obs and gynae 3a Flashcards
detail the steps in the menstrual cycle (hormones)
hypothalamus–>GnRH–> anterior pituitary gland–>Fsh and LH
1) FSH stimulates follicule maturation
2) Oestrogen produced by maturing follicule
3) At low oestrogen levels oestrogen inhibits LH (negative feedback on anterior pituitary)
4) FSH secreted at low oestrogen levels (rise in oestrogen=fall in FSH)
5) Oestrogen levels rise and stimulate LH secretion
6) LH triggers ovulation
7) corpus luteum secretes oestrogen, inhibin and progesterone–> negative feedback inhibiting secretion of FSH (preventing further follicule maturation).
8) Porgesterone stimulates endometrial growth and inhibits GnRH production
9) Corpus luteum degenerates. Fall in progesterone (endometrium shed)–> GnRH not inhibited–> stimulates new cylcle (FSH and LH)
Describe the hormonal changes that occur to allow labour to commence
progesterone and oestrogen DROP
prostaglans RISE- causes uterus to contract
progesterone and oestrogen initially produced by corpus luteum in first trimester, then by placenta
progesterone is a smooth muscle and so inhibits uterine contraction
what is the metabolic disturbance seen in hyperemesis gravidarum
Hypochroraemic alkalosis
management of gestational diabetes melitus
Aim for BM <7.8 post prandial
1) diet and exercise
2) metformin
3) insulin
4) detailed anomaly scan and monitor growth (risk of preterm delivery, miscarriage, cardiac malformations, polyhydramnios, macrosomia, IUGR
5) increased risk of developing T2DM after delivery- screen annually
define pre-eclampsia
raised blood pressure >140/90 AFTER 20 weeks
proteinuria >0.3g/24 hrs
management of pregnancy induced hypertension
=hypertension occurring AFTER 20 weeks
if >150/100- labetalol
weekly BP and urine- excluse Pre-eclampsia
regular growth scans- increased risk of fetal growth restriction
risk factors for pre-eclampsia
PROF CANT DO *Personal history* Renal disease Older Family history *Chronic hypertension* *Autoimmune disease* Nuliparity Twin pregnancies *Diabetes* Obesity
investigations of pre-eclampsia
urine dip- raised proteins
protein-creatinine ratio
fetal US- look for fetal grwoth restriciton
Bloods- U+Ez, LFTs, FBC, GFR- Exclude HELLP
Define HELLP
severe variant of pre-eclampsia
H-Haemolysis
EL- elevated liver enzymes
LP- low platelets
Symptoms: epigastric/ RUQ pain, N+V, dark urine (haemolysis), raised BP, hepatomegaly, bruising
Risk of DIC, placental abruption, renal failure
Deliver is 34 weeks+
Define eclampsia + management
Tonic-clonic seizures and pre-ecampsia- can occur before, during or after pregnancy
ABCDE magnesium sulfate O2 Iv labetalol Delivery by C section once mother stable
What is part of the antenatal screening programme?
1) <10 weeks- sickle cell and thalasaemia blood test
2) Early pregnancy- syphilis, Hep B, HIV blood test
3) 10-14 weeks- combined test for downs, edwards and pataus (nuchal translucency and serum markers
4) 14-20 weeks- quadruple test- If combined test not possible- blood test screens for Downs
5) 18-21 weeks major abnormalities scanned for
If a fetus is small for dates at two dates 2 weeks apart, what does this indicate and what further investigations should be carried out
Fetal Growth Restriction
Ultrasound measurement of amniotic fluid—> if low–>uterine and umbilical artery doppler–indicates placental dysfunction
Management of fetal growth restriction
1) grwoth scans every 2-3 eeks + doppler
2) give corticosteroids for fetal lung maturityup to 35+6 weeks
3) plan birth- normal dopplers induce at 37 weeks/ abnormal dopplers concider LSCS
presentation of ectopic pregnancy
Pain (unilateral, sudden onset), amenorrhoea 6-8 weeks, bleeding, D+V, dizziness and syncope
cervical excitation and adnexal tenderness, abdo distension, rebound tenderness
Serum hCG and urine pregnancy test positive
Transvaginal ultrasound- uterus empty
history of ectopic, PID, previous uterine surgery, IVF, chlamydia, pregnancy despite IUD
management of ectopic pregnancy
1) stabilise patient
2) if asymptomatic/ hCG<3000/ ectopic <3cm on scan/ no fetal heart beat–> MEDICAL MANAGEMENT- IM methotrexate
3) if significant pain/ opossite of above–> SURGICAL MANAGEMENT- Laproscopic salpingectomy
presentation of molar pregnancy
Significantly raised hCG
exaggerated pregnancy symptoms- severe morning sickness and pre-eclampsia
most present with early pregnancy failure- heavy bleeding, molar tissue looks like frogspawn
US- snowstorm effect/ grapes
Management: Terminate pregancy
Management of a missed abortion
1) medical- mifepristone (antiprogesterone- allows contractions) and misoprostol (prostaglandin- brings on contractions)
2) Surgical- evacuation of retained products of conception
3) expectant- rarely
In general, what is the likely diagnosis of an antepartum haemorrhage
1) PAINFUL
2) PAINLESS
1) pain- abruption
2) painless- preavia
What is the name for placenta lying in lower uterine segment?
placenta preavia
diagnosed on ultasound scan
management of placenta preavia
if minor= placental edge >2cm from os
stay at home until 37 weeks as long as mum can get in quickly, deliver at 39 weeks
if major= placental edge <2cm from os
delivery by C section at 39 weeks
Give steroids 24-34 weeks
Placental abruption definition
Part of placenta becomes detached from uterus before dilvery- can be significant maternal bleeding behind
concealed (80%)- blood goes directly into myometrium, blood loss amount easily underestimated
revealed- dark bleeding
placental abruption presentation
PAIN
woody hard uterus
Tender contracting uterus, tachycardia, hypotemsion, fetal distress, poor urine output
complications- fetal death due to placental insufficiency
Name 3 clinical features of normal labour
1) contractions
2) cervical effacement and dilation
3) show- plug of cervical mucus and blood
outline the 3 stages of labour
FIRST STAGE
initiation of contractions–>full cervical effacement and dilation
latent- irregular contractions, dilation up to 4cm
established- regular contractions, dilation up to 10cm
SECOND STAGE
full cervical dilation–> delivery of baby
passive- head decending to pelvic floor- takes up to 2 hours
active- pushing- up to 3 hours
THIRD STAGE
delivery of fetus to delivery of placenta
<500mls blood loss normal
what is given to aid the 3rd stage of labour?
Syntometrine- oxytocin and ergometrine
contaction of uterus and decreased bleeding
what is used in induction of labour
if ruptured membraines but not progressing to spontaneous labour give vaginal prostaglandin and oxytocin infusion
what biomarker indicates an increased risk of prematurity
fetal fibronectin
what can be given to supress premature labour?
Tocolytics- atositiban/ nifedipine
define primary and secondary post partum haemorrhage
Primary= >500mls blood lost in first 24 hours secondary= excessive blood loss 24hrs- 6 weeks after delivery
What are the causes of a primary post partum haemorrhage?
tone- uterine atony (not contracting well)- 90%
tissue- retained POC
Trauma- genital tract trauma
Thrombin- clotting disorders
what are the causes of a secondary PPH
most commonly endometritis +/- retained placental tissue
also C section, prolonged rupture of membranes, manual removal of placenta, extreme of mothers age, lower socioeconomic status
explain the difference between baby blues, post natal depression and puerperal psychosis
BABY BLUES
Seen in around 60-70% of women
Typically seen 3-7 days following birth and is more common in primips
Mothers are characteristically anxious, tearful and irritable
Reassurance and support, the health visitor has a key role
POST NATAL DEPRESSION
Affects around 10% of women
Most cases start within a month and typically peaks at 3 months
Features are similar to depression seen in other circumstances
Cognitive behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine* may be used if symptoms are severe** - whilst they are secreted in breast milk it is not thought to be harmful to the infant
PUERPERAL PSYCHOSIS
Affects approximately 0.2% of women
Onset usually within the first 2-3 weeks following birth
Features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations)
Admission to hospital is usually required
There is around a 20% risk of recurrence following future pregnancies
