Obs gyn important Flashcards
Physiological changes of pregnancy
Immune - not privileged, but trophoblast does not elicit allogeneic responses, no interface with maternal circulation immunogenically, thymus involutes in pregnancy, lymph nodes draining uterus enlarge
Cervix - reduction in collagen and accumulation of glycosaminoglycans and water, hypertrophies, more mucous, more vascularity
Vascular - hypertrophy of vessels, 50-500mL/min 10 weeks to term, invasion of spiral arterioles, 100-150 arterioles supply intervillous space (one per cotyledon)
Contractility - suppressed by progesterone, increased resting membrane potential, start by 7 weeks
CO - 40% increase 1st trimester, further increase after this, SV increases, HR increases
TPR - falls 4-6 weeks and halves by mid-pregnancy (allows BV to expand)
Arterial blood pressure - Sound 5 is for diastolic, MBP falls to mid-pregnancy, supine hypotension common in second half
Blood - Red cell mass increases by 20-30%, physiological anaemia
Respiratory - increase in minute ventilation, PaCO2 falls (right shift allows better unloading to foetus due to more 2,3DPG –> foetus is left shifted due to HBF), resp diseases usually not much effect on pregnancy
Renal function - GFR rises, some glycosuria and mild proteinuria common
Nutrients - Albumin falls, globulin rises, amino acids except alanine and glutamic acid decrease, HYPERLIPIDAEMIC, FFA (HPL)
Endocrine - placenta –> steroids betides and prostainoids, CRH and ACTH, Lowered oxytocin, GH, LH, FSH suppressed by placental gonadotrophin, pituitary gland grows, more prolactin, TFT’s increase, Aldosterone increases
Placental growth and development
Embryo –> morula –> blastocyst (formation of fluid filled cavity) –> penetrates endometrium by day 7 –> decidual reaction (syncytium phagocytksed by stromal cells) –> cytotrophoblast grow down to layers of decide and penetrate endometrial venules and capillaries –> forms intervillous space
2 arteries and one vein - high venous pressure preserves integrity of venous flow
Fetal cotyledon is functional unit
Angiotensin II important in regulating utter-placental blood flow
Placental transfer by simple diffusion, facilitated diffusion, active transport and pinocytosis
2x amount of glycogen in fetal liver - helps with birth
Insulin, glucagon, HPL, growth hormone - do not cross placenta (maternal Glucose levels major regulatory factor in placental)
Placenta makes –> BHCG, HPL, Progesterone, Oestrogens, Corticosteroids, CRH (last 4 are steroids, first two are protein)
Age, race, maternal height, weight and parity –> determine fetal birth weight
Fetal development
Ear by 10 weeks, inner by 24
Amniotic fluid sac as early as 7 days - turnover every 2-3 hours - sucked –> excreted in urine
1L by term
Oligo –> club foot, skull deformities, wry neck –> cord compression too
Poly –> unstable lie, cord proslapse/limbprolapse, abruption, PPH (over distension), discomfort and dyspnoea
Perinatal mortliaty
Australian 8.4/1000
Stillbirths - APH/IPH, IUGR, placental conditions, unexplained most common though
Neonatal - respiratory, congenital, neurological, extreme prematurity
Common causes of direct - sepsis, eclampsia, Thromboembolism, AFE, early pregnancy deaths
Indirect - cardiac, other indirect, neurological
Symptoms of pregnancy
N and V
Back pain - rule out peel, UTI, early labour - needs physiological and simple analgesics
Abdominal pain - suspect ectopic, miscarriage, gynae causes, UTI, surgical causes, later obstetric causes - otherwise common
Heartburn - rule out cardiac, pre-eclampsia, fatty liver –> conservative treatment, antacids and PPI if not working
Constpiation - due to progesterone –> fluid and dietary fibre
Frequency of urinartion
Snycope - progesterone + caval compression - exclude anaemia, hypoglycaemia, dehydration and arrhythmias - sit before standing enough hydration too
Lethargy
Varicosities - exclude DVT nd thrombophelbitis
Carpal tunnel - splints, severe steroid injections
SPD - due to relaxin - physiotherapy, support, analgesics
Breast tenderness and heainess
Foetal movements
Pica
Exam of pregnant woman
General, systemic and obstetric
Height weight and vitals
Thyroid status important and anaemia
Heart and lungs - benign flow murmurs, respiratory distress may occur
Head and neck - chloasma, look for pallor, dental hygiene
Breast - enlargement, vascularity, pigmentation of areolae,
Abdomen - striae gravidarum, hepatosplenomegaly, renal enlargement
UTERUS PALAPBE AT 12 weeks - 12 weeks above PS 24 weeks at umbilicus 36 at xiphisternum After 24 weeks number of weeks correlates to height above PS Girth 2.5 cm every week after 24 weeks
Limbs - oedema, varicose veins, increased lumbar lordosis may lead to back pain
Pelvic exam - speculum, cervix in later, VE contraindicated in later pregnancy until praevia excluded, plane of pelvic margins
Ischial spines - transverse
AP - least from inferior PS to coccyx (TRANSECTS LINE FROM ISCHIAL SPINES)
Should be gaining half a kilo a week after 18th week
ANTENATAL CARE
SEE handout from GP
Preconceptual - serology, influenza + pap smear, folic acid, iodine supplementation, change medications, nutritious diet and regular exercise, STOP ILLICIT
Smoking –> IUGR, lower crown-heel length
Alcohol –> FAS, growth retardation, structural defects, joint anomalies, cardiac
Ilicit –> IUGR, preterm, perinatal death
Cocaine –> cardiac arrhythmias, CNS damage, abruption
Amphetamine –» miscarriage, reterm, IUGR, abruption, fetal death and developmental abnormalities
Marjiuana can be teratogenic
Blood tests - Hb, B12, folate ABO antibodies Rubella and varicella Syphilis RPR, VDRL, FTA Hepatitis HIV GBS UTI OGTT - booking and 26-28
USS, CTFS/NIPT
No soft cheese, meats, salad bars, soft serve –> listeria
Protein 60-80 a day
Iron, calcium, iodine, magnesium, zinc, Vitamins A and B, B2, B5, ascorbic acid, folic acid
2000-2500kcalories a day
Exercise important, excessive exertion not good
Avoid coitus only if PPROM, APH, Placenta praaevia
Hygiene, brassiere
Lactation consultatnt
Motherrisk.org
NO NSAIDS
Hypertensive pregnancy disorders
0.3g/L OR 1g/L o random sample 2 or more occasions 6 hours apart
Pre-eclampsia –> abruption, convulsions, proteinuria, hypertension and oedema –> haemorrhage, renal and hepatic failure
- NEED SYSTEMIC MANIFESTATION
Vasoconstriction –> reduced utter-placental circulation –> DIC (slow, if fast –> HELLP) –> pro fibrin filtration –> reduced GFR –> sodium retention –> intracellular shifts of sodium –> vasoconstriction –> continues
ATERIOLAR VASOCONSTRICTION + DIC = PREECLAMPSIA
(MAP = CO x SVR) - loss of sensitivity to ATII and placental bed damage from vasoconstriction –> DIC
RF - genetic, autoimmune, thrombophilias, underlying CKD or essential hypertension, increased FFA’s, fetomaternal host response
Investigations - FBC, UEC, uric acid, LDH, Clotting studios, catecholamine, USS, CTG, Urinalysis Urine MCS
Give methyldopa, hydralazine, labetalol, prazosin, nifedipine
Give 2 doses IM betamethasone if severe enough when admitting as well
Prevention - aspirin, thrombophilia, calcium supplements
HEADACHE, RUQ pain, blurring of vision, sudden onset of vomiting, hyperactive reflexes, oedema - ALWAYS ASK ABOUT SEIZURES TOO
IOL - gestation over 37, uncontrollable BP, HELLP, deteriorating renal, eclampsia, APO, CTG compromise, reversal or end diastolic flow in umbilical artery, no fetal growth over 2 weeks, abruption
Leads to IUGR, Hypoxia, death
Maternal –> renal failure, hepatic failure, seizures, DIC< ARDS, cerebral infarction, heart failure,
Leads to infarction and abruption too
If seizure give MgSO4 and keep fluids up using CVO
IV hydralazine or labetalol if eclampsia too
APH
Placenta praaevia, placenta abruption, vasa praecvia, unexplained, infections of vagina, lesions of cervix
Praaevia - admit, IV, FBC and cross match, CTG, USS, anti-D
Abruption - associated with dietary deficiencies, folate deficiency, tobacco, hypertension, thrombophilia, IUGR, (not usually trauma)
- PAIN, bleeding, increased uterine activity, blood clot and increased tone
- use USS sometimes to differentiate from praevia but this is usually painful
- lie is usually longitudinal in this compared to mal in praevia
- Hb, IV, Transfuse, fluids, fetal condition, conservative management delivery by CS if 38 weeks and before if severe and persistent loss
- DDX acute hydramnios, perforated ulcer, volvulus of bowel, strangulated inguinal hernia
NOT ALLOWED TO USE EPIDURAL UNTIL CLOTTING SCREEN –> use opiates
Multiple pregnancy
Complications - n and V, anaemia, miscarriage, APH, pre-eclampsia, gestational HTN, eclampsia, IUGR, preterm labour
- IF MONOCHORIONIC - TTTS –> hydros fetalis, and cardiomegaly and polyhydramnios
Structural abnormalities increased
Antenatal supervision and USS to detect growth anomaly and TTTS
IUGR common, need to IOL
C section or vaginal
IV line needs to be in, epidural given if second twin complicated. - 30 minutes accepted between two deliveries –> C section
Obstruction and transverse –> C
Failure to descent with second twin breech –> guide foot and breech into pelvis (have to grasp foot with intact membranes to avoid cord prolapse)
IF placenta separates –> C section
EMCS - locked twins
Conjoined twins - C section
Higher perinatal mortality, often due to prematurity
Prolonged pregnancy
Postmaturity syndrome - dry skin, no fine hair, loss of subset fat, meconium staining of skin
–> mortality, distress, operative delivery, meconium aspiration
41+5 booking policy at most hospitals
<5cm AFI –> need to deliver
CTG and normal liquor –> doesn’t matter how you deliver
Breech
More irregular presenting part –> more risk of prolapsed cord or limb
Can deliver through incompletely dilated cervix as bitrochanteric less than biparietal
- ECV after 36
- –> DONT DO IF APH, abnormal CTG, placenta praevia, uterine scar or multiple pregnancy
- Give nifedipine or IM terbutaline
- stop if bradycardia and not past half way
Complications of eco - cord entanglement,abruption and ROM, persistent foetal bradycardia, 50% success, 1/200 emergency LSCS, abruption 0.1%, 3% revert
If 32-28 weeks or >4kg need to do C
VAGINAL:
Lift legs out –> once trunk out –> arms one at a time by sliding fingers over the shoulder and sweeping them downwards across fetal head (arm can be delivered by flexing at elbow and shoulders - Loveset’s manoeuvre - rotate body to do other arm) –> suspend trunk for 30 seconds –> grasp legs and swing upward through 180 degrees until can see mouth –> then do as normal
C section if <1.5 or >4
LCSC unless preterm
Unstable lie, transverse and shoulder presentation
May lead to prolapse of cord
No action until 37 unless labour starts
Look for USS to explain
39 weeks need to admit - in case SROM with prolapsed cord - allows for rapid C section
If any complicating - C section
If arrives in labour with shoulder presentation or prolapsed arm –> have to do C section (classical if arm wedged into pelvis)
Medical problems in pregnancy
Anaemia - physiological –> need more iron and folate
- Mainly affects mother, but can cause anaemia in child when born –> maternal mortality though
GDM - pregnancy is diabetogenic –> previous large infant, previous GDM, first degree with diabetes, obesity, ethnicity, macrosomia, unexpected perinatal death, PCOS< Polyhdramnois,
- Increases infections, polyhydramnios, macrosomia, increased risk of still birth, shoulder dystocia, instrumental, tears, IOL, C section - usually resolves
CHOLESTASIS
- Debilitating, prolongation on clotting, small stillbirth and preterm, high recurrence
- GIVE UDC, topical emollients, antihistamines, serial growth USS and CTG’s, OCP not to be used, oral vitamin K if clotting!!!!!!!
- Induce at 37, if unbearable for mother earlier
Fatty liver:
AFLP - variant of pre-eclampsia?
Fat people and multiple and first pregnancy
- N, V abdominal pain, malaise, jaundice, hypoglycaemia, can have maternal death due to encephalopathy haemorrhage, fetal mortality,
NEED TO GIVE MDT supportive, dialysis may be necessary after delivery
Infections
Varicella - congenital is eye defects, limb, neurological –> USS
Parvovirus - fever rash and arthropathy in mother, anaemia, heart failure or miscarriage in kid - analgesics, contact avoidance, in utero blood transfusions
Influenza - preterm, stillbirth, death, give oseltamivir and rest support, immunisation
HIV - HAART, miscarriage, IUGR, prematurity, stillbirth (if advanced)< C section usually, but can do vaginal if viral load is normal, NO breastfeeding (screen from birth - 12 weeks) and HAART for child
Hepatitis - No impact on pregnancy, sometimes preterm labour –> Mainly want to reduce vertical transmission, avoid use of instruments, give immunoglobulin and vaccination at birth
TB - streptomycin gives ototoxicity, need to give therapy, rarely crosses placenta
Malaria - IUGR, preterm, congenital, death
Acute peel - asymptomatic needs to be treated (pyuria)
VTE - need to give compression stockings, heparin, no OCP later on if conrfirmed diagnosis
Pre-existing medical conditions
Renal - pre-eclampsia, IUGR, preterm, C section
- Give aspirin, BP, renal function, UTI, prophylactic heparin if proteinuria, prophylactic antiobtics if multiple UTI, genetic counselling of PCKD, if calculi- longer antibiotics
Diabetes
- need more insulin, reduced signs of hypoglycaemia, complications accelerated, pre-eclampsia, preterm, polyhydramnios, instrumental delivery, IUGR, need to go to nursery, jaundice for child after, miscarriage, fetal abnormality
- change meds, MDT, tight parameters, control BP, ophthalmic assessment due to retinopathy
Thyroid
- Oestrogen increases thyroid
- need more in hypothyroid –> abortion, pre-eclampsia, HTN, PPH, LBW, IQ, cretin, monitor, and iodine adequate
- hyper –> don’t need as much as pregnancy needs more thyroxine –> augur, pre-eclampsia, prematurity, still births, thryotoxicosis
Obesity
- Miscarriage, congenital, pre-eclampsia, GDM, PPH, IOL, instrumental, C section, tears, VTE, Macrosomia, stillbirth, nurses, childhood diabetes, obesity for child, need more folic acid, OGTT
Thrombophilia - need to give LMHX, aspirin, heparin
- Pre-Eclampsia, abruption, IGUR, miscarriage (antiphospholipid especially),
Epilepsy - minimal - abnormalities, may need vitamin K, counselling, no stopping abruptly, breastfeeding safe
Headache - usually drop - no prophylaxis as vasoconstrictive
Autoimmune - some effect placental function, some like crohn’s improve due to altered
Haemoglobinpathies - N, V, anaemia, infection, need to give folic acid, aspirin, prophylactic antibiotics, avoid dehydration, VTE prophylaxis
Congenital abnormlaities
In over 50%, 70% miscarriages, 15% of deaths
Neural tube defects - anencephaly, microcephaly, spina video, 1/200 risk, normal intelligence, need folic and,
Heart - IUGR< oligohydramnios, defects
Defects of abdominal wall - exompahlos has a sac, gastroschisis doesn’t
Downs syndrome most common chromosomal
Risks - age, drugs, previous history, maternal disease, persistent breech, vaginal bleeding, abnormal AFI, abnormal foetal movements, IUGR
First USS - 11-13+6 - CRL, NT
20 week USS - Anatomical survey
CTFS - 9-13+6 or NIPT ANYtime
Second - 14+2-20 weeks not as sensitive
Counselling should be good
Amniocentesis of CVS sampling has risks - can terminate if they so choose, surveillance, some things can be treated
Screening not always works
AFI must be 2-8 single deepest pocket or at least 8 overall
FHR, breathing, movements, tone, normal foetus sleeps up to 40 so monitor for that long
Stages of labour
First early latent up to 3cm, active phase 3cm-10
Second fully dilated to delivery
Third - placenta and membranes
Regular - painful contractions that increase in frequency and duration, radiate down,
CRH –> more prostaglandins and oestrogen and less progesterone
Collagen breakdown due to leucocyte inflation
Latent is 6-8 in nulliparous, 4-6 in multiparous, - ACTIVE SHOULD BE 1cm per hour at least from 3-4 to full dilation
No progress with brow –> C SECTION
If lags more than 2 hours behind in active latent phase - if CPD excluded –> augment with oxytocin
Keep adequately hydrated, only light amount of food
