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Y4 Reproductive Health > Obstetrics Passmed 1 > Flashcards

Obstetrics Passmed 1 Flashcards

1
Q

Give some of the key causes of abdominal pain during pregnancy

A

Early:
Ectopic pregnancy / Miscarriage

Late:
Labour
Placental abruption
Uterine rupture
Symphysis pubis dysfunction
Pre-eclampsia/HELLP syndrome

Any time:
Appendicitis
UTI

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2
Q

Risk factors for ectopic pregnancy?

A

damage to tubes (salpingitis, surgery)
previous ectopic
IVF (3% of pregnancies are ectopic)

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3
Q

How can an ectopic pregnancy present?

A

female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding

lower abdominal pain: usually constant and may be unilateral, due to tubal spasm
vaginal bleeding: usually less than a normal period, may be dark brown in colour

peritoneal bleeding can cause shoulder tip pain and pain on defecation / urination

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4
Q

How does a threatened miscarriage present?

A

painless vaginal bleeding occurring before 24 weeks
typically occurs at 6 - 9 weeks
cervical os is closed

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5
Q

How does a missed (delayed) miscarriage present?

A

a gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion

mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear

when the gestational sac is > 25 mm and no embryonic/fetal part can be seen = ‘blighted ovum’ or ‘anembryonic pregnancy’

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6
Q

How does an inevitable miscarriage present?

A

cervical os is open
heavy bleeding with clots and pain
can be complete or incomplete

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7
Q

What happens in an incomplete miscarriage?

A

not all products of conception have been expelled
heavy bleeding and crampy, lower abdo pain
(in complete miscarriage there is less bleeding)

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8
Q

What is placental abruption? Key clinical features?

A

Placental abruption is separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space

Clinical features:
shock out of keeping with visible blood loss
constant pain
tender, tense uterus
normal lie and presentation
fetal heart: absent/distressed
coagulation problems

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9
Q

What is symphysis pubis dysfunction?

A

Ligament laxity increases in response to hormonal changes of pregnancy
Causes pain over the pubic symphysis with radiation to the groin and the medial aspects of the thighs
A waddling gait may be seen

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10
Q

Describe the abdominal pain seen in pre-eclampsia

A

epigastric / RUQ pain
associated with hypertension / proteinuria

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11
Q

How does uterine rupture present?

A

Ruptures usually occur during labour but occur in third trimester
Risk factors: previous caesarean section
Presents with maternal shock, abdominal pain and vaginal bleeding to varying degree

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12
Q

Give some risk factors for uterine rupture

A

Previous caesarean section – this is the greatest risk factor for uterine rupture
Classical (vertical) incisions carry the highest risk

Previous uterine surgery – such as myomectomy

Induction – (particularly with prostaglandins) or augmentation of labour

Obstruction of labour – this is an important risk factor to consider in developing countries

Multiple pregnancy

Multiparity

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13
Q

Describe the location of the abdominal pain seen in appendicitis during pregnancy

A

Location changes depending on gestation

RLQ in the first trimester
umbilicus in the second
RUQ in the third

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14
Q

Alpha-fetoprotein (AFP) is a protein produced by the developing fetus.

Give some causes of a raised AFP

A

Neural tube defects (meningocele, myelomeningocele and anencephaly)
Abdominal wall defects (omphalocele and gastroschisis)
Multiple pregnancy

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15
Q

Give some causes of a low AFP

A

Down’s syndrome
Trisomy 18
Maternal diabetes mellitus

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16
Q

Amniotic fluid emboli occur when fetal cells/ amniotic fluid enter the mothers bloodstream. The majority of cases occur during labour.

What are the symptoms and signs?

A

Symptoms include: chills, shivering, sweating, anxiety and coughing

Signs include: cyanosis, hypotension, tachycardia, bronchospasm, arrhythmia and MI

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17
Q

Key points of mx for antenatal N+V?

A

natural remedies - ginger and acupuncture on the ‘p6’ point (by the wrist)
antihistamines should be used first-line (promethazine)

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17
Q

Risk factors for amniotic fluid embolism?

A

increasing maternal age
induction of labour
C section
multiple pregnancy

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18
Q

How does placenta praevia present?

A

shock in proportion to visible loss
no pain , uterus not tender
lie and presentation may be abnormal
fetal heart usually normal
coagulation problems rare , small bleeds before large

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19
Q

Why should vaginal examinations not be performed in primary care for suspected antepartum haemorrhage?

A

women with placenta praevia may haemorrhage

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20
Q

Define antepartum haemorrhage

A

bleeding after 24 weeks

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21
Q

How should antepartum haemorrhage be investigated?

A

FBC
Clotting profile, Group and Save & Cross-match
Kleihauer test if the woman is Rhesus negative (to determine the amount of feto-maternal haemorrhage and thus the dose of Anti-D required)

U&Es and LFTs
to exclude pre-eclampsia and HELLP syndrome, and any other organ dysfunction

Assess Fetal Wellbeing using CTG in women above 26 weeks gestation

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22
Q

Give some maternal complications of APH

A

anaemia
coagulopathy
maternal shock
infection
renal tubular necrosis
prolonged hospital stay
psychological sequelae

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23
Q

Give some fetal complications of APH

A

hypoxia
SGA and growth restriction
prematurity
fetal death

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24
Q

Causes of vaginal bleeding in the 1st trimester?

A

Spontaneous abortion
Ectopic pregnancy
Hydatidiform mole

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25
Q

Causes of vaginal bleeding in the 2nd trimester?

A

Spontaneous abortion
Hydatidiform mole
Placental abruption

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26
Q

Causes of vaginal bleeding in the 3rd trimester?

A

Bloody show
Placental abruption
Placenta praevia
Vasa praevia

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27
Q

How does Hydatidiform mole present?

A

Typically bleeding in first or early second trimester associated with exaggerated symptoms of pregnancy e.g. hyperemesis

Uterus may be large for dates and serum hCG is very high

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28
Q

How does Vasa praevia present?

A

Rupture of membranes followed immediately by vaginal bleeding. Fetal bradycardia is classically seen

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29
Q

Mx of nipple candidiasis?

A

miconazole cream for the mother and nystatin suspension for the baby

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30
Q

Mx of mastitis?

A

treat ‘if systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal of if culture indicates infection’

Oral fluclox 10-14 days, continue breastfeeding

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31
Q

How does Raynaud’s disease of the nipple present? Mx?

A

intermittent pain present during and immediately after feeding
blanching of the nipple followed by cyanosis and/or erythema

Mx: minimising exposure to cold, use of heat packs following a breastfeed, avoiding caffeine and stopping smoking

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32
Q

Which abx should be avoided in breastfeeding?

A

ciprofloxacin, tetracycline, chloramphenicol, sulphonamides

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33
Q

Which psychiatric drugs should be avoided in breastfeeding mothers?

A

lithium, benzodiazepines

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34
Q

What techniques can be used to suppress lactation?

A

stop the lactation reflex i.e. stop suckling/expressing
supportive measures: well-supported bra and analgesia
cabergoline

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35
Q

What is the difference between a frank and footling breech presentation?

A

A frank breech is the most common presentation = hips flexed and knees fully extended

A footling breech = one or both feet come first with the bottom at a higher position, rarer but carries a higher perinatal morbidity

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36
Q

What are the main risk factors for breech presentation?

A

uterine malformations, fibroids
placenta praevia
polyhydramnios or oligohydramnios
fetal abnormality
prematurity

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37
Q

How should breech presentations be managed?

A

if < 36 weeks: many fetuses will turn spontaneously
> 36 weeks (or 37 weeks if multiparous) :external cephalic version (ECV)
if the baby is still breech then delivery options include planned caesarean section or vaginal delivery

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38
Q

What are the contraindications to ECV (pressure applied to abdomen to try and turn the baby)?

A

where caesarean delivery is required
antepartum haemorrhage within the last 7 days
abnormal cardiotocography
major uterine anomaly
ruptured membranes
multiple pregnancy

39
Q

What are Category 1 C sections?

A

an immediate threat to the life of the mother or baby

examples indications include: suspected uterine rupture, major placental abruption, cord prolapse, fetal hypoxia or persistent fetal bradycardia

delivery of the baby should occur within 30 minutes of making the decision

40
Q

What are Category 2 C sections?

A

maternal or fetal compromise which is not immediately life-threatening
delivery of the baby should occur within 75 minutes of making the decision

41
Q

What are Category 3 and 4 C sections?

A

3 = delivery is required, but mother and baby are stable
4 = elective

42
Q

What are the 2 main types of C section?

A

lower segment caesarean section: most common
classic caesarean section: longitudinal incision in the upper segment of the uterus

43
Q

What is Cardiotocography (CTG)?

A

used to record pressure changes in the uterus using internal or external pressure transducers

44
Q

What is normal fetal heart rate?

A

100-160 / min

45
Q

What is fetal baseline bradycardia?

A

Heart rate < 100 /min
Causes: Increased fetal vagal tone, maternal beta-blocker use

46
Q

What is fetal baseline tachycardia?

A

Heart rate > 160 /min
Causes: Maternal pyrexia, chorioamnionitis, hypoxia, prematurity

47
Q

What are early decelerations?

A

Deceleration of the heart rate which commences with the onset of a contraction and returns to normal on completion of the contraction
Usually indicates head compression

48
Q

What are late decelerations?

A

Deceleration of the heart rate which lags the onset of a contraction and does not return to normal until after 30 seconds following the end of the contraction

Indicates fetal distress e.g. asphyxia or placental insufficiency

49
Q

What are variable decelerations?

A

Independent of contractions

May indicate cord compression

50
Q

What are the features of fetal varicella syndrome?

A

skin scarring, eye defects (microphthalmia), microcephaly, limb hypoplasia and learning disabilities

51
Q

How should chickenpox exposure in pregnancy be managed?

A

if there is any doubt about the mother previously having chickenpox maternal blood should be urgently checked for varicella antibodies

if <20 weeks gestation and not immune to varicella: given varicella-zoster immunoglobulin (VZIG) as soon as possible

if > 20 weeks gestation and not immune to varicella then either VZIG or antivirals (aciclovir) should be given days 7 to 14 after exposure

52
Q

How should diagnosed chickenpox in pregnancy be managed?

A

oral aciclovir should be given if the pregnant women is ≥ 20 weeks and she presents within 24 hours of onset of the rash

53
Q

What is Chorioamnionitis? Mx?

A

ascending bacterial infection of the amniotic fluid / membranes / placenta

major risk factor is the premature rupture of membranes which expose the normally sterile environment of the uterus to potential pathogens

Mx = prompt delivery and IV abx

54
Q

How does Down’s syndrome present in antenatal testing?

A

↑ HCG, ↓ PAPP-A, thickened nuchal translucency

55
Q

What is pre-eclampsia?

A

condition seen after 20 weeks gestation

triad:
pregnancy-induced hypertension (140/90)
proteinuria
oedema

eclampsia is pre-eclampsia + seizures

56
Q

How should pre-eclampsia be managed?

A

arrange emergency secondary care assessment

oral labetalol is first-line, nifedipine (e.g. if asthmatic) and hydralazine may also be used

women with blood pressure ≥ 160/110 mmHg are likely to be admitted and observed

57
Q

How should eclampsia be managed?

A

in eclampsia an IV bolus of magnesium sulphate (4g over 5-10 minutes) should be given followed by an infusion of 1g / hour

urine output, reflexes, respiratory rate and oxygen saturations should be monitored during tx

tx should continue for 24 hours after last seizure or delivery

58
Q

What is the first-line treatment for magnesium sulphate induced respiratory depression?

A

calcium gluconate

59
Q

What are the risks of sodium valproate and phenytoin in pregnancy?

A

sodium valproate: associated with neural tube defects

phenytoin: associated with cleft palate

60
Q

How can neural tube defects be prevented during pregnancy?

A

all women should take 400mcg of folic acid until the 12th week of pregnancy

women at higher risk of conceiving a child with a NTD should take 5mg of folic acid from before conception until the 12th week of pregnancy

61
Q

Which women should take more folic acid?

A

M = Metabolic conditions e.g. T1DM, coeliacs
O = Obesity (BMI>30)
R = Relative (PMHx)
E = epilepsy (on anti-epileptics)

62
Q

Causes of placental abruption?

A

A = Abruption previously
B = Blood pressure (i.e. hypertension or pre-eclampsia)
R = Ruptured membranes, either premature or prolonged
U = Uterine injury (i.e. trauma to the abdomen);
P = Polyhydramnios
T = Twins or multiple gestation
I = Infection in the uterus, especially chorioamnionitis
O = Older age (over 35 years old)
N = Narcotic use

63
Q

What is a galactocoele?

A

cystic lesion in the breast caused by a build up of milk
usually painless

64
Q

Give some risk factors for gestational diabetes

A

BMI of > 30 kg/m²
previous macrosomic baby weighing 4.5 kg or above
previous gestational diabetes
first-degree relative with diabetes
family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)

65
Q

What is used to screen for gestational diabetes?

A

OGTT

women who’ve previously had gestational diabetes: OGTT should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal

women with risk factors: 24-28 weeks

66
Q

What is diagnostic for gestational diabetes?

A

fasting glucose is >= 5.6 mmol/L
2-hour glucose is >= 7.8 mmol/L

67
Q

How should gestational diabetes be managed?

A

fasting plasma glucose level < 7 mmol/l = a trial of diet and exercise should be offered
- if glucose targets not met within 1-2 weeks metformin should be started
- if glucose targets are still not met insulin should be added (short-acting)

if the plasma glucose level is between 6-6.9 mmol/l, and there is evidence of complications such as macrosomia or hydramnios, insulin should be offered

if at the time of diagnosis the fasting glucose level is >= 7 mmol/l insulin should be started

68
Q

What are the fetal complications of GD?

A

Macrosomia – this can cause complications during labour, such as shoulder dystocia, obstructed/delayed labour, and/or higher rates of instrumental deliveries

Organomegaly (particularly cardiomegaly)

Erythropoiesis (resulting in polycythaemia)

Polyhydramnios

Increased rates of pre-term delivery

69
Q

How should pre existing diabetes be managed in pregnancy?

A

weight loss for women with BMI of > 27 kg/m2

stop oral hypoglycaemic agents (bar metformin) and commence insulin, ensure tight glycaemic control

folic acid 5 mg/day from pre-conception to 12 weeks gestation

detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts

treat retinopathy as can worsen during pregnancy

70
Q

What is a hydatidiform mole?

A

Benign tumour of trophoblastic material

occurs when an empty egg is fertilized by a single sperm that then duplicates its own DNA, all 46 chromosomes are of paternal origin

71
Q

Benzylpenicillin is the antibiotic of choice for Group B Strep intrapartum antibiotic prophylaxis (IAP). Who should be offered it?

A

women with a previous baby with GBS disease
women in preterm labour
women with a pyrexia during labour (>38ºC)

women who’ve had GBS detected in a previous pregnancy should be offered (IAP) OR testing in late pregnancy and then antibiotics if still positive

72
Q

What is HELLP syndrome? How should it be managed?

A

Hemolysis, Elevated Liver enzymes, and a Low Platelet count

Features:
nausea & vomiting
right upper quadrant pain
lethargy

Mx = delivery of the baby

73
Q

What techniques can be used to reduce vertical transmission of HIV?

A

maternal antiretroviral therapy
mode of delivery (caesarean section)
neonatal antiretroviral therapy
infant feeding (bottle feeding)

74
Q

What modes of delivery are available to mothers with HIV?

A

vaginal delivery is recommended if viral load is less than 50 copies/ml at 36 weeks, otherwise caesarian section is recommended

a zidovudine infusion should be started four hours before beginning the caesarean section

75
Q

What neonatal antiretroviral therapy is offered to babies of mothers with HIV?

A

zidovudine orally if maternal viral load is <50 copies/ml

Otherwise triple ART should be used

Therapy should be continued for 4-6 weeks

76
Q

Define hypertension in pregnancy

A

systolic > 140 mmHg or diastolic > 90 mmHg

or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic

77
Q

How should pregnancy induced hypertension (htn after 20 weeks with no oedema or proteinuria) be managed?

A

oral labetalol is now first-line
oral nifedipine (e.g. if asthmatic) and hydralazine

78
Q

Indications for induction of labour?

A

prolonged pregnancy, e.g. 1-2 weeks after the estimated date of delivery

prelabour premature rupture of the membranes

maternal medical problems

intrauterine fetal death

79
Q

How can the Bishop Score be interpreted?

A

a score of < 5 = labour is unlikely to start without induction

a score of ≥ 8 = cervix is ripe, or ‘favourable’ - high chance of spontaneous labour, or response to interventions made to induce labour

80
Q

What is the membrane sweep?

A

involves the examining finger passing through the cervix to rotate against the wall of the uterus, to separate the chorionic membrane from the decidua

81
Q

What is the NICE guidance on methods used to induce labour?

A

if the Bishop score is ≤ 6:
vaginal prostaglandins or oral misoprostol
(balloon catheter can be considered if the woman is at higher risk of hyperstimulation or has had a previous caesarean)

if the Bishop score is > 6:
amniotomy and an intravenous oxytocin infusion

82
Q

What is uterine hyperstimulation?

A

prolonged and frequent uterine contractions - sometimes called tachysystole

the main complication of induction of labour

may cause fetal hypoxemia and acidemia or rarely
uterine rupture

stop the infusion!!!

83
Q

How should intrahepatic cholestasis of pregnancy be managed?

A

induction of labour at 37-38 weeks and ursodeoxycholic acid - both widely used but evidence base not clear

vitamin K supplementation

84
Q

What is intrahepatic cholestasis of pregnancy?

A

when outflow of bile acids is reduced, causing them to build up in the blood
thought to be due to increased oestrogen and progesterone levels

85
Q

how does intrahepatic cholestasis of pregnancy present?

A

pruritus (hands and feet)
jaundice
fatigue
dark urine
pale greasy stools

86
Q

What are the 3 stages of labour?

A

stage 1: from the onset of true labour to when the cervix is fully dilated

stage 2: from full dilation to delivery of the fetus

stage 3: from delivery of fetus to when the placenta and membranes have been completely delivered

87
Q

Complications of obstetric cholestasis?

A

maternal - increased risk of gallstones and liver disease

fetal - increased risk of passing meconium during labour, prematurity and stillbirth

88
Q

What monitoring should be provided in labour?

A

FHR monitored every 15min (or continuously via CTG)

Contractions assessed every 30min

Maternal pulse rate assessed every 60min

Every 4 hours:
Maternal BP and temp
VE should be offered
Maternal urine should be checked for ketones and protein

89
Q

What are the 2 phases of stage 1 of labour?

A

latent phase = 0-3 cm dilation, normally takes 6 hours
active phase = 3-10 cm dilation, normally 1cm/hr

90
Q

What are the 2 phases of stage 2 of labour?

A

‘passive second stage’ refers to the 2nd stage but in the absence of pushing
active second stage’ refers to the active process of maternal pushing

91
Q

What are the options if stage 2 of labour lasts for longer than 1 hour?

A

Ventouse extraction, forceps delivery or caesarean section

92
Q

Indications for a forceps delivery?

A

fetal / maternal distress in the second stage of labour
failure to progress in the second stage of labour
control of head in breech delivery

93
Q

Define lochia

A

vaginal discharge containing blood mucous and uterine tissue which may continue for 6 weeks after childbirth

if it persists beyond 6 weeks an USS is indicated

94
Q

In oligohydramnios there is reduced amniotic fluid (less than 500ml at 32-36 weeks). What can cause this?

A

premature rupture of membranes
Potter sequence (bilateral renal agenesis + pulmonary hypoplasia)
intrauterine growth restriction
post-term gestation
pre-eclampsia

Y4 Reproductive Health (13 decks)

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