obstetrics Flashcards

Question

Absolute contraindications to epidural in labour? 5 Relative contraindications? 2

Answer 1

ABSOLUTE - patient refusal - anti-coagulants - bleeding disorder - systemic infection - anaphylaxis to LA RELATIVE - massive haemorrhage - spinal surgery nb contractions in augmented labour (ie with oxytocin drip) tend to be more painful so these women more likely to need epidural

Answer 2

IMMEDIATE - failure - slightly increases chance of instrumental delivery (though not section!) - hypotension - LA toxicity - total spinal DELAYED - post-dural puncture headache - haematoma - epidural abscess - neurological damage (temp more common than permanent) nb epidurals do not: - cause backache (pregnancy does!) - increase risk of c-section - prolong labour nb if, following birth, woman's legs get heavier (instead of effect gradually wearing off) then suspect epidural haematoma and DO MRI (abscess takes a few days and norm have fever too)

Answer 3

EPIDURAL - high block - LA toxicity CONDITIONS OF PREGNANCY - aorto-cava compression - PE from amniotic fluid OR DVT - cardiomyopathy - anaemia (haemorrhage, iron-deficiency) MEDICAL CONDITIONS - asthma attack - anaphylaxis - myocardial infarction - pneumonia

Answer 4

Basically induce when risk of carrying on with pregnancy is higher than risk of delivering AND vaginal birth is seen as best option MOST COMMON = post-maturity (41-42 wks) MATERNAL REASONS - Diabetes (Gestational, type 1, type 2) - Obstetric Cholestasis - Maternal cardiac disease - Pregnancy Induced hypertension or pre-eclampsia - Poor obstetric history (ie previous stillbirth etc) - Maternal Choice (eg if parter is home from army etc) FOETAL REASONS - Prelabour rupture of membranes (PROM) - Intrauterine growth restriction (IUGR) - Reduced fetal movements (RFM) - Suspected fetal macrosomia, ie large baby (risk of shoulder dystocia, forceps delivery etc) - Small antepartum Haemorrage (APH) (if large or previa, section) - Intrauterine death (IUD) NB HAVE TO BE ABLE TO EXPLAIN THESE TO A WOMAN!

Answer 5

augmentation is when labour has already started but is not progressing fast enough - so add oxytocin drip

Answer 6

ABSOLUTE - acute foetal compromise - unstable lie (must be cephalic) - placenta previa - pelvic obstruction (eg fibroids) RELATIVE - previous LSCC (ie VBAC) - breech - prematurity - high parity (>4 parity) NB HAVE TO BE ABLE TO EXPLAIN THESE TO A WOMAN!

Answer 7

Membrane sweep ('stretch and sweep') May increase chances of spontaneous labour and avoid induction in some cases. Offered before formal IOL ``` Nulliparous = 40-41 weeks antenatal visit Multiparous = 41 weeks ``` Gloved finger passed between cervix and membranes on digital VE (separates chorionic membrane from decidua) Releases prostaglandins which may trigger labour.

Answer 8

Assesses cervix and descent of baby to determine likelihood of going into spontaneous labour given points (0-3) for each parameter, eg dilatation of >5cm gives score of 3 for dilatation 1) DILITATION of cervix (in cm) 2) LENGTH of cervix (in cm, shorter is better) 3) STATION of baby head relative to pelvis (-3 to +2, more positive is better) 4) CONSISTENCY of cervix (firm nose, medium chin, soft cheek) 5) POSITION of cervix (posterior, central, anterior - anterior is best) score each component 0-3 then add for total higher number is better (ie more likely to progress spontaneously) <5 is unlikely to progress spontaneously >9 will likely progress spontaneously use it after sections of induction to ascertain need for more levels etc

Answer 9

stage 1: CERVICAL RIPENING - Pessaries for nulliparous (Propess) for 24hrs - Gel for multiparous (Prostin) for 24hrs - then reassess with a VE and bishops score - Soften and shorten the cervix - Cause uterine tightening Stage 2: AMNIOTOMY - aka artificial rupture of membranes (ARM) - possible once cervix is fully effaced (length = 0) - performed using 'amniohook' at time of vaginal examination Stage 3: SYNTOCINON (cervical dilation) - IV synthetic oxytocin to stimulate contractions - dose is titrated up/down to produce 3-4 strong contractions every 10 mins - must have CTG monitoring NB HAVE TO BE ABLE TO EXPLAIN THESE TO A WOMAN!

Answer 10

CERVICAL RIPENING - can cause hyperstimulation and foetal distress - monitor intermittently with CTG AMNIOTOMY - risk of cord prolapse if presenting part is high CERVICAL DILITATION - risk of uterine hyper-stimulation - continuous CTG monitoring while on drip - titrate syntocinon up/down - give tocolytics (eg terbutaline) if hyperstimulation OTHER GENERAL RISKS - increased pain (more likely to need epidural) - foetal distress - uterine hypertonia with possible rupture (hence use w caution in VBAC) - very rapid delivery - operative delivery - amniotic fluid embolus - systemic effects NB HAVE TO BE ABLE TO EXPLAIN THESE TO A WOMAN!

Answer 11

- explain benefits and risks and likely outcomes if she still doesn't want one then: - offer daily scans - offer c-section

Answer 12

Discussion with mother: Women should be informed about induction of labour and the process involved Healthcare professionals should always explain: - The reason the induction is being offered - The risks and benefits of induction of labour in specific circumstances - That induction may not be successful and what the women’s options would be If a women chooses not to have an induction of labour, an alternative should be considered eg if woman with diabetes or post-rem is not induced, higher risk of stillbirth (+ higher risk of shoulder dystocia in DM)

Answer 13

LIE = the relationship between the long axis of the foetus and the mother = longitudinal, transverse or oblique PRESENTATION = The foetal part that enters the mothers pelvis first = cephalic or breech POSITION = the position of the foetal head as it exits the birth canal = occipito-anterior (OA), occipito-posterior (OP) or occipito-transverse - nb can only tell this by doing VE during labour IDEAL = longitudinal, cephalic and OA nb if lie is transverse then presentation is neither breech or cephalic nb 90% of non-OA end up OA by the end of labour as they rotate through the pelvis

Answer 14

- Prematurity - Fetal abnormalities - Multiple pregnancy - Primiparity - Uterine abnormalities (e.g fibroids, partial septate uterus) - Placenta praevia

Answer 15

during abdominal palpation in obstetric examination do abdo USS to confirm position and lie offer external cephalic version (ECV) ideally at 36-38 weeks gestation

Answer 16

- Uterine relaxants given prior to/ during procedure e.g. Terbutaline or Salbutamol - Anti-D given if rhesus positive Gentle pressure applied to maternal abdomen to turn the foetus Foetal heart monitored with CTG before and after procedure 50% success rate

Answer 17

- Cord prolapse - Difficulty in delivering head - Foetal hypoxia - Increased foetal mortality and morbidity

Answer 18

ABSOLUTE CI - Placenta praevia - Uterine malformations - Ruptured membranes - Abnormal CTG - Multiple pregnancy RELATIVE CI - Previous LSCS - Preeclampsia - Maternal cardiac disease - Active labour - Oligohydramnios - Foetal abnormality - Hyperextension of foetal head

Answer 19

Trying to prevent need for section (LSCS) or vaginal breech delivery (which have their own risks if doesn't work: - LSCS (almost always) - vaginal breech delivery (very rare) RISKS - foetal distress - cord entanglement - transient bradycardia

Answer 20

``` dichorionic diamniotic (DCDA) twins = each has their own separate placenta with its own separate inner membrane (amnion) and outer membrane (chorion) ``` ``` monochorionic diamniotic (MCDA) twins = share a single placenta with a single outer membrane and 2 inner membranes ``` ``` monochorionic monoamniotic (MCMA) twins = share both the inner and outer membranes ``` All non-identical twins are DCDA, and a third of identical twins are DCDA. The other two-thirds of identical twins are MCDA, and just 1 in 100 identical twins are MCMA.

Answer 21

Dichorionic Diamniotic: - --> Deliver at 37-38 weeks - If first twin cephalic, vaginal delivery recommended - If first twin breech = LSCS Monochorionic Diamniotic: Delivery at 36 weeks via LSCS Monochorionic Monoamniotic: Delivery at 34 weeks via LSCS.

Answer 22

- Continuous CTG monitoring - Foetal scalp electrode (FSE) for twin 1 once cervix sufficiently dilated - IV access Experienced staff and neonatologists on call.

Answer 23

- cervical dilation - descent of the head - position of head - frequency of contractions - strength of contractions - foetal HR - liquor colour - maternal obs (HR, BP, temp etc)

Answer 24

cervical dilatation of <2cm in 4 hrs (and/or slowing down in progress in multips)

Answer 25

POWER: - Strength of uterine contractions = In 1st stage labour, this is the only factor that can be changed PASSENGER: - Foetal position and size PASSAGE: - Parity and maternal pelvis TO INCREASE POWER: - Artificial rupture of membranes - Oxytocin – Syntocinon infusion If failure to progress in 1st stage of labour (and synt etc doesn't help) then LSCS is only option

Answer 26

1) Vacuum extraction aka. Ventouse ( nb cannot manually rotate baby into correct head position for birth) 2) Traction forceps 3) Rotational forceps

Answer 27

- Slow progress in 2nd stage of labour - Maternal exhaustion - To avoid raising ICP - To avoid raising BP - Presumed foetal compromise BASICALLY when need to deliver baby and mother is fully dilated! instrumental delivery can ONLY be performed in 2nd stage of labour (ie when fully dilated) - if in first stage then need LSCS

Answer 28

Explain that the forceps 'cradle' the babies head to help guide it out and/or rotate it so it has more space to get out - explain why need to do it - explain maternal and foetal complications - explain that is preferable to LSCS as baby is already far descended and risks with LSCS mother needs to EMPTY BLADDER before start NEED TO KNOW: - adequate contractions (add synt if need to) - membranes are ruptured (ARM if needed) - accurate knowledge of foetal postion (palpate and USS if needed) NEED adequate ANALGESIA before start = epidural, spinal or pudendal nerve block

Answer 29

MATERNAL - increased blood loss - post-partum pain - psychological distress - perineal trauma (3rd degree tears etc) - weakened pelvic floor nb always need an episotomy if have forceps delivery (to make space for the forceps) nb vontouse better for mother as don't need as much pain relief and less perineal trauma, but can't rotate baby so forceps used more commonly FOETAL (VENTOUSE) - cephalohaematoma - retinal haemorrhage FOETAL (FORCEPS) - facial bruising - facial nerve palsy

Answer 30

- change mother's postion (can help turn baby) - good hydration of mother - good pain relief (helps relax muscles) - start or increase oxytocin drip

Answer 31

Shoulder dystocia is when the baby’s head has been born but one of the shoulders becomes stuck behind the mother’s pubic bone, delaying the birth of the baby’s body (ie when the anterior shoulder impacted behind the pubic bone) occurs in 0.7% of births RISK FACTORS - diabetes (gestational or otherwise - induce/delivery early to reduce risk) - BMI >30 - previous shoulder dystocia before - long labour - induced labour - instrumental delivery Main risk to baby is brachial plexus injury (erbs palsy) - occurs in 10% of babies who have shoulder dystocia increased risks to mother - perineal tears - PPH

Answer 32

- discourage maternal pushing effort - call for help (is obstetric emergency) 1) MCROBERTS MANOUVERE - flex + externally rotate maternal hips to stretch the symphisis + open pelvic outlet 2) SUPRAPUBIC PRESSURE MORE INVASIVE OPTIONS: - episiotomy (won't relieve bony obstruction but will allow for internal vaginal manoeuvres - internal rotational manoeuvres - delivering posterior arm reduces diameter of oetal shoulders (risk of humeral #) - break clavicle Emergency LSCS if nothing else works

Answer 33

1) DESCRIBE PROCEDURE – what will be done, AND WHY it is being done 2) Any OTHER anticipated PROCEDURES – e.g. spinal anaesthesia, hysterectomy, blood TRANSFUSION, repair of damage to bowel, bladder or vessels. 3) INTENDED BENEFITS – to secure the safest and quickest route of delivery in the circumstances at time of decision - --> Because risks to mother and/or baby of an alternative mode of delivery outweigh those of a section 4) RISKS OF PROCEDURE (see other flashcard) 5) ANASTHETIC CONSENT: - Form of anaesthesia planned (spinal, epidural, GA) - Benefits - Risks - Discussion w anaesthetist before surgery

Answer 34

COMMON MATERNAL RISKS: - persistent wound + abdo discomfort - increased risk of section if VBAC attempted in future pregnancies - haemorrhage - infection COMMON FOETAL RISK: - scalp laceration (2-3%) SERIOUS MATERNAL RISKS: - bladder, bowel or ureteric injury - emergency hysterectomy - need for further surgery - VTE - admission to ICU - death (very rare) SERIOUS RISKS TO FUTURE PREGNANCIES, increased risk of: - uterine rupture - antepartum stillbirth - placenta previa and placenta accreta

Answer 35

PROM = premature rupture of membranes - waters break before labour starts but is AT TERM so just wait for labour or induce if not happened within 24hrs PPROM = preterm premature rupture of membranes - waters break BEFORE TERM, is trickier to manage - got to think about risks vs benefits of delivering so basically PROM is at term and PPROM is before term nb 'premature' can also be 'prelabour' in some definitions = same thing

Answer 36

- multiple pregnancy - prev history of preterm delivery - prev hx of late miscarriage (after 14 weeks) - previous cervical surgery (eg LLETZ for dysplasia)

Answer 37

CERVICAL WEAKNESS / INSUFFICIENCY, shortening in T2 - True cervical insufficiency: painless dilatation and shortening of the cervix in T2, resulting in pregnancy loss or delivery. Caused by cervical anomaly, trauma, or unknown. Diagnosis made in retrospect – uterine activity ruled out. Most women with insufficiency have normal anatomy. ASCENDING INFECTION - any cause that triggers an inflammatory process i.e. prostaglandins.

Answer 38

1) cervical length measurement (norm via TV USS?**) 2) foetal fibronectin test - protein involved in connection between placenta and uterus. Positive finding indicates preparation for labour. if evidence of cervical shortening or positive fibronectin then offer treatment Offered if: - Hx of preterm delivery - Hx late miscarriage - Hx cervical treatment/ surgery

Answer 39

Cervical Stitch - Can be placed pre-conception in those with poor history. Progesterone treatment (pessaries from wk16-24 to wk 34)

Answer 40

24-29wks preterm labour = magnesium sulphate (prevent cerebral palsy) - may also give at later gestations 34wks or less in preterm labour = IM steroids (betamethasone) 12 hours apart (use tocolytics until 24hrs after last dose) if membranes ruptured = prophylactic erythromycin for up to 10 days or until labour starts (whichever is sooner) - if at term (over 37wks) then induce 24hrs after waters break if still no labour if want to delay labour = tocolytics only use: 1) to allow steroids to work (take until 24hrs after 2nd steroid dose) 2) to allow transfer to unit with a neonatal cot nb tocolytics are useless if membranes have broken or any bleeding or signs of infection

Answer 41

- pre-term delivery: follows within 48hrs in >50% of cases - infection (chorioamnionitis, also can have of foetus, placenta or cord) - prolapse of umbilical cord nb infection is sometimes the cause of PPROM

Answer 42

vaginal loss - gush of clear fluid, followed by trickle or dampness STERILE speculum - pool of fluid visible in posterior fornix Abdo exam - check lie and presentation (can do digital exam to check for cord prolapse if presentation not cephalic - but do with caution as high risk of introducing infection) ALSO DO MATERNAL OBS AND CTG

Answer 43

- Fever/ malaise - Tachycardia (foetal and maternal) - Abdominal pain +/- contractions - Uterine tenderness - Purulent/ offensive vaginal discharge/ liquor

Answer 44

Swabs (do during sterile speculum) - HVS - VVS - MSU - CTG (plus obvs maternal obs) bloods: - FBC - CRP - Group + save (only last 72hrs in obstetrics) USS - for foetal presentation, weight and liquor volume (will go down once waters broken)

Answer 45

CHORIOAMNIONITIS - Steroids (betamethasone 12mg IM) - broad spectrum abx (benpen) - deliver baby NO CHORIOAMNIONITIS - Steroids = betamethasone 12mg IM, 2x 12 hrs apart - Prophylactic Antibiotics = erythromycin QDS for 10 days - liaise with neonatal team - Outpatient monitoring until 34 weeks delivery

Answer 46

PV bleeding after 24wks gestation (before 24wks = threatened miscarriage) minor bleed = <50mls major bleeds = >50mls UTERINE CAUSES - placental abruption - placental previa - vasa previa - marginal bleed CERVICAL CAUSES - "show" = loss of mucus plug from cervix - cervical cancer - cervical polyp - ectropian VAGINAL CAUSES - trauma - infection DON'T DO VAGINAL EXAMINATION (until after a scan) - AS MAY BE PREVIA!!

Answer 47

Premature separation of a normally situated placenta from the uterine wall – resulting in maternal haemorrhage into the intervening space RISK FACTORS - Previous abruption - Hypertensive disorders - Thrombophilias - Smoking - Cocaine - Abdo trauma

Answer 48

SYMPTOMS - Vaginal bleeding (not always present! - blood usually dark red) - Abdominal pain - Uterine contractions SIGNS - uterine tenderness +++ - Tense, ‘woody’ abdomen - Shock (disproportionate to visible blood loss) - Normal lie and presentation - Foetal heart absent or distressed on CTG BEWARE of pre-eclampsia, DIC, anuria

Answer 49

Placenta is wholly or partially implanted in the lower segment of the uterus (nb doesn't necessarily have to be covering os to be called previa) GRADING ``` I = placenta reaches lower segment but not internal os II = placenta reaches internal os but doesn't cover it III = placenta covers internal os before dilation, but not when dilated IV = placenta completely covers the internal os ``` RISK FACTORS - multiparity - previous LSCS - multiple pregnancy

Answer 50

SYMPTOMS painless, bright red vaginal bleeding - small bleeds before large SIGNS - shock (proportionate to visible blood loss) - non-tender uterus - lie and presentation may be abnormal - foetal heart normally normal

Answer 51

- 5% at 20wk scan - 0.5% at delivery If see at 20wks, rescan at 34wks no need to limit activity or intercourse, unless bleeding If still present at 34 wks and grade I or II, scan every 2wks If abnormal lie (or grade III or IV) at 37 wks then LSCS vaginal delivery for grade I

Answer 52

- CROSS MATCH - FBC - U+E - clotting - admit to hospital - treat shock - deliver by LSCS betwen 37-38wks

Answer 53

BLOOD LOSS - previa = bright red, small then large - abruption = may be absent, dark red if present SHOCK - previa = proportionate to visible blood loss - abruption = more severe in proportion to visible blood loss UTERUS - previa = non-tender - abruption = tender,. hard, woody PRESENTATION / LIE - previa = may be abnormal - abruption = normal CTG FINDINGS - previa = normally normal - abruption = absent or distressed FHR

Answer 54

A-E approach - get IV access (grey in both) - call for help - left lateral position bloods - crossmatch 4 units - FBC - clotting replace fluid / clotting factors (also blood if need) put catheter in (and monitor fluid balance) anti-D to all rh neg women do USS to assess position of placenta if stable: - monitor baby with CTG - consider elective LSCS at 37wks if unstable: - emergency section immediately (mother's life takes priority)

Answer 55

sometimes no signs! - tachycardia - hypotension - reduced O2 sats - pleuritic chest pain - SOB - collapse - reduced air entry nb women of all gestation and post-partum are at higher risk! - though most common in 3rd trimester

Answer 56

A-E approach facial oxygen - 15L nrbm - get ABG - ECG - CXR (exclude other causes) - V/Q scan (spiral CT if can't) if clinically suspicious anti-coagulate while awaiting results nb don't do d-dimer in pregnancy (as always raised)

Answer 57

LMWH (warfarin CI in pregnancy) use for remainder of pregnancy and till at-least 6wks post-partum high-risk in future pregnancies - consider prophylactic dose

Answer 58

X-RAYS - CXR is fine in all trimesters (protect abdo with shield) - Abdo / pelvic xray is fine in 2nd and 3rd trimester CT scans much higher risk (but still do if benefit outweighs risk)

Answer 59

1st DEGREE - injury to skin only 2nd DEGREE - injury to perineum, involving perineal muscle - includes episiotomy 3rd DEGREE - injury to perineum involving external anal sphincter (EAS) - 3a = <50% of EAS torn - 3b = >50% of EAS torn - 3c = internal anal sphincter torn 4th DEGREE - tear through anal mucosa (ie through perineum, EAS, IAS and rectal mucosa) 1% of vaginal deliveries result in 3rd or 4th degree tears

Answer 60

- nulliparity - birthweight >4kg - shoulder dystocia - persistent occiput-posterior position - 2nd stage > 1 hour - induction of labour - epidural - forceps delivery - midline episiotomy

Answer 61

- suture asap (difficult ones repair in theatre) - rectal exam before and after (to ensure no injury to anal sphincter) - adequate analgesia (spinal, epidural, caudal block) - broad spectrum abx - stool softener - review 6wks afterwards - physio input warn risk of faecal, fluid and flatal incontinence (also dyspareunia) - 60-80% will have good result and be symptom-free at 12 months If symptom-free by next pregnancy, risk of recurrence is 10% if symptomatic at time of next pregnancy, risk is higher, offer elective LSCS nb suturing is done in lithotomy position (ie legs in stirrups)

Answer 62

woman can do perineal massage antenatally - warm compress on perineum as head is crowning - episiotomy if looks like tear may occur

Answer 63

blood loss of 500ml or more from genital tract primary = within 24hrs of delivery secondary = 24hrs of delivery to 6wks post-partum

Answer 64

The 4 T's TONE (most common) = uterine atony = failure to contract fully after delivery TISSUE - large placenta - abnormal placental site (eg pervia or accretia) - retained placenta TRAUMA - genital tract trauma (pernieal tears, episiotomy, lacerations to cervix) - uterine rupture or inversion THROMBIN - coagulation disorders (see other flashcard)

Answer 65

- over distended uterus (eg multiparity) - foetal macrosomia - placental abruption - prolonged labour (2nd stage failure) - failure to actively manage 3rd stage - general anaesthetic - retained tissue - infection - previous PPH

Answer 66

- severe pre-eclampsia (PET) - placental abruption - sepsis - autoimmune disease - liver disease - inherited/acquired coagulation disorders

Answer 67

ANTENATAL - Previous PPH - Previous retained placenta - Maternal Hb <8.5 at onset of labour - High BMI - Para 4+ - Maternal age >35 - Antepartum haemorrhage - Placenta praevia - Over-distension of the uterus - Uterine abnormalities INTRAPARTUM - Induction of labour - Use of oxytocin - Prolonged labour - Precipitate labour (ie unusually rapid) - Vaginal operative delivery - LSCS

Answer 68

investigate and treat any maternal anaemia | also look for position of placenta

Answer 69

A-E approach - IV access (grey) - bimanual compression to stop bleeding - position patient flat - warmed crystalloid infusion - warm patient - blood transfusion (if required) - urgent group + save OR crossmatch - FBC - coagulation also do repeat maternal obs every 15 mins UTERINE ATONY - ergometrine IV bolus - syntocinon infusion - consider prostaglandins (misoprostol PR) if no response - may need examination under anaesthesia +/- laparotomy nb ergometrine often causes N+V and is contraindicated in HTN RETAINED PLACENTA - manual removal under GA or spinal (depending on condition) GENITAL TRACT TRAUMA - repair surgically ALL PPH are at increased risk of VTE - so should be given prophylactic LMWH

Answer 70

when uterus literally inverts on itself - presents as vaso-vagal shock (pale, clammy, hypotensive & bradycardic) and a mass at the introitus - significant haemorrhage, clotting abnormalities and renal dysfunction can occur if not corrected promptly - shock corrects itself when uterus is replaced - O’Sullivan’s method - reduce inversion by hydrostatic technique associated with grand multips and incorrect management of the third stage nb this is RARE - just be aware it exists!

Answer 71

commonest cause = retained products +/- endometritis check for evidence of infection - ie bloods, swabs, purulent discharge, other sites of infection, maternal obs TV USS to look for retained products management - at least 24hr antibiotics - evacuation of retained products

Answer 72

Eclampsia: one or more generalised convulsions or coma in the setting of pre-eclampsia and absence of other neurologic conditions often get epigastric pain alongside the seizures 40% of seizures occur post-partum

Answer 73

A-E approach - IV magnesium suplhate or diazepam to stop fits - prevent further fits with IV magnesium sulphate infusion (continue until 24hrs after last seizure) antihypertensives (labetalol 1st line) deliver baby (regardless of gestation) MONITOR fluid balance (at risk of fluid overload - don't give fluid if hypertensive) nb magnesium sulphate can cause resp depression (reverse with calcium gluconate) - can also affect reflexes, urine output and o2 sats

Answer 74

1st line: labetalol 2nd line: nifedipine 3rd line: hydralazine (rarely used)

Answer 75

Maternal = strep A Neonatal = strep B "A comes before B, the mother cam before the child"

Answer 76

aetiology obscure but 70% maternal mortality signs + symptoms include: - collapse - DIC - unaccountable bleeding diagnosis of exclusion or at post-mortem MANAGEMENT - conservative - early transfer to ITU (as likely to need renal + inotrope support) - correct clotting

Answer 77

1 in 200 women in labour after one previous c-section (risk goes up if multiple sections) risk in multiparous women on oxytocin infusion risk very low in primigravid

Answer 78

EARLY SIGNS - raised maternal HR - localised scar pain (breaks through epidural) - abnormal CTG / foetal distress LATER SIGNS - fresh vaginal bleeding - haematuria - constant severe abdo pain (breaks through epidural) - shock

Answer 79

A-E approach - IV access and basic resus (incl oxygen) Immediate laparotomy to salvage baby - repair damage or hysterectomy

Answer 80

- Haemolysis - Elevated Liver enzymes - Low Platelet it is a complication of severe pre-eclampsia (though can rarely occur with no prior history of PET) - nausea + vomiting - RUQ pain - lethargy (nb also symptoms of pre-eclampsia) - FBC (haemolysis + low platelets) - LFT (elevated liver enzymes - esp ALT + GGT - ALP less useful) - clotting - group + save OR crossmatch deliver the baby!!!

Answer 81

6 weeks post-delivery UTERUS SIZE - Immediately: uterus shrinks down to level of umbilicus - 2 weeks postpartum: no longer palpable above symphysis - 6 weeks: uterus returned to non-pregnant size Lochia: decidual sloughing after delivery, should gradually get less (if increases or more purulent/blood then likely infection) sex safe as soon as ready, norm after 2-3 weeks return of menstruation within 6-8wks

Answer 82

Colostrum = thick yellow fluid produced from ~20weeks gestation - High level of secretory IgA + rich in protein - Important part in gut maturation and immunity in infant - Produced in small quantities following birth of baby

Answer 83

Produced rapidly post-delivery – feed within first 2 hrs increases volume - Increasing to around 500ml for 5 days postpartum More energy efficient than formula milk Cabergoline is given to supress lactation (dopamine receptor agonist)

Answer 84

``` ADVANTAGES FOR BABY: lower incidence of: - allergies - GI infections - otitis media - resp infections ``` ADVANTAGES FOR MOTHER: - reduce risk of breast ca, ovarian ca + osteoporosis - bonding experience - lactational amenorrhoea - helps uterine involution

Answer 85

approx 8 times a day - ‘Demand’ feeding encouraged: results in less weight loss in immediate postpartum period and increased duration of feeding. Reduced risk of hyperbilirubinemia and prevents breast engorgement Recommend exclusive breast feeding for 4-6 months decreases milk production: - COCP - smoking women with Sheehan syndrome (pituitary gland damaged during childbirth) do not lactate

Answer 86

- HIV (possible if undetectable viral load but still discouraged!) - varicella (also some meds - see other flashcards)

Answer 87

AVOID - chloramphenicol - ciprofloxacin - erythromycin - tetracyclines - sulphonamides PERMITTED - cephalosporins - penicillin - clarithromycin - trimethoprim

Answer 88

AVOID - amiodarone - ACE inhibitors - aspirin PERMITTED - beta-blockers (labetalol) - digoxin - hydralazine - warfarin - heparin

Answer 89

AVOID - lithium - benzodiazepines - ??? fluoxetine (*check) PERMITTED - carbamazepine - sodium valproate - SSRIs - tricyclic antidepressants

Answer 90

- Carbimazole = unsafe - Cytotoxic drugs = unsafe - glucocorticoids = safe - Iodines = unsafe - Levothyroxine = safe - Methotrexate = unsafe - NSAIDs = safe - Paracetamol = safe - Salbutamol = safe - Sulphonylureas = unsafe - Theophyllines = safe

Answer 91

May occur 2-4 days postpartum in women who are not breast-feeding, or at any time if breast-feeding is interrupted MANAGEMENT - tight bra - ice packs - analgesia

Answer 92

regional infection of breast parenchyma - norm staph aureus nb more common in primips focal unilateral breast erythema, oedema, tenderness overcome ductal obstruction by continuing to breastfeed or pump - analgesia also Abx indications: - systemically unwell (fever, chills) - nipple fissure present - symptoms don't improve after 12-24hrs of effective milk removal - culture indicates infection fluoxetine (10-14 days) breast abscess - palpable lump - needs incision + drainage (and abx) nb mastitis occurs in 10% of breastfeeding women

Answer 93

immediate mother - maternal obs - uterine fundus palpated - vaginal bleeding recorded immediate baby - apgar score - given vit K injection hours and days for mother - early ambulation (+ hydration) - adequate pain management 6 week check for both do babies get a TORCH screen too?? ***

Answer 94

need contraception from 21 days (ie 3wks) after delivery 2 in 100 will get pregnant in a year using lactational amenorrhoea - ONLY effective if exclusively breastfeeding (ie not mixed) discussed at 6 week check (if not before as well)

Answer 95

IMMEDIATELY - condoms - any progesterone only (POP, implant, injection) FROM 21 DAYS - emergency contraceptive pill (don't need before this!) 3-6 WEEKS (depending on breastfeeding + VTE risk factors) - combined (pill, patch, ring) ``` 4 WEEKS (or within 48hrs) - IUD/IUS ``` 6 WEEKS - Diaphragm (check it fits first!)

Answer 96

mild transient depression, occurs in >50% of women begins around day 3 post-birth, resolves within 10 days (so by 2 weeks in total from birth) - tearfullness - irritability - anxiety - poor sleep provide support and reassurance

Answer 97

10-15% get postnatal depression symptoms from 2 months, resolve slowly over 6-12 months screened at: - antenatal appointments - 4-6wks check - 3-4 months post-birth risk factors - previous postpartum depression (70%) - history of depression (30%)

Answer 98

``` general symptoms of depression PLUS: - fears about baby's health - feelings of maternal deficiencies - marital tensions (incl loss of libido) ``` Edinburgh Postnatal Depression Scale

Answer 99

CBT (and self help) SSRIs - fluoxetine should be avoided if breastfeeding as long half life (others are safe)

Answer 100

a range of psychotic conditions presenting in immediate postnatal period presents within 2-3 weeks of birth 1 in 500 deliveries suicide risk = 5% infanticide risk = 4%

Answer 101

Personal hx of mental illness - Bipolar Affective Disorder - Previous puerperal psychosis Family Hx of mental illness - 1st degree relative with hx of BAD - 1st degree relative with hx puerperal psychosis - young age - primiparity - traumatic birth or pregnancy

Answer 102

- hallucinations - delusions - mania - low mood - loss of inhibitions - feeling suspicious or fearful - restlessness - feeling very confused - behaving in a way that's out of character

Answer 103

IF HIGH RISK - refer to specialist perinatal mental health service in antenatal period - can use prophylactic medication IMMEDIATE - risk assessment (harm to self + others, incl baby) - urgent psychiatric assessment + treatment - admit to hospital (ideally specialist mother + baby unit - MBU) TREATMENT OPTIONS - antidepressant or antipsychotic medication - mood stabilisers - ECT (rare) most patient make a full recovery - although high rate of recurrence in future pregnancies

Answer 104

ASK ABOUT - urine normal - bowels normal - eating and drinking? - mobilising well? - enough analgesia? DIRECTLY OBSERVE - lochia - involution (uterus shrinking) - wounds (section scars or perineum) - signs of VTE - neonatal feeding + care FORMALLY ASSESS - VTE risk - mental health risk assessment - signs of anaemia - check Hb give anti-D to women (if they're negative and baby positive)

Answer 105

MATERNAL FACTORS - Age >40 (at EDD) - Age <16 (at booking) - BMI >30 at booking - grand multiparity (G6) - IVF pregnancy - Tocophobia (pathological fear of childbirth - late booking PREV OBS Hx - recurrent miscarriage - molar pregnancy - stillbirth / neonatal death / T2 loss - preterm delivery (<37wks) - large for gestational age (LGA >90th centile) - small for gestational age (SGA <10th centile) - congenital abnormality - pre-eclampsia - gestational diabetes - puerperal psychosis - red cell antibodies (ie rh -ve) - prev traumatic delivery - shoulder dystocia - 3rd/4th degree tear - LSCS (or other uterine scarring) - significant antepartum or post-partum haemorrhage - retained placenta with PPH - prev placenta accretia

Answer 106

PAST GYNAE Hx - pelvic fracture - pelvic mass - uterine abnormalities - endometrial resection - hx of subfertility - cone biopsy or >1 LLETZ - Female genital mutilation PAST MED HX - Psychiatric disorder (prev admission, suicide attempt or meds) - neurological disorder (incl epilepsy) - Cardiac disease / murmur - hypertension - haematological disorder (incl prev VTE) - cystic fibrosis - severe asthma (or other resp prob) - GI disease - endocrine disease (incl DM) - renal disease

Answer 107

FHx - 1st deg relative pre-eclampsia - 1st deg relative gestational DM - 1st degree relative VTE <50yo - foetus at risk of inherited disease / abnormality SHx - mother smoking during pregnancy - mother taking recreational drugs during preg - mother drinking excessive alcohol during pregnancy

Answer 108

MATERNAL CONDITIONS - hypertension / proteinuria / pre-eclampsia - gestational DM MATERNAL INFECTIONS - newly diagnosed STI - 2 or more UTIs - confirmed exposure to Zika virus MATERNAL SYMPTOMS - PV bleeding after 1st trimester - persistent haematuria BLOOD RESULTS - low Hb not responding to treatment - deranged LFTs (HELLP or obs chole) PLACENTA - abnormal umbilical artery doppler - placenta previa FOETUS - multiple pregnancy - RFM (>1 episode) - abnormal foetal growth / SGA - abnormal amniotic fluid volume (high or low) - foetal abnormality - incorrect presentation / orientation at 36 wks

Answer 109

basically if have any risk factor - either at booking or discovered later in pregnancy then see consultant! (nb if consultant-led care, still see community midwifes, just have ANC appts as well)

Answer 110

direct = VTE Indirect = cardiac

Answer 111

8-10 weeks with midwife (takes about an hour) - obstetric hx - medical hx (incl LMP) (basically fill in a massive form covering all potential risks to see if woman high or low risk) - BP (baseline for comparison) - urineanalysis (protein, blood, infection) - BMI bloods - FBC - Group + save (rh status) - blood infection screen (can opt out) - haemoglobinopathies (SSA, thalassaemia) offer / discuss antenatal screening: - combined screening - chlamydia test (if <25) meds to take - flu vaccine - folic acid (400mg for first 3 months, 5g if risk factors like obesity, DM, epilepsy) - vit D FOODS TO AVOID - soft cheese (camembert, brie, stilton) AND pate + contact w live lambs (listeria) - cat faeces, gardening (toxoplasmosis) - raw or partially cooked eggs and meat, esp poultry (salmonella) - liver (vit A) nb nuts, eggs, salad + honey are fine OTHER LIFESTYLE - stop smoking (incl education re stillbirths) - stop alcohol - be aware of carbon monoxide risk (test CO levels!)

Answer 112

BMI >30 - OGTT at 26 wks - growth scans at 30 + 36 wks BMI > 40 - same as above PLUS an OGTT at 16wks

Answer 113

screens for: - downs - edwards - patau between 10-14 wks - at same time as dating scan - blood test in addition to scan - nuchal translucency (high is bad, want <3.5mm) - PAPP-A (low is bad) - HCG (High is bad) ^ these are taken together with maternal age! If risk is >1 in 150 then result is 'high risk' if high risk, woman offered chorionic villus sampling or amniocentesis (1 in 100 risk of miscarriage) - CVS 11-14wks - amniocentesis wk 15 ^these tests will be able to say if have or not but not to what severity If too late (or can't obtain nuchal translucency) then can have quadruple blood testing between 14-20 wks - only screens for downs - not as accurate as combined - measures bHCG, inhibin-A, AFP, estriol nb can have NIPT (non-invasive prenatal testing) IONA tests in private sector - get foetal DNA from mothers blood

Answer 114

- HIV - Hep B - syphilis nb these are all opt-out

Answer 115

1) what do they know about test already? 2) what conditions is it screening for? 3) can't tell you whether they do or don't have conditions, just gives a chance as a number, if high risk, can do other test to confirm 4) think about what you are going to do with the results? would you get further tests? would you terminate? whenever discussing downs etc - always talk about the 'chance' or 'likelihood' of foetus having it, not 'risk'

Answer 116

11+2-14+1 weeks crown rump length (CRL) - approximate gestational age in weeks (get EDD from this) - presence of gestational sac - yolk sac and embryo - foetal cardiac activity - single or multiple foetus? - evaluate uterus + adnexal structures part of combined screening - measure nuchal translucency (want <3.5mm)

Answer 117

18 - 20+6 weeks ANATOMY SURVEY - face (excl cleft palate) - brain - spine - limbs - heart (incl activity) - stomach bubble - umbilical cord insertion - kidneys - bladder - gentalia OTHER - assess growth / age - amniotic fluid volume - umbilical cord + number of vessels - placental location - cervical length - evaluate uterus + adnexa also exclude multiple pregnancies again

Answer 118

WHO NEEDS - any risk / concerns around foetal growth (eg DM, small/large on SFH measurements, prev small/large baby, smoker etc) - >1 episode of RFM (1st episode do CTG) 1) ESTIMATED FOETAL WEIGHT (EFW) - combination of: = head circum (HC) = abdo circum (AC) = femur length (FL) 2) LIQUOR VOLUME - measure deepest pool, if this is high or low then measure all 3) DOPPLER STUDIES - foetal heart beat - uterine artery pulsitility index, indicator of resistance (PI or UAPI - want low) - umbilical artery end-diastolic flow (EDF - want positive) - middle cerebral artery (MCA - may be proportionally higher if foetus compensating) 4) FOETAL MOVEMENTS - see if move, turn mum on side and back to try and stimulate 5) PRESENTATION AND LIE - also placental position if low-lying at 20wks

Answer 119

FOR ALL - 28wks gestation (?at 34wks aswell) - following birth (but only if baby is rh positive) ALSO GIVE IF: - any TOP (medical or surgical) - any miscarriage over 12wks - any surgical management of miscarriage - any surgical management of ectopic - antepartum haemorrhage (bleeding >24wks) - external cephalic version (ECV) - amniocentesis / chorionic villus sampling - foetal blood sampling (FBS) - abdominal trauma (during preg) nb these are all for rh negative women only (never need to give anti-D if mother rh positive)

Answer 120

take cord blood for: - FBC - blood group - coombs test if baby is rh positive, give mother another dose of anti-D

Answer 121

1 in 4 women experience domestic abuse / violence in lifetime - 30% of this begins in pregnancy existing abuse may also get worse during pregnancy or after birth increases risk of: - miscarriage - infection - premature birth - injury or IUD

Answer 122

20-30% of smokers continue to smoke during pregnancy - very difficult group to teach, cultural beliefs that labour will be easier if it's a smaller baby etc increases risk of: - miscarriage - stillbirth / IUD - premature birth - low birth weight - perinatal mortality also: - sub-fertility - menopause 3-5 years earlier than otherwise

Answer 123

FOETAL ALCOHOL SYNDROME - facial abnormalities (short palpebral fissure, hypoplastic upper lip, smooth/absent filtrum) - microcephaly - learning difficulties - growth retardation - cardiac malformations May show signs of withdrawal at birth: - irritable - hypotonic - tremors

Answer 124

FOETUS - IUGR - cerebral infarction - placental abruption - congenital abnormalities (dt cocaine-induced vasospasm during preg) MOTHER - Uterine rupture - HTN - seizures - death

Answer 125

1) NAUSEA + VOMITING - 'morning sickness' - mainly in 1st trimester, norm resolves by 16-20wks - caused by bHCG levels MANAGEMENT = increase fluids = smaller meals = antiemetics (metoclopramide) ``` REFLUX - throughout pregnancy (esp T3) - affects 70% - caused by progesterone -> relaxation of oesophageal sphincter (plus incressed abdo pressure) MANAGEMENT = use extra pillows (worse if supine) = avoid spicy foods = antacids = ranitidine (if bad) ``` ``` CONSTIPATION - caused by progesterone -> reduces smooth muscle tone - often made worse by iron supplements - very common, can improve with gestation MANAGEMENT = increase fibre = drink more water = fibre supplements = stool softeners (ispaghula husk) = osmotic laxatives (lactulose) ``` ``` HAEMORRHOIDS - mainly in T3 - dt constipation + increased abdo pressure MANAGEMENT = avoid constipation = ice packs = digital reduction = suppositries = topical haemorrhoid preparations licensed in pregnancy (eg corticosteroids, local anaesthetic etc) = surgical removal if thrombosed ```

Answer 126

1) Increased urgency (throughout) - avoid caffeine + late-night fluids 2) stress incontinence (esp in T3) - may need pads 3) UTIs nb creatinine and urea are low in pregnancy due to increased glomerular filtration rate

Answer 127

all women get dipstick at booking TREAT ASYMPTOMATIC BACTERURIA! If symptomatic, ALWAYS take cultures (ie MSU) Nitrofurantoin = 1st + 2nd trimester only - neonatal haemolysis if in T3 Trimethoprim = 3rd trimester only - teratogenic in T1 + 2 2ND LINE - cephalosporins and penicillins are safe (but avoid co-amoxiclav!!)

Answer 128

pre-eclampsia - can present with epigastric pain though MUCH more likely to just be reflux do BP and dip urine for protein

Answer 129

need to exclude ruptured membranes!! - watery, profuse discharge candida is very common - treat with clotrimazole pessary (NOT oral anti-fungals!) Exclude STIs too!! basically if woman presents with change in discharge in pregnancy, do a speculum to look for ROM and swab for candida and other infections, incl STIs

Answer 130

``` SYMPHISIS PUBIS DYSFUNCTION (SPD) - pelvic pain in pubic + sacroilliac joints MANAGEMENT - physio - care with leg abduction - corsets - analgesia ``` ``` BACKACHE +/- SCIATICA - almost universal - caused by altered posture, pressure on sciatic nerves MANAGEMENT - physio - massage - postural advice - corset ``` ``` CARPAL TUNNEL SYNDROME - caused by oedema compressing median nerve - usually resolves after pregnancy MANAGEMENT - splints - positional advice while sleeping ```

Answer 131

common, normally self limiting - can use emollients and refer to derm if bad Exclude: - obstetric cholestasis - infectious causes (eg varicella) OBS CHOLE - check sclera for jaundice - do LFTs (this is 1% of pregnancies!!) INFECTIOUS CAUSES - inspect rash - ask about any contact with other people with rashes

Answer 132

Where excessive nausea and vomiting in early pregnancy (NVP) is so severe as to cause severe dehydration, weight loss, or electrolyte disturbance About 1 in 100 - 1 in 700 pregnancies most common 8-12wks (though can go up to 20wks) RISK FACTORS / ASSOCIATIONS: - nulliparity - IVF or assisted reproduction - Trophoblastic disease (eg molar) - multpile pregnancies - obesity - hyperthyroidism

Answer 133

SYMPTOMS - nausea + vomiting - epigastric pain - excessive salivation - reduced urine output SIGNS - dehydration - epigastric tenderness - ketonuria

Answer 134

urine dipstick - to look for ketones (also exclude infection) - FBC - U+E - LFT - TFT (rule out thyroid probs) TV USS - to exclude molar pregnancy

Answer 135

- encourage oral fluid intake - antiemetics (eg cyclizine, metoclopramide) WHEN TO ADMIT 1) Continued N+V, unable to keep down oral fluids + oral antiemetics 2) ketonuria despite oral antiemetics 3) weight loss >5% body mass 4) co-existing condition (eg DM) which may be affected by continued N+V MANAGEMENT IN HOSP - IV fluids - IV antiemetics = NG feeding = thiamine to prevent deficiencies (also correct other electrolytes) = corticosteroids if really severe

Answer 136

MOTHER - Wernicke's encephalopathy (prevent with thiamine) - mallory-weiss tear - acute tubular necrosis FOETUS - growth restriction - pre-term birth

Answer 137

LOW BIRTH WEIGHT = < 2.5kg, regardless of gestational age SMALL FOR GESTATIONAL AGE (SGA) = weight of foetus or newborn is <10th centile for gestational age INTRA-UTERINE GROWTH RESTRICTION (IUGR) = foetus that has failed to achieve its growth potential due to genetic or environmental factors AGA = 10th to 90th centile for gestational age (ie normal FOETAL MACROSOMIA = estimated weight (not birth weight) >4.5kg LARGE FOR GESTATIONAL AGE = > 90th centile (incidence is 5%)

Answer 138

Symmetric: foetus is proportionally small, suggesting long term compromise Asymmetric: foetal head is proportionally larger than body – short term compromise with sparing of the brain.

Answer 139

FOETAL GENETIUC FACTORS (5-15%) - Chromosomal anomalies e.g. trisomy’s and sex chromosome abnormalities - Single gene defects e.g. dwarfism, phenylketonuria FOETAL STRUCTURAL ABNORMALITIES - Cardiovascular anomalies - Bilateral renal agenesis MULTIPLE PREGNANCY - Risk of IUGR increases with foetal number - Worse in MCDA + MCMA (twin-twin transfusion syndrome) UTEROPLACENTAL INSUFFICIENCY (25-30%) - Chronic hypertension, pre-eclampsia - Antiphospholipid antibody syndrome - Chronic placental abruption - Velamentous (ie abnormal) insertion of umbilical cord. DRUG / TOXIIN EXPOSURE - Illicit drugs e.g. cocaine - Heavy cigarette smoking, esp. in older mothers MATERNAL MALNUTRITION gestational malnutrition superimposed on poor pregnancy nutritional status MATERNAL MEDICAL CONDITIONS - Poorly controlled hyperthyroidism - Haemoglobinopathies - Chronic pulmonary disease - Cyanotic heart disease - Anaemia - Diabetes (though more commonly causes big baby) ``` MATERNAL INFECTION (5-10%) - Malaria (single biggest cause of IUGR worldwide) - Rubella - Cytomegalovirus - Varicella ```

Answer 140

- multiple pregnancy - previous IUGR (recurrence 20%) - pre-eclampsia (40% have IUGR) - maternal smoking - other maternal medical conditions (ie high risk pregnancies)

Answer 141

based on estimates foetal weight for gestation other evidence of foetal compromise - oligohydramnious - abnormal dopplers (ie diagnose on scan,. but can also get scan if SFH are not increasing like they should)

Answer 142

- Perinatal mortality: commonest cause of stillbirth (50%) - Preterm birth - Birth asphyxia - Neonatal hypoglycaemia - Neonatal polycythaemia due to chronic hypoxia

Answer 143

determine aetiology - USS for anomalies - check karyotype - exclude infection - regular foetal scans (twice weekly if need) - repeat CTG consider delivery after 34wks if deterioration or once foetal lung maturation is documented (ie 24hrs after 2nd steroid dose) 50-80% IUGR babies will develop foetal distress in labour so may try for vaginal but many end up having LSCS Send placenta for pathology to look for evidence of vasculopathy

Answer 144

MOST COMMON: 1) Maternal diabetes (35-40%) 2) Post-term pregnancy, ie after 42wks (10-20%) 3) Maternal obesity (10-20%) OTHER RISK FACTORS - multiparity - prev macrosomic infant - male infant - increased maternal height - advanced maternal age - beckwith-wiederman syndrome (chromosomal abnormality)

Answer 145

FOETUS: - increased incidence of IUD + neonatal death - shoulder dystocia + brachial plexus palsy - hypoglycaemia - polycythaemia - jaundice MOTHER - Increased maternal morbidity (increased incidence of LSCS) - PPH - perineal trauma / forceps - puerpral infection

Answer 146

antenatal growth scans induce or elective section before 40wks (exactly when depends on cause) - vaginal delivery under high risk supervision

Answer 147

ASTHMA!!! It's a beta blocker! use nifedipine instead!

Answer 148

- duration? - how active were they before? - have movements come back now? - ever had this before - vaginal loss (incl waters) / PV bleeding? - abdo pain? - well in yourself? any fever? - any problems in this pregnancy so far? - any problems ion prev pregnancies? (incl SGA)

Answer 149

- SFH - uterine tenderness - maternal obs (incl temp) - CTG do bloods if suspect infection do USS if: - abnormal CTG - more than one episode of RFM consider early delivery (+/- steroids) if: - evidence of IUGR / foetal distress - recurrent RFM can always do repeat dopplers

Answer 150

any pregnancy exceeding 42wks from first day of LMP 3-10% incidence (depending on whether EDD or LMP used) common in primips if prev prolonged pregnancy , recurrence = 30%

Answer 151

DIZYGOTIC - ie non-identical twins - 2 eggs, 2 sperms MONOZYGOTIC (identical) = dichorionic diamniotic (DCDA) - split day 0-4 - lamda sign = monochorionic diamniotic (MCDA) - split day 4-8 - T sign = monochorionic monoamniotic (MCMA) - split day 8-12 - risk of cords tangling around each other nb all dizygotic twins are DCDA, as well as a 1/3rd of monozygotic twins) CHORIONCITY = the number of placentas

Answer 152

- FHx of twins / multiple pregnancy - IVF - older maternal age incidence = 1 in 80

Answer 153

FOETAL - miscarriage - IUD / vanishing twin - perinatal mortality - IUGR - pre-term delivery - polyhydramnios - malpresentation - cord prolapse MATERNAL - hyperemesis - anaemia - pre-eclampsia - gestational DM - acute fatty liver - placenta previa - placental abruption - PPROM (10-20%) - high chance of operative delivery - PPH

Answer 154

MCDA and MCMA at risk - as share placenta - risk is 20% nb DCDA don't get TTT as don't share same placenta vary severity, perinatal mortality is 40-80% RECIPIENT TWIN - polycythaemia - HTN - cardiac hypertrophy - oedema (hydrops) - polyhydramnios DONOR TWIN - anaemia - IUGR - hypotension - oligohydramnios - TEND TO FAIR WORSE! MANAGEMENT - expectant management - serial amniocentesis - laser obliteration of placental vascular communications

Answer 155

- high dose folic acid (5mg) - iron - also aspirin (if indicated for another reason) DCDA - growth scans = 28, 32, 36wks - delivery at 38wks (induction if baby 1 is cephalic, or LSCS if breech or transverse) MCDA + MCMA - USS every 2 wks from 16-24 wks (to look for TTTS) - growth scans same as DCDA MCDA = deliver 36-37wks - induce if twin 1 is cephalic, LSCSC if not or TTTS MCMA = deliver at 32wks by LSCS (high risk of cord entanglement after this)

Answer 156

PRE-EXISTING HTN - HTN (>140/90 prior to 20wks) - different mechanism, though is a risk factor for gestational HTN / pre-eclampsia GESTATIONAL HTN - new-onset, persistent BP >140/90 after 20wks WITHOUT proteinuria OR symptoms of PET - or an increase above booking readings of >30 systolic or >15 diastolic PRE-ECLAMPSIA (PET) - new-onset, persistent BP >140/90 after 20wks PLUS significant proteinuria (>300mg/24hrs or >1+ on urine dip) OR symptoms of PET (nb exclude UTI before diagnosing PET) ECLAMPSIA = one or more generalised convulsions or coma in the setting of pre-eclampsia and absence of other neurologic conditions ``` HELLP syndrome - a complication of severe pre-eclampsia = Haemolysis = Elevated Liver enzymes = Low Platelets ```

Answer 157

= prev Hx of pre-eclampsia = chronic HTN = pre-existing diabetes = chronic renal disease = anti-phospholipid syndrome (or lupus) - FHx of pre-eclampsia - BMI >35 - black ethnicity - extremes of maternal age (high + low) - multiple pregnancy nb nulliparity may also slightly increase risk, risk resets if new partner ASPIRIN 150mg - taken from 12th wk (ideally, useless if started after 20wks) until delivery

Answer 158

PRE-EXISTING HTN - continue antihypertensives (stop any ACEi or diuretics and switch to labetalol, nifedipine) - give aspirin from 12wks - foetal growth scans GESTATIONAL HTN - Give labetalol (nifedipine 2nd line, hydralazine 3rd line) - continue to monitor for PET and make mother aware of symptoms to look out for

Answer 159

6-8% of pregnancies in UK can only make diagnosis after 20wks!!! SYMPTOMS - persistent severe headache - visual disturbances - facial swelling - epigastric / RUQ pain (liver capsule stretch) can also get SOB if got ARDS as a complication SIGNS - peri-orbital oedema - hyper-reflexia - clonus

Answer 160

- BP - protein dipstick (always exclude UTI if protein) 24hr urine collection (looking for >300mg in 24hrs) ^ now mainly do PCR?? **** - FBC - LFTs - U+Es - Group + save

Answer 161

Features of severe pre-eclampsia hypertension: - typically > 170/110 mmHg and proteinuria as above - proteinuria: dipstick ++/+++ - headache - visual disturbance - papilloedema - RUQ/epigastric pain - hyperreflexia - platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome PRE-ECLAMPSIA COMPLICATIONS: - Eclampsia - Stroke - HELLP Syndrome - DIC - Multi system organ failure: Renal, Hepatic, Pulmonary oedema, ARDS

Answer 162

antihypertensives to reduce stroke risk - labetalol 1st line (then nifedipine and hydralazine) STEROIDS = 24-34 weeks, IM betamethasone 24hrs apart = 34-36 wks, CONSIDER giving the above MAGNESIUM SULPHATE = if severe pre-eclampsia or foetus before ?*28wks?? = if severe pre-eclampsia, give during labour and 24hrs postpartum to prevent eclampsia MILD PET = deliver once >36wks - also repeat USS to look for IUGR SEVERE PET = weigh up risk, close monitoring, norm deliver by 32wks OBSERVE - blood pressure - renal function - hepatic function - foetal distress (repeat CTGs)

Answer 163

- previous gestational DM - previous macrosomic baby (>4.5kg) - BMI >30 - 1st degree relative with DM (of any kind) - Black, south asian or middle eastern ethnicity IF RISK FACTORS: - OGTT at 26wks nb if previous gestational DM then do OGTT at 16wks and then again at 26 wks (if first is normal) GESTATIONAL DIABETES if, either - fasting glucose >= 5.6mmol OR - 2-hour glucose >= 7.8 "remember 5 6 7 8"

Answer 164

MOTHER - DKA - pre-eclampsia / PIH - Obstetric cholestasis - instrumental delivery - higher risk of needing a LSCS nb women with gestational DM are more likely to get type 2 DM later in life FOETUS - miscarriage / still birth - birth defects (incl spinal bifida, renal, cardiac, GI probs) - macrosomia +/- shoulder dystocia (nb can also get IUGR though) - preterm birth - respiratory distress syndrome - neonatal hypoglycaemia - neonatal jaundice - increased risk of diabetes later in life

Answer 165

nb give pre-conceptual advice to improve control and reduce weight if possible! under care of joint diabetic and obstetric team: consultant-led care STOP - oral hypoglycaemics (except metformin) - ACE inhibitors - Statins switch oral meds to insulin SAFE TO USE: - metformin - insulin EXTRA TO TAKE - 5mg (ie high dose) folic acid - 150mg aspirin (from 12wks) LIFESTYLE - loose weight if BMI >27 - tight glycaemic control will drastically reduce complication risk (though beware of DKA + hypos) also monitor eyes as retinopathy can worsen during pregnancy detailed anatomy scan at 20wks (incl 4 chamber view of heart) - also additional growth scans in 3rd trimester

Answer 166

pre-existing (ie type 1 or 2) = deliver at 37-39weeks gestational = deliver 39-40weeks nb these both assume no maternal or foetal complications secondary to the diabetes - if these are present, cionsider earlier delivery planned delivery can be done by induction or LSCS - depending on other comorbidities etc

Answer 167

5% of pregnancies 1st line: - diet 2nd line: - metformin 3rd line: - insulin POST-BIRTH - warn mother of risk of type 2 DM later in life (give dietary/exercise advice) - do fasting glucose test at 6 week check

Answer 168

monitopr blood glucose every HOUR during labour - should be between 4 and 7 SLIDING SCALE FOR: - all type 1 DM - anyone who's BMs are not between 4 and 7

Answer 169

nb pregnancy in itself is a risk factor PREGNANCY-RELATED RISKS - hyperemesis / dehydration - pre-eclampsia - excessive blood loss - prolonged labour - trauma to pelvic veins during delivery - parity >4 - multiple pregnancy - IVF / ART OTHER RISKS - Previous VTE - FHx of VTE in 1st degree relative <50 - BMI >30 - >35 years - immobility - travel - surgery - gross varicose vein - severe infection - sickle cell anaemia (SCA) - inflammatory disorders - thrombophilia (eg anti-phospholipid) PROPHYLACTIC LMWH - prev VTE of FH, give LMWH antenatally + 6wks post-partum - 3+ risk factors = LMWH from 28wks - 6wks postpartum - 4+ risk factors = LMWH immediately - 6wks post-partum nb in women at extremes of body weight or other high-risk factors, routine measurement of peak anti-Xa activity for patients on LMWH for treatment of acute VTE in pregnancy recommended

Answer 170

DVTs - 90% left leg - 70% above the knee (above knee = increased embolic risk) - nb Mostly occur below the knee in non-pregnancy state DVT - leg USS / doppler PE - VQ scan (increases risk of leukaemia for baby) - CTPA (if essential) also do: - ABG - ECG D-DIMER IS USELESS during pregnancy (as pregnancy raises it) Give treatment-dose LMWH if high clinical suspision of VTE in pregnancy (even if can't do imaging) - ie have a low index of suspision - give for 3 months can giv ethrombolysis (alteplase etc) only if life-threatening DON'T USE WARFARIN OR DOACS DURING PREGNANCY!

Answer 171

The woman's!! She should be given written information about repeated section vs VBAC and also have a chance to discuss both options with a dr in antenatal clinic elective sections norm booked around 36wks - take place at 39wks

Answer 172

ADVANTAGES: - A vaginal birth (better for mother + baby - less likely to have resp problems) - greater chance of an uncomplicated normal birth in future pregnancies - shorter recovery (can drive/lift asap) and shorter stay in hospital - less abdo pain after birth - not having surgery 75% who have VBAC will be successful (ie won't need an emergency section) Will need CTG monitoring during labour risk of scar rupture: - 0.5% if natural - 3% if induced/augmented (ie if have oxytocin) ABSOLUTE CI - 3 or more previous sections - prev uterine rupture - high uterine incision (classical c-section scar) - other pregnancy complications that require a section (eg previa)

Answer 173

ADVANTAGES - virtually no risk of scar rupture - knowledge of date of delivery (though 10% of women will go into labour before this) nb discuss with women what their wishes would be if they went into spontaneous labour before elective - want emergency section or try VBAC DISADVANTAGES OF REPEAT SECTIONS - longer (+ potentially more difficult) operation - need for elective section in future pregnancies - all major risks (placenta accretia, large PPH etc) increase with number of sections performed DISADVANTAGES OF SECTIONS GENERALLY - damage to other organs (bladder, bowel, ureter) - VTE risk (5x increased risk) - increased risk of bleeding - increased risk of infection - anaesthetic risks (say anaesthetist will discuss) - longer recovery (can't drive or lift for 6 weeks) - transient neonatal respiratory problems more common than if vaginal birth - 2% risk of scalp laceration to baby FUTURE PREGNANCY RISKS - higher risk of rupture - placenta accretia - still birth

Answer 174

5mg folic acid - take as long before conception as possible aim for monotherapy Although most anti-epileptic medications are teratogenic to greater or lesser degrees, the risks of uncontrolled epilepsy during pregnancy generally outweigh the risks of medication to the foetus risk reduction through - 5mg folic acid - aiming for monotherapy with least teratogenic medication which is still effective in keeping woman seizure-free

Answer 175

nb all anti-epileptics are considered teratogenic to some level but the risks of uncontrolled epilepsy during pregnancy generally outweigh the risks of medication to the foetus SODIUM VALPROATE - very teratogenic - only use if it's definitely the only thing which maintains seizure-free - neural tube defects - neurodevelopmental delay in children CARBAMAZEPINE - often considered the least teratogenic of the older antiepileptics PHENYTOIN - associated with cleft palate - give oral vit K in last month of pregnancy to reduce clotting disorders in newborn LAMOTRIGINE - studies to date suggest the rate of congenital malformations may be low. The dose of lamotrigine may need to be increased in pregnancy LAMOTRIGINE + CARBAMAZEPINE + LEVITERACETAM are the safest!! nb breast feeding is generally considered safe for mothers taking antiepileptics with the possible exception of the barbiturates

Answer 176

- fatigue - fainting - chest pain - palpitations - SOB - orthopnoea may also pick up a murmur on auscultation (nb some are normal in pregnancy - check which one**)

Answer 177

mitral stenosis - less common in british women, consider in immigrant women - norm associated with rheumatic heart disease do 12-lead ECG (24hr if nothing found) if any symptoms involve cardiology and MDT team early if congenital or acquired consider early delivery if mother has cardiac problems - monitor mother closely during labour/section

Answer 178

HTN increases risk of: - pre-eclampsia - placental abruption - IUGR - preterm delivery - maternal morbidity + mortality (eg stroke, retinopathy) - neonatal morbidity/mortality SWITCH TO: - labetalol - nifedipine - methyldopa give aspirin from 12wks

Answer 179

death from 6wks to a year post-natally from a cause related to pregnancy or birth biggest cause = suicide suicide within a year of birth is classed as a DIRECT maternal cause of death nb overall 1 in 7 maternal deaths is from suicide

Answer 180

- maternal death from overdose - IUGR - preterm delivery - stillbirth - placental abruption (esp w cocaine) - neonatal withdrawal syndrome

Answer 181

check antibodies - if immune, no action needed - if not immune, give IV Ig immediately if patient presents within 24hrs of rash onset, give oral acyclovir

Answer 182

T1 = Hb >110 T2/3 = Hb >105 post-partum = HB >100 Give oral iron 1st line if anaemic during pregnancy - advise re constipation and co-prescribe laxatives if need - also recommend have on empty stomach with orange juice to increase absorption

Answer 183

FGM = “All procedures that involve partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons” REMOVAL of ALL or PART of: - type 1 = clitoris + clitoral hood (clitoridectomy) - type 2 = clitoris + labia minora +/- excision of labia majora (excision) - type 3 = closure of the vagina, narrowing of the vaginal opening (infibulation) - type 4 = other harmful procedures to genetalia (eg burning clitoris, piercing, cutting or scarring vaginal opening, stretching labia In Africa, around 50% girls undergo FGM between birth and 5 years. Remainder at risk between 5 and 15 years.

Answer 184

IMMEDIATE - Severe pain - urinary retention - haemorrhage - damage to adjacent organs - fractures from forcible restraint - wound infection (-> sepsis) - tetanus + gangrene - BBV infection (HIV, hep B) - death LONG-TERM - recurrent UTI - difficulty voiding urine + faeces - painful menstruation - keloid scarring + cysts, infibulation cysts - sexual difficulties - psychological problems - infertility PREGNANCY - delay in final stage of childbirth = high rates of LSCS, instrumental delivery, PPH + death - high rates of foetal asphyxia + perinatal death

Answer 185

FGM or arranging FGM overseas for a UK resident is illegal (can go to prison for 14 years for organising the trip) if woman has a vaginal birth then will perform a vertical episiotomy (ie cut through what's been sewn up) and won't stitch it back up again must document in notes if someone has had FGM If a child has had FGM, call the polic (and notify safeguarding lead) If child is at risk of having it, contact safeguarding lead + refer to social services

Answer 186

- A family which belongs to a community in which FGM is practised - A family making preparations to take a child on holiday to an area where FGM is practised, for example arranging vaccinations. If the family is from a community known to practise FGM, travel to any country (not just their country or origin) should raise suspicions - A child from an FGM-practising community that is talking about a ‘special procedure or ceremony’ that is going to take place - You become aware of a mother who has already undergone FGM. This might prompt concern for any daughters, girls or young women in the family - A school nurse may notice a girl from an FGM-practising community avoiding specific classes or activities such as PE or sports, perhaps giving reasons of bladder, menstrual or abdominal problems

Answer 187

paracetamol = safe NSAIDs = AVOID - causes miscarriage + malformation in T1, premature closure of ductus arteriosus in T3 - are safe in breastfeeding though - aspirin is okay (but lower doses)

Answer 188

nitrofurantoin = yes in T1 +T2, no in T3 (neonatal haemolysis) trimethoprim = no in T1 + T2, yes in T3 (anti-folate, teratogenic) cephalosporins + penicillins = safe except co-amoxiclav!! (relative CI - risk of necrotising enterocolitis in baby) Tetracyclines = absolute CI (neonatal tooth discolouration) Macrolides (erythromycin etc) = safe! clindamycin = safe metronidazole = safe

Answer 189

FIRST LINE T1 + T2 = Nitrofurantoin (DO NOT USE in 3rd trimester (neonatal haemolysis)) T3 = Trimethoprim ((anti folate drug) DO NOT use in 1st trimester (teratogenic)) SECOND LINE = Cephalosporins and penicillins safe (but avoid co-amoxiclav in pregnancy due to risk of necrotising enterocolitis (NEC) in baby) nb DO NOT USE Tetracyclines – neonatal tooth discolouration

Answer 190

use penicillins and macrolides (eg erythromycin) co-amoxiclav is NOT safe!

Answer 191

Erythromycin for 7 days to prevent chorioamnionitis ``` Chorioamnionitis treatment = IV Cefuroxime AND = IV Metronidazole ```

Answer 192

co-amoxiclav = 1st line if pen allergic = clindamycin AND metronidazole nb can give co-amoxiclav for endometritis as baby is no longer in uterus!

Answer 193

Do not use ACE inhibitors ARBs in pregnancy - fetal renal damage in 2nd and 3rd trimester and possibly malformation in 1st trimester