obstetrics Flashcards
(115 cards)
1
Q
How can you categorise itch in pregnancy? what are the most common causes of itch in pregnancy?
A
Itch with rash
Itch without rash
Itch with rash- polymorphic eruption of pregnancy, atopic eruption of pregnancy, pemphigoid eruptions (Very rare)
Itch without rash - obstetric cholestasis
2
Q
what trimester does polymorphic eruptions of pregnancy occur? What does it look like? where on the body.
A
3RD trimester
abdomen around the stria, excludes the umbilicus
urticarial papules that coalesce into plaques
3
Q
what trimester does obstetric cholestasis occur? What does it look like? where on the body.
A
28 weeks onwards
no rash often no jaundice
palms and soles
4
Q
which of the pruitic conditions in pregnancy are a risk for the foetus?
A
obstetric cholestasis. consider delivery at 37 weeks and pemphigoid. Both remain for a few weeks after pregnancy. the others resolve as soon as birth.
5
Q
What are the indications for continuous CTG?
A
- oxytocin
- PV bleed during labour
- Severe HTN >160/110
- suspected chorioamnionitis or sepsis, or a temperature of 38°C or above
- The presence of SIGNIFICANT MECONIUM
6
Q
What would a normal foetal blood monitoring during labour be?
A
7.2
7
Q
What is placenta previa and what is is associated with?
A
Placenta previa is a placenta that covers the internal os (incomplete or complete). this is normal and usually resolves by 34-36 weeks. if it doesnt- In the presence of risk factors then C section at 36- 36+7 weeks. - In the absence of risk factors then C section at 37- 37+7 weeks.
it is associated with vasa previa (where the foetal blood vessels cross the os that are exposed (not within the cord). - The classic triad of the vasa praevia is:
- membrane rupture
- painless vaginal bleeding
- Foetal Brady or foetal death
WHERE THE TWO ARE TOGETHER OR IT IS VASA PREVIA ALONE DO ELECTIVE C SECTION BY 35-36 WEEKS.
8
Q
what is placenta accreta spectrum?
A
Attachment of the placenta beyond the decidua basalis
- Divided into accreta, increta and percreta
- Accreta= The chorionic villi have moved beyond the decidua basalis but not yet INTO the myometrium
- Increta= the chorionic villi have moved INTO the myometrium but not beyond
- Percreta= the chorionic villi have moved BEYOND the myometrium and attached to external parts of the uterus
manage the same as placenta previa
9
Q
what are the causes of 1st trimester bleeding
A
spontaenous abortion
ectopic pregnancy
hyatidiform mole
10
Q
what are the causes of 2nd trimester bleeding
A
Spontaneous abortion
placental abruption
Hydatidiform mole
11
Q
what are the causes of 3rd trimester bleeding
A
placental abruption
Placenta praevia
Vasa praevia
bloody show
12
Q
PV bleeding and tense tender uterus
A
placental abruption
13
Q
Before doing a PV exam what do you need to exclude? (CI)
A
placenta previa
14
Q
PV bleeding, non tense, non-tender uterus
A
placenta previa
15
Q
TRIAD- rupture of membranes, painless vaginal bleeding, foetal bradycardia or death.
A
vasa previa
16
Q
ANAEMIA IN PREGNANCY
A
Hb <110g/L 1st trimester OR <105g/L in the 2nd and 3rd trimesters, OR 100 g/L post partum
17
Q
Foetus reaches the umbilicus (weeks gestation?)
A
20
18
Q
Foetus reaches the Xiphoid (weeks gestation?)
A
36
19
Q
postpartum haemorrhage classed as
A
PV blood loss from the start of labour >500mL
minor or major
minor 500-1000mL
major >1000mL
20
Q
4Ts of post partum haemorrhage
A
tissue - retained placenta
thrombus - DIC, HELLP, vasa previa, placental abruption
trauma - instrumental delivery, C section, epistiotomy,
Tone - Multiple pregnancy, prolonged labour (>12hr), polyhydramnios, age, Induction, placenta accreta.
21
Q
After 24 weeks you would only expect the fundal height to increase by
A
1cm a week
22
Q
Management of T- tone for PPH?
A
Resus A-E approach
- A- PROTECT AIRWAYS
- B- 15L 100% NON REBREATHER
- C- ASSESS AND INSERT 2X 14G CANNULA, TAKE BLOODS AND START CIRCULATORY RESUS. GIVE CROSS-MATCHED BLOOD AS SOON AS POSSIBLE, UNTIL THEN GIVE UP TO 2L WARMED CRYSTALLOID + 1-2L WARMED COLLOIDS THEN TRANSFUSE O NEGATIVE OR UNCROSS MATCHED GROUP SPECIFIC BLOOD.
- D- MONITOR GCS/AVPU
- E- EXPOSE BLEEDING SOURCES
definitive management
- bimanual compression - one fist into anterior fornix pushing up, the other on the abdomen pushing down tamponade the uterine vessels.
- medical
–> syntocinon
–> ergometrine
–> carboprost
–> misopristol - surgical
–> intrauterine balloon tamponade, haemostatic suture around uterus (e.g. B-lynch), bilateral uterine or internal iliac artery ligation, hysterectomy (as a last resort).
23
Q
Free head on palpation is normal until
A
37 weeks then should be engaged
24
Q
The average normal birth length is
A
47-53cm
25
what is the difference between chorioamnioitis and endometritis?
chorioamnionitis - antepartum infection. Triad of maternal pyrexia, maternal tachycardia, and fetal tachycardia
endometritis - post partum infection.
26
Why antibiotic prophylaxis for C section?
to prevent wound infection and more importantly endometritis
27
Do you give intrapartum antibiotics to all pregnant women for GBS prevention?
I DONT THINK SO?
28
if there is a risk for cord prolapse due to HIGH RISING fetus/free head what pain relief should you give?
epidural >pethidine because if there is a cord prolapse then they may need emergency C section and to do a spinal would take too long so you’d have to do a GA so they wouldn’t b able to see the birth.
29
When closing uterus close from outside in because
that will help tamponade bleeding as the uterine arteries are on the sides of the uterus.
30
C section classifications 1-4
1- not planned, to salvage a failed vaginal birth WITHIN 30 MINUTES
2- not planned, to salvage a failed vaginal birth WITHIN 45-70 MINUTES
3- planned but expedited
4- planned
31
C section indications
- vessel issues
- placental issues
- cephalopelvic disproportion / macroosmia >4.5kg / shoulder dystocia
- multiple pregnacny where first isnt cephalic
- elective
- odd lie/ presenting part
- HIV in mother and high virus load
- Maternal medication conditions where labour would be too dangerous for them i.e., cardiomyopathy
- PRIMARY genital herpes in the 3rd trimester as there is no time for development and transmission of HSV antibodies.
32
Pre treatment for C section
- PPI/ranitidine (H2- antiacid adn prokinetic stops aspiration - chemical pneumonia)
- 4 units pRBC group and save
- cefalexain? when?
- prophylactic antibiotics
- Steroids if <35 weeks
33
What is the importance of putting in a catheter in C sections?
allows uterus to contract fully to stop PPH. reduces risk of rupturing and allows to displace when operating on uterus.
34
Bishops score >6 induction agents?
rupture of membranes/amniotomy
Oxytocin
THIS IS BECAUSE ONCE IT HITS 7 YOU’RE MORE THAN LIKELY TO HAVE INDUCTION OF LABOUR. 8= Spontaenous labour is likely to occur.
35
Bishops score ≤6 induction agents?
misopristol IS FIRST LINE, Membrane sweep IS AN ADJUNCT
Balloon catheter if history of UTERINE HYPERSTIMULATION SYNDROME
36
The patient goes onto ALL FOURS or LEFT LATERAL RECUMBENT POSITION FOR?
Cord prolapse
37
Cord prolapse CI
Pushing back in (vasospasm). you may push back presenting part.
38
LOCHIA?
differential for PPH <500mL blood or mixture of vaginal discharge containing blood, mucous, and uterine tissue which can continue for 6 weeks following childbirth. if continues over 6 weeks review it.
39
Management of chickenpox EXPOSURE in pregnancy
POST EXPOSURE PROPHYLAXIS
- VZIG WITHIN 10 DAYS IF ≤20 WEEKS
- ACICLOVIR IF >20 WEEKS BETWEN 7-14 DAYS OF EXPOSURE
40
Management of chickenpox in pregnancy
- aciclovir if ≥ 20 weeks and presents within 24 hours of onset of the rash
- 800mg 5 times a day for 7 days if >20 weeks pregnant
if <20 weeks dont give anything as RISK OF TERATOGENICY
41
Breast feeding drugs to avoid:
Aspriin for pain relief or AMIODARONE
Biotics (certain antibiotics - tetracyclins, quinolones, macrolides in large single doses.
Codeine phosphate
Decongestants
+/- sodium valproate
42
Drugs for HTN in pregnancy?
Lois- labetalol
N- nifedipine
M- methylodopa
43
CI of each of the following
Labetalol
Nifedipine
Methylodopa
Asthma
Heart failure (even high output cardiac failure as in pregnancy)
Depression
44
if you use NSAIDS in the 3rd trimester you get
EARLY CLOSURE OF PDA
OLIGOHYDRAMNIOS (because the baby inhales the amniotic fluid)
45
Give indamethocin for? When?
- It is given to newborn if PDA exists on USS 1 week after delivery It acts by inhibiting prostaglandin E2. SIGNS OF PDA = subclavian thrill, loud apex beat, bounding pulse, continuous high pitched machinery murmur heard best in the pulmonary area.
if associated with another congenital heart defect amenable to surgery then prostaglandin E1 is useful to keep the duct open until after surgical repair
Alprostadil (prostaglandin E1) and dinoprostone (prostaglandin E2) are potent vasodilators that are effective for maintaining the patency of the ductus arteriosus.
46
How many visits for primigravid? How many for multigravid?
10
7
47
Purpose of the 8 - 12 weeks (ideally < 10 weeks) visit
Booking visit/initial visit
- Confirms pregnacny
- HIV, syphillis, Hep B
- BP, blood glucose, urine dip, Rhesus status
- sickle cell
- thalasemmia
+ general information e.g. diet, alcohol, smoking, folic acid, vitamin D, antenatal classes
48
purpose of the 10 - 13+6 weeks visit
Early scan to confirm dates, exclude multiple pregnancy
49
purpose of the 11 - 13+6 weeks visit
Combined test- Down's syndrome screening including nuchal scan, AFP and Beta HcG
50
purpose of the 16 weeks visit
Information on the upcoming anomaly scan and the blood results.
If Hb < 11 g/dl consider iron (Hb <11 in first trimester = anaemia, Hb <10.5 in 2nd and 3rd and Hb <10 post partum = anaemia)
Routine care: BP and urine dipstick
51
purpose of the 18-20+6 week visit
anomaly scan
52
25 week visit is specific to PRIMIGRAVIDA. what is its purpose?
routine care
- BP
- urine dipstick
- symphysis-fundal height (SFH)
*from 24 weeks should expect 1cm a week*
53
purpose of the 28 week visit
Routine care:
- BP
- Urine dipstick
- SFH
AND REPEAT OGTT
Second screen for anaemia and atypical red cell alloantibodies.
If Hb < 10.5 g/dl consider iron.
First dose of anti-D prophylaxis to rhesus negative women.
54
31 week visit is specific to PRIMIGRAVIDA. what is its purpose?
routine care as above
55
Purpose of the 34 week visit?
Routine care (BP, urine dipstick, SFH, Hb) +Second dose of anti-D prophylaxis to rhesus negative women.
+ information about labour and post partum
+ Steroids if indicated for baby.
56
Purpose of the 36 week visit?
Routine care (BP, urine dipstick, SFH, Hb)
- CHECK PRESENTATION AND OFFER EXTERNAL CEPHALIC VERSION IF MEMBRANES STILL INTACT
Information on
- breast feeding
- vitamin K
- 'baby-blues'
57
purpose of the 38 week visit?
primigravida only routine care (BP, urine dipstick, SFH, Hb)
58
Purpose of the 40 week visit?
Routine care (BP, urine dipstick, SFH, Hb)
Discussion about options for prolonged pregnancy
59
Purpose of the 41 week visit?
induction talks
60
Why do newborns get Vit K? Within how many hours? And what dose?
- It prevents VITAMIN K BLEEDING DISORDER (PREVIOUSLY KNOWN AS haemorrhagic disease of the newborn)
- They get Vit K because vitamin K passes the placenta poorly, levels in breast milk are low and the gut flora that in adults produces vitamin K, has not yet developed. It can also result from maternal medications that interact with vitamin K such as warfarin, phenytoin, or rifampicin.
- 0.1mg usually in ampoules of 0.2mg/2ml so they get 1ml if >2.5kg, or if preterm 400 micrograms/kg
61
What is the APGAR score and how often is it measured?
APGAR STANDS FOR
Activity (tone)
Pulse
Grimace (reflexes)
Appearance
Respiration
SCORES ARE 0-2
62
TERATOGENS IN PREGNANCY
ACE inhibitors- Renal dysgenesis AND Craniofacial abnormalities
Alcohol- Craniofacial abnormalities
Aminoglycosides- Ototoxicity
Carbamazepine- Neural tube defects AND Craniofacial abnormalities
Chloramphenicol- 'Grey baby' syndrome
Cocaine- Intrauterine growth retardation AND Preterm labour
Diethylstilbesterol- Vaginal clear cell adenocarcinoma
Lithium- Ebstein's anomaly (atrialized right ventricle)
Maternal diabetes mellitus- Macrosomia AND Neural tube defects AND Polyhydramnios AND Preterm labour AND Caudal regression syndrome
Smoking - Preterm labour AND Intrauterine growth retardation
Tetracyclines- Discoloured teeth
Thalidomide- Limb reduction defects
Valproate- Neural tube defects AND Craniofacial abnormalities
Warfarin- Craniofacial abnormalities
63
what is ASHERMAN’S SYNDROME and what causes it?
- intrauterine adhesions caused by trauma to the basal layer from
- operative hysteroscopy
- complicated dilation and curettage (D&C) or
- cesarean section (c-section)
- history of pelvic infections
- Radiation therapy
IUDs are not commonly linked to the condition.
64
what are the symptoms of ashermanns syndrome?
Women with Asherman’s syndrome may experience light or no periods, pelvic pain or infertility.
65
When does the ductus arteriosus close?
Within 2 to 3 days
66
Why would you call in a paedatrician to a C section?
breech
67
Are maternal beta blockers contraindicated in pregnancy? labour? or C section?
- Can cause neonatal hypoglycemia
- Can cause neonatal bradycardia
- Can cause intra-uterine growth restriction
NOT CI BUT NEEDS EXTRA MONITORING POSTNATALLY.
68
What are the signs of neonatal hypoglycemia (how can you divide them?)
autonomic and neuroglycopenic
AUTONOMIC
- 'jitteriness'
- irritable
- tachypnoea
- pallor
NEUROGLYCOPENIC
- poor feeding/sucking
- weak cry
- drowsy
- hypotonia
- seizures
- other features may include
- apnoea
- hypothermia
69
What does the BISHOPS score mean? *mnemonic BISHOP*
B- bishop
I- ffacement
S- tation (of the head)
H- ard or soft cervix (consistency)
O- opening (dilatation)
P- position
70
When would you take a placental blood sample?
- If foetal distress
71
How long do you store placenta in fridge for and why?
- 48-72hr in case baby goes septic to do analysis on it
72
What are the risk factors for ectopic pregnancy?
- anything that slows down transit of ovum = Ashermanns, IVF, PID, POP, IUD, endometriosis, previous surgery.
73
A patient with reduced organ mobility, a tender nodularity in the posterior vaginal fornix and intra menstrual bleeding
endometriosis
74
what patients need aspirin in pregnancy?
What week is aspirin taken from?
Taken from week 12 until birth
- HTN in previous pregnancy or chronic HTN
- CKD
- AI diseases like SLE or antiphospholipid syndrome
- T1DM, T2DM
OR if you have >1 moderate risk factor which include -->
- nulliparity
- ≥40 years
- pregnancy interval ≥10 years
- BMI ≥35
- FH of pre eclampsia
- Mutli-foetal pregnancy
i.e., a nulliparous women diagnosed at 10 week USS with twins, a nulliparous women that is fit and well but mother had preeclampsia, a nulliparous women with bmi ≥35, a nulliparous woman who is ≥40.
75
What is sheehans syndrome?
pituitary necrosis post partum haemorrhage
76
A woman who has just had a C section cannot make breast milk, feels really tired and can't shift her baby weight.
Consider sheehans syndrome if there is history of PPH
77
How would you investigate a woman who has just had a C section cannot make breast milk, feels really tired and can't shift her baby weight?
investigate for sheehan syndrome
- CT and MRI look for empty sella turca sign
Treatment
- Hormone replacement
78
What is pre eclampsia? What are the symptoms?
How is it managed?
DUO of
- HTN IN >20 weeks, up to 6 weeks post partum WITH 1 OR MORE OF THE FOLLOWING
- proteinuria OR
- Renal insufficiency (creatininine >90 micromol/litre) OR
- Liver involvement
- Neurological complications i.e., blindness, altered mental status, stroke, clonus, SEVERE headaches
- Haematological complications
- Uteroplacental dysfunction i.e., foetal growth restriction or abnormal umbilical artery doppler analysis.
Symptoms
- Papilloedema
- Headache
- frothy urine
- swelling
- visual disturbance
- liver pain
- easier bleeding or bruising
Complications
- placental abruption
- haemorrhagic stroke
- HELLP syndrome (considered a SEVERE FORM OF PRE-ECLAMPSIA)
Treatment
- arranging emergency secondary care assessment for any woman in whom pre-eclampsia is suspected UP TO 4 WEEKS POST PARTUM
- If bp ≥ 160/110 mmHg are likely to be admitted and observed REGARDLESS OF PROTEINURIA
treatment is to resolve HTN and treat other complications
- oral labetalol, nifedipine and methyldopa.
- Consider delivery of the baby if in distress or tocolytics if preterm to relax the uterus and halt contractions and labour. Tocolytics may also be used for uterine relaxation to reduce the likelihood of separation of the placenta from the uterine wall.
Note though if seizure and NO CHANGES (epileptic with no other signs like HTN, liver enzyme changes or low platelets, headache, proteinuria etc) OR CHANGES TO FOETAL CTG then don't induce.
79
What is eclampsia. How is it managed?
Pre-eclampsia + seizures.
80
What are the risk factors for pre eclampsia?
81
What is HELLP syndrome?
- A severe form of pre-eclampsia
- Haemolysis (micvroangiopathic haemolytic anaemia)
- Elevated liver enzymes
- Low platelets
82
How are seizures managed in pregnant women?
Give IV Lorazepam up to 4 mg or 10-20 mg rectal Diazepam if no IV access (can be repeated in 10 minutes if necessary)
If any possibility of eclampsia- give IV Magnesium sulphate (MgSO4) 4 grams over 5-10 minutes followed by 1 gram/hour for 24 hours
83
... should be considered in any pregnant person presenting in the second half of gestation or immediately postpartum with significant new-onset epigastric/upper abdominal pain until proven otherwise.
HELLP SYNDROME
84
How do you diagnose HELLP?
- Haemolysis indicated by elevated total bilirubin (>1.2 mg/dL [>20.5 micromol/L]), LDH and AST elevations, and characteristic findings (schistocytes) on a peripheral blood smear, haematuria, worsening anaemia, and a low serum haptoglobin.
- liver transaminases >70 IU/L, or twice the upper limit of normal concentration
- platelet count should be <100 x 10⁹/L
85
How do you manage SUSPECTED HELLP? i.e., a patient with HTN, blurred vision, haematuria and upper abdo pain?
- obviously definitively diagnose with BLOODS but risk manage in the meantime
-Manage HTN using labetolol.
- Seizure prophylaxis = magnesium sulfate: 4-6 g intravenously as a loading dose, followed by 1-2 g/hour infusion for at least 24 hours, maximum 40 g/day. If Mg >9mg/dL stop and recommence when level <8)
- + IV dexamethosone if <34 weeks gestation to enhance foetal lung maturation and diminish risk of intraventricular bleeding and necrotising enterocolitis by increasing platelet count and reducing haemolysis
86
How do you manage CONFIRMED HELLP?
- Delivery (induction or C section) within 48-72HR even in pre-viable gestations <23 weeks.
- Tx HTN
- Tx seizure prophylaxis
- Tx low platelets
- Tx low RBC
87
Red hot painful unilateral breast. No cracking
mastitis
88
Cracked burning nipple with white discharge
nipple candidiasis
89
Newborn weighed 4.5kg now weighs 4.05kg a week later
No intervention needed, up to 10% weight loss is normal. if over 10% refer to midwife led breastfeeding
90
First line for nipple candidiasis
Mother - Miconazole
Newborn - Nyastatin
91
Mother fasting glucose 5.5
this is okay
92
Mother fasting glucose 5.6
Trial exercise and diet for a week then if it doesnt work - metformin
93
Mother fasting glucose is >7
offer insulin (SHORT ACTING NOT LONG FOR PREGNANT WOMEN)
94
Mothers fasting glucose is <7 but her baby is seen to have macrosomia
Insulin
95
Risk factors for GBS infection
Prematurity
Prolonged rupture of the membranes
Previous sibling GBS infection
Maternal pyrexia e.g. secondary to chorioamnionitis
96
Why are mothers giving birth to premature infants offered IV benzypenicillin?
increased risk of GBS in premature infants.
97
Placental abruption risk factors
A- abruption previously
B- Blood pressure (HTN)
R- Ruptured membranes
U- Uterine injury
P- polyhydramos (pressure)
T- twins
I- Infeciton
O- Older age (>35)
N- Narcotic use (inclu. cocaine and smoking)
98
when would a placental growth factor (PlGF)-based testing be used?
HTN to rule out pre-eclampsia
99
What conditions would you give Anti-D in. what is the time limit?
- ECV
- Miscarriage ≥12 weeks
- uterine trauma
- Placenta previa
- Placental abruption
- Surgical management of ectopic pregnancy
- Any termination of pregnancy
- amniocentesis, chorionic villus sampling, fetal blood sampling
- Has to be given within 72 hours:
100
What signs would you see in the infant of a mother previously sensitised to Rhesus D on birth?
Hydrops fetalis
- hepatomegaly (as contiued haemolysis causes extramedullary haematopoesis), followed by swollen/oedematous (because concentrating on EMH causes a reduction in albumin, kernicterus (brain damage from high levels of billirubin), anaemia, heart failure
101
Why do people w obstetric cholestasis have to be induced at 37 weeks or 36 if they have risk factors?
becuase continued bilirubin can damage the babys brain (KERNICTERUS)
102
recurrent DVTs and now 10 weeks pregnant. aspirin? UFH> LMWH?
LMWH for all pregnancy till 6 weeks post partum
103
When can you start a pregnant women on the birth control pill?
3 weeks post partum if NOT breastfeeding
6 weeks if they are (takes a while for hormones to retunr --> VTE risk)
104
If not put in the first 48hr best to wait 4 weeks.
IUS, IUD, POP. WHY?
105
DEFINE MISCARRIAGE
spontaneous loss of a pregnancy before 24 weeks
106
how is miscarriage diagnosed. How is it managed if there is a foetal heart rate? How is it managed if there is NO foetal heart rate?
TV USS + serial HcG (If cant detect the pregnancy to see if it's implanting or recent miscarriage. take 2 samples at least 48hr difference)
admit if haemodynamically unstable or signif blood loss
IF VIABLE PREGNACNY (FOETAL HEART BEAT)= VAGINAL MICRONISED PROGESTERONE (400MG BD) if they have PREVIOUSLY HAD A MISCARRIAGE- Continue this unit; 16 weeks
- If <6 weeks (foetal heart rate cant usually be detected here anyway) - expectant management of missed miscarriage then pregnancy test after 3 WEEKS. Same goes if >6 weeks but no pain/haemodynamic instability
- IF SYMPTOMS STILL PERSIST ≥2 WEEKS THEN COME BACK IN and if no foetal heart rate offer MEDICAL MANAGEMENT.
107
- Snow storm appearance on USS
Complete hydatidiform mole
also No foetal parts
108
How is baseline variability defined?
variation in one heart beat to the next- should be = ≥5 beats per minute.
109
most common reason for loss of baseline variability if it goes on for <40 minutes?
sleeping baby
110
causes of loss of baseline variability if it goes on for >40 minutes?
- foetal hypoxia ?cord prolapse ?vasa previa ?placental abruption
- foetal acidosis
- maternal drugs (such as benzodiazepines, opioids or methyldopa - not paracetamol),
- prematurity (< 28 weeks)
- congenital heart abnormalities
111
How do you detect if PROM/P-PROM has occured?
Get px to lie on couch for ≥30 minutes then speculum and look for pooling in the posterior fornix
Actim-PROM (Medix Biochemica) – uses a swab test looking for IGFBP-1 (insulin-like growth factor binding protein-1) in vaginal samples. The concentration in amniotic fluid is 100 – 1000 times the concentration of maternal serum. This test is unlikely to be affected by blood contamination.
A high vaginal swab should be taken, IF IT GROWS Group B Streptococcus (GBS) THEN antibiotics SHOULD BE GIVEN INTRA-PARTUM AND THIS GIVES information as to a potential cause for PPROM (bacterial vaginosis is commonly implicated).
112
at what point should you induce in P-PROM and PROM?
if GBS then immediate induction of labour or caesarean birth.
AFTER 24HR IF >37 WEEKS
UP TO MUM IF 34-37 WEEKS- expectant management until 37+0 weeks OR induction of labour with her taking into consideration the risks to the woman (for example, sepsis, possible need for caesarean birth), risks to the baby (for example, sepsis, problems relating to preterm birth) and local availabilitv of neonatal intensive care facilities
113
a woman presents w this scar and would like to discuss her options for delivery and would like home birth.
Vaginal birth after Caesarean (VBAC)
planned VBAC is an appropriate method of delivery for pregnant women at >= 37 weeks gestation with a single previous Caesarean delivery
around 70-75% of women in this situation have a successful vaginal delivery
contraindications include previous uterine rupture or classical caesarean scar
114
How would you manage a 14 week pregnant lady who wanted an abortion?
Patient choice: medical or surgical
Medical
- oral mifepristone (one - take it first) (to stop the uterine wall supporting the pregnancy)
- then 36-48hr later take misoprostol (to prime the cervix, contract the uterus and help evacuation). IF UNDER 10 WEEKS THEN ONLY ONE LOADING DOSE IS NEEDED, BUT IF >10 WEEKS THEN A LOADING DOSE + A MAINTENANCE DOSE IS NEEDED TO CONTINUE THE EVACUATION (given every 3 hours)
Surgical requires cervical priming
- This is done with MISOPROSTOL 1HR BEFORE IF SUBLINGUAL, 3HR BEFORE IF VAGINAL
- Mifepristone (1 day before) if under 16 weeks (2nd line) or >19 weeks. basically none between 16-19 can take mifepristone
- Osmotic dilators 1 day before if >14 weeks
115
How would you manage a women who has had transvaginal bleeding no pain in the 1st trimester (primigravida)?
3 ways: expectant (1ST LINE) medical or surgical.
TVUSS to confirm that the foetal heart rate.
If no HR then this is a missed/incomplete miscarriage.
If there is a HR think of this as a threatened miscarriage.
Missed or incomplete
- expectant is always first line unless there is a haemorrhage/clotting condition, or sign of infection.
-1ST LINE: EXPECTANT: see if self resolves in 7-14 days, if bleeding hasnt stopped return for MEDICAL OR SURGICAL MANAGEMENT
- 2ND LINE: MEDICAL: MISOPROSTOL 1 LOADING DOSE, CONTACT THE DOCTOR IF NO BLEEDING WITHIN 24HR
- 2ND LINE: SURGICAL: vacuum or surgical management in theatre.
Threatened
- Manage expectantly.
- Inform that if bleeding gets worse, or persists beyond 14 days to return for further assessment.
- If the bleeding stops, she should start or continue routine antenatal care
- If this was not her first pregnancy or misscarriage then she would be offered 400mg micronised progesterone to stabilise the pregnancy and this should be CONTINUED until 16 weeks.
