Obstetrics Flashcards
(300 cards)
1
Q
What can happen during pregnancy to chronic medical problems?
A
Worsen/flare
2
Q
What pre-existing disorders may worsen during pregnancy?
A
Asthma
Epilepsy
Thyroid
Renal
Diabetes
Cardiac
SLE
Rheumatoid arthritis
3
Q
Name 3 pregnancy specific disorders
A
Pre-eclampsia/eclampsia
Obstetric cholestasis
Gestational diabetes
Acute fatty liver (rare)
Thromboembolism
Mental health disorders
4
Q
What is important in the management of pre-existing medical conditions in pregnancy?
A
Be familiar with normal physiological changes of pregnancy
Preconception assessment
Effect of pregnancy on medical condition
Effect of medical condition of the pregnant woman and her baby - including impact of maternal medication
MDT at all stages
5
Q
What should you do pre-pregnancy for women with pre-existing condition?
A
Optimise disease control
Defer pregnancy until medical condition is stable
Rationalise drug therapy to minimise effects of baby - alter medication to drugs safe in pregnancy
Advise on risks to mum and baby
Agree a plan of care - MDT
Effective contraception until ready to conceive
6
Q
Name a condition that may worsen during pregnancy
A
Mitral stenosis
7
Q
Name a condition that may improve during pregnancy
A
Rheumatoid arthritis
8
Q
What effect might the medical disorder have on the pregnancy?
A
Increased risk of pregnancy complications
eg essential hypertension/renal disease -> risk of superimposed pre-eclampsia
9
Q
What effect might the medical disorder have on the foetus?
A
Teratogenic drug effects
Premature delivery
10
Q
How are women with pre-existing medical conditions cared for in the antenatal period?
A
Obstetrician with expertise in medical problems and physician with expertise in pregnancy +/- nurse/midwife specialist
Improved communication
Reduced hospital visits for the woman with co-ordinated care
Facilitates audit and research
11
Q
What is important to be put in place if necessary before a woman with pre-existing medical condition delivers?
A
Safest mode of delivery
Neonatal support
Anaesthetic expertise
HDU/ITU facilities
Ongoing postpartum care - maternal condition may initially deteriorate
12
Q
What is the definition of anaemia?
A
Haemoglobin < 105gm/L
13
Q
Why are pregnant women more likely to get anaemia?
A
Increased iron requirement in pregnancy (2-3 fold) and folate (10-20 fold)
14
Q
What is the most common type of anaemia in pregnancy?
A
Iron deficiency
Followed by folate deficiency
15
Q
What is anaemia in pregnancy associated with?
A
Low birthweight and preterm delivery
16
Q
How is asthma affected by pregnancy?
A
Increased metabolic rate and O2 consumption (20%)
Increased minute ventilation due to tidal volume - respiratory rate unchanged
Increased arterial pO2 and decreased pCO2 decrease -> mild compensated respiratory alkalosis in pregnancy
17
Q
What is important in asthma before pregnancy?
A
Optimise control
18
Q
When is the risk of asthma exacerbation highest in pregnancy?
A
Third trimester
19
Q
What is the leading cause of maternal death?
A
Cardiac disease
20
Q
What needs to be done with women with pre-existing cardiac disease?
A
Joint care with cardiologist
Ideally with pre-pregnancy assessment
21
Q
How is the heart affected during pregnancy?
A
Cardiac output rises by 40% mainly due to increased stroke volume
22
Q
What cardiac problems are low risk in pregnancy?
A
Mitral incompetence
Aortic incompetence
ASD
VSD
23
Q
What cardiac problems are high risk in pregnancy?
A
Aortic stenosis
Coarctation of aorta
Prosthetic valves
Cyanosed patients
24
Q
What are the key aspects of management of cardiac problems in pregnancy?
A
Pre-pregnancy assessment -> risk of complications/death
Pregnancy/postpartum care -> prediction and prevention of heart failure - echo/ECG
Anticoagulation -> mechanical heart valves
Drug therapy -> need to alter/add medication
Monitor foetal growth and wellbeing -> scan
Timing and mode of delivery and postpartum complications
25
How common is obstetric cholestasis?
Commonest liver disease in pregnancy
Genetic predisposition - more prevalent in Scandinavia and Chile
26
How does obstetric cholestasis present?
Presents with itching - no rash
Abnormal liver function - raised AST, ALT and bile acid
27
What is the recurrence risk of obstetric cholestasis?
Recurrence risk > 80%
28
What are the risks to the foetus in obstetric cholestasis?
Stillbirth/premature birth
29
How is obstetric cholestasis treated?
Ursodeoxycholic acid -> does not reduce foetal complications but improves biochemical abnormalities
30
What happens with hyperthyroidism during pregnancy?
Often improves in pregnancy after first trimester
31
What is the risk to the mother with hyperthyroidism?
Thyroid crisis with cardiac failure
32
What is the risk to the foetus with hyperthyroidism?
Thyrotoxicosis due to transfer of thyroid stimulating autoantibodies
33
What is important to monitor in mothers with hyperthyroidism?
Foetal growth if mother has stimulating antibodies
34
What medication should be used to treat hyperthyroidism during pregnancy and why?
Propylthiouracil (maternal liver failure) over carbimazole (foetal abnormalities)
35
What happens with untreated hypothyroidism in pregnancy?
Early foetal loss and impaired neurodevelopment
36
How should you manage hypothyroidism in pregnancy?
Aim for adequate replacement with thyroxine especially in first trimester
37
What is gestational diabetes?
Carbohydrate intolerance first recognised in pregnancy
38
How should you manage a women pre-conception with diabetes?
HbA1c < 48mmol/L
Folic acid 5mg
Stop ACEi and statins
Retinal screening
Check renal function and microalbuminuria
39
What are the maternal complications of diabetes?
DKA
Pre-eclampsia
Progression of retinopathy
Hypoglycaemia
40
What are the foetal complications of diabetes?
Miscarriage
Foetal abnormality
Still birth
Premature labour
Macrosomia -> shoulder dystocia
Neonatal hypoglycaemia, hypocalcaemia and polycythaemia
Respiratory distress
Most complications due to maternal hyperglycaemia
41
Why do babies get macrosomia in mothers with diabetes?
Insulin -> growth factor -> macrosomia
42
How can you treat diabetes in pregnancy?
Insulin
Metformin
All other hypoglycaemics contraindicated
Statins and ACEi contraindicated
43
Why are pregnant women more at risk of UTIs?
Urinary tract dilates in pregnancy secondary to progesterone -> predisposing to ascending infection and acute pyelonephritis and renal stones
44
What happens to renal function during pregnancy?
50% increase in renal blood flow and GFR
Serum creatinine, urate, and albumin fall
45
What are the maternal complications of chronic renal disease?
Severe hypertension
Superimposed pre-eclampsia
Deterioration of renal disease
C-section
46
What are the foetal complications of chronic renal disease?
Foetal malformations secondary to drugs
Intrauterine growth restriction
Stillbirth
Prematurity
47
How should chronic renal disease in pregnancy be managed?
Pre-pregnancy risk assessment
MDT care
Close monitoring of renal function and blood pressure during pregnancy
Regular assessment of foetal growth and wellbeing
48
How common are migraines during pregnancy?
1:5
49
How common is epilepsy during pregnancy?
1:150
50
How common is MS during pregnancy?
1:1000
51
How common is eclampsia during pregnancy?
1:2000
52
How common is cerebral vein thrombosis during pregnancy?
1:2500-10000
53
How common is MG during pregnancy?
1:25000
54
How common are malignant brain tumours during pregnancy?
1:50000
55
What are the maternal complications of epilepsy?
Increase in seizure frequency 25-35%
Sudden unexpected death in epilepsy - mainly in women who don't take medication
56
What are the foetal complications of epilepsy?
Risk of foetal abnormality due to meds and epilepsy itself
Inheritance of epilepsy
Risk of foetal hypoxia with maternal seizures
57
What is important to remember with anti-epileptic treatment during pregnancy?
All anti-epileptics associated with risk of foetal abnormalities
Sodium valproate highest risk
58
What can sodium valproate during pregnancy lead to?
Neural tube defect
ASD
Cleft palate
Hypospadias
Polydactyly
Craniosynestosis
Learning difficulties
Autism
59
How should you manage epilepsy during pregnancy?
○ Preconception assessment
High dose folic acid
Rationalise medication
Once pregnant - offer screening for foetal anomalies
Control seizures
Plan for delivery - pain relief, avoid prolonged labour
Postpartum support
60
What can increase your risk of VTE in pregnancy?
Increased maternal age, BMI, operative delivery
61
How do you investigate a suspected VTE?
Doppler USS +/- V/Q scan +/- CTPA
62
How do you treat a VTE in pregnancy?
LMWH
Warfarin and other anticoagulants CI
63
What is a premature infant?
Born before...
37 weeks
259 days from LMP
245 days after conception
64
What is the definition of a LBW infant?
<2500gm at birth regardless of GA
VLBW < 1500gm
ELBW < 1000gm
65
What improvements have there been in neonatal intensive care?
Antenatal steroids
Artificial surfactant
Ventilation
Nutrition
Antibiotics
66
How common are spontaneous preterm deliveries?
70% preterm deliveries
67
When might a preterm delivery be indicated?
Medial/obstetric disorders 30%
68
What can increase your risk of a preterm delivery?
No apparent risk factor in 50%
Non-recurrent
- APH, other vaginal bleeding
- Multiple pregnancy
Recurrent
- Race
- Previous preterm birth
- Genital infection
- Cervical weakness
- Socioeconomics
69
What infections can increase the risk of pre-term birth?
Genital - bacterial vaginosis (x2 risk)
Non-genital
- UTI
- Pyelonephritis
- Appendicitis
70
What treatment can be given in bacterial vaginosis to reduce risk of preterm birth?
Rx with metronidazole and erythromycin may reduce rate of SPTB
71
What primary prevention strategies are there to prevent preterm birth?
Reducing population risk
Effective interventions not demonstrable yet - Smoking and STD prevention
- Prevention of multiple pregnancy
- Planned pregnancy
- Variable work schedules
- Physical and sexual activity advice
- Cervical assessment at 20-26 weeks
72
What secondary prevention strategies are there to prevent preterm birth?
Select increased risk for surveillance and prophylaxis
Transvaginal cervical USS for cervical length
Qualitative foetal fibronectin test
73
What is the qualitative foetal fibronectin test?
Extracellular matrix protein found in choriodecidual interface
Abnormal finding in cervicovaginal fluid after 20 weeks - may indicate disruption of attachment of membranes to decidua
Reappears close to term as labour approaches
False +ve - cervical manipulation, sexual intercourse, lubricants, bleeding
74
What tertiary prevention strategies can be put in place to prevent premature birth?
Treatment after diagnosis
Aim to reduce morbidity/mortality
Prompt dx and referral
Drugs - tocolysis, antibiotics
Corticosteroids
75
What hormone has been shown to prevent premature birth?
Recent studies suggest benefit women at high risk
76
How is preterm labour diagnosed?
Persistent uterine activity and change in cervical dilatation and/or effacement
77
What are the treatment principles of preterm labour?
Identify associated cause, treat if possible
Assess foetal maturity
Consider tocolysis and give steroids
Decide best route of delivery
Plan with neonatologists and in best place, consider in utero transfer
78
How common is hypertension in pregnancy?
Complicates 7-10% pregnancies
- 70% gestational hypertension/pre-eclampsia - eclampsia
- 30% chronic hypertension
79
How common is eclampsia?
Eclampsia 0.05% incidence
20% maternal deaths
10% preterm births
80
What causes eclampsia?
Aetiology unknown
81
What can predispose you to eclampsia?
Primigravida
Young female x3 increased risk
Black x2 increased risk
Multifoetal pregnancies
Hypertension
Renal disease
Collagen vascular disease
Diabetes
82
What is gestational hypertension?
New HT after 20 weeks
Systolic > 140 diastolic > 90
No or little proteinuria
83
How many people with gestational hypertension will develop pre-eclampsia?
25%
84
What is the definiction of pre-eclampsia?
New HT after 20th week (earlier with trophoblastic disease)
Increased BP (gestational BP elevation) with proteinuria
- Systolic > 140 diastolic > 90
- Proteinuria > 0.3g protein/24 hr
- > 2+ on urine dip
85
What is eclampsia?
Features of pre-eclampsia plus generalised tonic-clonic siezures
86
What is chronic hypertension?
Hypertension diagnosed before pregnancy, before 20th week gestation, during pregnancy and not resolved postpartum
87
How do you diagnosed pre-eclampsia superimposed on chronic hypertension/renal disease?
Chronic hypertension - HT and no proteinuria < 20 weeks, new onset proteinuria > 20 weeks
Renal disease - HT and proteinuria < 20 weeks
- Sudden increase in proteinuria
- Sudden increase in BP when HT well controlled
- Thrombocytopenia < 100,000
- Abnormal ALT/AST
88
What is severe pre-eclampsia?
One or more
- BP > 160 systolic, > 110 diastolic
- Proteinuria > 5gm/24hr, over 3+ urine dip
- Oligouria < 400ml in 24hr
- CNS - visual changes, headache, scotomata, mental status chage
- Pulmonary oedema
- Epigastric or RUQ pain
- Impaired LFTs
- Thrombocytopenia < 100,000
- Intrauterine growth restriction
- Oligohydramnios
89
What is the pathology of pre-eclampsia/eclampsia?
Failure of conversion of spiral arteries to vascular sinuses -> placental ischaemia -> foetal growth retardation and placenta produces thromboplastins causing DIC, renin causing vasoconstriction -> poor renal perfusion, hypertension, proteinuria, oedema -> pre-eclampsia
90
What happens if pre-eclampsia goes untreated?
Poor renal perfusion, hypertension, proteinuria, oedema -> eclampsia
91
How is maternal pre-eclampsia characterised?
Vasospasm
Activation of coagulation system
Derangement in humoural and autocoid control of blood volume and pressure
Oxidative stress and inflammatory-like responses
Ischaemia from poor placentation
92
What happens to the kidneys in pre-eclampsia?
GFR and renal blood flow decrease
Raised uric acid levels
Proteinuria
Hypoclaciuria - alterations in regulatory hormones
Impaired Na excretion and suppression of renin-angiotensin system
93
What happens to the coagulation system in pre-eclampsia?
Thrombocytopenia, low antithrombin III, higher fibronectin
94
What happens to the liver in pre-eclampsia?
HELLP syndrome - Haemolysis, Elevated ALT and AST (Liver enzymes), Low Platelets
95
What happens in the CNS with pre-eclampsia?
Headache and visual disturbances
Scotomata
Cortical blindness
Eclampsia
96
What are the symptoms of pre-eclampsia?
Visual disturbances
Headache similar to migraine - N&V
Epigastric pain - hepatic swelling and inflammation, stretch of liver capsule
+/- oedema
Rapid weight gain
Physical findings
- BP
- Proteinuria
- Retinal vasospasm or oedema
- RUQ abdominal tenderness
- Brisk/hyperactive reflexes common
- Ankle clonus - neuromuscular irritability that raises concern
97
What are the possible differential diagnoses of pre-eclampsia?
TTP
Haemolytic uraemic syndrome
Acute fatty liver of pregnancy
98
What lab tests can you do for pre-eclampsia?
Haemoglobin, platelets
Serum uric acid
LFTs
If 1+ protein by clean catch dip stick - timed collection for protein and creatinine
Accurate dating and assessment of foetal growth
99
What is the goal of pre-eclampsia treatment?
Prevent eclampsia and other severe complications
Palliate maternal condition to allow foetal maturation and cervical ripening
100
When should you hospitalise someone with pre-eclampsia?
New-onset to assess maternal and foetal conditions
Pre-term onset of severe gestational hypertension or pre-eclampsia
101
What are the maternal indications for delivery in pre-eclampsia?
Gestational age 38 weeks
Platelet count < 100,000 cells/mm3
Progressive deterioration in liver and renal function
Suspected abruptio placentae
Persistent severe headaches, visual changes, nausea, epigastric pain, or vomiting
Favourable cervix
Delivery based on maternal and foetal conditions as well as gestational age
102
What are the foetal indications for delivery in pre-eclampsia?
Severe foetal growth restriction
Non-reassuring foetal testing results
Oligohydramnios
103
What is the cure for pre-eclampsia?
Delivery
Always beneficial for mother
Deleterious for baby
104
What is the preferable route of delivery in pre-eclampsia?
Vaginal preferable
Labour induction (usually within 24 hours)
Neuraxial (epidural, spinal, and combined) techniques offer advantages
Hydralazine/labetalol pretreatments to reduce hypertension during delivery
MgSO4 - for seizures in delivery and brain ripening for baby
105
What anti-convulsive therapy can you give to women with eclampsia?
Parenteral magnesium sulphate reduces frequency of eclampsia and maternal death
106
How do you treat acute severe hypertension in pregnancy?
Parenteral hydralazine and labetalol (avoid in women with asthma and CHF)
Oral nifedipine used with caution
Sodium nitroprusside
107
What is acute severe hypertension?
SBP > 160 and/or DBP > 105
108
What post-partum counselling should you give to women who had pre-eclampsia?
Counselling for future pregnancies
109
What can increase the risk of recurrent pre-eclampsia?
Pre-eclampsia < 30 weeks
New father
Black
110
What is the puerperium?
From delivery of placenta to 6 weeks following birth
Return to pre-pregnant state
Initiation/suppression of lactation
111
What physiological changes occur during the puerperium?
Endocrine changes
Involution of uterus and genital tract
Lochia rubra
Lochia serosa
Lochia alba
Breast changes
112
What endocrine changes occur during the puerperium?
Profound decrease in serum levels of placental hormones (human placental lactogen, hCG, oestrogen, progesterone)
Increase of prolactin
113
What changes occur in the uterus and genital tract during the puerperium?
Muscle - ischaemia, autolysis, and phagocytosis
Decidua - shed as lochia, rubra, serosa, alba
114
When is the lochia rubra and what happens during it?
Day 0-4
Blood
Cervical discharge
Decidua
Foetal membrane
Vernix
Meconium
115
When is the lochia serosa and what happens during it?
Day 4-10
Cervical mucus
Exudate
Foetal membrane
Micro-organisms
White blood cells
116
When is the lochia alba and what happens during it?
Day 10-28 Cholesterol
Epithelial cells
Fat
Micro-organisms
Mucus
Leukocytes
117
What breast changes occur during the puerperium?
Establishment of lactation
At birth presence of colostrum
Lactogenesis
- Prolactin - milk production
- Oxytocin - milk ejection reflex
Lactation suppression 7-10 days
118
What are the health benefits of breast feeding in women?
Reduced breast cancer
119
What are the health benefits of breast feeding for babies?
Reduction in 4 acute conditions in infants - gastrointestinal disease, respiratory disease, otitis media, necrotising enterocolitis
120
What is lactoferrin?
Multifunctional protein in milk
121
In what is lactoferrin highest?
Colostrum x7 higher than later milk
122
What are the functions of lactoferrin?
Regulates iron absorption in intestines and delivery of iron to cells
Protection against bacterial infection, some viruses and fungi
Involved in regulation of bone marrow function
Boosts immune system
123
What minor post-natal problems can occur?
Infection
Post-partum haemorrhage
Fatigue
Anaemia
Backache
Breast engorgement/mastitis
Urinary stress incontinence
Haemorrhoids/constipation
The blues
124
What major post-natal problems can occur?
Sepsis
Severe PPH
Pre-eclampsia/eclampsia
Thrombosis
Uterine prolapse
Incontinence (urinary/faecal)
Post-dural puncture headache
Breast abscess
Depression/psychosis
125
What is the normal post-natal care?
Midwives
Breastfeeding support workers
Doulas
Support workers
Nursery nurses
Housekeepers
Domestics
126
What is the complex post-natal care?
Normal +
Obstetricians +/- GP
Paediatricians
Anaesthetics
Physios
Substance use specialists
Microbiology ect
127
What are the symptoms of PPH?
Sudden and profuse blood loss or persistent increased blood loss, faintness, dizziness, palpitations/tachycardia
128
What are the symptoms of post-partum infection?
Fever, shivering, abdominal pain, and/or offensive vaginal loss
129
What are the symptoms of pre-eclampsia?
Headaches accompanied by one or more of the following symptoms within first 72 hours after birth - visual disturbances, N&V
130
What are the symptoms of a VTE?
Unilateral calf pain, redness, swelling, SOB/chest pain
131
What is sepsis?
Infection + systemic manifestations of infection
132
What is severe sepsis?
Sepsis + sepsis induced organ dysfunction or tissue hypoperfusion
133
What is septic shock?
Persistence of hypoperfusion despite adequate fluid replacement therapy
134
What risk factors can increase your risk of sepsis post-natally?
Obesity
Diabetes
Anaemia
Amniocentesis/invasive procedures
Prolonged SROM
Vaginal trauma/cs
Ethnicity BME
135
What are the likely causes of sepsis post-natally?
Endometritis
Skin and soft tissue infection
Mastitis
UTI
Pneumonia
Gastroenteritis
Pharyngitis
Infection related to epidural/spinal
136
What are the signs of sepsis?
3Ts white with sugar
- Temperature < 36 or > 38
- Tachycardia > 90bpm
- Tachypnoea > 20bpm
- WCC > 12 or < 4
- Hyperglycaemia > 7.7mmol
137
What in the history/signs might point you towards a new infection/source?
PROM/offensive liquor
Offensive lochia
Catheter or dysuria
Headache + neck stiffness
Cellulitis/would infection
D and V
Breast redness or pain
Cough, sputum, chest pain
Abdominal pain
138
What are the sepsis 6?
BUFALO
- Blood cultures
- Urine output
- Fluid resuscitation
- Antibiotics
- Lactate
- Oxygen
139
What should you add to the sepsis 6 in obstetrics?
Consider delivery ERPC and VTE prophylaxis
140
What are the red flags in sepsis?
BP < 90 syst/ > 40 drop from norm
HR > 130
RR > 25
O2 sats < 90%
Urine output < 30ml/hr
Lactate > 2 mmol/L
141
What lab markers indicate sepsis?
Creatinine > 177
Platelets < 100
APTT > 60s
INR > 1.5
142
What is a primary PPH?
>500ml estimated blood loss after birth
143
What is a minor PPH?
< 15000mls and no clinical signs of shock
144
What is a major PPH?
15000mls loss or more and continuing to bleed or clinical shock
145
What is a secondary PPH?
Abnormal or excessive bleeding from birth canal between 24 hours and 12 weeks postnatally
146
How common are secondary PPH?
Affects around 1% all pregnancies
147
What can cause secondary PPH?
Endometritis
Retained products of conception
Subinvolution of placental implantation site
Pseudoaneurysms
Ateriovenous malformations
148
What investigations should you do in PPH?
Assess blood loss
Assess haemodynamic status
Bacteriological testing (HVS and endocervical swab)
Pelvic USS
149
How common is eclampsia post-natally?
50% after birth
26% seizures > 48 hours after birth
150
How common is pre-eclampsia post-natally?
New onset postpartum pre-eclampsia incidence 0.3-27.5%
151
What is the VTE risk during pregnancy?
Risk increases with gestational age reaching max just after birth
Relative risk postpartum five-fold higher compared to antepartum
152
When is the risk of VTE highest?
Absolute risk peaks in first 3 weeks postpartum
Risk persists up to 6 weeks postpartum
153
What categorises you as high risk for VTE?
Any previous VTE
Anyone requiring antenatal LMWH
High risk thrombophilia
Low risk thrombophilia + FHx
154
How do you treat high risk VTE?
Treat with at least 6 weeks postnatal prophylactic LMWH
155
What categorises you as intermediate risk VTE?
C-section in labour
BMI > 40
Readmission or prolonged admission > 3 days in puerperium
Any surgical procedure in puerperium except immediate repair of perineum
Medical co-morbidities eg cancer, HF, active SLE, IBD or inflammatory polyarthropathy, nephrotic syndrome, T1DM with nephropathy, SCD, current IVDU
156
How are people who are intermediate risk for VTE treated?
At least 10 days postnatal prophylactic LMWH
157
How common is accidental dural punture?
1/100-1/500
158
Why do you get a post-dural puncture headache?
Leakage of CSF and reduced pressure in fluid around brain
159
What are the symptoms of a post-dural puncture headache?
Headache worse on sitting/standing, starts 1-7 days after spinal/epidural
Neck stiffness
Photophobia
160
What is the treatment for post-dural puncture headache?
Lying flat
Simple analgesia
Fluids and caffeine
Epidural blood patch
161
What is urinary retention?
Abrupt onset of aching or acheless inability to completely micturate, requiring urinary catheterisation over 12 hours after birth or not voiding spontaneously within 6 hours of vaginal delivery
162
What are the risks of inappropriate diagnosis of urinary retention?
Inappropriate diagnosis can lead to bladder dysfunction, UTI and catheter related complications
163
What are the risk factors for urinary retention?
Epidural analgesia
Prolonged second stage of labour
Forceps or ventouse delivery
Extensive perineal lacerations
Poor labour bladder care
164
What is the treatment of urinary retention?
Varies locally and aims to
- Maintain bladder function
- Minimise risk of damage to urethra/bladder
- Provide appropriate management strategies for women who have problems with bladder emptying
- Prevent long term problems with bladder emptying
165
What factors can make mental health disorders difficult to detect in the puerperium?
Fear of treatment
Fear of children being removed
Lurching from day to day, just coping
Stigma of mental illness
Cultural lack of recognition
Belief that health workers not interested
Denial by woman/partner/family
Lack of recognition of seriousness from health practitioners
166
What are the red flags of a mental health condition post-natally?
Recent significant change in mental state or emergence of new symptoms
New thoughts or acts of violent self-harm
New and persistent expressions of incompetency as a mother or estrangement from the infant
167
How common is postnatal depression?
10% new mothers
168
What are the symptoms of postnatal depression?
Depressed
Irritable
Tired
Sleepless
Appetite changes
Negative thoughts
Anxiety
Affects bonding
169
How common is postpartum psychosis?
1-2:1000
170
What are the symptoms of postpartum psychosis?
Depression
Mania
Psychosis
Excited/elated
Severely depressed
Restless
Sleepless
Rapid mood changes
Unable to concentrate
Confused/disorientated
Experiencing psychotic symptoms - delusions/hallucinations
171
How common is PTSD postnatally?
3.1% full symptoms
33% some symptoms
172
What can increase your risk of PTSD postnatally?
Perceived lack of care
Poor communication
Perceived unsafe care
Perceived focus on outcome over experience of mother
173
How can PTSD present postnatally?
Anger, low mood
Self-blame
Suicidal ideation
Isolation and dissociation
Intrusive and distressing flashbacks
174
What are the potential consequences of post-natal PTSD?
Delay/avoid future pregnancies
Request c-sections to avoid vaginal delivery
Avoidance of intimate physical relationships
Impact on breastfeeding
175
What is the definition of a maternal death?
Death of a woman whilst pregnant or within 42 days of termination of pregnancy irrespective of duration and site of pregnancy, from any cause related to or aggravated by pregnancy or it's management, but not from accidental or incidental causes
176
What direct causes are there of maternal death?
Pregnancy with abortive outcome
Hypertensive disorders in pregnancy, childbirth, and puerperium
Obstetric haemorrhage
Pregnancy related infection
Other obstetric complications
Unanticipated complications of management
Non-obstetric complications
177
What other causes are the of maternal death?
Unspecified
Coincidental
178
What is the leading cause of direct maternal death?
Thrombosis and thromboembolism leading cause of direct maternal death up to 6 weeks postnatally
179
What is the leading cause of indirect maternal death?
Cardiac disease
180
What is the role of an anaesthetisit?
Provision of pain relief for labour
Provision of anaesthesia for instrumental/operative delivery
Input on obstetric HDU
Anaesthetic antenatal clinic
181
What is labour pain?
Associated by intermittent periods of intense pain
Continues for many hours
Many factors will influence woman's perception of pain and ability to cope with it
Psychological and physiological factors are involved
Extremely complicated and poorly understood
182
What is the first stage of labour and what nerves are involved in it?
Uterine contraction, cervical effacement, dilatation
T10-L1
S2-S4
183
What is the second stage of labour and what nerves are involved in it?
Stretching vagina and perineum, extrauterine pelvis structures
S2-4 pudendal
L5-S1
184
What non-pharmacological therapies for labour pains are there?
Trained support
Acupuncture
Hypnotherapy
Massage
TENS
Hydrotherapy Alternative therapy - homeopathy, aromatherapy
185
What is entonox?
Gas and air
50% N20 50% O2
Rapid onset analgesia
Minimal S/E
Self limiting
Theoretical risk of bone marrow suppression
Green house gas
186
What oral analgesia is available?
Paracetamol/codeine
187
What single shot parenteral opioids are available?
Morphine/diamorphine/pethidine
188
What are the S/E of opioids?
Sedation, respiratory depression, N&V, pruritis
Lipid soluble therefore cross placenta rapidly
Pethidine metabolites can cause seizures - avoid epileptics and PET
Diamorphine rapidly eliminated by placenta
189
What PCA opioids can you give and how are the given?
IV cannula
Fentanyl - v lipid soluble, rapid onset of action, long half life 8 hours
Alfentanil - shorter half life 90 mins
Remifentanil - unique metabolism by tissue esterases, context insensitive half life < 10 mins
190
What regional techniques can you use to give pain relief during labour?
Epidural
Spinal
Combined spinal-epidural
191
What local anaesthetics can you give for neuroaxial drugs?
Bupivacaine
192
What opioids can you give neuroaxially?
Fentanyl
Diamorphine
193
What are the indications for epidural?
Maternal request
PIH, PET
Cardiac/other medical disease
Augmented labour
Multiple births
Instrumental/operative delivery likely
194
What absolute CI are there for using regional techniques for pain relief?
Maternal refusal
Local infection
Allergy LA
195
What relative CI are there for using regional techniques for pain relief?
Coagulopathy
Systemic infection
Hypovolaemia
Abnormal anatomy
Fixed cardiac output
196
What are the effects of regional pain relief?
Autonomic -> sensory -> motor
Vasodilatation -> reduced MAP
Analgesia
Motor blockade
Fever
197
What are the cardiac adverse effects of regional pain relief?
Hypotension
Bradycardia
198
What are the respiratory adverse effects of regional pain relief?
Blocked intercostal nerves
Poor cough
199
What are the neurological adverse effects of regional pain relief?
Haematoma
Abscess
Headache
200
What are the drug related adverse effects of regional pain relief?
Allergy
Anaphylaxis
Neurotoxicity
201
What epidural regimens are there?
Traditional (intermittent bolus)
Continuous infusion
Continuous infusion + bolus
Combined spinal-epidural
202
What are the analgesic outcomes of anaesthesia?
Superior analgesia
Maternal satisfaction between with low dose
May prolong labour
May increase instrumental delivery
Maternal pyrexia ?significance
No increase in CS rate
No association back pain
No effect on neonatal APGAR score
203
When would you use general anaesthesia for operative delivery?
Imminent threat to mother and/or foetus
204
What are the risks of general anaesthesia?
Increased risks associated with altered physiology
Aspiration
Failed intubation
205
What is important to give pre-operatively with general anaesthesia?
Antacids pre-operatively
Adequate preoxygenation
206
What are the advantages of regional anaesthesia for operative delivery?
Safer
Can see baby immediately
Partner present
Improved post-op analgesia
207
What are the disadvantages of regional anaesthesia for operative delivery?
Hypotension
Headache
Discomfort associated with pressure sensations
Failure
208
Why is foetal monitoring during pregnancy important?
UK has one of highest stillbirth rates in developed world
Prevalence of stillbirth not fallen over the last 20 years and is about 5.1 per 1000 births
Accurate FHR monitoring may help us identify babies at risk of stillbirth
209
What antenatal care is provided to low risk women?
Community (midwives and GPs)
210
What antenatal care is provided to high risk women?
Shared between hospital and community, will see in antenatal clinics
211
What constitutes a high risk woman?
Underlying medical conditions eg hypertension, diabetes, epilepsy, rheumatoid arthritis, asthma, ITP
Complications in previous pregnancy eg previous c section, 3rd/4th degree tear, previous traumatic delivery, previous pre-eclampsia, previous PPH, previous small baby or preterm birth, previous stillbirth
Complications in current pregnancy eg pre-eclampsia, breech presentation, gestational diabetes, multiple pregnancy, placental praevia
Issues with woman herself - raised BMI/low BMI, smoking/alcohol/drugs, old/young
212
What is the aim of antenatal foetal monitoring?
Identify those babies at risk of stillbirth and deliver them before they die
213
What are the types of foetal monitoring?
USS to assess
- Growth (HC, AC, FL, estimated foetal weight)
- Liquor volume
- Umbilical artery dopplers
Intermitted auscultation with hand held doppler or pinard stethoscope - can listen to foetal heart
CTG - can identify hypoxic babies
214
What intrapartum monitoring is there for low risk women?
Intermittent auscultation
215
What intrapartum monitoring is there for high risk women?
Continuous monitoring
216
How is intermittent auscultation carried out intrapartum?
Pinard stethoscope
Hand-held doppler
217
What are the advantages of intermittent auscultation?
Inexpensive
Non-invasive
Can be used in home setting
218
What are the disadvantages of intermittent auscultation?
Variability and decelerations cannot be detected
Long-term monitoring not possible
Quality of FHR affected by maternal HR and maternal movement
219
What happens in continuous foetal monitoring?
Doppler USS to measure FHR
220
What are the advantages of continuous foetal monitoring?
Provides information about FHR and uterine contractions
Long-term monitoring possible
Average variability can be determined
221
What are the disadvantages of continuous foetal monitoring?
No improvement in perinatal outcome has been shown in low-risk
No morphological assessment of the heart
No true beat-to-beat FHR data
Foetal exposure to USS insonation
Ambulatory monitoring may not be possible
222
How can you interpret a CTG?
Dr C Bravado
- Dr = define risk
- C = contractions
- Bra = baseline rate
- V = variability
- A = accelerations
- D = decelerations
- Early decelerations
- Variable decelerations
- Late decelerations
- O = overall assessment
223
What methods are there for foetal ECG?
Direct
- Scalp ECG (STAN)
Abdominal foetal ECG
224
What are the advantages of a scalp ECG?
Gold standard for direct FHR monitoring
True beat-to-beat information
225
What are the disadvantages of a scalp ECG?
Invasive therefore rarely used
Monitoring only in labour
Membranes absent and at least 2cm dilated
Associated with scalp injury and perinatal infection
226
What are the advantages of abdominal foetal ECG?
Non-invasive
True beat-to-beat FHR and morphological analysis possible
227
What are the disadvantages of abdominal foetal ECG?
Research tool, may be found at STH only
Signal not guaranteed antenatally
228
Name 3 maternal obstetric emergencies
Antepartum haemorrhage
Postpartum haemorrhage
VTE
Pre-eclampsia
229
Name 2 foetal obstetric emergencies
Foetal distress
Cord prolapse
Shoulder dystocia
230
What are the categories of maternal obstetric emergencies?
Related to pregnancy
- Disorders of any system
- Disorders of uterus and genital tract
Unrelated to pregnancy
231
What is an antepartum haemorrhage?
Bleeding from anywhere in the genital tract after 24 weeks gestation - uterus, cervix, vagina, vulva
232
How common are antepartum haemorrhages?
3-5% pregnancies
No identifiable cause in 40%
233
What can cause an antepartum haemorrhage?
Low lying placenta/placenta praevia
Placenta accreta
Vasa praevia
Minor/major abruption
Infection
234
What is a low lying placenta?
Any part of placenta that has implanted into lower segment
235
What is a major placenta praevia?
Covering/reaching os
236
What is a minor placenta praevia?
In lower segment/encroaching
237
How is placenta praevia diagnosed?
20 week anomaly scan
High presenting part, abnormal lie, painless bleed
Minor praevia repeat scan at 36 weeks
Major praevia repeat scan at 32 weeks
Placenta must be > 20mms from cervical os
Placenta remains < 20mms elective c section
238
How is placenta praevia managed?
Advise symptoms to watch for
Outpatient management if asymptomatic
If recurrent bleeds, may need admission until delivery with weekly X match
Remember anti-D if rhesus negative
Elective c-section at 38-39 weeks
239
How do you manage a bleeding placenta praevia?
ABCDE
If major bleed - 2 14/16 G cannulas, IV fluids X match 6 units, inform senior team and paeds
Examination
- General and abdominal
- Vaginal (avoid digital)
- USS (check 20 week scan)
Foetal monitoring (CTG) +/- delivery
Steroids in < 34 weeks gestation
240
What are the potential complications of APH?
Premature labour/delivery
Blood transfusion
Acute tubular necrosis +/- renal failure
DIC
PPH
ITU admission
ARDS (secondary to transfusion)
Foetal morbidity (hypoxia) and mortality
241
How is placenta accreta diagnosed?
At 20 weeks scan watch for anterior LLP if previous CS
Loss of definition between wall of uterus and abnormal vasculature
MRI may be useful
242
How is placenta accreta treated?
Arrange elective C-section at 36-37 weeks
Discussion and consent includes possible interventions such as hysterectomy, leaving placenta in place, cell salvage and intervention radiology
MDT involvement in pre-op and procedure
Blood and blood products available
Local availability of HDU bed
243
What is vasa praevia?
Foetal vessels coursing through membranes over internal cervical os and below foetal presenting part, unprotected by placental tissue or umbilical cord
No major maternal risk, major foetal risk
CTG abnormalities
244
Why is vasa praevia a major foetal risk?
Membrane rupture leads to major foetal haemorrhage
245
How common is vasa praevia?
1 in 2,000-6,000 pregnancies
Mortality 60%
246
What is placental abruption?
Premature separation of placenta from uterine wall
Concealed or revealed haemorrhage
247
How does placental abruption present?
Woody-hard, tense uterus
Foetal distress
Maternal shock out of proportion to bleeding
248
How is placental abruption managed?
Small abruptions may be managed conservatively
Large abruptions need resuscitation and delivery
249
What is primary PPH?
Within 24 hours of delivery, blood loss > 500mls
250
What is a secondary PPH?
After 24 hours and up to 12 weeks post delivery
251
What are the 4 causes of PPH?
Tissue - ensure placenta complete
Tone - ensure uterus contracted
Trauma - look for tears (repair)
Thrombin - check clotting
252
What can increase your risk of PPH?
Big baby
Nulliparity and grand multiparity
Multiple pregnancy
Precipitate or prolonged labour
Maternal pyrexia
Operative delivery
Shoulder dystocia
Previous PPH
253
What can increase the risk of maternal sepsis?
Obesity
Diabetes
Impaired immunity/immunosuppression
Anaemia
Vaginal discharge
History of pelvic infection
History of GBS
Amniocentesis and other invasive procedures
Cervical cerclage
Prolonged SROM
Group A strep infection in close contacts/family
254
What are the S&S of maternal sepsis?
Pyrexia
Hypothermia
Tachycardia
Tachypnoea
Hypoxia
Hypotension
Oligouria
Impaired consciousness
Failure to respond to treatment
255
How is maternal sepsis treated?
Timely recognition
Sepsis 6
Ongoing MDT care
256
What is the criteria for severe pre-eclampsia?
Hypertension + proteinuria +/- at least one of the following
- Severe headache
- Visual disturbances eg blurring/flashing lights
- Papilloedema
- Clonus
- Liver tenderness
- Abnormal LFTs
- Platelet count falls to < 100
257
How is severe pre-eclampsia treated?
Stabilise BP (labetalol, nifedipine, methyldopa)
Check bloods including platelets, U&Es, LFTs
Magnesium sulphate if applicable eg hyperreflexia
Monitor urine output
Treat coagulation defects
Foetal wellbeing
Delivery
258
What is eclampsia?
Onset of seizures in a woman with pre-eclampsia
259
How is eclampsia treated?
IV MgSO4 4gms given over 5 mins, infusion of 1g/hr maintained for 24 hours
Recurrent seizures may require further doses
Treat hypertension
Stabilise mum then deliver baby
If strong suspicion of foetal compromise ie prolonged bradycardia or foetal acidosis on scalp sample deliver
260
How common is cord prolapse?
Rare 0.2-0.6%
261
What is cord prolapse?
Occurs when cord presenting after rupturing membrane
Exposure of cord leads to vasospasm
Can cause significant risk of foetal morbidity and mortality from hypoxia
262
What can increase the risk of cord prolapse?
Premature rupture membranes
Polyhydramniosis (large volume of amniotic fluid)
Long umbilical cord
Foetal malpresentation
Multiparity
Multiple pregnancy
263
How is cord prolapse treated?
999 or emergency buzzer
Infuse fluid into bladder via catheter if at home
Trendelenburg position - feet higher than head
Constant foetal monitoring
Alleviate pressure on cord
Transfer to theatre and prepare for delivery
264
What is shoulder dystocia?
Failure for anterior shoulder to pass under symphysis pubis after delivery of foetal head
High risk for maternal morbidity and foetal mortality and morbidity
265
How common is shoulder dystocia?
1% pregnancies
266
What are the maternal risks of shoulder dystocia?
PPH
Extensive vaginal tear (3rd and 4th degree)
Psychological
267
What are the neonatal risks of shoulder dystocia?
Hypoxia
Fits
CP
Injury to brachial plexus
268
What can increase the risk of shoulder dystocia?
Macrosomnia
Maternal diabetes
Previous should dystocia
Disproportion between mother and foetus
Postmaturity and induction of labour
Maternal obesity
Prolonged 1st or 2nd stage labour
Instrumental delivery
269
How is shoulder dystocia treated?
HELPERR(R)
- Call for help
- Evaluate for episiotomy
- Legs in McRoberts
- Suprapubic pressure
- Enter pelvis
- Rotational manoeuvres
- Remove posterior arm
- Replace head and deliver
270
Why do we do imaging in pregnancy?
Assess normality
Foetus and placenta location
Assess for abnormality
Can figure out management of child once born
In-utero treatment?
Delivery options
271
How can imaging be done in pregnancy?
USS
MRI
272
What imaging may be done pre-pregnancy?
Usually related to fertility issues
USS of uterus assessing for anomalies
Hysterosalpingography - checks patency of fallopian tubes
USS for collecting eggs
273
What routine scans are offered during pregnancy/
12 weeks - dating scan
20 weeks - anomaly scan
274
What is assessed during the 12 week dating scan?
Heart beat to assess viability
Crown rump length to date pregnancy
Number of foetuses and chrionicity (identical/not)
Nuchal translucency
275
What is assessed during the 20 week anomaly scan?
Abnormalities of foetus
Nature of abnormality
Placenta and location
Femur length for dating
GI and head size
Blood flow through umbilicus
276
When might additional scans be required?
Low placenta
277
What other imaging investigations might happen during pregnancy?
Bloods
Amniocentesis - Downs, Edwards, Pataus
Further USS for bones and heart
MRI
278
What is the definition of prematurity?
< 37 weeks
< 259 days from LMP
< 245 after conception
279
What is a LBW infant?
< 2500g at birth regardless of GA
280
What is a VLBW infant?
< 1500g
281
What is an ELBW infant?
< 1000g
282
What should you remember for LBW babies?
Can be appropriate for GA if preterm
Can be small for GA at preterm/term
283
What is the largest cause of perinatal death?
Preterm birth
284
What can preterm birth cause in babies?
Developmental delay
Visual impairment
Chronic lung disease
CP
285
What has contributed to improved survival for preterm babies?
Improvements in neonatal intensive care
Antenatal steroids
Artificial surfactant
Ventilation
Nutrition
Abx
286
What are the spontaneous causes of pre-term delivery?
Preterm labour
Preterm premature rupture of membranes (PPROM)
Cervical weakness
Amnionitis
287
What are the indicated reasons for pre-term delivery?
Medical/obstetric disorders
288
In how many people is there no apparent risk factor for PTB?
50%
289
What are the non-recurrent RF for PTB?
Antepartum haemorrhage/other vaginal bleeding
Multiple pregnancy
IVF
290
What are the recurrent RF of PTB?
Black
Previous PTB
Genital infection
Cervical weakness
Socioeconomics
Smoking
291
What is the risk of BV and preterm birth?
2x increased risk
292
Which systemic infection can increase the risk of PTB?
UTI
Pyelonephritis
Appendicitis
293
What are the 2 methods of infection of the amniotic fluid (amnionitis)?
Blood
Ascending through vagina
294
What genital infections can increase risk of PTB?
Chlamydia
U urealyticum
GBS
BV
295
What are the primary preventative strategies for PTB?
Reducing population risk
Smoking and STD prevention
Prevention of multiple pregnancy
Planned pregnancy
Variable work schedules
Physical and sexual activity advice
Cervical assessment at 20-26 weeks
296
What are the secondary prevention methods for PTB?
Select increased risk women for surveillance and prophylaxis
TV USS - cervical length (if shortened, threatened PTB)
Qualitative foetal fibronectin test
- Extracellular matrix protein found in choriodecidual interface
- Abnormal if in cervicovaginal fluid > 20 weeks, indicates disruption of attachment of membranes to decidua
- Reappears as labour approaches
Progesterone - IM/pessary
297
What is the tertiary prevention of PTB?
Treatment after diagnosis
Aim to reduce morbidity/mortality
Prompt Dx and referral
Drugs - tocolysis (preventing labour), Abx esp if ROM
Steroids
298
What is placenta accreta?
Implants deeply into uterine wall
299
What is placenta increta?
Attaches into myometrium
300
What is placenta percreta?
Goes through myometrium, may invade into nearby organs like bladder
