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Obs and gynae > Obs - pregnancy and labour > Flashcards

Obs - pregnancy and labour Flashcards

1
Q

What are the 3 newborn screening programmes?

A

Newborn blood spot - CF, CHT, SCD, IMD (maple syrup, MCADD)
Newborn hearing test
Newborn and 6-8 week infant physical examination

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2
Q

What are the 3 antenatal screening programmes?

A

Fetal anomaly screening programme - tristomies (10-14 and 20+6 weeks)
Infectious diseases
Sickle cell and thalassaemia

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3
Q

When does it count as ‘active labour’?

A 
4cms onwards 
Regular, progressive contractions 
Oxytocin released = ripening of cervix = dilation
Should progress
-nulliparous 0.5-1cm/h
-multiparous 1-2cm/h
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4
Q

What is effacement?

A

starts in fundus
shortening/retraction of muscle fibres and amplitude increases as labour progresses
fetus moves down to press in cervix

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5
Q

What is involved in latent phase of labour?

A 
irregular contractions 
mucoid plug shown 
lasts 6 hours - 2-3 days
-nulliparous about 18h
-multiparous about 12h
cervix thinning
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6
Q

What are the hormones for communication between blastocyst and endometrium?

A

human chorinic gonadotrophins, progestins, oestrogens

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7
Q

What causes myometrial contraction in parturition?

A

Increase in calcium due to oxytocin releasing calcium from intracellular stores

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8
Q

What causes myometrial contraction in parturition?

A

Increase in calcium due to oxytocin releasing calcium from intracellular stores

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9
Q

What conditions are linked to failed endovascular invasion?

A

premature birth, fetal growth restriction, recurrent miscarriage, placental abruption, pre-eclampsia

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10
Q

How do you tests/treat/prevent rhesus haemolytic disease?

A

Test at booking, 28 and 34 weeks
Assess fetal anaemia with MCA doppler
anti-D immunoglobulin
Kleihauer test

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11
Q

Who is at risk of rhesus haemolytic disease?

What is it?

A

Rhesus - mum with rhesus + baby

Maternal antibody response mounted against fetal red blood cells

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12
Q

What are some key factors that can determined from a CTG? And what is the full name?

A 
Dr. C Bravado - cardiotography
Determine risk 
Contraction rate 
Baseline rate - 110-160
Variability - >5bpm, acceleration and deceleration 15bpm for 15 seconds 
Accelerations 
Decelerations 
Overall Assessment
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13
Q

What is gestational trophoblastic disease?

A

abnormal cells or tumours that start in the womb from cells that would normally develop into the placenta

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14
Q

What is the difference between complete and partial molar pregnancy?

A

Complete - empty ovum fertilised with sperm and it multiplies
Partial - ovary fertilised by 2 sperm

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15
Q

How would you test for molar pregnancies?

A

US - snowstorm appearance inside uterus

high beta hCG

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16
Q

How would you treat molar pregnancies?

A

Surgical removal

Methotrexate but only if beta hCG fails to fall satisfactorily

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17
Q

What is hyperemesis gravidarum?

A

excessive vomiting, dehydration and ketosis

can lead to weight loss and faintness

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18
Q

How would you treat hyperemesis gravidarum?

A

bland, small meals and oral rehydration

antiemetics, IV rehydration nutritional support, thymine (to prevent Wernicke’s), folic acid

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19
Q

What are the risk factors of hyperemesis gravidarum?

A

primigravida, multiple pregnancy, obesity, personal or family history, history of eating disorder

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20
Q

What are the differential diagnosis of hyperemesis gravidarum?

A

Infections, GI problems, metabolic problems, drugs, gestational trophoblastic disease

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21
Q

How common are ectopic pregnancies and what are the risk factors?

A

1% births
Most are in the fallopian tubes
IVF, prior ectopic (10% risk), tubal injury or surgery, PID, endometrial injury, IUD, endometriosis, placenta pravida, uterine abnormalities, smoking, increased maternal age, history of abortion, chlamydia, fibroids, Asherman’s

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22
Q

What are the symptoms of ectopic pregnancy?

A 
one sided lower abdo pain 
abdominal tenderness
vaginal bleeding 
cervical excitation on examination 
palpable adnexal mass
shoulder tip pain
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23
Q

How would you test for an ectopic pregnancy?

A

beta hCG is rising slower than expected or is static
progesterone lower than expected for gestational age
transvagainal US
Diagnostic laparoscopy

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24
Q

How would you treat an ectopic pregnancy?

A

Medical - methotrexate (if small) it targets rapidly proliferating trophoblast
Surgical - salpingotomy (removal) and ectopic gestation removed
salpingostomy if possible (incision)

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25
Q

How would you treat a delayed miscarriage?

A

mifepristone - anti-progesterone

misoprostol - synthetic prostaglandin so a uterine stimulant

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26
Q

What happens to hCG in a miscarriage?

A

Drop or stagnation in hCG

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27
Q

What is placenta praevia?

What are the classifications?

A

low lying placenta - partial/minor or major
should be at least 20mm from os
Marginal - close to OS (2cm)
Major - placenta lies over OS

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28
Q

What should you avoid in placenta praevia?

A

do not do a vaginal exam

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29
Q

What is placenta accreta?

How would you test and treat it?

A

when placenta penetrates decidua bascalis through myometrium
USS, MRI
Aim to deliver by 35-36wks, CS (+/- hysterectomy)

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30
Q

What is vasa praevia?

A

fetal vessels crossing through membranes over internal os and below fetal presenting part, unprotected placental tissue or umblicial cord
fetal vessels run in membrane below presenting fetal part
major fetal risk

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31
Q

What is placental abruption?

A

premature seperation of placenta from uterine wall

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32
Q

What are the types of placental abruption? and the symptoms

A 
concealed or revealed 
Sudden onset, mild lower abdominal pain with uterine tenderness, woody-hard, tense, uterus, Bleeding
can cause premature labour
fetal distress 
maternal shock due to blood loss
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33
Q

What is the difference between primary and secondary and minor and major postpartum haemorrhage?

A

primary - within 24 hours of delivery less than 500 mls
secondary - post 24 hours, up to 12 weeks post delivery
Minor 500-1000ml
Major >1000ml

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34
Q

What are the causes of post partum haemorrhage?

A

Tissue - partial placental loss
Tone - ensure uterus is contracted (not contracting = uterine atony)
Trauma - look for tears
Thrombin - check clotting

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35
Q

How would you treat eclampsia?

A

magnesium sulphate

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36
Q

What is antiphospholipid syndrome?

A

increased aPL antibodies to phospholipid related proteins
Autoimmune
Causes recurrent thrombosis and pregnancy morbidity

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37
Q

How would you treat antiphsopholipid syndrome?

A

aspirin 75mg

low molecular weight heparin

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38
Q

Name 3 risk factors for miscarriage

A

Early <12 weeks
Causes - chromosomal abnomaly antiphospholipid syndrome
Late >12
causes - cervical incompetence

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39
Q

How would you manage pre-eclampsia?

A 
monitoring - creatinine, serum urate, CXR, U&amp;E, APTT, fibrinogen, bilirubin
assess if indication for delivery 
decreased BP - labetalol, hydralazine 
IV magnesium sulphate
Steroids at 34 weeks
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40
Q

What is the definition of pre-eclampsia?

What are the symptoms?

A 
gestational hypertension 
>140/ or >/90 after 20 weeks gestation
proteinuria 
visual disturbances, headache, RUQ/epigastric pain
facial oedema, brisk hyperreflexive
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41
Q

What are 3 pre-existing medical conditions altered by pregnancy?

A

asthma - exacerbations in 3rd trimester
cardiac e.g. mitral stenosis, which are worsened by increased CO
DM - high glucose = teratogenic
renal
epilepsy - increased frequency of seizures in 25-33%

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42
Q

Name 3 causes of small babies

A

small for gestational age
- constituionally, infection, chromosomal abnormalities
growth restriction - smoking, pre-eclampsia

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43
Q

What are the 3 measures of fetal growth?

A

abdominal circumference is the best measure
head circumference
leg length

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44
Q

What are 3 pregnancy specific conditions?

A

pre-eclampsia, acute fatty liver, obstetric cholestasis, gestatinal DM, anaemia

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45
Q

What is the difference between direct and indirect causes of maternal death? Name 3 causes of maternal death

A

thromboembolism, haemorrhage, sepsis, pre-eclampsia
Direct - death resulting from obstetric complications of pregnancy, labour
Indirect - death resulting from pre-existing disease/disease that developed in pregnancy

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46
Q

What are the common maternal mental health problems and their commonality?

A

post-partum depression 10%
post-partum psychosis 1-2/1000
PTSD 3% full, 33% some symptoms

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47
Q

What are some red flags in maternal mental health?

A

recent change in mental state/new symptoms
new thoughts/acts of violent self-harm
new/persistent expressions of incompetency as mother/estrangement

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48
Q

Trisomy triple test - when it is done and what is tested for?

A 
Down, Patau, Edwards 
10-14 weeks 
increased nuchal tranlucency 
Beta hCG (high)
PAPP-A (low)
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49
Q

Trisomy quadruple test - when is it done and what is tested for?

A

Down, patau, Edwards
14-20 weeks
Beta hCG & Inhibin A (high)
alpha feroprotein & unconjugated estrodial (low)

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50
Q

What should be routinely offered to women with a very high BMI?

A

post-natal thromboprophylaxis, pre-eclampsia screening, obstetric anaesthetist referral, actively manage 3rd stage of labour due to risk of PPH, Vit D daily

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51
Q

What is a missed miscarriage?

A

loss of pregnancy without passing contents of conception or bleeding

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52
Q

What structures does an episitomy involve?

A

bulbospongiosus, superficial transverse perineii, vgainal mucosa and perineal membrane
Avoid ischiocarvernosus

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53
Q

What happens to bloods in DIC (disseminated intravascular coagulation)?

A

increased prothrombin, aPTT and bleeding time

decreased platelets

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54
Q

What are hydatidiform moles?

A

Benign trophoblastic tumour - genetically abnormal, large and small villi scalloped outlines, trophoblastic hyperplasia

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55
Q

What are the bony landmarks of pelvic outlet?

A

pubic arch, ischial tuberosities, coccyx

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56
Q

When does an embryo become a foetus?

A

8 weeks

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57
Q

At what point is the fetal heartbeat detectable?

A

8 weeks

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58
Q

When is methotrexate to treat ectopic pregnancy contraindicated?

A

rupture, mass > 3.5 cm, foetal cardiac activity, bhCG >6000

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59
Q

What other medication can be used for direct injection, other than methotrexate to treat ectopic ?

A

potassium chloride

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60
Q

What is the normal weight of a baby?

A

5lbs8 - 8lbs13

2500-4000g

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61
Q

What are 2 acute and 2 long terms risks of IUGR?

A

Acute - stillbirth, prematurity, nectrotising enterocolitis, hypoxic brain injury, retinopathy of prematurity
Chronic: CVD, T2DM, small kidneys, low IQ, impaired visuomotor development

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62
Q

What are two acute and 2 long term risks of macrosomnia?

A

Acute: shoulder dystocia, clavicular fracture, long labour, hypoxia
Long term: obesity, hypoglycamia, DM, hypertension, metabolic syndrome

63
Q

What are two maternal risks of macrosomnia?

A

Perineal tears, PPH, uterine rupture

64
Q

When is labour induced for IUGR?

A

37 weeks if normal doppler

65
Q

What are the risks of macrosomnia?

A

cephalopelvic disporportion, shoulder dystocia

66
Q

How are macrosomnia risks managed?

A

US at 38 weeks, 40 weeks

consider instrumental delivery or C-section

67
Q

What test do smoking mothers take?

A

Carbon monoxide test

68
Q

What blood test would be raised in pre-eclampsia?

A

uric acid

69
Q

What blood test is predictive for small-for-gestational age?

A

PAPP-A

70
Q

When is SFH (symphisis-fundal height) less useful?

A

BMI>35, large fibroids, polyhydraminos

71
Q

What screening tests should be undertaken for an SGA baby at 18 weeks?

A

detailed anatomical survey, karyotype, serology (CMV, toxoplasmosis, syphillis), malaria

72
Q

What hormone causes cervical dilation?

A

oxytocin

73
Q

What is the purpose of oestrogen during labour?

A

inhibit progesterone, prepare smooth muscle

74
Q

What is the purpose of prostaglandins during labour?

A

trigger labour, effacement and dilation, stimulate contractility, vasoconstriction and vasodilation, close ductus arteriosus
Decrease cervical resistance (cervical ripening) and cause release of oxytocin from post pituitary

75
Q

What is the purpose of beta endorphins in labour?

A

endogenous pain relief

76
Q

What are the 3 Ps of labour?

A

Powers, passage, passenger

77
Q

What are the primary powers?

A

Involuntary contractions 3-6 per minute, 4=labour, 40-60 seconds long

78
Q

What are the secondary powers?

A

voluntary bearing down in reponse to cervical stretching, causing contraction of abdominal muscles and diaphragm to increase intraabdominal pressure

79
Q

What are the 3 sections of the bony pelvis?

A

inlet/brim, midpelvis/cavity, outlet

80
Q

What is the most common and birth-friendly subpubic angle/pubic arch?

A

Gynaecoid

81
Q

What are the components that make up the passenger?

A

head size, presentation, lie, attitude, position, station, engagement, placenta

82
Q

What is the best position for labouring women?

A

changing, upright, lateral, all fours

83
Q

What are the different types of presentation?

A

Cephalic - head first
Breech - feet or sacrum first
Shoulder

84
Q

What is the definition of presentation?

A

foetal body part entering pelvic inlet first

85
Q

What is the definition of lie?

A

Angle of fetal spine in relation to maternal spine

86
Q

What are the two types of lie?

A

longitudinal/vertical lie - parallel

transverse/horizontal/oblique lie - right angle

87
Q

What is the defintion of fetal attitude?

A

position of fetal body parts in relation to each other

88
Q

What is general flexion attitude?

A

rounded back, chin on chest, thighs on abdomen, legs flexed, arms crossed

89
Q

What is position of fetus?

A

Relation of presenting part to pelvic inlet?

90
Q

What is ROA position of fetus?

A

occiput at right anterior part of maternal pelvis

91
Q

What is station of a fetus?

A

relation of presenting part to ischial spines/degree of descent through birth canal

92
Q

What is engagment?

A

The largest transverse diameter of the presenting part has passed through the maternal pelvic inlet

93
Q

What is the definition of failure to engage?

A

> 18-24 hour regular contractions without delivery

94
Q

What should FTP be suspected and diagnosed in primigravid?

A

Suspect with cephalopelvic disproportion, weak contractions and high BMI
1 hour, diagnose at 2 hours, baby born in 3

95
Q

When should FTP be suspected and diagnosed in multiparous?

A

30 mins active labour, diagnose after 1, baby born within 2

96
Q

What are the conditions for instrumental delivery?

A

FORCEPS - fully dilated cervix, occipitoanterior postion, ruptured membranes, cephalic presentation, engaged presenting part, pain relief, sphincter empty, no signs of cephalopelvic disproportion

97
Q

What is flexed and extended breech?

A

general flelxion in longitudinal lie with head up, extended= feet extended towards head

98
Q

What is footling breech?

A

one foot out - highest risk of cord prolapse

99
Q

What is occipito-transverse, occipitoanterior or occipitoposterior?

A

transverse - occiput to one side - fetal head usually engages in this position
anterior - back to back
post - back to front (best)

100
Q

What score is used to decide whether to induce labour?

A

Bishop score - cervical dilation, effacement, consistency and position, foetal station

101
Q

What are the first and second line inductions?

A

First - ARM

Second - oxytocin induction with syntocinon or pitocin

102
Q

How does MAS present?

A

meconium stained liquor, foetal distress, airway obstruction, surfactant dysfunction, inflammation, pulmonary oedema, bronchoconstriction

103
Q

What are some risk factors for MAS?

A

post-maturity, placental insufficiency, maternal hypertension, oligohydramnios, smoking, cocaine, older age

104
Q

How do you treat MAS?

A

emergency C section if fetal blood <7.21, bradycardia for 5 minutes, suction minimal (do if apgar <5 or meconium visible in mouth)
observe for signs of respiratory distress

105
Q

How do you reduce the risk of developing pre-eclampsia?

A

Aspirin from week 12 of pregnancy

- before this carries miscarriage risk

106
Q

Why would you give prostaglandins during labour?

A

To dilate cervix enough to break waters

107
Q

Why would you give syntocinon during labour?

A

an articifical oxytocin

  • accelerates labour if not progressing at 1cm/hour
  • must have CTG on as it can cause hyperstimulation
108
Q

What conservative measures would you take if a labour was not progressing?

A

move position and get woman mobile, analgesia, rehydration, ARM (releases prostaglandins)

109
Q

Which foetal position has the highest risk of cord prolapse?

A

Footling breach

- cord prolapse = get help and aim for instrumental delivery as quickly as possible

110
Q

What are the normal engagement and birth positions?

A

Engagement - occipito-tranvserse

Occipito-anterior

111
Q

Name 2 causes of cervical shock

A

uterine inversion when trying to remove placenta

miscarriage products stuck in cervix

112
Q

How should active labour progress?

A

contractions of 3-4/10 minutes
1/2-1 cm per hour - nulliparous
1-2cm/hr multiparous
- failure to progress if <2cm in 4h

113
Q

How long can membranes be ruptured in term babies before needing action?

A

24 hours

114
Q

If meconium presents during labour what should first course of action be?

A

CTG - has high sensitivity and low specificity

115
Q

What are 3 causes that can cause antepartum haemorrhages?

When does this occur?

A

Bleeding from genital tract after 24 weeks, prior to labour
In third trimester
miscarriage, placenta praevia, placental abruption, vasa praevia, uterine rupture, trauma, infection, show, genital tract pathology

116
Q

What are 3 symptoms of hypovolaemic shock?

A

tachycardia, postural hypotension, tachypnoea, fatigue, blurred vision, cold, clammy skin

117
Q

What are some risk factors of placental abruption?

A

History of it, hypertension, trauma, smoking, cocaine, PROM, pre-eclampsia, IUGR, rapid uterine decompression

118
Q

What are the symptoms of placenta praevia?

A 
Sudden onset, prior to ROM
no pain 
bright red spots, stops spontaneously after 1-2 hours
fetal malpresentation
do diagnostic US
119
Q

What are some risk factors of placenta praevia?

A

History of it, C-section or PP, multiparity, multiple pregnancy, older mother, smoking, short intervals, miscarriage

120
Q

What are the symptoms of vasa praevia?

A

Sudden onset after ROM of APH
no pain
foetal blood, foetal distress

121
Q

What are the symptoms of uterine rupture?

A

sudden severe abdominal pain during labour

122
Q

What are some risk factors for post-partum haemorrhage?

A

obesity, fever during pregnancy, antepartum haemorrhage, heart disease
C-section, pre-eclampsia, instrumental delivery, induction of labour, general anaesthesia, past surgery, previous PPH, grand muliparity, maternal age >40, multiple pregnancy, polyhydramnios, abruption placenta praevia, pre-existing anaemia, retained placenta, big baby, prolonged labour, fast labour

123
Q

What are some risk factors for placenta accreta?

A 
previous uterine surgery 
placenta praevia or low lying placenta 
maternal age >35
previous childbirth
C-section
124
Q

What is the different between placenta increta and percreta?

A

Increta - invade uterine muscles

percreta - through uterine wall

125
Q

What drug can be given to increase tone or contraction of uterus?

A

ergometrine

126
Q

How do you diagnose labour?

A

painful, regular, progressive uterine contractions
cervical dilation and effacement
- usually show (pink/white mucus plug) and/or ROM

127
Q

What can cause abnormal 1st stage and their treatment?

A

*Inefficient uterine contractions - common in nulliparous
Treat with amniotomy and syntocinon
*Cephalopelvic disproportion - common in multiparous, problem with passenger or passage, can lead to secondary arrest
Treat - C-section

128
Q

How would you treat prolonged 2nd stage?

A

assisted vaginal delivery or C-section

129
Q

How should you manage 3rd stage of labour?

A

Allow cord to stop pulsating before clamping and cutting, placenta delivered by maternal effort alone
Assist with IM syntocinon, deferred clamping/cutting or cord, controlled cord traction

130
Q

What is gestational diabetes?

How do you diagnose?

A

carbohydrate intolerance diagnosed in pregnancy
- due to change in carb metabolism and antagonistic effects of hPL, progesterone and cortisol
OGTT -oral glucose tolerance test - done at booking and 24-28 weeks
Positive is >7.8mmol/L

131
Q

What are some risk factors for gestational diabetes?

A

BMI >30
previous macrosomic baby
previous GDM - themselves or first degree relative

132
Q

What are the effects of GDM?

A

increased risk of DKA, hypo, and progression of retinopathy/nephropathy
effects on pregnancy - SMASH
shoulder dystocia, macrosomnia, amniotic fluid excess, still birth, HTN/hypoglycaemia

133
Q

How would you treat GDM?

A

insulin, metformin, glibenclamide
must give folic acid as there is increased risk of neural tube defects
Fetal monitoring - US 2-4 weekly, fetal echo 20-24 weeks
Manage labour with insulin slide scale + IV dextrose
Postpartum - Breastfeed, monitor fetal BG, stop insulin and have OGTT 6 weeks postpartum

134
Q

What are the 3 hypertensive disorders of pregnancy?

A

chronic hypertension (before preganancy)
Pregnancy induced hypertnesion
pre-eclampsia - hypertension and proteinuria

135
Q

What is the pathophysiology of pre-eclampsia and risk factors?

A

failure of trophoblastic endovascular remodeling, spiral arteries remain high-resistance causing placental ischaemia
NOPE 2 FAT
nulliparity, obesity, previous history, extremes of age, 2 babies, family history, autoimmune, twins

136
Q

What are complications of pre-eclampsia?

A

eclampsia, headaches, visual disturbances, HELLP (haemolysis, increased ALT and AST, lowered platelets)
renal and liver failure, stroke, placental abruption
IUFD, preterm, IUGR, oligohydramnios, pulmonary oedema

137
Q

How do you manage placenta praevia?

A

avoid sex and intense exercise
Admit for monitoring until delivery - IV, Group and Save
Deliver by elective section at 37-39 weeks
Steroids between 34-35 weeks

138
Q

How do you treat placental abruption?

A

immediate delivery

emergency CS +resus

139
Q

How could you surgically manage PPH?

A

Rusch/Bakri balloon, B-lynch suture, ligation of uterine arteries, ligation of internal iliac arteries, hysterectomy, intervetnional radiology

140
Q

What drugs could you give to manage PPH?

A

oxtocyin (contraction), ergometrine (increases tone and contraction), carboprost, misoprostol, tranexamic acid (stabilises clots)

141
Q

What are some conservative ways to manage PPH?

A

massage uterus
empty catheter
bimanual compression

142
Q

What are the types of placental accreta?

A

Accreta - chorionic villi attach to myometrium
Increta - chorionic villi invade into myometrium
Percreta - chorionic villi invade through myometrium

143
Q

How would you prepare for delivery with placenta praevia or accreta?

A

Elective CS 36-38 weeks
Consent to all possible interventions
consultant obstetric/anaesthetic input
anticipate major haemorrhage, have blood available and cell salvage, HDU bed

144
Q

What is twin-to-twin transfusion and what type of twins would have it?

A

when one twin receives a lower blood supply and it has slower growth rate
monozygomotic monochoronic diamniotic

145
Q

What are the blood tests done at booking?

A

HIV, sphyillis, rubella, hep B

146
Q

How to manage rupture of membranes early in pregnancy?

A

US
infection markers
observation

147
Q

How do you test for pulmonary embolism in pregnant women?

A

ventilation/perfusion scintigraphy

148
Q

What are the symptoms of rupture ectopic pregnancy?

A

fainting, pain, high hCG, free fluid in pouch of Douglas and no uterine pregnancy

149
Q

How do you manage shoulder dystocia?

A

emergency buzzer

McRobert’s position - hyperflexing mother’s legs tightly to abdomen

150
Q

How to manage PPH?

A 
Get help 
massage uterus
empty bladder 
bimanual compression 
review causes - 4Ts
mosprostol PR
theatre
151
Q

What is Sheenan’s?

A

hypopitutarism caused by severe hypertension (necrosis of pituitary gland) e.g. PPH

152
Q

What is cytomegaly virus? What are the symptoms?

A

Usually asymptomatic
deafness, IUGR, thrombocytopenia
newborn hydrocephalus, chorioretinitis, convulsions, death

153
Q

How would you monitor the child of a mother with uncontrolled diabetes?

A 
glucose tolerance test 
urinalysis 
uterine arterial doppler 
blood glucose 
BP
154
Q

What do progestins do?

A

released from corpus leutum and placenta
prepares endometrium and uterus for implantation
lowers oxytocin

Obs and gynae (8 decks)

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