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ALS > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

Placental Abruption

A

Separation of the placenta from the uterine wall, bleed into the space

= shock ≠ visible loss, constant pain, tender tense uterus, normal lie and presentation

Inv - distressed/ absent foetal HR

-> immediate c-section if distressed, if not observe + steroids <36wks or vaginal >36wks, induce vaginal if dead

Comp - shock, DIC, renal failure, PPH

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2
Q

Abruption: RF

A

A - Abruption before
B - Blood pressure
R - Ruptured membranes, prolonged or premature
U - Uterine injury/ trauma
P - Polyhydraminos, previous children
T - Twins
I - Infection
O - Old age
N - Narcotics (cocaine)

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3
Q

Placenta Praevia

A

Placenta lying in the lower uterine segment, risk of PPH

RF - multiparity, multiple pregnancy, prev C section

= shock ≈ loss, no pain, uterus not tender

Inv - DON’T DO PV exam, abdo US (incidental), TV US

-> if low at 20wks then rescan at 32wks, still present scan every 2 weeks, decide on delivery at 36-37wks, elective c-section for 3/4 (emergency c-section if labour before/ unstable or term bleeding)

  1. placenta reaches lower segment but not os
  2. reaches os but doesn’t cover it
  3. covers the os before dilation
  4. placenta completely covers os
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4
Q

Down’s Syndrome Screening

A

Combined test (11-14wks) - ^hCG, v PAPPA-A, thick nuchal translucency (US) thickened US
*Lower hCG in Edwards and Patau

Quadruple test (15-20wks) - ^inhibin A, ^hCG, v AFP, v oestriol

‘higher chance’ offered NIPT (99% spec/sens) or amniocentesis/ CVS

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5
Q

AFP

A

Protein produced by developing foetus

Increased in NTD, abdo wall defects, twins
Decreased in downs, edwards (18), maternal DM

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6
Q

Quadruple Test

A

AFP, uc Oestriol, HCG, Inhibin A

Downs - low, low, high, high
Edwards - low, low, low, normal
NTD - high, normal, normal, normal

High chance (>1 in 150)

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7
Q

Preterm Prelabour Rupture of the Membranes

A

Inv - sterile speculum exam (pooling of amniotic fluid in post vaginal vault), avoid DVE, placental PAMG1 or insulin-like GF protein 1, US (oligohydramnios)

-> admit, 10d PO erythromycin, antenatal steroids, consider delivery at 34 weeks

Comp - premature delivery (40% linked to PPROM), pulm hypoplasia, chorioamnionitis

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8
Q

Management of Miscarriage

A

Expectant: 7-14d watch and wait, next if doesn’t work

Medical or surgical if evidence of infection, risk of bleed (late T1, coagulopathies) or prev adverse experience with pregnancy

-> Medical
Missed: oral mifepristone, misoprostol 48hrs after, see Dr if no bleed in 24 hours
Incomplete: single dose misoprostol (PV/ PO)
-> Surgery; vacuum aspiration or ERPC

*Pregnancy test at 3wks to confirm

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9
Q

Amniotic fluid embolism

A

Reaction 2nd to fetal cells/ amniotic fluid in maternal bloodstream

RF - ^age, induction of labour

= most during labour, chills, sweating, anxiety, cough, v BP, ^HR, bronchospasm, arrhythmia, MI

-> supportive, critical care unit

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10
Q

Antenatal timetable

A

8-12wks = Booking, general info, BP, BMI, urine culture, FBC, blood group, rhesus, RC alloantibodies, Hb disease, syphilis, Hep B, HIV offered

10-14wks = Dating scan and Down’s screen, excl. multiple

16wks = review prev, iron if <110, BP, urine dip

18-21wks = Anomaly scan

*BP, dip, SFH at all below

28wks = screen Hb and allo, 1st anti-D dose

34wks = 2nd anti-D dose, labour info

36wks = presentation (offer ECV), BF info

38wks = routine

41wks = info on induction

Primip also get 25wks, 31wks, 40wks

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11
Q

Weight gain and breastfeeding

A

1/10 lose the 10% threshold of weight in week 1

-> examine infant, referral to midwife-led BF clinics, monitor weight until regains

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12
Q

Drugs to avoid in breastfeeding

A

Methotrexate
Benzos

Carbimazole, chemo drugs
Lithium
Aspirin
Sulphonylureas
Sulphonamides

Amiodarone
Ciprofloxacin, chloramphenicol
Tetracycline

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13
Q

Breech Presentation

A

25% are breech at 28wks, 3% at term

RF - uterine malformation, fibroids, praevia, prem, poly/ oligohydramnios, foetal abnormality

-> offer ECV at 36wks (37wks if multiparous), plan vaginal or c-section

ECV contra if c-section required, APH in last 7d, abnormal CTG, major uterine anomaly, ruptured membranes, twins

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14
Q

Categories of C section urgency

A

1 - immediate threat to life, deliver <30 min
E.g., uterine rupture, major abruption, cord prolapse

2 - maternal or fetal compromise but not threatening life, <75 min

3 - required but both stable

4 - elective

VBAC: at 37wks+, 75% success if one previous c-section, contra if prev uterine rupture or classic C section scar

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15
Q

Cardiotocography (CTG)

A

Baseline bradycardia (<100): ^fetal vagal tone, beta blockers

Baseline tachycardia (>160): maternal fever, chorioamnionitis, hypoxia, prematurity

Loss of variability (<5): hypoxia, prematurity

Early deceleration (starts with onset of contraction, returns to normal at end of it): harmless head compression

Late deceleration (lags onset of contraction, returns >30secs after end): fetal stress e.g., asphyxia

Variable deceleration (independent of contractions): cord compression

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16
Q

Chickenpox in Pregnancy

A

Management of exposure
-> any doubt if mum has had it previously then check IgG, oral acyclovir 7-14d after exposure

Management of chicken pox:
-> specialist advice, PO acyclovir if <24hrs of rash and 20wk+ of pregnancy, consider if under 20 weeks

Comp - 5x pneumonitis in mum, fetal varicella syndrome (exposed <20wk, scars, small eyes/ head, limb hypoplasia, LD), neonatal varicella (rash 5d before- 2d after birth, 20% mort), shingles in infancy

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17
Q

Chorioamnionitis

A

Life-threatening, ascending bacterial infection of amniotic fluid/ membranes/ placenta

PF - PPROM

-> prompt delivery, IV Abx

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18
Q

Eclampsia

A

Development of seizures in association with pre-eclampsia (new proteinuria and HTN after 20wks)

-> MgSO4 (4g bolus + 1g/hr, until 24hrs from last seizure or delivery), calcium gluconate if Mg resp depression
*Monitor RR, urine output, reflexes, o2 sats

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19
Q

Folic Acid

A

Converted to tetrahydrofolate for DNA/RNA synthesis

RF - phenytoin, methotrexate, pregnancy, alcohol

-> 400mcg before conception-12wks, 5mg if high risk (F/Hx of NTD, antiepileptics, coeliac, DM, thalassaemia, BMI >30)

Comp - NTD, macrocytic megaloblastic anaemia

20
Q

Gestational Diabetes

A

Diabetes that develops during pregnancy, 1 in 20

RF - BMI>30, prev macrosomia (4.5kg+), prev gestational DM, 1st degree relative with DM, family origin

Inv - OGTT (asap after booking if prev GDM, 24-28wks if RF)

Fasting = 5.6+, 2hr = 7.8+

-> seen in diabetic antenatal clinic <1wk, diet and exercise for 1-2wk, metformin if targets not met, add short-acting insulin (1st line if fasting 7+ or evidence of comp)

21
Q

GDM Targets

A

Fasting - 5.3
1hr after meal - 7.8
2hr after meal - 6.4

22
Q

Group B Streptococcus

A

Most common cause of early neonatal sepsis, e.g., Streptococcus agalactiae

RF - prem, prolonged ROM, prev baby infected, maternal fever

Inv - swabs at 35-37wks or 3-5wks before delivery

-> intrapartum Abx proph (benpen) if prev. GBSD baby or fever in labour >38, offer to any prem, IAP or testing in late pregnancy (+/- Abx) if GBS detected prev.

23
Q

HELLP Syndrome

A

Haemolysis, elevated liver enzymes and low platelets

RF - severe pre-eclampsia (10-20% develop HELLP)

= n+v, RUQ pain, lethargy

-> deliver baby

24
Q

Hep B and pregnancy

A

All offered screening

If born to mother with chronic infection -> full course of vaccines and hep B Ig

Safe to breastfeed

25
Q

HIV and pregnancy

A

Screening offered to all, management based on viral load

<50 at 36wks -> vaginal delivery, PO zidovudine to neonate

> 50 -> c-section, zidovudine infusion started 4hrs before, triple ART to neonate for 4-6wks

Cannot breastfeed

26
Q

HTN in pregnancy

A

Normal for BP to fall until 20-24wks then increase to term

RF - HTN in prev pregnancy, CKD, DM, AI disorders

Pre-existing: HTN <20wks
Pregnancy-induced: >20wks but no proteinuria or oedema
Pre-eclampsia: >20 weeks with proteinuria (>0.3g/d)

-> PO labetalol (nifedipine if asthmatic), aspirin 75mg OD 12wks-birth if high risk of pre-eclampsia

27
Q

Induction of Labour

A

Use - prolonged pregnancy, PPROM, diabetic mother >38wks, pre-eclampsia, obs cholestasis, IU death

Bishop score: <5 unlikely to start without induction, 8+ high chance of spont labour

Options
Membrane sweep - an adjunct, 40-41wk appt
Vaginal prostaglandin E2 - dinopostone
Oral prostoglandin E1 - misoprostol
Oxytocin infusion
Amniotomy - break the waters
Cervical ripening balloon

Bishop 6 or below offer prostaglandin, >6 offer amniotomy or IV oxytocn

Comp - uterine hyperstimulation (v fetal blood supply), amniotic fluid embolisim

28
Q

Intrahepatic Cholestasis of Pregnancy

A

= itchy palms and abdo, 20% get jaundice, ^BR

-> induce at 37-38wks, ursodeoxycholic acid

Comp - likely to recur in next pregnancy

29
Q

Stages of Labour

A

1 - onset of true labour to fully dilated cervix
Latent phase: 0-3 cm dilation, 6hr
Active phase: 3-10 cm, 1cm/hr

2 - full dilation to delivery, passive or active (pushing), 1hr, if longer consider instruments

30
Q

Oligohydraminos vs Polyhydraminos

A

Oligo
Causes - PROM, Potter sequence (bilateral renal agenesis, pulm hypoplasia), IUGR, pre-eclampsia or post term

Poly
Causes - maternal DM, twin-twin transfusion syndrome, twins

31
Q

Perineal Tears

A

First degree - superficial, no muscles involved -> no repair

Second degree - perineal muscle but not anal sphincter -> suture on ward

Third degree - a) <50% external sphincter, b) >50% EAS, c) internal AS torn -> repair in theatre

4th - anal sphincter and rectal mucosa -> theatre

32
Q

Placenta accreta

A

Attachment of the placenta to the myometrium, doesn’t separate properly during labour so ^PPH

RF - prev c-section, placenta praevia

Accreta: chorionic villi attached to myometrium (not restricted within decidua basalis)
Increta: invade into the myometrium
Percreta: through the perimetrium

33
Q

PPH

A

Blood loss >500ml after vaginal delivery, primary <24hrs

Causes - 4Ts - tone (atony, most common), trauma, tissue retained, thrombin

RF - prev PPH, prolonged labour, pre-eclampsia, ^age, polyhydramnios, emergency c section, placental issues, macrosomia

-> A-E, rub uterine fundus to stimulate contraction, catheterise, IV oxytocin, IV/IM ergometrine, IM carboprost, surgery (IU balloon tamponade if atony)

Secondary PPH: 24hrs - 6wks, caused by endometritis or retained placental tissue

34
Q

Postpartum Thyroiditis

A

= hyper, hypo then normal, high recurrence

Inv - anti-TPO Ab (90%)

-> propranolol for hyper, thyroxine for hypo

35
Q

Pre-eclampsia

A

BP >140/90 after 20 weeks + one of; proteinuria or organ dysfunction

Risk Factors
High - HTN in prev pregnancy/ chronic, CKD, AI (SLE), DM
Mod - 1st pregnancy, 40yrs+, preg interval >10yrs, BMI 35+, multiple pregnancy, FHx

= HTN, frothy urine, headache, visual issues, RUQ pain, hyperreflexia

Urgent hospital assessment if suspected

-> 1 high or 2 mod RF then 75mg aspirin from 12wk-birth, admit if BP>160/110, treat HTN, delivery is definitive

Comp - eclampsia, IUGR, prem, HELLP, haemorrhage, HF

36
Q

Anaemia

A

Measure at booking and 28wk appt
- T1 <110, T2/3 <105, pp <100

-> continue PO ferrous sulphate until 3m after resolution

37
Q

Normal changes in pregnancy

A

Increase
CO, HR, SV, tidal volume
Blood volume, WCC, ESR
Fibrinogen and factors
ALP
GFR
Trace glycosuria

Reduced
Diastolic BP in T1/2
PLT
Fibrinolytic activity
Albumin

38
Q

Reduced fetal movements

A

Movements by week 24, earlier if prev. children

RF - postural (inc when lying), distraction, placental/ fetal position, alcohol, sedatives, body habitus, fetal size

Inv - handheld doppler to confirm HB

> 28wks -> CTG 20mins vs immediate US if HB not found

If 24wks and still no movement-> refer to fetal medicine

39
Q

RA and pregnancy

A

Symptoms get better in pregnancy

-> Stop methotrexate 6m before conception, use sulfasalazine/ hydroxychloroquine, may use low dose steroids, no NSAIDs after 32wks

Refer to obs anaesthetist (risk of atlantoaxial subluxation)

40
Q

Shoulder dystocia

A

Inability to deliver body using gentle traction after head already delivered, ant. shoulder impacted on pubic symphysis

RF - macrosomia, DM, prolonged labour, fat mum

-> McRoberts (flexion and abduction of hips), episiotomy

41
Q

Symphsis fundal height

A

Top of pubic bone to top of uterus

Should match gestational age (+/- 2cm) after 20wks

42
Q

Umbilical Cord Prolapse

A

Umbilical cord descends ahead of the presenting part of the fetus

RF - prem, multiparity, polyhydramnios, twins, abnormal presentation, 50% after artificial rupture of membranes

= abnormal HB, palpable cord

-> push presenting part of fetus back in, minimal handling if cord visible, keep it warm/ moist, go on all fours, tocolytics (v contractions), retrofill bladder, c-section

Comp - cord compression, cord spasm

43
Q

Rhesus-ve Pregnancy

A

Sensitising events;
Delivery of Rh+ve baby
Termination
Miscarriage >12 weeks
Ectopic managed surgically
ECV
APH
Amniocentesis/ CVS
Abdominal trauma

-> anti-D Ig <72hrs, Kleinhauer test if >20wks, all babies born to Rh-ve mum should have cord blood taken for FBC, BG, Coombs

Rhesus Disease
= hydrops fetalis (oedematous), jaundice, anaemia, hepatosplenomegaly, HF, kernicterus
-> transfuse, UV phototherapy

44
Q

Bleeding in 1st Trimester

A

Causes - miscarriage, ectopic, implantation, ectropion

Positive test + any of; abdo pain, pelvic tenderness or cervical motion tenderness
-> immediate EPAU

Bleeding + no RF for ectopic;
>6wks -> EPAU (TV US)
<6wks -> observe 7-10d then repeat HCG, return if pos, miscarriage if neg

45
Q

Hyperemesis Gravidarum

A

RF - ^hCG (multiple, trophoblastic), 8-12wks, nulliparous, smoking reduces the risk

= triad of 5% pre-pregnancy weight loss, electrolyte imbalance and dehydration

Inv - Pregnancy-Unique Quantification of Emesis (PUQE) score of severity

-> anti-histamine 1st (cyclizine, chlorpromazine), metoclopramide (no more than 5d) or ondansetron (^cleft in T1) 2nd, 0.9% NaCl + K to rehydrate

46
Q

When to admit N+V

A

Cannot keep liquid down
Associated ketonuria or 5% weight loss despite antiemetics
Suspected co-morbidity

47
Q

When to do continuous CTG during labour

A

suspected chorioamnionitis or sepsis, or a temperature of 38°C or above
severe hypertension 160/110 mmHg or above
oxytocin use
the presence of significant meconium
fresh vaginal bleeding that develops in labour

ALS (22 decks)

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