Obstetrics Flashcards
What is a miscarriage?
The spontaneous termination of pregnancy; early is before < 12 weeks and late is 12 to 24 weeks
Different classifications of miscarriage?
Missed - no symptoms but the foetus is dead
Threatened - vaginal bleeding, cervix closed and foetus alive
Inevitable - vaginal bleeding with an open cervix
Incomplete - retained products of conception
Complete - full miscarriage
Aembryonic - no embryo, just gestational sac
Investigation for miscarriage
TVUS
1) Foetal HR?
2) Crown-rump length of 7mm?
3) Gestational sac of 25 mm diameter and foetal pole
Management of miscarriage
Less than 6 weeks - expectant
More than 6 weeks - expectant, medical (misoprostol) or SMM
Types of SMM
Manual vacuum aspiration - LA, syringe to aspirate, must be below 10 weeks. Better in parous women
Electric vacuum aspiration - GA
Rhesus D proph to rhesus negative women
Incomplete miscarriage management
Medical - misoprostol
Surgical - ERPC (evacuation of retained products of conception)
When to be concerned about miscarriages?
Infection or heavy bleeding
Define recurrent miscarriages
3 x first trimester
1 x second trimester
Causes of recurrent miscarriages
Idiopathic
Haematological (APLS and inherited thrombophilias)
Structural (fibroid, cervical insufficiency, congenital)
Genetics - balanced translocations
Chronic diseases - DM, thyroid, SLE
Other - chronic histiocytic intervillositis
Management of recurrent miscarriages
Referral to specialist
Pelvic US
Blood tests - APLS and hereditary thrombophilia
Genetics - of conception products and parents
Presentation of ectopic
Abdo/pelvic pain
Missed period
Bleeding
Cervical excitation
Dizziness and shoulder tip pain
Investigation for ectopic
TVUS - bagel sign
Management of ectopic pregnancy
Expectant - if unruptured, less than 35 mm, hCG < 1500, no HB or significant pain
Medical with methotrexate - same as above but hCG less than 5000
Surgical - laparoscopic salpingectomy or salpingotomy, with rhesus D proph is rhesus negative
Timeline of sickness in pregnancy
Starts at 4-7 weeks, peaks at 10 to 12 weeks and settles at 16-20 weeks
Definition of hyperemesis gravidarum
Protracted N&V plus 5% loss of body weight, dehydration an electrolyte imbalance
Can use PUQE score to quantify
Management
Obs, ketones, can they keep stuff down, weight
Cyclizine, prochlorperazine or metoclopramide, in that order
Think about reflux as an issue
Ginger and acupuncture
Depending on severity admission may be indicated for IV fluids, electrolyte correction, observation, IV antiemetics, thiamine and VTE proph
What is a hydatidiform mole?
A molar pregnancy is a tumour that grows like a pregnancy in the uterus
Two types: a complete and partial mole
Complete - no foetal material; two sperm fertalise and empy egg
Partial - some foetal material; two sperms fertilise an eg
Presentation of a molar pregnancy
Increased N&V
Vaginal bleeding
Abnormally large uterus
Abnormally high hCG
Thyrotoxicosis - hCG mimics TSH
Investigation for molar pregnancy
TVUS - snowstorm appearance
Management of molar pregnancy
Refer to gestational trophoblastic disease centre
Evacuation and follow-up
Anaemia in pregnancy
Screen at booking and 28 weeks, 110 and 105 respectively
Micro - give iron
Macro - give folate/B12
Remember pregnancy is a high volume, low pressure physiology and so there will be a dilutional anaemia to some degree
Pre-existing diabetes in pregnancy
5 mg of folate
Diet, metformin and insulin only
Opthalmology review shortly after booking and at 28 weeks
Planned delivery between 37 and 38+6
Sliding scale during labour if type 1
Gestational diabetes RFs
Had it previously, big baby, BMI over 30, ethnic origin and family hx of diabetes
They get OGTT at 24- 28 weeks, previous gestational diabetes also get one soon after booking
OGTT results and actions
Fasted, then give 75g of glucose
Fast - 5.6 upper limit
After 2 hours - 7.8 upper limit
fasted < 7 - a 1-2 week trial of exercise and diet
fasted >7 - inulin +/- metformin
if > 6 but big baby then start treatment anyway
Targets of 5.3 fasted, 7.8 an hours after meal and 6.4 two hours after
Why is diabetes bad?
Babies:
- big
- neonatal hypoglycaemia
- jaundice
- CHD
- cardiomyopathy
Mum:
- delivers bigger baby
If already has HTN, which meds?
- labetalol
- nifedipine
- methyldopa
- aspirin from 12 wekks
Management of gestation hypertension (> 20 weeks)
- treat for 135/85
- admit if 160/110
- dipstick weekly
- weekly blood tests
- serial growth scans
- PlGF at least once
- aspirin from 12 weeks if 1 x HRF or 2 x MRF
Management of pre-eclampsia
Largely the same as gestation HTN except for weekly dipsticks not needed as a diagnosis was made, BP every 48 hours and two weekly scans
Management of pre-eclampsia
Labetalol, nifedipine or methyldopa, with aspirin if needed
Management of eclampsia
Magnesium sulphate
Other considerations of pre-eclampsia
Planned delivery and corticosteroids?
High RFs for pre-eclampsia
- pre-existing HTN
- previous NTH in pregnancy
- autoimmune disorders
- diabetes
- CKD
Moderate RFs for pre-eclampsia
- age of 40
- BMI over 30
- 10 years since last pregnancy
- multiple pregnancy
- first pregnancy
- FHx of pre-eclmapisa
Presentation of pre-eclampsia
- N&V
- headache
- visual disturbances
- abdominal pain
- oedema
- reduced urine output
- brisk reflexes
Diagnosis pre-eclampsia
HTN plus organ dysfunction either on dipstick, blood tests or placental scans
Complications of pre-eclampsia
HELPP (haemolysis, elevated liver enzymes and low platelets)
UTI in pregnancy
Pregnant women are routinely tested for UTI and symptomatic bacteremia
- nitrofurantoin (not in the third trimester)
- amoxicillin (need sensitivities)
- cefalexin
Can lead to premature birth
Medication for women with epilepsy
Lamotrigine and levetiracetam preferred, 5mg of folate
Depression in pregnancy
Common, can still take medications but a discussion about risks vs benefits needs to be had
Issues with obesity in pregnancy
Mum:
- thrombosis
- gestational diabetes
- HTN and pre-eclampsia
- increase likelihood of IoL, C-section, anaesthetic complications and wound infections
Baby:
- big baby
- NTD
- miscarriage and stillbirth
5mg dose of folic acid
VZV in pregnancy
- More severe in pregnant women leading to pneumonitis, hepatitis, encephalitis
- Foetal varicella syndrome in unborn or severe infection if around delivery
- If previous chickenpox then woman safe
- Any doubt then IgG should be tested
- If unprotected, then IV varicella IGs should be given within 10 days of exposure
- If rash has developed, then give oral aciclovir if less than 24 hours and more than 20 weeks
What is congenital varicella syndrome?
If infected in the first 28 weeks, can cause:
- growth restriction
- microcephaly, hydrocephalus and LD
- scars and skin changes across dermatomes
- limb hypoplasia
- cataracts and chorioretinitis
Syphilis during pregnancy
- prem
- stillbirth/miscarriage
- small baby
- issues with placenta and cord
TORCH?
- Toxoplasmosis
Tiad of intracranial calcification, hydrocephalus and chorioretinitis
- Others - syphilis and hep B
- Rubella
MMR during conception/after birth, live vaccine so not during pregnancy. Can cause deafness, cataracts, CHD and LD
- CMV
FGR, microcephaly, vision loss, hearing loss, LD, seizures
- HSV (HIV and Zika sometime included)
Define labour
process of uterine contractions and cervical dilation that enables the uterus to deliver a viable foetus (24 weeks), placenta and membranes. Diagnosed when there are regular and increasing painful uterine contraction brining about cervical dilation and/or effacement
What is the first stage of labour?
Onset of regular and increasing painful contractions to full dilation of the cervix
Latent is fully effaced and 3cm dilated (6-8 hours first time and 4-6 hours after that) and active is to fully dilated (0.5cm/hr)
Stage 2 of labour
From full dilation to delivery of foetus (hur first time, half an hour after that)
Stage 3 of labour
From delivery of the foetus to delivery of placenta and membranes (15 mins or less with active management)
Causes of slow labour?
Power, passenger or passage
Active management of third stage
Syntometrine and controlled traction of cord
Three key steps to a successful labour
Reassurance, hydration and analgesia
Slow labour management
Oxytocin at 2- 4MU/min, then can increase by 2-4 MU if needed
Aiming for 4-5 contractions every 10 minutes lasting at least 40 seconds
Usually achieved at the 8-12 MU mark
Beware of hyperstimulation, uterine rupture and water intoxication (ADH effect)
Process of labour
Enters occipito-trasnverse
Head flexion
Internal rotation
Extension
Restitution (external rotation)
Anterior shoulder then posterior shoulder
Presentation of cord prolapse
Compression of the cord leads to foetal hypoxia, showing as foetal distress on the CTG
Can be palpated and seen on PV and speculum exam
Management of cord prolapse
- put the mother in the left lateral position or knee-chest position
- keep cord wet and warm (saline and gauze) with minimal handling
- push presenting part of the head back
- organise emergency caesarian
- tocolytic agents
Biggest RF for cord prolapse
Abnormal lie
Presentation of shoulder dystocia
- struggle to deliver head
- failure of restitution
- turtle-neck sign
