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Describe the schedule of antenatal visits.
- 4 weekly until k28
- 2 weekly until k36
- 1 weekly to delivery
Investigations at first booking for a pregnant patient?
- Blood group & antibodies
- Serology (HIV, hep B & C, syphillis, rubella titre)
How would you manage pre-term labour? (include drug doses)
- Tocolysis - nifedipine - PO 20mg, 3 half-hourly doses
- Steroids if >k24 - betamethaone 11.4mg IM, 2 24-hourly doses (to mature lungs and reduce IVH)
- Antibiotics if ruptured membranes - penicillin 1.2g IV bolus, then 600mg q4h
- Neuroprotection - MgSO4, 4g loading dose, then 1g hourly for 4-24h
- Consider transfer
Risk factor based GBS prophylaxis?
- Preterm labour
- Full term with maternal risk factors
- - GBS colonisation/bacteruria in current pregnancy
- - Previous baby with EOGBSD
- - >18h ROM
- - T >38C
Antibiotic regime for GBS (list 2)?
- IV ABs if intrapartum:
- - Benzylpenicillin 1.2g loading, then 600mg q4h until birth
- - Ampicillin 2g loading, then 1g q4h until birth
- - Lincomycin 600mg q8h
- If labour not imminent, oral ABs:
- - Erythromicin 333mg q8h
Indications for vaginal delivery in PROM?
- Advanced active labour
- Chorioamnionitis (+AB)
- Full term (expectant Mx for max 72h, then induce with dinoprostone - cervidil & prostin)
- Foetal compromise
Management of PPROM <k23?
- Advise - previable - 50% deliver in 1/52, 25% still pregnant 1/12 later; 15% result in stillbirth.
- Expectant Mx - reduce activity & monitor for infection
- ToP - misoprostol or D&C
How would you manage PROM?
Depends on gestational age.
Tests for ROM?
- Pad checks over 24h
- Speculum for posterior fornix pooling
- USS AFI
Risks associated with PPROM for the baby
- Respiratory distress syndrome
- Pulmonary hypoplasia & pulm HTN
- Intraventricular haemorrhage
- Infection (NEC)
- Placental abruption
- Cord prolapse
Risks associated with PPROM for mother?
List 8 RFs for PPROM
- Past Hx of PPROM
- Multiple gestations
- Antepartum haemorrhage
- Short cervical length (<25mm)
- fFN +
- High AFI
- Urogenital infection
What is PPROM?
Preterm (<k37) premature (prelabour) rupture of membranes
Labour is the presence of uterine contraction with aequate frequency, strength and duration to result in progessive effacement and dilatation of the cervix.
Stages of labour?
- First stage - onset of labour until full cervical dilatation/10cm
- --> latent - irregular, infrequent contractions that often and efface cervix
- --> active - cervix reaches 3-4cm of diltation, incr diltation, effacement and foetal descent
- Second stage - fully dilated to delivery of child
- Third stage - delivery of placenta
How do you calculate EDC?
- Naegele's Rule = 1st day of LMP + 1y - 3 months + 7 days (i.e. 40wks from LMP)
- First trimester USS - more accurate than LMP
Early signs of pregnancy?
- Chadwick's sign = blue tinged cervix/vagina
- Goodall's sign = soft cervix
- Hegar's sign = soft uterus
- Chloasma = facial pigmentation
- Dark nipples
- Medical Hx
- Genetic counselling
- Screening - rubella, BP, Pap
- Previous pregnancies
- Iron supplement if indicated - 250mg FeSO4/day
- Folate daily 0.5mg or 5mg (high risk = FHx neural tube defect, anti-epileptic medication, DM1) - 3/12 before and after conception
Screens/investigations throughout pregnancy & dates
- First visit - FBE, blood group/AB, serology, MSU
- k11-13+6: trisomy 18 or 21 - PAPP-A, free BHCG & nucchal translucency
- k14-20: trisomy/neural tube - AFP, BHCG, uE3 +/- iA & morph. scan
- k26-28: GDM GCT
- FBE k28, 36
- GBS is opportunistic in Qld
Management of Rh - woman?
- Standard anti-D prophylaxis (625IU) at k28, 34 & 40
- Additional with procedures/trauma (250IU if <k12; 625IU thereafter)
Define hyperemesis gravidarum
N & V in early pregnancy severe enough to cause dehydration, weight loss, electrolyte disturbances and compromised birth weight.
RFs for hyperemesis gravidarum?
- Multiple gestations
- Gestational trophoblastic disease
- (? rapid rise in BHCG as cause)
Mx of hyperemesis gravidarum?
- Hx & O/E
- Ix - FBE (Hb, TFTs), eLFTs, MSU, ketones, USS
- Simple advice - benign but 20% persist; water & cracker in bed, avoid eating late at night, avoid irritating foods, take a multivitamin
- If patient is unwell:
- - IV fluids
- - Acute anti-emetic
- - Thiamine (B1)
List 3 anti-emetics that are safe in pregnancy, their MoA, dosage, route & SEs.
- A. Metoclopramide - central DA antag - 10mg IV - EPSE, drowsiness, Na/K imbalances
- A. Pyridoxine (B6) - incr RBC production - 25mg bd PO - rare
- B1. Stemetil/prochlorperazine - ?CTZ or DA - 10mg bd PO - EPSE
- B1. Ondansetron - 5HT3 antag - 8mg IV/IM - rare
Mx of antepartum haemorrhage
- 1. Assess - vitals, CTG, gestational age +/- help!
- 2. O2 - 6L Hudson mask
- 3. 2 x 16G cannulas, bloods then 1L N/S stat
- 4. FBE, group & hold 3U, coags, baseline eLFTs (? Anti-D)
- 5. Look for cause - pelvic examination & USS - tenderness, masses - placental abruption, placenta previa, rupture of mass/ectopic
Define placental abruption.
Separation of normally implanted placenta before delivery of foetus --> haemorrhage.
Clinical presentation of placental abruption?
- PV bleed
- Hypovolaemic shock
- Port-wine discoloration of amniotic fluid
- Back pain
- Uterine pain/tenderness/irritability
- Hypertonic uterine contractions
- Foetal distress (CTG non-reassuring) & demise
Risk factors associated with placental abruption?
- Uterine abnormality - e.g. leiomyomata
- High parity
- Trauma --> sudden decompression of uterus
- Short umbilical cord
- Poor nutrition
- Hx of placental abruption
Mx of placental abruption?
- Resuscitate & monitor mother: IVL, fluids (RBC, platelets, FFP, cryoprecipitate), bloods (FBE, coags, eLFTs, cross-match), monitor UO
- Monitor foetus: CTG
- Definitive Mx:
- - Expectant Mx if mild abruption with minimal bleeding, stable mother & foetus, esp. if premature
- - Induction of labour & VD if moderate abruption, ongoing bleeding, stable mother & foetus
- - C-section if severe abruption, brisk ongoing bleeding, unstable mother/foetus
- - If severe persistent bleeding unresponsive to syntometrine or correction of coagulapathy --> arterial embolization, bilateral ligation of hypgastric arteries or postpartum hysterectomy
List 5 risk factors associated with cord prolapse.
- Foetal malpresentation
- Incr liquor
- Low placenta
- Long cord
- Premature labour
- Cephalopelvic disproportion
- Extrauterine masses
List 5 reasons why a woman should present to ORC/birth suite post k36?
- Contractions (painful, regular, incr frequency)
- PV bleed
- Decr FM
- Intense headache w/ spots in vision
Normal neonatal feeding?
6-12x per day
Normal neonatal urinary habits?
6-7 wet nappies per day
Normal neonatal bowel habits?
1 nappy every 3 days to 3 nappies per day
Definition of perinatal death (NPDC)?
>k20 or 400g BW up to 28 days old - i.e. includes stillbirths and neonatal deaths
Define stillbirth/foetal death.
>k20 or weight over 400g
Define neonatal death.
Death of a live-born baby of >k20/400g within 28 days of delivery.
List 3 risk factors for perinatal mortality
- Young maternal age
- Older maternal age (>35)
- Maternal Indigenous status
- Maternal overweight/obesity
- Socioeconomic disadvantage
- Prolonged pregnancy
- Multiple gestation
Leading cause of perinatal death at k20-21?
Leading cause of death at k22-27?
Leading cause of death at k28-36?
Unexplained antepartum death
What are the 3 leading causes of perinatal mortality?
- Congenital abnormalities
- Unexplained antepartum death
- Extreme prematurity
Perinatal mortality rate in Australia?
Maternal mortality rate in Australia?
List 3 obstetric indicators of birth asphyxia
- Abnormal CTG
- Foetal acidosis
- Presence of meconium liquor
List 3 neonatal indicators of birth asphyxia
- Apgar score
- Delay in breathing
- Hypoxic ischaemic encephalopathy
Define cerebral palsy.
Neurological impairments characterised by abnormal control of movement or posture resulting from abnormalities in brain development or an acquired non-progressive cerebral lesion.
List 3 associations with cerebral palsy.
- Extreme prematurity
- Foetal vascular events
- Intrauterine infective causes (rubella, CMV, toxoplasmosis, listeriosis)
- Genetic causes
- Metabolic causes (iodine deficiency)
- Intrapartum hypoxia (<10%) - less than 2% of CP is caused by obstetric care alone!!!
In order to establish a definitive relationship between intrapartum events and cerebral palsy (ANZPS)?
- Evidence of metabolic acidosis (intrapartum foetal or umbilical arterial cord samples)
- Early onset mod-severe encephalopathy in >k34
- Cerebral palsy of the spastic quadriplegic or dystonic type
- A hypoxic event noted immediately before/during labour
- Sudden rapid and sustained deterioration of foetal HR pattern
- Apgar <6 for >5 minutes
- Evidence of multisystem involvement
- Early imaging evidence of acute cerebral abnormality
Define maternal mortality.
Death of woman while pregnant or within 42 days of termination of pregnancy. WHO definition excludes accidental or incidental causes.
List 4 direct causes of maternal mortality.
- Amniotic fluid embolism
- Hypertensive disease
- Obstetric haemorrhage
List 3 indirect causes of maternal mortality.
- Cardiac conditions
- Psychiatric causes
- Non-obstetric haemorrhage (e.g. ruptured cerebral anneurysm)
HTN + involvement of 1+ other organ system/foetus.
How would you diagnose pre-eclampsia?
- HTN >k20 plus one of:
- - proteinuria
- - serum creatinine >90umol/L
- - oliguria
- - thrombocytopaenia
- - haemolysis
- - DIC
- - inc ALT & AST
- - severe epigastric/RUQ pain (subcapsular haematoma)
- - hyperreflexia & clonus
- - severe headache
- - persistent visual disturbances
- - stroke
- Pulmonary oedema
- Placental abruption
List 4 typical clinical features of pre-eclampsia.
- Platelet dysfunction
- Deranged clotting
List 5 RFs for pre-eclampsia.
- Previous Hx of pre-eclampsia
- FHx of pre-eclampsia
- Antiphospholipid antibodies
- Pre-existing DM
- BMI >25
- Maternal age >40
- Multiple pregnancy
- Diastolic BP >80 @ first visit
List 5 indications for delivery in pre-eclampsia
- Refractory HTN
- Deteriorating platelet count
- Deteriorating LFTs
- Deteriorating renal function tests
- Persistent neuro Sxs
- Persistent GIT symptoms
- Acute pulmonary oedema
- Placental abruption
- Severe IUGR
- Non-reassuring foetal status
Mx of pre-eclampsia?
- Definitive Tx = delivery - NB. care with anaesthesia (epidural & GA associated with complications)
- Antihypertensive, esp. if >170/110 - labetalol, hydralazine
- Anti-seizure - MgSO4, 2mg/min of diazepam
List 3 antihypertensives used in pregnancy, and side effects
- 1st line:
- methyldopa - centrally acting - dry mouth, blurred vision, depression
- labetalol - beta-blocker - bradycardia, bronchospasm, headache, nausea, tingling scalp
- 2nd line:
- hydralazine - vasodilator - flushing, headache, nausea, lupus-like syndrome
- nifedipine - CCB - severe headache, flushing, tachycardia, peripheral oedema, constipation
- prazosin - alpha block - first dose -> orthostatic hypotension
- The above are safe in breastfeeding too
- NB. ACEI & ARBs are contraindicated!!!
MgSO4 regimen in pregnancy (neuroprotection & eclampsia) - side effects?
- 4g loading dose over 10 min
- 1-2g/h over 24h
- Hypocalcaemia, hyporeflexia, cardiac arrest
LT consequences for mother after gestational HTN?
CVD - HTN & CAD
List 5 causes of APH.
- Placenta praevia
- Placental abruption
- Marginal bleed
- Vasa praevia
- Uterine rupture
- Local causes - cervicitis, polyps, ectropion, Cx Ca
List 3 risk factors associated with placenta praevia
- Previous C/S
- Previous placenta praevia
- Previous D & C
- Maternal age >35
List 2 other obstetric complications are associated with placenta praevia?
- Abnormal placental implantation - placenta accreta, increta, percreta
Define placenta accreta/increta/percreta
- Accreta: invasion of myometrium (partial thickness)
- Increta: full thickness
- Percetra: invades through full uterine wall, can attach to bladder/bowel
What is normal for placental site?
>5 cm from cervical os
Mx of placenta praevia?
- Premature, minimal/no bleeding: restricted activity, expectant Mx
- Mature, minimal/no bleeding: C/S if mature
- Premature, minimal bleeding: steroids & tocolysis - if successful, expectant Mx, if not, C/S
- Severe bleeding @ any k: C/S
What is vasa praevia & how is it diagnosed?
Foetal vessels crossing/running close to cervical os, often associated with velamentous insertion of vessels in membrane. Ass'd with APH.
Define postpartum haemorrhage.
- >500ml if VD
- >1000ml if CS
- Early PPH: 1st 24h
- Late PPH: 24h-6 weeks
Causes of early stage PPH?
- Tone - atonic uterus
- Tissue - retained products
- Trauma - lacerations of vulva/vagina/cervix; uterine rupture (vertical uterine CS)
- Thrombus - coagulopathy (2ndary to infection, embolism, placental abruption, pre-eclampsia)
- Uterine inversion
How could some cases of PPH be avoided?
Active Mx of 3rd stage - syntometrin, clamp, watching for signs of separation & applying cord traction
What are the 4 signs of placental separation?
- Cord lengthening
- Fresh blood
- Firm, globular uterus
- Rising uterus
Mx of PPH?
- 1. Get help
- 2. 2 large bore IVLs - N/S infusion & syntometrin
- 3. FBE, coags, x-match - 3 packed units RBC
- 5. Catheterise
- 6. Rub fundus
- 7. Treat cause - consent patient & organise curettage.
Mx of cord prolapse
- Replace cord in vagina
- Reduce pressure on cord with Sim's + 15deg Trendelenberg or knees to chest on fours
- C/S if foetus is alive; Vaginal delivery if stillborn
List 4 RFs for shoulder dystocia.
- Past dates
- Maternal obesity/wt gain
- Older mother
- Previous LGA/shoulder dystocia
- Prolonged 2nd stage
- Delay in head descent
List 4 possible consequences of shoulder dystocia.
- Foetal hypoxia
- Brachial plexus damage to baby
- # of humerus/clavicles
- Maternal injury
How would you manage shoulder dystocia?
- H - help!
- E - episiotomy
- L - legs in McRobert's
- P - suprapubic pressure
- E - entry manouvres - Wood's screw
- R - remove posterior arm
- R - roll patient if unsuccessul & wait for help.
List 8 causes of oblique lie.
- Placenta: praevia
- Fluid: oligohydramnios, polyhydramnios
- Baby: foetal demise, neuro, MSK, less mature than estimated, twin
- Uterus: septate, fibroids, poor tone
- Ovarian: cysts
- Bladder: full
- Abdominal wall: poor tone
What is the rate of gestational diabetes?
Once a woman has had GDM, what is her lifetime risk of devleoping type II diabetes?
What is the screen for GDM?
k26-28 GCT (high risk if over 7.8)
When managing a woman with GDM, what BSL levels are ideal?
- Pre-breakfast <5.5
- 2h post meal <7
Which ethnicities are at high risk of thalassaemia?
- Eastern Mediterranean
- Middle Eastern
- Indian subcontinent
- SE Asia
What are the risks associated with CS delivery?
- Higher mortality
- Infection (wound, endometritis, UTI - prophylactic ben pen post-op)
- Anaesthetic (regional better):
- Aspiration pneumonia
- ARDS (fluid retention)
- Birth trauma
Post-CS care advice?
- O/E: vitals, fundus, wound
- Pain Mx: epidural/PRN panadol/ibuprofen
- Dietary/fluid: IVF until eat/drink
- VTE prophylaxis: TEDS, early mobility + IDC removal
- DC: 4-5 days with follow up with midwife/GP
Ix for IUFD/stillborn/neonatal death for BABY
- Autopsy (consent)
- Chromosomal studies (skin)
- Cord bloods/cardiac stab
- Swab baby & placenta
- Placenta histology (chorioamnionitis)
Ix for IUFD/stillborn/neonatal death for MOTHER
- Thrombophilia screen
- Blood gp & antibodies
Define hydrops fetalis
- Presence of 2 or more abnormal fetal fluid collections (2ndary to HF):
- pericardial effusion
- pulmonary oedema
List 3 causes for hydrops fetalis.
- Immune: Rh disease; anti-Kell, anti-Duffy
- Chromosomal: aneuploidy (trisomy 13, 18, 21)
- Dereased osmotic pressure (liver disease, nephropathy)
- Incr venous pressure (heart problems)
- Incr capillary permeability (TORCH infections)
List 7 DDx for postpartum fever.
- Wound infection (C/S, episiotomy repair, obstetric lacerations)
- Breast engorgement
- Respiratory - atelectasis, pneumonia
- Bacterial endocarditis
List 7 RFs for VTE in pregnancy.
- Personal Hx of VTE
- FHx of VTE
- Med Hx - nephrosis, cardiac disease, cancer, IBD, sickle cell
- Pregnancy Hx: ovarian hyperstimulation syndrome, pre-eclampsia, hyperemesis
- Age >35
- BMI >30
- Parity >4
- Gross varicose vein
- Current infection
- Prolonged labour >12h
- Operative delivery
- Immobilisation (e.g. epidural!)
Ix for suspected PE in pregnancy.
- Doppler US
- V/Q scan > CTPA
- NB. D-dimer values are deranged in pregnancy normally
Full thrombophilia screen includes (list 8+)
- Prothrombin (II) gene mutation
- Antithrombin III deficiency
- Factor V Leiden mutation
- Activated protein C resistance
- Protein C deficiency
- Protein S deficiency
- Antiphosphlipid antibodies (lupus anticoag, anticardiolipin antibodies, B2GP1)
Mx of established VTE?
- Enoxaparin 1mg/kg SC bds
- for entire duration of pregnancy, then 6/52 PP (calf vein) or 6/12 (DVT/PE/recurrent)
VTE prophylaxis antepartum?
- Low risk: survey clinically at each r/v
- Mod/high risk: clinical surveillance; prophylactic LMWH if immobilised
- Pre-existing anticoagulation: cliical surveillance; therapeutic dose LMWH
Intrapartum VTE prophylaxis?
- SCUDS or TEDS
- Anticoagulation must be ceased during labour
Postnatal VTE prophylaxis?
- Low risk: avoid dehydration & mobilise early
- Mod risk: TEDS; prophylactic enoxaparin w/in 6h and until fully mobile/DC
- High risk: TEDS & SCUDS until mobilising, then TEDS; enoxaparin until day 5 or fully mobile (whichever later)
Dose for VTE prophylaxis?
- LMWH 40mg SC daily
- NB. does not cross placenta
Why is it so important to have tight BSL control at conception?
Directly related to risk of NTD.
Why is it so important to have tight BSL control pre-labour?
Directly related to risk of neonatal hypoglycaemia
Intrapartum & immediate postpartum Mx of diabetes?
- Insulin/dextrose infusion with regular BGLs
- Cease insulin for all types of diabetes immediately post-partum with regular BGLs
What maternal complications are associated with maternal diabetes?
- Placental abruption
- Incr infection
What foetal complications are associated with maternal diabetes?
- Incr congenital malformation
- Incr NTD
- IUFD/still birth
- Pre-term delivery
Bacterial vaginosis is associated with what pregnancy complications?
- Pre-term labour
List 7 markers of foetal well being.
- Biophysical profile - breathing, gross body mvt, muscle tone, AFI & non-stress test (i.e. reactive FHR)
- Growth chart
- Umbilical doppler flow (EDF)
- Foetal scalp pH/lactate (
Mx of asymptomatic UTI in pregnancy?
Amoxycillin 500mg TDS 3/7
How common are UTIs in pregnancy?
- Asymptomatic UTI - 15% --> 30% develop pyelonephritis
- Cystitis - 4%
- Pyelonephritis - 4% (usually 2nd/3rd T)
Symptoms of cystitis?
Mx of cytitis?
- Cephalexin 500mg bd 10/7 OR
- Nitrofurantoin (if penicillin allergy)
What is the risk of trisomy 21 in a 20 year old as compared with a 40 year old?
1/2000 v 1/100
What is the overall risk of chromosomal abnormalities in a 20 year old compared with a 40 year old?
1/500 v 1/50
How does one contract listeriosis?
- Uncooked foods (seafood/dairy/coleslaw)
- Reheated meats
How does listeriosis present clinically?
- Fever/flu-like illness
- Blood culture/genital swab +ve
- Transplacental spread:
- 50% MC in T1
- 40-50% pregnancy loss in T2-3\
- Not teratogenic
How do you treat listeriosis?
Amoxyl/ampicillin & gentamicin
What is the significance of BV in pregnancy?
- Preterm labour
List 6 TORCH organisms.
- Others - varicella, parvovirus, syphillis
What neonatal problems are associated with TORCH infections?
- Cerebral palsy
- Delayed development
- Haematological: anaemia/thrombocytopenia/hepatosplenomegaly
How do you acquire toxoplasmosis?
- Unwashed vegetables
- Undercooked meat
- Garden dirt
How do you treat toxoplasmosis?
Spiramycin or pyramethamine/sulphadoxine (with folic acid)
How would you manage a non-immune pregnant woman was exposed to varicella?
- Exposure <96h - vaccinate & Varizig (Ig)
- If high risk, add acyclovir
If the pregnant woman develops chicken pox, how would you treat her?
- <24h --> acyclovir
- >24h - observe
- If unwell, admit (pneumonitis --> 40% mortality)
- Foetal varicella syndrome is very uncommon (<2%)
ToP in infections?
- Toxoplasmosis with amnio/USS evidence of sequallae
- Rubella in T1
- CMV in T1
Obstetric cholestasis carries what risks for the foetus?
- Preterm birth
- Meconium liquor