Obstetrics Flashcards
(152 cards)
1
Q
Missed miscarriage
A
the uterus still contains foetal tissue, but the fetus is no longer alive.
the woman is asymptomatic so does not realise something is wrong.
The cervical os is closed
2
Q
Threatened miscarriage
A
vaginal bleeding with a closed cervix and a fetus that is alive,the cervical os is closed. There may be little or no pain
3
Q
Inevitable miscarriage
A
often heavy vaginal bleeding and pain with an open cervix.foetus is currently intrauterine but the cervical os is open
4
Q
Incomplete miscarriage
A
retained products of conception remain in the uterus after the miscarriage
5
Q
Complete miscarriage
A
full miscarriage has occurred, and there are no products of conception left in the uterus.The os is usually closed.The patient may have been alerted to the miscarriage by pain and bleeding.
6
Q
Cause of miscarriage
A
Embryo chromosomal abnormalities
Endocrine factors - PCOS, poor diabetes, thyroid dysfunction
Immunological causes autoimmune/alloimmune
Uterine anomalies
Cervical incompetence
Infections
unexplained
7
Q
Risk factors for miscarriage
A
Previous miscarriage
Age
Occupational and environmental factors (such as heavy metals, pesticide, high dose radiation, and lack of micronutrients)
Advanced paternal age
Lifestyle factors, such as stress, obesity, and smoking
Cervical trauma is a second trimester risk
Radiation
8
Q
Clinical presentation miscarriage
A
Pain
Vaginal bleeding
Vaginal discharge
Discharge of tissue from vagina
No longer experiencing symptoms of pregnancy like sickness and breast tenderness
9
Q
Miscarriage Ix
A
transvaginal ultrasound scan
looking for
- Mean gestational sac diameter
- Fetal pole and crown-rump length
- Fetal heartbeat
Serial serum hCG measurements 48 hours apart can help give an indication of the location and prognosis of the pregnancy
10
Q
Repeated HCG indicating miscarriage
A
A fall of more than 50%
11
Q
Repeated HCG indicating intrauterine pregnancy
A
A rise of more than 63% after 48 hours
12
Q
Repeated HCG indicating indicating ectopic
A
A rise of less than 63% after 48 hours
13
Q
Less Than 6 Weeks Gestation
miscarriage mx
A
expectant if no pain or other risk factors
A repeat urine pregnancy test is performed after 7 – 10 days, and if negative, a miscarriage can be confirmed
14
Q
More Than 6 Weeks Gestation
miscarriage mx options
A
expectant
medical (misoprostol)
surgical
15
Q
Misoprostol MOA
A
prostaglandin analogue
soften the cervix and stimulate uterine contractions
16
Q
Surgical mx of miscarriage
A
manual vacuum aspiration (<10w g)
Electric vacuum aspiration
Prostaglandins (misoprostol) are given before surgical management to soften the cervix
17
Q
Ix for recurrent miscarriage
A
Antiphospholipid antibodies
Cytogenetics analysis Genetic testing of the products of conception from the third or future miscarriages
Genetic testing on parents, Parental blood karyotyping
Pelvic USS - uterine anatomy
Inherited thrombophilias
18
Q
The four major sources of bleeding in early pregnancy are
A
- Ectopic pregnancy.
- Miscarriage (threatened, inevitable, incomplete, complete).
- Implantation of the pregnancy.
- Cervical, vaginal, or uterine pathology (eg, polyps, inflammation/infection, trophoblastic disease).
19
Q
Ectopic pregnancy
A
pregnancy is implanted outside the uterus. The most common site is a fallopian tube
20
Q
Risk factors for ectopic pregnancy
A
PID
Genital infection e.g. gonorrhoea
Pelvic surgery
Having an intrauterine device e.g. copper coil or Levonorgestrel-releasing intrauterine system (e.g. Mirena©) in situ
Assisted reproduction e.g. IVF
Previous ectopic pregnancy
Endometriosis
Smoking
older age
21
Q
Clinical presentation ectopic
A
typically presents around 6 – 8 weeks gestation
Pelvic iliac fossa pain may be unilateral
Shoulder tip pain
Abnormal vaginal bleeding
Haemodynamic instability caused by blood loss if the ectopic ruptures
D &V
Abdominal examination may reveal unilateral tenderness
Cervical tenderness (chandelier sign) on bimanual examination
22
Q
options for ectopic pregnancy mx
A
Expectant management (awaiting natural termination)
Medical management (methotrexate)
Surgical management (salpingectomy or salpingotomy)
23
Q
Conservative mx ectopic pregnancy
A
criteria
Follow up needs to be possible to ensure successful termination
The ectopic needs to be unruptured
Adnexal mass < 35mm
No visible heartbeat
No significant pain
HCG level < 1500 IU / l
24
Q
Medical mx ectopic pregnancy
A
one-off dose of methotrexate
criteria
same as expectant management, except:
HCG level must be < 5000 IU / l
Confirmed absence of intrauterine pregnancy on ultrasound
25
Surgical Mx for an advanced ectopic pregnancy
An advanced ectopic is suspected if any of the following are present:
The patient is in a significant amount of pain
There is an adnexal mass of size ≥35mm
B-hCG levels are ≥5000IU/L
Ultrasound identifies a foetal heartbeat
26
complete mole
two sperm cells fertilise an ovum that contains no genetic material (an “empty ovum”). These sperm then combine genetic material, and the cells start to divide and grow into a tumour
27
partial mole
two sperm cells fertilise a normal ovum (containing genetic material) at the same time. The new cell now has three sets of chromosomes (it is a haploid cell). The cell divides and multiplies into a tumour
28
Clinical presentation of molar pregnancy
More severe morning sickness
Vaginal bleeding, especially in first of early second trimester
Increased enlargement of the uterus
Abnormally high hCG
Thyrotoxicosis
29
US findings molar pregnancy
“snowstorm appearance” of the pregnancy.resulting from the presence of a complex vesicular intrauterine mass containing many 'grape-like' cysts
30
Mx molar pregnancy
evacuation of the uterus to remove the mole
histological examination to confirm a molar pregnancy
hCG levels are monitored until they return to normal
Occasionally the mole can metastasise, and the patient may require systemic chemotherapy
31
abortion can be performed before 24 weeks if
continuing the pregnancy involves greater risk to the physical or mental health of:
The woman or
Existing children of the family
32
An abortion can be performed at any time during the pregnancy if:
Continuing the pregnancy is likely to risk the life of the woman
Terminating the pregnancy will prevent “grave permanent injury” to the physical or mental health of the woman
There is “substantial risk” that the child would suffer physical or mental abnormalities making it seriously handicapped
33
Marie Stopes UK
charity that provides abortion services. They offer a remote service for women less than 10 weeks gestation, where consultations are held by telephone and medication are issued remotely to be taken at home.
34
Medical abortion
Mifepristone (anti-progestogen,blocks the action of progesterone, halting the pregnancy and relaxing the cervix)
Misoprostol (prostaglandin analogue) 1 – 2 day later
35
Surgical abortion
first medications are used for cervical priming (softening and dilating the cervix with misoprostol, mifepristone or osmotic dilators)
then suction of the contents of the uterus (usually up to 14 weeks)
or
evacuation using forceps (between 14 and 24 weeks)
36
First line anti emetics in pregnancy
cyclizine, prochlorperazine or promethazine.
37
Congenital rubella syndrome features
affects the developing foetus, most commonly causing deafness, eye abnormalities and congenital heart defects.
38
congenital toxoplasmosis
Infected mothers may be asymptomatic or have mild flu-like symptoms. Early infection with toxoplasma can lead to congenital toxoplasmosis, a severe condition typically presenting with hydrocephalus, seizures, visual and hearing impairment
39
Reproductive health and HIV
Caesarean section should be used unless the mother has an undetectable viral load =????
a ???? infusion should be started four hours before beginning the caesarean section
Caesarean section should be used unless the mother has an undetectable viral load, less than 50 copies/ml at 36 weeks.
a zidovudine infusion should be started four hours before beginning the caesarean section.
Newborns to HIV positive mothers should receive ART for 4 weeks after birth to reduce the risk of vertical transmission.zidovudine is usually administered orally to the neonate if maternal viral load is <50 copies/ml.Otherwise triple ART should be used.
40
dizygotic twins
Fertilization of two separate eggs with two separate sperm
41
Twin-Twin Transfusion Syndrome
occurs when the fetuses share a placenta
The recipient gets the majority of the blood, and can become fluid overloaded, with heart failure and polyhydramnios. The donor has growth restriction, anaemia and oligohydramnios
42
Delivery for Monoamniotic twins
require elective caesarean section at between 32 and 33 + 6 weeks.
43
delivery for dichorionic twin pregnancy
Women with dichorionic twin pregnancies should be offered elective birth from 37 weeks 0 days
44
delivery for monochorionic twin pregnancy
c section 36 w
45
gestational age
refers to the duration of the pregnancy starting from the date of the LMP
46
Gravida
is the total number of pregnancies a woman has had
47
Para
number of times the woman has given birth after 24 weeks gestation, regardless of whether the fetus was alive or stillborn
48
first trimester
start of pregnancy until 12 weeks gestation
49
second trimester
13 weeks until 26 weeks gestation
50
third trimester
27 weeks gestation until birth
51
Preconception Lifestyle advice
folic acid supplementation (400 micrograms/day), ideally at least 3 months before conception and continue until at least 12 weeks' gestation
vit d
avoid alcohol and smoking
Whooping cough (pertussis) from 16 weeks gestation and Influenza (flu) vaccine available
Live vaccines, such as the MMR vaccine, are avoided in pregnancy
avoid unpasteurised milk, soft cheeses, raw or undercooked meat, poultry, and shellfish
can fly safely until 36 weeks' gestation
52
Features of congenital varicella syndrome include:
Low birth weight
Limb hypoplasia
Skin scarring
Microcephaly
Eye defects
Learning disability
53
If a non-immune pregnant woman comes into contact with someone infected with varicella zoster
immunoglobulin can be given as prophylaxis.
if more than 20w g then can also give acyclovir
54
timepoints for routine anti D prophylaxis
offered to all non‑sensitised pregnant women who are rhesus D‑negative between 28 and 34 weeks
55
booking test
8-10w
The visit includes BP, urine dipstick, BMI check. Bloods include FBC, blood group, Rhesus status, red cell alloantibodies, hepatitis B, syphilis, rubella, HIV test is offered, and urine culture
56
Anomaly scan
18-20 +6w
evaluates anatomical structures of the foetus, placenta, and maternal pelvic organs
57
combined test
offered in the first trimester to assess the chance of the baby having Down’s syndrome, Edwards’ syndrome or Patau’s syndrome
nuchal translucency ( higher result= greater risk) beta‑human chorionic gonadotrophin, pregnancy‑associated plasma protein‑A ( lower result= greater risk)
happens between 11-13 w
58
triple or quadruple test
offered between 14 weeks and 20 weeks
1. b-hcg (higher is increased risk)
2. Alpha-fetoprotein (AFP) (lower result= greater risk
3. Serum oestriol (female sex hormone) (lower result =greater risk)
4. for quadruple test, add inhibin A (higher result= greater risk)
59
Chorionic villus sampling
involves an ultrasound-guided biopsy of the placental tissue. This is used when testing is done earlier in pregnancy (before 15 weeks).
60
Amniocentesis
involves ultrasound-guided aspiration of amniotic fluid using a needle and syringe. This is used later in pregnancy once there is enough amniotic fluid to make it safer to take a sample.
61
N&V in early pregnancy Mx
rest
non pharm: avoid triggers, eat plain, bland, small free meals, cold meals may be better, drinks little and often ,ginger
pharm: antihistamine eg (oral cyclizine or oral promethazine, oral metoclopramide or onndansetron for 5 days
62
Hyperemesis gravidarum
severe vomiting with onset before 20 weeks of gestation.
associated with electrolyte disturbance, dehydration, weight loss and ketonuria. Usually occurs in the second trimester
63
Mx Hyperemesis gravidarum
Fluid replacement
Potassium chloride as excessive vomiting usually causes hypokalaemia
Anti-emetic cyclizine
Thiamine and folic acid to prevent development of Wernicke's encephalopathy
Antacids to relieve epigastric pain
Thromboembolic (TED) stockings and low molecular weight heparin as there is increased risk of VTE
64
ECV timepoints for null and multip
After 36 weeks for nulliparous women (women that have not previously given birth)
After 37 weeks in women that have given birth previously
65
NICE (2008) advise giving anti-D to non-sensitised Rh -ve mothers at
28 and 34 weeks
66
Kleihauer test
a test to determine if there has been and the size of Foeto-maternal haemorrhage (FMH) FMH estimation is is performed to ensure that pregnant women who have undergone potentially sensitising events are given adequate quantities of anti-D
67
foetal alcohol syndrome symptoms
poor growth e.g. low birth weight
distinct facial features (e.g. short palpebral fissures, smooth philtrum and thin upper lip)
learning and behavioural problems.
functional or structural nervous system abnormalities e.g. decreased cranial size, structural brain abnormalities, abnormal neurological signs
Pan systolic murnur
68
Patients with RF for diabetes are offered
OGTT at 26-28 weeks gestation
RF:
BMI above 30kg/m2.
Previous macrosomic baby (weighing 4.5kg or above).
Previous gestational diabetes.
First degree relative with diabetes.
Ethnic origin with a high prevalence of diabetes (South Asian, black Carribbean, Middle Eastern)
69
If you have type 1 or type 2 diabetes, you may be at higher risk of having:
birth defects
macrosomia
Shoulder dystocia and Birth injury
Preterm labor and premature birth
Hypoglycaemia
Diabetes risk for baby
Pre -eclampsia
70
Recommendations for pregnancy women with HIV
patients should take multiple ART medications, should not breastfeed and that their child should have zidovudine therapy from birth.
71
Preeclampsia
new high blood pressure (hypertension) in pregnancy with end-organ dysfunction, notably with proteinuria after 20w gestation
72
preeclampsia triad
Hypertension
Proteinuria
Oedema
73
Complications and risks of preeclampsia
maternal organ damage, fetal growth restriction, seizures, early labour, death
74
Risk factors for pre-eclampsia
High-risk factors are: ( disease states)
Pre-existing/chronic hypertension
Previous hypertension in pregnancy
Existing autoimmune conditions (e.g. SLE , antiphospholipid syndrome )
Diabetes type 1 or 2 CKD
Moderate-risk factors are: ( characteristics of mother)
Older than 40
BMI > 35
More than 10 years since previous pregnancy
twin/Multiple pregnancy
First pregnancy
Family history of pre-eclampsia
75
Pre-eclampsia Symptoms
Headache
Visual disturbance
N&V
pain
oedema
Reduce urine output
brisk reflexes
weight gain suddenly
76
Dx pre eclampsia
systolic above 140 and diastolic above 90
and
proteinurea (Urine protein:creatinine ratio above 30mg/mmol,
Urine albumin:creatinine ratio above 8mg/mmol or at least 1 g/litre [2+] on dipstick testing)
or
other maternal organ dysfunction
or uteroplacental dysfunction
77
placental growth factor (PlGF) testing
PIGF is released by the placenta that functions to stimulate the development of new blood vessels. In pre-eclampsia, the levels of PlGF are low
use PlGF between 20 and 35 weeks gestation to rule-out pre-eclampsia.
78
choice of antiHTN in pregnancy
First-line treatment is usually labetalol if not contraindicated.
Consider nifedipine for women in whom labetalol is not suitable.
Consider methyldopa if both labetalol and nifedipine are not suitable.
79
Mx pre eclampsia
Aspirin is used for prophylaxis from 12w g onwards
routinely monitored at antenatal checks
Scoring systems are used to determine whether to admit the woman (fullPIERS or PREP‑S
Blood pressure is monitored closely (at least every 48 hours)
Ultrasound monitoring of the fetus, amniotic fluid and dopplers is performed two weekly
Labetolol is first-line as an antihypertensive, then nifedipine, then methyldopa
Intravenous hydralazin for icu
IV magnesium sulphate is given during labour and in the 24 hours afterwards to prevent and manage seizures
80
HELLP Syndrome
complication of pre-eclampsia and eclampsia. It is an acronym for the key characteristics:
Haemolysis ( destruction of rbc)
Elevated Liver enzymes
Low Platelets
81
Acute fatty liver of pregnancy
occurs in 3rd trim pregnancy or the period immediately following delivery.
There is a rapid accumulation of fat within the hepatocytes, causing acute hepatitis,results from impaired processing of fatty acids in the placenta
82
Clinical presentation Acute fatty liver of pregnancy
General malaise and fatigue
Nausea and vomiting
Jaundice
Abdominal pain
Anorexia (lack of appetite)
Ascites
Headache
Hypoglycaemia
severe disease may result in pre-eclampsia
83
Obstetric cholestasis
usually develops later in pregnancy (i.e. after 28 weeks), and is thought to be the result of increased oestrogen and progesterone levels,, the outflow of bile acids is reduced, causing them to build up in the blood, resulting in pruritus
84
Clinical presentation Obstetric cholestasis
pruritus esp palms of the hands and soles of the feet
Fatigue
Dark urine
Pale, greasy stools
Jaundice
no rash
85
Mx Obstetric cholestasis
Ursodeoxycholic acid improves LFTs, bile acids and symptoms.
Symptoms of itching can be managed with:
Emollients (i.e. calamine lotion) to soothe the skin
Antihistamines (e.g. chlorphenamine) can help sleeping
Water-soluble vitamin K can be given if clotting (prothrombin time) is deranged, A lack of bile acids can lead to vitamin K deficiency
86
Labour times
normally occur between 37 and 42 weeks gestation (full term)
A postterm pregnancy, also called prolonged pregnancy, is one that has extended beyond 42 weeks
87
First stage of labour
from the onset of labour (true contractions) until 10cm cervical dilatation
88
Second stage of labour
from 10cm cervical dilatation until delivery of the baby
89
Third stage of labour
from delivery of the baby until delivery of the placenta
90
Diagnosing the Onset of Labour
Show (mucus plug from the cervix)
Rupture of membranes
Regular, painful contractions
Dilating cervix on examination
91
Progress in labour is influenced by the three P’s:
Power (uterine contractions)
Passenger (size, presentation and position of the baby)
Passage (the shape and size of the pelvis and soft tissues)
Psyche can be added as a fourth P
92
Management of Failure to Progress
Amniotomy, also known as artificial rupture of membranes for women with intact membranes
Oxytocin infusion
Instrumental delivery
Caesarean section
93
Breech presentation
legs of the fetus closest to the cervix
Complete breech – with hips and knees flexed (like doing a cannonball jump into a pool)
Frank breech – with hips flexed and knees extended, bottom first
Footling breech – with a foot hanging through the cervix
94
ideal presentation
The baby should be head down and facing towards the mothers back ( occiput anterior)
95
Active management of the third stage
involves an intramuscular dose of oxytocin (10 IU) after delivery of the baby.
The cord is clamped and cut within 5 minutes of birth
Controlled cord traction is carefully applied during uterine contractions to help deliver the placenta,At the same time the other hand presses the uterus upwards (in the opposite direction) to prevent uterine prolapse.
96
instrumental delivery increases the risk to the mother of:
Postpartum haemorrhage
Episiotomy
Perineal tears
Injury to the anal sphincter
Incontinence of the bladder or bowel
Nerve injury (obturator or femoral nerve)
97
instrumental delivery increases the risk to the baby by
Cephalohaematoma with ventouse
Facial nerve palsy with forceps
98
indications for c section
Breech presentation
Multiple pregnancy
Transmission of bloodborne viruses
Placenta praevia
Morbidly adherent placenta
99
Prematurity is defined as
birth before 37 weeks gestation
100
Risk factors for preterm birth
Preterm birth in a past pregnancy
Having a short cervix early in pregnancy
Early cervical dilation
Past gynecologic conditions or surgeries
Injury during a past delivery
Current pregnancy complications
Carrying more than one fetus
Vaginal bleeding during pregnancy
Infections during pregnancy
Low prepregnancy weight
Smoking during pregnancy
Dietary deficiencies
Younger than 17 or older than 35
101
Prophylaxis of preterm labour options
Vaginal Progesterone
Cervical Cerclage
102
Dx of Preterm Prelabour Rupture of Membranes P-PROM
amniotic sac ruptures, releasing amniotic fluid, before the onset of labour and in a preterm pregnancy (under 37 weeks gestation)
diagnosed by speculum examination revealing pooling of amniotic fluid in the vagina
Where there is doubt:
Insulin-like growth factor-binding protein-1 (IGFBP-1) is a protein present in high concentrations in amniotic fluid, which can be tested on vaginal fluid if there is doubt about rupture of membranes
Placental alpha-microglobin-1 (PAMG-1) is a similar alternative
103
Mx Preterm Prelabour Rupture of Membranes P-PROM
Prophylactic antibiotics should be given to prevent the development of chorioamnionitis.
NICE recommend erythromycin 250mg four times daily for ten days, or until labour is established if within ten days.
104
several options for improving the outcomes in preterm labour:
Fetal monitoring (CTG or intermittent auscultation)
Tocolysis with nifedipine: nifedipine is a calcium channel blocker that suppresses labour
Maternal corticosteroids: can be offered before 35 weeks gestation to reduce neonatal morbidity and mortality
IV magnesium sulphate: can be given before 34 weeks gestation and helps protect the baby’s brain
Delayed cord clamping or cord milking: can increase the circulating blood volume and haemoglobin in the baby at birth
105
Induction of labour is also offered in situations where it is beneficial to start labour early
Prelabour rupture of membranes
Fetal growth restriction
Pre-eclampsia
Obstetric cholestasis
Existing diabetes
Intrauterine fetal death
Low PAPPA can be a reason
106
Bishop score
scoring system used to determine whether to induce labour.A score of 8 or more predicts a successful induction of labour.
Cervical position (scored 0 – 2)
Cervical consistency (scored 0 – 2)
Cervical effacement (scored 0 – 3)
Cervical dilatation (scored 0 – 3)
Fetal station (scored 0 – 3)
107
Options for Induction of Labour
Membrane sweep -not recommended if waters have broken.
Vaginal prostaglandin E2 (dinoprostone) - stimulates the cervix and uterus to cause the onset of labour
Cervical ripening balloon
Artificial rupture of membranes with an oxytocin infusion
108
Uterine Hyperstimulation
the main complication of induction of labour with vaginal prostaglandins. This is where the contraction of the uterus is prolonged and frequent, causing fetal distress and compromise.
109
Mx Uterine Hyperstimulation
Removing the vaginal prostaglandins, or stopping the oxytocin infusion
Tocolysis with terbutaline (Terbutaline is used as a fast-acting bronchodilator (often used as a short-term asthma treatment) and as a tocolytic to delay premature labor.)
110
McRoberts manoeuvre
involves hyperflexion of the mother at the hip (bringing her knees to her abdomen). This provides a posterior pelvic tilt, lifting the pubic symphysis up and out of the way.Applying suprapubic pressure can aid effectiveness of this manoeuvre . It aims to release the baby's shoulder by applying pressure over the pubic bone
111
Rubins manoeuvre
involves reaching into the vagina to put pressure on the posterior aspect of the baby’s anterior shoulder to help it move under the pubic symphysis.
112
Wood’s screw manoeuvre
is performed during a Rubins manoeuvre. The other hand is used to reach in the vagina and put pressure on the anterior aspect of the posterior shoulder.
113
Zavanelli manoeuver
involves pushing the baby’s head back into the vagina so that the baby can be delivered by emergency caesarean section.
114
key complications of shoulder dystocia are:
Fetal hypoxia (and subsequent cerebral palsy)
Brachial plexus injury and Erb’s palsy
Perineal tears
Postpartum haemorrhage
115
Neonatal herpes simplex virus infection presentation
local features:vesicular lesions on the skin, eye or oral mucosa
Disseminated features :seizures, encephalitis, hepatitis or sepsis. Symptoms commonly appear in the first week of birth
116
Tx for Neonatal herpes simplex virus infection
parenteral acyclovir along with intensive supportive therapy for severe cases
An elective caesarean section or intra-partum IV acyclovir may be advised if active primary herpes lesions are present on the mother at term or there has been a primary outbreak within 6 weeks of labour
117
hydrops fetalis
excessive extravasation of fluid into the third space in a fetus which could be due to heart failure, volume overload, decreased oncotic pressure, or increased vascular permeability
may manifest as:
fetal pleural effusion
fetal pericardial effusion
fetal ascites
generalised body oedema: fetal anasarca/nuchal oedema/cystic hygroma
placental enlargement
polyhydramnios
hepatomegaly
118
risk factors for hydrops fetalis:
Maternal infections: CMV, rubella, syphilis, viral esperialy PV-B19
Iron deficiency
Preeclampsia
119
Antepartum haemorrhage
defined as any vaginal bleeding from 24 weeks gestation until delivery.
120
Placental abruption
refers to either partial or complete separation of the placenta from uterus prior to delivery.
121
Placenta abruption clinical presentation
Sudden onset severe abdominal pain that is continuous
Vaginal bleeding
Shock
CTG indicating fetal distress, fetal heart may be absent
Characteristic “woody” abdomen on palpation
Enlarged uterus disproportionate to gestational age of fetus
122
initial steps with major or massive haemorrhage are:
Urgent involvement of a senior obstetrician, midwife and anaesthetist
2 x grey cannula
Bloods include FBC, UE, LFT and coagulation studies
Crossmatch 4 units of blood
Fluid and blood resuscitation as required
CTG monitoring of the fetus
Close monitoring of the mother
123
Placenta praevia
where the placenta is attached in the lower portion of the uterus, lower than the presenting part of the fetus, near or covering the internal cervical os within the lower segment of the uterus.
US 20-week anomaly scan is used to assess the position of the placenta and diagnose placenta praevia
124
Placenta praevia clinical presentation
Many women with placenta praevia are asymptomatic.
It may present with painless vaginal bleeding in pregnancy
Bleeding usually occurs later in pregnancy (around or after 36 weeks).
fetal heart usually normal
125
Vasa praevia
defined as the presence of fetal placental vessels lying over internal cervical os.
diagnosed by ultrasound during pregnancy.
may present with antepartum haemorrhage, with bleeding during the second or third trimester of pregnancy.
126
placenta accreta
placenta embeds past the endometrium, into the myometrium and beyond.
can present with bleeding (antepartum haemorrhage) in the third trimester and dx on US
127
classification of postpartum haemorrhage
500ml after a vaginal delivery
1000ml after a caesarean section
128
four causes of postpartum haemorrhage
Tone
Trauma
Tissue
Thrombin
129
treatment options for stopping the bleeding in post part haemorrhage
Mechanical treatment options involve: Fundal massage,Bimanual compression,catheterisation
Medical treatment options involve: oxytocin, Ergometrine,Carboprost ,Misoprostol ,tranexamic acid
Surgical treatment options involve: Examination under anaesthesia (EUA),repair tear, Intrauterine balloon tamponade ,B-Lynch/brace suture,Uterine artery ligation,Hysterectomy
130
Secondary Postpartum Haemorrhage
bleeding occurs from 24 hours to 12 weeks postpartum. This is more likely to be due to retained products of conception (RPOC) or infection (i.e. endometritis).
131
Meconium aspiration syndrome
passage of the meconium from the amniotic fluid into the foetal lungs.
Can present with newborn appearing to have laboured breathing, expiratory grunting and nasal flaring. tends to present in term or post-term babies.The emociom can also stain the skin of the baby greenish.
Should be admitted to NICU for oxygen and antibiotic therapy and suctioning
132
five key features to look for on a CTG:
Contractions – the number of uterine contractions per 10 minutes
Baseline rate – Stacy is>160,brady is <100
Variability – how the fetal heart rate varies up and down around the baseline ( 5-25 bpm is normal)
Accelerations – periods where the fetal heart rate spikes
Decelerations – periods where the fetal heart rate drops
133
Foetal blood sampling
indicated when there is a suspicious cardiotocograph. It is used during labour to confirm whether there is foetal hypoxia.
134
stillbirth
baby is born dead after 24 completed weeks of pregnancy.
135
preventing still birth
not smoking
avoiding alcohol and drugs
not going to sleep on your back after 28 weeks
attending all your antenatal apts
folic acid
limiting caffeine
136
Post partum endometritis
refers to inflammation of the endometrium, usually caused by infection.
ccurs more commonly after caesarean section
137
Post partum endometritis presentation
Foul-smelling discharge or lochia
Bleeding that gets heavier or does not improve with time
Lower abdominal or pelvic pain
Fever
Sepsis
Chills , malaise
138
Retained products of conception
placental tissue or fetal membranes remain in the uterus after delivery. It can also occur after miscarriage or termination of pregnancy.
Placenta accreta is a significant risk factor
139
Retained products of conception presentation
Vaginal bleeding that gets heavier or does not improve with time
Abnormal vaginal discharge
Lower abdominal or pelvic pain
Fever (if infection occurs)
140
Complications of Evacuation of retained products of conception (ERPC)
Endometritis
Asherman’s syndrome (adhesions)
141
Baby blues
seen in the majority of women in the first week or so after birth
142
Postnatal depression
seen in about one in ten women, with a peak around three months after birth
143
Puerperal psychosis
is seen in about one in a thousand women, starting a few weeks after birth
144
Sheehan syndrome
are complication of post-partum haemorrhage, where the drop in circulating blood volume leads to avascular necrosis of the pituitary gland. Low blood pressure and reduced perfusion of the pituitary gland leads to ischaemia in the cells of the pituitary, and cell death.
145
Fertility is not considered to return until
21 days after giving birth, and contraception is not required up to this point.
146
Lactational amenorrhea
over 98% effective as contraception for up to 6 months after birth. Women must be fully breastfeeding and amenorrhoeic
147
Prolactin; from the anterior pituitary: leads to
stimulation of continued lactogenesis (milk production); and disruption of pulsatile GnRH secretion (causing lactational amenorrhea)
148
Oxytocin; from the posterior pituitary: leads to
stimulation of milk ejection (letdown); and uterine contractions
149
breastfeeding MOA
Suckling of the baby stimulates the mechanoreceptors in the nipple which results in the release of both prolactin and oxytocin from the pituitary gland (anterior and posterior parts respectively).
150
Benefits of breastfeeding for infants
Decreased risk of middle ear, respiratory, gastrointestinal and uti ,breast milk immunoglobulins (especially igA) and wbc provide passive immunity for the child
Better gastrointestinal function and motility
Lower risk of asthma allergies obesity and diabetes mellitus
Reduces risk of cot death
151
Maternal Benefits of breastfeeding
Faster uterine involution and postpartum weight loss
Lower risk of ovarian and breast cancers and diabetes
Postpartum contraception ( lactational amenorrhea)
Improved bonding with infant
Reduced costs
152
congenital toxoplasmosis
Infected mothers may be asymptomatic or have mild flu-like symptoms. Early infection with toxoplasma can lead to congenital toxoplasmosis, a severe condition typically presenting with hydrocephalus, seizures, visual and hearing impairment
