Obstetrics🤰 Flashcards
1
Q
Stages of labour
A
Latent phase (cervix begins to efface and dilate)
First stage - Dilation up till 10cm
Second stage - from full dilation to birth
Third stage - from birth of fetus to expulsion of placenta
2
Q
Steps of fetal journey to birth
A
Descent –> Flexion –> Internal rotation –> Extension –>Restitution –>External rotation –>Delivery of body
3
Q
What is aortocaval compression syndrome?
A
If a woman is in the supine position at birth she will have
- Decreased venous return
- Decreased cardiac output
- Decreased arterial pressure
It reduces uteroplacental perfusion leading to fetal distress
Left lateral is a good position for women.
4
Q
What is gestational hypertension?
A
- New HT after 20 weeks gestation
- Systolic >140 Diastolic >90
- No or little proteinuria
5
Q
Causes of APH?
A
Placenta praevia, placenta accreta, vasa praevia, minor/major abruption or infection
6
Q
Causes of PPH?
A
qFOUR Ts
TISSUE - Ensure the placenta is complete
TONE - Ensure uterus is fully contracted
TRAUMA - look for tears
THROMBIN - Check clotting
7
Q
Red flag symptoms in postnatal depression?
A
Ideation of suicide
Feeling incompetent as a parent
Estrangement from child
Hallucinations
8
Q
Red flag symptoms in postnatal depression?
A
Ideation of suicide
Feeling incompetent as a parent
Estrangement from child
Hallucinations
9
Q
What is the management of placenta praevia?
A
- If diagnosed in 20 week scan the RCOG recommends TVS at 32 and 36 weeks gestation to guide decisions about delivery.
- Corticosteroids are given between 34 weeks and 35+6 weeks gestation to mature the fetal lungs, given risk of preterm labour.
- Planned delivery may be considered between 36/37 weeks to decrease risk fo spontaneous labour and bleeding. Planned C-Section is required.
10
Q
What is the Bishop Score used for?
A
It is used to help assess whether induction of labour will be required.
11
Q
What happens are 8-12 weeks?(ANTENATAL CARE)
A
Booking visit and booking bloods. Urine sample.
12
Q
What happens at 10-13+6 weeks?
A
Early scan to confirm dates and exclude multiple pregnancy
13
Q
What happens at 16 weeks?
A
Information on the anomaly scan and blood results. If Hb is less that 11g/dl then you can consider oral iron supplements.
14
Q
When are doses of anti-D prophylaxis given?
A
28 weeks and 34 weeks.
15
Q
What is Mirror syndrome?
A
Mirror syndrome, also called Ballantyne syndrome, is a rare condition in pregnancy, defined by the presence of the clinical triad of fetal hydrops, placentomegaly and maternal oedema. Any aetiology of fetal hydrops, including rhesus iso-immunization, congenital infection, twin-to-twin transfusion, structural anomalies and fetal malignancies, can lead to the syndrome.
16
Q
What medication can be used to suppress lactation?
A
Cabergoline (dopamine receptor agonist which inhibits prolactin production causing suppression of lactation)
17
Q
When should iron supplementation be taken in the first trimester
A
110g/L in the first trimester
18
Q
What is the definition of postpartum haemorrhage?
A
Postpartum haemorrhage is defined as blood loss of 500 ml after a vaginal delivery
19
Q
What foods should be avoided in pregnancy?
A
listeriosis: avoid unpasteurised milk, ripened soft cheeses (Camembert, Brie, blue-veined cheeses), pate or undercooked meat
salmonella: avoid raw or partially cooked eggs and meat, especially poultry
20
Q
HIV in pregnancy
A
HIV in pregnancy: vaginal delivery is recommended if viral load is less than 50 copies/ml at 36 weeks
21
Q
What is a normal birth?
A
Spontaneous in onset, low risk at the start of labour and remaining so throughout labour and delivery. Infant is born spontaneously in vertex position between 37+42 weeks of pregnancy. Afterbirth mother and infant are in good condition.
22
Q
What are indications for foetal blood sampling?
A
FBS is indicated when there is a suspicious cardiotocograph. It is used during labour during labour to confirm whether there is foetal hypoxia.
23
Q
Contraindications for foetal blood sampling
A
- Prolonged decelerations on Cardiotocography
- Maternal infection e.g. HIV, Herpes simplex
- Prematurity (<34 weeks)
23
Q
Contraindications for foetal blood sampling
A
- Prolonged decelerations on Cardiotocography
- Maternal infection e.g. HIV, Herpes simplex
- Prematurity (<34 weeks)
24
What are absolute contraindications for VBAC?
Classical (vertical) caesarean scar
Previous history of uterine rupture
The usual contraindications to vaginal delivery
25
What colour is vaginal bleeding in placental abruption?
May be absent but often dark
26
What are some risk factors for GBS infection in a newborn?
- Maternal pyrexia
- Prematurity
- Previous sibling GBS infection
- Prolonged rupture of membranes
27
When can you diagnose polyhydramnios?
Usually diagnosed at an AFI of >24cm (or 2000ml+)
28
When can you diagnose oligohydramnios?
Usually diagnosed with an AFI of <5cm (or under 200ml)
29
What is the most common cause of polyhydramnios?
Idiopathic
30
What is McRoberts manouvre?
- Hyperflexion and abduction of the mother's legs tightly to the abdomen
- This may be accompanied with applied SUPRAPUBIC pressure
- Routine traction in an axial direction should be applied to assess whether the shoulders have been released.
31
What is a Woods' screw manoeuvre?
In shoulder dystocia - anterior shoulder is pushed towards the foetal chest and the posterior shoulder is pushed towards the foetal back.
32
What is the Zavanelli manoeuvre?
In shoulder dystocia - it is the replacement of the head into the canal and then subsequent delivery by caesarean section
32
What is the Zavanelli manoeuvre?
In shoulder dystocia - it is the replacement of the head into the canal and then subsequent delivery by caesarean section
33
What should you do when a woman with diagnosed hypothyroidism becomes pregnant but is it a euthyroid state?
Increase levothyroxine by 25mcg as soon as pregnancy is confirmed.
34
What vaccine should you avoid in pregnancy?
Live attenuated vaccines such as MMR
35
Who do you give anti- D to?
Rhesus negative women
36
What are normal laboratory findings in pregnancy compared to normal?
Reduced urea, reduced creatinine, increased urinary protein loss
37
Which anti-emetic used for hyperemesis gravidarum causes EPSEs?
Metoclopramide
38
How does pre-eclampsia cause oligohydramnios?
This is due to hypoperfusion of the placenta
39
After what period of time would continued lochia warrant further investigation?
6 weeks
40
How long should magnesium sulphate treatment last?
it should be continued for 24 hours after delivery or after last seizure whichever is later
41
What is the first line treatment for magnesium sulphate induced respiratory depression?
Calcium gluconate
42
What are the signs of pre-eclampsia and why?
Hyperreflexia - PET leads to increased intracranial pressure, which causes a loss of inhibitory fibres and therefore increased tendon reflexes
Epigastric pain - oedema in the liver capsule
Papilloedema and visual disturbance are caused the pressure of oedema on the optic nerve
43
When are women screened for anaemia?
Booking visit and 28 week appointment
44
What is the Kleinhauer test used for?
It is used to detect the amount of fetal haemoglobin in the mothers bloodstream. It is usually needed in Rh negative mothers to determine the correct amount of Anti-D has been given following a potentially sensitising event
45
What should the baseline rate of fetus be on CTG?
Should be 110-160bpm
46
What should the normal baseline variability be on CTG?
Should vary between 5 to 25 beats per minute
47
What are accelerations on CTG?
Accelerations are a rise in fetal heart rate of at least 15 beats lasting for 15 seconds or more. There should be 2 separate accelerations every 15 minutes. Accelerations typically occur with contractions.
48
What are decelerations on CTG?
Reduction in the fetal heart rate by 15 beats or more for at least 15 seconds.
49
What is fetal hydrops (hydrops fetalis)?
The abnormal accumulation of serous fluid in 2+ fetal compartments - pleural/pericardial effusions, ascites, skin oedema, polyhydramnios or placental oedema
Causes are either immune (blood group incompatibility between mother and fetus) or non immune.
50
What are some non immune causes of hydrops fetalis?
- Severe anaemia - Congenital parvovirus B19 infection, alpha thalassaemia major, massive materno-feto haemorrhage
- Cardiac abnormalities
- Chromosomal abnormalities - Trisomy 13,18,21 or turners
- Infection - toxoplasmosis, rubella, CMV, varicella
- Twin-twin transfusion syndrome (in the recipient twin)
- Chorioangioma
51
What is the most common cause of anaemia in pregnancy?
Iron deficiency
52
What is the preferred method of induction?
Vaginal PGE2
53
What causes increased AFP?
- Neural tube defects (meningocele, myelomeningocele and anencephaly)
- Abdominal wall defects (omphalocele and gastroschisis)
- Multiple pregnancy
54
What causes decreased AFP?
- Down's Syndrome
- Trisomy 18
- Maternal diabetes mellitus
55
What are the symptoms and signs of amniotic fluid embolism?
Symptoms: chills, shivering, sweating, anxiety and coughing
Signs: cyanosis, hypotension, bronchospasms, tachycardia, arrhythmia and myocardial infarction
56
What bloods are checked in the booking bloods/urine?
FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies
- Hepatitis B, Syphilis
- HIV test is offered to all women
- Urine culture to detect asymptomatic bacteriuria
57
What should a woman at moderate or high risk of pre-eclampsia to reduce risk?
Aspirin 75mg-150mg daily from 12 weeks gestation until the birth
58
When is induction of labour offered in intrahepatic cholestasis of pregnancy?
37-38 weeks gestation as beyond this increases the risk of stillbirth
59
What is the treatment for a first degree perineal tear?
They do not require suturing as they heal on their own
60
What is the treatment for a second degree tear?
Require suturing on the ward by a suitably experiences midwife or clinician
61
What are the treatments recommended by NICE for nausea and vomiting in pregnancy?
natural remedies - ginger and acupuncture on the 'p6' point (by the wrist) are recommended by NICE
antihistamines should be used first-line (BNF suggests promethazine as first-line)
62
When is the Nuchal scan?
11 - 13+6
63
What investigations do you do for Preterm prelabour rupture of the membranes?
- A sterile speculum examination should be performed (looking for pooling of amniotic fluid in the posterior vaginal vault)
- DIGITAL EXAMINATION SHOULD BE AVOIDED DUE TO RISK OF INFECTION
- Ultrasound may also be useful to show oligohydramnios
64
What is the management for PPROM?
- admission
- regular observations to ensure chorioamnionitis is not developing
- oral erythromycin should be given for 10 days
- antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome
- delivery should be considered at 34 weeks of gestation - there is a trade-off between increased risk of maternal chorioamnionitis with a decreased risk of respiratory distress syndrome as the pregnancy progresses
65
What foods shouldn't be eaten to avoid listeriosis?
Avoid unpasteurised milk, ripened soft cheeses (Camembert, Brie, blue-veined cheeses) pate or undercooked meat.
66
What foods shouldn't be eaten to avoid salmonella?
Avoid raw or partially cooked eggs and meat, especially poultry
67
When should you refer to an obstetrician for lack of fetal movements?
24 weeks
68
What is a velamentous cord insertion?
It is an umbilical cord attachment to the membranes surrounding the placenta instead of the central mass
69
If an abdominal trauma occurs in a rhesus negative woman between 12 and 20 weeks, what should you do?
For potentially sensitising event between 12 and 20 weeks gestation, a minimum dose of 250 IU of anti-D Ig prophylaxis should be administered within 72 hours of the event
70
What is involved in active management of the third stage of labour?
1. Injection of a uterotonic drug such as oxytocin
2. Clamping of the cord between 1 and 5 minutes after delivery of the infant
3. Delivery of the placenta by controlled cord traction
71
What is the first-line antibiotic for asymptomatic bacteriuria at booking?
Oral nitrofurantoin 100mg modified-release tablets twice a day for seven days
72
What is a common first-line regimen for HIV diagnosed in pregnancy?
All pregnant women who have been diagnosed with HIV should start antiretroviral therapy (ART) during pregnancy and be advised to continue lifelong treatment. Tenofovir disoproxil/emtricitabine is a common first-line regime.
73
What is given to an infant born to a low-risk HIV positive mother?
| i.e. low viral load <50HIV RNA copies/ml
Zidovudine monotherapy is used for post-exposure prophylaxis in an infant born to a low-risk mother (i.e. low viral load, <50 HIV RNA copies/mL). Zidovudine is also used for the management of untreated women presenting in labour at term, and is given intravenously throughout labour.
74
What happens with anti-epileptic drugs during labour?
women should continue taking their regular anti-epileptic drugs orally during labour where tolerated
75
What is the most common cause of secondary postpartum haemorrhage?
Endometritis typically presents between 2 and 10 days postpartum
76
As well as antiemetics what do you give in hyperemesis gravidarum?
- Fluids
- Potassium chloride
- Thiamine and folic acid to prevent development of Wernicke's encephalopathy
- Antacids to relieve gastric pain
77
What is the aetiology of polyhydramnios?
Either due to excess production due to increased fetal urination:
- Maternal diabetes mellitus
- Foetal renal disorders
- Foetal anaemia
- Twin-to-twin transfusion syndrome
Or insufficient removal can be due to reduced foetal swallowing:
- Oesophageal or duodenal atresia
- Diaphragmatic hernia
- Anencephaly
- Chromosomal disorders
78
What is frank breech presentation?
Where the legs are fully extended up to the shoulders and the presenting part is the buttocks
79
What is complete breech presentation?
Complete breech is where the hips and knees are both flexed and the presenting part is the buttocks
80
What is footling breech presentation?
Footling breech is where one or both legs are fully extended towards the pelvic inlet with the foot or feet being the presenting part
81
What is the best predictor for a successful VBAC?
A previous vaginal birth
82
What existing mental health condition puts you at highest risk of puerperal psychosis?
Bipolar affective disorder
83
What is the risk of faecal or flatal incontinence after Grade 3C tear?
40%
84
Who should be offered cervical cerclage?
- Women with singleton pregnancy and three or more previous preterm births should be offered
85
After what gestation should amniocentesis be performed?
15+0 weeks
86
After what gestation should Chorionic villus sampling be performed?
10+0 weeks and where possible, to reduce the risk of technical challenges, CVS should be performed from 11+0 weeks gestation onwards
87
If suprapubic pain persists despite epidural what could this indicate?
Uterine rupture
88
When do levels of bHCG typically peak and at what gestational ages?
In a singleton pregnancy, levels peak at around 10 weeks’ gestation at a concentration of approximately 100,000 mIU/mL.
89
What organism is chorioamnionitis caused by?
Usually a polymicrobial infection involving multiple organisms ascending from the vagina into the uterine cavity
90
What should a baby born to a mother with chronic hepatitis B receive?
HBIG and Hep B vaccination
91
When are congenital syndromes related to viral infections most likely to occur?
First trimester
92
Compared with non-pregnant women, where in the abdomen is the appendix located in the third trimester of pregnancy?
It is higher in the abdomen. In the third trimester, the appendix is located in the right mid to upper quadrant of the abdominal cavity
93
At what gestational age is the amniotic fluid at its maximum?
Amniotic fluid volume is maximal at around 30–32 weeks’ gestation (800–1,000 mL). Thereafter, amniotic fluid volume decreases slowly to term (400–500 mL) and then more rapidly after 40 weeks.
94
When do you get Monochorionic/monoamniotic placentation?
If the blastocyst divides between days 9 and 12 post-conception
95
When do you get dichorionic/diamniotic placentation?
If the embryo divides before day 3 post-conception
96
When do you get monochorionic/diamniotic placentation?
If the embryo divides between days 4 and 8 post-conception.
97
What happens if embryo division occurs after 12 days post-conception?
The embryo never completely separates and a conjoined twin pregnancy results
98
What is the single greatest cause of intrauterine growth restriction (IUGR) **worldwide**?
Malaria
the malarial parasites clog up the maternal lacunae preventing adequate exchange of oxygen and nutrients
99
What are the layers for C-Section?
During a lower segment Caesarian section, the following lies in between the skin and the fetus:
Superficial fascia
Deep fascia
Anterior rectus sheath
Rectus abdominis muscle (not cut, rather pushed laterally following incision of the linea alba)
Transversalis fascia
Extraperitoneal connective tissue
Peritoneum
Uterus
100
What is the location of injury for Erb's palsy?
C5-C6
101
What should you use in suspected preterm labour before 24 weeks with a TVUS cervical length of <25mm
Vaginal progesterone - This decreases the activity of the myometrium and prevents cervix remodelling
102
What is the defect you are most likely to see if Sodium Valproate has been used in pregnancy?
Hypospadias (0.7%)
Spina Bifida (0.6%)
Atrial septal defect (0.5%)
Cleft Palate (0.3%)
Polydactyly (0.2%)
103
What antibiotics are given for PPROM
PO Erythromycin
104
What is the combined test for Down Syndrome
Nuchal Translucency, Beta hCG, PAPP-A
105
What is the Triple test for Down Syndrome?
AFP, unconjugated oestriol, hCG
106
What is the Quadruple test for Down Syndrome?
AFP, unconjugated oestriol, hCG and Inhibin A
107
When do you give Varicella-Zoster immunoglobulin ASAP without checking Antibodies?
Before 20 weeks of gestation
108
What are the absolute contraindications to breast feeding?
- Infants of mothers with TB infection
- Infants of mothers with uncontrolled/unmonitored HIV
- Infants of mothers who are taking medications which may be harmful e.g. amiodarone
