Obstetrics Flashcards
Definition of inevitable abortion
Cervix dilated, no products expelled
Definition of septic abortion
spontaneous abortion complicated by uterine infection
Definition of incomplete abortion
some but not all products expelled, retained products
Definition of complete abortion
all products expelled
Definition of missed abortion
fetal demise but no uterine activity
Definition of recurrent abortion
> / consecutive pregnancy losses
Risk factors for spontaneous abortion
Advanced maternal age
Thrombophilia, autoimmune disease
Infection
Previous SA
Uterine abnormalities
Investigations for spontenous abortion
Beta HCG
CBC
Group and screen ?Rho
G and C
US
When to give Anti-D and what dose in spontaneous abortion
If Rh Neg administer Anti D (<12 week give 120 IM, >12 week give 300 IM)
Management options of spontaenous abortion
- Expectant management
- Misoprostol 800 mcg vaginally and then in 24-72h if no bleeding
- RhoGAM if Rh negative
- Vacuum aspiration if hemodynamically unstable or septic
Preabortion care
Discuss options such as term bityh, abortion adoption
Discuss methods
Discuss risks
Support and confirmation that decision is voluntary
Emotional neds, values, coping abilites
Discuss future contraception
What is included and discussed in consent for medical abortion
- MA involves using drugs to end pregnancy
- Mifeprostine 200mg oral and misoprostol 800mcg vaginally are as effective as SA before 49d after LMP, and highly effective up to 70d after LMP
- MA is irreversible but does not eliminate the need for SA. If ongoing pregnancy then SA if recommended.
- Must have access to medical care for 7-14d after medication taken
- Risks include: bleeding, cramping/pelvic pain, GI upset, headaches, fevers/chills, pelvic/lower gential infection, mortality is 0.3 per 100 000 usually from infection or undiagnosed ectopic.
Medical evaluation prior to abortion
bHCG, CBC, Rh ABO, STI screen
Determine gestational age and pregnancy location with medical history/LMP, gyne exam and US
Absolute and relative contraindications to MA
Absolute:
Ectopic
Chronic adrenal failure
Inherited porphyria
Uncontolled asthma
Relative:
Unconfirmed GA
IUD
Concurrent systemic corticosteroids
Hemorrhagic disorder
Concurrent antioag
Regimen for MA
If Rh neg and 49d give Rh immunoglobulin 24h prior to MA
Day 1: Mifepristone, Day 2-3 Misoprostol
Day 14: FU: US, decrease in bHCG more than 80% and contraception
When to swab to GBS
35-37w
Management for GBS
IV penicillin during labour or Cefazolin if penicillin allergy
When to give prophylactic abx for GBS and immediate delivery
PROM/in labour >37w and any of the following:
- GBS swab +
- Previous infant with GBS
- GBS bacteremia in currenty preg
> / 37 weeks unknown GBS and ROM >18h
Give 48h of IV abx if ROM/inlabour <37 and unknown or positive GBS
Reasons for induction of labour
- Spontaneous ROM
- IUGR
- Decreased fetal movement
- Post dates
- Pre-eclampsia
- Maternal conditions: T2DM, renal dz, pulmonary dz, PIH
Risks of induction of labour
- Increased risk of operative delivery
- Abnormal FHR
- Uterine rupture
- Cord prolapse
- Wrong dates/ pre-term infant
Contraindications of induction of labour
- Previous uterine rupture
- Fetal transverse lie
- Placenta previa/vasa previa
- Invasive cervical cancer
- Active gential herpes
Bishop score
Points: 0 -1 - 2 -3
Dilation: 0 - 1 to 2 - 3 to 4 - 5 to 6
Effacement: 0 to 30 - 40 to 50 - 60 to 70 - 80
Station: -3 - -3 - -1/0 - +1+2
Consistency: firm - med - soft - X
Position: posterior - mid - anterior - X
Options for cervical ripening
- Intracervical/Intravaginal PGE Prepidil 0.5mg q6-12h up to 3 doses - do not use in VBAC
- Foley catheter (increased need for oxytocin, can use in VBAC, slower than PGE)
Definition of labour dystocia
- During active first stage of labour >4 hours or <0.5cm/hr dilation or 0 cm/2hr
- During second stage >1hr with no descent during active pushing nullparious >3hr with regional anesthetic or 2h without; parous >2hr with regional anaesthetic or 1hr without
Etiology of labour dystocia
Power - leading cause, inadequate maternal effort, poor contractions
Passenger - fetal position, size, anomalies
Passage - pelvic structure, maternal soft tissue factors
Psyche - psyche, anxiety, pain
Approach to non-reassuring fetal heart rate
Fetal tracing
Call fo help
LLD position
100% O2
Stop oxytocin
Correct low BP
Fetal scalp monitor
R/o cord prolapase
Look for causes ?infection ?drugs
What to rule out with variable decelerations
60s (severe): <60bpm, <60bpm from baseline, >60 with slow return to baseline
What is placental abruption
Premature separation of placenta after 20w
Risk factors for placental abruption
Previous hx, HTN, vascular dx, smoking, ETPH, multiparity, increased age, PPROM, uterine abnormalities, trauma
Symptoms and signs of placental abruption
Painful vaginal bleeding, sudden onset, constant, localised to lower back and uterus, +/- fetal distress
Complications of placental abruption
Neonatal: fatality, prematurity, hypoxia
Maternal: mortality, DIC, ARF, anemia, shock, pituitary necrosis, amniotic fluid embolism
Ix and management of placental abruption
US on 15% sensitive. CBC, fibrinogen, type and cross
Stabilize, monitors, blood products, may need c/s
Management of PROM
GBS status - if + or unknown then start abx
Consider Celestone if preterm
If term and GBS - can wait 24h prior to induction
Investigations of preterm labour
Fetal fibronectin, US for cervical length
Management of preterm labour
Consider Celestone 12mg IM q24h x 2
Bed rest.
Tocolytics: nifedipine or indomethacin
What to do if imminent preterm birth and </ 33 + 6
D/C tocolytic and consider antenatal magnesium sulfate 4g IV loading dose over 30 min +/- 1g/hr (max 12h) for fetal neuroprotection.
Definition of shoulder dystocia
Impact of anterior shoulder on symphysis pubis after delivery of the head
Risk factors for shoulder dystocia
Obesity, DM, multiparity, macrosomia, increased gestation, prolonged second stage, advanced maternal age, induction
Management of shoulder dystocia
ALARMER
A: Apply suprapubic pressure / Ask for help
L: Legs in full flexion
A: Anterior shoulder disimpaction
R: Release posterior shoulder
M: Manual corkscrew
E: Episiotomy
R: Roll over hand and knees
Risks for uterine rupture
Previous uterine scar - classical higher risk.
Oxytocin, grand multip, previous uterine manipulation.
Complications for uterine rupture
Maternal mortality, hemorrhage, shock, abnormal FHR
Management of uterine rupture
R/O abruption, immediate delivery
Definition of first stage of labour
Regular contractions causing cervical dilation
Dystocia >4 h of <0.5cm / hr dilation or 0cm / 2 hr
Definition of latent first stage of labour
Complete when nulliparous >/4cm, parous 4-5cm
Cervical length generally <1cm
Definition of active first stage of labour
Starts when nulliparous >/4cm, parous >4-5cm
Definition of second stage of labour
Full dilation to delivery of baby
Dystocia >1hr of active pushing without descent of the presenting part
Definition of third stage of labour
Immediately after delivery of baby to delivery of placenta
Definition of forth stage of labour
Immediately after delivery of placenta to 1h postpartum
When to use continuous EFM in labour
Decelerations or abnormal intermittent auscultation, single umbilical artery, velamentous cord insertion, >/3 nuchal loops of cord, combined spinal-epidural anesthetic, labour dystocia, FHR arrhythmia, pre pregnancy BMI >35
Etiology of postpartum hemorrhage
Tone: uterine atony, prevent by giving oxytocin with delivery of ant shoulder
Tissue: retained placenta or clot
Trauma: laceration, hematoma, rupture
Thrombin: coagulopathy, DIC
Management of postpartum hemorrhage
Oxytocin 20U/L NS IV continuous infusion
Ergotamine 0.25mg IM q5min up to 1.25mg - causes smooth muscle contraction
Hemabate 0.25mg IN q15min tp to 2mg - prostaglandin
May require D and Cm laparotomy with ligation of urine arteries, hysterectomy +/- angio embolization
Management of retained placenta
- Explore uterus and assess blood loss
- 2 large bore IVs
- Type and screen
- Firm traction on umbilical cord with suprapubic pressure and oxytocin 10 IU in 20ml NS
- Manual removal - D and C
Definition of postpartum fever
Fever >38 on any 2 of the first 10 days postpartum, not including first day
Etiology of postpartum fever
Wind - pneumonia, atelectasis
Wound - episiotomy site, incisions
Water - UTI
Walking - DVT
Womb - endometritis
Breast - mastitis
Empiric treatment for wound infections in postpartum
Clindamycin and Gentamicin
When to give rhogam post partum
Give 300ug IM within 72 hours of delivery if infant is RH positive
Contraception counselling postpartum
Non lactating - OCP 3 weeks post partum
Lactating - Micronor 6 weeks PP and change to OCP when supplemental feeding or OCP at 3 months if breastfeeding exclussively
IUD - 6 weeks PP
Post partum blues onset and length
Onset 3-10 days, doesn’t last longer than 2 weeks
Numbers for gestational diabetes
50g OGCT <7.8
If 7.8 - 11.1 order 2h 75g OGTT
Target HbA1c and BG for gestational diabetes
<6
2h post pranial <6.7
1h post pranial <7.8
Monitoring in gestational diabetes
Monitor growth q3-4 weeks starting at 24weeks
offer induction 38-40 weeks
Monitor newborn for hypoglycemia
Number for severe hypertension in pregnancy
Higher than 160/110
How long? to avoid pregnancy following live vaccines
Four weeks
When to give tdap during pregnancy
between 21 and 32 weeks
