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4.2 WACH > Obstertrics > Flashcards

Obstertrics Flashcards

12
Q

Anetanatal test diagnostic of Down syndrome

A

Trisomy 21 on amniocentesis - chorionic villous sampling

Low PAPP-A and high b-HCG = increased risk (NOT diagnostic)

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13
Q

Investigation for suspected endometriosis

A

Laparoscopy

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14
Q

Difficulty breastfeeding after PPH in delivery is caused by?

A

Sheehan’s syndrome: PPH—> pituitary necrosis —> hypopituisim (inadequate prolactin and gonodotropin stimulation)

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15
Q

Adhesions and fibrosis of endometrial cavity due to dilation and curettage

A

Asherman’s syndrome

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16
Q

Psychiatric disorders post pregnancy

A

Baby blues, postnatal depression and puerperal psychosis

Baby blue: anxious, tearful and irritable
Reassure and health visitor

Postnatal depression: start within a month and peak at 3 months - reassure, CBT and SSRI (paroxetine and Sertraline)

Puerperal psychosis : severe mood swings (bipolar), disordered perception (auditory). Admission to hospital as treatment

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17
Q

Female genital tract source sepsis

A

Amoxicillin/ampicillin 2g IV 6 hourly
Gentamicin 4-7 mh/kg IV
Metronidazole 500 mg IV 12- hourly

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18
Q

Risk factors for ovarian factors

A

Family history of BRAC1, BRAC2 gene
Early menarche, late menopause an nulliparity

CA125 test raised —> ultrasound

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19
Q

Ectopic locations

A

Ampulla = main

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20
Q

Blood glucose frequency in T1DM during pregnancy

A

Daily fasting, pre-meal, post meal 1hr, bedtime

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21
Q

McRobert’s manoeuvre

A

Supine with both hips fully flexed and abducted

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22
Q

Endometrial hyperplasia

A 
Irregular proliferation of endometrial glands 
Simple
Complex, 
Simple atypical 
Complex atypical

Protective factors: OCP

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23
Q

Origin of adenomcarcinoma in gynae

A

Endometrium

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24
Q

Blood test for HELLP syndrome

A

Epigastric pain, nausea, headache and general malaise.
HELLP is severe form of pre-eclampsia
Characterised by H (haemolysis- low Hb raised raised LD) EL(elevated liver enzyme) and LP (low plalete)

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25
Q

CIN classification

A

CIN 1 = lower 1/3 of epithelium (LSIL low grad)
CIN 2 = lower 2/3 of epithelium (HSIL high grad)
CIN 3 = all layers (HSIL)

Loss of stratification, abnormal mitosis, increase nuclei size

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26
Q

Layers cut in lower segment of Caesarian section

A 
Superficial fascia
Deep fascia 
Anterior rictus sheath
Rectus abdominus
Transversals fascia
Extraperitoneal connective tissue
Peritoneum
Uterus
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27
Q

Postpartum haemorrhage cause

A

Most common = uterine Antony

the 4 t’s
T = tone
T = tissue (retained placenta)
T = trauma
T = thrombin (coagulation abnormalities)
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28
Q

First line for respiratory depression caused by MgSulphate

A

Calcium gluconate

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29
Q

Types of ovarian cancer

A

Epithelium - Fallopian tube or ovary
Germ cell - egg production cells
Stromal cell - start in cell that produce estrogen and progesterone

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30
Q

Stromal cell types of ovarian cancer

A

Granulosa - releases inhibit, releases estogen

Sertraline leading - renin release —> HTN

Gynandroblastoma

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31
Q

An 83-year-old lady attends with a history of falls. She has a past medical history of osteoporosis, constipation, frequent urinary tract infections, ischaemic heart disease and urge incontinence.

After a thorough history and examination, you decide that these are likely multifactorial related to a combination of physical frailty, poor balance and medication burden. Which one of the following medications should you stop in the first instance?

A

Oxybutynin

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32
Q

PID followed by liver inflammation

A

Fitz-Hugh Curtis - adhesions in liver, liver capsule - Glisson’s capsule

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33
Q

Hypermesis gravidarum electrolyte disturbance

A

Hyponatraemia, hypokalemia, hypochlorite and metabolic alkalosis

Molar pregnancy and multiple pregnancy

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34
Q

A 30-year-old woman who is 26 weeks pregnant is admitted to the maternity unit with heavy vaginal bleeding. She is Rhesus negative.

What is the most appropriate management for prophylaxis of Rhesus sensitisation?

A

One dose of Anti-D immunoglobulin followed by Kleihauer test - to detect fetal cell in maternal circulation (required post 20 weeks) check Australia guidelines

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35
Q

Woody uterus

A

Placental abruption with pain

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36
Q

Management of contact with chickenpox

A

Only VZIG

If rash present - then acyclovir

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37
Q

Post-Partum contraception

A

Needed 21 days after birth

Can use progesterone only pill - anytime after 21 days
IUD 0 within 48 hours of childbirth or after 4 weeks

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38
Q

Calculation of EDD

A

Taking date of last LMP, counting forward by nine months and adding 7 days
If cycles longer than 28 days then add the difference between cycle length and 28 days

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39
Q

What is used for ultrasound dating of pregnancy

A

Crown-rump length up to 13 weeks + 6 days

Head circumference from 14-20 weeks

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40
Q

Alcohol in pregnancy

A

Complete abstinence is advised.
Alcohol is not harmful in small amounts (less than one drink per day)
Binge drinking is associated with fetal alcohol syndrome

41
Q

What is gravida and what is parity

A 
Gravida = total number of pregnancies (regardless of end)
Parity = number of live births or stillbirths after 24 weeks

Twins count as 2 gravida and 2 parity

42
Q

Obstetric history

A

Age, date of birth, occupation, ethnicity and first pregnancy
Reason for visit
This pregnancy:
Dating the pregnancy - from LMP - add nine month and 7 days. Antenatal care so far
Ultrasound

Previous obstetric history 
Recurrent miscarriage 
Preterm delivery 
Pre-eclampsia 
Abruption 
Congenital abnormality 
Macroscopic baby
FGR 
Still birth 
Method of delivery

Past gynae history
Length of cycle, contraceptive history , PID history last cervical smear (cone biopsy), pelvic masses, history of sub-fertility

Medical and surgical history : pre-existing conditions, previous surgery, psych history

Drug history: over-the counter, homeopathic and herbal
Allergies

Family history
Maternal and first degree

Social history: partner, who lives at home, income, housing, plan to work during pregnancy, domestic violence
Smoking, alcohol and illicit drug history

43
Q

What is maternal diabetes linked with

A

Macrosomia, FGR, congenital abnormality, pre-eclapmsia, still birth, neonatal hypoglycaemia

44
Q

What is maternal hypertension associated with

A

Pre-eclampsia

45
Q

What is maternal renal disease associated with

A

Worsening renal disease, pre-eclampsia, FGR, preterm delivery

46
Q

What is maternal epilepsy associated with

A

Increased fit frequency, congenital abnormality

47
Q

what is venous thromboembolic disease associated with

A

Increased risk during pregnancy, thrombophilia, increased thromboembolism risk and increased risk of pre-eclampsia and FGR

48
Q

What is maternal HIV associated with

A

Risk of mother to child transfer

49
Q

What is myasthenia Travis/myotonic dystrophy associated with

A

Fetal neurological effect, increase maternal muscular fatigue in labour

50
Q

What is knife cone biopsy associated with

A

Increased risk of cervical incompetence (weakness) and stenosis (leading to preterm delivery and dystocia)

51
Q

What is LLETZ associated with

A

LLETZ (large loop excision of the transformation zone)
Is associated with a small increase in risk of preterm birth
More than one excision = shorter cervix, which does increase the risk of second and third trimester delivery

52
Q

What would you do a speculum exam in pregnancy

A

Excessive or offensive discharge
Vaginal bleeding (in absence of placental praevia)
To perform cervical smear
To confirm potential rupture of membrane

53
Q

Contraindications to digital exam in pregnancy

A

Known placenta praevia, or vaginal bleeding when the placental site in unknown and the presenting part unengaged
Prelabour rupture of membranes (increased risk of ascending infection)

54
Q

What are the things used to calculate a bishops score

A 
Dilation of cervix in cm
Consistency of cervix
Length of cervical canal
Positive 
Station of presenting part (cm abnove ischial spine)

DCLPS
Women dilate consistently only the length of a positive station

55
Q

What is included in antenatal screening in Australia

A 
?
Down syndrome
Fetal anomaly - via u/s
Haemoglobinopathies
Rubella 
HIV/Hep B
Tay-Sach’s in high risk
56
Q

What is included in newborn screening

A 
Hearing 
Phenylketonuria
Congenital hypothyroidism
Cystic fibrosis
Medium chain acyl co-A dehydrogenase deficiciency
57
Q

Measures for maternal death

A

MMR = number of maternal deaths in a population divided by the number of live births - shows risk of maternal death relative to number of live births

MMRate (maternal mortality rate) - number of maternal death in population divided by the number of women of reproductive age, - reflecting not only the risk of maternal death per pregnancy or per birth but also the level of fertility in population

58
Q

Volume homeostasis in pregnancy

A

Rapid expansion of blood vol at 6-8 weeks up to 32-34 weeks of gestation
Accounts for 8-10 kg of weight gain
6.5L to 8.5 L

  • increased cardiac output
  • increased renal blood flow
  • physiological anemia : increased plasma volume relatively to erythrocytes volume
  • lower plasma albumin concentration

Water retention occurs from changes in osmoregulation and RAAS system —> active sodium reabsoption in renal tubles —> retention
Other factors resulting in fluid retention: sodium ratio in, reduced thirst threshold, reduced plasma oncotic pressure

Plasma osmolality decreased by 10 mOsmol/kg in preg

59
Q

Consequences of fluid retention in pregnancy

A 
Reduced haemoglobin concentration
Reduced haematocrit
Reduced serum albumin oncentration
Increased stroke volume
Increased renal blood flow
60
Q

Haematological concequences of pregnancy results in decrease in

A

Haemoglobin concentration, haematocrit, plasma folate concentration, protein s activity, plasma protein concentration, creatinine, urea and uric acid

61
Q

Haematological concequence of pregnancy results in increase of

A 
Erythrocytes sedimentation rate
Fibrinogen concentration
Activated protein c resistance
Factor VII, VIII, IX, X and XII 
D-dimmer
Alkaline phosphatase
62
Q

immune system in pregnancy

A

IgG antibodies
Reduced CD8 T-cell acitivity
Increase innate immunity - increase NK cells
Unchanged WBC count

63
Q

Changes to eyes during pregnancy

A

Corneal sensitivity decreases - returns 8 wk post partum
Increased corneal thickness - odema
Reduced tear production
Increased curvature of crystalline lens

64
Q

Role of relaxin in pregnancy

A

Allows ligamentaous attachment to relax during pregnancy
Includes ribcage to relax increasing subcostal angle
Relaxin is producer by ovary and planceta and usually softens and widens the cervix

65
Q

What causes physiological dyspnoea of pregnancy

A

Increase tidal volume - increases minute ventilation which is perceived a SOB which is 60-70%
Resolves immediately postpartum

66
Q

Oxygenation during pregnancy

A

Increase in 2,3 diphosphaglycerate (2,3-DPG) concentration increases. 2,3 DPG preferencially binds to deoxygenated Hb and promotes the release of oxygen from Red cells at relatively lower levels of Hb saturation - this increases the availability of oxygen within tissues

67
Q

Difference in fetal and adult haemoglobin

A

Two beta-chains are replaced by gamma-chains
2-3, DPG binds to preferentially to beta chains therefore in fetus the oxygen-Hb dissociation curve is shifted to left relative to mother.

68
Q

Blood gas and acid-base changes

A 
Reduced PCO2 
Increase PO2
pH alters little 
Increased bicarbonate excretion 
Increased oxygen availability to tissue and placenta
69
Q

Cardiovascular changes in pregnancy

A 
Increase heart rate (10-20 beat)
Increased stroke volume (10%)
Increased cardiac output - 5 weeks of gestation 
Reduced mean arterial pressure (10%)
Reduced pulse pressure
Reduced peripheral resistance (35%)

Palpitation + premature atrial and ventricular ectopic

70
Q

Gastrointestinal changes in pregnancy

A

Oral - gingivitis (due to vascular permeability), increased dental caries, increased tooth mobility

Gut- uterus displaces the stomach and intestine upwards, reduced LOS tone (progesterone effect ), increased placental gastrin production and increased gastric acidity (progesterone effect) —> increased reflux oesophagiits and heartburn. Reduced gastric motility and increased stomach volume —> increase in gastric content aspiration post 16/40
Liver- common to find findings of talengiectasia and palmar erythema as liver can clear increased levels of estrogen and progesterone

71
Q

Changes to kidney during pregnancy

A

increased kidney size

Dilation of calyces, renal pelvis and ureter—> looks like obstruction

72
Q

Functional changes in kidney during pregnancy

A 
Increased GFR 50%
Increased renal blood flow 60-75%
Increase renal plasma flow
Increased clearance of most substances
Reduced plasma creatinine, urea and urate
Glycouria is normal for
73
Q

Sodium balance in pregnancy in kidney

A

Increased filteration but also increased sodium reabsorption in proximal (oncotic pressure) and distal (hormonal factors)

74
Q

Affect of pregnancy on uterus

A

Increased blood flow
Hyperplasia and hypertrophy of myometrium (estrogen and prosgesterone)
Increased weight
Hypertrophy of uterine artery
Lower segment = thinner, less muscle and fewer blood vessels - therefore caesarean incision here
Increased intercellular gap - increased depolarisation

75
Q

Braxton Hicks

A

Uterine contraction
Painless contraction
Allow pacemaker activity of uterine fundus to promote the coordinated, fundal-dominant contraction

76
Q

Changes in breast during pregnancy

A

Deposition of fat around glandular tissue, and the number of glandular duct increases (oestrogen effect)
Progesterone and human placental lactogen (hPL) increases number of gland alveoli
Prolactin - imp in milk secretion - during pregnancy prolactin level increase but does not cause secretion as it is antagonised bu oestrogen at alveolar receptor level
The drop is oestrogen level 48 hr after delivery removes inhibitor
The early suckling —> ant and post pituitary releases prolactin oxytocin - oxytocin released from post pit causes contraction of myoepithelium cell squeezing the milk

77
Q

Prolactin in pregnancy

A

Increased by 15 fold in pregnancy by anterior pituitary
Oestrogen = stimulators and hPL is inhibitory
Promotes breast engorgement and alveoli distension with milk
Receptors for prolactin are also present in trophoblast cell and within the amniotic fluid
Prolactin many regulate insulin secretion and glucose homeostasis

78
Q

Thyroid function during pregnancy

A

HCG similar to TSH
First trimester - TSH suppressed, due to reduced release to TRH
After 20 week increase T3, T4
Increased GFR increased renal loss of iodised - which results in thyroid taking up too much iodide from circulation and then iodised deficiency
Use free T4 and free T3 not total T3 and T4
Reduced fT4 late pregnancy, reduced TSH early pregnancy

79
Q

Skin changes in pregnancy

A

Hyperpigmentation
Striae gravidarum
Hirsuitism
Increased sebaceous gland activity

80
Q

Causes of FGR

A

Fetal - genetic: chromosomes 13 (Palau syndrome), 18 (Edward’s syndrome) and trisomy 21 (Down syndrome)- trisomy 21 = less severe
- infection: rubella, cytomegalovirus, toxoplasma and syphilis
Maternal
- physiological: maternal height, weight, age and ethnicity
- behavioural : smoking, alcohol and drug use. Smoking (CO or vascular effects on uteroplacental circulation), alcohol crosses placenta
- chronic disease: restricts fetal growth, hypertension (placental infarction), lung or cardiac conditions
Placenta
- infarction

81
Q

PPH mangement

A
  1. Call for help, rapid if there is shock, do not leave the women
    Basic measures: lie flat, keep warm, monitor virals every 5 mins and temp 15 mins
  2. Initial assessment: ABCD
    - look for reversible causes: remove blots, massage
    - insert catheter - empty bladder (>30ml/hr)
    - IV access - FBC, coats, crossmatch 4 unit, Ca (repeat 30-60 mins)
    - give O2 10-15 L/min
  3. History
  4. medical management
    - syntocin 2nd IV - 5 units
    - synotocin infusion IV - w/ saline and hartmans 40 units over 4 hours
    - ergometrine (if no HTN) - IV and IM
    —— contraindication: retained placenta, twin preg, hypertension, sepsis, heart disease, pvd, impaired hepatic or renal function
    - carbopristil IM or intramyometrial
  5. Operative theatre
    - MTP
    - bimanual compression of the way
    - uterine massage
    - ballon tamponade: bakri ballon
    - haemostatic brace suture
    - bilateral ligation uterine artery
    - bilateral ligation internal iliac
    - arterial embolisation
    - hysterectomy
82
Q

Causes of PPH

A 
The 4 T’s 
Tone
Trauma
Tissue
Thrombin
83
Q

Management of shoulder dystocia

A
  1. Recognise: turtle size and failure to progress
  2. Call for help - obstetrician, paediatric + Time (7 mins)
  3. Simple manoeuvres
    - McRoberts Manoeuvre
    - Suprapubic pressure : down and rotate
  4. Consider episiotomy - access
  5. Manoeuvre
    - internal rotation manoeuvre ant and post
    - deliver posterior arm
    - be on all 4’s : reverse McRoberts
  6. Repeat on reverse McRoberts
  7. Zavonelli’s : push head back in and cesarean
  8. Symphisiotomy

4.2 WACH (3 decks)

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