Obstetrics Flashcards
(34 cards)
Miscarriage
Investigation:
1st line TVS
2nd line hCG
Management
1st line: Depends on classification of miscarriage. Most commonly medical management (Day 1 mifepristone, Day 2 misoprostol).
2nd line: Surgical indicated if shock, GTD or infection with vacuum <12 weeks or ERCP >12 weeks
An Evacuation of Retained Products of Conception (ERPC) is a small operation to remove any remaining products of conception that are still inside your uterus (womb) following a miscarriage or termination of pregnancy.
Ectopic pregnancy investigations and management
Investigations:
1st line Urinary beta-HCG
2nd line If positive? Abdominal USS
3rd line If not intra-uterine pregnancy? TVS
4th line Pregnancy of unknown origin? Serum beta-HCG
Management
1st line: Depends on size of mass, if mother is stable, pain presence. Either IM methotrexate OR surgical laparoscopic salpingectomy OR conservative watchful waiting
Gestational Diabetes- ix and mx
Investigation: OGTT
Management:
1st line: Lifestyle changes
2nd line: Medical (1. Metformin 2.Glibenclamide)
Glib - sulfonylurea - increases insulin production
Varicella zoster virus investigations and mx in pregnancy
Investigation: Clinical diagnosis 1st line. Testing maternal immune status with VZV serology for IgG and IgM.
Management:
If confirmed no immunity: Give VZIG
If presenting if maternal chickenpox: Aciclovir given, counselled on complications, referred to fetal medicine for serial USS for fetal abnormalities
Parvovirus B19
Investigation: Viral serology for IgG and IgM
Management: If positive screen, immediate referral to FMU for serial US and doppler scanning until 30 weeks for signs of fetal hydrops.
CMV
Investigation: Maternal viral serology
Management: Maternal positive screen? Refer to FMU. No antiviral available for mother. Wait until 21 weeks (kidney development) to see if mother transmitted infection (1/3 chance) via Amniocentesis at 21 weeks. If PCR sample shows CMV present then offer TOP or US surveillance.
Rubella
Investigation: Maternal viral serology
Management:
Positive screen, send to FMU.
Maternal symptomatic Tx and educated on infective periods (7 days prior and 4 days after symptoms onset).
Fetal Mx dependent on gestational age: <12 weeks TOP offered. 12-20 weeks amniocentesis and RT-PCR done, if positive offer TOP or US surveillance. If >20 weeks no action required
Anaemia
Investigations: FBC for Hb and MCV . Ferritin checked in known haemoglobinopathy
Management:
Fe deficiency Microcytic / normocytic = Trial of ferrous sulphate TDS then repeat FBC in 2 weeks
Beta thalassaemia microcytic= Folate supplement and blood transfusions. Hb aim for 80g/l during pregnancy and 100g/l during delivery
Folate deficiency macrocytic anaemia= Folate supplementation OD, can be increased to TDS if required.
Sickle cell disease normocytic anaemic = Folate and Fe supplementation
Referral:
If Hb <70g/l, late gestation (>34 weeks), ineffective oral Fe supplement
Follow up:
Continue oral Fe post partum for 3 months and 6 weeks. Anaemia (<100g/l) get 100-200g Fe, Non-anaemic get 65g and repeat FBC in 8 weeks.
Antiphospholid syndrome
Investigations:
1st line Exclude DVT with US
2nd line: APS screening
Diagnosis:
Requires minimum of 1 clinical and 1 laboratory indicator.
-Clinical: Vascular thrombosis Hx / Pregnancy morbidity Hx
-Laboratory: Lupus anticoagulant / Anticardiolipin Ab / Anti B2 glycoprotein I
Management:
Prenatal- Warfarin in vascular thrombosis Hx
Antenatal- If Hx of recurrent miscarriage, give LMWH + low-dose aspirin. If Hx of IUGR or pre-eclampsia, give low-dose aspirin.
Post natal- Immediate thromboprophylaxis
VTE in pregnancy
Investigations:
If DVT + PE Sx: Duplex US. If positive, no need for CTPA or V/Q
If DVT only: Duplex US. If negative, repeat on days 3 and 7.
If PE only: ECG and CXR initially. Diagnostic CTPA andV/Q
Management:
VTE confirmed on Duplex US: LMWH until 6 weeks postpartum. Withhold 24hrs before OIL or at delivery
VTE at term: Unfractioned heparin considered. Withhold 6 hours before IOL or CS.
Thyroid disease
Referral
Yes: History of thyrotoxicosis and thyroid carcinoma –> Endocrinologist clinic
No: Hypothyroidism –> Seen at CLU ANC
Investigations:
TSH
Free T3 and T4
Antibodies: TRAbs (Graves), Anti-TG Abs and Anti TSH Reception Abs (Hashimoto’s)
Management:
Hypothyroidism: Prophylactic increase in thyroxine by 25mcg upon positive pregnancy test. Check levels 6 weeks after each dose change. Return to pre-pregnancy dose after delivery.
Hyperthyroidism: PTU 1st line. After initial stabilisation, reduce dose. RAI contra-indicated in pregnancy or when trying.
Hypertension in pregnancy
MANAGEMENT
At risk of pre-ecampsia: Referral to CLU ANC. Prophylactic Aspirin 75mg OD from 12 weeks gestation onwards. Monitor urine proteins and BP at each antenatal appt. Warn of symptoms of pre-eclampsia (headache, oedema, blurred vision)
Pre-existing HTN / Chronic HTN: Lifestyle advice and low Na diet. Referral to obstetric care at booking. Stop ACEIs or ARBs.Offer medication if BP >140/90 (1st line Labetalol. 2nd line Methyldopa or Nifedipine).
Gestational hypertension: Admit if severe HTN (>160/110), proteinuria 1+ or pre-eclampsia symptoms. If >140/90 medication management with aim of 135/85
FOLLOW UP
Chronic HTN: Regular post natal BPs and continue meds for 2 weeks until review (note switch methyldopa after 2 days postnatal).
Gestational HTN:
- If taken medication continue for 2 weeks until review. If required for more than 2 weeks then referral to GP.
- If no medication taken, monitor BP and commence medication if >149/99
ALL WOMEN: 6-8 weeks post natal review with GP or specialist
Obstetric Cholestasis
Investigation:
Diagnosis based on clinical presentation (pruritus at abdomen, palms and soles) with deranged LFTs and bile acids studies
Mangement:
1st line: Symptomatic relief with creams/ointments and antihistamines. Ursodeoxycholic acid to reduce bile salt level and normalise LFTs. Vitamin K 10mg taken OD from 36 weeks
At delivery: In CLU with neonatal unit. Neonate given vitamin K.
Monitoring:
Antenatal = Under CLU ANC. LFT and bile salt monitoring weekly or bi-weekly. Foetal assessment with CTG, US for growth and fluid volume assessed.
Post natal = 6 weeks followup to assess that LFTs have normalised.
GTD
Px
O/E
Ix
Mx
Presentation: History of PV bleeding and abdominal pain. Later leads to hyperemesis, hyperthyroidism and anaemia. O/E large and boggy, large for dates uterus.
Investigation:
Monitoring with serum b-HCG.
Diagnosis: US for complete mole showing granular “snowstorm” appearance. POC history for definite Dx for all molar or non-viable pregnancies. If partial viable pregnancy, placental history performed.
Mangement: Complete or non viable partial moles --> URGENT suction curettage Partial moles (with foetal development or late gestation) --> Medical evacuation and urinary b-HCG 3 weeks later to confirm. Given methotrexate if level not fallen.
Gestational trophoblastic disease (GTD) is the term given to a group of rare tumors that develop during the early stages of pregnancy. After conception, a woman’s body prepares for pregnancy by surrounding the newly fertilized egg or embryo with a layer of cells called the trophoblast. The trophoblast helps the embryo implant itself to the uterine wall. These cells also form a large part of the tissue that make up the placenta — the organ that supplies nutrients to a developing fetus. In GTD, there are abnormal changes in the trophoblast cells that cause tumors to develop.
Most GTD tumors are benign (noncancerous), but some have the potential to turn malignant (cancerous). GTD is usually classified into one of two categories:
Hydatidiform moles
Gestational trophoblastic neoplasia (GTN)
Hyperemesis gravidarum
Persistent vomiting in pregnancy with triad of: Weight loss >5%, electrolyte imbalances and dehydration
Investigation: Bedside (urine dipstick, vitals)
Labs (FBC, U+Es, infection, MSU, Glucose)
Imaging (foetal viability, GTD, multiple preg)
Management:
Mild = Community advice and dietary advice. Oral anti-emetics +hydration.
Moderate: Ambulatory day care with IV fluids, parenteral anti-emetics and thiamine.
Severe: Inpatient
Anti-emetics: 1st line 1 week of anti-histamine (cyclizine, promethazine) or phenothiazine (proclorperazine). 2nd line 5 days ondansatron or metoclopramide
When to admit?
- Co-morbid health condition
- N+V associated with either ketonuria or weight loss that has not responded to anti-emetics
Amniotic fluid embolism
S/S- Liked to shock with DIC within 4 hrs
Ix:
- Bloods: FBC, Mg, Ca, Coagulation screen
- ECG: Ischaemic changes
- CXR: Pulmonary oedema
Management
1st line: Resus
Next: Mother stable? Imminent delivery with continuous foetal monitoring. Maternal compromise? Perimortem section to facilitate maternal CPR
Definitive diagnosis: Port-mortem pulmonary aspirate (foetal squamous cells and debris present)
Pre-eclampsia
Px: Can be asymptomatic - Frontal headache -Blurred vision or flashing lights - Oedema in face, feet, hands -Vomiting -Hyper-reflexia
Investigation:
- BP on 2 occasions, 4 hrs apart
- Urine dipstick (24hr collection to quantify)
Diagnosis requirements:
- HTN
- Proteinuria (>300mg in 24hrs or >30mg/mmolin urinary ACR)
- > 20 weeks gestations
Prophylaxis:
If 1x high risk factor or 2x moderate risk factor –> 75mg OD aspirin from 12 weeks onwards
Management:
Antenatal- Admit all severe pre-eclampsia. Medication given to all severe or persistent >140. 1st line is labetalol, 2nd line nifedipidine. ACEI contraindicated. Target bp <135. Regular BP monitoring. Urine dip repeated only if clinical indicated. Foetal monitoring at diagnosis then auscultate HR every NC, 2 weekly US, CTG if indicated. Regular blood tests for end-organ damage (Twice/week in mild and moderate, 3times/week in severe)
Intrapartum: Give corticosteroid if early delivery likely within next week. During labour regular BP hourly, continue HTN meds
Post-natal: Keep as inpatient for 24hr post-partum monitoring. Continue HTN medication for first 2 weeks of discharge until review appt. All women get 6-8 week follow-up for medication review and urine strip test (if 1+ then repeat in 3 months, if 2+ then renal specialist referral)
Eclampsia
Px: New onset tonic-clonic seizures, in the presence of pre-eclampsia
Ix:
- FBC: Low Hb, platelets (DIC Dx)
- U+Es: High urea, creatinine, urate. Low urine output.
- LFTs: High aminotransferases, bilirubin
- Clotting studies (DIC Dx)
- Blood glucose (Hypoglycaemic seizure?)
- Abdominal US: Placental abruption?
CTG: Fetal distress or bradycardia?
Mx:
- Resus (ABCDE + left lateral position)
- Cessation of seizures with MgSO4)
- BP control (IV labetalol or hydralazine)
- Delivery (CS then mother to HDU for 24hrs)
- Monitoring (Fluid balace for pulmonary oedema and AKI. Bloods and biochem for 72 hrs)
Complications of eclampsia
Maternal mortality rate 1.8%
Foetal mortality rate 30%
Maternal:
- HELLP syndrome - DIC - AKI - ARDS - Cerebrovascular haemorrhage - Permanent CNS damage - Death
Fetal:
- Placental abruption - Prematurity - IUGR - Intrauterine fetal death - Infant respiratory distress syndrome
Induction of labour indications contra-ix methods assessment complications
Indications:
- Uncomplicated pregnancies between 40+0 and 40+14wks
- Maternal health problems
- PROM
- Foetal distress
- Foetal death
Conta-indications Absolute: - Major placenta praevia - Cord prolapse -Transverse lie - Vasa praevia -Active primary genital herpes - Previous classical CS Relative: -Breech -2+ lower abdominal incision CS -multiple pregnancy
Methods:
1st line - Membrane sweep
2nd line- Vaginal prostaglandins
3rd line- ARM/Amniotomy or Cook’s balloon
Assessment: Bishops score
Complications: Failure of induction, infection, uterine hyperstimulation, Cord prolapse
PROM
RF’s
Ix
Mx
Risk factors:
- Smoking
- Infection (UTI or chorioamniocentesis)
- Hx of PROM or P-PROM
- Large amniotic sac (polyhydramnios or multiple pregnancy)
- Vaginal bleeding in pregnancy
Ix:
- History
- Speculum: after laying 30 mins there is pooling at posterior fornix
All women get HVS [high vaginal swab] for GBS
Management
>36 weeks: IOL recommended. Monitor for chorioamniotitis. Watch and wait for labour within 24hrs (60% will occur). After 24hrs IOL. Give penicillin or clindamycin during labour if GBS positive.
34-36 weeks: IOL recommended.Monitor for chorioamniotitis. Prophylactic erythromycin QDS for 10 days. Give penicillin or clindamycin during labour if GBS positive. If <34+6 give corticosteroids.
24-33 weeks: Expectant management until 34 week. Monitor for chorioamniotitis. Prophylactic erythromycin QDS for 10 days. Give penicillin or clindamycin during labour if GBS positive. If <34+6 give corticosteroids. Expectant management until 34 week.
Placental abruption
Risk factors - Previous abruption ** - Intrauterine growth restriction e.g. twins - Pre-eclampsia - Pre-existing hypertension - Abnormal lie of fetus e.g. transverse - Polyhydramnios Smoking or drug use e.g. cocaine
Presentation:
History= Pain +/- bleeding
OE = Woody hard uterus. Tender abdomen. Absent/abnormal foetal heart sounds
Investigations:
Diagnosis is clinical
Monitoring foetus: CTG if >26 weeks. US if stable/.
Monitoring Mum: FBC, x-match, coagulation screen, Kleihauer if Rh negative. Hourly UO, U+Es, LFTs
Management:
- Assess and resus: Admit. Give steroids if <34 weeks. Anti-D if Rh -ve.
- Delivery: If distress then CS. If no distress but 37+ weeks then IOL. Dead fetus then IOL.
- Conservative management: Admit and give steroids if <34 weeks, no distress and minor abruption.
- Postpartum: Risk of PPH
Placenta Praevia
Classified: Marginal or major
Risk factors:
- PREVIOUS CS
- Previous placenta praevia
- Twins
- Polyhydramnios
- GU anatomical abnormality (infection, endometriosis, ablation, TOP)
- High maternal age
- High parity
Complications
- Foetal distress / hypoxia
- Obstruction
- Transverse lie
- Placenta accreta or percreta
Presentation
- Painless bleeding (Initially intermittend but worsens. Blood is red and profuse)
Investigation
-Diagnosis by US
Management.
If asymptomatic: Incidental finding at 20 week US scan. Repeat scan at 32 weeks (major) or 36 (minor)
If bleeding: Admit and ABCDE. Steroids for <34 weeks. Anti-D for Rh -ve within 72 hours.
Delivery: Elective CS at 38 weeks.
Risk: PPH
Ruptured vasa praevia
When the foetal vessels run in the membranes infront of the presenting part
Ix: US
Px: Painless, moderate bleeding after ROM + foetal distress
Mx: CS
