obstetrics Flashcards
1
Q
Name the urine and blood tests at booking
A
MSU - dipstick for blood and protein
Hb, blood group and antibody screen
BBV - syphilis, rubella, HIV
Consider sickle cell test, Hb electrophoresis for haemoglobinopathy, 25-hydroxyvitamin D if relevant.
2
Q
At what gestation do you screen for chromosomal and structural abnormalities?
A
Booking (11-13+6)
3
Q
What investigations should be performed at every antenatal visit?
A
Urine dipstick for protein, BP, fundal height.
4
Q
When are Hb and Rh antibodies tested and what is administered?
A
Test all Rh- mothers for antibodies at booking
give anti-D if needed at 28 and 34 weeks
5
Q
From what gestation should a Kleihauer test be performed to determine foetal RBC leak?
A
20+0
6
Q
Anti-D should be given within 72h of which situations
A
Delivery of a Rh+ infant Any TOP or miscarriage after 12wks Surgical mx of miscarriage/ectopic at any gestation ECV APH or abdo trauma Amniocentesis/CVS/Foetal blood sampling
7
Q
What measurements are used to date pregnancy?
A
Crown-rump length at 6-12wks
Biparietal diameter 14-34wks (peaks in accuracy at 20wks)
8
Q
Causes of increased nuchal translucency
A
Down’s syndrome
congenital heart defect
abdominal wall defect
9
Q
What is the underlying aneuploidy in Edward’s syndrome, describe the clinical presentation
A
trisomy 18
rarely survive 1yr, micrognathia, low set ears, rocker bottom feet, overlapping fingers
10
Q
What is the underlying aneuploidy in Patau’s syndrome and describe the clinical presentation
A
trisomy 13
die soon after birth, microcephalic, cleft lip/palate, exomphalos, holoprosencephaly, polydactyly.
11
Q
What does the combined test consist of and when should it be performed?
A
11-13+6 weeks
NT + serum b-hcg + Pregnancy Associated Plasma Protein A.
12
Q
You are in antenatal clinic with a 37 year old woman, G6P4 who is 15 weeks gestation and missed her booking appointment. She has stated she would like screening for Down’s syndrome and other trisomy. What test is used?
A
15-20wks
triple/quadruple test - AFP + unconjugated estradiol + hCG (± inhibin-A)
13
Q
In antenatal clinic you are counselling a lady who is currently 12+2 and has just been informed that the combined test indicates the foetus to have T21. You have mentioned invasive testing to confirm the diagnosis.
Describe what is involved in each test and what gestational periods can they be performed in?
A
Chorionic Villus Sampling - 11-14/40 - transabdominal (rarely transcervical) needle to retrieve cell sample from placenta. Not recommended in dichorionic pregnancy
Amniocentesis - 15-18/40 - US guided needle aspirates amniotic fluid to analyse foetal cells shed by skin/gut.
Both yield results in 3 working days (few weeks in rarer disease needing enzyme/gene probe analysis). Risks - increased rates miscarriage (less so in amniocentesis), BBV transmission.
14
Q
Define hyperemesis gravidarum, at what gestation would you expect it to occur?
A
Persistent vomiting in pregnancy causing dehydration, electrolyte imbalance and weightloss (>5% from pre-pregnancy weight). Most common between 8 and 12 weeks, can persist up to 20wks.
15
Q
Risk factors for hyperemesis gravidarum
A
multiple pregnancy, trophoblastic disease, previous Hyperemesis Gravidarum, primiparity, obesity, hyperthyroidism
16
Q
How might someone with hyperemesis gravidarum present?
A
Persistent vomiting, unable to keep food/fluid down, weightloss, dehydration, tachycardia, postural hypotension, hypovolaemia, hyponatraemia, hypokalaemia, ketoacidosis, polyneuritis (vit B deficiency)
17
Q
When should you consider admission for someone with hyperemesis gravidarum?
A
If they are on oral anti-emetics but still have persistent vomiting and are:
- Unable to keep fluid/anti-emetics down
- still displaying ketonuria/weightloss/severe electrolyte imbalance
- confirmed or suspected co-morbidity e.g. UTI
18
Q
Ix in suspected hyperemesis gravidarum
A
Urine - MSU for infection and ketones
Blood - FBC (increased haematocrit), U+Es (hypo-natraemia/kalaemia)
19
Q
How would you manage hyperemesis gravidarum?
A
Admission if needed to correct electrolyte imbalance/dehydration
IV fluids - 0.9% saline, Na+ and K+ guided by daily U+;Es
Anti-emetics - antihistamine (promethazine)/cyclizine, consider corticosteroids if intractable.
Additional - 5mg folic acid, thiamine/pabrinex for Wernicke encephalopathy, if in hospital thromboprophylaxis (e.g. enoxaparin) and TEDs
20
Q
What inheritance pattern does sickle cell disease show?
A
Autosomal recessive
21
Q
What is sickle cell disease?
A
Haemoglobinopathy which predisposes to sickling of RBCs in low O2 conditions leading to vaso-occlusion in small vessels and a tendency to haemolytic
22
Q
Give 5 risks associated with sickle cell disease in pregnancy
A
Increased risk of perinatal mortality, premature labour, IUGR, painful crises inc acute chest syndrome, increased risk of haemolytic disease of newborn
23
Q
How does acute chest syndrome present?
A
Cough, tachypnoea, chest pain and CXR shows new infiltrates.
24
Q
A 27 year old woman with known sickle cell disease comes to the GP to discuss getting pregnant, what are some investigations/interventions which should be performed prenatally?
A
Assess current disease:
- ECHO less than 1yr old for pulm htn
- BP and urinalysis
- U+Es and LFTs
- retinal screening
Prophylactic abx and update vaccines (HBV, HiB, MenC, pneumococcal, influenza) due to increased risk infection
Start 5mg folic acid and stop ACEi/A2A drugs and hydroxycarbimide >3/12 pre-conception
25
Should someone with SCD take aspirin?
Yes from 12 weeks gestation to reduce risk pre-eclampsia 75mg OD
26
What anti-depressants are the safest in pregnancy?
SSRIs - in particular sertraline
27
What foetal risks are associated with sertraline use?
Small risk of congenital heart disease with use in T1, persistent pulmonary hypertension with use in T3 and tiny risk of neonatal withdrawal (breastfeeding helps)
28
```
Which of the following anti-depressant is safest in breastfeeding mothers:
A) Sertraline
B) Paroxetine
C) Fluoxetine
D) Citalopram
```
Sertraline
Paroxetine should not be used due to risk of cardiac malformation in T1, fluoxetine and citalopram both present in high conc in breast milk
29
What congenital malformations are associated with sodium valproate use?
Neural tube defects, craniofacial abnormalities, neurodevelopmental problems
30
Women should not breastfeed while taking lamotrigine true or false?
False, breastfeeding is generally considered safe with the exception of barbiturates.
31
Lithium use during pregnancy risks what 3 conditions in the newborn?
heart defect including ebsteins anomaly
neonatal thyroid abnormality
floppy baby syndrome
32
What dose of folic acid should women on anti-epileptics be on and when should they start taking it?
5mg 3 months pre-conceptually
33
A 27 year old G1P0 lady with a history of bipolar disorder comes to antenatal clinic. Having previously tried other mood stabilisers, lithium seems to be the only agent that works and for that reason she feels it is safer for her and her child to stay on lithium despite the risk of congenital malformations. Counsel her on what this means for her antenatal care and labour
detailed foetal anomaly scan should be offered with foetal echo ~wk6 and 18
lithium levels will be monitored 4-weekly until 36 weeks and form then on measured weekly
Lithium will be stopped during labour and restarted based on 12h post dose level
NO breastfeeding!
34
When are pregnant women screened for anaemia? what levels define anaemia during pregnancy?
booking <110g/l
week 28 <105g/l
physiological decrease in Hb steepest at 20wks
35
Risk factors for anaemia during pregnancy
pre-existing anaemia, frequent pregnancies, multiple pregnancy, poor diet
36
investigations for anaemia during pregnancy
FBC, iron studies (IDA = decreased serum iron, TIBC, serum ferritin), folate (increased MCV, decreased serum and ref cell folate)
37
What is the most common cause of anaemia during pregnancy?
iron deficiency, then folate deficiency
38
How would you manage iron deficiency anaemia in pregnancy?
PO ferrous sulphate 200mg BD - can take every other day if GI s/e
not tolerated = ?parenteral iron but can cause anaphylaxis so only administer if CPR facility hand. Late severe anaemia <90 may require blood transfusion
39
Risk factors for HIV vertical transmission
Breastfeeding, vaginal delivery, ROM >4h, viral load >400 copies/ml, seroconversion during pregnancy, advanced disease, preterm labour, HCV
40
How do you minimise risk of vertical transmission of HIV mom to baby?
Elective C-section (can consider vaginal if on HAART and viral load <400 /not on and <50)
Bottle-feeding not breast feeding
Maternal anti-retrovirals
41
A G1P0 lady is found to be HIV+ from her booking bloods. What is your immediate management?
Discuss starting anti-retrovirals to start before 24wks and continue until at least delivery
Screen for and treat any genital infections whether symptomatic or not
Ensure up to date non-live vaccines - flu, pneumococcal, HBV.
42
What HbA1c should women aim for before getting pregnant?
=<6.1% (43)
43
at what HbA1c would you advise a woman to avoid getting pregnant?
>= 10%
44
A 26 year old lady with diabetes comes to you for a medication review as she plans to start trying to get pregnant in the next few months. What medications would you stop/start?
Stop statins, ace inhibitors/a2as, all oral hypoglycaemic except metformin
Start high dose 5mg folic acid
45
What should you screen for prenatally in a diabetic woman planning to get pregnant?
Nephropathy and retinopathy
46
Give 4 maternal risks of diabetes
Hypoglycaemia unawareness - especially during 1st trimester
pre-eclampsia
infection
increased rates of c-section
47
Give 6 foetal risks of diabetes
```
Miscarriage
Malformation
Macrosomia/IUGR
Polyhydramnios
Prematurity
Stillbirth
```
48
How often should a woman with diabetes during pregnancy attend growth scans?
Every 4 weeks from 28 weeks
49
When should a pregnant diabetic woman measure BMs
On waking (fasting), pre-meal and 1hr post-prandial for every meal, and bedtime.
50
What are the target capillary BMs for pregnant diabetic women - fasting, and post-prandial?
fasting 5.3mmol/l
| post-prandial either 7.8 at 1h, 6.4 at 2.
51
What level should BM be intra-partum?
4-7mmol/l, if it is not maintained at this consider IVI - insulin and dextrose.
52
When should you aim to deliver a baby of a diabetic mother?
37-38+6 if type 1/2
| By 40+6 if GDM
53
What diabetes medications can be used while breastfeeding?
Metformin, insulin, glibenclamide
54
Risk factors for gestational diabetes
Hx of GDM in prior pregnancy, prev macrosomic baby weighing >4.5kg, BMI>30, certain ethnicities (Middle Eastern, Caribbean, south asian), first degree relative with diabetes
55
How is gestational diabetes diagnosed?
Oral glucose tolerance test 7.8mmol/l or fasting glucose 5.6mmol/l
56
When does screening for GDM occur?
At 24-28 weeks for any woman with risk factor for GDM, an additional test at booking if hx GDM
57
How do you manage GDM?
fasting glucose >7 = immediately start on insulin as well as diet and exercise changes.
Fasting glucose 5.6-7 - trial 1-2 weeks of lifestyle modifications, if this does not work then add metformin, then add insulin.
58
Normal pregnancy mimics hyper or hypo thyroidism? how and why?
Hyper - goitre, anxiety, tachycardia, warm moist skin
- Increased TBG and T4 output to maintain free T4 levels
- high levels hCG mimic TSH
59
Risks associated with hyperthyroidism during pregnancy
Harder to conceive, prematurity and miscarriage
60
What changes are made to the medication of someone with hypothyroidism when they become pregnant? How are they monitored?
Aim for TSH <2.5mmol/l.
Usually require higher dose of levothyroxine
Monitor every 4-6weeks during pregnancy, usually return to pre-pregnancy dose levothyroxine postpartum
61
A 27 year old woman comes in c/o tonsillitis. Hx = odynophagia, pyrexia (38). PMH hyperthyroidism. Dhx - NKDA, carbimazole.
How would you manage this patient?
FBC for agranulocytosis due to carbimazole
62
Which of the thyroid medications is considered safest to use during breastfeeding - levothyroxine or carbimazole
levothyroxine, in hyperthyroidism pylthiouracil is preferred during T1 (less transplacental transfer) and breastfeeding.
63
A 40 year old lady G4P2 30/40 comes to the GP c/o unbearable itchiness which is preventing her sleeping and asks for antihistamines. She says it does affect her palms, soles and abdomen. O/E she is slightly jaundiced.
What is the likely diagnosis and how would you investigate?
Intrahepatic cholestasis of pregnancy - pruritis affecting abdomen, palms and soles, jaundice in 3rd trimester.
Ix - FBC, LFTs (mildly raised), bile acids (mildly raised), virology (Hep A/B/C, EBV, CMV), autoimmune screen (anti-smooth muscle and anti-mitochondrial for chronic hepatitis, primary biliary cirrhosis), liver USS
64
How would you manage obstetric cholestasis?
Offer elective IOL at 37+0 with continuous elective foetal monitoring intrapartum.
Sx'atic relief - ursodeoxycholic acid. Otherwise symptoms resolve within days of delivery.
65
How would you expect acute fatty liver of pregnancy to present? What is the general outline of management?
3rd trimester/immediately following delivery
abdo pain, jaundice, N+V, headache ± thrombocytopenia, pancreatitis. Associated pre-eclampsia in 30-60%. Elevated ALTs
Mx - supportive rx liver/renal failure and hypoglycaemia, correct clotting, monitor BP, once stable expedite delivery
66
What is HELLP syndrome?
Haemolysis, elevated liver enzymes, low platelets. Serious condition develops late in pregnancy, can follow pre-eclampsia.
Sx - N+V, malaise, RUQ/epigastric pain, dark urine, htn
Ix - FBC (low platelets), LFTs (increased), bilirubin (increased), LDH (increased)
Mx - deliver the baby
67
A booking urine dip has found asymptomatic bacteriuria in a 12+6/40 woman. How should it be treated?
7 day course nitrofurantoin to prevent pyelonephritis which can cause IUGR, prematurity or foetal death.
68
At what point gestation is nitrofurantoin and trimethoprim used and why?
T1 use nitrofurantoin as trimethoprim is an anti-folate
| T3 use trimethoprim as nitrofurantoin risks HDN
69
Why is pyelonephritis more common in pregnant women/
dilatation of the upper renal tract
70
how might pyelonephritis present in a pregnant woman? How is it managed?
Can present as urinary frequency and malaise or more dramatically with N&V, loin pain, pyrexia/rigors. Take blood and urine culture, start IV cefuroxime awaiting sensitivities, IV abx for at least 24h and oral for 2-3 weeks.
71
A 19/40 G1P0 presents with a second confirmed UTI during this pregnancy, what is your next step?
Renal USS and consider prophylactic abx e.g. low dose oral amoxicillin.
72
Causes of seizure in pregnancy
```
Eclampsia
Epilepsy
Intracranial mass
Infection
Stroke
Hypoglycaemia/Hyponatraemia
```
73
Management of epilepsy in pregnancy
Can consider stopping AEDs if no seizure for 2yrs, otherwise aim for monotherapy on lowest dose of safest agent (e.g. LTG, basically not valproate/carbamazepine) and start 5mg folic acid 3/12 pre-conception.
Vitamin K in last 4wks of pregnancy if on - phenytoin, ethosuximide, carbamazepine (hepatic enzyme inducers reducing vit K dependent clotting factors increasing risk HDN) and vit K to newborn
Avoid early discharge (risk fit highest in first 24h), encourage breastfeeding, gradually reduce AED dose to pre-natal levels.
74
How does antiphospholipid syndrome present and how do you diagnose?
Hx venous/arterial thrombosis, recurrent miscarriage (3+ unexplained <10/40, 1 >10/40), thrombocytopenia, prolonged APTT, lupus anticoagulant/anti-cardiolipin/anti-B2 glycoprotein antibodies on 2 tests taken 8 weeks apart.
75
Mx antiphospholipid syndrome in pregnancy
Specialist management
Regular growth scans + doppler flow studies from 20wks
Aspirin 75mg OD and LMWH e.g. enoxaparin from when foetal heart identified.
Postpartum LMWH/warfarin (can breastfeed on either)
76
Who should take aspirin 75mg OD from 12/40 and why
Those at high risk pre-eclampsia:
hypertensive disease during previous pregnancy
CKD
autoimmune disorder e.g. antiphospholipid/SLE
DM1/2
77
What is the physiological pattern of blood pressure during pregnancy?
Drops during trimester 1, continuing to decrease due to drop in vascular resistance til 20-24 weeks then stroke volume increases = BP rises back to pre-pregnancy levels by term.
78
How is hypertension in pregnancy defined?
Systolic >140 or diastolic >90 OR an increase of sys>30/dia>15 on booking value.
79
How is hypertension in pregnancy categorised?
Pre-existing or 'chronic' htn - measured as >140/90 before 20wks, no proteinuria/oedema
Pregnancy induced - >140/90 after 20wks, no proteinuria/oedema, usually resolved around ~1m postpartum but increased risk future htn/pre-eclampsia
Pre-eclampsia - pregnancy induced htn + proteinuria (±oedema)
80
Mx of hypertension in pregnancy
```
Lifestyle - cut down salt <6g/day (ideally <3), caffeine, smoking cessation, balanced diet, exercise.
Weekly BP (aim for <135/85), urine dipstick for protein, FBC, U+Es, LFTs
Growth scan and umbilical a doppler every 4 weeks (from 28/presentation)
Medication - labetalol (2nd amlodipine 3rd methyldopa) + 75mg aspirin OD from 12 weeks.
```
81
A 29 year old women with htn comes to the clinic to discuss getting pregnant, what should you advise her in regard to her medication?
Stop ACEi/ARBs/thiazide diuretics due to risk of congenital malformation and switch to labetalol
Start aspirin at 12wks 75mg OD
82
Pre-eclampsia predisposes to the following problems...
```
foetal - IUGR, prematurity
Eclampsia
Haemorrhage - placental abruption, intra-ado, intra-cerebral
cardiac failure
multi-organ failure
```
83
High risk factors for pre-eclampsia
Hypertensive disorder in previous pregnancy
Chronic htn
CKD
autoimmune disease e.g. SLE, anti-phospholipid synd
DM1/DM2
84
Moderate risk factors for pre-eclampsia
```
Primiparity
Age 40+
BMI 35+ at booking
family hx pre-eclampsia
multiple pregnancy
```
85
Describe the features of severe pre-eclampsia
Severe htn - typically >160/110 + proteinuria >0.5g/d
Hyperreflexia
RUQ/epigastric pain
Headache, visual disturbance and papilloedema
HELLP syndrome
86
How is pre-eclampsia treated?
Control BP with labetalol
Give magnesium sulphate to prevent seizures (and by definition eclampsia)
Deliver the baby
87
At what blood pressure would you admit a pregnant woman to hospital?
160/110
88
Describe intrapartum/postpartum care for a woman with hypertension
As long as Bp remains <160/110 can let pregnancy go beyond 37wks
AMTS - syntocinon alone, not ergometrine as can cause stroke in htn due to worsening htn.
Check BP on day 1, 2, then once day 3-5, then at 2wks
Stop methyldopa postpartum (risk PND), switch to nifedipine/labetalol/amlodipine if antihypertensive still needed. Aim to keep <150/100, consider reducing/stopping if <130/80
89
When should VTE risk be assessed
Booking, during each antenatal admission, during labour and postnatally
90
At what point from conception to post-partum is risk VTE highest?
Postpartum
91
Risk factors for VTE in pregnancy - pre-existing, obstetric and transient
Pre-existing - thrombophilia, medical co-morbidities (e.g. cancer), age >35, BMI >30, para>3, smoking, varicose veins, paraplegia
Obstetric - multiple pregnancy, pre-eclampsia, prolonged labour, C-section, preterm birth, PPH, stillbirth
Transient - any surgical procedure in pregnancy/puerperium, dehydration (e.g. HG), admission/immobility, ovarian hyperstimulation synd, long distance travel, systemic infection
92
Who is offered thromboprophylaxis and what thromboprophylaxis would they get?
Any woman with 4 risk factors T1/2 (<28wks), 3 risk factors T3 (>28wks), 2 in postpartum period. LMWH for remainder of pregnancy and 6wks postpartum. Also consider 10d LMWH in any woman who has a c-section.
93
How might DVT present in a pregnant woman? Provide a ddx
Usually in proximal veins L leg (gravid uterus pressure on L iliac vein). Unilateral leg pain and swelling ± pyrexia, pitting oedema, tenderness.
Ddx - cellulitis, ruptured Bakers cyst, superficial vein thrombophlebitis, normal pregnancy
94
How might PE present in pregnant woman? provide a ddx
Sudden onset dyspnoea, pleuritic chest pain and cough (rarely haemoptysis). O/E may have tachycardia, tachypnoea, pleural rub; rarely raised JVP/pleural effusion.
Ddx - many but important to r/o aortic dissection, ACS, pneumothorax and pneumonia.
95
Investigating suspected DVT in pregnancy
Bloods - FBC, U&Es, LFTs, clotting
D-dimer not indicated as rises in pregnancy physiologically.
Compression duplex USS (if negative but high clinical suspicion, initiate anticoag and repeat in 1wk)
96
Investigating suspected PE in pregnancy
Bloods - FBC, U&Es, LFTs, clotting
No D-dimer as rises physiologically in pregnancy
ECG and CXR
Definitive - CTPA or V/Q scan (V/Q increased risk of childhood ca but lower risk breast ca)
97
if a pregnant woman presents with signs of DVT and PE how do you investigate her?
Bloods (FBC, U&Es, LFTs, clotting)
Perform compression duplex USS as if positive don't bother with CTPA or V/Q which would be unnecessary radiation exposure.
98
How is VTE treated in pregnancy?
LMWH started immediately until diagnosis excluded by definitive testing, dose titrated against booking weight.
If VTE confirmed continue taking LMWH until 6-12wks postpartum, however omit dose 24h before planned C-section or IOL/if they think they are going into labour
99
37 year old female referred to the Haematology-obstetric clinic for discussion of prophylaxis. She has had one previous DVT after an appendicectomy 10 years ago.
Does this patient require thromboprophylaxis, if so when?
Provoked DVT by surgery - start LMWH at 28wks
100
28 year old female referred to haem-obs clinic as she is planning a pregnancy in the near future. PMH - PE 5 years ago, no cause found, otherwise well. DHx - NKDA. She states she feels well, has never had any further VTE, it was an 'out of the blue' occurrence that her doctors could not explain, except for suggesting it may have been to do with her COCP which she then stopped. Otherwise well.
Does she need thromboprophylaxis if so when?
Unprovoked/ possible oestrogen related DVT (still unprovoked for the purposes of mx) - LMWH throughout antenatal period
101
Which 3 conditions should be ruled out in a pregnant woman with a maculpapular rash?
Measles, parvovirus B19, rubella
102
A 23 year old Irish Traveller woman presents to the GP with her 3 year old son, who developed a generalised maculopapular erythematous rash 2 days ago. O/E of note he has a temperature of 37.8 and white 'salt grain-like' spots on the buccal mucosa around the molars. His mother is concerned as she is 14 weeks pregnant and worries about picking up an infection.
What is the diagnosis and how will you manage the impact this may have on this womans pregnancy?
Measles
Measles in pregnancy is associated with foetal loss + pre-term delivery, mortality + sig morbidity from pneumonia and encephalitis.
Mx - contact HPT for advice, check her IgG measles antibodies and if -ve administer human normal Ig up to 6/7 after exposure.
103
A 23 year old woman presents to the GP with a maculopapular erythematous rash which appeared on her face 2 days ago and is now on her trunk, she reports having a 'virus' for a few days beforehand. O/E she has sub occipital and submandibular lymphadenopathy. She is also 14 weeks pregnant .
What is the diagnosis and how will you manage the impact this may have on this womans pregnancy?
Rubella
Risk congenital rubella syndrome - risk of damage to foetus is highest at 8-10 weeks, rare after 16/40. Sx - sensorineural deafness; congenital cataracts and 'salt and pepper' chorioretinitis, microphthalmia; congenital heart defect; growth retardation; hepatosplenomegaly; purpuric skin lesions; cerebral palsy.
Mx - report to HPT, check parvovirus B19 + rubella IgM serology, administer MMR vaccine after giving birth
104
A 23 year old Irish Traveller woman presents to the GP with her 3 year old son, who developed a red rash on his face this morning. O/E of note he has a temperature of 37.8 and a maculopapular erythematous rash on both cheeks. His mother is concerned as she is 14 weeks pregnant and worries about picking up an infection.
What is the diagnosis and how will you manage the impact this may have on this womans pregnancy?
Slapped cheek syndrome
Mother is contact so check parvovirus B19 IgG and IgM, serial USS for foetal anaemia. Before 20/40 risk of foetal suppressed erythropoiesis and cardiac toxicity leading to cardiac failure and hydrops fetalis.
105
A 23 year old woman attends the antenatal clinic for a routine appointment, and mentions having developed a painful and itchy rash on her crotch last week. O/E she has a crop of small, closely grouped blisters on an erythematous base on the left labia majora. She has never experienced anything like this before, she has had multiple sexual partners in the last year and is 29 weeks pregnant.
What is the diagnosis and how will you manage the impact this may have on this womans pregnancy?
Genital herpes caused by HSV
Refer to GUM to screen for other infections and confirm it is primary genital herpes (mentions having not had anything like this before). Offer PO acyclovir and elective C-section as she has primary infection in T3 and is over 28wks. If this was not primary she may be on suppressive rx which confers low transmission risk, especially due to maternal antibodies in recurrence.
Neonatal infection risks blindness, reduced IQ, epilepsy, jaundice, resp distress, DIC and death.
106
A 23 year old Irish Traveller woman presents to the GP with her 3 year old son, who developed an itchy red rash on his trunk. O/E of note he has a temperature of 37.8 and an erythematous itchy papular rash, with some vesicles, on his trunk. His mother is concerned as she is 14 weeks pregnant and worries about picking up an infection.
What is the diagnosis and how will you manage the impact this may have on this womans pregnancy?
Chickenpox - varicella zoster virus
Risk foetal varicella syndrome under 28wks (esp under 20wks) gestation - skin scarring, microphthalmia, limb hypoplasia, microcephaly, learning disabilities.
Mx - check maternal antibodies for exposure status if unsure, if not immune give VZIG within 10d of exposure (or appearance of rash in index indiv), PO acyclovir if they present with a rash, within 24h of the rash appearing, and are 20+0 or further; avoid contacts with other at risk individuals until lesions crust over.
107
List indications for continuous CTG monitoring during labour
IOL, epidural anaesthesia, multiple pregnancy, premature/post-dates, ante/intra-partum haemorrhage, maternal illness, previous uterine scar, PROM, signs of sepsis or chorioamnionitis, IUGR/macrosomia, poly/oligo-hydramnios, malpresentation in primip, any condition which increases risk of foetal hypoxia.
108
A low-risk woman is currently giving birth on the labour ward, how is she likely to be monitored during labour?
Intermittent auscultation with sonic aid (doppler US) for 1 minute after contractions every 15 minutes during 1st stage, and every 5 minutes in the 2nd stage.
109
Define pre-eclampsia and briefly describe the pathophysiology
A placental disease characterised by hypertension and proteinuria seen after 20 weeks gestation. Failure of trophoblastic invasion of spiral arteries results in high resistance, low flow uteroplacental circulation, the resultant hypertension, hypoxia and oxidative stress from inadequate placental perfusion leads to a systemic inflammatory response and endothelial cell dysfunction.
110
What are high-risk factors for pre-eclampsia?
Previous pre-eclampsia/eclampsia/hypertension in pregnancy, chronic htn, pre-existing CKD, DM, autoimmune disease.
111
What are moderate-risk factors for pre-eclampsia?
Nulliparity, multiple pregnancy, maternal age 40+, Maternal BMI 35+ at booking, family hx pre-eclampsia, pregnancy interval >10 yrs.
112
Who should be offered pre-eclampsia prophylaxis and what is pre-eclampsia prophylaxis?
Anyone with 1 high risk or 2 moderate risk factors for pre-eclampsia. PO aspirin 150mg daily from 12 weeks gestation until 38wks.
113
How is pre-eclampsia classified?
Mild - >140/>90
Moderate - >150/>100
Severe - >160/>110 with proteinuria >0.5mg/day OR symptomatic
114
How might pre-eclampsia present?
Usually picked up on screening at routine antenatal appt with BP and urine dipstick
Sx can include visual disturbance, headaches, peripheral oedema that is non-dependent and sudden onset, epigastric pain, hyperreflexia.
115
Complications of pre-eclampsia
Maternal - eclampsia, HELLP syndrome, AKI, DIC, ARDS, htn, cerebrovascular haemorrhage, death
Foetal - IUGR, prematurity, placental abruption, intrauterine death.
116
How would you investigate ?pre-eclampsia
BP
Urine dip
FBC (anaemia, low plt), U+Es, LFTs (increased ALT/AST)
117
How would you manage pre-eclampsia?
Is it possible to deliver? - only definitive rx
- Antihypertensives - labetalol, or if asthmatic nifedipine. To reduce risk haemorrhagic stroke. Monitor BP in ANC, then daily 0-2/7 postpartum, then once between day 3-5
- Severe pre-eclampsia - IV magnesium sulphate 4g in 100ml saline.
- VTE prophylaxis if inpatient
- Advise risk of pre-eclampsia in subsequent pregnancy
118
How would you manage eclampsia?
Obstetric emergency call for senior help
A-E assessment - put in L lateral position if possible, start continuous CTG and IV magnesium sulphate bolus (4g in 100ml 0.9% NaCl) then maintenance, IV labetalol.
Once stable deliver baby ASAP and repeat bloods (FBC, U+Es, LFTs) 72h postpartum, BP daily for 2wks post partum. F/U at 6weeks to ensure BP and bloods return to baseline.
Continue IV MgSO4 for 24h post-delivery or last seizure whichever is latest; monitor UO, reflexes, RR and sats during rx, rx resp depression - calcium gluconate
119
Risk factors for prematurity
Previous pre-term birth, multiple pregnancy, cervical surgery (LLETZ, cone bx), uterine anomalies, pre-existing medical conditions, pre-eclampsia, IUGR
120
How might acute pre-term labour present?
Commonly SROM.
Mild lower abdo pain, increased PV discharge and O/E bulging membranes - assoc w/cervical weakness
Lower abdo pain, painful uterine contractions, PV loss - assoc with infection/inflamm/abruption.
121
How would you diagnose real pre-term labour?
membranes intact - transvaginal cervical length =<15mm, positive fibronectin assay
PPROM - speculum examination amniotic fluid pooling in posterior vaginal fornix, if not seen perform IFGBP-1 and PAMG-1 testing on vaginal fluid (positive indicates PPROM).
122
Who should be offered tocolytics and what tocolytics?
PO nifedipine - woman in pre-term labour with intact membranes 26+0-33+6 (consider if 24-26/40) to allow for transfer or time for corticosteroids
123
Contraindications for tocolytics
Chorioamnionitis, foetal death or lethal abnormality, condition requiring immediate delivery. Relative - foetal distress/IUGR, pre-eclampsia, placenta Praevia/abruption, cervix >4cm.
124
What medications should be considered in women with preterm labour?
IM corticosteroids - betametasone for lung development
IV magnesium sulphate - neuroprotection
?tocolytics if intact membranes
prophylactic PO erythromycin QDS if PROM - until delivery or 10d course (whichever comes first)
125
What forms of prophylaxis are there for preterm labour?
Vaginal progesterones and cervical cerclage
126
How would you manage a woman with PROM with respect to timing delivery?
>24 weeks - no contraindications to continue pregnancy then expectant management until 34 weeks for IOL, mx as outpatient avoid swimming/sex/source of infection, weekly follow up for FBC + CRP. IM corticosteroids.
>34 weeks - expectant management for 24h or offer immediate IOL with vaginal progesterones.
127
Should you use tocolytics in PPROM
No evidence to support use, and increased risk of infection giving tocolytics before 34wks.
128
What is 'small for gestational age'?
An estimated foetal weight or abdominal circumference of less than 10th centile for corrected gestational age. (severe less than 3rd centile)
129
Causes for SGA
Normally - constitutionally small 50-70% cases, small size at all stages but growth follows centile, no pathology, contributing factors = ethnicity, sex, parental height.
Placental-mediated growth restriction - usually normal growth initially which slows; placental insufficiency - pre-eclampsia, placental infarction/abruption, CKD, DM, chronic htn, low pre-pregnancy weight, substance abuse/smoking, autoimmune disease.
Non-placental - foetal factors - genetic abnormality (T13/18/21), congenital anomaly/infection, error in metabolism.
130
Major risk factors for SGA
```
Prev SGA baby or parental SGA, prev stillbirth
Maternal age >40
Smoker 11+/day or cocaine use
Maternal disease
Heavy bleeding
Low PAPPA
```
131
Minor risk factors for SGA
```
Maternal age 35+
Nulliparity
BMI <20
IVF
Smoker <10/d
previous pre-eclampsia
```
132
How are those at risk of SGA assessed?
High risk - refer for consultant led care, serial USS including umbilical artery doppler from 26-28/40
3+ minor risk factors - umbilical artery doppler at 20-24wks to assess need for serial USS.
133
How are SGA pregnancies managed?
Prevention - smoking cessation, optimise medical rx
Surveillance - umbilical a dopplers every 14d and growth scan every 2-3 weeks
Delivery - normal growth scans and dopplers IOL at 37/40 with CTG; abnormal dopplers offer IOL before 37/40; absent/reversed end diastolic flow on dopplers deliver by LSCS
134
Complications of SGA
birth asphyxia, hypothermia, hypo/hyper-glycaemia, polycythaemia, ROP, PPH, pulm haemorrhage, NEC, CP, DM2, obesity, htn, behavioural problems, etc.
135
Causes of LGA
Maternal obesity or DM2, constitutionally large
136
When should LGA deliver?
Care on consultant led ward but delivery as normal. No evidence that early IOL or delivery improves outcome.
137
In a post dates pregnancy when do UHL offer IOL?
Term + 12 (or +7 at maternal request)
138
Risk factors for post-dates pregnancy
Nulliparity, maternal age >40, personal/family hx prolonged pregnancy, high BMI.
139
Complications of prolonged pregnancy
STILLBIRTH, risk placental insufficiency leading to foetal academia and meconium aspiration, foetal hypoglycaemia
140
How is post-dates pregnancy managed?
Membrane sweep offered from 40+0 (primip) or 41+0 (multip)
IOL 41+0 - 42+0 with vaginal prostaglandins ± oxytocin
if declined offer twice weekly CTG monitoring + USS with liquor volume to assess foetal distress
141
Define antepartum haemorrhage
bleeding from the genital tract during pregnancy after 24+0 weeks gestation
142
List some causes of APH
Dangerous - placental abruption, placenta Praevia and vasa praevia
Lower genital tract - cervical polyps/ectropion/carcinoma, cervicitis, vaginitis, vulval varicosities.
Placental sinuses, circumvallate placenta
143
What is placental abruption?
Part/all of the placenta separates from the uterine wall prematurely. Rupture of maternal vessels in the endometrium causes blood to accumulate and separating the placenta from endometrium which then causes foetal compromise.
144
How does placental abruption present?
Constant lower abdominal pain
PV bleeding - or can have a concealed bleed where retroplacental clot forms, leading to shock >> bleeding
O/E tender tense uterus, normal lie/presentation, foetal heart absent/distressed
Risk of DIC, coagulation problems, anuria, pre-eclampsia
145
Risk factors for placental abruption
```
Previous placental abruption/pre-eclampsia/hypertensive disorder
Abdominal trauma - ?domestic violence
Smoking/substance abuse e.g. cocaine
Polyhydramnios
T1 bleeding
Multiple pregnancy
Underlying thrombophilia
Abnormal lie of the baby
```
146
What is placenta praevia?
Part or all of the placenta is attached to the lower uterine segment, it can be classified as major (placenta covers the internal cervical Os) or minor (placenta is low lying but does not cover the internal cervical os) and confers a greater risk of haemorrhage either spontaneously or from minor trauma.
147
Risk factors for placenta praevia
```
Prev placenta praevia
Previous C-section
High parity
Maternal age >40
Multiple pregnancy
Hx endometritis
Endometrial curretage - previous TOP or miscarriage
```
148
Presentation of placenta praevia
Painless PV bleed, usually a small bleed before a large bleed and is in proportion with shock.
May have abnormal lie/presentation, foetal heart rate usually normal
149
What is vasa praevia?
Foetal vessels run through the free placental membrane unprotected by placental tissue or Whartons jelly of the umbilical cord increasing risk of rupture especially in active labour or amniotomy.
150
How does Vasa Praevia present?
Classically - SROM followed immediately by PV bleed and foetal compromise (bradycardia)
Asymptomatic and felt O/E in labour - pulsating foetal vessels may be felt inside internal cervical os
151
How would you manage APH?
A to E assessment and resus if required
Admit unless use spotting
Ix - bloods (FBC, U+;Es, LFTs, clotting, G+S, X-match, Rh- = Kleihauer), CTG (>26/40), pelvic USS (placenta praevia usually identified at 20 week scan, rescanned at 32 if major or 36 if minor)
Rh- administer anti-D within 72h
Delivery - consult senior obstetrician
- placenta praevia - C-section usually planned, if vaginal require AMTS due to increased risk PPH
- placental abruption - any foetal/maternal compromise deliver immediately, APH at term without compromise then IOL
152
How is premature ROM different to pre-term premature ROM?
```
PROM = ROM >=1hr prior to onset of labour at >=37/40
PPROM = ROM <37 weeks
```
153
Define labour
Onset of regular painful contractions associated with cervical dilatation and descent of the presenting part
154
Define the 1st stage of labour and describe its management
Onset of regular painful contractions to the point of full cervical dilatation; can be divided into latent phase (0-3cm, painful, often irregular contractions as cervix effaces) and active phase (3-10cm, painful regular contractions with dilatation, normally 1cm/hr)
Assess contractions every 30mins for at least 1 minute (strength and frequency - should be 3-4 every 10mins), hourly pulse, 4-hourly temp, BP and PV exam, record frequency of urination.
155
Define the 2nd stage of labour and describe its physiology and management
Full cervical dilatation - delivery of the baby; lasting 1hr in multip/2h in primip = delay in 2nd stage ?ventouse/forceps required. Contractions are stronger and occur more freq (2-5mins)
Passive - in the absence of pushing. Active - baby is visible, expulsive contractions as mom pushes
BP, pulse and PV exam hourly, temp 4 hourly, measure contractions for at least 1 min every 5mins. If contractions are waning ?oxytocin. May require mediolateral episiotomy during crowning.
156
Define the 3rd stage of labour and describe its physiology and management
Delivery of baby - expulsion of placenta and membranes.
Sx - cord lengthening -> PV bleed -> uterus rises and contracts (felt with hand as globular mass). Usually takes less than 1hr and can be physiological or active (IM syntometrine as ant shoulder delivers, controlled cord traction, delayed cord clamping), check placenta is complete.
157
Pros and cons of AMTS
Pro - reduced rates of PPH
| Con - increased rates of N+V, can make afterpains worse.
158
contraindications to use of syntometrine
severe htn/heart/liver/renal disease, pre-eclampsia. If unknown BP during labour can only use oxytocin (not ergometrine)
159
Which foetal head presentations have the smallest diameter (thus better for delivering vaginally)?
Suboccipitobregmatic - vertex flexed
| Submentobregmatic - face
160
Describe the normal mechanism of labour- movements through which the foetus delivers
Descent - foetal head descends into pelvis, usually happens pre-labour but can happen in established labour if multigravida
Engagement - largest diameter of foetal head descends into maternal pelvis (abdo feel 3/5ths or less) taking up L or R occipitotransverse position
Flexion - foetal head touches pelvic floor = cervical flexion to suboccipitobregmatic position to smaller diameter to aid passage through pelvis
Internal rotation - gutter shape of pelvic floor rotates head to OA position
Crowning - widest diameter of foetal head through the narrowest part of pelvis, head visible at vulva does not retreat during contractions
Extension - occiput slips beneath suprapubic arch, head extends and delivers
Restitution and ext rotation - head externally rotates to face the medial aspect of R/L thigh and aligning spine, anterior shoulder delivers, then posterior
161
Indications for IOL?
Prolonged gestation, IUGR, premature ROM >37/40, (34-37 weigh risks), maternal health problems (e.g. obstetric cholestasis, DM)
162
Contraindications for IOL?
Cephalopelvic disproportion, placenta/vasa Praevia, cord prolapse, transverse lie, previous classical C-section, active genital herpes.
Relative - breech, triplets, prev 2+ LSCS.
163
Can a woman who has previously had an LSCS have a subsequent IOL?
Yes as long as she is assessed by a consultant who approves this. Higher risk of uterine rupture and emergency C-section.
164
What methods are used for IOL?
Vaginal prostaglandins - tablet/gel/pessary, 1 cycle in 24h; ripen cervix and aid uterine contraction.
Membrane sweep - not a formal IOL but an adjunct to promote physiological PG release increasing likelihood of spontaneous delivery. Offered at 40 if nullip, 41 if parous.
Amniotomy ± syntocinon - if ripe cervix, NICE says only if vaginal prostaglandins are contraindicated.
165
How is suitability for IOL assessed?
Bishop score assesses cervical ripeness, <5 suggests IOL needed to start labour; score of 8+ is 'favourable', spontaneous labour is likely.
166
Complications of IOL?
Failure, uterine hyper stimulation (can cause foetal distress, requires tocolytics like terbutaline), cord prolapse, infection, pain, increased rates of further intervention than spontaneous labour, uterine rupture (rare)
167
How would you manage a woman with delay in 1st stage of labour (<2cm in 4h or slowing in second labour)
Assess woman - r/v notes, palpate foetal lie, presentation and contractions, foetal HR, check amniotic fluid. PV exam - dilatation, effacement, station, position.
Pain relief, get obstetrics involved - amniotomy and/or oxytocin (oxytocin needs senior r/v If prev c-section or multiparous)
168
How would you manage delay in 2nd stage (delivery not imminent after 1h in multip or 2h in primip)
Support, anaesthesia, obstetrician r/v for consideration of instrumental delivery or C-section
169
Give most commonly used methods of anaesthesia for labour
Nitrous oxide + O2 (entonox) - patient controlled, short-acting and quick onset.
IM pethidine + cyclizine
Pudendal nerve block with lignocaine
Epidural anaesthesia - bupivicaine and fentanyl in L3/L4 spinal catheter
Spinal anaesthesia - used for LSCS, easier to insert than epidural but shorter acting.
170
Predisposing factors for a multiple pregnancy?
Previous multiple pregnancy, family hx dizygotic twins, increasing maternal age, induced ovulation and IVF, race e.g. Afro-Caribbean
171
Which is more common - dizygotic or monozygotic twins?
Dizygotic 80%
172
A 28 year old lady comes for her dating scan at 13+0 weeks gestation, on the USS you note she is having twins. How would you identify the chorionicity of twins she is having (MCMA/DCDA)
```
MCDA = T sign at the inter-twin membrane placental junction (forms a right angle)
DCDA = lambda sign, triangular projection of chorion between the layers of the inter-twin membrane
```
173
Features of a twin pregnancy
Usually identified on USS - 2+ foetal poles, multiplicity of foetal parts, 2 foetal heart rates heard. May also have hyperemesis, LFD, polyhydramnios
174
Complications of twin pregnancy
Increased risk of polyhydramnios, APH, anaemia, pre-eclampsia, GDM, operative delivery
175
Foetal complications of twin pregnancy?
```
Twin-twin transfusion syndrome if monochorionic
Prematurity
IUGR
perinatal mortality
malformations
```
176
Labour complications of twin pregnancy
PPH, malpresentation, vasa praaevia rupture, cord prolapse/entanglement, placental abruption
177
Main themes of managing a multiple pregnancy and delivery
Consultant led care as it is high risk
USS - monthly if DC, fortnightly if MC
+ other risk factor for pre-eclampsia = aspirin from 12/40
Uncomplicated DC = offer elective at 37; uncomplicated MC offer elective at 36 with steroids; MCMA 32+0-33+6
Labour - continuous CTG and AMTS, paeds present
Postnatal support groups
178
Breech presentation risk factors
```
uterine malformations (e.g. bicornuate) or abnormality e.g. fibroids
Placenta praevia
Oligo/poly-hydranios
Foetal abnormality
Prematurity
```
179
What is a breech presentation? most common type? Most dangerous type and why?
When caudal end of the foetus occupies the lower segment of the uterus. Frank breech presentation with hips flexed and legs extended. Footling - risk cord prolapse
180
Mx of breech presentation
<36/40 reassure most turn on their own
Offer ECV if woman is breech at 36wks (P0) or 37 weeks (P1+)
Can have planned vaginal or C-section - c-section associated with lower risk morbidity and mortality during delivery but no evidence of detriment to long-term health
181
Contraindications to ECV
```
C-section required
ROM
Multiple pregnancy
Abnormal CTG
APH in last 7/7
major uterine anomaly
```
182
Define cord prolapse
Descent of the cord through the cervix below the presenting part after ROM. Cord compression and vasospasm from cord exposure can result in foetal asphyxia
183
Risk factors for cord prolapse
Prematurity, malpresentation, multiple pregnancy, multiparity, polyhydramnios, cephalopelvic disproportion, long umbilical cord, high foetal station
184
When do the majority of cases of cord prolapse occur?
ARM
185
How might cord prolapse present?
Abnormal foetal HR + palpable/visible cord PV
186
Mx of cord prolapse
Senior help
Get patient on all fours, prep for emergency C-section
Push presenting part of foetus back into uterus to avoid compression
187
What is shoulder dystocia?
A delivery requriing additional obstetric manoeuvres to release shoulders after gentle downward traction has failed, associated with maternal and foetal morbidity. Usually occurs as anterior shoulder impacts maternal pubic symphysis.
188
Complications of shoulder dystocia
Foetal - brachial plexus injury, clavicle fracture
| Maternal - PPH, perineal tears
189
Risk factors for shoulder dystocia
Foetal macrosomia/post-dates, maternal obesity, diabetes, prolonged labour, IOL/use of oxytocin, assisted vaginal delivery
190
Mx of shoulder dystocia
Call for senior help
McRoberts manoeuvre + suprapubic pressure
Internal manoeuvres (may require episiotomy for better access)
191
Describe McRoberts manoeuvre
Flexion and abduction of the hips such bringing the patients thighs touch her abdomen to increase relative anteroposterior angle of the pelvis
192
Indications for an operative vaginal delivery
Maternal - delay in 2nd stage (pushing 2hr in P0, 1hr in P1+), exhaustion, medical avoidance of pushing e.g. severe cardiac disease or unable to push (paraplegic)
Foetal - suspected distress, after coming head in breech
193
Complications of an instrumental delivery
Maternal genital tract trauma, incontinence, VTE, PPH shoulder dystocia, infection
Foetal cephalhaematoa, scalp lacerations, face bruising, facial n palsy, skull #, retinal haemorrhage, neonatal jaundice.
194
Indications for c-section
breech/other malpresentation, absolute cephalopelvic disproportion, grade 3/4 placenta praevia, delay in 2nd stage, pre-eclampsia, foetal compromise, prolapsed cord, IUGR/post dates, multiple pregnancy where twin 1 not cephalic, vaginal infection/cervical ca.
195
List 3 measures required before c-section which you as an F1 could do?
Bloods - FBC and G+S
VTE risk assessment - if appropriate prescribe TEDS ± LMWH
H2 receptor antagonist (ranitidine) ± metoclopramide
196
List in order the layers you would dissect using a pfannenstiel incision for a LSCS
```
Skin
Subcutaneous tissue - superficial Campers fascia + deep Scarpas fascia
Rectus sheath
Rectus muscle
Parietal peritoneum of uterus
Visceral peritoneum of uterus
Uterus
```
197
Risks of c-section
Frequent - infection, PPH, persistent wound/abdominal discomfort for up to months post-op, risk of emergency c-section in subsequent VBAC, foetal lacerations
Serious - emergency hysterectomy, need for further surgery, admission to ICU, VTE, bladder/ureteric injury, increased risk of uterine rupture/stillbirth/placenta praevia or accrete in subsequent pregnancy.
198
Advantage of VBAC over ERCS?
Quicker recovery and shorter stay in hospital (if uncomplicated)
Increased chance of successful VBAC in future
Avoid risks of operation
Reduced incidence of transient resp difficulties in baby
199
Advantage of ERCS over VBAC?
Planned C-section less risky than an emergency C-section - risk of having to convert to this in VBAC
Less risk of scar dehiscence/ uterine rupture
No risk of perineal injury
Less maternal mortality (though both risks small)
200
How should VBAC be managed
Deliver in hospital setting with facilities for advanced neonatal resuscitations and emergency c-section
Avoid IOL with prostaglandins increase risk rupture (instead ARM with amniotomy if required)
Continuous CTG during labour
Cautious use of oxytocin risk rupture
201
Contraindications to VBAC?
Previous classical C-section (longitudinal scar)
Previous uterine rupture
CIs to vaginal delivery as normal - e.g. placenta praevia
Relative - complex scars or 3+ previous LSCS
202
Define PPH
loss of 500+ml blood from genital tract after delivery. Can be primary (within 24h) or secondary (24h-12wks).
203
How much blood is lost in a major PPH?
1L with ongoing bleeding or clinical shock
204
Causes of primary PPH
Uterine atony 90% cases, clotting disorders, genital trauma
205
Risk factors for primary PPH
Prolonged labour, pre-eclampsia, geriatric pregnancy, polyhydramnios, emergency c-section, placenta praevia/accreta, macrosomia
206
Mx of primary PPH
A to E assessment and call for senior help
Secure airway and high flow O2
2x14g cannula - FBC, U+Es, LFTs, clotting, X-match 4-6u
IV fluid resuscitation while waiting blood transfusion
Catheterise
Uterine atony - bimanual compression massage uterus
Medical - oxytocin (slow IV injection), IV ergometrine (CI htn), IV oxytocin, IM carboprost (repeat doses 15min)
Surgical - intrauterine balloon tamponade, B Lynch suture, ligation of uterine/internal iliac arteries, hysterectomy
207
Causes secondary PPH
retained placental tissue or endometritis
208
Amniotic fluid embolism presentation
Classically seen following ROM, mainly during labour
Sudden collapse, dyspnoea/chest pain/hypoxia/resp arrest -> ARDS, foetal distress, hypotension, anxiety, chills, sweating, shivering, reduced consciousness, seizures, cardiac arrest. Most will have DIC in 48h
209
Caput succedaneum vs cephalhaematoma
swellings on presenting part (usually vertex of head) seen in infants born after prolonged, difficult labour
CH bleeding into (typically parietal) periosteum, CS boggy soft generalised swelling due to oedema
CH limited by suture lines, CS is not
CH onset within hours of birth, can take months to resolve; CS present at birth and resolves in days
210
What is a chignon
Iatrogenic caput succedaneum typically seen after ventouse delivery
211
Classification of perineal tears
1st degree - superficial damage, no muscle involvement
2nd - damage to the perineal muscle, no anal sphincter complex involvement
3rd - damage to anal sphincter complex but not rectal mucosa. A) EAS thickness <50% torn, B) EAS thickness >50% torn, C) EAS and IAS torn
4th - damage to anal sphincter complex and rectal mucosa
212
Risk factors for perineal tears
Primigravida, large babies, precipitant labour, shoulder dystocia, forceps delivery
213
Define puerperal pyrexia and its most common causes
T > 38+ in first 14d.
Causes - endometritis, UTI, wound infection, mastitis, VTE. R/o endometritis as needs admission for IV clindamycin + gentamicin.
214
What is lochia?
PV discharge containing blood, mucus and uterine tissue seen after delivery, can continue for up to 6wks post-partum
215
How do baby blues typically present?
Onset within 3d birth, peak 5 days, usually self-resolve within 2wks. Tearful, irritable, anxious about baby, poor concentration.
216
Risk factors for PND
Hx of PND or uni/bi-polar depression, unplanned pregnancy, poor social support/circumstances, sleep deprivation
217
How does PND typically present?
Onset within 1m delivery, peak around 3 months. Features similar to other depression.
218
How would you assess and manage PND
Edinburgh PND scale
Involve dad, encourage opening up about worries/woes, normalise, low threshold for referral to specialist team.
Mx - CBT ± sertraline/paroxetine if severe (safe to breastfeed)
219
Risk factors for post partum psychosis
Prev episode post partum psychosis or mental illness, poor social support.
220
how does post partum psychosis present?
2-3wks following birth, psychosis with prominent affective sx, rapidly fluctuating sx, mood instability, insomnia, disordered perception e.g. hallucinations.
221
When is contraception required in postnatal period?
21 days
222
What are the criteria for effective use of lactational amenorrhoea as a contraceptive and how does it work?
<6m postpartum, amenorrhoeic, and breastfeeding without any formula feeding.
Breastfeeding suppresses the frequency and amplitude of gonadotrophin surges so while they do increase, not sufficient to cause ovulation.
223
When can progesterone only pill start post-partum?
Any time, but if after 21d cover with additional contraception for 2 days
224
Conditions for COCP use post partum
Not breastfeeding = can start day 21, need 7d additional cover
Breastfeeding = CI <6wks; can start at 6wks if no other acceptable alternative methods contraception but 6wk-6m is a UKMEC2. Can affect milk production.
225
When can IUCD/IUS be started after childbirth?
Within 48h of childbirth or after 4 weeks (interval risk of uterine perforation on insertion)
226
causes of oligohydramnios
```
ROM
placental insufficiency
renal agenesis or non-functioning foetal kidneys
obstructive uropathy
genetic or chromosomal abnormality
viral infection (can also cause poly)
```
227
what is Oligohydramnios?
amniotic fluid volume <5th centile for gestational age
228
what investigations could you use to determine whether cause of oligohydramnios is ROM?
bedside test - IGFBP1 test of ?amniotic fluid sample
| USS - liquor volume
229
what are the complications associated with oligohydramnios?
prematurity (either PPROM leading to labour, or planned IOL and delivery in placental insufficiency)
disabling severe muscle contractures - foetus can't exercise move limbs in utero.
230
what is polyhydramnios?
amniotic fluid vol >95th centile for gestational age
231
what investigations would you perform in a woman with Polyhydramnios?
repeat USS - liquor volume, structural abnormality in foetus
maternal IGTT - ?DM
maternal TORCH screen - ?torch infection causative
