Obs Flashcards
(113 cards)
1
Q
List features of the foetal heart rate that are used to define and interpret CTG traces
A
- Baseline (normal= 110-160 beats/min abnormal <100 or >180)
- Baseline variability (normal= 5-25beats/min, abnormal <5 or >25 for >50mins)
- Decelerations (late decels, brady and prolonged)
Each feature can be described as reassuring, non-reassuring or abnormal
2
Q
How can a CTG trace be categorised?
A
- Normal (if all features reassuring)
- Suspicious (if one feature non reassuring)
- Pathological (one abnormal feature or two non reassuring features)
- Need for urgent intervention (acute bradycardia or prolonged deceleration)
3
Q
Give the normal, borderline and abnormal values for pH and lactate in a foetal blood sample
A
pH:
Normal >7.25
Borderline 7.2-7.25
Abnormal <7.2
Lactate
Normal <4.1
Borderline 4.2-4.8
Abnormal >4.9
4
Q
Describe the categories of caesarean section
A
Cat 1: Immediate threat to life of woman or foetus, time from decision to delivery should be <30mins
Cat 2: Maternal or foetal compromise which is not immediately life threatening, time from decision to delivery should be <75mins
Cat 3: No maternal or foetal compromise but requires early delivery
Cat 4: Delivery timed to suit women or staff
5
Q
List indications for elective caesarean section
A
- Maternal request
- Malrpresentation, failed ECV
- Multiple pregnancy and first twin not cephalic
- Placenta praevia
- Placenta accreta
- Previous C-S
- Previous traumatic delivery
- Transmissible diseases e.g. HIV, genital HSV
- Cephalopelvic disproportion
- Maternal conditions e.g. diabetes, cardiovascular disease
6
Q
Methods of monitoring for foetal wellbeing
A
CTG
Foetal scalp monitoring
Foetal pulse oximetry
Foetal blood sampling
Foetal ECG
Transabdominal ultrasound
7
Q
Which sensory modalities can be assessed to check the adequacy of neuraxial block prior to c-section, and which height of block should be achieved for each?
A
- Light touch to T5 bilaterally
- Temperature e.g. cold to T4 bilaterally
8
Q
What degree of motor block is consistent with adequate neuraxial block for c-section?
A
Inability to straight leg raise against gravity bilaterally
9
Q
Give reliable signs that indicate sympathetic block associated with neuraxial anaesthesia
A
Warm and dry feet bilaterally
10
Q
State three ways that initially inadequate spinal block can be improved to allow caesarean section to proceed
A
- Positioning - flex hips to flatten lumbar lordosis, cautious head down tilt, lateral tilt if block is not equal to both sides
- Epidural/ top-up
- Repeat spinal with reduced dose (if some block present), patient positioning to reduce risk of high spinal
11
Q
What are the risk factors for failure of neuraxial anaesthesia
A
Surgical
* Greater operative urgency
* Longer surgery
Patient
* High BMI
* First c-section
Anaesthetic
* No intrathecal opioid used
12
Q
What are the risk factors for post-operative pain when epidural is used for C-section
A
- High top-up volume required to achieve adequate block
- Adrenaline not used
- Higher number of clinican administered boluses during labour
13
Q
Aside from improving block and providing a GA, what can you do for management of pain during C-section?
A
- Nitrous oxide
- Fast acting opioids e.g. alfentanil 250-500mcg boluses
- Ketamine 10mg boluses
14
Q
Define late intrauterine fetal death
A
Fetal death in utero after 24 completed weeks of pregnancy
15
Q
List pre-existing maternal conditions that are associated with inreased risk of IU-fetal death
A
- Diabetes
- SLE
- Advanced maternal age
- Obesity
- Maternal drug use
- Maternal thrombophilias
- RhD -ve
16
Q
List obstetric causes of IU-fetal death
A
- Pre-eclampsia
- PROM
- Placental abruption
- Cord prolapse
- Ascending infection
- Uterine rupture
- Obstetric cholestasis
17
Q
State ways in which the approach to pain relief may differ between labour with IU-fetal death and live birth
A
- Maternal pain may be greater due to psychological distress
- Choice to use analgesia may be affected by holistic situation
- No concerns over placental transfer of analgesics - longer acting and higher opiate doses can be used if needed
- Opiates with fewer side effects e.g. morphine can be used instead of pethidine
- Causes of consequences of IUFD may induce coagulopathy, contraindicating neuraxial and intramuscular analgesia
18
Q
Give abnormal haematological results which may contraindicate epidural analgesia, and why these might be seen in IU-fetal death
A
- Raised WCC - maternal sepsis contributing to IUFD, or as a consequence of IUFD
- Low platelets - severe pre-eclampsia or HELLP
- Derranged coagulation - DIC from pre-eclampsia/HELLP/thrombophilia/abruption/uterine rupture or because of IUFD itself
19
Q
Give the features of a post-dural puncture headache
A
- Fronto-occipital
- Develops within five days of puncture
- Worse on standing, improves on lying
- Neck stiffness
- Tinnitus
- Photophobia
- Sound intolerance
- Cranial nerve palsies e.g. II, III, IV, VI. VIII
20
Q
Give risk factors for accidental dural puncture
A
- Extremes of BMI
- Increased depth to epidural space
- Operator inexperience
- Inability of patient to remain still (e.g. advanced labour)
21
Q
What are the differential diagnoses of post-partum headache?
A
- Meningitis
- Sinusitis
- Migraine
- Cerebral vein thrombosis
- Dehydration
- Lactation headache
22
Q
What conservative management do you advice for post dural puncture headache?
A
- Simple analgesia e.g. paracetamol, NSAIDs
- Good hydration
- Caffeine
- Encourage mobilisation, if unable give antiembolism stockings
- Avoid straining - laxatives
- Antiemetics if needed
23
Q
What are the risks of epidural blood patch?
A
- Failure
- Bruising
- Temporary back pain/stiffness
- Further accidental dural puncture
- Nerve damage
- Infection
- Spinal canal haematoma
24
Q
What are the causes of mitral stenosis?
A
- Infective endocarditis
- Degenerative calcification
- Rheumatic fever
25
What are the physiological cardiovascular changes in pregnancy and how can these exacerbate pathophysiology of mitral stenosis
* Increased circulating volume - fixed left atrial output unable to cope, pulmonary oedema, increased left atrial stretch, risks atrial fibrillation, further reduced left atrial emptying
* Increased heart rate - shorter diastole and reduced time for flow across stenosed valve, reduced left ventricular filling, reduced cardiac output
* Reduced SVR - reduction in coronary artery perfusion, risk of ischaemia
* Increased oxygen consumption (due to fetus + maternal metabolism) requires increased cardiac output which cannot be facilitated with severely stenosed mitral valve, leading to decompensated heart failure
26
List the pharmacological interventions that might be required to manage mitral stenosis in pregnancy
* Beta blocker for heart rate control
* Anticoagulation if at risk of AF
* Diuretics if congestive symptoms
27
What are the haemodynamic goals for mitral stenosis and how can they be achieved during management of labour
* Avoid tachycardia - early pain management with epidural, avoid oxytocin boluses, prompt management of hypovolaemia
* Maintain afterload - slowlu incremental epidural block, alpha-agonist infusion e.g. phenylephrine
* Avoid arrhythmia - continue prescribed medications e.g. beta agonists, avoid increasing load of left atrium with excessive fluid administration, electrical cardioversion if haemodynamic instability following acute onset AF
* Avoid rises in pulmonary arterial pressure - assisted delivery to avoid valsalva from pushing, avoid nitrous oxide, avoid ergometrine
28
Which events after delivery can predispose to pulmonary oedema in a patient with mitral stenosis?
* Autotransfusion due to contraction of uterus
* Loss of aortocaval compression
29
A 28-year old woman presents for acute appendicectomy - she is 22 weeks pregnant. List the risks to fetus during GA and why they may occur.
* Hypoxia - maternal hypoxia in event of difficult airway management
* Fetal hypercarbia and myocardial depression - maternal hypercarbia in event of difficult airway management
* Fetal artery vasoconstriction - maternal hypocarbia due to hyperventilation or hypercarbia in event of difficult maternal airway
* Fetal hypoperfusion - aortocaval compression, maternal hypotension during induction
* Adverse neurological outcomes - anaesthetic-induced neuronal apoptosis in developing brain
* Miscarriage - more likely secondary to disease process necessating surgery
30
Give pre and intraoperative steps to maximise fetal safety if a GA is required to a mother at 27 weeks
* Consider risk of premature labour - involvement of NICU and obstetricians
* Consider fetal monitoring
* Consider tocolysis
* Consider steroids for fetal lung maturation
* Avoid NSAIDs (risks premature closure of ductus arteriosus)
31
Which changes in maternal physiogy in late pregnancy increase the risk of maternal and therefore fetal hypoxia at induction of general anaesthesia
* Reduction in functional residual capacity - reduced apnoeic time before desaturation
* Increased oxygen consumption due to increased metabolic demand of pregnant woman and increased oxygen demand due to fetoplacental uit
32
Give considerations to maximise the safety of laparoscopic surgery in a pregnant patient
* Control maternal end-tidal carbon dioxide
* Use open technique to enter abdomen
* Low pneumoperitoneum pressures < 12 mmHg
* Limit trendelenburg positioning, achieve desired position slowly
* Fetal monitoring if feasible
33
Which analgesics are contraindicated when breast feeding
* Codeine phosphate (respiratory depression baby)
* Tramadol (respiratory depression baby)
* Analgesic dose aspirin (Reye's syndrome)
34
What is required to make an advance decision valid in order to refuse life-saving treatment?
* Patient over 18 years old
* Patient has capacity at time of writing decision
* Patient has lost capacity at time of application of advance decision
* Written document
* Signed by patient or on patient's direction if unable to sign
* Witnessed with signature
* Specifies the treatments the patient refuses to have
* Acknoweledges risk of death as a consequence of refusal
* Has not been later withdrawn in writing or verbally
35
What pharmacological approaches can be used to minimise the risk of consequences of haemorrhage in an elective c-section with placenta praevia and fibroid uterus
* Pre-op optimisation of haemoglobin with iron
* Consider need for erythropoetin
* Uterotonics e.g. oxytocin infusion, long acting oxytocin (carbetocin), escalation plan for uterotonics
* Stop any drugs with an adverse effect on bleeding e.g aspirin, low molecular weight heparin
* Use tranexamic acid
36
Jehova's witness patient, refusing blood products. Elective CS, fibroids, placenta praevia.
State risks to be discussed with this patient before they make their advanced decision
* Potential for haemorrhage is increased due to fibroids and placenta praevia
* Risk of death if blood not given in event of massive haemorrhage - no true blood alternatives
* Risk of major morbidity from massive haemorrhage including prolonged ICU stay, prolonged ventilation, poor wound healing, infection, hysterectomy, difficulties caring for newborn
37
Give advantages of intraoperative cell salvage during c-section
* Avoids risks of allogenic transfusion e.g. blood administration errors, transfusion reactions, viral/bacterial/prion tranmission
* Blood reinfused at room temperature, reduce risk of transfusion associated hypothermia
* Useful in patients with atypical antibodies where cross match is difficult and turnaround is longer
* Salvaged blood has normal 2,3-DPG levels so normal oxygen carrying behaviour
* Often acceptable to Jehova's witnesses
* Consumables only cost slightly more than one unit of donated blood
38
Give the problems associated with intraoperative cell salvage during c-section
* Leucocyte depletion filter slows infusion rate and can result in release of bradykinin causing hypotension
* Does not reinfuse platelets or coagulation products
* Risk of air embolism and amniotic fluid embolism
* Red cell lysis due to "skimming" reduces the availability of whole cells for reinfusion
* Staff training necessary
* Risk of bacterial contamination
* Risk of electrolyte imbalance
* Risk of circulatory overload
39
State the definition of pre-eclampsia
* New onset hypertension (>140/90 two readings 4 hours apart) after 20 weeks gestation
* Accompanied by evidence of proteinuria/ maternal organ dysfunction (neuro, liver, kidney, haem)/uteroplacental dysfunction
## Footnote
Neuro e.g. headache, central scotoma, altered mental status, seizures. Liver- transaminitis. Kidneys- creatinine above 90, haem - platelets < 150, DIC, haemolysis)
40
List the symptoms of pre-eclampsia that should be reported by women if experienced
* Severe headache
* Visual changes e.g. blurring, flashing
* Severe pain just below the ribs
* Vomiting
* Sudden swelling of hands, face or feet
41
Define eclampsia
Seizures on a background of pre-eclampsia
42
Give risk factors for the development of pre-eclampsia
* Hypertensive in previous pregnancy
* CKD
* Autoimmune disease
* Pregestational diabetes
* Primip
* >40 yrs
* BMI over 35kg/m2
43
Which drugs may be used intravenously to control raised blood pressure in pre-eclampsia
* Labetalol (10-20mg initially)
* Hydralazine (5-10mg initially)
44
When is magnesium sulphate indicated for pre-eclampsia
* Severe pre-eclampsia in critical care setting when delivery planned within 24hrs
* For seizures and prevention of further seizures
45
What are the features of severe pre-eclampsia?
* SBP ≥160 mmHg or DBP ≥110 mmHg
* Thrombocytopaenia (platelet count ≤100x10^9/L)
* Impaired liver function (ALT/AST> twice the upper limit of normal, severe persistent right upper quadrant or epigastric pain not accounted for by alternative diagnoses)
* AKI (doubling of creatinine)
* Pulmonary oedema
* New onset headache, unresponsive to medication and not accounted for by alternative diagnoses
* Visual disturbance
46
What are the advantages of epidural analgesia in labour for women with pre-eclampsia?
* Vasodilation improves blood pressure control
* Obtunds spikes in blood pressure associated with contraction pain
* Can be topped up for urgent delivery if indicated, avoiding GA
* Avoids opioid analgesia which might impaire ability to assess neurology
47
State the issues in pre-eclampsia which may impact of the safe provision of GA and state how they are mitigated
A:
- Laryngeal oedema- video laryngoscopy, smaller tube size
- Laryngeal oedema may worsen during surgery - ensure leak on cuff deflation prior to extubation
- Coagulopathy may result in airway bleeding - video laryngoscope with hyperangulated blade to avoid stretching soft tissues and optimise first pass
B:
- Pulmonary oedema - higher airway pressures and PEEP, consider CPAP or ventilation post-operatively, fluid restrict to 1ml/kg/hr up to 80ml/hr unless matching blood losses
C:
- Pressor response to laryngoscopy may precipitate intracranial haemorrhage - use esmolol, alfentanil or remifentanil to obtund pressor response
D:
- Reduced neurology may not be able to consent appropriately - antenatal clinic discussions to enable more informed best interests decisions
- Seizure risk - magnesium
48
Give patient risk factors that contribute to difficult airway in obestetrics
* Increased fatty tissue, tongue size and chest size
* Non-starved patient
* Obesity
* Co-morbidities e.g. asthma, pre-elcampsia
* Active labour may impair co-operation and positioning
49
Give situational factors that contribute to difficult airway in obstetrics
* Intubation is infrequent (compared to neuraxial), less experience and awareness of healthcare professionals about difficult airway
* Commonly out-of-hours with less experienced staff e.g. trainees
* Intubation often urgent, impairs airway assessment
* Obstetric theatre often isolated from main theatres, less help and equipment available
50
What can be done to maximise oxygenation of an obstetric patient at time of induction
* Optimise position - head up, ramped
* Pre-oxygenate to FeO2 above 90%, start pre-oxygenation early
* High flow nasal oxygen
* Facemask ventilation between attempts if required
51
Which factors would influence a decision to wake or proceed with c-section in case of failed intubation
* Maternal condition
* Fetal condition
* Experience of anaesthetist
* BMI of patient
* Surgical complexity
* Risk of aspiration
* Feasibility of alternative anaesthesia or awake intubation
* Airway factors
1. Reliability of current airway e.g. FONA, difficult facemask, facemask, LMA
2. Airway hazards to further attempts e.g. oedema, stridor, bleeding, trauma, secretions
## Footnote
Mum and baby, me, obs (for obesity and surgical complexity), asp, alt, airway
52
What were the recommendations from NAP4 regarding airway management in pregnant women?
* Difficult airway and CICO skills kept up to date
* Obs anaesthetists should be familiar with 2nd generation supraglottic airway devices for airway rescue
* Awake fibreoptic intubation skills and equipment should be available anywhere in the hospital
* All recovery staff including midwives should be properly trained and skills regularly updated to facilitate difficult airway management
53
Give early symptoms of spinal block that is ascending too high
* Difficulty breathing
* Tingling in hands and arms
* Nausea/vomiting
* Feeling faint
54
Give early signs of spinal block that is ascending too high
* Decreased respiratory effort
* Bradycardia and hypotension
* Objective weakness of hands, arms and shoulders
* Obtundation
55
Give symptoms that would lead you to consider serious underlying cause of post-partum headache
* Reported focal neurology
* Seizures
* Drowsiness
* Significant neck stiffness
56
Give signs that would lead you to consider a serious underlying cause of post-partum headache
* Focal neurology
* Hypertension
* Paplloedema
* Fever
* Reduced conscious level
57
What blood results would lead you to consider a serious underlying cause of post-partum headache
* Raised WCC and CRP
* Derranged transaminases and bilirubin
* Low platelets, derranged clotting
58
What are the important non-clinical aspects of management for IU-fetal death
* One-to-one senior midwife care, trained in caring for women with IUFD
* Good communication amongst the healthcare team to avoid lack of awareness or insensitivity
* Clear discussions regarding expectations and wishes for delivery
* Dedicated delivery space away from noise of delivery suite
59
What are the advantages of regional anaesthesia is C-S required for IU-fetal death other than avoiding risks of GA
* Optimum post-operative pain relief
* Facilitates early contact with baby
* Permits clearer recollection of events which may be important to woman
* Facilitates presence of birth partner
60
What are the three most common direct causes of maternal death in MRBRACE 2020
1. VTE
2. Suicide
3. Sepsis
61
What are the two leading causes of indirect maternal death in MBRACE 2020
1. Cardiac disease
2. COVID-19
62
What are the respiratory, cardiovascular, neurological, haematological and obstetric features in the presentation of amniotic fluid embolism
Respiratory:
* Pulmonary oedema
* ARDS
* Cyanosis
* Dyspnoea
* Bronchospasm
Cardiovascular:
* Hypotension
* Cardiac arrest
Neurological:
* Seizures
* Agitation
Haematological:
* DIC
Obstetric:
* Fetal distress
* Uterine atony
63
What would be some non-obstetric differential diagnoses of amniotic fluid embolism
* PE
* Sepsis
* Anaphylaxis
* Air embolism
* Heart failure
* Aspiration
64
What would be some obstetric differential diagnoses of amniotic fluid embolism?
* Eclampsia
* Uterine rupture
* Placental abruption
* Peripartum cardiomyopathy
65
Give the pathophysiological theories of amniotic fluid embolism
* Mechanical theory: amniotic fluid with other fetal elements such as vernix and squamous cells pass into the maternal circulation resulting in physical obstruction of pulmonary vasculature and right heart failure
* Immune-mediated theory: anaphylacticoid reaction due to immunologically active and prothrombotic contents of amniotic fluid e.g. PAF, TNF, trigger a systemic inflammatory response
66
What patient factors contribute to the increased prevalence of awareness under GA in obstetrics
* Female
* Young age
* Obesity
* Difficult airway
* High anxiety state preceding emergency S-D
* Raised cardiac output so reduced duration of action of induction agents and longer time to establish adequate partial pressure of volatiles
67
What situational factors contribute to the increased prevalence of awareness under GA in obstetrics
* Out-of-hours
* Trainee anaesthetist
* Stress of emergency situation
* Brief interval between induction and surgical stimulation
68
What anaesthetic factors contribute to the increased prevalence of awareness under GA in obstetrics
* Thiopentone use
* RSI
* Use of NMBD
* Omission of opioid at induction
* Failure to dose for body weight
* Intentional underdosing of inhalational agent due to concern for uterine tone
* Unfamiliarity of GA for CS
69
Why is thiopentone associated with increased risk of awareness in obstetrics
* Accidental unrecognised syringe swap with antibiotic
* Unfamiliarity with thiopentone (use declining in non-obstetric naesthesia)
* Broad dosing range
70
Give three recommendations for obstetric anaesthesia from NAP5
* Increased risk of awareness in obstetrics should be communicated to patient during consent
* Anaesthetic technique should target adequate anaesthesia in healthy patients by ensuring appropriate doses of induction agents and rapid attainment of end-tidal inhalational ahent levels, use nitrous oxide and maintain uterine tone with uterotonic agents
* Make a plan for management of awareness during difficult intubation including additional dose of hypnotic agent available
* Failed neuraxial should be viewed as a risk factor for accidental awareness
* Clearly label syringes of antibiotic and physically separate from thiopentone
71
Give measures that can be undertaken to achieve successful intubation after a failed first intubation attempt in obstetrics
* Remove cricoid
* External laryngeal manipulation
* Reposition head or neck
* Use of a boujie or stylet
72
Give indications where remifentanil is preferable to epidural analgesia (except patient preference)
* Neuraxial contraindicated due to coagulation abnormalities
* Structural abnormality of lumbar spine
* Localised sepsis
* Local anaesthetic allergy
73
Give pharmacodynamic or pharmacokinetic properties of remifentanil that make it suitable for analgesia in labour
* Minimal histamine release so reduced risk of hypotension
* Rapid metabolism by plasma and tissue esterases so minimal fetal accumulation
* Non-saturatable metabolism pathway
* Breakdown products have a neglibile action
74
What are the advantages of remifentanil PCA compared to IM pethidine?
* Better reduction in pain scores, less likely to need subsequent epidural
* Associated with reduced rate of instrumental delivery
* Can be used in circumstances where IM is contraindicated e.g. severe clotting disorders
75
Give details of a prescription for dosing of remifentanil PCA
20-40mcg bolus with 2 minute lockout, no background infusion
76
Apart from the availability of resuscitation equipment and routine observations, state other measures to maximise safety of remifentanil PCA in labour
* One-to-one midwifery care in room at all times
* Dedicated IV line away from joint to avoid line obstruction and subsequent large bolus delivery
* Routine use of supplemental oxygen
* Instruction that only the labouring woman can administer a dose
77
Which actions should be taking by an anaesthetic department implementing remifentanil PCA service for the first time in obstetrics
* Establish a guideline for setting up PCA, monitoring patients and essential equipment
* Create patient information leaflet
* Set up training for staff
* Audit local patient satsifaction and incident reporting
* Input of outcomes into international registry
78
List the normal physiological changes of pregnancy that may cause decompensation in a patient with adult congenital heart disease
* Increased circulating volume may overload system
* Tachycardia may reduce coronary artery perfusion and increase coronary metabolic demand
* Reduced systemic vascular resistance and so reduced afterload
* Impaired venous return due to caval compression
* Cardiovascular system may be unable to compensate for increased oxygen demand due to fetal requirements and increased maternal metabolism
79
List the normal physiological events of labour that may cause decompensation in a patient with adult congenital heart disease
* Valsalva manoeuvre when pushing causes variable venous return to heart
* Tachycardia spikes during pain of contractions
80
List the normal post-partum physiological events that may cause decompensation in a patient with adult congenital heart disease
* Autotransfusion due to uterine contraction results in acute increase in circulating volume and so preload
* Sudden loss of aortocaval compression results in acute increase in venou return
81
Give low risk adult congenital heart disease lesions which could be managed in a nonspecialist centre
* Patent ductus arteriosus
* Mitral valve prolapse
* Mild pulmonary stenosis
* Anomalous pulmonary venous drainage
82
Give high risk adult congenital heart disease lesions that would necessitate delivery at a specialist cardiac centre
* Mechanical valve
* Fontan circulation
* Pulmonary hypertension
* Left ventricular outflow tract obstruction
83
List the aspects of management for a patient with adult congenital heart disease in labour
* Consider induction to facilitate appropriate timing and location of delivery
* Early venous access to allow for rapid response to blood loss
* Consider continuous ECG monitoring to detect arrhythmias
* Consider need for arterial line for continous blood pressure monitoring
* Early epidural to minimise pain related tachycardia
* Minimise pushing to reduce valsalva manouevre
* Aim for euvolaemia - monitor fluid balance, treat fluid losses e.g. haemorrhage, avoid fluid overload
84
Give the uterotonic drugs and doses suitable for use in patients with adult congential heart disease
* Vaginal, oral, sublingual or rectal misoprostol 0.2-0.8mg
* Intravenous oxytocin 2 units over 10 minutes followed by infusion if required
85
Define obesity
* Surplus of adipose tissue with detrimental effect on physiology, categorised as BMI>30kg/m2
86
Define class 3 obesity
BMI > 40kg/m2
87
What are the cardiovascular complications of obesity in pregnancy?
* IHD
* HTN
* Cardiomyopathy
88
What are the neonatal complications of obesity in pregnancy
* Preterm delivery
* Small for gestational age
* Large for gestational age
* Congenital abnormalities e.g. spina bidifa
* Stillbirth
89
What are the peripartum complications due to obesity in pregnancy
* VTE
* Infection/sepsis
* Pre-eclampsia
* Gestational diabetes
* Prolonged labour
* Anaesthetic complications
90
Why is early epidural recommended for obese obstetric patients
* Late epidurals will be challenging due to combination of BMI and advanced labour pain causing difficulty remaining still in optimal position
* Epidural can be topped up for instrumental or surgical delivery (increased risk in obesity)
* Avoids risks of opioid analgesia with associated risks to airway and respiratory depression
91
Apart from chest and urine infections, which infections are obese women at greater risk of developing post-partum
* Wound infection
* Genital tract sepsis
92
How should the dose of low molecular weight heparin be calculated in an obese obstetric patient with a DVT, how long should she remain on treatment
* Dose based on booking weight
* To be taken at least 6 weeks post-partum and until 3 months of treatment has been given
93
Give obstetric causes of intrapartum haemorrhage
* Placenta praevia
* Placental abruption
* Uterine rupture
* Genital tract bleeding
94
Give the specific actions taken to manage uterine atony after vaginal delivery
* Uterotonic given on delivery of anterior shoulder e.g. oxytocin 10 units IM or syntometrine IM (0.5mg ergometrine, 5 units oxytocin)
* Clamp the cord between 1-5 minutes after delivery
* Controlled cord traction after placental separation
* Fundal massage to aid contraction
* Catheterisation to ensure bladder is empty
* Additional 5 units oxytocin by slow IV injection
95
Which drugs with doses can be used in ongoing management of uterine atony causing post-partum haemorrhage
* Oxytocin 5 units slow intravenous bolus
* Ergometrine 0.5mg IM or slow IV if diluted
* Carboprost 0.25mg IM repeaed every 15 mins to maximum 2mg
* Misoprostol 0.8mg sublingual, oral, vaginal or rectal
96
List non-pharmacological approaches to manage post-partum haemorrhage due to uterine atony
* Bimanual uterine compression
* Intrauterine balloon catheter
* Haemostatic compression sutures
* Ligation of blood supply to uterus
* IR guided arterial embolisation of uterine arteries
* Hysterectomy
97
A 25-year-old woman who is 37 weeks pregnant is admitted to your labour ward with a blood
pressure of 180/115mmHg and proteinuria. A diagnosis of severe pre-eclampsia is made.
What is the main reason to correct BP
To prevent intracranial haemorrhage
98
What doses of magnesium would you give for pre-eclampsia
4g IV bolus over 20 minutes, then 1-2g/hr for 24 hrs
99
What monitoring would you use for a patient with severe pre-eclampsia on IV magnesium?
* Hourly BP or art line
* Pulse oximetry
* ECG
* Respiratory rate
* Fluid input/output
* Hourly reflexes and clonus
100
The patient with severe pre-eclampsia has had a caesarean section. She has lost 500mls of blood and has had adequate, appropriate fluid replacement.
How would you manage ongoing fluid balance in the post-operative period?
* Ideally stop IV fluids and allow oral fluids only
* Restrict all IV fluids to 80-100ml/hr
* Record accurate fluid input and output
* If urine output < 0.5ml/kg/hr, give IV fluid challenge. If still no response, consider invasive monitoring
101
Give two reasons for pulmonary oedema in pre-eclampsia
* Leaky capillaries
* Low oncotic pressure
102
Give the features of severe pre-eclampsia that suggest planned birth before 37 weeks
* Three agent blood pressure control and remains hypertensive
* Deterioration in renal function, liver function or evidence of thrombocytopenia/haemolysis
* SpO2 < 90% on RA
* Neurological features e.g. intractable headache, central scotoma, seizures
* Placental abruption
* Reverse umbilical artery flow in diastole, non reassuring CTG or stillbirth
103
Definition of gestational diabetes
Diabetes that develops during pregnancy
104
Risk factors associated with developing gestational diabetes
* Overwieght
* Prediabetic
* Gestational diabetes in previous pregnancy
* FH diabetes
* PCOS
105
Obstetric complications of diabetes
* Caesarean section
* Macrosomia/polyhydramnios
* Pre-eclampsia
* Induced labour
106
Target BMs for gestational diabetes in labour
5-8mmol/L
107
When is variable rate insulin used for gestational diabetes in labour
* CBG target not achieved by usual medications
* Reduced/no oral intake and risk of hypoglycaemia on usual regime
108
Complications of variable rate insulin in gestational diabetes labour
* Hypokalaemia
* Hyponatraemia
* Errors in connecting IV
* Errors in discontinuing VRIII
* Failure to administer glucose alongside insulin
* Delayed commencement resulting in DKA
109
Treatment of hypoglycaemia on VRIII during labour
* Stop VRIII
* Give 100mls 20% glucose
* Recheck BM in 10 minutes
110
3 differences to ALS in obs
1. Neonatal and maternity arrest calls
2. Left sided uterine displacement
3. Perimortem C-S within 4 mins
111
Antihypertensive treatment options for pre-eclampsia to reduce risk of premature delivery or stroke (in community)
* Labetalolol 100mg BD
* Nifedipine 10mg OD
112
If there is a diagnosis of pre-eclampsia, when do bloods need to be taken within to allow neuraxial block
6 hours
113
Complications of PDPH
* Subdural haematoma
* Cerebral venous thrombosis
* Persistent CSF leak
* Cranial nerve palsy
* Death
