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Obstetrics Flashcards

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1
Q

When are health preggo women going to have routine scans?

A

10-14 weeks dating scan

18-21 week anomaly scan

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2
Q

What screening are women routinely offered?

A
  • fetal anomalies (down syn opt in. and ALL women anomaly scan at 18-21 wks)
  • Infectious diseases (HIV, Heb B, syphillis, rubella)
  • Rh-ve
  • Hb globinopathies
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3
Q

What prenatal diagnostic tests are offered? Indications for these tests?

A
  • Chorionic villus sampling (+11wks) = inc risk of miscarriage
  • Amniocentesis (15wks)
  • Suspected chromosomal abnormality, NTD, abnormal maternal serum analyte
  • Age > 35
  • Previous child with congenital abnormality
  • One of the parents has a chromosomal abnormality or other FHx
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4
Q

Maternal serum sampling at 11wks detects which hormones?

A

hCG (inc in downs and tri 18)

PAPP-A (preggo assoc plasma protein A) - Dec in down and Tri 18

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5
Q

Quadruple screening occurs when and includes which hormones?

A

15-20wks

  • hCG = inc in downs
  • Estriol (E3) = dec in downs and tri 18
  • AFP (NTD)
  • Inhibit A = inc in downs
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6
Q

What ultrasound scan is performed between 11-14 weeks and what does it look at?

A

CRL (accurate at measuring gestational age) - better than biparietal or femur length

Nuchal translucency (thickness of subcut tissue in nuchal region. > 3mm assoc with CV defects, and downs)

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7
Q

All women receive this scan at 20 weeks. what is it and what does it include?

A

Anomaly scan between 18 and 26 was.

  • Looks for list of conditions (anencephaly, myelomeningocele, gastrochisis, cleft lip, heart defects)
  • Head circus, abdo circum, femur length,
    (macro or microsomia)
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8
Q

Rh-ve mum with rh-ve child = problem?
Rh-ve mum with 2nd rh+ve child = problem?
Rh-ve mum with 1st rh+ve child = problem?

Rx?

A

No to a rh-ve child and Not really problem if first pregnancy rh+ve but still offered treatment

If rh+ve child on second preggo, then sensitisation to the Rh+ve may have occurred in the mum to produce IgG Abs which can cross the placenta unlike in the first preggo where IgM Abs can not cross.
- If antigens from Rh+ve on 2nd preggo, enter maternal circulation, IgG response will occur.
The IgG Abs can cause haemolysis of the fetal RBC can haemolytic disease of the newborn.

Treatment is to give all Rh-ve women anti-D Ig IV at 28-30 days
= neutralises foetal Rh+ve antigens which would have entered the maternal blood leading to IgG production
IM injection of anti-D given after baby is delivered

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9
Q

What is hyperemesis gravidarum?

A

Excessive N&V of pregnancy such that women can not maintain adequate hydration and lose wt ( >2-5kg)

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10
Q

Peak onset and clinical features of hyperemesis gravidarum? Effect on foetus?

A

1% of preggos.
6-11wks

N&V
Excess salivation
Reduced urine output and epigastric pain
Signs of dehydration 
inc ketones in urine and liver tenderness

If >10% wt loss then foetus could be restricted in growth.

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11
Q

In which trimester is heartburn more prevalent?
Adv to women?
What must you also be concerned about with epigastric tenderness?

A

Third trimester (70%). Reassure.

Adv low fat set, bland foot, small portions.
Adv against later night food. Adv raising head at night.
Avoid gastric irritants (caffeine)
Anatacids (magnesium trisilicate) = if lifestyle mods are ineffective.

Consider pre-eclampsia if unresponsive to simple antacids. Check BP and protein.

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12
Q

What are you likely to see on blood tests in hyperemesis?

A

Raised hCG. Raised TFTs without signs suggestive of hyperthyroidism. Inc urea if dehydrated. Electrolyte disturbances.

Check UandEs, LFTs, TFTs

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13
Q

Prevalence of Nausea in preggo?
Vomit in preggo?

Associated with?

A

N >80% from 4-6wks. should ease by 14-16wks.
V 50%

Any time of the day.
Odours and preparation/sight of food.

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14
Q

Mx of N&V, and hyperemesis gravidarum?

A

Reassure.
Exclude other causes of vomiting such as UTI, thyrotoxicosis.
Adv small, frequent fluid and small amounts of carbs.
Self help = ginger and P6 acupressure

If dehydrated, and not tolerating oral intake = admit. Consider IV rehydration.
Antihistamine antiemetics such as cyclizine work best.

If prolonged, Vitamin B supplementation may be needed as Wernickes encephalopathy has been reported. High dose Corticosteroids may of benefit if severe.

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15
Q

Prevalence of constipation in preggo?

Rx?

A

40%
Inc fluid and fibre intake.
If necessary use a bulk forming laxative such as ispaghula husk (avoid stimulants as these inc uterine activity)

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16
Q

Prevalence of backache in preggo?

A

60%. worse in evenings. adv light exercise unless CI (pre-eclampsia)

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17
Q

What does HELLP stand for?

A

Haemolysis and elevated liver enzymes with low platelet count.

Variant of pre-eclampsia

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18
Q

How would you categorise high risk pregnancies?

A

Maternal conditions

  • Obesity, DM, HTN
  • chronic (renal, cardiac, endocrine, haem, AI), epilepsy
  • Infections (HIV, HepB)

Social factors

  • Maternal age > 40 or < 18
  • Multiparous (inc risk of PPH) = Para > 6 or > 3 miscarriage
  • Smoker, domestic violence, substance abuse

Obstetric issues in previous preggo

  • Previous C-section
  • Previous preterm delivery, still birth, death
  • Pre-eclampsia, Eclampsia, HELLP
  • Previous GDM
  • Previous tears
  • Previous psych illness

Problems in this preggo

  • Multiple preggo
  • Small or large for gestational age
  • Placenta previa
  • GDM
  • pre-eclampsia
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19
Q

What are the four major mechanisms responsible for preterm labour?

A

Stress (maternal or foetal)
Infection (IU)
Stretch (excessive due to multiple preggo, polyhydramnios)
Haemorrhage (decidual = placental abruption)

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20
Q

Main causes of preterm labour?

A

PPROM
Intra-amniotic infection/inflammation
Idiopathic

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21
Q

Difference between PROM and PPROM?

A

PROM = premature rupture of membranes before onset of labour

PPROM = preterm premature rupture of membranes < 37wks

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22
Q

Absolute contradictions to the use of tocolytics?

A

Tocolytics = suppress uterine contractions

Indications = prolongation of preggo is beneficial for lung maturity etc.

CI

  • APH
  • Infection (evidence of chorioamniotitis = maternal pyrexia, uterine tenderness, raised WCC, CRP, foetal tachy)
  • Foetal distress
  • IU foetal demise

Caution in those with DM as betamimetics inc gluconeogenesis and therefore precipitate a DKA.

PPROM is a relative CI

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23
Q

Preggo lady at 31 wks presents and has suspected preterm labour. No CI. Mx?

A

Tocolytics
- Nifedipine (calcium channel blocker) 1st line
SE hypoTN, reflex tachycardia, nausea, headache, hepatotoxicity

  • if nifedipine CI, then oxytocin receptor antagonists (atosiban)
    SE N, headache, chest pain, arthalgia

Maternal corticosteroids

Magnesium sulphate for neuroprotection

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24
Q

Absolute indications for a C-section?

A

Maternal

  • failed induction
  • failure to progress
  • cephalopelvic disproportion

Utero-placental

  • Previous uterine surgery
  • previous uterine rupture
  • Outflow obstruction (fibroids)
  • Placenta previa/large placental abruption

Foetal

  • foetal distress
  • cord prolapse
  • foetal malpresentation (transverse lie)
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25
Relative indications for C-section?
Maternal - elective repeat C-section - maternal disease (severe pre-eclampsia, cardiac disease, DM) Utero-placental - prior uterine surgery - funic presentation Foetal - Foetal malpresentation (brow, breech, compound) - Foetal anomaly (hydrocephalus) - Macrosomia
26
Most common indication for first time C-section?
Failure to progress
27
What are the types of C-sections?
- Transverse (lower uterine segment) = most common. less blood loss - high vertical (classic) = inc blood loss - lower segment vertical
28
Complications of C-section?
- Haemorrhage - Infection (inc chance if obese, DM, emergency section, fever, anaemia etc.) - Injury to foetus - Injury to adjacent organs (bladder, bowel, ureters)
29
Maternal mortality from C-section? and compared to vaginal delivery? Maternal morbidity assoc with C=section?
<0.1%. Vaginal delivery is 2-10fold less Morbidity = infection, thromboembolic events, wound dehiscence
30
Chance of success of VBAC? Features that inc chance of success?
65-80% | - prior vaginal delivery, total wt < 4kg, non-recurrent indication for previous section (breech, previa), not CPD
31
contraindications for attempted VBAC?
- absolute (prior classic section, foetal distress, placenta previa, transverse lie) - relative (prior uterine rupture, breech presentation, previous full thickness myomectomy)
32
Benefits of VBAC?
shorter hospital stay and quicker recovery time Reduce operative complications Reduced risk of future complications
33
Risks of VBAC?
``` - risk of vaginal delivery = Pain and bruising from a tear incontinence Higher risk of - needing a blood transfusion - uterine rupture - uterine infection ```
34
Signs and symptoms of a uterine rupture?
Sinus bradycardia in 70% Abdo pain in 10% Vaginal bleeding in 5% Haemodynamic instability
35
Hx: what are the presenting complaints you're going to ask in an obs hx?
- Pain, - Bleeding (fresh, clots, tissue) - N&V - Dysuria/freq - Headaches, visual changes, swelling --> ?pre-eclampsia - foetal movements, - Leg pain/swelling --> ?DVT SOCRATES each Have they had it before?
36
Hx: Details to ask regarding history of current pregnancy?
- First pregnancy? - Date of LMP - EDD (scan or LMP + 7/7 + 9/12) - How was the preggo confirmed? - use of contraception - Antenatal tests and investigations (dating or anomaly scan = placental location, growth on track) - Foetal movements - Labour pains - Planned method of delivery - Complications + 1st half = N+V + 2nd half = BP, anaemia, bleeding, UTI, DM,
37
What is gravida?
Number of times the mother has been pregnant irrespective of outcome
38
What is parity?
Para X + Y X = number off deliveries after 24 wks (stillbirths or live) Y = number of losses before 24 wks (spontaneous/induced)
39
What term would be given to a lady with Para 0 + 3?
Nulliparous = woman who has never given birth over 24 wks
40
What term would be given to a woman who has given birth one or more times over 24 wks?
Multiparous
41
Previous obs hx would include what questions?
Details of any previous pregnancies - Live/stillborn - Sex/wt/gestation - mode of delivery (spont labour, induced, Section) - current health of babies Complications - Antenatal (IUGR, hyperemesis gravidarum, pre-eclampsia) - Labour (failure to progress, perineal tears, shoulder dystocia) - Postnatal (PPH, retained products of conception)
42
As part of an obs hx, would would you ask in terms of a gynae hx?
- Menstrual cycle + sx + LMP (how long bleed for, flow) + IMB, PCB - Smear hx +are you up to date?, has everything been normal? - Contraception + what?, how long? previous contraception? STDs
43
PMHx relevant to an obs hx?
- Past gynae and surgical hx - Medical conditions Thrombophillic Epilepsy - antiepileptics some are teratogenic DM - macrosomia + congenital defects Hypothyroidism - risk of congenital hypoTH Previous pre-eclampsia - higher risk of developing again HTN IHD
44
What drugs are teratogenic?
``` W TERATO Warfarin Tetracyclines Retinoids ACE-i Trimethoprim OCP ``` Methotrexate Antiepileptics
45
What to include in the Fhx and Shx section of an obs hx?
Fhx = has everyone else's pregnancies in the family been okay? - twins, - inherited disease - obs/medical problems Shx - occupation (maternal leave) - smoker (IUGR) - alcohol (foetal alcohol syndrome) - relationships - Living circumstances and carers - independent. ADLs
46
How long is a regular menstrual period? Menses last for how long? Blood loss?
Anywhere between 23-35 days 2-8 days Blood loss < 60-80mls
47
List three categories of hormonal contraception?
Combined Progestogen only Emergency
48
Give some examples of combined methods of hormonal contraception?
COCP = oestrogen + progestogen Patch Ring
49
Give some examples of progestogen only methods of hormonal contraception?
Injection * Implant * IUS (mirena) * POP
50
Give some examples of emergency methods of hormonal contraception?
Levonelle (progestogen only emergency contraception) Ulipristal (elaine) Copper coil (emergency IUD)
51
Non hormonal methods off contraception?
IUD (copper) * - Male/female condom - Diaphragm and cervical cap - Withdrawal method - Natural method - Sterilisation
52
What are the most effective contraceptives according to NICE?
``` IUS = mirena coil - 0.2% failure Injection = IM injection every 12 wks. Failure 0.4% Implant = subnormal implant for 3 yrs. Failure 0.05%. ``` IUD = failure 0.6-0.8%
53
Hormone thought to cause N&V in pregnancy?
hCG
54
Management of morning sickness? Adv
Small meals, inc fluid intake Ginger Acupressure Antiemetics (prochlorperazine, cyclizine)
55
Hormone thought to cause reflux in preggo? which trimester worse?
Progesterone - relaxes oesophageal sphincter and allows reflux of gastric contents. worse in later trimester due to inc in adobo pressure as foetus grows
56
Mx of reflux?
Lifestyle (sleep propped up, avoid spicy meals) simple antacids like gaviscon If severe H2RA - ranitidine.
57
Constipation inc or dec throughout preggo? Hormone and mechanism?
Dec. | Progesterone reduces smooth muscle tone and therefore slows bowel activity
58
Mx of constipation?
Lifestyle (inc fruit, fibre, water) Fibre supplements Osmotic diuretics (lactulose)
59
Mx of back pain?
Sleeping position relaxation and massage physio input simple analgesia
60
Urinary sx often seen in preggo? When during?
1st trimester - inc in freq as GFR inc and uterus presses on bladder 3rd trimester = stress incontinence due to pressure on pelvic floor UTIs are common (assoc with preterm labour) - Urine dipstick (nitrites, leech, protein) - MSU - Abx (amoxicillin 250mg TDS 7 days) - analgesia - inc fluid intake
61
What element of the urine dipstick is most strongly assoc with a UTI in preggo?
Nitrites. | blood, leuc and protein raised suspicion.
62
Profuse or watery vaginal discharge? White, clear and mucoid discharge? Offensive, coloured or itchy?
- rupture of membranes - normal due to inc in blood flow to vagina and cervix - suggestive of infection
63
Mx of vaginal discharge?
important to exclude rupture of membranes and STI and candidiasis (Intravaginal clotrimazole. NOT oral). Reassure
64
Preggo women with mild breathlessness - what would yo like to exclude?
PE | Anaemia
65
Define APH?
Bleeding from genital tracts in pregnancy at >24 wks gestation before onset of labour
66
Causes of PV bleeding?
<24 wks = - Miscarriage - implantation - polyps, trauma, cervicitis > 24wks = APH - PP - PA - uterine rupture - VP
67
Risk factors for Placenta prevue?
- Previous PP - maternal age - previous C-section - Multiple preggo - illicit drugs
68
Features of PP?
Bright red Painless PV bleeding > 24 wks gestation. | Abdo SNT
69
grading of PP?
Major (completely covers OS) or minor (Within 2cm of OS)
70
Examination of pregnant women presenting with PV bleeding after 24wks?
Maternal assessment - ABCDE - HR, BP, RR - signs of cyanosis, peripheral vasoconstriction - assess the blood - Abdo exam (SFH, distension, scars, linea nigra, foetal lie, presentation, size) Foetal assessment - sonic aid of foetal HR
71
Ix of PV bleeding in a woman?
- Preggo test - FBC (group and save) - USS (determine location of placenta) - Serum hCG - later preggo may need clotting, and CTG
72
Complications of PP?
Maternal - haemorrhage - air embolism Foetal - anaemia - IUGR - malpresentation - cord prolapse
73
Mx of PP?
DO not do a PV examination until exclusion of PP with USS - ABC assessment - if major then will need LSCS and admitted after 34 wks. - if early in preggo then Placenta is likely to move
74
Presentation of placental abruption?
``` Abdo pain (sudden, constant and severe) Uterus tender and hard to palpate Variable PV bleeding, often dark Maternal signs of shock Foetal distress ```
75
Risk factors for PA?
- trauma - multiparrous - previous PA - previous section - pre-eclampsia - smoking - multiple preggo
76
Ix & Mx for PA?
ABCDE - assess and optimise signs of shock - gain access USS to determine placental location + exclude PP CTG for foetal distress If foetal distress of maternal compromise = emergency C section. If pain and bleeding cease without foetal distress then consider delivery to term.
77
Complications fo PA?
Maternal - Hypovolaemic shock - DIC - AKI - PPH Foetal - IUGR - prematurity - anaemia - coagulopathy
78
Interpretation of CTG?
DR C BrAVaDO ``` DR = define risk C = contractions Baseline rate Accelerations Variability Decelerations Overall impression (normal reassuring, non reassuring and abnormal) ```
79
Impression of a reassuring CTG?
Baseline rate = 110-160bpm Variability = 5-25 beats /min excl accel or decels Decelerations = None Accel = present
80
Definition of an acceleration on a CTG? | Why do they occur?
Inc in FHR > 15bpm and lasts >15 seconds | Often in response to movement or uterine activity
81
Prolonged loss of variability may indicate what on a CTG?
Hypoxia
82
Types of miscarriage and assoc findings?
Complete (Bleed + cease of pain + closed OS) + empty uterus Inevitable (Bleed + pain + open Os) + some POC visible but not lost Threatened (Bleed + pain + closed Os) Missed (Closed Os, ?bleed, ?pain, no FHR) Incomplete (Bleed + pain + open Os) + some POC already left
83
Ix for suspected miscarriage?
Vaginal examination Preggo test Blood test (Cross match and FBC if shocked) TA USS (foetal viability and ectopic) Septic abortion (BUFFALO, swabs, cross match, Rh)
84
Mx of threatened and complete miscarriage?
``` Complete = anti-D if > 12 wks. hCG to exclude ectopic. Re if Bleed > 2 wks Threatened = anti-D if > 12wks or heavy bleeding ```
85
Mx of incomplete or inevitable miscarriage?
Expectant management preferred with adv with TV US at 2 wks to check. Medical Surgical + Anti D > 12 wks or heavy bleed or surgical
86
Mx of missed miscarriage?
Expectant, medical surgical + anti D > 12 wks
87
Complications of surgical management of miscarriage?
infection, haemorrhage, IU/cervical damage, Retained products, adhesions
88
What is the generic medical management of miscarriage?
Prostaglandins (misoprostol) - inc uterine activity Antiprogesterone (mifepristone) = soften cervix Done at home or hospital. Adv re heavy bleeding and mod abdo pain 24 hr telephone adv and emergency available 90% successful if less than 9 wks gestation
89
Rx for suspected PE in pregnancy?
LMWH - enoxaparin BD
90
Preggo Pt present with SOB, pleural chest pain, some swollen and tender calves. Mx?
``` ABCDE - 15L o2 - ABG - IV access - CXR - ECG - V/Q mismatch - CTPA Hx Exam - hypotensive, dec AE, tachycardia, ```
91
Risk factors for VTE in preggo?
Pregnancy is a prothrombotic state therefore increases clot risk ``` Other factors - obesity - age >35 high parity - pre-eclampsia - C-section - Thrombophilia (15% of population will have this) ```
92
What percentage and where are DVTs most likely to present in preggo?
80% L sided due L common iliac more compressed by uterus as it passes under right common iliac A. 70% iliofemoral.
93
How long should you continue LMWH for after delivery? if prophylactic? or confirmed PE?
6 wks | 3 months - ?6 months
94
Considerations at onset of labour if pt has had PE during preggo?
Pt is likely to be on LMWH Needs to stop 24 hrs prior to planned delivery - DO not use regional anaesthesia until ?24hrs since last dose (inc risk of bleed/haematoma) - Restart heparin 3hr post op or > 4hr epidural - DO not remover epi catheter within 12 hrs of LMWH
95
Estimated wt < 10th centile = ?
SGA
96
Physiological factors that affect growth and birth weight of a foetus?
- maternal ht and wt - parity - ethnicity - gender of foetus
97
IUGR are at how many times inc risk of cerebral palsy compared to general pop?
4 times
98
Assoc features of IGUR in terms of complications?
``` Intrapartum foetal distress meconium aspiration EmLSCS NEC Hypoglycaemia and hypocalcaemia ```
99
Most common cause of IUGR?
Uteroplacental insufficiency
100
Effects of progesterone in preggo?>
Causes the sx assoc with preggo (constipation, reflux etc.) Physiological changes - Inc CO (inc in HR & SV) - Dec in BP (to reduce PVR to allow more blood to placenta) - Inc in RR due to dec lung capacity - Uterine quiescence (quiet state without contractions) - Immune deficient state (T cells deactivated to not reject foetus) - Inc risk of UTIs
101
Clinical diagnosis of pregnancy?
Amenorrhoea N+V Breast engorgement and enlargement
102
When is hCG detectable in the urine for a preggo test?
4 wks after LMP
103
How to monitor growth of foetus? examination and ix?
- Hx - Exam (SFH) - USS (liquor volume, HC, AC, FL)
104
What is head sparing?
Preferential flow of blood to the head with minimal blood to the abdomen therefore the head may appear to be growing well, but the AC is below its gentile.
105
What is included in a biophysical profile in an USS?
Foetal breathing movement, foetal movements, foetal tone and amniotic fluid volume
106
What does a uterine artery doppler show?
Whether there is any resistance in blood flow. can be measured form 23 wks. Any resistance suggests placental insufficiency FLOW from mother to placenta during systole AND Diastole. If reduced or reversed then consider delivery
107
List chorionicitys in order of complications rates
Dichorionic diamniotic lowest monochorionic diamniotic monochorionic monoamniotic
108
Is MCDA identical or non-identical? why?
identical = zygote splits
109
is DCDA identical or non-identical? why?
Both. 2/3 = non identical = two eggs are fertilised by 2 different sperm 1/3 = identical = 1 zygote splits
110
Timing of delivery of MCDA? DCDA? MCMA?
``` DCDA = 37/38 wks MCDA = 36/7 wks MCMA = 34/35 wks ```
111
Are vaginal deliveries allowed for multiple pregnancies?
Yes, along as T1 is cephalic.
112
What percentage of T2 will need a C-section following NVD of T1?
5%
113
Complications of DCDA?
Maternal = anaemia, increased tiredness, PET, DVT, GDM, preterm labour, Foetal = IUGR, Prematurity, inc risk of congenital malformations.
114
What are the extra complications of MCDA? HUH? WHAT ARE THEY? TELL ME!
All complications of DCDA are increased plus TTTS
115
What sign on USS would you see for DCDA? MCDA?
``` DCDA = lambda MCDA = T ```
116
What will you adv pt if multiple preggo?
- Explain inc risk of IUGR, preterm labour, PET etc. As high risk pregnancy will need to keep close eye on growth - serial growth scans (2/3/4wkly depending on chorionicity) - important to cont with vitamin supplements (iron and folate, Via D) - method of delivery (vaginal as along as T1 cephalic) - may need emergency LSCS - IOL by 37/38wks for DCDA and may be earlier if MCDA or MCMA - any questions, written leaflet, support, any problems then get in touch.
117
What increases the risk of twins?
- Previous hx of twins - FHx of twins - Increasing maternal age - IVF/induced ovulation
118
How to monitor SGA babies?
Serial growth scans 4 wkly Dopplers - uteroplacental insufficiency Liquor volume

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