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OB & Gynecology > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

Why would pregnant woman has pain & bleeding but then it resolves?

A

• Implantation at time menses
• Cervical trauma during intercourse
• Subchorionic hemorrhage

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2
Q

Can trans Abdominal U/S detect ectopic pregnancy?

A

No, only trans vaginal

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3
Q

How you manage Ectopic Pregnancy?

A

If the patient is stable ~> MTX (HCG < 5000)
If not (ruptured tube) ~> Surgery (Salpingectomy & Salpingotomy)

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4
Q

What associated with Duodenal atresia?

A

Duodenal atresia is commonly associated with trisomy 21 (Down syndrome)
and
VACTERL (Vertebral, Anal atresia, Cardiac, Tracheoesophageal fistula, Esophageal atresia, Renal, Limb) association

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5
Q

What cause the followings:
1- Diaphragmatic hernia, rocket bottom feet and clenched hands
2- Holoprosencephaly
3- Horseshoe kidney
4- Myelomeningocele (spina bifida)
5- Periventricular calcifications
6- VSD

A

1- Trisomy 18 (Edward syndrome)
2- Trisomy 13 (patau syndrome)
3- 45x (Turner syndrome)
4- Folate deficiency
5- Congenital CMV infection
6- Trisomy 21 (Down Syndrome)

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6
Q

Bulk symptoms (rectal pain or pressure) + cervical protruding mass + heavy vaginal bleeding =

A

Cervical leiomyoma

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7
Q

Vaginal bleeding + High HCG + Enlarged uterus =

A

Choriocarcinoma

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8
Q

Amenorrhea + Blind vaginal pouch =

A

Complete mullerian agenesis

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9
Q

Abdominal pain + Foul smelling vaginal discharge + Vaginal bleeding + something seen in vagina on exam =

A

Foreign body

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10
Q

Postmenopausal woman + Pelvic pressure + Vaginal bulge increased with valsava =

A

Pelvic organ prolapse

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11
Q

Infancy + Polypoid or grapelike mass protruding through vagina + Vaginal bleeding + Vaginal discharge =

A

Sarcoma botryoides

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12
Q

How B-HCG change during pregnancy

A

Double every 48 hours
Peak (100k) at 8-10 weeks
Decline until 12k in 20 weeks

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13
Q

How you determine fetal age by U/S

A
  • CRL
  • BPD
  • FL
  • HC
  • Abdominal circumference
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14
Q

How you determine fetal age

A
  • LMP
  • 1st U/S
  • URINE OR BLOOD TEST
  • FETAL MOVEMENT
  • SFH
  • LAST U/S
  • PATIENT OPINION
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15
Q

When SFH mismatches with fetal age

A

Incorrect dating or:

  • Larger than expected ~> Poly - Molar - Multiple - Full bladder - Fibroid - Macrosomia
  • Less than expected ~> Oligo - IUGR - IUD
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16
Q

What are signs expected to see in pregnancy

A

شلج بالحمل:
- Chadwik ~> Blue discolouration of cervix & vagina
- Ladin ~> Softening of uterus
- Goodel ~> Softening of cervix

Linea nigra - Palmar erythema - Talangectesia - Stria Gravidarum

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17
Q

What worsen and what improves with pregnancy regarding cardiac pathology

A

Regurgitation ✅
Stenosis ❌

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18
Q

What are physiological changes in pregnancy

A
  • Respiratory alkalosis
  • Dilutional anaemia
  • Hypercoagubility
  • High cardiac output & High plasma volume (peak at 32wks) & Low hematocrit
  • Supine HOTN
  • Edema (high renin) & Frequency
  • Goiter (B-HCG work as TSH & High TBG)
  • Weight gain
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19
Q

منو الي متكدر تتمرن وهي حامل عندها خطر يعني

A
  • Cervical incompetence
  • Multiple gestation
  • Leaking liquor
  • PET
  • PL PRV
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20
Q

How NSaids affect pregnancy

A
  • After 20wks ~> Oligohydramnios
  • In 3rd trimester ~> Close ductus arteriosus
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21
Q

What are 1st trimester screenings

A
  • BMI
  • Blood Pressure & Serum glucose level
  • CBC (exclude anaemia + establish baseline)
  • Blood group & RH
  • GUE & Culture
  • Infections
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22
Q

1- How you detect allo-antibodies between mother and fetus
2- why you wanna know blood group of pregnant woman
3- when we give anti-D rather than RH incompatibility

A

1- Indirect coomps test

2- Blood transfusion

3- SAB & Amniocentesis & Trauma

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23
Q

How you determine RH group of the fetus

A
  • Cell free DNA testing (in mother’s blood)
  • Amniocentesis
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24
Q

If MCA doppler of baby reveals High flow, it means:

A

Fetal Anaemia

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25
Q

If mother isn’t immuned for rubella & varcilla, should they have vaccines in pregnancy?

A

Never, Mx is:
- Avoid exposure
- Postpartum immunisation

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26
Q

Mx of Hepatitis B in pregnancy

A
  • Vaccine in pregnancy is OK
  • HBUG & HBV after birth
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27
Q

Mx of Hepatitis B in pregnancy

A
  • Vaccine in pregnancy is ok
  • HBIG & HBV after birth
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28
Q

Gestational DM screenings?

A

-Screening (Performed 24 to 28 weeks):
50 gram, one-hour glucose challenge test(GCT)

  • Diagnostic test:
    • 100-gram, three-hour oral glucose tolerance test (GTT)
    • Fasting for 6 hours
    • Baseline, one-hour(180) , two-hour (155) , and three-hour (140) glucose testing
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29
Q

What vaccines pregnant woman should take

A
  • Tetanus
  • Influenza
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30
Q

What Maternal Serum Markers Abnormal levels associated with aneuploidy

A

بابا ينحب على الفا وبيتا وسيستر الي انفصل عنها

  • PPAAP,A
  • Inhibin A
  • AFP
  • BHCG
  • Unconjugated Estriol
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31
Q

What are the trisomies and how you differentiate between them

A

1- Down (21) ~> Nuchal T + Inhibin A + BHCG
الBHCG طويل في الي يكوله يصير منغولي لإن ينعوج حلكه ويظل ينحب

2- Edward (18) ~> Nuchal T

3- Ptau (13) ~> Determined by U/S

Note/ In 1st trimester only U/S but in 2nd maternal lab

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32
Q

When AFP get high and low

A

High:
- Multiple gestation
- Abdominal wall defects
- NTD
- Incorrect Dating

Low:
- Trisomy 21, 18
- Fetal demise
- Incorrect dating

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33
Q

How diagnose aneuploidy definitely

A
  • Chorion villous sampling (10-13wks) لإن الماي قليل متكدر تسوي الجوا
  • Amniocentesis (15-20wks)
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34
Q

What’s Reactive and non reactive NST

A

Reactive
- 2 accelerations in 20m

Non reactive
- Insufficient accelerations after 40m
DDx ~> (Sleep & Hypoxia) for baby and hypoglycaemia for mom
Mx ~> Repeat after 30m & Vibroacoustic stimulation & U/S & Biophysical profile

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35
Q

What’s Biophysical profile

A
  • NST
  • 4 U/S parameters:
    Movement & Tone & Breathing & Amniotic fluid volume
    حركة بشدة عالية تخليك تعرك وتتنفس اسرع

6~> Repeat in 24hrs
0-4 ~> Delivery

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36
Q

How you asses fetus during pregnancy

A
  • NST
  • Contraction stress test
  • Biophysical profile
  • Umbilical artery doppler
  • AF index
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37
Q

Talk about umbilical artery doppler

A

Determines flow velocity and direction
• Flow should not stop and always be forward
• Absent or backward diastolic flow = abnormal
• Absence of end-diastolic flow velocity (AEDV)
• Reversal of end-diastolic flow velocity (REDV) -fetal demise imminent (indicates urgent delivery)

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38
Q

Braxton hix contractions

A
  • Irregular
  • Not increase in frequency & duration & intensity over time
  • Relieved by analgesics
  • Not associated with cervical changes
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39
Q

Breech presentation subtypes

A

• Frank breech (50-75%): rear first,flexed hips,extended knees
• Footling breech (20%): one or both legs first
• Complete breech (5-10%): rear first, flexed hips and knees

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40
Q

What’s effacement and how you know it’s started

A
  • Thining & Shortening & Softening

“Bloody show”
• Blood-tinged mucous released vaginally
• Associated with onset of effacement

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41
Q

Bishop score

A

• Clinical tool for assessment of cervix in pregnant women according to:
- Dilation
- Effacement
- Position
- Consistency
- Station of fetus

• Maximum score = 13

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42
Q

Cardinal movement

A

EFDI ERE
• Engagement
• Flexion
• Descent
• Internal rotation
• Extension
• External rotation = restitution
• Expulsion

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43
Q

Time in hours for each stage in labour

A
  • Latent ~> 8-10
  • Active ~> 4-6 (1cm per hour)
  • 2nd ~> 2
  • 3rd ~> 30m
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44
Q

Indications for IOL
بشرط البيشوب اكبر او يساوي 6

A
  • Post date or term
  • Oligohydramnios
  • IUGR
  • IUD
  • PROM
  • Intrahepatic cholestasis
  • Maternal alloimmunization
  • Gestational diabetes at term
  • Twin beyond 38 weeks
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45
Q

CI of induction of labour

A
  • Complete placenta praevia or Vasa praevia
  • Transverse lie
  • Cord prolapse
  • Previous classical caesarean section or myomectomy
  • Fetal distress
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46
Q

Oxytocin side effects

A
  • Tachysystole (may cause rupture or fetal hypoxemia)
  • Hyponatremia (Same action of ADH)
  • Hypotension (relaxes vascular smooth muscles)
  • Fatigue & Sleepiness
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47
Q

What are Abnormal Labor Patterns in First Stage

A

• Protracted latent phase (dilation<6cm)

• Protracted active phase (dilation>6cm)
- Dilation progress less than1cm/hour

• Arrested active phase
- No cervical changes in 4hrs despite efficient uterine contractions

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48
Q

Causes of protracted (prolonged) 2nd stage

A
  • CPD
  • Malposition (OP)
  • Hypotonic concentrations
  • Inefficient mother’s push

Note/ Intervention by Instruments or Oxytocin or CS

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49
Q

How to diagnose ROM

A
  • Speculum (pooling of fluid in posterior vaginal vault)
  • Oligohydramnios in U/S
  • Amniocure
  • Nitrazzine test
  • Fern test
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50
Q

Post term pregnancy complications

A
  • Macrosomia
  • Dysmaturity syndrome
  • Oligohydramnios
  • Mortality
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51
Q

Group B streptococcus infection manifest as

A
  • Asymptomatic bacteriuria
  • UTI
  • Chorioamniotitis
  • Postpartum endometritis
  • Neonatal sepsis
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52
Q

When we give ABx prophylaxis to a pregnant woman before labour

A
  • Positive culture for GBS
  • GBS infection during pregnancy
  • Hx of neonatal GBS infection
  • Preterm labour
  • PPROM
  • Prolonged ROM
  • Fever

Note/ ABx given 4 hours prior to delivery

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53
Q

What ABx given for prophylaxis of GBS infection

A
  • Ampicillin or penicillin
    If allergy with low anaphylaxis risk ~> Cefazolin
    If allergy with high anaphylaxis risk ~> Clindamycin & Vancomycin
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54
Q

S&S of chorioamniotitis

A

• Fever
• Maternal leukocytosis
• Maternal tachycardia
• Fetal tachycardia (>160/min)
• Uterine tenderness
• Purulent or malodorous amniotic fluid
• Rarely bacteremia (usually with GBS or E.coli)

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55
Q

Mx of chorioamniotitis

A
  • Broad spectrum ABx
    • Intrapartum: ampicillin and gentamycin
    • Cesarean delivery: add clindamycin or metronidazole
  • Prompt IOL or CS
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56
Q

Deceleration types and causes

A
  • Early ~> Head compression
  • Late ~> Placental insufficiency
  • Variable ~> Cord compression or Oligohydramnios
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57
Q

Risks of preterm birth

A
  • Hx of preterm labour
  • Polyhdramnios
  • Multiple gestation
  • Cervical insufficiency
  • Infection
  • DM
  • Smokinh
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58
Q

Mx of PPROM

A

If more than 36wks ~> Delivery
If less:
- Steroids
- Azithromycin + Ampicillin

If has contractions or any signs of maternal of fetal distress ~> Delivery

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59
Q

How can you predict preterm labour

A
  • Cervical length in 13,16 weeks
  • Fetal fibronectin in 22, 34 weeks
  • Cervical dilation
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60
Q

Mx of preterm labour

A

• Beyond 34 weeks: admit and deliver
• Before 34 weeks:
- Maternal betamethasone (Tocolytic drugs to give steroids time to work)
- GBS prophylaxis (penicillin, ampicillin or clindamycin)
- Magnesium sulfate: neuroprotective (reduce risk of cerebral palsy according to ACOG)

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61
Q

How you identify miscarriage or SAB

A

• Often identified by falling serial hCG levels or ultrasound findings
• Presents clinically as vaginal bleeding and pelvic cramping

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62
Q

Causes of SAB

A

• Fetal chromosomal anomalies
• Maternal anatomic anomalies
• Uterine fibroids
• Uterine polyps or septa
• Abnormal implantation
• Corpus luteum failure
• TORCH infections
• Trauma

Risks:
- Age > 35
- Maternal (DM, HTN, Thyroid)
- Smoking & Alcohol

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63
Q

When you say this is complete abortion

A

Documented pregnancy & Closed OS & No RPOC on U/S & Vaginal bleeding with cramping

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64
Q

كيف تميز بين الاسقاط المحتمل والمفروغ منه

A

اثنينهم بيهم الم ونزف والطفل عايش بس عنق الرحم اذا انفتح يعني سيتم اسقاط

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65
Q

Causes of bleeding that resolves

A

• Implantation at time menses
• Cervical trauma during intercourse
• Subchorionic haemorrhage (due to developing placenta)

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66
Q

How you deal with abortion medically

A
  • Mifepristone: progesterone antagonist
    • Causes endometrial degeneration
    • Only dispensed to limited facilities that perform terminations
  • Misoprostol: prostaglandin E1 analog
    • Causes uterine contractions
    • Must be hemodynamically stable
    • Must have no evidence of hemorrhage or infection
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67
Q

شلون تعرف الطفل مات

A

تجيك الأم تكلك مدا احس الطفل يتحرك فمن تفحص لا تسمع نبض للطفل ولا تشوف حجم الرحم يناسب عمر الطفل ومن تسوي سونار صدك يطلع ماكو نبض

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68
Q

طفل ومات ببطن امه شتسوي فحوصات

A

• Fetal autopsy
• Placental examination
• Drug screen
• Fetal chromosome testing
• Testing for antiphospholipid syndrome
• Testing for fetomaternal hemorrhage

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69
Q

الطفل اذا مات ببطن امه هم ممكن يسوي sepsis

A

فقط في حالة الأم تعمدت تسوي اسقاط ودخلت شغلات غريبة بجسمها فتشوفها جايتك مصخنة وبيها ريحة افرازات تشك الخشم

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70
Q

Kleihauer-Betke acid elution assay

A

• Test of red cells in maternal circulation
• Detects hemoglobin F in fetal red cells
• Reports percentage fetal red cells in circulation

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71
Q

شوكت نكول هاي الأم عندها اسقاطات متكررة وشنو الأسباب

A
  • More than 3 consecutive pregnancies
  • Causes:
    — Genetic
    — Uterus ~> Cervical insufficiency & Polyp & Fibroid & Adhesions
    — Immunological ~> APS
    — Endocrine ~> Hypothyroidism & DM
    — Haematological ~> Hypercoaguable state
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72
Q

When we say there’s cervical insufficiency

A
  • Obstetric Hx ~> Pregnancy loss with no Sx
  • Examination ~> Dilated & Effaced in early pregnancy
  • U/S ~> Cervical length < 25 mm
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73
Q

Sites of ectopic pregnancy

A
  • Fallopian Tubes ( Ampulla > Isthmus > Fimbrae)
  • Abdomen
  • Cervix
  • Scar
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74
Q

What HTN in Pregnancy called

A

• It is a sign of an underlying pathology that may be preexisting or appears for the first-time during pregnancy that is why it is also called as TOXEMIA OF PREGNANCY

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75
Q

How you define proteinuria

A

• 300 mg/24 hour.
• 100 mg/dl concentration or more in 2 random specimens taken 6 hour apart
• +1 on dip stick method.

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76
Q

How PET classified

A

• Mild: diastolic blood pressure 90–99 mmHg, systolic blood pressure 140–149 mmHg

• Moderate: diastolic blood pressure 100–109 mmHg, systolic blood pressure 150–159 mmHg

• Severe: diastolic blood pressure ≥110 mmHg, systolic blood pressure ≥160 mmHg

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77
Q

Risk Factors for PIH (pregnancy induced hypertension)

A
  • 18 > Age > 45
  • APS & SLE
  • Hx in previous pregnancy or Family Hx or being Primi
  • MP & Molar
  • BMI > 35 & DM
  • Chronic hypertension
  • Chronic renal disease
  • Smoking
  • Booking proteinuria
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78
Q

Gestational HTN

A

sustained rise of blood pressure to 140/90 mm of Hg or more on at least two occasions 4 or more hours apart beyond the 20th week of pregnancy or within the first 48 hours of delivery in the absence of other findings suggestive of preeclampsia in a previously normotensive women

Note/ if BP returns to baseline by 12 weeks postpartum = Transient hypertension of pregnancy
Note/ ثلثهم يصيرون بريكلامسيا

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79
Q

Postnatal investigation, monitoring and treatment of gestational HTN

A

• Measure blood pressure as clinically indicated
• Reduce antihypertensive treatment if their blood pressure falls below 130/80mmHg
• If a woman on methyldopa, stop 2 days after birth and change to alternative treatment if necessary
• women who did not take antihypertensive treatment and have given birth, treatment if their blood pressure is 150/100mmHg or higher.
• Offer all women medical review with their GP or specialist 6–8 weeks after birth

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80
Q

Define PE

A

It is a multisystem disorder of unknown etiology characterized by development of hypertension to the extent of 140/90 mm of Hg or more recorded on at least two separate occasions and at least 4 hours apart and in the presence of at least 300 mg protein in a 24-hour collection of urine, arising de novo after the 20th week of pregnancy in a previously normotensive, non-protein uric women and resolving completely by the sixth postpartum week

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81
Q

What are the eye Sx in PET

A

Eye symptoms- blurring, flashing lights, dimness of vision or at times complete blindness.
regained within 4-6 weeks following delivery

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82
Q

When we say this is mild-moderate PE

A

• BP<160 systolic and <110 diastolic with significant proteinuria and no maternal complications
2+ protein OR >300 mg proteinuria/ 24h

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83
Q

How you manage Mild-Moderate PE

A

• admission is advised:
• protein: creatinine ratio, the normal value In general is >30 equates to >300 mg proteinuria/ 24h
• 2-hourly BP
• 24 h urine collection for protein
• Daily fetal assessment with CTG
• Regular blood test (every 2-3 days unless symptoms or signs worsen)
• Regular US assessment

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84
Q

How you define severe PET

A

• blood pressure of 160/ 110mmHg or more in the presence of significant proteinuria
(>1g/24hor >or=2+ on dipstick) or if maternal complications occur

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85
Q

How you manage severe PET

A

• Offer pharmacological treatment to all women. Aim for BP of 135/85 mmHg or less

• Blood pressure measurement: Every 15–30 minutes until BP is less than 160/110 mmHg, then at least 4 times daily while the woman is an inpatient, depending on clinical circumstances

• Dipstick proteinuria testing: Only repeat if clinically indicated

• Blood tests: Measure full blood count, liver function and renal function 3 times a week

• Strict fluid balance chart, consider a catheter

• Fetal assessment: ultrasound assessment of the fetus, evidence of IUGR, estimate weight if severely preterm, assess condition using fetal and umbilical artery doppler

• CTG monitoring of the fetus

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86
Q

Anti hypertensive drugs

A

Aldomate (appears after 48 hours):
- Reduce Sympathetic drive
- Dose: 250-500 mg every 6-8 hours up to a maximum dose of 4gm/day.
- Loading single dose of 2 gm may act within 1-2 hours

Hydralazine:
- It is a vasodilator, increases renal and uteroplacental blood flow
- Dose: Initially 5 to 10 mg by slow intravenous injection

Nifidepine:
- Can be given sublingually (acts within 10 minutes) or orally (acts within 30 minutes) in a
- Dose: 10-20 mg 2-3 times daily

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87
Q

What are fetal indications (in doppler and CTG) for immediate delivery regarding PE

A

• reversed end-diastolic flow in the umbilical artery Doppler velocimetry
• non reassuring cardiotocography, or IUD

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88
Q

Timing of birth in PE

A

• Before 34 weeks:
- Continue surveillance, intravenous magnesium sulfate and a course of antenatal corticosteroids

• From 34 to 36+6 weeks:
- Planned early birth
- Course of antenatal corticosteroids

• 37 weeks onwards; Initiate birth within 24–48 hours

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89
Q

Postnatal investigation, monitoring and treatment of PE

A
  • In women who did not take antihypertensive treatment:
    • measure blood pressure at least 4 times a day while the woman is an inpatient
    • start antihypertensive treatment if blood pressure is 150/ 100mmHg or higher
    • Ask women about severe headache and epigastric pain each time blood pressure is measured
  • In women with pre-eclampsia who took antihypertensive treatment and have given birth:
  • measure blood pressure at least 4 times a day while the woman is an inpatient
  • every 1–2 days for up to 2 weeks after transfer to community care until the woman is off treatment and has no hypertension

• Reduce antihypertensive treatment if their blood pressure falls below 130/80 mmHg
• If a woman has taken methyldopa to treat pre-eclampsia, stop within 2 days after the birth and change to an alternative treatment if necessary
• Measure platelet count, transaminases and serum creatinine 48–72 hours after birth

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90
Q

What percentage of PE complicated by Eclampsia and when

A

• It complicate 1-2% of preeclamptic pregnancies
• May be the initial presentation of PE and may occur before hypertension or proteinuria
• Ante - Intra - Post (within 48h)

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91
Q

Mx of Eclampsia

A
  • CABC
  • IV access
  • CBC & RFT & LFT & LDH & GUE
  • MgSO4 (watch for toxicity every 1h)
  • Antihypertensive if 160/110
  • Foley catheter
  • Strict monitoring for Vital signs & CTG
  • Deliver once mom is stable (hird stage, 5-10U oxytocin, no Ergometrine because of increase BP)
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92
Q

How we give MgSO4

A

MgSo4 for control of fits and preventing further seizures.
Loading 4g over 5-10min followed by an infusion 1g/h for 24h.
Further 2g if further fits

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93
Q

When we give MgSO4

A

• ongoing or recurring severe headaches
• visual scotomata
• nausea or vomiting
• epigastric pain
• oliguria and severe hypertension
• progressive deterioration in laboratory blood tests

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94
Q

What drugs you give for urgent BP control in Pregnancy

A

Labetolol:
10 – 20 mg IV, then 20 – 80 mg every 20 – 30 minutes to a maximum dose of 300 mg
Constant infusion 1 – 2 mg/min IV

Hydralazine:
5 mg IV or IM, then 5 – 10 mg IV every 20 – 40 min
Constant infusion 0.5 – 10 mg/h

Nifedipine:
10 - 20 mg orally, repeat in 30 minutes if needed, then 10 - 20 mg every 2 - 6 hours

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95
Q

How you know MgSO4 toxicated your patient

A
  • Confusion
  • Loss of reflexes
  • Respiratory depression
  • Hypotension
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96
Q

How you manage MgSO4 toxicity

A

• Stop MgSO4
• IV 1 g 10% calcium gluconate slow
• Administer Oxygen

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97
Q

What percentage of PE complicated by HEELP

A
  • 5-20% of preeclamptic pregnancies
  • Liver enzymes increase, platelets decrease before hemolysis occurs
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98
Q

What are S&S for HEELP

A

Symptoms:
• Epigastric or RUQ pain
• Nausea and vomiting
• Urine is tea-colored due to hemolysis

Signs:
• Tenderness in RUQ
• Increase BP and other features of PE (Hypertension may be mild or even absent)
• Eclampsia may co-exist

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99
Q

Mx of HEELP

A

• Treatment is supportive and as for eclampsia (MgSo4 is indicated)
• Although platelet levels may be very low, infusions only required if bleeding, or for surgery and <40

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100
Q

Corticosteroids to manage HELLP syndrome

A

Do not use dexamethasone or betamethasone for the treatment of HELLP syndrome

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101
Q

Chronic hypertension in pregnancy

A

The presence of HTN of any cause antedating or before the 20th week & beyond the 12w after delivery

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102
Q

Fetal monitoring in chronic hypertension

A

• Ultrasound for fetal growth, amniotic fluid volume assessment, and umbilical artery doppler velocimetry at 28 weeks, 32 weeks and 36 weeks

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103
Q

How you manage chronic hypertension in pregnancy

A

Note/ If BP normal or low: no treatment

  • Weight management & Exercise & Diet
  • Aspirin 75 mg once daily from 12 weeks until 4w before delivery
  • Consider labetalol to treat chronic hypertension in pregnant women. Nifedipine for women in whom labetalol is not suitable, or methyldopa if both labetalol and nifedipine are not suitable
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104
Q

Chronic hypertension in pregnancy & Timing of birth

A

Do not offer planned early birth before 37 weeks to women with chronic hypertension whose blood pressure is lower than 160/110 mmHg, with or without antihypertensive treatment, unless there are other medical indications

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105
Q

Treatment of HTN during lactation

A

• Enalapril to treat hypertension in women during the postnatal period, with appropriate monitoring of maternal renal function and maternal serum potassium

• Nifedipine or Amlodipine if the woman previously used this to successfully control her blood pressure

• Atenolol or labetalol to the combination treatment

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106
Q

What’s HG

A
  • Weight loss
  • Muscle wasting
  • ketonuria
  • Dehydration
  • Electrolyte disturbance
  • ptyalism (inability to swallow saliva)
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107
Q

DDx of HG

A

Obstetrical causes:
• Multiple gestation
• GTN

Non obstetrical causes:
• Renal problem :UTI (which often coincides with hyperemesis)
• Electrolyte disturbance: hypercalcaemia
• Endocrine : Addison’s disease & thyrotoxicosis & DKA
• GIT: Cholecystitis & Appendicitis
• Neurological: Raised intracranial pressure

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108
Q

Risks of HG

A
  • Missed abortion
  • IUGR
  • Preterm labour
  • Maternal hyponatraemia leading to central pontine myelinolysis
  • Thiamine deficiency leading to Wernicke’s encephalopathy
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109
Q

Hx of HG

A

– Abdominal pain
– Urinary symptoms
– Infection, fever
– Drug history
– FBM
– Vaginal bleeding
– Headache
– Chrome H.Pylori infection
– Thyroid, DM

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110
Q

Investigations for HG

A
  • CBC
  • U/S
  • Dipstick for ketonuria
  • TFT & LFT & RFT
  • Urea & electrolyte
  • Serum Glucose
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111
Q

When you admit patient with vomiting

A

● Continued nausea and vomiting and inability to keep down oral antiemetics
● Continued nausea and vomiting associated with ketonuria and/or weight loss (greater than 5% of body weight), despite oral antiemetics
● Confirmed or suspected comorbidity (such as urinary tract infection and inability to tolerate oral antibiotics)

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112
Q

1st line Tx of vomiting

A
  • Cyclizine 50mg every 8h
  • Promethazine
  • Prochlorperazine
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113
Q

2nd line Tx of vomiting

A
  • Metaclopramide
  • Ondasetron
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114
Q

3rd line Tx of Vomiting

A

Corticosteroids

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115
Q

Things to avoid in Tx in HG

A

• Pyridoxine is not recommended for NVP and HG
• Diazepam is not recommended for the management
• Dextrose infusions are not appropriate unless the serum sodium levels are normal and thiamine has been administered

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116
Q

Non pharmacological Tx of NVP

A

● Frequent small meal
● Good hydration
● Avoiding iron-containing preparations
● Rest with psychological support
● Ginger (1000mg): may be used by women wishing avoid antiemetic therapies in mild-moderate NVP
● Acustimulations : acupuncture, acupressure

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117
Q

What are the dimensions of pelvic brim

A
  • Antroposterior ( true conjugate) : 11 cm
  • Transverse (widest) : 13.5cm
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118
Q

Dimensions of pelvic cavity

A

TD, APD: 12 cm

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119
Q

How you assess adequacy of pelvic cavity

A

1- Assess the sacrum ( straight or curved)

2- palpation of the sacrospinous ligaments,which should be of a length that will accommodate three fingers-breadths

3- Palpate side walls( concave, straight, converging)

4- prominence of ischial spines, & interspinous diameter

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120
Q

Dimensions of pelvic outlet

A
  • AP: 13.5 cm (Widest) is measured from the lower part of symphysis pubis to the lower end of the sacrum (not the coccyx because it is a movable bone)
  • TD: is measured between the inner surface of the ischial tuberosities : 11cm.
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121
Q

How you assess adequacy of pelvic outlet

A
  • The intertuberous diameter can be determined by external palpation using closed fist. Intertuberous diameter should accept 4 knuckles on pelvic exam (10 cm)
  • Wide Sub-pubic arch (Broad), Accept ˃2 fingers
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122
Q

What’s the best pelvis for vaginal delivery

A
  • Sacral promontory can not be felt
  • Diagonal conjugate: ˃11.5 cm
  • Curved concave sacrum
  • Ischial spines are not prominent
  • Interspinous diameter: ˃ 9.5 cm
  • Intertuberous diameter accept 4 knuckles on pelvic exam ≥10 cm
  • Wide Subpubic arch. Accept ≥ 2 fingers
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123
Q

Angle of inclination

A
  • It is the angle that any pelvic plane makes with the horizontal
  • The angle of the inlet is normally 60 to the horizontal in the erect position
    More angle = delay the head entering the pelvis during labour
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124
Q

Pelvic axis

A

Imaginary curved line which shows the part which the fetal head follows during its passage through the pelvis during childbirth

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125
Q

Plateyloid pelvis

A

Pelvic brim TD&raquo_space;>APD Æ kidney shape
Sacral promontory pushed forwards

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126
Q

Anthropoid

A

Pelvic brim APD > TD
Long & narrow pelvic canal with long, concave sacrum
Divergent pelvic sidewalls

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127
Q

Android pelvis

A

Pelvic brim is heart shaped or triangular
Pelvis funnels from above downwards (convergent sidewalls)
Prominent ischial spine
Straight sacrum → contracted pelvic outlet
Narrow pubic arch

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128
Q

Gynecoid pelvis

A

TD diameter ˃ APD (inlet)
Rounded—slightly oval inlet
Straight pelvic sidewalls with roomy pelvic cavity Good sacral curve Concave
Ischial spines are not prominent
Wide subpubic arch ˃ 90 ̊

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129
Q

The skull is formed of the face , the vault & the base
What’s vault?

A

The bones of the vault (not joined) are frontal , parietal & occipital, temporal

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130
Q

Occiput, Sinciput and vertex?

A
  • Occiput
    boney prominence behind post fontanelle
  • Vertex
    diamond shaped area between ant & post fontanelles & parietal eminences
  • Sinciput
    The area in front of the anterior fontanelle
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131
Q

Sutures of fetal skull

A
  1. Sagittal suture: between 2 parietal bones
  2. Frontal suture: between 2 frontal bones
  3. Coronal suture: between parietal & frontal
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132
Q

Fontanelles

A

1.the anterior fontanelle: (bregma)
2.the posterior fontanelle: (lambda)

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133
Q

In OP position, what’s the attitude of fetal skull

A

Ociipitofrontal 11.5 cm

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134
Q

In brow presentation, what’s the attitude of fetal skull

A

Mentovertical 13.5cm

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135
Q

In face presentation, what’s the attitude of fetal skull

A

Submento vertical (bregmatic) 9.5cm

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136
Q

HCG half life, peak and function

A

Half life of 6- 24 hr
Peak in pregnancy at 9-11wk gestation
يحافظ على الجستيشنال ساك حتى تتكون المشيمة

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137
Q

Pregnancy tests

A

Urine:
- By rapid dipstick test (1-2 min)
- Detection limit of around 50iu/L
- Positive 14 days after ovulation

Blood:
- Detection limit around 0.1-0.3 iu/L
- It can detct pregnancy 6-7 days after ovulation

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138
Q

When U/S can detect pregnancy

A
  • TVS the GS can be visualized(2-4mm) around 4.4-4.6 wk(32-34 days) following the onset of LMP
  • Abdominal US, GS can be seen during the 5th wk post menstruation
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139
Q

The 1st embryonic structure seen inside the chorionic cavity is

A

Secondary yolk sac, which indicate a true gestational sac thus excluding the possibility of a peudosac or an ectopic pregnancy

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140
Q

Why do plasma volume rise in pregnancy

A

Steroids cause S&W retention

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141
Q

Acceptable levels of HB in pregnancy

A

A level of Hb≥ 11g/dl is adequate in 1st trimester
A level of ≥10.5g/dl is adequate in 2nd& 3rd trimester
A level of ≥10g/dl is adequate postpartum

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142
Q

How diaphragm affected by pregnancy

A

Diaphragm is elevated 4 cm

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143
Q

Cardiac output varies with stages of labour

A

• 1st stage and 2nd stage.
- ↑ H.R because of Pain, maternal effort.
- ↑plasma volume. Uterine contractions which seqeezes 300- 500 ml into maternal circulation

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144
Q

How uterus affected by pregnancy

A
  • Pear shaped, 6.5cm, 70 gm, Pelvic organ
    In pregnancy, oval shape, 32cm long, 1000gm (Hypertrophy & hyperplasia of muscle cells)
  • It has two parts: corpus body & cervix
    3rd trimester uterus — upper and lower segment
  • Uterine blood flow 700ml/min
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145
Q

Chadwick sign

A

Increase vascularity = Bluish discolouration of cervix

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146
Q

How blood glucose affected by pregnancy

A

• In 1st half of pregnancy FBS reduced
• In 2nd half FBS ↑( increased insulin resistance)

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147
Q

Incidence of breech presentation

A

• Incidence :20% at 28 wks
• 3-4% at term

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148
Q

Causes of breech presentation

A

• Maternal :fibroids ,congenital uterine abnormalities and uterine surgery

• Fetal :multiple gestation ,prematurity ,fetal abnormality (anencephaly or hydrocephaly),
fetal neuromuscular conditions ,oligohydramnios and polyhydramnios

• Placental: placenta praevia

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149
Q

When we perform ECV

A

Performed at or after completed 37 wks

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150
Q

How we perform ECV

A
  • Experienced obstetrician
  • Nifedipine
  • Left lateral tilt
  • Empty bladder
  • U/S Guidance
  • Shouldn’t last more than 10m
  • anti D should be given if the women is RH negative
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151
Q

CI to ECV

A

• Fetal abnormalities like hydrocephalus
• Placenta praevia
• Oligohydramnios or polyhydramnios
• History of APH
• Previous cesarean or myomectomy scar on the uterus
• Multiple gestation
• Preeclampsia or hypertension
• Plan to deliver by caesarean section

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152
Q

Complications of ECV

A

• placental abruption
• premature rupture of membrane
• cord accident
• Transplacental haemorrhage
• Fetal bradycardia

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153
Q

How you deliver breech baby vaginally

A

• Delivery of buttocks with episiotomy can be cut when fetal anus seen at maternal fourchette
• Delivery of the leg by pinard manoeuver
• Delivery of the body
• Delivery of shoulders by Lovesets manoeuver
• The head is delivered by Mawriceau Smellie Veit manoeuver or by using forceps

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154
Q

Source of amniotic fluid

A
  • secreted by amnion but by 10th weeks via the skin and umbilical cord
  • At 16th weeks gestation the fluid will mainly formed of fetal urine ,and lung secretion
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155
Q

If woman reached term what will happen to amniotic fluid, increase or decrease

A

From term there is rapid fall in volume

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156
Q

What are the functions of amniotic fluid (4p’s)

A
  • Protect the fetus from mechanical injury
  • Permit movement of fetus and prevent limb contractures
  • Permit fetal lung development
  • Prevent adhesions between fetus and amnion
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157
Q

How you diagnose Polyhydramnios

A

DVP = 8cm
AFI = 25 cm (above 95 centile)

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158
Q

Causes of Polyhydramnios

A
  • 2/3rd are idiopathic
  • Fetal causes that is associated with impaired swallowing like esophageal atresia,duodenal atresia
  • Anencephaly
  • Twin to twin transfusion syndrome
  • Parvovirus B19 infection
  • Maternal causes like multiple pregnancies ,maternal diabetes mellitus and Rh incompatibility
  • Lithium
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159
Q

Mx of polyhydramnios

A
  • Tx of the cause if possible
  • Amniodrainage
  • Assessing the risk of preterm labour due to uterine overdistension
  • Pharmacological like NSAID (indomethacin ) and sulindac
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160
Q

Complications of polyhydramnios

A

Maternal:
Respiratory compromise - abdominal discomfort - APH - PPH - Preterm labour

Fetal:
Congenital malformations - Preterm birth - Increased perinatal morbidity and stillbirth
umbilical cord prolapse - abnormal fetal presentation

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161
Q

How you diagnose Oligohydramnios

A

AFI of less than 5 cm or DVP of less than 2cm

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162
Q

Causes of oligohydramnios

A
  • Idiopathic
  • Preterm premature rupture of membrane
  • Birth defect like renal agenesis ,renal dysplasia and posterior urethral valve
  • Post term pregnancy >40wks
  • Placental dysfunction like placental thrombosis infarction and placental abruption
  • Maternal diseases like GDM ,preeclampsia ,chronic hypertension and connective tissue diseases
  • Drugs like ACE inhibitor and NSAID
  • Fetal chromosomal abnormalities
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163
Q

Clinical presentation of oligohydramnios

A
  • Patient may give history of leaking liquor
  • The patient may give history of reduced fetal movement
  • Fundal height is less than the expected for corresponding gestational age
  • Uterus appear full of fetus
  • Examination by speculum may reveal leaking liquor
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164
Q

Investigations for Oligohydramnios

A
  • U/S examination to assess AFI, DVP and Doppler study
  • Biophysical profile
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165
Q

Complications of oligohydramnios

A

Maternal:
- Operative delivery
- Preterm labour
- Miscarriage

Fetal:
- Cord compression
- Pressure deformities like club foot
- Lung hypoplasia
- Meconium aspiration
- IUFD

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166
Q

When we say this pregnancy is high risk

A
  • Maternal age <18 or >35
  • Chronic disease – hypertension, diabetes, cardiovascular or renal disease, thyroid disorder
  • Preeclampsia
  • Rh isoimmunization
  • History of stillbirth
  • FGR
  • Postterm pregnancy
  • Multiple gestation
  • History of preterm labor
  • Previous cervical incompetence
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167
Q

What factors can reduce fetal movement

A

• Sleep
• Sound
• Smoking
• Drugs
• Blood glucose level

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168
Q

What’s Non stress test (NST)

A
  • Monitoring the fetal heart rate in response to fetal movement

• Reactive: 2 or more FHR accelerations at least 15 bpm with duration of at least 15 seconds in 20m
• Nonreactive NST: reactive criteria not met within 30 minutes

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169
Q

Fetal Acoustic & Vibroacoustic Stimulation

A

• Applied to maternal abdomen for 2-5 seconds up to 3 times
• Stimulates fetal movement - acceleration of FHR

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170
Q

Contraction stress test

A

• Records FHR response to stress of uterine contractions (Compress arteries to placenta)
• Uterine Contractions induced by nipple stimulation or Oxytocin (Caution: may cause pt to go into labor!)

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171
Q

What are interpretations of contraction stress test

A

– Negative: 3 good contractions lasting 40 seconds in 10 minute interval with no late decelerations

– Positive: persistent late decelerations with more than 50% of the contractions

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172
Q

What you can know by U/S regarding pregnancy

A

• Early identification of pregnancy & dating & gender
• FHR and breathing movements
• Anomalies
• Amniotic fluid index
• Location of placenta and grading
• Fetal death
• Determination of fetal position and presentation
• Accompanying procedures (ex: Amniocentesis)

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173
Q

US assessment of fetal well-being

A

• Amniotic fluid assessment
• Biophysical profile
• Umbilical artery & MCA Doppler

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174
Q

What’s biophysical profile

A

1) Fetal breathing movement
2) Fetal movement of body or limbs
3) Fetal tone
4) Amniotic fluid volume
5) Reactive NST with activity

• Scoring:
– 2 is given for normal
– 0 is given for an abnormal finding
– Between 8-10 is good

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175
Q

When doppler is abnormal

A

Absent or reversed velocities abnormal

Note/ We use ut for anaemia & echo & preeclampsia & fetal wellbeing

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176
Q

Why we do amniocentesis

A

– Genetics
– Fetal lung maturity

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177
Q

شلون تعرف الطفل عنده IUGR شنو اول شي يصير والتغيرات الي تلحقه بعدين

A

حركته تقل بعدها الماي يقل لإن ميبول بعدها تغيرات بالدوبلر ومن ثم يموت

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178
Q

Normal fetal growth

A

• Cellular hyperplasia.(8- 20w) symetric
• Hyperplasia and hypertrophy (20-28) mixed
• Hypertrophy only. (28-40) asymetric

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179
Q

Symmetrical IUGR causes and definition

A

• Head circumference, length and weight are all proportionally reduced

• Causes:
1- chromosomal or genetics abnormality or anomalies
2- congenital infection
3- maternal cause ( age, weight, hypertension, smoking, alcohol abuse, thrombophilia, nutrition)

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180
Q

ASYMETRICAL IUGR definition

A

• Fetal weight is reduced , but normal length and head circumference

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181
Q

What parameters in U/S determine the type of IUGR and what determine management

A

BPD & FL & Abdominal circumference = Type
Amniotic volume & Doppler ultrasound = Mx

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182
Q

The optimum timing of delivery is determined by

A

• Gestational age
• Underlying etiology
• Fetal condition

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183
Q

Role of steroids

A

Steroids reduce the incidence of RDS, IVH and death

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184
Q

Mx of IUFD

A

• Confirmation of IUFD
• Base line investigation (Blood group , Rh, fibrinogen, CBC)
• Induction of labor
• Caesarean section

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185
Q

Post delivery Mx for IUFD

A

• Psychological support
• Suppression of lactation (dopamine agonists)
• Evaluation of the new born baby (اوديه للأطفال يشوفون شنو سبب الموت حتى اتجنبه بالأحمال السابقة)

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186
Q

What’s Shoulder dystocia

A
  • The anterior shoulder becomes trapped behind the symphysis pubis
  • The posterior shoulder may be in the hollow of the sacrum or high above the sacral promontory
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187
Q

Causes of Shoulder dystocia

A

• Fetal Macrosomia
• Maternal Obesity
• Instrumental delivery
• Anencephaly
• Fetal ascites or congenital abnormalities

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188
Q

How you may know that shoulder dystocia is about to happen

A

Once the head delivered it looks like it is trying to return to vagina, which is caused by reverse traction

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189
Q

Mx of Shoulder dystocia

A

H = Call for help
E = Episiotomy
L = Leg (McRobbert)
P = Suprapubic Pressure
E = Entermaneuver (Rubin & Clockscrew)
R = Arm (Wood)
Cleidotomy
Zavenelli
Craniotomy if baby is dead

Note/ All done for 30s

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190
Q

Complications of shoulder dystocia

A
  • The vessel in the fetal neck are occluded after delivery of the head and cerebral damage will occur if delivery is delayed more than 5 minutes
  • Erbs palsy if traction
  • PPH
  • CS in next pregnancy
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191
Q

What’s the thing you advice women to take before pregnancy and antenatally

A

All pregnant women advised to take folic acid (0.4 mg, once daily) pre-pregnancy and antenatally

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192
Q

Aim of ANC

A

• To optimize pregnancy outcomes for women and babies
• To prevent, detect and manage those factors that adversely affect the mother and baby
• To provide advice, reassurance, education and support for the woman and her family
• To deal with the ‘minor ailments’ of pregnancy
• To provide general health screening

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193
Q

What things you should do in booking visit

A
  • BMI
  • BP
  • Dietary & Exercise advice
  • Investigations (CBC & B GROUP & RH & SICKLE CELL & THALASSEMIA & GUE & OGTT)
  • Infections screening (HBV & HCV & STI & RUBELLA)
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194
Q

What acceptable weight should pregnant woman gain

A

If normal BMI = 11-16
If overweight BMI = 7-11
If obese BMI = 5-9

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195
Q

What are maternal complications of obesity

A

MATERNAL ANTENATAL:
• Difficult to assess growth and anatomy of the fetus
• Increase risk of GDM (3 times >BMI<30)
• HT disorders of pregnancy
• Risk of VTE

Maternal intrapartum :
• Difficulty with anesthesia
• Difficulty with monitoring in labour
• Increase instrumental delivery ,c/s rate
• Shoulder dystocia

• Maternal postnatal :
• VTE risk
• Wand break down and infection
• Postnatal depression

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196
Q

What are the fetal complications of obesity

A
  1. Increase congenital malformations :NTD 3 times (folic acid 5mg /day)
  2. Macrosomia
  3. FGR
  4. Miscarrage & Stillbirth
  5. Increase risk of childhood obesity and diabetis
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197
Q

Aspirin فوائد

A
  • IUGR
  • PRETERM BIRTH
  • MISCARRIAGE
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198
Q

اذا عرفت وحدة عندها ضغط باول ترايمستر شتسويلها او شنو تستفاد من هالمعلومة

A

This enables early initiation of treatment including antihypertensive agents and low-dose aspirin

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199
Q

Complications of Rubella

A
  • Blindness
  • Deafness
  • Intracranial calcification
  • Handicap
  • Mental retard
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200
Q

وحدة عندها HBV وجابت شتسوي للطفل

A

The infant should receive hepatitis B vaccine and one dose of hepatitis B immune globulin within the first 12 hours of life ,1 and 6 months of age

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201
Q

How you can deal with patient having HIV in pregnancy

A
  • Antiretroviral therapy (ART) by 24 weeks’ gestation
  • Planned elective c/s for those with viral load ≥400 HIV RNA copies/ml at 36wk gestation
  • Exclusive formula feeding
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202
Q

When it’s the best time to do dating U/S

A

Best performed between 11+3 and 13+6 weeks’ gestation when the
crown–rump length (CRL) measures between 45 and 84 mm

203
Q

How you predict preterm birth

A

Serial cervical length screening with or without fetal fibronectin to detect increased risk of preterm birth

204
Q

From which week we start to measure SFH

205
Q

What group of women should receive 5mg of folic acid

A

5mg for those with: Previous h/o NTD ,DM,SCA,OBESITY, EBELIPSY

206
Q

Mx of backache in pregnancy

A

• Excessive weight gain should be avoided
• Rest with elevation of the legs to flex the hips
• Massaging the back muscles
• Analgesics and rest

207
Q

Mx of leg cramps in pregnancy

A
  • Supplementary calcium therapy after the principal meals may be effective
  • Massaging the leg
  • Local heat and vitamin B1
208
Q

Mx of N&V in pregnancy

A

تاكل بسكت وتوست واطعمة غنية بالبروتين بس تبتعد عن الدهون وتخلي وجباتها frequent & small

209
Q

Mx of constipation in pregnancy

A
  • Taking plenty of fluids & milk & vegetables
  • Stool softeners
210
Q

Mx of varicose veins in pregnancy

A
  • Elastic crepe bandage during movements
  • Elevation of the limbs during rest
211
Q

Mx of acidity and heartburn in pregnancy

A
  • Avoid overeating before bed
  • Antacids
212
Q

Mx of haemorrhoids in pregnancy

A
  • Laxative to keep the bowel soft
  • Local application of hydrocortisone ointment
  • Replacement of piles
213
Q

شنو اهم شي تسويه بالFirst trimester بخصوص الANC

A

اهم شي تسويه بأول ترايمستر هو الBooking visit وشغلاته ال5 وتدور انفكشن وتسوي سونار وتدور تشوهات وتحدد خطورة الحمل

214
Q

Risk factors for developing diabetes in pregnancy

A
  • Having DM before pregnancy
  • Hx of GDM in previous pregnancy
  • Hx of macrosomia & Polyhydramnios
  • Family Hx of DM
  • High BMI
215
Q

If woman is high risk to develop DM when you perform OGTT

A

• Women with history of GDM should have 75mg OGTT at 16–18 weeks’ gestation
• The test should be repeated at 24–28 weeks of pregnancy

216
Q

Is the rate of MP increasing or decreasing

A

The high prevalence of multiple pregnancy is explained by increasing use of assisted fertility

217
Q

Complications of MP

A
  • All physiological changes like N&V and Heartburn exaggerated
  • HTN & DM
  • APH & PPH
  • PRETERM LABOUR, Especially if Di,Di
  • THROMBO EMBOLITIC DISEASE
  • IUGR
  • Fetal mortality as result of extreme prematurity
218
Q

Does Increasing maternal age is one of the key risk factors for multiple pregnancy
Why?

A

Yes, one theory is that older women have high FSH

219
Q

How MP classified

A
  • Number of fertilized eggs: zygosity (dizygotic 70% or monozygotic 30%)
  • Number of placentae: chorionicity
  • Number of amniotic cavities: amnionicity
220
Q

Lambda sign

A

Impn the dichorionic type there is an extension of placental tissue into the base of the inter-twin membrane, forming the lambda sign

221
Q

معلومة شاطحة عن التوأم

A
  • Dichorionic, Diamniotic have the two cavities are separated by thick three-layer membrane
    fused amnion in the middle with chorion on either side
  • The vast majority of monochorionic twins have two amniotic cavities (diamniotic) but the dividing membrane is thin, as it consists of a single layer of amnion alone
222
Q

Monozygotic twins chorions and amnions according to days of separation

A

Di - Di = Before day 4 (shortly after fertilisation)
Monochorionic - Diamniotic = Between 4 to 8
Mono - Mono = After 8 to 12
Conjoid = After 13

223
Q

U/S in MP

A

Regular ultrasound assessment is used to date the pregnancy, perform first trimester screening and to monitor growth every 2 weeks

224
Q

Anaemia in MP (ANC)

A

Full blood count should be checked at 20 and 28 weeks’ gestation and supplementation with iron, folic acid or vitamin B12 initiated

225
Q

قارن بين معدل الوفيات في جماعة المشيمة الواحدة والمشيمتين

A

المشيمة الواحدة ٣٠ لكل الف
المشيمتين ٣،٨ لكل الف
اي ان معدل الوفيات هو عشر اضعاف

226
Q

اذا التوأم واحد بيهم مات، هل يفرق ان يكونون مونوكوريون او داي كوريون

A
  • Fetal death of one twin in monochorionic twins may result in immediate complications in the survivor
    (Death or handicup)
    وبهذول يكون اصلا معدل نقص النمو اكبر وحتلو مات واحد حاول متجيب قبل ال٢٨-٣٠
  • If dichorionic, intrauterine death of one fetus may be associated with the onset of labour
227
Q

TTT syndrome unique to

A

Monochorionic twin (10% of monochorionic diamniotic pregnancies and 5% in monoamniotic)

228
Q

TTTS is diagnosed based on the following ultrasound criteria:

A

Single placental mass
Concordant gender
Oligohydramnios with maximum vertical pool (MVP) less than 2 cm in one sac
Polyhydramnios in the other sac (MVP >8 cm)
Discordant bladder appearances
Haemodynamic and cardiac compromise

229
Q

Quintero staging

A
  • Stage I: oligo and poly sequence and bladder of donor twin visible Dopplers in both twins are normal
  • StageII: oligo and poly sequence, but bladder of donor not visualized, Dopplers in both twins normal
  • Stage III: oligo and poly sequence, non-visualized bladder and abnormal Dopplers. There is absent/reversed end-diastolic velocity in the umbilical artery, reversed flow in a-wave of the DV or pulsatile flow in the umbilical vein in either fetus
  • Stage IV: One or both fetuses show signs of hydrops
  • Stage V: One or both fetuses have died
230
Q

Definitive treatment for severe TTT syndrome for severe (defined as Quintero stage II or above) TTTS

A
  • Between 16 and 26 weeks’ gestation Fetoscopic laser ablation:
    Under ultrasound guidance a 2–3 mm diameter fetoscope is introduced into the amniotic cavity of the recipient twin. Following the laser therapy, the fetoscope is removed and an amnioreduction is performed until the amniotic fluid volume appears normal by ultrasound
  • Above 26 weeks, delivery may be considered
231
Q

Mono-mono, talk about hospitalisation & delivery & complications

A
  • Hospitalized from 28 weeks’ gestation and fetal heart auscultation performed several times daily using cardiotocography in an effort to detect signs of cord compression
  • Delivery by caesarean section generally at 32–34 weeks’ gestation
  • Congenital anomalies including neural tube defects and abdominal wall and urinary tract malformations & Discordant birthweight affects 20% of surviving twin
232
Q

How many ANC appointments does pregnant woman with twin needs

A
  • 9 if monochorionic
  • 8 if dichorionic
233
Q

Screening in MP

A
  • Dating U/S to accurately estimate GA (CRL), To determine chorionicity (number of placental masses and assessing for the lambda or Tsign and membrane thickness), To screen for Down’s syndrome
  • DV at 11–13 weeks’ gestation may help identify monochorionic pregnancies at risk of severe TTTS as reversed a-wave is associated with an increased risk of developing severe TTTS
  • Both amniocentesis and chorion villous sampling (CVS) can be performed in twin pregnancies, but in dichorionic pregnancies, it is essential that both fetuses are sampled
234
Q

Monozygotic or dizygotic twins, which one carries higher risk

A
  • Monozygotic twins are two to three times more likely to have structural defects than dizygotic twins or singleton fetuses. These include anencephaly and holoprosencephaly
  • In general only 1 affected so, if dichorionic do selected feticide but if monochorionic do cord occlusion
235
Q

Growth assessment in MP

A

Growth assessments Multiple pregnancies are at high risk of FGR. As a result, fetal weight should be calculated from 20 weeks’ gestation at a maximum of 4 week intervals. A growth discrepancy of 25% or greater should be considered clinically significant

236
Q

Time of delivery in MP

A
  • Dichorionic twin pregnancies delivery from 37 weeks
  • monochorionic twin pregnancies should be offered elective delivery from 36 weeks
237
Q

Triplet pregnancy ANC & Time of delivery

A
  • Monochorionic triamniotic and dichorionic triamniotic triplet pregnancies be offered at least 11 antenatal appointments with a health care professional from the core team
  • It is not recommended to prolong pregnancy beyond 36 weeks’ gestation
238
Q

Define anaemia in pregnancy according to CDC

A
  • Hemoglobin level of less than 11 g/dL, or hematocrit less than 33%, the first or third trimester
  • Hemoglobin less than 10.5 g/dL, or hematocrit less than 32% in the second trimester
239
Q

How you classify anaemia according to it’s severity

A

• Mild: 10-11 gm/dl
• Moderate: 7-10 gm/dl
• Severe: 4-7 gm/dl
• Very severe: <4 gm/dl

240
Q

Criteria for physiological anaemia

A

• Hb: 10gm%

• PCV: 30%

• RBC: 3.2 million/mm3

• Peripheral smear showing normal morphology of RBC with central pallor

241
Q

Effects of anaemia on mother & pregnancy

A
  • Higher incidence of (PET, placenta previa, abruption, preterm labor or PROM)
  • Predisposed to infections like – UTI, puerperal sepsis
  • Poor weight gain
  • Dysfunctional Labour
  • Increased risk to PPH
  • Sub involution of uterus
  • Lactation failure
  • Maternal mortality – due to CHF & Cerebral anoxia & postnatal sepsis
242
Q

S&S of anaemia

A
  • Symptoms
    weakness, fatigue, dyspnoea, palpitation, Loss of appetite, Digestive upset
  • Signs
    pallor, facial puffiness, tachycardia, tachypnea, Pale Tongue, Glossitis, stomatitis, chelosis, &brittle hair
243
Q

Hx of anaemia

A
  • Age
  • Parity
  • Diet
  • Chronic bleeding
  • Worm infestation
  • Piqua
  • S&S of anaemia
244
Q

شوكت تسوي فحوصات الانيميا

A

Hb & Haematocrit, at first visit, 28-30 weeks & 36

245
Q

Examination of anaemia

A
  • Pallor
  • Glossitis
  • Splenomegaly & Jaundice in hemolytic anemia
  • Purpura – bleeding disorder
  • Evidence of chronic disease – Renal, TB
  • Anasarca & signs of cardiac failure in severe cases
246
Q

If it decreases, it’s one of the most sensitive indices in anaemia

247
Q

Risks for IDA

A
  • Diet
  • MP or Short intervals between pregnancies
  • Piqua
  • Absorption defects (worm infestation, amoebiasis, giardiasis)
  • Increases loss
248
Q

Requirements of iron intake

A

4-6 mg daily & 1000mg in total:
- 2.5 mg/day in early pregnancy
- 5.5 mg/day from 20-32 weeks
- 6-8 mg/day from 32 weeks onwards

249
Q

Iron studies

A

↓ ↓ Serum ferritin – first abnormal laboratory test
↓ ↓ Transferrin saturation – second to be affected
↑ ↑ Serum transferrin receptor – best indicator
TIBC

250
Q

Mx of IDA When anemia is of mild to moderate degree and there is time (>30days) before EDD

A
  • Oral iron therapy with 200 mg elemental iron with 5mg Folic acid / day
    Will improve the Hb by 0.8 gm in week
251
Q

Mx of IDA in moderate anemic, pregnancy near term (32-34 weeks), or oral iron is not tolerated

A
  • Parenteral Iron therapy should be considered (Sucrose & Sorbitol & Dextran)
  • Parenteral therapy will take 4-6 weeks to reach their optimal effect
252
Q

Mx of IDA when Hb is < 5gm % or pt. is near term or obstetrical hemorrhage

A
  • Blood transfusion.
  • PCV transfusion, if available is preferred than Whole Blood خصوصاً اذا عندها مشاكل بالقلب
253
Q

Mx of IDA to the patients having chronic renal disease complicating pregnancy and to non-responders to oral / parenteral iron therapy

A

Recomponent EPO

254
Q

Daily folate requirement

A
  • Non pregnant women –——– 50 -100 microgram
  • Pregnant woman –——– 300- 400 microgram
255
Q

Dx of folate deficiency anaemia

A
  • Increased MCV (> 100 fl)
  • Peripheral smear: - Macrocytosis, hypochromia
  • Hypersegmented neutrophils (> 5 lobes)
  • Neutropenia
  • Thrombocytopenia
  • Low Serum folate level
256
Q

Dx & Tx of Vitamin B12 deficiency

A
  • Vitamin B12 level < 80 pico g/ml
  • Vit B12 1mg I/M weekly for 6 weeks
257
Q

Heterotopic pregnancy

A

The simultaneous development of two pregnancies: one within and one outside the uterine cavity

258
Q

Causes of ectopic pregnancy
Hx of Ectopic Pregnancy

A
  • Tubal factors (Ligation & Infection & Surgery (even abdominal) & Endometriosis)
  • IVF & Ovulation induction (PRG effect)
  • Uterine causes (IUD & uterine synechiae & multiple fibroids)
  • Age
  • Smoking
259
Q

Threesome of ectopic pregnancy Dx

A

Amenorrhea
Abdominal pain
Vaginal bleeding

260
Q

What should not do in patient suspected to have ectopic pregnancy that may induce rupture

A

Speculum or bimanual examination should not be performed

261
Q

Empty uterus with an adnexal mass in TV U/S means what and what if it was associated with Free fluid

A
  • Sensitivity 90% and specificity of 95% in the diagnosis of EP
  • The presence of moderate to significant free fluid is suggestive of a ruptured EP
262
Q

B-HCG in women with ectopic

A
  • In patients with EP, the rise of hCG is often suboptimal
  • 1500-2000 HCG & empty uterus & adnexal mass = EP
263
Q

What’s PUL and what investigations should be done

A
  • A PUL is a working diagnosis defined as an empty uterus with no evidence of an adnexal mass on TVUSS (in a patient with a positive pregnancy test)

Investigation of a PUL
• consecutive measurement of serum hCG concentrations
• An endometrial biopsy can occasionally be helpful when hCG levels are static
• laparoscopy or laparotomy to visually confirm an ectopic pregnancy or PUL and other organs, This takes place in an operating room with anesthesia

264
Q

When we choose expectant management for ectopic

A

• patient is hemodynamically stable and asymptomatic (and remain so)
• less than 100 ml fluid in the pouch of Douglas
• hCG less than 1000 iu/l at initial presentation
• Adnexal mass less than 3cm

265
Q

When we choose MTX as Mx for EP

A

• No hemodynamic instability
• No tubal rupture
• Fertility desired
• Gestational sac < 4cm
• Beta HCG level < 5000mIu/ml
• No cardiac motion on USG (nonviable fetus)
• Ability and willingness to comply with follow up

266
Q

Dose of MTX and follow up

A
  • 50 mg/m2
  • measured on days 4, 7 and 11, then weekly thereafter until undetectable
267
Q

CI for MTX

A

(1) chronic liver, renal or hematological disorder
(2) active infection
(3) Immunodeficiency
(4) breastfeeding

268
Q

What 2 important advice you want to give to patient’s taking MTX

A
  • Avoid intercourse during Tx and 3months after it avoid conceive
  • Avoid sunlight exposure & Alcohol
269
Q

Dx & Mx of thalasemia

A
  • CBC / Low mcv & mch but normal mchc
  • Smear / nucleated RBC
  • Electrophoresis / HbA2 Minor & Hb F major

Mx:
- Parenteral iron should be avoided because of iron overload
- If no respond to oral folate —I/M folic acid
- Blood transfusion close to time of delivery

270
Q

Sickeling crises

A

Under hypoxic conditions, HbS polymerizes, gels or crystallizes leading to hemolysis of cells
& thrombosis of vessels in various organs (due to necrosis)
In long standing cases, multiple organ damage frequently occurs in pregnancy, puerperium & in state of hypoxia like general anesthesia G/A and Haemorrhage

271
Q

Complication of sickle cell anaemia in pregnancy

A
  • Infertlility
  • Abortion and still birth
  • IUGR & premature birth
  • Preeclampsia
  • placental abruption
  • Painful crisis
272
Q

Antenatal care for patients with sickle cell anaemia

A
  • Visit every 2 wks up to 28 wks and then weekly until delivery
  • Regular monitoring of Bp and urinalysis for proteinuria for early diagnosis of pre-eclampsia
  • Folic acid 5mg
273
Q

Can we use Ergometrine for patients with sickle cell anaemia

A

Never, due to risk of hypertension

274
Q

What things patients having sickle cell anaemia should do after delivery

A
  • Continue iron (if deficient) & folate therapy for 3 months after delivery
  • Take progestin only contraceptives
275
Q

Can we give estrogen contraceptives or IUCD for patients with sickle cell anaemia

A

Never, mini pills only

276
Q

شنو اكثر شي تنساه بالدگنزة مال مسكرج

277
Q

Risk factors for prolonged pregnancy

A
  1. History of previous prolonged pregnancy
  2. Inaccurate dating
  3. Anencephaly, fetal adrenal hypoplasia
  4. Nulliparous / white ethnicity
  5. Male fetus
  6. Obese
278
Q

Risks of prolonged pregnancy on mother

A
  • Labour dystocia
  • Shoulder dystocia
  • Increase operative delivery
  • PPH
  • C/S rate
  • Emotional impact
279
Q

1st trimester miscarriage causes

A

• Genetic: Chromosomal abnormalities (50%)
• Luteal Phase Defect (LPD), Deficient progesterone, Thyroid abnormalities, Diabetes mellitus
• Haemoglobinopathies
• Infections but Spirochetes hardly cause abortion before 20th week because of effective thickness of placental barrier
• Drugs/chemicals. methotrexate, some antiepileptic drugs
• Immunological: Antiphospholipid antibody syndrome (APAS), autoimmune

280
Q

2nd trimester miscarriage causes

A

• Cervical incompetence
• Infection, may occur with or without ruptured membranes
• Thrombophilias
• Uterine abnormalities: submucous fibroids, uterine congenital malformation, uterine septa
• Chromosomal abnormalities: may not become apparent until the second trimester.
• Environmental: Cigarette smoking, alcohol, X-ray exposure, Contraceptive agents—IUD
• Blood group incompatibility
• Unexplained (M/C)

281
Q

Biochemical pregnancy loss

A

Pregnancy not located on scan where there is/has been a positive pregnancy test which subsequently becomes negative

282
Q

Empty sac or false pregnancy

A

Gestational sac with absent or minimal structure

283
Q

Hx of miscarriage

A

• LMP: regularity, use of contraception around time of conception, (for calculating GA)
• Symptoms: pain and/or bleeding.
• Past obstetric and gynecological history may provide evidence for sexually transmitted infection or pelvic inflammatory disease. It is important to ascertain the last smear date and any history of cervical abnormality/colposcopic treatment
• Past medical history: poorly controlled diabetes mellitus is known to be associated with miscarriage
• Medication: prescribed, non-prescribed and recreational

284
Q

Examination for patients with miscarriage

A
  • General: Vital signs
  • Abdominal: SFH & Site of pain & Internal bleeding
  • Vaginal: Cervix opening & Local causes of bleeding & Any cervical abnormalities
285
Q

Investigations for miscarriage

A
  • CBC & Blood group & RH
  • Virology screening
  • U/S
  • HCG
  • PRG
286
Q

How HCG indicates failure of pregnancy

A

13% decrease in 48h are associated with a possible ectopic pregnancy; and a decrease of more than 13% is associated with a failing pregnancy

287
Q

Can PRG indicates miscarriage

A

Progesterone level equal to or below 10ng/mL predicted a non-viable pregnancy in 96.8% of cases

288
Q

What you should consider in expectant management of miscarriage

A

• A repeat ultrasound scan is not required to confirm completion
• Women may be advised to take a urinary pregnancy test after 3 weeks and attend if it is positive

289
Q

What’s the medical Tx fir miscarriage

A

• PG E1 (misoprostol) 800 mg vaginally in the posterior fornix is given and repeated after 24h
• Pretreatment with the progesterone antagonist mifepristone (if over 9 weeks’ gestation)
• Post treatment Pregnancy test recommended
• Surgical intervention may be needed if bleeding is heavy or medical Mx failed

290
Q

When we go for surgical Mx for miscarriage

A
  • Failed Medical Tx
  • Hemodynamically unstable patient
  • Heavy bleeding
  • Patient’s preference
291
Q

Mx of Inevitable miscarriage

A

• Active Treatment: Before 12 weeks: D&C
• After 12 weeks: The uterine contraction is accelerated by oxytocin drip
• If the placenta is not separated, digital separation under general anesthesia

292
Q

Mx of incomplete abortion

A
  • Medical management: Tablet misoprostol 200 µg is used vaginally every 4 hours
  • Evacuation of the retained products of conception (ERCP) is done
    Early abortion: Dilatation and evacuation under analgesia or general anaesthesia
    Late abortion: Uterus evacuated under GA and products removed by ovum forceps or blunt curette
  • The removed materials are subjected to a histological examination
293
Q

Investigations for septic abortion

A

• Cervical or high vaginal swab for culture& sensitivity
• CBC and blood for culture
• ABO and Rh grouping.
• Urine analysis including culture
• Ultrasonography (utero-fallopian sepsis)
• Plain X-ray

294
Q

Complications of septic abortion

A

• Haemorrhage & Injury due to abortion process and also due to injury inflicted during interference
• Spread of infection leads to Generalized peritonitis
• Acute renal failure
• Lungs: atelectasis, ARDS
• Thrombophlebitis (Dic)
• maternal deaths

Remote: chronic debility, chronic pelvic pain and backache, dyspareunia, ectopic
pregnancy, secondary infertility due to tubal blockage and emotional depression

295
Q

Due septic abortion needs surgery

A

• Injury to the uterus or to bowel
• Foreign body in abdomen seen by U/S or X- ray or felt through fornix on bimanual examination
• Unresponsive peritonitis suggestive of collection of pus.
• Septic shock or oliguria not responding to the conservative treatment.
• Uterus too big to be safely evacuated per vagina

296
Q

Causes of recurrent abortionn

A

• Genetic factors (3–5%): Parental chromosomal abnormalities
• Endocrine and metabolic: DM, Presence of thyroid autoantibodies, Luteal phase defect (LPD) & PCOS
• Infection
• Inherited thrombophilia
• Autoimmune Disease (APS)
• Unexplained

297
Q

Antibodies in lupus or APS

A

lupus anticoagulant
anticardiolipin antibodies
anti b glycoprotein-I

298
Q

How to be systematic in remembering causes of abortion

A

Genetic - Anatomic - Endocrine - Haematological - Immunological - Infection

299
Q

Investigations for recurrent miscarriages

A

• Blood-glucose (fasting and postprandial), thyroid function test
• VDRL for STI
• ABO and Rh grouping (husband and wife)
• Toxoplasma antibodies IgG and IgM
• Autoimmune screening—lupus anticoagulant and anticardiolipin antibodies (APHS)
• Serum LH on D2 /D3 of the cycle
• Ultrasonography—to detect congenital malformation of uterus, polycystic ovaries and uterine fibroid
• HAG in the secretory phase to detect cervical incompetence, uterine synechiae and malformation
• Karyotyping (husband and wife)
• Endocervical swab to detect chlamydia, mycoplasma and bacterial vaginosis

300
Q

Tx of APS during pregnancy

A

low-dose aspirin (75 mg/day) & low molecular weight heparin (LMWH) up to 34 weeks

301
Q

What’s the dose of Anti-D and we give it to whom

A
  • Dose of 50 µg (250 IU) as soon as possible and within 72 hours of the surgery
  • Anti-D immunoglobulin should be given to all non-sensitized RhD-negative women who have a spontaneous miscarriage after 12 weeks of pregnancy but not required for threatened, incomplete or complete natural miscarriage (unless non sensitised) and PUL
302
Q

شكد لازم يكون السكر التراكمي للمرأة حتى تكدر تحمل

A

HbA1c of < 42 mmol/mol (4-7) without inducing hypoglycaemia

ملاحظة/ هاي النسبة لازم تكون نفسها حتى تكدر تجيب ويطلع الطفل معنده هبوط

303
Q

In pregnant women in her 1st trimester, can HbA1c be beneficial

A
  • The level of HbA1c in early pregnancy also correlates with the risk of early fetal loss
  • An HbA1c of >85 mmol/mol is associated with a fetal loss during pregnancy of around 30%
304
Q

Fetal Complications of uncontrolled DM o

A
  • Sacral agenesis
  • PDA & VSD
  • Spina bifida
  • Polyhydramnios & preterm birth
  • Lung hypoplasia
  • IUFD or Stillbirth
  • Macrosomia & Shoulder dystocia
  • Neonatal hypoglycaemia
305
Q

Pregnant women with uncontrolled DM at high risk 3 fold to develop PET, how you prevent this

A

Low-dose aspirin from 12 weeks’ gestation

306
Q

How you minimise risk of retinopathy in Diabetic pregnant women

A

Retinal screening at booking, 16–20 weeks’ and 28 weeks’ gestation

307
Q

Maternal complications of DM

A
  • PET
  • Retinopathy
  • Nephropathy
  • Infection
  • DKA
  • Instrumental delivery
308
Q

How many times you encourage pregnant women to measure her blood glucose and what’s you targer

A
  • 7 times a day (before and 1 hour after meals)
  • Targets of with targets of <5.3 mmol/l and 1-hour postprandial levels of <7.8 mmol/l
309
Q

How you adjust the dose of insulin in pregnancy

A

In 2nd trimester increase the dose

310
Q

Anomaly scan done in what week

A

19-20 wks

Note/ increase the dose if you want to give steroids

311
Q

provided the pregnancy has gone well, the aim would be to achieve a vaginal delivery at

A

between 38 and 39 weeks

312
Q

Risk factors for developing DVT in pregnancy

A
  • Age > 35
  • Pregnancy itself
  • Multiparty > 4
  • Smoking
  • Obesity
  • PET
  • APS
  • Infection
  • Thrombophilia
  • Operative delivery
313
Q

Can DVT cause bilateral leg swelling

A

Only in case of IVC blockage
Note/ Bilateral edema more commonly caused by PET & Pregnancy itself

314
Q

Investigations for DVT

A

• Compression Doppler US
• Venography (not used in pregnancy)
• MRI
• D –dimer non specific during pregnancy

315
Q

Prevention & Tx of DVT

A

Prevention:
- Early mobilisation
- Good hydration
- Stockings

Tx/ LMWH = 1mg per kg per day
ملاحظة/ دي في تي وهي حامل مثلا 3 اشهر اول 10 ايام مرتين باليوم بكد وزنها بعدين لحدما تجيب 1 باليوم بكد وزنها

316
Q

Duration of Tx in DVT

A

• For the whole duration of pregnancy
• Following delivery we can convert to warfarin which is safe in breast feeding
• Elastic stocking should be worn for 2 years following DVT to prevent post phlebitis syndrome

317
Q

Side effects of anoxibarin

A

Haematoma
Thrombocytopenia

318
Q

S&S of Pulmonary embolism

A
  • Tachypnoea
  • Dyspnoea
  • Haemoptysis
  • Pleuritic chest pain
  • Tachycardia
  • Cyanosis
  • Pyrexia
  • Syncope or varying degree of shock
319
Q

Investigations for Pulmonary embolism

A

• Chest X- ray, ECG, Blood gases
• Compression Doppler US to exclude DVT
• Ventilation-perfusion isotope lung scan (V/Q)
• Spiral CT
• CT angiography

320
Q

Mx of pulmonary embolism

A
  • C A B C
  • Heparin (LMWH) 1 mg /kg/day *2 ( for 2 weeks) then switched to prophylactic dose of enoxaparin for the whole period of pregnancy
321
Q

شوكت توكف استعمال الهيبارين قبل العملية

A

اذا جرعة وقائية (مرة باليوم) قبل ١٢ ساعة اما اذا دوائية (مرتين) قبل ٢٤ ساعة
وبعد ٦ ساعات من العملية تكدر تبلش وارفرين
اذا هي تستعمل اسبرين لازم ينكطع قبل ٤ اسابيع

322
Q

Causes of APH

A

Maternal: Trauma - Infection - Cervical causes
Fetal: Vasa praevia
Placental: Abruption & PRV

323
Q

Hx of APH

A

• Gravidity and parity/ gestational age
• Amount of bleeding (clots)
• Triggering factors (e.g. postcoital bleed)
• Presence of abdominal pain or contractions
• Fetal movement
• Signs of anaemia
• History of the same condition in this pregnancy or the previous one
• Mode of delivery / any uterine surgery
• Last cervical smear
• Past medical history (hypertension)
• Over distended uterus (multiple pregnancy, polyhydramnious)
• IVF
• Trauma
• Smoking

324
Q

Examination of APH

A

• General look for signs of anaemia
• Vital signs
• Abdomen: soft- hard, tender, contraction
• Fetal heart auscultation/CTG
• Speculum vaginal examination (PL PRV)

325
Q

Investigations for APH

A

• Full blood count,
• Coagulation profile
• Blood group & Rh
• Renal function test
• Ultrasound (fetal size, amniotic fluid, placental position and morphology)

326
Q

Risk factors for placenta abruption

A

• Previous history of abruption
• Hypertension (including preeclampsia)
• Smoking , cocaine
• Trauma
• polyhydramnios
• Multiple pregnancy
• Fetal growth restriction (FGR)
• Thrombophilia (APS)

327
Q

C/F of abruption and Dx

A

Clinical Dx:
- Vaginal bleeding
- Abdominal pain
- Absence or reduced fetal movements
- Sweating
- Shock
- Hypotension
- Tachycardia
- Tense painful abdomen

328
Q

Every abruption has to be associated with tense painful abdomen?

A

The absence of a tense abdomen or ultrasound changes does not rule out a placental abruption

329
Q

Risk factors for having PL PRV

A

• Multiple gestation
• Previous caesarean section/ uterine surgery (curettage)
• Uterine structural anomaly
• Assisted conception
• Increase maternal age
• Submucous Fibroid
• Endometritis

330
Q

Clinical presentation of PL PRV

A
  • The bleeding may trigger preterm labour so often patients with bleeding from placenta praevia will have irregular abdominal pain associated with uterine contractions
  • High SFH
  • Malpresentation
331
Q

Timing of delivery for PL PRV

A

Delivery should be considered between 36+0 and 37+0 weeks

332
Q

How to diagnose and confirm PL PRV

A

If after 16 weeks the placenta thought to be low lying (less than 20 mm from internal os) or praevia (covering the os) at the routine fetal anomaly scan

A follow-up U/S examination including a TVS is recommended at 32 weeks of gestation to diagnose persistent low-lying placenta and/or placenta praevia

333
Q

According to what you subdivide placenta accreta

A

Depending on the depth of villous tissue invasiveness
- Creta: without interposing decidua
- Percreta: villi penetrate deeply into myometrium down to serosa
- Increta: villous tissue perforates through the entire uterine wall

334
Q

The presence of fetal vessels in vasa PRV on cervical os is from

A

Either velamentous insertion of the umbilical cord or may be joining an
accessory (succenturiate) placental lobe

335
Q

Best diagnostic accuracy for vasa praevia

A

Combination of both transabdominal and transvaginal colour doppler imaging (CDI) ultrasonography

336
Q

Timing of delivery in VASA PRV

A

Elective CS should be carried out prior to onset of labour at 34-36 weeks

337
Q

Maternal Complications of APH

A

Anaemia
Infection
Maternal shock
Renal tubular necrosis
Consumptive coagulopathy (DIC)
Postpartum haemorrhage
Prolonged hospital stay
Psychological sequelae
Complications of blood transfusion
Preterm labour

338
Q

Mx of APH

A

● C A B C
● Oxygen by mask at 10–15 litres/minute
● Intravenous access (14-gauge cannula x 2)
● Position left lateral tilt
● Keep the woman warm
● Foley’ catheter
● Until blood is available, infuse up to 3.5 litres of warmed crystalloid solution (2 litres) and/colloid (1–2 litres) as rapidly as required
● Blood transfusion

339
Q

Resuscitation in APH aim to keep

A

• The Hb concentration above 8 g/dL
• The pulse rate below 100 bpm
• The systolic blood pressure above 100 mmHg
• The platelet count above 75 *10 9
• The prothrombin and activated prothrombin times <1.5 * mean control
• Fibrinogen >1 g/L

340
Q

Blood transfusion should be according to HB level?

A

Blood replacement should be based on the amount of blood lost, the vital signs and the likely ongoing clinical scenario, not the haemoglobin

341
Q

Best thing to do in PL Abruption

A

urgency of delivery in an interval from decision to delivery of 20 min or less

342
Q

Ripening

A

Cervix changes in consistency prior to the onset of labour: collagen content and cross‐linking decline and water content increases.
The cervix becomes softer, shortens, moves forward, effaces and starts to dilate

343
Q

Methods of IOL

A
  • Membrane sweeping
  • ARM (amniotomy)
  • Oxytocin infusion
  • Vaginal prostaglandins (PGs)
  • Mifepristone (antiprogesterone) & misoprostol
  • Mechanical methods
344
Q

Sweeping

A

عملية جداً امنة وسهلة كأنك تدخل اصبعك بين البرتقالة وقشرها وعادي يصير نزيف والم
تسويها اسبوعياً بعد الاسبوع الأربعين

345
Q

Amniotomy not indicated as primary method for IOL and if we want to do it there must be:

A

Opened cervical os (ripened cervix )

346
Q

To give oxytocin there must be

A

ROM whether artificial or spontaneous

347
Q

The recommended regimens for PGs in IOL are

A
  • One cycle of vaginal PGE2 tablets or gel: one dose, followed by a second dose after 6 hours if labour is not established (up to maximum two doses)
  • One cycle of vaginal PGE2 controlled-release pessary: 1 dose over 24 hours

اذا اكو سيرفكس مرتب وانطيته فتوصل ولادة خلال 24 ساعة
والخطر من النزيف يكون اقل مقارنة بالARM & Oxytocin

348
Q

Mechanical methods for IOL

A

• Extra‐amniotic saline solution infusion
• Laminaria hygroscopic dilator
• Extra‐amniotic foley catheter placement (Best option)
• Cervical ripening balloon

349
Q

The most important thing you should do prior to use PGs

A

Cardiotocograph should be performed to confirm that the FHR is normal prior to prostaglandin insertion

350
Q

PV & CTG done after PGs use for IOL

A

The cardiotocographic assessement should be repeated when contractions begin, normally 2–6 hours after PG administration

PV every 6 hours to determine if there has been any change in the cervix

351
Q

Relative contraindications to induction of labour:

A

Breech presentation
Preterm gestation
Previous CS

352
Q

When we say IOL failed

A
  • An ARM is still impossible after the maximum number of doses of prostaglandin have been given
  • If the cervix remains uneffaced and less than 3cm dilated after an ARM has been performed and oxytocin has been running for 6-8hours with regular contractions.
353
Q

Complications of IOL

A

• pain
• Failure
• Uterine hyperstimulation
• Cord prolapse
• Emergency caesarean birth
• Intrauterine infection
• Increased risk of PPH
• Increased risk of fetal distress
• Risk of scar rupture in previous CS

354
Q

شنو المحرمات بالنسبة لل IOL

A

• IOL before 34 weeks in absence of any additional risks
• IOL for fetal growth restriction with confirmed fetal compromise
• IOL for history of precipitate labour
• Amniotomy, alone or with oxytocin, as a primary method of IOL

355
Q

What’s the definition of maternal collapse

A

Acute event results in reduced or absent consciousness at any stage in pregnancy and up to 6 weeks after delivery

356
Q

Can women at risk of impending collapse be identified early?

A

An obstetric modified early warning score (MEWS) chart should be used for all women undergoing observation

357
Q

Causes of maternal collapse

A
  • 4H = Hypovolemia & Hypoxia & Hypothermia & Hypo/Hyper kalemia
  • 4T = TED & Toxicity & Tension pneumothorax & Temponade
  • Eclampsia
  • ICH
358
Q

Define AFE

A
  • Presents as collapse during labour or birth, or within (usually) 30 minutes of birth, in the form of
    acute hypotension, respiratory distress and acute hypoxia, Seizures and cardiac arrest may occur
  • هي لو يصير عندها فشل بالقلب لو تعديها بس تدخل بدايس وببتش
359
Q

In patient with AFE and had cardiac arrest, Perimortem caesarean section should be carried out within

A
  • 5 minutes or as soon as possible
  • This is for the benefit of the woman to improve the effect of resuscitation
360
Q

What’s the difference between direct and indirect causes of death related to pregnancy

A
  • Direct death ~> Related to pregnancy so, if she’s not pregnant this will not happen
  • DVT direct but Cardiac disease (ischaemia and sudden arrhythmic cardiac death) not direct
361
Q

Examples of Cardiac diseases in pregnancy

A
  • Ischaemia
  • Sudden arrhythmic cardiac death
  • Dissection of the coronary artery
  • Acute left ventricular failure
  • Infective endocarditis
  • Pulmonary oedema
362
Q

What’s Bacteraemia

A

Bacteraemia, which can be present in the absence of pyrexia or a raised white cell count, can progress rapidly to severe sepsis and septic shock leading to collapse
يعني بدون اعراض

363
Q

The most common organisms implicated in obstetric sepsis are

A
  • Streptococcal groups A, B and D
  • Pneumococcus
  • Escherichia coli
364
Q

Risk factors for developing obstetric sepsis

A
  • PROM & PPROM
  • Immunocompromised patients
  • Obesity
  • DM minority
  • Anaemia
  • UTI
  • Previous pelvic infection
  • Group A & B streptococcal infection
  • Amniocentesis
  • Cervical cerclage
365
Q

Mx of sepsis

A
  • Obtain blood cultures prior to antibiotic administration.
  • Administer broad-spectrum antibiotic within 1 hour of recognition of severe sepsis
  • Measure serum lactate if 4 or more give crystalloid
  • If no response, administer vasopressors for hypotension that not respond to initial fluid resuscitation
  • Aim to achieve:
    mean arterial pressure (MAP) ≥ 65 mmHg (risk for pulmonary edema)
    central venous pressure (CVP) of ≥8 mmHg
    venous oxygen saturation ≥70% or mixed venous oxygen saturation ≥65%

كل ساعة تتأخرها يزيد خطر الوفاة ٨

366
Q

How you define severe sepsis

A
  • Temperature >38ºC
  • 100 beats per minute
  • Respiratory rate >20 respirations per minute
  • White cell count >17 or 10% immature band forms
367
Q

What ABx we use to treat sepsis

A
  • Co amoxylav provides gram-positive and anaerobe cover
  • Clindamycin for streptococci & staphylococci
  • Gentamicin provides gram-negative cover against coliforms and Pesuodomonas
  • Metronidazole for anaerobs
368
Q

Most common drug toxicity in obstetrics

A

MgSo4 in presence of renal impairment or another anaesthetic agent

369
Q

Risk factors for genital tract lacerations

A
  • Rapid labor & delivery
  • Operative delivery
  • Episiotomy
  • Shoulder dystocia
  • Cesarean delivery
  • Uterine rupture
  • Macrosomic fetus
  • Obesity
370
Q

How you classify injuries

A

• 1st degree: includes part of vaginal wall & perineal skin
• 2nd degree: as 1st degree & the perineal muscles (include episiotomy)
• 3rd degree: as 2nd degree in addition to injury to anal sphincter
• 4th degree tears involves injury to anal sphincter extending into rectal mucosa (fecal incontinence)

371
Q

Complications of cervical injury

A

PPH
shock
anemia
(cervical incompetence & preterm labour) in future

372
Q

Risks for cervical detachment

A
  • cervical dystocia
  • During labour with unproved way of removing cervical cerclage
373
Q

Risks for uterine rupture

A
  1. Scar dehiscence
  2. Neglected obstructed labour
  3. Abuse of oxytocin for Induction or augmentation
  4. Forceps use, fetal version
  5. Rupture of rudimentary horn of the uterine cavity
  6. Placenta percreta
  7. Macrosomic fetus
374
Q

Signs & symptoms of impending rupture

A
  • Maternal tachycardia
  • Restless agitated mother
  • Bandl′s ring between upper & lower uterine segment, also a strong, tetanic uterine contractions
  • Abnormal tenderness on the previous scar
  • Sudden change in FHR tracing (deceleration)
375
Q

signs & symptoms of already ruptured uterus

A

• Mother feel something bursts in her abdomen
• stopping of uterine contraction (constant dull pain)
• Fresh bleeding per vagina
• Signs of internal or external haemorrhage (signs of shock are out of proportion to visible blood loss)
• Fetal parts are felt superficially under the abdominal skin, & on PV exam. no presenting part
• Absent fetal heart sounds
• Haematuria (due to pressure of fetal head on bladder or ruptured uterus into bladder)

376
Q

Mx of ruptured uterus

A
  • Immediate resuscitation of ABC
  • prepare the mother for Immediate laparotomy to deliver the baby and repair the uetrus
  • IF the mother is grand multipara & she complete her family → hysterectomy (total, subtotal)
  • IF she is young & the uterus is reparable & she doesn’t complete her family → repair
  • IF she is young & complete her family & the uterus is reparable → repair the uterus with sterilization
377
Q

Causes of VV fistula

A
  • CS
  • Forceps
  • Neglected obstructed labour (appear 1wk after delivery)
  • Uterine rupture
  • During Hysterectomy
378
Q

Does uterine inversion causes shock

A

Traction on peritoneal structures → vasovagal vasodilatation + neurogenic shock

379
Q

Risk factors for uterine inversion

A
  1. Lax atonic uterus
  2. Fundal insertion of the placenta
  3. Short umbilical cord
  4. Morbidly adherent placenta
  5. Precipitate labour
380
Q

Degrees of uterine inversion

A
  • 1st degree:- fundus is turned inside out the uterine cavity, but not protrude outside cervix
  • 2nd degree:- = & protrude from cervix & lies within vagina butnot seen outside introitus
  • 3rd degree :- whole uterus is seen hanging outside the introitus
381
Q

Mx of inversion

A
  1. Resuscitate the patient (ABC)
  2. Two intravenous lines should be started
  3. Not to remove the placenta if it is still attached (this will increase bleeding)
  4. Immediately replace the uterus through the cervix
  5. If this fails, hydrostatic pressure can be applied by pouring warmed normal saline 4-5 L into the vagina
  6. Tocolysis (to relax the cervical ring) & manual replacement under GA. when the uterus is replaced, keep the hand inside uterine cavity, give oxytocin & then separate the placenta if still attached
  7. Last resort, surgery to reposition the uterus from above (pull on the round ligament & the assistance
    pushes the uterus from below)
  8. If this fails, we do longitudinal incision posteriorly
382
Q

Sites of hematoma

A
  • Beneath the skin covering the external genitalia
  • Beneath the vaginal mucosa
  • In the broad ligament
383
Q

Types of Hematoma (classification)

A

• Infralevator hematomas (ischiorectal fossa)
Include those of the vulva & perineal as well as paravaginal hematomas

• Supralevator haematomas (retroperitoneal space)
Spreads upwards & outwards beneath the broad ligament or bulge into the walls of the upper vagina

384
Q

When you intervene surgically to treat hematoma

A

If > 5cm
Give ABx & Analgesics

385
Q

Complications of hematoma

A

Severe pain
Shock
Anaemia
Infection

386
Q

Mx of sub peritoneal hematoma (broad ligament)

A
  • Broad ligament hematoma may be treated either conservatively (expectant) with blood transfusion, fluid resuscitation, and observation
  • If it is not possible to maintain a stable haemodynamic state prompt surgical exploration is recommended & evacuation or hysterectomy may be indicated
387
Q

شلون تعالج الهيماتوما

A

حسب حجمها اذا اقل 5
كونسرفتف واسويلها ماركر بالجلد واخليلها كمادات بارده وانطيها مسكن

اذا اكبر من 5
اسويلها درنج يعني افرغها وانطيها مسكن وانتيبايتك

388
Q

When we can say this is Eclampsia

A

Fitting + HTN after 20 weeks gestation may be attributable to eclampsia, notably where there is no known history of epilepsy

389
Q

Why anaphylaxis is dangerous

A
  • There is significant intravascular volume redistribution, which can lead to decreased cardiac output
  • Acute ventricular failure and myocardial ischaemia may occur
  • Upper airway occlusion secondary to angioedema, bronchospasm and mucous plugging of smaller airways all contribute to significant hypoxia
390
Q

What criteria should met so we can say this is anaphylaxis

A
  1. sudden onset and rapid progression of symptoms
  2. life-threatening airway and/or breathing and/or circulation problems
  3. skin and/or mucosal changes (flushing, urticaria, angioedema)
391
Q

How can you confirm Dx of Anaphylaxis

A

Mast cell tryptase levels

392
Q

How you assess breathing in collapsed patient

A
  • Look for chest movements, listen for breath sounds and feel for air movement for a maximum of 10m
     If breathing is present, give high-flow oxygen
     If breathing is absent, start ventilation
393
Q

In collapsed patient, why we put the patient on left lateral position

A

Minimize aorto-caval compression
Minimize risk of aspiration

394
Q

اذا الairways نظيفة مبيها شي بس ماكو تنفس فشنو المشكلة هنا

A

Absence of circulation

395
Q

How you assess disability

A

AVPU score (Alert, responds to Voice, responds to Pain, Unresponsive)
Glasgow coma score (GCS)

396
Q

When the patient needs intubation

A

GCS 8 or less
Absent breathing

397
Q

After beginning with CPR how long you will wait until decision of delivery is made and why

A

4 minutes, because delivery will help in resuscitation

398
Q

Ideal ANC visits

A
  • Every 4wks until 30
  • Every 2wks until 36
  • Weekly until delivery
399
Q

Adequate ANC visits

A
  • 1 in first trimester
  • 1 in second trimester
  • 2 in third trimester
  • 1 after delivery
400
Q

What questions you should ask in 1st trimester

A
  • N&V
  • Pain
  • Bleeding
  • UTI
  • Infection
  • Folic acid
401
Q

What questions you should ask in 2nd trimester

A
  • N&V
  • Pain
  • Bleeding
  • UTI & Infection
  • Folic acid & Iron
  • Anaemia & Blood transfusion
  • HTN & DM
  • Fetal movement
  • Vaccinations
402
Q

What questions you should ask in 3rd trimester

A
  • Pain
  • Bleeding
  • UTI & Infection
  • Anaemia & Blood transfusion
  • Fetal movement
  • Edema
  • DM & HTN
403
Q

Hx of labour

A

• At home or hospital?
• Onset? (gradual or sudden)
• Duration?»»primigravida»24hr,,,,,multipara»16hr
• Time
• Characters of the pain?
• Spontaneous? Induced?
• Difficult or easy?
• Vaginal delivery, cesarean section, episiotomy, forceps used or not

404
Q

What questions you will ask about baby

A

• Live or dead
• Male or female
• Weight of baby
• Crying after birth
• Infant movement
• Cyanosis –jaundice – anemia – blood exchange
• Fetal distress
• Admission to the neonatal intensive care unit
• Feeding (breast or bottle or mixed)
• Neonatal care
• APGAR score (Appearance – pulse – grimace – activity - respiratory effort)

405
Q

What’s APGAR score

A
  • Appearance
    – Pulse
    – Grimace (irritability)
    – Activity
    – Respiratory effort
406
Q

Most important things to ask to woman who delivered vaginally

A

PPH
DVT
puerperal sepsis

407
Q

Past obstetric Hx

A
  • Date of marriage and her age at that time
  • Date of her first pregnancy
  • Interval between each pregnancy
  • Type of delivery and Place
  • Ask about the baby
  • Pureperium: Fever, bleeding, depression, breast feeding, any complication
408
Q

Family Hx

A

• Any chronic disease (HTN, DM, Thyroid, Epilepsy, TED)
• Consanguineous marriage
• History of twin pregnancy or congenital anomalies or cerebral palsy
• History of Genetic problems
• History of malignancy in family
• History of T.B or allergies or Bleeding disorders or psychiatric disorders

409
Q

شنو اكثر شي تنساه بالهستري مال النزف

A
  • Anaemia
  • Itching & Soreness
  • Thyroid disease
410
Q

شنو اكثر شي تنساه بالهستري مال الم البطن

A
  • Frequency & Intensity & Duration
  • Associated symptoms (VB, FM, fever, nausea, vomiting, dysuria, frequency)
411
Q

How you classify PPH

A
  • Primary within 24 hours of birth
  • Secondary PPH: abnormal or excessive bleeding from the birth canal between 24 hours and 12 weeks
412
Q

When the obstetric haemorrhage becomes major

A

Blood loss ≥2,500 ml
Requiring a blood transfusion ≥5 units red cells
Treatment for coagulopathy (DIC)

413
Q

اكثر سبب تنساه يسوي pph

A

Anaemia & Hx of previous PPH & Full bladder & APH

414
Q

How you can assess amount of blood loss

A

Visually
Weight - Scale
Direct measurement

415
Q

اكثر شي تنساه بالمنجمنت مال اي حالة خطرة

A

Left lateral tilt & Catheter

416
Q

In dic what you should aim for

A
  • To administer FFP at a rate to keep the activated partial thromboplastin:control ratio <1.5;
  • To administer packed platelets to maintain a platelet count >75 × 109/L; 4
  • To administer cryoprecipitate to keep the fibrinogen level >1 g/L.
417
Q

When you should give platelets

A

Platelets should be given if levels fall below 50 × 109/L

418
Q

Complications of PPH

A
  • Renal failure
  • Liver failure
  • DIC
  • Sheehan syndrome
  • Hysterectomy
  • Shock
  • Anemia & complication of blood transfusion
  • ARDS
  • Death
419
Q

Investigations for secondary PPH

A

• CBC
• B-hCG titer
• High and low vaginal swabs & blood cultures if pyrexia
• Pelvic USS may help to exclude the presence of retained products of conception

420
Q

How you can prevent PPH

A
  • Optimize haemoglobin prior to delivery
  • Active management of third stage of labour (AMTSL)
421
Q

AMTSL

A
  1. In less than one minute, administer uterotonic drug
  2. Early cord clamping
  3. Apply controlled cord traction
  4. After delivery of the placenta, immediately start massaging the uterus
  5. Examine the placenta to make sure it is complete and none of it has been retained in the uterus
  6. Examine the woman’s vagina, perineum and external genitalia for lacerations and active bleeding
422
Q

Indications for CS

A

• Multiple pregnancy
• Breech presentation and transverse lie
• Placenta praevia and Morbidly adherent placenta
• Mother-to-child transmission of maternal infections (HIV & HSV)
• CPD
• Fetal macrosomia > 4500 gm
• VV fistula repair
• More than 2 CS

423
Q

Classification of CS urgency

A

• Category 1
– when there is immediate threat to the life of the woman or fetus
– Perform category 1 CS within 30 minutes

• Category 2
– when there is maternal or fetal compromise which is not immediately life threatening
– Perform within 75 minutes

• Category 3
– no maternal or fetal compromise but needs early delivery

• Category 4
– delivery timed to suit woman or staff (elective)

424
Q

Skin incisions in CS

A
  • Joel Cohen: straight, transverse incision
  • Pfannenstiel: low transverse, curved, suprapubic incision 2cm above symphysis pubis
  • Vertical: usually midline sub-umbilical incision
  • Maylard
425
Q

Indications for classical uterine incision in CS

A
  • Transverse lie with SROM and back presenting
  • Fibroids or Structural abnormality that makes lower segment approach difficult
  • Fetal abnormality (conjoint twin, hydrocephalus)
  • Ant PP & abnormally vascular lower segment
  • Mother dead & rapid delivery is required
  • Very preterm delivery
426
Q

Advantages of lower segment in CS

A
  • Low risk of rupture & Haemorrhage & Infection
  • Better healing
    بي ريهه
427
Q

Preparation for CS
١١ الى ١٣ شغلة

A
  • Admission and open file
  • Take detailed history
  • Explain to the Pt & husband all complications and obtain consent
  • Obtain consent for hysterectomy if risky patient
  • Obtain consent for tubal ligation as patient desires
  • CBC & Blood group & RH & Crossmatching of blood
  • Virology screen for HBV & HCV & HIV
  • Mode of anaethesia
  • Catheterize the bladder
  • Thromboprophylaxis
  • Prophylactic antibiotics before skin incision incidence of infection
  • Cut off anticoagulants
  • Control DM & Hypertension
  • Sodium citrate 20 ml , metoclopramide 10 mg IV
  • Fasting for 6-8 hrs
428
Q

Postnatal care of CS
تقريباً عشر اشياء

A
  • Vital signs & blood loss must be monitored.
  • Uterine fundus palpated
  • Hydration
  • Analgesics
  • Remove urinary catheter once woman is mobile after a regional anaesthetic and not sooner than 12 hours after the last epidural ‘top up’ dose
  • Early mobilization
  • Deep breathing & coughing encouraged
  • Wound care
  • Breast care & feeding
  • Prophylaxis for thromboembolism
  • Offer early discharge
429
Q

When to remove catheter in CS

A
  • Remove urinary catheter once woman is mobile after a regional anaesthetic
  • Not sooner than 12 hours after the last epidural ‘top up’ dose
430
Q

Immediate complications of CS

A
  • Anaesthetic complications
  • Bladder or bowel injury
  • Intra abdominal bleeding
  • PPH
  • Wound hematoma
  • Fetal injury
431
Q

Moderate complications of CS

A
  • Paralytic ileus
  • Infection
  • DVT
432
Q

Late complications of CS

A
  • Subfertility
  • Uterine rupture
  • Placenta accreta or preavia
  • Fistula
433
Q

What’s Peurperium

A

Period approximately 6 weeks following delivery

434
Q

مراحل نزول الرحم بعد الولادة

A

• After delivery uterus below level of umbilicus in the midline
• The uterus lies in the pelvis after 2 weeks of delivery
• At 6 weeks post delivery the uterus return to its normal size

435
Q

What are things expected to see in Peurperium

A
  • Lochia
  • Abdominal pain
  • Constipation
  • Dilation of cervix
  • Lactation
  • Secondary PPH
  • Thromboembolism
  • Pyrexia
  • Chest complication (24 hours post delivery)
  • Sepsis
436
Q

Constipation causes in Peurperium

A
  • عندها ابزيوتومي فتخاف تروح للحمام
  • قبل العملية هي اصلا لا ماكلة ولا شاربة
  • من الألم متكدر تاكل
437
Q

Perineum Swelling after delivery completely disappear within

438
Q

How lactation occurs after delivery

A

• During pregnancy , estrogen and progesterone secreted by placenta prepare the breast for lactation. Estrogen inhibit milk production until the end of pregnancy

• After delivery of placenta , the E2 level decrease and stimulation of anterior pituitary to produce prolactine which result in milk production

• Suckling stimulate oxytocin release which cause milk ejection

439
Q

What’s puerperal pyrexia

A

• Temperature of 38 C or more on any two of the first 10 days postpartum

440
Q

Causes of puerperal pyrexia

A

• Chest complication (pneumonia & atelectasis)
• Genital tract infection (wound infection including episiotomy)
• Urinary tract infection
• DVT
• Mastitis

441
Q

How to prevent chest complications in Puerperium

A

اكلها تكح وتضرب ع ظهرها او تكلها احسبي من 1 لل10 واذا عندها بلغم اكلها طلعيه

442
Q

S&S of Puerperal sepsis

A

• Malaise, headache, rigour
• Fever & Tachycardia
• Vomiting and diarrhoea
• Abdominal discomfort (Uterus is boggy and tender) or Peritonism
• Offensive lochia
• Secondary PPH
• Infected wound
• Paralytic ileus
• PV mass fulling in the adnexia - abscess

443
Q

Risk factors for puerperal sepsis

A

• Antenatal intrauterine infection
• Caesarean section
• Cervical circlage
• Prolong rupture of membrane, prolong labour
• Multiple vaginal examination
• Instrumental delivery
• Obesity, DM, HIV
• Manual removal of placenta, retained POC

444
Q

Investigations for puerperal sepsis

A

• CBC (leukocytosis)
• Urea and electrolyte (sepsis may lead to RF)
• HVS (swap)
• US (abscess)
• Clotting screen (DIC)
• Arterial blood gas analysis

445
Q

Tx of puerperal sepsis

A

• Mild to moderate ~> oral broad spectrum antibiotics ( co- amoxiclav + metronidazole)
• Severe infection (septicaemia, septic shock) need intensive care admission and MDT
• Necrotizing fasciatis ~> need debridement of necrotic tissue under GA and skin graft later on

446
Q

What are ABx we use as prophylaxis before delivery or CS

A
  • Single intraoperative dose of (amoxiclav or cephalosporin + metronidazole)
  • Either 4h before delivery or after cord clamping
447
Q

Why we do episiotomy

A
  • Prevention of perineal lacerations by anatomical incision and repair of the episiotomy
  • = prolonged and overstretch of perineum which predisposes to prolapse and stress incontinence
  • Minimising compression and decompression of the head which causes intracranial haemorrhage
448
Q

Advantages of midline episiotomy

A
  • Less blood loss
  • Easier to repair
  • Heals quickly
  • Less pain in postpartum period
  • Less dyspareunia
449
Q

Indications for episiotomy

A
  • Fetal distress
  • Short or inelastic perineum
  • Shoulder dystocia
    *Fetal malposition e.g. occiput post
  • An instrumental
  • Breech delivery
  • Previous pelvic floor surgery
450
Q

What’s the recommendation now to do episiotomy (from to begin and where ends)

A

Now the recommendation is to use mediolateral episiotomy but also must begin in midline and suture 1cm above the apex

451
Q

Causes of preterm labor

A
  • Hx of same condition
  • Infection
  • APH
  • DM
  • Polyhydramnios
  • Macrosomia
  • Cervical insufficiency
  • MP
  • Trauma
  • Smoking
452
Q

What affect fetus in toxoplasmosis infection 1ry or latent infection

A

• 1ry only
• Maternal 1ry infection usually asymptomatic or appear as:
- Lymphadenopathy & Fever & chills & sweats

453
Q

What’s the classic triad for toxoplasmosis infection in children

A

• Hydrocephalus
• Chorioretinitis (inflammation of choroid in eye)
• Intracranial calcifications (often on prenatal US imaging)

454
Q

Tx of toxoplasmosis

A

• Pyrimethamine - sulfadiazine
• leucovorin (used for the 2 above)
• Spiramycin (2-3g /day until delivery)

455
Q

What’s congenital rubella syndrome

A

• Sensorineural deafness
• Congenital cataracts
• Cardiac malformations (classically PDA)
• Purpuric skin lesions (blueberry muffin baby)
• Microcephaly
• Intellectual disability
• Autism

456
Q

How to diagnose and prevent rubella

A

Dx: rubella IgM/IgG or viral culture
Prevention: MMR prior to pregnancy (live vaccine)

457
Q

How diagnosis of asymptomatic bacteriuria made

A

Presence of 100,000 bacterial colonies per ml in freshly voided urine by mid stream clean catch sampling

458
Q

M/C cause of UTI

459
Q

Tx For asymptomatic bacteruria & lower urinary tract infection

A

Nitrofurantoin 100 mg, ampicillin or cephalexin 500 mg for 7- 14 days

460
Q

Tx of pyelonephritis

A
  • Hospitalization, intravenous hydration should be started to get UOP> 30 ml/h
  • Culture & Intravenous antibiotics as cephalosporines, gentamicin or ampicillin 1g /6h
  • Repeat culture after 1 wk from Tx
  • Opiate analgesia can also be given
  • The fetus should be followed up by CTG or US to detect IUGR& oligohydramnios
461
Q

Consequences of Infections in Pregnancy

A

■ Nothing
■ Miscarriage – from fetal infection or maternal pyrexia
■ Congenital malformations
■ Intrauterine growth restriction
■ Preterm labour and delivery
■ Neonatal sepsis/infections

462
Q

What organisim causes GBS infection

A

Streptococcus agalactiae

463
Q

Tx of GBS infection

A

■ Intravenous penicillin 3g as soon as possible after the onset of labour and 1.5g 4-hourly until delivery
■ Clindamycin 900 mg intravenously 8-hourly to those allergic to penicillin

464
Q

Use of nonoxynol-9 spermicidal products or vaginal douching associated with

A

Bacterial vaginosis

465
Q

S&S of Bacterial vaginosis

A

■ ฀Thin, gray or white homogeneous vaginal discharge
■ ฀Increased vaginal discharge odor (fishy) after intercourse
■ ฀Alkaline pH (> 4.5);
■ Bacterial vaginosis does not cause vaginal itching or dysuria

466
Q

Tx of Bacterial vaginosis

A

Metronidazole(Flagyl) 500mg orally twice daily for 7 days

467
Q

Clue cells are diagnostic for

A

Bacterial vaginosis

468
Q

S&S of candiasia

A

■ Vaginal and vulvar irritation (erythematous and oedematous)
■฀Pruritic, white, curd cheesy vaginal discharge ฀
■ Yeasty odor
■฀Dysuria ฀
■ Dyspareunia
■ Wet mount microscopically examined: shows hyphae, pseudohyphae and budding yeast
■ ฀Usually pH more than 4.7

469
Q

Tx of candiasis

A

Antifungal drug intravaginally such as clotrimazole, miconazole or terconazole

470
Q

S&S of gonorrhoea

A

■ ฀Vaginal discharge: may be profuse purulent and yellow green
■ ฀Itching or swelling of vulva ฀
■ Dysuria
■ ฀Dyspareunia
■ ฀Joint and tendon pain
■ ฀Anal discharge, discomfort and pain with rectal infection

471
Q

Dx of gonorrhoea

A

PCR
High vaginal swap
Endocervical culture

472
Q

Tx of gonorrhoea

A

■ cefixime, 400 mg orally
■ one dose of Ceftriaxone, 125 mg intramuscularly

473
Q

Greatest neonatal risk of gonorrhoea

A

Gonococcal ophthalmia, which can cause blindness

474
Q

Dx and Tx of chlamidya

A

Dx: NAAT
Tx for pregnant woman: One gram of oral azithromycin (1 dose)
Tx for baby: Oral Erythromycin

475
Q

How Dx of HIV made

A

Diagnosis:
■฀Enzyme immunoassay
■ Western blot test
■ Immunofluroscence assay
■ Immunoglobulin PCR

476
Q

Postpartum care for patients with AIDS

A

■ ฀Breast feeding should be prevented
■ ฀Zidovudine syrup, 2mg/kg, given to the neonate 4 times daily for first 6 weeks of life

477
Q

Intrapartum care for patients with HIV

A

■ Zidovudine IV infusion starting at onset of labour or 4 hours before CS until cord clamping is done
■ Amniotomy and oxytocin augmentation for vaginal delivery should be avoided whenever possible
■ Elective caesarean delivery is recommended at 38 weeks of women receiving HAART

478
Q

Numerate some things if present = abnormal labour

A
  • Poor progress
  • Fetal malpresentation or makposition
  • Multiple gestation
  • Uterine scar
  • IOL
479
Q

M/C indication for primary cesarean birth

A

Failure to progress

480
Q

When you can say there’s Poor progress in 1st stage labour

A

Cervical dilatation of less than 2 cm in 4 hours

481
Q

M/C cause of poor progress in labour

A

Dysfunctional uterine activity

482
Q

Mx of poor progress in 1st stage of labour

A
  • Hydration
  • Good pain relief
  • Emotional support
  • Repeat vaginal examination 2,rather than 4, hours after the last, If delay is confirmed = ARM
  • If there is still poor progress in a further 2 hours = oxytocin infusion to augment the contractions
  • If still poor progress after 4 to 6 hours = CS
483
Q

Relative CPD is more common and occurs with

A

Malposition of the fetal head

484
Q

Oxytocin must never be used in

A

Multiparous woman where CPD is suspected

485
Q

Can we give oxytocin to women with Relative CPD

A

Yes, as long as CTG is reactive

486
Q

What’s cervical dystocia

A

Non-compliant cervix which effaces but fails to dilate

487
Q

When delay is suspected in 2nd stage of labour

A

Delay is diagnosed if delivery is not imminent after 2 hours of pushing in a nulliparous labour
(1 hour for a parous woman)

488
Q

M/C cause of poor progress in 2nd stage of labour is

A

2ry uterine inertia

489
Q

Mx of poor progress in 2nd stage of labour

A
  • Rehydration and intravenous oxytocin
    Full assessment of the patient:
  • General = vital sign ,assessment of the patient contraction ,sign of obstructed labour
  • Vaginal exam = presentation ,position ,engagement ,presence of caput ,moulding, vaginal dryness
  • If there is no contraindication deliver the patient by assisted vaginal delivery
  • If there any contraindication ,fetal distress ,sign of obstructed labour C/S is indicated
490
Q

1ry protracted labour or arrested labour is

A

Poor progress in the active phase of labour (2 cm cervical dilatation/4 hours)

491
Q

Secondary labour arrest is

A

Progress in active phase of 1st stage initially good but then slows, or stops typically after 7cm dilatation

492
Q

Symptoms of CMV infection on mother

A

■ Malaise
■ Myalgia
■ Persistent fever
■ Cervical lymphadenopathy
■ Pneumonitis
■ Hepatitis

493
Q

Non-immune hydrops caused by

A

Parvovirus B-19
CMV

494
Q

How you diagnose mother suspected to have CMV infection
Or
Interpretation of IgG results

A

■ Low avidity indicates recent infection (within 18-20 weeks)
■ High avidity indicates past infection (12-16 weeks)
■ Avidity performed before 16-18th week identifies 100% of infected fetuses

495
Q

Gold standard test to detect fetal infection with CMV

A

■ PCR searching for DNA

Note/ Amnocentesis can be used also

496
Q

Mx of CMV infection

A

■ Ganciclovir
■ Cidoforvir

497
Q

Which drug never used to treat CMV in pregnancy

498
Q

Mx of HSV infection

A

اذا تجي وحدة عندها HSV-2 واول مرة تنصاب حتكون كلش خطيرة اصابتهم ننطيهم acyclovir ابو ال200 على 4 مرات باليوم لمدة اسبوعين

499
Q

Mode of delivery in HSV infection

A

اذا 4 ساعات وما طاك الممبرين جيبها قيصرية بس اذا طك اكثر من 4 ساعات خلص العدوى انتقلت فجيبها طبيعي

500
Q

Dx & Tx of parvovirus

A

■ PCR
■ Fetal hydrops
■ Doppler US of MCA

Tx: Transfusion

501
Q

When does the baby get congenital varcilla syndrome if his mother infected

A

Before 20wks … 25%
After 20wks … 1%

502
Q

Dx of Chickenpox

A
  • Electron microscopy
  • Culture of fluid from vesicles
  • Viral PCR for quick results
503
Q

pneumonitis complicate which infection

A

V-Z (chickenpox)

504
Q

Mx of Chickenpox

A

■ Give VZ immunoglobulin - effective up to 10 days after contact (most effective within 3-4 days)
■ Manage as potentially infectious from 8-28 days after
■ Protection is only for 3 weeks maximum

OB & Gynecology (4 decks)

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