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Week 12 Flashcards

PPH, perineal injury, postpartum (314 cards)

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1
Q

How much does active management of the 3rd stage reduce your risk of PPH by?

A

50%

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2
Q

What is the rate of PPH in australia?

A

5-15%

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3
Q

What is the definition of PPH?

A

> 500ml

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4
Q

What is the definition of primary PPH?

A

within the first 24 hours

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5
Q

What is the blood lfoe to the placental bed at term?

A

750ml/minute

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6
Q

What is average blood volume at term?

A

100ml/kg or 7L

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7
Q

What is carbetocin?

A

long acting oxytocin receptor agonist, doesn’t need refrigeration

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8
Q

What is the leading cause of maternal death globally?

A

PPH

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9
Q

What is a severe PPH?

A

traditionally >1000ml
more recently if signs of haemodyanmic compromise regardless of EBL

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10
Q

At what % of blood loss not replaced can bleeding be life threatening in labour?

A

30%

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11
Q

What is the principle mechanism for avoiding excessive blood loss post partum?

A

s through constriction of the blood vessels supplying the placental bed by uterine contraction.

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12
Q

What are the supplementary ways you reduce excessive blood loss in PPH?

A

vasoconstriction
platelet aggregation
clot formation

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13
Q

What are the keys to prevention of PPH?

A

risk factors - all though most women with PPH don’t have any. correct anaemia
Placental location - all women should have location of of placental assessed antnatally
active management of third stage

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14
Q

Why do we recommend active management of the third stage?

A

reduced PPH rate by 50 and need for RBC

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15
Q

What is the drug of choice for the 3rd stage for women without risk factors?

A

oxytocin

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16
Q

What is the drug of choice for women for 3rd stage with risk factors and why?

A

syntometrine - reduced likelihood of needing addition uterotonics but no reduction in risk of severe PPH or RBC vs oxytocin alone

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17
Q

What is the cornerstone of resuscitation in PPH?

A

restoring blood volume and oxygen carrying capacity

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18
Q

What are the 5 steps of PPH management?

A
  1. recognition
  2. communication
  3. resuscitation
  4. monitoring and investigating
  5. management of PPH - tone, tissue, trauma, thrombin and theatre
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19
Q

What should be considered for resuscitation of PPH?

A

aims to restore volume and oxygen carrying capacity
ABCs
high flow oxygen
warms IV fluids
IV wide bore access, bloods
O neg blods
keep warm and lying flat

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20
Q

What is included in monitoring and investigation of PPH?

A

correct location for ongoing monitoring and bloods including UO
clexane when bleeding controlled

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21
Q

What is the most common cause of Primary PPH?

A

tone

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22
Q

what are the two aspects of tone management?

A

mechanical and pharmacological

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23
Q

What is the dose of oxytocin in managing PPH?

A

5IV or 10IM, can be repeated after 3rd stage prophylactic management

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24
Q

What is the dose of ergometrine, frequency and max?

A

0.25mg slow IV or IM
repeat 5 minutes
max 1mg if no CI

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25
What is the max dose of miso and route?
1000mcg PR
26
What is the dose, frequency and maximum for carboprost?
IM 0.25mg every 15 minutes max 2mg
27
what adverse effect can you get with carboprost?
diarrhoea, hypertension and bronchospasm
28
What are the contraindications to carboprost?
active lung, heart, renal or liver disease
29
What are the CI to ergometrine?
retained placenta, PET, sepsis, peripheral vascular disease, heart disease, HTN, hepatic or renal impairment
30
What is in 1ml of syntometrine?
5IU oxtocin and 500mcg of ergometrine
31
If a woman is shocked and the amount of bleeding is normal what should you consider?
ruptured uterus, broad ligament haematoma, subcapsular liver rupture, ruptured spleen, ruptured splenic artery, hepatic or pancreatic artery aneurysm
32
What dose of TXA do you give and when can you repeat it?
1g IV 30 minutes
33
When should you consider cyropreciptate in a PPH?
fibrinogen is less than 2.0g
34
What is the dose of intrauterine carboprost?
0.5mg every 15 minutes up to 2mg
35
What should you be aiming for in ongoing major PPH on bloods?
platelets >75 fibrinogen >2.0 APPT <40 seconds Prothrombin ratio/INR <1.5
36
When ongoing bleeidng in PPH how often should you check coag and FBC?
hourly
37
What order of ecbolics does the TWO guideline reccomend?
oxytocin bolus --> infusion --> syntometrine --> TXA --> foley --> transfer to OT --> carboprost --> further syntometrine
38
What features of PPH would need critical care?
1. Coagulopathy 2. Need for ventilation 3. Ionotropic support 4. Multiorgan failure 5. Unplanned peripartum hysterectomy
39
What are the % causes of PPH?
Tone 70% trauma 20% tissue 10% thrombin 1%
40
What does TWO advise for total IVF prior to RBC?
3L then blood
41
What is the success rate of carboprost when used with other ecbolics?
95%
42
What is the MOA of TXA?
a lysine analogue which stops plasminogen being converted to plasmin. Plasmin usually breaks down fibrin
43
What are CI to TXA?
DIC, active VTE, anaphylaxis, sub arachnoid haemorrhage
44
What is the overall incidence of OASI in vaginal birth?
2.9%
45
What is the risk of OASI in primips vs multips?
6.1 vs 1.7%
46
What is the definition of a first degree tear?
injury to the vaginal mucosa or perineal skin
47
what is the definition of a second degree tear?
injury to the perineal muscles but not the anal sphincter
48
What is the definition of a third degree tear?
injury to the perineum including the anal sphincter complex
49
What is the definition of a forth degree tear?
injury to the perineum, the anal sphincter complex and the anorectal mucosa
50
What is the definition of anal incontinence?
involuntary loss of flatus and or faeces effecting QOL
51
What are the risks for OASI?
asian ethnicity nulliparity forceps prolonged second stage previous OASI vacuum shoulder dystocia OP presentation BW >4kg
52
What is the RR of another OASI after previous?
RR 5.51
53
How much does warm compress reduce OASI by?
RR 0.48
54
What is the recommended systematic assessment for genital trauma?
* Explanation of the assessment & why * Confirmation by the woman that effective analgesia is in place * Visual assessmentthe apex of the injury and assessment of bleeding * Rectal examination
55
What kind of suture knots should be avoided in OASI?
figure of 8 - ischemia
56
How should you repair the anorectal mucosa at OASI repair?
continuous or interrupted sutures, seperately to the IAS. Can be vicryl, knots don't need to be in the rectal mucosa. vicryl 3 0 as it is less irritating than PDS
57
How should you repair the IAS in OASI?
interrupted or mattress sutures, do not overlap 2 0 vicryl or 3 0 PDS
58
How do you repair the EAS in OAIS?
2.0 vicryl or 3.0 PDS can over lap or end to end
59
What is the difference in end to end vs overlapping for OASI 3b or c?
overlapping lower faecal urgency and incontinence and lower risk of deterioration of anal incontinence over 12 months. Outcomes at 36 months were the same of flatus or faecal incontinence
60
What is the risk of suture migration in OASI repair? What can be done about it?
7%, trim under local anaesthetic
61
What is the prognosis at 12 months after EAS repair?
60-80% will be asymptomatic
62
Which patients with a previous OASI should be counselled around a CS as per GTG?
All women who have previous OASIS and who are symptomatic or who have abnormal endoanal USS and/or manometry should be counselled regarding the option of ELCS
63
What is the risk of sustaining another OASI?
5-7%
64
What is the risk of worsening faecal symptoms after a second vaginal delivery with a hx of 3rd degree tear? Who is most at risk?
17% if the women has symptoms beyond 3/12 but resolved by 6/12
65
What is the definition of maternal collapse?
an acute event involving the cardiorespiratory systems and or CNS resulting in reduced or absent conscious level at any stage in pregnancy and up to 6 weeks after birth
66
What is a maternal collapse?
an acute event involving the cardiorespiratory system and or CMS resulting in reduced or absent conscious level at any stage in pregnancy or up to 6 weeks post birth
67
What are the 4 Hs and 4 Ts?
hypoxia hypovolemia hyper/hypokalemia hypothermia Thrombus tamponade toxins tension penumo
68
What are the main obstetric causes of maternal collapse?
VTE AFE cardiac disease anaphylaxis haemorrhage eclampsia intracerebral haemorrhage drug over dose or use - MgSO4, LAST Sepsis
69
How does AFE present?
hypotension, hypoxia, RDS
70
What are the stages of AFE?
1. Pulmonary hypertension from vascular occlusion of constriction 2. Left ventricular dysfunction and failure 3. Coagulopathy and PPH Fetal distress
71
What are cardiac disease causes of maternal collapse?
cardiomyopathy, dissection, LV failure, infective endocarditis, pulmonary oedema.
72
What are the most common causes of obs sepsis?
group A, B, D, ecoli and pneumococcus
73
When do you do tryptase in suspected anaphylaxis?
as soon as able, 1-2 hour and 24 hours
74
What is the definition of anaphylaxis?
Severe life threatening generalised or systemic hypersensitivity reaction resulting in rep, cutaneous, circulatory and GI disturbance and collapse.
75
What occurs in anaphylaxis?
○ Fluid redistribution and reduced cardiac output, ventricular failure and myocardial ischemia may occur. Angioedema, bronchospasm and mucous plugging of smaller airways --> hypoxia
76
What is the incidence of severe obstetric anaphylaxis?
1-3.5 in 100 000
77
What is the mortality rate of severe anaphylaxis?
1%
78
How much is plasma volume increase in pregnancy?
50% increase
79
How much is the HR increased in pregnancy?
15-20 bpm
80
How much is CO increased in pregnancy?
40%
81
How much CO is to the uterus in pregnancy?
10% at term
82
How much is oxygen consumption increased by in pregnancy?
20%
83
How much is residual capacity reduced by in preganncy?
25%
84
How much blood can women lose prior to showing signs?
35%
85
What are the optimal steps in management of a maternal collapse?
1. relieve aortocaval compression 2. Airway - intubate with cuff tube 3. Breathing - high flow oxygen 10-15L/min 4. circulation - 2 wide bore IVs, start CPR, USS to look for bleeding 5. Drugs 6. consider reversible causes
86
What are the same about CPR in maternal collapse compared to adult?
same doses or drugs same energy levels same rate and 30:2
87
What % of infants will survive after a PMCS by 5 minutes?
69%
88
How much does aortocaval compression reduce venous return?
60%
89
WHat are the benefits of a PMCS?
reduced oxygen consumption reduction of aortocaval pressure and improved CO improved compressions improved ventilation allows internal chest compressions - from diaphragm
90
What is LAST?
'local anaesthetic systemic toxicity, LAST' is a rare but serious complication with use of LA which primarily effects the CNS and CVS with tinnitus, altered mental status, seizures, arrythmias, hypotension and cardiac arrest
91
What do you give in LAST?
20% intralipid, 1.5ml/kg in one minute then 15ml/kg/hour
92
What do you give in anaphylaxis?
0.5ml of 1 in 1000 adrenaline IM, can repeat after 5 minutes
93
What is the rate of anaphylaxis to a course or penicillins?
1-4 in 10 000
94
What is the cross reactivity of allergy from penicillins to cephalosporins?
1-3%
95
What serum lactate should prompt discussion with the critical care team?
4.0
96
What should be done in sepsis in labour other than abx and investigations?
CTG, caution with spinal/epi, caution with FBS
97
What % of maternal death are from sepsis worldwide?
11%
98
What is the maternal death rate in the UK?
2.5 deaths per 100 000 deliveries
99
What are the most common pathology causing maternal sepsis?
1. pneumonia 44% 2. UTI 20% 3. Genital tract 18%
100
What is maternal sepsis?
a life threatening condition defined as organ dysfunction resulting from infection during pregnancy, childbirth, post abortion, or postpartum period.
101
What is shock?
life-threatening, generalised form of acute circulatory failure with inadequate oxygen delivery to, and consequently oxygen utilisation by the cells
102
Wha is septic shock defined as?
sepsis with persisting hypotension requiring vasopressors to maintain adequate blood pressure alongside abnormal lactate 2.0 despite adequate fluid resuscitation.
103
What are maternal risk factors for sepsis?
* Obesity * Impaired glucose tolerance * Impaired immunity * Anaemia * Vaginal discharge * History of pelvic infection * History of group B strep infection * GAS infection in close contacts/family members * Black or other minority ethnic group origin * Renal, liver, cardiac disease IV drug use
104
What are obstetric risk factors for sepsis?
* Amniocentesis and other invasive procedures * Cervical cerclage * Prolonged SROM * Caesarean section * Multiple gestation * RPOC Vaginal trauma
105
How can genital trauma sepsis present?
constant severe abdominal pain and tenderness, unrelieved by usual analgesia, and this should prompt urgent medial review
106
What other conditions can masquerade as sepsis?
PET or TTP, transfusion reaction, misoprostol, AFLD, autoimmune disease
107
What are red flag obs for sepsis?
GCS <15 RR 25 or more sats 94 or less RA HR 130 or more SBP 90 or less UO - HNPUed in 12 hours or <0.5ml/kg/hr
108
What investigations micro should you consider in sepsis?
blood cultures x 2 HSV PCR vaginal swabs MSU throat swab stool spec viral swabs
109
What bloods should you do in sepsis?
CRP lactate FBC creatinine Na K LFTs urea ccoags
110
What does CRP do in viral illness?
rarely rises
111
if ALT x 10 and normal bilirubin in sepsis what should be considered?
herpes hepatitis
112
What are the most common pathogens involved in maternal death?
GAS ecoli
113
What are the common pathogens in chorio?
often mixed gram neg and pos. bacteroides and peptostretococcus are associated
114
What are common pathogens in maternal sepsis?
GAS GBS 2nd e coli 1st HSV COVID ESBL MRSA
115
What kind of organism if streptococcus?
gram positive, cocci, in couples or chains, facultative anerobe
116
What kind of organism if staphylococcus?
gram positive, cocci, in clusters, facultative anerobe
117
What kind of organism is coliforms?
gram negative, rod, facultative anaerobe
118
What is the increase in invasive GAS infection in pregnant women compared to non pregnant?
20 x
119
What is the increase in invasive GAS infection in postpartum women compared to non pregnant?
80 x
120
What should be done for care in GAS?
barrier nursing, masks, own toilet, and room. consider treatment with antibiotics
121
If the baby or Mum develop GAS illness what should happen?
you should treat the other
122
What acute pathology can GAS cause?
pneumonia meningitis endocarditis skin and soft tissue bone and joint necrotising fasciitis endomyometritis TSS
123
What post infectious sequelae can occur in GAS?
post strep glomerulonephritis RHD
124
What symptoms raise suspicion for necrotising fasciitis?
pain out of keeping with skin changes, later signs are bruising, blisters, and finally obvious necrosis. Bruising in the context of sepsis should raise concern for nec fasciitis.
125
When should you consider adding IV aciclovir in maternal sepsis?
If not responding to antibiotics, hepatitis or vesicular lesions
125
What symptoms would make you concerned fro TSS?
N+V, diarrhoea, out of proportion pain due to nec fasc, watery vaginal discharges, sunburn rash, conjunctival suffusion
126
What antibiotics should be given in life threatening sepsis with unknown organism and why?
tazocin or meropenem (gram negative cover) AND clindamcycin (anaerobic and gram +ve)
127
What is in the sepsis bundle?
escalate to senior oxygen IV access bloods IV abx IV fluids monitor
128
When should women be transferred to ICU in maternal sepsis?
CVS - hypotension, raised lactate persistently, ionotropes Resp - pulmonary oedema, ventilation, airway protection renal - dialysis neuro - reduced LOC other - multiorgan failure, acidosis, hypthermia
129
When if IVIg used?
in gram positive necrotising infections and TSS not improving with other measures
130
What does gent cover?
staph including MRSA, gram negative
131
What does penicillin cover?
Group A and B strep and anerobes
132
What does Augmentin cover?
staph, strep, some coliforms, anaerobes
133
What does cefuroxime cover?
staph, strep
134
What does tazocin/meropenem cover?
staph, strep, anaerobes and gram negative (not MRSA)
135
What does clindamycin cover?
MRSA, staph, strep, anerobes
136
What does vanc cover?
MRSA, staph, strep
137
What fetal risks are increased in sepsis?
CP and encephalopathy
138
What % of pharyngitis is from GAS?
10%
139
What are the ten steps to successful breastfeeding from WHO?
1. hospital policies 2. staff competency 3. antenatal care 4. care right after birth 5. support mothers with breastfeeding 6. supplementing 7. rooming in 8. responsive feeding 9. bottles, teats and pacifiers 10. discharge
140
What are the fetal benefits of breast feeding?
reduced GI and pneumonia. later - possibly reduced obesity and high BMI, diabetes, intelligence others quoted: reflux otitis media SIDS atopy TIs
141
What does WHO recommend for breast feeding duration?
6 months exclusive then up to 2 years or beyond combined
142
What are neonatal feeding cues?
* Opening their mouth * Moving their head side to side Sucking on their hands
143
What are the fiver stages of breast development in pregnancy and post partum?
1. mammogenesis 2. lactogenesis I 3. lactogenesis II 4. Lactogenesis III 5. involution
144
What happens in mammogensis?
prenatal breast development * Occurs in the first trimester * Progesterone and oestrogen levels rise. Progesterone inhibits prolactin release * Presence of ductal sprouting/budding, mammary cell and lobular proliferation
145
What happens in lactogenesis I?
secretory differentiation * 16th prenatal week until delivery of placenta * Initiation of milk synthesis * Differentiation of alveolar cells into secretory cells * Prolactin stimulates mammary cells to produce colostrum but the progesterone inhibits milk secretion * During this time it is endocrine control
146
What happens in lactogenesis II?
ecretory activation * Occurs 30-40 hours after birth. Women notice milk production occurs day 3-5 PP. * Triggered by a rapid drop in mothers progesterone levels leading to increased prolactin levels * Onset of copious milk secretion * Endocrine control (occurs if you are feeding your baby or not)
147
What occurs in lactogensis III?
galactopoiesis * Maintenance phase of milk production * Occurs from day 9 * Autocrine control - controlled by supply and demand
148
when does involution occur after breastfeeding and how?
40 days after feeding apoptosis of galactocytes and replaced with adipocytes
149
When does milk production go from endocrine to autocrine control?
around day 9
150
When does breast engorgement occur?
during lactogenesis II hour 3-40 to day 9
151
What is the incidence of mastitis and highest risk time?
3-20%, first 6 weeks
152
How often will acute mastitis develop into an abscess?
3-11%
153
What causes mastitis?
ducts become narrowed and obstructued either externally or internally leading to inflammation
154
When should you do milk cultures in mastitis?
if severe recurrence recurrence in same location no improvement after 2 days of abx unusual presentation
155
What conservative measures can be done for mastitis?
NSAIDs cool packs 10 minutes every 30 avoid restrictive clothing rest the breast - just feed or pump what baby needs dont heat or massage gentle lymphatic drainage can be trialled USS if abscess suspected IVF therapeutic USS
156
When should you start abx of mastitis?
If woman is ill or not improving in 12-24 hours or conservative measures see GP or LMC
157
What is first line antibiotic for mastitis?
oral flucloxacillin 1g TDS IV 1g flucloxacillin q6hrly
158
What is antibiotics for mastitis if mild penicllin allergy?
oral cefalexin 500mg 6hlry IV cefazolin 1g 8hrly
159
What is antibiotics for mastitis if delayed penicllin allergy?
clindamycin oral 450mg 8hrly IV 600mg 8hrly
160
What pathogens can cause mastitis?
staph strep including GBS ecoli klebsiella
161
What proportion of women will develop mental illness during or after pregnancy?
1 in 5-10
162
What is the most commonly used cut off score of the EDS?
12 high NPV PPV only 57%
163
What are the names of some other screening tools for anxiety and depression?
GAD2 and GAD7, PHQ-9
164
What is the classic timeframe for the PN blues?
Day 3-10 starts 48 hours to peak day 5
165
How common is the baby blues?
50-80%
166
What are the typical symptoms of the baby blues?
tearful, irritiable, anxious
167
What % of women will have persistence of PN depression after the first year?
30%
168
What proportion of women with PN depression will have symptoms AN?
50%
169
What is the definition time frame of PN depression?
in the 12 months after birth
170
What is the time frame PN depression develops and peaks over?
can start from 2 weeks, peak presentations at 2-4 and 10-14 weeks
171
What are risk factors for PN depression?
history of major depression 42% FHx PN depression15% high levels anxiety, ambivalence about pregnant, lack of social suport, chronic adversity, life events
172
Whats the risk of recurrence in PN depression?
1 in 2 to 1 in 3
173
What disorders are included in psychotic disorders?
schizophrenia, bipolar, schizoaffective, psychotic depression
174
What is the risk of post partum psychosis in women with a psychotic disorder histroy?
25-50%
175
How common is postpartum psychosis?
1-2 in 1000 births
176
What is the typical time frame and speed of onset of PP psychosis?
usually presents in the first 2-4 weeks PP but can be up to 90 days Can occur in labour. onset hours
177
What are ddx of PN psychosis?
PET, toxin ingestions, baby blues, infection
178
What should be done if a woman is suspected to have PP psychosis?
1:1 care with mental health nurse, do not leave alone Need a acute review in 4 hours by senior psychiatrist in patient assessment and admission to M+B Treat pharmacologically ECT responsive
179
What treatment can be needed for PP psychosis?
antipsychotic med mood stabiliser - lithium, valproic acid, carbamazepine antidepressant ECT
180
What is the recurrence risk of PP psychosis?what can be done?
50% some have prophylaxis with lithium or olanzapine
181
What are the features of poor neonatal adaption syndrome (PNA) from mental health drugs?
irritability, sleep disturbance, crying, tachypnoea, hypoglycemia, thermal regulation issues, seizures,.
182
What are the risks in labour and antenatal with SSRIs use?
PPH small possible increase in cardiac defects
183
What are the newborn risks with antidepressant use?
small increase in persistent pulmonary hypertension significant increase in poor neonatal adaptation syndrome
184
What is the timeframe and presentation of poor neonatal adaptation syndrome?
irritability, sleep disturbance, persistent crying, tachypnoea, hypoglycaemia, poor thermal regulation and occasionally seizures, usually mild & self-limiting. Usually resolves by 72 hours. Increased risk with polypharmacy
185
what SSRIs have the lowest and highest relative infant dose in breast feeding?
paroxetine and sertraline 3% lowest fluoxetine 14% highest
186
When should lithium be used in preganncy?
if other antiphyschotic medications have failed
187
What are the antenatal risks with lithium?
ebsteins anomaly - ASD and displaced triscuspid valve) toxicity
188
What is the toxic levels of lithium?
>1.2 mmol/L
189
What should be done in labour with lithium?
withhold and check level at 12 hours to reduce placental transfer PN before restarting
190
Should you breast feed on lithium?
no
191
What are the risks associated with carbamazepine in pregnancy and newborn?
risk of NTDs, cardiovascular, urogential and oral cleft haemorrhagic disease of the newborn, PNA, seizures, impaired verbal performance in infancy
192
What can be done to reduce risks of carbemazapine in mum and baby?
folic acid 5mg oral vitamin K mum from 36 weeks IM vitamin K baby
193
Should you breast feed wtih carbamazepine?
do with caution, RID up to 7%, unknown effect on fetus
194
What should be told to mums about use of lamotrigine in pregnancy?
possible increase in oral clefts but no significant association.
195
When should you check lamotrigine levels in pregnancy and PP?
each trim 37-38 weeks every 1-2 weeks until 6 weeks PN
196
Should you breastfeed with lamotrigine?
caution, risk of SJS and high infant dose RID up to 18%
197
What is the risk of cardiac malformations with sodium valproate?
10%
198
When should contraception after childbirth be intiated?
21 days
199
What are the risks associated with an IPI of <12 months?
low birth weight PTB SGA
200
When can you get pregnant from after childbirth?
21 days
201
When should breast feeding Mothers start a COCP ?
6 weeks
202
what is the evidence on postpartum COCP and breastfeeding?
limited evidence but the best quality studies show no adverse effect on BF or infant outcomes
203
When is Lactation ammenorrhoea contraception become less effective?
after 6 months, if feeding decreases, periods return
204
When can IUD safely be inserted post partum?
up to 48 hours, then from 28 days
205
Women who are not breastfeeding and without additional risk factors for VTE can start the COCP with PP?
3/52
206
When does contraception need to be started from after an abortion to prevent preganncy?
5 days
207
When can jadelle be inserted with MTOP?
with mife
208
What contraception can increase the risk of failed abortion if given at time of mife?
dop provera
209
When can contraception be initated after ectopic or miscarriage?
immediately
210
When can an IUD be inserted after a medical management or MTOP?
as soon as pregnancy expelled
211
When do women need contraception from after ectopic or miscarrriage?
5 days
212
When can a woman get pregnant again after a partial mole?
until two negative sequential HCGs
213
What methods are safe to prevent pregnancy during follow up for a molar?
all but IUD
214
How long should women who need chemo for GTD prevent pregnancy for?
one year post treatment
215
After a complete molar pregnancy how long should women avoid pregnancy?
at least 6/12
216
Why are women after a molar pregnancy told to avoid IUD during follow up?
risk of perforation and bleeding
217
What are the adverse outcomes associated with untreated MMH?
PTB, low birth weight increased risk of hospitalisation in first year of life, doubled risk of death behavioural problems poor attachment and developmental outcomes
218
What are second generation antipsychotics?
atypical more selective and have serotonergic properties, less side effects quietiapine, olanzapine, respiradone, clozapine, arpriprazole
219
What are the adverse effects with second generation antipsychotics?
weight gain, GDM, sedation, hyperprolactinaemia, PTB, SGA, LGA, CS extrapyramidal SEs - parkinsonism, tremor, dystonia
220
What are the new born effects of second generation antipsychotics?
structural effects likley du eto GDM - LGA, marcocephaly, NTDs, hipdysplasia SGA poor neonatal adaptation syndrome
221
can you breastfeed with second generation antipsychotics?
yes, benefits outweigh risks, monitor new born
222
What is the definition of PND?
any non psychotic depressive illness occurring in the first postnatal year
223
How is postpartum psychosis charactarised?
hallucinations or delusions associated with functional impairments
224
What is the risk of postpartum psychosis if you or a mother or sister have had previously?
50%
225
What is the risk of lapse of bipolar PP?
50%
226
What are the pregnancy concerns with benzos?
possible increase in cleft, analtresia, IUGR, SGA ? confounding. consider tapering in T3
227
What are the newborn effects of benzos?
hypotonia, feeding trouble, withdrawal symptoms can last 2-3 weeks
228
What benzos should you be cautious with breast feeding?
long acting - diazepam, clonazepam
229
What is the risk with zopiclone use in pregnancy?
PTB (up to 2 weeks)
230
What are the newborn risks with lithium?
hypotonia PNA toxicity - arrythmia, poor feeding, respiratory depression needing ventilation.
231
How do you monitor a newborn after lithium in pregnancy?
cord bloods. neonatal at birth avoid dehydration repeat bloods at 24-48 hours if concerns (peak day 2)
232
What is Persistent pulmonary hypertension of the new born?
a rare complication where the fetal circulation persists after birth and causes cyanosis associated with antidepressants
233
What is poor neonatal adaptation?
a mild collection of symptoms usually resolved by 72 hours associated with psychotropic medications
234
What is the frequency of PNA?
1/3 of those exposed to antiDepressants
235
What % of women who have a vaginal birth will have some kind of tear?
85%
236
What is selective use of episiotomy associated with?
lower rates of posterior trauma, less suturing and healing complications increased rates of anterior trauma
237
What are the benefits of episiotomy vs 2nd degree tear?
less suture material faster to repair fewer healing complications
238
What is the EAS innervated by, what kind of muscle and what kind of control?
the pudenal nerve, striated muscle, voluntary control
239
How much resting tone is the IAS responsible for?
75%, thus crucial in maintaining continence
240
What kind of control and muscle is the IAS?
autonomic continuation of circular smooth muscle from the distal colon
241
What is a vulval haematoma usually an injury of?
a branch of the pundenal artery
242
What causes a paravaginal haematoma?
vaginal tears into the vaginal fornix or at CS tear into the vagina
243
What can be complicated about a paravaginal haematoma?
when tamponade release difficult to control bleeding. close to ureters. IR can be helpful
244
How do broad ligament haematomas from a vaginal birth occur?
vaginal tear or cervical tear that extended into the uterine or vaginal artery
245
What structures are cut in an episiotomy?
vaginal muscosa perineal skin transverse perineal muscle bulbocavernosus muscle Muscle fascia Transverse perineal branches of the pudendal vessels and nerves
246
What is a uterine inversion?
when the uterine fundus descends down into endometrial cavity and the inner walls of the uterus may be exposed through the cervix or vagina
247
What is the rate of maternal death with uterine inversion?
15%
248
What are the degrees of uterine inversion?
1. inside cavity still 2. through cervical os 3. at or beyond introitus 4. complete inversion including vagina 90%
249
What are the steps of management in uterine invesion?
stop uterotonics do not try to detach placenta johnsons maneuvre ASAP proceed to OT if not successful try again with tocolysis hydrostatic pressure laparotomy remove placenta consider bakri antibiotics 12 hours of oxytocin
250
What are the maneuvers done at laparotomy for uterine inversion?
huntingtons - clamps on rounds and traction Haultains procedure - posterior dissection of uterus and repair
251
How do you do hydrostatic replacement of uterus with inversion?
anaethesia trendelenberg lithotomy replace structures in vagina need 4-5 L of warm isotonic fluid either use hand with IV tubing 2-4 and place in vagina and occlude or use neonatal mask run warmed fluids through from 1 meter height
252
What is one theory about why you get hypotension with uterine inversion?
neurogenic shock from from pelvic parasympathetic nerves
253
What should be done for a baby if lamotrigine being taken while breastfeeding?
monitor infant and neonatologist involved where possible can get SJS
254
What is the maternal mortality ratio?
the number of maternal deaths in a given time per 100 000 births in that time
255
With activation of the MTP what are you trying to optimise?
oxygenation CO tissue perfusion metabolic state
256
What values are indicative of critical physiological derangement in MHP?
temp <35 pH <7.2 lacatet >4 ionised ca <1.1 platelets <50 APTT >1.5 x normal fibrinogen <2.0 only difference to non obs
257
what is the incidence of AFE?
1 in 16 000 to 55 000
258
What makes up a mammary gland?
15-25 lobes
259
What makes up a breast lobe?
multiple lobules
260
What is in a breast lobule?
alveoli made up of epithelial cells and myoepithelail cells
261
What drains a breast lobe?
a lactiferous duct
262
What kind of cell is a lactocyte?
epithelial cell
263
What are the maternal benefits of breastfeeding?
* Increased return to pre pregnancy weight * Decreased ovarian cancer risk * Decreased breast cancer risk * Decreased cost * Assists with uterine involution and reduces PPH * Amenorrhoea and contraception Bonding
264
What is the physiology behind lactational ammenorrhoea
Breast feeding and prolactin disrupts GnRH from creating an LH surge. FSH is still present so some follicles develop but they fail to rupture so become atresic. no ovulation
265
What is the success rates of lactational amenorrhoea?
>98%
266
What is the hormonal events which occur after nipple stimulation at breast feeding?
Prolactin releasing hormone from the hypothalamus Prolactin hormone is released from APG Prolactin acts on lactocytes to make milk
267
What is involved in the milk ejection reflex?
Infant suckling stimulates nerves in nipple This releases oxytocin from PPG Oxytocin causes myoepithelial cells to contract and expel milk
268
What is the pathogenesis of bacterial mastits?
○ Poor breast drainage milk stasis and engorgement ○ Presence of colonising organism ○ Local injury (cracked nipple) facilitating entry Systemic vulnerability to infection (fatigue, poor nutrition, illness)
269
What does the cochrane review on perineums in seconds stage of labour show reduces risk of OASI?
warm compress RR 0.47 intra labour perineal massage RR 0.49 hands off vs on, no difference
270
What are the classes of haemorrhagic shock? volume and % lost
I <750ml <15% II 750-1500ml 15-30% III 1500-2000ml 30-40% IV >2000ml >40%
271
What happens to pulse pressure in haemorrhagic shock?
narrows
272
What is permissive hypotension?
allowing SBP 80-100mmHg while bleeding is controlled
273
What are the risks with aggressive fluid resuscitation?
oedema, compartmen syndrome, acute lung injury exacerbating anaemia, thrombocytopenia and coagulopathy disrupting clots exacerbating bleeding
274
What is the first coagulation factor to fall in MHP?
fibrinogen factor 1
275
Does FFP have high or low fibrinogen and what can occur with use?
low TRALI or TACO
276
What is the recomended dose of oral iron?
100-200mg daily, can consider 20-80 if mild and side effects
277
Which antibodies are associated with HDN?
D c K
278
what consideration should be made to for blood for women of child bearing age?
K negative blood if -ve or status unknown
279
When can you give factor VII?
when conventional methods have failed including surgical
280
When should you not give factor VII?
DIC
281
What is the definition of anaemia?
* Hb 2SD below the mean * Antenatally <110 Postpartum <100
282
What are the adverse outcomes associated with anaemia?
Low birth weight, PND, maternal mortality, placental abruption
283
What is the difference in how heparin and LMWH work?
Both activate anti thrombin III which then: heparin - equally inhibits IIa and Xa LMWH - inhibits Xa selectively
284
When should treatment for VTE be started?
When you have a clinical suspicion until diagnosis is excluded
285
If DVT is suspected but high level of suspicion for DVT but negative USS what should be done?
stop clexane, repeat USS on day 3 and 7
286
In a woman with clinical suspicion of VTE what should be done?
CXR ECG FBC LFTs U+E clinical assessment start clexane
287
If signs of DVT with symptoms of do you decide which investigation to do for PE?
DVT symptoms - bilateral leg compression duplex USS CXR abnormal - CTPA CXR normal - V/Q If unstable CTPA
288
What should be discussed with patient when choosing between V/Q and CTPA?
V/Q slight increase in risk of childhood cancer but lower maternal breast cancer risk risks are very low
289
What are the benefits of CTPA over VQ?
Less fetal radiation Can find other pathology Readily available
290
What are the benefits of VQ scan
Lower breast irradiation
291
What is the NPV, chance of a positive result and non diagnostic scan with V/Q ad CTPA?
similar 28% will need more than one investigation modality
292
Who should you be cautious getting a CTPA over a VQ scan for in ? PE?
a young woman with risk factors for breast cancer eg FHx, or multiple previous scans
293
What is the fetal dose of radiation in CTPA vs VQ? what is the implication of this?
0.5 vs 0.1 mGy both are well below concerning levels or teratogenicity. very small increase in childhood cancers
294
What is the maternal breast radiation dose in CTPA vs V/Q?
20mGy vs 1 or less mGy
295
What are common ECG changes of PE?
TWI S1Q3T3 RBBB
296
Why is LMWH preferred for VTE treatment over heparin
reduced risk of severe PPH, heparin induced thrombocytopenia and heparin induced osteoporosis
297
What weight should be used for dosing clexane?
early pregnancy or booking weight
298
Who should anti Xa levels be checked on?
extremes of weight <50kg or >90kg renal impairment recurrent VTE
299
Who should have platelet count checked when receiving heparin?
Obstetric patients who are postoperative and receiving unfractionated heparin should have platelet count monitoring performed every 2–3 days from days 4 to 14 or until heparin is stopped.
300
What are treatment options for massive life threatening PE? what is preferred
UFH IV - preferred optoin thrombolysis thoracotomy surgical embolectomy
301
What should be done in a life threatening massive PE?
consult medics, CTPA within one hour. consider thrombolysis
302
Why is UFH preferred in massive PE?
rapid effect, short half life, can be adjusted if thrombolysis needed.
303
What is the half life of LMWH vs UFH?
LMWH - 4.5 hours UFH - 30-90 mins
304
How do you given Heparin in massive PE?
IV 80unit/kg bolus then 18units/kg/hour if thrombolysis omit bolus
305
When do you check APTT with UFH in massive PE?
4-6 hours afer loading dose 6 hours after change in dose or each day if in range
306
What APTT are you aiming for with UFH in massive PE?
1.5-2.5
307
How long should VTE Tx continue for in prgenancy/PP?
at least 6 week PP, minimum 3/12 duration
308
When should treatment clexane, UFH SC or UHF IV be stopped prior to IOL/elective CS?
LMWH - 24 hours prior SC UFH - 12 hours prior IV UHF - 6 hours prior
309
How long should you wait after a clexane therapeutic dose to remove epidural catheter>
12 hours
310
In women at high risk of bleeding needing anticoagulation PP what should be given and why?
UFH IV due to short T1/2 and reversibility
311
How does protamine sulphate work?
reverses anti IIa but not Xa (which is the main way clexane works)
312
What is post thrombotic syndrome? and how is it reduced?
chronic pain, swelling, heaviness, cyanosis, pigmentation, eczema and varicose veins. Quoted in up to 42% in pregnancy complete 3/12 tx
313
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