Obstetrics Flashcards

Question

FHR monitoring findings

Answer 1

- Normal baseline - >110-160 - Baseline bradycardia - >hypothermia/oxaemia/glycaemia/thyroidism - >heart block - Baseline tachycardia - >infection/maternal fever - >hyperthyroid - >anaemia - >catecholamines - >arrhythmia - >hypoxaemia - HRV - >normal =5-25bpm - >presence of normal variability is reassuring - >absence/reduced is poor predictor of acidaemia/hypoxia - Accelerations (>+15 for 15s) - >presence is reasurring - >absence is poor predictor of acidaemia/hypoxia - Early decelerations (normal response to fetal head compression - >with peak of uterine peak contractions - Late deceleration - >occur post peak uterine contraction - >fetal hypoxia due to constriction of uterine arteries - >insignificant when with good variability and accelerations - >recurrence with minimal variability/accelerations is bad - Variable decelerations - >due to cord compression - >initial compression of umbilical veins = increase FHR - >compression of umbilical artery follows = decrease FHR - >uterine relaxation = effects occur in reverse - >concerning, requires close attention - Prolonged deceleration (due to fetal hypoxia of any cause - >up to 2 mins = non reassuring - >more than 3 mins = abnormal - >more than 10 mins = new baseline (severe hypoxia) - Sinusoidal pattern - >3-5 cycles/minute for 20 minutes with no variability - >severe hypoxia or fetal anaemia - >rare and very concerning

Answer 2

Epidemiology - 10-20% colonisation of vagina/rectum - >neonatal colonisation rate = 40-50% - >early infection rate = 0.5-0.05% Aetiology - Risk factors - >prematurity - >prolonged rupture of membranes (>18hrs) - >maternal fever - >heavy maternal colonisation - >low level maternal/fetal serotype specific Ig - >previous infant with early GBS disease - Neonatal infection - >intra-amniotic infection (with intact membranes) - >passage through birth canal - >contact with outside environment Pathophys - early onset <24hrs - >sepsis (most common) - >pneumonia - >meningitis - late onset <90 days - >fever/bacteraemia (most common) - >meningitis - >septic arthritis/osteomyelitis - >cellulitis - mortality - >overall = 3% - >pre-term early = 30% - morbidity - >CP - >ID - >seizures - >hearing/vision loss Screening - rectovaginal swap/culture for all women - >false negative approx 5% - timing - >general = 35-37wks - >high risk for preterm = 3-5wks prior to EDD - exceptions - >GBS bacteruria/previous infant GBS = empiric rx Labour management - Intrapartum antibiotics - >IV penicillin G or ampicillin - >at least 4hrs prior to delivery - >reduces risk of early disease by 80% - >risk of late onset unchanged - Indication for intrapartum antibiotics - >GBS+/GBS bacteruria - >previous early GBS disease - >unknown status + preterm labour/PPROM/prolonged rupture of membranes/intrapartum maternal fever

Answer 3

Compared to normal vaginal delivery - Positives - >delivery date known - >avoids post-term neonatal mortality increase - >avoids risk of emergency caesarian - >lower rate urinary and bowel incontinence - >lower rate pelvic organ prolapse/perineal tear - >lower rate HIE/birth injury/asphyxia - >less vertical transmission HIV/HSV - Negatives - >higher rate TTN/RDS (only if <39 weeks) - >higher neonatal mortality - >longer hospitalisation/recovery time - Same - maternal mortality rate - post partum sexual function - pain 4 months post partum Complications (HOISTED) - Haemorrhage - >approx 1L - >less than 5% need transfusion - Obstructed bowel (ileus) - >15% - Infection - >2% - Surgical error (rare) - >bowel/bladder perforation - >laceration to baby - Thrombosis (stroke/MI/VTE) - >3x vaginal delivery risk - >0.25% for VTE - Endometritis - Death - >less than 0.1% Anaesthetic risk - neuraxial - general Long term risk - abnormal placentation - >placenta accreta/previa/abruption - adhesions - hernias - nerve pain around scar VBAC - uterine rupture - >TOLAC = 0.5% (< if previous successful delivery) - >twice as high as risk with repeat caesar - outcome of rupture - >1/3rd hysterectomy - >neonatal death <3% - neonatal - >mortality 2-3x higher with TOLAC (very low) - >resus 2x higher with TOLAC Categories - 1 = immediate threat to maternal/fetal life (30mins) - 2 = compromise with no threat to life (1hr) - 3 = earlier than planned without compromise - 4 = maternal request - >possible if harm/benefit understood by patient Timing of planned/maternal request - before 39 wks - >increased risk of blood transfusion - >higher rates RDS/TTN - >higher neonatal mortality - at 39 wks - >approx 10% will require emergency CD prior to 39wks - >emergency has 2x risk of complications - after 39 wks - >increase perinatal mortality - >macrosomia - >dysmaturity syndrome

Answer 4

Epidemiology -approx 10% births Aetiology - Fetal - >genetic abnormality - >TORCH infections - Placenta - >pre-eclampsia - >abruption - Maternal (ACHINGS) - >age (extremes of) - >CKD - >HTN - >Insulin resistance - >nutritional deficiency - >genetics (previous SGA or personally SGA) - >SLE - Exposures - >teratogenic meds - >alcohol/smoking/cocaine/heroin/marujuana Pathophys - Foetal response to compromised nutrient supply - >redirect blood flow to brain/heart/adrenals - >reduces overall size/fat/BMD/glycogen stores - >reduces renal blood flow and oligohydramnios - >preserve brain growth - >accelerate lung maturation - >increased RBCs - >decrease - Symmetric - >proportional reduction of body components - >chromosomal or infection - >occurs early in gestation - Asymmetric (majority) - >weight/abdominal size reduced more than length/HC - >adaptation to pathological stressor - >occurs later in gestation

Answer 5

Hx - PC - >unwell lately? - >headaches/vision changes - >loss of blood or fluid - >pain? - >fetal movements - This pregnancy - >any complications - >scans (morph + aneuploidy) + serology - Past obstetric - >G/P - >G/A and route - >small babies - >HTN/diabetes - Past medical - >any chronic illnesses - Allergies - Medications - Supplements and food avoidance - Social - >Smoking/drinking/drugs - >contact with children - >proximity for follow Exam - Height/weight/BMI - BP - Abdo palp - Fundal height - Doppler Confirm diagnosis with ultrasound - Urgent CTG - SGA - >weight below 10th centile in second trimester - >may be constitutional or restricted growth - >consider AC/AFI/growth velocity Determine cause - Fetal survey - >doppler (umbilical/uterine/middle cerebral arteries) - >BPP - Anatomy scan - >if abnormal, consider cell free DNA for aneuploidy - >if negative, consider amniocentesis for microarray - Infection workup - >maternal CMV/rubella/varicella seropositivity

Answer 6

Monitoring - Usually monitored as outpatients - Weight - >review every 2 weeks if concerned - >consider velocity (normal in constitutional) - US doppler - >umbilical artery most useful - >review every 2 weeks if first two are normal - >review weekly if abnormal or concerned - >reduced/absent end-diastolic flow = consider delivery - BPP or NST with AFI - >not needed if mild - >twice weekly if severe - >daily if abnormal doppler Delivery consideration - Issue - >pre term delivery has high mortality/morbidity - >each day in utero between 26-29wks increases survival up to 2% - >mortality in IUGR rises sharply at time (placental insufficiency) - GRIT trial - >randomised to immediate or delayed delivery - >when obstetrician was uncertain - >immediate group = fewer stillbirths/more neonatal deaths - >long term neurodevelopment outcome similar - DIGITAT trial - >randomised to spontaneous/expectant at term - >spontaneous had lower birth weight - >same adverse events/same caesarian rate/long term developmental outcomes - Consider - >dopplers/BPP/NST/risk factors - >gestational age - >patient preference - >need for caesarian delivery if poor dopplers - >corticosteroids and magnesium sulfate Intrapartum - Issues - >intrapartum heart rate abnormalities - >birth asphyxia/HIE - >meconium aspiration - >polycythaemia - >hypothermia - >hypoglycaemia - Approach - >continuous fetal heart monitoring - >low threshold for emergency caesarian - >neontal support present - >umbilical blood gas and glucose at birth Long term - catch up growth - CVD/diabetes/renal disease/neurodevelopment

Answer 7

Epidemiology - Rh -ive - >15% of caucasians - >7% africans - incompatibility in 10% pregnancies Aetiology - Rh -ive mother - Rh +ive baby - >inherited from father Pathophys - sensitising event - >occurs in majority of pregnancies - >fetomaternal haemorrhage (most placental insults) - >passage of fetal cells across placenta - formation of maternal anti-D Ig - >formation of memory B lymphocytes - >future challenge leads to plasma cell Ig production - haemolytic disease of the new born - >maternal Ig cross placenta attache to fetal RBC - >RBCs sequestered in spleen and destroyed - >extramedullary haematopoeisis - >hepatosplenomegaly/pHTN/HF/cerebral hypoxia - >hydrops fetalis/intrauterine death Screening for incompatibility - blood group, Rh status, antibodies - >first antenatal visit - >Rh -ive repeated at 24-28wks - >after any sensitising event Diagnosing incompatibility - if mother Rh antibody +ive - >paternal blood group - Paternal zygosity if Rh +ive (PCR for RHD genes) - >if homozygous = fetus Rh +ive - >if heterozygous = 50% chance fetus Rh +ive - Amiocentesis (>15wks) or cfDNA (>10wks) if heterozygous Monitoring incompatability - Baby Rh +ive - >serial (monthly) maternal indirect coombs - If antibody titre rises above critical threshold - >doppler MCA for severe anaemia ever 1-2wks - If suspected sensitising event - >rosette test = presence of fetal RBC in maternal blood Sensitisation prevention - Rh incompatibility diagnosed - >maternal Ig present = no benefit of anti-D - >routine prophylaxis = anti-D at 28wks - >fetomaternal haemorrhage = anti-D - >sensitising procedure = anti-D 72hrs prior - >delivery = additional anti-D 72hrs prior - Dosage - >Kleihauer test/flow cytometry = %fetal RBC

Answer 8

Epidemiology - fecundability - >85% over 12 months regular unprotected sex - >25% in first 3 months, then decreases Aetiology - Risk factors - >age >35 - >obesity/low BMI - >smoking - >previous STD Pathogenesis - Female factors (1/3rd) - >diminished ovarian reserve with age (majority) - >oligo/anovulation (PCOS/prolactin/hypogonadism/hypothalamus) - >tubal (post infection/endometriosis/pelvic adhesions) - >uterine (adhesions/mullerian abnormalities) - >smoking/obesity - Male factors (10%) - >oligo/azoospermia (majority idiopathic) - >primary/secondary hypogonadotrophinism - >congenital testicular disorder (klinefelter/cryptochordism) - >acquired testicular disorder (infection/drugs/exposure) - Combined factors (1/3rd) - Idiopathic 5%

Answer 9

Hx - Menstrual hx - >regular menses/moliminal symptoms = ovulatory - >long = anovulation - >short = anovulation/endometrial dysfunction - Sexual hx - >timing and regularity - >dyspareunia (PID/endometriosis/adhesions/uterine abnormality) - Hypothalamus - >stress/weight loss/exercise - >anosmia - Pituitary - >headache/vision changes/nipple discharge - Ovaries - >acne/hirsuitism/overweight/irregular periods - >SLE/UC - Tubes - >pelvic surgery/STD - >endometriosis/pelvic pain/menorrhagia/dysmenorrhea - Uterus - >procedures/instrumentation - Social - >smoking - >alcohol and substances - >stress/mood/psychiatric disorders - >occupational exposure Exam - height/weight/BMI - inspection - >hirsutism/acne - >galactorrhea - >secondary sex characteristics/syndromic features - pelvic - >abnormal shape uterus - >nodular pouch of douglas (endometriosis) - >adnexal mass/tenderness Assess ovulation - serum progesterone - >7 days before menses - >ovulation if high - urine LH sticks - >serial assessments at home - >predicts ovulation approx 24hrs in advance - serial ultrasounds - >usually restricted to during treatment - if anovulatory - >FSH/LH (hyper/hypogonadotrophic hypogonadism) - >androgens (PCOS) - >TSH - >prolactin - >karyotyping Anatomical assessment - Imaging - >transvaginal ultrasound (uterine/tubal/ovarian morph) - >hysterosalpingography (uterine/tubal path) - >saline infusion sonography (uterine path) - >MRI (uterine path pre-op planning) - Surgical - >laparoscopy (endometriosis/adhesions) with chromotubation (tubal patency) - >hysteroscopy (uterine path) Ovarian reserve testing - Basal FSH on day 3 - >less than 2 = hypogonadotrophinism - >greater than 10 = possible reduced ovarian reserve - >greater than 30 = menopausal/ovulatory surge - Antral follicle count on day 3 - >transvagianl ultrsound - >less than 4 indicates diminished reserve - AMH on any day - >less than 1 ng/mL indicates diminished reserve

Answer 10

Non pharm - Diet - >limited evidence - >beneficial for future pregnancy - Weight loss - >high BMI or PCOS - Weight gain - >athlete/low BMI/anorexia - Reduce smoking/drinking/substances - Psychology support - >high stress associated with infertility - >stress/psychological morbidity risk factor for infertility Ovarian stimulation - Clomiphene - >indicated for normogonodotrophic ovulatory dysfunction - >ineffective in hypogonadotrophic hypogonadism - Letrozole - >indicated for normogonadotrophic ovulatory dysfunction - Gonadotrophin therapy - >failed first line treatment - >hypogonadotrophic hypogonadism Tubal abnormalities - IVF - >failed ovulation treatment - >tubal abnormality - >male infertility - >uterine abnormalities with surrogate - Tubal patency improving procedures - >distal occlusion may be treated/proximal should not - >fimbrioplasty (lysis of adhesions/dilation of strictures) - >neosalpingostomy (new tubal opening) Uterine abnormalities - Setate - >some evidence for surgical intervention - Fibroids - >consider surgery if other treatments failed - >best evidence for submucosal - Polyps - >polypectomy for large endometrial polyps Specific aetiologies - Endometriosis - >first line = IVF - >surgical ablation of impants/adhesiolysis - PCOS additional treatments - >ovarian stimulation - >metformin - >ovarian drilling - Hyperprolactinaemia - >bromocriptine

Obstetrics Flashcards

(34 cards)