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Obstetrics Flashcards

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1
Q

how to calculate expected date of delivery

A

EDD = LMP - 3months + 7 days and 1 year + days if cycle is longer than 28 days
can use USS and crown-rump length at 12 week scan (11-13+6 week scan)

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2
Q

diagnosis of GDM (16% preg women)

A

fasting glucose of 5.6mmol/L or more

GGT at 24-28 weeks (2hrs after 75mg glucose) >7.8mmol/L

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3
Q

why is pregnancy diabetogenic

A

glucose tolerance decreases due to

  • altered carb metabolism
  • antagonistic effect lactogen, cortisol and progesterone
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4
Q

fetal and maternal complications of DM

A

Fetal: congen ab (NTD) 3-4x increase, prem >10%, lung maturity decreased, macrocosmic, dystocia and birth trauma
Mat: increase insulin requirements, UTI, ketoacidosis, wound/endometrial infection, HTN, preE , IHD worsens, CS or instrumental, nephtopathy and retinopathy

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5
Q

what weight in DM should you go to ECS and when

A

deliver 37-39 weeks, >4kg ECS

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6
Q

fetal consequences of premature

A

50% of CP, 20% perinatal mortality, CLD, blind, minor disability, cog, behavioural, RD. risk <5% at 32 weeks but at 24 weeks 1/3 handicapped and 1/3 die

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7
Q

IX prem

A

negative point of care test for prem = fetal fibronectin assay
TVUSS cervical length (>15mm unlikely in next week)
CTG USS fetus
swabs, CRP, WCC
VE unless ROM/PP

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8
Q

Mx prem

A

steroids 23-34 weeks
tocolytics (nifedipine/oxytocin R antag)
Abx if infection
chorioamnionitis - IV ABx and asap delivery
MgSO4 4g slow injection IV <12hrs neuroprotectIVE, 23-34 weeks
transfer NICU esp if <27 weeks and <800g
delivery: vaginal if can but most breech so CS; paediatric facilities mobilised; cord not clamped for 45 secs unless reusus; ABX if premature

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9
Q

define preterm prelabour ROM and what proportion of prem labours does this occur in

A

Membranes rupture <37weeks before labour
occurs in 1/3 prem
pre term labour follows in >50%

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10
Q

HX and complications Preterm prelabour ROM

A

gush then leak liquid. infection fetus, choriamnionitis, funisitis, prolaptse cord

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11
Q

Ix preterm prelabour ROM

A

(actim partus and other point of care tests not v reliable)
USS (may decrease liquor)
HVS, FBC, CRP, ?lactate, CTG

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12
Q

Mx preterm prelabour ROM

A
  • admit for 48hrs at least
  • steroids
  • obs
  • deliver if 34-36 weeks
  • infection -> IV ABx and deliver
  • erythromycin prophylaxis
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13
Q

causes of APH

A
  • placenta praevia
  • placental abruption
  • vasa praevia (vessels in membranes in front presenting part, normally with velamentous insertion)
  • uterine rupture
  • Gynaecology origin bleed
  • undetermined origin
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14
Q

classic presentation of Placenta praevia vs placental abruption

A

PP - small painless bleeds (red) increasing in pregnancy, transverse lie, not engaged, USS, no fetal distress
Placental abruption - painful, dark bleeds, uterine tenderness, labour may ensue, ss of blood loss, fetal distress (ab/absent fetal tones)

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15
Q

management PP

A

woman with bleed: Admit, FBC, cross match, clotting factors, antiD if neg, CTG, IV access, steroids if <34. if severely prem may give transfusion to prolong. severe loss -> CS
without bleed: delay admission til delivery (ECS 39 week or earlier if heavy)
placenta accrete/percreta: ECS with interventional radiology. incision away from placenta then Rush balloon compression.

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16
Q

key compilation following Placenta praevia or abruption

A

PPH

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17
Q

management of placental abruption

1) fetal distress
2) no FD >37 weeks
3) no FD <37 weeks
4) fetal death

A

All: Admit, FBC, cross match, clotting factors, antiD if neg, CTG, IV access, steroids if <34, analgesia

1) urgent CS
2) IOL with amniotomy, urgent CS if fetal distress develops
3) monitor on antenatal ward, may discharge if minor, steroids, serial USS for growth
4) IOL with amniotomy, transfuse blood and FFP as likely to have coagulopathy

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18
Q

what is SGA and IUGR

A

SGA = <10th decile or <2.7kg at term

IUGR about genetic potential

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19
Q

what does decreased PAPP-A indicate

A

?Chr. ab, higher risk IUGR, placental abruption, still birth

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20
Q

what percentage decrease in abdominal growth indicated IUGR on USS

A

30% Decrease in rate

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21
Q

what does absent end diastolic flow or reversed end diastolic flow indicate on umbilical a Doppler waveform

A

severe placental dysfunction

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22
Q

what is combined with umbilical a doppler after 34 weeks

A

MCA doppler and cerebroplacental ratio

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23
Q

what would indicate compromise on MCA doppler

A

MCA low resistance pattern compared to thoracic aorta or renal vessels as increase dia, head sparing.
only used in high risk preg or ?anaemia. not routinely used.

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24
Q

what is ductus enosis waveform a measure of

when would you use doppler waveform of fetal venous circ

A

fetal cardiac function.

use if v prem <28 weeks, to assess twin-twin transfusion syndrome. only fetal med centres.

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25
how to differentiate SGA and IUG
USS and umb A doppler. decrease growth velocity 30% abdomen circ = IUGR often oligohydramnios CTG for fetal distress
26
management SGA
recheck growth with USS at 2-3 weekly intervals. >37 weeks arrange delivery or wait til spontaneous at term if no abs and >3rd centile
27
what would the next steps be if EFW <10th centile and ab umbilical A doppler at <34 weeks
- repeat anomaly scan - check maternal CMV and toxoplasmosis (IgM) status - consider uterine a, karyotype, MCA doppler
28
next steps for: placental origin of IUGR, gest <24, EFW <500g
see in 1-2 weeks til >24 or >500g -> umbilical a doppler
29
next steps for: placental origin of IUGR, >24 weeks and 500g, umbilical a doppler normal
repeat 2-3/wk | monitor BP and urinalysis
30
next steps for: placental origin of IUGR, >24 weeks and 500g, umbilical a doppler ab
- <32wks do daily CTG | - >/=32 deliver CS
31
classification of CTG - normal - suspicious/non-reassuring - pathological
- normal = all reassuring - suspicious/non-reassuring = 1 non-reassuring and 2 reassuring - pathological = 1 ab or 2 non-reassuring
32
normal baseline variability and ab
10-25bpm, ab <5
33
types of deceleration
early - with contractions. benign. variable - cord compression and fetal hypoxia late decals - maternal hypo, preE Prolonged decals >3mins, ab
34
how often are maternal obs done
temp and BP very 4 hours | pulse every hour first stage then every 15 mins second
35
how often is FHR measured
15 mins first stage, 5 mins second stage
36
what to do if slow progress in active first stage
if slow after latent tx with ARM -> slow -> oxytocin (in null and multi once exclude malpresentation)
37
management face presentation
if chin ant, VD, if post CS
38
brow presentation management
fetal compromise common. CS
39
ph <7.2 FBS
= fetal compromise. deliver fastest route
40
CTG indications
PreE, IUGR, prev CS, IOL | meconium, oxytocin, >38degree temp, epidural
41
SE systemic pain relief eg pethidine, Meptid IM
RD newborn, out control, sed, nausea (prescribe antiemetics)
42
CI to epidural anaesthesia
severe sepsis, coagulopathy, active neuro H disease, hypovolaemia
43
when to contact maternity services
contractions reg, painful, last 30 secs every 3-4 min or ROM
44
how often are contractions in first stage of labour and what is dilation
every 2-3 mins | latent <4cm, active 4-10
45
when to do instrumental delivery in second stage
2hrs null/1multi -> ventouse/forceps
46
when to go to CS in first stage
not fully dilated 12-16 hrs -> CS
47
what is used in active 3rd stage
IM oxytocin to help contract and decrease PPH
48
what is used in active 3rd stage and define retained
IM oxytocin to help contract and decrease PPH | >30 mins
49
success rate ECV
50%. 3% return and 3% not done do turn
50
CI to ECV
fetal compromise, VD CIs, twins, recent APH, ROM
51
procedure ECV
- tocolytic (nifedipine, atosiban) - USS guidance, in hosp - CTG after - Anti-D if need
52
key points in breech birth vaginal delivery
only push once buttocks visible | may use forceps to deliver head
53
how many CS is an absolute CI to IOL
>1 (ie 2 or more)
54
Methods of induction:
- PGE2 (allows amniotomy) - amniotomy, then plus oxytocin infusion if labour not started - amniotomy if SROM - Natural induction with cervical sweeping
55
what do you do after IOL
CTG for 1hr. if oxytocin use CTG t/o
56
VBAC CIs
2 or more CS vertical all indications for CS prev uterine rupture
57
VBAC success rate | VBAC maternal death rate
72-75%. but increase in emergency CS needed compared to plan. 13/100000 (double planned CS)
58
presentation scar rupture and management
FD, scar pain, stopped contractions, vaginal bleed, mat collapse laparotomy and CS
59
2 risks of prelabour term ROM
- neonatal infection | - cord prolapse
60
management prelabour term ROM
check lie/presentation avoid VE unless risk cord prolapse. sterile. fetal auscultation/CTG wait <24hrs labour. if 18-24hrs/meconium of ?infection -> induce, Abs for GBS OR just induce
61
indications instrumental delivery
``` Prolonged 2nd stage (1-2hrs pushing) FD prophylactic eg if don't want to push HTN/cardiac disease breech if mod traction doesn't do descent do CS ```
62
difference between Simpsons and keillands and what positions to use in
simpsons: non rotational for OA. | Keilland's rotational for palpositioned.
63
prerequisites for instrumental delivery
``` head not palpable abdominal ie engaged head at/below ischail spines cervix fully dilated know head position adequate analgesia bladder empty ```
64
pain relief for mid and low cavity delivery
low : pudendal n block with perineal infiltration | mid : spinal or epidural
65
emergency CS indications
acute antepartum issue eg abruption prolonged first stage (full dilation not imminent by 12-16hrs) or if was fast now v slow or if 10cm but cant do instrumental eg insufficient uterus or other Ps FD (FHR, FBS) CS if fastest route
66
CS absolute indications | relative
pp, severe antenatal compromise, uncorrectable ab lie, prev vertical CS, gross pelvic deformity breech, severe IUGR, twin, med disorders, prev CS, older nulliparous. <34 weeks eg PreE, severe IUGR
67
Presentation amniotic fluid embolism and management
ss: anaphylaxis, dyspnoea, hypoxia, hypotension, seizure, cardiac arrest. >30 mins would present DIC, pul oedema ARDS. MX: massive ob haemorrhage protocol, rests and supportive, clotting, x match, FBC, U and E s
68
manoeuvres for shoulder dystocia
1) McRoberts (legs hyperextended into abdomen and suprapubic pressure) 2) episiotomy for manual rotation Woodscrew manouvre (pressure behind posterior shoulder, rotate 180 degrees or oblique) or get posterior arm and bring down 3) symphisiotomy 4) zavanelli manœuvre (push back in and CS. likely already damaged)
69
Management cord prolapse
Give tocolytics eg terbutaline. if above Introitus, push back gently. if below do not force back inside, keep cord warm. all 4s and deliver safest route. normally CS. Instrumental if appropriate (fully dilated and low head).
70
mx uterine rupture
resus, IV fluid and blood for cross match, clotting, give blood, laparotomy repair or removal uterus
71
mx uterine inversion
(haemorrhage, pain, shock) push up into vagina. GA and replacement performed with hydrostatic pressure of several litres of saline over clenched fist
72
mx epiletiform seizure
clear airway, suction, o2 cardiopulmonary resus if no cardiopulmonary collapse, diazepam. only give magnesium sulphate if sure eclamptic seizure.
73
management pre-existing HTN in preg
IX: assess renal function, proteinuria measured and uric acid level as baseline, rule out Phaeochromocytoma with 24hr measurement of catecholamines ss often not present: check renal bruits, radio femoral delay and fundal changes management: ideally change meds before pregnancy. ACEI stopped as teratogenic. labetalol or nifedipine. low dose aspirin (high risk preE). deliver 38-40.
74
dx process of Pre-eclampsia
urine dipped if 1+ quantified by 24hr protein or Protein creatinine ratio >0.3g/day or 30mg/nmol = significant bloods: increase uric acid, Hb often high rapid fall platelets or increase LFTs (ALT) = HELLP renal function mild impair: rising creatinine means RF USS, umbilical a doppler and CTG for fetal monitoring uterine a doppler at 20 weeks screens ratio sFlt-1:PIGF in maternal blood can show who will develop
75
diagnosis of pre-existing HTN in preg
<20 weeks >140/90. usually not proteinuria unless renal cause
76
diagnosis of pre-existing HTN in preg
<20 weeks >140/90. usually not proteinuria unless renal cause
77
management preE (before delivery)
assessment: >140/90 assessed. sFlt:PIGF. if no oproteinuria and mild/mod HTN manage as output. BP and urinalysis repeated 2x per week and USS every 2-4 weeks unless show feral compromise admit if severe HTN or proteinuria signif (>0.3g/day/30mg/nmol) antiHTN to keep BP 140/90: if 150/110 give labetalol for maintenance (nifedipine second). if serious oral nifedipine for initial control or 2nd line IV labetolol if severe magnesium sulfate: treatment and prevention. IV loading dose then infusion. deliver if need this. toxicity can -> RD, hypotension steroids if <34 weeks
78
prevention PE
75mg aspirin if 1 high risk factor or 2 moderate | high dose vit D and Calcium
79
mx PreE delivery
by 36 weeks if deteriorate, complications or reduced SVT on CTG -> deliver CS indications: (epidural help lower BP), <34 weeks, severe GR, ab CTG >34 weeks can induce with prostaglandin anti HTN in labour avoid pushing in 2nd stage if BP 160/110 Oxytocin deffo for 3rd stage (not ergometrine)
80
when should you deliver if gestational HTN
at 40 weeks as long as monitor fetes
81
postnatal care in preE
BB nifedipine and ACE-i second line for several weeks

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