Obs Flashcards
Name 5 teratogenic drugs.
ACEi Sodium Valproate Methotrexate Retinoids Trimethoprim
What does progesterone do during pregnancy? (main pregnancy hormone)
- 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)
Role of HCG in pregnancy?
Responsible for the maintenance of the corpus luteum on the ovary, that continues to secrete oestrogens + progesterone.
Why do levels of HCG fall after 8-10wks of pregnancy (if it is needed to maintain the corpus luteum to secrete oestrogens/progesterone)?
At 8wks gestation, the placenta begins independent production of O&P. So HCG levels fall and corpus luteum recedes.
(Physiological changes in pregnancy)
Cardiovascular?
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)
(Physiological changes in pregnancy)
Renal?
GFR ^50%
Renal pelvis + ureters dilate (progesterone), ^infection risk.
(Physiological changes in pregnancy)
Endocrine?
T3/4 decrease
Anterior pituitary doubles in size
^cortisol, ^insulin
(Physiological changes in pregnancy)
MSK?
Progesterone softens joints + ligaments.
What are the effects of Progesterone as a SMOOTH MUSCLE RELAXANT during pregnancy?
Relaxes bile ducts = cholestasis
Relaxes bladder/urethra = UTIs
Relaxes blood vessels = Drop BP
Relaxes GOJ + stomach = GORD (use ranitidine + omeprazole).
What does the Dating Scan show? (offered at 10-14wks)
Estimated due date (also can use LMP+7 +9months)
Identifies multiple pregnancies
Nuchal translucency measurement- to screen for chromosomal abnormalities.
What bloods are booked during The Booking Visit (10wks)?
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
What consent is obtained in The Booking Visit
Consent for antenatal screening:
- Combined screening (opt in)
- Quadruple test (if miss combined)
How is the risk of Tri-21 calculated?
Maternal age x risk ratio from combined screening test.
SCREENING POSITIVE = risk of >1/150
What is the significance of nuchal translucency?
The larger it is (>5mm), the higher risk of structural defects.
(blood test from combined screening) What is the significance of PAPP-A (pregnancy-associated plasma protein A)
Protein produced by the placenta during pregnancy.
Low levels = higher risk (of Down’s, Edward’s, Patau’s)
(blood test from combined screening) What is the significance of hCG?
(in 1st + 2nd trimester)
High levels = higher risk of Down’s
Low levels = higher risk of Edward’s/ Patau’s
In the quadruple test (14-20wks), if Down's was detected what would the following results be? (low/high) hCG Inhabin-A AFP Estriol
hCG : up
Inhabin-A : up
AFP : down
Estriol : down
(Prenatal Diagnostic Tests)
NON-INVASIVE:
Explain what US can diagnose?
Neural tube defect
Twin-to-Twin transfusion syndrome
Gastroschisis
(Prenatal Diagnostic Tests)
NON-INVASIVE:
Explain what cffDNA (cell-free foetal DNA) is used for?
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)
(Prenatal Diagnostic Tests)
NON-INVASIVE:
Explain what a IONA test can diagnose?
Down’s, Edward’s or Patau’s
Sex determination
(Prenatal Diagnostic Tests)
INVASIVE:
What are CVS / amniocentesis used to diagnose?
And what is the risk?
Down’s
CF
Thalassaemia
1% risk of miscarriage
Process of Chorion Villus Sampling (10-13 wks)?
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
Process of Amniocentesis? (15+wks)
Aspiration of amniotic fluid which contains foetal cells from skin + gut.
Transabdo, results in 3wks
Risks: miscarriage (0.5%)
What happens if a woman is Rhesus -ve?
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.
What happens to Rhesus -ve mother if a baby is Rhesus +ve after they are born?
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)
How is HIV managed during pregnancy to avoid risk of vertical transmission?
Use of ARTs throughout pregnancy (+ 6wks for newborn)
C-section
Avoid breastfeeding
How is active Syphilis managed during pregnancy?
Mother must receive treatment (Benzylpenicillin) >4wks before delivery, otherwise newborn undergoes IV therapy.
Name 5 pieces of pre-conception/ early pregnancy advice.
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)
(Early pregnancy advice)
Mother with PRIOR PRE-ECLAMPSIA?
Low-dose aspirin (75mg), taken asap from 1st tri, up to 20wks (2nd stage of placental growth, in order to maintain adequate perfusion).
(Early pregnancy advice)
Mother with PREVIOUS C-SECTION?
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.
(Early pregnancy advice)
Mother who SMOKES?
All offered CO blood reading.
Pregnancies at risk of: IUGR, SGA, placental abruption, preterm labour, stillbirth.
(Early pregnancy advice)
Mother with ANAEMIA?
Oral iron supplements (FeSO4) if:
Hb<100mg/dL
MCV<80
(Early pregnancy advice)
Mother with GDM?
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
What is the most important measurement for assessing foetus’ growth/size?
Abdominal Circumference (AC)
What is Crown-Rump length used for?
Most accurate for dating pregnancy in 1st trimester.
What does a dopple of the umbilical arteries measure?
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.
Doppler waveforms in foetal circulation: Meaning of: -'High resistance' -'Low resistance' -'Increased velocity'
- 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
(Antenatal Problems: Maternal- MINOR)
Why is itching more common?
Management?
Linked to hormones + abdo skin stretching.
Rare + serious = gestational cholestasis + liver complications (check jaundice + LFTs)
Can give antihistamines (chlorphenamine)
(Antenatal Problems: Maternal- MINOR)
a) What is Pelvic girdle
b) Why does it occur in pregnancy?
c) Management?
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.
(Antenatal Problems: Maternal- MINOR)
Why is heartburn common (70%!) in pregnancy?
What is the associated caution?
Progesterone relaxes GOS, causes gastric stasis. Also baby pushes on stomach.
Mx= ranitidine, antacids.
Caution: pre-eclampsia can present with epigastric pain!
(Antenatal Problems: Maternal- MINOR)
Vaginitis in pregnancy- why and what is the mx?
Itchy, non-offensive, white-grey discharge.
Due to candidiasis (common in pregnancy)
Mx= vaginal pessaries (Clotrimazole)
(Antenatal Problems: Maternal- MINOR)
What common complaints can you reassure on?
Sciatica- resolves after delivery.
Constipation- exacerbated by oral iron
What are some risk factors for Hyperemesis Gravidarum?
1st pregnancy Large placental site (twins) Molar pregnancy Infertility treatment Hyperthyroidism (basically anything that increases hCG levels)
Symptoms of Hyperemesis Gravidarum?
Peak onset 6-11wks, usually resolves by wk20.
N&V
Excess salivation + ptyalism (inability to swallow saliva)
Reduced urine output
Epigastric pain
Management of Hyperemesis Gravidarum?
Reassurance + simple advice.
Admission for U&Es/LFTs, and IV fluids (NOT DEXTROSE as can precipitate Wernicke’s)
Intrahepatic Cholestasis in Pregnancy- treatment?
Deliver at 37-38wks
Ursodeoxycholic acid!
UTI in pregnancy:
Treatment?
Screening?
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).
What is the difference between symmetrical and asymmetrical growth restriction of a foetus?
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.
What is the most common cause of IUGR/SGA?
Uteroplacental insufficiency.
Management for SGA?
Small but consistently growing babies with normal umbilical artery doppler do not need intervention.
Always investigate with umbilical artery doppler!!!
Umbilical artery doppler interpretation in IUGR:
a) Normal Doppler
b) ^resistance but +ve end diastolic flow
c) Absent/reversed end diastolic flow.
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.
Risk factors of foetal macrosomia (>4500g)?
- Maternal diabetes
- Post-term pregnancy
- Maternal obesity
How is the volume of amniotic fluid measured?
USS by either the DEEPEST VERTICAL POOL, or by adding the deepest pools in 4 quadrants of the uterus (amniotic fluid index: AFI).
Complications of Oligohydramnios?
- PROM (=delivery +/- intrauterine infection)
- Lung hypoplasia if <22wks
- Limb abnormality
Definition of Oligohydramnios?
Reduced fluid, deepest pool <2cm or AFI<8cm.
Definition of Polyhydramnios?
Increased fluid, deepest pool >8cm or AFI>22cm.
Causes of Polyhydramnios?
- 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)
Complications of polyhydramnios?
- Preterm delivery (too much uterine stretch)
- Duodenal atresia associated with tri21
When are foetal movements:
a) First felt?
b) Reduced?
a) 18-20wks
b) 32wks (plateau off)
Presenting with Reduced Foetal Movements:
a) <24wks?
b) 24-28wks?
c) >28wks?
a) Reassure may be normal, especially if primip.
b) Sonicaid to exclude death. (anterior placenta may hide movements <28wks)
c) As above, + USS + CTG.
Still birth risk evaluation?
FGR HTN Diabetes Maternal age Primiparity Smoking Placental insufficiency Congenital malformation Obesity Genetic factors
Definition of PPROM? (preterm pre-labour rupture of membranes)
When membranes break before labour starts >37 weeks!!!
Complications of PPROM?
Pre-term delivery
Infection: foetus, placenta (chorioamnionitis), cord (funisitis).
Presentation of PPROM?
‘Popping sensation, gushing of clear fluid + continuous liquid draining’
(chorioamnionitis= fever/malaise, abdo pain + contractions, purulent discharge)
PPROM:
a) Examinations?
b) Investigations?
a) Maternal obs, obstetrics exam, speculum, do NOT do vaginal exam (introduces infection)
b) HVS (high vaginal swab), bloods, foetal wellbeing (CTG)
Management of PPROM:
a) 24 - 36+6 wks
b) >37wks
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.
Group B strep in pregnancy: complications and management?
High maternal carriage rate, major cause of severe neonatal illness.
Treated with intrapartum penicillin for high-risk groups/in 3rd trimester.
Types of multiple pregnancies?
Monozygotic= only one egg, identical, mitotic division (most are monochorionic + diamniotic- meaning shared placenta) Dizygotic= 2 eggs. Separate amniotic sacs + placenta (dichorionic + diamniotic)
How would you behave differently with twins:
a) Pregnancy mx
b) Delivery mx
c) Delivery induction?
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
How can you determine chorionicity in twins? (in USS, between 11-14wks)
- Dichorionic: widely separates ‘Lambda’ sign, dividing membranes.
- Monochorionic: T-sign
Twin-to-twin transfusion syndrome (TTTS) for monochorionic twins- what is the treatment?
- Laser ablation of placental anastomoses
- Selective foeticide
- Serial amnioreductions
How do you manage chronic HTN in pregnancy?
defined by >140/90 before 20wks
- Lifestyle advice
- STOP ACEi & ARBs!! (feto-toxic)
- Labetalol 100mg BD !!!! (or methyldopa/ nifedipine)
- Aspirin 75mg OD from 12wks to birth
How do you manage pregnancy induced HTN during labour?
Check BP hourly, if uncontrolled = c-section!
Avoid ergometrine ! (which controls post-natal bleeding by contracting uterus)
What is the pathophysiology of pre-eclampsia?
- Malformation/ fibrosis/ narrowing of spiral arteries (leading to ischaemic placenta >20wks)
- Impaired placental blood supply!
- 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!)
Risk factors for Pre-eclampsia?
- 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.
RED FLAG symptoms for pre-eclampsia? (4)
- Headache
- Visual disturbance
- Epigastric/RUQ pain
- Sudden onset oedema
Diagnosis of Pre-eclampsia?
- BP readings on 2 occasions, 2hrs apart.
2. Dipstick protein:creatinine >30mg/mol over 24hrs
What is HELLP? (a maternal complication of pre-eclampsia)
Haemolysis
Elevated liver enzymes
Low platelets
Presents RUQ/epigastric pain.
Management of pre-eclampsia?
- Frequent BP/ urinalysis/ serial growth scans.
- Labetolol! (or nifedipine/ methyldopa)
- IV mag sulf (seizure prophylaxis)
- Betamethasone (if considering delivery <34wks, within next 7days)
- Delivery! (only cure), try to get to 34wks. Epidural helps reduce BP.
Emergency management of Eclampsia?
- Turn pt onto side (prevents aorto-caval compression)
- Magnesium Sulphate for seizures (4g IV over 10mins)
- Control HTN (oral nifedipine) (IV labetolol)
- Constant CTG monitoring
Foetal complications from diabetes in pregnancy?
SMASH! Shoulder dystocia Macrosomia/IUGR Amniotic fluid excess Stillbirth HTN + neonatal Hypoglycaemia
Stepwise management of Diabetes in pregnancy?
- Give glucometer (x4 daily checks), advise re diet + exercise.
- If no improvement after 2wks= oral hypoglycaemic agents (metformin)
- Insulin
Also give Aspirin 75mg OD to reduce pre-eclampsia risk!!
How do you manage delivery in a diabetic mother?
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
Postnatal management of diabetic mother?
Reduce insulin requirement immediately after birth (or discontinue immediately in GDM)
GTT booked for 6wks postpartum
What LMWH prophylaxis can be used in pregnancy for VTE?
Enoxaparin
Dalteparin
Tinzaparin
(contraindications= bleeding disorder, APH/PPH, eGFR<30)
How do you manage a suspected PE/DVT in pregnancy?
Doppler USS leg (dont do D-dimer as high in pregnancy anyway).
Contraindications for Vaginal Birth after C-section (VBAC)?
A vertical/classical uterine scar
Multiple previous C-sections (>3)
Previous uterine rupture
Risks of VBAC?
- Risk of uterine rupture= 1/200 (doubles if induced)
- Chance of needing emergency CS= 25%
- Risk of blood transfusion/uterine infection
Thyroid disease in pregnancy:
- Hypothyroidism?
- Hyperthyroidism?
- 1% pregnant women. Untreated=perinatal mortality.
2. 0.2%. Treated with propylthiouracil (not carbimazole)
What is the definition of a miscarriage?
The loss of a pregnancy before viability (applies up to 24wks, after which is becomes a stillbirth).
What may differentiate between the causes of miscarriage?
1st tri- think chromosomal abnormality.
2nd tri- think imcompetent cervix.
Investigations for miscarriage?
- Blood group + Rh factor
- Pregnancy test (urine + blood), will usually still be +ve up to 48hrs.
- Transvaginal US (no visible heartbeat)
What is a threatened miscarriage?
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.
What is an inevitable miscarriage?
Presents as a miscarriage (bleeding/clots/pain/os open)
What is a missed/delayed miscarriage?
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.
What are the 3 types of management for an incomplete miscarriage?
1) Expectant (allows body to complete miscarriage ‘naturally’)
2) Surgical (evacuation of retained products of conception- ERPC)
3) Medical (Misoprostol!)
What is the definition of Recurrent Miscarriage?
The loss of 3 or more consecutive pregnancies with the same partner
Risk factors for ectopic pregnancy?
PID (esp. chlamydia) Previous ectopic Tubal surgery Sterilisation IUCD
What are USS findings suggestive of an ectopic?
Free peritoneal fluid
Thickened endometrium
Adnexal mass adjacent to ovary
Surgical management of ectopic prengnacy?
Salpingectomy (advised for 1st tubal pregnancy). Affected fallopian tube removed.
Medical management of ectopic pregnancy?
Methotrexate IM (takes 4-6wks to completely resolve). Wait 3 months for next pregnancy.
What is a Complete Hydatidiform Mole?
Benign tumour of trophoblastic material. Empty egg + single sperm duplicates. 46XX
What is a Partial Hydatiform Mole?
Normal cell
Sperm duplicates
69XXX / 69XXY
The proliferation may have characteristics of malignant tissue.
Symptoms of Gestational Trophoblastic Disease?
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’
Management of a molar pregnancy?
Urgent referral to specialist -> evacuation of uterus + methotrexate
Avoid pregnancy in next 12months
Follow-up v important.
How do you manage a pregnancy of unknown location (PUL)?
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)
Prevention of rhesus isoimmunisation?
Administer Anti-D to rhesus -ve women at 28wks + after potentially sensitising events.
What tests do babies need after being born to Rh -ve women?
Cord blood taken at delivery for FBC, blood group and direct Coombs test.
(Coombs = direct antiglobulin, will determine antibodies on RBCs of baby)
What is the Kleihauer test?
Quantifies amount of foetal RBC in maternal blood (if >5ml, mother needs extra dose Anti-D)
What physiological changes happen towards the end of pregnancy?
Oestrogen: stimulates prostaglandins release + makes body more acceptable to oxytocin.
Cervical effacement + dilation.
Myometrial ^stretching + contractility.
How is effacement recorder?
In terms of % (100%= paper thin)
Describe the latent phase of labour?
Cervical effacement (shorter, softer + moves from posterior fornix to anterior fornix) Braxton hicks contractions.
Pneumonic to remember phases/stages of labour?
Don't Forget I Eat Rhubarb In Labour: Descent Flexion Internal rotation of hear Extention of head Restitution Internal rotation of shoulders Lateral flexion
(labour) Briefly describe:
Stage 1
Stage 2
Stage 3
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
Active management in Stage 3 of labour?
Routine use of uterotonic drugs (IM oxytocin, brand name: syntocinon) after delivery of anterior shoulder.
Causes of pain in Stage 1 of labour?
- Uterine contractions (T10-L1)- visceral, collicky pain.
2. Pressure on structures (from head descent) (L2-S1), somatic pain, sharp and well localised.
Cause of pain in Stage 2 of labour?
Dilation + pressure on pelvic organs + structures (S2-4 pudendal nerve), somatic pain, sharp + well localised.
Pharmacological pain management in labour?
- Entonox (nitrous oxide + oxygen)
- Non-opioids (paracetamol. NOT NSAIDS as can cause premature closure of ductus arteriosus)
- Opioids (pethidine, meptide)
Where is LA injected in a spinal?
LA injected through dura mater into CSF.
1st choice for CS if not already epidural
Epidural process of injection and action?
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)
Contraindications for Epidural?
Anticoagulants/ bleeding disorders
Local/severe infection
Anaphylaxis to LA
When is Intermittent Foetal Heart Rate (FHR) Auscultation used?
Low risk pregnancies!!
With Pinard’s stephoscope or hand-held doppler.
Contraindications to foetal blood sampling? (FBS)
Maternal infection Foetal bleeding disorders Prematurity (<34wks) Maternal pyrexia Significant meconium Prolonged bradycardia
Interpreting a CTG:
Contractions?
Normal: 4-5/10mins labour.
Abnormal: >5 is hyperstimulation.
Interpreting a CTG:
Baseline rate?
Normal: 110-160 bpm
Tachycardia: fever/fetal infection?
Bradycardia: could be sleep, could be acute fetal distress
Interpreting a CTG:
Accelerations?
Rise of >15bpm for 15s
Good! (usually due to stimulation)
Interpreting a CTG:
Variability?
> 5bpm
A reflection of autonomic NS, so FIRST thing to become abnormal in hypoxia.
Interpreting a CTG:
Decelerations?
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
Management if ?hypoxia on CTG?
High false +ve rate, so hypoxia must be confirmed by foetal scalp pH sample (except in acute-prolonged foetal brady)
What do you do if worried about the CTG?
Change maternal position to Left Lateral (^circulation as IVC not compressed) Give fluids Foetal scalp stimulation Foetal blood sample Delivery
What organism is the most common cause of neonatal sepsis?
management?
Group B Streptococcus
Mx: prevent vertical transmission w/ IV benzylpenicillin prophylaxis
Definition of delayed 1st stage of labour?
Cervical dilation of <2cm in 4hrs.
or a slowing down of process in multiparous women
4 risk factors associated with induction of labour?
1) Uterine hyperstimulation: pain + foetal distress.
2) Precipitate delivery: perineal injury, post/pre-partum.
3. Amniotic embolus (anaphylactic response)
4. Uterine rupture + overstimulation
Maternal indications for induction of labour?
Pre-eclampsia
Diabetes (38wks)- due to effect of diabetes on placental blood vessels.
Obstetric cholestasis
Severe/ uncontrolled HTN
Deteriorating medical condition/ treatment of malignancy
Obstetric indications for induction of labour?
Prolonged pregnancy (>42wks= ^risk stillbirth, reduced placental function, decreased amniotic fluid)
PROM
Antepartum haemorrhage
Contraindications for induction of labour?
Acute foetal compromise
Abnormal lie
Placenta praevia
Pelvic obstruction (pelvic mass, deformity, fibroids)
What is a membrane sweep?
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!!
What is the Bishop’s Score?
The ‘ripeness’ of the cervix (^score = ^NVD)
Interpretation + management of the following Bishop’s Scores:
a) >6
b) <5
a) >6= favourable cervix (ARM + syntocinon)
b) <5= may need ripening (prostaglandins, membrane sweep or oxytocin)
What is the process of ARM?
- Forewaters rupture with amnihook
- If contractions dont start (in primip:2hrs, multip:4hrs), then the OXYTOCIN infusion should be started! (synctocinon= exogenous oxytocin)
- Oxytocin should NOT be started within 6hrs of prostaglandins (hyperstimulation)
What drug can counteract hyperstimulation due to prostaglancins/oxytocin being used together?
Turbataline!
How are prostaglandins used for induction of labout?
Preffered agent for cervical ripening. Given intravaginally into posterior fornex.
Prepidil/prostin (gel)
Propess (pessary)
Definitions of positions of labour:
a) Longitudinal
b) Oblique
c) Transverse
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)
Types of Breech?
a) Frank breech
b) Complete breech
c) Footling
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.
Process of External Cephalic Version?
36wks
- Meds to relax uterus (tocolytic)
- Give Anti-D after
- Monitor foetal HR throughout
Define:
a) Ventouse
b) Non-rotational forceps
c) Rotational forceps (Kielland’s)
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.
Complications of C-section?
Haemorrhage Blood transfusions Uterine/wound sepsis Thromboembolism Subsequent pregnancies ^risk placenta praevia/accreta.
What is shoulder dystocia?
Anterior shoulder stuck behind pubic symphosis. (consequences= damage to brachial plexus= Erb’s palsy)
Management for shoulder dystocia?
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
Risk factors for Preterm Labour?
Cervical incompetence (e.g. from LLETZ) Multiple pregnancy Polyhydramnios Foetal compromise Subclinical infections
What are tocolytics used for? (+give examples)
Relax uterus.
Used to stop preterm labour, ECV, in-utero resus.
Indomethacin (NSAID)
Nifedipine + Nitrites
Mag Sulph
Terbutaline
What are uterotonics used for? (+give examples)
Stimulate contractions. Used for induction, augmentation, prevent/treat PPH.
Oxytocin (syntocinon) Ergometrine Syntometrine (ergometrine + oxytocin) Carboprost Misoprolol
Symptoms of Placental Abruption?
Placenta peels away from uterus wall.
- Sudden, constant pain
- Continuous, dark bleeding.
- Foetal distress.
- Rigid uterus (hypertonic + tender).
Symptoms of Placenta Praevia?
Placenta implanted in lower uterus.
- Painless
- Bright red bleeding
- No foetal distress
- Soft, non-tender uterus.
How may the abdomen feel in Antepartum Haemorrhage?
Tender, ‘woody’ and tense.
Do not perform vaginal examination!!!
Presentation of Vasa Praevia?
Rupture of membranes followed immediately by vaginal bleeding.
Foetal bradycardia is classically seen.
Definition of Primary Postpartum Haemorrhage?
Bleeding >500ml if VD, >1L if CS
Within first 24hrs!
4 causes of primary PPH? (the 4 T’s!)
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.
(Management of PPH)
Tone??
a. Fundal uterine massage/ bimanual uterine compression
b. Empty bladder
c. IV oxytocin
d. IV ergometrine
e. Consider prostaglandins (carboprost + misoprostol)
(Management of PPH)
a. Trauma?
b. Tissue?
c. Thrombin?
a. Repair!
b. Remove under GA
c. Give RBCs, FFP, platelets.
Management of Secondary PPH?
- Check for signs of shock + infection
- Vaginal swabs
- Refer to USS for retained POC
- Broad-spec abx for endometritis
Define the types of tear in perineal trauma.
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.
How/when do you perform an episiotomy?
Performed in 2nd stage.
Most common right posterolateral.
Lidonocaine.
Explain the pathophysiology that leads to Sheehan Syndrome.
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)
What are the collection of symptoms in Sheehan Syndrome?
a. Agalactorrhoea (lack of prolactin)
b. Amenorrhoea (lack of FSH + LH)
c. Low BP, cold intolerance + wt gain (lack of TSH).
What is the most common cause of Sepsis in the postnatal period?
Strep A, and retained products of conception.
classic sx of group A strep infection= D&V, generalised rash, severe abdo pain + watery vaginal discharge
What is the first presentation that pre-eclampsia has progressed to eclampsia?
Grand Mal Convulsions! (persistent fitting- give magnesium sulphate/ diazepam)
What are the 5 changes that occur during Puerperium? (6wk period after birth)
- Involution: fundus below umbilicus immediately, no longer palpable after 2/52
- ‘After pains’ : contractions, 4days.
- Internal Os closes day 3
- Lochia: blood stained discharge 4/52
- Lactation: prolactin + oxytocin
Physiology of lactation?
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!
What drugs should you avoid whilst breastfeeding?
- Abx: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
- Psychiatric: lithium, benzodiazepines
- Aspirin
- Carbimazole
- Sulphonylureas
- Cytotoxic drugs
- Amiodarone
What is postpartum contraception advice for a woman not breastfeeding?
<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)
What is postpartum contraception advice for a woman breastfeeding?
- Lactational amennorhoea unreliable
- 20days to 6wks: condoms, POP/implant, CuIUD.
- > 6wks: all!! (better to wait 6months for COCP)
What may Lithium cause if taken during pregnancy?
Ebstein’s abnormality (atrialised right ventrical)
What is indicated and contra-indicated during pregnancy/breastfeeding:
a. UFH
b. LMWH (tinzaparin)
c. Warfarin
d. Clot busters (alteplase)
a. Indicated
b. Indicated
c. Contraindicated
d. Give if life-threatening
What may Warfarin cause if taken during pregnancy/breastfeeding?
- Stillbirth
- Prematurity
- Haemorrhage
- Ocular defects
Foetal warfarin sydrome: nasal hypoplasia, hypoplasia of extremities, and developmental delay.
Why must you avoid NSAIDs (like ibuprofen) during pregnancy?
1st tri = miscarriage + malformation
3rd tri= premature closure of ductus arteriosus
Why must you NOT use the following abx in pregnancy for UTI:
a. Trimethoprim
b. Nitrofurantoin
c. Co-amox
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.
Why must NOT use ACEi/ARBs (for HTN) in pregnancy?
1st tri: malformation
2nd/3rd tri: foetal renal damage
