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RHCN > Obstetrics > Flashcards

Obstetrics Flashcards

(64 cards)

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1
Q

What are the 3 main appointments during pregnancy

A
  1. booking visit at 8-11 weeks
  2. dating scan at 12 weeks
  3. foetal anomaly scan at 20 weeks
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2
Q

What is placenta praevia

A

When the placenta is blocking the internal Os (cervix) - this prevents delivery of the baby and likely to cause haemorrhage

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3
Q

What is perinatal

A

Any time from when you become pregnant through pregnancy and delivery until 1 year postpartum

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4
Q

What is the classic sign of placental abruption

A

Firm, ‘woody’ feeling uterus

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5
Q

Symptoms of placental abruption

A

Pain
Fresh PV bleeding
If blood from abruption is trapped and forms a haematoma, may present with old blood during delivery instead (when dislodged)

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6
Q

What are the stages of labour

A

1st - contractions infrequent, <4cm cervical dilation
2nd - divided into latent and active, contractions more regular and active pushing may begin, 4-10cm dilation
3rd - delivery of placenta

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7
Q

Distinguishing between baby blues and postnatal depression in terms of timeframe

A

Baby blues = in first 2 weeks postpartum, peaks within 5 days due to hormone flux
Postnatal depression = up to 1 year postpartum, depressive symptoms must be present for at least 2 weeks

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8
Q

Medical treatment options for postpartum haemorrhage

A 
Bimanual compression 
Oxytocin 5 units slow IV
Ergometrine 0.5mg slow IV/IM
Carboprost (Hemabate) 0.25mg IM up to 8 doses
Misoprostol 1000mg PR
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9
Q

Surgical treatment options for postpartum haemorrhage

A 
Balloon tamponade
Haemostatic brace suturing
Bilateral ligation of uterine  or internal iliac arteries
Selective arterial embolisation 
Hysterectomy
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10
Q

Mechanism of action of Carboprost (Hemabate)

A

Synthetic prostaglandin (F2 alpha) stimulates the uterus to contract to provide haemostasis

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11
Q

Mechanism of action of Oxytocin in PPH

A

Peptide hormone causes uterine contraction to provide haemostasis

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12
Q

Mechanism of action of Misoprostol in PPH

A

Synthetic prostaglandin (E1) causing contraction of the uterus and reduces cervical tone

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13
Q

What is the definition of pre-eclampsia

A

New onset hypertension after 20 weeks gestation (also up to 6 weeks postpartum) and proteinuria with or without oedema

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14
Q

Moderate risk factors for PET

A

First pregnancy, maternal age over 40, maternal BMI over 35, FHx PET, pregnancy intervals of greater than 10 years, multiple pregnancy

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15
Q

High risk factors for PET

A

Hx HTN/eclampsia/PET, CKD, autoimmune disease e.g. SLE or APS, T1/2DM, chronic HTN

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16
Q

Differential diagnoses for PET

A
  1. essential hypertension (before 20 weeks gestation)
  2. pregnancy-induced hypertension (after 20 weeks gestation without proteinuria)
  3. eclampsia (seizures + PET)
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17
Q

What is classified as significant proteinuria

A

> 300mg protein in 24hr urine sample OR >30mg/mmol PCR

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18
Q

What BP level is classed as HTN

A

Systolic >140 or diastolic >90

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19
Q

Classification of pre-eclampsia and relevant thresholds

A 
Mild = BP 140/90 - 149/99
Moderate = BP 150/100 -  159/109
Severe = BP > 160/110 (with proteinuria) or BP >140/90 with proteinuria + SYMPTOMS
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20
Q

Symptoms of pre-eclampsia

A

Frontal headaches
Visual disturbance (diplopia, flashing lights)
Epigastric pain
Sudden onset oedema (facial or peripheral)
Vomiting

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21
Q

Signs of pre-eclampsia

A

Altered mental status
Dyspnoea
Clonus (hyper-reflexia)
Oedema

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22
Q

Maternal complications of pre-eclampsia

A 
HELLP syndrome
DIC
Eclampsia
ARDS
Cerebrovascular haemorrhage
Death
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23
Q

Foetal complications of pre-eclampsia

A

Prematurity
Intrauterine growth restriction
Placental abruption
Intrauterine foetal death

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24
Q

What is HELLP syndrome

A

Haemolysis
Elevated liver enzymes
Low platelets

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25
Suggested pathophysiology of pre-eclampsia
- incomplete remodelling of spiral arteries - muscular integrity of arteries is maintained - leads to high resistance/low flow circulation to the placenta - results in poor perfusion
26
Prevention of pre-eclampsia
Aspirin 75-150mg OD from 12 weeks until delivery | Lifestyle and exercise advice - address modifiable risk factors and diabetes management
27
Management of pre-eclampsia
``` Only cure is delivery VTE prophylaxis (LMWH) Antihypertensives: - Labetalol - Nifedipine - Methyldopa Consider early delivery if severe/unresponsive to treatment/complications Monitor BP initially postpartum ```
28
Difference between primary and secondary PPH
``` Primary = loss of >500ml within 24 hours of delivery Secondary = abnormal bleeding from 24 until six weeks postpartum ```
29
Antenatal risk factors for PPH
``` Antepartum haemorrhage Placenta praevia Placental abruption Multiple pregnancy Pre-eclampsia/HTN Previous PPH Maternal obesity Maternal age over 40 ```
30
Delivery related risk factors for PPH
``` C section Retained placenta Mediolateral episiotomy IOL Labour longer than 12 hours Macrosomic baby ```
31
Maternal haemorrhagic conditions which are risk factors for PPH
Factor 8 deficiency (haemophilia A carrier) Factor 9 deficiency (haemophilia B carrier) Von Willebrand's disease
32
4 T's of PPH
Tone - uterine atony Trauma - lacerations of uterus/cervix/vagina Tissue - retained placenta or clots Thrombin - coagulopathy
33
4 components of PPH management
1. communication to relevant team members 2. resuscitation 3. monitoring and investigation 4. measures to stop bleeding
34
Physical methods of managing PPH secondary to uterine atony
Bimanual uterine compression (bladder emptied)
35
Pharmacological methods of managing PPH secondary to uterine atony
1. oxytocin 5 units by slow IV 2. ergometrine 0.5mg slow IV oxytocin + ergometrine = syntometrine 3. carboprost 0.25mg IM (x8 doses max) 4. misoprostol 1000mg PR
36
Surgical methods of managing PPH secondary to uterine atony
Balloon tamponade Bilateral ligation of uterine or internal iliac arteries Hysterectomy
37
5 complications of PPH
1. hypovolaemic shock 2. disseminated intravascular coagulation 3. AKI 4. liver failure 5. acute respiratory distress syndrome
38
2 most common causes of secondary PPH
1. endometritis | 2. retained products of conception
39
Risk factors for endometritis
``` C section Prolonged ROM Severe meconium Long labour with multiple examinations Manual removal of placenta Low socioeconomic status Maternal anaemia Prolonged surgery GA ```
40
Symptoms of endometritis
``` Fever Abdo pain Offensive smelling discharge (lochia) Abnormal PV bleeding/discharge Dyspareunia Dysuria General malaise ```
41
Signs of endometritis
Fever, rigors, tachycardia Tenderness of suprapubic area and adnexae Elevated fundus which feels boggy (RPOC)
42
Management of endometritis
If septic - fluids, oxygen, antibiotics (tazocin)
43
Management of RPOC
Elective curettage with antibiotic cover
44
Indications for IOL
``` Post-term Foetal compromise Maternal request Pre-eclampsia Pre-labour ROM past 37/40 Intra-uterine death (maternal permission) ```
45
Contraindications for IOL
Placenta praevia Transverse foetus Bishop score <4
46
What is the Bishop score
Cervix score, pre-labour scoring system to determine whether IOL is required >8 favours IOL <6 IOL not ideal
47
Methods to induce labour
1. membrane sweep/cervical sweep | 2. vaginal prostaglandin E2 (PGE2) as a pessary or gel
48
What is a membrane sweep
Doctor/midwife inserts fingers through the cervix to rotate against the wall of the uterus. Separates the amniotic membrane to promote labour.
49
Definition of antepartum haemorrhage
Bleeding from 24 weeks until birth of the baby
50
Common causes of antepartum haemorrhage
``` Unknown (50%) Placenta praevia Placental abruption Vulval/cervical infection Uterine rupture Partner violence ```
51
What is placental abruption
Placenta detaches from the lining of the uterus, causing rupture in the spiral arteries leading to massive haemorrhage
52
Risk factors for placental abruption
Pre-eclampsia/HTN Smoking Trauma Multiparity
53
What is placenta praevia
Placenta is positioned blocking the cervix and therefore blocking the outflow tract for the foetus during labour - delivery cannot be vaginal unless far enough away from the cervical os
54
Management of antepartum haemorrhage
Admit to hospital for assessment and management If foetal distress, immediate delivery is necessary irrespective of gestation FBC, group and save, clotting, crossmatch, U&E, LFT
55
What is rhesus disease
Haemolytic disease of the foetus and newborn (HDFN) Mother with rhesus negative blood who has previously been sensitized to rhesus positive (i.e. previous rhesus positive pregnancy) + further rhesus positive pregnancy. Mother has antibodies against RhD positive blood (anti-D antibodies) from previous pregnancy which leads to haemolytic disease in the second RhD positive pregnancy.
56
Risk factors for gestational diabetes
``` Previous hx of GD Previous macrosomic baby (>4.5kg) BMI >30 Ethnic origin: black Caribbean, middle Eastern, south Asian FHx diabetes PCOS Smoking ```
57
Foetal implications of gestational diabetes
Foetal hyperglycaemia - glucose is transported across the placenta but insulin isn't therefore foetus increases its own insulin supplies (hyperinsulinaemia). After birth, maternal glucose supply is no longer therefore foetus becomes hypoglycaemic.
58
Investigation for gestational diabetes
Oral glucose tolerance test Diagnosis if: - fasting glucose >5.6mmol/L - postprandial (after 75g glucose drink) glucose >7.8mmol/L
59
When should glucose tolerance test be offered
At 24-28 weeks gestation to women with risk factors | At booking for women with previous GD
60
Management of gestational diabetes
Lifestyle - diet, exercise, measurement of glucose levels 4x day Metformin, insulin Additional growth scans at 28, 32 and 36 weeks Aim to deliver baby at 37-38 weeks
61
Postnatal care for gestational diabetes
Stop all anti-diabetic medication immediately after delivery Blood glucose measured before discharge to ensure levels are normal Fasting glucose test at 6-13 weeks postpartum
62
Risks of gestational diabetes to mother
``` Miscarriage Pre-eclampsia Preterm labour Diabetic retinopathy Stillbirth Perinatal mortality ```
63
Risks of gestational diabetes to foetus
``` Congenital malformations Macrosomia Postnatal hypoglycaemia Organomegaly Erythropoiesis Polyhydramnios ```
64
When does the booking visit take place
8-12 weeks gestation

RHCN (5 decks)

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