Obstetrics Flashcards
(353 cards)
1
Q
pregnancy- when is the window of blastocyst formation and why?
A
cycle day 20-24- perfect balance of hormones
2
Q
pregnancy- what happens after blastocyst formation?
A
blastocyst buries- interstitial implantation
this starts the primary decidual reaction
3
Q
pregnancy- what basic placental structures form after interstitial implantation?
A
floating and anchoring villi
4
Q
pregnancy- what do cytotrophoblast progenitor stem cells differentiate into?
A
1- terminal differentiation into syncytiotrophoblast
2- extra-villus trophoblasts
3- regenerate new cytotrophoblasts
5
Q
pregnancy- what are the functions of the extra-villous trophoblasts?
A
spinal artery remodelling- endovascular invasion of the myometrium
6
Q
during pregnancy, when does full placental blood flow occur?
A
week 10-12
7
Q
during pregnancy, what can poor endovascular remodelling lead to?
A
reduced fetal O2 and nutrient supply, which results in:
- pre-eclampsia
- intrauterine growth restriction
- preterm birth
- recurrent miscarriage
8
Q
pregnancy- what is human chorionic gonadotrophin (hCG)?
A
- hormone secreted from day 6-7 trophoblast cells of the blastocyst
- promotes maintenance fo corpus luteum
- maintains production of oestrogen and progesterone
9
Q
where is progesterone produced?
A
up to week 7/8- corpus luteum
after this it is made in the placenta
10
Q
what are the functions of progesterone in pregnancy?
A
- prepare uterus for implantation
- makes cervical mucous thick and impenetrable to sperm after fertilisation
- decrease immune response- allows pregnancy to occur
- decreases contractility of uterine smooth muscle to prevent pre-term labour
11
Q
what does progesterone inhibit during pregnancy?
A
lactation
after delivery, falling progesterone levels triggers milk production
12
Q
what is the function of human placental lactogen (hPL)?
A
- mobilises glucose from fat
- insulin antagonist to facilitate energy supply to foetus
- converts mammory glands into milk-secreting tissue
13
Q
what is the function of prolactin?
A
milk production
14
Q
what is the function of oxytocin?
A
milk ejection reflex
15
Q
what happens to maternal glucose levels during the early stages of pregnancy?
A
low- due to fat deposition and glycogen synthesis
16
Q
what happens to maternal glucose levels during the late stages of pregnancy?
A
high
alongside maternal insulin resistance- ensures glucose sparing for foetus
17
Q
what happens to maternal insulin levels throughout pregnancy?
A
rise until week 32
hPL then induces insulin resistance
18
Q
what immunity changes occur after fertilisation?
A
increases in GF’s, proteolytic enzymes and inflammatory mediators to facilitate implantation
19
Q
why is blastocyst implantation not rejected?
A
change in self: non-pattern recognition molecules (HLA and MHC)
20
Q
Why are syncytiotrophoblasts and extra-villus trophoblasts not rejected?
A
- Syncytiotrophoblast has no self:non-self markers
- extra-villus trophoblast has modified self:non self markers
21
Q
what happens to the T helper ratio during pregnancy?
A
pregnancy- more Th2 (in ‘normal’ physiology, Th1 and Th2 are balanced)
22
Q
what are the functions of the following antibodies in pregnancy
IgA IgD IgE IgG IgM
A
IgA- secreted in breast milk
IgD- on B-cell membranes
IgE- mast cells (anaphylaxis)
IgG- only one that crosses placenta
IgM- early antibody
23
Q
explain the pathophysiology of Rhesus disease
A
- haemolytic disease of new born
- Rh -ve mother (dd) and Rh +ve father (Dd or DD)
- sensitisation in first pregnancy igM
- rapid response by IgG of subsequent pregnancy
24
Q
what is the definition of a normal pregnancy and birth?
A
- term- 37-42 weeks
- spontaneous onset
- infant born spontaneously in vertex position
birth occurs without:
- induction of labour
- spinal/ epidural/ general analgesia
- forceps/ ventrose delivery
- caesarean section/ episiotomy
25
what occurs in each of the 3 stages of labour (generally)?
1st- contractions- has two phases- early labour (cervix gradually effaces and dilates) and active labour (cervix dilates rapidly and contractions are longer, stronger and closer together)
2nd- fully dilated, ends with birth of baby
3rd- right after birth, ends with delivery of placenta
26
what are the 3P's of pregnancy?
Power- contractions need to be strong enough
Passage- pelvis- anterior-posterior diameter and transverse diameter
Passenger- baby needs to be in correct position
27
describe the landmarks of the baby's head felt on vaginal examination to assess the baby's position
- attitude- how much neck is flexed (ideally is well flexed). can be deflexed- brow presentation (extended to 90') or face presentation hyperextended to 120')
- position- OT (occipito-transverse), OA (occipito-anterior)
- size of head- head compressed through pelvis (moulding), swelling causes during delivery (caput)
28
how long on average is the first stage of pregnancy?
5-12= multiparious
8-12- primiparous
29
describe the early/ latent phase of the first stage of labour
- irregular, painful contractions
- 'show'- plug of cervical mucus and blood
- cervix is effacing and thinning
- dilates to 4cm
30
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
31
what is presentation?
anatomical part of the foetus which presents itself first through birth canal
32
what is 'lie' during labour?
relationship between long axis of fetus and long axis of the uterus
33
what is 'station' during labour?
relationship between the lowest point of presenting part and the ischial spines
34
describe the active phase of labour (2nd)
- further dilation from 4cm (0.5cm each hour)
- 3-4 regular contractions per hour
- vaginal exam every 4 hours to assess degree of dilation
- oxytocin- syntocinon relationship induces labour
35
how is pain (generally) managed in labour?
- psychological- relaxation, hypnosis
- sensory methods- hydrotherapy, posture
- birth environment
- complementary - message, aromatherapy
- pain relief mediations
36
what 3 types of pain relief medications are commonly used in labour?
- entonox
- opiates- morphine. pethidine
- epidural
37
what is entonox and what are side effects of it?
- used in labour- 'gas and air'
SE- nausea and vomiting
38
what opiates are used in labour and what are some maternal and fetal side effects?
- pethidine/ morphine
- maternal SE- euphoria/ dysphoria, nausea/ vomiting, increased length of 1st and 2nd stage of labour
- fetal SE- respiratory depression, diminishes breath seeking/ breast feeding behaviours
39
what are some maternal and fetal side effects of epidurals?
- maternal- increased length of 1st and 2nd stage, increased incidence of malposition, loss of mobility, loss of bladder control, hypotension, pyrexia
- fetal- tachycardia, diminishes breast feeding behaviour
40
describe the initial transition stage of the second stage of labour
- SROM- spontaneous rupture of membranes
- irritable, anxious, distressed
- start to feel pressure
- contractions can slow/ stop
- support/ reassurance required
41
describe the second stage of transition during labour
- full dilatation- 10cm
- externally- head visible
- spent bearing down
42
in what timeframe would you:
- suspect delay
- diagnose delay
- expect baby to be born
in primigravid women
- suspect delay- 1 hour
- diagnose delay- 2 hour
- born- within 3 hours of pushing
43
in what timeframe would you:
- suspect delay
- diagnose delay
- expect baby to be born
in multiparous women
- suspect delay- 30 mins
- diagnose delay- 1 hour
- born within 2 hours of pushing
44
what happens in the 3rd stage of labour?
- pushing out placenta
- physiological management- blood less
- active management- oxytocin
45
function of relaxin during labour
- released from placement, membrane surrounding baby and uterine lining
- softens ligaments and cartilages of pelvis so it can expand
- helps cervix loosen and soften
- makes baby's body more flexible and allows head to mould
46
function of oxytocin during labour
- stimulates uterine contractions during orgasm and childbirth
- large amounts released when cervix is opened, trigging fetal ejection reflex
- contracts uterus post-birth to deliver placenta and limit bleeding
47
functions of prostaglandins during labour
- ripens cervix and causes it to begin process of thinning and opening
- stimulates uterine contractions
48
what are the 5 types of malpresentation during pregnancy?
- breech
- occipitoposterior position
- face presentation
- brow presentation
- transverse lie
49
causes of a breech presentation
- idiopathic
- uterine abnormalities
- prematurity
- placenta previa
- oligohydramnios
- foetal abnormalities- hydrocephalus
50
how can a breech presentation be reversed?
external cephalic version
51
what are the complications of an external cephalic version?
- placenta previa
- APH
- ruptured membranes
52
how is a breech presentation diagnosed?
ultrasound
53
what are the 3 types of breech presentation?
frank breech
complete breech
footling breech
54
what is a frank breech?
where the hips are flexed and the legs are extended
55
what is a complete breech?
hips and knees are flexed and the feet are below the level of the foetal buttocks
56
what is a footling breech?
where one or both feet are presenting as the lowest part of the foetus
57
which breech presentation is associated with the highest risk of cord prolapse?
footling breech
there is nothing to act as a plug over the cervix if the membranes rupture
58
what mode of delivery is most appropriate for a breech presentation?
- vaginal delivery has a risk of foetal hypoxia and birth trauma
- planned C-section
59
how is an occipitoposterior position diagnosed?
antenatally via palpation
vaginal examination
60
why is labour prolonged in occipitoposterior position?
because of the degree of rotation needed, so adequate analgesia and hydration are required
61
describe a face presentation and the method of delivery
- occurs by chance- head extends rather than flexes as it engages
- early vaginal examination- nose and eyes may be felt
- forceps delivery
62
describe a brow presentation and the management of it
- head is between full flexion and full extension- can revert to either
- vaginal delivery NOT possible !
- delivery by LSCS
63
what is an LSCS delivery?
lower segment caesarean section
64
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
65
what are the most common reasons for inducing labour?
- prolonged pregnancy
- premature rupture of membranes
- diabetic mother >38 weeks
- rhesus incompatibility
66
what is the Bishop score?
used to assess if induction is required
- score <5= unlikely to start without induction
- score >9= likely to start spontaneously
67
what 5 factors are included within the bishop score?
- cervical dilation (cm)
- length of cervix (cm)
- station of head (cm above ischial spines)
- cervical consistency
- position of cervix
68
in the bishop score, each factor has a score of 0,1 or 2.
for cervical dilation, state what each score implies
0= 0cm
1= 1-2cm
2= 3-4cm
69
in the bishop score, each factor has a score of 0,1 or 2.
for the length of the cervix, state what each score implies
0= >2cm
1= 1-2cm
2= <1cm
70
in the bishop score, each factor has a score of 0,1 or 2.
for 'station of head' , state what each score implies
0= 3cm above ischial spines
1= 2cm above ischial spines
2= 1cm above
71
in the bishop score, each factor has a score of 0,1 or 2.
for cervical consistency, state what each score implies
0= firm
1= medium
2= soft
72
in the bishop score, each factor has a score of 0,1 or 2.
for position of cervix, state what each score implies
0= posterior
1= middle
2= anterior
73
what must be checked prior to induction?
- lie and position of foetus
- volume of amniotic fluid
- tone of uterus
- ripeness of cervix
74
what are contra-indications for induction?
- severe degree of placenta praevia
- transverse fetal lie
- severe cephalopelvic disproportion
- cervix <4 on bishops score
75
what is the induction procedure?
- membrane sweep
- prostaglandin gel or pessary high in vagina (misoprostol)
- amniotomy- ROM
- Oxytocin/ syntocinon infusion (post ROM)
76
What is cardiotocography?
electronic fetal monitoring for risk factors
77
what is a normal CTG?
- HR 110-160
- variability of 5bpm
- no decelerations
- accelerations present- reassuring when baby is moving
78
on CTG, what would a heart rate over 160 indicate?
maternal pyrexia
chorioamnionitis
hypoxia
prematurity
79
on CTG, what would a heart rate under 100 indicate?
increased foetal vagal tone
maternal beta blocker use
80
on CTG, what would a loss of baseline variability inicate?
prematurity/ hypoxia
81
on CTG, what would late deceleration indicate?
foetal distress- asphyxia/ placental insufficiency
82
on CTG, what would variable decelerations indicate?
cord compression
83
what mnemonic is helpful for interpreting CTG's?
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
84
what is hyperemesis gravidarum?
vomiting in early pregnancy, starts from 4-10 weeks and ends by week 20
associated with WL of more than 5% body mass and ketosis
85
clinical features of hyperemesis gravidarum
- persistent vomiting
- >5% weight loss
- dehydration
TRIAD OF:
- >5% weight loss
- electrolyte imbalance
- dehydration
(plus vomiting)
86
how is hyperemesis gravidarum managed?
- mild-moderate- reassurance, avoid fatty foods, avoid large volume drinks
- severe- admissions and antoemetics
87
what anti-emetics are used in the treatment of hyperemesis gravidarum?
- dopamine antagonist- metoclopramide
- phenothiazines- prochloperazine
- ondansteron
88
complications of hyperemesis gravidarum
- Wernicke's
- mallory-weiss tear
- pre-term baby
89
what is puerperal pyrexia?
defined as a temperature of >38'c in the first 14 day following delivery
90
causes of puerperal pyrexia
endometritis
UTI
wound infection
mastitis
VTE
91
risk factors for VTE in pregnancy
- age over 35
- BMI >30
- parity >3
- immobility
- FH
- smoker
- varicose veins
- pre-eclampsia
92
what is the leading cause of morbidity and mortality in pregnancy in developed countries?
VTE
| preventable- includes ,DVT, PE
93
when are VTE risk assessments done?
- booking
- antenatal admission
- labour
- postnatally
94
what are some indications for LMWH thromboprophylaxisis and compression stockings in pregnancy?
- risk factors of VTE present
if required, LMWH must be given until 6 weeks postpartum
95
if a pregnant/ post partum lady collapses what is the immediate concern?
PE
96
investigations in a suspected VTE during pregnancy
- FBC, U&E, LFT, clotting screen
- if suspected PE- ABG, ECG, CXR
imaging:
- DVT- duple US
- PE- CXR, duplex us
97
what is anaemia in pregnancy defined as?
HB <105g/l
98
risk factors for anaemia during pregnancy
- starting pregnancy anaemic
- frequent pregnancies
- twin pregnancy
- poor diet
99
what antenatal screening is done for anaemia?
- Hb estimation at booking and at 28 weeks
black patients- must check sickle cell
100
risk factors for group B strep infection?
- prematurity
- prolonged ROM
- previous group B strep sibling
- maternal pyrexia
101
group B strep- if a patient is isolated during labour what should be given?
IV benzyl penicillin to reduce neonatal transmission
102
clinical features of group b strep infection in pregnancy
- UTI- frequency, urgency, dysuria
- chorioamnionitis- fever, foul discharge, tachycardia
- endometritis- fevers, lower abdo pain, intermenstrual bleeding, foul discharge
103
symptoms of measles in pregnancy
fever
generalised maculopapular, erythematous rash
Koplik's spots
cough
coryza
104
how is rubella spread?
respiratory droplets
105
features of rubella
Cataracts 8-9 weeks
Deafness 5-7 weeks
Cardiac lesions 5-10 weeks
- Cerebral Palsy
106
what congenital defects are associated with cytomegalovirus?
```
IUGR
microcephaly
hepatoslenomegaly
jaundice
chorioetinitis
```
later- motor and cognitive impairment
107
what are the symptoms of toxoplasmosis?
similar to glandular fever- fever, rash and eosinophilia
108
cause and treatment of toxoplasmosis
cause- raw meat/ cat faeces
tx- pyrimethamine + sulphadiazine + spiramycin
109
how is parvovirus B19 spread?
DNA virus
respiratory droplets
4-20 day incubation period
110
what syndrome may occur in pregnancy with Parvovirus B19?
slapped cheek syndrome
111
what are the consequences to the foetus of Parvovirus B19 infection?
- foetal suppression of erythropoiesis
| - cardiac toxicity- leading to cardiac failure
112
what should you give to a mother with hepatitis B?
- Screen all mothers
| - give immunoglobulin and vaccinate babies of carriers and infected mothers at birth
113
what should be done if a pregnant mother develops chickenpox near delivery?
- aim for delivery after 7 days
- give baby varicella immune immunoglobulin at birth
- monitor for 28 days
- if baby develops chickenpox- treat with acyclovir
114
features of foetal varicella syndrome
- skin scarring
- eye defects
- neurological abnormalities
115
what is gonococcal conjunctivitis and what are the features of it?
- occurs within 4 days of birth
| - purulent discharge and lid swelling
116
how should infants born with gonorrhoea be managed?
cefotaxime and chloramphenicol
117
what investigations must be done in an infant with jaundice?
- LFT's
- urine dip- bile
- serology
- HBsAG- Hep B surface antigen
118
when is obstetric cholestasis (intrahepatic cholestasis of pregnancy) typically seen and what are some features of it?
- 3rd trimester
| - jaundice, pruritis of palms and soles, NO RASH, worse at night, raised bilirubin
119
how is obstetric cholestasis managed?
- ursodeoxycholic acid
| - symptoms resolve upon delivery
120
complications of obstetric cholestasis
stillbirth
preterm labour
meconium
foetal distress
121
when does acute fatty liver of pregnancy occur and what are some features?
- rare- occurs in 3rd trimester
- very serious !
- jaundice, abdo pain, malaise etc, hypoglycaemia, pre-eclampsia
122
complications of acute fatty liver of pregnancy
hepatic steatosis
coma, death
123
investigations and management of acute fatty liver of pregnancy
- high ALT
management- delivery is definitive management
124
where do the majority of ectopic pregnancies lie?
97%- fallopian tubes- typically the ampullary (most common) or isthmic portions
125
what is an ectopic pregnancy?
pregnancy that occurs anywhere outside the uterus
126
risk factors for an ectopic pregnancy?
- IVF
- age
- PID
- Previous ectopic
- smoking
- adhesions from infection and inflammation from endometriosis
- previous tubal surgery
127
clinical presentation of an ectopic pregnancy
- abdo/pelvic pain and tenderness
- amenorrhoea- 6-8 weeks
- vaginal bleeding
- dizziness, fainting, syncope
- rebound tenderness
- shoulder tip pain- diaphragmatic irritation from blood if ruptures
128
differential diagnosis of an ectopic pregnancy
threatened miscarriage
appendicitis
bowel ischaemia
129
diagnostic tests and results in an ectopic pregnancy
- pregnancy test- no rapid decline of bhCG
- transvaginal USS
- empty uterus and positive pregnancy test
130
treatment of an ectopic pregnancy
- medical- if no complications- single dose methotrexate
| - surgery- salpingectomy, salpingotomy
131
side effects of methotrexate treatment (in an ectopic pregnancy)?
conjuctivitis
stomatitis
diarrhoea
abdo pain
132
what must be given/ used alongside methotrexate?
contraception- methotrexate is teratogenic
133
what is a molar pregnancy?
gestational trophoblastic disease
- molar pregnancy- non-viable fertilised egg= implants into uterus- will not come to term
134
aetiology of a complete molar pregnancy
all genetic material comes from father- so empty oocyte is fertilised
sperm+ empty egg
135
aetiology of a partial molar pregnancy
- trophoblast cells have 3 sets of chromosomes (triploid)
- 2 sperms fertilise ovum at same time
- 2 sperms plus one egg
136
what follows a molar pregnancy in 2-3% of cases?
choriocarcinoma
137
risk factors for a molar pregnancy
- age <16 or >45
- multiple pregnancies
- previous molar pregnancy
- women with menarche over the age of 12
- OCP
- asian
138
what is an invasive mole?
when. complete mole invades the myometrium
139
how does a molar pregnancy present clinically?
- first half of pregnancy- vaginal bleeding
- uterine evacuation- 10 weeks of gestation
- exaggerated Sx of pregnancy- hyperemesis gravidarum
- pre-eclampsia
- unexplained anaemia
140
how is a molar pregnancy diagnosed?
- bhCG- very high levels in blood and urine
- history
- USS- 'snowstorm appearance' in 2nd trimester
141
treatment of a molar pregnancy
- urgent referral
- suction curettage and HCG monitoring
- chemo- cisplatin
- effective contraception- ensure female does not get pregnant until hCG levels have been normal for 6 months
- ERPC- evacuation of retained products of contraception
142
what is the definition of a miscarriage?
defined as the loss of pregnancy before 24 weeks of gestation
- does not include ectopic or molar
143
what is a complete miscarriage?
TVUS shows crown rump length >7mm
gestational sack >25mm
no foetal heartbeat
144
what is a threatened miscarriage?
mild symptoms of bleeding with little/ no pain, cervical os is closed
145
what is an inevitable miscarriage?
heavy bleeding with clots and pain
cervical os is open
pregnancy will not continue- proceeds to incomplete/ complete
146
what is an incomplete miscarriage?
products of conception are partially expelled
cervical os is open
pain and vaginal bleeding
147
what is a missed miscarriage?
foetus is dead but retained
uterus is small for dates
pregnancy test remains +ve
closed cervical os
148
how does a missed miscarriage present?
presents with a history of threatened miscarriage
persistent dirty brown discharge
149
what is a habitual/ recurrent miscarriage?
3 or more consecutive miscarriages
150
causes of a miscarriage?
- abnormality- foetal development, cervix, uterus, placenta
- PCOS
- previous miscarriage
- BV infection
151
risk factors of miscarriage
- age >30
- incidence increase with parity
- smoking >14 per day
- excess alcohol
- illicit drug use
- uncontrolled DM
- uterine surgery
152
epidemiology of miscarriages
15-20% of recognised pregnancies
85% occur in 1st trimester
153
clinical presentation of a miscarriage?
- vaginal bleeding with/ without abdo pain
- passing products of contraception
- cervical os open enough to admit 1 finger
- uterine size small for dates
154
differentials of a miscarriage
- ectopic pregnancy
- neoplasia
- hydatiform mole
- chorionic cyst
155
diagnosis of a miscarriage
- transvaginal USS
| - serum hCG- to exclude ectopic pregnancy
156
medical, surgical and social treatment of a miscarriage
medical:
- <12 weeks- mifepristone (anti-progesterone), then give misoprostol 36-48 hours later
- >12 weeks- vaginal misoprostol
surgical:
- if <13 weeks, suction evacuation under GA
social:
- counselling
- anti-D rhesus prophylaxis
157
causes of recurrent miscarriages
- antiphospholipid syndrome
- endocrine- poorly controlled DM, thyroid, PCOS
- Smoking
- parental chromosomal abnormalities
- uterine abnormality- uterine septum
158
when must pregnancies be terminated before?
week 24 of gestation
159
what exceptions can be made for terminating a pregnancy after week 24?
- risk to mothers life
- risk of grave, permanent injury to mothers physical/ mental health
- substantial risk to child- physical/ mental abnormalities serious enough
160
how are pregnancies terminated?
medical:
- mifepristone to prime cervix
- misoprostol
surgical:
- vaccum aspiration
161
what is pre-eclampsia?
defined as pregnancy-induced hypertension in association with proteinuria (>0.3g in 24h) with or without oedema
162
how is severe pre-eclampsia defined?
diastolic BP of at least 110mmHg or systolic BP of at least 160mmHg and/ or symptoms of biochemical and haematological impairment
163
what may happen to the foetus in severe pre-eclampsia?
neurological damage due to hypoxia
164
describe the 2 stages of pre-eclampsia
stage 1- incomplete trophoblastic invasion of spiral arterioles, decreased utreroplacental blood flow
stage 2- endothelial cell damage resulting in vaso-constriction, lotting dysfunction and increased vascular permeability
165
what must be given and when for women with high/ moderate risk factors of pre-eclampsia?
aspirin at 12 weeks
166
what are some high risk factors of pre-eclampsia?
- pre-eclampsia/ HTN in previous pregnancy
- CKD
- autoimmune disease- SLE/ antiphospholipid syndrome
- T1/2 DM
167
what are some moderate risk factors of pre-eclampsia?
- 10+ years since last pregnancy
- first pregnancy
- age >40
- BMI > 25
- FH (mother/sister) of pre-eclampsia
- multiple pregnancies
168
clinical presentation of pre-eclampsia
- systolic BP >140mmHg or diastolic BP >90mmHg in second half of pregnancy
- 1+ proteinuria
- new HTN
- severe HTN
169
what are some signs of severe HTN seen in pre-eclampsia?
- severe headache
- visual disturbance
- sudden swelling of face, hands and feet
- RUQ pain
- epigastric pain +/- vomiting
- HELLP syndrome- haemolysis, elevated liver enzymes, low platelets
- pappiloedmea
- foetal distress/ reduced foetal movement
- small for gestational age infant
170
diagnosis + results for pre-eclampsia
- urinalysis- dipstick for proteinuria
- urine culture- exclude infection
- clotting studies
- USS of foetus- foetal growth, volume of amniotic fluid
171
if a urine dipstick shows no proteinuria in a patient with suspected pre-eclampsia, what is the diagnosis?
gestational HTN
172
what BP measurements indicate, mild, moderate and severe pre-eclampsia?
mild- 140-149 systolic, 90-99 diastolic
moderate- 150-159 systolic, 100-109 diastolic
severe- >160/110
173
management of mild pre-eclampsia
monitor BP 4x daily
twice weekly blood tests
174
management of moderate pre-eclampsia
monitor BP 4x daily
start labetalol (BB)
3 blood tests each week
175
management of severe pre-eclampsia
- monitor BP 4x daily
- labetalol
- blood tests 3x week
- magnesium sulphate
- deliver baby once woman is stable and baby is >34 weeks
176
what medications must be avoided in pre-eclampsia?
ACE inhibitors and angiotensin- II receptor antagonists
177
maternal complications of pre-eclampsia
- eclampsia
- cerebrovascular haemorrhage
- HELLP
- DIC
- liver failure, rupture
- renal failure
- pulmonary oedema
178
foetal complications of pre-eclampsia
IUGR
placental abruption
preterm birth
179
what is eclampsia?
onset of convulsion in a pregnancy complicated by pre-eclampsia
180
how is eclampsia treated and managed?
obstetric emergency !
- control fits- magnesium sulphate
- control BP- labetalol, nifedipine, epidural analgesia
- infant delivery
181
what is the function of magnesium sulphate in eclampsia?
- helps control fits
- suppresses convulsions and inhibits muscular activity
- reduces DIC risk as it reduces platelet aggregation
182
what is the risk of the use of magnesium sulphate in pre-eclampsia?
reduced reflexes and respiratory depression
183
what is HELLP syndrome?
Haemolysis, Elevated Liver enzymes, Low Platelets
complication of pregnancy which usually presents in women who have pre-eclampsia/ eclampsia
184
risk factors for developing HELLP syndrome
- age >35
- nulliparity
- previous gestational HTN
- multiple pregnancies
- previous HELLP
- caucasian
- antiphospholipid syndrome
185
when do cases of HELLP syndrome typically present
usually in last half of pregnancy- 70% between 27-37 weeks
30% present post-partum
186
symptoms and signs of HELLP syndrome
- non-specific- malaise, fatigue, RUQ pain etc
- rapid onset
- headache and isual disturbance
- worse at night, better during day
SIGNS
- hepatomegaly
- bruising/ purpura
- oedema, HTN and proteinuria
- jaundice
187
differential diagnosis of HELLP syndrome
- acute fatty liver of pregnancy
- TTP/ ITP
- exacerbation of SLE
- viral hepatitis
188
how is HELLP syndrome diagnosed?
- haemolysis w/ fragmented red cells on blood film
- raised LDH with a raised bilirubin
- raised liver enzymes
- low platelets
189
how is HELLP syndrome treated?
- deliver foetus
- magnesium sulphate
- blood transfusion and control BP
190
what is intrauterine growth retardation (IUGR)?
When a baby's growth slows or ceases when it is in the uterus
191
give some maternal, placental, foetal and genetic factors that can contribute to IUGR?
maternal- >40, smoker, cocaine, previous SGA baby, diabetes, antiphospholipid syndrome
placental- pre-eclampsia
foetal- trisomy 13/18/21, turners, infection- CMV, rubella
genetic- FH
192
what is the acronym for the high and rare high risk factors for IGUR?
SHITS CRAP
```
high:
Smoking
HTN/ pre-eclampsia
IUGR previously
Twins
Stillbirth
```
```
rare high:
Cocaine
Renal disease
Antiphospholipid snydrome
PAAP-A levels low
```
193
what is PAPP-A?
Pregnancy Associated Plasma Protein-A (PAPP-A)
produced by placenta- low levels associated with low birth weights and early delivery
194
what is symmetrical IUGR?
- cause of IUGR earlier in pregnancy
- antenatal scan shows small head, abdo and femur length
- postnatal weight, length and head circumference all reduced
195
what is asymmetrical IUGR?
- cause of IUGR later in pregnancy
- antenatal scan shows small abdo circumference (head and femur length normal)
- postnatal- reduction in weight but length and head circumference normal
196
long term complications of IUGR?
- lower scores on cognitive testing
- developmental delay
- cerebral palsy
- ADHD
- more susceptible to adult onset diseases- diabetes, HTN, obesity, CHD
197
how is IUGR diagnosed?
- foetal abdo circumference or estimated foetal weight <10th centile
- reduced amniotic fluid index (AFI)
198
management of IUGR
- LSCS
| - corticosteroids to assist lung development
199
what is the difference between sepsis, severe sepsis and septic shock?
sepsis- infection + systemic manifestations of infection
severe sepsis- sepsis w/ sepsis-induced organ dysfunction or evidence of tissue hypo-perfusion
septic shock- persistent tissue hypo-perfusion despite adequate fluid replacement
200
what is the most common cause of sepsis?
group A strep (community acquired)
201
causes of sepsis in pregnancy
- pyelonephritis
- chorioamnionitis
- post-partum endometritis
- wound infection
- pneumonia
202
risk factors of sepsis in pregnancy
- usual stuff- obesity, diabetes etc
- vaginal discharge
- history of pelvic infection
- invasive procedures- amniocentesis
- cervical discharge
203
signs and symptoms of sepsis
- fever, rigors, diarrhoea, vomiting
- rash
- abdo/ pelvic pain
- SIRS criteria
- hypoxia, HTN
- oliguria
- impaired consciousness
204
what is the SIRS criteria for sepsis?
3T's white with sugar
```
Temperature >38 or <36
Tachycardia >90bpm
Tachypnoea- >20bpm
WBC <4 or >12
Sugar (glucose) >7.7 in absence of dm
```
205
What is the sepsis 6 and what else must be considered in a pregnant patient with sepsis?
blood cultures, urine output, fluid resuscitation, broad spec antibiotics IV, lactate, 02
- consider delivery and VTE prophylaxis
206
what is chorioamnionitis?
acute inflammation of foetal amnion and chorion membranes due to ascending bacterial infection in setting of membrane rupture
207
clinical features of chorioamnionitis
uterine tenderness
ROM
foul odour of amniotic fluid
maternal signs of infection- tachycardia, pyrexia, leucocytosis
208
how is chorioamnionitis managed?
delivery (C section if necessary) and IV Abx
209
what is the definition of a premature labour?
presence of contractions of sufficient strength and frequency to effect progressive effacement and dilation of the cervix before week 37 of gestation
210
risk factors for a premature labour
- multiple pregnancy
- cervical incompetence that requires surgery
- previous preterm labour/ miscarriage
- previous prelabour rupture of membranes
211
clinical presentation of a premature labour
- contractions
- bleeding/ amniotic fluid loss
- dilatation of cervix
212
how is a premature labour managed?
- not viable if <24 weeks
- tocolysis
- corticosteroids- betamethasone or dexamethasone
- magnesium sulphate
213
what is tocolysis and what medications are used in a premature labour?
tocolysis- obstetrical procedure carried out with the use of medications with the aim of delaying the delivery of a foetus in women presenting with preterm contractions
- prostaglandin synthesis inhibitors- indomethacin
- CCB- nifedipine
- atosiban
214
what is the definition of preterm premature rupture of membranes and give some RF for this?
rupture of the membranes <37 weeks
RF:
- UTI
- multiple pregnancy
- polyhyromnias
- malpresentation
215
in a patient with suspected preterm premature rupture of membranes, what musnt be done on a speculum exam?
dont put fingers in !
216
how is preterm premature rupture of membranes treated in mid-trimester, early and late?
mid-trimester (<24 weeks)- poor outcomes- pulmonary hypolasia
early (24-34 weeks)- dexamethasone+erythromycin
late (>34 weeks)- induce labour
217
what is an antepartum haemorrhage?
bleeding from birth canal after 24th week of pregnancy
218
aetiology of antepartum haemorrhage
- placenta praevia
- placenta abruption
- vasa previa
- cervical polyps/ erosions/ carcinoma
- cervicitis/ vaginitis
219
clinical presentation of an antepartum haemorrhage
- bleeding
- pain may be present
- uterine contractions
- malpresentation/ failure of foetal head to engage
- foetal distress
- hypovolaemic shock
220
in a patient with an antepartum haemorrhage, what differential must be excluded and how is this done?
placenta praevia- USS
221
treatment of an antepartum haemorrhage
- ABC + IV access
- left lateral position to avoid aortocaval compression
- group+save/ cross match
- replacement fluid/ blood
- ANTI-D
222
what is abruptio placenta?
premature separation of placenta from the uterus
significant cause of third-trimester bleeding associated with foetal and maternal morbidity and mortality
223
aetiology of abruptio placenta
- maternal HTN (most common)
- maternal trauma
- smoking, alcohol, drugs
- short umbilical cord
- sudden decompression of uterus
224
risk factors for abruptio placenta
- smoking
- previous abruption
- HTN/ pre-eclampsia
- thrombophillia
- cocaine
- trauma
225
how does a patient with abruptio placenta present clinically?
- pain
- vaginal bleeding- dark red blood
- foetal distress
- 'woody, hard uterus'
226
how is abruptio placenta treated?
same as antepartum haemorrhage:
- ABC + IV access
- left lateral position to avoid aortocaval compression
- group+save/ cross match
- replacement fluid/ blood
- ANTI-D
227
what is placenta praevia?
when the placenta is inserted wholly or in part into the lower segment of the uterus
228
RF for placenta praevia
- previous
- previous C section
- increased maternal age + parity
- smoking
- cocaine use during pregnancy
229
what is the difference between major and minor placenta praevia?
major- placenta covers the 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)
230
clinical presentation of placenta praevia
- painless bleeding after week 28 (acute onset)
- bright red blood
- pre-term delivery
- high-presenting part/ abdominal lie
231
how is placenta praevia treated?
- minor- deliver vaginally
- C-section at week 38
- ANTI-D
- steroids if <34 weeks
232
give 3 complications of placenta praevia?
- PPH (post-partum haemorrhage)
- Placenta accreta
- Placenta percreta
233
what is placenta accrete?
abnormal adherence of all/part of the placenta to the uterus
234
what is the difference between placenta increta and placenta percreta?
- increta- myometrium is invaded
| - percreta- reaches serosa
235
how are placenta increta/ percreta diagnosed?
prenatally- colour doppler US MRI
236
what is vasa praevia and how is it managed?
- foetal vessels run/ cross the internal os, resulting in a risk of membrane rupture- leading to foetal haemorrhage
managed via Caesarean section
237
what is a primary post-partum haemorrhage?
defined as bleeding from the genital tract in excess of 500ml's in the first 24h after delivery of the baby
238
what is a secondary post-partum haemorrhage?
abnormal vaginal bleeding any time in the puerperium up to 6 weeks
239
how are post-partum haemorrhages classified into massive, major and minor?
massive= >1500ml
major= >1000ml
minor= 500-100ml
240
aetiology of primary post-partum haemorrhage
4 T's
TONE- atonic uterus
Tissue- retained placenta w/ prolonged 3rd stage
Trauma- tears and repairs
Thrombin- pre-eclampsia/ DIC
241
what is the most common cause of a secondary post-partum haemorrhage?
secondary to infection
242
risk factors for a post-partum haemorrhage
- uterine over-distension (due to multiple pregnancies)
- prolonged labour/ instrumental delivery
- previous
- multiple fibroids
- thrombin- HELLP, sepsis, DIC
243
what must be given as prophylaxis to prevent a post-partum haemorrhage with an anterior shoulder delivery?
oxytocin IM
244
how is a post-partum haemorrhage treated and managed?
- ABC- fluid resus
- bi-manual uterine compression (massage and compress uterus to expel clots)
- IV oxytocin +/- ergometrine
- misoprostol
surgical- evacuation, balloon tamponade, hysterectomy
245
the seven cardinal movements- what are they (definition)?
positional changes that assist the baby in the passage through the birth canal
engagement, descent, flexion, internal rotation, extension, external rotation, expulsion
246
the seven cardinal movements- what happens during engagement?
entering of the biparietal diameter (measuring ear tip to ear tip across the top of the baby's head) into the pelvic inlet
247
the seven cardinal movements- what is descent?
- lightening- baby's head moves deep into pelvic cavity
- head becomes moulded
- biparietal diameter descends into pelvic inlet
248
the seven cardinal movements- what is flexion?
- occurs due to resistance between head and soft tissues of pelvis
- resistance causes flexion of head so chin meets chest
- smallest diameter of head presents into pelvis
249
the seven cardinal movements- what is internal rotation?
- head rotates as it reaches pelvic floor
- baby moves from a sideways position to one where the sagittal suture is in the AP diameter of outlet (back of baby's head is against front of pelvis)
250
the seven cardinal movements- what is extension?
- rest- neck is under pubic arch
| - extension occurs as head, face and chin are born
251
the seven cardinal movements- what is external rotation?
- pause after head is born
| - restitution- baby rotates to fit shoulders under pubic arch
252
the seven cardinal movements- what is expulsion?
- after external rotation- anterior shoulder moves out from under pubic bone
- rest of baby is then born with an upward motion by care provider
253
what is shoulder dystocia?
occurs when baby's shoulders are halted at pelvic outlet due to inadequate space through which to pass
usually the anterior shoulder which impacts on the maternal symphysis
254
aetiology of shoulder dystocia
3P's= Power (uterus), Passenger (foetus), Pelvis
Power/ uterine factors= infrequent contractions, primigravid
Passenger/ foetal= position or lie, macrosomia
Pelvic passage= long, oval brim, cephalopelvic disproportion (due to scoliosis, kyphosis or rickets)
255
risk factors of shoulder dystocia
- maternal DM
- foetal macrosomia
- maternal obesity
- induction + prolonged labour
- use of oxytocin
- assisted vaginal delivery
256
how does shoulder dystocia present clinically (i.e. during birth)?
- difficulty with delivery of face
- head remaining tightly applied to vulvula or retracting (turtle-neck sign)
- failure of head to restitute
- failure of shoulders to descend
257
how is shoulder dystocia managed?
- stop mother pushing
- McRobert's manoeuvre- hyperflex mothers hips to abdomen
- Woods screw manoeuvre
- epiostomy
- Zavvenelli's- may require C section
258
complications for foetus and mother of shoulder dystocia
foetal:
- brachial plexus injury (Erb's palsy)
- perinatal morbidity and mortality from hypoxia
- fractured humerus or clavicle
- pneumothorax
maternal:
- PPH
- 3/4th degree tear
- vaginal lacerations
- cervical tear
- bladder/ uterine rupture
259
what is a cord prolapse?
when the umbilical cord descends below the presenting part and causes hypoxia in the baby
260
risk factors for cord prolapse
- pre-term labour
- breech presentation
- spontaneous early rupture of membranes
- polyhydramnios
- abnormal lie
- twin pregnancy
261
how can cord prolapse be prevented?
elevate presenting part manually or by filling urinary bladder to stop presenting part occluding cord
262
how is a cord prolapse managed?
- tocolytics to reduce compression
- push presenting part of foetus back into uterus
- patient on all 4's
263
what is an amniotic fluid embolism?
liquid enters maternal circulation- leading to anaphylaxis with sudden, dyspnoea, hypoxia and hypotension
264
what severe consequences can amniotic fluid embolism cause?
DIC
pulmonary oedema
ARDS
265
how is an amniotic fluid embolism managed?
resus and support- O2, fluids, bloods etc
266
what are some clinical signs of uterine rupture?
- foetal heart rate abnormalities
- vaginal bleeding
- cessation of contractions
- maternal shock
- foetal distress
267
risk factors for uterine rupture
- labour with scarred uterus- from C section, deep myomectomy or previous surgery
- neglected obstructed labour
- breech extraction
268
management of uterine rupture
- maternal resus
| - emergency C section if suspected in labour
269
what is Bishops score?
- pre-labour scoring system used to assist in predicting whether induction of labour will be required
- used to assess the odds of spontaneous preterm delivery
270
what causes gestational diabetes?
- increased resistance to insulin due to placental production of anti-insulin hormones (hPL, glucagon and cortisol)
- plus increased appetite in pregnancy (particularly to fatty foods)
271
risk factors for the development of gestational diabetes
- previous large infant
- previous GD
- 1st deg. relative with diabetes
- obesity
- south asian, black Caribbean or middle eastern
- macrosomia
- glycosuria
272
clinical features of gestational diabetes
- can be asymptomatic
- polydipsia
- polyuria
- dry mouth
- tiredness
273
how is gestational diabetes screened for?
screen at risk groups by 75g OGTT (oral glucose tolerance test) at 28 weeks
274
what are the implications of gestational diabetes to each trimester of the pregnancy?
1st- none
2nd- pre-eclampsia and macrosomia
3rd- same as 2nd + recurrent infections, intrauterine death, polyhydramnios, congenital malformations
275
what is the effect of gestational diabetes on:
- labour
- delivery
- post-natal
- long term (for both mother and baby)
- labour- risk of still/ premature birth, induction required
- delivery- C-section usually/ instrumental birth, shoulder dystocia
- post-natal- neonatal hypoglycaemia, respiratory distress syndrome, jaundice
- long term, T2DM (mother), obesity (baby)
276
what acronym can be used to remember the risk from Gestational diabetes?
SMASH
```
Shoulder dystocia
Macrosomia
Amniotic fluid excess (polyhydromnias)
Stillbirth
HTN+neonatal hypoglycaemia
```
277
why is polyhydromnias seen in gestational diabetes?
increased in foetal glucose results in polyuria, hence more amniotic fluid
278
why does macrosomia occur in gestational diabetes?
increased foetal insulin- too much glucose is absorbed
279
what is the 'rule' for the results of the OGTT in gestational diabetes?
5.6.7.8
fasting= >5.6
after 2 hours= >7.8
280
how is gestational diabetes managed?
- diet and exercise
- metformin and glibenclamide
- insulin
281
what is Lochia?
- normal discharge/ bleeding in the first 2 weeks after giving birth
282
in a patient presenting with Lochia, what symptoms indicate the need for further investigation?
smell
increased volume of blood
bleeding hasn't stopped
283
why are infections common in pregnancy?
placental surface in the surface is vulnerable to infection- it is exposed to the vagina
284
what peripartum events and lead to a chronic infection in pregnancy?
- prolonged membrane rupture
- chorioamnionitis
- repeated vaginal examinations
- poor personal hygiene
- catheterisation
- C section/ instrumental deliveries
- perineal trauma
- manual removal of placenta
285
for Endometritis, state:
- symptoms
- aetiology
- clinical features
- symptoms- fever, lower abdo pain
- secondary to PPH+foul-smelling vaginal discharge
- aetiology- group A haemolytic strep, aerobic gram-negative rods
- CF- tachycardic and tender
286
predisposing factors to developing a UTI during pregnancy
- previous UTI
- polycystic kidneys
- congenital abnormalities of renal tract
- neuropathic bladder
287
clinical features of a UTI
- voiding difficulty- urgency and frequency
- dysuria
- fever
- pain
288
diagnosis of a UTI
- nitrates
| - urinalysis- protein and leucoytes
289
what organisms commonly cause UTI's?
E.coli, Kliebsiella, proteus
290
features of lactation mastitis
- breast pain
- fever
- erythema
- arises after breast feeding
291
what organism commonly causes lactation mastitis?
staph aureus
292
how is lactation mastitis managed?
- pain- analgesia, warm compresses and ensure Pt completes emptying of breast after feeding
- if infected nipple fissure + bacteria culture +ve, give oral flucloxacillin
293
what antibiotics cannot be given to mothers who are breastfeeding?
- ciprofloxacin
- tetracycline
- chloramphenicol
- sulphonamides
294
what psychiatric drugs cannot be given to mothers who are breastfeeding?
- lithium
- benzo's
- fluoxetine
295
other than antibiotics and psychiatric drugs, what other medications cannot be given to to breastfeeding mothers?
- aspirin
- carbimazole
- methotrexate
- sulphonlyureas
- cytotoxic drugs
- amiodarone
296
what are some risk factors for developing psychiatric illness after birth?
- hx of mental health problems
- alcohol/ drug misuse
- womans attitude towards pregnancy
- mother-baby relationship
- living conditions/ social isolation
- FH
- domestic violence and abuse
- socioeconomic status
297
clinical features of post-natal depression
- low mood
- low energy
- exhausted
- irritable
- unable to cope
- feeling guilty about not being able to cope/ not loving baby enough
- anxiety about baby
- tearful
- difficulties in bonding with baby
- difficulties in relationships with family
298
features of the 'baby blues'
- common, transient
- 3-7 days after primip birth- may last 2 weeks
- tearful, anxious and irritable
- reassurance and support
299
when is post-natal depression commonly seen?
- 10% of pregnancies
| - starts within a month and peaks at 3 months
300
how is post-natal depression treated?
- reasurrance and support
- CBT
- SSRI's (sertraline/ paroxetine)
- tricyclics
301
How does puerperal psychosis present and how is it managed?
- rare- presents up to 2-3 weeks after birth
- severe mood swings and disordered perception
- treatment= mood stabilisers, antidepressants, ECT
- to treat psychotic symptoms= antipsychotics/ long acting benzo's
302
causes of placental insufficiency
- abnormal trophoblast invasion- pre-eclampsia, palcenta accreta
- infarction
- abruption
- placenta praevia
- tumours- chorioangioma
303
how is a retained placenta diagnosed?
when the placenta does not spontaneously delivery within an hour after birth
304
risk factors for a retained placenta
- high parity
- prolonged use of oxytocin
- history of uterine surgery
- IVF conception
305
why is a retained placenta such a serious complication?
delivery of the placenta allows the uterus to contract; without this it will continue to bleed leading to haemorrhage
306
how is a retained placenta managed?
- by hand- but risk of infection
| - physiological processes can also help- e.g. urinating and breastfeeding
307
what is Sheehan's syndrome?
excessive blood loss during pregnancy/ after delivery leading to dysfunction of the pituitary gland. This results in hypopituitarism
essentially postpartum hypopituitarism caused by necrosis of the pituitary gland
308
how does sheehan's syndrome present clinically?
lactation failure post-partum
can take a long time to diagnosis
- axillary/ pubic hair loss
- weakness
- premature ageing
- hyperpigmentation
- amenorrhoea
- hypothyroidism
309
explain the pathology of rhesus disease
- fetal cells cross into maternal circulation (normal)
- fetus carries gene for antigen which the mother does not have- fetus nay be D/d (rhesus D +ve) whereas mother is d/d (-ve)
- if this is the first occurence/ first pregnancy, IgM is produced which cannot cross placenta so pregnancy is not at risk
- re-exposure in a subsequent pregnancy causes B cells to produce IgG which crosses into foetal circulation and destroys erythrocytes, resulting in haemolytic anaemia (fatal to foetus)
310
when are pregnant women screened for rhesus?
booking, 28 and 34 weeks
311
how can foetal RBC lysis be prevented in rhesus negative mothers?
Anti-D prophylaxis is given- destroys Rh+IgG- hence no RBC's are destroyed
312
when may sensitisation to Rhesus disease occur during pregnancy?
- miscarriage
- abortion
- amniocentesis
- placental abruption
- delivery
313
what must be given to a rhesus negative mother whilst having amniocentesis?
Anti D- risk of sensitisation
314
give some clinical signs for polyhydramnios
- increased abdo size (out of proportion)
- AFI (amniotic fluid index) >20 on USS
- maternal dyspnoea
- faint foetal heart sounds
315
aetiology of polyhydramnios
- maternal diabetes
- foetal- dudonal atresia
- multiple gestation
316
what are some consequences of polyhydramnios?
- cord prolapse
- PPH
- IGUR
- preterm labour
317
what is oligohydramnios?
low amniotic fluid level- defined as <8cm AFI
318
Aetiology of oligohydramnios
- leakage of amniotic fluid
- reduced fetal urine production- IUGR, fetal renal failure
- obstruction to foetal urine output- posterior urethral valves
319
what are some complications of oligohydramnios?
- preterm rupture of membranes
- IUGR
- reduced volume- lung hypoplasia
320
how is oligohydramnios managed?
- 34-36 weeks- induce labour
| - if before 34-36 weeks- give oral erythromycin, monitor for infection, monitor until induction at 34-36 weeks
321
what trisomies are tested for during pregnancy?
13- Patau's
18- Edward's
21- Down's
322
what does the Combined test assess for and how is this done?
- Down syndrome- done in 1st trimester
| - Nuchal transulcency scan + serum levels of PAPP-A and free beta HCG
323
What is the quadrouple test?
- test for Down's in 2nd trimester
324
if screening for Down's has a positive result, what is done next?
- app at foetal medicine unit within 3 days
| - diagnostic test- Chorionic Villous Biopsy and Amniocentesis
325
when are screening ultrasounds done and what do they aim to identify?
- 8-10- viability of pregnancy
- 11-13- dating and gestational age
- 20- anomaly scan- identify major abnormalities (spina bifida, cleft lip, trisomy 13,18 etc)
326
what are haemoglobinopathies?
recessively inherited disorders of haemoglobin
327
what are the Quantitate haemoglobinopathies?
- Alpha thalassaemia- if major= incompatible with extra-uterine life
- Beta thalassaemia- life threatening anaemia
328
what Qualitative haemoglobinopathy is screened for?
sickle cell anaemia
329
how are haemoglobinopathies screened for?
- identification of carriers
- 8-10 weeks
- haematological test rather than genetic
330
what is the New-born blood spot (NBBS)?
- early diagnosis and treatment of conditions to prevent irreversible damage
- heel prick in days 5-8
331
how many conditions does the NBBS screen for (and what are the main 3 !)?
- 9 in total
main 3:
- Cystic fibrosis
- congenital hypothyroidism
- sickle cell anaemia
332
how is the newborn's hearing screened?
- within 4 weeks of birth
| - automated otoacoustic emission identifies response in cochlea to soft sounds from earpiece
333
what are the 2 categories of disorders that can lead to female infertility/ subfertility?
- disorders of ovulation
| - disorders of anatomy (tubes, uterus, cervix)
334
examples of 'disorders of ovulation' leading to female infertility
- PCOS
- pituitary tumour
- ovarian failure
- Sheehans
335
examples of 'disorders of anatomy' leading to female infertility
- PID
- endometriosis
- Ashermans
- STI
336
what should a patient be instructed to do if they have missed 1 COCP?
- take the missed one (even if thats 2 in 1 day)
| - still 'covered' for protection as long as missed dose is taken within 12 hours
337
what should a patient be instructed to do if they have missed 2 COCP?
- take last missed pill (not both)
| - must use condoms until back on track with pill regime for 7 days
338
give some contraindications for the use of the COCP
- migraine with aura
- breast feeding <6 weeks post-partum
- current breast cancer
- >35 BMI
- carrier of breast cancer gene
339
when does the progesterone only pill offer protection?
- up to day 5 of cycle
| - additional contraception needed for 2 days
340
what should be done >3 and <3 hours after missing a dose?
<3 hours- continue as normal
>3 hours- take missed pill and use barrier methods for next 48 hours
341
what is the Depo Provera method of contraception?
contains medroxyprogesterone acetate 150mg
given via IM injection every 12 weeks
342
what is the function of the IUD and what are some consequences of this?
- prevents fertilisation by decreasing sperm motility and survival
- is effective immediately
- makes periods heavier, longer and more painful
- risk of PID after insertion
343
what is levonorgestrel?
- progesterone- given as emergency contraception
| - delays ovulation, must be taken within 72 hours
344
Give some causes of infertility
- ovulatory
- tubal
- uterine
- male factors
345
what investigations would a GP do in a couple presenting with infertility?
- hormones- D2, FSH, D21 progesterone
TFT
Rubella
Smear
semen analysis
346
how is ovulation assessed in a patient presenting with infertility?
measure mid-luteal progesterone
347
what sperm count level warrants further investigation?
<5m/ml
- endocrine tests
- karyotyping
348
what 2 hormones are assessed to determine the patients ovarian reserve?
FSH
AMH
349
how is tubal patency investigated in a patient presenting with infertility?
- HSG (hysterosalpingogram) imaging
| - laparoscopy
350
if a mild, moderate, severe abnormality is present in a patient concerned with infertility, what can be done?
mild- intrauterine insemination
moderate- IVF
severe- intra-cytoplasmic sperm injection
351
describe the process of IVF
Ovarian stimulation -> egg collection -> insemination -> fertilisation check -> embryo culture -> embryo transfer -> luteal support
352
give 4 risk factors associated with IVF
- multiple pregnancy
- miscarriage
- ectopic pregnancy
- foetal abnormality
353
what is the APGAR scoring system?
assesses how well the baby is doing after birth (1-10, above 7 is good)
```
Appearance (Skin colour)
Pulse
Grimace (reflex irritability)
Activity
Respiration
```
