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Flashcards in Obstetrics Deck (54):
1

What is the definition of parity?

Refers to the pregnancies that resulted in delivery beyond 28weeks of gestation.

2

What is the definition of gravidity?

Refers to the number of pregnancies that a woman has had (to any stage)

3

What is an episiotomy?

An operation performed to enlarge the outlet to hasten birth of a distressed baby, for instrumental or breech delivery, to pre taste a premature head, and to try and prevent 3rd degree tears.

The tissues incised are vaginal epithelium, perineal skin, bulbocavernous muscles and superficial and deep transverse perineal muscles.

4

Describe Placental Abruption, its risk factors, symptoms, and management.

Accidental haemorrhage a form of anterpartum haemorrhage (APH). Part of the placenta becomes detached from the uterus. The outcome depends o the amount of blood loss and degree of separation.

Risk Factors: Pre-eclampsia, smoking, increased maternal age, thrombophilia, cocaine/amphetamine use, infection, multiple pregnancy. PROM.

Symptoms: Shock out of keeping with visible blood loss. Constant pain. Tender, tense uterus, normal lie and presentation, fetal heart absent/distressed, coagulation problem.

Management:
-admit, resuscitate, get help, deliver that baby

5

Describe Preterm rupture of membranes (PROM) and its management.

There are two foetal membranes, the amnion and chorion, which make up the amniotic sac. These may rupture and lead to spontaneous labour, waters breaking. If the membranes ruptured and 18hrs pass it is prolonged rupture of membranes. The mother may give a history of a popping sensation or a gush with continues watery liquid draining thereafter.

Management:
-admit do temperature, MSU and HVS, assess for causes e.g. Abruptions, twins, polyhydraminios.
-Give corticosteroids Betamethasone to help foetal surfactant production.
-In 80% membrane rupture induces labour. The problem with the remaining 20% is balancing advantages of remaining in utero I.e. Maturity and surfactant production) against the threat of infection which causes 20% of neonatal deaths after PROM.
-Prophylactic erythromycin 250mg/6h IV for 10 days or until delivery
-Monitor for signs of infection and treat if develops and expedite labour.

6

What is Cephalopelvic disproportion?

The appropriate label given if diameters are unfavourable, and/or the head is big. A clinically favourable pelvis is one where the sacral promontory cannot be felt, the ischial spines are not prominent, the supra public arch and base of supra sinuous ligaments both accept 2 fingers, and the inter tuberous diameter accepts 4 knuckle when the woman is examined.

7

What is dystocia?

Describes difficulty in labour implying problems with one or more of the three P's:
-Passages, there may be soft tissue (e.g. Fibroid or cervical dystocia after cervical biopsy or genital mutilation) or bony obstruction
-Passenger, owing to a large baby, e.g. Impacted shoulders or an abnormal presentation.
-Propulsion, thanks to the uterine powers.

8

Describe Down's Syndrome, it's signs at birth, and associated problems.

Due to trisomy 21, and related to increased maternal age.

Signs at birth: flat facial profile, abundant neck skin, dysplastic ears, muscle hypotonia, and X-Ray evidence of a dysplastic pelvis, simian palmar crease, protruding tongue.

Associated Problems: Duodenal atresia, VSD, PDA, Low IQ, short stature, Alzheimers, Lung problems, hearing loss, leukaemia (AML),

9

Describe Pre-Eclampsia, it's risk factors, symptoms, and management.

Pregnancy-induced hypertension with proteinuria, +/- oedema. Usually affecting pregnant woman from around 20 weeks. May develop into seizures (eclampsia) in 1% which can be life-threatening for baby (IUGR, Prematurity) and mother (Stroke, Eclampsia)

Risk factors:
-High risk: Diabetes, Hypertension, CKD, SLE, Antiphospholipid syndrome
-Medium Risk: FHx, 40+yrs, 1st pregnancy, pregnancy interval more than 10yr, BMI greater than 35, multiple pregnancy.

Symptoms: Asymptomatic (Raised BP, Proteinuria (more than 300mg in24hr urine or PCR greater than 30), raised serum urate, picked up on antenatal appointments), Other symptoms include headache (flashes floaters), chest or epigastric pain, vomiting, tachycardia, visual disturbances, shaking, hyperreflexia, irritability, facial oedema. HELLP syndrome due to loss of protein C+S in urine, DIC.

Management:
-if high risk or 2 medium risk 75mg Aspirin PO OD from 12th week
until delivery to prevent eclampsia.
-Admit if BP rises more than 30/20mmHg over booking BP, BP over 160/100mmHg, BP over 140/90mmHg and 1+ proteinuria, or there is IUGR.
-measure BP 2-4hourly and monitor FBC, U+E and LFTS beware DIC and HELLP syndrome.
-If BP over 160/100mmHg use labetalol (or Methyldopa, nifedipine)
-If signs of severe pre-eclampsia, e.g. BP greater than 160/100mmHg with proteinuria or greater than 140/90mmHg plus proteinuria plus one of the following: Seizures, Headache or epigastric pain, thrombocytopenia, Visual disturbance, Papilloedema, raised ALT, clonus, Liver tenderness. Use prophylactic magnesium, IV labetalol/hydralazine (require CTG monitoring) and delivery is the only cure. Continue to monitor post delivery.
-treat eclampsia with magnesium sulfate.


10

What are the WETFAG calculations?

Weight in Kg: 0-12 months = (0.5 X age in months) + 4, 1-5years (2 X get in years) + 8, 6-12 years = (3 X age in years) + 7
Electricity for a DC shock: 4J per Kg
Tracheal tube: Internal diameter mm = (age/4)+4 prepare one size above and below
Fluid Bolus: 20ml/kg of Normal saline
Adrenaline: 0.1ml/kg of 1:10000 solution
Glucose: 0.5ml/kg of 10% glucose.

11

Describe Intrahepatic Cholestasis of Pregnancy, its symptoms, tests and management.

Symptoms: Jaundice, pruritis especially of palms and soles in the second half of pregnancy. There is risk of preterm labour, foetal distress, and stillbirth so monitor foetal wellbeing.

Tests: liver transaminase are mildly raised in 60%, and bilirubin raised in 25%. Exclude viral hepatitis.

Management:
-deliver baby if Bile acid greater than 40.
-offer delivery at 37weeks.
-Vitamin K 10mg/d PO to mother and 1mg IM at birth.
-Ursodeoxycholic acid reduces prutitis and abnormal LFTs.
-Symptoms resolve within days of delivery, LFTs normalise after 10days.
-it is a contraindication to oestrogen containing contraceptive pills.

12

Describe HELLP syndrome, its symptoms, and management.

Triad of haemolysis, elevated liver enzymes and low platelet count. Risk is higher in pre-eclampsia.

Symptoms: Upper abdominal pain, malaise, vomting, headache, jaundice, microangiopathic haemolytic anaemia, DIC, raised LDH, raised ALT.

Management:
-admit, get expert help
-deliver if severe.

13

What is the bishop score?

Used to help assess whether induction of labour will be required. A score of less than 5 indicates labour is unlikely to start without induction and a score over 9 indicates that labour will most likely commence spontaneously.

Cervical Position: posterior = 0 , intermediate =1, anterior =2
Cervical consistency: firm = 0, intermediate = 1 , soft = 2
Cervical effacement:0-30% = 0, 40-50%=1, 60-70% = 2 80% =3
Station of head (cm above ischial spines): -3 = 0, -2 = 1, -1-0=2, 1-2 = 3
Cervical dilation: 0cm = 0, 1-cm = 1, 2-3cm =2, more than 3 = 3

14

Describe Shoulder Dystocia, it's risk factor, and management.

Also known as impacted shoulders, this is the inability to deliver the shoulders after the head has been delivered. The danger is death from asphyxia as the cord is usually compressed at the pelvic inlet.

Risk factors: previous shoulder dystocia, macrosmia, raised BMI, induction of labour, slow first or second stage, increased abdominal circumference is good marker for large shoulders.

Management:
-HELPERR
-Help, call for help SOAPS = Senior Midwife, Obstetrician, Anaethetist, Porter, Scribe
-Evaluate for an episiotomy, if to attempt manoeuvres
-Legs, McRoberts position (hyperflexion of legs to abdomen)
-Pressure, suprapubic pressure.
-Enter, wood screw and reverse woodscrew
-Remove the posterior arm in attempt to delivery the posterior shoulder first.
-Roll the mother over to attempt manoeuvres again on all fours. Each manoeuvres should be attempted for 20-30 seconds.
-If these measure fail emergency C-section or deliberate fracture of anterior clavicle should be considered
-If fails anaesthetise, disengage baby and emergency CS

15

Describe Cord Prolapse and its management.

This is the descent of the cord through the cervix, either alongside or in front of the next presenting part in the presence of ruptured membranes. It is an emergency because cord compression causes foetal asphyxia. The problem is obvious if the cord is at the introitus, but the only sign may be foetal bradycardia or variable foetal heart rate decelerations, always for a vaginal examine in this context to exclude prolapsed cord.

Management:
-get help, activate alarms, tell labour ward
-displace the presenting part by putting a hand in the vagina, push it back up towards mothers head during contractions.
-use gravity, get woman on all fours.
-infuse 500ml into bladder
-tocolysis reduces contractions and helps bradycardia.
-consider Caesarian.

16

What is the puerperium?

The 6 weeks after delivery in which the body returns to a pre-pregnancy state.

17

Describe Antepartum Haemorrhage, it's causes, presentation, investigations, and management.

Defined as bleeding from the birth canal after the 24th week of pregnancy. It can occur at any time until the second stage of labour is complete, which marks the boundary of postpartum haemorrhage. Bleeding before 24 weeks is miscarriage.

Causes:
-Idiopathic
-placenta praevia
-placental abruption
-uterine rupture
-vasa praevia
-infection

Presentation: bleeding which may be accompanied by pain (suggestive of abruption) or be painless (suggesting praevia). There may also be malpresentation of failure to engage with placenta praevia. Mother may show signs of hypovoleaemia shock if bleeding is severe.

Investigations: no vaginal examination until placenta praevia is excluded by ultrasound. FBC and Group and save, clotting studies if platelet count abnormal. Crossmatch 4 units and check U+Es and LFTs.

Management:
-admit to hospital, ABCDE
-investigate and treat cause.

18

What are the stages of normal labour?

Usually spontaneous and occurs between 37 and 42 weeks. Can be split into 3 stages.

The first stage consists of the Latent phase and Active phase. It lasts from the onset of true labour to full cervical dilatation. Signs of true labour include, painful rhythmic uterine contractions, beginning of dilatation of cervix, show (leakage of mucus plug), and rupture of the membranes. During the Latent phase the cervic is gradually pulled up so that is one with the lower segment of the uterus a process known as effacement. During the active phase describes dilatation of the cervix.

The second stage involves expulsion of the foetus. It lasts from full dilatation of the cervic (10cm) to the birth of the baby. The baby becomes visible and expulsive contractions begin. Baby's head is flexed and descends into pelvic cavity in left occiput anterior position. Head then rotates to face the sacrum due to a guttering effect of the pelvic floor muscles. Head is born by extension during crowning. Restitution occurs after the head is born head turns laterally and the shoulders rotate internally to be born.

The third stage involves the separation and expulsion of the placenta and membranes and the control of maternal bleeding. Uterus contracts as placenta sloughs to prevent bleeding and products can pass passively. Signs of separation include cord lengthening followed by a gush of blood (retro placental haemorrhage) followed by contraction of the uterus (felt as globular mass) usually takes less than 1h. Examine the placenta to check it is complete, looking for complete puzzle effect (cotyledons), both membranes, if any vessels on the membranes look for suceenturate lobes.

19

Describe the timeline of appointments in routine antenatal care, and briefly describe the tests and screening offered.

Nulliparous women receive 11 appointments and Multips have 8. All appointments should include measuring BP and testing urine for proteinuria.

Booking (10wks): Folic acid + Vitamin D, lifestyle advice, medication review/advice, mental health screen, nutrition (no uncooked meat or fish, raw egg, unpasteurised milk or soft cheese, pate, more than two portions of oily fish, unwashed fruit of vegetables). Offer screening bloods for anaemia red cell allo-antibodies, Hep B, HIV, Rubella, Syphilis, Chlamydia, sickle cell and thalassaemia, screening for gestational diabetes in women with risk factors. Also discuss down's screening.

11-13+6wks: Dating Scan + Combined test (Down's)

16wks: review previous results. Quadruple test for down's if missed Combined window

18-20wks: Ultrasound Anomaly Scan, Quadruple test for down's if missed Combined window

25wks (Nulliparous only): Routine

28wks: Bloods for Hb, Antibodies and Glucose. Anti-D if Rh-ve, pertussis vaccination.

31wks (Nulliparous only): review of screening tests.

34wks: Repeat Hb, second dose Anti-D review of tests.

36wks: information given regarding breast-feeding, care of new baby, postnatal depression, vitamin K

38wks: routine

40wks (Nulliparous only): routine

41wks: Offer membrane sweep and discuss induction of labour

20

Describe Post-Partum Haemorrhage, it's causes, risk factors, and management.

Blood loss of more than 500mls in first 24hr after delivery. More than 1.5L becomes Major Obstetric haemorrhage.

Causes (4T's):
-Tone I.e. Uterine Atony (90%),
-Trauma to genital tract
-Tissue I.e. Retained products or clots
-Thrombin I.e. clotting disorders pre-existing or acquired

Risk Factors: previous PPH or retained placenta, BMI over 35, Maternal Hb less than 85 at onset of labour, antepartum haemorrhage, multiparty over 4, maternal age over 35, fibroids, polyhydraminos, twins, macrosomia, placental abruption, placenta praevia, pre-eclampsia, infection

Management:
-ABCDE
-bimanual uterine compression
-Oxytocin 5-10u slowly IV
-if uterine Atony is cause Carboprost (Haemabate) IM, Ergometrine.
-if fails, balloon tamponade, B-Lynch suture +/- uterine artery ligation.
-if severe uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure.

21

Describe Down's Syndrome antenatal testing.

Combined test is standard performed at 11-13+6 wks. It entails a nuchal translucency measurement + b-HCG (Raised in Down's)+ Pregnancy associated plasma protein A (PAPP-A) (reduced in Down's)

If women book later in pregnancy or change mind etc quadruple test can be offered between 15-20wks. It entails alpha-fetoprotein (Reduced in Down's), Unconjugated oestriol (Reduced in Down's), b-HCG (Raised in Down's), and inhibin A (Raised in Down's)

22

Describe Induction of Labour and its indications and methods.

A process where labour is started artificially.

Indications:
-prolonged pregnancy e.g. Over 12 days after EDD
-prelabour premature rupture of membranes, where labour does not start spontaneously
-diabetic mother after 38wks
-rhesus incompatibility
-Pre-eclampsia
-multiple pregnancy

Method:
-membrane sweeps / Stretch and sweep
-intravaginal prostaglandins via pessary/gel/tablet allow 24hours for onset of labour.
-artificial breaking of waters if above have failed
-after 4 hours consider syntocin infusion

23

Describe Placenta Praevia, its associations, symptoms, investigations, and management.

Low lying placenta, may be split into minor or major depending on whether there is partial (minor) or complete involvement of the internal cervical os. Less myometrium in lower segment and so less contractile, so risk of postpartum haemorrhage is increased.

Associations: previous Caesarian, sharp curette TOP, multiparity, multiple pregnancy, increased maternal age, assisted conception, fibroids.

Symptoms: Classically painless vaginal bleeding, or failure to engage.

Investigations: US at 24 wks, repeat at 32wks if major, 36wks if minor

Management:
-advice no sex
-If minor aim for normal delivery unless placenta encroaches within 2cm of internal so.
-Major requires Caesarian delivery. Bleeds tend to increase subsequently so admit if multiple bleeds for monitoring and preparation for delivery.

24

What are some indications for continuous CTG monitoring in labour?

Hypertension
Pre-eclampsia
Preterm Prolonged Rupture of Membranes
Syntocin IVI
Women over 40 after EDD
Gestational Diabetes
Preterm Labour
Multiple Pregnancy
Maternal Pyrexia
Cardiac Issues
Antiphospholipid syndrome
Abnormal Foetal Auscultation
Severe Asthma

25

Describe Hyperemesis Gravidarum, its symptoms, investigations, and management.

Defined as persisting vomiting in pregnancy which causes weight loss and ketosis. Most common between 8-12wks but may persist up to 20wks (and rarely beyond that)

Symptoms: Inability to keep food or fluids down, weight loss (2-5kg), dehydration, hypovolaemia, tachycardia, postural hypotension, Hypokalaemia, hyponatraemia, polyneuritis (Vitamin B deficiency), liver and renal failure.

Investigations: TFTs can guide severity, urinalysis ketones, blood ketones, weight, blood pressure, exclude UTI. U+E.

Management:
-admit to hospital if ketotic
-give thromboprophylaxis. and anti-embolisation stockings
-antihistamines (BNF suggests promethazine first line)
-thiamine suppletation + IV fluids
-be wary of rapid correction of hyponatraemia which can cause fatal central pontine myelinolysis

26

Describe Gestational Diabetes, it's risk factors, and management.

Diabetes in pregnancy, 1/3 go on to develop type 2 diabetes in later life. If 2 or more of below risk factors screen (OGTT) at 18wks and again at 28wks if just 1 then screen at 28wks. OGTT glucose greater than 7.8mmol/L is diagnostic of gestational diabetes. Gestational diabetes leads to increased risk of preterm labour, still birth, foetal malformations, macrosomia, neonatal jaundice, neonatal hypoglycaemia.

Risk factors: FHx of DM, Previous Gestational Diabetes, Raised BMI, Non-Caucasian, PCOS, TFT issues, Previous baby larger than 4.5kg, polyhydraminos.

Management:
-diet and exercise, careful monitoring before and 1hr after meals plus before bed.
-if uncontrolled Metformin and insulin may be used.
-recommend elective Caesarian at 38wks. CTG in labour + Insulin sliding scale and hourly glucose
-6wks postpartum fasting glucose and yearly checks due to increased risk of T2DM

27

Describe Oligohydraminos and its causes

Too little amniotic fluid, it is associated with IUGR. May be due to excess loss of fluid or decrease in foetal urine production/excretion.

Causes:
-excess loss of fluid e.g. Rupture of membranes, placental abruption, maternal dehydration, hypertension,
-decrease in foetal urine production/excretion. E.g. Foetal urinary tract malformations, hypoxia,

28

Describe polyhydraminos and its causes

Excess amniotic fluid, associated with adverse pregnancy outcomes.

Causes:
-decreased foetal swallowing eg. Upper GI abnormality, Foetal hypoxia, neuromuscular disorder/brain abnormalities
-excess foetal urination, e.g. Hyperglycaemia, foetal anemia
-congenital infection
-hydrops fetalis

29

Describe VTE in pregnancy, it's risk factors, and management.

Pregnancy itself is a risk factor for VTE. A risk assessment should be completed at booking.

Risk factors:
-previous VTE is high risk
-age over 35
-BMI over 30
-parity 3+
-smoker
-varicose veins
-current pre-eclampsia
-immobility
-FHx of unprovoked VTE
-low risk thrombophilia
-multiple pregnancy
-IVF pregnancy

Management:
-If previous VTE or four or more risk factor, immediate treatment with LMWH until 6 weeks post-natal
-if 3 risk factors LMWH initiated from 28wks and continued until 6 weeks post natal.

30

Describe Amniotic Fluid Embolism, its symptoms, and management.

Complication of Pregnancy, due to entry of amniotic fluid into the maternal circulation. Typically occurs at the end of the first stage of labour or shortly after delivery but may also occur in TOP, amniocentesis, placental abruption, CS, trauma.

Symptoms: Sudden dyspnoea, hypotension, seizures. Sudden LOC. 50% also develop DIC so bleeding occurs.

Management:
-ABCDE
-haemodynamic and respiratory management.

31

Describe Breech presentation, the types, and its management.

Commonest malpresentation, 40% of babies are breech at 20 weeks but only 20% at 28wks and 3% at term. Diagnosed antenatally during examination.

Types: Extended breech (buttocks presents) hips flexed knees extended. Flexed breech (buttocks, genitalia and feet presents) hip and knee flexed. Footling breech (feet present) has the greatest risk (5-20%) of cord prolapse.

Management:
-discuss options with mother I.e. Vaginal or CS
-CIs to vaginal: inadequate pelvis, footling breech, kneeling breech, baby more than 3800g or less than 2000g, previous CS, hyperextended neck, lack of clinicians experienced in vaginal breech delivery.
-External cephalic version I.e. Turning the breech by manoeuvering through a somersault only done if planned vaginal delivery. Version at 36 wks for primips and 37 for Multips. CI in placenta Praevia, multiple pregnancy, growth restriction, abnormal CTG, pre-eclampsia. Give anti-D to rhesus -ve mothers.
-USS hip for hip dislocation as increased risk if breech

32

Describe Epidural, it's side effects.

Pain relief by anaesthesia get pain fibres carried by T11-S5.

Give IV Ephedrine and volume preload before insertion. Monitor BP every 5 minutes for 15 minutes plus 30minutes CTG monitoring after set up and top ups.

Requires top ups 2 hourly. Assess level of sensory block hourly.

Side-effects: paralysis (increased need for forceps), urinary retention, headache, postural hypertension.

Combined spinal epidural may be used for quicker pain relief with little or no motor blockade. Reduces SEs such as urinary retention and paralysis, but hasn't shown to have an effect on rate of spontaneous delivery.

33

How do you interpret CTG monitoring?

Interpretation:
DR - Define Risk I.e reason for monitoring

C - Contractions, record the number in a 10 minute period. Each big square is equal to 1 minute. Assess Duration and intensity. Less than 5 in 10 minutes is normal more than this increase risk of foetal hypoxia

BRa - Baseline rate, the average heart rate of foetus in a 10 minute period normal foetal heart rate is between 110-160. Foetal tachycardia is defined as baseline rate greater than 160 and may be evidence of foetal hypoxia, Chorioamnionitis, hyperthyroidism, foetal or maternal anaemia, or a foetal tachyarrhythmia. Foetal Brady is a heart rate less than 110, prolonged Brady may be due to cord prolapse, cord compression. Heart rate over 180 or less than 100 is abnormal feature.

V - Variability, refers to variation of foetal heart rate. Reassuring is greater than 5bpm, non-reassuring is less than 5bpm for 40-90minutes and abnormal is less than 5bpm for more than 90minutes. Reduced variability can be due to foetal sleeping (but should not last more than 40 minutes), foetal acidosis, foetal tachycardia, prematurity, congenital heart abnormalities.

A - Accelerations are an abrupt increase in baseline heart rate of more than 15bpm for more than 15seconds. Their presence is a reassuring feature. There should be at least 2 every 15 minutes. Accelerations occurring alongside uterine contractions is a sign of healthy foetus.

D - decelerations are an abrupt decrease in baseline heart rate of more than 15bpm for more than 15 seconds. Early decelerations start when uterine contractions begins and recover when uterine contraction stops this is due to increased foetal intracranial pressure causing increased vagal tone, this is normal. Variable decelerations are observed as rapid fall in baseline witha. Variable recovery phase they may be less associated with uterine contractions and are most often seen during labour and in patients with reduced amniotic volume. Late decelerations begin at the peak of uterine contraction and revolver after the contract ends this type indicates there is insufficient blood flow through the uterus and placenta and are an abnormal feature. Foetal blood sampling for pH is indicated. Prolonged decelerations last more than 2 minutes are non-reassuring and more than 3 are abnormal.

O - overall impression may be normal, suspicious (one non-reassuring feature) or pathological (two or more non-reassuring or an abnormal feature).

34

Describe Multiple Pregnancy, the types, complications to pregnancy, foetal complications,and management.

More common if previous twins or family history of twins, increased maternal age, IVF.

Types:
-May be dizygotic (6/9) all of which go on to be DCDA or monozygotic (3/9).
-depending on when the blastocyst splits depends on the type of twins in monozygotic. In first 0-3days gives DCDA (8/9), 4-6 days gives MCDA (1/9), 7-9 days give MCMA and after 10days you get conjoined.

Complications in pregnancy:
-polyhydraminos, pre-eclampsia,

35

What are the top causes of maternal death in the UK?

In order of prevalence:
-VTE
-APH + PPH
-Sepsis
-Pre-eclampsia

36

Describe the Normal Physiological changes in pregnancy.

Haemodynamic Changes: from 10wks the plasma volume rises until 32wks when it is at 3.8L. Red cell volume increase. Hb falls due to dilutional anaemia. Platelets are raised thus VTE risk. Cardiac output rises from 5L/min to 6.5-7L/min in first 10 wks by increasing stroke volume and pulse rate. Peripheral resistance falls. Diastolic pressure falls during second trimester then rises to non-pregnant levels by term. Aorta-caval compression occurs after 20wks when gravid uterus compress these vessels reducing cardiac output by 30-40% can be relived by lying in the left lateral position.

Respiratory changes: Ventilation increases 40% tidal volume rises from 500 to 700mL th increase depth of breathing being an effect of progesterone. O2 consumption increases by 20%. Breathlessness is common as pcO3 is set lower to allow the foetus to offload CO2.

37

What are the main topics to discuss during pre-pregnancy counselling?

-Rubella screening +/- vaccine
-VTE risk assessment +/- prophylaxis, if FHx of VTE screen for thrombophilia
-optimal control of chronic disease e.g. Diabetes, hypothyroidism etc
-stop teratogens e.g. Paroxetine foetal heart defects wit 1st trimester use, lithium associated Ebsteins anomaly, HIV drugs didanosine and efavirenz teratogenic in 1st trimester, do not stop HIV drugs without expert advice.
-medications to protect foetus eg. Folate supplements (prevent neural tube defects), Vit D.
-avoidance of infection
-smoking and alcohol cessation

38

Describe Foetal Blood sampling and how to interpret the results.

Used to check for hypoxia in the presence of pathological foetal heart rate trace. Sample is taken with mother in left lateral position

39

Describe compound presentation, and it's management.

When a foetal limb present before or alongside the typical presenting part. Most commonly an arm presenting with the head.

Management:
-close observation, CTG monitoring, monitor progression, most will resolve spontaneously, pinching of limb or manoeuvering presenting limb may help.
-if labour not progressing consider emergency CS.

40

How often should FHR be monitored in normal labour?

Every 15 minutes in 1st stage and every 5 minutes in 2nd stage.

41

What are Braxton-Hicks contractions?

Painless tightening contractions during pregnancy practise contractions.

42

Describe Pelvic Girdle Pain, its symptoms, and management.

Caused by uneven movement of joints of pelvic girdle, therefore become less stable and painful. Worse with added weight putting strain on pelvis.

Symptoms: Pain in the pubic region, lower back, hips, groin, thighs or knees. Clicking or grinding in the pelvic area. Pain made worse by movement.

Management:
-keep active but get plenty of rest
-standing tall with bum and bottom tuck in a little.
-changing position frequently, try not to sit for more than 30 minutes
-sitting to get dressed and undressed
-put equal weight on each leg when you stand
-try keeping legs together when getting in and out of car
-lying on the less painful side when sleeping
-keeping knees together when turning over in bed
-use a pillow under your bump and between legs for extra support.
-get physio input
-acupuncture, warm baths

43

What is Lochia?

Lochia may be defined as the vaginal discharge contain blood, mucous and uterine tissue which may continue to 6 weeks after childbirth. It is red for the first 3 days then becomes yellow, and then white over the next 10days which may persist until 6 weeks. Persistent red Lochia may be indicative of retained products.

44

In an ABCDE emergency of a pregnant women what is the best position for them to be in?

Left lateral allows for better circulation.

45

Describe Amniocentesis, it's risks factors, and contraindications.

A procedure used in prenatal diagnosis, may be offered after screening tests have indicated high risk of foetal abnormality or in women to be deemed high risk. Will require anti-D

Around 20ml of fluid is removed by transabdominal needle under ultrasound guidance and foetal cells present in the fluid are studied to aid diagnosis.

Risks: foetal loss is 0.5-1%, 1/1000 results are incorrect due to maternal cells being analysed, infection, club foot if before 15wks, rhesus disease

Contraindications: Blood borne disease?

46

Describe Epilepsy in pregnancy, complications and management.

If seizures occur in pregnancy think could this be eclampsia?

Complications:
-Maternal: increased risk of 3rd trimester PV bleeding, 1% convulse in labour
-Foetal: Haemorrhagic disease of newborn can occur with enzyme inducers (e.g. Carbamazepine, ethosuximide, phenytoin, primed one, phenobarbital), congenital malformation is more common e.g. Cleft lip, neural tube defects (more common with valproate + carbamazepine)
-foetal valproate syndrome: major organ system anomalies, autism, small ears, small broad nose, a long upper lip, shallow philtrum, micrognathia.

Management:
-expert help with epilepsy specialist
-carbamazepine may be drug of choice (lamotrigine being prescribed more and more)
-Aim for 1 drug control
-High dose folic acid 5mg OD PO (reduced risk of NTDs)
-Vitamin K 20mg OD PO from 36 wks if taking enzyme inducers

47

Describe Hypertension in Pregnancy, its risk factors, and main classification.

Definition is systolic over 140 or diastolic over 90, or an increase above booking reading of 30mmhg systolic or 15mmhg diastolic.

Risk factors:
-previous hypertensive pregnancies
-CKD
-Autoimmune disorders e.g. SLE, antiphospholipid
-Diabetes

Classifications:
-Pre-existing hypertension, history of elevation before 20 weeks gestation, no proteinuria no oedema,
-Pregnancy induced Hypertension occuring after 20 weeks gestation, no proteinuria no oedema, typically resolves following birth
-Pre-eclampsia, PIH with proteinuria and oedema

48

How is mother to child transmission of HIV prevented?

1. Avoid breastfeeding where possible, cabergoline 1mg PO within 24hr to suppress lactation
2. Newborn treated within 4hr of delivery e.g, AZT BD for 4 weeks or HAART if high risk
3. Co-trimoxazole PCP prophylaxis to babies at high risk
4. Babies tested at day 1 6wks and 12 wks with confirmatory at 18mnths

49

Describe the risk of Down’s syndrome with increasing maternal age.

Age 20 Risk 1:1500
Age 30 Risk 1:800
Age 35 Risk 1:270
Age 40 Risk 1:100
Age over 45 Risk greater than 1:50

50

What are the key points in management of Rheumatoid Arthritis in pregnancy?

-Patients with early to poorly controlled RA should be advised to defer conception until their disease is more stable.
-RA symptoms tend to improve in pregnancy but only resolve in a small minority. Patients tend to have a flare following delivery.
-Methotrexate is not safe in pregnancy and needs to be stopped at least 3 months before conception
-Leflunomide is not safe in pregnancy
-Sulfasalazine and hydroxycholorquine are considered safe in pregnancy
-Studies looking at pregnancy outcomes in patients treated with TNF-alpha blockers do not show any significant increase in adverse outcomes, but data is not clear.
-Low-dose corticosteroids may be used in pregnancy to control symptoms
-NSAIDs may be sued until 32 weeks but after this time that should be withdrawn due to risk of early closure of the Ductus Arteriosus.
-Patient should be referred to an obstetric anaesthetist due to the risk of Atlanta-axial subluxation.

51

Describe the management of thyroid problems during pregnancy?

In pregnancy there is an increase in the levels of thyroxine-binding globulin. This causes an increase in the total levels of thyroxine but does not affect the free thyroxine level.

Thyrotoxicosis:
-Untreated thyrotoxicosis increases the risk of foetal loss, maternal heart failure and premature labour.
-Graves' disease is the most common causes of thyrotoxicosis in pregnancy. It is also recognised that activation of the TSH receptor by HCG may also occur - often termed transient gestational hyperthyroidism.. HCG levels will fall in second and third trimester
-Propylthiouracil has traditionally been the anti-thyroid drug of choice. However most guidelines recommend its use in the first trimester after this time switch to carbimazole as propylthiouracil is associated wit increased risk of maternal liver toxicity
-Maternal free thyroxine levels should be kept in the upper third of normal reference range to avoid foetal hypothyroidism.
-thyrotrophin receptor stimulating antibodies should be checked at 30-36 weeks gestation to help determine risk of neonatal thyroid problems.
-block and replace regimes should not be used in pregnancy and radio iodine is contradindicated.

Hypothyroidism:
-Thyroxine is safe during pregnancy
-Serum thyroid stimulating hormone measured in each trimester and 6-8weeks postpartum.
-Some women require an increased dose of thyroxine during pregnancy
-breast feeding is safe whilst on thyroxine.

52

When should asymptomatic bacturia be treated in pregnancy?

After two +Ve MSU according to sensitivities.

53

Describe Acute Fatty Liver of pregnancy, its features, and management

A rare life-threatening complication of pregnancy that occurs in the third trimester or immediate period after delivery. Thought to be caused by a disordered metabolism of fatty acids by mitochondria in the mother caused by a long-chain-3-hydroxyacyl-coenzyme A dehydrogenase deficiency.

Features: N+V, Anorexia, abdominal pain, jaundice, fever. Deranged LFTs Coagulopathy (DIC), Hypoglycaemia.

Management;:
-IV fluids, glucose and blood products to correct DIC.
-Induction possible emergency C section.

54

Describe Polymorphic Eruption of pregnancy, and its features.

Aka Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP) is an itchy eruption that starts in the last 3 months of pregnancy and clears with delivery. It consists of small, pink papules that appear in the stretch marks around the umbilicus these papules coalesce to form urticaria patches which can spread to involve the buttocks and thighs.