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MIDWIFERY NS3003 EXAM STUDY NOTES Challenges in the Pregnancy Continuum: At Risk Events WEEK 1 (module 1 + 2): Epidemiology associated with maternal and perinatal morbidity and mortality - Fertility - Assisted Reproductive Technologies (ART) - OHSS - Health risks for vulnerable populations - Perinatal Challenges related to early pregnancy (ectopic, GTD, teratogenesis) WEEK 2 (module 3): Haematological problems and infections in early pregnancy - Revision of blood - Isoimmunisation - ABO incompatibility - Infections (Rubella, Syphilis, Gonorrhoea, Herpes Simplex 2, Varicella, Hepatitis B) - Critical Coagulation issues (Hypovolemia, Gestational thrombocytopenia, Uterine Rupture, Cardiac Arrest, Mandelson’s Syndrome, DIC) WEEK 3 (module 4): Placental abnormalities, pelvic and uterine dysfunction. - APH - Placentation Errors - Placental Abruption - Cephalo-pelvic Disproportion - Uterine issues (dysfunction, rupture, inversion) - Amniotic fluid embolism WEEK 4 (module 5): Hypertensive Disorders of Pregnancy - Revision haemodynamic changes in pregnancy - Gestational/chronic HTN - Preeclampsia - Antihypertensive - Eclampsia - MgSO4 WEEK 5 (module 6): Diabetes in Pregnancy - Carbohydrate Metabolism - Diabetogenic State - Hyperinsulinemia - Gestational Diabetes Mellitus - Diabetic Ketoacidosis - Foetal complications

WEEK 6: Challenges to Labour and birth -

Malposition/malpresentation Occipitoposterior (OP) Breech Birth External Cephalic Version Types of abnormal presentations Assisted Vaginal Birth Intrauterine Growth Restriction (IUGR) Cord Prolapse Preterm labour Preterm Prelabour Rupture of Membranes (PPROM) Multiple Pregnancy

There are FOUR main aspects of this subject  Understanding pathophysiology of ‘at risk’ pregnancy events  Provision of evidence based midwifery and associated collaborative care  Evaluation of care modalities expected outcomes and possible adverse outcomes related to the at risk event  Provision of care that is structures within a woman centred care framework

WEEK 1 Maternal Mortality is maternal death within 42 days of the termination of a pregnancy no matter what gestation Fertility Fertility is defined as the ability of a person/couple to conceive a child. Factors Affecting Fertility A person is considered to be infertile after 12 months of unprotected sex where vaginal penetration has occurred, in the absence of known reproductive pathology.  Maternal age >35  Maternal BMI >25  Time of intercourse  Infection (chlamydia/gonorrhoea)  Nutrition  Socio-economic status  Levels of stress  Smoking and alcohol Pelvic Inflammatory Disease is a major factor in causing infertility among women. Caused by:  Chlamydia trachomatis Cause fallopian tube scarring  Neisseria Gonorrhoea  Severe endometriosis Assisted Reproductive Technologies (ART) ART is reproductive technology used primarily for infertility treatments. (4) Main types will be focused on for study: 1. In-vitro Fertilisation 2. Intra-cytoplasmic Sperm Injection 3. Gamete Intra-fallopian transfer 4. Ovulation Induction In-Vitro Fertilisation: assist in conception by using laboratory techniques to assist sperm and egg to unite and produce and embryo which is then inserted into the uterus. Intra-cytoplasmic Sperm Injection: Multiple ova are collected; healthy sperm are selected and then injected directly into the centre of each ovum - then placed into uterus. Gamete Intra-fallopian tube transfer: Same as IFV and ICSI, but instead of being replaced into uterus, it is placed into the fallopian tube for natural implantation Ovulation Induction: induction through medication, triggers release of mature egg for controlled conception timing

Ovarian Hyperstimulation Syndrome (OHSS)

Rare complication of ovarian stimulation due to ART and other infertility treatments  Usually develops by day 7 after oocyte retrieval or ART procedure CHARACTERISED BY:  Ovarian enlargement  Development of multiple ovarian cysts due to an acute fluid shift into extravascular space COMPLICATIONS:  Ascites (fluid in peritoneal cavity)  Haemoconcentration (increased RBC, decrease plasma fluid which increases clotting)  Hypovolemia (due to decreased plasma)  Electrolyte imbalance Mild Moderate Severe Grade 1: abdominal Grade 3: mild OHSS, USS Grade 4: moderate OHSS, distension and discomfort evidence of ascites ascites and hydrothorax + Grade 2: nausea and dyspnoea (laboured vomiting, diarrhoea, ovarian breathing due to fluid in enlargement chest) Grade 5: all of above plus haemodynamic changes TREATMENT  Symptomatic  Paracentesis (perforation in chest to remove fluid)  Management of coagulopathies  Intensive Care

OHSS is a severe and can be fatal

Issues affecting Indigenous Women/ NESB women  Access  Language  Culture  Co-morbidities  Birthing on country Advanced Maternal age (>35)  Increased risk of stillborn/LBW  Negative perinatal outcomes linked with increased maternal age  IUGR (due to placental insufficiency)  Co-morbidities (HTN, Diabetes, smoking, obesity)  Higher risk of C/S

Teenage Pregnancies

 Access  Language  Socio-economic status  Education  Often late and infrequent antenatal attenders Other issues:  Poor mobilisation of fats for adequate foetal nutrition  Limited reproductive development  Increased risk of PTL, LBW, PET, IUFD  Higher rates of smoking and poor nutritional choices Perinatal Challenges Related to Early Pregnancy (module 2)

Viability = 20/40 or above 400g

Miscarriage: expulsion of foetus before it reaches viability. Spontaneous M/C types: complete, incomplete, inevitable, threatened, missed, septic, recurrent Induced M/C types: social and therapeutic

TYPES Complete: every aspect of a foetus is now gone. An empty uterus is seen on USS Incomplete: part of foetal/placental tissue remains in the womb. Presents with PV bleeding Threatened: painful or painless PV bleeding with a closed cervical OS Inevitable: painful or painless PV bleeding with an open cervical OS Missed: early foetal demise/died unknowingly, brown or blood stained PV loss, low hCG levels in mother Recurrent: term used for 3 consecutive miscarriages Septic: miscarriage associated with serious uterine infection (PID) Social: choice by parents to protect mental health of mother Therapeutic: use of medication to induce a miscarriage DIAGNOSIS & TREATMENT  Speculum examination  Quantitative BhCG (measures level of hCG in mothers blood)  USS  Conservative Treatment (wait and see)  D&C (dilatation and curettage)  Suction curette (DC but suctioned not scraped)

Blighted Ovum

A fertilised egg that implants successfully but fails to develop. Seen on USS as an empty sac and may also be referred to as a missed miscarriage. Bleeding 80% effaced MANAGEMENT OPTIONS 1. Tocolysis Nifedipine + MgSo4 2. Progesterone Therapy Daily 200mg pessaries (PV pills) from 16-24/40. Used in presence of cervix shortening and history of PTL

Less than 35+6/40

Tocolysis Nifedipine PO 20mg stat Can repeat in 30 minutes Can repeat again in 30 minutes CHECK BP MAXIMUM DOSE: 160mg in 24hrs

Diagnosis 4 contractions in 20 minutes Cervical dilatation>2cm Effacement >80%

Antenatal Corticosteroids 11.4mg Betamethasone x2 given 24 hour apart IF birth indicated w/in 24 hours give 2nd dose after 12 hours

If BP stable, repeat 6/24 for 48 hours

Observations BP monitoring 30 minutely for first hour then 4/24 Continuous CTG until contractions cease

CONTRAINDICATION FOR TOCOLYSIS  Mature foetus  Dead foetus  IUGR  Active haemorrhage  Chorioamnionitis  PET  Placenta abruption

Antibiotic therapy Birth expected antibiotic regime for GBS prophylaxis If chorioamnionitis suspected, administer broad spectrum antibiotics and don’t suppress labour

Neuroprotection MgSO4 for at least 4 hours preceding birth to have effect

Observations: Neuro obs Urine output Respiratory rate BP 5 minutely for 30 minutes, ½ hourly for an hour then hourly

Corticosteroids  Between 24-33+6/40 = 11.4mg Betamethasone 2x given 24 hours apart  If birth expected to occur in 24 hours give 2nd dose at 12 hours  If TPL continues to be an issue, give weekly rescue doses of 11.4mg Betamethasone until 34+6/40 Neuroprotection  Currently recommended for preterm birth expected between 24-30/40  Recommendation is for MgSO4 to be given for at least 4 hours preceding birth to have effect  IF birth does not occur within 24 hours but again becomes imminent, administration can be repeated Antibiotic Therapy  If preterm labour continues and birth is expected, antibiotic regime for GBS prophylaxis should be followed  If chorioamnionitis suspected, administer broad spectrum antibiotics and don’t suppress labour Mode of Birth A preterm caesarean section is technically more difficult, and if the baby is cephalic an SVB is recommended. If the baby is BREECH and >25/40 a caesarean section is recommended

Preterm Rupture of Membranes Defined as rupture of membranes before onset of labour. It complicated approximately 2% of pregnancies, is associated with 40% of preterm births and can result in significant neonatal morbidity and mortality PPROM = Preterm Prelabour Rupture of Membranes 3 CAUSES of neonatal death associated with PPROM are:  Prematurity  Sepsis  Pulmonary hypoplasia AETIOLOGY  Most cause unknown  High intrauterine pressure (multiple pregnancy, polyhydramnios)  Placental abruption  Placenta praevia  Multiple amniocentesis  Bacterial infection MANAGEMENT  Confirmation (spec, Amnisure/ActiProm)  USS confirmation  Corticosteroids  Tocolysis  Antibiotics = erythromycin for 10 days then GBS prophylaxis

Multiple Gestation/Pregnancy

Zygosity = degree of identity in genomes Chorionicity = number of placentas/chorions/amnions Dizygotic = 2 zygotes (fraternal twins, developed from 2 different oocytes) Dichorionic = 2 chorionic membranes & 2 separate secs Diamniotic = 2 sacs but contained within 2 or 1 chorion Monozygotic = 1 zygote (identical twins, developed from 1 oocyte that has split) Monochorionic = 1 chorion & 1 placenta Monoamniotic = both twins are in 1 sac and share 1 placenta Twin-Twin Transfusions (placental perfusion) Is when the placenta unfairly perfuses the twins with blood and oxygen causing a deficit in one and an overload in the other  Occurs in 15-35% of monozygotic twins  Twins referred to as donor or recipient DONOR RECIPIENT Develops: Develops:  Hypovolemia  Hypervolemia  Polyuria  Oliguria  Polyhydramnios  Oligohydramnios  Polycythaemia (too much Hb)  Anaemia  Circulatory overload  Hydrops fetalis Management of Multiple Pregnancy COLLABORATIVE!  Frequent consultation with obstetrician  Frequent USS for foetal wellbeing...