General Obs Flashcards
(122 cards)
1
Q
Define antepartum haemorrhage
A
bleeding from genital tract after 24 wks gestation
2
Q
40% of antepartum haemorrhage is of UNDETERMINED ORIGIN. Name the other two COMMON causes of antepartum haemorrhage?
A
placenta praevia
placental abruption
3
Q
Name two UNCOMMON causes of antepartum haemorrhage?
A
vasa praevia
uterine rupture
4
Q
Blood vessels running in membrane in front of presenting part. May be punctured, with a foetal mortality of 60%! What is this condition called?
A
vasa praevia
have to stay as inpatient for 32 weeks!!
5
Q
What is placenta praevia?
A
low lying placenta
placenta implants in lower uterine segment
6
Q
A low lying placenta (praevia) may also be MORBIDLY ADHERENT to the uterine wall (particularly if placenta implants in previous caesarean scar). There are three grades of morbidly adherent placenta:
A
- accreta
- increta
- percreta
7
Q
Define placenta accreta
A
chorionic villi attach to myometrium (rather than just decidua basalis)
8
Q
Define placenta increta
A
chorionic villi invade INTO myometrium
9
Q
Define placenta percreta
A
chorionic villi invade THROUGH myometrium (can go through to bladder/bowel!)
10
Q
What is the placenta usually meant to attach to ?
A
Usually restricted to the decidua basalis. (shouldn’t attach to myometrium)
11
Q
What is the difference between minor and major placenta praevia
A
major - covering internal cervical os
minor - near os but not covering
12
Q
If an antepartum haemorrhage is PAINLESS, what is it likely to be?
A
Placenta praevia
13
Q
If an antepartum haemorrhage is dark painful bleeding, what is it likely to be?
A
Placental abruption
14
Q
Why don’t you do digital examination in placenta praevia?
A
Could put your finger through placenta!
Although transvaginal ultrasound is considered safe - more accurate than abdominal.
15
Q
What are the symptoms/signs of placenta praevia?
A
painless antepartum haemorrhage abnormal lie (e.g. transverse)
16
Q
Pregnant woman at 33 weeks presents with painless antepartum haemorrhage and transverse. Ultrasound confirms placenta praevia. You also do cross-match because she’s bleeding. What management do you do now?
A
- admit her, she’s bleeding
- treat shock, blood transfusion if necessary
- give steroids, she’s <34wks
- ANTI-D
CAESAREAN AT 36-38 WEEKS
17
Q
Confirmed placenta praevia. When does she need a Caesarean?
A
at 36-38 weeks
18
Q
What is the UK maternal mortality rate?
A
8.5 per 100,000
19
Q
Placenta praevia picked up at 20 wk routine scan. This might have moved by the time for delivery. When would you rescan to check?
A
34 wks
20
Q
Define placental abruption
A
separation of the placenta from the uterine wall
21
Q
Name some RFs for placental abruption
A
pre-eclampsia
smoking
IUGR
previous abruption!
= RFs for placental abruption
22
Q
What is the difference between REVEALED placental abruption and CONCEALED placental abruption?
A
revealed = pain + bleeding concealed = just pain
23
Q
A woman at 28 weeks presents with dark painful antepartum haemorrhage and a woody hard abdomen. Likely diagnosis?
A
Placental abruption (revealed)
24
Q
If placental abruption is minor, you use conservative management and do serial ultrasounds. If it is major….
A
Blood transfusion. Deliver
via Caesarean if foetal distress
if foetal death - induce labour (coagulopathy likely)
25
In antepartum haemorrhage, if there is maternal shock out of keeping with visible blood loss, what is the likely diagnosis?
Placental abruption
26
What are the four Ts which are the causes primary PPH?
Tissue
Tone
Tear
Thrombin
27
How does 'Tissue' cause PPH?
retained placenta (10%)
28
How does 'Tone' cause PPH?
uterus fails to contract (70%)
29
How does 'Tear' cause PPH?
bleed from episiotomy / peroneal / high vaginal tear (20%)
30
How does 'Thrombin' cause PPH?
coagulopathy (<1%) e.g. clotting disorder, anti-coags, DIC
31
Define PRIMARY post-partum haemorrhage
loss of >500ml within 24 hours of delivery
| or >100ml if after Caesarean
32
What is the difference between MINOR and MAJOR post-partum haemorrhage ?
```
minor = <1500ml, no signs of shock
major = >1500ml, signs of shock
```
33
Name some RFs for postpartum haemorrhage (there's loads)
grand multiparity,
multiple preg,
fibroids, polyhydramnios
instrumental / Caesarean delivery
prolonged labour
coagulopathy
previous PPH!
previous APH
previous Caesarean
34
How do you medically manage PPH?
```
ABC
estimate blood loss
bloods - (coag, FBC, group+save)
IV fluids + transfusion if necessary
see if placenta remnants
uterine massage --> bimanual compression
IV ergometrine / syntocinon
IV tranexamic acid
IM carboprost
```
continuing? …… GO TO THEATRE
35
If 'Tissue' is the cause of PPH, how do you treat it?
removed retained placenta manually
36
If 'Tone' is the cause of PPH, how do you treat it?
IV ergometrin / IV syntocinon
… to CONTRACT uterus.
If fails: IM carboprost (prostaglandin)
37
Give some examples of SURGICAL management of PPH?
B-lynch suture
Ligation of uterine arteries or internal iliac arteries
Rusch balloon
Hysterectomy :/
38
How do you estimate 500ml blood loss?
fills a kidney dish
39
How do you estimate >1500ml blood loss?
blood spilling off bed onto floor
40
What amount of blood loss is threatening in PPH?
If a woman loses more than 40% it's life threatening. (for 70kg woman this is around 2,800mls)
41
Excessive blood loss 24hrs - 6wks after delivery. What's this called?
Secondary PPH
| *** RECENTLY ITS BEEN CHANGED TO 12WKS AFTER!
42
What causes secondary PPH?
endometritis
retained placental tissue
rare - gestational trophoblastic disease
43
What do you find about the uterus and the internal os on a woman with secondary PPH?
uterus = enlarged and tender
| internal os = still open!
44
What is the treatment for secondary PPH? (which is only rarely massive bleeding - usually small amounts)
Antibiotics
Utertonics - syntocinon / syntometrine / carboprost
If continuing - ERPC
45
Investigations for secondary PPH (x3)?
1. high vaginal swab - endometritis?
2. abdo US - retained placenta?
3. bloods (fbc, u+e, group+save etc)
46
Why is ERPC risky in post partum period
uterus still soft - risk of perforation
47
What is syntometrine
oxytocin + ergometrine
48
What is carboprost?
prostaglandin F2
49
Name me some Uterotonics plz Kate
syntocinon
syntometrine
misoprostol
carboprost
(ergometrine is good for starting contractions. miso good for maintaining them)
50
What is misoprostol?
prostaglandin E1
51
What is syntocinon?
oxytocin
52
Artificial strengthening of contractions in established labour. What's this called?
Augmentation
53
Define induction
artificial initiation of labour
54
What are the three Ps as causes of failure to Progress in labour?
Power
Passenger
Passage
55
How does 'Power' cause failure to Progress in labour?
ineffective uterine contractions
56
How does 'Passenger' cause failure to Progress in labour?
malpresentation
| foetal size
57
How does 'Passage' cause failure to progress in labour?
cephalo-pelvic disproportion
58
After the latent phase (aka after 3cm dilated) usually dilate about __cm per hour. At the minimum, should dilate __ cm every two hours!
usually 1cm per hour
| minimum us 1cm every 2 hours
59
What graph tracks progress in labour?
partogram
this is according to DILATION OF CERVIX AND DESCENT OF HEAD
60
What two measures does partogram use to measure progress in labour
dilation of cervix
| descent of head
61
How often should you do a VE to assess progress in labour?
every 4 hrs
62
Which lines on a partogram help identify abnormal progress in labour
ALERT and ACTION lines
63
As well as measuring progress in labour, partogram also tracks what?
foetal wellbeing (colour of liquor, foetal HR)
medications
maternal vital signs
64
In active first stage of labour, how frequent should contractions be, how long in duration, and how strong?
4 every 10mins
lasting 1 min each
strong
65
Why is stressiness bad in labour?
adrenaline inhibits uterine contractions
change position, keep hydrated, relaxing environment
66
26 yr old primip will failure to progress in labour due to ineffective uterine contractions (trouble with Power!). Has been at 5cm dilation for past 6hrs. Admitted to labour ward. What physiological management? If doesn't work what then?
physiological:
- change position, hydrate on IV fluids, reassure, discuss pain management,
- start partogram!
if still failure to progress:
- artificial rupture of membranes
- CTG
- VEs 4hrly
- maybe start syntocinon
- may need Caesarean depending on CTG
67
a 33 yr old multip at 38 wks arrives on ward having ruptured her membranes four hours ago. Regular contractions, increasing intensity. A meconium stained liquor is noted on the pad (may be sign of foetal distress). Cervix is 3cm dilated but midwife not sure of presenting part. What is possible diagnosis?
trouble with Passenger: malpresentation.
need ULTRASOUND to see baby's position. (if breech cant do ECV anyway bc membranes ruptured).
would be instrumental or Caesarean depending on presentation
68
Why is occipito-posterior malposition a problem?
larger diameter needing to get through pelvic outlet.
69
A lady is having a really painful labour, back ache and an early desire to push. What are you thinking?
(Clue: it's a trouble with the Passenger)
occipito-posterior malposition
70
Name two rare malpresentations
face presentation
| brow presentation
71
What kind of delivery might occipto-transverse malposition need if it fails to spontaneously rotate?
Ventouse
72
Occipito-posterior malposition may need augmentation of labour. May spontaneously rotate. If not, what kind of delivery?
Kielland's forceps (they rotate the baby)
73
Malpresentations are all presentations of the foetus other than vertex presentation. Apart from breech, name three more.
Shoulder
Face
Brow
74
Why would there be cephalo-pelvic disproportion?
big foetal head or narrow pelvis!
75
Why is cephalo-pelvic disproportion higher in low-income countries?
poor nutrition - rickets, osteomalacia, poorly healed pelvic fractures
76
Apart from small pelvis / large head ,what else could block engagement and descent of head?
pelvis mass such as ovarian tumour or fibroids
--> caesarean
77
Foetal distress is usually said to mean foetal hypoxia. But what are 4 other causes of foetal distress?
1. foetal hypoxia
2. infection in labour e.g. GBS
3. meconium aspiration
4. trauma e.g. forceps, shoulder dystocia
5. foetal blood loss
78
What does meconium aspiration cause in the foetus?
chemical peritonitis
79
Long labour, use of oxytocin and epidural can be RFs for foetal hypoxia. Name 3 other acute causes of foetal hypoxia...
- placental abruption
- cord prolapse
- maternal hypotension (haemorrhage)
*pre-eclampsia and IUGR also RFs for foetal hypoxia
80
What might cause foetal blood loss leading to foetal distress?
vasa praevia (rare)
81
The management of malpresentation is dependent on what type it is. What is the management for breech?
ECV before labour
vaginal breech delivery
C section
82
Management of face malpresentation depends on where the chin is! Tell me more...
If the chin is posterior (mento-posterior), then need C section!
If the chin in anterior (mento-anterior), then normal labour poss but still risk of C section
83
What is the foetal lie? Name the three types of foetal lie.
"The relationship between the long axis of the fetus and the mother."
Longitudinal, transverse or oblique
84
What is the foetal presentation?
"The fetal part that first enters the maternal pelvis".
| Cephalic vertex presentation is most common and safest
85
What is the foetal position? Name the three types.
"The position of the fetal head as it exits the birth canal."
Occipito-anterior
Occipito-posterior
Occipito-transverse
86
When is the ideal time to attempt ECV?
after 37wks
87
The manipulation of the fetus to a cephalic presentation through the maternal abdomen. What's this?
ECV (external cephalic version)
88
ECV is contraindicated in women who've had a previous C section. True or false?
True!
89
What's the success rate of ECV?
about 50%
90
Complications of ECV are rare, but include...
foetal distress
placental abruption
emergency C-section
91
What are the three types of breech presentation ?
complete (flexed)
frank (extended)
footling
92
Quite a few babies are breech earlier on in the pregnancy but then go on to switcheroo. Past how many weeks does breech presentation become significant?
past 34 wks
| only 3% breech at term
93
Name 2 FOETAL risk factors for breech.
polyhydramnios (swimming around)
| prematurity (higher incidence earlier)
94
You feel breech on abdo ex. Where might you hear the foetal heartbeat compared to usual?
higher up
95
When the lie changes day to day, such as in polyhydramnios, what is this called?
unstable lie
96
A lady has ruptured membranes. You suspect breech. can you do ECV?
no, once ruptured membranes it's too late
97
You've just performed ECV and want to check you've not caused foetal distress. How?
CTG straight after ECV
98
Describe the management of breech presentation at term.
1. ECV
2. if not, elective Caesarean
3. may still choose vaginal breech birth :(
99
Which type of breech presentation is where both legs are flexed at the hips and knees?
complete (flexed)
100
Name 2 MATERNAL risk factors for breech.
pesky fibroid
multiparity
placenta praevia
101
Name 2 FOETAL risk factors for breech.
polyhydramnios
macrosomia
prematurity
102
In around 20% of cases, breech presentation is not diagnosed until labour. What might things make you suspect?
foetal distress - meconium liquor
| feel foot on VE!
103
What are the TWO main differentials for breech presentaiton.
Oblique lie
Transverse lie
(unstable lie)
104
You suspect breech. What investigation to confirm?
Ultrasound
| shows whether flexed/extended/footling
105
A lady, who's previous child was delivered via C section, presents at 37 wks with breech. You do an ultrasound which confirms this. Her membranes are intact. Do ECV?
NO - previous C section is contraindication to ECV
| as is recent APH
106
Give me 3 contraindications to ECV
ruptured membranes
previous C section
recent APH
107
When would you do C section for breech?
if ECV contradindicated / unsuccessful, or mother wants
108
Some women with breech still opt for vaginal delivery. What is the contraindication for this?
FOOTLING breech
| they get stuck with just the legs dangling
109
What is the Golden Rule when conducting a vaginal breech delivery?
"Hands Off the Breech"
dont wanna get the head trapped
110
Vaginal breech delivery: if baby doesnt deliver spontaneously, what specific manoeuvres might be requiddd?
Lovsett's manoeuvre
| Mariceau-Smellie-Veit
111
The umbilical cord drops down below the presenting part of the baby, and becomes compressed. What's this?
cord prolapse
112
What is cord prolapse?
umbilical cord drops below presenting part and gets compressed
113
What is the presenting part in cord prolapse?
the actewal cord itself
114
What is the difference between occult and overt cord prolapse?
occult - the cord is ALONGSIDE the presenting part
| overt - the cord is below the presenting part
115
Tell me a major complication of breech that has a high mortality rate.
cord prolapse
116
What is the cause of foetal death in cord prolapse?
foetal HYPOXIA.
cord get squashed.
cord gets cold causing arterial vasospasm.
117
Why does cord prolapse cause foetal hypoxia?
cord gets squashed.
| cord gets cold causing arterial vasospasm.
118
Name 3 risk factors for cord prolapse.
FOOTLING breech
unstable lie
ARM
119
Describe the management of cord prolapse, an obstetric emergency. (x4)
CALL FOR HELP!
left lateral position, manually elevate presenting part
tocolysis
EMERGENCY CAESAREAN
120
Why avoid handling cord when dealing with cord prolapse?
vasospasm
121
Give me 2 complications of breech.
cord prolapse
| birth asphyxia
122
Why give tocolysis (e.g. terbutaline) in cord prolapse?
suppress contractions
| - to take the pressure off
