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Finals Revision - Last Min > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

Changes and functions during pregnancy:

  • hCG?
  • progesterone?
  • oestrogen?
A

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

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2
Q

Gestational diabetes diagnosis?
Management?
If metformin not tolerated?
Aims once on meds?

A

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
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3
Q

Supplements in pregnancy?

A

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
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4
Q

Variable decelerations means?

Indicates?

A

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
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5
Q

Management of placental abruption <36 weeks and >36 weeks?

A

<36 weeks:

  • foetal distress on CTG - immediate C-sec
  • No foetal distress - admit for tocolysis and steroids

> 36 weeks
- immediate Csec

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6
Q

What is pre-eclampsia?
Features of severe?
- RF?

A
  • 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
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7
Q

What is routinely offered in screening at booking scan?

A
  • anaemia
  • bacteriuria
  • Blood group, rhesus, ABO
  • Trisomy
  • Foetal anomalies
  • HepB
  • HIV
  • Syphilis
  • neural tube defects
  • RF for pre-eclampsia (diabetes, CKD, autoimmune etc)
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8
Q

When is nuchal scan performed?

What does increased thickness mean?

A

11 - 13+6

Trisomy
Congenital heart defect
Bowel wall defect

Hyperechogenic bowel:
CF
Down’s
CMV infection

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9
Q

When is combined test done, what is the results?
Quadruple test?
If these come back high risk?

A

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

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10
Q

Trisomy 21?
Trisomy 18?
Trisomy 13?

A

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
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11
Q

Causes IUGR - maternal, foetal and utero-placental?

A

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
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12
Q

Causes LGA?

A 
Diabetes
Wrong dates
Polyhydramnios
Multiple pregnancy
Constitutionally large
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13
Q

Varicella exposure in pregnancy?
If develop chickenpox?
(rules for <20 and >20 weeks for both)

A

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

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14
Q

How to differentiate intrahepatic cholestasis from AFL of P?
How is each managed?
What else can cause itch in pregnancy?
Jaundice?

A

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
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15
Q

Sensitisation events?

A

Sensitisation events:

  • giving birth
  • previous TOP
  • miscarriage >12 weeks
  • ectopic managed surgically
  • antepartum haemorrhage
  • amnio/CVS/foetal blood sampling
  • external cephalic version
  • abdo trauma
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16
Q

What to do after sensitising events?

A

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)
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17
Q

Drugs for post-natal depression?

A

Sertraline or Paroxetine

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18
Q

What vaccines are live attenuated and so cannot be given in immunodeficiency/pregnancy?

A 
MMR
Varicella
Yellow fever
Rotavirus
Influenza
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19
Q

Contraindications for inducing labour?

A

Malpresentation
Praevia
Cord prolapse
Signs of foetal distress

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20
Q

What foods to avoid in pregnancy?
Travel?
Sports?

A

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

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21
Q

Diagnosis of PPROM?

Management?

A

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
22
Q

Pregnant woman with Hx of VTE?

A

LMWH throughout pregnancy until 6 weeks after

23
Q

If a HepB +ve woman gives birth?

A

HepB IVIG + vaccine within 12 hours of birth

Further vaccines at 2 and 6 months as per normal schedule

24
Q

Layers cut/torn through in a C-section

A 
Skin
Sup and Deep fascia
Anterior rectus sheath
Rectus (incision in linea alba then torn)
Transversalis fascia
Extraperitoneal connective tissue
Peritoneum
Uterus
25
Q

2 absolute indications for CS?

A

Cephalopelvic disproportion

Praevia grades 3/4

26
Q

Management if in breech?

Contraindications for ECV?

A

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
27
Q

When is hCG first detectable in the blood?

A

8 days post-conception

It is secreted by syncitiotrophoblasts

Level the doubles every 48 hours until 8-10 weeks then starts to subside

28
Q

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?

A

34 weeks

Yes, continue into labour

Epidural

29
Q

Hb level for treatment in pregnancy?

A

<110g/L at booking

<105g/L at 28 weeks

30
Q 
Post-partum thyroiditis:
3 stages?
Diagnosis?
What antibody is positive?
Management?
A 
Stages:
1. thyrotoxicosis
2. hypothyroidism
3. euthyroid 
(high recurrence in future pregnancies)

Diagnostic criteria:

  1. <12 months postpartum
  2. Clinical manifestation of hypothyroidism
  3. TFT support diagnosis

anti-TPO +ve in 90%

Management:

  • thyrotoxic phase - propranolol for symptoms
  • thyroxine if hypothyroid
31
Q

If woman has pre-eclampsia with hypertension and +++ protein in labour at term - management?

A

IV labetalol (or others) with target systolic <150 and diastolic 80-100

32
Q

When to stop taking statins before pregnancy?

A

3 months

33
Q

Times allowed for stage 2 of labour?

A

Nulli w/o anaesthesia - 2 hours

Nulli w anaesthesia - 3 hours

Multi w/o anaesthesia - 1 hours

Multi w anaesthesia - 2 hours

34
Q

Monitoring in labour?

A

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
35
Q

Criteria that must be met for operative vaginal delivery?

A
  • 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
36
Q

Main cause of PPROM?

A

Genital tract infection

37
Q

Management of confirmed foetal distress?

A
  • 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
38
Q

Nausea in 3rd trimester, no other symptoms, all bloods normal but slightly raised ALP?

A

Benign 3rd trimester nausea

Often due to pressure on stomach from expanding uterus

ALP can be slightly raised due to placental production

39
Q

Antipsychotics in pregnancy, what type are generally safer?

Risk of atypicals? What one is CI in breastfeeding?

A

Typicals

Atypicals - risk of gestational diabetes and IUGR

Clozapine CI in breastfeeding

40
Q

Management of antiphospholipid syndrome in pregnancy?

A

Aspirin from conception until foetal heart first seen

LMWH once foetal heart seen on USS (around 6 weeks) until 34 weeks, then stop

41
Q

Ix of DVT/PE in pregnancy?

Management?

A

If DVT: doppler USS

If also suspicious of PE:

  1. CXR and ECG
  2. 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

42
Q 
Foetal effects of:
- valproate?
- phenytoin?
- carbamazepine?
How should mothers with epilepsy be managed?
A

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

43
Q

If pre-existing HTN what should you do at start of pregnancy?

A

Stop ACEI/ARB

Don’t rush into new medication as BP naturally decreases in first trimester

44
Q

Consequences of hyperemesis?

Mandatory Ix?

A 
Ketosis
Dehydration (low Na, K)
Hypovolaemic shock
Nutritional deficiency (Wernicke's)
Acute tubular necrosis

Ix:

  • FBC, U&E, TFT
  • ketones
  • urine dip & culture
45
Q

When to admit for hyperemesis?
Treatment of vomiting?
3 other things to consider in management?

A
  • 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

46
Q

A woman who has PV bleeding at 19 weeks needs anti-D?

A

Yes

47
Q

Causes of bradycardia on CTG?

Tachycardia?

A

Brady:

  • hypoxia
  • aorta-caval compression
  • epidural/spinal
  • malpresentation

Tachycardia:

  • initial response to hypoxia
  • maternal/foetal infection
48
Q

Causes of decelerations:

  • early?
  • variable?
  • late?
A

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
49
Q

Causes of increased AFP in pregnancy? (3)

Decreased (2)

A

Increased:
Neural tube defects
Abdo wall defects
Multiple pregnancy

Decreased:
Trisomy
Diabetes

50
Q

Is it safe for a woman with HepB to breastfeed?

A

Yes

Finals Revision - Last Min (12 decks)

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