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Obs and Gynae > obstetrics > Flashcards

obstetrics Flashcards

1
Q

formula for calculating EDD

A

FIRST day of LMP minus 3 months plus 7 days if 28 day cycle. Add or subtract a day for each day longer/shorter the cycle is. Some obstetricians prefer to add 10 days

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2
Q

What proportion of women give birth within 5 and 10 days of their EDD?

A

40 within 5, 2/3 within 10

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3
Q

what is the average number of days from LMP to due date?

A

283 days

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4
Q

symptoms of pregnancy

A

nausea/vomitting, commonly within 2 weeks of missing period, frequency of micturation

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5
Q

what are the basic principles of CVS and amniocentesis?

A

amniocentesis; 15-17 weeks, 0.5-1% misscarraige, 2-5% won’t work, chromosome number by 3 days, karyotype 2-3 weeks, fine needle transabdo

CVS, slightly more risky 2% misscarriage, 10-12 weeks, not before as more risk, chromosome number by 3 days, karyotype 2-3 weeks, fine needle transabdo or transcervical

May detect other abnormalities eg CF, sickle cell, rhesus (will be given anti d injection),

Other risks, damage to placenta (usually repairs itself, fetal deformities in CVS (loss of digits, much lower after 10 weeks), club foot in amniocentesis (very low after 15 weeks), infection (about 1 in 1000). Very occasional detection of mosaicism in CVS meaning some placental cells affected some not, may require amniocentesis. CVS cannot detect neural tube defects, amnio and a blood test can

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6
Q

What routine screening is done on a first antenatal check

A

height, weight, BMI (less than 20 increased risk of fetal growth restriction and perinatal mortality, poor weight gain assoc with IUGR), bp, urine dip (proteinuria, haematuria, gycosuria)

Haematological for anaemia, blood group, rubella, syphilis

If risk factors, B-haemoglobinopathies, hep b, HIV

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7
Q

when is anaemia screened for during pregnancy,

A

first visit, 28 weeks and 36 weeks

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8
Q

what type of anaemia is more common during pregnancy, which others can occur?

A

Fe deficiency in 90% of cases, can be macrocytic due to folate deficiency/various parasitic infections

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9
Q

at what stage and in what incidences should patients be screened for diabetes?

A

28 week, 1st degree relative with diabetes, prev unexplained stillbirth, previous infant born >4kg, BMI >35, repeated glycosuria

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10
Q

What previous medical conditions need to be noted in an obstetric history?

A

Diabetes, cardiac disease, hypertension, renal, infectious disease (HIV/hepititis)

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11
Q

In diabetes screening, fasting blood glucose levels of less than ….mmol/l indicates no need to test further than this. If it is higher than this a gtt should be performed

A

4.5

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12
Q

What effects does smoking have on perinatal mortality/morbidity?

A

Reduces birthweight and crown heel length. Perinatal mortality increased 20% if smoking 20 a day and 35% in excess of this

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13
Q

What is the definition of pregnancy induced hypertension

A

Systolic at least 140 or diastolic at least 90 on 2 or more occasions after 20 weeks and before 24 hours postpartum. Can also be rise of at least 30 systolic/15 diastolic

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14
Q

What is the definition of protein urea

A

Concentrations greater than 0.3g/l in 24 hour collection or greater than 1g/l on random sample 2 occasions 6 hours apart

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15
Q

What is the definition of odema

A

Pitting odema or weight gain >2.3kg in a week

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16
Q

What is defined as mild/severepre-eclampsia

A

Diastolic 110 severe

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17
Q

What are the symptoms of pre-eclampsia/impending eclampsia? Which is most significant?

A

Frontal headache, blurred vision. Hyperactive reflexes, abdo pain (epigastric), abdo pain most significant

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18
Q

How would mild pre-eclampsia be managed?

A

Hospital. Rest and observation, plasma urate, plt count, 24 hr urine, creatinine clearance, assess fetal growth and placenta

Improves, manage as opt, persistent, anti hypertensive, deliver at 36 with epidural

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19
Q

How would severe preeclampsia be managed?

A

Anti-convulsants (mgSO4, diazepam), control bp hydralazine

Monitor bp, resp, CVP, colour, pulse, PCWP, strict fluid balance, delivery of infant

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20
Q

What are the complications of pre eclampsia?

A

Placental abruption, reduced glomerular filtration (oliguria and anuria), intrahepatic haemorrhage and liver failure, dic and consequences, maternal complications eg; cerebral infarction, heart failure, ards

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21
Q

Risk factors for developing pre eclampsia

A

History of preeclampsia. A personal or family history of preeclampsia increases your risk of developing the condition.
First pregnancy. The risk of developing preeclampsia is highest during your first pregnancy.
New paternity. Each pregnancy with a new partner increases the risk of preeclampsia over a second or third pregnancy with the same partner.
Age. The risk of preeclampsia is higher for pregnant women younger than 20 and older than 40.
Obesity. The risk of preeclampsia is higher if you’re obese.
Multiple pregnancy. Preeclampsia is more common in women who are carrying twins, triplets or other multiples.
Prolonged interval between pregnancies. This seems to increase the risk of preeclampsia.
Diabetes and gestational diabetes. Women who develop gestational diabetes have a higher risk of developing preeclampsia as the pregnancy progresses.
History of certain conditions. Having certain conditions before you become pregnant — such as chronic high blood pressure, migraine headaches, diabetes, kidney disease, rheumatoid arthritis or lupus — increases the risk of preeclampsia.

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22
Q

Which blood tests should be performed in pre eclampsia/hypertension and why?

A

FBC, especially platelets, renal and lfts, uric acid (good indicator of progression), clotting studies if severe, catecholamine (specially if severe and no protein, phaeochromocytoma)

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23
Q

What fetoplacental investigations should be performed in pre eclampsia?

A

Fetal ultrasound. Your doctor may also recommend close monitoring of your baby’s growth, typically through ultrasound twice a week This test directs high-frequency sound waves at the tissues in your abdominal area. These sound waves bounce off the curves and variations in your body, including your baby. The sound waves are translated into a pattern of light and dark areas — creating images of your baby on a monitor that can be recorded electronically or on film for a look at the inside of your uterus.
Nonstress test or biophysical profile. These make sure your baby is getting enough oxygen and nourishment. A nonstress test is a simple procedure that checks how your baby’s heart rate reacts when your baby moves. Your baby is doing fine if the heart rate increases at least 15 beats a minute for at least 15 seconds twice in a 20-minute period. A biophysical profile combines an ultrasound with a nonstress test to provide more information about your baby’s breathing, tone, movement and the volume of amniotic fluid in your uterus.

Doppler flow studies of umbilicus. Increase in systole to diastole flow ratio or reversal of flow indicate increased vascular resistance and fetal compromise,

Antenatal ctg

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24
Q

What would be the procedure for induction of a woman with preeclampsia?

A

Ripen cervix if not ripe with prostaglandin e2 in post fornix (Caesarian if unripe and persistent proteinuria/fits)

ARM

Oxytocin infusion if no labour within an hour of ARM. Infusions starting at 1-4mu/min increasing to 32 every half hour until response

Discontinue if evidence of fetal distress or excessively strong/frequent contractions

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25
Q

What drugs are used to treat acute hypertension in pregnancy

A

Hydralazine bolus 5mg, labetalol 20 mg

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26
Q

What percentage of pregnancies are affected by hypertension/pre eclampsia/eclampsia

A

In the uk, hypertension affects 10-15%, but only 2-3% will also develop proteinuria, les than 1 in 100 develop eclampsia

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27
Q

under which circumstances should delivery of infant occur in a patient with pre eclampsia

A

Nonreassuring fetal heart status
Ruptured membrane
Uncontrollable BP
Oligohydramnios, with amniotic fluid index (AFI) of less than 5 cm
Severe intrauterine growth restriction in which the estimated fetal weight is less than 5%
Oliguria (< 500 mL/24 hr)
Serum creatinine level of at least 1.5 mg/dL
Pulmonary edema
Shortness of breath or chest pain with pulse oximetry of < 94% on room air
Headache that is persistent and severe
Right upper quadrant tenderness
Development of HELLP syndrome

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28
Q

what should the management of eclampsia after delivery be?

A

continues for up to 7 days, fits can occur up to 4 weeks after delivery but majority occur before 48 hours. After this epilepsy or cortical vein thrombosis must be considered.

Management; maintain in quiet environment under constant observation, maintain appropriate sedation levels. MgSO4 if used continue to 24 hours after last fit, continue antihypertensives until bp normal. Hypertension may persist for 6 weeks

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29
Q

What proportion of eclamptic fits occur after delivery/after 48 hours

A

45% after deliver, 12% after 48hr

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30
Q

what are the values in a GTT suggest normal/abnormal glucose tolerance

A

75g loading dose of glucose, normal fasting less than 6mmol/l fasting and 2 hour less than 7.8 mmol

gestational IGT, fasting 6-7 and 2 hour 7.8-11.1

diabetes fasting >7 and 2 hour >11.1

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31
Q

what proportion of pregnancies are complicated by diabetes

A

02.-0.3%, 1-2% show evidence of IGT

32
Q

how should a woman with existing IDDM be counselled in terms of planning pregnancy?

A

optimise control prior to conception, advise of mat/fet complications, advise defer if levels exceed 12% or evidence of ischaemic heart disease, untreated proliferative retinopathy, hypertension or proteinuria

33
Q

what are the potential maternal complications of diabetes

A

diabetogenic pregnancy (hyperglycaemia, ketoacidosis, coma, death) Hypoglycaemia rare and will result in fetal death only if prolonged. These complications occur more commonly in early pregancy complicated by hyperemesis

Hydraminos, unstable lie and PROM

preeclampsia, prognosis poor where there is nephropathy

dystocia, particularly shoulder

34
Q

what are the potential fetal complications of diabetes

A

intrauterine death increased but can be kept near normal if control good, fetal acidosis in labour, should be constantly monitored

hypoglycaemia, particularly in 1st 48 hours of delivery, hyperplasia and hypertrophy of islets of langerhans,monitor blood glucose until feeding well establised

respiratory distress , jaundice, hypocalcaemia and hypomagnesaemia

congenital abnormalities in 7% of cases

35
Q

how should pregnancy related diabetes be managed?

A

diet containing 50% carbohydrate, 20-30% protein and 20-30% fat and 25-30% fat. Aim to keep blood glucose levels below 7mmol/l at all times by diet alone or insulin. Most gestational can be managed by diet

Hospital admission not essential unless additional complications eg pre eclampsia

measurement of bg every 2 weeks during 1st trimester and every week during 3rd

switch women on oral hypoglycaemic agents to short acting insulin

insulin requirements will generally increase in later stages of pregnancy and fall rapidly after birth

regular fortnightly or weekly antenatal checks and regular checks of renal funtion and retinal changes

careful monitoring of fetal growth and development using serial US scans, biphysical profiles and umbilical artery doppler

careful monitoring of blood sugar and fetal heart during labour, usually deliver between 38 and term, caesarian if fetal distress

36
Q

under what circumstances should vaginal examination be performed in an antepartum haemorhage?

A

serious doubt about dx, bleeding in establised labour and only in operating theatre prepped for c section and blood cross matched

37
Q

when are the trimesters of pregnancy

A

First Trimester: Starts with the first day of your last menstrual period (LMP) and ends with the last day of the 13th week thereafter. During your last period (which will be your last for a while), your uterus is preparing for ovulation and your body is gearing up for pregnancy, so technically, you can start counting from this point.

Second Trimester: Starts at the beginning of the 14th week after your LMP and lasts through the 27th week of pregnancy.

Third Trimester: Starts at the beginning of the 28th week after your LMP and ends with labor.

38
Q

risk factors of placenta praevia

A 
Have had a baby before, as the rate for first-time births is one in 250, compared with one in 90 of all births.
    Have had a caesarean section before.
    Are a smoker.
    Are over 35.
     multiparity
    social and nutritional factors
39
Q

what are the potential complications of placenta praevia?

A

bleeding, acreta and PPH (specially if prev caes), vasa praevia

40
Q

what can mothers be advised to do during pregnancy to help placenta praevia

A

eat healthy, iron rich food, move about plenty to prevent blood clots and drink plenty of water, avoid sex, have somebody available to take to hospital at short notice

41
Q

how is placenta praevia managed?

A

Managing placenta praevia is sometimes just a matter of your medical team watching and waiting, while monitoring the position of your placenta.

Your care will also vary, depending on whether or not you’ve had any bleeding. If you’ve had no bleeding, you’ll probably be able to stay at home. You may be advised to avoid having sex for the rest of your pregnancy.

You should have someone to help you at all times and be able to get to hospital at a moment’s notice. If you remain free of complications, you’re likely to be offered a planned caesarean at 38 weeks to 39 weeks.

If you have placenta accreta, or have had bleeding, you’ll be admitted to hospital when you’re 34 weeks pregnant. A planned caesarean will probably be scheduled for when you’re between 36 weeks and 37 weeks pregnant. A senior obstetrician will carry out the caesarean. Because you may be more vulnerable to bleeding during the operation, a blood transfusion will be on standby, just in case and blood crossmatched

If you have any bleeding, contractions or period-type pains before you’re due to be admitted, go straight to hospital, so you can be monitored. If your symptoms stop, you may be asked to stay until your baby is ready to be born.

If your symptoms don’t stop, or if you go into premature labour, your baby will need to be born by emergency caesarean section. If this happens before you are 35 weeks pregnant, your obstetrician will suggest that you have an injection of steroids. Steroids will help to speed up the development of your baby’s lungs.

42
Q

what is the incidence of placenta praevia?

A

around 0.5-1%

43
Q

`what will be the symptoms and examination findings in placenta praevia?

A

vaginal bleeding, malpresentation of fetus, uterine hypotonus, Likely bleeding after 28 weeks onwards as this is when development of lower uterine segment occurs

44
Q

what diagnostic tests can be done in patients with suspected placenta praevia?

A

ultrasound will localise placenta. MRI most accurate as internal cervical os can be visualised but not widely used

45
Q

what are the symptoms of placenta abrupta

A

painful bleeding, uterus increased tone, proteinuria, longitudinal lie

46
Q

what conditions may mimic placenta abrupta

A

acute polyhydraminos (no haemorrhage), perforated ulcer, strangulated inguinal hernia. Rare during pregnancy

47
Q

what are the possible complications of placenta abrupta

A

afibrinogenaemia and uncontrollable haemorrhage (if severe abruption causes release of thromboplastin into maternal circulation leading to intravascular coagulation and defibrination with development of hypo/afibrinogenaemia. Treat with fresh frozen plasma, platelet transfusion and fibrinogen infusion but only reversible by delivery)

renal tubule or cortical necrosis, monitor urine output. Rare

48
Q

how is placenta abrupta managed

A

if mild, conservative management, if severe, resusscitation

crossmatch, hartmann’s/blood substitutes until transfusion possible, CVP line, deliver fetus asap

fetus alive and no distress, surgical induction of labour, dilute syntocinon infusion. Fetus alive but distressed, C section emergency

pain relief by opiates, no epidural until clotting screen available

49
Q

what other conditions could cause APH

A

unexplained. These cases involve significantly increased risk of perinatal mortality and should be monitored carefully

vaginal infections (moniliasis or trichomoniasis)

cervical polyps/ca

50
Q

what are the risk factors for placental abruption?

A

pre-eclampsia/hypertension, social deprivation and particularly folic acid deficiency, more likely to be male, low birthweight, previous history of abruption, smoking worsens prognosis. Rarely trauma is a cause

51
Q

what conditions are associated with PROM

A

Primarily infection, also associated with 1st and 2nd trimester haemorrhage and smoking. Various organisms found to affect including group b haemolytic strep, c.trachomatis and organisms causing bacterial vaginosis

52
Q

how is PROM generally managed and what are the risks

A

major risk is infection but long term drainage of fluid may also result in fetal pulmonary dysplasia. Difficulty deciding when to deliver fetus and how as uterus often resistant to oxytocin. Speculum examination to confirm presence of amniotic fluid, nitrazine sticks can be used but limited value, tests using more specific markers such as AFP and IGF can be used but not widely because of cost. If in doubt assume membranes have ruptured, continue observation until no evidence of drainage of fluid and US confirms normal levels of amniotic fluid. Swabs of vagina. monitor for maternal sepsis. Administer appropriate abx if infection. If persistent infection induce labour using oxytocin infusion. If no evidence of infection conservative management with erythromycin cover. Tocolysis generally ineffective if contractions. Most women with PROM will deliver within 48 hours

53
Q

what drugs can be used to prevent premature delivery of an infant

A

b-adrenergic agonists (most commonly ritodrine/salbutamol.tetrabutaline)

prostaglandin synthetase inhibitors

mgso4

54
Q

under what conditions should a breech pregnancy be delivered by caesarian

A

less than 1500g more than 4000g, severe preeclampsia/placental abruption/praevia/previous c section

55
Q

what are the risks of a breech delivery

A

cord prolapse (particularly footling), entrapment of head behind cervix (sometimes cervix not fully dilated when trunk delivers, particularly in preterm), intercranial haemorrhage as skull doesn’t have time to mould, trauma to viscera (rupture of spleen or gut)

56
Q

what are the incidences of breech presentation at gestational ages

A

16% at 32 weeks, 7% 38 weeks and 3-5% term, hence most will turn themselves and unneccesary to turn before 38 weeks

57
Q

what are the types of breech

A

frank/extended (70%), flexed (15%), footling (15%)

58
Q

what are the indications/contraindications for external cephalic version?

A

indications, breech after 37 weeks,

contraindications; history of APH, placenta praevia, uterine scar, multiple pregnancy, delivering by c section

59
Q

what is the technique of external cephalic version

A

confirm breech by clinical examination and US if nec, check fetal HR before and during procedure, don’t use excessive force, return fetus to original position if bradycardia and not past halfway point

60
Q

what are the risks of external cephalic version

A

cord entanglement, abruption, PROM

61
Q

what is the technique for breech vaginal delivery

A

usually epidural to manage pain but not essential,

wait until cervix fully dilated, encourage mother to push until buttocks and anus in view, perform wide episiotomy under LA/epidural unless pelvic floor already lax.

Lift legs out of vagina, apply traction downwards and backwards

Deliver anterior shoulder by putting fingers over shoulder and sweeping arm downwards

move trunk laterally until posterior arm can be delivered

allow trunk to hang and head to enter pelvis, grasp legs and pelvis and swing upwards 180 degrees until mouth in view

suction of mouth to allow respiration to commence

wrigleys forceps to head to enable gentle controlled delivery of head. Syntometrine at this stage unless contraindicated and complete delivery of head

proceed as normal with cord clamping and placenta

62
Q

what are the risks of induction of labour

A

hyperstimulation causing fetal distress, cord prolapse, infection if prolonged interval

63
Q

what would be a suitable syntocinon infusion infusion for induction of labour

A

begin at 1mu/min and increase by 3mu/min every 15 mins until adequate contractions

64
Q

What are the indications for induction of labour

A

Pre eclampsia, prolonged pregnancy, over 42 weeks/294 days since lmp, placental insufficiency and iugr, aph/abruption, rhesus isoimmunisation, diabetes, chronic renal disease

65
Q

What defines a prolonged pregnancy. What are the implications

A

Over 294 days from first day lmp, perinatal mortality doubles after 42 weeks, trebles after 43 but routine induction has minimal effect on mortality rate, conservative management involves freq monitoring of fetus with us, assessment of liquor volume and induction if compromise

66
Q

How are early decelerations defined

A

Synchronous with uterine contractions, decrease generally less than 40/min, generally due to head/cord compression and considered usually to be physiological

67
Q

How are late decelerations defined

A

Onset of slowing after contraction established and doesn’t return to baseline until at least 20 secs after complete. Less common and sinister as indicative of hypoxia

68
Q

How are decelerations and accelerations defined

A

More than 15 beat change for more than 15 seconds

69
Q

How is fetal acid base status monitored peri partum

A

Scalp blood sampling

Obtained from scalp or buttocks through amnioscope through at least 2cm dilated cervix. Mother put into lithotomy(surgical) position or preferably lateral supine position. Small stab incision made and blood collected into heparinised capillary tube

70
Q

What are the normal pH values in fetal blood sampling

A

7.25-7.35 normal, below, repeat after 1 hr as raised paCO2 might mean resp acidosis. Less than 7.20 indication for delivery

71
Q

What are the stages of perineal tear during labour

A

1st degree. Damage to vaginal and perineal skin

2nd degree, involves post vaginal wall and underlying muscles but not anal sphincter

3rd degree, total/partial damage to sphincter

4th degree, tear into rectal mucosa

72
Q

What are the risk factors premature labour

A

Poverty, >35 <20, heavy stressful work, marital status, smoking, substance abuse

73
Q

How frequent and strong should normal contractions occur in labour

A

Every 5-15mins lasting at least 30-40 secs, reaching pressures of 5kpa/50mmHg

74
Q

What proportion of twin pregnancies result in labour before 37 weeks

A

40

75
Q

What are the common complications of twin pregnancy

A

Miscarriage, aph, polyhydraminos, pre eclampsia, preterm labour, twin twin transfusion

76
Q

What proportion of monochorionic twin pregnancies end in twin twin transfusion

A

10-15%

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