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1
Q

What is gestational hypertension?

A

Blood pressure of over 140/90mmHg

OR increase in over 30mm/Hg systolic or 15mm/Hg diastolic compared with previous / booking BP

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2
Q

What is pre-eclampsia?

A

Gestational hypertension

+ proteinuria (0.3g/day)

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3
Q

What does pre-eclampsia predispose a woman to?

A 
Eclampsia
HELLP syndrome
Cerebral haemorrhage
Placental abruption
IUGR
Renal failure
DIC
Pulmonary oedema
Stillbirth
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4
Q

What are the features of severe pre-eclampsia?

A 
Headaches
Nausea
Visual disturbance
Oedema / papilloedema
HELLP - RUQ or epigastric pain
Hyperreflexia
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5
Q

What is HELLP?

A

Haemolysis
Elevated liver enzymes
Low platelets

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6
Q

What are the risk factors for pre-eclampsia?

A 
Previous pregnancy with hypertension
CKD
Autoimmune disease
Diabetes
Chronic hypertension
FAT FUCK
Last pregnancy over 10 years ago
Multiple pregnancy
1st pregnancy
Extremes of age - old or young un
Family history of pre-eclampsia
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7
Q

What is the management of gestational hypertension and pre-eclampsia?
First line

A

If BP >150/100 - oral labetalol

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8
Q

At what BP would you give a pregnant lady medical treatment?

A

150/100mm/Hg

Give labetalol

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9
Q

If a patient with gestational hypertension or pre-eclampsia is not responding to first line treatment, what would you give?
(second line treatment ffs DUH)

A

Oral nifedipine

IV hydralazine

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10
Q

What is eclampsia?

A

Development of seizures with pre-eclampsia

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11
Q

How do you treat eclampsia?

medical - give doses and route

A

Magnesium sulphate
IV bolus - 4g over 5-10 mins
Infusion of 1g over an hour
Until 24 hours after last seizure / delivery

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12
Q

What is the definitive treatment for eclampsia?

A

DELIVERY

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13
Q

What do you need to monitor in a woman receiving magnesium sulphate for eclampsia?

A

Urine output
Reflexes (precedes hypotension in toxicity)
Resp rate - for respiratory depression (toxicity)
O2 sats

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14
Q

How would you treat magnesium sulphate toxicity in a woman with eclampsia?

A

Calcium gluconate

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15
Q

What are the teratogenic infections during pregnancy?

A 
CHRiST
CMV
Herpes zoster
Rubella
Syphilis
Toxoplasmosis
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16
Q

If a baby is born and develops temperature, resp distress and lethargy - sepsis, and has blood cultures done - what would this show? Ie what is the most likely infection?

A

GBS

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17
Q

What does group B strep infection cause to happen to a baby?

A

Neonatal sepsis

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18
Q

Where is group B strep carried in a woman?

A

Birth canal

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19
Q

How do you prevent transmission of Group B strep from mother to baby?

A

IV benzylpenicillin

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20
Q

What are the causes of antepartum haemorrhage?

A

Placenta praevia
Placental abruption
Vasa praevia
Uterine rupture

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21
Q

What is placenta praevia?

A

Implantation of the placenta into the lower segment of the uterus

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22
Q

What are the types of placenta praevia?

A 
1+2 = not over os
3+4 = over os
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23
Q

How does placenta praevia present?

A

Incidental on USS
Painless vaginal bleeding
Abnormal lie / breech presentation

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24
Q

What is the management of placenta praevia?

A

Give anti-D if rhesus negative
Give steroids if <34 weeks
Delivery by C section at 39 weeks

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25
What are the risk factors for placenta praevia?
Multiple birth Multiparous High maternal age Previous C section
26
What are the complications of placenta praevia?
Obstruction of engagement of head Abnormal lie (esp transverse) Severe haemorrhage - can be PPH Placenta accreta --> hysterectomy
27
What is placental abruption?
When all or part of the placenta separates before delivering foetus
28
What are the risk factors for placental abruption?
``` IUGR Pre-eclampsia Pre-existing hypertension Maternal smoking Previous abruption Cocaine abuse Multiple pregnancy Multiparous Autoimmune disease ```
29
How does placental abruption present?
WOODY HARD UTERUS PAINFUL bleeding / pain alone if bleeding concealed Difficult to feel foetus Shock out of keeping with visible loss (concealed) Foetal distress or absent heart sounds
30
How would you investigate a patient with placental abruption?
Foetal - CTG and USS | Maternal - FBC, coag screen, cross match, U&E, urine output
31
How would you manage a patient with placental abruption?
ABCDE Anti-D if rhesus negative Steroids if <34 weeks and no foetal distress C section if foetal distress Induction of labour with amniotomy if >37 weeks and no foetal distress Blood transfusion
32
What are the differences in presentation between placenta praevia and placental abruption?
Praevia = painless, abruption = painful
33
What is vasa praevia?
Fetal blood vessel runs in membranes before the presenting part
34
How would a woman present with ruptured vasa praevia?
Painless, moderate vaginal bleeding - at amniotomy or SROM
35
How would you manage a woman with a ruptured vasa praevia?
Immediate C section
36
Describe the passage of the foetus through the birth canal during labour
Engagement Descent and flexion Internal rotation (usually left occipito anterior) Descent Crowning Extension of head --> delivery of head Internal restitution of shoulders (anterior-posterior) Downward traction (delivery of anterior shoulder) Lateral flexion (and delivery of posterior shoulder) Then everything else shoots out
37
What are the mechanical factors that determine progress through labour?
3 Ps - Powers - Passage - Passenger
38
How do you diagnose labour?
Painful uterine contractions Cervical dilatation Cervical effacement
39
What, broadly speaking, is involved in stage 1 of labour?
From the start of labour to full cervical dilatation
40
What is stage 1 of labour made up of?
Latent labour Active labour Transition
41
What is involved in the latent phase of stage 1 labour?
Slow dilatation of the cervix up to about 4cm Slow Can have "show" ie mucoid plug passing
42
What is involved in the active phase of stage 1 labour?
3-10cm dilatation of cervix Frequent contractions Should last less than 12 hours
43
What, broadly speaking, is stage 2 of labour?
Full dilatation to delivery
44
What is stage 2 of labour made up of?
Passive stage | Active stage
45
What is involved in the passive phase of stage 2 of labour?
Until head reaches the pelvic floor - when woman experiences a desire to push Completed rotation and flexion
46
What is involved in the active phase of stage 2 of labour? + how long does it last
Pushing with contractions Should be in the most comfortable position, just not supine 20 mins for multiparous woman 40 mins for nulliparous woman
47
What negative impact can an epidural have on the progress of labour?
Can prevent the woman feeling the desire to push down
48
What is stage 3 of labour?
From delivery of foetus to the delivery of the placenta
49
What is the normal amount of blood loss in stage 3 of labour?
Up to 500ml
50
What can reduce blood loss in stage 3 of labour?
Active management: Use of oxytocin to contract the uterus Early clamping and cutting of cord CCT (controlled cord traction)
51
How would you manage a nulliparous woman who is not progressing through the first stage of labour?
Artificial rupture of membranes - amniotomy Then oxytocin IV Then C section if not progressed after 12 hours
52
How would you manage a nulliparous woman who is not progressing through passive 2nd stage of labour?
Oxytocin
53
How would you manage a woman who is not progressing through the active 2nd stage of labour, if the head is against the perineum?
Episiotomy
54
How would you manage a woman who is not progressing through the active 2nd stage of labour, if the head is not against the perineum?
Ventouse / forceps delivery
55
What could cause an obstruction in the passage of a foetus during labour?
Cephalo-pelvic disproportion Abnormal pelvic architecture - osteomalacia, poorly healed pelvic fracture, scoliosis, polio, congenital abnormalities Pelvic mass - fibroid or ovarian tumour
56
What abnormal presentations of the baby could cause issues during labour?
OP OT Brow Face
57
How would you manage a slow labour with an OP baby?
Augmentation of labour ie oxytocin | Instrumental delivery to rotate to OA
58
How would you manage a slow labour with an OT baby?
Rotation with traction ie ventouse
59
How would you know that a baby was brow-orientated?
Can palpate the anterior fontanelle, nose and supraorbital ridges
60
How would you manage a brow-orientated baby?
C section
61
How would you know that a baby was face-orientated?
Complete extension of the head - mouth, nose and eyes palpable
62
How would you manage a face-orientated baby?
If chin is mento-anterior can deliver vaginally | If mento-posterior need C section
63
What is the role of prostaglandins in labour?
Promotes cervical effacement and dilation (reduces cervical resistance) Increases oxytocin secretion from posterior pituitary
64
Where is oxytocin secreted from?
Posterior pituitary gland
65
Where are the pacemakers in the uterus?
Each cornu of the uterus
66
What is taken into account when calculating a Bishop's score?
``` Favourability of cervix Consistency of cervix Degree of effacement of cervix Extent of dilatation of cervix Station of the head ```
67
If a woman who is 41 weeks pregnant presents with a Bishop's score of <6, how would you encourage labour?
Vaginal prostaglandin gel
68
When inducing labour, where is the vaginal prostaglandin gel placed?
Posterior fornix of the vagina
69
If a woman who is 42 weeks pregnant presents with a Bishop's score of >6, how would you induce labour?
Amniotomy ± oxytocin
70
How would you perform an amniotomy?
Rupture membranes with an amnihook
71
How would you act if a woman has not progressed into labour after 2 hours following an amniotomy?
Start oxytocin infusion
72
How would you induce labour in a woman who's membranes have already ruptured?
Oxytocin infusion
73
What are the foetal indications for induction of labour?
``` Prolonged pregnancy Suspected IUGR or compromise Antepartum haemorrhage Poor obstetric history Preterm rupture of membranes ```
74
What are the materno-foetal indications for induction of labour?
Pre-eclampsia | Gestational diabetes
75
What are the contraindications for induction of labour?
``` Acute foetal compromise Abnormal lie Placenta praevia Pelvic obstruction Cephalo-pelvic disproportion ```
76
Why is prolonged pregnancy (ie >42 weeks) bad?
Macrosomia Neonatal hypoglycaemia Meconium aspiration
77
What would you offer if a 41 week pregnant lady presented to you without having started labour?
Membrane sweep
78
What are the complications of induction of labour?
Can not work Increased chance of instrumental delivery Increased chance of PPH Increased chance of cord prolapse
79
What are the obstetric emergencies?
``` Shoulder dystocia Cord prolapse Uterine rupture Amniotic fluid embolism Retained placenta ```
80
What is the definition of shoulder dystocia?
Inability to delivery the body of the foetus following delivery of the head
81
Why does shoulder dystocia occur?
Because the anterior shoulder is impacted on the maternal pubic symphsis
82
What complications can occur as a result of shoulder dystocia?
Mother: PPH Perineal tears Bladder and ureter injury ``` Child: Brachial plexus injury (Erbs palsy) Hypoxia Hypoxic-ischaemic encephalopathy Death ```
83
What nerves are affected in Erb's palsy?
C5-C7
84
What are some risk factors for shoulder dystocia?
``` Previous shoulder dystocia Macrosomia (so prolonged pregnancy) High maternal BMI Diabetes Prolonged labour ```
85
How do you manage a shoulder dystocia?
Call for help (unless you're da one man JonathAN) McRobert's manoeuvre Apply subrapubic pressure Internal manoeuvres ± episiotomy
86
What is McRobert's manoeuvre? + what does it do?
Bring mother's thighs towards abdomen Flexion and abduction of the hips Increases relative anterior-posterior angle of the pelvis
87
What are the internal manoeuvres used in shoulder dystocia?
Woodscrew manoeuvre Grab arm or some shit Symphisiotomy (OOF OWCHIE) Zavanelli manoeuvre (head born but you push head back in and do a C section)
88
What is cord prolapse?
When the umbilical cord descends ahead of the presenting part of the foetus
89
What are the types of cord prolapse?
``` Occult = when it lies alongside the presenting part Overt = when it lies past the present part ```
90
How does a cord prolapse present?
Visible cord | Or fetus bradycardia (or any other CTG abnormality)
91
How would you make a diagnosis of cord prolapse?
Is cord visible beyond the level of the introitus Is cord palpable vaginally CTG
92
What is the management of a cord prolapse?
Urgent delivery or instrumental if fully dilated and will be quickest option Don't handle the cord
93
Why should you try not to handle the cord in cord prolapse?
Can cause vasospasm
94
How should you manage a cord prolapse until delivery is possible?
If cord before level of introitus - push presenting part of baby back to avoid compression If cord below level of the introitus - keep warm and moist Tocolytics eg nifedipine
95
How do you classify uterine rupture?
Incomplete (occult) = separation of surgical scar but visceral peritoneum intact Complete = EMERGENCY - Traumatic = RTC, incorrect use of oxytocin, poorly conducted attempt at vaginal delivery - Spontaneous = history of C section or trauma, or multiparity leads to weakened uterus
96
How does uterine rupture present?
``` Maternal shock Severe abdominal pain Vaginal bleeding Chest / shoulder tip pain Sudden SOB CTG abnormalities ```
97
How would you manage a uterine rupture?
ABCDE - make sure mum stable Urgent surgical delivery Usually hysterectomy
98
CASE A 29 year old woman has just had SROM. She collapses, following sudden shortness of breath. What is your differential diagnosis?
Amniotic fluid embolism
99
What are the symptoms of amniotic fluid embolism?
PE DIC So sudden SOB, collapse (anaphylactic)
100
Outline the pathophysiology of amniotic fluid embolism
Fetal cells / amniotic fluid enter mother's bloodstream Stimulates massive immune reaction Leads to PE, anaphylaxis, DIC
101
How do you manage a woman with suspected amniotic fluid embolism?
``` ABCDE O2 - mechanical ventilation Maintain perfusion Correct coagulopathy - might need blood products Delivery - perimortem C section ```
102
How would you diagnose retained placenta in a woman who has undergone physiological management of 3rd stage labour?
Placenta not delivered within 60 mins of birth
103
How would you diagnose retained placenta in a woman who has undergone active management of 3rd stage of labour?
Placenta not delivered within 30 mins of birth
104
What are the causes of retained placenta?
Uterine atony Trapped placenta aka closed os Placenta accreta/percreta
105
What are the complications of a retained placenta?
PPH Genital tract infection Uterine inversion - can cause neurogenic shock
106
How would you manage a woman with a retained placenta?
Assess blood loss IM syntocinon Ensure bladder is empty Manually remove placenta in theatre
107
What are the methods of measuring foetal distress?
CTG Foetal blood sampling Foetal ECG
108
What is the definition of foetal distress?
Hypoxia that might result foetal death or damage if not reversed or foetus delivered urgently
109
What pH in the foetal scalp signifies hypoxia?
<7.2
110
What do you look for on a CTG to monitor for foetal distress?
DR C BRAVADO DR = define risk C = contractions per 10 minutes (hyperstimulation = >5) BR = baseline rate (110-160 = normal) V = variability (should be >5 beats per min) A = acceleration (with movement or contractions = reassuring) D = decelerations (early with contractions = benign, variable = ? cord compression, late after contractions = foetal hypoxia) O = overall assessment (if CTG normal = reassuring, abnormal patterns have high false positive)
111
What is normal for contractions on a CTG?
>5 is bad = hyperstimulation
112
What is a normal baseline rate for CTG?
110-160
113
What should the variability be on a CTG?
>5 beats per min
114
What are accelerations a sign of on CTG?
Reassuring if with movement or contractions
115
What are decelerations a sign of on CTG?
Early = benign Variable = ? cord compression Late (after contractions) = foetal hypoxia
116
What is the definition of primary post partum haemorrhage?
Loss of >500ml in the 24 hours after birth | Or >1000ml if C section
117
What are the causes of primary post partum haemorrhage?
``` Tone = uterine atony Trauma = perineal tear, episiotomy, cervical if instrumental Tissue = retained placenta Thrombin = coagulopathy ```
118
What is the definition of secondary post partum haemorrhage?
Excessive blood loss occurring between 24 hours and 6 weeks after delivery
119
What are the causes of secondary post partum haemorrhage?
Endometritis Retained placental tissue Gestational trophoblastic disease
120
What is the management of secondary post partum haemorrhage?
Antibiotics | Evacuation of retained products
121
How would you manage a primary PPH?
``` ABCDE IV syntocinon IM carboprost Removal of retained placenta B-Lynch suture, uterine or internal iliac artery embolisation, balloon If uncontrolled - hysterectomy ```
122
What tool do you use to diagnose postnatal depression?
Edinburgh score
123
What should you consider in a patient with suspected postnatal depression?
Postpartum thyroiditis
124
What are the risk factors for gestational diabetes?
``` BMI over 30 Previous macrosomic baby Previous gestational diabetes Family history of diabetes South asian / black caribbean / middle eastern origin ```
125
How / when do you screen for gestational diabetes? + what are the cut offs
Previous GD - OGTT after booking Again / everyone with a risk factor at 24-28 weeks Fasting glucose >5.6 OGTT of >7.8mmol/L
126
How do you manage gestational diabetes?
Diabetes clinic Fasting <7 - trial of diet and exercise for 1-2 weeks If that doesn't work - metformin If that doesn't work - insulin Fasting >7 - start insulin Or >6 and a risk factor - start insulin If can't tolerate metformin and refuse insulin - glibenclamide (sulfonylurea)
127
How do you manage pre-existing diabetes in pregnancy?
Weight loss 4 da fatties Stop all meds apart from metformin and start insulin Folic acid 5mg/day from preconception to 12 weeks Then aspirin 75mg/day from 12 weeks till birth (reduce risk of pre-eclampsia)
128
What is gravidy?
Number of times a woman has been pregnant
129
What is parity?
Number of times a woman has given birth to a fetus >24 weeks
130
What are the foetal complications associated with gestational diabetes?
Congenital abnormalities (neural tube + cardiac) Pre term delivery Fetal lung maturity reduced Increased birth weight and associated trauma Fetal compromise and fetal distress are more common Polyhydramnios -> increased chance of abruption Hypoglycaemia post delivery as baby is ‘accustomed’ to hyperglycaemia
131
What are the maternal complications associated with gestational diabetes?
``` HELLP UTI Wound / endometrial infection after delivery Retinopathy Nephropathy ```
132
What is the definition of normal labour?
``` Spontaneous onset Low-risk Vertex position Between 37 and 42 weeks Good condition after birth (no induction, anaesthesia, instrumental, CS or episiotomy) ```
133
What is the definition of small for dates (small for gestational age)? + its significance
<10th centile for gestation (no intervention if no deterioration, ie – growing normally)
134
What is the definition of IUGR? + its significance
Growth in utero has slowed, does not necessarily mean that they will end up SFD. Important factor as continued IUGR is indicative of pregnancy problems. Consider early delivery if continued IUGR.
135
What would you give to treat VTE in pregnancy?
Low molecular weight heparin - Warfarin is CI due to teratogenicity
136
What are the possible types of multiple pregnancy?
Mono or dizygotic (from one fertilised egg or more than one) Mono or dichorionic - do they share a placenta Mono or diamniotic - do they share amniotic fluid and sac
137
What are the risk factors of multiple pregnancy?
Previous multiple pregnancy Family history of multiple pregnancy Assisted conception
138
What are the risks associated with / complications of multiple pregnancy?
``` Preterm labour / birth Gestational hypertension / pre-eclampsia Anaemia Congenital birth abnormalities Twin to twin transfusion syndrome Placenta praevia Placental abruption / uterine rupture PPH ```
139
Outline twin to twin transfusion syndrome
In monochorionic twins Disproportionate blood supply - one twin gets more than the other One with more = recipient One with less = donor Donor has decreased growth and development, plus oligohydramnios Recipient has higher blood volume so heart failure (foetal hydrops) and pisses out more so polyhydramnios Treatment = serial amniocentesis to get rid of the polyhydramnios, laser therapy to cut the anastamosis between the blood supplies in the placenta
140
How do women present with multiple pregnancy?
Seen on scan Enlarged uterus Hyperemesis Polyhydramnios
141
What factors affect birth weight?
Maternal size & weight Parity Gestational diabetes Smoking + I'd guess like when its born lol
142
What is placenta accreta / increta / percreta?
Abnormal decidua basalis (area of endometrium between implanted chorionic villi and myometrium) Villi invade further Accreta = villi attached to myometrium Increta = villi invade 50% through myometrium Percreta = villi invade through whole myometrium, can involve bladder / bowel
143
How do you detect placenta accreta?
On US - usually for foetal anomaly scan
144
What are the risk factors for placenta accreta?
Previous accreta Previous C section Previous uterine surgery
145
What does placenta accreta put you at risk of?
Antepartum haemorrhage | Post partum haemorrhage
146
How do you manage placenta accreta?
MDT care - specialist care with blood products, neonatal care and adult intensive care unit Pre-emptive C section Hysterectomy - leaving the placenta in situ
147
Outline the formation of twins (chronionic / amniotic) with regards to the number of days at which cleavage happens
``` 1-3 = dichorionic, diamniotic 4-8 = monochorionic, diamniotic 8-13 = monochorionic, monoamniotic 13-15 = conjoined ```

Phase 3a (11 decks)

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