Obstetrics Flashcards
What is done at booking visit and when is it?
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
When is dating scan?
10-13+6 weeks
When is abnormality scan?
18-20+6 weeks
When does the initial downs screening take place
11-13+6 weeks
After which week can amniocentesis be performed?
15 weeks
What does combined test contain? What bloods tell u a high risk?
NT
BLOODS:
- PAPPA - lower = greater risk
- Beta-HCG - raised = greater risk
What does a triple test contain? What results indicate a higher risk?
Just bloods
Beta-HCG - high
AFP - LOW
Oestriol - LOW
What does a quadruple test contain? What results indicate a higher risk?
Beta-HCG - high
Oestriol - low
Inhibin A - high
AFP - low
When can a triple or quadruple test be performed? When can a combined test be performed?
14-20 weeks
11-13+6 weeks
When does normal N+V start? What is hyperemesis gravidarum? Risk factors for it?
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
Tests for hyperemesis G?
Assess severity - dehydration
Vitals, MSU and urine dip (ketones)
Bloods - FBC, U+E,
US - is there still a viable pregnancy? Or molar? Or multiple?
Treatment of hyperemesis G?
Anti-emetics - promethazine, cycling
2nd line - metoclopramide
3rd line - steroids
Admit if severe.
High dose folic acid - prevent wernickes encephalopathy
Fluid replacement
Definition of chronic hypertension
HTN Presenting at booking or before 20 weeks
Definition of gestational HTN
HTN presenting after 20 weeks without significant proteinuria
What is pre-eclampsia?
New HTN with significant proteinuria
What is eclampsia?
Convulsions, associated with pre-eclampsia
What is cause of pre-eclampsia?
Failure of trophoblastic spiral arteries
Risk factors for pre-eclampsia?
Previous P-ecl
HTN in previous pregnancy
Dm
Autoimmune disease
1st pregnancy
>40 years old
High BMI
Symptoms of pre-eclampsia?
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
Tests for pre-eclampsia
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
Management of pre-eclampsia
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
Mechanism of action of methyldopa
Alpha-agonist
Management of eclampsia
Call for help ABCDE Magnesium sulfate Calcium gluconate ready in case of toxicity Repeated seizures - diazepam Restrict fluids Delivery once mother is stable CTG
What medication is given to mothers at high risk of pre-eclamspia? When is it started and stopped?
Aspirin 75 mg / d
Started at 12 weeks, stopped at birth
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
Order of hypertensive use in pregnancy
Labetalol, nifedipine, methyldopa
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
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
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
Tests for jaundice in pregnancy
Usual - hepatitis screen, urine for bile
LFTs
US
Bile acids
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
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%
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
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%
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
What is an antepartum haemorrhage?
Bleeding from genital tract from week 24 until delivery
Differential of antepartum haemorrhage
Placental praevia Abruption Vasa praevia Cervical polyps Erosion, cancer Cervicitis Vaginitis
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
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)
Risk factors for placental abruption
Previous abruption Pre-ecpampsia Intra-uterine growth restriction Polyhydraminos Older mother Multiparty Low BMI Infection Trauma Smoking
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
Associations with placental praevia
C-section Multiparty Multiple pregnancy Mother >40 Fibroid Endometriosis
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
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
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
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
What is a babys lie?
Relationship between the long axis of fetus and mother
- longitudinal
- oblique
- transverse
What is the presentation of the fetus?
- fetal part to first enter the maternal pelvis
- cephalic - most common
- breech
- shoulder
- face
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
Management of malpresentation
External cephalic version (36-38 weeks)
Breech - c-section usually indicated
Brow - c section
Shoulder- c-sextion
What score is used to decide if someone is good for induction of labour?
Bishops score
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
When is misoprostal used?
Too strong for labour
Used in miscarriage and PPH
Mifeprestone- used as preparing agent - given 48h before misoprostal
What is misoprostal?
Prostaglandin E1 (can cause hyperstimilatiin syndrome so not used in labour)
Prostaglandin E2 is used in labour
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
Causes of anaemia in pregnancy
Iron deficiency most common (TIBC and ferritin low)
Foliate deficiency next common (MVC high)
Consider coeliac, CKD, autoimmune disease
What dose of folic acid should pregnant women be taking and until when?
400 mcg, 12th week
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
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
Presentation of molar pregnancy
Bleeding in first or early second trimester
Exaggerated symptoms of pregnancy (hyperemesis)
UTERUS LARGE FOR DATES
Hypertension and hyperthyroidism
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
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
If diabetes not controlled with metformin and diet, what should you do?
Add insulin
Presentation of cord prolapse
May be obvious
Fetal bradycardia often only sign
Variable heart decelerations on CTG
Do vaginal exam
Risk factors for cord prolapse
Most occur due to artifical rupture of membranes
Prematurity Multiparity Polyhydramnios Twin pregnancy Abnormal presentation
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
Variable deceleration of a CTG indicate what?
Cord prolapse
What should a syphasis-fundal height be?
Should match weeks pregnant
After 24 weeks - should grow by 1 cm per week
Drugs to avoid in breast feeding
Aspirin Abx - ciprofloxacin, chloramphenicol Psychiatric drugs- lithium and benzos Carbimazole Amiodarone
What happens to BP in pregnancy
Falls during first 10 weeks, then increases to pre-pregnancy levels by term
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
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
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
Women with a previous group B streptococcus should…
Be offered intravenous benzylpenicillin
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
Management of GBS?
Phorphylaxis = benzylpenicillin, if allergic = clindamycin
Observe baby for 24 hours for signs of sepsis
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
Management of shoulder dystocia
Senior help
McRoberts manoeuvre
Episiotomy
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
When should induction of labour be offered?
At 41 weeks
What is oxytocin used for?
Help with labour if not enough contractions
Called augmentation of labour if used
Also used in PPH (contracts uterus)
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
Risk factors of PPH?
Previous PPH Macrosomia Pre-eclampsia Emergency c-section Bmi >35 Fibroid Large placental site Prolonged labour
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
What medication is recommended for epilepsy in pregnancy?
Lamotrigine
What should be offered to women with cholestasis of pregnancy
Induction of labour at 37 weeks
Not elective c-section
What is tocoyltics used for?
Too soon Labour
Prevents contractions
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
Lack of milk production after PPH is a sign of what complication?
Sheehan’s syndrome
