Obstetrics Flashcards
What are the complications of gestational diabetes?
Large for date fetus
Macrosomia
Shoulder dystocia
What are the risk factors for gestational diabetes?
Previous gestational diabetes Previous macrosomic baby >4.5kg BMI>30 Ethnic origin: Black/Arab/Indian Family history of diabetes
What test is done for women with risk factors of gestational diabetes?
OGTT at 24-28 weeks
What is the diagnosis of gestational diabetes?
Normal results of OGTT:
Fasting <5.6mmol/l
At 2 hours: <7.8mmol/l
5-6-7-8
What is the management for gestational diabetes?
Fasting glucose <7: diet and exercise for 1-2 weeks followed by metformin then insulin
Fasting glucose >7: start insulin ± metformin
Fasting glucose >6 plus macrosomia: start insulin ± metformin
What should women with pre-existing diabetes do prior to getting pregnant?
Take 5mg folic acid from preconception until 12 weeks gestation
What happens to retinopathy screening for diabetic pregnant women?
Screening should be performed shortly after booking and at 28 weeks gestation
What happens at term for diabetic pregnant women?
Planned delivery between 37 and 38+6 weeks
women with gestational diabetes can give birth up to 40+6 weeks
What happens during labour for diabetic pregnant women
Sliding scale insulin regime is considered during labour for women with T1DM.
Also considered for women with poorly controlled T2DM
What is the postnatal care for diabetic pregnant women?
Gestational diabetic women can stop medication immediately and follow up with fasting glucose after 6 weeks.
Existing diabetic women should be vary of hypoglycaemia and lower insulin dose.
What is an amniotic fluid embolism?
When the amniotic fluid passes into the mother’s blood. Causes an immune reaction from the mother leading to systemic illness.
What are the risk factors for amniotic fluid embolism?
Increasing maternal age
Induction of labour
C-section
Multiple pregnancies
How does amniotic fluid embolism present?
Like sepsis, PE or anaphylaxis:
SOB Hypoxia Hypotension Coagulopathy Haemorrhage Tachycardia Confusion Seizures Cardiac arrest
What is management of amniotic fluid embolism?
Overall supportive but needs ABCDE
Definitions of different miscarriages
Missed: no longer alive, no symptoms have occurred
Threatened: vaginal bleeding with closed cervix and fetus alive
Inevitable: vaginal bleeding with open cervix
Incomplete miscarriage: retained products of conception
Complete miscarriage: full miscarriage and no products left
Anembryonic pregnancy: gestational sac is present but no embryo
What is the management for miscarriage at less than 6 weeks gestation?
Managed expectantly
Repeat urine pregnancy test after 7-10 days
What is the management for miscarriage after 6 weeks?
USS to confirm location and viability
Expectant management
Medical management (misoprostol)
Surgical management
What is the diagnosis of molar pregnancy?
More severe morning sickness Vaginal bleeding Increased enlargement of the uterus Abnormally high hCG Thyrotoxicosis
US shows snowstorm appearance
Confirmed with histology of mole
How is hypothyroidism managed in pregnancy?
Levothyroxine dose needs to be increased by at least 25-50mcg
Which hypertension medications are harmful in pregnancy?
ACE inhibitors (ramipril)
ARB (losartan)
Thiazide and thiazide like diuretics (indapamide)
Which hypertension medications can be used in pregnancy?
Labetalol Calcium channel blockers (e.g. nifedipine) Alpha clockers (doxazosin)
How is epilepsy managed in pregnancy?
5mg folic acid daily before conception
Levetricetam, lamotrigine and carbamazepine safe in pregnancy
NO SODIUM VALPROATE
How is rheumatoid arthritis managed in pregnancy?
Hydroxycholoroquine is considered safe and first line
Sulfasalazine is safe
Corticosteroids may be used during flare-ups
NO METHOTREXATE
What is placenta praevia?
When the placenta is over the internal cervical OS
Notable cause of antepartum haemorrhage
What are the risk factors for placenta praevia?
Previous C-section Previous placenta praevia Older maternal age Maternal smoking Structural uterine abnormalities (fibroids) Assisted reproduction (IVF)
What is the presentation and diagnosis of placenta praevia?
20 week anomaly scan is used to assess the placenta position and diagnose
Many are asymptomatic
May present with PAINLESS VAGINAL BLEEDING later in pregnancy (around or after 36 weeks)
What is the management of placenta praevia?
Corticosteroids are given between 34 and 35+6 weeks for lung maturity
Planned delivery between 36 and 37 weeks gestation
What are the risk factors for placental abruption?
Previous placental abruption Pre-eclampsia Bleeding early in pregnancy Trauma Multiple pregnancy Fetal growth restriction Multigravida Increased maternal age Smoking
What is the presentation of placental abruption?
Sudden onset severe CONTINIOUS abdominal pain
Vaginal bleeding
Shock (hypotension and tachycardia)
Abnormalities on CTG - fetal distress
WOODY abdomen on palpation
What are the guidelines regarding measurements for antepartum haemorrhages?
Minor: <50ml
Major: 50-1000ml
Massive: >1000ml or shock
What is the management of placental abruption?
2x grey cannula Bloods Crossmatch 4 units Fluid and blood resus CTG Monitor mother
USS to exclude placenta praevia
Steroids between 24 and 34+6
Rhesus-D negative require anti-D prophylaxis
What is the triad of preeclamsia?
Hypertension
Proteinuria
Oedema
After 20 weeks gestation
What are the risk factors for pre-eclampsia?
Pre-existing hypertension Previous hypertension in pregnancy Existing autoimmune conditions Diabetes CKD
What are the symptoms of pre-eclampsia?
Headache Visual disturbance/blurriness Nausea and vomiting Upper abdo/epigastric pain Oedema Reduced urine output Brisk reflexes
What is the diagnosis of pre-eclampsia?
Systolic >140 and diastolic >90
Plus any of:
Proteinuria
Organ dysfunction
Placental dysfunction
What is the management of pre-eclampsia during labour?
Prophylactic aspirin at 12 weeks gestation for women with a single high risk factor or two or more moderate risk factor
- Labetalol
- Nifedipine
- Methyldopa (stopped within 2 days of birth)
- IV hydralazine
- IV magnesium sulfate (stopped 24 hours after labour)
- Fluid restriction
What is the management of pre-eclampsia after labour?
Switch to one or a combination of:
- enalapril
- nifedipine or amlodopine (first line in black peeps)
- labetalol or atenolol
What is HELLP syndrome?
Haemolysis
Elevated Liver enzymes
Low Platelets
What is the criteria for an abortion to be performed at any time during pregnancy?
IF:
Continuing pregnancy is likely to risk the life of the woman
Terminating pregnancy will prevent “grave permanent injury” to the physical or mental health of woman
There is “substantial risk” that the child would suffer physical or mental abnormalities making it seriously handicapped
What are the legal requirements for an abortion?
Two registered medical practitioners must sign to agree abortion is indicated
Must be carried out by a registered medical practitioner in an NHS hospital
What are the medical abortion drugs
Mifepristone
Misoprostol 1-2 days later
What is vasa praevia?
where the fetal vessels are within the fetal membranes and travel across the internal cervical OS
What are the risk factors for vasa praevia?
Low lying placenta
IVF pregnancy
Multiple pregnancies
What is the presentation of vasa praevia?
May be diagnosed by USS
Antepartum haemorrhage during 2nd or 3rd trimester
Vaginal examination during labour
Fetal distress and dark red bleeding during labour
What is the management for vasa praevia?
For asymptomatic women: corticosteroids from 32 weeks and elective c-section for 34-36 weeks
What are the risk factors for a VTE in pregnancy?
Smoking Parity >3 Age >35 BMI >30 Reduced mobility Multiple pregnancy Pre-eclampsia Gross varicose veins Immobility FHx of VTE Thrombophilia IVF pregnancy
What is guidance regarding prophylaxis for VTE in pregnancy?
28 weeks if there are three risk factors
First trimester if there are four or more risk factors
LMWH e.g. enoxaparin, dalteparin and tinzaparin
Stopped when they go into labour and started afterwards
What is the diagnosis of DVT and PE in pregnancy?
DVT:
Doppler US
PE:
CXR and ECG first line
VQ scan diagnostic
What is the management of DVT in pregnancy>
LMWH and continued for 3 months after pregnancy
Which antibiotic should be given to children with group b strep sepsis?
Benzylpenicillin and gentamycin first line
OR
cefotaxime
What is the combined test?
First line and most accurate screening test for down syndrome performed between 11 and 14 weeks.
USS shows nuchal thickness >6mm
Blood test:
- high bHCG
- low PAPPA
What is the triple test?
Screening test for down syndrome performed between 14 and 20 weeks:
Bloods:
high bHCG
low AFP
low serum oestriol
Which form of contraception is safe in epilepsy?
If on enzyme inducers e.g. carbemazepine, phenytoin or topiramate: COPPER COIL, LEVONOGESTRAL IUS AND DEPO
If on non-enzyme inducers e.g. levetriacetam, lamotrigin, sodium valproate: ANYTHING
BUT DON’T GIVE COCP AND LAMOTRIGINE
What needs to be done in regards to COCP and surgery?
Stop 4 weeks before surgery and start 2 weeks after
What is the interaction between progesterone only pills and antibiotics
nothing
What is the treatment of bacterial conjunctivitis in pregnancy?
Topical fusidic acid eye drops
What are the classifications for post partum haemorrhage?
Defined as 500ml loss after vaginal delivery or 1000ml loss after C-section
Minor <1000ml
Major >1000ml
Moderate 1000-2000ml
Severe >2000ml
Primary: within 24hrs
Secondary: 24hr - 12weeks after birth
What are the causes of postpartum haemorrhage?
Four T’s
Tone
Trauma
Tissue
Thrombin
What is the management to stop the bleeding in postpartum haemorrhage?
Mechanical:
Rubbing uterus
Catheterisation
Medical: Oxytocin Ergometrine Caboprost Misoprostol TXA
Surgical: Intrauterine balloon tamponade B-lynch suture Uterine artery lligation Hysterectomy
What is Sheehan’s syndrome?
Rare complication of post partum haemorrhage where there is avascular necrosis of the anterior pituitary gland which leads to cell death
What are the features of sheehan’s syndrome?
Lack of lactation
Amenorrhea
Adrenal insufficiency and adrenal crisis
Hypothyroidism
Low cortisol and normal aldosterone
What is the management of Sheehan’s syndrome?
Oestrogen and progesterone
Levothyroxine
Hydrocortisone
Growth hormone
What is Meig’s syndrome?
Triad of:
Ovarian fibroma (benign ovarian tumour)
Pleural effusion
Ascites
What is cord prolapse?
When the umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina.
High risk of fetal hypoxia due to cord compression
What is the diagnosis of cord prolapse?
Should be suspected where there are signs of fetal distress on CTG.
Speculum exam: DIAGNOSTIC
What is the management of cord prolapse?
Emergency C-Section
Can push the presenting part of the baby back in
Woman lie in left lateral position or on all fours
Terabutaline can be used to minimise contractions
What is the definition of proteinuria?
Persistent urinary protein >300mg/25hr
What volume of amniotic fluid is consistent with polyhydraminos?
> 2-3L
What are the signs of uterine hyperstimulation?
Either:
>6 contractions within 10 minutes
or
<60s in between each contraction
Which babies are at risk of NRDS?
Diabetic mothers
What is the WHO guidelines for breast feeding?
Exclusively for 6 months and then combined with food for upto 2 years and beyond
What should be given to pregnant women who have a previous history of having a child with early/late onset group B strep?
IV antibiotic prophylaxis intrapartum
What is the preferred method of induction of labour?
Vaginal prostaglandin (PGE2)
What is the treatment for a RhD-ve women during pregnancy?
Anti-D
1st dose at 28 weeks
2nd dose at 34 weeks
