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4th year OBS AND GYNAE > Obstetrics > Flashcards

Obstetrics Flashcards

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1
Q

obstetric history acronym for obs part

…

A 
gets(2) a family 
Gestation - weeks
Estimated due date
Twins or singleton 
Sspecialist in charge
(2) Scans ok?
Anticipated or planned?
Folic Acid
Movement of fetes
ILness? 
Your choice or birth location?
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2
Q

Obstetric exam

A

General exam
Hands- cap refill, pulse, BP, Face (anaemia), peripheral oedema
Inspect abdo: shape, fetal movements, linea nigra, striae gravidarum,

Palpation: abdo tenderness in 9 regions

  • Uterus borders
  • determine fetal lie
  • determine fetal presentation
  • assess engagement
  • measure SFH
  • auscultate fetus heart rate
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3
Q

visits
initial contact
booking
dating scan which week?

16 weeks

18-20 weeks

28

34 weeks

36 weeks

38+40

41 weeks what do you offeR?

  • each time check urine for protein + BP
A

INITIAL - information giving, folic acid, food hygiene, screening tests offered

booking: before 10 weeks- offer screening tests, offer dating scan, booking bloods, calculate BMI, measure bp + urine

Dating: 11-14 weeks. determine gestational age, finalise eddoes, Detect multiple pregnancies

16: review test results, offer quadruple test if not screened for downs

18-20 ultrasound for structural abnormalities (anatomy/ anomaly)

28 weeks: provide info with - second screen for anaemia and red cell antibodies. anti d prophylaxis

34 = info on labour given. and borth. 2nd dose anti d prophylaxis

36: K for newborn, post-natal issues, breastfeeding info, palpate for presentation

38-40 palpate for presentation

141- OFFER MEMBRANE SWEEP

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4
Q

BOOKING VISIT

A
  • FBC
  • BLOOD Group AND RBC antibodies
  • URINALYSIS
  • RUBELLA
  • HEP B
  • HIV
  • HAEMOGLOBINOPATHIES
  • shyphillus
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5
Q

combined screening

A

gets offered at initial plan - opt in
done in week 11-14
1) crown rump length
2) nuchal translucency scan + maternal blood test for hCG and PAPA = Pregnancy Associated Plasma Protein-A

indicates downs, pauatu and edwards

–> when higher liklihood comes back: offer chronic villous sampling (11 weeks) or amniocentesis (15 weeks)

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6
Q

common MSK problems

A

backache
symphysis publus dysfunction
carpal tunnel syndrome

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7
Q

GI problems

A

Constipation
Morning sickness
GORD
haemorrhoids

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8
Q

Lower limbs

A

Varicose veins

Oedema

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9
Q

Obstetric cholestasis

A

Abnormal flow of bile duct –> causes bile salts to build up and leak into blood stream
Itching appearing last 3 months most commonly hands and feet
Worse at night
RF: multiple pregnancies, high dose oral contraception, south asian

Diagnosis: LFTs, serum bile salts

Management: Give birth, cream and antihistamine
URSODEOXYCHOLIC ACID
- Vitamin K offered as can affact ability of blood to clot

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10
Q

UTI

A

Recurrent cystitis and diabetes RF
presents different in pregnancy
general malaise (e.coli)

CANT give trimethoprim in 1st trimester (folate issue)
or nitrofurantoin in 3rd trimester
- cephalexin is fine in all

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11
Q

problems due to pelvic organ abnormality

A

Fibroids may enlarge during pregnancy (if lower cervix may prevent descent of presenting part)
Red degeneration: as it grows, fibroids may become ischamic and –> acute pain, vomiting

Retroversion of uterus: If it doesnt flip during pregnancy, then baby will grow in uterine cavitiy and –> stretch on bladder may cause urinary retention classically week 12- 14

Congenital abnormality: bicornate uterus: may cause PROM, pre-term, miscarridge.

Ovarian cysts: large ones can haemorrhage or twist –> acute abdo pain and may cause pre-term or miscarrriage.

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12
Q

hyperemesis gravidarum

A

Severe intractable nausea and vomiting
Diagnosis criteria triad:
5% pre-pregnancy weight loss, dehydration, electrolyte imbalance.

Severe cases may cause wernikes encephalopathy, oesophageal tear mallory weis, malnutrition

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13
Q

VTE prophylaxis

RF
- >35
parity >3
smoker
cross varicose veins
current pre-elampsia
immobility 
fhx
multiple pregnancy
A
  • 2 risk factors –> low risk so mobilisation in pregnancy and avoidance of dehydration + 10 days post-natal prophylaxis
    3 risk factors- prophylaxis from 28 weeks + 6 weeks post natal
  • 4+ = prophylaxis from 1st trimester + 6 weeks post natal
  • intermediate risk = antenatal prophylaxis with LMWH
  • high risk- antenetal prophylaxis with lmwh + refer to expert

based on booking scan weight

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14
Q

small for dates

A

<10th centile
Mostly reflect intra-uterine growth restriction
- head growth may be slow less as its prioritised
- doppler used to diagnose placental insufficiency
- reduced end-diastolic flow suggests increased placental resistance

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15
Q

large for dates

A
  • weight leg or head above 90th centile for gestational age
  • major factor is uncontrolled maternal/ gestational diabetes
  • increased risk of shoulder dystocia
  • hypoglycaemia in post-natal period
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16
Q

polyhydramnios

A
  • excess amniotic fluid >95th centile
  • may present as severe abdo swelling and discomfort
  • abdo appears distended
  • fetal poles hard to palpate
  • may need to perform amniodrainage
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17
Q

oligohydramnios

A

Amniotic fluid <5TH DECILE
may be suspected following history of PROM
- small for date uterus
- nsaids can cause

LOW AMNIOTIC FLUID

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18
Q

reduced fetal movement

A

First noticed between 18 and 20 weeks
Fetal movements increase until 32nd week then flatten
report any change in pattern after 28 weeks

(Move out the house at 18 so fetus starts to move at 18 weeks)

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19
Q

Prolonged pregnancy

A

Extended beyond 42 weeks

more likely need c section

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20
Q

PPROM = preterm prelabour rupture of membranes

A

Rupture of membranes before 37 weeks
gush of clear fluid followed by leaking of liquor
- hospital admission and fetal steroids if <34 weeks.
reduces risk of neonatal respiratory distress syndrome.
- prophylactic erythromycin may be used to prevent infection
- induction of labour if 36 weeks
- preterm delivery follows within 48 hrs in 50% cases

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21
Q

1st trimester
week 1- week 12
common issues

A

hyperemesis gravidum
ectopic pregnancy
miscarriage
fatigue

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22
Q

2nd trimester

week 12- week 27

A 
miscarriage (before 20)
placental previa / abruption 
preterm labour 
PPROM
pre-eclampsia (more common in 3rd)
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23
Q

3rd trimester

week 28- birth

A 
gestational diabetes
pre-eclampsia
-preterm labour
PPROM
placenta previa/abruption 
malpresentation 
antepartum haemorrhage
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24
Q

symmetrical IUGR

A

HC - head circumference is relative to the AC- Abdo circumference.

  • usually just genetically small
  • need fortnightly scans
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25
asymmetrical IUGR
head stays right size and baby uses brown fat stores to supply it energy. body small compared. if blood reedirected for too long, other organs can become ischaemic --> nectrotosing enterocolitis. tx - fortnightly scans, weekly doppler of umbilical circulation.
26
all dizygotic pregnanies
there are 2 placentas (dichorionic) and 2 amniotic sacs (diamniotic).
27
chorionicity
whether the babies share a placenta or chorion or not
28
multiple pregnancy treatment
- Oral iron, folic acid, 75mg aspirin - DCDA 4 weeky scans from 16 weeks - MC twins 2 weekly from 16 weeks timing of delivery - DCDA 37-38 weeks - MCDA 36 week MCMA 32-34 wees by C section
29
pre-elampsia
> 20 weeks of pregnancy (normally normotensive) BP >140/90 on two occasions 4 hours apart 300mg protein in a 24 hr collection of urine Resolves by 6th week postpartum
30
pre-existing diabetes
aim to deliver before 39 weeks (more stillbirths) increased risk cardiac + neural tube defects fetal macrosoma (big baby) + shoulder dystocia pre-eclampsia risk - can get worsening of diabetic retinopathy so RETINAL SCREEN 1) booking, 2) 16 weeks, 3) 28 weeks insulin sliding scale introduced in labour
31
gestational diabetes
those with 1+ risk factor should be tested RF:; obestity, fhx, previous baby 10lbs + oral glucose tolerance test fasting blood sample, then given 75g sugar, 2 hours later another sample taken performed between 24-28 weeks, 5. 6 = fasting diagnosis 7. 8 = two hour glucose level management: 1. 1-2 weeks lifetsyle trial 2. Metformin 3. Targets still not met = Insulin (or FBG was >7 at time of diagnosis)
32
commonest acquired thombophillia
antiphospholipid syndrome - lupus antibody + / anti-cardiolipin antibody often history of recurrent miscarriage
33
treatment of VTE in pregnancy
- stockings - LMWH as it does not cross placenta - dose calculated against mothers booking weight women taught to self inject used till at least 6 weeks post natally. when labour starts- discontinue lmwh/ 24 hrs before C section
34
VBAC
vaginal birth after C section 70% chance of normal delivery after increased risk of uterine rupture 2+. c section scars = CI
35
uterine rupture
``` severe lower abdo pain vaginal bleeding haematuria cessation of contractions maternal tachy fetal compromise ```
36
C section risks
``` increased risk of: infection bleeding injury to bowel scalpel injury to baby anaesthesia risk prolonged recovery future pregnancy rupture risk ```
37
sickle cell tx in pregnancy
5mg folic acid (high dose) | 75 mg aspirin
38
epilepsy in pregnancy
reduce to monotherapy where possible 5mg folic acid Na valproate worst risk associated with neural tube defects lamotragine safer option may need to increase dose as drug levels tned to decrease
39
cardiac in pregnancy
increased blood flow produces an ejection systolic murmer is 90% pregnant women ecg: t wave inversion and L axis deviation warfarin and ace inhibitors CONTRAINDICATED
40
pulmonary hypertension in pregnancy
high maternal mortlaity = usually contraindicated and terminated.
41
depression in pregnancy
tricyclic antidepressants are safe and carry no teratogenic effects SSRis increase risk of congenital abnormalities
42
tokophobia
anxiety about labour
43
``` drug affetcs on pregnancy lithium.. valproate.. SSRI.. BZ.. ```
L.. fetal cardiac disease and fetal anticonvulsant syndrome V..neural tube defects and fetal anticonvulsant syndrome SSRI.. feta cardiac disease + persistant pulmonary HTN BZ.. facial clefting and depressed resp effort at birth, hypotonicity and poor feeding = floppy baby syndrome
44
autoimmune hashimotots thyroiditis | - maternal thyroxine important in 1st trimester for developmental delay
tx should be carbimazole (not radioactive iodine) as completely obliterates fetal thyroid gland. uncontrolled thyrotoxicosis is assocaited with risk of miscarriage, preterm delivery and FGR.
45
recurrent miscarriage
3 or more consecutive pregnancies that end in miscarriage of the fetus before 24 weeks of gestation - investigate for antiphospholipid antibodies TX: heparin and low dose aspirin - inherited thrombophillia screen also
46
mid-trimester loss
12-24 week baby dies. | after 24 weeks = still birth
47
movement of head in passage
1) engagement in occipito-transverse 2) descent (uterine action) then flextion 3) internal rotation 90 degrees to occipito anterior 4) descent 5) extension to deliver head 6) restitution and delivery of shoulders (anterior first)
48
first stage of labour
time of onset to full dialatation 10cam Latent phase 0cm-4cm- cervix becomes effaced (2-3 days) Active phase / established labour: up to 10cm 2cm 4 hours
49
management of slow progress in 1st stage
artificial rupture of membranes | syntocinon
50
2nd stage
time from full dialatation to delivery of the foetus (4-5 hours) passive stage: no maternal urge to push active stage: maternal urge to push. fetal head is low. 40 min primp, 20 min multiple.
51
methods to help in 2nd stage
vaccum extraction traction forceps: need episiotomy - OA only rotational forceps: can be used in OA, OP or transverse
52
third stage
time from delivery of fetus to delivery of placenta
53
cord clamping
active: recommended as reduces PPH. 10 IU of oxytocin an controlled cord traction, deferred clamping and cutting of cord by 1min. physiological: placenta delivered by maternal effort and. no uterogenic drugs
54
thick bright green meconium
sign of intrauterine hypoxia or acidosis
55
fetal monitoring in labour
intermittent ausculatation of fetal heart using doppler or pinard steth high risk women : continuous monitoring ctg. - Fetal scalp electrode: indication- poor contact with abdo transducer, high BMI, twins, abdo scarring,
56
CTG normal variaability ? Normal baseline rate? early and late decelerations- which is concerining? definition of acceleration?
DR, C BRAVADO. Define Risk Contractions: per 10 minutes. >5 hyper? cant measure intensity- so palpate for this Baseline Rate: 110-160 (range 15) Accelerations: they are encouraging Decelerations: 'early' = not concerning 'late' = concerning (fetal hypoxia) Accelerations = increase in baseline heart rate of >15 bpm for >15 seconds. Variable - typical : <60s <60 change - atypical: >60s >60 change Overall assessment: reassuring? normal?
57
bishop score
score +8 indicates will deliver soon and easier shorter induction
58
cervical ripening
- insert tampon in posterior fornix that releases prostaglandins for 24 hours e.g. propess: 10mg over 24 hrs prostin gel: 1mg released over 6 hours
59
artifical rupture of membranes
- breaks waters - amnihook inserted through partially opened cervix and makes hole in membranes often give oxytocin samr time
60
syntocinon
oxytocin = slow IV drip until 3 contractions every 10 mins
61
membrane sweep
vaginal examination inserting finger through cervix and strips chorionic membrane from the underlying deducide. releases natural prostaglandins. offered at 40 and 41 week antenatal visits.
62
malpresentation
any presentation that is no cephalic e.g. breech - transverse lie: fetal long axis transverse - oblique lie: long axis of fetus crosses maternal long axis
63
malposition
ocipito-anterior is normal | ocipitotransverse or posterior = abnormal
64
vertex vertex breach breach vertex breach
twins both head down twins both bum down one twin head down one with one bum down
65
shoulder dystocia
need for additional obstetric manouvres to release shoulders after gentle downward traction has failed. can be heped with McRoberts manoevre
66
Management of symptomatic women in preterm labour Name 2 tocolytics? Drug for baby neuroprotection? When offer maternal steroids?
<22-24 weeks not viable with life maternal steroids should be offered from 26-34 weeks two injections of 12 mg IM dexamethasone 12 hours apart - Tocolytics: Nifedipine or Terbutaline = anticontraction medications - broad spec antibiotics - Magnesium sulfate: neuroprotection of baby if 24-29 weeks Maternal steroids: 12 mg Dexamethasone between 26 - 33 weeks to reduce resp disress syndrome
67
GBS positive: group b strep
preterm infants more susceptibe to early onset GBS infection allow consideration of intrapartum prophylaxis with benzylpenicillin.
68
placental abruption
separation of normally sited placenta from uterine wall --> vaginal bleeding syx: constant or frequent short lasting contractions - caused by irritable effects of blood within uterus - hard uterus - pain - shock disproportional to blood loss (lots inside still) - uterus may be firm and wooy = spasm - fetal HR may be hard to auscultate
69
placenta previa major: covering internal cervical os minor: placenta covering lower segment of uterus but not os placenta accreta increta percreta
- placenta implanted into lower segment of uterus - placenta accreta = abnormally adherant to uterine scar - placenta increta: invading part of utering wall - placenta percreta: through uterine wall
70
chronic hypertension pregnacy
treat if 150/100 with medication - oral labetalol | admit if >160/110
71
pre-elampsia
- incomplete trophoblastic invasion of spiral arterioles and atheromatous lesion --> exaggeration maternal inflammatory response --> widepsread endothelial damage - glomeruloendotheliosis = renal lesion highly characteristic HELLP - haemolysis - Elevated Liver enzymes - Low platelets
72
pre eclampsia syx? sign
Frontal headache oedema visual disturbance epigastric pain sign:bp 140/90, +++ protein, hyperreflexia, oedema
73
pre eclampsia managememnt
- antihypertensives Labetalol (not if asthmatic), methydopa or nifedipine Seizures: magnesium sulphate IV and prophylactically to prevent seizures 48 hrs post partum 12mg dexamethasone
74
cord prolapse
presentation of umbilical cord below fetal presenting part when the membranes are ruptures move women onto all 4s then c section
75
PPH
tone, tissue, traume and thrombin 1) communication: altert midwife and obstetrican and anaesthesit 2) resus A-E- fluid iv hartmans clotting screen etc 3) arrest bleeding: bimanual uterine compression - uterotonic drugs: rapid oxytocin infusion or iM bolus - intauterine balloon tamponade - hysterectomy if really bad SYNTOCINON inusion !!!! + ERGOMETRINE IV bolus
76
HELLP syndrome
Haemolysis Elevation of liver enzymes Low platelets SYX: Malaise, N+V,
77
Prevention of pre-elampsia in hgih risk women?
75 mg aspirin OD started at 12 weeks
78
What is Colostrum?
Yellowish fluid secreted by the breast as early as 16 weeks, replaced by milk 2nd day post-partum. Laxative effect to help baby get rid of meconium.
79
Best contraception post birth?
POP - progesterone only commenced day 21 following delivery
80
Peupeural psychosis When occurs? TX?
Usually occurs after day 4 postpartum Admit to Mother and baby psych unit Tx: Haloperidol and antidepressants
81
Obstetric cholestasis
Itching druring pregnancy COCP contraindicated in women who have had this TX: ursodeoxycholic acid
82
What is carbergaline?
stops lactation post partum for women not breast-feeding

4th year OBS AND GYNAE (4 decks)

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