Obs - pregnancy and labour Flashcards
(154 cards)
1
Q
What are the 3 newborn screening programmes?
A
Newborn blood spot - CF, CHT, SCD, IMD (maple syrup, MCADD)
Newborn hearing test
Newborn and 6-8 week infant physical examination
2
Q
What are the 3 antenatal screening programmes?
A
Fetal anomaly screening programme - tristomies (10-14 and 20+6 weeks)
Infectious diseases
Sickle cell and thalassaemia
3
Q
When does it count as ‘active labour’?
A
4cms onwards Regular, progressive contractions Oxytocin released = ripening of cervix = dilation Should progress -nulliparous 0.5-1cm/h -multiparous 1-2cm/h
4
Q
What is effacement?
A
starts in fundus
shortening/retraction of muscle fibres and amplitude increases as labour progresses
fetus moves down to press in cervix
5
Q
What is involved in latent phase of labour?
A
irregular contractions mucoid plug shown lasts 6 hours - 2-3 days -nulliparous about 18h -multiparous about 12h cervix thinning
6
Q
What are the hormones for communication between blastocyst and endometrium?
A
human chorinic gonadotrophins, progestins, oestrogens
7
Q
What causes myometrial contraction in parturition?
A
Increase in calcium due to oxytocin releasing calcium from intracellular stores
8
Q
What causes myometrial contraction in parturition?
A
Increase in calcium due to oxytocin releasing calcium from intracellular stores
9
Q
What conditions are linked to failed endovascular invasion?
A
premature birth, fetal growth restriction, recurrent miscarriage, placental abruption, pre-eclampsia
10
Q
How do you tests/treat/prevent rhesus haemolytic disease?
A
Test at booking, 28 and 34 weeks
Assess fetal anaemia with MCA doppler
anti-D immunoglobulin
Kleihauer test
11
Q
Who is at risk of rhesus haemolytic disease?
What is it?
A
Rhesus - mum with rhesus + baby
Maternal antibody response mounted against fetal red blood cells
12
Q
What are some key factors that can determined from a CTG? And what is the full name?
A
Dr. C Bravado - cardiotography Determine risk Contraction rate Baseline rate - 110-160 Variability - >5bpm, acceleration and deceleration 15bpm for 15 seconds Accelerations Decelerations Overall Assessment
13
Q
What is gestational trophoblastic disease?
A
abnormal cells or tumours that start in the womb from cells that would normally develop into the placenta
14
Q
What is the difference between complete and partial molar pregnancy?
A
Complete - empty ovum fertilised with sperm and it multiplies
Partial - ovary fertilised by 2 sperm
15
Q
How would you test for molar pregnancies?
A
US - snowstorm appearance inside uterus
high beta hCG
16
Q
How would you treat molar pregnancies?
A
Surgical removal
Methotrexate but only if beta hCG fails to fall satisfactorily
17
Q
What is hyperemesis gravidarum?
A
excessive vomiting, dehydration and ketosis
can lead to weight loss and faintness
18
Q
How would you treat hyperemesis gravidarum?
A
bland, small meals and oral rehydration
antiemetics, IV rehydration nutritional support, thymine (to prevent Wernicke’s), folic acid
19
Q
What are the risk factors of hyperemesis gravidarum?
A
primigravida, multiple pregnancy, obesity, personal or family history, history of eating disorder
20
Q
What are the differential diagnosis of hyperemesis gravidarum?
A
Infections, GI problems, metabolic problems, drugs, gestational trophoblastic disease
21
Q
How common are ectopic pregnancies and what are the risk factors?
A
1% births
Most are in the fallopian tubes
IVF, prior ectopic (10% risk), tubal injury or surgery, PID, endometrial injury, IUD, endometriosis, placenta pravida, uterine abnormalities, smoking, increased maternal age, history of abortion, chlamydia, fibroids, Asherman’s
22
Q
What are the symptoms of ectopic pregnancy?
A
one sided lower abdo pain abdominal tenderness vaginal bleeding cervical excitation on examination palpable adnexal mass shoulder tip pain
23
Q
How would you test for an ectopic pregnancy?
A
beta hCG is rising slower than expected or is static
progesterone lower than expected for gestational age
transvagainal US
Diagnostic laparoscopy
24
Q
How would you treat an ectopic pregnancy?
A
Medical - methotrexate (if small) it targets rapidly proliferating trophoblast
Surgical - salpingotomy (removal) and ectopic gestation removed
salpingostomy if possible (incision)
25
How would you treat a delayed miscarriage?
mifepristone - anti-progesterone
| misoprostol - synthetic prostaglandin so a uterine stimulant
26
What happens to hCG in a miscarriage?
Drop or stagnation in hCG
27
What is placenta praevia?
| What are the classifications?
low lying placenta - partial/minor or major
should be at least 20mm from os
Marginal - close to OS (2cm)
Major - placenta lies over OS
28
What should you avoid in placenta praevia?
do not do a vaginal exam
29
What is placenta accreta?
| How would you test and treat it?
when placenta penetrates decidua bascalis through myometrium
USS, MRI
Aim to deliver by 35-36wks, CS (+/- hysterectomy)
30
What is vasa praevia?
fetal vessels crossing through membranes over internal os and below fetal presenting part, unprotected placental tissue or umblicial cord
fetal vessels run in membrane below presenting fetal part
major fetal risk
31
What is placental abruption?
premature seperation of placenta from uterine wall
32
What are the types of placental abruption? and the symptoms
```
concealed or revealed
Sudden onset, mild lower abdominal pain with uterine tenderness, woody-hard, tense, uterus, Bleeding
can cause premature labour
fetal distress
maternal shock due to blood loss
```
33
What is the difference between primary and secondary and minor and major postpartum haemorrhage?
primary - within 24 hours of delivery less than 500 mls
secondary - post 24 hours, up to 12 weeks post delivery
Minor 500-1000ml
Major >1000ml
34
What are the causes of post partum haemorrhage?
Tissue - partial placental loss
Tone - ensure uterus is contracted (not contracting = uterine atony)
Trauma - look for tears
Thrombin - check clotting
35
How would you treat eclampsia?
magnesium sulphate
36
What is antiphospholipid syndrome?
increased aPL antibodies to phospholipid related proteins
Autoimmune
Causes recurrent thrombosis and pregnancy morbidity
37
How would you treat antiphsopholipid syndrome?
aspirin 75mg
| low molecular weight heparin
38
Name 3 risk factors for miscarriage
Early <12 weeks
Causes - chromosomal abnomaly antiphospholipid syndrome
Late >12
causes - cervical incompetence
39
How would you manage pre-eclampsia?
```
monitoring - creatinine, serum urate, CXR, U&E, APTT, fibrinogen, bilirubin
assess if indication for delivery
decreased BP - labetalol, hydralazine
IV magnesium sulphate
Steroids at 34 weeks
```
40
What is the definition of pre-eclampsia?
| What are the symptoms?
```
gestational hypertension
>140/ or >/90 after 20 weeks gestation
proteinuria
visual disturbances, headache, RUQ/epigastric pain
facial oedema, brisk hyperreflexive
```
41
What are 3 pre-existing medical conditions altered by pregnancy?
asthma - exacerbations in 3rd trimester
cardiac e.g. mitral stenosis, which are worsened by increased CO
DM - high glucose = teratogenic
renal
epilepsy - increased frequency of seizures in 25-33%
42
Name 3 causes of small babies
small for gestational age
- constituionally, infection, chromosomal abnormalities
growth restriction - smoking, pre-eclampsia
43
What are the 3 measures of fetal growth?
abdominal circumference is the best measure
head circumference
leg length
44
What are 3 pregnancy specific conditions?
pre-eclampsia, acute fatty liver, obstetric cholestasis, gestatinal DM, anaemia
45
What is the difference between direct and indirect causes of maternal death? Name 3 causes of maternal death
thromboembolism, haemorrhage, sepsis, pre-eclampsia
Direct - death resulting from obstetric complications of pregnancy, labour
Indirect - death resulting from pre-existing disease/disease that developed in pregnancy
46
What are the common maternal mental health problems and their commonality?
post-partum depression 10%
post-partum psychosis 1-2/1000
PTSD 3% full, 33% some symptoms
47
What are some red flags in maternal mental health?
recent change in mental state/new symptoms
new thoughts/acts of violent self-harm
new/persistent expressions of incompetency as mother/estrangement
48
Trisomy triple test - when it is done and what is tested for?
```
Down, Patau, Edwards
10-14 weeks
increased nuchal tranlucency
Beta hCG (high)
PAPP-A (low)
```
49
Trisomy quadruple test - when is it done and what is tested for?
Down, patau, Edwards
14-20 weeks
Beta hCG & Inhibin A (high)
alpha feroprotein & unconjugated estrodial (low)
50
What should be routinely offered to women with a very high BMI?
post-natal thromboprophylaxis, pre-eclampsia screening, obstetric anaesthetist referral, actively manage 3rd stage of labour due to risk of PPH, Vit D daily
51
What is a missed miscarriage?
loss of pregnancy without passing contents of conception or bleeding
52
What structures does an episitomy involve?
bulbospongiosus, superficial transverse perineii, vgainal mucosa and perineal membrane
Avoid ischiocarvernosus
53
What happens to bloods in DIC (disseminated intravascular coagulation)?
increased prothrombin, aPTT and bleeding time
| decreased platelets
54
What are hydatidiform moles?
Benign trophoblastic tumour - genetically abnormal, large and small villi scalloped outlines, trophoblastic hyperplasia
55
What are the bony landmarks of pelvic outlet?
pubic arch, ischial tuberosities, coccyx
56
When does an embryo become a foetus?
8 weeks
57
At what point is the fetal heartbeat detectable?
8 weeks
58
When is methotrexate to treat ectopic pregnancy contraindicated?
rupture, mass > 3.5 cm, foetal cardiac activity, bhCG >6000
59
What other medication can be used for direct injection, other than methotrexate to treat ectopic ?
potassium chloride
60
What is the normal weight of a baby?
5lbs8 - 8lbs13
| 2500-4000g
61
What are 2 acute and 2 long terms risks of IUGR?
Acute - stillbirth, prematurity, nectrotising enterocolitis, hypoxic brain injury, retinopathy of prematurity
Chronic: CVD, T2DM, small kidneys, low IQ, impaired visuomotor development
62
What are two acute and 2 long term risks of macrosomnia?
Acute: shoulder dystocia, clavicular fracture, long labour, hypoxia
Long term: obesity, hypoglycamia, DM, hypertension, metabolic syndrome
63
What are two maternal risks of macrosomnia?
Perineal tears, PPH, uterine rupture
64
When is labour induced for IUGR?
37 weeks if normal doppler
65
What are the risks of macrosomnia?
cephalopelvic disporportion, shoulder dystocia
66
How are macrosomnia risks managed?
US at 38 weeks, 40 weeks
| consider instrumental delivery or C-section
67
What test do smoking mothers take?
Carbon monoxide test
68
What blood test would be raised in pre-eclampsia?
uric acid
69
What blood test is predictive for small-for-gestational age?
PAPP-A
70
When is SFH (symphisis-fundal height) less useful?
BMI>35, large fibroids, polyhydraminos
71
What screening tests should be undertaken for an SGA baby at 18 weeks?
detailed anatomical survey, karyotype, serology (CMV, toxoplasmosis, syphillis), malaria
72
What hormone causes cervical dilation?
oxytocin
73
What is the purpose of oestrogen during labour?
inhibit progesterone, prepare smooth muscle
74
What is the purpose of prostaglandins during labour?
trigger labour, effacement and dilation, stimulate contractility, vasoconstriction and vasodilation, close ductus arteriosus
Decrease cervical resistance (cervical ripening) and cause release of oxytocin from post pituitary
75
What is the purpose of beta endorphins in labour?
endogenous pain relief
76
What are the 3 Ps of labour?
Powers, passage, passenger
77
What are the primary powers?
Involuntary contractions 3-6 per minute, 4=labour, 40-60 seconds long
78
What are the secondary powers?
voluntary bearing down in reponse to cervical stretching, causing contraction of abdominal muscles and diaphragm to increase intraabdominal pressure
79
What are the 3 sections of the bony pelvis?
inlet/brim, midpelvis/cavity, outlet
80
What is the most common and birth-friendly subpubic angle/pubic arch?
Gynaecoid
81
What are the components that make up the passenger?
head size, presentation, lie, attitude, position, station, engagement, placenta
82
What is the best position for labouring women?
changing, upright, lateral, all fours
83
What are the different types of presentation?
Cephalic - head first
Breech - feet or sacrum first
Shoulder
84
What is the definition of presentation?
foetal body part entering pelvic inlet first
85
What is the definition of lie?
Angle of fetal spine in relation to maternal spine
86
What are the two types of lie?
longitudinal/vertical lie - parallel
| transverse/horizontal/oblique lie - right angle
87
What is the defintion of fetal attitude?
position of fetal body parts in relation to each other
88
What is general flexion attitude?
rounded back, chin on chest, thighs on abdomen, legs flexed, arms crossed
89
What is position of fetus?
Relation of presenting part to pelvic inlet?
90
What is ROA position of fetus?
occiput at right anterior part of maternal pelvis
91
What is station of a fetus?
relation of presenting part to ischial spines/degree of descent through birth canal
92
What is engagment?
The largest transverse diameter of the presenting part has passed through the maternal pelvic inlet
93
What is the definition of failure to engage?
> 18-24 hour regular contractions without delivery
94
What should FTP be suspected and diagnosed in primigravid?
Suspect with cephalopelvic disproportion, weak contractions and high BMI
1 hour, diagnose at 2 hours, baby born in 3
95
When should FTP be suspected and diagnosed in multiparous?
30 mins active labour, diagnose after 1, baby born within 2
96
What are the conditions for instrumental delivery?
FORCEPS - fully dilated cervix, occipitoanterior postion, ruptured membranes, cephalic presentation, engaged presenting part, pain relief, sphincter empty, no signs of cephalopelvic disproportion
97
What is flexed and extended breech?
general flelxion in longitudinal lie with head up, extended= feet extended towards head
98
What is footling breech?
one foot out - highest risk of cord prolapse
99
What is occipito-transverse, occipitoanterior or occipitoposterior?
transverse - occiput to one side - fetal head usually engages in this position
anterior - back to back
post - back to front (best)
100
What score is used to decide whether to induce labour?
Bishop score - cervical dilation, effacement, consistency and position, foetal station
101
What are the first and second line inductions?
First - ARM
| Second - oxytocin induction with syntocinon or pitocin
102
How does MAS present?
meconium stained liquor, foetal distress, airway obstruction, surfactant dysfunction, inflammation, pulmonary oedema, bronchoconstriction
103
What are some risk factors for MAS?
post-maturity, placental insufficiency, maternal hypertension, oligohydramnios, smoking, cocaine, older age
104
How do you treat MAS?
emergency C section if fetal blood <7.21, bradycardia for 5 minutes, suction minimal (do if apgar <5 or meconium visible in mouth)
observe for signs of respiratory distress
105
How do you reduce the risk of developing pre-eclampsia?
Aspirin from week 12 of pregnancy
| - before this carries miscarriage risk
106
Why would you give prostaglandins during labour?
To dilate cervix enough to break waters
107
Why would you give syntocinon during labour?
an articifical oxytocin
- accelerates labour if not progressing at 1cm/hour
- must have CTG on as it can cause hyperstimulation
108
What conservative measures would you take if a labour was not progressing?
move position and get woman mobile, analgesia, rehydration, ARM (releases prostaglandins)
109
Which foetal position has the highest risk of cord prolapse?
Footling breach
| - cord prolapse = get help and aim for instrumental delivery as quickly as possible
110
What are the normal engagement and birth positions?
Engagement - occipito-tranvserse
| Occipito-anterior
111
Name 2 causes of cervical shock
uterine inversion when trying to remove placenta
| miscarriage products stuck in cervix
112
How should active labour progress?
contractions of 3-4/10 minutes
1/2-1 cm per hour - nulliparous
1-2cm/hr multiparous
- failure to progress if <2cm in 4h
113
How long can membranes be ruptured in term babies before needing action?
24 hours
114
If meconium presents during labour what should first course of action be?
CTG - has high sensitivity and low specificity
115
What are 3 causes that can cause antepartum haemorrhages?
| When does this occur?
Bleeding from genital tract after 24 weeks, prior to labour
In third trimester
miscarriage, placenta praevia, placental abruption, vasa praevia, uterine rupture, trauma, infection, show, genital tract pathology
116
What are 3 symptoms of hypovolaemic shock?
tachycardia, postural hypotension, tachypnoea, fatigue, blurred vision, cold, clammy skin
117
What are some risk factors of placental abruption?
History of it, hypertension, trauma, smoking, cocaine, PROM, pre-eclampsia, IUGR, rapid uterine decompression
118
What are the symptoms of placenta praevia?
```
Sudden onset, prior to ROM
no pain
bright red spots, stops spontaneously after 1-2 hours
fetal malpresentation
do diagnostic US
```
119
What are some risk factors of placenta praevia?
History of it, C-section or PP, multiparity, multiple pregnancy, older mother, smoking, short intervals, miscarriage
120
What are the symptoms of vasa praevia?
Sudden onset after ROM of APH
no pain
foetal blood, foetal distress
121
What are the symptoms of uterine rupture?
sudden severe abdominal pain during labour
122
What are some risk factors for post-partum haemorrhage?
obesity, fever during pregnancy, antepartum haemorrhage, heart disease
C-section, pre-eclampsia, instrumental delivery, induction of labour, general anaesthesia, past surgery, previous PPH, grand muliparity, maternal age >40, multiple pregnancy, polyhydramnios, abruption placenta praevia, pre-existing anaemia, retained placenta, big baby, prolonged labour, fast labour
123
What are some risk factors for placenta accreta?
```
previous uterine surgery
placenta praevia or low lying placenta
maternal age >35
previous childbirth
C-section
```
124
What is the different between placenta increta and percreta?
Increta - invade uterine muscles
| percreta - through uterine wall
125
What drug can be given to increase tone or contraction of uterus?
ergometrine
126
How do you diagnose labour?
painful, regular, progressive uterine contractions
cervical dilation and effacement
- usually show (pink/white mucus plug) and/or ROM
127
What can cause abnormal 1st stage and their treatment?
*Inefficient uterine contractions - common in nulliparous
Treat with amniotomy and syntocinon
*Cephalopelvic disproportion - common in multiparous, problem with passenger or passage, can lead to secondary arrest
Treat - C-section
128
How would you treat prolonged 2nd stage?
assisted vaginal delivery or C-section
129
How should you manage 3rd stage of labour?
Allow cord to stop pulsating before clamping and cutting, placenta delivered by maternal effort alone
Assist with IM syntocinon, deferred clamping/cutting or cord, controlled cord traction
130
What is gestational diabetes?
| How do you diagnose?
carbohydrate intolerance diagnosed in pregnancy
- due to change in carb metabolism and antagonistic effects of hPL, progesterone and cortisol
OGTT -oral glucose tolerance test - done at booking and 24-28 weeks
Positive is >7.8mmol/L
131
What are some risk factors for gestational diabetes?
BMI >30
previous macrosomic baby
previous GDM - themselves or first degree relative
132
What are the effects of GDM?
increased risk of DKA, hypo, and progression of retinopathy/nephropathy
effects on pregnancy - SMASH
shoulder dystocia, macrosomnia, amniotic fluid excess, still birth, HTN/hypoglycaemia
133
How would you treat GDM?
insulin, metformin, glibenclamide
must give folic acid as there is increased risk of neural tube defects
Fetal monitoring - US 2-4 weekly, fetal echo 20-24 weeks
Manage labour with insulin slide scale + IV dextrose
Postpartum - Breastfeed, monitor fetal BG, stop insulin and have OGTT 6 weeks postpartum
134
What are the 3 hypertensive disorders of pregnancy?
chronic hypertension (before preganancy)
Pregnancy induced hypertnesion
pre-eclampsia - hypertension and proteinuria
135
What is the pathophysiology of pre-eclampsia and risk factors?
failure of trophoblastic endovascular remodeling, spiral arteries remain high-resistance causing placental ischaemia
NOPE 2 FAT
nulliparity, obesity, previous history, extremes of age, 2 babies, family history, autoimmune, twins
136
What are complications of pre-eclampsia?
eclampsia, headaches, visual disturbances, HELLP (haemolysis, increased ALT and AST, lowered platelets)
renal and liver failure, stroke, placental abruption
IUFD, preterm, IUGR, oligohydramnios, pulmonary oedema
137
How do you manage placenta praevia?
avoid sex and intense exercise
Admit for monitoring until delivery - IV, Group and Save
Deliver by elective section at 37-39 weeks
Steroids between 34-35 weeks
138
How do you treat placental abruption?
immediate delivery
| emergency CS +resus
139
How could you surgically manage PPH?
Rusch/Bakri balloon, B-lynch suture, ligation of uterine arteries, ligation of internal iliac arteries, hysterectomy, intervetnional radiology
140
What drugs could you give to manage PPH?
oxtocyin (contraction), ergometrine (increases tone and contraction), carboprost, misoprostol, tranexamic acid (stabilises clots)
141
What are some conservative ways to manage PPH?
massage uterus
empty catheter
bimanual compression
142
What are the types of placental accreta?
Accreta - chorionic villi attach to myometrium
Increta - chorionic villi invade into myometrium
Percreta - chorionic villi invade through myometrium
143
How would you prepare for delivery with placenta praevia or accreta?
Elective CS 36-38 weeks
Consent to all possible interventions
consultant obstetric/anaesthetic input
anticipate major haemorrhage, have blood available and cell salvage, HDU bed
144
What is twin-to-twin transfusion and what type of twins would have it?
when one twin receives a lower blood supply and it has slower growth rate
monozygomotic monochoronic diamniotic
145
What are the blood tests done at booking?
HIV, sphyillis, rubella, hep B
146
How to manage rupture of membranes early in pregnancy?
US
infection markers
observation
147
How do you test for pulmonary embolism in pregnant women?
ventilation/perfusion scintigraphy
148
What are the symptoms of rupture ectopic pregnancy?
fainting, pain, high hCG, free fluid in pouch of Douglas and no uterine pregnancy
149
How do you manage shoulder dystocia?
emergency buzzer
| McRobert's position - hyperflexing mother's legs tightly to abdomen
150
How to manage PPH?
```
Get help
massage uterus
empty bladder
bimanual compression
review causes - 4Ts
mosprostol PR
theatre
```
151
What is Sheenan's?
hypopitutarism caused by severe hypertension (necrosis of pituitary gland) e.g. PPH
152
What is cytomegaly virus? What are the symptoms?
Usually asymptomatic
deafness, IUGR, thrombocytopenia
newborn hydrocephalus, chorioretinitis, convulsions, death
153
How would you monitor the child of a mother with uncontrolled diabetes?
```
glucose tolerance test
urinalysis
uterine arterial doppler
blood glucose
BP
```
154
What do progestins do?
released from corpus leutum and placenta
prepares endometrium and uterus for implantation
lowers oxytocin
