Obstetrics Flashcards
Fertilisation to implantation?
What is blastocyst?
Fertilisation in ampulla Day 1 - fertilised Day 5 - blastocyst Day 5-8 - blastocyst attaches to endometrium Day 12 - implantation complete
Blastocyst:
- divided into 2 cell masses
- inner = embryo
- outer = trophoblast (initial progesterone and implantation, goes on to produce placenta
Placenta:
- components?
- when is it fully functional?
- functions?
- maternal cells and trophoblast cells
5 weeks
Functions:
- hormone secretion - progesterone and hCG
- gas exchange
- nutrient exchange - Ca and Fe are only 2 which go unidirectional from mother to baby
Changes and functions during pregnancy:
- hCG?
- progesterone?
- oestrogen?
hCG:
- peaks at 10 weeks then reduces
- stimulates corpus lute to produce progesterone
- ensures early nutrition of embryo
Progesterone:
- initially produced by corpus luteum then placenta
- levels steadily rise through pregnancy
- prepares and maintains endometrium
- later, decreases uterine contractions
Oestrogen:
- principal site of production is placenta
- levels steadily rise through pregnancy
- enlarges uterus, develops breasts, relaxes pelvic ligaments
E3 - indicator of foetal viability
E4 - only produced through pregnancy
CVS changes in pregnancy?
CO increases from week 6, peaks at week 24, decreases then increases again in labour
SV up 30%, HR up 15% & cardiac output up 40%
Systolic BP is unaltered
diastolic BP is reduced in the 1st and 2nd trimester, returning to non-pregnant levels by term
IVC compression causes ankle oedema, supine hypotension and varicose veins
Resp changes in pregnancy?
Pulmonary ventilation up 40%, tidal volume up 200ml
O2 requirements up 20% - over breathing causes low CO2
-> this may cause sense of dyspnoea, accentuated by diaphragm compression
Metabolic changes in pregnancy?
BMR up 15%, probably due to thyroid or adrenalcorticotrophic hormones
Haem changes in pregnancy?
Blood volume up 30% but cells less than plasma, causing relative anaemia
Rise in fibrinogen and clotting factors, increased DVT risk, esp with IVC compression
Lower platelet count
Urinary changes in pregnancy?
GFR, renal blood flow increased
Urinary protein loss increased
Salt and water reabsorption increased due to increased sex steroid levels
Calcium changes in pregnancy?
Significantly increased requirements, esp in 3rd trimester with lactation
Ca is transported to foetus through placenta
Serum levels of Ca and PO4 drop due to fall in protein, but total ionised calcium remains the same
Gut absorption of Ca increases significantly due to increased VitD activity
Uterine changes?
100g -> 1100g
Hyperplasia and later hypertrophy
Increased cervical ectropion and cervical discharge
Braxton Hicks - practice contractions late in pregnancy
Hormones in labour?
Ferguson reflex?
Progesterone - prevents contractions
Oestrogen - stimulates contractions
Oxytocin - stimulates contractions and prostaglandin release
PG - increases contractions
Ferguson reflex:
- positive feedback loop
- stretch of cervix causes release of oxytocin which causes further stretching of cervix
Gestational diabetes diagnosis?
Management?
If metformin not tolerated?
Aims once on meds?
Diagnosis:
- fasting 5.6+
- 2 hours OGTT 7.8+
Management:
- Fasting 5.6-7: diet/exercise
If no better after 1-2 weeks - metformin
if still no improvement, short-acting insulin
- If 7+ at diagnosis, insulin straight off the bat
Glibenclamide
Aims:
- fasting 5.3
- 1 hour 7.3
- 2 hour 6.4
When should foetal movements be felt?
What is reduced foetal movements?
Ix?
24 weeks - if not then refer to foetal medicine unit
- Usually start at 18-20 weeks and gradually increase to 32 weeks then plateau
- No definition but generally <10 movements in 2 hours past 28 weeks
Ix:
- handheld doppler 1st line
- If <28 weeks, just confirm presence of heartbeat, if not present then immediate referral
> 28 weeks:
- If present on doppler, do CTG for 10 mins
- If not present on doppler or still concern after CTG, do immediate USS
Supplements in pregnancy?
VitD 400IU throughout pregnancy
Folic acid for first 12 weeks
400mcg
5mg if:
- obese >30 BMI
- FHx neural tube defect
- coeliac, diabetes, thalassaemia
- alcohol excess, phenytoin, methotrexate
Variable decelerations means?
Indicates?
Rapid fall in foetal HR with variable recovery phase
Indicate cord compression and potential cord prolapse
- Elevate presenting part either manually or by filling urinary bladder
- Get on all fours
- Consider tocolysis and prep for C-sec
Management of placental abruption <36 weeks and >36 weeks?
<36 weeks:
- foetal distress on CTG - immediate C-sec
- No foetal distress - admit for tocolysis and steroids
> 36 weeks
- immediate Csec
What is pre-eclampsia?
Features of severe?
- RF?
- New onset HTN >140/90 past 20 weeks gestation
Plus one of: - proteinuria (ankle oedema)
- Organ involvement (renal, liver, haem, neuro, uteroplacental dysfunction)
Severe:
- Hypertension >160/110
- protein ++/+++
- Headache
- visual disturbance
- papilloedema
- RUQ/epigastric pain
- Hyperreflexia
- HELLP
RF:
- HTN normally of in prev preg
- CKD
- Diabetes
- autoimmune
- Primi
- > 40
- Preg interval 10 years
- BMI >35
- FHx
- Multiple preg
How to prevent pre-eclampsia?
Referral?
Management of pre-eclampsia?
75mg aspirin from 12 weeks on if 2+ RF
- Emergency secondary care assessment in any suspected
- If BP >160/110 usually admitted for observation
Drugs:
- labetalol 1st line (CI asthma)
- Nifedipine 2nd line
- Hydralazine
- Methyldopa (CI depression)
Fluid restriction may be
What is HELLP?
Management?
Presents with nausea, vomting, RUQ pain in 10-20% with severe pre-eclampsia
Haemolysis
Elevated liver enzymes
Low platelets
Delivery
What is eclampsia?
Management and comps?
How long treat for?
Seizures due to pre-eclampsia
Management:
- Magnesium both prevents and treats seizures
- Monitor urine output, resp rate and O2 sats
- Calcium glutinate treats Magnesium induced resp depression
- treat for 24 hours after delivery or after last seizure
Management of shoulder dystocia?
- McRobert’s - maximally flex and abduct hips
- Suprapubic pressure in McRobert’s
- Episiotomy (may help but allows extra room for internal manoeuvres)
- Rubin, push on posterior shoulder
- Wood’s screw, zavanellib, symphesiotomy, emergency CS
Placenta praaevia?
Normally picked up on 20 week scan
If low lying, repeat USS at 34 weeks
Suspect if painless vaginal spotting that starts >30 weeks and increases in frequency and volume
TVUS
CS to prevent labour
What is routinely offered in screening at booking scan?
- anaemia
- bacteriuria
- Blood group, rhesus, ABO
- Trisomy
- Foetal anomalies
- HepB
- HIV
- Syphilis
- neural tube defects
- RF for pre-eclampsia (diabetes, CKD, autoimmune etc)
What is placenta accreta?
RF?
Small print but different types?
Defect in decidua basalis causing placenta to attach to myometrium, risk of significant PPH as it doesn’t detach properly
Decidua basalis is the endometrial cells of the placenta, normally there is a fibrinous layer separating this from normal uterine wall
RF:
- previous CS
- placenta praevia
Accreta - chorionic villi attach to myometrium instead of decidua basalis
Increta - Chorionic villi invade myometrium
Percreta - Chorionic villi invade through perimetric
When is nuchal scan performed?
What does increased thickness mean?
11+3 - 13+6
Trisomy
Congenital heart defect
Bowel wall defect
Hyperechogenic bowel:
CF
Down’s
CMV infection
When is combined test done, what is the results?
Quadruple test?
If these come back high risk?
11-13+6 weeks
- increased nuchal translucency
- Increased bHCG
- decreased PAPP-A
If between 15-20 weeks - quadruple test:
- increased inhibin-A
- increased bHCG
- decreased AFP
- decreased unconjucated oestriol
CVS - 10-13 weeks
2% risk miscarriage
Amniocentesis - 15 weeks
1% risk miscarriage
Sample may not be adequate
Trisomy 21?
Trisomy 18?
Trisomy 13?
Down’s:
- appearance, learning disability, AVSD, duodenal atresia/Hirshprung’s, leukaemia, thyroid, epilepsy, alzheimers
18 - Edwards:
- Cardiac, GI, uro abnormalities
- Severe mental disability
- Die soon after birth
12 - Patau
- cleft palate, microcephaly
- severe mental disability, die soon after birth
How to measure foetal size?
What is SGA and LGA?
Examination - SFH USS: (- crown rump length if early) - femur length - head circumference - abdo circumference Final 3 measurements put into Hadlock equation
SGA - SFH <2cm Gest age after 20 weeks
LGA >2cm
Causes IUGR - maternal, foetal and utero-placental?
Symmetrical/asymmetrical reductions?
Complications in pregnancy, neonatal and lateral life?
Maternal:
- poor nutrition
- alcohol, smoking, drugs
- HTN, diabetes, anaemia,
- B-blockers
Foetal:
- multiple pegnancy
- congenital/chromosomal abnormality
- toxoplasma/CMV
Placental:
- pre-eclampsia
- uterine malformation
- placental insufficiency
If reduced head and abdo size suggests growth restrictions throughout pregnancy
If asymmetrical growth suggests growth reduction has occurred later in pregnancy due to placental insufficiency
Still birth/preterm labout
Jaundice, neonatal sepsis
Later life: obesity, HTN, T2DM
Causes LGA?
Diabetes Wrong dates Polyhydramnios Multiple pregnancy Constitutionally large
Drugs to avoid in breastfeeding:
- abx?
- psych?
- endocrine?
- cardiac?
- others?
abx: cipro, tetracyclines, chloramphenicol, sulphonamides (co-trimox, but trimethoprim safe)
psych: lithium, benzos, clozapine
endocrine: sulfonylurea, carbimazole
Cardiac: ACEI, amiodarone
Others: aspirin, naproxen, methotrexate, cytotoxic
Varicella exposure in pregnancy?
If develop chickenpox?
(rules for <20 and >20 weeks for both)
If any doubt, check antibodies
If <=20 weeks and NOT immune, offer IVIG within 10 days
If >20 weeks and NOT immune, wait until 7 days post-exposure and give IVIG or aciclovir for 7 days
If chickenpox:
If >=20 weeks, oral aciclovir with within 24 hours of onset
If < 20 weeks, aciclovir should be considered with caution
Management of PPH?
Initial - lie flat give O2, assess 4T’s, blood X match, rapid IV fluid replacement
- Rub uterus/bimanual palpation
- Oxytocin +/- ergometrine IM (avoid ergometrine in HTN)
- Tranexamic acid 1g slow infusion
- Oxytocin infusion (over 4 hours)
- urinary catheter
- Carboprost IM - every 15 mins up to 8 doses
- Misoprostol PR
Theatre:
- Balloon tamponade
- B-lynch sutures
- Arterial ligation
- hysterectomy
How to differentiate intrahepatic cholestasis from AFL of P?
How is each managed?
What else can cause itch in pregnancy?
Jaundice?
Cholestasis:
- pruritus palms, soles, abdo
- jaundice in 20%
- small raised bili and cholestatic enzymes
Rx: induce labour at 37 weeks (risk of still birth)
Symptomatic - Ursode acid
VitK supplements
AFL of P:
- RUQ pain, vomiting
- Jaundice
- Headache
- Hypoglycaemia
- Severe disease may cause pre-eclampsia
- ALT >500
Rx: stabilise and delivery
Itch: Prurigo of pregnancy - itchy papular rash over abdo and legs >35 weeks - creams and delivery
Jaundice:
- HELLP
- Gilbert’s can flare
Differentiating between ITP and gestational thrombocytopaenia?
Why can it be important?
Difficult - usually if low platelets at booking scan or previous ITP will be tested for anti-platelet antibodies
If slow progression of decreased platelets gestational TCP presumed, but if dangerously low then ITP presumed and given steroids
Gest TCP doesn’t affect newborn, but ITP can cause TCP in newborn as IgG crosses placenta - can cause haemorrhage in newborn - high risk if prolonged ventouse
Pathophysiology of RhD disease?
Sensitisation events?
If Rh- mother has Rh+ baby, this causes anti-D IgG to form.
This usually happens in first pregnancy as blood mixes during delivery. This causes IgG to cross placenta in future pregnancies
In first pregnancy this can also occur due to sensitisation events.
Sensitisation events:
- giving birth
- previous TOP
- miscarriage >12 weeks
- ectopic managed surgically
- antepartum haemorrhage
- amnio/CVS/foetal blood sampling
- external cephalic version
- abdo trauma
When to give anti-D?
What to do after sensitising events?
If woman is already sensitised?
Test all Rh- women for anti-D at booking - indirect coombs test (indirect antiglobulin)
Give anti-D to all non-sensitised Rh- women at 28 and 34 weeks
After a sensitising event:
- <20 weeks give 250 units anti-D
- > 20 weeks give 500 units and Kleihauer (tests for quantity of foetal blood in maternal circulation)
If already sensitised nothing can be done unfortunately
If woman has anti-D antibodies what will happen?
Cross placenta and cause Rhesus haemolytic disease - spectrum
- progressive anaemia
- CCF
- hepatosplenomegaly
- bilirubin -> kernicterus
- hydrops fetalis
(hydrops - oedematous as albumin falls because liver devoted to RBC production)
If foetus still viable, can deliver if appropriate gestation, and transfuse once born and give phototherapy
Risk factors for abruption?
- Proteinuria/HTN/pre-eclampsia
- cocaine abuse
- polyhydramnios
- multiparity
- trauma
- increasing maternal age
Presentation of abruption?
Lower abdo pain May be some blood Usually pain out of proportion with findings Tender, hard uterus May have shock - anuria/DIC/tachy/hypo
If >36 weeks - emergency CS
If <36 weeks check CTG
- distress - emergency CS
- no distress yet - admit for steroids
Amniotic fluid embolism:
- presentation?
- test?
- Rx?
Usually in labour, can happen in CS or immediate postpartum period as well
Essentially same as PE
Dyspnoea, coughing, chest pain, tachycardia, tachypnoea, hypotension, cyanosis, arrhythmia
No definitive test, diagnosis of exclusion
ICU MDT, mainly supportive
Suspected DVT/PE in pregnancy:
- Ix DVT?
- Ix PE?
- Rx?
- thrombolysis?
DVT: Duplex USS
PE:
- ECG and CXR
- If DVT, duplex USS - if present treat (no need for CT/VQ)
- if no DVT, decision between CTPA/VQ is with radiologist and pt
CTPA - higher dose radiation to mother, risk breast cancer
VQ - higher dose radiation to baby, risk childhood cancer
D dimers useless as raised in pregnancy
Rx: LMWH (DOAC and Warfarin CI in pregnancy)
Thrombolysis also CI in pregnancy as it will result in catastrophic haemorrhage for mother and foetus
Most common cause of cord prolapse?
Artificial rupture of membranes
3/4 commonest pregnancy-related causes of bleeding in each trimester?
Maternal causes for any trimester?
1st:
- implantation
- spontaneous abortion
- ectopic pregnancy
- mole
2nd:
- abortion
- mole
- abruption
3rd (antepartum haemorrhage):
- bloody show
- abruption
- placenta praevia
- vasa praevia
Maternal:
- genital tract infection
- Cervical ectropion, polyp or malignancy
When is Hb checked in pregnancy?
If Fe depleted?
Booking, 28 and 34 weeks
200mg ferrous sulphate
Types of miscarriage:
- complete?
- incomplete?
- missed/delayed?
- anembryonic pregnancy?
- threatened?
- inevitable?
Complete - empty uterus
Incomplete - pain and bleeding, some products of conception still there, os open, some have been expelled
Missed/delayed - some light spotting/no bleeding at all - dead foetus, os closed
Anembryonic pregnancy - gestational sac >25mm but no foetal parts
Threatened - painless bleeding <24 weeks, os closed, pregnancy continues
Inevitable - some bleeding with clots and pain, os open, miscarriage about to happen
1st line management for miscarriage?
Criteria for intervention?
Medical management?
Surgical management?
Expectant - wait 14 days
Criteria:
- Increased risk of haemorrhage (late 1st trimester or coagulopathy)
- signs of infection
- previous adverse/traumatic experience
Medical:
- Oral misoprostol
- give anti-emetics and analgesics
Surgical:
- vacuum aspiration (LA, outpatient)
- surgical evacuation (GA, inpatient)
How to diagnose miscarriage?
Can diagnose if sac >25mm or CRL >7mm and no heartbeat, but need 2 sonographers to confirm
If <25mm or <7mm cannot diagnose on first scan - pregnancy of uncertain viability - need to wait a week and rescan
What is needed for TOP? How is it done if: - <9 weeks (early)? - 9-12 weeks (late)? - 12-14 weeks (mid-trimester)?
- 2 medical practitioners to sign off on it
- in emergency only one is needed (risk to life)
Method:
<9 weeks - mifepristone (progesterone antagonist) followed by misoprostol 48 hours later - this can be completed at home
9-12 weeks - vacuum aspiration
> 12 weeks - medical - in hospital
If someone has discharge very early e.g. 25 weeks, how can you test if it is from gestational sac?
What should you do?
foetal fibronectin test of fluid in speculum test
Admit for 2 doses of steroids in case of preterm labour
What is someone with insulin-controlled diabetes e.g. T1DM needs 2 high dose steroids IM?
Admit and monitor BM’s closely, adjusting insulin accordingly
Group B strep: RF for infection? If GBS in previous pregnancy? To women in preterm labour? If fever in labour?
20-40% of women are carriers
RF:
- prematurity
- PPROM
- Previous GBS sibling
- Maternal pyrexia (chorioamnionitis)
If GBS in prev pregnancy they should be offered intrapartum benzylpenicillin or testing 3-5 weeks before delivery (and Rx if +ve)
Intrapartum abx should be offered to ALL women in preterm labour regardless of GBS status
Offer intrapartum abx to ALL women with temp >38 in labour
Baby blues?
Postnatal depression?
Puerperal psychosis?
Baby blues:
- affects 60% women, first 3-7 days following birth, anxious, tearful and irritable
Postnatal depression:
- affects 10%
- Symptoms start in first month and peak at 3 months
- Support, CBT
- Sertraline and Paroxetine only ones licensed
Puerperal psychosis?
- affects 0.2%
- onset first 2-3 weeks following birth
- severe mood swings (similar to bipolar), disordered perception (auditory hallucinations)
- 25-50% chance of reoccurrence in future pregnancies
What vaccines are live attenuated and so cannot be given in immunodeficiency/pregnancy?
MMR Varicella Yellow fever Rotavirus Influenza
Maternal indications for inducing labour?
- Prolonged pregnancy >41 weeks
- PPROM
- Hypertension, diabetes, cholestasis, APH, deteriorating illness
Foetal:
- macrosmia
- IUGR
Contraindications for inducing labour?
Malpresentation
Praevia
Cord prolapse
Signs of foetal distress
What foods to avoid in pregnancy?
Travel?
Sports?
Listeriosis:
- unpasteurised milk, soft cheeses (camembert, brie, blue), pate
Salmonella:
- undercooked meat/poultry/eggs
Vit A:
- Liver (teratogenic)
Air travel:
Avoid >37 weeks in singleton pregnancies and >32 in multiple pregnancies - wear compression stockings
Sports:
Avoid high impact sports and scuba diving
PPROM:
- complications?
- how to determine?
- management?
Comps:
foetal - prematurity, infection, pulmonary hypoplasia
maternal - chorioamnionitis
Determine:
- sterile speculum exam to look for pooling of fluid in posterior vaginal vault
- Avoid digital exam - risk of infection
- If no pooling but suspicion, USS to look for oligohydramnios
Management:
- admit
- regular obs to ensure no chorioamnionitis
- Erythromycin 10 days
- Steroids
- Consider delivery at 34 weeks
DVT/VTE prophylaxis in pregnancy?
Any woman with previous VTE get LMWH throughout entire pregnancy until 6 weeks post-natal
Risk factors:
- Age >35
- BMI >30
- Parity >3
- Smoker
- varicose veins
- current pre-eclampsia
- immobility
- FHx VTE
- thrombophilia
- multiple pregnancy
- IVF
If 4+ of above factors - LMWH throughout pregnancy until 6 weeks postpartum
If 3 of above LMWH from 28 weeks -> 6 weeks postpartum
If a HepB +ve woman gives birth?
HepB IVIG + vaccine within 12 hours of birth
Further vaccines at 2 and 6 months as per normal schedule
Layers cut/torn through in a C-section
Skin Sup and Deep fascia Anterior rectus sheath Rectus (incision in linea alba then torn) Transversalis fascia Extraperitoneal connective tissue Peritoneum Uterus
Absolute and relative indications for C-section?
Absolute:
Cephalopelvic disproportion
Praevia grades 3/4
Relative: Pre-eclampsia Post-dates IUGR Foetal distress in labour/cord compression Failure to progress Brow malpresentation Abruption (if foetal distress - if dead deliver vaginally) Vaginal infection (e.g. active herpes) Cervical cancer
'Serious' risks of C-section: - maternal? - future pregnancies? 'Frequent risks: - maternal? - foetal?
Serious maternal:
hysterectomy, retained placental tissue, VTE, bladder/ureteric injury, subfertility due to adhesions, death (1/12000)
Serious future:
uterine rupture, still birth, praevia, accreta
Frequent maternal:
Persistent wound, abdo discomfort, future CS, readmission to hospital, haemorrhage, infection (wound, endometritis, UTI), prolonged ileum
Frequent foetal:
Laceration (2/100)
VBAC recommendations?
If CS was due to foetal factor such as distress, may try VBAC
CI = previous uterine rupture or classical cesarian
Which presentation has the greatest morbidity and mortality?
Footling breech - breech but one foot hanging down - 20% chance cord prolapse
Breech risk factors?
Management?
Contraindications for ECV?
RF:
- fibroids
- praevia
- poly/oligo-hydramnios
- foetal abnormality (CNS, chromosomal)
- prematurity
If breech at 36 weeks try ECV (37 in multiparous women)
If doesn’t work can still do vaginal or CS delivery
CI for ECV:
- APH in last 7 days
- CS required
- abnormal CTG
- uterine abnormality
- ruptured membranes
- multiple pregnancy
When is hCG first detectable in the blood?
8 days post-conception
It is secreted by syncitiotrophoblasts
Level the doubles every 48 hours until 8-10 weeks then starts to subside
How does face presentation occur?
Prognosis?
Normally occurs by chance as the head extends rather than flexes as it engages
99% rotate so the chin lies behind the symphysis so the head can be born by flexion
1% rotate so the chin is behind the sacrum - emergency C section
After what gestation is same day delivery an option in pre-eclampsia?
Should treatment continue into induced labour?
What can help BP if induced labour?
34 weeks
Yes, continue into labour
Epidural
When are women screened for anaemia?
Cut off?
Booking visit and 28 weeks
<110g/L at booking
<105g/L at 28 weeks
Oral iron tablets
Indications for forceps delivery?
- foetal or maternal distress in second stage of labour
- failure to progress 2nd stage
- control of head in breech delivery
Requirements
- Ruptured membranes
- Full dilation, in 2nd stage
- Cephalic presentation, preferably OA
- Station 0 or below, cannot be palpated abdominally
- Pain relief
- Bladder empty (catheterisation)
Post-partum thyroiditis: 3 stages? Diagnosis? What antibody is positive? Management?
Stages: 1. thyrotoxicosis 2. hypothyroidism 3. euthyroid (high recurrence in future pregnancies)
Diagnostic criteria:
- <12 months postpartum
- Clinical manifestation of hypothyroidism
- TFT support diagnosis
anti-TPO +ve in 90%
Management:
- thyrotoxic phase - propranolol for symptoms
- thyroxine if hypothyroid
On USS what is suspicious of praevia after presenting with painless bleeding?
- high presenting part
- abnormal presentation
If woman has pre-eclampsia with hypertension and +++ protein in labour at term - management?
IV labetalol (or others) with target systolic <150 and diastolic 80-100
Statins and pregnancy?
Stop taking statins 3 months before conception
criteria for continuous CTG in labour?
- Maternal request
- Temp >38 or suspected chorioamnionitis/sepsis
- Hypertension >160/110
- Oxytocin use
- Meconium
- Fresh vaginal bleeding in labour
(fresh vaginal bleeds in labour most commonly placental rupture or praevia)
Most common cause of antepartum haemorrhage?
- placental rupture
2. placenta praevia
3 parameters of contractions?
- frequency
- start 10-15 mins apart, increase in frequency, usually 3-4/10 mins at peak - Duration
- initially 10-15 secs
- 1 min at peak - Intensity
- amount of pain
Factors of the passenger?
- size
- lie
- presentation (what part enters pelvis first)
- position (foetal occiput in relation to pelvis e.g. OA)
CI for induction of labour?
Malpresentation
Placenta praevia
Cord prolapse
Signs of foetal distress
Methods of induction?
Membrane sweep - offered to nulliparous women at 40 and 41 weeks and porous women only at 41 weeks
Topical prostaglandins - mainstay
Amniotomy - only once cervix is deemed ‘ripe’, sometimes done alongside syntocinon infusion
IV syntocinon - membranes must be ruptured
Stages of labour?
Stage 1: onset to full dilation
- latent: 0-4cm, can last variable amount of time
- active - 4-10cm dilation, usually lasts a few hours, assoc w regular, intense contractions
Stage 2: full dilation to delivery
Stage 3: delivery of baby to delivery of placenta
- active management preferred. 30 mins max active, or 60 mins passive
- Methods: controlled cord traction, syntocinon, ergometrine (not in HTN/cardiac disease)
Times allowed for stage 2 of labour?
Nulli w/o anaesthesia - 2 hours
Nulli w anaesthesia - 3 hours
Multi w/o anaesthesia - 1 hours
Multi w anaesthesia - 2 hours
What is engagement?
What is descent?
Engagement - when head enters pelvis
Measured in 5th palpable in abdo
Descent - passage through birth canal, measured in stations from ischial spine from -5 to +5
Aided by moulding
7 cardinal movements?
Engagement - enters pelvis OT
Descent
Flexion
Internal rotation (usually to OA, sometimes OP
Extension
External rotation (restitution) - head rotates back in line with shoulders
Expulsion - delivery of shoulders
Assessment of labour?
Via partogram:
- contractions
- cervical dilation
- stations of descent
- amniotic fluid - presence and colour
- Maternal obs: pulse, temp, BP
- foetal observations: HR, position of head, presence of moulding (sign of obstruction)
Assessment of cervix:
- consistency, effacement and dilatation
Monitoring in labour?
FHR every 15 mins (or continuously via CTG if required)
Contractions every 30 mins
Maternal pulse every hour
Every 4 hours:
- maternal BP and temp
- vaginal exam for progression
- maternal urine for protein and ketones
Pain relief in labour:
- non-pharm/basic?
- opiates?
Massage, aromatherapy, water bath
Entonox - 50% air 50% NO
Opiates:
- Penthidine or diamorphine
- Maternal SE: N&V
- foetal SE: drowsiness, neonatal RDS
Epidural:
- disadvantages?
- SE?
LA/opioid mix in epidural fat space - most effective form of analgesia
Onset 20-30 mins and can be topped up as labour continues
Dis:
- slow second stage of labour
- malpresentation
- need for operative vaginal delivery (not CS)
- cannot lie flat - aorta-caval compression
Maternal SE:
- headache (low pressure)
- urinary retention
- hypotension
Foetal SE:
- risk of distress (prolonged labour)
- Bradycardia (if maternal hypotension persists) - treated with IV fluids and ephedrine
Spinal anaesthetic?
Injection of LA/opioid into subarachnoid space
Much quicker onset but doesn’t last as long
Anaesthetic of choice for CS
SE: similar to epidural but hypotension can be more profound
Pudendal nerve block:
- where?
- use?
Injection of LA into pudendal nerve (S2-S4)
Find ischial spines then move 2 finger breadths lateral which allows needle to be passed through sacrospinous ligament into pudendal nerve
Most commonly used during operative vaginal delivery
Puerperium:
- discharge?
- What else happens?
Lochia
- Rubra - dark red - 3-4 days
- Serosa - pinkish brown - 4-10 days
- Alba - whitish yellow - 10-28 days
Also:
- lactation
- uterine involution
- highest risk of VTE
Indications for operative vaginal delivery?
Criteria?
Contraindications?
Foetal - distress/compromise
Maternal - exhaustion, failure to progress, indications against prolonged pushing e.g. cardiac/hypertensive disease
Criteria:
- Head fully engaged (not palpable abdominally)
- Station at least 0
- membranes ruptured
- cervix fully dilated
- Caput and moulding no more than moderate
- exact position of head determined (for proper placement of instruments)
- able to give woman appropriate analgesia
CI:
- breech
- absolute cephalopelvic disproportion
Common complications with forceps delivery and ventouse delivery?
Forceps:
- perineal trauma
- facial bruising
- temporary facial nerve palsy
Ventouse:
- higher failure rate
- cone head - chignon
- increased risk of retinal haemorrhage and cephalhaematoma
Categoris of C section?
Elective indications?
Emergency indications?
1 - immediate threat to life
2 - no immediate threat to life
3 - requires early delivery
4 - elective
Elective:
- breech
- praevia
- known cephalopod-pelvic disproportion
- maternal infection (HIV/HSV)
Emergency:
- eclampsia
- foetal distress
- abruption
- cord prolapse
- failure to progress
What can cause PPROM?
genital tract infection
What is classed as prolonged latent phase?
Primary arrest?
Secondary arrest?
Latent - longer than 8 hours to get to 4cm dilated
Primary - poor progress of active phase - <7cm after 4 hours
Secondary - poor progress after reaching 7cm dilated
Causes of failure to progress?
Management for poor contractions, malposition and malpresentation?
Weak, irregular contractions
Disproportion
- absolite
- relative (malposition of head in pelvis)
Malpresentation
Management:
- contractions: examine every 2 hours, offer ROM if not occurred, commence CTG and syntocinon
- > if still slow progress over 4-6 hours or foetal distress then section
- malposition: usually operative vaginal if head at station
- malpresentation: depends on presentation, breech usually delivered via section
Risk factors for foetal distress?
Prematurity/postmaturity Multiple pregnancy SGA VBAC Maternal disease: HTN, diabetes, cholestasis Use of regional anaesthesia Ovarian hyperstimulation
Foetal assessment:
- liquor?
- HR?
- CTG?
- Vaginal exam?
Liquor:
- normally clear, if meconium may be due to postdates or distress
HR:
- via doppler, every 15 mins in stage 1, every 5 mins or after every contraction in stage 2
CTG:
- commenced if: maternal request, pyrexia on 2 separate occasions, abnormal HR, syntocinon, meconium
- bradycardia, loss of variability, late decelerations
Exam:
- excessive caput/moulding
Management of confirmed foetal distress?
- sit mother up
- IV fluids
- Stop syntocinon
- take foetal blood sample
- Consider terbutaline and plan CS
Blood sample:
- pH >7.25 = normal
- pH 7.2-7.25 = borderline, repeat in 30 mins
- pH <7.2 = acidotic, immediate delivery
Where is episiotomy cut into?
What should women be given?
Posterolateral incision through skin and perineal muscle from vagina to ischioanal fossa
Laxatives, abx, analgesia
Nausea in 3rd trimester, no other symptoms, all bloods normal but slightly raised ALP?
Benign 3rd trimester nausea
Often due to pressure on stomach from expanding uterus
ALP can be slightly raised due to placental production
Antipsychotics in pregnancy, what type are generally safer?
Risk of atypicals? What one is CI in breastfeeding?
Typicals
Atypicals - risk of gestational diabetes and IUGR
Clozapine CI in breastfeeding
Foetal alcohol syndrome?
Low IQ
Hearing problems
Heart and kidney malformations
Facial dysmorphism: short palpebral folds, thin upper lip, indistinct philtrum
Treatment of pyelonephritis in pregnancy?
Co-amoxiclav
Management of antiphospholipid syndrome in pregnancy?
Aspirin from conception until foetal heart first seen
LMWH once foetal heart seen on USS (around 6 weeks) until 34 weeks, then stop
Ix of DVT/PE in pregnancy?
Management?
If DVT: doppler USS
If also suspicious of PE:
- CXR and ECG
- Patient decides between V/Q scan (higher risk of childhood cancer) and CTPA (higher risk of maternal breast cancer)
D-dimer useless as raised in pregnancy anyway
Rx:
- LMWH until 6 weeks post pregnancy, or for 3 months, whichever is longer
Foetal effects of: - valproate? - phenytoin? - carbamazepine? How should mothers with epilepsy be managed?
valproate - spina bifida, cardiac problems, autism, dysmorphic face
Phenytoin - cleft palate, cardiac defects
Carbamazepine - neural tube defects, VitK deficiency
Manage:
Try and optimise treatment on monotherapy, folic acid 5mg, detailed anomaly scan, VitK to mum at 36 weeks AND baby following delivery
When are women screened for diabetes?
Diagnosis of gestational diabetes?
Management?
Blood glucose targets for fasting, 1 hour and 2 hour after meal?
Booking and 24-28 weeks
Diagnosis:
- fasting 5.6+
- OGTT 7.8+
Management:
- if 5.6-7, trial diet & exercise for 1-2 weeks
- if still no improvement, Metformin (or glibenclamide)
- if >7, insulin
- if on metformin and still high, add insulin
Targets:
- fasting 5.3mmol/L
- 1 hour 7.8mmol/L
- 2 hour 6.4mmol/L
Management of pre-existing diabetes in pregnancy?
Before pregnancy:
- weight loss if BMI>27
- stop oral hypoglycaemic except metformin and start insulin if needed
- folic acid 5mg
In pregnancy:
- tight glycemic control
- 20 week anomaly scan
Diagnosis of HTN in pregnancy?
> 140/90 on 2 occasions
Diastolic >110 on any occasion
Severe >160/110
If pre-existing HTN what should you do at start of pregnancy?
Stop ACEI/ARB
Don’t rush into new medication as BP naturally decreases in first trimester
Main cause of death in pre-eclampsia?
Pulmonary oedema
When is hyperemesis most common?
RF for hyperemesis?
What is protective?
Most common at 8-12 weeks as hCG peaks, and can last up until 20 weeks
RF:
- first pregnancy
- young maternal age
- Multiple/molar pregnancy
- diabetes/hyperthyroid
Smoking is protective
Consequences of hyperemesis?
Mandatory Ix?
Ketosis Dehydration (low Na, K) Hypovolaemic shock Nutritional deficiency (Wernicke's) Acute tubular necrosis
Ix:
- FBC, U&E, TFT
- ketones
- urine dip & culture
When to admit for hyperemesis?
Treatment of vomiting?
3 other things to consider in management?
- unable to keep food, fluids or oral antiemetics down
- Ketonuria or 5% weight loss despite antiemetics
- confirmed comorbidity (e.g. unable to keep down oral abx for UTI)
Vomiting: 1. Cyclizine 2. Ondansetron (or metoclopramide but EPSE) 3. Dexamethasone also ginger and P6 accupuncture
Others:
VTE prophylaxis: LMWH
Saline and electrolyte replacement
Thiamine - pabrinex
What do healthy start vitamins contain?
Folic acid, ViaC and VitD - given if poorer background as may not be able to afford supplements
What 3 things can be checked on doppler USS if a baby is LGA or SGA?
Umbilical artery
Middle cerebral artery
Ductus venosus
3 examples of AD inherited diseases?
3 examples of AR?
Explain x-linked recessive?
2 examples of it?
AD - Huntington’s, NF, Marfan’s
AR - CF, sickle cell, Tay Sachs
X-linked recessive:
- Dad affected will pass on to daughters who become carriers - not sons
- Mum carrier may pass on to son or daughter:
- 50% of sons affected, 50% unaffected
- 50% daughters carrier, 50% unaffected
Examples: DMD, Haemophilia A
A woman who has PV bleeding at 19 weeks needs anti-D?
Yes
Shape of anterior and posterior fontanelles?
Anterior - diamond
Posterior - triangle
Causes of bradycardia on CTG?
Tachycardia?
Brady:
- hypoxia
- aorta-caval compression
- epidural/spinal
- malpresentation
Tachycardia:
- initial response to hypoxia
- maternal/foetal infection
Causes of reduced variability on CTG <5bpm?
Prematurity Acidosis/hypoxia Spinal/epidura; Sleeping (<40 mins) Opiates
What are accelerations on CTG?
> 15 bpm for >15 seconds
Causes of decelerations:
- early?
- variable?
- late?
Early:
- normal response to head compression. Begin at start of compression
Variable:
- rapid fall from baseline with variable recovery
- May/may not be pathological, worry if >90 mins (cord compression)
- Shouldering - HR increase before and after decel - cord compression
Late:
- always pathological - starts mid-contraction and doesn’t stop until after contraction ends
- Sign of hypoxia - needs delivered
Normal liquor volume?
As seen on USS?
500-1500ml
2-8cm
Causes of polyhydramnios?
Symptoms?
O/E?
- usually idiopathic
- twins (if unilateral - TTTS)
- diabetes
- problem with swallowing (atresia, neuromuscular)
- hydrops fetalis
SOB, abdo discomfort, feels like she is about to burst, unable to lie flat
O/E - tense, shiny abdo, large uterus with difficulty feeling foetus
Complications of polyhydamnios?
Preterm labour
Cord prolapse
PPROM
Management:
- USS to confirm
- address and treat RF
- increase monitoring
What is oligohydramnios?
Causes?
Diagnosis?
What is seen in foetus?
<500ml/<2cm amniotic fluid
IUGR
Renal agenesis
Diagnosis - USS
Potter’s syndrome:
- club feet
- pulmonary hypoplasia
- flat nose, recessed chin, low set ears, skeletal abnormalities
What is zygosity, chorionicity and amnionicity?
What will dizygotic twins be?
What will monozygotic twins be?
What is the most common?
zygosity - number of eggs
chorionicity - number of placenta
amnionicity - number of amniotic sacs
Dizygotic twins will always be dichorionic and diamniotic
Monozygous twins can be any
Monochorionic diamniotic is most common
4 characteristic features of Patau Syndrome?
Trisomy 13
Microcephaly, small eyes
Cleft lip
Polydactyly
Scalp lesions
4 characteristic features of Edwards Syndrome?
Trisomy 18
Micrognathia
Low set ears
Rocker bottom feet
Overlapping fingers
Characteristic features of Down’s Syndrome?
Trisomy 21
Management of uterine inversion?
1st line - manual replacement of uterus
2nd line - hydrostatic replacement under pressure with warm saline
OR
Manual replacement under anaesthetic
Give oxytocin after replacement
When is booking done?
What is done at booking?
8-12 weeks
General info - weight, diet etc
BP, urine, BMI
Bloods/urine:
- FBC, G&S, Rh status, red cell ABO, haemoglobinopathies
- HepB, syphilis
- HIV
- Urine culture for asymptomatic bacteriuria
When is scan to confirm dates and exclude multiple pregnancy?
10-13+6 weeks
When is down syndrome screening?
Combined test (nuchal, hCG, PAPP-A): 11-13+6
Quadruple (hCG, AFP, inhibin-A, UE3): 15-20 weeks
When is anomaly scan done?
18-20+1 weeks
What is done at 28 week appointment?
BP, urine dipstick, SFH
Second screen for anaemia and ABO (if <10.5 consider Fe)
First dose anti-D if -ve
What is done at 34 week appt?
BP, urine dipstick, SFH
Second dose anti-D
What is done at 36 week appt?
BP, urine, SFH
Check presentation - offer ECV
Info on breast feeding, VitK, baby blues
(also give VitK if on carbamazepine)
Causes of increased AFP in pregnancy? (3)
Decreased (2)
Increased:
Neural tube defects
Abdo wall defects
Multiple pregnancy
Decreased:
Trisomy
Diabetes
Screening for post-natal depression?
Edinburgh post-natal depression scale
Is it safe for a woman with HepB to breastfeed?
Yes
