Flashcards in Week 235 - Pregnancy 2 Deck (76):
Week 235 - Pregnancy 2: What are the fetal indications for operative vaginal delivery?
Week 235 - Pregnancy 2: What are the maternal indications for operative vaginal delivery?
• Medical indications to avoid Valsalva e.g.
- Cardiac disease
- Hypertensive crisis
- Myasthenia gravis
- Spinal cord injury
Week 235 - Pregnancy 2: What are indications for operative vaginal delivery due to inadequate progress of labour?
• Nulliparous women - Lack of progress for three hours with regional anaesthesia or two hours without regional anaesthesia.
• Multiparous women - Lack of progress for two hours with regional anaesthesia or one hour without regional anaesthesia.
• Maternal fatigue/exhaustion
Week 235 - Pregnancy 2: What are the 8 requirements for instrumental delivery?
• Valid reason
• Head must not be palpable abdominally
• Head must be at or below the level of the ischial spines
• Cervix must be fully dilated
• Position of the fetal head must be known
• Adequate analgesia
• Bladder should be empty
• Must have facilities to perform C-section in case of failure.
Week 235 - Pregnancy 2: What are the two methods for instrumental delivery?
• Ventouse - Suction cup attached to point 2-3cm anterior to posterior fontanelle.
• Forceps - Non-rotational and rotational (Kiellands)
Week 235 - Pregnancy 2: What are the eight positions of the fetal head?
• Direct Occiput Anterior - Ideal position
• Right/Left Occiput anterior
• Right/Left Occiput Transverse
• Direct Occiput Posterior - 'Face to Pubes'
• Right/Left Occiput Posterior
Week 235 - Pregnancy 2: What is the station of the babies head?
The level of the bony part of the fetal head in relation to the ischial spines. - is above and + is below.
Week 235 - Pregnancy 2: When should operative vaginal delivery be stopped?
• There is no evidence of progressive descent with each pull.
• Or delivery is not imminent following three pulls of a correctly applied instrument by an experience operator.
Week 235 - Pregnancy 2: What are the complications of caesarean section?
• Venous thromboembolism
Week 235 - Pregnancy 2: What sort of incision is normally performed in the skin during a c-section?
Pfannensteil (Curved horizontal incision)
Week 235 - Pregnancy 2: What are the indications for emergency c-section?
• Prolonged first stage of labour
• Fetal distress
Week 235 - Pregnancy 2: What are the absolute indications for caesarean section?
• Placenta praevia
• Severe antenatal fetal compromise
• Uncorrectable abnormal lie
• Previous classical c-section
• Pelvic deformity
Week 235 - Pregnancy 2: What are the relative indications of caesarean section?
• Breech presentation
• Previous c-section
• Older nulliparous women
Week 235 - Pregnancy 2: What are the predisposing factors to having a multiple pregnancy?
• Increasing maternal age
• Family History
• Assisted conception
Week 235 - Pregnancy 2: What is the difference between monozygotic and dizygotic twins?
• Monozygotic - A single zygote splits into two equal zygote they share the same genetic material. - Identical twins.
• Dizygotic - Two different zygotes are formed by fertilization of two eggs by two different sperms - Different genetic material.
Week 235 - Pregnancy 2: What does chorionicity refer to?
Refers to placentation.
Week 235 - Pregnancy 2: What does amniocity refer to?
This refers to the relation of the amniotic membranes between the twins.
Week 235 - Pregnancy 2: What is dichorionic-diamniotic twinning?
This is where each twin has its own placenta and amniotic sac.
Week 235 - Pregnancy 2: When each baby has its own placenta, there will be two chorions and two amnions. What is this known as?
Week 235 - Pregnancy 2: What is mono-chorionic diamniotic twinning?
This is where each twin has its own sac but they share a common placenta.
Week 235 - Pregnancy 2: What is it called when each baby has its own amniotic sac but share a placenta?
Mono-chorionic diamniotic twinning.
Week 235 - Pregnancy 2: What is it called when twin babies share both the amniotic sac and placenta?
Week 235 - Pregnancy 2: What is monochorionic-monoamniotic twinning?
This is when both twins share the same amniotic sac and placenta.
Week 235 - Pregnancy 2: In terms of chorionicity and amniocity what are dizygotic twins always?
Week 235 - Pregnancy 2: Chorionicity is the the most important part of the management of twin pregnancy. Which form carries the highest risk? What are the risks?
- Congenital abnormalities
- Perinatal loss
Week 235 - Pregnancy 2: At which time should DCDA and MCDA twins be delivered?
• Uncomplicated DCDA 37-38wks
• Uncomplicated MCDA 36-37wks
Week 235 - Pregnancy 2: How does cardiac output change during pregnancy?
- Increases by 30-50%
- Blood volume increases to 150% of non-pregnant level.
- Stroke volume increases 30%
- Heart rate increases by about 15%
Week 235 - Pregnancy 2: What changes during pregnancy in relation to preload and afterload? Why is this?
• Preload - increases due to increase in blood volume.
• Afterload - Reduced due to reduction systemic vascular resistance.
Week 235 - Pregnancy 2: What occurs to BP during pregnancy?
• Reduction in systemic arterial BP during first 24 weeks, due to smooth muscle relaxation due to progesterone.
• The BP then gradually rises after this to non-pregnant levels by term.
Week 235 - Pregnancy 2: What is the mechanism behind the peripheral oedema associated with pregnancy? What is the benefit of it?
• Increased Renin-angiotensin-aldosterone activity leading to retention of water and sodium.
- This causes peripheral oedema but also increases intravascular volume.
Week 235 - Pregnancy 2: What are some of the ECG changes that may occur with pregnancy?
• Borderline sinus tachycardia.
• Axis deviation to left.
• ST changes and inversion of T wave in lead III/AVF may occur.
Week 235 - Pregnancy 2: What changes occur to the coagulation system during pregnancy? What is the benefit and problem with this change?
• Increase of factors I, VII, VIII, IX, X, XII
- This protects from haemorrhage at delivery BUT
- Increases risk of thromboembolism
Week 235 - Pregnancy 2: Haemorrhage is well tolerated in pregnant ladies. How much can be tolerated and what is the management of any haemorrhage?
• Tolerate 1.5L but then will rapidly decompensate.
• Loss needs to be estimated and monitored with early replacement of volume/02 carrying capacity and clotting factors.
Week 235 - Pregnancy 2: What changes in terms of lung capacity during pregnancy?
• Increased 02 requirements of fetus is met by,
- Increase in tidal volume of 30-40%
- Decreased residual volume by 20%
- RR and vital capacity remain unchanged.
Week 235 - Pregnancy 2: Why do pregnant women have a compensated respiratory alkalosis?
This facilitates fetomaternal 02 transfer at the placenta.
Week 235 - Pregnancy 2: What are the two reasons for pregnant women to feel short of breath?
• Subjective feeling due to progesterone.
• Rising fundus.
Week 235 - Pregnancy 2: How does Renal physiology change in pregnancy? (5 ways)
• Renal blood flow increases by 75%
• GFR increases 150% of non-pregnant rate.
• Altered tubular function - increased glycosuria, proteinuria, calciuria and bicarbonaturia.
• Plasma urea and creatinine fall due to increased creatinine clearance.
• Plasma renin, ATII and aldosterone rise.
Week 235 - Pregnancy 2: Why do pregnant women suffer from increased reflux?
Progesterone causes smooth muscle relaxation so the lower oesophageal sphincter has less tone.
Week 235 - Pregnancy 2: Why does a pregnant lady have reduced GI motility what is the side effect of this?
• Oestrogen and progesterone reduce motility.
• This allows for better absorption but can lead to constipation.
Week 235 - Pregnancy 2: Why do pregnant ladies develop an altered gait and exaggerated lordosis?
Connective tissue is softened - sacroiliac, symphysis pubis, intercostal and interspinous ligaments.
Week 235 - Pregnancy 2: What impact does pregnancy have on the thyroid hormones?
• Oestrogen causes the liver to increase the levels of thyroxine-binding globulin (TBG).
• This leads to reduced freeT4 and elevated TSH.
• Ultimately leading to increased T3 and T4.
• hCG will bind to TSH receptor causing transient hyperthyroidism.
Week 235 - Pregnancy 2: What is the are the causes of bleeding in early pregnancy?
• Ectopic pregnancy
Week 235 - Pregnancy 2: What is a threatened miscarriage?
This is where there is bleeding, the foetus is alive and the OS is closed.
Week 235 - Pregnancy 2: What is an inevitable miscarriage?
This is where there is heavy bleeding, the foetus may be be alive and the OS is open.
Week 235 - Pregnancy 2: What is an incomplete miscarriage?
This is where there is bleeding, some foetal parts are passed and the OS is open.
Week 235 - Pregnancy 2: What is a complete miscarriage?
This is when all pregnancy tissue has passed, bleeding has settled and the OS is closed.
Week 235 - Pregnancy 2: What is a missed miscarriage?
This is where the foetus has not developed or has died in utero. The OS is closed, often asymptomatic.
Week 235 - Pregnancy 2: What is a septic miscarriage?
Infected uterine contents, offensive loss and a tender uterus.
Week 235 - Pregnancy 2: What is the medical management of miscarriage?
Mifepristone and misoprostol (Prostaglandin)
- Success rate varies.
Week 235 - Pregnancy 2: What are the indications for the surgical management of miscarriage?
• Unstable vital signs
• Infected retained tissue.
Week 235 - Pregnancy 2: What should be given to all rhesus -ve mothers after surgical/medical intervention of miscarriage?
Week 235 - Pregnancy 2: What is the most common location of ectopic pregnancies?
Ampulla of tube.
Week 235 - Pregnancy 2: How can an ectopic pregnancy be diagnosed?
• Cautious examination
• hCG does not rise as expected.
Week 235 - Pregnancy 2: What is the medical and surgical management of an ectopic pregnancy?
• Medical - Methotrexate
• Surgical - Laparoscopy/Laparotomy
Week 235 - Pregnancy 2: What are the signs and symptoms of a molar pregnancy?
• Very high HCG
• Biochemical hyperthyroid
Week 235 - Pregnancy 2: What are the signs of haemorrhage in late pregnancy?
• Reduced urine output
• Foetal hear abnormalities
• Increased HR
• Bleeding - obvious/hidden
Week 235 - Pregnancy 2: What are the clinical features of placenta praevia?
• Painless - Bright red bleed
• Malpresentation/high presenting part
Week 235 - Pregnancy 2: What are the clinical features of a placental abruption?
• Vaginal bleeding (Unless concealed).
• Abdominal pain.
• Irritable 'woody hard' uterus.
• Uterine tenderness
• Disproportionate shock
• Foetal distress
Week 235 - Pregnancy 2: What are the risk factors for developing placenta praevia?
• Previous praevia
• Previous lower segmental Caesarean section.
• Older mother
• Defective endometrium
• Previous TOP
• Assisted Conception
Week 235 - Pregnancy 2: What are the risk factors for developing a placental abruption?
• Previous abruption
• Smoking/drug abuse
• 1st trimester bleeding
• Blunt force trauma
• Assisted Conception
• Low BMI
Week 235 - Pregnancy 2: Aside from placenta praevia and placental abruption what are the other main causes of late pregnancy bleeding?
• Placenta Accreta - Firmly adherent placenta.
• Placenta Increta - Placenta invades the myometrium.
• Placenta Percreta - Invades through to serosa and beyond.
• Vasa Praevia - Placental vessels overlie the cervix due to a succenturiate lobe of the placenta.
Week 235 - Pregnancy 2: What is the timescale for primary and secondary post-partum haemorrhage?
• Primary - 24hrs-6 weeks post delivery.
Week 235 - Pregnancy 2: What are the risk factors for developing post-partum haemorrhage?
• Pregnancy - Previous hx, Ante-partum haemorrhage, placenta praevia, twins, nulliparity, pre-eclampsia, Maternal obesity, maternal age >40.
• Delivery - Emergency C-section, repeat elective c-section, operative vaginal birth, induction of labour, long labour, large foetal birth weight.
Week 235 - Pregnancy 2: What are the four broad causes of PPH? Give examples of each.
• Thrombin - Pre-eclampsia, placental abruption, pyrexia in labour, bleeding disorders.
• Tissue - Retained placenta, placenta accreta, retained products of conception.
• Tone - Placenta praevia, overdistension of uterus (macrosomia, multiple pregnancy), uterine relaxants, previous PPH.
• Trauma - instrumental delivery, episiotomy, macrosomia.
Week 235 - Pregnancy 2: What is the management of PPH due to tone?
• Empty bladder.
• 'Rub up' a contraction.
• Bimanual compression.
• Give oxytocics.
Week 235 - Pregnancy 2: What is the management of PPH due to trauma?
• Repair perineal and cervical tears.
Week 235 - Pregnancy 2: What is the management of PPH due to tissue?
• Empty uterus if not delivered.
• Remove placenta/products.
Week 235 - Pregnancy 2: What is the management of PPH due to thrombin?
• Check coag.
• Replace clotting factors / blood products.
Week 235 - Pregnancy 2: What are the three key elements of pre-eclampsia?
• Increased BP
Week 235 - Pregnancy 2: What are the minor symptoms of pre-eclampsia?
• Visual disturbances
• Nausea or vomiting
• Epigastric pain
• Sudden weight gain - fluid
• Brisk refelexes
Week 235 - Pregnancy 2: What are the risk factors for developing pre-eclampsia?
• Multiparous but with a new partner
• Previous pre-eclampsia
• Multiple pregnanacy
• 35 years
• Renal Failure
Week 235 - Pregnancy 2: What are the classifications of pre-eclampsia?
• Mild - Proteinuria and mild/moderate HT 140-159
• Moderate - Proteinuria with severe HT >160
• Severe - Proteinuria with mild-severe HT with one of;
- Seizures, visual disturbance, clonus, headache or epigastric pain, papilloedema, liver tenderness, HELLP, platelets 70
Week 235 - Pregnancy 2: What is HELLP syndrome?
Complication of pre-eclampsia
- Elevated Liver enzymes
- Low Platelets
Week 235 - Pregnancy 2: What is the conservative treatment of a lady with pre-eclampsia?
• Admit if severe HT or new proteinuria >2+
• Magnesium sulphate - treatment and prevention of eclampsia
• Corticosteroids - aide foetal lung development for early delivery.
Week 235 - Pregnancy 2: In severe pre-eclampsia what is the management?
Immediate c-section (if greater than 34 weeks)