OBGYN Flashcards
VTE in pregnancy
Patients are either started on LMWH immediately, at 28 weeks, or non-medical (mobilisation) depending on their risk score. VTE prophlaxis is continued for 6weeks/3mo after (LMWH/DOAC).
Requirements for:
1. Starting immediately and referring to experts
2. Considering starting immediately
2. Starting at 28 weeks
3. Non-medical
- High risk (previous VTE; not related to major surgery).
- Intermediate risk (medical comorbidity, high-risk thrombophilia, previous surgery+/-VTE, any admission). And those with 4+ general RFs.
- 3+
- <3.
General risk factors
* Age >35
* Parity >3
* BMI >30
* IVF
* Immobility
* Smoker
* Gross varicose veins
* FHx of VTE
* Multiple pregnancy
* Smoker
* Low risk thrombophilia
Gestational HTN, Anaemia, DM.
- Gestational HTN
- Anaemia of pregnancy
- Gestational diabetes
Also
* Pre-existing HTN
- HTN after 20 weeks with BP of >140 systolic of >90 diastolic. or increase by 15mmHg diastolic or 30 systolic. Labetalol/Nifedipine + weekly Monitoring (bloods, urine dipstick, growth scans). Admit for observation if BP >160/110.
- Hb <110 at booking (12wk) or <105 at 28 wks. Ferrous Sulfate.
- fasting glucose >5.6 or 2hr gluocse >7.8. Exercise/diet 2 weeks –> Metformin –> Insulin
> 140/90 before 20 weeks; advise changing teratogenic meds (ACE-I/ARBs/thiazides) –> Labetaolol/Nifedipine
Diabetes and birth
* gestational
* gestational + complications
* pre-exisiting
- up to 40+6
- elective birth <37 weeks
- advised elective birth 37-38+6 (induced/C-section)
Pre-eclampsia
Mild/moderate/severe
* typical triad
* Diagnosis
* Investigations
* Investigation to rule out pre-eclampsia (20-35 weeks)
* Criteria for admission
* symptoms/signs
* management - medication (1st, 2nd, 3rd line). What is first line to swap to after birth?
* prevention for women (1 high risk factor or 2 moderate)
* screening (2)
* complications (3)
- HTN, oedema, proteinuria
- HTN >140/90 past 20 wks + 1 of proteinuria (>30mg/mmo urine Protein:creatine ration) or end organ dysfunction (renal failure - rising CRP; liver failure - deranged LFTs; hamatological markers - low Plt)
- Urine PCR/urinalysios; U&E,LFT, coag
- PlGF: low levels in P-E (produced by placenta to stimulate growth of new vessels) -
- Admit high clinical suspicion for pre-eclampsia or BP >160/110
- Abdominal pain, headache, visual disturbance (blurry), hyperreflexia, N+V, leg swelling
Management
* 1st line - Labetalol.
* 2nd line - Nifedipine.
* 3rd line - Methyldopa.
* After birth –> Enalapril (note CCB if black)
* If <24 wk ? termination. Otherwise - monitor and anticipate early delivery.
Prevention
* Aspirin 75-150mg from 12 wks
Screening
- Doppler (20wk)
- Ratio of dFlt-1:PIGF; used to rule out PE
Comps
- Maternal: eclampsia, stroke, end-organ damage inc. HELLP/DIC
- Fetal compromise; stillborn; IUGR; prem
RIsk factors for aspirin prophylaxis for pre-eclampsia:
high risk - 1 of (3)
moderate risk - 2 or more (6)
HIGH RISK - OFFER AT 12 WEEKS, if either:
* known hypertension or hypertensive disease in previous pregnancy
* auto-immune disease (inc.DM)
* chronic kidney disease
MODERATE RISK - OFFER AT 12 WEEKS IF 1+ RISK FACTOR
- Nulliparity
- extreme obese (BMI >35 at first visit)
- FHx of P/E
- Multiple pregnancy
- >40
- Pregnancy interval >10 years
Causes of jaundice in pregnancy
* Intrahepatic cholestasis
* Acute fatty liver
Which is found in 1%, due to increased reproductive hormones –> stasis of bile acids?*
* Symptoms
* It can lead to…
* Inv findings
* Mx - symptomatic? delivery? if PT deranged?
- Intrahepatic cholestasis
- Severe pruritus, dark urine/pale greasy stools, jaundice.
- Placental insufficiency. Complications for mother (malabsorption, liver failure) and fetus (FGR, stillbirth).
- Deranged LFTs, raised bile acids, Abdo U/S - blockage within ducts + inflamm.
- Ursodeoxycholic acid
- IOL (37wk)
- monitoring/follow-up of LFTs.
- If pt deranged –> Vitamin K
Acute fatty liver
- rare, T3 or just after delivery
- raised ALT; deranged clotting; abdo pain, jaundice, N+V etc
- like hepatitis with ascites
- obstetric emergency - requires immediate admission and delivery
- more likely differential is HELLP
2nd stage of labour (pushing) involves…
Every Day Fine Infants Enter Engage and Excited
Engagement - largest diameter of head is within the pelvis.
Descent
Flexion
Internal rotation
Extension
External rotation
Expulsion
Labour
Define FTP in
* 1st stage - onset of contractions until 10cm dilatation.
* (latent: irregular contractions, cervical effacement and dilatation –> 4cm. Active: regular contractions, –> 10cm).
* 2nd stage - until delivery of baby.
* (passive and active)
* 3rd stage - until delivery of placenta / membranes.
* (active or physiological.)
FTP
1. <2cm dilation in 4hr (nulliparous) or slow to progress (multiparous)
2. Active stage >2hr (nulli); >1hr (multi)
3. Physiological >60m. Active >30m.
Indications for active mx of 3rd stage of labour (3)
What does it involve?
- FTP (>60 mins physiological mx)
- Prevention of PPH
- Patient choice
- Oxytocin (Syntocin) & cord traction
Prevention of PTL
Diagnosis, investigation for:
* PPROM
* PTL w/ intact membranes
Prevention options:
* 16-24 wks (3)
* 16-28wks (1)
* 24-32 wks - drugs used for tocolysis (2). Extra indications if suspected labour before 34 wk (1) 36 wk (1).
- Pooling of amniotic fluid within vagina + positive IGTBP-1 or PAM-G1
- Contractions w/o ROM; cervical shortening less than 15mm. Confirmed with fetal fibronectin >50g/ml if >30wks.
Prevention 16-24 wks
* Cervical cerclage (if <25mm)
* progesterone pessary/gel
14-28 wks
* rescue cerclage - dilatation without ROM.
14-32 wks: tocolysis
* Nifedipine (1) or Atosiban
* MgSo4 + close monitoring
* Betamethasone IM x2 (24hrs apart)
Fetal monitoring
low risk (intermittent auscultation in 2nd/3rd stage) and high risk (CTG).
CTG indications - fetal distress/RFM, pre-eclampsia, maternal raised tachycardia meconium passed + use of oxytocin during labour etc.
* Interpreting a cardiotocogram: DRCBRAVADO.
* Risk statification? - for further intervention/alert senior.
* What is the most concerning finding on an ECG?
* SHort episodes of loss of baseline variability- most common cause?
Concerning features
- Loss of baseline variability (prolonged) <5bpm variation in heartrate from baseline
- Late decellerations (after contraction)
- Variable decelerations (no coordination with contraction) or prolonged
- Define Risk
- Contractions = 3-4/10 minutes = normal.not progressing/hyperstimulation
- Baseline rate = brady (< 100); tachy (>160)
- Variability = how much heart rate changes along baseline rate: normal 5-25
- Accelerations - signs of baby moving; good sign
- Decelerations -
- Early- start at same time as uterine contraction,
- Late - begins after contraction starts, recovers as contraction ends
- Variable - no association with uterine contraction at all
- Prolonged - >3minutes: abnormal
- Overall impression - risk stratify into normal, suspicious, pathological, requiring urgent attention
Causes of;
* Reduced variability - baby sleeping, maternal opiate use (or hypoxia)
* Early decc - normal; head compression by uterus
* Late decc - abnormal: maternal hypotension, pre-eclampsia, uterine hyperstimulation
* Varibale or prolonged decc - umbilical cord compression
Mx for fetal bradycardia
3 mins
6 mins
9 mins
12 mins
- Alert senior
- Move to theatre
- Prep for delivery
- Deliver within 3 mins (15 mins)
eg peristent fetal bradycarida (reduced BPM on ctg) - urgent c-section category 1
IOL
* Indications for IOL (Bishop score) - takes into account which factors (5)?
* Bishops >9 means? Bishops <5?
* 2 initial methods for manual ROM (2)
* If above fail (no labour within 24hrs) what happens next? (1)
* Main risk associated with prostaglandins/oxytocin
* Main risk of ARM
Bishop = cervical position, effacement, dilatation, consistency + fetal station (-3 –>2)
>9 = labour likely to happen spontenously.
<5 = labour unlikely to start without induction. Indication for IOL. Note less than 3 means IOL is unlikely to be successful.
1. Cervical ripening methods:* Prostaglandins (*Propess or Prostin) or Balloon (24hrs). Cervical membrane sweep as adjunct.
2. Artificial ROM (amiotomy) +/-oxytocin (+ epidural if given oxytocin due to increased frequency and strength of contractions)
Risks
- Uterine hyperstimulation –> fetal distress/uterine rupture/emergnecy section. >5 contractions /10 mins
- Cord prolapse
C-section Categories 1-4 and time frame for delivery (categories 1 and 2)
- Life-threatening maternal & fetal compromise; deliver within 30 mins
- Non LF M&F compromise; within 75 mins
- Stable M&F, but section reqd.
- Elective
Vaginal delivery after C-section (VDAC)
* Success rate
* Contraindications (2)
- 72-75%
- Classical C-section scar (longitudinal), previous uterine rupture
Perineal tears (1-4) & mx
- Superficial - skin only –> conservative
- Deep; skin + perineal muscle –> suture on ward
- Extends to anal sphincter –> theatre
- Extends to anal mucosa/rectum –> theatre
PPH:
Can be prevented by active mx of 3rd stage (IM oxytocin); tranexamic acid in C-section, antenatal control.
* define minor and major (moderate, severe).
* Define primary vs secondary
* Causes of PPH: Primary - 4 Ts (what is most common) and Secondary (2)
Bleeding within the 3rd stage of labour (after vaginal delivery or C-section).
* Minor = 500-1000ml
* Major = >1000 (moderate); >2000(severe)
* Primary = within 24 hrs of birth
* Secondary = 24hrs –> 12wks post birth
Causes
- Tone - Uterine atony (failure of uterus to vasoconstrict after delivery)
- Tissue - RPOC; retained placental tissue
- Trauma - e.g. during C-section, instrumental delivery
- Thrombin - existing bleeding disorder
Typically cause secondary (24hours - 6 weeks)
- RPOC or infection (endometritis)
PPH Emergency Mx
- initial
- stopping bleeding (mechanical, medical, surgical)
- Rare complication of PPH
- Resus; A-E (oxygen)
- 2 x grey cannula (bloods - FBC, U&E, coag screen)
- cross match 4 units blood
- IV crystalloid (warmed) and blood resus (+ FFP if nec)
If severe –> active major haemorrhage protocol –> 4 units O neg blood
Stopping bleeding
Mechanical - uterine compression (10mins) & catheterisation
Medical - - Oxytocin IM–> IV.
- Ergometrine - unless hx of HTN
- Carboprost - unless hx of asthma
- Misoprostol
+/- Tranexamic acid
Surgical -
1.** Intrauterine Bakir catheter (balloon tamponade)**
2.Alternatives: B-Lynch suture, uteirne artery ligation, hysterectomy (last resort)
Sheehan’s syndrome = anterior pituitary avascular necrosis.
Massive blood loss –> reduced perfusion to anterior pituitary –> depleting TSH, FSH, LH, ACTH, prolactin, GH. Mx with hormone replacement.
HELLP syndrome
- Complication of pre-eclampsia - can lead to DIC
- Haemolysis, Elevated Liver enzymes, Low Plt
- Abdominal pain (R sided - liver inflammation) N+V, HTN
Requirments for forceps delivery: FORCEPS.
* And contra-indications for instrumental delivery in general?
* Indications for forceps delivery (3)
* Preterm births can have instrumental delivery but only one type - which is it?
* Advantage for forceps?
- Fully diated cervix
- OA/OP position
- ROM
- Cephalic presentation
- Engagement (of fetal head within pelvis)
- Pain relief
- Sphincter empty - catheter
CIs for instrumental
* cervix not dilated, non engagement, large fetal head
Indications for forceps
* 2nd stage - FTP or maternal/fetal distress
* Control of ehad in breech delivery
type of instrumental for prem
* Forceps (can’t use venthouse suction cup on preterm; risk of cephalohaematoma etc)
advantage
* Forceps doesn’t require maternal effort and has a higher success rate.
Breech
* 3 main types
* Mx options at 36 weeks
* Is vaginal birth possible with breech presentation?
* Complications
- Complete (hips flexed, knees flexed), Frank (hips flexed, knees extended), footling (one hip extended; foot/buttock presenting part)
- ECV + Terbutaline (uterine muscle relaxant) at 36wk. If fails or CIed (e.g. past C-section/haemorrhage) –> C-section.
- Vaginal birth possible but not advised (?hands off approach, or other manouvres e.g. Lovsette’s/MSV)
- Cord prolapse, asphyxia, ICH, DDH (requires US at 6 weeks)
Shoulder dystocia
* Main risk factor
* Signs (3)
* Immediate mx: call for help; advise to stop pushing, don’t pull. Episiotomy.
* Manouvres (1st line & other options)
* Complications
- Macrosomia; maternal DM
- Turtle neck sign; failure of rotation
- McRobert’s (knee flexion) + suprapubic pressure
- Rubin’s & screw manouvres
- Posterior shoulder pressure
- Hypoxia, Erb’s palsy, PPH etc.
Cord-prolapse:
can result in fetal hypoxia and death. Risk factors - ARM, polyhydramnios, multiple pregnancy, breech presentation, PROM (waters break before fetus has moved into birth canal). Can be diagnosed by:
1. Abnormal CTG (fetal bradycardia) and palpable cord in vagina
2. VIsible cord beyond level of introitus
Mx(3) - 3 initial management steps before definitive delivery
Alternatives to that method of delivery?
What else can help to reduce uterine contractions?
What can help to elevate presenting part of fetus from crushing the cord?
- Presenting part of fetus pushed back into uterus to avoid compression.
- If cord below introitus –> minimal handling; keep cord warm and moist.
- All-4s OR left lateral position –> C section
- Alternative - instrumental delivery if head is low and cervix fully dilated
- Tocolytics
- Retro-filling bladder with saline
The puerperium
* 3 physical changes after birth
* Typical blood finding 1/7 after
* Sign of post-partum endometritis, and risk factors (2)
* What is the normal pattern of postpartum thyroiditis?
- Uterine involution (6-8wk, cramps)
- Lochia (discharge: blood, endometrial tissue, mucus: dark red–> brown –> yellow; 6-8wk; avoid tampons)
- Leucocytosis
- Foul smelling lochia + abdominal pain, menorrhagia + fever. ERPC (for RPOC) & C-section. Mx with abx community/hospital.
- 3mo -Throtoxicosis –> 6mo -hypothyroid –> 1yr - return to normal. Treat like normal with meds.
