Perinatal medicine Flashcards
(75 cards)
1
Q
Still birth
A
fetes with no signs of life >= 24/40
2
Q
Perinatal mortality rate definition
A
still births and deaths within the FIRST WEEK per 1000 live births and still births
3
Q
Neonatal mortality rate
A
deaths of live born infants within the first 4 WEEKS after birth per 1000 live births
4
Q
Preterm
A
5
Q
term
A
37-41 weeks
6
Q
post term
A
> =42 weeks
7
Q
12 advice for mother planning conception
A
- smoking - low birth weight, miscarriage, still birth
- pre-pregnancy folic acid - neural tube defects
- Mx diabetes/epilepsy/HIV etc
- avoid teratogens e.g. warfarin, valproate, retinoids
- alcohol/drugs
- congenital rubella - maternal immunisation before pregnancy
- toxoplasmosis - avoid undercooked meat and cat litter
- listeria - unpasturised dairy, soft cheese, pate
- avoid eating liver - high vitamin A (not good)
- obesity - gest diabetes/HTN
- risk of inherited disorders e.g. maternal age, FHx, consanguinity
- complication of delivery e.g. previous preterm, recurrent miscarriage - identify and tx/mx
8
Q
12 advice for mother planning conception
A
- smoking - low birth weight, miscarriage, still birth
- pre-pregnancy folic acid - neural tube defects
- Mx diabetes/epilepsy/HIV etc
- avoid teratogens e.g. warfarin, valproate, retinoids
- alcohol/drugs
- congenital rubella - maternal immunisation before pregnancy
- toxoplasmosis - avoid undercooked meat and cat litter
- listeria - unpasturised dairy, soft cheese, pate
- avoid eating liver - high vitamin A (not good)
- obesity - gest diabetes/HTN
- risk of inherited disorders e.g. maternal age, FHx, consanguinity
- complication of delivery e.g. previous preterm, recurrent miscarriage - identify and tx/mx
9
Q
Perinatal mortality rate definition
A
still births and deaths within the FIRST WEEK per 1000 live births and still births
10
Q
Neonatal mortality rate
A
deaths of live born infants within the first 4 WEEKS after birth per 1000 live births
11
Q
Cause of hydrous fetalis
A
Fetal anaemia due to:
- rhesus disease (immune)
Non-immune causes: 2. fetal IDA 3. maternal parvovirus B19 (fifth disease), syphilis, CMV, diabetes, hyperthyroidism 4. noonan, turners etc
12
Q
complications associated with poorly controlled maternal diabetes
A
macrosomia (fetal hyperglycaemia –> hyperinsulinism)
IUGR (2o to maternal microvascular disease)
congenital malformations
polyhydramnios
pre-eclampsia
early fetal loss
congenital malformtions
late unexplained intrauterine death (esp ketoacidosis)
neonatal hypoglycaemia, rds, hypertrophic cardiomyopathy, polycythemia
13
Q
large for gestational age
A
birthweight > 90th centime for gestational age
14
Q
12 advice for mother planning conception
A
- smoking - low birth weight, miscarriage, still birth
- pre-pregnancy folic acid - neural tube defects
- Mx diabetes/epilepsy/HIV etc
- avoid teratogens e.g. warfarin, valproate, retinoids
- alcohol/drugs
- congenital rubella - maternal immunisation before pregnancy
- toxoplasmosis - avoid undercooked meat and cat litter
- listeria - unpasturised dairy, soft cheese, pate
- avoid eating liver - high vitamin A (not good)
- obesity - gest diabetes/HTN
- risk of inherited disorders e.g. maternal age, FHx, consanguinity
- complication of delivery e.g. previous preterm, recurrent miscarriage - identify and tx/mx
15
Q
when is amniocentesis performed?
A
> 15 weeks gestation
16
Q
when is chorionic villous sampling performed?
A
> 10 weeks gestation
17
Q
Potter syndrome
A
Oligohydramnios causing pulmonary hypoplasia and limb and facial deformities from pressure on the fetus
18
Q
What features of mother and fetus are associated with polyhydrmnios
A
maternal diabetes
structural GI abnormalities eg atresia in fetus
19
Q
Arnold Chiari malformation
A
‘lemon shaped’ skull identifiable on US
abnormal cerebellum
associated with spina bifida
20
Q
treatment for fetal SVT
A
Give mother digoxin or flecainide
21
Q
Cause of hydrous fetalis
A
fetal anaemia due to: 1. rhesus disease (immune) Non-immune causes: 2. fetal IDA 3. maternal parvovirus B19 (fifth disease), syphilis, CMV, diabetes, hyperthyroidism 4. noonan, turners etc
22
Q
Risks of multiple pregnancies
A
prenatal: IUGR, congenital abnormalities, low BW
delivery: preterm (~37 weeks), complicated ?c/s
postpartum: housework, finances, emotional and physical exhaustion
NB. local and national support groups for parents of multiple births.
23
Q
complications associated with poorly controlled maternal diabetes
A
macrosomia IUGR polyhydramnios pre-eclampsia early fetal loss congenital malformations late unexplained intrauterine death (esp ketoacidosis) neonatal hypoglycaemia, rds, hypertrophic cardiomyopathy, polycythemia
24
Q
affect of maternal graves disease
A
fetal hyperthyroidism:
fetal tachycardia on CTG
fetal goitre on USS
irritability, weihgt lose, tacky, heart failure,diarrhoea, exopthalmos in neonate
25
carbimazole
treatment for hyperthyroidism
| thyroid peroxidase inhibitor
26
Affect of maternal SLE
```
associated with antiphospholipid syndrome:
recurrent miscarriage
IUGR
preeclapsia
placental abruption
preterm delivery
```
neonatal lupus - self limiting rash, heart block
27
effects of anticonvulsants during pregnancy (carbamezapine, valproate, phenytoin)
midfacial hypoplasia
CNS, limb and cardiac malformations
developmental delay
28
effect of cytotoxic drugs in pregnancy
congenital malformations
29
effect of lithium during pregnancy
congenital heart disease
30
tetracycline during pregnancy
enamel hypoplasia of teeth
31
effect of thalidomide in pregnancy
```
(= immunomodulatory drug)
limb shortening (phocomelia)
```
32
effect of vitamin a or retinoids in pregnancy
increased spontaneous abortions, abnormal face
33
effect of warfarin in pregnancy
interferes with cartilage formation
cerebral haemorrhages
microcephaly
34
fetal alcohol syndrome
```
growth restriction
developmental delay
cardiac defects
saddle shaped nose
maxillary hypoplasia
absent philtrum between nose and upper lip
```
35
smoking in pregnancy
increased risk of miscarriage and still birth, low birth weight, IUGR
36
complications of IUGR
```
fetal distress
fetal asphyxia (lack of oxygen)
neonatal hypoglycaemia or hypocalcaemia
meconium aspiration
impaired neurodevelopment
intrauterine death
T2D and HTN in adult life
```
37
Risk factors for IUGR
```
high maternal age
smoking
high intensity exercise
cocaine
Chronic hypertension, diabetes and vascular disease, renal impairment, antiphospholipid syndrome
pre-eclampsia
severe maternal bleeding
low maternal weight
```
placental insufficiency = head sparing
fetal prob eg chromosomal abnormality = uniform IUGR
38
apgar
score used to describe baby's condition 1 min and 5 min after birth ( 5 min intervals thereafter if condition remains poor)
total = /10
score 0, 1 or 2 for the following:
appearance (pale/blue, blue extremities, pink)
pulse (absent, 100)
grimace/irritability (none, grimace, cry/cough)
activity (flaccid, some flexion, good flexion/active)
resp (absent, gasping/irregular, regular/crying)
39
infants at higher risk of haemorrhagic disease of newborn
mothers taking anti-convulsants (impair synthesis of vitamin K dependant clotting factors)
40
Guthrie test
day 5-9 of life
```
phenyketouria
hypothyroidism
sickle cell anaemia + thalassaemia
CF - serum immunoreactive trypsin (raised if pancreatic obstruction)
MCADD
```
41
clinical signs of shock
```
early (compensated):
tachycardia
tachypnoea
decreased skin turgor
sunken eyes and fontanelle
cap refill > 2 sec
mottled, pale, cold skin
core-peripheral temperature gap > 4oC
decreased urinary output
```
```
late (decompensated)
Kussmaul breathing
bradycardia
confusion/depressed cerebral state
blue peripheries
absent urine output
hypotension
```
42
informed consent
Given voluntarily (with no coercion or decit)
Given by an individual who has been fully informed about the issue
Given by an individual who has capacity
Can be written, verbal or non-verbal/implied
43
consent in children
* at 16 years or older a young person can be treated as an adult and can be presumed to have capacity to decide
* under the age of 16 years children may have capacity to decide, depending on their ability to understand what is involved
* where a competent child refuses treatment, a person with parental responsibility or the court may authorise investigation or treatment which is in the child's best interests*
those under the age of 13 years are considered unable to legally consent to sexual activity
44
Fraser guidelines
* the young person understands the professional's advice
* the young person cannot be persuaded to inform their parents
* the young person is likely to begin, or to continue having, sexual intercourse with or without contraceptive treatment
* unless the young person receives contraceptive treatment, their physical or mental health, or both, are likely to suffer
* the young person's best interests require them to receive contraceptive advice or treatment with or without parental consent
45
Abortion Act
• Legal grounds for abortion –
o A) The pregnancy is less than 24 weeks and that the risks to the physical and mental health of the woman or any children in her family are greater if the pregnancy were continued (accounts for 97% of all UK abortions, 87% are carried out before 13 weeks in the UK. The inherent risks of pregnancy compare to the low risk of early abortion mean that pregnancy will almost always pose a greater physical risk than an abortion).
o B) At any stage of pregnancy:
• I. Necessary to prevent grave and permanent injury to the mother.
OR
• II. Continuing pregnancy would involve a greater risk to the life of the pregnant woman than termination.
OR
• III. Substantial risk of serious physical or mental handicap (Down’s syndrome accounts for 20% of abortions performed on the grounds of “serious handicap”)
46
foetal rights
The fetus is a recognised entity in law but has no right to life. Once born it acquire full legal rights.
The fact that a woman is pregnant does not affect her legal right in anyway. She can engage in (lawful) behaviour that is harmful to the foetus. She can refuse medical treatment including caesarean section even if it risks the life of the baby
47
• Stillbirth
death of foetus >24 weeks
48
Neonatal death
death of a newborn within 28 days (early neonatal death = within 7 days, late neonatal death = lives over 7 days)
49
Miscarriage
death of foetus
50
Corrected perinatal mortality
excludes stillbirths and deaths secondary to congenital malformations
51
• Most common cause of perinatal mortality
Antepartum stillbirth
52
8 causes of perinatal mortality
Antepartum stillbirth
pre-eclampsia,
lethal congenital abnormalities,
antepartum haemorrhage
intrapartum hypoxia
infection,
birth trauma,
foetal/foetomaternal haemorrhage
53
risk factors of perinatal mortality
* Extremities of maternal age
* Smokers/recreational drug users
* Poor nutrition
* Highly parous
* Afrocribbean/Asian
* Multiple pregnancies
54
Gavidity
the number of times a woman has been pregnant
55
Parity
the number of times a woman has delivered potentially viable babies (beyond 24 weeks)
56
Expected date of delivery
add one year, subtracting 3 months, and adding 7 days to the first day of a woman’s last menstrual period.
57
lie
The relationship between the foetus and the long axis of the uterus (longitudinal = head and buttocks palpable at each end etc.)
58
presentation
The foetal part that occupies the lower segment or the pelvis (with a longitudinal lie, the head or buttocks will be presenting)
59
engagement
Engagement describes the decent of the foetal head into the pelvis. It is described as fifths palpable. If only 2 fifths are palpable then more than half of the head has entered the pelvis and so the head must be engaged
60
HTN in pregnancy definition
* systolic > 140 mmHg or diastolic > 90 mmHg
| * or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic
61
HTN in pregnancy DD
pre existing HTN:
A history of hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation
No proteinuria, no oedema
Occurs in 3-5% of pregnancies and is more common in older women
pregnancy induced HTN
Hypertension (as defined above) occurring in the second half of pregnancy (i.e. after 20 weeks)
No proteinuria, no oedema
Occurs in around 5-7% of pregnancies
Resolves following birth (typically after one month). Women with PIH are at increased risk of future pre-eclampsia or hypertension later in life
pre-eclampsia
Pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours)
Oedema may occur but is now less commonly used as a criteria
Occurs in around 5% of pregnancies
62
Urinalysis
pH, protein, glucose, nitrites, ketones, leukocytes, erythrocytes/haemoglobin
63
Genital swabs
Gynae triple swabs are usually taken to screen for infection in symptomatic women. Most infections should be diagnosed on history and examination with confirmation from the laboratory investigations.
* Swab 1 “HVS” – High vaginal swab taken in the posterior fornix, testing for TV, BV (“heavy growth of anaerobes”), Candida (& group B Strep) on Stuart’s medium
* Swab 2 “ECS” – Endocervical swab cultured on Stuart’s medium, looking for gonorrhoea
* Swab 3 “Chlamydia” – Endocervical swab looking for Chlamydia (intracellular)
Stuart’s medium is an agar and charcoal culture medium – standard medium for most microbiological specimens
Chlamydia is an obligate intracellular parasite so can be identified by PCR (NAATS). The swab needs to be taken in a particular way, 5 rotations in the cervix in the same direction followed by 10 dunks in the appropriate preservative solution.
64
Features of dyskaryosis on smear test
```
abnormally high nuclear:cytoplasmic ratio,
abnormal mitotic figures,
clumping of chromatin,
pleomorphism,
abnormal outline of nuclear membrane,
crowding of cells
```
65
Menopause
the permanent cessation of menstruation resulting from loss of ovarian follicular activity. It occurs at a median age of 51 years. Natural menopause is recognised to have occurred after 12 consecutive months of amenorrhoea.
66
Perimenopause
This includes the time beginning with the first features of the approaching menopause, such as vasomotor symptoms and menstrual irregularity, and ends 12 months after the last menstrual period.
67
when does BhCG peak in normal pregnancy
12 weeks gestation (when placental growth is complete)
68
HPV linked to what cancers
* over 99.7% of cervical cancers
* around 85% of anal cancers
* around 50% of vulval and vaginal cancers
* around 20-30% of mouth and throat cancers
69
HPV vaccine
Girls aged 12-13 years are offered the vaccine in the UK.
Given as 2 doses - girls have the second dose between 6-24 months after the first, depending on local policy
Gardasil protects against HPV 6, 11, 16 & 18, used since 2012.
Introducted in 2008, the initial vaccine, Cervarix, only protected against HPV 16 and 18, leaving high risk of disease burden from genital warts.
Injection site reactions are particularly common with HPV vaccines.
70
Number of deaths in UK prevented from cervical screening
1,000-4,000 deaths per year
NB cervical adenocarcinomas, which account for around 15% of cases, are frequently undetected by screening
71
Who is screened and how often?
* 25-49 years: 3-yearly screening
* 50-64 years: 5-yearly screening
In Scotland women from the ages of 20-60 years are screened every 3 years.
72
How many smears are abnormal?
about 5%
73
when do most PEs and DVTs occur
2nd week post delivery
74
amniotic fluid embolism PC
```
dyspnoea
hypotension
hypoxia
seizures
heart failure
```
75
primary vs secondary PPH
primary: >= 550ml blood loss from genital tract within 24 hours of birth.
minor = 500-1000ml, major = >1000ml, severe = >2000ml
secondary = abnormal or excessive bleeding between 24 hours and 12 weeks postnatally.
