Obstetrics Flashcards
(101 cards)
1
Q
Cord prolapse risks
A
prematurity multiparity polyhydramnios twin pregnancy cephalopelvic disproportion abnormal presentations e.g. Breech, transverse lie placenta praevia long umbilical cord high fetal station
2
Q
Cord prolapse management
A
Manually move cord back up - with hand or by filling bladder UNLESS it is below the level of the intritous, then just keep it warm and wet
Usually deliver by C-section
Put patient on all fours
Can use tocyolytics e.g terbertaline can be used while preparing for C section
3
Q
When does cord prolapse tend to happen
A
With ARM
4
Q
Signs of cord prolapse
A
Variable decelerations on CTG
Palpable/visibile cord
5
Q
Oligohydramnios Causes
A
premature rupture of membranes fetal renal problems e.g. renal agenesis intrauterine growth restriction post-term gestation pre-eclampsia
It’s associated w/ chromosomal abnormalities, medication (ACEi, indomethacin) and multiple pregnancies
6
Q
Oligohydramnios Rx
A
Term - deliver if not contrindicated
Preterm - Monitor w/ serial USS for growth, liquor volume, dopplers + regular CTG –> deliver if necessary
7
Q
total contraindications for COCP
A
more than 35 years old and smoking more than 15 cigarettes/day
migraine with aura
history of thromboembolic disease or thrombogenic mutation
history of stroke or ischaemic heart disease
breast feeding < 6 weeks post-partum
uncontrolled hypertension
current breast cancer
major surgery with prolonged immobilisation
8
Q
When should lochia stop post partum
A
6w
9
Q
Obstetric Cholestasis - signs
A
Generally in 2nd half of pregnancy (3rd trimester)
No other cause
Pruritis in the absence of rash (worse at night and over palms and soles) –> excoriations
Raised LFTS, bilirubin, raised bile acids can have decreased clotting factors (due to decreased vit K absorption)
Rarely get dark urine and steatorrhoea
10
Q
Obsetric Cholestasis - Management
A
Weekly LFTs and clotting
Serial USS and intermittent CTG for monitoring
[Chlorpheniramine to control pruritus]
Ursodeoxycholic acid (to reduce bile acids and pruritus) –> dexamethasone if no response
Vit K
Induce at 37w due to increased risk of foetal death
Ensure resolution of LFTs and 10d post partum
11
Q
Acute Fatty Liver in pregnancy
A
Rare, in 3rd trimester
On spectrum w/ Pre-eclampsia
Malaise, vomiting, jaundice, vague epigastric pain and thirst are early features
Acute hepatorenal failure, DIC and hypoglycaemia come later
Treatment is supportive - dextrose, blood products, careful fluid balance, occasionally dialysis
12
Q
Safest anti-epileptics in pregnancy
A
Carbamazapine and Lamotragine
Give folic acid with them
13
Q
what epilepsy drug should ideally not be used
A
Sodium valproate
Congential abnormalities (orofacial, neural tube and heart defects) and Low IQ
14
Q
What anomaly can Lithium cause
A
Ebstein’s anomaly
15
Q
what occurs regarding pre-existing epilepsy in pregnancy
A
Change in seizure frequency due to increased renal and hepatic drug clearance, increased volume of distribution, decreased absorption, and compliance issues
16
Q
What epilepsy drugs need to be monitored in pregnancy
A
Levetriacem and Lamotregine
17
Q
What do you need to give if a woman if on an enzyme inducing anti-epileptic and why
A
Vitamin K - prevent haemorrhage disease of the newborn
18
Q
Contraindications for VBAC
A
Previous uterine rupture
Classic Section scar
Contraindication to vaginal birth - e.g major placenta praevia
19
Q
When do pre-eclampsia and gestational HTN begin to occur
A
20 weeks
20
Q
Definition of PPH
A
> 500mls blood loss
21
Q
1st line Treatment for PPH
A
IM Syntocin
22
Q
Treatment for Polyhydramnios
A
Indomethican
Reducitve amniocentesis
23
Q
most common cause of PPH
A
uterine atony
24
Q
Causes of 2º PPH & rx
A
endometritis and retained products of conception
Abx, evacuate retained products only if unavoidable as increased risk of uterine perforation
25
treatments for PPH
Atony - Bimanual compression, IM Syntocin (oxytocin + ergometrine), IM carboprost, PR msioprosol
Intrauterine ballon insertion, uterine artery embolisation, laparotomy and insertion of brace suture
hysterectomy is severe
If trauma - suture
If retained products - manually evacuate in theatre §
26
Early deceleration on CTG
Head compression
27
Late deceleration on CTG
foetal distress - asphyxia or placental insufficency
28
variable decelerations on CTG
head compression
29
what is normal variability on CTG. what causes reduced variability
>5
Loss = prematurity, hypoxia, foetus is asleep (if short period)
30
what is foetal tachycardia on CTG
| what can cause this
>160bpm
| maternal pyrexia, chorioamnioniitis, hypoxia, prematurity
31
what is foetal bradycardia on CTG
<100
32
what do you give if a woman is at risk of GBS
Intrapartum antibiotics
33
When do you give the neonate antibiotics with regards to GBS
If there are signs of sepsis
34
what is placenta acreta and what is the risk of this
attachment of the placenta to the myometrium (Muscle layer
risk = PPH --> often requiring hysterectomy
35
what are risk factors for placenta acreta
placenta praevia,
| previous C section
36
how do you treat seizures in eclampsia and how is it given
Magnesium sulphate, IV, 4g bolus then 1g per hour
should continue until 24hrs after last seizure or delivery
urine output, reflexes, respiratory rate and oxygen saturations should be monitored during treatment
37
A woman has a blood pressure of 150/95 at 13 weeks. what does she have
PRe-existing HTn
38
A woman has a blood pressure of 150/95 at 25 weeks, with no proteinuria, what does she have
Gestational HTN
39
A woman has a blood pressure of 150/95 at 25 weeks with >0.3g proteinuria in 24hours , what does she have?
Pre-eclampsia
40
what symptoms would you expect with pre-eclampsia
```
CAN BE ASYMPTOMATIC
Headache
oedema (especially face)
Visual disturbances
RUQ pain due to liver capsule swelling
Hyperreflexia
```
41
Rx for mild-moderate pre-eclampsia
Regular BP monitoring and urinalysis
Regular blood testing
Serial USS for foetal growth
Regular CTGs
Aspirin - [if nuliparious, age >40, BMI >35, Fhx of pre-eclampsia, multiple pregnancy, HTN in previous pregnancy, CKD, Autoimmune disease, diabetes or chronic HTN]
Antihypertensives - labetelol (methydopa, nifedipine)
Delivery at 36/37weeks
42
Rx for severe pre-eclampsia/foetal compromise
```
Admit and monitor
Delivery (Steroids if necessary)
Antihypertensives
Seizure prophylaxis (Iv Mag Sulph)
Fluid restriction
Strict fluid balance
```
43
what is the BP for severe pre-eclampsia and what do you do
160/110
| ADMIT
44
Increased AFP causes
Neural tube defects
Abdominal tube defects e.g omphaocele
Multiple pregnancy
45
Decreased AFP causes
Down's
Edwards (t18)
DM
46
Diagnostic criteria for hyperemesis gravidarum
5% pre-pregnancy weight loss, electrolyte imbalance, dehydration, ketosis
47
Associations with hyperemesis gravidarum?
```
multiple pregnancies
hyperthyroidism
obesity
nulliparity
trophoblastic disease
```
48
What decreases risk of hyperemesis gravidarum
smoking
49
Rx for hyperemesis gravidarum
Anti-histamine anti emetics are first line - cyclizine, promethazine
metoclopromide and ondansetron can also be used
IV fluids if dehydrated
50
when is hyperemesis gravidarum most common, and when can it persist beyond
8-12 weeks
| can persist up to 20 weeks and rarely beyond
51
placenta praviea signs
```
PAINLESS bleeding
Shock in accordance with visible loss
non tender uterus
can have abnormal lie/presentation
small bleeds before large
foetal heart usually normal
should be diagnosed on 20 week ultrasound
```
52
Associations with placenta praevia
nuliparity
previous pregnancy
previous caesarian - can implant in scar
53
Aortic dissection in preganancy associations
3rd trimerster
Ehlers-Danlos
Bicuspid valve
(can get ST elevation if right coronary involved - causing MI)
54
Most common valve issue in immigrant pregnant woemn
Mitral Stenosis
Becoming less common in UK so suspect in immigrants
assoc with rheumatic heart disease
hear mid diastolic murmur
55
what do you use to treat ~VTE in pregnancy and for how long
LMWH throughout pregnancy and until 4-6 weeks after
| - warfarin is contraidnidcated
56
Ix for placenta praevia
Scan at 16-20 weeks should pick it up
Rescan at 34 weeks
If still high at 34 weeks, scan every 2 weeks]
if still there and grade 3/4 at 37 weeks - C section
If high presenting part or abnormal lie at 37 weeks - also C section
57
Management for placenta praevia
Consider delivery options e.g C section at 37 weeks if present
Don't have to avoid sex/acitvity unless bleeding
If bleeding:
Admit
Cross match blood
Treat shock
58
1º surgical management for PPH
Uterine balloon tamponade
59
Inevitable miscariage
heavy bleeding with clots and pain
| cervical os is open
60
incomplete miscarriage
not all products of conception have been expelled
pain and vaginal bleeding
cervical os is open
61
Missed/delayed miscarriage
a gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion
mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear. Pain is not usually a feature
cervical os is closed
when the gestational sac is > 25 mm and no embryonic/fetal part can be seen it is sometimes described as a 'blighted ovum' or 'anembryonic pregnancy'
62
Threatened miscarriage
painless vaginal bleeding occurring before 24 weeks, but typically occurs at 6 - 9 weeks
the bleeding is often less than menstruation
cervical os is closed
complicates up to 25% of all pregnancies
63
what advice regarding breast feeding do you give for peupleural mastitis
what do you do regarding abx?
Continue!
or express/pump if too painful
Antibiotics are only recommended if the lady has an infected nipple fissure, symptoms do not improve or are worsening after 12-24 hours despite effective milk removal, or bacterial culture is positive.
The first line antibiotic is flucloxacillin 500 mg qds for 14 days (erythromycin 250 mg to 500 mg qds for 14 days if penicillin allergic)
64
Score for assessing hyperemesis gravidarum
Pregnancy-Unique Quantification of Emesis (PUQE) score
65
when to offer ECV
The RCOG recommend ECV should be offered from 36 weeks in nulliparous women and from 37 weeks in multiparous women
Not after rupture of membranes
66
what is the questionnaire for postnatal depression
Edinburgh Postnatal Depression Scale
67
Symptoms of Placental Abruption
severely PAINFUL bleeding, which is constant with exacerbations
Tender, hard, "woody" uterus
Bleeding can be absent or dark
Shock is inconsistent with blood loss - maternal collapse
Lie is often normal and baby engaged
Baby can be dead or distressed
Most common cause of DIC
Can cause poor urine output or renal failure
68
Risk factors for placental abruption
IUGR
Pre-eclampsia/Pre-exisiting HTN
Maternal smokinf
Previous abruption
69
Rx for placental abruption
Resusitate
Give steroids if <34 weeks
Give anti-D to Rh- women
If foetus distressed - C section
If no foetal distress but >37 weeks - induce with an ARM, monitor, C section if distress
If no foetal distress, appears to be a minor bleed and pregnancy is preterm - closely monitor on wards
If baby is dead - coagulopathy is likely so give blood products and induce labour
70
Symptoms of vasa praevia
what is it's cause
what do you do?
ONCE MEMBRANES RUPTURE:
Massive foetal blood loss = foetal distress --> bradycardia, late decelerations, loss of variability
Painless moderate PV bleeding for mother
Cause by rupture of foetal blood vessels running in front of the presenting part --> usually occur when umbilical cord is attached to the membrane, not placenta
C-section, before if you know the vessels run there, in emergency if there's bleeding
71
SGA
Smaller than the 10th gentile for gestation
72
IUGR
Small compared to genetic determination, and compromised
| Often maternal illness e/g renal, pre-eclampsia, multiple pregnancy, chromosomal abnormalities, infections, smoking
73
When and what's in the Booking visit
```
before 10w GA
Full Hx and Ex inc previous pregnancies, obstetric history, baseline blood pressure etc
FBC
Serum antibodies e/g anti-D
Test for syphillis, HIV, Hep B
Rubella immunity is checked
Urine MC&S
USS happens at 11-13+6 = dating scan --> using crown rump length --> can also screen for multiple pregnancies and nuchal translucency
```
74
When is the dating scan & what does it measure
between 11 and 13+6 weeks , crown rump length
75
When is the anomaly scan
20 weeks
76
From when can you preform chorionic villus sampling
from 11 weeks
77
when can you perform amniocentesis & what can you diagnose
from 15 weeks
| Chromosome abnormalities, Sickle cell, CF, Toxoplasmosis, CMV
78
What is in the combined test, when does it occur, what is it for
11-13+6 (dating scan time)
Measure Nuchal translucence on USS, β-HCG (high) and PAPP-A (low)
Chromosomal abnormalities e/g down's
79
What is in the quadruple test and when is it used
14-22 weeks
| AFP (low) , total HCG, inhibin (high) and oestriol (low)
80
When do you measure the AGPAR score
1, 5, and 10 mins
81
Rx of PPROM
admission
regular observations to ensure chorioamnionitis is not developing
oral erythromycin should be given for 10 days
antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome
delivery should be considered at 34 weeks of gestation - there is a trade-off between increased risk of maternal chorioamnionitis with a decreased risk of respiratory distress syndrome as the pregnancy progresses
82
What types of twins do you need to have twin to twin trransfusion syndrome
Monochorionic, diamniotic --> one gets Oligohydramnios, one gets Polyhydramnios
83
What is the criteria for continuous CTG monitoring in labour
suspected chorioamnionitis or sepsis, or a temperature of 38°C or above
severe hypertension 160/110 mmHg or above
oxytocin use
the presence of significant meconium
fresh vaginal bleeding that develops in labour
84
Medical RX of ectopic
methotrexate is most commonly given as a singleintramuscular dose of 50 mg/m2(see Appendix II).86Serumb-hCG levels are measured on days 4 and 7post methotrexate
85
Complications of olgiohydramnios
Labour - CTG abnormalities, meconium liquor, emergency CS
| Neonate - pulmonary hypoplasia, limb deformities
86
Complications of polyhydramnios
```
Preterm labour
Placental abruption
Cord prolapse
PPH
Increased risk of caesarian
```
87
when is the biggest risk of congenital toxoplasmosis and what does it present with
First trimester
```
Encephalitis
thrombocyopenia
Intracranial tram track calcifications
Retinochoroditis
IUGR
hepatosplenomegaly
#rash
```
(+preterm labour, miscarriage, foetal death(
88
when is the greatest risk for congenital rubella and what does it present with
First trimester
```
Deafness
VSD
PDA
Cataracts
CNS defects
IUGR
Hepatosplenomegaly
thrombocytopenia
Rash
```
89
When is parvovirus B19 infection a risk in preganacy and what does it cause
between 4 and 20 weeks
| Fetal hydrops
90
was does congenital CMV cause
```
miscarriage/still birth
IUGR
Microcephaly
Intracerebral calcification
Sensori-neural deafness
hepatosplenomegaly
skin rash
pneumonitis
mental retardation
```
91
infection before when will cause foetal varicella syndrome
What does it cause
before 28w
Skin scarring
eye defects
limb deformities
Neurological abnormalities
92
what viral load allows for a vaginal birth in pregnancy
| what do they need during labour
<50 if they're on HAART
they need IV zidovudine
Always C section if theyre on zidovudine monotherapt
93
How long does the neonate need antriretrovirals for after birth in HIV
When is PCR testing
4-6 weeks
94
what viral load do you need for zidovudine monotherapy in preganacy
<10000
95
when do you test the baby for HIV post partum
at birth, within 48hrs, on discharge, 6 weeks, 12 weeks, 18m
96
should the woman breastfeed if she's HIV+
No, she's recommended not to
97
what are the cut off values for a diagnosis of GDM
FPG >5.6
| 2hr OGTT >7.8
98
what are the target plasma glucoses for a woman with GDM or pre-existing diabetes
FPG <5.3
1hr post meal <7.8
2hr post meal <6.4
(maintain >4 if on insulin)
99
What is the Rx for GDM
Diet, exercise if FPG <7
Can add metformin if blood glucose not below target in 1-2w
Insulin therapy if >7
Consider immediate treatment with insulin, with or without metformin[2], as well as changes in diet and exercise, for women with gestational diabetes who have a fasting plasma glucose level of between 6.0 and 6.9 mmol/litre if there are complications such as macrosomia or hydramnios
100
what bishops score suggests induction of labour
<6
101
what bishops score suggests that labour will continue spontaneously
>8
