Obstetrics Flashcards
(104 cards)
1
Q
what is the triad of symptoms in Pre-eclampsia?
A
hypertension
proteinuria
oedema
2
Q
when does pre-eclampsia occur?
A
after 20 weeks gestation
3
Q
when is a woman given aspirin as prophylaxis for pre-eclampsia?
A
if they have one high risk factor (e.g pre-existing hypertension, previous gestational hypertension, autoimmune conditions e.g SLE, diabetes, CKD) or two moderate risk factors (>40, BMI >35, >10 years since previous pregnancy, multiple pregnancy, first pregnancy, FH of pre-eclampsia)
4
Q
what are the symptoms of complications of pre-eclampsia?
A
headache visual disturbance oedema reduced UO nausea and vomiting brisk reflexes upper abdo pain
5
Q
what is the diagnostic criteria for pre-eclampsia?
A
BP > 140/90 plus one of:
- urine protein:creatinine ratio >30mg/mmol
- maternal organ dysfunction
- uteroplacental insufficiency: FGR, abnormal doppler studies
6
Q
what antihypertensives are given in pregnancy?
A
labetolol- 1st line
nifedipine- 2nd line
methyldopa- 3rd line
IV hydralazine- used in critical care for severe pre-eclampsia
7
Q
what antihypertensives are used postnatally?
A
enaparil- 1st line
nifedipine or amlodipine- 1st line in black African or carribean patients
labetolol or atenolol
8
Q
what are the BP targets antenatally and postnatally?
A
antenatally- 135/85
postnatally- 140/90
9
Q
what is IV magnesium sulphate used for in pre-eclampsia?
A
given during labour and 24 hours after for prophylaxis and treatment of eclamptic seizures
10
Q
what is HELLP syndrome?
A
a combination of features that occur as a complication of pre-eclampsia
Haemolysis
Elevated Liver enzymes
Low Platelets
11
Q
when is delivery recommended in pre-eclampsia?
A
if hypertension is well controlled and no complications- 37 weeks
where delivery is indicated prior to 36 weeks maternal antenatal corticosteroids should be considered
12
Q
what is considered severe gestational hypertension?
A
160/110
patient should be admitted
13
Q
what is placental growth factor (PIGF) testing used for?
A
used between 20 and 35 weeks to rule out pre-eclampsia
PIGF is low in pre-eclampsia
14
Q
what are the foetal complications of pre-eclampsia?
A
intrauterine growth restriction
prematurity
15
Q
when is oral glucose tolerance testing offered in pregnancy?
A
at booking if previous GDM at 24-28 weeks if they have: -any risk factors for GDM -large for dates fetus -polyhydramnios -glucose on urine dip
16
Q
what are risk factors for GDM/
A
previous GDM BMI>30 previous macrocosmic baby >4.5kg black Caribbean, Middle Eastern or south asian ethnicity family history of diabetes
17
Q
what are the diagnostic values for GDM on an OGTT?
A
fasting plasma glucose >5.6mmol/L
2 hopur plasma glucose >7.8mmol/L
18
Q
how is gestational diabetes managed?
A
fasting glucose <7- trial of diet and exercise for 1-2 weeks followed by metformin then insulin if not controlled
fasting glucose > 7 or >6 + macrosomia- start insulin with or without metformin
19
Q
what are the complications of gestational diabetes?
A
mother:
- macrosomia- more painful birth and increased risk of shoulder dystocia
-perinatal mortality
- incduced labour, c-section delivery
- increased risk of T2DM after pregnancy
baby:
- macrosomia, shoulder dystocia, birth injuries (nerve palsies)
-neonatal hypoglycaemia, jaundice, polycythemia (^ haemoglobin)
- ^ risk of obesity and T2DM in later life
- ^ risk of congenital heart disease and cardiomyopathy
20
Q
when should women with uncomplicated gestational diabetes give birth?
A
no later than 40+6 weeks
21
Q
what is placenta praevia?
A
the placenta is attached in the lower part of the uterus, lower than the presenting part of the foetus and is covering the internal cervical os
22
Q
what is a low lying placenta?
A
the placenta is within 20mm of the internal cervical os
23
Q
what are the risks associated with placenta praevia?
A
antepartum haemorrhage emergency c-section emergency hysterectomy maternal anaemia and transfusions preterm birth and low birthweight still birth
24
Q
what are the risk factors for placenta praevia?
A
previous C section previous placenta praevia older maternal age maternal smoking structural uterine abnormalities(e.g. fibroids) assisted reproduction (e.g. IVF)
25
how does placenta praevia present?
usually found on the 20 week anomaly scan
may present with painless vaginal bleeding, usually post coitally
abnormal lie and presentation
26
how is low lying placenta or placenta praevia managed?
if a low lying placenta is detected at the 20 week scan repeat transvaginal ultrasound scans are offered at 32 weeks and 36 weeks to check if the placenta has migrated (9 in 10 do)
corticosteroids- given between 34 and 35+6 weeks to mature fatal lungs given the risk of premature delivery
planned early C section at 37 weeks
emergency C-section if there is premature labour or antenatal bleeding
27
what is placental abruption?
where the placenta separates from the wall of the uterus during pregnancy. it is a significant cause of antepartum haemorrhage
28
what are the risk factors for placental abruption?
```
previous placental abruption
pre-eclampsia
bleeding early in pregnancy
trauma (consider domestic violence)
multiple pregnancy
Fetal growth restriction
multigravida
increased maternal age
smoking
cocaine or amphetamine
```
29
how does placental abruption present?
sudden onset severe abdominal pain that is continuous
vaginal bleeding (antepartum haemorrhage)
shock (hypotension and tachycardia)
abnormalities on the CTG (metal distress)
characteristic 'woody' abdomen on palpation suggesting a large haemorrhage
30
how is the severity of antepartum haemorrhage quantified?
minor- less than 50ml
major- 50-1000ml
massive- >1000ml
31
what is a concealed abruption?
the cervical os remains closed and any bleeding that occurs remains within the uterine cavity. in this case the severity of the bleeding can be significantly underestimated
32
how is placental abruption managed?
it is an obstetric emergency
CTG monitoring of foetus
fluid and blood resuscitation as required
anti-d should be given to rhesus-D negative
emergency C-section if the mother is unstable or there is fetal distress
33
what is vasa praevia?
a condition where the metal vessels are within the metal membranes (chorioamniotic membranes) and are not contained within the umbilical cord and travel across the internal cervical os. these vessels are prone to bleeding, particularly when the membranes are ruptures during labour. it is a cause of antepartum haemorrhage
34
what are the types of vasa praevia?
type 1- velementous umbilical cord- the umbilical cord inserts into the chorioamniotic membranes and the fetal vessels travel unprotected through the membranes before joining the placenta
type 2- an accessory lobe of the placenta is connected by metal vessels which travel through the chorioamniotic membranes
35
what are the risk factors for vasa praevia?
low lying placenta
IVF pregnancy
multiple pregnancy
36
how does vasa praevia present?
may be diagnosed by ultrasound during pregnancy
may present with antepartum haemorrhage in the 2nd or 3rd trimester
may be detected by vaginal examination during labour- pulsating fetal vessels seen through the cervix
may be detected during labour when bleeding and fetal distress occurs following rupture of membranes. carries a high risk of fatal mortality
37
how is vasa praevia managed?
if vasa praevia is diagnosed early: corticosteroids to mature fetal lungs and elective C section planned for 34-36 weeks.
where antepartum haemorrhage occurs emergency C section is required to deliver the fetus before death occurs
38
how many antenatal clinic appointments will a nulliparous and porous woman have during an uncomplicated pregnancy?
10 for nulliparous woman
| 7 for porous woman
39
when is the booking scan and anomaly scan carried out?
booking scan- between 11+2 and 14+1 weeks
| anomaly scan- between 18 and 20+6 weeks
40
when is the combined test carried out and what does it test for?
between 10 and 14 weeks
it involves a blood test and a nuchal thickness measurement
tests for downs syndrome, Edwards syndrome and pataus syndrome
41
what does the quadruple test test for and when can it be carried out?
the quadruple test is a blood test which screens for downs syndrome. can be carried out between 14 and 20 weeks
42
what is done during routine antenatal care appointments?
symphysis fundal height measurement
BP and urine dipstick
birth preferences discussions
smoking
screen for risks- VTE, pre-eclampsia, gestational diabetes, monitor fetal growth and wellbeing
assessment of fetal position from 36 weeks
43
what additional interventions are carried out in a raised BMI pregnancy (>30)?
```
OGTT for GDM
LMWH for VTE
aspirin- for pre eclampsia
additional growth scans for IUGR
increased dose of folic acid (5mg)
offer consultant lead antenatal care
```
44
how much folic acid should be taken in pregnancy?
400 micrograms until 12 weeks
45
when should anti-d be given?
should be given to any rhesus negative women within 72 hours of a sensitising event. a sensitising event includes a vaginal bleed, amniocentesis, CMV, labour and delivery C section, external cephalic version, abdominal trauma
46
when is anaemia screened for in pregnancy?
at booking and at the 28 week appointment
47
what are the diagnostic values for anaemia in pregnancy?
Hb of <110 in the 1st trimester
| <105 in the 2nd and 3rd trimester
48
what is the blood transfusion threshold?
<70g/L or 71-80g/L if symptomatic
49
what are the targets for pre-existing diabetes in pregnancy?
HbA1c- <48mmol/L
| fasting blood glucose <5.3mmol/L, 1 hour after meals <7.8 mmol/L, 2 hours <6.4 mol/L
50
what additional interventions should be carried out in pregnancy with pre-existing diabetes?
retinal assessment- pre pregnancy or after first antenatal appointment, and at 28 weeks
renal assessment- pre-pregnancy or at first contact during pregnancy
aspirin- for pre-eclampsia
USS to monitor metal growth and amniotic fluid volume every 4 weeks from 28 to 36 weeks
diabetes antenatal clinics
monitor capillary blood glucose every hour during labour and maintain it between 4 and 7 mmol/L
consider an IV dextrose and insulin infusion during labour
51
when should women with pre-existing diabetes give birth?
advise women to have an induction or C-section between 37 and 38+6 weeks
52
what hypertensive medications should be stopped in pregnancy?
ACE inhibitors
ARBs
thiazide and thiazide-like diuretics
53
what additional interventions should be carried out for women with epilepsy in pregnancy?
5mg folic acid
stope teratogenic medications e.g sodium valproate or phenytoin
serial growth scans at 28,32,36 and 40 weeks to detect SGA babies
54
what causes hyperemesis gravidarum?
higher levels of hCG
conditions resulting in higher levels of hCG such as multiple pregnancy and molar pregnancy are associated with more severe nausea and vomiting
55
what are the diagnostic criteria for hyperemesis gravidarum?
severe protracted NVP with the triad of :
- more than 5% weight loss compared with pre pregnancy
- dehydration
- electrolyte imbalance
onset must be in the 1st trimester
56
how is hyperemesis gravidarum managed?
mild and no complications:
antiemetics in community
moderate and no complications: ambulatory daycare management until no ketonuria (antiemetics, fluid and electrolyte replacement, thiamine supplementation)
complications: inpatient management (same as daycare management plus thromboprophylaxis and consider corticosteroids)
57
what are the antiemetic options in hyperemesis gravidarum?
1st line- promethazine, cyclizine, prochlorperazine
2nd line- metoclopramide, ondansetron
3rd line- corticosteroids
58
when should VTE prophylaxis be started?
from 28 weeks if there are 3 risk factors
1st trimester if there are 4 or more risk factors
and continued for 6 weeks postnatally (temporarily stopped when the woman is in labour)
59
how is a DVT or PE managed?
LMWH
can be switched to a DOAC after delivery
PE with haemodynamic compromise: heparin, thrombolysis or surgical embolectomy
60
treatment of lower UTI in pregnancy
1st line- nitrofurantoin (avoid in 3rd trimester)
2nd line- amoxicillin (only if sensitivities known), or cefalexin
trimethoprim (avoid in 1st trimester)
61
how is intrauterine fetal death managed?
1st line- vaginal birth, either induction or expectant management
C-section if vaginal birth is contraindicated
dopamine agonists- suppress lactation after stillbirth
testing to determine the cause of stillbirth (with parental consent)
counselling for parents and family
62
how does obstetric cholestasis present?
itching particularly affecting the palms of hands and soles of feet
other symptoms- fatigue, dark urine, pale, greasy stools and jaundice
usually develops later in pregnancy (28 weeks)
63
what are the diagnostic values for obstetric cholestasis?
abnormal LFTs- ALT >30 (ALP always raised in pregnancy)
| raised bile acids->14
64
how is obstetric cholestasis managed?
consultant led care
LFTs 1-2 weekly
additional fetal monitoring- growth scans, amniotic fluid monitoring, CTG during labour
symptom control- skin creams (calamine lotion), antihistamines, cool baths and loose clothing
vitamin K
induction of labour- if bile acids >100 consider from 35 weeks, if <100 can wait till 39 weeks
65
what is P-PROM?
preterm pre labour rupture of membranes
| the amniotic sac ruptures before the onset of labour and before 37 weeks
66
how does P-PROM present?
```
leakage of fluid
vaginal discharge
vaginal bleeding
pelvic pressure
with the absence of contractions
```
67
how is P-PROM diagnosed?
speculum examination shows pooling of amniotic fluid in the vagina
diagnostic tests:
insulin like growth factor binding protein-1 (IGFBP-1)- present in high concentrations in amniotic fluid. the test is called the amnisure test
placental alpha-microglobin-1- similar alternative to IGFBP-1
68
how is P-PROM managed?
prophylactic antibiotics- erythromycin 250mg 4 times daily for 10 days or until labour is established- prevent development of chorioamnionitis
induction of labour may be offered from 34 weeks- give corticosteroids and Mg sulphate if delivering before 36 weeks
69
what is considered preterm?
birth before 37 weeks
babies are considered non-viable below 23 weeks
generally from 23 to 24 weeks resuscitation is not considered if there are no signs of life
70
what are the options for prophylaxis of preterm labour?
vaginal progesterone- given by gel or pessary, decreases activity of the myometrium and prevents cervical remodelling, offered to women with a cervical length less than 25cm between 16 and 34 weeks
cervical cerclage- putting a stitch in the cervix to add support and keep it closed. the stick is then removed once the woman goes into labour or reaches term
offered to women with a cervical length less than 25cm between 16 and 34 weeks who have had previous preterm birth or cervical trauma
71
how is preterm labour diagnosed?
speculum examination to assess for cervical dilation
transvaginal ultrasound to assess cervical length
fetal fibronectin- found in the vagina during labour. a result of <50 suggests preterm labour is unlikely
72
when is tocolysis used?
used to stop uterine contractions. nifedipine is the medication of choice
can be used between 24 and 33+6 weeks to delay delivery and buy time for further metal development, administration of maternal steroids or transfer to a more specialised units
only used short term (< 48 hours)
73
when are corticosteroids given in pregnancy?
used in women with suspected preterm Labour if less than 34 weeks to help develop metal lungs and reduce respiratory distress syndrome
usually 2 doses of IM betomethasone 24 hours apart
74
when is magnesium sulphate given in pregnancy?
given to women between 24 and 30 weeks in established preterm labour or having a planned preterm birth within 24 hours. helps protect fetal brain and reduces risk and severity of cerebral palsy.
given as an IV bolus followed by and infusion for up to 24 hours
monitor for magnesium toxicity in mother
75
how is breech presentation managed?
external cephalic version (ECV)- can be done after 36 weeks in nulliparous women and 37 weeks in parous women to try and turn the baby
where ECV fails women are offered a choicebetween vaginal delivery and C-section. around 40% chance of requiring emergency C section with vaginal birth
76
why are women with an unstable or transverse lie admitted from 37 weeks?
due to the risk of cord prolapse
77
what are the stages of labour?
stage 1- from onset of labour until 10cm dilation. can be split into latent and active phase
stage 2- full dilation to delivery of baby. involves a passive phase (1 hour) and an active phase- pushing
stage 3- delivery of the placenta
78
how can delay in the 1st stage of labour be managed?
augment contractions with an amniotomy (artificial rupture of membranes) or give oxytocin (strengthens contractions)
79
how can delay in the 2nd stage be managed?
```
changing positions, encouragement and analgesia
oxytocin
episiotomy
instrumental delivery
C-section
```
80
what is active management of the 3rd stage of labour?
IM oxytocin and controlled cord traction
81
indications for instrumental delivery
failure to progress
fetal distress
maternal exhaustion
control of the head in various metal positions
maternal medical conditions that mean active pushing should be limited
82
complications of instrumental delivery
mother- postpartum haemorrhage, episiotomy, perineal tears, VTE, incontinence, nerve injury (obturator/femoral)
baby- cephalohaematoma (collection of blood between skull and periosteum) with ventouse, facial nerve palsy with forceps, serious risks (subgleal haematoma, intracranial haemorrhage, skull fracture, spinal cord injury)
83
contraindications of vaginal birth after C section
previous uterine rupture
vertical incision scar
other usual contraindications to vaginal delivery
84
management of shoulder dystocia
1st line- mcroberts manoeuvres, suprapubic pressure
2nd line- internal manoeuvres (delivery of posterior arm, internal rotation)
further manoeuvres- cleidiotomy (fracture metal clavicle), symphysiotomy (cut the symphysis pubis), zanvenelli (push the metal head back inti pelvis for delivery by C-section
85
what is an episiotomy?
a cut is made in the perineum at around 45 degrees in the mediolateral direction. it is performed under local anaesthetic
86
management of cord prolapse
category 1 emergency C section
keep cord warm and wet with minimal handling
push presenting part of the fetus upwards or lie in left lateral position with a pillow under the hip to relieve compression on the cord
tocolytic medication (terbutaline) to minimise contractions whilst awaiting C-section
87
what are the 4 Ts in postpartum haemorrhage?
tone- uterine atony(uterus fails to contract following delivery) is the most common cause
tissue- retention of placental tissue, preventing the uterus contracting
trauma- damage to reproductive tract during delivery (vaginal, cervical tears)
thrombin- coagulopathies (von Willenbrands disease, haemophilia, ITP or acquireD coagulopathy: DIC, HELLP) and vascular abnormalities (placental abruption, hypertension, pre-eclampsia)
88
management of postpartum haemorrhage
ABCDE resuscitation with fluids and blood
mechanical treatment- rub uterus to stimulate contraction, catheterisation (full bladder prevents contraction)
medical- oxytocin, ergometrine (contraindicated in hypertension), carboprost (contraindicated in asthma), misoprostol, tranexamic acid
surgical- intrauterine balloon tamponade, B-lynch suture, uterine artery ligation, hysterectomy
89
causes of secondary PPH
retained products of conception
| infection
90
options for induction of labour
membrane sweep
vaginal prostaglandins
cervical ripening balloon
artificial rupture of membranes and oxytocin
oral mifepristone plus misoprostol- used where intrauterine fetal death has occurred
if fails- C section
91
what is uterine hyperstimulation?
complication of induction with vaginal prostaglandins.
| contractions are prolonged and frequent causing fatal distress
92
what is the bishops score?
used to determine the readiness of the cervix for induction of labour
takes into account fetal position, cervical position, cervical dilatation, cervical effacement and cervical consistency.
given a score out of 13 and a score of 8 or more predicts successful induction of labour. a score below 8 suggests cervical ripening may be required to prepare the cervix
93
what is twin-twin transfusion syndrome?
occurs when twins share a placenta and one fetus receives the majority of the blood from the placenta resulting in one fetus having fluid overload, with heart failure and polyhydramnios. the donor fetus will have growth restriction, anaemia and oligohydramnios
94
what additional scans will a multiple pregnancy have?
2 weekly scans from 16 weeks for monochorionic twins
| 4 weekly scans from 20 weeks for dichorionic twins
95
what are the options for delivery of mono amniotic and diamniotic twins?
```
monoamniotic twins requrire elective C section between 32 and 37 weeks
diamniotic twins (aim to deliver between 37 and 38 weeks):
- vaginal delivery is possible when the first baby is cephalic, elective C section is advised when the presenting twin is breech
```
96
what are the two key causes of sepsis in pregnancy?
chorioamnionitis
| UTI
97
what are the symptoms of chorioamnionitis?
abdominal pain
uterine tenderness
vaginal discharge
signs of sepsis
98
what is the most common cause of infective mastitis?
staph aureus
99
what is the 1st line management of infected mastitis?
flucloxacillin or erythromycin if penicillin allergic
100
what are the key complications of evacuation of retained products of conception (ERPC)?
endometritis
| ashermans syndrome- adhesions form within the uterus
101
when does an atopic eruption of pregnancy usually occur?
1st trimester
102
how does pruritic urticarial papule and plaques of pregnancy present?
usually in 3rd trimester
pruritic urticarial papule that coalesce into plaques. typically starts on the abdomen often first on the striae but the umbilical region is spared. typically disappears after 10 days of delivery
103
what is pemphigoid gestations and how does it present?
very rare autoimmune condition which presents in 2nd/3rd trimester. pruritic erythematous urticarial papule/plaques on the abdomen particularly the umbilicus
104
what is the puerperium?
the 6 weeks period following birth during which the changes that occurred during pregnancy revet to the non-pregnant state
