Recommendations for Feeding Low-Birthweight Infants

Low-birthweight infants, those with a birthweight of less than 2,500 g, should be exclusively breastfed for the first six months of life, according to WHO recommendations. If the mother’s milk is not available, donor human milk should be sought. If that is not possible, standard formula milk can be used. There is no difference in the duration of exclusive breastfeeding between low-birthweight and normal-weight infants. Daily vitamin A supplementation is not currently recommended for low-birthweight infants, but very low-birthweight infants should receive daily supplementation of vitamin D, calcium, and phosphorus. Low-birthweight infants who are able to breastfeed should start as soon as possible after birth, once they are clinically stable.

This patient is suspected to have a post-partum infection and sepsis in the puerperium, which can be fatal. A thorough examination is necessary to identify the source of infection, which is most likely to be the genital tract. Other potential sources include urinary tract infection, mastitis, skin infections, pharyngitis, pneumonia, and meningitis. The patient is experiencing abdominal pain, fever, and tachycardia, indicating the need for iv antibiotics and senior review. Regular observations, lactate measurement, and iv fluid support should be provided as per sepsis pathways. Blood cultures and vaginal swabs should be taken, and iv antibiotics should be administered within an hour of presentation. The patient is not a candidate for ambulatory treatment and needs to be admitted for further investigation and treatment.

There is a strong indication of a ruptured ectopic pregnancy based on the clinical presentation. The patient’s condition has deteriorated significantly, with symptoms of shock and a systolic blood pressure below 90 mmHg. Due to her unstable cardiovascular state, urgent consideration must be given to performing an emergency laparotomy.

Understanding Ectopic Pregnancy

Ectopic pregnancy occurs when a fertilized egg implants outside the uterus. This condition is characterized by lower abdominal pain and vaginal bleeding, typically occurring 6-8 weeks after the start of the last period. The pain is usually constant and may be felt on one side of the abdomen due to tubal spasm. Vaginal bleeding is usually less than a normal period and may be dark brown in color. Other symptoms may include shoulder tip pain, pain on defecation/urination, dizziness, fainting, or syncope. Breast tenderness may also be reported.

During examination, abdominal tenderness and cervical excitation may be observed. However, it is not recommended to examine for an adnexal mass due to the risk of rupturing the pregnancy. Instead, a pelvic examination to check for cervical excitation is recommended. In cases of pregnancy of unknown location, serum bHCG levels >1,500 may indicate an ectopic pregnancy. It is important to seek medical attention immediately if ectopic pregnancy is suspected as it can be life-threatening.

The risk of placental abruption is increased by cocaine abuse due to its ability to cause vasospasm in the placental blood vessels. Ceftriaxone use, which is the treatment of choice for gonorrhoeae, is not a known risk factor for placental abruption and is therefore a distractor. Although gonorrhoeae can lead to chorioamnionitis, which is a known risk factor for placental abruption, there is no evidence to suggest that this is the case and it is less likely than cocaine use. Primiparity is an incorrect answer as it is actually multiparity that is a risk factor for placental abruption.

Placental Abruption: Causes, Symptoms, and Risk Factors

Placental abruption is a condition that occurs when the placenta separates from the uterine wall, leading to maternal bleeding into the space between them. Although the exact cause of this condition is unknown, certain factors have been associated with it, including proteinuric hypertension, cocaine use, multiparity, maternal trauma, and increasing maternal age. Placental abruption is not a common occurrence, affecting approximately 1 in 200 pregnancies.

The clinical features of placental abruption include shock that is disproportionate to the visible blood loss, constant pain, a tender and tense uterus, and a normal lie and presentation of the fetus. The fetal heart may be absent or distressed, and there may be coagulation problems. It is important to be aware of other conditions that may present with similar symptoms, such as pre-eclampsia, disseminated intravascular coagulation (DIC), and anuria.

In summary, placental abruption is a serious condition that can have significant consequences for both the mother and the fetus. Understanding the risk factors and symptoms of this condition is important for early detection and appropriate management.

It is important for pregnant individuals with type 1 diabetes to closely monitor their blood glucose levels by testing multiple times throughout the day. This is recommended by NICE NG3.

Gestational diabetes is a common medical disorder affecting around 4% of pregnancies. Risk factors include a high BMI, previous gestational diabetes, and family history of diabetes. Screening is done through an oral glucose tolerance test, and diagnostic thresholds have recently been updated. Management includes self-monitoring of blood glucose, diet and exercise advice, and medication if necessary. For pre-existing diabetes, weight loss and insulin are recommended, and tight glycemic control is important. Targets for self-monitoring include fasting glucose of 5.3 mmol/l and 1-2 hour post-meal glucose levels.

Pregnant women who are obese (with a BMI greater than 30 kg/m²) should be prescribed a high dose of 5mg folic acid. It is recommended that all pregnant women take 400 IU of vitamin D daily throughout their pregnancy. Additionally, folic acid should be taken daily for the first 12 weeks of pregnancy, with the dosage depending on the presence of risk factors for neural tube defects such as spina bifida. If there are no risk factors, the dose is 400 micrograms daily, but if risk factors are present, the dose should be increased to 5 mg daily. As maternal obesity is a risk factor for neural tube defects, pregnant women with a BMI greater than 30 kg/m² should take the higher dose of folic acid.

Folic Acid: Importance, Deficiency, and Prevention

Folic acid is a vital nutrient that is converted to tetrahydrofolate (THF) in the body. It is found in green, leafy vegetables and plays a crucial role in the transfer of 1-carbon units to essential substrates involved in the synthesis of DNA and RNA. However, certain factors such as phenytoin, methotrexate, pregnancy, and alcohol excess can cause a deficiency in folic acid. This deficiency can lead to macrocytic, megaloblastic anemia and neural tube defects.

To prevent neural tube defects during pregnancy, it is recommended that all women take 400mcg of folic acid until the 12th week of pregnancy. Women at higher risk of conceiving a child with a neural tube defect should take 5mg of folic acid from before conception until the 12th week of pregnancy. Women are considered higher risk if they or their partner has a neural tube defect, they have had a previous pregnancy affected by a neural tube defect, or they have a family history of a neural tube defect. Additionally, women with certain medical conditions such as coeliac disease, diabetes, or thalassaemia trait, or those taking antiepileptic drugs, or who are obese (BMI of 30 kg/m2 or more) are also considered higher risk.

In summary, folic acid is an essential nutrient that plays a crucial role in DNA and RNA synthesis. Deficiency in folic acid can lead to serious health consequences, including neural tube defects. However, taking folic acid supplements during pregnancy can prevent these defects and ensure a healthy pregnancy.

Pregnant women should not use novel oral anticoagulants, so those who are currently taking them should switch to low molecular weight heparin.

Venous Thromboembolism in Pregnancy: Risk Assessment and Prophylactic Measures

Pregnancy increases the risk of developing venous thromboembolism (VTE), a condition that can be life-threatening for both the mother and the fetus. To prevent VTE, it is important to assess a woman’s individual risk during pregnancy and initiate appropriate prophylactic measures. This risk assessment should be done at the first antenatal booking and on any subsequent hospital admission.

Women with a previous history of VTE are automatically considered high risk and require low molecular weight heparin throughout the antenatal period, as well as input from experts. Women at intermediate risk due to hospitalization, surgery, co-morbidities, or thrombophilia should also be considered for antenatal prophylactic low molecular weight heparin.

The risk assessment at booking should include factors that increase the likelihood of developing VTE, such as age over 35, body mass index over 30, parity over 3, smoking, gross varicose veins, current pre-eclampsia, immobility, family history of unprovoked VTE, low-risk thrombophilia, multiple pregnancy, and IVF pregnancy.

If a woman has four or more risk factors, immediate treatment with low molecular weight heparin should be initiated and continued until six weeks postnatal. If a woman has three risk factors, low molecular weight heparin should be initiated from 28 weeks and continued until six weeks postnatal.

If a diagnosis of deep vein thrombosis (DVT) is made shortly before delivery, anticoagulation treatment should be continued for at least three months, as in other patients with provoked DVTs. Low molecular weight heparin is the treatment of choice for VTE prophylaxis in pregnancy, while direct oral anticoagulants (DOACs) and warfarin should be avoided.

In summary, a thorough risk assessment and appropriate prophylactic measures can help prevent VTE in pregnancy, which is crucial for the health and safety of both the mother and the fetus.

The progesterone-only pill can be taken by postpartum women (both breastfeeding and non-breastfeeding) at any time after delivery. It is categorized as UKMEC 1, meaning there are no restrictions on its use. Women can start taking it immediately if they choose to do so, and there is no need to wait for three weeks before starting. The combined oral contraceptive pill (COCP) can be taken as UKMEC 2 after three weeks in non-breastfeeding women, and after six weeks in breastfeeding women or as UKMEC 1 in non-breastfeeding women. In breastfeeding women, the COCP can be taken as UKMEC 1 after six months. The progesterone-only pill is safe for breastfeeding women as it has minimal transfer into breast milk, and there is no harm to the baby.

After giving birth, women need to use contraception after 21 days. The progesterone-only pill (POP) can be started at any time postpartum, according to the FSRH. Additional contraception should be used for the first two days after day 21. A small amount of progesterone enters breast milk, but it is not harmful to the infant. On the other hand, the combined oral contraceptive pill (COCP) is absolutely contraindicated (UKMEC 4) if breastfeeding is less than six weeks post-partum. If breastfeeding is between six weeks and six months postpartum, it is a UKMEC 2. The COCP may reduce breast milk production in lactating mothers. It should not be used in the first 21 days due to the increased venous thromboembolism risk post-partum. After day 21, additional contraception should be used for the first seven days. The intrauterine device or intrauterine system can be inserted within 48 hours of childbirth or after four weeks.

The lactational amenorrhoea method (LAM) is 98% effective if the woman is fully breastfeeding (no supplementary feeds), amenorrhoeic, and less than six months post-partum. It is important to note that an inter-pregnancy interval of less than 12 months between childbirth and conceiving again is associated with an increased risk of preterm birth, low birth weight, and small for gestational age babies.

In the case of umbilical cord prolapse, the priority is to limit compression on the cord and reduce the chance of cord vasospasm. This can be achieved by pushing any presenting part of the baby back into the uterus, putting the mother on all fours, and retrofilling the bladder with saline. In addition, warm damp towels can be placed over the cord to limit handling. It is important to note that this is a complex emergency that requires immediate attention, as it can lead to foetal bradycardia and limit the oxygen supply to the baby. In this scenario, a category 1 Caesarean section would be necessary, as the pathological CTG demands it. Delivering the baby as breech immediately is not recommended, as it is a high-risk strategy that can lead to morbidity and mortality. IM corticosteroids are indicated for premature rupture of membranes, but the immediate priority is to deal with the emergency. McRobert’s manoeuvre is not appropriate in this case, as it is used to correct shoulder dystocia, which is not the issue at hand.

Understanding Umbilical Cord Prolapse

Umbilical cord prolapse is a rare but serious complication that can occur during delivery. It happens when the umbilical cord descends ahead of the presenting part of the fetus, which can lead to compression or spasm of the cord. This can cause fetal hypoxia and potentially irreversible damage or death. Certain factors increase the risk of cord prolapse, such as prematurity, multiparity, polyhydramnios, twin pregnancy, cephalopelvic disproportion, and abnormal presentations like breech or transverse lie.

Around half of all cord prolapses occur when the membranes are artificially ruptured. Diagnosis is usually made when the fetal heart rate becomes abnormal and the cord is palpable vaginally or visible beyond the introitus. Cord prolapse is an obstetric emergency that requires immediate management. The presenting part of the fetus may be pushed back into the uterus to avoid compression, and the cord should be kept warm and moist to prevent vasospasm. The patient may be asked to go on all fours or assume the left lateral position until preparations for an immediate caesarian section have been carried out. Tocolytics may be used to reduce uterine contractions, and retrofilling the bladder with saline can help elevate the presenting part. Although caesarian section is the usual first-line method of delivery, an instrumental vaginal delivery may be possible if the cervix is fully dilated and the head is low.

In conclusion, umbilical cord prolapse is a rare but serious complication that requires prompt recognition and management. Understanding the risk factors and appropriate interventions can help reduce the incidence of fetal mortality associated with this condition.

Folic Acid Supplementation in Pregnancy

Explanation: Folic acid supplementation is recommended for all women who are trying to conceive and during pregnancy to reduce the risk of neural tube defects and other congenital abnormalities. The recommended dose is 400 micrograms daily from the preconception period until the 12th week of gestation. However, women with certain high-risk factors, such as diabetes, a family history of neural tube defects, or obesity, are advised to take a higher dose of 5 mg daily from the preconception period until the 12th week of gestation. It is important to continue folic acid supplementation until the end of the first trimester to ensure proper formation of the brain and other major organs in the body. Side-effects of folic acid treatment may include abdominal distension, reduced appetite, nausea, and exacerbation of pernicious anaemia.