Obstetrics Flashcards
(389 cards)
1
Q
When is the window of blastocyst implantation and why?
A
Cycle day 20-24- due to the perfect balance of hormones
2
Q
What happens after blastocyst implantation in pregnancy?
A
The blastocyst buries (Interstitial Implantation)→ primary decidual reaction
3
Q
What basic placental structures form after interstitial implantation in pregnancy?
A
- Floating villi
- Anchoring villi
4
Q
What do Cytotrophoblast progenitor stem cells differentiate into?
A
1) Terminal→ syncytiotrophoblast
2) Extra-villus trophoblasts
3) Regenerate new CTBs
5
Q
What are the functions of extra-villous trophoblasts in pregnancy?
A
Spinal artery remodelling
6
Q
What is spinal artery remodelling in pregnancy?
A
Endovascular invasion myometrium- optimum 02 and nutrient supply
Due to extra-villus trophoblast invasion
7
Q
When does full placental blood flow occur in pregnancy?
A
Week 10-12
8
Q
What may poor endovascular remodelling lead to in pregnancy?
A
Reduced fetal 02 and nutrient supply and subsequently = Pre-eclampsia
Intrauterine growth restriction (IUGR)
Preterm birth
Recurrent miscarriage
9
Q
What is human chorionic gonadotrophin (hCG)?
A
A hormone secreted by trophoblast cells of the blastocyst on days 6-7 that:
- Promotes maintenance of corpus luteum
- Maintains production of oestrogen and progesterone
10
Q
Where is Progesterone produced in pegnancy?
A
Corpus Luteum makes it until 7-8 weeks
Afterwards the placenta takes over
11
Q
What are the 4 functions of Progesterone?
A
- Prepares uterus for implantation
- Makes the cervical mucous thick and impenetrable to sperm after fertilisation
- Decreases immune response to allow pregnancy to happen
- Decreases contractility of uterine smooth muscle to prevent pre-term labour
12
Q
What does progesterone inhibit?
A
Lactation during pregnancy.
Fall in progesterone following delivery triggers milk production
13
Q
What is the name of the breast milk that is produced at birth?
A
Colostrum
14
Q
What is the function of Hyman Placental Lactogen (hPL)?
A
- Mobilises glucose from fat reserves
- Insulin antagonist to facilitate energy supply to foetus
- Converts mammory glands into milk-secreting tissue
15
Q
What is the function of Prolactin?
A
Milk production
16
Q
What is the function of Oxytocin during pregnancy?
A
Milk ejection reflex
Uterine contraction
17
Q
What is the principle foetal nutrient during pregancy?
A
Glucose
18
Q
What happens to maternal glucose levels at the early stages of pregnancy?
A
Low glucose levels due to fat deposition and glycogen synthesis
19
Q
What happens to maternal glucose levels at the late stages of pregnancy?
A
High glucose levels and maternal insulin resistance to ensure glucose sparing for the foetus
20
Q
What happens to maternal insulin levels throughout pregnancy?
A
- Progressive rise until peak at 32 weeks.
- hPL induces insulin resistance to ensure glucose sparing to the foetus
21
Q
What are the initial immunity changes after fertilisation?
A
Increases in:
- GFs
- Proteolytic enzymes
- Inflammatory mediators
Facilitates implantation
22
Q
Why is blastocyst implantation not rejected due to immunity?
A
Change in self:non self pattern recognition molecules (HLA and MHC proteins)
23
Q
Why are syncytiotrophoblasts and extra-villus trophoblasts not rejected due to immunity?
A
Syncytiotrophoblasts: have no self:non-self markers = no maternal immune system
Extra-Villus trophoblasts (EVT): have modified self:non-self markers = modified maternal immune response
24
Q
What happens to T helper subtype ratio when you’re pregnant?
A
Normaly = balanced Th1 and Th2
Pregnant = >Th2
25
What is the only antibody that can cross the placenta?
IgG
26
Name the relevance of the following Antibodies to pregnancy:
IgA?
IgD?
IgE?
IgG?
IgM?
IgA: secreted in breast milk
IgD: on b-cell membranes
IgE: mast cells (anaphylaxis)
IgG: 4 subtypes and the only Ig to cross the placenta
IgM: pentameric structure (early antibody)
27
How would you describe a 'perfect' pregnancy?
- 37-42 weeks
- Spontaneous in onset + vertex position
Without the use of:
- Forceps/C-section/ventose delivery
- Induction of labour
- Epidural/general anaesthesia
28
What are failure to progress pregnancies 3 P's?
Power
Passage
Passenger
29
Describe the pathophysiology of 'Power' in failure to progress pregnancy
Need contractions to be strong enough
Difficult in nulliparous women- may need instrumental delivery
30
Describe the pathophysiology of 'Passage' in failure to progress pregnancy
'Pelvis' abnormalities in:
- Anterior-posterior diameter (AP) (front to back distance)
- Transverse diameter (side to side length)
31
Describe the pathophysiology of 'Passenger' in failure to progress pregnancy
The baby needs to be in the correct position
32
Describe the baby head landmarks felt on vaginal examination to assess baby position
Attitude: How well the babies head is flexed (well flexed is best)
- Extended 90° = brow presentation
- Hyperextended >120° = face presentation
Position: occipito anterior/ transverse/ posterior
1) OT when entering inlet
2) OA when entering outlet
3) Then turn 90° to come out facing mothers medial thigh
Size of head
33
Define moulding
Head compressed through the pelvis
34
Define caput
Swelling caused during delivery
35
How long on average is the first stage of pregnancy?
5-12 weeks: Multiparious
8-12 weeks: Primiparous
36
Describe the early/latent phase of the first part of labour
2-3 days:
- Irregular painful contractions
- Cervix is effacing and thinning
- Dilation to about 4cm
- Mucoid plug
37
What is Engagement?
How far above the pubic symphysis the babies head is:
3/5th of the head within pelvic brim = engaged
38
What is Presentation?
Anatomical part of the foetus that presents itself first through the birth canal
39
What is Lie?
Relationship between long axis of the foetus and long axis of the uterus
40
What is station?
Relationship between lowest point of presenting part and ischial spines
41
Describe the Active Phase of Labour (2nd)
- Further dilation from 4cm (0.5cm every hour)
- Regular contractions (3-4 an hour)
- Vaginal exam every 4 hours to assess degree of dilation
- Role of oxytocin/syntocinon inducing labour
42
What is Entonox?
Name its side effects
Gas and air
SE: N+V
43
Name the maternal side effects of the most effective form of pain relief during labour
Epidural maternal SE:
- Increase length of 1st and 2nd stage
- Loss of mobility
- Loss of bladder control
- Need for more oxytocin
- Increase incidence of malposition
- Increase instrumental rate
- hypotension & pyrexia
44
Name the foetal side effects of the most effective form of pain relief during labour
Epidural foetal SE:
- Tachycardia: due to maternal temperature
- Diminished breast feeding behaviour
45
Name an opiate that could be used as pain relief during labour
Morphine
46
Name 2 foetal side effects of opiates being used as pain relief during labour
They cross the placenta readily:
- Respiratory depression
- Diminish breath seeking/breast feeding behaviours
47
Name 4 maternal side effects of opiates being used as pain relief during labour
1) Sedation
2) Euphoria/ dysphoria
3) N+V
4) Longer 1st and 2nd stage
48
Describe the initial Transition stage of the second stage of labour
Spontaneous rupture of membranes (SROM):
- Start to feel pressure (anxious and distressed)
- Contractions can slow/stop
49
Describe the second part of the Transition stage of the second stage of labour
- Full dilation (10cm)
- External signs (head visible)
- Check baby head landmarks to assess if correct position
50
In what timeframe should you in In primigravid and multiparous women:
- Suspect delay?
- Diagnose delay?
- Baby be born?
Primigravid:
- Suspect delay: 1hr
- Diagnose delay: 2hr
- Baby born: within 3 hours of pushing
Multiparous:
- Suspect delay: 30mins
- Diagnose delay: 1hr
- Baby born: within 2 hours of pushing
51
Why is there now delayed cord clamping?
Early clamping doesn't benefit baby/ mother
Improves iron intake
52
What happens to endovascular invasion after implantation in the myometrium?
Narrow bore high resistance vessels become wide bore low resistance vessels
53
Name some maternal CVS changes during pregnancy
- Increased RBC & plasma volume
- Increased plasma volume → decline in haematocrit
- Increased Q due to increase Fe demand (peripheral vasodilation)
- Hypercoagulable = increased risk of embolism
54
Name the 4 forces that determine fluid movement in/out of a capillary
Out of the capillary :
- Capillary pressure
- Interstitial fluid colloid oncotic pressure
Into the capillary :
- Interstitial fluid pressure
- Plasma colloid oncotic pressure (albumin)
55
Why is there an increased risk of UTIs in pregnancy
Kidney dilation
Decreased uretal tone and peristalsis = urinary stasis
56
What is the effect of delayed gastric emptying in pregnancy
Increased heartburn
Increased nutrient uptake
Increase water reabsorption- may cause constipation
57
What is Chadwick’s Sign?
Early sign of pregnancy where the labia/cervix may appear blue due to increased blood flow (at 6-8 weeks)
58
Describe the function of the following hormones at birth:
Oxytocin
Prolactin
Oestrogen
Progesterone
Beta-endorphins
Adrenaline
Oxytocin: induces onset & labour contractions
Prolactin: begins milk production in mammary glands
Oestrogen: inhibits progesterone and prepare smooth muscle for labour
Progesterone: aids in cervical ripening
Beta-endorphins: natural pain relief
Adrenaline: energy for birth
59
What are the 9 Mechanisms of Labour?
**DFICERIL**:
- Descent
- Flexion
- Internal rotation
- Crowning
- Extension
- Restitution/External Rotation
- Internal restitution of shoulders
- Lateral flexion
60
How is haemolytic disease of a newborn caused?
1) Rhesus - mother and + father
2) Rhesus - mother and + baby
3) Baby has D antigen and mother does not
4) Mother produces antibody against D antigen and haemolysis of newborns RBCs
61
Which antibodies can destroy the foetal red blood cells?
IgG antibodies can cross the placenta and destroy foetal RBCs
62
What can haemolytic disease of a newborn do to the baby?
- Anaemia
- Jaundice
- Brain damage
- Fatal = miscarriage/ stillborn
63
How can you diagnose haemolytic anaemia?
Raised reticulocyte count, unconjugated bilirubinaemia and urinary urobilinogen
Abnormal RBC shape
Positive Coombes test
Raised red cell precursors in bone marrow
64
How can foetal RBC lysis be prevented in rhesus negative mothers?
Anti-D prophylaxis: destroys Rh+ IgG so no RBC are attacked
65
A rhesus- mum is having an amniocentesis.
What must you give her prior to this procedure?
Anti-D!
There is a risk of sensitisation
66
When is Anti-D given to rhesus negative women?
- Dose 1: 28 weeks
- Dose 2: 34 weeks
67
What are the potential consequences, if left untreated, of a rhesus - mother having a rhesus + foetus?
There is a risk of RBC lysis → foetal anaemia and death
68
Describe internal rotation during labour
When the babies head hits the pelvic floor, it turns straight again
(Has to go through pelvis at an angle to fit!)
69
Describe crowing during labour
When the head pokes out
70
Describe internal restitution of the shoulders during labour
1) When the head is out it will turn to left/right
2) Shoulders will follow within pelvis
71
Describe the third stage of labour
- Pushing out the placenta
- Physiological management due to increased blood loss
- 5-30mins
72
Why may oxytocin be given in the 3rd stage of labour
- To create uterine contraction so that the placenta can separate
- Prevents excessive blood loss/postpartum haemorrhage
73
Where is Relaxin released from?
What is its function in labour?
- Released from placenta, membranes and lining of the uterus
- Softens ligaments and cartilage of the pelvis, cervix + babies body so that they expand
74
What is the function of oxytocin in labour?
- Stimulates uterine contractions during orgasm and childbirth
- Triggers foetal ejection reflex when cervix fully dilated
- Contracts uterus post birth to deliver placenta and limit bleeding
75
What is the function of prostaglandins?
Ripens the cervix → thinning and opening
Stimulates uterine contractions
76
Describe a breech
Not head first in uterus
Commonest malpresentation
Can be reversed by external cephalic version
77
What are the complications of an external cephalic version
- Placenta praevia
- APH
- Ruptured membranes
78
What is a face presentation and the likely method of delivery?
Head extends rather than flexes
Forceps delivery
79
What is a brow presentation and the method of delivery?
Head is between full flexion and extension
LSCS delivery
80
How is a transverse lie antenatally diagnosed?
- Ovoid uterus wider at the sides
- Lower pole is empty
- Head lies in one flank
- Foetal heart heard in variable positions
81
In which malpresentation is there the highest risk of cord prolapse?
What method of delivery would you perform as a result?
Tranverse lie
If persists at 37 weeks and ECV fails = C-section
82
What is a Occipitoposterior position?
What method of delivery would you perform?
Posterior fontanelle found to lie in posterior quadrant of pelvis
Labour is prolonged due to degree of rotation needed
Instrumental/C-section sometimes required
83
What is a Primary dysfunctional labour?
Most common in first labour
Due to insufficient uterine contractions
84
What is the management of Primary dysfunctional labour?
Hydration + Comfort + Analgesia = initial management
Syntocinon infusion after ROM
85
What is secondary dysfunctional labour and what is the likely cause?
Labour progresses to full dilation and then stops
Likely due to cephalopelvic disproportion (passenger or passage)
86
What management can delay the 1st stage of labour?
Amniotomy (AROM)
Oxytocin (offer epidural)
87
What management can delay the 2nd stage of labour?
Instrumental/ LSCS delivery
88
What is quiescence?
There are no contractions when the myometrium is inactive
89
What are the most common reasons for inducing labour?
- Prolonged pregnancy
- Premature rupture of membranes and labour doesn't start
- Diabetic mother >38 weeks
- Rhesus incompatibility
- Pre-eclampsia
- Diabetes
- Growth restriction
- Reduced foetal movements
90
What is the bishop score?
Assesses whether induction is required
<5 = unlikely to start without induction
>9 = likely to start spontaneously
91
Describe the 5 parts of the bishop score
- Cervical dilation (cm)
- Length of cervix (cm)
- Station of head (cm above ischial spines)
- Cervical consistency
- Position of cervix
92
In the bishops score you can either get 0, 1 or 2.
For each of the 5 parts state what would give a score of 0?
- Cervical dilation (0cm)
- Length of cervix (>2cm)
- Station of head (3cm above ischial spines)
- Cervical consistency (firm)
- Position of cervix (posterior)
93
In the bishops score you can either get 0,1 or 2.
For each of the 5 parts state what would give a score of 1?
- Cervical dilation (1-2cm)
- Length of cervix (1-2cm)
- Station of head (2cm above ischial spines)
- Cervical consistency (medium)
- Position of cervix (middle)
94
In the bishops score you can either get 0,1 or 2.
For each of the 5 parts state what would give a score of 2?
- Cervical dilation (3-4cm)
- Length of cervix (<1cm)
- Station of head (1cm above ischial spines)
- Cervical consistency (soft)
- Position of cervix (anterior)
95
What should be checked prior to induction?
- Lie and position of foetus
- Volume of amniotic fluid
- Tone of uterus
- Ripeness of cervix (using bishops system)
96
What are contra-indications for induction?
- Severe degree of placenta praevia
- Transverse fetal lie
- Severe cephalopelvic disproportion
- Cervix <4 on bishops score
97
How is induction performed?
1) Membrane sweep
2) Prostaglandin gel and pessary high in vagina
3) Amniotomy: ROM
4) Oxytocin/ Syntocinon (oxytocin analogue ) (post ROM)
98
List 11 types of labour pain relief
- Education (breathing, coping, birth partner)
- Transcutaneous electrical nerve stimulation (TENS)
- Water birth (reduces need for anaesthesia)
- Pudendal nerve block S2,S3,S4 (for instrumental)
- Local anaesthesia (lidocaine before epsiotomy/surturing vaginal tears)
- Epidural (T10-S5 (performed at L3-L4))
- Spinal anaesthesia
- Gas and air: entonox
- Paracetamol
- Codeine
- Opioids e.g. pethidine, diamorphine
99
Where is spinal anaesthesia injected into?
The CSF
100
Name an anaesthetic that can be given as an epidural
Bupivacaine
101
Give 3 indications for an epidural
- Maternal request
- Augmented labour
- Twins
- Existing co-morbidities
102
Give 3 contraindications for an epidural.
- Maternal refusal
- Local infection
- Allergy
103
Describe the physiology behind a post-dural puncture headache?
Accidental dural puncture → CSF leakage → decreased pressure in fluid around the brain.
104
Give 3 symptoms of a post dural puncture headache
- Headache is worse on sitting/standing
- Neck stiffness
- Photophobia
105
How would you treat a post dural puncture headache?
- Lying flat
- Analgesia
- IV fluids
106
What is the significance of meconium liquor on the pad?
Foetal distress- possible breech
107
What are the 3 types of breech presentation?
Frank breech
Complete breech
Footling breech
108
Describe a Frank breech
Hips flexed
Legs extended
109
Describe a complete breech
Hips and knees are flexed
Feet are below the level of the foetal buttocks
110
Describe a footling breech
One of both feet are presenting as the lowest part of the foetus (dangling legs)
111
What is the most favourable position for vaginal delivery and why?
Occipito-anterior- smallest diameter comes through the pelvis
112
Which breech presentation is associated with highest-risk of cord prolapse?
Footling breech
There is nothing to act as a plug over the cervix if the membranes rupture.
(also true for transverse or oblique lies)
113
The mentovertical diameter is associated with what presentation?
Brow
114
What is the usual position of the head at engagement?
Occipito-transverse
115
The presenting diameter is submento-bregmatic what does this mean?
Face presentation
116
What is hyperemesis gravidarum?
Persistent + excessive vomiting associated with weight loss (5% body mass), dehydration and ketosis during pregnancy
117
What placental hormone is hyperemesis gravidarum associated with?
B-hCG
118
What triad is found in Hyperemesis Gravidarum?
>5% weight loss
Electrolyte imbalance
Dehydration
119
What is the management of Hyperemesis Gravidarum?
Mild:
- Avoid large volume drinks
- Small carb meals
Severe:
- Anti-emetics
- IV fluids
- Thromboprophylaxis
- Thiamine supplements
120
Give 3 types of anti-emetics and an example for each one
Dopamine antagonist: Metoclopramide
Phenothiazines: Prochloperazine
5HT selective serotonin antagonists: Ondansetron
121
What is Puerperal Pyrexia?
Maternal fever (>38°) in the first 14 days following delivery
122
What causes Puerperal Pyrexia?
- Endometritis
- UTI
- Mastitis
- VTE
123
What is the management of Puerperal Pyrexia?
Endometritis suspected = hospital admission for IV Abx (clindamycin and gentamycin) until afebrile for >24hrs
124
What is the leading cause of morbidity and mortality during pregnancy in developed countries?
VTE (DVT of legs, pelvis and PE)
Preventable
125
When should you have a VTE risk assessment during pregnancy?
- Booking
- Antenatal admission
- Labour
- Postnatally
126
What are the risk factors for VTE during pregnancy?
BMI >30
Immobility
Smoking
FHx
Aged >35
Gross varicose veins
Pre-eclampsia
IVF
Multiple pregnancy
Parity >3
127
What medication can be given postnatally to reduce a woman’s risk of VTE?
LMWH
TED stockings
128
When is LMWH thromboprophylaxis, compression stockings and early mobilisation indicated in pregnancy?
- Has any risk factor
- If a women requires antenatal LMWH (must be given until 6 weeks postpartum)
129
If a pregnant/postpartum lady collapses what should you presume?
PE
130
What is anaemia during pregnancy?
Hb <105g/L
The fall in Hb is steepest ≈20 weeks gestation
131
What are the risk factors for anaemia?
- Menorrhagia/Malaria/hookworm
- Frequent pregnancies
- Twins
- Poor diet
132
How would you investigate anaemia in pregnancy?
- Hb estimation at 28 weeks antenatally- test for sickle cell in black patients
- Fe deficiency: low serum Fe, TIBC and serum ferritin
133
What causes anaemia during pregnancy?
- 2x increase in iron requirements → micro-cytic aneamia (most common cause)
- B12/folate deficiency → macrocytic anaemia
134
What is the management of iron deficiency anaemia?
Treat cause:
Ferrous sulphate (oral iron therapy) 2x/week
- May cause N/D/V, abdo pain and constipation
Iron rich diet
- Meat and dark green vegetables
Blood transfusion
135
What should you give to a mother with Hepatitis B?
All mothers should be screened
Give immunoglobulin
Vaccinate babies of carriers and infected mothers at birth
136
If mother develops Varicella Zoster (Chickenpox) near delivery what should be done to the baby?
Give varicella immune immunoglobulin at birth + monitor for 28 days
Treat with Aciclovir if neonate develops chickenpox
137
How is Jaundice investigated?
LFTs
Urine dip: bile
Serology
HBsAG (Hep B surface Antigen)
Get expert help PROMPTLY: can be lethal
138
What inheritance pattern is associated with obstetric cholestasis?
Autosomal dominant
139
What is the clinical presentation of Obsteteric Cholestasis?
- Jaundice
- Pruritis (palms and soles)
- Worse at night
140
What investigations would you perform for obstetric cholestasis?
LFTs: raised AST, ALT, GGT and bilirubin
Raised bile acid
141
Management of Obstetric Cholestasis?
Ursodeoxycholic acid
Emollients (i.e. calamine lotion): soothes skin
Antihistamines (e.g. chlorphenamine): sleeping
Weekly LFTs
Induced at 37 weeks
142
What are the complications of Obstetric Cholestasis?
- Stillbirths
- Preterm labour
- Meconium
- Foetal distress
143
In which trimester is Intrahepatic cholestasis and acute fatty liver of pregnancy generally seen?
3rd
144
What is the clinical presentation of Acute fatty liver of pregnancy?
- Jaundice
- Abdominal pain
- Pre-eclampsia
- Hypoglycaemia
- Malaise
- Fatigue
- Nausea
- Headache
145
ECTOPIC PREGNANCY
What is it?
A pregnancy that occurs anywhere outside the uterus
146
What is the most common place for an ectopic pregnancy
Ampulla of Fallopian tube
147
What are the risk factors for Ectopic Pregnancy?
- IVF
- Age
- PID
- Ectopic Hx
- Smoking
- Progesterone only pill
- Endometriosis
148
What is the clinical presentation of Ectopic Pregnancy?
- Amenorrhoea (missed period for 6-8 weeks)
- Vaginal bleeding
- Dizzy → fainting
- Abdo pain/tenderness
- Shoulder tip pain
- Haemoperitoneum (blood in peritoneal cavity)
149
How is Ectopic Pregnancy diagnosed?
Positive pregnancy test (hCG)
Transvaginal USS:
- Empty uterus
- Fluid in uterus
150
How is Ectopic pregnancy managed?
Terminate pregnancy:
- Expectant management (awaiting natural termination)
- Medical management (methotrexate if no complication)
- Surgical management (salpingectomy or salpingotomy)
151
What is the criteria for expectant management of Ectopic Pregnancies?
Follow up
Unruptured
Adnexal mass <35mm
No visible heartbeat
No significant pain
HCG level < 1500 IU / l
152
What is the criteria for methotrexate management of Ectopic Pregnancies?
Follow up
Unruptured
Adnexal mass <35mm
No visible heartbeat
No significant pain
HCG level < 5000 IU / l
US: confirmed absence of intrauterine pregnancy
153
What is the criteria for surgical management of Ectopic Pregancies?
Does not fit medical or expectant management +:
Pain
Adnexal mass > 35mm
Visible heartbeat
HCG levels > 5000 IU / l
154
Name 4 side-effects of Methotrexate
- Conjunctivitis
- Stomatitis
- Diarrhoea
- Abdominal pain
155
What is gestational trophoblastic disease (GTD)?
A group of pregnancy related tumours
156
What is a Molar Pregnancy?
1) Abnormality in chr number during fertilisation
2) Non-viable fertilised egg implants into uterus
3) Will not come to term
4) Grows into uterus mass
A type of GTD
157
What is a complete molar pregnancy?
- Empty oocyte + one sperm (duplicates)
- 46 chromosomes (diploid): all of paternal origin
- No foetal tissue
158
What is a partial molar pregnancy?
- Normal egg + two sperm
- 69 chromosomes (triploidy)
- Some foetal tissue recognisable
159
What is an invasive molar pregnancy?
When a complete mole invades the moymetrium
160
What are risk factors for molar pregnancies?
Aged <16 or >45
Previous molar
Multiple pregnancies
Oral contraceptive
Asian
Menarche >12
161
What are the complications of Molar Pregnancies?
Choriocarcinoma's
162
What is the clinical presentation of Molar Pregnancies?
- Vaginal bleeding (early)
- Abdominal pain (early)
- Hyperemesis (late)
- Hyperthyroidism (late)
- Very high hCG levels (causes late symptoms)
- Large uterus
- Pre-eclampsia
- Unexplained anaemia
163
How are Molar Pregnancy investigated?
Urine and bloods: very high bhCG
Histology
US:
- 'Snowstorm appearance' in 2nd trimester
- Large
164
How are molar pregnancies managed?
Urgent referral to specialist centre
Uterine evacuation
Suction curettage
Chemotherapy: Cisplatin (metastasise indicated by hCG is >20,000)
No pregnancy until hCG levels normal for 6 months: give contraception
165
What is a miscarriage?
The loss of pregnancy <24 weeks gestation
Excludes ectopic or trophoblastic disease
166
What is a complete miscarriage?
No products of conception left in uterus
TVUS: crown rump length >7mm
Gestational sack: >25mm
No foetal heartbeat
167
What is crown-rump length?
US measures the length of foetus from the top of the head (crown) to the bottom of the buttocks (rump).
Estimates gestational age
168
What is a threatened miscarriage?
Vaginal bleeding +/- pain + closed cervix + alive foetus
169
What is an Inevitable miscarriage?
Vaginal bleeding +/- pain + open cervix + alive foetus
Pregnancy will not continue → complete/incomplete miscarriage
170
What is an incomplete miscarriage?
Products of conception remain in uterus after miscarriage
Vaginal bleeding +/- pain + open cervix
171
What is a missed miscarriage?
Foetus is dead + remains in uterus + no symptoms + closed cervix
Uterus: small for dates
No fetal HB + crown rump length is >7mm
Pregnancy test: + for weeks
Hx
Persistant dirty brown discharge
172
What is recurrent miscarriage?
≥3 consecutive miscarriages
173
What are the causes of recurrent miscarriage?
Abnormal foetal development
Uterine abnormality
Incompetent cervix
Placental failure
Multiple pregnancy
174
What are the risk factors for miscarriage?
Age >30
Smoking >14 a day
Alcohol
Drug use
Uterine surgery
Uncontrolled DM
Increased parity
175
What is the epidemiology of miscarriages?
15-20% of pregnancies
Majority: 1st trimester
176
What is the clinical presentation of miscarriages?
- Vaginal bleeding +/- abdominal pain following amenorrhoea
- Cervix is open enough to admit one finger
- Uterine size: small for dates
- Passing products of conception
177
How is a miscarriage investigated?
TVUS:
- Mean gestational sac diameter
- Foetal pole and crown-rump length
- Foetal heartbeat (only measured if >7mm crown-rump length)
Serum hCG (excludes ectopic)
178
How are miscarriages <12 weeks managed?
Mifepristone (antiprogesterone to prime cervix) THEN Misoprostol 36-48hrs later
179
How are miscarriages >13 weeks managed?
Vaginal misoprostol- bleeding may continue for 3 weeks
Manual vacuum aspiration under GA
180
Until what week can a lady legally have an abortion?
- 24 weeks under the Abortion Act 1967
- >24 weeks: illegal unless there is a substantial risk to the woman’s life OR foetal abnormalities.
181
How is a termination of pregnancy carried out surgically?
Vacuum aspiration (adminster misoprostol before surgery to prepare cervix)
182
How is a termination of pregnancy carried out medically?
Mifepristone (antiprogesterone to prime cervix) THEN Misoprostol 36-48hrs later
183
When may a dilation and curettage procedure be performed?
Incomplete miscarriage
Retained placenta after delivery
Elective abortion
184
What is a complication of dilatation and curettage?
Asherman's Syndrome
185
What are the investigations for Asherman's Syndrome?
Hysterscopy
USS
Hysterosalpingogram (HSG) + dye
186
What is the management of Asherman's Syndrome?
Operative hysterscopy + Abx to prevent infection + oestrogen (improve quality of uterine lining)
187
Define gestational hypertension
New high BP >20w gestation and resolves after giving birth
**There is no proteinuria**
188
What is Pre-Eclampsia?
New hypertension 20 weeks post-gestation + proteinuria (>0.3g protein/24h) +/- oedema
189
What is the pathophysiology of pre-eclampsia?
Abnormal placenta spiral arteries increase vascular resistance
190
Describe the two stages of pre-eclampsia
Stage 1: incomplete trophoblastic invasion of spiral arterioles → decreased uteroplacental blood flow
Stage 2 : Ischaemic placenta induces endothelial cell damage → vaso-constriction, clotting dysfunction and increased vascular permeability
191
How is mild pre-eclampsia defined?
140/90-149/99 mmHg
192
How is moderate pre-eclampsia defined?
150/100-159/109 mmHg
193
How is severe pre-eclampsia defined?
>160/110 mmHg
194
What may happen to the foetus in severe pre-eclampsia?
Neurological damage due to hypoxia
195
What are the moderate risk factors of pre-eclampsia?
- 10 years since last pregnancy
- 1st pregnancy
- Aged >40yrs
- BMI >25
- FHx
196
What are the high risk factors in pre-eclampsia?
- Hx Pre-eclampsia/HTN
- CKD
- Autoimmune disease (SLE or antiphospholipid syndrome)
- DM 1/2
197
What is the Clinical Presentation of Pre-eclampsia?
New hypertension 140/90
Late signs:
- Severe headache
- Visual disturbances
- Swelling of face/hands/feet
- Liver tenderness/RUQ pain
- Vomiting
- Ankle clonus and brisk reflexes
HELLP syndrome
198
How is pre-eclampsia diagnosed?
>140/90 mmHg
**+ 1 of:**
1) Proteinuria:
- ≥1+ urine dipstick
- Urine protein:creatinine ratio (>30mg/mmol)
- Urine albumin:creatinine ratio (>8mg/mmol)
- No proteinuria= gestational hypertension
2) Organ dysfunction:
- LFT
- FBC
- Urine: MCS
3) Placental dysfunction:
- Foetal growth restriction
- Abnormal doppler
199
Why would you do a urine culture in pre-eclampsia?
Excludes infection
200
Why would you do an US of the foetus in pre-eclampsia?
Checks:
- Foetal growth
- Volume of amniotic fluid
- Doppler velocimetry of umbilical arteries
201
What treatment can be given to women with gestational hypertension/pre-eclampsia?
- Monitor BP 4x/day
- Blood tests 2x/week
- If not at term: labetelol (BB) to lower BP (>135/85 mmHg)
- If no response, delivering the baby will normalise BP
- Aspirin 75 mg OD (from 12 weeks gestation)
- LMWH: to prevent VTE
202
What antihypertensives should be avoided in pre-eclampsia?
ACE inhibitors
Angiotensin-II receptor antagonists
203
What further monitoring should be done for pre-eclampsia?
USS: of foetus and amniotic fluid
CTG
Delivery once woman is stable and baby >34 weeks
204
What are 4 maternal complications of pre-eclampsia?
Cerebrovascular haemorrhage
HELLP syndrome
Liver/renal failure
Pulmonary oedema
205
What are 3 foetal complications of pre-eclampsia?
IUGR
Placental abruption
Preterm birth
206
Define Eclampsia
Pre-eclampsia (gestational hypertension + proteinuria) and generalised tonic-clonic seizures
207
Why does Eclampsia occur?
Failure to notice worsening pre-eclampsia
208
When does Eclampsia occur during pregnancy?
Antepartum
Intrapartum
Postpartum
209
What is the management of eclampsia?
Seizures: Magnesium sulphate
BP: IV Labetolol, nifidepine + Epidural analgesia during Labour
Deliver baby
210
Why is Magnesium sulphate used in Eclampsia?
- Surpresses convulsions and inhibits muscular activity
- Reduces DIC risk by reducing platelet aggregation
211
What should be monitored if using magnesium sulphate?
Magnesium levels: reduces reflexes and causes respiratory depression
212
What is HELLP Syndrome?
Complication of pre-eclampsia/eclampsia at 27-37 weeks gestation
213
What is the acronym of HELLP Syndrome?
- **H**aemolysis (anaemia)
- **E**levated **L**iver Enzymes (ALT and AST) (blockage by fibrin)
- **L**ow **P**latelet Count (from consumption)
214
What are the risk factors for HELLP Syndrome?
Aged >35
Nulliparity
Hx
Renal Disease/ DM
Afro-carib
Obese
HTN
215
What do 10.5% of HELLP syndrome patients have?
Antiphospholipid syndrome
216
When do the majority of HELLP patients present?
27-37 weeks
217
In HELLP Syndrome, when do symptoms get:
Worse?
Better?
Worse: at night
Better: during the day
218
What is the clinical presentation of HELLP Syndrome?
**RUQ/mid-epigastric pain**
Flu-like
Headache
Visual symptoms
Bruising/purpura
Oedema
Jaundice
219
How is HELLP Syndrome diagnosed?
- **May not have hypertension or proteinuria**
- Blood film: schistocytes + haemolysis
- FBC: anaemia + low platelets
- Raised LDH + bilirubin
- Raised LFTs
220
Why are fragmented red cells seen on HELLP Syndrome blood films?
Microangiopathic haemolytic anaemia
221
How is HELLP Syndrome managed?
- IV magnesium sulfate
- IV dexamethasone (foetal lung development)
- BP control
- Blood transfusion
- Deliver foetus
222
What is Intrauterine Growth Retardation (IUGR)?
Baby’s growth slows/ceases within the uterus
223
What are the causes of Intrauterine Growth Retardation (IUGR)?
- Maternal factors
- Placental factors
- Foetal factors
- Genetic factors
224
What are risk factors for Intrauterine Growth Retardation (IUGR)?
SHITS CRAP:
Smoking
Hypertension
IUGR previously
Twins
Still birth
Cocaine
Renal disease
Antiphospholipid syndrome
PAPP-A levels low
225
What is symmetrical Intrauterine Growth Retardation (IUGR)?
Cause of early IUGR:
Antenatally: small head circumference, abdominal circumference and length
Postnatally: small head circumference, weight and length
226
What is asymmetrical Intrauterine Growth Retardation (IUGR)?
Cause of late IUGR:
Antenatally: small abdominal circumference, but NORMAL head circumference and length
Postnatally: small weight, but NORMAL length and head circumference
227
What adult onset diseases will IUGR babies be more susceptible to?
- Metabolic syndrome
- CHD
228
How is Intrauterine Growth Retardation (IUGR) investigated?
- Foetal abdominal circumference or estimated foetal weight <10th centile
- Reduced Amniotic Fluid Index (AFI)
229
What causes reduced Amniotic Fluid Index (AFI) in IUGR?
1) Reduced O2 to baby → blood away from organs e.g. kidneys
2) Reduced urine output and smaller amniotic fluid volume
230
How is Intrauterine Growth Retardation (IUGR) managed?
Lower segment Caesarean section (LSCS)
Corticosterioids: lung development up to 35+6 weeks
231
List 4 complications of symmetrical Intrauterine Growth Retardation (IUGR)
- Learning difficulties
- Developmental delay
- ADHD
- Cerebral Palsy
232
What is Sepsis?
Infection in the bloodstream + systemic symptoms
233
What is Severe Sepsis?
Sepsis + organ dysfunction + tissue hypo-perfusion
234
What is Septic shock?
Hypotension + hyperlactaemia + tissue hypo-perfusion despite adequate fluid replacement
235
What are 9 causes of sepsis?
- Pyelonephritis
- Chorioamnionitis
- Postpartum endometritis
- Wound infection
- Pneumonia
- Acute appendicitis
- Acute cholecystitis
- Pancreatitis
- Necrotising enterocolitis
236
What are 10 risk factors for sepsis?
- Obesity
- Diabetes
- Immunosuppressed
- Anaemia
- Vaginal discharge
- Hx PID
- Hx Group B Strep infection
- Amniocentesis
- Prolonged spontaneous rupture of membranes
- Group A strep infection
237
What is the Clinical Presentation of Sepsis?
- Fever, rigors, diarrhoea and vomiting
- Non-blanching rash (meningococcal septicaemia via Neisseria meningitidis)
- Abdominal + pelvic pain
- Hypoxia
- Hypotension
- Oliguria
- Impaired GCS
- Failure to respond to treatment
238
Why does meningococcal septicaemia cause non-blanching rashes?
Meningococci release endotoxins into blood → WBCs attracted → endothelial lining damage → capillary leakage → haemorrhagic rash
239
What criteria is used to identify severe sepsis?
Systemic Inflammatory Response Syndrome (SIRS) Criteria
240
Describe the SIRS Criteria
3Ts White with Sugar: ≥2 points = SIRS = Severe Sepsis
Temperature >38° or <36°
Tachycardia >90bpm
Tachypnoea >20bpm
WBC <4 or >12
Sugar >7.7mmol/L: in absence of diabetes
241
What investigations would you order for Sepsis?
- **FBC:** raised WCC
- **CRP:** raised
- **U&Es:** AKI common
- ABG: raised **Lactate** (2° to reduced end-organ perfusion → no oxygen to use glucose → anaerobic respiration)
- **Blood cultures:** identifies ****causative organism
- Urine output: reduced
242
What is the management of Sepsis?
Blood cultures BEFORE Abx (Broad spec IV):
- Mother: piperacillin + tazobactam
- <3m= Cefotaxime + Amoxicillin + Aciclovir
Fluid resuscitation
Oxygen (94-98%)
Intubation and ventilation
Consider delivery
VTE prophylaxis
243
What is Chorioamnionitis?
Membrane rupture → acute inflammation of amnion and chorion membranes due to an ascending bacterial infection
244
What is the most common cause of Chorioamnionitis?
Group B streptococcus (GBS)
245
What is the clinical presentation of Chorioamnionitis?
- Maternal signs (pyrexia, tachycardia, leucocytosis)
- Foul amniotic fluid
- Maternal/foetal tachycardia
- Uterine tenderness
- ROM
246
What is the management of Chorioamnionitis?
C-section delivery
IV benzyl Penicillin
247
Why must Chrorioaminonitis be treated?
To prevent Neonatal sepsis
248
What are the complications of maternal Group B Step infections?
Chrorioaminonitis → neonatal sepsis
249
If a patient is isolated during labour, what should be given to prevent vertical Group B Step transmission to baby?
IV benzyl Penicillin
250
Define Premature Birth
Presence of contractions of sufficient strength and frequency to effect progressive effacement and dilation of the cervix <37 weeks gestation
251
When would a premature birth be considered non-viable?
<23 weeks
252
What organs are most likely to be affected in babies born prematurely and why?
Lungs and brain develop in the 3rd trimester
253
What is a very low birth weight?
<1500g
254
What is a extremely low birth weight?
<1000g
255
What is an incredibly low birth weight?
<750g
256
What are the risk factors for Premature Birth?
Unexplained
Multiple pregnancy
Cervical incompetence (e.g. surgery)
Hx
Premature rupture of membranes (PROM)
257
What is the Clinical presentation of Premature Birth?
- Contractions
- Bleeding
- Amniotic fluid loss
- Dilation of cervix
258
What are the investigations for Premature Birth?
Speculum examination: pooling of amniotic fluid in vagina
TVUS: cervical length
Fetal fibronectin: >50 ng/ml (indicates labour)
Insulin-like growth factor-binding protein-1 (IGFBP-1) or Placental alpha-microglobin-1 (PAMG-1): reveals ROM
Vaginal swab
259
What is the management of Preterm Labour with Intact Membranes?
Fetal monitoring (CTG or intermittent auscultation)
Tocolysis: nifedipine (<48hr usage)
Maternal corticosteroids: <36 weeks gestation
IV magnesium sulphate: <34 weeks gestation a
Delayed cord clamping
Delivery
260
What is the management of Preterm Prelabour Rupture of Membranes?
Prophylactic abx: erythromycin 250mg TD for ten days/until delivery (prevents chorioamnionitis)
Induction of labour: >34 weeks gestation
261
What is Tocolysis?
Give 3 examples
Drugs that delay delivery for up to 48 hours
Work by suppressing contractions
Prostaglandin synthesis inhibitors: Indomethacin
CCBs: Nifedipine
Oxytocin antagonist: Atosiban
262
How does nifedipine inhibit premature contractions?
Nifedipine is a CCB → muscle contraction inhibition
263
Why are corticosteroids used in premature birth?
Give two examples
Surfactant production for foetal lung maturity
Betamethasone
Dexamethasone
264
Why is magnesium sulfate used in premature births?
Neuroprotection: reduces risk of cerebral palsy
265
What is premature rupture of membranes (PROM)?
Rupture of membrane <37 weeks gestation
266
What are the risks of PROM?
Infection
>24 hours = chorioamnionitis + endometriosis
Spontaneous labour
267
What is the prognosis for mid-trimester PROM (<24 weeks)?
Poor outcome: pulmonary hypoplasia even after steroids
268
What is the treatment for PROM 24-34 weeks gestation?
Maternal Steroids: Dexamethasone
Erythromycin
MgSO4
Daily review for signs of infection
269
What is the treatment for PROM >34 weeks gestation?
MgSO4
Induce labour
270
What is antepartum haemorrhage?
Bleeding from the birth canal >24 weeks gestation (before is a miscarriage)
271
What are the causes of antepartum haemorrhage?
Majority idiopathic
Placenta praevia
Placental abruption
Vasa praevia
272
What percentage of very preterm babies are born in association with APH?
20%
273
What is the clinical presentation of antepartum haemorrhage?
- Bleeding +/- pain
- Uterine contractions
- Malpresentation or engagement failure
- Foetal distress
- Hypovolaemic shock
274
What are the investigations of antepartum haemorrhage?
US: Exclude placenta praevia
275
What is the management of antepartum haemorrhage?
Anti-D
Replacement fluids/blood
IV access
CTG
Delivery may save mothers life
276
What is placental abruption?
Premature seperation of placenta from the uterine wall
Significant cause of third-trimester bleeding + foetal and maternal morbidity and mortality
277
What are causes of placental abruption?
- Maternal hypertension (common)
- Maternal trauma
- Smoking
- Alcohol
- Drugs
- Short umbilical cord
- Decompression of the uterus
278
What is the clinical presentation of placental abruption?
- Abdominal examination: ‘woody-hard’ and tense uterus
- Sudden continuous abdo pain
- DARK red vaginal bleeding
- Uterine contractions
- Foetal distress
279
What is meant by a woody uterus in placental abruption?
'Hard' uterus due to blood invading myometrium
280
How is placental abruption diagnosed?
Clinically
281
What is the management of placental abruption?
Emergency!
- Induction of labour
- C-Section: if foetus in distress, vaginal if not
- Crossmatch 4 units of blood
- Fluid and blood resuscitation
- CTG monitoring of the fetus and mother
- Anti-D prophylaxis: in Rhesus-D - women
282
Where should normal placenta invade into?
The decidua
283
What is placenta praevia?
Placenta is inserted wholly/partly into the lower segment of the uterus
284
What are the risk factors for placenta praevia?
- Hx placenta praevia/ C-section / abortion
- Increased maternal age/parity
- Smoking
- Cocaine
- Deficient endometrium
- Assisted conception
285
What is the pathophysiology of placenta praevia:
Major?
Minor?
Major: placenta covers the entire internal cervical os (grade 3/4)
Minor/Partial: leading edge is in the lower segment, but not covering the os (grade 1/2)
286
What is a low-lying placenta?
Placenta is within 20mm of the internal cervical os
287
What is the clinical Presentation of placenta praevia?
Normally asymptomatic
Painless bleeding >28 weeks gestation
BRIGHT RED BLEEDING
High presenting part or abnormal lie
288
What are the complications of Placenta Praevia?
PPH
Placenta accreta or percreta
289
Would a woman with a LLP complain of pain?
No, LLP is classically painless
290
When might placenta abnormalities be detected?
On the 20w US anomaly scan
Placenta must be >25mm from the cervical os
291
How should a LLP be managed?
- Advise mum on the symptoms to look out for
- Seek early advice.
- If recurrent bleeds: admit until delivery
- Elective c-section at 38 weeks
292
What is the difference in blood between placenta abruption and praevia?
Abruption: dark red
Praevia: bright red
293
What is Placenta Accreta?
Placenta implants on the surface of the myometrium
294
What is Placenta Increta?
Placenta attaches deeply into the myometrium
295
What is Placenta Percreta?
Placenta invades past the myometrium and perimetrium → other organs e.g. bladder
296
What is Vasa Praevia?
Foetal vessels within the foetal membranes run across the internal cervical os
Risk of rupture: unsupported by the umbilical cord or placental tissue
297
How to prepare for delivery with Placenta praevia, Placenta accreta and Vasa Praevia?
Elective LSCS 36-38 weeks
Consent to include all potential interventions e.g.
hysterectomy
Anticipate major obstetric haemorrhage
Crossmatch + Groupsave + Cell salvage
Corticosteroids: due to preterm risk
298
Define puerperium
Period between placental delivery → 6w post-delivery
299
What is postpartum haemorrhage (PPH)?
Bleeding after delivery of the baby and placenta
300
What is the most common cause of obstetric haemorrhage?
PPH
301
What is a primary postpartum haemorrhage (PPH)?
>500mls vaginal bleeding in the first 24 hours post-delivery
302
What is a secondary postpartum haemorrhage (PPH)?
>500ml vaginal blood loss between 24 hours→ 6w post-delivery
303
What is minor postpartum haemorrhage (PPH)?
500-1500ml vaginal blood loss + no signs of shock
304
What is major postpartum haemorrhage (PPH)?
≥1500mls vaginal bleeding + continuing to bleed OR clinical shock
305
What are the causes of postpartum haemorrhage (PPH)?
4 Ts:
Tone: atonic uterus (Is the uterus contracted?)
Tissue: retained placenta with prolonged 3rd stage (Is the placenta complete?)
Trauma: tears and repairs
Thrombin: pre-eclampsia/DIC (check clotting)
306
What are the risk factors for postpartum haemorrhage (PPH)?
Hx
>40yrs
Multiple pregnancy
Polyhydramnios
Abruption or Placenta praevia
Pre-eclampsia/gestational hypertension
BMI >35
Pre-existing anaemia
Operative Delivery (LSCS or instrumental)
Induction of labour
Retained placenta
Big baby
Pyrexia in labour
Prolonged labour
Fibroids
307
What is the conservative, medical and surgical management of postpartum haemorrhage (PPH)?
ABCDE
Fluid Resus
O2
Rubbing the uterus through abdominal: stimulates uterine contractions
IM Oxytocin = given with delivery of anterior shoulder
IM Ergometrine: if significant RFs (+ no HTN)
Catheterisation: give birth with empty bladder to increase uterine contraction
IM Carboprost: prostaglandin analogue stimulates uterine contraction (Consider theatre if > 2 doses required)
Misoprostol: prostaglandin analogue
IV Tranexamic acid: antifibrinolytic reduces bleeding during CS
Surgical:
Evacuation of retained products
Bi-manual uterine compression: expels clots
Balloon tamponade
B-lynch suture
Consider hysterectomy
308
When must you never give Ergometrine in PPH?
if the patient has hypertension (vasoconstrictor)
309
What are the seven cardinal movements of labour?
EDFIEEE
- Engagement
- Descent
- Flexion
- Internal rotation
- Extension
- External rotation/ restitution
- Expulsion
310
Describe Engagement
Biparietal diameter (top of baby's head) in pelvic inlet
311
Describe Descent
Baby's head deep into the pelvic cavity (Lightening)
312
Describe Flexion
Smallest diameter of the baby's head presents into the pelvis due to tissue resistance
313
Describe Internal Rotation
Head rotates to accomodate the changes of pelvic diameter
Sideways → facing back of the mother (back of head against the front of the pelvis)
314
Describe Extension
As head is born
315
Describe External Rotation
- Slight pause in labour after the baby's head is born
- Babies head rotates face down → mothers inner thigh
316
Describe Expulsion
From symphysis pubis the following moves out:
Anterior shoulder → posterior shoulder→ rest of the body
317
What is the largest diameter of the pelvic outlet?
Front to back
318
Why is external rotation necessary?
So shoulders can fit
319
What happens if external rotation is not successful?
Shoulder Dystocia
320
What is shoulder dystocia?
Inadequate space for shoulders to pass pubic symphysis during external rotation (after head passes)
Usually the anterior shoulder
321
What are the causes of shoulder dystocia?
3 Ps:
Power (uterus)
Passenger (foetus)
Passage (pelvis)
322
What are power causes of shoulder dystocia?
Uncoordinated uterine activity/short infrequent contractions
323
What are pasenger causes of shoulder dystocia?
- Position or lie
- Macrosomia (>4.5kg)
- Large abdominal circumference: head circumference
324
What are passage causes of shoulder dystocia?
- Long and oval brim
- Cephalopelvic disproportion: e.g. due to scoliosis, kyphosis or rickets
325
What is the main risk factors for shoulder dystocia?
- **Gestational diabetes** → macrosomia
326
What is the clinical presentation of shoulder dystocia?
- Difficulty delivering the face
- Head remaining tightly applied to the vulva or retracting: 'Turtle-neck Sign'
- Failure of head to restitute
- Failure of shoulders to descend
327
What is the management of of shoulder dystocia?
HELPERR:
Call for **H**elp.
**E**valuate for Episiotomy: to allow Wood's screw manoeuvre
**L**egs in McRoberts Manoeuvre (alters symphysis pubis)
Suprapubic **P**ressure
**E**nter pelvis
**R**otational manoeuvres
**R**emove posterior arm
Stop pushing
Last resorts:
Symphisiotomy
Zavanelli manouvere (push baby back in→ CS)
328
What are the complications of shoulder dystocia?
Fetal hypoxia (→ cerebral palsy)
Brachial plexus injury and Erb’s palsy
Perineal tears
Postpartum haemorrhage
329
What is cord prolapse?
Umbilical cord descends cervix after membrane rupture
Foetal hypoxia due to cord compression
330
What is the main risk factor for cord prolapse?
Breech presentation
331
How can cord prolapse be diagnosed?
CTG: foetal distress CTG
Vaginal examination
Speculum examination
332
What is the management of cord prolapse?
Tocolytics: terbutaline (reduce contractions)
DO NOT PUSH CORD BACK IN: handling causes vasospasms
Cord kept warm and wet
Patient on all 4s
CS
333
Give a consequence of cord prolapse
Foetal hypoxia → morbidity and mortality
334
What is Amniotic Fluid embolism?
When the liquor enters maternal circulation leading to anaphylaxis:
- Sudden dyspnoea
- Hypoxia
- Hypotension
335
What are the dangers of amniotic fluid embolism?
80% mortality:
Membrane rupture → seizures and cardiac arrest
336
Management of amniotic fluid embolism
Emergency management!
337
What is uterine rupture?
Myometrium ruptures
338
What is the major risk of uterine rupture?
Hx CS: wound dehiscence
339
What is the clinical presentation of uterine rupture?
RUPTURE USUALLY IN LABOUR
**Ceasing of uterine contractions**
- Abdominal pain
- Foetal distress
- Vaginal bleeding
- Maternal shock
340
What is the management of uterine rupture?
Resuscitation
Transfusion
Emergency CS
Hysterectomy
341
What is gestational diabetes?
Diabetes triggered by pregnancy
342
What is the pathophysiology of gestational diabetes?
1) Increased resistance to insulin due to the placental production of anti-insulin hormones
2) If maternal pancreas cannot increase insulin production to combat = GM
343
Why does gestational diabetes cause macrosomia?
1) Excess glucose → excess glucose to foetus
2) Increased foetal insulin → more tissue/fatty deposits
344
Why does gestational diabetes cause neonatal hypoglycaemia?
Increased foetal insulin → lower glucose intake after birth compared to intra-uterine
345
Why does gestational diabetes cause Polyhydramnios?
Increase in foetal glucose → polyuria → more fluid release from the foetus
346
Name 3 anti-insulin hormones produced by the placenta in gestational diabetes
- Human placental lactogen (hPL)
- Glucagon
- Cortisol
347
What are the risk factors for gestational diabetes?
HX of GM
Hx of macrosomic baby (≥ 4.5kg)
BMI > 30
Ethnic origin (black Caribbean, Middle Eastern and South Asian)
FHx of DM
348
What is the clinical presentation of gestational diabetes?
Mainly during 3rd trimester
DM presentation +:
- Pre-eclampsia
- Macrosomia
- Recurrent infections
- Intrauterine death
- Polyhydramnios
349
What are the complications of gestational diabetes?
SMASH:
Shoulder dystocia
Macrosomia
Amniotic fluid excess (polyhydramnios)
Stillbirth
Hypertension + neonatal hypoglycaemia
350
What is the diagnosis of gestational diabetes?
OGTT at 24-28 weeks
5,6,7,8 RULE:
- Fasting: >5.6
- 2 hours: >7.8
351
What is the management of gestational diabetes?
**Lifestyle:**
- BMI <27
- Low glycaemic index diet
- 30 min physical activity/day
Metformin (1st line)
Insulin (2nd line)
Deliver at TERM: CS if macrosomia/pre-eclampsia
352
List 5 peripartum events that can lead to chronic infections
- Prolonged ROM
- Chorioamnionitis
- Repeated vaginal exams
- Catheterisation
- Instrumental deliveries/C-sectionn
353
What 10 drugs should be avoided during breastfeeding?
Ciprofloxacin
Tetraycline
Aspirin
Lithium
Fluoxetine
Benzodiazepines
Carbimazole
Methotrexate
Sulphonyureas
Amiodarone
354
Give 3 red flag signs that a mother may be developing mental health problems postnatally
- Recent change in mental state
- Thoughts/acts of self harm
- Estrangement from the infant
355
Name the 4 types of postnatal mental illness
- Baby blues
- Postnatal depression
- Puerperal psychosis
- PTSD following childbirth
356
What is post-natal depression?
Low mood post-nataly
Normally 3 months post-natal and lasts >2 weeks
357
What are the risk factors for post-natal depression?
- Mental health hx
- Alcohol and drugs
- Traumatic experience
- Social isolation
- Domestic/childhood maltreatment
- Socioeconomic status
358
What is the classic presentation of post-natal depression?
Low mood
Anhedonia (lack of pleasure in activities)
Low energy
Unable to cope
Feeling of guilt about not loving baby enough
Difficulty bonding with baby/ poor relationships with family
Tearful
Poor sleep
Poor appetite
359
What is the treatment of post-natal depression?
SSRIs (Sertraline/paroxetine)
CBT
Reassurance and support
360
How long should baby blues last?
2 week
361
What is the clinical presentation of baby blues?
Mood swings
Low mood
Anxiety
Irritability
Tearfulness
362
Does baby blues require treatment?
No, the majority of mothers experience this
363
What is puerperal psychosis?
Psychosis 2-3 weeks post-nataly
364
What is the clinical presentation of puerperal psychosis?
Delusions
Hallucinations
Depression
Mania
Confusion
Thought disorder
365
What is the management of puerperal psychosis?
Hospital admission:mother and baby unit
CBT
Medications: antidepressants, antipsychotics or mood stabilisers
Electroconvulsive therapy (ECT)
366
Name 3 neonatal screening programmes
1. New born blood spot: days 5-8
2. Hearing test: within 4 weeks
3. New born (within 72 hours) and GP 6-8w physical examination
367
When would a woman have her booking appointment?
8-10 weeks
368
What is performed in the 8-10 week booking scan?
Determine location, viability and dating pregnancy
General lifestyle advice
Obstetric history and examination
Check: HIV, Hep.B, Syphillis and Rubella
369
What is tested in the 11-13 week dating scan?
Gestational age
Crown-rump length
Risk factors for: pre-eclampsia/GDM
Proteinuria/bacteriuria
370
What is the combined test in antenatal screening?
Screens congenital anomalies (11-14 weeks):
- PAPP-A
- bHCG
- Nuchal Translucency (fluid collection in back of neck suggests chromosomal disorder)
- Mothers age
371
What is the quadruple test in antenatal screening?
Screens for Down's syndrome (14-20 weeks):
- bHCG
- AFP
- Inhibin A
- Unconjugated oestradiol
372
When should a foetal anomaly screening test be done?
Blood sample: by 14+1 weeks.
Anomaly scan: by 18-20+6 weeks.
373
What diseases are screened in the foetal anomaly screening test?
1. Down’s (T21)
2. Edward’s (T18)
3. Patau’s (T13)
374
What is Non-invasive prenatal testing?
Tests for T21, T13 and T18
Only be done in private sector: analyses fragments of fetal DNA in maternal blood
375
What is done in the 20 week anomaly scan?
- Detailed US
- Plan delivery
- Identify major abnormalities
376
What 9 conditions are part of the new-born blood spot in the neonatal screening programme?
1) CF
2) Hypothyroidism
3) Sickle cell
INHERITED METABOLIC DISEASES
1) Phenylketouria (PKU)
2) Medium chain acyl-coA dehydrogenase deficiency (MCADD)
3) Maple syrup urine disease (MSUD)
4) Isovaleric acidaemia (IVA)
5) Glutaric aciduria tye 1 (GA1)
6) Hymocystinuria (HCU)
377
Name 4 things that a new born physical examination is looking for in the neonatal screening programme
1. Eye problems
2. Heart defects
3. Dysplasia of the hips
4. Undescended testes
378
Give 2 methods to monitor foetal heart rate
1. Intermittent auscultation: via pinard stethoscope or a hand held doppler
2. Continuous monitoring: cardiotocography (CTG)
379
What is the gold standard method for direct FHR monitoring?
Scalp ECG
380
How do you define a normal CTG? (BraVAD)
1. Baseline HR: 110-160 bpm
2. Variability: >5
3. Accelerations: present
4. Decelerations: none
381
What mnemonic is helpful for interpreting CTGs and determining the need for CS?
DR C BRAVADO
DR- Define risk: why are they having it? (e.g pre-eclampsia)
Contractions: 5/10 mins
BRA-Baseline rate: 110-160bpm
V- Baseline variability:
- Normal = 5-25 bpm
- Reduced = <5bpm
Accelerations:
- Rise by 15 beats for >15s
- 2 separate accelerations every 15 min
Decelerations :
- Reduction of 15 beats for at least 15 seconds
- Late decelerations = slow recovery hypoxia
Overall Impression:
- Terminal Bradycardia = <100bpm for >10 mins
- Terminal Deceleration = HR drops and does not recover for >3 min
382
What are causes of Oligohydramnios?
PROM
Fetal renal problems e.g. renal agenesis
IUGR
Pre-eclampsia
383
What is colour should Meconium be?
Green/brown
383
What does meconium stained amniotic fluid
(MSAF) indicate?
Foetal distress from hypoxia → passing meconium whilst still inside the uterus
384
What can meconium stained amniotic fluid
(MSAF) lead to?
Meconium aspiration syndrome: baby inhales the meconium → Respiratory Distress
385
How is MSAF treated?
Surfactant/inhaled nitric oxide
386
Define maternal death
The death of a woman while pregnant or within 42 days of pregnancy termination
Not due to accidental causes
387
What are the 3 most common causes of maternal death?
1. VTE
2. Haemorrhage
3. Pre-eclampsia
388
Name 3 foetal emergencies
1. Foetal distress
2. Cord prolapse
3. Shoulder dystocia
