Then you can do a speculum if not a low lying placenta
Try and see source of bleed and take high vaginal swabs
263
What is the kleihauer test?
Blood test to measure amount of fetal Hb transferred to mother's blood stream
Performed to identify women with large FMH >6mL of packed cells who may need additional dose of RhD IgG
264
What is a standard dose of RhD-IgG and how many red cells does it destroy?
625IU destroys 240 red cells/50 low power field or 6mL of packed detal blood cells
265
Kelihauer tests are only done on Rh+ve women if...
severe abdo trauma, non-reassuring CTG, inactive fetus on USS
