Obs Flashcards
What is gestational hypertension?
Blood pressure of over 140/90mmHg
OR increase in over 30mm/Hg systolic or 15mm/Hg diastolic compared with previous / booking BP
What is pre-eclampsia?
Gestational hypertension
+ proteinuria (0.3g/day)
What does pre-eclampsia predispose a woman to?
Eclampsia HELLP syndrome Cerebral haemorrhage Placental abruption IUGR Renal failure DIC Pulmonary oedema Stillbirth
What are the features of severe pre-eclampsia?
Headaches Nausea Visual disturbance Oedema / papilloedema HELLP - RUQ or epigastric pain Hyperreflexia
What is HELLP?
Haemolysis
Elevated liver enzymes
Low platelets
What are the risk factors for pre-eclampsia?
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
What is the management of gestational hypertension and pre-eclampsia?
First line
If BP >150/100 - oral labetalol
At what BP would you give a pregnant lady medical treatment?
150/100mm/Hg
Give labetalol
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)
Oral nifedipine
IV hydralazine
What is eclampsia?
Development of seizures with pre-eclampsia
How do you treat eclampsia?
medical - give doses and route
Magnesium sulphate
IV bolus - 4g over 5-10 mins
Infusion of 1g over an hour
Until 24 hours after last seizure / delivery
What is the definitive treatment for eclampsia?
DELIVERY
What do you need to monitor in a woman receiving magnesium sulphate for eclampsia?
Urine output
Reflexes (precedes hypotension in toxicity)
Resp rate - for respiratory depression (toxicity)
O2 sats
How would you treat magnesium sulphate toxicity in a woman with eclampsia?
Calcium gluconate
What are the teratogenic infections during pregnancy?
CHRiST CMV Herpes zoster Rubella Syphilis Toxoplasmosis
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?
GBS
What does group B strep infection cause to happen to a baby?
Neonatal sepsis
Where is group B strep carried in a woman?
Birth canal
How do you prevent transmission of Group B strep from mother to baby?
IV benzylpenicillin
What are the causes of antepartum haemorrhage?
Placenta praevia
Placental abruption
Vasa praevia
Uterine rupture
What is placenta praevia?
Implantation of the placenta into the lower segment of the uterus
What are the types of placenta praevia?
1+2 = not over os 3+4 = over os
How does placenta praevia present?
Incidental on USS
Painless vaginal bleeding
Abnormal lie / breech presentation
What is the management of placenta praevia?
Give anti-D if rhesus negative
Give steroids if <34 weeks
Delivery by C section at 39 weeks
What are the risk factors for placenta praevia?
Multiple birth
Multiparous
High maternal age
Previous C section
What are the complications of placenta praevia?
Obstruction of engagement of head
Abnormal lie (esp transverse)
Severe haemorrhage - can be PPH
Placenta accreta –> hysterectomy
What is placental abruption?
When all or part of the placenta separates before delivering foetus
What are the risk factors for placental abruption?
IUGR Pre-eclampsia Pre-existing hypertension Maternal smoking Previous abruption Cocaine abuse Multiple pregnancy Multiparous Autoimmune disease
How does placental abruption present?
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
How would you investigate a patient with placental abruption?
Foetal - CTG and USS
Maternal - FBC, coag screen, cross match, U&E, urine output
How would you manage a patient with placental abruption?
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
What are the differences in presentation between placenta praevia and placental abruption?
Praevia = painless, abruption = painful
What is vasa praevia?
Fetal blood vessel runs in membranes before the presenting part
How would a woman present with ruptured vasa praevia?
Painless, moderate vaginal bleeding - at amniotomy or SROM
How would you manage a woman with a ruptured vasa praevia?
Immediate C section
Describe the passage of the foetus through the birth canal during labour
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
What are the mechanical factors that determine progress through labour?
3 Ps
- Powers
- Passage
- Passenger
How do you diagnose labour?
Painful uterine contractions
Cervical dilatation
Cervical effacement
What, broadly speaking, is involved in stage 1 of labour?
From the start of labour to full cervical dilatation
What is stage 1 of labour made up of?
Latent labour
Active labour
Transition
What is involved in the latent phase of stage 1 labour?
Slow dilatation of the cervix up to about 4cm
Slow
Can have “show” ie mucoid plug passing
What is involved in the active phase of stage 1 labour?
3-10cm dilatation of cervix
Frequent contractions
Should last less than 12 hours
What, broadly speaking, is stage 2 of labour?
Full dilatation to delivery
What is stage 2 of labour made up of?
Passive stage
Active stage
What is involved in the passive phase of stage 2 of labour?
Until head reaches the pelvic floor - when woman experiences a desire to push
Completed rotation and flexion
What is involved in the active phase of stage 2 of labour?
+ how long does it last
Pushing with contractions
Should be in the most comfortable position, just not supine
20 mins for multiparous woman
40 mins for nulliparous woman
What negative impact can an epidural have on the progress of labour?
Can prevent the woman feeling the desire to push down
What is stage 3 of labour?
From delivery of foetus to the delivery of the placenta
What is the normal amount of blood loss in stage 3 of labour?
Up to 500ml
What can reduce blood loss in stage 3 of labour?
Active management:
Use of oxytocin to contract the uterus
Early clamping and cutting of cord
CCT (controlled cord traction)
How would you manage a nulliparous woman who is not progressing through the first stage of labour?
Artificial rupture of membranes - amniotomy
Then oxytocin IV
Then C section if not progressed after 12 hours
How would you manage a nulliparous woman who is not progressing through passive 2nd stage of labour?
Oxytocin
How would you manage a woman who is not progressing through the active 2nd stage of labour, if the head is against the perineum?
Episiotomy
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?
Ventouse / forceps delivery
What could cause an obstruction in the passage of a foetus during labour?
Cephalo-pelvic disproportion
Abnormal pelvic architecture - osteomalacia, poorly healed pelvic fracture, scoliosis, polio, congenital abnormalities
Pelvic mass - fibroid or ovarian tumour
What abnormal presentations of the baby could cause issues during labour?
OP
OT
Brow
Face
How would you manage a slow labour with an OP baby?
Augmentation of labour ie oxytocin
Instrumental delivery to rotate to OA
How would you manage a slow labour with an OT baby?
Rotation with traction ie ventouse
How would you know that a baby was brow-orientated?
Can palpate the anterior fontanelle, nose and supraorbital ridges
How would you manage a brow-orientated baby?
C section
How would you know that a baby was face-orientated?
Complete extension of the head - mouth, nose and eyes palpable
How would you manage a face-orientated baby?
If chin is mento-anterior can deliver vaginally
If mento-posterior need C section
What is the role of prostaglandins in labour?
Promotes cervical effacement and dilation (reduces cervical resistance)
Increases oxytocin secretion from posterior pituitary
Where is oxytocin secreted from?
Posterior pituitary gland
Where are the pacemakers in the uterus?
Each cornu of the uterus
What is taken into account when calculating a Bishop’s score?
Favourability of cervix Consistency of cervix Degree of effacement of cervix Extent of dilatation of cervix Station of the head
If a woman who is 41 weeks pregnant presents with a Bishop’s score of <6, how would you encourage labour?
Vaginal prostaglandin gel
When inducing labour, where is the vaginal prostaglandin gel placed?
Posterior fornix of the vagina
If a woman who is 42 weeks pregnant presents with a Bishop’s score of >6, how would you induce labour?
Amniotomy ± oxytocin
How would you perform an amniotomy?
Rupture membranes with an amnihook
How would you act if a woman has not progressed into labour after 2 hours following an amniotomy?
Start oxytocin infusion
How would you induce labour in a woman who’s membranes have already ruptured?
Oxytocin infusion
What are the foetal indications for induction of labour?
Prolonged pregnancy Suspected IUGR or compromise Antepartum haemorrhage Poor obstetric history Preterm rupture of membranes
What are the materno-foetal indications for induction of labour?
Pre-eclampsia
Gestational diabetes
What are the contraindications for induction of labour?
Acute foetal compromise Abnormal lie Placenta praevia Pelvic obstruction Cephalo-pelvic disproportion
Why is prolonged pregnancy (ie >42 weeks) bad?
Macrosomia
Neonatal hypoglycaemia
Meconium aspiration
What would you offer if a 41 week pregnant lady presented to you without having started labour?
Membrane sweep
What are the complications of induction of labour?
Can not work
Increased chance of instrumental delivery
Increased chance of PPH
Increased chance of cord prolapse
What are the obstetric emergencies?
Shoulder dystocia Cord prolapse Uterine rupture Amniotic fluid embolism Retained placenta
What is the definition of shoulder dystocia?
Inability to delivery the body of the foetus following delivery of the head
Why does shoulder dystocia occur?
Because the anterior shoulder is impacted on the maternal pubic symphsis
What complications can occur as a result of shoulder dystocia?
Mother:
PPH
Perineal tears
Bladder and ureter injury
Child: Brachial plexus injury (Erbs palsy) Hypoxia Hypoxic-ischaemic encephalopathy Death
What nerves are affected in Erb’s palsy?
C5-C7
What are some risk factors for shoulder dystocia?
Previous shoulder dystocia Macrosomia (so prolonged pregnancy) High maternal BMI Diabetes Prolonged labour
How do you manage a shoulder dystocia?
Call for help (unless you’re da one man JonathAN)
McRobert’s manoeuvre
Apply subrapubic pressure
Internal manoeuvres ± episiotomy
What is McRobert’s manoeuvre?
+ what does it do?
Bring mother’s thighs towards abdomen
Flexion and abduction of the hips
Increases relative anterior-posterior angle of the pelvis
What are the internal manoeuvres used in shoulder dystocia?
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)
What is cord prolapse?
When the umbilical cord descends ahead of the presenting part of the foetus
What are the types of cord prolapse?
Occult = when it lies alongside the presenting part Overt = when it lies past the present part
How does a cord prolapse present?
Visible cord
Or fetus bradycardia (or any other CTG abnormality)
How would you make a diagnosis of cord prolapse?
Is cord visible beyond the level of the introitus
Is cord palpable vaginally
CTG
What is the management of a cord prolapse?
Urgent delivery
or instrumental if fully dilated and will be quickest option
Don’t handle the cord
Why should you try not to handle the cord in cord prolapse?
Can cause vasospasm
How should you manage a cord prolapse until delivery is possible?
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
How do you classify uterine rupture?
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
How does uterine rupture present?
Maternal shock Severe abdominal pain Vaginal bleeding Chest / shoulder tip pain Sudden SOB CTG abnormalities
How would you manage a uterine rupture?
ABCDE - make sure mum stable
Urgent surgical delivery
Usually hysterectomy
CASE
A 29 year old woman has just had SROM. She collapses, following sudden shortness of breath.
What is your differential diagnosis?
Amniotic fluid embolism
What are the symptoms of amniotic fluid embolism?
PE
DIC
So sudden SOB, collapse (anaphylactic)
Outline the pathophysiology of amniotic fluid embolism
Fetal cells / amniotic fluid enter mother’s bloodstream
Stimulates massive immune reaction
Leads to PE, anaphylaxis, DIC
How do you manage a woman with suspected amniotic fluid embolism?
ABCDE O2 - mechanical ventilation Maintain perfusion Correct coagulopathy - might need blood products Delivery - perimortem C section
How would you diagnose retained placenta in a woman who has undergone physiological management of 3rd stage labour?
Placenta not delivered within 60 mins of birth
How would you diagnose retained placenta in a woman who has undergone active management of 3rd stage of labour?
Placenta not delivered within 30 mins of birth
What are the causes of retained placenta?
Uterine atony
Trapped placenta aka closed os
Placenta accreta/percreta
What are the complications of a retained placenta?
PPH
Genital tract infection
Uterine inversion - can cause neurogenic shock
How would you manage a woman with a retained placenta?
Assess blood loss
IM syntocinon
Ensure bladder is empty
Manually remove placenta in theatre
What are the methods of measuring foetal distress?
CTG
Foetal blood sampling
Foetal ECG
What is the definition of foetal distress?
Hypoxia that might result foetal death or damage if not reversed or foetus delivered urgently
What pH in the foetal scalp signifies hypoxia?
<7.2
What do you look for on a CTG to monitor for foetal distress?
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)
What is normal for contractions on a CTG?
> 5 is bad = hyperstimulation
What is a normal baseline rate for CTG?
110-160
What should the variability be on a CTG?
> 5 beats per min
What are accelerations a sign of on CTG?
Reassuring if with movement or contractions
What are decelerations a sign of on CTG?
Early = benign
Variable = ? cord compression
Late (after contractions) = foetal hypoxia
What is the definition of primary post partum haemorrhage?
Loss of >500ml in the 24 hours after birth
Or >1000ml if C section
What are the causes of primary post partum haemorrhage?
Tone = uterine atony Trauma = perineal tear, episiotomy, cervical if instrumental Tissue = retained placenta Thrombin = coagulopathy
What is the definition of secondary post partum haemorrhage?
Excessive blood loss occurring between 24 hours and 6 weeks after delivery
What are the causes of secondary post partum haemorrhage?
Endometritis
Retained placental tissue
Gestational trophoblastic disease
What is the management of secondary post partum haemorrhage?
Antibiotics
Evacuation of retained products
How would you manage a primary PPH?
ABCDE IV syntocinon IM carboprost Removal of retained placenta B-Lynch suture, uterine or internal iliac artery embolisation, balloon If uncontrolled - hysterectomy
What tool do you use to diagnose postnatal depression?
Edinburgh score
What should you consider in a patient with suspected postnatal depression?
Postpartum thyroiditis
What are the risk factors for gestational diabetes?
BMI over 30 Previous macrosomic baby Previous gestational diabetes Family history of diabetes South asian / black caribbean / middle eastern origin
How / when do you screen for gestational diabetes?
+ what are the cut offs
Previous GD - OGTT after booking
Again / everyone with a risk factor at 24-28 weeks
Fasting glucose >5.6
OGTT of >7.8mmol/L
How do you manage gestational diabetes?
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)
How do you manage pre-existing diabetes in pregnancy?
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)
What is gravidy?
Number of times a woman has been pregnant
What is parity?
Number of times a woman has given birth to a fetus >24 weeks
What are the foetal complications associated with gestational diabetes?
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
What are the maternal complications associated with gestational diabetes?
HELLP UTI Wound / endometrial infection after delivery Retinopathy Nephropathy
What is the definition of normal labour?
Spontaneous onset Low-risk Vertex position Between 37 and 42 weeks Good condition after birth (no induction, anaesthesia, instrumental, CS or episiotomy)
What is the definition of small for dates (small for gestational age)? + its significance
<10th centile for gestation (no intervention if no deterioration, ie – growing normally)
What is the definition of IUGR? + its significance
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.
What would you give to treat VTE in pregnancy?
Low molecular weight heparin - Warfarin is CI due to teratogenicity
What are the possible types of multiple pregnancy?
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
What are the risk factors of multiple pregnancy?
Previous multiple pregnancy
Family history of multiple pregnancy
Assisted conception
What are the risks associated with / complications of multiple pregnancy?
Preterm labour / birth Gestational hypertension / pre-eclampsia Anaemia Congenital birth abnormalities Twin to twin transfusion syndrome Placenta praevia Placental abruption / uterine rupture PPH
Outline twin to twin transfusion syndrome
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
How do women present with multiple pregnancy?
Seen on scan
Enlarged uterus
Hyperemesis
Polyhydramnios
What factors affect birth weight?
Maternal size & weight
Parity
Gestational diabetes
Smoking
+ I’d guess like when its born lol
What is placenta accreta / increta / percreta?
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
How do you detect placenta accreta?
On US - usually for foetal anomaly scan
What are the risk factors for placenta accreta?
Previous accreta
Previous C section
Previous uterine surgery
What does placenta accreta put you at risk of?
Antepartum haemorrhage
Post partum haemorrhage
How do you manage placenta accreta?
MDT care - specialist care with blood products, neonatal care and adult intensive care unit
Pre-emptive C section
Hysterectomy - leaving the placenta in situ
Outline the formation of twins (chronionic / amniotic) with regards to the number of days at which cleavage happens
1-3 = dichorionic, diamniotic 4-8 = monochorionic, diamniotic 8-13 = monochorionic, monoamniotic 13-15 = conjoined
