Obstetrics Flashcards
(176 cards)
1
Q
When can the combined test (blood & NT) be done for Downs Syndrome?
A
11 to 13+6 weeks
2
Q
When is a booking visit usually done?
A
8 to 12 weeks
3
Q
When can solely blood tests be done for Downs syndrome?
A
15 to 20 weeks
4
Q
When is an anomaly scan done?
A
18 to 20+6 weeks
5
Q
When is anti-D prophylaxis given?
A
28 weeks (+/- 34 weeks)
6
Q
What investigations should be carried out at the booking visit?
A
Bloods (FBC, ABO, Rhesus, syphilis, HIV, HepB&C)
Urinalysis (MSSU for culture and sensitivities)
USS ( confirm viability, no of fetuses, gestation)
7
Q
Is HCG increased or decreased in babies with downs syndrome?
A
Increased
8
Q
Is PAPP-A increased or decreased in babies with downs syndrome?
A
Decreased
9
Q
Is AFP increased or decreased in babies with downs syndrome?
A
Decreased
10
Q
In what circumstances would AFP be raised in pregnancy?
A
Multiple pregnancy, placental abruption, anencephaly, spina bifida
11
Q
What level of risk from the initial downs syndrome testing warrants invasive testing?
A
Risk of 1 in 150 or more
12
Q
What are the two invasive tests for Downs syndrome?
A
Chorionic Villous sampling
Amniocentesis
13
Q
When is chorionic villous sampling carried out?
A
11-13 weeks
14
Q
When is amniocentesis carried out?
A
15+ weeks
15
Q
What is the risk of miscarriage in chorionic villous sampling?
A
2%
16
Q
What is the risk of miscarriage with amniocentesis?
A
1%
17
Q
When should Anti-D be given acutely?
A
Within 72 hours of a sensitising event (e.g. CVS, amniocentesis, ectopic, miscarriage, termination)
18
Q
How is Anti-D administered?
A
IM injection into deltoid muscle
19
Q
What maternal factors can cause poor growth of the fetus?
A
Age (>35, <16), low socioeconomic status, parity (0 or >5), interpregnancy interval (<6 months, >120 months), medical conditions (e.g. SLE, asthma, pre-eclampsia etc), previous SGA, drug abuse, ART, maternal infection (TORCH, malaria, TB, UTIs, BV)
20
Q
What fetal factors can cause poor growth?
A
Chromosomal anomalies (trisomies 13, 18, 21) Major congenital anomalies Congenital infections Multiple pregnancy Genetic syndromes
21
Q
What placental factors can cause poor growth?
A
Placental dysfunction (e.g. pre-eclampsia) Placental abruption
22
Q
What is symmetrical IUGR?
A
Global growth restriction
23
Q
What are the causes of symmetrical IUGR?
A
Aneuploidy, infection, maternal substance abuse
24
Q
What is an asymmetrical IUGR?
A
Reduced abdominal circumference (normal head circumference, biparietal diameter and femur length)
25
What are the causes of an asymmetrical IUGR?
Placental insufficiency
26
What are the main features of IUGR?
Decreased fundal height
Reduced liqor
Reduced fetal movements
27
What investigations should be done to assess growth of fetuses?
CTG
Biophysical assessment (looking at fetal movement, breathing, tone and liqor)
Doppler USS of umbilical artery
28
What does absent or reversed end diastolic flow on doppler USS of the umbilical artery indicate?
It indicates placental resistance which means there is a problem. The placenta is usually a low resistance, high flow organ.
29
What are the causes of large for dates?
```
Constitutionally large
Polyhydramnios
Multiple pregnancy
Diabetes
Beckwith-Widemann syndrome
```
30
What are the causes of polyhydramnios?
Twins, fetal anomaly, maternal diabetes, idiopathic, hydrops fetalis
31
What is Hydrops fetalis?
Abnormal accumulation of fluid in 2 or more fetal compartments. Caused by rhesus disease, infection, congenital anomalies
32
What are some symptoms of polyhydramnios for the mother?
Discomfort, breathlessness, heartburn
33
What are some potential complications of polyhydramnios?
Cord prolapse, placental abruption, preterm labour
34
How is polyhydramnios managed?
Expectant management
35
Which type of twins are at the most risk of complications?
Monochorionic monozygotic
36
What are the signs/symptoms of multiple pregnancy?
Exaggerated pregnancy symptoms, high AFP, large for dates
37
What is twin to twin transfusion syndrome?
Placental anastamoses result in blood being moved disproportionately from one twin to another. Donor twin becomes dehydrated and has reduced growth. Recipient twin becomes fluid overloaded.
38
What twin type is at risk of TTS?
Monochorionic twins
39
Can twins be delivered normally?
Yes as long as one is cephalic
40
What dose of folic acid should pre-existing diabetic patients take?
5mg
41
In pregnant pre-existing diabetics, what drugs should be stopped/ continued?
All should be stopped except metformin and insulin
42
What are complications of pre-existing diabetes and pregnancy?
```
Hypoglycaemia unawareness
Pre term labour
Stillbirth
Polyhydramnios
Macrosomia or IUGR
Congenital anomalies
```
43
When should diabetics be offered induction of labour?
From 38 weeks to prevent macrosomia
44
What are complications for large for dates babies?
Risk of birth injuries e.g. shoulder dystocia
Prone to immaturity of suckling and swallowing
Hypoglycaemia
Hypocalcaemia
Polycythaemia (increased risk of jaundice)
45
By what week of pregnancy is the placenta functional?
Week 5
46
What vessel transports oxygen rich fetal blood?
Umbilical vein
47
What vessel transports oxygen low maternal blood?
Uterine vein
48
What 3 things mean fetal oxygen carrying capacity is good?
Fetal Hb can carry more oxygen
Fetus' have more Hb
The Bohr Effect
49
What happens to cardiac output in pregnancy?
Increases (can cause ECG changes, murmurs etc)
50
What happens to stroke volume in pregnancy?
Increases
51
What happens to blood pressure in pregnancy?
Decreases in 2nd trimester and then steadily starts to increase until term
52
What happens to respiratory rate in pregnancy?
Increases
53
What happens to both tidal volume and minute volume in pregnancy?
Increase
54
Do oxygen requirements in pregnancy increase or decrease?
Increase
55
What happens to plasma volume in pregnancy?
Increases
56
What happens to RBC count in pregnancy?
Increases
57
What happens to Hb in pregnancy?
Decreases by dilution (due to increased RBC)
58
What happens to platelets in pregnancy?
Decrease
59
What happens to GFR in pregnancy?
Increases
60
When does HCG peak?
10 weeks then declines
61
What oestrogen is an indicator of fetal vitality?
Estriol
62
When is the anabolic phase of pregnancy?
1-20 weeks
63
When is the catabolic phase of pregnancy?
21-40 weeks
64
What hormone causes growth of the ductile system in the breast?
Oestrogen
65
What hormone causes the development of the lobular alveolar complex in the breast?
Progesterone
66
What hormone stimulates milk production?
Prolactin
67
What hormone is released following a suckling stimulus?
Oxytocin
68
What is pre-existing HTN of pregnancy defined as?
Hypertension occurring before pregnancy/before 20 weeks gestation
69
How should women with pre-existing HTN be managed?
Switch patient to labetalol from ACEi/ARB
Do urine dip
Start aspirin 75mg from 12 weeks
70
What is pregnancy induced hypertension?
Hypertension occurring after 20 weeks with NO proteinuria or symptoms of pre-eclampsia
71
What is pre-eclampsia?
Pregnancy induced hypertension, proteinuria (>0.3g/l) +/- oedema
72
What is thought to be the underlying mechanism behind pre-eclampsia?
Abnormal trophoblastic invasion leading to abnormal placental perfusion and placental ischaemia. This causes release of anti-angiogenic substances into the circulation, causing the presentation of PET
73
What are risk factors for pre-eclampsia?
Age >40, BMI >30, personal history, family history, nulliparity, multiple pregnancy, pre-existing renal disease/hypertension/diabetes/SLE
74
What are symptoms of pre-eclcampsia?
Headache, visual disturbance, epigastric/RUQ pain, N&V, rapidly progressive oedema
75
What are some signs of pre-eclampsia?
```
Increased BP
Proteinuria
Oedema
Abdominal tenderness
Disorientation
Intra-uterine death/SGA
Hyperreflexia/clonus
```
76
What is eclampsia?
Tonic-clonic seizure with features of pre-eclampsia
77
How is eclampsia treated?
BP control (IV Labetalol/Hydralazine)
Neuroprotection - IV Magnesium Sulphate 4g over 5 mins
Deliver baby
78
How should fluids be managed in eclampsia?
The patient should be run DRY - 80ml/hr as the main cause of maternal death is pulmonary oedema
79
What is HELLP syndrome?
Haemolysis
Elevated Liver enzymes
Low Platelets
80
When should women with hypertension be admitted?
BP >170/110 or >140/90 with ++proteinuria
Significant symptoms
Significant proteinuria
Fetal compromise
81
What blood pressure in pregnancy is an indication to initiate treatment?
>150/100 regardless of aetiology
82
What medications are used to treat blood pressure in pregnancy?
Labetalol, nifedipine, methyldopa, hydralazine
83
What is the only cure for pre-eclampsia?
Delivery of the baby
84
How is blood pressure treated post partum?
Slow reduction of medications based on blood pressure readings
85
How soon after delivery should methyldopa be stopped and why?
By day 2 as it poses a risk of depression
86
What is antepartum haemorrhage?
Bleeding after 24 weeks and before delivery of the baby
87
What are the main causes of APH?
```
Placenta praevia
Placental abruption
Placenta accreta
Uterine rupture
Vasa praevia
Local causes (ectropion, polyp, cancer etc)
```
88
What is a minor APH defined as?
<50mls of blood that has settled
89
What is a major APH defined as?
50-1000mls of blood with no clinical signs of shock
90
What is a massive APH defined as?
>1000mls of blood and/or significant shock
91
What is placenta praevia?
Placenta is partially or totally implanted in the lower uterine segment
92
What is the difference between a minor and major placenta praevia?
Minor does not cover the os, major does
93
What are risk factors for placenta praevia?
Previous c-section, previous placenta praevia, asian ethnicity, smoking, previous TOP, age >40, multiparity, multiple pregnancy, ART
94
How does placenta praevia present?
Painless bleeding, unusually unprovoked but can be triggered by sex. Uterus soft, non-tender. CTG normal. No fetal distress.
95
How does placenta praevia affect delivery?
If within 2cm of os - c-section
| If over 2cm from os - vaginal delivery
96
What is placental abruption?
Premature separation of the uterus from the placenta.
Vasospam leads to arteriole rupture, blood then escapes into the myometrium which causes tonic contraction of the uterus leading to disrupted circulation and in turn hypoxia.
97
What are risk factors for placental abruption?
Pre-eclampsia, hypertension, trauma, smoking, cocaine, renal disease, diabetes, polyhydramnios, multiple pregnancy, previous abruption
98
How does a placental abruption present?
```
Severe, continous abdominal pain
Bleeding (may be concealed)
Pre-term labour
Maternal collapse
'Woody hard abdomen and tense uterus'
CTG - IUD/irritable
```
99
How does placental abruption affect delivery?
Urgent delivery needed by c-section or ARM and induction
100
What is placenta accreta?
When the placenta invades the uterine wall
101
How is placenta accreta diagnosed?
MRI scan
102
What are placenta increta and placenta percreta?
Increta - invasion of myometrium
| Percreta - invasion of serosa/bladder/bowel
103
What are some risk factors for placenta accreta?
Previous c-section, placenta praevia
104
How is placenta accreta managed?
Insert prophylactic internal iliac balloon
May need caesarean hysterectomy
Expect >3L blood loss
105
What is uterine rupture?
Full thickness opening of the uterus
106
What are risk factors for uterine rupture?
Previous c-section, uterine surgery, multiparity, syntocinon use, obstructed labour
107
How does uterine rupture present?
Shoulder tip pain, severe abdominal pain, maternal collapse, PV bleed, loss of contractions, peritonism, fetal distress
108
What is vasa praevia?
Fetal vessels lie in the fetal membranes across the os
109
What are risk factors for vasa praevia?
Placental anomalies (e.g. bilobed placenta, succeturiate lobe), placenta praevia, multiple pregnancy, ART
110
How is vasa praevia diagnosed?
USS with colour doppler
111
How does vasa praevia present?
Sudden PV bleed, painless
Fetal bradycardia, IUD
Fetal Hb may be found in PV bleed
112
How is delivery affected in vasa praevia?
Must do c-section
113
How are all APHs generally managed?
Admit to hospital
IV access via 2 large bore cannulae
FBC, LFTs, U&Es, Kleinhauer test
Crossmatch 4-6 litres of blood
Give IV fluids/transfuse if blood available
Anti-D if Rh-ve
FOR FETUS - CTG monitoring, administer steroids and MgSO4 for lung development and neuroprotection
114
What is post-partum haemorrhage?
Loss of blood following delivery of baby
115
What is a minor PPH defined as?
500-1000ml blood loss
116
What is a major PPH defined as?
>1000ml blood loss
117
What are some antenatal risk factors for PPH?
Previous PPH or retained placenta, BMI >35, APH, multiparity, maternal age >35, fibroids, large placental site, overdistended uterus
118
What are some labour risk factors for PPH?
Prolonged labour
Induction/oxytocin use
Operative delivery/c-section
119
What are the causes of PPH?
The 4 T's - Tone, trauma, tissue, thrombin
TONE - uterine atony, vessels don't get clamped. May occur due to prolonged labour/overdistension
TRAUMA - vaginal/vulval lacerations
TISSUE - retained placental
THROMBIN - haemophilia, von willebrands etc
120
How is PPH prevented?
Use of uterotonics - syntocinon
121
What is given if a woman has no risk factors for PPH and has a vaginal delivery?
Syntocinon 10iu IM injection
122
What is given if a woman has no risk factors for PPH and had a c-section?
Syntocinon 5iu by slow IV infusion
123
What is given if a woman has risk factors for PPH?
Syntometrine (CI in hypertension)
124
How is the bleeding managed in a minor PPH?
Uterine massage - expel any clots
5 units syntocinon IV stat
40 units syntocinon in 500ml Hartmanns - 125ml/hr
125
How is the bleeding managed medically in a major PPH?
Confirm delivery of placenta and membranes complete
500mcg ergometrine IV
Prompt repair of vaginal/perineal trauma
Carboprost 250mcg IM every 15 mins (max 8 doses)
Misoprostol 800mcg sublingual./PR
Tranexaminc acid 1g IV
Packs, balloons, tissue sealants, arterial emboliztion
126
How can a major PPH be managed surgically?
Undersuturing, B-Lynch sutures, uterine/internal iliac artery ligation, hysterectomy
127
What fluid should be given in PPH?
Up to 2L of warmed crystalloid (e.g. saline, hartmanns) given asap
Up to 1.5L of warmed colloids until blood arives
Can do intra-operative cell salvage
128
What is the first stage of labour?
Cervical dilatation
129
What is the latent phase of the first stage of labour?
Up to 4cm cervical dilatation. Mild irregular uterine contractions, cervix softens and shortens
130
What is the active phase of the first stage of labour?
4-10cm cervical dilatation. Contractions become increasingly rhythmic and strong.
131
What is the second stage of labour?
From complete cervical dilatation to delivery of the baby
132
How long should the second stage of labour last in nulliparous women?
Up to 2 hours or 3 hours if given regional anaesthesia
133
How long should the second stage of labour last in multiparous women?
Up to 1 hour or 2 hours if given regional anaesthesia
134
What is the third stage of labour?
After delivery of the baby until expulsion of the placenta and fetal membranes
135
What are braxton-hicks contractions?
Tightening of the uterus muscles to prepare the body for birth. Felt from 2nd/3rd trimester onwards. Do not increase in frequency/intensity. Relatively painless, resolve on ambulation
136
What are labour contractions?
Tightening of the top of the uterus, pushing the baby down into the birth canal. Described as a wave.
137
What hormone initiates and sustains contractions?
Oxytocin
138
What is the lie of the fetus?
Relation of the longitudinal axis of the fetus to the longitudinal axis of the mother
139
What is the normal lie of a fetus?
Longitudinal
140
What is vertex?
The baby being head down in the uterus
141
What is fetal presentation?
The leading part of the fetus which occupies the lower pole of the uterus (e.g. cephalic, breech)
142
What is fetal position?
Relation of the denominator of the presenting part to the quadrants of the maternal pelvis
143
What is normal position for delivery?
Occipito-anterior
144
What is station?
The location of the presenting part of the fetus in the birth canal (from -5 to+5) above and below the ischial spines
145
What is it called when the head of the baby reaches the vulval ring and perineum stretches over its head?
Crowning
146
Which shoulder is delivered first?
Anterior shoulder
147
What signs indicate separation of the placenta from the uterus?
Uterus contracts, hardens and rises
Umbilical cord lengthens
Gush of blood
148
What are the analgesia options for labour?
```
Paracetamol/co-codamol
Entonox
Diamorphine
Epidural
Remifentanyl
Combined spinal epidrual
```
149
With regard to puerperium, how long does it take for the funal height to reach the umbilicus?
2 weeks
150
In what conditions is there increased nuchal translucency?
Downs syndrome
Congenital heart defects
Abdominal wall defects
151
When and how much folic acid should be taken?
400mcg from trying to concieve until 12 weeks
152
24 hours after delivery. Pain, vaginal bleeding, heavy offensive lochia, boggy poorly contracted uterus
Retained products
153
What diabetic medication is safe in breast feeding?
Metformin
154
When should methotrexate be stopped before trying to concieve?
For at least 3 months
155
What scale is used to measure post natal depression?
Edinburgh Scale
156
What is the criteria for hyperemesis gravidarum?
Dehydration
Electrolyte imbalance
5% pre-pregnancy weight loss
157
What is the first line treatment for hyperemesis?
Antihistamines used first like (e.g. cyclizine, prochloperazine)
Metoclopramide and ondansetron second line
158
What is hyperemesis associated with?
Multiple pregnancy, trophoblastic disease, hyperthyroidism, nulliparity, obesity
159
What is fetal fibronectin?
Protein released from gestational sac. High level correlates with increased chance of premature labour
160
What are indications for instrumental labour?
Fetal or maternal distress in 2nd stage
| Failure to progress
161
What are requirements for instrumental delivery?
```
Fully dilated cervix
OA or OP position
Ruptured membranes
Cephalic presentation
Engaged presenting part
Pain relief
Sphincter (bladder) empty
```
162
How should a non-immune pregnant woman who has been in contact with someone with chicken pox be managed?
Single dose varicella zoster immunoglobulin
163
What are indications for induction of labour?
Prolonged pregnancy
PPROM
Diabetic mothers >38 weeks
Rhesus incompatibility
164
What are the methods of inducing labour?
Membrane sweep
Intravaginal prostaglandins
Breaking waters
Oxytocin
165
How does obstetric cholestasis present?
Widespread itch worse on palms and soles of feet
166
What risk does obstetric cholestasis cause?
Preterm birth
167
How is obstetic cholestasis managed?
Induction at 37 weeks
Urseodoxycholic acid
Vitamin K
168
What Bishops score indicates that labour is unlikely to start without induction?
Less than 5
169
What Bishops score indicates that labour is likely to start spontaneously?
Over 9
170
Which vitamin in high levels is teratogenic?
A
171
What is the management of a breech baby before 36 weeks gestation?
Nothing - most babies turn around before this stage
172
When should external cephalic version be performed?
From 36 weeks for nulliparous women
| From 37 weeks if multiparous
173
What is McRoberts manouevre for?
Shoulder dystocia
174
How is the McRoberts manouevre done?
Patient lies supine with hips fully flexed and abducted. Suprapubic pressure is applied
175
What is the antibiotic treatment for PPROM?
Oral erythromycin (10days)
176
What treatment is used for prevention of pre-eclampsia in at risk women?
Aspirin
