Obstetrics Flashcards
Surgical planning considerations for placenta accreta
Accreta therefore highly likely to require caesarean hysterectomy
Needs consent for CS hysterectomy - risks of significant bleeding needing transfusion, infection, injury to urinary tract, bowels,
GA, midline incision (and blood products) Experienced surgeon Involvement Gyn Onc (and urology, maybe vasc or int radiology), consider pre-op iliac balloons and ureteric stents 4-6U blood xs matched Anaesthetic review, 2 experienced anaes in OT At least 2 large bore IV, consider central line Blood in OT at commencement
How do you manage a suspected rectus sheath dehiscence after caesarean?
How do you manage suspected preterm labour?
Assess:
* Symptoms
* Obstetric history ?RFs
* Confirm gestation and pregnancy care to date
* Observations
* Abdo palpation - size, fetal lie and presentation (verify on USS)
* Speculum - cervix, liquor pooling
* VE if cervix open and in labour
Counsel:
* PTL is common, in the rearly stages it maybe able to deferred with medications but difficult to put off entirely
* Risk of fetal distress, infection, NICU admission, LBW, respiratory distress, jaundice, hypoglycaemia and hypothermia, perinatal mortality
* Baby likely to need to care for in NICU (depends on gestation) afterwards, expect duration of stay to be approximately until baby’s due date
* Recurrence risk
Manage:
* MDT - obstetrics, neonates (consultation), anaesthetics, MW staff, social work
* Transfer to appropriate centre for gestation
* IV access
* CTG
* IM corticosteroids (if <35weeks)
* IV MgSO4 (if <30weeks)
* PO nifedipine (if no bleeding and not established labour)
* Monitor for choprioamnionitis
* Paeds at delivery, aim delayed cord clamping, may need NeoHelp bag if extremely premature
* Take paired umbilical cord gasses
* Send placenta
* Ensure breastfeeding support
* Contraception
* Debrief re future recurrence - modify RFs, cervical length surveillance from 16weeks, consider vaginal progesterone or cerclage
Multifibroid uterus in pregnancy - how do you manage and counsel?
Risks, antenatal management
Risks:
* Red degeration
* PTB
* IUGR
* Malpresentation
* Labour dystocia
* Need for CS - may need to be upper segment
* PPH
Management:
* Growth USS from 28weeks
* Delivery plan once know presentation and location of fetal head if lower segment
* Hb, Fe optimisation
* If VB - active 3rd stage, have blood available, mark fundal height
* If CS - have blood available, USS prior, aim for lower segment but incise away from fibroid, document location of incision. Usually not for myomectomy. Counsel re higher risk of hysterectomy.
A woman presents at 22+0 weeks with confirmed SROM, fetal presentation is breech, there is a large lower segment fibroid. How do you proceed?
Counsel with MDT - obstetric, neonates (depends on unit and agreed viability).
Transfer to appropriate centre.
Options - continue, TOP
Counsel re risks of anhydramnios (pulmonary hypoplasia, limb contractures), perinatal mortality, infection, prematurity
Admit for monitoring of infection, labour
Take bloods and vaginal swabs - CBC, CRP
Consider steroids, MgSO4 if delivery imminent
ABx to be considered once viable
No evidence for amnioinfusion
Discuss delivery controversial - if not expecting to be viable or termination would aim vaginal. If expecting to rescuscitate then careful discussion re vaginal vs CS (classical)
Document agreed care plan
PPROM 22weeks, large fibroid, fully steroided at 24weeks
The same woman presents at 25+0 after PPROM at 22weeks with offensive liquor and fevers, fetal presentation is breech. How do you proceed?
Communicate to obs SMO, neonates, midwifery team, anaesthetics - chorioamnionitis needing preterm delivery by classical CS
2x large bore IV lines
CBC, Cr, LFTs, coags, lactate, cultures, G&H
Xmatch 4units
Cultures - HVS, urine
Triple ABx therapy (or as per guidelines)
DW anaesthetics re spinal or GA given sepsis
Consent for classical CS - impact on future pregnancy, higher risk of infection, bleeding, need for hysterectomy
Vaccination recommendations during pregnancy:
- Influenza:
- Recommended any time.
- Why: increased risk of maternal ICU admission and mortality. Miscarriage, IUGR, PTB, perinatal death. Passive immunity for baby up to 6 months.
- Pertussis:
- Recommended from 28 weeks
- Why: passive immunity transferred to baby to provide protection
- COVID-19 vaccination:
- Any time during pregnancy
- Why: 5 x ICU, 22 x maternal death, IUGR, PTB, PET, VTE
- Not safe in pregnancy:
- Live attenuated vaccines: rubella, VZV. Avoid conception for 28 days following vaccination.
You are called to review a woman who has had a caesarean 4hours ago who is bleeding heavily vaginally. How do you proceed?
Simultaneous - assess, arrest, resuscitate, communicate
- Drs ABCs
- Help from MDT - senior obs, midwives, anaesthetics, haemtology, OT
- Review operation note
- Assess abdomen for peritonism, expose wound, fundal height and tone, vagina and perineum
- Weigh loss if possible and keep running total
- Ensure adequate IV access
- Take bloods - FBC, renal, electrolytes, coags, G&H if not valid. Utilise TEG if concern re coagulopathy
- Give warmed IVFs
- Insert IDUC, fluid balance
- Cross match 4units RBCs, send when ready and prepare to activate MTP
- Give ecbolics - IV oxytocin, new infusion, syntometrine IM, carboprost, misoprostol
- 1g IV TXA
- If not improving transfer to OT - EUA, Bakiri balloon +/- laparotomy, uterine artery ligation, internal illiac ligation, hysterectomy
- Utilise cell salvage if available
- Consider interventional radiology if available and established pathway in centre
- Post op cares - HDU/ICU, documentation, VTE prophylaxis, breastfeeding support, contraception, debrief (early and delayed), monitor for signs of Sheehan’s syndrome
How do you consel about pregnancy after a classical uterine incision?
- Not suitable for VBAC - risk of rupture ~4%
- Recommend elective caesarean section, prelabour
- Pregnancy interval minimum 12-18months - recommend LARC
- Future pregnancy should document classical incision (higher risk of accreta)
- Review indication for early/classical incision and its risk of recurrence e.g. spont PTL -> cervical length monitoring, PET -> APLS screen, aspirin
- VTE prophylaxis
- Breastfeeding support
- MH screen
- PN debrief, clear documentation
Routine pregnancy care
- Booking bloods; FBC, HbA1c, G&S, serology for rubella syphilis Hep B/C and HIV.
- Urince culture
- Offer to perform swabs and smear now.
- Discuss vaccinations: COVID 19, pertussis, influenza. (Rubella PP if not immune)
- Varicella serology if unsure of immunity
- Prescribe folic acid and iodine
- Gestational weight gain, diet and exercise
- Infection prevention - food safety (toxo, listera), avoid children’s saliva (CMV)
- Genetic carrier screening - combined or stepwise
- Aneuploidy screening - CFTS, MSS2, NIPT
- Anatomy scan at 20 weeks
- GDM screen 24-28weeks
- FBC, Ferritin, RBC antibody screen 28weeks
- If Rh -ve - routine anti-D 28 and 34weeks, any sensitising event, cord bloods at birth
- Fundal height assessment, growth scan if concerns, innacurate or RFs
- BP and urinalysiseach check
- Sleep on side and FMs monitoring from 28weeks
- Document birth plan - location, timing, mode, other
- Contraception
- VTE risk
Large for dates DDx
- Incorrect dates
- Multiple pregnancy
- Polyhydramnios
- LGA
- GTD
- Fibroids
You see a patient in clinic who has had a previous CS. How do you proceed?
Assess:
* Review notes - indication and type of last CS, safety of VBAC
* Number of previous CS
* Maternal preference for delivery, antipicated family size
* Obstetric complications or other indications for CS
* If TOLAC - assess predictors of success
Counsel:
* TOLAC vs ElCS
* TOLAC - 70% chance of success, 1:200 risk of scar dehiscence/rupture, 1:7 severe complication if ruptures, OASI, EMCS risks >ElCS risks. Shorter recovery time if successful, more likely to have VB in future.
* ElCS - risks of bleeding, infection, injury to adjacent organs, VTE, impacts in future pregnancies (abnormal placentation, need for CS delivery), higher maternal morbidity, TTN. Lower POP, HIE.
Manage:
* TOLAC - labour in hospital, IV line, CTG monitoring, progress monitoring. Make a plan if doesn’t spontaneously labour - can still have IOL but use foleys (2x scar dehiscence risk)
* ElCS - from 39weeks. Make a plan if labour spontenously prior (10%)
* Contraception
Management of PROM
Assess:
* Obstetric history
* Duration of PROM
* Stage of labour
* GBS status
* Signs of chorio - uterine tenderness, purulent liquor, fever, tachycardia
* CTG
Counsel:
* Risk of maternal or fetal infection (chorioamnionitis), PPH, neonatal admission, GBS sepsis
* Recommend labour augmentation and IVABx to reduce risk of infection
Manage:
* Labour in hospital
* IV line in
* IV ABx for GBS prophylaxis - benzylpenicillin 1.2g loading, 0.6g Q4H until delivery. Aim 2x doses pre delivery.
* Labour augmentation - IOL if no established, oxytocin if slow progress in established labour
* Continuous CTG
* Regular maternal observations
* Analgesia
* Switch to broad spectrum if chorio - maternal tachycardia, pyrexia, fetal tachycardia, uterine tenderness, malodorous liquor
* Paediatrics at birth - PROM observations
* No need for ongoing maternal ABx but monitor for infection, low threshold for review if features of endometritis
Describe how a growth USS is undertaken
TA probe - curvilinear transducer
MSL view - presentation
FHR check
Placental assessment - location, appearance
Liquor assessment - AFI or DVP
Head - transverse view, falx in midline, CSP, thalami present. Measure BDP outer to inner bone table. Measure BPD around skull.
AC - transverse view, stomach bubble, J of portal vein, spine at 3 o’clock. Single rib border. No kidney or lungs. Measure around skinline.
FL - follow femur from pelvis, measure metaphyses.
Calculate EFW using Hadlock 2, plot on customised chart.
Anatomy check - bladder, kidneys, cardiac - 4ch, LVOT, RVOT, 3VV, Arrow view
How do you manage a concealed pregnancy?
Assess - LMP, Pregnancy symtpoms, Obs history, PMHx, Meds, Social - in particular underlying factors which may be relevant to concealed pregnancy
USS - viability, plurality, placental location, screen for major anomalies, EFW for gestation, utilise FL
Standard intrpartum cares
CTG
Postpartum - breastfeeding (support or cessation), VTE prophylaxis, contraception, MH surveillance
