General Obs 3 Flashcards
What counts as prolonged pregaz? (post dates)
> 42 wks
What kinds of woman get prolonged pregnancies?
nulliparous, old, fat, with FHx
Why does the rate of stillbirth rise exponentially after 37wks?
increased placental insufficiency
What could be an explanation for post dates?
inaccurate dating!
Why might a post-dates newborn have dry flaky skin?
lost their vernix caseosa
What is vernix caseosa?
white flaky cheese
not there in preterms or postdates
When should mum have a dating scan?
12 wks
Mum still hasn’t given birth beyond 42 wks. What investigations will you check? dont worry if not right :)
ultrasound (check growth)
liquor vol
Dopplers
What are the most common features of a prolonged pregnancy?
static growth / macrosomia
oligohydramnios
reduced foetal movements
When does NICE recommend delivery by to reduce risk of stillbirth.?
42 wks
When would you do a membrane sweep to avoid prolonged preg?
40-41-ish wks
What is a membrane sweep for?
try to kickstart labour to prevent prolonged preg (>42wks)
When would you offer other methods of induction of labour (not including membrane sweep) to prevent prolonged preg?
41-42-ish wks
You’ve got a lady who is at risk of prolonged preg, but she declines membrane sweep and induction. What do you do?
surveillance
(CTG, US)… if foetal distress - C section
Mum wants induction. Not necessarily safer for baby to be delivered rather than staying in utero. What does NICE say?
In the UK, NICE guidelines (2008) state that induction of labour should NOT be offered on maternal request alone.
Women with uncomplicated pregnancies are offered some kind of induction from when?
40wks
What is management of prolonged preg?
induction
You offer induction for uncomplicated pregs from 40wks. What other main scenario would you offer induction?
IUGR
(deliver before foetal compromise)
(and PROM)
What are the three main methods of induction?
membrane sweep (adjunct rlly)
ARM
vaginal prostaglandins
What are the mainstay of induction?
vaginal prostaglandins
What two things do vaginal prostaglandins do to induce labour?
ripen cervix
contract uterus Smooth muscle
Vaginal prostaglandins come as a tablet, gel, or pessary. Yes?
yes
What’s another word for ARM (artificial rupture of membranes)?
amniotomy
done with an AMNIOHOOOOOOK
How do you do artificial rupture of membranes?
amniohook poke
+ syntocinon to help the contractions along
What does NICE recommend as the primary method of induction of labour?
VAGINAL PROSTAGLANDINS
only use ARM + syntocinon when these are contraindicated.
What does the Bishop score assess?
cervical ripeness
Vaginal prostaglandin pessary is given in 1 cycle….
1 dose over 24hrs
Vaginal prostaglandin tablet /gel is given in 1 cycle
1st dose, then 2nd dose if labour hasn’t started 6hrs later
Score of 7 or above on Bishop’s suggests…….
cervix is ripe
… induction is poss
Score of 4 or below on Bishop’s suggests…..
not ripe, will need vaginal prostaglandins and maybe caesarean
What is a risk of labour induction when the womb goes crazy contracting?
uterine hyperstimulation syndrome
Cervical position Cervical consistency Cervical effacement Cervical dilation Foetal station
…are all involved in what?
Bishop’s score
PCEDS
‘Third day blues’ or baby blues are common. How many mothers do they affect and how long last?
50%
7 days
(emotional lability)
3 risk factors for postnatal depression
social isolation
pregnancy complications
Hx depression
10% of women get postnatal depression but likely under-reported. Why?
stigma
denial by partner
fear of children being removed
3 red flags for postnatal depression.
- significant change in mental state
- new thoughts / acts of self-harm
- estrangement from infant / expressions of incompetency as mother
What must you rule out as a cause of postnatal depression?
postpartum thyroiditis
What scale used to assess postnatal depression?
Edinburgh Postnatal Depression Scale
New mother has had three months of tiredness, feeling of guilt and worthlessness which are affecting her bonding with her baby. What three forms of treatment might she benefit from.
social support
psychotherapy
ant-depressants if severe
If a woman is breastfeeding and needs anti-depressants, have to weigh up risks and benefits. Which two anti-depressants are likely to be most suitable?
paroxetine and sertraline (SSRIs)
Treatment for postnatal depression?
social support
psychotherapy
anti-depressants if severe
Sudden onset of psychotic symptoms around FOURTH day. (0.2% of women). What’s this?
puerperal psychosis
fourth day
Two risk factors for puerperal psychosis
prima gravida
Family Hx
previous puerperal psychosis (high recurrence)
Prima gravida who gave birth a week ago presents to GP with psychotic symptoms. Needs?
urgent assessment by specialist mental health services
You have to weight up risks and benefits of staying on psychiatric treatment in pregnancy. What is the risk of lithium in pregnancy?
congenital heart defects
Ebstein’s anomaly
new >140/90 at 20wks without proteinuria??
gestational hypertension
new >140/90 at 20wks WITH protineuria?
pre-eclampsia
hypertension before 20wks, then at 20wks new proteinuria. What’s this?
pre-eclampsia superimposed on chronic hypertension
features of pre-eclampsia + epileptform seizures = ?
eclampsia
define gestational hypertension.
new >140/90 at 20wks without proteinuria.
define pre-eclampsia
new >140/90 at 20wks with proteinuria.
define eclampsia.
features of pre-eclampsia + epileptiform seizures
define pre-eclampsia superimposed on chronic HTN
hypertension before 20wks, then at 20wks new onset proteinuria.
what is the pathophys of pre-eclampsia?
incomplete trophoblast invasion – endovascular remodelling – spiral artery flow REDUCTION – infl response - endothelial damage
- dodgy CLOTTING
- increased vascular PERMEABILITY
- VASOCONSTRICTION
in pre-eclampsia, incomplete trophoblast invasion – endovascular remodelling – spiral artery flow REDUCTION – infl response – ENDOTHELIAL DAMAGE, which leads to 3 things….
- dodgy CLOTTING
- increased vascular PERMEABILITY
- VASOCONSTRICTION
- dodgy CLOTTING
- increased vascular PERMEABILITY
- VASOCONSTRICTION
are three features of what?
pre-eclampsia
give me some RFs for pre-eclampsia
nulliparity Afro-Caribbean obesity diabetes renal disease
pre-eclampsia is usually asymptomatic! but it can present with… (x4)
headache
visual disturbance
epigastric pain
oedema
why do they get epigastric pain in pre-eclampsia
liver damage
right. in pre-eclampsia there’s three things about the urine. give me them :)
dipstick [>2 protein]
protein 24hr collection [0.3g/24hr]
protein:creatinine ratio [>30mg/mmol]
A lady who is 26 wks pregnant presents with headaches, epigastric pain, visual disturbance and oedema. You test her urine dipstick and the protein is >2. What other urine tests would you do and what results would you expect?
protein 24hr collection [0.3g/24hr]
protein:creatinine ratio [>30mg/mmol]
protein: creatinine ratio in pre-eclampsia is >30. what units??
> 30mg/mmol
protein 24hr collection in pre-eclampsia is >0.3. what unirs?
0.3g/24hr
in pre-eclampsia you test the urine dipstick protein, protein 24hr collection, and protein:creatinine ratio. What other investigations would you want to monitor?
BP, urine output!
FBC, U+Es, LFTs
foetal surveillance.
2 differentials for pre-eclampsia
haemolytic uraemic syndrome
acute fatty liver of pregnancy
what are the three broad elements of pre-eclampsia management?
treat HTN
prevent eclampsia
delivery
talk me through the treatment of pre-eclampsia
oral nifedipine or IV labetalol
Mg sulfate
induce @37wks
give IM dexamethasone to promote surfactant production before when?
34wks
why would fluid restrict in pre-eclampsia?
prevent pulm oedema
what is HELLP?
haemolysis
elevated liver enzymes
low platelets
5 MATERNAL complications of pre-eclampsia?
eclampsia HELLLP DIC! pulm oedema liver failure, renal failure
why have you to be careful with Mg sulfate in renal impairment?
toxicity
pulm oedema, liver failure, renal failure and DIC are all complications of …
pre-eclampsia
also eclampsia and HELLP
3 FOETAL complications of pre-eclampsia?
IUGR
preterm birth
placental abruption
IUGR, preterm birth and placental abruption are all foetal complications of………
pre-eclampsia
