obsterics Flashcards
combined test for down syndrome done when
and quadruple test done
10-14 weeks
14-20 weeks
combined test
triple test
quadruple test
hCG+PAPP-A(high #hCG, low pappa)
hCG+APF+uncong oestriol
hCG+APF+uncong oestriol+ inhibin A(uncong low, low AFP, high hCG, high inhibin A )
thickened nuchal translucency
maternal group B strep(GBS) is a risk factor for neonatal sepsis
observe the baby for 24hrs if more than two risk factors empirical antibiotic treatment
antibiotic of choice for GBS prophylaxis
benzylpenicillin
antidiabetic safe for breastfeeding
metformin
testing for gestational diabetes
if had before OGTT at booking repeat at 24-28 weeks
normally at 24-28 weeks
antidepressant of choice in postnatal depression
sertraline or paroxetine since low milk plasma ratio
antihypertensive of choice for pre-eclampsia
oral labetalol or nifedipine/hydralazine
when and how much aspirin is given to women with a risk of preeclampsia
moderate risk at 12 weeks start 75mg OD until birth
the most common cause of mastitis
staph aureus
a first-line antibiotic for mastitis
oral flucloxacillin for 10-14 days if penicillin-allergic give erythromycin
the standard dose of folic acid
0.4mg(400mcg) preconception until 13 weeks pf pregancy
women with a higher risk of neural tube defect(NTD)
take 5mg of folic acid risk factors include- previous NTD DM on antiepileptic obese HIV +ve sickle cell/thalasemia
layers cut through for lower segment c section
ant. rectus sheath- rectus abdominis muscles- tranversalis fascia- extraperitoneal connective tissue- peritonium- uterus
indication for forceps delivery
fetal distress
maternal distress
failure to progress
the requirement for forceps delivery
FORCEPS nmumonic F-ully dialted cervix O-A position R-uptured membranes C-ephalic presenation E-ngaded presenting parts P-ain relief S-hincter(bladder empty )
puerperal pyrexia definition
temp >38c in first 14 days following delivery
cause by endometritis
tx iv clindamycin and gentamycin
McRoberts maneuver with suprapubic pressure
flexion and abduction of maternal hips increases AP angle of pelvis indicated in shoulder dystocia
station
head in relation to ischial spine
bishops score used for
assessment to see if induction of labor is required
painless vaginal bleed after 20 weeks
OE non tender uterus, high presenting part and abnormal fetal lie
placenta previa
routine US scan at 20 weeks
chorioamnionitis
potentially a life-threatening emergency
result of bacterial infection of amniotic fluid/membranes/placenta
risk factor preterm premature rupture of membranes
tx prompt deliver and iv antibiotics
risk for VTE in pregnancy
give LWMH antenatally and postnatally
postnatal depression assessment tool
Edinburgh scale or PHQ9
hCG
secreted by syncytiotrophoblasts maintains productions of progesterone by corpus luteum and itsmaintainance and detected on day 8 in maternal blood
Spontaneous abortion
Threatened miscarriage - painless vaginal bleeding typically around 6-9 weeks
Missed (delayed) miscarriage - light vaginal bleeding and symptoms of pregnancy disappear
Inevitable miscarriage - complete or incomplete depending or whether all fetal and placental tissue has been expelled.
Incomplete miscarriage - heavy bleeding and crampy, lower abdo pain.
Complete miscarriage - little bleeding
Ectopic pregnancy
Typically history of 6-8 weeks amenorrhoea with lower abdominal pain (usually unilateral) initially and vaginal bleeding later. Shoulder tip pain and cervical excitation may be present
Hydatidiform mole or molar pregnancy
Typically bleeding in first or early second trimester associated with exaggerated symptoms of pregnancy e.g. hyperemesis. The uterus may be large for dates and serum hCG is very high
on US it resembles a solid collection of echos with small anechoic spaces
Placental abruption
Constant lower sudden abdominal pain in 3rd trimester and, woman may be more shocked than is expected by visible blood loss/blood loss not necessary. Tender, tense uterus* with normal lie and presentation. Fetal heart may be distressed
Placenta praevia
Vaginal bleeding, no pain. Non-tender uterus* but lie and presentation may be abnormal
Vasa praevia
Triad- Rupture of membranes followed immediately by painless vaginal bleeding. Fetal bradycardia is classically seen
fetal blood vessel cross or run near internal orifice of the uterus
diagnosis for hyperemesis gravidarum
5% pre-pregnancy weight loss and dehydration and electrolyte imbalance
first line treatment for hyperemesis
antihistamines
cyclizine
substance abuse in pregnancy
Smoking Increased risk of miscarriage Increased risk of pre-term labour Increased risk of stillbirth IUGR Increased risk of sudden unexpected death in infancy
Alcohol Fetal alcohol syndrome (FAS) learning difficulties characteristic facies: smooth philtrum, thin vermilion, small palpebral fissures IUGR & postnatal restricted growth microcephaly
Binge drinking is a major risk factor for FAS
Cannabis
Similar to smoking risks due to tobacco content
Cocaine
Maternal risks
hypertension in pregnancy including pre-eclampsia
placental abruption
Fetal risk prematurity neonatal abstinence syndrome Heroin Risk of neonatal abstinence syndrome
pregnancy safe antiepileptic
lamotrigine at low doses
UTI drug safe in pregnancy
nitrofurantoin
cause of PPH
atony of uterus
when should EVC be offered
at 36 weeks for nulliparous
at 37 weeks for multiparous
initial management of primary PPH
give oxytocin 10 units or syntometrine or egomertine 500 microgms
IM carboprost
placental abruption
seperation fo normal sited placenta from the uterine wall clinical feautures shock pain woody uterus/firm tender and tensed uterus blood seen is dark red
lochia
Lochia may be defined as the vaginal discharge containing blood mucous and uterine tissue which may continue for 6 weeks after childbirth
degree of perineal tear
first degree: superficial damage with no muscle involvement
second degree: injury to the perineal muscle, but not involving the anal sphincter
third degree: injury to perineum involving the anal sphincter complex (external anal sphincter, EAS and internal anal sphincter, IAS):
3a: less than 50% of EAS thickness torn
3b: more than 50% of EAS thickness torn
3c: IAS torn
fourth degree: injury to perineum involving the anal sphincter complex (EAS and
IAS) and rectal mucosa
the main cause of chord prolapse
artificial rupture of membranes
anti D is given to whom?
Rh -ve mothers who are not sensitized at 28 and 34 weeks
vaicella zoster exposure in pregnant women
give single dose varicella-zoster immunoglobulin up to 10 days after contact
aciclovir is only given 24hrs after the onset of rash in pregnant women with chickenpox
management of preterm prelabour rupture of membranes
admission observation oral erythromycin to prevent infection antenatal corticosteroids dexamethasone to reduce respiratory distress syndrome consider delivery at 34 weeks
antenatal care timetable
8 - 12 weeks (ideally < 10 weeks)
Booking visit
general information e.g. diet, alcohol, smoking, folic acid, vitamin D, antenatal classes
BP, urine dipstick, check BMI
Booking bloods/urine
FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies
hepatitis B, syphilis
HIV test is offered to all women
urine culture to detect asymptomatic bacteriuria
10 - 13+6 weeks
Early scan to confirm dates, exclude multiple pregnancies
11 - 13+6 weeks
Down’s syndrome screening including nuchal scan
16 weeks
Information on the anomaly and the blood results. If Hb < 11 g/dl consider iron
Routine care: BP and urine dipstick
18 - 20+6 weeks
Anomaly scan
25 weeks (only if primip) Routine care: BP, urine dipstick, symphysis-fundal height (SFH)
28 weeks
Routine care: BP, urine dipstick, SFH
Second screen for anemia and atypical red cell alloantibodies. If Hb < 10.5 g/dl consider iron
First dose of anti-D prophylaxis to rhesus negative women
31 weeks (only if primip) Routine care as above
34 weeks
Routine care as above
Second dose of anti-D prophylaxis to rhesus negative women*
Information on labour and birth plan
36 weeks
Routine care as above
Check presentation - offer external cephalic version if indicated
Information on breast feeding, vitamin K, ‘baby-blues’
38 weeks
Routine care as above
40 weeks (only if primip) Routine care as above Discussion about options for prolonged pregnancy
41 weeks
Routine care as above
Discuss labour plans and possibility of induction
hep b in pregnancy
all women should be screened
safe for breastfeeding
babies born to hep b mothers should be given complete course of vaccination and immunoglobulin
absolute contraindication of induction of labour and vaginal birth
previous classical c-section
methods of induction of labour
membrane sweep
intravaginal prostaglandins
breaking of water
oxytocin
what reduces the risk of hyperemesis
smoking
woodscrew maneuver can be best described as
putting a hand in the vagina and rotating the fetus 180o to dislodge anterior shoulder from symphysis pubis
most common cause of fever in newborn infant
group B strep
lisinopril should be avoided in preeclampsia
because it is feto toxic
management of chord prolapse
push back presenting part of fetus
tocolytics
instrumental vaginal delivery possible
c-section
clinical features of cholestasis in pregnancy
itching jaundice obstructive LFT normal WBCs no evidence of coagulopathy
women with abdominal trauma during pregnancy
should get ABO and Rhesus because Rh -ve women should be given anti D
The following drugs can be given to mothers who are breastfeeding:
antibiotics: penicillins, cephalosporins, trimethoprim
endocrine: glucocorticoids (avoid high doses), levothyroxine*
epilepsy: sodium valproate, carbamazepine
asthma: salbutamol, theophyllines
psychiatric drugs: tricyclic antidepressants, antipsychotics**
hypertension: beta-blockers, hydralazine
anticoagulants: warfarin, heparin
digoxin
The following drugs should be avoided:
antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides psychiatric drugs: lithium, benzodiazepines aspirin carbimazole methotrexate sulfonylureas cytotoxic drugs amiodarone
avoid liver in antenatal diet
cause it contains vitamin A which is a teratogen
Conditions which all pregnant women should be offered screening
Anaemia Bacteriuria Blood group, Rhesus status and anti-red cell antibodies Down's syndrome Fetal anomalies Hepatitis B HIV Neural tube defects Risk factors for pre-eclampsia Rubella immunity Syphilis
The following should be offered depending on the history:
Placenta praevia Psychiatric illness Sickle cell disease Tay-Sachs disease Thalassaemia
Conditions for which screening should not be offered
Bacterial vaginosis Chlamydia Cytomegalovirus Fragile X Hepatitis C Group B Streptococcus Toxoplasmosis
do not perform ECV if
have ruptured during active labour and membrane
medication used to suppress lactation
cabergoline
NICE recommendation for CTG monitering when
suspected chorioamnionitis or sepsis severe hypertension 160/110 oxytocin use meconium fresh vaginal bleeding develops in labour- a sign of placental rupture or previa
metoclopramide is prescribed with caution
because it can have extrapyramidal side effects in young women
erbs palsy (waiters tip)
due to upper brachial plexus damage caused by shoulder dystocia
characteristic adduction and internal rotation of arm and pronation of forearm
klumpke palsy
is due to damage to the lower brachial plexus leading to claw hand appearance
the highest risk of neonatal hemorrhage
prolonged ventouse delivery
Risk of prematurity
increased mortality depends on gestation respiratory distress syndrome intraventricular haemorrhage necrotizing enterocolitis chronic lung disease, hypothermia, feeding problems, infection, jaundice retinopathy of newborn, hearing problems
AFP levels indiacte
raised in Neural Tube defects, abdominal wall defects and multiple pregnancies
decreased in Down syndrome, trisomy 18 maternal diabetes, edwards syndrome
Distinguishing placental abruption from praevia
Placental abruption shock out of keeping with visible loss pain constant tender, tense uterus* normal lie and presentation fetal heart: absent/distressed coagulation problems beware pre-eclampsia, DIC, anuria
Placenta praevia shock in proportion to visible loss no pain uterus not tender* lie and presentation may be abnormal fetal heart usually normal coagulation problems rare small bleeds before large
rubella not routinely screened in booking visit
so contact health protection unit in all rubella related cases
abdominal pain in early pregnacy
Ectopic pregnancy
This is the single most important cause of abdominal pain to exclude in early pregnancy
0.5% of all pregnancies are ectopic
Risk factors (anything slowing the ovum’s passage to the uterus)
damage to tubes (salpingitis, surgery)
previous ectopic
IVF (3% of pregnancies are ectopic)
A typical history is a female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding
lower abdominal pain: typically the first symptom. Pain is usually constant and may be unilateral. Due to tubal spasm
vaginal bleeding: usually less than a normal period, may be dark brown in colour
history of recent amenorrhoea: typically 6-8 weeks from start of last period; if longer (e.g. 10 wks) this suggest another causes e.g. inevitable abortion
peritoneal bleeding can cause shoulder tip pain and pain on defecation / urination
Miscarriage Threatened miscarriage painless vaginal bleeding occurring before 24 weeks, but typically occurs at 6 - 9 weeks cervical os is closed complicates up to 25% of all pregnancies
Missed (delayed) miscarriage
a gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion
mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear
when the gestational sac is > 25 mm and no embryonic/fetal part can be seen it is sometimes described as a ‘blighted ovum’ or ‘anembryonic pregnancy’
Inevitable miscarriage
cervical os is open
heavy bleeding with clots and pain
Incomplete miscarriage
not all products of conception have been expelled
abdominal pain in late pregnancy
Labour Regular tightening of the abdomen which may be painful in the later stages
Placental abruption Placental abruption describes the separation of a normally sited placenta from the uterine wall, resulting in maternal hemorrhage into the intervening space
Occurs in approximately 1/200 pregnancies
Clinical features
shock out of keeping with visible loss
pain constant
tender, tense uterus
normal lie and presentation
fetal heart: absent/distressed
coagulation problems
beware pre-eclampsia, DIC, anuria
Symphysis pubis dysfunction Ligament laxity increases in response to hormonal changes of pregnancy
Pain over the pubic symphysis with radiation to the groins and the medial aspects of the thighs. A waddling gait may be seen
Pre-eclampsia/HELLP syndrome Associated with hypertension, proteinuria. Patients with HELLP also have haemolysis, elevated liver enzymes and a low platelet count.
The pain is typically epigastric or in the RUQ
Uterine rupture Ruptures usually occur during labour but occur in third trimester
Risk factors: previous caesarean section
Presents with maternal shock, abdominal pain and vaginal bleeding to varying degree
abdominal pain at any point in the pregnancy
Appendicitis
most common non-obstetric surgical emergency
Higher morbidity and mortality in pregnancy
Location of pain changes depending on gestation, moving up from the RLQ in the first trimester to the umbilicus in the second and the RUQ in the third
Urinary tract infection (UTI) 1 in 25 women develop in UTI in pregnancy
Associated with an increased risk of pre-term delivery and IUGR
blood sugar testing for type I diabetic pregnancy women
daily fasting, premeal, 1 hr post-meal and bedtime measurement
intrahepatic cholestasis of pregnancy
ictching with jaundice
increased nuchal translucency seen in
down syndrome,
congenital heart defects
abdominal wall defects
Sheehan syndrome
a complication of severe PPH causing ischemic necrosis of pituitary gland leading to
lack of postpartum milk production and amenorrhea
calcium gluconate used to treat
Magnesium sulfate induced respiratory depression
ergometrine
avoided in hypertension
amniotic fluid embolism
this is when fetal cells/amniotic fluid enters mothers bloodstream occurs 30mins after labour
SS- respiratory distress, hypoxia, hypotension, cyanosis, bronchospasm, tachycardia
vaginal prostaglandin gel used
to help make the cervix more favorable
epidural analgesia is contraindicated in
coagulopathy
oligohydramnios
condition where there is a deficiency of amniotic fluid(less than 500ml at 32-36weeks) caused by renal agenesis
streptococcus agalacticae causes
GBS
gram +ve anerobic cocci
carboprost is contraindicated in
asthama
contraindicated in breastfeeding
lithium
macrocytic anemia with hypersegmented neutrophils
folate deficiency
MMR vaccine
should not be administered to womwn know to be pregnant or attempting to become pregnant for 28 days
causes of placental abruption
cocain abuse (hyperreflexia and dialted pupils )
pre eclampsia
HELLP
methotrexate is used to treat rheumatoid arthritis
both men and women should stop it before
