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