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Obstetrics Basics Flashcards

1
Q

Describe the female HPO axis in:

1) follicular phase
2) midcycle
3) luteal phase
4) pregnancy

A
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2
Q

Describe LH, FSH, oestradiol and progesterone changes during the menstrual cycle

A
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3
Q

Describe foetal growth (correlate organs grown with gestational age)

A

The vast majority of all the organogenesis will be completed by week 12.

The CNS continues to develop throughout the last few stages of pregnancy, + after the birth

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4
Q

Why might SFH (symphysis-fundal height) be lower or higher than expected?

A

If we measure a baby that is smaller, it may be because

  • We have the wrong dates
  • The baby is small for gestational age
  • Oligohydramnios
  • Transverse lie

Larger: wrong dates

  • We have the dates wrong
  • Molar pregnancy
  • Multiple gestation
  • Large for gestational age
  • Polyhydramnios
  • Maternal obesity
  • Fibroids
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5
Q

When is SFH measured? When is this plotted on a growth chart?

A
  • SFH measured from 24wks –> plot on growth chart
  • every antenatal visit from 24wks should measure SFH
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6
Q

Which biometric parameters are used to measure foetal growth on US?

A
  • 11+3 – 13+6 wks = CRL (crown-rump length = 45-84mm)
  • 14-20wks = HC (head circumference)
  • 20+ wks = USS biometry (biparietal diameter, head circumference, abdo circumference and femur length serially for 4wks)
    • CRL and HC alone become less accurate (genes and environmental factors influence foetal size)
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7
Q

What is the purpose of the anomaly scan?

A
  • 20-22 weeks
  • Detailed structural scan to assess foetal anatomy à can detect spina bifida, major congenital anomalies, diaphragmatic hernias, renal agenesis etc.
  • Assesses growth and size
  • Assesses amniotic fluid volume
  • Placental position
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8
Q

What is the combined screening test that occurs at the dating US scan?

A
  • screens for Down’s and other chromosomal abnormalities (Edward’s, Patau’s)
    • 3 parts to combined screening test:
      1. Measurement of nuchal translucency on USS
      2. Measurement of beta hCG and pregnancy-associated plasma protein A (PAPP-A)
        1. In trisomy 21 the b-hCG conc is higher (2x) and PAPP-A is lower (0.5x)
      3. Maternal age
    • –> These are combined to give a risk of Down’s à 90% detection rate
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9
Q

When is the quadruple test indicated? What is this?

A
  • Screening for Down’s, Patau’s and Edward’s can also be done between 14-20wks or if nuchal translucency measurement is not possible –> uses quadruple test (only maternal biomarkers)
    • Measures maternal AFP, hCG, unconjugated oestradiol and inhibin A
    • 80% detection rate with 5% false positive rate
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10
Q

When is invasive prenatal testing indicated?

A
  • If a high-risk result is given (for Down’s, Edward’s and Patau’s from the quadruple/combined screening test) the mother can be offered invasive prenatal testing to confirm the diagnosis (CVS/amniocentesis)
    • Remember high-risk is usually 1 in 150
    • If diagnosis is confirmed, mother must be counselled about continuing vs TOP
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11
Q

Describe the hormonal changes that take place during pregnancy

A

Human chorionic gonadotrophin is the key hormone produced by human pregnancy. It is a functional homologue of LH, driving the production of oestrogens and progesterones from the ovaries (drives the corpus luteum).

The corpus luteum degenerates towards the end of the last week of the menstrual cycle. The fall in progesterone results in the breakdown of endometrium. To keep the pregnancy going, we need progesterone. HcG drives the progesterone production from the corpus luteum. It peaks and falls in the first trimester.

Placental lactogen is produced, and levels increase as the size of the placenta increases. The same pattern of production is seen in progesterone and oestrogens.

There is a switch over in the production of steroids: for the first couple of months, the corpus luteum produces these hormones. For the next few months, the placenta takes over oestrogen/progesterone production.

  • hCG shows peak levels in maternal plasma in the first trimester, and declines thereafter
  • Other main hormones (or hormone families) increase as pregnancy progresses
  • Increases in progesterone, oestrogens and placental lactogen parallel the increased size of the placenta
  • By 10 weeks gestation, the placenta is the source of all progesterone (up to then, mainly corpus luteum)

Levels of progesterone (up to 1µM) and estrogens (up to 20nM) greatly exceed the levels seen during the normal menstrual cycle, so they may have potent effects on the maternal system in pregnancy. Low progesterone levels, or administration of a progesterone antagonist, will lead to loss of the pregnancy at all gestational ages.

The maternal endocrine system is modified substantially during pregnancy, with the high levels of steroids suppressing the HPG, leading to very low levels of LH and FSH throughout pregnancy, and hence no cyclic ovarian or uterine functions.

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12
Q

Describe the 3 phases of labour

A
  • PHASE I: can last many hours, and involves contractions and cervical/uterine changes
    • Contractions become more powerful and more coordinated
    • The cervix begins to soften (ripening) and gets thinner (effacement)
    • The length of phase I is incredibly variable (12 to 48 hours)
  • PHASE II: can last hours, and the baby is delivered in this phase
  • PHASE III: approximately half an hour long, in which the placenta is delivered
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13
Q

What are the stages in Phase 1 of labour?

A
  1. Cervical ripening and effacement
    • Change from rigid to flexible structure
    • Remodelling (loss) of extracellular matrix
    • Recruitment of leukocytes (neutrophils)
    • This is an inflammatory process – production of:
      • Prostaglandin E2, interleukin-8
      • Local (paracrine) change in IL-8
  2. Co-ordinated myometrial contractions
    • Fundal dominance
    • Increased co-ordination of contractions
    • Increased power of contractions
    • Key mediators
      • Prostaglandin F2a (E2) levels increased from fetal membranes
      • Oxytocin receptor increased
      • Contraction associated proteins
  3. Rupture of foetal membranes
  • Loss of strength due to changes in amnion basement component
  • This is what is happening when a woman’s ‘water breaks’
  • Inflammatory changes, leukocyte recruitment
    • This is modest in normal labour, exacerbated in pre-term labour
  • Increased levels and activity of MMPs
  • Inflammatory process in fetal membranes
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14
Q

Which parameters are observed and are clinically important on a CTG? (how does one read a CTG?)

A

DR C BRAVADO

  • DR: Define risk
  • C: Contractions
  • BRa: Baseline rate
  • V: Variability
  • A: Accelerations
  • D: Decelerations
  • O: Overall impression
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15
Q

What are some reasons a pregnancy may be defined as high risk?

A

Maternal medical illness

  • Gestational diabetes
  • Hypertension
  • Asthma

Obstetric complications

  • Multiple gestation
  • Post-date gestation
  • Previous cesarean section
  • Intrauterine growth restriction
  • Premature rupture of membranes
  • Congenital malformations
  • Oxytocin induction/augmentation of labour
  • Pre-eclampsia

Other risk factors

  • Absence of prenatal care
  • Smoking
  • Drug abuse
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16
Q

Which parameters are used to assess (maternal) contractions?

A

Duration: How long do the contractions last?

Intensity: How strong are the contractions (assessed using palpation)?

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17
Q

What does each 1 big square in a CTG equal to time-wise?

A

1 big square = 1 minute

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18
Q

What is a normal foetal HR?

A

normal fetal heart rate is between 110-160 bpm

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19
Q

List some causes of foetal tachycardia

A

Causes of fetal tachycardia include:

  • Fetal hypoxia
  • Chorioamnionitis
  • Hyperthyroidism
  • Fetal or maternal anaemia
  • Fetal tachyarrhythmia
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20
Q

In which situations is it common to have a baseline foetal heart rate of between 100-120 bpm ?

A
  • Postdate gestation
  • Occiput posterior or transverse presentations
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21
Q

Define Severe prolonged bradycardia. What does it indicate?

A

<80 bpm for more than 3 minutes, indicates severe hypoxia

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22
Q

What are some causes of prolonged severe foetal bradycardia?

A

Causes of prolonged severe bradycardia include:

  • Prolonged cord compression
  • Cord prolapse
  • Epidural and spinal anaesthesia
  • Maternal seizures
  • Rapid fetal descent
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23
Q

What is normal variability in foetal HR?

A

Normal variability is between 5-25 bpm

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24
Q

How can foetal HR variability be categorised?

A

Variability can be categorised as either reassuring, non-reassuring or abnormal.

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25
Q

Define a reassuring foetal HR variability

A

Reassuring: 5 – 25 bpm

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26
Q

Define a non-reassuring foetal HR variability

A

Non-reassuring:

  • less than 5 bpm for between 30-50 minutes
  • more than 25 bpm for 15-25 minutes
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27
Q

Define an abnormal foetal HR variability

A

Abnormal:

  • less than 5 bpm for more than 50 minutes
  • more than 25 bpm for more than 25 minutes
  • sinusoidal
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28
Q

Why might reduced foetal HR variability occur?

A

Reduced variability can be caused by any of the following:

  • Fetal sleeping: this should last no longer than 40 minutes (this is the most common cause)
  • Fetal acidosis (due to hypoxia): more likely if late decelerations are also present
  • Fetal tachycardia
  • Drugs: opiates, benzodiazepines, methyldopa and magnesium sulphate
  • Prematurity: variability is reduced at earlier gestation (<28 weeks)
  • Congenital heart abnormalities
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29
Q

Define accelerations in foetal HR

A

Accelerations are an abrupt increase in the baseline fetal heart rate of >15 bpm for >15 seconds.

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30
Q

Are foetal HR accelerations reassuring or non-reassuring?

A

accelerations = reassuring

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31
Q

Accelerations occurring alongside uterine contractions is reassuring or non-reassuring?

A

acceleratios + contrations = reassuring

32
Q

Is the absence of accelerations with an otherwise normal CTG reassuring or non-reassuring?

A

The absence of accelerations with an otherwise normal CTG is of uncertain significance.

33
Q

Define foetal HR decelerations

A

Decelerations are an abrupt decrease in the baseline fetal heart rate of >15 bpm for >15 seconds.

34
Q

What are the 3 types of foetal HR decelerations?

A
  • early
  • late
  • variable
35
Q

Define early decelerations. Are they normal or pathological?

A
  • Early decelerations start when the uterine contraction begins and recover when uterine contraction stops
  • This is due to increased fetal intracranial pressure causing increased vagal tone.
  • It therefore quickly resolves once the uterine contraction ends and intracranial pressure reduces.
  • This type of deceleration is, therefore, considered to be physiological and not pathological
36
Q

Define variable foetal HR decelerations.

A

Variable decelerations are observed as a rapid fall in baseline fetal heart rate with a variable recovery phase.

They are variable in their duration and may not have any relationship to uterine contractions.

37
Q

When are variable decelerations most commonly seen?

A

They are most often seen during labour and in patients’ with reduced amniotic fluid volume.

38
Q

What pathology most commonly causes variable decelerations?

A

Variable decelerations are usually caused by umbilical cord compression.

39
Q

What are the ‘shoulders of deceleration’?

A

The accelerations before and after a variable deceleration are known as the shoulders of deceleration

40
Q

What do the shoulders of deceleration suggest?

A
  • Their presence indicates the fetus is not yet hypoxic and is adapting to the reduced blood flow.
  • Variable decelerations without the shoulders are more worrying, as it suggests the fetus is becoming hypoxic
41
Q

How might variable decelerations resolve naturally?

A

If the mother changes position (may be due to cord compression)

42
Q

Define late foetal HR decelerations

A

Late decelerations begin at the peak of the uterine contraction and recover after the contraction ends

43
Q

What does late decelerations suggest clinically?

A
  • This type of deceleration indicates there is insufficient blood flow to the uterus and placenta.
  • As a result, blood flow to the fetus is significantly reduced causing fetal hypoxia and acidosis.
44
Q

What are some causes of reduced uteroplacental blood flow ?

A

Causes of reduced uteroplacental blood flow include:1

  • Maternal hypotension
  • Pre-eclampsia
  • Uterine hyperstimulation
45
Q

Define prolonged feoetal HR decelerations

A

A prolonged deceleration is defined as a deceleration that lasts more than 2 minutes:

46
Q

How are prolonged decelerations categorised?

A
  • non-reassuring (2-3mins duration)
  • abnormal (>3mins duration)
47
Q

What does a sinusoidal foetal HR look like on a CTGG

A

A sinusoidal CTG pattern has the following characteristics:

  • A smooth, regular, wave-like pattern
  • Frequency of around 2-5 cycles a minute
  • Stable baseline rate around 120-160bpm
  • No beat to beat variability
48
Q

What does a sinusoidal pattern indicate on a CTG?

A

A sinusoidal pattern usually indicates one or more of the following:

  • Severe fetal hypoxia
  • Severe fetal anaemia
  • Fetal/maternal haemorrhage
49
Q

What does a reassuring overall impression look like on a CTG?

A

Reassuring

Baseline heart rate

  • 110 to 160 bpm

Baseline variability

  • 5 to 25 bpm

Decelerations

  • None or early
  • Variable decelerations with no concerning characteristics for less than 90 minutes
50
Q

What does a non-reassuring overall impression look like on a CTG?

A

Abnormal

Baseline heart rate:

  • 100 to 109 bpm OR
  • 161 to 180 bpm

Baseline variability

  • Less than 5 for 30 to 50 minutes OR
  • More than 25 for 15 to 25 minutes

Decelerations

Any of the below would be classed as non-reassuring:

  • Variable decelerations with no concerning characteristics for 90 minutes or more.
  • Variable decelerations with any concerning characteristics in up to 50% of contractions for 30 minutes or more.
  • Variable decelerations with any concerning characteristics in over 50% of contractions for less than 30 minutes.
  • Late decelerations in over 50% of contractions for less than 30 minutes, with no maternal or fetal clinical risk factors such as vaginal bleeding or significant meconium.
51
Q

What does an abnormal overall impression look like on a CTG?

A

Abnormal

Baseline heart rate

  • Below 100 bpm OR
  • Above 180 bpm

Baseline variability

  • Less than 5 for more than 50 minutes OR
  • More than 25 for more than 25 minutes OR
  • Sinusoidal

Decelerations

Any of the below would be classed as abnormal:

  • Variable decelerations with any concerning characteristics in over 50% of contractions for 30 minutes (or less if any maternal or fetal clinical risk factors – see above).
  • Late decelerations for 30 minutes (or less if any maternal or fetal clinical risk factors).
  • Acute bradycardia, or a single prolonged deceleration lasting 3 minutes or more.
  • Regard the following as concerning characteristics of variable decelerations:
  • Lasting more than 60 seconds
  • Reduced baseline variability within the deceleration
  • Failure to return to baseline
  • Biphasic (W) shape
  • No shouldering
52
Q

What is a A high-risk pregnancy?

A

A high-risk pregnancy is one that threatens the health or life of the mother or foetus

  • Often requires specialised care
  • Some pregnancies become high-risk as they progress; others are high-risk from the beginning
53
Q

What are the risk factors for a high risk pregnancy?

A

Risk factors can include:

  • Pre-existing medical conditions:
    • HTN, DM, VTE asthma, epilepsy, psychiatric illness etc.
  • Risk of obstetric conditions/development of obstetric conditions:
    • Previous delivery <34wks, previous recurrent miscarriage, cervical incompetence, PPROM, previous shoulder dystocia, recurrent antepartum haemorrhage
    • Pre-eclampsia, obstetric cholestasis, hyperemesis gravidarum etc.
    • IVF pregnancy
    • Multiple pregnancy
  • Environmental/social/lifestyle factors:
    • Alcohol, smoking, recreational drugs
    • Mothers <18yo/>35yo
    • Social vulnerability
    • Obesity
    • Domestic violence
    • Women who decline blood products
54
Q

Where can births take place?

A
  • home
  • birth centre (midwife-led)
  • labour ward (hospital)
55
Q

What does a GP do prior to the booking visit?

A

Advice given on:

  • Folic acid and vitamin D supplements
  • Nutrition, diet and food hygiene
  • Lifestyle factors (smoking, drinking)
  • Antenatal screening tests
  • Exploring risks, e.g. domestic violence, FGM, mental health
56
Q

When does the booking visit occur?

A

8-12wks

57
Q

What happens at a booking visit?

A
  • Midwife takes a detailed Hx, examines the woman and does routine Ix
  • History and investigations:
    • Risk factors for complications, incl. gestational DM, pre-eclampsia
    • Psych history and mood
    • Social history, domestic violence, FGM
    • BMI calculated
      • If BMI >35 → review by obstetrician
      • For normal weight women, recommended total weight gain is 11-16kg; for overweight women 7-11kg; for obese women 5-9kg
      • If overweight/obese, counsel women about weight loss and risks of high BMI in pregnancy
      • Women is not re-weighed at other antenatal appts
    • BP measurement
    • Urine tests:
      • Screened for protein (renal disease/pre-eclampsia), glycosuria (DM/GDM), nitrites (UTI)
      • MSU sent for MC&S  screen for asymptomatic bacteriuria
    • Blood tests:
      • FBC (anaemia)
      • Blood group and antibody screen (identify Rh -ve, blood grouping for possible transfusion)
      • Haemoglobinopathy screening (thalassaemia/sickle cell) – if high-risk
    • Infection screening:
      • Routine: syphilis, HBV, HIV
      • Rubella was stopped in 2016 (very rare now)
      • HCV for high-risk women (IVDU, HBV, HIV)
  • Advice:
    • General dietary advice:
      • Don’t eat for 2 → normal portion sizes
      • Fibre-rich foods (oats, beans, lentils, fruits, veg, wholegrain bread, brown rice etc.)
      • Base meals on starchy foods (potatoes, bread, rice, pasta – wholegrain if possible)
      • Restrict intake of fried food, sugary drinks/food, high fat food etc.
      • Eat at least 5 fruit and veg / day
      • Dieting is not recommended but controlling weight gain is advocated
    • General exercise advice:
      • Aerobic and strength and conditioning exercise is encouraged
      • Aim is to stay fit, rather than reach peak fitness
      • Avoid contact sports
    • Education about pregnancy symptoms (nausea, heartburn, swelling, backache etc.)
    • Info about smoking, alcohol and drug use during pregnancy
      • Smoking cessation programmes
      • Alcohol/drug support services
    • Advice about antenatal screening (e.g. combined test)
    • Explain the pregnancy care pathway
    • Breastfeeding education:
      • Education given about benefits of breastfeeding  improves uptake, engages women with breastfeeding services
    • Options for pregnancy care:
      • Discussed with midwife; maternal choice and risks taken into account
      • Home birth, birth centre, labour ward
    • Info about antenatal classes
      • Group discussions/education about pregnancy/labour, opportunity to meet other parents
58
Q

When does the dating USS occur?

A

12wks

  • Best performed at 11+3 – 13+6 wks (CRL measures 45-84mm)
59
Q

If the dating scan is performed late, which parameter is used?

A
  • 14-20wks: head circumference is used
  • Beyond 20wks, becomes less accurate (genes and environmental factors influence foetal size)
    • Best method is USS biometry (biparietal diameter, head circumference, abdo circumference and femur length serially for 4wks)
60
Q

When does the Anomaly USS Scan occur?

A
  • 20-22 weeks
61
Q

What does the Anomaly USS Scan assess?

A
  • Detailed structural scan to assess foetal anatomy → can detect spina bifida, major congenital anomalies, diaphragmatic hernias, renal agenesis etc.
  • Assesses growth and size
  • Assesses amniotic fluid volume
  • Placental position
62
Q

What must happen at every antenatal visit?

A
  • Urine dip, BP and SFH should be measured
    • Urine screened for protein (pre-eclampsia), glycosuria (DM), nitrites (UTI)
      • If nitrites positive → send for MC&S
      • Identification and treatment of asymptomatic bacteriuria reduces pyelonephritis risk
    • SFH measured from 24wks → plot on growth chart
63
Q

Summarise the schedule of antenatal visits, and what happens at each one

A
64
Q

Outline the antenatal screening programme

A
  • Blood tests at booking (HIV, HBV, syphilis, haemoglobinopathies, anaemia, RBC antibodies)
  • Urine tests at booking (and every appt)
  • Combined test (1st trimester screening) (performed at dating USS scan )
  • Anomaly scan
  • Gestational diabetes screening (OGTT)
65
Q

What is the combined screening test?

A

The combined screening test is performed at dating USS scan → screens for Down’s and other chromosomal abnormalities (Edward’s, Patau’s)

  • 3 parts to combined screening test:
    • Measurement of nuchal translucency on USS
    • Measurement of beta hCG and pregnancy-associated plasma protein A (PAPP-A)
      • In trisomy 21 the b-hCG conc is higher (2x) and PAPP-A is lower (0.5x)
      • Maternal age
    • These are combined to give a risk of Down’s → 90% detection rate
66
Q

What done instead of the combined screening test if it delayed until 14-20wks?

A
  • Screening can also be done between 14-20wks or if nuchal translucency measurement is not possible  uses quadruple test (only maternal biomarkers)
    • Measures maternal AFP, hCG, unconjugated oestradiol and inhibin A
    • 80% detection rate with 5% false positive rate
67
Q

What is offered if the combined/quadruple screening test determines high risk of chromosomal abnormalities?

A
  • If a high-risk result is given, the mother can be offered invasive prenatal testing to confirm the diagnosis (CVS/amniocentesis)
    • Remember high-risk is usually 1 in 150
    • If diagnosis is confirmed, mother must be counselled about continuing vs TOP
68
Q

When is the OGTT offered to women?

A
  • Offered to women at risk at 26wks (24-28wks)
    • E.g. previous GDM, previous macrosomia, BMI >30, 1st degree relative with DM, Asian/Afro-Caribbean/Middle Eastern
  • If previous Hx of GDM, do OGTT at 16-18wks, then repeat at 24-28wks
69
Q

What are the a) indications b) contraindications c) adverse effects of ferrous sulfate?

A
70
Q

What are the a) indications b) contraindications c) adverse effects of mefenamic acid?

A
71
Q

What are the a) indications b) contraindications c) adverse effects of tranexamic acid?

A
72
Q

What are the a) indications b) contraindications c) adverse effects of GnRH analogues?

A
73
Q

What are the a) indications b) contraindications c) adverse effects of HRT?

A
74
Q

What are the a) indications b) contraindications c) adverse effects of antiemetics?

A
75
Q

Name some common teratogenic drugs, and their effects

A
  • Alcohol, tobacco, cocaine
  • Carbamazepine, valproate  neural tube defects
  • Lithium  Ebstein anomaly
  • ACE inhibitors  renal and lung abnormalities
  • Warfarin  nasal hypoplasia, depressed nasal bridge
  • Aminoglycosides  ototoxicity
  • Vitamin A (retinoids)  spontaneous abortion, various malformations

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