Obstetrics Flashcards
(212 cards)
1
Q
peritoneal bleeding from ectopic can cause
A
shoulder tip pain and pain on peeing and pooing
2
Q
bleeding at 6-9 weeks
A
think ectopic or miscarriage. ectopic liekly to also present with pain
3
Q
tense tender uterus
A
placental abruption
4
Q
while preg pain over pubic symphysis with radiation to groin and medial aspect of thighs
A
symphysis pubis dysfunctio
5
Q
pain in pre- eclampsia/ HELLp sydnrome is typically
A
epigastric or in RUQ
6
Q
rf for uterine rupture
A
previous c section
7
Q
increeased AFP
A
neural tube defects
abdo wall defects eg omphatocele/ gastroschisis
multiple preg
8
Q
decreases AFP casues
A
downs synd
trisomy 18
materna diabetes
9
Q
amniotic fluid embolism presetn swith
A
chills, shivering,sweating , coughing, cyanossi , hypotension …
10
Q
amniotic fluid embolism is when
A
fetal cells/amniotic fluid neters the mothers blood stream
11
Q
antental care
A
folic acid from before conception to 12 weeks (400mcg)
vit D
12
Q
preg women should avoid
A
vit D and liver as high in vit A
unpasterurised milk ripened soft cheese eg Camember, brie, pate or undercooked meat (listeria)
Salmonella - avoid raw or partially cooked eggs and meat
singleton preg no fly after 37 weeks and 32 if multiplepreg
avoid high impact sports
13
Q
N+V
A
ginger and wrist bands recomended and antihistmaines. BNF recomenned promethazine
14
Q
antepartum haemorrhage defined as bleeding after
A
24 weeks
15
Q
vag exam should not be performed in any women with antepartum haemorrhage
A
as women with placenta praevia may haemorrhage
16
Q
2 cuases of antepartum haemorrhage
A
placental abruption and placental praevia
17
Q
bleeding in first trimester
A
miscarriage
ectopic
Hydatidiform mole
18
Q
bleeding in 3 trimester
A
bloody show
placental abruption
placental praevia
vasa praevia
19
Q
STI and cervical polyps should be excluded as a cause of bleeeding in preg
A
20
Q
Typically bleeding in first or early second trimester associated with exaggerated symptoms of pregnancy e.g. hyperemesis. The uterus may be large for dates and serum hCG is very high
A
Hydatidiform mole
21
Q
how does vasa praevia present
A
rupture of membranes followed immediately by vaginal bleeding. Fetal bradycardia is classically seen
22
Q
what can cause nipple pain when breastfeeding
A
blocked duct - advice on positioning of baby and breast masssage
23
Q
nipple candidiasis treatmetn
A
miconazole cream for mother and nystatin for baby
24
Q
treat mastitis if symptoms font improve after
A
12-24hrs of effective milk removal & if culture indicates infection
25
engorgent occurs first few days after baby born and almost always affects both breasts
pain is typically worse just ebfore a feed
26
engorgement can
make it hard for baby to attach and suckle. fever may be presetn but usually settles after 24hrs. breasts can appear red. although it may be initially painful, hand expression of milk may help relieve the discomofrt
27
baby losing more than 10% of weight in first week of life, need review
midwife clinic
28
contraindication to breast feeding
galactosaemia
viral infections
29
drug that can supress lactation
cabergoline
30
most common type of breech
frank
31
worrying breech
footling
32
when do external cephalic version if breech
36 weeks
33
msot common c section
lower segment
34
c section categories
1- 30mins
2- 75 mins
3- mother and baby stable
4 - elective
35
contraindications to having vaginal birth if had
previous uterine rutpure or classical c section ( so not a lower segment c section which is mcuh more common)
36
normal fetal heart rate
100-160
37
normal feature that indicates head compression
early deceleration ( deceleration of heart at onset of contraction)
38
variable decelerations indicates
cord compression
39
Risk of what to preg mother if get chickenpox
5 times greater risk of pneumonitis
40
fetal varicella sydnrome has
skin scarring, eye defects, limb hypoplasia
41
chicken pox exposure in preg (post exposure prophylaxis)
any suspcition - maternal blood should be urgenty checked for varicella antibodes
- antivirals should be given at day 7-14 after exposure, not immediately
42
preg women >20weeks with chickenpox +rash
oral aciclovir
43
major rf of chorioamnionitis
preterm premature rupture of membranes
44
mx of chorioamnionitis
prompt delivery of baby and IV antibiotics
45
antental testing for downs
increased HCG
thickened nuchal translucency
decreased PAPP-A
(patuau and edwards syndrome give simialr results but the hCG tends to be lower)
46
when is combined test doen (11-14 weeks)
47
quadruple test done
15-20 week
48
downs results of quadruple test
low afp
low oestriol
raised Hcg
raised inhibin A
49
results of downs either give a low chance or high chanc of
1 in 150 less or more than this
50
after combined/quadruple test if high chance then offered
Non invasive prenatal sceenign test or amniocentessis or CVS
(NIPT is preferred)
51
NIPT
analyses DNA fragments in women (cell fetal free DNA testing ) highly sensitive and specific
52
eclampsia if after how many weeks
20
53
what is given in pre eclampsia to prevent seizure and treat seizures
Mag sulphate
54
once given mag sulphate for pre eclampsia monirot
Urine output, resp rate and ox sats
55
mag sulphaet in pre eclampsia can cause resp depression what is teh first line treatment for this
Calcium gluconate
56
Mg sulphate should continue for how long after last seizure or delivery
24hrs
57
avoid what in pre eclampsia
fluid overload
58
antiepileptic known to cause cleft palate
phenytoin
59
antiepileptic in breastfeeding
genrally considered safe to breastfeed with the excpetion of barbiturates
60
It is advised that pregnant women taking phenytoin are given vitamin K in the last month of pregnancy to prevent clotting disorders in the newborn
61
what antiepileptic is considered the least teratogenic of the older epileptics
carbamazepine
62
good source of folic acid
green leafy veg
63
4 cuases of folic acid def
phenytoin
methotrexate
preg
alcohol excess
64
BMI over what should take 5mg instead of 400mcg of folic acid
30
65
galactocele typiclaly occur
in women who have recently stopped breastfeeding
66
women who've previosuly had gestational diabetes
OGTT right away and at 24-28
67
threhold for gestational diabetes
fasting>5.6
2 hr >7.8
68
mx of gestational diabetes
referred to joint diabtes and antenatal clinic
self monitoring of blood glucose
low hylcaemic index
69
mx if fasting <7
trial of diet and exercise, if targerts mot met within 1-2 weeks should start metformin. if still not met then add short acting insulin
70
alternative drug if cannot tolerate methotrexate
glibenclamide
71
mx of pre existing diabetes in preg
stop oral hypogylcaemic apart from metformin and start insulin
folic acid
72
what in diabetics can worsen during preg
retinopathy
73
benign tumour of trophoblastic material
Complete hydatidiform mole
74
what mole has 46 paternal chromosmes
complete - empty egg fertilised by a single sperm that duplicates its own DNA
75
Features
bleeding in first or early second trimester
exaggerated symptoms of pregnancy e.g. hyperemesis
uterus large for dates
very high serum levels of human chorionic gonadotropin (hCG)
hypertension and hyperthyroidism* may be seen
complete hydatidiform mole
76
mx of complete hydatidofrm mole
urgent referral to specialist care anad evacuation of uterus
effective contraception is recommneded to avoid preg in the next 12 montsh
77
around 2-3 of complete hydatidiform mole go on to develop
choriocarcinoma
78
why can hyperthytroidism be seen in complete hydatiform mole
hCG can mimic TSH
79
partial mole
normal haploid egg fertilised by 2 sperm or one sperm that suplciates teh paternal chromostome. So there is both maternal and paternal. usually triploid and fetal parts may be seen
80
women had group B sterp in prev preg then risk of gbs is 50% so should be offered
antibiotic prophylaxis or testing in late preg and tehn antibiotics if still pos
81
if women to have swabs for GBS should be done
3-5 weeks before anticiapted delviery date
82
intra partum antibiotic prophylaxis for group B strep should also be given to preterm labour regardless of their GBS status
also should be given if got pyrexia during labour e.g >38
83
what is the antibiotic of choice for group B strep
benzylpenicilin
84
HELP can present with
N+V and RUQ pain
85
treatment for HELP
delivery baby
86
all women should be offered screening for HEP B
if chroncially infected or if had acute hep B infection during preg should receive
complete course of hep B vaccination and immunoglobilin
(Hep B cannot be trasmitted via breastfeeding in contrast to HIV)
87
Factors which reduce vertical transmission (from 25-30% to 2%)
maternal antiretroviral therapy
mode of delivery (caesarean section)
neonatal antiretroviral therapy
infant feeding (bottle feeding)
HIV
88
all women with HIV in preg
should be offered antiretroviral tehrapy
89
when can you do vaginal delivery in HIV mother
if viral loas is less than 50 copies/ml at 36 weeks
90
in HIV mother an infusion of what should be started 4hrs before beginning the c section
zidovudine
91
can women breastfeed if HIV
no
92
neonatal antiretroviral therapy for HIV
if viral loas <50 = oral zidovudine. if not then triple ART should be given for 4-6 weeks
93
main role of human chorionic gonadotropin
prevent disintegration of the corpus luteum
94
hcg levels in preg
double apprx every 48hrs in first few weeks and peak around 8-10 weeks
95
when does blood pressure fall in preg
first trimester especillay the diastolic and continues to fall until 20-24 weeks
96
hypertension in preg
>140
>90
or increase above booking reading sys>30 or dia>15
97
women at risk of pre eclampsia eg if hyperetnsive?
aspirin from 12 weeks until birth
98
mx of hypertension in preg
oral labetaolol (first line)
oral nifedipine (if asthmatic)
hydralazine
99
pregnancy induced hypertension (after 20weeks)
resolves follwing birth (typcially one month after)
100
Bishop score <5
labour is unlikely to start without induction. >8 high chance of spontaenous labour
101
methods of inudction of labour
membrane sweep first babay - 40-41 weeks
had baby before - 41 weeks
prostaglandin e2 (dinoprostone)
prostaglandin E1 (misoprostol)
maternal oxtocin infusion
amniotomy (breaking of waters)
102
Nice recommend for induction of labour
Bishop score <6 = vaginal prostaglandin or oral misoprostol
>6 = amniotomy and IV oxytocin infusion
103
uterine hyperstimualtion refers to
prolonged and frequent uterine contractions
104
mx of uterine hyperstimulation
remove prostangaldins or oxytocin infsuion and consider tocolysis
105
intrahepatic cholestasis of preg assocaitd with an
increased risk of premature birth
106
features of intrahepatic cholestasis in preg
itch typcially owrse on palms, soles and abdomen
raised bilirubin
may have jaundice
107
mx of intrahepatic cholesatsis
induction of labour at 37-38 weeks
ursodeoxycholic acid
108
3 satges of labour
1- onset of true labour to cervix fully dilated
2- full dialtion to delviery of baby
3- delivery of baby to when palcenta and membranes have been completeld delivered
109
stage 1 has 2 phases
latent phase - 0-3cm (6hrs)
active = 3-10cm (normally 1cm/hr)
110
head normally delivers in occipito anterior but enters teh pelvis
occipito - lateral
111
stage 2 of labour can be divided into pass and active
passive no pushing
active - pushing
112
stage 2 of labour is less painful than 1st as
pushing masks pain
lasts approx 1hr
113
stage 2 is associated with
transient fetal bradycardia
114
lochia refers to
vaginal dsicharge containing blood mucous and uterine tissue which may continue for 6 weeks after childbirth
115
olighydramnios
amniotic fluid less than 500ml at 32-36 weeks
116
cuases of oligohydramnios
premature rupture of membranes
potter sequence
117
pottern sequence has
oligohydramnios, bilateral renal agenesis, pulmonary hypoplasia
118
perineal tear
1st - no muscle involvement 2nd- perineal muscle
3- involves ansl spincter
4- also affects rectal mucosa
119
mx of first and 2nd degree perineal teat
1- nothing
2nd- suturing on ward
120
Placenta accreta descibes the attachment of the placenta to the myometrium due to a defective
decidua basalis
121
there is a risk of what in placenta accreta
PPH
122
accreta = chorionic villi attach to myometrium
increta= chorionic villis ivade myometrium
percreta = chorionic villi invade perimetrium
123
placenta praevia describes
low lieing palcenta
124
what go to do before vag exam in placental praevia
US
125
placental praevia scan
US
126
I - placenta reaches lower segment but not the internal os
II - placenta reaches internal os but doesn't cover it
III - placenta covers the internal os before dilation but not when dilated
IV ('major') - placenta completely covers the internal os
127
mx of placenta praevia
if low lying at 20 week scan repeat at 32 weeks. if still present US eveery 2 weeks
128
if got placenta praevia no need to limit activity or intercourse unless
they bleed
129
final US is done at 36-37 weeks to determine method of delivery in placenta praevia
elective c section for grades 3/4 at 37-38 weks
if women with known placental praevia goes into labour before the elective c section and emergency c section should be performed due to the risk of PPH
130
if a women with known placental praevia goes into labour then do
emergency c section
131
major cause of death in women with placental praevia is
PPH
132
cocaine use increases risk of
placental abruption
133
tender tense uterus % shock out of keepin with visible loss
placental abruption
134
mx of placental abruption <36 weeks
fetal distress= immediate c section
no fetal distress = observe closely, steriods,
135
mx of placental abruption >36 weeks
fetal distress= immediate c section
no fetal distreess - delvier vaginally
136
if fetus dead in placental abruption
induce vaginal delivery
137
post term preg if beyond
42 weeks
138
primary PPH
occurs within 24hrs
139
4 T's of priamry PPH
tone trauma tissue thrombin
140
PPH mx
2 cannula
lie women flat
blood -group and dave
warm crystalloid
rub fundus
catheterisation to prevent baldder distension and mintor UO
med- slow Iv injection followed by IV infusion
ergometrine (unless history of hypertension)
carboprost (unless hisotry of asthma)
misoprostolol sublingual
141
first line surgery for PPH
intrauterine balloon tamponade
142
secondary PPH occurs between 24hrs - 12 weeks and is typically due to
retained placental tissue or endometritis
143
cant give ergometrine if
hypertensive
144
cant give carboprost if
asthmatic
145
postnatal depression mostly start within a month and typcially peak at
3 months
146
`puerperal psychosis onset isi usally within
2-3 weeks of birht
147
SSRIs that may be used in post natal depresson
sertraline and paroxetine
148
recurrence rate of postnatal psychosis is
25-50%
149
edinburgj post natal depression scale for
>13 indicates depressive illness
150
post partum thyroiditis causes
thyrotoxicossi then hypothyroid then normal
151
post partum thyroiditis mx
Management
thyrotoxic phase
propranolol is typically used for symptom control
not usually treated with anti-thyroid drugs as the thyroid is not overactive.
hypothyroid phase
usually treated with thyroxine
152
pre eclampsia
new onset hypertension
proteinuria
oedema
153
The current formal definition is as follows
new-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of the following:
proteinuria
other organ involvement (see list below for examples): e.g. renal insufficiency (creatinine ≥ 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction
pre eclampsia
154
what is seen in liver in pre eclampsia
elevated transaminases
155
pre eclampsia mx
emergency secondary care assessment
if BP>160/110 likley to be admitted and observed
mx - labetalol. Nifedipien id asthamtic and hydrazaoline
delivery of baby is most definitive mx
156
when are preg women screened for anemai
booking visit
28 weeks
157
Gestation
Cut-off
First trimester < 110 g/L
Second/third trimester < 105 g/L
Postpartum < 100 g/L
cut off for needing iron in preg
treatmetn should be continued for 3 months after iron def is corrected to allow iron stores to be replenished
158
dvt in preg
duplex US
159
Pe in preg
ECG and cxr in all pts
if duplex shows DVT then no further ix needed
V/Q or CTPA needs to be discussed
160
d dimer
useless in preg
161
CTPA vs V/Q
CTPA = icnreased risk of maternal breast cancer
v/q scan = icnreases risk of childhood cancer
162
intraheparic choelstasis of preg
itch often on palms and soles
raised bilirbin
ursodeoxycholic acid for symptom relief
weekly lfts, women are typcially induced at 37 weeks
complciations = increased rate of stillbirth
163
acute fatty liver of preg can occur when
3rd trimester or period immediatly follwing delviery
abdo pain
alt is typcially elevates
mx - supportive
delivery baby
164
obese in preg if BMI over
30
165
risk of obesity to preg
miscariage, prematurity, gesttional diabetes
- however should not diet while preg
166
Management
obese women should take 5mg of folic acid, rather than 400mcg
all obese women should be screened for gestational diabetes with an oral glucose tolerance test (OGTT) at 24-28 weeks
167
what is unaltered in preg
systolic BP
168
diastolic BP is reduced in 1st and 2nd trimester in preg but return to noraml by term
169
trace glycosuria is common due to the increased GFR and reduction in tubular reabsorption of filtered glucose
170
Braxton-Hicks: non-painful 'practice contractions' late in pregnancy (>30 wks)
171
Complications of PPROM
fetal: prematurity, infection, pulmonary hypoplasia
maternal: chorioamnionitis
pre term pre labour rupture of membrnes
172
Confirming PPROM
a sterile speculum examination should be performed (to look for pooling of amniotic fluid in the posterior vaginal vault) but digital examination should be avoided due to the risk of infection
if pooling of fluid is not observed, NICE recommend testing the fluid for placental alpha microglobulin-1 protein (PAMG-1) (e.g. AmniSure) or insulin-like growth factor binding protein-1 (IGFBP-1)
173
premature prerupture of membranes
amniotic fluid in the posterior vaginal vault
174
to confirm PPROM if no maniod fluid in posterior vault do
test fluid for placetnal alpha microgloblin 1 protein or insulin like growth factor binding protei
175
mx of PPROM
regular obs to ensure chorioamnitotis is not developing
- oral erythromcyin should be given for 10 days
- antental steriod to reduce risk of resp distress ( especially if before 34 weeks
- Iv mag sulphate for neuroprotection if <30 weeks
delviery at 37 weeks
176
what antibiotic is given for PPROM
erythromycin
177
steriods if before
34 weeks
178
puerperal pyrexia is fver >38 in first 14 days follwing delviery. most common cause
endometritis
179
mx of endometritis
IV antibitoics (clindamycin and gent untile afebrile for greater than 24hrs)
180
fetal movemtens from
18/20 weeks until 32 weeks then movemetns plateua
181
multiparous woemn ususlay experiecen fetal movemetns sooner eg 16-18
weeks
182
towards teh end of preg fetal movemtns should
not reduce
183
There is no established definition for what constitutes reduced fetal movements (RFM), but the RCOG considers less than 10 movements within 2 hours (in pregnancies past 28 weeks gestation) an indication for further assessment
184
fetal movemtns should be esatblished by
24 weeks
185
if women reports reduced fetal movemtns what should be done as fist step
handhel doppler to to confirm heartbeat. if cant detect then immediate US
186
if fetal Hr present should do CTG for at least 20mins
if still concerns
US to get abdo cirumferencem estiamted fetal weight ( to exclude small gestational age) and amniotic fluid volume measurement
187
no fetal movements felt by when should refer
24 weeks
188
if not got anti D can do what to future fetus
haemolyssi
189
anti d given
28 and 34 weeks
190
In cases of Rhesus (Rh) negative pregnancy, if a sensitising event occurs in the 2nd or 3rd trimester (e.g., trauma, bleeding, or invasive procedures), it is crucial to administer a large dose of anti-D immunoglobulin. This is typically 1500 IU, given intramuscularly within 72 hours of the event to prevent Rh sensitisation.
The Kleihauer-Betke test is performed to quantify the amount of fetal red blood cells (RBCs) that have entered the maternal circulation. This test involves
191
anti D should be given within 72 hrs in any of tehse
delivery of a Rh +ve infant, whether live or stillborn
any termination of pregnancy
miscarriage if gestation is > 12 weeks
ectopic pregnancy (if managed surgically, if managed medically with methotrexate anti-D is not required)
external cephalic version
antepartum haemorrhage
amniocentesis, chorionic villus sampling, fetal blood sampling
abdominal trauma
192
Tests
all babies born to Rh -ve mother should have cord blood taken at delivery for FBC, blood group & direct Coombs test
Coombs test: direct antiglobulin, will demonstrate antibodies on RBCs of baby
Kleihauer test: add acid to maternal blood, fetal cells are resistant
193
affected fetus if not had anti d before
oedematous ( hydrops fetalis)
194
RA in preg
defer till disease stable
symptoms tend to imprive in preg but flare after delviery
methotrexate needs to be stoppped 6 months prior
sulfasalzine and hydroxychlolrquine are safe
NSAIDs may be used until 32 weeks but after this time should be withdrawn due to the risk of early close of the ductus arteriosus
patients should be referred to an obstetric anaesthetist due to the risk of atlanto-axial subluxation
195
rubella is caused by what virus
togavirus
196
rubella is infectious
7 days before symptoms adn 4 days after rash
197
congential rubella syndrome
sensor deafness, conegnotal catarct
congen heart disease
-it should be noted that it is very difficult to distinguish rubella from parvovirus B19 clinically. It is therefore important to also check parvovirus B19 serology as there is a 30% risk of transplacental infection, with a 5-10% risk of fetal loss
198
mx of rubella in preg
disucss with lcoal health protection unit
rubella immunity is no longer checked at boooking visit
if a woman is however tested at any point and no immunity is demonstrated they should be advised to keep away from people who might have rubella
non-immune mothers should be offered the MMR vaccination in the post-natal period
MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant
199
mx of shoulder dystocia
McROberts manoeuvre
200
It should match the gestational age in weeks to within 2 cm after 20 weeks, e.g. if 24 weeks then the a normal SFH = 22 to 26 cm
symphysis - fundal height
201
msot common position if in transverse lie
scapulo anterior - remeber longitudinal lie tho is really teh msot common
202
most babies have moved from transvers to longitudinal lie by
32 weeks
203
if transverse lie at 36 weeks
External cephalic version
c section
204
contraindications to ECV
maternal rupture in the last 7 days, multiple pregnancy (except for the second twin) and major uterine abnormality. Success rate is around 50%
205
mx of twins
additional iron + folate
weekly antental care past 30 weeks
2 obstetricans present most twins are induced by 38-40 weeks
206
A nuchal scan is performed at 11-13 weeks. Causes of an increased nuchal translucency include:
Down's syndrome
congenital heart defects
abdominal wall defects
Causes of hyperechogenic bowel:
cystic fibrosis
Down's syndrome
cytomegalovirus infection
207
around 50% of cord prolapses occur after
artifical rupture of membranes
208
mx of cord prolapse
fetus pushed back into uterus to avoid compression
if cord is past level of introitus should be minimal handlung and it should be kept warm and moist to avoid vasospasm
pt asked to go on all fours until preperation for immediate c -section have been carrried out
tocolytics may be used to reduce uterine contractiosn
retrofilling the bladder with saline may be helpful as it gnetly elevates teh presentign part
209
women who is preg and has had previous VTE history
LMWH during preg
210
if rf for VTE in preg
LMWH continued until 6 weeks postnatal
211
if dx of DVT is made shortly after delviery continue anticoag for at least
3 months as in other pts with provoked DVTS
212
LMWH is the treatment of choice for VTE prophylaxis in preg
DOACs and warfarin should be avoided in preg
