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Obstetrics 4 Flashcards

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1
Q

When a placenta previa is picked up at 20 week scan when are they next scanned for the position?

A

32 weeks

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2
Q

What are the risk factors for preterm:

A

Too much inside:

  • multiple pregnancy
  • polyhydramnios

Placenta defects (fetus wants out)

  • IUGR
  • Chromosomal abnormalities

Poor integrity of the uterus:

  • short cervix (previous LETZ procedure)
  • lots of previous pregnancies (uterus
    stretched)

Maternal:

  • smoking
  • Low BMI
  • Alcohol
  • Maternal disease (Gestation diabetes)
  • maternal age

Infection

  • UTI infection
  • Chorioamnionitis
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3
Q

What investigations do you want into a woman who you think is about to go into preterm labour?

A 
Bloods: 
- FBC 
- U&Es 
- G&S 
(incase they go into labour)

+/- blood cultures - looking for causes of going into preterm

Orifices:

  • Urine dip
  • High vaginal swap

Preterm labour tests:

  • fetal fibronectin
  • Actim
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4
Q

What are some differentials for contractions?

A

Braxton Hicks
- doesn’t lead to cervical changes

MSK

UTI
- very common

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5
Q

How long are tocolytics used during pre-term labour?

A

48 hours

they don’t stop labour they just give time for steroids to work

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6
Q

What are two non-pharmacological managements to help prevents PPH?

A

Uterine rub
- massaging the fundus to stimulate contraction

Early suckling
- increases oxytocin release causing contraction

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7
Q

What are the core reasons for failure of progression?

A

Insufficient uterine contractions
- maternal fatigue

Palpresentation

Malposition
- anterior occipital

Cephalo-pelvic disproportion

Cervicle dystocia

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8
Q

What are the components of the Bishop score?

A

Position of the cervix

Dilation

Effacement

Consistency (how firm does it feel)

Fetal station

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9
Q

What are the risks of oxytocin?

A

Uterine Hyperstimulation

  • normal is <4 contractions per 10mins
  • excessive contraction can cause fetal distress

Uterine rupture
- more common in multiparous women

Water intoxication
- oxytocin has ADH like properties

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10
Q

What are some complications of artificially ventilating a a preterms lungs?

A

Retinopathy of prematurity

Pneumothorax

Pulmonary interstial emphysema

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11
Q

If there is artificial rupture of the membranes and patient starts to bleed and there is fetal distress what is the likely underlying diagnosis?

A

Vasa praevia

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12
Q

What are some risk factors for placental abruption?

A 
Previous placental abruption 
C-section 
ECV 
Cocaine use 
pre-eclampsia
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13
Q

When is Antepartum officially diagnosable and what is before it?

A

Antepartum is >24 weeks

<24 weeks is miscarriage type bleeding

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14
Q

In a woman with antepartum bleeding what questions, examinations and investigations do you want to do?

A

Questions:

  • Pain
  • Fetal movement?
  • When are they due?
  • Ask about risk factors?
  • Sex before bleeding?

Examination:

  • Abdominal
  • Speculum
  • do not do vaginal examination due to risk of placenta previa

Bloods:

  • FBC
  • U&Es
  • Coagulation
  • LFTs
  • CXM
  • Keilhauer test

Orifices:
- Urine analysis

X-rays:
- USS

Baby:
- CTG

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15
Q

List some current risk factors in a pregnancy that would warrant it to be high risk and thus consultant led on the red pathway.

A

Multiple pregnancy

PV bleeding in 1st sememster

> 2 UTIs

Hypertension

Proteinuria

Pre-eclampsia

Placenta abnormalities

Malpresentation at 36/40

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16
Q

When should Anti-D be given following a sensitising event and how is it administered?

A

Within 72 hours of the event

  • IM injection
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17
Q

What screening can be done to assess the risk of a woman going into pre-term labour? and which women are offered this screening?

A

Cervical length screening

Offered:

  • Previous preterm birth
  • 2nd trimester loss
  • Previous LETZ operation
  • Cone biopsy
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18
Q

What tests do you want in in someone you suspect has entered preterm?

A

Bloods:

  • FBC
  • G&S

Orifices:

  • High vaginal swab
  • MSUS

Baby:
- CTG

Special tests:

  • Fetal fibronectin
  • Actim Partus
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19
Q

What are the complications of epidurals?

A

Hypotension
Prolonged 2nd stage
Risk of instrumental delivery

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20
Q

In a normal delivery when is syntocinon given? and by which route?

A

IM following delivery of anterior shoulder

Or if there is failure to progress - oxytocin can be given to speed things up

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21
Q

When has established labour said to begun?

A

Regular painful contractions with >4cm dilation

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22
Q

What is it called when the fetus head enters into the pelvis and when may this occur?

Study These Flashcards
A

Engagement

  • usually occurs some 2-3weeks prior to delivery
  • sits in flexed position
23
Q

Why does the baby enter into the pelvis cavity at a transverse position then move into a anterior-occipital position and what is the final movement of the head to allow allow delivery of the shoulders?

Study These Flashcards
A

Engagement: occipital transverse position
- widest part of head fits through widest part of pelvic inlet

Entering into pelvis floor: Flexion of head

  • compressed against the floor the baby will flex its neck
  • creates smaller size

Passes further down: Occipital - anterior position
- this is seen as crowning

Passing under the arch: extension of head

External rotation of head to a occipital transverse position
- head is delivered

Restitution: shoulders rotate transversely to follow

24
Q

What are some contraindications to fetal blood sampling?

Study These Flashcards
A

Maternal infection

  • HIV
  • herpes

<34 weeks

Haemoglobinopathies

Breech presentation

25
List some indications for induction of labour:
Post term Maternal compromise - if mother has underlying health conditions it may be safer to carry out induction at 37 weeks Diabetes Fetal distress PROM - if >37 weeks and spontaneous labour hasn't occurred then induction is usually done since the risk of infection outweighs preterm complications Maternal age
26
What are two of the main complications of oxytocin use?
Uterine hyperstimulation Fluid retention and reduced urine output - has ADH like properties
27
What can be done prior to induction:
Membrane sweep This is a help adjunct which can stimulate labour increasing the chances of labour within 48 hours. typically used at 40-41 weeks.
28
For a still birth what is the most appropriate management to induce labour?
Use of misoprostol and mifepristone *misoprostol has increased risk of uterine hyperstimulation which is harmful to an alive baby but in this situation it is not warranted
29
What are the values for gestation diabetes and does it resolve following pregnancy? what are some risk factors for it?
Fasting glucose: >5.6 OGTT: 7.8 Yes it resolves following pregnancy Risk factors: - previous GDM - BMI >30 - Previous macrosomia baby - South Asian - PCOS *any of the above risk factors should initiate the fasting and OGTT
30
What are the complications of GDM for the mother and fetus?
Maternal: - increased UTIs - increased risk of pre-eclampsia - increased risk of C-secretion or instrumental delivery - increased risk of PPH Neonate: - hypoglycaemia - macromania - shoulder dystocia - Respiratory distress syndrome of new born due to poor production of surfactant
31
How is gestational diabetes managed during pregnancy?
Multi-disciplinary care: - endocrine - obstetrics - dieticians Aim for bloods between 4-7mmol. 1st line: - diet exercise If not met: - metformin >7mmol - Insulin Delivery: - CTG monitoring - at a centre with NICU - remove insulin postpartum - aimed for 38-39weeks induction
32
Does having gestational diabetes increase the likely hood of the mother developing diabetes in the future?
Yes. *6 weeks postpartum women should be offered a fasting blood glucose test. 50% likely to in the next 10 years.
33
Where does the rupture occur in placenta abruption? and list some risk factors:
Occurs in the decidua basalis Risk factors: - previous placental abruption - C-section - Smoking - Pre-eclampsia - external cephalic rotation
34
Is smoking a risk factor for pre-eclampsia?
no.
35
In pre-eclampsia what is looked for on US and how often should they be done?
Every 2 weeks: looking for: - Monitoring growth - liquor volume (this demonstrates fetal urine output which is proportional to placenta function) - Umbilical artery flow
36
When are ant-hypertensives started in pre-eclampsia?
150/100mmHg or >30mmHg from baseline
37
What can be given prophylactically at intra-partum for pre-eclamptic women and when should they followed up and what's the prognosis?
Magnesium sulphate can be given prophylactically at birth for severe cases Follow up 6 weeks in primary care - assess BP - urinalysis Prognosis: - 25% likely to have pre-eclampsia in another pregnancy - increased likely hood of cardiovascular disease in the future
38
What are some differentials for preterm labour?
Essentially differentiating if someone is in labour: - Braxton Hicks contractions - MSK pain - UTI Placental differentials: - placenta abruption - uterine rupture
39
Whats your management of preterm labour?
Identify causes: - UTI, infection etc Confirm: - fibronectin if <4cm: - corticosteroids - tocolytics (for 48 hours) - inform neonatal team >4cm: - corticosteroids - inform neonatal team * <30 weeks magnesium sulphate * IV antibiotics if group B strep
40
What are some risk factors for preterm labour?
``` previous pre-term smoking pre-eclampsia cervical incompetence infection multiple pregnancy ``` **these are also the risk factors for PPROM
41
What are the investigations that should be done into suspected chorioamnionitis and what is the gold standard investigation? and what are some risk factors?
Bloods: - FBC - CRP - U&Es - ABG Orifices: - high vaginal swab - urine culture Chest x-ray CTG monitoring gold standard: - amniotic fluid cultures * this is rarely done though as it usually adds little to the evidence of chorioamnionitis Risk factors: - group B step colonisation - Pro-longed rupture of membranes - preterm - Young mother - UTI infection
42
What measurements are used to assess the estimated fetal weight and list the general management of IUGR along with some risk factors:
Measurements: - head circumference - abdominal circumference - femur length General management for suspected IUGR - umbilical artery doppler studies - Growth scans (to guide delivery management) - maternal assessment (BP, infection etc) Delivery: - <36 weeks: steroids - <30 weeks: Magnesium sulphate C-section at 37 weeks C-section at 34 weeks if reverse diastolic flow *C-section due to risk of fetus during delivery. Risk factors: - Maternal age >40 - maternal illness (diabetes) - Drugs and smoking - pre-eclampsia - maternal nutrition
43
What is the management for Haemolytic disease of the fetus/ newborns and list some sensitising events and what is the major complication in-utero?
Sensitising events: - Abortion - Ectopic - External cephalic rotation - Amniocentesis - Antepartum bleeding - Trauma Management: - Delivery at 36 weeks. Severe: - intrauterine blood transfusion - Delivery of fetus then blood transfuse Newborns: - Jaundice management - usually needs transfusion Major complication in-utero: - fetalis hydrops
44
When is Anti-D given?
28 weeks Following sensitising events At birth - following sampling of the umbilical cord to see status of child
45
How is delivery of a still birth conducted and what important drugs should be considered for another side effect which may be distressing to the mother:
Mifepristone + Misoprostol Dopamine agonists - to supress lactation
46
What is the 'best' treatment for pre-eclampsia?
Delivery of baby and placenta
47
What advice can be given to parents following a miscarriage?
Next menstrual cycle will be different and heavier - endometrium returning to normal Avoid trying to conceive for another month 80% chance of successful future pregnancy
48
What is Asherman's syndrome?
Adhesions within the uterus due to surgical procedures
49
Why might seizures become more frequent in pregnancy in patients who suffer from epilepsy?
Change in medication Increased dilution of anti-epileptic medication due to increased blood volume Increase in steroid binding hormone can lower anti-epileptic medication Increased amounts of vomiting
50
What is general management of epilepsy in pregnancy?
Consultant led with obstetricians and neurologists. Folic acid 5mg in first trimester Mono-therapy - carbamazepine is ideal Life style advice - no swimming - adequate sleep Labour: - careful hydration - avoidance of pethidine (lowers seizure threshold) - birth in special unit - continual CTG monitoring Post-partum: - anti - epileptics are safe in breast feeding - if on COCP dose adjustment may be needed due to CYP450 enzyme activity
51
What is the follow up of Gestational diabetes?
6 weeks follow up - assess blood glucose levels 50% chance of developing DM within 10 years
52
What are some neonatal complications of diabetes in pregnancy?
Hypoglycaemia Birthing injuries Respiratory distress - high glucose shuts off surfactant production Jaundice Still birth
53
What are the risks associated with hypothyroidism in pregnancy?
Miscarriage/ still birth PPH Reduced IQ of child IUGR Deafness
54
If a mother has hypothyroidism what should be done to the levels of medications following confirmation of pregnancy?
Increase dose by 25% *returns to normal after pregnancy

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