Obstetrics Flashcards
(311 cards)
1
Q
What are the signs of threatened miscarriage?
A
- Vaginal bleeding
- Abdo/pelvic pain
in early pregnancy = threatened miscarriage. There is a closed internal cervical os. Bleeding and pain are reasonably mild.
2
Q
What is an inevitable miscarriage?
A
Heavy vaginal bleeding w dilation of the cervical canal, bleeding is usually more severe than w threatened miscarriage. There is often pain. Foetus is still currently intrauterine.
3
Q
What is an incomplete miscarriage?
A
Intense vaginal bleeding and abdo pain. Cervical os may be open w products of conception being passed, need an USS to see if products of conception are still in the uterus.
4
Q
What is a complete misscarriage?
A
Hx of bleeding abdo pain and tissue passage. USS = vacant uterus. Can see an aborted fetus w complete placenta.
5
Q
What is the definition of a miscarriage?
A
Pregnancy lost before 24 weeks.
6
Q
What are the causes of miscarriage?
A
Foetal pathology - genetic disorder, abnormal development, placental failure
Maternal pathology - uterine abnormality, cervical incompetence, PCOS, poorly controlled diabetes or thyroid disease, anti-phospholipid syndrome, previous uterine surgery, smoking
7
Q
What are the differentials for vaginal bleeding before 24 weeks?
A
Ectopic pregnancy - pain is the first and dominant symptom, normally minor vaginal bleeding
Cervical/uterine malignancy
Hydatidform mole
Miscarriage
8
Q
What are the ix into potential miscarriage?
A
- Transvaginal USS - any foetal components in the uterine cavity and if foetal heartbeat
- Mean sac diameter = >25mm can make diagnosis of failed pregnancy, <25mm need to repeat scan in 2 weeks
- Serial serum hCG measurements 48 hours apart can indicate the location and prognosis of a pregnancy
9
Q
What do different serial serum hCGs indicate?
A
- Levels fall = foetus will not develop and there has been miscarriage
- Slight increase/plateau in hCG levels = maybe ectopic pregnancy
- Normal increase in hCG = foetus growing normally but doesn’t exclude ectopic pregnancy
10
Q
What is the management of a miscarriage?
A
- Often can’t stop or prevent it - need to remove all of foetal material
- Expectant management = allow products of conception to naturally expels, high risk of infection, haemorrhage and pain
- Medical management = misoprostol
- Surgical management = ERPC (evacuation of retained products of conception) dilatation and curettage, manual vacuum aspiration if <12 weeks
- If the woman is rhesus neg they need anti-D prophylaxis
11
Q
What is misoprostol?
A
Synthetic prostaglandin E1 analogue that is used unliscenced to for medical abortion and management of miscarriage, induce labor, cervical ripening and treat post partum haemorrhage.
12
Q
How do you define recurrent miscarriage?
A
Loss of 3 or more consecutive pregnancies
13
Q
What are the ix into recurrent miscarriage?
A
- Bloods - antiphospholipid ab, thrombophilia screen
- Cytogenetic analysis of products of conception - if abnormal parents need to be karyotyped
- Pelvic US
14
Q
What are the causes of recurrent miscarriage? How do you manage each cause?
A
- Genetic disorder - genetic counselling, use donor egg/sperm
- Uterine structural abnormality - can treat surgically but some malformations won’t be treated
- Cervical incompetence - US monitoring of cervix, cervical cerclage = stitch cervix closed
- PCOS - no consensus on management
- Antiphospholipid syndrome - heparin or low dose aspirin
- Thrombophilia - heparin
- Diabetes - improve glycemic control
15
Q
What is molar pregnancy?
A
Hydatidiform mole - part of gestational trophoblastic disease. Imbalance in number of chromosomes from mother and father. Likely under 16 and over 45 years old.
16
Q
What is a complete mole?
A
1 sperm and an empty egg w no genetic material - sperm replicates to give normal no of chromosomes and is diploid, all chromosomes are of paternal origin. There is no foetal tissue just proliferation of swollen chorionic villi.
17
Q
What is a partial mole?
A
2 sperm and a normal egg - both paternal and maternal genetic material is present. Variable evidence of foetal parts.
18
Q
What are the CFs of molar pregnancies?
A
- Vaginal bleeding
- Nausea
- Hyperemesis gravidarum
- Thyrotoxicosis - hCG related to TSH and can activate its receptors
- Uterus larger than expected for gestational age - due to excessive growth of trophoblasts and retained blood
19
Q
What are the ix of molar pregnancy?
A
- B-hCG levels higher than would be expected in normal pregnancy
- Trans vaginal US - complete molar pregnancy = snowstorm appearance, low resistance of blood vessel flow and absence of a foetus
20
Q
What is the management of molar pregnancy?
A
- Need to reduce likelihood of complications eg. choriocarcinoma or invasion from developing
- Suction curettage to remove from uterus = molar pregnancy won’t survive
- Hysterectomy if fertility doesn’t need to be preserved
- Two weekly serum and urine hCG until levels normal
- Partial mole = hCG 4 weeks later, if normal = discharged
- Complete mole = monthly repeat hCG for 6 months
21
Q
What are some differentials for bleeding in early pregnancy?
A
- Miscarriage
- Hydatidiform mole
- Ectopic pregnancy
22
Q
What is a missed miscarriage?
A
- Asymptomatic or hx of threatened miscarriage
- On going discharge
- Small uterus for length of pregnancy
- No fetal heart beat where CRL >7mm
23
Q
What is a septic miscarriage? How is it managed?
A
- Infected POC
- Fever, rigors, uterine tenderness
- Bleeding/discharge, pain
- Medical or surgical management of miscarraige
- IV abx and fluids
24
Q
What is an ectopic pregnancy?
A
Any pregnancy implanted outside the uterine cavity.
Most commonly the ampulla and isthmus of the fallopian tube, less commonly the ovaries, cervix or peritoneal cavity.
25
What are the RF of ectopic pregnancy?
- PMH - previous ectopics, PID + endometriosis = adhesion formation
- Contraception - IUD or IUS can cause fallopian tube ciliary dysmotility
- Pelvic surgery and embryo transfer
26
What are the CFs of ectopic pregnancy?
- PAIN - lower abdo/pelvic pain +/- vaginal bleeding
- Shoulder tip pain = diaphragm irritated by blood in peritoneal cavity, supraclavicular nerves and diaphragm share C3-C5 dermatomes
- Vaginal discharge - brown, prune juice
- Cervical excitation or adnexal tenderness
- If ruptured = haemodynamically unstable
27
What are the ix into ectopic pregnancy?
- Pregnancy test
- If positive need pelvic USS, if can't find = pregnancy of unknown location
- B-hCG >1500 and no intrauterine pregnancy on USS = ectopic pregnancy until proven otherwise
- B-hCG <1500 and pt stable, repeat in 48 hours would double if viable and half if miscarriage
28
What is the initial management of an ectopic pregnancy?
AtoE to resus patient - blood products if signs of haemodynamic instability
29
What is the medical management of an ectopic pregnancy?
- IM methotrexate - anti folate cytotoxic and disrupts cell division of fetus = gradually resolves
- Serum B-hCG level monitored to ensure is decreasing, if not need a repeat dose
- Given if pt stable and have well controlled pain and B-hCG levels <1500, needs to be unruptured and no heartbeat
- If treatment fails need surgery, need to use contraception for 3-6 months after
30
What is the surgical management of ectopic pregnancy?
- Laparoscopic salpingectomy - remove ectopic and the tube it is implanted in
- Salpingotomy - cut open fallopian tube to remove ectopic and preserve future fertility, risk of treatment failure
- High success rate
- Surgical risks
- If rhesus negative need anti d prophylaxis
31
What is the conservative management of ectopic pregnancy?
- Watchful waiting of stable patient and allowing the ectopic to resolve naturally
- Not suitable for most ectopic pregnancies - need intervention in 25%
- Need to monitor serum B-hCG every 48 hours to see if its falling
32
What are the complications of ectopic pregnancy?
Fallopian tube rupture - hypovolaemic shock from blood loss = organ failure and death
33
What is anti D prophylaxis?
Rhesus neg women and rhesus pos baby during delivery, bleeding, C section and miscarriage blood mixes and mum makes anti D ab
Next time mum is pregnant w rhesus pos baby the ab cross the placenta and attack its red cells resulting in severe anaemia
During a sensitisation event need to give anti D prophylaxis so mum doesn't make anti D ab so when she is pregnant next the prophylaxis has gone and mum doesn't attack her baby's RBC
34
What is hyperemesis gravidarum?
Persistent and severe vomiting during pregnancy = weight loss, dehydration and electrolyte imbalance. Onset before 20 weeks of gestation. Severe enough to require hospital admission.
35
What are the RFs of hyperemesis gravidarum?
- First pregnancy
- Previous hx
- Raised BMI
- Multiple pregnancy
- Hydatidiform mole
36
What are the differentials for hyperemesis gravidarum?
Is a diagnosis of exclusion:
- Gastroenteritis
- Cholecystitis
- Hepatitis
- Pancreatitis
- H.pylori infection and peptic ulcers
- UTI or pyelonephritis
- Metabolic and neurological conditions
- Drug induced
37
What are the ix into hyperemesis gravidarum?
- Bedside - weight, urine dipstick (ketonuria?), BM
- MSU, FBC, U+E, amylase, LFTs, TFTs, ABG
- USS - confirm gestation, exclude multiple pregnancy and trophoblastic disease
38
What is the management of hyperemesis gravidarum?
- Mild - in community w oral antiemetics, oral hydration, dietary advice and reassurance
- Moderate - IV fluids, parentral antiemetics and thiamine (prevent Wernicke's encephalopathy) - manage until ketonuria resolves
- Severe - inpatient mangement
IV rehydration = 0.9% saline + potassium chloride
Antacids to relieve epigastric pain
TED stockings and LMWH as increased risk VTE
39
What are the recommended anti emetic therapies in hyperemesis gravidarum?
1st line - cyclizine, prochlorperazine, promethazine, chlorpromazine
2nd line - metoclopramide (max 5 days), domperidone, ondansetron
3rd line - hydrocortisone IV - then to oral - then to taper
40
What are the complications of hyperemesis gravidarum?
- GI probs - malnutrition, anorexia, Mallory Weiss tears
- Dehydration
- Hyponatraemia, Wernicke's encephalopathy, kidney failure, hypoglycaemia
- Depression, PTSD, resentment to pregnancy
- Foetal complications - low birth weight, growth restriction, premature labour
41
What is a pregnancy of unknown origin?
Woman has a positive pregnancy test but there are no signs of an intrauterine or extrauterine pregnancy on transvaginal US.
42
What are the causes of pregnancy on unknown origin?
- Early viable or failing intrauterine pregnancy
- Complete miscarriage
- Ectopic pregnancy
43
What is gestational trophoblastic disease?
Group of pregnancy related tumours:
- Pre malignant conditions - partial or complete molar pregnancy
- Malignant conditions - invasive mole, choriocarcinoma, placental trophoblastic site tumour, epithelioid trophoblastic tumour
44
What is a choriocarcinoma?
- Malignancy of trophoblastic cells of the placenta
- Commonly co exists w molar pregnancy
- Characteristically metastasises to the lung
45
What are the trophoblastic tumours?
- Placental site trophoblastic tumour - malignancy of trophoblasts which normally anchor the placenta to the uterus, most commonly after a normal pregnancy
- Epithelioid trophoblastic tumour - malignancy of the placental cells, mimics SCC
46
What are the RF for GTD?
- Maternal age - less than 20 or more than 35
- Previous GTD
- Previous miscarriage
- Use of the oral contraceptive pill
47
What are the CFs of GTD?
- Molar pregnancy - vaginal bleeding, large boggy uterus
- Hyperemesis - ?increased B-hCG
- Hyperthyroidism - gestational thyrotoxicosis due to hCG stim thyroid
- Anaemia
- Large for dates uterus later in pregnancy
48
What are the ix into GTD?
- Urine B-hCG - measured in cases of persistent post partum bleeding
- Blood B-hCG - markedly elevated at diagnosis, used to monitor disease
- USS - complete mole = snowstorm appearance
- Histological exam of POC - post treatment for molar pregnancies and all non viable pregnancies
- If suspect mets = MRI, CT chest abdo pelvis, pelvic US
49
What is the management of non molar pregnancy types of GTD?
Single/multi agent chemo +/- surgery is mainstay but v v specialist don't need to know : )
50
What are the principles of safe drug prescription during pregnancy?
- Only prescribe drugs in pregnancy if the benefit to the mother > risk to the fetus
- Avoid all drugs if possible in the first trimester - greatest risk of teratogenesis if from 3rd to 11th week
- Preferentially prescribe drugs extensively used in pregnancy and at lowest effective dose
51
What is the legal framework of abortion?
1967 Abortion act and 1990 Human fertilisation and embryology act. Latest gestational age for abortion is 24 weeks.
52
What are the criteria for an abortion before 24 weeks?
If continuing the pregnancy involves great risk to the physical or mental health of the women or existing children of the family. Is a matter of clinical judgement and opinion of medical practitioners.
53
What are the criteria for abortion at any time?
- Continuing the pregnancy is likely to risk the life of the woman
- Terminating the pregnancy will prevent grave permanent injury to the physical or mental health of the women
- There is substantial risk that the child would suffer physical or mental abnormalities making it seriously disabled
54
What are the legal requirements for an abortion?
- Two registered medical practitioners must sign to agree abortion is indicated
- Must be carried out by registered med practitioner in an NHS hospital or approved premise
55
What is involved in pre abortion care?
- Access - GP, self referral, GUM or family planning clinic
- Offer counselling and information to help decision making from trained practitioner - need informed consent
56
What is involved in a medical abortion?
- Mifepristone - blocks action of progesterone = pregnancy stops and cervix relaxed
- Misoprostol - activates prostaglandin receptors, cervix softened and uterine contractions stim, from 10 weeks gestation additional misoprostol doses every 3 hours are needed ntil expulsion
- Rhesus negative women w gestational age >10 weeks need anti D prophylaxis
57
What is involved in a surgical abortion?
- Local +/- sedation or general
- Need cervical priming before surgery = soften and dilate cervix
- Up to 14 weeks - cervical dilation and suction of POC out the uterus
- 14-24 weeks - cervical dilation and evacuation w forceps
- All rhesus neg women need anti D prophylaxis
58
What are the complications of abortion?
- Bleeding
- Pain
- Infection
- Failure of abortion - pregnancy cont
- Damage to cervix, uterus
59
What do you need to tell a women post abortion?
- Vaginal bleeding and abdo cramps intermittently for up to 2 weeks after procedure
- Urine pregnancy test 2 weeks after abortion to confirm completion
- Contraception discussed and started
- Support and counselling
60
What are some teratogenic drugs?
- ACEi
- Sodium valproate
- Methotrexate
- Retinoids
- Trimethoprim
61
What are some medications frequently used in pregnancy?
- Folic acid 400 micrograms, daily when trying and for first trimester to reduce risk of neural tube defect
- Oral iron
- Antiemetics
- Antacids
- Aspirin
62
What are the CFs of pre eclampsia?
- Hypertension >140/90mmHg
- Proteinuria >+1
- Oedema
- Occurs after 20 weeks gestation
also ... peripheral oedema, severe headache, drowsiness, visual disturb, epigastric pain, N+V, hyperreflexia, reduced urine output, papilloedema
63
What are the RF for pre eclampsia?
- First pregnancy M
- Previous hx or FH H
- Increasing maternal age M
- Existing disease - HTN, DM, renal/autoimmune disease eg. CKD or SLE H
- Obesity M
- Multiple pregnancy M
- 10 years or more since last pregnancy M
64
What are the maternal and foetal complications of pre eclampsia?
Maternal - eclampsia, organ failure, DIC, HELLP syndrome
Foetal - intrauterine growth restriction, pre term delivery, placental abruption, neonatal hypoxia
65
What is the management of pre eclampsia?
Aspirin is prophylaxis against pre eclampsia, given for 12 weeks until birth in women w 1 high RFs or 2 mod RFs.
Labetalol = 1st line antihypertensive
Delivery of placenta is only curative treatment, IM steroids <35 weeks to help fetal lung development
IV magnesium sulphate to prevent and treat eclamptic seizures - given during labour and 24 hours after.
IV hydralazine used in severe pre eclampsia and eclapmsia.
66
What is HELLP syndrome?
Haemolysis
Elevated liver enzymes
Low platelets
Normally during third trimester and is a type of hypertensive disorder of pregnancy, a complication of pre eclampsia.
67
What are the CFs of HELLP syndrome?
- Headache
- N+V
- Epigastric pain
- RUQ pain due to liver distention
- Blurred vision
- Peripheral oedema
68
What is the management of HELLP syndrome?
Definitive treatment = delivery of baby. Some mothers require transfusions or steroids during pregnancy.
69
Eclampsia vs pre eclampsia
Pre eclampsia - new hypertension in pregancy w end organ dysfunction and proteinuria.
Eclampsia - seizures associated w pre eclampsia
70
What is the pathophysiology of pre eclampsia?
Spiral arteries of the placental form abnormally = high vascular resistance.
71
What is needed for a diagnosis of pre eclampsia?
Systolic BP >140 mmHg and diastolic >90 mmHg
plus:
- Proteinuria (+1 on dipstick)
- Organ dysfunction (raised creatinine, elevated LFTs, seizures, thrombocytopenia, haemolytic anaemia)
- Placental dysfunction
72
What is the management of pre eclampsia after delivery?
- Enalapril = 1st line
- Nifedipine/amlodipine 2nd line (1st line in black or Caribbean patient)
- Labetolol or atenolol = 3rd line
May be needed for up to 3 months post partum
73
How do you screen for pre eclampsia?
Routine BP measurements, ask about symptoms, urine dipstick for proteinuria
74
How do you manage gestational hypertension?
No proteinuria.
- Aim BP below 135/185 mmHg
- Admit when >160/110 mmHg
- Urine dipstick testing weekly
- Monitor bloods weekly - FBC, LFTs, renal profile
- Monitoring fetal growth
75
What are the ix into pre eclampsia?
- Urinalysis - microscopy, culture, sensitivities if proteinuria present
- Bloods - FBC, LFT, renal function, electrolytes, serum urate = helps to guide decision as to when to deliver eg. HELLP syndrome
- Clotting studies if severe pre eclampsia or thrombocytopenia
- 24 hour urine collection
- US to assess fetus
- MRI or CT to exclude haemorrhage if focal neuro deficits or coma
76
What is placenta praevia?
Placenta overlying the cervical os
77
What are the CFs of placenta praevia?
- Bright red vaginal bleeding, painless - antepartum haemorrhage (vaginal bleeding >24 weeks)
- Bleeding usually later in pregnancy, after 28th week
- May be asymptomatic - found on routine US
78
What are the ix into placenta praevia?
- Transvaginal US - check position of placenta when first bleed and then again at 37 weeks to reassess
- FBC, clotting profile, Kleihauer test, G+S, cross match, U+E, LFT
79
What is the management of placenta praevia?
- Bleeding w unknown placental position - AtoE, resus, stabilise and US, if bleeding not controlled = need C section
- Bleeding w known placenta praevia - AtoE, resus, stabilise, if not stable = C section
- In labour - C section
- No bleeding and not in labour - monitor w US, pelvic rest and hospital if significant bleeding
- Term - placental overlap at 35 weeks = elective C section at 37-38 weeks gestation
- Give steroids 34-36 weeks or 24-34 weeks if risk of pre term labour
80
What are the RFs of placenta praevia?
- Previous C section or placenta praevia
- Older maternal age
- Maternal smoking and cocaine use during pregnancy
- Structural uterine abnormalities eg. fibroids
- Assisted reproduction
81
What are the grades of placenta praevia?
Minor praevia/grade 1- lower in uterus but doesn't reach int cervical os
Marginal praevia/grade 2 - reaching but not covering int cervical os
Partial praevia/grade 3 - placenta partially covering int cervical os
Complete praevia/grade 4 - placenta completely covers int cervical os
82
What do you look for o/e of antepartum bleeding?
- Pallor, distress, CRT
- Abdo tender
- Tense uterus - placental abruption
- Palpable contractions
- Check the lie and presentation of fetus and its HB
- Cusco speculum exam
83
What is placental abruption? What are the two types?
Premature separation of the placenta from the uterine wall during pregnancy = maternal haemorrhage.
Revealed - bleeding tracks down and drains through cervix = vaginal bleeding
Concealed - bleeding remains in uterus, clot retroplacentally, not visible bleeding but can cause systemic shock
84
What are the CFs of placental abruption?
- Abdo pain - sudden and severe
- Woody hard uterus
- Contractions
- Vaginal bleeding, can be confined to uterus = concealed, antepartum haemorrhage
- Reduced fetal movements and abnormal CTG
- Hypovolaemic shock, disproportionate for vaginal bleeding visible
85
What are the RFs of placental abruption?
- Maternal trauma - assault, RTA
- Pre eclampsia or HTN
- Multiparity or increased maternal age
- Polyhydramnios - too much amniotic fluid
- Previous history of abruption
- Substance use during pregnancy - smoke and cocaine
- Existing coag disorders
86
What is the management of placental abruption?
- AtoE resus, don't delay maternal resus in order to determine fetal viability
- Emergency delivery by C section
- Induction of labour for haemorrhage at term w/o maternal or fetal compromise
- Conservative if partial w no compromise
- anti D prophylaxis if rhesus negative
87
What are the ix into placental abruption?
- FBC, clotting, Kleihauer test, G+S, crossmatch
- U+E, LFTs
- Cardiotocograph
- US but if negative can't rule out abruption
88
What is obstetric cholestasis?
Liver disease unique to pregnancy characterised by pruritis and elevated bile acids.
89
What are the pregnancy associated liver diseases?
- Intrahepatic cholestasis of pregnancy
- HELLP syndrome
- Acute fatty liver of pregnancy
- Liver dysfunction in pre eclampsia and hyperemesis gravidarum
90
What are the RFs of obstetric cholestasis?
- Past history of obstetric cholestasis
- FH
- Multiple pregnancy
- Presence of gallstones
- Hep C
- Asian
- Pruritis on COCP
91
What are the signs and symptoms of obstetric cholestasis?
Symptoms - usually late second or third trimester:
- Pruritis, mainly on soles and palms, worse at night - insomnia
- RUQ pain
- Nausea and anorexia
- Steatorrhoea
Signs - excoriations, jaundice
92
How is obstetric cholestasis diagnosed? Ix
- Serum bile acids >40 micromol/L for severe cholestasis (more likely to have fetal complications), cut off is 10 micromol/L
- May be deranged LFTs but usually minimally elevated
- Liver US to exclude alt diagnosis - no structural defects associated w ICP
93
What are the fetal complications of ICP?
- Stillbirth
- Spont or iatrogenic pre term labour
- Meconium stained amniotic fluid - meconium aspiration
- Neonatal resp distress syndrome - need NICU
94
What is the management of ICP?
Ursodeoxycholic acid - UDCA but doesn't seem to improve fetal outcomes. Reduces mum symptoms.
Chlorpenamine for itch.
Vit K reduce likelihood of haemorrhage.
Weekly blood tests to determine bile acid levels.
Perinatal and maternal morbidity increase from 37 weeks of gestation onwards so induction of labour is recommended from this point.
LFT 10 days postnatally.
95
What is gestational diabetes? How is it caused?
Any degree of glucose intolerance with its onset during pregnancy, usually resolves shortly after delivery.
In pregnancy there is progressive insulin resistance, for woman w borderline pancreatic reserve there isn't enough insulin = hyperglycaemia.
96
What are the RFs for poor pancreatic reserve/GDM?
- BMI >30
- Asian
- Previous GDM
- 1st degree relative w diabetes
- PCOS
- Previous macrosomic baby = >4.5 kg
- Smoking
- Previous stillbirth
97
What are the fetal complications of gestational diabetes?
- Macrosomia
- Orgnomegaly, esp cardiomegaly
- Erythropoiesis = polycythaemia
- Polyhydramnios
- Increased rates of pre term delivery - can lead to resp distress syndrome
- Hypoglycaemia in new born = seizure?
98
Who is screened for GDM and what is involved?
Everyone with a RF should be screened at 24-28 weeks. If have glycosuria +2 once or +1 twice need screening.
- Oral glucose tolerance test
- If had GDM before - early self monitoring of BM
99
What are the perimeters for GDM diagnosis?
Fasting glucose >5.6 mmol/L
2 hours post prandial glucose >7.8 mmol/L
100
What is the management of gestational diabetes?
Good glycaemic control for the whole pregnancy!
- Lifestyle advice
- Metformin if target BM not met in 1-2 weeks by lifestyle mods
- Glibenclamide if metformin not tolerated
- Insulin if fasting glucose >7mmol/L
- Aim to deliver at 37-38 weeks
101
What is the post natal care of a woman with gestational diabetes?
All meds stopped immediately after delivery. DM measured before discharge to ensure returned to normal levels.
Fasting glucose test around 6-12 weeks post partum, if normal will need yearly tests to monitor for diabetes as increased risk of developing in the future.
102
What are the TFT changes in pregnancy?
- Total T4 and T3 increase
- Free T4 and T3 remain within normal range
- TSH doesn't change
103
How does overt hypothyroidism present in pregnancy?
- Dry skin w yellowing, esp around eyes
- Weakness, tiredness, hoarseness, hair loss, intolerance to cold, constipation, sleep disturb
- Goitre
- Anaemia, low T4 raised TSH
- More common than hyperthyroidism in pregnancy
104
How is hypothyroidism treated in pregnancy?
Needs larger doses of thyroxine than when not pregnant and then return to pre pregnancy dose post delivery.
105
What are the complications of hypothyroidism in pregnancy?
- Congestive heart failure
- Megacolon, adrenal crisis, organis psychosis, myxoedema coma, hyponatraemia
106
What is postpartum thyroiditis?
Silent thyroiditis 3-6 months post partum, usually painless w +ve test for thyroid peroxidase ab and normal ESR.
Doesn't need treating.
107
What is an APGAR score?
Assessment of clinical status of infants immediately following birth.
1 and 5 mins after cleaning and drying baby in warm towel. Is not the only measure of clinical status.
108
Detail the APGAR score
Activity - muscle tone
Pulse - HR
Grimace - reflex irritability
Appearance - colour
Resp effort
109
What is breech presentation?
Fetus is buttocks or feet first. If >37 weeks is risky - increased risk perinatal mortality and morbidity.
Normal - cephalic = head first
110
What is the management of breech position?
- External cephalic version
- C section if above didn't work
- Vaginal breech birth - some women may choose - hand off the breech, may need to use manoeuvres to deliver the baby
111
What are the different step of the mechanisms of labour?
1. Engagement
2. Descent
3. Flexion
4. Int rotation
5. Crowning
6. Extension
7. Ex rotation and restitution
8. Delivery of shoulder and body
112
What is engagement?
When the largest diameter of babys head fits into the largest diameter of maternal pelvis.
The fetal head engages = moves into the pelvic brim, either L or R occipito transverse position.
Widest part of baby head through widest part of pelvis.
113
What is descent?
Baby through pelvis inlet to pelvic floor. Due to:
- Uterine contractions
- Pressure of amniotic fluid
- Voluntary abdo muscle contractions
114
What is flexion?
When the cervical head makes contact w the pelvic floor it flexes, this reduced fetal skull diameter to assist passage through the pelvis.
115
What is int rotation?
Head rotates, either to the L or R, to lie in the occipito ant position.
116
What is crowning?
Clinically = head no longer retracts between contractions and is visible in the vulva.
The widest diameter of babys head is though the narrowest part of pelvis.
117
What is extension?
Occiput underneath the suprapubic arch = head extends and stretches the perineum.
118
What is ex rotation and restitution?
Head ex rotates to face the R or L thigh of the mother.
Restitution - shoulders rotate from transverse to ant post position.
119
What is delivery of shoulder and body?
Midwife places downward traction on the head to deliver ant shoulder and then upward traction on head to deliver post shoulder.
120
What happens before labour?
Plug of mucus/blood = bloody show or amniotic sac ruptures = triggers labour and true contractions which progress in freq and intensity. These cause the cervix to dilate and efface.
121
What are the stages of labour?
1st stage - early and active phases, contractions
2nd stage - pushing phase, ends when baby delivered (mechanisms of labour, already made flashcards on)
3rd stage - delivery of the placenta
4th stage - adaptation to blood loss and uterine involution
122
Describe the 1st stage of labour
Early phase:
- Irreg contractions, every 5-30 mins, cervix dilates 0->3cm
- Reg contractions, every 3-5 mins, cervix dilates 3->6cm
Active phase - cervix 6->10cm, is fully effaced. Contractions every 30secs-2mins, last 60-90secs and can overlap. Amniotic sac often ruptures now if hasn't yet.
123
How is a women cared for in her first stage of labour?
Partogram - record obs and events during labour. Monitor HR hourly, obs 4 hourly, urinary frequency and freq of contractions every half hour.
Vaginal exam hourly.
124
How is a women cared for in her second stage of labour?
Partogram, monitor BP hourly, temperature 4 hourly, urinary freq and freq of contractions every half hour.
Intermittent auscultation of foetal HR after a contraction for 1 min and every 5 mins. Palpate mum pulse every 15 mins.
Vagina exam 4 hourly.
Check pain and wellbeing reg, offer analgesia as needed.
125
What is the third stage of pregnancy?
Delivery of the placenta - uterus contracts causing separation of the placenta from the uterine wall.
126
What is the active management of placenta delivery?
- Use uterotonic (uterine stimulants) drugs to encourage expulsion of placenta and membranes
- Deferred cutting and clamping of the cord
- Careful and controlled traction of the cord once signs of separation of placenta
127
What are some examples of uterotonic drugs?
Oxytocins
Prostaglandins
Ergot alkaloids eg. ergometrine
128
What are signs of placental separation and delivery?
- Gush of blood
- Lengthening of umbilical cord
- Ascension of uterus in abdo
129
How long should the third stage of labour take?
30mins - hour w physiological management (naturally). Delayed if not complete in 60 mins.
5-10 mins - active management. Delayed if not complete in 30 mins.
130
What are false labour contractions?
Braxton Hicks contractions = not effective and less intense
131
What is discussed in the booking visit?
- Explain how baby develops during pregnancy
- Exercise to do and pelvic floors
- Place of birth and pregnancy care pathway
- Participant led antenatal classes
- Further discussion and offer of all antenatal screening
- Discussion of mental health issues
- W community midwife and ideally before 10 weeks
132
What routine tests are offered to all pregnant women at booking?
- Electrophoresis - sickle cell and talassaemia
- FBC - anaemia
- Blood group and red cell ab screen - Rh
- Infection - asymptomatic bacteriuria, syphilis, Hep B, HIV
- Urinalysis - glycosuria, proteinuria, haematuria
- BP and urinalysis at every antenatal visit for pre eclampsia
133
How much folic acid should someone take?
400 mcg daily for first three months of pregnancy and whilst trying to conceive.
134
What is involved in trisomy testing?
- Performed at 12 week scan = USS for nuchal translucency
- 20 weeks scan again for trisomy
- Lower chance result = 1/150 chance baby has Down syndrome
- Higher chance result - >1/150 chance will have Down syndrome, can then have further testing
- NIPT screen to see if should have diagnostic test
- Diagnostic test = amniocentesis
135
What extra things do you check at antenatal visits later in the pregnancy?
- From 24 weeks check fundal symphysis height
- From 36 weeks check fetal presentation on USS if uncertain
136
When are the different antenatal appointments?
- 11-14 weeks = USS to determine gestational age and multiple pregnancy, offer anomaly screen
- 18-20 weeks = screen for anomalies and placental location
- 24 weeks = measure fundal symphysis height and monitor foetal movements
- 28 weeks = Rh neg women get anti D, recheck FBC, Ab and blood group ,discuss birth plans and post natal period
- 36 weeks = abdo palpataion to identify if breech, confirm w USS
137
What are the endocrine changes during pregnancy?
Increased thyroxin to support the baby as fetal thyroid gland not functional until second trimester.
Insulin resistance to ensure continuous supply of glucose for the foetus - increased risk of ketoacidosis in pregnancy.
138
What are the CVS changes during pregnancy?
- Increased progesterone = decrease systemic vascular resistance = decrease diastolic BP
- Cardiac output increases by 30-50%
- RAAS is activated = increased Na and water retention = increased total blood volume
139
What are the resp changes during pregnancy?
- Diaphragm pushed upwards but total lung capacity stays relatively the same as transverse and ant post diameters of thorax increase
- Minute ventilation rate increases to meet increased oxygen demands - many women can experience hyperventilation - increased CO2 production and progesterone increases resp drive
140
What are the GI system changes during pregnancy?
- Upward displacement. of the stomach = increase intra gastric pressure = reflux, N+V
- Progesterone. =SM relaxation. =decreases gut motility = can lead to constipation.
- Progesterone = relaxation of the gallbladder = biliary tract stasis = gallstones
141
What are the urinary system changes during pregnancy?
- GFR increased by 50-60% = increased renal excretion = reduced urea and creatinine
- Relaxation of ureter and bladder = urinary stasis, UTIs and pyelonephritis
142
What are the haematological changes during pregnancy?
- Increased fibrinogen and clotting factors = increased risk of VTE
- Treat w LMWH as warfarin can cross the placenta and is teratogenic
- Plasma volume increases a lot but red cell mass stays the same - dilutional anaemia
143
When is anaemia diagnosed in pregnancy?
Hb <110 g/L at booking, postpartum is <100 g/L.
144
What is the management of anaemia in pregnant women?
- If ferritin levels low can offer oral supplements
- Folate supplementation for thalassaemia and sickle cell
145
What is the conservative management of dyspepsia in pregnancy?
- Sitting up just after eating
- Sleeping propped up
- Small freq meals, not eating w/i 3 hours of going to bed
- Reduce fatty and spicy foods, fruit juice, chocolate and caffeine
146
What is the medical management of dyspepsia in pregnancy?
- Gaviscon
- Omeprazole in severe reflux not controlled w antacids
147
What is pelvic girdle dysfunction?
Pain from sacro iliac and symphysis pubis joints - pain in lower back, buttocks, thighs, hips, groin or pubic bones.
Can also experience grinding pains.
Symptoms are normally mild but can be severe and disabling.
148
What is the advice for women with PGP?
- Relaxation and good posture
- Physio
- Pelvic support belt
- Regular paracetamol - 1g every 4-6 hours
- May require higher dose pain relief from dr
149
What is defined as premature birth?
- Before 37 weeks, non viable if below 23 weeks gestation
- Under 28 weeks - extreme pre term
- 28-32 weeks - v pre term
- 32-37 late preterm
150
What is prophylaxis of pre term labour?
Cervix less than 25mm on vaginal US between 16-24 weeks gestation - vaginal progesterone.
Cervix less than 25mm on vaginal US between 16-24 weeks gestation w previous premature birth or cervical trauma - cervical cerclage.
151
How is pre term pre labour rupture of membranes diagnosed and treated?
Pooling of amniotic fluid in the vagina and give mum prophylactic ab to prevent chorioamnionitis.
Erythromycin
Benzylpenicillin if GBS +ve
From 34 weeks may induce labour ?
152
What is the management of pre term labour?
- Fetal monitoring
- Tocolysis (using meds to delay labour) w nifedipine - suppresses labour - used 24 and 33+6 weeks, is a short term measure
- IM corticosteroids - offer before 35 weeks gestation to reduce neonatal morbidity and mortality
- IV magnesium sulphate before 34/32 ? weeks gestation, reduces risk cerebral palsy, given w/i 24 hours of delivery, need to monitor for Mg toxicity
- Delayed cord clamping or cord milking - increases circ blood vol and Hb to baby at birth
153
What are the indications for induction of labour?
- 41-42 weeks gestation
- Prelabour rupture of membranes
- Fetal growth restriction
- Pre eclampsia
- Obstetric cholestasis
- Intrauterine fetal death
154
What is the Bishop score?
Used to determine whether to induce labour:
- Cervical position
- Dilation
- Effacement
- Consistency
- Fetal station
<5 = labour won't begin w/o induction
<3 = IOL won't be successful
>9 = labour will be spont
155
What are the options for induction of labour?
- Membrane sweep
- Vaginal prostaglandin E2 - dinoprostone
- Cervical ripening balloon
- Artificial rupture of membranes
- Amniotomy - amnihook ruptures membranes
156
How is labour induced if there is intrauterine fetal death?
Oral mifepristone and misoprostol
157
What is dinoprostone?
GEl, tablet or pessary into vagina - local prostaglandins over 24 hours to stim cervix and uterus to cause onset of labour.
158
What is a cervical ripening balloon?
Inserted into the cervix where it gently inflates to dilate the cervix - used where vaginal prostaglandins have failed or previous C section
159
How are membranes ruptured?
- Membrane sweep - finger into cervix to stim, can be performed in clinic and should produce labour w/i 48 hours, used from 40 weeks
- Artificial rupture of membranes w oxytocin infusion, only when vaginal prostaglandins have been tried
- Amniotomy
160
What is uterine hyperstim? What can it lead to?
- Complication of induction of labour w vaginal prostaglandins
- Contraction of uterus prolonged and freq = fetal distress and compromise
- Lead to need for emergency C section and uterine rupture
161
What is the management of uterine hyperstim?
- Remove vaginal prostaglandins or stop oxytocin infusion
- Tocolysis w terbutaline
162
What is cardiotocography? CTG
Measures the fetal HR and contractions of the uterus - monitors fetal condition and activity of labour
163
What are the indications for cont CTG monitoring?
- Sepsis
- Maternal tachycardia >120
- Significant meconium
- Pre eclampsia
- Fresh ante partum haemorrhage
- Delay in labour
- Use of oxytocin
- Disproportionate maternal pain
164
What are the different types of decelerations?
- Early decelerations - gradual dips and recoveries in HR corresponding w contractions, normal
- Late decelerations - delay between uterine contraction and deceleration, caused by hypoxia
- Variable decelerations - abrupt decelerations unrelated to uterine contractions - intermittent compression of umbilical cord = fetal hypoxia, brief accelerations before and after = shoulders and are a good sin fetus is coping
- Prolonged decelerations - 2-10 mins long, concerning, compression of umbilical cord = fetal hypoxia
165
What is the rule of 3s for fetal bradycardia?
- 3 mins - call for help
- 6 mins - move to theatre
- 9 mins - prepare for delivery
- 12 mins - deliver baby (by 15 mins)
166
How should you read a CTG?
DR C BRaVADO
DR - define risk
Contractions
BRa - baseline rate
Variability
Accelerations
Decelerations
Overall impression
167
What is fetal tachycardia defined as and what are the causes?
>160 bpm
Causes:
- Fetal hypoxia
- Chorioamnionitis
- Hyperthyroidism
- Fetal or maternal anaemia
- Fetal tachyarrhythmia
168
What is fetal bradycardia defined as and what are the causes?
<110 bpm
Causes:
- Prolonged cord compression
- Cord prolapse
- Epidural and spinal anaesthesia
- Maternal seizures
- Rapid fetal descent
169
What is normal variability?
5-25 bpm
170
What is sinusoidal CTG and what does it indicate?
- Smooth regular wave like pattern
- Associated w high rates of fetal morbidity. and mortality
- Indicates - severe fetal hypoxia or anaemia, fetal/maternal haemorrhage
171
How do you manage a pathological CTG?
- Pt needs review
- Exclude acute events eg. uterine rupture, cord prolapse, uterine hyperstim and correct underlying causes
- Start conservative measures
- Digital fetal scalp stim
- Still pathological - fetal blood sampling, speed up birth
172
What are conservative measures for managing abnormal CTG?
- Encourage woman to adopt alt position
- IV fluids for hypotensive woman
- Stop/reduce oxytocin to reduce contraction freq
173
What pain relief is used in labour?
- Conservative - support, changing position, controlled breathing, TENS machines in early labour, water
- Simple analgesia
- Gas and air - short term pain relief during contractions = entonox
- IM pethidine and diamorphine
- Remifentanil - pt controlled IV bolus
- Epidural
174
What is an epidural? What drugs are used?
Catheter into epidural space in lower back then infuse local anaesthetic medications into the epidural space - into surround tissues and spinal cord.
Options - levobupivacaine or bupivacaine usually mixed w fentanyl
175
What are the adverse effects of epidural?
- Headache after insertion
- Hypotension
- Motor weakness in legs
- Nerve damage
- Prolonged second stage
- Increased probability of instrumental delivery
176
What are the layers the needle has to pass through to perform an epidural?
Skin
Fat
Supraspinous ligament
Interspinous ligament
Ligamentum flavum
Dura mater
Then in epidural space
177
What are the RFs of perineal tears?
- Nulliparity
- Large babies
- Shoulder dystocia
- Asian ethnicity
- Occipito post position
- Instrumental deliveries
178
What is the classification of perineael tears?
1st degree - injury limited to frenulum of the labia minora and superficial skin
2nd degree - includes perineal muscles
3rd degree - includes anal sphincter - 3a = less than 50% ex, 3b - more than 50% ex, 3c = ex and int affected
4th degree - includes rectal mucosa
179
What is the management of perineal tears?
1st degree don't usually need sutures
2nd degree normally requires sutures
3rd or 4th = repairing in theatre
Also - abx, laxatives, physio and follow up
180
What are the complications of perineal tears?
Short term - pain, infection, bleeding, wound dehiscence
Long term - urinary and anal incontinence, fistular between vagina and bowel, sexual dysfun and dyspareunia, mental health consequences
181
What is episiotomy?
45 degree diagonal cut from the opening of the vagina down and lateral to avoid damaging the anal sphincter, done in anticipation of needing extra room for delivery of baby eg. before forceps delivery.
182
What is perineal massage?
Method for reducing the risk of perineal tears, involves massaging the skin and tissues between the vagina and anus, done from 34 weeks onward.
183
What are the contraindications for induction of labour?
- Major placenta praevia
- Vasa praevia
- Cord prolapse
- Transverse lie
- Active primary genital herpes
- Previous classical C section
- Breech presentation
- Triplet or higher
184
How do you define prolonged second stage of labour? What is the management?
- Nulliparous women. =>3 hours w epidural or >2 hours w/o
- Multiparous women >2 hours w epidural or >1 hour w/o
Management = instrumental delivery
185
What are indications for instrumental delivery?
- Failure to progress
- Fetal distress
- Maternal exhaustion
186
What are the risks of having an instrumental delivery?
- Postpartum haemorrhage
- Episiotomy
- Perineal tears
- Injury to the anal sphincter
- Incontinence of the baladder or bowel
- Nerve injury
- Cephalohaematoma w ventouse
- FN palsy w forceps
187
What are the tools used in instrumental delivery?
Ventouse - suction baby out
Forceps
188
What are the different types of retained placenta?
189
What is primary post partum haemorrhage?
Loss of >500ml blood per vagina w/i 24 hours of delivery
1. Minor PPH - 500-1000ml blood loss
2. Major PPH - >1000ml blood loss
190
What are the causes of primary PPH?
4Ts:
Tone - uterine atony, most common cause, uterus fails to contract well enough following delivery
Tissue - retention of placental tissue, prevents the uterus from contracting
Trauma - damage to repro tract during delivery eg. tears - forceps, episiotomy, C section
Thrombin - coagulopathies and vascular abnormalities
191
What are the CFs of PPH?
- Bleeding from the vagina
- Dizziness, palpitations, SOB
Tachypnoea, prolonged CRT, tachy, hypotension
- Abdo exam may show signs of uterine rupture
- Speculum exam - sites of local trauma causing bleeding
- Examine for a complete placenta
192
What are the ix into primary PPH?
- FBC
- Crossmatch 4-6 units of blood
- Coag profile
- U+E
- LFT
193
What is the management of primary PPH?
TRIM
Teamwork - midwives, obs, anaesthetists, blood bank, haematologist
Resus
Ix and monitoring - obs every 15 mins
Measures to arrest bleeding (definitive management)
194
What is the definiitve management of uterine atony?
- Bimanual compression to stim uterine contraction - fist in the vagina pressing ant uterine wall and other hand applies pressure to abdo on post aspect of uterus
- Pharm - act to increase uterine myometrial contraction
- Surgery - intrauterine balloon tamponade, haemostatic suture around uterus, bilat uterine or int iliac arter ligation
195
What are the other definitive management for other causes of primary PPH?
Trauma - primary repair of laceration, if uterine rupture = laparotomy and repair or hysterectomy
Tissue - admin IV oxytocin, manual removal of placenta w regional or general anaesthetic
Thrombin - correct coag abnormalities w blood products under advice of haem team
196
What drugs are used in primary PPH?
Syntocinon - synthetic oxytocin, causes contraction of myometrium
Ergometrine - causing contraction of myometrium
Carboprost - causes myometrial contractions helping to expel the placenta, can't use in asthma
Misoprostol - increases uterine tone and dereases post partum bleeding
197
What can be done to prevent PPH?
Active management of 3rd stage of labour reduces by 60%:
- Vaginally - 5-10 units IM oxytocin
- C section - 5 units IV oxytocin
198
What is secondary PPH?
Excessive vaginal bleeding from 24 hours after delivery to 12 weeks post partum. Not usually as severe as primary PPH but 10% can have massive haemorrhage.
199
What are the RF of secondary PPH?
- Uterine infection
- Retained placental fragments or tissue
- Abnormal involution of placental site
- Trophoblastic disease
200
What are the ix into secondary PPH?
- Bloods - FBC, U+E, CRP, coag, G+S, blood cultures
- Pelvic US
201
What is the management of secondary PPH?
- ABx ampicillin and metronidazole, gentamicin in cases of tender uterus or sepsis
- Uterotonics
- Surgery - excessive or continuing bleeding
202
What are the indications for C section?
- Breech, unstable lie
- Twin pregnancy when first twin not cephalic
- Maternal medical conditions
- Fetal compromise
- Transmissible disease
- Primary genital herpes
- Placenta praevia
- Maternal diabetes or shoulder dystocia
- Previous 3rd/4th degree perineal tear
- Maternal request
203
VBAC vs elective repeat C section
- Shorter recovery for VBAC if successful
- Nil risk uterine rupture in elective C section, higher in VBAC
- Risk of maternal death higher in C section
- No risk anal sphincter injury in C section
- Both carry a risk of neonatal resp problems
204
What is involved in the management of VBAC delivery?
- Deliver in a hospital setting w continuous CTG monitoring
- If need additional analgesia = indication of uterine rupture
- Avoid induction where possible
205
What are the contradindications of VBAC?
- Classical C section scar
- Previous uterine rupture
206
What is oxytocin and what is it used for?
Hormone secreted by the body - ripens the cervix and causes contractions of the uterus, involved in lactation and breastfeeding. Used in medicine to:
- Induce labour
- Progress labour
- Improve uterine contractions
- Prevent/treat post partum heamorrhage
Syntocinon
207
What is ergometrine?
Used in the third stage of labour and post partum to prevent post partum haemorrhage - only after delivery of baby.
Can't give in pre eclampsia as worsens condition. Can't be used in HTN.
208
What is terbutaline?
B 2 agonist, like salbutamol - acts on uterus SM to suppress uterine contractions, used for tocolysis in uterine hyperstimulation
209
What is carboprost?
Synthetic prostaglandin - stimulates uterine contraction during post partum haemorrhage, needs to be avoided in patients with asthma
210
What are the indications for elective c section?
- Previous c section
- Sympmtomatic after previous significant perineal tear
- Placenta praevia
- Breech presentation
- Multiple pregnancy
- Uncontrolled HIV infection
- Cervical cancer
211
What are the complications of elective c sections?
- Bleed, infection, pain, VTE
- Postpartum aemorrhage, wound infection nd dehiscence, endometritis
- Damage to ureter, bladder, bowel, blood vessels
- Ileus, adhesions, hernias
- Increased risk repeat c section, uterine rupture, placenta praevia, stillbirth
212
What are the key causes of sepsis in pregnancy?
- Chorioamnionitis
- UTIs
213
What is chorioamnionitis? What are the specific CF of it?
Infection of chorioamniotic membranes and amniotic fluid - usually in later pregnancy and labour.
CF:
- Abdo pain
- Uterine tenderness
- Vaginal discharge
214
What are the non specific signs of sepsis?
- Fever
- Tachy
- Increased RR and reduced O2 sats
- Low BP
- Alt conc
- Reduced urine output
- Raised WBC
- Fetal compromise on CTG
215
What are the specific CF of UTI?
- Dysuria
- Urinary freq
- Suprapubic pain or discomfort
- Renal angle pain
- Vomiting
216
What are the ix into maternal sepsis?
- Bloods - FBC, U+E, CRP, LFT, clotting
- Blood cultures
- ABG
- Urine dipstick. andMSU
- High vaginal swab, throat swab, wound swab
- LP
217
What is the management of maternal sepsis?
- Sepsis six
- Continual maternal and fetal monitoring - may need emergency c section if fetal distress - general anaesthesia normally for a women w maternal sepsis
- Follow local guidelines for abx
218
What are the different type of breech presentations?
- Frank - breech w extended legs - most common
- Complete - breech w fully flexed legs
- Incomplete - footling = one or both thighs extended
- CAn also have a transverse lie
219
What are the options of management of breech presentation?
- Ex cephalic version
- Choose vaginal delivery or elective c section if ECV fails - c section normally considered safer
220
What is ex cephalic version and what are the indications?
Offered at 36 weeks for breech presentation for first pregnancy and 37 weeks for consecutive pregnancy.
ECV is a manual procedure where you attempt to turn baby with ur hands on mums abdomen - 50% success rate.
Mum needs analgesia, tocolytics and anti D prophylaxis.
221
What are the absolute contraindications of ECV?
- C section already indicated for other reason
- Antepartum haemorrhage in last 7 days
- Non reassuring CTG
- Major uterine abnormality
- Placental abruption or placenta praevia
- Membranes have ruptured
- Multiple pregnancy
222
What are the CF of cord prolapse?
Umbilical cord descended below the presenting part of fetus into the vagina - risk of presenting part compressing cord = fetal hypoxia. Can confirm on examination.
223
What is the management of cord prolapse?
Emergency c section - not recommended to push cord back in as handling can cause vasospams = keep pit warm and wet.
Can push presenting part back when baby compressing cord, women in left lateral position of knee chest position, fill the bladder w warmed saline can prevent further prolapse.
Tocolytic medication to post pone labour until c section can start.
224
What is shoulder dystocia?
Ant shoulder of the baby is stuck behind the pubic symphysis of the pelvis after the head has been delivered. Is an obstetric emergency. Often caused by macrosomia secondary to gestational diabetes.
Failure of restitution - head remains face down and doesn't turn sideways as expected.
225
What is the management of shoulder dystocia?
- Episiotomy - enlarge the vaginal opening to reduce risk of perineal tears
- McRoberts manoeuvre - knees to abdo to move pubic symphysis up and out of the way
- Pressure on ant shoulder - press on suprapubic region of abdo to encourage shoulder down and under pubic symphysis
- Rubins manoeuvre is. theabove but through the vagina
- Zavanelli - push baby back into vagina to be delivered by emergency c section
226
What are the complications of shoulder dystocia?
- Fetal hypoxia and cerebral palsy
- Brachial plexus injury and Erb's palsy
- Perineal tears
- Post partum haemorrhage
227
What is amniotic fluid embolisation?
Amniotic fluid passes into mothers blood, usually during labour and delivery - mother has an immune reaction, similar to anaphylaxis.
228
What is the presentation of amniotic fluid embolisation?
- SOB and hypoxia
- Hypotension
- Coagluopathy
- Haemorrhage
- Tachycardia
- Confusion
- Seizures
- Cardiac arrest
229
What is the management of AFE?
- Supportive - ITU
- AtoE assessment
- Immediate c section if cardiac arrest and CPR
230
What is normal length of first stage of labour?
1cm dilate every 2 hours if first pregnancy or every 1 hour in subsequent pregnancies
231
Define the following:
Monozygotic
Dizygotic
Monoamniotic
Diamniotic
Monochroionic
Dichorionic
Monozygotic - identical twins, from a single zygote
Dizygotic - non identical twins from 2 different zygotes
Amniotic - either share or don't share amniotic sac
Chorionic - either share or don't share placentas
232
Which type of twins have the best outcome and why?
Diamniotic and dichorionic as each fetus has their own nutrient supply
233
How can you determine the type of twins using an USS?
- Dichorionic diamniotic twins have a membrnae between them - lambda sign = triangular appearace of the membrane blends into the chorion
- Monochorionic diamniotic twins - membrane between the twins = T sign, abruptly meets the chorion
- Monochorionic monoamniotic twins have no membrane separating them
234
What are the complications of a multiple pregnancy to the mother?
- Anaemia
- Polyhydramnios
- HTN
- Malpresentation
- Spont pre term birth
- Instrumental delivery or c section
- PPH
235
What are the complications of multiple pregnancy to the fetuses?
- Miscarriage
- Stillbirth
- Fetal growth restriction
- Prematurity
- Twin twin transfusion syndrome
- Twin anaemia polycythaemia sequence
- Congenital abnormalities
236
What is twin twin transfusion syndrome?
When the fetuses share a placenta. One fetus receives the maj of the blood from the placenta while the other fetus is starved of blood.
Recipient - fluid overload = HF and polyhydramnios
Donor - growth restriction, anaemia and oliogydramnios
There is a diffference in the size of the fetuses
237
What additional antenatal care do women w multiple pregnancies require?
- Additional monitoring for anaemia w FBC at booking, 20 and 28 weeks
- Additional US - 2 weekly scans from 16 weeks for monochorionic twins and 4 weekly scans from 20 weeks for dichorionic twins
238
When is birth planned for twins?
Between
- 32 and 33 weeks+6 for uncomplicated monochorionic monoamniotic twins
- 36 and 36+6 for uncomplicated monochorionic diamniotic twins
- 37 and 37+6 weeks for uncomplicated dichorionic diamniotic twins
- Before 35+6 weeks for triplets
Need corticosteroids to help mature lungs and waiting any longer is assoicated w increased risk of fetal death
239
What are the different options for delivery for the different types of twins ?
Monoamniotic twins need elective C section between 32 and 33+6 weeks
Diamniotic twins:
- Vaginal delivery is possible when first baby has cephalic presentation
- C section for second baby maybe
- Elective c section when presenting twin is not cephalic presentation
240
How is fetal size estimated?
- Estimated fetal weight
- Fetal abdominal circumference
Both done on USS
241
What is small for gestational age defined as?
Below the 10th percentile for their gestational age
242
What are causes of SGA?
- Constitutionally small - mother and others in family are also small
- Fetal growth restriction - small fetus, not growing as expected due to pathology reducing the amount of nutrients and oxygen delivered to fetus
243
What are the causes of fetal growth restriction?
- Placenta mediated growth restriction - idiopathic, pre eclampsia, maternal smoke or alcohol, anaemia, malnutrition, infection, maternal health conditions
- Non placenta medicated growth restriction - genetic and structural abnormalities, fetal infection, errors in metabolism
244
What are other signs of fetal growth restriction?
- Reduced amniotic fluid volume
- Abnormal Doppler studies
- Reduced fetal movements
- Abnormal CTGs
245
What are the complications of fetal growth restriction?
Short term - stillbirth, birth asphyxia, neonatal hypothermia and hypoglycaemia
Long term - CVS and HTN, T2DM, obesity, mood and behavioural problems
246
What are the minor RFs for SGA?
- >35
- Smoke 1-10/day
- Nulliparity
- Under weight or overweight
- IVF singleton
- Previous pre eclampsia
- Pregnancy interval small or big
- Low fruit intake pre pregnancy
247
What are the major RFs for small for gestational age?
- >40
- Smoker >11/day
- Previous SGA baby, maternal/paternal SGA
- Previous stillbirth
- Cocaine use
- Daily vigorous exercise
- Maternal disease - HTN, renal impairment, DM, vascular disease, antiphospholipid
- Heavy bleeding
- Low PAPP-A
248
What is the monitoring of SGA?
- Low risk women - symphysis fundal height every antenatal appointment, if less than 10th centile = serial growth scans and umbilical artery doppler
- Serial growth scans w umbilical artery doppler if 2 or more minor RF one or more major RF, issues w measuring symphysis fundal height
- Have or at risk of SGA - estimated fetal weight and abdo circumference scans, umbilical arterial pulsatility index, amniotic fluid vol
249
What is the management of SGA?
- Identify those at risk
- Aspirin to those w risk of pre eclampsia
- Treat modifiable RFs eg. stop smoke
- Serial growth scans to monitor growth
- Early delivery where growth is static or concerns - reduces risk of stillbirth
- Rule out underlying cause - BPM, urine dipe, uterine artery doppler scan, detailed fetal anatomy scan, karyotyping, test for infection
250
Oligohydramnios vs polyhydramnios
Oligo - below 5th centile for gestational age
Poly - above 95th centile
251
What are the main causes of olioghydramnios?
- Pre term pre labour rupture of membranes
- Placental insufficiency - blood flow redistributed to fetal brain rather than abdo and kidneys = poor urine outut
- Renal agenesis
- Non functional fetal kidneys
- Obstructive uropathy
- Genetic and chromosomal anomalies
- Viral infections
252
How is oligo/polyhydramnios diagnosed?
USS:
- Amniotic fluid index - max cord free vertical pocket of fluid in four quadrants of the uterus and adding them together
- Maximum pool depth - vertical measure of any area - not often used
Probably don't need to know either
253
What is the mangement of oligohydramnios?
- Due to ruptured membranes labour will likely start w/i 24-48 hours, if pre term rupture should consider IOL around 34-36 weeks, give steroids for fetal lungs and abx to reduce risk of ascending infection
- Placental insufficiency - babies likely to be delivered before 36-37 weeks
Basically treatment is optimising delivery date, keep baby inside for as long as possible.
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What are the main causes of polyhydramnios?
- Idiopathic 50-60% of the time
- Conditions that prevent the fetus from swallowing - oesophageal atresia, CNS abnormalities, muscular dystrophy
- Duodenal atresia
- Anaemia
- Fetal hydrops
- Twin to twin transfusion syndrome
- Increased lung secretions
- Genetic/chromosomal abnorm
- Maternal diabetes
- Maternal ingestion of lithium
- Macrosomia
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What is the management of polyhydramnios?
Most women don't need any treatment.
Can do amnioreduction if maternal sx are severe eg. breathlessness but associated w infection and placental abruption.
Indomethacin used to enhance water retention and reduce fetal urine output but associated w premature closure of ductus arteriosus so not used beyond 32 weeks.
Idiopathic - needs NG tube before first feed to rule out fistula/atresia
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What are some complications of polyhydramnios?
Increased perinatal mortality due to underlying abnormality or congential malformation and increased incidence of preterm labour.
Malpresentation more likely as fetus has more room to move - need to be taken w rupture of membranes as higher risk of cord prolapse.
Higher incidence of PPH.
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What are you concerned about with decreaes fetal movements?
- Increased risk of stillbirth
- Fetal distress
- Congenital malformation
- Perinatal brain injury or disturb neurodevelopment
- Low birth weight
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What are normal fetal movements?
10 or more fetal movements in 2 hours felt when lying on her side and focusing on the movement. Normally felt from 20 weeks.
During sleep cycles fetal movements can be absent and usually last 20-40 mins.
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What history should be taken from a women presenting with decreased fetal movements?
- How long have DFM been going on for
- Any fetal movements have been felt ?
- Previous episodes?
- Any known FGR, placental insufficiency or congenital malformation
- Maternal factors eg. HTN, DM, smoke, extremes of age, obesity
- Previous obstetric adverse events
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How do you examine a women presenting w DFM?
- Measure symphysis fundal height and palpate abdo - comare to previous measurements
- Auscultate fetnal heart to determine viability
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What is the management of DFM?
- Confirm fetal viability
- CTG to exclude fetal compromise if >28 weeks gestation
- Signs of fetal distress = IOL or planned c section
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What are the causes of stillbirth?
- 50% unexplained
- Pre eclampsia
- Placental abruption
- Vasa praevia
- Cord prolapse
- Obstetric cholestasis
- Diabetes
- Thyroid disease
- Infections - rubella, parvovirus, listeria
- Genetic abnormalities or congenital malformation
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What is the management of intrauterine fetal death?
- Visualise fetal heartbeat to confirm the fetus is still alive
- Rhesus negative women need anti D prophylaxis, Kleihauer test is used to quantify how much fetal blood is mixed w maternal blood, determines the dose of anti D
- Vaginal birth = first line, IOL or expectant management = wait for natural labour, not acceptable if sepsis, pre eclampsia or haemorrhage
- IOL = mifepristone and misoprostol
- Dopamine agonists suppress lactation after stillbirth
- Can test stillbirth to determine cause
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Placental accreta vs increta
Accreta - placental fibres extend beyond the decidual endometrial layers and attach themselves to the superficial myometrium but don't invade the muscle layer
Increta - placenta invades the myometrium - major RF for PPH, need C section for delivery, definitive treatment = hysterectomy
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How do you interpret a Bishop score?
A score of 5 or less indicates that labour is unlikely to happen w/o induction.
<3 = IOL will fail
9+ = labour will progress spont
First line = prostaglandin pessary
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What is the definition of uterine hyperstimulation?
>5 contractions w/i 10 mins
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What is Naegele's rule?
Add 7 days to the first day of your LMP and then subtract 3 months
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What is colostrum?
After birth the breasts produce ~40ml/day, has less water soluble vitamins, fat and sugar than mature milk but has more proteins (esp immunoglobulins) and fat soluble vitamins.
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What regulates milk production?
During pregnancy = progesterone causes alveoli development but once the placenta is delivered the alveoli respond to prolactin = causes secretion.
Prolactin controlled by dopamine, dopamine secretion reduced by suckling = increases prolactin.
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What is the milk let down reflex?
Oxytocin released when suckling, stimulates myoepithelial cells surrounding alveoli to contract = milk squeezed from the breast.
Can be conditioned eg. cry or sight of an infant can cause let down.
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How is milk production maintained?
Sufficient suckling stimulation at each feed to maintain prolactin secretion and remove accumulated milk. If suckling stops milk production also stops gradually.
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What are the benefits of breast feeding to baby?
- Reduced risk of obesity and CVS disease in adulthood
- Reduce infections due to Ab passing through breast milk
- Reduces risk of all diseases and promtes healthy weight gian, preventing childhood obesity
- Reduces risk of sudden infant death syndrome
- Only breast mulk for the first 6 months, then can start solid foods and breast milk for as long as want
- Goo bonding between mum and baby
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What are the maternal benefits of breastfeeding?
Reduce breast and ovarian cancer. Reduce risk of osteoporosis, CVD and obesity.
Helps the mental health of mum and baby.
Helps to encourage uterus back into original size and reduces blood loss.
Less expensive.
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What is mastitis?
Inflam of breast tissue caused by obstruction of ducts and accumulation of milk. Complication of breastfeeding but reg expression of milk reduces this. Can be associated w infection, normally staph aureus.
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What is the presentation of mastitis?
- Breast pain and tenderness
- Erythema in focal area of breast tissue
- Local warmth and inflam
- Nipple discharge
- Fever
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What is the management of mastitis?
- Blockage of ducts = conservative management - cont breastfeeding, express milk and breast massage, simple analgesia
- Infection/conservative management not effective = fluclox 1st line/erythromycin
- Should cont breastfeeding even when infection suspected
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What is the presentation of candida of the nipple?
- After course of ab
- Sore nipples bilat, esp after feeding
- Nipple tenderness and itch
- Cracked, flaky areola - let bacteria in = recurrent mastitis
- Baby sx = white patches in mouth or tongue or candidal nappy rash
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What is the management of canddida of the nipple?
- Topical miconazole 2% after each breastfeed
- Treat baby
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What are the contraindications to breastfeeding?
- Mother w TB infection
- Uncontrolled/unmonitored HIV
- Mothers taking harmful meds eg. amiodarone
- Galactosaemia in baby
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What is the presentation of fetal compromise?
- Reduced fetal movements
- Fetal arterial Doppler can detect reduced resistance when placental func impaired
- Abnormal CTTG
- Abnormal amounts of amniotic fluid
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How is fetal compromise managed?
- Monitor w view to IOL or C section
- Reduced risk of intrauterine hypoxia but increased risks of prematurity when delivering preterm
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What is meconium stained liquor?
Meconium passed while in utero - stains amniotic fluid. Can result in meconium aspiration syndrome - increased risk of operative delivery, birth asphyxia, neonatal sepsis and need for NICU admission.
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What is the management of meconium stained amniotic fluid?
- Intrapartum - cont fetal monitoring if significant, fetal blood sample obstained if <7.21pH = emergency delivery
- Sick neonate at delivery airway suctioning, ventilation support, O2, Abx, surfactant replacement therapy
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What are the RF of VTE in pregnancy?
- Smoking
- Parity >3
- Age >35
- BMI >30
- Reduced mobility
- Multiple pregnancy
- Pre eclapmsia
- Gross varicose veins
Immobility
- Family hx of VTE
- Thrombophilia
- IVF
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When should VTE prophylaxis be started in pregnancy? What prophylaxis is given?
- 28 weeks if 3 RF
- First trimester if 4+ RF
LMWH unless contraindicated, stopped when women. gointo labour and cont immediately after delivery except PP haemorrhage
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How is VTE treated in pregnancy?
- Start LMWH if sx w/o diagnosis confirmation
- Cont LMWH for rest of pregnancy and 6 week postnatally or 3 months in total
- Can switch to oral anticoag after delivery eg. DOAC
- Massive PE - unfractionated heparin, thrombolysis, surgical embolectomy
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What is different to the management of HTN in a pregnant women?
Switch from ACEi, ARBs and thiazide diuretics to labetalol, CCB or a blockers
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What is the advice around epilepsy in pregnacy?
- Pregnancy can worsen seizure control, not harmful to the pregnancy however
- Control epilepsy w one single drug before pregnant ideally
- Safe = levetiracetam, lamotrigine or carbamazepine
- Unsafe = Na valproate and phenytoin
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What medications should be avoided in pregnancy?
NSAIDs - block prostaglandins, need them for maintaining ductus arteriosus
B blockers - fetal growth restriction, bradycardia and hypoglycaemia in neonate
ACEi and ARBs - oligohydramnios, hypocalvaria, renal fail
Opiates during pregnancy = w/drawl sx in neonate after birth = neonatal abstinence syndrome
Lithium - cardiac abnormalities
SSRIs - congenital malformations
Isotretinoin - teratogenic
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How is anaemia in pregnancy managed?
- Ferrous sulphate 200mg 3xday
- IM hydroxocobalamin injection or oral cyanocobalamin for B12 def
- Folic acid 400mcg day nor def, if deficient. =5mg a day
- Thalassaemia and sickle cell - high dose folic acid, close monitoring and transfusions
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What are the clinical features of congenital rubella syndrome?
Sensorineural deafness, cataracts or retinopathy, congenital heart disease.
Other features - organ dysfunc, microcephaly, micrognathia, low birth weight, developmental delay and learning disability
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Why is chickenpox dangerous in pregnancy?
More severe in mothers - varicella pneumonitis, hepatitis, encephalitis. Fetal varicella syndrome. Severe neonatal varicella infection.
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How is exposure of chicken pox and chickenpox in pregnancy managed?
Exposure - prev had = safe, test VZV IgG levels to see if immune, if not immune = IV varicella immunoglobulins to prevent developing chickenpox
Have chickenpox - oral aciclovir if present w/i 24hr and >20w
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What is congeital varicella syndrome?
Infection w/i first 28 weeks:
- Fetal growth restriction
- Microcephaly, hydrocephalus, learning disability
- Dermatomal scars and skin changes
- Limb hypoplasia
- Cataracts and chorioretinitis
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What are the CFs of congenital cytomegalovirus?
- FGR
- Microcephaly
- Hearing and vision loss
- Learning disability
- Seizures
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What is the impact of zika virus infection in pregnancy?
Congenital Zika syndrome:
- Microcephaly
- FGR
- Ventriculomegaly and cerebellar atrophy
No treatment but need to be monitored.
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What is the management of a HIV+ pregnant women?
- Combination antiretroviral therapy ASAp
- <50 viral load can have normal vaginal delivery, if >50 need C section
- Baby = infant PEP
- Formula milk, avoid breastfeeding but low viral load and women on cART can try breastfeeding as long as they are aware of the risks
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What are the complications of parvovirus infection during pregnancy?
- Miscarriage or fetal death
- Severe fetal anaemia
- Hydrops fetalis - fetal HF due to anaemia
- Maternal pre eclampsia like syndrome/mirror syndrome
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What is the spectrum of postnatal mental health illness?
Baby blues - seen in maj of women in 1st week after birth, due to hormonal changes, sleep deprivation, responsibility, recovery
Post natal depression - 1/10 women, peaks. at3 months
Puerperal psychosis - 1/1000 women, starts a few weeks after birth
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What is the management of postnatal depression?
- Edinburgh postnatal depression scale, >10/30 have postnatal depression
- Mild - selfhelp, followup, support
- Mod - SSRIs and CBT
- Severe - specialist psych services and inpt care on inpt mother and baby unit
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What are the CFs of puerperal psychosis?
- 2-3 weeks after delivery
- Delusions
- Hallucinations
- Depression
- Mania
- Confusion
- Thought disorder
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What is the management of puerperal psychosis?
- Urgent assessment
- Admission to mother and baby unit
- CBT
- Antidepressants, antipsychotics, mood stabilisers
- ECT
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What weeks are each trimester?
1st - 0-13 weeks
2nd - 14-26 weeks
3rd - 27-40 weeks
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What is the management of PROM? - pre labour ROM
- If labour doesn't commence w/i 24 hours = IOL
- Give abx for the risk of chorioamnionitis
- May need emergency C section if fetal compromise
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What is PPROM?
Pre term pre labour ROM before 37 weeks
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How is PPROM managed?
- IM corticosteroids
- IV abx
- Tocolysis - only for ~48 hours to give corticosteroids a chance, normally nifedipine
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What are the glucose parameters in gestational diabetes?
Fasting glucose >5.6 mmol/L
Random glucose >7.8 mmol/L
Fasting glucose >7 = immediate insulin therapy
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What is the first line tocolytic agent?
Nifedipine
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What is a type of GBS?
Streptococcus agalacticae
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What are the reasons for having more folic acid?
MORE folid acid (5mg)
Metabolic disease
Obesity
Relative - FH of NTD
Epilepsy
311
Placenta praevia vs vasa praevia
Placenta praevia -painless vaginal bleeding and baby fine
Vasa praevia - (rupture of membranes then) painless bleeding and baby distressed -bradycardia and late decel
