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Phase 3a > Obs > Flashcards

Obs Flashcards

1
Q

What is gestational hypertension?

A

Blood pressure of over 140/90mmHg

OR increase in over 30mm/Hg systolic or 15mm/Hg diastolic compared with previous / booking BP

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2
Q

What is pre-eclampsia?

A

Gestational hypertension

+ proteinuria (0.3g/day)

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3
Q

What does pre-eclampsia predispose a woman to?

A 
Eclampsia
HELLP syndrome
Cerebral haemorrhage
Placental abruption
IUGR
Renal failure
DIC
Pulmonary oedema
Stillbirth
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4
Q

What are the features of severe pre-eclampsia?

A 
Headaches
Nausea
Visual disturbance
Oedema / papilloedema
HELLP - RUQ or epigastric pain
Hyperreflexia
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5
Q

What is HELLP?

A

Haemolysis
Elevated liver enzymes
Low platelets

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6
Q

What are the risk factors for pre-eclampsia?

A 
Previous pregnancy with hypertension
CKD
Autoimmune disease
Diabetes
Chronic hypertension
FAT FUCK
Last pregnancy over 10 years ago
Multiple pregnancy
1st pregnancy
Extremes of age - old or young un
Family history of pre-eclampsia
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7
Q

What is the management of gestational hypertension and pre-eclampsia?
First line

A

If BP >150/100 - oral labetalol

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8
Q

At what BP would you give a pregnant lady medical treatment?

A

150/100mm/Hg

Give labetalol

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9
Q

If a patient with gestational hypertension or pre-eclampsia is not responding to first line treatment, what would you give?
(second line treatment ffs DUH)

A

Oral nifedipine

IV hydralazine

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10
Q

What is eclampsia?

A

Development of seizures with pre-eclampsia

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11
Q

How do you treat eclampsia?

medical - give doses and route

A

Magnesium sulphate
IV bolus - 4g over 5-10 mins
Infusion of 1g over an hour
Until 24 hours after last seizure / delivery

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12
Q

What is the definitive treatment for eclampsia?

A

DELIVERY

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13
Q

What do you need to monitor in a woman receiving magnesium sulphate for eclampsia?

A

Urine output
Reflexes (precedes hypotension in toxicity)
Resp rate - for respiratory depression (toxicity)
O2 sats

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14
Q

How would you treat magnesium sulphate toxicity in a woman with eclampsia?

A

Calcium gluconate

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15
Q

What are the teratogenic infections during pregnancy?

A 
CHRiST
CMV
Herpes zoster
Rubella
Syphilis
Toxoplasmosis
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16
Q

If a baby is born and develops temperature, resp distress and lethargy - sepsis, and has blood cultures done - what would this show? Ie what is the most likely infection?

A

GBS

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17
Q

What does group B strep infection cause to happen to a baby?

A

Neonatal sepsis

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18
Q

Where is group B strep carried in a woman?

A

Birth canal

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19
Q

How do you prevent transmission of Group B strep from mother to baby?

A

IV benzylpenicillin

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20
Q

What are the causes of antepartum haemorrhage?

A

Placenta praevia
Placental abruption
Vasa praevia
Uterine rupture

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21
Q

What is placenta praevia?

A

Implantation of the placenta into the lower segment of the uterus

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22
Q

What are the types of placenta praevia?

A 
1+2 = not over os
3+4 = over os
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23
Q

How does placenta praevia present?

A

Incidental on USS
Painless vaginal bleeding
Abnormal lie / breech presentation

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24
Q

What is the management of placenta praevia?

A

Give anti-D if rhesus negative
Give steroids if <34 weeks
Delivery by C section at 39 weeks

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25
Q

What are the risk factors for placenta praevia?

A

Multiple birth
Multiparous
High maternal age
Previous C section

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26
Q

What are the complications of placenta praevia?

A

Obstruction of engagement of head
Abnormal lie (esp transverse)
Severe haemorrhage - can be PPH
Placenta accreta –> hysterectomy

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27
Q

What is placental abruption?

A

When all or part of the placenta separates before delivering foetus

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28
Q

What are the risk factors for placental abruption?

A 
IUGR
Pre-eclampsia
Pre-existing hypertension
Maternal smoking
Previous abruption
Cocaine abuse
Multiple pregnancy
Multiparous
Autoimmune disease
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29
Q

How does placental abruption present?

A

WOODY HARD UTERUS
PAINFUL bleeding / pain alone if bleeding concealed
Difficult to feel foetus
Shock out of keeping with visible loss (concealed)
Foetal distress or absent heart sounds

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30
Q

How would you investigate a patient with placental abruption?

A

Foetal - CTG and USS

Maternal - FBC, coag screen, cross match, U&E, urine output

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31
Q

How would you manage a patient with placental abruption?

A

ABCDE
Anti-D if rhesus negative
Steroids if <34 weeks and no foetal distress
C section if foetal distress
Induction of labour with amniotomy if >37 weeks and no foetal distress
Blood transfusion

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32
Q

What are the differences in presentation between placenta praevia and placental abruption?

A

Praevia = painless, abruption = painful

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33
Q

What is vasa praevia?

A

Fetal blood vessel runs in membranes before the presenting part

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34
Q

How would a woman present with ruptured vasa praevia?

A

Painless, moderate vaginal bleeding - at amniotomy or SROM

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35
Q

How would you manage a woman with a ruptured vasa praevia?

A

Immediate C section

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36
Q

Describe the passage of the foetus through the birth canal during labour

A

Engagement
Descent and flexion
Internal rotation (usually left occipito anterior)
Descent
Crowning
Extension of head –> delivery of head
Internal restitution of shoulders (anterior-posterior)
Downward traction (delivery of anterior shoulder)
Lateral flexion (and delivery of posterior shoulder)
Then everything else shoots out

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37
Q

What are the mechanical factors that determine progress through labour?

A

3 Ps

  • Powers
  • Passage
  • Passenger
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38
Q

How do you diagnose labour?

A

Painful uterine contractions
Cervical dilatation
Cervical effacement

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39
Q

What, broadly speaking, is involved in stage 1 of labour?

A

From the start of labour to full cervical dilatation

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40
Q

What is stage 1 of labour made up of?

A

Latent labour
Active labour
Transition

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41
Q

What is involved in the latent phase of stage 1 labour?

A

Slow dilatation of the cervix up to about 4cm
Slow
Can have “show” ie mucoid plug passing

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42
Q

What is involved in the active phase of stage 1 labour?

A

3-10cm dilatation of cervix
Frequent contractions
Should last less than 12 hours

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43
Q

What, broadly speaking, is stage 2 of labour?

A

Full dilatation to delivery

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44
Q

What is stage 2 of labour made up of?

A

Passive stage

Active stage

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45
Q

What is involved in the passive phase of stage 2 of labour?

A

Until head reaches the pelvic floor - when woman experiences a desire to push
Completed rotation and flexion

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46
Q

What is involved in the active phase of stage 2 of labour?

+ how long does it last

A

Pushing with contractions
Should be in the most comfortable position, just not supine

20 mins for multiparous woman
40 mins for nulliparous woman

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47
Q

What negative impact can an epidural have on the progress of labour?

A

Can prevent the woman feeling the desire to push down

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48
Q

What is stage 3 of labour?

A

From delivery of foetus to the delivery of the placenta

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49
Q

What is the normal amount of blood loss in stage 3 of labour?

A

Up to 500ml

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50
Q

What can reduce blood loss in stage 3 of labour?

A

Active management:
Use of oxytocin to contract the uterus
Early clamping and cutting of cord
CCT (controlled cord traction)

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51
Q

How would you manage a nulliparous woman who is not progressing through the first stage of labour?

A

Artificial rupture of membranes - amniotomy
Then oxytocin IV
Then C section if not progressed after 12 hours

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52
Q

How would you manage a nulliparous woman who is not progressing through passive 2nd stage of labour?

A

Oxytocin

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53
Q

How would you manage a woman who is not progressing through the active 2nd stage of labour, if the head is against the perineum?

A

Episiotomy

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54
Q

How would you manage a woman who is not progressing through the active 2nd stage of labour, if the head is not against the perineum?

A

Ventouse / forceps delivery

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55
Q

What could cause an obstruction in the passage of a foetus during labour?

A

Cephalo-pelvic disproportion
Abnormal pelvic architecture - osteomalacia, poorly healed pelvic fracture, scoliosis, polio, congenital abnormalities
Pelvic mass - fibroid or ovarian tumour

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56
Q

What abnormal presentations of the baby could cause issues during labour?

A

OP
OT
Brow
Face

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57
Q

How would you manage a slow labour with an OP baby?

A

Augmentation of labour ie oxytocin

Instrumental delivery to rotate to OA

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58
Q

How would you manage a slow labour with an OT baby?

A

Rotation with traction ie ventouse

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59
Q

How would you know that a baby was brow-orientated?

A

Can palpate the anterior fontanelle, nose and supraorbital ridges

60
Q

How would you manage a brow-orientated baby?

A

C section

61
Q

How would you know that a baby was face-orientated?

A

Complete extension of the head - mouth, nose and eyes palpable

62
Q

How would you manage a face-orientated baby?

A

If chin is mento-anterior can deliver vaginally

If mento-posterior need C section

63
Q

What is the role of prostaglandins in labour?

A

Promotes cervical effacement and dilation (reduces cervical resistance)
Increases oxytocin secretion from posterior pituitary

64
Q

Where is oxytocin secreted from?

A

Posterior pituitary gland

65
Q

Where are the pacemakers in the uterus?

A

Each cornu of the uterus

66
Q

What is taken into account when calculating a Bishop’s score?

A 
Favourability of cervix
Consistency of cervix
Degree of effacement of cervix
Extent of dilatation of cervix
Station of the head
67
Q

If a woman who is 41 weeks pregnant presents with a Bishop’s score of <6, how would you encourage labour?

A

Vaginal prostaglandin gel

68
Q

When inducing labour, where is the vaginal prostaglandin gel placed?

A

Posterior fornix of the vagina

69
Q

If a woman who is 42 weeks pregnant presents with a Bishop’s score of >6, how would you induce labour?

A

Amniotomy ± oxytocin

70
Q

How would you perform an amniotomy?

A

Rupture membranes with an amnihook

71
Q

How would you act if a woman has not progressed into labour after 2 hours following an amniotomy?

A

Start oxytocin infusion

72
Q

How would you induce labour in a woman who’s membranes have already ruptured?

A

Oxytocin infusion

73
Q

What are the foetal indications for induction of labour?

A 
Prolonged pregnancy
Suspected IUGR or compromise
Antepartum haemorrhage
Poor obstetric history
Preterm rupture of membranes
74
Q

What are the materno-foetal indications for induction of labour?

A

Pre-eclampsia

Gestational diabetes

75
Q

What are the contraindications for induction of labour?

A 
Acute foetal compromise
Abnormal lie
Placenta praevia
Pelvic obstruction
Cephalo-pelvic disproportion
76
Q

Why is prolonged pregnancy (ie >42 weeks) bad?

A

Macrosomia
Neonatal hypoglycaemia
Meconium aspiration

77
Q

What would you offer if a 41 week pregnant lady presented to you without having started labour?

A

Membrane sweep

78
Q

What are the complications of induction of labour?

A

Can not work
Increased chance of instrumental delivery
Increased chance of PPH
Increased chance of cord prolapse

79
Q

What are the obstetric emergencies?

A 
Shoulder dystocia
Cord prolapse
Uterine rupture
Amniotic fluid embolism
Retained placenta
80
Q

What is the definition of shoulder dystocia?

A

Inability to delivery the body of the foetus following delivery of the head

81
Q

Why does shoulder dystocia occur?

A

Because the anterior shoulder is impacted on the maternal pubic symphsis

82
Q

What complications can occur as a result of shoulder dystocia?

A

Mother:
PPH
Perineal tears
Bladder and ureter injury

Child:
Brachial plexus injury (Erbs palsy)
Hypoxia
Hypoxic-ischaemic encephalopathy
Death
83
Q

What nerves are affected in Erb’s palsy?

A

C5-C7

84
Q

What are some risk factors for shoulder dystocia?

A 
Previous shoulder dystocia
Macrosomia (so prolonged pregnancy)
High maternal BMI
Diabetes
Prolonged labour
85
Q

How do you manage a shoulder dystocia?

A

Call for help (unless you’re da one man JonathAN)
McRobert’s manoeuvre
Apply subrapubic pressure
Internal manoeuvres ± episiotomy

86
Q

What is McRobert’s manoeuvre?

+ what does it do?

A

Bring mother’s thighs towards abdomen
Flexion and abduction of the hips

Increases relative anterior-posterior angle of the pelvis

87
Q

What are the internal manoeuvres used in shoulder dystocia?

A

Woodscrew manoeuvre
Grab arm or some shit
Symphisiotomy (OOF OWCHIE)
Zavanelli manoeuvre (head born but you push head back in and do a C section)

88
Q

What is cord prolapse?

A

When the umbilical cord descends ahead of the presenting part of the foetus

89
Q

What are the types of cord prolapse?

A 
Occult = when it lies alongside the presenting part
Overt = when it lies past the present part
90
Q

How does a cord prolapse present?

A

Visible cord

Or fetus bradycardia (or any other CTG abnormality)

91
Q

How would you make a diagnosis of cord prolapse?

A

Is cord visible beyond the level of the introitus
Is cord palpable vaginally
CTG

92
Q

What is the management of a cord prolapse?

A

Urgent delivery
or instrumental if fully dilated and will be quickest option

Don’t handle the cord

93
Q

Why should you try not to handle the cord in cord prolapse?

A

Can cause vasospasm

94
Q

How should you manage a cord prolapse until delivery is possible?

A

If cord before level of introitus - push presenting part of baby back to avoid compression
If cord below level of the introitus - keep warm and moist
Tocolytics eg nifedipine

95
Q

How do you classify uterine rupture?

A

Incomplete (occult) = separation of surgical scar but visceral peritoneum intact

Complete = EMERGENCY

  • Traumatic = RTC, incorrect use of oxytocin, poorly conducted attempt at vaginal delivery
  • Spontaneous = history of C section or trauma, or multiparity leads to weakened uterus
96
Q

How does uterine rupture present?

A 
Maternal shock
Severe abdominal pain
Vaginal bleeding
Chest / shoulder tip pain
Sudden SOB
CTG abnormalities
97
Q

How would you manage a uterine rupture?

A

ABCDE - make sure mum stable
Urgent surgical delivery
Usually hysterectomy

98
Q

CASE

A 29 year old woman has just had SROM. She collapses, following sudden shortness of breath.

What is your differential diagnosis?

A

Amniotic fluid embolism

99
Q

What are the symptoms of amniotic fluid embolism?

A

PE
DIC

So sudden SOB, collapse (anaphylactic)

100
Q

Outline the pathophysiology of amniotic fluid embolism

A

Fetal cells / amniotic fluid enter mother’s bloodstream
Stimulates massive immune reaction
Leads to PE, anaphylaxis, DIC

101
Q

How do you manage a woman with suspected amniotic fluid embolism?

A 
ABCDE
O2 - mechanical ventilation
Maintain perfusion
Correct coagulopathy - might need blood products
Delivery - perimortem C section
102
Q

How would you diagnose retained placenta in a woman who has undergone physiological management of 3rd stage labour?

A

Placenta not delivered within 60 mins of birth

103
Q

How would you diagnose retained placenta in a woman who has undergone active management of 3rd stage of labour?

A

Placenta not delivered within 30 mins of birth

104
Q

What are the causes of retained placenta?

A

Uterine atony
Trapped placenta aka closed os
Placenta accreta/percreta

105
Q

What are the complications of a retained placenta?

A

PPH
Genital tract infection
Uterine inversion - can cause neurogenic shock

106
Q

How would you manage a woman with a retained placenta?

A

Assess blood loss
IM syntocinon
Ensure bladder is empty
Manually remove placenta in theatre

107
Q

What are the methods of measuring foetal distress?

A

CTG
Foetal blood sampling
Foetal ECG

108
Q

What is the definition of foetal distress?

A

Hypoxia that might result foetal death or damage if not reversed or foetus delivered urgently

109
Q

What pH in the foetal scalp signifies hypoxia?

A

<7.2

110
Q

What do you look for on a CTG to monitor for foetal distress?

A

DR C BRAVADO
DR = define risk
C = contractions per 10 minutes (hyperstimulation = >5)
BR = baseline rate (110-160 = normal)
V = variability (should be >5 beats per min)
A = acceleration (with movement or contractions = reassuring)
D = decelerations (early with contractions = benign, variable = ? cord compression, late after contractions = foetal hypoxia)
O = overall assessment (if CTG normal = reassuring, abnormal patterns have high false positive)

111
Q

What is normal for contractions on a CTG?

A

> 5 is bad = hyperstimulation

112
Q

What is a normal baseline rate for CTG?

A

110-160

113
Q

What should the variability be on a CTG?

A

> 5 beats per min

114
Q

What are accelerations a sign of on CTG?

A

Reassuring if with movement or contractions

115
Q

What are decelerations a sign of on CTG?

A

Early = benign
Variable = ? cord compression
Late (after contractions) = foetal hypoxia

116
Q

What is the definition of primary post partum haemorrhage?

A

Loss of >500ml in the 24 hours after birth

Or >1000ml if C section

117
Q

What are the causes of primary post partum haemorrhage?

A 
Tone = uterine atony
Trauma = perineal tear, episiotomy, cervical if instrumental
Tissue = retained placenta
Thrombin = coagulopathy
118
Q

What is the definition of secondary post partum haemorrhage?

A

Excessive blood loss occurring between 24 hours and 6 weeks after delivery

119
Q

What are the causes of secondary post partum haemorrhage?

A

Endometritis
Retained placental tissue
Gestational trophoblastic disease

120
Q

What is the management of secondary post partum haemorrhage?

A

Antibiotics

Evacuation of retained products

121
Q

How would you manage a primary PPH?

A 
ABCDE
IV syntocinon
IM carboprost
Removal of retained placenta
B-Lynch suture, uterine or internal iliac artery embolisation, balloon
If uncontrolled - hysterectomy
122
Q

What tool do you use to diagnose postnatal depression?

A

Edinburgh score

123
Q

What should you consider in a patient with suspected postnatal depression?

A

Postpartum thyroiditis

124
Q

What are the risk factors for gestational diabetes?

A 
BMI over 30
Previous macrosomic baby
Previous gestational diabetes
Family history of diabetes
South asian / black caribbean / middle eastern origin
125
Q

How / when do you screen for gestational diabetes?

+ what are the cut offs

A

Previous GD - OGTT after booking
Again / everyone with a risk factor at 24-28 weeks

Fasting glucose >5.6
OGTT of >7.8mmol/L

126
Q

How do you manage gestational diabetes?

A

Diabetes clinic
Fasting <7 - trial of diet and exercise for 1-2 weeks
If that doesn’t work - metformin
If that doesn’t work - insulin

Fasting >7 - start insulin
Or >6 and a risk factor - start insulin

If can’t tolerate metformin and refuse insulin - glibenclamide (sulfonylurea)

127
Q

How do you manage pre-existing diabetes in pregnancy?

A

Weight loss 4 da fatties
Stop all meds apart from metformin and start insulin
Folic acid 5mg/day from preconception to 12 weeks
Then aspirin 75mg/day from 12 weeks till birth (reduce risk of pre-eclampsia)

128
Q

What is gravidy?

A

Number of times a woman has been pregnant

129
Q

What is parity?

A

Number of times a woman has given birth to a fetus >24 weeks

130
Q

What are the foetal complications associated with gestational diabetes?

A

Congenital abnormalities (neural tube + cardiac)
Pre term delivery
Fetal lung maturity reduced
Increased birth weight and associated trauma
Fetal compromise and fetal distress are more common
Polyhydramnios -> increased chance of abruption
Hypoglycaemia post delivery as baby is ‘accustomed’ to hyperglycaemia

131
Q

What are the maternal complications associated with gestational diabetes?

A 
HELLP
UTI
Wound / endometrial infection after delivery
Retinopathy
Nephropathy
132
Q

What is the definition of normal labour?

A 
Spontaneous onset
Low-risk
Vertex position
Between 37 and 42 weeks
Good condition after birth
(no induction, anaesthesia, instrumental, CS or episiotomy)
133
Q

What is the definition of small for dates (small for gestational age)? + its significance

A

<10th centile for gestation (no intervention if no deterioration, ie – growing normally)

134
Q

What is the definition of IUGR? + its significance

A

Growth in utero has slowed, does not necessarily mean that they will end up SFD.
Important factor as continued IUGR is indicative of pregnancy problems.
Consider early delivery if continued IUGR.

135
Q

What would you give to treat VTE in pregnancy?

A

Low molecular weight heparin - Warfarin is CI due to teratogenicity

136
Q

What are the possible types of multiple pregnancy?

A

Mono or dizygotic (from one fertilised egg or more than one)

Mono or dichorionic - do they share a placenta
Mono or diamniotic - do they share amniotic fluid and sac

137
Q

What are the risk factors of multiple pregnancy?

A

Previous multiple pregnancy
Family history of multiple pregnancy
Assisted conception

138
Q

What are the risks associated with / complications of multiple pregnancy?

A 
Preterm labour / birth
Gestational hypertension / pre-eclampsia
Anaemia
Congenital birth abnormalities
Twin to twin transfusion syndrome
Placenta praevia
Placental abruption / uterine rupture
PPH
139
Q

Outline twin to twin transfusion syndrome

A

In monochorionic twins
Disproportionate blood supply - one twin gets more than the other
One with more = recipient
One with less = donor

Donor has decreased growth and development, plus oligohydramnios
Recipient has higher blood volume so heart failure (foetal hydrops) and pisses out more so polyhydramnios

Treatment = serial amniocentesis to get rid of the polyhydramnios, laser therapy to cut the anastamosis between the blood supplies in the placenta

140
Q

How do women present with multiple pregnancy?

A

Seen on scan
Enlarged uterus
Hyperemesis
Polyhydramnios

141
Q

What factors affect birth weight?

A

Maternal size & weight
Parity
Gestational diabetes
Smoking

+ I’d guess like when its born lol

142
Q

What is placenta accreta / increta / percreta?

A

Abnormal decidua basalis (area of endometrium between implanted chorionic villi and myometrium)
Villi invade further
Accreta = villi attached to myometrium
Increta = villi invade 50% through myometrium
Percreta = villi invade through whole myometrium, can involve bladder / bowel

143
Q

How do you detect placenta accreta?

A

On US - usually for foetal anomaly scan

144
Q

What are the risk factors for placenta accreta?

A

Previous accreta
Previous C section
Previous uterine surgery

145
Q

What does placenta accreta put you at risk of?

A

Antepartum haemorrhage

Post partum haemorrhage

146
Q

How do you manage placenta accreta?

A

MDT care - specialist care with blood products, neonatal care and adult intensive care unit
Pre-emptive C section
Hysterectomy - leaving the placenta in situ

147
Q

Outline the formation of twins (chronionic / amniotic) with regards to the number of days at which cleavage happens

A 
1-3 = dichorionic, diamniotic
4-8 = monochorionic, diamniotic
8-13 = monochorionic, monoamniotic
13-15 = conjoined

Phase 3a (11 decks)

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