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Obstretrics and Gynaecology > Obs and Gynae > Flashcards

Obs and Gynae Flashcards

1
Q

Mean age for menopause

A

51

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2
Q

Premature menopause is defined before what age? and how common?

A

41

1/100

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3
Q

What is menopause/casues it’s symptoms?

A

Loss of production of estradiol and progesterone by ovaries

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4
Q

Is estrogen still produced after menopause?

A

Yes, by ovaries and bone, blood vessels, brain

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5
Q

How is menopause defined?

A

Cessation of menses for 12 months. Given retrospective diagnosis

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6
Q

Symptoms of menopause are…

A

variable from woman to woman

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7
Q

Short term consequences of menopause

A 
vasomotor symptoms (hot flashes, palpitations, migrain)
CNS menopausal syndrome (mood swings, irritability, sleep disturbance, libido depression, fatigue)
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8
Q

Long term consequences menopause

A 
Genital tract atrophy
CVD
Osteoporosis
Effect on skin, teeth, liver, eyes
?brain function, Alzheimers
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9
Q

Osteoporosis is diagnosed with

A

Bone densinometry <2.5

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10
Q

RFs for osteoporosis

A

Fhx, smoking, alcohol, low BMI, steroids, low calcium, low exercise, liver disease, arthritis, hyperthyroid, renal

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11
Q

Mx for osteoporosis

A 
Non-medical= exercise, diet
Medical= bisphosphonates, calcium, vit D, HRT
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12
Q

SE’s bsiphosphonates

A

GI side effects

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13
Q

What % of women whave symptoms of menopause

A

80%

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14
Q

Pathophys of hot flashes?

A

Unknown

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15
Q

Why add progesterone in HRT?

A

To prevent “unopposed” oestrogen–>endometrial proliferation, adenocarcinoma

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16
Q

Consequences of menopause are all related to low … level?

A

estrogen

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17
Q

Advantages of HRT

A

Relieves symptoms, improves bone density

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18
Q

Disadvantages of HRT

A

increase breast cancer (only proven in estrogen-progesterone combo HRT- small increase too), increase in CHD for older HRT users, increase stroke, VTE
MAIN: unwanted bleeding (progesterone) leading to unneccessary investigations

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19
Q

Contraindications for HRT

A

Thromboembolic disease, oestrogen dependent carcinoma, undiagnosed vaginal bleeding
Relative CIs= CHD risks (eg HTN, DM), benign breast disease

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20
Q

Counselling about HRT important points

A 
Relieves symptoms
Decrease fracture risk
Increase risk for other things
Alternatives
Should only use short term
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21
Q

Alternatives to HRT

A

Tibolone- synthetic steroid with weak oestrogen, progesterone and androgenic action- improves symptoms and decreases fracture but no data on risks of breast/endometrial cancer etc

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22
Q

Other non-hormonal medications to decrease hot flashes?

A

gabapentin, SSRI, clonidine

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23
Q

What is the MSAFP screening for?

A

Risk of neural tube defect

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24
Q

MSAFP >… or … percentile associated with

A

2.2, 97th, open neural tube/abdo wall defect, multiple gestation, fetal demise, incorrect dates

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25
Q

What type of test is MSAFP?

A

biochemical

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26
Q

2 factors that influence background risk of chromosomal abnormality?

A

Maternal age, gestation at testing

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27
Q

Maternal age increases risk of chromosomal abnormality…

A

exponentially

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28
Q

Risk of any chromosomal defect in birth in WA?

A

5-7 per 1000 live births

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29
Q

Risk of Down’s specifically in WA?

A

2-3 per 1000 live births

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30
Q

Increase in gestational age at testing decreases risk of triploidy at 14 weeks to…

A

ZERO!

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31
Q

Relative risk of Down’s syndrome decreases to what % in third trimester?

A

60% (not as much as most, but still more likely not to have if pregnancy has progressed that far)

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32
Q

Obstetric cholestasis affects ~ how many women?

A

1%

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33
Q

3 features of obstetric cholestasis

A

Pruritis without rash
Increased serum bile acids
Abnormal LFTs

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34
Q

What is maternal serum screening?

A

Serum concentrations of alpha-fetoprotein, estriol and hCG at 15-18 weeks gestation to stratify women in to low and high risk for trisomy 21

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35
Q

General patterns of MSAFP, hCG and estriol in trisomy 21 babies

A

MSAFP= 25% lower
hCG= twice normal
Estriol= 25% lower
Lvels reflect functional immaturity of placenta

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36
Q

What is done in a first trimester screen?

A

Nuchal translucency, free b-hCG, PAPP-A

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37
Q

What does nuchal translucency assess?

A

Aneuploidy screen, association with some chromosomal and fetal structural anomlaies

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38
Q

Detection rate of Down’s in FTS?

A

80-90% using combination of tests and maternal age to stratify risk

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39
Q

Free b-hCG should… with gestational age, but if not suspect…

A

decrease, Down’s

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40
Q

PAPP-A normally… with gestation, but if not suspect…

A

increases, Down’s

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41
Q

What is PAPP-A and function

A

Plasma protein in placenta that has immunologic and angiogenesis function

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42
Q

Very low PAPP-A associated with…

A

IUGR, still birth, abruption

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43
Q

At what level of risk do you do furthe testing to diagnose Down’s

A

<1:300. If greater than 1:300 routine care

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44
Q

How do you definitely diagnose Down’s?

A

Karyotyping via amniocentesis

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45
Q

False positive rate of FTS for Down’s?

A

3.9%

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46
Q

Complications of amniocentesis

A

PPROM, Resp distress, postural deformity, fetal trauma, alloimmunisation

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47
Q

What weeks to do karyotyping?

A

15-17

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48
Q

Fetal loss rate of amniocentesis?

A

.5-1%

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49
Q

Mid-trimester ultrasound can…

A

accurately estimate gestational age, identify multiple pregnancy, congenital anomalies, placental location, review uterus and adnexae

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50
Q

Limitations of mid-trimester ultrasound

A

Greatly limited by tester (training), maternal obesity and fetal position
Can detect uncertain things (low lying placenta rates for example 5%, but .5% at 37weeks)
Deficit not tyet manifest (late defects, IUGR)

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51
Q

Future of pregnancy screening…

A

non-invasive prenatal testing via fetal cell-free DNA (simple blood test!!!–>currently issues that need ironing out though)

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52
Q

Why give anti-D to rhesus negative pregnant women. Explain rationale as well

A

To prevent haemolytic disease of new born. In rhesus negative women who have rhesus positive baby, if they are exposed (sensitised) to fetal blood cells, they will create rhesus negative antibodies (sensitisation). These can cross placenta in future pregnancies and cause HDN

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53
Q

When to give anti-D

A

28 weeks and booster at 34

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54
Q

Why give anti-D at 28 weeks?

A

most sensitisation events occur after this

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55
Q

Sensitisation events in pregnancy for Rh-ve women

A

Delivery, ECV, C-section, amniocentesis, ectopic, miscarraige, idiopathic

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56
Q

Is sensitisation common in Rh-ve women?

A

NO. about 13%, but still prevents alot of fetal deaths/extremely ill babies

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57
Q

When else to give anti-D apart from routine?

A

After sensitisation events in early pregnancy

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58
Q

What is the kelihauer test?

A

Detects presence of fetal blood passing in to maternal circulation

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59
Q

What is the coombs test?

A

confirms haemolytic anaemia, for IgG antibodies that may have passed through placenta and caused HDN

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60
Q

How does ABO haemolytic disease differ from Rh-D HDN?

A

Less common, occur in mostly in first born baby. About 1/5 of pregnancies have incompatibiltiy but symptoms do not develop in vast majority

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61
Q

Clinical features of obstetric cholestasis

A

Itching, in particular hands and feet, raised SBAs and LFTs

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62
Q

Risks of cholestasis and management

A

Mx is to deliver baby (recommended at 38 weeks when lungs are mature).
Fetal risk: fatal distress, meconium ingestion/aspiration, stillbirth
Maternal: debilitating itch, PROM, deranged clotting (needs VitK)

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63
Q

Theories on pathophys of obstetric cholestasis

A

Hormonal and genetic. Mainly occurs in 3rd trimester (hormones are highest). Higher incidence in twin and triplet pregnancies (higher hormones). ICP resolves quickly when placental hormone production ceases. High dose estrogen OCP increased ICP

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64
Q

Rx Cholestasis

A

Ursodeoxycholic Acid

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65
Q

At what week gestation can you hear fetal heart?

A

Week 5-6

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66
Q

Why induce labor?

A

Risks of continuing pregnancy for maternal-fetal wellbeing outweigh risks of delivery

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67
Q

Indications for induction

A

Post dates (1 week or more)
Maternal health condition eg PE, GDM, Chole
PROM–>without resultant labour in 24 hours
Chorio or high risk of chorio
Placental dysfunction
Slowing baby growth, baby health condition requiring treatment (polyhydramnios)
Woman lives far from medical service
Psychosocial
Fetal macrosomia
Intrauterine fetal death (mifepristone + miso)

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68
Q

What pain relief options are offerred during induction?

A

Same as spont labor

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69
Q

What is augmented labor?

A

Labour that starts spontaneously but fails to progress because of weak/ineffective contractions. Can be helped with some induction methods

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70
Q

Methods of induction

A

Mechanical- stretch and sweep, foleys, AROM

Medical- Oxytocin, prostaglandins

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71
Q

How do prostaglandins work in induction?

A

Soften cervix and dilate it via gel/pessary overnight

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72
Q

What to always do pre-induction to determine approach?

A

Pelvic exam to get Bishops score on state of cervix

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73
Q

Bishops score >? favours induction

A

5

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74
Q

How does stretch and sweep work?

A

Separation of amniotic membrane from cervix can dilate and soften it by increasing bodies prostaglandin levels naturally

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75
Q

How does syntocin work to induce labour?

A

Mimics bodies own oxytocin which is sent from hypothalamus and posterior pituitary to cause uterine contractions

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76
Q

How does foleys work?

A

Constant pressure against cervix causes dilation and softening

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77
Q

General risks of induction…

A

Failure–> C-section
Those who are induced are more likely to need C-section than natural labour (except post-dates women)
Increases risk of uterine rupture in VBAC patients–>haemorrhage, hysterectomy, amniotic fluid emoblus to mother

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78
Q

Risks of prostaglandin/oxytocin induction

A

Uterine overstimulation–>fetal distress

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79
Q

Risk of stretch and sweep?

A

Bleeding, infection (infrequent)

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80
Q

ARM increases risk of…

A

Infection, cord prolapse (C-section), lengthy labour (if ARM to early for cervix)

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81
Q

Risk of foleys…

A

infection, bleeding

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82
Q

2 stages of labour induction

A

cervical ripening, uterine contractions

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83
Q

Which cells secrete what to allow remodelling of cervix?

A

Infiltrative macrophages, fibroblasts

Collagenase, elastase (break collagen, elastin down)

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84
Q

What is the main mediators of cervical ripening thought to be?

A

Prostaglandins (PGE2!), NO, Progesterone

also (PGF2a, MMP2, MMP9)

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85
Q

What % of women having IOL deliver vaginally?

A

<2/3

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86
Q

What happens to collagen in cervix as term approaches?

A

Infiltration of hyaluronic acid that causes increase water molecules intercallating between collagen fibres as well as increased collagenase to break down collagen. Decreases allignment and fibre strength

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87
Q

How does NO cause cervical ripening?

A

Unsure. But levels are high at onset of labour and decrease during labour

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88
Q

What week should all women be offerred stretch and sweep and why?

A

Post 37 weeks in practice (guidelines say 41)–> prevent induction of labour and post-dates

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89
Q

SEs of stretch and sweep

A

Vaginal spotting, mild abdo cramp

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90
Q

Maternal contraindication to IOL

A

Previous transmural uterine surgery, >2 C-sections, unexplained maternal pyrexia, regular contractions, active herpes

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91
Q

Fetal contraindications to IOL

A

Malpresentations (eg face, brow, breech), cord prolapse, severe fetal growth restriction

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92
Q

Placental contraindications to IOL

A

Placenta previa, vasa previa

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93
Q

What position should cervix be in for favourable labour (Bishops score)

A

Anterior

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94
Q

5 parts of Bishops score

A

position, consistency, dilatation and effacement of cervix. Station of presenting part

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95
Q

Recommended timing for IOL?

A

41-42 weeks. BUT no evidence to say stillbirth is reduced at this time, so up to woman still.

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96
Q

Mx if woman opts to go >42 weeks

A

twice weekly CTG and Ultrasound of max amniotic fluid pool depth

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97
Q

What is main danger of mechanical methods of induction with low lying placenta?

A

Ante-partum haemorrhage

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98
Q

Mechanical method disadvantage for IOL

A

Patient discomfort, less efficacy

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99
Q

Advantages of mechanical method IOL

A

lower risk of fetal heart rate abnormality, low risk of hyper stimulation

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100
Q

Does chorio rate increase for mechanical IOL?

A

NO- not unless already PROM

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101
Q

HOw does mifepristone work?

A

Anti-progesterone, anti-glucocorticoid

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102
Q

What drug increases rate of uterine rupture for induction in VBAC patients?

A

Misoprostol

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103
Q

Risk of uterine rupture for VBAC?

A

74 in 100000

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104
Q

Evidence for PGE2 increasing uterine rupture for VBAC?

A

inconclusive

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105
Q

risk factors for cord prolapse in ARM

A

polyhydramnios, high presenting head

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106
Q

due to fact evidence is inconclusive about risks of IOL for C-sections, most important thing to do is…

A

assess each case on its merits. Cervical ripeness, threshold for fetal distress and use of fetal monitoring are all factors that will affect eventual outcome

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107
Q

Why might an oxytocin infusion give drowsiness, headache and lethargy?

A

Hyponatremia- similar structure to ADH and can cross react with ADH receptor

108
Q

Indications to use CTG in IOL?

A 
Mec stained liquor
Abnormal fetal heart
Maternal pyrexia
Unexplained fresh bleeding developing in labour
Use of oxytocin
Maternal request
109
Q

Correlation between fetal fibronectin and time to delivery?

A

positive, also predictive of successful induction

110
Q

Best way of predicting vaginal delivery in IOL cervical dilatation vs FFN vs sonographic measure cervical length

A

cervical dilatation and Bishops!

111
Q

VBAC compared to ERCS increases risk of… BUT…

A

perinatal morbidity/mortality, maternal morbidity. BUT overall risk is extremely low for both, therefore mother’s choice and VBAC is seen relatively safe

112
Q

VBAC success rates

A

70%

113
Q

Risk of uterine scar rupture

A

.5%

114
Q

Prevalence of placenta previa?

A

.5%

115
Q

Ceasarean risk and placenta previa/accreta

A

1,2,>3= 1%,2%,5% for PP

.3%, .6%, 2.4% for PA

116
Q

Risk of placenta accreta?

A

Haemorrhage!!! Severe cause maternal mortality

117
Q

Risk of uterine rupture for VBAC vs ERCS

A

50 per 10,000 for VBAC

2 per 10,000 for ERCS

118
Q

Types of non-pharm analgesia in labour?

A

Hydrotherapy, acupunture, intradermal water blocks, continuous labour support, positional change

119
Q

Types of pharm analgesia in labour?

A

NOS gas, opioids (pethidine, morphine, fentanyl IV, oral, PCEA), epidural

120
Q

What is gold standard for analgesia in labour

A

Epidural

121
Q

How NO works as analgesic in labour?

A

Not sure, but thought to increase inhibitory pain pathways in brain

122
Q

Advantages of NO for analgesia

A

Rapid onset and rapid elimination therefore minimal side effects. Cheap, no monitoring, no effect on uterine contractions (therefore doesn’t alter progress). No effect on fetus (APGAR unchanged)

123
Q

SEs of NO analgesia

A

drowsiness, dizziness, N+V (1/3 women)

unconsciousness (but extremely rare due to demand valve

124
Q

When given with pethidine there is a danger of…

A

oxygen desaturation

125
Q

Main disadvantage of NO is…

A

efficacy in later labour

126
Q

Peak onset of effect after inhalation is… therefore…

A

50 seconds. Therefore need to anticipate contraction for best effect

127
Q

Advantages of opioids

A

Cheap, easily available and efficacious (although some studies have shown non-pharm to be more efficacious!!)

128
Q

Greatest concern with opioids

A

Fetal respiratory depression

129
Q

New better opioids for analgesia in labour. Why?

A

Fentanyl. shorter half life, therefore less side effects.

130
Q

Drugs used for epidural

A

bupivicaine + fentanyl

131
Q

Contraindications to epidural

A

thrombocytopenia, overlying skin infection, raised ICP

132
Q

Risks of epidural

A 
incomplete block (1 in 8), failure (1 in 20), headache (1 in 100)
rare: nerve damage, epidural abscess, meningitis, haematoma, paralysis
133
Q

Ceasarean rates and intstrumental rates for epidural

A

Ceasar not increased. Instrumental increased

134
Q

Best approach to analgesia is…

A

multimodal

135
Q

Side effects of epidural

A

inhibition of symp outflow and decrease catecholamines= vasodilation and hypotension in up to 80% (good for pre-eclampsia!)

136
Q

Pain during first stage of labour is mediated by?

A

t10-L1 (visceral innervation of myometrium)

137
Q

Pain during second and third stage also added mediation by…

A

Somatic fibres (perineal stretch) of S2-S4

138
Q

risks of no pain control in labour

A

increased catecholamines in stress result in tacky, hypertension and increase cardiac output (can cause heart failure in those at risk)
decrease gastric emptying, increasing risk of aspiration in event of emergency GA

139
Q

pain relief satisfaction with epidural reported rate is

A

95%

140
Q

Prolonged pregnancy defined as lasting longer than…

A

42 weeks

141
Q

Incidence of prolonged pregnancy

A

5-10%

142
Q

main cause of “prolonged pregnancy”

A

innaccurate dates

143
Q

Risk of recurrence of prolonged pregnancy

A

20%

144
Q

Risk factors for prolonged pregnancy

A

previous prolonged, primib, Fhx, male fetus, fetal abnormality, maternal obesity

145
Q

Fetal risks of prolonged pregnancy 2 categories

A

Decreased uteroplacental function= oligohydramnios, reduced growth, passage of meconium (aspiration), STILLBIRTH
Normal placental function: trauma during birth, shoulder dystocia, neuro injury

146
Q

Maternal risks of prolonged pregnancy

A

Macrosomic fetus (perineal damage), cephalopelvic disproportion, labour dystocia, C-section required, chorio, PPH

147
Q

Diagnostic criteria for PCOS

A

Need 2 of 3
Oligo/anovulation
Clinical or biochemical evidence of excess androgens
Polycystic ovaries

148
Q

Signs of hyperandrogenisms

A

Acne, hirsuitism, alopecia

149
Q

Characteristics of ovaries in PCOS

A

Increased stroma and multiple subcapsular follicles (12 or more 2-9mm in one ovary) and increased ovarian volume

150
Q

Prevalence of PCOS

A

5-7%

151
Q

What % of women with oligomenorrhoea have PCOS?

A

90

152
Q

Of women with PCOS what % are hirsute, obese

A

70%

50%

153
Q

Describe genetic basis for PCOS

A

Suggestion of autosomal dominance from family cluster studies with strong environmental influences on genetic susceptibility (eg obesity–> increased insulin resistance)

154
Q

What % of women with PCOS are insulin resistant?

A

50% of lean women! Much greater for obese!

155
Q

Treatment options for hirsuitism?

A

OCP to reduce free testosterone

anti-androgens (CPA, flutamide, spironolactone)

156
Q

3 Effects of insulin on sex hormones

A

Decreased hepatic SHBG production
Increased ovarian androgen production via increased IGF-1
Increased ovarian LH receptor expression

157
Q

Treatment for fertility issues in PCOS

A

Mainly due to chronic anovulation
Use clomiphene to induce ovulation (works in 80%)
FSH will induce ovulation in 80% of remaining
Ovarian drilling found to be as effective as FSH in resistant patients

158
Q

Risk of using clomiphene to induce ovulation?

A

INcrease risk for multiple pregnancy x5

159
Q

Advice for fertility in woman with PCOS?

A

Lose weight! Improves ovulation and insulin sensitivity.

Low fat diet and exercise

160
Q

Insulin resistance causes what long term complications for PCOS women?

A

7.5 times risk of MI

10x incidence of carotid plaques

161
Q

Weight loss of just 5% results in what improvements for PCOS women

A

INcreased ovulation, improved spontaenous pregnancy rate, reduction in miscarraige, longterm benefits to patient, improved psychological measures

162
Q

What % of women with PCOS miscarry?

A

44%

163
Q

When PCOS women do conceive there is increased risk of?

A

All pregnancy related complications

164
Q

Management of substance abuse patient in pregnancy revolves around a … team involving… with the aim being…

A

Multidisciplinary
Specialist midwife, GP, Social services, mental health and drug services, police
Compliance with and access to antenatal care

165
Q

Problems associated with substance misuse in pregnancy can be broken into 5 categories…

A

physical- injecting related problems, BBVs, overdose, injury
psychological- life dominated by drugs, chronic anxiety, sleep disorders, memory, stress, depression
Social- family break up, poverty, unemployment
Financial
Legal

166
Q

Are abstinence and detoxification priority of substance abuse patient in pregnancy?

A

NO!

167
Q

What % of female IV drug users report needle sharing (usually with sexual partner)?

A

25%

168
Q

What is the evidence behind substance misuse in pregnancy effect on fetus and why?

A

Scarce! Complex nature of cases make them difficult to follow long term, plus the fact it is so hard to separate effect of drugs alone from other usual co-existing environmental factors (eg smoking, drinking, poor nutrition, stress, violence, poverty)

169
Q

What is the main effect of tobacco on fetus?

A

IUGR

170
Q

High alcohol consumption in pregnancy has been shown to result in…

A 
lower birthweight
physical anomalies (e.g. fetal alcohol syndrome)
171
Q

Cocaine has been shown to cause what physiological effect in pregnancy that results in IUGR, miscarraige, preterm labor and placental abruption?

A

Vasoconstriction

172
Q

Negative associations between cocaine and physical growth, development and language skills??

A

NO- no proof in studies

173
Q

Heroin withdrawl can cause…

A

smooth muscle spasm and risk preterm labor

174
Q

Do opiates cause poor mental or psychomotor development of infant long term?

A

No evidence

175
Q

What drug is given to treat opiate addiciton in pregnancy?

A

Methadone- once daily with slow weaning to gestation

Buprenorphine also starting to be used

176
Q

What is more important than complete drug absitnence in pregnancy?

A

Drug stability and achievable goals

177
Q

HCV prevalence in IVDU?

A

Up to 50% in some areas

178
Q

Vertical transmission of HCV unlikely unless…

A

viremic

179
Q

If syphillis is left untreated transmission to fetus is at a rate of…

A

70-100%

180
Q

Rx Syphillis

A

Penicillin (erythro if allergic)

181
Q

STI testing protocol in drug abusers?

A

Same as normal. Except repeat in 3rd trimester in case re-infected (esp sex workers)

182
Q

Intrapartum issues for IVDU?

A

IV access can be difficult

Opioid addiction/use of buprenorphine/methadone can make opioid analgesia less effective

183
Q

What is NAS?

A

Neonatal abstinence syndrome- CNS hyperirritability, GI dysfunction, resp distress and vague autonomic symptoms

184
Q

Mx for NAS

A

Non-pharmacological- mother encouraged to swaddle, parent, feed and nuture infant to settle it

185
Q

Medical conditions that may present similarly to NAS are…

A

hypoglycaemia, CNS haemorrhage, infection

186
Q

Alcohol recommendations in pregnancy

A

1-2 units, once or twice a week

187
Q

FAS is said to be the … cause of non-genetic mental disability in the Western world and the only one that is … preventable

A

greatest

100%

188
Q

Fetal alcohol spectrum disorder sequelae

A 
Growth restriction
Facial anomalies (flat philtrum, long upper lip, mid face hypoplasia)
CNS anomalies (microcephaly, agenesis of corpus callosum, cerbellar hypoplasia)
Neurodevelopmental abnormalities (reduced IQ, behavioral problems)
189
Q

Should heavy drinkers be advised to stop drinking straight away in pregnancy?

A

NO- withdrawl can threaten life of fetus and cause tachycardia, hypertension and seizures in mother. Slow withdrawl in inpatient setting is recommended

190
Q

Alcohol effect on breast feeding

A

Not stored in breast milk but its levels parallel in the maternal blood. Encourage breast feeding still but alcohol may disrupt lactation and milk supplies

191
Q

Approx % of RhD-ve women and % of babies that are RhD pos born to RhD-ve women

A

15%, 10% (of all births!!!)

192
Q

Can ABO blood group incompatibility cause HDN?

A

Yes but disease is usually mild

193
Q

How does HDN come about…?

A

Fetal positive antigen RBCs cross placenta to mother and immune response occurs to foreign antigen (mother has no antibodies to RhD). This is called sensitization event. Then in future pregnancies, if baby is RhD+ve these antibodies in maternal blood can re-cross placenta and cause haemolysis (initially antibodies are IgM in sensitisation so can’t cross placenta)

194
Q

Events to increase risk of fetal-maternal haemorrhage (increasing risk of sensitisation)

A 
Traumatic delivery eg C-section
Manual placental removal
Stillbriths and intrauterine deaths
Abdo trauma in 3rd trimester
Twins
Unexplained hydrops fetalis
195
Q

Signs of hydrops on ultrasound?

A

Polyhydramnios (Increased AFI), fluid around babies body (eg ascites)

196
Q

Severity of HDN ranges from…

A

mild jaundice to intrauterine death

197
Q

Mx of HDN…

A

depends on severity of disease. In mild can use phototherapy. In severe need transfusion

198
Q

Features of severe HDN

A

Hydrops: oedema, hepatosplenomegaly, ascites, pleural and pericardial effusion

199
Q

How to prevent rhesus isoimmunisation

A

Screen and give anti-D to mothers who are Rh-ve

200
Q

How does giving anti-D work?

A

Binds to fetal antigen positive cells in maternal blood to prevent sensitisation event

201
Q

Dosage of anti-D for RhD-ve women

Mx post-partum

A

500IU at 28 and 34 weeks plus within 72 hours postpartum.
PLUS 500IU for any possible sensitising event
Must determine amount of feto-maternal haemorrhage and adjust anti-D accordingly

202
Q

Sensitising events requiring anti-D prophylaxis

A 
Invasive testing eg amniocentesis, chorion villus smapling
Ante-partum haemorrhage
ECV
Closed abdo injury
Intrauterine death or miscarraige
203
Q

Other events to give Anti-D for…

A

Ectopic, therapeutic termination, spontaneous miscarraige >12 weeks

204
Q

In pregnancy there is a shift from… immunity to… immunity opening women up to… infections

A

cell mediated, humoral, intracellular pathogens (eg listeria, influenza, varicella)

205
Q

UTIs more common in pregnancy because of…

A

progesterone and compression by gravid uterus

also higher urinary glucose and pH facillitates bacterial growth

206
Q

Resp infections more severe in pregnancy due to…

A

diaphragmatic elevation decreases secretion clearance.
increased oxygen demand, reduced tolerance to hypoxia
Gastric acid aspiration more common too

207
Q

WOmen at high risk of HIV should be tested…

A

At booking AND 3rd trimester

208
Q

Infections to screen for in early pregnancy

A

Hep B, HIV, rubella, syphilis

Urine MCS

209
Q

Abx safe in pregnancy

A

Penicillins, cephalosporins, macrolides

210
Q

Tetracyclines can cause… in pregnancy

A

fulmninant maternal hepatitis

211
Q

Gentamicin and vancomycin can cause…

A

fetal ototoxicity/nephrotoxicity

212
Q

PPROM causes what % of preterm deliveries

A

40%

213
Q

Prophylactic Abx of choice in PROM

A

erythromycin

214
Q

Diagnosis of chorioamnionitis suggested by…

A

fever late in pregnancy, uterine tenderness, offensive vaginal discharge, fetal tachycardia

215
Q

Consequences of chorio for neonate

A

Neonatal sepsis–>pneumonia, meningitis

216
Q

If chorio is suspected what is definitive Mx

A

Deliver the baby!

217
Q

Main causes Endometritis?

A

polymicrobial (serious when GAS, GBS)

218
Q

What % of feveres in women who have just delivered are endometritis?

A

30%

219
Q

Rx for chorio for baby?

A

Ampicillin and gentamicin (broad spec)

220
Q

Asymptomatic bacteruria occurs in what % pregnant women

A

4-7%

221
Q

ASB develops into symptomatic UTI in what%

A

20-40%

222
Q

UTI in pregnancy is 75-90% which bug and use what Rx?

A

E.Coli, cephalosporin

223
Q

Cystitis and pyelonephritis occur in what % pregnancies

A

2% (each)

224
Q

WHich kidney most affected by pyelonephritis in pregnancy and why?

A

Right.

Dextro-rotation of the uterus causes compression of right ureter and ascending infection

225
Q

Mx of pyelonephritis post Abx/discharge?

A

Follow up monthly urine cultures

226
Q

Fetal effects of untreated pyelonephritis?

A

Preterm delivery, low birth weight

227
Q

Varicella is more… in pregnancy

A

severe (35% mortality vs 11% non-preg)

228
Q

Progression of varicella to penumonia in pregnancy is…%

A

10-20%

229
Q

Classical CXR for varicella pneumonia

A

bilateral miliary nodular shadowing with later pulmonary calcification

230
Q

Risk of vertical transmission of HBV

A

95% if e-antigen and B-surface antigen positive

231
Q

Risk of HCV vertical transmission. risk of transmission increased to … if with HIV

A

6%, 15%

232
Q

Screening is carried out routinely for which hepatitis in pregnancy?

A

Hep B

233
Q

Rx Hep B

A

IgG

234
Q

Important DDx in pregnancy rash

A

Rubella, parvovirus, varicella, measles, enterovirus, EBV

235
Q

Enteroviruses (eg coxsackie and echo) cause what in mothers/neonates?

A

Myocarditis, meningitis–> multisystem life threatening complications

236
Q

Measles causes what in pregnancy

A

intrauterine death and preterm delivery (not congenital infection)

237
Q

What drug to avoid in TB treatment of pregnant women for fetal 8th nerve damage association?

A

Streptomycin

238
Q

Malaria is much more… in pregnancy. causes increased…

A

severe

maternal mortality, severe anaemia, preterm birth, miscarraige, stillbirth

239
Q

Parvovirus is associated with fetal…

A

hydrops

240
Q

2nd most common cause of mental retardation after Downs?

A

Fetal CMV infection

241
Q

Congenital syphillis can result in…

A

polyhydramnios, hepatomegaly, osteochondritis, purpura, late interstitial keratitis

242
Q

Mx of obese women in pregnancy general principles

A

1) GET HEALTHY BEFORE FALLING PREGNANT!–>get the BMI measure
2) advise them of increased risk of medical complications for themselves (CVS, pulmonary, HTN, PE, Gestational diabetes)
3) Diet and exercise advice during pregnancy
4) Anatomy scan at possibly later date
5) advise fetus at risk of congenital abnormalities
6) Increased risk of C-section
7) Increased risk VTE- consider prophylaxis

243
Q

Obesity in pregnancy increases risk of…

A

Spontaneous abortion
Hypertension in pregnancy (PE, HELLP)
Gestational Diabetes, Macrosomic child
C-section with increased blood loss, increased op time, increased post op wound infection and endometritis, increased risk for vertical skin incision
Increased decision to delivery interval
Unexplained stillbirth (decreased perception fetal movement, hyperlipidaemia, hypoxia due to apnoea

244
Q

Difficulties in assessing obese women include…

A

Ultrasound at all stages
Fetal monitoring in labour
Uterine monitoring in labour

245
Q

General success of VBAC vs obese VBAC

A

80%

50-70% (heavier is much worse, 13% for >136kg)

246
Q

Anaesthetic difficulties in obese women

A 
Difficult intubation
Difficult epidural (multiple attempts)
247
Q

Incidence VTE normal vs obese

A

0.6% vs 2.5%

248
Q

Rx VTE prophylaxis >30BMI

A

Clexane 3-5 days post partum

consider ante-natally for extreme obese

249
Q

Overall message about obesity in pregnancy…

A

Get fit before getting pregnant!! Preventative medicine is best

250
Q

Define ante-partum haemorrhage?

A

Any bleeding from genital tract after 20th week but before birth

251
Q

Causes of APH?

A

Placenta praevia (31%)
Placental abruption (22%)
Labor, show, ruptured vasa praevia, marginal sinus bleed
Local lesions of cervix/vagina
Causes outside genital tract- varicosities, haemorrhoids

252
Q

Define placental abruption?

A

Premature separation of placenta from uterus

253
Q

Define placenta praevia

A

Placenta lies partly or wholly in lower uterine segment

254
Q

What are the types of placenta praevia in stages?

A 
Minor
Stage 1- doesn't reach os
Stage 2- extends to but doesn't cover os
Major
Stage 3- partially covers os
Stage 4- complete praevia (covers os)
255
Q

What % have a low lying placenta on 20Wk US?

A

5%

256
Q

Of those with low lying placenta at 20wks, what % will have normal implantation at >30wks and then at term?

A

90%

99.5%

257
Q

How close to os does PP have to be to require C-section

A

2cm

258
Q

Risk factors for placental abruption

A

PP POSTIT

Pre-ecalmpsia
Placental insufficiency
Previous Hx
Overdistention (twins, polyhydram)
Smoking and substance absue
Trauma
Increasing age and parity
Maternal thrombophilia
259
Q

Risk factors for placenta praevia

A

CUP TAPSID

Previous C-section
Previous uterine instrumentation
Previous PP Hx
Twins
Increasing age, parity
Smoking, drugs (cocaine)
IVF procedures
260
Q

Differences in clinical presentation of abruption and praevia?

A

Abruption- may have no PV bleed (or little), often sudden onset abdo pain with constant pain between contractions, tender to palpate and hypertonic uterus
Praevia- Soft, non-tender abdo with unrpovoked bright painless bleeding

261
Q

Why can you get no bleeding clinically in placental abruption?

A

It can be “concealed” in the pocket between the placental and uterine wall and therefore not drip out of vagina

262
Q

First part of investigating an APH?

A

Ultrasound! Placental location, fetal wellbeing and presentation.
Then you can do a speculum if not a low lying placenta
Try and see source of bleed and take high vaginal swabs

263
Q

What is the kleihauer test?

A

Blood test to measure amount of fetal Hb transferred to mother’s blood stream
Performed to identify women with large FMH >6mL of packed cells who may need additional dose of RhD IgG

264
Q

What is a standard dose of RhD-IgG and how many red cells does it destroy?

A

625IU destroys 240 red cells/50 low power field or 6mL of packed detal blood cells

265
Q

Kelihauer tests are only done on Rh+ve women if…

A

severe abdo trauma, non-reassuring CTG, inactive fetus on USS

Obstretrics and Gynaecology (2 decks)

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