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Obs and Gynae > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

How would a threatened miscarriage present?

A

painless vaginal bleeding occurring before 24 weeks, but typically occurs at 6 - 9 weeks
the bleeding is often less than menstruation
cervical os is closed
complicates up to 25% of all pregnancies

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2
Q

How would a incomplete miscarriage present?

A

not all products of conception have been expelled
pain and vaginal bleeding
cervical os is open

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3
Q

How would a missed (delayed) miscarriage present?

A

a gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion
mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear. Pain is not usually a feature
cervical os is closed
when the gestational sac is > 25 mm and no embryonic/fetal part can be seen it is sometimes described as a ‘blighted ovum’ or ‘anembryonic pregnancy’

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4
Q

How would an inevitable miscarriage present?

A

heavy bleeding with clots and pain
cervical os is open

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5
Q

What 3 features are the pre-eclampsia triad?

A

new-onset hypertension
proteinuria
oedema

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6
Q

What is the first line tx for pregnancy induced hypertension?

A

Oral labetalol

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7
Q

What is the first line tx for pregnancy induced hypertension if they are asthmatic?

A

Oral nifedipine

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8
Q

What is the first line tx for moderate to severe depression in pregnancy (1st time ocurrence)?

A

1) CBT
2) Antidepressants

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9
Q

What are the threshold blood pressure measurements for mild, moderate and severe gestational hypertension?

A

Hypertension Systolic Diastolic
Mild 140-149 mmHg 90-99 mmHg
Moderate 150-159 mmHg 100-109 mmHg
Severe >160 mmHg >110 mmHg

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10
Q

What are the anti-depressants of choice for post natal depression if the mother is breastfeeding?

A

Sertraline or paroxetine are the SSRIs of choice in breastfeeding women

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11
Q

How would septic miscarriage present?

A

Offensive vaginal loss, tender uterus +/- fever. If there is a pelvic infection you will also get abdominal pain and peritonism.

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12
Q

What are the examinations for suspected miscarriage?

A

Abdominal examination - palpation for tenderness of the uterus, if septic miscarriage then signs of peritonitis - rebound tenderness, guarding, rigid abdomen.
Speculum exam
*make sure you ask if conception was assisted = heterotropic pregnancy*

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13
Q

What are the investigations for suspected miscarriage?

A

Bedside: Obs and MEWS
Bloods: Serum hCG level. Decline in hCG of greater than 50% suggests non-viable pregnancy
FBC
Rhesus group
G&S
Imaging: Transvaginal US

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14
Q

What is the management for miscarriage?

A

In threatened miscarriage, cervical os is closed and 75% pregnancies will not end - safety net and discharge.

Admit if ectopic suspected, profuse bleeding or woman is symptomatic.

Resus if pain, bleeding, vasovagal shock. IM ergometrine can reduce bleeding - only used if fetus non-viable - do TVUS before and speculum exam. Fever = swabs and IV Abx.

Expectant - If woman willing and no signs of infection. Successful within 2-6 weeks. Large intact sac less successful. Safety net the woman and partner, discharge with info. Give direct access to 24hr emergency gynae service for advice/tx.

Medical - Vaginal or oral prostaglandin - Misoprostol. Confirmatory pregnancy test after 4 weeks. Give direct access to 24hr emergency gynae service for advice/tx. Anti D Ig.

Surgical - Surgical management/’evacuation’. Under anaesthetic using vacuum aspiration - used for woman’s wishes/heavy bleeding/signs of infection. Histological tissue examination to exclude molar pregnancy. Anti D Ig.

+ Counselling - Reassure, empathise, refer to support group - www.miscarriageassociation.org.uk.

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15
Q

Define recurrent miscarriage

A

>=3 miscarriages in succession. Affects 1% of couples.

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16
Q

What are the complications of miscarriage and their management?

A

Vaginal bleeding
Infection -> systemic -> sepsis
Asherman’s syndrome
Perforated uterus

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17
Q

What are the investigations for recurrent miscarriage?

A

Bedside: Obs and MEWS
Bloods: Antiphospholipid antibody screen, TFTs
Imaging: Pelvic ultrasound, MRI, hysterosalpingogram
Other: Speculum exam and endocervical and high vaginal swabs; karyotyping of fetal miscarriage tissue

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18
Q

What are the investigations for hyperemesis gravidarum?

A

Bedside: Obs and MEWS, check urine output, urine dipstick and MCS
Bloods: Serum hCG, U&Es, creatinine, eGFR, blood gas
Imaging: Transvaginal US (rule out multiple pregnancy and gestational trophoblastic disease)

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19
Q

What is the management for hyperemesis gravidarum?

A

Admit
A
B
C - large bore cannula, IV rehydration + antiemetics - metaclopramide/cyclizine/ondansetron + thiamine (prevent Wernicke’s encephalopathy - vitamin B1 depletion)
D - food may need to be given parenterally or via ng tube etc, psychological support needed
E
Steroids in severe places

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20
Q

What are the investigations for gestational trophoblastic disease?

A

Bedside: Obs and MEWS, check urine output, urine dipstick and MCS
Bloods: Serum hCG (elevated greatly), FBC, U&Es, creatinine, eGFR, blood gas, G&S
Imaging: Transvaginal US (rule out multiple pregnancy ) - sign on US is a ‘snowstorm’ appearance of the swollen villi with complete moles - may need histological biopsy to confirm.

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21
Q

How is gestational trophoblastic disease managed?

A

Admit, NBM, consent, FBC, G&S

1) Suction curettage (ERPC) + histological diagnosis confirmation
2) Serial blood/urine hCG levels - persistent/rising will indicate malignancy
3) Register with a supraregional centre for ongoing management and follow up
4) Oral contraception - avoid pregnancy till after surveillance period is finished

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22
Q

What are clinical signs of a trophoblastic malignancy?

A

Elevated hCG
*********Persistent vaginal bleeding********
Blood-borne metastasis to lung

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23
Q

How is trophoblastic malignancy managed?

A

Low risk: methotrexate + folic acid
High risk: combi chemotherapy

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24
Q

Aside from trophoblastic malignancy what other complication arises from gestational trophoblastic disease?

A

Recurrence of molar pregnancy

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25
Q

What are the different types of gestational trophoblastic disease?

A

Hydatidiform mole - complete (one sperm fertilises empty oocyte) and partial (2 sperm enter an oocyte)
Malignant - Invasive mole (local invasion to uterus only), Choriocarcinoma (metastasis), placental site trophoblastic tumour (presents 3.4 years after the original pregnancy; uncommon)

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26
Q

What are the examinations for ectopic pregancy?

A

Abdominal exam - tenderness on palpation and rebound tenderness
Speculum exam + bimanual exam - cervical excitation, tender adnexa, closed cervical os, small uterus
Cardiac examination - reflex tachycardia, hypotension

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27
Q

What are the Ix for ectopic pregnancy?

A

Bedside: Obs, MEWS, urine pregnancy test
Bloods: Serum hCG - declining or slowly rising hCG *must ask about conception to see whether there could be a heterotropic pregnancy*, FBC, G&S, rhesus status
Imaging: Transvaginal US - nothing in uterus, in adnexa: blood clot, free fluid or gestational sac with or without fetus, probe may elicit tenderness
Other: laparoscopy

28
Q

What is the Mx for ectopic pregnancy?

A

Admit
ABC - IV access, DE, G&S, Give Anti D if rhesus negative
Acute: If haemodynamically unstable: expedient resus and surgery, laparoscopy or laparotomy (more common) -> salpingectomy or salpingostomy

Subacute:
Surgical management: if woman unable to follow up/has ectopic and has significant pain/>35mm ectopic/ruptured ectopic/ serum hCG >5000IU/mL/fetal heartbeat detected. Laparoscopic salpingostomy or salpingectomy.

Medical management: if woman is available to return for follow-up, has no significant pain, ectopic is un-ruptured, adnexal mass <35mm, no fetal heart activity seen, no co-existing intrauterine pregnancy. Ideally hCG <1500IU/ml. Systemic single dose methotrexate. Then serial hCG levels to confirm that all trophoblastic tissue us gone. Second dose can be given (15% women). 10% women need surgery.

Serial hCG <20IU/ml confirms ectopic resolution. Also give information. Safety net. Support and counselling for fertility loss. Patient support groups www.ectopic.org.uk.

29
Q

What is routine medical termination of pregnancy?

A

Mifepristone (antiprogesterone) + misoprostol (PG) 36-48 hrs later.
From 22 weeks, we also perform feticide to prevent live birth (KCl is injected into umbilical vein or the fetal heart). Anti D Ig.

30
Q

What Ix should be undertaken before a TOP?

A

Bloods: FBC - Hb, G&S, rhesus status, testing for haemoglobinopathies - Hb electrophoresis?
STI screen
Contraception discussion

31
Q

How is surgical TOP completed?

A

Suction curettage 7-12/14 weeks. Above 14 weeks can do dilatation and evacuation by skilled clinician - cervix is prepared with vaginal misoprostol + Abx prophylaxis.. Anti D Ig from 12 weeks.

32
Q

When may a selective abortion be performed?

A

Multiple pregnancy of high number or abnormal fetus in multiple pregnancy

33
Q

What are the complications of therapeutic abortion?

A

Haemorrhage 1/1000
Infection 10%
Uterine perforation 1-4/1000
Cervical trauma (can impact future pregnancies)
Failure of abortion (may retain tissue or fail to stop the pregnancy)
Subsequent preterm delivery
Psychological sequelae

34
Q

What is the first trimester?

A

Up to and including 12 weeks

35
Q

What is the second trimester?

A

13-27 weeks

36
Q

What is the 3rd trimester?

A

28 weeks till end of pregnancy (term)

37
Q

What are signs and symptoms of fetal varicella syndrome?

A

Skin scarring
Eye defects (microphthalmia)
Limb hypoplasia
Microcephaly
Learning disabilities

38
Q

Which women are at a high risk of their baby having a neural tube defect and therefore should be given a higher dose of 5mg folic acid OD when trying the conceive?

A

The following are at increased risk of conceiving a child with a NTD and therefore should receive the higher dose folic acid:
Either parent has a NTD
Previous pregnancy affected by NTD
Family history of NTD
Woman taking anti-epileptic medication
Woman with diabetes
Obese (BMI > 30mg/kg2)
Sickle cell disease (take 5mg folic acid OD throughout pregnancy)
Thalassaemia trait or thalassaemia (take 5mg folic acid OD throughout pregnancy)

39
Q

What are the RF for hyperemesis gravidarum?

A

multiple pregnancies
trophoblastic disease
hyperthyroidism
nulliparity
obesity
(smoking decreases the risk of HG)

40
Q

How is an oral glucose tolerance test carried out?

A

An oral glucose tolerance test involves taking a fasting blood sugar test in the morning. The patient is not supposed to have any food or drink intake in the preceding 8-10 hours. A glucose drink will then be provided to the patient. Another blood test will be taken 2 hours post-ingestion of the drink. The 2-hour glucose level would have to be >7.8mmol/L to diagnose gestational diabetes.

41
Q

What are the different grades of placenta praevia?

A

Praevia is divided into four grades depending on the relationship and distance to the internal cervical os:

grade I: low-lying placenta: placenta lies in the lower uterine segment but its lower edge does not abut the internal cervical os (i.e lower edge 0.5-2.0 cm from internal os).
grade II: marginal praevia: placental tissue reaches the margin of the internal cervical os, but does not cover it
grade III: partial praevia: placenta partially covers the internal cervical os
grade IV: complete praevia: placenta completely covers the internal cervical os

Sometimes grades I and II are termed a “minor” or “partial” placenta praevia, and grades III and IV are termed a “major” placenta praevia 5.

42
Q

How should delivery be managed in a woman with a grade 3/4 placenta praevia?

A

Elective C-section at 37-38 weeks (to prevent major obstetric haemorrhage)

43
Q
A
44
Q

What haemoglobin level cut off should be used, to determine whether iron supplementation should be started post-partum?

A

A cut-off of 100 g/Lshould be used in the postpartum period to determine if iron supplementation should be taken

Mx: oral ferrous sulfate or ferrous fumarate, treatment should be continued for 3 months after iron deficiency is corrected to allow iron stores to be replenished

45
Q

What are the threshold for iron supplementation treatment peri-natally?

A

115 for non-pregnant women, 110 in early pregnancy, 105 in later pregnancy, and 100 after childbirth.

46
Q

How should we manage a pregnant woman who is at risk of developing gestational hypertension?

A

Aspirin 75mg OD from 12 weeks till delivery

47
Q

Who is at risk of developing gestational hypertension?

A
  • hypertensive disease during previous pregnancies
  • chronic kidney disease
  • autoimmune disorders such as SLE or antiphospholipid syndrome
  • type 1 or 2 diabetes mellitus
48
Q

What is the most common organism causing mastitis?

A

Staphylococcus aureus (Encourage analgesia and encourage to keep breastfeeding, also help mum with breastfeeding attachment etc if doesn’t improve in 2 days, prescribe Abx: First-line choice is oral flucloxacillin (500mg four times a day for 14 days) or erythromycin if penicillin allergic. Second-line choice is co-amoxiclav.)

49
Q

What are the RF of gestational diabetes?

A

Obesity

FH Diabetes Mellitus

Previous GDM

Previous macrosomic baby (>=4.5kg)

Ethnicity of high prevalence of DM i.e. South Asian

50
Q

How is gestational diabetes defined?

A

Diabetes (elevated blood sugar levels) that arises in pregnancy and usually resolves post-partum.

Diagnosis is via:

>= 5.6 mmol/L (fasting plasma glucose)

>= 7.8 mmol/L (2 hour blood glucose via oral glucose tolerance test)

51
Q

How is gestational diabetes screened for in the pregnancy?

A

Glycosuria

52
Q

Define gestational hypertension?

A

>=20 weeks

Hypertension arising after 20 weeks without proteinuria

>=140/90 mmHg

53
Q

Define pre-eclampsia

A

Hypertension and significant proteinuria arising after 20 weeks of the pregnancy that resolves completely by the 6th week post partum

54
Q

After the initial urine dipstick test for protein, how is significant proteinuria defined?

A

Protein:creatinine ratio >30mg/mmol

Albumin:creatinine ratio >8mg/mmol

55
Q

What are the RF for pre-eclampsia?

A

Previous pre-eclampsia

Nullip

>40 years age

Obesity

Multiple pregnancy

56
Q

What are the complications of pre-eclampsia?

A

Eclampsia

Foetal growth restriction

Placental abruption

Pre-term delivery

HELLP syndrome

57
Q

What is HELLP syndrome?

A

HELLP syndrome is a complication of pre-eclampsia and eclampsia that is characterised by haemolysis, elevated liver enzymes and low platelets.

58
Q

What type of anaemia do you get in HELLP syndrome?

A

Microangiopathic haemolytic anaemia

59
Q

What would you see on the bloodfilm of a micro or macro angiopathic haemolytic anaemia i.e. in HELLP syndrome?

A

Schistocytes

60
Q

What is an alternative name for schistocytes?

A

Helmet cells

Fragmented red blood cells

61
Q

What can HELLP cause?

A

Disseminated intravascular coagulation

Hepatic subcapsular adenoma

Liver infarction

Liver haemorrhage

Placental abruption (also causes DIC)

Kidney failure (end organ damage)

62
Q

What is the management for HELLP syndrome?

A

Delivery if >=34 weeks

Give corticosteroids to mother

Dexamethasone

Blood transfusion

Anti-hypertensives + MgSO4

63
Q

What is the management for pre-eclampsia?

A

ABCDE

Inform seniors - Reg on call

Admit if 160/110mmHg

Monitor: Plt, ALT, creatinine, fetal compromise (CTG)

64
Q

Why are haptoglobin levels low in HELLP syndrome?

A

When red blood cells are damaged, they release more hemoglobin into the bloodstream. That means more of the haptoglobin-hemoglobin complex will be cleared from the body. The haptoglobin may leave the body faster than the liver can make it. This causes your haptoglobin blood levels to drop. If your haptoglobin levels are too low, it may be a sign of a disorder of the red blood cells, such as anemia.

65
Q

A 39 year old female G2 P2 has just delivered a baby. Several hours later, she starts experiencing severe shortness of breath, cyanosis, hypotensive shock. Chest auscultation is positive for bilateral wet chest crackles. The patient started coughing up pink, frothy sputum. She then also began to bleed from her mouth, nose, anus, vagina and surgical wound.

What is the diagnosis?

A

Amniotic fluid embolism -> Dissemination Intravascular Coagulation

Embolism releases tissue factor, activating fibrin causing diffuse coagulation and bleeding afterwards.

Amniotic fluid embolism can also release fetal antigens, causing an anaphylactic response in the mother and leading to cardiorespiratory collapse.

66
Q
A
67
Q

What vaginal infection increases the risk of preterm delivery and late miscarriage?

A

Bacterial vaginosis i.e. by Gardnerella Vaginalis

Obs and Gynae (2 decks)

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