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Obstetrics Flashcards

(47 cards)

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1
Q

Placental Abruption

A

Separation of the placenta from the uterine wall, bleed into the space

= shock ≠ visible loss, constant pain, tender tense uterus, normal lie and presentation

Inv - distressed/ absent foetal HR

-> immediate c-section if distressed, if not observe + steroids <36wks or vaginal >36wks, induce vaginal if dead

Comp - shock, DIC, renal failure, PPH

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2
Q

Abruption: RF

A

A - Abruption before
B - Blood pressure
R - Ruptured membranes, prolonged or premature
U - Uterine injury/ trauma
P - Polyhydraminos, previous children
T - Twins
I - Infection
O - Old age
N - Narcotics (cocaine)

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3
Q

Placenta Praevia

A

Placenta lying in the lower uterine segment, risk of PPH

RF - multiparity, multiple pregnancy, prev C section

= shock ≈ loss, no pain, uterus not tender

Inv - DON’T DO PV exam, abdo US (incidental), TV US

-> if low at 20wks then rescan at 32wks, still present scan every 2 weeks, decide on delivery at 36-37wks, elective c-section for 3/4 (emergency c-section if labour before/ unstable or term bleeding)

  1. placenta reaches lower segment but not os
  2. reaches os but doesn’t cover it
  3. covers the os before dilation
  4. placenta completely covers os
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4
Q

Down’s Syndrome Screening

A

Combined test (11-14wks) - ^hCG, v PAPPA-A, thick nuchal translucency (US) thickened US
*Lower hCG in Edwards and Patau

Quadruple test (15-20wks) - ^inhibin A, ^hCG, v AFP, v oestriol

‘higher chance’ offered NIPT (99% spec/sens) or amniocentesis/ CVS

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5
Q

AFP

A

Protein produced by developing foetus

Increased in NTD, abdo wall defects, twins
Decreased in downs, edwards (18), maternal DM

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6
Q

Quadruple Test

A

AFP, uc Oestriol, HCG, Inhibin A

Downs - low, low, high, high
Edwards - low, low, low, normal
NTD - high, normal, normal, normal

High chance (>1 in 150)

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7
Q

Preterm Prelabour Rupture of the Membranes

A

Inv - sterile speculum exam (pooling of amniotic fluid in post vaginal vault), avoid DVE, placental PAMG1 or insulin-like GF protein 1, US (oligohydramnios)

-> admit, 10d PO erythromycin, antenatal steroids, consider delivery at 34 weeks

Comp - premature delivery (40% linked to PPROM), pulm hypoplasia, chorioamnionitis

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8
Q

Management of Miscarriage

A

Expectant: 7-14d watch and wait, next if doesn’t work

Medical or surgical if evidence of infection, risk of bleed (late T1, coagulopathies) or prev adverse experience with pregnancy

-> Medical
Missed: oral mifepristone, misoprostol 48hrs after, see Dr if no bleed in 24 hours
Incomplete: single dose misoprostol (PV/ PO)
-> Surgery; vacuum aspiration or ERPC

*Pregnancy test at 3wks to confirm

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9
Q

Amniotic fluid embolism

A

Reaction 2nd to fetal cells/ amniotic fluid in maternal bloodstream

RF - ^age, induction of labour

= most during labour, chills, sweating, anxiety, cough, v BP, ^HR, bronchospasm, arrhythmia, MI

-> supportive, critical care unit

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10
Q

Antenatal timetable

A

8-12wks = Booking, general info, BP, BMI, urine culture, FBC, blood group, rhesus, RC alloantibodies, Hb disease, syphilis, Hep B, HIV offered

10-14wks = Dating scan and Down’s screen, excl. multiple

16wks = review prev, iron if <110, BP, urine dip

18-21wks = Anomaly scan

*BP, dip, SFH at all below

28wks = screen Hb and allo, 1st anti-D dose

34wks = 2nd anti-D dose, labour info

36wks = presentation (offer ECV), BF info

38wks = routine

41wks = info on induction

Primip also get 25wks, 31wks, 40wks

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11
Q

Weight gain and breastfeeding

A

1/10 lose the 10% threshold of weight in week 1

-> examine infant, referral to midwife-led BF clinics, monitor weight until regains

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12
Q

Drugs to avoid in breastfeeding

A

Methotrexate
Benzos

Carbimazole, chemo drugs
Lithium
Aspirin
Sulphonylureas
Sulphonamides

Amiodarone
Ciprofloxacin, chloramphenicol
Tetracycline

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13
Q

Breech Presentation

A

25% are breech at 28wks, 3% at term

RF - uterine malformation, fibroids, praevia, prem, poly/ oligohydramnios, foetal abnormality

-> offer ECV at 36wks (37wks if multiparous), plan vaginal or c-section

ECV contra if c-section required, APH in last 7d, abnormal CTG, major uterine anomaly, ruptured membranes, twins

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14
Q

Categories of C section urgency

A

1 - immediate threat to life, deliver <30 min
E.g., uterine rupture, major abruption, cord prolapse

2 - maternal or fetal compromise but not threatening life, <75 min

3 - required but both stable

4 - elective

VBAC: at 37wks+, 75% success if one previous c-section, contra if prev uterine rupture or classic C section scar

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15
Q

Cardiotocography (CTG)

A

Baseline bradycardia (<100): ^fetal vagal tone, beta blockers

Baseline tachycardia (>160): maternal fever, chorioamnionitis, hypoxia, prematurity

Loss of variability (<5): hypoxia, prematurity

Early deceleration (starts with onset of contraction, returns to normal at end of it): harmless head compression

Late deceleration (lags onset of contraction, returns >30secs after end): fetal stress e.g., asphyxia

Variable deceleration (independent of contractions): cord compression

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16
Q

Chickenpox in Pregnancy

A

Management of exposure
-> any doubt if mum has had it previously then check IgG, oral acyclovir 7-14d after exposure

Management of chicken pox:
-> specialist advice, PO acyclovir if <24hrs of rash and 20wk+ of pregnancy, consider if under 20 weeks

Comp - 5x pneumonitis in mum, fetal varicella syndrome (exposed <20wk, scars, small eyes/ head, limb hypoplasia, LD), neonatal varicella (rash 5d before- 2d after birth, 20% mort), shingles in infancy

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17
Q

Chorioamnionitis

A

Life-threatening, ascending bacterial infection of amniotic fluid/ membranes/ placenta

PF - PPROM

-> prompt delivery, IV Abx

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18
Q

Eclampsia

A

Development of seizures in association with pre-eclampsia (new proteinuria and HTN after 20wks)

-> MgSO4 (4g bolus + 1g/hr, until 24hrs from last seizure or delivery), calcium gluconate if Mg resp depression
*Monitor RR, urine output, reflexes, o2 sats

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19
Q

Folic Acid

Study These Flashcards
A

Converted to tetrahydrofolate for DNA/RNA synthesis

RF - phenytoin, methotrexate, pregnancy, alcohol

-> 400mcg before conception-12wks, 5mg if high risk (F/Hx of NTD, antiepileptics, coeliac, DM, thalassaemia, BMI >30)

Comp - NTD, macrocytic megaloblastic anaemia

20
Q

Gestational Diabetes

Study These Flashcards
A

Diabetes that develops during pregnancy, 1 in 20

RF - BMI>30, prev macrosomia (4.5kg+), prev gestational DM, 1st degree relative with DM, family origin

Inv - OGTT (asap after booking if prev GDM, 24-28wks if RF)

Fasting = 5.6+, 2hr = 7.8+

-> seen in diabetic antenatal clinic <1wk, diet and exercise for 1-2wk, metformin if targets not met, add short-acting insulin (1st line if fasting 7+ or evidence of comp)

21
Q

GDM Targets

Study These Flashcards
A

Fasting - 5.3
1hr after meal - 7.8
2hr after meal - 6.4

22
Q

Group B Streptococcus

Study These Flashcards
A

Most common cause of early neonatal sepsis, e.g., Streptococcus agalactiae

RF - prem, prolonged ROM, prev baby infected, maternal fever

Inv - swabs at 35-37wks or 3-5wks before delivery

-> intrapartum Abx proph (benpen) if prev. GBSD baby or fever in labour >38, offer to any prem, IAP or testing in late pregnancy (+/- Abx) if GBS detected prev.

23
Q

HELLP Syndrome

Study These Flashcards
A

Haemolysis, elevated liver enzymes and low platelets

RF - severe pre-eclampsia (10-20% develop HELLP)

= n+v, RUQ pain, lethargy

-> deliver baby

24
Q

Hep B and pregnancy

Study These Flashcards
A

All offered screening

If born to mother with chronic infection -> full course of vaccines and hep B Ig

Safe to breastfeed

25
HIV and pregnancy
Screening offered to all, management based on viral load <50 at 36wks -> vaginal delivery, PO zidovudine to neonate >50 -> c-section, zidovudine infusion started 4hrs before, triple ART to neonate for 4-6wks Cannot breastfeed
26
HTN in pregnancy
Normal for BP to fall until 20-24wks then increase to term RF - HTN in prev pregnancy, CKD, DM, AI disorders Pre-existing: HTN <20wks Pregnancy-induced: >20wks but no proteinuria or oedema Pre-eclampsia: >20 weeks with proteinuria (>0.3g/d) -> PO labetalol (nifedipine if asthmatic), aspirin 75mg OD 12wks-birth if high risk of pre-eclampsia
27
Induction of Labour
Use - prolonged pregnancy, PPROM, diabetic mother >38wks, pre-eclampsia, obs cholestasis, IU death Bishop score: <5 unlikely to start without induction, 8+ high chance of spont labour Options Membrane sweep - an adjunct, 40-41wk appt Vaginal prostaglandin E2 - dinopostone Oral prostoglandin E1 - misoprostol Oxytocin infusion Amniotomy - break the waters Cervical ripening balloon Bishop 6 or below offer prostaglandin, >6 offer amniotomy or IV oxytocn Comp - uterine hyperstimulation (v fetal blood supply), amniotic fluid embolisim
28
Intrahepatic Cholestasis of Pregnancy
= itchy palms and abdo, 20% get jaundice, ^BR -> induce at 37-38wks, ursodeoxycholic acid Comp - likely to recur in next pregnancy
29
Stages of Labour
1 - onset of true labour to fully dilated cervix Latent phase: 0-3 cm dilation, 6hr Active phase: 3-10 cm, 1cm/hr 2 - full dilation to delivery, passive or active (pushing), 1hr, if longer consider instruments
30
Oligohydraminos vs Polyhydraminos
Oligo Causes - PROM, Potter sequence (bilateral renal agenesis, pulm hypoplasia), IUGR, pre-eclampsia or post term Poly Causes - maternal DM, twin-twin transfusion syndrome, twins
31
Perineal Tears
First degree - superficial, no muscles involved -> no repair Second degree - perineal muscle but not anal sphincter -> suture on ward Third degree - a) <50% external sphincter, b) >50% EAS, c) internal AS torn -> repair in theatre 4th - anal sphincter and rectal mucosa -> theatre
32
Placenta accreta
Attachment of the placenta to the myometrium, doesn't separate properly during labour so ^PPH RF - prev c-section, placenta praevia Accreta: chorionic villi attached to myometrium (not restricted within decidua basalis) Increta: invade into the myometrium Percreta: through the perimetrium
33
PPH
Blood loss >500ml after vaginal delivery, primary <24hrs Causes - 4Ts - tone (atony, most common), trauma, tissue retained, thrombin RF - prev PPH, prolonged labour, pre-eclampsia, ^age, polyhydramnios, emergency c section, placental issues, macrosomia -> A-E, rub uterine fundus to stimulate contraction, catheterise, IV oxytocin, IV/IM ergometrine, IM carboprost, surgery (IU balloon tamponade if atony) Secondary PPH: 24hrs - 6wks, caused by endometritis or retained placental tissue
34
Postpartum Thyroiditis
= hyper, hypo then normal, high recurrence Inv - anti-TPO Ab (90%) -> propranolol for hyper, thyroxine for hypo
35
Pre-eclampsia
BP >140/90 after 20 weeks + one of; proteinuria or organ dysfunction Risk Factors High - HTN in prev pregnancy/ chronic, CKD, AI (SLE), DM Mod - 1st pregnancy, 40yrs+, preg interval >10yrs, BMI 35+, multiple pregnancy, FHx = HTN, frothy urine, headache, visual issues, RUQ pain, hyperreflexia Urgent hospital assessment if suspected -> 1 high or 2 mod RF then 75mg aspirin from 12wk-birth, admit if BP>160/110, treat HTN, delivery is definitive Comp - eclampsia, IUGR, prem, HELLP, haemorrhage, HF
36
Anaemia
Measure at booking and 28wk appt - T1 <110, T2/3 <105, pp <100 -> continue PO ferrous sulphate until 3m after resolution
37
Normal changes in pregnancy
Increase CO, HR, SV, tidal volume Blood volume, WCC, ESR Fibrinogen and factors ALP GFR Trace glycosuria Reduced Diastolic BP in T1/2 PLT Fibrinolytic activity Albumin
38
Reduced fetal movements
Movements by week 24, earlier if prev. children RF - postural (inc when lying), distraction, placental/ fetal position, alcohol, sedatives, body habitus, fetal size Inv - handheld doppler to confirm HB >28wks -> CTG 20mins vs immediate US if HB not found If 24wks and still no movement-> refer to fetal medicine
39
RA and pregnancy
Symptoms get better in pregnancy -> Stop methotrexate 6m before conception, use sulfasalazine/ hydroxychloroquine, may use low dose steroids, no NSAIDs after 32wks Refer to obs anaesthetist (risk of atlantoaxial subluxation)
40
Shoulder dystocia
Inability to deliver body using gentle traction after head already delivered, ant. shoulder impacted on pubic symphysis RF - macrosomia, DM, prolonged labour, fat mum -> McRoberts (flexion and abduction of hips), episiotomy
41
Symphsis fundal height
Top of pubic bone to top of uterus Should match gestational age (+/- 2cm) after 20wks
42
Umbilical Cord Prolapse
Umbilical cord descends ahead of the presenting part of the fetus RF - prem, multiparity, polyhydramnios, twins, abnormal presentation, 50% after artificial rupture of membranes = abnormal HB, palpable cord -> push presenting part of fetus back in, minimal handling if cord visible, keep it warm/ moist, go on all fours, tocolytics (v contractions), retrofill bladder, c-section Comp - cord compression, cord spasm
43
Rhesus-ve Pregnancy
Sensitising events; Delivery of Rh+ve baby Termination Miscarriage >12 weeks Ectopic managed surgically ECV APH Amniocentesis/ CVS Abdominal trauma -> anti-D Ig <72hrs, Kleinhauer test if >20wks, all babies born to Rh-ve mum should have cord blood taken for FBC, BG, Coombs Rhesus Disease = hydrops fetalis (oedematous), jaundice, anaemia, hepatosplenomegaly, HF, kernicterus -> transfuse, UV phototherapy
44
Bleeding in 1st Trimester
Causes - miscarriage, ectopic, implantation, ectropion Positive test + any of; abdo pain, pelvic tenderness or cervical motion tenderness -> immediate EPAU Bleeding + no RF for ectopic; >6wks -> EPAU (TV US) <6wks -> observe 7-10d then repeat HCG, return if pos, miscarriage if neg
45
Hyperemesis Gravidarum
RF - ^hCG (multiple, trophoblastic), 8-12wks, nulliparous, smoking reduces the risk = triad of 5% pre-pregnancy weight loss, electrolyte imbalance and dehydration Inv - Pregnancy-Unique Quantification of Emesis (PUQE) score of severity -> anti-histamine 1st (cyclizine, chlorpromazine), metoclopramide (no more than 5d) or ondansetron (^cleft in T1) 2nd, 0.9% NaCl + K to rehydrate
46
When to admit N+V
Cannot keep liquid down Associated ketonuria or 5% weight loss despite antiemetics Suspected co-morbidity
47
When to do continuous CTG during labour
suspected chorioamnionitis or sepsis, or a temperature of 38°C or above severe hypertension 160/110 mmHg or above oxytocin use the presence of significant meconium fresh vaginal bleeding that develops in labour

ALS (22 decks)

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