Obs 2017 Flashcards
When / what is done in the booking visit?
When is the combine test?
When is the anomaly scan?
Before 10 weeks - screen for complications
-urine culture, FBC, antibody screen, syphilis, rubella. HIV, hep b
11-13wks
18-21 weeks
What does the combine test involve? Levels in downs ? Other disease it looks for? What is offered if there is a 1 in 150 risk of downs or more?
Blood sample
- pregnancy associated plasma protein-A (PAPP-A)
- Free B-hCG
Ultra sound scan
-Nuchal translucency
Downs - PAPPA=low, NT/BHCG=raised
Edwards
Another US and CVS or amniocentesis
What happens in an anomaly scan (20 week scan)? What 3 things are measured ?
US Shape of brain and head Check cleft lip Spine Abdo wall covers organs Heart Kidneys Hands and feet Placenta
Will measure - head circumference, abdominal circumference, femur length
What is amniocentesis?
When is it Safe?
What can it diagnose?
What is the risk?
Ultrasound guided removal of a sample of amniotic fluid
Safest from 15 week gestation
Can diagnose chromosomal abnormalities, infections (e.g. CMV), inherited disorders (e.g. sickle cell anaemia, cystic fibrosis)
Risk of miscarriage (1%)
What is cvs? When can it be done? What advantage over amniocentesis?
Biopsy of trophoblast
Done after 11 weeks
Earlier than amniocentesis so abortion could still be performed if abnormality identified
Treatment of pulmonary oedema as a complication of pre eclampsia
Furosemide, oxygen
Maternal complications of pre eclampsia?
Eclampsia: grand mal seizures, Tx magnesium sulphate
Cerebrovascular haemmorhage
‘HELLP’ syndrome: Haemolysis, Elevated Liver enzymes, Low Platelets
Other: DIC, liver failure, liver rupture
Renal Failure
Pulmonary oedema, Tx furosemide, oxygen
Fetal complications of pre eclampsia
IUGR
Placental abruption
Preterm birth
3 aspects of screening / prevention of pre eclampsia
Regular BP and urinalysis checks, uterine artery doppler, 75mg aspirin starting before sixteen weeks in high risk women.
Mx of pre eclampsia
When do you use antihypertensives?
Steroids?
Delivery time?
Antihypertensives if BP >150/100,
Steroids if moderate/severe at <34wks
Delivery: Mild by 37 wks, moderate/severe 34-36 wks, maternal complications deliver whatever the gestation
Which type of maternal antibody crosses the placenta in RBC isoimmunization?
IgG
What scalp pH would indicate significant fetal hypoxia
<7.2
4 methods of induction
Prostaglandins:
Prostaglandin E2 gel
Inserted into the vagina posterior to the cervix
Starts labour or alters the ripeness of the cervix allowing amniotomy
Amniotomy:
Artificial rupture of the membranes using an amnihook
Natural Induction:
Cervical sweeping
Use of finger to strip between membranes and uterus
Oxytocin:
Used alone if there is spontaneous rupture of membranes or following amniotomy after around 2 hours if labour hasn’t started
Ix and management of placenta previa
Investigations
FBC, U&E, Clotting, Group and save
USS
CTG
Management Admit (until delivery if previa) Resuscitation Steroids Anti-D (if resus negative) C-section
Absolute CI to VBAC ?
Placenta/vasa previa
Cephalopelvic disproportion
4 ways f preventing vertical transmission of HIV?
Maternal ART
Elective C/S
Avoid breast feeding
Neonatal ART
What is in the quadruple test for downs?
B-hCG, AFP, Inhibin-A and free estriol 3 (after 14 weeks)
Vomiting in pregnancy in around 50% but what is hyperemesis gravidarum ? Mx?
Severe vomiting with dehydration and electrolyte abnormalities
IV rehydration, anti-emetics, thiamine and psychological support
Cause? Diagnosis and mx of gestational diabetes?
Increased insulin resistance
Glucose tolerance test at 24-28 weeks
Metformin 1st line
Insulin 2nd line
Intrahepatic cholestasis of pregnancy ix? Risk? Mx?
LFT
Bile acid levels
Risk of premature birth
Induce at 37 weeks
Ursodeoxycholic acid
Vit k if prolonged clotting
Physiological changes in pregnancy
CV
- Increase CO, HR
- Decrease serum albumin
- Increase in coagulation
- Vena cava compression by uterus
Kidneys
-Increase GFR
Lungs
-Increase tidal volume and resp rate
GI
- n+V
- delayed gastric emptying
- prolonged small bowel transit time
Mx of PPH
ABC
Retained placenta removal if not expelled in 60 mins
Atony PGF2a into the myometrium
EUA
Rescue methods
Rusch balloon
Brace suture
Hysterectomy
Usual cause of of perinatal sepsis and chorioamnionitis?
Group A strep
Risks of HIV in pregnancy? Prevent transmission by?
IUGR, Still birth, pre-eclampsia, prematurity (gestational DM in mother)
Preventing vertical transmission Maternal ART Elective C/S Avoid breast feeding Neonatal ART
Parovirus b19 causes?
Anaemia
Tobacco in pregnancy?
Cocaine?
Tobacco
increase miscarriages, prematurity, PROM, abruption and praevia
Cocaine
= abruption in examland
What is gravity and parity?
Gravidity: The number of pregnancies that a woman has had, to any stage.
Parity: The number offspring that a woman has delivered beyond week 28.
Method of reducing pain in labour without drugs?
Waterbirth
When is entonox (NO) CI?
Pneumothorax
What narcotic injection can be given in labour? When should it not be given? How to reverse?
Pethidine IM 50-150mg
Not given if birth expected in 2 hours - due to neonatal respiratory depression
Naloxone to reverse
When do you need to be careful with epidural?
In mothers receiving heparin
What can be used for instrumental delivery for pain relief?
Pudendal block
-lidocaine injected into area containing sacral nerve routes
2 types of small for GA?
Constitutionally small - Approriate size for maternal size and ethnicity
IUGR - growth is normal in early part and then slows by at least 2 measurements
Maternal and fetal RF for IUGR
Maternal Age Maternal weight extremes Smoking Alcohol Hx Anaemia Hypertension
Fetal Multiple gestation Chromosomal TORCH infection Placental dysfunction
Mx of IUGR ?
Complications ?
Increased monitoring
Umbilical artery Doppler
Short term
- Meconium aspiration
- hypothermia
- Feeding difficulties
- jaunduce
- NEC
Long term
-Learning difficulties, CP
Define hyperemisis gravidarum
Persistent vomiting in pregnancy which causes weight loss and ketosis
Rf for hyperemesis?
Young
Primi
Hyperthyroid
Multiple pregnancy
Define chronic hypertension?
Gestational hypertension?
Chronic Hypertension: HTN pre-dating pregnancy or which develops before 20 weeks gestation.
Gestational Hypertension: HTN after 20 weeks gestation which is not complicated by proteinuria.
Mx of chronic hypertension in pregnancy
STOP ACEi, ARB
Give labetalol aim for <150/90
Give aspirin from 12th week
Reversal of magnesium toxicity if given?
Calcium glucornate
Define placenta acretta? Next 2 severities?
Mx?
Placenta accreta: chorionic villi penetrate the decidua basalis to attach to the myometrium.
Placenta increta; the villi penetrate deeply into the myometrium.
Placenta percreta: the villi breech the myometrium into the peritoneum.
C section ± hysterectomy
Ectopic Ix? Mx?
Investigation
TVUS
Repeat
Management
Medical: Oral methotrexate to cause fetal death (warn of pain and ensure f/u arranged)
Surgical
Salpingectomy – remove entire tube and fetua
Salpingotomy – remove affected section of tube only (allows fertility to be preserved)
Rf for PPH.
Bmi >35 Uterine malformations / fibroids Antepartum haemairrhage Prolonged labour Use of oxytocin
Management of primary PPH
Give oxytocin 5u slowly (IV)
Give high flow oxygen
If signs of shock (ABCDE approach), give Gelofusine or Blood transfusion (ideally matched but O –ve in emergency)
Is the placenta delivered? If not – explore uterus.
Is there trauma? If so – correct.
MX of retained placenta if uterus well contracted? If bulky?
If the uterus is well contracted, the placenta is probably separated but trapped by the cervix. Wait for the cervix to relax, and release the placenta.
If the uterus is bulky, the placenta may have failed to separate:
Rub up a contraction
Give 20u oxytocin into umbilical vein
If still no placental delivery after 30 min, consider need for manual removal.
Manual removal of placenta how?
Epidural
Use a hand and separate placenta
Prophylactic Abx (Doxy and metronidazole) are required
Classic sx of amniotic fluid embolism ?
Mx?
Sudden dyspnea and hypotension
±seizures, DIC, Pulm oedema
1- Prevent death from respiratory failure: Oxygen +/- ventilatory support
2- Obtain IV access in case DIC develops.
3- If hypotensive give fluids rapidly, but don’t over hydrate to avoid pulmonary oedema.
4- Transfer to ICU
5- If the mother dies, peri-mortem CS is indicated, and this may aid resuscitation of the mother.
Indications for operative delivery
Delay or exhaustion in second stage
Reduced urge to push - eg epidural
Malposition of head
Fetal distress
