obstetrics summary Flashcards by Monica Palumbo

preconcepton care

diet - folate
weight - BMI
exercise
smoking/alcohol advice - assess intake and provide advice
pregnancy history - screen for modifyable risk factors
genetic screening - if indicated from personal/family history
medical history
pychosocial screening - DV and mental health screen
environmental screening - work, home
contraception/family planning
infectious screen and vaccinations
breast exmination

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first antenatal visit

planned vs. unplanned
LMP and tests to date
obstetric history
gynaecological history
medical history (personal and family)
social history
care options
provide pregnancy health record

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antenatal examination

height/weight (BMI)
BP
urinalysis
cardio exam
abdominal examination - fundal height, palpation for lie/presentation (from 28 weeks), FHR auscultation

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initial investigations

MSU
rubella
syphilis
antibodies
blood group
chlamydia/gonorhhea
FBC
globinopathies
HIV/HBV/HCV
iron sstudies and immunications

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subsequent investigations following antenatal visit

US:
dating - 8-12 weeks
first timester screen 11-14 weeks
anatomy scan 18-20 weeks
OGTT 24-28 weeks
GBS screen 36 weeks

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screening test

combined first trimester screening test
non-invasive prenatal testing
triple test

if any are poitive > CVS vs. amniocentesis

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rhesus D negative

mother with rhesus negative and foetus with resus positive
risk of maternofoetal haemorrhage
RhD Ig binds Rh positive foetal cells to prevent immune response

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preterm labour and birth complications

birth after 20 weeks and before 37 weeks gestation
complications:
- mother - increased risk of obstetic intervention
- neonate - ICH, respiratory support, bowel necrosis, sepsis, death
- child - CP, chronic lung disease, deafness, blindness, developmental delay
- adult - metabolic syndrome, diabetes, heart disease

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risk factors for preterm birth

previous pre-term birth, FHx, smoking, extremes of age, stress/anxiety, previous preinatal loss, short cervical length

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aetiologies of pre-term birth

spontaneous preterm labour, PPROM, preeclampsia, diabetes, APH, multiple pregnancies, infectons, uterine abnormalities, cervical surgeries

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prevention of pre-term birth

optimal control of risk factors (smoking cessation)
measure cervical length ot foetal anatomy + subsequent scans
vaginal progesterone is history of spontenous preterm birth

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what to do for short cerrvical length

200mg vagnal progesterone in evening if cervix <25mm
consider cervical cerclage is cervix <10mm
vaginal progesterone is history of spontaneous preterm birth

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workup of preterm labour

diagnosis - regular painful contractions and cervical change
history - gestational age, contractions, presence of fluid
examination - temperature, abdominal exmiantion, sterile speculum

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investigations in preterm laabour

fFN - foetal fibronectin
MSU
HVS
USS
EFM

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management of preterm labour

admit - offer analgesia, baselne investigatons, CTG
tocolysis - <34 weeks gestations nifedpine, IV salbutamol, GTN patch
corticosteroids - 2 doses 11.4mg IM metamethasone 24 hours apart
MgSO4 - foetal neuroprotection in women <30 weeks gestation
antibiotics - ntrapartum benzylpenicillin for GBS prophylaxis

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breech ppresentation

c-secton reduced rissk of short tern maternal and foetal complications

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risk factors for breech presentation

nullipparity, previous breech, uterine and plecntal abnormalitiess, poly/oligohydramnios, multiple pregnancies, grand multiprity
foetal - extended legs, short umbilical cord, early gestation, foetal abnormality, IUGR

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PROM

premature rupture of membranes before labour begins
history - tme, type and colour of fluid, presence of signs indicative of infection (odour, abdominal pain, fever, dysuria, discharge)

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exmination and investgations for PROM

examinations - vitals, abdominal examination, sterile speculum
investigations - bloods (FBC, UEC, CRP), MSU LVS, ECS, STI screen, amnicator, USS exmaination

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PPROM management

admit and observe - CTG
oral erythromycin
remove cervical cerclage
discharge if >72 hours with no evidence of infection/preterm labour with approprate education

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when to do IOL in PPROM

signs of chorioamnionitis/maternal sepsis or foetal compromise

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PROM management

expectant managemnt is cepahlic presentation, clear liquor, no sign s of infection, no cervicaal suture, assess temperature 4 hourly/vaginal loss/foetal movements
at 18 hours post ROM commence antibiotics

when to do OIL for PROM

24 hours following ROM or if criteria for expectant management not met

early pregnancy loss

spontaneous interuption of established pregnancy <20 weeks gestation

risk factors for early pregnancy loss

AMA, medical conditions (diabetes/coagulopathies/APS), uterine abnormalities, SLE, infections, drugs, smoking, cevicaal incompetance, prevous spontaneous miscariage

presentation of early pregnancy loss

PV bleeding/spotting , suprapubic cramping, lower abdominal/back pain

workup for early pregnancy loss

abdominal examination, speculum examination, B HCG, FBC, blood group and antbodies, USS

types of miscarrage

threatened inevitable incomplete complete missed

management options for early preganancy loss

expectant medical - PV misopristol, approppriate analgesia surgical - dilatation and curettage, haaemodynamicaally stable, failure of medical Mx

hypertensve disorders of pregnancy

genstational HTN Chronic HTN pre eclampsia pre eclampsia superimposed on chronic hypertension eclampsia

new onset hypertension post 20 weeks gestation management

BP, ECG, spit urine PCR, FBC, UEC, LFT, US to assess foetal growth, AFI, dopplers, CTG if > 30 weeks

if features of pre-eclampsia are present

MSU urinalysis (protein/urine microscopy) investigations for DIC/haemolysis if presence of thrombocytopaenia or falling Hb

management of acute severe hypertension

>170/110 nifedipine 10mg PO labetolol 20-80mg IV hydralazine 5-10mg IV

management of maintenance therapy of hypertension

BP > 140/90 methydopa or labetolol hydralazine, nifedipine, prazosin

definitive management of pre-eclampsia

delivery

indiications of delivery for pre-eclampsia

gestational age >37 weeks inability to control hypertension deteriorating platelet count, liver function, renal function placental abruption peristent neurological symptoms/eclampsia APO severe FGR/non-reasurring foetal status

management of eclampsia

resus - IV access, secure aairway, oxygen by mask if seizure is extended give IV midazolam MgSO4

after acute manaagement of eclampsia

continue MgSO4 pot resus to prevent further seizures contorl HTN to below 160/100 arrange c-section

gestational diabetes define

any degree of lgucoe intolerance wtih onset, or first recogntion during pregnancy includes pregnant women with previous diabetes not diagnosed until pregnancy

screening for gestational diabetes

OGTT for all women at 24-28 weeks ealrier OGTT if higher risk

diagnosis of gestational diabetes

fasting > 5.1 mmol/L 1 hour BG > 10 mmol/L 2 hour BG > 8.5 mmol/L

symptoms of gestational diabetes

frequent urination blurrred vision thrist weakness

monitoring and management

BGL monitoring serial USS/umbilical artery doppler - 34 weeks (macrosomia/PH) glycaemic control birth planning

foetal complications of gestational diabetes

macrosomia hypoglycaemia reppiratory disstrress preterm birth jaaundice overweight/obesity dysglycaemia dyslipidaemia hypertension

antepartum haemorrhage causes

placental abruption

partial orr complete seperaation of the placenta from the utuerus prior to delivery

placenta praevia

placenta is inserted wholly or in part into the lower segment of the uterus major if lying over internal cervical os minor/partial if leading edge of placenta is in the lowerr uterine segment but not covering cervical os

vasa praevia

fetal vessels coursing through membraanes over internal cervical is and below fetal presenting part, unprotected by placental tissue or umbilical cord

Symptoms of placental abruption

lower abdominal pain vaginal bleeding rigid uterus, tenderness fetal distress

antepartum aemorrhage workup

history - blood loss, pain assessment, presence of contractions, triggers, presence of foetaal movements, risk assessment examination - maternal vitals (haemodynamic stability), abdominal exmination, foetal observations, spec exam)

investigations of antepartum haemorrhage

kleihhauer test FBC, G+H, cross match coagulation screen UEC LFT USS

management of antepartum haemorrhage

A-E assessment rule out obvious causes of external bleedings consider need for blood transfusion, delivery, corticosteroids anti D if Rh -ive

management of post partum haemorhage

assess A-E - vitals, 4Ts, extent of bleeding, labour resus - IV access, investigations, O2, fluid replacement, tranexamic acid arrest - fundal massage, bimanual compression, IDC insertion, uterotonics (oxytocin +/- ergometrine), oxytocin infusion, carboprost IM 15 minutely