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Obs Flashcards

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1
Q

At what point is the uterus palpable in a pregnant patient? At what point does it cross the umbilicus?

A

12/40

20/40

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2
Q

How can pregnancy be dated with scanning? Specifics!

A

USS - 14wks bipariatal diameter

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3
Q

What rule allows the dating of pregnancy without a scan? What is it?

A

Naegele’s rule

1st day of LMP + 7 days + 9 months

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4
Q

Limitation of naegele’s rule

A

Assumes regular cycles

Assumes can remember 1st day of LMP

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5
Q

Why is dating important in pregnancy

A

Know when baby is overdue
Know when baby is viable (for resus if over, can abort if under - crude!)
Can monitor for normal development

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6
Q

When would USS first see something in pregnancy?

When would a heart be first detectable?

A 
5 weeks (foetal sac)
6 weeks
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7
Q

What routine USS are done in pregnancy?

When?

A

Dating 11-14/40

Abnormality 18-20/40

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8
Q

Why should overdue babies be induced? When is it offered?

A

Placental function decreases
Offer at 40+7
Always at 40+14

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9
Q

What increase should be seen in betaHCG in a normal pregnancy? What do variations in this suggest?

A

Double every two days
Less than this suggests ectopic
Dropping suggests failing pregnancy

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10
Q

Problems with alcohol in pregnancy

A

Foetal alcohol syndrome

Increased miscarriage

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11
Q

Problems with smoking in pregnancy

A

Miscarriage
Preterm labour
Small for date
Placenta pravia and abruption

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12
Q

When should folic acid supplementation commence and end in pregnancy

A

1 month pre conception until 14 weeks

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13
Q

What should trigger high dose folic acid in pregnancy

A 
Previous neural tube defect
Antiepileptics 
Obese 
Diabetic 
HIV +ve on co-trimoxazole
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14
Q

When would a pregnancy test be positive?

A

Day 9 to 20 weeks

5 days post foetal death or miscarriage

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15
Q

What should be considered when examining a patient with placenta pravia? Concomitant lifestyle advice?

A

Don’t examine PV

Avoid penetrative sex

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16
Q

Risk factors for placenta previa

A 
>40
Previous c-section 
Fibroids 
Multiple pregnancy 
Multiparity 
Assisted conception
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17
Q

Management of placenta praevia

A

Major (covering OS) - needs c-section

Minor - aim for PV but may need c-section

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18
Q

Presentation of placenta praevia

A

Antepartum haemorrhage

Failure of head to engage

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19
Q

What placental problem can accompany placenta praevia? What is it? Problem?

A

Placenta accreta
Invasion of the placenta into the myometrium
Heavy bleeding

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20
Q

When should LMWH be considered in pregnancy? Duration?

A

Two or more risk factors - post labour for 7 days
Three or more risk factors - from as early as possible to 6 weeks post partum
OR
BMI >40 or caesarian - post delivery for 7 days

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21
Q

Dietary advice in pregnancy

A 
Pasturised milk only
No ripened or mouldy cheese
No pate
Undercooked food
Raw eggs
Raw meat
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22
Q

When will morning sickness generally pass by?n

A

16-20 weeks

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23
Q

Non pharmacological and pharmacological methods to reduce morning sickness?

A

Ginger
Wrist accupresure
Antihistamines

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24
Q

Treatment for varicose veins in pregnancy

A

Compression stockings

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25
What should raise suspicion of candidiasis in vaginal discharge during pregnancy? Treatment?
Itch Sore Offensive smell Dysuria Topical imidazole. No oral antifungals
26
Routine bloods on booking
FBC Group and save Haemoglobinopathy screen in at risk groups Hep B, syphalis and HIV screen
27
What are the screening tests for downs syndrome?
``` 1st trimester (11-13 weeks) perform combined test measuring nuchal translucency with HCG and PrAP-A combined with patient age to stratify risk 2nd trimester (15-20 weeks) perform quadruple test measuring AFP, estriol, HCG, inhibin A and combine with patients age ```
28
Above what risk will invasive testing for downs be performed?
1:150
29
Symptoms of pregnancy
Lethargy Morning sickness Amenorrhoea
30
What should you advise a patient wanting to take nsaids in pregnancy? Why?
Try to avoid and definitely not in 3rd trimester | In utero closure of ductus arteriosus and fetal hypertension
31
What is hyperemesis gravidarum? Risk factors?
Persistant vomiting in pregnancy with weight loss and ketosis - young, non-smoker, primip, diabetes, psychiatric illness, family history, multiple pregnancy and molar pregnacy (high HCG)
32
What complications are patients with hyperemesis gravidarum at risk of?
``` Dehydration and shock Postural hypotension and collapse Electrolyte disturbance (hypokalaemia and hyponatraemia) Malnutrition Liver and renal failure Hyperthyroidism ```
33
Tests in hyperemeisis?
FBC, U+E, LFTs, TFTs TVUSS (twins? Molar?) Postural BP Urine dip
34
Conservative Treatment of hyperemesis gravidarum
Ginger Bland food Rest
35
Medical treatment of hyperemesis gravidarum in order of use
``` Thromboprophylaxis Thiamine supplementation IV fluids and urine output Cyclizine Hydrocortisone and prednisolone Parenteral nutrition ```
36
Definition of preeclampsia with diagnostic values
Hypertension (>140/90 x3) with proteinuria (dipstick >1+ or 1+ with raised PCR)
37
Risk factors for pre eclampsia
``` Maternal age PMH (sle, dm, htn, ckd) FHx Obesity Multiple pregnancy Primip ```
38
Management of someone with risk factors of preeclampsia presenting early in pregnancy.
Aspirin if one major (pmh) or 2 minor risk factors from week 12
39
Presentation of pre-eclampsia?
``` Asymptomatic Headache, visual disturbance (increased icp) SOB, frothy sputum (pulmonary oedema) PE/DVT (hypercoagubility) RUQ pain (liver capsule stretch) Peripheral oedema Decreased fetal movements (fetal growth restriction) Hyperreflexia ```
40
Complications of preeclampsia
Subarachnoid haemorrhage (sudden severe headache) Placental abruption (severe abdo pain +/- pv bleed) HELLP Seizure
41
Why are preeclamptic patients susceptible to clotting?
Endothelial damage causing renal failure and loss of antithrombin 3, also resulting in DIC
42
Investigations in suspected preeclampsia
``` FBC (Hb and platelets) U+E (creatinine and K+) Clotting LFTs (albumin, bilirubin, ALT) Urine dip and MSC CTG / USS ```
43
Why do Hb, K and bilirubin in preeclampsia?
Risk of HELLP thus haemolysis
44
What is HELLP
Haemolysis, elevated liver enzymes, low platelets
45
What is severe preeclampsia
BP >160/110 or >140/90 with symptoms / severe signs (HELLP, papilloedema, clonus)
46
Management of severe pre eclampsia
Prophylactic magnesium sulphate Catheterise and fluid restrict Decrease BP Deliver
47
Drugs to lower BP in pregnancy and contraindication
Nifedipine Methyldopa - mental health Labetalol - asthmatics (also decreases hypo awareness)
48
What medication can be used IV to rapidly lower BP?
Hydralazine
49
Complications of preeclampsia on delivery?
BP too high - tube causes reflex HTN - stroke Low platelets - spinal bleeds DIC - severe PPH snd DVT/PE
50
What is a complication of magnesium therapy in preeclampsia? Reversal?
Arrhythmia and resp depression Patients become hyporeflexic Reverse with calcium gluconate
51
Definition of primary and secondary PPH
Blood loss of >500ml 1o within 24 hrs of delivery 2o after 24 hrs of delivery
52
Definition of massive haemorrhage?
>1.5L not controlled
53
What four factors contribute to PPH?
Thrombus (lack of!) Tone (atony!) Trauma Tissues (retained!)
54
Causes of uterine atony resulting in PPH
Exhaustion - prolonged labour, uterine infection | Overstretch - induction, multiple pregnancy, macrosomia, polyhydraminos, fibroids
55
Traumatic causes of PPH
Episiotomy or tear Macrosomy Instrumentation Previous c-section
56
Medical treatment of PPH
``` External massage Bimanual compression IM syntocinon IV syntocinon infusion IM ergometrine IM carboprost PR misoprostal ```
57
Surgical treatments of PPH
Balloon compression Uterine artery ligation Brace sutures Hysterectomy
58
Major side effect of ergometrine
Significant BP increase
59
Main cause of secondary PPH
Infection or retained products
60
Big risk post resolved PPH , why, tx
DVT/PE Massive transfusion, hard to balance clotting, Give LMWH after 24 hrs
61
Management of placenta accreta
Conservative - leave and will reabsorb Surgical - hysterectomy Medical - all on ABX as will need lots of examinations
62
Effect of maternal diabetes on the fetus and mechanism
- High maternal BM - High fetal BM - polyuria - POLYHYDRAMINOS - High fetal insulin - fetal growth - MACROSOMIA - Macrosomia + maternal small vessel disease placental insufficiency FETAL HYPOXIA, GROWTH RESTRICTION - Fetal hypoxia - MISCARRIAGE, STILL BIRTH, POLYCYTHEMIA
63
Specific fetal abnormalities associated with maternal diabetes
Sacral agenesis | Cardiac abnormalities
64
Risks and problems to mother of diabetes during pregnancy?
Must switch to insulin (+/- metformin) | High risk of DKA in T3
65
Complications for mother and fetus in maternal diabetes for stage 1/2 labour
Hypo/hyperglycaemia Abnormal lie 2o polyhydraminos Shoulder dystocia due to macrosomia
66
In maternal diabetes risks to mother in 3rd stage labour. Important info to know in managing this?
Sudden decreased insulin requirements thus hypoglycaemia | Must know what tx on before pregnancy - go back to that!
67
In maternal diabetes, risks to baby once born. Management?
Large pancreas thus hypoglycaemia and hypercalcaemia - feed quickly and lots! Polycythemia - haemolysis - jaundice
68
What problems does pregnancy pose to screening for diabetes?
Glycosiuria and ketonuria are normal during pregnancy
69
Who should be screened for gestational diabetes?
FHx Previous GD Previous miscarriage or stillborn
70
How can a baby in breech be delivered?
Deliver PV breech C-section External cephalic version and PV delivery
71
Risk of complications delivering breech PV?
1:20
72
When would external cephalic version be carried out? Where? Risks?
36-37 weeks Delivery suite Fetal distress mandating delivery
73
What meds would you give prior to external cephalic version?
Ranitidine incase of csection need | Anti d if rh neg
74
Success rate of external cephalic version
50-60% can be turned | 5% then turn back
75
Can external cephalic version be repeated? Anything different?
Yes! Can be done under epidural
76
Complications of multiple pregnancy?
``` Increased risk of pre eclampsia Increased risk of anaemia Premature labour Increased risk of non cephalic presentation Increased risk of PPH Increased risk of small baby Twin to twin transfusion ```
77
What medications will patients with multiple pregnancies tend to recieve?
Iron supplementation
78
How will multiple pregnancies tend to be delivered?
Twins - PV but second often needs instrumentation or csection Triplets or more - csection
79
Presentation of obstetric cholestasis? When in pregnancy?
Generalised itching, worse on palms and soles, worse at night, mild jaundice or dark urine may occur Usually post 28 weeks
80
Diagnosis of obstetric cholestasis
LFTs and bile acids | USS to rule out gallstones
81
Effect of obstetric cholestasis on fetus?
Increased chance of merconium in waters, premature birth and stillbirth (very slight if at all)
82
Conservative treatment of obstetric cholestasis
Skin creams, keep nails short, cool baths, loose fitting clothes
83
Medical treatment of obstetric cholestasis
``` Vit K due to liver disfunction Skin creams Antihistamines to aid sleep Ursideoxycholic acid Induce at 37 weeks roughly ```
84
Follow up advice for obstetric cholestasis post delivery
GP in 2 months to check lfts 45-90% chance of repeat next pregnancy Can be best to avoid COCP
85
Contraindications to fetal blood sampling
BBV Fetal blood disorder Malpresentation
86
When would fetal blood sampling be performed? When would it not be performed (not a contraindication)
Signs of fetal distress | Dont do in fetal bradycardia - needs delivery whatever the result
87
Complications of fetal blood sampling
Infection, trauma to somewhere not intended (mother or fetus), bleeding
88
Interpretation of pH in fetal blood sample with action
>7.24 - normal | 7.2-7.24 - repeat in 30 minutes once
89
What is the medical term for breaking the waters? Indications?
Amniotomy | Induction of labour, prolonged stage 1 labour, suspicion of merconium
90
Why does an amniotomy result in induction of labour?
Releases prostoglandins
91
Complications of amniotomy
Injury to cervix | Cord prolapse
92
Disadvantages of pinnard use?
User variability Not real time for everyone in room Hard with multiple pregnancies
93
Contraindications to fetal scalp electrode use
BBV, bleeding disorder, malpresentation
94
Complications of fetal scalp electrode use
Infection, injury to mother, injury to baby
95
Indications for instrumental delivery
``` >2 hrs stage two labour Fetal compromise at full dilatation Unable to push (eg paralysis) Risk of pushing (eg pre-eclampsia, high ICP) Aiding delivery of breech ```
96
What should be done prior to an instrumental delivery?
Empty the bladder
97
Contraindications to an instrumental delivery
Cervix not fully dilated | Cephalopelvic disproprotion
98
Complications of instrumental delivery
Injuries to baby or cervix | Uterine rupture
100
Risk factors for preterm labour
``` Previous Hx Multiple pregnancy (low space) Polyhydraminos (low space) Uterine abnormality (low space) UTI PPROM (usually 2o subclinical chorioamnoitis) Extremes of age ```
101
Definition of labour
Progressive and strengthening contractions with cervical dilatation
102
How can PPROM be tested for?
Test pH of vaginal fluid
103
What test can be done with a high negative predicative value for labour if a patient presents with preterm pains?
Fetal fibronectin swab
104
Broad managment of preterm labour prior to 34 weeks
Steroids Tocolysis Move to centre with neonatal itu ABX if PPROM
105
What drugs can be used for tocolysis
Atociban (oxytocin receptor antagonist) Nifedipine Indomethacin
106
Contraindications to tocolysis
Suspected infection Fetus dead Maternal condition requiring delivery APH
107
Can tocolysis be repeated? Why | .
No | Commonly preterm labour is due to infection so repeating leaves child in infectious environment
108
How should PPROM be managed in the absence of labour?
ABX | Expectant management, if signs of infection (on bloods ie. Increasd crp - do not wait for symptoms) then deliver
109
Problem with use of indomethacin as tocolytic
Prematurely closes ductus arteriosus
110
Complications of fetal hypoxia at delivery?
Death | Cerebral palsy
111
Investigation to run in a small for date baby to check for hypoxia?
Doppler ultrasound - MCA - high flow suggests hypoxia - umbilical artery - should have positive end diastolic flow, absent or negative suggests incased flow resistance
112
Ways of monitoring a fetus antinatally
Movements - any reported change in pattern Pinnard CTG USS
113
How often should a low risk pregnancy be monitored during delivery ?
1st stage pinnard every 15 minutes and after each contraction 2nd stage pinnard every 5 minutes and after each contraction
114
What is the benfit and problems with ctg monitoring in high risk labour
Decreases neonatal seizure but no change to long term outcomes and increases rate of instrumentation and csection
115
Interpretation of a ctg
DR - determine risk C - contractions - frequency, intensity, regularity BR - baseline rate 110-160 A - accelerations VA - variability >5bpm D - decelerations - early, late or variable O - overall assessment
116
Causes of fetal tachycardia
``` Fever Hypoxia Arrhythmia Anxiety Dehydration ```
117
Causes of fetal bradycardia
Medications Heart block Cord compression
118
Differentiate early and late decelerations
Early occur peak to peak with contractions, - normal | Late occur 15s after - pathological
119
What is a deceleration
Decrease of 15bpm or more for 15 seconds or more
120
Management of an worrying ctg, conservative to surgical?
Position left lateral to increase pacental blood flow (clear ivc) Stop syntocinon Fetal blood sample Deliver
121
Signs of uterine rupture during delivery.
``` CTG abnormalities Severe pain between contrations Shoulder tip pain Shock Vaginal bleeding Scar tenderness Loss of effective contractions Breakthrough pain through epidural Loss of station ```
122
What percentage of children can be delivered PV. How does this change post section?
80% falling to 75%
123
Advantages of VBAC
``` Avoids surgery (bladder damage, blood loss, hysterectomy, infection, cut nto baby. ) Faster recovery (thrombosis, no driving for 6 weeks) ```
124
Disadvantages of VBAC
Weakening to rupture in 1:200 Higher risk to baby 25% will need emergency c-section which is higher risk of blood transfusion
125
Contraindications to VBAC
Upper segment csection | >2 csections
126
What must happen in a VBAC birth that is not always necessary in normal vaginal?
In hospital with IV access and CTG
127
What would increase the risk of scar rupture in VBAC?
Induction of labour
128
What options are there for downs screening?
1st trimester - combined test 2nd trimester - triple test Detailed scan (50%)
129
How can the results of a amniocentesis or cvs be sped up?
FISH test paid for privately
130
Risk in cvs sampling
1% risk of miscarriage 1% risk of placental mosaicism Infection
131
When can cvs be performed for downs
Weeks 11-14
132
When can amniocentesis be performed?
Weeks 15-20
133
Other than age what increases the risk of downs syndrome in pregnancy?
Previous downs pregnancy
135
What patients should recieve treatment for group b strep?
All those that test positive in this pregnancy or any previously positive babies
136
What is treatment for group b strep?
IV antibiotics for mother for at least 4 hours prior to delivery If not possible antibiotics for baby and admission
137
Background prevalence of GBS Infection rate of GBS for babies Mortality of GBS infection in babies
20% 1:2000 10%
138
What are the torch infections? What is the relevance?
``` Toxoplasmosis Other (syphallis, cocksackie, lymes, malaria, HIV) Rubella CMV Herpes ``` Common infections acquired by the mother than can be passed to the child vertically transplacentally or at delivery. Results in sepsis or malformation in the infant.

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