High Yield Obs and Gynae Flashcards
Risk factors for ectopic pregnancy?
damage to tubes (salpingitis, surgery)
previous ectopic
IVF (3% of pregnancies are ectopic)
What is placental abruption? Key clinical features?
Placental abruption is separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space
Clinical features:
shock out of keeping with visible blood loss
constant pain
tender, tense uterus
normal lie and presentation
fetal heart: absent/distressed
coagulation problems
Alpha-fetoprotein (AFP) is a protein produced by the developing fetus.
Give some causes of a raised AFP
Neural tube defects (meningocele, myelomeningocele and anencephaly)
Abdominal wall defects (omphalocele and gastroschisis)
Multiple pregnancy
Give some causes of a low AFP
Down’s syndrome
Trisomy 18
Maternal diabetes mellitus
How does placenta praevia present?
shock in proportion to visible loss
no pain , uterus not tender
lie and presentation may be abnormal
fetal heart usually normal
coagulation problems rare , small bleeds before large
Define antepartum haemorrhage
bleeding after 24 weeks
What are the main risk factors for breech presentation?
uterine malformations, fibroids
placenta praevia
polyhydramnios or oligohydramnios
fetal abnormality
prematurity
How should breech presentations be managed?
if < 36 weeks: many fetuses will turn spontaneously
> 36 weeks (or 37 weeks if multiparous) :external cephalic version (ECV)
if the baby is still breech then delivery options include planned caesarean section or vaginal delivery
What are the contraindications to ECV (pressure applied to abdomen to try and turn the baby)?
where caesarean delivery is required
antepartum haemorrhage within the last 7 days
abnormal cardiotocography
major uterine anomaly
ruptured membranes
multiple pregnancy
What are Category 1 C sections?
an immediate threat to the life of the mother or baby
examples indications include: suspected uterine rupture, major placental abruption, cord prolapse, fetal hypoxia or persistent fetal bradycardia
delivery of the baby should occur within 30 minutes of making the decision
What are Category 2 C sections?
maternal or fetal compromise which is not immediately life-threatening
delivery of the baby should occur within 75 minutes of making the decision
What are Category 3 and 4 C sections?
3 = delivery is required, but mother and baby are stable
4 = elective
What is normal fetal heart rate?
100-160 / min
What is fetal baseline bradycardia?
Heart rate < 100 /min
Causes: Increased fetal vagal tone, maternal beta-blocker use
What is fetal baseline tachycardia?
Heart rate > 160 /min
Causes: Maternal pyrexia, chorioamnionitis, hypoxia, prematurity
What are early decelerations?
Deceleration of the heart rate which commences with the onset of a contraction and returns to normal on completion of the contraction
Usually indicates head compression
What are late decelerations?
Deceleration of the heart rate which lags the onset of a contraction and does not return to normal until after 30 seconds following the end of the contraction
Indicates fetal distress e.g. asphyxia or placental insufficiency
What are variable decelerations?
Independent of contractions
May indicate cord compression
How does Down’s syndrome present on the combined test?
↑ HCG, ↓ PAPP-A, thickened nuchal translucency
What is pre-eclampsia?
condition seen after 20 weeks gestation
triad:
pregnancy-induced hypertension (140/90)
proteinuria
oedema
eclampsia is pre-eclampsia + seizures
How should eclampsia be managed?
in eclampsia an IV bolus of magnesium sulphate (4g over 5-10 minutes) should be given followed by an infusion of 1g / hour
urine output, reflexes, respiratory rate and oxygen saturations should be monitored during tx
tx should continue for 24 hours after last seizure or delivery
What are the risks of sodium valproate and phenytoin in pregnancy?
sodium valproate: associated with neural tube defects
phenytoin: associated with cleft palate
How can neural tube defects be prevented during pregnancy?
all women should take 400mcg of folic acid until the 12th week of pregnancy
women at higher risk of conceiving a child with a NTD should take 5mg of folic acid from before conception until the 12th week of pregnancy
Which women should take more folic acid?
M = Metabolic conditions e.g. T1DM, coeliacs
O = Obesity (BMI>30)
R = Relative (PMHx)
E = epilepsy (on anti-epileptics)
Causes of placental abruption?
A = Abruption previously
B = Blood pressure (i.e. hypertension or pre-eclampsia)
R = Ruptured membranes, either premature or prolonged
U = Uterine injury (i.e. trauma to the abdomen);
P = Polyhydramnios
T = Twins or multiple gestation
I = Infection in the uterus, especially chorioamnionitis
O = Older age (over 35 years old)
N = Narcotic use
Give some risk factors for gestational diabetes
BMI of > 30 kg/m²
previous macrosomic baby weighing 4.5 kg or above
previous gestational diabetes
first-degree relative with diabetes
family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
What is used to screen for gestational diabetes?
OGTT
women who’ve previously had gestational diabetes: OGTT should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal
women with risk factors: 24-28 weeks
What is diagnostic for gestational diabetes?
fasting glucose is >= 5.6 mmol/L
2-hour glucose is >= 7.8 mmol/L
How should pre existing diabetes be managed in pregnancy?
weight loss for women with BMI of > 27 kg/m2
stop oral hypoglycaemic agents (bar metformin) and commence insulin, ensure tight glycaemic control
folic acid 5 mg/day from pre-conception to 12 weeks gestation
detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts
treat retinopathy as can worsen during pregnancy
Benzylpenicillin is the antibiotic of choice for Group B Strep intrapartum antibiotic prophylaxis (IAP). Who should be offered it?
women with a previous baby with GBS disease
women in preterm labour
women with a pyrexia during labour (>38ºC)
women who’ve had GBS detected in a previous pregnancy should be offered (IAP) OR testing in late pregnancy and then antibiotics if still positive
What is HELLP syndrome? How should it be managed?
Hemolysis, Elevated Liver enzymes, and a Low Platelet count
Features:
nausea & vomiting
right upper quadrant pain
lethargy
Mx = delivery of the baby
What modes of delivery are available to mothers with HIV?
vaginal delivery is recommended if viral load is less than 50 copies/ml at 36 weeks, otherwise caesarian section is recommended
a zidovudine infusion should be started four hours before beginning the caesarean section
What neonatal antiretroviral therapy is offered to babies of mothers with HIV?
zidovudine orally if maternal viral load is <50 copies/ml
Otherwise triple ART should be used
Therapy should be continued for 4-6 weeks
Define hypertension in pregnancy
systolic > 140 mmHg or diastolic > 90 mmHg
or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic
Indications for induction of labour?
prolonged pregnancy, e.g. 1-2 weeks after the estimated date of delivery
prelabour premature rupture of the membranes
maternal medical problems
intrauterine fetal death
How can the Bishop Score be interpreted?
a score of < 5 = labour is unlikely to start without induction
a score of ≥ 8 = cervix is ripe, or ‘favourable’ - high chance of spontaneous labour, or response to interventions made to induce labour
What is the NICE guidance on methods used to induce labour?
if the Bishop score is ≤ 6:
vaginal prostaglandins or oral misoprostol
(balloon catheter can be considered if the woman is at higher risk of hyperstimulation or has had a previous caesarean)
if the Bishop score is > 6:
amniotomy and an intravenous oxytocin infusion
How should intrahepatic cholestasis of pregnancy be managed?
induction of labour at 37-38 weeks and ursodeoxycholic acid - both widely used but evidence base not clear
vitamin K supplementation
What monitoring should be provided in labour?
FHR monitored every 15min (or continuously via CTG)
Contractions assessed every 30min
Maternal pulse rate assessed every 60min
Every 4 hours:
Maternal BP and temp
VE should be offered
Maternal urine should be checked for ketones and protein
How should pre-eclampsia be managed?
arrange emergency secondary care assessment
oral labetalol is first-line, nifedipine (e.g. if asthmatic) and hydralazine may also be used
women with blood pressure ≥ 160/110 mmHg are likely to be admitted and observed
How should antepartum haemorrhage be investigated?
FBC
Clotting profile, Group and Save & Cross-match
Kleihauer test if the woman is Rhesus negative (to determine the amount of feto-maternal haemorrhage and thus the dose of Anti-D required)
U&Es and LFTs
to exclude pre-eclampsia and HELLP syndrome, and any other organ dysfunction
Assess Fetal Wellbeing using CTG in women above 26 weeks gestation
What are the fetal complications of GD?
Macrosomia – this can cause complications during labour, such as shoulder dystocia, obstructed/delayed labour, and/or higher rates of instrumental deliveries
Organomegaly (particularly cardiomegaly)
Erythropoiesis (resulting in polycythaemia)
Polyhydramnios
Increased rates of pre-term delivery
Complications of obstetric cholestasis?
maternal - increased risk of gallstones and liver disease
fetal - increased risk of passing meconium during labour, prematurity and stillbirth
Give some maternal complications of APH
anaemia
coagulopathy
maternal shock
infection
renal tubular necrosis
prolonged hospital stay
psychological sequelae
Give some fetal complications of APH
hypoxia
SGA and growth restriction
prematurity
fetal death
How can perineal tears be classified?
first degree:
superficial damage with no muscle involvement
do not require any repair
second degree:
injury to the perineal muscle, not involving the anal sphincter
require suturing on the ward
third degree:
injury to perineum involving the anal sphincter
require repair in theatre
fourth degree:
injury to perineum involving the anal sphincter and rectal mucosa
require repair in theatre
Risk factors for perineal tears?
primigravida
large babies
precipitant labour
shoulder dystocia
forceps delivery
What is placenta accreta? Risk factors?
attachment of the placenta to the myometrium, due to a defective decidua basalis
= inc risk of PPH
Risk factors:
previous caesarean section
placenta praevia
What is placenta praevia? How can it be graded?
placenta lying wholly or partly in the lower uterine segment
I - placenta reaches lower segment but not the internal os
II - placenta reaches internal os but doesn’t cover it
III - placenta covers the internal os before dilation but not when dilated
IV (‘major’) - placenta completely covers the internal os
What are the risk factors for placenta praevia?
Maternal age >40 years
Previous C section
Multiparity
Multiple pregnancy
Previous placenta praevia
History of uterine infection (endometritis)
Curettage to the endometrium after miscarriage or termination
Mx of placenta praevia with bleeding?
admit
ABC approach to stabilise the woman
if not able to stabilise → emergency caesarean section
if in labour or term reached → emergency caesarean section
in all cases of antepartum haemorrhage, give anti-D within 72 hours of the onset of bleeding if the woman is rhesus D negative
How should placental abruption be managed?
no fetal distress:
< 36 weeks = observe closely, steroids
> 36 weeks = deliver vaginally
fetal distress: immediate caesarean
fetus dead : induce vaginal delivery
Complications of placental abruption?
Maternal:
shock
DIC
renal failure
PPH
Fetal:
IUGR
hypoxia
death
Postpartum haemorrhage (PPH) is defined as blood loss of > 500 ml after a vaginal delivery or 1000ml blood loss after C section.
What are the causes of primary PPH?
Tone (uterine atony - failure of adequate contractions): the vast majority of cases
Trauma (e.g. perineal tear)
Tissue (retained placenta)
Thrombin (e.g. clotting/bleeding disorder)
Give some risk factors for primary PPH
previous PPH
pre-eclampsia
polyhydramnios
prolonged labour
placenta praevia, placenta accreta
macrosomia
increased maternal age
emergency Caesarean section
What is classed as minor v major PPH?
minor is under 1000ml blood loss
major is over 1000ml blood loss
How should PPH be managed?
escalate to senior staff members immediately
STABILISE:
two peripheral cannulae (14G), bloods including group and save
lie the woman flat
commence warmed crystalloid infusion
MECHANICAL:
palpate the uterine fundus and rub it to stimulate contractions
catheterisation to prevent bladder distension and monitor urine output
MEDICAL:
IV oxytocin (slow IV injection followed by an IV infusion) , ergometrine , carboprost IM (unless there is a history of asthma) , misoprostol sublingual
SURGICAL:
intrauterine balloon tamponade where uterine atony main cause of haemorrhage
other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
hysterectomy is sometimes performed as a life-saving procedure
Postpartum mental health problems range from the ‘baby-blues’ to puerperal psychosis.
What score can be used to screen for this?
The Edinburgh Postnatal Depression Scale
maximum score of 30
score > 13 indicates a ‘depressive illness of varying severity’
What are the potential complications of pre-eclampsia?
progression to eclampsia
altered mental status, blindness, stroke, clonus, severe headaches
liver involvement (elevated transaminases)
haemorrhage: placental abruption, intra-abdominal, intra-cerebral
cardiac failure
fetal complications (intrauterine growth retardation, prematurity)
What preventative tx can be given to women at moderate or high risk of developing pre-eclampsia?
aspirin 75-150mg daily from 12 weeks gestation until the birth
Acute fatty liver of pregnancy is rare complication which may occur in the third trimester or the period immediately following delivery.
How does it present?
headache
abdominal pain, N+V
jaundice
hypoglycaemia
severe disease may result in pre-eclampsia
ALT raised on investigation
Risks of smoking in pregnancy?
Increased risk of miscarriage, pre-term labour and stillbirth
IUGR
Increased risk of sudden unexpected death in infancy
What are the risks of premature delivery?
intraventricular haemorrhage (brain bleed)
retinopathy of prematurity
hearing problems
respiratory distress syndrome
necrotizing enterocolitis (inflamed SI)
chronic lung disease, hypothermia, feeding problems, infection, jaundice
How should PPROM be managed?
admission
regular observations to ensure chorioamnionitis is not developing
oral erythromycin should be given for 10 days
antenatal corticosteroids
Puerperal pyrexia may be defined as a temperature of > 38ºC in the first 14 days following delivery.
What are the main causes?
endometritis: most common cause
UTI
wound infections (perineal tears + caesarean section)
mastitis
venous thromboembolism
How should endometritis be managed?
patient should be referred to hospital for intravenous antibiotics (clindamycin and gentamicin until afebrile for greater than 24 hours)
How should shoulder dystocia be managed?
McRoberts’ manoeuvre should be performed:
this manoeuvre entails flexion and abduction of the maternal hips, bringing the mother’s thighs towards her abdomen
A nuchal US scan is performed at 11-13 weeks.
Causes of an increased nuchal translucency include:
Down’s syndrome
congenital heart defects
abdominal wall defects
Umbilical cord prolapse involves the umbilical cord descending ahead of the presenting part of the fetus. Left untreated, this can lead to compression of the cord or cord spasm, which can cause fetal hypoxia.
What are the main risk factors?
prematurity
polyhydramnios
multiparity
multiple pregnancy
cephalopelvic disproportion
abnormal presentations e.g. Breech, transverse lie
50% of cord prolapse occurs after artificial rupture of membranes
How should cord prolapse be managed?
the presenting part of the fetus may be pushed back into the uterus to avoid compression
if the cord is past the level of the introitus, there should be minimal handling and it should be kept warm and moist to avoid vasospasm
the patient is asked to go on ‘all fours’ until emergency C section
tocolytics may be used to reduce uterine contractions (e.g. terbutaline)
What is the most common explanation for short episodes (< 40 minutes) of decreased variability on CTG?
foetus is asleep
If after 28/40 weeks, if a woman reports reduced fetal movements and no heart is detected with handheld Doppler, what should be offered?
immediate USS
Management of patients on methotrexate trying to conceive?
must be stopped at least 6 months before conception in both men and women
Down’s syndrome: quadruple test result?
↓ AFP
↓ oestriol
↑ hCG
↑ inhibin A
When is the booking visit?
8 - 12 weeks (ideally < 10 weeks)
Test results for molar pregnancy?
High beta hCG, low TSH, high thyroxine
(imagine beta HCG acts like TSH)
Risk factors for pre-eclampsia?
40 years or older
Nulliparity
Pregnancy interval of more than 10 years
FMH/PMH of pre-eclampsia
BMI > 30
Pre-existing vascular disease/ renal disease
Multiple pregnancy
Indications for continuous CTG monitoring in labour?
suspected chorioamnionitis or sepsis, or a temperature of 38°C or above
severe hypertension 160/110 mmHg or above
oxytocin use
the presence of significant meconium
fresh vaginal bleeding that develops in labour
