Obs Flashcards
(204 cards)
1
Q
what is the booking visit?
A
the first appt with a midwife, that shoudl occur before 10 weeks
2
Q
what important things need to be discussed at a booking visit?
A
- heath and lifestyle - vitamines
- folic acid - 400mcg daily
- food hygiene
- stop smoking, alcohol and drugs and the implications of them on baby
- all antenatal screening
- perform risk assessment to know whether low, moderate or high risk pregnancy
3
Q
what clincal examination of a pregant women occurs at booking appt?
A
- BMI
- if not accessed healthcare in UK before, shld be offered a general clinic exmaination
- breast and pelvic examination not recommended (Except in FGM)
- signs of domestic violence
4
Q
what routine tests are done at booking appt?
A
- electrophoresis (for heamoglobinopathy - sickle cell and beta thalasseamia)
- FBC (anaemia)
- blood grp and red cell antibody screening (rhesus state, non rhesus antibodies)
- infection screen (syphilis, HIV, hep B, asymptomatic bacteruria)
- urinalysis (glycosuria, proteinuria, heamaturia)
5
Q
- risk factors for gestational diabetes?
A
- BMI above 30
- previosu macrosomic baby weighing above 4.5kg
- FHx of diabetes
- family origin with high prevalence of diabetes
6
Q
risk factors for pre eclampsia?
A
- age 40 or older
- nulliparity
- pregnancy interval of more than 10 yrs
- FHx or previous Hx of pre eclampsia
- BMI 30 or above
- pre existing vascular disease e.g. HTN
- pre existing renal disease
- multiple pregnancies
7
Q
hwo do you screen for pre eclampsia?
A
check BP and urinalysis at each antenatal visit
8
Q
when is screening for trisomy 13, 18 and 21 done?
A
before end of first trimester (13 weeks and 6 days)
(NT, B-hCG and PAPP-A done)
9
Q
what is the frequency of antenatal appts?
A
uncomplicated nulliparous women - 10 appts
uncomplicated parous women = 7 appts
10
Q
what should occur at each antenatal visit?
A
- BP and urine check
- from 24 wks - symphysis fundal height measured and recorded
- from 36 wks - check fetal presentation (USS needed if uncertain)
(routine antenatal CTG not required)
11
Q
what is the definition of labour?
A
progressive effacement and dilatation of the cervix in the presence of regular uterine contractions
12
Q
what is the average time of labour for a nulliparous and multiparous
A
nulliparous - 9.5 hours
multiparous - 6 hours
13
Q
what are teh stages of labour
A
stage 1 - from regular contractions to fully dilated cervix (10cm)
stage 2 - from gully dilated cervix to when baby comes out
stage 3 - when baby comes out to when paacenta is delivered
14
Q
what 3 Ps affect labor?
A
- the passage (pelvis and birth canal)
- the power (contractions)
- the passenger (baby)
15
Q
how often to contractions occur in early and advanced labour?
A
early - every 3-4 mins
advanced - every 2-3 mins
16
Q
why does an occiptoanterior position favour labour?
A
this position means the babys head circumferance is smaller coming out of the path therefore labor is shorter
17
Q
what the the 6 stages for the mechanism of labour?
A
- engagement
- flexion
- descent
- internal roation
- extension
- external rotation
18
Q
why is hydration important maternally in labour?
A
dehydration of a patient can cause diminished contractions
19
Q
why is bladder care important in labour?
A
patient needs to be frequently voiding
if have an epidural the patient needs to have an indwelling catheter
a big bladder can obstruct the baby’s delivery and also can cause bladder obstruction issues post delivery
20
Q
why is it dangerous for mother to be flat on back durign labour ?
A
if mother on her back = compression of great vessels (aorta or vena cava) = hypotension of mother and then baby = baby bradycardia
21
Q
what fetal monitoring is important in labour?
A
fetal heart rate monitoring via CTG
colour of liquor - clear, pinky, red or meconium (sign of fetal distress)
22
Q
what is a partogram?
A
way to assess progress of labour
23
Q
what is the normal progress of cervix dilatation in labour>
A
0.5-1cm per hour
24
Q
name some common problems in labour?
A
- failure to progress (delay in first or second stage)
- malpresentation/malposition
- suspected fetal compromise (fetal distress)
- vaginal birth after c section (VBAC)
- operative delivery
- shoulder dystocia
25
name some reasons why labour would be failing to progress?
- inadequate contractions
- fetal malposition/malpresentation
- cephalopelvic disproportion
- obstructed labour
- maternal exhaustion
26
do you do normal delivery or c section if the baby is in oblqieu or transverse lie
c section always
27
what are the three different breech presentations
complete
incomplete
frank
28
what complications can you have at breech vaginal delivery?
- trapped aftercoming head
- cord prolapse
- intracranial heamorrhage
- internal injuries
29
what are teh different delivery options for breech presenation?
- external cephalic version
- elective c section
- vaginal breech delivery
30
what signs show fetal compromise?
- passage of meconium
- non reassuring CTG: baseline tachy or brady, reduced baseline variability, absence of acceleration, presence of decelerations
31
what is fetal acid-base status?
result from taking a fetal scalp blood sampling (FBS) done when CTG is abnormal to check if anythign wrong with baby
32
risks of VBAC?
- emergency c section in labour
- uterine scar dehiscence/rupture 0.5%
33
when would you do a instrumental (ventouse, forceps) delivery?
1. failure to progress in 2nd stage
2. fetal distress in 2nd stage
3. maternal reasons
34
complications in instrumental delivery?
- failure
- fetal trama (cephalic haematomas, lacerations)
- maternal trauma
- postpartum heamorrhage
- urinary retention (need to empty baldder beforehand!!)
35
how do you know if a baby has a cephalic heamorrhage instead of a normal swelling from ventouse?
- cephalic heamorrhage (=horns) stops at suture lines so looks more like a bump/lump instead of a general swelling of head
36
complications of c sectino?
- heamorrhage
- infection
- bladder/bowel injury
- thromboembolic disease
- requirement for blood transfusion
- TTN
- fetal trauma
37
what aneasthia is used for c section
regional anaesthetic used:
spinal aneasthesia if elective
spinal and epidural if complicated
if emergency can 'top up' epidural or do spinal as well
38
when is an emergency c section done?
- failure to progress
- fetal distress mternal reasons
- malpresentation/malposition
- failed instrumental delivery
39
what is shoulder dystocia?
inability to deliver shoudlers after delivery of head
anterior shoulder does not enter pelvic head
40
which babies are at risk of shoulder dystocia?
- macrosomic fetus
- fetus in diabetic mother
- rotational instrumnetal delivery
- previous baby with shoulder dystocia
41
how can fetal death occur during shoulder dystocia?
babys head comes out and they start to gasp but cant expand lungs as chest wedged in birth canal so tries to get blood supply through cord
cord is compressed so can't get o2 = hypoxia and distress
42
what are the complications fo shoulder dystocia?
- fetal death
- asphyxia with resulting hypoxic damage
- birth trauma (erbs palsy, fractures bones)
- maternal trauma (soft tissue trauma, psychological)
43
what is the management of shoulder dystocia?
1. mcroberts position (push mothers legs to chest)
2. suprapubic pressure
3. other obstetric manouevres: woodscrew manouevre, put woman on all fours, zavanelli manouevre, cut pubic symphysis
44
how do you treat erbs palsy?
- physio (most are treated w physio)
- surgery
may have long term neurological issues
45
what are the methods used for prenatal diagnosis?
Hx
maternal serum screening
US
invasive procedures
46
what questions shld be asked in a Hx for prenatal diagnosis ?
maternal age
maternal disease - DM, epilepsy
previous obs Hx - previous child with genetic disorder, structural abnormality
consanguinity
parent with known balanced translocation
exposure to pregnancy drug related malformations - antiepileptics, warfarin, vitA
intrauterine infection: rubella, CMV, parvovirus, zika virus
47
what maternal blood screening is important for prenatal diagnosis?
heamoglobinopathy: thalasseamia, sickle cell diseae
VDRL screenign (syphilis)
HIV, hep B
maternal rhesus antibody
combined 1st trimester serum screening fro trisomy 21, 18 + 13
48
what screenings occur in the first and second trimester?
1st:
- fetal NT, serum screening
- combined first trimester screening
2nd:
- serum screening
- integrated screening
- 20 wk anomaly scan
49
what does the first trimester combined screenign programmes test for?
trisomy 21 (downs), 18 (edwards) and 13 (pataus)
50
how mnay US do pregannt women have?
offered 2 scans.
one in first trimester and one in second trimester (18-20 wk scan)
51
what occurs in first trimester US?
accurate dating
twin determination and chorionicity
detection of fetal abnormalities (anencephaly, large anterior abdo wall defects, cystic hygroma)
measurement of nuchal translucency
52
what occurs in second trimester US?
- check viability of fetus
- measurements (growths)
- liquor volume
- fetal anatomy
- placental location
- assessment of normal variants for aneuploidy and fetal growth
53
what invasive procedures can be done for prenatal diagnosis ?
- aminocentesis
-chorion villus sampling
- fetocide
- aspiration of fluid filled fetal cavities
- aminoreduction/aminodrainage
54
what are the indications for aminocentesis/chorion villous sampling?
1. assessment of fetal karyotype
2. molecular genetic testing
3. virology screen
55
what is aminocentesis?
performed under direct US after 15 wks gestation
15-20ml aspirated and fluid cultured and tested (FISH/PCR)
56
what is chorion villus sampling?
taken after 10wks gestation
US guided to take sample of placental tissue
57
risks of aminocentesis?
miscarriage
preterm delivery
chronic liquor leak
58
what is feticide
act of termination of fetus
59
what is the lambda sign seen on US?
it is the sign of dichorionic twins - shows two different placentas
60
what is twin to twin trasnfusion syndrome?
prenatal condition in which twins share unequal amounts of the placenta's blood supply resulting in the two fetuses growing at different rates
occurs in 5-15% of MC twins
80-100% mortality wihtout treatment
61
what is the puerperium?
time from delivery until the anatomic and physiologic changes of pregnancy have resolved - takes up to 6 wks
62
what are the 3 main physiological changes in puerperium?
1. lochia and uterine involution
2. lactation
3. menstruation and resumption of ovulation
63
what is lochia and how does it change?
lochia is the vaginal discharge you release after delivery
- bloody for 1st day
- serosanguinous for up to 7-10 days
- clear for 6 wks
64
how does the uterus change in post partum period?
at umbilicus after delviery
becomes pelvic organ by 10 days
os closed by 3 weeks
65
how does lactation occur post partum?
- oestrogen stimulates duct growth
- progesterone stimulates alveolar growth
- placental lactogen affects growth of epithelium in alveoli
- initiation of lactation is dependent on fall in oestrogen which stimualtes release of prolactin from hypothalamus
- milk ejection needs oxytocin from post pituitary
- colostrum (serosangious fluid) produced for first 3 days!
- followed by establishment of milk secretion and continued lactationd depends on baby suckling on breast
66
when does resumption of menstruation occur in non lactating women?
approx 8 wks
first ovulation approx 10 wks
(about 40% of first cycles are ovulatory)
67
when does menstruation resume in lactating women?
if for < 1 month then approx 10 wks
if breast feed after first month: average interval to first ovulation = 16 wks
68
what further visits/dicussions needs to occur post natally?
- inform GP + arrange midwife and health visitor
- anti-D if indicated
- discuss contrception
- discuss breast feeding
- perineal care and postnatal exercise
- vaginal loss/Hb check
- post natal visit at 6 weeks (dicuss problems and assess urinary/faecal incontinence)
69
what examination are important to do post natally at 6 wk check ?
- obs
- uterine size and involution
- vaginal bleedin g
- lochia/discharge
- abdo wound (if CS)
- perineum and para vaginal tissue
- breast
- lower limbs for DVT
- enquire about bladder and bowel function
70
if not breast feeding and would liek the COCP post partum when is allowed to be started?
3 weeks post partum - any earlier can cause icnreased risk of trhombosis
71
advantages of breast feedings?
- easily digested nutrients
- antibodies in colostrium
- avoid milk allergies
- good source of nutrition expect vitC, D and iron
- cannot overfeed
- lower risk of hypocalcaemia
for mother:
- improves uterine involution
- safe and cheap
- reduced risk of breast cancer
- promotes bonding with baby
72
clinical features of mastitis?
- fever
- chills
- pain
- erythema
- tender
73
Tx of mastitis?
continue breastfeeding!!
if abscess then drain
74
name some complications of the mother in the puerperium?
- puerperal pyrexia
- secondary postpartum heamorrhage
- thromboembolic disease
- mood changes, postnatal depression
- urinary or faecal incontinence
75
what is puerperal pyrexia?
temp of 38 wks or more at any point in post partum period
76
definition of primary and secondary postpartum heamorrhage
primary - in first 24hrs
seocndary - after the first 24hrs
77
what prophylactic measures are used post partum to reduce risk of thromboembolic disease?
- TED stocking
- LMWH when pt has risk factors
78
what iis treatment to psot partum urinary incontience?
- pelvic floor exercises are key!
- if not improving then referral
79
what are some common mental health disorders post partum/
anxiety
depression (including psotnatal depression)
postpartum blues
puerperal psychosis
PTSD
pre existing illness
eating disorder
80
risk factors for perinatal poor mental health?
- prior diagnosis of mental health illness
- FHx
- HX of childhood abuse and neglect
- doemstic violence
- inadequate social support
- substance misuse
- migration status, language and cultural abrriers
- unplanned/unwanted pregnancy
- pregnancy complications or traumatic birth
- fetal or neonatal loss
81
difference between postnatal blues and postnatal depression
postnatal blues- 50%, postnatal depression - 15%
postnatal blues onset withihn few days of giving birth and depression is usually 1-2 months
post natal depression - lower mood, feelings of harming baby, depressive symptomss
post natal blues - tired, irritbale, over reacting, tearful
82
Tx for postnatal depression
antidepressants
antenatal and post natal peer support groups
referrals to specialists (if mroe severe)
83
symptoms of puerperal psychosis?
- feeeling manic
- paranoia
- hallucinations/delusiosn
- severe confusion
- anxiety, irritability
- behaviour out fo character
- hard to sleep
- withdrawn
84
Tx for puerperal psychosis ?
onset usually within a few days post partum so management with MDT on mother baby unit
Tx with antipsychotics, mood stabilisers, antidepressants
CBT in recovery phase
ECT used in severe depressive psychosis
85
which mental health drugs do you have to be careful of in
- sodium valproate
- carbamazepine
- lithium
- lamotrigine
- olanzepine
- SSRI
- antimanic drugs ( require lots continuous fetal monitoring)
86
which mental health drugs do you have to be careful of in
- sodium valproate
- carbamazepine
- lithium
- lamotrigine
- olanzepine
- SSRI
- antimanic drugs ( require lots continuous fetal monitoring
87
what is neonatal withdrawl syndrome?
a group of conditions cuased when a baby withdraws from certain drugs hes exposed to in the womb before birth (e.g. when taking opioids)
88
what are teh different types of hypertensive disorders in pregnancy?
gestational (pregnancy induced) HTN
pre-eclampsia
chronic HTN
pre-eclampsia superimposed on chronic HTN
eclampsia
89
when do pregnancy inudced HTN problems occur?
after 20 wks (if spotted beforehan, the HTN is not pregnancy idnuced)
90
what is gestational inudced HTN?
diagnosis of new onset raised BP after 20/40 gestation
no proteinuria and normal blood values
25% will develop pre eclampsia
91
what is pre eclampsia?
multisystem disorder
characterised by raised BP (>140/90mmHg) and proteinuria (>300mg per 24hrs) after 20/40 gestation
92
name some maternal pre eclampsia complications
CNS - eclampsia, intracranial heamorrhage/stroke (!!!), cortical blindness
renal - renal tubular necrosis
resp - pulmonary oedema
liver - HELLP syndrome, lvier capsule heamorrhage, liver rupture
heamotological - DIC, VTE
placenta - placental abruption
93
name soem fetal complications of pre-eclampsia?
- stillbirth
- infants born small
- premature birth
94
cuases fo pre eclampsia?
- multfactorial, not completely understood
- genetic correlation
- poor placentation relation
- immunological (poorly developed gestational immune tolerance)
95
what is the pathophysiology behind pre eclampsia?
**occurs after 20 wks
failed trophoblastic invasion and adaptation of spiral arteries (poor placentation)
reduced placental perfusion and placental ischaemia = oxidative stress = endothelial dysfunction = increased capillary permeability and increased systemic vascualr resistance
96
who is at risk of preeclampsia?
- primigravida
- first preg with new partner
- > 10 yrs since last preg
- age 40yo and above at booking
- bmi>35
- FHx
- multiple pregnancy
- molar pregnancy
- previosu pre eclampsia with other pregnancy
- HTN
- CKD
- austoimmune disorder e.g. lupus or antiphospholipid disorder
- diabetes
97
how to reduce risk of pre-eclampsia?
- reduce risk factors (e.g. losing weight)
- optimisation of pre-exisitng conditions
- aspirin 150mg daily from 12 wksk to 38 wks gestations for those at risk
- dalteparin if anti-phosopholipid syndrome or other pro-anticogulation disorders
98
symptoms/signs of preeclampsia?
- headahce
- visual disturbance
- sudden icnrease in swelling
- geenrally unwell
- vomiting
- reduced fetal movements
- abdo pain
- bleeding
- HTN
- proteinuria
- non depedent oedema
- hyperreflexia/clonus
- fetal growth restriction
- oligohydramnios
- abnormal fetal doppler
99
what investigations woudl you do to test for pre-eclampsia (maternal and fetal tests)
- platelet count (FBC)
- renal function (U+Es, eGFR)
- LFTS
- DIC
- level of proteinuria (Protein: creatinine ratio, 24 hr collection)
fetal:
- growth velocity (fetal growth US)
- fetal wellbeing (CTG, amniotic fluid volume, fetal doppler)
100
what factors must you take into account when deciding whether yo temporise or terminate pregnancy with maternal pre eclampsia?
- gestation
- severity of maternal disease
- speed of progression
- presence of complications
- fetal wellbeing
101
what antihypertensives are used in pre eclampsia?
- labetalol
(- nifedipine)
(- methyldopa)
102
what antihypertensive do you use in emergency severe pre eclampsia
- labetalol
(- hydralazine)
103
Mx of severe pre eclampsia?
- control HTN
- prevent seizures
- administer steroids fro lung maturation if preterm
- deliver by most appropriate route
- strict fluid balance
- HDU care
104
definition of eclampsia
seizures occuring in pregnancy or within 10 days of delivery and with at least two of the following within 24 hrs of seizure:
- HTN
- proteinuria at least 0.3g/24hr
- thrombocytopenia less than 100000
- raised transaminases
105
acute Mx of eclampsia?
- IV access
- bolus of 4g magnesium sulphate
- continuous infusion of magnesium sulphate
- control HTN
- if antenatal - plan for delivery by most appropriate route
- fluid balance
- HDU care
106
postnatal Mx of eclampsia?
- may require antihypertensive treatment for 6-12 wks post natally
- increased risk of VTE
- if severe, follow up bloods
- postnatal HTN clinic
- discuss contraception before discharge
- discuss implications for future pregnancy
- write to GP with details of treatment, delviery, aftercare
107
adverse pregnancy risks when a mother has diabetes?
- miscarriage
- congenital abormalities
- macrosomia
- preeclampsia
- preterm brith
- c section
- perinatal mortality
- increased rates of diabetes and obesity in fetus when grown
108
what physiological changes occur in pregnancy when a women has pre exisitng diabetes?
during pregnancy increase the level of insulin resistance = need more insulin to compensate
pancreas cannot keep up with this demand = hyperglyceamia = glucose crossing into fetus = increase growth factors and baby puts on weight
109
name some fetal abnormalities due to gestational diabetes
1. heart defects
2. spina bifida, anencephaly
3. caudal regression/sacral agenesis
110
what pre pregnancy care is needed if the mother has diabetes?
- aim for HbA1c of <48 mmol/mol
- advise on how to lose weight if BMI >27
- renal assessment
- renital assessment
- medications: folic acid, aspirin 75mg from 12/40, VTE prophylaxis, vit D supplements, stop unsafe meds
111
how much folic acid given before pregnancy and when to start taking it ? (in women who have preexisting diabetes)
5mg a day and begin taking 3/12 before trying to conceive
112
what is the acronym SAFER stand for in regards to pregnancy with pre existing DM?
Stop - think about when pregnancy is safe
Ac1 - make sure HbA1c is <48 mmol/mol
Folic acid - supplement
Enjoy...
Referral - to specialist team
113
risk factors for gestational diabetes?
- BMI >30
- previosu GDM
- previous macrosomic baby
- first degree relative with DM
- family origin with high prevalence of DM
114
what is the delivery guidelines for mothers with pre existing diabetes
delivery between 37 to 38+6
- induction of labour (37 to 38+6)
- elective CS (38 to 39 weeks)
115
how is gestational diabetes diagnosed?
- test at 26-28wks (or 16-18 wks if high risk of GDM)
- test fasting glucose if >5.6mmols THEN
- 75g load rapilose gel
- and 2hr BG >7.8mmols
= GDM
*** remember values by 5,6,7,8
116
GDM treatment and Mx
- regular antenatal visits (evry 4 wks)
- regular scans (12/40, 20+/40, 3wkly after 26/40)
- self monitoring blood glucose
- weight control, diet control, exercise
if conservative fails after 1-2 wks then:
- metformin
+/- insulin
117
when should insulin in GDM be given?
if fastign blood glucose of >7mmol/L or if fetal complications seen
or if metformin not keeping blood glucose low
118
for uncomplicated GDM when should delivery be planned for?
deliver 39 to 40+6 weeks
IOL: 39-40 wks
elective CS: >39-40+6
119
postnatal Mx of GDM?
- stop all treatment and BG monitoring at delivery
- fasting BG @ 6-13 wks
- HbA1c @ 13 wks and yrly after
- lifestyle advice
- contraception needed?
120
clincial features fo obstetric cholestasis ?
- pruritis without rash-skin trauma from intense scratching
- palms and soles
- intense in night
- insomnia and malaise
(- abnormal LFTs - increased ALP, primary bile acids, bilirubin)
121
what Ix are done to test for obstetric cholestasis?
- LFT and bile acid
- viral screen - hep A, B, C, EBV, cytomegalovirus
- liver autoimmune screen: chronic active hepatitis, primary biliary cirrhosis
- USS abdo - liver and gallstones
122
name soem maternal risks of obestetirc cholestasis
- vit K deficiency
- PPH
123
fetal risks in obstetric cholestasis?
- perinatal mortality increased up to 11%
- fetal distress
- meconium
- preterm labour
- intracranial heamorrhage
- stillbirth
124
Mx for obstetric cholestasis?
- maternal vit k (from 36 wks)
- neonatal vit k
- fetal surveillance
- drug Tx to reduce pruritis: antihistamine, calamine, ursodeoxycholic acid
- delivery at fetal maturity (37 wks)
- LFTs done 10 dyas post natal
125
pre existig risk factors that icnrease chance of thromboembolism in pregnancy?
- obesity BMI > 30
- age > 35
- parity > 3
- smoking
- gross varicose veins
- paraplegia
- medical comorbidities
- thrombophilia
- previous VTE
126
name some obstetric risk factors that can icnrease risk of thromboembolism in pregnancy?
- multipl epregnancy
- PET
- CS
- prolonged labour > 24hrs
- mid cavity or rotational operative delivery
- stillbirth
- preterm birth
- PPH > 1L
127
Ix for DVT diagnosis?
gold standard = venography with fetal shield
or
doppler US of leg veins to protect baby
128
Ix to diagnose PE?
- CXR
- ECG - classical S1Q3T3 is rare
- FBC - leukocytosis
- BAG - hypocapnia +/- hypoxaemia
- diagnossis confirmed w CTPA
** commence LMWH if suspected !! no need to wait fo rinvestigations results (unless contraindicated)
129
Mx of DVT/PE?
- LMWH e.g. dalteparin or enoxaparin
- TEDS
- leg care advice
- advice for future prophylaxid e.g. , flying , sruger, pregnancy
130
definition of obstetric heamorrhage?
blood loss of 500mls or more from the genital tract within 24 hrs after delivery
131
how much blood loss is minor and major obstetric heamorrhage?
- minor: 500-1000mls
- major: >1000mls
- moderate: 1000-2000mls
- massive: > 2000mls
132
antepartum cuases of obstetric heamorrhage
- previous PPH
- placenta - abruption praevia/accreta
- grand multipartiy
- aneamia
- medical OC
- PET
- overdistended uterus
- HELLP
133
intrapartum cuases of obstetric heamorrhage
- prolonged 1st, 2nd stage
- oxytocin use
- precipitate labour
- operative vaginal delivery - episiotomy
- 2nd stage CS
134
postpartum cuases of obstetric heamorrhage?
- uterine atony
- retained products
- trauma (episiotomy)
- thrombin (problem w coagulation pathway )
135
what is placental praevia?
low lying placenta partially or completely covering the cervical os
136
define placental accreta, increta and percreta?
accreta - invasion into endometrium
increta - into myometrium
percreta - beyond outer surface of uterus
137
define vasa previa?
presentation of umbilical vessels lacking wharton's jelly below the presenting part - rupture of vessel = bleedign from fetus
138
what is placental abruption?
seperation of the placenta
139
clinical features of placental abruption?
- painful bleeding
- reduced absent fetal movements
- coagulopathy
- tense tender abdo
- PPH
140
mode of delivery for placental praevia?
c section at fetal maturity
or
if massive heamorrhage is antental period - done then
141
how is placental abruption managed?
emergency !!!
induction of labour and delivery or CS
142
what antental Mx is important for women at risk of obstetric heamorrhage?
- optimise Hb antenatally
- treat is hB<10.5
- hB check at booking then 28/40 then 36/40
- corssmatching completed
- prophylactic 10 units oxytocin IM at delivery
143
intrapartum Mx fro minor heamorrhage?
cannulation
FBC
coagulation screen - fibrinogen
G&S
pulse, resp rate and BP - every 15 mins
commence warmed crystalloid infusion
144
what fluid therapy is used in obstetric heamorrhage?
- crystalloids
- colloids
- blood (o -ve in fridge)
- fresh frozen plasma
- platelets
- cryoprecipitate
145
what drugs can be used int he Mx of PPH?
- oxytocin
- ergometrine
- syntometrine
- misoprostol
- carboprost
146
what are the four T's in relation to cuases of PPH?
Tone: reduction in uterine tone, typically result of prolonged labour, macrosomia, twins, uterine anomalies or polyhydraminos
Trauma: episiotomy, extensive perineal tears or uterine rupture
TIssue: retained placenta, placenta accreta
Thrombin: pre-existing or newly developed coagulopathies
147
surgical Mx of uterine atony, when uterotonics not working?
create uterine tamponade - bakri balloon
148
if ongoing PPH after insertion of bakri balloon what is next step?
laparotomy with uterine heamostatic sutures or internal iliac ligation
or if very extensive hysterectomy !
149
how is fetal growth assessed in antenatal period?
- abdo palpation of fundal height
- symphysis - fundal height measurement using a measuring tape
- US assessment (most accurate)
150
what is the normal range of symphysis - fundal height measuremnt?
= to amount of weeks +/- 2cm
151
what are they key anthropometric measurements of fetal growth?
- head circumference (and biparietal diamete)
- abdo circumference
- femur length
152
definition of small for dates and alarge for dates baby?
small fro dates - below 10th population centile for gestational age
large for dates - above 95th population centile for gestational age
153
why do small babies have increased mortality and morbidity?
intrauterine hypoxia, acidaemia, prematuritiy (often iatrogenic) and neonatal complications
154
risk factors for growth restricted baby?
- age
- low or high BMI
- amoking
- alcohol
- substance abuse
- domestic violence
- prescriptiona dn OTC drugs
- high altitude
- previous FGR
- recurrent fetal loss
- previous unexplained still birth
- raised AFP
- infection
- HTN
- heamoglobinopathies
- antiphospholipid syndrome
- renal disease
- collagen vascular disease
155
define normal small, abnormal small, infected small, starved small and wrong small for FGR?
normal small - constitutionally small healthy baby
wrong small - incorrect dates or measurements
abnormla small - chromosomal abnormalitied, syndrome, congenital malformations
infected small - infection during preggo (commonly CMV)
starved small - 'placental FGR'. poor placentation, smoking, maternal disease affecting placenta, multiple pregnacies etc
156
what 3 factors does adequate trans-placental transfer depend on:
1. uteroplacental blood flow (from uterine artery to placenta)
2. villous structuce at interface of maternal and fetal blood
3. fetoplacental blood flow (from umbilical arteries to palcenta)
157
what can successful trophoblast invasion be measured by?
uterine artery doppler (can measure at 20 wks)
158
what sonopgraphic measures can be used to determine whether a baby is normal small or starved small?
- centile position (lower down the high risk of pathology)
- symmetry (decreased symmetry, higher risk of pathology)
- liquor volume (decreased volume = higher risk of pathology
- UMA doppler (increased resistance = higher risk of pathology)
- growth velocity (lack of growth velocity = hgihg risk of patholgoy)
159
how to monitor small babies trhoughout preggo if maternal pathology?
- asses for modifiable factors (smoking)
- assess for presence of maternal disease
- continue monitoring for pre-eclampsia, with BP and urine checks in regualr intervals
160
how to monitor small babies trhoughout preggo if fetal pathology?
- serial growth measurements (every 2-4 wks)
- fetal wellbeing surveillancce
- fetal doppler
- amniotic volume measurements
- biophysical profile
- maternal perception of fetal movements
161
diffeence between use of uterine and umbilical arteyr dopplers?
uterien arteyr doppler: used for screenign at 20 wks
umbilical artery doppler: used for surveillance for FGR
162
if their is an abnormal umbilical artery doppler, what week shoudl you deliver before?
deliver before 34 wks !
163
what risks there for the fetus after delivery if they had FGR?
- perinatal death
- increased need for resuscitation
- hypothermia and hypoglycaemi a
- RDS and NEC
- neurodevelopmental disability
- cerebral palsy
- adult disease
164
other causes (bar normal fetal large for dates) for a large fetus?
- uterine fibroids
- pelvic mass pushing up against uterus
- polyhydramnios
- maternal obesity
165
cuases of a large fetus?
maternal:
- obesity
- diabetes
- increased maternal age
- mulitparity
- large stature
fetal:
- consitutional
- male gender
- postmaturity
- genetic disorder (beckwith wiedeman)
166
maternal risk fo having large fetus?plications
- prolonged labour
- operative delivery
- PPH
- genital tract trauma
167
fetal complications of having large fetus?
- birth injury
- perinatal asphyxia from diffciult delivery
- shoudler dystocia/erbs palsy
- hypoglyceamia (+/- seizures)
- childhood obesity
- metabolic syndrome
168
Mx of a large fetus?
- exclude maternal diabetes
- absence of polyhydramnios, treat preggo as normal
- if maternal diabetes present + macrosomia, offer CS
- anticipate shoulder dystocia
- monitor hypoglycaemia in neonatal period
169
definition of extremely, very and moderately preterm?
- extremely prterm <28 2ks
- very preterm 28-32 wks
- moderately preterm 32-36+6 wks
170
neonatal risks of prematurity?
<28wks = neurodevelopmental problems
neonatal death
RDS (due to decreased surfactant)
chronic lung disease
intraventricular heamorrhage
NEC
sepsis
retinopathy of prematurity
171
main cause of preterm birth?
PPROM: preterm prelabour rupture of membranes
172
complications of PPROM?
- cord prolpase
- prematurity
- sepsis and chorioamnionitis
- pulmonary hypoplasia
173
clinical features of PPROm?
- gush of lfuid from vagin a
- leaking vaginal fluid
- icnreased watery discharge
- concern or uncertainty about urinary incontinence
174
examination adn investigation when suspectign PPROM?
- sterile speculum examination (pool of fluid in vagina = confirmed diagnosis)
- if no fluid: perform tests (swab) : actimPROM, amniSure
- FBC, CRP, HVS
175
what is actimPROM?
swab used to detect IGFBP-1 - produced by decidual cells and present in amniotic fluid
if sac ruptures it will be present in the vagina (which is not normal)
176
Mx of PPROM?
- admit for observation for 48-72hr at least (infrom NICU)
- corticosteroids if between 24 to 33+6wks to promote surfactant production
- prophylactic ABx: erythrocmycin fro 10 dyas or until labour
- monitr infection markers and temp for chorioamnionitis
- delivery at 37 wks unless signs of maternal or fetal compromise (if GBS infection, consider >34wks)
177
definition of preterm labour?
regular contractions resulting in dilatation and effacemnt of cervix before 37/40
178
definition of threatened preterm labour and established preterm labour
threatened -> 4cm dilatation preterm
established -> active labour preterm
179
risks that cuase preterm labour
- previous preterm delivery (most commmon)
- extremes of age
- smoking
- drug abuse
- BV
- trauma to cervix
- HTN
- diabetes
- pre-eclampsai
180
which risk factors fro PPROM require moniotirng and possible intervention throughout pregnancy?
- previous spontatenous preterm birth
- mid trimester loss (16/40+)
- Previous PPROM
- cervical trauma
181
what moniotring for PPROM high risk pts can be doen throughout pregnancy?
- TV USS cervical length
- HVS
182
indications PPROM prevention?
if shortening of cervic ebtween 16-24wks
183
what can be done for PPROM prevention?
- cervical cerclage (to be removed before labour)
- prophylacti vaginal progresterone
184
what examinations shoudl be done when suspecting preterm labour?
- abdo exam (assess firmness, fetal size, fetal position)
- contractions (frequency, intensity, duration)
- review fetal HR
- speculum: estimate cervical dilation, assess blood or fluid
185
what Ix shoudl be done when suspecting preterm labour?
- TV USS (if <15mm cervical lenght confimred PTL and offer Tx)
- fetal fibronectin (detect fro it in vagina and confimred = preterm labour)
- actim partus swab
186
what is actim partus?
detects PHIGFBP-1 (produced by decidua, leaks into cervix wen decidua and chorion detach)
positive test = confirmed PTL
187
preterm labour Mx?
- admission
- tocolysis (slow down contractions with nifedipine or atosiban)
- lung maturity (corticosteroids if <34wks)
- rescue cerclage (is <28wks)
- in labour: magnesium sulphate, ABx, continous monitoring
188
what are retained products of conception? (RPOC)
placental and/or fetal tissue that remains in the uterus after a miscarriage, planned pregnancy termination, or preterm/term delivery
189
signs of retained products of conception?
heavy/prolonged uterine bleeding
pelvic pain
190
signs of infected RPOC?
pyrexia, offensive discharge or uterine tenderness.
191
Ex and Ix done when suspected retained products of conception in a woman?
abdo exam
speculum and pelvic exam
- Bloods (FBC and CRP)
- TV USS
192
Mx of RPOC?
TV USS RPOC =<30mm
then no Tx required, pt needs PT in 3 wks
TV USS RPOC >30mm
then either expectant (<50mm), medical or surgical Tx and re-scan in 7-14 days
193
when is MVC (manual vacuum aspiration) used and ERPC (evacuation of retained products of conception) used in miscarriage Mx?
MVC used when fetus is <12wks
and ERPC used when fetus is >12wks (requires opening of the os)
194
when is Anti-D given in miscarrigae/termination?
if patient is rhesus negative and fetus >12 wks
195
what are teh differenr grades of perineal tear
grade 1 - skin
grade 2 - skin and perineal muscles
grade 3 - skin, perineal muscles, partial anal sphincter
grade 4 - skin, perineal muscles, complete anal sphincter
196
Tx of different grades of perineal tear ?
grade 1 - no treatment
grade 2 - stitches by midwife or dr
grade 3 and 4 - surgical repair in theatre with post op laxatives
197
causes of polyhydramnios
macrosomia
gestational diabetes
twin pregnancy
infection
gut atresia in baby
198
indications for IOL?
40 wks to 40+14 with an umcomplicated preganncy
>34 wks and PPROM has occured
or <34 wks and PPROM has occurred + obs factors that put mother and baby at risk
199
methods for induction of labour?
- vaginal prostoglandins
- amniotomy (artifical rupture of membranes)
- membrane sweep
200
what is bishops socre?
assessment of ‘cervical ripeness‘
201
at what bishops score is IOL possible ?
>=7
202
when is syntometrine given in pregnancy?
IM injection given as soon as baby delivered vaginally to help with active delivery of placenta
203
what is misoprostol?
prostaglandin analgoue
204
what is mifepristone?
progesterone analgoue
