Obstetrics Flashcards
Normal Pregnancy
- Trimester 1,2 + 3 weeks
-
Trimesters
1st = 0-13 weeks
2nd = 14-26 weeks
3rd = 27-40 weeks
(37-39/52 = early term. 39 weeks = full term)
Appointments
8-12 weeks = Booking
- General info given: diet, alcohol, smoking, folic acid, vit D, antenatal classes
- Following taken:
- BP, urine dip, BMI - baseline
- Urine culture - ?asymp bacteruria (tx in preg)
- Infection screen: hepatitis B, syphilis, HIV
- FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies (all thalssaemia, only high risk sickle cell)
10 - 13+6
- Early scan (confirm dates, viability, exlcude multiple pregnancy, major abnormalities eg. anencephaly)
- From 11/52 can also do Down’s syndrome screening (combined test) (if this is missed can do quad test from 14+2 - 20+0)
16 weeks
- Info on anomaly scan + blood results (Hb <11 - give iron)
- BP + urine dip
18 - 20+6
- Foetal anomaly scan (11 conditions: anencephaly, open spina bif, cleft lip, diaphragmatic hernia, exomphalosus, cardiac, B/L renal agenesis, lethal skeletal dysplasia, Edwards/Pataus)
25 weeks (primips only)
- BP, urine dip, symphysis-fundal height
28 weeks
- BP, urine dip, SFH
- 2nd screen: anaemia, atypical red cell alloantibodies
- If Hb <10.5 - iron
- 1st dose anti-D prophylaxis to rhesus -ve women
31 weeks (primip only)
BP, urine dip, SFH
34 weeks
BP, urine dip, SFH
2nd dose anti-D prophylaxis (some places only give one dose - similar efficacy)
Labour info + birth plan
36 weeks
- BP, urine dip, SFH
- Check presentation - offer external cephalic version if needed
- Info on Breast feeding, vit K, baby blues
38 weeks
- BP, urine dip, SFH
40 weeks (only primips)
- BP, urine dip, SFH
- Discussion re prolonged pregnancy
41 weeks
- BP, urine dip, SFH
- Discuss labour plans + possibiilty of induction
What is involved in screening for foetal anaomalies in pregnancy?
Combined Test (11-14)
- age, B-HCG, Papp-A, gestational age (from CRL), nuchal translucency
- Gives risk of: Downs, Edwards, Patau
Quad Test (14+2 -20) (if combined test missed, less sensitive)
- age, AFT, HCG, uE3, inhibin A
Foetal Anomaly Scan (18-20+6)
- looks for 11 conditions (on prev card)
Abnormal results
If high risk for chromosomal abnormality can:
- NIPT (private) (if abnormal -> invasive)
Or Invasive testing (do if high risk screening, prev child w/ abnormality, known carrier/fam hx, USS evidence)
- Chorionic Villous Sampling (11 - 13+6) - 97% accurate (but can get mosaicism). SE: miscarriage (1%), PV bleed, pain, infection, resus sensitisation
- Amniocentesis (>15 weeks) - SE: miscarriage (0.5%), pain, infection, rhesus sensitisation
N.B. for amnio + CVS give RhD if rhesus -ve mother.
What are the physiological changes that occur in pregnancy?
Immunological
- immunosupression. At risk of infection, esp viral.
Vaginal pH increase
- Increased candida infection
Increased weight
Increased progesterone –> ligmanentous laxity, reduced gastric motility (constipation), GORD, gallstones
Hypercoaguable State
Anaemia, increased cardiac output, initial drop in BP (returns to normal in 3rd trimester)
Increased renal blood flow + eGFR
Appendix displaced (can present w/ RUQ pain)
Insulin resistance + compensatory increase in insulin secretion (allows glucose to be used by foetus, mum switches to lipolysis)
Reduced serum proteins (goes to foetus), raised cholesterol (but protected by increase in antioxidants)
Increased melanin -> melasma, striae, linea alba -> linea nigra
Raised prolactin (can get colustrum expressed from 3-4/12 but full lactation inhibited by high oestrogen/progesterone)
Breast development
Increase thyroid size + hormone production (free levels remain constant but more available to go to foetus for neural development)
Which supplements are commonly given in pregnancy?
When is aspirin given prophylactically during pregnancy?
**Folic Acid **
Taken to prevent neural tube defects
- All women - 400mcg OD until 12/52
- High risk - 5mg OD pre-conception till 12/52
- Risk: either partner w/ NTD, prev preg w/ NTD, fam Hx of NTD, woman taking anti-epileptic (esp phenytoin), coealic, DM, thalassaemia, obese (BMI >30)
Vitamin D - all women should take daily supplment
NB. Vitamin A is NOT advised (can be teratogenic at high levels)
Aspirin
- Low dose given to those w/ high-risk for pre-eclampsia, from 12/52 till delivery
- Hx of pre-eclampsia, multiple pregnancy, renal disease, autoimmune disease, DM, chronic HTN
Give maternal, foetal, neonatal complications of the following conditions. How are they managed during pregnancy?
- Diabetes
- Obesity
Obesity (BMI >30)
- Maternal risks: miscarriage, VTE, gestational DM, pre-eclampsia, PPH, wound infection
- Foetal risk: prematurity, congenital anomaly, macrosomia, stillbirth, metabolic syndrome, neontal death
Management in pregnancy
- 5mg folic acid
- Screen for gestational DM at 24-28/52 (OGTT)
- Explain do NOT try to lose weight/diet
- BMI >35 - give birth in consultant lead obstetric unit; BMI >40 - antenatal consultant w/ obstetric anaesthetist
Diabetes
- maternal: polyhydramnios, preterm labour, increased insulin requirement during preg, increased risk pre-eclampsia
- Neonatal macrosomia (or IUGR), hypoglycaemia, resp distress (delayed surfactant production), polycythaemia + jaundice, increased CNS/CVS malformation, stillbirth, shoulder dystocia, low ca/mg
Management during pregnancy
- Continue Metformin + insulin
- Stop: PO hypoglycaemics, ACEi (switch to insulin, labetalol)
- Low dose aspirin from 12/52
- Regular monitoring of foetal growth, maternal regular ophthlamic assessment
- Sliding scale during labour + monitor for neonatal hypoglycaemia
- Mum can return to normal DM management once eating/drinking
Which conditions are tested for on heelprick testing?
Done at 5 days old, looks for 9 conditions
- Sickle cell disease
- Cystic fribosis
- Congenital hypothyroidism
- 6 Inherited metabolic diseases:
- 1. Phenylketonuria (PKU)
- 2. med-chain acyl-CoA dehydrogenase def (MCADD)
- 3. Maple syrup urine disease (MSUD)
- 4. Isovaleric Acidaemia (IVA)
- 5. Glutaric aciduria type 1(GA1)
- 6. Homocystinuria (HCU)
- Some places als check for severe combined immunodeficiency
What are the advantages, complications and contraindications of breastfeeding?
Advantages
Reduced risk of following for baby
- Infection
- Diarrhoea + vomiting
- Sudden infant death syndrome
- Childhood leukaemia
- Obesity
- CVS disease
Reduced risk of following for mum:
- Breast + ovarian cancer
- osteoporosis
- CVS disease
- Obesity
Complications
- Mastitis - tx if systemically unwell, nipple fissure, nil improvement in 24h. Give flucloxacillin (10-14d) + continue breast feeding/expressing throughout.
- Engorgement - common in first few days, normally bilateral. Pain worse just prior to feeding +/- fever. Manage w/ hand expression of milk.
Contraindications
Non-medication related
- Galactosaemia
- Viral infections
Medication Related
- Abx: ciprofloxacin, tetrocycline, chloramphenicol, sulphonamides
- Psych: lithium, benzodiazepines
- Aspirin (risk of Reye’s syndrome in baby)
- Carbimazole
- Methotrexate
- Sulfunolyureas
- Cytotoxic drugs
- Amiodarone
Notable drugs that you can take: warfarin, anti-epileptics, penicillin, steroids, digoxin, most antipsychotics (not clozapine)
Give possible causes of abdominal pain during pregnancy
Early Pregnancy:
- Miscarriage (in gynae) ** under 24/52**
- Ectopic Pregnancy (in gynae) around 6-8/52
Late Pregnancy:
- Placental abruption ** after 20/52** (covered separately)
- Symphysis pubis dysfunction - pain over pubic symphysis radiating to groins + medial thigh
- HELLP syndrome/pre-eclampsia after 20/52 (covered separately)
- Labour - regular tightening of abdomen
- Uterine rupture - normally in labour but can be in 3rd trimester. RF = prev C-section. -> maternal shock, abdo pain, PV bleeding
Non-obstetric:
- Appendicitis - can be RUQ pain due to displacement of appendix in preg - -higher mortality/morbidity in pregnancy
- UTI - increased risk of preterm delivery + IUGR
- Ovarian Torsion
Pre-Eclampsia
Pathophysiology/Diagnosis
Presentation
Management
Complications + their management
Pathophysiology/Diagnosis
New onset BP >140/90 after 20/52 AND 1 or more of:
- Proteinuria
- Other organ involvement: renal insuf (creat >90), liver, neuro, haem, uteroplacental dysfunction
High risk factors
- HTN in previous pregnancy
- CKD
- Autoimmune disease (eg. SLE, anti-phospholipid)
- DM (1 or 2)
- chronic HTN
Moderate risk factors
- 1st pregnancy or pregnancy interval >10yrs
- >40yo
- BMI >35
- Family hx pre-eclampsia
- Multiple pregnancy
Presentation
Many asymptomatic
Features of severe pre-eclampsia:
- HTN >160/110 + proteinuria ++/+++
- Frontal Headache
- Visual disturbance: halos, flashing light, double/blurred vision and papiloedema
- RUQ pain + vomiting (hepatic capsule distension)
- Epigastric pain
- Hyper-reflexia
Complications
- Foetal -> IUGR, prematurity
- Haemorrhage: abruption, intra-abdo, intra-cerebral
- Heart failure
- HELLP syndrome - Haemolysis, Elevated liver enzymes, Low Platelets
- Eclampsia - Seizures in someone w/ pre-eclampsia
Management
Prevention - anyone w/ 1 high risk of 2 mod risk factors -> aspirin 75mg from 12/52 till birth
Acute management
- secondary care emergency assessment if suspect pre-eclampsia. Women >160/110 admitted.
- Ongoing: 1st: labetalol; 2nd: nifedipine or hydralazine.
- Mg sulfate can be used to prevent seizures in severe pre-eclampsia
- Delivery of baby = definitive management
Management of eclampsia
- 1st - for seizures: magnesium sulfate (IV 4g over 5-10mins then infuse at 1g/hr)
- Monitor: urine output, reflexes, rr, O2 during treatment. MgS can –> resp depression (treat w/ calcium gluconate)
- Continue treatment for 24h after last seizure or delivery (40% seizures occur post-partum)
Describe the difference in presentation and management of the following conditions:
- Placenta Praevia
- Placental Abruption
- Vasa Praevia
Placenta Praevia
Path - all/part of placenta implants in lower uterine segment. Diagnosed >20/52 (before this = low lying placenta)
Grading - minor (low but not covering internal os), major (covers os)
Presentation - painless PV bleed >20/52, abnormal foetal lie w/ high presenting part, normal uterine tone
Diagnosis- USS or MRI (do if prev c-section, ?accreta)
Other Ix- bloods/G&S; Kleihauer (if Rh-ve to determine anti-D dose); CTG if >26/52 to assess foetal wellbeing
N.B. avoid PV exam -> rupture + massive bleed
Management
If pre-term + non-life threatening
- admit + monitor
- Re-scan at 36/52 (if minor) or 32/52 (if major)
- Plan C-section at 38/52
If unstable
- Resus + C-section
In all RhD -ve women give Anti-D within 72h of bleed onset.
Placental Abruption
Path - bleed between placenta + uterine wall
Pres- shock out of keeping w/ visible loss, constant pain, tender/tense/woody uterus, normal lie/presentation, foetal heart absent/distressed. Can -> coagulopathy, DIC, pre-eclampsia, anuria, couvelaire uterus
Ix- bloods, kleihauer, USS
Management - resus, anti-D within 72h if rh-ve
If mild/pre-term -> monitor + deliver at 38/52
other -> surgical rupture of membranes OR c-section (if foetus or mother unstable)
Vasa Praevia
Path- foetal vessels lie in membranes across cervical os. ROM -> big bleed + rapid exsanguination of foetus
Ix- diagnosed on doppler USS/foetal anomaly scan
Pres - painless big bleed
