1
Q
What is an ectopic pregnancy?
A
embryo implanted outside the uterus
2
Q
What is the most common site for ectopic pregnancy?
A
fallopian tube
3
Q
What are possible locations for an ectopic pregnancy?
A
- MC tubal (ampulla)
- most danger of rupture in isthmus
- ovary, cervix, peritoneum
4
Q
What are the risk factors for ectopic pregnancy?
A
- previous ectopic
- previous pelvic inflammatory
- tubal damage
- IVF
- IUD/IUS/POP
- older age
- smoking
5
Q
What is the presentation of an ectopic pregnancy?
A
- vaginal bleeding
- missed period
- lower abdominal pain (L/RIF)
- lower abdo/pelvic tenderness
- cervical motion tenderness - chandelier sign
- shoulder tip pain (bleeding irritates diaphragm)
- dizziness
6
Q
What investigations are done for an ectopic pregnancy?
A
- transvaginal ultrasound scan
- gestational sac containing a yolk sac or fetal pole
7
Q
What is seen on USS for an ectopic?
A
- non-specific mass containing empty gestational sac
- blob/bagel/tubal ring sign
- mass moves separately to ovary (corpus lutem would move with ovary)
- empty/fluid filled uterus
8
Q
What are the criteria for conservative management of an ectopic?
A
- for minimal/no symptoms
- repeat β-hCG testing
- unruptured ectopic
- adnexal mass <35mm
- no visible heartbeat
- no significant pain
- hCG < 1500 IU/l
9
Q
What does medical management of an ectopic pregnancy involve and what are the criteria?
A
- hCG <1500IU/L
- confirmed absence of IU pregnancy on USS
- IM methotrexate in buttock
- teratogenic - spontaneous termination
10
Q
What are the side effects of methotrexate?
A
- vaginal bleeding
- n+v
- abdo pain
- stomatitis
- advised not to get pregnant for 3 months
11
Q
What are the criteria for surgical management of ectopic pregnancy?
A
- ruptured
- pain
- adnexal mass >35mm
- visible heartbeat
- hCG >5000 IU/l
12
Q
What is a salpingectomy?
A
removal of the fallopian tube (containing the ectopic pregnancy)
13
Q
What is a salpingotomy?
A
- used in women with inc risk of infertility due to other damaged tube
- cut made in tube, ectopic removed and tube closed
14
Q
What is pregnancy of unknown location?
A
- positive pregnancy test but no intra/extrauterine evidence of pregnancy on transvaginal USS
15
Q
How is pregnancy of unknown location monitored?
A
- serum hCG tracked and repeated over 48hrs
- monitor clinical signs or symptoms
16
Q
What rises in hCG indicate which types of pregnancy?
A
- rise of > 63% intrauterine pregnancy
- <63% indicates ectopic
- fall of >50% indicates miscarriage
17
Q
What is a missed miscarriage?
A
- fetus no longer alive
- no symptoms occurred
18
Q
What is a complete miscarriage?
A
- full miscarriage
- no products of conceptions left in the uterus
19
Q
What is an incomplete miscarriage?
A
- products of conception retained in the uterus
20
Q
What is a threatened miscarriage?
A
- vaginal bleeding
- closed cervix
- fetus is alive
- little/no pain
21
Q
What are the symptoms of an inevitable miscarriage?
A
- heavy vaginal bleeding
- pain
- open cervix
22
Q
How is miscarriage diagnosed?
A
- transvaginal ultrasound
- mean gestational sac diameter
- fetal pole and crown-rump length
- fetal heartbeat
23
Q
How does fetal heartbeat affect crown-rump length?
A
- heartbeat expected when length is 7mm or more
- if less than 7mm, scan is repeated after 1 week to ensure heartbeat develops
- 7mm+ and no heartbeat = non-viable pregnancy
24
Q
What is an anembryonic pregnancy?
A
- gestational sac is present
- no embryo
25
When is a fetal pole seen?
- expected when mean gestational sac diameter is >25mm
- if this is present without a fetal pole:
- repeat scan after 1 week then confirm anembryonic pregnancy
26
How is a miscarriage of <6 weeks gestation managed?
- expectant management
- awaiting without investigations and treatment
- repeat urine pregnancy test after 3 weeks
- if negative a miscarriage can be confirmed
27
How is a miscarriage of >6 weeks gestation managed?
- early pregnancy assessment service referral (EPAU)
- arrange USS to confirm location and viability
- consider and exclude ectopic
28
What is expectant management of a miscarriage?
- 1st line without risk factors for heavy bleeding and pregnancy
- 1-2 weeks to allow it to occur spontaneously
- repeat urine pregnancy after 3 weeks to confirm complete
- persistent/worsening bleeding requires further assessment and repeat USS in case of incomplete miscarriage
29
What is medical management of a miscarriage?
- misoprostol
- vaginal suppository or oral
- causes heavier bleeding, pain, vomiting, diarrhoea
30
What is surgical management of miscarriage?
- give misoprostol
- manual vacuum aspiration
- electric vacuum aspiration
31
How does manual vacuum aspiration work?
- local anaesthetic applied to cervix
- syringe inserted through
-<10 weeks gestation
- more appropriate for parous women
32
How does electric vacuum aspiration work?
- traditional surgical management
- general anaesthetic
- cervix widened with dilators
- pregnancy removed with electric powered vacuum
33
How is incomplete miscarriage managed?
- retained products carry infection risk
- misoprostol or evacuation
- ERPC using vacuum aspiration and curettage (scraping)
- complication is endometriosis
34
What is hyperemesis gravidarum?
- vomiting a lot during pregnancy
35
What are the RCOG guidelines for hyperemesis?
- more than 5% weight loss compared with before pregnancy
- dehydration
- electrolyte imbalance
36
How is the severity of hyperemesis assessed?
- pregnancy-unique quantification of emesis (PUQE)
- <7 = mild
- 7-12 = moderate
- >12 = severe
37
What is the management of hyperemesis?
- antiemetics
1. prochlorperazine
2. cyclizine
3. ondansetron
4. metoclopramide
38
How is severe hyperemesis managed?
- IV/IM antiemetics
- IV fluids
- KCl for hypokalaemia
- thiamine and folic acid to prevent Wernicke's encephalopathy
- TED stockings and LmwH
39
When should admission be considered in hyperemesis?
- unable to tolerate antiemetics
- more than 5% weight loss vs prepregnancy
- ketones present (2+ is significant)
40
What is the definition of recurrent miscarriage?
- three or more miscarriages
41
What are the causes of recurrent miscarriage?
- smoking
- antiphospholipid syndrome
- hereditary thrombophilia
- uterine abnormalities
- chronic disease: diabetes, SLE, thyroid
- genetic factors
42
What is PPH?
- post partum haemorrhage
- bleeding after delivering baby and placenta
- most common cause of significant obstetric haemorrhage
43
How much blood loss is needed to be classified as PPH?
- 500ml after vaginal delivery
- 1000ml after c-section
44
What is the difference between major and minor PPH?
- Minor: under 1000ml
- Major: over 1000ml
45
How can major PPH be subclassified?
- Moderate: 1000-2000ml loss
- Severe >2000ml loss
46
What is the difference between primary and secondary PPH?
Primary: within 24hrs of birth
Secondary: between 24hrs - 12 weeks after birth
47
What are the causes of PPH (4 T's)?
- tone (uterine atony)
- trauma (perineal tear)
- tissue (retained POC)
- thrombin (bleeding disorder)
48
What are risk factors for PPH?
- previous PPH
- retained placenta
- placenta accreta
- instrumental delivery
- multiple pregnancy
- macrosomia
- prolonged 3rd stage
- failure to progress from 2nd stage
49
What are some preventative measures for PPH?
- treating anaemia during antenatal period
- giving birth w empty bladder
- active management of 3rd stage
- IV tranexamic acid (in 3rd stage C-section in high risk pt)
50
What is mechanical treatment of PPH?
- rubbing uterus to stimulate contraction
- catheterisation (bladder distention prevents contractions)
51
What is medical treatment of PPH?
- oxytocin
- ergometrine (IV/IM) stimulates smooth muscle contraction
- carboprost/misprostol: prostaglandin analogues stimulating uterine contraction
- tranexamic acid: antifibrinolytic
52
What is surgical treatment of PPH?
- IU balloon tamponade: presses against bleeding
- B-lynch suture: suture around uterus to compress
- uterine artery ligation
- hysterectomy
53
What causes secondary PPH?
- most likely due to retained products of conception or infection
54
How is secondary PPH investigated?
- USS for RPOC
- endocervical and high vaginal swabs for infection
55
How is secondary PPH managed?
- surgical evacuation for RPOC
- Abx for infection
56
What is placental abruption?
when the placental separates from the uterine wall during pregnancy
57
What does placental abruption lead to?
- site of attachment can bleed
- significant cause of antepartum haemorrhage
58
What are risk factors for placental abruption?
- prev abruption
- pre-eclampsia
- trauma
- multiple pregnancy
- inc maternal age
- smoking/cocaine
- multiparity/gravida
59
How does placental abruption present?
- woody, hard uterus
- sudden onset, severe, continuous abdo pain
- vaginal bleeding
- hypovolaemic shock
- dec fetal movements and distress on CTG
60
How is the severity of antepartum haemorrhage defined?
- spotting: spots on underwear
- minor: <50ml blood loss
- major: 50-1000ml loss
- massive: >1000ml or signs of shock
61
What is a concealed abruption?
- cervical os remains closed
- bleeding remains within uterine cavity
62
When are steroids given in placental abruption?
- between 24 and 34+6 weeks
- mature fetal lungs
- in anticipation of preterm delivery
63
What is the management of abruption?
- FBC, U&Es, LFT, coagulation
- crossmatch 4 units
- CTG of foetus and monitor mother
- fluid and blood resus as required
- senior obstetrician, midwife, anaesthetist
64
What is placenta praevia?
- low lying placenta, potentially covering cervical os
- lower than presenting part (part of baby to be delivered first - head in cephalic presentation) of the fetus
65
What is the difference between low-lying placenta and placenta praevia?
- low-lying: within 20mm of os
- praevia: placenta is over os
66
What can placenta praevia cause?
- antepartum haemorrhage
- emergency c-section
- emergency hysterectomy
- maternal anaemia and transfusion
- preterm birth and low weight
- stillbirth
67
What are risk factors for placenta praevia?
- prev c-sections
- prev praevia
- older age
- smoking
- uterine abnormalities
- IVF
68
What are the grades of praevia?
- minor/grade 1: in lower uterus but not reaching os
- marginal/grade 2: reaching but not covering os
- partial/grade 3: partially covering os
- complete/grade 4: completely covering os
69
What is the presentation of placenta praevia?
- painless bright red vaginal bleeding
- occurs after 24 weeks
70
What is the management of placenta praevia?
- if diagnosed early:
- repeat TVUS at 32 and 36 weeks
- corticosteroids 34 - 35+6 weeks to mature fetal lungs
- planned delivery 36-37 weeks
- planned C-section
- emergency c-section if premature labour/antenatal bleeding
71
What is a perineal tear?
- when external vaginal opening is too narrow for baby
- tearing of skin and tissues
72
What are risk factors for perineal tears?
- first baby
- large baby (over 4kg)
- shoulder dystocia
- Asian ethnicity
- occipito-posterior position
- instrumental deliveries
73
How are perineal tears classified?
- 1st degree: frenulum of posterior labia minor and superficial skin
- 2nd: including perineal muscles
- 3rd: including anal sphincter
- 4th: including rectal mucosa
74
How are 3rd degree tears subcategorised?
- 3a: <50% of ext sphincter affected
- 3b: >50% ext sphincter affected
- 3c: ext and int sphincter affected
75
What are the short term complications of tears?
- pain
- infection
- bleeding
76
What are the long lasting complications of perineal tears?
- urinary incontinence
- anal incontinence/altered bowel habit (3rd/4th degree)
- rectovaginal fistula
- sexual dysfunction and dyspareunia
- psych and mental consequences
77
What is the management of tears?
- 1st: none
- 2nd: suture
- 3rd/4th: theatre + elective C-section for subsequent pregnancies
- antibiotics
- laxatives
- physio and followup
78
What is an episiotomy?
- cuts perineum before delivery - anticipation
- 45 degree diagonal from vagina, downwards and laterally
- mediolateral episiotomy
- sutured after delivery
79
What is perineal massage?
- reduces risk
- massaging skin and tissues
- from 34 weeks
80
What is shoulder dystocia?
- anterior shoulder becomes stuck behind pubic symphysis after head has been delivered
81
What is a cause of shoulder dystocia?
- macrosomia (large baby)
- secondary to gestational diabetes
- advanced maternal age
- short stature
- small pelvis
- gestation >42 weeks
82
How does shoulder dystocia present?
- difficulty delivering face and head
- failure of restitution (baby head remains downwards (occipito- anterior))
- turtle-neck sign: head is delivered then retracts back into vagina
83
What are complications of shoulder dystocia?
- fetal hypoxia (+ subsequent cerebral palsy)
- brachial plexus injury
- perineal tear
- PPH
84
Why should fundal pressure not be applied in shoulder dystocia?
- can lead to uterine rupture
- may exacerbate shoulder impaction
- discouraging maternal pushing
85
What is the 1st line manoeuvre for shoulder dystocia?
- McRobert's manoeuvre
- hyperflexion of hip to provide posterior pelvic tilt
- knees to abdomen
- moves pubic symphysis out of way
86
What is the second line manoeuvre for shoulder dystocia?
- suprapubic pressure
- pressure on the posterior aspect of the anterior shoulder
- encourages it down and under the pubic symphysis
87
What is Rubins and Wood's screw manoeuvre?
- Rubins: reaching into vagina to put pressure on posterior aspect of anterior shoulder to move under symphysis
- Wood's: other hand reaches inside to put pressure on anterior aspect of posterior shoulder
- top shoulder pushed forwards and bottom pushed back
- rotates baby and helps delivery
- opposite can be tried
88
What is the last line manoeuvre for shoulder dystocia?
- Zavanelli manoeuvre
- pushing baby's head back into vagina for emergency C-section
89
What is instrumental delivery?
- vaginal delivery with ventouse suction cup or forceps
90
What are key indications for instrumental delivery?
- failure to progress
- fetal distress
- maternal exhaustion
- control of head in various fetal positions
91
What are the risks to the mother with instrumental delivery?
- PPH
- episiotomy
- perineal tears
- injury to anal sphincter
- bladder/bowel incontinence
- obturator/femoral nerve injury
92
What are the key risks to the baby with instrumental delivery?
- cephalohaematoma with ventouse
- facial nerve palsy with forceps
93
What more serious risks are there to the baby with instrumental delivery?
- subgaleal haemorrhage
- intracranial haemorrhage
- skull fracture
- spinal cord injury
94
What is a cephalohaematoma?
- collection of blood between the skull and periosteum (membrane covering bones)
95
What is ventouse?
- a suction cup on a cord
- cup goes on baby's head
- careful traction on cord to pull baby out
96
What are forceps?
- two pieces of curved metal allowing grip of baby's head
- can cause facial nerve palsy or facial paralysis
- can cause bruising or fat necrosis
97
What occurs in femoral nerve compression?
- femoral nerve compressed against inguinal canal
- weakness of knee adduction
- loss of patella reflex
- numbness of anterior thigh and medial lower leg
98
What occurs in obturator nerve compression?
- weakness of hip adduction and rotation
- numbness of medial thigh
99
At how many weeks gestation is induction of labour offered?
- 41-42 weeks
100
When is induction of labour beneficial?
- pre labour ROM
- fetal growth restriction
- pre-eclampsia
- obstetric cholestasis
- existing diabetes
- IU fetal death
101
What criteria are assessed in the Bishop score?
- fetal station (0-3)
- cervical position (0-2)
- cervical dilatation (0-3)
- cervical effacement (0-3)
- cervical consistency (0-2)
- 8 or more predicts success
- <8 - cervical ripening needed
102
What is a balloon and how is it used to induce labour?
- cervical ripening balloon
- silicone balloon is inserted into cervix and gently inflated to dilate it
- used in multiparous women (≥3), prev c-section, vaginal prostaglandin failure
103
What is a membrane sweep?
- inserting finger into cervix to stimulate and begin labour
- should produce onset within 48hrs
- used from 40 weeks
104
What is ARM?
- artificial rupture of membranes
- oxytocin infusion
- can be used to progress labour
105
What are prostaglandins?
- vaginal prostaglandin E2 (dinoprostone)
- inserting gel, tablet or pessary into vagina
- similar to tampon, releases local prostaglandins over 24hrs
- simulates cervix and uterus
106
How is labour induced in IU fetal death?
- oral mifepristone
- is an anti-progesterone
- plus misoprostol
107
How is induction of labour monitored?
- CTG for fetal HR and uterine contractions
- Bishop score
108
What are the criteria for uterine hyperstimulation?
- individual contractions lasting >2 mins in duration
- more than 5 contractions every 10 mins
109
What is the main complication of induction of labour?
- uterine hyperstimulation
- occurs with vaginal prostaglandins
- prolonged and frequent uterine contraction
- causes fetal distress and compromise
110
What are the consequences of uterine hyperstimulation?
- fetal compromise > hypoxia and acidosis
- emergency c-section
- uterine rupture
111
How is uterine hyperstimulation managed?
- removing vaginal prostaglandins
- stopping oxytocin infusion
- Tocolysis with terbutaline
112
What is cord prolapse?
- umbilical cord descends below presenting part of fetus, through cervix and into vagina after ROM
113
What is a risk factor for cord prolapse?
- abnormal lie after 37 weeks gestation
- unstable, transverse or oblique
- cephalic: head is in pelvis so no room for cord
114
How is cord prolapse diagnosed?
- fetal distress on CTG
- vaginal exam
- speculum to confirm
115
How is cord prolapse managed?
- emergency c-section
- NVD has high risk of cord compression and hypoxia to baby
- minimal handling otherwise vasospasm
116
What position can be used to manage baby compressing cord prolapse?
- presenting part pushed upwards
- woman lies in left lateral position or knee to chest on all fours
- terbutaline used to minimise contractions
117
What is the pathophysiology of rhesus?
- rhesus +ve baby's blood may mix with mother's
- blood mixes and mother's body makes antibodies against Rh D antigen
- mother becomes sensitised affecting future pregnancies
118
What happens if a rhesus negative woman becomes pregnant again?
- anti Rh D antibodies cross placenta
- if placenta is Rh + then haemolysis of RBC occurs
- called haemolytic disease of newborn
119
How are rhesus negative women managed?
- IM anti-D injections into the women
- attaches itself to Rh D antigens in mother's circulation
- destroys antigens and prevents mother becoming sensitised to Rh D antigen
120
When are anti-D injections given?
- 28 weeks
- birth (if baby's blood is +ve)
- antepartum haemorrhage
- amniocentesis procedures
- abdo trauma
121
What is the Kleihauer test?
- how much fetal blood has passed into mother's blood
- used after any sensitising event past 20 weeks gestation
- assesses whether further anti D needed
122
How does the Kleihauer test work?
- add acid to sample of mother's blood
- fetal Hb is more resistant so protected from acidosis
- fetal Hb persists, mother's Hb destroyed
- No of cells remaining is calculated
123
What is pre-eclampsia?
- new hypertension
- end-organ dysfunction
- proteinuria
124
When does pre-eclampsia occur and why?
- after 20 weeks
- spiral arteries of placenta form abnormally
- leads to high vascular resistance
125
Describe the pathophysiology of pre-eclampsia
- high vascular resistance in spiral arteries
- poor perfusion of placenta > oxidative stress
- release of inflammatory chemicals into systemic circulation
- systemic inflammation and impaired endothelial function
126
What is the triad featured in pre-eclampsia?
- hypertension
- proteinuria
- oedema
127
What are high-risk factors for pre-eclampsia?
- pre-existing hypertension
- prev hypertension in pregnancy
- existing autoimmune conditions
- diabetes
- CKD
128
What are moderate risk factors for pre-eclampsia?
- age >40
- BMI >35
- >10yrs since prev pregnancy
- multiple pregnancy
- first pregnancy
- family history
129
What prophylaxis is offered for pre-eclampsia and when?
- 75-150mg aspirin from 12 weeks
- one high-risk factor
- two or more moderate-risk factors
130
What is HELLP syndrome?
- complication of pre-eclampsia and eclampsia
- haemolysis
- elevated liver enzymes
- low platelets
131
What is eclampsia?
- seizures associated with pre-eclampsia
132
How is eclampsia treated?
- IV magnesium sulphate
133
What is chronic hypertension?
- high blood pressure existing before 20 weeks gestation
- not caused by dysfunction in placenta
134
What is gestational hypertension?
- hypertension occurring after 20 weeks gestation
- without proteinuria
135
What are the symptoms of pre-eclampsia?
- headache
- visual disturbance/blurriness
- nausea and vomiting
- upper abdo/epigastric pain (liver swelling)
- oedema
- dec urine output
- brisk reflexes
136
What are the NICE criteria for diagnosis of pre-eclampsia?
- over 140 systolic or 90 diastolic
- PLUS
- proteinuria (1+ or more)
- organ dysfunction
- placental dysfunction
137
What indicates organ dysfunction in pre-eclampsia?
- raised creatinine
- elevated liver enzymes
- seizures
- thrombocytopenia
- haemolytic anaemia
138
What values indicate proteinuria in pre-eclampsia?
- protein:creatinine above 30mg/mmol
- albumin:creatinine above 8mg/mmol
139
What is medical management of pre-eclampsia?
- labetolol (antihypertensive)
- nifedipine
- methyldopa
- IV hydralazine in critical care
- fluid restriction during labour
140
How is gestational hypertension managed?
- aim for BP below 135/85
- admit if above 160/110
- urine dipstick + bloods weekly
- serial growth scans
- placental growth factor testing
141
How is pre-eclampsia managed after diagnosed?
- scoring system (fullPIERS or PREP-S)
- BP monitored at least every 48hrs
- USS monitoring of fetus, amniotic fluid and dopplers fortnightly
142
How is pre-eclampsia managed after delivery?
- BP monitored + returns to normal after placenta delivered
- enalapril
- nifedipine or amlodipine (black patients)
- labetolol
143
How is delivery managed for pre-eclampsia?
- planned early delivery if BP uncontrolled or complications
- corticosteroids for premature
144
What are the risk factors for gestational diabetes?
- prev gestational diabetes
- prev macrosomic baby <4.5kg
- BMI >30
- black Caribbean, Middle Eastern, South Asian
- FH of diabetes
145
What is gestational diabetes?
- diabetes triggered by pregnancy
- reduced insulin sensitivity during pregnancy
- resolves after birth
146
What complications are there of gestational diabetes?
- large for dates fetus
- macrosomia >shoulder dystocia
- long-term: higher risk of T2DM
147
When and how is gestational diabetes screened for?
- OGTT
- at booking if prev GD or 24-28 weeks
- large for dates fetus
- polyhydramnios
- glucose on urine dipstick
148
How is an OGTT performed?
- morning after a fast
- pt drinks 75g glucose
- blood sugar measured before drinking and 2hrs after
149
What results in an OGTT indicate gestational diabetes?
- fasting ≥5.6mmol/l
- at 2hrs ≥7.8 mmol/l
150
How is gestational diabetes monitored?
- joint diabetes and antenatal clinic
- dieticians
- monitoring BMs
- 4-weekly USS from 28-36 weeks for fetal growth and amniotic fluid vol
151
What is the medical management of gestational diabetes?
- fasting glucose <7mmol/l: trial diet and exercise for 1-2 weeks > metformin > insulin
- > 7mmol/l: insulin ± metformin
- >6mmol/l + macrosomia: insulin ± metformin
152
What are the blood sugar targets in gestational diabetes?
- fasting: 5.3mmol/l
- 1hr post meal: 7.8mmol/l
- 2hr post meal: 6.4 mmol/l
- avoid levels of 4mmol/l or below
153
What alternative medication can be used for women declining insulin?
- glibenclamide
- sulfonylurea
- used if not tolerating metformin
154
How are women with pre-existing diabetes managed in pregnancy?
- 5mg folic acid from preconception - 12 weeks gestation
- aim for same insulin target levels
- metformin ± insulin - other diabetes medications stopped
155
How is labour altered for women with pre-existing diabetes?
- planned delivery 37-38+6 weeks
- gest diabetes can go up to 40+6
- sliding scale insulin: dextrose and insulin infusion
156
What screening is done for pre-existing diabetic women in pregnancy?
- retinopathy screening
- shortly after booking and at 28 weeks
- ophthalmologist referral to check for diabetic retinopathy
157
What happens to gestational diabetes postnatally?
- diabetes improves immediately after birth
- stop diabetic medications
- followup fasting glucose after 6 weeks
- if pre-existing: lower insulin dose and be wary of hypoglycaemia
- insulin sensitivity inc after birth and w breastfeeding
158
What risks of complications are there for babies of diabetic mothers?
- neonatal hypoglycaemia
- polycythaemia
- jaundice
- congenital heart disease
- cardiomyopathy
159
How is neonatal hypoglycaemia monitored?
- regular BM checks and frequent feeds
- aim to maintain above 2mmol/l
- If falling below then IV dextrose nasogastrically
160
What is obstetric cholestasis?
- intrahepatic cholestasis of pregnancy
- reduced outflow of bile acids from liver
161
What are the causes of obstetric cholestasis?
- resulting from inc oestrogen and progesterone levels
- genetics
- more common in south asians
162
What is the pathophysiology behind obstetric cholestasis?
- bile acids produced from breakdown of cholesterol
- flow from liver to hepatic ducts, past gallbladder and through bile duct into intestines
- outflow reduced causing buildup in blood
163
How does obstetric cholestasis present?
- third trimester
- pruritus of palms and soles
- fatigue
- dark urine
- pale, greasy stools
- jaundice
- NO rash
164
What are differentials for obstetric cholestasis?
- gallstones
- acute fatty liver
- autoimmune hepatitis
- viral hepatitis
165
What investigations are done for obstetric cholestasis?
- LFTs and bile acids
- abnormal LFTs: ALT, AST, GGT
- raised bile acids
166
How is obstetric cholestasis managed?
- emollients
- chlorphenamine (antihistamine)
- water-soluble vit K if clotting is deranged
- planned delivery if severely deranged bloods
167
What complication can occur from obstetric cholestasis?
- stillbirth (intrauterine death)
168
What is anaemia?
- low concentration of Hb in blood
169
When are women screened for anaemia in pregnancy?
- booking clinic
- 28 weeks gestation
170
What is the pathophysiology behind anaemia in pregnancy?
- plasma volume increase in pregnancy
- dec Hb conc
- blood is diluted
- must be treated so woman has reserves if significant blood loss in delivery
171
How does anaemia in pregnancy present?
- SOB
- fatigue
- dizziness
- pallor
172
What are the normal ranges for haemoglobin in pregnancy?
- booking bloods: >110g/l
- 28 weeks gestation: > 105g/l
- post partum: 100g/l
173
What screening for anaemia are women routinely offered at booking clinic?
- haemoglobinopathy screening
- for thalassaemia and sickle cell disease
174
How is iron deficiency in pregnancy managed?
- iron replacement e.g. ferrous sulphate
- 200mg 3x a day
- if not anaemic but low ferritin > supplementary iron
175
How is B12 deficiency managed?
- test for pernicious anaemia
- IM hydroxocobalamin
- oral cyanocobalamin
176
How is folate deficiency managed?
- should already be taking 400mcg/day
- started on 5mg daily
177
How are thalassaemia and sickle cell anaemia managed?
- managed jointly with specialist haematologist
- high dose folic acid (5mg)
- close monitoring
- transfusions
178
What is prematurity?
- birth before 37 weeks gestation
- <28 weeks: extreme preterm
- 28-32 weeks: very preterm
- 32-37 weeks: moderate-late preterm
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Below what gestation are pregnancies considered non-viable?
- non-viable <23 weeks
- 23 weeks = 10% chance of survival
- >24 weeks = inc chance and full resus offered
180
What is tocolysis?
- medication to stop uterine contractions
- nifedipine (CCB)
- used 24 - 33+6 weeks gestation
181
Why is tocolysis used?
- delays delivery
- allows for fetal development, maternal steroids or transfer to specialist unit
182
What is an alternative tocolytic?
- atosiban
- oxytocin receptor antagonist
183
What antenatal steroids are given and why?
- 2 doses IM betamethasone
- develop fetal lungs
- reduce resp distress syndrome
- used in suspected preterm labour <36 weeks gestation
184
Why is magnesium sulphate used?
- IV
- protects fetal brain in premature delivery
- reduces risk and severity of cerebral palsy
185
When is magnesium sulphate given?
- within 24hrs of delivery of preterm babies
- <24 weeks gestation
186
What are key signs of magnesium toxicity?
- 4hrly obs
- reduced RR
- reduced BP
- absent reflexes
187
How does vaginal progesterone prevent preterm labour?
- gel or pessary
- maintains pregnancy and decreases myometrial activity
- prevents cervical remodelling
188
What is P-PROM?
- preterm prelabour ROM
- amniotic sac ruptures before labour and in preterm pregnancy
189
How is P-PROM diagnosed?
- speculum for pooling of amniotic fluid in vagina
- IGFBP-1 testing
- PAMG-1 testing
190
How is P-PROM managed?
- prophylactic Abx to prevent chorioamionitis
- erythromycin 250mg QDS for 10 days
- induction of labour offered from 34 weeks
191
What is placenta accreta?
- placenta implants deep
- through and past endometrium
- difficult to separate placenta after baby delivered
192
What is superficial placenta accreta?
- placenta implants in surface of myometrium
193
What is placenta increta?
- placenta attaches deeply into myometrium
194
What is placenta percreta?
- placenta invades past myometrium, reaching other organs
195
Where does the placenta usually attach?
- to the endometrium
196
What are risk factors for placenta accreta?
- previous accreta
- previous endometrial curettage
- previous C-section
- multigravida
- increased maternal age
- low-lying/placenta praevia
197
How is abortion accessed?
- self-referral, GP, GUM or family planning clinic
- doctors who object should pass on the referral
198
Which 2 acts constitute the legal framework for an abortion?
- 1967 abortion act
- 1990 human fertilisation and embryology act
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What does the 1990 HFEA act say?
- expanded the criteria for abortion
- reduced latest age from 28 to 24 weeks
200
What are the criteria for abortion before 24 weeks?
- continuing pregnancy involves greater risk to physical or mental health of the woman or existing children of the family
- threshold is a matter of clinical judgement
201
Which factors allow an abortion to be performed after 24 weeks?
- continuing pregnancy risks woman's life
- terminating prevents 'grave permanent injury' to woman
- substantial risk that the child would suffer physical/mental abnormalities > severe handicap
202
What are the legal requirements for abortion (who agrees/carries it out)?
- 2 registered medical practitioners must sign to agree
- must be carried out by registered medical practitioner in an NHS hospital or approved premise
203
Which symptoms may be experienced post-abortion?
- vaginal bleeding
- abdominal cramps for up to 2 weeks
- UPT performed 3 weeks after to confirm complete
204
What are the treatments used in a medical abortion?
- mifepristone
- misoprostol 1-2 days later
- additional misoprostol doses every 3hrs until expulsion
205
What is the action of mifepristone?
- anti-progestogen
- blocks action of progesterone
- halts pregnancy
- relaxes cervix
206
What is the action of misoprostol?
- prostaglandin analogue
- activates receptors
- softens cervix
- stimulates uterine contractions
207
What types of anaesthetic are used in surgical abortion?
- local
- local + sedation
- general
208
What are complications of an abortion?
- bleeding
- pain
- infection
- failure of abortion
- damage to cervix, uterus or other structures
208
Which medications are used prior to surgical abortion?
- cervical priming
- misoprostol
- mifepristone
- osmotic dilators
209
What are the options for surgical abortion?
- cervical dilatation and suction of contents (<14 weeks)
- cervical dilatation and evacuation with forceps (14-24 weeks)
210
How are pregnant women protected against chickenpox?
- if not immune: given varicella zoster immunoglobulins
- protection post exposure
211
What is the risk of chickenpox in pregnancy before 28 weeks?
- developmental problems in fetus
- congenital varicella syndrome
212
What is the risk of chickenpox during delivery?
- can lead to neonatal infection
- treated with VZ immunoglobulins and Aciclovir
