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Medicine > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

What is done at booking visit and when is it?

A

8-10 weeks (could be up to 12)

History, exam, advice on nutrition

Booking bloods/urine
- Fbc, blood group, rhesus status, hepatitis B, Hb, syphilis and rubella, HIV, urine culture - asymptomatic haematuria

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2
Q

When is dating scan?

A

10-13+6 weeks

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3
Q

When is abnormality scan?

A

18-20+6 weeks

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4
Q

When does the initial downs screening take place

A

11-13+6 weeks

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5
Q

After which week can amniocentesis be performed?

A

15 weeks

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6
Q

What does combined test contain? What bloods tell u a high risk?

A

NT
BLOODS:
- PAPPA - lower = greater risk
- Beta-HCG - raised = greater risk

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7
Q

What does a triple test contain? What results indicate a higher risk?

A

Just bloods

Beta-HCG - high
AFP - LOW
Oestriol - LOW

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8
Q

What does a quadruple test contain? What results indicate a higher risk?

A

Beta-HCG - high
Oestriol - low
Inhibin A - high
AFP - low

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9
Q

When can a triple or quadruple test be performed? When can a combined test be performed?

A

14-20 weeks

11-13+6 weeks

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10
Q

When does normal N+V start? What is hyperemesis gravidarum? Risk factors for it?

A

4-7 weeks and usually gone by 20 weeks
HG = protracted N+V and - >5% pre-pregnancy weight loss, electrolyte disturbance, dehydration

Risk factors - multiple pregnancies, molar pregnancies, previous HG

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11
Q

Tests for hyperemesis G?

A

Assess severity - dehydration
Vitals, MSU and urine dip (ketones)
Bloods - FBC, U+E,
US - is there still a viable pregnancy? Or molar? Or multiple?

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12
Q

Treatment of hyperemesis G?

A

Anti-emetics - promethazine, cycling
2nd line - metoclopramide
3rd line - steroids

Admit if severe.

High dose folic acid - prevent wernickes encephalopathy

Fluid replacement

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13
Q

Definition of chronic hypertension

A

HTN Presenting at booking or before 20 weeks

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14
Q

Definition of gestational HTN

A

HTN presenting after 20 weeks without significant proteinuria

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15
Q

What is pre-eclampsia?

A

New HTN with significant proteinuria

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16
Q

What is eclampsia?

A

Convulsions, associated with pre-eclampsia

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17
Q

What is cause of pre-eclampsia?

A

Failure of trophoblastic spiral arteries

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18
Q

Risk factors for pre-eclampsia?

A

Previous P-ecl
HTN in previous pregnancy
Dm
Autoimmune disease

1st pregnancy
>40 years old
High BMI

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19
Q

Symptoms of pre-eclampsia?

A 
Headaches 
Absent 
Visual disturbance - floaters, blurred
Swelling/oedema (facial is what we're most concerned about) 
Enigmatic pain - liver capsule enlargement 
Brisk reflexes 
Clonus
Vomiting
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20
Q

Tests for pre-eclampsia

A 
FBC- Decreased Hb and platelets 
LFTs (HELLP syndrome)
U+E - raised urea, creatinine, urate 
Urine dip - protein (p:cr ratio >30)
Ask for foetal movements and do CTG

BP serial checks
US - growth scans

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21
Q

Management of pre-eclampsia

A

Depends on severity
Check bloods regularly
Monitor fetal and mother wellbeing (BP, CTG, urinalysis, blood test, growth scans)

GET BP DOWN
- LABETALOL first drug of choice (apart from asthmatics and afro-carribean)
Then try nifedipine, then methyldopa

Anti-convulsant = magnesium sulfate if needed
VTE prophylaxis
Delivery - only cure
Prevention - aspirin to women of high risk

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22
Q

Mechanism of action of methyldopa

A

Alpha-agonist

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23
Q

Management of eclampsia

A 
Call for help
ABCDE
Magnesium sulfate
Calcium gluconate ready in case of toxicity 
Repeated seizures - diazepam
Restrict fluids 
Delivery once mother is stable 
CTG
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24
Q

What medication is given to mothers at high risk of pre-eclamspia? When is it started and stopped?

A

Aspirin 75 mg / d

Started at 12 weeks, stopped at birth

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25
Q

What is hellp syndrome?

A

Severe variant of pre-eclampsia
Haemolysis, elevated liver enzymes, low platelets

Symptoms = epigastric or RUQ pain, N+V, dark urine (haemolysis)

Treatment - as for eclampsia
Indication for delivery

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26
Q

Order of hypertensive use in pregnancy

A

Labetalol, nifedipine, methyldopa

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27
Q

Complications of pre-eclampsia

A 
Mother:
Eclampsia 
HEllp
Pulmonary oedema 
Cerebral haemorrhage 
Cortical blindness
DIC
Renal failure 
Death 
Baby:
Foetal growth restriction 
Placental abruption 
Intrauterine death 
Prematurity
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28
Q

What should bd done for someone with pre-eclampsia after 37 weeks?

A

Admit
Plan for delivery with 24-48 hours
Consider Mg sulfate - especially for those at risk of eclampsia developing

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29
Q

Differentials of pregnancy-associated liver disease

A 
Cholestasis of pregnancy 
HELLP syndrome 
Acute fatty liver of pregnancy 
Liver dysfunction in pre-eclampsia
Liver dysfunction in hyperemesis gravidarum
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30
Q

Tests for jaundice in pregnancy

A

Usual - hepatitis screen, urine for bile
LFTs
US
Bile acids

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31
Q

What is obstetric cholestasis? Symptoms?

A 
Disease unique to pregnancy characterised by pruritus and elevated bile acids 
Variable elevation in LFTs
Pruritus - especially in soles/palms 
RUQ pain 
Anorexia 
Steatorrhoea
Scratch marks 
Jaundice
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32
Q

Tests for cholestasis of pregnancy

A

Diagnosis of exclusion
Test for hepatitis, autoimmune screen,
US of liver - no structural abnormalities
Usually made on the presence of pruritus and elevated bile acids in pregnancy
LFTs - AST/ALT are raised in 60%

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33
Q

Management of cholestasis of pregnancy

A

Offer ursodeoxycholic acid to all to help with symptoms and improve LFTs
Offer IOL from 37-38 weeks - if bile acids >100, offer at 36 weeks
Vitamin K if abnormal clotting screen and 1mg to baby
Symptoms improve within days after delivery

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34
Q

Presentation of acute fatty liver of pregnancy

A 
Jaundice 
Abdo pain 
Vomiting 
Pancreatitis 
Thrombocytopenia 
Uraemia
Severe hypoglycaemia 
Clotting disorder
Coma 
Death 
Associated with pre-eclampsia in up to 60%
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35
Q

Management of acute fatty liver of pregnancy

A

Manage in ITU
Monitor BP
Give supportive treatment for liver and kidney failure
Treat hypoglycaemia vigorously (CVP line)
Correct clotting disorders
Expedite delivery
Beware PPH and neonatal hypoglycaemia

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36
Q

What is an antepartum haemorrhage?

A

Bleeding from genital tract from week 24 until delivery

37
Q

Differential of antepartum haemorrhage

A 
Placental praevia 
Abruption 
Vasa praevia 
Cervical polyps
Erosion, cancer
Cervicitis
Vaginitis
38
Q

Investigsations for antepartum haemorrhage

A 
FBC - anaemia 
Clotting profile
Kleihauer test
Group and save
Cross match

U+Es
LFTs

If baby >26 weeks = CTG
If <26 weeks = US

39
Q

Features of placental abruption

A 
Dark red blood (but not always bleeding as they can be concealed)
Hard woody uterus
Shock
Back pain 
No foetal heart sound
Severe pain 
Unknown onset 
No blood loss (concealed)
40
Q

Risk factors for placental abruption

A 
Previous abruption 
Pre-ecpampsia
Intra-uterine growth restriction 
Polyhydraminos
Older mother
Multiparty
Low BMI
Infection 
Trauma
Smoking
41
Q

Management of antepartum haemorrhage

A

ABCDE
Fluid resus
Blood products as needed
Senior support
EMERGENCY DELIVERY - If foetal/maternal compromise. C-section
Induction of labour - for haemorrhage at term without compromise
All cases - anti-D within 72 hours of onset of bleeding if women is rhesus negative

42
Q

Associations with placental praevia

A 
C-section 
Multiparty
Multiple pregnancy 
Mother >40
Fibroid
Endometriosis
43
Q

Investigations for placenta praevia

A

US may reveal it (but may be gone by delivery)

If uS <24 weeks reveals it = re-scan at 30 weeks

44
Q

Management of placenta praevia

A

Major (covering the internal os) - c-section

Minor (does not) - aim for normal delivery unless within 2 cm of internal os

45
Q

Features of placental praevia

A 
No pain 
Foetal parts felt
Foetal heart present 
Soft-non-tender uterus 
Degree of shock matches amount of blood loss 
Post costal onset 
Warning haemorrhage
46
Q

The stages of labour

A

Stage 1:

  • contractions till 10cm dilated
  • Latent - very slow 0-4 cm (can be hours or days)
  • Active - 4-10 cm - 1cm every hour. Should not be allowed to go on longer than 16 hours

Stage 2:
- 10 cm - delivery
Should not be allowed to go on past 2 hours - unless epidural
- passive - baby descending (15-20 mins)
- active - when baby hits pelvic floor (woman has urge to push)
- 40-45 mins

Stage 3:
- delivery of placenta and membranes

47
Q

What is a babys lie?

A

Relationship between the long axis of fetus and mother

  • longitudinal
  • oblique
  • transverse
48
Q

What is the presentation of the fetus?

A
  • fetal part to first enter the maternal pelvis
  • cephalic - most common
  • breech
  • shoulder
  • face
49
Q

What is the position of the fetus?

A

Position of fetal head as it exists the birth canal

  • occipito-anterior (most common)
  • occipito-posterior
  • occipito-transverse
50
Q

Management of malpresentation

A

External cephalic version (36-38 weeks)
Breech - c-section usually indicated
Brow - c section
Shoulder- c-sextion

51
Q

What score is used to decide if someone is good for induction of labour?

A

Bishops score

52
Q

Induction options

A

Non favourable cervix:
Memrane sweep - release prostaglandin
Intravaginal prostaglandin- (if bishops score <7)
- propess pessary (long acting) - give 1 in 24 hours then re-evaluate and can give prostin if not favourable still
- prostin gel - given every 6 hours

Favourable cervix:
Amniotomy- given half an hour for contractions, if not then give syntocin

Oxytocin

If failed induction of labour = c-section

53
Q

When is misoprostal used?

A

Too strong for labour
Used in miscarriage and PPH

Mifeprestone- used as preparing agent - given 48h before misoprostal

54
Q

What is misoprostal?

A

Prostaglandin E1 (can cause hyperstimilatiin syndrome so not used in labour)

Prostaglandin E2 is used in labour

55
Q

Delay in first stage of labour management

A

Offer amniotomy - reassess in 2 hours
If membranes ruptured - oxytocin infusion and reassess in 4 hours
If multiparus or previous LSCS - get senior help due to increase risk of rupture

56
Q

Causes of anaemia in pregnancy

A

Iron deficiency most common (TIBC and ferritin low)
Foliate deficiency next common (MVC high)

Consider coeliac, CKD, autoimmune disease

57
Q

What dose of folic acid should pregnant women be taking and until when?

A

400 mcg, 12th week

58
Q

What is the higher dose of folic acid to be taken in pregnancy and what may put someone at higher risk?

A

5 mg

Obesity
Previous pregnancy affected by neural tube defect 
Either partner has a neural tube defect 
Family history of neural tube defect
Diebtic women 
HIV taking co trimox 
Sickle cell
59
Q

What should you do if someone is found to have placenta praevia at 20 week scan?

A

Re-scan at 34 weeks
No need to liti activity
If present at 34 weeks rescan every 2 weeks
Final US at 36/37 weeks to determine method of delivery

60
Q

Presentation of molar pregnancy

A

Bleeding in first or early second trimester
Exaggerated symptoms of pregnancy (hyperemesis)
UTERUS LARGE FOR DATES
Hypertension and hyperthyroidism

61
Q

Tests and management of molar pregnancy

A

Tests - very high bHCG
Hyperthyroidism - (low TSH, high thyroxine)
US

Urgent referral - evacuation of uterus
Effective contraception to avoid pregnancy in next year

62
Q

Target blood capillary glucose for diabetics in pregnancy

A

Fasting- 5.3 mmol/L
And 1 hour post-prandial - 7-8 mmol/L
And 2 hour post-prandial - 6.4 mmol/L

63
Q

If diabetes not controlled with metformin and diet, what should you do?

A

Add insulin

64
Q

Presentation of cord prolapse

A

May be obvious
Fetal bradycardia often only sign
Variable heart decelerations on CTG
Do vaginal exam

65
Q

Risk factors for cord prolapse

A

Most occur due to artifical rupture of membranes

Prematurity 
Multiparity 
Polyhydramnios
Twin pregnancy 
Abnormal presentation
66
Q

Management of cord prolapse

A 
Get help - sound alarms
Keep cord in vagina
Displace presenting part - push it 
Keep chest position so bottom is higher than head 
(All fours ideally)
Infuse 500 ml saline into bladder

Tocolysis- terbutaline (considered while preparing for caesarian

67
Q

Variable deceleration of a CTG indicate what?

A

Cord prolapse

68
Q

What should a syphasis-fundal height be?

A

Should match weeks pregnant

After 24 weeks - should grow by 1 cm per week

69
Q

Drugs to avoid in breast feeding

A 
Aspirin 
Abx - ciprofloxacin, chloramphenicol
Psychiatric drugs- lithium and benzos
Carbimazole
Amiodarone
70
Q

What happens to BP in pregnancy

A

Falls during first 10 weeks, then increases to pre-pregnancy levels by term

71
Q

What should a pregnant woman do if exposed to chicken pox?

A

Check varicella antibodies if unsure of immunity

Varicella-zoster immunoglobulin ASAP if not immune and <20 weeks
If >20 weeks = either immunoglobulin or antivirals

72
Q

Pathophysiology of rhesus D

A

If a rhesus negative women delivers a rhesus positive child- leak of RBCs may occur
This causes anti-D igG antibodies to form in mother
In later pregnancies these can cross the placenta and cause haemolysis in foetus

73
Q

When do you give anti-D

A

Test for rhesus D at booking

Give to all non-sensitised rhesus negative women at 28 and 34 weeks

Delivery of rhesus positive infant 
Any termination of pregnancy 
Miscarriage >12 weeks
Ectopic if managed surgically
Antepartum haemahorage 
CVS or amniocentesis 
Abdo trauma
74
Q

Women with a previous group B streptococcus should…

A

Be offered intravenous benzylpenicillin

75
Q

When to give women benzylpenicillin for GBS

A 
Positive high vaginal swab at any point in pregnancy
Any baby born previously with GBS
Gestation <37 weeks, preterm Labour 
Intrapartum fever 
Fever during labour
76
Q

Management of GBS?

A

Phorphylaxis = benzylpenicillin, if allergic = clindamycin

Observe baby for 24 hours for signs of sepsis

77
Q

Management of placental abruption

A

Admit
Foetal or maternal compromise - emergency delivery via c-section
Fetus alive, no distress - if <36 weeks = admit, observe steroids. If >36 weeks labour induction
Fetus alive, >36 weeks - deliver vaginally
Dead fetus - delivery vaginally

78
Q

Management of shoulder dystocia

A

Senior help
McRoberts manoeuvre
Episiotomy

79
Q

What is the McRoberts manoeuvre?

A

Used in shoulder dystocia

  • flexion and abduction of the maternal hips, bringing mother’s thighs towards her abdomen
  • Suprapubic pressure
80
Q

When should induction of labour be offered?

A

At 41 weeks

81
Q

What is oxytocin used for?

A

Help with labour if not enough contractions

Called augmentation of labour if used
Also used in PPH (contracts uterus)

82
Q

Causes of post-partum haemorrhage

A

4 T’s

Tone - uterine atony (uterus fails to contract after delivery)
Tissue - retained products
Trauma - genital tract trauma
Thrombin - clotting disorders

83
Q

Risk factors of PPH?

A 
Previous PPH
Macrosomia 
Pre-eclampsia
Emergency c-section 
Bmi >35
Fibroid 
Large placental site 
Prolonged labour
84
Q

Management of PPH

A 
ABCDE
2 wide bore cannula
Call for help 
O2
Assess airway 
Fluids - heartmanns

Drugs - IV syntocin (oxytocin), IM carboprost

If medical management fails - surgical - B-lynch suture, ligation of arteries, hysterectomy as life saving procedure

85
Q

What medication is recommended for epilepsy in pregnancy?

A

Lamotrigine

86
Q

What should be offered to women with cholestasis of pregnancy

A

Induction of labour at 37 weeks

Not elective c-section

87
Q

What is tocoyltics used for?

A

Too soon Labour

Prevents contractions

88
Q

Management of preterm labour

A

Admit for 48 h
Rule out sepsis
Give corticosteroids and erythromycin for 10 days until delivery
Consider tocolytics - nifedepine, autosiban, terbutaline

89
Q

Lack of milk production after PPH is a sign of what complication?

A

Sheehan’s syndrome

Medicine (25 decks)

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