6 - Pregnancy Flashcards
1
Q
Possible sites of ectopic pregnancy
A
Fallopian tube = 95 % Interstitial = 2% Cervical = 0.1% Ovarian = 0.01% C/S scar -rare Abdominal - rare
2
Q
Risk factors for ectopic pregnancy
A
Previous PID Previous tubal surgery Previous ectopic pregnancy Infertility Assisted reproduction IUD Smoking Increased maternal age
3
Q
When should women with confirmed ectopics be scanned in subsequent pregnancies?
A
6 weeks to confirm IUP
4
Q
Symptoms of ectopic pregnancy
A
Amenorrhoea
PV Bleeding
Abdominal pain
GI symptoms
5
Q
Signs of ectopic pregnancy
A
Lower abdominal tenderness
Adnexal tenderness
Cervical excitation
Shock / collapse
6
Q
Diagnosis of ectopic pregnancy
A
USS - empty uterus, variable endometrial thickening, thin endometrium, intrauterine pseudogestational sac.
- adnexal - hyperechoic tubal ring, mixed adnexal mass, ectopic sac / embryo
Adnexal tenderness to vaginal probe
Fluid in POD
7
Q
Investigations in ectopic pregnancy
A
FBC
G+S (2U crossmatch)
BhCG
8
Q
Who can have methotrexate to mange ectopic pregnancy
A
No significant pain Unruptured adnexal mass <35 mm with no visible heartbeat Serum hCG <1500 IU/litre Able to return for FU
9
Q
Who can have expectant management of ectopic pregnancy
A
Absent clinical symptoms
No signs of rupture or intraperitoneal bleeding
Absence of haemoperitoneum
Tubal mass
10
Q
Exclusion criteria for treating ectopic with methotrexate
A
Intraperitoneal haemorrhage Hepatic dysfunction Thrombocytopenia Ectopic mass > 3.5cm BhCG > 5000 Concurrent corticosteroid therapy
11
Q
Follow up after salpingotomy
A
Follow up weekly until BhCG
12
Q
Follow up after salpingectomy
A
UPT in 3 weeks
13
Q
Management of ectopic with collapse
A
ABC 2222 2x IV cannulae - at least 16g - fluid resus FBC, clotting, cross match 4U Oxygen Catheter Admit Emergency laparotomy - clamp tube, salpingectomy and wash out Consider HDU Anti-D
14
Q
Miscarriage rate
A
20% of pregnancies
15
Q
Definition of complete miscarriage
A
Previously confirmed intrauterine pregnancy - products completely passed, cervix closed, no bleeding or cramping.
16
Q
Definition of incomplete miscarriage
A
Some products of conception have passed, some remain in utero.
Cervical os open
Cramping and bleeding
17
Q
Definition of missed miscarriage
A
No products of conception passed
Spotting, some pain or no symptoms.
No fetal heart after a previously identified FH
18
Q
Definition of a failed pregnancy
A
Gestation sac >25mm
No embryo or yolk sac
Or CRL >7mm with no FH
19
Q
History in miscarriage
A
Gestation Nature of bleeding Nature of pain Any previous scans Faintness, fever, offensive PV bleeding EBL
20
Q
Assessment of suspected miscarriage
A
Abdominal ex Pelvic ex FBC G+S (cross match) USS
21
Q
Advantages of expectant management of miscarriage
A
Safe
Natural
Autonomy
22
Q
Disadvantages of expectant management of miscarriage
A
Discomfort Less predictable Needs follow up Up to 6 weeks bleeding Increased likelihood of subsequent further intervention
23
Q
Advantages of medical miscarriage
A
Scheduled
Safe
Autonomy
Avoids surgery and GA
24
Q
Disadvantages of medical miscarriage
A
Hospital admission Discomfort Follow up 3 weeks bleeding 5-15% require surgical management
25
Frequency of ectopic pregnancy
1 : 80 pregnancies
26
Advantages of surgical miscarriage
Scheduled
Quick
Safe
Most effective
27
Disadvantages of surgical miscarriage
Hospital admission
GA or LA
Uterine instrumentation
28
Medication for medical management of miscarriage
Misoprostal
29
What is moulding
Change in anatomical relations of bones of detail skull during labour and delivery
30
Where is the fetal vertex
Between anterior and posterior fontanelles
31
Where is the fetal occiput
Posterior to the posterior fontanelle
32
Where is the fetal bregma
The area of the anterior fontanelle
33
Where is the fetal brow
Anterior to anterior fontanelle to root of nose
34
What is inadequate progress in labour for a nulliparous woman
Lack of continuing progress for 3 hours with regional anaesthesia.
or 2 hours without regional anaesthesia
35
What is inadequate progress in labour for a Multiparous woman
Lack of continuing progress for 2 hours with regional anaesthesia.
or 1 hour without regional anaesthesia
36
Conditions where forceps would be preferred to ventouse
Poor maternal effort
Operator or maternal preference, when either instrument would be suitable
Large amount of caput
Gestation of less than 34 weeks (at 34–36 weeks of gestation, ventouse is relatively contraindicated)
Marked active bleeding from a fetal blood-sampling site
After-coming head of the breech
Face presentation.
37
Indications for FBS include:
pathological CTG in labour (cervix dilated >3 cm)
| suspected acidosis in labour (cervix dilated >3 cm).
38
What is a normal FBS result
PH ≥7.25
Normal FBS result.
Repeat after 1 hour if CTG remains the same
39
What is the cut off for an abnormal FBS result
PH ≤7.20 - consider delivery
40
Contraindications to FBS
Contraindications include:
maternal infection (e.g. HIV, hepatitis viruses and herpes simplex virus)
Fetal bleeding disorders (e.g. haemophilia)
Prematurity (birth at less than 34 weeks of gestation)
Acute fetal compromise (e.g. prolonged fetal bradycardia of >3 minutes).
41
Limitations imposed by the use of continuous EFM
reduced mobility
possibility that woman will not be the centre of care in labour
increased intervention
variation in interpretation of CTG trace
chorioamnionitis could make interpretation unreliable
litigation
42
Normal CTG features
Baseline rate 100-160
Variability >5
Decelerations - none or early
43
Non-reassuring CTG features
Baseline rate 161-180
| Variability 50% of contractions
44
Abnormal CTG features
Baseline rate 180
Variability 90 minutes
Late decelerations >30mins with >50% of contractions
Bradycardia/prolonged deceleration >3min
45
management of non-reassuring CTG
commence conservative measures – left lateral position, oral / intravenous fluids, stop oxytocin, consider tocolysis.
46
management of abnormal CTG
Offer to take fetal blood sample (FBS; for lactate or pH) after implementing conservative measures, or expedite birth if an FBS cannot be obtained and no accelerations are seen as a result of scalp stimulation.
47
What are late decelerations suggestive of
Fetal hypoxia
48
What are late decelerations controlled by
Reflex central nervous system response to hypoxia and acidaemia.
49
Consequences of maternal fever on the fetus
Fetal tachycardia.
Loss of variability
Increased oxygen demand
Late decelerations
50
How does fetal baseline variability change with gestation
Baseline variability is low in early pregnancy and increases with gestation
51
Non-hypoxia related causes of decreased variability
```
Anencephaly
Central nervous system defects
Drugs - opiates, magnesium sulphate, atropine
Sepsis
Defective cardiac conduction
Quiet fetal sleep
```
52
Can cord compression cause decelerations?
Yes - variable decelerations
53
Most common type of deceleration in labour
80% variable decelerations
5% late decelerations
Isolated early decelerations - rare
54
change in blood volume in pregnancy
rapid increase in extracellular fluid - esp circulating plasma
Increase in total body water by 2L
55
effect of pregnancy on cardiovascular system
increased cardiac output
Increased heart rate
increased stroke volume
Decreased mean arterial pressure, pulse pressure and peripheral resistance.
56
effect of pregnancy on renal blood flow
increased renal blood flow in pregnancy
57
effect of pregnancy on sodium levels
sodium retention in pregnancy and water retenction.
But plasma sodium levels slightly decrease
Sodium is sequestered in fetal tissues / placenta / membranes
58
effect of pregnancy on Hb concentration and haematocrit
decreased Hb and haematocrit due to haemodilution effect
59
effect of pregnancy on plasma albumin level
albumin levels fall in pregnancy
60
effect of pregnancy on folic acid
pregnancy increases renal clearance of folic acid and plasma levels fall.
61
effect of pregnancy on iron levels
increased requirement for iron therefore increased intestinal iron absorption.
But physiological iron deficiency anaemia due to - increase in erythrocyte mass, transfer of iron stores to fetus
62
effect of pregnancy on haemostasis and coagulation
Pregnancy is a hypercoagulable state
Returns to normal 4wk PN
Increased procoagulant factors 7, 8, 9, 10, 12 and fibrinogen.
Increased von willebrand factor
Stable antithrombin 3 + decreased protein S = relative increased activated protein C.
63
effect of pregnancy on D-dimer levels
D-Dimer levels rise from conception until delivery.
64
effect of pregnancy on fibrinolytic system
increased plasminogen levels
Decreased α2-antiplasmin (inhibits plasmin)
increased D-dimer and fibrin degredation products.
65
effect of pregnancy on U+Es
decreased serum creatinine, uric acid and urea concentrations
66
effect of pregnancy on pain tollerance
increased pain tollerance in pregnancy mediated by B-endorphins and spinal cord K-opiate receptors.
67
effect of pregnancy on the eyes / vision
Increased corneal thickness due to odema
Decreased tear production
transient loss of accomodation
change in refection altering vision
68
effect of pregnancy on thoracic anatomy
weight gain in pregnancy affects neck, oropharyngeal tissues, breasts and chest wall.
Airway oedema
69
effect of pregnancy on ventilation
Iincreased minute ventilation and tidal volume
| Decreased residual volume and functional residual capacity.
70
effect of pregnancy on blood gas and acid-base balance
Decreased pCO2
increased pO2
Increased bicarb excretion
increased oxygen availability to tissues / placenta.
71
effect of pregnancy on the renal system
```
increased kidney size
Dilatation of renal pelvis and ureters
Increased renal blood flow and GFR.
Decreased plasma creatinine, urea and urate
Glycosuria.
```
72
effect of pregnancy on the uterus
increased uterine blood flow
Hyperplasia and hypertrophy of uterine myometrium
Increased gap junctions
73
effect of pregnancy on breasts
Deposition of fat around glandular tissue
Number of glandular ducts increases.
Increased number of gland alveoli.
Prolactin stimulates milk secretion
Oxytocin causes alvoli to squeeze milk towards the nipple and helps bonding.
74
Where is BhCG produced from
Trophoblast cells
75
What influences BhCG production
Cytokine leukaemia inhibitory factor
| Isoform of GnRH
76
Function of BhCG
Maintain function of corpus luteum
| Suppresses secretion of FSH and LH by anterior pituitary
77
When do circulating levels of BhCG start to fall and why
After 12 weeks
| Placental production of progesterone becomes dominant
78
Risk of maternal factor V Leiden deficiency in pregnancy
Increased VTE risk
79
Risk of maternal epilepsy in pregnancy
Increased fit frequency
80
Risk of maternal myasthenia gravis in pregnancy
Increased maternal muscle fatigue in labour
81
Management of maternal heart valve problems in instrumental labour
Antibiotic prophylaxis for instrumental delivery.
82
Define gravidity
No. Of pregnancies regardless of outcome
83
Define parity
No. of live births + still births >24/40
84
What is the maternal mortality ratio?
The number of maternal deaths in population divided by the number of live births.
(The risk of maternal death relative to the number of live births)
85
What is the maternal mortality rate?
Number of maternal deaths in a population divided by the number of women of reproductive age.
(Reflects risk of maternal deaths per pregnancy and level of fertility in the population)
86
Define stillbirth
Baby born > 24 weeks with no signs of life
87
Define perinatal death
Stillbirth > 24 weeks gestation or death within 7 days of birth
88
Define live birth
Any baby born with signs of life regardless of gestation
89
Define maternal death
Death of a woman while pregnant within 42 days of termination of pregnancy from any cause related to all aggravated by the pregnancy or its management.
Not accidental or incidental death
90
Define perinatal mortality rate
Number of stillbirths and early neonatal deaths per 1000 live births and stillbirths
91
Where is the foramen ovale located
Atrial septum
92
What carries oxygenated blood from the placenta to the fetus
Umbilical vein
93
What connects the pulmonary artery to the descending aorta in the fetus
Ductus arteriosus
94
What vessel shunts blood away from the liver in the fetus - from the umbilical vein to the vena cava
Ductus venosus
95
What to primitive forms proceed The fetal urinary tract
Pronephros and mesonephros
96
At how many weeks gestation do the fetal kidneys produce amniotic fluid
16
97
Which can be performed earlier amniocentesis or chorionic villus sampling
CVS
98
Benefit of Cordocentesis
Provides a fetal blood sample
99
Why do women with an unstable lie need AN admission at term?
Risk of cord prolapse
100
Success rate of ECV
50%
101
What causes gastro-oesophageal reflux in pregnancy
Hormonal relaxation of the sphincter
| Pressure affect of growing uterus
102
What is the Lambda sign
When to amniotic sac's arise from different chorionic plates
103
What is the T sign on ultrasound of twins
When amniotic sac's arise from the same chorion and no inter-twin membrane is present - in MCMA twins
104
In monozygotic twins how high is the risk of death or handicap in the co-twin
25%
105
What type of twins is the result of a single embryo splitting between four and eight days after fertilisation
monochorionic Diamniotic twins
106
What genetic material is present in a complete molar pregnancy
all the genetic material comes from the father.
| Empty oocyte lacking maternal genes is fertilised
107
What fetal tissue is found in complete and partial molar pregnancies
Complete molar pregnancies have no fetal tissue - empty ovum fertilised by sperm.
Partial molar pregnancy may have abnormal fetal tissue - 2 sperm fertilise one ovum.
108
What genetic material is present in a partial molar pregnancy
three sets of chromosomes. Two sperm fertilise the ovum at the same time.
10% are tetraploid or mosaic
109
What is placenta previa major
Insertion of the placenta in the lower section of the uterus overlying the cervical os
110
Fetal Skull bones
```
Frontal
Parietal
Temporal
Sphenoidal
Occipital
```
111
Fetal skull sutures
```
Frontal
Sagittal
Coronal
Lambdoidal
Squamous
```
112
Fetal skull fontanelles
Anterior
Posterior
Sphenoidal
Mastoid
113
Bi-parietal diameter
9.5cm
114
What is the bregma
Anterior fomtanelle
| Diamond shape
115
When does the anterior fontanelle close
18 months
116
When does the posterior fontanelle close
Two months
117
Minimum dose of anti-D required for a woman having cell salvage blood returned after CS
1500 IU minimum + do kleihauer
118
First line treatment of normocytic / microcytic anaemia in preg / PN
Oral ferrous sulphate
119
Antenatally when is FBC monitored
Booking
28/40
+20-24/40 if multiple gestation
120
When should parenteral iron be used for anaemia in obstetrics
If PO iron not tolerated
| Approaching term + insufficient time for PO iron.
121
How many days old can the sample be for transfusion if pregnant or within 3m of delivery
3/7
122
Major obstetric haemorrhage blood group
Group O, Rh -ve, kell -ve
123
When is intra-operative cell salvage recommended
When anticipated blood loss significant enough to cause anaemia
Or estimated blood volume >20%
124
In RBC transfusion when is FFP required
FFP 12-15ml/kg every 6 units of RBC during major haemorrhage
+ subsequent FFP guided by clotting - aim to maintain PT : APTT ratio
125
What is the critical level platelets must not fall below
50
| Platelet transfusion trigger of 75 if ongoing bleeding
126
What group should platelet transfusion be
Same ABO group as patient
