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Vascular Surgery > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

What is a miscarriage?

A

The spontaneous termination of pregnancy; early is before < 12 weeks and late is 12 to 24 weeks

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2
Q

Different classifications of miscarriage?

A

Missed - no symptoms but the foetus is dead
Threatened - vaginal bleeding, cervix closed and foetus alive
Inevitable - vaginal bleeding with an open cervix
Incomplete - retained products of conception
Complete - full miscarriage
Aembryonic - no embryo, just gestational sac

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3
Q

Investigation for miscarriage

A

TVUS
1) Foetal HR?
2) Crown-rump length of 7mm?
3) Gestational sac of 25 mm diameter and foetal pole

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4
Q

Management of miscarriage

A

Less than 6 weeks - expectant
More than 6 weeks - expectant, medical (misoprostol) or SMM

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5
Q

Types of SMM

A

Manual vacuum aspiration - LA, syringe to aspirate, must be below 10 weeks. Better in parous women

Electric vacuum aspiration - GA

Rhesus D proph to rhesus negative women

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6
Q

Incomplete miscarriage management

A

Medical - misoprostol
Surgical - ERPC (evacuation of retained products of conception)

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7
Q

When to be concerned about miscarriages?

A

Infection or heavy bleeding

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8
Q

Define recurrent miscarriages

A

3 x first trimester
1 x second trimester

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9
Q

Causes of recurrent miscarriages

A

Idiopathic
Haematological (APLS and inherited thrombophilias)
Structural (fibroid, cervical insufficiency, congenital)
Genetics - balanced translocations
Chronic diseases - DM, thyroid, SLE
Other - chronic histiocytic intervillositis

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10
Q

Management of recurrent miscarriages

A

Referral to specialist

Pelvic US
Blood tests - APLS and hereditary thrombophilia
Genetics - of conception products and parents

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11
Q

Presentation of ectopic

A

Abdo/pelvic pain
Missed period
Bleeding
Cervical excitation
Dizziness and shoulder tip pain

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12
Q

Investigation for ectopic

A

TVUS - bagel sign

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13
Q

Management of ectopic pregnancy

A

Expectant - if unruptured, less than 35 mm, hCG < 1500, no HB or significant pain

Medical with methotrexate - same as above but hCG less than 5000

Surgical - laparoscopic salpingectomy or salpingotomy, with rhesus D proph is rhesus negative

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14
Q

Timeline of sickness in pregnancy

A

Starts at 4-7 weeks, peaks at 10 to 12 weeks and settles at 16-20 weeks

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15
Q

Definition of hyperemesis gravidarum

A

Protracted N&V plus 5% loss of body weight, dehydration an electrolyte imbalance

Can use PUQE score to quantify

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16
Q

Management

A

Obs, ketones, can they keep stuff down, weight

Cyclizine, prochlorperazine or metoclopramide, in that order

Think about reflux as an issue

Ginger and acupuncture

Depending on severity admission may be indicated for IV fluids, electrolyte correction, observation, IV antiemetics, thiamine and VTE proph

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17
Q

What is a hydatidiform mole?

A

A molar pregnancy is a tumour that grows like a pregnancy in the uterus

Two types: a complete and partial mole

Complete - no foetal material; two sperm fertalise and empy egg

Partial - some foetal material; two sperms fertilise an eg

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18
Q

Presentation of a molar pregnancy

A

Increased N&V
Vaginal bleeding
Abnormally large uterus
Abnormally high hCG
Thyrotoxicosis - hCG mimics TSH

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19
Q

Investigation for molar pregnancy

A

TVUS - snowstorm appearance

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20
Q

Management of molar pregnancy

A

Refer to gestational trophoblastic disease centre

Evacuation and follow-up

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21
Q

Anaemia in pregnancy

A

Screen at booking and 28 weeks, 110 and 105 respectively

Micro - give iron
Macro - give folate/B12

Remember pregnancy is a high volume, low pressure physiology and so there will be a dilutional anaemia to some degree

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22
Q

Pre-existing diabetes in pregnancy

A

5 mg of folate
Diet, metformin and insulin only
Opthalmology review shortly after booking and at 28 weeks
Planned delivery between 37 and 38+6
Sliding scale during labour if type 1

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23
Q

Gestational diabetes RFs

A

Had it previously, big baby, BMI over 30, ethnic origin and family hx of diabetes

They get OGTT at 24- 28 weeks, previous gestational diabetes also get one soon after booking

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24
Q

OGTT results and actions

A

Fasted, then give 75g of glucose
Fast - 5.6 upper limit
After 2 hours - 7.8 upper limit

fasted < 7 - a 1-2 week trial of exercise and diet
fasted >7 - inulin +/- metformin
if > 6 but big baby then start treatment anyway

Targets of 5.3 fasted, 7.8 an hours after meal and 6.4 two hours after

25
Q

Why is diabetes bad?

A

Babies:

  • big
  • neonatal hypoglycaemia
  • jaundice
  • CHD
  • cardiomyopathy

Mum:
- delivers bigger baby

26
Q

If already has HTN, which meds?

A
  • labetalol
  • nifedipine
  • methyldopa
  • aspirin from 12 wekks
27
Q

Management of gestation hypertension (> 20 weeks)

A
  • treat for 135/85
  • admit if 160/110
  • dipstick weekly
  • weekly blood tests
  • serial growth scans
  • PlGF at least once
  • aspirin from 12 weeks if 1 x HRF or 2 x MRF
28
Q

Management of pre-eclampsia

A

Largely the same as gestation HTN except for weekly dipsticks not needed as a diagnosis was made, BP every 48 hours and two weekly scans

29
Q

Management of pre-eclampsia

A

Labetalol, nifedipine or methyldopa, with aspirin if needed

30
Q

Management of eclampsia

A

Magnesium sulphate

31
Q

Other considerations of pre-eclampsia

A

Planned delivery and corticosteroids?

32
Q

High RFs for pre-eclampsia

A
  • pre-existing HTN
  • previous NTH in pregnancy
  • autoimmune disorders
  • diabetes
  • CKD
33
Q

Moderate RFs for pre-eclampsia

A
  • age of 40
  • BMI over 30
  • 10 years since last pregnancy
  • multiple pregnancy
  • first pregnancy
  • FHx of pre-eclmapisa
34
Q

Presentation of pre-eclampsia

A
  • N&V
  • headache
  • visual disturbances
  • abdominal pain
  • oedema
  • reduced urine output
  • brisk reflexes
35
Q

Diagnosis pre-eclampsia

A

HTN plus organ dysfunction either on dipstick, blood tests or placental scans

36
Q

Complications of pre-eclampsia

A

HELPP (haemolysis, elevated liver enzymes and low platelets)

37
Q

UTI in pregnancy

A

Pregnant women are routinely tested for UTI and symptomatic bacteremia

  • nitrofurantoin (not in the third trimester)
  • amoxicillin (need sensitivities)
  • cefalexin

Can lead to premature birth

38
Q

Medication for women with epilepsy

A

Lamotrigine and levetiracetam preferred, 5mg of folate

39
Q

Depression in pregnancy

A

Common, can still take medications but a discussion about risks vs benefits needs to be had

40
Q

Issues with obesity in pregnancy

A

Mum:
- thrombosis
- gestational diabetes
- HTN and pre-eclampsia
- increase likelihood of IoL, C-section, anaesthetic complications and wound infections

Baby:
- big baby
- NTD
- miscarriage and stillbirth

5mg dose of folic acid

41
Q

VZV in pregnancy

A
  • More severe in pregnant women leading to pneumonitis, hepatitis, encephalitis
  • Foetal varicella syndrome in unborn or severe infection if around delivery
  • If previous chickenpox then woman safe
  • Any doubt then IgG should be tested
  • If unprotected, then IV varicella IGs should be given within 10 days of exposure
  • If rash has developed, then give oral aciclovir if less than 24 hours and more than 20 weeks
42
Q

What is congenital varicella syndrome?

A

If infected in the first 28 weeks, can cause:

  • growth restriction
  • microcephaly, hydrocephalus and LD
  • scars and skin changes across dermatomes
  • limb hypoplasia
  • cataracts and chorioretinitis
43
Q

Syphilis during pregnancy

A
  • prem
  • stillbirth/miscarriage
  • small baby
  • issues with placenta and cord
44
Q

TORCH?

A
  • Toxoplasmosis

Tiad of intracranial calcification, hydrocephalus and chorioretinitis

  • Others - syphilis and hep B
  • Rubella

MMR during conception/after birth, live vaccine so not during pregnancy. Can cause deafness, cataracts, CHD and LD

  • CMV

FGR, microcephaly, vision loss, hearing loss, LD, seizures
- HSV (HIV and Zika sometime included)

45
Q

Define labour

A

process of uterine contractions and cervical dilation that enables the uterus to deliver a viable foetus (24 weeks), placenta and membranes. Diagnosed when there are regular and increasing painful uterine contraction brining about cervical dilation and/or effacement

46
Q

What is the first stage of labour?

A

Onset of regular and increasing painful contractions to full dilation of the cervix

Latent is fully effaced and 3cm dilated (6-8 hours first time and 4-6 hours after that) and active is to fully dilated (0.5cm/hr)

47
Q

Stage 2 of labour

A

From full dilation to delivery of foetus (hur first time, half an hour after that)

48
Q

Stage 3 of labour

A

From delivery of the foetus to delivery of placenta and membranes (15 mins or less with active management)

49
Q

Causes of slow labour?

A

Power, passenger or passage

50
Q

Active management of third stage

A

Syntometrine and controlled traction of cord

51
Q

Three key steps to a successful labour

A

Reassurance, hydration and analgesia

52
Q

Slow labour management

A

Oxytocin at 2- 4MU/min, then can increase by 2-4 MU if needed

Aiming for 4-5 contractions every 10 minutes lasting at least 40 seconds

Usually achieved at the 8-12 MU mark

Beware of hyperstimulation, uterine rupture and water intoxication (ADH effect)

53
Q

Process of labour

A

Enters occipito-trasnverse
Head flexion
Internal rotation
Extension
Restitution (external rotation)
Anterior shoulder then posterior shoulder

54
Q

Presentation of cord prolapse

A

Compression of the cord leads to foetal hypoxia, showing as foetal distress on the CTG

Can be palpated and seen on PV and speculum exam

55
Q

Management of cord prolapse

A
  • put the mother in the left lateral position or knee-chest position
  • keep cord wet and warm (saline and gauze) with minimal handling
  • push presenting part of the head back
  • organise emergency caesarian
  • tocolytic agents
56
Q

Biggest RF for cord prolapse

A

Abnormal lie

57
Q

Presentation of shoulder dystocia

A
  • struggle to deliver head
  • failure of restitution
  • turtle-neck sign
58
Q
A

Vascular Surgery (5 decks)

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