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MFSRH > 6 - Pregnancy > Flashcards

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
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2
Q

Risk factors for ectopic pregnancy

A 
Previous PID
Previous tubal surgery
Previous ectopic pregnancy
Infertility
Assisted reproduction 
IUD 
Smoking
Increased maternal age
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3
Q

When should women with confirmed ectopics be scanned in subsequent pregnancies?

A

6 weeks to confirm IUP

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4
Q

Symptoms of ectopic pregnancy

A

Amenorrhoea
PV Bleeding
Abdominal pain
GI symptoms

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5
Q

Signs of ectopic pregnancy

A

Lower abdominal tenderness
Adnexal tenderness
Cervical excitation
Shock / collapse

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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

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7
Q

Investigations in ectopic pregnancy

A

FBC
G+S (2U crossmatch)
BhCG

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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
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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

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10
Q

Exclusion criteria for treating ectopic with methotrexate

A 
Intraperitoneal haemorrhage
Hepatic dysfunction
Thrombocytopenia 
Ectopic mass > 3.5cm
BhCG > 5000
Concurrent corticosteroid therapy
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11
Q

Follow up after salpingotomy

A

Follow up weekly until BhCG

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12
Q

Follow up after salpingectomy

A

UPT in 3 weeks

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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
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14
Q

Miscarriage rate

A

20% of pregnancies

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15
Q

Definition of complete miscarriage

A

Previously confirmed intrauterine pregnancy - products completely passed, cervix closed, no bleeding or cramping.

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16
Q

Definition of incomplete miscarriage

A

Some products of conception have passed, some remain in utero.
Cervical os open
Cramping and bleeding

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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

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18
Q

Definition of a failed pregnancy

A

Gestation sac >25mm
No embryo or yolk sac

Or CRL >7mm with no FH

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19
Q

History in miscarriage

A 
Gestation
Nature of bleeding
Nature of pain
Any previous scans
Faintness, fever, offensive PV bleeding
EBL
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20
Q

Assessment of suspected miscarriage

A 
Abdominal ex
Pelvic ex
FBC
G+S (cross match)
USS
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21
Q

Advantages of expectant management of miscarriage

A

Safe
Natural
Autonomy

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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
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23
Q

Advantages of medical miscarriage

A

Scheduled
Safe
Autonomy
Avoids surgery and GA

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24
Q

Disadvantages of medical miscarriage

A 
Hospital admission
Discomfort
Follow up 
3 weeks bleeding 
5-15% require surgical management
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25
Q

Frequency of ectopic pregnancy

A

1 : 80 pregnancies

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26
Q

Advantages of surgical miscarriage

A

Scheduled
Quick
Safe
Most effective

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27
Q

Disadvantages of surgical miscarriage

A

Hospital admission
GA or LA
Uterine instrumentation

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28
Q

Medication for medical management of miscarriage

A

Misoprostal

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29
Q

What is moulding

A

Change in anatomical relations of bones of detail skull during labour and delivery

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30
Q

Where is the fetal vertex

A

Between anterior and posterior fontanelles

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31
Q

Where is the fetal occiput

A

Posterior to the posterior fontanelle

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32
Q

Where is the fetal bregma

A

The area of the anterior fontanelle

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33
Q

Where is the fetal brow

A

Anterior to anterior fontanelle to root of nose

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34
Q

What is inadequate progress in labour for a nulliparous woman

A

Lack of continuing progress for 3 hours with regional anaesthesia.
or 2 hours without regional anaesthesia

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35
Q

What is inadequate progress in labour for a Multiparous woman

A

Lack of continuing progress for 2 hours with regional anaesthesia.
or 1 hour without regional anaesthesia

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36
Q

Conditions where forceps would be preferred to ventouse

A

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.

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37
Q

Indications for FBS include:

A

pathological CTG in labour (cervix dilated >3 cm)

suspected acidosis in labour (cervix dilated >3 cm).

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38
Q

What is a normal FBS result

A

PH ≥7.25
Normal FBS result.
Repeat after 1 hour if CTG remains the same

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39
Q

What is the cut off for an abnormal FBS result

A

PH ≤7.20 - consider delivery

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40
Q

Contraindications to FBS

A

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).

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41
Q

Limitations imposed by the use of continuous EFM

A

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

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42
Q

Normal CTG features

A

Baseline rate 100-160
Variability >5
Decelerations - none or early

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43
Q

Non-reassuring CTG features

A

Baseline rate 161-180

Variability 50% of contractions

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44
Q

Abnormal CTG features

A

Baseline rate 180
Variability 90 minutes
Late decelerations >30mins with >50% of contractions
Bradycardia/prolonged deceleration >3min

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45
Q

management of non-reassuring CTG

A

commence conservative measures – left lateral position, oral / intravenous fluids, stop oxytocin, consider tocolysis.

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46
Q

management of abnormal CTG

A

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.

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47
Q

What are late decelerations suggestive of

A

Fetal hypoxia

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48
Q

What are late decelerations controlled by

A

Reflex central nervous system response to hypoxia and acidaemia.

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49
Q

Consequences of maternal fever on the fetus

A

Fetal tachycardia.
Loss of variability
Increased oxygen demand
Late decelerations

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50
Q

How does fetal baseline variability change with gestation

A

Baseline variability is low in early pregnancy and increases with gestation

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51
Q

Non-hypoxia related causes of decreased variability

A 
Anencephaly
Central nervous system defects
Drugs - opiates, magnesium sulphate, atropine
Sepsis
Defective cardiac conduction
Quiet fetal sleep
52
Q

Can cord compression cause decelerations?

A

Yes - variable decelerations

53
Q

Most common type of deceleration in labour

A

80% variable decelerations
5% late decelerations
Isolated early decelerations - rare

54
Q

change in blood volume in pregnancy

A

rapid increase in extracellular fluid - esp circulating plasma
Increase in total body water by 2L

55
Q

effect of pregnancy on cardiovascular system

A

increased cardiac output
Increased heart rate
increased stroke volume
Decreased mean arterial pressure, pulse pressure and peripheral resistance.

56
Q

effect of pregnancy on renal blood flow

A

increased renal blood flow in pregnancy

57
Q

effect of pregnancy on sodium levels

A

sodium retention in pregnancy and water retenction.
But plasma sodium levels slightly decrease
Sodium is sequestered in fetal tissues / placenta / membranes

58
Q

effect of pregnancy on Hb concentration and haematocrit

A

decreased Hb and haematocrit due to haemodilution effect

59
Q

effect of pregnancy on plasma albumin level

A

albumin levels fall in pregnancy

60
Q

effect of pregnancy on folic acid

A

pregnancy increases renal clearance of folic acid and plasma levels fall.

61
Q

effect of pregnancy on iron levels

A

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
Q

effect of pregnancy on haemostasis and coagulation

A

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
Q

effect of pregnancy on D-dimer levels

A

D-Dimer levels rise from conception until delivery.

64
Q

effect of pregnancy on fibrinolytic system

A

increased plasminogen levels
Decreased α2-antiplasmin (inhibits plasmin)
increased D-dimer and fibrin degredation products.

65
Q

effect of pregnancy on U+Es

A

decreased serum creatinine, uric acid and urea concentrations

66
Q

effect of pregnancy on pain tollerance

A

increased pain tollerance in pregnancy mediated by B-endorphins and spinal cord K-opiate receptors.

67
Q

effect of pregnancy on the eyes / vision

A

Increased corneal thickness due to odema
Decreased tear production
transient loss of accomodation
change in refection altering vision

68
Q

effect of pregnancy on thoracic anatomy

A

weight gain in pregnancy affects neck, oropharyngeal tissues, breasts and chest wall.
Airway oedema

69
Q

effect of pregnancy on ventilation

A

Iincreased minute ventilation and tidal volume

Decreased residual volume and functional residual capacity.

70
Q

effect of pregnancy on blood gas and acid-base balance

A

Decreased pCO2
increased pO2
Increased bicarb excretion
increased oxygen availability to tissues / placenta.

71
Q

effect of pregnancy on the renal system

A 
increased kidney size
Dilatation of renal pelvis and ureters
Increased renal blood flow and GFR. 
Decreased plasma creatinine, urea and urate
Glycosuria.
72
Q

effect of pregnancy on the uterus

A

increased uterine blood flow
Hyperplasia and hypertrophy of uterine myometrium
Increased gap junctions

73
Q

effect of pregnancy on breasts

A

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
Q

Where is BhCG produced from

A

Trophoblast cells

75
Q

What influences BhCG production

A

Cytokine leukaemia inhibitory factor

Isoform of GnRH

76
Q

Function of BhCG

A

Maintain function of corpus luteum

Suppresses secretion of FSH and LH by anterior pituitary

77
Q

When do circulating levels of BhCG start to fall and why

A

After 12 weeks

Placental production of progesterone becomes dominant

78
Q

Risk of maternal factor V Leiden deficiency in pregnancy

A

Increased VTE risk

79
Q

Risk of maternal epilepsy in pregnancy

A

Increased fit frequency

80
Q

Risk of maternal myasthenia gravis in pregnancy

A

Increased maternal muscle fatigue in labour

81
Q

Management of maternal heart valve problems in instrumental labour

A

Antibiotic prophylaxis for instrumental delivery.

82
Q

Define gravidity

A

No. Of pregnancies regardless of outcome

83
Q

Define parity

A

No. of live births + still births >24/40

84
Q

What is the maternal mortality ratio?

A

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
Q

What is the maternal mortality rate?

A

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
Q

Define stillbirth

A

Baby born > 24 weeks with no signs of life

87
Q

Define perinatal death

A

Stillbirth > 24 weeks gestation or death within 7 days of birth

88
Q

Define live birth

A

Any baby born with signs of life regardless of gestation

89
Q

Define maternal death

A

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
Q

Define perinatal mortality rate

A

Number of stillbirths and early neonatal deaths per 1000 live births and stillbirths

91
Q

Where is the foramen ovale located

A

Atrial septum

92
Q

What carries oxygenated blood from the placenta to the fetus

A

Umbilical vein

93
Q

What connects the pulmonary artery to the descending aorta in the fetus

A

Ductus arteriosus

94
Q

What vessel shunts blood away from the liver in the fetus - from the umbilical vein to the vena cava

A

Ductus venosus

95
Q

What to primitive forms proceed The fetal urinary tract

A

Pronephros and mesonephros

96
Q

At how many weeks gestation do the fetal kidneys produce amniotic fluid

A

16

97
Q

Which can be performed earlier amniocentesis or chorionic villus sampling

A

CVS

98
Q

Benefit of Cordocentesis

A

Provides a fetal blood sample

99
Q

Why do women with an unstable lie need AN admission at term?

A

Risk of cord prolapse

100
Q

Success rate of ECV

A

50%

101
Q

What causes gastro-oesophageal reflux in pregnancy

A

Hormonal relaxation of the sphincter

Pressure affect of growing uterus

102
Q

What is the Lambda sign

A

When to amniotic sac’s arise from different chorionic plates

103
Q

What is the T sign on ultrasound of twins

A

When amniotic sac’s arise from the same chorion and no inter-twin membrane is present - in MCMA twins

104
Q

In monozygotic twins how high is the risk of death or handicap in the co-twin

A

25%

105
Q

What type of twins is the result of a single embryo splitting between four and eight days after fertilisation

A

monochorionic Diamniotic twins

106
Q

What genetic material is present in a complete molar pregnancy

A

all the genetic material comes from the father.

Empty oocyte lacking maternal genes is fertilised

107
Q

What fetal tissue is found in complete and partial molar pregnancies

A

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
Q

What genetic material is present in a partial molar pregnancy

A

three sets of chromosomes. Two sperm fertilise the ovum at the same time.
10% are tetraploid or mosaic

109
Q

What is placenta previa major

A

Insertion of the placenta in the lower section of the uterus overlying the cervical os

110
Q

Fetal Skull bones

A 
Frontal
Parietal
Temporal
Sphenoidal
Occipital
111
Q

Fetal skull sutures

A 
Frontal
Sagittal
Coronal
Lambdoidal
Squamous
112
Q

Fetal skull fontanelles

A

Anterior
Posterior
Sphenoidal
Mastoid

113
Q

Bi-parietal diameter

A

9.5cm

114
Q

What is the bregma

A

Anterior fomtanelle

Diamond shape

115
Q

When does the anterior fontanelle close

A

18 months

116
Q

When does the posterior fontanelle close

A

Two months

117
Q

Minimum dose of anti-D required for a woman having cell salvage blood returned after CS

A

1500 IU minimum + do kleihauer

118
Q

First line treatment of normocytic / microcytic anaemia in preg / PN

A

Oral ferrous sulphate

119
Q

Antenatally when is FBC monitored

A

Booking
28/40
+20-24/40 if multiple gestation

120
Q

When should parenteral iron be used for anaemia in obstetrics

A

If PO iron not tolerated

Approaching term + insufficient time for PO iron.

121
Q

How many days old can the sample be for transfusion if pregnant or within 3m of delivery

A

3/7

122
Q

Major obstetric haemorrhage blood group

A

Group O, Rh -ve, kell -ve

123
Q

When is intra-operative cell salvage recommended

A

When anticipated blood loss significant enough to cause anaemia
Or estimated blood volume >20%

124
Q

In RBC transfusion when is FFP required

A

FFP 12-15ml/kg every 6 units of RBC during major haemorrhage
+ subsequent FFP guided by clotting - aim to maintain PT : APTT ratio

125
Q

What is the critical level platelets must not fall below

A

50

Platelet transfusion trigger of 75 if ongoing bleeding

126
Q

What group should platelet transfusion be

A

Same ABO group as patient

MFSRH (18 decks)

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