1
Q
Name the two primitive duct systems that males and females have in early embryo.
A
- Wolffian
- Mullerian
2
Q
Which primitive duct system develops, and which degenerates in males?
A
- Develops into reproductive tract = Wolffian
- Degenerates = Mullerian
(Opposite in females)
3
Q
Describe the development of male reproductive system in terms of hormones.
A
- Testosterone (stimulated by human chorionic gonadotropin from placenta) released from foetal testes
+
Mullerian inhibiting factor (induces regression of mullerian ducts)
4
Q
Define estimated date of delivery.
A
40 weeks from the first day of the LMP
Reality gestational age is 14 days less as ovulation is at day 14 of cycle
5
Q
Define the following times of delivery:
a) At term
b) Pre-term
c) Post-term
A
a) 37-42 weeks
b) before 37 weeks
c) after 42 weeks
6
Q
Describe the role of prostaglandins in parturition.
A
- synthesised within the human fetal membranes (the amnion and the chorion)
- kept within the membranes
- During pregnancy membranes are intact and prostaglandins are not released
- in labour, the membranes not intact, prostaglandins released, ripen the cervix
- also used for induction of labour (PGI2)
7
Q
Describe the role of relaxin in parturition.
A
- Causes relaxation of the ligaments in the pelvis (relaxation of the pelvic floor)
- Softens and widens the cervix
- Produced by the ovaries and placenta
8
Q
Describe the role of oxytocin in parturition.
A
- Produced by the hypothalamus
- Secreted by the posterior pituitary
- Causes contraction of the uterus (increases production of the prostaglandins)
9
Q
What are the two things that are required for successful labor?
A
- Dilation of the cervical
- Contractions of the uterine myometrium
10
Q
State the 3 stages of labour.
A
1- Onset of regular contractions to fully dilated cervix - Cervical dilation
2- Delivery of baby - Fully dilated cervix to birth (around 1 hour)
3- Expulsion of the placenta and the membranes (Up to one hour)
11
Q
Describe the two phases of the first stage of labour.
A
Stage = Onset of regular contractions to a fully dilated cervix
Phase 1 = Latent Phase
- Regular contractions
- Cervical effacement and dilation to 3-4cm
Phase 2 = Active Phase
- Increase in the frequency of contractions
- Cervical dilation to 10cm
12
Q
Describe the second stage of labour.
A
Stage = full cervical dilation to birth
- increase in frequency of contractions
- the presenting part descends
- Baby moves from cervix into vagina
- Stretch receptors in the vagina cause abdominal wall contractions which augment the uterine contractions
- Ferguson Reflex takes place = when the pelvic floor stretches increases release of oxytocin which increases uterine contractions which in turn causes more pelvic floor stretching and more oxytocin
13
Q
Describe the third stage of labour.
A
Stage = Expulsion of the placenta and membranes
- Contraction of the myometrium afterwards prevents haemorrhage by constricting blood vessels at site of placenta attachment
14
Q
What is the name of the shrinkage of the uterus to pre-pregnancy size?
A
Post-partum involution (takes 4-6 weeks, fall in oestrogen and progesterone levels)
15
Q
What is meant by full dilation?
A
Dilation to 10cm
16
Q
What is a key trigger of labour?
A
- Estrogne synthesis form placenta –> increase in estrogen receptors in myometrium
- Oestrogen -> Increase in gap junctions (coordinated contraction of cervix) and increase in oxytocin receptors (increased sensitivity)
- Oestrogen -> increase in PG’s -> increase oxytocin receptors and softens cervix
17
Q
What are the stages of breast physiological development?
A
- Birth - lactiferous ducts without alveoli
- Puberty - lactiferous ducts + alveoli (alveoli is a lobule which is made out of milk producing glands)
- During pregnancy - estrogen, progesterone, prolactin leads to glandular tissue replacing adipose tissue
- From week 16 - fully developed but in quiescent awaiting activation
18
Q
Which hormone stimulates duct development during pregnancy?
A
Oestrogen
19
Q
Which hormone stimulates Lobule development during pregnancy?
A
Progesterone
20
Q
Which hormones stimulates the production/synthesis of milk?
A
Prolactin
21
Q
a) Name the two cells which are involved in lactation and secretion of milk.
b) state the hormones that stimulate these cells respectively.
A
1- Secretory alveoli/acini cells - produce milk stimulated by prolactin
2- Contractile myo-epithelial cells surround each alveolus stimulated by oxytocin
22
Q
Why does prolactin have no effect on lactation before parturition?
A
Oestrogen and progesterone levels are high prior to parturition
These hormones inhibit the effects of prolactin
23
Q
Explain the neurohormonal reflexes that control milk production during lactation.
A
Suckling -> Mechanoreceptors in nipple stimulates -> hypothalamus stimulated -> decrease in prolactin-inhibiting hormone and increase in prolactin-releasing hormone -> stimulates the anterior pituitary -> increase in prolactin -> stimulates milk secretion
Suckling -> Mechanoreceptors -> hypothalamus -> nervous pathway stimulates the posterior pituitary -> Increase in Oxytocin -> contraction of myoepithelial cells around alveoli -> milk ejection
24
Q
What happens to milk production after weaning?
A
No suckling -> no oxytocin -> no milk ejection -> build up of milk -> pressure build up acts directly on epithelial cells -> no milk
No suckling -> no prolactin -> no milk
25
What is the recommendation period for exclusive breast feeding?
6 months
26
What is colostrum milk?
the first milk that is secreted by the mammary lobule/glands after birth
Rich in antibodies
27
Which antibodies are found in Colostrum?
IgG
| IgA
28
A) When does colostrum change into mature milk?
B) Describe Colostrum in comparison to mature milk.
a) after 21 days
b)
Colostrum
- Lower Calories 58 vs 70
- Lower carbs (5.3 vs 7.4g) and fats (2.9g vs 4.2g)
- Higher protein (3.7 vs 1.3g)
- More zinc and sodium
- More fat-soluble vitamins
- Greater amounts of immunoglobulins (IgG and IgA) and a number of growth factors - conferring passive immunity
29
Which pulmonary cells produce surfactant?
- Type II Pulmonary Cells
| Reduces surface tension of the alveoli so lungs do not collapse
30
How does a baby begin to breath?
- Within 1 minute
| - They are in asphyxiated state then there is a stimulus from the suddenly cooled skin
31
Usually a baby begins to breath in the first minute, however if this does not happen, why may they start breathing in the following minute if there are no other problems?
No breathing in the first minute --> baby hypoxic + hypercapnic --> stimulus enough to begin breathing in the following minute
32
List causes of delayed breathing of the baby after birth.
These lead to the depression of the respiratory centre
1- Anaesthesia in the mother crossing over to the baby's system
2- Trauma during delivery (prolonged hypoxia)
3- Prolonged delivery (prolonged hypoxia)
4- Hypoxia during delivery (compression of umbillical cord, premature separation of placenta, excessive contractions of the uterus)
33
After how long would brain lesions and permanent brain damage develops while a baby is hypoxic?
- 8-10 minutes
34
Describe respiratory distress syndrome.
- Most common in premature babies
- due to inadequate quantities of surfactant
- Many premature babies cannot produce sufactant
35
List risk factors for New-born respiratory distress syndrome.
- Diabetic mother
- low weight baby
- premature baby with immature lung development
36
After oxygenated blood is transferred through the umbilical vein, which organ does it bypass through the ductus venosus?
Liver
37
Explain why an infant loses weight during the first few days of life.
▪ Fetus feeds on mothers glucose
▪ When that is gone, infant uses stored protein and fat as energy source until milk is avaliable
▪ Takes few days for mother's milk to develop
▪ Fluid turn over of a baby is 7 times that of an adult
Infants weight decreases 5 to 10% and sometimes as much as 20% within first 2-3 days of life due to loss of fluids
38
What is the normal neonate Respiratory Rate?
40bpm
39
Give details of how new-born blood volume changes in the first few minutes and hours after birth.
Blood volume = 300ml at birth --> stripping of umbilical cord means more blood into neonate --> 375ml --> in next few hours fluids enters tissue --> increase in hematocrit but decrease in volume to 300ml again
40
Explain how plasma bilirubin concentration changes over the first few days after birth.
▪ Rise from 1mg to an average of 5 mg/dl in the first 3 days : physiological hyperbilirubinemia --> mild jaundice
This is because the liver is not developed enough to conjugate a lot of bilirubin
41
What is Erythroblastosis Fetalis?
Hemolytic anemia in the fetus (or neonate, as erythroblastosis neonatorum) caused by transplacental transmission of maternal antibodies to fetal red blood cells. The disorder usually results from incompatibility between maternal and fetal blood groups, often Rho(D) antigens.
- Jaundice, reduced muscle tone, and hepatic encephalitis, and potentially learning disabilities maybe caused
42
Give brief details about how immature kidneys can lead to fluid and/or acid/base disturbances in the neonate.
- Metabolic rate twice as high
- Twice as much acid formed
- immature kidneys can only concentrate urine 1.5 time blood plasma unlike adults where it is 3-4 times
- There is marked fluid turnover
- Tendency towards acidosis, dehydration, and rarely over hydration
43
List four effects of deficient liver function in the neonate.
1. Poor conjugation of bilirubin --> small amount of bilirubin is excreted
2. Low blood plasma protein concentration due to poor plasma protein formation (can lead to hypoproteinemic edema)
3. Deficient gluconeogenesis --> drop in blood glucose levels --> depend on stored fats for energy until proper feeding commences
4. Deficient blood factor formation for coagulation
44
How does digestion and absorption and metabolism differs in neonates compared with older children?
- Deficiency in secretion of pancreatic amylase
| - Reduced fat absorption from GI tract (so if you feed cow milk it might be poorly absorbed)
45
Briefly, explain the body temperature changes in the first approx. 12 hours after birth.
▪ Body surface area is large in relation to body mass, heat is readily lost from the body
▪ This occurs in the first few hours
▪ Returns to normal in 7-10 hours
Premature babies lose heat even faster.
46
Briefly describe key nutritional needs of the neonate in the early weeks of life.
- Need calcium for rapid bone ossification and vitamin D required for the absorption of the calcium
- Need iron in their diet (usually store it from mother for 4-6 months but incase she is deficient) to make RBC
- Need vitamin C - required for formation of cartilage and intracellular structure (prescribe orange juice if deficient)
47
Explain how the new-born’s immunological state changes over the first few months of life.
▪ By the end of the first month, there is decrease in gamma goblins (which contain antibodies) up to half - and as such decrease in the immunity of the neonate
▪ Concentration of gamma immunoglobulins returns to normal by the age of 12-20 months.
▪ Mothers immunoglobulins protect the baby from major infections (diphtheria, measles and polio) up till 6 months of age
48
Describe physiological haematological changes during pregnancy.
- Hb declines (110 -> 105 -> 100g/l) increase in RBC but bigger increase in plasma
- Rise in white blood cells (neutrophils)
- Fall in platelets (gestational thrombocytopenia) - due to increase in plasma not pathological
- Rise in fibrinogen and factors VIII, IX, X - hypercoagulable state
49
What is the normal platelet count?
150-450 x10 to the 9 /L
50
Where is thrombopoietin produced?
Liver
51
Under what platelet level does a person start bleeding easily, and having nose bleeds etc...?
under 50x10 to the 9
52
Which of the following conditions is life-threatening:
Immune Thrombocytopenic Purpura
or
Thrombotic thrombocytopenic purpura.
TTP
53
Describe the pathophysiology of Immune/Idiopathic/Autoimmue thrombocytopenic purpura.
- Autoimmune condition
- Antibodies are produced which destroy platelets leading to a low platelet count
- Presents with bruising/rash but also risks bleeding and haemorrhages if platelet count gets low enough
54
Who does immune thrombocytopenic purpura affect?
Children and adults
Some risk of neonatal thrombocytopenia due to IgG antibodies crossing placenta
55
Describe the management of immune/idiopathic thrombocytopenic purpura.
- Watch and wait as it is usually self-limiting (treatment is needed if the mother is lower than 50 on platelet count as that is required for labour)
- Steroids (Predinsolone)
- IV immunoglobulins (these IG's bind to the immune cells that would usually attack the platelets to stop them from doing so)
- Splenectomy
56
Describe the pathophysiology of Thrombotic Thrombocytopenic Purpura.
- Syndrome characterised by microangiopathic haemolytic anaemia and thrombocytopenic purpura
- This is because very small vessels form clots from platelets
- This is due to deficiency in ADAMTS13 enzyme which usually inactivates/cleaves Von Willebrand factor/polymers that allow platelet aggregation (without the enzyme there is abnormally large VW factors)
- This leads to clots forming in small vessels as they adhere to the vessel wall
- Leads to low platelet count else where
57
A) What are the symptoms of TTP?
| B) Describe management.
A) Pentad of: Fever, renal failure, haemolytic anaemia, neurological abnormalities, and thrombocytopenia - coagulation screen usually normal (and a rash) (So you need to check haemoglobin and platelet count plus clinical features, not all patients have the whole pentad)
B) Treated with plasma-exchange therapy (to replace the enzyme) and corticosteroids
58
A) What period in and around pregnancy is classified as high risk/hypercoagulable state?
B) Name additional risks.
C) What condition can occur as a result of this state?
A) Through out pregnancy and 6-weeks post-partum
B) smoking, age, previous clot, obesity, twins
C) thromboembolic disease like PE, DVT
59
During late pregnancy it is normal to have leg swelling as the pelvic veins are compressed by the uterus. How do you differentiate normal leg swelling from a DVT?
If the swelling is:
- Unilateral
- Tenderness
- Progressive pain
60
What do you do if you suspect a DVT in a pregnancy woman?
1- Doppler exam of leg
2- Chest X-ray
3- if X-ray abnormal then CT pulmonary Angiogram (CTPA) higher radiation dose but more reliable than V/Q scan
(Note- D-Dimer unhelpful as it is raised in pregnancy)
61
Which anticoagulation medication do you use for Thromboembolic disease?
Low Molecular Weight Heparin (monitor anti Xa levels 3-4 hours after dose to show effective dosing)
- No Warfarin as it is contraindicated
- No DOAC's as it is not licensed
62
List symptoms of Pre-eclampsia.
- Hypertension
- Proteinuria
- Fluid Retention (oedema)
- Epigastric pain due to liver swelling
- Headache
- Visual Disturbances
- Urate high
63
What is the greatest risk factor for HELLP syndrome?
Pre-eclampsia
64
What is HELLP Syndrome?
- Haemolysis
- Elevated liver enzymes
- Low platelets
(Management = delivery)
65
A) What is Disseminated intravascular coagulation?
B) What are the risk factors for this condition during pregnancy?
C) Describe the treatment of this condition.
A) Systemic activation of the coagulation cascade which results in the deposition of the fibrin and platelets plugs within the vessels
B) (this is generally set off by infection, injury or illness, burns etc..) Placental abruption, Amniotic fluid embolism (amniotic fluid gets into circulation and get into lungs and cause problems and can set off coagulation cascade), dead foetus
C) Treat the cause, use coagulation factors and platelets
66
In terms of blood groups, what does someone with blood group O have on their blood red blood cells?
- H Substance only
67
Which antibody/immunoglobulin is usualyl present against the A or B antigens found on red blood cells with those blood groups?
IgM (Does not cross the placenta)
E.g. someone with group A blood, they have A antigens on their cells and have Anti-B antibodies present in their blood
68
If someone is Rhesus Negative, which antigen do they lack?
- Antigen D
some people will have naturally occurring antibodies but can develop in response to pregnancy
69
What is haemolytic Disease of the Newborn?
Mother produces IgG antibodies as some of the child's blood crosses over to hers which stimulate this, the antibodies then cross to the foetus and cause anaemia, jaundice, brain damage, foetal death
70
What test looks for fetal cells in maternal circualtion?
Kleihauer test
71
How do you manage haemolytic disease of the new born in neonates?
- Clinical assessments
- Blood count and reticulocytes/group/red cells/antibodies/billrubin etc...
- Allow antibodies to decline
- Phototherapy to increase bilirubin conjugation
72
Describe haemoglobin structure/
- 4 folded chains
- 2 alpha (chromosome 16)
- 2 beta chains (chromosome 11)
- each chain has one haem molecules with iron in the middle of it
- the central iron atom is what the oxygen attaches to.
73
State the globin chains in the following haemoglobin:
1) Hb A (adults)
2) Hb A2
3) Hb F (Foetal)
1) 2 Alpha, 2 Beta
2) 2 Alpha, 2 Delta
3) 2 alpha, 2 gamma
74
1) What is meant by haemoglobinopathies
| 2) give examples of haemglobinopathies
1) An issue with the haemoglobin
| 2) Sickle cell, thalassaemia (this is any globin chain imbalance)
75
List haemoglobinopathy conditions that cause significant disease / are transfusion dependent .
1- Sickle cell homozygous (in this condition they produce Haemoglobin S which causes RBC to be sickle shaped - chronic anaemia - typically in african caribbean and occasional cases in middle east - sickle cell crisis causes small vessels in bones first to be blocked and pain all over) - management by managing symptoms and pain from sickle cell crisis and transfusion
2- Sickle Cell with Hb C/D/E/Beta thalassaemia (sickle cell with co-inherited condition - same severity)
3- Beta thal homozygous (tansfusion dependent condition not from birth as they have alpha chain and gamma chain but from birth they cant make beta chains for adult haemoglobin so they become considerably anaemicat few months of age)
4- Alpha thal 3 gene deletion (Hb H) (transfusion dependent state - deletion of two genes will be not a problem as the person is barely anaemic but three you require transfusions at set intervals in time)
76
How do you detect haemogloinopathy/thalassaemia carriers during pregnancy?
1- Screen for ethnic origin (mediterranean, asian, african)
2- Most will be microcytic e.g. mean cell volume <80 and mean cell Hb (MCH) <27
3- Cellulose acetate Hb electrophoresis (not used much now - but Hb electrophoresis is to identify types of Hb in blood)
4- High performance Liquid Chromatography (HPLC) - to separate a mixture of compounds in analytical chemistry and biochemistry so as to identify, quantify or purify the individual components of the mixture.- Gene copy number
6- Gene sequences
77
Using HPLC, how would the following haemoglobinopathies show:
1) Beta Thalassaemia heterozygous.
2) Alpha thalassaemia with one gene deletion
3) Alpha thalassaemia with two deletions
1) Low MCV and MCH and Hb A2 >3.5%
2) No change
3) low MCV
78
A) Describe Pre-natal screening in low prevalence areas for haemoglobinopathies.
B) what happens if the foetus is at risk of serious Hb disorder?
A)
1- FBC at booking to check if MCH is <27pg
2- fill in questionnaire on ethnic origin for both partners
3- if either is positive then HPLC is done to look for thal/haemoglobinopathy
B)
- 11-14 weeks chorionic villous sampling foetal DNA or 15 weeks+ amniocentesis
79
What is the differential diagnosis for a maculopapular rash during pregnancy? (Congenital and peri-natal infections)
- Rubella
- Measles
- Parvovirus
80
Name a cause of a vesicular rash during pregnancy.
Chicken pox
81
List the manifestations of a congenital infection.
- Growth retardation
- Congenital malformation
- Fetal Loss
82
A) What is the most common type of pathogen that causes congenital infections?
B) Provide 5 examples.
A) Viruses mainly (there is one bacterial and one parasitic causative agents)
B) Rubella virus, Varicella Zoster Virus, Cytomegalovirus, Human Parvovirus B19, Listeria Monocytogenes (other: HIV)
```
Bacterial = Treponema Pallidum (Syphillis)
Parasite = Toxoplasma gondii
```
83
Where do maculopapular rashes and vesicular rash start?
behind the ears
(maculo = behind ears -> head -> neck and body)
(Vesicular rash = ears -> all body and happens in crops)
84
What infection is 'slapped cheek' sydnrome followed by maculopapular rash indicative of?
Parvovirus
85
A) What is meant by fetal hydrops?
B) Which conditions causes fetal hydrops?
A)
- Life-threatening condition in newborns
- Fluid accumulation around lungs, heart or abdomen
- Severe anaemia leading to heart failure
B)
- Parvovirus
- Cytomegalovirus
86
What infection causes Kolpik Spots?
Measles
Other symptoms:
- Fever
- Maculopapular rash
- Cough
87
List common presentations of the following congenital infections (these are infection transmitted across the placenta):
1- Rubella Virus
2- CMV
3- Toxoplasmosis Gondii
4- Treponema pallidum
1- Skin rash, Bony abnormalities, cardiac defects, Hepatosplenomegaly , Cataracts, chorioretinitis, IUGR and prematurity
2- Skin rash (petechial), microcephaly, No bony abnormalities, Neurodevelopmental problems such as sensorineural hearing loss, cerebral palsy, epilepsy and cognitive impairment No cataracts, Chorioretinitis, Hepatosplenomegaly, IUGR and prematurity (10% get this 90% are normal)
3- No skin rash, Bony abnormalities, hepatosplenomegaly, cataracts (not common), Chorioretinitis, IUGR and prematurity
4- Skin rash, No thrombocytopenia, Bony abnromalities, hepatosplenomegaly, no catracts, no hydrocephaly, IUGR and prematurity
88
Confirmation of diagnosis of congenital rubella, CMV, Toxoplasma, and syphilis
1- Serology (Rubella specific IgM, CMV-specific IgM, Toxoplasma-specific IgM and persistently raised Toxoplasma IgG)
2- if there is IgG and IgM in mothers blood you move on to test the foetus through Amniocentesis or chorionic villus sample, Polymerase chain reaction (PCR)
89
What does a CT scan of a new born show if they have intrauterine CMV?
- Intracranial Calcification (e.g. periventricular calcifications)
90
Name three congenital/intrauterine infections that cause intracranial calcification.
- CMV
- Toxoplasma Gondii
- Rubella
91
Describe the clinical features, Investigations, and management of CMV.
(Transmitted vertically, during or after birth)
CF:
- Can be asymptomatic
- Can lead to deafness or missing a milestone, fetal death, ocular disease or cerebral damage
- Immunocompromised or organ transplant can lead to severe pneumonitis, retinitis or gut infection
Dx:
- Nucleic acid amplification test (NAAT) on blood, urine or respiratory sample
Mx:
Initial treatment = Valganciclovir
Severe = Ganciclovir (the earlier this is sed in infants with the infection the better to avoid further sensorineural hearing loss) together with immunoglobulin in the case of pneumonitis
92
What is the most common congenital infection?
CMV
(50% of women are susceptible to this infection in Europe)
(Many of the infections which are primary during pregnancy are asymptomatic)
93
What is the alternative treatment for CMV other than Ganciclovir?
Foscarnet
94
When should treatment be offered for CMV for infants?
If:
Symptomatic Focal organ disease
- E.g. Hepatitis, severe bone marrow suppression (anaemia, thrombocytopenia)
or
CNS Disease
- E.g. Microcephaly, positive CMV CSF PCR, Chorioretinitis, or sensorineural hearing loss
95
Describe the following for a Rubella Infection:
A) Clinical Features
B) Diagnosis
C) Management
A)
Adult: Fever, fine red maculopapular rash, lymphadenopathy, Prodrome phase shows red pint point lesions occur on the soft palate
Complications: Arthritis (F>M) and self-limiting encephalitis
Infants (congenital): Growth restriction, cataracts, hepatomegaly, splenomegaly, rash, intracerebral calcification
B)
- Detection of IgM and IgG (IgM does not cross placenta so infection recent after birth) antibodies in serum or saliva, can also be detected in urine
- Congenital = specific IgM persistent antibodies (>6months) in an infant or viral detection by culture or NAAT
96
When is the MMR vaccine given?
between 13 and 15 months
97
What does the following indicate in rubella infections diagnosis:
1) IgG +ve and IgM -ve
2) IgG -ve and IgM -ve
3) IgG -ve and IgM +ve
1) past infection or prior immunisation
2) Susceptible
3) Possible recent infection
98
A) How do you contract Toxoplasmosis?
B) What are the most common manifestations of Toxoplasmosis in infants due to congenital infection?
C) Describe the treatment of toxoplasmosis.
A) Consumption of undercooked meat and from contact with the faeces of recently infected cats
B)
- Retinopathy
- Acute fundal chorioretinitis
- Cerebral calcification
- Hydocephalus
C)
- Pyrimethamine
- Sulfadiazine
- 12 months duration recommended
99
What is the recurrence of chickenpox called?
Shingles (remains latent in the dorsal root ganglion reactivating in 20% of patients)
100
Name the virus that causes Chickenpox.
Varicella Zoster Virus
101
How is chickenpox transmitted?
Contact and airborne spreading from patients with vesicles
102
In what age group is chicken pox most common?
4-10yo
103
Describe how the rash of chicken pox appears.
- Vesicular rash (Macules -> papules -> vesicles -> rupture -> crust -> spontaneous healing)
- Appears in crops
- 2-3 days apart
- Affects all parts of the body including oropharynx and genitourinary tract
- Lasts for 7-10 days and resolution may take as long
104
Secondary infection in a VZV can occur.
A) name the bacteria that can cause this secondary infection.
B) Describe how you may determine second infection from lesions.
A) Staph Aureus or strep pyogenes
B) Lesions may have redness around them
105
Name a complication of VZV that is more common in adults.
- Pneumonia (especially in immunocompromised)
| - Post-infection encephalitis can occur too
106
A) Describe diagnosis process of VZV.
B) Describe treatment and prevention of VZV in pregnant women.
A)
1- Clinically
2- Naat
3- Staining fluid from vesicles may show characteristic giant cells
B)
- Aciclovir for both chicken pox and shingles in adults
- Live attenuated vaccine available
If pregnant woman at high risk = Varicella-Zoster immunoglobulin
107
A neonate develops severe scarring of the skin, ocular and neurological damages and digital dysplasia.
A) Name the likely congenital infection that caused such complications.
B) When during the pregnancy was this infection likely contracted.
A) VZV
B) <20 weeks (after 28 weeks no risk, decrease in risk as gestation increases.
108
What does perinatal infection mean?
One that is caught 5 days before or after delivery when the fetus is unprotected by maternal antibodies and the viral dose is high
109
Describe management of perinatal chicken pox.
- Susceptible women protected with varicella zoster immune globulin and treated with Aciclovir
- Infants with Zoster immunoglobulin
110
Which cells does HIV mainly affect?
Those with CD4 receptor e.g. T Cells and Macrophages -> diminished cell-mediated immunity
Clinical signs of AIDs occur due to secondary infections when CD4 cell count falls
111
Describe Clinical features of HIV.
Clinical features:
1st: there is mononucleosis-like syndrome develops (fever, rash, lymphadenopathy) then the CD4 count will decline enough for secondary infections and malignancy to take place
When infections and malignancy develops this is now AIDs (Acute immunodeficiency this is after CD4 count falls considerably)
112
How does a neonate/child usually get HIV?
- Usually mother-to-child-transmission (MTCT) during pregnancy (intrauterine), during delivery (intrapartum) or through breast-feeding (Post-partum)
113
Describe investigation and management of HIV during pregnancy.
Antenatally detection of HIV actively carried out
If +ve then check viral load, resistance testing (check that the virus that the lady is infected with is not resistent to medications
ART (Antiviral therapy) used to reduce viral load and reduce chances of transmission to baby.
114
What are the two categories of neonatal sepsis.
- Early onset = <48HRS after birth (ascended form birth canal -> amniotic fluid -> fetal lungs direct contact with fluid -> pneumonia and secondary bacteraemia)
- Late Onset = >48hrs
115
List some symptoms of neonatal sepsis.
- Fever
- Poor feeding
- Vomiting
- Bradycardia (less than 120-160)
- Respiratory distress
- Seizures (need to think of neonatal meningitis)
- Tense or bulging fontanelle (meningitis)
- Head retraction (very late sign of meningitis)
116
How are early-onset viral perinatal infections transmitted like Listeria?
placenta following maternal infection
117
Name causative agents of late-onset sepsis in neonates.
Gram +ve = Stap Aureus, Group B Strep, Enterococcus faecalis
Gram -ve = Escherichia Coli, Pseudomonas, Klebsiella
118
List risk factors for GBS.
- Preterm
- Prolonged rupture of membranes
- Maternal fever during labour >38
- Maternal chorioamnionitis
- Previous infect infant
119
A child is born less than 48 hours ago. They have purulent discharge with conjuctival injection and swelling of the eyelids.
What is the likely causative agent?
Gonococcal infection
120
Name causative agents that cause purulent discharge and swelling of eyelids in neonates.
- Gonococcal infection (usually <48 hrs after birth)
| - Chlamydia trachomatis (usually 1-2 weeks of age but could be present shortly after birth)
121
A) How is perinatal Herpes Simplex Virus usually contracted by neonates?
B) How does it usually present in neonates?
C) how do you treat HSV in neonates?
(Note many women don't know they have it because they are asymptomatic)
During the passage through birth canal or occassionally by ascending infection
B)1-2 weeks after, can present just as skin and mucus membranes lesions or it can also manifest as disseminated disease where skin is involved but also liver with hepatitis and jaundice or CNS where there is seizures and apnea
C) Ganciclovir
122
List three perinatal mental health conditions that are related to childbirth.
1- Postnatal Blues
2- Post-natal depression
3- Puerperal Psychosis
4- PTSD
123
A) Describe Postnatal Blues.
B) When is its onset?
C) Symptoms?
D) Management?
A) Mild form of post partum depression experienced by the mother due to sudden changes in hormones following delivery, stress, sleep deprivation, and fatigue
B) 3-10 days post-partum (peaks within one weeks and lasts two)
C) Irritability, tearful, emotional fragility
D) Spontaneous resolution (usually in days)
124
A) Describe Postnatal-depression.
B) When is its onset?
C) Symptoms?
D) Management?
A) Depression following childbirth due to hormonal changes, psychological adjustment to motherhood, and fatigue. (Longer and more severe in comparison to postnatal blues)
B) Within 12 months of child birth
If baby blue last more than two weeks then consider postnatal depression
C) Common depression symptoms (Low mood, Anhedonia, Anergia etc.…)
D) Self-help strategies, Therapy, Medication
125
A) Describe Puerperal Psychosis.
B) When is its onset?
C) Symptoms?
D) Management?
A) Serious mental illness that effects a woman soon after having a baby. An emergency. Unknown cause.
B) Within days or weeks of childbirth
C) Hallucinatiosn, delusions, depression or mania or both, anxiety, irritability (symptoms change from one hour to the other)
D) Hospital admission to the mother and baby unit, medications, and psychotherapy
126
A) Describe PTSD following pregnancy
B) When is its onset?
C) Symptoms?
D) Management?
A) Anxiety disorder caused by a very stressful, frightening, distressing event
B) immediately, weeks or months after birth
C) Re-experiencing events (intrusive thoughts, flashbacks, nightmares), Hyperarousal(feeling on edge, easily irritated, angry and insomnia)
D) Psychotherapy (CBT), Medications (sertraline)
127
What is meant by a neonate?
First 4 weeks of life (but problems with neonates can continue further than that.
128
List the presentations that indicate illness in a neonate.
- Fever (>38, consider sepsis, temperature instability however means that they may have low temp but still have sepsis)
- Feeding (volume in the last 24hrs is 50% less)
- Responsiveness (poor response, weak cry)
- Urine Output (less than 4 nappies in the last 24 hrs indicating low fluid intake)
- Peripheral Circulation
- Activity (sleeping more or less movement)
- Breathing Difficulties (signs of respiratory distress: tachypnoea (>60/min), recession/retractions (e.g. subcostal), expiratory grunt, nasal flaring, cyanosis)
- Apnoea (a pause in respiration for more than 20 seconds)
- Vomiting (Any vomit excess of normal, however it is norma for neonates to vomit, bile-staining indicates obstruction - need admission)
- Cyanosis
- Seizures
- Severe Jaundice (Risk of bilirubin encephalopathy if haemolytic)
129
A) The immune system of a neonate has what can be described as an immune gap due to their immature immune system. This gap makes the neonate particularly vulnerable to certain organisms. Name these organisms.
B) What medication is used for treatment of such infection?
A) Group B Streptococcus
B) Sepsis in neonates is treated with high doses of IV Benzylpenicillin
130
Name a serious (but rare) complication of untreated jaundice in babies.
Kernicterus (brain damage which can happen in new-borns with jaundice)
131
What is the reason behind neonatal jaundice?
▪ Before a baby is born they are depending on their mother for nutrients and oxygen
▪ Therefore, they require a high haematocrit to maintain any oxygen
▪ Once they are born and can breath they no longer need it
▪ Therefore, there is increased breakdown of RBC and as such increased production of Serum Bilirubin
▪ There is decreased removal (transient liver enzyme insufficiency)
Increased reabsorption (enterohepatic circulation)
132
How do you treat hyperbilirubinemia?
Phototherapy (Causes photoisomerization of bilirubin - changes from fat soluble into water-soluble so it can be excreted)
133
Name risk factors for hyperbilirubinemia.
▪ Breast feeding
Low birth weight, prematurity and ill babies (low levels of bilirubin can cause brain damage therefore intervention required at lower serum levels)
134
When should a neonate with jaundice be investigated?
▪ If it is Early Jaundice (day 1 / in the first 24 hours) - pathological until proven otherwise.
○ Consider sepsis (feeding? Breathing? Urine? Fever?)
○ Consider haemolytic conditions such rhesus and ABO incompatibility (haemolysis from blood type incompatibility play a significant role in neonatal hyperbilirubinemia - this is usually when the mother has type O)
Consider haemolysis from other inherited or congenital causes (E.g. hereditary spherocytosis - - or elliptocytosis)
135
Describe normal physiological jaundice.
▪ 2-10 Days
▪ Does not occur on day 1
▪ It peaks around day 3
Resolves by day 10
136
Describe Prolonged Jaundice.
→ 1% remain jaundiced at 3 weeks of age even tho they are healthy
→ Persistent jaundice at 3 weeks of age and beyond must be referred urgently for investigations
→ Need to check if the bilirubin is unconjugated - meaning there is an extension of physiological jaundice
→ Conjugated - due to obstructive liver disease
→ If jaundice is unconjugated - as long haemolysis, hypothyroidism, and urine infection are excluded then the cause if breast milk jaundice (diagnosis of exclusion, peaks in the 2nd to 3rd week, may persist 3-4 weeks before declining) - harmless, no action required, can continue to breast feed
We want to exclude is biliary atresia - obstructive jaundice with conjugated bilirubin - treatable with surgery in the first 6 weeks life for normal life but if late diagosis can lead to liver cirrhosis and require transplant
137
What is the name of the tool used to assess severity of jaundice?
Kramer's Rule (1-5, 5 most severe with whole body involved, 1 least severe with just the head involved)
138
What is the normal crying of a baby when they are born?
6-8 weeks will cry on average 3/24 hours - normal physiological behaviour
139
What is meant by infant colic?
Excessive crying of a baby
- More than 3 hours in 24 hours
- For more than 3 days a week
140
If a child has infant colic , what are things you should check straight away?
- Reflux oesphagitis
- Cows milk protein or lactose intolerance
- UTI
- Hair-thread tourniquet syndrome
- Inguinal hernia
141
If an infant vomits mucus and occasional blood-streaked in the first few hours after birth, should you be worried?
No, it is normal as it is stuff they have swallowed usually during birth
142
Describe situations when vomiting in a new born should be taken seriously and investigated.
▪ Occurs shortly after birth and is persistent - could be intestinal obstruction or raised intracranial pressure
▪ If there is a history of polyhydramnios - can be upper gastrointestinal (oesophageal, duodenal, ileal) atresia
○ Shows as "double-bubble" sign that confirms the diagnosis of duodenal atresia on film
-- Bile-stained emesis suggests intestinal obstruction beyond the duodenum and requires investigation
143
Describe the features and presentations of a Newborn with hypertrophic pyloric stenosis.
▪ Often first-born males
▪ Common in Caucasian infants
▪ FH of the condition in some cases
There is projectile vomiting
144
What is the partogram?
Collection of data about the mother, foetus and the passage by which the foetus will exit.
Info on length, duration, and frequency of contractions, fetal heart beat, and well being of baby and check passage of dilation and effacement
145
What is induction of labour?
Process of starting labour (if by the end of the pregnancy the cervix does not dilate and efface then labour maybe induced for the safety of the mother and foetus)
146
What is meant by augmentation of labour?
Process of accelerating labour that is already underway
| So occurs when active labour has began on its own but for whatever reason it cannot continue
147
Give examples of situations where you may need to augment labour/situations where labour requires augmentation?
Give examples of situations where you may need to augment labour/situations where labour requires augmentation?
1- Labour has began, but the contractions are either too weak, irregular or have stopped.
2- Labour has began but the amniotic sac/membranes have not ruptured on their own (the doctor will rupture it (amniotomy) and if no progress then oxytocin is given in order to augment contractions)
3- Pre-labour rupture of the membranes (Give oxytocin in order to make the uterus contract)
Delay in first/second stage of labour
148
Give examples of situations where you may need to induce labour?
1- Induction due to chronic illness/ill health of mother that may put her life at risk if you leave the pregnancy to progress any further (hypertensive disorders like pre-eclampsia, diabetes, twin pregnancy, maternal age,
2- Baby is in danger (reduced fetal movements, fetal growth restriction/placental insufficiency/macrosomia)
149
What are the uses of Misoprostol?
- Labour induction
- Pregnancy termination
Treatment of post-partum haemorrhage
150
When are misoprostol (Synthetic prostaglandin analogue) and mifepristone (synthetic steroid which is anti-progestin blocking effects of progesterone and shedding lining of uterus) indicated for labour induction?
Where there is fetal death
151
What is the right number of contractions to achieve when augmenting labour?
3-4 contractions every 10 minutes
152
List pharmacological treatment for induction and augmentation of labour?
1- Prostaglandins (PGE2) - aims to ripen cervix and contract the uterus
2- Syntocinon (Synthetic Oxytocin) - only used after amniotomy and used for uterine contractions, you aim for 4 every 10 minutes)
153
List mechanical treatment for induction and augmentation of labour?
◊ Membrane Sweep (finger inserted by the doctor or the midwife, and sweeping circular motion is carried out. This intends to separate the sac surrounding the baby from the cervix - helps to induce natural labour - If successful induces labour within 48 hours)
◊ Amniotomy (ARM - Artificial Rupture of Membranes)
• Used for induction and augmentation (augmentation if contractions started but no rupture)
• More likely to require oxytocin augmentation
◊ Other
• Balloons
○ (Extra: Filled with air and sterile saline water
When inflated presses again the cervical cells helping it dilate and increasing the tissues response to oxytocin and prostaglandins)
154
What is the bishop score?
- This is a scoring system that is used to determine whether to induce labour - calculates the chance of spontaneous labour occurring
- Helps determine whether you need induction or not, augmentation or not, and the likelihood of going into vaginal birth
- Looks at cervical dilatation, length, station of presenting part, consistency of cervix, and position of cervix.
- Score <8 = unfavourable cervix --> ripen with PG
- Score 8+ = favourable cervix --> proceed with amniotomy
155
Describe non-pharmachological analgesia and anaesthesia during labour.
◊ Maternal Support
• 1:1 care in labour
• If there is good relationship between the mother and the mid-wife then the mother can concentrate on something else
◊ Birthing Pools
◊ Breathing & relaxation techniques, acupuncture (Chinese medicine - fine needles inserted under the skins, thought to release pain reliving factors such as endorphins), massage, hypnosis (however there is limited evidence to support the effectiveness of all this)
156
Describe Pharmachological analgesia and anaesthesia during labour.
◊ Inhaled
• Entonox
○ Mixture of oxygen and nitrous oxide
○ SE's: nausea, vomiting, drowsiness)
◊ Opioid
• Diamorphine - 5-10m mg
○ Limited effects as women still feel contractions
○ Causes an ithch that can be so bad that women would rather have the pain
○ Maternal SE: nausea and vomiting --> need an anti-emetic
○ Neonatal SE: Drowsiness/respiratory depression
○ Ideally should not be administered within 3-4 hours of delivery
• Continuous IV Infusion
○ Remifentanil (Short acting, begin when contractions are felt, allows woman time between contractions to recover)
○ This is rarely used
◊ Regional
• Epidural - more effective!
○ It is a tube catheter so you can have regular doses, takes 45 mins, small doses
○ Cons: prolonged second stage in AVD (assisted vaginal delivery), and there is more obstetric intervention as there is need to top up
○ SE: Hypotension (light-headedness/nausea), pruritis, potential temporary loss of bladder control
• Spinal (needle into the spinal space/subarachnoid space)
○ More for C-section than natural labour
○ Single shot = 2-4 hrs
○ SE: Hypotension, pyrexia, high block (blocking nerves)
◊ General Anaesthetic
• Higher risk in pregnant women than none
• Usually avoided due to the physiological changes in women
• Only used in emergencies usually
• SE: reduced gastro-oesophageal tone, increased intrabdominal pressure, delayed gastric emptying, toxicity with the medications, and can cause respiratory depression to the baby
157
What options are available for analgesia/anaesthesia during delivery.
```
◊ Local anaesthetic
• Perineal
• Pudendal (pudendal nerve carries sensation to the external genitalia and skin around anus)
◊ Regional
GA
```
158
What is the purpose of fetal assessment?
The purpose of intrapartum fetal monitoring is the prevention of death and morbidity due to hypoxia, this is because hypoxia causes changes in the fetal heart rate pattern (decreased to preserve oxygen as fetus cannot increase the frequency and depths of breaths). So if the baby is compromised then there will be a change in their heartbeat. Normal to see changes in heart rate but significant hypoxia is rare.
159
How does routine Fetal monitoring influence rates of C-Section?
There is an increase in rate (30%) due to over-diagnosis of fetal distress, this in turn restricts
160
Describe the control of the fetal heart beat.
▪ Nerve supply where rate is reduced by the vagus nerve (parasympathetic) and increased by the sympathetic supply.
▪ Hormonal control by circulating catecholamines
▪ CNS activity
▪ Changes in blood pressure
▪ Changes in fetal blood gases (O2, CO2, pH)
161
When do you carry out Intermittent Auscultation?
▪ Doppler USS (Pinards)
▪ Performed immediately after first contraction. At least one minute, every 15 minutes
▪ Act on any changes (you assess the position, hydration and contraction frequency and tone), you may increase auscultation frequency and carry out continuous CTG (ctg monitors fetal heart and uterus contractions)
162
List some of the indications for continuous CTG monitoring in labour.
```
▪ Maternal tachycardia
▪ Maternal pyrexia
▪ Suspected chorioamnionitis or sepsis
▪ Presence of significant meconium
▪ Fresh vaginal bleeding
▪ Hypertension
```
163
What is the average heart rate of a foetus near delivery?
110-160 per minute
164
What does DR C BRAVADO stand for? AND what is it used for?
- Used for reading CTG
- Dr - Determine Risk (is it a high risk pregnancy?)
C - Contractions (Records contractions - we look at how many contractions in 10 minute) - this lets ou see the duration of the contractions! Palpation is used for strength
BRA - Baseline Rate (average heart rate of the fetus within 10 minutes - normal is 110-160)
▪ Fetal Tachycardia causes = maternal or fetal anaemia, hypoxia, chorioamnionitis,
▪ Fetal Bradycardia causes = post-date gestation, occiput posterior or transverse presentations (100-120) less than 80bpm for more than 3 minutes (severe hypoxia) causes = cord compression,epidurla and spinal anaesthesia, maternal seizures
V - Variability
► Variability can be categorised as follows: 3
• Reassuring – 110-160 bpm, 5 – 25bpm baseline variability , Decelerations = none or early, variable decelerations with no concerning characterstics (for less than 90 minutes)
• Non-reassuring:
-- 100-109 bpm or 161-180 bpm
-- less than 5bpm for between 30-50 minutes BLV
-- more than 25bpm for 15-25 minutes BLV
• Abnormal:
-- Below 100 bpm
-- Above 180 bpm
-- less than 5bpm for more than 50 minutes
-- more than 25bpm for more than 25 minutes
sinusoidal
A - Accelerations - Accelerations are an abrupt increase in the baseline fetal heart rate of greater than 15 bpm for greater than 15 seconds - presence of these is reassuring
D - Decelerations - Decelerations are an abrupt decrease in the baseline fetal heart rate of greater than 15 bpm for greater than 15 seconds. (This reduction in heart rate to reduce myocardial demand is referred to as a deceleration.) - there is physiological decelerations which coincide with uterine contractions and these re normal. However pathological deceleration do not coincide with uterine contractions
• If it lasts between 2-3 minutes it is classed as non-reassuring.
• If it lasts longer than 3 minutes it is immediately classed as abnormal. (prolonged deceleration)
• Various pathological conditions can cause decelerations including cord compression, pre-eclampsia, maternal hypo tension
O - Overall Assessment
165
Describe reassuring and non-assuring fetal blood sampling and management.
- Reassuring = >7.25ph
| - Non-reassuring = <7.25ph - immediate delivery
166
Describe normal vaginal delivery steps.
1. Head should be in the pelvic brim in the left or right occipitolateral position
2. Neck flexes so that the presenting diameter is suboccipitobregmatic (smaller diameter than if the head goes straight in.
3. Head descends and engages
4. Head reaches the pelvic floor and occiput rotates to occiptoanterior
5. Head delivers by extension (then restitutes as it external rotates to realign with the shoulders)
6. Descent continues and shoulders rotate into the anteroposterior diameter of the pelvis
167
What is operative assisted vaginal delivery?
Using forceps or vacuum (Ventouse delivery)
168
List some of the indications for assisted vaginal delivery.
▪ Maternal (failure to progress during active second stage of labour)
▪ Fetal (Suspected fetal compromised in second stage of labour, abnormal CTG)
▪ Prophylactic shortening of second stage (hypertensive crisis)
169
List a particular condition where operative vaginal delivery may be appropriate during labour .
▪ Shoulder Dystocia (impaction of the fetal anterior shoulder behind the symphesis pubis
170
Describe management of shoulder dystocia.
```
H - call for help
E - Episiotomy
L - legs to McRoberts
P - Pressure
E - Enters manouvers
R- Remove posterior arm
R - Roll over
```
171
Describe the criteria for assisted vaginal delivery.
▪ Consent/analgesia/empty bladder
▪ Abdominal palpation 0/5 with head engaged
▪ Vaginal exam = membrane rupture, cervix fully dilated, presenting part at/below ischial spines
▪ Position of the fetal head ( if malposition then we will have to use rotational delivery using forceps or ventouse)
172
List risks associated with assisted/operative vaginal delivery.
Vaginal tearing or episiotomy, higher risk of blood clots, or urinary incontinence
173
Which perinearl tear classification describe damage to the perineal skin and/or vaginal muscosa only?
First-degree
174
What is a second-degree perineal tear?
Injury to perineum involving perineal muscles but not involving anal sphincter
175
What is a 4th degree perineal tear?
- Injury to perineum and internal anal sphincter and external anal sphincter and anorectal mucosa
176
What are the two types of C-Section?
* Elective C-Section (usually at 39 weeks and over)
| * Emergency C-Section
177
List 5 indications for Elective C-Section.
▪ Previous C-Section
▪ Placenta Praevia
▪ Breech Presentation/malpresentation
▪ Cephalopelvic Disproportion (large baby small pelvis)
▪ IUGR
▪ (Or female choice after considering pros and cons)
178
List some of the malpresentations of a baby.
▪ Face
▪ Brow
▪ Breech
▪ Transverse lie and oblique lie
179
Describe the 4 categories of Emergency C-Section.
▪ Cat 1 = immediate threat to the life of the mother or baby. (target decision to delivery is 30 minutes)
▪ Cat 2 = There is not imminent threat to life, but caesarean is required urgently due to compromise of the mother or baby (target is 75 minutes)
▪ Cat 3 = delivery is required but mother and baby are stable
Cat 4 = this is an elective caesarean as described above
180
Name the type of anaesthesia that is used for C-Section.
spinal Anaesthetic (For Example Lidocaine)
181
List 4 potential complications of C-Section.
▪ General Surgical Risks (Bleeding, infection, pain, VTE)
▪ Damage to local structures (E.g. ureter, bladder)
▪ Effect on future pregnancies (E.g. Increased risk of repeat caserean, increased risk of placenta praevia, Increased risk of uterine rupture)
▪ Effect on Baby (E.g. Risk of lacerations)
182
Describe what is meant by VBAC.
▪ Vaginal Birth After Caesarean
▪ This is possible provided the cause of the C-Section is unlikely to occur
High success rate (75%)
183
Name a contraindication to VBAC.
▪ Previous uterine rupture
184
Describe VTE prevention following an emergency C-section.
▪ TED Stocking
▪ LMWH for 10 days after
▪ Elective ones do not need LMWH unless there is other conditions.
185
Name the two leading causes of direct maternal deaths postpartum.
▪ Thrombosis and Thromboembolic disease (during and up to 6 weeks after end of pregnancy)
▪ Suicide
186
List 4 causes of maternal collapse.
▪ Hypoxia (Due to pulmonary oedema, or sepsis)
▪ Eclampsia / Pre-eclampsia
▪ Thromboembolic VTE/AFE
▪ Hypovolaemia (Haemorrhage)
187
Define a primary postpartum haemorrhage.
▪ Blood loss of >500ml within 24 hours of delivery
▪ Minor = 500-1000ml (No Hypovolemic shock)
▪ Major = >1000ml (Hypovolaemic shock)
188
Define secondary postpartum haemorrhage.
▪ Significant vaginal bleed >24 hours and <12 weeks following delivery
189
List three risk factors of post-partum haemorrhage
▪ Previous PPH
▪ Multiple pregnancies
▪ Pre-eclampsia
190
List the four causes of PPH.
▪ Tone - this is 90% (uterine third stage contractions lead to compression in intramyometrial blood vessels d placental site increasing likelihood - so if there is atony then there is increased chance of bleed)
▪ Trauma (perineal tear, episiotomy, cervical tear)
▪ Tissue (retained placental tissue, inhibiting uterine contractility
▪ Thrombin (Coagulopathy)
191
Describe the Management of PPH.
- Resuscitation (ABCDE approach including IV fluid/blood resuscitation as required)
- Large bore cannula
- Group and cross match
- Get experienced help
- If severe 'activate the major haemorrhage protocol' will give you quick access to 4 units of cross matched O -ve blood
192
Describe the management of atony
▪ Mechanical
□ Balloon tamponade (insert an inflatable balloon into the uterus to press against the bleeding)
□ Brace Sutures (putting a suture around the uterus to compress it)
▪ Medical/Pharmacological
□ Syntocinon
□ Ergometrine
□ Carboprost (prostaglandin analogue - stimulates uterine contraction - caution in asthma)
□ Misoprostol (prostaglandin analogue and stimulates uterine contraction)
□ Tranexamic Acid (to reduce bleeding)
▪ Surgical/Advanced Procedures
□ Uterine artery ligation (ligation of one or more of the arteries supplying the uterus to reduce blood flow and slow bleeding)
□ Hysterectomy (Last Resort)
193
Differentiate between the following: Chronic hypertension, gestational hypertension, pre-eclampsia, severe pre-eclampsia, mild, moderate and severe hypertension.
1- Chronic Hypertension = it presents at the booking or before 20 weeks of gestation and can be primary or secondary
2- Gestational hypertension = new hypertension after 20 weeks without significant proteinuria
3- Pre-eclampsia = new hypertension after 20 weeks with significant proteinuria /organ dysfunction/IUGR
4- Severe pre-eclampsia = pre-eclampsia with severe hypertension and/or with symptoms, and/or biochemical and/or haematological impairment
194
List risk factors for pre-eclampsia.
- Hypertensive disease in previous pregnancy
- chronic kidney disease
- Age >40
- Chronic hypertension
- Diabetes type 1 or 2
- Twin
- BMI >35
195
List signs and symptoms of pre-eclampsia.
- Headache
- Visual disturbance
- RUQ pain
- Oedema
- Vomiting
- Papilloedema
- Hyperflexia
196
What do you take as prophylaxis for pre-eclampsia/
Aspirin low dose
197
Describe pathophysiology of pre-eclampsia
- Abnormal placentation
- Inadequate trophoblastic invasion leading to inadequate or deranged placental perfusion
- Widespread endothelial damage and dysfunction
- Vessels become leaky
198
What is Management of pre-eclampsia?
1- Delivery
2- Blood pressure = labetalol, nifedipine, methyldopa (alpha adrenergic receptors agonist leading to reduced systemic resistance)
3- eclampsia = MgSO4
199
Describe complications of pre-eclampsia.
HELLP syndrome/DIC
Hypertensive crises
Fluid Crises
Fetal compromise
200
How can you estimate gestational age?
○ LMP + 40 weeks (280 days)
○ Clinical examination
○ Ultrasound
201
Describe conjunctivitisin new born?
Sticky eyes common in the neonatal period starting on the 3rd or 4th day of life
Purulent discharge with conjutival injection and swelling of the eyelids <48hrs of life may be due to gonococcal infection
Chlamydia trachomatis usually presents with purulent discharge together with swelling of the eye lids at 1-2 weeks of age present shortly after birth
2- Labour and Delivery
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