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FINALS REVISION > obstetrics > Flashcards

obstetrics Flashcards

1
Q

what are the risk factors for cord prolapse

A 
breech presentation
prolonged labour
polyhydramnios
twins
prematurity
multiparity
artificial membrane rupture
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2
Q

what is the management of cord prolapse

A

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

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3
Q

what are the complications of cord prolapse

A

fetal distress, hypoxia, HIE/CP

fetal mortality

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4
Q

when would you suspect cord prolapse

A

signs of fetal distress on CTG

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5
Q

what are the RFs for folate deficiency

A
  • anti-epileptics
  • obesity (BMI 30+)
  • relative with NTD
  • coeliac, diabetes, thalassaemia
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6
Q

what blood cells would you see in folate deficiency

A

macrocytic megaloblastic anaemia

hypersegmented neutrophils

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7
Q

what investigation for gestational diabetes and how to interpret results

A

ogtt
fasting >5.2 = diabetes
2hr >7 = diabetes

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8
Q

how is gestational diabetes treated

A 
if low fasting glucose <7
trial wk exercise diet
metformin
short acting insulin
glibenclamide if declines insulin
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9
Q

how should pre-existing diabetes be managed in pregnancy

A 
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
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10
Q

what RFs for gest diabetes

A 
obesity
prev gest diabetes
prev macrosomia
family history diabetes
BAME
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11
Q

when to screen for gest diabetes

A

at booking if previous gest diabetes

24-28 weeks if RFs

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12
Q

what is an ectopic pregnancy and where is the most common place

A

fertilised egg implants outside uterus - commonly in ampulla or isthmus of fallopians

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13
Q

what symptoms of ectopic

A

constant lower abdo pain (usually unilateral) then PV bleeding after 6-8 weeks amenorrhea
shouldertip pain if peritoneal bleeding
pain on defecation/micturition

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14
Q

what signs on examination in ectopic

A 
cervical motion tenderness (excitation)
adnexal mass (do not palpate as may rupture)
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15
Q

what risk factors for ectopic

A 
PID
previous ectopic
copper coil
previous fallopian surgery
older age
smoking
progesterone only pill
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16
Q

what investigation in ectopic

A

TVUSS - gestational sac, fetal pole/yolk sac, pseudogestational sac
bHCG levels

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17
Q

what management in ectopic

A

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)

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18
Q

when is surgical mgmt indicated in ectopic

A 
pain
adnexal mass >35mm
rupture
visible heartbeat
HCG >5000
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19
Q

what must be given to women undergoing surgical management of ectopic

A

anti-D if Rh neg

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20
Q

what is placenta praevia

A

low-lying placenta, covers the cervical os

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21
Q

what are the symptoms of placenta praevia

A

painless PV bleeding
shock in keeping with visible blood loss
fetal distress, hypoxia

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22
Q

how is placenta praevia diagnosed

A

usually picked up in 20 week anomaly scan

TVUSS

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23
Q

what RFs for placenta praevia

A 
smoking
previous c-section
multiparity
multiple pregnancy
fibroids
IVF
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24
Q

how is placenta praevia managed

A 
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
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25
Q

what is placental abruption

A

separation of placenta from uterine wall

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26
Q

how does placental abruption present

A 
painful PV bleeding
shock not in keeping with visible blood loss
woody uterus
fetal distress
DIC
anuria
coagulation problems
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27
Q

what are the RFs for placental abruption

A 
previous placental abruption
trauma (consider domestic abuse)
cocaine
increasing maternal age
smoking
IUGR
multiple pregnancy
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28
Q

how is major placental abruption managed in the immediate sense

A
  • 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
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29
Q

if no shock/fetal distress at <36 weeks, how is placental abruption managed

A

admit and administer steroids to mature lungs.

no tocolytics

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30
Q

if fetus >36 weeks and abruption

A

immediate c-section

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31
Q

what are the maternal complications of placental abruption

A 
PPH
shock
death
DIC 
renal failure
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32
Q

what are the fetal complications of placental abruption

A

IUGR
hypoxia
death

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33
Q

there is an increased risk of PPH in placental abruption. how is this risk managed

A

active third stage - IV syntocinon

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34
Q

what are the four causes of PPH

A 
4Ts
tone
tissue
trauma
thrombin
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35
Q

what are the main causes of uterine atony

A

large uterus

  • macrosomia
  • polyhydramnios
  • multiple pregnancy

maternal age
prolonged labour
placental problems

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36
Q

what causes of trauma (PPH)

A

c-section
episiotomy
instrumental delivery

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37
Q

what causes of thrombin (PPH)

A 
coagulation problems
DIC/HELLP (acquired) 
placental abruption 
pre-eclampsia
HTN
vWF
haemophilia
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38
Q

what mgmt of PPH

A

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
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39
Q

how can PPH be prevented

A

active management - IM syntocinon in third stage of labour

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40
Q

what is the triad of features of pre-eclampsia

A

new HTN after 20 weeks
proteinuria
oedema

41
Q

what are the complications of pre-eclampsia

A 
eclampsia
IUGR
HELLP
haemorrhage
cardiac failure
42
Q

what are the features of sheehan’s syndrome

A

PPH - avasc nec of anterior pituitary

  • amenorrhea (no LH/FSH)
  • no lactation (no prolactin)
  • addisonian crisis (no ACTH)
  • hypothyroidism (lack of TSH)
43
Q

what symptoms/signs of severe pre-eclampsia

A 
BP >160/110
headache
visual disturbances
papilloedema
proteinuria
RUQ/epigastric pain
hyperreflexia
HELLP
44
Q

what are some major RFs for pre-eclampsia

A

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
45
Q

what prevention of pre-eclampsia

A

75-150mg aspirin OD from 12 weeks until birth

46
Q

how is pre-eclampsia managed

A 
labetalol
nifedipine
methyldopa
hydralazine
fluid restrict to prevent fluid overload

steroids to mature fetal lungs if prem labour

47
Q

how is pre-eclampsia managed during labour and following 24 hours

A

mag sulf

48
Q

what is eclampsia and how is it managed

A

seizures associated with pre-eclampsia

IV mag sulf to protect CNS

49
Q

what side effect of mag sulf and how can this be treated

A

mag sulf can cause respiratory depression

treat with calcium gluconate

50
Q

what complications of pre-eclampsia

A

maternal:

  • eclampsia
  • HELLP
  • heart failure
  • haemorrhage
  • blindness
  • stroke
  • headaches

fetal:
IUGR
prematurity

51
Q

list some sensitising events in a rh-ve mother

A
  • 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
52
Q

what is a small for dates baby and which measurements are used to determine this

A

<10th centile
EFW
AC
plotted on customised growth charts

53
Q

what causes for small for dates

A

constitutionally small

iugr

54
Q

what causes for iugr

A

placental insufficiency or genetic/structural abnormality

55
Q

what causes for placental insufficiency

A 
pre-eclampsia
smoking
alcohol
anaemia
malnutrition
infection
autoimmune
idiopathic
56
Q

what other signs aside from low EFW/AC can indicate Iugr

A

oligohydramnios
abnormal doppler studies
reduced fetal movements
abnormal CTGs

57
Q

what are the complications of IUGR

A 
neonatal hypoglycaemia
neonatal polycythaemia and jaundice
birth asphyxia
death
neonatal hypothermia
58
Q

what monitoring if to assess baby growth if risk for iugr

A

SFH plotted on customised growth chart

if <10th centile women are booked for serial growth scans and umbilical artery doppler

59
Q

if <10th centile SFH, what investigations

A

serial growth scans and umbilical artery doppler

60
Q

what umbilical artery doppler finding indicates placental insufficiency

A

absent end-diastolic flow

61
Q

what management of IUGR/small for dates?

A

stop smoking
aspirin 75mg from 12 weeks until birth
serial growth scans to monitor growth
early deliver if no growth/concerns

62
Q

when fetus is identified as SGA what investigations for underlying cause

A 
BP and urine dip for pre-eclampsia
uterine artery doppler
detailed fetal anomaly scan
karyotyping
testing for TORCH infections
63
Q

what are the RFs for IUGR

A 
obesity
smoking
diabetes
existing hypertension
low PAPPA
antepartum haemorrhage
antiphospholipid syndrome
pre-eclampsia
infections
genetic abnormalities
maternal illness
anaemia
CKD
64
Q

what medical management for top

A

mifepristone and misoprostol (more required if >10wks gestation)
if rh-ve and >10 weeks gestation, anti-D

65
Q

what is mifepristone

A

anti-progesterone. halts pregnancy and relaxes cervix

66
Q

what is misoprostol and how is it used in top

A

prostaglandin analogue - stimulates uterine contractions and softens cervix

67
Q

what surgical management of top

A

mifepristone and misoprostol
osmotic cervical dilation

up to 14 weeks, dilation and suction
14-24 weeks, dilation and forceps removal

68
Q

what is vasa praevia

A

vessels cover the internal cervical os, before foetus

69
Q

what are the RFs for vasa praevia

A

placenta praevia
IVF
multiple pregnancy

70
Q

what management for vasa praevia detected antenatally

A

steroids from 32 weeks to mature lungs

c-section 34-36 weeks

71
Q

how does vasa praevia present

A

dark red bleeding following membrane rupture

fetal distress

72
Q

how is vasa praevia managed in labour

A

immediate c-section

73
Q

how is placenta accreta managed

A

c-section 35-36+6 weeks with steroids to mature fetal lungs
hysterectomy
uterus preserving surgery
expectant management

74
Q

what are the risks of expectant management in placenta accreta

A

bleeding

infection

75
Q

what management for preterm prelabour rupture of membranes

A

prophylactic antibiotics to prevent chorioamnionitis
- erythromycin for 10 days

offer induction of labour after 34 weeks

76
Q

what investigation for preterm labour with intact membranes

A

fetal fibronectin test

77
Q

what mgmt of preterm labour with intact membranes

A
  • CTG monitoring
  • tocolysis with nifedipine/atosiban
  • steroids to mature fetal lungs
  • IV magnesium sulf for fetal neuroprotection
  • delayed cord clamping/cord milking
78
Q

what are the symptoms of mag toxicity after magsulf treatment in women

A

absent reflexes
respiratory depression
hypotension

treat with calcium gluconate

79
Q

what prophylaxis for preterm labour

A

vaginal progesterone

cervical cerclage

80
Q

what are the symptoms of chorioamnionitis

A

PPROM
fever
maternal/fetal tachycardia
uterine tenderness

81
Q

how is chorioamnionitis managed

A

prompt delivery of fetus

antibiotics

82
Q

what prophylaxis for chorioamnionitis

A

erythromycin qds for 10 days

83
Q

what prophylaxis for vte in preg

A

lmwh until 6 weeks postnatal

84
Q

if DVT in preg how to manage

A

LMWH for 3 months (considered provoked)

85
Q

what are the RFs for VTE in preg

A 
pre-eclampsia
maternal age
previous DVT
thrombophilia
gross varicose veine
obesity
parity >3
smoking
immobility
FH
IVF
86
Q

what monitoring for pts on LMWH in preg

A

monitor factor Xa

87
Q

what investigations for vte in preg

A

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

88
Q

what mgmt of vte in preg

A

lmwh immediately until investigations rule out vte
until 6 weeks post partum
3months if provoked

89
Q

what are the features of antiphospholipid syndrome

A

thrombosis

recurrent miscarriages

90
Q

what antibodies are found in antiphospholipid syndrome

A

anticardiolipin
lupus anticoagulant
antiphospholipid antibodies
anti-beta-2-glycoprotein-1

91
Q

how is antiphospholipid syndrome managed

A

long term warfarin

if preg, LMWH and aspirin to prevent pre-eclampsia

92
Q

what conditions associated with antiphospholipid syndrome

A

livedo reticularis
liebmann sacks endocarditis
thrombocytopaenia

93
Q

what is the relationship between APTT and antiphospholipid syndrome

A

APTT paradoxical rise in antiphospholipid syndrome

94
Q

what is acute fatty liver of pregnancy

A

rapid accumulation of lipid in hepatocytes - acute hepatitis

95
Q

what symptoms of acute fatty liver of pregnancy

A 
ascites
anorexia
nausea vomiting
jaundice
hypoglycaemia
malaise fatigue
96
Q

what might severe acute fatty liver of pregnancy lead to

A

pre-eclampsia

97
Q

what investigations for acute fatty liver of pregnancy

A

LFTs - raised AST, ALT, bilirubin
raised WCC, low platelets
deranged clotting - INR and PTT raised

98
Q

how is acute fatty liver of pregnancy managed

A

admission and delivery of baby

consider liver transplant

FINALS REVISION (17 decks)

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