Pregnancy Flashcards
(118 cards)
1
Q
Maternal mortality definition
A
Death of women while pregnant or within 42 days of termination of pregnancy from any cause per 100 000 deliveries
2
Q
Timing of first trimester screening
A
Once, ideally before 12 weeks
3
Q
What does first trimester screening include
A
- IPS testing
- Ultrasound for dating
- Labs (CBC, blood type, electrophoresis if anemia, infection (gonorrhea, chlamydia, HIV, VDRL, HBsAg, urine culture and sensitivity, Rubella)
- PAP test
4
Q
A mother is not immune to rubella on screening. What action do you take?
A
Must avoid sick contact during pregnancy and immunize postpartum
5
Q
A mother has gonorrhea, chlamydia, bacterial vaginosis or trichomonad during pregnancy. What do you do?
A
Treat
6
Q
What can cause a false VDRL reading?
A
Lupus
7
Q
What is included in 2nd trimester screening
A
- Morphology ultrasound at 18-20 weeks (only mandatory ultrasound)
- Blood - hemoglobin, ABO, Rh, Rh antibody at 24-28 weeks
- Gestational diabetes screen with non-fasting 50g glucose load at 24-28 weeks
8
Q
Gestational diabetes screening algorithm
A
Tony’s pg 12
9
Q
3rd trimester screening
A
- GBS vaginal and rectal swab at 35-37 weeks
10
Q
How to interpret symphysial fundal height
A
Distance from pubic bone crest to top of uterus to measure growth
FSH should be roughly equal to gestational age (+/- 2 cm) and increase 1 cm per week
Use starting at 12 weeks
11
Q
What is crown rump length
A
Longest straight line from outer margin of cephalic pole to rump
Most accurate estimation of gestational age in 1st trimester after 6 weeks
12
Q
What is a biophysical profile
A
Usually done in high-risk pregnancies in 3rd trimester
U/S evaluation of fetal well-being using Manning’s score system and non stress test
13
Q
Oligohydramniosis cut off and associations
A
<5
Associated with placental insufficiency and baby in stress
14
Q
Polyhydroamniosis
A
> 25
Associated with diabetes, chromosomal abnormalities and anatomical abnormalities
15
Q
Trisomy 18
A
Edwards syndrome
Severe mental retardation and other
<10% survive 1 year
16
Q
Trisomy 13
A
Patau syndrome
Severe mental retardation and other
5% survive 3 years
17
Q
Trisomy 16
A
Lethal, often first trimester spontaneous abortions
18
Q
45,X
A
Turner syndrome
First-trimester spontaneous abortions
Slightly lower IQ
19
Q
47, XXX; XYY, XXY
A
Klinefelter syndrome
Tall, eunuchoid habitus and small testes
20
Q
del(5p)
A
Cri du chat syndrome
Severe mental retardation, microcephaly, distinctive facial features, characteristic cat’s cry sound
21
Q
What birth defect risk does not increase with maternal age
A
Open neural tube defects
22
Q
What does IPS screen for
A
Risk of Down’s, Edward’s and neural tube defects
23
Q
What does IPS include
A
- Ultrasound (nuchal translucency >3 mm and absence of nasal bone increases risk for Down Syndrome) and PAPP-A (lower in trisomy 21) at 11-14 weeks for Down’s
- Maternal serum screening at 15-21 weeks, ideally at 15+3 weeks
Free beta-hCG - higher in Down’s
AFP - high in NTD
uE3 - low in Down’s and Edward’s
24
Q
Types of pre-natal screening for birth defects
A
- Non-invasive – IPS, MSS
- Invasive – chorionic villous sampling and amniocentesis
Now instead of IPS can do EFTS (one stop shop mainly meant to rule out Down Syndrome). EFTS has 7% false positive rate vs 10% false positive rate in IPS
NIPT is probably going to start to replace EFTS soon
Amniocentesis will always be the gold standard (performed if positive screening with IPS or EFTS) and is a diagnostic test
25
Indications for invasive pre-natal screening
1. Positive prior screening test (IPS or maternal serum screening)
2. Family history of genetic disease
3. Maternal age >40
4. Specific u/s finding that need to be f/u
26
Purpose of invasive pre-natal screening
Test for other genetic and birth defects outside of Down's, Edward's and NTD
27
Chorionic villous sampling
1. Done at 11-13 weeks
2. Sample taken from placental villi
3. 1% miscarriage rate (higher than amniocentesis)
4. Results come back in 2-3 weeks
5. Do not detect NTD so AFP need to be done at 15-20 weeks
28
Amniocentesis
1. Done at 15-22 weeks
2. Sample taken from amniotic fluid
3. <1% miscarriage rate
4. Results come back within 3 weeks (rapid aneuploidy 1 week, conventional chromosome study 2-3 weeks)
5. Can detect NTD
29
Cordocentesis
Done at >18 weeks
30
Normal placenta
1. Discoid
2. 500 grams, 15-20 cm in diameter, 2-3 cm thick
3. Situated in upper uterine segment in fundal portion of uterus
31
Trimesters in weeks
1- end of 12 - 1st trimester
13- end of 26 - 2nd trimester
27 onward - 3rd trimester
32
3rd trimester bleeding differential diagnosis
1. Pregnancy related
Placenta - placental abruption, placenta previa, vasa previa
Uterus - uterine rupture
Cervix - cervical insufficiency (thin cervix), cervical friability, cervical cancer
Vagina - laceration of trauma
Physiologic - bloody show associated with labour
```
2. Non-pregnancy related cause
PALM COEIN
Polyps
Adenomyosis
Leiomyoma
Malignancy (including trophoblastic disease)
Coagulopathy
Endometrial dysfunction
```
33
NIPT
Non invasive prenatal testing
Replacing amniocentesis because of risk of miscarriage
Measures fetal cells in maternal serum
Results in 10 days
Not currently covered by the ministry unless maternal age 40+
34
HIV contraindications for pregnancy and childbirth
No ergot if post partum hemorrhage
No instrumentation/vacuum
No breastfeeding
35
Degrees of shock and associated signs and symptoms
Mild - <20% - cool extremities, increased cap refill
Moderate - 20-40% - tachycardia, tachypnea, postural hypotension, oliguria
Severe - >40% - hypotension, agitation/confusion, hemodynamic instability
36
Limit of neonatal viability
22 weeks
37
4 main causes of preterm births
Spontaneous
- preterm labour with intact membranes
- PPROM
Indicated
- maternal or fetal complications requiring early delivery
- Twins or high-order multiples
38
Pre term labour risk factors
SES
Genetic factors (maternal race, history, age)
Increased uterine distension (polyhydramnios, multifetal gestation)
Multifetal gestation
Infection (UTI, periodontal, bacterial vaginosis) —> treat even if asymptomatic in pregnancy
Behavioural (low maternal weight, substance abuse, smoking)
Short inter-pregnancy interval (delivery <12 months)
Vaginal bleeding (T2>T1)
Cervical surgery
Uterine congenital malformations: bicornuate/didelphys
39
Pathogensis of preterm labour
Stress response via HPA axis
- Increased maternal cortisol or fetal ACTH by fetal adrenals
- Increases CRH production by placenta/membranes and decidua
- Estrogen conversion of adrenal DHEA leads to increased myometrial receptivity
Inflammation/infection -
Decidual hemorrhage
Uterine Stretch
40
Prevention for preterm labour
Not very successful
Screening in women with risk factors (cervical length 10th centriole <26 mm, bacterial vaginosis swab first trimester)
Interventions:
Modifying behavioural risks - alternating positions (strict bedrest not shown to be of any benefit)
Progesterone in women with previous PTB or short cervix once there is change in cervix
41
Pre term labour diagnosis
Painful contractions
Pelvic pressure
Back pain
Bleeding
```
Signs:
Palpable contractions
Short cervix
Open cervix on spec
Dilated cervix on digital exam
```
42
Diagnosis of PTL
Fetal fibronectin
- Glycoproteins in cervicovaginal secretions, swab for these in posterior fornix
- Marker for impending preterm labour
- Poor sensitivity in asymptomatic women
- Negative predictive value 98%, PPV 30%
- Useful 24-34 weeks with intact membranes
- Can not have had internal examination within 24h
43
When to avoid doing a digital exam
If you are unsure of the location of the placenta (have not gotten 2nd trimester morphology screen)
Do speculum exam instead
44
Management of PTL
1. Determine fetal presentation
2. Celestone
3. Tocolytics?
4. Antibiotics for GBS prevention
5. Transfer to tertiary center
6. Paediatric consultation
7. Neuroprotection (MgSO4)
45
What’s the deal with antenatal steroids?
Betamethasone 12 mg IM q 24h x 2 doses
<34 weeks
Activates fetal surfactant production to decrease RDS
One course good for each pregnancy
46
Risk factors for PPROM
```
Antepartum bleeding
Previous cervical surgery
Smoker
Low SES
Cervical incompetency (cervix opens without contractions, presents with pressure, discharge)
```
47
PPROM diagnosis
1. Pooling
2. Cough test
3. Nitrazine - pH (amniotic fluid basic, vagina acidic)
- false positive with blood, sperm, BV, alkaline urine
4. Ferning - false positive 20% (sperm, cervical mucous), false negative 40%
- Swab in the fornix, not in the cervix because mucous will can false positive
Obstetrical ultrasound
1. Fetal position
2. Amount of amniotic fluid
3. Dating
4. Fetal well being
48
PPROM complications
Maternal
1. Infection (chorioamniotis, endometriosis, Baxter Emma)
2. Increased risk of CS
Fetal
1. Infection
2. Preterm delivery (50% deliver in first 24h, 70-80% in following week)
3. Cord prolapse
4. Abruption
5. Pulmonary hypoplasia
49
PPROM Management
1. Confirm diagnosis
2. Ensure maternal and fetal well being
3. Address underlying cause that needs management (ex. Abruption, chorio)
4. Avoid digital exam unless in labour (push up bacteria each time)
5. GBS swabs
6. Ultrasound
7. Decide on expectant vs active management
50
Indications for induction
1. Weight gains in maturity against infection risk
2. Earlier PPROM more likely to gain significant time
3. After 34 weeks gain in time smaller
4. Most will induce after 35 weeks
51
Expectant management
```
<34 weeks
Goal is to increase latency period
Antibiotic prophylaxis
Maternal and fetal monitoring
Antenatal steroids
Possible transfer to tertiary center
```
52
Infertility definition
1 year of unprotected intercourse without conception
53
2 most important factors for natural conception rate
1. Female age
| 2. Duration of infertility
54
What past medical history would be concerning for tubal injury?
Ruptured appendix
55
What are some screening tests available to predict fertility potential
Day 3 FSH, LH, Estradiol
Antral follicle Count (AFC) - most reliable early in cycle
Anti-Mullerian Hormone (AMH)- don’t need to time in cycle, but not covered by OHIP
56
Femal einfertility management class 1
Weight gain
GnRH pump
Gonadotropins
IVF
57
Class II Female management
```
1st line - Weight loss
1st line med - Femara or Letrizole
Aromataste inhibitors
Insulin-sensitizing agents (ex. Metformin)
Laparoscopic ovarian drilling
Gonadotropins
IVF
Bromocriptine or other dopamine agonist (only in cases of hyperprolactinemia and anovulation)
```
58
Class III Infertility Management
Expectant management
?Gonadotropins/IVF
Donor egg - best treatment option to have pregnancy
Adoption
59
Tubal etiology infertility investigations
Hysterosalpingogram (HSG)
SonoHSG
Laparoscopy
60
Tubal factor infertility treatment
IVF
| Consider tubal surgery if due to tubal ligation or do not want IVF
61
Hirsutism definition
Excess facial and body hair caused by excess androgen production
Unwanted
62
Virilization definition
Clitoromegaly, depending of voice, balding, body habitus changes
...
63
Whole blood contents
RBCs, plasma, fibrinogen
No platelets
64
Packed RBCs
RBCs only
No fibrinogen, no platelets
65
Fresh Frozen Plasma FFP
Colloid, fibrinogen
No platelets
66
Cryoprecipitate
Fibrinogen, other clotting factors
No platelets
67
Placental abruption risk factors, pathophysiology, presentation, complications, diagnosis, treatment
Risk factors
1. Maternal - AMA, prior abruption, prior CS, multi-parity, comorbidity, cocaine
2. Current pregnancy - multiple gestation, short umbilical cord, PPROM, Prolonged ROM, polyhydramnios, trauma
Pathophysiology
- placental lining separated from uterus, bleeding from maternal side of placenta
Marginal, partial or complete
Clinical presentation
1. Bleeding per vagina with painful uterine contraction
2. Tenderness and hard uterus or back pain
3. Fetus distress as shown by fetal heart rate monitoring
Complications
Fetal complication usually followed by maternal
- fetal distress
- premature delivery
- fetal hypotension, anemia, CP and developmental problem
- couvelaire uterus (penetration of blood into uterine myometrium and into peritoneal cavity)
- Maternal hypovolemic shock and end organ damage
- Maternal DIC
Diagnosis
- Clinically based on vaginal bleeding, abdo tenderness and/or fetal distress
- Trans abdominal or vaginal u/s to rule out placenta previa and detect large abruption
Treatment
- Stabilize and deliver (unless premature and no fetal distress, then consider close observation)
68
Placenta previa risk factors, pathophysiology, clinical presentation, complication, investigation, diagnosis, treatment
Risk factors
1. Maternal factors
- AMA, prior placenta previa, multiparity >5, previous uterus surgery
- illicit drugs, smoking
2. Current pregnancy factors
- multiple gestation
Pathophysiology
Placenta inserted in lower uterine segment such that it is near or partially covers or completely covers the internal cervical os
Grade 1 - low lying, placenta within 5 cm of internal cervical os
Grade 2 - marginal, placenta reaches margin of os but does not cover
Grade 3 - Partial previa, placenta partially covers os
Grade 4 - Complete previa, placenta completely covers os
Clinical Presentation
- Painless bright red vaginal bleeding during 2nd half of pregnancy
Complication
- Maternal hypovolemic shock
- Preterm delivery
Investigation
- Blood work including Kleihauer-Betke stain, HIV, Hepatitis B
- TA or TV U/S
Diagnosis
- definitive diagnosis with TA/TV U/S
Treatment
Definitive treatment delivery by C-section
69
Vasa Previa risk factors
1. Pregnancy achieved with assisted reproductive technology
| 2. Placenta - resolved placenta previa, bilobed or succinturiate lobed placenta
70
Vasa previa pathophysiology
Fetal vessels unsupported by umbilical cord that overlie the cervix or lies between cervix and fetal presenting part
71
Vasa previa clinical presentation
Classic triad
1. Membrane rupture
2. leading to painless vaginal bleeding
3. and fetal bradycardia (or sinusoidal pattern)
Pelvic exam - rarely, pulsating vessel in membrane overlying cervical os
72
Vasa previa diagnosis
Pre-natally - identification of membranous fetal vessel passing internal cervical os on ultrasound
May be diagnosed clinically based on presentation of triad
73
Vasa previa treatment
Definitive treatment is delivery by C section
74
Definition and classification of hypertension in pregnancy
Hypertension in pregnancy diagnosed based on blood pressure 9mean of at least 2 measurements taken at least 15 minutes apart using same arm)
- SBP 140+ and or/ DBP 90+
- Severe hypertension 160+ SBP or 100+ DBP
Classification:
1. Pre-existing (chronic) hypertension less than 20 weeks GA
2. Gestational hypertension that develops 20+ weeks GA
Both of these are defined as hypertension with resistance, proteinuria, adverse condition or severe complications
75
Pathophysiology of preeclampsia and eclampsia syndrome
1. Decidual immune cell and extravillous trophoblast interactions cause invasion and uteroplacental artery remodelling
Interaction can be precipitated by
- Immune factors causing antigen exposure such as primi-gravidity, primi-paternity, donor gametes
- Genetic factors including epigenetic, familial risks
- Lowered threshold from metabolic syndrome, chronic infection or inflammation, CKD, diabetes
2. Interactions of decidual cells and extravillous trophoblast result in inadequate placentation and uteroplacental mismatch, resulting in release of mediators (intervillous soup)
Intervillous soup includes placental debris, innate immune activation, oxidative stress, eicosanoids, cytokines
3. Intervillous soup results in endothelial cell activation and dysfunction within vulnerable multi-organ systems, resulting in systemic effects
76
What are the symptoms, signs, lab tests and diagnostic methods for gestational hypertension
Investigations:
Pre-existing hypertension/early
- CBC, lytes, Cr, fasting blood glucose
- Urine analysis (protein without RBCs or casts)
Suspected pre-eclampsia
- O2 sat (<97% in pre-eclampsia)
- CBC (anemia in HELLP, thrombocytopenia in pre-eclampsia), film (RBC framgentation in micro-angiopathy), Cr (renal failure), uric acid (increased) glucose, AST, ALT, bilirubin (liver dysfunction), albumin (decreased due to liver dysfunction), LDH, INR, aPTT (increased in DIC), fibrinogen (decreased in DIC)
Fetal testing
- Monitoring
- Deepest amniotic fluid pocket (oligohydramnios)
- Uterine artery doppler velocimetry (uni or bilateral notching, elevated plurality or resistance index suggestive of placental insufficiency)
- Fetal growth (IUGR)
- Umbilical artery doppler (increased resistance, absent or reversed end diastolic flow in pre-eclampsia)
- Ductus venous doppler (increased resistance, absent or reversed A wave in pre-elclampsia)
- MCA doppler (cerebral redistribution with decreased resistance or brain sparing effect)
77
Gestational hypertension prevention and management
Prevention - calcium, folic acid, lifestyle
- High risk (history, abnormal uterine artery Doppler before 24 weeks gestation) - low dose aspirin, L-arginine, rest, prostaglandin precursor, Mg supplementation, heparin to prevent VTE, LMWH
Management
1. Lifestyle
2. BP control
No comorbidity target - SBP 130-155 and DBP 80-105
Comorbidity target - SBP 130-139 and DBP 80-89
1st line - Methyldopa (but makes moms dopey), lebatalol, nifedipine XL
2nd line - BB except atenolol, HCT, hydralazine
3. Manage non severe pre-eclampsia (inpatient)
a) <24 weeks GA
- counselling about delivery within days
b) 24-34 weeks
- expectant management
- consider ante-natal corticosteroid for fetal maturation
c) 34-37 weeks
- expectant management or immediate delivery
- consider ante-natal CS if CS delivery
d) 37+ weeks
- immediate delivery
4. Manage severe pre-eclampsia
- Vitals monitoring, investigations
- BP control 1st line - Nifedipine, Hydrazine, Labetalol
Refractory treated with sodium Nitroprusside IV
- Prophylaxis against eclampsia with MgSO4 4g IV loading dose followed by 1g/h (can also treat existing eclampsia)
- HELLP treated with FFP transfusion or plasma exchange
- Consult OB
- Delivery is the only definitive intervention to resolve pre-eclampsia, thus all severe pre-eclampsia are OB emergencies and require immediate delivery regardless of GA
5. Post-partum management within 6 weeks
- Continuous monitoring and labs
- Control BP with anti-hypertensives according to CHEP guidelines
6. Post partum long term management after 6 weeks
- Screen for pre-existing HTN, renal disease
- Address CVD risk factors
78
Maternal and fetal complications of gestational hypertension, and signs and symptoms of each
```
Recurrence of pre-eclampsia
Chronic hypertension
TIIDM, metabolic syndrome
CKD
Premature CVD including CAD, CVD, PVD
```
79
Pre-eclampsia definition
Hypertensive disorder of pregnancy defined as SBP 140+ and/or DBP 90+ with 1+ of the following:
1. New proteinuria >300 mg/24h
2. 1+ Adverse condition
3. 1+ severe complication
Severe pre-eclampsia is pre-eclampsia with 1+ severe complication
80
What is HELLP syndrome
Type of severe pre-eclampsia
| Hemolysis, Elevated Liver enzymes, Low Platelets
81
What is eclampsia
Generalized tonic clonic convulsive seizure, which is a complication of pre-eclampsia
82
What does expectant management for pre-eclampsia entail?
IV access (no volume expansion)
Administration of anti-hypertensives
CS for fetal lung maturation
Daily bio-physical profile and fetal assessment
Daily maternal pre-eclampsia labs
Daily clinical assessment of mother and fetus
83
Indication for hospitalization with maternal hypertension
Severe hypertension >160/110
or
Severe pre-eclampsia
84
Normal post partum blood pressure pattern
Drop PP day 1-2
Peak PP day 2-7
Decline after PP day 7
Normalize by 3 months
85
Anti-hypertensives acceptable for use during breast feeding
```
Nifedipine
Labetalol
Methyldopa
Captopril
Enalapril
```
Dopey Ned took some ace inhibitors and beta blocker
86
Ectopic pregnancy risk factors
1. Demographics: older women, African descent
2. Uterine structural abnormality: fibroids, adhesions, abn anatomy
3. Ob/Gyn history: prior ectopic, IUD, PID, salpingitis, infertility
4. Surgery: abdo, pelvic, IVF
5. Medication: clomiphene citrate
87
Ectopic pregnancy signs and symptoms
Pain, vaginal bleeding
Missed menstrual period, Chadwick's sign, Hegar's sign, fever, peritoneal signs, cervical motion tenderness, palpable adnexal mass, tenderness on bimanual
88
Ectopic pregnancy labs and diagnostic tests
Serial beta-hCG
- <8 weeks gestation normally doubles ever 2 days
- Non viable has slower rise, plateau or decreasing before 8 weeks
U/S (tubal ring on TVUS)
- visible on u/s when b-hCG >1500 for TVUS and >6000 for TAUS
Laparoscopy
Diagnosis -- elevated b-hCG and visualization on U/S or laparoscopy
89
Ectopic pregnancy management
1. Stabilize
2. Abortion (medical or surgical, similar success rate)
a) Surgical - linear salphingostomy (preserve tube) or salpingectomy (remove tube)
b) Medical - methotrexate IM
90
Ectopic pregnancy implications for fertility
With surgical abortion 40-60% of cases will be fertile and become pregnant again after surgery
With medical abortion 80% preserve Fallopian tube patency
91
Most common site for ectopic pregnancy
Fallopian tube (98%) specifically in the ampulla (70%)
92
Indications for surgical abortion
1. >3.5 cm ruptured ectopic pregnancy
2. Fetal heart rate present
3. b-hCG >5000
4. Liver or renal or hematological disease
5. Poor compliance, unable to follow up
Indication for salphingectomy - damaged tube, recurrent ipsilateral ectopic
Indication for salpingostomy - if no indication for salphingectomy
93
Indications for medical abortion
1. <3.5 cm ruptured ectopic pregnancy
2. Fetal heart rate absent
3. b-hCG <5000
4. No liver, renal, hematological disease
5. Good compliance, able to follow up
94
Clinical presentation of spontaneous abortion
Abdominal cramping, vaginal bleeding, ROM, passage of tissue and clots
95
Spontaneous abortion definition
non-induced embryonic or fetal death or passage of products of conception before 20 weeks GA
96
Threatened abortion definition
Vaginal bleeding with closed cervix and viable fetus, which can resolve or progress to spontaneous abortion
97
Inevitable abortion
Dilated cervix, but conception products have not been expelled, will progress to spontaneous abortion
98
Incomplete abortion
Some, but not all of conception products have been passed, retained products may include fetus, placenta or membrane
99
Complete abortion
All conception products have been passed without need for surgical or medical intervention
100
Missed abortion
Fetal demise but no uterine activity to expel conception products
101
Septic abortion
Spontaneous abortion complicated by intra-uterine infection
102
Most common fetal cause of spontaneous abortion
Chromosomal abnormalities in 50% of cases
103
Cause of recurrent spontaneous abortions
MAKE ID
Mechanical uterine anomalies including congenital septate uterus, leiomyoma, endometrial polyps, intra-uterine adhesions
Autoimmune factors including anti-phospholipid syndrome
Karyotype including aneuploidy, chromosomal rearrangement
Endocrinopathy including thyroid disease, DM, PCOS
Maternal infection including TORCH, listeria
Drugs including smoking, illicit drugs and other environmental factors
104
Complication of spontaneous abortion and presentation
Septic spontaneous abortion, which presents with fever, hypotensive shock, abdo pain and leukocytosis
105
Management of spontaneous abortion with retained products
1. Watch and wait
2. Misoprostol
3. D&C +/- Oxytocin
106
Vaginal bleeding in 1st and 2nd trimester
1. Physiologic - implantation of placenta
2. Abortion
3. Abnormal pregnancy - ectopic, gestational trophoblastic disease
4. Trauma
5. Genital lesion - polyps, cancer
107
What are the only non-pharmacological pain relief methods that have been shown to have some benefit in relieving pain
Vertical position during 1st stage of labour
Continuous support
Acupuncture
108
Types of opioids that can be used in intermittent bolus parenteral method of pain control, and the pros and cons of each
1. fentanyl - fastest onset, shortest duration, lower effect re neonatal respiratory depression
2. Meriperine - slowest onset
3. Morphine - longest duration
4. Nalbuphine - longest duration, lower effect re neonatal respiratory depression
109
Indication for intermittent bolus parenteral opioid administration
- 3rd line
| - Early labour or very late stage labour where epidural is not an option
110
Patient controlled analgesia types of opioids used
- Fentanyl most commonly
| - Remifentanil
111
Disadvantage of Patient controlled analgesia
Requires continuous O2 sat monitoring and one-on-one nursing
112
PCA indication
- 2nd line pain control
- Epidural refused on contraindicated
- Intrauterine fetal demise or termination of pregnancy
113
Inhalation nitrous oxide (entonox (50NO: 50 oxygen) indication
Usually used before or in conjunction with opioids or epidural
114
First line pain management in labour option
Epidural
115
Epidural contraindications
Absolute
- Patient must be able to sit still for procedure
- Patient refusal
- Increased intra-cranial pressure
- Infection at site of injection
- Systemic infection
- Coagulopathy
Relative
- Uncorrected maternal hypovolemia
- Active neurological disorder
- Inadequate training or equipment
116
Epidural procedure steps
1. Needle inserted at L2-L5 (usually L3-4) between vertebrae midline into epidural space just beyond the ligamentum flavum
2. Catheter inserted through needle and left in-situ
3. Local (bupivicaine or ropivicaine) +/- opioids are inserted via catheter
117
Role of local anesthesia in epidural
1. Block nerve endings bathed in epidural space innervating the birth canal
2. Ideally blocks only sensory component (motor intact)
3. 15-20 minutes to take effect
118
What is the effect of epidural analgesia on labour?
1. Prolong 2nd stage of labour, but not clinically significant
2. Epidural analgesia does not increase risk of C section
3. Does not increase risk of back pain postpartum
