Obstetrics Flashcards
(34 cards)
Miscarriage
Investigation:
1st line TVS
2nd line hCG
Management
1st line: Depends on classification of miscarriage. Most commonly medical management (Day 1 mifepristone, Day 2 misoprostol).
2nd line: Surgical indicated if shock, GTD or infection with vacuum <12 weeks or ERCP >12 weeks
Ectopic pregnancy
Investigations:
1st line Urinary beta-HCG
2nd line If positive? Abdominal USS
3rd line If not intra-uterine pregnancy? TVS
4th line Pregnancy of unknown origin? Serum beta-HCG
Management
1st line: Depends on size of mass, if mother is stable, pain presence. Either IM methotrexate OR surgical laparoscopic salpingectomy OR conservative watchful waiting
Gestational Diabetes
Investigation: OGTT
Management:
1st line: Lifestyle changes
2nd line: Medical (1. Metformin 2.Glibenclamide)
Varicella zoster virus
Investigation: Clinical diagnosis 1st line. Testing maternal immune status with VZV serology for IgG and IgM.
Management:
If confirmed no immunity: Give VZIG
If presenting if maternal chickenpox: Aciclovir given, counselled on complications, referred to fetal medicine for serial USS for fetal abnormalities
Parvovirus B19
Investigation: Viral serology for IgG and IgM
Management: If positive screen, immediate referral to FMU for serial US and doppler scanning until 30 weeks for signs of fetal hydrops.
CMV
Investigation: Maternal viral serology
Management: Maternal positive screen? Refer to FMU. No antiviral available for mother. Wait until 21 weeks (kidney development) to see if mother transmitted infection (1/3 chance) via Amniocentesis at 21 weeks. If PCR sample shows CMV present then offer TOP or US surveillance.
Rubella
Investigation: Maternal viral serology
Management:
Positive screen, send to FMU.
Maternal symptomatic Tx and educated on infective periods (7 days prior and 4 days after symptoms onset).
Fetal Mx dependent on gestational age: <12 weeks TOP offered. 12-20 weeks amniocentesis and RT-PCR done, if positive offer TOP or US surveillance. If >20 weeks no action required
Anaemia
Investigations: FBC for Hb and MCV . Ferritin checked in known haemoglobinopathy
Management:
Fe deficiency Microcytic / normocytic = Trial of ferrous sulphate TDS then repeat FBC in 2 weeks
Beta thalassaemia microcytic= Folate supplement and blood transfusions. Hb aim for 80g/l during pregnancy and 100g/l during delivery
Folate deficiency macrocytic anaemia= Folate supplementation OD, can be increased to TDS if required.
Sickle cell disease normocytic anaemic = Folate and Fe supplementation
Referral:
If Hb <70g/l, late gestation (>34 weeks), ineffective oral Fe supplement
Follow up:
Continue oral Fe post partum for 3 months and 6 weeks. Anaemia (<100g/l) get 100-200g Fe, Non-anaemic get 65g and repeat FBC in 8 weeks.
Antiphospholid syndrome
Investigations:
1st line Exclude DVT with US
2nd line: APS screening
Diagnosis:
Requires minimum of 1 clinical and 1 laboratory indicator.
-Clinical: Vascular thrombosis Hx / Pregnancy morbidity Hx
-Laboratory: Lupus anticoagulant / Anticardiolipin Ab / Anti B2 glycoprotein I
Management:
Prenatal- Warfarin in vascular thrombosis Hx
Antenatal- If Hx of recurrent miscarriage, give LMWH + low-dose aspirin. If Hx of IUGR or pre-eclampsia, give low-dose aspirin.
Post natal- Immediate thromboprophylaxis
VTE in pregnancy
Investigations:
If DVT + PE Sx: Duplex US. If positive, no need for CTPA or V/Q
If DVT only: Duplex US. If negative, repeat on days 3 and 7.
If PE only: ECG and CXR initially. Diagnostic CTPA andV/Q
Management:
VTE confirmed on Duplex US: LMWH until 6 weeks postpartum. Withhold 24hrs before OIL or at delivery
VTE at term: Unfractioned heparin considered. Withhold 6 hours before IOL or CS.
Thyroid disease
Referral
Yes: History of thyrotoxicosis and thyroid carcinoma –> Endocrinologist clinic
No: Hypothyroidism –> Seen at CLU ANC
Investigations:
TSH
Free T3 and T4
Antibodies: TRAbs (Graves), Anti-TG Abs and Anti TSH Reception Abs (Hashimoto’s)
Management:
Hypothyroidism: Prophylactic increase in thyroxine by 25mcg upon positive pregnancy test. Check levels 6 weeks after each dose change. Return to pre-pregnancy dose after delivery.
Hyperthyroidism: PTU 1st line. After initial stabilisation, reduce dose. RAI contra-indicated in pregnancy or when trying.
Hypertension in pregnancy
MANAGEMENT
At risk of pre-ecampsia: Referral to CLU ANC. Prophylactic Aspirin 75mg OD from 12 weeks gestation onwards. Monitor urine proteins and BP at each antenatal appt. Warn of symptoms of pre-eclampsia (headache, oedema, blurred vision)
Pre-existing HTN / Chronic HTN: Lifestyle advice and low Na diet. Referral to obstetric care at booking. Stop ACEIs or ARBs.Offer medication if BP >140/90 (1st line Labetalol. 2nd line Methyldopa or Nifedipine).
Gestational hypertension: Admit if severe HTN (>160/110), proteinuria 1+ or pre-eclampsia symptoms. If >140/90 medication management with aim of 135/85
FOLLOW UP
Chronic HTN: Regular post natal BPs and continue meds for 2 weeks until review (note switch methyldopa after 2 days postnatal).
Gestational HTN:
- If taken medication continue for 2 weeks until review. If required for more than 2 weeks then referral to GP.
- If no medication taken, monitor BP and commence medication if >149/99
ALL WOMEN: 6-8 weeks post natal review with GP or specialist
Obstetric Cholestasis
Investigation:
Diagnosis based on clinical presentation (pruritus at abdomen, palms and soles) with deranged LFTs and bile acids studies
Mangement:
1st line: Symptomatic relief with creams/ointments and antihistamines. Ursodeoxycholic acid to reduce bile salt level and normalise LFTs. Vitamin K 10mg taken OD from 36 weeks
At delivery: In CLU with neonatal unit. Neonate given vitamin K.
Monitoring:
Antenatal = Under CLU ANC. LFT and bile salt monitoring weekly or bi-weekly. Foetal assessment with CTG, US for growth and fluid volume assessed.
Post natal = 6 weeks followup to assess that LFTs have normalised.
GTD
Presentation: History of PV bleeding and abdominal pain. Later leads to hyperemesis, hyperthyroidism and anaemia. O/E large and boggy, large for dates uterus.
Investigation:
Monitoring with serum b-HCG.
Diagnosis: US for complete mole showing granular “snowstorm” appearance. POC history for definite Dx for all molar or non-viable pregnancies. If partial viable pregnancy, placental history performed.
Mangement: Complete or non viable partial moles --> URGENT suction curettage Partial moles (with foetal development or late gestation) --> Medical evacuation and urinary b-HCG 3 weeks later to confirm. Given methotrexate if level not fallen.
Hyperemesis gravidarum
Persistent vomiting in pregnancy with triad of: Weight loss >5%, electrolyte imbalances and dehydration
Investigation: Bedside (urine dipstick, vitals)
Labs (FBC, U+Es, infection, MSU, Glucose)
Imaging (foetal viability, GTD, multiple preg)
Management:
Mild = Community advice and dietary advice. Oral anti-emetics +hydration.
Moderate: Ambulatory day care with IV fluids, parenteral anti-emetics and thiamine.
Severe: Inpatient
Anti-emetics: 1st line 1 week of anti-histamine (cyclizine, promethazine) or phenothiazine (proclorperazine). 2nd line 5 days ondansatron or metoclopramide
When to admit?
- Co-morbid health condition
- N+V associated with either ketonuria or weight loss that has not responded to anti-emetics
Amniotic fluid embolism
S/S- Liked to shock with DIC within 4 hrs
Ix:
- Bloods: FBC, Mg, Ca, Coagulation screen
- ECG: Ischaemic changes
- CXR: Pulmonary oedema
Management
1st line: Resus
Next: Mother stable? Imminent delivery with continuous foetal monitoring. Maternal compromise? Perimortem section to facilitate maternal CPR
Definitive diagnosis: Port-mortem pulmonary aspirate (foetal squamous cells and debris present)
Pre-eclampsia
Px: Can be asymptomatic - Frontal headache -Blurred vision or flashing lights - Oedema in face, feet, hands -Vomiting -Hyper-reflexia
Investigation:
- BP on 2 occasions, 4 hrs apart
- Urine dipstick (24hr collection to quantify)
Diagnosis requirements:
- HTN
- Proteinuria (>300mg in 24hrs or >30mg/mmolin urinary ACR)
- > 20 weeks gestations
Prophylaxis:
If 1x high risk factor or 2x moderate risk factor –> 75mg OD aspirin from 12 weeks onwards
Management:
Antenatal- Admit all severe pre-eclampsia. Medication given to all severe or persistent >140. 1st line is labetalol, 2nd line nifedipidine. ACEI contraindicated. Target bp <135. Regular BP monitoring. Urine dip repeated only if clinical indicated. Foetal monitoring at diagnosis then auscultate HR every NC, 2 weekly US, CTG if indicated. Regular blood tests for end-organ damage (Twice/week in mild and moderate, 3times/week in severe)
Intrapartum: Give corticosteroid if early delivery likely within next week. During labour regular BP hourly, continue HTN meds
Post-natal: Keep as inpatient for 24hr post-partum monitoring. Continue HTN medication for first 2 weeks of discharge until review appt. All women get 6-8 week follow-up for medication review and urine strip test (if 1+ then repeat in 3 months, if 2+ then renal specialist referral)
Eclampsia
Px: New onset tonic-clonic seizures, in the presence of pre-eclampsia
Ix:
- FBC: Low Hb, platelets (DIC Dx)
- U+Es: High urea, creatinine, urate. Low urine output.
- LFTs: High aminotransferases, bilirubin
- Clotting studies (DIC Dx)
- Blood glucose (Hypoglycaemic seizure?)
- Abdominal US: Placental abruption?
CTG: Fetal distress or bradycardia?
Mx:
- Resus (ABCDE + left lateral position)
- Cessation of seizures with MgSO4)
- BP control (IV labetalol or hydralazine)
- Delivery (CS then mother to HDU for 24hrs)
- Monitoring (Fluid balace for pulmonary oedema and AKI. Bloods and biochem for 72 hrs)
Complications of eclampsia
Maternal mortality rate 1.8%
Foetal mortality rate 30%
Maternal:
- HELLP syndrome - DIC - AKI - ARDS - Cerebrovascular haemorrhage - Permanent CNS damage - Death
Fetal:
- Placental abruption - Prematurity - IUGR - Intrauterine fetal death - Infant respiratory distress syndrome
Induction of labour
Indications:
- Uncomplicated pregnancies between 40+0 and 40+14wks
- Maternal health problems
- PROM
- Foetal distress
- Foetal death
Conta-indications Absolute: - Major placenta praevia - Cord prolapse -Transverse lie - Vasa praevia -Active primary genital herpes - Previous classical CS Relative: -Breech -2+ lower abdominal incision CS -multiple pregnancy
Methods:
1st line - Membrane sweep
2nd line- Vaginal prostaglandins
3rd line- ARM/Amniotomy or Cook’s balloon
Assessment: Bishops score
Complications: Failure of induction, infection, uterine hyperstimulation, Cord prolapse
PROM
Risk factors:
- Smoking
- Infection (UTI or chorioamniocentesis)
- Hx of PROM or P-PROM
- Large amniotic sac (polyhydramnios or multiple pregnancy)
- Vaginal bleeding in pregnancy
Ix:
- History
- Speculum: after laying 30 mins there is pooling at posterior fornix
All women get HVS for GBS
Management
>36 weeks: IOL recommended. Monitor for chorioamniotitis. Watch and wait for labour within 24hrs (60% will occur). After 24hrs IOL. Give penicillin or clindamycin during labour if GBS positive.
34-36 weeks: IOL recommended.Monitor for chorioamniotitis. Prophylactic erythromycin QDS for 10 days. Give penicillin or clindamycin during labour if GBS positive. If <34+6 give corticosteroids.
24-33 weeks: Expectant management until 34 week. Monitor for chorioamniotitis. Prophylactic erythromycin QDS for 10 days. Give penicillin or clindamycin during labour if GBS positive. If <34+6 give corticosteroids. Expectant management until 34 week.
Placental abruption
Risk factors - Previous abruption ** - Intrauterine growth restriction e.g. twins - Pre-eclampsia - Pre-existing hypertension - Abnormal lie of fetus e.g. transverse - Polyhydramnios Smoking or drug use e.g. cocaine
Presentation:
History= Pain +/- bleeding
OE = Woody hard uterus. Tender abdomen. Absent/abnormal foetal heart sounds
Investigations:
Diagnosis is clinical
Monitoring foetus: CTG if >26 weeks. US if stable/.
Monitoring Mum: FBC, x-match, coagulation screen, Kleihauer if Rh negative. Hourly UO, U+Es, LFTs
Management:
- Assess and resus: Admit. Give steroids if <34 weeks. Anti-D if Rh -ve.
- Delivery: If distress then CS. If no distress but 37+ weeks then IOL. Dead fetus then IOL.
- Conservative management: Admit and give steroids if <34 weeks, no distress and minor abruption.
- Postpartum: Risk of PPH
Placenta Praevia
Classified: Marginal or major
Risk factors:
- PREVIOUS CS
- Previous placenta praevia
- Twins
- Polyhydramnios
- GU anatomical abnormality (infection, endometriosis, ablation, TOP)
- High maternal age
- High parity
Complications
- Foetal distress / hypoxia
- Obstruction
- Transverse lie
- Placenta accreta or percreta
Presentation
- Painless bleeding (Initially intermittend but worsens. Blood is red and profuse)
Investigation
-Diagnosis by US
Management.
If asymptomatic: Incidental finding at 20 week US scan. Repeat scan at 32 weeks (major) or 36 (minor)
If bleeding: Admit and ABCDE. Steroids for <34 weeks. Anti-D for Rh -ve within 72 hours.
Delivery: Elective CS at 38 weeks.
Risk: PPH
Ruptured vasa praevia
When the foetal vessels run in the membranes infront of the presenting part
Ix: US
Px: Painless, moderate bleeding after ROM + foetal distress
Mx: CS
