Obstetrics Flashcards
Define an APH
Bleeding in pregnancy after 24 weeks
Name 4 differentials for an APH
Placental abruption/praevia
Vasa Previa
Maternal genital infection
Trauma
Ectropion
GTD
Define placental abruption
Separation of placenta from uterine wall
Name 4 risk factors for placental abruption
Pre-eclampsia
Polyhydramnios
Older mother
Multiparity
Cocaine
Smoking
Trauma
Name 4 sx of placentla abruption
PV bleeding
Pain
shock
contranctions
Name 4 signs associated with placetnal abruption
Woody hard uterus
Tachycardia
Hypotension
Tenderness on palaption
CTG - Foetal distress and decreased fetal movements
What investigations are required in placental abruption
USS - R/O placenta praevia
Speculum examination - identify the source of the bleed
Maternal blood
- FBC / Group and save / Clotting / Crossmatch
Placental abruption management
ABCDE
Anti-D prophylaxis
IM steroids if <36
Define placenta praevia
Pacenta overlying cervical os
Name 4 RF for placenta praevia
Uterine structural abnormality - fibroids
Hx C sections
Mulltiparity
Smoking
Older age
Symptoms of placenta praevia
Painless bright red PV bleed
What are the examination findings in placenta praevia
Abnormal lie and presentation of foetus
What are the examination findings in placenta praevia
Abnormal lie and presentation of foetus
What are the examination findings in placenta praevia
Abnormal lie and presentation of foetus
What are the examination findings in placenta praevia
Abnormal lie and presentation of foetus
What are the examination findings in placenta praevia
Abnormal lie and presentation of foetus
How is placenta praevia picked up
Anomaly scan - 20 weeks
TVUS
What is contraindicated in APH
DVE - Especially in Placenta praevia due to risk of provoking a severe haemorrhage
What is vasa praevia
foetal vessels run near to or across the internal cervical os
What are the clinical features of vasa praevia
painless PV bleed
Rupture of membranes
foetal bradycardia
Name 3 risk factors of vasa praevia
multiple pregnancy
placenta praevia
IVF
What is the management of vasa praevia
elective c-section prior to ROM
Describe the differences between placenta: Acreeta, Increta and Percreta
Acreeta - attachment of palcenta onto myometrium without penetration
Increta - Chorionic villi invade into but not through myometrium
Percreta - chorionic villi invade through full thickness of myometrium
Name 4 risk factors for placental invasion
Previous TOP
Dilatation and curettage
previous c section
advanced maternal age
uterine structural defects
Outline pre-existing HTN of pregnancy
High BP prior to 20 weeks gestation
No proteinuria
No oedema
Outline pregnancy induced hypertension
Hypertension occuring following 20 weeks gestation
No proteinuria
No oedema
Outline pre-eclampsia
new-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of the following:
proteinuria
other organ involvement (see list below for examples): e.g. renal insufficiency (creatinine ≥ 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction
Who should take aspirin
1 high risk RF
2 Moderate risk RF
Name 3 high risk RF for pre-eclampsia
prev HTN disease in pregnancy
CKD
DM
Chronic HTN
AI - SLE / Antiphospholipid
Name 3 moderate risk RF for Pre-eclampsia
FHx
Multiple pregnancy
BMI>35
1st pregnancy
>40 years old
Name 4 sx of pre-eclampsia
Headache
visual disturbance
RUQ pain
Vomiting
Name 4 signs of pre-eclapmsia
Altered emntal status
Hyper-reflexia
Peripherla oedema
Proteinuria
N+V
What blood tests would you order and what would be seen in a patient with pre-eclampsia
FBC - Raised HB and low platelets
U+E - Raised Ur / creatinine / urate
PLGF - low
Why does eclamsia occur in a patient with pre-eclampsia
cerebrovascular vasospasm
Name 4 complications of pre-eclampsia for the foetus
IUGR
PRre-term delivery
Placental abruption
Neonatal hypoxia
What are the consequences / clinical features of HELLP
H - Dark urine / Raised LDH / Anameia
EL - RUQ pain / liver failure / Abnormal clotting
Name 4 risk factors for GDM
BMI > 30
Previosu macrosomic baby
previous GDM
1st degree relative with diabetes
When should the OGTT be done
Previous GDM - Booking + 28 weeks
All other - 28 weeks
Name 2 complications of GDM
Macrosomia
Shoulder dystocia
Pre term delivery
Neonatal hypoglycaemia
congenitla heart defects
Polycythaemia
Outline the classification and the causes of SGA
SGA - Foetal weight <10th centile
constitutionally small - based on sex/ parents height/ethnicity
placental mediated - growth slown in utero
Placental insufficiency
Foetal factors - infection / chromosomes
Name 3 causes of polyhydramnios
increased foetal urination
- foetal renal disorders
- twin to twin trasfusion
- maternal DM
Reduced foetal swallowing
- oesophageal or duodenal atresia
- chromosomal disorder
- diaphragmatic hernia
How does polyhydramnios present
Uterus feels tense
large for dates
difficult to palapte foetal parts
What investigations are required for polyhydramnios
USS and examination
TORCH screen
Maternal OGTT
Name 4 causes of oligohydramnios
Maternal
- PROM
- Placental insufficiency
Foetal
- PCKD
- Renal agenesis
- Urethral obstruction
- Chromosomal abnormalities
Name 3 complications of oligohydramnios
clubbed feet
congenital hip dysplasia
pulmonary hypopasia
What is potter sequence
Bilateral renal agenesis + pulmonary hypoplasia
what is obstetric choelstasis
condition occurring after 24 weeks gestations due to build up of bile acids
Associated with high risk stillbirth
What are the clinical features of obstetric cholestasis
itching - worse on hands and feet
fatigue
Nausea
mild jaundice - dark urine and pale stools
RUQ pain
What investigations are required for obstetric cholestasis
LFTs - Abnormal
Bilirubin - raised
What is the management of obstetric cholestasis
Induction of labour: 37-38 weeks
Ursodeoxyxholic acid - reduce serum bile acids
Chlorphenamine - improves sleep
Vit K - reduce risk of haemorrhage
Name 4 risk factors for VTE in pregnancy
Smoker
>35
multiplt pregnancy
BMI>30
IVF pregnancy
Pre-eclampsia
How is VTE in pregnancy managed
Treatment determined at booking clinic appointment
> 4 RF –> LMWH antenatal and 6 weeks post partum
3 Risk factors start at 28 weeks
How do you estimate due date
Add 1 year and 7d to LMP
Subtract 3 months
What is the bishop score and what does it indicate
Indicates if IOL will be successful
Score > 8 - indicates success
Score < 8 - indicates cervical ripening required first
What are the methods for induction of labour
Membranse sweep
Vaginal prostaglandins
cervical ripening balloon
AROM + IV oxytocin
What is monitored during IOL
CTG - Foetal HR / Contractions
Bishop score - assess progress
What is uterine hyperstimulation syndrome
Due to vaginal prostaglandins causing prolonged and frequent contractions causing foetal compromise
What is uterine hyperstimulation syndrome
Due to vaginal prostaglandins causing prolonged and frequent contractions causing foetal compromise
Risk of uterine rupture
How is uterine hyperstimulation syndrome managed
stopping prostaglandins
starting tocolytics - terbutaline
How do you manage Braxton Hicks
Hydration and relaxation
What is the 2st stage of labour
onset of labour to 10cm dilated
cervical dilatation and effacement
How do you recognise the onset of labour
ROM
Cervical show
Regular painful contractions
Dilatation of cervix
Describe the management of the 3rd stage of labour - active and physiological
Physiologiclal - placenta delivered via maternal effort. No cord traction or medication
Active -
IM Oxytocin following delivery of the baby
delayed cord clamping
cord traction to deliver placenta
What are the options for pain management in labour
Gas and Air - short term
IM Diamorphine
PCA - IV Remifentanil
Epidural - Bupivocane + Fentanyl
Name 4 adverse effects of an epidural
headache after insertion
hypotension
motor weakness in the legs
nerve damage
prolonged 2nd stage
urinary retention
increased risk of instrumental delivery
What are the parameters for failure to progress in each stage of labour
1st stage
- >2cm every 4 hours
2nd stage
- primiparous > 2 hours
- multiparous > 1 hour
3rd stage
- active > 30 mins
- passive > 60 mins
What factors affect progression in 2nd stage of labour
3 Ps
Power
Passage - cephalopelvic disproportion
Passenger
- Lie
- Attitude
- Presentation
- Size
Describe the cardinal movements of labour
Every darn fool in Egypt eats raw eggs
Engagement
Descends
Flexion
Internal rotation
Crowning
Extension
External rotation
Restitution
Expulsion
What is required following instrumental delivery
Co-amoxiclav
What are the indications for instrumental delivery
Failure to progress - 2nd stage
foetal distress
maternal exhaustion
Breech
What are the foetal risks to delivery via forceps and ventouse
ventouse - cephalohaematoma
forceps - facial nerve palsy
Name 4 causes of malpresentation
Multiple pregnancy
Uterine abnormalities
Polyhydramnios
Placenta praevia
Preterm labour
What is involved in prophylaxis of preterm labour
Done between 16-24 weeks for women with cervical length <2.5cm
Vaginal progesterone - decreases activity of myometrium and prevents cervical remodelling
Cervical cerclage
How is ROM diagnosed
Speculum - amniotic fluid pooling in vagina
Insulin like growth factor binding protein - present in high concentration in amniotic fluid
Give 2 optiosn for tocolysis
Nifedipine
Atosiban - oxytoxcin receptor antagonist
Layers for C section
Skin
Subcutaneous tissue
Fascia / rectus sheath
Rectus abdominis muscles
Peritoneum
Uterus (perimetrium, myometrium and endometrium)
Amniotic sac
Why shoudl you not handle the cord during a cord prolapse
causes vasospasm
How is cord prolapse managed
Push presenting part upwards
Woman on all 4’s
Tocolytics
C- section
What is shoulder dystocia
Anterior shoulder of foetus gets stuck behind pubic symphisis
How is shoulder dystocia managed
Episiotomy
Mc Robertson manoevere
Name 3 complications of shoulder dystocia
Foetal hypoxia
Brachial plexus injury
Erbs palsy
Perneal tears
PPH
Name 3 signs and sx of chorioamnionits
Fever
Tachy
High resp rate
Abdominal pain
Uterine tenderness
Vaginal discharge
Describe the classifications of a PPH
> 500mls - vaginal
1000ml - C section
Describe the primary and secondary classifications of a PPH
Primary - within 24hrs of birth
Secondary - from 24 hours to 12 weeks
Name 3 preventative measures to a PPH
Treating anaemia during antental period
give birth with empty bladder
Active 3rd stage management
Give 3 causes of PPH - Tone
Polyhydramnios
Multiple pregnancy
Macrosomia
Fatigue - prolonged labour
Medications - Tocolytics
Why does Retained products in Tissue lead to PPH
Retained placenta prevents contractions –> Atony
Give 3 causes of PPH - Trauma
Perineal tear
Episeotomy
Rupture
Outline the management of a PPH
ABCDE
2 wide bore cannulas
Bloods - FBC / U+E / Clotting
Group and save + cross match
Uterine massage + catheterisation
IV Oxytocin
Ergormetrine - CI in HTN
Carboprost - Caution in Asthma
Uterine balloon tampoande
Hysterectomy
Name 2 causes of secondary PPH
Endometritis - Uterine infection
Lower abdominal pain / Fever / Foul smelling lochia
Retained tissue -Uterue palpable highly
What are the investigations for secondary PPH
USS - Retained products
Swabs - Endocervical and HVS
Name 4 features of congenital rubella
Congenital deafness
Congenital cataracts
CHD - PDA and pulmonary stenosis
LD
Give 4 features of congenitla varicella syndrome
Occurs within 28 weeks gestation
FGR
Microcepahly
LD
Skin scarring
Limb hypoplasia
Cataracts
Name 4 features of Congenital CMV
FGR
Microcephaly
Hearing loss
Vision loss
LD
Seizures
Give 4 features of toxoplasmosis
Intracranial calcification
Hydrocephalus
Chorioretinitis
Give 4 general lifestyle measures for infertility
400mcg folic acid
healthy BMI
Avoid smoking and drinking
Intercourse 2-3 days
Name 4 hormones tested for in infertility - female
Serum LH and FSH - On day 2-5 of the cycle
D21 progesterone
TFT
Prolactin
What does high FSH indicate
Low ovarian reserve
What does high LH indicate
PCOS
What does high LH indicate
PCOS
What does AMH indicate
Measured at any point in the cycle - marker of ovarian reserve
released by granulosa cells
What is the MOA of clomifine
Anti-oestrogen - selective oestrogen receptor modulator
given on day 2 - 6 of cycle
Stops the -ve feedback of oestrogen on hypothalamus
