Obstetrics Flashcards
(300 cards)
1
Q
What happens to blood pressure during pregncancy
A
It falls in early pregnancy due to fall in vascular resistance but then begins to rise after 24 weeks
2
Q
What blood pressure reading is a medical emergency in pregnancy and how should an acute severe episode like this be treated
A
160/105 or greater
Give parenteral labetalol (avoid in CHF and asthma) and methyldopa
Sodium Nitroprusside
3
Q
How is hypertension different to pre-eclampsia
A
Pre-eclampsia has proteinuria
4
Q
What is chronic hypertension in pregnancy
A
Hypertension present before pregnancy/before 20 weeks gestation and is there throughout pregnancy and post partum
5
Q
What hypertension drugs shouldn’t be used in pregnancy and what should they be changed to
A
ACEi, A2A2 agonists and thiazide - they can cause congenital abnormality
Change to labetalol or methyldopa
6
Q
What is gestational hypertension and what is there a high risk of these women developing
A
Hypertension that develops after 20 weeks gestation in absence of proteinuria
high risk of developing pre-eclampsia
7
Q
What is given to manage gestational HTN
A
Monitor BP and urine weekly
Labetalol
8
Q
What is the definition of pre-eclampsia
A
Newly diagnosed hypertension and proteinuria at 20 weeks gestation
9
Q
What is the definition of eclampsia
A
features of pre-eclampsia + generalised tonic/clonic seizures
10
Q
What occurs in pre-eclampsia
A
Not very well understand but caused by development of abnormal placenta and poorly developed spiral arterioles leading to:
poorly perfused placenta
inflammatory like-responses - ?vasospasm
vasospasm - leading to ischaemia of maternal organs
activation of coagulation system - HELLP syndrome
11
Q
What are risk factors for pre-eclampsia
A
Previous pregnancy pre-eclampsia Chronic or Gestational HTN T2DM Multiple pregnancies Obesity BMI >30 FHx Renal Disease
12
Q
What organs can pre-eclampsia affect
A
Liver - raised LFTs Kidneys - proteinuria Eyes - blurred vision Brain - cerebral haemorrhage, seizures Coagulation system - mini thromboli and haemolysis
13
Q
What are the complications of pre-eclampsia
A
IUGR Renal failure Placental abruption Eclampsia HELLP syndrome Cerebral Haemorrhage
14
Q
How does pre-eclampsia effect the liver
A
hepatic swelling and inflammation causing elevated LFTs and RUQ pain
15
Q
How does pre-eclampsia affect the retina
A
Scotoma, blurred vision and flashing lights
16
Q
How does pre-eclampsia affect the renal system
A
Causes proteinuria - lowering plasma volume and causing oedema (limbs and face)
17
Q
How does pre-eclampsia affect the brain
A
Headaches, confusion, cerebral haemorrhage and seizures
18
Q
How does pre-eclampsia effect the coagulation system
A
HELLP syndrome - haemolysis
19
Q
How does pre-eclampsia effect the fetus
A
Intrauterine growth restriction
Placenta abruption
Still birth
20
Q
What are the symptoms of pre-eclampsia
A
Absent in mild Visual Disturbances RUQ pain Headaches Oedema
21
Q
What are the signs of pre-eclampsia
A
HTN proteinuria retinal oedema RUQ tenderness brisk reflexes ankle clonus
22
Q
What is the diagnosis of pre-eclampsia
A
Gestational HTN: >140/90 Proteinuria: 0.3g of protein or more in 24hrs and +2 or more on urine dipstick abnormal LFTs raised creatine anaemia from haemolysis prolonged PT and APTT
23
Q
Management of all new pre-eclampsia
A
All new pre-eclampsia should involve admission to hospital to monitor mother and fetus
24
Q
What is the management of mild pre-eclampsia before 37 weeks
A
Keep in hospital for monitoring - if persistent HTN, proteinuria, abnormal Ix, Abnormal growth and unreliable patient
Send home with home BP kit and 2wk maternal and fetal evaluation
25
What is the management of mild pre-eclampsia 37 weeks and onwards
Favourable cervix, patient symptomatic or fetal jeopardy - magnesium sulphate delivery
Stable condition and unfavourable cervix deliver at 40 weeks
26
What is the criteria of severe pre-eclampsia
BP >160/110
Proteinuria >5mg in 24 hrs or over 3+ urine dipstick
Impaired Liver function tests
Severe Signs and Symptoms of pre-eclampsia
27
What is the treatment of severe pre-eclampsia
Before 34 weeks:
1st line: Labetalol to lower BP
Don't offer delivery unless severe HTN doesn't resolve once treated or there if fetal/maternal comprimise
34 weeks onwards:
Delivery should be offered following a course of corticosteroids
28
Delivery of severe pre-eclampsia
Stabilise BP- using Labetalol, Methyldopa or nifidepine
Bloods including platelets, renal and liver function
Monitor urine output
Fetal wellbeing - CTGs, US
Vaginal delivery preferable
Give prophylactic magnesium Sulphate
29
Why should you give prophylactic magnesium sulphate in women with pre-eclampsia
It prevents recurrent seizures in women with eclampsia
or prevent seizures in women with pre-eclampsia
Parenteral magnesium sulphate reduces eclampsia and maternal death!!!
30
What is HELLP syndrome
Haemolysis, Elevated LFTs and Low Platelets
| Treatment: deliver fetus
31
Treatment of Eclampsia
Treat HTN IV Labetalol, Methyldopa, Nifidepine, Hydralazine
Give Magnesium Sulphate to manage seizures
Recurrent seizures give further dose
Stabilise mum
Deliver the baby (LCSC may be quickest route)
32
What is the definition of prematurity
Born before 37 weeks
33
What are the risk factors for prematurity
```
Unknown
Cervical weakness or surgery
Intra-amniotic infection/chorioamnonitis
Bacterial Vaginosis
STIs e.g gonorrhoea or chlamydia
Uterine abnormalities
Pre-eclampsia
Previous premature birth
Multiple pregnancies
APH
Diabetes
```
34
How to manage PROM
Admit to hospital
Rule out evidence of chorioamnionitis
Using sterile speculum take temperature, MSU, high vaginal swab
Give corticosteroids for fetal lung maturity and erythromycin to reduce fetal mortality
In 80% PROMS intiates labour
35
If there is no advance to labour within 48hrs of PROM what needs to be considered
```
It needs to be weighed up whether to keep baby in utero despite risk of infection or deliver baby
If baby stays in utero
- monitor weekly
- avoid swimming, intercourse
- aim to deliver 34 weeks if cephalic
```
36
What are the risks of PROMS
prematurity
infection
limb contractures
pulmonary hypoplasia
37
What should you give before delivery of premature labour
Corticosteroids and ABx e.g erythromycin
38
Why do you give Betamethasone in premature labour
To increase surfactant production
39
What are tocolytics
They arrest uterine contractions during episode of preterm labour
40
What is a first line tocolytic in preterm labour to delay delivery
Nifidepine - reduces risk of newborn respiratory distress syndrome
41
What are the treatment principles for premature labour
Find cause and treat if possible
Assess fetal maturity
Consider tocolytics and give steroids
Decide best route of delivery
42
How can you try to screen for preterm labour in high risk women
TVS
| Fetal fibronectin Test
43
What is antepartum haemorrhage and what are the most common causes
Genital tract bleeding from 24 weeks
Minor <50
Major 50-1000
Massive >100
Causes:
Cervical ectropion, Vaginal infection, bleeding from placenta edge, placenta praevia, Abruption
44
What is placenta abruption
When part of the placenta becomes detached from the uterus wall
45
What are the risks associated with placenta abruption
```
Pre-eclampsia
Smoking
Increasing maternal age
Infection
PROMS
Cocaine
Multiple pregnancy
thrombophillia
IUGR
Abdominal trauma
```
46
Why do women often present with shock but no clear blood loss in placenta abruption
Bleeding is often delayed or concealed (trapped between wall of uterus and placenta)
47
What are the symptoms of placenta abruption
Abdominal pain
Back ache if posterior abruption
Vaginal bleeding
48
What are the consequences of placental abruption
Placental insufficiency causing IUGR, fetal death
DIC
Haemorrhage leading to shock
49
What is placental preavia
Placenta lies in lower uterine segment
| leading to high risk of haemorrhage
50
What is the significant difference in bleeding between abruption and preavia
Bleeding is always revealed in praevia
51
What is high risk in placenta abruption after birth of fetus
post partum haemorrhage
52
What are the risk associated with placenta praevia
```
C-section
dilation and curettage TOP
Multiparity
Multiple pregnancy
increased maternal age
Assisted contraception
Fibroids and Endometriosis
```
53
How is placenta abruption diagnosed
TVS
54
How is placenta abruption treated
Under 34 weeks:
abruption mild, no fetal distress - monitoring in hospital
if severe/fetal distress delivery will be necessary
Over 34 weeks:
mild abruption closely monitered vaginal delivery
severe abruption emergency: C-section
55
How is placenta praevia diagnosed
TVS - may show abnormal fetal lie
56
What is major placenta praevia and how is it managed
Placenta covers internal os
| Requires C-section
57
What is minor placenta praevia
Placenta doesn't cover internal os
| Aim for normal delivery unless encroaches within 2cm of os
58
What are the complications of praevia
Bleeding
Poor lower uterine contractility
PPH
59
Is pain present in:
placenta praevia?
placenta abruption?
No
| Yes
60
Is there fetal distress in:
placenta praevia?
placenta abruption?
No
| Yes
61
Does blood loss match symptoms of shock in:
placenta praevia?
placenta abruption?
Yes
| No
62
Is the uterus tender in:
Placenta praevia?
Placenta Abruption?
No
| Yes
63
Is there normal lie and presentation in:
Placenta praevia?
Placenta abruption?
No
| Yes
64
Is there coagulation problems in:
Placenta praevia?
Placenta Abruption?
No
| Yes (DIC)
65
How does placenta praevia present
```
Bleeding matching symptoms of shock
No pain
No uterine tenderness
Abnormal lie and presentation
Coagulation normal
```
66
How does placenta abruption present
```
Bleeding doesnt match symptoms of shock
Pain
Uterine tenderness/ Woody Hard Uterus
Abnormal lie and presentation
Abnormal coagulation
```
67
How to manage APH
```
ABCDE
Raise legs, take bloods and put on IVI
Give O2
Send blood for clotting screeing
Catheterise bladder and moitor fluids
Bleeding severe - emergency C-section
Not as severe - establish cause
```
68
What can anaemia increase the risk of
infection
PPH
Low birth weight
premature labour
69
What is anaemia in pregnancy associated with
```
anaemia before pregnancy
Malaria
haemoglobulinopathies
poor diet
multiple pregnancy
```
70
What are the most common types of anaemia in pregnancy
Iron deficency anaemia (low MCV) iron low
| Folate deficiency anaemia (high MCV) folate low
71
How is anaemia treated in pregnancy
Iron and folate supplements
| Oral iron e.g ferrous sulphate
72
What are the risks associated with asthma and pregnancy
increased risk of exacerbation in 3rd trimester
IUGR - due to inadequate placenta perfusion
Premature labour - due to deterioration of mother
73
What asthma medications can be used in pregnancy
Short acting and long acting Beta agonists
Inhaled steroids
Theophyllines
Steroid tablets in severe asthma
74
What cardiac disease lesions are low risk in pregnancy
Mitral incompetence
Atrial incompetence
ASD
VSD
75
What cardiac disease lesions are high risk in pregnancy
aortic stenosis
coarctation of the aorta
prosthetic valves
cyanosed patients
76
What is the management of patients with cardiac disease
```
Joint care with cardiologist
pre-pregnancy assessment of risk of complications/death
pregnancy and post partum care:
prevention and prediction of heart failire: ECHO/ECG
anticoagulation for heart valves
drug therapy-change medication
Monitor fetal growth
Plan timing and delivery of fetus
```
77
What does obstetric cholestasis present with
Prutritus
Abnormal LFTs
Raised bile acids
78
What are the risks of obstetric cholestasis on the fetus and what is the main cause
Still birth and premature labour
| caused by increased bile acids
79
What can improve bile acids and LFTs but not reduce fetal complications
Ursodeoxycolic Acid
80
What are the risks of hyperthyroidism on the mother and baby
Often improves after 1st trimester of pregnancy
Maternal - Thyroid crisis causing cardiac failure
Fetus - Thyrotoxicosis due to transfer of thyroid stimulating antibodies
81
How do you manage hyperthyroidism in pregnancy
Anti-Thyroid Medication:
Propylthiouracil (preferred drug less likely to cause congenital abnormality)
Carbimazole (risk of congenital abnormality)
82
What are the risks of hypothyroidism in pregnancy
Miscarriage
| Impaired neurodevelopment
83
How should hypothyroidism be treated in pregnancy
Adequate thyroxine replacement
84
What are the 3 types of diabetes in pregnancy
Type 1 - autoimmune destruction of beta cells in islets of langerhans in pancreas
Type 2 - increased resistance to insulin
Gestational - carbohydrate intolerance
85
What is there a risk of developing after having gestational diabetes
Type 2 diabetes
86
What should be done preconception for diabetic patients
```
HbA1C should be under 48
Retinal screening
Give folic acid 5mg
Stop ACEi, A2A and statins
renal function and microalbuminuria
```
87
What are the complications associated with pregnancy and diabetes
```
Hypoglycaemia
Increased risk of pre-eclampsia
Fetal abnormality
Miscarriage
Still birth
Macrosomia - shoulder dyscosia
Prematurity
```
88
What is the key management of diabetes in pregnancy
```
Good glycemic control:
Insulin
Metformin
Glibenclamide
ALL other hypoglycaemics are contrindicated
ALL ACEi and statins are contraindicated
```
89
the ureters dilate during pregnancy what does this predispose women to
UTIs and pyelonephritis
90
What are the risks associated with chronic renal disease
```
Severe hypertension
Pre-eclampsia
Renal failure
IUGR
Prematurity
Still birth
```
91
What should be monitored in pregnant women with renal disease
BP
Creatine levels and proteinuria
Renal function
Regular Growth scans and fetal check ups
92
What are the risks associated with epilepsy and pregnancy
high risk of sudden unexpected death in epilepsy due to women being reluctant to take anticonvulsants during pregnancy and breastfeeding
high risk of fetal abnormality - due to anticonvulsants - SODIUM VALPORATE
High risk of fetal hypoxia during maternal seizures
inheritance of epilepsy
Neural tube defect - spinal bifida
93
How should epilepsy be managed in pregnancy
Preconception: Give high dose of folic dose to reduce risk of NTD and discuss medication options e.g stopping
Offer regular scans for fetal abnormality
Control seizures
Discuss timing and mode of delivery
94
What are the risk factors for VTE
```
increased BMI
Increased maternal age
Operative delivery
Family Hx
Thrombophilia
```
95
How should a DVT be investigated
Doppler US
96
How should a PE be investigated
V/Q (ventilation/perfusion) scan
| CTPA
97
How should VTE be managed
LMWH
6 weeks in high risk
10 days in intermediate risk
(low risk early mobilisation and hydration)
98
Why should warfarin not be used
Crossing placenta can cause fetal abnormality and intracranial bleeding
99
What is the biggest cause of maternal death in the UK
Cardiac disease
100
When is highest risk of VTE
Postpartum
101
What is placenta accreta
abnormal adherance of part/all of placenta into uterine wall (grows to deeply into uterus)
102
What is placenta increta
if myometrium is infiltrated
103
What is placenta percreta
if penetration reaches serosa
104
What are the risks of placenta acreta
PPH
C-section
Hysterectomy
105
What increases risk of acreta
Previous C-section
106
How should acreta be managed
Watch for placenta praevia (can co-exist)
20 wk US scan will show loss of definition between wall of uterus and abnormal vasculature
MRI scan
Elective C-section 36-37 wks
107
What is vasa praevia
When fetal vessels cross the internal os - unprotected
108
What can vasa praevia cause
No risk to mother
But can cause fetal haemorrhage!!!
May be CTG abnormalities
109
What is the management of vasa praevia
if vasa praevia found on scan - elective C section
| if presents as fetal haemorrhage - emergency C-section
110
What is cord prolapse
the descent of the cord through the cervix below the presenting part so it is ahead of the baby after rupture of membranes
111
What makes cord prolapse an emergency
It leads to cord compression
exposure of the cord can cause vasospasm
These both can lead to asphyxia/hypoxia
112
What are the risk factors for cord prolapse
```
Multiple pregnancy
Multiple parity
PROMS/prematurity
malpresentation of fetus
long umbilical cord
polyhydramnios
```
113
What is the management of cord prolapse
```
Get senior help
Fetal monitoring - CTG
Infuse fluid into bladder via catheter
Trendelenburg position with hip and knees up
Push presenting part back up off cord
Transfer to theatre ready to deliver
```
114
What is shoulder dystocia
Failure for the anterior shoulder to pass under symphysis pubis after delivery of the head it requires specific manouvers to deliver the baby
115
Associations of shoulder dystocia
```
Macrosomia
Maternal diabetes
Disproportion between mother and fetus
Postmaturity or induced labour
Maternal obesity
Prolonged 1st and 2nd stage of labour
Instrumental delivery
Previous shoulder dyscosia
```
116
What is the management for shoulder dystocia
```
H - call for help
E - Evaluate for Episiostomy
L - Legs in McRoberts
P - Suprapubic Pressure
E - Enter the Pelvis
R - Rotational Manouvers
R - Remove posterior arm
R - Replace head and deliver by LCSC
```
117
What are the complications of shoulder dystocia
```
Maternal:
PPH
Extensive 3rd or 4th degree tear
Neonatal:
Hypoxia
Fits
Cerebral Palsy
Damage to brachial plexus
```
118
If mother is comprimised in pregancy
Always stabilise mother before attempting to deliver a baby - as maternal comprimise will always lead to fetal comprimise
119
If fetus is comprimised e.g prolonged bradycardia or fetal acidosis on scalp sample what should be done
DELIVER
120
What are the risk factors for uterine rupture
```
Dehiscence of CS scars
obstructed labour
previous cervical or uterine surgery
high forceps delivery
breech extraction
induced labour
```
121
What is the risk of having a vaginal delivery after C-section
Uterine rupture
122
What are the signs and symptoms of uterine rupture
```
Pain - variable
Bleeding - variable
Cessation of uterine contractions
Maternal shock e.g tachycardia
Disappearance of presenting part
```
123
When does uterine rupture usually occur
Labour
124
What is the management of uterine rupture
Emergency C-section
Give o2, crossmatch blood - may need blood transfusion for shock
Senior obstetric decision - small rupture may be repairable, large rupture may need hysterectomy
125
What is primary PPH
The loss of more than 500 mls of blood in thr first 24hrs after delivery
126
What is secondary PPH
Blood loss after 24 hrs of delivery and up to 12 weeks after delivery
Minor: 500-1000 mls lost
Major: >1000 mls lost
127
What are the causes of PPH
```
4 Ts
Tissue: retained products of conception
Tone: uterine atony
Trauma: genital tract trauma
Thrombin: clotting disorders
```
128
How do you manage PPH and the 4 Ts
ABCDE, O2, Cannulate (bloods, crossmatch, clotting)
Start IV fluids and catheterise
Tissue: make sure all of placenta has been passed
Tone: ensure uterus is contracted
Trauma: Look for tears and repair
Thrombin: Check clotting
129
What are the risk factors for PPH
```
Macrosomia
Nulliparity or grand multiparity
Multiple pregnancy
Shoulder dyskocia
Operative delivery
Precipitate or Prolonged labour
Previous PPH
Placenta abnormalities
```
130
What drugs are used to contract the uterus in PPH
```
Syntometrine
Oxytocin
Ergometrine
Misopristol
Haemobate
```
131
What could cause secondary PPH
Endometritis
Retained products of conception
Pseudoaneurysms
Arteriovenous malformations
132
What cause is most common post natal infection
Group A beta-haemolytic Streptococcus
| E.Coli
133
What is sepsis
Infection but systemic manifestations of infection
134
What is severe sepsis
Sepsis plus sepsis induced organ dysfunction or tissue hypoperfusion
135
What is septic shock
The persistance of tissue hypoperfusion despite adequate fluid replacement
136
What are the risk factors for Sepsis
```
Obesity
Diabetes
Immunodeficiency
Anaemia
Vaginal trauma/ C-section
Hx of Group B Strep
Prolonged rupture of membranes
```
137
What are the likely causes of SEPSIS
```
Endometritis
Skin and soft tissue infection
Mastitis
UTI
Pneumonia
Gastroenteritis/appendicitis/pancreatitis
Infection from epidural/spinal
```
138
Signs and Symptoms of Sepsis
```
2 signs/symptoms:
3 T's white with sugar
Temperature: <36 or >38
Tachycardia: HR >90
Tachypnoea: >20
WCC >12
Hyperglycaemia >7.7
Hypotension <90mmHg systolic
(Impaired mental state, offensive discharge, D&V, Dysuria, Breast pain, wound infection, lactate)
```
139
What is the management of SEPSIS
B lood cultures, FBC, U&Es, clotting, glucose
U rine output
F luid resusitation (bolus of hartmans/saline)
A ntibiotics IV within the hr, broad spectrum
L actate >2 and organ failure contact ITU
O xygen high flow
140
What are the two phases of the 1st stage of labour
Latent
| Active
141
What is the latent phase of 1st stage labour
```
Irregular contracts
'show' mucoid plug
can last from 6hr to 2-3 days
Cervix is effacing and thinning
Encouraged to stay at home
Paracetamol, position, water and snacks
```
142
What is effacement
When the cervix (dilates) soften, thins and open out
Starts in the fundus
Retraction and shortening of muscle fibres
Build in amplitude as labour progresses
Fetus is forced down
143
What is full effacement/dilation of cervix
10cm
144
What needs to be assessed in labour
Presentation - anatomical presenting part
Lie - relationship of long axis of fetus and uterus
Attitude - presenting flexed or deflexed
Engagement - widest part of presenting part has passed into pelvis
Station - relationship between lowest point of presenting part and ischial spines
145
What is active labour in the 1st stage
regular, frequent contractions from 4cm dilation
Progressive
Role of oxytocin
146
Transition from 1st to 2nd stage labour
```
near 10cm - contactions longest and strongest
SROM - clear liquor
irritable, anxious, distressed
start feeling pressure
need support and reassurance
```
147
What are the two phases of 2nd stage labour
Latent
| Active
148
What is the latent phase of 2nd stage of labour
Complete cervical dilation to 10cm
| No pushing
149
Wha is the active phase of 2nd stage labour
Maternal pushing and visible external signs - head visible
150
How long to expect delivery in active 2nd stage labour in nulliparous women
3hrs of commencement of pushing
151
How long to expect delivery in active 2nd stage labour in multiparous women
2hrs of commencement of pushing
152
What is the best position of fetus for delivery
Cephalic Occipital Anterior
153
How do you determine position of fetus on delivery
skull sutures
154
What is the 3rd stage of labour
Delivery of the placenta
Rush of blood
Active management - oxytocin, cut and clamp cord
155
Why do you inject oxytocin in 3rd stage
Shorten length of 3rd stage and delivery of placenta
| Reduce incidence of PPH
156
Why do you use delayed cord clamping
Reduces prevalence of neonatal anaemia
1min term
3min preterm
157
What nerves cause labour pain in the 1st stage of labour
T10 - L1
| S2 - S4
158
What nerves cause labour pain in the 2nd stage of labour
S2 - S4
| L5 - S1
159
What are non-pharmological therapies to manage labour pain
```
Trained support
Education
presence of birth partner
Accupuncture, Hypnosis, Homeopathy
Massage
Birth environment - e.g water birth
TENS - Transcutaneous electrical nerve stimulation
```
160
Systemic Analgesia
Nitrous Oxide (entonox)
Simple - paracetamol, codine
Single shot opiods - Diamorphine, Morphine
161
What is the benefits and drawbacks of nitrous oxide
```
Rapid onset
Minimal SE
Self limiting
May cause N&V
Green house gas
```
162
What are two examples of simple analgesia for childbirth
Paracetamol
| Codine
163
What are three examples of single shot opiod analgesia
Morphine
Diamorphine
Pethidine (can cause seizures avoid in epileptics)
164
What are the SE of single shot opiods
```
Sedation
Respiratory Depression
N&V
Pruritus
Cross placenta causing respiratory depression and drowsiness of baby
```
165
What are three types of regional techniques for childbirth
Epidural - high concentration LA + opioid
Spinal - heavy bupivacaine plus opioid
Combined spinal-epidural
166
What level should epidurals be performed at
L3/4
167
What local anaesthetic is used in epidural
Bupivacaine
168
What are the indications for an epidural
maternal request
cardiac, HTN, other disease
multiple births
operative/instrumental delivery likely
169
What are adverse effects of regional analgesia
```
Cardiac - hypotension & bradycardia
Respiratory - block intercostal muscle nerves
Drug related - anaphylaxis, allergy
Loss of bladder control and mobility
Headache!!!
Fever
Prolonged labour
Increase in instrumental rate and malposition
```
170
What can Combined spinal-epidural do
Quicker pain relief
171
Whats the most effective form of pain relief
Epidural
172
What are the fetal SE of epidural
tachycardia due to rise in maternal temp
173
What types of Anaesthesia are used in C-section
General Anaesthesia
Regional Anaesthesia
e.g. Spinal, Epidural, Combined
174
What are the indications for General Anaesthesia
Imminent threat to mother or fetus
Contraindication to regional
Maternal preference
Failed regional
175
What are the risks of general anaesthesia
Increased risks associated with altered physiology
Aspiration
Failed incubation
176
What are the advantages of regional
Safer
Can see baby immediately
Partner can be present
Improved post op analgesia
177
What are the disadvantages of regional
Hypotension
Headache
Discomfort
Failure
178
What are indications for operative vaginal delivery using forceps or ventouse
prolonged 2nd stage of labour
maternal exhaustion
pushing not possible
suspected fetal distress
179
What are the complications of using operative vaginal delivery tools
Trauma to genital tract
| Injury to fetus especially ventouse e.g cephalohaematoma
180
What are indications for C-section
```
Repeat C-section
Severe pre-eclampsia
Placenta Praevia
Malpresentation of fetus
Failure to progress or faile induction
Fetal/Maternal comprimise
```
181
What are the complications of C-section
```
Blood loss
Hysterectomy
Bladder or bowel injury
Wound infection
Endometritis
VTE!!!
Increased risk of accreta, uterine rupture
```
182
What are the indications of induction of labour
```
Post-maturity/prolonged pregnancy
Diabetes
Pre-eclampsia
HTN
Rhesus Disease
```
183
What assessment tool is used to assess state of cervix for induction and what does it mean
Bishops score
Score less than <5 indicates labour is unlikely to happen without induction
>8 indicates labour is likely to occur spontaneously without induction
184
How is labour induced
Prostaglandin e.g Misoprostol
185
After artificial rupture of membranes if contractions haven't started what should you use
IV oxytocin
186
What are the predisposing factors for twins
Previous twins
FH twins
Increasing maternal age
IVF
187
What are complications of twins
```
Polyhydramnios
Pre-eclampsia
Uterine Abruption and Praevia - APH
Anaemia
Gestational DM
Operative Delivery
IUGR
Prematurity/ Stillbirth
Malformation
Cord Prolapse
```
188
What are the three types of breech
Top two the buttocks sit in the
Extended breech - flexed at hips, extended at knees
Flexed Breech - flexed at hips and knees
Footlings Breech - on or both feet point down as presenting part
189
What increases risk of breech
```
Idiopathic
Prematurity
Uterine abnormalities
Placenta Praevia
Oligohydramnios
Fetal abnormalities
```
190
What is the manouver you can perform to try and turn a breech and when should it be offered
External Cephalic Version
| If baby is still in breech at 36 weeks
191
What are the risks of vaginal delivery of a breech
Hypoxia
| Birth Trauma
192
What is the best mode of delivery of a breech baby
C-section
193
What are some common symptoms of pregnancy
```
N&V
Headaches
Breathlessness
Urinary Frequency
GORD
Carpal Tunnel Syndrome
Itchy rashes
```
194
What should you rule out for increased breathlessness in pregnancy
VTE/PE
195
What should you rule out for increased frequency of urine
UTI
196
What should you use 1st line to treat a UTI in preganancy
Nitrofuritonin
197
Why shouldn't you use Trimethoprim in pregnancy
It lowers folic acid
198
What is the diagnosis of persistant vomiting during pregnancy causing weight loss
Hyperemesis Gravidum
(Thought to be related to high hCG levels e.g multiple pregnancy)
Can be fatal!!!
199
What does Hyperemesis Gravidum present as
```
Inability to keep food/drink down
Weight loss/ Malnutrition
Hypokalaemia, Hyponatraemia
Dehydration
Shock
Mallory - Weiss tears
```
200
What is the management of hyperemesis Gravidum
Admit to hospital if unable to keep anything down
Fluid replace correct metabolic imbalance
Give Anti-emetics e.g Promethazine
Try steroids e.g Prednisolone
May need to perform TOP
201
What are the baby blues
Transient 3-5 days of feeling low, tearful and anxious
202
How should you manage baby blues
Reassurance from midwife
Family support
Symptoms don't resolve - psychiatric review
203
What are three key things to note for diagnosing mental disorders of the puepurium
1. A recent significant change in mental state/ new symptoms
2. Recent thought of violence or self - harm
3. New/Persistant thoughts of incompetency as a mother or estrangement from baby
204
What is postnatal depression
risk of major depression after pregnancy
205
What are two major risk factors for postnatal depression
Hx of postnatal depression
| Hx of unipolar/bipolar depression
206
What are the signs and symptoms of postnatal depression
```
Depressed
Irritable
Tired
Crying at night/ sleepness
Anxiety
Sense of Foreboding
```
207
Management of postpartum depression
```
Don't put off treatment
Screen for depression
Counselling (CBT)
Short term Antidepressents (possible SE to baby from breastmilk)
ECT - severe cases
```
208
What tool is used to screen for depression in post partum women
Edinburgh postnatal depression scale
209
What is postpartum psychosis
Depression
Mania
Psychosis
210
What are the signs and symptoms of psychosis
Rapid mood changes from depressed to elated
Confused or disorientated
Restless
Insomnia
Unable to concentrate
Psychotic Symptoms e.g delusions, hallucinations
211
What are the risk factors for post partum psychosis
Previous postpartum psychosis
FHx of mental health problems
Bipolar disorder or other mental health problems
212
How can you prevent postpartum psychosis
identify high risk patients
| antenatal, perinatal and postpartum individualised care plan
213
How can you manage postpartum psychosis
early detection
hospitilisation if necessary
Combination of medication:
Affective symptoms: mood stabiliser, antidepressants, ECT
Psychotic symptoms: 2nd generation antipsychotic
Therapy, reassurance
214
Why is early detection essential in postpartum psychosis
Due to risk of self and baby e.g infantiside
215
What is oligohydramnios
deficiency of amniotic fluid
216
What is polyhydramnios
excess of amniotic fluid
217
What can cause oligohydramnios
smaller babies, fetal malpresentation, chromosomal abnormalities, infection
218
What complications can oligohydramnios cause
cords compression
IUGR
pulmonary hypotension
219
How can you manage olighydramnios
maternal hydration
| severe - amniofusion
220
What causes polyhydramnios
```
birth defects/chromosomal abnormalities
multiple pregnancy
maternal DM
TORCH infections
fetal anaemia
```
221
What are complications of polyhdramnios
prematurity
placental abruption
Cord prolapse
Still birth
222
How is polyhydramnios treated
Can cause SOB, swelling and discomfort
Ensure plenty of rest and birth plan
Amnioreduction if severe
223
What infection can be asymptomatic in mothers and can sometimes be passed to babies during childbirth causing serious infection
Group B Streptococcus
224
What babies are at risk of developing Group B Strep
Prematurity
Previous baby has developed GBS
Maternal fever
Prolonged labour
225
How is Group B strep usually diagnosed
routine high vaginal swabs carried out 34-36 weeks
226
What does early onset GBS present as
Pneumonia
Meningitis
Septicaemia
227
What signs and symptoms may be present in an infected neonate with GBS
floppy/unresponsive
fevers/rigors
tachy/bradypnoea
tachy/bradycardia
228
If a mother with GBS is at risk of passing GBS to newborn what management should be carried out
Give high dose IV benzylpenicillin throughout labour
229
How would you manage a newborn with chlamydia
Eye cleansing + erythromycin for baby
| Give parents Doxycycline or Azithromycin
230
How would you manage a newborn with Gonorrhoea conjuctivitis
Cefotaxime and chloramphenicol eye drops
231
What is the only antibody which can cross the placenta during pregnancy
IgG
232
How is Rhesus Disease caused
RhD -ve mothers deliver Rh +ve baby causing a leak of fetal cells into the mothers circulation this stimulates her to produce anti-D IgG antibodies
233
What happens in subsequent pregnancies once the mother has produced anti-D IgG antibodies
Anti-D IgG antibodies cross the placenta into the fetus causing rhesus haemolytic disease
234
Does rhesus haemolytic disease worsen with each pregnancy
yes
235
How can 1st pregnancies be effected by rhesus disease
```
threatened miscarriage
APH
mild trauma
amniocentesis
Chorionic Villous sampling
```
236
What is the subsequent consequence of fetal blood cells being destroyed in rhesus disease
Fetal Anaemia
237
What does fetal anaemia in rhesus disease cause
anaemia associated congestive heart failure
| Hypoalbuminaemia - liver too busy making RBC to make proteins
238
What can severe rhesus disease lead to
hydrops fetalis
239
What is hydrops fetalis
An oedamatous fetus with stiff oedamtous lungs
240
What are the signs of a neonate born from rhesus disease
Jaundice and kernicterus from hyperbilirubinaemia
Yellow vernix
CCF (oedema)
Hepatosplenomegaly (due to high RBC demand)
Proggressive anaemia
Bleeding
CNS signs
241
What is kernicterus
acute bilirubin encephalopathy - can cause athetoid movements, deafness and low IQ
242
What investigations should be done for suspected rhesus disease in pregnancy
Screen all Rh-ve mothers for anti D antibodies at 28 and 34 wks gestation
If baby is at risk:
Perform doppler US to assess fetal blood flow (thinner means anaemia)
US to check for hepatosplenomegaly
Amniocentesis - to sample fetal blood
243
What is a risk from amniocentesis
Misscarriage
244
What management can be performed in pregnancy in severe cases of rhesus disease
Intrauterine transfusion
245
How is rhesus disease diagnosed in the new born
Coombs test
246
How is rhesus disease managed in the new born
Phototherapy
Blood transfusion
(IV IG may be used in some cases alongside phototherapy)
247
What can be used to prevent rhesus diseaase
injection of anti-D immunoglobulin to prevent sensitisation in 3rd trimester or if there is a risk that the antigens may have entered mothers blood e.g haemorrhage
248
What are the symptoms of a post dural headache
headaches thats worse sitting or standing
neck stiffness
dislike of bright lights
249
What is the treatment of a post dural headache
Epidural blood patch
Lying flat
Simple analgesia
250
What is low birth weight
birth weight under <2500g regardless of gestational age
Very low - < 1500g
Extremely low - < 1000g
251
What is small for gestational age
Birth weight below 10th percentile for gestastional age
252
What is IUGR
failure of growth in utero which may or may not result in baby being small for SGA
253
What is symmetric SGA
all growth parameters are symemetrically small suggesting fetus was affected early pregnancy e.g chromosomal abnormalities or constitutionally small
254
What is asymmetric SGA
the weight centile is < length and head circumference due to IUGR or insult later in pregnancy e.g pre-eclampsia
255
What increases risk for SGA
```
Smokers
Older mothers
Poverty
Previous SGA
Diabetes
HTN
Renal problems
```
256
How should SGA be managed
Umbilcal artery dopplers
Growth scans
Concerning? - consider LSCS (give corticosteroids)
257
What methods are used for continuous fetal heart rate monitoring
Cardiotocography (CTG)
258
What can CTG monitor
uses doppler US to measure:
FHR
Uterine contractions
259
What is a disadvantage of CTG
No improvement in perinatal outcome
| Doesnt reduce prevelance of still birth
260
What are two methods of performing fetal electrocardiogram
Scalp ECG - Gold standard however invasive (monitoring only in labour)
Abdominal ECG - Non invasive its a research tool
261
What is Wilson and Jungers criteria for screening
Knowledge of the disease:
The condition should be important
There should be a latent or early symptomatic stage
The natural course of the condition should be understood
Knowledge of test:
Suitable test or examination
Test acceptable to the population
Case-finding should be a continuous process
Treatment for disease:
Accepted treatment for patients with recognised disease
Facilities for diagnosis and treatment available
Agreed policy concerning whom to treat as patients
Cost considerations:
The cost of case-finding (including diagnosis and subsequent treatment) should be balanced by the expenditure on care as a whole
262
What is screening
a process of identifying apparently healthy individuals who may be at an increased risk of a disease or condition
263
What is detection rate
proportion of affected individuals who will be identified by screening test
264
What is false positive rate
proportion of unaffected individuals with a higher risk/screen positive result
265
What is false negative rate
proportion of affected individuals with a low risk/screen negative result
266
What are the antenatal screening programmes
Fetal anomaly screening program
Infectious Disease screening programme
Sickle cell and thalassaemia screening programme
267
What are the new born screening programmes
New Born blood spot screening programme
New Born hearing programme
New born and 6-8 week infant physical exam screening programme
268
What does the fetal anomaly screening programme screen for
Downs Syndome - Trisomy 21
Edwards Syndrome - Trisomy 18
Pateaus Syndrome - Trisomy 13
269
What is Downs Syndrome and how does it present
Extra copy of chromosome 21
Prevelance increases with maternal age
```
learning/ intellectual disability
Low Average height
Hearing loss, recurrent otitis media
Hypothyroidism
Gastrointestinal Malformation (duodenal atresia)
Hypogonadism, Low Fertility
congenital heart conditions (AVSD)
early onset alzheimers
Obesity
Delayed motor onset/ Hypotonia
Single Transverse Palmer Crease
Sandal Gap
```
270
What is Edwards Syndrome and how does it present
Extra copy of 18
Increases maternal age
Most die soon after birth and survival after a year is rare
```
Prominent Occiput
Rocker - Bottom Feet
Intellectual Disability
Non Disjunction
Clenched fists
Ears (Low set)
```
271
What is Pateaus Syndrome and how does it present
Extra copy of 13
Increases with maternal age
Most will die before birth, stillborn or die shortly after birth
Symptoms:
Microcephaly, Cleft lip palate, polydactyl and congenital heart defects
272
What test is used to screen for Trisomies in the 1st Trimester and when it can be carried out
The combined test - Nuclear translucency measurement and serum testing
11 -13 weeks
273
A woman presents late as pregnant put she is past 13 weeks what test can she have instead to pick up trisomnies
the quadruple test - uses serum markers only
Can be done in the 2nd trimester: 15 - 20 weeks
274
If a baby is screened with a positive test for anomaly testing what two further tests can she undergo
```
Invasive:
Chorionic Villus Biopsy (10-13 weeks)
Amniocentesis (15 weeks onwards)
Non Invasive:
Only available private
```
275
What do invasive anomaly tests increase the frequency of
miscarriage
276
What two scans should be offered to women during pregnancy
12 week scan - 8 -14 weeks + combined test
| 20 week scan - 18 - 21 weeks
277
What is the first early scan used to check
Confirm viability
Assess GA
Multiple pregnancy
(May reveal fetal abnormality)
278
What is the second scan used to check
Identify structural abnormalities
279
What three infectious diseases are screened for during pregnancy
HIV
Syphillius
Hep B
280
What two haemoglabobinopathies are screened antenatally
Alpha and Beta thalassaemias
| Sickle cell disease
281
What does sickle cell disease cause
Painful crises where RBC sickle blocking capillaries and depriving tissues of oxygen
282
What thalassaemia is imcompatible with extrauterine life
Alpha Thalassaemia major
283
What does beta thalassaemia major present as
life threatening anaemia - patient will need regular blood transfusions and iron chelation therapy
284
What is the purpose of sickle cell and thalssaemia screening
Identify women who are carriers
Test partners of screen positive women
Identify at risk patients
285
Screen Positive results in haemoglobinopathies
Discussion, termination is offered
286
What does the new - born blood spot test involve
Screens 9 conditions to enable early detection and treatment before irreversible damage
287
Where and when is new born blood spot test made
Heal prick blood 5-8 days of age
288
What diseases are screened for in the new born heal test
Cystic Fibrosis
Congenital Hypothyroidism
Sickle Cell disease
6 x Inherited metabolic diseases - these can be life threatening
289
When is hearing screening performed
Prior to discharge home or within 4 weeks of brith
290
What is screened for in new born infant physical examination
```
General Examination plus:
Eye problems
Congenital Heart defects
Developmental Dysplasia oh hips
Undescended Testes
```
291
What two points is NIPE performed
72 hrs of birth
| 6-8 weeks
292
Name two inherited metabolic disorders
Maple Syrup Disease
MCADD
Phenylketonuria
293
What is present in the milk at birth
Colostrum
294
What does the colostrum provide
Growth factors - to stimulate development of fetal gut
| Antibodies - to provide passive immunity
295
What is lactogenesis 2
onset of production of copious milk after expulsion of placenta and withdrawal from pregnancy hormones e.g progesterone - usually by 72 hrs
296
What are the two hormones used in breatfeeding
Prolactin - anterior pituitary gland
| Oxytocin - posterior pituitary gland
297
What does oxytocin do
Causes expulsion of milk from contraction of myo-epithelial cells
298
What does prolactin do
Stimulates lactocytes to produce milk
299
What is a normal CTG
Accelerations present
Variability >5bpm
No decelerations (except when there on contractions - decelerations are normal)
HR 110-160
300
What is the management of APH
```
ABCDE
IV Access
Bloods, G&S
IV Fluids
Blood Transfusion
Delivery of Baby
```
