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Obstetrics Flashcards

1
Q

What is a first degree perineal tear?

A

Tear limited to the superficial perineal skin or vaginal mucosa only

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2
Q

What is a second degree perineal tear?

A

Tear extends to perineal muscles and fascia, but anal sphincter is intact

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3
Q

What is a third degree perineal tear?

A

3a: less than 50% of the thickness of the external anal sphincter is torn
3b: more than 50% of the thickness of the external anal sphincter is torn, but the internal anal sphincter is intact
3c: external and internal anal sphincters are torn, but anal mucosa is intact

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4
Q

What is a fourth degree perineal tear?

A

Perineal skin, muscle, anal sphincter and anal mucosa are torn

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5
Q

What degree of perineal tear is an episiotomy?

A

Second degree tear

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6
Q

What is placenta praevia?

A

the placenta overlying the cervical os

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7
Q

Presentation of placenta praevia

A

bright red, painless, vaginal bleeding
>24 weeks

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8
Q

management of placenta praevia

A

Bleeding w/ unknown placental position:
- ABC approach, resuscitation and stabilisation
- if stable, urgent US
- if bleeding not controlled, immediate caesarean section
Known placenta praevia:
- monitor with US
- give advice about pelvic rest (no sex)
- corticosteroids if between 24-34 weeks and there is risk of preterm labour
In labour:
- caesarean section
At term:
- any degree of placental overlap at 35 weeks, elective caesarean at 37-38 weeks
- if placental edge is greater than 20mm from internal cervical os, women can be offered trial of labour

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9
Q

what is placenta abruption

A

premature separation of the placenta from the uterine wall during pregnancy

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10
Q

Presentation of placenta abruption

A

bleeding with pain
sudden & severe abdo pain
‘woody’ hard uterus
contractions
hypovolaemic shock which is often disproportionate to the amout of visible vaginal bleeding

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11
Q

Management of placenta abruption

A

resuscitation using ABCDE approach
emergency delivery (usually c-section)
Induction of labour: for haemorrhage at term w/o maternal or foetal compromise
Give anti-D within 72 hours of the onset of bleeding if the woman is rhesus D negative

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12
Q

What is polyhydramnios?

A

the presence of too much amniotic fluid in the uterus

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13
Q

Features of polyhydramnios

A

a uterus that feels tense or large for dates
may be difficult to feel foetal parts on palpation of the abdomen

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14
Q

Management of Amniotic Fluid Embolism

A

Oxygen and fluid resus (call anaesthetist)
Intensive care
Continuous foetal monitoring necessary
Correct any coagulopathy (fresh frozen plasma for prolonged PT, cryoprecipitate for low fibrinogen; platelet transfusion for low platelets)

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15
Q

What is an amniotic fluid embolism?

A

When amniotic fluid enters the maternal circulation

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16
Q

Features of amniotic fluid embolism

A

^ resp rate
tachycardia
hypotension
hypoxia
disseminated intravascular coagulopathy

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17
Q

First stage of labour - latent phase

A

Dilation of the cervix from 0cm to 3cm

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18
Q

First stage of labour - active phase

A

Cervical dilation from 3cm to 10cm

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19
Q

Management of breech presentation at 36 weeks

A

External cephalic version to be performed around 37-39 weeks, to manually turn foetus into a cephalic presentation

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20
Q

Management of shoulder dystocia

A
  1. McRobert’s manoeuver
  2. All fours position
  3. Internal rotational manoeuvers
  4. Cleidotomy or symphysiotomy (division of the foetal clavicle or maternal symphysial ligament)
  5. Zavanelli manoeuvre
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21
Q

McRobert’s Manoeuvre

A

Hyperflexion and abduction of mother’s legs tightly to abdomen
May be accompanied with applied suprapubic pressure

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22
Q

When is the first dose of anti-D prophylaxis administered to rhesus negative women?

A

At 28 weeks, one 1500IU dose of Anti-D immunoglobulin
–> further doses if sensitising events occur

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23
Q

Supplements and vitamins recommended in pregnancy

A

Folic Acid 400 micrograms per day.
–> to all women pre-pregnancy and up to 12 weeks gestation
–> higher dose of 5mg recommended to women at ^ risk of NTD

Vitamin D 10 micrograms (400 units) per day: throughout pregnancy and breastfeeding

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24
Q

Why is folic acid recommended in pregnancy?

A

shown to reduce the occurrence of neural tube defects (NTD)

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25
Why is vitamin D recommended in pregnancy?
Shown to be beneficial in foetal bone formation
26
What is the Kleihauer test?
Used to quantify the dose of Rh-D antigen in maternal circulation. Guides the quantity of anti-D immunoglobin needed to prevent maternal sensitisation
27
What are sensitisation events? Give examples
Events which carry risk of foetal blood crossing the placenta into the maternal circulation and triggering formation of anti-D antibodies. - antepartum haemorrhage - significant abdo trauma - ectopic pregnancy - miscarriage - termination - intrauterine death - external cephalic version - invasive uterine procedures e.g. CVS or amniocentesis - delivery of foetus (vaginal or caesarean)
28
Risk factors for Group B Streptococcus (GBS)
+ve GBS culture in current or previous pregnancy previous birth resulting in neonatal GBS infection preterm labour prolonged rupture of membranes intrapartum fever >38 chorioamnionitis
29
Management of GBS infection
Intrapartum Abx prophylaxis most effective at preventing GBS infection in the newborn
30
Clinical features of obstetric cholestasis
Pruritus: commonly worse in hands and feet. Not accompanied by rash, may have excoriation marks from itching. Fatigue Nausea Loss of appetite Abdo pain - RUQ Rarely: mild maternal jaundice (dark urine, pale stools)
31
Management of obstetric cholestasis
Chlorphenamine to reduce itch Vitamin K to reduce risk of haemorrhage Scheduling of early delivery to avoid risk of spontaneous intrauterine death
32
Risk factors for shoulder dystocia
Maternal gestational diabetes Macrosomia Birthweight >4kg Advanced maternal age Maternal short stature or small pelvis Maternal obesity Post-dates pregnancy
33
Uterine hyper-stimulation definition
Greater than 5 contractions occurring within 10 minutes and is due to administration of prostaglandins or oxytocin for IOL
34
Risk factors for ectopic pregnancy
PID Genital infection e.g. gonorrhoea Pelvic surgery Having an intrauterine device in situ Assisted reproduction e.g. IVF Previous ectopic Endometriosis
35
First line treatment for pre-eclampsia
Labetalol
36
What is a molar pregnancy?
Part of a spectrum of gestational trophoblastic disease. Occurs when there is an imbalance in the number of chromosomes from mother and father. Also known as hydatidiform mole
37
Features of a complete mole
- formed from 1 sperm and an empty egg w/ no genetic material - sperm replicates to give normal no. of chromosomes; so diploid and all chromosomes are of paternal origin - no foetal tissue present; just a proliferation of swollen chorionic villi
38
Features complete mole
- formed from 2 sperm and a normal egg - both paternal and maternal genetic material present - variable evidence of foetal parts
39
Clinical Features of Molar Pregnancy
- vaginal bleeding - nausea - hyperemesis gravidarum - thyrotoxicosis - uterus larger than expected for gestational age (due to excessive growth of trophoblasts and retained blood)
40
Ix for molar pregnancy
B-hCG levels often much higher than expected in normal pregnancy Trans-vaginal US may show 'snowstorm' appearance, low resistance of blood vessel flow, and absence of a foetus
41
Oligohydramnios definition
Presence of a lower than normal volume of amniotic fluid in the uterus
42
Causes of Oligohydramnios
- Uteroplacental insufficiency leading to intrauterine growth restriction e.g. maternal disease such hypertension or pre-eclampsia, maternal smoking and placental abruption. - Abnormalities with the foetal urinary system(amniotic fluid is derived mainly from foetal urine). E.g. renal agenesis, polycystic kidneys or urethral obstruction. - Premature rupture of membranes - Post-term gestation - Chromosomal anomalies - Maternal use of certain drugs (prostaglandin inhibitors, ACE-inhibitors)
43
Naegele's Rule
EDD (expected date of delivery) is calculated by adding 9 months to the LMP (last menstrual period) plus 7 days
44
Signs of placental separation
- gush of blood - lengthening of umbilical cord ascension of uterus in the abdomen
45
risk factors placental abruption
maternal trauma e.g. assault, RTA pre-eclampsia or hypertension mulitparity ^maternal age polyhydramnios previous hx of abruption substance abuse during pregnancy (particularly smoking and cocaine) coagulation disorders
46
Absolute contraindications for vaginal birth after caesarean section
Classical (vertical) caesarean scar Previous hx of uterine rupture Usual contraindications to a vaginal delivery
47
When is the combined test carried out?
between 11 and 13 weeks of pregnancy
48
What is measured in the combined test?
Nuchal translucency using US scan PAPP-A hormone (level reduced in Down's syndrome) Beta-hCG hormone (^in Down's syndrome)
49
If past point of combined test what can be offered to screen for Down's syndrome?
Triple test or quadruple test
50
What is the triple test?
Beta-hCG (^in DS) AFP (reduced in DS) uE3 (reduced in DS)
51
What is the quadruple test?
Inhibin-A levels (^ in DS) Beta-hCG (^ in DS) AFP (reduced in DS) uE3 (reduced in DS)
52
Causes of Polyhydramnios
Can be due to excessive production of amniotic fluid or insufficient removal of amniotic fluid. Excessive production can be due to ^ foetal urination: - maternal diabetes - foetal anaemia - foetal renal disorders - twin-to-twin transfusion syndrome Insufficient removal due to reduced foetal swallowing: - oesophageal or duodenal atresia - diaphragmatic hernia - anencephaly - chromosomal disorders
53
Maternal complications of polyhydramnios
- maternal respiratory compromise (^ pressure on diaphragm) - ^ risk of UTI - worsening of reflux, constipation, peripheral oedema, stretch marks - ^ incidence of C-section - ^ risk of amniotic fluid embolism
54
Foetal complications of polyhdramnios
- pre-term labour and delivery - premature rupture of membranes - placental abruption - malpresentation of the foetus - umbilical cord prolapse
55
Clinical features of congenital toxoplasmosis
Toxoplasmosis infection in pregnancy can lead to miscarriage, neonatal death, premature labour, low birth weight. Many infected infants are asymptomatic, however, may go on to develop symptoms later in life such as: - CNS problems such as cerebral palsy, epilepsy and hydrocephalus - learning disability - visual impairment - hearing loss
56
Management of toxoplasmosis infection in pregnancy
Abx spiramycin used to treat during pregnancy and is thought to reduce transmission to the baby
57
Features of Neonatal Herpes Simplex infection
Vesicular lesions on the skin, eye, or oral mucosa, w/o organ involvement. Disseminated feature include seizures, encephalitis, hepatitis or sepsis.
58
Management of Neonatal Herpes Simplex Virus infection
parenteral acyclovir intensive support therapy for severe cases
59
First line management of active management of third stage labour
IM oxytocin (10IU)
60
Clinical Features of Acute Fatty Liver of Pregnancy
Jaundice Abdominal pain Disseminated Intravascular Coagulation Nausea and/or vomiting Malaise Fatigue Oliguria Tachycardia Fever
61
Management of acute fatty liver of pregnancy
Delivery of foetus and intensive support care
62
Bishop Score
Cervical Score 0 1 2 3 Position Posterior Middle Anterior N/A Consistency Firm Medium Soft N/A Effacement 0-30% 40-50% 60-70% ≥80% Dilation Closed 1-2cm 3-4cm ≥5cm Foetal station -3 -2 -1, 0 +1, +2
63
Causes of Postpartum Haemorrhage
4 Ts: Tone, Trauma, Tissue, Thrombin Tone: uterine atony, the failure of the uterus to contract after delivery. Trauma: birth canal injury or tear, ^ risk in instrumented deliveries. Tissue: retained placental or foetal tissue can lead to continued bleeding. Thrombin: coagulopathies can lead to continued bleeding due to a failure of clotting.
64
Frank breech presentation
Legs extended up to head Buttocks are presenting part
65
Complete breech presentation
Hips and knees are flexed Buttocks are the presenting part
66
Incomplete breech presentation
One or both hips are extended Knee or foot is the presenting part
67
Footling breech presentation
One or both legs are fully extended Foot/feet is the presenting part
68
Gestational Hypertension Management
Labetalol Nifedipine (Asthma) Methyldopa
69
When is the anomaly scan usually performed?
18 - 20+6 weeks
70
Placenta accreta definition
Adherence of the placenta directly to superficial myometrium but does not penetrate the thickness of the muscle.
71
Placenta increta definition
the villi invade into but not through the myometrium
72
Placenta percreta definition
The villi invade through the full thickness of the myometrium to the serosa. Increased risk of uterine rupture and in severe cases the placenta may attach to other abdominal organs such as the bladder or rectum.
73
Risk factors for Gestational Diabetes
- FHx - Previous GDM - Large babies >4.5kg - Previous stillbirth or perinatal death - Maternal obesity (>30)
74
When is early scan to confirm dates?
11+2 - 14+1 weeks
75
What are tocolytics?
Drugs used to suppress contractions and therefore labour
76
First line tocolytics agent
Nifedipine
77
When can a tocolytic be used?
<34 weeks
78
Management if mother is +ve for HbsAg and HbeAg (Hep B)
HBV IgG and HBV vaccination within 24 hours of delivery
79
Birth timing w/ gestational diabetes
Women with gestational diabetes should give birth no later than 40+6 weeks of gestation
80
Sequence of layers to dissect during C-section
Skin - subcutaneous fat - rectus sheath - rectus abdominus muscle - peritoneum - uterine myometrium - amniotic sac
81
Which hormone is responsible for the promotion of smooth muscle relaxation, which contributes to reduced oesophageal tone and reflux oesophagitis?
Progesterone - ^ in pregnancy - promotes smooth muscle relaxation in GI, GU systems and uterus
82
What bishop score suggests labour is unlikely to occur without induction?
5 or less
83
What is the first-line management for induction of labour?
Prostaglandin pessary
84
Polymorphic eruption of pregnancy
- itchy red patches - first appears over abdo - thrid trimester - also known as pruritic urticarial papules and plaques of pregnancy (PUPPP)
85
Normal CTG in first stage of labour
Baseline rate: 125bpm. Variability: 15bpm. Accelerations: present. Decelerations: absent

Medicine (13 decks)

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