Obs stuff you forget Flashcards
5 High risk indications for aspirin in pregnancy (i.e. only need one of to offer aspirin)
- Hypertensive disease during previous pregnancy
- CKD
- AID such as SLE or APS
- Type 1 or 2 DM
- Chronic HTN
6 moderate risk indications for aspirin in pregnancy (i.e. need 2+ of to offer aspirin)
Nulliparous
Age >40
Pregnancy interval >10yrs
BMI >35 at booking
FHx of pre-eclampsia
Multiple pregnancy
S/S of pre-eclampsia
Usually asymptomatic
Visual change e.g. blurred vision, flashing lights
Headaches (esp. frontal)
Epigastric/RUQ pain (liver involvement and capsule distension)
More severe oedema, neuro Sx (facial spasm, retinal vasospasm, ankle clonus and hyperreflexia). Also foetal GR.
When is aspirin started in patients at risk of pre-eclampsia?
12 weeks until delivery.
Describe delivery Mx of pre-eclampsia (</> 34wks)
Delivery indicated if clinical deterioration or maternal Cx
<34wks or severe IUGR - CS
>34wks - induce w/ prostaglandins, epidural helps avoid pushing.
Oxytocin > ergometrine for 3rd stage as latter can increase BP.
How long should MgSO4 be continued after delivery/last seizure?
24hrs after delivery or last seizure
If fails twice, diazepam.
Signs and Tx of MgSO4 toxicity
Px - confusion, loss of reflexes, resp depression and hypotension
Tx - calcium gluconate.
When, who and how do you screen for GDM?
GTT at 24-28wks (those with previous DM screened earlier at booking)
Who:
- Previous macrosomia (>4.5kg) or unexplained stillbirth
- 1st degree relative w/ DM
- BMI >30
- Ethnic minority
- Pregnancy RF - polyhydramnios, persistent glycosuria
Can you give statins in pregnancy?
Nope
Mx of GDM (fasting glucose </> 7mmol)?
NB folic acid should be 5mg
If fasting glucose <7mmol/L (but above 5.6 warranting GDM diagnosis), 2 weeks diet/exercise. If fails, meftormin started (Glibenclamide if refused)
If fasting >7mmol immediately start insulin +/- metformin
Aspirin from 12wks as high risk pre-eclampsia.
Resp - what happens to TV, RR, TLC, RV and ERV in pregnancy
Tidal volume increases by 40%
RR - no change
TLC decreases due to uterus pushing on diaphragm.
RV decreases and ERV decreases to cause the above.
Which AEDs safe in pregnancy?
Lamotrigine > Levetiracetam.
Folic acid 5mg and Vit K offered
What do LFTs show in obstetric cholestasis?
High ALT, AST and GGT
PT may be prolonged due to reduced Vit K
Raised bile acids (bilirubin raised)
NB ALP normally increases in pregnancy because the placenta produces it
Describe what opiates, cocaine, ecstasy, BDZs and cannabis do in pregnancy
- Opiates - not teratogenic but associated with preterm, IUGR, stillbirth, developmental delay. Stay on methadone
- Cocaine - esp associated with IUGR and placental abruption.
- Ecstasy - teratogenic, cardiac defects and gastroschisis
- BDZ - facial clefts and neonatal hypotonia
- Cannabis - IUGR and development problems
Give the ABRUPTION mnemonic for abruption
Abruption previously
Blood pressure (HTN/Pre-eclampsia)
Ruptured membranes (PROM or prolonged)
Uterine injury (abdo trauma)
Polyhydramnios
Twins (multiple preg)
Infection (chorioamnionitis)
Older age (>35)
Narcotic use (cocaine, smoking)
How is placental abruption diagnosed?
Clinically. Ix help establish severity (CTG, US, bloods)
How is placental abruption managed?
Admission if pain and uterine tenderness (even if no bleeding)
Resuscitate - IV fluids.
Steroids if <34wks, opiate analgesia, anti-D.
If foetal distress, urgent CS required. If >37+ but no distress then IOL with amniotomy. If <34wks steroids and monitor on antenatal ward.
RF for praevia
Previous CS / uterine scarring
Smoking, older maternal age, fibroids, IVF.
Should you do vaginal exam in placenta praevia?
NO! Can provoke massive bleeding. Generally 20wk anomaly scan <2cm from internal os likely to be praevia at term.
If low lying at 20wks, repeat at 32wks and 36 (unless corrected).
CS by senior. Main Cx is haemorrhage - blood transfusions.
Should you do vaginal exam in vasa praevia?
NO! Contraindicated due to risk of rupturing exposed vessels.
Vasa praevia triad of presentation, Ix and Mx.
1) Presents at rupture of membranes
2) Moderate painless bleeding (foetal bleeding)
3) Foetal bradycardia/severe foetal distress
Vasa praevia due to velamentous insertion (vessels attach to membrane not placenta or accessory lobe).
Rarely diagnosed on US.
Tx w/ corticosteroids and CS but often not fast enough.
When is labour diagnosed?
Painful, progressive uterine contractions are progressive and accompany dilatation (>4cm) and effacement of the cervix.
Describe 7 steps of labour
Hint EICREDD
Engagement and descent (head enters in OT position, with increasing flexion)
Internal rotation to OA (at level of ischial spines)
Crowning (head extends whilst delivered)
Restitution (head rotates so head straight)
External rotation (shoulders rotate to OT kind of position, so you see the head rotate)
Delivery of anterior shoulder
Delivery of posterior shoulder
What are 3 stages of labour (2 parts of first and second stage - hint LAPA)
First stage - diagnosis of labour until cervix is dilated by 10cm (fully dilated)
- Latent phase - start to first 3cm. May take hours/days.
- Active phase - 3cm to 10cm. Usually 1cm/hr in nulliparous or 2cm/hr in multiparous, however <0.5cm/hr is unacceptable (augment)
Second stage - full dilatation of cervix to delivery.
- Passive - full dilatation until head reaches pelvic floor and desire to push.
- Active - mum is pushing. 40mins nulli or 20mins multi (>1hr = unlikely to spontaneously deliver)
Third stage - delivery of placenta, usually lasts 15mins and can lose 500mL of blood.
S
What is pyrexia in labour?
> 37.5C.
Take vaginal, urine and blood cultures.
Slow progression in labour - inefficient uterine power, describe:
- Aetiology
- Treatment
Common in nulliparous and induced. Also more anxious.
Treated in nulliparous 1st stage:
- Augmentation w/ ARM
- If fails over 2hrs, IV oxytocin if foetus safe.
- CS if foetal distress or fails within 4hrs.
In 2nd stage, oxytocin can help or instrumental delivery (active)
Multiparous 1st stage - less likely to give oxytocin because inefficient uterine power less likely to be the cause, and pelvic capacity proven. Also more likely to rupture Augmentation w/ oxytocin must be preceded w/ exclusion of malpresentation. May do CS.
How will labour be if OP Px? How is it managed?
Longer, more painful, backache, early desire to push.
If labour progresses normally, no Mx required.
If labour progress slow, augmentation used. May require CS.
Prolonged 2nd stage - instrumental delivery.
How is OT managed in 2nd stage?
NB OT is normal finding in first stage. It is associated with poor powers.
Rotation w/ traction required for delivery to occur, usually w/ ventouse.
Do you stink?
Yes
How is brow and face presentation usually managed?
Brow - CS required.
Face - can do vaginal a lot but CS often required.
Describe indications for IOL
- Foetal (x4)
- Foetal maternal (x2) - where both mum and foetus benefit
- Maternal (x1)
- Routine induction
Foetal - Prolonged pregnancy, suspected IUGR/compromise, antepartum haemorrhage, PPROM
Materno-foetal - pre-eclampsia, maternal disease e.g. DM
Maternal - in utero death.
Routine - current trend
What Bishops scores = spontaneous labour (un)likely?
8+ (/13) - spontaneous labour likely
<8 means may need to induce labour.
It is based on favourability of cervix - consistency, effacement, dilatation, station of foetus.
Algorithm for inducing labour
Adjunct - membrane sweep - more of an adjunct rather than actual IOL.
First line
- Balloon catheter - patient can go home, needs to be removed after 24hrs)
- Hormone pessary containing PGE2 (can remove pessary if hyperstimulation, not gel). CTG 30mins before and after, VE 6hrs after.
Second line - maternal oxytocin infusion, only 6hrs after PG to prevent hyperstimulation. Best if ruptured. Double dose every 30mins
Third line - ARM, more augmentation that IOL as cervix has to be open.
Risks of IOL
Prematurity if iatrogenic (e.g. pre-eclampsia) or unintentional (wrong estimated GA)
Cord prolapse with ARM
SE of drugs - uterine hyperstimulation, foetal distress
PGs can rarely cause non-selective stimulation of other smooth muscle leading to N/V, diarrhoea and bronchoconstriction, maternal pyrexia.
Oxytocin has ADH properties so can cause hyponatraemia rarely.
Describe 4 absolute and 2 relative contraindications to IOL
Absolute - acute foetal compromise e.g. on CTG, abnormal lie, placenta praevia, pelvic obstruction
Relative - previous C-section and prematurity.
Describe active management of third stage of labour
Uterotonics (syntocinon, ergometrine or syntometrine)
Clamping and cutting of the cord
Controlled cord traction
This reduces PPH rates however can lead to N/V and headache.
Describe normal CTG (baseline rate, variability, accelerations, decelerations)
Baseline rate 110-160bpm. Tachy is fever.
Baseline variability should be >5bpm except in sleep (<45mins). Prolonged reduced variability suggests hypoxia.
Accelerations are reassuring.
Decelerations:
- Early decelerations synchronous w/ contraction - normal response to head compression
- Variable - reflect cord compression which can cause hypoxia.
- Late decelerations - foetal hypoxia.
Mx of foetal distress
Put mum in left lateral position (take pressure off IVC)
Oxygen if required.
If on epidural consider epidural induced hypotension so IV fluids
Oxytocin/PGE2 STOPPED, can reverse contractions w/ terbutaline.
Consider tocolysis if CTG shows excessive uterine contractions.
Name 4 contraindications of VBAC
Usual indications for CS
Vertical uterine scar
Previous uterine rupture
2+ previous CS
IOL usually avoided due to rupture, same with augmentation.
Contraindications to labetolol in pregnancy?
Asthma
Heart failure
Heart block
Maximum waiting time for labour after ROM at term? What abx given and for how long?
72hrs
Oral erythromycin should be given for 10 days. Steroids.
Consider induction from 34 weeks onwards.
7 RF for malposition - breech/transverse
Multiple pregnancy - prevents turning
Fibroids (leiomyomas)
Multiparous
Prematurity - babies may take 36wks to settle
Placenta praevia
Polyhydramnios/oligohydramnios
Foetal abnormalities
Mx of transverse lie before and after 36wks
<36wks gestation - No mx required as many spontaneously move into longitudinal lie.
>36wks - several options:
- ECV, can even be done in labour if membranes have NOT ruptured. CI = ROM, multiple pregnancy.
- ELCS
When is ECV offered for breech Px in nulli and multiparous women?
36wks onwards in nulliparous
37wks onwards in multiparous
6 absolute contraindications to ECV
CS required
Antepartum haemorrhage in last 7 days
Abnormal CTG
Major uterine anomaly
ROM
Multiple pregnancy
Prerequisites for instrumental delivery
Head must not be palpable abdominally
On vaginal exam, head must be at or below ischial spines
Cervix must be fully dilated
2nd stage reached
Position known
Bladder must be empty (catheterisation)
What is CS associated w/ higher and lower risk of?
Higher - abdo pain, VTE, bladder/ureteric injury, hysterectomy, maternal death.
Lower - perineal pain, urinary incontinence, uterovaginal prolapse.
What are the 4 categories of CS?
Cat 1 - immediate/crash CS. <30mins (scalp pH<7.2, abruption, cord prolapse)
Cat 2 - Urgent compromise but not immediately life-threatening.
Cat 3 - Scheduled CS. No compromise but needs delivery, e.g. pre-eclampsia, IUGR, failed IOL.
Cat 4 - Elective CS. Singleton breech, maternal HIV.
Mx of shoulder dystocia (HELPERR)
Help!
Episiotomy
Legs in McRobert’s
suprapubic Pressure
Enter pelvic (Rubin’s)
(Wood screw’s)
Release posterior arm
Roll onto all 4s.
Cord prolapse - main RF, diagnosis, Mx
Main RF = abnormal lie after 37wks.
Also preterm, polyhydramnios, abnormal lie, twin pregnancy.
Px with foetal distress on CTG. Diagnosed via vaginal exam
Women on all 4’s, tocolytics (terbtualine), immediate CS
Describe degrees of vaginal tears (1, 2, 3abc, 4) and their Mx
1 - tear in mucosa/skin only
2 - tear into SC tissue involving perineal muscles (includes episiotomy)
3 - extends to external anal sphincter (rectal mucosa NOT involved)
- 3a - <50% of external anal sphincter torn
- 3b - >50% of EAS thickness torn
-3 c - IAS torn
4 - IAS and EAS torn into rectal mucosa.
1-2 - sometimes no Mx or suture (on wards)
3-4 - broad spec abx and taken to theatre. Stool softeners, PT.
In Rh-ve, when may sensitisation occur?
Miscarriage/abortion
Amniocentesis
Placental abruption/trauma/FMH
During delivery
Multiparity?
When is routine anti-D given?
28 and 34wks.
What is lochia?
Discharge from the uterus after giving birth. May be blood stained for 4 weeks then yellow/white.
Definition of PPH (1o/2o), 4T’s (most common cause) and Mx
> 500mL blood loss <24hrs of delivery (1o) or 24hrs-12w. Major is >1500mL.
Tone (90%) - atony more common w/ prolonged labour, anything to over-distend the uterus (multiparity, multiple preg, polyhydramnios)
Tissue - large placenta, abnormal site, retained placenta)
Trauma - tears
Thrombin - coagulation disorder
Most common cause of 2o is RC or infection/endometritis (instrumentation)
Oxytocin/ergometrine can prevent. ABCDE, 2 cannulae, lie flat. Tranexamic acid, rubbing uterus. Start IV oxytocin/ergometrine, 2nd line is carboprost (unless asthma -> misoprostol)
If these fail - laparotomy - Rusch balloon up to hysterectomy.
What is Sheehan’s syndrome?
Cx of PPH where pituitary has ischaemic necrosis -> hypopituitarism -> lack of postpartum milk production and amenorrhoea. Dx w/ prolactin/Gonadotropin stimulation test.
Define postpartum pyrexia
> 38C in first 14 days. Infection most common cause (Group A strep, Staph, E.coli)
Lochia may be offensive.
Sepsis 6 protocol.
Which SSRIs preferred during pregnancy and postpartum?
Pregnancy - Fluoextine.
Breastfeeding/postpartum - Paroxetine.
How does puerperal psychosis differ from PND?
Psychotic sx or manic episode around 4 days after birth, whereas PND is 2 weeks.
More common with primigravid women w/ FHx.
Define mono/di -zygotic, -amniotic, -chorionic for multiple pregnancy
How might it present?
Monozygotic - single zygote (always same sex). Dizygotic is 2 ova separately being fertilised and 80% due to IVF.
Mono/diamniotic - single/2 amniotic sacs
Mono/dichorionic - single/2 placentas
HG but mainly US. Signs are lambda sign = dichorionic twins, T signs = monochorionic pregnancy.
Most twins are induced at 38-40wks.
What is twin-twin transfusion syndrome and TAPS.
TTTS - Occurs with monochorionic, diamniotic twins. Recipient receives most blood (can be overloaded => HF and polyhydramnios) while donor is starved.
May require laser treatment if severe.
TAPS is similar but one is anaemic and the other polycythaemic.
How is mastitis treated if breastfeeding?
Abx required if systemically unwell, nipple fissure present, Sx do not improve after 12-24hrs of effective milk removal or culture.
Flucloxacillin for 10-14days and breastfeeding continued.
Drugs contraindicated while breastfeeding?
LAMBAST mothers Ceen taking
Lithium
Amiodarone
Methotrexate
Benzodiazepines
Aspirin
Sulphonamides (abx)
Tetracyclines (abx - doxycyline for CT)
And the 4C’s - carbimazole, Ciprofloxacin, Chloramphenical (abx for conjunctivitis and cytotoxics).
Causes of oligohydramnios (maternal, foetal, placental)
Maternal - any cause of placental insufficiency - pre-eclampsia, chronic HTN; medications like ACEi, PG inhibitors (NSAIDs, steroids - decrease blood flow to kidneys of foetus), mum dehydration, infections.
Foetal - renal agenesis, DS, PROM, IUGR
Placental - abruption, TTTS
What infections do we screen in pregnancy and when?
Usually at booking
Syphilis
Hep B
HIV
Which infections are teratogenic in pregnancy and what general things can they cause?
CMV, Rubella, Toxoplasmosis, Syphilis, Herpes Zoster (rare)
A lot cause things like:
- Miscarriage / stillbirth
- IUGR
- CP
- Jaundice / hepatosplenomegaly
- Neuro
CMV in pregnancy manifestation, Tx and Mx
Hearing loss (asymptomatic neonates at 20% risk of deafness)
Other neuro sequelae - visual/mental impairment, seizures
IUGR/low birth weight
Petechial rash with thrombocytopenia
Microcephaly
Hepatosplenomegaly w/ jaundice
Diagnosed via serology only on requesting.
No treatment required, monitor.
Triad of congenital Herpes zoster and how are exposed mums treated?
Hypertrophic scars (rather than CMV petechial rash)
Limb hypoplasia
Ocular defects (e.g. cataracts, microphthalmia)
Pregnant women exposed tested for immunity. If non-immune 10 days Ig, aciclovir if infection.
Triad of congenital rubella and treatment
Sensorineural deafness
Eye abnormalities (e.g. retinopathy and catarcts)
Congenital heart disease (esp pulmonary artery stenosis and PDA)
If <16wks gestation, TOP offered.
Describe toxoplasmosis organism, clinical features and managemnet
A protozoan parasite.
Cerebral Calcification
Chorioretinitis
Hydrocephalus (on US)
Presenting as mental handicap, convulsion’s, spasticity, visual impairment
Wash hands. Spiramycin as soon as diagnosed. May add pyrimethamine w/ folinic acid.
Antenatal care timetable song
The first visit is from eight
Urine, bloods and rhesus state
Give advice and educate
From eleven to thirteen
Is the best time to do the Downs screen
While you’re at it, check the dates
At sixteen or ten plus six
Do BP and multistix
Second scan is at twenty
Make sure theres twenty - fingers/toes
Once again at twenty-eight
Urine, blood and rhesus state
Anti-D if appropriate
Must give anti-D once more
When the week is thirty-four
And plan for the birth, what a chore
Check the lie at thirty-six
If breech offer a quick fix
Last visit at thirty-eight
All that is left it to wait
Describe DS test at 11-13+6 weeks
and the quadruple test
11-13+6wks is combined test: Nuchal translucency measurement (↑), serum bhCG (↑), PAPPA (↓)
If late booking, quadruple test offered 15-20weeks
hCG (↑), inhibin (↑), alpha-fetoprotein (↓), oestradiol (↓) - HeIgh
NIPT offered if higher chance - DNA analysis from maternal blood.
At what GA do you worry about reduced foetal movements?
Refer if no foetal movements felt by 24 weeks.
What 3 measurements are used to estimate foetal weight?
Head circumference
Abdo circumference
Femur length
What do you do if GBS +ve in pregnancy?
On swab - Only treat with IV abx when labour starts (treating before doesnt reduce chance of baby developing GBS)
If positive for GBS in urine culture, treat immediately and offer in labour.
We do not routinely screen for GBS in UK.
What is quickening and describe how foetal movements should progress through pregenancy
Quickening is onset of foetal movements between 18-20wks gestation (multiparous feel it sooner)
If no foetal movements by 24 weeks, needs assessment.
Increase up to 32 weeks gestation and then plateau. They should NOT reduce.
How are RFM assessed at >28wks, 24-28wks and <24wks gestation?
> 28wks - handheld doppler to confirm foetal heartbeat. If none, immediate US. If present CTG for 20mins.
24-28wks - handheld doppler for heartbeat
<24wks - handheld doppler
What is the advice regarding folate and vitamin D in pregnancy
All pregnant women should take 400IU vitD OD throughout pregnancy
All women should take 400ug folic acid until 12th week of pregnancy
Higher risk should take 5mg until 12wk - high risk:
- Hx of NTD
- Woman on AEDs, has coeliac, DM or thalassaemia
- Woman is obese (BMI > 30)
Out of placental abruption, placenta praevia and vasa praevia, what is multiple pregnancy a RF for?
Multiple pregnancy is a RF for abruption and vasa praevia
It is NOT a RF for placenta praevia.
