Obstetrics Flashcards
Management of acute placenta praevia?
<34w = corticosteroids >34w = C section
Management of placental abruption
Urgent involvement of seniors 2 x grey cannula - bloods Crossmatch 4 units Fluid + blood resus if needed CTG monitoring
If fetal distress - immediate CS
If no fetal distress + <36w = Steroids + observe
If no fetal distress +>36w = Delivery vaginally
Drugs to avoid in pregnancy
x
Drugs to avoid in breastfeeding
- aspirin
- lithium
- ciprofloxacin
- methotrexate
- amiodarone
- carbimazole
- benzodiazepines
- tetracyclines
- sulphonamides
- sulphonylureas
What is hydrops fetalis?
Abnormal fluid accumulation in two or more fetal compartments
Due to severe fetal anaemia
Causes of polyhydramnios
Impaired swallowing - oesophageal atresia/duodenal atresia, diaphragmatic hernia
Increased production - foetal anaemia, maternal DM, twin to twin, foetal renal disorders
Causes of oligohydramnios
Reduced production - renal agenesis, polycystic kidney disease
IUGR
PPROM
Management of pre-eclampsia
1) Labetalol (or nifedipine/methyldopa)
2) IV mag sulphate if becomes eclampsia
Who needs aspirin and from when?
If 1 high risk factor or 2 moderate risk factors
Aspirin daily from 12 WEEKS
What are high risk and moderate risk factors for pre-eclampsia?
High risk = previous pre-eclampsia, multifetal gestation, chronic HTN, diabetes, renal disease, autoimmune disease
Moderate risk = mother/sister with pre-eclampsia, nulliparity, obesity, age 40 years or older, multiple pregnancy
Who needs LMWH and from when
If 3 risk factors - LMWH from 28 weeks pregnancy to 6 weeks postpartum
If 4 risk factors - LWMH from first trimester to 6 weeks postpartum
What are risk factors for VTE in pregnancy?
Smoking Parity >3 Age >35 BMI >30 Reduced mobility Multiple pregnancy Pre-eclampsia Varicose veins Family history Thrombophilia IVF pregnancy
Note: D-dimer is not useful in pregnancy
How long do you take folic acid for?
From before conception until 12th week of pregnancy (end of first trimester)
What is chorionic blood sampling and when is it used?
used for diagnosis of Down syndrome
prior to 15 weeks gestation
2% risk of miscarriage
Amniocentesis
used for diagnosis of Down syndrome
after 15w gestation
1% risk of miscarriage
Management of cord prolapse
Need emergency CS
Whilst awaiting theatre:
- Push in presenting part to avoid decompression
- Ask patient to go on all fours
- Retrofilling the bladder with saline can help to gently elevate the presenting part
Management of shoulder dystocia
McRobert’s manoeuvre
Apply suprapubic pressure
Management of perineal tears
First degree - superficial. No management needed.
Second degree - perineal msuclebut not anal sphincter. suturing on the ward.
third degree - affects anal sphincter. needs suturing in theatre.
fourth degree - affects rectal mucosa. needs suturing in theatre.
What are the 4 T’s of postpartum haemorrhage? How is postpartum haemorrhage managed?
Tone - uterine atony
Trauma - perineal tear
Thrombin - coagulation disorder
Tissue - retained products of conception
Insert 2x wide bore cannula
Crossmatch + group and save
- Bimanual uterine compression
- IV Oxytocin/Syntocinon/Ergometrine
- IM Carboprost
What is an amniotic fluid embolism?
How does it present?
How is it managed?
When amniotic fluid enters mothers bloodstream
Usually occurs during labour
Chills, shivering, sweating, anxiety
Cyanosis, hypotension, tachycardia
Can cause collapse
Management is supportive
What is the stepwise management for induction of labour?
- Membrane sweep
- Vaginal prostaglandins
- Cervical ripening balloon
Congenital rubella
Sensorineural deafness
Congenital cataracts
Congenital heart disease
Glaucoma
Congenital toxoplasmosis
Cerebral calcification
Chorioretinitis
Hydrocephalus
Congenital varicella syndrome
Skin scarring
Limb hypoplasia
Microcephaly
Which conditions do pregnant women get screened for?
Anaemia Bacteriuria Blood group, Rhesus status and anti-red cell antibodies Down's syndrome Fetal anomalies Hepatitis B HIV Neural tube defects Risk factors for pre-eclampsia Syphilis
What are examples of sensitisation events?
x
Gestational diabetes thresholds
Fasting >5.6
2 hour >7.8
Fasting >7 = straight to insulin (Short acting only - gestational diabetes is not managed with long acting insulin)
Targets:
Fasting = 5.3
2 hour = 6.4
What is a complication of induction? How is it managed?
Uterine hyperstimulation
prolonged and frequent uterine contractions - sometimes called tachysystole
Management=
removing the vaginal prostaglandins if possible and stopping the oxytocin infusion if one has been started
Tocolytics
Which rash in pregnancy spares the umbilicus and how is it managed?
Polymorphic eruption of pregnancy
Emollients/topical steroids
Which rash in pregnancy causes fluid filled blisters around the umbilicus?
Pemphigoid gestationitis
When to deliver someone with
1) obstetric cholestasis
2) gestational diabetes
1) 37-38 weeks
2) 37-38 weeks
What is vasa praevia and how is it managed? (if it is diagnosed on ultrasound and if it presents as bleeding)
Foetal vessels exposed outside of the umbilical cord/placenta
Vessels pass through internal cervical os
Exposed vessels = prone to bleeding
Presentation=
1) Painless bleeding
2) Ruptured membranes
3) Fetal bradycardia
If diagnosed on ultrasound - planned CS at 35-36w
If patient goes into labour - immediate CS needed.
How to interpret Bishop score?
Bishop score of less than 5 = induction will likely be necessary
Bishop score of above 9 = labour will likely occur spontaneously
Who gets screened for gestational diabetes?
BMI of > 30 kg/m²
previous macrosomic baby weighing 4.5 kg or above
previous gestational diabetes
first-degree relative with diabetes
family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
Anaemia iron supplementation requirement cut offs – pregnancy
First trimester = 110
Second/third trimester = 105
Postpartum = 100
When do you need to do a Kleihauer test?
Any sensitisation event after 20 weeks
How does obstetric cholestasis present and how is it managed?
intense pruritus, jaundice, raised biluribin
Management:
Ursodeoxycholic acid
Induction at 37-38w
Obstetric cholestasis vs. acute fatty liver of pregnancy
Obstetric cholestasis - intense pruritus, jaundice, raised biluribin
Acute fatty liver - rare. Abdominal pain, N+V, headache, hypoglycaemia, elevated ALT. Delivery is definitive management.
When can an IUD/IUS be inserted post-partum?
Either in first 48 hours or otherwise then wait 4 weeks.
What are risk factors for cord prolapse?
Artificial rupture of membranes Prematurity Multiparity Polyhydramnios Twin pregnancy Abnormal presentation - breech, transverse
What should the symphysis-fundal height be?
After 20 weeks - should match gestational age within 2cm
E.g. at 24 weeks should be 22-26cm
What tool is used to screen for postnatal depression?
Edinburgh Scale
Which antidepressant in breastfeeding women?
Sertraline or Paroxetine
What are the three methods of testing for Down syndrome in pregnancy?
Combined testing = bHCG+PAPP-A + nuchal thickness
Triple testing = bHCG + AFP + uE3 (Unconjugated oestriol)
Quadruple testing = bHCG + AFP + uE3 + Inhibin-A
What is the window for combined testing?
Between 11 and 13 weeks
After 13 weeks -> Triple test (bHCG/AFP/uE3) or quadruple test (bHCG, AFP, uE3, Inhibin-A)
What gestation to do chorionic villous sampling vs. Amniocentesis?
After 15 weeks - Amniocentesis.
What are indications for foetal blood sampling?
Suspicious CTG to confirm presence of hypoxia
How can you interpret foetal blood sampling? How do you manage this?
pH <7.2 = abnormal
Lactate >4.9 = abnormal
If abnormal foetal blood sampling = immediate CS
When does postpartum depression usually present?
Around 3 months after birth
What are the 2 main causes of maternal sepsis?
Chorioamnionitis and UTI
If maternal sepsis - do urine dip + high vaginal swab
How is chorioamnionitis managed?
IV abx + prompt delivery
When should you do active management of third stag of labour?
if placenta has not passed after 1 hour
How to management PPROM?
Admission for 10 day course of erythromycin + ACS
Congenital cytomegalovirus infection
LBW
Purpuric skin lesions
Sensorineural deafness
Microcephaly
Fetal alcohol syndrome
Flat philtrum
Short palpebral fissure
Microcephaly
Learning disability
