Case 8 Session 1 PDF

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Case 8 Session 1 Social:  What is the role of the midwife/ health visitor? And relationship with mother? The midwife in the community can be in the hospital. Midwives also provide postnatal care. Hospital midwives - labour wards, antenatal and postnatal wards. Weigh babies, urine dipstick, heel prick test etc.

What support in the community? Are antenatal clinics/ classes successful (obesity/ smoking/ drug use)? Is the support the same everywhere? Postcode lottery? Target lower income areas - increase the amount of kids in underprivileged areas that are getting an education - Flying start - eu funded charity. Gp or midwives can inform about antenatal classes. 

What stigma surrounds smoking/ obesity/ drug use during pregnancy? Why has she not stopped yet? Women can still use nicotine replacement therapy whilst pregnant if it means that they don’t smoke - not recommended to take tablets as they still contain harmful compounds Some women have their own ideas about whats good for their health .  Smoking percentage, males/ females? Men 20% Women 17% Overall 19%  Single parents may be entitled to job seeker’s allowance and in relation to this can go to the Jobcentre Plus where they can see an advisor. Single parents can also get child tax credits and child benefit of £20.70 for first child per week and £13.70 for each subsequent child. Working parents can also claim child tax credits and child benefits if their income is less than £50,000 per year. For those who live in rented accommodation then they can get housing benefit, single parents may be able to receive benefit with prescription costs and council tax reduction schemes.  To get a council house you need to apply to your council and will be put on a waiting list. Your position in the queue can be boosted if you have certain conditions met such as being homeless. 

Clinical:  What are the adverse effects on the foetus of smoking? (IUGR) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2656811/ The adverse effects on the fetus of maternal smoking are likely to be multi-factorial, including indirect effects such as poor nutritional status of the mother associated with the anorexigenic effect of nicotine, carbon monoxide exposure, and blood flow restriction to the placenta due to the vasoconstrictive effects of catecholamines released from the adrenals and nerve cells after nicotine activation. Nicotine and carbon monoxide. Nicotine is a stimulant that increases heart rate and blood pressure and in response arteries constrict so that less blood goes to the placenta. CO reduces the oxygen carrying capacity of the blood so restricted oxygen to the foetus. Nicotine can cause constriction of the fallopian tube so ectopic pregnancies can occur. Ratio of 2.5 for women who smoke 20 a day for ectopic pregnancy compared to non-smokers. IUGR is more likely for those who smoke more cigarettes. IUGR applies to babies who weigh less than 5.51b. Many risk factors e.g. pre-eclampsia, alcohol, drugs, anaemia, recent pregnancy, CVD, hypertension, coeliac disease, uterine malformation, multiple gestation. Increased risk of ADHD and conduct disorder. Increased risk of placental abruption and placenta previa.

- Heart defects that are common include right ventricular outflow tract obstructions and atrial septal defects. Lung growth is affected.

Metabolic genes?

 What are the adverse effects on the foetus of obesity Obstetric Complications in Obese Pregnant Women

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2621047/ Complication

OR (95% CI) or % vs Normal Weight P

Early pregnancy Spontaneous abortion (miscarriage) After spontaneous conception

1.2 (1.1–1.5)

.04

After IVF conception

1.8 (1.1–3.0)

< .05

3.5 (1.1–21.0)

.04

Neural tube defects

1.8 (1.1–3.0)

< .05

Spina bifida

2.6 (1.5–4.5)

< .05

Congenital heart disease

1.2 (1.1–1.3)

< .05

Omphalocele

3.3 (1.0–10.3)

< .05

Recurrent miscarriage Congenital anomalies

Late pregnancy Hypertensive disorder of pregnancy Gestational nonproteinuric hypertension 2.5 (2.1–3.0)

< .0001

Preeclampsia

3.2 (1.8–5.8)

.007

Gestational diabetes mellitus

2.6 (2.1–3.4)

< .001

Preterm birth

1.5 (1.1–2.1)

< .05

Intrauterine fetal demise (stillbirth)

2.8 (1.9–4.7)

< .001

Cesarean delivery

47.7% vs 20.7%

< .01

Decreased VBAC success

84.7% vs 66%

.04

Operative morbidity

33.8% vs 20.7%

< .05

Peripartum

Anesthesia complications Excessive blood loss Postpartum endometritis Wound infection/breakdown Postpartum thrombophlebitis Fetal/neonatal complications Fetal macrosomia (EFW ≥ 4500 g)

2.2 (1.6–3.1)

< .001

Shoulder dystocia

3.6 (2.1–6.3)

< .001

Birth weight < 4000 g

1.7 (1.4–2.0)

.0006

Birth weight < 4500 g

2.0 (1.4–3.0)

< .0001

Childhood obesity

2.3 (2.0-2.6)

< .05

http://www.acog.org/Patients/FAQs/Obesity-and-Pregnancy

Over 30kg/m . 2

BMI 30.0–34.9 (Class I) BMI 35.0–39.9 (Class 2) BMI 40 and over (Class 3 or morbid obesity) Increased risk of gestational diabetes and caesarean section. Higher risk of pre-eclampsia which can lead to seizures a condition called eclampsia - stroke can occur. They can get sleep apnoea which makes pregnancy harder, increases the risk of high blood pressure, preeclampsia, eclampsia. Macrosomia (baby is larger than normal) can increase the risk of the baby being injured during birth e.g. the shoulder can get stuck during delivery shoulder dystocia. The foetus is more at risk of stillbirth and congenital abnormalities. Higher likelihood of the baby having chronic conditions e.g. heart disease or diabetes as an adult. Increased risk of heart defects. If the mother has preeclampsia it is more likely they will have a preterm birth. Risk of miscarriage also increases.   



What are the adverse effects of drug use (recreational and therapeutic) in pregnancy on foetus?

Obstetrics and gynaecology by Impey Crack babies - led to subtle deficits - cognitive tasks later in life. Can increase the risk of early miscarriage, placental abruption, low birth weight. Can cause IUGR. Heart problems respiratory problems stroke. Baby can have withdrawal symptoms- shaking etc. Can be passed on through breast milk. Babies are irritable and cry all the time - harder to feed. Weed - Tabacco - similar effects to smoking. Baby can have a bowel movement when in the womb which can cause early delivery and foetal distress. Increased risk of SIDS. THC (tetrahydrocannabinol) gets into bloodstream of the the baby so the same effects that occur in

the mother e.g. increased risk of schizophrenia can also occur in the baby. Increased risk of anencephaly the neural tube defect (almost doubled). Opiates - SIDS, pre-term birth Caffeine is weakly associated with spontaneous abortion. Can cause irritability and low birth weight. It can decrease the absorption of iron which can increase the risk of anaemia. NHS recommends a limit of 200mg a day - the equivalent of 2 cups of instant coffee a day - also applies when breast-feeding. No aspirin or ibuprofen in the last three months of pregnancy. Reye’s syndrome? Exposure

to NSAIDs after 30 weeks' gestation is associated with an increased risk of premature closure of the fetal ductus arteriosus and oligohydramnios. Before 30 weeks it is prescribed routinely to treat fever, pain and inflammation. Antidepressants e.g. paroxetine can increase the risk of cardiac abnormalities in the baby. Can’t take some antibiotics eg: gentamicin, streptamicin, metronidazole (in 1 trimester) st

Women abusing drugs in pregnancy are often vulnerable personally and socially. They are at risk of other illnesses such as sexually transmitted infections (STIs), HIV and Hepatitis C, and are at increased risk of maternal death. Pregnancy care should be multidisciplinary and include social support. The newborn may be the subject of a care order. Depending on the drugs taken, the foetus may be at increased risk of congenital abnormalities; the pregnancy should be considered high risk particularly of IUGR and preterm delivery. Opiates: These are not teratogenic, but their use is associated with preterm delivery, IUGR, stillbirth, developmental delay and sudden infant death syndrome. Methadone maintenance, without the use of street drugs, is advised; withdrawal of methadone is not. Some neonates experience severe withdrawal symptoms and convulsions. Ecstasy is teratogenic, with an increased risk of cardiac defects and probably gastroschisis. Pregnancy complications ate probably similar to cocaine and counselling and social support are required. Benzodiazepines have been associated with facial clefts, and cause neonatal hypotonia as well as withdrawal symptoms. Cannabis: Abuse of other drugs makes attribution of risk difficult but cannabis may cause IUGR and affect later childhood development



What are the physiological effects on mother of pregnancy? (showing bump, breasts enlarge, areola gets darker, linea nigra, swollen feet, cravings, diastasis- rectus abdominis splits?

Cardiac output adapts to meet the requirements of the placenta. During pregnancy bloodflow through the uterine artery rises from 50-70ml/min to 600-1000ml/min. There is also an increase in metabolic rate hence maternal cardiac output rises by 30-50% due to increased stroke volume and heart rate (CO=SVxHR). Plasma volume of blood rises by about 50% so the total circulating blood volume increases. But haemoglobin only rises by about 30% hence there is a slight drop in haemoglobin concentration. There is a small increase in WBCs but a decrease in platelets (although still stay in the normal range). Despite the drop

on platelets pregnancy sends the woman into a hypercoagulable state because levels of fibrinogen and clotting factors VII-X are increased (increased risk of deep vein thrombosis). There are small reductions in the functional residual capacity, expiratory reserve volume, residual volume and total lung capacity near the end of the pregnancy, possibly due to obstruction caused by the uterus as it pushes up on the diaphragm. In contrast the resting tidal volume may increase by as much as 40%. As cardiac output increases, the renal blood flow increases, hence so does the GFR (glomerular filtration rate) by about 30-50%. Hence creatinine and urea levels in the maternal blood fall. Increased micturition is due to increased renal output and later on the size of the foetus pushes against the bladder. Angiotensin II production is increased but its hypertensive effects are counteracted by a reduction in sensitivity of blood vessels to angiotensin. But the increased angiotensin will increase aldosterone level which increases the reabsorption of salt and water from the distal tubular fluid and this balances out the increased loss of water and salt due to increased GFR. Total body water increases by 6-8 litres during pregnancy. Sickness seems to coincide with the rising hCG production from the invading syncytiotrophoblasts in the first 10-12 weeks. Pregnant women have a heightened sense of smell- certain smells can causes nausea (avoid teratogens). A placental hormone similar to thyroid stimulating hormone (TSH) increases thyroid function and stimulates the secretion of thyroxine (may lead to symptoms of hyperthyroidismtachycardia, palpitations, sweating and anxiety) Calcium store levels drop during pregnancy so parathyroid hormone secretion is increased to increase the intestinal absorption of calcium by increasing plasma levels of 1,25dihydroxycholecalciferol (hormonally active metabolite of vitamin D). In pregnancy, tissues show an increased sensitivity to insulin leading to a lower blood glucose level. Gestational diabetes can be caused by a carbohydrate intolerance which goes away when the baby is born. 50%-minute volume increases, tidal volume increases , compensated respiratory alkalosis The lobular ductal- alveolar system that was laid down during adolescence undergoes hypertrophy and the ducts proliferate further and the alveoli mature. The placental steroid hormones oestradiol and progesterone and the placental peptide hPL are responsible. Possibly growth hormone and prolactin are involved in breast development Cravings: increase in neuropeptide Y and ghrelin from the hypothalamus - appetite stimulants. Insular cortex in the brain - physiological changes occur which create cravings. Baby bump develops between 12-16 weeks. Linea nigra - increase in melanocyte stimulating hormone produced by placenta which also causes melisma (face pigmentation) and darkened areola – 75% of women have it.

Pregnancy The Three Trimesters Pregnancy has three trimesters, each of which is marked by specific fetal developments. A pregnancy is considered full-term at 40 weeks; infants delivered before the end of week 37 are considered premature. Premature infants may have problems with their growth and development, as well as difficulties in breathing and digesting.

First Trimester (0 to 13 Weeks) The first trimester is the most crucial to your baby's development. During this period, your baby's body structure and organ systems develop. Most miscarriages and birth defects occur during this period. Your body also undergoes major changes during the first trimester. These changes often cause a variety of symptoms, including nausea, fatigue, breast tenderness and frequent urination. Although these are common pregnancy symptoms, every woman has a different experience. For example, while some may experience an increased energy level during this period, others may feel very tired and emotional.

Second Trimester (14 to 26 Weeks) The second trimester of pregnancy is often called the "golden period" because many of the unpleasant effects of early pregnancy disappear. During the second trimester, you're likely to experience decreased nausea, better sleep patterns and an increased energy level. However, you may experience a whole new set of symptoms, such as back pain, abdominal pain, leg cramps, constipation and heartburn. Somewhere between 16 weeks and 20 weeks, you may feel your baby's first fluttering movements.

Third Trimester (27 to 40 Weeks) You have now reached your final stretch of pregnancy and are probably very excited and anxious for the birth of your baby. Some of the physical symptoms you may experience during this period include shortness of breath, hemorrhoids, urinary incontinence, varicose veins and sleeping problems. Many of these symptoms arise from the increase in the size of your uterus, which expands from approximately 2 ounces before pregnancy to 2.5 pounds at the time of birth.

What normal BP changes are there? VS. Abnormal BP changes? Include postural hypotension Blood pressure - section in Pocock. Diastolic pressure drops in the first 2 trimesters returns to normal after 24 weeks.The drop is due to the placenta acting as an arterio-venous shunt and peripheral vasodilation factors progesterone and oestrogen which cause increased endothelial synthesis of PG E2 and prostacyclins. The progesterone relaxes the walls of the blood vessels. Hypo is normal. Hyper is abnormal but common - affects 1 in 10 people. Mild-moderate does not seriously affect the baby. High blood pressure can lead to pre-eclampsia. 

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When you try to stand up, you may experience orthostatic hypotension because your circulatory system expands rapidly during pregnancy, blood pressure is likely to drop. This is normal, and blood pressure usually returns to your pre-pregnancy level after you've given birth.  What are normal side effects of pregnancy? Morning sickness occurs at the same time as high levels of hCG. There is also an association with depression and high levels of nausea and vomiting. Women who experience sickness are less likely to miscarry, sickness may have a protective function. Peak sickness occurred at 6-18 weeks during the period of embryonic organogenesis. Sickness has also been associated with increased amount of free thyroxine T4 and decreased thyroid stimulating hormone. There is a link between altered thyroid function and excessive vomiting. Morning sickness may be protective against teratogens in the time of organogenesis. Bland food without spicy odours and flavours are craved. Heartburn: most problematic after 30 weeks. The relaxing effect of progesterone on the smooth muscle of the cardiac sphincter between the stomach and the oesophagus. In non-pregnant women the sphincter tone increases in response to raised intragastric pressure. This is diminished in pregnancy as peristaltic activity is slowed as is gastric emptying. The uterus increases intragastric pressure flattening the diaphragm and distorting the shape of the stomach by decreasing the angle at the gastrojejunal junction. Ptaylism: excess salivation. It may lead to loss of fluids and electrolytes and dehydration. Pica: ingestion of non-nutritious substances such as coal washing starch soap and toothpaste. Hormones and metabolic changes have been implicated. Constipation: Very common. Can lead to the development of haemorrhoids. Increase in progesterone causes relaxation and reduced peristalsis of the G.I tract. Exercise, live yoghurt containing bifidus and mild laxatives may help.

Skin: anterior pituitary production of melanocyte stimulating hormone is increased by progesterone and oestrogen. This increases skin pigmentation during pregnancy which is called chloasma or pregnancy mask. Palmar erythema may be seen due to increased circulation. Striae gravidarun of pregnancy occurs due to rupturing of small amounts of tissue under the skin caused through stretching of the skin layers. Varicosities: circulation becomes sluggish and veins dilate. Haemorrhoids are common. Vulval varicosities can occur which can cause haemorrhage in delivery especially if an episiotomy is necessary. These are very painful. Backache – relaxin and progesterone- pelvic ligaments movement of symphisis pubis and lumbosacral joints. Relaxin may make I.V joints unstable under increased weight. Carpal tunnel syndrome- fluid retention and swelling of connective tissue compresses the median nerve as it runs through the carpal tunnel. Half of women still have problems post pregnancy. Fatigue – 97% of women experience fatigue in the first trimester. Sleep patterns change. Sleep may be disturbed due to urinary frequency leg cramps, breathing problems and vomiting. Lack of sleep is associated with depression, pre-eclampsia and preterm birth.  What are the effects of diabetes on pregnancy? Risk factors: BMI above 30, previously macrosomic baby (4.5Kg or above), Previous gestational diabetes, family history of diabetes (first degree relatives), minority ethnic groups have a higher chance. Complications for the baby: stillbirth, baby can grow slower due to poor circulation, damaged vessels. Risk increases in women with poor glucose control. Can cause macrosomia if there is high levels of glucose. The pancreas of the mother makes more insulin to get rid of it and this is put down as fat and so the baby is large. Birth injury can occur due to macrosomia, shoulder dystocia, hypoglycaemia of the baby after birth. Respiratory distress as lungs don’t grow fully.

Often a membrane sweep is offered which can induce labour within a few days. A finger is inserted into the cervix and swept in a circular motion to release prostaglandins. The risk of waiting beyond 41 weeks is death of the foetus. The GDM increases the women...