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Premature Rupture of Membranes

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2581. Intrapartum Fetal Monitoring

hypoxia: [ , ] Low gestational age (24-30 weeks) plus: postnatal dexamethasone use; patent ductus arteriosus; severe hyaline membrane disease; resuscitation in the delivery room; and intraventricular haemorrhage have all been shown to be associated with higher rates of cerebral palsy. Whereas antenatal corticosteroid use in very preterm infants is associated with a lower rate. [ ] There appears to be at best a tenuous connection between cardiotocographic findings, what they signify about the fetal (...) labour Antenatal maternal risk factors Antenatal fetal risk factors Intrapartum risk factors Previous caesarean section Suspected fetal growth restriction Augmentation of labour using oxytocin Pre-eclampsia or pregnancy-induced hypertension Suspected oligohydramnios or polyhydramnios Epidural analgesia Recurrent antepartum haemorrhage Abnormal presentation: breech, transverse or oblique Fresh vaginal bleeding during labour Prolonged membrane rupture (>24 hours) High or free head in a nulliparous

2008 Mentor

2582. Infant Respiratory Distress Syndrome

to the gestational age of the infant. It affects approximately one half of infants born at 28-32 weeks of gestation. It may (rarely) occur at term. The incidence of IRDS decreases with: The use of antenatal steroids. However, there are uncertainties over the efficacy for some groups such as the very early preterm babies, late preterm babies and multiple gestations. [ ] Pregnancy-induced or chronic maternal hypertension. Prolonged rupture of membranes. Risk factors [ ] Premature delivery. Male infants. Infants (...) preterm delivery. Presents with respiratory distress very soon after birth: tachypnoea, expiratory grunting, subcostal and intercostal retractions, diminished breath sounds, cyanosis and nasal flaring. May rapidly progress to fatigue, apnoea and hypoxia. Differential diagnosis Other causes of respiratory distress in neonates: Pulmonary air leaks (eg, , interstitial emphysema, pneumomediastinum, pneumopericardium). In premature infants, these may occur from excessive positive pressure ventilation

2008 Mentor

2583. Meningitis

[ ] See also separate general article . Neonates are at greater risk of meningitis. Risk factors for the development of meningitis include low birth weight (below 2500 g), premature delivery, premature rupture of membranes, traumatic delivery, fetal hypoxia and maternal peripartum infection. Intrapartum prophylactic antibiotics in pregnant mothers who carry, or who are at risk of colonising, group B streptococci, have been effective in reducing the risk of neonatal group B streptococcal meningitis (...) by local guidelines and close liaison with a microbiologist. Initial 'blind' therapy Children 3 months and older and young people should be given intravenous ceftriaxone as empirical treatment before identification of the causative organism. If calcium-containing infusions are required at the same time, cefotaxime is preferable. Children younger than 3 months should be given intravenous cefotaxime plus either amoxicillin or ampicillin. NB : ceftriaxone should not be used in premature babies

2008 Mentor

2584. Multiple Pregnancy

by caesarean section for twin 2. Triplets and higher multiple deliveries are usually managed by caesarean section and in tertiary-level fetal medicine centres. Vaginal delivery of twins With no complicating factors, the mother can go into spontaneous labour provided the first twin has a cephalic presentation. Where the first twin presents in a breech or transverse position, caesarean section is preferred. In most cases, vaginal birth proceeds as normal. With rupture of membranes, check for prolapse (...) . Ideally these should all be performed at the same scan. Chorionicity should be determined using the number of placental masses, the lambda or T-sign and membrane thickness. The risks are greater if the fetuses share a placenta (monochorionic), so it is important that this is established early. Scanning to screen for structural anomalies takes place as per singleton pregnancies (at 18 to 21 weeks), but the procedure takes longer. Multiple pregnancies should be monitored carefully for intrauterine

2008 Mentor

2585. Management of HIV in Pregnancy

can be reduced to less than 1%. Risk of MTCT This is increased with: Higher levels of maternal viraemia. HIV core antigens. Lower maternal CD4 count. Primary HIV infection occurring during pregnancy. Chorioamnionitis. Co-existing other sexually transmitted disease . Possibly malaria. [ ] Invasive intrapartum procedures - eg, fetal scalp electrodes, forceps, ventouse. Rupture of membranes (especially if delivery is more than four hours after the membranes ruptured). Vaginal delivery. Preterm birth (...) delivery providing they are taking effective ART. Delivery by pre-labour caesarean section between 38-39 weeks to prevent labour and/or ruptured membranes is recommended for: Women taking ART who have a plasma viral load greater than 50 copies/ml . Women taking ZDV monotherapy as an alternative to ART. Delivery by pre-labour caesarean section for obstetric indications or maternal request should be delayed until after 39 weeks in women whose plasma viral load is less than 50 copies/ml, to reduce

2008 Mentor

2586. Stillbirth and Neonatal Death

abnormality Haemorrhage, during pregnancy or labour Placental insufficiency Placental abruption Pre-eclampsia Obstetric complications Spontaneous premature labour Premature rupture of membranes Polyhydramnios Oligohydramnios Intrapartum asphyxia Birth trauma Cord prolapse Intra-uterine growth restriction Liver disease - obstetric cholestasis, intrahepatic cholestasis of pregnancy Diabetes Infections during pregnancy In England the latest report into causes of perinatal death was the Centre for Maternal (...) factor for stillbirth. A 2012 study of stillbirths in England showed the risk to be significantly higher where the growth restriction was not detected antenatally, suggesting this as an important avenue for reducing stillbirth rates in the future. [ ] It concluded strategy should focus on improving antenatal detection of growth restriction, and subsequent management of pregnancy and delivery. Preterm birth: [ ] This is the biggest risk factor for neonatal death. Obstetric and neonatal care can have

2008 Mentor

2587. Deafness

health professional can look down with a torch. At the end of the canal is the eardrum. This separates the external ear from the middle ear. The eardrum is a tightly stretched membrane, a bit like the skin of a drum. Our picks for Hearing Problems Your ears do the remarkable job of allowing you to hear a huge range of sounds, from a whisper t... 4min The middle ear is an air-filled compartment. Inside it are the three smallest bones in the body, called the malleus, incus and stapes. These bones (...) If there is a problem in the ear canal or the middle ear, this causes what is known as a conductive hearing loss. In conductive hearing loss, the movement of sound (conduction) is blocked or does not pass into the inner ear. This is often as the result of earwax (cerumen) or fluid in the middle ear, although it may also be caused by a burst (ruptured) eardrum or by otosclerosis (see below). Sensorineural hearing loss If the fluid-filled chamber called the cochlea or the hearing nerve is not working properly

2008 Mentor

2588. Deafness in Adults

health professional can look down with a torch. At the end of the canal is the eardrum. This separates the external ear from the middle ear. The eardrum is a tightly stretched membrane, a bit like the skin of a drum. Our picks for Hearing Problems Your ears do the remarkable job of allowing you to hear a huge range of sounds, from a whisper t... 4min The middle ear is an air-filled compartment. Inside it are the three smallest bones in the body, called the malleus, incus and stapes. These bones (...) If there is a problem in the ear canal or the middle ear, this causes what is known as a conductive hearing loss. In conductive hearing loss, the movement of sound (conduction) is blocked or does not pass into the inner ear. This is often as the result of earwax (cerumen) or fluid in the middle ear, although it may also be caused by a burst (ruptured) eardrum or by otosclerosis (see below). Sensorineural hearing loss If the fluid-filled chamber called the cochlea or the hearing nerve is not working properly

2008 Mentor

2589. Diabetic Retinopathy and Diabetic Eye Problems

. Leakage results in intraretinal haemorrhages and localised or diffuse oedema. These processes result in the characteristic features seen at various stages of DR: Microaneurysms - physical weakening of the capillary walls which predisposes them to leakages. Hard exudates - precipitates of lipoproteins/other proteins leaking from retinal blood vessels. Haemorrhages - rupture of weakened capillaries, appearing as small dots/larger blots or 'flame' haemorrhages that track along nerve-fibre bundles (...) -operative PRP reduces the stimulus for neovascularisation. Complications The main complication of DR is visual loss secondary to: . Macular ischaemia. . . However, treatment modalities are also associated with risks. Complications of focal/grid photocoagulation Impaired central vision. Paracentral scotoma. Choroidal neovascularisation. Epiretinal membrane formation. Worsening of macular oedema in a minority. Complications of panretinal photocoagulation (PRP) Constriction of visual field. Nocturnal

2008 Mentor

2590. Ehlers-Danlos Syndrome

subtypes and within subtypes. They are described in more detail below. There is some symptom overlap with and . The first presentation, at birth, may be premature rupture of the membranes. Investigations [ ] In the case of hEDS, diagnosis is normally made on the clinical presentation, by a specialist with expertise in the area. Molecular genetic testing is now recommended for the definitive diagnosis of the other subtypes, although not all patients with the specific condition will demonstrate (...) that can follow a period of over-activity. There is an increased risk of vaginal and perineal tearing in labour, and particular care is needed to slow delivery. There is an increased risk of early rupture of membranes and premature delivery if either parent has cEDS. Both mitral regurgitation and (more rarely) aortic root dilatation are sometimes seen in cEDS. Classical-like Ehlers-Danlos syndrome [ ] Also called tenascin-X deficient Ehlers-Danlos syndrome This very rare condition is similar to cEDS

2008 Mentor

2591. Congenital HIV Infection and its Prevention

, ventouse. Rupture of membranes (especially if delivery is more than four hours after the membranes ruptured). Vaginal delivery. Advanced maternal age. The firstborn of twins (born to an HIV-infected mother). Preterm birth. Female babies more likely to be infected early (transplacental/perinatal routes). [ ] Co-existent malaria may increase HIV transmission rates although this is not firmly established. [ ] Presentation It is to be hoped that most cases of UK-based HIV infection in pregnant mothers

2008 Mentor

2592. Congenital Infections in Neonates

to exposure to a vast array of new pathogens ex utero. Parturition also places the baby in direct contact with maternal blood or genital secretions and infections may result, especially if there was prolonged or early rupture of membranes. At birth, an infant's immune system remains immature. Some protection is provided by maternal antibodies (IgG) crossing the placenta. This process is less complete in the premature baby, especially if markedly premature. If a mother develops a new infection close (...) after delivery. Hepatitis B See separate article. Hepatitis C See separate article. Group B streptococci (GBS) GBS are found in 12-26% of pregnant women, especially in the urine. Infection has been associated with preterm delivery, and ascending infection following rupture of membranes may result in fetal infection. Maternal carriage of GBS is associated with a higher risk of chorioamnionitis and neonatal disease. Neonatal GBS disease occurs at a rate of 0.5 cases/1,000 births. The rate is increased

2008 Mentor

2593. Childhood AIDS

(especially if delivery is more than four hours after the membranes ruptured). Vaginal delivery. Advanced maternal age. The firstborn of twins (born to an HIV-infected mother). Preterm birth. Female babies more likely to be infected early (transplacental/perinatal routes). [ ] Co-existent malaria may increase HIV transmission rates although this is not firmly established. [ ] Presentation It is to be hoped that most cases of UK-based HIV infection in pregnant mothers will be identified before delivery, so (...) -infected children in the UK and Ireland). 44% were born in the UK or Ireland, 55% were born abroad and 2% were of unknown origin. Risk factors The following factors increase the risk of MTCT: Higher levels of maternal viraemia. HIV core antigens. Lower maternal CD4 count. Primary HIV infection occurring during pregnancy. Chorioamnionitis. Co-existing other sexually transmitted infection (STI). Invasive intrapartum procedures - eg, fetal scalp electrodes, forceps, ventouse. Rupture of membranes

2008 Mentor

2594. Breech Presentations

reduces the risk of a breech presentation at term but may be more likely to lead to a late preterm birth [ ] . Contra-indications (such as having another indication for caesarean delivery, antepartum haemorrhage in the last week, abnormal cardiotocography (CTG) trace, major uterine anomaly, ruptured membranes) occur in only 4% of women with breech presentation at term. Spontaneous reversion to breech presentation after a successful ECV occurs in fewer than 5%. It should only be carried out (...) , irrespective of the outcome of ECV [ ] . Complications associated with ECV are uncommon but include placental abruption, uterine rupture and fetomaternal haemorrhage. ECV is offered from 36 weeks in nulliparous women and 37 weeks in multiparous women. ECV can be attempted in post-date women and can even be performed in early labour provided membranes are intact. Attempting ECV between 34 and 36 weeks of gestation compared with after 37 weeks of gestation is more likely to be successful and considerably

2008 Mentor

2595. Abdominal Pain In Pregnancy

: Constant pain, profound shock, fetal distress and vaginal bleeding; usually presents during labour and with history of uterine scar. Rarely, occurs without labour and without uterine scar. Chorioamnionitis: This usually follows premature rupture of membranes but can occur with membranes intact. Acute fatty liver of pregnancy: Presents in the second half of pregnancy with abdominal pain, nausea/vomiting, jaundice, malaise and headache. Acute polyhydramnios. Rupture of utero-ovarian vessels. [ ] Severe (...) causes, see separate . Obstetric causes [ , ] Labour pain - premature labour or term. Pre-eclampsia or HELLP syndrome - epigastric or right upper quadrant pain. Placental abruption: Typically, sudden severe pain and a 'woody' hard, tender uterus; fetal distress ± vaginal bleeding. With posterior placenta, pain and shock may be less severe, with pain felt in the back; diagnose by pattern of fetal contractions (excessive and frequent) with fetal heart pattern suggesting hypoxia. Uterine rupture

2008 Mentor

2596. Abbreviations

-gamma peroxisome proliferator-activated gamma PPROM preterm, prelabour rupture of membranes PPV pneumococcal polysaccharide vaccine PR progesterone receptor PRA preoperative risk assessment PRL prolactin prn pro re nata (when required) PRNP PR ioN P rotein PRP polyribosyl ribitol phosphate PS polysomnography PSA prostate specific antigen PSVT paroxysmal supraventricular tachycardia PT prothrombin time PTA polymyxin/tobramycin/amphotericin PTBD percutaneous transhepatic biliary drainage PTCA (...) Ambulance Incident Officer AJ ankle jerk ALF acute liver failure ALS amyotrophic lateral sclerosis AMAs anti-mitochondrial antibodies AMH anti-Müllerian hormone AMHP Approved Mental Health Professional ANA antinuclear antibody ANCA antineutrophil cytoplasmic antibody Anti-GBM antiglomerular basement membrane antibody anti-RNP antibodies to ribonucleoprotein anti-U1-RNP anti-U1-ribonucleoprotein a-NVH asymptomatic non-visible haematuria AP anteroposterior aPL antiphospholipid aPPT activated partial

2008 Mentor

2597. Antenatal Care

rupture of membranes or if there is placenta praevia, although evidence is limited. [ ] Alcohol [ ] High levels of alcohol consumption during pregnancy may result in the fetal alcohol syndrome (FAS). There are various components including growth restriction, general learning disability, facial anomalies and behavioural problems. Not all women who drink heavily in pregnancy have babies with FAS, so there are other components, which are as yet poorly understood. It is not known how much alcohol is safe (...) start a gentle programme of regular exercise. Moderate exercise has not been shown to cause any harm but the patient should be warned of the dangers of highly energetic and contact sports that would risk damage to the abdomen, falls or excessive joint stress. Scuba diving should be avoided, as it can cause fetal birth defects and fetal decompression disease. Sexual intercourse This has not been shown to cause any harm during pregnancy. It may be advisable to avoid it if there is risk of preterm

2008 Mentor

2598. Antenatal Infections and their Consequences

in the event of rupture of membranes or onset of labour. Caesarean section should be recommended, as the risk of HSV transmission is very high (41%). If HSV antibody tests subsequently confirm a recurrent infection, when initially it had been thought to be a primary infection, caesarean may no longer be indicated. In recurrent HSV infection, risk of neonatal herpes is low, even if lesions are present at time of delivery (0-3% for vaginal delivery). Aciclovir may not be needed but daily suppression (...) with oral aciclovir may be used from 36 weeks of gestation. Delivery by caesarean section should be offered but the final choice should be made by the woman. If a primary episode of genital herpes simplex occurs at the onset of labour, caesarean section should be recommended. If vaginal delivery cannot be prevented, application of fetal scalp electrodes, fetal blood sampling, artificial rupture of membranes and/or instrumental deliveries should all be avoided. Human immunodeficiency virus [ ] affects T

2008 Mentor

2599. Viral Meningitis

infection. Neonatal meningitis [ ] See also separate general article . Neonates are at greater risk of meningitis. Risk factors for the development of meningitis include low birth weight (below 2500 g), premature delivery, premature rupture of membranes, traumatic delivery, fetal hypoxia and maternal peripartum infection. Intrapartum prophylactic antibiotics in pregnant mothers who carry, or who are at risk of colonising, group B streptococci, have been effective in reducing the risk of neonatal group B (...) by local guidelines and close liaison with a microbiologist. Initial 'blind' therapy Children 3 months and older and young people should be given intravenous ceftriaxone as empirical treatment before identification of the causative organism. If calcium-containing infusions are required at the same time, cefotaxime is preferable. Children younger than 3 months should be given intravenous cefotaxime plus either amoxicillin or ampicillin. NB : ceftriaxone should not be used in premature babies

2008 Mentor

2600. Haemophilus Influenzae

months to 4 years. Hib causes septic arthritis and cellulitis in children younger than 2 years. Hib septic arthritis also occurs in adults. Neonatal infection: Often due to non-typeable H. influenzae , which colonises the maternal genital tract. Infection is associated with premature birth, premature rupture of membranes, low birth weight and maternal chorioamnionitis. Presentations include meningitis, pneumonia, respiratory distress, scalp abscess, conjunctivitis and vesicular eruption

2008 Mentor

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