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Year 4 GOSH > Obs > Flashcards

Obs Flashcards

1
Q

Name 5 teratogenic drugs.

A 
ACEi
Sodium Valproate
Methotrexate
Retinoids
Trimethoprim
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2
Q

What does progesterone do during pregnancy? (main pregnancy hormone)

A
  • Secreted by ovary to support thickening of the endometrial lining.
  • Modification of maternal physiology: cardiovascular, bronchodilation, uterine quiescene.
  • Immunosuppresion (one reason of miscarriage is woman can’t accept the foetus)
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3
Q

Role of HCG in pregnancy?

A

Responsible for the maintenance of the corpus luteum on the ovary, that continues to secrete oestrogens + progesterone.

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4
Q

Why do levels of HCG fall after 8-10wks of pregnancy (if it is needed to maintain the corpus luteum to secrete oestrogens/progesterone)?

A

At 8wks gestation, the placenta begins independent production of O&P. So HCG levels fall and corpus luteum recedes.

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5
Q

(Physiological changes in pregnancy)

Cardiovascular?

A

40%^ in plasma volume, cardiac output + tidal volume.
20%^ RBCs (therefore haemodilution as plasma col increases more than Hb)
Ejection systolic murmur + 3rd heart sound = normal in pregnancy!!!
BP reduces (in 2nd tri, but back to normal by term)
Clotting ^ (^ in factors 7,8,10 and fibrinogen)

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6
Q

(Physiological changes in pregnancy)

Renal?

A

GFR ^50%

Renal pelvis + ureters dilate (progesterone), ^infection risk.

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7
Q

(Physiological changes in pregnancy)

Endocrine?

A

T3/4 decrease
Anterior pituitary doubles in size
^cortisol, ^insulin

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8
Q

(Physiological changes in pregnancy)

MSK?

A

Progesterone softens joints + ligaments.

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9
Q

What are the effects of Progesterone as a SMOOTH MUSCLE RELAXANT during pregnancy?

A

Relaxes bile ducts = cholestasis
Relaxes bladder/urethra = UTIs
Relaxes blood vessels = Drop BP
Relaxes GOJ + stomach = GORD (use ranitidine + omeprazole).

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10
Q

What does the Dating Scan show? (offered at 10-14wks)

A

Estimated due date (also can use LMP+7 +9months)
Identifies multiple pregnancies
Nuchal translucency measurement- to screen for chromosomal abnormalities.

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11
Q

What bloods are booked during The Booking Visit (10wks)?

A 
FBC (anaemia in preg usually due to iron def, normal values in early preg= Hb>110. FBC usually repeated at 28wks)
Haemoglobinopathies
Blood group + antibody screen
HIV, Syphilis, Hep B
Plus STI screen if <25
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12
Q

What consent is obtained in The Booking Visit

A

Consent for antenatal screening:

  • Combined screening (opt in)
  • Quadruple test (if miss combined)
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13
Q

How is the risk of Tri-21 calculated?

A

Maternal age x risk ratio from combined screening test.

SCREENING POSITIVE = risk of >1/150

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14
Q

What is the significance of nuchal translucency?

A

The larger it is (>5mm), the higher risk of structural defects.

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15
Q

(blood test from combined screening) What is the significance of PAPP-A (pregnancy-associated plasma protein A)

A

Protein produced by the placenta during pregnancy.

Low levels = higher risk (of Down’s, Edward’s, Patau’s)

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16
Q

(blood test from combined screening) What is the significance of hCG?

A

(in 1st + 2nd trimester)
High levels = higher risk of Down’s
Low levels = higher risk of Edward’s/ Patau’s

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17
Q 
In the quadruple test (14-20wks), if Down's was detected what would the following results be? (low/high)
hCG
Inhabin-A
AFP
Estriol
A

hCG : up
Inhabin-A : up
AFP : down
Estriol : down

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18
Q

(Prenatal Diagnostic Tests)
NON-INVASIVE:
Explain what US can diagnose?

A

Neural tube defect
Twin-to-Twin transfusion syndrome
Gastroschisis

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19
Q

(Prenatal Diagnostic Tests)
NON-INVASIVE:
Explain what cffDNA (cell-free foetal DNA) is used for?

A

For women at higher risk for Down’s, Edward’s or Patau’s
Determines RhD status in RhD negative mothers
Foetal sex determination (for sex-linked disorders)
Single gene disorders (CF)

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20
Q

(Prenatal Diagnostic Tests)
NON-INVASIVE:
Explain what a IONA test can diagnose?

A

Down’s, Edward’s or Patau’s

Sex determination

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21
Q

(Prenatal Diagnostic Tests)
INVASIVE:
What are CVS / amniocentesis used to diagnose?
And what is the risk?

A

Down’s
CF
Thalassaemia

1% risk of miscarriage

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22
Q

Process of Chorion Villus Sampling (10-13 wks)?

A

US guided trans-abdo/trans-cervical
Aspiration of TROPHOBLASTIC CELLS (for karyotyping, PCR, FISH)
Results in 48hrs

Risks: miscarriage (1-2%), vertical transmission of BBV

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23
Q

Process of Amniocentesis? (15+wks)

A

Aspiration of amniotic fluid which contains foetal cells from skin + gut.
Transabdo, results in 3wks

Risks: miscarriage (0.5%)

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24
Q

What happens if a woman is Rhesus -ve?

A

Anti-D prophylaxis to prevent rhesus D iso-immunisation + haemolytic disease of the newborn.

Anti-D is offered at28wks, after any sensitising event (trauma), and at delivery.

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25
Q

What happens to Rhesus -ve mother if a baby is Rhesus +ve after they are born?

A

The mother must receive anti-D within 72hrs of delivery (otherwise their immune system will react to the baby’s blood left in the circulation)

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26
Q

How is HIV managed during pregnancy to avoid risk of vertical transmission?

A

Use of ARTs throughout pregnancy (+ 6wks for newborn)
C-section
Avoid breastfeeding

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27
Q

How is active Syphilis managed during pregnancy?

A

Mother must receive treatment (Benzylpenicillin) >4wks before delivery, otherwise newborn undergoes IV therapy.

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28
Q

Name 5 pieces of pre-conception/ early pregnancy advice.

A

1) Folic acid (400 micrograms until wk 12)
2) Vit-D (10 micrograms daily) if BMI>30, or southasian/afrocarrbbean.
3) Are other medical conditions (e.g. diabetes/HTN) well controlled? (anti-epileptics: carbamazepine/lamotrigine safest)
4) Stop TERATOGENIC medicines (avoid NSAIDS- ^miscarriage, premature closure of ductus arteriosus)
5) Avoid certain food (soft cheese/pate/raw eggs or meat/ only pasteurised milk)

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29
Q

(Early pregnancy advice)

Mother with PRIOR PRE-ECLAMPSIA?

A

Low-dose aspirin (75mg), taken asap from 1st tri, up to 20wks (2nd stage of placental growth, in order to maintain adequate perfusion).

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30
Q

(Early pregnancy advice)

Mother with PREVIOUS C-SECTION?

A

Those who had c-section for nonrecurrent conditions should be offered trial of vaginal delivery!
NICE guidelines dont recommend vaginal delivery after 3 previous C-secs.

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31
Q

(Early pregnancy advice)

Mother who SMOKES?

A

All offered CO blood reading.

Pregnancies at risk of: IUGR, SGA, placental abruption, preterm labour, stillbirth.

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32
Q

(Early pregnancy advice)

Mother with ANAEMIA?

A

Oral iron supplements (FeSO4) if:
Hb<100mg/dL
MCV<80

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33
Q

(Early pregnancy advice)

Mother with GDM?

A 
Glucose Tolerance Test at 26wks.
GTT at 16wks if:
-BMI>30
-Previous GDM
-1st degree FHx of diabetes
-South Asian/ Afro-Caribbean origin
-Previous baby's weigh >4.5kg
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34
Q

What is the most important measurement for assessing foetus’ growth/size?

A

Abdominal Circumference (AC)

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35
Q

What is Crown-Rump length used for?

A

Most accurate for dating pregnancy in 1st trimester.

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36
Q

What does a dopple of the umbilical arteries measure?

A

Measures velocity waveforms in the uterine arteries.
Increased resistance = reduced foetal diastole = PLACENTAL DYSFUNCTION!!
(so a raised doppler is bad!)

Therefore it identifies which small foetuses are actually growth restricted + compromised.

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37
Q 
Doppler waveforms in foetal circulation:
Meaning of:
-'High resistance'
-'Low resistance'
-'Increased velocity'
A
  • High resistance: NORMAL!
  • Low resistance: ‘brain sparing’ in the growth retarded foetus (when blood is preferentially shunted to the brain/heart/adrenals, rather than abdo/muscles)
  • Increased velocity: foetal anaemia
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38
Q

(Antenatal Problems: Maternal- MINOR)
Why is itching more common?
Management?

A

Linked to hormones + abdo skin stretching.
Rare + serious = gestational cholestasis + liver complications (check jaundice + LFTs)

Can give antihistamines (chlorphenamine)

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39
Q

(Antenatal Problems: Maternal- MINOR)

a) What is Pelvic girdle
b) Why does it occur in pregnancy?
c) Management?

A

a) Discomfort in pubic + sacroiliac joints; radiates to thighs, perineum.
b) Progesterone relaxes ligaments that hold pelvic bones together.
c) Physio, analgesics, take care with induction.

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40
Q

(Antenatal Problems: Maternal- MINOR)
Why is heartburn common (70%!) in pregnancy?
What is the associated caution?

A

Progesterone relaxes GOS, causes gastric stasis. Also baby pushes on stomach.
Mx= ranitidine, antacids.

Caution: pre-eclampsia can present with epigastric pain!

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41
Q

(Antenatal Problems: Maternal- MINOR)

Vaginitis in pregnancy- why and what is the mx?

A

Itchy, non-offensive, white-grey discharge.
Due to candidiasis (common in pregnancy)

Mx= vaginal pessaries (Clotrimazole)

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42
Q

(Antenatal Problems: Maternal- MINOR)

What common complaints can you reassure on?

A

Sciatica- resolves after delivery.

Constipation- exacerbated by oral iron

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43
Q

What are some risk factors for Hyperemesis Gravidarum?

A 
1st pregnancy
Large placental site (twins)
Molar pregnancy
Infertility treatment
Hyperthyroidism
(basically anything that increases hCG levels)
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44
Q

Symptoms of Hyperemesis Gravidarum?

A

Peak onset 6-11wks, usually resolves by wk20.
N&V
Excess salivation + ptyalism (inability to swallow saliva)
Reduced urine output
Epigastric pain

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45
Q

Management of Hyperemesis Gravidarum?

A

Reassurance + simple advice.

Admission for U&Es/LFTs, and IV fluids (NOT DEXTROSE as can precipitate Wernicke’s)

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46
Q

Intrahepatic Cholestasis in Pregnancy- treatment?

A

Deliver at 37-38wks

Ursodeoxycholic acid!

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47
Q

UTI in pregnancy:
Treatment?
Screening?

A

Treatment:
1st >Nitrofurantoin (avoid 3rd trimester/term)
2nd > Amoxicillin
3rd > Cefalexin

Screening: for asymptomatic bacteria at BOOKING (need to treat! Associated with IUGR and LBW).

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48
Q

What is the difference between symmetrical and asymmetrical growth restriction of a foetus?

A

Symmetric: entire body small, early onset, often chromosomal abnormality, prognosis relatively poor.
Asymmetric: undernourished foetus, compensating by directing energy + results in ‘brain-sparing effect’. Often due to placental insufficiency.

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49
Q

What is the most common cause of IUGR/SGA?

A

Uteroplacental insufficiency.

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50
Q

Management for SGA?

A

Small but consistently growing babies with normal umbilical artery doppler do not need intervention.
Always investigate with umbilical artery doppler!!!

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51
Q

Umbilical artery doppler interpretation in IUGR:

a) Normal Doppler
b) ^resistance but +ve end diastolic flow
c) Absent/reversed end diastolic flow.

A

a) Repeat doppler every 2 weeks. Aim delivery >37wks.
b) Repeat doppler 2x weekly. Aim delivery by 34wks
c) Daily dopplers. Aim delivery by 32wks.

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52
Q

Risk factors of foetal macrosomia (>4500g)?

A
  1. Maternal diabetes
  2. Post-term pregnancy
  3. Maternal obesity
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53
Q

How is the volume of amniotic fluid measured?

A

USS by either the DEEPEST VERTICAL POOL, or by adding the deepest pools in 4 quadrants of the uterus (amniotic fluid index: AFI).

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54
Q

Complications of Oligohydramnios?

A
  • PROM (=delivery +/- intrauterine infection)
  • Lung hypoplasia if <22wks
  • Limb abnormality
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55
Q

Definition of Oligohydramnios?

A

Reduced fluid, deepest pool <2cm or AFI<8cm.

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56
Q

Definition of Polyhydramnios?

A

Increased fluid, deepest pool >8cm or AFI>22cm.

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57
Q

Causes of Polyhydramnios?

A
  • Infection!
  • ^foetal urine production (maternal diabetes, twin-twin transfusion syndrome)
  • Foetal inability to absorb/swallow amniotic fluid (foetal GI tract obstruction eg. duodenal atresia. Foetal neuro/muscular abnormality)
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58
Q

Complications of polyhydramnios?

A
  • Preterm delivery (too much uterine stretch)

- Duodenal atresia associated with tri21

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59
Q

When are foetal movements:

a) First felt?
b) Reduced?

A

a) 18-20wks

b) 32wks (plateau off)

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60
Q

Presenting with Reduced Foetal Movements:

a) <24wks?
b) 24-28wks?
c) >28wks?

A

a) Reassure may be normal, especially if primip.
b) Sonicaid to exclude death. (anterior placenta may hide movements <28wks)
c) As above, + USS + CTG.

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61
Q

Still birth risk evaluation?

A 
FGR
HTN
Diabetes
Maternal age
Primiparity
Smoking
Placental insufficiency
Congenital malformation
Obesity
Genetic factors
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62
Q

Definition of PPROM? (preterm pre-labour rupture of membranes)

A

When membranes break before labour starts >37 weeks!!!

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63
Q

Complications of PPROM?

A

Pre-term delivery

Infection: foetus, placenta (chorioamnionitis), cord (funisitis).

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64
Q

Presentation of PPROM?

A

‘Popping sensation, gushing of clear fluid + continuous liquid draining’
(chorioamnionitis= fever/malaise, abdo pain + contractions, purulent discharge)

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65
Q

PPROM:

a) Examinations?
b) Investigations?

A

a) Maternal obs, obstetrics exam, speculum, do NOT do vaginal exam (introduces infection)
b) HVS (high vaginal swab), bloods, foetal wellbeing (CTG)

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66
Q

Management of PPROM:

a) 24 - 36+6 wks
b) >37wks

A

a) -Steroids (betamethasone)
- Antibiotics (erythromycin for 10days or labour- whichever is sooner)
- Magnesium sulphate (neuroprotective)
- Admit for 48hrs for close monitoring
- MAC x2weekly
b) -Go home, come back 24hrs for induction of labour.

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67
Q

Group B strep in pregnancy: complications and management?

A

High maternal carriage rate, major cause of severe neonatal illness.
Treated with intrapartum penicillin for high-risk groups/in 3rd trimester.

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68
Q

Types of multiple pregnancies?

A 
Monozygotic= only one egg, identical, mitotic division (most are monochorionic + diamniotic- meaning shared placenta)
Dizygotic= 2 eggs. Separate amniotic sacs + placenta (dichorionic + diamniotic)
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69
Q

How would you behave differently with twins:

a) Pregnancy mx
b) Delivery mx
c) Delivery induction?

A

a) Consultant led, folic acid+iron, Aspirin (if another pre-eclampsia risk factor), more scans if mono.
b) CS preferred. Can discuss vaginal if 1st foetus is cephalic.
c) -DC: induce at 37wks
- MC: induce at 37wks

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70
Q

How can you determine chorionicity in twins? (in USS, between 11-14wks)

A
  • Dichorionic: widely separates ‘Lambda’ sign, dividing membranes.
  • Monochorionic: T-sign
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71
Q

Twin-to-twin transfusion syndrome (TTTS) for monochorionic twins- what is the treatment?

A
  • Laser ablation of placental anastomoses
  • Selective foeticide
  • Serial amnioreductions
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72
Q

How do you manage chronic HTN in pregnancy?

defined by >140/90 before 20wks

A
  • Lifestyle advice
  • STOP ACEi & ARBs!! (feto-toxic)
  • Labetalol 100mg BD !!!! (or methyldopa/ nifedipine)
  • Aspirin 75mg OD from 12wks to birth
73
Q

How do you manage pregnancy induced HTN during labour?

A

Check BP hourly, if uncontrolled = c-section!

Avoid ergometrine ! (which controls post-natal bleeding by contracting uterus)

74
Q

What is the pathophysiology of pre-eclampsia?

A
  1. Malformation/ fibrosis/ narrowing of spiral arteries (leading to ischaemic placenta >20wks)
  2. Impaired placental blood supply!
  3. Ischaemic placenta causes maternal inflammatory response:
    a) Vasoconstriction- kidney damage, retinal arteries, liver (epigastric pain)
    b) ^vascular permeability- oedema (peripheral, lungs and cerebral: seizures + hyperreflexia!)
75
Q

Risk factors for Pre-eclampsia?

A
  • Previous pre-eclampsia (strongest RF)
  • Age >40yrs
  • Primiparity
  • Pregnancies with large placentas (molar/multiple)
  • Obesity/smoking
  • FHx
  • Pre-existing conditions: autoimmune, HTN, renal disease, diabetes.
76
Q

RED FLAG symptoms for pre-eclampsia? (4)

A
  1. Headache
  2. Visual disturbance
  3. Epigastric/RUQ pain
  4. Sudden onset oedema
77
Q

Diagnosis of Pre-eclampsia?

A
  1. BP readings on 2 occasions, 2hrs apart.

2. Dipstick protein:creatinine >30mg/mol over 24hrs

78
Q

What is HELLP? (a maternal complication of pre-eclampsia)

A

Haemolysis
Elevated liver enzymes
Low platelets
Presents RUQ/epigastric pain.

79
Q

Management of pre-eclampsia?

A
  1. Frequent BP/ urinalysis/ serial growth scans.
  2. Labetolol! (or nifedipine/ methyldopa)
  3. IV mag sulf (seizure prophylaxis)
  4. Betamethasone (if considering delivery <34wks, within next 7days)
  5. Delivery! (only cure), try to get to 34wks. Epidural helps reduce BP.
80
Q

Emergency management of Eclampsia?

A
  1. Turn pt onto side (prevents aorto-caval compression)
  2. Magnesium Sulphate for seizures (4g IV over 10mins)
  3. Control HTN (oral nifedipine) (IV labetolol)
  4. Constant CTG monitoring
81
Q

Foetal complications from diabetes in pregnancy?

A 
SMASH!
Shoulder dystocia
Macrosomia/IUGR
Amniotic fluid excess
Stillbirth
HTN + neonatal Hypoglycaemia
82
Q

Stepwise management of Diabetes in pregnancy?

A
  1. Give glucometer (x4 daily checks), advise re diet + exercise.
  2. If no improvement after 2wks= oral hypoglycaemic agents (metformin)
  3. Insulin

Also give Aspirin 75mg OD to reduce pre-eclampsia risk!!

83
Q

How do you manage delivery in a diabetic mother?

A

Delivery 37-38+6wks
Elective CS if >4.5kg
Maintain glucose levels in labour with ‘sliding scale’ insulin/dextrose infusion.
Post labour: feed baby within 30mins

84
Q

Postnatal management of diabetic mother?

A

Reduce insulin requirement immediately after birth (or discontinue immediately in GDM)
GTT booked for 6wks postpartum

85
Q

What LMWH prophylaxis can be used in pregnancy for VTE?

A

Enoxaparin
Dalteparin
Tinzaparin
(contraindications= bleeding disorder, APH/PPH, eGFR<30)

86
Q

How do you manage a suspected PE/DVT in pregnancy?

A

Doppler USS leg (dont do D-dimer as high in pregnancy anyway).

87
Q

Contraindications for Vaginal Birth after C-section (VBAC)?

A

A vertical/classical uterine scar
Multiple previous C-sections (>3)
Previous uterine rupture

88
Q

Risks of VBAC?

A
  • Risk of uterine rupture= 1/200 (doubles if induced)
  • Chance of needing emergency CS= 25%
  • Risk of blood transfusion/uterine infection
89
Q

Thyroid disease in pregnancy:

  1. Hypothyroidism?
  2. Hyperthyroidism?
A
  1. 1% pregnant women. Untreated=perinatal mortality.

2. 0.2%. Treated with propylthiouracil (not carbimazole)

90
Q

What is the definition of a miscarriage?

A

The loss of a pregnancy before viability (applies up to 24wks, after which is becomes a stillbirth).

91
Q

What may differentiate between the causes of miscarriage?

A

1st tri- think chromosomal abnormality.

2nd tri- think imcompetent cervix.

92
Q

Investigations for miscarriage?

A
  • Blood group + Rh factor
  • Pregnancy test (urine + blood), will usually still be +ve up to 48hrs.
  • Transvaginal US (no visible heartbeat)
93
Q

What is a threatened miscarriage?

A

Mild sx of bleeding/pain suggest miscarriage, but pregnancy continues.
Examination= cervical os is closed/ uterus size correct for dates.
The cause is unknown + no long-term harm to baby for remainder of pregnancy.

94
Q

What is an inevitable miscarriage?

A

Presents as a miscarriage (bleeding/clots/pain/os open)

95
Q

What is a missed/delayed miscarriage?

A

The entire gestation sac (can include embryo) is retained within the uterus.
Pregnancy stopped, foetal heart stopped.
Bleeding minimal, os closed but uterus smaller than gestational age.

96
Q

What are the 3 types of management for an incomplete miscarriage?

A

1) Expectant (allows body to complete miscarriage ‘naturally’)
2) Surgical (evacuation of retained products of conception- ERPC)
3) Medical (Misoprostol!)

97
Q

What is the definition of Recurrent Miscarriage?

A

The loss of 3 or more consecutive pregnancies with the same partner

98
Q

Risk factors for ectopic pregnancy?

A 
PID (esp. chlamydia)
Previous ectopic
Tubal surgery
Sterilisation
IUCD
99
Q

What are USS findings suggestive of an ectopic?

A

Free peritoneal fluid
Thickened endometrium
Adnexal mass adjacent to ovary

100
Q

Surgical management of ectopic prengnacy?

A

Salpingectomy (advised for 1st tubal pregnancy). Affected fallopian tube removed.

101
Q

Medical management of ectopic pregnancy?

A 
Methotrexate IM (takes 4-6wks to completely resolve).
Wait 3 months for next pregnancy.
102
Q

What is a Complete Hydatidiform Mole?

A

Benign tumour of trophoblastic material. Empty egg + single sperm duplicates. 46XX

103
Q

What is a Partial Hydatiform Mole?

A

Normal cell
Sperm duplicates
69XXX / 69XXY
The proliferation may have characteristics of malignant tissue.

104
Q

Symptoms of Gestational Trophoblastic Disease?

A 
Bleeding in 1st / early 2nd trimester
Exaggerated sx of pregnancy
Uterus large for dates
High serum hCG
HTN + hyperthyroidism (hCG can mimic TSH)
USS ‘snowstorm’
105
Q

Management of a molar pregnancy?

A

Urgent referral to specialist -> evacuation of uterus + methotrexate
Avoid pregnancy in next 12months
Follow-up v important.

106
Q

How do you manage a pregnancy of unknown location (PUL)?

A

2x hCGs 48hrs apart to differentiate:

1) Ectopic- hCG stable
2) Complete miscarrage- hCG decreasing
3) Early pregnancy- hCG increasing slowly (need to scan 7-14days)

107
Q

Prevention of rhesus isoimmunisation?

A

Administer Anti-D to rhesus -ve women at 28wks + after potentially sensitising events.

108
Q

What tests do babies need after being born to Rh -ve women?

A

Cord blood taken at delivery for FBC, blood group and direct Coombs test.
(Coombs = direct antiglobulin, will determine antibodies on RBCs of baby)

109
Q

What is the Kleihauer test?

A

Quantifies amount of foetal RBC in maternal blood (if >5ml, mother needs extra dose Anti-D)

110
Q

What physiological changes happen towards the end of pregnancy?

A

Oestrogen: stimulates prostaglandins release + makes body more acceptable to oxytocin.
Cervical effacement + dilation.
Myometrial ^stretching + contractility.

111
Q

How is effacement recorder?

A

In terms of % (100%= paper thin)

112
Q

Describe the latent phase of labour?

A 
Cervical effacement (shorter, softer + moves from posterior fornix to anterior fornix)
Braxton hicks contractions.
113
Q

Pneumonic to remember phases/stages of labour?

A 
Don't Forget I Eat Rhubarb In Labour:
Descent
Flexion
Internal rotation of hear
Extention of head
Restitution
Internal rotation of shoulders
Lateral flexion
114
Q

(labour) Briefly describe:
Stage 1
Stage 2
Stage 3

A

Stage 1: from onset of established labour (4cm) to full dilation of cervix (10cm)
Stage 2: full dilation to birth of baby
Stage 3: From birth of baby to expulsion of placenta

115
Q

Active management in Stage 3 of labour?

A

Routine use of uterotonic drugs (IM oxytocin, brand name: syntocinon) after delivery of anterior shoulder.

116
Q

Causes of pain in Stage 1 of labour?

A
  1. Uterine contractions (T10-L1)- visceral, collicky pain.

2. Pressure on structures (from head descent) (L2-S1), somatic pain, sharp and well localised.

117
Q

Cause of pain in Stage 2 of labour?

A

Dilation + pressure on pelvic organs + structures (S2-4 pudendal nerve), somatic pain, sharp + well localised.

118
Q

Pharmacological pain management in labour?

A
  1. Entonox (nitrous oxide + oxygen)
  2. Non-opioids (paracetamol. NOT NSAIDS as can cause premature closure of ductus arteriosus)
  3. Opioids (pethidine, meptide)
119
Q

Where is LA injected in a spinal?

A

LA injected through dura mater into CSF.

1st choice for CS if not already epidural

120
Q

Epidural process of injection and action?

A

LA injected continuously into epidural space between L3-4
20-30mins for full effect
Complete sensory + partial motor blockade from upper abdo down (need catheter)

121
Q

Contraindications for Epidural?

A

Anticoagulants/ bleeding disorders
Local/severe infection
Anaphylaxis to LA

122
Q

When is Intermittent Foetal Heart Rate (FHR) Auscultation used?

A

Low risk pregnancies!!

With Pinard’s stephoscope or hand-held doppler.

123
Q

Contraindications to foetal blood sampling? (FBS)

A 
Maternal infection
Foetal bleeding disorders
Prematurity (<34wks)
Maternal pyrexia
Significant meconium
Prolonged bradycardia
124
Q

Interpreting a CTG:

Contractions?

A

Normal: 4-5/10mins labour.
Abnormal: >5 is hyperstimulation.

125
Q

Interpreting a CTG:

Baseline rate?

A

Normal: 110-160 bpm
Tachycardia: fever/fetal infection?
Bradycardia: could be sleep, could be acute fetal distress

126
Q

Interpreting a CTG:

Accelerations?

A

Rise of >15bpm for 15s

Good! (usually due to stimulation)

127
Q

Interpreting a CTG:

Variability?

A

> 5bpm

A reflection of autonomic NS, so FIRST thing to become abnormal in hypoxia.

128
Q

Interpreting a CTG:

Decelerations?

A

Drop of >15bpm for 15s

‘Early’ – not concerning
‘Late’ – concerning, present after contraction (hypoxia)
‘Variable’ – Typical: <60s + <60bpm Atypical: >60s + >60bpm

Variable may indicate cord compression

129
Q

Management if ?hypoxia on CTG?

A

High false +ve rate, so hypoxia must be confirmed by foetal scalp pH sample (except in acute-prolonged foetal brady)

130
Q

What do you do if worried about the CTG?

A 
Change maternal position to Left Lateral (^circulation as IVC not compressed)
Give fluids
Foetal scalp stimulation
Foetal blood sample
Delivery
131
Q

What organism is the most common cause of neonatal sepsis?

management?

A

Group B Streptococcus

Mx: prevent vertical transmission w/ IV benzylpenicillin prophylaxis

132
Q

Definition of delayed 1st stage of labour?

A

Cervical dilation of <2cm in 4hrs.

or a slowing down of process in multiparous women

133
Q

4 risk factors associated with induction of labour?

A

1) Uterine hyperstimulation: pain + foetal distress.
2) Precipitate delivery: perineal injury, post/pre-partum.
3. Amniotic embolus (anaphylactic response)
4. Uterine rupture + overstimulation

134
Q

Maternal indications for induction of labour?

A

Pre-eclampsia
Diabetes (38wks)- due to effect of diabetes on placental blood vessels.
Obstetric cholestasis
Severe/ uncontrolled HTN
Deteriorating medical condition/ treatment of malignancy

135
Q

Obstetric indications for induction of labour?

A

Prolonged pregnancy (>42wks= ^risk stillbirth, reduced placental function, decreased amniotic fluid)
PROM
Antepartum haemorrhage

136
Q

Contraindications for induction of labour?

A

Acute foetal compromise
Abnormal lie
Placenta praevia
Pelvic obstruction (pelvic mass, deformity, fibroids)

137
Q

What is a membrane sweep?

A

Stretch + Sweep! Involves the examining finger passing through cervix to rotate against uterus wall, to separate the chorionic membrane from the decidua.
Only use if head is in pelvis!!

138
Q

What is the Bishop’s Score?

A

The ‘ripeness’ of the cervix (^score = ^NVD)

139
Q

Interpretation + management of the following Bishop’s Scores:

a) >6
b) <5

A

a) >6= favourable cervix (ARM + syntocinon)

b) <5= may need ripening (prostaglandins, membrane sweep or oxytocin)

140
Q

What is the process of ARM?

A
  1. Forewaters rupture with amnihook
  2. If contractions dont start (in primip:2hrs, multip:4hrs), then the OXYTOCIN infusion should be started! (synctocinon= exogenous oxytocin)
  3. Oxytocin should NOT be started within 6hrs of prostaglandins (hyperstimulation)
141
Q

What drug can counteract hyperstimulation due to prostaglancins/oxytocin being used together?

A

Turbataline!

142
Q

How are prostaglandins used for induction of labout?

A

Preffered agent for cervical ripening. Given intravaginally into posterior fornex.
Prepidil/prostin (gel)
Propess (pessary)

143
Q

Definitions of positions of labour:

a) Longitudinal
b) Oblique
c) Transverse

A

a) Cephalic/ breech presentation.
b) Head in iliac fossa
c) Transverse: head in flank (back/shoulders first, if dont correct itself then need C sec)

144
Q

Types of Breech?

a) Frank breech
b) Complete breech
c) Footling

A

a) Just buttocks, hips flexed + knees extended. Consider VD. Most common breech!
b) Bum+legs, hips/knees flexed. Consider VD.
c) Foot/knee first/ High risk of cord prolapse. Must have C-sec.

145
Q

Process of External Cephalic Version?

A

36wks

  • Meds to relax uterus (tocolytic)
  • Give Anti-D after
  • Monitor foetal HR throughout
146
Q

Define:

a) Ventouse
b) Non-rotational forceps
c) Rotational forceps (Kielland’s)

A

a) Attached by suction. Suitable for most deliveries. Do NOT use if baby needs rotating.
b) Grip + allow traction. Need opiesastomy. Only if OA position!
c) Allow rotation by operator to OA position before traction.

147
Q

Complications of C-section?

A 
Haemorrhage
Blood transfusions
Uterine/wound sepsis
Thromboembolism
Subsequent pregnancies ^risk placenta praevia/accreta.
148
Q

What is shoulder dystocia?

A

Anterior shoulder stuck behind pubic symphosis. (consequences= damage to brachial plexus= Erb’s palsy)

149
Q

Management for shoulder dystocia?

A

Stop mum pushing!
HELPERR:
H - call for HELP
E - Episiotomy?
L - Legs: McROBERT’S MANOEUVRE
P - Pressure – to suprapubic region (pubic symphysis)
E - Enter: Woodscrew + Reverse Woodscrew manoeuvres
R - Remove posterior arm
R - Roll pt onto her hands + knees, repeat the above manoeuvres

150
Q

Risk factors for Preterm Labour?

A 
Cervical incompetence (e.g. from LLETZ)
Multiple pregnancy
Polyhydramnios
Foetal compromise
Subclinical infections
151
Q

What are tocolytics used for? (+give examples)

A

Relax uterus.
Used to stop preterm labour, ECV, in-utero resus.

Indomethacin (NSAID)
Nifedipine + Nitrites
Mag Sulph
Terbutaline

152
Q

What are uterotonics used for? (+give examples)

A

Stimulate contractions. Used for induction, augmentation, prevent/treat PPH.

Oxytocin (syntocinon)
Ergometrine
Syntometrine (ergometrine + oxytocin)
Carboprost
Misoprolol
153
Q

Symptoms of Placental Abruption?

A

Placenta peels away from uterus wall.

  • Sudden, constant pain
  • Continuous, dark bleeding.
  • Foetal distress.
  • Rigid uterus (hypertonic + tender).
154
Q

Symptoms of Placenta Praevia?

A

Placenta implanted in lower uterus.

  • Painless
  • Bright red bleeding
  • No foetal distress
  • Soft, non-tender uterus.
155
Q

How may the abdomen feel in Antepartum Haemorrhage?

A

Tender, ‘woody’ and tense.

Do not perform vaginal examination!!!

156
Q

Presentation of Vasa Praevia?

A

Rupture of membranes followed immediately by vaginal bleeding.
Foetal bradycardia is classically seen.

157
Q

Definition of Primary Postpartum Haemorrhage?

A

Bleeding >500ml if VD, >1L if CS

Within first 24hrs!

158
Q

4 causes of primary PPH? (the 4 T’s!)

A

1) Tone (80%)- uterine atony, which is failure of uterus to effectively contract + restrict blood vessels after delivery.
2) Trauma (10-20%)- tears/uterine rupture.
3) Tissue (10%)- retained POC. ^risk if placenta accreta. Uterus feels woody/spongy.
4) Thrombin (1%)- bleeding disorders. Can be pre-existing or caused by eclampsia.

159
Q

(Management of PPH)

Tone??

A

a. Fundal uterine massage/ bimanual uterine compression
b. Empty bladder
c. IV oxytocin
d. IV ergometrine
e. Consider prostaglandins (carboprost + misoprostol)

160
Q

(Management of PPH)

a. Trauma?
b. Tissue?
c. Thrombin?

A

a. Repair!
b. Remove under GA
c. Give RBCs, FFP, platelets.

161
Q

Management of Secondary PPH?

A
  1. Check for signs of shock + infection
  2. Vaginal swabs
  3. Refer to USS for retained POC
  4. Broad-spec abx for endometritis
162
Q

Define the types of tear in perineal trauma.

A

1ST DEGREE: damage to fourchette. Superficial damage with no muscle involvement.
2ND DEGREE: perineal muscle. Injury to perineal muscle, doesn’t involve anal sphincter.
3RD DEGREE: anal sphincter complex (internal + external).
4TH DEGREE: anal mucosa. Involves internal + external anal sphincter + mucosa.

163
Q

How/when do you perform an episiotomy?

A

Performed in 2nd stage.
Most common right posterolateral.
Lidonocaine.

164
Q

Explain the pathophysiology that leads to Sheehan Syndrome.

A

After childbirth, pituitary is v active and the lactotrophins ^size to release prolactin to stimulate lactation. If mother loses blood+++ then pituitary may become ischaemic/necrosed. This means drop in hormones (includ. adrenocorticotrophic, gonadotrophic + TSH)

165
Q

What are the collection of symptoms in Sheehan Syndrome?

A

a. Agalactorrhoea (lack of prolactin)
b. Amenorrhoea (lack of FSH + LH)
c. Low BP, cold intolerance + wt gain (lack of TSH).

166
Q

What is the most common cause of Sepsis in the postnatal period?

A

Strep A, and retained products of conception.

classic sx of group A strep infection= D&V, generalised rash, severe abdo pain + watery vaginal discharge

167
Q

What is the first presentation that pre-eclampsia has progressed to eclampsia?

A

Grand Mal Convulsions! (persistent fitting- give magnesium sulphate/ diazepam)

168
Q

What are the 5 changes that occur during Puerperium? (6wk period after birth)

A
  1. Involution: fundus below umbilicus immediately, no longer palpable after 2/52
  2. ‘After pains’ : contractions, 4days.
  3. Internal Os closes day 3
  4. Lochia: blood stained discharge 4/52
  5. Lactation: prolactin + oxytocin
169
Q

Physiology of lactation?

A

Prolactin from anterior pituitary stimulates milk profuction.
Decreased oestrogen/progesterone (prolactin antagonists produced by placenta) lead to milk secretion.
Oxytocin from posterior pituitary created ejection response to suckling.
Prolactin suppresses FSH + LH = amenorrhoea!

170
Q

What drugs should you avoid whilst breastfeeding?

A
  • Abx: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
  • Psychiatric: lithium, benzodiazepines
  • Aspirin
  • Carbimazole
  • Sulphonylureas
  • Cytotoxic drugs
  • Amiodarone
171
Q

What is postpartum contraception advice for a woman not breastfeeding?

A

<21days postpartum:

  • barrier method (condoms)
  • POP (can start straight away)

21+days:

  • Condoms
  • POP
  • COCP (provided NO other VTW risk factors, otherwise contraindicated)
  • Cu-IUD (either within 48hrs, or >4wks. High expulsion rate)
172
Q

What is postpartum contraception advice for a woman breastfeeding?

A
  • Lactational amennorhoea unreliable
  • 20days to 6wks: condoms, POP/implant, CuIUD.
  • > 6wks: all!! (better to wait 6months for COCP)
173
Q

What may Lithium cause if taken during pregnancy?

A

Ebstein’s abnormality (atrialised right ventrical)

174
Q

What is indicated and contra-indicated during pregnancy/breastfeeding:

a. UFH
b. LMWH (tinzaparin)
c. Warfarin
d. Clot busters (alteplase)

A

a. Indicated
b. Indicated
c. Contraindicated
d. Give if life-threatening

175
Q

What may Warfarin cause if taken during pregnancy/breastfeeding?

A
  • Stillbirth
  • Prematurity
  • Haemorrhage
  • Ocular defects

Foetal warfarin sydrome: nasal hypoplasia, hypoplasia of extremities, and developmental delay.

176
Q

Why must you avoid NSAIDs (like ibuprofen) during pregnancy?

A

1st tri = miscarriage + malformation

3rd tri= premature closure of ductus arteriosus

177
Q

Why must you NOT use the following abx in pregnancy for UTI:

a. Trimethoprim
b. Nitrofurantoin
c. Co-amox

A

a. Trimeth (anti-folate drug): dont use in 1st trimester as teratogenic.
b. Nitro: dont use in 3rd trimester as neonatal haemolysis.
c. Co-amox: risk of NEC.

178
Q

Why must NOT use ACEi/ARBs (for HTN) in pregnancy?

A

1st tri: malformation

2nd/3rd tri: foetal renal damage

Year 4 GOSH (3 decks)

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