Obs & Gynae 2 Flashcards
1
Q
What % of pregnancies results in miscarriage?
A
20%
2
Q
What is a threatened miscarriage?
A
A pregnancy with vaginal bleeding with or without abdominal pain
3
Q
How do you best identify a delayed (missed) miscarriage?
A
USS - an empty sac is seen or foetal pole with no heart beat
4
Q
When can you expectantly manage an incomplete miscarriage?
A
Gestational age less that 8 weeks and not heavily bleeding
5
Q
Define gestation diabetes.
A
reduced response to insulin causing hyperglycaemia with first onset during pregnancy.
6
Q
A foetus presents with macrosomia. What further tests do you want to perform?
A
- Blood glucose/HbA1C
- USS
- Umbilical artery doppler
7
Q
How do you treat gestational diabetes?
A
- advise on diet and lifestyle
- consider metformin
- consider C-section to avoid shoulder dystocia
8
Q
What are the causes of prolonged labour (failure to progress)?
A
3 Ps Passenger: -size of baby - macrosomia -presentation - brow and face first = greater diameter. cephalic -lying transverse, not rotating head -head no flexing
Passages:
- pelvic abnormalities
- soft tissue - cervical dilation dependent on uterine contracts + pressure on foetal head
- vagina + perineum must be over come - may require episiotomy
Power:
-poor uterine contractions common in nulliparous women
-uterine atony:
~induction or augmentation with oxytocin
~polyhydramnios
9
Q
What are risk factors for failing to progress in labour?
A
maternal:
- primi parity
- high BMI/weight gain
Foetal:
- macrosomia
- large head circumference
- malpresentation
10
Q
What role do prostaglandins play in labour?
A
- reduce cervical resistance and increase release of oxytocin from the posterior pituitary
- Used as a first component of labour induction to soft and thin the cervix. Activation of collagenase - remodelling of extracellular matric and generation of uterine contractions.
MISOPROSTOL
11
Q
What role does oxytocin have during pregnancy?
A
- stimulate uterine contractions
- contractions promote dilation
- give low dose and gradually increase to augment labour
12
Q
What are the side effects of giving misoprostol?
A
-prostaglandin receptors present throughout the body so may have an effect on other systems - meconium stained liquour, diarrhoea, abdo pain.
13
Q
What are the possible side effects of giving syntocinon?
A
- uterine tachystole
- abnormal foetal HRs due to reduction in blood flow during contractions = hypoxaemia
14
Q
What is recorded on a partogram? why is it important to do?
A
Maternal:
- HR
- BP
- temperature
- urine output
- abdo exam - descent of head
Foetal:
-heart rate (CTG)
Contractions:
- frequency
- duration
- strength
15
Q
What are maternal consequences of failure to progress in pregnancy?
A
- infection
- post-partum urinary retention
16
Q
What are the foetal consequences on failure to progress in labour?
A
- hypoxia
- cerebral palsy
- mortality
17
Q
A woman is failing to progress due to inefficient uterine contractions. How do you manage this lady? How common is this?
A
- most common cause of failure to progress - common in nulliparous women
- artificial rupture of membrane (amniotomy)
- augmentation with oxytocin
18
Q
A woman is failing to progress in labour because of uterine contractions that are too strong. What is this called? How do you treat it?
A
- hyperactive uterine action
- can cause foetal distress - reduced placental perfusion - ischaemia
- treat with C section
19
Q
When would you C section a nulliparous woman who has failed to progress?
A
not achieved full dilation by 12-16 hours
20
Q
What indications are there for induction of pregnancy?
A
Foteal:
- over due - risk of IU foetal death
- IUGR
Maternal:
- still birth
- social reasons
- APH
- Preterm ROM
Both:
- preeclampsia
- diabetes
21
Q
What are some contraindication for induction of labour?
A
- acute foetal compromise
- abnormal lie
- placenta praevia
- pelvic obstruction
22
Q
What colours of liquor would be concerning?
A
- green = meconium stained = foetal distress
- red = blood ~ not good
23
Q
A baby is in breech position, what could you attempt to turn it round?
A
-external cephalic version (ECV)
24
Q
What would you management of a foetus in breech position be?
A
- CTG moitoring
- examine every 4 hours
- foetal blood sampling ig pH <7.21 emergency C section ASAP
25
What's the difference between primary and secondary post partum haemorrhage?
- primary = occurs within 24 hours of birth
| - secondary = occurs >24 hours - 12 weeks
26
What are risk factors for PPH?
- previous PPH
- prolonged labour
- pre-eclampsia
- increased maternal age
- polyhydramnios
- emergency C section
- placenta praevia or accrete
- macrosomia
27
What 3 ways may you induce labour?
- amniotomy
- prostaglandin pessary (misoprostol)
- sweep
-IV oxytocin for more contractions
28
What is bishops score used for and what parameters does it measure?
```
-assesses likelihood of having a vaginal delivery (when thinking about induction)
Vaginal examination measuring:
-cervical position
-cervical consistency
-cervical effacement
-cervical dilation
-foetal station
```
-greater than 8 points = likely good delivery
29
What acronym is used for reading CTG? (explain said acronym)
DR. C BRaVADO
- Define Risk - what risk factors does the person have for a complicated pregnancy
- Contractions - frequency, intensity, consistency, duration and resting tone
- Baseline Rate - normal baseline rate is between 110-160bpm
- Variability - can fluctuate between 10-15bpm which is considered a good thing. decreased variability longer than 40 mins is suspicious and probably result in C section. less than 40 mins is probs sleep.
- Acceleration - these are normal a good sign
- Decelerations = are periodic or episodic (start of contraction back to normal by the end)
- late decelerations are bad and may suggest foetal distress due to decreased placental blood flow
- Overall impression - normal, suspicious or pathological?
30
What would make a CTG suspicious?
- decreased variability
- progressing tachycardia
- decrease in baseline rate
- late decelerations with reduced variability
31
What would make a CTG pathological?
- persistent late decelerations with reduced variability
- variable decelerations if prolonged or associated with other signs
- little or no variability for greater than 40 mins
- severe bradycardia
32
If a woman has diabetes preconception, what must you advise + do?
- advise HbA1c control of <48mmol
- start follic acid 5mg
- CONTRAINDICATED ACEi and statins
- retinal screening
- do renal function
33
What are maternal risks of diabetes in pregnancy?
- DKA
- hypos
- progression of retinopathy
- pre-eclampsia
- premature labour
34
What are the feotal risks of diabetes in pregnancy?
- miscarriage
- macrosomia+ shoulder dystocia
- fetal abnormalities
- late still birth
- neonatal hypoglycemia
- respiratory distress
- hyocalcaemia
35
How do you treat diabetes in pregnancy?
- Insulin bolus regime
- metformin
- Glibenclamide
- all other hypoglycaemics are contraindicated
36
If a woman has a preexisting medical condition pre pregnancy what can be done to ensure baby and mother are safe?
- planned delivery & postpartum care
- "safest" mode of delivery
- neonatal support
- anaesthetic expertise
- HDU/ITU facilities
- Ongoing care postpartum
37
What are 2 common caused of anaemia in pregnancy?
- Iron deficiency
- folate deficiency
- both due to increased requirements in pregnancy
38
What complications is iron deficient anaemia during pregnancy associated with?
- low birth weight
| - preterm delivery
39
What would be the expected FBC result of someone with iron deficiency anaemia?
- low haematocrit
- low MCV (microcytic)
- low MCH (hypochromic)
- normal or low reticulocyte count
40
What What would be the expected FBC result of someone with folate deficiency anaemia?
- high MCV (macrocytic)
| - high homocysteine
41
When is the risk of asthma exacerbation highest?
3rd trimester
42
What effects does maternal asthma have on the foetus?
- IUGR due to inadequate placental perfusion
| - premature delivery due to deterioration in maternal condition
43
What's the leading cause of maternal death in UK?
Cardiac disease
44
What are low risk and high risk cardiac lesions during pregnancy?
Low:
- mitral incompetence
- aortic incompetence
- ASD and VSD
High:
- aortic stenosis
- coarctation of aorta
- prosthetic valves
- cyanosed pts
45
Tell me about obstetric cholestasis.
- commonest liver disease in prgnancy
- presents with itching + NO rash
- abnormal LFTs
- resolves after delivery
- recurrence risk is 80%
46
What are the complications of obstetric cholestasis?
-stillbirth due to level of bile acid
47
what is the treatment for obstetric cholestasis?
- ursodeoxcolic acid has some benefit to biochemistry abnormalities
- Delivery is the best
48
What is the maternal and foetal risks of hyperthryoidism?
maternal - thyroid crisis with cardiac failure
| foetal - thyrotoxicosis due to transfer for thryoid stimulating antibodies
49
How do you manage hyperthyroidism in pregnancy?
- Propylthiouracil
- carbimazole
- if mother has stimulating antibodies monitor fetal growth with USS
50
What are the risks of untreated hypothyroidism in pregnancy?
early foetal loss
| impaired neurodevelopment
51
What is the management for hypothyroidism in pregnancy?
-adequate replacement of thyroxine especially in first trimester
52
What complications can chronic renal disease in pregnancy cause? WHY?
WHY - eGFR increases by 50% in pregnancy
- severe HTN
- deterioration of renal function
- pre-eclampsia
- IUGR
- stillbirth
- premature delivery
- abnormalities due to drug therapy
53
How do you manage someone with chronic renal disease in pregnancy ?
- MDT
- Close renal function monitoring
- close BP management
- regular foetal growth and well being assessments
54
What are the 3 feotal changes associated with sodium valporate use during pregnancy?
- congenital malformations (spina bifida, cleft palate, hypospadias, polydactyly)
- Reduced IQ (dose related)
- ASD risk
55
What would increase the risk of a woman to have a VTE in pregnancy?
- obesity
- maternal age
- operative delivery
- general increase for everyone due to hypercoagulable state of pregnancy
56
What is the VTE treatment in pregnancy?
-LMWH - doesn't cross placenta and cause bleeding (deltiparin)
57
What is the cause of endometrial cancer?
PROLONGED UNOPPOSED OESTROGEN
- HRT
- PCOS
- nulliparity
- Late menopause
- ovarian tumours
- Pelvic irradaition
- Tamoxifen
- Diabetes
- Obesity
58
In what order would you perform investifagations for post menopausal bleeding suspecting endo Ca?
- TVUS
- Biopsy
- Hysteroscopy
59
How do you treat Endometrial Cancer?
- Hysterectomy +/- pelvic lymph node removal
- Radiotherapy
- progesterone therapy
60
What causes cervical cancer?
- High risk HPV
- early age intercourse
- multiple sexual partners
- STDs
- Cigarette smoking - HPV more persistent
- previous CIN
- Multiparity
- OCPusage
- Other genital tract neoplasm
61
What are the 2 main onco genes of HPV?
HPV 16 & 18
62
What is persistent HPV associated with?
-increased risk of high grade CIN
63
What is Gardasil? When is it given?
- HPV vaccine against strains 6, 11, 16, 18
- 1st dose given to 12/13 year olds in year 8
- 2nd dose either in year 8 or 9
64
What are the 2 most common types of cervical cancer?
- Squamous (90%)
| - Adenocarcinoma
65
how would you treat a stage one cervical Ca?
LLETZ
| -Large loop excision of the transformation zone
66
How would you treat stage 2 and above cervical Ca?
- Radiotherapy
- chemotherapy
- Palliative care
67
What are the 2 common aetiolgies of vulval cancer?
-VIN (HPV)
-Lichen sclerosis
(90% squamous)
68
What are some symptoms associated with vulval cancer?
- vulval itching
- vulval soreness
- persistent lump
- bleeding
- pain on PU
- past hx of VIN or lichen sclerosis
69
What are genetic causes of ovarian cancer?
- BRAC 1/2
| - HNPCC
70
What non-genetic causes of ovarian cancer?
OVULATION
- early menarche
- late menopause
- nuliparity
- breast feeding
- OCP
- hysterectomy
- ovulation induction
71
How do you investigate suspected ovarian Ca?
- CA125
- TVUS
RMI (risk of malignancy index) = CA125 x USS score (1 or 3 for more than one abnormal feature of cyst on scan) x pre or post menopausal (1 or 3)
72
Define placenta accreta. increta & percreata.
Accreta - placenta attaches too deeply in the uterine wall
Increta - placenta attaches to the myometrium
Percreta - placenta goes all the way through the uterine wall and sometimes attaches to other nearby viscera i.e. bladder
73
How do you treat PPROM?
- 10 day ABx prophalyaxsis - erythromycin
- steroids for lung maturation before 34 weeks
- magnesium sulphate infusion for cerebral palsy protection
- deliver between 34-36 weeks
74
Define PPROM.
Premature rupture of membranes before week 37 of pregnancy
75
Define PROM.
premature rupture of membranes - membranes rupture before labour begins.
76
Why is group b strep a bad thing?
- can cause sever infection in the neonate e.g. sepsis, pneumonia, meningitis
- 5% mortality rate
77
What are risk factors for a neonate getting a GBS infection?
- previous GBS infection of another sibling
- prematurity <37 weeks
- ROM >24hrs before delivery
- oyrexia during labour
- +ve GBS test in mother
- mother diagnosed with a GBS UTI during pregnancy
78
How is GBS detected?
- swab of vagina and rectum
- done in high risk women:
- UTI or Chorioamnionitis
- STI sx pre-pregnancy
- Previous GBS infected bab
79
How does one prevent a neonate from getting a GBS infection?
-High dose pen-ben throughout labour in high risk women
80
When is IV Ben-Pen given to women during labour to prevent neonatal GBS?
- GBS positive swabs
- A UTI caused by GBS during this pregnancy
- Previous baby with GBS infection.
- Pyrexia during labour
- Labour onset <37 weeks
- Rupture of membranes >18 hours
81
What are some possible sensitising events?
- Ectopic pregnancy
- Evacuation of retained products of conception and molar pregnancy
- Vaginal bleeding < 12 weeks, only if painful, heavy or persistent
- Vaginal bleeding > 12 weeks
- Chorionic villus sampling and amniocentesis
- Antepartum haemorrhage
- Abdominal trauma
- External cephalic version
- Intra-uterine death
- Post-delivery (if baby is RhD-positive)
82
When is Anti-D given to previously non-sensitised women who have not had a sensitising event?
-all non-sensitised RhD -ve women @ 28 and 34 weeks
