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
2 absolute indications for CS?
Cephalopelvic disproportion
Praevia grades 3/4
Management if in breech?
Contraindications for ECV?
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
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
Hb level for treatment in pregnancy?
<110g/L at booking
<105g/L at 28 weeks
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
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
When to stop taking statins before pregnancy?
3 months
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
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
Criteria that must be met for operative vaginal delivery?
- 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
Main cause of PPROM?
Genital tract infection
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
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
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
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
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
A woman who has PV bleeding at 19 weeks needs anti-D?
Yes
Causes of bradycardia on CTG?
Tachycardia?
Brady:
- hypoxia
- aorta-caval compression
- epidural/spinal
- malpresentation
Tachycardia:
- initial response to hypoxia
- maternal/foetal infection
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
Causes of increased AFP in pregnancy? (3)
Decreased (2)
Increased:
Neural tube defects
Abdo wall defects
Multiple pregnancy
Decreased:
Trisomy
Diabetes
Is it safe for a woman with HepB to breastfeed?
Yes
