Obs and Gynae Flashcards
1
Q
What is Paulik’s grip
A
One-handed technique to grasp the fetal head
2
Q
What suture separates the frontal and parietal bones
A
Coronal sutures
3
Q
What suture separates the parietal bones
A
Agitate
4
Q
What suture separates the occipital bone from the parietal
A
Lambdoid
5
Q
What suture separates the two frontal bones
A
Frontal
6
Q
What is a fontanelle
A
When two or more sutures meet - irregular membranous area
7
Q
Where is the anterior fontanelle found
A
Between coronal and saggital sutures - ossifies at 18 months
8
Q
Where is the posterior fontanelle seen
A
Junction between sagittal and laboidal sutures
9
Q
What is the occiput
A
Bony prominence that lies behind the posterior fontanelle
10
Q
What is the vertex
A
Area between the anterior and posterior fontanelles
11
Q
What is the bregma
A
Area around the anterior fontanelle
12
Q
What is the sinciput
A
Area in front of the anterior fontanelle
13
Q
Describe the assessment of degree of moulding of the fetal head
A
No moulding: suture lines are separate
1+ moulding: suture lines meet
2+ moulding: when bones overlap but can be reduced with gentle digital pressure
3+ moulding: when bones overlap and are irreducible with gentle pressure
14
Q
Describe the early development of the placenta
A
- Zygote enters uterus in 3-5 days -> blastocyst
- Implantation of blastocyst on day 7-11:
Inner cell mass forms embryo, yolk sax and amniotic cavity
Trophoblast forms future placenta, chorion and extra embryonic mesoderm - Blastocyst embeds into the decider + trophoblast cells differentiate to form two layers of trophoblasts (inner cytotrophoblasts and outer multinucleate syncytiotrophoblast)
- Invading trophoblast penetrates endometrial blood vessels -> intertrophoblastic maternal blood-filled sinuses
- Trophoblast cells -> villi (cytotrophoblasts surrounded by syncytiotrophoblast)
- Days 16-17, surface of blastocyst is covered by villi + chorion starts developing a future placenta (chorionic frondosum)
- Lacunar spaces become confluent with one another
- Embryo of decider capsular becomes thinner as embryo grows, converting chorion to chorionic leave
- Villi in chorionic frondosum divides and proliferates to form decide basis
Starts at 6 weeks and stem villi established by 12 weeks.
15
Q
How does the placenta differentiate between the fetal and maternal surface
A
Smooth, amnion with umbilical attached at centre vs rough and spongy appearance (cotyledons)
Branches of umbilical blood vessels visible vs each cotyledon supplied by spinal artery
16
Q
Role of the umbilical cord
A
Vascular cable that connects fetes to placenta (10 to 90 cm)
Carries deoxygenated blood form fetes to placenta and oxygenated blood to baby via the umbilical vein.
17
Q
What is contain din the umbilical cord
A
Two umbilical arteries and one umbilical vein
Embedded in wharton’s jelly
18
Q
Role of spiral arteries
A
IF there is an increased demand of blood supply to placental bed, they become low pressure and high flow vessels by dilating and becoming less elastic from trophoblast invasion
19
Q
Describe age fetoplacental circulation
A
- Two umbilical arteries carry deoxygenated blood from fetes -> chorionic plate under amnion.
- Arteries divide to enter chorionic villi -> arterioles -> capillaries
- Blood flows to umbilical vein and countercurrent between maternal and fetal blood
20
Q
What cell produces hCG
A
syncytiotrophoblasts
21
Q
When is hCG detected after fertilsation
A
6 days
22
Q
At what point of gestation does hCG reach peak concentration
A
10-12 weeks then plates for rest of pregnancy
23
Q
Role of the placenta
A
- Barrier to infection and drugs
2. Produces oestrogen, hCG, progesterone
24
Q
Where is progesterone produced
A
Corpus lutes until day 35
Placenta thereafter
25
Role of progesterone
Promotes smooth muscle relaxation and raises body temperature
Prevents preterm labour
26
Role of oestrogen during pregnancy
1. Increased breast, nipple growth and pigmentation of areola
2. Promote uterine blood flow, myometrial growth and cervical softening
3. Increased sensitivity and expression of myometrial oxytocin receptors
27
Role of hPL
1, Similar to Gh
2. Increased energy supply to fetes
3. Increased insulin secretion, low insulin peripheral effect to divert to fetes
28
What does the pituitary gland during pregnancy
1. Enlarges
2. Prolactin levels increase substantially due to oestrogen
3. Gonadotrophin secretion is inhibited and increased ACTH levels
4. Increased plasma cortisone output
Posterior pituitary releases oxytocin during labour and during suckling
29
Effect of pregnancy during thyroid
1. TBG doubled = T3 and T4 rises early on then falls for remainder
Thyroid drugscan cross the placenta
30
Haemodynamic changes during pregnancy
1. Increase in plasma volume + weight gain due to oedema
2. Rise in red cell volume but hb conc doesn't chang e3. Decreased eosinophils during labour
3. Platelets decreased during pregnancy
4. Hypercoagulable state during pregnancy + ESR
31
CV changes during pregnancy
1. CO increased as blood from intervillous spam increases
2. Progressive enlargement of the uterus, heart and diaphragm
3. Reduced peripheral resistance
4. Vasodilatation and hypotension may stimulate RAAS
5. Respiratory changes, as level of diaphragm rises so resp rate changes
32
Physiology of the uterus during pregnancy
1. Muscle hypertrophy at 20 week s
2. Uterine blood flow increases
3. Hypertrophy of uterine and ovarian arteries
33
Three section of the uterus
Cervic, isthmus and body of uterus
34
What happens to the cervix during pregnancy
1. Reduction in cervical collagen
2. Hypertrophy of cervical glands = more cervicla mucus for infection barrier
3. Increased vaginal discharge due to cervical ectopy
35
Changes to the uterine body
INcreases
36
Changes to the vagina in pregnancy
1. High oestrogen levels stimulate glycogen synthesis and deposition
2. Lactobacilli on glycogen in vaginal cells produce lactic acid to lower pH for pathogen free
37
Changes to breast during pregnancy
1. Lactiferous ducts and alveoli develop du etc oestrogen, progesterone and prolactin
2. Forom 3-4 months colostrum can be expressed from the breast
3. Prolactin stimulates cells of the alveoli to secrete milk (effect is blocked during pregnancy by oestrogen and prog), drop in hormones allows lactation
4. Suckling causes prolactin nd oxytocin release
Oxytocin allows contraction of myoepithelial cells
38
Changes in the urinary tract during pregnancy
. Uric acid increases in clearance
| 2. Increased renal blood flow
39
Changes in the alimentary system during pregnancy
1. Decreased sphincter tone
2. Reduced gastric mobility
3. Increased abdominal pressure causes heartburn
40
Changes in skin during pregnancy
1. Palmar erythema
2. Spider nave
3. Pigmentation of nipple and areola
41
At what age does chance of conceiving start to decline
35 and over
42
What other risks ar involved in pregnant older mothers
Down syndrome
2 Pre-eclampsia
3. DM
43
How long after stopping the pill can women try to concieve
3 months
44
What is the recommended dose of folic acid
400 mcg a day
45
What supplements should be given to pregnant women
Iron
2, Calcium
3. Iodine
4. Zinc
46
What is the normal weight gain in women during pregnancy
11-16kg - should consume 350kcal a day
47
What is the ideal diet for a pregnant woman
1. Protein rich, dairy food for calcium, starchy food, fruits and vegetables
Avoid sugary, salty or fatty foods
48
What food should be avoided during pregnancy
1. Undercooked metas, eggs, pates, cheese, shellfish, raw fish and under pasteurised milk as sources of listeria and salmonella
49
4 pre-pregnancy checks at GP
1. Blood test s
2. HIV screen
3. Dental exam
4. Urine dipstick
50
Common symptoms of early pregnancy
1. Nausea and vomiting
2. Pressure effect of the uterus no the bladder can cause increased urination
3. Fatigues (goes away by 12)
4. Breast tenderness
5. Fetal movements
51
What is pica
Abnormal desire to eat something not regarded as nutritive
52
Clinical features of pregnancy on examination
1. Vagina and cervix are blue due to blood congestion
2. Size of uterus increased and can be palpable after 12 weeks.
3. Fetal heart can be heard
53
How can we date a pregnancy
1. LMP
2. USS between 8 to 13 weeks is most accurate
3. After this, crown-rump length which is from one fetal pole to another.
54
What is assessed in fetal ultrasound for their growth
1. Biparietal diameter and head circumference
2. Abdo circumference
3. Femur length
55
Blood tests during antenatal care
1. FBC
2. Rubella
3. Syphilis
4. Hep B
5. HIV
Electrophoresis of Hb
Gestational diabetes
56
Risk factors for gestational diabetes
1. Previous GDM
2. Fmaily history of diabetes
3. Obesity
4. Glycosuria
57
GI symptoms of pregnancy
1. Nausea and vomiting - metoclopromide
2. Reflux: Ranitidine and antacids
3. Constipation: lactulose + fibre)
58
Name symptoms involved in MSK pregnancy
1. Symphysis pubis dysfunction (pelvic pain) - physic, analgesia, limit abduction during delivery
2. Backache and sciatica
3. Carpal tunnel syndrome
4. Haemorrhoids: Ice packs,
5. Varicose veins
59
Urinary symptoms during pregnancy
1. Frequeny in first trimester
2. Stress incontinence on third
3. UTI: avoid caffeine and fluid late at night)
Vaginal dischargeL Exclude sit and candiasis
Itching an rashes: Emollients
Stretch marks, labile mood, calf cramps
60
What is vasa praaevia
Fetal vessels runin membranes unsupported by placental tissue or umbilical cord
PV bleeding after rupture and rapid fetal distress
61
Risk factors of vasa praevia
1. IVF pregnancy
| 2. Multiple pregnancy
62
What is placenta apreavia
1. Placenta is inserted into lower segments of uterus
63
What is grade 3/4 placenta praaevia
1. Placenta lies over cervical os
64
What is grade 1/2 placenta praaevia
Placenta close to cervical os
65
Diagnosis of placenta praaevia
1. Transvaginal USS
66
How is antepartum haemorrhage managed
1. GBC
2. Kleinbauer testing
3. Group and save serum
3. Coagulation screen
USS toe establish fetal wel lbeing
Umbilical artery doppler
Managed by surveillance
67
What is placental abruption
1. Placenta separates partly or completely from uterus before delivery so blood accumulates behind placenta in uterine cavity or loss through cervix
68
Types of placental abruption
Concealed: no external bleeding
Revealed: vaginal bleeding
69
CF of placenta abruption
1. ABdo pain
2. Sudden onset
3. Backache
4. Uterus tender on palpitation and become 'woody' - hard
Bleeding is dark and many are in labour
Fetal distress
70
Management of placenta abruption
1. Admit women and manage fetal distress
71
What defines Pregnancy-induced hypertension
140/90 in second half of pregnancy in the absence of proteinuria or other markers of pre-eclampsia
72
What symptoms of hypertension point to post part pre-eclampsia
1. Epigastric pain
2. Visual disturbance
3. New-onset proteinuria
73
Postnatal management of HTN
1. Methyldopa changed to beta blocker because of depression
2. Captopril
3. Nifedipine
74
What is pre-eclampsia
1. BP>140.90 and >300mg proteinuria in 24hr collection
| 2. Already have HTN: rise in systolic 30mmHg or diastolic 15mmHg
75
Risk factors for pre-eclampsia
1. Previous pre-eclampsia
2. Age>40
3. Obesity
4. Multiple pregnancies (>5)
76
Investigations for pre-eclampsia
FBC:
Thrombocytopenia
High Hb
Anaemia
```
Biochemistry:
Increased urea and creatinine
Abnormal LFTs
Increased Lactate Dehydrogenase - haemolysis
Proteinuria
```
77
Prevention of pre-eclampsia
1. 75mg aspirin before 16 weeks
78
Symptoms of pre-eclampsia
1. Headache frontal
2. Visual disturbances (flashing lights)
3. Epigastric and RUQ pain
4. Nausea and vomiting
5. Rapid oedema in face
```
Signs:
HTN
Proteinuria (>300 mg)
Facial oedema
Confusion
Hyperreflexia
Uterine tenderness or vaginal bleeding
Fetal growth restriction on ultrasound
```
79
How is pre-eclampsia managed in following patients:
BP<160/110
No proteinuria or low
Asymptomatic
1. Warn about development of symptoms
1-2 weeks review of BP and urine
Weekly review of blood biochemistry
80
How is pre-eclampsia managed in th efolowing patients:
1. 160/110 BP
2. 2+ protein
3. >300mg proteinuria
1. 4-hourly BP
2. 24hr urine collection
3> Daily urinalysis
4. Daily fetal assessment with CTG
5. Regular blood tests
6. Ultrasound assessment of fetal growth
81
If BP in preeclampsia is over 160/110 what should be done
Antihypertensive medication:
1/ Methyldopa
2. Nifedipine
Hydrazine
82
How is severe pre-eclampsia managed (BP >160/110 or significant proteinuria <2)
BP: PO nifedipine 10mg twice 30 min apart
Still high: IV Labetalol infusion and theen maintenance with labetalol/methyldopa if asthmatic
Other: Bloods
Fluid balance chart/catheter
Cog monitoring of fetes
Ultrasound fetes
<34 weeks, give steroids
83
What is eclampsia
1. Tonic-clonic seizure with diagnosis of pre-eclampsia
84
What is HELLP syndrome
Severe pre-eclampsia: H 9hameolysis), EL (elevated liver enzymes), LP (low platelets)
85
Clinical features of HELLP syndrome
1. Increase in liver enzymes and platelets drop before haemolysis
2. Epigastric or RUQ pain
3. Nausea and vomiting
4. Tea coloured urine from haemolysis
Treat as with eclampsia although platelet infusion is only indicated if bleeding
86
Management of eclampsia
1. ABCDE and IV access
2. MGSO4 to control fits - 4g over 5-10 mins followed by 1g/h for 24 hrs
3. Pulse, BP, resp rate, oxygen sats veery 15 mins
4. Promoter and hourly urine
5. Fluid restriction to 80mL/h
High dose steroids if HELLP syndrome exists
6. HTN: oral nifedipine
IV Labetaolol
Monitor fetes with CTG
87
If fitting doesn't stop with 4g MgSO4 what should be done
1. further 2g bolus
Still doesn't work - Diazepam and intubation
88
Clinical features of Mg toxicity
1. Confusion
2. Loss of reflexes
3. Respiratory depression
4. Hypotension
89
How is mg toxicity treated
1g calcium glutinate over 10 mins
90
What are monozygotic twins
1. Division into two of a single already developing embryo
91
How are monozygotic twins diagnosed
1. Hyperemesis gravidarum
2. Uterus is larger than expected
3. Three or more fetal poles palpable at 24 weeks
4. Two fetal hearts on auscultation
Nuchal translucency scan
92
4 indicators for chornionicity
1. Widley separated sacs or placentae
2 .membrane insertion showing lambda sign
3. Absence of lambda sign
4. Foetuses of different sex
93
How are multiple pregnancies managed
1. Iron and folate
2. 75mg aspirin - pre eclampsia
3. Growth scans at 28, 32, 36
4. Offer delivery at 37-38 weeks
94
Risks associated with multiple pregnancies
1. Hyperemesis gravidarum
2. Anaemia
3. Pre eclampsia
4. GD
5. Placenta praaevia
95
Fetal risks associated with multiple pregnancies
1. Neural tube defects
2. IUGR
3. Pr term labour
4. risk of disability
5. Vanishing twin syndrome
96
What is twin to twin transfusion syndrome
1. Vascular anastomoses can redistribute blood, one twin becomes a donor and the other is a recipient
Requires monitoring USS: laser ablation of anastomosis
Donor: Hypovolaemic and anaemic
Growth restriction
Recipient:
Hypervolemic
Polycythaemic
Cardiac overload
97
What is twin reversed arterial perfusion
1. Twin is structurally abnormal with no or a rudimentary heart and receives blood from the other - the pump twin. Normal twin may die of cardiac failure
98
What is dichorionic
1. Both have their own nutrient supply and circulation
99
What is monochorinoinc
1. Same circulation and nutrients sharing
100
Risks associated with multiple pregnancy
1. Fetal hypoxia in second twin
2. Cord prolapse
3. post-partum haemorrhage
101
Management of labour and twin delivery
1. 38 weeks induced labour
2. Iv access
3. CTG monitoring of fetes
4. Epidural
5.Second twin delivered within 20 mins of first
6. Oxytocin to help contractions going
7. If fetal distress occurs in second - forces delivery
if forceps doesn't work, do breech extraction
8. PROPHYLACTIC oxytocin infusion is recommended
102
What is breech extraction
1. Gentle and continuous traction on one or both feet : only done in twins
103
Three types of breaches
1. Extended breech (both legs extended feet by head and presenting part is buttocks)
2. Flexed (legs flexed at knees so both buttocks and feet are presenting
3. Footling breach: one leg flexed and one extended
104
Causes of breech presentation
1. Preterm delivery
2. Uterine abnormalities
3. Placenta praaevia
4. Multiple pregnancies
105
Risks of breech presentation
1. Hypoxia and trauma
106
Diagnosis of breech presentation
1. Lie is longitudinal
2. Head is planted at funds
3. Presenting part is not hard
4. Fetal heart is best heard up on uterus
ULTRASOUND
107
What is external cephalic version
1. Turning a breech or transverse presentation into cephalic - 36 weeks
108
How is external cephalic version carried out
1. Forward roll technique
109
Contraindications of ECv
1. C section
2. fetal compromise
3. Pre eclampsia
4. Oligohydramnios
