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GOSH > Complications of pregnancy - intrapartum and post partum > Flashcards

Complications of pregnancy - intrapartum and post partum Flashcards

1
Q

In intrahepatic cholestasis of pregnancy, why is labour induced at 37-38 weeks?

A

There is an increased risk of stilbirth

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2
Q

When should the COCP be started again after pregnancy if the Mum is a) planning to breast feed and b) not planning to breastfeed

A

a) 6weeks
b) 3 weeks
nb that COCP is contraindicated until 21 days postpartum due to increased VTE risk

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3
Q

In post partum haemorrhage, if more than 500ml of blood is lost what is the next step in management?

A

Compress the uterus and catheterise the patient because the most common cause of PPH is uterus atony

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4
Q

At what time, post partum, is contraception first required?

A

Post-partum, women only require contraception 21 days from giving birth

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5
Q

For women with Group B streptococcus infection in pregnancy, which antibiotic is given in labour and why?

A

Benzylpenicillin.
Group B streptococcus is a Gram-positive organism which is typically susceptible to benzylpenicillin.

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6
Q

Why is Aspirin avoided in breastfeeding?

A

There’s a hypothetical risk of Reye’s syndrome.

This condition is defined as an acute encephalopathy with hepatic dysfunction stemming from mitochondrial damage and it has been associated with children under 16 years old being exposed to aspirin.

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7
Q

(MNEMONIC, ABRUPTION) What are the risk factors for placental abruption?

A

A for Abruption previously;
B for Blood pressure (i.e. hypertension or pre-eclampsia);
R for Ruptured membranes, either premature or prolonged;
U for Uterine injury (i.e. trauma to the abdomen);
P for Polyhydramnios;
T for Twins or multiple gestation;
I for Infection in the uterus, especially chorioamnionitis;
O for Older age (i.e. aged over 35 years old);
N for Narcotic use (i.e. cocaine and amphetamines, as well as smoking)

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8
Q

What are HIGH risk factors for pre-eclampsia? (5)

A
  1. Hypertensive disease in a previous pregnancy
  2. Chronic kidney disease
  3. Autoimmune disease, such as SLE or anti-phospholipid syndrome
  4. Type 1 or type 2 diabetes
  5. Chronic hypertension
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9
Q

What are moderate risk factors for pre-eclampsia? (6)

A
  1. First pregnancy
  2. 40 years or older
  3. Pregnancy interval of more than 10 years
  4. Body mass index (BMI) of 35 kg/m² or more at first visit
  5. Family history of pre-eclampsia
  6. Multiple pregnancy
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10
Q

What is the difference between a salpingotomy and a salpingectomy?

A

Salpingotomy = removal of an ectopic pregnancy whilst preserving the fallopian tube
Salpingectomy = Removal of the fallopian tube

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11
Q

What does a Bishop score of 5 or under indicate?

A

labour is unlikely to start without induction

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12
Q

What does a Bishop score of ≥ 8 usually indicate?

A

the cervix is ripe, or ‘favourable’ - there is a high chance of spontaneous labour, or response to interventions made to induce labour

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13
Q

In the induction of labour, what is vaginal prostaglandin E2 known as?

A

dinoprostone

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14
Q

In the induction of labour, what is oral prostaglandin E1 generally known as?

A

misoprostol

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15
Q

What is a “membrane sweep”?

A

insertion of a finger passing through the cervix to rotate against the wall of the uterus, to separate the chorionic membrane from the decidua

it is done prior to formal induction of labour using medications

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16
Q

If a pregnant woman is not immune to Rubella/has not had her vaccination, when should it be given?

A

MMR vaccine to be given in the post natal period.
This is because MMR is a live attenuated vaccine and therefore is not recommended during pregnancy in case of active infection leading to congenital rubella syndrome.

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17
Q

Why is a C section always indicated in placenta praevia?

A

High risk of post partum haemorrhage

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18
Q

In suspicion of premature rupture of membranes, what investigation is performed?

A

GF binding protein-1 testing or placental alpha microglobulin-1 (PAMG-1) test.

These tests identify the presence of amniotic fluid in the vaginal canal, thereby ruling out or confirming PPROM.

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19
Q

In termination of pregnancy, when is Anti-D prophylaxis given?

A

anti-D prophylaxis should be given to women who are rhesus D negative and are having an abortion after 10+0 weeks’ gestation

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20
Q

What is the 1st line investigation for PPROM

A

speculum exam
looking for pooling of amniotic fluid in the posterior vaginal vault

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21
Q

What is the best investigation for ectopic pregnancies?

A

The investigation of choice for ectopic pregnancy is a transvaginal ultrasound.

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22
Q

What are the features of a hydatidiform mole?

A
  1. vaginal bleeding
  2. uterus size greater than expected for gestational age
  3. abnormally high serum hCG
  4. ultrasound finding: ‘snow storm’ appearance of mixed echogenicity
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23
Q

When is the earliest ECV can be done in breech presentation?

A

36 weeks in nulliparous women and 37 weeks in multiparity.

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24
Q

What is amniotic fluid embolism?

A
  • Patient has a sudden collapse after a rupture of membranes
  • Caused by amniotic fluid entering the mother’s bloodstream and stimulates the reaction of chills, shivering, sweating and anxiety.
  • Supportive care - critical care unit
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25
Q

What is the most common cause of PPH?

A

Uterine atony, where there are inadequate contractions. If the uterus doesn’t contract strongly enough, the blood vessels bleed freely and haemorrhage occurs.

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26
Q

Once placenta praevia is discovered at the 20 week scan, when are rescans done?

A

32 weeks and then at 36-37 weeks to determine the mode of delivery

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27
Q

Management of a woman with known placenta praevia if she does into labour before the C section

A

Emergency CSAT 1
High risk of PPH

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28
Q

What is the management of PPROM (premature pre-term rupture of membranes)?

A
  1. Rule out chorioamnionitis (do FBC, abdominal exam and CTG to monitor the foetus)
  2. Avoid PV exam
  3. Admission for at least 48 h to observe vitals and CTG
  4. Erythromycin 250mg QDS for 10 days
  5. Betamethasone 12mg IM 2 doses 48 hours apart
  6. If LABOUR STARTS, give IV magnesium sulphate
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29
Q

If there are signs of infection in a PPROM, what is the management?

A

Delivery

30
Q

Why is Magnesium sulphate IV given in PPROM/premature labour?

A

Evidence supports magnesium sulphate (MgSO4) for women at risk of imminent birth at < 32–34 weeks to reduce the likelihood of cerebral palsy in the child.

31
Q

Management of placental abruption if the foetus is alive and there is no distress and is less than 36 weeks

A
  • Monitor closely with CTG
  • Give corticosteroids
  • Threshold to deliver is dependent on the gestation
32
Q

Management of placental abruption if the foetus is alive and there is no distress and is over 36 weeks

A

Deliver vaginally

33
Q

Management of placental abruption if there is foetal distress

A

Immediate cesarean no matter what the gestation is

34
Q

For shoulder dystocia, when performing the McRobert’s manoeuvre what position is the patient in? Why does it help?

A
  1. flexion and abduction of the maternal hips, bringing the mother’s thighs towards her abdomen
  2. rotation increases the relative anterior-posterior angle of the pelvis and often facilitates a successful delivery.
35
Q

Risk factors of shoulder dystocia

A
  • Fetal macrosomia
  • High maternal BMI
  • Diabetes Mellitus
  • Prolonged labour
36
Q

What is a first degree perineal tear?

A
  • superficial damage with no muscle involvement
  • do not require any repair
37
Q

what is a second degree perineal tear?

A

injury to the perineal muscle, but not involving the anal sphincter

require suturing on the ward by a suitably experienced midwife or clinician

38
Q

what is a third degree perineal tear?

A

injury to perineum involving the anal sphincter complex, external anal sphincter

Requires repair in theatre

39
Q

What is a fourth degree tear?

A

injury to perineum involving the anal sphincter complex (EAS and IAS) and rectal mucosa

Requires repair in theatre

40
Q

In ectopic pregnancy, when is a salpingotomy favoured over a salpingectomy?

A

It should be considered for women with risk factors for infertility such as contralateral tube damage e.g. the ectopic is in the left tube but the right tube has adhesions

41
Q

What is the main cause of retinopathy of prematurity in the new born?

A

Over oxygenation in NICU can cause retinal vessel proliferation > loss of red reflex

42
Q

What condition is the most common cause of recurrent first trimester spontaneous miscarriage?

A

Antiphospholipid syndrome

43
Q

Give 5 causes of oligohydramnios (Reduced amniotic fluid - less than 500ml at 32-36 wks)

A
  • PPROM
  • Bilateral renal agenesis
  • Intrauterine growth restriction
  • Post term gestation
  • Pre-eclampsia
44
Q

What is the biggest risk factor for Placenta accreta and why?

A

Previous C-sections.
Scarring can cause abnormal adherence of the placenta to the myometrium.

45
Q

What is the medical management of cholestasis of pregnancy?

A

Ursodeoxycholic acid, antihistamines and emollients.

46
Q

How often should blood glucose be tested in pregnancy for patients with already existing type 1 diabetes?

A
  • Daily fasting
  • Pre meal
  • 1 hour post meal
  • Bed time test
47
Q

What are the main risk factors for gestational diabetes?

A
  1. BMI over 30
  2. Previous macrosomic baby (over 4.5kg)
  3. Previous gestational diabetes
  4. First degree family hx of diabetes
48
Q

When should an OGTT be performed in pregnancy?

A

as soon as possible after booking appointment and at 24-28 weeks if the first test is normal

49
Q

What is the diagnostic criteria for gestational diabetes?

A

gestational diabetes is diagnosed if either:

fasting glucose is >= 5.6 mmol/L

2-hour glucose is >= 7.8 mmol/L

50
Q

General management advise for mothers with gestational diabetes

A
  • Diet and exercise (including eating foods with a low glycaemic index)
  • If glucose level is still over 7mmol/l, introduce metformin and if this is still not managed, add insulin.
51
Q

What is the most concerning finding on cardiovascular examination of a pregnant patient?

A

Pulmonary oedema - fourth most common cause of maternal morbidity and a frequent cause of ITU admission during pregnancy.

52
Q

Why is a third heart sound and an ejection systolic murmur a common finding in pregnancy?

A

The increased cardiac output and volume increase in pregnancy

53
Q

What is the management of post-partum haemorrhage? (INITIAL, MECHANICAL AND MEDICAL)

A

Initial: A-E

  • Alert seniors immediately*
    lie woman flat
    2 peripheral cannulae 14G
    Bloods - group and save
    Commence warmed crystalloid infusion

Mechanical:

Palpate the fundus and massage the uterus to stimulate contractions
Catheterisation

Medical:

IV oxytocin: slow IV injection followed by an IV infusion
Ergometrine slow IV or IM (unless there is a history of hypertension)
Carboprost IM (unless there is a history of asthma)
Misoprostol sublingual

54
Q

When does secondary PPH occur? What is it commonly caused by?

A

between 24 hours - 12 weeks post partum

retained placental tissue or endometritis.

55
Q

What is the triad of chorioamnionitis?

A

maternal pyrexia, maternal tachycardia, and fetal tachycardia

56
Q

Raised Alpha Feto-protein indicates

A
  1. Neural tube defects (meningocele, myelomeningocele and anencephaly)
  2. Abdominal wall defects (omphalocele and gastroschisis)
  3. Multiple pregnancy
57
Q

Decreased alpha feto-protein indicates

A
  1. Down’s syndrome
  2. Trisomy 18
  3. Maternal diabetes mellitus
58
Q

What is the diagnostic criteria for Hyperemesis gravidarum?

A
  1. 5% pre-pregnancy weight loss
  2. dehydration
  3. electrolyte imbalance
59
Q

Management of umbilical cord prolapse

A
  1. If the cord is past the level of the introitus = minimal handling and it should be kept warm and moist to avoid vasospasm.
  2. Patient should be on ‘all fours’ until preparations for an immediate caesarian section have been carried out
  3. Tocolytics to reduce uterine contraction
  4. 500-700ml of saline retrofilling the bladder
60
Q

If there are reduced foetal movements past 28wk gestation (3 steps)

A
  1. handheld Doppler should be used to confirm fetal heartbeat.
  2. If no fetal heartbeat detectable, immediate ultrasound should be offered.
  3. If fetal heartbeat present, CTG should be used for at least 20 minutes to monitor fetal heart rate which can assist in excluding fetal compromise.
61
Q

If there are reduced foetal movements between 24 and 28 weeks gestation, what is done?

A

Handheld Doppler should be used to confirm presence of fetal heartbeat.

62
Q

If below 24 weeks gestation, and fetal movements have previously been felt, what is done?

A

Handheld Doppler should be used to confirm presence of fetal heartbeat.

63
Q

What happens if no foetal movements have been felt by 24 weeks gestation?

A

Referral should be made to a maternal fetal medicine unit.

64
Q

Which drug is given for Pre-eclampsia when the patient has severe asthma?

A

Nifedipine, as Labetalol is a beta blocker and thus is contra-indicated

65
Q

What is the definition of primary post partum haemorrhage?

A

The loss of 500ml or more form the genital tract within 24 hours of a vaginal delivery

66
Q

How should you counsel this woman on the risks of ondansetron use in pregnancy?

A

Ondansetron during pregnancy is associated with a small increased risk of cleft palate/lip if used in the first trimester

67
Q

Pre-existing hypertension diagnostic criteria and management

A

A history of hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation.

No proteinuria, no oedema

If taking ACEi or ARB, this needs to be changed to labetalol (or nifedipine)

68
Q

Pregnancy-induced hypertension diagnostic criteria and management

A

Hypertension (as defined above) occurring in the second half of pregnancy (i.e. after 20 weeks)

No proteinuria, no oedema

Typically resolves after one month of delivery

69
Q

Diagnostic criteria of Pre-eclampsia

A

Pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours)

Oedema may occur but is now less commonly used as a criteria

70
Q

What is done if a patient with hypothyroidism becomes pregnant?

A

NICE) guidelines recommend increasing the dose of levothyroxine by 25–50 μg and referral to an endocrinologist at diagnosis of pregnancy

GOSH (17 decks)

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