Obstetrics Flashcards
blood tests in ?suspected cholestasis
conjugated bilirubin
AST
ALT
ALP
GGT
signs: meconium aspiration
- meconium stained liquor
- green staining of infant
- foetal respiratory distress
- low APGAR score
- limp infant
- crackles on auscultation of foetal lungs
tx: meconium aspiration
- suctioning of mouth and nose
- prophylactic abx
- O2 administration
- monitor
- ventilate in severe cases
antenatal appt schedule: obs
10-12 weeks booking clinic - screen for RFs, dating scan and T21
20 weeks - anomaly scan
28,34 and 36 weeks - midwife appts, monitor foetal growth (SFH) and heart
40 weeks - offered stretch and sweep
41+ - offered IoL
24-28 weeks - screen for GDM
28 and 34 weeks - anti-D
obs taken: antenatal appointments
- BP
- urinalysis
- SFH
dating pregnancy: antenatal scan
<14/40 - CRL (crown rump length) and BPD (biparietal diameter)
>14/40 - head circumference (BPD), abdominal circumference and femur length
standard dose: folic acid
400 micrograms
RFs: higher dose folic acid
5mg
* previous baby affected by neural tube defect
* either parent with NTD
* stong fhx NTD
* BMI >30
* diabetes
* coeliac
* thalassaemia
* multiple pregnancy
* drugs - antiepileptics
screening: booking scan
- HIV
- Hep B
- syphilis
- blood group
- Rh status
- rubella immunity
- anaema
- urinalysis for symptomatic bacteriuria
genetic screening: combined test
COMBINED TEST - first line and most accurate
USS (nuchal translucency) and bloods (BhCG and PAPP-A)
* 11-14/40
abnormal result (increased risk)
* USS >6mm nuchal translucency
* increased BhCG
* low PAPP-A (pregnancy-associated plasma protein-A)
genetic screening: triple test
between 14-20 weeks
ONLY MATERNAL BLOODS
higher risk:
* BhCG high
* AFP loow
* serum oestriol low
genetic screening: quadruple test
14-20 weeks
identical to triple test +inhibin-A
higher risk:
* BhCG high
* AFP low
* oestriol low
* inhibin-A high
genetic screening: antenatal diagnostic testing
if risk score >1/150 - woman offered testing for karytyping foetal cells
<15/40 chorionic viillus sampling (CVS) - USS biopsy placental tissue
>15/40 amniocentesis - USS aspiration of amniotic fluid (later in pregnancy when safe to take amniotic fluid)
genetic screening: NIPT
non-invasive prenatal testing (Harmony testing) - currently private
from >10/40
- blood test from mother containing foetal DNA from placental tissue
- not definitive test but gives indication if foetus is affected
- gradually rolled out as alternative to invasive tesing
growth chart: antenatal care
- personalised on mothers demographics
- x= fundal height
- o = estimated weights to scan
- centile lines show overall trend
- falling across centile or <2nd centile = USS repeat in 2 weeks
trimesters: anternatal care
0-12 weeks first trimester
13-26 weeks second trimester
27 weeks - birth third trimester
foetal movements: anternatal care
from 20 weeks until birth
vaccines: antenatal care
whooping cough )pertusis) from 16 weeks
influenza in autumn/winter
live vaccines avoided in pregnancy
pregnancy lifestyle advice: antenatal care
- take folic acid from before 12 weeks
- take vitamin D supplement (10mcg or 400IU daily)
- avoid vitamin A (liver or pate - teratogenic in high doses)
- avoid alcohol (foetal alcohol ssyndrome)
- avoid smoking
- avoid unpasteurised dairy (listeriosis)
- avoid undercooked or raw poultry (risk of salmonella)
- continue moderate excercise but avoid contact sports
- sex is safe
- flying increases VTE risk
- place seatbelt above or below bump (not acorss it)
foetal alcohol syndrome: antenatal care
effects greatest in first 3 months - miscarriage, small for dates, preterm delivery and foetal alcohol syndrome)
FAS:
* microcephaly
* thin upper lip
* smooth flat philtrum
* short palpebral siddures (short distance from one side of eye to other)
* learning disability
* behavioural difficulties
* hearing and vision problems
* cerebral palsy
smoking in pregnancy: antenatal care
- foetal growth restriction
- miscarriage
- stillbirth
- preterm labour and delivery
- placental abruption
- pre-eclampsia
- cleft lip/palate
- sudden infant death syndrome (SIDS)
flying in pregnancy: antenatal care
37 weeks single pregnancy
32 weeks in twin
after 28 weeks airlines often require letter from healthcare stating pregnancy going well and no additional risks
LGA: antenatal care
- growth >95th centile
causes:
* constitutional
* obesity
* diabetes
risks:
* birth injury
* hypoglycaemia
def: SGA
growth <10th centile
no underlying pathology
causes: SGA
- maternal height/weight
- ethnicity
rx: SGA
- growth and umbilical artery doppler 2-3 weekly
- if abnormal - do CTG
- if CTG ok - continue monitoring
- if CTG abnormal - deliver
causes: IUGR
- diagnoses: PET, DM, CKD
- lifestyle: alcohol, smoking, malnutrition
- infections: CMV, rubella
- congenital: trisomies, turners, IEM (inborn errors of metabolism)
signs: IUGR
- decreased foetal movements
- decreased amniotic fluid
- abnormal umbilical artery doppler - absent or reversed end diastolic flow)
- abnormal CTG
management: IUGR
- 2 weekly growth scans, doppler and fluid measurement
- <32/40 and abnormal doppler = daily CTG
- if CTG abnormal = deliver
- > 34/40 and abnormal doppler = deliber
- if delivering preterm - consider corticosteroidss and MgSO4
rx: delivery preterm
corticosteroids lungs
MgSO4 neuroprotective
def: hyperemesis gravidarum
prolonger vomiting causing dehydration or >5% weight loss
caused by high B-hCG levels
ix: hyperemesis gravidarum (5)
- U+E (K)
- urinalysis (ketones)
- FBC
- bone profile
- USS
rx: hyperemesis gravidarum (5)
- antiemetics (cyclizine, promethazine, prochlorperazine)
- fluid replacement
- pabrinex (wernicke’s)
- LMWH and TEDS
- corticosteroids
def: hypertension in pregnancy
BP >140/90
* <20/40 - essential HTN
* >20/40 - NO PROTEINURIA gestational HTN
* >20/40 - PROTEINURIA pre-eclampsia
rx: hypertension in pregnancy
1st line = labetalol (NOT ASTHMA)
2nd line = nifedepine (asthma)
ACE/ARB contra-indicated in pregnancy
def: pre-eclampsia
multi-system disorder
hypertension with proteinuria or end-organ dysfunction or placental dysfunction
triad = hypertension, proteinuria and oedema
high risk: pre-eclampsia
1+ RF = take aspirin
* essential/chronic HTN
* previous HTN in pregnancy
* diabetes
* CKD
SLE or anti-phospholipid syndrome
moderate risk: pre-eclampsia
2+ RF = take aspirin
FAMOUS
first pregnancy
age >40
multiple pregnancy
obese BMI >30
unusual gap between pregnancies
strong fhx of HTN
symptoms: pre-eclampsia
- headache
- blurred vision/flashes
- apigastric/RUQ pain
- oedema in hands and feet
- N+V
- brisk reflexes
- reduced urine output
- IUGR
rx: PET
1st line labetalol
2x weekly USS (foetus, fluid, doppler)
2-3x weekly bloods = FBC, U+E, LFT and clotting
if BP can’t be stabilised or mother v unwell (risk of eclampsia) - give MgSO4 (until 24 hours post birth or seizure) and deliver
risk of pulmonary oedema - fluid balance and restrict
def: eclampsia
IV MgSO4 (and emergency delivery)
cure - removal placenta
complications: pre-eclampsia
- eclampsia
- HELLP syndrome (haemolysis (low Hb, elevated liver enzymes, low platelets)
- stroke
- renal or liver failure
- pulmonary oedema
- DIC
- placental abruption
- stillbirth
def: obstetric cholestasis
- reduced flow of bile acids from liver (intrahepatic cholestasis)
- usually develops after 28/40
CAUSE: PBSTETRIC CHOLESTASIS
- increased oestrogen and progesterone levels
- genetic component
- more common in south asian ethnicity
symptoms: obstetric cholestasis
itching (esp palms and soles)
complications: obstetric cholestasis
increased risk stillbirth - planned birth 37/40
ix: obstetric cholestasis
LFTs - ALT, AST, GGT and raised bile acids
rx: obstetric cholestasis
- ursodeoxycholic acid
- emollients (calamine lotion)
- antihistimines (chlorphenamine)
RFs: GDM
- BMI >30
- previous hx GDM
- previous baby >4.5kg
- ethnic origin - south asian, middle eastern or afro-carribean
- 1st degree relative with DM
ix: GDM
- screening at booking for RFs
- screening at 24-28 weeks for RFs
- likely to develop in 2nd trimester
- OGTT 26 weeks
OGGT: GDM
fasting glucose 5.6mmol/l
2hr after glucose 7.8mmol/l
rd: GDM
if fasting <7mmol/
1st line diet and excercise
2nd line metformin
3rd line insluin
if fasting >7mmol/l
insulin
complications: GDM
- stillirth
- macrosomia
- polyhydramnios
- shoulder dystocia
- hypoglycaemia neonatally
postnatal check: GDM
6week post natal glucose check (high risk of developing T2DM)
pre-existing DM: risks and prophylaxis
- PET - aspirin 75mg from12/40
- malformations - high dose folic acid 5mg
- worsening retinopathy - screening at 28/40
- HbA1c- each trimester
- neonatal risks - foetal growth monitored closely
pre-existing DM: neonatal complications
- macrosomia
- hypoglycaemia
- LGA/IUGR
- RDS
rx: pre-existing DM
- stop hypoglycaemics
- continue metformin
- start insulin
- aim for bith 37-39/40
- sliding scale insulin during labour and birth
epilepsy: antenatal
- pre-conception high dose folic acid 5mg
- lowest dose antiepileptic (stop phenytoin (cleft lip) and sodium valproate (neural tube defects)
- seizures likely intra-post-partum
multiple pregnancy: TTTS
- monochorionic twins
- placental anastomosis in shared placents
- donor twin - volume depleated, IUGR, anaemia
- recipient twin - fluid overload, polycythaaemia, large for dates
def: labour abbreviations
ROM - rupture of membranes
SROM - spontaneous rupture of membranes
PROM - premature rupture of membranes
PROM - prolonged rupture of membranes (more than 18hrs before delivery)
PPROM - membranes ruputure before onset of labour and before 37 weeks gestation
def: prelabour ROM
prelabour rupture of membranes >37 weeks
rx: PROM
- give women 24 hours to go into labour
- if labour doesnt start start oxytocinin infusion
ix: PROM
- sterile speculum examination
- 30 mins lying flat - look for pooling in posterior fornix
- amnisure - assess for presence of amniotic fluid
- foetal fibronectin - assesses liklihood of going into labour (premature)
- NEVER DO DIGITAL EXAM
rx: PROM
- erythromycin for 10 days or until labour (chorioamnionitis)
- assess foetus - CTG and USS
- corticosteroids - 12g betamethasone IM 24 hours apart
- avoid sex and pools
prophylaxis: preterm labour
- vaginal progesterone (cervical length <25mm between 16-24 weeks)
- cervical cerclage
ix: reduced foetal movements
foetal movement should be established by 24/40
RFM should always be reported (reduced risk stillbirth)
* doppler assessment of heart beat
* if heartbeat present - CTG monitoring
* if no heartbeat - USS immediately
rx: preterm delivery
steroids - betamethasone 2x 12mg IM 24 hours apart (matures foetal lungs)
MgSO4 - neuroprotective <12hours before birth
nifepedine - tocolysis can delay delivrey for few hours
antepartum haemorrage before 24/40
threatened miscarriage
antepartum haemorrhage: painless bleeding differentials
placenta previa
vasa previa
antepartum haemorrhage: painful bleeding differentials
placental abruption
uterine rupture
def: placenta praevia
placenta over internal cervical os
(low-lying when placenta within 20mm of internal cervical os)
diagnosed at 20 weeks at anomaly scan
RFs: placenta praevia
- prev C/S
- prev placenta praevia
- older maternal age
- maternal smoking
- structural uterine abnormalities
- assisted reproduction IVF
rx: placenta praevia
- repeat TVUSS at 32 weeks and 36 weeks if present at 32 weeks
- corticosteroids given between 34 and 35+6 weeks to mature foetal lungs (preterm risk)
- planned C/S delivery between 36 and 37 weeks
- blood transfusions
- intrauterine balloon tamponade
- uterine artery occlusion
- emergency hysterectomy
def: vasa previa
- foetal vessels exposed and travel across cervical os
- bleeding at ROM with foetal distress
type I - foetal vessels exposed as velamentous umbilical cord
type II - accessory placental lobe
rx: vasa praevia
corticosteroids given from 32 weeks
elective C/S 34-36 weeks
def: placental abruption
placenta separates from uterine wall
signs: placental abruption
- painful bleeding
- woody, tender uterus
- sudden severe onset and continuous
- maternal shock and foetal distress
rx: placental abruption
- emergency C/S
- call senior obstetrician, medwife and anaesthetist
- 2x grey cannula
- bloods - FBC, U+E, LFT and coag
- crossmatch 4 units blood
- fluid and blood resus
- CTG monitoring of foetus
- close monitoring of mother
- anti-D prophylaxis
test for foetal and meternal blood mixing
Kleihauer
def: uterine rupture
- usually during labour in 3rd trimester
- RF: prev C/S and VBAC
- acutely unwell mother with abd pain
- decreased uterine contrations
- foetal distress
- emergency C/S
labour: 1st stage
onset of labour (true contractions) effacement and dilation of cervix to 10 cm
latent 0-3cm, 0.5cm/hr - irregular contractions
active 3-7cm, 1cm/hr - regular contractions
transition 7-10cm, 1cm/hr strong and regular contractions
failure to progress: 3Ps
passage - cephalopelvic disproportion
passenger - foetal malpresentation
power - in-cordinate contractions
contractions: aim
3-4 in 10 minutes lasting 60 seconds
labour: 2nd stage
10cm dilatation until delivery of baby
+/- 1 hour passive
delayed pushing <2hours if nulliparous and <1hr if multiparous
labour: 3rd stage
delivery of placenta
physiological - up to 60 minutes
active - up to 30 minutes (IM oxytocin and controlled cord contraction)
contracindiation: ergometrine
HTN and heart disease
def: Bishop score
assess cervix for IoL or during labour
Pregnancy Can Enlarge Dainty Stomachs
Position of cervix
Consistency of cervix
Effacement of cervix
Dilation of cervix
Station of foetal head
score >8 favourable for IoL
score <6 unfavourable and cervical ripening agents considered
diagnosis: onset of labour
- show (mucous plug)
- rupture of membranes
- regular, painful contractions
- dilating cervix O/E
def: latent first stage
painful contractions and change to cervix with effacement up to dilation of 4cm
def: established first stage
regular, painful contractions and dilation from 4cm onwards
induction of labour options
vaginal sweep - offered at 40/40
vaginal prostoglandins - pessary over 24 hours, prostogladin gel (aim to break waters)
cooks balloon/foley catheter - mechanical IoL (aim pressure of balloon dilates cervix, ballon falls out and waters break)
amniotomy and oxytocin - artificial ROM followed by infusion within 2 hours
complications: IoL
uterine hyperstimulation - >5 contractions in 10 mins or lasting >2mins
maternal in left lateral position, stop oxytocinin infusion, tocolytics (terbutaline) consider fluid bolus
eg: tocolytic
terbutaline
def: PPH
primary - first 24 hours
secondary - up to 12 weeks postnatal
expected blood loss: labour
vaginal <500mls
C/S <1000mls
casues: PPH
4Ts
tone - uterine atony most common
tissue - reatined placenta or membranes
trauma - check perineum and repair
thrombin - clotting disorder in maternal hx (check coag)
visual blood loss estimated
bed 1000mls
bed anf floor 2000mls
kidney dish 500mls
inco pad 250 mls
sanitary pad 100mls
def: major PPH
1000-2000mls
def: severe PPH
> 2000mls
management: PPH
uterine massage
oxytocinin/syntometrine IM
ergometrine IM
oxytocinin infusion (40 units in 500ml @125ml/hr)
carboprost (prostoglandin)
misoprostal
tranexamic acid 1g slow IV
bimanual compression and go to theatre
surgical rx: PPH
intrauterine balloon tamponade
bracing B lynch suture
uterine artery embolisation
hysterectomy
rx: PPH protocol
activate major haemorrhage protocol
senior obstetrician. midwife and anaesthetics
2 grey cannulas
4 units blood crossmatched
fluid and blood resus as required
insert SRCc
CABCDE
increased risk DIC adn need fibrinogen
def: shoulder dystocia
bony impaction of anterior shoulder on symphysis pubis causing pressure on brachial pressure
complications: shoulder dystocia
erbs palsy (C5/6)
PPH
4th degree tear
foetal death
def: cord prolapse
foetal distress on CTG
rx: cord prolapse
- do not handle cord
- mother on all4s
- emergency C/S
RFs: cord prolapse
PPROM abnormal lie
post ROM
def: amniotic fluid embolism
- liquor enters maternal circulation causing cardipulmonary arrest
- around time of birth
- suddden onset SOB, hypoxia, hypotension, seziures, cardiac arrest
meconium stained liquor
small amount - light green/yellow - continue labour
equal amount liquor and meconium - darkgreen and foetal istress = immediate delivery
meconium dominates labour - black colour = emergency
def: placenta accreta
placenta implants on surface of myometrium but not beyond
def: placenta increta
pacenta attaches deep in myometrium
def: placenta percreta
placenta invades past myometium and perimetrium ?reaching other organs
RFs; placenta accreta
- previous placenta accreta
- prev endometrial curretage
- previous C/S
- multigravida
- increased maternal age
- low lying placenta/placenta praevia
rx: placenta accreta
- planned delivery 35 - 36+6 weeks with C/S
- additional maagement - ICU, blood transfusions, uterine surgery, NICU
after delivery - hysterectomy
- uterus preserving surgery
- expectant management
RFs; VTE pregnancy
smoking
aprity >=3
age >35
BMI >30
reduced mobility
multiple pregnancy
pre-eclampsia
varicose veins
family hx
thrimbophilia
IVF pregnancy
prophylaxis: VTE in pregnancy
first trimester if 3 RFs
28 weeks if 4+ RFs
high risk: VTE in pregnancy
40mg or 60mg (below or above 90kg) for 6 weeks post natal
intermediate risk: VTE in pregnancy
10 days postnatal prophylaxis
antenatal infection causing: hydrocephalus, chorioretinitis and hearing impairment in baby with flu like symptoms in mum at beginning of pregnancy
Toxoplasma gondii
perineal tears: degrees
1st degree - tear to superficial perineal skin or vaginal mucosa only
2nd degree - perineal muscles and fascia but anal sphincter intact (episiotomy)
3a - less than 50% thickness external anal sphincter torn
3b - more than 50% thickness external sphincter torn but internal anal sphincter intact
3c - external and internal anal sphincters torn but anal mucosa intact
4th - perineal skin, muscle, anal sphincter and. Anal mucosa torn
USS: snowstorm appearance
molar pregnancy - high levels BhCG
rx: perineal tears
1st degree - may not require sutures (no muscle involvement and likely to heal quickly)
2nd - suturing by experienced midwife
3rd and 4th - surgical repair in theatre with broad-spectrum and and laxatives post-op
unpasteurised cheese: infection
listeria monocytogenes
def: McRobert’s manoeuvre
macroscomic baby who’s shoulders fail to deliver and retracts
mum in McRobert’s position with hyperflexion and abduction of legs tightly to abdomen to relieve impact of shoulder
suprapubic pressure can also be applied
