Obstetrics fifth yr Flashcards
Summary of oligohydramnios?
Reduced amniotic fluid. Definitions vary but include less than 500ml at 32-36 weeks and an amniotic fluid index (AFI) < 5th percentile.
Causes:
premature rupture of membranes
Potter sequence (bilateral renal agenesis + pulmonary hypoplasia)
intrauterine growth restriction
post-term gestation
pre-eclampsia
What are the risks of chickenpox exposure to both mother and fetus?
Mother - 5 times greater risk of pneumonitis
Fetal varicella syndrome - skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning disabilities
Shingles in infancy
Severe neonatal varicella
Management of chickenpox exposure in pregnancy?
if doubt about immunity - maternal blood should be urgently checked for varicella antibodies
if <20 weeks and not immune - VZIG, effective up to 10 days post exposure
if the pregnant woman > 20 weeks gestation is not immune to varicella then either VZIG or antivirals (aciclovir or valaciclovir) should be given days 7 to 14 after exposure
Management of chickenpox in pregnancy?
specialist input should be sought
oral aciclovir should be given if the pregnant women is ≥ 20 weeks and she presents within 24 hours of onset of the rash
if the woman is < 20 weeks the aciclovir should be ‘considered with caution’
Summary of breastfeeding problems?
Nipple pain
Blocked duct
Nipple candidiasis - miconazole cream for the mother and nystatin suspension for the baby
Mastitis - treat ‘if systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal of if culture indicates infection’. The first-line antibiotic is flucloxacillin for 10-14 days. Continue breastfeeding. Can develop into breast abscess.
Engorgement - causes blocked milk ducts, mastitis and difficulties with breastfeeding and, subsequently, milk supply.
Raynaud’s disease of nipple - Blanching of the nipple may be followed by cyanosis and/or erythema. Nipple pain resolves when nipples return to normal colour.
Options of treatment for Raynaud’s disease of the nipple include advice on minimising exposure to cold, use of heat packs following a breastfeed, avoiding caffeine and stopping smoking. If symptoms persist consider specialist referral for a trial of oral nifedipine (off-license).
What is a miscarriage?
spontaneous termination of a pregnancy before 24 weeks.
Early miscarriage is before 12 weeks gestation.
Late miscarriage is between 12 and 24 weeks gestation.
Types of miscarriage?
Missed miscarriage – the fetus is no longer alive, gestational sac containing dead foetus before 20 weeks, but no symptoms have occurred. Cervical os closed
Threatened miscarriage – vaginal bleeding before 24 wks, with a closed cervix and a fetus that is alive
Inevitable miscarriage – vaginal bleeding (heavy with clots and pain) with an open cervix
Incomplete miscarriage – retained products of conception remain in the uterus after the miscarriage. Cervical os open. Pain and PV bleed.
Complete miscarriage – a full miscarriage has occurred, and there are no products of conception left in the uterus
Anembryonic pregnancy – a gestational sac is present but contains no embryo
Ix of miscarriage?
TVUS is Ix of choice
3 features to look for in early pregnancy. As each appears, the previous feature becomes less relevant:
Mean gestational sac diameter
Fetal pole and crown-rump length
Fetal heartbeat
Fetal heartbeat - pregnancy considered viable. Expected once crown-rump length is 7mm or more.
Crown-rump length less than 7mm without fetal heartbeat, the scan is repeated after at least one week to ensure a heartbeat develops. When there is a crown-rump length of 7mm or more, without a fetal heartbeat, the scan is repeated after one week before confirming a non-viable pregnancy.
A fetal pole is expected once the mean gestational sac diameter is 25mm or more. When there is a mean gestational sac diameter of 25mm or more, without a fetal pole, the scan is repeated after one week before confirming an anembryonic pregnancy.
Management of miscarriage?
<6 wks - managed expectantly if no pain or other complications or RFs. No Ix or Tx. Repeat pregnancy test after 7-10 days, if negative then miscarriage confirmed. When bleeding continues, or pain occurs, referral and further investigation is indicated.
> 6wks - refer to EPAU. USS to confirm location and viability of the pregnancy.
Expectant - first line if not RFs for heavy bleeding or infection. 1-2 weeks given for miscarriage to occur spontaneously. A repeat urine pregnancy test should be performed three weeks after bleeding and pain settle to confirm the miscarriage is complete. Persistent/worsening bleeding - further assessment and repeat US
Medical - misoprostol (prostaglandin analogue) to soften cervix and stimulate uterine contractions. PV or oral. SE = heavier bleeding, pain, vomiting, diarrhoea
Surgical - LA or GA. Manual vacuum aspiration under LA, electric vacuum aspiration under GA. Prostaglandins given to soften cervix.
Manual vacuum aspiration - below 10 wks, appropriate for parous women
Anti-rhesus D prophylaxis is given to rhesus negative women having surgical management of miscarriage.
Summary of incomplete miscarriage?
occurs when retained products of conception (fetal or placental tissue) remain in the uterus after the miscarriage. - risk of infection!
2 options:
medical - misoprostol
surgical - evacuation of RPOC (complication = endometritis)
Summary of HELLP syndrome?
acronym for Hemolysis, Elevated Liver enzymes, and a Low Platelet count
late stages. overlap with severe pre-eclampsia, and 10-20% of pt’s with severe pre-eclampsia fo on to develop HELLP
Features - N+V, RUQ pain, lethargy
Ix - FBC, LFTs
Tx - delivery of baby
Definition of pre-eclampsia?
new-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of the following:
proteinuria
other organ involvement (see list below for examples): e.g. renal insufficiency (creatinine ≥ 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction
precursor to eclampsia
Features of pre-eclampsia?
Triad - new-onset HTN, proteinuria, oedema
Eclampsia - and other neurological complications - altered mental status, blindness, stroke, clonus, severe headaches, or persistent visual scotomata
Fetal complications - intrauterine growth retardation, prematurity
Liver involvement - elevated transaminases
Haemorrhage - placental abruption, intra-abdominal, intra-cerebral, cardiac failure
Features of severe - HTN >160/110 and proteinuria, proteinuria ++/+++, headache, visual disturbance, Papilloedema, RUQ/epigastric pain, hyperreflexia, platelet count <100*10^6/l, abnormal liver enzymes or HELLP
Risk factors for pre-eclampsia?
High:
hypertensive disease in previous pregnancy
CKD
AI disease - SLE, APS
type 1/2 DM
chronic HTN
Moderate:
first pregnancy
age 40 years or older
pregnancy interval of more than 10yrs
BMI of 35 kg/m2 or more at first visit
family history of pre-eclampsia
multiple pregnancy
How to reduce risk of hypertensive disorders in pregnancy?
women with the following should take aspirin 75-150mg daily from 12 weeks gestation until the birth:
>1 high risk factors
>2 moderate risk factors
Management of pre-eclampsia?
Emergency secondary care assessment for any woman in suspected pre-eclampsia
Women with BP >160/110 are likely yo be admitted and observed
Oral labetalol. Nifedipine (if asthmatic) and hydralazine
Delivery of baby is definitive
Causes of abdominal pain in early pregnancy?
Ectopic pregnancy - lower abdo pain, PV bleeding, recent amenorrhoea, peritoneal bleeding
Miscarriage - threatened, missed, inevitable, incomplete
UTI - associated with increased risk of pre-term delivery and IUGR
Appendicitis
