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MD3 ONG Flashcards

1
Q

Best way to estimate the duration of a pregnancy on palpation?

A

From Pubic symphysis to top of palpable uterus (fundus) - at 20 weeks fundus will be at belly button, at 40 weeks it will be just below the rib cage. Between them around 30 weeks.

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2
Q

How can you tell if a baby is getting ready to come on palpation?

A

Head will descend (in non-breach) and will lose mobility.

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3
Q

What is the normal number of weeks before labour and at what point after this period is the baby at risk?

A

37 to 42 weeks, a week after that, risk of stillbirth begins to rise.

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4
Q

What actually is amniotic fluid?

A

Baby pee - marker of well hydrated and nourished baby.

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5
Q

What is the cutoff for pre-eclampsia and which 3 areas of the body are uniquely at risk?

A

140/90.
Vessels - made stiff - leads to hypertension
Kidneys - hypertension/placental mystery molecules cause proteinuria
Brain - low threshold for seizures

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6
Q

What is HELLP syndrome?

A

Think of it is a severe form of pre-eclampsia.
H - haemolysis
EL - elevated LFTs causes DIC as all coags are up.
LP - low platelets

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7
Q

What is the medication given to raise seizure threshold in pre-eclampsia?

A

Magnesium sulphate - but makes patients feel like shit

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8
Q

What is the only true cure for pre-eclampsia and what are some temporary measures?

A

true cure - remove placenta

in the meantime - atenolol, hydralazine, and mag sulph

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9
Q

Define the following acronyms: EDD, GTT, PPH, LMP

A

Estimated date of delivery
Glucose tolerance test
Post partum haemorrhage
Last menstrual period

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10
Q

Which two conditions are key to specifically touch on in past obstetric hx at the booking visit?

A

HTN and diabetes

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11
Q

What is the tool to test for perinatal depression?

A

Edinburgh Post-natal depression score

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12
Q

When does everyone do a GTT? What about if Hx of gestational diabetes?

A

28 week visit.
Earlier if PHx. (do twice)

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13
Q

Mnemonic for Ix performed at initial antenatal visit?

A

FBI RUSHH (CVS)
FBE
Blood group and Rhesus
Iron
Rubella
Urine (MSU for UTI, consider STIs)
Syphilis
Hep B and C
HIV

Consider CVS - CST (opportunistic), varicella serology and scan (USS)

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14
Q

Define primary and secondary PPH and major and minor PPH.

A

Primary = in first 24 hours after birth
secondary - 24hrs to 12 weeks after.

Minor = 500ml to 1000ml blood loss.
Major is over 1000 or signs of shock.

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15
Q

What is 3rd stage of delivery?

A

between baby and placenta delivery.

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16
Q

What is the main management difference between a minor and major PPH?

A

Major needs transfusion immediately, start O neg then switch, consider also FFP and cryoprecipitate (has fibrinogen that’s why).

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17
Q

Describe these 3 major acute causes of PPH - uterine atony, placenta accreta, placenta previa.

A

atony - uterus not contracting, contraction squeezes blood vessels shut normally.

Accreta - placenta imbedded into uterine wall - doesnt detach with birth - bleeds heavily

previa - placenta covering cervix.

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18
Q

One pharm and one surg Mx for uterine atony.

A

pharm - oxytocin
surg - balloon tamponade

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19
Q

What medication may help prevent pre-eclampsia and when should it be ceased?

A

low dose aspirin to be ceased at 36 weeks.

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20
Q

What is an ECV?

A

Extra cephalic version - palpate the baby away from breach position into better position

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21
Q

3 major Ix/interventions performed at the 28 week appointment vs the 36 week?

A

28 - FBE, anti-D if needed, GTT

36 - FBE, anti-D if needed, GBS swab

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22
Q

Who needs Anti-D?

A

Rho neg mums with + babies

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23
Q

When are the two main USS done for most women?

A

12 and 20 weeks.

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24
Q

Which complication does folic acid aim to avoid?

A

Spina bifida

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25
Q

Is warfarin safe for pregnancy?

A

No, it is teratogenic

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26
Q

List 4 key discussion topics for the initial pregnancy visit

A
  1. confirm pregnancy/dates
  2. folate
  3. medication check
  4. Lifestyle/diet tips
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27
Q

Approximately when do most pregnant women stop working?

A

Week 34

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28
Q

What are the main two complications to look for at each antenatal visit?

A
  • pre-eclampsia (HTN)
  • Poor growth (IUGR/placental insufficiency)
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29
Q

Are proteinuria and glucosuria common in pregnancy?

A

Yes both in small amounts

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30
Q

What is chorioamnionitis? Which complication is it closely linked with?

A

Infection of the chorion/amnion with vaginal flora. Closely linked with pre-term labour.

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31
Q

List some risk factors and signs of chorioamnionitis.

A

Risks - long labour and multiple examinations in labour

Signs - foul amnion, fever, tachycardia

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32
Q

Abx treatment for chorioamnionitis?

A

IV Amp + gent/ceft, and metranidazole or clindamycin for anaerobes.

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33
Q

Which bacteria typically causes post-partum sepsis?

A

Group A Strep (pyogenes)

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34
Q

Mx for positive GBS swab?

A

IV benpen prophylactically at delivery

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35
Q

CMV is associated with which fetal complication?

A

Deafness

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36
Q

When are the 4 doses of Hep B vaccine?

A

At birth, then at 2, 4 and 6 months.

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37
Q

Which medicine can be given as prophylaxis for HBV vertical transmission in a HBV + mum?

A

tenofovir (if viral load above 200,000)

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38
Q

If active HSV lesions are present during late term, what is the best mx?

A

Ceasar instead of vaginal birth
acyclovir for prophylaxis

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39
Q

What are the two biggest causes of maternal mortality in Australia?

A

Cardiac Disease and DVT.

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40
Q

What is the key physiological cardiac change during pregnancy and how does this impact the risk of associated pathologies?

A

cardiac output MUST rise during pregnancy. If there is an underlying pathology that is worsened by higher CO (eg. aneurysm) or that prevents a rise in CO (eg. a left sided stenotic valve) then this is DANGEROUS.

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41
Q

Which cardiovascular condition has the highest risk of maternal death in pregnancy?

A

Pulmonary Hypertension

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42
Q

What are the physiological changes to the respiratory system in pregnancy?

A
  • airway edema common
  • RR up
  • diaphragm pushed up by uterus reduced functional residual capacity (FRC) which acts as an O2 storage.
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43
Q

Is breathlessness normal in pregnancy?

A

Yes very common but it is important to seperate it from a potential PE

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44
Q

List two physiological changes that put the airway at risk in pregnancy.

A
  • laryngeal/airway swelling
  • reduced osephageal sphinctre tone increasing reflux
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45
Q

How do sugar levels change in pregnancy and how might this impact a type 1 diabetic?

A

Pregnancy requires both hyperglycemia and hyperlipidemia to feed baby - T1DM will need more insulin during pregnancy.

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46
Q

How does pregnancy impact blood/plasma?

A

Levels greatly increase, causing haemodilution.

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47
Q

How are T and B cells impacted by pregnancy?

A

T cells usually inhibited to allow for fetal growth - this may mean autoimmune diseases flare less when pregnant.

B cells are unimpaired which is why vaccines still work during pregnancy.

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48
Q

Why does lying position impact pregnancy?

A

Aortocaval compression = compression of the IVC and aorta due to the position of the fetus.
Solution = left lateral tilt

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49
Q

Is it safe to defib while pregnant?

A

If a woman’s heart is not working then the baby is in danger, it is safest to defib. The most unsafe thing for the baby is for the mother to die.

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50
Q

Can rubella and varicella vaccines be given during pregnancy?

A

These are live vaccines so cannot be given in pregnancy. Can be given in planning or afterward.

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51
Q

What is the mx for pregnant women with a clot risk?

A
  • clexane subcut
  • educate around DVT/PE signs and symptoms
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52
Q

Signs of pre-eclampsia?

A

Headaches, visual changes, swelling, N+V

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53
Q

When do fetal movements usually start for mum?

A

Around 17 weeks but everyone is different

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54
Q

What Ix would you order for reported reduction in fetal movements?

A
  • CTG and USS
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55
Q

What is primigravid?

A

First pregnancy

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56
Q

What is a fetal station?

A

How far down the baby’s head is in pelvis

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57
Q

What does an USS look for when looking for reduced fetal movements?

A

placental insufficiency as evidenced by DVP. Deepest vertical pocket of amniotic fluid. If less than 2cm = placental insufficiency.

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58
Q

What is macrosomia and what are the delivery options?

A

Big baby.
1. Watch and wait - risk of obstruction (ceasar) and risk of shoulder dystocia

  1. Ceasar - bleeding risk and longer recovery (4-6 weeks)
  2. Induction eg. balloon dilatation and ARM
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59
Q

What is a key medical thing to do for women moving forward after a stillbirth?

A

Lactation suppression

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60
Q

What is an amniotomy and what is syntocinon?

A

Amniotomy (ARM) = artifical rupture of membranes

syntocinon = synthetic oxytocin to force contractions

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61
Q

What is meconium and what does it mean if it is present in the amniotic fluid?

A

First poop of baby - sticky green bile stuff. If present in amniotic fluid it may be a sign of fetal distress or an overdue baby - CTG.

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62
Q

What are the 3 stages of delivery?

A

First phase - labour until full dilation
Second - full dilation to birth
Third - birth to placental delivery

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63
Q

What is station 0 for the fetus?

A

Head is at level of ischial spines

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64
Q

What is caput?

A

Swelling of the baby’s head

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65
Q

What is crowning?

A

baby’d head no longer retreats after contractions.

66
Q

Why is oxytocin given after baby is born?

A

To prevent PPH

67
Q

How does pregnancy impact clotting factors?

A

They go up massively (800% up) to prep for delivery haemorrhage. DVT risk massive

68
Q

How does delivery of the baby impact the cardiac system?

A

All of the fluid that was shunting into the placenta returns to the system - strain on heart.

69
Q

What are the main two groups of medications used for analgesia in delivery?

A
  • nitrous oxide for contractions
  • opioids, typically morphine - 10mg IM 2-3 hourly.
70
Q

How can an epidural help pre-eclampsia?

A

An epidural and spinal can cause hypotension due to shutting off the sympathetic mechanisms in the spine. This lowered BP can help in those with HTN.

71
Q

Which combo of medications are given in an epidural?

A

Local anaesthetic: bupivicaine or ropivicaine

+ opioid - fentanyl

CAN DO IT AS A PCA

72
Q

Why would you avoid GA in pregnancy?

A

Many reasons. Very risky in pregnancy due to airway risks, aorto-caval compression may not be recognised, hypoxia risk due to reduced FRC, and GA will cross to baby.
Plus partner cannot be in the room to be involved.

73
Q

Explain gravida vs parity?

A

gravida = number of times pregnant
parity = birth of fetus over 20 weeks (live or stillbirth)

74
Q

What is the average baby birth weight? (at 40 weeks)

A

3.5kg

75
Q

Why might appendicitis be missed in pregnancy?

A

McBurney’s point MOVES due to growth of abdomen and some symptoms may be similar to regular pregnancy symptoms eg. nausea

76
Q

What pharm management can help in pre-eclampsia and in IUGR (intra uterine growth restriction)?

A

low dose aspirin

77
Q

To really clarify someone’s gestation period you can which two methods?

A

USS - 7 weeks sac + CRL + heart rate.
5 weeks just sac, 6 weeks just sac and CRL.
CRL often dates pregnancy.

Serial BHCG - should double every 48 hrs in successful pregnancy.

78
Q

If BHCG is rising weirdly and not doubling every 48 hrs as expected, what might you consider?

A

ectopic

79
Q

When is the NIPT done?

A

10 weeks

80
Q

What is the chance of miscarriage on average before 3 months?

A

Around 30-40%

81
Q

When to the first and second visits tend to be in pregnancy and what is done at these?

A
  • first visit is the ‘i am pregnant visit’ around 6 weeks. Confirm pregnancy (BHCG) and discuss folate, discuss lifestyle changes, removing teratogenic meds.
  • next visit = 12 weeks. Blood tests. FBI RUSHH (+varicella, CMV, etc depending on clinician). Combined first trimester screening = USS for nuchal translucency and then the triple blood test algorithm.
82
Q

What blood tests are part of the triple blood test for the combined first trimester screening?

A

BHCG, alpha fetoprotein, PAPP-A

83
Q

What are the two diagnostic tests for aneuploidy and what are their risk levels?

A

amniocentesis - 16 weeks - 0.5% risk

chorionic venous sampling - 13 weeks - 1% risk.

84
Q

When is the 3rd major pregnancy visit? What is done?

A

20 weeks - morphology scan.

85
Q

Describe the main tests done at the 28 and 36 week visits?

A

28 weeks - anti D if needed, FBE, iron, Ab test (always every fkn visit). GTT

36 weeks - GBS swab

86
Q

What are some reasons for a planned ceasar?

A
  • mum’s choice
  • active HSV
  • breach
  • giant baby
  • transverse lie
  • abnormal placenta (accreta, previa, vasoprevia)
87
Q

Why does hardly anyone in the western world go beyond 41 weeks + 3?

A

Risk of stillbirth rises each day

88
Q

What is the normal baby position on vaginal delivery?

A

occipital-anterior.
Occipital bone of baby against mum’s anterior side (pubic symphisis)

89
Q

What are the 3 stages of pregnancy?

A

1 = in labour but not fully dilated to 10cm
2 = fully dilated until birth
3 = post birth until placenta delivery

90
Q

Which two injections are given to the baby within an hour of being born?

A

Hep B and Vit K

91
Q

What 4 things are tested for on the fetal heelprick?

A
  • PKU
  • congenital hypothyroid
  • cystic fibrosis
  • congenital adrenal hyperplasia
92
Q

What is the ‘normal’ timeline for physiological neonatal jaundice ?

A

Between 24hrs and 2 weeks jaundice is likely normal.

93
Q

What is the cause of physiological jaundice in neonates?

A

Babies need high Hb (around 180) to deal with the hypoxic conditions of the womb and the delivery - once born they no longer need this Hb so the heme is broken down into bilirubin. Their inefficient livers are unable to conjugate this bilirubin leading to increased unconjugated bilirubin levels.

94
Q

What is the validity of different oral contraceptive pills following pregnancy?

A

mini pill - no side effects. Safe once baby is born.

combined pill - estrogen will turn off lactation

95
Q

What day is usually the peak of physiological jaundice?

A

Day 5 or so

96
Q

What is the most common cause (by far) of pathological neonatal jaundice? What usually leads to this pathology?

A

Haemolysis. 99/100 says John Mills.
USUALLY this is due to iso-immunisation - i.e the crossing of maternal IgG across the placenta to target baby antigens. Nowadays this is typically ABO cross reactivity.

97
Q

Which iso-immunisations are most common?

A

In the olden days Rhesus disease (Ab made by Rhesus neg mum in response to Rhesus positive baby following maternal sensitisation due to prior pregnancy or maternal fetal haemorrhage) was the most common cause of iso-immunisation and subsequent neonatal jaundice. Now we give anti-D.

Now the most common cause is ABO cross reactivity.

98
Q

What percentage of women are rhesus negative and how does anti-D work?

A

15% are rhesus negative.
Anti-D mimics the maternal Ab that would be produced and mops up the fetal DNA that leaks across the placenta so that the mother herself does not mount an immune response and make her own Ab.
This is given before and after birth.

99
Q

What is a dangerous complication of fetal anemia (ie due to haemolysis)?

A

hydrops fetalis

100
Q

What six blood tests are done for jaundiced baby?

A
  1. Bilirubin level (conjugated as well)
  2. Baby blood group
  3. Direct Antigen test (Coombs) tests for Ab in fetal circulation
  4. Hb
  5. G6PD - haemolysis due to oxidative stress
101
Q

Which population is most likely to get G6PD and what are 3 main causes?

A

South East Asian.
Legumes (Flava beans), anti-TB drugs and sulphur antibiotics.

102
Q

What is the main treatment for pathological neonatal jaundice to avoid bilirubin buildup leading to kernicterus? What is the second line in extreme cases?

A

Phototherapy.
If it is really bad: exchange blood transfusion - blood goes in and out at some time manually in 20ml aliquots.

103
Q

If, more than 2 weeks post birth, a baby becomes jaundiced and bilirubin levels are largely conjugated, what would you suspect?

A

Obstruction - conjugated bilrubin is spilling out the liver into the blood instead of into the bowel. Query biliary atresia (non-formation of biliary system and gallbladder).

104
Q

What are the key components of a post-natal checkup? (POSSIBLE OSCE)

A
  • how is baby (but leave most of it for GP/peadiatrician)
  • how is mum
  • breastfeeding
  • mood - edinburgh depression score
  • bleeding, discharge (period)
  • bowels/bladder
  • lifestyle things like return to exercise
  • CST
  • contraception
  • immunisations
    +/- exam for scars/sutures
105
Q

Jaundice after 2 weeks may be due to which common cause?

A

Breast milk jaundice - in some women a molecule in breast milk inhibits conjugation of bilirubin in liver

106
Q

It’s important not to forget that _____ can cause pathological neonatal jaundice.

A

sepsis

107
Q

What are the cut off values for the 3 stages of the oral GTT?

A

Fasting - should be below 5
after 1 hr - should be below 10
After 2 hrs - should be below 8.5

108
Q

How often should women with gestational diabetes test their sugars?

A

4x a day, 1 first thing fasting and then 3x in the day 2 hours after each meal

109
Q

What is the typical first line management for gestational diabetes?

A

Insulin

110
Q

Which blood test may serve as an indicator of future pre-eclampsia?

A

PAPP-A (part of the combined first trimester blood screen) may indicate future pre-eclampsia if it is low

111
Q

What is the realistic earliest point you can deliver a baby and it still lives normally (with assistance initially) ?

A

26 weeks though some may survive even at 22 weeks.

112
Q

Why is fetal haemolysis such a risk ?

A

Haemolysis leads to anaemia which in the fetus can cause hydrops fetalis - cerebral palsy risk etc

113
Q

List some causes of antepartum bleeding.

A
  • Miscarriage
  • Labour
  • Placental abruption (maybe linked to pre eclampsia)
  • Uterine rupture
  • Placenta previa
  • Placenta accreta
  • Vaso previa (painless)
  • Infection eg. chorio
  • GYNAE causes: STI, fibroid, polyp, gynae cancer
114
Q

What is the pain level in placenta accreta, previa and vasoprevia

A

usually all are painless

115
Q

Which 3 questions do you ask all pregnant women regardless of gestation?

A
  • pain
  • bleeding/discharge
  • fetal movements
116
Q

Instructions for GTT?

A

Fast 8-12 hours before, so often light snack before bed because don’t want to be over fasted. Just water the morning of the procedure.
3 blood tests over 2 hours, drink the drink.

117
Q

What is lichen sclerosis and what is the long term risk?

A

Vulval skin changes appearing like plaques - precursor to squamous cell carcinoma

118
Q

Can you do CST and DTP vaccine antepartum?

A

Yes both!
DTP often given in third trimester and CST ‘anytime, anywhere’

119
Q

What do the ovaries feel like on bimanual exam on a normal person?

A

Not palpable

120
Q

What are the degrees of vaginal tears in labour?

A

(They build upon each other)
First degree - vaginal mucosa
Second - perineum
Third - anal sphincter
Fourth - anal mucosa/rectum

121
Q

Non-pharm intrapartum mx for preventing tears?

A

Warm compress to vasodilate perineum

122
Q

What is the most common side effect of ergometrin (used PPH and induction)?

A

Vomiting - most vomit

123
Q

Defining features of pre-eclampsia? What is the difference to eclampsia?

A
  • hypertension
  • small baby
  • proteinuria
  • low PAPP-A

Real eclampsia = seizures

124
Q

After 32 weeks, Lionel says you really have to check 3 things:

A
  • size of the baby
  • pre - eclampsia
  • which way is the baby facing
125
Q

What is a missed abortion?

A

Miscarriage with no fluid from the vagina, cervix still shut but baby has no heart beat.

126
Q

Which hormone causes muscle aches in pregnancy?

A

Relaxin

127
Q

What is the significance of a cervix length under 25mm?

A

Short cervix one ultrasound is increased risk of pre-term birth.

128
Q

What is the risk of a low lying placenta?

A

Risk of placenta previa

129
Q

What is the feared complication of congenital parvovirus?

A

Fetal anemia

130
Q

Goal for a pre-eclamptic mum with a small baby at 31 weeks?

A

Must come out or it will die

131
Q

Risk of vasoprevia, management?

A

In labour baby will descend and burst a vessel lying in the way of the uterus - very quick fetal death. Management is an early Caesar, can’t risk labour.

132
Q

What are some causes for repeat miscarriages?

A
  • coagulopathy
  • SLE/anti-phospholipid
  • chromosomal abnormality (worst one, no fix)
133
Q

Advice for mums to avoid CMV?

A

Avoid little kids, under 2 are the biggest risk, don’t hate cutlery, kiss on the head not the mouth.

134
Q

Initial mx for gestational diabetes?

A

Lifestyle + exercise

135
Q

What is metaraminol?

A

Alpha 1 agonist (indirect) used to raised BP in spinal/epidural patients.

136
Q

What is miscarriage risk of an 8 week embryo with normal CRL+HR on USS with healthy mum?

A

Below 5%

137
Q

When do stop aspirin in pre-eclampsia risk
?

A

Stop 36 weeks

138
Q

Difference between minor and major PPH and primary and secondary PPH?

A

Minor = 500 to 1000ml
Major = over 1000ml

Primary - within 24 hrs of birth
Secondary - between 24 hrs and 6 weeks after birth

139
Q

What are the causes of a primary PPH?

A

The 4 T’s: (in this order)
- tone (uterine atony)
- tissue (retained intrauterine products)
- trauma (from birth eg, forceps)
- thrombus

140
Q

Two main causes of secondary PPH?

A
  • retained uterine products
  • infection
141
Q

List two causes of polyhydramnios and two causes of oligohydramnios:

A

Remember amniotic fluid is baby pee.

Oligo: placental issue (no nutrients for baby to make pee) OR kidney issue - baby can’t make pee

Poly: baby can’t swallow (producing pee but not swallowing it) and gestational diabetes

142
Q

Some considerations for a First Nations/regional pregnant woman?

A
  • Koori Maternal services
  • fetal monitoring/scans can be done regionally
  • telehealth for some visits is possible
  • Birthing on country may be important to some
  • placental rituals are common in First Nations groups
  • can suggest relocating for a short time at the 34 week mark or so
143
Q

Extra referral made antenatally for twins?

A

Lactation consultant - breastfeeding twins can be tough, best to prepare

144
Q

What is AEDF?

A

Absent End Diastolic flow - on umbilical cord using doppler - sign of fetal distress

145
Q

When is the usual cutoff for IV steroids to increase surfactant for baby?

A

Usually before 34 weeks.

146
Q

Pharm Mx for chorio?

A

Gent, Amp, Clinda (or Metro)
For PROM - premature rupture of membranes (risk of chorio)
- add IV steroids for baby surfactant

147
Q

How long ago must last period be to be defined as menopause?

A

12 months

148
Q

What is ITP?

A

Immune thrombocytopenic purpura - low platelets

149
Q

What is aplastic anaemia, how does it impact an FBE?

A

Autoimmune destruction of the bone marrow (can be cause by many things eg. radiation, chemo, infection, congenital etc). Virtually everything on FBE will be low - Hb, WBC, platelets, reticulocytes etc.

150
Q

Vaginal bleeding in an obese, post-menopausal woman should ring alarm bells for?

A

Endometrial cancer - fat produces estrogen, and after menopause this unopposed estrogen is a risk for gynae cancers.

151
Q

What is the likely management of a post-menopausal woman with endometrial cancer?

A

Likely a hysterectomy with bilateral oophorectomy due to no longer being fertile.

152
Q

What is Asherman’s syndrome?

A

intrauterine adhesions (often from past surgery) that may cause pelvic pain, amenorrhea, abnormal uterine bleeding or an inability to get and stay pregnant.
(SECONDARY AMENORRHEA)

153
Q

What is fragile X and what are some key clinical findings?

A

Genetic cause of mental retardation.
Findings include long face, large ears, prominent jaw, macro-orchism, mitral prolapse

154
Q

What is the Abx for pertussis?

A

Macrolide - azithro or erithro

155
Q

What are the 3 diseases screened for in basic carrier screening?

A

CF, spinal muscular dystrophy and Fragile X.

156
Q
A
157
Q

3 key mx in urge incontinence:

A
  1. Bladder diary
  2. Retraining - pelvic physio
  3. Pharm eg. Oxybutinin
158
Q

Which two mechanisms allow progesterone only contraception to impair fertility?

A
  • thins endometrium preventing implantation
  • thickens cervical mucus prevent travel of sperm and egg
159
Q

When is anti D given to rhesus negative mums?

A

28 and 34 weeks

160
Q

What is the most effective emergency contraception?

A

Copper IUD

MD (17 decks)

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