Obstetrics Flashcards
RF for hyperemesis gravidarum
obesity
nulliparity
non-smoker
multiple pregnancy
Hydatidiform mole (molar pregnancy)
APGAR score components
max score and is this good or bad?
Range for a good score
Appearance - 0 cyanosis all over, 1 peripheral cyanosis, 2 pink
Pulse - 0 0, 1 <100, 2 100-140
Grimace - 0 no response on stimulation, 1 weak response 2 crying on stimulation
Activity (tone) - 0 floppy 1 some flexion 2 well flexed and resisting extension
Resp - 0 apnoeic 1 slow irregular 2 strong crying
10 GOOD!!
7-10 is good
rf for ectopic pregnancy
increasing age
prev ectopic
prev gynae surgery
prev PID
Coil
Smoking
4 types of miscarriage and the features
threatened - painless bleeding, os closed
inevitable - painful heavy bleeding, os open
missed - no symptoms but has occured
incomplete - incomplete expulsion of tissues
talk through down syndrome screening
see geeky medics flow chart for answer
signs and sx of amniotic fluid embolism
when does it occur
during labour
chills, sob, cyanosis, hypotension, coughing
how long should you take folate for and what dose
what if you are high risk for neural use defect
for 3 months pre pregnancy and first 12 weeks
400 micrograms
5mg if high risk
what constitutes as high risk for neural tube defects during pregnancy
Previous pregnancy with neural tube defect
you or the baby’s biological father have a neural tube defect
you or the baby’s biological father have a family history of neural tube defects
you have diabetes
you’re very overweight
you have sickle cell disease
you’re taking certain epilepsy medicines
you’re taking antiretroviral medicines for HIV
when are the 2 doses of anti D given
28 and 34
when is presentation checked and ECV offered if needed
36 weeks
when is a pregnancy considered term
37 weeks
2 top causes of antepartum haemorrhage. Compare their presentations
placenta abruption and praevia
abruption - painful bleeding, woody uterus, coat disturbances, shock > visible bleeding
Praevia - painless bleeding, may have abnormal lie or presentation
Rx of placental abruption if >36 weeks and no/fetal distress
Rx if <36weeks with no and fetal distress
> 36 distress - EmCS
36 no distress - vag delivery
<36 distress - EmCs
<36 no distress - observe, steroids
what bp would you admit a pregnant lady for observation regardless of whether she has symptoms
> 160/110
SSRIs of choice when breastfeeding
sertraline or paroxetine
methods of TOP and when is each done ie medical and surgical
medical usually before 9 weeks - mifepristone followed by misoprostol
surgical - 10+weeks - cervical dilation followed by either suction or evacuation (forceps)
is anti d needed for rhesus neg women in top
only if >10 weeks
who should take 5mg of folic acid instead of the usual 400 micrograms
fhx of NTD
mum or partner pmhx of NTD
taking anti epileptic meds
BMI>30
what should women on phenytoin be given in the last month of pregnancy and why
vit k to prevent clotting disorders in the newborn
breastfeeding and epileptics
generally safe with possible exception of barbiturates
RF for gestational diabetes
prev gestational diabetes
prev macrosomic baby
BMI >30
first degree relative that had it
screening for gestational diabets - who, how and when
those at high risk
OGTT is gold standard
done asap after booking. If normal then repeat at 24-28 weeks
diagnostic thresholds for GD
> 5.6 fasting
7.8 random
rx of GD
if >5.6 but <7 fasting - offer 2 weeks lifestyle, then 2 weeks metformin. If no satisfactory improvement, start on short acting insulin
if fasting >7 - start on insulin
+lifestyle advice for everyone
maternal and fetal complications of GD (inc pathophys for fetal)
M - HTN, increased risk of infection
F - macrosomia and polyhydramnios, neonatal hypoglycaemia
macrosomia caused by increase glucose, increase, insulin, increase glucose uptake
polyhdramnios - increase glucose, increase fetal osmotic diuresis
presentation of HELLP syndrome
n+v
ruq pain
lethargy
prev diagnosis of pre eclampsia
rx of HELLP
deliver baby
pre eclampsia triad
htn
proteinuria
oedema
criteria for pre eclampsia
new onset BP >140/90 after 20 weeks
PLUS at least 1 of
- proteinuria
- other organ involvement eg renal insufficiency, liver problems, neurological or haematological
maternal and fetal complications of non severe pre eclampsia
M - eclampsia (seizures, severe headaches, blindness, stroke) PPH, liver involvement,
F - IUGR, prematurity
Features of severe pre-eclampsia
proteinuria +++
bp >160/110
visual disturbances
papilloedema
hyperreflexia
HELLP - ruq pain. low platelets, deranged LFTS
risk factors of pre eclampsia
> 40
prev pre eclampsia
BMI >35
fhx
multiple pregnancy
first pregnancy
high risk
- diabets
- prev pre eclampsia
- APL, SLE, chronic htn
- CKD
rx of pre eclampsia
if have risk factors
aspirin 75mg daily from 12 weeks until birth
labetolol or nifedipine (if Asthma)
rx of chicken pox in pregnancy
acyclovir
rx of chicken pox exposure in pregnancy
if not sure whether had it before - check blood for varicella antibodies
if had before - give VZIG
drug used for preventing and for treating seizures in eclampsia
mag sulf
considerations during treatment with magnesium sulphate
monitor - urine output, rr, o2 sats and reflexes
IV
continue for at least 24hrs after last seizure or after delivery
rx of mag self induced respiratory depression
calcium gluconate
rx of mother who tests positive for GBS
Intrapartum Abx - benpen
Indications for intrapartum abx
GBS carrier or prev baby with GBS
pyrexia during labour
preterm rupture of membranes
what antihypertensives are CI in pregnancy
ACEi and ARBs - risk of fetal renal damage
features of obstetric cholestasis
itching
jaundice
rx of obstetric cholestasis
ursodeoxycholic acid
IOL at 37-38 weeks
rx of placental abruption if
<36 weeks ± fetal distress
>36 weeks ± fetal distress
<36 no fetal distress - steroids and observe
<36 with fetal distress - EmCS
> 36 no fetal distress - vaginal delivery
36 fetal distress - EmCS
maternal and fetal complications of placental abruption
m - shock, dic, renal failure, pph
f - IUGR, death, hypoxia
causes of placental abruption
trauma, cocaine, older age, multiple pregnancy, polyhydramnios
4 causes of pph
Tone - uterine atony
Trauma - episiotomy
Tissue - placenta retention
Thrombin - clotting disorder
rf for pph
EmCS
macrocosmic baby
prolonged labour
increased maternal age
multiparty
placenta praevia
polyhydramnios
Rx of PPH
SENIORS!
A-E
- cannulas
- bloods inc G&S and x match
- lie woman flat
- catheterise to prevent bladder distension and monitor urine output
- rub up the fundus
-give IV uterotonics eg oxytocin, ergometrine
- tranexamic acid
- surgical - intrauterine balloon tamponade
when does secondary PPH occur and what is most likely cause
24hrs - 6 weeks after
caused by placenta retention or endometritis
baby blues, post natal depression and puerperal psychosis comparison inc rx
BB - 3-7 days after birth, rx - reassurance
PND - 1 month to 6 months rx - reassurance, CBT, sertraline/paroxetine if severe
PP - 2-3 weeks rx - mother and baby unit admission. high rate of recurrence in future pregnancies
postpartum thyroiditis - course
thyrotoxicosis then hypothyroidism then normal
rx of hyperthyroid phase is beta blockers and hypothyroid is thyroxine
physiological changes in pregnancy
increased CO
increased tidal volume
increase in clotting factors - hence increased VTE risk
increased eGFR - trace glycosuria is common
risks associated with smoking in pregnancy
preterm labour
miscarriage
stillbirth
IUGR
SIDS
Fetal alcohol syndrome
wide eyes
flat philtrum
microcephaly
epicentral folds
learning difficulty
IUGR
ix of PPROM
speculum exam to observe any pooling
if non observed - AMNIsure or USS for oligohydramnios
complications of PPROM
fetal: prematurity, infection, pulmonary hypoplasia
maternal: chorioamnionitis
Rx of PPROM
admission
regular observations to ensure chorioamnionitis is not developing
oral erythromycin should be given for 10 days
antenatal corticosteroids should be administered to reduce the risk of respiratory distress syndrome
delivery should be considered at 34 weeks of gestation
most common cause of pyrexia after delivery and rx
endometritis
admit for IV clindamycin and gentamicin
when should fetal movements be well established
24 weeks
haemolytic disease of the newborn presentation
oedematous (hydrops fetalis, as liver devoted to RBC production albumin falls)
jaundice, anaemia, hepatosplenomegaly
heart failure
kernicterus
which twin type have more complications
mono amniotic, monozygotic
complications inc - TTTS, spontaneous miscarriage, IUGR, perinatal mortality,
risk factors for cord proplapse
prematurity
multiparity
polyhydramnios
twin pregnancy
cephalopelvic disproportion
abnormal presentations e.g. Breech, transverse lie
Rx of cord prolapse
mum on all fours,
push presenting part of foetus back into uterus,
minimal handling of cord and keep it warm and moist to prevent vasospasm ,
tocolytics eg indomethacin, nifedipine, terbutaline to reduce contractions
indications for induction of labour
prolonged pregnancy, e.g. 1-2 weeks after the estimated date of delivery
prelabour premature rupture of the membranes, where labour does not start.
maternal medical problems
- diabetic mother > 38 weeks
- pre-eclampsia
- obstetric cholestasis
intrauterine fetal death
what is the bishop score used for, what is measured and what do the points mean
likelihood of spontaneous labour
measures
- cervical effacement
- cervical position
- cervical consistency
- cervical dilation
- fetal station
<5 unlikely to progress
>8 likely to progress
IoL methods and when offered
if 40 weeks - membrane sweep offered as an adjunct
if bishop <6 - vaginal prostaglandins or oral misoprostol
if bishops >6 amniotomy and IV oxytocin infusion
complication of IOL and rx
uterine hyperstimulation - can cause fetal hypoxia or uterine rupture (rare)
stop drugs, consider tocolytics
definition of decelerations on CTG
abrupt decrease in baseline HR of >15 for >15s
what do variable decelerations usually indicate
umbilical cord compression
CTG normal variability
5-25bpm
features of normal ctg
- baseline bpm
- baseline variability
- decelerations
- interpretation
- management
- 110-160
- 5 - 25
- no repetetive decels
- no fetal distress
- no management
features of suspicious CTG
- baseline bpm
- baseline variability
- decelerations
- interpretation
- management
lacking at least one feature of normality but no pathological features
features of pathological CTG
- baseline bpm
- baseline variability
- decelerations
- interpretation
- management
- > 180 or <100
- Less than 5 (reduced) >50 minutes OR More than 25 (saltatory) >30 minutes OR sinusoidal for >30 minutes
- Repetitive, late or prolonged decelerations with any concerning characteristics >30 minute OR A single prolonged deceleration (below 100 bpm) lasting 3 minutes or more
- high probability of hypoxia or acidosis
- reverse causes. if not possible, deliver baby
when is it recommended to star measuring the symphis fungus height
what is normal
24 weeks
week of pregnancy ± 2cm
triad of vasa praevia
rupture of membranes
painless vaginal bleeding plus fetal bradycardia
first line med for breast milk suppression
cabergoline
bromocripitine can be used but has a worse side effect profile
normal number of contractions in 10 mins
4 or less
how much blood loss is deemed a pph
500ml
