OBSTETRICS Flashcards
(258 cards)
1
Q
Where is the oocyte normally fertilised and what does it become?
A
In the ampulla of the fallopian tubes, a zygote
2
Q
What happens after fertilisation?
A
Zygote divides mitotically as it is swept to the uterus, becoming a morula then a blastocyst which implants into the endometrium 6-10 days after ovulation
3
Q
What is the trophoblast?
A
Outer layer of the blastocyst which becomes the placenta.
4
Q
What is the function of hCG and where is it produced?
A
Produced by the trophoblast (placenta). Maintains the corpus luteum to produce progesterone and oestrogen. until 12 weeks when placenta takes over
5
Q
When is the placenta formed?
A
by 12 weeks, by trophoblastic proliferation leading to formation of chorionic villi
6
Q
What is the blastocyst made up of?
A
Inner cell mass becomes the embryo, trophoblast becomes the placenta (inner cytotrophoblast and outer syncytiotrophoblast)
7
Q
When does organogenesis occur including heartbeat?
A
Organogenesis is 2-8 weeks after conception, heartbeat established by 4-5 weeks and detectable by 6 weeks on TVUSS
8
Q
What are spiral arteries?
A
Maternal arteries that occupy intervillous space in the placenta. Converted to larger vessels for increased blood flow, failure of which can lead to IUGR and eclampsia
9
Q
What are the constituents of the umbilical cord?
A
2 arteries (deoxygenated blood from foetus to placenta) and 1 vein (oxygenated from placenta to foetus)
10
Q
What is the blood supply of the uterus?
A
Uterina and ovarian arteries
11
Q
Cardiac/heamatological physiological changes of pregnancy
A
40% increase in plasma volume, 20% increase in RBC (haemodilution)
40% increase in cardiac output
increased clotting risk
12
Q
Respiratory physiological changes of pregnancy
A
40% increase in tidal volume, oxygen demand increases by 15%
13
Q
Metabolic physiological changes of pregnancy (4)
A
increased urinary protein loss
insulin secretion doubles
cortisol rises
increased calcium demand
14
Q
What is labour?
A
Expulsion of foetus and placenta from the uterus, occurring at 37-42 weeks gestation normally. Painful uterine contractions accompany dilatation and effacement of the cervix to facilitate.
15
Q
What are the stages of labour?
A
Stage 1 - full dilatation of cervix (early labour is gradual effacement and dilatation <3cm, active labour is more rapid with more forceful contractions)
Stage 2 - fully dilated cervix to delivery of foetus
Stage 3 - from delivery of foetus to delivery of placenta
16
Q
What are the mechanical factors involved in pregnancy?
A
Powers (force expelling foetus)
Passage (pelvic dimensions, resistance of tissue)
Passenger (diameter of foetal head)
17
Q
How long on average does stage 1 labour take?
A
10hr nulliparous, 6hr multiparous
18
Q
Describe stage 1 labour (5)
A
Contractions 2-3 minutes apart
Amniotic membranes rupture
Cervical effacement and dilatation - Latent phase <3cm, active 3-10cm
Head descends from engaged position
90 degree rotation from occipito-transverse to occipito-anterior facing down (or posterior)
19
Q
Describe stage 2 labour
A
Faster, stronger contractions
Head descends and flexes
Pushing starts when head reaches pelvic floor
Head extends as delivery occurs and rotates back to transverse before shoulders deliver
20
Q
Describe Stage 3 labour?
A
Placental delivery up to an hour after birth
21
Q
What is misoprostol and what does it do?
A
Prostaglandin.
Causes effacement of the cervix and contractions, given to induce labour
22
Q
What is oxytocin and what does it do?
A
Hormone that induces labour released from posterior pituitary, only if cervix is ripe. (synctocinon given if prostaglandins haven’t induced labour)
23
Q
What is prolactin and what does it do?
A
Hormone produced by the anterior pituitary, important role in breastfeeding
24
Q
Define small for dates
A
Small for gestation, below the 10th centile. (10% of foetuses)
25
Constitutional causes of small for dates (4)
Small mother, nulliparous, Asian, female foetus
26
Pathological causes of small for dates/IUGR (5)
```
Maternal disease - pre-eclampsia, infection
Multiple birth
Smoking, drugs
Malnutrition
Congenital abnormality
```
27
8 risks of small for dates/IUGR
```
Stillbirth
Cerebral palsy
Prematurity
Maternal mortality (c section)
Jaundice
Feeding problems
NEC
Hypoxia
```
28
Symptoms of IUGR (3)
Reduced foetal movements
Pre-eclampsia
Plateau of symphysis-fundal height
29
Diagnosis of IUGR
USS to determine if SFD
Serial USS and umbilical artery doppler
Reduced amniotic fluid
If consistent growth and normal doppler, constitutional SFD not pathological and no intervention.
30
What would umbilical artery doppler show if IUGR
Foetal redistribution of blood to middle cerebral artery - head sparing
31
What is symmetrical and asymmetrical IUGR
Symmetrical - whole foetus small
Asymmetrical - distribution of blood to vital organs i.e. brain, heart. Have normal head size but small body and limbs, likely placental insufficiency
32
Management of IUGR at term if abnormal doppler?
Delivered at 36 weeks by induction or c section
33
Management if preterm IUGR and abnormal doppler?
Prevent stillbirth and neurological damage
Maximise gestation
If absent end diastolic flow indicating vascular distress, give steroids if before 34 weeks to mature lungs and admit
C section delivery
34
Define pregnancy induced hypertension
When blood pressure rises above 140/90mmHg after 20 weeks
35
What is pre-eclampsia?
A disorder in which hypertension and proteinuria (0.3g/24hr) appear in the second half of pregnancy, often with oedema
36
What is eclampsia?
The occurrence of epileptiform seizures in pregnancy where there is hypertension
37
What is gestational hypertension?
New hypertension presenting after 20 weeks WITHOUT proteinuria
38
What causes pre-eclampsia?
Of placental origin - spiral arteries fail to fully convert due to incomplete trophoblastic invasion, leading to reduced flow increased resistance and hypertension
39
How does pre-eclampsia affect maternal organs?
Blood vessel endothelial damage and exaggerated inflammation leads to vasospasm, increased capillary permeation and clotting dysfunction affecting organs
Proteinuria due to increased vascular permeability
Eclampsia due to reduced cerebral blood flow
40
How does pre-eclampsia affect the foetus? (4)
Reduced placental blood flow causing IUGR
Preterm birth
Placental abruption
Hypoxia
41
Risk factors for pre-eclampsia (9)
```
First pregnancy
Family history
Long time between pregnancys
Obesity
Extremes of age
Chronic hypertension or renal disease
Diabetes
Antiphospholipid disease
Multiple pregnancy
```
42
Symptoms of pre-eclampsia
```
Usually asymptomatic
Headache
Drowsiness
Visual disturbance
Nausea
Oedema
```
43
What is HELLP syndrome?
Considered a variant of pre-eclampsia:
Haemolysis
Elevated liver enzymes
Low platelets
44
How is HELLP syndrome treated?
Supportive
| Magnesium sulfate prophylaxis
45
Complications of pre-eclampsia (5)
```
HELLP
Stroke
DIC
Liver or renal failure
Pulmonary oedema
```
46
How is pre-eclampsia monitored?
Regular blood pressure and urinalysis
Uterine artery Doppler at 23 weeks
Low dose aspirin before 16 weeks if at risk
47
When is pre-eclampsia managed in the community?
If no proteinuria or BP <160/110, outpatient with twice weekly BP/urinalysis and two weekly USS
48
When is a woman admitted for pre-eclampsia? (4)
If symptomatic
>0.3g/24hr proteinuria
BP >160/110
Suspected foetal distress
49
How is pre-eclampsia treated
Labetalol for BP if >150/100
Magnesium sulfate IV - delivery indicated
Steroids if <34 weeks
Deliver
50
When should baby be delivered in mild, moderate and severe pre-eclampsia
Mild by 37 weeks
Moderate-severe 34-36 weeks
If maternal complications, whenever
51
What needs to be checked when giving magnesium sulfate for pre-eclampsia
Patellar reflexes as absence precedes respiratory depression
| Renal function
52
Risks of HIV during pregnancy (5)
```
Pre-eclampsia
Prematurity
IUGR
Stillbirth
Vertical transmission
```
53
How if HIV treated in pregnancy?
Combination antiretroviral therapy
Elective C-section
Avoid breastfeeding
54
What is CMV?
Cytomegalovirus, 40% chance of transmission to baby if mother infected during pregnancy.
55
What are foetal complications of CMV infection? (7)
```
Deafness - 10% severely affected
Learning difficulty
Vision impairment
Low birth weight
Microcephaly
Hepatosplenomegaly
Rarely, fatal
```
56
Foetal complications of rubella infection? (5)
Deafness
Eye abnormalities - retinopathy, cataract
Congenital heart disease
Systemic effects - liver, spleen, LBW
Later life - autism, schizophrenia, developmental delay, learning disability
57
Prevention of rubella infection?
Termination offered if before 16 weeks
| Vaccination
58
Management of herpes simplex infection during pregnancy
C-section if primary infection <6 weeks before delivery
| Aciclovir given
59
Symptoms of foetal herpes infection (3)
Skin/eyes/mouth herpes - no internal involvement
CNS herpes - encephalitis, seizures
Disseminated herpes - particularly affects liver
60
Group B streptococcus infection and treatment
High maternal carrier rate causing severe neonatal illness, more common in preterm.
Treat with penicillin intrapartum IV if positive 3rd trimester screen or high risk
61
Complications of group B strep infection in the baby (4)
Trouble breathing
Unresponsive
Extremes of temperature
Can cause sepsis, meningitis
62
Complications of group A streptococcus in pregnancy (3)
Chorioamnionitis
Puerperal sepsis
Treat with Abx
63
Herpes zoster infection during pregnancy
Many immune to chickenpox
If <20 weeks can be teratogenic
Infection close to delivery needs IgG for neonate
64
Symptoms of foetal varicella syndrome (4)
Patches of scarred skin or skin loss
Limb hypoplasia
Microcephaly
Vision problems
65
Hepatitis B risk during pregnancy
High risk of transmission and foetal mortality
| Screen, if needed give neonatal immunoglobulin
66
Chlamydia risk in pregnancy
Causes preterm delivery
Neonatal conjunctivitis
Screen in case antibiotics needed
67
Risk of bacterial vaginosis during pregnancy
Preterm labour - treat if previous preterm birth clindamycin
68
Define antepartum haemorrhage
Bleeding from the genital tract after 24 weeks gestation (up to 24 weeks is threatened miscarriage)
69
3 common causes of APH
Undetermined origin
Placental abruption
Placenta praevia
70
3 rarer causes of APH
Incidental pathology
Uterine rupture
Vasa praevia
71
What is placenta praevia?
Implantation of the placenta in the lower section of the uterus - at 20 weeks many placentas are low, but most move upwards and only 10% are low at term
72
Types of placenta praevia (4)
Type I - low lying placenta
Type II - marginal (not covering os)
Type III - major (partially covering os)
Type IV - major (completely covering os)
73
Risk factors for placenta praevia (4)
Twin pregnancy
High parity
Age
Scarred uterus
74
Why is placenta praevia problematic?
Obstructs engagement of the head, may cause the lie to be transverse and need a C-section
Haemorrhage postpartum can be severe as lower uterus less able to contract
75
Symptoms of placenta praevia
Intermittent painless bleeds increasing in frequency and intensity over weeks
1/3 experience no bleeding
76
Sign on examination of placenta praevia
Head not engaged - breech or transverse
77
What examination is never performed if placenta praevia suspected
PV exam - can provoke haemorrhage
78
Management of placenta praevia
Admit if bleeding - give anti D if Rh negative
If asymptomatic admit when 37 weeks
Deliver by C-section at 39 weeks
79
What is placenta accreta?
Placenta implanted too deep in the uterine wall - attaches to the myometrium instead of just the endometrium. Often over a C-section scar
80
What is placenta increta?
Placenta implanted deeper in the uterine wall and penetrates the myometrium
81
What is placenta percreta?
Placenta implanted so deep it penetrates through the uterine wall myometrium and possibly invades other organs such as the bladder
82
What is the risk of placenta accreta/increta/percreta? (3)
Massive haemorrhage at C-section
Damage to other organs
Thromboembolism
83
What is placental abruption?
When part or all of the placenta separated from uterus before delivery of the foetus
84
Complications of placental abruption (3)
Bleeding
30% foetal mortality
Maternal DIC and renal failure
85
Risk factors for placental abruption (8)
```
IUGR
Pre-eclampsia
Autoimmune disorders
Smoking/drugs
Previous abruption
Multiple pregnancy
High parity
Trauma
```
86
Symptoms of placental abruption (5)
```
Shock
Severe pain/tenderness
May be dark blood or no bleeding
Hard woody uterus
Foetal head often engaged but distressed
```
87
What is a concealed abruption?
Just pain, bleeding not escaped uterus
88
Treatment of placental abruption (6)
CTG foetal monitoring and USS
Fluids, transfusion for mother
steroids if <34 weeks
Urgent C-section if foetal distress
Induce labour if >37 weeks and no distress
If <37 weeks and no distress, monitor as high risk
89
What is vasa praevia?
When a foetal blood vessel runs in the membranes in front of the presenting part - rare and hard to detect
90
Risk of vasa praevia
If membranes and vessels rupture, massive painless bleeding and severe foetal distress
91
Symptoms of vasa praevia
Typically painless moderate bleeding
92
Management of vasa praevia
Elective C-section
| Often not quick enough if emergency after rupture and foetus exsanguinates
93
What is gestational trophoblastic disease
When trophoblastic tissue proloferates more aggressively than usual and hCG is secreted in excess
94
What is a hydatiform mole
Local non invasive proliferation of trophoblastic tissue
95
What is complete and incomplete hydatiform mole
Complete - paternal in origin, sperm fertilises empty oocyte and no foetal tissue present
Incomplete - two sperms fertilise on egg, variable foetal tissue
96
Complications of GTD
May have malignant characteristics - invasive mole, choriocarcinoma if any tissue left behind after the usual miscarriage
97
Symptoms of GTD (4)
Large uterus
Early pre-eclampsia
Vaginal bleeding
Vomiting
98
Investigations of GTD
'snowstorm' appearance of complete mole
| confirmed histologically
99
Treatment of GTD
Tissue removed by evacuation of retained products of conception - suction curettage
If persistent high hCG, suggests malignancy
Chemotherapy and methotrexate
100
What is rhesus disease?
A type of haemolytic disease of the newborn, typically occurring in subsequent pregnancies of a Rh negative woman with a Rh positive father
101
Mechanism of rhesus disease
During a first pregnancy and birth, the woman is exposed to fetal blood
Rhesus negative woman develops antibodies against Rhesus D if the foetus is rhesus positive
In subsequent pregnancies, the antibodies can pass through the placenta and attack the fetal RBC in rapid immune response
Causing fetal anaemia and possible death
102
What are some sensitising events in rhesus disease? (6)
```
Birth
Termination of pregnancy
ERPC after miscarriage
Ectopic pregnancy
Early or heavy bleeding
Invasive uterine procedure
```
103
Prevention of rhesus disease
Administed anti-D antibodies to the mother to prevent her immune system producing its own anti-D - the administered version will bind to fetal RBCs entering her bloodstream and prevent maternal recognition
104
When is anti-D administered?
To all Rh-ve women at 28 weeks
At all sensitising events
Kleihauer-Bletke test can be used to see how much fetal blood has crossed and thus dose of anti-D
105
Management of rhesus disease
Assess severity of foetal condition by MCA Doppler and foetal blood sampling
If anaemia, antenatal blood transfer
Deliver if >36 weeks
106
What causes gestational diabetes?
Decreased glucose tolerance in pregnancy due to altered carbohydrate metabolism and antagonistic effects of pregnancy hormones
107
Risk factors of gestational diabetes (6)
```
Family history
PCOS
Previous large or stillborn baby
High BMI
Glycosuria
Polyhydramnios
```
108
Foetal complications of gestational diabetes (4)
Congenital abnormalities
Preterm labour
Birth trauma (shoulder dystocia)
Stillbirth
109
Maternal complications of gestational diabetes (7)
```
Increased insulin need
Hypoglycaemia
Worsening diabetes if pre-existing
Pre-eclampsia
Infection
Instrumental/operative delivery
Ketoacidosis
```
110
Treatment of gestational diabetes
Diet control
Metformin
Insulin
Delivery by 40 weeks
111
Treatment of gestational diabetes if pre-existing disease
Stabilise glucose before conception
Aspiring from 12 weeks to prevent pre-eclampsia
Tight insulin control
Induction or C-section by 39 weeks
112
Screening for gestational diabetes
Glucose tolerance test at 28 weeks
| If previous history or RFs at 18 weeks
113
Define primary postpartum haemorrhage
Loss of >500mL of blood within 24 hours of delivery, or >1000mL after C-section - occurs in 10%
114
Causes of PPH (4)
Retained placenta
Uterine causes - failure to contract, from atony if prolonged labour or overdistension
Vaginal tear, episiotomy
DIC, anticoagulants
115
Risk factors of PPH (10)
```
Previous haemorrhage
Previous C-section
Coagulation defect or anticoagulants
Instrumental or C-section
Retained placenta
APH
Multiple pregnancy
Multiparity
Prolonged labour
Induction
```
116
Prevention of PPH
Use of oxytocin (synctocinon) in 3rd stage of labour
117
Management of PPH (7)
RESUS
Remove retained placenta, identify any trauma
Bimanual compression of uterus
IV synctocinon or ergometrine to compress
Prostaglandin (carboprost) for uterine atony
Evac under anaesthetic if fails
Balloon tamponade surgery or artery embolisation
Hysterectomy last resort
118
Define secondary post partum haemorrhage
Excessive blood loss, occurs between 24hrs-6 weeks after birth
119
Causes of secondary post partum haemorrhage
Endometritis (with or without retained tissue)
Incidental pathology
Trophoblastic disease
120
Treatment of secondary post partum haemorrhage
Antibiotics
| ERPC
121
What is preterm birth?
Delivery after 24 weeks and before 37 weeks. Occurs in 8% of deliveries and causes 20% of perinatal mortality
122
What are the categories of preterm birth?
Extremely premature <28 weeks
Very premature 28-32 weeks
Moderate to late preterm 32-37
123
Causes of preterm birth (8)
```
Subclinical infection
Cervical incompetence
Multiple pregnancy or polyhydramnios (overdistension)
Antepartum haemorrhage
Diabetes
Foetal compromise
Uterine abnormalities
Prev. late miscarriage or premature birth
Idiopathic/iatrogenic
```
124
Risks of preterm birth (6)
```
Causes 50% of cerebral palsy
Foetal death
Respiratory distress syndrome, pneumothorax
Persistent pulmonary hypertension
Intracranial haemorrhage
Retinopathy of prematurity
```
125
Prevention of preterm birth (5)
Antibiotics if history of infection in preterm labour
Cervical suture at 12 weeks if incompetent cervix
Progesterone pessaries at 12 weeks or if cervix shortens
Foetal reduction of multiple pregnancy
Amnioreduction if polyhydramnios
126
Investigations for preterm birth (4)
```
Identify risk factors
TVUSS for cervical length
High vaginal swab for infection
If symptomatic of labour, fetal fibronectin test - if negative, small chance she will deliver in next 2wks
CTG for fetus
```
127
Management of preterm birth (4)
Steroids if <34 weeks
Antibiotics if confirmed labour only
Tocolysis (labour suppression) for 24hrs i.e. to give time for steroids
Magnesium sulphate for neuroprotection
128
How is slow labour defined?
Progress slower than 1cm/hour after the latent phase
129
How is prolonged labour defined?
>12 hours active phase (after latent phase)
130
Causes of slow/prolonged labour (5)
Nulliparity
Inefficient uterine contractions
Large foetus
Disorder of fetal flexion or rotation during birth - MALPRESENTATION
Pelvic disproportion, cervical resistance
131
Management of slow/prolonged labour (6)
Supportive treatment
Mobilise
Amniotomy 1st line
Give oxytocin 2nd line if nulliparous, or if multiparous and malpresentation excluded
C-section if first stage
Instrumental then C section if needed if second stage
132
What are the 6 normal fetal movements in labour
1 - engagement in occipito-transverse
2 - descent and flexion
3 - rotation 90 degrees to occipito anterior
4 - descent
5 - extension to deliver
6 - restitution and delivery of shoulders
133
What is vertex presentation?
Maximal flexion - ideal presentation with occiput leading
134
What is brow presentation?
90 degree less flexion - forehead first, requires C-section mostly
135
What is face presentation?
120 degree less flexion - face first, fetal compromise common
136
Complications of occipito-posterior rotation position instead of occipito-anterior?
Facing up instead of towards mother's rectum
Prolongs labour and causes more pain
Instrumental or C-section may be needed
137
Complications of failing to rotate from occipito-transverse position?
Requires ventouse delivery for rotation with traction to fi through pelvis
138
Normal lie and types of abnormal lie?
```
Normal - cephalic, head down
Transverse
Oblique
Breech
Abnormal lie normally rectifies itself later in pregnancy
```
139
Causes of abnormal lie - circumstances allowing more room to turn (2)
Polyhydramnios
| Multiparity (laxer uterus)
140
Causes of abnormal lie - conditions preventing foetus turning (3)
Foetal abnormality
Multiple pregnancy
Anyhydramnios
141
Causes of abnormal lie - prevented engagement
Placenta praevia
142
Complications of abnormal lie (3)
Prevent delivery
Cause arm or cord prolapse
Uterine rupture
143
Management of abnormal lie
>37 weeks admit and USS to identify cause
Try to manually turn fetus unless contraindicated and do amniotomy
C-section if persistent
144
What is breech presentation?
Buttocks are presenting part - can be extended, flexed or footling
145
Causes of breech presentation (5)
```
Previous breech
Foetal or uterine abnormalities
Twins
Placenta praevia
Pelvic deformity
```
146
Symptom of breech presentation
Upper abdominal pain, confirmed on USS
147
Complications of breech presentation (3)
Neurological problems i.e. cerebral palsy
Cord prolapse
Trapped head - quickly fatal
148
What is external cephalic version and when is it done?
Turning the fetus manually from outside pressure, success rate around 50%
Tried after 37 weeks
149
Management of breech birth
ECV
C-section if unsuccessful
90% of vaginal births are successful if breech, but C-section overall safer
150
When is external cephalic version not performed? (4)
Twins
APH
Ruptured membranes
Foetal compromise
151
What is preterm prelabour rupture of membranes?
Membranes rupture before labour at less than 37 weeks, occurs before 1/3 of preterm deliveries
152
Complications of preterm prelabour rupture of membranes? (4)
Preterm delivery - occurs within 48hrs in >50%
Infection - chorioamnionitis
Cord prolapse
Pulmonary hypoplasia if before 24 weeks
153
Symptoms of preterm prelabour rupture of membranes? (2)
Gush of clear fluid then leaking
| Pain, fever, tachycardia, offensive liquor if chorioamnionitis
154
Investigations fo preterm prelabour rupture of membranes? (3)
US for reduced liquor
High vaginal swab, FBC for infection
CTG for fetus
155
Management of preterm prelabour rupture of membranes? (4)
```
Risk of preterm vs risk of infection!
Admit and give steroids
Prophylactic antibiotics
Close surveillance
Induction at 34-6 weeks if not already had baby
```
156
Management of chorioamnionitis?
IV Abx and delivery!
157
Prevention of preterm labour?
Cervical cerclage to strengthen cervix and keep it shut, if history of preterm birth or evidence of incompetent cervix on USS
Rescue suture if dilated cervix but no ROM or labour
158
What is prelabour term rupture of membranes?
Rupture of membranes after 37 weeks
159
Management of prelabour term rupture of membranes?
Wait for spontaneous labour (80% in 24hr)
Fetal CTG
Antibiotics if over 24hr prophylactically
Induce
160
What is uterine rupture?
Tear in the uterine muscle wall, spontaneously or at the site of an old c section scar
161
Complications of uterine rupture (4)
Extruded fetus
Contracting bleeding uterus
Maternal haemorrhage
Fetal hypoxia, death
162
Symptoms of uterine rupture? (5)
```
Fetal heart rate abnormalities
Lower abdominal pain
Vaginal bleeding
Maternal collapse
Cessation of contracttions
```
163
Causes of uterine rupture? (3)
Scarred uterus in labour
Neglected obstructed labour
Congenital uterine abnormalities
164
Management of uterine rupture? (4)
Avoid induction and oxytocin in scarred patients
Resuscitation
Urgent c section and repair uterus
C section for subsequent pregnancies
165
What is the cervical show?
Mucus plug that seals cervical canal during pregnancy to protect against infection, may have a bloody tinge,discharges when cervix starts to dilate
166
What bacterium is usually responsible for puerperal sepsis?
Group A streptococcus (strep pyogenes)
167
Risk factors for puerperal sepsis?
PROM
Prolonged labour
Multiple examinations
Manual removal of placenta
168
Treatment of puerperal sepsis?
Broad spec Abx - clindamycin, gentamicin
169
Why does risk of venous thromboembolism increase during pregnancy?
Blood clotting factors increased
Fibrinolysis reduced
Blood flow altered - obstruction, immobility
170
Most common site of DVT in pregnancy?
Left iliofemoral
171
How is VTE in pregnancy treated? (4)
SC low molecular weight heparin continued into puerperium if high risk
Mobilisation
Fluids
Compression stockings
172
Why is anaemia common in pregnancy?
40% increase in blood volume is greater then increase in red cell mass
Resulting fall in Hb concentration
Iron and folic acid requirements increase
173
Management of anaemia in pregnancy
Oral iron
Folic acid and B12
Prophylaxis if high risk
174
Why is UTI in pregnancy a problem?
Associated with preterm labour, anaemia, increased perinatal morbidity and mortality
Asymptomatic bacteriuria more likely to progress to pyelonephritis in pregnancy
175
Management of UTI in pregnancy?
Bacteriuria cultured at booking and treated
Routine urinalysis - culture if nitrites high
Erythromycin, nitrofurantoin
176
Symptoms of pyelonephritis?
Loin pain
Rigors
Vomiting
Fever
177
Most common causative organism of UTI in pregnancy?
E.coli
178
Treatment of pyelonephritis in pregnancy?
IV Abx (poss. ceftriaxone)
179
What is cephalo-pelvic disproportion?
The pelvis is too small to allow passage of the baby's head
180
How is cephalo-pelvic disproportion diagnosed?
Mostly retrospectively, inability to deliver despite presence of adequate uterine activity and absence of malpresentation
181
What is inefficient uterine action and when is is more common?
Most common cause of slow progress in labour, common in nulliparous women and in induced labour
182
Treatment of inefficient uterine action? (3)
Amniotomy
Oxytocin if fails
C section if fails
183
What is obstructed labour?
Failure to progress in labour with normal contractions due to physical block - >12 hours active labour
184
Causes of obstructed labour? (4)
Large baby
Malpresentation
Small/deformed pelvis
Narrow vagina/peritoneum factors (FGM)
185
Complications of obstructed labour? (5)
```
Hypoxia and fetal death
Infection
Uterine rupture
PPH
Obstetric fistula
```
186
Management of obstructed labour? (3)
C section
Ventouse extraction
Possible widening of symphysis pubis surgically
187
What is cord prolapse and what can it cause?
When the umbilical cord prolapses into the cervix when after rupture of membranes, can cause fetal asphyxia and uterine rupture
188
Risk factors for cord prolapse?
Twins
Footling breech
Shoulder presentation
189
Management of cord prolapse? (6)
If thought to be a risk before ROM, C section
Displace presenting part by pushing it up but do not handle cord
Place woman head down so gravity relieves pressure
Bladder infusion via catheter
Deliver by forceps/vaginally QUICKLY if imminent delivery
If not usually deliver by C section
190
Types of instrumental delivery?
Ventouse, forceps (non rotational and rotational)
191
When is instrumental delivery indicated? (4)
Prolonged second stage of labour - if 1hr of active pushing has failed to deliver
Fetal distress
Breech delivery
If maternal pushing contraindicated i.e. hypertension
192
Complications of instrumental delivery?
Maternal trauma - lacerations, haemorrhage, tears
| Fetal trauma - lacerations, bruising, facial nerve injury, hypoxia
193
What is the common c section?
Lower segment (LSCS)
194
Indications for C section? (5)
```
Breech
Previous LSCS
Placenta praevia
Failure to advance
Fetal distress
```
195
Complications of C section? (5)
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Haemorrhage
Infection
VTE
Anaesthetic risk
Risk of uterine rupture in subsequent pregnancies
```
196
What is polyhydramnios?
Increased liquor volume - deepest pool >10cm abnormal
197
Cause of polyhydramnios? (3)
Gestational diabetes, renal failure
Twins
Fetal anomaly - upper GI, inability to swallow, chest abnormalities, myotonic dystrophy
198
Presentation of polyhydramnios (4)
Maternal discomfort
Large for dates
Taut uterus
Difficult palpation
199
Management of polyhydramnios? (5)
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USS for anomaly
Blood glucose screening for GD
If <34 weeks and severe, amnioreduction or use NSAIDs to reduce fetal urine output
If <34 weeks consider steroids
Vaginal delivery
```
200
Complications of polyhydramnios?
Preterm labour
Maternal discomfort
Malpresentation
201
What is oligohydramnios?
Reduced liquor volume, non specific, more common in compromised fetuses
202
Cause of oligohydramnios? (4)
Preterm rupture of membranes
Placental insufficiency
Renal agenesis or multicystic dysplastic kidneys
Chromosomal abnormality
203
Management of olighydramnios?
if PROM, manage as preterm or term PROM
| Monitor fetus, deliver when distressed but optimal gestation
204
What are dizygotic twins?
Most common type
| Result from fertilisation of different oocytes by different sperm, not identical
205
What are monozygotic twins?
Result from mitotic division of a single zygote into identical twins, sharing of the amnion and placenta depends on when they divided
206
What are dichorionic diamniotic MZ twins?
Division of the zygote before day 3, leads to separate placentas and amnions
207
What are monochorionic diamniotic MZ twins?
Division of the zygote between days 4-8 (most common), leads to shared placenta but different amnions
208
What are monochorionic monoamniotic MZ twins?
Division of the zygote between days 9-13, very rare, leads to a shared placenta and amnion
209
How do conjoined twins occur?
Incomplete division of the zygote
210
Cause of twins? (5)
```
Genetics
Assisted conception - multiple embryo transfer in IVF
Clomifene
Increased age
Increased parity
```
211
Maternal complications of twins? (3)
Gestational diabetes
Pre-eclampsia
Anaemia
212
Fetal complications of twins? (4)
```
Placental insufficiency and IUGR
Preterm birth
Malpresentation
Miscarriage - co-twin death
Congenital abnormalities (MC)
```
213
Complications of monochorionicity? (MCDA and MCMA)
Twin to twin transfusion syndrome
IUGR
Co-twin death
Cord entanglement in MCMA
214
What is twin to twin transfusion syndrome?
Only occurs in MCDA twins
| Results from unequal blood distribution through vascular anastomoses of the shared placenta
215
Symptoms of TTTS?
Donor: oligohydramnios, anaemia, IUGR
Recipient: polyhydramnios, polycythaemia, cardiac failure
216
Complications of TTTS?
Massive distended uterus
Preterm birth
In utero death
Fetal neurological damage
217
Management of TTTS?
US monitoring from 12 weeks
| Laster therapy of the placental anastomoses
218
Management of twin pregnancy? (6)
Increased surveillance
Laser treatment if TTTS
Deliver: 34-37 weeks if MC, 37-38 weeks if DC
C section if first twin not cephalic
If vaginal, ECV for second twin if not cephalic
Amniotomy when 2nd twin engaged
219
What is Bishop's score sued for?
Used to determine favourability/ripening of the cervix, if high score cervix is favourable and induction more likely to succeed
220
What is Bishop's scoring system parameters (5)
```
Dilation of cervix (0->5cm)
Consistency of cervix (firm-soft)
Length of cervical canal (>2-<0.5)
Position of cervix (posterior-anterior)
Station of presenting part (-3 to below spines)
```
221
What is hyperemesis gravidarum?
Pregnancy complication characterised by severe nausea, vomiting, weight loss, dehydration
222
Management of hyperemesis gravidarum? (4)
Exclude UTI, hydatiform mole
IV fluids
Antiemetics - metoclopramide
Thiamine
223
What is the partogram?
Used to record progress in dilatation of the cervix, +/- descent of the head
224
How is the partogram completed?
Vaginal examination to assess cervical dilatation, plotted against time
225
Purpose of the partogram?
To aid identification of abnormal progress through labour (i.e. slower than 1cm/h after the latent 0-3cm phase) and record maternal vital signs
226
What is cardiotocography?
Records the fetal heart rate on paper from a transucer placed on the abdomen or a clip in the vagina attached to the fetal scalp
A second transducer monitors contractions
227
Worrying features on CTG? (5)
Steep, sustained deterioration in HR
Reduced variability <5bpm
Variable decelerations
Late decelerations (persisting after contractions)
228
What should FHR be on CTG?
110-160
229
What is fetal scalp sampling?
Amnioscope inserted vaginally, small cut made in scalp which collects blood, pH analysed
230
What is a worrying pH on scalp sampling and how is it managed?
<7.2
| Delivery expedited
231
What is induced labour?
Labour started artificially
232
When is labour induced? (6)
```
Prolonged pregnancy
Suspected IUGR
Fetal compromise
Prelabour term rupture of membranes
Pre-eclampsia
APH/poor obstetric history
```
233
Contraindications to induction? (4)
Acute fetal compromise
Abnormal lie
Placenta praevia
Pelvic obstruction
234
How is labour induced? (3)
Prostaglandin E2 gel into the vagina - starts labour or improves cervical ripening for amniotomy
Can give 2 doses
Amniotomy rupture of membrane
Oxytocin infusion
235
Indications fo C section? (5)
```
Acute fetal distress
Failure to progress - indications for instrumental not met
i.e. not fully dilated
Placenta praevia
Breech
Previous LSCS
```
236
Difference between small for dates and IUGR?
SFD weight less than 10th centile
| IUGR fail to reach individual growth potential
237
What is doppler umbilical artery monitoring and what is it used for?
Doppler used to measure velocity wave forms in the umbilical arteries
Can identify IUGR and compromise
238
What is abnormal umbilical artery waveforms?
Reduced flow in fetal diastole compared to systole
| Suggests placental dysfunction, high resistance circulation
239
What is doppler waveforms of the fetal circulation?
Commonly measures the middle cerebral artery and ductus venosus
240
What are abnormal fetal circulation waveforms?
MCA develops low resistance compared to rest of body, head sparing
Velocity of flow increases
Suggestive of fetal anaemia
241
What is amniocentesis?
Diagnostic test that removes amniotic fluid using a needle under US guidance- after 15 weeks
242
What is amniocentesis used for? (3)
Prenatal diagnosis of chromosomal abnormalities, sickle cell anaemia, CMV
243
Risks of amniocentesis? (4)
Miscarriage 1%
Fetal injury
Rhesus sensitisation
Chorioamnionitis
244
What is chorionic villus sampling?
Diagnostic test involving biopsy of the trophoblast using a needle - after 11 weeks
245
What is chorionic villus sampling used for?
Earlier result than amniocentesis - abortion easier
| Used to diagnose chromosomal problems and autosomal dominant and recessive conditoins
246
What are the increased risks of chorionic villus sampling?
Miscarriage (more than amniocentesis)
247
What are the mechanisms used to obtain results in amniocentesis and CVS?
Fluorescent in situ hybridisation FISH
| Polymerase chain reaction PCR
248
What are the 5 things checked for in APGAR scoring?
```
Activity (muscle tone)
Pulse
Grimace (reflex irritability)
Appearance (colour)
Respiration
Higher score the better
```
249
What are the stages or preimplantation development?
```
2 cell stage
4 cell stage
8 cell stage
Morula
Blastocyst
Hatched blastocyst
```
250
What are the components of the blastocyst?
Trophectoderm (outer layer)
Inner cell mass
Blastocoele cavity
251
What are 3 essential factors for embryo implantation?
Receptive endometrium
Healthy blastocyst
Communication between mother and baby
252
What is fertilisation?
Fusion of gametes (egg and sperm) to form a zygote and initiate development
253
What is capacitation?
Changes in the sperm that occur in the female tract to increase motility and prepare the membrane for acrosome reaction
254
What is the zona pellucida?
Outer layer of the egg, containing glycoproteins that trigger the acrosome to burst and release enzymes to break down the ZP
255
What is the cortical reaction?
Sperm has entered the centre of the egg and cortical granules fuse with the membrane of the egg to harden the ZP and make it impermeable to further sperm
256
How is a zygote formed?
The oocyte undergoes a second meiotic division to become haploid
The sperm and ovum nucleus fuse and membranes dissolve, creating diploid zygote
257
How is a blastocyst formed from a zygote?
Mitotic cell division - cleavage
Morula (16 blastomeres) compacts - forms hollow ball of inner cell mass and trophoblast -and forms blastocyst by day 5 when enters uterus
258
How does blastocyst implant?
Hatches from the zona pellucida
| Implants in endometrium with the trophoblast
