obstetrics Flashcards
placenta accreta
placenta attaches to the myometrium
placenta increta
placenta invades into the myometrium
placenta percreta
placenta percolates through the perimetrium
what is the cut off for iron supplementation in the first trimester
<110g/L
what is the cut off for iron supplementation in the second/third trimester
<105g/L
what is the cut off for iron supplementation post partum
<100g/L
when are preg women screened for anaemia
the booking visit (often done at 8-10 weeks)
28 weeks
formal definition of 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: e.g. renal insufficiency (creatinine ≥ 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction
high RFs for pre-eclampsia
- hypertensive disease in a previous pregnancy
- chronic kidney disease
- autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
- type 1 or type 2 diabetes
- chronic hypertension
moderate RFs for pre-eclampsia
- first pregnancy
- age 40 years or older
- pregnancy interval of more than 10 years
- body mass index (BMI) of 35 kg/m² or more at first visit
- family history of pre-eclampsia
- multiple pregnancy
what to do it 1+ high Rfs or 2+ mod Rfs for pre-eclampsia
take aspirin 75-150mg (low dose) daily from 12 weeks gestation until the birth
first line for pre-eclampsia
oral labetalol
nifedipine if asthma
delivery is definitive
who to admit for pre-eclampsia
≥ 160/110 mmHg
causes of PPH
Tone (uterine atony): the vast majority of cases
Trauma (e.g. perineal tear)
Tissue (retained placenta)
Thrombin (e.g. clotting/bleeding disorder)
RFs primary PPH
previous PPH
prolonged labour
pre-eclampsia
increased maternal age
polyhydramnios
emergency Caesarean section
placenta praevia, placenta accreta
macrosomia
the effect of parity on the risk of PPH is complicated. It was previously thought multiparity was a risk factor but more modern studies suggest nulliparity is actually a risk factor
mx PPH
ABC approach
- two peripheral cannulae, 14 gauge
- lie the woman flat
- bloods including group and save
- commence warmed crystalloid infusion
mechanical
- palpate the uterine fundus and rub it to stimulate contractions (‘rubbing up the fundus’)
- catheterisation to prevent bladder distension and monitor urine output
medical
- IV oxytocin: slow IV injection followed by an IV infusion
- ergometrine slow IV or IM (unless there is a history of hypertension)
- carboprost IM (unless there is a history of asthma)
- misoprostol sublingual
- there is also interest in the role tranexamic acid may play in PPH
surgical:
- intrauterine balloon tamponade
- B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure
when is a baby dx w foetal macrosomia
birth weight >4kg
PPH def
blood loss of > 500 ml after a vaginal delivery and may be primary (within 24 hrs) or secondary.
erb’s palsy arm position
adduction and internal rotation of the arm, with pronation of the forearm.
RFs of shoulder dystocia
fetal macrosomia (hence association with maternal diabetes mellitus)
high maternal body mass index
diabetes mellitus
prolonged labour
mx shoulder dystocia
McRoberts’ manoeuvre (mums knees to abdo)- providing a posterior pelvic tilt
Pressure to anterior shoulder
Episiotomy
Rubins manoeuvre
Wood’s screw manoeuvre
Zavanelli manoeuvre
RFs for gestational diabetes
BMI of > 30 kg/m²
previous macrosomic baby weighing 4.5 kg or above
previous gestational diabetes
first-degree relative with diabetes
family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
how to screen for gestational diabetes
OGTT
if had it previously: OGTT asap after booking + at 24-28 wks if 1st test is normal
any other RFs: OGTT at 24-28 wks
diagnostic thresholds for gestational diabetes
fasting glucose is >= 5.6 mmol/L
2-hour glucose is >= 7.8 mmol/L