Obstetrics Flashcards
(374 cards)
1
Q
PREGNANCY PHYSIOLOGY
When is the window of blastocyst implantation and why?
A
Cycle day 20-24 due to the perfect balance of hormones.
2
Q
PREGNANCY PHYSIOLOGY
what happens after blastocyst implantation?
A
the blastocyst buries which is called ‘Interstitial Implantation’
This starts the primary decidual reaction
3
Q
PREGNANCY PHYSIOLOGY
What basic placental structures form after interstitial implantation
A
- floating villi
- Anchoring villi
4
Q
PREGNANCY PHYSIOLOGY
What do Cytotrophoblast progenitor stem cells differentiate into?
A
1) Terminal differentiation into syncytiotrophoblast
2) Extra-villus trophoblasts
3) Regenerate new CTBs
5
Q
PREGNANCY PHYSIOLOGY
What are the functions of extra-villous trophoblasts?
A
- Spinal artery remodelling
6
Q
PREGNANCY PHYSIOLOGY
what is spinal artery remodelling?
A
Endovascular invasion myometrium where there is optimum 02 and nutrient supply.
(Due to extra-villus trophoblast invasion)
7
Q
PREGNANCY PHYSIOLOGY
When does full placental blood flow occur?
A
week 10-12
8
Q
PREGNANCY PHYSIOLOGY
What may poor endovascular remodelling lead to?
A
reduced fetal 02 and nutrient supply and subsequently =
Pre- eclampsia
Intrauterine growth restriction (IUGR)
Preterm birth
Recurrent miscarriage
9
Q
PREGNANCY PHYSIOLOGY
what is human chorionic gonadotrophin (hCG)?
A
a hormone that is secreted from day 6-7 trophoblast cells of the blastocyst that:
Promotes maintenance of corpus luteum
Maintains production of oestrogen and progesterone
10
Q
PREGNANCY PHYSIOLOGY
Where is Progesterone produced?
A
Corpus Luteum makes it until 7-8 weeks when the placenta makes it
11
Q
PREGNANCY PHYSIOLOGY
Function of Progesterone?
A
- Prepares uterus for implantation
- makes the cervical mucous thick and impenetrable to sperm after fertilisation
- Decreases immune response to allow pregnancy to happen
- Decreases contractility of uterine smooth muscle to prevent pre-term labour
12
Q
PREGNANCY PHYSIOLOGY
What does progesterone inhibit?
A
progesterone inhibits lactation during pregnancy. The fall in progesterone levels following delivery is one of the triggers for milk production.
13
Q
PREGNANCY PHYSIOLOGY
What is the function of Hyman Placental Lactogen (hPL)
A
- Mobilises glucose from fat reserves
- Insulin antagonist to facilitate energy supply to foetus
- Converts mammory glands into milk-secreting tissue
14
Q
PREGNANCY PHYSIOLOGY
What is the function of Prolactin?
A
- Milk production
15
Q
PREGNANCY PHYSIOLOGY
What is the function of Oxytocin?
A
Milk ejection reflex
Uterine contraction
16
Q
What happens to maternal glucose levels at the early stages of pregnancy?
A
Low glucose levels due to fat depositioon and glycogen synthesis
17
Q
What happens to maternal glucose levels at the late stages of pregnancy?
A
High glucose levels and maternal insulin resistance to ensure glucose sparing for the foetus
18
Q
What happens to maternal insulin levels throughout pregnancy?
A
progressive rise until the peak at 32 weeks. hPL induces insulin resistance to ensure glucose sparing to the foetus
19
Q
IMMUNITY
What are the initial immunity changes after fertilisation?
A
Increases in:
GFs,
proteolytic enzymes
inflammatory mediators
facilitates implantation
20
Q
IMMUNITY
Why is the blastocyst implantation not rejected?
A
Change in self:non self pattern recognition molecules (HLA and MHC proteins)
21
Q
IMMUNITY
Why are syncytiotrophoblasts and extra-villus trophoblasts not rejected?
A
➢Syncytiotrophoblast -has no self:non-self markers = no maternal immune system
➢ Extra-Villus trophoblast (EVT) - has modified self:non-self markers = modified maternal immune response
22
Q
IMMUNITY
What happens to T helper subtype ratio when you’re pregnant?
A
normal people = balanced Th1 and Th2
Pregnant = more Th2 (more antibody production involved in humoral response)
23
Q
IMMUNITY
Name the relevance of the following Antibodies to pregnancy
IgA IgD IgE IgG IgM
A
IgA- Secreted in breast milk
IgD- on b-cell membranes
IgE- mast cells (anaphylaxis)
IgG - has 4 subtypes and the only Ig to cross the placenta
IgM - pentameric structure ‘early antibody’
24
Q
NORMAL LABOUR
How would you describe a ‘perfect’ pregnancy?
A
- 37-42 weeks
- Spontaneous in onset in vertex position
Without the use of:
- Forceps/ C-section/ ventose delivery
- Induction of labour
- Epidural/ general anaesthesia
25
FAILURE TO PROGRESS
What are the 3 Ps?
power
passage
passenger
26
FAILURE TO PROGRESS
Describe the 'Power' of the 3 P's to think about before birth
Need contractions to be strong enough. in nulliparous women this may be difficult and need instrumental delivery (4 every 10 min)
27
FAILURE TO PROGRESS
Describe the 'Passage' of the 3 P's to think about before birth
'Pelvis'
Anterior-posterior diameter (AP) -front to back distance
Transverse diameter- side to side length
28
FAILURE TO PROGRESS
Describe the 'Passenger' of the 3 P's to think about before birth
The baby needs to be in the correct position
29
NORMAL LABOUR
Describe the baby head landmarks felt on vaginal examination to assess baby position
Attitude:
How well the babys head is flexed (well flexed is best)
extended 90 = brow presentation
Hyperextended >120 = face presentation
Position:
either occipito anterior/ transverse/ posterior
OT when entering inlet
OA when entering outlet
then turn 90 to come out facing mothers medial thigh
Size of head
30
NORMAL LABOUR
Define the words:
Moulding
Caput
Moulding = head compressed through the pelvis
Caput = Swelling caused during delivery
31
NORMAL LABOUR
How long on average is the first stage of pregnancy?
5-12 Multiparious
| 8-12 Primiparous
32
NORMAL LABOUR
Describe the early/latent phase of the first part of labour
- Irregular painful contractions
- Cervix is effacing and thinning
- Dilation to about 4cm
- Mucoid plug
(2-3 days)
33
NORMAL LABOUR
What is Engagement?
How far above the pubic symphysis the babies head is
3/5 of the head within pelvic brim is classed as engaged
34
NORMAL LABOUR
What is Presentation
anatomical part of the foetus that presents itself first through the birth canal
35
NORMAL LABOUR
What is Lie?
Relationship between long axis of the foetus and long axis of the uterus
36
NORMAL LABOUR
What is Station?
Relationship between lowest point of presenting part and ischial spines
37
NORMAL LABOUR
Describe the Active Phase of Labour (2nd)
- further dilation from 4cm. (0.5cm every hour)
- regular contractions (3-4 an hour)
- Vaginal exam every 4 hours to assess degree of dilation
- Role of oxytocin/ syntocinon inducing labour
38
PAIN
What is Entonox and name the side effects
gas and air
SE: N+V
39
PAIN
Name the maternal side effects of the most effective form of pain relief: epidural
Maternal Side effects:
- Increase length of 1st and 2nd stage
- Loss of mobility
- Loss of bladder control
- Need for more oxytocin
- Increase incidence of malposition
- Increase instrumental rate
- hypotension & pyrexia
40
PAIN
Name the foetal side effects of the most effective form of pain relief: epidural
Tachycardia due to maternal temperature
Can diminish breast feeding behaviour
41
PAIN
Name an opiate that could be used as pain relief?
Morphine
Pethidine
42
PAIN
Name some foetal side effects of opiates being used as pain relief during labour
Respiratory depression
Diminish breath seeking/ breast feeding behaviours
43
PAIN
Name some maternal side effects of opiates being used as pain relief during labour
- euphoria/ dysphoria
- N+V
- Longer 1st and 2nd stage
44
NORMAL LABOUR
Describe the initial Transition stage of the second stage of labour
Spontaneous rupture of membranes (SROM)
- Start to feel pressure (anxious and distressed)
- Contractions can slow/stop
45
NORMAL LABOUR
Describe the second part of the Transition stage of the second stage of labour
- full dilation (10cm)
- external signs (head visible)
- check baby head landmarks to assess if correct position
46
NORMAL LABOUR
In what timeframe should you
- Suspect delay
- Diagnose delay
- baby be born
in primigravid and multiparous women
Primigravid:
Suspect delay - 1hr
Diagnose delay - 2hr
baby born - within 3 hours of pushing
multiparous:
Suspect delay - 30mins
Diagnose delay - 1hr
baby born - within 2 hours of pushing
47
Why is there now delayed cord clamping?
Evidence that early clamping doesn't benefit baby/ mother and improves iron intake
48
PREGNANCY PHYSIOLOGY
What happens to the appearance of the endovascular invasion after implantation in the myometrium
Narrow bore high resistance vessels become
WIDE BORE LOW RESISTANCE vessels
49
PREGNANCY PHYSIOLOGY
Name some maternal CVS changes
- increased RBC & plasma volume
- Increase plasma volume means overall decline in haematocrit
- increase Q due to increase Fe demand (peripheral vasodilation)
- Hypercoagulable = increased risk of embolism
50
Name the 4 forces that determine fluid movement in/out of a capillary
Out of the capillary :
Capillary pressure
Interstitial fluid colloid oncotic pressure
Into the capillary :
Interstitial fluid pressure
Plasma colloid oncotic pressure (albumin)
51
Why is there an increased risk of UTIs in pregnancy
Kidney dilation
Decreased uretal tone and peristalsis = urinary stasis
52
What is the effect of delayed gastric emptying in pregnancy
Increased heartburn
Increased nutrient uptake
Increase water reabsorption May cause constipation
53
What is Chadwick’s Sign?
Early sign of pregnancy where the labia/cervix may appear blue due to increased blood flow
(6-8 weeks it is visible)
54
HORMONES OF BIRTH
Describe the function of the following hormones at birth:
```
Oxytocin
Prolactin
Oestrogen
Progesterone
Beta-endorphins
Adrenaline
```
Oxytocin: induce onset & labour contractions
Prolactin: begin milk production in mammary glands
Oestrogen: inhibit progesterone and prepare smooth muscle for labour
Progesterone: aid cervical ripening
Beta-endorphins: natural pain relief
Adrenaline: energy for birth
55
What are the Mechanisms of Labour?
- Descent
- Flexion
- internal rotation
- crowning
- Extension
- Restitution / External Rotation
- Internal restitution of shoulders
- Lateral flexion
DFICERIL
56
How is haemolytic disease of a newborn caused?
Rhesus negative mother and rhesus positive father.
If the mothers negative blood crosses with the positive fetal blood the mother can make antibodies against the fetal red blood cells
57
Which antibodies can destroy the fetal red blood cells?
IgG antibodies can cross the placenta and start to destroy the fetal RBCs
58
What can haemolytic disease of a newborn cause for a baby?
- Anaemia
- jaundice
- Brain damage
- Fatal = miscarriage/ stillborn
59
MECHANISMS OF LABOUR
What is meant by the following term:
Internal rotation
when the babies head hits the pelvic floor, it turns straight again
(has to go through pelvis at an angle to fit!)
60
MECHANISMS OF LABOUR
What is meant by the following term
Crowning
When the head pokes out
61
MECHANISMS OF LABOUR
What is meant by the following term
internal restitution of the shoulders
When the head is out it will turn to left or the right;
shoulders will follow within pelvis
62
NORMAL LABOUR
Describe the third stage of labour
- Pushing out the placenta
- Physiological management due to increased blood loss
- 5-30mins
63
NORMAL LABOUR
Why may oxytocin be given in the 3rd stage of labour
- to create uterine contraction so that the placenta can separate
- prevent excessive blood loss/ postpartum haemorrhage
64
Where is Relaxin released from and what is its function in labour?
- released from placenta, membranes and lining of the uterus
- Softens ligaments and cartilage of the pelvis so that it can expand
softens (cervix, vaginal tissues, babies body, perineum)
65
Function of oxytocin in labour?
- Stimulates uterine contractions during orgasm and childbirth
- Triggers fetal ejection reflex when cervix fully dilated
- Contracts uterus post birth to deliver placenta and limit bleeding
66
Function of prostaglandins
ripens the cervix and causes it to begin process of thinning and opening
Stimulates uterine contractions
67
MALPRESENTATIONS
Describe a breech
SEARCH DIAGRAM FOR MALPRESENTATION APPEARANCES
commonest malpresentation diagnosed by ultrasound. Can be reversed by external cephalic version
68
What are the complications of an external cephalic version
- Placenta praevia
- APH
- ruptured membranes
69
MALPRESENTATIONS
Describe a face/brow presentation and the likely method of delivery
SEARCH DIAGRAM FOR MALPRESENTATION APPEARANCES
Face- head extends rather than flexes = FORCEPS delivery
Brow - head is between full flexion and extension= LSCS delivery
70
How is a transverse lie antenatally diagnosed
- ovoid uterus wider at the sides
- lower pole is empty
- head lies in one flank
- foetal heart heard in variable positions
71
In which malpresentation is there the highest risk of cord prolapse
Tranverse lie- if persists at 37 weeks and ECV fails = C-section
72
MALPRESENTATIONS
Describe an Occipitoposterior position
SEARCH DIAGRAM FOR MALPRESENTATION APPEARANCES
Posterior fontanelle found to lie in posterior quadrant of pelvis
labour is prolonged due to degree of rotation needed
some require INSTRUMENTAL/C-SECTION delivery
73
What is a Primary dysfunctional labour and what is the treatment
Most common in first labour this is likely due to insufficient uterine contractions.
Hydration, comfort and analgesia is the initial management + syntocinon infusion after ROM
74
What is secondary dysfunctional labour and what is the likely cause?
Labour progresses to full dilation and then stops.
Likely due to cephalopelvic disproportion (passenger or passge)
75
Management to a delay in the 1st stage?
Amniotomy (AROM)
Oxytocin (offer epidural)
76
Management to a delay in the 2nd stage?
Instrumental/ LSCS delivery
77
INDUCTION
Most common reasons for inducing labour?
- Prolonged pregnancy (70% induced after 41 weeks)
- Premature rupture of membranes and labour doesnt start
- Diabetic mother >38 weeks
- Rhesus incompatibility
78
INDUCTION
What is the bishop score?
score to assess whether induction is required
<5 = unlikely to start without induction
>9 = likely to start spontaneously
79
INDUCTION
Describe the 5 parts of the bishop score
- Cervical dilation (cm)
- Length of cervix (cm)
- Station of head (cm above ischial spines)
- Cervical consistency
- Position of cervix
80
INDUCTION
In the bishops score you can either get 0,1 or 2.
For each of the 5 parts state what would give a score of 0
- Cervical dilation (0cm)
- Length of cervix (>2cm)
- Station of head (3cm above ischial spines)
- Cervical consistency (firm)
- Position of cervix (posterior)
81
INDUCTION
In the bishops score you can either get 0,1 or 2.
For each of the 5 parts state what would give a score of 1
- Cervical dilation (1-2cm)
- Length of cervix (1-2cm)
- Station of head (2cm above ischial spines)
- Cervical consistency (medium)
- Position of cervix (middle)
82
INDUCTION
In the bishops score you can either get 0,1 or 2.
For each of the 5 parts state what would give a score of 2
- Cervical dilation (3-4cm)
- Length of cervix (<1cm)
- Station of head (1cm above ischial spines)
- Cervical consistency (soft)
- Position of cervix (anterior)
83
INDUCTION
What should be checked prior to induction?
- Lie and position of foetus
- volume of amniotic fluid
- tone of uterus
- ripeness of cervix (using bishops system)
84
INDUCTION
Contra-indications of induction?
- Severe degree of placenta praevia
- transverse fetal lie
- Severe cephalopelvic disproportion
- Cervix <4 on bishops score
85
INDUCTION
Induction procedure?
1) membrane sweep
2) Prostaglandin gel and pessary high in vagina
3) Amniotomy - ROM
4) Oxytocin/ Syntocinon (post ROM)
86
List types of labour pain relief
- Education (breathing, coping, birth partner)
- Transcutaneous electrical nerve stimulation (TENS)
- water birth (reduces need for regional anaesthesia)
- Entonox
- Narcotics (diamorphine/ pethidine)
- Pudendal nerve block S2,S3,S4 (for instrumental)
- Local anaesthesia (lidocaine before epsiotomy/ surturing vaginal tears)
- Epidural (regional- T10 to S5- normally inserted at L3-L4)
87
Describe a normal Cardiotography (CTG)
HR 110-160
Variability >5bpm
No decelerations
Accelerations present (reassuring feature as it shows baby moving)
88
Cardiotography (CTG)
Possible indications for a HR of >160
- Maternal pyrexia
- Chorioamnionitis
- Hypoxia
- Prematurity
89
Cardiotography (CTG)
Possible indications for a HR of <100
- Increased foetal vagal tone
| - Maternal beta blocker use
90
Cardiotography (CTG)
Possible indications for
loss of baseline variability (<5bpm)
- Prematurity
| - Hypoxia
91
Cardiotography (CTG)
Possible indications for early deceleration
usually innocuous- comes with normal contractions
92
Cardiotography (CTG)
Possible indications for late deceleration
foetal distress- asphyxia / placental insufficiency
93
Cardiotography (CTG)
Possible indications for variable decelerations
cord compression
94
Significance of meconium liquor on the pad?
Foetal distress, possible breech
95
What are the 3 types of breech presentation?
Frank breech
Complete breech
Footling breech
96
Describe a Frank breech
where the hips are flexed and the legs extended
97
Describe a complete breech
Hips and knees are flexed and the feet are below the level of the foetal buttocks
98
Describe a footling breech
Where one of both feet are presenting as the lowest part of the foetus (dangling legs)
99
Mos favourable position for vaginal delivery and why?
Occipito-anterior. this allows for the smallest diameter to come through the pelvis
100
3. Which breech presentation is associated with highest-risk of cord prolapse?
Footling breech
There is nothing to act as a plug over the cervix if the membranes rupture. This is also the case with transverse or oblique lies.
101
the mentovertical diameter is associated with what presentation
brow
102
The usual position of the head at engagement
Occipito transverse
103
The presenting diameter is submento-bregmatic what does this mean?
Face presentation
104
The presenting diameter is submento-bregmatic what does this mean?
Face presentation
105
HYPEREMESIS GRAVIDARUM
What is it?
Persistent pregnancy-related vomiting associated with weight loss (5% body mass) and ketosis
106
HYPEREMESIS GRAVIDARUM
Triad?
>5% weight loss
Electrolyte imbalance
Dehydration
107
HYPEREMESIS GRAVIDARUM
Management?
mild: avoid large volume drinks, small carb meals
```
Severe:
Anti-emetics
IV fluids
thromboprophylaxis
Thiamine supplements
```
108
give 3 types of anti-emetics and an example drug for each type
Dopamine antagonist:
Metoclopramide
Phenothiazines: Prochloperazine
5HT selective serotonin antagonists: Ondansetron
109
PUERPERAL PYREXIA
What is it?
A temperature of >38 degrees in the first 14 days following delivery
110
PUERPERAL PYREXIA
Causes?
- Endometritis
- UTI
- Mastitis
- VTE
111
PUERPERAL PYREXIA
Management?
If endometritis suspected the patient should be referred to hospital for IV Abx (clindamycin and gentamycin) until afebrile for greater than 24hrs
112
What is the leading cause of morbidity and mortality in pregnancy in developed countries?
VTE-
preventable (includes DVT of legs, pelvis and PE)
113
VTE IN PREGNANCY
When should you have a VTE risk assessment?
- Booking
- Antenatal admission
- Labour
- Postnatally
114
VTE IN PREGNANCY
Risk factors?
Modifiable and non modifiable
Non-Modifiable:
BMI >30
Immobility
Smoking
Family Hx of VTE
Age >35
Gross varicose veins
Pre-eclampsia
IVF
Multiple pregnancy
Parity >3
115
VTE IN PREGNANCY
Indications for LMWH thromboprophylaxis?
+ compression stockings and early mobilisation
If the women has any risk factors
If a women requires antenatal LMWH, this must be given until 6 weeks postpartum
116
How many more times common are DVTs than PEs and what percentage of DVTs lead to PE?
DVT 3x more common
16% of DVTs lead to PE in untreated patients
117
VTE IN PREGNANCY
Symptoms of DVT
- Leg swelling
- Pain
- Redness
- Pitting oedema
- Distended veins
118
VTE IN PREGNANCY
Symptoms of PE
- SOB
- Pleuritic chest pain
- Haemoptysis
- Tachycardia
Severe: cyanosis, increased JVP
119
If a pregnant/postpartum lady collapses what should you presume
PE
120
VTE IN PREGNANCY
Investigations?
FBC, U&E, LFTs, clotting screen
D-dimer
PE-
ABG - Type 1 respiratory failure (O2 <8kPa)
ECG- (inverted T in V1-V6 and RBBB)
CXR
121
VTE IN PREGNANCY
Imaging investigation?
PE and DVT
DVT: Compression or duplex US of deep veins
PE: CXR and duplex US of deep veins (can assume PE if positive alongside respiratory symptoms)
122
VTE IN PREGNANCY
Treatment?
should start as soon as clinical suspicion and only stopped once ruled out.
LMWH.
Dalteparin
Warfarin/ NOAC
123
VTE IN PREGNANCY
How do you monitor dosage of treatment and how does treatment work?
Anti-Xa
- Activation of anti-thrombin III which inhibits factor Xa and stops coagulation cascade
124
Gold standard imaging of PE?
CTPA - CT pulmonary angiogram
125
ANAEMIA IN PREGNANCY
Definition?
Hb <105g/L.
The fall in Hb is steepest around 20 weeks gestation
126
ANAEMIA IN PREGNANCY
Risk factors?
- Menorrhagia/Malaria/hookworm
- Frequent pregnancies
- twins
- Poor diet
127
ANAEMIA IN PREGNANCY
Investigations?
- Hb estimation at 28 weeks antenatally, test for sickle cell in black patients
- Serum iron, TIBC and serum ferritin are low in Fe deficiency
128
ANAEMIA IN PREGNANCY
causes?
Commonest- Iron deficiency
- Folate deficiency
129
ANAEMIA IN PREGNANCY
Treatment?
Oral iron. once every 2/3 days
130
GROUP B STREP INFECTION
Risk factors?
- Prematurity
- Prolonged ROM
- Previous GBS sibling
- Maternal pyrexia
131
GROUP B STREP INFECTION
IF a patient is isolated during labour what should be given?
IV benzyl Penicillin to reduce neonatal transmission
132
GROUP B STREP INFECTION
Features of Chorioamnionitis?
- Fevers
- Lower abdo tenderness
- foul discharge
- Maternal/foetal tachycardia
133
Symptoms of measles?
- Fever
- Generalised maculopapular erythematous rash
- Koplik's spots
- Cough
- Coryza
134
Features of Rubella?
Cataracts 8-9 weeks
Deafness 5-7 weeks
Cardiac lesions 5-10 weeks
- Cerebral Palsy
135
Congenital defects associated with Cytomegalovirus?
- IUGR
- Microcephaly
- Hepatosplenoegaly
- Jaundice
- Chorioretinitis
LATER = motor and cognitive impairment
136
Symptoms and treatment of Toxoplasmosis
Similar to glandular fever (fever, rash, eosinophilia)
FLU LIKE
Caused by raw meat/ cat faeces
Tx= Pyrimethamine + Sulphadiazine + Spiramycin
137
What should you give to a mother with Hepatitis B?
all mothers should be screened.
- Give immunoglobulin and vaccinate babies of carriers and infected mothers at birth
138
If mother develops Varicella Zoster (Chickenpox) near delivery what should be done to the baby?
give varicella immune immunoglobulin at birth and monitor for 28 days
Treat with ACICLOVIR if neonate develops chickenpox
139
Signs of Parvovirus B19?
often no symtpoms but slapped cheek syndrome may occur
140
JAUNDICE
Investigations?
LFTs
Urine dip- bile
Serology
HBsAG (Hep B surface Antigen)
Get expert help PROMPTLY- can be lethal
141
Features of Obsteteric Cholestasis?
- Jaundice
- Pruritis (palms and soles)
- Worse at night
- raised bilirubin
142
Management of Obstetric Cholestasis?
Ursodeoxycholic acid
Weekly LFTs
Induced at 37 weeks typically
143
Complications of Obstetric Cholestasis
- Stillbirths
| - Preterm labour, meconium, foetal distress
144
In which trimester is Intrahepatic cholestasis and acute fatty liver of pregnancy generally seen?
3rd trimester
145
features of Acute fatty liver of pregnancy?
- Jaundice
- Abdominal pain
- Pre-eclampsia (30-60%)
- Hypoglycaemia
non specific- Malaise, fatigue, nausea, headache
146
ECTOPIC PREGNANCY
What is it?
A pregnancy that occurs anywhere outside the uterus
| 97% in fallopian tubes
147
ECTOPIC PREGNANCY
What is the most common place for an ectopic pregnancy
Ampulla of Fallopian tube
| isthmic after
148
ECTOPIC PREGNANCY
Risk factors?
- IVF
- Age
- PID
- previous ectopic
- smoking
- progesterone only pill
- Endometriosis
149
ECTOPIC PREGNANCY
Clinical presentation?
Symptoms:
- Amenorrhoea (missed period for 6-8 weeks)
- Vaginal bleeding
- dizzy, fainting
Signs:
Abdo pain/tenderness
Shoulder tip pain
Possible haemoperitoneum
150
ECTOPIC PREGNANCY
Ddx?
- threatened miscarriage
- Appendicitis
- Bowel Ischaemia
151
ECTOPIC PREGNANCY
Diagnostic tests?
- Transvaginal USS
| - Empty uterus & positive pregnancy test
152
ECTOPIC PREGNANCY
Medical treatment?
If no complications= single dose methotrexate (no haemoperitoneum on TVS)
- FBC
- IV fluids
153
ECTOPIC PREGNANCY
Surgical treatment?
- Salpingectomy
| - Salpingotomy
154
Side effects of Methotrexate?
- Conjunctivitis
- Stomatitis
- Diarrhoea
- Abdominal pain
155
MOLAR PREGNANCY
What is it?
Non-viable fertilised egg= implants into uterus -> will not come to term
156
MOLAR PREGNANCY
What is a complete molar pregnancy?
- empty oocyte is fertilised
Sperm + empty egg
no foetal tissue
157
MOLAR PREGNANCY
What is a partial molar pregnancy?
- Triploid
2 sperm + 1 egg
some foetal tissue recognisable
158
MOLAR PREGNANCY
What is an invasive mole?
When a complete mole invades the moymetrium
159
MOLAR PREGNANCY
Risk factor?
```
Age <16 or >45
Previous molar
Multiple pregnancies
Oral contraceptive
Asian
Menarche >12
```
160
MOLAR PREGNANCY
Malignant complications?
Choriocarcinoma (2-3%)
| Placental site trophoblastic tumours
161
MOLAR PREGNANCY
Clinical presentation
- Vaginal bleeding
- very high hCG levels
- Large uterus
- Pre-eclampsia
- Unexplained anaemia
162
MOLAR PREGNANCY
Diagnostic tests and results?
- Urine and blood levels very high bhCG
- histology
- USS 'snowstorm appearance' in 2nd trimester + Large
163
MOLAR PREGNANCY
Treatment?
Uterine evacuation
Suction curettage
- Urgent referral to specialist centre
- No pregnancy until hCG levels have been normal for 6 months- give effective contraception
164
MOLAR PREGNANCY
What is given if the hCG is >20,000
Chemo - Cisplatin
165
MISCARRIAGE
Definition?
The loss of pregnancy before 24 weeks gestation
| doesn't include ectopic or trophoblastic disease
166
MISCARRIAGE
What is a complete miscarriage
TVUS shows crown rump length >7mm
gestational sack >25mm
no foetal heartbeat
167
What is meant by crown rump length
Crown-rump length (CRL) is the measurement of the length of human embryos and fetuses from the top of the head (crown) to the bottom of the buttocks (rump). It is typically determined from ultrasound imagery and can be used to estimate gestational age.
168
MISCARRIAGE
What is a threatened miscarriage?
Mild symptoms of bleeding with little or no pain,
cervical os is closed
169
MISCARRIAGE
What is an Inevitable miscarriage?
Heavy bleeding with clots and pain,
cervical os is open.
the pregnancy will not continue, proceed to complete/incomplete miscarriage
170
MISCARRIAGE
What is an incomplete miscarriage
Occurs when the products of conception are partially expelled.
Cervical os open.
Pain + vaginal bleeding
171
MISCARRIAGE
What is a missed miscarriage?
foetus is dead but retained.
Uterus is small for dates
Pregnancy test can remain positive for several weeks.
History of threatened miscarriage with PERSISTENT DIRTY BROWN DISCHARGE
Closed os
172
MISCARRIAGE
What is recurrent miscarriage?
Three or more consecutive miscarriages
173
MISCARRIAGE
Causes?
```
Abnormality to:
foetal development
cervix
uterus
Placenta
```
PCOS
Previous miscarriage
BV infection
174
MISCARRIAGE
risk factors?
```
Age >30
Smoking >14 a day
Excess alcohol
Drug use
Uterine surgery
Uncontrolled DM
```
Incidence increases with parity
175
MISCARRIAGE
Epidemiology?
15-20% of recognised pregnancies
85% in first trimester
176
MISCARRIAGE
Clinical presentation?
Vaginal bleeding with/without abdominal pain
Cervical os is open enough to admit one finger
uterine size small for dates
Passing products of conception
177
MISCARRIAGE
Ddx?
- Ectopic pregnancy
- Neoplasia
- Hydatiform mole
- Chorionic cyst
- Sub chorionic haemorrhage
178
MISCARRIAGE
Diagnostic tests and results?
transvaginal USS
Serium hCG (to exclude ectopic)
179
MISCARRIAGE
Medical treatment before 12 weeks?
<12 weeks :
Mifepristone (antiprogesterone to prime cervix) THEN
Misoprostol 36-48hrs later
180
MISCARRIAGE
Medical treatment after 12 weeks?
Vaginal misoprostol
| bleeding may continue for 3 weeks following medical treatment
181
MISCARRIAGE
Surgical treatment?
Suction evacuation under GA if under 13 weeks
182
MISCARRIAGE
Causes for recurrent miscarriages?
APS/ DM/ thyroid disorders/ PCOS
Smoking
Uterine abnormality (uterine septum e.g.)
183
Under what circumstances can a termination of pregnancy occur after 24 weeks?
- Risk to mothers life
| - Substantial risk that if the baby was born it would be seriously handicapped
184
How is a termination of pregnancy carried out surgically?
Vacuum aspiration (adminster misoprostol before surgery to prepare cervix)
185
How is a termination of pregnancy carried out medically?
regimes of Mifepristone- to prime CERVIX
then Misoprostol (prostaglandin)
186
PRE-ECLAMPSIA
What is it?
pregnany induced hypertension in association with:
- Proteinuria (>0.3g in 24hrs)
with or without oedema
187
PRE-ECLAMPSIA
How is severe pre-eclampsia defined?
diastolic BP of 110 +
systolic BP of 160
AND symptoms/haemotological/biochemical impairment
188
PRE-ECLAMPSIA
What may happen to the foetus in severe pre-eclampsia
Foetus may have neurological damage due to hypoxia
189
PRE-ECLAMPSIA
Describe the two stages of pre-eclampsia
Stage 1: incomplete trophoblastic invasion of spiral arterioles = decreased uteroplacental blood flow
Stage 2 : Ischaemic placenta induces endothelial cell damage which leads to vaso-constriction, clotting dysfunction and increased vascular permeability
190
PRE-ECLAMPSIA
What are the high risk factors? and what should be done in response?
- Pre-eclampsia/HTN in previous pregnancy
- CKD
- Autoimmune disease (SLE, Antiphospholipid syndrome)
- DM 1/2
START ON ASPIRIN AT 12 WEEKS
191
PRE-ECLAMPSIA
What are the moderate risk factors? and what should be done in response?
- 10 years since last pregnancy
- first pregnancy
- >40 years or more
- BMI over 25
- Family history of pre-eclampsia
192
When may a dilation and curettage procedure be performed?
incomplete miscarriage,
retained placenta after delivery,
an elective abortion.
193
Diagnosis and treatment of Asherman's Syndrome?
Hysterscopy
USS
Hysterosalpingogram (HSG- dye inserted)
Tx= Operative hysterscopy + Abx to prevent infection + oestrogen to improve quality of uterine lining
194
Diagnosis and treatment of Asherman's Syndrome?
Hysterscopy
USS
Hysterosalpingogram (HSG- dye inserted)
Tx= Operative hysterscopy + Abx to prevent infection + oestrogen to improve quality of uterine lining
195
PRE-ECLAMPSIA
Clinical presentation?
New hypertension 140/90
Late signs:
- Severe headache
- Visual disturbances
- Swelling of face/hands/feet
- Liver tenderness/RUQ pain
- vomiting
HELLP syndrome
Small for gestational age infant
196
PRE-ECLAMPSIA
Diagnostic tests?
Urinalysis - Dipstick for proteinuria
No proteinuria =Gestational pre-eclampsia
HTN
Frequent monitoring of FBC, LFTs, Renal function
197
PRE-ECLAMPSIA
Why would you do a urine culture
Exclude infection
198
PRE-ECLAMPSIA
Why would you do an USS of foetus
CHECK:
- Foetal growth
- Volume of amniotic fluid
- Doppler velocimetry of umbilical arteries
199
PRE-ECLAMPSIA
How is mild pre-eclampsia defined and what is the treatment?
140-149/90-99
- Monitor BP 4 times a day
- blood tests 2 times a week
200
PRE-ECLAMPSIA
How is severe pre-eclampsia defined and what is the treatment?
>160/110
- Monitor BP 4 times a day
- blood tests 2 times a week
Start antihypertensive e.g Labetolol
Magnesium sulphate to reduce risk of eclampsia
201
PRE-ECLAMPSIA
How is moderate pre-eclampsia defined and what is the treatment?
150-159/100-109
- Monitor BP 4 times a day
- blood tests 2 times a week
Start antihypertensive e.g Labetolol
202
PRE-ECLAMPSIA
What antihypertensives should be avoideed?
ACE inhibitors
Angiotensin-II receptor antagonists
203
PRE-ECLAMPSIA
What antihypertensives should be avoideed?
ACE inhibitors
Angiotensin-II receptor antagonists
204
PRE-ECLAMPSIA
What further monitoring should be done?
USS of foetus and amniotic fluid
CTG
Delivery once woman is stable and baby >34 weeks
205
PRE-ECLAMPSIA
Maternal complications?
Cerebrovascular haemorrhage
HELLP syndrome
Liver/renal failure
Pulmonary oedema
206
PRE-ECLAMPSIA
Foetal complications?
IUGR
Placental abruption
Preterm birth
207
Definiton of ECLAMPSIA?
Onset of convulsion in a pregnancy complicated with pre-eclampsia
208
Why does Eclampsia occur and when can it happen?
Failure to notice worsening pre-eclampsia
Can occur antepartum, intrapartum and postpartum
209
Treatment of ECLAMPSIA
Control fits: Magnesium sulphate
Control BP: IV Labetolol, nifidepine, Epidural analgesia during labour
210
Why is Magnesium sulphate used in Eclampsia treatment
- Suppresses convulsions and inhibits muscular activity
| - Reduces DIC risk as it reduces platelet aggregation
211
What should be monitored if using magnesium sulphate
Magnesium levels: Can cause reduced reflexes and respiratory depression
212
What should be monitored if using magnesium sulphate
Magnesium levels: Can cause reduced reflexes and respiratory depression
213
HELLP SYNDROME
What is it?
A complication of pregnancy which usually present in women who have pre-eclampsi or eclampsia
214
HELLP SYNDROME
What is it characterised by?
- Haemolysis
- Elevated liver enzymes
- Low platelet count
215
HELLP SYNDROME
What do affected women show
Signs of liver damage and abnormalities of blood clotting
216
HELLP SYNDROME
Risk factors?
```
Age >35
nulliparity
previous hx of HELLP, pre-eclampsia
Renal Disease/ DM
Afro- carib
Obese
HTN
```
217
HELLP SYNDROME
What do 10.5% of HELLP syndrome patients have?
Antiphospholipid syndrome
218
HELLP SYNDROME
when do symptoms present?
70% before pregnancy 27-37 weeks
30% post partum
219
HELLP SYNDROME
Symptoms?
Usually non specific: Malaise, fatigue, RUQ/epigastric pain, flu-like
Headache and visual symptoms
Bruising/purpura
Oedema/hypertension/proteinuria
Jaundice
220
HELLP SYNDROME
When do symptoms get worse / better?
Worse at night
better during the day
221
HELLP SYNDROME
Ddx?
- Acute fatty liver of Pregnancy
- thrombotic thrombocytopenic purpura (TTP)
- Immune thrombocytopenia (ITP)
- Haemolytic uraemic syndrome
- Acute exacerbation of SLE
- Viral hepatitis
- Cholangitis
222
HELLP SYNDROME
Diagnostic tests and results
- haemolysis with fragmented red cells on blood film
- riased LDH with raised bilirubin
- Raised liver enzymes
- low platelets
223
HELLP SYNDROME
Treatment?
- Delivery of foetus
- Magnesium sulphate
- blood transfusion
- Control BP
224
HELLP SYNDROME
Symptoms?
Usually non specific: Malaise, fatigue, RUQ/epigastric pain, flu-like
Headache and visual symptoms
Bruising/purpura
Oedema/hypertension/proteinuria
Jaundice
225
HELLP SYNDROME
When do symptoms get worse better?
Worse at night
better during the day
226
HELLP SYNDROME
Why are fragmented red cells seen on blood film?
Microangiopathic haemolytic anaemia
227
INTRAUTERINE GROWTH RETARDATION (IUGR)
What is it?
When a baby’s growth slows or ceases when it is in the uterus
228
INTRAUTERINE GROWTH RETARDATION (IUGR)
What are the contributing factors/ causes?
- Maternal factors
- Placental factors
- Foetal factors
- Genetic factors
229
INTRAUTERINE GROWTH RETARDATION (IUGR)
Name some maternal factors
```
Age >40
Smoker
cocaine use
previous SGA baby
Diabetes
Antiphospholipid
HTN
```
230
INTRAUTERINE GROWTH RETARDATION (IUGR)
Name some placental factors
Abnormal trophoblastic implantation e.g pre-eclampsia
Placental dysfunction
placental abruption
231
INTRAUTERINE GROWTH RETARDATION (IUGR)
Name some foetal factors
Genetic abnormalities:
Trisomy 13,18,21
Turner's
Congential heart disease
232
INTRAUTERINE GROWTH RETARDATION (IUGR)
Name some genetic factors
Placental genes
Foetal genes
Materna; genes
233
What is Trisomy 18
Edwards Syndrome
234
What is Trisomy 13
Patau Syndrome (most die within 7-10 days)
235
INTRAUTERINE GROWTH RETARDATION (IUGR)
Name some high risk factors?
```
S moking
H ypertension
I UGR previously
T wins
S till birth
```
SHITS
236
INTRAUTERINE GROWTH RETARDATION (IUGR)
Name some rarer high risk factors?
C ocaine
R enal disease
A ntiphospholipid syndrome
P APP-A levels low
CRAP
237
INTRAUTERINE GROWTH RETARDATION (IUGR)
Describe symmetrical IUGR
cause of IUGR EARLIER in pregnancy
Antenatally: small head, abdomen and foetal length
Postnatally: weight, length and head circumference all reduced
238
INTRAUTERINE GROWTH RETARDATION (IUGR)
Describe asymmetrical IUGR
cause of IUGR LATER in pregnancy
Antenatally: small abdominal circumference but head and femur length normal
Postnatally: reduced weight but length and head circumference normal
239
INTRAUTERINE GROWTH RETARDATION (IUGR)
List some long term complications
- Lower scores on cognitive tests
- Learning difficulties
- Developmental delay
- ADHD
- Poor perceptual performance
- CEREBRAL PALSY
240
INTRAUTERINE GROWTH RETARDATION (IUGR)
What adult onset diseases will the baby be more susceptible too
- Diabetes
- Hypertension
- Obesity
- Metabolic syndrome
- CHD
241
INTRAUTERINE GROWTH RETARDATION (IUGR)
Diagnostic tests and results
- Foetal abdominal circumference or estimated foetal weight <10th centile
- Reduced Amniotic Fluid Index (AFI)
242
INTRAUTERINE GROWTH RETARDATION (IUGR)
How is a reduced Amniotic Fluid Index (AFI) caused
1) Reduced O2 to baby leads to redistribution of blood away from organs e.g. kidneys
2) reduced urine output and smaller amniotic fluid volume
243
SEPSIS
What is it?
Infection + systemic manifestations of infection
244
INTRAUTERINE GROWTH RETARDATION (IUGR)
Treatment?
- LSCS
Offer corticosterioids- Lung development up to 35+6
245
SEPSIS
What is severe Sepsis?
Sepsis with sepsis-induced organ dysfunction or evidence of tissue hypo-perfusion
246
SEPSIS
What is Septic shock
Persistent tissue hypo-perfusion despite adequate fluid replacement
247
SEPSIS
Causes?
- Pyelonephritis
- Chorioamnionitis
- Postpartum endometritis
- Wound infection
- Pneumonia
- Acute appendicitis
- Acute cholecystitis
- Pancreatitis
- Necrotising enterocolitis
248
SEPSIS
Risk factors?
- Obesity
- Diabetes
- Impaired immunity/immunosuppressant medication
- Anaemia
- Vaginal discharge
- History of pelvic infection
- History of group B streptococcal infection
- Amniocentesis and other invasive procedures
- Cervical cerclage
- Prolonged spontaneous rupture of membranes
- Group A strep infection in close contacts / family members
249
SEPSIS
Signs and symptoms?
- Fever, rigors, diarrhoea, vomiting
- Rash
- Abdominal + pelvic pain
- Hypoxia
- Hypotension
- Oliguria
- Impaired consciousness
- Failure to respond to treatment
250
SEPSIS
Describe 3Ts white with Sugar to describe Sepsis clinical signs
SIRS CRITERIA:
Temperature >38 or <36
Tachycardia >90bpm
Tachypnoea >20bpm
WBC <4 or >12
Sugar >7.7 in absence of diabetes
251
SEPSIS
Management? (involve experts early)
```
Blood cultures
Urine output
Fluid resuscitation
Antibiotics (broad spec IV)
Lactate, Hb, Glucose
Oxygen
```
+2 -
Consider delivery and VTE prophylaxis
252
CHORIOAMNIONITIS
What is it and why is it caused?
Acute inflammation of amnion and chorion membranes due to ascending bacterial infection in setting of membrane rupture
253
CHORIOAMNIONITIS
Clinical features and management?
- Uterine tenderness
- ROM
- Foul odour of amniotic fluid
- Maternal signs (pyrexia, tachycardia, leucocytosis)
Management- C-section delivery & IV Abx
254
PREMATURE BIRTH
Definiton?
Presence of contractions of sufficient strength and frequency to effect progressive effacement and dilation of the cervix before 37 weeks gestation
255
PREMATURE BIRTH
Risk factors?
```
30% unexplained
30% multiple pregnancy
- Cervical incompetence (e.g. surgery)
- Previous preterm/ miscarriage after 14weeks
- Preterm prelabour rupture of membranes
```
256
PREMATURE BIRTH
How many births take place before 32 weeks gestation?
1.4% of U.K births but this 1.4% accounts for 51% of infant deaths
257
PREMATURE BIRTH
Clinical presentation?
- Contractions
- Bleeding or amniotic fluid loss
- Dilation of cervix
258
PREMATURE BIRTH
Diagnostic tests and results?
Screening & +ve risk factors
- transvaginal USS - measurement of cervical
length
- Vaginal swab
259
PREMATURE BIRTH
Treatment?
TOCOLYTICS
- Corticosteroids
- Magnesium sulfate
- Cervical stitch
- Delivery
260
PREMATURE BIRTH
What is tocolysis and give some examples
Drugs that delay delivery up to 48 hours
Prostaglandin synthesis inhibitors- Indomethacin
CCBs- Nifedipine
Atosiban if cant use CCB
261
PREMATURE BIRTH
Why are corticosteroids used?
Give examples
To help with foetal surfactant production
Betamethasone
Dexamethasone
262
PREMATURE BIRTH
Why is magnesium sulfate used?
For neuroprotection
Reduced risk of cerebral palsy
263
PREMATURE RUPTURE OF MEMBRANES
What is it?
Rupture of mebranrd <37 weeks
264
PREMATURE RUPTURE OF MEMBRANES
What are the risks?
Risk of serious infection.
After 24 hours = chorioamnionitis + endometriosis
60% will go into spontaneous labour
265
PREMATURE RUPTURE OF MEMBRANES
What is the treatment for mid-trimester PROM <24 weeks
Normally poor outcome- pulmonary hypoplasia even after steroids
266
PREMATURE RUPTURE OF MEMBRANES
What is the treatment for 24-34 weeks gestation PROM
Maternal Steroids- Dexamethasone
Erythromycin
Daily review for signs of infection
267
PREMATURE RUPTURE OF MEMBRANES
What is the treatment for >34 weeks gestation
Induce labour
268
ANTEPARTUM HAEMORRHAGE
What is it?
Bleeding from the birth canal after 24 weeks gestation (before is a miscarriage)
269
ANTEPARTUM HAEMORRHAGE
Causes?
- 50% idiopathic
Placenta praevia (low lying placenta)
Placental abruption
Vasa praevia
Lower genital tract causes:
Cervical polyps/erosions/ carcinoma
Cervicitis/Vaginitis
270
ANTEPARTUM HAEMORRHAGE
Epidemiology?
3-5% of all pregnancies
Up to 20% of very preterm babies are born in association with APH
271
ANTEPARTUM HAEMORRHAGE
Clinical signs and symptoms
- Bleeding with/without pain
- Uterine contractions
- Malpresentation or failure for foetal head to engage
- Foetal distrss
- Signs of hypovolaemic shock
272
ANTEPARTUM HAEMORRHAGE
Diagnostic tests and results
Exclude placenta praevia with USS
273
ANTEPARTUM HAEMORRHAGE
Treatment
Anti-D
Replacement fluids/blood
IV access
CTG
Delivery may save mothers life
274
PLACENTAL ABRUPTION
What is it?
Premature seperation of placenta from the uterus
Significant cause of third-trimester bleeding associated with foetal and maternal morbidity and mortality
275
PLACENTAL ABRUPTION
Cause?
- Maternal hypertension (common)
- Maternal trauma
- Smoking,alcohol,drugs
- Short umbilical cord
- decompression of the uterus
276
PLACENTAL ABRUPTION
Risk factors?
- Smoking
- Previous abruption
- HTN/ pre-eclampsia
- Thrombophilia
- Cocaine
- Trauma
277
PLACENTAL ABRUPTION
Clinical presentation?
- Pain
- DARK red vaginal bleeding
- uterine contractions
- Foetal distress
278
PLACENTAL ABRUPTION
What is meant by a woody uterus
'Hard' uterus due to blood invading myometrium
279
PLACENTA PRAEVIA
What is it?
When the placenta is inserted wholly or in part into the lower segment of the uterus
280
PLACENTA PRAEVIA
Risk factors?
- Previous placenta praevia/ C-section / abortion
- Increased maternal age/ parity
- Smoking/ Cocaine
- Deficient endometrium
- Assisted conception
281
PLACENTA PRAEVIA
What is the pathophysiology of Major/Minor placenta praevia
Major: Placenta covers the entire internal os of the cervix (grade 3/4)
Minor/Partial: If the leading edge is in the lower segment but not covering the os (grade 1/2)
282
PLACENTA PRAEVIA
Clinical Presentation?
Painless bleeding after the 28th week
BRIGHT RED BLEEDING
- High presenting part or abnormal lie
283
Methods of assisted conception?
intrauterine insemination (IUI)
in vitro fertilisation (IVF).
284
What is Vasa Praevia and what are the risks?
when fetal blood vessels cross or run near the internal opening of the uterus. These vessels are at risk of rupture when the supporting membranes rupture, as they are unsupported by the umbilical cord or placental tissue
285
PLACENTA PRAEVIA
Complications?
PPH
Placenta accreta or percreta
286
What is Vasa Praevia and what are the risks?
when fetal blood vessels cross or run near the internal opening of the uterus. These vessels are at risk of rupture when the supporting membranes rupture, as they are unsupported by the umbilical cord or placental tissue
287
PLACENTA PRAEVIA
How is a placenta defined 'low lying'
IF within 2cm of the cervix before 26 weeks
288
Difference in blood between placenta abruption and praevia?
Abruption tends to be darker red
Praevia tends to be bright red
289
Difference in blood between placenta abruption and praevia?
Abruption tends to be darker red
Praevia tends to be bright red
290
What is Placenta Accreta?
chorionic villi attach to the myometrium,
| rather than being restricted within the decidua basalis
291
What is Placenta Increta?
Chorionic villi invade the myometrium
292
What is Placenta Percreta?
Chorionic villi invades THROUGH the myometrium
293
How to prepare for delivery with Placenta praevia and accreta
Elective LSCS 36-38 weeks
Consent to include all potential interventions including
hysterectomy
Consultant obstetric/anaesthetic input
Anticipate major obstetric haemorrhage
Blood available + consider cell salvage
Ensure critical care bed available
294
POSTPARTUM HAEMORRHAGE (PPH)
What is a primary PPH?
Bleeding from the genital tract in excess of 500mls in the first 24 hours after delivery of the baby
295
POSTPARTUM HAEMORRHAGE (PPH)
What is a secondary PPH?
Abnormal vaginal bleeding any time between 24 hours and 6 weeks
296
POSTPARTUM HAEMORRHAGE (PPH)
What is a minor PPH
Estimated blood loss >500mls but less than 1500 and no signs of shock
297
POSTPARTUM HAEMORRHAGE (PPH)
What is a major PPH
Estimated blood loss of 1500mls or moreand continuing to bleed OR clinical shock
298
POSTPARTUM HAEMORRHAGE (PPH)
Causes?
4 Ts
Tone (70%) - atonic uterus
Tissue (10%) - Retained placenta with prolonged 3rd stage
Trauma (20%) - tears and repairs
Thrombin (<1%) - pre-eclampsia/ DIC
299
POSTPARTUM HAEMORRHAGE (PPH)
Risk factors?
Past history of postpartum haemorrhage
Grand multiparity
Maternal age >40 years
Multiple pregnancy
Polyhydramnios
Abruption Placenta praevia
Pre-eclampsia/gestational hypertension
BMI>35
Pre-existing anaemia
Operative Delivery (LSCS or instrumental)
Induction of labour
Retained placenta
Big baby
Pyrexia in labour
Prolonged labour
Fibroids
300
POSTPARTUM HAEMORRHAGE (PPH)
Prophylaxis?
IM Oxytocin = given with delivery of anterior shoulder
If significant RFs (+ no HTN) then consider adding: Ergometrine
301
POSTPARTUM HAEMORRHAGE (PPH)
Medical Treatment?
Fluid Resus + ABC, O2
IV Oxytocin or Ergometrine
Misoprostol
IM Carboprost
(Consider theatre if > 2 doses required)
IV Tranexamic acid
302
POSTPARTUM HAEMORRHAGE (PPH)
Surgical treatment?
Evacuation of retained products
Bi-manual uterine compression to expel clots (massage and compress)
Balloon tamponade
B-lynch suture
Consider hysterectomy
303
POSTPARTUM HAEMORRHAGE (PPH)
When must you never give Ergometrine?
if the patient has hypertension (vasoconstrictor)
304
What are the seven cardinal movements?
- Engagement
- Descent
- Flexion
- Internal rotation
- Extension
- External rotation/ restitution
- Expulsion
EDFIEEE
305
Describe Engagement
| Cardinal Movement 1
Entering the biparietal diameter (ear tip to ear tip across the top of baby's head) into the pelvic inlet
306
Describe Descent
| Cardinal Movement 2
Baby's head deep into the pelvic cavity (Lightening)
When the occiput is at the level of the ischial spines it can be assumed that the biparietal diameter is engaged and then descends into the pelvic inlet
307
Describe Flexion
| Cardinal Movement 3
- Occurs during descent, the resistance from the tissues of the pelvis brings about flexion to the baby's head
- Smallest diameter of the baby's head presents into the pelvis
308
Describe Internal Rotation
| Cardinal Movement 4
Head rotates to accomodate the changes of pelvic diameter because:
Pelvic inlet: diameter widest from right to left
Pelvic outlet: diameter widest from front to back
Therefore baby must go from sideways to facing back of the mother (back of head against the front of the pelvis)
309
Describe Extension
| Cardinal Movement 5
After internal rotation extension occurs as the head is born
310
Describe External Rotation
| Cardinal Movement 6
- Slight pause in labour after the baby's head is born
| - Babies head must rotate from face down to facing one of the mothers inner thigh
311
Describe Expulsion
| Cardinal Movement 7
Immediately after external rotation, the anterior shoulder moves out from under the symphysis pubis.
The perineum become distended by the posterior shoulder which is then also born, followed by the rest of the body.
(upward motion by midwife)
312
What is the largest diameter of the pelvic outlet?
Front to back
313
Describe internal rotation
baby moves from a sideways position (inlet) to one where the sagittal suture is in the anteropsoterior diameter of the outlet
314
Describe internal rotation
baby moves from a sideways position (inlet) to one where the sagittal suture is in the anteropsoterior diameter of the outlet
315
Why is external rotation necessary
'Restitution' is necessary for the shoulders to fit around and under the pubic arch
316
Why is external rotation necessary
'Restitution' is necessary for the shoulders to fit around and under the pubic arch
317
What happens if external rotation is not successful
Shoulder Dystocia
318
SHOULDER DYSTOCIA
What is it?
When the baby's shoulders are halted at the pelvic outlet due to inadequate space through to which to pass
- Usually the anterior shoulder which impacts on the maternal symphysis
319
SHOULDER DYSTOCIA
What is it?
When the baby's shoulders are halted at the pelvic outlet due to inadequate space through to which to pass
- Usually the anterior shoulder which impacts on the maternal symphysis
320
SHOULDER DYSTOCIA
Cause?
3 Ps
Power (uterus)
Passenger (foetus)
Passage (pelvis)
321
SHOULDER DYSTOCIA
Uterine causal factors?
- Uncoordinated uterine activity/ short infrequent contractions.
Oxytocin can enhance and co-ordinate uterine contractions
322
SHOULDER DYSTOCIA
Foetal causal factors?
- Position or lie
- Macrosomia (>4.5kg)
Large AC compared to HC ratio
(AC= abdominal circumference, HC = head circumference)
323
SHOULDER DYSTOCIA
Pelvic passage causal factors?
- Long and oval brim
| - Scoliosis, kyphosis and rickets can lead to cephalopelvic disproportion
324
SHOULDER DYSTOCIA
Risk factors?
- Diabetes
- Macrosomia
- Obesity
- Induction of labour
- Assisted vaginal delivery (forceps/vacuum)
- Oxytocin use
- Prolonged labour
- Previous shoulder dystocia
325
SHOULDER DYSTOCIA
Clinical presentation?
- difficulty when delivering the face
- head remaining tightly applied to the vulva or retracting: 'Turtle-neck Sign'
- failure of head to restitute
- Failure of shoulders to descend
326
SHOULDER DYSTOCIA
Management?
- Stop pushing
- McRobert's Manoeuvre
- Epsiotomy to allow Wood's screw manoeuvre
Last resorts include symphisiotomy and the Zavanelli manouvere (which includes Caesarean section)
327
SHOULDER DYSTOCIA
Foetal complications?
- Brachial Plexus injury (10% permanent damage)
(upper = Erbs Palsy, lower = Klumpke's Palsy)
- hypoxia and acidosis can lead to perinatal morbidity/mortality
- Fractured humerus/clavicle (4%)
- pneumothorax
328
SHOULDER DYSTOCIA
Maternal complications?
- PPH
- third and fourth degree tears
- Vaginal lacerations
- Cervical tear
- Bladder/uterine rupture
329
What is Zavenelli's Manoeuvre?
returning the head to the occiput anterior or occiput posterior position if the head has rotated from either position. The second step is to flex the head and slowly push it back into the vagina, following which cesarean delivery is performed
330
What is Zavenelli's Manoeuvre?
returning the head to the occiput anterior or occiput posterior position if the head has rotated from either position. The second step is to flex the head and slowly push it back into the vagina, following which cesarean delivery is performed
331
CORD PROLAPSE
What is it?
When the umbilical cord descends below the presenting part and causes hypoxia for the baby due to compression or spasm
332
CORD PROLAPSE
Risk factors?
- Pre-term labour/ ROM
- Breech presentation
- Polyhydraminos
- Twins
333
CORD PROLAPSE
Management?
Tocolytics to reduce compression (Terbutaline)
- Presenting part pushed back into uterus for C-section
- Patient on all 4s
334
What is Amniotic Fluid embolism?
When the liquor enters maternal circulation leading to Anaphylaxis:
- Sudden dyspnoea
- Hypoxia
- Hypotension
335
Dangers of amniotic fluid embolism
80% mortality
Associated with seizures and cardiac arrest- usually occurs when membranes rupture
336
Management of amniotic fluid embolism
Resus
O2, fluids, bloods etc
ABC
337
UTERINE RUPTURE
Causes?
- New
| - Old scar from previous C-section - wound dehiscence
338
UTERINE RUPTURE
Signs?
RUPTURE USUALLY IN LABOUR
- Foetal HR abnormality
- Abdominal pain
- Foetal distress
- Maternal shock
- Cessation of contractions
339
UTERINE RUPTURE
Risk factors?
- Labours with scarred uterus
(c-section or deep myomectomy/previous uterine surgery or cervical surgery)
- Breech extraction
340
UTERINE RUPTURE
Management?
Maternal resus
Emergency C/S if suspected in labour
Repair if small
341
What is Bishops score?
A pre scoring system to assist in prediciting whether induction will be required
Used to assess the odds of spontaneous preterm delivery
342
GESTATIONAL DIABETES
Cause?
1) Increased resistance to insulin due to the placental production of anti-insulin hormones
2) If maternal pancreas cannot increase insulin production to combat = GM
343
GESTATIONAL DIABETES
Risk factors?
- Previous GD
- Obesity
- FH of DM
- Ethnic background
- Glycosuria
- Macrosomia (previously)
- Hx of PCOS
- Polyhydraminios
344
GESTATIONAL DIABETES
Clinical features?
- May be asymptomatic
- Polydipsia
- Polyuria
- Dry mouth
- Tiredness
345
GESTATIONAL DIABETES
Implications in 1st trimester?
Rarely seen
346
GESTATIONAL DIABETES
Implications in 2nd trimester?
Pre-eclampsia
Macrosomia
347
GESTATIONAL DIABETES
Name some anti-insulin hormones produced by the placenta
- Human placental lactogen (hPL)
- Glucagon
- Cortisol
348
GESTATIONAL DIABETES
Implications in 3rd trimester?
- Pre-eclampsia
- Macrosomia
- Recurrent infections
- Intrauterine death
- Polyhydramnios
349
GESTATIONAL DIABETES
Implications at delivery?
- Poor progress/ stillbirth (especially if pre-existing diabetes)
- Traumatic (C-section/ instrumental)
- Shoulder dystocia
350
GESTATIONAL DIABETES
Implications postnatally?
- Neonatal hypoglycaemia
- Respiratory distress syndrome
- Jaundice
351
GESTATIONAL DIABETES
Long term implications?
- Type 2 DM later in life
| - Childhood obesity
352
GESTATIONAL DIABETES
Complications and risks from GD?
SMASH
Shoulder dystocia
Macrosomia
Amniotic fluid excess (polyhydramnios)
Stillbirth
Hypertension + neonatal hypoglycaemia
353
GESTATIONAL DIABETES
Diagnosis?
Management?
OGTT at 24-28 weeks
5,6,7,8 RULE
Fasting = >5.6
2 hours = >7.8
- Glucose control
- Deliver at TERM unless macrosomia/pre-eclampsia
354
GESTATIONAL DIABETES
Name some anti-insulin hormones produced by the placenta
- Human placental lactogen (hPL)
- Glucagon
- Cortisol
355
GESTATIONAL DIABETES
Why does this cause macrosomia?
1) Excess glucose leads to excess glucose transferred to foetus.
2) Foetus produces increased amounts of insulin and therefore more tissue/fatty deposits.
356
GESTATIONAL DIABETES
Why is Polyhydramnios caused?
Increase in fetal glucose = polyuria and more fluid release from the foetus
357
GESTATIONAL DIABETES
Why is neonatal hypoglycaemia caused?
Increased fetal insulin- lower glucose intake after birth compared to intra-uterine
358
GESTATIONAL DIABETES
Methods of glucose control?
- Diet (Avoid glucose fluctuations) + Exercise
- Metformin &
- Glibenclamide
- Insulin (Short acting before meals)
359
List some peripartum events that can lead to chronic infections
- Prolonged ROM
- Chorioamnionitis
- Repeated vaginal exams
- Catheterisation
- Instrumental deliveries/ C-sectionn
360
What drugs should be avoided during breastfeeding?
Ciprofloxacin, Sulphonamides, tetraycline
```
Aspirin,
Lithium
Fluoxetine
Benzodiazepines
Carbimazole
Methotrexate
Sulphonyureas
Amiodarone
```
361
Name the 4 classifications of Postnatal mental illness
- Baby blues
- Postnatal depression
- Puerperal psychosis
- Post traumatic stress sydnrome following childbirth
362
Risk factors of PND?
- Mental health hx
- Alcohol and drugs
- Traumatic experience
- Social isolation
- Domestic/childhood maltreatment
- Socioeconomic status
363
Clinical features of PND?
- Low mood
- Low energy/libido
- Irritable
- Unable to cope
- Feeling of guilt about not loving baby enough
- Tearful
- Poor sleep
- Poor appetite
- Difficulty bonding with baby/ poor relationships with family
364
Treatment of PND?
10% of women
SSRIs (Sertraline/paroxetine)
Reassurance and support
365
Features of puerperal psychosis?
Severe mood swings and disordered perception
Needing hospital admission and long acting benzodiazepine
366
ANTENATAL SCREENING
Describe the Combined test (for Down's syndrome)
Scans for:
1) Nuchal translucency (fluid collection in back of neck suggests chromosomal disorder)
2) Beta-hCG
3) PAPP-A
Detection rate 85%, must be done in 1st trimester to allow TOP
367
ANTENATAL SCREENING
What is Non-invasive prenatal testing
Tests for T21, T13 and T18
only be done in private sector, analyses fragments of fetal DNA in maternal blood
368
ANTENATAL SCREENING
What is tested in the 8-10 week booking scan
Determine location, viability, dating of pregnancy
369
ANTENATAL SCREENING
What is tested in the 11-13 week dating scan
Gestational age
crown- rump length
risk factors for pre-eclampsia / Gestational DM
Test for proteinuria/ bacteriuria
370
ANTENATAL SCREENING
What is done in the 20 week anomaly scan
- Detailed US
- Plan delivery
- Identify major abnormalities
371
ANTENATAL SCREENING
What are the 9 conditions that are part of the new-born blood spot?
1) CF
2) Hypothyroidism
3) Sickle cell
INHERITED METABOLIC DISEASES
1) phenylketouria (PKU)
2) Medium chain acyl-coA dehydrogenase deficiency (MCADD)
3) Maple syrup urine disease (MSUD)
4) Isovaleric acidaemia (IVA)
5) Glutaric aciduria tye 1 (GA1)
6) Hymocystinuria (HCU)
3-6 are 1 in 100,000 RARE
372
When is Anti-D given to rhesus negative women?
28 weeks Dose 1
| 34 weeks Dose 2
373
What mnemonic is helpful for interpreting CTGs?
Describe it
DR C BRAVADO
DR- Define risk- why are they having it? (e.g pre-eclampsia)
C- Contractions (5 in 10 mins)
BRA- Baseline rate should be 110-160bpm
V- Baseline variability
Normal = 5-25 bpm
Reduced = <5bpm
A- Accelerations
Rise by 15 beats for more than 15 seconds. Should be 2 separate accelerations every 15 mins
D- Decelerations
Reduction of 15 beats for at least 15 seconds
Late decelerations = sign of slow recovery hypoxia
O- Overall Impression
Terminal Bradycardia = <100bpm for >10 mins
Terminal Deceleration = HR drops and does not recover for more than 3 minutes
These make up a 'pre-terminal' CTG and indicators of emergency C-section
374
Causes of Oligohydramnios?
```
premature rupture of membranes
fetal renal problems e.g. renal agenesis
intrauterine growth restriction
post-term gestation
pre-eclampsia
```
