Obs Flashcards
What assessments should you always do at every antenatal appointment?
General maternal well-being BP Urinalysis Fetal movements FHR (USS or doppler) Measure and plot SFH
RF for ectopic pregnancy
IUD Previous ectopic Woman with tubal defects Previous PID IVF Older maternal age
Symptoms of ruptured ectopic
Lower abdo/pelvic pain - sudden onset, sharp, severe pain
Small amount of PV bleed
6-8 w amennorhea
Abdo tenderness + mass
Cervical motion tenderness (but shouldn’t examine!)
Shoulder tip pain
Peritonitis
Shock/haemodynamic instability
Investigations for suspected ectopic
Pregnancy test
TVUSS (location, FHR)
- Mass
- Free fluid in pouch of Douglas
Serum hCG and repeated 48 hours after (in normal pregnancy bCHG should double in 48h, rise of >66% indicates not ectopic) ?
What factors would allow expectant management of unruptured ectopic?
<35mm
No fetal Hb
bHCG <1000
No pain
What is medical management of ectopic and when should you use it?
IM Methotrexate (stops cell division of fetus) (SE: photosensitivity, pregnancy issues). Requires follow up. Then measure hCG.
Stable patient <35mm No significant pain No fetal Hb <1500 bHCG
What other investigation do you need to do for a woman with ectopic?
Rhesus status - give anti-D if negative
First investigation in first trimester bleed?
Pregnancy test - check if complete miscarriage
2nd line investigation in first trimester bleeding? and what do results mean?
TV/TAUSS –>
Empty uterus = pregnancy of unknown location (ectopic, early, miscarriage).
(if early, bHCG should double in 48h, if ectopic <66% rise, miscarriage reduce)
Intrauterine pregnancy correct size –> OS open = inevitable miscarriage, OS closed = reassure (threatened miscarriage)
Investigation for suspected molar pregnancy and findings?
Pregnancy test
TV USS –> ‘snowstorm’ appearance
Sx of molar pregnancy
Vomiting (caused by high levels of bHCG) PV bleeding (spotting/heavy) Other normal pregnancy changes
How does a partial molar pregnancy form?
Two sperm fuse with egg cell
How does a complete molar pregnancy form?
A sperm cell fertilise an ‘empty’ ovum (has no genetic material). So only trophoblastic tissue forms.
Management of molar pregnancy
Surgical evacutation –> suction curettage
What can a molar pregnancy turn into?
Choriocarcinoma (rare malignant tumour of trophoblastic cells)
(Check to see if hCG still increasing)
Presentation of threatened miscarriage (Sx and USS findings)
Painless PV bleeding and closed cervical OS
Ectopic pregnancy: If fetal heartbeat is present, what type of management must be used?
Surgical
Date of booking scan
10 weeks
Date of dating scan
10-13+6 weeks
Date of anomaly scan
18-20 weeks
Bloods at booking scan?
Anaemia Rhesus status Sickle cell Thalassaemia Infectious diseases --> HIV, Hep B, syphillis, rubella GD if RFs
Non routine: Hep C
Treatment for high resk of pre-eclampsia and when?
150mg Aspirin OD from 12 weeks –> delivery
Treatment for baby if mother is hep B positive?
(High chance of infection)
6 weeks post birth - give hep B vaccinations.
RF for chromosomal abnormalities
Older maternal age
FHx
Consanguinity
What is the quadruple test?
If missed combined screen. 14+2 - 20+0 weeks.
AFP (low abnormal)
hCG (high abnormal)
Oestriol (low abnormal)
Inhibin A (high abnormal)
Why do pregnant women get constipation? & management
Progesterone reduces smooth muscle tone, affects bowel activity. (not worrying!)
Iron tablets exacerbate.
Lifestyle
Lactulose (osmotics)
Why do pregnant women get heart burn? Management?
Progesterone relaxes smooth muscle - relaxes GO sphincter which causes gastric reflux, which WORSENS with increasing intra-abdominal pressure
1) Lifestyle –> sleep up, avoid spicy foods, light meals
2) Alginate preparations and simple antacids
3) H2 receptor antagonists
Differentials for nausea and vomiting in pregnancy?
Management?
HG
Multiple pregnancy
Molar pregnancy
Lifestyle
Acupressure on wrists
Antiemetics (ondansetron, cyclizine) & fluid replacement
Hyperemesis Gravidarum diagnostic triad
5% weight loss
Dehydration (clinical signs)
Electrolyte imbalance
Investigations for HG?
PUQE scoring system USS to exclude multiple/molar pregnancy MSU - UTI FBC - increase in haematocrit U&E - K+, Na+, metabolic alkalosis LFT - increase transaminases, decrease albumin
Admission criteria and complications for HG?
ADMISSION Weight loss >5% Failure of antiemetics in controlling Tx Ketones (2+) on dipstick Other medical condition present
COMPLICATIONS Liver/renal failure Hypnoatraemia Thiamine deficiency --> wernicke's Fetal growth restriction Fetal death (wernickes' encepatholopathy)
Pathological causes of small for dates baby?
Pre-existing maternal disease (AID, renal) Smoking Drug usage Pre-eclampsia Infections (e.g. CMV)
IUGR management
Doppler If abnormal - review at least 2x a week - Try to get pregnancy to at least 34 weeks - steroids for baby's lungs - Daily CTG - C section if consistently abnormal
Key points for delivery of LGA baby?
Delivery on consultant lead unit Experienced midwife/obstetrician Access to theatre if needed Active management of 3rd stage Early decision for CS if needed Paediatrician attending
GD risk factors
BMI >30 Prev baby >4.5 Diabetes PCOS Afro-caribbean/middle eastern/south asian ethnicity 1st degree relative with diabetes
Why does left lateral position work?
Prevents IVC compression which sends more blood to baby
Management for RFM?
Doppler - confirm heart beat
No heartbeat –> immediate USS
Heartbeat –> CTG for 20 mins
Difference between pregnancy induced HTN, pre-exisitng HTN and pre-eclampsia
Pre-existing = Before 20 weeks
Pregnancy induced = After 20 weeks
Pre-eclampsia = Hypertension + proteinuria in >20 weeks
Management of HTN in pregnancy?
Stop ACEi and ARBs –> teratogenic
Manage with labetalol (2nd line nifedipine/methyldopa)
Aim for BP <150/100 (140/90 if end organ damage)
What level of HTN needs hospital admission?
BP >160/100
High risk factors for pre-eclampsia?
Chronic HTN Pre-eclampsia in previous pregnancy Pre-existing CKD Diabetes Mellitus Autoimmune disease (SLE, antiphospholipid syndrome)
Treatment of eclampsia
Magnesium sulphate
Delivery
Fetal blood sampling pH ranges and management?
> 7.25 = normal
7.20 - 7.25 = borderline, repeat in 30 mins and continue CTG
<7.20 = abnormal. Deliver immediately.
What are the 3 stages of established labour?
1st stage (latent = 0-4cm, active = 4-10cm) 2nd stage (full dilatation --> baby) 3rd stage (placenta delivery)
What are the fetal positions in each mechanism of labour?
Descent Engagement Neck flexion Internal rotation Crowning Extension of presenting part Restitution (external rotation) Internal rotation
What is active management of the 3rd stage of labour? (and why is it done?)
Active management prevents PPH
Rub uterine fungus to help contraction
Controlled cord traction with counter pressure above pubic bone
Give syntometrine
Delayed cord clamping
Different degrees of perineal tears?
1st degree = vaginal epithelium + vulval skin injury
2nd degree = perineal muscles, not anal sphincter (equivalent to episiotomy)
3rd degree = perineum and anal sphincter
4th degree = anal sphincter and rectal mucosa
In which direction is an episiotomy cut made?
Mediolateral
Risks/benefits of VBAC?
RISKS
Uterine rupture risk increased (0.5%)
Risk of anal sphincter injury
Risk of hypoxic ischaemic encephalopathy (HIE) to neonate (0.08%)
Risk of stillbirth >39 weeks while awaiting spontaneous labour
BENEFITS
Lower overall risk of maternal death
Good chance for future VBACS if successful
Lower risk of transient respiratory difficulties in neonate
How to manage shoulder dystocia?
McRoberts Manoeuvre (knees to chest) Suprapubic pressure 2nd line: internal rotation, deliver posterior arm
When would membrane sweep and IOL be offered?
Membrane sweep = from 40+0 weeks in nulliparous and 41+0 weeks in multiparous
IOL = 41+0 - 42+0
When would membrane sweep and IOL be offered?
Membrane sweep = from 40+0 weeks in nulliparous and 41+0 weeks in multiparous
IOL = 41+0 - 42+0
When would membrane sweep and IOL be offered?
Membrane sweep = from 40+0 weeks in nulliparous and 41+0 weeks in multiparous
IOL = 41+0 - 42+0
What is Bishop’s score?
Measures likely success of induction - deduces ripeness of cervix
Score >8 means ready for IOL.
Measures: Length Cervical dilation Consistency of cervix Position of cervix Fetal station
How to carry out cervical ripening?
Prostaglandin pessary / gel
Postpartum haemorrhage definitions
Primary = within 24h of birth Secondary = 24 hour - 12 weeks
Minor PPH = <1000ml loss
Moderate PPH = 1000ml-2000ml loss
Severe PPH = >2000ml loss
Causes of PPH
TONE - Uterus fails to contract
TRAUMA - tears, episiotomy, c-section
TISSUE - retention of placental tissue prevents uterine contraction
THROMBIN - coagulopathy, placental abruption, hypertension
Preventative measures for PPH?
Empty bladder
Active management of 3rd stage of labour
IV tranexamic acid during CS in third stage
Definitive management of PPH
Empty bladder
Bimanual compression
Oxytocin 5 units IV infusion Ergometrine 0.5mg IM/IV Carboprost 0.25mg IM Misoprostol 1000 micrograms PR/SL Tranexamic acid IV
Surgical = uterine balloon tamponade, B-lynch suture, uterine artery ligation, hysterectomy
Definitive management of PPH
Bimanual compression
Oxytocin Ergometrine IM/IV Carboprost IM Misoprostol SL Tranexamic acid
Surgical = uterine balloon tamponade, B-lynch suture, uterine artery ligation, hysterectomy
Indications for induction of labour
Post-dates (>41 weeks)
Maternal illness (or GDM etc)
Foetal distress
Mechanism of induction of labour
Stretch and sweep
Prostaglandins (pessary 24h/gel) - Promotes cervical effacement
ARM
Syntocin - Promotes uterine contractions. Start low and increase every 30 mins.
Definition and stages of labour
Labour = cervical dilatation and strong regular contractions
1st stage = onset of labour (4cm) to full dilatation (10cm) (should be 1cm per hour)
2nd stage = Full dilatation to delivery (passive and active: urge to push)
3rd stage = placental dilatation
PPH causes
TONE - uterine atony (most common)
TISSUE - retained placental tissue
THROMBIN - coagulopathy/vascular abnormality
TRAUMA - tears, episiotomy, C-section
PPH treatment
ABCDE APPROACH
Fluid resucitaiton - up to 2L warmed crystalloid, 2L warmed colloid, then Onegative
IV tranexamic acid given during 3rd stage in all high risk patients.
THEN MEDICAL MANAGEMENT; (Oh Elp Can’t Make it sTop)
Oxytocin 40 units in 500ml IV
Ergometrine IV 500mcg (stimulates smooth muscle contraction)
Carboprost IM (prostaglandin analogue, stimulates contraction)
Misoprostol SL/PR (prostaglandin analogue)
Tranexamic acid IV
SURGICAL
Intrauterine balloon tamponade
Ligation of uterine arteries
Last resort = hysterectomy
Normal/abnormal times for each stage of labour =
1st stage = 3-8 hours. Should be 1cm per hour (abnormal =<1cm in 2 hours)
2nd stage = passive 1-2 hours, active 1 hour multi / 2 hours nulli (abnormal = >3 hours)
3rd stage = no more than 30 mins medical, 60 mins physiological
Assessment of woman post-birth
PPH Endometritis Surgical complications Breast Feeding Depression Contraception VTE Eclampsia
SGA investigations
Thorough Hx
Examination
USS and doppler - head, abdo circumference. Serial measurements.
Findings on FBS and what they mean
> 7.25 normal
7.20 - 7.25 = repeat in 1/2 hour
<7.20 delivery
Most common cause of indirect maternal death
Cardiac
Difference between monozygotic and dizygotic twins
Monozygotic = identical: same ovum splits into two Dizygotic = non-identical: two different ova
Which way round are the chorion and amnion
Amnion on inside next to baby, chorion on outside
Investigations for small for dates
USS growth surveillance Ratio of head and arm circumference Amniotic fluid volume - reduced in placental insufficiency Fetal anatomical survey Uterine artery doppler Karyotype Infection screen
USS umbilical artery doppler - what are you looking for and what does it mean?
End diastolic flow
Absence or reversal = baby isn’t getting blood = emergency delivery
How to send a cross match / group & save
How to activate MHP
Cross match / group & save = pink bottles. Two samples must be taken at two sites, by two different people, 40 minutes apart.
MHP:
- Activate if >50% blood loss in 3 hours (about 2500ml for average person)
- Call 2222 and ask for MHP.
- Receive: 6 units RBCs, 4 units FFP, 4 units platelets
What are the mechanisms of established labour?
Flexion and descent (engagement) Internal rotation Extension Restitution (external rotation) Delivery of anterior shoulder Delivery of posterior shoulder
What does Bishop’s score indicate and at what score/
Ripeness of cervix and thus likelihood of spontaneous delivery
>8 = IOL will be successful <8 = cervical ripening needed
CS counselling:
Risks
GENERAL RISKS: Common: - Infection - Bleeding - Pain - Next delivery ? a little more tricky Uncommon: - Organ damage (bladder) - Excessive bleed
MANAGEMENT:
- Blood transfusion
- Bladder repair
- Hysterectomy
- Readmission
BABY RISKS:
- Transient tachypnoea of the newborn
- Fetal lacerations
Suspected miscarriage. USS shows amniotic sac with CRL 6mm, no visible heart beat. Management?
Return for repeat scan in 7 days.
CRL <7mm is too small to have a heart beat, so cannot be sure whether fetus is still viable or not.
Woman 5 weeks pregnant. Presents with vaginal bleeding. USS shows empty uterus. Diagnosis and management?
PUL.
Serum HcG 2 results 48h apart
>63% increase = likely viable intrauterine & just very early rescan in 7-10 days
>50% decrease = pregnancy unlikely to continue, advise pregnancy test in 2/3 weeks
In between = ?ectopic
Management of miscarariage
Conservative –> Allow pass naturally. Pregnancy test in 3 weeks.
Medical –> vaginal/oral misoprostol
Surgical –> MVA under LA or surgical D&C (under GA)
+ Anti-D if over 12 weeks !!!
At what level of bHCG are you sure an ectopic pregnancy is present?
> 1500
In which patients can you use methotrexate to manage ectopic pregnancy?
Stable patient
Fetal length <35mm
Pain controlled
No visible heart beat
Most common site of ectopic pregnancy
Ampulla
When is placenta praevia normally diagnosed?
20 week anomaly scan
Management of stable placenta praevia
Repeat TVUSS at 32 and 36 weeks
Corticosteroids at 34 weeks (risk of preterm)
Plan delivery 36-37 weeks (CS - reduce risk of spontaneous delivery)
When is a placenta considered low lying vs praevia?
Low lying = less than 20mm from os
Praevia = overlying os itself
Management of bleeding in placenta praevia
Stabilise mother CTG TVUSS Anti D Rescan at 32 weeks
Do not speculum - may disturb praevia.
Complications of abruption
Foetal death
DIC –> give platelets, FFP, blood
Complications of abruption
Foetal death
DIC –> give platelets, FFP, blood
Treatment of eclampsia & management afterwards
ABCDE - left lateral Magnesium sulphate BP control - labetalol / hydralazine Continuous CTG Delivery PROMPTLY Monitor fluid balance --> AKI/oedema common risks
POSTNATAL CARE: Counsel RE next pregnancy Bloods at 72h including LFTs etc (HELLP) Check BP Consider CT head Follow up at 6 weeks
RFs for amniotic fluid embolism
Multiple pregnancy Increasing maternal age Induction of labour CS / instrumental Eclampsia Polyhydramnios
Management of shoulder dystocia
Stop pushing, apply downward traction, consider episiotomy
- McRoberts Manoeuvre (knees to chest)
- Suprapubic pressure
- Posterior arm manoeuvres and internal rotation
Rfs for shoulder dystocia
Macrsomia Previous shoulder dystocia High BMI Induction Prolonged 1st stage / 2nd stage Augmentation of labour with oxytocin
Management of cord prolapse
Elevate presenting part of baby (without touching cord !!!)
Mum in left lateral / McRoberts
Tocolysis
Emergency CS (unless delivery imminent)
Most common cause of primary PPH
Uterine Atony
Most common cause of secondary PPH & management
Retained products
Antibiotics & evacuation
Why does a ruptured ectopic cause shoulder tip pain?
Phrenic nerve irritation caused by diaphragmatic irritation.
Key points on TVUSS to recommend medical management over surgical for ectopic pregnancy?
Heartbeat
Size (< around 5cm)
Free fluid (suggests rupture)
What urinary PCR level is significant for pre-eclampsia?
> 30mg
Management of eclampsia
IV labetalol
IV mag sulphate
Steroids for fetal lung development
At what number of weeks should you do a CTG to check for fetal distress?
> 26
Which antibiotics to treat chorioamnionitis
Cefuroxime
Which antibiotics to treat chorioamnionitis
Cefuroxime + metronidazole
Most common causes of maternal death
Sepsis
PET (CS important RF!)
VTE Cardiac
Mental health (13%)
