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Obs Flashcards

1
Q

What assessments should you always do at every antenatal appointment?

A 
General maternal well-being
BP
Urinalysis
Fetal movements
FHR (USS or doppler) 
Measure and plot SFH
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2
Q

RF for ectopic pregnancy

A 
IUD
Previous ectopic
Woman with tubal defects 
Previous PID
IVF
Older maternal age
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3
Q

Symptoms of ruptured ectopic

A

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

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4
Q

Investigations for suspected ectopic

A

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) ?

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5
Q

What factors would allow expectant management of unruptured ectopic?

A

<35mm
No fetal Hb
bHCG <1000
No pain

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6
Q

What is medical management of ectopic and when should you use it?

A 
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
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7
Q

What other investigation do you need to do for a woman with ectopic?

A

Rhesus status - give anti-D if negative

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8
Q

First investigation in first trimester bleed?

A

Pregnancy test - check if complete miscarriage

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9
Q

2nd line investigation in first trimester bleeding? and what do results mean?

A

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)

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10
Q

Investigation for suspected molar pregnancy and findings?

A

Pregnancy test

TV USS –> ‘snowstorm’ appearance

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11
Q

Sx of molar pregnancy

A 
Vomiting (caused by high levels of bHCG)
PV bleeding (spotting/heavy)
Other normal pregnancy changes
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12
Q

How does a partial molar pregnancy form?

A

Two sperm fuse with egg cell

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13
Q

How does a complete molar pregnancy form?

A

A sperm cell fertilise an ‘empty’ ovum (has no genetic material). So only trophoblastic tissue forms.

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14
Q

Management of molar pregnancy

A

Surgical evacutation –> suction curettage

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15
Q

What can a molar pregnancy turn into?

A

Choriocarcinoma (rare malignant tumour of trophoblastic cells)
(Check to see if hCG still increasing)

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16
Q

Presentation of threatened miscarriage (Sx and USS findings)

A

Painless PV bleeding and closed cervical OS

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17
Q

Ectopic pregnancy: If fetal heartbeat is present, what type of management must be used?

A

Surgical

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18
Q

Date of booking scan

A

10 weeks

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19
Q

Date of dating scan

A

10-13+6 weeks

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20
Q

Date of anomaly scan

A

18-20 weeks

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21
Q

Bloods at booking scan?

A 
Anaemia
Rhesus status
Sickle cell
Thalassaemia
Infectious diseases --> HIV, Hep B, syphillis, rubella
GD if RFs

Non routine: Hep C

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22
Q

Treatment for high resk of pre-eclampsia and when?

A

150mg Aspirin OD from 12 weeks –> delivery

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23
Q

Treatment for baby if mother is hep B positive?

A

(High chance of infection)

6 weeks post birth - give hep B vaccinations.

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24
Q

RF for chromosomal abnormalities

A

Older maternal age
FHx
Consanguinity

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25
Q

What is the quadruple test?

A

If missed combined screen. 14+2 - 20+0 weeks.

AFP (low abnormal)
hCG (high abnormal)
Oestriol (low abnormal)
Inhibin A (high abnormal)

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26
Q

Why do pregnant women get constipation? & management

A

Progesterone reduces smooth muscle tone, affects bowel activity. (not worrying!)
Iron tablets exacerbate.

Lifestyle
Lactulose (osmotics)

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27
Q

Why do pregnant women get heart burn? Management?

A

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

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28
Q

Differentials for nausea and vomiting in pregnancy?

Management?

A

HG
Multiple pregnancy
Molar pregnancy

Lifestyle
Acupressure on wrists
Antiemetics (ondansetron, cyclizine) & fluid replacement

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29
Q

Hyperemesis Gravidarum diagnostic triad

A

5% weight loss
Dehydration (clinical signs)
Electrolyte imbalance

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30
Q

Investigations for HG?

A 
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
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31
Q

Admission criteria and complications for HG?

A 
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)
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32
Q

Pathological causes of small for dates baby?

A 
Pre-existing maternal disease (AID, renal)
Smoking
Drug usage
Pre-eclampsia
Infections (e.g. CMV)
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33
Q

IUGR management

A 
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
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34
Q

Key points for delivery of LGA baby?

A 
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
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35
Q

GD risk factors

A 
BMI >30
Prev baby >4.5
Diabetes 
PCOS
Afro-caribbean/middle eastern/south asian ethnicity
1st degree relative with diabetes
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36
Q

Why does left lateral position work?

A

Prevents IVC compression which sends more blood to baby

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37
Q

Management for RFM?

A

Doppler - confirm heart beat

No heartbeat –> immediate USS
Heartbeat –> CTG for 20 mins

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38
Q

Difference between pregnancy induced HTN, pre-exisitng HTN and pre-eclampsia

A

Pre-existing = Before 20 weeks
Pregnancy induced = After 20 weeks
Pre-eclampsia = Hypertension + proteinuria in >20 weeks

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39
Q

Management of HTN in pregnancy?

A

Stop ACEi and ARBs –> teratogenic
Manage with labetalol (2nd line nifedipine/methyldopa)
Aim for BP <150/100 (140/90 if end organ damage)

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40
Q

What level of HTN needs hospital admission?

A

BP >160/100

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41
Q

High risk factors for pre-eclampsia?

A 
Chronic HTN
Pre-eclampsia in previous pregnancy 
Pre-existing CKD
Diabetes Mellitus
Autoimmune disease (SLE, antiphospholipid syndrome)
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42
Q

Treatment of eclampsia

A

Magnesium sulphate

Delivery

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43
Q

Fetal blood sampling pH ranges and management?

A

> 7.25 = normal
7.20 - 7.25 = borderline, repeat in 30 mins and continue CTG
<7.20 = abnormal. Deliver immediately.

44
Q

What are the 3 stages of established labour?

A 
1st stage (latent = 0-4cm, active = 4-10cm)
2nd stage (full dilatation --> baby)
3rd stage (placenta delivery)
45
Q

What are the fetal positions in each mechanism of labour?

A 
Descent
Engagement 
Neck flexion
Internal rotation
Crowning
Extension of presenting part 
Restitution (external rotation)
Internal rotation
46
Q

What is active management of the 3rd stage of labour? (and why is it done?)

A

Active management prevents PPH

Rub uterine fungus to help contraction
Controlled cord traction with counter pressure above pubic bone
Give syntometrine
Delayed cord clamping

47
Q

Different degrees of perineal tears?

A

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

48
Q

In which direction is an episiotomy cut made?

A

Mediolateral

49
Q

Risks/benefits of VBAC?

A

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

50
Q

How to manage shoulder dystocia?

A 
McRoberts Manoeuvre (knees to chest)
Suprapubic pressure 
2nd line: internal rotation, deliver posterior arm
51
Q

When would membrane sweep and IOL be offered?

A

Membrane sweep = from 40+0 weeks in nulliparous and 41+0 weeks in multiparous

IOL = 41+0 - 42+0

51
Q

When would membrane sweep and IOL be offered?

A

Membrane sweep = from 40+0 weeks in nulliparous and 41+0 weeks in multiparous

IOL = 41+0 - 42+0

51
Q

When would membrane sweep and IOL be offered?

A

Membrane sweep = from 40+0 weeks in nulliparous and 41+0 weeks in multiparous

IOL = 41+0 - 42+0

52
Q

What is Bishop’s score?

A

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
53
Q

How to carry out cervical ripening?

A

Prostaglandin pessary / gel

54
Q

Postpartum haemorrhage definitions

A 
Primary = within 24h of birth
Secondary = 24 hour - 12 weeks

Minor PPH = <1000ml loss
Moderate PPH = 1000ml-2000ml loss
Severe PPH = >2000ml loss

55
Q

Causes of PPH

A

TONE - Uterus fails to contract
TRAUMA - tears, episiotomy, c-section
TISSUE - retention of placental tissue prevents uterine contraction
THROMBIN - coagulopathy, placental abruption, hypertension

56
Q

Preventative measures for PPH?

A

Empty bladder
Active management of 3rd stage of labour
IV tranexamic acid during CS in third stage

57
Q

Definitive management of PPH

A

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

57
Q

Definitive management of PPH

A

Bimanual compression

Oxytocin 
Ergometrine IM/IV
Carboprost IM
Misoprostol SL 
Tranexamic acid

Surgical = uterine balloon tamponade, B-lynch suture, uterine artery ligation, hysterectomy

58
Q

Indications for induction of labour

A

Post-dates (>41 weeks)
Maternal illness (or GDM etc)
Foetal distress

59
Q

Mechanism of induction of labour

A

Stretch and sweep
Prostaglandins (pessary 24h/gel) - Promotes cervical effacement
ARM
Syntocin - Promotes uterine contractions. Start low and increase every 30 mins.

60
Q

Definition and stages of labour

A

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

61
Q

PPH causes

A

TONE - uterine atony (most common)
TISSUE - retained placental tissue
THROMBIN - coagulopathy/vascular abnormality
TRAUMA - tears, episiotomy, C-section

62
Q

PPH treatment

A

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

63
Q

Normal/abnormal times for each stage of labour =

A

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

64
Q

Assessment of woman post-birth

A 
PPH
Endometritis
Surgical complications
Breast Feeding
Depression
Contraception
VTE
Eclampsia
65
Q

SGA investigations

A

Thorough Hx
Examination
USS and doppler - head, abdo circumference. Serial measurements.

66
Q

Findings on FBS and what they mean

A

> 7.25 normal
7.20 - 7.25 = repeat in 1/2 hour
<7.20 delivery

67
Q

Most common cause of indirect maternal death

A

Cardiac

68
Q

Difference between monozygotic and dizygotic twins

A 
Monozygotic = identical: same ovum splits into two
Dizygotic = non-identical: two different ova
69
Q

Which way round are the chorion and amnion

A

Amnion on inside next to baby, chorion on outside

70
Q

Investigations for small for dates

A 
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
71
Q

USS umbilical artery doppler - what are you looking for and what does it mean?

A

End diastolic flow

Absence or reversal = baby isn’t getting blood = emergency delivery

72
Q

How to send a cross match / group & save

How to activate MHP

A

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
73
Q

What are the mechanisms of established labour?

A 
Flexion and descent (engagement)
Internal rotation
Extension
Restitution (external rotation)
Delivery of anterior shoulder
Delivery of posterior shoulder
74
Q

What does Bishop’s score indicate and at what score/

A

Ripeness of cervix and thus likelihood of spontaneous delivery

>8 = IOL will be successful
<8 = cervical ripening needed
75
Q

CS counselling:

Risks

A 
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
76
Q

Suspected miscarriage. USS shows amniotic sac with CRL 6mm, no visible heart beat. Management?

A

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.

77
Q

Woman 5 weeks pregnant. Presents with vaginal bleeding. USS shows empty uterus. Diagnosis and management?

A

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

78
Q

Management of miscarariage

A

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 !!!

79
Q

At what level of bHCG are you sure an ectopic pregnancy is present?

A

> 1500

80
Q

In which patients can you use methotrexate to manage ectopic pregnancy?

A

Stable patient
Fetal length <35mm
Pain controlled
No visible heart beat

81
Q

Most common site of ectopic pregnancy

A

Ampulla

82
Q

When is placenta praevia normally diagnosed?

A

20 week anomaly scan

83
Q

Management of stable placenta praevia

A

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)

84
Q

When is a placenta considered low lying vs praevia?

A

Low lying = less than 20mm from os

Praevia = overlying os itself

85
Q

Management of bleeding in placenta praevia

A 
Stabilise mother
CTG
TVUSS
Anti D
Rescan at 32 weeks

Do not speculum - may disturb praevia.

86
Q

Complications of abruption

A

Foetal death

DIC –> give platelets, FFP, blood

86
Q

Complications of abruption

A

Foetal death

DIC –> give platelets, FFP, blood

87
Q

Treatment of eclampsia & management afterwards

A 
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
88
Q

RFs for amniotic fluid embolism

A 
Multiple pregnancy
Increasing maternal age
Induction of labour
CS / instrumental
Eclampsia 
Polyhydramnios
89
Q

Management of shoulder dystocia

A

Stop pushing, apply downward traction, consider episiotomy

  1. McRoberts Manoeuvre (knees to chest)
  2. Suprapubic pressure
  3. Posterior arm manoeuvres and internal rotation
90
Q

Rfs for shoulder dystocia

A 
Macrsomia
Previous shoulder dystocia
High BMI
Induction
Prolonged 1st stage / 2nd stage 
Augmentation of labour with oxytocin
91
Q

Management of cord prolapse

A

Elevate presenting part of baby (without touching cord !!!)
Mum in left lateral / McRoberts
Tocolysis
Emergency CS (unless delivery imminent)

92
Q

Most common cause of primary PPH

A

Uterine Atony

93
Q

Most common cause of secondary PPH & management

A

Retained products

Antibiotics & evacuation

94
Q

Why does a ruptured ectopic cause shoulder tip pain?

A

Phrenic nerve irritation caused by diaphragmatic irritation.

95
Q

Key points on TVUSS to recommend medical management over surgical for ectopic pregnancy?

A

Heartbeat
Size (< around 5cm)
Free fluid (suggests rupture)

96
Q

What urinary PCR level is significant for pre-eclampsia?

A

> 30mg

97
Q

Management of eclampsia

A

IV labetalol
IV mag sulphate
Steroids for fetal lung development

98
Q

At what number of weeks should you do a CTG to check for fetal distress?

A

> 26

99
Q

Which antibiotics to treat chorioamnionitis

A

Cefuroxime

100
Q

Which antibiotics to treat chorioamnionitis

A

Cefuroxime + metronidazole

101
Q

Most common causes of maternal death

A

Sepsis
PET (CS important RF!)
VTE Cardiac
Mental health (13%)

GOSH (3 decks)

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