Child Birth Flashcards
1
Q
The external obliques attach between the lower ribs and what other three structures?
A
Iliac crests
Pubic tubercle
Linea alba (midline blending of aponeuroses)
2
Q
What direction do the fibres of the external obliques run in?
A
Same direction as external intercostals
3
Q
The internal obliques and transverse abdominis attach between the lower ribs and what three other structures?
A
Thoracolumbar fascia
Iliac crest
Linea alba
4
Q
What do the dividing the rectus abdominis into 3 or 4 smaller muscles do?
A
Improves mechanical efficiency
5
Q
Where does the linea alba run from?
A
Xiphoid to pubic symphysis
6
Q
What is the arcuate line?
A
Horizontal line
Marks the lower limit of the posterior rectus sheath
7
Q
Where do the inferior epigastric vessel perforate the rectus abdominis?
A
At the arcuate line
Half way between umbilicus and pubic crest
8
Q
What is the anterior rectus sheath composed of?
A
External oblique aponeurosis
AND
Anterior lamina of internal oblique aponeurosis
9
Q
What is the posterior rectus sheath composed of?
A
Posterior lamina of internal oblique aponeurosis
AND
Transverse abdominis aponeurosis
10
Q
What is the structure of the rectus sheath below the arcuate line?
A
All 3 layers of aponeuroses make the sheath which runs anterior to the rectus abdominis:
- External oblique aponeurosis
- Internal oblique aponeurosis
- Transverse abdominis aponeurosis
11
Q
What part(s) of the rectus sheath are cut when undertaking a suprapubic incision (lower segment Cesarean section)?
A
Anterior sheath only (as it is below arcuate line)
12
Q
Why is the rectus sheath stitched closed after surgery?
A
Increased wound strength
Reduced risk of would complications:
- Incisional hernia
13
Q
From what spinal segment does the iliohypogastric nerve arise?
A
L1
14
Q
From what spinal segment does the ilioinguinal nerve arise?
A
L2
15
Q
Where plane do the nerves supplying the anteriolateral abdominal wall travel in?
A
Plane between:
- Internal oblique and
- Transverse abdominis
16
Q
What part of the abdominal wall do the superior epigastric arteries supply?
A
Anterior wall
17
Q
What artery do the superior epigastrics originate from?
A
Continuation of internal thoracic arteries
18
Q
Where do the superior epigastric arteries arise from and lie?
A
Emerge at superior aspect of abdominal wall
Lie posterior to rectus abdominis
19
Q
What part of the abdominal wall do the inferior epigastric arteries supply?
A
Anterior
20
Q
What artery do the inferior epigastric arteries originate from?
A
Branch of external iliac
21
Q
Where do the inferior epigastric arteries arise from and lie?
A
Emerge at inferior aspect of abdominal wall
Lie posterior to rectus abdominis
22
Q
What part of the abdominal wall do the intercostal and subcostal arteries supply?
A
Lateral wall
23
Q
What artery do the intercostal and subcostal arteries originate from?
A
Continuation of posterior intercostal arteries
24
Q
Where do the intercostal and subcostal arteries arise from?
A
Lateral aspect
25
In a LSCS incision, what happens to the rectus muscles?
NOT cut:
| - Separated laterally towards their nerve supply
26
What layers are cut/separated in an LSCS?
1. Skin and fascia
2. (Anterior) rectus sheath (inferior to arcuate line)
3. Rectus abdominis (separated)
4. Fascia and peritoneum
5. Bladder retracted
6. Uterine wall
7. Amniotic sac
27
What layers of the abdominal wall are stitched closed after an LSCS?
Uterine wall (with visceral peritoneum)
Rectus sheath
Fasica (if high BMI)
Skin
28
What layers are opened for a laparotomy?
Skin and fascia
Linea alba
Peritoneum
29
What layers are stitched closed following a laparotomy?
Peritoneum
Linea alba
Skin (fascia if high BMI)
30
Why does a laparotomy have an increased risk of wound complication?
Bloodless
31
What wound complications can result after a laparotomy?
Dehiscence
| Incisional hernia
32
When inserting a lateral laparoscopic port, what must be avoided?
Inferior epigastric artery
33
How can the pelvic organs be viewed during laparoscopy?
Forceps inserted through vagina to grasp cervix and manipulate uterus
34
Where does the inferior epigastric artery emerge?
Just medial to the deep inguinal ring
Halfway between:
- ASIS
- Pubic tubercle
35
What direction does the inferior epigastric artery move in?
Superomedial direction posterior to rectus abdominis
36
Why must care be taken during a hysterectomy in regards to arteries?
Differentiate the ureters and uterine arteries:
- Ureter passes inferior to artery
- Ureters will 'vermiculate' when touched
37
What are the 3 components of the pelvic floor?
Pelvic diaphragm
Muscles of perineal pouches
Perineal membrane
38
What is the deepest layer of the pelvic floor?
Pelvic diaphragm
39
What does the pelvic diaphragm consist of?
2 muscle groups:
- Levator ani
- Coccygeus
40
There is an anterior gap between the medial borders of the pelvic diaphragm, what is this called and what does it allow?
Urogenital hiatus allowing passage of:
- Urethra (M and F)
- Vagina (F)
41
What are the origins of the levator ani?
Pubic bones
Ischial spines
Tendinous arch of levator ani
42
What are the insertions of the levator ani?
Perineal body
Coccyx
Walls of organs in the midline
43
What are the 3 parts of the levator ani?
Puborectalis
Pubococcygeus
Ilicoccygeus
44
What must the levator ani do to allow urination and defaecation?
Relax
45
What is the levator ani innervated by?
```
Pudendal nerve (S3, S4)
Nerve to levator ani (S4)
```
46
Where does the deep perineal pouch lie?
Below fascia covering the inferior surface of the pelvic diaphragm
Superior to perineal membrane
47
What does the deep perineal pouch contain?
```
Part of urethra (and vagina)
Bulbourethral glands (male)
Neurovascular bundle for penis/clitoris
Extensions of the:
- Ischioanal fat pads
- Muscles
```
48
Where does the perineal membrane attach?
Laterally to the sides of the pubic arch (close urogenital triangle)
49
What are the openings in the perineal membrane for?
Urethra
| Vagina
50
What parts of the penis does the superficial perineal pouch contain in males?
```
Bulb of penis - Corpus spongiosum
Crura of penis - Corpus cavernosa
Associated muscles:
- Bulbospongiosus
- Ischiocavernosus
```
51
What else does the superficial perineal pouch contain (apart from parts of the penis) in males?
```
Proximal spongy (penile) urethra
Superficial transverse perineal muscle
Branches of:
- Internal pudendal vessels
- Pudendal nerve
```
52
What parts of the female erectile tissue does the superficial pouch contain?
```
Clitoris and crura - Corpus cavernosa
Bulbs of vestibule (paired)
Associated muscles:
- Bulbospongiosus
- Ischiocavernosus
```
53
What else does the superficial perineal pouch contain (apart from parts of the female erectile tissue) in females?
```
Greater vestibular glands
Superficial transverse perineal muscles
Branches of:
- Internal pudendal vessels
- Pudendal nerve
```
54
What does tonic contraction of the puborectalis do?
Bends anorectum anteriorly:
| - Maintains faecal continence
55
What does active contraction of the puborectalis do?
Maintains continence after rectal filling
56
What does urinary continence depend on?
Urinary bladder neck support
External urethral sphincter
Smooth muscle in urethral wall
57
What is a cystocoele?
Bladder moves through prolapse in anterior vaginal wall
58
What is an enterocoele?
Loops of small bowel move through prolapse in upper posterior vaginal wall
59
What is a rectocoele?
Rectum moves through prolapse in lower posterior vagina wall
60
What is a 1st degree uterine prolapse?
Lowest part descends halfway down vagina
61
What is a 2nd degree uterine prolapse?
Lowest part at vaginal entrance
62
What is a 3rd degree uterine prolapse?
Lowest part lies outside of vagina
63
What is a 3rd degree uterine prolapse also known as?
Procidentia
64
What are the symptoms of a uterine prolapse?
Dragging sensation
Feeling of a 'lump'
Urinary incontinence
65
When is a sacrospinous fusion carried out?
To repair a cervical or vault descent
66
How is a sacrospinous fusion carried out?
Vaginally:
- Sutures placed in sacrospinous ligament
- Just medial to the ischial spin
67
What does a sacrospinous fusion risk injury to?
Pudendal neurovascular bundle
| Sciatic nerve
68
How is incontinence surgery carried out?
```
Trans-obturator approach
Mesh through obturator canal:
- Space in obturator foramen for passage of NVB
- Create a sling around urethra
- Incisions through vagina and groin
```
69
What are the three key factors for labour?
Power (of uterine contractions)
Passage (size of maternal pelvis)
Passenger (size of foetus)
70
What role does progesterone play in labour?
Promotes smooth muscle relaxation (keeps uterus 'settled')
Prevents formation of gap junctions
Reduces contractility of myocytes
71
What role does oestrogen play in labour?
Makes uterus contract
| Promotes prostaglandin production
72
What role does oxytocin play in labour?
Initiates and sustains contractions
| Acts on decidual tissue to promote prostaglandin release
73
What synthesises oxytocin during labour?
Decidual tissue
Extra-embryonic foetal tissues
Placenta
74
What happens to the number of oxytocin receptors near the pregnancy? In what tissues?
Increases in:
- Myometrium
- Decidual tissues
75
What does myometrial stretch do in the initiation of labour?
Increases excitability of myometrial fibres
76
What is the Ferguson reflex?
1. Increased pressure on cervix
2. Oxytocin release
3. Contractions
4. Positive feedback to step 1.
77
What does the secretion of pulmonary surfactant into the amniotic fluid do?
Prostaglandin synthesis
78
What does a rise in foetal cortisol?
Increases maternal oestriol
79
What does an increase in myometrial oxytocin receptors and their activation do?
Phospholipase C activity:
- Increased cytosolic calcium
- Increased uterine contractility
80
What is the latent phase of the first stage of labour?
Up to 3-4cm cervical dilatation
81
What is the active phase of the first stage of labour?
4-10cm (full) cervical dilatation
82
What is the second stage of labour?
From full dilatation to delivery of the baby
83
What is the third stage of labour?
From delivery of baby to the expulsion of placenta and membranes
84
What happens during the latent phase of the first stage of labour?
Mild irregular uterine contractions
| Cervix shortens and softens
85
How long does the latent phase of the first stage of labour last?
Variably duration:
| - May last a few days
86
What happens during the active phase of the first stage of labour?
```
4-10cm cervical dilatation
Slow descent of the presenting part
Contractions progressively become more:
- Rhythmic
- Strong
```
87
In nulliparous women, when is the second stage of labour deemed prolonged?
If it lasts longer than:
- 3 hours if there is regional anaesthesia
- 2 hours without regional anaesthesia
88
In multiiparous women, when is the second stage of labour deemed prolonged?
If it lasts longer than:
- 2 hours if there is regional anaesthesia
- 1 hour without regional anaesthesia
89
How often is vaginal examination done to assess cervical dilatation in low risk care?
Infrequently
90
How long does the third stage of labour last for?
```
10 minutes
(Can last from 3 minutes longer)
```
91
What is the expectant management of the third stage of labour?
Spontaneous delivery of placenta
92
What is the active management of the third stage of labour?
Use of oxytocic drugs
| Controlled cord traction
93
What does the active management of the third stage of labour reduce the risk of?
Post-Partum haemorrhage
94
What drugs can be used during the active management of the third stage of labour?
```
Administration of Syntometrine - 1ml ampoule containing:
- 500mcg ergometrine maleate AND
- 5 IU oxytocin
OR
Administration of 10 IU oxytocin
```
95
How else can active management of the third stage of labour be carried out?
Cord clamping and cutting
Controlled cord traction
Bladder emptying
96
What effect does hyaluronic acid have on the cervix?
Increases molecules between collagen fibres:
| - Results in cervical softening
97
What effect does reduced collagen fibre bridging have on the cervix?
Reduces cervical firmness:
| - Results in cervical softening
98
What causes cervical ripening?
```
Reduced collagen fibre alignment
Reduced collagen fibre strength
Reduced tensile strength of the cervical matrix
Increased cervical decorin:
- Dermatan sulfate proteoglycan 2
```
99
What are Braxton Hicks Contractions?
Tightening of the uterine muscles:
| - Thought to aid the body prepare for labour
100
How early can Braxton Hicks Contractions start?
6 weeks
101
When are Braxton Hicks Contractions usually felt?
2nd or 3rd trimester
102
What effect can Braxton Hicks Contractions have on the cervix?
Thin it
103
How can Braxton Hicks Contractions be differentiated from uterine contractions in labour?
Irregular
Frequency and duration stay constant:
- Do not increase
Relatively painless
104
How can Braxton Hicks Contractions be resolved?
Ambulation
| Change in activity
105
What is the spacing of true labour contractions?
Evenly spread:
- Typically starts at about 5 minutes apart
- Time between them shortens
106
How do true labour contractions change as they progress?
Get more intense
Get more painful
Last longer
107
What is the purpose of true labour contractions?
Tighten the top of the uterus:
| - Pushes baby down into birth canal
108
How does the abdomen feel during true labour contractions?
Rigid
109
What cervical changes occur during true labour contractions?
Softening
Effacement
Dilatation
110
How does position affect true labour contractions?
Do not resolve
111
What kind of muscle is in the uterus?
Smooth
112
Where is uterine muscle most dense?
At fundus
113
What is cervical tissue made up of?
```
Collagen (mainly), types:
- 1
- 2
- 3
- 4
Smooth muscle
Elastin
```
114
What are the components of cervical tissue held together by?
Connective tissue ground substance
115
Where is the pacemaker for uterine contractions? What does it do?
Region of the tubal ostia:
- Wave spreads downwards
- Synchronisation of contraction waves from both ostia
116
What happens to the upper segment of the uterus during contractions?
Contracts
| Retracts
117
What happens to the lower segment of the uterus (and the cervix) during contractions?
Stretch
Dilate
Relax
118
Where is the dominance of the uterine contractions?
Fundus
119
What is the intensity of a uterine contraction essentially?
Degree of uterine systole
120
When is the intensity of uterine contractions greatest?
2nd stage of labour
121
What is the typical frequency of uterine contractions?
Up to 3-4 in 10 minutes
122
How long does a uterine contraction last initially and what is the max length?
Initially 10-15 seconds
| Max 45 seconds
123
What is the typical gynaecoid AP diameter of the pelvic outlet?
12-13cm
124
What is the typical gynaecoid transverse diameter of the pelvic inlet?
13.5-14cm
125
What is the typical gynaecoid transverse diameter of the pelvic outlet?
11cm (between ischial tuberosities)
126
What is the typical gynaecoid oblique diameter of the pelvic outlet?
12cm
127
What is the oblique diameter of the pelvis?
Sacroiliac joint to contralateral iliopubic eminence
128
What is the shape of the anthropoid pelvis?
Oval shaped inlet
| AP > Transverse diameter
129
What is the shape of an android pelvis?
A typically 'male' pelvis
| Heart shaped/Triangular inlet
130
What results in the shape of an android pelvis?
Prominent sacrum
131
Who is an android pelvis most common in?
Afro-Caribbean women
132
What is the normal foetal position?
```
Longitudinal lie
Cephalic presentation
Position:
- Occipitoanterior
- Head engages occipitotransverse
Flexed head
```
133
What are abnormal foetal positions?
```
Presentation:
- Breech
- Oblique lie
- Transverse lie
Position:
- Occipitoposterior
```
134
What is the sequence of movements of the foetus during labour?
1. Engagement and descent of the head in an occipitotransverse position as it descends through pelvic inlet
2. Neck flexion
3. Internal rotation of neck to OA position
4. Crowing and extension of neck
5. Restitution and external rotation (head back to OT to aid shoulder delivery)
6. Expulsion
135
How is the anterior shoulder delivered?
Downward traction:
| - Lateral flexion posteriorly
136
How is the posterior shoulder delivered?
Upward traction:
| - Lateral flexion anteriorly
137
How is the descent of the foetal head measured?
In abdominal fifths
138
What parts of the foetal head are used to determine the position of the foetal head?
Frontal synciput
| Occipital eminences
139
When are vaginal exams for cervical assessment carried out during normal labour?
~4 hourly
140
What is crowning?
Appearance of a large segment of foetal head at the introitus
Labia stretched to full capacity
Largest head diameter encircled by vulval ring
141
What does the Bishop Score aid in the assessment of?
Cervix
Helps determine if labour will be:
- Spontaneous
- Induced
142
What are the dilatation scores in the Bishop Score?
```
0cm = 0 points
1-2cm = 1 point
3-4cm = 2 points
>5cm = 3 points
```
143
What are the effacement scores in the Bishop Score?
```
0-30% = 0 points
40-50% = 1 point
60-70% = 2 points
80-100% = 3 points
```
144
What are the station scores in the Bishop Score?
-3 = 0 points
-2 = 1 points
-1 = 2 points
+1 or +2 = 3 points
145
What are the cervical consistency scores in the Bishop Score?
```
Firm = 0 points
Med. = 1 point
Soft = 2 points
```
146
What are the cervix position scores in the Bishop Score?
```
Posterior = 0 points
Mid. = 1 point
Anterior = 2 points
```
147
What Bishop's Score indicates labour is likely to be spontaneous/induction would likely work?
>=9 points
148
What Bishop's Score indicates labour is likely to proceed and induction will likely not work?
=<5 points
149
What amount of blood loss is normal during labour?
<500 ml
150
What amount of blood loss is abnormal and more significant?
>1500 ml
151
Where is the plane of separation for the placenta?
Spongy layer of decidua basalis
152
What causes placental separation?
Shearing force
153
What are the methods of placental separation?
```
Matthew Duncan:
- Marginal
- Most common
Schultz:
- Central
```
154
What 3 signs indicate placental separation in the 3rd stage of labour?
Uterus hardens, contracts and rises
Umbilical cord lengthens permanently
Gush of blood cariable
155
When is the 3rd stage of labour considered normal up to?
30 minutes
156
How is haemostasis after labour achieved?
Tonic contraction:
- Lattice pattern of uterine muscles strangulates blood vessels
Thrombosis of torn vessel ends:
- Hypercoagulability in pregnancy
Myo-tamponade due to opposition of AP walls
157
How long does it take the tissues to return to a non-pregnant state after labout?
Over 6 weeks
158
What is the lochia rubra?
The 1st vaginal discharge after labour:
- Fresh red
- Lasts 3-5 days
159
What is the lochia serosa?
The second vaginal discharge after labour:
- Brownish-red and watery
- Continues until 10 days after delivery
160
What is the lochia alba?
The third vaginal discharge after labour:
- Yellow
- 2-6 weeks after delivery
161
What weight does the uterus decrease from and to after labour?
Down from 1kg to 50-100g
162
How long does it take for the fundal height to move from the umbilicus to pelvis?
2 weeks
163
How long does the endometrium take to regenerate?
By the end of the first week post-labour
164
When does diuresis occur post-natally?
2-3 days
165
What causes labour pain?
Compression of paracervical nerves
| Myometrial hypoxia
166
What is Entonox?
Inhaled analgesic:
| - Nitrous oxide and oxygen
167
What is TENS and where can it be carried out?
Transcutaneous Electrical Nerve Stimulation:
- T10-L1
- S2-S4
168
How can morphine be delivered during labour?
IM
169
What drug can be given IV in a patient-controlled analgesia?
Remifentanil
170
How does epidural anaesthesia affect uterine activity?
No effect
171
What is the typical solution of epidural anaesthesia used?
Levobupivacaine (10-15ml of 0.0625-0.1%) for LA
WITH
Fentanyl (1-2mcg/ml) Opiod
172
What are the side effects of epidural anaesthesia?
```
Hypotension
Dural pressure
Headache
Back pain
Atonic bladder
```
173
When is delayed labour suspected in stage 1 of labour if nulliparous?
<2cm dilation in 4 hours
174
When is delayed labour suspected in stage 1 of labour if multiparous?
<2cm dilation in 4 hours
OR
Slowing in progress
175
In regards to the 'Power', what can delay labour?
Inadequate contractions:
- Frequency +/or
- Strength
176
In regards to 'Passages', what can delay labour?
Short stature
Trauma
Shape
177
In regards to 'Passenger', what can delay labour?
Big baby
| Malposition
178
What are the measurements recorded on a partogram?
```
Foetal heart rate
Contractions
Amniotic fluid
Cervical dilatation
Descent
Obstruction
Maternal observations
```
179
When is a Doppler auscultation of the foetal heart carried out in stage 1 of labour?
During and after a contraction
| Every 15 minutes
180
When is a Doppler auscultation of the foetal heart carried out in stage 2 of labour?
Every 5-10 minutes
181
If there are risk factors for foetal hypoxia, how often is the foetal heart monitored?
Continuously
182
What is foetal tachycardia on CTG?
>150
183
What is foetal bradycardia on CTG?
<110
184
What is a normal/reassuring variability on CTG?
5-25bpm
185
What is a reduced/non-reassuring variability on CTG?
<5bpm for 30-90 minutes
186
What is an abnormal/complete loss of variability on CTG?
<5bpm for >90 minutes
187
What is a saltatory variability on CTG?
>25bpm
188
What is an acceleration on CTG?
An increase in baseline HR >15bpm for >15 seconds
189
How often should an acceleration occur on CTG?
At least 2 every 15 seconds
| Occurring alongside contractions
190
What causes an early deceleration on CTG?
Increased foetal ICP resulting in increased vagal tone (physiological)
191
What causes variable decelerations on CTG?
Reduced amniotic fluid volume
192
What causes late decelerations on CTG?
Insufficient blood flow through uterus and placenta:
- Maternal hypotension
- Pre-eclampsia
- Uterine hyperstimulation
193
How can foetal distress be managed?
```
Change maternal position
IV fluids
Stop syntocinon
Scalp stimulation
Consider tocolysis (suppresses labour):
- Terbutaline 250mcg S/C
Maternal assessment
Foetal blood sampling
C-section
```
194
What does a scalp pH of >7.25 suggest?
Normal
| No action needed
195
What does a scalp pH of 7.20-7.25 suggest?
Borderline
| Repeat in 30 minutes
196
What does a scalp pH of <7.20 suggest?
Abnormal
| Deliver baby
197
When are monthly antenatal visits carried out?
From 12 weeks until 28 weeks
198
When can Anti-D be given?
28 weeks and 34 weeks
199
When are fortnightly antenatal visits carried out?
28-36 weeks
200
When are weekly antenatal visits carried out?
From 37 weeks until delivery
201
If there is hypertension present at booking appointment or <20 weeks pregnancy, what kind is it?
Chronic (essential) hypertension
202
If there is hypertension that is new >20 weeks pregnancy without significant proteinuria, what is it?
Gestational hypertension
203
If there is hypertension that is new >20 weeks pregnancy with significant proteinuria, what is it?
Pre-eclampsia
204
What is HELLP syndrome?
Haemolysis
Elevator Liver enzymes
Low Platelets
205
If there are risk factors for pre-eclampsia, what can be prescribed?
Aspirin
206
When is Nifedipine used to manage hypertension in pregnancy?
If monotherapy of either fails:
- Labetalo OR
- Methyldopa
207
What can be used for severe hypertension in pregnancy?
Labetalol PO or IV
Hydralazine IV
Nifedipine PO
208
What is severe hypertension in pregnancy defined as?
>165/110
209
What is the target BP aim in hypertension without end organ damage in pregnancy?
<150/100
210
What is the target BP aim in hypertension with end organ damage in pregnancy?
<140/90
211
If a pregnant woman's BP is <140/90, what should be done?
Consider reducing dose
212
If a pregnant woman's BP is <130/90, what should be done?
Reduce dose
213
When should a foetus be delivered, ideally, in pre-eclampsia?
37 weeks
214
```
If there are signs of:
- Vasoconstriction
- Kidney, liver, eye disease
- Foetal IUGR, abruption, death
What should be done if there is hypertension in regards to monitoring?
```
Growth scans
215
How can pregnancy affect diabetes?
Poorer control
Deterioration of renal function
Deterioration of ophthalmic disease
Gestational DM
216
How can diabetes affect pregnancy?
```
Miscarriage
Foetal malformations
IUGR/Macrosomia
Unexplained IUD
Pre-eclampsia
```
217
When should labour be induced in diabetes?
37-38 weeks
218
What does foetal macrosomia increase the risk of?
Birth injury
| Shoulder dystocia
219
What does polyuria and polyhydramnios increase the risk of?
Preterm labour
Malpresentation
Cord prolapse
220
What does increased oxygen demand and polycythaemia increase the risk of?
Unexplained term stillbirth
221
What does neonatal hypoglycaemia increase the risk of?
Cerebral palsy
222
How does polycythaemia arise in maternal hyperglycaemia?
```
Foetal hyperglycaemia results in hyperinsulinaemia
Increased metabolism results in:
- Tissue hypoxia
- Increased EPO
- Erythroblastosis
Hyperinsulinaemia also results in:
- Increased EPO
- Erythroblastosis
```
223
What are the aims for BM and HbA1C in the management of gestational diabetes?
```
BM = 4-6
HbA1c = <6.0
```
224
How is gestational diabetes managed postnatal?
Stop treatment
| Monitor blood glucose for 48hrs
225
How can VTE be treated in pregnancy?
LMWH
226
What is the biggest risk factor for a VTE during pregnancy?
Previous VTE (Except 1 event due to surgery)
227
If a pregnant woman has had any previous VTE (except related to surgery), how should this be managed?
HIGH RISK
| Antenatal LMWH
228
If there are >=4 lifestyle risk factors, for VTE in pregnancy, how should this be managed?
LMWH from 1st trimester
229
If there are 3 lifestyle risk factors, for VTE in pregnancy, how should this be managed?
LMWH from 28 weeks
230
If there are <3 lifestyle risk factors, for VTE in pregnancy, how should this be managed?
Mobilisation
| Avoidance of dehydration
231
If any of the following are met, how should the risk of postnatal VTE be reduced:
- Any previous VTE
- Anyone requiring antenatal LMWH
- High risk thrombophilia
- Low risk thrombophilia and FHx
At least 6 weeks of LMWH
232
If there is an intermediate risk of postnatal VTE, how should it be managed?
At least 10 days LMWH
233
If there is an intermediate risk, or >3 intermediate risk factors or the intermediate risk persists beyond initially prophylaxis, what should be done?
Extend LMWH
234
What is the ratio of left:right DVT?
8:1
235
What is the therapeutic dose of LMWH during pregnancy after DVT or PE?
1mg/kg twice (or once) daily
236
When should LMWH be continued in following a DVT or PE?
3 months after pregnancy
OR
6 months after treatment began
237
How long should therapeutic heparin be stopped before a planned delivery where an epidural is to be given?
24 hours
238
How long should prophylactic heparin be stopped before a planned delivery where an epidural is to be given?
12 hours
239
How soon before delivery should warfarin be stopped?
6 weeks
240
How should hypothyroidism dosing be changed in pregnancy?
Increase dose by 25-50mcg in 1st trimester
| Repeat TFTs every trimester
241
How should hyperthyroidism dosing be changed in pregnancy?
Gets worse due to hCG in 1st trimester
| Improves in 2nd and 3rd trimesters
242
How can hyperthyroidism affect pregnancy?
IUGR
Preterm labour
Thyroid storm
243
How is asthma affected in the 3rd trimester?
Often improves
244
What are the dysmorphic features of Foetal Anticonvulsant Syndrome?
V-shaped eyebrows
Low set ears
Broad nasal bridge
Irregular teeth
245
What are the other features of Foetal Anticonvulsant Syndrome?
Hypertelorism:
- Increased distance between 2 organs/body parts
Hypoplastic nails and distal digits
246
Postpartum, how is a foetus treated if the mother was given anticonvulsants during pregnancy?
1mg IM Vitamin K
247
Half of suicides occur up to what stage postnatally?
12 weeks
248
What can predict a psychiatric disorder following pregnancy?
Previous mental illness
Other vulnerable factors
FHx of bipolar disorder
249
What anticonvulsant causes the following foetal abnormalities:
- Neural tube defects
- Craniofacial defects
- CV abnormality
- IUGR
- Reduced IQ
- Cleft lip/palate
- Genitourinary anomalies
Sodium valproate
250
What anticonvulsant causes the following foetal abnormalities:
- Facial dysmorphism
- Cardiac anomalies
- Fingernail hypoplasia
- Neural tube defects
Carbamazepine
251
What anticonvulsant causes the following foetal abnormalities:
- Cleft lip/palate
- SJS to baby if breastfed
Lamotrigine
252
What drug causes foetal Ebstein's anomaly?
Lithium
253
Are antipsychotics safe in pregnancy?
Yes
254
What can atypical antipsychotics result in during pregnancy?
Gestational diabetes
| IUGR
255
All antipsychotics are sedating and have long half lives. What should babies be observed for following birth?
Lethargy
Sedations
Developmental milestones
256
What antipsychotic drugs are contraindicated in breastfeeding any why?
Clozapine:
- Can induce life-threatening events in infant
Olanzapine:
- Can induce extrapyramidal reactions
257
What can venlafaxine cause in pregnancy?
Hypertension
258
What can paroxetine cause in pregnancy?
Cardiac abnormalities
259
What can SSRIs cause in pregnancy?
Pulmonary hypertension after 20 weeksq
260
What antidepressants enter breast milk?
TCAs
SSRIs:
- Citalopram and Fluoxetine have high levels!
261
What TCAs are safe in pregnancy and breastfeeing
Amitriptyline
| Nortriptyline
262
When does 'baby blues' occur?
Days 3-10
263
When does postnatal depression first present?
2-6 weeks postnatally
264
What clinical features can differentiate postnatal depression from 'baby blues'?
```
Lack of enjoyment
Weight loss
Presenting as concersns about baby
Has effects on:
- Bonding
- Marriage
- Child development
```
265
When does puerperal psychosis tend to present?
Within 2 weeks of delivery
266
What are the early symptoms of puerperal psychosis?
Sleep disturbance
Confusion
Irrational ideas
267
What are some later symptoms of puerperal psychosis?
Mania
Delusions
Hallucinations
Confusion
268
How is puerperal psychosis managed?
```
Admission to hospital
Antidepressants
Antipsychotics
Mood stabilisers
ECT
```
269
What is Wernicke's Encephalopathy?
Triad of:
- Ophthalmoplegia
- Ataxia
- Confusion
270
What is Korsakoff syndrome?
```
Anterograde amnesia
Retrograde amnesia
Confabulation
Minimal content in conversation
Lack of insight
Apathy
```
271
What teratogenic effects can amphetamines have in pregnancy?
Microcephaly
Cardiac
Genitourinary
Limb
272
What other complications of pregnancy can result from amphetamine use?
Pre-eclampsia
| Abruption
273
What complications of pregnancy can result from ecstasy use?
```
IUGR
Pre-term labour
Miscarriage
Developmental delay
SIDS
Withdrawal
```
274
What complications of pregnancy can result from opiate use?
```
Maternal death (1-2%)
Neonatal withdrawal
IUGR
SIDS
Stillbirth
```
275
What complications of pregnancy can result from nicotine use?
```
Miscarriage
Abruption
IUGR
Stillbirth
SIDS
```
276
What is placental abruption?
Separation of a normally implanted placenta BEFORE birth of the foetus
277
What can result from a placental abruption?
```
Revealed/Concealed bleeding
Couvelaire uterus
PPH
DIC
Foetal/Maternal death
```
278
What is a couvelaire uterus?
Bleeding penetrates myometrium and forces into peritoneal cavity
279
How does a placental abruption present?
```
Small/Large blood loss
Pain
Uterine tenderness/Wooden hard
Uterus feels larger
Difficulty feeling foetal parts
CTG:
- Abnormally frequent contractions
- Abnormal uterine hypertonus
```
280
What is placenta praevia?
Placenta is partially OR totally implanted in the lower uterine segment
281
How can placenta praevia be classified according to position?
Lateral
Marginal
Incomplete centralis
Complete centralis
282
What are the grades of placenta praevia?
Grades I-IV
283
What defines major or minor placenta praevia?
Distance from cervix on USS:
- Major is =<2cm from/covering os
- Minor is >2cm from os
284
How does placenta praevia present?
```
Painless (+ 'causeless') recurrent 3rd trimester bleeding
Uterus soft and non-tender
Malpresentations
High head
CTG usually normal
```
285
How is placenta praevia diagnosed?
```
Anomaly scan (20 weeks)
32/34 week scan
```
286
When is a vaginal exam carried out in placenta praevia?
NOT until praevia excluded
287
How is a major placenta praevia managed?
Caesarean section
288
How is a minor placenta praevia managed?
Consider vaginal delivery
289
What is placenta accreta?
Placenta invades myometrium
290
What is placenta percreta?
Placenta has reached serosa
291
What is placenta accreta associated with?
Severe bleeding
PPH
Hysterectomy
292
What are the risk factors for placenta accreta?
Placenta praevia
| Prior C-section
293
How does uterine rupture present?
```
Small/Large volume
Intrapartum loss of contractions
Obstructed labour
Peritonism
Foetal head high
Foetal distress/IUG
Haematuria
```
294
What are the risk factors for uterine rupture?
Previous C-section
| Previous uterine surgery
295
What is vasa praevia?
```
Velamentous insertion of cord:
- Umbilical cord inserts into foetal membranes
OR
Succenturiate lobe:
- A smaller accessory placental lobe
```
296
What happens in velamentous insertion of cord?
Travels to placenta
| Exposed vessels vulnerable to rupture
297
How does vasa praevia present?
Bleeding (foetal blood - 200ml) after rupture of membranes
| Foetal death
298
How is placenta praevia managed?
```
ADMIT
IV
USS
Anti-D
Steroids
Delivery:
- <2cm carry out C-section at 38-39 weeks
```
299
How is delivery timed in placenta praevia?
```
Major bleeding may require preterm deliver
C-section at 37-38 weeks if:
- Prior bleeding
- Suspected/Confirmed placenta accreta
Cell saver
Steroids
```
300
How is placental abruption managed?
```
ADMIT
IV
Resuscitate/Manage DIC
Deliver a viable baby
If stillbirth -> Vaginal delivery
Anti-D
Steroids if expectant management
```
301
If there is any history of acute bleeding 23-32 weeks, how long should the mother be admitted for?
Minimum stay of 24 hours clear of bleeding
302
If there is any history of recurrent bleeding after 28 weeks, how long should the mother be admitted for?
Minimum stay 72 hours
| Consider admission until delivery
303
If there is any history of bleeding after 32 weeks, how long should the mother be admitted for?
Minimum stay of 72 hours
| Consider admission until delivery
304
If there is any history of major placenta praevia with no bleeding after 36 weeks, how long should the mother be admitted for?
Consider:
- Social circumstances
- Obstetric factors
- Need for admission until delivery
305
What is the role of steroids in labour?
Promote foetal lung surfactant production
306
When do steroids need to be given to reduce the risk of neonatal respiratory distress syndrome by up to 50%?
24-48 hours before delivery
307
When are steroids administered up to? Up to what point to they have significant effects?
Up to 36 weeks
| Only significant up to 34 weeks
308
Which steroid is best to aid in foetal lung surfactant production?
Betamethasone > Dexamethasone
309
What is one course of steroids before delivery?
12mg Betamethasone IM, 2 injections, 12 hours apart
310
When is C-section planned in placenta accreta?
At 37 weeks
311
How many units should be cross-matched following how much PV bleeding when antenatally admitted?
2-4 units with any bleeding >1tsp
312
After what test should anti-D be administered if the mother is Rh-?
Kleihauer test:
| - Looks for foetal blood in mother's blood
313
What is the classic definition of PPH?
>500ml
314
What is primary PPH?
Within 24 hours
315
What is secondary PPH?
24hrs - 6 weeks
316
What is a minor PPH?
<500ml
317
What is a moderate PPH?
500-1500ml
318
What is a major PPH?
>=1500ml
319
What are the possible aetiologies of PPH?
The "4 Ts":
- Tone (70%)
- Trauma (20%)
- Tissues (10%)
- Thrombin (<1%)
320
A pregnant woman presents with vaginal bleeding. On examination the uterus is soft. On USS, the placenta is complete?
Uterine atony
321
A pregnant woman presents with vaginal bleeding. On examination the uterus is soft and contracted. On USS, the placenta is incomplete?
Retained placental tissue
322
A pregnant woman presents with vaginal bleeding. On examination the uterus is well contracted. On USS, the placenta is complete?
Vaginal/Cervical/Perineal trauma
323
A pregnant woman presents with abdominal pain. There is no vaginal bleeding. She is hypotensive, with a weak, thready pulse. She is hypothermic. The uterus is seen at the vulva and is not palpable.
Inverted uterus
324
A pregnant woman presents with vaginal bleeding, severe abdominal pain that has spread to the shoulder tip. The uterus is extremely painful on palpation.
Ruptured uterus
325
A pregnant woman presents with continual vaginal bleeding. There is some oozing from a perineal wound site. The uterus is soft.
Coagulopathy
326
How is a PPH initially managed?
Uterine massage
5 units IV Syntocinon stat.
40 units Syntocinon in 500ml Hartmanns at 125m/hr
327
How is persistent PPH managed?
```
Confirm placenta and membranes complete
Urinary catheter
500mcg Ergometrine IV, avoided if:
- Cardiac disease
- Hypertension
PGF2-alpha (Carbaprost/Haemabate) 250mcg IM (up to 8x)
```
328
What are the non-surgical managements of persistent PPH >1500ml?
Packs and balloons
Tissue sealants
Factor VIIa
Arterial embolisation
329
What are the surgical managements of persistent PPH >1500ml?
```
Undersuturing
Brace sutures
Uterine artery ligation
Internal iliac artery ligation
Hysterectomy
```
330
When does maternal BP reach its lowest point during pregnancy?
22-24 weeks
331
What happens to BP after delivery?
Falls
| Subsequently rises - Peaks at day 3-4 postnatal
332
How is hypertension diagnosed in pregnancy?
>=140/90 on 2 occasions
Diastolic BP >110
ACOG >30/15 compared to booking BP
333
When might essential hypertension be a retrospective diagnosis?
If BP has not returned to normal within 3 months of delivery
334
When does pregnancy-induced hypertension resolve after delivery?
Within 6 weeks
335
What is proteinuria defined as in pre-eclampsia?
>=0.3g/L
OR
>=0.3g/24 hours
336
What is the pathogenesis behind stage 1 of pre-eclampsia?
Abnormal placental perfusion
337
What is the pathogenesis behind stage 2 of pre-eclampsia?
Maternal syndrome
338
What is the proposed overall pathogenesis of pre-eclampsia?
```
Abnormal placentation and trophoblast invasion:
- Failure of normal vascular remodelling
Spiral arteries fail to adapt to become:
- High capacitance
- Low resistance
```
339
What does placental ischaemia in pre-eclampsia result in?
Widespread endothelial damage and dysfunction
340
What does endothelial activation in pre-eclampsia result in?
```
Increased capillary permeability
Increased expression of CAM
Increased prothrombotic factors
Increased platelet aggregation
Vasoconstriction
```
341
When should a woman be referred to the day care unit (in regards to hypertension)?
BP >=140/90
Proteinuria (++)
Oedema!!
Symptoms - esp. Persistent headache
342
When should a woman be admitted (in regards to hypertension)?
```
BP >=170/110 OR >140/90 with proteinuria (++)
Significant symptoms:
- Headache
- Visual disturbance
- Abdominal pain
Abnormal biochemistry
Significant proteinuria - UPCR >30mg/mmol
Need for antihypertensive therapy
Signs of foetal compromise
```
343
What is a contraindication for using methyldopa in hypertension?
Depression
344
What is a contraindication for using labetalol in hypertension?
Asthma
345
How does methyldopa work?
Centrally acting alpha-agonist
346
How does labetalol work?
Alpha and Beta antagonist
347
How can seizures be prevented during pregnancy?
Magnesium sulfate:
- Loading dose is 4g IV over 5 mins
- Maintenance dose is IV infusion 1g/hr
- 2g for further seizures
348
How are persistent seizures treated in pregnancy?
10mg Diazepam IV
349
What is the main cause of death in pregnancy?
Pulmonary oedema:
- Capillary leak
- Fluid overload
- Cardiac failure
350
What is urge urinary incontinence?
Involuntary urine leakage
| Accompanied by/Immediately preceding by urgency
351
What is Overactive Bladder Syndrome?
Urgency +/- UUI:
- OAB wet = UUI present
- OAB dry = UUI absent
In absence of pathological/metabolic conditions
352
How does Overactive Bladder Syndomr present?
Urgency, usually with:
- Frequency
- Nocturia
353
What can trigger urge incontinence?
Running water
Opening a door
Removing underwear
354
What is mixed urinary incontinence?
```
Involuntary leakage associated with urgency (UUI)
Also with stress urinary incontinence:
- Exertion
- Sneezing
- Coughing
```
355
What is OAB associated with?
Involuntary detrusor contractions that may cause UUI
356
What can SUI be caused by?
```
Urethral hypermotility
Displacement of urethra/bladder neck during:
- Exertion
- Increased intra-abdominal pressure
Urethral sphincter weakness due to:
- Trauma
- Hypoestrogenism
- Ageing
- Surgical procedures
```
357
What is the initial treatment for OAB (+/-UUI)?
Bladder retraining (Bladder drills):
- For minimum of 6 weeks
- Aim to increase bladder capacity and reduce frequency
358
If frequency is a problem in OAB, what can be used as treatment?
Retraining plus antimuscarinic
359
What lifestyle factors can aid in OAB?
Sensible fluid intake
Reduce caffeine
Reduce weight if BMI >30
360
In what kinds of urinary incontinence are pelvic floor muscle exercises effective in?
SUI
| MUI
361
How long should pelvic floor muscle exercises be carried out for urinary incontinence?
Minimum 3 months
362
How do antimuscarinic agents improve urinary incontinence?
Reduce intravesical pressure
Increase compliance
Increase volume threshold for micturition
Reduce uninhibited contractions
363
What is the first line antimuscarinic agent for urinary incontinence (UUI or MUI)?
```
Oxybutynin:
- Immediate release 2.5-5mg PO bd/tid
OR
- Extended release 5mg PO od
OR
- Transdermal patch if side effects
```
364
What other antimuscarinics are available for UUI or MUI?
```
Tolterodine
Solifenacin
Darifenacin
Propiverine
Trospium
Fesoterodine
```
365
What are the side effects of antimuscarinic agents?
Dry mouth
Constipation
Blurred vision
Somnolence
366
What type of drug is Mirabegron?
Selective beta-3 adrenoreceptor agonist
367
What effects does Mirabegron have?
Relaxes bladder smooth muscle
Increases voiding interval
Inhibits spontaneous bladder contractions during filling
368
When is Mirabegron recommended?
If antimuscarinics are:
- Contraindicated
- Ineffective
- Causing unacceptable side effects
369
What are the contraindications to Mirabegron?
Severe uncontrolled hypertension (>=180/110)
| eGFR <15ml/min
370
What is Percutaneous Posterior Tibial Nerve Stimulation useful in?
Reducing symptoms in OAB
371
What is uroflowmetry?
Measurement of volume of urine (ml) expelled from the bladder each second
372
What are the indications for uroflowmetry?
```
Hesitancy
Voiding difficulty
Neuropathy
History of urine retention
Postoperative follow up
```
373
What does flow rate enable the measurement of? What is the minimum amount of urine that must be voided?
Peak flow
Mean flow
Voided volume
200mls
374
What is cystometry?
Method by which the pressure/volume relationship of the bladder is measured during:
- Filling
- Provocation
- Voiding
375
What is the normal post-void residual?
10-80ml
376
What is an abnormal post-void residual?
>100-150ml
377
What causes overflow incontinence?
Obstruction of urethra
| Poor contractile bladder muscle
378
What must be done in overflow incontinence?
Find out post-void residual
| Must stop anticholinergics
379
What are the lifestyle treatments of SUI?
Lose weight
Stop smoking
Avoid caffeine
Avoid excessive fluids
380
What are the physiotherapy treatments of SUI?
PFME
Biofeedback
Electrical stimulation
Pessaries
381
What drugs can be used in SUI?
Duloxetine:
- Combined NA and 5-HT reuptake inhibitor
- Increases intraurethral closure pressure
?Pseudoephedrine
382
What are the surgical options for SUI?
Low tension vaginal tape
Intraurethral injection
Artificial sphincters
Colposuspension
383
What volume of leakage is seen in OAB?
Large volume
384
What volume of leakage is seen in SUI?
Small
385
Is nocturia present in OAB?
Usually
386
Is nocturia present in SUI?
Seldom
387
What are the three compartments of pelvic organ prolapse?
Anterior
Middle/Apical
Posterior
388
What are the symptoms of a cystocoele and enterocoele?
```
Bulging, pressure, 'mass'
Difficulty voiding and incomplete emptying
Splinting vaginal wall
Difficulty inserting tampon
Painful intercourse
```
389
What are the symptoms of a rectocoele?
Bulging, pressure, 'mass'
Difficulty defaecating
Splinting vaginal wall
Difficulty inserting tampon
390
How many sites are measured in the Pelvic Organ Prolapse Quantification System?
6 when patient is straining
| 3 when patient is resting
391
What is measured at each site in the Pelvic Organ Prolapse Quantification System?
Each measured (cm) in relation to 'fixed' hymenl ring:
- Zero point of reference
- If above hymen = Negative number
- If below hymen = Positive number
392
What is a Manchester repair and what is it used for?
Cervix amputated
Uterosacral ligaments shortened
Used in uterine/vault prolapse
393
When are pessaries used in prolapse?
```
Unsuitable for surgery
Symptom relief while awaiting surgery
Further pregnancies planned/currently pregnant
As diagnosis
Patient request
```
394
When are vaginal oestrogens used in prolapse?
If symptomatic atrophic vaginitis
