Intro Flashcards
antal fødsler årligt i DK?
60.000
I hvilken uge er “survival weeks”
24 uger, her er overlevelsesraten 24%
Hvor mange kvinder udvikler graviditetsdiabetes
2-4% for graviditetsdiabetes
Hvor mange kvinder udvikler svangerskabsforgiftning
Svangerskabsforgiftning 2-4%
TIlhører placenta barnet eller moderen og hvorfor er det relevant?
Placenta bærer barnets kromosomer, og placenta er derfor noget fetus udvikler for at sikre overlevelse
Hvor meget vejer en nyfødt og en placenta
1/6 af barnets vægt, som ofte er ca. 3500 gram
The three major diseases entitities in obstetrics
- pre elcampsi
- fetal growth retardation (22% or less)
- preterm delivery (preterm and extreme preterm)
Hvad udveskles mellem mmoder og fetus
from mother to fetus
- nutrients
- minerals (iron)
from fetus to mother
- CO2
- waste products
Syncytiotrophoblaster proces what?
- hormoner
- ## DNA
Karakteriser placenta funktioner og vækst
- connection mellem moder og barn
- filter, cleaning, exchange regulation
- producerer mange hormoner
- founded around 6-8 uger
- primarily grows from week 20 onwards
- influences maternal metabolism –> GDM (gestitionel diabetes)
- perfused with 600-800 ml pr min ved fødselstidspunktet
Opdel placenter i trimestre
- op til (12-14)
- organonesis
- legal abortion - op til (XX)
- fetal growth
- survival becomes possible - op til (xx)
- fetal growth
Placentas anatomical issues
Placental malformations
- Tumors
- cancer like growth: mola, invasive mola, choriocarcinoma
- locally invasive growth - usually after C-section
fx by growing into the myometrium or into nabour organs
Types: accrete placenta, increte placenta, percrete placenta –> bleeding problems
Problems with accrete placenta and treatment
BLEEDING, up to 20 liters
- surgical treatment: B-lynch, vascular procedures, hysterectomi, removal of involved organs ie the bladder
Risk factors for accrete placenta
- previous surgery in the placenta
- resection of fibroma
- previous C-section
Hormones produces by the placenta
- østrogen (E2)
- progesteron
- human placenta lactogen (hPl)
- hCG
- hPGH (human placenta growth hormone)
- many more
Why do they develope GDM
Insulin resistance developes for all women during pregnancy
- makes pregnant woman a bit diabetic
- mainly from week 20
- ensures higher level of blood glucose –> as to make the fetus extract glucose
which hormone or substance: unknown
Beskriv kvinder med DM1 som bliver gravide
All receive insulin before preganacy. Around week 19-20 the insulin dosis requirements increases and hits 70% by week 33 and therefore all women af insulin resistant in the last week of pregnancy.
The blood glucose level reaches higher levels and steaper curves and to compensate for that the insulin production increases –> the insulin production is too much for the level of glucose and the fetus will extract the glucose from the blood –> more insulin are produces to compensate –> all women develops a degree of diabetes due to this compensation
Beskriv kort preeclampsia
2-7% of all pregnancies
Elevated blood pressure (>140/90) and proteinuri (or severe IUGR or severe maternal symptoms or.. sign of end organ damage!)
Rarely before week 22
Causes disturbances in the blood thrombotic/hæmostatic balance –> thrombosis –> organ affection (liver, brain, kidneys (proteinuria)) –> Ecalmpsia (fits, convulsions) due to thromber
Deadthly in less developed contries
Etiology: placenta! (paternal influence, ie immunerelated disorder where the mothers immunesystem reacts to the paternal antigenes) - affects the vessels of the placenta to contract and the mothers BP raises in compensation
The treatment is delivery of the placenta (and fetus)
Symptoms and findings of eclampsia
- elevated BP + proteinuria at a routine exam (screening!)
- rapid weight grain, oedema
- headache, visual distubances, oppressing sensation
- pain and discomfort located in the live area
- less fetal movements
Blood samples in case of preeclampsia
hæmoglobin, ALAT, LDH, creatinin, uric acid
–> due to hemolysis
Low platelet counts –> HELLP syndrome –> Hemolysis, Elevated Liver, Low Platelets
Complications later in life for GDM
High risk for developing DM2
Complication later in life for preeclampsia
High risk for hypertension and cardiovascular diseases
How is SGA defined
When the birthwegit is less than other newborns (less than 2.5%-10% depending on the country)
Define IUGR (intrauterin growth restriction)/ FGR (fetal growth restriction)
IUGR = FGR = when the fetus does not reach its genetic potential for growth
FGR is a continues thing while the SGA is a momental status
The two ways of being little
Genetic or pathological reasons
- SGA: the genetic trait
- IUGR: the pathological condition
Difficult to differentiate SGA from FGR
22% or less below the average of the gestational age
FGR etiology
- smoking
- syndromes, genetics
- infections
- elevated BP, preeclampsia
- maternal diseases (kidney disease, loss of protein, malabsorption, heart conditions and a low saturation,
- epigenetics
- unknown
The more the mother gains during the pregnancy, the larger the baby, especially lipids has an influence and at greenland/iceland, babies are bigger due to the intake of fish oils
What is essential when evaluating if the baby must be delivered
- flow! (can be measure in the umbilical cord, the head (middle cerebellar arteries) or the liver)
- biophysical profile (flows, movements, amniotic fluid)
Risk of repeated FGR pregnancy
20-30%
Depending on if it is isolated FGR or concurrent diseases
- preeaclempsia
- chromosomal abberations
- maternal diseases
hvad er cephalic presentation
Barnet der fødes i position med hovedet først
Benævn forløbet af en normal fødsel
- dilation and decent of the baby
- delivering of the baby
- delivering of the placenta
Present the stages of the birth
- stage (latent)
- dilation (until 10 cm) - stage (active)
- orificium 10 cm until birth of the child
- descent and pushing - stage
- delivering of the placenta (often delivered spontaneously in 15 min)
What to look for at the labor ward
- uterus, contractions
- fetal size, presentation (cephalic, ?), fetal heart rate
- vaginal examination (cervix length, position of the cervix, dilation of the orificium, leadnig part (head, butt,?), station (where in the pelvis), rotation of the head, membranes)
- partogram at “active labor”
- BP
Describe rotation of the baby during birth
looking at one side –> ending up looking at the mothers anal area (child stations of presentation video)
The posterior side are longer than the anterior??
Fingers above... \+3 = the level of the pelvic floor \+2 = the level behind spina ischadia \+1 = 0 = - 1 = -2 = mid pelvic level
What is progression in labour depending on
- power (contractions)
- passage (birth canal)
- passenger (fetus)
Why is birth a challenge for the baby
- reduced blood flow during contractions (lack of oxygen –> changes in fetal heart rate)
not a problem for a healthy fetus, but a problem in case of growth restriction
how to monitor fetal heart rate
- midwife stetoskope
- doppler UL
- EFM/CTG (high risk pregnancy, i.e. small baby, preeclampsia)
CTG = kardiotokografi
How to look at a EFM/CTG
top: fetal heart rate
bottom: contractions
look for:
- variability: small occilations
- de-/accelerations
how to reduce pain non-pharmacological
- antenatal classes for tecniques (fødselsforberedelse)
- hot water, shower, bath tub
- acupuncture
- water papules (bistik)
- massage
how to reduce pain pharmacological
Stage 1
- N2O (lattergas)
- morphine
- epidural (walking epidural)
- spinal analgesia
Stage 2
- pudendal block
- infiltration analgesia (suturing the damage in vagina/perineum)
Describe epidural side effects
- side effects: no or suboptimal effects, hypotension, fever, urinary retention, puncture of dura (spinal headache), infections in the back
pros: the most efficient
Precautions with epidural
- anticoagulant therapy (LMWH)
- preeclampsia
- thrombocytopenia
- septic infections
- local infections near point of placement
- high intracranial pressure??
how to score a new born
- APGAR: respiration, heart rate, color, tone, reflexes
0-2 point each, at max 10
What can cause a low APGAR score and what tests should be made?
- hypoxia
- sickness such as?
pH and SBE: a. umb. and v. umb
How long to wait for placenta delivery before manually removing it
60 minutes
Post partum observations
- uterus contractions
- bleeding (up to 500 ml)
- injuries, lacerations, haematomas,
- temperatures
- lactation
Devision among the fetal presentations
Normal
- cephalic (95%)
- occiput anterior (90%)
Abnormal (the fetus does not present as occiput anterior at term)
- abnormal cephalic presentation (occiput posterior “stjernekigger”)
- breech (legs/butt first)
- transverse/oblique
Deflexions: parietal, brow, face
Risk: prolonged labor/operative delivery
Desribe the breech presentation
4% at term
25% in week 30
Causes:
- FGR
- uterine anomaly
- oligo/poly hydraamnoin
- malformation of the fetus
- decreased muscle tone
Associated risk:
- perinatal mortality and morbiditet increased, independent of mode of delivery
- planned vignal delivery vs C-section – perinatal mortality and morbidty increased
- planned vaginal delivery on strict criteria
OBS hypoxia
Solution:
- try to turn the baby from gestational age 36 (success rate 40-50%)
The risk of this for acute C-section is <1%
What is the breech challenge
The largest part of the baby is delivered lastly –> arrest of the baby –> suffocation of the baby
What is the breech challenge
The largest part of the baby is delivered lastly –> arrest of the baby –> suffocation of the baby
Hence most babies in breech position is delivered by C-section
Which 2 types of women exists at the birth ward
nulliparae and multiparae
Causes of prolonges labour
Power
- dystocia (oxytocin might help)
Passeger
- mechanical disproportion (fetal magnus, abnormal presentation
Passage
- contracted pelvis (unusual in DK but is often due to malnutritun in 3. world countries)
Define prolonged labour
- stage
- a dilation less 2 cm over 4 hours (from 4-6 cm) - stage (descent)
- caput has not reached the pelvic floor in 3 hours - stage (pushing)
- the baby is not delivered in 2 hours
How to diagnose prolonged labour
Using a partogram with station of presenting part and orificium dilation (SE SLIDE OG EKSEMPEL)
Treatment of prolonged labour
power problem: labour augmentation oxytoscin
Passengar problem - operative delivert - vaginal or CS
How to decide is operative vaginal delivery is possible
Is a natural vaginal delivery possible?
- orificium is fully dilated
- hear beneath the interspinal level
Accept from the mother
Operative delivery by vacuum options
metal cup or silicone cup or foreceps
how to perform a cuum extraction
pull only during contraction
max 3-4 contraction / 10–15 min
Risk of shoulder dystocia and anal shincter rupture
STOP if the baby does not follow
Define shoulder dystocia
the anterior……..
risk factors for shoulder dystocia
big baby
maternal DM
prolonged labour
turtle sign
How to manage shoulder dystocia during labours
- get more space by moving the mother’s legs
- rotate
- diminish the size of the shoulders by compressing from the outside
- deliver the posterior arm first by catching it
Causes of maternal mortality
- severe bleeding
- obstructied labour
- infection
- unsafe abortion
- eclampsia
Where do women bleed from and what do the body do to compensate
placenta –> contraction of uterus (compression of vessels) and hypercoagulation
why do women bleed doo much
Atony (insufficient contraction) (70%)
lesions (20%)
retained tissue (10%)
coagulopati (1%)
(rarely because of lack of coagulation)
How much do they bleed
> 500 ml: 17 %
1000 ml: 6%
1500 ml: 3%
2000 ml: 2%
“2% bleeding more than 2 liters” –> transfusion!
Risk factors for bleeding
- gemelli (mere end én baby)
- placenta previa
- previous C-section
- para 6
- previous postpartum haemorrage
How to manage PPH
- prophylaxis for high risk patients: syntocinon (decreases bleeding by 60%)
- early diagnosis: measure the blood
- compress the uterus from the outside, bimanual compression, aorta compression, balloon compression
- medications i.v. (oxytocin, Metergin)
- trendelenburg
- O2
- transfusion (0 rh neg) or crystalloider –> blood-FFP-trombocytter –> if severe bleeding tranexamic acid and fibrinogen
- move to OP
WATCH FOR INCREASING PULSE RATE
OP options as treatment for bloodloss
- B-lynch (suture around the uterus) (risk of ischemia in the uretus afterwards)
- ligating aa uterina
- stepwise devasculation of the uterus
- ligating aa iliacae interna
- embolisation
- hysterectomi
Global challenges associated with C-sections
- maternal mortality
- adaopting western principles
- TOL after CS-risk (scar will detach)
- many children
What is the C-section frequency
20% in DK, 15% world wide
Indications for CS (fetal)
planned: FGR/placental insufficiens, transverse/breech presentation
acute: hypoxia (CTG, pH, lactate), prolapse umbilical cord, placental abruption, uterine rupture
Indications for CS (maternal)
Prior to labour:
- severe preeclampsia
- placenta previa
- previous uterine operation
- CS >1
During labour:
- dystocia
- disproportion
- maternal request (often due to a complicated first delivery or a previous CS)
Maternal complications to CS (acute)
- mortality <1 pr year in DK
- reoperation because of bleeding <1%
- venous thrombosis <1%
- organ lesion (bladder/ intestines) <1%
- infections incl. UTI 10%
- wound infections 2%
- uterine rupture in the next labour 0,5%
Maternal complications to CS (long term)
- adhesions
- placenta previa
- placenta accreta/percreta (placenta forløser sig ikke korrect og kan vokse ind i omkringliggende væv)
- pregnancy implantation in CS scar
- endometriosis
Fetal complications to CS
- no rise in level of catecholamines (som hjælper respirationen og at presse væske ud af lungerne) —> respiratory problems –> CPAP
- no contact with bacteria from the maternaI GI tract –> influence on immune system are unclear
Which week is the most optimal for a CS
week 39
Analgesia for CS
Spinal - epidural
- safest and the mother experiences to give birth
GA
- risk of aspiration and risk in case of AK-treatment
Why dont we like to put pregnant women in GA
Big abdomen and never have an empty stomach –> aspiration
Describe uterine rupture (incidence, preparations and warning signs)
incidence 0,5%
TOL after CS demands: an organisation ready to act immediately, informed consent, intensive monitoreirn of mother and fetus
warning signs: CTG changes(!!!), pain, sudden dissapearance of contractions, ……. (SE SLIDE)
What is the incidence of PPH > 1 liter
6-9%
Anovulation, infertilitet og blødningsforstyrrelser skyldes enten…
Abnorm FSH/LH sekretion eller ovarial defekt med abnorm dannelse af modne follikler
Hvilket hormon måles som markør for den reproduktive alder og bruges i forbindelse med fertilitetsbehandling
Antimüllersk hormon (AMH)
Meget lavt ved kvinder som har ophørt eller reduceret ovariefunktion og højt hos ptt med PCOS
Symptomer på PCOS
Anovulation med oligomenore eller amenore, hirsutisme, acne og sebore. Ofte overvægt.
Diagnostiske kriterier ved PCOS
Rotterdam kriterierne:
- Oligo- eller anovulation
- Klinisk eller biokemisk tegn på hyperandrogenæmi
- Polycystiske ovarier
Factors affecting lung deposition in asthma
- compliance
- particle size
- speed of inspiration
- integrity of airways
- proper inhaled device technique
Diff til astma
- CF
- kronisk atelektase
- vocale cord dysfunction
- tumor/granulomer i lungerne pga kompression
- non-CF bronkoektasi
- kroniske lungesygdomme hos børn (interstitielle lungesygdomme, emfysem, allergisk alveolitis, postinfektiøst bronkiolitis, pulmonal hemosiderosis,
- neonatale pulmonale sygdomme (kongenitale malformationer, bronkopulmonaldysplasi)
- primær immundefekt
- andre øvre luftvejs sygdomme
Anamnese ved mistanke om artritis hos børn
Diurnal variation
- morning stifness
- day to day variation
- pain (during rest? when active? sudden movement?, minor trauma?)
- decreased insurance (need for rest)
Any changes observed?
- swollen joint?
- awareness of joint?
- redness?
Redness of joint
- septisk arthritis
- reactive arthritis
- familiar Mediterranean fever
- systemtisk JIA
Hyppigste reumatiske sygdomme i barndommen
- Autoimmune sygdomme (SLE, juvenil dermatomyositis, sclerodermi)
- Juvenil idiopatisk artritis (HYPPIGST)
- Pain syndromes
- Vasculitis (henoch schønlein purpura, kawasaki, GPA, MPA)
- Autoinflammation (monogenic fever syndromes)
- Knoglesygdomme (kroniske non-infektion, osteomyelitis)
Diff diagnoser for JIA
- infektiøs artritis (aureus, h influenzae, borreliosis)
- postinfektiøs artritis (prygenes, campylobacter, coxitis simplex)
- autoimmune sygdomme (SLE, juvenil dermatomyositis)
- vasculitis (Kawasaki, henoch-schønlein purpura, Wegener)
- orthopediske (calve-perthes sygdom, epifysiolysis)
- non-inflammatoriske (growing pain, hypermibilitet)
- malignitet (leukæmi , neuroblastom, knogletumor)
- haematologiske (hæmofili, thalassæmi, seglcelleanæmi)
- andre (sarcoidosis, familiær Mediterranean fever, reumatisk feber)
Hvad kan ses på røntgen af ektremiteter ved leukæmi
Leuchemic bands ved epifyseskiverne
Hvor mange subkategorier inddeles JIA i
7
- oligo (1-4 joints) (50%)
- poly (>5 joints) (20%)
- systemtisk (m feber) (15%)
- psoriasis artitis (10%)
- enthesitis related (10%)
- unidentified (10%)
Symptomer på systemisk JIA
- quotidian feber >14 dage (sav-takket temperaturkurve, max 39C)
- fluctuating macular exanthema
- genelized lymphadenopathy
- hepato/splenomegali
- pericarditis/pleuritis
- arthritis, atralgia, myalgia
- anæmi, træthed, profuse sweating
- hypersedimentation, leukocytosis, trombocytosis
Inddeling af polyarticular JIA
- RF-negativ (20%)
- RF-positiv (5%)
