Obstetrics Flashcards
(220 cards)
1
Q
In what ways might a foetus lie?
A
- Longitudinal-> fundus of uretus to lower segment
- Transverse-> sideways
- Oblique-> somewhere between 2
2
Q
What is the presenting part?
A
Bit of foetus that’s 1st in the pelvic inlet-> eg cephalic or breech
3
Q
What is the station of the foetus?
A
- Level of presenting part compared to superior pubic rami (fixed part of mum’s pelvis)
- Station 0-> head level with ischial spines
- +/- 3 either side
4
Q
What is the engagement of the foetus?
A
- Presenting part in pelvic islet measured in 1/5ths
- Engaged-> 3/5 in pelvis + 2/5 palpable above inlet
5
Q
What is the symphysial-fundal height?
A
- Measurement of fundus of uterus to top of midpoint of symphysis pubis
- From 20 weeks-> estimate size of foetus
6
Q
What is the ‘fertilisation’ stage of early pregnancy development?
A
- Sperm binds to zona pellucida
- Acrosome reaction-> vesicle releases contents by exocytosis
- Hydrolytic enzymes help sperm burrow into ZP
- Sperm + egg plasma membranes fuse
- Cortical reaction-> egg depolarises + ZP hardens
- Zygote produced
- 2 haploid nuclei of sperm + egg combine-> single diploid nucleus
7
Q
What is the ‘cleavage’ stage of early pregnancy developement?
A
- 2 cells divide to 8-> compaction
- Then 16-32-> morula with 2 layers + fluid inbetween
- Blastocyst-> ZP encases trophoblast, embryoblast + blastocyst cavity
8
Q
What is the ‘implantation’ stage of early pregnancy development?
A
- Blastocyst hatches from ZP + attaches to endometrium
- Trophoblast’s embryonic pole in contact with endometrium-> proliferate + fuse to form cytoplasm (synctiotrophoblast)
9
Q
What does the blastocyst consist of at the ‘implantation’ stage of early pregnancy development?
A
- Trophoblast-> includes synctiotrophoblast
- Embryoblast-> inner cell mass with primary ectoderm (epiblast) + primary endoderm (hypoblast)
- Cytotrophoblast-> cell walls + membrane
10
Q
What happens at day 9 in early pregnancy development?
A
- Fluid between epiblast forms amniotic cavity (cells- amnioblasts)
- Cell migration from hypoblast to line blastocyst cavity-> form primary yolk sac
- Placenta begins forming from synctiotrophoblast
11
Q
What happens at day 12 of the early pregnancy development?
A
Blastocyst cavity-> now definitive yolk sac
12
Q
What happens on day 14 of early pregnancy development?
A
Bilaminar germ disc suspended in chorionic cavity
13
Q
What is the ‘gastrulation’ stage of early pregnancy development?
A
- In week 3
- Depression of epiblast (primitive streak)
- Converts from bi- to tri-laminar disc-> epiblast cells migrate into hypoblast-> mesoderm
- Epiblast now ‘ectoderm’ but mesoderm + endoderm derived
14
Q
What does the mesoderm (from the trilaminar disc) develop into?
A
Early CNS
- Notocordal process + notocord
- Neural plate forms in epiblast
- Lateral neural plates-> neural crest cells
- Paraxial mesoderm-> somites-> axial skeleton + neck/trunk dermis
15
Q
Why does fluid retention occur in pregnancy?
A
- 30-50% increase in plasma volume
- Increased Na+ in extracellular fluid-> increased retention
- Influenced by capillary pressure (fluid out) + oncotic pressure (fluid in)
- Increased osmolality-> fluid increases but not urinated-> general oedema
16
Q
What happens to renal physiology in pregnancy?
A
- Increases in size
- 50-60% increased blood flow to afferent arteriole
- Increased eGFR as increased fluids
- UTI risks as low urethral tone
- May get glucosuria
17
Q
What happens to cardiovascular physiology in pregnancy?
A
- Peripheral vasodilation
- HR increases
- Increased cardiac output
- BP down in early-mid pregnancy then increases
- Dilutional anaemia due to increased extracellular volume
- Hypercoagulation-> increased risk of VTE
- May see axis deviation on ECG
18
Q
What happens to blood pressure during pregnancy?
A
Decreases in early-mid then increases to term
19
Q
What happens to respiratory physiology in pregnancy?
A
- Increased oxygen consumption
- Increased diaphragm + subcostal angle-> rib cage splays
- Increased thoracic circumference
- Bronchial smooth muscle relaxatio
- Subjective dyspnoea-> breathe more air per breath but not increase in RR
- Lower pCO2-> increase gas exchange with baby
- Foetal Hb has high oxygen affinity-> mum’s Hb gives up more O2 at same partial pressure
20
Q
What happens to the GI and hepatic tracts in pregnancy?
A
- Lower gastric + bowel emptying-> constipation
- Cardiac sphinter relaxes-> heartburn
- Gallbladder motility decreases-> increased risk of stones
- Altered appetite
- Excess saliva
- Pica-> ingest non-edible substances
21
Q
What happens to blood glucose in pregnancy?
A
- In early pregnancy peaks lower-> storing for foetus use
- In late pregnancy stays higher for longer-> foetal use?
- Foetus uses from maternal circulation
- Risk of glucosuria + gestational diabetes
22
Q
What happens to the uterus in pregnancy?
A
- Hyperplasia + hypertrophy
- Natural killer cells
- Immune privilege-> allows foreign body to grow inside
- Endovascular remodelling ie spiral arteries infiltrated + stripped out by endovascular-> low resistance + pools of blood
23
Q
What is Chadwick’s sign?
A
Blue tinge to the cervix due to oestrogen + increased blood flow
24
Q
How is a pregnancy monitored in general?
A
- US for growth-> head circumference, abdominal circumference, femur length, weight
- Liquor volume
- Umbillical artery doppler
- Growth chart-> gestational age, weight, centile lines (conpared to mum’s height + weight and previous babies)
- Intermittent auscultation
- Cardiotocography (CTG) at >28 weeks
25
In low risk pregnancies, when do scans occur?
- Dating scan-> 11-13 weeks
| - Anomaly-> 20 weeks
26
When is a pregnancy considered high risk?
Co-morbidities, smoker, twins or more, age 35+ or <17, complications in previous pregnancy
27
When is sickle cell and thalassaemia tested for in pregnancy?
- All women by 8-10 weeks
- Dad if mum a carrier
- Both carriers-> prenatal diagnosis + counselling by 12 weeks
- In newborn blood spot screen
28
When are infectious diseases screened for in pregnancy and what happens if the tests are positive?
- HIV, Hep B + syphilis-> recommended to all in early pregnancy
- Offer again at 20 weeks
- If +ve-> contact within 10 days
- Hep B-> baby vaccinated at 24 hours then imms schedule
29
What is the foetal anomaly screening test (in general)?
- Offered to all
- For Patau's (chromosome 13), Edward's (18) + Down's (21)
- Combo test, quad test, early scan and/or non-invasive prenatal testing (NIPT)
30
What does the combination test for foetal anomaly screening entail?
- At 11+2 to 14+1 weeks
- Maternal age
- US-> crown rump length + nuchal transluency
- Serum PAPPA
- Serum bHCG
31
What does the quad test for foetal anomaly screening entail?
- At 14+2 to 20+0 weeks
| - Serum markers-> AFP, bHCG, oestradiol + inhibin A
32
What is the 'early scan' and when does it occur?
- At 8-12 weeks
- To see if-> viable, single/multiple pregnancy, major anomaly
- Check gestational age-> dating scan
33
What is non-invasive prenatal testing (NIPT)?
- Can be used as foetal anomaly screening
- From 10 weeks
- Only private
- Analyse foetal DNA fragments from maternal blood
34
What is the 'anomaly scan' and when does it occur?
- For all pregnancies at 18+0 to 20+6 weeks
- Look for-> anencephaly, exophalmos, serious cardiac defects, bilateral renal agenesis, lethal skeletal dysplasia, chromosome abnormalities
35
When is a Newborn Infant Physical Exam (NIPE) performed?
- Within 72 hours of birth
| - Then at 6-8 weeks after
36
What might a Newborn Infant Physical Exam (NIPE) reveal?
Cataracts, CHD, DDH, bilateral undescended testes
37
When would a baby by referred to a specialist after a Newborn Infant Physical Exam (NIPE) and how long would that take?
- Eye problems-> within 2 weeks
- Heart-> ASAP
- Bilateral testes undescended-> within 24 hours
- Unilateral testes-> 6 weeks to GP
- DDH concerns-> 2 weeks
38
What are the risk factors for developmental dysplasia of the hip?
- Breech at birth or when >36 weeks
- 1st degree FH of hip problems
- Twins + 1 breech
39
When is the first newborn hearing screening test done and what is it?
- Within 4 weeks of birth
- Automated otoacoustic emission test
- Earpiece plays sound + equipment picks up response
- Picks up permanent moderate/severe/profound deafness
40
What test is performed as part of the newborn hearing screen if the automated otoacoustic emission test detects a problem?
- Automated brainstem response
- Done within 4 weeks of AUOT
- Sensors on head pick up response of headphones clicking
- Referal to specialist if 1 or both ears
41
When is the newborn blood spot test performed?
Day 5 of life
42
What does the newborn blood spot test screen for?
- Sickle cell disease
- Congenital hypothyroidism
- Cystic fibrosis
- 6 metabolic disorders-> includes phenylketonuria and maple syrup urine disease
43
What is the normal circulation from the placenta to the foetus?
- 500-600ml/min to allow O2 transfer via conc gradient
- Spiral arteries respond to increased demand of blood supply to placental bed-> lower pressure + increased flow
- 2 umbilical arteries carry oxygenated blood from foetus to chorionic plate to chorionic villi to capillaries then venous + umbilical veins-> maternal vessels alongside
44
What causes placental insufficiency?
- Doesn't develop properly
- Damaged
- Mum's blood supply inadequate
45
What are the effects of placental insufficiency on the foetus?
- Hypoxia-> hypoglycaemia, hypercapnia, acidaemia, hyperlactaemia
- Hypoglycaemia but low glycogen stores so hard to get over-> growth axis downregulated (involved insulin + IGF-1)
- Try to increase O2-carrying capacity of blood-> EPO release + polycythaemia-> increase blood viscosity + occulsions
- Brain sparing-> blood directed to brain, adrenals + heart to increase survival but often CNS maturity delayed
46
What are the complications of placental insufficiency?
Foetal distress, pre-eclampsia, IUGR, stillbirth, hypothyroidism
47
What factors influence foetal growth?
- Maternal-> size, weight, BMI, nutritional state, anaemia, smoking, substance abuse, environmental noise exposure, uterine blood flow, infection
- Placental-> size, microstructure, umbilical blood flow, transporters + binding proteins, nutrition production + utilisation, transplacental glucose
- Foetal-> genome, nutrition productio, hormone output, genetic conditions, insulin
48
What are the 3 categories of factors that influence foetal growth?
Maternal, placental and foetal
49
What maternal factors influence foetal growth?
size, weight, BMI, nutritional state, anaemia, smoking, substance abuse, environmental noise exposure, uterine blood flow, infection
50
What placental factors influence foetal growth?
size, microstructure, umbilical blood flow, transporters + binding proteins, nutrition production + utilisation, transplacental glucose
51
What foetal factors influence foetal growth?
genome, nutrition production, hormone output, genetic conditions, insulin
52
What is intra-uterine growth restriction?
When foetus not as big as would expect for gestational age-> symmetrical or asymmetrical
53
What is symmetrical intra-uterine growth restriction?
All of the baby's body is small (30% of IUGRs)
54
What is asymmetrical intra-uterine growth restriction?
Baby's head and brain is normal size but body small-> 70% of IUGRs
55
What is the definition of small for gestational age?
- <10th centile for gestational age
| - Height/weight <2SDs of population mean
56
What is the definition of a low birth weight?
<2.5kg (5 pounds 8 oz) when born
57
What are the signs and investigations for intra-uterine growth restriction?
- Reduced foetal movements
- Oligohydramnios
- Low/absent/reversed end diastolic flow on umbilical artery doppler
58
How is intra-uterine growth restriction managed?
- Monitor-> growth charts, 20 week scan measurements (abdominal + head circumference etc), umbilical artery doppler
- Mum-> manage co-morbidities, diet advice, bed rest
- Induction + early delivery-> when stopped growing etc
59
What are the potential consequences of intra-uterine growth restriction?
- NICU admission
- Breathing + feeding problems
- Difficulties maintaining body temperature
- Hypoglycaemia
- Increased infections
- Chronic conditions
60
What is macrosomia?
Weighs 4kgs (8 pounds 13 oz) at birth
61
What is the definition of large for gestational age?
>90th centile for gestational age
62
How is macrosomia managed?
- Prevent-> pre-conception appointment (when overweight)
- Maternal and foetal tests for diabetes (+ manage if have)
- Weight monitoring
- C-section-> when over 9lb 15oz + DM or >11lb + shoulder dystocia
- Vaginal-> inhospital as more likely forceps/ventouse
63
What are the potential complications of macrosomia?
- Mum-> shoulder dystocia, GU lacerations, bleed after delivery (hypotonia + PPH risk), uterine scar rupture
- Baby-> hypoglycaemia, obesity, metabolic syndromes, increased MI/stroke risk
64
What are the potential causes of bleeding in pregnancy?
- Early-> implantation spotting, cervical changes
- Throughout-> miscarriage, ectopic
- Later-> infection, placenta praevia, abruption
65
What are the investigations for PV bleeding during pregnancy?
- Vaginal/pelvic exam
- TV/abdominal US
- Serum hCG
66
What is the definition of miscarriage?
Loss of pregnancy before 24 weeks of gestation
67
When do most miscarriages occur?
Within first 12 weeks of pregnancy
68
How many pregnancies in the UK end in miscarriage?
20-25%
69
What are the potential causes of miscarriage?
- Genetics
- Hormones (eg irregular periods),
- Blood clots (eg in placenta)
- Infection (eg rubella)
- Anatomical-> weak cervix opens as uterus grows, irregular uterus shape
- Large fibroids
70
What are the potential causes of recurrent miscarriage?
Increased maternal age, low BMI, PCOS, clotting problems, abnormal karyotype, antiphospholipid syndrome, abnormal uterus
71
What are the symptoms of miscarriage?
Bleeding, pain, lack/loss of pregnancy symptoms
72
What are the types of miscarriage?
- Complete
- Incomplete
- Anembryonic
- Missed
- Inevitable
- Threatened
- Recurrent
- Septic
73
What is a complete miscarriage?
All products of conception expelled
74
What is an incomplete miscarriage?
Some products of conception remain in the uterus
75
What is an anembryonic miscarriage?
- Blighted ovum/empty sac
| - Gestational sac present but embryo absent or stops growing early
76
What is a missed miscarriage?
When the baby has passed away or not developed but has not yet been expelled from the uterus
77
What is an inevitable miscarriage?
Internal os open + bleeding but products of conception still in the uterus
78
What is a threatened miscarriage?
Some bleeding + pain but os closed + viable pregnancy
79
What is recurrent miscarriage?
3+ consecutive miscarriages
80
What is septic miscarriage?
Tissue from missed/incomplete miscarriage gets infected
81
How is miscarriage diagnosed?
- US-> no heartbeat, crown rump length >7mm
- Expelled contents examination
- hCG-> rule out ectopic
- Clotting screen + cytogenics
82
How is miscarriage managed?
- Oral/vaginal prostaglandin analogues
| - Surgical-> evacuation of retained products (ERPC) if bleeding/infection
83
What is an ectopic pregnancy?
Pregnancy that implants + develops outside the uterine cavity (usually fallopian tubes)
84
What are the risk factors for ectopic pregnancy?
IVF + assisted conception, PID, endometriosis, previous ectopic, smoking, IUD, fallopian tube/cilia damage
85
How does ectopic pregnancy present?
- Unilateral abdominal pain
- Bleeding
- Amenorrhoea-> if don't know pregnant
- Shoulder tip pain-> intraabdominal blood irritates diaphragm
- Collapse
86
How is ectopic pregnancy investigated?
- Serum hCG + repeat in 24 hours-> rise but not as much as would expect
- TV US> locate
- Serum progesterone-> <20nmol/L suggests failing
- Laparoscopy
87
How is ectopic pregnancy managed?
- Expectant + monitoring as may dissolve by self
- IM single dose MTX-> stop growth
- Laparoscopic partial or total fallopian tube removal
- Laparotomy if ruptured
88
When does ectopic pregnancy usually rupture?
At 14-16 weeks
89
What is pregnancy of unknown location (PUL)?
Positive pregnancy test but doesn't appear as intrauterine, ectopic or retained products of conception
90
How does pregnancy of unknown location (PUL) present?
Asymptomatic, abdominal pain, bleeding
91
How is pregnancy of unknown location (PUL) investigated?
- Progesterone
- hCG
- Laparoscopy
92
What are the potential outcomes of pregnancy of unknown location (PUL)?
Intrauterine pregnancy, ectopic, failing pregnant, persistent PUL, ovarian/CNS tumour
93
What is a molar pregnancy?
Hydatidiform mole-> unusual + rapid growth of placenta, cysts burrow in uterine wall, complete or partial
94
What is complete molar pregnancy?
Sperm fertilises empty ovum + foetus doesn't develop
95
What is partial molar pregnancy?
2 sperms fertilise the ovum + foetus might be present
96
How does molar pregnancy present?
- Irregular bleeding
- Uterus large for dates
- Pain
- Exaggerated pregnancy symptoms-> hyperemesis gravidarum
97
What is the characteristic US appearance of molar pregnancy?
Snowstorm appearance
98
How is molar pregnancy managed?
Surgical/medical evacuation
99
What is hyperemesis gradivarum and how does it present?
Symptoms due to excess b-hCG
- Vomiting
- Weight loss
- Muscle wasting
- Dehydration
- Electrolyte imbalances
100
How is hyperemesis gradivarum investigated?
- Urinalysis + MSU
- FBC, U+E, LFT
- US-> molar pregnancy
101
How is hyperemesis gradivarum managed?
Oral/IV fluids, monitoring, antiemetics, thiamine, thromboprophylaxis
102
What is pre-eclampsia?
Hypertension + proteinuria at 20+ weeks of pregnancy
103
What is the pathophysiology of pre-eclampsia?
- Incomplete trophoblast invasion into spiral arteries-> not lower resistance
- Decreased blood flow to placenta-> ischaemia + growth prevention
- Affect RAAS-> vasoconstriction + DIC
104
What are the risk factors for pre-eclampsia?
Primigravida, young, BAME, multipregnancy, hypertension, renal disease
105
How is pre-eclampsia investigated?
- BP-> 140/90-149/99 (mild), 150/100-159/109 (moderate), 160/110+ (severe)
- Urine-> proteinuria
- May have oligouria
- Bloods-> deranged LFTs, low platelets
- IUGR
106
How is pre-eclampsia treated?
- Labetolol or nifedipine
- MgSO4-> pre-seizure management
- Delivery+ anti-hypertensives
- NOT push in labour if >160 systolic-> intracerebral bleeding risk
107
How is pre-eclampsia prevented?
Aspirin 75mg-> at 12-28 weeks of pregnancy
108
What is eclampsia?
Tonic clonic seizures
109
What is the definition of hypertension in pregnancy?
- Gestational-> new, 20+ weeks, no proteinuria
| - Chronic-> before pregnancy or <20 weeks
110
How is hypertension managed in pregnancy?
Aspirin 150mg from 12 weeks-> reduce pre-eclampsia risk
111
What is placenta praevia?
- Placenta inserted wholly or partially into the lower segment of the uterus
- Usually called 'low-lying placenta' until >37 weeks as often moves
112
What are the different grades of placenta praevia?
- Minor (I/II)-> close to/encroaching on cervical os (<2cm)
| - Major (III/IV)-> lies over os, can cause cervical effacement + dilation, bleeding + death
113
How does placenta praevia present?
- Asymptomatic
| - Painless bleeding triggered by sex or injury
114
How is placenta praevia monitored?
- 20 weeks-> US + TVUS
- 32 weeks-> check position + may measure cervix (assess early labour risk)
- 36 weeks-> check again
115
How is placenta praevia managed?
- Regular monitoring
- Stay home-> asymptomatic + close to hospital etc
- Symptoms-> admit from 34+ weeks
- Steroid injections-> at 34-36 weeks
- Magnesium sulphate-> if <32 weeks
- C-section likely at 36-37 weeks
- Irons supplements + regular Hb measurements
116
What is placental abruption?
Placenta separates from uterine wall-> concealed or revealed
117
How does placental abruption present?
Pain, PV bleeding, hard/woody uterus, haemodynamic instability
118
How is placental abruption managed?
- Watch + wait if small
- Induction at 37+ weeks
- C-section
119
What is placental accreta?
When the placental villi grows into deeper tissues + makes delivery more difficult
- Accreta-> attached to myometrium
- Increta-> into the myometrium
- Percreta-> through myometrium to serosa + other structures
120
What causes placental accreta?
Previous C-section (into scar), uterus surgery, fibroids, bicornate uterus, 35+, IVF, previous childbirth
121
How is placental accreta diagnosed?
- Suspected via US or MRI
| - Confirm in delivery-> placenta not delivered in 30 minutes or 1 hour
122
What are the risks/implications of placental accreta?
- Severe bleed (PPH) especially if retained-> DIC, RDS, kidney failure
- Damage other organs-> bladder
- Occult blood loss-> behind placenta
123
How is placental accreta managed?
- FBCs, group save + crossmatch
- IV access
- Oxytocin into umbilical vein + wait
- Manual removal of placenta (MROP)-> take out with hands in 1 piece then give oxytocin for 4 hours + IV antibiotics
- Often need delivery at 32 weeks ish
124
What is vasa previa?
- Foetal vessels through membranes over internal cervical os
| - Unprotected by placental tissue + umbilical cord-> prone to bleeding
125
How does vasa previa present?
- Moderate PV bleed
- Foetal distress
- Especially after membrane rupture
126
How is vasa previa managed?
- TV US
| - Emergency C-section
127
What are the risk factors for uterine rupture?
Previous C-section
128
How does uterine rupture present?
- CTG abnormalities
- Feel foetal parts on abdomen
- Severe pain between contractions
- Maternal shock
129
What is antepartum haemorrhage?
A bleed at any point up to 24 weeks of pregnancy
130
What can cause antepartum haemorrhage?
Placental abruption
- Placenta praevia
- Severe chorioamnionitis
- Sepsis
- Severe pre-eclampsia-> hepatic rupture
- Retained deceased foetus
- Ectopic
131
How is antepartum haemorrhage managed?
- Admit for 24 hours-> high risk of rebleed
- Maternal-> FBC, coagulation screen, Kleinhaur test (see if rhesus change from negative + need anti-D)
- Foetal-> US, umbilical artery doppler, increase monitoring
- Resus if need
- Left lateral tilt-> reduce VC compression + increase return
132
What is the definition of primary post-partum haemorrhage?
Blood loss of >500ml in first 24 hours after delivery
133
What is the definition of secondary post-partum haemorrhage?
Excess vaginal bleeding from 24 hours to 12 weeks after delivery
134
What is the definition of minor post-partum haemorrhage?
<1500ml blood loss + no shock
135
What is the definition of major post-partum haemorrhage?
>1500ml blood loss + shock
136
Why can post-partum haemorrhage progress quickly?
- Uterus blood flow at term is 500-800ml/min-> potential to lose lots
- Can tolerate 10-15% but lose CV compensation if 30-40+%
137
What causes primary post-partum haemorrhage?
4T's...
- Tone-> uterine atony
- Tissue-> retained products
- Trauma-> to genital tract
- Thrombin-> coagulopathy
138
What causes secondary post-partum haemorrhage?
- Infection of retained products
- Gestational trophoblastic disease
- Uterine AV malformation
139
How does CMV present in pregnancy?
Asymptomatic or infective mononucleosis picture in mum
140
How is CMV in pregnancy managed?
- Antibodies-> IgG
- Avidity index-> low means 1st infection
- Amniocentesis
- 4 weeks of acyclovir
141
What are the complications of CMV in pregnancy?
Sensorineural hearing loss, microcephaly, SGA, large ventricles, calcifications, hepatosplenomegaly
142
How are chronic diseases managed in pregnancy (generally)?
- Preconception counselling-> consider effect of pregnancy on condition
- Optimise disease control
- Contraception if defer pregnancy
- Joint obstetric-medical clinics
143
What are the cardiac risks in pregnancy and what should be considered?
IHD risk 3-4x higher
- Postural hypotension
- If have stenosis-> pulmonary oedema + HF
- Manage-> echo/ECGs, monitor foetal growth, no ACE-i's
144
What are the cardiac risks in pregnancy and what should be considered?
IHD risk 3-4x higher
- Postural hypotension
- If have stenosis-> pulmonary oedema + HF
- Manage-> echo/ECGs, monitor foetal growth, no ACE-i's
145
What effects might being pregnant have on a person with asthma?
- If not controlled likely to worsen in 3rd trimester
- Safe to use-> SABA, LABA, ICS, LTAs, steroids etc
- Affect on foetus-> IUGR (eg poor placental perfusion), prematurity, neonatal hypoxia
146
How is hyperthyroidism managed in pregnancy?
- Usually improves in 1st trimester
- Measure thyroid antibodies + baby growth
- Risks-> thyroid crisis + thyrotoxicosis in baby
- Give propylthiouracil in 1st trimester then carbimazole later (can cause foetal anomalies)
147
How is hypothyroidism managed in pregnancy?
- Complications of foetal loss + neurodevelopmental problems
| - Increase thyroxine in 1st trimester
148
How might CKD affect pregnancy?
- Renal blood flow usually increases by 50% (healthy)
- Investigate-> BP, creatinine, proteinuria
- Maternal risks-> severe HTN, pre-eclampsia
- Baby risks-> prematurity, stillbirth, microsomia
149
What neuro conditions are common in pregnancy?
- Migraine
- Epilepsy
- Spina bifida in baby-> epilepsy + meds etc
150
How is epilepsy managed in pregnancy?
- Folic acid 5mg (high dose)
- Screen for abnormalities
- Delivery plan-> exhaustion + pain can predispose to seizures
- NOT sodium valproate
151
What are the risks associated with epilepsy in pregnancy?
- Foetal abnormalities-> eg valproate SEs
- Inheritance
- Seizure in labour-> foetal hypoxia
152
What effect might pulmonary hypertension have in pregnancy?
- Baby-> IUGR, premature, drug SEs
| - Need anaesthetic input in birth
153
What is the pathophysiology of obstetric cholestasis?
- Changes to bowels-> increased transit times, decreased emptying, peristalsis, low oesophageal sphincter pressure
- Bile moves slower-> can stasis
154
How does obstetric cholestasis present?
Itching without rash
155
How is obstetric cholestasis investigated?
- AST + ALT raised
- Liver scan
- Bile acids increased
156
How is obstetric cholestasis managed?
- Ursodeoxycholic acid
| - Resolves after delivery
157
What are the complications of obstetric cholestasis?
- Premature labour
- Stillbirth
- Recurs in future pregnancy in 80%
158
What are the definitions of anaemia in pregnancy?
- 1st trimester-> <110 Hb
- 2nd + 3rd-> <105
- Post-delivery-> <100
159
What happens to the blood in pregnancy?
- Increased volume-> dilutional anaemia
- WCC, clotting and fibrinogen up
- Haematocrit, Hb, antithrombin, platelets down
- Iron requirements increase by 2-3x
- Folate requirements up by 10-20x
160
What complications might iron deficiency anaemia in pregnancy cause?
- PPH
- Post-natal depression
- Prematurity
- Low birthweight
161
How is iron deficiency anaemia in pregnancy managed?
Supplements-> ferrous sulphate 200mg TDS for a month then check again
162
How is B12/folate deficiency anaemia in pregnancy managed?
5mg folic acid OD then recheck in 4 weeks
163
What is gestational diabetes?
Carbohydrate intolerance first recognised in pregnancy-> increases chance of T2DM
164
How is pre-existing diabetes managed in pregnancy?
- Aim for HbA1c of <48mmol/l
- Folic acid 5mg
- Stop ACEis and statins
- Retinal + renal screening
- If pre-conception HbA1c >68mmol/L-> advise against pregnancy (likely abnormalities)
165
What are the potential complications of diabetes in pregnancy?
- Baby-> sencondary foetal hyperinsulinaemia, excess glucose, macrosomia, IUGR, miscarriage, stillbirth, shoulder dystocia + Erb's palsy)
- Mum-> DKA, hypos, retinopathy, pre-eclampsia, prematurity
166
What is the definition of labour?
Regular uterine contractions with progressive cervical effacement + dilation
167
What are the stages of labour?
- Stage 1-> latent (cervix <4cm) + active (4-10cm)
- Stage 2-> giving birth
- Stage 3-> from baby delivery to delivery of placenta
- After-> increased oxytocin for bonding + uterus contraction
168
What are the features of labour?
- Membrane rupture + amniotic fluid leakage
- Foetus through pelvis-> engage + descent, internal rotation, crowning, restitution, external rotation, anterior the posterior shoulder delivery
- Contractions-> from fundus down to expel baby
- Effacement-> soften + thinning of uterus
169
What is the most common shape of the female pelvis?
Gynaecoid
170
What are the different stages of the foetus moving through the pelvis during birth?
- engage + descent-> head occipital-transverse
- internal rotation at ischial spine-> head occipital anterior
- crowning ie head extends
- restitution-> head rotates so in line with foetal spine
- external rotation
- anterior then posterior shoulder delivery
171
What are the 3Ps of successful labour?
- Passageway (pelvis)
- Passenger
- Power
172
What is the modified Bishop's score of the cervix?
- Looks for if labour is likely to start spontaenously
- If 8+ then is likely
- If lower may need to induce
173
What is the role of prostaglandins in induction of labour?
- Into posterior fornix via gel/pessary
- Prep cervix + helps opening in response to contractions
- SEs of prolonged contractions + pain + diarrhoea
174
What is the role of oxytocin (eg syntocinon) in labour?
- Via infusion
- 6 hours after prostaglandins used
- Initiate uterine contractions via myometrium contractions
- When membranes ruptured
175
What pain management options are available in labour?
- Non-medical-> pool birth, upright, slow breaths, aromatherapy
- Medical-> paracetamol, codeine, entonox, opioids, epidural (eg fentanyl + bupivacaine)
176
What is delayed cord clamping?
- Allow 1 minute of blood transfusion
| - Benefits-> increases RBCs, iron and stem cells
177
What are some options for management of 3rd stage of labour?
- IV oxytocin
- Controlled cord traction-> risk of cord snapping or uterus inversion
- Examination
178
How is the foetus monitored in labour?
- Intermittent auscultation-> Pinnard/doppler every 15 mins for 1 min
- Cardiotocography (CTG)-> intermittent or continuous depending on risk level
- Foetal ECG-> on scalp or abdomen
- Foetal blood sample-> when abnormal CTG + >4cm dilation
179
What is monitored on cardiotocography (CTG)?
DR C BRaVADO
- DR-> define risk
- Contractions-> worry if >5 every 10 mins
- Bradycardia-> >3 mins (definite), 6 (think about theatre), 9 mins (theatre), 12 (born)
- Variability-> 5-25bpm normal + baseline 110-160bpm
- Accelerations
- Decelerations-> normal in contractions as compressed but variable or after contraction may be worrying
- Overall-> normal (all OK), suspicious (1+ abnormal), abnormal (2+)
180
How does foetal blood samples be interpretted?
Look at pH
- >7.25 is normal
- 7.21-7.24 is borderline + should repeat in 30 mins
- <7.2 should consider delivery
181
What are the different types of rupture of membranes?
- Spontaneous
- Artificial
- Premature
182
What is the definition of failure to progress (in 1st stage of labour)?
- <2cm dilation in 4 hours or slowing of dilation
- Primary dysfunctional labour-> from early active phase
- Secondary arrest-> slowing when previously adequate
183
What causes failure to progress (in 1st stage of labour)?
- Insufficient uterine power/activity
- Malposition/malpresentation
- Large baby
- Inadequate pelvis eg too small
184
What is failure to progress (in 2nd stage of labour)?
When baby not delivered within 1 hour of active pushing (multiparous) or 2 hours (nulliparous)
185
What are the risk factors for failure to progress (in 2nd stage of labour)?
Epidural, amniotic sac problems, diabetes, PROM
186
What are the consequences of failure to progress in labour?
Foetal distress, foetal intracranial haemorrhage, increased chance of needing operative delivery, injury (CP, HIE), foetal infection, birth canal damage, PPH, post-partum infection
187
What is a malpresentation?
Baby in any position other than vertex/cephalic lying near internal os
188
What is the best presentation for baby to be in?
Cephalic-> left occipital anterior
189
What can cause malpresentation?
- Maternal-> multiparous, pelvic tumours, contracted pelvis
- Foetal-> premature, multipregnancy, macrosomia, death
- Placenta-> previa etc
190
What are the types of breech presentation?
- Extended/Frank-> feet by head
- Flexed/complete-> bum + feet
- Footling-> 1 foot
191
How is breech presentation managed?
Try ECV at 36 weeks
192
What are the types of malpresentation?
- Breech
- Face-> hyperextension of neck
- Brow-> midway between flex + extension
- Cord-> emergency as risk of cord prolapse
193
What is cord prolapse?
- Cord presents after rupture of membranes
| - Exposure leads to vasospasm + compression-> hypoxia in baby
194
What are the risk factors for developing cord prolapse?
PROM, malpresentation, polyhydramnios, multiparity, multipregnancy
195
How is cord prolapse managed?
- Emergency-> want to deliver in a few minutes
- Elevate foetal head so not pushing
- Trendelenburg-> mum on all 4s, feet higher than head etc
196
What is shoulder dystocia?
Failure to deliver the anterior shoulder
197
What are the risk factors for shoulder dystocia?
Diabetes, previous shoulder dystocia, macrosomia, obesity, prolonged labour, instrumental delivery
198
What are the complications of shoulder dystocia?
- Mum-> PPH, vaginal tears, PTSD
| - Neonate-> hypoxia, fits, CP, Erb's palsy (C5-6 nerves)
199
How might Erb's palsy be prevented in shoulder dystocia?
- Breaking bones eg clavicle or humerus
| - Episiotomy
200
How is shoulder dystocia managed?
HELPERRR
- Help
- Evaluate for episiotomy
- Legs in McRobert's ie full flexion
- Suprapubic pressure
- Enter pelvis
- Rotational manouvre
- Remove posterior arm
- Replace head + CS
201
What is the puerperium?
Time from delivering the placenta to 6 weeks after
202
What is involution in the puerperium?
Shrinking of the uterus + genital, muscle changes + decidua (mucous membrane lining the uterus)
203
What are the different stages of lochia expulsion during involution in the puerperium?
- Lochia rubra-> day 0-4, blood, discharge, decidua, foetal membrane, vernix (protective layer on baby), meconium
- Lochia serosa-> day 4-10, WBCs, mucous, exudate, foetal membrane
- Lochia alba-> day 10-28, cholesterol, epithelial fat, mucous, leukocytes
204
What is the role of prolactin in the puerperium?
- Produced during suckle-> sensory input from nipple to brain
- Secreted from anterior pituitary-> blood
- Lactocytes-> produce milk + suppress ovulation
- Increases at night + during feeds
205
What is the role of oxytocin in the puerperium?
- Suckle causes sensory input to brain
- Secreted from posterior pitutary
- Causes myoepithelial contraction + expulsion of milk
- Increased when sees baby
- Decreases when stressed
206
What is the role of lactoferrin in breastfeeding?
- Protein-> 7x more in colostrum (early milk)
- Regulate iron absorption to cells
- Protects from infection
207
What are the risk factors for developing maternal sepsis?
Obesity, diabetes, BAME, anaemia, amniocentesis, prolonged SROM, vaginal trauma
208
What can cause maternal sepsis?
- Endometriosis
- Skin + soft tissue infections
- Mastitis
- UTI
- Pneumonia
- GE
- Pharyngitis
- Epidural/spinal
209
How does maternal sepsis present?
3Ts white with sugar
- Temperature <36 or >38
- Tachycardia (90+)
- Tachypneoa (20+)
- WCC >12 or <4
- Hyperglycaemia (>7.7)
- Clues for source-> PROM, offensive liquor/lochia, dysuria, meningism, D+V, breast
210
What are the risk factors for developing VTE in pregnancy?
- Increased age
- High BMI
- Operative delivery
- Previous VTE
- Thrombophilia
- After birth-> 5x risk
211
How is VTE managed in pregnancy?
- Doppler US, VQ scan, CTPA
- High risk-> 6+ weeks postnatal LMWH
- Intermediate risk-> 10+ days LMWH
212
What is the baby blues?
Emotional or tearful for 3-10 days after birth-> affects 85%
213
What are some signs of postnatal depression?
- Low mood
- Irritability
- Bonding with baby affected
- 10% affected
214
What are some signs of postpartum psychosis?
- Depression
- Mania
- Psychosis-> delusions + hallucinations
215
What are some signs of post-natal PTSD?
- Anger, dissociating, flashbacks
- Avoiding intimacy with partner
- Requesting C-section for next birth
216
What are th risk factors for developing post-natal PTSD?
Perceived lack of care, poor communications, feeling unsafe, focus on outcome not mum
217
What is the definition of a maternal death?
- Death whilst pregnant or within 42 days of TOP
- Irrespective of duration of pregnancy + site
- For any caused related to or aggravated by pregnancy or its management
- Not from an accident or incident
218
When do maternal deaths usually take place?
Postnatal (70%)
219
What is a direct maternal death?
- Directly related to pregnancy
- VTE, haemorrhage, pre-eclampsia
- 1/3 deaths
220
What is an indirect maternal death?
- Not directly due to pregnancy
- Pre-existing medical disorder (75%), cardiac disease, neuro, MH problem
- Includes suicide
- 2/3 maternal deaths
