Obs and gynae Flashcards
what can mimic pre term labour with intermittent cramps?
placental abruption - separation of placenta from uterus
What test can exclude pre term labour?
how does it work?
fetal fibronectin
if not found pre term labour unlikely in next 1 -2 weeks
what are the two traces on a CTG
What are the normal parameters on CTG?
Baseline rate ~140bpm = normal
Normal variability ~15bpm
Accelerations present
No decelerations
Contractions present 3 every 10min
what can cause fetal tachycardia
Fetal hypoxia
Chorioamnionitis
Hyperthyroidism
Fetal or maternal anaemia
Fetal tachyarrhythmia
what can cause fetal bradycardia?
Severe bradycardia?
Bradycardia
* Post date gestation
* Occiput posterior or transverse presentations
Severe bradycardia
* Prolonged cord compression
* Cord prolapse
* Epidural and spinal anaesthesia
* Maternal seizures
* Rapid fetal descent
How do you manage pre term labour?
Tocolytic (anti contraction) - oral nifidepine 20mg 30min up to 60mg then QID
Betamethasone 11.4mg IM x2 24hrs apart
IV Antibiotics: Benzylpenicillin 1.2g stat
Neuroprotection: MgSO4 4g over 30min, then 1g/hr infusion
Disposition = Retrieval to obstetric / paediatric facility
what does no fetal pole mean?
non viable pregnancy
Missed Miscarriage / Anembryonic pregnancy / Blighted ovum
how do you manage a missed miscarriage?
Expectant Mx -see what happens
Medical Mx – misoprostol 800mg PV
Surgical Mx – suction evacuation
what are two absolute indications for surgical management of miscarriage
severe bleeding
septic miscarriage
what is the dose and route of Rh Igs
250 international units IM
- **?labour established **- presence of pelvic pressure and low back pain - ?contractions
- **?ruptured membranes **- fluid, blood, mucous PV - ?dilation of cervic
- Stage of labour - cervical length/effacement
- **fetal well being **- CTG
- **mother well being **- observations
- risk factors for preterm labour - UTI/IUGR. drug use
what medications are used in pre term labour and their indication
1.** betamethasone 11.4mg IM** - for lung maturity if under 34 weeks
2. nifidepine 20mg PO - tocolysis in preterm if fetus at risk from prematuritt
3. **MGsulphate 4g IV over 20 mins then 1g/hr - fetal neuroprotection in pre term
4. IV antibiotics **- amox, metronidazole - chorio-amnioitis
abdo pain and collapse
what does US show?
what could this mean in young person?
fluid in morrisons pouch
fluid in splenorenal angle
in young - ectopic - do BHCG to confirm
what are the management priorties in ecoptic pregnancy
- urgent O+G for surgical assessment
- resus fluids - large bore Iv
- analgesia
- psych support
- anti D if resus negative
what is the preferred technique using US for fetal wellbeing in under 14 weeks
M mode as less thermal damage from tissue heating
what could be inclusion and exclusion criteria for bedside US to assess viability in early pregnancy
list the steps you would take to manage surprise labour in the ED for someone who did not not know they were pregnant
- call for help - specialty teams if there
- resus space
- 2 teams - mum and baby
- call on anyone with O+G experience
- baby- resus equipement, resusicatire, obtain guidelines, correct sized equipment
- mother - pain relief, monitoring, IV access
how quick should a baby with shoulder dystocia be delivered to avoid fetal hypoxia
under 10
techniques for shoulder dystocia
- McRoberts - lay flat and flex and abduct hips
- episiotomy
- mother on all fours
- delivery of posterior arm to allow exit
- cleidotomy
what are the features of routine immediate management of newborn
- clamp cord and cut
- temp control - warm, rub, dry
- airway - anticipate cry and stimulate id needed
- APGAR scoring
what is the third stage of labour and how do you manage?
delivery of placenta
Steps
* check no twin
* administer 10 units oxytocin IV
* deliver placenta via controlled cord traction
* uterine massage
* obseve for PV loss
* observe perineum for tears
how do you manage incomplete placenta delivering and heavy PV loss?
- ensure O+G there
- uterine massage
- resus - IV access, blood and fluid
- IDC and empty bladder
- visual inspection ?trauma
- ergometrine/syntocin
- bimanual uterine compression
list four differentials
pre eclampsia
HELLP
HUS/TTP
acute fatty liver of pregnancy
bliary disease
management priorities?
- call O+G
- IV access and resus
- treat hypertension - IV hydralazine 5mg every 5-10 mins aiming BP under150 systolic
- IV mg 4g to prevent seizures
- consider correcting coagulopathy
what is the medical treatment for eclamptic seizure
1st line - IV Mg 4g followed by 1g/hr infusion
2nd line - IV midaz
on a CTG what indicates fetal distress?
- fetal HR above 180 or below 100
- variable or late decelerations (normal is none or early)
what are the treatment steps in eclamptic seizure?
- Urgent O+G input
- ensure airway secure and give o2
- left lateral position
- IV access
- drugs - 4g IV mg
- R/O hypoglucaemia
name labelled parts
A - baseline HR
B - late deceleration
C - uterine contraction
what are risk factors for ectopic?
- IVF
- previous ectopic
- PID
- IUD
- history of tubal surgery
list 3 criteria on US to exclude ectopic
- . IUP with fetal HR/pole
- . no abnormal adnexal mass
- . no increased pelvic free fluid
list two criteria on pelvic US that would characterise pregnancy of unknown location
- interuterine sac without visible fetal heartbeat or pole
- no abnormal adnexal mass discovered
interpret and diagnosis
Management
- HAGMA
- delta ratio over 2 so metabolic alkalosis too
- exp c02 is 32
- hypokalaemia
- normal lactate
Diagnosis - hyperemesis gravidarum with starvation ketosis
Management
1. antiemetic 10mg meto IV
2. IV hartmanns
3. correct ketosis with dextrose infusion
4. replace electrolytes
differentials
pre-eclampsia
hypertension in pregnancy
migraine
SAH
SOL
ICH
CVA
meningio-encephalitis
key examinations and investigations
exam:
reflexes - clonus
neuro exam - focal deficit
investigations
FBC - ?HELLP
urine - proteinuria for preeclampsia
FBC - infection
CT head - SAH
CTG - fetal wellbeing
what is HELLP
haemolysis
elevated liver enzymes
low platelets
what are some life threatening consequences of HELLP or pre eclampsia?
- placental abruption
- acute renal failure
- seizures
- death to fetus
- subcapsular liver haematoma
what in history is suggestive of PID?
prior PID
vaginal discharge
new/multiple partners
recent IUD
deep dyspareunia
investigation and justification in ?PID
urine pcr - chlamydia and gonorrhea
high vaginal swab - culture STD organisms
b-hcg - ?pregnany and antimicrobial choice
pelvic US - ?tubal abscess
what is the management of PID
- abx
- analgesia
- sexual health education/follow up
- contact tracing
what are the four categories of PPH and examples
- Tone - uterine relaxants, placent praevia (low in cervic)
- Trauma - C section, episiotomy
- Tissue - retained placenta, retained products of conception, placenta accreta (grows into uterine wall)
- Thrombin - VWD, blood thinners, sepsis, DIC
what are the most common reasons for PPH with large baby eg GD
uterine atony
retained tissue
what are the complications of pre eclampsia
eclampsia
fetal death
maternal death
DIC
AKI
HELLP
what exam features support pre eclampsia?
peripheral oedema
hyper reflexia
tender hepatomegaly
papilloedema
BP over 140/90 or 30/15 from baseline
what investigations would you do to look for complications of pre eclampsia
Urate – elevated
Urea/creat – acute renal failure
Platelets – low in HELLP
LFTS – raised in HELLP
Coags – DIC
CTG monitoring – all patients to determine fetal distress / viability
Hb – low in haemolysis in HELLP
Urine protein
what exam features suggest pre term labour
rupture of membranes
increasing frequent contractions
increasing low back and pelvic pain
cervical dilatation and shortening
fetal descent to pelvis
what tests suggest pre term labour
vaginal fluid ph > 6.5
CTG shows regular contractions
fetal fibronectin
in someone undergoing preterm labour what the the contra indications for transfer to O+G centre
- active labour with fetal parts on view or cervic over 5cm
- fetal brady or no HR
- haemodynamic instability of mum
- no staff able to transfer
- cord prolapse
what newborn features suggest urgent resus
poor tone
lack of response to stimuli
HR below 100
resp distress or lack of spontaneous breathing
following parameters for neonatal resus
* oxygenation
* ventilation
* CPR trigger
* CPR rate of compressions
* CPR ratio
- oxygenation - room air then 100% if not responding
- ventilation - PPV with 5-8cm H20
- CPR trigger - HR under 60 after 60 seconds PPV
- CPR rate of compressions - 90/min
- CPR ratio 3:1
values in neonatal resus:
ETT size
ETT depth
Vascular access device & size
Adrenaline
Fluid type & volume
- ETT size -1.5-3.5 uncuffed
- ETT depth - weight =6cm
- Vascular access device & size - umbilical line size 5 or 24g cannula
- Adrenaline- 10mcg/kg IV
- **Fluid type & volume **- normal saline 10ml/kg
when may you cool in neonatal resus
hypoxic ischaemic encephelopathy
what are some risk factors for pre term labour
uterine abnormalities - fibroids
cervical abnormalities - incompetence, short cervic
premature rupture of membranes
smoker
stimulant use
infection eg uti
low socioeconomic status
differentials and assessment feature for PV bleeding and a negative BHCG
- DUB - absence of any other cause
- cervical cancer - lesion on spec
- trauma - obvious laceration
- endometrial ca - mass on US
- PID - discharge, deep pain, IUD
- coagulopathy - deranged coags
what are the pharmacological treatments for DUB
- TXA 500mg TDS
- NSAIDS - ibuprofen or mefenemic acid
- norethisterone
abdo pain mid cycle - differentials with negatvie bhcg
- ovarian torsion
- ruptured ovarian cyst
- haemorrhagic cyst
- mittelschmertz
- endometriosis
- adenomyosis
what on US and CT suggests PID?
US
* normal
* fluid in pouch of douglas
* presence of tubo ovarian abscess
CT
* oophritis
* salpingitis
* cervicitis
* simple fluid collection/abscess
what is the classical picure of shoulder dystocia?
why does it happen anatomically?
head appears then retracts
bony impaction of anterior shoulder behind pubic symphysis
what are the common causes of third trimester PV bleeding?
- **placenta previa **- covers all or part of cervix but still attached to uterus
- placenta abruption - partially or completey becomes detached from uterus
what clinical features distinguish between placent previa and abruption?
What exam should be avoid?
Previa
* painless
* non tender uterus
* no fetal distress
* shock in proportion to PV loss
abruption
* constant pain
* tender uterus
* fetal distress
* shock out of propertion to pv loss
avoid digital vagina exam as if previa can cause more bleeding
what are the management steps for placenta previa and abruption in ED?
- Resus
- 2 large bore cannula, fluids and blood
- group and hold
- O+G input
- high flow o2
- bloods to check coags
- CTG
Differentials for post partum fever?
- mastitis/breast abscess
- UTI
- endometriits
- pyelonephritis
- pneumonia
- C section wound infection
- episiotimy wound infection
- toxic shock
- meningoencephalitis
with post partum fever what methods of delivery are relevant to potential causes?
- spontaeous - retined placenta
- C-section - scar infection
- episotomy - infection
- epidural - CNS infection
- IV lines - thromophlebitis
- prolonged rupture of membranes - endometriitis
risk factors for breech delivery?
premature
fibroids
polyhydraminos
uterine malformations
fetal malformations
inital APGAR 0
what are the management priorities
dry baby to stimulate breathing
warm baby
suction mouth ?meconium
PPV
CPR if HR below 60
risk factors for pre eclampsia/eclampsia
FH
first pregnancy
teen pregnancy
older 35
low socioeconomic status
multiple gestations
poor outcome of prevous pregnancy
what examination features suggest a seizure is eclamptic in origin
hypertension
peripheral oedema
hyperreflexia
what are the indications for a resuscitative hysterotomy?
maternal cardiac arrest
within 15 minutes of arrest
gestational age over 20-24 weeks or palpable above umbilicus
how is a resuscitative hysterotomy performed?
- pre skin (if time)
- vertical incision from pubis to umbilicus
- use scissors to open peritonuem
- vertical incision in uterus and try and avoid bladder
- place hand through incision into uterine cavity and try and deliver baby - clamp cord
- deliver placenta - scoop out with hand and cord traction
- syntocin 30IU
- pack uterus
list three changes to the CV and respiratry system in pregnancy and effect on ALS?
CV
1. 10% cardiac output to baby so increaed risk of haemorrhage
2. hr inc 15-20 so increased CPR demand
3. 50% increase plasma volume so reduced o2 capacity and shock signs appear later
Resp
1. inc RR so more chance acidosis
2. increased laryngeal airway to difficult tube
3. increased upper airway blood supply so more chance of bleeding
when do you use a Kleihauer test?
confirm dose of anti d
what are the four major CV changes in pregnancy?
- plasma volume increases by half
- HR increase 15-20
- cardiac output increased by 40% with pressure in IVC
- uterine blood flow is 10% cardiac output
in preggo and abdo trauma what conditions must be met for discharge
- normal abdo exam
- normal fetal movements
- no PV bleeding
- safe discharge environment
what changes occur in respiratory physiology in pregnancy
- TV increases by 35%
- TLC decreases
- RR and MV increase
- pc02 decreases giving resp alkalosis
- expiratory reserve volume decreases
how do you perform a perimortem caeser
leading causes of death in pregnancy
VTE
trauma
infection
eclampsia
pre existing cardiac disease
mnemonic for reading CtG
DR C Bravado
