4th Year > Obstetrics > Flashcards

Obstetrics Flashcards

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1
Q

How many antenatal appointments for a nulliparous woman?

A

10

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2
Q

How many antenatal appointments for a parous woman?

A

7

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3
Q

What is done at the booking visit?

A 
Full obstetric history
FGM screen
Height and weight, BMI
Urinalysis for proteinuria
Urine MC+S for asymptomatic bacteriuria
Booking bloods
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4
Q

What blood tests are in the booking bloods?

A 
FBC
Haemoglobinopathies and Red Cell Alloantibodies
ABO blood group and Rhesus status
Hepatitis B
Rubella, Syphilis, Chickenpox serology
HIV test is offered
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5
Q

What is offered on the Combined test?

A

Nuchal transluceny
beta-HCG
Pregnancy associated plasma protein A (PAPP-A)

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6
Q

Combined (and extra) findings in Down’s Syndrome

A 
Thickened nuchal translucency
Increased beta HCG
Low PAPP-A
Low Oestriol
Low alpha Fetoprotein
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7
Q

How should dating scan be made if CRL is >84mm

A

Use head circumference

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8
Q

If the placenta is praevia on Foetal anomaly scan, when should another scan be offered?

A

32 weeks

Most low-lying placentas will have resolved by then

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9
Q

What is done at routine antenatal visits?

A

BP
Urine dip for proteinuria
SFH measurement from 24 weeks

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10
Q

Which visits are only for nulliparous women?

A

25 weeks
31 weeks
40 weeks

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11
Q

When is Anti-D offered?

A

28 and 34 weeks

or sensitising events

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12
Q

When should External Cephalic Version be offered?

A 
36 weeks (primip)
37 weeks (multip)
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13
Q

Sensitising events to Rh -ve mothers?

A 
Delivery
Amniocentesis
Chorionic villus sampling
Foetal blood sampling
External cephalic version
Miscarriage > 12 weeks
Surgically managed ectopic pregnancy
Termination of pregnancy
Antepartum Haemorrhage
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14
Q

When is amniocentesis performed?

A

15-20 weeks

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15
Q

When is chorionic villus sampling performed?

A

11-14 weeks

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16
Q

Risks of Amniocentesis/ CVS

A 
Pain/ discomfort
Infection
Miscarriage
Inadequate result
Needing anti-D prophylaxis
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17
Q

Clinical signs of pregnancy

A 
Amenorrhoea
Nausea and vomiting
Chadwick sign (blue vaginal discolouration)
Hegar sign (Cervical softening)
Skin pigmentation
Palpable uterus 6-12 weeks
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18
Q

Time frame of usual nausea and vomiting in pregnancy

A

Begins 4 weeks

Most ended 16-20 weeks

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19
Q

Treatment of non-complicated nausea and vomiting

A

Ginger
P6 wrist acupuncutre
Antihistamines e.g. Chlorphenamine

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20
Q

Risk factors for hyperemesis gravidarum

A 
Obesity
Nulliparity
Hyperthyroidism
Multiple pregnancy
Trophoblastic disease
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21
Q

Protective factors for hyperemesis gravidarum

A

Smoking

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22
Q

Anti-emetic therapy for hyperemesis gravidarum

1st, 2nd and 3rd line?

A

Cyclizine/ Promethazine are 1st line
Metoclopramide or Ondansetron 2nd line
Corticosteroids reserved for severe cases

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23
Q

Complications of hyperemesis gravidarum

A 
Wernicke's encephalopathy
Mallory-Weiss tear
central pontine myelinolysis
acute tubular necrosis
Increased VTE risk
fetal: small for gestational age, pre-term birth
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24
Q

How to diagnose obstetric cholestasis vs normal itching?

A

Raised AST/ALT

Alk phos is raised normally in pregnancy- unreliable marker

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25
Management of itching and obstetric cholestasis
Topical emollients and steroids Ursedeoxycholic acid Delivery is only cure
26
Symptoms of symphysis pubis dysfunction
Difficulty walking Weight bearing problems Limited/ painful hip abduction Lying/ sitting position discomfort
27
Therapies for leg cramps in pregnancy
Sodium chloride Calcium Quinine
28
Definition of SGA
Foetus less than 10th centile for weight or other Biophysical parameter Severe if < 3rd centile
29
Major risk factors for SGA
``` Maternal age 40+ Smoking 11+ daily Cocaine Maternal or paternal SGA Previous SGA baby/ stillbirth PAPP-A <0.4 MoM Chronic hypertension Antiphospholipid syndrome Diabetes Renal impairment ```
30
Minor risk factors for SGA
``` Maternal age 35+ IVF singleton pregnancy Nullipartiy BMI under 20 BMI 25-34 Low fruit intake Previous pre-eclampsia ```
31
Investigations for SGA if 1 major criteria:
Serial USS and umbilical artery doppler from 26-28 weeks
32
Investigations for SGA if 3 minor criteria:
Assess foetal size and umbilical artery doppler in 3rd trimester
33
Management/ delivery in SGA
Delivery at 37 weeks 32 weeks if severe 34 weeks if static growth over 3 weeks Administer steroids
34
Which cause of Large for Gestational Age (LGA) babies is associated with Amoxicillin use in pregnancy?
Hydrops fetalis
35
Most common type of IUGR
Asymmetrical (70% of cases) Occurs later in pregnancy Head sparing pattern Low SC fat, risk of hypoglycaemia and hypoxia
36
Maternal death
Death within 42 days of end of pregnancy
37
Direct causes of maternal death
Obstetric complications or resulting from interventions/ omissions/ incorrect treatments
38
Indirect causes of maternal death
Previously existing disease or disease developed during pregnancy
39
At which point should RFM be investigated for neuromuscular conditions?
24 weeks
40
Name of practice contractions that occur prior to labour
Braxton-Hicks contractions
41
Investigations of PPROM and pre-term labour
``` Bloods (FBC, CRP) Urine dip and MSU CTG Cervical swabs for GBS Placental alpha-Microglobulin-1 test ```
42
Why is a TVUS performed in suspected pre-term labour
If Cervical length < 15 mm at 30+0 weeks, this is diagnostic of pre-term labour
43
Why is foetal fibronectin used as a test for pre-term labour
Its not normally detectable in vaginal secretions before 36 weeks Positive if greater than 50ng/ml
44
Drugs used in pre-term labour
Erythromycin 250mg QDS 10 days for chorioamnionitis prophylaxis Nifedipine- Tocolysis, allows steroid administration Steroids before 34 weeks e.g. Betamethasone Magnesium sulphate before 34 weeks- neuroprotective
45
What do steroids help protect against in pre-term labour?
Respiratory distress syndrome | Peri-ventricular leukomalacia
46
Rules for delivery in pre-term labour
Vaginal OK if cephalic No foetal scalp electrode use before 34 weeks Delayed cord-clamping
47
Preventing preterm labour
Vaginal progesterone or cervical cerclage treatment - Women with hx of spontaneous birth/ mid-trimester loss between 16 and 34 weeks - TVUS shows a cervical length < 25mm between 16 and 24 weeks
48
When does a DCDA twin form?
Before day 3
49
When does a MCDA twin form?
Between days 4-8
50
When does a MCMA twin form?
Days 9-13
51
When do conjoined twins form?
After day 13
52
What signs suggest multiple pregnancy?
Increased membrane thickness and T sign on USS Uterus large-for-dates Increased hyperemesis incidence
53
How frequently are growth scans performed in multiple pregnancy?
4-weekly in Dichorionic | 2-weekly in Monochorionic
54
When are DCDA twins delivered?
37 weeks
55
When are MCDA twins delivered?
36 weeks
56
When are MCMA twins delivered?
32-34 weeks
57
Potential causes of GDM
Increased physiological demands in pregnancy Human Placental Lactogen production Less renal tubular reabsorption
58
Risk factors for GDM needing screening
``` BMI 30+ Previous macrosomic baby 4.5kg 1st degree family history Ethnicity Glycosuria at antenatal visit ```
59
Diagnosis of GDM
2 hour 75g OGTT used at 24-28 weeks - 7.8mmol/L (2 hour glucose) OR 5.6mmol/L fasting glucose
60
Major/ Greatest risk factors for Antenatal VTE prophylaxis
``` Hospital Admission Previous VTE related to major surgery High Risk Thrombophilia e.g. F5 Leiden Medical co-morbidity Surgical procedure Ovarian Hyperstimulation Syndrome ```
61
Which medical co-morbidities are considered high-risk for antenatal VTE prophylaxis?
``` Cancer Heart failure SLE IBD/ Inflammatory polyarthropathy Nephrotic syndrome Sickle cell disease Current IVDU ```
62
What are the minor individual risk factors for antenatal VTE prophylaxis which may require treatment?
``` BMI 30+ Age 35+ Parity 3+ Smoker IVF Varicose veins Current pre-eclampsia Immobility 1st degree family history of unprovoked VTE Multiple pregnancy ```
63
What is the management of VTE antenatally if 2 minor risk factors or less are present?
Mobilisation and avoid dehydration
64
What is the management of VTE antenatally if 3 risk factors are present?
Prophylaxis from 28 weeks
65
What is the management of VTE antenatally if 4 or more risk factors are present?
Prophylaxis from 1st trimester
66
What is the single greatest risk factor requiring immediate antenatal VTE prophylaxis?
Previous VTE not caused by a surgical event
67
Which high-risk factors warrant the use of 6 weeks postnatal prophylactic LMWH?
Any previous VTE LMWH required antenatally High risk thrombophilia Low risk thrombophilia and VTE F/H
68
Which high-risk factors warrant the use of 10 days + postnatal prophylactic LMWH?
``` LSCS in labour BMI 40+ Prolonged postnatal admission 72hrs + Surgical procedure in the puerperium Medical co-morbidity Any 2+ minor risk factors ```
69
Which minor risk factors do not require VTE postnatal prophylaxis? (if less than 2 risk factors)
``` Age 35+ BMI 30+ Smoker Immobility Family history Varicose veins Current infection Current pre-eclampsia Multiple pregnancy Preterm Stillbirth Prolonged labour 24 hours + PPH >1L or blood transfusion ```
70
Normal cardiac changes in pregnancy
``` Ejection systolic murmur Cardiomegaly on CXR Increased pulmonary vascular markings Ectopic beats Q waves T wave inversion in lead 3 ```
71
Blood pressure changes in pregnancy
BP falls until 24 weeks due to reduced SVR Increases after 24 weeks due to increased stroke volume
72
What protein: Creatinine Ratio (PCR) in urine is diagnostic of Pre-Eclampsia?
> 30mg/mmol
73
Above which blood pressure should mothers be admitted for pre-eclampsia?
140/90 mmHg Any mother with evidence of high blood pressure and proteinuria
74
Above which blood pressure should mothers be treated for pre-eclampsia with antihypertensives?
150/100 mmHg
75
When should delivery occur in pre-eclampsia?
Conservative management until 34 weeks if no Eclampsia Offer delivery between 34 and 37 weeks Deliver in 24 hours after 37 weeks
76
When do most cases of HELLP syndrome occur?
27-37 weeks
77
What are the key symptoms that MAY differentiate HELLP syndrome to standard pre-eclampsia?
Bleeding and RUQ pain/ tenderness
78
Investigations for HELLP syndrome (in terms of each of the components)
``` Haemolysis (FBC shows low Hb, LFTs- high LDH, prolonged PT/PTT) Elevated Liver enzymes (raised AST, ALT, Bilirubin, LDH, Uric acid) Low Platelets (low Hb, thrombocytopaenia <100x10^9/L) ```
79
Type 1 FGM
Partial or total removal of the clitoris and/or the prepuce (clitoridectomy).
80
Type 2 FGM
Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision).
81
Type 3 FGM
Narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation).
82
Type 4 FGM
All other harmful procedures to the female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and cauterization.
83
Definition of slow progress in first stage of labour
Less than 2cm dilation in 4 hours
84
What describes a Station of zero in the first stage?
The fontanelle is aligned with the ischial spines
85
When may the active management of the third stage of labour begin?
Upon delivery of the anterior shoulder
86
Passage of labour
Engagement (largest diameter of head in pelvis) Flexion and descent (2/5 of head palpable) Internal rotation Extension Restitution (external rotation) Expulsion
87
Normal position of delivery
Occipitoanterior
88
Indications for CTG monitoring (antenatal)
``` High-risk pregnancy (maternal factors) VBAC or previous CS Placenta previa Multiple pregnancy SGA/ IUGR ```
89
Indications for CTG monitoring (during labour)
``` Maternal pulse >120BPM Temp 38+ ?Chorioamnionitis/ Sepsis Abnormal pain Oxytocin use Significant Meconium Fresh vaginal bleeding in labour Pre-eclampsia signs Confirmed 1st/2nd stage delay ```
90
Response to abnormal CTGs
1. Position mother in Left Lateral 2. Administer IV fluids 3. Foetal scalp stimulation 4. Foetal blood sampling 5. Delivery
91
pH Monitoring in Foetal Blood samples
Normal: pH 7.25 + Borderline: pH 7.20- 7.25 Abnormal: pH <7.20
92
Lactate on Foetal blood samples
Normal: < 4.1mmol/l Borderline: 4.2-4.8 mmol/l Abnormal: 4.9 mmol/L
93
What is an Occipito-Posterior position typically associated with?
Long anthropoid pelvis (up to 50% mothers)
94
What is an Occipito-Transverse position typically associated with?
Poor power in labour
95
Most common type of breech presentation
Extended/ Frank 70% of breech presentations
96
Symptoms/ signs of a breech presentation
Pain under ribs can occur | Longitudinal lie, no head palpable on palpation
97
Management of brow presentation
LSCS
98
Management of face presentation
Can deliver vaginally
99
Compound shoulder presentation/ transverse lie
ECV then LSCS if unsuccessful
100
Sources of pain in first stage of labour
``` Uterine contraction (T10-L1) Pelvic structure pressures (L2-S1) ```
101
Side effects of Nitrous Oxide/ Entonox for analgesia
Dizziness Nausea Amnesia
102
Opioids that should be available for analgesia in all births
Morphine Diamorphine Pethidine IM Remifentanil
103
Factors associated with a poor outcome in VBAC
Needing an induction Slow progress BMI 30+
104
Contra-indications to VBAC
2 previous LSCS' Classic uterine scar Previous uterine rupture Standard LSCS contra-indications
105
Potential indications for a vertical CS
Premature, structural abnormality, fibroids, some placenta previa cases
106
Category 1 CS (Crash)
Immediate life-threat to foetus or mother, and delivery should be made within 30 minutes of decision. E.g. severe foetal distress, placental abruption, bradycardia
107
Category 2 CS
No immediate threat to life, but the baby should be delivered within 1 hour E.g. failure to progress, shoulder dystocia
108
Category 3 CS
Scheduled, semi-elective CS where an early delivery is needed but there is no compromise e.g. pre-eclampsia, or failed induction
109
Category 4 CS
Elective, carried out after 39 weeks (if less than 39, corticosteroids are given for foetal lung maturity).
110
Indications for Induction of Labour
``` Prolonged pregnancy (41-42 weeks; perinatal mortality increases due to decreased placental function). IUGR or Intra-Uterine Death Antepartum Haemorrhage PPROM/ Prelabour rupture of membranes: significant risk of infection once ruptured. Maternal Hypertension/ Pre-Eclampsia Diabetes Poor Obstetric history Intrauterine Death ```
111
Absolute contra-indications to IOL
Placenta praevia Acute foetal compromise Unstable lie Pelvic obstruction
112
Bishop's Score domains
``` Cervical Dilatation Cervical Length Station of presenting part Consistency Position ```
113
Bishop's Score needed for labour
5+ is 'favourable' | 7+ suggests labour likely to begin naturally
114
Where is PGE2 inserted for induction of labour?
Posterior fornix of the vagina
115
Maximum dose of Oxytocin infusion for induction of labour
18mg/hr
116
What is the most common cause of APH?
Marginal bleed
117
When is a bleed in pregnancy classed as an APH?
After 24 weeks
118
Grading of Placenta Previa
Grades 1 and 2- Minor | Grades 3 and 4- Major
119
Blood products to use in APH
ABO Rh compatible cross-matched blood OR O Rh-ve blood
120
Management of APH if under 34 weeks
Conservative if stable - Steroids - Tocolytics WITH CAUTION - Deliver at 37 weeks
121
Management of APH after 34 weeks
Oxytocin following amniotomy Oxytocin/ Ergometrine post-3rd stage Cat 1 CS consider
122
How often does PPH occur
6% of deliveries
123
When is the third stage of labour prolonged
Placenta not delivered in: - 60 minutes (physiological managment) - 30 minutes (pharmacological management)
124
Initial (non drug) treatments of primary PPH
Empty bladder Uterine massage to stimulate contraction Controlled cord traction if not already delivered
125
Initial drug treatments of primary PPH
Bolus of one of: - Oxytocin 10 units - Ergometrine 0.5mg IM - Combined Oxytocin and Ergometrine (5U/0.5mg)
126
Dose of oxytocin in PPH
10 units bolus SE: Uterine hyperstimulation, headaches, nausea and vomiting, arrhythmias
127
Dose of Ergometrine in PPH Contraindications
0.5mg IM Eclampsia, sepsis
128
Dose of Carboprost in PPH
250mg IM every 15 minutes, max 8 doses CIs: Pelvic infection, cardiac disease, pulmonary disease
129
2nd management of PPH if first drugs fail
Another bolus of first drug THEN - Misoprostol 1mg PR - Carboprost 250mg IM
130
Uterine inversion presentation
Vasovagal shock Haemorrhage Clotting abnormalities Renal dysfunction
131
Management of uterine inversion
Reduce manually- O'Sullivan's Method Tocolytics Leave placenta before replacement
132
Risk Factors for AF embolism
``` Multiple pregnancy Maternal age CS Instrumental delivery Eclampsia Polyhydramnios Uterine rupture Placental abruption ```
133
Presentation of AF embolism
Collapse, Dyspnoea, Chest Pain Hypotension Cardiac arrest Reduced LOC
134
Management of AF embolism
ITU treatment with highest O2 available Inotrope support e.g. Dobutamine Treat DIC Deliver baby if cardiac arrest
135
Uterine rupture presentation
``` Severe pain, persisting between contractions Scar/ uterine tenderness Bleeding/ haematuria Reduced contractions Loss of presenting part from station Shock/ collapse ```
136
Management of uterine rupture
Cat 1 CS ± hysterectomy Cefuroxime and Metronidazole cover Correct shock with fluids
137
1st Degree Perineal Tear
Skin only
138
2nd degree perineal tear
Perineal muscle involved
139
3A Degree Perineal Tear
External Anal Sphincter torn < 50%
140
3B Degree Perineal Tear
External Anal Sphincter torn 50%+
141
3C Degree Perineal Tear
External and Internal Sphincters torn
142
4th Degree Perineal Tear
Anorectal mucosal tear involvement Risk of permanent anovaginal fistulae Repaired surgically/ under a GA/ epidural
143
When is the uterus pelvic post-partum?
10 days
144
When is the cervical os closed post-partum?
3 days
145
Colour of lochia
Blood-stained initally | Yellow/ white until 6 weeks
146
When is breast engorgement noticeable postpartum
3-4 days postpartum
147
What drug may be used to antagonise lactation?
Cabergoline (Dopamine receptor antagonist)
148
Which hormones are lactation dependent upon?
Prolactin (produced by anterior pituitary) | Oxytocin (produced on nipple sucking, stimulates prolactin release)
149
When is postnatal contraception required?
As early as 21 days (not breastfeeding) | Breastfeeding is good until 6 months (98% effective)
150
When may the Progesterone only Pill be used post-partum?
Any time
151
When can COCP be used post-partum
After 6 weeks (UKMEC 4 before this)
152
When can IUD be inserted?
Usually after 4 weeks
153
Indications for Folic Acid 5mg
``` Diabetes Epilepsy Malabsorption BMI 30+ Sickle cell disease ```
154
Indications for oral iron in pregnancy
Hb below 11g/100ml at first contact | 10.5g/100ml at 28 weeks
155
Drug that can be used for sleep problems in pregnancy
Promethazine
156
Which women are unsuitable for monitoring of growth by SFH measurement, and how should this be done instead
BMI 35+ Large fibroids USS and foetal doppler from 26-28 weeks
157
Criteria indicating need for a major haemorrhage protocol
``` 5L blood loss in 24 hours 2.5L blood loss in 2 hours 150ml blood loss/minute Maternal HR 110+ Maternal systolic BP less than 90 ```

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