Obstetrics Flashcards
(457 cards)
1
Q
What are some causes of abdominal pain in the early stages of pregnancy ?
A
Ectopic pregnancy
Miscarriage
2
Q
What are some causes of abdominal pain in the later stages of pregnancy ?
A
Labour
Placental abruption
Pre-eclampsia
Uterine rupture
3
Q
What are some risk factors for ectopic pregnancy ?
A
Damage to tubes - salpingitis, surgery
Previous ectopic
IVF ( 3% )
4
Q
At what stage of pregnancy do ectopic pregnancies present ?
A
6-8 weeks
5
Q
What are some features of ectopic pregnancy ?
A
Lower abdominal pain - constant
Vaginal bleeding
Peritoneal bleeding that can cause shoulder tip pain
6
Q
What is a missed miscarriage ?
A
This is when the gestational sac contains a dead foetus before 20 weeks without the symptoms of expulsion.
Mother may have light vaginal bleeding / discharge
7
Q
What is placental abruption ?
A
Describes separation of a normally sited placenta from the uterine wall resulting in maternal haemorrhage into the intervening space
8
Q
What are the clinical features of placental abruption ?
A
Disproportionate shock for blood loss
Constant pain
Tender tense pain
Coagulation problems
9
Q
What is related to an increased alpha Feto-protein ?
A
Neural tube defects - meningocoele
Abdominal wall defects - gastroschisis
Multiple pregnancy
10
Q
What is related to a decreased alpha Feto-protein ?
A
Down’s syndrome
Trisomy 18
Maternal diabetes mellitus
11
Q
What is alpha Feto-protein produced by ?
A
The developing foetus
12
Q
What is an amniotic fluid embolism ?
A
This is when foetal cells / amniotic fluid enters the mothers bloodstream and stimulates a reaction causing the presentation.
13
Q
What are some risk factors for amniotic fluid embolism ?
A
Maternal age
Induction of labour
14
Q
What are the signs and symptoms of amniotic fluid embolism ?
A
Chills - shivering
Anxiety
Coughing
Cyanosis
Hypotension
Bronchospasms
Tachycardia
MI
15
Q
How is a diagnosis of amniotic fluid embolism made ?
A
Clinical diagnosis of exclusion
No definitive testing
16
Q
What is the management of amniotic fluid embolism ?
A
Critical care unit by MDT team
Supportive management
17
Q
What are some lifestyle recommendations for pregnancy ?
A
Folic acid 400 mcg
Iron supplementation should not be offered
Vitamin D 10mcg
Avoid alcohol
Avoid smoking
Avoid unpasteurised milk, ripened cheese or undercooked meat
Safe to work
Avoid high impact sports
18
Q
Why is folic acid important in pregnancy ?
A
400mcg should be given before conception until week 12 to reduce the risk of neural tube defects
19
Q
Why should vitamin A be avoided in pregnancy ?
A
Might be teratogenic
20
Q
What are the risks of smoking during pregnancy ?
A
Low birth weight
Preterm birth
21
Q
What are the NICE guidelines for managing nausea and vomiting in pregnancy ?
A
Natural remedies - ginger and acupuncture
Antihistamines - promethazine
22
Q
How many antenatal visits should there be in the first pregnancy ?
A
10
23
Q
How many antenatal visits should there be in subsequent pregnancies ?
A
7
24
Q
What is the purpose of the 8-12 week antenatal visit ?
A
General information - diet, alcohol, smoking and folic acid
BP, urine dip, BMI
Bloods - FBC, rhesus status, hepatitis B, HIV
25
When should Down syndrome be screened ?
11- 13 + 6 weeks
26
At what stage is the symphysis - fundal height measured antenatally ?
25 weeks
27
If a woman is rhesus negative at what stage should she be given anti-D prophylaxis ?
First dose- 28 weeks
Second dose - 34 weeks
28
Which conditions should be offered screening for in all pregnant women ?
Anaemia
Bacteruria
Blood group, rhesus D
Down’s syndrome
Hepatitis B
HIV
Neural tube defects
Risk factors for pre-eclampsia
Syphilis
29
What are some conditions that should be offered screening depending on the history during pregnancy ?
Placenta praevia
Psychiatric illness
Sickle cell anaemia
Tay-sachs disease
Thalassaemia
30
What is an antepartum haemorrhage ?
Defined as bleeding from the genital tract after 24 weeks pregnancy, prior to the delivery of the foetus
31
What are some features of placenta praevia ?
Shock in proportion to visible loss
No pain
Uterus not tender
32
What are some causes of bleeding in pregnancy in the 1st trimester ?
Spontaneous abortion
Ectopic pregnancy
Hydatidiform mole
33
What are some causes of bleeding in pregnancy in the 2nd trimester ?
Spontaneous abortion
Hydatidiform mole
Placental abruption
34
What are some causes of bleeding in pregnancy in the 3rd trimester ?
Bloody show
Placental abruption
Placenta praevia
Vasa praevia
35
What occurs in Hydatidiform mole ?
Typically bleeding in first or early second trimester associated with exaggerated symptoms of pregnancy
Large uterus and high hCG
36
What occurs in vasa praevia ?
Rupture of membranes followed immediately by vaginal bleeding
Foetal bradycardia is usually seen
37
What are some minor breastfeeding problems ?
Nipple pain - poor latch
Blocked duct ( milk bleb )
Nipple candidiasis
38
What is the management to nipple candidiasis during breastfeeding ?
Miconazole cream for the mother
Nystatin suspension for baby
39
What advice should be given if there is a blocked duct during breastfeeding ?
Breastfeeding should continue
Breast massage
Advice about positioning the baby
40
In what circumstances does the BNF advise treatment for mastitis during breastfeeding ?
If systemically unwell
Nipple fissure
If symptoms do not improve after 12-24 hours of effective milk removal
If culture indicates infection
41
What is the management of mastitis during pregnancy ?
Flucloxacillin for 10-14 days
Breastfeeding or expressing should be continued
42
If left untreated what can develop in mastitis ?
Breast abscess
43
What is the management of a breast abscess ?
Incision and drainage
44
What are some features of breast engorgement ?
Breast pain - typically worse before feed
Both breast affected
Fever settling witching 24 hours
Erythema
45
What are some complications of breast engorgement ?
Blocked milk ducts
Mastitis
Difficulties breastfeeding and with milk supply
46
What can relieve breast pain when the breasts are engorged ?
Hand expression of milk can help relieve the discomfort
47
What occurs in Raynaud’s disease of the nipple ?
Intermittent pain
Blanching of the nipple followed by cyanosis and / or erythema
48
What are some management options for Raynaud’s disease of the nipple ?
Minimise exposure to the cold
Use heat packs following breastfeeding
Avoid caffeine
Stop smoking
Specialist - if no improvement trial of nifedipine
49
What is a breech position in labour ?
The caudal end of the foetus occupies the lower segment
50
What is a frank breech position ?
Most common presentation with the hips flexed and knees fully extended
51
What is a footling breech presentation ?
Where one or both feet come first with the bottom at a higher position
Rare but carries a higher perinatal morbidity
52
What are some risk factors for breech position ?
Uterine malformations, fibroids
Placenta praevia
Polyhydraminos or oligohydraminos
Foetal abnormality
Prematurity
53
What is the management of a breeched baby ?
Before 36 weeks - most will spontaneously turn
If still breeched after 36 weeks - NICE recommend external Cephalic version ( ECV )
If still breeched after ECV plan a C section
54
What are some contra-indications of external cephalic version ?
Where C section delivery is required
Antepartum haemorrhage within the last 7 days
Abnormal cardiotocography
Major uterine anomaly
Ruptured membrane
Multiplier pregnancy
55
When is breastfeeding contra-indicated ?
Medication use
Galactosaemia
Viral infections - such as HIV
56
What medications should be avoided in breastfeeding mothers ?
Antibiotics - ciprofloxacin, tetracycline, sulphonamides
Psychiatric drugs - lithium, benzos
Aspirin
Carbimazole
Methotrexate
Sulfonylureas
Cytotoxic drugs
Amiodarone
57
What medication is first line in suppressing lactation ?
Cabergoline
58
What are the 2 types of caesarean section ?
Lower segment caesarean section
Classic c section - longitudinal incision in upper uterus
59
What are some indications for a c section ?
Absolute cephalopelvic disproportion
Placenta praevia 3/4
Pre-eclampsia
IUGR
Foetal distress
Placental abruption
Vaginal infection
Cervical cancer
60
What is a category 1 c section ?
An immediate threat to life of the mother or baby
Delivery should occur within 30 minutes
61
What are some examples for a category 1 c section decision ?
Suspected uterine rupture
Major placental abruption
Cord prolapse
Foetal hypoxia
Persistent foetal bradycardia
62
What is a category 2 c section ?
Maternal or foetal compromise which is not immediately life threatening
Delivery should be performed within 75 minutes
63
What is a category 3 c section ?
Delivery is required but mother and baby are stable
64
What is a category 4 c section ?
Elective c section
65
What are some serious complications of a c section ?
Emergency hysterectomy
Need for further surgery at a later date
Admission to ITU
Thromboembolic disease
Bladder or ureteric injury
Death ( 1 in 12000 )
66
What are some complications for future pregnancies of having a c section ?
Increased risk of uterine rupture
Increased risk of antepartum stillbirth
Increased risk of subsequent pregnancies of placenta praevia and accreta
67
What are some frequent complications of a c section of the mother ?
Persistent wound and abdominal discomfort in the first few months after surgery
Increased risk of repeat c section
Re admission to hospital
Haemorrhage
Infection - wound, UTI Endometritis
68
What are some frequent complications of a c section of the foetus ?
Lacerations ( 1-2 babies per 100 )
69
What is a baseline bradycardia in a foetus ?
HR under 100
70
What are some causes of a foetal baseline bradycardia ?
Increased foetal vagal tone
Maternal beta blocker use
71
What is a baseline tachycardia in a foetus ?
HR over 160
72
What are some causes of foetal baseline tachycardia ?
Maternal pyrexia
Chorioamnionitis
Hypoxia
Prematurity
73
What is early deceleration of the heart rate of the foetus ?
Deceleration of the HR which commences with the onset of a contraction and returns to normal on completion of the contraction
74
What can early deceleration indicate in a foetus ?
Innocuous feature and indicates head compression
75
What is late deceleration of HR in a foetus ?
Deceleration of the HR which lags the onset of a contraction and does not return to normal until after 30 seconds following the end of the contraction
76
What can late deceleration of foetal HR indicate ?
Indicates foetal distress - asphyxia or placental insufficiency
77
What does a cardiotocography ?
Records pressure changes in the uterus using internal or external pressure transducers.
Measures foetal HR
78
What are some features of foetal varicella syndrome ?
Skin scarring
Eye defects ( microphthalmia )
Limb hypoplasia
Microcephaly
Learning disabilities
79
At what stage of pregnancy is there the highest risk of developing foetal varicella syndrome from maternal varicella exposure ?
Before 20 weeks of gestation
80
What is the management of chicken pox exposure in pregnancy ?
If there is any doubt about the mother having chicken pox maternal blood should be urgently checked for varicella antibodies.
Administration of varicella zoster immunoglobulin
Oral aciclovir is first choice for post-exposure prophylaxis
81
What is chorioamnioitis ?
A potentially life threatening condition to both mother and foetus and is therefore considered a medical emergency.
It usually results from an ascending bacterial infection of the amniotic fluid / membranes / placenta.
82
What is the main risk of chorioamnionitis ?
Pre-term premature rupture of membranes which exposure the normally sterile environment of the uterus to potential pathogens.
83
What is the management of chorioamnionitis ?
Prompt delivery of the foetus
IV antibiotics
84
What test is standard for screening for Down’s syndrome ?
Combined test
85
What are some features seen during antenatal screening that suggest Down’s syndrome ?
Increased HCG
Decreased PAPP-A
Thickened nuchal translucency
86
What distinguishes Down’s syndrome from Patau or Edward syndrome during antenatal screening ?
Patau and Edward syndrome has lower hCG than downs
87
What is the condition caused by trisomy 18 ?
Edward syndrome
88
what is the condition caused by trisomy 13 ?
Patau syndrome
89
What is eclampsia ?
Defined as the development of seizures in association with pre-eclampsia.
90
What can be used to prevent seizures in severe pre-eclampsia ?
Magnesium sulphate
91
what is first line for managing magnesium sulphate induced respiratory depression ?
Calcium gluconate
92
What are the aims of management of epilepsy in pregnancy ?
Aim for monotherapy
No indication to monitor anti epileptic drug levels
Sodium valproate - neural tube defects
Carbamazepine - least teratogenic
Phenytoin - cleft palate
Lamotrigine - congenital malformations
93
Can mothers breastfeed on antiepileptics ?
Yes it is generally considered safe with the exception of barbiturates
94
What are some causes of folic acid deficiency ?
Phenytoin
Methotrexate
Pregnancy
Alcohol excess
95
What is a good source of folic acid ?
Green leafy vegetables
96
What are some consequences of folic acid deficiency ?
Macrocytic megaloblastic anaemia
Neural tube defects
97
how can neural tube defects be prevented during pregnancy ?
Women should take 400mcg of folic acid until the 12th week of pregnancy
Women at high risk of conceiving a chid with neural tube defects should take 5mg of folic acid until the 12th week
98
What are the indications for a forceps delivery ?
Foetal distress in the second stage of labour
Maternal distress in the second stage of labour
Failure to progress in the second stage of labour
Control of head in breech deliver
99
What is the galactocoele ?
Occurs in women who have recently stopped breastfeeding and is due to occlusion of a lactiferous duct.
A build up of milk creates a cystic lesion in the breast.
100
What are the risk factors for gestational diabetes ?
BMI over 30
Previous macrosomic baby weighing 4.5kg or above
Previous gestational diabetes
First degree relative with DM
Family origin
101
What are some screening tests for gestational diabetes ?
Oral glucose tolerance test
102
What are the diagnostic thresholds for gestational diabetes ?
Fasting glucose - more than 5.6mmol/L
2 hour glucose - mor than 7.8mmol/L
103
What is the management of gestational diabetes ?
Newly diagnosed women
Advice about diet and exercise should be given
If glucose targets are not met Metformin should be started
104
What is the management of pre-existing diabetes in pregnancy ?
Weight loss for women with a BMI over 27
Stop oral hypoglycaemic agents apart from metformin and commence insulin
Folic acid 5mg/day from pre-conception to 12 weeks
Tight glycaemic control
105
What is the fasting target for blood glucose in pregnant women with pre-existing and gestational diabetes ?
5.3 mmol/L
106
What is gestational thrombocytopenia ?
Common condition of pregnancy that results from a combination of dilution, decreased production and increased destruction of platelets.
107
Does ITP affect the neonate ?
It can do if the maternal antibodies cross the placenta.
108
What are some gestational trophoblastic disorders ?
Complete Hydatidiform mole
Partial Hydatidiform mole
Choriocarcinoma
109
What is complete Hydatidiform mole ?
Benign tumour of the trophoblastic material.
Occurs when an empty egg is fertilised by a single sperm that then duplicates its own DNA hence all the 46 chromosomes are of paternal origin
110
What are the features of complete Hydatidiform mole ?
Bleeding in the first or early second trimester
Exaggerated symptoms of pregnancy
Uterus - large
Very high levels of hCG
HTN
111
What is the management of complete Hydatidiform mole ?
Urgent referral to specialist centre - evacuation of the uterus is performed
Effective contraception is recommend to avoid pregnancy in the next 12 months
112
What is the most common cause of severe infection in the neonatal period ?
Group B streptococcus
113
Where can neonates be exposed to group B streptococcus ?
During labour
114
What are the risk factors for group B streptococcus in neonates ?
Prematurity
Prolonged rupture of the membranes
Previous sibling GBS infection
Maternal pyrexia
115
What is the management of group B streptococcus in neonates ?
Women who have had GBS in previous pregnancy should be offered intrapartum abx prophylaxis.
Antibiotics
116
What is the group B streptococcus prophylaxis in neonates ?
Benzylpenicillin
117
What is HELLP syndrome ?
Haemolysis, elevated liver enzymes and a low platelet count.
Serious condition that can develop in the later stages of pregnancy
( significant overlap with pre-eclampsia in terms of features )
118
What are some features of HELLP syndrome ?
Nausea and vomiting
Right upper quadrant pain
Lethargy
119
What are the investigations for HELLP syndrome and what is seen ?
Bloods - haemolysis, elevated liver enzymes and low platelet
120
What is the treatment of HELLP syndrome ?
Delivery of baby
121
What is the management when babies are born to mothers who are chronically infected with hepatitis B ?
Complete course of vaccination and hepatitis B immunoglobulin
122
What are some factors which reduce vertical transmission when mothers have HIV ?
Maternal antiretroviral therapy
Mode of delivery
Neonatal antiretroviral therapy
Infant feeding
123
What is the mode of delivery if a woman has HIV ?
Vaginal delivery is recommended if viral load is less than 50 copies/ml at 36 weeks
124
What is given for the neonate in a mother who has HIV ?
Zidovudine is administered orally to the neonate if maternal viral load is below 50 copies/ml
Otherwise ART should be used
125
Should women breastfeed with HIV ?
No
126
Should women breastfeed with hepatitis B ?
They can breastfeed
127
What is human chorionic gonadotropin ?
A hormone first produced by the embryo and later by the placental trophoblast
128
What is the main role of human chorionic gonadotropin ?
To prevent the disintegration of the corpus luteum
129
When does the hCG levels peak during pregnancy ?
Around 8-10 weeks gestation
130
How does BP change during pregnancy ?
Blood pressure usually falls during the first trimester
Continues to fall until 20-4 weeks
After this time the blood pressure usually increases to pre-pregnancy levels by term
131
What are some features of pregnancy induced HTN ?
Occurs in the second half of pregnancy
No Proteinuria
No oedema resolves after birth
132
What is the management of hypertension during pregnancy ?
Oral labetalol
Oral nifedipine ( if asthmatic )
133
What is induction of labour ?
Describes a process where labour is started artificially.
It happens in around 20% of pregnancies
134
What are some indications for inducing labour ?
Prolonged pregnancy ( 1-2 weeks after estimated date )
Prelabour premature rupture of the membranes where labour does not start
Maternal medical problems - diabetic mother, pre-eclampsia
Intra-uterine foetal death
135
What is the bishop score for inducing labour ?
Used to help assess whether induction of labour will be required.
136
What are the components of the bishop score ?
Cervical position
Cervical consistency
Cervical effacement
Cervical dilation
Foetal station
137
What score on the bishop score indicates that labour is unlikely without induction ?
Less than 5
138
At what score on the bishop score is the cervix ripe and there is a high chance of spontaneous labour ?
8 or more
139
What are some possible methods for inducing labour ?
Membrane sweep
Vaginal prostaglandin E2
Oral prostaglandin E1
Maternal oxytocin infusion
Amniotomy
Cervical ripening balloon
140
What are the NICE guidelines for induction if the bishop score is under 6 ?
vaginal prostaglandins or oral misoprostol
141
What are the NICE guidelines for induction if the bishop score is under 6 ?
Amniotomy and IV oxytocin infusion
142
What are the complications of inducing labour ?
Uterine hyperstimulation - prolonged and frequent uterine contractions
143
What is the management of uterine hyper stimulation ?
Removing the vaginal prostaglandins if possible and stopping the oxytocin infusion if one has been started
Consider tocolysis
144
What are some features of intrahepatic cholestasis of pregnancy ?
Pruritus - intense and worse in the palms, soles and abdomen
Clinically detectable jaundice occurs in aorund 20%
Raised bilirubin seen in over 90%
145
What is the management of intrahepatic cholestasis in pregnancy ?
Induction of labour at 37-38 weeks
Ursodeoxycholic acid
Vitamin K supplement
146
What is labour ?
Defined as the onset of regular and painful contractions associated with cervical dilation and descent of the presenting part.
147
What are the signs of labour ?
Regular and painful uterine contractions
A show ( shedding of mucous plug )
Rupture of the membranes
Shortening and dilation of the cervix
148
What is stage 1 labour ?
From the onset of true labour to when the cervix is fully dilated
149
What is stage 2 labour ?
Full dilation to delivery of the foetus
150
What is stage 3 labour ?
From delivery of foetus to when the placenta and membranes have been completely delivered
151
What monitoring is performed during labour ?
FHR monitored every 15min
Contractions assessed every 30min
Maternal pulse rate assessed every 60min
Maternal BP and temp should be checked every 4 hours
Maternal urine should be checked for ketones and protein every 4 hours
152
How long does stage 1 of labour take in a primigravida ?
10-16 hours
153
What are the phases of cervical dilation in stage 1 ?
Latent phase - 0-3cm normally takes 6 hours
Active phase - 3-10cm normally 1cm every hour
154
How does the head enter the pelvis ?
Occipito - lateral position
155
What is the normal head position for delivery ?
Occipito-anterior position
156
What is passive second stage of labour ?
Refers to the 2nd stage but in the absence of pushing
157
What is active second stage of labour ?
The active process of maternal pushing
158
Which is the most painful stage of labour ?
1st
Pushing masks pain in the second stage
159
How long does the second stage of labour last ?
1 hour
160
If the second stage of labour lasts longer than an hour what should be considered ?
Ventouse extraction
Forceps delivery
Caesarian section
161
What is Lochia ?
Defined as the vaginal discharge containing blood, mucous and uterine tissue which may continue for 6 weeks
162
What is oligohydraminos ?
Reduced amniotic fluid
Less than 500ml at 32 - 36 weeks and an amniotic fluid index below the 5th percentile
163
What are some causes of oligohydraminos ?
Premature rupture of membranes
Potter sequence
Intrauterine growth restriction
Post term gestation
Pre-eclampsia
164
What is the potter sequence?
Bilateral renal agenesis and pulmonary hypoplasia
165
What is a first degree perineal tear ?
Superificial damage with no muscle involvement
No repair required
166
What is a second degree perineal tear ?
Injury to the perineal muscle but not involving the anal sphincter
Requires suturing on the ward
167
What is a third degree muscle tear ?
Injury to the perineum involving the anal sphincter complex
168
What is the management of a third degree perineal tear ?
repair in theatre by a clinician
169
What is a fourth degree perineal tear?
Injury to the perineum involving the anal sphincter complex and rectal mucosa
170
What is the management of a fourth degree perineal tear ?
Require repair in theatre by a clinician
171
What are some risk factors for perineal tears ?
Primigravida
Large babies
Precipitant labour
Shoulder dystocia
Forceps delivery
172
What is placenta accreta ?
Describes the attachment of the placenta to the myometrium due to defective decidua basalis.
173
What is a complication that may occur during labour in placenta accreta ?
Post partum haemorrhage
174
What are the risk factors of placenta accreta ?
Previous Caesarian section
Placenta praevia
175
What is placenta praevia ?
Describes the placenta lying wholly or partially in the lower uterine segment
176
What are some associated factors for placenta praevia ?
Multiparity
Multiple pregnancy
Embryos are more likely to implant in the lower segment scar from previous C sections
177
What are some clinical features of placenta praevia ?
Shock in proportion to visible loss
No pain
Uterus not tender
Small bleeds before large
178
What is contra-indicated in placenta praevia ?
Digital vaginal examination
179
What investigation should be performed to diagnose placenta praevia ?
Transvaginal ultrasound
180
What is grade 1 placenta praevia ?
Placenta reaches lower segment but not the internal os
181
What is grade 2 placenta praevia ?
Placenta reaches internal os but doesn’t cover it
182
What is grade 3 placenta praevia ?
Placenta covers the internal os before dilation but not when dilated
183
What is grade 4 placenta praevia ?
Placenta completely covers the internal os
184
What is the mode of delivery in grade 1 placenta praevia ?
Trial of vaginal delivery may be offered
185
What is the mode of delivery in grade 3/4 placenta praevia ?
Elective Caesarian section between 37-38 weeks
186
What should be performed if a woman with known placenta praveia goes into labour before the elective C section ?
Emergency C section should be performed due to risk of post partum haemorrhage
187
What is the management of placenta praevia with bleeding ?
Admit
ABC approach to stabilise woman
If not able to stabilise or in labour - emergency c section
188
What is placental abruption ?
Describes separation of a normally sited placenta from the uterine wall resulting in maternal haemorrhage into the intervening space
189
What are some associated factors of placental abruption ?
Proteinuric hypertension
Cocaine use
Multparity
Maternal trauma
Increasing maternal age
190
What are some features of placental abruption ?
Shock out of keeping with visible loss
Constant pain
Tender tense uterus
Absent or distressed foetal HR
Coagulation problems
191
What is the management of placenta abruption if the foetus is alive and less than 36 weeks ?
If in distress - immediate Caesarian
If there is no foetal distress - observe closely, steroids
192
What is the management of placenta abruption if the foetus is alive and more than 36 weeks ?
Foetal distress - immediate Caesarian
No foetal distress - deliver vaginally
193
What is the management of placenta abruption if the foetus is not alive ?
Induce vaginal delivery
194
What are some maternal complications of placental abruption ?
Shock
DIC
Renal failure
Post partum haemorrhage
195
What are some foetal complications of placental abruption ?
IUGR
Hypoxia
Death
196
What is the definition of post term pregnancy ?
A pregnancy that has extended to or beyond 42 weeks
197
What are some neonatal complications of post term pregnancy ?
Reduced placental perfusion
Oligohydraminos
198
What are some maternal complications of post term pregnancy ?
Increased rates of intervention including forceps and C section
Increased rates of labour induction
199
What is post partum haemorrhage ?
Defined as blood loss of more than 500ml after a vaginal delivery.
May be primary or secondary
200
When does a primary postpartum haemorrhage occur ?
Occurs within 24 hours
201
What are the causes of primary postpartum haemorrhage ?
Tone ( uterine atony )
Trauma ( perineal tear )
Tissue ( retained placenta )
Thrombin ( clotting / bleeding disorder )
202
What are some risk factors for primary postpartum haemorrhage ?
Previous PPH
Prolonged labour
Pre-eclampsia
Increased maternal age
Polyhydraminos
Emergency c section
Placenta praevia, placenta accreta
Macrosomia
203
What are the steps in the management of postpartum haemorrhage ?
1 . ABC approach
2 . Mechanical
3 . Medical
4 . Surgical
204
What is involved in the ABC approach in the management of PPH ?
2 peripheral cannulae
Lie woman flat
Bloods including group and save
Commence warmed crystalloid infusion
205
What is involved in the mechanical management of PPH ?
Palpate the uterine fundus and rub it to stimulate contractions
Catheterisation to prevent bladder distension and monitor urine output
206
What is involved in the medical management of PPH ?
IV oxytocin - slow IV injection followed by IV infusion
Ergometrine slow IV or IM
Carboprost IM
Misoprostol sublingual
207
When is surgical management required in postpartum haemorrhage ?
When medical management has failed to control the bleed and should be considered urgently
208
What is involved in the surgical management of PPH ?
Intrauterine balloon tamponade
If severe - consider a hysterectomy
209
What is secondary PPH ?
Occurs between 24 hours - 12 weeks
Typically caused by retained placental tissue or Endometritis
210
What is used to assess postpartum depression ?
Edinburgh postnatal depression scale
211
What are the baby blues ?
Mothers feel anxious, tearful and irritable
Typically seen 3-7 days after birth
212
What is the management of baby blues ?
Reassurance and support
Health visitor plays a large role
213
What is postnatal depression ?
Features are similar to depression
Starts within a month and peaks at 3 months
214
What is the management of postnatal depression ?
Reassurance and support
CBT may be beneficial
If severe - SSRI’s such as sertraline and paroxetine may be used
215
What is puerperal psychosis ?
Features include severe mood swings
Disordered perception - auditory hallucinations
Starts within 2-3 weeks
216
what is the management of puerperal psychosis ?
Admission to hospital ideally in a mother and baby unit
217
What are the 3 stages of postpartum thyroiditis ?
Thyrotoxicosis
Hypothyroidism
Normal thyroid function
218
What is the management of postpartum thyroiditis ?
Thyrotoxic phase - propranolol for symptom control
Hypothyroid phase - treated with thyroxine
219
What is the current formal definition of pre-eclampsia ?
New onset blood pressure of more than 140/90 mmHg after 20 weeks of pregnancy AND 1 or more of the following :
- Proteinuria
- other organ involvement ( renal insufficiency, liver, neurological, haematological, uteroplacental dysfunction
220
What are some potential consequences of pre-eclampsia ?
Eclampsia
Foetal complications - intrauterine growth retardation
Liver involvement
Haemorrhage
221
What are some features of severe pre-eclampsia ?
Hypertension over 160/110 mmHg
Proteinuria
Headache
Visual disturbance
Papilloedema
RUQ/epigastric pain
Hyperreflexia
222
What are some high risk factors for pre-eclampsia ?
Hypertensive disease in a previous pregnancy
CKD
Autoimmune disease such as SLE or antiphospholipid disease
Type 1 or 2 diabetes
223
What are some moderate risk factors for pre-eclampsia ?
First pregnancy
Age 40 +
Pregnancy interval more than 10 years
BMI of 35 or more
Family history
Multiple pregnancy
224
What can help reduce the risk of hypertensive disorders in pregnancy ?
Aspirin 75-150mg from 12 weeks gestation until birth
225
What is the initial assessment for pre-eclampsia ?
Arrange emergency secondary care assessment for any woman where pre-eclampsia is suspected
Women with a BP 0ver 160/110 are likely to be admitted and observed
226
What is the management of pre-eclampsia ?
Oral labetolol
Nifedipine if asthmatic
Delivery of the baby is definitive
227
At what stages of pregnancy is anaemia screened for ?
The booking visit ( 8 - 10 weeks )
28 weeks
228
What is the management of anaemia in pregnancy ?
Oral ferrous sulfate or ferrous fumarate
Should be continued for 3 months after iron deficiency is corrected
229
For patients with a suspected DVT in pregnancy what should be performed ?
Compression duplex ultrasound should be undertaken where there is clinical suspicion of DVT
230
What should be performed for all patients with suspected PE in pregnancy ?
ECG and CXR
Decision to perform CTPA or V/Q should be taken locally
231
What are the risks of performing a CTPA in pregnancy ?
Slightly increases risk of maternal breast cancer.
Pregnancy makes breast tissue more sensitive to the effects of radiation
232
What are the risks of performing a V/Q scan in pregnancy ?
Carries a slightly increased risk of childhood cancer compared to CTPA
233
Is D dimer testing useful in pregnancy for a suspected DVT or PE ?
Limited use for thromboembolism as it is often raised in pregnancy
234
What stage of pregnancy is intrahepatic cholestasis seen ?
Third trimester
235
What are the features of intrahepatic cholestasis of pregnancy ?
Pruritus - often palms and soles
No rash
Raised bilirubin
236
What is the management of intrahepatic cholestasis of pregnancy ?
Ursodeoxycholic acid for symptom relief
Weekly liver function tests
Women are typically induced at 37 weeks
237
What are some complications of intrahepatic cholestasis of pregnancy ?
Increase rate of stillbirth
238
When does acute fatty liver of pregnancy occur ?
Third trimester
The period immediately following delivery
239
What are the features of acute fatty liver of pregnancy ?
Abdo pain
N & V
Headache
Jaundice
Hypoglycaemia
Severe disease may result in pre-eclampsia
240
What is seen on investigations in acute fatty liver of pregnancy ?
Elevated ALT ( 500 )
241
What is the management of acute fatty liver of pregnancy ?
Support care
Once stabilised delivery is definitive
242
What are some maternal risks of obesity in pregnancy ?
Miscarriage
VTE
Gestational diabetes
Pre-eclampsia
Dysfunctional labour
Postpartum haemorrhage
Wound infections
243
What are the foetal risks of obesity in pregnancy ?
Congenial anomaly
Prematurity
Macrosomia
Stillbirth
Increased risk of developing obesity and metabolic disorders in childhood
Neonatal death
244
What is obesity in pregnancy defined as ?
BMI over 30 at the first antenatal visit
245
What is the management of obesity in pregnancy ?
Take 5mg of folic acid instead of 400mcg
Screened for gestational diabetes
If BMI greater than 35 women should give birth in a consultant led obstetric unit
If BMI greater than 40 an antenatal consultation with an obstetric anaesthetist and plan made
246
How does pregnancy affect the CVS ?
Stroke volume increased by 30%
HR increased by 15%
Cardiac output increased by 40%
Enlarged uterus may interfere with venous return causing ankle oedema, supine hypotension and varicose veins
247
How does pregnancy affect the respiratory system ?
Pulmonary ventilation increased by 40%
O2 requirement increased by 20%
248
How does pregnancy affect the blood ?
Blood volume increased by 30%
Increase in coagulant activity
Rise in fibrinogen, factors VII, VIII and X
249
How does pregnancy affect the urinary system ?
Blood flow increases by 30%
GFR increases by 30-60%
Salt and water reabsorption increased by sex steroid levels
Trace glycosuria is common
250
What does pregnancy affect the liver ?
Hepatic blood flow not affected
ALP raises by 50%
Albumin levels fall
251
How does pregnancy affect the uterus ?
100g —— > 1100g
Hyperplasia then hypertrophy
Increase in cervical ectropion and discharge
252
What are some risks of smoking during pregnancy ?
Increased risk of miscarriage
Increased risk of pre-term labour
Increased risk of stillbirth
IUGR
Increased risk of sudden unexpected death in infancy
253
How does alcohol affect pregnancy ?
Foetal alcohol syndrome ( learning difficulties, smooth philtrum, small palpebral fissues, Microcephaly )
254
What are the maternal risks of cocaine during pregnancy ?
Hypertension including pre-eclampsia
Placental abruption
255
What are the foetal risks of cocaine during pregnancy ?
Prematurity
Neonatal abstinence syndrome
256
How does heroin affect pregnancy ?
Risk of neonatal abstinence syndrome
257
What can prematurity put a neonate at risk of ?
Increased mortality depending on gestation
Respiratory distress syndrome
Intraventricular haemorrhage
Necrotising enterocolitis
Chronic lung disease
Retinopathy of prematurity
Hearing impairment
258
What are some complications of preterm prelabour rupture of the membranes ?
Foetal - prematurity, infection, pulmonary hypoplasia
Maternal - chorioamnionitis
259
How can you diagnose preterm prelabour rupture of the membranes ?
Sterile speculum exam - look for pooling of amniotic fluid in the posterior vaginal vault
USS to assess for oligohydraminos
260
What is the management of preterm prelabour rupture of the membranes ?
Admission
Regular observation
Oral erythromycin for 10 days
Antenatal corticosteroids should be given
Delivery should be considered at 34 weeks gestation
261
What is puerperal pyrexia ?
Defined as a temperature of more than 38 degrees in the first 14 days following delivery
262
What are some causes of puerperal pyrexia ?
Endometritis
UTI
Wound infection
Mastitis
VTE
263
What is the management of puerperal pyrexia if it is caused by Endometritis ?
Referred to hospital for IV abx ( clindamycin and gentamycin until afebrile for greater than 24 hours
264
What can reduced foetal movements indicate ?
Foetal distress as it is a method of foetal compensation to reduce oxygen consumption as a response to chronic hypoxia.
265
What is quickening in pregnancy ?
The first onset of recognised foetal movements
266
When does quickening occur ?
18 - 20 weeks gestation and increase til 32 weeks
267
What is considered concerning and warranting a further assessment in foetal movement ?
Less than 10 movements within 2 hours in pregnancies past 28 weeks gestation
268
What are some risk factors for reduced foetal movements ?
Posture ( more prominent when lying down, less when sitting in standing )
Distraction ( if a woman is busy )
Placental position ( anterior have lesser awareness )
Medication ( alcohol, benzos or opiates )
Body habits ( obesity )
Oligohydraminos and polyhydraminos
269
What are some investigations for reduced foetal movements ?
Maternal perception
Objective - handheld Doppler or ultrasonography
270
Why is it concerning if a mother is rhesus D negative and the baby is rhesus D positive ?
If a rhesus D - mother delivers a rhesus D + baby a leak of foetal red blood cells may occur.
This causes the mother to create anti-D IgG antibodies.
In later pregnancies these can cross the placental barrier and cause haemolysis in the foetus
271
How is haemolysis of a newborn from rhesus D prevented ?
Test for rhesus D antibodies in all rhesus D - mothers
Advise giving anti-D to non-sensitised mothers at 28 and 34 weeks
Anti-D immunoglobulin should be given
272
If a foetus is affected by rhesus D haemolysis how does it present ?
Oedematous ( hydrops fetalis )
Jaundice, anaemia and hepatosplenomegaly
Heart failure
Kernicterus
273
What is the management of a foetus affected by rhesus D haemolysis ?
Transfusions
UV phototherapy
274
Is methotrexate considered safe in pregnancy ?
No and should be stopped at least 6 months before conception
275
Are NSAIDs safe to use in pregnancy ?
They may be used until 32 weeks but after this should be stopped due to risk of early closure of the ductus arteriosus
276
Is sulfasalazine or hydroxychloroquine safe to use in pregnancy ?
Yes
277
What is rubella ?
A viral infection caused by the togavirus.
Now is rare
278
What are some features of congenital rubella syndrome ?
Sensorineural deafness
Congenital cataracts
Congenital heart disease
Growth retardation
Hepatosplenomegaly
Purpuric skin lesions
Microphthalmia
Cerebral palsy
279
What is shoulder dystocia ?
A complication of vaginal Cephalic delivery.
Entails the inability to deliver the body of the foetus using gentle traction with the head having already been delivered.
Occuring due to impaction of the anterior foetal shoulder on the maternal pubic symphysis
280
What are the risk factors for shoulder dystocia ?
Foetal macrosomia
High BMI
DM
Prolonged labour
281
What is the management of shoulder dystocia ?
Senior help should be called as soon as shoulder dystocia is identified.
McRobert’s manoeuvre should be performed
282
How is the McRobert’s manoeuvre performed ?
Entails flexion and abduction of the maternal hips, bringing the mothers thighs towards her abdomen
This rotation increases the relative anterior-posterior angle of the pelvis
283
What are some potential maternal complications of shoulder dystocia ?
Postpartum haemorrhage
Perineal tears
284
What are some potential foetal complications of shoulder dystocia ?
Brachial plexus injury
Neonatal death
285
What is symphysis - fundal height ?
Measured from the top of the pubic bone to the top of the uterus in cm.
286
What is foetal lie ?
The term which refers to the long axis of the foetus relative to the longitudinal axis of the uterus
287
What are the 3 types of foetal lie ?
Longitudinal ( 99.7% )
Transverse ( 0.3% )
Oblique ( less than 0.1% )
288
What are some risk factors for a transverse lie of a foetus ?
Previous pregnant
Fibroids and other pelvic tumour
Twins or triplets
Prematurity
Polyhydraminos
289
How is a diagnosis of transverse lie of a foetus found ?
Detected during routine antenatal visits :
- abdo exam
- USS
290
What are some complications of transverse lie of a foetus ?
Preterm rupture of membranes
Cord prolapse
291
What is the management of a transverse lie of the foetus before 36 weeks ?
No management required
Most foetuses will spontaneously move into the longitudinal lie
292
What is the management of a transverse lie of the foetus after 36 weeks ?
Active management - external Cephalic version of the foetus
Elective c section ( where ECV is unsuccessful or contraindicated )
293
What is a dizygotic twin ?
Non-identical twins and develop from 2 separate ova that were fertilised at the same time
294
What are monozygotic twins ?
Identical and develop from a single ovum which has divided to form two embryos
295
What are monoamniotic monozygotic twins associated with ?
Increased spontaneous miscarriage
Perinatal mortality rate
Increased malformations
IUGR
Prematurity
296
What are some pre-disposing factors for dizygotic twins ?
Previous twins
FH
Increasing maternal age
Multigravida
Induced ovulation or IVF
Race - Afro-Caribbean
297
What are some antenatal complications of twins ?
Polyhydraminos
Pregnancy induced hypertension
Anaemia
Antepartum haemorrhage
298
What are some labour complications of having twins ?
Increased risk of Postpartum haemorrhage
Malpresentation
Cord prolapse
Cord entanglement
299
What are some considerations and management of having twins ?
Rest
USS for diagnosis
Additional iron and folate
Precaution with labour
300
When does a nuchal scan take place ?
11-13 weeks
301
What are some causes of increased nuchal translucency ?
Down’s syndrome
Congenital heart defects
Abdominal wall defects
302
What are some causes of a hyperechogenic bowel ?
CF
Down’s syndrome
CMV infection
303
What is an umbilical cord prolapse ?
Involves the umbilical cord descending ahead of the presenting part of the foetus.
304
If umbilical cord prolapse is left untreated what can occur ?
Compression in the cord or cord spasm which can cause foetal hypoxia and irreversible damage or death
305
What are some risk factors for cord prolapse ?
Prematurity
Multiparty
Polyhydraminos
Twin pregnancy
Abnormal presentations - breech, transverse lie
306
What is the management of cord prolapse ?
It is an obstetric emergency
The presenting part of the foetus is pushed back into the uterus to avoid compression.
Go on all fours until preparations for an immediate c section
Tocolytics can be used to reduce contractions
Emergency C section
307
What are some risk factors for a pregnant lady developing a VTE ?
Age over 35
BMI over 30
Parity over 3
Smoker
Gross varicose veins
Current pre-eclampsia
Immobility
Multiple pregnancy
IVF pregnancy
308
What is the treatment of choice for VTE prophylaxis in pregnancy ?
Low molecular weight heparin
309
How long should a couple be struggling with conceiving a child naturally before further investigations be started ?
12 months without success
310
What are the most common causes of infertility ?
Sperm problems
Ovulation problems
Tubal problems
Uterine problems
Unexplained
311
What is some general advice for couples trying to get pregnant ?
Women should take 400mcg folic acid daily
Aim for a healthy BMI
Avoid smoking and drinking excessive alcohol
Reduce stress
Aim for intercourse every 2-3 days
Avoid timing intercourse
312
What is timed intercourse ?
Timing it to coincide with ovulation which is not necessary or recommended as it can lead to stress and pressure in a relationship
313
What are some initial investigations to be performed in primary care if a couple are struggling to conceive ?
BMI
Chlamydia screening
Semen analysis
Female hormonal testing
314
What are further investigations to perform in secondary care if a couple are struggling to conceive ?
USS pelvis
Hysterosalpingogram - patency of Fallopian tubes
315
What is a hysterosalpingogram ?
A type of scan used to assess the shape of the uterus and the patency of the fallopian tubes.
316
how is a hysterosalpingogram performed ?
A small tube is inserted into the cervix and contrast is injected into the uterine cavity and Fallopian tubes and an X-ray is taken.
317
what are some complications of doing a hysterosalpingogram ?
Infection so antibiotics are given for prophylaxis
318
What is the management for infertility caused by anovulation ?
Weight loss
Clomifene
Letrozole
Gonadotropins
319
What is Clomifene ?
An anti-oestrogen
Given on days 2-6 of the menstrual cycle.
Stops the negative feedback of oestrogen on the hypothalamus resulting in a greater release of LH and FSH.
320
What is the management of infertility if caused by tubal factors ?
Tubal cannulation during hysterosalpingogram
Laparoscopy to remove lesions or endometriosis
IVF
321
What is the management of infertility if caused by uterine factors ?
Surgery to correct polyps, adhesions or structural abnormalities
322
What is the management of infertility if caused by sperm problems ?
Surgical sperm retrieval
Surgical correction
Intra-uterine insemination
Donor insemination
323
What are some factors that affect semen analysis and sperm quality and quantity ?
Hot baths
Tight underwear
Smoking
Alcohol
Raised BMI
Caffeine
324
What is in vitro fertilisation ?
Involves fertilising an egg with sperm in a lab then injecting the embryo into the uterus.
325
What is the process of IVF ?
Suppressing the natural menstrual cycle
Ovarian stimulation
Oocyte collection
Insemination sperm injection
Embryo culture
Embryo transfer
326
What are the complications of IVF ?
Failure
Multiple pregnancy
Ectopic pregnancy
Ovarian hyperstimulation syndrome
327
What is an early miscarriage ?
Spontaneous termination of a pregnancy before 12 weeks gestation
328
What is a late miscarriage ?
Spontaneous termination of a pregnancy between 12 and 24 weeks gestation
329
What is a missed miscarriage ?
The foetus is no longer alive but no symptoms
330
What is the investigation of choice for diagnosing a miscarriage ?
Transvaginal USS
331
What are the features to look for on an USS for assessing the viability of a pregnancy ?
Mean gestational sac diameter
Foetal pole and crown rump length
Foetal heartbeat
332
What is misoprostol ?
A prostaglandin analogue meaning it binds to prostaglandin receptors and activates.
This softens the cervix and stimulates uterine contractions.
333
What is the medical management of a miscarriage ?
A dose of misoprostol to expedite the process of miscarriage.
This can be a vaginal suppository or an oral dose
334
What are the key side effects of misoprostol ?
Heavier bleeding
Pain
Vomiting
Diarrhoea
335
What is the surgical management of a miscarriage ?
Manual vacuum aspiration under local
Electric vacuum aspiration under general
336
What is manual vacuum aspiration ?
Local anaesthetic to the cervix.
A tube is inserted with a syringe into the uterus to aspirate contents of the uterus.
337
What is electric vacuum aspiration ?
Traditional surgical management of miscarriage under general anaesthetic.
The operation is performed through the vagina and cervix without any incisions.
The cervix is gradual at widened using dilators and products are removed the cervix using an electric powered vacuum.
338
What is an incomplete miscarriage ?
This occurs when retained products of conception remain in the uterus after the miscarriage.
339
What is a risk of a incomplete miscarriage ?
Infection
340
What are some causes of miscarriage ?
Idiopathic especially in older women
Antiphospholipid syndrome
Hereditary Thrombophilias
Uterine abnormalities
Genetic factors
Chronic diseases - DM, untreated thyroid disease and SLE
341
What can be given to reduce the risk of recurrent miscarriages in antiphospholipid syndrome ?
Low dose aspirin
Low molecular weight heparin
342
What are some hereditary thrombophilias ?
Factor v Leiden
Factor II gene mutation
Protein S deficiency
343
What are some uterine abnormalities that can cause recurrent miscarriages ?
Uterine septum - partition through the septum
Unicornutae uterus - single horned uterus
Cervical insufficiency
Fibroids
344
What are some investigations for recurrent miscarriages ?
Antiphospholipid antibodies
Testing for hereditary thrombophilias
Pelvic USS
Genetic testing
345
Until what gestational age can an abortion be performed ?
Up to 24 weeks
346
What is the criteria for an abortion ?
Before 24 weeks
If continuing the pregnancy involves greater risk to the physical health or mental health to the :
- the woman
- existing children of family
347
What is the legal requirements for an abortion ?
2 registered medical practitioners must sign to agree to an abortion
Must be carried out by a registered medical practitioner in an NHS or approved premise
348
What is mifepristone ?
An anti-progestogen medication that blocks the action of progesterone halting pregnancy and relaxing the cervix.
349
What are the 2 medical abortion treatments ?
Mifepristone
Misoprostol
350
After how long is a pregnancy test performed after an abortion ?
3 weeks
351
What are some complications of an abortion ?
Bleeding
Pain
Infection
Failure to the abortion
Damage to the cervix, uterus or other structures
352
What hormone is thought to be responsible for nausea and vomiting in pregnancy ?
hCG
353
What are the features needed to diagnose hyperemesis gravidarum ?
Protracted NVP
+
More than 5% weight loss compared with before pregnancy
Dehydration
Electrolyte imbalance
354
What are some medications that can be given for nausea and vomiting in pregnancy ?
( order of preference )
1 . Prochlorperazine
2 . Cyclizine
3 . Ondansetron
4 . Metoclopramide
355
At what stage of pregnancy is the symphysis fundal height measured ?
24 weeks onwards
356
Which 2 vaccines should be offered to all pregnant women ?
Whooping cough from 16 weeks
Influenza when available
357
What are some vaccines that should be avoided in pregnancy ?
Live vaccines such as MMR
358
What is the booking clinic ?
The initial appointment to discuss the pregnancy and arrange plans for the pregnancy.
This ideally occurs before 10 weeks gestation.
359
What bloods are performed in the booking clinic ?
Blood group, antibodies and rhesus D
FBC
Screening for thalassaemia
Antibodies for HIV, hepatitis B and syphilis
360
When is the triple test performed ?
14 to 20 weeks gestation
361
What blood tests are included in the triple test ?
Beta hCG
AFP
Serum oestriol
362
What results of the triple test indicate Down’s syndrome ?
Higher beta-hCG
Lower AFP
Lower serum oestriol
363
What are some antenatal tests for Down’s syndrome ?
Chorionic villus sampling
Amniocentesis
364
What is chorionic villus sampling ?
Involves an ultrasound - guided biopsy of the placental tissue
365
What is an amniocentesis ?
Involves ultrasound guided aspiration of amniotic fluid using a needle and syringe.
366
How can untreated or undertreated hypothyroidism affect pregnancy ?
Miscarriage
Anaemia
Small for gestational age
Pre-eclampsia
367
How should hypothyroidism in pregnancy be treated ?
Increased dose of levothyroxine by 25-50 mcg
368
Which anti-hypertensive medication should be stopped in pregnancy ?
ACEi
Angiotensin receptor blockers
Thiazide and thiazide like diuretics
369
Which epilepsy medication should be stopped during pregnancy ?
Phenytoin - cleft palate and lip
Sodium valproate
370
Which DMARDs should be avoided in pregnancy ?
Methotrexate as it is teratogenic and can cause miscarriage and congenital abnormalities
371
Which DMARDs are safe in pregnancy ?
Hydroxychloroquine
Sulfasalazine
372
How can beta blockers affect pregnancy ?
Foetal growth restriction
Hypoglycaemia in the neonate
Bradycardia in the neonate
373
How can ACEi and ARB’s affect pregnancy ?
Oligohydraminos
Miscarriage or foetal death
Renal failure in the neonate
Hypotension in the neonate
374
How can warfarin affect pregnancy ?
Foetal loss
Congenital malformations - craniofacial problems
Bleeding during pregnancy - PPH, foetal haemorrhage and intracranial bleeding
375
Which dermatological medication should be avoided in pregnancy and why ?
Isotrentinoin - teratogenic
Causes miscarriage and congenital defects
376
What are the features of congenital CMV ?
Foetal growth restriction
Microcephaly
Hearing loss
Vision loss
Learning disability
Seizures
377
What can parvovirus B19 cause in pregnancy ?
Miscarriage or foetal death
Severe foetal anaemia
Hydrops fetalis
Maternal pre-eclampsia like syndrome
378
What are some features of congenital Zika virus ?
Microcephaly
Foetal growth restriction
Ventriculomegaly and cerebellar atropy
379
What are some placenta mediated growth restriction ?
Idiopathic
Pre-eclampsia
Maternal smoking
Maternal alcohol
Anaemia
Malnutrition
Infection
Maternal health conditions
380
What are some short term complications of foetal growth restrictions ?
Foetal death or stillbirth
Birth asphyxia
Neonatal hypothermia
Neonatal hypoglycaemia
381
What are some risk factors of small for gestational age foetuses ?
Previous small baby
Obesity
Smoking
DM
Existing hypertension
Pre-eclampsia
Older mother ( 35 )
Multiple pregnancy
Antepartum haemorrhage
Antiphospholipid syndrome
382
What are some causes of macrosomia ?
Constitutional
Maternal diabetes
Previous macrosomia
Maternal obesity or rapid weight gain
Overdue
Male baby
383
What are some risks to the mother in macrosomia ?
Shoulder dystocia
Failure to progress
Perineal tears
Instrumental delivery or c section
PPH
Uterine rupture
384
What are some risks to the baby in macrosomia ?
Birth injury
Neonatal hypoglycaemia
Obesity in childhood and later life
T2DM
385
What are some investigations for a large for gestational age baby ?
USS to exclude polyhydraminos and estimate the foetal weight
Oral glucose tolerance test for gestational diabetes
386
Which antibiotics for a UTI should be avoided in certain parts of pregnancy ?
Nitrofurantoin in third trimester
Trimethoprim in first trimester
387
Why should trimethoprim be avoided in pregnancy ?
It is a folate antagonist.
It can cause congenital malformations - neural tube defects ( spina bifida )
388
how is obstetric cholestasis managed ?
Symptoms of itching
- emollients and antihistamines
389
What is polymorphic eruption of pregnancy ?
Pruritic and urticarial papules and plaques of pregnancy.
Starts as an itchy rash in the third trimester
390
What are the features of polymorphic eruption of pregnancy ?
Urticarial papiles
Wheals
Plaques
391
What is atopic eruption of pregnancy ?
Refers to eczema that flares up during pregnancy
Presents in the 1st and 2nd trimester
392
What is melasma ?
( mask of pregnancy )
Increased pigmentation to patches of the skin on the face - usually symmetrical and flat
393
What are the reversible causes of cardiac arrest ?
4T’s -
- thrombosis
- tension pneumothorax
- toxins
- tamponade ( cardiac )
4H’s -
- hypoxia
- hypovolaemia
- hypothermia
- hyperkalaemia, hypoglycaemia
394
What are the 3 major causes of cardiac arrest in pregnancy ?
Obstetric haemorrhage
Pulmonary embolism
Sepsis
395
What are some causes of obstetric haemorrhage ?
Ectopic pregnancy
Placental abruption
Placenta praevia
Placenta accreta
Uterine rupture
396
What are Braxton Hicks contractions ?
Occasional irregular contractions of the uterus where the woman experiences temporary and irregular tightening or mild cramping in the abdomen.
Usually felt in the 2nd and 3rd trimester
397
What advice can be given to help reduce braxton-hicks contractions ?
Stay hydrated and relaxing
398
What are some signs indicating the onset of labour ?
Show ( mucus plug from the cervix )
Rupture of membranes
Regular painful contractions
Dilating cervix on examination
399
What is rupture of membranes ?
The amniotic sac has ruptured spontaneously
400
What is prelabour rupture of the membranes ?
The amniotic sac has ruptured before onset of labour
401
What is preterm prelabour rupture of the membranes ?
The amniotic sac has ruptured before the onset of labour and before 37 weeks gestation
402
What is prolonged rupture of the membranes ?
The amniotic sac ruptures more than 18 hours before delivery
403
What is the definition of prematurity ?
Birth before 37 weeks
404
At what gestational age is resuscitation not considered if no signs of life are seen ?
23-24 weeks
405
At what gestational age are babies deemed non-viable ?
Below 23 weeks gestation
406
What are some prophylaxis options for preterm labour ?
Vaginal progesterone
Cervical cerclage
407
How does vaginal progesterone work as prophylaxis for preterm labour ?
Progesterone has a role in maintaining pregnancy and preventing labour by decreasing activity of the myometrium and preventing the cervix remodelling in preparation for delivery.
408
What is cervical cerclage ?
Involves putting a stitch in the cervix to add support and keep it close which is removed when the woman goes into labour.
409
How is preterm prelabour rupture of the membranes diagnosed ?
Using a speculum examination - revealing pooling of amniotic fluid in the vagina.
410
What is the management of preterm prelabour rupture of the membranes ?
Prophylactic antibiotics should be given to prevent chorioamnionitis - erythromycin
Induction of labour may be offered from 34 weeks
411
What is preterm labour with intact membranes ?
Involves regular painful contraction and cervical dilation without rupture of the amniotic sac.
412
How is a diagnosis of preterm labour with intact membranes made ?
Less than 30 weeks - clinical assessment
More than 30 weeks - a transvaginal USS can be used to assess cervical length
413
What management options are available for preterm labour with intact membranes ?
Feotal monitoring
Tocolysis with nifedipine
Maternal corticosteroids - before 35 weeks
IV magnesium sulphate - before 34 weeks
Delayed cord clamping or cord milking
414
What is tocolysis ?
Involves using medications to stop uterine contractions
415
What medication is preferred for tocolysis and how does it work ?
Nifedipine - a CCB that suppresses labour
416
When can tocolysis be used ?
24 - 33+6 gestation
417
What can help reduce respiratory distress syndrome in foetuses ?
Giving the mother corticosteroids to help develop the foetal lungs
418
Why is IV magnesium sulphate beneficial in preterm babies ?
Helps protect the foetal brain during premature delivery and reduces the risk and severity of cerebral palsy
419
When should magnesium sulphate be given to mothers of preterm babies ?
Within 24 hours of delivery
420
What are some signs of magnesium toxicity ?
Reduced respiratory rate
Reduced blood pressure
Absent reflexes
421
What are infusions of oxytocin used for ?
Indication of labour
Progress labour
Improve the frequency and strength of uterine contractions
Prevent or treat postpartum haemorrhage
422
Where is oxytocin released from ?
Secreted by the posterior pituitary gland and produced by the hypothalamus
423
What is the function of oxytocin ?
Effects on mood and social interactions in everyday life but plays a vital role in labour and delivery.
424
What role does oxytocin play in labour ?
Stimulates ripening of the cervix and contractions of the uterus
425
What does ergometrine do ?
Stimulates smooth muscle contraction both in the uterus and blood vessels.
426
What are some side effects of ergometrine ?
Hypertension
Diarrhoea
Vomiting
Angina
427
When should ergometrine be avoided ?
Eclampsia
428
What is terbutaline ?
A beta 2 agonist
Acts on the smooth muscle of the uterus to suppress uterine contractions
429
What is the indication for terbutaline in pregnancy ?
Tocolysis in uterine hyperstimulation
430
What is carboprost ?
A synthetic prostaglandin analogue stimulating uterine contractions
431
When is carboprost given ?
In postpartum haemorrhage where ergometrine and oxytocin have been inadequate.
432
When does carboprost need to be avoided ?
In asthma as it can cause a potentially life threatening exacerbation of asthma
433
what are some options for pain relief during labour ?
Simple analgesia
Entonox
IM pethidine and diamorphine
Patient controlled analgesia
Epidural
434
What is an epidural ?
Involves inserting a small tube into the epidural space in the lower back and local anaesthetic is infused through it
435
What medications can be infused during an epidural ?
Levobupivacaine or bupivacaine mixed with fentanyl
436
What are the adverse effects of an epidural ?
Headache after insertion
Hypotension
Motor weakness in the legs
Nerve damage
Prolonged second stage
Increased probability of instrumental delivery
437
What is uterine inversion ?
A rare complication of birth where the fundus of the uterus drops down through the uterine cavity and cervix turning the uterus inside out.
438
How does uterine inversion present ?
Large post partum haemorrhage
Maternal shock or collapse
439
What are the options for treating uterine inversion ?
Johnson manoeuvre
Hydrostatic methods
Surgery
440
What is the Johnson manoeuvre ?
It involves using a hand to push the fundus back up into the abdomen and the correct position. The whole hand and forearm will be inserted into the vagina to return the fundus to the correct position.
It is held there for several minutes while medications are given to creat uterine contraction
441
What is hydrostatic methods for the management of uterine inversion ?
Involves filling the vagina with fluid to inflate the uterus back to the normal position
It requires a tight seal at the entrance of the vagina which can be challenging.
442
In the days after delivery what support and care is provided ?
Analgesia
Help establish breast or bottle feeding
VTE risk assessment
Monitoring for PPH
Monitoring for sepsis
Monitoring BP
FBC
Routine baby check
443
What topics are covered in the 6 week postnatal check ?
General wellbeing
Mood and depression
Bleeding and menstruation
Scar healing
Contraception
Breastfeeding
Fasting blood glucose - gestational diabetes
BP
Urine dip
444
What is menstruation like after birth ?
There will be vaginal bleeding as the endometrium initially breaks down.
There is a mix of blood, endometrial tissue and mucus called lochia.
Initially red in colour then will turn brown and become lighter in flow and colour.
445
How long after childbirth is fertility not considered ?
Until 21 days
446
How long is lactational amenorrhoea an effective contraception ?
For up to 6 months after birth
447
How can postpartum Endometritis present ?
Foul smelling discharge or lochia
Bleeding that gets heavier or does not improve with time
Lower abdo or pelvic pain
Fever
Sepsis
448
How is a diagnosis of postpartum Endometritis made ?
Vaginal swabs
Urine culture and sensitivities
449
What is postpartum anaemia ?
Defined as a haemoglobin of less than 100 g/l in the postpartum period
450
In what circumstances is a FBC performed the day after delivery ?
PPH over 500ml
C section
Antenatal anaemia
Symptoms of anaemia
451
If the Hb is under 100g/l what treatment should be given for postnatal anaemia ?
Start oral iron ( ferrous sulphate 200mg 3x daily )
452
If the Hb is under 90g/l what treatment should be given for postnatal anaemia ?
Comsider an iron infusion in addition to oral iron
453
If the Hb is under 70g/l what treatment should be given for postnatal anaemia ?
Blood transfusion in addition to oral iron
454
What is sheehan’s syndrome ?
A rare complication of PPH where the drop in circulating blood volume leads to avascular necrosis of the pituitary gland.
Low blood pressure and reduced perfusion of the pituitary gland leads to ischaemia in the cells of the pituitary gland and cell death.
455
What part of the pituitary gland is affected in sheenan’s syndrome ?
Anteior
456
How does Sheenan’s syndrome present ?
Reduced lactation
Amenorrhoea
Adrenal insufficiency and adrenal crisis
Hypothyroidism
457
What is the management of shenaan’s syndrome ?
Oestrogen and progesterone as hormone replacement therapy
Hydrocortisone
Levothyroxine
Growth hormone
