obs and gynae Flashcards
Risk of diabetes
S- Shoulder dystocia M- macrosomia A- amniotic fluid excess S- Still birth H- Hypertension and neonatal hypoglycaemia
What is gravida
the number of times a women has concieved
What is parity
no. of times women has delivered p >24 and up smaller is <24 doesnt include the current preganancy
currently 12/40 two miscariages 8/40 and 20/40 and son born at 38/40
G= 4 - conceived 4 times P= 1+2
not pregnant has twins born 34/40
g= 1 p =2+0
currently 28/40 one previous ectopic two terminations of pregnancy both 6/40 one still birth at 25/40
g= 5 P= 1+3 - doesnt include the current pregnancy
primigravid meaning
G1P0
nulliparous
no live baby delivered - so name is given to those who have never given birth and to those who have had stillbirths
multiparous
one or more babies delivered
What is nagele rule
LMP subtract 3 months add 1 year 7 days
the two tests in the first trimester
booking (10 weeks), dating scan (11 weeks) and combined screening test (at 11-13 weeks)
What is tested in combined scrrening
NT and two serum markers PAPPA and hCG gives a early result and has a high detection rate
What to do if late for combined testing
Quadruple test
Quadruple test consists of
AFP HCG oestriadiol and inhibin A combined with maternal age gives a individualised risk
What happens with a positive quadruple or combo test
offered cvs or amniocenthesis - cvs is earlier andtherefore has a higher miscarriage rate
If you are rich what test can you do
non invasive prenatal testing in which detect free dna of fetus in maternal circulation
Are cephalic and breech types of lie
no
The risks of breech presentation
fetal hypoxia
increase fetal mortality and morbiditu
cord prolapse
Difficulty delivering head
How is ECV done
uterine relaxants are given to relax the uterus pripr to the prcoedure these are tetrabutaline or salbutamol fetal heart and ctg are monitoried benefits is it may prevent c section and all the risks that come with it
Causes of polyhydraminos
DITCH - Diabetes, idiopathic, twins, congenital abnormalities , heart failure
RRisks of polyhydraminos
6p’s - placental abruption, pretty unusual lie premature labour prolapse of cord post partum haemhorrhage oerinatal mortality
MOL - Every decent female is crowned rubies lovingly
enhgagement in transverse position
decent of head into pelvis
flexsion
internal rotation as head hits the floow
crowns- extends head in delivery
restitiution- external rotation
lateral flexsion of head to deliver shoulders
Inidications for induction
4p’s - post dates prelabour rupture of membranes preeclampsia plus diabetes
how does membrane swweep work
digital vaginal examination into the uterus to release hormones which may tirgger labour
Three stages of induction
cervical ripening and artificial rupture of mmebranes cervicall diataiton to fully dilates
when is propess and prostin used
propess in nulliparous its a pessary and gel prostin in multips
bishop score less than 5
more prostin needed
Bisphop score 5-8
consider more propess but artifical rupture of memebranes may be needed
BS greater 8
amniotomy further prostin not needed - but amniotomy has a risk of cord prolapse
how are contractions generated to create cervical dilatation
by iv oxytocin
What is the management in uterine hyperstimulation
terbutaline must be administered
WHat is pelivc girdle pain
symphysieal pubis dysfunction due to mechanical strain on the pelvic girl
what is symphyseal pubis pain
radiates to groin and medical tights worse on standing on one leg and going up stairs worse when abducting hip when getting out of bath or into the car tender of the pubis symphesis hip abduction reporduces symptoms
mangement of pelvic girdle and sympheseal pubis pain
keep active within limits of pain and sleep witha . pillow between legs pelvic floor excersizes get a physio to help iuse paracetamol and avoid NSAIDS
coMFORT ZONE OF A WOMEN
MEASURE THE COMFORT ZONE AND AVOID ABUCTION BEYOND THE COMFORT ZONE AND OFFER EPIDURAL IN LABOUR ESPECIALLY IN W OMEN WHO IS HAVE SYMPHYSEAL PELVIS OR PELVIC GIRLDLE PAIN
effect of pregnancy on pre exisiting diabetes
deterioration in renal funtion if pre exisitinf nephropathy can manifest as hypertension and hyperglycaemia
What timester does GDM start
second trimester - preganacy is in a diabretogenic state
When is the OGTT taken
24-28 weeks but after booking if had GDM in a previous prganancy - this is the only form of diagnosis monitoring thereafter will take place with HBA1C
gdm Values which are abnormal
fasting more than 5.6 with 5.6 or less being normal and more than 7.8 after 2 hours with 7.8 or less being normal
Manouvres in shoulder dystocia - Remember (Dr Mcroberts)
Mc roberts - flex and externally rotate hips to stre symphysis and pelvic outlet Suprapubic pressure and epsiotomy
The advanced manourvers in shouder dystocia
the woodscrew manouvre - rotate shoulder, deliver posterior arm break clavicle. then emergency c section in zanvelli manourvre
Checklist in an antenatal exam
SALPINX - sixe and SFH, Amniotic fluid, lie, presenting part, inlet of pelvis- engagement, number of fetuses, marks the spot ober upper fetal aback for fopppler and pinard
the weeks around which hypertension in preganancy revolves around
20 weeks - pregestiing is before pregnancygestation is less than 20 weeks gestation and preeclampsia is after 20 weeks
difference between severe and hypeternsion values
140/90 is hypetension the more serious is 160/100
First and second line management of hypertension
first line labetaolo but if asthma Second line nifedipine or labetalol
How much is proteinuria
> 0.3g/24 hours
How to prevent preeclampsia
give 75g of aspirin from 12 weeks gestation onwards
who would recieve preeclampsia prevention
ECLAMP- existing hypention, CKD, SLE, antiphospholipid syn, maternal diabetes, prvious pregnancy with hypertension
Maternal shame and complication with pre eclampsia
SHAME - stroke, hELLP which leads to DIC, abruption of placenta, multi organ failure , eclampsia
would you admit all pregnancy women with HTN
YES
which of the hypertensions would you treat
the mod and severe ones so anything above 150/100
What are the four red flag symptoms of eclampsia
headache visual disturbance epigastric or RUQ pain - due hepatic distention and infarcts, breathlessness due to ARDS
what are the three red flag signs of eclampsia
periorbital odema hyperreflexia and clonus
how to moniotro eclampsia
sympt and BP monitor, fetal growth monitor and umbilical artery blood flow monitor pre eclampsia bloods
What are the pre eclampsia bloods
FBC - for low platelets Low hb due to HELLP syn. u&e cause urea and creatine raised LFT raised bilrubin if haemolysis
WHAT ARE the plans for delivery with eclampsia
keep baby survival till 34 weeks give mother sterios till then
how do steroids help a premature baby
prevent necrotising entercollitis resp distress intravascular haemhorrhage
what must you do if high BP imparied renal or hepatic function and fetal distress
delivery bby
emergency management of eclampsia
control fits with magnesium sulphate and control hypertension with iv labetalol and hydrazalaine
treatment of cervcal shortening
cervical stitch
if membranes have ruptured and signs of infection what do you do
it is not appropriotw to use tocolytics to stop contractions so you deliver
if membranes have not ruptured can tolytic med be used
yes if no sign of infection
mangement of preterm rupture three steps
- consider antenatal corticosteroids
- consider tocolysis
- consider trnafer to nenonatal teritary unit
preterm prom born 24-34 weeks what is the managment
daily review for infection and steroids for lungs and erythromycin to prevent necrotising neterocollitis
zygosity meaning
this is what parents care about itis the identical or not deteminating factor
dividision at day . 1)0-3 2)4-8 3)8-13
1) DCDA . 2)MCDA . 3)MCMA
true or false Dizytoic twins are always dichorionic and chorinoic menaing
true and dichorionic meaning two placentas
Which type highest risk of TTS
Monchorionic
How can you tell how many placenta there are
look for lambda sign indicating two amniotic sacs indicating DCDA or the t sign indicating mCDA
ANTENATAL MANAGMENT OF TWINS
aspirin and from 16-24 weeks uss for TTTS every 2 weeks and elective cs at 32-34 weeks due to cord entanglement risk not because of TTTS. bp and glucose will need monitoring as more likley to dev preeclampsia and diabetes and dvelivery will be befoer 40 weeks but additional scans will be needed to deliver babies before 40 weeks
Fetal complications of twin pregnancy
miscarrigae vanishing twin syndrome, IUGR abdruptions and intrauterine death polyhydraminos malpresentation preterm delivery and cord prolapse
what is ttts
umbilical arteries feeld the umlilcan vien of the recipient and the donor twin becoems naemic and growth risticted where as the reciepient twin become polycythaemic hypertensive and may have heart failure
causes of small of gestational age and complication
SWAN - starved small IUGR Wrong small abnormal small and normal small STILLBIRTH is biggest complication
what will graph of a wrong small or normal small look like
along the lower deciles following the pattern
what will graph of starved small look like
will follow the average lines and level out tworards the date
What will the graph of a abnormal small look like
outside the gestatioal deciles
neonatal complciations of SGA
hypoglycaemia polycythaemia and complciations of prematurity e.g. intrventricular haemhorrhage resp distress and encrotising enterocollitis
High risk prgannacies
SHIT - smoking HTN IUGR previously and twins - need continuous screenign and growht monitoring
what concerns you on umbilical doppler
absent end disasytolic flow indicates placental resistance and increase MCA causing brain sparing
Management of absent end diasystolic flow
1, surveillance- CTG liquor vol, umbilical a doopler
- consider early delivery
- prenatual steroids for prematurity - two doses beclamethasone/dexamethasone 12-24hrs apart max effect within 7 days of second dose reduces risk of intraven haemhorrhage, resp distress and enctosifing enterocolitis
How would youmonitor high risk preganancoies
screen pre eclampsia
risk reduced and optimise medical conditions
Serial scans fetal growth liquor volume and umbilical artery
antepartum and post partum separated by what value
antepartum is bleeding at more than 24 weeks and misscarriage is bleeding less than 24 weeks
Symptoms of placental abruption
vaginal bleeding - although this can be concelaed
Blood is usually dark red and abdominal pain and uterine contractions
Signs of placental abruption (4)
- woody hard uterus
- uterine tenderness
- fetal distress
- shock
Placenta previa symptoms (4)
- painless bright red vaginal bleeding
- blood on toes - severe bleeding with shock
- fetus unaffected
managment of placenta previa
remain in hospital till delivery major previas delivered by cs at 39 weeks or before a signficant bleed but avoid examination and sex until placental site has be determined
WHAT MUST BE GIVEN TO WOMEN ROUTINELY WHO HAVE HAD PLACENTA PREVIA AND ABRUPTION
ANTI D in the second pregannacy
examples of sensitising events
Aminocenthesis/CVS ECV APH Threatened or complete miscarrigaage after 12/40 closed abdo injusry top
classification of PPH
within 24 hours and 6 weeks Blood loss of 1. minor 500-1000 2. major >1000 3. massive obs haemhorrahed >1500
primary causes of PPH
TONE (UTERINE MUSCLE AND CONTENT) TISSUE TRAUMA THROMBIN
RF FOR PPH
BIG BABY OR MILTIPLE PREGANNACY , PROLONGED PREGANANCY
PROPHYLAXIS OF pph
oxytocin to deliver the ant shoulder if significant RF consider oxytocin with ergometrine and remeber most PPH dont have RF
Mx of PPH
- Left lateral positon - avoid autocaval compression
- kleiheauher - look for fetal cells in maternal circulation) also fo FBC clotting group and save
- Replace fluid loss, blood loss and clotting factor loss
stepwise surgical managment of PPH
EVACUALTION OF RETAINED PLACENTA INTRAUTERINE BALLOON TAMPNOADE haemhostatic suture interal illiac ligation hysterectomy
postpartum aim for pre-exisiting diabetes
4-9 and resume insulin
post partum aim for GDM
- STOP their insulin
- Do OGTT at 6 weeks to calculate future risk ( revolves around > 7 being high risk and <6 being low risk)
6-6.9 inc risk
>7 have DM
< 6 low probability - diet and excersize recommended - If past 13 weeks and no OGTT done - a HBA1C can be done to calculate risk
no risk < 39
39-47 high risk
> 48 have type 2
