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
2
Q
When is dating scan?
A
10-13+6 weeks
3
Q
When is abnormality scan?
A
18-20+6 weeks
4
Q
When does the initial downs screening take place
A
11-13+6 weeks
5
Q
After which week can amniocentesis be performed?
A
15 weeks
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
7
Q
What does a triple test contain? What results indicate a higher risk?
A
Just bloods
Beta-HCG - high
AFP - LOW
Oestriol - LOW
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
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
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
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?
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
13
Q
Definition of chronic hypertension
A
HTN Presenting at booking or before 20 weeks
14
Q
Definition of gestational HTN
A
HTN presenting after 20 weeks without significant proteinuria
15
Q
What is pre-eclampsia?
A
New HTN with significant proteinuria
16
Q
What is eclampsia?
A
Convulsions, associated with pre-eclampsia
17
Q
What is cause of pre-eclampsia?
A
Failure of trophoblastic spiral arteries
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
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
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
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
22
Q
Mechanism of action of methyldopa
A
Alpha-agonist
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
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
25
What is hellp syndrome?
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
26
Order of hypertensive use in pregnancy
Labetalol, nifedipine, methyldopa
27
Complications of pre-eclampsia
```
Mother:
Eclampsia
HEllp
Pulmonary oedema
Cerebral haemorrhage
Cortical blindness
DIC
Renal failure
Death
```
```
Baby:
Foetal growth restriction
Placental abruption
Intrauterine death
Prematurity
```
28
What should bd done for someone with pre-eclampsia after 37 weeks?
Admit
Plan for delivery with 24-48 hours
Consider Mg sulfate - especially for those at risk of eclampsia developing
29
Differentials of pregnancy-associated liver disease
```
Cholestasis of pregnancy
HELLP syndrome
Acute fatty liver of pregnancy
Liver dysfunction in pre-eclampsia
Liver dysfunction in hyperemesis gravidarum
```
30
Tests for jaundice in pregnancy
Usual - hepatitis screen, urine for bile
LFTs
US
Bile acids
31
What is obstetric cholestasis? Symptoms?
```
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
```
32
Tests for cholestasis of pregnancy
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%
33
Management of cholestasis of pregnancy
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
34
Presentation of acute fatty liver of pregnancy
```
Jaundice
Abdo pain
Vomiting
Pancreatitis
Thrombocytopenia
Uraemia
Severe hypoglycaemia
Clotting disorder
Coma
Death
Associated with pre-eclampsia in up to 60%
```
35
Management of acute fatty liver of pregnancy
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
36
What is an antepartum haemorrhage?
Bleeding from genital tract from week 24 until delivery
37
Differential of antepartum haemorrhage
```
Placental praevia
Abruption
Vasa praevia
Cervical polyps
Erosion, cancer
Cervicitis
Vaginitis
```
38
Investigsations for antepartum haemorrhage
```
FBC - anaemia
Clotting profile
Kleihauer test
Group and save
Cross match
```
U+Es
LFTs
If baby >26 weeks = CTG
If <26 weeks = US
39
Features of placental abruption
```
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
Risk factors for placental abruption
```
Previous abruption
Pre-ecpampsia
Intra-uterine growth restriction
Polyhydraminos
Older mother
Multiparty
Low BMI
Infection
Trauma
Smoking
```
41
Management of antepartum haemorrhage
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
Associations with placental praevia
```
C-section
Multiparty
Multiple pregnancy
Mother >40
Fibroid
Endometriosis
```
43
Investigations for placenta praevia
US may reveal it (but may be gone by delivery)
| If uS <24 weeks reveals it = re-scan at 30 weeks
44
Management of placenta praevia
Major (covering the internal os) - c-section
| Minor (does not) - aim for normal delivery unless within 2 cm of internal os
45
Features of placental praevia
```
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
The stages of labour
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
What is a babys lie?
Relationship between the long axis of fetus and mother
- longitudinal
- oblique
- transverse
48
What is the presentation of the fetus?
- fetal part to first enter the maternal pelvis
- cephalic - most common
- breech
- shoulder
- face
49
What is the position of the fetus?
Position of fetal head as it exists the birth canal
- occipito-anterior (most common)
- occipito-posterior
- occipito-transverse
50
Management of malpresentation
External cephalic version (36-38 weeks)
Breech - c-section usually indicated
Brow - c section
Shoulder- c-sextion
51
What score is used to decide if someone is good for induction of labour?
Bishops score
52
Induction options
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
When is misoprostal used?
Too strong for labour
Used in miscarriage and PPH
Mifeprestone- used as preparing agent - given 48h before misoprostal
54
What is misoprostal?
Prostaglandin E1 (can cause hyperstimilatiin syndrome so not used in labour)
Prostaglandin E2 is used in labour
55
Delay in first stage of labour management
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
Causes of anaemia in pregnancy
Iron deficiency most common (TIBC and ferritin low)
Foliate deficiency next common (MVC high)
Consider coeliac, CKD, autoimmune disease
57
What dose of folic acid should pregnant women be taking and until when?
400 mcg, 12th week
58
What is the higher dose of folic acid to be taken in pregnancy and what may put someone at higher risk?
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
What should you do if someone is found to have placenta praevia at 20 week scan?
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
Presentation of molar pregnancy
Bleeding in first or early second trimester
Exaggerated symptoms of pregnancy (hyperemesis)
UTERUS LARGE FOR DATES
Hypertension and hyperthyroidism
61
Tests and management of molar pregnancy
Tests - very high bHCG
Hyperthyroidism - (low TSH, high thyroxine)
US
Urgent referral - evacuation of uterus
Effective contraception to avoid pregnancy in next year
62
Target blood capillary glucose for diabetics in pregnancy
Fasting- 5.3 mmol/L
And 1 hour post-prandial - 7-8 mmol/L
And 2 hour post-prandial - 6.4 mmol/L
63
If diabetes not controlled with metformin and diet, what should you do?
Add insulin
64
Presentation of cord prolapse
May be obvious
Fetal bradycardia often only sign
Variable heart decelerations on CTG
Do vaginal exam
65
Risk factors for cord prolapse
Most occur due to artifical rupture of membranes
```
Prematurity
Multiparity
Polyhydramnios
Twin pregnancy
Abnormal presentation
```
66
Management of cord prolapse
```
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
Variable deceleration of a CTG indicate what?
Cord prolapse
68
What should a syphasis-fundal height be?
Should match weeks pregnant
| After 24 weeks - should grow by 1 cm per week
69
Drugs to avoid in breast feeding
```
Aspirin
Abx - ciprofloxacin, chloramphenicol
Psychiatric drugs- lithium and benzos
Carbimazole
Amiodarone
```
70
What happens to BP in pregnancy
Falls during first 10 weeks, then increases to pre-pregnancy levels by term
71
What should a pregnant woman do if exposed to chicken pox?
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
Pathophysiology of rhesus D
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
When do you give anti-D
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
Women with a previous group B streptococcus should...
Be offered intravenous benzylpenicillin
75
When to give women benzylpenicillin for GBS
```
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
Management of GBS?
Phorphylaxis = benzylpenicillin, if allergic = clindamycin
Observe baby for 24 hours for signs of sepsis
77
Management of placental abruption
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
Management of shoulder dystocia
Senior help
McRoberts manoeuvre
Episiotomy
79
What is the McRoberts manoeuvre?
Used in shoulder dystocia
- flexion and abduction of the maternal hips, bringing mother's thighs towards her abdomen
- Suprapubic pressure
80
When should induction of labour be offered?
At 41 weeks
81
What is oxytocin used for?
Help with labour if not enough contractions
Called augmentation of labour if used
Also used in PPH (contracts uterus)
82
Causes of post-partum haemorrhage
4 T's
Tone - uterine atony (uterus fails to contract after delivery)
Tissue - retained products
Trauma - genital tract trauma
Thrombin - clotting disorders
83
Risk factors of PPH?
```
Previous PPH
Macrosomia
Pre-eclampsia
Emergency c-section
Bmi >35
Fibroid
Large placental site
Prolonged labour
```
84
Management of PPH
```
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
What medication is recommended for epilepsy in pregnancy?
Lamotrigine
86
What should be offered to women with cholestasis of pregnancy
Induction of labour at 37 weeks
Not elective c-section
87
What is tocoyltics used for?
Too soon Labour
| Prevents contractions
88
Management of preterm labour
Admit for 48 h
Rule out sepsis
Give corticosteroids and erythromycin for 10 days until delivery
Consider tocolytics - nifedepine, autosiban, terbutaline
89
Lack of milk production after PPH is a sign of what complication?
Sheehan's syndrome
