Obstetric flashcards
What law covers abortions?
The abortion act 1967 amended 1991
Where are terminations usually done?
In private sector often, but in Sheffield the NHS does most of them
What was the amendment to the abortion act?
The time limits due to neonatal care becoming better 28 to 24
Why can people die from abortions?
Rare complications or sometimes comorbidity.
Why can people die from abortions?
Rare complications or sometimes comorbidity.
How many criteria are there for abortion?
5 most under 3
What are the reasons for terminations?
A risk to life for mother if continue pregnancy.
B termination will prevent grave permanent injury physical or mental to woman
C pregnancy is less than 24 weeks and would be high risk to continue pregnancy
D not after 24 weeks continuing would cause risk to the family or other children.
E substantial risk to child if it were born from physical or mental abnormalities
How many pregnancies are aborted?
about 1/3 pregnancies are terminated
What is required to authorise an abortion/
2 Doctors have to agree in good faith that the termination should go ahead
Why can termination almost always be justified?
Termination deaths are much less than going through with pregnancy.
What are the medical termination method?
Antiprogesterone called mifepristone sublingual or vaginally that tries to stop the placenta working.
Then misoprostol a prostaglandin to cause the uterus to expel the products of conception.
Where are medical abortions done?
They can have mifepristone at home then misoprostol at home as well for some if under 10 weeks. As they are later they are more likely needed to take in hospital
What are the surgical types of abortion?
Vacuum aspiration available up to 14 weeks
Dilatation and evacuation 14 to 24 weeks
need nusioristol to open cervix before Vaccume aspiration
When does anti d need iving in TOP?
anyone haveing termination after 9+6 who are rhesus negative if medical but for surgical test everyone no matter gestation.
When should prophylactic antibiotics be given in TOP?
When STI infection is likely or when having surgical termination.
What conditions do GUM/Sexual health practitioners deal with,
Chlamydia, Gonorrhea, PID, Non specific urethritis, Epididymorchitis, Genital warts, Genital herpes, Trichomonas vaginalis, Syphilis, HIV, Hep B&C, Non-STI Candidiasis, Bacterial vaginosis, Lichen sclerosis, Balanitis, Vulvodynia, Vestibulitis, Psychosexual problems sexually acquired reactive arthritis, sexual assault victims.
What is special about Sexual health history?
History of presenting complaind GU history, Past gneral history, Abx in past month, Sexual history for 3-12 months. Last sexual intercourse, Regular/casual partner, Male female Condom use type of sex. Menstrural history pregnancy history smear contraception and in men when did last go to toilet
What to examine in genitals?
Both genital skin inguinal lymph nodes, pubic hair, Vulva perineum, vagina Cervix bimanual pelvic examination possible anus or throat, penis scrotum urethral meatus Anus and oropharynx in MSM
What tests do you get for asymptomatic screeen for female?
Vulvovaginal swabs for NAAT and Bloods for Syphylis and HIV
What is asymptomatic screen for men(non-MSM)?
First void urine and bloods for Syphilis and HIV
What is asymptomatic screen for men MSM?
First void urine NAAT Pharengeal swabs and rectal swabs blood for syphylis HIC HeB
For female symtomatic screeening?
High vaginal swab wet and dry slides for BV TC Candida and Gonorrhoea, Vulvovaginal NAAT, Cervical swab for slide and culture Bloods and bimanual if pelvic pain
Symptomatic screeening for heterosexual male?
Urethral swab for slide, Gororhoea culture, First void urine for Gonorrhoea Chlamydia NAAT Dipstick analysis and bloods
sYMPTOMATIC screening for MSM?
Urethral swab for slide, Gororhoea culture, First void urine for Gonorrhoea Chlamydia NAAT Dipstick analysis and bloods
Pharyngela and rectal swabs and urethral rectal slides and or culture
When to test for Herpes?
When have symptomatic genital ulcer
When to test for mycoplasma genitalium?
Urine men with NSU epididyymorchitis or contact of know patient Culvovaginal swab for PID
What is dark ground microscope?
Genital ulcer for treponemes to diagnose primary syphillis.
Who gets Hep B screen?
MSM comercial sex workers ICDU and partners, people from high risk areas
What is a normal birth?
Spontaneous in onset, low-risk at the start of labour and remaining so throughout labour and delivery. The infant is born spontaneously in the vertex position between 37 and 42 completed weeks of pregnancy. After birth, mother and infant are in good condition WHO
Birth without induction of labour, spinal or epidural analgesia, general anaesthesia, forceps or ventouse delivery, caesarean section or episiotomy.
What happens in latent phase of labour?
Contractions not usually reular mucous plug goes, cervical riening can last 2-3 days
What happens in the active first stage fo labour/
Stronger contractions dilation to 10cm.
What is the second stage?
Second stage From full dilatation to the birth of the fetus
What is the third stage of labour/
Fromthe birth of the fetus to expulsion of placenta
What are the presentations?
Cephalic Breech Transverse lie
What is effacement?
The proces of shortening AND WIDENING of the cervical appeture
How long is the cervix usually?
4cm long
What are the sutures on a babys head?
Lamboid posteriorly, saggital in middle anterior fontanel corronal suture
What are the characteristics of the anterior fotntanell?
It has 4 sutures forming it
What are the stages of labour in terms of the mechanism?
Descent Flexion of the neck, Internal rotation extension of neck restitution external rotation and delivery of the body.
Why is flexion important?
It allows the babys head to present the smallest area to the cervix
What is internal rotation?
the head needs to rotat to be OA usually this is by about 90 degrees
What is extension?
When the head has been delivered the head is facing thebacl and the neck extends
How much amniotic fluid is there?
500-800mls
What imortant substances can and can’t cross the placenta?
Morphine and opiates can, IgG can gas and air can’t alcohol and nicotine can
What are the pain management methodis in order of escalation?
Water, warm water baths, aromatherapy, hypnobirthing, Paracetamol Codine Entonox, Opioids pethidine epidural
Where do the breasts lymph drain to?
The axilliary lymph nodes mainly some to internal mammary or abdominal around the liver
What are the cyclical changes to the breast/
They proliferate just after ovulation then Involute after
What changes with age in breast tissue?
It gets more fatty and less dense
What are things to look for on mammogram?
Asymetrical densities, focal masses parenchymal distortion, Microcalcification, Skin thickeneing enlarged lymph nodes
What is immaging pathwa for breast under 35/
Clinical examination and ultrasound
What is immaging pathway for breast patient over 35?
Mammogram ultrasound clinical examination
What are the characteristics of maternal physiological changes?
Anticipatory precede fetal demands/growth, In excess of fetal requireent and are dynamic, they all aim to encourage growth of the baby
When do the changes start in pregnancy?
Mid luteal phase after ovilation
What happens to maternal fluid?
30-50% increase in plasma volume mainly form fluid retention by 1-2 Litres Sodium ion is most abundant so has an effect
What happens to electrolytes in women/
Sodium retention and increased Potassium absorption.
What endocrine changed favour fluid retention?
naturietic factors increase like ANP and Progesterone. Increase in antinaturetic factors RRAA Deocyvortisone oestrogen
What happens to the blood in pregnancy?
Dilutional affects reduction in osmolality without diuresis, decreased threshold for thirst plasma oncotic pressure as 20% serum albumin diluted. Dilutional anaemia decreased haematocrit this facilitates placental perfusion, increase in white cells, hypercoaguable increase in fibrinogen and clotting factors
What happens to the kidney in pregnancy?
Increase kidney size at term dilation of the uretal tone and renal pelvis
What is relevent about ureter tone reduction/
More prone to pylonephritis
What are changed to GFR and relevance to care?
Renal bloodflow increases and GFR increases by 50% increased creatinine clearance glucosuria aminoaciduria
What are blood pressure changes in pregnancy?
Early to mid get decrease in pressure as decreased peripheral resistance and in late it goes up more this is from NO prostaglandin vasodilator pathway
What happens to cardiac outiput in pregnacny/
Increases rapidly and stays high, SV increases then decreases and HR increases later in pregnancy.
What is aortocaval compression syndrome?
The uterus can press on the abdominal vena cava decreaseing venous return cardiac output and artereal presure and can cause hypotension and can increase risk of stillbirth
What osition should pregnant women lie in?
Left lateral
What heart changes are there?
ECG changes, Heart sounds move, QRS axisdeviation of the heart itelf. flow murmurs
What happens to maternal respiratory anatomyin pregnancy
Diaphragm elevated, subcostal angle increases, thoracic circumference and decreased chest compliance
What is change in respiratory volumes?
increased tidal volume
What is the effect of tital volume increase?
Causes respirator alkalosis from excess CO2 blow off subjective dyspnoea
Why is maternal alkalosis a good thing?
Allows Co2 to better diffuse from the placenta, also affects binding of Oxygen to haemoglobin
What happens in 2,3DPG?
Increased in RBC in pregnancy to cause haemoglobin to release oxygen/
What is double bohr effect?
CO2 high on maternal blood at placenta and DPG increase in maternal
What are GI effects in pregnancy?
Heart burn effects cardiac sphincter relaxation aspiration pneumonitis
What is change in Hepatic system?
Redced CK reduged gall bladder motility increased dyspepsia obstetric cholestasis
Why does pregnancy increase constipation?
Loger gut transit time so mar water absorbed
How does pregnancy affect pharacology?
CYP450 altered actiiyy Gastric pH decreased, Increased GFR, increased gut transit gastric emptying increase ECF volume drug dilution
What happens to glucose in placenta?
There is not much regulation by placenta so all from maternal goes into fetal, excessive glucose can cause fetal harm
What happens with insulin sensitivity later in pregnancy?
Insulin resistance happens later in pregnancy more and more through pregnancy
What are uterine natural killer cells?
The uterus is immune rivilaged as it allows trophoblast gells to invaid to spiral arteries
What are conditions thoughtto be associated with placenta-mediated disease?
Pre-eclampsia, Premature birth, Placental abruption, recurrent miscarriage and fetal growth restriction
What are complications of hypertnesion in pregnancy?
Maternal death and preterm birth
What are risk factors for gestational hypertension?
Primigravity, young 3x risk, Black 2x increased risk, Multifetal pregnacies preexisting hypertension renal disease colagen vascular disease
what are the risk factors for PET?
Nulliparity, Obesity, previous pre-eclampsia, chronic hypertension, multifetal, low or hight maternal age, CKD, Diabetes
What is Gestational hypertension/
New HTN after 20 weeks gestation, Systolic>140 Diastolic>90 no or little proteinuria
What is the definition of Preeclampsia?
HTN in pregnancy, with protenuria
What to look at in proteinuria?
0.3g protein /24horus or 2++ on urine dip specimen
PCR protein creatinine ratio greater than 30mg/mol
What separates severe preeclampsia from less severe?
Grade of HTN or with symproms or haematological imparmetn less than 400ml, Visual changes headache, scotomata mental status change pulmonary oeedemea epigastric or RUQ
Clinically, oligohydramnious, thrombocytopenic IUGR, Impared liver function tests
What are maternal complications of preeclampsia?
Cerebrovascular incident Haemolysis eleveated liver enzymes low platelets, HELLP syndrome DIC, Liver failure Renal failure, Pulmonary oedema.
What are the fetal complications of preeclampsia?
Eclampsia, IUGR, Preterm birth Placental abruption, Hypoxia
What are phsyical findings of preeclampsia?
Abdominal RUQ abdominal tenderness, Proteunuria
How is preeclampsia managed during pregnancy?
No much to do just control HTN stop exlampsia and other complications.
When should Preeclamptic ladies be delivered?
IF mild and cervix is facourable and mother sistable wait till 40 weeks, if mother symptomatic after 37 weekks Mg SO4 delivery, if under 37 keep in hospital and manage until latest possible
How to prevent and treat eclampsia?
Reduces frequency of fits and maternal death, Be careful in renal faliure
Which drugs are used for BP control/
Nifedipine, hydralazine and labetalol
When to deliver with preeclampsia?
Gestation over 38 weeks platelet could low, deterioration of renal and liver function, suspected placental abruption, persistent severe headaches, visual changes nausea epigastric pain or vomitting, delivery should be bast on maternal and rfetal condition as well as gestational age
How should baby of preeclampsi be delivered?
Vaginal prefered but need to deliver faster
What is used to prevent preeclampsia/
Aspirin
What are complications of preterm birth?
Developmental delay, visual imparment chronic lung disease and cerebral palsy
What are the causes for preterm bith ?
PPROM, Preterm labour, Cervical weakness, Amnionitis or on purpose obstetric disorders
What are risk factor for Preterm birth?
Non-recurrent, Antepartum haemorrhage, Other vaginal bleeding, Multiple pregnancy, Recurrent Race Precious preterm, Smoking, birth (preventable, genital infection cervical weakenss and socioeconomics
What is tertiary prevention of preterm birht?
Tocolysis antibiotis corticosteroids
What is secondary prevention of preterm birht?
Fibronectin test and transvaginal ultrasound
