Obstetrics Flashcards
What are the signs of threatened miscarriage?
- Vaginal bleeding
- Abdo/pelvic pain
in early pregnancy = threatened miscarriage. There is a closed internal cervical os. Bleeding and pain are reasonably mild.
What is an inevitable miscarriage?
Heavy vaginal bleeding w dilation of the cervical canal, bleeding is usually more severe than w threatened miscarriage. There is often pain. Foetus is still currently intrauterine.
What is an incomplete miscarriage?
Intense vaginal bleeding and abdo pain. Cervical os may be open w products of conception being passed, need an USS to see if products of conception are still in the uterus.
What is a complete misscarriage?
Hx of bleeding abdo pain and tissue passage. USS = vacant uterus. Can see an aborted fetus w complete placenta.
What is the definition of a miscarriage?
Pregnancy lost before 24 weeks.
What are the causes of miscarriage?
Foetal pathology - genetic disorder, abnormal development, placental failure
Maternal pathology - uterine abnormality, cervical incompetence, PCOS, poorly controlled diabetes or thyroid disease, anti-phospholipid syndrome, previous uterine surgery, smoking
What are the differentials for vaginal bleeding before 24 weeks?
Ectopic pregnancy - pain is the first and dominant symptom, normally minor vaginal bleeding
Cervical/uterine malignancy
Hydatidform mole
Miscarriage
What are the ix into potential miscarriage?
- Transvaginal USS - any foetal components in the uterine cavity and if foetal heartbeat
- Mean sac diameter = >25mm can make diagnosis of failed pregnancy, <25mm need to repeat scan in 2 weeks
- Serial serum hCG measurements 48 hours apart can indicate the location and prognosis of a pregnancy
What do different serial serum hCGs indicate?
- Levels fall = foetus will not develop and there has been miscarriage
- Slight increase/plateau in hCG levels = maybe ectopic pregnancy
- Normal increase in hCG = foetus growing normally but doesn’t exclude ectopic pregnancy
What is the management of a miscarriage?
- Often can’t stop or prevent it - need to remove all of foetal material
- Expectant management = allow products of conception to naturally expels, high risk of infection, haemorrhage and pain
- Medical management = misoprostol
- Surgical management = ERPC (evacuation of retained products of conception) dilatation and curettage, manual vacuum aspiration if <12 weeks
- If the woman is rhesus neg they need anti-D prophylaxis
What is misoprostol?
Synthetic prostaglandin E1 analogue that is used unliscenced to for medical abortion and management of miscarriage, induce labor, cervical ripening and treat post partum haemorrhage.
How do you define recurrent miscarriage?
Loss of 3 or more consecutive pregnancies
What are the ix into recurrent miscarriage?
- Bloods - antiphospholipid ab, thrombophilia screen
- Cytogenetic analysis of products of conception - if abnormal parents need to be karyotyped
- Pelvic US
What are the causes of recurrent miscarriage? How do you manage each cause?
- Genetic disorder - genetic counselling, use donor egg/sperm
- Uterine structural abnormality - can treat surgically but some malformations won’t be treated
- Cervical incompetence - US monitoring of cervix, cervical cerclage = stitch cervix closed
- PCOS - no consensus on management
- Antiphospholipid syndrome - heparin or low dose aspirin
- Thrombophilia - heparin
- Diabetes - improve glycemic control
What is molar pregnancy?
Hydatidiform mole - part of gestational trophoblastic disease. Imbalance in number of chromosomes from mother and father. Likely under 16 and over 45 years old.
What is a complete mole?
1 sperm and an empty egg w no genetic material - sperm replicates to give normal no of chromosomes and is diploid, all chromosomes are of paternal origin. There is no foetal tissue just proliferation of swollen chorionic villi.
What is a partial mole?
2 sperm and a normal egg - both paternal and maternal genetic material is present. Variable evidence of foetal parts.
What are the CFs of molar pregnancies?
- Vaginal bleeding
- Nausea
- Hyperemesis gravidarum
- Thyrotoxicosis - hCG related to TSH and can activate its receptors
- Uterus larger than expected for gestational age - due to excessive growth of trophoblasts and retained blood
What are the ix of molar pregnancy?
- B-hCG levels higher than would be expected in normal pregnancy
- Trans vaginal US - complete molar pregnancy = snowstorm appearance, low resistance of blood vessel flow and absence of a foetus
What is the management of molar pregnancy?
- Need to reduce likelihood of complications eg. choriocarcinoma or invasion from developing
- Suction curettage to remove from uterus = molar pregnancy won’t survive
- Hysterectomy if fertility doesn’t need to be preserved
- Two weekly serum and urine hCG until levels normal
- Partial mole = hCG 4 weeks later, if normal = discharged
- Complete mole = monthly repeat hCG for 6 months
What are some differentials for bleeding in early pregnancy?
- Miscarriage
- Hydatidiform mole
- Ectopic pregnancy
What is a missed miscarriage?
- Asymptomatic or hx of threatened miscarriage
- On going discharge
- Small uterus for length of pregnancy
- No fetal heart beat where CRL >7mm
What is a septic miscarriage? How is it managed?
- Infected POC
- Fever, rigors, uterine tenderness
- Bleeding/discharge, pain
- Medical or surgical management of miscarraige
- IV abx and fluids
What is an ectopic pregnancy?
Any pregnancy implanted outside the uterine cavity.
Most commonly the ampulla and isthmus of the fallopian tube, less commonly the ovaries, cervix or peritoneal cavity.
What are the RF of ectopic pregnancy?
- PMH - previous ectopics, PID + endometriosis = adhesion formation
- Contraception - IUD or IUS can cause fallopian tube ciliary dysmotility
- Pelvic surgery and embryo transfer
What are the CFs of ectopic pregnancy?
- PAIN - lower abdo/pelvic pain +/- vaginal bleeding
- Shoulder tip pain = diaphragm irritated by blood in peritoneal cavity, supraclavicular nerves and diaphragm share C3-C5 dermatomes
- Vaginal discharge - brown, prune juice
- Cervical excitation or adnexal tenderness
- If ruptured = haemodynamically unstable
What are the ix into ectopic pregnancy?
- Pregnancy test
- If positive need pelvic USS, if can’t find = pregnancy of unknown location
- B-hCG >1500 and no intrauterine pregnancy on USS = ectopic pregnancy until proven otherwise
- B-hCG <1500 and pt stable, repeat in 48 hours would double if viable and half if miscarriage
What is the initial management of an ectopic pregnancy?
AtoE to resus patient - blood products if signs of haemodynamic instability
What is the medical management of an ectopic pregnancy?
- IM methotrexate - anti folate cytotoxic and disrupts cell division of fetus = gradually resolves
- Serum B-hCG level monitored to ensure is decreasing, if not need a repeat dose
- Given if pt stable and have well controlled pain and B-hCG levels <1500, needs to be unruptured and no heartbeat
- If treatment fails need surgery, need to use contraception for 3-6 months after
What is the surgical management of ectopic pregnancy?
- Laparoscopic salpingectomy - remove ectopic and the tube it is implanted in
- Salpingotomy - cut open fallopian tube to remove ectopic and preserve future fertility, risk of treatment failure
- High success rate
- Surgical risks
- If rhesus negative need anti d prophylaxis
What is the conservative management of ectopic pregnancy?
- Watchful waiting of stable patient and allowing the ectopic to resolve naturally
- Not suitable for most ectopic pregnancies - need intervention in 25%
- Need to monitor serum B-hCG every 48 hours to see if its falling
What are the complications of ectopic pregnancy?
Fallopian tube rupture - hypovolaemic shock from blood loss = organ failure and death
What is anti D prophylaxis?
Rhesus neg women and rhesus pos baby during delivery, bleeding, C section and miscarriage blood mixes and mum makes anti D ab
Next time mum is pregnant w rhesus pos baby the ab cross the placenta and attack its red cells resulting in severe anaemia
During a sensitisation event need to give anti D prophylaxis so mum doesn’t make anti D ab so when she is pregnant next the prophylaxis has gone and mum doesn’t attack her baby’s RBC
What is hyperemesis gravidarum?
Persistent and severe vomiting during pregnancy = weight loss, dehydration and electrolyte imbalance. Onset before 20 weeks of gestation. Severe enough to require hospital admission.
What are the RFs of hyperemesis gravidarum?
- First pregnancy
- Previous hx
- Raised BMI
- Multiple pregnancy
- Hydatidiform mole
What are the differentials for hyperemesis gravidarum?
Is a diagnosis of exclusion:
- Gastroenteritis
- Cholecystitis
- Hepatitis
- Pancreatitis
- H.pylori infection and peptic ulcers
- UTI or pyelonephritis
- Metabolic and neurological conditions
- Drug induced
What are the ix into hyperemesis gravidarum?
- Bedside - weight, urine dipstick (ketonuria?), BM
- MSU, FBC, U+E, amylase, LFTs, TFTs, ABG
- USS - confirm gestation, exclude multiple pregnancy and trophoblastic disease
What is the management of hyperemesis gravidarum?
- Mild - in community w oral antiemetics, oral hydration, dietary advice and reassurance
- Moderate - IV fluids, parentral antiemetics and thiamine (prevent Wernicke’s encephalopathy) - manage until ketonuria resolves
- Severe - inpatient mangement
IV rehydration = 0.9% saline + potassium chloride
Antacids to relieve epigastric pain
TED stockings and LMWH as increased risk VTE
What are the recommended anti emetic therapies in hyperemesis gravidarum?
1st line - cyclizine, prochlorperazine, promethazine, chlorpromazine
2nd line - metoclopramide (max 5 days), domperidone, ondansetron
3rd line - hydrocortisone IV - then to oral - then to taper
What are the complications of hyperemesis gravidarum?
- GI probs - malnutrition, anorexia, Mallory Weiss tears
- Dehydration
- Hyponatraemia, Wernicke’s encephalopathy, kidney failure, hypoglycaemia
- Depression, PTSD, resentment to pregnancy
- Foetal complications - low birth weight, growth restriction, premature labour
What is a pregnancy of unknown origin?
Woman has a positive pregnancy test but there are no signs of an intrauterine or extrauterine pregnancy on transvaginal US.
What are the causes of pregnancy on unknown origin?
- Early viable or failing intrauterine pregnancy
- Complete miscarriage
- Ectopic pregnancy
What is gestational trophoblastic disease?
Group of pregnancy related tumours:
- Pre malignant conditions - partial or complete molar pregnancy
- Malignant conditions - invasive mole, choriocarcinoma, placental trophoblastic site tumour, epithelioid trophoblastic tumour
What is a choriocarcinoma?
- Malignancy of trophoblastic cells of the placenta
- Commonly co exists w molar pregnancy
- Characteristically metastasises to the lung
What are the trophoblastic tumours?
- Placental site trophoblastic tumour - malignancy of trophoblasts which normally anchor the placenta to the uterus, most commonly after a normal pregnancy
- Epithelioid trophoblastic tumour - malignancy of the placental cells, mimics SCC
What are the RF for GTD?
- Maternal age - less than 20 or more than 35
- Previous GTD
- Previous miscarriage
- Use of the oral contraceptive pill
What are the CFs of GTD?
- Molar pregnancy - vaginal bleeding, large boggy uterus
- Hyperemesis - ?increased B-hCG
- Hyperthyroidism - gestational thyrotoxicosis due to hCG stim thyroid
- Anaemia
- Large for dates uterus later in pregnancy
What are the ix into GTD?
- Urine B-hCG - measured in cases of persistent post partum bleeding
- Blood B-hCG - markedly elevated at diagnosis, used to monitor disease
- USS - complete mole = snowstorm appearance
- Histological exam of POC - post treatment for molar pregnancies and all non viable pregnancies
- If suspect mets = MRI, CT chest abdo pelvis, pelvic US
What is the management of non molar pregnancy types of GTD?
Single/multi agent chemo +/- surgery is mainstay but v v specialist don’t need to know : )
What are the principles of safe drug prescription during pregnancy?
- Only prescribe drugs in pregnancy if the benefit to the mother > risk to the fetus
- Avoid all drugs if possible in the first trimester - greatest risk of teratogenesis if from 3rd to 11th week
- Preferentially prescribe drugs extensively used in pregnancy and at lowest effective dose
What is the legal framework of abortion?
1967 Abortion act and 1990 Human fertilisation and embryology act. Latest gestational age for abortion is 24 weeks.
What are the criteria for an abortion before 24 weeks?
If continuing the pregnancy involves great risk to the physical or mental health of the women or existing children of the family. Is a matter of clinical judgement and opinion of medical practitioners.
What are the criteria for abortion at any time?
- Continuing the pregnancy is likely to risk the life of the woman
- Terminating the pregnancy will prevent grave permanent injury to the physical or mental health of the women
- There is substantial risk that the child would suffer physical or mental abnormalities making it seriously disabled
What are the legal requirements for an abortion?
- Two registered medical practitioners must sign to agree abortion is indicated
- Must be carried out by registered med practitioner in an NHS hospital or approved premise
What is involved in pre abortion care?
- Access - GP, self referral, GUM or family planning clinic
- Offer counselling and information to help decision making from trained practitioner - need informed consent
What is involved in a medical abortion?
- Mifepristone - blocks action of progesterone = pregnancy stops and cervix relaxed
- Misoprostol - activates prostaglandin receptors, cervix softened and uterine contractions stim, from 10 weeks gestation additional misoprostol doses every 3 hours are needed ntil expulsion
- Rhesus negative women w gestational age >10 weeks need anti D prophylaxis
What is involved in a surgical abortion?
- Local +/- sedation or general
- Need cervical priming before surgery = soften and dilate cervix
- Up to 14 weeks - cervical dilation and suction of POC out the uterus
- 14-24 weeks - cervical dilation and evacuation w forceps
- All rhesus neg women need anti D prophylaxis
What are the complications of abortion?
- Bleeding
- Pain
- Infection
- Failure of abortion - pregnancy cont
- Damage to cervix, uterus
What do you need to tell a women post abortion?
- Vaginal bleeding and abdo cramps intermittently for up to 2 weeks after procedure
- Urine pregnancy test 2 weeks after abortion to confirm completion
- Contraception discussed and started
- Support and counselling
What are some teratogenic drugs?
- ACEi
- Sodium valproate
- Methotrexate
- Retinoids
- Trimethoprim
What are some medications frequently used in pregnancy?
- Folic acid 400 micrograms, daily when trying and for first trimester to reduce risk of neural tube defect
- Oral iron
- Antiemetics
- Antacids
- Aspirin
What are the CFs of pre eclampsia?
- Hypertension >140/90mmHg
- Proteinuria >+1
- Oedema
- Occurs after 20 weeks gestation
also … peripheral oedema, severe headache, drowsiness, visual disturb, epigastric pain, N+V, hyperreflexia, reduced urine output, papilloedema
What are the RF for pre eclampsia?
- First pregnancy M
- Previous hx or FH H
- Increasing maternal age M
- Existing disease - HTN, DM, renal/autoimmune disease eg. CKD or SLE H
- Obesity M
- Multiple pregnancy M
- 10 years or more since last pregnancy M
What are the maternal and foetal complications of pre eclampsia?
Maternal - eclampsia, organ failure, DIC, HELLP syndrome
Foetal - intrauterine growth restriction, pre term delivery, placental abruption, neonatal hypoxia
What is the management of pre eclampsia?
Aspirin is prophylaxis against pre eclampsia, given for 12 weeks until birth in women w 1 high RFs or 2 mod RFs.
Labetalol = 1st line antihypertensive
Delivery of placenta is only curative treatment, IM steroids <35 weeks to help fetal lung development
IV magnesium sulphate to prevent and treat eclamptic seizures - given during labour and 24 hours after.
IV hydralazine used in severe pre eclampsia and eclapmsia.
What is HELLP syndrome?
Haemolysis
Elevated liver enzymes
Low platelets
Normally during third trimester and is a type of hypertensive disorder of pregnancy, a complication of pre eclampsia.
What are the CFs of HELLP syndrome?
- Headache
- N+V
- Epigastric pain
- RUQ pain due to liver distention
- Blurred vision
- Peripheral oedema
What is the management of HELLP syndrome?
Definitive treatment = delivery of baby. Some mothers require transfusions or steroids during pregnancy.
Eclampsia vs pre eclampsia
Pre eclampsia - new hypertension in pregancy w end organ dysfunction and proteinuria.
Eclampsia - seizures associated w pre eclampsia
What is the pathophysiology of pre eclampsia?
Spiral arteries of the placental form abnormally = high vascular resistance.
What is needed for a diagnosis of pre eclampsia?
Systolic BP >140 mmHg and diastolic >90 mmHg
plus:
- Proteinuria (+1 on dipstick)
- Organ dysfunction (raised creatinine, elevated LFTs, seizures, thrombocytopenia, haemolytic anaemia)
- Placental dysfunction
What is the management of pre eclampsia after delivery?
- Enalapril = 1st line
- Nifedipine/amlodipine 2nd line (1st line in black or Caribbean patient)
- Labetolol or atenolol = 3rd line
May be needed for up to 3 months post partum
How do you screen for pre eclampsia?
Routine BP measurements, ask about symptoms, urine dipstick for proteinuria
How do you manage gestational hypertension?
No proteinuria.
- Aim BP below 135/185 mmHg
- Admit when >160/110 mmHg
- Urine dipstick testing weekly
- Monitor bloods weekly - FBC, LFTs, renal profile
- Monitoring fetal growth
What are the ix into pre eclampsia?
- Urinalysis - microscopy, culture, sensitivities if proteinuria present
- Bloods - FBC, LFT, renal function, electrolytes, serum urate = helps to guide decision as to when to deliver eg. HELLP syndrome
- Clotting studies if severe pre eclampsia or thrombocytopenia
- 24 hour urine collection
- US to assess fetus
- MRI or CT to exclude haemorrhage if focal neuro deficits or coma
What is placenta praevia?
Placenta overlying the cervical os
What are the CFs of placenta praevia?
- Bright red vaginal bleeding, painless - antepartum haemorrhage (vaginal bleeding >24 weeks)
- Bleeding usually later in pregnancy, after 28th week
- May be asymptomatic - found on routine US
What are the ix into placenta praevia?
- Transvaginal US - check position of placenta when first bleed and then again at 37 weeks to reassess
- FBC, clotting profile, Kleihauer test, G+S, cross match, U+E, LFT
What is the management of placenta praevia?
- Bleeding w unknown placental position - AtoE, resus, stabilise and US, if bleeding not controlled = need C section
- Bleeding w known placenta praevia - AtoE, resus, stabilise, if not stable = C section
- In labour - C section
- No bleeding and not in labour - monitor w US, pelvic rest and hospital if significant bleeding
- Term - placental overlap at 35 weeks = elective C section at 37-38 weeks gestation
- Give steroids 34-36 weeks or 24-34 weeks if risk of pre term labour
What are the RFs of placenta praevia?
- Previous C section or placenta praevia
- Older maternal age
- Maternal smoking and cocaine use during pregnancy
- Structural uterine abnormalities eg. fibroids
- Assisted reproduction
What are the grades of placenta praevia?
Minor praevia/grade 1- lower in uterus but doesn’t reach int cervical os
Marginal praevia/grade 2 - reaching but not covering int cervical os
Partial praevia/grade 3 - placenta partially covering int cervical os
Complete praevia/grade 4 - placenta completely covers int cervical os
What do you look for o/e of antepartum bleeding?
- Pallor, distress, CRT
- Abdo tender
- Tense uterus - placental abruption
- Palpable contractions
- Check the lie and presentation of fetus and its HB
- Cusco speculum exam
What is placental abruption? What are the two types?
Premature separation of the placenta from the uterine wall during pregnancy = maternal haemorrhage.
Revealed - bleeding tracks down and drains through cervix = vaginal bleeding
Concealed - bleeding remains in uterus, clot retroplacentally, not visible bleeding but can cause systemic shock
What are the CFs of placental abruption?
- Abdo pain - sudden and severe
- Woody hard uterus
- Contractions
- Vaginal bleeding, can be confined to uterus = concealed, antepartum haemorrhage
- Reduced fetal movements and abnormal CTG
- Hypovolaemic shock, disproportionate for vaginal bleeding visible
What are the RFs of placental abruption?
- Maternal trauma - assault, RTA
- Pre eclampsia or HTN
- Multiparity or increased maternal age
- Polyhydramnios - too much amniotic fluid
- Previous history of abruption
- Substance use during pregnancy - smoke and cocaine
- Existing coag disorders
What is the management of placental abruption?
- AtoE resus, don’t delay maternal resus in order to determine fetal viability
- Emergency delivery by C section
- Induction of labour for haemorrhage at term w/o maternal or fetal compromise
- Conservative if partial w no compromise
- anti D prophylaxis if rhesus negative
What are the ix into placental abruption?
- FBC, clotting, Kleihauer test, G+S, crossmatch
- U+E, LFTs
- Cardiotocograph
- US but if negative can’t rule out abruption
What is obstetric cholestasis?
Liver disease unique to pregnancy characterised by pruritis and elevated bile acids.
What are the pregnancy associated liver diseases?
- Intrahepatic cholestasis of pregnancy
- HELLP syndrome
- Acute fatty liver of pregnancy
- Liver dysfunction in pre eclampsia and hyperemesis gravidarum
What are the RFs of obstetric cholestasis?
- Past history of obstetric cholestasis
- FH
- Multiple pregnancy
- Presence of gallstones
- Hep C
- Asian
- Pruritis on COCP
What are the signs and symptoms of obstetric cholestasis?
Symptoms - usually late second or third trimester:
- Pruritis, mainly on soles and palms, worse at night - insomnia
- RUQ pain
- Nausea and anorexia
- Steatorrhoea
Signs - excoriations, jaundice
How is obstetric cholestasis diagnosed? Ix
- Serum bile acids >40 micromol/L for severe cholestasis (more likely to have fetal complications), cut off is 10 micromol/L
- May be deranged LFTs but usually minimally elevated
- Liver US to exclude alt diagnosis - no structural defects associated w ICP
What are the fetal complications of ICP?
- Stillbirth
- Spont or iatrogenic pre term labour
- Meconium stained amniotic fluid - meconium aspiration
- Neonatal resp distress syndrome - need NICU
What is the management of ICP?
Ursodeoxycholic acid - UDCA but doesn’t seem to improve fetal outcomes. Reduces mum symptoms.
Chlorpenamine for itch.
Vit K reduce likelihood of haemorrhage.
Weekly blood tests to determine bile acid levels.
Perinatal and maternal morbidity increase from 37 weeks of gestation onwards so induction of labour is recommended from this point.
LFT 10 days postnatally.
What is gestational diabetes? How is it caused?
Any degree of glucose intolerance with its onset during pregnancy, usually resolves shortly after delivery.
In pregnancy there is progressive insulin resistance, for woman w borderline pancreatic reserve there isn’t enough insulin = hyperglycaemia.
What are the RFs for poor pancreatic reserve/GDM?
- BMI >30
- Asian
- Previous GDM
- 1st degree relative w diabetes
- PCOS
- Previous macrosomic baby = >4.5 kg
- Smoking
- Previous stillbirth
What are the fetal complications of gestational diabetes?
- Macrosomia
- Orgnomegaly, esp cardiomegaly
- Erythropoiesis = polycythaemia
- Polyhydramnios
- Increased rates of pre term delivery - can lead to resp distress syndrome
- Hypoglycaemia in new born = seizure?
Who is screened for GDM and what is involved?
Everyone with a RF should be screened at 24-28 weeks. If have glycosuria +2 once or +1 twice need screening.
- Oral glucose tolerance test
- If had GDM before - early self monitoring of BM
What are the perimeters for GDM diagnosis?
Fasting glucose >5.6 mmol/L
2 hours post prandial glucose >7.8 mmol/L
What is the management of gestational diabetes?
Good glycaemic control for the whole pregnancy!
- Lifestyle advice
- Metformin if target BM not met in 1-2 weeks by lifestyle mods
- Glibenclamide if metformin not tolerated
- Insulin if fasting glucose >7mmol/L
- Aim to deliver at 37-38 weeks
What is the post natal care of a woman with gestational diabetes?
All meds stopped immediately after delivery. DM measured before discharge to ensure returned to normal levels.
Fasting glucose test around 6-12 weeks post partum, if normal will need yearly tests to monitor for diabetes as increased risk of developing in the future.
What are the TFT changes in pregnancy?
- Total T4 and T3 increase
- Free T4 and T3 remain within normal range
- TSH doesn’t change
How does overt hypothyroidism present in pregnancy?
- Dry skin w yellowing, esp around eyes
- Weakness, tiredness, hoarseness, hair loss, intolerance to cold, constipation, sleep disturb
- Goitre
- Anaemia, low T4 raised TSH
- More common than hyperthyroidism in pregnancy
How is hypothyroidism treated in pregnancy?
Needs larger doses of thyroxine than when not pregnant and then return to pre pregnancy dose post delivery.
What are the complications of hypothyroidism in pregnancy?
- Congestive heart failure
- Megacolon, adrenal crisis, organis psychosis, myxoedema coma, hyponatraemia
What is postpartum thyroiditis?
Silent thyroiditis 3-6 months post partum, usually painless w +ve test for thyroid peroxidase ab and normal ESR.
Doesn’t need treating.
What is an APGAR score?
Assessment of clinical status of infants immediately following birth.
1 and 5 mins after cleaning and drying baby in warm towel. Is not the only measure of clinical status.
Detail the APGAR score
Activity - muscle tone
Pulse - HR
Grimace - reflex irritability
Appearance - colour
Resp effort
What is breech presentation?
Fetus is buttocks or feet first. If >37 weeks is risky - increased risk perinatal mortality and morbidity.
Normal - cephalic = head first
What is the management of breech position?
- External cephalic version
- C section if above didn’t work
- Vaginal breech birth - some women may choose - hand off the breech, may need to use manoeuvres to deliver the baby
What are the different step of the mechanisms of labour?
- Engagement
- Descent
- Flexion
- Int rotation
- Crowning
- Extension
- Ex rotation and restitution
- Delivery of shoulder and body
What is engagement?
When the largest diameter of babys head fits into the largest diameter of maternal pelvis.
The fetal head engages = moves into the pelvic brim, either L or R occipito transverse position.
Widest part of baby head through widest part of pelvis.
What is descent?
Baby through pelvis inlet to pelvic floor. Due to:
- Uterine contractions
- Pressure of amniotic fluid
- Voluntary abdo muscle contractions
What is flexion?
When the cervical head makes contact w the pelvic floor it flexes, this reduced fetal skull diameter to assist passage through the pelvis.
What is int rotation?
Head rotates, either to the L or R, to lie in the occipito ant position.
What is crowning?
Clinically = head no longer retracts between contractions and is visible in the vulva.
The widest diameter of babys head is though the narrowest part of pelvis.
What is extension?
Occiput underneath the suprapubic arch = head extends and stretches the perineum.
What is ex rotation and restitution?
Head ex rotates to face the R or L thigh of the mother.
Restitution - shoulders rotate from transverse to ant post position.
What is delivery of shoulder and body?
Midwife places downward traction on the head to deliver ant shoulder and then upward traction on head to deliver post shoulder.
What happens before labour?
Plug of mucus/blood = bloody show or amniotic sac ruptures = triggers labour and true contractions which progress in freq and intensity. These cause the cervix to dilate and efface.
What are the stages of labour?
1st stage - early and active phases, contractions
2nd stage - pushing phase, ends when baby delivered (mechanisms of labour, already made flashcards on)
3rd stage - delivery of the placenta
4th stage - adaptation to blood loss and uterine involution
Describe the 1st stage of labour
Early phase:
- Irreg contractions, every 5-30 mins, cervix dilates 0->3cm
- Reg contractions, every 3-5 mins, cervix dilates 3->6cm
Active phase - cervix 6->10cm, is fully effaced. Contractions every 30secs-2mins, last 60-90secs and can overlap. Amniotic sac often ruptures now if hasn’t yet.
How is a women cared for in her first stage of labour?
Partogram - record obs and events during labour. Monitor HR hourly, obs 4 hourly, urinary frequency and freq of contractions every half hour.
Vaginal exam hourly.
How is a women cared for in her second stage of labour?
Partogram, monitor BP hourly, temperature 4 hourly, urinary freq and freq of contractions every half hour.
Intermittent auscultation of foetal HR after a contraction for 1 min and every 5 mins. Palpate mum pulse every 15 mins.
Vagina exam 4 hourly.
Check pain and wellbeing reg, offer analgesia as needed.