Obs and gynae Flashcards

1
Q

what can mimic pre term labour with intermittent cramps?

A

placental abruption - separation of placenta from uterus

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2
Q

What test can exclude pre term labour?
how does it work?

A

fetal fibronectin
if not found pre term labour unlikely in next 1 -2 weeks

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3
Q

what are the two traces on a CTG

A
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4
Q

What are the normal parameters on CTG?

A

Baseline rate ~140bpm = normal
Normal variability ~15bpm
Accelerations present
No decelerations
Contractions present 3 every 10min

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5
Q

what can cause fetal tachycardia

A

Fetal hypoxia
Chorioamnionitis
Hyperthyroidism
Fetal or maternal anaemia
Fetal tachyarrhythmia

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6
Q

what can cause fetal bradycardia?
Severe bradycardia?

A

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

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7
Q

How do you manage pre term labour?

A

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

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8
Q

what does no fetal pole mean?

A

non viable pregnancy
Missed Miscarriage / Anembryonic pregnancy / Blighted ovum

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9
Q

how do you manage a missed miscarriage?

A

Expectant Mx -see what happens
Medical Mx – misoprostol 800mg PV
Surgical Mx – suction evacuation

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10
Q

what are two absolute indications for surgical management of miscarriage

A

severe bleeding
septic miscarriage

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11
Q

what is the dose and route of Rh Igs

A

250 international units IM

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12
Q
A
  1. **?labour established **- presence of pelvic pressure and low back pain - ?contractions
  2. **?ruptured membranes **- fluid, blood, mucous PV - ?dilation of cervic
  3. Stage of labour - cervical length/effacement
  4. **fetal well being **- CTG
  5. **mother well being **- observations
  6. risk factors for preterm labour - UTI/IUGR. drug use
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13
Q

what medications are used in pre term labour and their indication

A

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

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14
Q

abdo pain and collapse
what does US show?
what could this mean in young person?

A

fluid in morrisons pouch
fluid in splenorenal angle

in young - ectopic - do BHCG to confirm

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15
Q

what are the management priorties in ecoptic pregnancy

A
  1. urgent O+G for surgical assessment
  2. resus fluids - large bore Iv
  3. analgesia
  4. psych support
  5. anti D if resus negative
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16
Q

what is the preferred technique using US for fetal wellbeing in under 14 weeks

A

M mode as less thermal damage from tissue heating

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17
Q

what could be inclusion and exclusion criteria for bedside US to assess viability in early pregnancy

A
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18
Q
A
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19
Q

list the steps you would take to manage surprise labour in the ED for someone who did not not know they were pregnant

A
  1. call for help - specialty teams if there
  2. resus space
  3. 2 teams - mum and baby
  4. call on anyone with O+G experience
  5. baby- resus equipement, resusicatire, obtain guidelines, correct sized equipment
  6. mother - pain relief, monitoring, IV access
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20
Q

how quick should a baby with shoulder dystocia be delivered to avoid fetal hypoxia

A

under 10

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21
Q

techniques for shoulder dystocia

A
  1. McRoberts - lay flat and flex and abduct hips
  2. episiotomy
  3. mother on all fours
  4. delivery of posterior arm to allow exit
  5. cleidotomy
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22
Q

what are the features of routine immediate management of newborn

A
  • clamp cord and cut
  • temp control - warm, rub, dry
  • airway - anticipate cry and stimulate id needed
  • APGAR scoring
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23
Q

what is the third stage of labour and how do you manage?

A

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

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24
Q

how do you manage incomplete placenta delivering and heavy PV loss?

A
  • ensure O+G there
  • uterine massage
  • resus - IV access, blood and fluid
  • IDC and empty bladder
  • visual inspection ?trauma
  • ergometrine/syntocin
  • bimanual uterine compression
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25
Q

list four differentials

A

pre eclampsia
HELLP
HUS/TTP
acute fatty liver of pregnancy
bliary disease

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26
Q

management priorities?

A
  1. call O+G
  2. IV access and resus
  3. treat hypertension - IV hydralazine 5mg every 5-10 mins aiming BP under150 systolic
  4. IV mg 4g to prevent seizures
  5. consider correcting coagulopathy
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27
Q

what is the medical treatment for eclamptic seizure

A

1st line - IV Mg 4g followed by 1g/hr infusion
2nd line - IV midaz

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28
Q

on a CTG what indicates fetal distress?

A
  • fetal HR above 180 or below 100
  • variable or late decelerations (normal is none or early)
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29
Q

what are the treatment steps in eclamptic seizure?

A
  1. Urgent O+G input
  2. ensure airway secure and give o2
  3. left lateral position
  4. IV access
  5. drugs - 4g IV mg
  6. R/O hypoglucaemia
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30
Q

name labelled parts

A

A - baseline HR
B - late deceleration
C - uterine contraction

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31
Q

what are risk factors for ectopic?

A
  • IVF
  • previous ectopic
  • PID
  • IUD
  • history of tubal surgery
32
Q
A
33
Q
A
34
Q

list 3 criteria on US to exclude ectopic

A
  • . IUP with fetal HR/pole
  • . no abnormal adnexal mass
  • . no increased pelvic free fluid
35
Q

list two criteria on pelvic US that would characterise pregnancy of unknown location

A
  1. interuterine sac without visible fetal heartbeat or pole
  2. no abnormal adnexal mass discovered
36
Q

interpret and diagnosis

Management

A
  • 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

37
Q

differentials

A

pre-eclampsia
hypertension in pregnancy
migraine
SAH
SOL
ICH
CVA
meningio-encephalitis

38
Q

key examinations and investigations

A

exam:
reflexes - clonus
neuro exam - focal deficit

investigations
FBC - ?HELLP
urine - proteinuria for preeclampsia
FBC - infection
CT head - SAH
CTG - fetal wellbeing

39
Q

what is HELLP

A

haemolysis
elevated liver enzymes
low platelets

40
Q

what are some life threatening consequences of HELLP or pre eclampsia?

A
  • placental abruption
  • acute renal failure
  • seizures
  • death to fetus
  • subcapsular liver haematoma
41
Q

what in history is suggestive of PID?

A

prior PID
vaginal discharge
new/multiple partners
recent IUD
deep dyspareunia

42
Q

investigation and justification in ?PID

A

urine pcr - chlamydia and gonorrhea
high vaginal swab - culture STD organisms
b-hcg - ?pregnany and antimicrobial choice
pelvic US - ?tubal abscess

43
Q

what is the management of PID

A
  1. abx
  2. analgesia
  3. sexual health education/follow up
  4. contact tracing
44
Q

what are the four categories of PPH and examples

A
  1. Tone - uterine relaxants, placent praevia (low in cervic)
  2. Trauma - C section, episiotomy
  3. Tissue - retained placenta, retained products of conception, placenta accreta (grows into uterine wall)
  4. Thrombin - VWD, blood thinners, sepsis, DIC
45
Q

what are the most common reasons for PPH with large baby eg GD

A

uterine atony
retained tissue

46
Q

what are the complications of pre eclampsia

A

eclampsia
fetal death
maternal death
DIC
AKI
HELLP

47
Q

what exam features support pre eclampsia?

A

peripheral oedema
hyper reflexia
tender hepatomegaly
papilloedema
BP over 140/90 or 30/15 from baseline

48
Q

what investigations would you do to look for complications of pre eclampsia

A

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

49
Q

what exam features suggest pre term labour

A

rupture of membranes
increasing frequent contractions
increasing low back and pelvic pain
cervical dilatation and shortening
fetal descent to pelvis

50
Q

what tests suggest pre term labour

A

vaginal fluid ph > 6.5
CTG shows regular contractions
fetal fibronectin

51
Q

in someone undergoing preterm labour what the the contra indications for transfer to O+G centre

A
  • 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
52
Q

what newborn features suggest urgent resus

A

poor tone
lack of response to stimuli
HR below 100
resp distress or lack of spontaneous breathing

53
Q

following parameters for neonatal resus
* oxygenation
* ventilation
* CPR trigger
* CPR rate of compressions
* CPR ratio

A
  • 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
54
Q

values in neonatal resus:
ETT size
ETT depth
Vascular access device & size
Adrenaline
Fluid type & volume

A
  • 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
55
Q

when may you cool in neonatal resus

A

hypoxic ischaemic encephelopathy

56
Q

what are some risk factors for pre term labour

A

uterine abnormalities - fibroids
cervical abnormalities - incompetence, short cervic
premature rupture of membranes
smoker
stimulant use
infection eg uti
low socioeconomic status

56
Q

differentials and assessment feature for PV bleeding and a negative BHCG

A
  1. DUB - absence of any other cause
  2. cervical cancer - lesion on spec
  3. trauma - obvious laceration
  4. endometrial ca - mass on US
  5. PID - discharge, deep pain, IUD
  6. coagulopathy - deranged coags
57
Q

what are the pharmacological treatments for DUB

A
  1. TXA 500mg TDS
  2. NSAIDS - ibuprofen or mefenemic acid
  3. norethisterone
58
Q

abdo pain mid cycle - differentials with negatvie bhcg

A
  • ovarian torsion
  • ruptured ovarian cyst
  • haemorrhagic cyst
  • mittelschmertz
  • endometriosis
  • adenomyosis
59
Q

what on US and CT suggests PID?

A

US
* normal
* fluid in pouch of douglas
* presence of tubo ovarian abscess

CT
* oophritis
* salpingitis
* cervicitis
* simple fluid collection/abscess

60
Q

what is the classical picure of shoulder dystocia?

why does it happen anatomically?

A

head appears then retracts

bony impaction of anterior shoulder behind pubic symphysis

61
Q

what are the common causes of third trimester PV bleeding?

A
  • **placenta previa **- covers all or part of cervix but still attached to uterus
  • placenta abruption - partially or completey becomes detached from uterus
62
Q

what clinical features distinguish between placent previa and abruption?

What exam should be avoid?

A

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

63
Q

what are the management steps for placenta previa and abruption in ED?

A
  1. Resus
  2. 2 large bore cannula, fluids and blood
  3. group and hold
  4. O+G input
  5. high flow o2
  6. bloods to check coags
  7. CTG
64
Q

Differentials for post partum fever?

A
  • mastitis/breast abscess
  • UTI
  • endometriits
  • pyelonephritis
  • pneumonia
  • C section wound infection
  • episiotimy wound infection
  • toxic shock
  • meningoencephalitis
65
Q

with post partum fever what methods of delivery are relevant to potential causes?

A
  1. spontaeous - retined placenta
  2. C-section - scar infection
  3. episotomy - infection
  4. epidural - CNS infection
  5. IV lines - thromophlebitis
  6. prolonged rupture of membranes - endometriitis
66
Q
A
67
Q

risk factors for breech delivery?

A

premature
fibroids
polyhydraminos
uterine malformations
fetal malformations

68
Q

inital APGAR 0
what are the management priorities

A

dry baby to stimulate breathing
warm baby
suction mouth ?meconium
PPV
CPR if HR below 60

69
Q

risk factors for pre eclampsia/eclampsia

A

FH
first pregnancy
teen pregnancy
older 35
low socioeconomic status
multiple gestations
poor outcome of prevous pregnancy

70
Q

what examination features suggest a seizure is eclamptic in origin

A

hypertension
peripheral oedema
hyperreflexia

71
Q

what are the indications for a resuscitative hysterotomy?

A

maternal cardiac arrest
within 15 minutes of arrest
gestational age over 20-24 weeks or palpable above umbilicus

72
Q

how is a resuscitative hysterotomy performed?

A
  1. pre skin (if time)
  2. vertical incision from pubis to umbilicus
  3. use scissors to open peritonuem
  4. vertical incision in uterus and try and avoid bladder
  5. place hand through incision into uterine cavity and try and deliver baby - clamp cord
  6. deliver placenta - scoop out with hand and cord traction
  7. syntocin 30IU
  8. pack uterus
73
Q

list three changes to the CV and respiratry system in pregnancy and effect on ALS?

A

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

74
Q

when do you use a Kleihauer test?

A

confirm dose of anti d