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Medicine > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

What is a first degree perineal tear?

A

Tear limited to the superficial perineal skin or vaginal mucosa only

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2
Q

What is a second degree perineal tear?

A

Tear extends to perineal muscles and fascia, but anal sphincter is intact

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3
Q

What is a third degree perineal tear?

A

3a: less than 50% of the thickness of the external anal sphincter is torn
3b: more than 50% of the thickness of the external anal sphincter is torn, but the internal anal sphincter is intact
3c: external and internal anal sphincters are torn, but anal mucosa is intact

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4
Q

What is a fourth degree perineal tear?

A

Perineal skin, muscle, anal sphincter and anal mucosa are torn

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5
Q

What degree of perineal tear is an episiotomy?

A

Second degree tear

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6
Q

What is placenta praevia?

A

the placenta overlying the cervical os

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7
Q

Presentation of placenta praevia

A

bright red, painless, vaginal bleeding
>24 weeks

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8
Q

management of placenta praevia

A

Bleeding w/ unknown placental position:
- ABC approach, resuscitation and stabilisation
- if stable, urgent US
- if bleeding not controlled, immediate caesarean section
Known placenta praevia:
- monitor with US
- give advice about pelvic rest (no sex)
- corticosteroids if between 24-34 weeks and there is risk of preterm labour
In labour:
- caesarean section
At term:
- any degree of placental overlap at 35 weeks, elective caesarean at 37-38 weeks
- if placental edge is greater than 20mm from internal cervical os, women can be offered trial of labour

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9
Q

what is placenta abruption

A

premature separation of the placenta from the uterine wall during pregnancy

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10
Q

Presentation of placenta abruption

A

bleeding with pain
sudden & severe abdo pain
‘woody’ hard uterus
contractions
hypovolaemic shock which is often disproportionate to the amout of visible vaginal bleeding

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11
Q

Management of placenta abruption

A

resuscitation using ABCDE approach
emergency delivery (usually c-section)
Induction of labour: for haemorrhage at term w/o maternal or foetal compromise
Give anti-D within 72 hours of the onset of bleeding if the woman is rhesus D negative

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12
Q

What is polyhydramnios?

A

the presence of too much amniotic fluid in the uterus

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13
Q

Features of polyhydramnios

A

a uterus that feels tense or large for dates
may be difficult to feel foetal parts on palpation of the abdomen

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14
Q

Management of Amniotic Fluid Embolism

A

Oxygen and fluid resus (call anaesthetist)
Intensive care
Continuous foetal monitoring necessary
Correct any coagulopathy (fresh frozen plasma for prolonged PT, cryoprecipitate for low fibrinogen; platelet transfusion for low platelets)

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15
Q

What is an amniotic fluid embolism?

A

When amniotic fluid enters the maternal circulation

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16
Q

Features of amniotic fluid embolism

A

^ resp rate
tachycardia
hypotension
hypoxia
disseminated intravascular coagulopathy

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17
Q

First stage of labour - latent phase

A

Dilation of the cervix from 0cm to 3cm

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18
Q

First stage of labour - active phase

A

Cervical dilation from 3cm to 10cm

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19
Q

Management of breech presentation at 36 weeks

A

External cephalic version to be performed around 37-39 weeks, to manually turn foetus into a cephalic presentation

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20
Q

Management of shoulder dystocia

A
  1. McRobert’s manoeuver
  2. All fours position
  3. Internal rotational manoeuvers
  4. Cleidotomy or symphysiotomy (division of the foetal clavicle or maternal symphysial ligament)
  5. Zavanelli manoeuvre
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21
Q

McRobert’s Manoeuvre

A

Hyperflexion and abduction of mother’s legs tightly to abdomen
May be accompanied with applied suprapubic pressure

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22
Q

When is the first dose of anti-D prophylaxis administered to rhesus negative women?

A

At 28 weeks, one 1500IU dose of Anti-D immunoglobulin
–> further doses if sensitising events occur

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23
Q

Supplements and vitamins recommended in pregnancy

A

Folic Acid 400 micrograms per day.
–> to all women pre-pregnancy and up to 12 weeks gestation
–> higher dose of 5mg recommended to women at ^ risk of NTD

Vitamin D 10 micrograms (400 units) per day: throughout pregnancy and breastfeeding

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24
Q

Why is folic acid recommended in pregnancy?

A

shown to reduce the occurrence of neural tube defects (NTD)

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25
Q

Why is vitamin D recommended in pregnancy?

A

Shown to be beneficial in foetal bone formation

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26
Q

What is the Kleihauer test?

A

Used to quantify the dose of Rh-D antigen in maternal circulation.
Guides the quantity of anti-D immunoglobin needed to prevent maternal sensitisation

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27
Q

What are sensitisation events? Give examples

A

Events which carry risk of foetal blood crossing the placenta into the maternal circulation and triggering formation of anti-D antibodies.

  • antepartum haemorrhage
  • significant abdo trauma
  • ectopic pregnancy
  • miscarriage
  • termination
  • intrauterine death
  • external cephalic version
  • invasive uterine procedures e.g. CVS or amniocentesis
  • delivery of foetus (vaginal or caesarean)
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28
Q

Risk factors for Group B Streptococcus (GBS)

A

+ve GBS culture in current or previous pregnancy
previous birth resulting in neonatal GBS infection
preterm labour
prolonged rupture of membranes
intrapartum fever >38
chorioamnionitis

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29
Q

Management of GBS infection

A

Intrapartum Abx prophylaxis most effective at preventing GBS infection in the newborn

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30
Q

Clinical features of obstetric cholestasis

A

Pruritus: commonly worse in hands and feet. Not accompanied by rash, may have excoriation marks from itching.
Fatigue
Nausea
Loss of appetite
Abdo pain - RUQ
Rarely: mild maternal jaundice (dark urine, pale stools)

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31
Q

Management of obstetric cholestasis

A

Chlorphenamine to reduce itch
Vitamin K to reduce risk of haemorrhage
Scheduling of early delivery to avoid risk of spontaneous intrauterine death

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32
Q

Risk factors for shoulder dystocia

A

Maternal gestational diabetes
Macrosomia
Birthweight >4kg
Advanced maternal age
Maternal short stature or small pelvis
Maternal obesity
Post-dates pregnancy

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33
Q

Uterine hyper-stimulation definition

A

Greater than 5 contractions occurring within 10 minutes and is due to administration of prostaglandins or oxytocin for IOL

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34
Q

Risk factors for ectopic pregnancy

A

PID
Genital infection e.g. gonorrhoea
Pelvic surgery
Having an intrauterine device in situ
Assisted reproduction e.g. IVF
Previous ectopic
Endometriosis

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35
Q

First line treatment for pre-eclampsia

A

Labetalol

36
Q

What is a molar pregnancy?

A

Part of a spectrum of gestational trophoblastic disease.
Occurs when there is an imbalance in the number of chromosomes from mother and father.
Also known as hydatidiform mole

37
Q

Features of a complete mole

A
  • formed from 1 sperm and an empty egg w/ no genetic material
  • sperm replicates to give normal no. of chromosomes; so diploid and all chromosomes are of paternal origin
  • no foetal tissue present; just a proliferation of swollen chorionic villi
38
Q

Features complete mole

A
  • formed from 2 sperm and a normal egg
  • both paternal and maternal genetic material present
  • variable evidence of foetal parts
39
Q

Clinical Features of Molar Pregnancy

A
  • vaginal bleeding
  • nausea
  • hyperemesis gravidarum
  • thyrotoxicosis
  • uterus larger than expected for gestational age (due to excessive growth of trophoblasts and retained blood)
40
Q

Ix for molar pregnancy

A

B-hCG levels often much higher than expected in normal pregnancy
Trans-vaginal US may show ‘snowstorm’ appearance, low resistance of blood vessel flow, and absence of a foetus

41
Q

Oligohydramnios definition

A

Presence of a lower than normal volume of amniotic fluid in the uterus

42
Q

Causes of Oligohydramnios

A
  • Uteroplacental insufficiency leading to intrauterine growth restriction e.g. maternal disease such hypertension or pre-eclampsia, maternal smoking and placental abruption.
  • Abnormalities with the foetal urinary system(amniotic fluid is derived mainly from foetal urine). E.g. renal agenesis, polycystic kidneys or urethral obstruction.
  • Premature rupture of membranes
  • Post-term gestation
  • Chromosomal anomalies
  • Maternal use of certain drugs (prostaglandin inhibitors, ACE-inhibitors)
43
Q

Naegele’s Rule

A

EDD (expected date of delivery) is calculated by adding 9 months to the LMP (last menstrual period) plus 7 days

44
Q

Signs of placental separation

A
  • gush of blood
  • lengthening of umbilical cord
    ascension of uterus in the abdomen
45
Q

risk factors placental abruption

A

maternal trauma e.g. assault, RTA
pre-eclampsia or hypertension
mulitparity
^maternal age
polyhydramnios
previous hx of abruption
substance abuse during pregnancy (particularly smoking and cocaine)
coagulation disorders

46
Q

Absolute contraindications for vaginal birth after caesarean section

A

Classical (vertical) caesarean scar
Previous hx of uterine rupture
Usual contraindications to a vaginal delivery

47
Q

When is the combined test carried out?

A

between 11 and 13 weeks of pregnancy

48
Q

What is measured in the combined test?

A

Nuchal translucency using US scan
PAPP-A hormone (level reduced in Down’s syndrome)
Beta-hCG hormone (^in Down’s syndrome)

49
Q

If past point of combined test what can be offered to screen for Down’s syndrome?

A

Triple test or quadruple test

50
Q

What is the triple test?

A

Beta-hCG (^in DS)
AFP (reduced in DS)
uE3 (reduced in DS)

51
Q

What is the quadruple test?

A

Inhibin-A levels (^ in DS)
Beta-hCG (^ in DS)
AFP (reduced in DS)
uE3 (reduced in DS)

52
Q

Causes of Polyhydramnios

A

Can be due to excessive production of amniotic fluid or insufficient removal of amniotic fluid.

Excessive production can be due to ^ foetal urination:
- maternal diabetes
- foetal anaemia
- foetal renal disorders
- twin-to-twin transfusion syndrome

Insufficient removal due to reduced foetal swallowing:
- oesophageal or duodenal atresia
- diaphragmatic hernia
- anencephaly
- chromosomal disorders

53
Q

Maternal complications of polyhydramnios

A
  • maternal respiratory compromise (^ pressure on diaphragm)
  • ^ risk of UTI
  • worsening of reflux, constipation, peripheral oedema, stretch marks
  • ^ incidence of C-section
  • ^ risk of amniotic fluid embolism
54
Q

Foetal complications of polyhdramnios

A
  • pre-term labour and delivery
  • premature rupture of membranes
  • placental abruption
  • malpresentation of the foetus
  • umbilical cord prolapse
55
Q

Clinical features of congenital toxoplasmosis

A

Toxoplasmosis infection in pregnancy can lead to miscarriage, neonatal death, premature labour, low birth weight.

Many infected infants are asymptomatic, however, may go on to develop symptoms later in life such as:

  • CNS problems such as cerebral palsy, epilepsy and hydrocephalus
  • learning disability
  • visual impairment
  • hearing loss
56
Q

Management of toxoplasmosis infection in pregnancy

A

Abx spiramycin used to treat during pregnancy and is thought to reduce transmission to the baby

57
Q

Features of Neonatal Herpes Simplex infection

A

Vesicular lesions on the skin, eye, or oral mucosa, w/o organ involvement.

Disseminated feature include seizures, encephalitis, hepatitis or sepsis.

58
Q

Management of Neonatal Herpes Simplex Virus infection

A

parenteral acyclovir
intensive support therapy for severe cases

59
Q

First line management of active management of third stage labour

A

IM oxytocin (10IU)

60
Q

Clinical Features of Acute Fatty Liver of Pregnancy

A

Jaundice
Abdominal pain
Disseminated Intravascular Coagulation
Nausea and/or vomiting
Malaise
Fatigue
Oliguria
Tachycardia
Fever

61
Q

Management of acute fatty liver of pregnancy

A

Delivery of foetus and intensive support care

62
Q

Bishop Score

A

Cervical Score 0 1 2 3
Position Posterior Middle Anterior N/A
Consistency Firm Medium Soft N/A
Effacement 0-30% 40-50% 60-70% ≥80%
Dilation Closed 1-2cm 3-4cm ≥5cm
Foetal station -3 -2 -1, 0 +1, +2

63
Q

Causes of Postpartum Haemorrhage

A

4 Ts: Tone, Trauma, Tissue, Thrombin

Tone: uterine atony, the failure of the uterus to contract after delivery.
Trauma: birth canal injury or tear, ^ risk in instrumented deliveries.
Tissue: retained placental or foetal tissue can lead to continued bleeding.
Thrombin: coagulopathies can lead to continued bleeding due to a failure of clotting.

64
Q

Frank breech presentation

A

Legs extended up to head
Buttocks are presenting part

65
Q

Complete breech presentation

A

Hips and knees are flexed
Buttocks are the presenting part

66
Q

Incomplete breech presentation

A

One or both hips are extended
Knee or foot is the presenting part

67
Q

Footling breech presentation

A

One or both legs are fully extended
Foot/feet is the presenting part

68
Q

Gestational Hypertension Management

A

Labetalol

Nifedipine (Asthma)
Methyldopa

69
Q

When is the anomaly scan usually performed?

A

18 - 20+6 weeks

70
Q

Placenta accreta definition

A

Adherence of the placenta directly to superficial myometrium but does not penetrate the thickness of the muscle.

71
Q

Placenta increta definition

A

the villi invade into but not through the myometrium

72
Q

Placenta percreta definition

A

The villi invade through the full thickness of the myometrium to the serosa.

Increased risk of uterine rupture and in severe cases the placenta may attach to other abdominal organs such as the bladder or rectum.

73
Q

Risk factors for Gestational Diabetes

A
  • FHx
  • Previous GDM
  • Large babies >4.5kg
  • Previous stillbirth or perinatal death
  • Maternal obesity (>30)
74
Q

When is early scan to confirm dates?

A

11+2 - 14+1 weeks

75
Q

What are tocolytics?

A

Drugs used to suppress contractions and therefore labour

76
Q

First line tocolytics agent

A

Nifedipine

77
Q

When can a tocolytic be used?

A

<34 weeks

78
Q

Management if mother is +ve for HbsAg and HbeAg (Hep B)

A

HBV IgG and HBV vaccination within 24 hours of delivery

79
Q

Birth timing w/ gestational diabetes

A

Women with gestational diabetes should give birth no later than 40+6 weeks of gestation

80
Q

Sequence of layers to dissect during C-section

A

Skin - subcutaneous fat - rectus sheath - rectus abdominus muscle - peritoneum - uterine myometrium - amniotic sac

81
Q

Which hormone is responsible for the promotion of smooth muscle relaxation, which contributes to reduced oesophageal tone and reflux oesophagitis?

A

Progesterone
- ^ in pregnancy
- promotes smooth muscle relaxation in GI, GU systems and uterus

82
Q

What bishop score suggests labour is unlikely to occur without induction?

A

5 or less

83
Q

What is the first-line management for induction of labour?

A

Prostaglandin pessary

84
Q

Polymorphic eruption of pregnancy

A
  • itchy red patches
  • first appears over abdo
  • thrid trimester
  • also known as pruritic urticarial papules and plaques of pregnancy (PUPPP)
85
Q

Normal CTG in first stage of labour

A

Baseline rate: 125bpm. Variability: 15bpm. Accelerations: present. Decelerations: absent

Medicine (13 decks)

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