Obstetrics Flashcards
1
Q
Ectopic pregnancy
A
Pregnancy implanted outside uterus
2
Q
Most common site ectopic pregnancy
A
Fallopian tube
3
Q
Sites of ectopic pregnancy
A
Fallopian tube, entrance to the fallopian tube, ovary, cervix, abdomen
4
Q
RF ectopic pregnancy
A
SO TOPIC
Smoking Older age Tubal ligation Ovulation induction (fertility treatment) Previous ectopic pregnancy Previous PID Intrauterine coils
5
Q
Ectopic pregnancy presentation (5) (3)
A
Presents 6-8 weeks Vaginal bleeding (dark/fresh) Constant lower abdominal pain in LIF/RIF Missed period Cervical motion tenderness (pain when moving the cervix during bimanual examination)
Possible dizziness, syncope
Shoulder tip pain (peritonitis)
Painful defaecation/urination
6
Q
Ectopic pregnancy investigations
A
Uring B-hCG: +ve
TVUS (empty uterus, mass i.e. blob,bagel,tubal rign sign)
Serum hCG (rise of >63% intrauterine, rise of <63% ectopic, fall of <50% miscarriage)
7
Q
Ectopic pregnancy management
A
Expectant management (await natural termination)
Medical management (IM methotrexate)
Surgical management: Laparoscopic salpingectopmy/ salpingotomy ALWAYS GIVE anti-D prophylaxis
8
Q
Criteria for expectant management EP
A
Ectopic is unruptured Adnexal mass <35mm No visible heart beat No significant pain HCG levels <1500 IU/ L
9
Q
Criteria for medical management EP
A
Same as expectant but HCG levels must be <5000 IU/L : and confirmed absence of intrauterine pregnancy on US
10
Q
Criteria for Surgical management EP
A
Pain
Adnexal mass >35mm
Visible heart beat
HCG levels >5000 IU/ L
11
Q
Methotrexate S/E
A
Vaginal bleeding
Nausea/Vomiting
Abdominal pain
Stomatitis (inflammation of mouth)
12
Q
Miscarriage
A
Spontaneous termination of pregnancy. Early miscarriage <12 weeks, late = 12-24 weeks
13
Q
Missed miscarriage
A
Foetus dead but no symptoms
14
Q
Threatened miscarriage
A
Vaginal bleeding with closed cervix, foetus alive
15
Q
Inevitable miscarriage
A
Vaginal bleeding, open cervix
16
Q
Incomplete miscarriage
A
Retained products of conception after miscarriage
17
Q
Complete miscarriage
A
full miscarriage, no retained products
18
Q
anembryonic pregnancy
A
gestational sac present but contains no embryo
19
Q
RF miscarriage
A
SAD BURTH
SLE Age Diabetes BV Uterine/Cervical abnormalities (fibroids) Thrombophilia
20
Q
Miscarriage investigations
A
Serial serum bHCG (to show falling levels)
TVUS (assess mean gestational sac diameter, fetal heartbeat, crown rump length and pole)
Bloods: check anaemia and if Rh-ve
21
Q
Miscarriage management
A
Expectant management (do nothing and wait spontaneous miscarriage)
Medical management (misoprostol)
Surgical management (manual vacuum aspiration/electric vacuum aspiration)
22
Q
Misoprostol S/E
A
Heavier bleeding
Pain
Vomiting
Diarrhoea
23
Q
Incomplete miscarriage management
A
Evacuation of retained products of conception
24
Q
Recurrent miscarriage
A
> /= 3 consecutive miscarriages
25
Causes recurrent miscarriage (6)
```
Idiopathic
Antiphospholipid syndrome
Hereditary thrombophilias
Uterine abnormalities
Genetic factors
(other diseases diabetes, thyroid disease, SLE)
```
26
Recurrent miscarriage investigations
```
Antiphospholipid antibodies
Testing for hereditary thrombophilias
Pelvic ultrasound
Genetic testing of products of conception
Genetic testing on parents
```
27
Treatment recurrent miscarriage
none but possibly vaginal progesterone pessaries
28
What are the medical abortion options
Mifepristone (anti-progesterone)
Misoprostol (prostaglandin analogue)
Also anti-D-prophylaxis
29
What are the surgical options abortion
Cervical dilatation and suction of contents (usually up to 14 weeks) vs Cervical dilatation and evacuation using forceps (between 14 and 24 weeks)
30
Potential cause of hyperemesis gravidarum
HCG from placenta
31
Hyperemesis Gravidarum DDx
Morning sickness
Reflux esophagitis
Other obstetric causes: pre-eclampsia, fatty liver of pregnancy
Non-obstetric diseases: Gastroenteritis, appendicitis, raised ICP
32
Hyperemesis Gravidarum investigations
urinalysis (increased ketones, exclude UTI)
FBC: exclude infection
U+E (increased urea, decreased K+ and Na+)
LFTs: exclude liver/pancreatic cause
33
Hyperemesis Gravidarum management
Antiemetics (prochlorperazine, cyclizine)
34
Hyperemesis gravidarum cause for admission
Unable to tolerate oral antiemetics
More than 5% weight loss compared with pre-pregnancy
Ketones present in urine on dipstick
35
Molar pregnancy?
When a hydatidiform mole, tumour grows inside the uterus
36
Molar pregnancy diagnosis
Ultrasound (snowstorm appearance)
| Confirmed with histology of mole after evacuation
37
Molar pregnancy management
Evacuation of uterus
38
SGA
Foetus that measures below 10th centile for their gestational age
39
SGA measurements used
EFW (weight), AC (abdominal circumference)
40
Severe SGA?
foetus below 3rd centile
41
Low birth weight?
Birth weight less than 2500g
42
Causes of SGA
constitutionally small
| IUGR (Intrauterine growth restriction)
43
IUGR split into 2 categories
Placenta mediated growth restriction
| Non placenta mediated growth restriction
44
Placenta mediated growth restriction (6)
```
Idiopathic
Pre-eclampsia
Maternal smoking, alcohol
Anaemia
Malnutrition
Infection
```
45
Non-placenta mediated growth restriction
Genetic abnormalities
Structural abnormalities
Foetal infection
errors of metabolism
46
Complications of SGA
Foetal death/still birth
Birth asphyxia
Neonatal hypothermia
Neonatal hypoglycaemia
47
SGA management and investigations
```
Critical management:
Identify those at risk
Give aspirin to those with pre-eclampsia
Treat modifiable risk factors (smoking)
Serial growth scans to monitor
Early delivery where growth is static (corticosteroids given)
```
To identify those at risk:
Blood pressure and dipstick (pre-eclampsia)
Uterine artery doppler scanning
Detailed fetal anatomy scan by fetal medicine
Karyotype from chromosomal abnormalities
Test for infections (toxoplasmosis, CMV, syphilis, malaria)
48
LGA
EFW above 90th centile/ weight more than 4.5kg
49
Causes of macrosomia
```
Constitutional
Maternal diabetes
Previous macrosomia
Maternal obesity
Overdue
```
50
Risks of LGA (4) (4)
Soulder dystocia
Failure to progress
Perineal tears
Postpartum haemorrhage
Birth injury (Erbs palsy, clavicular fracture, foetal distress, hypoxia)
Neonatal hypoglycaemia
Obesity in childhood and later life
T2DM in adulthood
51
LGA investigations
Ultrasound to exclude polyhydramnios and estimate foetal weight
OGTT for gestational diabetes
52
Pre-eclampsia
New high blood pressure in pregnancy with end organ dysfunction, notably proteinuria
53
When does pre-eclampsia occur?
After 20 weeks gestation, when the spiral arteries of the placenta form abnormally leading to high vascular resistance
54
Features of Pre-eclampsia
HTN
Proteinuria
Oedema
55
Eclampsia?
Seizures as a result of pre-eclampsia
56
Pregnancy induced HTN/Gestational HTN
HTN after 20 weeks gestation
57
Pre-eclampsia pathophysiology
When the blastocyst implants on the endometrium, the outermost layer i.e. synctiotrophoblast grows into the endometrium.
Trophoblast invasion of endometrium sends signals to the spiral arteries, reducing vascular resistance, making them more fragile.
The blood flow to these arteries increase, they breakdown, and leave pools of blood (lacunae)
When the process of forming lacunae is inadequate, the woman develops pre-eclampsia
58
Pre-eclampsia RF
```
Pre-existing HTN
Previous HTN in pregnancy
Existing autoimmune conditions (SLE)
Diabetes
CKD
```
Nulliparity
Multiple pregnancy
>40 yrs
59
Pre-eclampsia presentation (7)
```
Headache
Visual disturbance/blurriness
Nausea/ vomiting
Upper abdominal/epigastric pain (liver)
Oedema
Reduced urine output
Brisk reflexes
```
60
Diagnosis pre-eclampsia
Systolic >140mmHg
Diastolic <90mmHg
PLUS one of proteinuria, organ dysfunction, placental dysfunction
61
Criteria for proteinuria
Urine protein: creatine ration (>30mg/mmol)
Urine albumin: creatine ratio (>8mg/mmol)
62
Pre-eclampsia management
Aspirin used as prophylaxis against development (given 12 weeks until birth)
First management
Labetalol (first line)
Nifedipine (second line)
Methyldopa (third line, needs to be stopped within 2 days of birth)
Second management
Planned early birth may be necessary to avoid complications/if HTN not control. Corticosteroids given.
63
Eclampsia management
IV magnesium suplhate
64
HELLP syndrome
Combination of features that occurs as a complication of pre-eclampsia and eclampsia
Haemolysis
Elevated Liver enzymes
Low platelets
65
Gestational diabetes
Diabetes triggered by pregnancy. Caused by reduced insulin during pregnancy and resolves after birth.
66
Most significant complication for Gestational Diabetes
LGA
67
Risk factors for GD
```
Previous GD
Previous macrosomia
BMI >30
Ethnic origin (black,asian, middle eastern)
FHx
```
68
When is GD screened and how
OGTT at 24-28 weeks
69
OGTT results for GD
Fasting: >5.6mmol/L
| At 2 hrs: >7.8mmol/L
70
GD management
Fasting glucose <7mmol/L - diet and exercise 1-2 weeks, followed by metformin, then insulin
Fasting glucose >7mmol/L - insulin +/- metformin
Fasting glucose <6mmol/L plus macrosomia - insulin +/- metformin
71
Obstetric cholestasis
intrahepatic cholestasis of pregnancy, characterised by reduced outflow of bile acids from liver
72
Obstetric cholestasis presentation
```
Pruritus (mainly palms and soles)
Fatigue
Dark urine
Pale, greasy stools
Jaundice
```
73
Obstetric cholestasis DDx
Gallstones
Acute fatty liver
Autoimmune hepatitis
Viral hepatitis
74
Obstetric cholestasis investigations
LFTs (raised ALT, AST, GGT)
| Raised bile acids
75
OC management
Ursodeoxycholic acid
Emollients
Antihistamines (helps sleeping not itching)
76
Placenta praevia
Where placenta is attached in the lower portion of the uterus, lower than the presenting part of the fetus.
77
Placenta praevia RF
```
Previous C-sections
Previous PP
Older maternal age
Maternal smoking
Fibroids
IVF
```
78
Presentation PP
Painless vaginal bleeding
| Usually late around 36 weeks
79
PP management
For those diagnosed at 20 weeks, TVUS scan at 32 weeks and 36 if still present
Planned delivery (between 36-37) , corticosteroids given
80
PP complication
Hemorrhage
81
Vasa praevia
Condition where foetal vessels are within the foetal membranes (chorioamniotic membranes) and travel across the internal cervical os
82
Vasa praevia pathophysiology
In vasa praevia, the foetal vessels are exposed, outside the protection of the umbilical cord/placenta.
The foetal vessels travel through the chorioamniotic membranes and pass into internal cervical os.
These exposed vessels are prone to bleeding (especially during birth/labour) and lead to foetal blood loss and death
83
VP presentation
Antepartum haemorrhage
84
VP investigation
Ultrasound (not reliable)
Detected by vaginal examination during labour (pulsating vessels seen in membranes through dilated cervix)
During labour (dark-red bleeding occur through rupture of the membranes)
85
VP management
Corticosteroids given from 32 weeks
| Elective C-section 34-36 weeks
86
Placental abruption
When placenta separates from the wall of the uterus during pregnancy.
87
RF PA
```
Pre-eclampsia
Bleeding early in pregnancy
Trauma (domestic violence)
Multiple pregnancy
Foetal growth restriction
Multigravida
older age
Smoking
Cocaine/ amphetamine
```
88
PA presentation
```
Sudden continuous abdominal pain
Vaginal bleeding
Shock
Abnormalities on CTG
Woody abdomen on palpation *suggestive of large haemorrhage
```
89
Severity of antepartum haemorrhage
Spotting: spots of blood noticed on underwear
Minor: less than 50ml
Major: 50-1000ml
Massive: > 1000ml/ signs of shock
90
Massive haemmorhage management
Urgent involvement of senior obstetrician, midwife and anaesthetist
2x grey cannula
Bloods include FBC, UE, LFT, coagulation studies
Crossmatch 4 units of blood
Fluid and blood resuscitation
CTG monitoring of foetus
91
PA management
Antenatal steroids between 24-34+6 weeks
Rhesus-D negative
Emergency C-section
92
Placenta accreta
Condition when placenta implants deeper, through and past the endometrium, making it difficult to separate the placenta after delivery of baby.
93
Placenta accreta pathophysiology
Usually placenta attaches to the endometrium. With placenta accreta, placenta embeds past the endometrium, into the myometrium and beyond.
This may happen due to a defect in the endometrium. Imperfections may occur due to previous uterine surgery, such as C-section/Cutterage procedure
94
Placenta accreta RF (5)
```
Previous endometrial cutterage
Previous C-section
Multigravida
Increased maternal age
Low-lying placenta/placenta praevia
```
95
Placenta accreta presentation
Antepartum haemorrhage
96
Placenta accreta investigations
Ultrasound scans
| MRI scans used to assess depth and width of invasion
97
Placenta accreta management
35-36+6 week delivery
| Steroids
98
Breech presentation
When the presenting part of the foetus is the legs and bottom
99
Types of breech
Complete breech
Incomplete breech
Extended breech
Footling breech
100
Breech presentation management
ECV at 37 weeks
Where ECV fails give choice of vaginal delivery vs elective C-section
