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Obs & Gynae > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

What are the two sphincters of the cervix?

A

Internal and external os

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2
Q

What are the two layers of the uterus?

A

Endometrium and myometrium

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3
Q

What are the different parts of the fallopian tube?

A

Ismuth, Ampulla, Infundibulum, Fimbrae

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4
Q

What is the opening of the fallopian tube called?

A

Proximal ostium

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5
Q

What are the three parts of the uterus?

A

Fundus
Body
Cervix

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6
Q

What is the blood supply to the uterus?

A

Uterine artery

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7
Q

What are the 3 components of he hip bone?

A

Ileum
Pubis
Ischium

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8
Q

Outline the Hypothalamic-pituitary-gonodal axis

A

Hypothalamus releases GnRH.
GnrH stimulates anterior pituitary to produce LH and FSH.
These stimulate the ovaries to release oestrogen and progesterone.
This has a negative feedback on the hypothalamus and pituitary.

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9
Q

Where is oestrogen released?

A

The follicles of the ovaries (theca granulosa cells)

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10
Q

What does oestrogen stimulate?

A

Promotes female secondary sexual characteristics:

  • Breast tissue development
  • Growth/ development of female sex organs at puberty
  • Blood vessel development in uterus
  • Development of endometrium
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11
Q

Where is progesterone produced normally?

A

Corpus luteum after ovulation

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12
Q

Where is progesterone produced during pregnancy?

A

By the placenta (from 10 weeks gestation)

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13
Q

What are the actions of progesterone?

A

Thickens and maintains endometrium
Thickens cervical mucus
Increases body temperature

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14
Q

At what age does puberty usually start in females?

A

8-14

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15
Q

Why do overweight children tend to start puberty earlier?

A

Aromatase is an enzyme found in adipose (fat) tissue that is important in the creation of oestrogen so overweight children have more of it.

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16
Q

What does puberty start with in females?

A

Development of breast buds, followed by pubic hair and then periods

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17
Q

What is the first episode of menstruation called?

A

Menarche

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18
Q

What scale is used to determine the stage of pubertal development?

A

Tanner stage

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19
Q

What are the two phases of the menstrual cycle?

A

Follicular phase and Luteal phase

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20
Q

What days of the cycle make up the follicular cycle?

A

1-14 (May be longer or shorter)

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21
Q

What days of the cycle make up the luteal phase?

A

14- 28 (ALWAYS 14 days before menstruation)

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22
Q

What are the four stages of development of ovarian follicles?

A

Primordial follicles
Primary follicles
Secondary follicles
Antral follicles

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23
Q

What is the name of the egg cells in the ovaries and what surrounds them?

A

Oocytes surrounded by granulosa cells

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24
Q

At what stage of development do follicles develop FSH receptors and therefore require stimulation to further develop?

A

At the secondary follicle stage

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25
Q

What is day 1 of the menstrual cycle?

A

First day of bleeding

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26
Q

What is day 14 of the menstrual cycle?

A

Ovulation

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27
Q

What happens during the follicular phase?

A

There is rising FSH, which causes development of follicles.

Follicles release oestrogen which begins to inhibit FHS, leading to one dominant follicle.

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28
Q

What happens during ovulation? (Stimulated by what hormones)

A

The increased oestrogen levels triggers a surge in LH, causing the follicle to release the ovum.

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29
Q

What happens during the luteal phase?

A

The follicle forms the corpus luteum which secretes progesterone.

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30
Q

What happens to the progesterone level during the luteal phase and what does this trigger?

A

Peaks 7 days after ovulation, then the falling progesterone level triggers menstruation.

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31
Q

When is the menstrual phase of the cycle?

A

Day 1~5

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32
Q

What are the different phases that the endometrium goes through during the menstrual cycle?

A 
Menstrual phase (1-5)
Proliferative phase (5-14)
Secretory phase (14-28)
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33
Q

What happens to the endometrium during the menstrual phase?

A

Falling levels of progesterone cause shedding

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34
Q

What happens to the endometrium during the proliferative phase?

A

Rising oestrogen levels causes the endometrium to grow.
There is early development of glands/ spiral arterioles
Cervical mucus becomes thin/ watery to aid sperm entry

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35
Q

What happens to the endometrium during the secretory phase?

A

After ovulation, progesterone predominates and the endometrium begins to prepare for implantation.
There is development of complex glands and arterioles.

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36
Q

If fertilisation occurs, how is the corpus luteum maintained and what does this cause?

A

The syncytiotrophoblast of the embryo secretes hCG which maintains the corpus luteum and therefore the endometrium is maintained.

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37
Q

What is hCG?

A

Human chorionic gonadotrophin.

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38
Q

What are the 3 layers of primary follicles?

A

Primary oocyte in centre
Zona pellucida
Granulosa cells

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39
Q

What is the further layer that follicles develop and what does it consist of?

A

Theca folliculli:
Theca interna- secretes androgen hormones
Theca externa- made up of connective tissue

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40
Q

What does the secondary follicle develop to become an antral follicle?

A

Antrum- single large fluid fillled area/

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41
Q

What happens to the dominant follicle when there is a surge of LH?

A

The smooth muscle of the theca externa squeezes, causing the follicle to burst and the ovum to escape.

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42
Q

What happens to the ovum once it has escaped the follicle?

A

It is swept up by the fimbrae into the fallopian tubes.

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43
Q

What happens to the primary oocyte around the time of ovulation?

A

It undergoes meiosis, splitting into two haploid (23 chromosome) cells

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44
Q

What happens to the other 23 chromosomes when the primary oocyte splits?

A

They float off and become a polar body

The other is the secondary oocyte.

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45
Q

What does the released ovum consist of (layers)?

A

Secondary oocyte
First polar body
Zona pellucida
Corona radiata (made up of granulosa cells)

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46
Q

What happens when a sperm enters the vagina?

A

It travels up the uterus into the fallopian tube and attempts to penetrate the corona radiata and zona pellucida to fertilise the egg

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47
Q

Where does fertilisation occur?

A

Ampulla of the fallopian tube

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48
Q

How long does an unfertilised egg stay in the fallopian tube?

A

24 hours before it dies

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49
Q

How long is the fertilisation window each month and why?

A

6 days- ovulation is only one day but sperm can survive for up to five days in the female body

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50
Q

What is the name of the fertilised egg?

A

Zygote

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51
Q

What does the zygote rapidly turn into?

A

Morula (mass of cells)

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52
Q

What does the morula become?

A

Blastocyst

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53
Q

What does the blastocyst contain?

A

The embryoblast and blastocele (fluid filled cavity), surrounded by trophoblast (outer layer)

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54
Q

How many cells does the blastocyst consist of when it enters the uterus?

A

100-150

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55
Q

How long does it take for the blastocyst to reach the uterus after ovulation?

A

8-10 days

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56
Q

What happens during implantation?

A

The trophoblast (outer layer of blastocyst) undergoes adhesion to the stroma of endometrium.

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57
Q

What is the outer layer of the trophoblast called and what happens to it during implantation?

A

The syncytiotrophoblast.

It projects into the stroma and mixes with endometrial cells.

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58
Q

What is the decidua?

A

Cells of the endometrial stroma that specialise to provide nutrients to the trophoblast

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59
Q

What does the syncytiotrophoblast produce and why is this essential?

A

HCG which maintains the corpus luteum, allowing it to continue producing progesterone and oestrogen.

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60
Q

What happens to hCG levels during pregnancy?

A

They are high in early pregnancy, plateau at 10 weeks gestation then start to fall.

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61
Q

What are the functions of the placenta?

A 
Respiration
Nutrition
Excretion
Endocrine
Immunity
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62
Q

What hormones does the placenta produce?

A

hCG
Oestrogen
Progesterone

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63
Q

What are the 3 stages of labour?

A 
1= Onset of labour until 10cm dilated
2= from 10cm dilated to delivery
3= from delivery of baby to delivery of placenta
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64
Q

What happens in the first stage of labour?

A

Cervical dilation and effacement

The show

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65
Q

What is cervical effacement?

A

When the cervix gets thinner from front to back

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66
Q

What is the ‘show’ and when does it happen?

A

When the mucus plug in the cervix that prevents bacteria from entering the uterus during pregnancy falls out during the first stage of pregnancy.

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67
Q

What are the 3 phases of the first stage of labour?

A

Latent phase
Active phase
Transition phase

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68
Q

What happens in the latent phase of pregnancy?

A

There is 0cm to 3cm dilation of the cervix, at around 0.5cm per hour
There are irregular contractions

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69
Q

What happens in the active phase of labour?

A

From 3cm to 7cm dilation of the cervix, at around 1cm per hour with regular contractions/

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70
Q

What is the transition phase of labour?

A

From 7cm to 10cm dilation of the cervix at about 1cm per hour.
There are strong and regular contractions.

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71
Q

What is the second stage of labour?

A

From 10cm dilation of the cervix to the delivery of the baby

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72
Q

What does the success of the second stage of labour depend on?

A

The 3 P’s

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73
Q

What are the 3 P’s of labour?

A

Power
Passenger
Passage

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74
Q

What does power refer to?

A

The strength of the uterine contractions

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75
Q

What does passage refer to and what can hinder this part of labour?

A

The size and shape of the pelvis.

There may be anatomical problems, ovarian cysts, fibroids, broken bones e.t.c.

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76
Q

What are the 4 components of the ‘passenger’ portion of the 3 P’s?

A

Size
Attitude
Lie
Presentation

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77
Q

What is the attitude of the fetus?

A

The posture (e.g. how the back is rounded and how the head and limbs are flexed)

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78
Q

What is the lie of the fetus?

A

The position of the fetus in relation to the mothers spine /

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79
Q

What are the potential ways the fetus may lie?

A

Longitudinal lie
Transverse lie
Oblique lie

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80
Q

What does presentation refer to?

A

The part of the fetus closest to the cervix

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81
Q

What are the different types of presentation?

A

Cephalic (head) presentation
Shoulder presentation
Breech presentation

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82
Q

What are the different types of breech presentation?

A 
Complete breech (hips and knees flexed)
Frank breech (hips flexed, knees extended) 
Footling breech (foot hanging down)
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83
Q

What are the structures that allow a babies skull/ brain to grow?

A

Posterior and anterior fontanelle

Sutures

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84
Q

Where is the posterior fontanelle?

A

Between the occipital bone and two parietal bones

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85
Q

Where is the anterior fontanelle?

A

Between the two parietal bones and two frontal bones

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86
Q

Ideally, which part of the babies head should come out first?

A

The occiput (back of the head)

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87
Q

What can you feel for when doing a vaginal exam to work out the position of the baby? for delivery?

A

Fontanelles

Face

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88
Q

What are the 7 stages of labour?

A 
Engagement
Descent
Flexion (though baby should be flexed through whole above process) 
Internal rotation
Extension
Restitution
External rotation
Lateral flezion
(Expulsion)
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89
Q

What are the borders of the pelvic outlet?

A

Tipc of coccyx
Ischial tuberosity
Pubic arch

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90
Q

Which diameter is greater at the pelvic inlet?

A

The transverse diameter

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91
Q

Which diameter is greater at the pelvic outlet?

A

The Antero-posterior diameter

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92
Q

What causes the fetal head to rotate from the transverse to an anterior-posterior position ?

A

The pelvic floor muscles

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93
Q

What causes descent?

A

Uterine contractions
Amniotic fluid pressure
Abdominal muscle contraction

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94
Q

What is engagement?

A

When the largest diameter of the fetal head descends into the pelvis.

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95
Q

What is crowning?

A

When the widest part of the fetal head gets through the narrowest part of the pelvis, causing it to become visible at the vulva

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96
Q

What is restitution?

A

When the shoulders naturally align with the head

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97
Q

How is descent measured and in relation to what?

A

In centimetres from -5 to +5 in relation so the mothers ischial spines.

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98
Q

What is the third stage of labour?

A

The completed birth of the baby to the delivery of the placenta

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99
Q

What would prompt active management of the third stage?

A

Haemorrhage

More than a 60 minute delay in delivery

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100
Q

What does active management of the third stage involve?

A

Giving a dose of intramuscular oxytocin to help uterine contractions.

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101
Q

What are Braxton-Hicks contraction?

A

Occasional contractions of the uterus that do not indicate the onset of labour.

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102
Q

What are the different parts of the baby that can present first?

A 
Occiput (Back of head) 
Mentum (chin)
Sacrum
Face
Brow
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103
Q

Where do contractions start?

A

The fundus

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104
Q

What is SROM?

A

Spontaneous rupture of membranes

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105
Q

What is ARM?

A

Artificial rupture of membranes

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106
Q

What are the two membranes of the placenta?

A

The amnion and the chorion

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107
Q

What is the amnion?

A

The placental membrane that acts as a bag around the baby

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108
Q

What is the chorion?

A

The membranes around the placenta

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109
Q

What are some hollistic methods for labour pain management?

A 
Water bath 
Aromatherapy
Massage
Hypnotherapy
TENS machine
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110
Q

What is entonox?

A

Gas and air

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111
Q

What are non-invasive pain relief options for labour?

A

Entonox
Paracetamol
Codeine

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112
Q

What is miscarriage?

A

The spontaneous termination of pregnancy before 24 weeks?

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113
Q

When is early miscarriageE?

A

Before 12 weeks gestation

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114
Q

When is late miscarriage?

A

Between 12 and 24 weeks gestation

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115
Q

What is a missed miscarriage?

A

When the fetus is no longer alive but no symptoms have occured

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116
Q

What is threatened miscarriage?

A

Vaginal bleeding with a closed cervix and the fetus is still alive

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117
Q

What is inevitable miscarriage?

A

Vaginal bleeding with an open cervix

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118
Q

What is incomplete miscarriage?

A

When the retained products of conception (RPOC) remain in the uterus after miscarriage

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119
Q

What is complete miscarriage?

A

When there are no products of conception left in the uterus

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120
Q

What is an anembryonic pregnancy?

A

When a gestational sac is present but contains no embryo

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121
Q

What is the investigation of choice for diagnosing a miscarriage?

A

Transvaginal ultrasound

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122
Q

What are the 3 key features that sonographers look for in early pregnancy, in order of development?

A
  1. Mean gestational sac diameter
  2. Fetal pole and crown-rump length
  3. Fetal heart beat
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123
Q

What is the fetal crown-rump length?

A

The baby is measured in cm from the crown (top of head) to the bottom of their buttocks (rump).

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124
Q

What is the fetal pole?

A

First direct imaging manifestation of the fetus- thickening of the yolk sac margin visible approx. 6 weeks after conception.

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125
Q

When would a fetal heartbeat be expected?

A

When the crown-rump length is >7mm

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126
Q

If the crown-rump length is <7mm without a fetal heartbeat, how soon is there a repeat scan?

A

After at least 1 week to ensure heart beat develops

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127
Q

If there is a crown-rump length of >7mm without a fetal heart beat, what happens?

A

There is a repeat scan a week later before confirming a non-viable pregnancy

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128
Q

When would a fetal pole be expected to be seen?

A

Once the mean gestational sac diameter is >25mm

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129
Q

What is the management of a miscarriage at <6 weeks gestation?

A

Expectant

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130
Q

What is expectant miscarriage management before 6 weeks gestation?

A

Awaiting the miscarriage without investigations of treatment.
A repeat pregnancy test is performed after 7-10 days to confirm miscarriage.

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131
Q

What do the NICE guidelines recommend for a woman at >6 weeks gestation and a positive pregnancy test?

A

Referral to an early pregnancy assessment service (EPAU)

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132
Q

What investigation is given to a woman at >6 weeks gestation and bleeding?

A

An ultrasound to confirm location and viability of pregnancy (and to exclude ectopic pregnancy)

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133
Q

What are the 3 options for managing a miscarriage?

A

Expectant
Medical
Surgical

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134
Q

When would expectant management be offered for miscarriage?

A

If <6 weeks gestation

If >6 weeks with no risk factors for heavy bleeding or infection

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135
Q

How long is given for expectant management before moving on to other measures?

A

1-2 weeks given to allow miscarriage to occur spontaneously.

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136
Q

How soon after pain/ bleeding settle from expectant miscarriage should a repeat pregnancy test be done to confirm?

A

3 weeks

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137
Q

What factors may indicate an incomplete miscarriage?

A

Persistent or worsening bleeding

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138
Q

What is the medical management of miscarriage?

A

Misoprostol

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139
Q

What is misoprostol/ its mechanism of action?

A

A prostaglandin analogue- binds to prostaglandin receptors and activated them

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140
Q

Why does misoprostol stimulate miscarriage?

A

It activates prostaglandins which soften the cervix and stimulate uterine contractions

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141
Q

How is misoprostol given?

A

Either as a vaginal suppository or an oral dose

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142
Q

What are the key side effects of misoprostol?

A

Heavier bleeding
Pain
Vomiting
Diarrhoea

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143
Q

What are the indications for surgical management of miscarriage?

A

Sepsis, heavy bleeding or haemodynamic instability, suspicion of gestational trophoblastic disease.

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144
Q

What are the two options for surgical management of miscarriage?

A

Manual vacuum aspiration

Electric vacuum aspiration

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145
Q

Is manual vacuum aspiration done under local or general anaesthetic?

A

Local anaesthetic applied to the cervix as an outpatient

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146
Q

Is electric vacuum aspiration done under local or general anaesthetic?

A

General

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147
Q

What is given before surgical management of miscarriage and why?

A

Misoprostol to soften the cervix

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148
Q

What happens during manual vacuum aspiration?

A

A syringe attached to a tube is inserted into the uterus, and the contents are manually aspirated.

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149
Q

What are the indications for manual instead of electric vacuum aspiration?

A

Women consents
Below 10 weeks gestation
(More appropriate for parous women- those who have previously given birth)

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150
Q

What happens during electric vacuum aspiration?

A

Under general anaesthetic, the cervix is gradually widened using dilators and the products of conception are removed through the cervix using an electric -powered vacuum

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151
Q

What is given to rhesus negative women having surgical management of pregancy?

A

Anti-rhesus D prophylaxis

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152
Q

What is the risk of incomplete miscarriage?

A

The retained products create a risk of infection

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153
Q

What are the two options for treating an incomplete miscarriage?

A

Medical management

Surgical management

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154
Q

What is the surgical management for incomplete miscarriage?

A

Evacuation of retained products of conception (ERPC)

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155
Q

What happens during Evacuation of retained products of conception (ERPC)?

A

Cervix is widened using dilators, retatined products are manually removed using vacuum aspiration and curettage (Scraping)

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156
Q

What is a key complication of evacuation of retained products of conception surgery?

A

Endometritis

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157
Q

What is classed as recurrent miscarriage?

A

Three or more consecutive miscarriages

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158
Q

What increases the risk of miscarriage?

A

Increased age

50% in women aged 40-45

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159
Q

What are the causes of miscarriage?

A

Idiopathic
Bleeding disorders (Antiphospholipid syndrome, Hereditary thrombophilias)
Uterine abnormalities
Genetic factors
Chronic diseases (diabetes, thyroid disease, SLE)

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160
Q

What is antiphospholipid syndrome?

A

A disorder associated with antiphospholipid antibodies, where blood becomes prone to clotting (hyper-coagulable state)

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161
Q

What is given to pregnant ladies with antiphospholipid syndrome?

A

Low dose aspirin

LMWH

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162
Q

What is ectopic pregnancy?

A

When a pregnancy is implanted outside the uterus

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163
Q

Where is the most common site for an ectopic pregnancy?

A

The fallopian tube

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164
Q

What is the name of the entrance to the fallopian tube?

A

Cornual region

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165
Q

Where can an ectopic pregnancy occur?

A 
Fallopian tube
Cornual region
Ovary 
Cervix
Abdomen
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166
Q

What are the key risk factors for developing an ectopic pregnancy?

A 
Previous ectopic pregnancy
Previous PID
Previous surgery to fallopian tubes
IUD
Older age
Smoking
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167
Q

At what gestation does ectopic pregnancy usually present?

A

6-8 weeks

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168
Q

What are the key features of an ectopic pregnancy?

A

Missed period
Constant lower abdominal pain in right or left iliac fossa
Vaginal bleeding
Lower abdominal/ pelvic tenderness
Cervical motion tenderness (Pain in cervix during bimanual exam)
Dizziness/ syncope
Shoulder tip pain (peritonitis)

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169
Q

What are the 9 regions of the abdomen?

A

R hypochondriac, Epigastric, L Hypochondirac, R lumbar, umbilical, L lumb, R iliac, hypogastric, L iliac

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170
Q

Why might you get shoulder tip pain during ectopic pregnancy?

A

Bleeding in the peritoneal cavity can irritate the diaphragm and therefore phrenic nerve which causes referred pain.

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171
Q

What is the investigation of choice for diagnosing a miscarriage?

A

TVUS (Transvaginal ultrasound scan)

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172
Q

What may be seen in a TVUS during ectopic pregnancy?

A

Gestational sac containing yolk soc or fetal pole in fallopian tube

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173
Q

What is a blob sign?

A

When a mass containing an empty gestational sac is seen on TVUS

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174
Q

What is a PUL?

A

Pregnancy of unknown location

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175
Q

How is a PUL diagnosed?

A

When there is a positive pregnancy test and no evidence of pregnancy on ultrasound

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176
Q

How often are serum hCG levels repeated during PUL?

A

After 48 hours to measure change from baseline

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177
Q

What change in hCG should be seen in a normal pregnancy?

A

Should double every 48 hours

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178
Q

What produces hCG?

A

The developing syncytiotrophoblast

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179
Q

What may a rise of more than 63% hCG after 48 hours indicate?

A

A normal intrauterine pregnancy

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180
Q

Over what hCG level should a pregnancy be visible on ultrasound?

A

> 1500 IU/L

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181
Q

What may a rise of less than 63% hCG indicate?

A

An ectopic pregnancy

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182
Q

What is a fall of >50% of hCG likely to indicate?

A

A miscarriafe

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183
Q

What is the immediate management of any women with suspected ectopic pregnancy?

A

Pregnancy test

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184
Q

What needs to happen to women with pelvic pain and and a positive pregnancy test?

A

Need to be referred to an early pregnancy assessment unit or gynae service

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185
Q

What are the 3 management options for ectopic pregnancy?

A

All must be terminated:
Expectant
Medical
Surgical

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186
Q

What is the criteria for expectant management for ectopic pregnancy?

A 
Ectopic must be unruptured
Adnexal mass <35mm 
No visible heartbeat
No significant pain
HCG level <1500
Must be available for follow up
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187
Q

What followup must be given to women on expectant management for ectopic?

A

Close monitoring of hCG

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188
Q

What is the criteria for medical management for ectopic?

A

Same as expectant but HCG must be <5000 and confirmed absence of intrauterine pregnancy on ultrasound

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189
Q

What is the medical management for ectopic pregnancy?

A

Methotrexate

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190
Q

Why is methotrexate given to treat ectopic?

A

It is highly teratogenic.

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191
Q

How is methotrexate given?

A

As an IM injection to the buttock.

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192
Q

How long should women treated with methotrexate wait to try for another baby?

A

3 months

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193
Q

What are common side effects of methotrexate?

A

Vaginal bleeding
Nausea/ vomiting
Abdominal pain
Stomatitis

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194
Q

What is the criteria for surgical management to treat ectopic pregnancy?

A

Pain
Adnexal mass >35mm
Visible heartbeat
HCG levels >5000

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195
Q

What is the most likely treatment option for most ectopic pregnancies?

A

Surgical

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196
Q

What are the two options for surgical management of ectopic pregnancy?

A

Laparoscopic salpingectomy

Laparoscopic salpingotomy

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197
Q

What is laparoscopic salpingectomy?

A

Key hole surgery to remove fallopian tube and ectopic pregnancy.
Done under general anaesthetic

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198
Q

What is laparoscopic salpingotomy?

A

The removal of the ectopic from the fallopian tube, but re-closing the tube to keep it there.

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199
Q

Which is the first line surgical treatment for ectopic pregnancy and why?

A

Laparoscopic salpingectomy as there is higher success rate.

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200
Q

What are the adnexa?

A

Ovaries, fallopian tubes, and ligaments that hold the reproductive organs in place

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201
Q

What is a molar pregnancy?

A

When a tumour called a hydatidiform mole grows like a pregnancy

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202
Q

What are the two types of molar pregnancy?

A

Complete mole

Partial mole

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203
Q

What is a complete mole?

A

When two sperm cells fertilise an ovum that contains no genetic material. The sperm then combine genetic material and the cells start to divide and grow into a tumour (complete mole)

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204
Q

What is a partial mole?

A

When two sperm cells fertilise a normal ovum at the same time, so the new cell has 3 sets of chromosomes.

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205
Q

What features can differentiate between a normal pregnancy and a molar pregnancy?

A 
More severe morning sickness
Vaginal bleeding
Increased enlargement of uterus
Abnormally high hCG
Thyrotoxicosis
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206
Q

Why may molar pregnancy cause thyrotoxicosis?

A

hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4

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207
Q

What investigation is done to diagnose molar pregnancy?

A

Pelvis USS which shows characteristic ‘snowstorm appearance’

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208
Q

What investigation confirms diagnosis of molar pregnancy?

A

Histology of mole after evacuation

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209
Q

What is the management of molar pregnancy?

A

Evacuation of the uterus to remove the mole.
Referral to the gestational trophoblastic disease centre for management and follow up.
Monitoring of hCG levels until they return to normal

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210
Q

Why may a patient with a molar pregnancy require systemic chemotherapy?

A

Because the mole can metastasise

About 1 in 10 people

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211
Q

What is the name of the legal framework for the termination of pregnancy?

A

1967 Abortion Act

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212
Q

What is the latest gestational age where abortion is legal?

A

24 weeks

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213
Q

What is the key criteria that must be used to justify an abortion?

A

Continuing the pregnancy involves greater risk to the physical or mental health of the woman, or existing children of the family

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214
Q

What criteria allows an abortion to be perfomed at any time during the pregnancy?

A
  1. Continuing the pregnancy is likely to risk the life of the woman
  2. Terminating the pregnancy will prevent ‘grave permenant injury’ to the physical or mental health of the woman
  3. There is ‘substational risk’ that the child would suffer physical or mental abnormalities
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215
Q

What are the legal requirements for abortion?

A

Two registered medical practitioners must sign to agree abortion is indicated.
Carried out by a registered medical practitioner in and NHS hospital/ approved premise

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216
Q

How can abortion services be accessed?

A
  • Self-referral
  • GP
  • GUM
  • Family planning clinic referral
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217
Q

When is medical abortion most appropriate?

A

Earlier in pregnancy

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218
Q

What does medical abortion involve?

A

Mifepristone

Misoprostol 2 days later

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219
Q

What is Mifepristone?

A

An anti-progesterone medication that blocks the action of progesterone, therefore halting the pregnancy and relaxing the cervix

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220
Q

What is Misoprostol?

A

A prostaglandin analogue, that binds to prostaglandin receptors and activates themm therefore softening the cervix and stimulating uterine contractions

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221
Q

What are the types of anaesthetic surgical abortion can be performed under?

A

Local
Local + sedation
General

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222
Q

What is given to patients prior to surgical abortion?

A

Misoprostol, Mifepristone or osmotic dilators, to soften and dilate the cervix.

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223
Q

What are osmotic dilators?

A

Devices inserted into the cervix that gradually expand as they absorb fluid, opening the cervical canal

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224
Q

What are the two options for surgical abortion?

A

Cervical dilation and suction of uterus contents (<14 weeks)

Cervical dilation and evacuation with forceps (14-24 weeks)

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225
Q

What happens after abortion?

A

Women may have bleeding and cramps for up to 2 weeks after.
Pregnancy test performed after 3 weeks
Support, counselling and contraception advice is given.

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226
Q

What are the complications of abortion?

A 
Bleeding 
Pain
Infection
Failure
Damage to uterus, cervix and surrounding structures
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227
Q

How many weeks is trimester 1?

A

0-12

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228
Q

When is trimester 2?

A

12-26 weeks

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229
Q

When is trimester 3?

A

27-40 weeks

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230
Q

What is the mechanism of miscarriage?

A

If the implantation site is not well established, then the fetus does not burrow properly. This leads to a decrease in HCG which causes progesterone levels to fall. The low progesterone causes the endometrium to break down the the uterus contracts to let unwanted contents out.

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231
Q

In a normal pregnancy, what effect does HCG have on progesterone?

A

Positive effect, more HCG= More progesterone so endometrium doesn’t die and the egg can burrow

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232
Q

What are the two types of shock that can occur with miscarriage?

A

Hypovolaemic–> Excessive bleeding lowers the blood pressure
Vagal stimulation–> When the cervix is forcibly dilated, it causes vagal stimulation which decreases the blood pressure (parasympathetic nervous system)

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233
Q

Why is a previous surgery a danger to pregnancy?

A

As usually the endo-myometrial interface prevents the fetus burrowing into the myometrium. However, if this has a cut it can perforate through.

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234
Q

What does LMP refer to?

A

Last menstrual period

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235
Q

What is GA?

A

Gestational age

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236
Q

What is EDD?

A

Estimated date or delivery

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237
Q

What is gravida?

A

The total number of pregnancies including the current one

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238
Q

What does primigravida mean?

A

Patient that is pregnant for the first time

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239
Q

What does multigravida mean?

A

A patient is pregnant for at least the second time

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240
Q

What does para/ parity refer to?

A

Number of times a women has given birth after 24 weeks gestation, regardless of outome

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241
Q

What does nulliparous mean?

A

Patient has never given birth after 24 weeks gestation

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242
Q

What does primiparous mean?

A

A patient that has given birth after 24 weeks once before

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243
Q

What does multiparous mean?

A

A patient that has given birth after 24 weeks two or more times

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244
Q

What would be the gravida and para for a pregnant woman with three previous deliveries and one miscarriage?

A

G4P3+1

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245
Q

When do fetal movements typically start?

A

From around 20 weeks

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246
Q

When does booking clinic occur?

A

Before 10 weeks

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247
Q

What pregnancy milestone should happen between 10 and 13+6 weeks?

A

Dating scan

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248
Q

How is the gestational age calculated?

A

From the crown rump length

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249
Q

What milestone occurs at 16 weeks?

A

Antenatal appointment

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250
Q

What milestone happens between 18 and 20+6 weeks?

A

Anomaly scan

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251
Q

At what weeks are there further antenatal appointments?

A

25, 28, 31, 34, 36, 38, 40 +

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252
Q

What additional appointments may be necessary for pregnant women?

A

Additional for higher risk/ complicated pregnancies
Oral glucose tolerance test for those at risk of gestational diabetes
Anti-D injections in rhesus negative women (28 and 34 weeks)
USS at 32 weeks for those with placenta praevia
Serial growth scans for those increased risk of fetal growth restriction

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253
Q

What is measured from 24 weeks onwards?

A

Symphysis-fundal height

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254
Q

What is assessed from 36 weeks onwards?

A

Fetal presentation

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255
Q

What is measured to assess for pre-eclampsia?

A

Urine dipstick

Blood pressure

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256
Q

What 2 vaccines are offered to all pregnant women?

A 
Whooping cough (from 16 weeks) 
Flu jab (in autumn/ winter months)
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257
Q

What supplements are recommended in pregnancy?

A

Folic acid

VItamin D

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258
Q

When should you take folic acid and why is important to take folic acid in normal pregnancy?

A

From before pregnancy to 12 weeks

It reduces risk of neural tube defects

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259
Q

What things should be avoided in pregnancy?

A 
Vitamin A 
Liver or pate (high in vitamin A)
Alcohol
Smoking
Unpasteurised dairy/ blue cheese
Undercooked/ raw poultry
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260
Q

What are the risks of drinking alcohol in early pregnancy?

A

Miscarrige
Small for GA
Preterm delivery
Fetal alcohol syndrome

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261
Q

What are the key features of fetal alcohol syndrome?

A 
Microcephaly (small head) 
Thin upper lip
Smooth flat philtrum (groove between nose and upper lip)
Short palpebral fissure (from one side of eye to another) 
Learnng disability
Behavioural difficulties
Hearing/ vision problems
Cerebral palsy
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262
Q

What are the risks of smoking in pregnancy?

A 
Fetal growth restriction
Miscarriage
Stillbirth
Preterm labour/ delivery
Placental abruption
Pre-eclampsia
Cleft lip/ palate
SIDS
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263
Q

What is SIDS?

A

Sudden infant death syndrome

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264
Q

Up to what stage in pregnancy is it ok to fly?

A

37 weeks

32 in twin pregnancy

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265
Q

At what stage of pregnancy does booking clinic occur?

A

Before 10 weeks gestation

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266
Q

What topics should be covered in booking clinic?

A 
Stages of pregnancy
Lifestyle advice
Supplements
Plans for birth
Screening tests
Antenatal classes
Breastfeeding classes
Mental health
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267
Q

What bloods are taken at booking clinic?

A

Blood grouo
Antibodies
Rhesus D status
FBC for anaemia
Screening for thalassaemia and sickle cell disease (for those at higher risk)
Screening for infectious disease (HIV, Hep B, Syphillis)

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268
Q

What is done at booking clinic?

A 
Educating woman on pregnancy topics
Bloods
Weight, Height & BMI
Urine (protein & bacteria) 
Blood pressure
Discuss FGM/ domestic violence
Risk assessment for pregnancy complications
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269
Q

What conditions are women risk assessed for at booking clinic?

A 
Rhesus negative
Gestational diabetes
Fetal growth restriction
VTE
Pre-eclampsia
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270
Q

Who is at more risk of have a baby with Down’s syndrome?

A

Older mothers

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271
Q

What are the different screening tests for Down’s syndrome?

A

Combined test
Triple test
Quadruple test

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272
Q

Which is the first line screening test for Down’s syndrome?

A

The combined test

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273
Q

At what stage is the combined test completed?

A

11-14 weeks

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274
Q

What does the combined test involve?

A

Combining results from ultrasound and maternal blood tests

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275
Q

What does the ultrasound measure in the combined test for Down’s?

A

Nuchal translucency

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276
Q

What is nuchal translucency and what thickness would indicate Down’s?

A

The thickness of the fluid filled space at the back of the neck
6mm

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277
Q

What maternal blood tests are included in the combined test and what results would indicate greater risk of Down’s?

A

Beta-HCG (higher result = higher risk)

Pregnancy- associated plasma protein- A (PAPPA)- Lower result = greater risk

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278
Q

When is the triple test for Down’s syndrome completed?

A

Between 14 and 20 weeks gestation

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279
Q

What does the triple test for Down’s involve?

A

Three maternal blood tests:
Beta-HCG
Alpha-fetoprotein
Serum oestriol

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280
Q

When would the quadruple test for Down’s be completed?

A

Between 14 and 20 weeks gestation

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281
Q

What does the quadruple test involve?

A

4 blood tests:

  1. Beta HCG
  2. Alpha-fetoprotein
  3. Serum oestriol
  4. Inhibin A
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282
Q

For each of the blood tests in the quadruple test, what result would indicate a higher risk?

A
  1. Beta HCG–> High
  2. AFP–> Low
  3. Serum oestriol–> Low
  4. Inhibin-A–> High
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283
Q

What risk score from the Down’s screening tests would trigger further action?

A

Risk of greater than 1 in 150

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284
Q

What is offered to the woman if there is a greater than 1 in 150 risk of Down’s?

A

Amniocentesis or

Chorionic villus sampling

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285
Q

What is Chorionic villus sampling?

A

Ultrasound-guided biopsy of the placental tissue in order to karyotype the fetal cells and confirm Down’s

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286
Q

What is amniocentesis?

A

Ultrasound-guided aspiration of amniotic fluid using a needle and syringe

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287
Q

When would chorionic villus sampling be used instead of amniocentesis?

A

Early in the pregnancy (before 15 weeks) when there is not enough amniotic fluid to safely take a sample

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288
Q

What is NIPT?

A

Non-invasive prenantal testing

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289
Q

What does NIPT involve?

A

Blood test from the mother, containing fragments of fetal DNA which can be analysed to detect chromosomal conditions.

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290
Q

What chronic conditions may be problematic in pregnancy?

A

Hypothyroidism
Hypertension
Epilepsy
RA

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291
Q

How is hypothyroidism managed in pregnancy?

A

Levothyroxine dose increased by 30-50% to provide enough to the developing fetus

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292
Q

What changes may need to happen to women with existing hypertension during pregnancy?

A

STOP:

  • Ace inhibitors
  • ARB’s
  • Thiazide-like diuretics
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293
Q

What medications can be continued/ changed to to treat existing hypertension in pregnancy?

A

Labetalol
CCB’s
Alpha-blockers

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294
Q

What adverse effects may pregnancy cause to women with epilepsey?

A

Can worsen seizure control due to additional stress, lack of sleeps, hormonal changes and altered medication regimes

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295
Q

What epilepsey medication should be avoided in women of childbearing age due to its teratogenic effects?

A

Sodium valproate

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296
Q

Which anti-epileptics are safer in pregnancy?

A

Levetiracetam
Lamotrigine
Carbamazepine

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297
Q

What medication for RA should be avoided in pregnancy?

A

Methotrexate- teratogenic

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298
Q

What key drugs should be avoided in pregnancy?

A 
NSAIDs
Beta-blockers
ACE inhibitors
ARB's
Opiates
Warfarin
Sodium Valproate
Lithium
SSRIs
Isotretinoin
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299
Q

Why should NSAID’s be avoided in pregnancy?

A

They work by blocking prostoglandins (which are important in maintaining the ductus arteriosus in the fetus and neonate, and soften the cervix/ stimulate contractions in labour)

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300
Q

At which stage of pregnancy are NSAIDs particularly avoided and why?

A

Third trimester as they can cause premature closure of the ductus arteriosus and delay labour

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301
Q

Why are beta- blockers contraindicated in pregnancy?

A

They can cause FGR, hypoglycaemia and bradycardia in the neonate

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302
Q

Why are medications that block the RAAS system (ACE inhibitors/ ARB’s) contraindicated in pregnancy?

A

They can cross the placenta and enter the fetus, affecting the fetal kidneys and reducing the production of urine (and therefore amniotic fluid)

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303
Q

What are the complications of using ACE/ ARB’s in pregnancy?

A

Oligohydramnios
Hypocalvaria (incomplete formation of skull bones)
Miscarriage/ fetal death
Renal failure/ hypotension in neonate

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304
Q

Why are opiates contraindicated in pregnancy?

A

They can cause neonatal abstinence syndrome (NAS)- withdrawal symptoms in the neonate after birth

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305
Q

What is NAS and how does it present?

A

Neonatal abstinence syndrome

Presents 3-72 hours after birth with irritability, tachypnoea, fevers and poor feeding

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306
Q

Why is warfarin avoided in pregnancy?

A

It is teratogenic and can cross the placenta to cause fetal loss, congenital malformations or bleeding

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307
Q

Why is sodium valproate contraindicated in pregnancy?

A

It causes neural tube defects and developmental delay

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308
Q

Why is lithium contraindicated in pregnancy?

A

Linked to congenital cardiac abnormalities in the first trimester.
Can also enter the breast milk and be toxic to the infant

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309
Q

Why are SSRI’s contraindicated in pregnancy?

A

First trimester- linked with congenital heart defects
Third trimester- linked to persistent pulmonary hypertension in the neonate
Neonates can experience withdrawal symptoms

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310
Q

What is isotretinoin and why is it contraindicated in pregnancy?

A

A retinoid (related to vitamin A) used to treat severe acne, that is highly teratogenic and can cause miscarriage and congenital defects

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311
Q

What viruses are most risky to pregnant women?

A 
Rubella
Chickenpox
Listeria
Congenital Cytomegalovirus
Congenital toxoplasmosis
Parvovirus B19
Zika virus
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312
Q

What causes congenital rubella syndrome?

A

Maternal infection with the rubella virus during the first 20 weeks of pregnancy

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313
Q

Should women be given the MMR vaccine when pregnant if not already immune?

A

No- it is a live vaccine

Should be given after birth

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314
Q

What are the features of congenital rubella syndrome?

A

Congenital deafness
Congenital cataracts
Congenital heart disease
Learning disability

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315
Q

Why is Chickenpox dangerous in pregnancy?

A

It can lead to varicella syndrome or severe infection in the mother

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316
Q

What can be tested if the mother is unsure if she is immune to chickenpox?

A

IgG levels for VZV (Varicella zoster virus)

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317
Q

What should happen if a woman is exposed to chickenpox in pregnancy?

A
  • If unsure about immunity, test VZV IgG levels.
  • If not immune, treat with IV varicella immunoglobulins
  • If present with a rash, treat with oral aciclovir
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318
Q

What is listeria and which patients are more at risk?

A

A gram-positive bacteria that causes listeriosis. It is a lot more likely in pregnant women.

319
Q

What are the risks of developing listeriosis in pregnancy?

A

High rate of miscarriage, fetal death or severe neonatal infection

320
Q

How is listeria typically transmitted?

A

By unpasteurised dairy products, processed meats and contaminated foods (why women should avoid blue cheese)

321
Q

What is CMV and how is it spread?

A

Congenital cytomegalovirus. Spread via infected saliva or urine of asymptomatic children/

322
Q

What is the classic triad of features in congenital toxoplasmosis?

A

Intracranial calcification
Hydrocephalus
Chorioretinitis (inflammation of eye)

323
Q

What is parvovirus B19 more commonly known as?

A

Slapped cheek syndrome

or fifth disease/ erythema infectiosum

324
Q

What are the complications of parvovirus B19 in pregnancy?

A

Miscarriage/ fetal death
Severe fetal anaemia
Hydrops fetalis (fetal heart failure)

325
Q

What does rhesus refer to?

A

The various types of rhesus antigens on the surface of RBC’s

326
Q

When someone is ‘rhesus-negative’, what does that refer to?

A

Whether the rhesus-D antigen is present on the red blood cell surface

327
Q

Do rhesus positive or rhesus negative women need additional treatment during pregnancy?

A

Rhesus negative

328
Q

Outline how a rhesus-negative mother may become sensitised during pregnancy:

A

If a woman who is rhesus-negative has a rhesus positive baby, the babys red blood cells may enter her blood stream and display the rhesus-D antigent. Her immune system will therefore develop antibodies to the foreign D antigen and become sensitised.

329
Q

Why is becoming sensitised to rhesus-D antigens an issue for the mother?

A

During subsequent pregnancies, the mothers anti-D antibodies can cross the placenta and attach to the fetal red blood cells, causing haemolysis

330
Q

What is haemolytic disease of the newborn?

A

When a sensitised mothers antibodies attack a rhesus-D positive fetus’s red blood cells.

331
Q

What is the mainstay of management in rhesus disease?

A

Prevention of sensitisation

332
Q

How is sensitisation prevented in rhesus-negative pregnant women?

A

IM anti-D injections

333
Q

How do anti-D injections work?

A

It attaches to the rhesus-D antigens on fetal RBC’s in the mothers circulation, causing them to be destroyed. This prevents the mother’s immune system creating antibodies against them.

334
Q

When are anti-D injections given?

A

Routinely at:
-28 weeks
-Birth (if the baby is found to be rhesus +ve)
At any time when sensitisation may occur:
-Antepartum haemorrhage
-Amniocentesis
-Abdominal trauma

335
Q

What test is used to see how much fetal blood has passed into the mother’s blood?

A

Kleihauer Test

336
Q

How is fetal size measured?

A

USS:

  • Estimated fetal weight (EFW)
  • Fetal abdominal circumference (AC_
337
Q

At what percentile is a fetus defined as small for gestational age?

A

Below the 10th centile

338
Q

What percentile classes as severe SGA?

A

Below the 3rd centile

339
Q

What is defined as low birth weight?

A

Less than 2500g

340
Q

What are the two causes of SGA?

A

Constitutionally small

Fetal growth restriction (FGR)

341
Q

What is fetal growth restriction?

A

When the fetus is not growing as expected due to pathology reducing the amount of nutrients and oxygen being delivered

342
Q

What are the two categories relating to the causes of FGR?

A

Placenta mediated growth restriction

Non-placenta mediated growth restriction

343
Q

What are some causes of placenta mediated growth restriction?

A 
Idiopathic
Smoking
Drugs
Alcohol
Pre-eclampsia
Anaemia
Malnutrition
Infection
Maternal health conditions
344
Q

What are the causes of non-placenta mediated growth restriction?

A

Genetic abnormalities
Structural abnormality
Fetal infection
Errors of metabolism

345
Q

What are signs of FGR other than on ultrasound?

A
  • Oligohydramnios
  • Abnormal Doppler studies
  • Reduced fetal movements
  • Abnormal CTG’s
346
Q

What are the short term complications of FGR?

A

Fetal death/stillbirth
Birth asphyxia
Neonatal hypothermia
Neonatal hypoglycaemia

347
Q

What are the long term risks of growth restricted babies?

A

Cardiovascular disease
T2 diabetes
Obesity
Mood/ behavioural problems

348
Q

What are the risk factors for SGA?

A 
Previous SGA baby
Obesity
Smoking
Diabetes
Hypertension
Pre-eclampsia
Geriatric pregnancy
Multiple pregnancy
Low PAPPA
Antepartum haemorrhage
Antiphospholipid syndrome
349
Q

At what point in pregnancy are women assessed for risk factors for SGA?

A

Booking clinic

350
Q

How are women at low risk of SGA monitored?

A

Symphysis fundal height measured at every antenatal appointment from 24 weeks onwards and plotted on customised growth chart

351
Q

What happens if the symphysis fundal height is found to be less than the 10th centile during pregnancy?

A

Women are booked for serial growth scans with umbilical artery doppler

352
Q

Under what circumstances would women be booked for serial growth scans and umbilical doppler?

A
  • If the fetus is found to be <10th centile
  • If they have 3 minor risk factors
  • If they have a major risk factor
  • If there are issues with measuring the SFH (e.g. large fibroids/ BMI>35)
353
Q

How are women at high risk or with confirmed SGA monitored?

A

Serial USS (usually every 4 weeks from 28 weeks) measuring;

  • Estimated fetal weight + Abdominal circumference
  • Umbilical arterial pulsality index
  • Amniotic fluid volume
354
Q

What is the management of SGA?

A 
Identify those at risk
Try to identify underlying cause
Treat cause/ risk factors (e.g. give aspirin to those with pre-eclampsia, stop smoking) 
Serial growth scans
Early delivery if growth is static
355
Q

What investigations can be done to identigy the underlying cause of SGA?

A 
BP and urine dipstick for pre-eclampsia
Uterine artery doppler
Fetal anatomy scan
Karyotyping for chromosomal abnormalities
Testing for infections
356
Q

When would a baby be defined as large for gestational age?

A

If the weight is >4.5kg at birth

or the EFW is >90th centile

357
Q

What is macrosomia?

A

Being large for gestational age

358
Q

What are the causes of macrosomia?

A 
Constitutional
Gestational diabetes
Previous macrosomia
Maternal obesity/ rapid weight gain
Overdue
Male baby
359
Q

What are the risk of LGA to the mother?

A 
Shoulder dystocia
Failure to progress
Perineal tears
Instrumental delivery/ C-section
Postpartum haemorrhage
Uterine rupture
360
Q

What are the risks of LGA to the baby?

A

Birth injury (e.g Erbs palsy, clavicle fracture, fetal distress)
Neonatal hypoglycaemia
Obesity in later life
T2 diabetes in adulthood

361
Q

What investigations are done for LGA babies?

A

Ultrasound to exclude polyhydramnios and estimate fetal weight
Oral glucose tolerance test for gestational diabetes

362
Q

What are monozygotic twins?

A

Twins from a single zygote- identical

363
Q

What are dizygotic twins?

A

From two different zygotes- Non-identical

364
Q

What does monoamniotic mean?

A

There is a single amniotic sac

365
Q

What does diamniotic mean?

A

There are two seperate amniotic sacs

366
Q

What does monochorionic mean?

A

Twins share a single placenta

367
Q

What is dichorionic?

A

When there are two seperate placentas

368
Q

What type of twin pregnancy has the best outcome and why?

A

Diamniotic, dichorionic as each fetus has its own nutrient supply

369
Q

How is multiple pregnancy usually diagnosed?

A

On booking ultrasound scan

370
Q

How are diachorionic diamniotic twins diagnosed using ultrasound?

A

There is a membrane between the twins, with a lambda/ twin peak sign

371
Q

How are monochorionic diamniotic twins diagnosed with ultrasound?

A

Membrane between twins with a T sign

372
Q

What are the risks of a multiple pregnancy to the mother?

A 
Anaemia
Polyhydramnios
Hypertension
Malpresentation
Spontaneous pre-term birth
Instrumental delivery/ C-section
Postpartum haemorrhage
373
Q

What are the risks of multiple pregnancy to the fetuses?

A 
Miscarriage
Stillbirth
FGR
Prematurity
Twin-twin transfusion syndrome
Congenital abnormalities
374
Q

What is twin-twin transfusion syndrome?

A

When there is a connection between the blood supplies of the two fetuses, and one fetus (the recipient) recieves the majority of the blood from the shared placenta, starving the other (the donor)

375
Q

What is the risk to the recipient in twin-twin transfusion syndrome?

A

Fluid overload
Heart failure
Polyhydramnio

376
Q

What is the risk to the donor in twin-twin transfusion syndrome?

A

Growth restriction
Anaemia
Oligohydramnios

377
Q

What additional monitoring do women with multiple pregnancies require?

A

Additional FBC’s to monitor for anaemia

Additional USS to monitor FGR, unequal growth and twin-twin transfusion syndrome

378
Q

When is planned birth offered to mothers with multiple pregnancies?

A

Uncomplicated monochorionic, monoamniotic twins= 32-33+6 weeks
Uncomplicated monochorionic diamniotic twins= 36-36+6 weeks
Uncomplicated dichorionic diamniotic twins= 37-37+6 weeks
Triplets= before 35+6 weeks

379
Q

Why is planned birth before certain dates essential for multiple pregnancy?

A

Waiting too long is associated with increased risk of fetal death

380
Q

How must monoamniotic twins be delivered?

A

Elective C-section between 32 and 33+6 weeks

381
Q

What are the risks of a UTI in pregnancy?

A

Increase risk of preterm delivery, low birth weight and pre-eclampsia

382
Q

What is asymptomatic bacteriuria?

A

Bacteria present in urine without symptoms of infections

383
Q

Why is asymptomatic bacteriuria a risk in pregnany?

A

Pregnant women are more at risk of developing lower UTI and pyelonephritis, and therefore at risk of preterm birth

384
Q

When are pregnant women tested for asymptomatic bacteriuria?

A

At booking and routinely throughout pregnancy

385
Q

What may be found in a midstream sample of someone who has a UTI?

A

Nitrites

Leukocyte esterase

386
Q

What is the most accurate indication of a UTI?

A

Nitrites

387
Q

What are the most common bacterial causes of UTI’s?

A

E.coli

Klebsiella pneumoniae

388
Q

How are UTI’s managed in pregnancy?

A

7 days of antibiotics

389
Q

What are the antibiotic options to treat UTI in pregnancy?

A

Nitrofurantoin
Amoxicillin
Cefalexin

390
Q

At what stages of pregnancy are women screened for anaemia?

A

Booking clinic

28 weeks gestation

391
Q

Why are women more prone to anaemia in pregnancy?

A

The plasma volume increases during pregnancy, resulting in a reduced haemoglobin concentration.

392
Q

What are the normal ranges of haemoglobin in pregnancy?

A

Booking: >110g/L
28 weeks: >105
Post partum: >100

393
Q

What screening are women offered at booking clinic to reduce the risk of anaemia?

A

Haemoglobinopathy screening: Screens for thalassaemia and sickle cell disease

394
Q

How is anaemia managed in pregnancy?

A

Depends on cause: e.g.

  • Iron replacement
  • B12
  • Folic acid
395
Q

Why is VTE more common in pregnancy?

A

Pregnancy is a hyper-coagulable state

396
Q

What are the key risk facotrs for VTE in pregnancy?

A 
Smoking
Parity>3
Age>35
BMI>30
Reduced/ immobility
Multiple pregnancy
Pre-eclampsia
Gross varicose veins
Family history of VTE
Thrombophilia
IVF
397
Q

How many VTE risk factors are an indication for starting prophylaxis (in the first trimester and at 28 weeks?)

A

First trimester: 4 or more risk factors

28 weeks: three risk factors

398
Q

Under which conditions would VTE prophylaxis be given no matter the number of risk factors?

A 
Hospital admission
Surgical procedues
Previous VTE
Cancer
Arthritis
High-risk thrombophilias
Ovarian hyperstimulation syndrome
399
Q

When do pregnant women have a risk assessment for VTE?

A

At their booking appointment and again after birth

400
Q

What prophylaxis is used for pregnant women at increased risk of VTE?

A

LMWH (E.g. Dalteparin, enozaparin, tinzaparin)

401
Q

How long is VTE phrophylaxis continued for?

A

From first trimester (very high risk) or 28 weeks (high risk) until 6 weeks postnatally.

402
Q

At what point in pregnancy is VTE prophylaxis temporarily stopped?

A

During labour (started immediately after delivery)

403
Q

What is pre-eclampsia?

A

New hypertension in pregnancy with end-organ dysfunction and proteinuria

404
Q

At what point in pregnancy does pre-eclampsia usually start?

A

after 20 weeks gestation

405
Q

Why does pre-eclampsia usually start after 20 weeks gestation?

A

This is when the spiral arteries of the placenta form abnormally, leading to high vascular resistance

406
Q

What is the pre-eclampsia triad?

A

Hypertension
Proteinuria
Oedema

407
Q

What is the difference between gestational hypertension and pre-eclampsia?

A

Pre-eclampsia involves proteinuria

408
Q

What is eclampsia?

A

When seizures occur as a result of pre-eclampsia

409
Q

What causes pre-eclampsia?

A

High vascular resistance in the spiral arteries and poor perfusion of the placenta. This causes oxidative stress in the placenta, causing the release of inflammatory chemicals which impair endothelial function in blood vessels

410
Q

What are the HIGH risk factors for pre-eclampsia?

A 
Previous pre-eclampsia
Pre-existing hypertension
Autoimmune conditions
Diabetes
CKD
411
Q

What are the MODERATE risk factors for pre-eclampsia?

A 
>40 
BMI > 35
>10 years since previous pregnancy
Multiple pregnancy
First pregnancy
Family history
412
Q

What is offered as phrophylaxis against pre-eclampsia?

A

Aspirin from 12 weeks

413
Q

How many pre-eclampsia risk factors negate prophylactic aspirin?

A

One high risk factor

>1 moderate risk factor

414
Q

What are the symptoms of pre-eclampsia?

A 
Headache
Visual disturbance
Nausea & vomiting
Epigastric pain (due to liver swelling) 
Oedema
Reduced urine output
Brisk reflexes
415
Q

How is pre-eclampsia diagnosed?

A 
Systolic >140 OR diastolic >90 
\+ ONE OF: 
-Proteinuria
-Organ dysfunction
-Placental dysfunction
416
Q

How is proteinuria confirmed?

A

+1 or more on urine dipstick
Urine protein:creatinine ratio >30
Urine albumin:creatinine ratio >8

417
Q

What investigations may indicate organ dysfunction?

A 
Raised creatinine
Raised liver enzymes
Seizures
Thrombocytopenia
Haemolytic anaemia
418
Q

What should be measured at least once during pregnancy in patients with suspected pre-eclampsia?

A

Placental growth factor (PlGF)–> Protein released by the placenta that stimulates the development of new blood vessels. Will be low in pre-eclampsia

419
Q

How are pregnant women monitored for pre-eclampsia?

A

At every antenatal appointment, check:

  • Blood pressure
  • Symptoms
  • Urine dipstick for proteinuria
420
Q

How is gestational hypertension managed?

A 
Aim for 135/85
Urine dipstick weekly
Weekly bloods
Serial growth scans
PlGF testing
421
Q

How is pre-eclampsia managed?

A

BP monitored every 48 hours
USS monitoring of fetus, amniotic fluid and dopplers every 2 weeks
Medical management

422
Q

What is the first line medical management of pre-eclampsia?

A

Labetolol

423
Q

What is the second line medical management of pre-eclampsia?

A

Nifedipine

424
Q

What drug is given to pre-eclamptic patients during labour to prevent seizures?

A

IV magnesium sulphate

425
Q

What may be necessary to have a safe birth in pre-eclampsia women?

A

Planned early birth

426
Q

What is given to women having a premature birth to help mature the fetal lungs?

A

Corticosteroids

427
Q

What is HELLP syndrome?

A

The combination of features that occur as a complication of pre-eclampsia and eclampsia

428
Q

What does HELLP stand for?

A

Haemolysis
Elevated Liver enzymes
Low Platelets

429
Q

What causes gestational diabetes?

A

Reduced insulin sensitivity during pregnancy

430
Q

What are the biggest complications of gestational diabetes?

A 
LGA
Macrosomia (large newborn) 
Shoulder hystocia
Developing T2 diabetes after pregnancy
Neonatal hypoglycaemia
431
Q

What are the risk factors for gestational diabetes?

A 
Previous GD
Previous macrosomic baby 
BMI >30
Ethnic origin
Family history of diabetes
432
Q

What is characterised as a macrosomic baby?

A

> 4.5kg

433
Q

What test should be done on any pregnant lady with risk factors for gestational diabetes?

A

OGTT ( Oral Glucose Tolerance Test)

434
Q

When is a GTT usually performed?

A

24-28 weeks

435
Q

Why would an OGTT be done?

A

If there are risk factors for gestational diabetes

If there are features of gestational diabetes

436
Q

What features may suggest gestational diabetes?

A

Large for dates fetus
Polyhydramnios
Glucose on urine dipstick

437
Q

What is polyhydramnios?

A

Increased amniotic fluid

438
Q

How is an OGTT performed?

A

Patient drinks 75g glucose drink in the morning (after fasting). Blood sugar level measured before the drink and 2 hours fter

439
Q

What are normal results of an OGTT?

A

Fasting <5.6 mmol/L
2 hours: <7.8mmol/L

(REMEMBER 5,6,7,8)

440
Q

What monitoring do women with gestational diabetes need?

A

Under joint diabetes and antenatal clinics

28-36 weeks: Four weekly USS to monitor fetal growth and amniotic fluid volume

441
Q

What is the management for GD patients with fasting glucose <7?

A

Trial of diet & exercise for 1-2 weeks, followed by metformin, then insulin

442
Q

What is the management for GD patients with fasting glucose >7?

A

Insulin +/- metformin

443
Q

What is the management of GD patients with fasting glucose >6 with macrosomia/ other complications?

A

Insulin +/- metformin

444
Q

What medication can be given to women who can’t have insulin/ metformin?

A

Glibenclamide (sulfonylurea)

445
Q

What are the target blood sugar levels for women with gestational diabetes?

A

Fasting: 5.3
1 hour post meal: 7.8
2 hours post meal: 6.4

446
Q

What is advised for pregnant women with pre-existing diabetes?

A

Retinopathy screening
Aim to maintain target insulin levels
Planned delivery between 37 and 38+6 weeks

447
Q

How soon after birth can women with gestational diabetes stop their medication?

A

Immediately after birth (will need a follow up fasting glucose 6 weeks later)

448
Q

What are babies of mother with diabetes at risk of?

A 
Neonatal hypoglycaemia
Polycythaemia
Jaundice
Congenital heart disease
Cardiomyopathy
449
Q

Why do babies need close monitoring for neonatal hypoglycaemia?

A

They become accustomed to a large supply of glucose during pregnancy so after birth may struggle to maintain their supply with oral feeding alone

450
Q

What are the three main causes of antepartum haemorrhage?

A

Placenta praevia
Placental abruption
Vasa previa

451
Q

What are causes of spotting or minor bleeding in pregnancy?

A

Cervical ectropion
Infection
Vaginal abrasions

452
Q

What is placenta preavia?

A

When the placenta is over the internal cervical os

453
Q

What is a low-lying placenta?

A

When the placenta is within 20mm of the internal cervical os

454
Q

What are the main risks of placenta praevia?

A 
Antepartum haemorrhage
Emergency C-section
Emergency hysterectomy
Anaemia 
Preterm birth/ Low birth weight
Stillbirth
455
Q

What are the different grades of placenta praevia?

A 
1= Minor (placenta doesn't reach internal cervical os)
2= Marginal (Reaches but doesn't cover internal os) 
3= Partial preavia (partially covers internal os) 
4= Complete preavia (Completely covers internal cervical os)
456
Q

What are the risk factors for placenta praevia?

A 
Previous C--section
Previous placenta praevia
Older age
Maternal smoking
Structural uterine abnormalities (e.g. fibroids)
IVF
457
Q

When is placenta praevia usually diagnosed?

A

20 week anomaly scan

458
Q

How does placenta praevia present?

A

Usually asymptomatic

May present with painless vaginal bleeding around 36 weeks

459
Q

What happens if low-lying placenta/ placenta praevia is diagnosed early in pregnancy?

A

Repeat transvaginal USS at 32 and 36 weeks to guide delivery decisions

460
Q

What is given to women with placenta praevia given the risk if pre-term delivery?

A

Corticosteroids

461
Q

When is planned delivery considered for with placenta preavia and why?

A

36-37 weeks to reduce the risk of spontaneous bleeding and labour

462
Q

What management is required with low-lying placenta/ placenta praevia?

A

Planned C-section

463
Q

What is the management of antepartum haemorrhage?

A 
Emergency C-section
Blood transfusions
Intrauterine balloon tamponade
Uterine artery occlusion
Emergency hysterectomy
464
Q

What is vasa praevia?

A

When the fetal vessels are exposed (outside of umbilical cord or placenta) and lie over the internal cervical os.

465
Q

What do the fetal vessels consist of?

A

Two umbilical arteries and single umbilical vein

466
Q

Where should the fetal vessels be?

A

Should be in the umbilical cord inserting directly into the placenta

467
Q

What does the umbilical cord contain that protects the fetal vessels?

A

Wharton’s jelly–> Layer of soft connective tissue

468
Q

What are the two instances where the fetal vessels may be exposed (outside of the placenta or umbilical cord)?

A
  • Velamentous umbilical cord
  • When an accessory lobe of the placenta is connected by fetal vessels that travel through the chorioamniotic membranes between the placental lobes.
469
Q

What is velamentous umbilical cord?

A

Where the umbilical cord inserts into the chorioamniotic (fetal) membranes, and the vessels travel unprotected through the membranes before joining the placenta

470
Q

What is the risk of vasa praevia?

A

Exposed vessels are prone to bleeding, especially when membranes are ruptured during labour/birth. Can lead to fetal blood loss and death

471
Q

What are the two types of vasa praevia?

A

Type 1: Fetal vessels are exposed as a velamentous umbilical cord
Type 2: Fetal vessels are exposed as they travel to an accessory placental lobe

472
Q

What are the risk factors for vasa praevia?

A

Low lying placenta
IVF pregnancy
Multiple pregnancy

473
Q

How is vasa preavia diagnosed?

A

USS
Antepartum haemorrhage (second or third trimester)
Vaginal examination during labour (pulsing vessels felt)
During labour with fetal distress and bleeding after rupture or membranes

474
Q

How is vasa praevia managed in asymptomatic patients?

A

Corticosteroids from 32 weeks to mature fetal lungs

Elective C-section for 34-36 weeks

475
Q

What is placental abruption?

A

When the placenta seperates from the wall of the uterus during pregnancy

476
Q

What are the risk factors for placental abruption?

A 
Previous placental abruption
Pre-eclampsia
Bleeding early in pregnancy
Trauma
Multiple pregnancy
FGR
Multigravida
Increased maternal age
Smoking
Cocaine/ amphetamine use
477
Q

How does placental abruption usually present?

A 
Sudden onset, continuous sever abdominal pain
Vaginal bleeding (antepartum haemorrhage) 
Shock
CTG abnormaliites (fetal distress)
478
Q

What is the characteristic finding on examination of placental abruption?

A

‘woody’ abdomen (suggesting large haemorrhage)

479
Q

What are the different severities of antepartum haemorrhage?

A

Spotting
Minor (<50mls)
Major (50-1000ml)
Massive (>1000ml/ signs of shock)

480
Q

What is concealed abruption?

A

Where the cervical os remains closed and bleeding remains in the uterine cavity.

481
Q

How is placental abruption diagnosed?

A

Clinical diagnosis based on presenation- no diagnostic test

482
Q

What are the initial steps with major or massive haemorrhage?

A
  • Urgent involvement of senior obstetrician, midwife & anaesthetist
  • 2X grey cannula
  • Bloods
  • Crossmatch
  • Fluid/ blood resuscitation
  • CTG monitoring
  • Mother monitoring
483
Q

What is placenta accreta?

A

When the placenta implants deeper past the endometrium, making it difficult to seperate after delivery.

484
Q

What are the 3 layers of the uterine wall?

A

Endometrium (Stroma, epithelia cells, blood vessels)
Myometrium (smooth muscle)
Perimetrium (serous membrane)

485
Q

What does the placenta usually attach to?

A

The endometrium

486
Q

Why may placenta accreta occur?

A

Due to a defect in the myometrium:

-Previous uterine surgery (e.g. prev C-section)

487
Q

What are the 3 types of placenta accreta?

A

Superficial (implants on surface of myometrium)
Increta (Deep into myometrium)
Percreta (Invades past myometrium and perimetrium, reaching other organs)

488
Q

What are the risk factors for placenta accreta?

A 
Prev placenta accreta
Prev endometrial curettage procedures (e.g. miscarriage/ abortion) 
Prev C-section
Multigravida
Increased maternal age
Low-lying placenta/ placenta praevia
489
Q

How may placenta accreta present?

A

Usually asymptomatic
May present with antepartum haemorrhage
May be diagnosed with USS
May be diagnosed at birth when it becomes difficult to deliver placenta

490
Q

How is placenta accreta managed?

A

Planned delivery 35-36+6 weeks:

  • Hysterectomy
  • Uterus preserving surgery (remove placenta and part of endometrium)
  • Expectant management (placenta can be reabsorbed over time)
491
Q

What is acute fatty liver of pregnancy?

A

Rapid accumulation of fat in the hepatocytes in the third trimester of pregnancy, causing acute hepatitis

492
Q

What causes acute fatty liver of pregnancy?

A

Impaired processing of fatty acids in the placenta due to a fetal genetic condition (LCHAD deficiency), causing them to enter into the maternal circulation and accumulate in the liver

493
Q

How does acute fatty liver of pregnancy present?

A 
Vague symptoms: 
General malaise/ fatigue
N&V
Jaundice
Abdomial pain
Anorexia
Ascites
494
Q

What investigation is done into acute fatty liver of pregnancy and what will this show?

A 
LFT's= Elevated ALT and AST
Raised bilirubin
Raised WBC
Deranged clotting
Low platelets
495
Q

What condition should you think of if there are elevated liver enzymes and low platelets in pregnancy?

A

HELLP syndrome

Then acute fatty liver

496
Q

How is acute fatty liver of pregnancy managed?

A

Prompt delivery of baby

497
Q

What is obstetric cholestasis?

A

Reduced outflow of bile acids from the liver during pregnancy

498
Q

At what point in pregnancy would obstetric cholestasis usually present?

A

After 28 weeks

499
Q

What causes obstetric cholestasis?

A

Raised oestrogen and progesterone levels

500
Q

What is the pathophysiology of obstetric cholestasis?

A

Bile acids are produced in the liver from the breakdown of cholesterol. These flow from the liver to the hepatic ducts, past the gallbladder and out of the bile duct into the intestines. In obstetric cholestasis the outflow of bile acids is reduced, causing them to build up in the blood.

501
Q

How does obstetric cholestasis present?

A 
Pruritis (palms of hands/ soles of feet) 
Fatigue
Dark urine
Pale, greasy stools
Jaundice
502
Q

What are the differential diagnosis for obstetric cholestasis?

A

Gallstones
Acute fatty liver
Autoimmune hepatitis
Viral hepatitis

503
Q

How is obstetric cholestasis investigated?

A 
LFT's (abnormal)
Bile acids (raised)
504
Q

Which liver enzyme is normally raised in pregnancy and why?

A

ALP, it is also produced by the placenta

505
Q

How is obstetric cholestasis managed?

A

Ursodeoxycholic acid
Emollients (to soothe itching)
Antihistamines (to help sleeping)
Vitamin K (If clotting is deranged)

506
Q

What are the main pregnancy-related skin changes?

A 
Polymorphic eruption of pregnancy
Atopic eruption of pregnancy
Melasma
Pyogenic granuloma
Pemphigoid gestationis
507
Q

What is polymorphic eruption of pregnancy?

A

Itchy rash that start in the third trimester, usually beginning in the abdomen and associated with stretch marks

508
Q

What is polymorphic eruption of pregnancy characterised by?

A 
Urticarial papules (raised itchy lumps) 
Wheals (raised itchy areas of skin) 
Plaques (larger inflamed areas of skin)
509
Q

What is atopic eruption of pregnancy?

A

Eczema that flares up during pregnancy (may or may not be pre-existing)

510
Q

When does atopic eruption of pregnancy usually present?

A

In the first or second trimester

511
Q

What are the two types of atopic eruption of pregnancy?

A

E-type: Eczematous, inflamed itchy skin on insides of elbows, back of knees etc
P-type: Intense itchy papules on abdomen, back and limbs

512
Q

What is melasma?

A

Increased pigmentation to patches of the face. (mask of pregnancy)

513
Q

What is pyogenic granuloma?

A

Benign rapid growing tumour of the capillaries (discrete dark red lump)

514
Q

What is pemphigoid gestationis?

A

Autimmune skin condition that occurs in pregnancy, causing large fluid filled blisters

515
Q

When does nausea and vomiting start in pregnancy and when does it usually peak and resolve?

A

Starts in first trimester (4-7 weeks) and peaks around 8-12 weeks, Resolve by 16-20 weeks

516
Q

What is hyperemesis gravidarum?

A

Severe form of nausea and vomiting in pregnancy

517
Q

What causes N&V in pregnancy?

A

hCG

518
Q

In what kind of pregnancies is N&V worse and why?

A

Molar pregnancies and multiple pregnancies due to high hCG levels

519
Q

How is hyperemesis gravidarum classified?

A

Protracted (prolonged) N&V
>5% weight loss compared to pre-pregnancy
Dehydration
Electrolyte imbalance

520
Q

How is the severity of hyperemesis gravidarum assessed?

A

PUQE score:
<7= mild
7-12= moderate
>12= severe

521
Q

How is hyperemesis gravidarum managed?

A

Antiemetics

Ompeprazole to treat acid reflux

522
Q

When would admission be condsidered for mild cases of hyperemesis gravidarum?

A

Unable to keep down fluids
>5% weight loss
Ketones present in urine

523
Q

What is the treatment of moderate- severe cases of hyperemesis gravidarum?

A 
Ambulatory care/ admission: 
IV/ IM antiemetics
IV fluids
Monitoring of U&E's 
Thiamine supplementation
524
Q

What does the anterior pituitary gland do during normal pregnancy?

A

Produces more ACTH, prolactin and melanocyte stimulating hormone

525
Q

What do higher ACTH levels in pregnancy cause?

A

Rise in steroid hormones (cortisol and aldosterone), leading to improvement in autoimmune conditions

526
Q

What do increased prolactin levels in pregnancy cause?

A

Suppression of FSH and LH

527
Q

What can increased melanocyte stimulating hormone cause in pregnancy?

A

Increased pigmentation of skin, leading to linea nigra and melasma

528
Q

What happens to the thyroid hormones during pregnancy?

A

TSH stays normal

T3 and T4 levels rise

529
Q

What happens to HCG levels during pregnancy?

A

They double roughly every 48 hours until 8-12 weeks when they plateau and then fall

530
Q

What happens to progesterone levels during pregnancy?

A

They rise throughout pregnancy

531
Q

What is the action of progesterone in pregnancy?

A

Maintains the pregnancy
Prevents contractions
Suppresses the mother’s immune reaction to fetal antigens

532
Q

By how much does the uterus increase in size during pregnancy?

A

From 100g to 1.1kg

533
Q

What changes happen to the uterus during pregnancy?

A

It increases in size

There hypertrophy of the myometrium and blood vessels

534
Q

What may happen to the cervix during pregnancy?

A

There may be cervical ectropion and increased cervical discharge

535
Q

What happens to the vagina during pregnancy?

A

Hypertrophy of the vaginal muscles and increased vaginal discharge

536
Q

What happens to the cervix just before delivery?

A

Prostoglandins break down its collagen allowing it to dilate and efface

537
Q

What cardiovascular changes occur during pregnancy?

A

Increased blood volume, plasma volume, cardiac output, stroke volume and heart rate
Decreased peripheral vascular resistance and blood pressure

538
Q

What may happen in pregnancy due to increased peripheral vasodilation?

A

Flushing
Hot sweats
Varicose veins

539
Q

What respiratory changes occur in pregnancy?

A

Increased tidal volume and respiratory rate to meet increasing oxygen demands

540
Q

What renal changes occur in pregnancy?

A

Increased blood flow to the kidneys, GFR, aldosterone levels (leading to increased salt and water reabsorption and retention) and protein excretion
Dilation of the ureters and collecting system leading to hydronephrosis (kidney swelling)

541
Q

What haematological changes occur during pregnancy?

A
  • Increased RBC production, leading to higher iron, folate and B12 requirements
  • Increased plasma volume (leading to lower concentration of RBC’s and therefore anaemia)
  • Increased clotting factor production, leading to hyper-coagulable state
  • Increased WCC
  • Increased ALP
  • Decreased platelets
542
Q

What skin and hair changes may occur in pregnancy?

A 
Increased skin pigmentation
Stria gravidarum (stretch marks) 
Pruritus
Spider naevi
Palmer erythema
543
Q

By how much does the total plasma volume increase in pregnancy?

A

30-50% (1-2L)

544
Q

What are the management options for a breech pregnancy?

A
  • External cephalic version (ECV): Putting pressure on the pregnant abdomen to turn the fetus to the cephalic position
  • C-section
545
Q

What is given to women before ECV?

A

Tocolysis to relax the uterus

Anti-D phrophylaxis if required

546
Q

What is the definition of stillbirth?

A

Birth of a dead fetus after 24 weeks gestation

547
Q

What is IUFD?

A

Intrauterine fetal death

548
Q

How common in IUFD?

A

1 in 200 pregnancies

549
Q

What are the causes of stillbirth?

A 
50% Unexplained
Pre-eclampsia
Placntal abruption
Vasa praevia
Cord prolapse/ wrapped around neck
Obstetric cholestasis
Diabetes
Thyroid disease
Infections
Genetic/ congenital abnormalities
550
Q

What factors increase the risk of stillbirth?

A 
Smoking
Alcohol
FGR/ SGA
Increased maternal age
Maternal obesity
Twins
Sleeping on back
551
Q

How is stillbirth prevented?

A

Serial growth scans for those with fetal growth restriction
Aspirin for pre-eclampsia
Treat modifiable risk factors

552
Q

What 3 key symptoms should always be asked about in pregnancy and should be reported immediately by women?

A
  1. Reduced fetal movement
  2. Abdominal pain
  3. Vaginal bleeding
553
Q

How is IUFD diagnosed?

A

USS to visualise fetal heartbeat

554
Q

What is the management of IUFD?

A

Vaginal birth= First line:
May be expectant or have induction of labour
Can do testing after to find out cause

555
Q

What can be used to suppress lactation after stillbirth?

A

Dopamine agonists

556
Q

What are the 4 T’s of reversible causes of adult cardiac arrest?

A

Thrombosis
Tension pneumothorax
Toxins
Tamponade

557
Q

What are the 4 H’s of reversible causes of adult cardiac arrest?

A

Hypocia
Hypovolaemia
Hypothermia
Hyperkalaema/ glycaemia

558
Q

What additional causes of cardiac arrest may be found in pregnancy?

A

Eclampsia

Intracranial haemorrhage

559
Q

What are the 3 main causes of cardiac arrest in pregnancy?

A

Obstetric haemorrhage
Pulmonary embolsim
Sepsis

560
Q

Why might obstetric haemorrhage cause cardiac arrest?

A

It causes severe hypovolaemia

561
Q

What are the causes of massive obstetric haemorrhage?

A 
Ectopic pregnancy
Placental abruption
Placenta praevia
Placenta accreta
Uterine rupture
562
Q

What is aortocaval compression?

A

When a woman lies on her back the the uterus compresses the inferior vena cava and aorta, reducing the cardiac output and leading to hypotension .

563
Q

What is the solution to aortocaval compression?

A

Place the woman in the left lateral position to relieve the compression of the inferior vena cava

564
Q

What is the difference between standard adult life support and doing it in pregnancy?

A

Use a 15 degree tilt to the left for CPR
Early intubation and supplementary oxygen
Agressive fluid rescucitation
Delivery of the baby after 4 minutes

565
Q

When would an immediate C-section be performed in an unresponsive pregnant woman?

A

When there is no response after 4 minutes of CPR

566
Q

What is ROM?

A

Rupture of membranes (amniotic sac rupture)

567
Q

What is SROM?

A

Spontatneous rupture of membranes

568
Q

What is ARM?

A

Artificial rupture of membranes

569
Q

What is PROM?

A

Prelabour rupture of membranes (before onset of labour)
OR
Prolonged rupture of membranes (>18 hours before delivery)

570
Q

What is P-PROM?

A

Preterm prelabour rupture of membranes (before 37 weeks)

571
Q

What is classifies as premature labour?

A

Before 37 weeks gestation

572
Q

What are the 3 classifications of prematurity?

A

Extreme preterm = <28 weeks
Very preterm= 28-32 weeks
Moderate-late preterm = 32-37 weeks

573
Q

What are the prophylaxis options for preterm labour?

A

Vaginal progesterone

Cervical cerclage

574
Q

What is cervical cerclage?

A

Putting a stitch in the cervix to add support and keep it closed/

575
Q

How can rupture of membranes be diagnosed?

A

With speculum examination revealing pooling of amniotic fluid in the vagina
(can test for IGFBP-1 or PAMG-1 if unsure)

576
Q

How is P-PROM managed?

A

Prophylactic antibiotics to prevent chorioamniotis

Induction of labour from 34 weeks

577
Q

How does preterm labour with intact membranes present?

A

Regular painful contraction and cervical dilation without rupture of amniotic sac

578
Q

What is the clinical assessment of preterm labous?

A

Speculum examination to assess for cervical dilation

>30 weeks can use TVUS to assess cervical length (<15mm)

579
Q

What are the management options for preterm labour?

A 
Fetal monitoring
Tocolysis with nifedipine
Maternal corticosteroids
IV magnesium sulphate
Delayed cord clamping
580
Q

What is Tocolysis?

A

Using medications to stop uterine contractions

581
Q

What is the action of Nifedipine?

A

Calcium channel blocker that suppresses labour

582
Q

Why is the mother given steroids in preterm labour?

A

To help develop the fetal lungs and reduce respiratory distress syndrome

583
Q

Why is magnesium sulfate given in preterm labour?

A

Helps protect fetal brain

584
Q

What are the indications for induction of labour?

A
  • When the due date is passed (41-42 gestation)
  • PROM
  • FGR
  • Pre-eclampsia
  • Obstetric cholestasis
  • Existing diabtes
  • IUFD
585
Q

What score is used to determine whether to induce labour?

A

Bishops score

586
Q

What are the 5 assessment criteria used in the Bishops score?

A 
Fetal station
Cervical position
Cervical dilation
Cervical effacement
Cervical consistency
587
Q

What does cervical effacement refer to?

A

The dilation and stretching of the cervix

588
Q

What does fetal station refer to?

A

Where the presenting part is in the pelvis

589
Q

What Bishops score would be a successful indication for induction?

A

8 or more

590
Q

What may be required if there is a Bishops score of <8?

A

Cervical ripening

591
Q

What are the options for the induction of labour?

A 
Membrane sweep
Vaginal prostaglandin E2
Cervical ripening balloon
ARM
Oral mifepristone
592
Q

What is involved in a membrane sweep?

A

Inserting a finer into the cervix to stimulate it and begin the process of labour

593
Q

Within what time frame should labour begin if a membrane sweep is successful?

A

48 hours

594
Q

How is vaginal prostaglandin E2 used to induce labour?

A

Progesterone gel, tablet or pessary inserted into the vagina to stimulate cervix and uterus

595
Q

How does a cervical ripening balloon work?

A

Silicone balloon inserted into the cervix and gently inflated to dilate the cervix

596
Q

What is amniotomy and how is it done?

A

Artificial rupture of membranes with an oxytocin infusion or puncturing with hook

597
Q

When would AROM be used ?

A

When vaginal prostaglandins are contraindicated or if they have been tried and failed

598
Q

What is used to induce labour where IUFD has occured?

A

Oral mifepristone (antiprogesterone) and misoprostol

599
Q

How is induction of labour monitored?

A

CTG

Bishops score

600
Q

What are the options when there are no/ slow progress after IOL?

A 
Further vaginal prostoglandins
ARM
Oxytocin infusion
CRB
ELCS
601
Q

What is the main complication of IOL with vaginal prostaglandins?

A

Uterine hyperstimulation causing fetal distress and compromise

602
Q

What is the classification of uterine hyperstimulation?

A

Contractions lasting more than 2 minutes

More than 5 contractions every 10 minutes

603
Q

What can uterine hyperstimulation lead to?

A

Fetal compromise (hypoxia, acidosis)
Emergency C-section
Uterine rupture

604
Q

What is the management of uterine hyperstimulation?

A

Remove vaginal prostaglandins

Tocolysis with terbutaline

605
Q

What is CTG and what is it used for?

A

Cardiotocography used to measure the fetal heart rate and contractions of the uterus

606
Q

How is a CTG carried out?

A

One transducer placed above fetal heart to monitor heartbeat using Doppler ultrasound.
One placed near fundus of uterus, using USS to assess tension of uterine wall

607
Q

What are the indications for continours CTG monitoring in labour?

A 
Sepsis
Maternal tachycardia
Significant meconium
Pre-eclampsia
Fresh antepartum haemorrhage 
Delay in labour
Use of oxytocin
Disproportionate maternal pain
608
Q

What are the 5 key features to look for on CTG?

A 
Contractions (no. per 10 mins) 
Baseline fetal heart rate
Variability in heart rate
Accelerations
Decelerations
609
Q

What is the baseline rate on a normal CTG?

A

110-160

610
Q

What is the variability in a normal CTG?

A

5-25 bpm

611
Q

Should accelerations and decelerations be present in a normal CTG?

A

Accelerations should but not decelerations

612
Q

What is the baseline rate and variability in a non-reassuring CTG?

A 
BR= 100-109 OR 161-180
Variability= <5 for 30-50 mins OR >25 for 15-25 mins
613
Q

What is the baseline rate and variability in an abnormal CTG?

A 
BR= <100 OR >180
V= <5 in over 50 mins OR >25 for over 25 mins
614
Q

Why are decelerations a concerning finding in a CTG?

A

The fetal heart rate drops in response to hypoxia

615
Q

What are the 4 types of deceleration to be aware of?

A

Early
Late
Variable
Prolonged

616
Q

What are early decelerations?

A

Gradual dips and recoveries in heart rate that correspond with uterine contractions (considered normal)

617
Q

What causes early decelerations?

A

The uterus compressing the head of the fetus, stimulating the vagus nerve and slowing the heart rate

618
Q

What are late decelerations?

A

Gradual falls in heart rate that starts after the uterine contraction has already begun

619
Q

What causes late decelerations?

A

Hypoxia in the fetus
Excessive uterine contractions
Maternal hypotension
Maternal hypoxia

620
Q

What are variable decelerations?

A

Abrupt decelerations that may be unrelated to uterine contractions

621
Q

What causes variable decelerations?

A

Intermittent compression of the umbilical cord causing fetal hypoxia

622
Q

What are prolonged decelerations?

A

Decelerations that last between 2 and 10 minutes with a drop of more than 15bpm from baseline

623
Q

Which types of decelerations are reassuring?

A

No decelerations
Early decelerations
<90 minutes of variable decelerations

624
Q

What kind of decelerations are always abnormal?

A

Prolonged decelerations

625
Q

What are the 4 categories of CTG?

A

Normal
Suspicious (1 non-reassuring feature)
Pathological (2 non-reassuring features of 1 abnormal feature)
Need for urgent intervention (acute bradycardia, prolonged deceleration of >3 minutes)

626
Q

What is the ‘rule of 3’ management for fetal bradycardia?

A

3 minutes= call for help
6 mins= move to theatre
9 mins= prepare for delivery
12 mins= deliver baby (before 15 mins)

627
Q

What is a sinusoidal CTG?

A

A CTG with a pattern similar to a sine wave associated with fetal anaemia

628
Q

What is the pneumonic for assessing the features of a CTG?

A 
DR C BRaVADO:
Define risk
Contractions 
Baseline rate
Variability
Accelerations
Deceleraions
Overall impression
629
Q

Where is oxytocin secreted from?

A

Posterior pituitary

630
Q

What is the action of oxytocin in labour and delivery?

A

Stimulates ripening of cervix and contractions of uterus

also involved in lactation

631
Q

When might oxytocin infusions be used?

A

To induce labour
To progress labour
To improve the frequency/ strength of uterine contractions
To prevent/ treat PPH

632
Q

What is the action of Ergometrine and when might it be used in labour?

A

Stimulates smooth muscle contraction.

Used in the third stage of labour to deliver the placenta and postpartum to treat PPH

633
Q

What three P’s influence progress in labour?

A

Power
Passenger
Passage

634
Q

When is failure to progress classified in the first stage of labour?

A

<2cm dilation in 4 hours

Slowing of progress in multiparous women

635
Q

What is used to measure a womans progress in the first stage of labour?

A

Partogram

636
Q

What is recorded on a partogram?

A 
Cervical dilation
Descent of the fetal head
Maternal pulse, BP, Temp, urine output
Fetal HR
Frequency of contractions
Status of membranes
Drugs/ fluids given
637
Q

How often is cervical dilation measured?

A

4 hourly vaginal examination

638
Q

How are uterine contractions measured?

A

Measured by number in 10 minutes (e.g. 2 in 10)

639
Q

What is crossing the alert line on a partogram an indication for?

A

Amniotomy

Repeat exam in 2 hours

640
Q

What is classified as a delay in the second stage of labour?

A

When the active stage lasts over :
2 hours in nulliparous women
1 hour in multiparous women

641
Q

What does power refer to in the 3 P’s?

A

The strength of the uterine contractions

642
Q

What can be given if there are weak uterine contractions?

A

Oxytocin infusion to stimulate the uterus

643
Q

What 4 things does passenger refer to in the 3 P’s?

A
  • Size
  • Attitude
  • Lie
  • Presentation
644
Q

What does attitude refer to in terms of the fetus?

A

The posture (e.g. how the back is rounded and how the head/ limbs are flexed)

645
Q

What the are potential ways the fetus may lie?

A

Longitudinal lie
Transverse lie
Oblique lie

646
Q

What does presentation refer to?

A

The part of the fetus closest to the cervix

647
Q

What are the different presentation options?

A

Cephalic
Shoulder
Breech (complete, frank, footling)

648
Q

What does passage refer to in the 3 P’s?

A

The size and shape of the pelvis

649
Q

What is classified as a delay in the third stage of labour?

A

> 30 min delay in delivery of placenta with active management

>60 min delay with physiological management

650
Q

What is the active management of delay in placental delivery?

A

Intramuscular oxytocin

Controlled cord traction

651
Q

What are the main options for treating failure to progress?

A

Amniotomy
Oxytocin infusion
Instrumental delivery
C-section

652
Q

What are the different pain relief options in labour?

A 
Simple analgesia (paracetamol + codeine)
Entonox
IM Pethidine/ DIamorphine
IV Remifentanil (patient controlled) 
Epidural
653
Q

What is entonox?

A

Gas and air (50% nitrous oxide, 50% oxygen) for short term pain relief

654
Q

What does an epidural involve?

A

Inserting a catheter into the epidural space in the lower back and infusing local anaesthetics

655
Q

What is cord prolapse?

A

When the umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina after rupture of membranes

656
Q

What is the main risk of cord prolapse?

A

That the presenting part will compress the cord, resulting in fetal hypoxia

657
Q

What is the main risk factor for cord prolapse?

A

When the fetus is in an abnormal lie after 37 weeks gestation

658
Q

How is cord prolapse diagnosed?

A

Signs of distress on CTG

Vaginal examination

659
Q

How is cord prolapse managed?

A

Emergency C-section

Can push presenting part away from cord to prevent compression

660
Q

What is shoulder dystocia?

A

When the anterior shoulder of the baby becomes stuck behind the pubic symphysis of the pelvis after the head has been delivered

661
Q

What causes shoulder dystocia?

A

Macrosomia secondary to gestational diabetes

662
Q

Is shoulder dystocia an obstectric emergency?

A

Yes

663
Q

How does shoulder dystocia present?

A

Difficulty delivering the head and obstruction in delivery the shoulders.
Failure of restitution (head will remain facing downwards instead of turning sideways)

664
Q

What are the different management options for shoulder dystocia?

A 
Episiotomy 
McRoberts manoeuvre
Pressure to anterior shoulder
Rubins manoeuvre
Wood's screw manoeuvre
Zavanelli manoeuvre
665
Q

What is episiotomy?

A

Incising the area between the vagina and anus (not the perineal body) to create a larger space for delivery

666
Q

What is McRoberts manoeuvre?

A

Hyperflexion of the mother at the hip to create a posterior pelvic tilt so the pubic symphysis moves out of the way

667
Q

What are the key complications of shoulder dystocia?

A

Fetal hypoxia
Brachial plexus injury (Erbs palsy)
Perineal tears
PPH

668
Q

What is instrumental delivery?

A

Vaginal delivery assisted by either ventouse suction cup or forceps

669
Q

What should be given to the mother after an instrumental delivery?

A

Co-amoxiclav to reduce risk of infection

670
Q

What are the indications for instrumental delivery?

A 
Failure to progress
Fetal distress
Maternal exhaustion
Control of the head in certain fetal positions
Epidural
671
Q

What are the risks of instrumental delivery to the mother?

A 
PPH
Episiotomy
Perineal tears
Injury to anal sphincter
Incontinence of bladder/ bowel
Nerve injury
672
Q

What are the key risks of instrumental delivery to the baby?

A

Cephalohaematoma with ventouse

Facial nerve palsy with forceps

673
Q

What is a ventuose?

A

A suction cup that goes on the baby’s head that, along with traction to the cord, helps pull the baby out of the vagina

674
Q

What maternal nerves may be affected in instrumental delivery?

A

Femoral nerve

Obturator nerve

675
Q

When are perineal tears more common?

A 
First births 
Large babies (>4kg) 
Shoulder dystocia
Asian ethnicity
Occipito-posterior position
Instrumental deliveries
676
Q

What are the 4 degrees of perineal tear?

A

First-degree- limited to the frenulum of the labia minora
Second degree- includes the perineal muscles
Third degree- Includes the anal sphincter
Fourth degree- Includes rectal mucosa

677
Q

How can third-degree tears be further classified?

A 
3A= <50% external anal sphincter affected
3B= >50% external anal sphincter affected
3C= External and internal anal sphincter affected
678
Q

How are perineal tears treated?

A

If larger than first degree, will need sutures or surgical repair
Antibiotics given
Laxatives and physiotherapy

679
Q

What are the short term complications of a perineal tear?

A

Pain
Infection
Bleeding
Wound breakdown

680
Q

What are lasting complications of perineal tears?

A 
Urinary incontinence
Anal incontinence/ altered bowel habit 
Fistula
Sexual dysfunction/ dyspareunia
Psychological
681
Q

What blood classifies a PPH?

A

> 500ml after vaginal delivery

>1000ml after C-section

682
Q

What is a minor PPH?

A

<1000ml blood loss

683
Q

What is a major PPH?

A

> 1000ml blood loss

684
Q

What is a severe PPH?

A

> 2000ml blood loss

685
Q

What is primary PPH?

A

Bleeding within 24 hours of birth

686
Q

What is secondary PPH?

A

Bleeding from 24 hours to 12 weeks after birth

687
Q

What are the 4T’s that cause PPH?

A

Tone (uterine atony)
Trauma (perineal tear)
Tissue (retained placenta)
Thrombin (bleeding disorder

688
Q

What are the risk factors for PPH?

A 
Previous PPH
Multiple pregnancy
Obesity
Large baby
Failure to progress in second stage
Prolonged third stage
Pre-eclampsia
Placenta accreta
Retained placenta
Instrumental deliery
General anaesthetic
Epiostomy/ perineal tear
689
Q

What preventative measures can reduce the risk of PPH?

A

Treating anaemia
Emptying bladder before birth
Active management of third stage
IV TXA during C-section in high risk patients

690
Q

How is PPH managed?

A 
ABCDE
Comfort/ warmth
2 large bore cannulas
Bloods (FBC, U&E, clotting screen) 
Group & Cross match
Warmed IV fluid and blood resuscitation
Oxygen
Frozen plasma if there are clotting abnormalities
691
Q

What are 3 categories of treatment option to stop the bleeding in PPH?

A

Mechanical
Medical
Surgical

692
Q

What are the mechanical treatment options to stop PPH?

A

Rubbing the uterus through the abdomen to stimulate uterine contraction
Catheterisation to prevent bladder from stopping contractions

693
Q

What are the medical treatment options to stop PPH?

A

Oxytocin
Ergometrine (stimulates smooth muscle contraction)
Carboprost (stimulates uterine contraction)
Misoprostol (stimulates uterine contraction)
TXA (antifibrinolytic)

694
Q

What are the surgical treatment options to stop PPH?

A

Intrauterine balloon tamponade
B-lynch suture
Uterine artery ligation
Hysterectomy

695
Q

What causes secondary PPH ?

A

Retained products of conception or infection

696
Q

What investigations can be done into secondary PPH?

A

USS

Endocervical or high vaginal swabs for infection

697
Q

After what gestation would an elective c-section usually be performed?

A

39 weeks

698
Q

What anaestetic is used for an elective C-section?

A

Spinal anaesthtic

699
Q

What are the indications for an elective C-section?

A 
Previous caesarean
Previous perineal tear
Placenta praevia
Vasa praevia
Breech
Multiple pregnancy
Uncontrolled HIV
Cervical cancer
700
Q

What are the 4 categories of emergency c-section?

A

1: Immediate threat to mother or babies life
2: Not imminent threat to life, but required urgently due to compromised mother or baby
3: Delivery required but mother and baby are stable
4: elective c-section

701
Q

What should the delivery time be in a category 1 emergency c-section?

A

30 minutes

702
Q

What should the delivery time be in a category 2 emergency c-section?

A

75 minutes

703
Q

What are the layers of the abdomen that need to be dissected during a c-section?

A 
Skin
Subcutaneous tissue
Fascia/ rectus sheath 
Rectus abdominis muscles
Peritoneum
Vesicouterine peritoneum (and bladder) 
Uterus 
Amniotic sac
704
Q

What happens during the c-section?

A

Straight incision in abdomen
Blunt dissection to seperate remaining layers
Deliver baby by hand
Close uterus using two layers of sutures

705
Q

What is the difference between an epidural and spinal anaesthetic?

A

Epidural involves putting a catheter into epidural space to receive continuous or periodic dose of anaesthesia
Spinal block is a single shot of anaesthesia into dural sac that lasts 1-2 hours.

706
Q

What are the risks of spinal anaesthetic?

A 
Takes longer than general 
Allergic reaction
Hypotension
Headache
Urinary retention
Nerve damage
Haematoma
707
Q

What measures are taken to reduce the risks of having a c-section?

A

H2 receptor agonists/ PPI’s before procedure
Prophylactic antibiotics
Oxytocin during procedure
VTE prophylaxis

708
Q

Why are H2 receptor agonists of PPI’s given before a C-section?

A

To reduce the risk of aspiration pneumonitis caused by acid reflux and aspiration during the prolonged period lying flat

709
Q

Why is oxytocin given during a c-section?

A

To reduce the risk of PPH

710
Q

What is the success rate of vaginal birth after c-section?

A

75%

711
Q

What are the contraindications of having a vaginal birth after a previous c-section?

A

Previous uterine rupture
Vertical incision
Normal contraindications fo vaginal delivery

712
Q

What are the two key causes of sepsis in pregnancy?

A

Chorioamnionitis

UTI

713
Q

What is chorioamnionitis?

A

Infection of the chorioamniotic membranes (membranes that surround fetus) and amniotic fluid

714
Q

What system is used to monitor maternity inpatients?

A

MEOWS: Maternity early obstetric warning system

715
Q

What are the non-specific signs of sepsis to look out for?

A 
Fever
Tachycardia
Raised RR
Reduced oxygen sats
Low BP
Altered consciousness
Reduced urine output
Raised WCC
Evidence of fetal compromise on CTG
716
Q

What are additional signs that might be seen in chorioamnionitis?

A

Abdominal pain
Uterine tenderness
Vaginal discharge

717
Q

What additional signs might be seen in a UTI?

A 
Dysuria
Urinary frequency
Suprapubic pain/ discomfort
Pyelonephritis
Vomiting
718
Q

How would you investigate suspected maternal sepsis?

A 
Blood tests 
Urine dipstick
High vaginal swab
Sputum culture
Wound swab
Lumbar puncture?
719
Q

What blood tests would be performed to investigate suspected sepsis?

A 
FBC (WCC, Neutrophils) 
U&E's 
LFT's
CRP
Clotting
Blood cultures
Blood gas (lactate)
720
Q

How is sepsis managed?

A 
Sepsis 6: 
Tests: 
1. Blood lactate
2. Blood cultures
3. Urine output

Treatments:

  1. Oxygen
  2. Empirical broad-spectrum antibiotics
  3. IV fluids
721
Q

What is amniotic fluid embolisation?

A

When the amniotic fluid passes into the mother’s blood

722
Q

Why is amniotic fluid passing back to the mother a concern?

A

The amniotic fluid contains fetal tissue, so causes an immune reaction in the mother (mortality of 20%)

723
Q

What are the main risk factors for amniotic fluid embolus?

A

Increasing maternal age
Induction of labour
C-section
Multiple pregnancy

724
Q

How does amniotic fluid embolisation present?

A

Similarly to sepsis, PE or anaphylaxis:

  • SOB
  • Hypoxia
  • Hypotension
  • Coagulopathy
  • Haemorrhage
  • Tachycardia
  • Confusion
  • Seizures
  • Cardiac arrest
725
Q

When does amniotic fluid embolisation usually present?

A

Around time of labour and delivery (can be post partum)

726
Q

How is amniotic fluid embolisation managed?

A

Supportive

ABCDE

727
Q

What is uterine rupture?

A

A complication of labour where the myometrium ruptures

728
Q

What is an incomplete uterine rupture?

A

When the uterine serosa (perimetrium) surrounding the uterus remains intact

729
Q

What is a complete uterine rupture?

A

When the serosa ruptures along the myometrium, and the contents of the uterus are released into the peritonel cavity

730
Q

What are the main risk factors for uterine rupture?

A 
*Previous C-section (due to weakness at scar) 
VBAC
Previous uterine surgery
Increased BMI
High parity
Increased age
Induction of labour
Use of oxytocin to stimulate contractions
731
Q

How does uterine rupture present?

A 
Acutely unwell mother
Abnormal CTG
Abdominal pain
Vaginal bleeding
Ceasing of contractions
Hypotension
Tachycardia
Collapse
732
Q

How is uterine rupture managed?

A

Resuscitation and transfusion
Emergency C-section
Repair or remove uterus
(Obstetric emergency with high morbidity and mortality)

733
Q

What is uterine inversion?

A

Where the fundus of the uterus drops down through the uterine cavity and cervix during birth, turning the uterus inside out (very rare)

734
Q

What is the introitus?

A

The opening of the vagina

735
Q

What is incomplete uterine inversion?

A

When the fundus descends inside the uterus/ vagina but not as far as the introitus

736
Q

What is complete uterine inversion?

A

When the uterus descends through the vagina to the introitus

737
Q

What can cause uterine inversion?

A

Pulling too hard on the umbilical cord during active management of the third stage of labour

738
Q

How does uterine inversion typically present?

A

With PPH, maternal shock or collapse

739
Q

What are the management options for treating uterine inversion?

A 
Johnson manoeuvre (pushing it back up) 
Hydrostatic methods (filling vagina with fluids to inflate uterus) 
Surgery
740
Q

What will happen to the woman in the days after delivery?

A

Routine midwife-led care:

  • Analgesia if required
  • Help establishing breast/ bottle feeding
  • VTE risk assessment
  • PPH/ sepsis/ BP monitoring
  • Anti-D if necessary
  • Monitoring if had any surgery/ complications
  • Routine baby check
741
Q

What will be discussed in routine midwife led postnatal follow up appointments?

A 
General wellbeing
Mood/ depression
Bleeding/ menstruation
Urinary incontinence/ pelvic floor exercises
Scar healing
Contraception
Breastfeeding
Vaccines
742
Q

How many weeks postpartum is a routine postnatal check performed?

A

6 weeks

743
Q

What is lochia?

A

The mix of blood, endometrial tissue and mucus that comes out of the vagina in the period following birth

744
Q

Why does a woman have vaginal bleeding after birth?

A

As the endometrium breaks down then returns to normal

745
Q

How long after birth should bleeding settle?

A

6 weeks

746
Q

Why may breastfeeding cause more bleeding?

A

It releases oxytocin which causes to uterus to contract

747
Q

What is lactational amenorrhoea?

A

When women who are breastfeeding don’t have a return to normal menstruation for around 6 months after birth

748
Q

How long after birth should women who are bottle feeding expect a menstrual period?

A

3 weeks onwards

749
Q

How long after birth does fertility return?

A

21 days

750
Q

What contraception should be given to women who are breastfeeding?

A

Lactational amenorrhoea is effective

POP or implant

751
Q

What contraception should be avoided after birth?

A

COCP

752
Q

When after birth can a copper coil or IUD be inserted?

A

Either within 48 hours or after 4 weeks

753
Q

What is endometritis?

A

Inflammation of the endometrium

754
Q

When is endometritis more common and why?

A

Postpartum as bacteria from the vagina may travel upwards during delivery
*Especially after C-section

755
Q

How does endometritis present?

A 
Foul smelling discharge or lochia
Bleeding that gets heavier
Lower abdominal/ pelvic pain
Fever
Sepsis
756
Q

How is endometritis diagnosed?

A

Vaginal swabs
Urine culture/ sensitivities
USS may be used to rule out RPOC

757
Q

How is endometritis managed?

A

May need sepsis 6

Oral antibiotics

758
Q

What is RPOC?

A

Retained products of conception

759
Q

What is the main risk factor for RPOC?

A

Placenta accreta

760
Q

How may RPOC present?

A

Vaginal bleeding
Abnormal discharge
Lower abdominal/ pelvic pain
Fever

761
Q

How is RPOC diagnosed?

A

USS

762
Q

How is RPOC managed?

A 
Surgical removal (ERCP- Evacuation of retained products of conception):
Dilation and curettage
763
Q

What haemoglobin level is defined as postpartum anaemia?

A

<100 g/L

764
Q

Under what circumstances would a FBC be taken the fay after delivery?

A

PPH >500ml
C-section
Antenatal anaemia
Symptoms of anaemia

765
Q

How can postpartum anaemia be treated?

A

Oral iron
Iron infusion
Blood infusion

766
Q

When is an iron infusion contraindicated?

A

If there is active infection

767
Q

What are the three levels on the spectrum of postnatal mental illness?

A

Baby blues
Postnatal depression
Puerperal psychosis

768
Q

How long does the baby blues last and what percentage of women does it affect?

A

50% in the first week after birth

769
Q

How many women are affected by postnatal depression and how long after birth does it peak?

A

1 in 10

Peaks around 3 months after birth

770
Q

How common is puerperal psychosis and how long after birth does it usually start?

A

1 in 1000 women

Starts a few weeks after birth

771
Q

What may be the causes of baby blues?

A 
Significant hormonal changes
Recovery from birth
Fatigue/ sleep deprivation
New responsibility
Establishing feeding
772
Q

What triad is seen in postnatal depression?

A

Low mood
Anhedonia
Low energy

773
Q

What is anhedonia?

A

Lack of pleasure in activities

774
Q

How is postnatal depression treated?

A

Mild- support and self-help
Moderate- SSRI’s, CBT
Severe- specialist psychiatry services

775
Q

What screening tool is used to assess postnatal depression?

A

Edinburgh Postnatal Depression Scale

776
Q

What symptoms are experiened in puerperal psychosis?

A 
Delusions
Hallucinations
Depression
Mania
Confusion
Thought disorder
777
Q

How is puerperal psychosis managed?

A

Admission to mother & baby unit
CBT
Medications
Electroconvulsive therapy

778
Q

What is mastitis?

A

Inflammation of breast tissue

779
Q

What is the main cause of mastitis?

A

Obstruction in the ducts and accumulation of milk when breast feeding
Can also be caused by infection

780
Q

How does mastitis present?

A 
Unilateral breast pain/ tenderness
Erythema
Local warmth and inflammation
Nipple discharge
Fever
781
Q

How is mastitis managed when breast feeding is the cause?

A

Conservative: Continued breastfeeding, expressing milk, breast massage, simple analgesia, heat packs

782
Q

How is mastitis managed if infection is the cause or conservative is not effective?

A

Antibiotics: Flucloxacillin = 1st line

783
Q

When might candida of the nipple occur?

A

After a course of antibiotics

784
Q

What can canidida of the nipple lead to?

A

Recurrent mastitis due to the cracked skin that can create an entrance for infection

785
Q

How might candida of the nipple present?

A

Bilateral sore nipple
Nipple tenderness/ itching
Cracked, flaky or shiny areola
Symptoms in baby (white patches, nappy rash)

786
Q

How is candida of the nipple treated?

A

Topical Miconazole after each feed on the mother

Miconazole gel for the baby

787
Q

What is postpartum thyroiditis?

A

Condition where there are changes to the thyroid function within 12 months of delivery

788
Q

What are the 3 typical stages of postpartum thyroiditis?

A
  1. Thyrotoxicosis
  2. Hypothyroid
  3. Gradual return to normal
789
Q

How is postpartum thyroiditis managed?

A 
TFT's 6-8 weeks after delivery
Symptomatic control (Propanolol) 
Levothyroxine for hypothyroidism
790
Q

What is Sheehan’s syndrome?

A

Complication of PPh where the drop in circulating volume leads to avascular necrosis of the pituitary gland

791
Q

What gland does Sheehan’s syndrome affect?

A

The anterior pituitary

792
Q

Where does the anterior pituitary get its blood supply from and why does this make it more susceptible to avascular necrosis?

A

Hypothalamo-hypophyseal portal system that is susceptible to rapid drops in blood pressure

793
Q

What does Sheehan’s cause and therefore how does it present?

A

Lack of hormones produced by the pituitary:

  • Reduced lactation
  • Amenorrhoea
  • Adrenal insufficiency/ adrenal crisis
  • Hypothyroidism
794
Q

How is Sheehan’s syndrome managed?

A

Replacement of missing hormones

Obs & Gynae (4 decks)

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