HD2 Revision 3 Flashcards
Name 4 complications of forceps delivery
Ranges from bruising and marks on the skin to squashing and crushing of skull and brain
Cephalohematoma 9%
Retinal hemorrhage 30%
Skull fracture
Permanent nerve / brain damage
Complications of ventouse delivery to baby? [4]
Bruising and laceration of the face and injury to fetal scalp and skull
Scalp abrasion/laceration 13%
Scalp necrosis 1.5%
Cephalohematoma 25%
Intracranial hemorrhage 2.5%
Retinal hemorrhage 50%
Explain the significance and causes of acceleration and early deceleration in Cardiotocography [2]
Acceleration:
- Sympathetic activation in response to fetal movement or scalp stimulation. Baby is moving around in the uterus / cervix. Normal
Early deceleration:
- Parasympathetic response to head compression
- Fetal HR decreases BEFORE contractions: normal
Strategies that may help with during episodes of non-reassuring fetal statusinclude [5]
- Changing the mother’s position
- Increasing maternal hydration
- Maintaining oxygenation for the mother
- Amnioinfusion, where fluid is inserted into the amniotic cavity to relieve pressure on the umbilical cord
- Tocolysis, a temporary stoppage of contractions that can delay preterm labour
- Intravenous hypertonic dextrose – gives mother more energy
Explain manoeuvre used to fix shoulder dystopia? [1]
Whats are two other options? [2]
- McRoberts manoeuvrers tries to dislodge shoulder from being stuck on the pubis by pelvic symphysis orientated more horizontally to facilitate shoulder delivery
- Changing the mother’s position
- An episiotomy: surgical widening of the vagina, may be needed to make room for the shoulders
Possible complications of shoulder dystopia? [4]
- Fetal brachial plexus injury: Erb-Duchenne palsy - Single nerve stretching eg radial nerve
- Fetalfracture: Humerus or collar-bone break, which usually heal without problems
- Hypoxic-ischemic brain injury, or a low oxygen supply to the brain: Cerebral palsy
- Maternal complications include uterine, vaginal, cervical or rectal tearing and heavy bleeding after delivery
Explain the two phases of 2nd stage of labour [2]
- what position is the baby in the first part? [1]
-
2nd Stage - Fully dilated labour to delivery of baby:
- Propulsive / passive phase full dilation until the head reaches the pelvic floor. Head is typically high in pelvis, the head is occipitotransverse and mother has little urge to push
- Expulsive / active phase: fetal head reaches the pelvic floor: causes mother invol. desire to push
Explain 3rd stage of labour [1]
What does active managment of 3rd stage of labour decrease the risk of ? [1]
Which drug do you use for ^? [1]
Expulsion of placenta and membranes
Active management decreases risk of PPH - use oxytocin to stimulate placental delivery
How do you manage failure to progress:
- Initially? [1]
- If continued? [4]
- If still continued? [2]
How do you manage failure to progress:
- Initially: relax and wait
- If continued: givelabour-inducing medications: Oxytocin; misoprostal; mifepristone; oestrogen pessary
- If still not delivered: membrane sweep or c section
Underlying causes and conditionsthat cause fetal distress include? [5]
Insufficient oxygen levels
Maternal anemia
Pregnancy-inducedhypertensionin the mother
Intrauterine growth retardation (IUGR)
Meconium-stained (baby poo) amniotic fluid: baby drinks own amniotic fluid
Explain the significance and causes of variable decelerations and late deceleration in Cardiotocography [2]
Late deceleration:
* placenta is compressed and o2 to baby is compromised: causes vagal stimulation or myocardial depression
* Late and bradycardia: emergency C-section
variable decelerations:
- Abrupt decrease with rapid recovery from cord compression
- Looking at length of recovery of HR (as long as recovery is rapid, its fine)
- When contraction lessens is when HR should return to normal
Name the drugs used for Tocolysis (a temporary stoppage of contractions that can delay preterm labour) [5]
- nifedipine (calcium antagonist)
- atosiban: oxytocin receptor antagonists
- indomethacine NSAID: inhibitors of prostaglandin synthesis
- nitroglycerine: NO donors, Betamimetics (sympathetic beta agonsists)
- magnesium sulphate
Should dystocia: more likely to affect 1st or 2nd pregnancies? [1]
More likely to affect 1st pregnancies, and is responsible forhalf of allcaesarean deliveries in this group
CTG deceleration:
Abrupt decrease in baseline heart rate of >[] bpm for >[] seconds
Abrupt decrease in baseline heart rate of >15 bpm for >15 seconds
Explain potential complications of secondary perinatal apnea [3]
Not getting o2 in lungs and distributing surfactant.
Can lead to hypoxaemia: brain damage, heart damage and cause resp. acidosis.
Score system used to investigate perinatal asphyxia? [1]
What score would indicate [1]
APGAR score
Low score (0-3) for > 5 mins
What are the three types breech pregnancies?
Frank: Has most favourable outcomes for vaginal deliveries
Complete
Footing
What are the 4 types of placenta previa? [4]
Minor praevia, or grade I – the placenta is in the lower uterus but not reaching the internal cervical os
Marginal praevia, or grade II – the placenta is reaching, but not covering, the internal cervical os
Partial praevia, or grade III – the placenta is partially covering the internal cervical os
Complete praevia, or grade IV – the placenta is completely covering the internal cervical os
What type of delivery occurs if placenta previa occurs? [1]
What can plecenta previa increase risk of? [1]
Treatment of placenta previa? [1]
Placenta previa:
- C section only
- Increases the liklihood of placenta accreta (when placenta becomes inseperable from uterus
- Treat with blood transfuison
What are potential complications of uterine rupture to mother [3] & baby [3]
Baby:
* Oxygen deprivation of baby: C section required
* Aspiration of amniotic fluid
* Higher chance of infection if delivery takes place in an unsterile location
Mother:
* Mother XS bleeding
* postpartum shock
* Increases risk of tearing and laceration to the cervix and vagina
Describe the two types of precipitous labour
1st is when it starts in the 1st stage of labour: lot of super intense contractions
2nd starts in the 2nd stage of labour: 2nd stage is “pushing stage”
Risk of precipitous labour? [1]
Uterus may become hypotonic - increase liklihood of PPH.
What is this type of primary PPH surgical treatment called? [1]
B-lynch
What is this type of primary PPH treatment called? [1]
Bakri balloon
What can delay uterine involution? [5]
Full bladder
Loaded rectum
Uterine infection like endometritis or parametritis (CT around uterus)
Retained products of conception: placenta
Fibroids
Broad ligament hematoma
Explain MoA causing PPH
Normally:
* contraction of the uterus in the third stage of labour causes compression of intramyometrial blood vessels,
* Stops bleeding
Postpartum hemorrhage:
* uterine atony: compression of vessels does NOT occur. Atony can occur following delivery of the placenta, or when part of the placenta is retained.
* Brisk venous bleeding
What are 4 causes of PPH? [4]
4Ts:
T – Tone (uterine atony – the most common cause)
T – Trauma (e.g. perineal tear)
T – Tissue (retained placenta)
T – Thrombin (bleeding disorder)
What is difference between primary and secondary PPH? [2]
What are primary [4] and secondary [2] PPH associated with?
Primary PPH: bleeding within 24 hours of birth:
- Polyhydamnios
- Macrocosmic fetus
- Uterus overstretched
- Multifetal preg.
Secondary PPH: from 24 hours to 12 weeks after birth:
- Infection
- Retained products of conception
Treatment of Primary PPH?
- Massage? [1]
- Drugs? [2]
- Surgery? [4]
Massage:
* Bimanual uterine massage and compression (one hand in vagina, pushing agaisnt the body of the uterus & the other hand compresses fundus from abdomen. Causes the uterus to contract)
Drugs: causes myometrium to contract – normal functioning
* Oxytocin agents
* prostaglandins
Surgery:
* suture tears:
- Bakri balloon: takes up 300ml of saline and is placed in the uterus, completely clear of the internal cervical os. Assisted by uterotonics, the balloon in the uterus will be hugged by the contracting uterus and drain blood out.
- B-lynch:hold uterus tight via stitching from anterior - posterior surface. Maintains compression
- uterine artery embolisation:: femoral artery –> internal iliac -> uterine artery: close artery
Future treatment for Secondary PPM? [1]
Tranexamic acid
Explain MoA of Tranexamic acid for PPH
Analogue of lysine
Binds to plasminogen and stops conversion of plasmin: causes bigger clots to form
What is a positive Homon’s sign for investigating thromboembolic disease? [1]
Positive Homon’s sign: Pain with forced dorsiflexion of the foot
Difference in timing between postpartum affective instability (baby blues) and post natal depression?
Baby blues:
- Symptoms peak on 4th or 5th day after delivery and usually last for the first 2-weeks postpartum
Postnatal depression:
- 2 weeks till a year postpartum
- Worse symptoms
Which screening scale is used for post natal depression? [1]
What score requires further evaluation? [1]
Edinburgh Postnatal Depression Scale (EPDS):
* 0 item, self-rated questionnaire used extensively for detection of postpartum depression
* Score of 10 or more on EPDS or an affirmative answer on question 10 requires further evaluation
* Presentation is clinically indistinguishable from major depression
Which drugs are used to treat PPH? [5]
Oxytocin (slow injection followed by continuous infusion)
Ergometrine (intravenous or intramuscular) stimulates smooth muscle contraction (contraindicated in hypertension)
Carboprost (intramuscular) is a prostaglandin analogue and stimulates uterine contraction (caution in asthma)
Misoprostol (sublingual) is also a prostaglandin analogue and stimulates uterine contraction
Tranexamic acid (intravenous) is an antifibrinolytic that reduces bleeding
Explain the hormonal causes of postnatal depression? [1]
- Oestrogen, progesterone and cortisol fall to zero dramatically within 48hrs of delivery. BUT this happens to all mothers. SO Women with postpartum depression express different transcripts associated with oestrogen and or progesterone metabolism
Which drugs are used as pharmalogical therapy for post natal depression? [4]
SSRIs: Selective serotonin reuptake inhibitors:
* Citalopram (SSRI)
* Sertraline (SSRI)
(SNRI) serotonin-noradrenaline reuptake inhibitor:
* Duloxetine (SNRI)
TCA: Tricyclic antidepressants
* Nortriptyline
What is the name of the progesterone metabolite important in PPD and which receptor does it work on? [2]
Progesterone metabolite allopregnanolone (ALLO) is a involved with GABA receptor and is a neurosteroidal transmitter
Without antidepressants - what can you give to reduce the number of PPD symptoms? [1]
Progesterone
How do oestrogen levels change after birth? [1]
Why reduced levels of oestrogen affect which NT in PPD? / Why is giving it good? [1]
The change of what family of enzymes alter oestroen levels after delivery? [1]
What do have to be careful with oestrogen therapy? [1]
Oestrogen levels acutely fall
Oestrogen gives rise to increased serotonin
Monoamine oxidases (family of enzymes) rise after birth till day 4-6: causes oestrogen levels to be depressed (and therefore depressive symptoms)
Oestrogen therapy has a bell curve effect (bad at extreme high / lows)
Describe the non-hormonal causes of PPD? [2]
Physcosocial factors (no consistent obstetric factors - to do wtih the surrounding environment)
Biological vulnerability (previous history of depression / Fx / history of antenatal depression / previous Hx of PPD: 90% recurrence)
- Gestational diabetes indepedently associated with increased PPD
- Not breastfeeding baby
- Sleep disturbance (treatment of insomnia in 3rd trimester - reduces the risk)
What tests would you do to exclude a medical cause for mood distubance? [2]
Thyroid dysfunction
Anaemia
Explain why giving oestrogen alone / in combination w/ antidepressants is beneficial for PPD [1]
Breast feeding surpresses the start of menstruation - so oestrogen levels are also depressed
Which anxiolytics may be recommended as an adjunctive treatment for PPD? [2]
Explain MoA [1]
Lorazepam and clonazepam
GABA benzodiazepines (enhances GABA activity)
What is brexanolone aka? [1]
What is MoA? [1]
allopregnanlone (a progesterone metabolite)
- Modulates synaptic GABA-receptors and extrasynaptic GABA-A receptors: (GABA is an inhibitory receptor)
- Allows GABA that binds to receptor to have a bigger effect on the GABA receptor Makes patients feel open and feeling of relaxtion
Which of the following does not cause nausea in mother?
fluoxetine
sertraline
citalopram
nortriptyline
duloxetine
Which of the following does not cause nausea in mother?
fluoxetine
sertraline
citalopram
nortriptyline
duloxetine
Which of the following has a possible risk of growth retardation in chiild?
fluoxetine
sertraline
citalopram
nortriptyline
duloxetine
Which of the following has a possible risk of growth retardation in chiild?
fluoxetine
sertraline
citalopram
nortriptyline
duloxetine
Which of the following has a possible risk of omphalocele and heart septal defects for fetus / neonate??
fluoxetine
sertraline
citalopram
nortriptyline
duloxetine
Which of the following has a possible risk of omphalocele and heart septal defects for fetus / neonate??
fluoxetine
sertraline
citalopram
nortriptyline
duloxetine
Which of the following has a possible risk of tachycardia and urinary retention in neonate and fetus?
fluoxetine
sertraline
citalopram
nortriptyline
duloxetine
Which of the following has a possible risk of tachycardia and urinary retention in neonate and fetus?
fluoxetine
sertraline
citalopram
nortriptyline
duloxetine
How do you treat postnatal psychosis? [3]
Mood stabilizer: (lithium, valproic acid and carbamazepine)
In combination with antipsychotic medications and benzodiazepines
electroconvulsive therapy is well tolerated and rapidly effective
Which drugs prescribed should women avoid breastfeeding [2] (and why) [1]
valproic acid and carbamazepine should avoid breastfeeding
Linked to hepatotoxicity in the infant
Why should you monitor affect of mood stabiliser lithium? [2]
Can be toxic and if breastfeed monitor levels of lithium and thyroid function
Explain how anti-psyc. drugs can lead to hyperprolactinemia
Anti-psychotic drugs work by inhibiting dopamine release
Dopamine inhibits prolactin release: reduced dopamine causes hyperprolactinemia (increased breast milk - can cause pain)
What can you give to prevent PPD in pregnancy? [1]
Omega-3 (fish oil etc)
Describe pathophysilogy of pre-menstrual dysphoric disorder (PMDD)
What is used to treat? [1]
Symptoms start at late luteal phase: corpus luteum is shutting down and you lose progesterone
Ends soon after menstruation starts
Use ALLO to treat
Question 1 of 3
How is a post-partum haemorrhage defined?
Loss of >500ml blood within 12 hours of delivery
Loss of >500ml blood within 24 hours of delivery
Loss of >1L blood within 12 hours of delivery
Loss of >1L blood within 24 hours of delivery
Question 1 of 3
How is a post-partum haemorrhage defined?
Loss of >500ml blood within 12 hours of delivery
Loss of >500ml blood within 24 hours of delivery
Loss of >1L blood within 12 hours of delivery
Loss of >1L blood within 24 hours of delivery
All of the following drugs are used in the management of primary PPH. Which one is a oxytocin analogue?
Ergometrine
Carboprost
Syntocinon
Misoprostol
All of the following drugs are used in the management of primary PPH. Which one is a oxytocin analogue?
Ergometrine
Carboprost
Syntocinon
Misoprostol
What is the name for this sign / test? [1]
What would a positive sign indicate? [1]
Homon sign
Positive sign indicates DVT / thromboemolic disease
