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Year 4 DECK OF MANY THINGS > Day 14 OBGYN > Flashcards

Day 14 OBGYN Flashcards

1
Q

Obstetric History (6)

A
  • pain
  • bleeding (when, how much, have you had this before? a scan?)

•baby movements (from 26w)

•vaginal loss/discharge

•headaches, visual disturbances, generalised swelling (esp high BP)

•lower leg pain/swelling (esp high risk VTE)

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2
Q

Obstetric Family + Social History

(5)

A

Are there any twins in the family?

Do any medical conditions run in the family?

Where do you work?

Do you drink alcohol or smoke?

Do you feel safe and supported at home?

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3
Q

What changes occur towards the end of pregnancy?

(6)

A

Myometrium

  • Stretching increases muscle excitability & contractility.
  • Gap junctions are formed under the influence of oestrogen enabling transmission of electrochemical signals from cell to cell and a synchronized contraction wave

Cervix

  • Decrease in collagen and an increase in water content enabling the cervix to soften, efface and dilate (ripen)

Hormones

  • Increased concentrations of oestrogen stimulate the production and release of prostaglandins.
  • Also promotes the formation of oxytocin receptors so that the myometrium is more sensitive to oxytocin.
  • Prostaglandins and oxytocin are strong myometrial stimulants and play a major role in cervical ripening
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4
Q

What are the two phases of normal labour?

A

Latent phase

a period of time, not necessarily continuous, when there are painful contractions, and some cervical change, including cervical effacement (stretches) and dilatation up to 4cm

Established labour

regular painful contractions, and progressive cervical dilatation beyond 4cm

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5
Q

Stages of established labour (3)

A

1st From onset of established labour (4cm) to full dilatation of the cervix (10cm)

2nd From full dilatation to birth of the baby

3rd From birth of the baby to expulsion of the placenta and membranes

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6
Q

What is Mobilising?

A

Walking and upright positions in the 1st stage of labour to reduce the duration of labour and the risk of caesarean birth, the need for epidural.

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7
Q

What is Delayed cord clamping?

A

Delayed cord clamping and waiting for the cord to stop pulsating reduces the risk of anaemia in babies

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8
Q

Methods of Monitoring of mother

(4)

A

—Contractions

—Vaginal examinations

—Vaginal loss

—Vital signs

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9
Q

What is the purpose of monitoring the foetus?

A

The monitoring of babies in labour aims to identify hypoxia before it is sufficient to lead to damaging acidosis and long-term neurological adverse outcome for the baby

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10
Q

What are the methods of Monitoring a fetus (2)

A

Low risk women

Intermittent auscultation of the fetal heart using a Doppler ultrasound or Pinard stethoscope

High risk women

Continuous fetal monitoring using a cardiotocograph (CTG)

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11
Q

What is a Pinard stethoscope

A
  • A Pinard horn is a type of stethoscope used to listen to the heart rate of a fetus during pregnancy.
  • It is a hollow horn, often made of wood or metal

The Pinard horn was invented by Dr. Adolphe Pinard, a French obstetrician, during the 19th century.

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12
Q

What are the stages of the mechanism of labour

(6)

A
  1. Descent and Flexion
  2. Internal rotation
  3. Crowning
  4. Extension
  5. Restitution (external rotation of head)
  6. Delivery of anterior and then posterior shoulder
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13
Q

What are the narrowest foetal skull diameters?

A
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14
Q

What occurs during restitution?

A
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15
Q

What is the purpose of Manual perineum protection?

A

prevention of Oasi (Obstetric anal sphinter injury)

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16
Q

What are the indications for induction of labour?

(6)

A
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17
Q

What is a bishop score?

A

If your Bishop score is high, it means that there’s a greater chance that an induction will be successful for you. If your score is 8 or above, it’s a good indication that spontaneous labor would start soon.

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18
Q

What are the relative/absolute contraindications to induction of labour?

A
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19
Q

What are the methods of induction of labour in order of severity?

(4)

A

“Stretch and Sweep”

↓

Administration of vaginal prostaglandins (with normal CTG)

↓

Artificial Rupture of Membranes (ARM)

↓

IV infusion of Oxytocin (with normal CTG)

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20
Q

Which method of induction is used if a patient has an abnormal CTG?

A

artificial membrane rupture

ARM

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21
Q

What is the first stage of induction of labour?

A

“Stretch and Sweep”

360 degrees sweep of examiner’s finger between internal os and foetal membranes, separating them, promoting natural secretion of prostaglandins

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22
Q

What is used in the second line of labour induction?

A

Propess - a pessary on a string, placed in the posterior fornix which slow-releases over 24 hrs to promote cervical ripening. Can be removed in circumstances of uterine hyperstimulation (shown on CTG)

Prostin - a gel inserted into the posterior fornix and allowed to work over 6 hours. Not recommended for patients with previous caesarean section as cannot be removed in cases of hyperstimulation

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23
Q

What is the third line of labour induction?

A

ARM (amniotic rupture)

  • Usually with a plastic amniohook but occasionally using a foetal scalp electrode
  • also encourages natural production of prostaglandins and oxytocin
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24
Q

What is the fourth line option in the induction of labour?

A

Intravenous infusion of oxytocin

  • timing of assessment for oxytocin depends on obstetric history, contractions present and maternal preference
  • started at a low dose and titrated to contractions half-hourly
  • Requires continuous electronic foetal monitoring (EFM
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25
Q

Methods of inducing labour-cervical ripening (3)

A

Propess: Dinoprostone(PGE2)10mg released over 24 hours

Prostin gel: Dinoprostone(PGE2) available in 1mg and 2mg doses released over 6 hours

Prostin tablet :Dinoprostone HSE (PGE2) 3mg, released over 6 hours

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26
Q

When is the first trimester?

A

First Trimester; 0 – 12 weeks

27
Q

When is the second trimester?

A

Second Trimester; 12 – 28 weeks

28
Q

When is the third trimester?

A

Third Trimester; 28 – 40 weeks

29
Q

What is the difference between stillbirth and miscarriage?

A

—Miscarriage; Loss of intrauterine pregnancy before 24 weeks

—Stillbirth; Loss of intrauterine pregnancy after 24 weeks

30
Q

Which vaginal changes are seen in pregnancy?

(4)

A
  • Softening of the cervix (Goodell’s sign); 4 -6 weeks
  • Bluish discolouration of the cervix and vagina due to engorgement of pelvic vasculature (Chadwick sign); 6 weeks
  • Uterine enlargement
  • Softening of the isthmus (Hegar’sign); 6 -8 weeks
31
Q

What investigations can be performed at different stages of pregnancy?

A

HCG;

+ve in serum ~ 9 days post conception

+ve in urine ~ 28 days after LMP

Transvaginal USS;

5 weeks; gestational sac visible

6 weeks; fetalpoleseen

7-8 weeks; fetal heart beat visible

Transabdominal USS;

6-8 weeks IU pregnancy visible

32
Q

How is Maternal cardiology different?

A

Increased CO, HR and blood volume (hyperdynamic circulation)

Decreased BP (especially diastolic, maximal in 2nd trimester) due to decreased peripheral vascular resistance (PVR)

Enlarging uterus compresses on IVC and pelvic veins causing Risk of hypotension (by decreasing venous return), varicose veins, haemorrhoids, leg oedema (due to increased venous pressure)

33
Q

How is maternal haematology different?

A

Increased leukocyte count

  • 5,000 to 12,000/uL in pregnancy
  • Up to 25,000/uL in Labour/postpartum
  • Often have improvement in autoimmune conditions

Gestational thrombocytopenia

  • Occurs in 8% of gestations, possible due to accelerated platelet consumption
  • Platelet count should normalize 2-12 weeks post delivery
34
Q

How does the Respiratory System change?

A

Increased O2 consumption by 20%

Increased sensitivity to CO2 (progesterone effect on respiratory centre) àHyperventilation + respiratory alkalosis compensated by increased renal excretion of serum bicarbonate

Minute ventilation increase by 50%

Decreased TLC, FRC, RV

VC unchanged

TV increase by 33-50%

Alveolar ventilation increase by 65%

35
Q

How is the maternal Gastrointestinal System different?

A

Increased GORD; decreased sphincter tone, delayed gastric emptying, increased intraabdominal pressure

Increased stasis in gallbaladder

Decreased GI motility and constipation

Upward displacement of the appendix (appendicitis may have atypical presentation)

Haemorrhoids caused by constipation and elevated venous pressure

36
Q

What are the maternal changes to the genitourinary system?

(5)

A

Increased GFR by 50% (therefore decreased BUN and serum creatinine) but no change to UO due to increased tubular reabsorption

Glycosuria; with increased GFR glucose reabsorption can be surpassed.

Increased urinary frequency

Physiologic dilatation of ureters and renal pelvis (R>L) due to progesterone-induced smooth muscle relaxation + uterine enlargement

Increased incidence of UTI and pyelonephritis

37
Q

Which maternal organs produce progesterone?

A

Produced by corpus luteum first 7 weeks, then placenta takes over

Maintains the endometrium

Absolutely necessary for pregnancy to continue

38
Q

Where is HCG produced?

What is it formed from?

What is its function?

A

Produced by placental trophoblastic cells

Peptide hormone composed of 2 subunits; alpha(common to all glycoproteins) and beta(specific to HCG)

Maintains the corpus luteum

39
Q

How do HCG levels change during pregnancy?

A

Plasma levels double every 1 -2 days, peak at 8-10 weeks and then falls to a plateau until delivery

40
Q

What happens when HCG levels fall?

A

—Levels below expected by dates àectopic, miscarriage or wrong dates

41
Q

What are high HCG levels indicative of?

(4)

A

multiple gestation

molar pregnancy

trisomy 21

wrong dates

42
Q

How does the maternal thyroid change?

(2)

A

Moderate enlargement and increased basal metabolic rate

Increased Total thyroxine and TBG

Free thyroxine index and TSH levels are normal

43
Q

How do maternal adrenal glands change

A

Maternal cortisol rises throughout pregnancy (total and free)

44
Q

Where is maternal prolactin produced?

What is its function?

A

Prolactin

—Produced by the pituitary in response to increased oestrogen in pregnancy

—Stimulates lactation

45
Q

Where is Relaxin produced?

What is the function of Relaxin?

(4)

A

—Produced by corpus luteum/ovary

—Relaxes symphysis pubis and other pelvic joints

—Helps soften and dilated the cervix

—Inhibits uterine contraction

46
Q

How does maternal skin change?

A

Striae gravidarum (atrophic linear scars- connective tissue changes)

47
Q

How does the maternal neurological system change?

A

Increased incidence of carpal tunnel and Bell’s palsy

48
Q

Which pigmentation changes are associated with motherhood?

A

—Increased around areola and perineum

—Linea nigra (midline abdominal pigmentation)

—Spider angiomas

—Palmar erythema

49
Q

Causes of Antepartum Haemorrhage

bleeding of the genital tract, occurring from 20 weeks of gestation until birth.

complicates between 2 and 5% of all pregnancies

A

Placenta Abruption

Placenta previa

Uterine rupture

Vasa previa

Placenta acretta

Cervical lesion; ectropion, polyp

Others; infection, trauma, malignancy

50
Q

What is Placenta Abruption?

(2)

A

premature separation of the normal-sited placenta from the uterus

Bleeding is often concealed, therefore vigilance is essential

51
Q

Causes of placental abruption

(3)

A

acute inflammation and chronic vascular dysfunction

Inflammatory process mediated by cytokines

Cytokines produce matrix metalloproteinases in trophoblast destruction of extracellular matrices and disruption of cell–cell interactionsàAbruption

52
Q

Investigations for Placenta Abruption

(3)

A

Investigation

FBC, U&Es, LFT,G&S (X-match 4 -6 units) Check for HELLP syndrome

Coag; Prothrombin time/activated partial thromboplastin time may be prolonged in the case of severe placental abruption indicating coagulopathy.

Fibrinogen concentration

Pregnancy is associated with hyperfibrinogenemia

modestly depressed fibrinogen levels may represent significant coagulopathy

A fibrinogen level of less than 200 mg/dl (2 g/l) suggests that the patient has a severe abruption

Kleihauer–Betke test;

detect fetal bld cells in maternal circulation. Helps with correct dose of Anti d (Rh neg mothers)

53
Q

Diagnosis of Placenta Abruption

A

Imaging

Ultrasound

Screening for risk of abruption

Uterine artery dopplers for patients at risk for SGA fetuses

54
Q

Environmental causes of Placenta Abruption

(8)

A
  1. Folic acid deficiency (essential for development of placenta vascular bed)
  2. Cocaine (can cause vasoconstriction and disrupt placenta adherence)
  3. Smoking
  4. PIH/PET (causes ishcaemic placenta disease)
  5. Thrombophilia
  6. Premature rupture of membranes (presence of inflammation + infection)
  7. Multiple pregnancy (sudden uterus decompression after delivery of first twin)
  8. Trauma
55
Q

Treatment (3) of placenta praevia

A

Management

Give steroids between 34+0 and 35+6 weeks of gestation for a low‐lying placenta or placenta praevia

Method of delivery

C/S is the usual method of delivery if the leading placental edge is within 20 mm from the internal os in third trimester.

For minor previa, vaginal delivery can be attempted if fetal head below leading edge of placenta

Method of delivery

If uncomplicated à delivery should be considered between 36+0 and 37+0 weeks of gestation

56
Q

What is Placenta Accreta (2)

A

Abnormally invasive placentation that can be categorised by depth of invasion – placenta accreta, increta and percreta.

decidua basalis, a layer that prevents invasion of the trophoblast cells deeper into the myometrium, can be damaged due to previous surgery à invasion to myometrium

57
Q

Define Placenta accreta

Define Placenta increta

Define Placenta percreta

A

Placenta accreta

chorionic villi attach directly to the myometrium in the absence of decidua.

Placenta increta

placental villi invade deeper into the myometrium, but do not extend to the outermost layers of the uterus.

Placenta percreta

chorionic villi penetrate through the myometrium up to the serosa.

58
Q

What is Vasa Previa

Why is it a problem

A

fetal vessels crossing the internal cervical os through the free placental membranes

vasa praevia is likely to rupture during active labour or iatrogenically with artificial rupture of membranes

Can lead to fetal haemorrhage, exsanguination and death

59
Q

Vasa Previa

Risk factors?

Disgnosis?

A

Risk factors?

  • IVF

Diagnosis?

  • vasa praevia is occasionally detected intrapartum during vaginal examination when vessels are felt in the membrane
  • USS
  • Vasa praevia diagnosed in the second trimester resolves in approximately 20% of patients prior to delivery, therefore a repeat scan at 32 weeks is warranted.
60
Q

How is Vasa Previa treated?

A

—prophylactic hospitalisation from 30–32 weeks should be considered

—Elective delivery via caesarean at 34–36 weeks with a course of antenatal steroids from 32 weeks is reasonable in an asymptomatic patient.

—If there is bleeding from a known or suspected vasa praevia, especially with suspected fetal compromise, delivery should be immediate and usually by caesarean section category 1

61
Q

What is Uterine Rupture?

What is the biggest risk factor?

A
  • full-thickness loss of integrity of the uterine wall and visceral peritoneum.
  • Most cases of uterine rupture occur during labour following previous caesarean section or other uterine surgery, such as myomectomy
62
Q

Risk Factors for uterine rupture

(8)

A
  1. High parity
  2. Previous uterine surgery
  3. induction of labour
  4. Hyperstimulation
  5. Malpresentation
  6. Macrosomia
  7. Uterine abnormalities
  8. Trauma; RTA
63
Q

Signs and Symptoms of Uterine Rupture

(5)

A
  • non-specific and conventional signs may be absent
  • women may compensate well for massive concealed haemorrhage.
  • abdominal pain between uterine contractions
  • cessation of uterine activity – particularly in second stage of labour – haematuria and blood-stained liquor.
  • CTG abnormalities are associated with 55–87% of uterine ruptures.
64
Q

How is Uterine Rupture treated?

A
  • stabilisation of the mother and emergency delivery are crucial
  • Emergency C/S

Year 4 DECK OF MANY THINGS (42 decks)

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