Obs & Gynae Peer Teaching Flashcards
Describe the cardiovascular system changes seen in pregnancy
- Increased plasma volume, cardiac output, stroke volume, heart rate
- Decreased serum albumin concentration + serum colloid osmotic pressure
- Increased coagulation factors and fibrinogen
- Compression of the Inferior Vena Cava by the uterus
Describe the changes seen in the kidneys during pregnancy.
- Increases in renal blood flow + glomerular filtration rate
Describe the changes seen in the liver during pregnancy.
Changes in Oxidative liver enzymes, such as cytochrome P450
Describe the changes seen in the lungs in pregnancy.
- Increase in tidal volume and minute ventilation
Describe the changes seen in the stomach and intestines during pregnancy.
- Nausea and vomiting
- Delayed gastric emptying
- Prolonged small bowel transit time
- Gastrointestinal reflux
List some causes of an Antepartum Haemorrhage.
- Placental Abruption
- Placenta Praaevia
Rare:
- vasa praevia
- uterine rupture
- 50% = unknown
- Consider domestic violence
Describe the presentation of a woman with placental abruption.
- Painful bleeding
- PV loss doesn’t correlate with severity (can be concealed)
- Patients may be in shock with a tender, firm uterus (‘woody hard’)
- Labour may ensue
- Foetal distress
Describe the presentation of a woman with placenta praevia.
- Painless bleeds (increasing severity and frequency)
- Foetus is often breech/transverse
- NEVER do a Vaginal Examination
What investigations should you order for a ?Placental abruption / ?Placenta praevia?
- FBC, U+E, Clotting, Group + Save
- USS
- CTG
Describe the Management of a patient with ?Placental abruption / ?placenta praevia.
- Admit (until delivery if praevia)
- Resuscitation
- Steroids
- Anti-D (if Rhesus negative_
- C-section
Define ‘placenta accreta’.
Placental villi are attached to the myometrium.
Normal = attached to decidua basalis
Define ‘placenta increta’.
Placental villi invaded into >50% of the myometrium.
Define ‘placenta percreta’.
Placental villi pass through the whole myometrium up to the serosa, potentially involving other viscera (bladder or bowel).
List some risk factors for placenta accreta.
- Uterine surgery (eg. C-section or Myomectomy)
- Repeated surgical termination of pregnancy
What is ‘Vasa praevia’?
Occurs when fetal vessels run in membranes below the presenting fetal part, unsupported by placental tissue or umbilical cord.
How might vasa praevia present?
- PV bleeding after rupture of fetal membranes follow by rapid fetal distress (from exsanguination).
List some risk factors for Vasa Praevia.
- Low-lying placenta
- Multiple pregnancy
- IVF pregnancy
- Bilobed placenta
List some gynaecological causes of an Antepartum Haemorrhage.
- Cervical polyps
- Cervical cancer
Describe a ‘threatened’ miscarriage.
- Painless bleeding before 24 weeks
- Cervical os = Closed
- Sonography
- Consider Anti-D for RhD -ve women after 12 weeks.
- Affects 1 in 4 pregnancies.
Describe a ‘missed’ or ‘delayed’ miscarriage.
- Dead foetus / empty uterus before 20 weeks
- Cervical os is closed
- Can be bleeding, but usually without symptoms.
What is the treatment for a ‘missed’ / ‘delayed’ miscarriage?
- Pain relief
- Anti-emetics
- Vaginal misoprostol
Describe an ‘inevitable’ miscarriage.
- Heavy bleeding with clots and pain
- Cervical os is open
Describe an ‘incomplete’ miscarriage.
- Not all products of conception have been expelled
- Pain + vaginal bleeding
- Cervical os is open
Describe the 3 ways in which an incomplete miscarriage could be managed.
- Expectant
- Medical
- Surgical
Describe ‘Expectant’ management of an incomplete miscarriage.
- Repeat pregnancy test in a week
Describe ‘Medical’ management of an incomplete miscarriage.
- Vaginal Misoprostol
- Pain relief
- Anti-emetics
Describe ‘Surgical’ management of an incomplete miscarriage.
- Vacuum aspiration
(under general anaesthetic) - Anti-D
Describe Stage 1 of Labour.
- From onset until cervix is fully dilated
- Latent phase: 0-3cm dilation
- Active phase: 3-10cm, at 1cm/hour
What interventions might be offered during Stage 1 of labour?
- Membrane sweep (done in the community)
- Prostaglandin pessary (done as an inpatient)
- Amniotomy (not routine)
- Oxytocin (offered for delayed 1st stage)
Describe Stage 2 of Labour.
- From full dilation to delivery of the foetus
- Lasts approx 1 hour.
If Stage 2 of Labour is delayed, what interventions can be offered?
- Ventouse
- Forceps
- C-section
What are the options for presentation of the foetus?
- Brow presentation
- Face presentation
- Compound / shoulder presentation
- Transverse lie
- OP / OT position
Which conditions are absolute contraindications to VBAC (Vaginal Birth after Caesarean)?
- Placenta praevia
- Vasa praevia
- Cephalopelvic disproportion
What should you do if a patient has shoulder dystocia?
- McRoberts -> spread legs + push
- Internal manœuvres (Wood screw + Zavanelli)
- Surgical rescue: Clavicular fracture, Symphysiotomy, hysterotomy
What position should a patient be in if they have a cord prolapse?
- On all fours
- Push foetus up
- C-section ASAP
Describe Stage 3 of Labour.
- From delivery of foetus to delivery of the placenta
Describe Active management of stage 3 of labour.
- Oxytocin
- Cord clamping after 1 minute
- Cord traction
Describe Physiological management of Stage 3 of Labour.
- Clamp cord after pulsation stops
When is Stage 3 of Labour considered to be ‘prolonged’?
- If it lasts over 30 minutes with active management
- If it lasts over 60 minutes with physiological management
- > VE with analgesia -> ?manual removal
Define ‘Post Partum Haemorrhage’.
> 500ml blood loss (1000ml for C-section)
- Primary: within the first 24 hours
- Secondary: 24hrs - 6 wees post partum
What the the causes of a Primary PPH?
- Tissue
- Tone (Oxytocin reduces incidence)
- Trauma
- Thrombin
Rare:
- Cervical tear
- High vaginal tear
- Uterine rupture
Describe the management of a Post partum haemorrhage.
- ABCDE!
- Removal of placenta if retained
- If uterine atony -> PGF2a into the myometrium
- Rescue methods:
> Rusch balloon
> Brace suture
> Hysterectomy
