Obstetrics Flashcards
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
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
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
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)
When is nuchal scan performed?
What does increased thickness mean?
11 - 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
Causes IUGR - maternal, foetal and utero-placental?
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
Causes LGA?
Diabetes Wrong dates Polyhydramnios Multiple pregnancy Constitutionally large
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
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
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
What to do after sensitising events?
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)
Drugs for post-natal depression?
Sertraline or Paroxetine
What vaccines are live attenuated and so cannot be given in immunodeficiency/pregnancy?
MMR Varicella Yellow fever Rotavirus Influenza
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
Diagnosis of PPROM?
Management?
Speculum - look for fluid pooling in posterior vault
Can check Fibronectin for chance of going into labour
USS can show oligohydramnios
Management:
- admit
- regular obs to ensure no chorioamnionitis
- Erythromycin 10 days
- Steroids
- Consider delivery at 34 weeks
Pregnant woman with Hx of VTE?
LMWH throughout pregnancy until 6 weeks after
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
