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Y4 ObGyn > Foetal abnormalities > Flashcards

Foetal abnormalities Flashcards

1
Q

What is a breech position? What are the 3 different types?

A

When the baby comes out buttocks or feet first rather than head first.
Complete: both legs flexed at hips and knee (cross legged), bum first
Frank (extended) breech: both legs flexed at hip but extended at knee (commonest)
Footling: one or both legs extended at hip so foot is presenting part

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2
Q

How common is breech presentation?

A

20% of babies are breech at 28 weeks gestation. most revert to a cephalic presentation (head down) spontaneously and only 3% are breech at term

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3
Q

What may cause breech presentation?

A

usually due to chance but 15% have RF:

  • multiparity
  • uterine malformation
  • fibroids
  • placenta praevia
  • prematurity
  • macrosomia
  • polyhydramnios
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4
Q

What are the clinical features of a breech presentation?

A
  • usually identified on clinical exam- round fetal head can be felt in upper uterus and irregular mass in the pelvis, the fetal heartbeat can be auscultated higher on maternal abdomen
  • however this isnt usually important until 32-35 weeks
  • 20% of breech presenation is not diagnosed until labour, this can present with fetal distress- eg meconium stained liquor, on vaginal examination the sacrum or foot may be felt though the cervical opening
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5
Q

how should a suspected breech presentation be investigated?

A
  • confirm with uss, also tells you the type of breech and predisposing fetal abnormalities
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6
Q

What are the 3 management options for breech presentation?

A
  • external cephalic version
  • c section
  • vaginal breech birth
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7
Q

What is external cephalic version and when is it used?

A
  • manipulation of fetus to cephalic presentation through the abdomen
  • if successful (40%) means they can have vaginal delivery
  • attempted in all unless recent antepartum haemorrhage, ruptured membranes, uterine abnormalities or previous c section
  • may get transient fetal heart abnormalities but these revert to normal
  • rarer complications inc placental abruption and more persistent heart rate abnormalities
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8
Q

When is c section used for breech births?

A
  • if external cephalic version is unsuccessful, contraindicated or declined, guidelines are they get a c section
  • perinatal morbidity and mortality is higher in planned breech vaginal births compared w/ c section
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9
Q

When may a vaginal breech delivery be used and not used?

A
  • cannot be used if footling breech as feet can slip through non- fully dilated cervix and shoulders/ head can be trapped
  • pt may choose a vaginal breech or it may be the only option if they present in advanced labour
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10
Q

How should breech deliveries by conducted?

A
  • ‘hands off breech’- putting traction on baby during delivery can cause fetal head to extend, getting it trapped during delivery
  • support the fetuses pelvis anteriorly
  • specific manoeuvres may be required: flexing fetal knees, lovsetts manoeuvre, MSV manoeuvre
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11
Q

List 3 complications of a breech presentation

A
  • cord prolapse (cord drops down below the presenting part of the baby and becomes compressed)
  • fetal head entrapment
  • premature rupture of membranes
  • birth asphyxia- usually secondary to delay in delivery
  • intracranial haemorrhage- due to rapid compression of head during delivery
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12
Q

What is the definition of lie, presentation and position?

A

Lie: relationship between long axis of fetus and mother- londitudinal, transverse or oblique
Presentation: the fetal part which enters the maternal pelvis- cephalic, breech, shoulder, face or brow
Position: the position of the fetal head as it exists the birth canal- usually occipito- anterior, may be occipito- posterior or transverse

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13
Q

how are fetal lie and fetal position determined?

A

fetal lie and presentation by abdo exam
fetal position by vaginal examination during labour
- any suspicion of abnormality should get confirmed by USS

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14
Q

How is a brow and shoulder presentation managed?

A
  • c section necessary
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15
Q

How is a face presentation managed?

A
  • if chin is anterior (mento- anterior) a normal labour is possible however likely to be prolonged and increased risk of c section being required
  • if chin is posterior then a c section is necessary
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16
Q

how are malpositions managed?

A

90% spontaneously rotate to occipito- anterior as labour progresses. If the fetal head does not rotate, rotation and operative vaginal delivery or c section can be performed

17
Q

What is oligohydramnios

?

A
  • low level of amniotic fluid

- below the 5th centile for gestational age

18
Q

How and when does amniotic fluid get produced and absorbed?

A
  • volume increases until 33 weeks and then plateaus at around 500ml
  • produced by fetal urine output w/ small amount from placenta
  • fetus breathes and swallows it, it gets processed and then voided out again
  • any thing that disrupts production of urine, output of urine or rupture of membranes can reduce amniotic fluid
19
Q

What may cause oligohydramnios?

A
  • preterm prelabour rupture of membranes
  • placental insufficiency (blood prioritised to brain rather than abdomen and kidney= low urine output)
  • renal agenesis
  • non functioning kidneys
  • obstructive uropathy
  • genetic/ chromosomal abnormalities
  • viral infections
20
Q

How is oligohydramnios diagnosed?

A
  • USS

- amniotic fluid index or maximum pool depth, both have similar diagnostic accuracy but AFI more commonly used

21
Q

How can ruptured membranes be tested for?

A
  • actim prom- bedside test to detect IGFBP-1 in vagina
  • this protein is found in amniotic fluid and if detected is strongly suggestive or membrane rupture
  • particularly useful if diagnosis unclear
22
Q

How should oligohydramnios be investigated?

A
  • IGFBP-1 if suspect membrane rupture
  • USS for structural abnormalities, renal agenesis and obstructive uropathy
  • USS for fetal size- if small do umbilical artery doppler for placental insufficiency
  • karyotyping if early unexplained oligohydramnios
23
Q

how should ruptured membranes be managed?

A
  • labour is likely to commence in 24- 48hrs
  • if preterm, and labour doesnt automatically start then induction should be considered around 34-36 weeks if no infection
  • course of steroids should be given to aid lung development and abx to reduce risk of ascending infection
24
Q

What is the prognosis like for oligohydramnios?

A
  • poor prognosis if in 2nd trimester as usually due to rupture of membranes (may be associated with infection) and so they get born very prem
  • if due to placental insufficiency then also higher rate of prem
  • fetus may develop severe muscle contractures despite physio after birth as low amniotic fluid reduces ability to move in utero
25
Q

What is the definition of polyhydramnios?

A

Amniotic fluid index above the 95th centile for gestational age

26
Q

What may cause polyhydramnios?

A
  • idiopathic in 50-60%
  • any condition affecting swallowing (oesphageal atresia, CNS abnormalities, muscular dystrophies, congenital diaphragmatic hernia
  • duodenal atresia
  • anaemia
  • fetal hydrops
  • twin to twin transfusion syndrome (disproportionate blood supply in twin pregnancies)
  • increased lung secretions- cystic adenomatoid malformation of lung
  • genetic or chromosomal abnormality
  • maternal diabetes- esp if poorly controlled
  • maternal ingestion of lithium (leads to fetal diabetes insipidus)
  • macrosomia
27
Q

How should polyhydramnios be invesgitaed?

A
  • USS to detect anomalies in fetal size, doppler to detect fetal anaemia
  • maternal glucose tolerance test for maternal diabetes
  • karyotyping esp if abnormalities detected or fetus is small
  • TORCH screen as some viral infections can cause
28
Q

How should polyhydramnios be managed if the woman is experiencing symptoms eg breathlessness?

A
  • aminoreduction can be considered but has infection and placental abruption risk so not routine
  • indomethacin can be used to enhance water retention so reduced fetal urine output but is associsated with premature closure of ductus arteriosus so isnt used after 32 weeks
29
Q

How should idiopathic polyhydramnios be managed after birth?

A

must be examined by paeds before first feed and an NG tube must be passed to ensure there is not a tracheoesphageal fistula or oesphageal atresia

30
Q

What complications are more likely due to idiopathic polyhydramnios?

A
  • preterm labour due to overdistension of uterus
  • underlying abnormality or congenital malformation
  • malpresentation more likely as baby more room to move
  • higher risk cord prolapse
  • higher incidence post partum haemorrhage as uterus has to contract further to achieve homeostasis

Y4 ObGyn (8 decks)

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