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prep for phase 3a > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

Ectopic pregnancy

A

Pregnancy implanted outside uterus

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2
Q

Most common site ectopic pregnancy

A

Fallopian tube

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3
Q

Sites of ectopic pregnancy

A

Fallopian tube, entrance to the fallopian tube, ovary, cervix, abdomen

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4
Q

RF ectopic pregnancy

A

SO TOPIC

Smoking
Older age
Tubal ligation
Ovulation induction (fertility treatment)
Previous ectopic pregnancy
Previous PID
Intrauterine coils
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5
Q

Ectopic pregnancy presentation (5) (3)

A 
Presents 6-8 weeks
Vaginal bleeding (dark/fresh)
Constant lower abdominal pain in LIF/RIF
Missed period
Cervical motion tenderness (pain when moving the cervix during bimanual examination)

Possible dizziness, syncope
Shoulder tip pain (peritonitis)
Painful defaecation/urination

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6
Q

Ectopic pregnancy investigations

A

Uring B-hCG: +ve

TVUS (empty uterus, mass i.e. blob,bagel,tubal rign sign)

Serum hCG (rise of >63% intrauterine, rise of <63% ectopic, fall of <50% miscarriage)

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7
Q

Ectopic pregnancy management

A

Expectant management (await natural termination)

Medical management (IM methotrexate)

Surgical management: Laparoscopic salpingectopmy/ salpingotomy ALWAYS GIVE anti-D prophylaxis

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8
Q

Criteria for expectant management EP

A 
Ectopic is unruptured
Adnexal mass <35mm
No visible heart beat 
No significant pain
HCG levels <1500 IU/ L
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9
Q

Criteria for medical management EP

A

Same as expectant but HCG levels must be <5000 IU/L : and confirmed absence of intrauterine pregnancy on US

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10
Q

Criteria for Surgical management EP

A

Pain
Adnexal mass >35mm
Visible heart beat
HCG levels >5000 IU/ L

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11
Q

Methotrexate S/E

A

Vaginal bleeding
Nausea/Vomiting
Abdominal pain
Stomatitis (inflammation of mouth)

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12
Q

Miscarriage

A

Spontaneous termination of pregnancy. Early miscarriage <12 weeks, late = 12-24 weeks

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13
Q

Missed miscarriage

A

Foetus dead but no symptoms

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14
Q

Threatened miscarriage

A

Vaginal bleeding with closed cervix, foetus alive

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15
Q

Inevitable miscarriage

A

Vaginal bleeding, open cervix

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16
Q

Incomplete miscarriage

A

Retained products of conception after miscarriage

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17
Q

Complete miscarriage

A

full miscarriage, no retained products

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18
Q

anembryonic pregnancy

A

gestational sac present but contains no embryo

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19
Q

RF miscarriage

A

SAD BURTH

SLE
Age
Diabetes
BV
Uterine/Cervical abnormalities (fibroids)
Thrombophilia
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20
Q

Miscarriage investigations

A

Serial serum bHCG (to show falling levels)
TVUS (assess mean gestational sac diameter, fetal heartbeat, crown rump length and pole)
Bloods: check anaemia and if Rh-ve

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21
Q

Miscarriage management

A

Expectant management (do nothing and wait spontaneous miscarriage)

Medical management (misoprostol)

Surgical management (manual vacuum aspiration/electric vacuum aspiration)

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22
Q

Misoprostol S/E

A

Heavier bleeding
Pain
Vomiting
Diarrhoea

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23
Q

Incomplete miscarriage management

A

Evacuation of retained products of conception

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24
Q

Recurrent miscarriage

A

> /= 3 consecutive miscarriages

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25
Q

Causes recurrent miscarriage (6)

A 
Idiopathic
Antiphospholipid syndrome
Hereditary thrombophilias
Uterine abnormalities
Genetic factors
(other diseases diabetes, thyroid disease, SLE)
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26
Q

Recurrent miscarriage investigations

A 
Antiphospholipid antibodies
Testing for hereditary thrombophilias
Pelvic ultrasound
Genetic testing of products of conception
Genetic testing on parents
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27
Q

Treatment recurrent miscarriage

A

none but possibly vaginal progesterone pessaries

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28
Q

What are the medical abortion options

A

Mifepristone (anti-progesterone)
Misoprostol (prostaglandin analogue)

Also anti-D-prophylaxis

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29
Q

What are the surgical options abortion

A

Cervical dilatation and suction of contents (usually up to 14 weeks) vs Cervical dilatation and evacuation using forceps (between 14 and 24 weeks)

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30
Q

Potential cause of hyperemesis gravidarum

A

HCG from placenta

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31
Q

Hyperemesis Gravidarum DDx

A

Morning sickness
Reflux esophagitis
Other obstetric causes: pre-eclampsia, fatty liver of pregnancy
Non-obstetric diseases: Gastroenteritis, appendicitis, raised ICP

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32
Q

Hyperemesis Gravidarum investigations

A

urinalysis (increased ketones, exclude UTI)
FBC: exclude infection
U+E (increased urea, decreased K+ and Na+)
LFTs: exclude liver/pancreatic cause

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33
Q

Hyperemesis Gravidarum management

A

Antiemetics (prochlorperazine, cyclizine)

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34
Q

Hyperemesis gravidarum cause for admission

A

Unable to tolerate oral antiemetics
More than 5% weight loss compared with pre-pregnancy
Ketones present in urine on dipstick

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35
Q

Molar pregnancy?

A

When a hydatidiform mole, tumour grows inside the uterus

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36
Q

Molar pregnancy diagnosis

A

Ultrasound (snowstorm appearance)

Confirmed with histology of mole after evacuation

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37
Q

Molar pregnancy management

A

Evacuation of uterus

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38
Q

SGA

A

Foetus that measures below 10th centile for their gestational age

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39
Q

SGA measurements used

A

EFW (weight), AC (abdominal circumference)

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40
Q

Severe SGA?

A

foetus below 3rd centile

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41
Q

Low birth weight?

A

Birth weight less than 2500g

42
Q

Causes of SGA

A

constitutionally small

IUGR (Intrauterine growth restriction)

43
Q

IUGR split into 2 categories

A

Placenta mediated growth restriction

Non placenta mediated growth restriction

44
Q

Placenta mediated growth restriction (6)

A 
Idiopathic
Pre-eclampsia
Maternal smoking, alcohol
Anaemia
Malnutrition
Infection
45
Q

Non-placenta mediated growth restriction

A

Genetic abnormalities
Structural abnormalities
Foetal infection
errors of metabolism

46
Q

Complications of SGA

A

Foetal death/still birth
Birth asphyxia
Neonatal hypothermia
Neonatal hypoglycaemia

47
Q

SGA management and investigations

A 
Critical management: 
Identify those at risk
Give aspirin to those with pre-eclampsia
Treat modifiable risk factors (smoking)
Serial growth scans to monitor
Early delivery where growth is static (corticosteroids given)

To identify those at risk:
Blood pressure and dipstick (pre-eclampsia)
Uterine artery doppler scanning
Detailed fetal anatomy scan by fetal medicine
Karyotype from chromosomal abnormalities
Test for infections (toxoplasmosis, CMV, syphilis, malaria)

48
Q

LGA

A

EFW above 90th centile/ weight more than 4.5kg

49
Q

Causes of macrosomia

A 
Constitutional
Maternal diabetes
Previous macrosomia
Maternal obesity
Overdue
50
Q

Risks of LGA (4) (4)

A

Soulder dystocia
Failure to progress
Perineal tears
Postpartum haemorrhage

Birth injury (Erbs palsy, clavicular fracture, foetal distress, hypoxia)
Neonatal hypoglycaemia
Obesity in childhood and later life
T2DM in adulthood

51
Q

LGA investigations

A

Ultrasound to exclude polyhydramnios and estimate foetal weight
OGTT for gestational diabetes

52
Q

Pre-eclampsia

A

New high blood pressure in pregnancy with end organ dysfunction, notably proteinuria

53
Q

When does pre-eclampsia occur?

A

After 20 weeks gestation, when the spiral arteries of the placenta form abnormally leading to high vascular resistance

54
Q

Features of Pre-eclampsia

A

HTN
Proteinuria
Oedema

55
Q

Eclampsia?

A

Seizures as a result of pre-eclampsia

56
Q

Pregnancy induced HTN/Gestational HTN

A

HTN after 20 weeks gestation

57
Q

Pre-eclampsia pathophysiology

A

When the blastocyst implants on the endometrium, the outermost layer i.e. synctiotrophoblast grows into the endometrium.

Trophoblast invasion of endometrium sends signals to the spiral arteries, reducing vascular resistance, making them more fragile.

The blood flow to these arteries increase, they breakdown, and leave pools of blood (lacunae)

When the process of forming lacunae is inadequate, the woman develops pre-eclampsia

58
Q

Pre-eclampsia RF

A 
Pre-existing HTN
Previous HTN in pregnancy
Existing autoimmune conditions (SLE)
Diabetes
CKD

Nulliparity
Multiple pregnancy
>40 yrs

59
Q

Pre-eclampsia presentation (7)

A 
Headache
Visual disturbance/blurriness
Nausea/ vomiting
Upper abdominal/epigastric pain (liver)
Oedema
Reduced urine output
Brisk reflexes
60
Q

Diagnosis pre-eclampsia

A

Systolic >140mmHg
Diastolic <90mmHg

PLUS one of proteinuria, organ dysfunction, placental dysfunction

61
Q

Criteria for proteinuria

A

Urine protein: creatine ration (>30mg/mmol)

Urine albumin: creatine ratio (>8mg/mmol)

62
Q

Pre-eclampsia management

A

Aspirin used as prophylaxis against development (given 12 weeks until birth)

First management
Labetalol (first line)
Nifedipine (second line)
Methyldopa (third line, needs to be stopped within 2 days of birth)

Second management
Planned early birth may be necessary to avoid complications/if HTN not control. Corticosteroids given.

63
Q

Eclampsia management

A

IV magnesium suplhate

64
Q

HELLP syndrome

A

Combination of features that occurs as a complication of pre-eclampsia and eclampsia

Haemolysis
Elevated Liver enzymes
Low platelets

65
Q

Gestational diabetes

A

Diabetes triggered by pregnancy. Caused by reduced insulin during pregnancy and resolves after birth.

66
Q

Most significant complication for Gestational Diabetes

A

LGA

67
Q

Risk factors for GD

A 
Previous GD
Previous macrosomia
BMI >30
Ethnic origin (black,asian, middle eastern)
FHx
68
Q

When is GD screened and how

A

OGTT at 24-28 weeks

69
Q

OGTT results for GD

A

Fasting: >5.6mmol/L

At 2 hrs: >7.8mmol/L

70
Q

GD management

A

Fasting glucose <7mmol/L - diet and exercise 1-2 weeks, followed by metformin, then insulin

Fasting glucose >7mmol/L - insulin +/- metformin

Fasting glucose <6mmol/L plus macrosomia - insulin +/- metformin

71
Q

Obstetric cholestasis

A

intrahepatic cholestasis of pregnancy, characterised by reduced outflow of bile acids from liver

72
Q

Obstetric cholestasis presentation

A 
Pruritus (mainly palms and soles)
Fatigue
Dark urine
Pale, greasy stools
Jaundice
73
Q

Obstetric cholestasis DDx

A

Gallstones
Acute fatty liver
Autoimmune hepatitis
Viral hepatitis

74
Q

Obstetric cholestasis investigations

A

LFTs (raised ALT, AST, GGT)

Raised bile acids

75
Q

OC management

A

Ursodeoxycholic acid

Emollients
Antihistamines (helps sleeping not itching)

76
Q

Placenta praevia

A

Where placenta is attached in the lower portion of the uterus, lower than the presenting part of the fetus.

77
Q

Placenta praevia RF

A 
Previous C-sections
Previous PP
Older maternal age
Maternal smoking
Fibroids
IVF
78
Q

Presentation PP

A

Painless vaginal bleeding

Usually late around 36 weeks

79
Q

PP management

A

For those diagnosed at 20 weeks, TVUS scan at 32 weeks and 36 if still present

Planned delivery (between 36-37) , corticosteroids given

80
Q

PP complication

A

Hemorrhage

81
Q

Vasa praevia

A

Condition where foetal vessels are within the foetal membranes (chorioamniotic membranes) and travel across the internal cervical os

82
Q

Vasa praevia pathophysiology

A

In vasa praevia, the foetal vessels are exposed, outside the protection of the umbilical cord/placenta.

The foetal vessels travel through the chorioamniotic membranes and pass into internal cervical os.

These exposed vessels are prone to bleeding (especially during birth/labour) and lead to foetal blood loss and death

83
Q

VP presentation

A

Antepartum haemorrhage

84
Q

VP investigation

A

Ultrasound (not reliable)

Detected by vaginal examination during labour (pulsating vessels seen in membranes through dilated cervix)

During labour (dark-red bleeding occur through rupture of the membranes)

85
Q

VP management

A

Corticosteroids given from 32 weeks

Elective C-section 34-36 weeks

86
Q

Placental abruption

A

When placenta separates from the wall of the uterus during pregnancy.

87
Q

RF PA

A 
Pre-eclampsia
Bleeding early in pregnancy
Trauma (domestic violence)
Multiple pregnancy
Foetal growth restriction
Multigravida
older age
Smoking
Cocaine/ amphetamine
88
Q

PA presentation

A 
Sudden continuous abdominal pain
Vaginal bleeding
Shock
Abnormalities on CTG
Woody abdomen on palpation *suggestive of large haemorrhage
89
Q

Severity of antepartum haemorrhage

A

Spotting: spots of blood noticed on underwear
Minor: less than 50ml
Major: 50-1000ml
Massive: > 1000ml/ signs of shock

90
Q

Massive haemmorhage management

A

Urgent involvement of senior obstetrician, midwife and anaesthetist
2x grey cannula
Bloods include FBC, UE, LFT, coagulation studies
Crossmatch 4 units of blood
Fluid and blood resuscitation
CTG monitoring of foetus

91
Q

PA management

A

Antenatal steroids between 24-34+6 weeks
Rhesus-D negative
Emergency C-section

92
Q

Placenta accreta

A

Condition when placenta implants deeper, through and past the endometrium, making it difficult to separate the placenta after delivery of baby.

93
Q

Placenta accreta pathophysiology

A

Usually placenta attaches to the endometrium. With placenta accreta, placenta embeds past the endometrium, into the myometrium and beyond.

This may happen due to a defect in the endometrium. Imperfections may occur due to previous uterine surgery, such as C-section/Cutterage procedure

94
Q

Placenta accreta RF (5)

A 
Previous endometrial cutterage 
Previous C-section
Multigravida
Increased maternal age
Low-lying placenta/placenta praevia
95
Q

Placenta accreta presentation

A

Antepartum haemorrhage

96
Q

Placenta accreta investigations

A

Ultrasound scans

MRI scans used to assess depth and width of invasion

97
Q

Placenta accreta management

A

35-36+6 week delivery

Steroids

98
Q

Breech presentation

A

When the presenting part of the foetus is the legs and bottom

99
Q

Types of breech

A

Complete breech
Incomplete breech
Extended breech
Footling breech

100
Q

Breech presentation management

A

ECV at 37 weeks

Where ECV fails give choice of vaginal delivery vs elective C-section

prep for phase 3a (6 decks)

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