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Obs & Gynae > Obs & Gynae 1 > Flashcards

Obs & Gynae 1 Flashcards

Obs

1
Q

Definition of labour

A

Regular painful uterine contractions accompanying dilatation and effacement of the cervix

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2
Q

What is effacement?

A

Thinning of the cervix
When the cervix is drawn up into the lower segment until it is flat
Commonly accompanied by a show or ROM

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3
Q

Mechanical factors affecting labour & delivery

A

3 P’s

  • power (force of uterine contractions)
  • passenger (fetus)
  • passage (bony pelvis, soft tissues & perineum)
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4
Q

Describe mechanical factors relating to power

A

Uterus contracts every 2-4 mins (for 45-60 secs each)

This pulls cervix up (effacement) & causes dilatation - aided by pressure of the head

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5
Q

Describe mechanical factors relating to passenger

A

Attitude: extension/flexion - ideal presentation = maximal flexion = vertex presentation
Position: rotation - degree of head rotation on the neck - must rotate 90 degrees in labour - usually delivered with occiput anterior
Size of head: head can be compressed during labour as sutures aren’t fused - pressure of scalp on cervix can cause localised swelling/caput

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6
Q

Describe mechanical factors relating to passage

A

Ischial spines used as landmarks to assess head descent = station 0 - head @ level of spines, station +2 - head 2cm below spines, station -2 - head 2cm above spines

Soft tissues & perineum overcome in 2nd stage of labour

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7
Q

1st stage of labour

A

Diagnosis until full dilatation (average duration - 8h nulliparous, 5h multiparous woman)

Latent phase: up to 4cm, irregular contractions (every 5-30min, 30 secs each)

Active phase: up to full dilatation, regular intense contractions (every 2 min, 60-90sec) - ROM now (naturally or artificially) if haven’t happened already

  • Cervix dilates until widest diameter of head passes through
  • Head descends, remaining flexed - maintains small diameter
  • 90 degree rotation from OT to OA
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8
Q

2nd stage labour

A

Full dilatation to delivery

Passive: full dilatation to head reaching pelvic floor & desire to push, rotation (from OT to OA) & flexion are completed

Active: woman is pushing

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9
Q

2nd stage of labour - delivery

A
  • head reaches perineum & extends to come out
  • perineum stretches
  • head then restitutes - rotating 90 degrees to adopt transverse position
  • then shoulders deliver (anterior shoulder under pubis symphisis first - aided by lateral body flexion in a posterior direction) (posterior shoulder aided by lateral body flexion in anterior direction)
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10
Q

3rd stage of labour

A

delivery of fetus to delivery of placenta

IM oxytocin given after birth
blood loss approx 500ml

uterine muscle fibres contract to compress the blood vessels formerly supplying the placenta

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11
Q

Perineal trauma

A

1st degree tear: minor damage to fourchette (frenulum of labia minora)
2nd degree tear & episiotomies: involve perineal muscle
3rd degree tear: involve anal sphincter (occur in 1% of deliveries)
4th degree tear: involve anal mucosa

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12
Q

Definition of spontaneous miscarriage

A

Expulsion or death of fetus before 24 weeks (majority occur less than 12 weeks)

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13
Q

Threatened miscarriage

A
  • bleeding but fetus is still alive
  • uterus is the size expected from the dates
  • cervical os is closed
  • only 25% will go on to miscarry
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14
Q

Inevitable miscarriage

A
  • heavier bleeding
  • fetus may be alive but cervical os is open
  • miscarriage is about to occur
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15
Q

Incomplete miscarriage

A
  • some fetal parts have been passed

- os is open

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16
Q

Complete miscarriage

A
  • all fetal tissue has been passed
  • bleeding has diminished
  • uterus no longer enlarged
  • cervical os is closed
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17
Q

Septic miscarriage

A
  • contents of uterus are infected causing endometritis
  • vaginal loss usually offensive
  • uterus is tender
  • fever may be absent
  • if pelvic infection occurs - abdo pain & peritonitis
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18
Q

Missed miscarriage

A
  • fetus has not developed or died in utero
    > but not recognised until bleeding occurs or USS is performed
  • uterus is smaller than expected from dates
  • os is closed
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19
Q

Clinical presentation of miscarriage

A
  • bleeding
  • pain (can confuse with ectopic)
  • severe tenderness o/e is unusual
  • examination findings of cervix depends on type
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20
Q

Investigations in miscarriage

A
  • USS - check if viable fetus in uterus, may detect retained fetal tissue
    > if doubt - repeat in a week if woman is stable
  • hCG
    > ^63% in 48hrs for viable intrauterine pregnancy
    > decrease >50% suggests non-viable pregnancy
    > between these values suggestive of ectopic
  • fbc
  • rhesus group
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21
Q

When do you give anti-D in miscarriage?

A
  • if rhesus -ve & if treated medically or surgically or if bleeding after 12 weeks gestation
  • decreases risk of isoimmunisation & rhesus disease in future pregnancies
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22
Q

Immediate management of miscarriage

A
  • admission if suspected ecoptic, septic or heavy bleeding
  • may need resuscitation
  • if retained products - can cause pain, bleeding & vasovagal shock - remove with speculum & polyp forceps
  • IM ergometrine to decrease bleeding by contracting uterus - only if fetus is non-viable
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23
Q

Medical management of non-viable pregnancy

A

Vaginal or oral misoprostol

  • success in >80% incomplete, 40-90% missed
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24
Q

Surgical management of non-viable pregnancy

A

Vacuum aspiration under anaesthetic

Indications: woman’s choice, heavy bleeding, sign of infection

  • success >95%
  • examine tissue histology to exclude molar pregnancy
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25
Q

Expectant management of non-viable pregnancy

A

NICE guidelines 1st line unless: there is an increased risk of bleeding, there are previous adverse experiences associated with pregnancy, there is increased risk from the effects of haemorrhage or there is evidence of infection

successful in 2-6 weeks in >80% if incomplete miscarriage & 30-70% missed miscarriage

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26
Q

Complications of expectant & medical management in a non-viable pregnancy

A
  • heavy bleeding
  • pain
  • infection
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27
Q

Complications of surgical management in a non-viable pregnancy

A
  • perforation of uterus

- can partially remove uterus causing Asherman’s syndrome

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28
Q

Define recurrent miscarriage

A

3 or more miscarriages in succession

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29
Q

Causes of recurrent miscarriage

A
  • antiphospholipid antibodies
  • parental chromosomal defects
  • uterine abnormalities
  • hormonal factors: thyroid, PCOS
  • obesity
  • smoking
  • ^^ caffeine intake
  • older maternal age
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30
Q

Investigations of recurrent miscarriage

A
  • antiphospholipid antibody screen (rpt @ 6 weeks if +ve)
  • karyotyping of fetal miscarriage tissue
  • thyroid function
  • pelvic USS (MRI ot hysterosalpingogram (HSG) if abnormal)
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31
Q

SGA baby

A

<10th centile (severe if <3rd centile)

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32
Q

What is taken into consideration for the customised growth chart for SFH?

A
  • maternal age
  • parity
  • BMI
  • ethnicity
  • birthweights of prev children
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33
Q

Major RF for SGA

A
  • prev hx of SGA or stillbirth
  • heavy smoking
  • cocaine usage
  • parental SGA
  • maternal illness e.g. diabetes, renal impairment, chronic htn
  • pre-eclampsia
  • maternal age >40
  • heavy antepartum bleeding
  • antiphospholipid syndrome
34
Q

Minor RF for SGA

A
  • maternal age >35
  • nulliparity
  • BMI <20
  • IVF
  • pregnancy induced htn
35
Q

Constitutional determinants causing SGA

A
  • i.e. genetic factors - cause SGA but not due to IUGR
  • small maternal weight & height
  • asian
  • female fetal gender
  • nulliparity
36
Q

Pathological determinants causing SGA

A
  • causing SGA via IUGR
  • pre-existing maternal disease e.g. renal, autoimmune
  • pre-eclampsia
  • multiple pregnancy
  • smoking & drugs
  • infection - CMV
  • extreme exercise & malnutrition
  • congenital abnormalities e.g. tuners, trisomy 13, 18, 21
  • maternal obesity & diabetes
  • placental factors (abnormal trophoblast invasion)
    > asymmetrical growth restriction - head sparing, decreased abdominal circumference
37
Q

Diagnosis of SGA

A
  • USS
  • repeat anomaly scan
  • determine cause e.g. placental or fetal origin
  • consider non-invasive prenatal testing or amniocentesis
    > infection - CMV, toxoplasmosis
    > chromosomal abnormalities
  • determine if IUGR (see separate card)
  • decreased amniotic fluid
  • CTG if severe compromise or fetal distress
  • serial measurements of SFH - may slow down
  • check BP & urine - pre-eclampsia commonly exists w/ IUGR (esp <34 weeks)
38
Q

Diagnosis of SGA to determine if IUGR

A
  • USS & umbilical artery doppler

- decrease in growth velocity by >30% of abdo circumference suggests IUGR

39
Q

Management of SGA only

A
  • pre-term
    > growth check - USS every 2-3 weeks
    > normal dopplers aim for IOL @ 37 weeks
  • > 37 weeks
    arrange delivery
    although if >3rd centile & normal umbA & CPR dopplers - may be appropriate to wait 40-41 weeks for spontaneous labour
40
Q

Management of IUGR

A
  • <34 weeks
    > reviewed twice a week
  • umbilical artery dopplers
  • if AEDF - admit for daily CTG, steroids
    > delivery delayed until 34 weeks or if CTG abnormal
  • consider c-setion - if <34 weeks give maternal magnesium sulphate
  • 34-37 weeks
    > delivery - IOL or c-section if CTG abnormal
  • delivery deferred if normal dopplers
  • > 37 weeks
  • delivery indicated - by IOL or c-section
41
Q

Complications of SGA/IUGR

A
  • NICU
  • still birth
  • fetal distress in labour
  • ^ in pre-term delivery (iatrogenic & spon)
  • maternal risks greater as pre-eclampsia may coexist & c-section often used
  • effects of IUGR in later life: ^ risk of htn, CAD, T2DM, autoimmune thyroid disease
42
Q

Definition of placenta praevia

A

occurs when the placenta is implanted in the lower segment of the uterus

43
Q

Classification of placenta praevia

A
  • marginal: placenta in lower segment of uterus but not covering os
  • major: placenta completely or partially covering internal cervical os
44
Q

Aetiology of placenta praevia

A
  • unknown
  • more common in:
    > twins
    > high parity
    > ^ age
    > scarred uterus e.g. prev c-section
    > intrauterine fibroids
    > smoking
45
Q

Clinical presentation of placenta praevia

A
  • intermittent painless bleeds - ^ frequency & intensity over several weeks
  • may be asymptomatic

O/E:

  • breech presentation and transverse lie are common
  • fetal head not engaged and high
  • vaginal examination can provoke massive bleed - don’t perform on women with vaginal bleeding unless praevia excluded
46
Q

Investigations of placenta praevia

A
  • is suspected - transvaginal USS
  • usually incidental finding on USS before bleeding has occured - if placenta is <2cm of os - praevia at term is likely
  • if low-lying placenta @ 2nd trimester USS - repeated @ 32 weeks (vaginally if placenta is posterior)
  • if anterior placenta & under c-section scar - 3D power USS to determine if placenta accreta & severity
47
Q

Assessment of maternal & fetal well-being in placenta praevia

A
  • where presentation is with bleeding:
  • CTG
  • fbc
  • clotting studies
  • cross-match
  • fetal distress is uncommon
48
Q

Management of placenta praevia

A
  • bleeding - admit
    > anti-d if rh -ve
    > IV access
    > steroids if <34 weeks
  • if asymptomatic - delay admission until delivery
49
Q

Delivery in placenta praevia

A
  • elective c-section @ 39 weeks
  • intraoperative & PPH common as lower segment of uterus doesnt contract well after delivery or because of placenta accreta
  • emergency delivery if severe bleeding <39 weeks
50
Q

Managmenet & delivery if placenta accreta

A
  • should have been anticipated
  • partial separation of placenta by uterine incision may provoke haemorrhage
  • compression of the inside of the scar after removal of the placenta with inflatable Rusch balloon
  • excision of the affected uterine segment or total hysterectomy
51
Q

Complications of placenta praevia

A
  • obstruction of head engaging - causes transverse lie, c-section needed
  • severe haemorrhage as lower segment less able to contract
  • placenta accreta
  • placenta percreta
52
Q

What is placenta accreta?

A

If placenta implants in myometrium in prev. scar may prevent placental separation

53
Q

What is placenta percreta?

A

placenta implants in myometrium as per accreta, then penetrates through uterine wall into surrounding structures e.g. bladder

54
Q

What is placental abruption?

A

When part (or all) of the placenta separates before delivery of the fetus

55
Q

Pathology behind placental abruption

A
  • rupture of maternal vessls within basal layer of endometrium
  • blood accumulates
  • splits placental attachment from the basal layer
  • detached portion of placenta unable to function - rapid fetal compromise
56
Q

Different types of placental abruption

A

Revealed - bleeding tacks down from site of placental separation - vaginal bleeding

Concealed - bleeding remains in uterus - typically forms a clot retroplacentally
> bleeding not visible but can be severe enough to cause systemic shock

57
Q

Risk factors for placental abruption

A
  • prev. abruption
  • pre-eclampsia
  • abnormal lie
  • polyhydramnios
  • abdo trauma
  • smoking or drug use, e.g. cocaine
  • bleeding in 1st trimester
  • multiple pregnancy
  • IUGR
  • underlying thromophilias
58
Q

Clinical presentation of placental abruption

A
  • painful bleeding
  • blood often dark
  • amount of blood doesnt reflect severity
  • o/e:
    > tender uterus - may be woody
    > ^ HR, decreased BP
    > poor urine output
    > fetus hard to feel, fetal heart tones often abnormal or even absent
59
Q

Investigations in placental abruption

A
  • diagnosis on clinical grounds
  • establish maternal well-being:
    > fbc
    > clotting profile, cross-match
    > group & save
    > u&e, lft
    > ? catheterisation
    > Kleihauer test - if rh -ve - determine about of feto-maternal haemorrhage and dose of anti-D required
  • establish fetal well-being:
    > CTG
    > USS - can exclude praevia but abruption may not be visible
60
Q

Management of placental abruption

A
  • admit
  • ABCDE
  • IV fluids, steroid if <34 weeks
  • anti-D if rh -ve
  • if maternal or fetal compromise:
    > urgent c-section (unless spon delivery is imminent or operative vaginal delivery is possible)
  • if no fetal distress and above 37 weeks:
    > induction of labour w/ amniotomy
    > if any fetal demise ensures - c-section

conservative management:
> if no fetal distress & preterm & degree of abruption is minor - steroids (<34 weeks), monitor until settled symptoms, pregnancy is now hight risk - serial USS for fetal growth

61
Q

When is induction of labour performed?

A

in situations where allowing the pregnancy to continue would expose the fetus +/- the mother to risk greater than that of induction

62
Q

Reasons for IOL

A
  • prolonged pregnancy
  • suspected IUGR
  • PROM
  • pre-eclampsia
  • htn, diabetes
  • abruption
  • placental insufficiency
63
Q

Induction with prostaglandins

A
  • PGE2
    = gel (1 in 6 hours) or vaginal pessary (1 in 24 hours)
  • in posterior vaginal fornix
64
Q

Induction with amniotomy +- oxytocin

A
  • ARM
  • if labour not started within 2 hours - oxytocin (start low and titrate up until 4 contractions in 10 mins)
  • can use oxytocin after SROM
  • monitor fetal HR - stop if fetal distress or uterine hyperstimulation (>5 contractions in 10 mins with fetal compromise)
65
Q

Natural induction

A
  • cervical sweeping - finger through cervix - between membranes & lower segment of uterus (separate chorionic membranes from decidua)
  • at 40 weeks this reduces need for formal induction
66
Q

Pre-term PROM

A

<34 weeks - delay IOL unless obstetric factors indicate otherwise e.g. fetal distress
>34 weeks - timing of IOL depends on risks vs benefits of delaying pregnancy further e.g. ^ risk of infection

67
Q

Complications in IOL

A
  • failed induction
  • uterine hyperstimulation
  • iatrogenic prematurity
  • infection
  • bleeding (vasa praevia)
  • cord prolapse (e.g. with high head at amniotomy)
  • c-section
  • ^ rates of instrumental delivery
68
Q

Management of induced labour

A
  • CTG - 1 hr after prostaglandins or when they stimulate uterine activity
  • oxytocin - CTG
69
Q

Absolute contraindications to IOL

A
  • placenta praevia
  • cord presentation
  • vasa praevia
  • active primary genital herpes
  • cephalopelvic disproportion
  • transverse lie

(these contraindications also CI for vaginal delivery)

70
Q

What is adequate progress in labour?

A

2cm dilatation per 4 hours of active labour

71
Q

What is a delay in the first stage of labour

A

<2cm/h dilatation in 4hours

72
Q

Delay in 2nd stage of labour in a primip

A

delay if delivery not imminent after 1 hour of active pushing

  • if no concerns can continue for 2 hours - if still not imminent - consider instrumental delivery or c-section
  • multiparous - consider instrumental or c-section after 1 hour
73
Q

Problems associated with prolonged pregnancy

A
  • intrapartum death
  • early neonatal death
  • ^ rates of IOL and operative delivery
  • possible placental insufficiency
  • macrosomia - shoulder dystocia, fetal injury
  • fetal skull more ossified so less mouldable
  • ^ meconium passage in labour
  • ^ fetal distress in labour
  • ^ c-section rates for labours >41 weeks
74
Q

How to manage a woman who refuses induction

A
  • at least twice weekly CTG & US - if CTG abnormal - c-section
  • estimate amniotic fluid depth to try & detect fetuses who may be coming hypoxic
  • doppler studies of cord blood flow may be used to look for AEDF as a predictor of fetal compromise
75
Q

Signs of postmaturity in the baby

A
  • dry, cracked, peeling, loose skin
  • decreased subcutaneous tissue
  • scaphoid (hollow) abdomen
  • meconium staining of nails and cord
76
Q

When should membrane sweeps be offered?

A

nulliparous - 40 weeks

multiparous - 41 weeks

77
Q

Risk factors for pre-term birth

A
  • previous preterm birth
  • multiple pregnancy
  • cervical surgery
  • uterine abnormalities
  • pre-existing medical conditions e.g. diabetes
  • pre-eclampsia
  • IUGR
  • vaginal infection
  • APH
  • polyhydramnios
78
Q

Investigations of preterm labour

A
  • digital VE unless ROM to assess dilatation
  • fetal fibronectin - +ve - 10% chance of preterm labour in next week
  • TVS - assess length of cervix - delivery unlikely if >15mm
  • vaginal swab for infection
  • CTG and US to assess fetus
79
Q

Management in preterm labour

A
  • nifedipine (if CI: atosiban) - delay labour
  • betamethsone or dexmethasone 24-34 weeks
  • magnesium sulphate 24-34 weeks
  • if in labour - IV benzylpenicillin - prevent GBS
80
Q

CI for tocolytics

A

absolute: chorioamnioitis, fetal death or lethal abnormality needing immediate delivery
relative: IUGR, fetal distress, pre-eclampsia, cervix >4cm, APH

Obs & Gynae (2 decks)

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