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4.2 WACH > Obstertrics > Flashcards

Obstertrics Flashcards

12
Q

Anetanatal test diagnostic of Down syndrome

A

Trisomy 21 on amniocentesis - chorionic villous sampling

Low PAPP-A and high b-HCG = increased risk (NOT diagnostic)

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13
Q

Investigation for suspected endometriosis

A

Laparoscopy

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14
Q

Difficulty breastfeeding after PPH in delivery is caused by?

A

Sheehan’s syndrome: PPH—> pituitary necrosis —> hypopituisim (inadequate prolactin and gonodotropin stimulation)

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15
Q

Adhesions and fibrosis of endometrial cavity due to dilation and curettage

A

Asherman’s syndrome

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16
Q

Psychiatric disorders post pregnancy

A

Baby blues, postnatal depression and puerperal psychosis

Baby blue: anxious, tearful and irritable
Reassure and health visitor

Postnatal depression: start within a month and peak at 3 months - reassure, CBT and SSRI (paroxetine and Sertraline)

Puerperal psychosis : severe mood swings (bipolar), disordered perception (auditory). Admission to hospital as treatment

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17
Q

Female genital tract source sepsis

A

Amoxicillin/ampicillin 2g IV 6 hourly
Gentamicin 4-7 mh/kg IV
Metronidazole 500 mg IV 12- hourly

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18
Q

Risk factors for ovarian factors

A

Family history of BRAC1, BRAC2 gene
Early menarche, late menopause an nulliparity

CA125 test raised —> ultrasound

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19
Q

Ectopic locations

A

Ampulla = main

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20
Q

Blood glucose frequency in T1DM during pregnancy

A

Daily fasting, pre-meal, post meal 1hr, bedtime

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21
Q

McRobert’s manoeuvre

A

Supine with both hips fully flexed and abducted

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22
Q

Endometrial hyperplasia

A 
Irregular proliferation of endometrial glands 
Simple
Complex, 
Simple atypical 
Complex atypical

Protective factors: OCP

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23
Q

Origin of adenomcarcinoma in gynae

A

Endometrium

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24
Q

Blood test for HELLP syndrome

A

Epigastric pain, nausea, headache and general malaise.
HELLP is severe form of pre-eclampsia
Characterised by H (haemolysis- low Hb raised raised LD) EL(elevated liver enzyme) and LP (low plalete)

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25
Q

CIN classification

A

CIN 1 = lower 1/3 of epithelium (LSIL low grad)
CIN 2 = lower 2/3 of epithelium (HSIL high grad)
CIN 3 = all layers (HSIL)

Loss of stratification, abnormal mitosis, increase nuclei size

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26
Q

Layers cut in lower segment of Caesarian section

A 
Superficial fascia
Deep fascia 
Anterior rictus sheath
Rectus abdominus
Transversals fascia
Extraperitoneal connective tissue
Peritoneum
Uterus
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27
Q

Postpartum haemorrhage cause

A

Most common = uterine Antony

the 4 t’s
T = tone
T = tissue (retained placenta)
T = trauma
T = thrombin (coagulation abnormalities)
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28
Q

First line for respiratory depression caused by MgSulphate

A

Calcium gluconate

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29
Q

Types of ovarian cancer

A

Epithelium - Fallopian tube or ovary
Germ cell - egg production cells
Stromal cell - start in cell that produce estrogen and progesterone

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30
Q

Stromal cell types of ovarian cancer

A

Granulosa - releases inhibit, releases estogen

Sertraline leading - renin release —> HTN

Gynandroblastoma

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31
Q

An 83-year-old lady attends with a history of falls. She has a past medical history of osteoporosis, constipation, frequent urinary tract infections, ischaemic heart disease and urge incontinence.

After a thorough history and examination, you decide that these are likely multifactorial related to a combination of physical frailty, poor balance and medication burden. Which one of the following medications should you stop in the first instance?

A

Oxybutynin

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32
Q

PID followed by liver inflammation

A

Fitz-Hugh Curtis - adhesions in liver, liver capsule - Glisson’s capsule

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33
Q

Hypermesis gravidarum electrolyte disturbance

A

Hyponatraemia, hypokalemia, hypochlorite and metabolic alkalosis

Molar pregnancy and multiple pregnancy

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34
Q

A 30-year-old woman who is 26 weeks pregnant is admitted to the maternity unit with heavy vaginal bleeding. She is Rhesus negative.

What is the most appropriate management for prophylaxis of Rhesus sensitisation?

A

One dose of Anti-D immunoglobulin followed by Kleihauer test - to detect fetal cell in maternal circulation (required post 20 weeks) check Australia guidelines

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35
Q

Woody uterus

A

Placental abruption with pain

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36
Management of contact with chickenpox
Only VZIG | If rash present - then acyclovir
37
Post-Partum contraception
Needed 21 days after birth Can use progesterone only pill - anytime after 21 days IUD 0 within 48 hours of childbirth or after 4 weeks
38
Calculation of EDD
Taking date of last LMP, counting forward by nine months and adding 7 days If cycles longer than 28 days then add the difference between cycle length and 28 days
39
What is used for ultrasound dating of pregnancy
Crown-rump length up to 13 weeks + 6 days | Head circumference from 14-20 weeks
40
Alcohol in pregnancy
Complete abstinence is advised. Alcohol is not harmful in small amounts (less than one drink per day) Binge drinking is associated with fetal alcohol syndrome
41
What is gravida and what is parity
``` Gravida = total number of pregnancies (regardless of end) Parity = number of live births or stillbirths after 24 weeks ``` Twins count as 2 gravida and 2 parity
42
Obstetric history
Age, date of birth, occupation, ethnicity and first pregnancy Reason for visit This pregnancy: Dating the pregnancy - from LMP - add nine month and 7 days. Antenatal care so far Ultrasound ``` Previous obstetric history Recurrent miscarriage Preterm delivery Pre-eclampsia Abruption Congenital abnormality Macroscopic baby FGR Still birth Method of delivery ``` Past gynae history Length of cycle, contraceptive history , PID history last cervical smear (cone biopsy), pelvic masses, history of sub-fertility Medical and surgical history : pre-existing conditions, previous surgery, psych history Drug history: over-the counter, homeopathic and herbal Allergies Family history Maternal and first degree Social history: partner, who lives at home, income, housing, plan to work during pregnancy, domestic violence Smoking, alcohol and illicit drug history
43
What is maternal diabetes linked with
Macrosomia, FGR, congenital abnormality, pre-eclapmsia, still birth, neonatal hypoglycaemia
44
What is maternal hypertension associated with
Pre-eclampsia
45
What is maternal renal disease associated with
Worsening renal disease, pre-eclampsia, FGR, preterm delivery
46
What is maternal epilepsy associated with
Increased fit frequency, congenital abnormality
47
what is venous thromboembolic disease associated with
Increased risk during pregnancy, thrombophilia, increased thromboembolism risk and increased risk of pre-eclampsia and FGR
48
What is maternal HIV associated with
Risk of mother to child transfer
49
What is myasthenia Travis/myotonic dystrophy associated with
Fetal neurological effect, increase maternal muscular fatigue in labour
50
What is knife cone biopsy associated with
Increased risk of cervical incompetence (weakness) and stenosis (leading to preterm delivery and dystocia)
51
What is LLETZ associated with
LLETZ (large loop excision of the transformation zone) Is associated with a small increase in risk of preterm birth More than one excision = shorter cervix, which does increase the risk of second and third trimester delivery
52
What would you do a speculum exam in pregnancy
Excessive or offensive discharge Vaginal bleeding (in absence of placental praevia) To perform cervical smear To confirm potential rupture of membrane
53
Contraindications to digital exam in pregnancy
Known placenta praevia, or vaginal bleeding when the placental site in unknown and the presenting part unengaged Prelabour rupture of membranes (increased risk of ascending infection)
54
What are the things used to calculate a bishops score
``` Dilation of cervix in cm Consistency of cervix Length of cervical canal Positive Station of presenting part (cm abnove ischial spine) ``` DCLPS Women dilate consistently only the length of a positive station
55
What is included in antenatal screening in Australia
``` ? Down syndrome Fetal anomaly - via u/s Haemoglobinopathies Rubella HIV/Hep B Tay-Sach’s in high risk ```
56
What is included in newborn screening
``` Hearing Phenylketonuria Congenital hypothyroidism Cystic fibrosis Medium chain acyl co-A dehydrogenase deficiciency ```
57
Measures for maternal death
MMR = number of maternal deaths in a population divided by the number of live births - shows risk of maternal death relative to number of live births MMRate (maternal mortality rate) - number of maternal death in population divided by the number of women of reproductive age, - reflecting not only the risk of maternal death per pregnancy or per birth but also the level of fertility in population
58
Volume homeostasis in pregnancy
Rapid expansion of blood vol at 6-8 weeks up to 32-34 weeks of gestation Accounts for 8-10 kg of weight gain 6.5L to 8.5 L - increased cardiac output - increased renal blood flow - physiological anemia : increased plasma volume relatively to erythrocytes volume - lower plasma albumin concentration Water retention occurs from changes in osmoregulation and RAAS system —> active sodium reabsoption in renal tubles —> retention Other factors resulting in fluid retention: sodium ratio in, reduced thirst threshold, reduced plasma oncotic pressure Plasma osmolality decreased by 10 mOsmol/kg in preg
59
Consequences of fluid retention in pregnancy
``` Reduced haemoglobin concentration Reduced haematocrit Reduced serum albumin oncentration Increased stroke volume Increased renal blood flow ```
60
Haematological concequences of pregnancy results in decrease in
Haemoglobin concentration, haematocrit, plasma folate concentration, protein s activity, plasma protein concentration, creatinine, urea and uric acid
61
Haematological concequence of pregnancy results in increase of
``` Erythrocytes sedimentation rate Fibrinogen concentration Activated protein c resistance Factor VII, VIII, IX, X and XII D-dimmer Alkaline phosphatase ```
62
immune system in pregnancy
IgG antibodies Reduced CD8 T-cell acitivity Increase innate immunity - increase NK cells Unchanged WBC count
63
Changes to eyes during pregnancy
Corneal sensitivity decreases - returns 8 wk post partum Increased corneal thickness - odema Reduced tear production Increased curvature of crystalline lens
64
Role of relaxin in pregnancy
Allows ligamentaous attachment to relax during pregnancy Includes ribcage to relax increasing subcostal angle Relaxin is producer by ovary and planceta and usually softens and widens the cervix
65
What causes physiological dyspnoea of pregnancy
Increase tidal volume - increases minute ventilation which is perceived a SOB which is 60-70% Resolves immediately postpartum
66
Oxygenation during pregnancy
Increase in 2,3 diphosphaglycerate (2,3-DPG) concentration increases. 2,3 DPG preferencially binds to deoxygenated Hb and promotes the release of oxygen from Red cells at relatively lower levels of Hb saturation - this increases the availability of oxygen within tissues
67
Difference in fetal and adult haemoglobin
Two beta-chains are replaced by gamma-chains 2-3, DPG binds to preferentially to beta chains therefore in fetus the oxygen-Hb dissociation curve is shifted to left relative to mother.
68
Blood gas and acid-base changes
``` Reduced PCO2 Increase PO2 pH alters little Increased bicarbonate excretion Increased oxygen availability to tissue and placenta ```
69
Cardiovascular changes in pregnancy
``` Increase heart rate (10-20 beat) Increased stroke volume (10%) Increased cardiac output - 5 weeks of gestation Reduced mean arterial pressure (10%) Reduced pulse pressure Reduced peripheral resistance (35%) ``` Palpitation + premature atrial and ventricular ectopic
70
Gastrointestinal changes in pregnancy
Oral - gingivitis (due to vascular permeability), increased dental caries, increased tooth mobility Gut- uterus displaces the stomach and intestine upwards, reduced LOS tone (progesterone effect ), increased placental gastrin production and increased gastric acidity (progesterone effect) —> increased reflux oesophagiits and heartburn. Reduced gastric motility and increased stomach volume —> increase in gastric content aspiration post 16/40 Liver- common to find findings of talengiectasia and palmar erythema as liver can clear increased levels of estrogen and progesterone
71
Changes to kidney during pregnancy
increased kidney size | Dilation of calyces, renal pelvis and ureter—> looks like obstruction
72
Functional changes in kidney during pregnancy
``` Increased GFR 50% Increased renal blood flow 60-75% Increase renal plasma flow Increased clearance of most substances Reduced plasma creatinine, urea and urate Glycouria is normal for ```
73
Sodium balance in pregnancy in kidney
Increased filteration but also increased sodium reabsorption in proximal (oncotic pressure) and distal (hormonal factors)
74
Affect of pregnancy on uterus
Increased blood flow Hyperplasia and hypertrophy of myometrium (estrogen and prosgesterone) Increased weight Hypertrophy of uterine artery Lower segment = thinner, less muscle and fewer blood vessels - therefore caesarean incision here Increased intercellular gap - increased depolarisation
75
Braxton Hicks
Uterine contraction Painless contraction Allow pacemaker activity of uterine fundus to promote the coordinated, fundal-dominant contraction
76
Changes in breast during pregnancy
Deposition of fat around glandular tissue, and the number of glandular duct increases (oestrogen effect) Progesterone and human placental lactogen (hPL) increases number of gland alveoli Prolactin - imp in milk secretion - during pregnancy prolactin level increase but does not cause secretion as it is antagonised bu oestrogen at alveolar receptor level The drop is oestrogen level 48 hr after delivery removes inhibitor The early suckling —> ant and post pituitary releases prolactin oxytocin - oxytocin released from post pit causes contraction of myoepithelium cell squeezing the milk
77
Prolactin in pregnancy
Increased by 15 fold in pregnancy by anterior pituitary Oestrogen = stimulators and hPL is inhibitory Promotes breast engorgement and alveoli distension with milk Receptors for prolactin are also present in trophoblast cell and within the amniotic fluid Prolactin many regulate insulin secretion and glucose homeostasis
78
Thyroid function during pregnancy
HCG similar to TSH First trimester - TSH suppressed, due to reduced release to TRH After 20 week increase T3, T4 Increased GFR increased renal loss of iodised - which results in thyroid taking up too much iodide from circulation and then iodised deficiency Use free T4 and free T3 not total T3 and T4 Reduced fT4 late pregnancy, reduced TSH early pregnancy
79
Skin changes in pregnancy
Hyperpigmentation Striae gravidarum Hirsuitism Increased sebaceous gland activity
80
Causes of FGR
Fetal - genetic: chromosomes 13 (Palau syndrome), 18 (Edward’s syndrome) and trisomy 21 (Down syndrome)- trisomy 21 = less severe - infection: rubella, cytomegalovirus, toxoplasma and syphilis Maternal - physiological: maternal height, weight, age and ethnicity - behavioural : smoking, alcohol and drug use. Smoking (CO or vascular effects on uteroplacental circulation), alcohol crosses placenta - chronic disease: restricts fetal growth, hypertension (placental infarction), lung or cardiac conditions Placenta - infarction
81
PPH mangement
1. Call for help, rapid if there is shock, do not leave the women Basic measures: lie flat, keep warm, monitor virals every 5 mins and temp 15 mins 2. Initial assessment: ABCD - look for reversible causes: remove blots, massage - insert catheter - empty bladder (>30ml/hr) - IV access - FBC, coats, crossmatch 4 unit, Ca (repeat 30-60 mins) - give O2 10-15 L/min 3. History 4. medical management - syntocin 2nd IV - 5 units - synotocin infusion IV - w/ saline and hartmans 40 units over 4 hours - ergometrine (if no HTN) - IV and IM —— contraindication: retained placenta, twin preg, hypertension, sepsis, heart disease, pvd, impaired hepatic or renal function - carbopristil IM or intramyometrial 5. Operative theatre - MTP - bimanual compression of the way - uterine massage - ballon tamponade: bakri ballon - haemostatic brace suture - bilateral ligation uterine artery - bilateral ligation internal iliac - arterial embolisation - hysterectomy
82
Causes of PPH
``` The 4 T’s Tone Trauma Tissue Thrombin ```
83
Management of shoulder dystocia
1. Recognise: turtle size and failure to progress 2. Call for help - obstetrician, paediatric + Time (7 mins) 3. Simple manoeuvres - McRoberts Manoeuvre - Suprapubic pressure : down and rotate 4. Consider episiotomy - access 5. Manoeuvre - internal rotation manoeuvre ant and post - deliver posterior arm - be on all 4’s : reverse McRoberts 6. Repeat on reverse McRoberts 7. Zavonelli’s : push head back in and cesarean 8. Symphisiotomy

4.2 WACH (3 decks)

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