Other Flashcards

Question

Low birth weight

Answer 1

BW of less than 2500 g

Answer 2

* Constitutionally small - growing appropriately on the growth chart * Fetal growth restriction - IUGR → small foetus due to a pathology reducing the amount of nutrients and oxygen being delivered to the foetus through the placenta

Answer 3

* Placenta mediated * Non-placenta mediated (usually genetic or structural abnormality)

Answer 4

* Idiopathic * Pre-eclampsia * Maternal smoking * Maternal alcohol * Anaemia * Malnutrition * Infection * Maternal health conditions

Answer 5

* Genetic abnormalities * Structural abnormalities * Fetal infection * Errors of metabolism

Answer 6

* Reduced amniotic fluid volume * Abnormal Doppler studies * Reduced fetal movements * Abnormal CTGs

Answer 7

Short term complications of fetal growth restriction include: * Fetal death or stillbirth * Birth asphyxia * Neonatal hypothermia * Neonatal hypoglycaemia Growth restricted babies have a long term increased risk of: * Cardiovascular disease, particularly hypertension * Type 2 diabetes * Obesity * Mood and behavioural problems

Answer 8

The critical management steps are: * Identifying those at risk of SGA * Aspirin is given to those at risk of pre-eclampsia * Treating modifiable risk factors (e.g. stop smoking) * Serial growth scans to monitor growth * Early delivery where growth is static, or there are other concerns When a fetus is identified as SGA, investigations to identify the underlying cause include: * Blood pressure and urine dipstick for pre-eclampsia * Uterine artery doppler scanning * Detailed fetal anatomy scan by ***fetal medicine*** * Karyotyping for chromosomal abnormalities * Testing for infections (e.g. toxoplasmosis, cytomegalovirus, syphilis and malaria) * Intrapartum * **Abnormalities in umbilical artery doppler or MCA doppler: delivery by 37 weeks** * **SGA with umbilical artery AREDV \<32 weeks: delivery by 32 weeks after completion of steroids** IOL can be offered with continuous CTG once contractions begin but high conversion to EMCS

Answer 9

* \>4.5kg (macrosomic) * \> 90th central EFW

Answer 10

* Constitutional * Maternal diabetes * Previous macrosomia * Maternal obesity or rapid weight gain * Overdue * Male baby * Syndromes - Beckmanwith-Wiedemann

Answer 11

* OGTT (GDM) * Bloods (serum HCG) * US (liquor volume) * Genetic testing

Answer 12

Most women with large for gestational age pregnancy will have a successful vaginal delivery. NICE guidelines (2008) advise against induction of labour only on the grounds of macrosomia.

Answer 13

The risks to the mother include: * Shoulder dystocia * Failure to progress * Perineal tears * Instrumental delivery or caesarean * Postpartum haemorrhage * Uterine rupture (rare) The risks to the baby include: * Birth injury (Erbs palsy, clavicular fracture, fetal distress and hypoxia) * Neonatal hypoglycaemia * Obesity in childhood and later life * Type 2 diabetes in adulthood

Answer 14

The risks at delivery can be reduced by: * Delivery on a consultant lead unit * Delivery by an experienced midwife or obstetrician * Access to an obstetrician and theatre if required * Active management of the third stage (delivery of the placenta) * Early decision for caesarean section if required * Paediatrician attending the birth

Answer 15

* Development of rhesus antibodies in a rhesus negative mother after exposure to Rh +ve RBCs. Always a Rh mother.

Answer 16

Needs a sensitising event. In subsequent pregnancies involving a RhD-positive foetus, maternal IgG antibodies will cross the placenta, forming complexes with RhD on foetal erythrocytes and destroying them.

Answer 17

Picked up on routine testing. Can lead to hydrops fetalis

Answer 18

* Amniocentesis, chorionic villus biopsy and cordocentesis * Antepartum haemorrhage/Uterine (PV) bleeding in pregnancy * ECV * Abdo trauma * Ectopic * Evacuation of molar pregnancy * Intrauterine death and still birth * Miscarriage * TOP * Delivery * Intra-operative cell salvage

Answer 19

* Prevention: Anti- D immunoglobulin prophylaxis recommended for RhD -ve mothers at 28 and 34 weeks * Anti-D Ig should be administered within 72hrs of any sensitising event: * \<12 weeks 250IU only for ectopic, TOP, molar and abnormal heavy uterine bleeding * 12-20 weeks 250IU * 20+ weeks 500IU + Kleihauer test (done to see how much fetal blood has passed into maternal blood stream) * If isoimmunisation has occurred, then blood transfusion for the foetus may be required

Answer 20

The Kleihauer test involves adding acid to a sample of the mother’s blood. Fetal haemoglobin is naturally more resistant to acid, so that they are protected against the acidosis that occurs around childbirth. Therefore, fetal haemoglobin persists in response to the added acid, while the mothers haemoglobin is destroyed. The number of cells still containing haemoglobin (the remaining fetal cells) can then be calculated.

Answer 21

Pulmonary embolism (PE) remains a leading direct cause of maternal death in the UK. There has been a significant fall in the maternal mortality rate from PE

Answer 22

* Many fatal antenatal VTE events occur in the first trimester and therefore prophylaxis for women with previous VTE should begin early in pregnancy * The risk for VTE increases with gestational age, reaching a maximum just after delivery * Caesarean section is a significant risk factor * The absolute risk peaked in the first 3 weeks postpartum

Answer 23

* All women should undergo a documented assessment of risk factors for VTE in early pregnancy or prepregnancy. * Risk assessment should be repeated if the woman is admitted to hospital for any reason or develops other intercurrent problems. * Risk assessment should be repeated again intrapartum or immediately postpartum.

Answer 24

* Women with previous VTE should be offered prepregnancy counselling and a prospective management plan for thromboprophylaxis in pregnancy made. Those who become pregnant before receiving such counselling should be referred at the earliest opportunity in pregnancy to a clinician with expertise in thrombosis in pregnancy. * Women with **previous VTE** (except those with a single previous VTE related to major surgery and no other risk factors) should be offered **thromboprophylaxis with LMWH throughout the antenatal period.** * Any woman with four or more current risk factors (other than previous VTE or thrombophilia) should be considered for prophylactic LMWH **throughout the antenatal period** and will usually re**quire prophylactic LMWH for 6** weeks postnatally but a postnatal risk reassessment should be made. * Any woman with three current risk factors (other than previous VTE or thrombophilia) should be considered for prophylactic LMWH f**rom 28 weeks and will usually require prophylactic LMWH for 6 weeks** postnatally but a postnatal risk reassessment should be made.

Answer 25

* Women with previous VTE associated with antithrombin deficiency (who will often be on long-term oral anticoagulation) should be offered thromboprophylaxis with higher dose LMWH (either 50%, 75% or full treatment dose) antenatally and for 6 weeks postpartum or until returned to oral anticoagulant therapy after delivery. * Management should be undertaken in collaboration with a haematologist with expertise in thrombosis in pregnancy and consideration given to antenatal anti-Xa monitoring and the potential for antithrombin replacement at initiation of labour or prior to caesarean section. * If anti-Xa levels are measured, a test that does not use exogenous antithrombin should be used and 4-hour peak levels of 0.5–1.0 iu/ml aimed for. * Other heritable thrombophilic defects are lower risk and can be managed with standard doses of thromboprophylaxis.

Answer 26

Women with VTE associated with the antiphospholipid syndrome (APS) (who will often be on longterm oral anticoagulation) should be offered thromboprophylaxis with higher dose LMWH (either 50%, 75% or full treatment dose) antenatally and for 6 weeks postpartum or until returned to oral anticoagulant therapy after delivery. Pregnant women with APS and prior VTE or arterial thromboses should be managed in collaboration with a haematologist and/or rheumatologist with expertise in this area

Answer 27

* Antenatal thromboprophylaxis for those with previous VTE should begin as early in pregnancy as practical. * Women without previous VTE and without particular first trimester risk factors or admission to hospital, but with four other risk factors, should be considered for antenatal prophylaxis throughout pregnancy. * Women without previous VTE and without particular first trimester risk factors or admission to hospital, but with three other risk factors, can start antenatal prophylaxis at 28 weeks of gestation.

Answer 28

* Women admitted with hyperemesis should be considered for thromboprophylaxis with LMWH and can discontinue thromboprophylaxis when the hyperemesis resolves. * Women with ovarian hyperstimulation syndrome should be considered for thromboprophylaxis with LMWH in the first trimester. * Women with an IVF pregnancy and three other risk factors should be considered for thromboprophylaxis with LMWH starting in the first trimester.

Answer 29

* Women receiving antenatal LMWH should be advised that if they have any vaginal bleeding or once labour begins they should not inject any further LMWH * Regional techniques should be avoided if possible until at least 12 hours after the previous prophylactic dose of LMWH. (24 for therapeutic dose) * LMWH should not be given for 4 hours after use of spinal anaesthesia or after the epidural catheter has been removed and the catheter should not be removed within 12 hours of the most recent injection. *

Answer 30

Women receiving antenatal LMWH having an elective caesarean section should receive a thromboprophylactic dose of LMWH on the day prior to delivery and, on the day of delivery, any morning dose should be omitted and the operation performed that morning

Answer 31

* The first thromboprophylactic dose of LMWH should be given as soon as possible after delivery provided there is no postpartum haemorrhage and regional analgesia has not been used. * Women at high risk of haemorrhage with risk factors including major antepartum haemorrhage, coagulopathy, progressive wound haematoma, suspected intra-abdominal bleeding and postpartum haemorrhage may be managed with anti-embolism stockings (AES), foot impulse devices or intermittent pneumatic compression devices. Unfractionated heparin (UFT) may also be considered * Thromboprophylaxis should be started or reinstituted as soon as the immediate risk of haemorrhage is reduced.

Answer 32

* All women with class 3 obesity (BMI greater than or equal to 40 kg/m2 ) should be considered for prophylactic LMWH in doses appropriate for their weight for **10 days after delivery.** * Women with two or more persisting risk factors should be considered for LMWH in prophylactic doses appropriate for their weight for **10 days after delivery.** * All women with a previous history of confirmed VTE should be offered thromboprophylaxis with LMWH or warfarin for **at least 6 weeks** postpartum regardless of the mode of delivery. * Women with a family history of VTE and an identified thrombophilia should be considered for **6 weeks’** postnatal thromboprophylaxis. * All women who have had caesarean sections should be considered for thromboprophylaxis with LMWH for 10 days after delivery apart from those having an elective caesarean section who should be considered for thromboprophylaxis with LMWH for **10 days after delivery** if they have any additional risk factors

Answer 33

Further advice on the management of a woman with both VTE risk factors and bleeding risk factors or LMWH allergy may be sought from a haematologist with expertise in the management of thrombosis and bleeding disorders in pregnancy.

Answer 34

* 6000 births to a drug user per year * Common to have psychiatric comorbidity

Answer 35

* Social Problems * Housing * Crime * Other children abused * Co-existent addictions * Malnutrition: especially iron, Vit B and C * Risk of viral infection: HIV, hep b

Answer 36

* increased risk of miscarriage * still birth and infant mortality * congenital anomalies * low birthweight * reduced gestational age * preterm delivery * Associated with foetal alcohol spectrum disorders

Answer 37

* damage to umbilical cord structure * miscarriage * increased risk of ectopic * low birth weight * placental abruption * preterm birth

Answer 38

* linked with preterm labour * low BW * small for gestational age * adverse consequences for foetal and adolescent brain * poorer academic achievement

Answer 39

premature rupture of membranes placental abruption preterm birth low BW

Answer 40

* low BW * resp problems * 3^rd trimester bleeding * neonatal abstinence syndrome (post natal withdrawal)

Answer 41

Line nigra

Answer 42

Striae gravidarum

Answer 43

Striae albicans

Answer 44

Pemphigoid Gestationis

Answer 45

* a rare (1 in 60 000 pregnancy) pruritic auto-immune bullous disorder. * Presents late in 2^nd or 3rd trimester starting on the abdomen (50% of cases) and progresses to widespread clusters of blisters which spare the face. * Management aims to relieve pruritis and prevent new blister formation, and is achieved through the use of potent topical steroids and/ or oral prednisolone * association with preterm delivery and small for gestational age births, but no increase in pregnancy loss It also recurs in most subsequent pregnancies

Answer 46

***Polymorphic eruption of pregnancy***

Answer 47

* self-limiting pruritic inflammatory disorder - * usually presents in 3rd trimester and/ or immediately post-partum. * Often occurs on lower abdomen on striae and extends to thigh, buttocks, legs and arms, while sparing the umbilicus and rarely involving the face, feet and hands. * Resembles toxic erythema. * Tx: symptomatic treatment is sufficient

Answer 48

***Prurigo of pregnancy***

Answer 49

* ***(1 in 300)*** * is simply a common pruritic disorder. * Looks like excoriated papules on extensor limbs, abdomen and shoulders. * Usually starts around 25-30 weeks of pregnancy and resolves after delivery. * Tx: symptomatic with topical steroids and emollients

Answer 50

***Pruritic folliculitis***

Answer 51

* pruritic follicular eruption with papules and pustules that mainly affect the trunk but can affect the limbs. * Tx: Topical steroids

Answer 52

Mastitis refers to ***inflammation*** of breast tissue, and is a common complication of ***breastfeeding***. It can occur with or without associated infection.

Answer 53

Mastitis can be caused by ***obstruction*** in the ducts and accumulation of milk. Regularly expressing breast milk can help prevent this occurring. Mastitis can also be caused by ***infection***. Bacteria can enter at the nipple and back-track into the ducts, causing infection and inflammation. The most common bacteria is ***staph aureus***.

Answer 54

* Breast pain and tenderness (unilateral) * Erythema in a focal area of breast tissue * Local warmth and inflammation * Nipple discharge * Fever

Answer 55

Where mastitis is caused by blockage of the ducts, management is conservative: * continued breastfeeding * expressing milk * breast massage. * Heat packs, warm showers and simple analgesia can help symptoms. When conservative management is not effective, or infection is suspect (e.g. the woman is febrile), antibiotics should be started. * ***Flucloxacillin*** is first line, or erythromycin if allergic to penicillin. * A sample of milk can be sent to the lab for ***culture and sensitivities***. * Fluconazole may be used for suspected candidal infections. * Women should be encouraged to continue breastfeeding, even when infection is suspected. * It will not harm the baby and will help to clear the mastitis by encouraging flow. Where breastfeeding is difficult, or there is milk left after feeding, they can express milk to empty the breast. A rare complication if not adequately treated, is a ***breast abscess***. This may need surgical ***incision and drainage***.

Answer 56

Candidal infection of the nipple can occur, often **after a course of antibiotics**. This can lead to ***recurrent mastitis***, as it causes cracked skin on the nipple that create an entrance for infection. It is associated with oral thrush and candidal nappy rash in the infant. Both the mother and baby need treatment, or it will reoccur. Treatment is with: * ***Topical miconazole*** 2% after each breastfeed * Treatment for the baby (e.g. ***miconazole gel*** or ***nystatin***)