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Y5 Gynae & Obstetrics > Antenatal Obstetric Complications > Flashcards

Antenatal Obstetric Complications Flashcards

1
Q

Why does backache occur in pregnancy?

A
  • Hormones induce laxity of spinal ligaments
  • Shifting in the centre of gravity as uterus grows
  • Additional weight gain
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2
Q

What back position is adopted in pregnancy?

A

Lumbar lordosis

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3
Q

What advice can you give to someone with backache in pregnancy?

A 
Adopt correct posture 
Avoid lifting heavy objects 
Avoid high heels 
Regular physiotherapy 
Analgesia (paracetamol)
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4
Q

Why does pubic symphysis disfunction occur?

A

Pubic symphisis becomes loose to prepare for childbirth, usually in third trimester

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5
Q

Why does pubic symphysis disfunction cause pain?

A

Because two halves of pelvis rub together when walking

Extremely painful

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6
Q

How do you treat pubic symphysis disfunction

A

Simple analgesia

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7
Q

Why does carpal tunnel occur in pregnancy?

A

Due to swelling of soft tissue
CT is a closed compartment
Median nerve is compressed

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8
Q

Why does constipation occur in pregnancy?

A

Hormones and mechanical factors slow gut motility

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9
Q

How do you treat comstipation in pregnancy?

A

High fibre diet
Lactulose
Avoid medications if possible

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10
Q

What is hyperemesis gravidarum?

A

Severe form of nausea and vomiting throughout pregnancy (worse in first trimester) related to excess beta hCG

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11
Q

What are dangerous consequences of hyperemesis gravidarum?

A 
Electrolyte imbalance 
Dehydration 
Poor nutritional intake 
Physical, psychological debilitation 
Adverse pregnancy outcomes (PTB, LBW)
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12
Q

What can severe hyperemesis gravidarum cause

A

malnutrition
vitamin deficiencies
mallory weiss tee

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13
Q

How do you treat hyperemesis gravidarum?

A

IV FLUID REPLACEMENT
thiamine supplementation
Antiemetics

Consider LMWH and PPI

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14
Q

What are first line antiemetics in pregnancy=?

A

Antihistamines (cyclising)

Phenothiazines (promethazine)

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15
Q

What are second line antiemetics in pregnancy=?

A

Ondasetron, Metoclopramide

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16
Q

What method do you use to assess severity of hyperemesis gravidarum?

A

PUQE

Pregnancy Unique Quantification of Emesis

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17
Q

what triad is needed to diagnose HE?

A

> 5% pre pregnancy weight loss
Dehydration
Electrolyte imbalance

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18
Q

When would you consider admitting a patient with hyperemesis gravidarum?

A
  • Continues N&V, cannot keep down oral antiemetics
  • Continued N&V + ketonuria + weight loss
  • Continued N&V and unable to tolerate oral antibiotics for comorbidity
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19
Q

Why does GI reflux occur

A

Weight effect of pregnant uterus
Hormonally induced relaxation of oesophageal sphincter

CAUSE REFLUX

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20
Q

How do you treat GI reflux in pregnancy

A

Lifestyle: stop smoking, stop alcohol, avoid spicy foods, avoid large meals before bed, sleep with head propped up

medical: antacids, H2 inhibitors, PPI

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21
Q

What is obstetric cholestasis?

A

Unexplained pruritus in pregnancy with abnormal LFTs and elevated bile salts that resolves spontaneously post part

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22
Q

Where and when does pruritus occur in OC?

A

Mainly on hands (and feet)

Worse at night

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23
Q

What are. RF for OC?

A 
Ethnicity (south asian) 
Multiple pregnancy 
Nulliparity 
Prior OC / FH OC 
Poor Diet
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24
Q

What conditions is OC associated with?

A

PET

GDM

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25
Q

What are complications of OC?

A

STILLBIRTH
Preterm birth (spontaneous/limitations)
Meconium passage + aspiration
PPH

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26
Q

When do OC symptoms usually onset?

A

3rd trimester

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27
Q

What are OC symptoms?

A

Pruritus (hands and feet)
ABSENCE of rash
Obstructive symptoms rare (jaundice, dark urine, pale stool)
Loss of appetite, fatigue

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28
Q

How do you investigate OC?

A

LFTs (1x/2x weekly)
Bile acids
Dx of exclusion: consider liver screen or USS biliary tract

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29
Q

What is the management for OC?

A 
Symptomatic tx: Emollients, antihistamines
Ursodeoxycholic acid (decreases bile acids and improves LFTs, but does not change chance of stillbirth) 
Consider delivery at term (37 weeks) with IOL/ELCS
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30
Q

What do you do to the mother after delivery in OC?

A

Repeat LFTs after delivery + 6/8 weeks later

Avoid future COCP (some link between oestrogen and OC)

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31
Q

Why do varicose veins occur in pregnancy?

A

Due to the relaxant effect of progesterone on SM

And the weight of the pregnant uterus

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32
Q

How do you manage varicose veins in pregnancy=

A

Support stocking, avoid standing for long yimr

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33
Q

What causes oedema in pregnancy?

A

Increased capillary permeability (allows fluid to leak to extravascular compartment)

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34
Q

What are fibroid problems during pregnancy?

A

May enlarge
If cervical, may obstruct vaginal delivery
Red degeneration

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35
Q

What is red degeneration?

A

As the fibroid grows, its blood supply becomes insufficient

So the fibroid becomes ischaemis

36
Q

What are sx of red degeneration?

A

Acute pain, tenderness over fibroid, vomiting

37
Q

How do you treat red degeneration of fibroid?

A 
Potent analgesic (opiate) 
IV fluids

Symptoms usually self resolve in few days

38
Q

What is a problem during pregnancy in women with a retroverted uterus?

A

Normally the retroverted uterus flips out into the pelvis and fills the abdominal cavity

If the uterus remains retroverted, it fills up the entire pelvic cavity
This causes stretching of the bladder and urethra
Can lead to urinary retention&raquo_space; severe bladder damage

39
Q

What must you do if the patient has a. retroverted uterus and they are experiencing bladder dysfunction?

A

IMMEDIATELY CATHERERISE

To prevent long term bladder damage

40
Q

What is a problem with having ovarian cysts during pregnancy?

A

They can tort, haemorrhage or rupture
This will cause acute abdominal pain and inflammation
Leading to miscarriage /preterm labour

41
Q

How do you handle ovarian cysts in pregnancy?

A

If asymptomatic, no surgery
If symptomatic try to postpone surgery as much asmpossible (if in late third trimester baby can be delivered if needed)
If gynae emergency, always perform surgery to ensure health of mother

42
Q

Why is VTE more likely in pregnancy?

A 
It is a hypercoaguable state 
- Increase F 8,9,10, fibrinogen
- Decreased protein C and antithrombin
Weight of gravid uterus puts pressure on IVC, causing venous stasis 
Immobility
43
Q

What is the first ix to do in suspected DVT?

A

Compression duplex ultrasound

44
Q

What IX should you do in suspected PE?

A

ECG, CXR, ABG to exclude dx

VQ scan /CTPA

45
Q

How accurate are D dimer levels in pregnancy?

A

NOT AT ALL

THEY are NORMALLY elevated

46
Q

How do you treat possible VTE?

A

Start treating before you have confirmation of dx!!!

LMWH / IV unfractionated heparin?
Thrombolysis (once PE confirmed)
Surgical embolectomy

47
Q

What is maintenance treatment for VTE

A

subcut LMWH for remainder of pregnancy and min 6 weeks post partum
MINIMUM of 3 months treatment in total!

48
Q

When should you stop LMWH if you are giving an epidural/planned delivery?

A

Stop LMWH 24h prior to epidural

49
Q

How long after epidural catheter is removed / spinal anaesthesia can you restart LMWH?

A

4h

50
Q

What is smoking associated to in pregnancy?

A

Reduced placental perfusion
Increased perinatal mortality
SGA babies
Placenta abruption

51
Q

what are functions of the amniotic fluid?

A

Protect the baby
Allow limb movement
Allow foetal lung expansion and breathing

52
Q

What is oligohydramnios?

A

Amniotic fluid index <5th centile for gestation

53
Q

What does oligohydramnios feel like on abdomen exam?

A

Foetal poles are obviious and hard

Small for date uterus

54
Q

What are causes of oligohyddramnios

A

INSUFFICIENT PRODUCTIO

  • relax agenesis
  • multi cystic kidneys
  • Urinary tract abnormality/obstruction
  • FGR, placental insufficiency
  • Maternal drugs (NSAIDS)

LEAKAGE
- PPROM

55
Q

What are risks of oligohydramnios’

A

pulmonary hypooplasia

limb deformity

56
Q

What is foetal renal agesesis also called?

A

Potter syndrome

57
Q

What is polyhydramnios?

A

Amniotic fluid index >95th centile for gestation

58
Q

How does a polydydramnios present?

A

Severe abdo distension, discomfort

59
Q

What are causes of polyhydramnios?

A

Maternal

  • Diabetes
  • Placental
  • Chorioangioma
  • AV fistula

Foetal

  • multiple gestation
  • Neuromusc condition (prevents swallowing)
  • Duodenal atrasia /GI problem
60
Q

How do you treat polyhydramnios caused by GDM?

A

Optimise glycemic control

This should correct the polyhydramnios as well

61
Q

How can you relieve discomfort in polyhydramnios?

A

Amniodrainage

62
Q

What must you NEVER offer for footling breech?

A

Never offer vaginal delivery

There may be cord prolapse / compression

63
Q

What is the risk of cord prolapse with breech? Compared to cephalic ?

A

1% risk of cord prolapse

Double the risk in cephalicn

64
Q

What are maternal and foetal predisposing factors for breevh=?

A

Maternal: fibroids, congenital uterine abnormality, uterine surgery

Foetal: multiple gestation, premature, placenta previa, oligo/polyhydramnios, foetal neuromuscular condition

65
Q

How does foetal lie/presentation change during gestation?

A

Breech is quite common early on in gestation as the baby is moving around
By 36 weeks the baby should be cephalic

66
Q

How do you confirm breech in >36 week gestation?

A

TAUSS

67
Q

What are the three management options for breech?

A

External cephalic version
Vaginal breech delivery
Elective CS

68
Q

When is external cephalic version done

A

36 weeks if primip

37 weeks if multip

69
Q

What is the risk of death in vaginal breech delivery?

A

3%

70
Q

When would an elective CS for breech be done?

A

39 weeks

71
Q

What medications must you administer with external cephalic version?

A

Tocolytic

Anti-D

72
Q

Give examples of tocolytics and the mode of administration

A

Calcium channel blocker e.g. nifedipine

Beta-2 agonist e.g. Tobutaline, salbutamol SC

73
Q

WHAT IS success rate of external cephalic version and what does it depend on the most?

A

50% success rate

Depends on operator experience

74
Q

What are risks of external cephalic version

A 
Placental abruption 
PROM 
Cord accident 
Transplacental haemorrhage
foetal bradycardia
75
Q

What are contraindications for external cephalic version

A 
Foetal abnormality e.g. hydrocephalus 
placenta previa 
oligo/polyhydramnios 
Hx APH 
Prior CS/myomectomy s ar 
Multiple gesttion
76
Q

How do you delivery vaginal breech?

A
  1. Full dilatation and descent of breech occur naturally
  2. Buttocks lie in AP diameter, usually delivery spontaneously
  3. Legs - if flexed, deliver spontaneously. If extended, need Pinards manoeuvre
  4. Deliver shoulders: Loveset’s manoeuvre
  5. Deliver head: Mauriceau-Smellie-Veit manoeuvre
77
Q

Explain Rhesus Isoimmunisation

A

Rhesus neg mother conceives baby who has inherited Rhh+ from father
Foetal cells gain access to maternal circulation in suffienct amount to provoke maternal antibody response
This pregnancy is not affected because primary immune response is weak and IgM cannot cross the placenta

In a subsequent pregnancy, Rh+ antibodies cross the placenta (igG) into foetal circulation

This causes haemolysis of the foetus and severe anaemia

78
Q

What must you do in a foetus undergoing haemolusis?

A

give blood transfusion

otherwise foetus may die

79
Q

What are potentially sensitising events?

A 
Miscarriage 
TOP 
APH 
Invasive prenatal testing (CVS, amniocentesis, cordocentesis) 
Delivery
80
Q

What do you give to prevent RhD exposure?

A

IM anti-D Ig

  • within 72h from sensitising event (do kleihauer test)
  • to all RhD- mothers give routine antenatal prophylaxis
81
Q

Explain routine antenatal prophylaxis with antiD

A

Either single regimen at 28wks

Or two dose regimen at 28, 34 weeks

82
Q

What does Kleihauer test do?

A

Measures the proportion of foetal cells in the maternal sample
Indicates the amount of anti-D required

83
Q

How do you manage giving anti-D depending on trimester?

A

First trimester (<12wks): 250IU, Kleihauer not necessary (foetal blood volume is small)

Second trimeste(12-20)r: minimum dose of 25IU + Kleihauer (give more if indicated)

Third trimester(>20): min 500IU + Kleihauer

84
Q

How can you tell if foetus is anaemic from scans?

A

Middle cerebral artery doppler

85
Q

What is the dose of anti D you give at 28 weeks

A

1500IU

86
Q

What are sensitising events for anti D

A
  • miscarriage / ectopic / termination of pregnancy
  • placental abruption, other APH
  • invasive prenatal testing (choriovillous sampling, amniocentesis, cordocentesis)
  • delivery

Y5 Gynae & Obstetrics (34 decks)

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