Obstetrics Flashcards
(31 cards)
When is a booking visit done?
8-12 weeks (ideally <10 weeks)
What should you make sure to explore in booking visit?
- Has their doctor given them extra folic acid?
- RF for gestational diabetes
- RF for pre-eclampsia
- Mental health hx
- Domestic violence risk
Booking visit tests
- BP
- BMI
- Urine dipstick and MC&S
- Blood group
- Rhesus D status
- Anaemia, haemoglobinopathies, red cell alloantibodies
- Hep B, HIV, syphilis
(BP, BMI, urine dip at every appointment)
Booking visit supplementation
- Folic acid - 400ug (from pre-conception) until 12 weeks, or 5mg if high-risk
- Vitamin D - 10ug
IOL indications
- 41+ weeks gestation
- PROM
- Obstetric cholestasis
- Diabetic mother >38 weeks
- Pre-eclampsia
- Rhesus incompatibility
- RFM (careful consultant-led counselling)
- BISHOP =<6
Method of IOL
Antenatal ward under care of midwifes
Move to labour ward when in active labour
Membrane sweeping before induction (from 40 weeks) - releases prostaglandins
- Vaginal prostaglandin (tablet/gel 2 doses 6 hours apart, pessary 1 over 24 hours). Cervical ripening balloon can avoid uterine hyperstimulation.
- Amniotomy
- IV syntocinon (2 hours after rupture if labour has not ensued)
If failed, rest and attempt again or C-section
When is PPROM classed as PPROM?
24 to 36+6 weeks
PROM from 37 weeks
PPROM investigations
Admit to antenatal ward Bedside, bloods, imaging approach • Obs (focus on BP) • Abdo exam • Speculum: Pooling of clear fluid in posterior vaginal vault. If negative, ROM plus test (test for IGFBP1 or placental a-microglobulin1). If negative, FFN test. • CTG
- FBC, CRP, U&E (fluid loss), G+S, X-match
- Abdo USS
PPROM counselling
- High chance you will give birth in the next week
- Need to be admitted to keep an eye on your health and baby
- Keep baby in for as long as possible to help them grow and mature, but will balance this with risk of infection
- Neonatalogist will care when baby is born
- Taken to NICU if extra support is needed
PPROM management
- Antibiotics (oral erythromycin)
- Intense clinical surveillance for signs of chorioamnitis and pre-term labour (admit until 28 weeks, after which 2-3x week outpatient monitoring)
- IM steroids
- IV magnesium sulphate if birth expected next 24 hours
(no tocolytics due to risk of infection)
Should you induce labour after PROM?
0-24 hours expectant
Meconium or >24 hours induce straight away
Breech investigations
- Obs
- Urinalysis
- Abdo exam - lie and presentation
- USS - gestational age, presentation, placental position, amniotic fluid index
Breech management counselling
- External cephalic version at 36/37weeks
- Obstetrician will gently move baby by pressing hands on abdomen - head down for easier delivery
- Medication to relax uterus (tocolytics)
- Monitored with CTG
- USS to guide procedure and confirm
- Recommend elective CS if no ECV
- Vaginal breech delivery has 40% risk of emergency CS
VBAC counselling
• Can have VBAC if singleton pregnancy and 37 weeks or elective CS at 39 weeks
VBAC
• Maternal risk of uterine rupture, emergency CS, instrumental delivery
• Foetal risk of HIE
Elective CS
• Maternal risk of placenta praevia/accreta in future, adhesions, infection, clots (will give LMWH for 10 days after)
• Foetal risk of respiratory problems
HIV in pregnancy counselling
- Go to a joint HIV physician and obstetric clinic every 1-2 weeks
- Monitor CD4 baseline and delivery, and viral load every 2-4 weeks, 36 weeks, and delivery
- ART compliance
- Delivery options - <50: vaginal appropriate, >50 or hep C: elective CS at 38 weeks with IV zidovudine
- Don’t breastfeed
- Neonatal ART for 2-4 weeks and testing
Pre-eclampsia investigations
- Obs
- Examination - abdo, swelling, reflexes
- Fundoscopy for papilloedema
- Urine dipstick
- PCR if 1+ protein
- FBC, G+S, X-match
- LFTs for HELLP
- Creatinine for renal function
• CTG
Severe pre-eclampsia (>160/110) management
Admit to antenatal ward
• Oral labetalol/nifedipine
• BP monitor 4x a day whilst controlling it
• Can discharge when BP controlled
• Monitor bloods and BP 2x a week once discharged
- Aim for delivery 37 weeks
- If >37 weeks, aim for 24-48 hours
- IV magnesium sulphate if within birth 24 hours to prevent eclampsia
- Elective CS or IOL choice
- Deliver in labour ward
- Epidural anaesthesia can control BP
- Observe for 24 hours after delivery
- Continue meds if needed
- Follow-up with GP 2 weeks later if still on meds
Gestational diabetes management
Review with joint diabetes and antenatal clinic within a week
Fasting <7
- Changes in diet and exercise
- Targets not met after 1-2 weeks: metformin
- Add insulin or glibenclamide
> 7 or >6 with complications
Insulin
Birth no later than 40+6
Discontinue meds immediately after delivery
Fasting blood glucose 6-13 weeks postnatal
Gestational diabetes counselling
- Body can’t produce enough insulin to meet demands of carrying a baby
- Maternal risks: hypertensive disease, traumatic delivery
- Foetal risks: macrosomia, neonatal hypoglycaemia
- Discuss treatment options and monitor glucose (fasting, pre-meal, 1-hour post-meal, bedtime) *not injection regimen
- D and AN clinic every 2 weeks
- USS growth scans every 4 weeks between 28-36 weeks
- After birth, stop meds but follow-up if problems continue
Obstetric cholestasis investigations
Bedside and bloods approach
• Obs
• Inspection - jaundice, excoriation marks
• Examination - lie, presentation, SFH
- LFTs
- Bile acids
- PT
Obstetric cholestasis counselling
- Slow down of bile through the liver, build up, and leakage into bloodstream causing symptoms (unsure why - hormonal? genetic?)
- RF of FHx, previous Hx, multiple pregnancy
• Offer IOL at 37 weeks and deliver on labour ward with continue CTG monitoring, due to risk of stillbirth
- Weekly LFTs and bile acid levels
- Wear cool, loose clothing
- Pay attention to foetal movements
- Symptomatic treatment: ice packs, emollients, ursodeoxycholic acid
• High recurrence rate
Placenta praevia / abruption investigations
Beside, bloods, imaging approach • Obs • Abdo exam (if tense, worried about abruption) • Pelvic exam but not digital • CTG
- FBC, blood type, X-match for 4 units of packed RBCs
- Kleihauer test (abruption)
• Abdominal USS with colour flow Doppler analysis
Asymptomatic placenta praevia management
- Avoid sex
- Rescan at 32 weeks
- If still low-lying/praevia, rescan at 36 weeks
- If still low-lying/praevia, elective CS within next couple of weeks
Symptomatic placenta praevia management
Admit and involve the MDT - call for senior obstetrician, call 2222 for major obstetric haemorrhage protocol
ABCDE • Gain IV access • Bloods if haven't done that yet as acute • Give anti-D in Rh-negative women • Continuous fetal monitoring
- Haem unstable/foetal distress: deliver
- Stable: steroids and discharge after 48 hours of observation with no bleeding
