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1. Fellowship Written - SAQ > Obs and gynae > Flashcards

Obs and gynae Flashcards

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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
list four differentials
pre eclampsia HELLP HUS/TTP acute fatty liver of pregnancy bliary disease
26
management priorities?
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
27
what is the medical treatment for eclamptic seizure
1st line - IV Mg 4g followed by 1g/hr infusion 2nd line - IV midaz
28
on a CTG what indicates fetal distress?
* fetal HR above 180 or below 100 * variable or late decelerations (normal is none or early)
29
what are the treatment steps in eclamptic seizure?
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
30
name labelled parts
A - baseline HR B - late deceleration C - uterine contraction
31
what are risk factors for ectopic?
* IVF * previous ectopic * PID * IUD * history of tubal surgery
32
33
34
list 3 criteria on US to exclude ectopic
* . IUP with fetal HR/pole * . no abnormal adnexal mass * . no increased pelvic free fluid
35
list two criteria on pelvic US that would characterise pregnancy of unknown location
1. interuterine sac without visible fetal heartbeat or pole 2. no abnormal adnexal mass discovered
36
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
37
differentials
pre-eclampsia hypertension in pregnancy migraine SAH SOL ICH CVA meningio-encephalitis
38
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
39
what is HELLP
haemolysis elevated liver enzymes low platelets
40
what are some life threatening consequences of HELLP or pre eclampsia?
* placental abruption * acute renal failure * seizures * death to fetus * subcapsular liver haematoma
41
what in history is suggestive of PID?
prior PID vaginal discharge new/multiple partners recent IUD deep dyspareunia
42
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
43
what is the management of PID
1. abx 2. analgesia 3. sexual health education/follow up 4. contact tracing
44
what are the four categories of PPH and examples
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
what are the most common reasons for PPH with large baby eg GD
uterine atony retained tissue
46
what are the complications of pre eclampsia
eclampsia fetal death maternal death DIC AKI HELLP
47
what exam features support pre eclampsia?
peripheral oedema hyper reflexia tender hepatomegaly papilloedema BP over 140/90 or 30/15 from baseline
48
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
49
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
50
what tests suggest pre term labour
vaginal fluid ph > 6.5 CTG shows regular contractions fetal fibronectin
51
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
52
what newborn features suggest urgent resus
poor tone lack of response to stimuli HR below 100 resp distress or lack of spontaneous breathing
53
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
54
when may you cool in neonatal resus
hypoxic ischaemic encephelopathy
55
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
55
differentials and assessment feature for PV bleeding and a negative BHCG
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
56
what are the pharmacological treatments for DUB
1. TXA 500mg TDS 2. NSAIDS - ibuprofen or mefenemic acid 3. norethisterone
57
abdo pain mid cycle - differentials with negatvie bhcg
* ovarian torsion * ruptured ovarian cyst * haemorrhagic cyst * mittelschmertz * endometriosis * adenomyosis
58
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
59
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
60
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
61
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
62
what are the management steps for placenta previa and abruption in ED?
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
63
Differentials for post partum fever?
* mastitis/breast abscess * UTI * endometriits * pyelonephritis * pneumonia * C section wound infection * episiotimy wound infection * toxic shock * meningoencephalitis
64
with post partum fever what methods of delivery are relevant to potential causes?
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
65
66
risk factors for breech delivery?
premature fibroids polyhydraminos uterine malformations fetal malformations
67
inital APGAR 0 what are the management priorities
dry baby to stimulate breathing warm baby suction mouth ?meconium PPV CPR if HR below 60
68
risk factors for pre eclampsia/eclampsia
FH first pregnancy teen pregnancy older 35 low socioeconomic status multiple gestations poor outcome of prevous pregnancy
69
what examination features suggest a seizure is eclamptic in origin
hypertension peripheral oedema hyperreflexia
70
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
71
how is a resuscitative hysterotomy performed?
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
72
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
73
when do you use a Kleihauer test?
confirm dose of anti d
74
what are the four major CV changes in pregnancy?
1. plasma volume increases by half 2. HR increase 15-20 3. cardiac output increased by 40% with pressure in IVC 4. uterine blood flow is 10% cardiac output
75
in preggo and abdo trauma what conditions must be met for discharge
1. normal abdo exam 1. normal fetal movements 1. no PV bleeding 1. safe discharge environment
76
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
77
78
how do you perform a perimortem caeser
79
leading causes of death in pregnancy
VTE trauma infection eclampsia pre existing cardiac disease
80
mnemonic for reading CtG
DR C Bravado

1. Fellowship Written - SAQ (30 decks)

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