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Flashcards in Week 235 - Pregnancy 2 Deck (76):
1

Week 235 - Pregnancy 2: What are the fetal indications for operative vaginal delivery?

Fetal compromise

2

Week 235 - Pregnancy 2: What are the maternal indications for operative vaginal delivery?

• Medical indications to avoid Valsalva e.g.
- Cardiac disease
- Hypertensive crisis
- CVD
- Myasthenia gravis
- Spinal cord injury

3

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

4

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.

5

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)

6

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

7

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.

8

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.

9

Week 235 - Pregnancy 2: What are the complications of caesarean section?

• Bleeding
• Infection
• Venous thromboembolism

10

Week 235 - Pregnancy 2: What sort of incision is normally performed in the skin during a c-section?

Pfannensteil (Curved horizontal incision)

11

Week 235 - Pregnancy 2: What are the indications for emergency c-section?

• Prolonged first stage of labour
• Fetal distress

12

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

13

Week 235 - Pregnancy 2: What are the relative indications of caesarean section?

• Breech presentation
• DM
• Previous c-section
• Older nulliparous women

14

Week 235 - Pregnancy 2: What are the predisposing factors to having a multiple pregnancy?

• Increasing maternal age
• Family History
• Race
• Assisted conception

15

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.

16

Week 235 - Pregnancy 2: What does chorionicity refer to?

Refers to placentation.

17

Week 235 - Pregnancy 2: What does amniocity refer to?

This refers to the relation of the amniotic membranes between the twins.

18

Week 235 - Pregnancy 2: What is dichorionic-diamniotic twinning?

This is where each twin has its own placenta and amniotic sac.

19

Week 235 - Pregnancy 2: When each baby has its own placenta, there will be two chorions and two amnions. What is this known as?

Dichorionic-diamniotic twinning.

20

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.

21

Week 235 - Pregnancy 2: What is it called when each baby has its own amniotic sac but share a placenta?

Mono-chorionic diamniotic twinning.

22

Week 235 - Pregnancy 2: What is it called when twin babies share both the amniotic sac and placenta?

Monochorionic-monoamniotic twinning.

23

Week 235 - Pregnancy 2: What is monochorionic-monoamniotic twinning?

This is when both twins share the same amniotic sac and placenta.

24

Week 235 - Pregnancy 2: In terms of chorionicity and amniocity what are dizygotic twins always?

Dichorionic-diamniotic

25

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?

Monochorionic
- Miscarriage
- Congenital abnormalities
- Preterm
- IUGR
- Perinatal loss
- TTT

26

Week 235 - Pregnancy 2: At which time should DCDA and MCDA twins be delivered?

• Uncomplicated DCDA 37-38wks
• Uncomplicated MCDA 36-37wks

27

Week 235 - Pregnancy 2: How does cardiac output change during pregnancy?

• Increases
- Increases by 30-50%
- Blood volume increases to 150% of non-pregnant level.
- Stroke volume increases 30%
- Heart rate increases by about 15%

28

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.

29

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.

30

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.

31

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.

32

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

33

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.

34

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.

35

Week 235 - Pregnancy 2: Why do pregnant women have a compensated respiratory alkalosis?

This facilitates fetomaternal 02 transfer at the placenta.

36

Week 235 - Pregnancy 2: What are the two reasons for pregnant women to feel short of breath?

• Subjective feeling due to progesterone.
• Rising fundus.

37

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.

38

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.

39

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.

40

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.

41

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.

42

Week 235 - Pregnancy 2: What is the are the causes of bleeding in early pregnancy?

• Miscarriage
• Ectopic pregnancy

43

Week 235 - Pregnancy 2: What is a threatened miscarriage?

This is where there is bleeding, the foetus is alive and the OS is closed.

44

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.

45

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.

46

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.

47

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.

48

Week 235 - Pregnancy 2: What is a septic miscarriage?

Infected uterine contents, offensive loss and a tender uterus.

49

Week 235 - Pregnancy 2: What is the medical management of miscarriage?

Mifepristone and misoprostol (Prostaglandin)
- Success rate varies.

50

Week 235 - Pregnancy 2: What are the indications for the surgical management of miscarriage?

• Unstable vital signs
- Excessive/persistant
- Bleeding

• Infected retained tissue.

51

Week 235 - Pregnancy 2: What should be given to all rhesus -ve mothers after surgical/medical intervention of miscarriage?

Anti-D prophylaxis

52

Week 235 - Pregnancy 2: What is the most common location of ectopic pregnancies?

Ampulla of tube.

53

Week 235 - Pregnancy 2: How can an ectopic pregnancy be diagnosed?

• Cautious examination
• Ultrasound
• hCG does not rise as expected.

54

Week 235 - Pregnancy 2: What is the medical and surgical management of an ectopic pregnancy?

• Medical - Methotrexate
• Surgical - Laparoscopy/Laparotomy

55

Week 235 - Pregnancy 2: What are the signs and symptoms of a molar pregnancy?

• Very high HCG
• Biochemical hyperthyroid
• Hyperemesis

56

Week 235 - Pregnancy 2: What are the signs of haemorrhage in late pregnancy?

• Pale
• Confused
• Reduced urine output
• Foetal hear abnormalities
• Increased HR
• Bleeding - obvious/hidden

57

Week 235 - Pregnancy 2: What are the clinical features of placenta praevia?

• Asymptomatic
• Painless - Bright red bleed
• Malpresentation/high presenting part
• USS

58

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

59

Week 235 - Pregnancy 2: What are the risk factors for developing placenta praevia?

• Previous praevia
• Previous lower segmental Caesarean section.
• Smoking
• Older mother
• Defective endometrium
• Previous TOP
• Assisted Conception

60

Week 235 - Pregnancy 2: What are the risk factors for developing a placental abruption?

• Previous abruption
• Smoking/drug abuse
• 1st trimester bleeding
• Pre-eclampsia
• Multiparity
• Blunt force trauma
• Assisted Conception
• Low BMI

61

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.

62

Week 235 - Pregnancy 2: What is the timescale for primary and secondary post-partum haemorrhage?

• Primary - 24hrs-6 weeks post delivery.

63

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.

64

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.

65

Week 235 - Pregnancy 2: What is the management of PPH due to tone?

• Empty bladder.
• 'Rub up' a contraction.
• Bimanual compression.
• Give oxytocics.

66

Week 235 - Pregnancy 2: What is the management of PPH due to trauma?

• Repair perineal and cervical tears.

67

Week 235 - Pregnancy 2: What is the management of PPH due to tissue?

• Empty uterus if not delivered.
• Remove placenta/products.

68

Week 235 - Pregnancy 2: What is the management of PPH due to thrombin?

• Check coag.
• Replace clotting factors / blood products.

69

Week 235 - Pregnancy 2: What are the three key elements of pre-eclampsia?

• Increased BP
• Proteinuria
• Oedema

70

Week 235 - Pregnancy 2: What are the minor symptoms of pre-eclampsia?

• Headaches
• Visual disturbances
• Nausea or vomiting
• Epigastric pain
• Sudden weight gain - fluid
• Brisk refelexes

71

Week 235 - Pregnancy 2: What are the risk factors for developing pre-eclampsia?

• Primiparous
• Multiparous but with a new partner
• Previous pre-eclampsia
• Multiple pregnanacy
• 35 years
• Obesity
• Diabetes
• Renal Failure

72

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

73

Week 235 - Pregnancy 2: What is HELLP syndrome?

Complication of pre-eclampsia
- Haemolysis
- Elevated Liver enzymes
- Low Platelets

74

Week 235 - Pregnancy 2: What is the conservative treatment of a lady with pre-eclampsia?

• Admit if severe HT or new proteinuria >2+

• Antihypertensive-
- Labetalol
- Nifedipine
- Hydralazine

• Magnesium sulphate - treatment and prevention of eclampsia

• Corticosteroids - aide foetal lung development for early delivery.

75

Week 235 - Pregnancy 2: In severe pre-eclampsia what is the management?

Immediate c-section (if greater than 34 weeks)

76

Week 235 - Pregnancy 2: What is pre-eclampsia?

Diffuse vascular endothelial dysfunction with circulatory disturbances involving renal, hepatic, cardiovascular, central nervous and coagulation systems.