Obstetrics Flashcards
(195 cards)
1
Q
When is the booking visit?
A
approx 10wks gestation
2
Q
How do you calculate EDD?
A
LMP + 7/7 + 9/12
3
Q
When is the dating scan?
A
approx 12 wks
4
Q
What is tested for in ‘booking bloods’?
A
- blood group and rhesus status
- FBC (for anaemia)
- haemoglobinopathies
- HIV
- hepatitis B
- syphilis
5
Q
When is the anomaly scan performed?
A
approx 20wks
6
Q
What is rhesus prophylaxis?
A
Given to all women who are rhesus negative
Prevents maternal antibodies attacking fetal blood
Cell free DNA or anti-D treatment
7
Q
How many antenatal visits do the average nulliparous and mutliparous women recieve?
A
Multiparous - 8
Nulliparous - 10
8
Q
What maternal factors effect fetal growth?
A
genetic: height, weight, parity, ethnic group
environmental: social class, nutrition, altitude, comorbidity
9
Q
How do you assess fetal growth?
A
Symphysis-fundal height
USS
10
Q
What measurments are taken in a growth scan?
A
biparietal diameter
head circumference
abdominal circumference
femur length
11
Q
How do you assess placental function?
A
Doppler studies to assess blood flow in fetal arteries
12
Q
What day in menstrual cycle does implantation occur?
A
23
13
Q
Where does fertilisation occur?
A
fallopian tube
14
Q
What are the effects of raised progesterone in pregnancy on the cardiovascular system?
A
increased CO (HR and SV both increased) BP decreases (fom decreased SVR)
15
Q
What are the effects of raised progesterone in pregnancy on the respiratory system?
A
increased resp rate
16
Q
What are the effects of raised progesterone in pregnancy on the uterine quiescence?
A
‘relaxation’
uterus doesn’t contract until the end of pregnancy
17
Q
What are the effects of raised progesterone in pregnancy on the immune system?
A
weakened to prevent attack on baby (foreign body!)
makes UTIs and thrush v common
18
Q
What are the effects of raised progesterone in pregnancy on the GI system?
A
progesterone is a muscle relaxant therefore –> constipation
19
Q
How quickly does the fetus grow before 12wks?
A
Doubles in size every week until week 12
20
Q
When does fetal heart activity begin?
A
6-7wks
21
Q
When do fetal limb buds form?
A
8wks
22
Q
What antenatal screening is offered?
A
fetal anomalies
infectious disease (HIV, hep B, syphilis)
haemoglobiopathies
rhesus negative
23
Q
What is the ‘combined screening’?
A
opt-in test offered at early pregnancy scan
measures nuchal tranluscency and maternal blood test for PAPPA and HCG
results show only ‘probability of increased risk’
24
Q
If the combined screening returns a ‘higher risk’ result, what can be offered to the mother?
A
- chorionic villous sampling (from 11wks)
- amniocentesis (from 15wks)
25
What is the risk of miscarriage with CVS and amniocentesis?
1% for both
26
Should a HIV diagnosis be written in a mother's notes?
NO
| confidential
27
Should a diagnosis of hepatitis B be written in a mother's notes?
YES
| clear documentation necessary as notifiable disase
28
What intervention is necessary in a pregnant women with a new diagnosis of hepatitis B?
- refer to hepatology
- new born vaccines (5 doses)
- household contact testing
29
What intervention is necessary in a pregnant women with a new diagnosis of syphilis?
- refer to GUM for abx
- need full treatment at least 4wks before delivery to prevent transmission
- partner tracing
30
Which of the following tests are opt-in or opt-out?
- HIV
- Hepatitis B
- syphilis
- haemoglobinopathies
- combined screening
```
HIV: opt-out
Hep B: opt-out
syphilis: opt-out
Haemoglobinopathies: opt-out
combined screening: opt-in
```
31
Why do pregnant women get carpal tunnel?
Due to signifiacnt oedema, causes compression on median nerve in wrist
32
In which trimester are women likely to suffer from haemorroids?
3rd trimester
33
Why do pregnant women get varicose veins?
progesterone relaxes vasculature and fetal mass effects pelvic venous return
34
How do urinary symptoms vary from 1st to 3rd trimester?
1st: frequency from increased glomerular filtration rate
3rd: stress incontinence from pressure on pelvic floor
35
Why is constipation common in pregnancy?
reduced gastric motility (mediated by progesterone)
36
What hormone is thought to be responsible for 'morning sickness' and when does it normally resolve?
HCG
| resolves by week 16-20
37
What is hyperemesis gravidarum?
excessive sickness and vomitting - warranting hospital admission
persisten intractable vomiting, can't keep down fluids, weight loss and severe dehydratioin
38
What is the treatment for hyperemesis gravidarum?
admit for oral fluids if can't keep down (saline or Hartmann's)
daily U&Es - replace K+ as necessary
NBM for 24hrs
antiemetics (promethazine or cyclizine)
39
What is SGA?
'small for gestational age' - born with weight less than 10th centile
40
How do you distinguish between a baby who is constitutionally small and one who has IUGR?
IUGR: head sparing, growth slows and plateaus
CS: always small but increasing size normally and otherwise healthy
41
What factors affect the placental transfer of nutrients (therefore are RFs for IUGR)?
Severe anaemia
low pre-pregnancy weight
substance abuse
42
What factors affect placental implantation and vascultaure (therefore are RFs for IUGR)?
```
pre-eclampsia
autoimmune disease
thrombophilias
renal disease
DM
HTN
```
43
What are the major RFs for IUGR?
```
maternal age >40
smoker
cocaine use
daily vigorous exercise
previous SGA baby
previous still birth
chronic HTN
DM with vascular disease
renal impairment
antiphospholipid syndrome
```
44
What factors can make measuring symphysis-fundal height inaccurate?
high BMI
large fibroids
multiple pregnancy
45
If a patients SFH measures small, what is done next?
Women with major risk factors are referred for serial USS and umbilical artery Doppler
Women with minor risk factors referred for Doppler - if abnormal, then serial USS as well
46
What medications should be given in severe IUGR?
Progesterone to prevent pre-term birth
| Maternal steroids in case of pre-term birth
47
What is macrosomia?
'large for dates'
| babies bown with a weight above the 90th centile
48
What are risk factors for macrosomia?
```
maternal diabetes
Hx of fetal macrosomia
maternal obesity
excessive weight gain in pregnancy
male infant
overdue
```
49
What complications arise from fetal macrosomia?
Maternal:
- prolonged vaginal delivery time (higher risk of CS)
- uterine rupture (if previous CS
- difficult/traumatic birth
Fetal:
- hypoglycaemia after delivery
- childhood obesity
- increased risk of birth defects
- respiratory distress
50
When should women be aware of fetal movements?
from 20 wks
51
What does fetal movement indicate?
integrity of CNS and MSK system
52
What are the risks associated with reduced fetal movement?
IUGR, placental insufficiency, congenital malformation
53
What is a prolonged pregnancy?
pregnancy exceeding 42wks form first day of LMP
54
What risks to the mother are associated with prolonged pregnancy?
anxiety and psychological stress
| increased need for intervention (IOL, operative delivery etc)
55
What risks to the fetus are associated with prolonged pregnancy?
- perinatal mortality
- meconium aspiration
- shoulder dystocia
- fetal distress in labour
- oligohydramnios
- neonatal hypothermia/hypoglycaemia/polycythaemia
- fetal post-maturity syndrome
56
What is the management of a prolonged pregnancy?
offer stretch and sweep from 41wks
offer IOL at 41-42wks
continuous fetal monitoring with CTG
57
What is PPROM?
preterm pre-labour rupture of membranes
58
What is PROM?
premature rupture of membranes (at term, but before onset of labour)
59
How do you diagnose ROM?
- pooling of amniotic fluid on speculum
| - nitrazine/ferning staining
60
At what gestation can labour be induced?
34wks
61
For women with PROM and PPROM, what is their chance of spontaneous labour?
PPROM - 80% within 7days
| PROM - 90% within 48hrs
62
How do you manage PPROM?
<34 wks
- aim for increased gestation
- monitor for signs of chorioamnionitis
- prophylactic erythromycin
- 2x12mg betametasone 24hrs apart
34-36wks
- monitor for signs of chorioamnionitis
- prophylactic erythromycin
- 2x12mg betametasone 24hrs apart
- IOL recommended
```
>36wks
-monitor for signs of chorioamnionitis
-clindamycin/penicillin during labour
watch and wait for 24hrs (may labour spont)
-IOL
```
63
What are the main complications associated with PPROM?
- chorioamnionitis
- oligohydramnios
- neonatal death
- placental abruption
- umbilical cord prolapse
64
What fetal risks are associated with IUGR?
- intrapartum fetal distress
- meconium aspiration
- emergency CS
- necrotising enterocoloitis
- hypoglycaemia and hypocalaemia
65
What social factors calss a pregnancy as high risk?
- teenage pregnancy
- maternal age >40
- high parity
- low interpregnancy interval
- alcohol intake
- substance misuse
- poor socioeconomic conditions
66
What obstetric history would cause the currecnt pregnancy to be classed as high risk?
```
CS
preterm delivery
recurrent miscarriage
stillbirth
GDM
pre-eclampsia
3rd-4th deg tear
```
67
What Hx of the current pregnancy would class it as high risk?
```
multiple pregnancy
SGA
placenta previa
GDM
pre-eclampsia
meconium stained liquor
worrying CTG
need for oxytocin
lack of progress
```
68
What is the management of hypertension in pregnancy?
1st: labetalol (contraindicated in asthma)
2nd: nifedipine
NB do not use ACEi in pregnancy
69
What is the stage of cleavage for various types of twins?
DCDA: day 1-3
MCDA: day 4-8
MCMA: day 8-13
conjoined: day 13-15
70
What are the maternal complications associated with multiple pregnancy?
- hyperemesis gravidarum
- anaemia
- miscarriage
- preterm labour
- pre-eclampsia
- antepartum and postpartum haemorrhage
- postnatal depression
71
What are the fetal risks associated with multiple pregnancy?
- prematurity
- congenital abnormalities
- fetal growth restriction
- intrauterine death
72
How regularly do multiple pregnancies recieve growth scans?
DCDA - 4wkly from 16wks
| MCDA/MD - 2wkly from 16 wks
73
When should multiple pregnanceis be delivered?
DCDA - 37-38wks
| MCDA - 36wks
74
What is recurrent miscarriage?
3 or more consecutive miscarriages in 1st trimesters with same biological father
75
What are possible causes of recurrent miscarriage?
- antiphospholipid syndrome
- genetic factors
- fetal chromosomal anomalies
- anatomical abnormalities
- large fibroids
- thrombophilic disorder
- infection
- 35% have no known cause
76
How should recurrent miscarriage be investigated?
- parental blood karyotyping
- cytogenic analysis of products of conception
- thrombophilia screen
- antibody testing
77
What is mid-trimester loss?
Loss of pregnancy between 12 and 24wks
78
What are possible causes of mid-trimester loss?
chronic disease (DM, HTN, lupus, CKD)
infection
medications (misprostol, retinoids, methotrexate, NSAIDs)
PCOS
79
Define stillbirth?
child delivered after 24wks gestation who did not breathe or show signs of life once completely expelled
80
define early and late neonatal death
death of a live born baby:
- early = <7 complete days from time of birth
- later = 7-28 days from time of birth
81
What are the criteria for labuor to be classified as 'normal'?
- term (37-42wks)
- singleton pregnancy
- baby presenting head first
- spontaneous labour
- low risk pregnancy
82
What changes happen to the cervix during labour?
RIPEN
| decrease in collagen and increase in water content enables cervix to soften, efface and dilate
83
What changes happen to the myometrium during labour?
stretches, increasing muscle excitabiltiy and contractility
| gap junctions for under influence of oestrogen - can get a synchronised wave of contraction
84
What hormonal changes occur during labour?
Increased concentrations of oestrogen
| Release of prostoglandins and oxytocin
85
What is the effect of increasing oestrogen concentrations during labour?
stimulate production of prostoglandins and promotes formation of oxytocin receptors in myometrium
86
What are the effecs of prostoglandin and oxytocin in labour?
strong myometrial stimulation, helps cervical ripening
87
What is the latent phase of labour?
period of time when painful contractions and some cervical changes (effacement and dilation up to 4cm)
88
What is established labour?
regular painful contractions and progressive cervical dilatation from 4cm
89
What is the 1st stage of labour?
from onset of established labour (dilated 4cm) to full dilatation of the cervix (10cm)
90
What is the 2nd stage of labour?
from full dilation to birth of baby
91
What is the 3rd stage of labour?
From birth of baby to expulsion of placenta and membranes
92
What is cervical effacement?
cervix getting shorter
93
What is the difference between an active and passive 2nd stage of labour?
passive - find full dilation before expulsive contractions
| active - expulsive and active maternal effort
94
What is involved in the active management of the 3rd stage of labour?
use of syntometrine
deferred clamping and cutting of cord
controlled cord traction
95
Who needs CTG monitoiring?
any women with high risk pregnancy
| if concerned on intermittent auscultation
96
What structure should you use to assess CTG?
Dr C Bravado
97
How do you assess contractions on CTG?
show frequency and duration but not intensity
| should be 4-5 every 10 mins
98
What are possible causes of fetal tachycardia?
```
premature
hypoxia
infection
drugs
hypothyroidism
maternal anaemia
```
99
What are possible causes of fetal bradycardia?
post-maturity
hypoxia
heart block
severe fetal distress
100
What is the normal range for baseline rate?
100-160 bpm
101
What is a normal acceleration on CTG?
rise >15bpm for 15s
102
What is normal variability on CTG?
5bpm or more
103
Why does variability occur on CTG?
from balance between parasympathetic and sypathetic nervous systems
104
Is sinusoidal variability a good or bad sign?
VERY VERY BAD
105
What are early decelerations due to?
normal vagal response to head compression in contraction
106
What are late deccelerations due to ?
interruption in utero-placental blood flow
107
What are defined as 'reassuring' deccelerations?
none or early or variable with no concerning features for <90mins
108
What are the classifications of 'overall impression' of a CTG?
- normal (all features reassuring)
- suspicious (1 non-reassuring feature)
- pathalogical (1 abnormal or 2 non-reasuring features)
- immediate intervention (prolonged deceleration)
109
What is a normal fetal blood pH?
>7.25
110
If fetal blood sample pH is <7.2, what should you do?
DELIVER THE BABY
111
When might you need to use a fetal scalp electrode?
When you can't get a good contact with the external transducer: high BMI, twins etc
112
What does a partogram show?
maternal monitoring
- cervical dilatation and descent of head
- frequency of contractions
- fetal HR
- liquor colour
- maternal observations
113
Which are slow vs fast nerve fibres:
C fibres = slow
| A delta fibres = fast
114
What is entonox?
nitrous oxide for inhalation - partial analgesia
115
What are the absolute contraindications of a spinal anaesthetic?
anti-coagulants
severe infection
anaphylaxis
116
What are possible complications of spinal and epidurals?
failure, hypotension, LA toxicity, total spinal, infection, haemotoma, neurological damage
117
What are the maternal indications for induction of labour?
- prolonged pregnancy (41-42wks)
- antepartum haemorrhage
- maternal hypertension/pre-eclampsia
- poor obstetric Hx
118
What are the fetal indications for induction of labour?
- IUGR
- PPROM
- DM (because of likely IUGR)
- multiple pregnancy
- intrauterine death
119
What are absolute contraindications to induction of labour?
- acute fetal compromise
- unstable lie
- placenta previa
- pelvic obstruction
120
What drug helps cervical ripening of the cervix?
prostoglandin
121
What are potential complications of induction of labour?
- fetal distress
- precipatate delivery
- operative delivery
- uterine hypertonia and possibly rupture
- amniotic fluid embolus
- systemic effects
122
Describe a frank (or extended) breech position
Bum down, legs up extended straight to head
123
Describe complete (or flexed) breech position
Bum down with legs flexed and folded
124
What are some associations with malposition?
```
preterm
previous breech
placenta previa
fetal abnormalities
uterine abnormalities
multiple pregnancy
```
125
What are the consequences of malposition?
Fetal - increased risk of hypoxia and trauma in labour
| Maternal - likely CS
126
What is ECV?
External cephalic version - apply gentle pressure to maternal abdo to turn the fetus
127
What are the contraindications to ECV?
```
placenta previa
uterine malformation
ROM
abnormal CTG
severe pre-eclampsia
```
128
What is unstable lie?
when lie is changing, up to several times per day
129
What is a transverse lie?
when baby lies across the uterus
130
What are the 3 P's of labour?
Power (contractions)
Passenger (baby)
Passage (parity/pelvis)
131
How quickly should a mother progress in 1st stage of labour?
Primip - less than 2cm in 4hrs
132
How would you manage a lady progressing slower than 2cm in 4 hrs?
Augmentation of labour
| ARM, syntocinon, CS
133
What should be the ideal presenting part?
'vertex'
| area between two parietal eminences , anterior and posterior fontanelle
134
What are the risks associated with twin delivery?
```
malpresentation
fetal hypoxia
cord prolapse
operative delivery
PPH
```
135
What are the requirements for an operative delivery? (FORCEPS)
```
F - fully dilated
O - occipito-anterior
R - ROM
C - cephalic
E - engaged
P - pain relief
S - sphincter (bladder) empty
```
136
What is a cephalohaematoma?
basically a big bad bruise on babies head, normally after ventouse delivery
137
What are the indications for CS?
repeat CS
fetal compromise
failure to progress
breech
138
What are the possible complications of CS?
blood loss, uterine injury, bowel/bladder laceration, hysterectomy, wound infection, future uterine rupture
139
What is the success rate of vaginal birth after CS (VBAC)?
75%
140
What is the risk of uterine rupture in VBAC?
0.3%
141
What is shoulder dystocia?
delivery that requires additional manouvres to deliver shoulders - usually anterior shoulder impacted against pubis symphysis
142
What are the fetal complications of shoulder dystocia?
```
hypoxia
brachial plexus palsy
fracture of clavicle or humerus
intracranial haemorrhage
cervical spine injury
rarely fetal death
```
143
What can increase risk of shoulder dystocia?
```
previosu Hx
fetal macrosomia
BMI>30
DM
post-term
```
144
What is the management of shoulder dystocia? (HELPERR)
```
H - call for help
E - episiotomy
L - legs to McRoberts
P - suprapubic pressure
E - enter pelvis for internal manouvres
R - release poterior arm by flexing
R - roll over to all 4s
```
145
What is pre-term labour?
24-37 wks
146
If someone is at high risk of pre-term labour?
2 x IM 12mg betametasone 24hrs apart
147
Define antepartum haemorrhage
bleeding from birth canal after 24th week of pregnancy until 2nd stage of labour complete
148
What is bleeding from the birth canal at <24wks?
threatened miscarriage
149
What are possible causes of APH?
```
placenta previa
placental abruption
local infection
partner violence
uterine rupture
congenital bleeding disorders
a show (bloody mucus plug)
```
150
What is the natural effect of pregnancy on blood pressure?
reduced until 24wks because of decreased vascular resistance
151
What is post-partum hypertension?
HTN arising in post-partum period - peaks 3-5 days post-partum
152
How common is pregnancy induced hypertension?
6-7% of pregnancies
153
What is pre-eclampsia?
BP >140/90mmHg and >300mg proteinuria
154
If someone is already hypertensive, what change would denote pre-eclampsia?
rise of >30 systolic of >15 diastolic
155
What is the rate of pre-eclampsia?
5% of pregnancies
156
What risk factors predispose to pre-eclampsia?
```
previous pre-eclampsia
age >40 or <18
FHx
obesity
primiparity
pre-existing (DM, HTN)
multiple pregnancy
long birht interval
hydatidiform mole
```
157
Signs and symptoms of pre-eclampsia?
```
often asymptomatic (picked up at ANC)
headache
visual disturbance
RUQ
N&V
rapid oedema
HTN
proteinuria
confusion
IUGR on scan
hyperreflexia
```
158
What are possible complications of pre-eclampsia?
```
Eclampsia
HELLP syndrome
cerebral haemorrhage
IUGR
renal failure
placenta abruption
```
159
What are the indications for immediate delivery in severe pre-eclampsia?
```
worsening thrombocytopenia
worsening liver or renal function
severe maternal symptoms
HELLP syndrome
eclampsia
fetal distress (CTG)
```
160
What medication can be given in hypertension/pre-eclampsia?
labetalol or nifedipine
161
What is eclampsia?
presence of tonic-clonic seizures in association with diagnosis of pre-eclampsia
162
What is the management for eclampsia?
```
call for help
A-E approach
most fits terminate spontaneously
MgSO4 immediately (4g over 5-10mins)
in repeat seizures, repeat MgSO4 + diazepam
strict monitoring
may need intubation and ventilation
IV labetalol if hypertensive
continuous CTG monitoring
deliver fetus as soon as mother stable enough
```
163
What is HELLP syndrome?
Variant of severe pre-eclampsia with:
- haemolysis
- elevated liver enzymes
- low platelets
164
What are the signs and symptoms of HELLP syndrome?
RUQ pain, N&V, brown wee, raised BP, eclampsia?
165
What is the management of HELLP syndrome?
deliver if mother stable enough
suppotive treatment
platelet infusion if actively bleeding or going for surgery
166
What is the leading cause of direct maternal mortality?
VTE
167
What percentage of obstetric VTE occur in peurperium?
50%
168
What are risk factors for obstetric VTE?
```
previous VTE
thrombophilia
sickel cell
age >35
parity >4
gross varicose veins
inflammatory disease
```
169
Where is DVT most likely to occur in pregnancy??
above the knee in the left leg
170
How should you treat suspected VTE in pregnancy?
LMWH ASAP (do not weight for investigations, treat on suspision)
171
What is the classification of perianal trauma?
1st: injury to skin only
2nd: injury to perineum involving perineal muscles
3rd: injury to perineum involving anal sphincter
- 3a - <50% of external anal sphincter
- 3b - >50% of external anal sphincter
- 3c - internal anal sphincter torn
4th: injury to perineum involving sphincter and anal epithelium`
172
What is an episiotomy?
surgical incision to enlarge the vaginal interosiuis
173
What are possible complications of an episiotomy?
```
bleeding
haematoma
pain
infection
scarring
dysparuenia
rarely - fistula formation
```
174
what is the peuperium?
6 weeks post-partum
175
Is lactational amenorrhoea indicative of contraceptive protection?
no
176
How much milk is produced per day by 5 days post-partum?
up to 500mL/day
177
How many women does 'baby blues' effect?
75%
178
How many women does post-natal depression effect?
10-15%
179
How many women does puerperal psychosis effect?
1:500
180
What are the main causes of antepartum haemorrhage?
placenta previa
placental abruption
local issues (cervical polyps, trauma)
181
What are the main causes of post-partum haemorrhage?
```
'the 4 T's'
tone (atonic uterus)
trauma
tissue (retained POC)
thrombin (abnormal clotting)
```
182
What is maternal mortality of uterine inversion?
up to 15%
183
What are risk factors for uterine inversion?
```
strong traction on umbilical cord
abnormal adherence of placenta
short cord
fundal implantation
uterine anomalies
previous uterine inversion
```
184
How would uterine inversion present?
```
haemorrhage
severe lower abdo pain
shock (out of proportion with blood loss)
uterine fundus not palpable
mass in vagina on VE
```
185
What are risk factors for uterine rupture?
1 in 200 after 1 previous CS
| mulitparity with oxytocin
186
How would a uterine rupture present?
```
fresh vaginal bleeding
haematuria
fetal distress
constant severe abdo pain (breaks through epidural)
shock
```
187
How do you manage uterine rupture?
A-E
| immediate laparotomy to salvage baby
188
What organism most commonly causes obstetric septic shock?
strep A
189
What is the management of obstetric septic shock?
cefotaxime + metronidazole +/- gentamicin
190
How quickly (from onset of symptoms) will a missed amniotic fluid emoblus lead to death?
3 hrs
191
What risk factors are associated with amniotic fluid embolism?
```
multiple pregnancy
older maternal age
CS
instrumental delivery
eclampsia
placenta previa
placental abruption
cervical laceration
uterine rupture
medical IOL
```
192
How would amniotic fluid embolism present?
```
VERY ACUTE ONSET
hypoxia/respiratory arrest
hypotension
fetal distress
convulsion
shock
reduced GCS
cardiac arrest
```
193
What is the adverse affect of using tetracyclines in pregnancy?
fetal tooth discolouration
194
What is the treatment of chorioamnionitis?
cefuroxime and metronidazole
195
How would you treat UTI in pregnancy?
trimethoprim (NOT IN 1st TRIMESTER)
nitrofurantoin (NOT IN 3rd TRIMESTER)
cephalosporins and penicillins
