Ob&Gyn Flashcards
Maternal adaptations to pregnancy- weight
Weight gain: 30Ib,
Due to fetus, placenta, amniotic fluid, uterus, blood volume
gain more weight if underweight and less if over weight
most weight gain during third trimester
Maternal adaptations to pregnancy: biochemical
Increase in fat soluble components- NEFA, FFA, TAGs, glycerol, cholesterol, Vitamin E
Decrease in water soluble components- aa, glucose, B12, folate, vit A, ions
Maternal adaptations to pregnancy: Cardiovascular
Increase HR, SV, CO
Decrease in TPR and BP
Maternal adaptations to pregnancy: Haematological
Increase in plasma volume due to activation of RASS
increase RBC synthesis but haematocrit from 40 to 32 falls due to hameodulation anaemia actually haematocrit<32
Increase BPG- offload O2
Increased coagulability- increase in plasma fibrinogen and clotting factors VII, VIII& X, decrease in fibrinolysis
Maternal adaptations to pregnancy: Respiratory
Increased Tidal Volume, RR,
ABG- compensated respiratory acidosis- PH 7.4-7.47,pCO2-3.6-4.3 PO2- 13.6-14
Maternal adaptations to pregnancy: Endocrine
Hormones: Oestrogen, Progesterone, HCG, , human Placental Lactogen, Leptin, Placental growth factor
Endocrine adaptations: placenta synthesises steroid hormones, neuropeptides, adrenaline NA
Oestrogen- stimulates fatty acid and cholesterol synthesis in liver, CVS adaptations, proliferation of uterus, Labour and parturition- increases gap junctions for coordinated contraction, stimulates cervical softening and ripening, stimulates RASS, weak anti insulin effects
Progesterone- secreted by CL for 8 weeks til taken over by placenta decreases immune system response against fetal Ag, substrate for fetal glucocorticoid and mineralocorticoid production, induces overbreathing increasing tidal volume and RR, labour- progesterone receptors internalise, maintains pregnancy- suppresses uterine contraction, growth of glandular tissue in breasts, secretory phase
HCG- maintains CL for 8 weeks levels peak at 8 weeks and subsequently decline, stimulates TSH receptor hyperthyroidism
Human placental lactogen-
Lipolysis- NEFA
Anti insulin effects- mobilises aa and glucose for placental transport
Angiogenesis- increase blood vessels
Leptin- secreted by placenta syncitio and cytotrophoblasts
placental transport of aa and FA
Placental growth factor- measure of placental function, placental growth angiogenesis increases blood vessels
Maternal adaptations to pregnancy: Renal
Increased CO to kidney Increased GFR- decreased plasma urea and creatinine
Increased frequency and urgency urination
Glycosuria- one off normal trace is normal, calciuria
Urinary Stasis and collecting duct dilation- increased UTI
Maternal adaptations to pregnancy: GI
Decreased smooth muscle tone, cardiac sphincter tone motility secretion
Biliary stasis
Constipation- increased water and nutrient absorption
Reflux
Hyperemesis gravidarum
Maternal adaptations to pregnancy: Skin
increased temperature hair and nail growth, reduced raynauds, nose bleeds, nasal stuffiness snoring
Labour stages
Stage 1:
Latent phase- irregular contractions cervical dilation 0-3cm-days
Active phase- regular contractions 3 in 10mins, cervical dilation from 3/4cm-10cm (0.5cm/hr) hrs
Transitional stage- head moves down into brith canal urge to push, change in mood
Stage 2: fully dilated to birth of baby lasts 1-2hrs, deliver head first then anterior shoulder then posterior shoulder then cord
Stage 3: from delivery of baby to delivery of placenta oxytocin important
Physiology of lactation
Milk production starts from 16 weeks but only can lactate post partum due to need for Oestrogen and progesterone levels to decrease
Prolactin is maintained til 3-4weeks without suckling
Suckling stimulates mechanoreceptors- stimulates VIP synthesis in PVN and decreases dopamine release- stimulates prolactin release- prolactin binds on to alveolar cells and stimulates lactogenesis
Suckling stimulates mechanoreceptors- synthesis and release of oxytocin from PVN and SON- causes myoepithelial cells surrounding alveolus to contract- forces milk into ductal system- increase in intramammary pressure- ejects from nipple
Lactation can be conditioned to baby’s cries
What is the puerperium?
from 3rd stage til 6-8weeks after birth
What are the changes that occur to the uterus during puerperium and the potential pathologies?
Uterus- involution- shrinking back
Lochia- vaginal discharge red and bloody to white and yellow completely gone by 6 weeks
Pathologies- PPH- EBL>500mls features of hypovolemic shock- anxious restless irritable confusion coma , tachycardia, tachypnenia, sweaty clammy pale cyanoses skin, rapid weak pulse, low pulse pressure, low BP reduced urine output
primary after birth secondary>24hrs
Causes: 4 Ts- Tone- uterine atony most common cause, Tissue- RPOC- placenta most common secondary cause, Thrombin- coagulopathy, Trauma- tears
Investigations- Vitals, Bloods- FBC, U&E, INR, Group and save, crosmatch, CRP, ESR, lactate, blood cultures monitor urine output
Management- surgery to cauterise bleeding, blood transfusion, fresh frozen plasma or platelet transfusion, remove RPOC
What are the changes that occur to the perineum during puerperium and potential pathologies that can occur?
Healing of tears, reduced swelling of vulva, regaining muscle tone, stretch
Pathologies- infection, pain, dyspareunia, urinary incontinence
What are the changes that occur to the abdomen during puerperium and potential pathologies that can occur?
healing of C section scar, shrinking back stretch
Pathologies- constipation after birth encourage plenty fluids laxatives, abdominal pain, infection
What are the changes that occur to the breasts during puerperium and potential pathologies that can occur?
lactation- first milk is colostrum- full of fat with Ab, breastfeeding
Pathologies- pain, infection, mastitis
What are the changes that occur to the mental health during puerperium and potential pathologies that can occur?
emotional time range of changes in emotion- adjustment anxious, teary baby blues normal
Pathologies:
Post partum depression- >6 weeks post partum experience any of following for >2 weeks: Anhedonia, Apathy, Low mood, tearfulness, disturbed sleep, tired, unable to bond with baby, thoughts of hurting self or baby, agitated restless withdrawn, lack concentration
Risk factors for PPD- Social- martial difficulties, lack of family support, domestic violence, negative life events, low SES, migration, Psycholgical- Past mental health issues, FHx, substance misuse
Biological- genetics, multiple births, increased parity,pregnancy/ birth complications,age, PMHx
Management- self help strategies- relaxation techniques mindfulness , talking therapies, CBT, medication- SSRIs
PTSD- any birth as birth is a traumatic experience for any woman, symptoms- months after flashbacks, night mares, sweating, negative thoughts palpitations, nausea vomiting headaches when think about it management- CBT, propranolol
Puerperal psychosis- comes in within 1month birth mental health emergency need to be admitted to mum and baby unit reviewed by psychiatry. Symptoms- delusions, hallucinations, thought disorder, thoughts of harming self/ baby more likely to occur again in subsequent pregnancy
Risk factors- previous puerperal psychosis, mum or sister, bipolar, schizophrenia
What are the changes that occur to the haematology during puerperium and potential pathologies that can occur?
increased risk of infection due to low immunity, increased plasma volume, increased coagulation
Pathologies- thrombosis, anaemia- blood loss, infection
Where is best to deliver baby?
Nulliparous women- midwife led unit or hospital
Multiparous women- home birth (carries no extra risk) or midwife led unit
High risk- obstetric led unit
Pain relief during labour
Non Pharmacological:
Breathing exercises, partner support, family and friends, relaxing music, warm water, massage, doula
Pharmacological:
Entonox- gas and air
Epidural- spinal anaesthesia
What is pre eclampsia?
Pregnancy induced hypertension
Hypertension after 20 weeks
Effects multiple systems
Pathophysiology of pre eclampsia
Failure of the trophoblast plug to regress and opening up of spiral arteries so spiral arteries remain vasoactive can respond to vasoconstrictors
Resolves 10 days after delivery
Risk factors for Preeclampsia
High risk: Chronic HTN, HTN, CKD, Autoimmune- SLE, APS, Preeclampsia in 2 or more previous pregnancies, Preeclampsia<34 weeks
Moderate risk: Age>=40, BMI>=35, Nulliparous, Multiple pregnancy, Pregnancy Interval>10yrs, FHx
In need of Aspirin 75mg from 12 weeks- 1 high risk or 2 moderate risk factors
Clinical presentation of pre eclampsia
Headache, Oedema- facial swelling, papilloedema Epigastric pain Visual disturbances- Blurred vision Proteinuria HTN N&V
Investigations
BP at all antenatal appointments Urine dip Bloods- FBC, U&E, LFTs PGF- screening tool Umbilical artery Doppler
Diagnostic criteria for Preeclampsia
BP>=160/110 severe
BP>=140/90 with proteinuria or one of: Epigastric pain, oedema, blurred vision, ALP>70, liver tenderness, clonus- tremor
HELLP syndrome- Haemolysis, Elevated Liver enzymes, Low Platelets
Management of Preeclampsia
Admit if BP rises by >30/20 or if BP>160/110 or 140/90 with proteinuria
Labetalol/ nifedipine/ methyldopa (change after delivery as SE postnatal depression)
Severe PET- MgSO4 prophylaxis prevent eclampsia
Definitive management- Delivery but can get post partum pre eclampsia within 72hrs
What is eclampsia and it’s management?
Pre eclampsia that has progressed to seizures
Management:
IV MgSO4 SE: Resp depression so stop if RR<14 or loss of tendon reflexes or urine output <20ml/hr
Reverse toxicity with Ca gluconate
If seizures still continue- diazepam, ventilate and consider other causes
Avoid discharge < 5days post partum
Puerperal sepsis
Infection
Clinical presentation- Fever, chills rigors, offensive vaginal discharge, abdominal pain, N&V, diarrhoea, rash, wound infection
Risk factors- obesity, C section, cervical cerclage, immunosuppressed, prolonged SROM, vaginal trauma, RPOC
Investigations- O2 saturations, ABG, bloods- blood cultures, lactate, FBC, U&E, LFT, CRP, ESR,
Monitor Urine output, urine dip
Management: IV Abx, IV fluids, O2 maintain sats>94%
