obstetrics Flashcards
what are the risk factors for cord prolapse
breech presentation prolonged labour polyhydramnios twins prematurity multiparity artificial membrane rupture
what is the management of cord prolapse
place mother on hand and knee position (all fours)
elevate presenting part of baby
avoid handling cord, keep warm and moist to prevent vasospasm
tocolytics (terbutaline)
fill bladder
c-section most of time, unless fully dilated and head is low
what are the complications of cord prolapse
fetal distress, hypoxia, HIE/CP
fetal mortality
when would you suspect cord prolapse
signs of fetal distress on CTG
what are the RFs for folate deficiency
- anti-epileptics
- obesity (BMI 30+)
- relative with NTD
- coeliac, diabetes, thalassaemia
what blood cells would you see in folate deficiency
macrocytic megaloblastic anaemia
hypersegmented neutrophils
what investigation for gestational diabetes and how to interpret results
ogtt
fasting >5.2 = diabetes
2hr >7 = diabetes
how is gestational diabetes treated
if low fasting glucose <7 trial wk exercise diet metformin short acting insulin glibenclamide if declines insulin
how should pre-existing diabetes be managed in pregnancy
stop hypoglycaemics aside from metformin insulin tight glycaemic control anomaly scan at 20 weeks folic acid 5mg pre-conception until 12 weeks treat retinopathy as can worsen in preg
what RFs for gest diabetes
obesity prev gest diabetes prev macrosomia family history diabetes BAME
when to screen for gest diabetes
at booking if previous gest diabetes
24-28 weeks if RFs
what is an ectopic pregnancy and where is the most common place
fertilised egg implants outside uterus - commonly in ampulla or isthmus of fallopians
what symptoms of ectopic
constant lower abdo pain (usually unilateral) then PV bleeding after 6-8 weeks amenorrhea
shouldertip pain if peritoneal bleeding
pain on defecation/micturition
what signs on examination in ectopic
cervical motion tenderness (excitation) adnexal mass (do not palpate as may rupture)
what risk factors for ectopic
PID previous ectopic copper coil previous fallopian surgery older age smoking progesterone only pill
what investigation in ectopic
TVUSS - gestational sac, fetal pole/yolk sac, pseudogestational sac
bHCG levels
what management in ectopic
expectant - await ectopic to resolve (monitor bHCG levels to ensure they are dropping)
medical - IM methotrexate - check bHCG to ensure dropping
surgical - salpingectomy, salpingotomy if abnormal contralateral fallopian (chance of retained trophoblast, check bHCG after to confirm complete removal)
when is surgical mgmt indicated in ectopic
pain adnexal mass >35mm rupture visible heartbeat HCG >5000
what must be given to women undergoing surgical management of ectopic
anti-D if Rh neg
what is placenta praevia
low-lying placenta, covers the cervical os
what are the symptoms of placenta praevia
painless PV bleeding
shock in keeping with visible blood loss
fetal distress, hypoxia
how is placenta praevia diagnosed
usually picked up in 20 week anomaly scan
TVUSS
what RFs for placenta praevia
smoking previous c-section multiparity multiple pregnancy fibroids IVF
how is placenta praevia managed
repeat TVUSS at 34 and 37 weeks planned c-section at 36-37 weeks steroids to mature foetal lungs if active bleeding, stabilise mum if unable to stabilise - emergency c-section if in labour - emergency c-section
what is placental abruption
separation of placenta from uterine wall
how does placental abruption present
painful PV bleeding shock not in keeping with visible blood loss woody uterus fetal distress DIC anuria coagulation problems
what are the RFs for placental abruption
previous placental abruption trauma (consider domestic abuse) cocaine increasing maternal age smoking IUGR multiple pregnancy
how is major placental abruption managed in the immediate sense
- Call for help - involve consultant, midwives, and anaesthetist
- A-E assessment - 2 large bore cannulae
- bloods - FBC, X-match group and save 6 units, coagulation studies, U+E, LFTs
- fluid and blood resus as required
- KLEIHAUER TEST
- monitor fetus via CTG
- close monitoring of mother
if no shock/fetal distress at <36 weeks, how is placental abruption managed
admit and administer steroids to mature lungs.
no tocolytics
if fetus >36 weeks and abruption
immediate c-section
what are the maternal complications of placental abruption
PPH shock death DIC renal failure
what are the fetal complications of placental abruption
IUGR
hypoxia
death
there is an increased risk of PPH in placental abruption. how is this risk managed
active third stage - IV syntocinon
what are the four causes of PPH
4Ts tone tissue trauma thrombin
what are the main causes of uterine atony
large uterus
- macrosomia
- polyhydramnios
- multiple pregnancy
maternal age
prolonged labour
placental problems
what causes of trauma (PPH)
c-section
episiotomy
instrumental delivery
what causes of thrombin (PPH)
coagulation problems DIC/HELLP (acquired) placental abruption pre-eclampsia HTN vWF haemophilia
what mgmt of PPH
A-E assessment
2 large bore cannulae (14 gauge), cross match, FBC, UE LFT, coagulation
bimanual uterine massage IV syntocinon intrauterine balloon tamponade b-lynch suture uterine artery ligation hysterectomy
how can PPH be prevented
active management - IM syntocinon in third stage of labour
what is the triad of features of pre-eclampsia
new HTN after 20 weeks
proteinuria
oedema
what are the complications of pre-eclampsia
eclampsia IUGR HELLP haemorrhage cardiac failure
what are the features of sheehan’s syndrome
PPH - avasc nec of anterior pituitary
- amenorrhea (no LH/FSH)
- no lactation (no prolactin)
- addisonian crisis (no ACTH)
- hypothyroidism (lack of TSH)
what symptoms/signs of severe pre-eclampsia
BP >160/110 headache visual disturbances papilloedema proteinuria RUQ/epigastric pain hyperreflexia HELLP
what are some major RFs for pre-eclampsia
major:
- previous pre-eclampsia
- CKD
- auto-immune disease (SLE/anti-PLD)
- diabetes
- chronic hypertension
moderate:
- age >40
- first pregnancy
- preg interval >10 years
- BMI high
- family history of pre-eclampsia
- multiple pregnancy
what prevention of pre-eclampsia
75-150mg aspirin OD from 12 weeks until birth
how is pre-eclampsia managed
labetalol nifedipine methyldopa hydralazine fluid restrict to prevent fluid overload
steroids to mature fetal lungs if prem labour
how is pre-eclampsia managed during labour and following 24 hours
mag sulf
what is eclampsia and how is it managed
seizures associated with pre-eclampsia
IV mag sulf to protect CNS
what side effect of mag sulf and how can this be treated
mag sulf can cause respiratory depression
treat with calcium gluconate
what complications of pre-eclampsia
maternal:
- eclampsia
- HELLP
- heart failure
- haemorrhage
- blindness
- stroke
- headaches
fetal:
IUGR
prematurity
list some sensitising events in a rh-ve mother
- delivery of Rh +ve infant (live/stillborn)
- termination of pregnancy
- haemorrage
- external cephalic version
- miscarriage >12 weeks
- surgical management of ectopic
- abdominal trauma
- amniocentesis/chorionic villous sampling/fetal blood sampling
what is a small for dates baby and which measurements are used to determine this
<10th centile
EFW
AC
plotted on customised growth charts
what causes for small for dates
constitutionally small
iugr
what causes for iugr
placental insufficiency or genetic/structural abnormality
what causes for placental insufficiency
pre-eclampsia smoking alcohol anaemia malnutrition infection autoimmune idiopathic
what other signs aside from low EFW/AC can indicate Iugr
oligohydramnios
abnormal doppler studies
reduced fetal movements
abnormal CTGs
what are the complications of IUGR
neonatal hypoglycaemia neonatal polycythaemia and jaundice birth asphyxia death neonatal hypothermia
what monitoring if to assess baby growth if risk for iugr
SFH plotted on customised growth chart
if <10th centile women are booked for serial growth scans and umbilical artery doppler
if <10th centile SFH, what investigations
serial growth scans and umbilical artery doppler
what umbilical artery doppler finding indicates placental insufficiency
absent end-diastolic flow
what management of IUGR/small for dates?
stop smoking
aspirin 75mg from 12 weeks until birth
serial growth scans to monitor growth
early deliver if no growth/concerns
when fetus is identified as SGA what investigations for underlying cause
BP and urine dip for pre-eclampsia uterine artery doppler detailed fetal anomaly scan karyotyping testing for TORCH infections
what are the RFs for IUGR
obesity smoking diabetes existing hypertension low PAPPA antepartum haemorrhage antiphospholipid syndrome pre-eclampsia infections genetic abnormalities maternal illness anaemia CKD
what medical management for top
mifepristone and misoprostol (more required if >10wks gestation)
if rh-ve and >10 weeks gestation, anti-D
what is mifepristone
anti-progesterone. halts pregnancy and relaxes cervix
what is misoprostol and how is it used in top
prostaglandin analogue - stimulates uterine contractions and softens cervix
what surgical management of top
mifepristone and misoprostol
osmotic cervical dilation
up to 14 weeks, dilation and suction
14-24 weeks, dilation and forceps removal
what is vasa praevia
vessels cover the internal cervical os, before foetus
what are the RFs for vasa praevia
placenta praevia
IVF
multiple pregnancy
what management for vasa praevia detected antenatally
steroids from 32 weeks to mature lungs
c-section 34-36 weeks
how does vasa praevia present
dark red bleeding following membrane rupture
fetal distress
how is vasa praevia managed in labour
immediate c-section
how is placenta accreta managed
c-section 35-36+6 weeks with steroids to mature fetal lungs
hysterectomy
uterus preserving surgery
expectant management
what are the risks of expectant management in placenta accreta
bleeding
infection
what management for preterm prelabour rupture of membranes
prophylactic antibiotics to prevent chorioamnionitis
- erythromycin for 10 days
offer induction of labour after 34 weeks
what investigation for preterm labour with intact membranes
fetal fibronectin test
what mgmt of preterm labour with intact membranes
- CTG monitoring
- tocolysis with nifedipine/atosiban
- steroids to mature fetal lungs
- IV magnesium sulf for fetal neuroprotection
- delayed cord clamping/cord milking
what are the symptoms of mag toxicity after magsulf treatment in women
absent reflexes
respiratory depression
hypotension
treat with calcium gluconate
what prophylaxis for preterm labour
vaginal progesterone
cervical cerclage
what are the symptoms of chorioamnionitis
PPROM
fever
maternal/fetal tachycardia
uterine tenderness
how is chorioamnionitis managed
prompt delivery of fetus
antibiotics
what prophylaxis for chorioamnionitis
erythromycin qds for 10 days
what prophylaxis for vte in preg
lmwh until 6 weeks postnatal
if DVT in preg how to manage
LMWH for 3 months (considered provoked)
what are the RFs for VTE in preg
pre-eclampsia maternal age previous DVT thrombophilia gross varicose veine obesity parity >3 smoking immobility FH IVF
what monitoring for pts on LMWH in preg
monitor factor Xa
what investigations for vte in preg
doppler artery ultrasound scan
if positive, no need for CTPA V/Q scan (unnecessary radiation)
CTPA - inc risk of breast cancer
V/Q - inc risk of childhood cancer
what mgmt of vte in preg
lmwh immediately until investigations rule out vte
until 6 weeks post partum
3months if provoked
what are the features of antiphospholipid syndrome
thrombosis
recurrent miscarriages
what antibodies are found in antiphospholipid syndrome
anticardiolipin
lupus anticoagulant
antiphospholipid antibodies
anti-beta-2-glycoprotein-1
how is antiphospholipid syndrome managed
long term warfarin
if preg, LMWH and aspirin to prevent pre-eclampsia
what conditions associated with antiphospholipid syndrome
livedo reticularis
liebmann sacks endocarditis
thrombocytopaenia
what is the relationship between APTT and antiphospholipid syndrome
APTT paradoxical rise in antiphospholipid syndrome
what is acute fatty liver of pregnancy
rapid accumulation of lipid in hepatocytes - acute hepatitis
what symptoms of acute fatty liver of pregnancy
ascites anorexia nausea vomiting jaundice hypoglycaemia malaise fatigue
what might severe acute fatty liver of pregnancy lead to
pre-eclampsia
what investigations for acute fatty liver of pregnancy
LFTs - raised AST, ALT, bilirubin
raised WCC, low platelets
deranged clotting - INR and PTT raised
how is acute fatty liver of pregnancy managed
admission and delivery of baby
consider liver transplant
