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RISHI Year 5 PACES 2 (Val edit) > Obstetrics Investigations and Management > Flashcards

Obstetrics Investigations and Management Flashcards

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1
Q

Investigations for suspected hyperemesis gravidarum

A
  • Examination => signs of dehydration
  • Basic observations => reduced BP, high HR, weight and calculate BMI
  • Urine dipstick à ketones
  • Bloods:
    • FBC => increased hct
    • U&Es => dehydration
  • PUQE score
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2
Q

Mx of hyperemesis gravidarum

A
  • Consider admission for the following patients:
    • Women unable to keep oral anti-emetics down
    • Continued N&V associated with ketonuria +/- >5% weight loss despite oral anti-emetics
    • Confirmed/suspected co-morbidity e.g. UTI
  • IV fluid resuscitation and correction of electrolyte abnormalities (usually with KCl)
  • IV antiemetics
    • 1st line = Cyclizine or promethazine
    • 2nd line = metoclopramide/ondansetron
  • Thiamine supplementation
  • Offer VTE prophylaxis with LMWH
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3
Q

Associations for hyperemesis

A
  • multiple pregnancies
  • trophoblastic disease
  • hyperthyroidism
  • nulliparity
  • obesity

Smoking associated with decreased risk

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4
Q

Ddx for pre eclampsia

A
  • Pre-eclampsia
  • Gestational HTN
  • Essential HTN
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5
Q

Mx of eclampsia

A
  • ABC approach
  • Labetalol + IV Magnesium sulphate
    • Prevent seizures in severe pre-eclampsia
    • Treat seizures once they develop
  • 4g loading dose
  • 1g/hour infusion 24hrs after last fit
  • Recurrent fits => further 2-4g over 5-15 mins
  • Monitor urine output, reflexes, RR and oxygen sats

labetalol: 1V 50 MG BOLUS (max of 4) CAN ALSO GIVE 200mg PO

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6
Q

First-line treatment for magnesium sulphate induced respiratory depression

A

Calcium gluconate

10% 10mls over 10mins

Measure sats, RR , ECG

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7
Q

RF for pre eclampsia

A

High Risk Factor:

  • HTN during previous pregnancy
  • CKD
  • Autoimmune SLE/antiphospholipid
  • T1DM/T2DM
  • Chronic HTN

Moderate Risk Factor:

  • First pregnancy
  • >40 years,
  • Pregnancy interval 10+ years
  • BMI 35+ at booking
  • FH of pre-eclampsia
  • Multiple pregnancy
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8
Q

Mx of HELLP

A
  • ABC approach
  • 1st line in confirmed HELLP is to deliver
  • IV Magnesium sulphate
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9
Q

How is high-risk Pre eclampsia managed?

A
  • 75 mg OD aspirin from 12 weeks until birth
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10
Q

For a patient with pre-eclampsia when would you consider delivery?

A
  • Uncontrollable BP despite 3+ antihypertensive classes at full dose
  • Maternal sats <90%
  • HELLP
  • Neuro features
  • Placental abruption
  • Reversed end-diastolic flow in umbilical artery doppler
  • Non-reassuring CTG
  • Stillbirth
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11
Q

Ix for suspected Obstetric cholestasis

A
  • Examination => jaundice, excoriation marks, SFH
  • Basic observations => BP, HR, temp
  • Urine dipstick
  • Bloods:
    • LFTs
    • Bile acids
    • WCC
    • Clotting screen – prolonged PT
  • CTG
  • Abdo USS
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12
Q

Mx of Obstetric cholestasis

A
  • Conservative:
    • Topical emollients
    • Wear loose fitting clothing
  • Medical:
    • Ursodeoxycholic acid
    • Vit K supplementation
  • Monitoring:
    • Obstetrician led care
    • Regular LFTs and more frequent scans
    • Safety net about reduced fetal movements
    • Offer induction at 37 weeks
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13
Q

Differentials for PV bleeding in pregnancy

A
  • Placenta praevia
  • Placental abruption
  • Vasa praevia
  • Bloody show
  • Cervical ectropion
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14
Q

Ix for PV bleeding

A
  • A to E approach
  • Examination – signs of anaemia, tense and tender abdomen
  • Basic observations – haemodynamic stability
  • CTG
  • TVUSS
  • Bloods:
    • FBC
    • Group and save
    • Coagulation profile à DIC
    • Kleihauer test
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15
Q

Mx of PV bleeding

A
  • A to E approach (IV access and fluid resuscitation)
  • Admit until bleeding stops for 24 hours
  • <34 weeks administer steroids and consider tocolytics (not in abruption)
  • Anti-D prophylaxis
  • Continuous fetal monitoring
  • EMCS if fetal distress/mother remains haemodynamically unstable
  • If low-lying placenta at 32 weeks then repeat TVUSS at 36 weeks
  • Deliver:
    • If uncomplicated PP: ELCS at 36 weeks onwards
    • If placenta accrete spectrum: ELCS at 35 weeks onwards
    • Abruption/vasa praevia with fetal or maternal compromise: EMCS
    • Stable abruption >34 weeks: consider ELCS or vaginal delivery with active mx of 3rd stage of labour
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16
Q

Ddx for abdo pain

A
  • Placental abruption
  • Premature labour
  • Braxton-Hick’s contractions
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17
Q

Ix for abdo pain

A
  • A to E approach
  • Examination – signs of anaemia, tense and tender abdomen
  • Basic observations – haemodynamic stability
  • CTG
  • TVUSS
  • Bloods:
    • FBC
    • Group and save
    • Coagulation profile à DIC
    • Kleihauer test
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18
Q

Ix for suspected VTE in pregnancy

A

DVT

  • GE: Unilateral lower limb oedema, erythema, tenderness, low grade pyrexia
  • Duplex USS

PE

  • GE: tachycardia, tachypnoea, low grade pyrexia, reduced O2 saturation, cardiorespiratory collapse
  • Chest auscultation: reduced air entry, creps
  • Cardiovascular: Loud P2
  • ABG: hypoxia and hypocapnia
  • ECG (sinus tachy + S1Q3T3) + CXR
  • If DVT suspected also duplex USS
  • If CXR abnormal à CTPA in preference to V/Q
  • If V/Q or CTPA normal but clinical suspicion high repeat or use alternative Ix
  • Bloods: FBC, U&Es, LFT, Clotting
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19
Q

Risk of CTPA or V/Q scan in pregnancy

A
  • V/Q has slightly increased risk of childhood cancer
  • CTPA has higher risk of maternal breast cancer
  • In both situations, the absolute risk is very small
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20
Q

Mx of VTE in pregnancy

A
  • LMWH (enoxaparin) titrated against booking weight
    • Treat upon clinical suspicion whilst awaiting results
    • If USS negative then discontinue but repeat USS on day 3 and 7
    • Continue for the rest of pregnancy
    • Discontinue 24 hrs before delivery
    • Do not give until 4 hours after spinal
    • Continue 6/52 after delivery or until 3 months Tx in total
    • Monitor platelets and peak anti-Xa levels
  • Massive PE
    • A to E approach
    • MDT
    • IV unfractionated heparin
    • Consider thrombolysis/thrombectomy
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21
Q

Ix for DM in Preganancy

A
  • Examination – SFH, signs or pre-eclampsia, BP, HR
  • Urine dip => glucose, proteinuria
  • Bloods:
    • FBC
    • Fasting blood glucose/OGTT à followed by capillary glucose monitoring
    • TFTs
    • LFTs
  • Monitoring:
    • CTG
    • Serial USS scans for growth and liquor volume
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22
Q

Management of Chronic HTN in pregnancy

A
  • Aim for target BP 135/85
  • Switch from ACEi/ARBs to labetalol
  • 2nd line = Nifedipine
  • 3rd line = Methyldopa (stop within 2 days after birth)
  • Placental growth factor testing 20-35 weeks
  • Anti-hypertensive review 2 weeks post delivery
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23
Q

Management of Gestational HTN

A
  • Aim for target BP 135/85
  • BP monitoring twice a week and dipstick proteinuria tests
  • Placental growth factor testing if pre-eclampsia suspected 20-35 weeks
  • Labetalol or nifedipine if contra-indicated
  • Reduce anti-HTN if BP<130/80 post-natally
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24
Q

Management of previous diabetes

A
  • Preconceptual:
    • Optimisation of glucose control
    • Folate 5mg
  • Medical:
    • Optimise diet
    • Consider converting oral hypoglycaemic to insulin
    • Likely to require increasing doses of insulin
  • Pregnancy:
    • Capillary blood glucose monitoring (monthly HbA1c is offered)
    • Monitor for pre-eclampsia à aspirin 75mg OD from 12 weeks
    • Serial USS for foetal growth
  • Delivery:
    • Sliding scale in labour (38 weeks)
    • MDT – if large then recommend C-section
  • Postpartum:
    • Return to pre-pregnancy doses of medications immediately to avoid hypos
    • Start feeding neonate within 30 mins and fed frequently to prevent hypoglycaemia
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25
Management of GDM
* Medical: * Diet/exerecise control for 2 weeks * Metformin +/- insulin * \> 7 fasting start insulin immediately * Glibenclamide should only be offered for women who cannot tolerate metformin * Pregnancy/delivery: As for pre-existing * Postpartum: Stop insulin after delivery, fasting blood glucose measured at 6/52 postpartum
26
Risk Factors for GDM
* previous baby \>4.5kg * BMI \>30 * Race * Polyhydramnios * previous GDM * previous unexplained stillbirth * 1st degree relative with DM
27
Targets for self monitoring of pregnant women (pre-existing and gestational diabetes)
* Fasting: 5.3 mmol/l * 1 hour after meals: 7.8 mmol/l * 2 hour after meals: 6.4 mmol/l
28
Complications of GDM
* ***Foetus:*** hyperglycaemia can affect development (NTD, hyperinsulinemia, shoulder dystocia, macrosomia (more than 8 pounds), polyhydramnios due to increased urination. * ***Neonatal:*** hypoglycaemia can occur when born due to change in glucose in its environment. * ***Mother:*** increased insulin requirement, UTI and wound infection postpartum, increased risk of C-section, increased risk of preterm delivery
29
Types of breech presentation
* Frank breech * Complete or flexed breech * Footling breech
30
RF for breech presentation
* ***Maternal:*** multiparity, uterine fibroids, previous breech, placenta praevia * ***Foetal:*** preterm delivery, oligohydramnios, foetal macrosomia, multiple pregnancy
31
Contraindications for ECV
* If C-section is required * Abnormal CTG * Ruptured membranes * Multiple pregnancy
32
Sensitising events for which you give anti-D immunoglobulin
* ECV * Surgical management of miscarriage or ectopic pregnancy * Abdominal trauma * Amniocentesis or chorionic villus sampling * Antepartum haemorrhage
33
Causes of IUGR
* Infection * Smoking * Drinking * Genetic problems with the baby * Pre-existing medical problems (e.g. hypertension, kidney disease)
34
How do you date scans in pregnancy?
* CRL: 10-14 weeks * Head Circumference: 14-20 weeks
35
How can you induce a labour?
* Membrane sweep (to try and stimulate labour) * Propess (24 hour pessary) * Prostin gel (may be used 6 hourly to further ripen the cervix) * Artificial rupture of membranes
36
IUGR: Concerning sign-on doppler?
Absence or reversal of end-diastolic flow
37
Investigations for PROM
* Examination – temp, HR, BP, uterine tenderness * Urine dip and MC&S * Sterile speculum examination * Offensive discharge * Pooling of amniotic fluid * If no pooling: swab for: * **insulin-like growth factor-binding protein-1** (IGFBP-1) or * **placental alpha micro-globulin-1** (PAMG-1) * Bloods: * FBC – raised WCC * CRP * CTG
38
Management of PROM
* Admit for monitoring (48-72 hours) * Antenatal steroids * Abx: erythromycin 250mg QDS for 10 days or until established labour =\> penicillin if not tolerated * Offer MgSO4 if 24-29 weeks * Monitor temperature (4 hours) * Aim to deliver after 34 weeks or earlier if infection * Consider rescue cervical cerclage between 16-28 weeks with dilated cervix an unruptured fetal membranes * Do not offer if PV bleeding, infection or uterine contractions * 23\> weeks then consider termination of pregnancy
39
Complications of PROM
* *Complications for mother*: sepsis and placental abruption * *Foetal:* chorioamnionitis, cord prolapse. PTL, pulmonary hypoplasia, limb contractures, death
40
Examples of tocolytics
* Nifedipine * Atosiban
41
What screening test can be used if you are unsure about whether a patient is in labour or not?
* Foetal fibronectin
42
What might be used as neuroprotection in a preterm delivery?
MgSO4
43
What are the stages of labour?
* Stage 1: onset of regular contractions to full dilatation of the cervix * Stage 2: full dilatation to delivery of the baby * Stage 3: from delivery of the baby to delivery of the placenta and membranes
44
Causes of prolonged labour
* Malposition * Epidural analgesia * Obstructed labour (e.g. CPD)
45
How can you actively manage the third stage of labour?
* IM syntocinon/ergometrine injection * Controlled cord traction * Should last \< 30 mins
46
How do you induce labour?
* Membrane sweep * Propess (24 hours) * Prostin (can be given 6 hourly) * ARM * Syntocinon
47
48
Management of cord prolapse
* The presenting part of the fetus may be pushed back into the uterus to avoid compression * Tocolytics may be used * If the cord is past the level of the introitus, it should be kept warm and moist but should not be pushed back inside. * Patient on all fours
49
Featurs of pre eclampsia
* hypertension: typically \> 170/110 mmHg and proteinuria as above * proteinuria: dipstick ++/+++ * headache * visual disturbance * papilloedema * RUQ/epigastric pain * hyperreflexia * platelet count \< 100 \* 106/l, abnormal liver enzymes or HELLP syndrome
50
When should a woman take 5mg of folic acid?
* either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a family history of a NTD * the woman is taking antiepileptic drugs or has coeliac disease, diabetes, or thalassaemia trait. * the woman is obese (defined as a body mass index [BMI] of 30 kg/m2 or more).
51
Management of uterine atony
* bimanual uterine compression to manually stimulate contraction * intravenous oxytocin and/or ergometrine * intramuscular carboprost * intramyometrial carboprost * rectal misoprostol * surgical intervention such as balloon tamponade * Other: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
52
RF for PPH
* previous PPH * prolonged labour * pre-eclampsia * increased maternal age * polyhydramnios * emergency Caesarean section * placenta praevia, placenta accreta * macrosomia * ritodrine (a beta-2 adrenergic receptor agonist used for tocolysis)
53
Definition of PPH
* Primary PPH: \>500 ml in 24 hours * Secondary PPH: 24 hours - 12 weeks * due to retained placental tissue or endometritis
54
55
What is the combined test and when is it offered?
Consists of: * Nuchal translucency measurement * Serum B-HCG * Pregnancy-associated plasma protein A (PAPP-A) Result: * Down's syndrome is suggested by ↑ HCG, ↓ PAPP-A, thickened nuchal translucency * trisomy 18 (Edward syndrome) and 13 (Patau syndrome) give similar results but the PAPP-A tends to be lower Offered: * 11 - 13+6 weeks
56
What is the alternative to the combined test?
If women book later in pregnancy either the triple or quadruple test should be offered between 15 - 20 weeks ***Triple test:*** * human chorionic gonadotrophin * alpha-fetoprotein * unconjugated oestriol ***Quadruple test***: 1. Human chorionic gonadotrophin 2. alpha-fetoprotein 3. unconjugated oestriol 4. inhibin-A
57
What is the difference between amniocentesis and CVS?
58
What is meant by SGA? What is IUGR?
The weight of the fetus is less than the tenth centile for age IUGR: doesn't live up to its growth potential. These can often be SGA babies
59
Common causes of SGA
* Constitutional factors * Idiopathic * Maternal disease, e.g. pre-eclampsia Smoking * Multiple pregnancy
60
Investigations for SGA/ IUGR
* History * Examination * General * Abdo * SFH * BP and urinanalysis * Imaging * CTG * USS * UmbA doppler (can see how healthy the blood flow is to the baby) * Foetal middle cerebral artery doppler (for cardiovascular distress, fetal anaemia and fetal hypoxia)
61
Causes of IUGR
We measure this by looking at the abdominal circumference of the foetus Symmetrical (\<20 weeks of gestation) * Chromosomal * Congenital Anomalies (NTD, CHD) * Congenital infections Asymmetrical (Mama, Made, Poor, Uterus) (\>20 weeks) * Maternal HTN * Maternal APS * Placental Insufficiency * Uterine anomalies * Substance abuse
62
When can ECV be managed?
* 36 weeks for nullips * 37 weeks for multips
63
Investigations for APH
* Bloods * Full blood count * Group and cross-match * Coagulation screen * Urea and electrolytes * Cardiotocography (CTG) (immediate) * Ultrasound scan (USS) to determine placental site/fetal viability Management * If heavy bleed: catheterize and record hourly urine output
64
Definition and investigations for reduced foetal movement
Less than 10 movements within 2 hours (\>28 weeks) If the patient is past 28 weeks: * Handheld doppler to confirm fetal heartbeat * Not detectable, ultrasound should be offered immediately * Heartbeat was detected, CTG should be used for 20 minutes to monitor the heart rate.
65
Investigations for PROM
* Sterile speculum (look for pooling in the posterior vaginal wall) * Test for the following if no pooling: * Insulin-like growth factor binding protein‑1 (IGFBP-1) * Placental alpha-microglobulin 1 (PAMG-1)
66
Oligohydramnios definition and causes
* \< 500ml at 32-36 weeks and an amniotic fluid index (AFI) \< 5th percentile Causes * premature rupture of membranes * fetal renal problems e.g. renal agenesis * intrauterine growth restriction * post-term gestation * pre-eclampsia

RISHI Year 5 PACES 2 (Val edit) (5 decks)

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