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Flashcards in Obstetrics Deck (58):
1

Diagnostic criteria for gestational DM

Fasting glucose of >= 5.5
2 hour post glucose intake value of >=7.8

2

When to perform an GTT (glucose tolerance test)

1. previous gestational DM
2. certain gestational groups (eg asian descent)
3. mother older than 40
4.mothers over 90kg, or BMI > 40
5.first degree family member
6. Hx of diabetic symptoms (polydipsia, polyuria, vaginal candidiasis.
7. Previous infant >4.5kg
8. previous stillbirth of unknown cause
9. severe polyhydramnios with no structural anomalies
10.repeated glycosuria
11. Polycystic ovarian syndrome
12. Acanthosis nigricans

3

Which hormone produced by the placenta results in increased insulin resistence.

Human placental lactogen

4

Antepartum effects of diabetes on pregnancy

1. Increased prevelence of congenital abnormalities
-cardiac
-neural tube
-skeletal
2. Macrosomia (N head, big body)
3. Intrauterine death
4. Polyhydramnios

5

Problems at delivery, diabetic mom

shoudler dystocia ...Erbs palsy

6

Postpartum effects of diabetes on pregnancy

1. Neonatal hypoglycaemia
2. Polycythaemia
3. Hyperbilirubinaemia
4. Respiratory distress syndrome

*poor cardiac function due to fetal heart hypertrophy from excess glycogen stores

7

Which fetal complication may occur in a mother with longstanding mircrovasc disease due to DM

IUGR

8

Glucose values, management guidelines

Fasting below 5.5
2hr postprandial <7.0
HbA1c <6.5%

9

Type 1 Diabetic management

Insulin + good diet
*3 injects (actrapid) breakfast, lunch, supper
*1 intermediate acting insulin before bed...Protaphane

10

Type 2 diabetic management

Metformin 500mg BD
Can be increased to 850mg TDS
+
good diet

11

How to calculate total amount of insulin needed per day

0.4U/kg/day

*40% for late eve protophane
20% for each meal

12

When does reactive hyperglycaemia (somogyi) occur

When too much insulin is given at night, resulting in hypogylcaemia. Body reacts by starting glycogenolysis and gluconeogenesis

Rx: lower night time insulin amount

13

How should diabetic mother regulate her glucose at home

test 2 hour post meal + first thing in the morning (glucose profile)

Measured once every 2 weeks in health care setting, and then once weekly after 36wks

14

General Antenatal managament and investions in diabteic mother

1. fundoscopy
2. 24 hour urine protein test and renal functions
-rule out diabetic nepropathy
3. Ultrasound @ 13, for general wellbeing
23, to check for gross anomalies, nuchal translucency
4. 32 weeks, detailed scan.. check for anomalies
5. 38weeks, for morphometry and to estimate weight
6. HbA1c @ first visit, and then again at 8weeks
7. Urine MC&S, asympto bacteruria
8. CTG´s weekly from 34wks
9. Patient should be made aware to look out for quiet pattern..count fetal movements

15

Wjat is issue with using Beta 2 receptor stimulants in diabetic mothers with preterm labour

B2 stimulants, stimulate the conversion of liver glycogen to glucose, which causes maternal hyperglycaemia

* adjust insulin dose accordingly
*Administer in saline solution, not dextrose

16

When do we deliver diabetic moms, and why

38weeks, due to danger of stillbirths

17

preferred method of delivery in diabetic mom

vaginal delivery

18

When do we do c sections in diabetic moms

When there are obstetric complications
fetal weight >4kg

If labour has lasted longer than 18 hours

19

Is oxytocin safe to use in diabetic mothers during delivery

yes

20

Delivery management in insulin dependant mom

1.Induction in the morning
2. Continuous IV insulin
3.Short acting insulin 1U/ hour administered by infusion pump
-if no infusion pump, add 10U insulin to 1 litre of 5% dextrose
-Albumin first placed in vaculitre (prevents adherence of insulin on the sides ). Mixture given @ 100ml/ hr

4.Give 5% dextrose solution simultaneously @ rate of 100ml/hr.

Blood glucose monitored hourly
Pts on oral agents continue as per usual

Continuous monitoring of fetus throughout
All patients delivered in lithotomy position, with preparation for shoudler dystocia.

21

What to do if ketonuria present at delivery (diabetes)

Increase insulin and glucose dose

22

What to check in the newborn

Hourly blood glucose
haematocrit (polycythemia)
Clinical exam for anomalies (esp cardiac)
Examination of neonate for hyperbilirubinemia
Be alert for resp distress syndrome

23

Definitions of post partum hemorrhage

1. blood loss 500ml with vag delivery
blood loss 1000ml with c section
2.Vag bleeding, or blood loss at csection with hypotension and tachy
3. Bleeding associated with drop in hematocrit of 10% or more
4. Bleeding at delivery necessitating blood transfusion

24

Estimation of blood loss and rx

mild increase in pulse: 700ml-fluids
increase pulse and tachypnoae-1500ml-fluids
Fall in blood pressure: 2000ml-fluids and blood
Cold, drowsy, high pulse rate, low BP: 2500ml, large transfusion.

25

When Can I transfer a patient with post partum haemorrhage...

Systolic > 90mmHg
Two Large bore IV in: one with blood, one with oxytocin
Foley´s cathether
Bimanuael compression if actively bleeding

26

What is primary PPH

with in 24hours

27

What is secondary PPH

from 24hr to 42 days

28

Causes of Primary PPH

UTERINE
-uterine atony
retained products
abnormal placentation
overdistention
idiopathic
-contracted uterus
cervical laceration
uterine rupture
-uterine inversion
NON UTERINE CAUSES
Lower genital lacerations
coagulopathy
haematoma

29

Causes of secondary PPH

Endometritis
Haematoma
Trophoblastic neoplasia

30

Risk factors for uterine atony

Full bladder
retained products of conception
Overdistention of uterus (multiple fetus, polyhydram)
Augmentation of labour with oxytocin
Halothane
Prolonged labour
Chorio-amnionitis
Grand multiparity
Administration of magnesium sulphate
Uterine tumours such as fibroids
Congenital abnormalitie of the uterus
Previous episodes of uterine atony
Abnormal placentation

31

Does c section increase the risk for future abnormal placentation

yes

32

How to prevent PPH (Rx)

1. Make sure bladder empty
2. Start oxytocin infusion, 20-40IU/L for at least 3hours. (6-8hours in high risk cases)
3.Monitor
- Vital signs
-Uterine fundal height
-Vaginal bleeding

33

When is bleeding excessive, practical tip

when pads have to be replaced every hour

34

Management of PPH

1. Feel uterus
2. Manually massage the uterus (myometrial contraction)
3. Empty the bladder
4. Insert 2IV lines
5. Initiate oxytocin infusion
6. Oxytocin infusion, 40IU/ L crystalloid fluid infused at 40 drops per minute
7. Syntometrine can be given IM
8. CALL FOR HELP
9. Cross match , order 2 units of packed red cells
10. Arrange for internal examination in theatre

* IF no retained products or lacerations:
Misoprostal, 2-5, 200microgram tablets rectally
Prostaglandin F2 alpha IM, or injected directly into
myometrium(1 ampoule). Repeat after half an hour if
needed.
Maintenence dose: 5mg in 500ml 0.9% saline
@ 10-30 drops per min IV

35

Ergometrine and prostaglandin F2 alpha are contraindicated in

Hypertension
active cardiac or renal disease
Pulmonary disease
hepatic disease

36

Management of massive hemorrhage

Fluid therapy:
2 IV lines, warm fluids ( if access difficult, do CVP)
2 litres of ringers, thereafter colloids
Cross match 4-6 Units of blood ( O neg ) FFP can be used too
Elevate patients legs and give oxygen @ 6l/min

*evaluate clotting profile:
Platelet count (reduced with massive transfusion)
Prothrombin time
Partial thromboplastin time (lenghthened with massive
transfusion)
Thrombin time (lengthened with DIC)
Fibrinogen (reduced in DIC)
If fibrinogen defect suspected, give FFP

* give calcium gluconate, 1 ampule for every 4 units of blood given

37

Monitoring of PPH

Systolic more than 100
Pulse rate we want below 100
Urine output of 30ml/ hour
SATS monitor

Check haematocrit, clotting profile, U & E

38

Indications for surgery in PPH

Uncontrollable hemorrhage
Sever clotting defect and DIC
Organ failure

39

Rx of retained placenta

IV 20-40IU/L oxytocin running at 30 drops per min
1. if no bleeding
allow 1 hr for seperation to take place, then attempt
manual removal in theatre (MROP)
Before theatre try:
steady cord traction with uterine counterpressure
Inject 10IU of oxytocin IV

2. With bleeding
Administer syntometrine 0.5mg IV, start oxytocin infusion

40

Uterine rupture:

Pain continuous between contractions
sudden onset of acute fetal distress with vag bleeding
abscence of contractions
sudden fetal death
Hematuria

41

How to diagnose retained products of conception

Uterus may be slightly enlarged, US will show products.
Rx: evacuation in theatre. If bleeding cannot be controlled, hytesterectomy is indicated.

42

Management of haematomas (PPH)

Small vulvar hematoma <5cm must be drained with analgesic and anti inflamm drugs

Larger hematomas need drainage: with incision at medial side.

Subperitoneal and supravaginal haematomas need laparotomy, tertiary level care

43

Up to how many weeks is the size of uterus determines by bimanual examination

12 weeks

44

How do we determine duration of pregnancy from 13 to 17 weeks

Abdominal examination

45

When how many weeks do we use the SF height to determine duration of pregnancy

18 weeks

46

uterus bigger than dates suggests

Multiple pregnancy
Polyhydramnions
A fetus which is large for gestational age
DM

47

Uterus smaller than dates suggests

IUGR
Oligohydramnios
Intra uterine death
Rupture of membranes

48

Causes of breech presentation

UTERINE
- congenital abnormalities, for eg unicornuate uterus
- Uterine tumours, leiomyomata
- Pelvic tumours compressing the uterus

FETAL
- Motor, or neurological abnormalities, for eg: spina bifida
- Hydrocephalus
- Short cord
- Fetal death

PREGNANCY
-Placenta previa
- Multiple pregnancy
- Polyhydramnios
- Oligohydramnios

49

In which head is the position in vaginal breech delivery

Head is in flexion

50

How to differentiate between cephalic and breech on vaginal exam

BREECH
-Irregular presenting part
- Buttox, sarcrum, genitals
-Anus in found in straight line between ischial tuberosities

FACE
-nose can be felt
-mouth forms triangle with the cheek bones.

51

Antenatal care in breech

refer to hosp
US to exclude multiple pregnancies and obvious abnormalities
External cephalic version
Delivery plan

52

How to do external cephalic version

Lift presenting part out of pelvis
Then turn fetus around to cephalic presentation

*may be facilitated by placing her in right lateral condition.
*Administer salbutamol 200micrograms IV slowly (to relax uterus)

53

Contraindications to external cephalic version

-APH
-ROM
-Multiple pregnancies
-Pregnancy <37 weeks
-HIV +

#prev c section-relative C/I
#Hypertensive disorder-relative C/I
#Suspicion of placental insuffiency -relative C/ I

54

Complications of External cephalic version

-ROM
-Abruptio placentae
-Tightening of a loop of umbilical cord
-feto maternal hemorrhage
Rutured Uterus

55

wHT must you do immediately after external cephalic version

Monitor fetal wellbeing with CTG

Administer 100micrograms anti-D if mother is RH neg

56

T/F: in breech presentation, vaginal delivery is less risky for baby

false

57

Is oxytocin augmentation allowed in breech delivery

no

58

Complications of breech presentation

Asphyxia in second stage of labour, delay in delivery

Cord prolapse, poorly fitting presenting part

Physical injury -difficulties with obstetric manoeuvres