Obstetrics Flashcards
What is the spectrum of postnatal depression?
Baby blues, postnatal depression and puerperal psychosis
How common is baby blues?
Seen in more than 50% of women in the 1st week after birth and particularly 1st time mothers
What are the symptoms of baby blues?
Mood swings, low mood, anxiety, irritability, tearful
What are some potential contributors to baby blues?
Significant hormonal changes, sleep deprivation, recovering from birth, establishing feeding
What is postnatal depression?
Similar to depression that occurs outside of pregnancy with low mood, anhedonia and low energy
When does postnatal depression present?
3 months after birth
What is the scoring system for postnatal depression?
Edinburgh Postnatal Depression Scale
What is puerperal psychosis?
Urgent severe illness of delusions, hallucinations, depression and mania
What is the typical onset time of puerperal psychosis?
2-3 weeks after delivery
What can SSRIs in pregnancy cause?
Neonatal abstinence syndrome
What is an ectopic pregnancy?
Foetus implanted outside of the uterus
What is the most common site of an ectopic pregnancy?
Fallopian tube - ampulla (widest point)
What are some risk factors of ectopic pregnancy?
Previous PID, previous ectopic, IUD, older age, smoking, fallopian tube surgery
What are some symptoms of an ectopic pregnancy?
Vaginal bleeding, missed period, lower abdominal or pelvic tenderness, cervical motion tenderness
What is the gold standard investigation for ectopic pregnancy?
Transvaginal USS
What are some criteria for managing ectopic pregnancies in an expectant manner?
No significant pain, no visible heartbeat, follow-up is possible and hCG level under 1500 IU
What are the main 4 options for managing an ectopic pregnancy?
Expectant
Methotrexate
Surgical - salpingotomy and salpingectomy
What is the 1st line surgical treatment for ectopic pregnancy?
Salpingectomy - removal of affected fallopian tube and foetus via key hole
What defines an early vs late miscarriage?
Early is before 12 weeks and late is between 12-24 weeks
What are some causes of miscarriage?
Chromosomal abnormality is most common
PCOS
DM
Toxoplasmosis
Syphilis
Factor V Leiden
What are the two key symptoms of miscarriage?
Pelvic pain and vaginal bleeding
What is the gold standard diagnosis for miscarriage?
Transvasginal USS
When is a foetal heartbeat expected to be visible?
Once the crown-rump length is 7mm+
When is a foetal pole expected to be visibile?
Once the mean gestational sac diameter is 25mm +
What is the management of a miscarriage of less than 6 weeks?
Expectant
What is expectant treatment for miscarriage?
Wait 1-2 weeks to allow spontaneous miscarriage and repeat pregnancy tests 3 weeks after bleeding and pain settles
What is the medical management of miscarriage?
Misoprostol
What is Misoprostol?
Prostaglandin E1 analogue which binds to prostaglandin receptors and activates them to soften the cervix and stimulate uterine contractions
When was the abortion act?
1967
When was the gestational age of abortion reduced?
1990 - reduced from 28 to 24 weeks
What are two options for abortion medication?
Mifepristone and Misoprostol
What are some indications for abortion?
Continuing is likely to risk woman’s life
Terminating will prevent ‘grave permanent injury’ to the physical or mental health of the woman
Substantial risk the child could suffer physical or mental abnormalities
Which twins have the best outcomes?
Diamniotic and dichorionic as they each have their own nutrient supply
What are some complications of multiple pregnancy for the mother?
Anaemia, polyhydraminos, HTN, malpresentation, postpartum haemorrhage
What are some complications of multiple pregnancy for the twins?
Miscarriage, stillbirth, foetal growth restriction, prematurity
What is twin-twin transfusion syndrome?
One foetus may receive majority of placental blood (recipient) and the other is starved (donor) causing the recipient to become fluid overloaded and the donor to have growth restriction
What are the maternal risks of obesity in pregnancy?
Thromboembolism pre-eclampsia, C-section, GDM, wound infection
What are some risks for the foetus in maternal obesity?
Congenital abnormalities
Diabetes
Pre-eclampsia
Shoulder dystocia
What is gestational diabetes?
Reduced insulin sensitivity during pregnancy which resolves after birth
What can gestational diabetes cause?
Large for dates
Macrosomia
Shoulder dystocia
Increases mothers risk of T2DM
What are some risk factors for GDM?
Previous GDM
Previous macrosomic baby
BMI over 30
Ethnic origin
Family history of DM
What is the diagnostic test for GDM?
Oral glucose tolerance test
What is the monitoring of GDM?
4 weekly USS to monitor foetal growth and amniotic fluid volume from 28-36 weeks
What can babies of GDM mothers have after birth?
Neonatal hypoglycaemia as they become accustomed to a large supply of glucose during pregnancy
What is the definition of pregnancy induced HTN?
Hypertension over 140/90 mmHg in the second half of pregnancy without proteinuria or other markers of pre-eclampsia
What is pre-eclampsia?
New HTN in pregnancy with end-organ dysfunction and proteinuria
What is the cause of pre-eclampsia?
After 20 weeks placental spiral arteries form abnormally leading to high vascular resistance
What is the triad of pre-eclampsia?
HTN, proteinuria and oedema
What is eclampsia?
Tonic-clonic seizures occur as a result of pre-eclampsia (cerebral vasospasm)
What are some risk factors for pre-eclampsia?
Pre-existing HTN
CKD
DM
Over 40 years
BMI over 35
More than 10 years since previous pregnancy
Family history
What is prophylaxis for pre-eclampsia?
If risk factors are present then aspirin may be given from 12 weeks
What is the presentation of pre-eclampsia?
Headache
Visual disturbance
N+V
Upper abdo pain from liver swelling
Oedema
Reduced urine output
What is placental growth factor?
Protein released by the placenta that functions to stimulate development of new blood vessels = low
What is 1st line anti-HTN for pre-eclampsia?
Labetolol
What is given for severe pre-eclampsia or eclampsia?
IV Hydralazine
What is given during labour and 24 hours after in pre-eclampsia?
IV magnesium sulphate to prevent seizures
What is a complication of pre-eclampsia?
HELLP syndrome
What is HELLP syndrome?
Haemolysis
Elevated Liver enzymes
Low Platelets
What is 1st line to induce early birth for pre-eclampsia?
Enalapril and Nidedipine or Amlodipine in Black African or Caribbean
What is the definition of postpartum anaemia?
Hb of less than 100g/l in the postpartum period
What is the treatment for postpartum anaemia under 90g/l?
Iron infusion
What is the treatment for postpartum anaemia under 70g/l?
Blood transfusion with oral iron
What is a contraindication for iron infusion?
Active infection as pathogens can ‘feed’ on the iron
What is the presentation of neonatal sepsis?
Fever, reduced tone and activity, vomiting, poor feeding, apnoea, hypoxia, seizures
What is the 1st line treatment for neonatal sepsis?
Ben pen and Gentamycin
What are some risk factors of VTE in pregnancy?
Obesity, aged over 35, pregnancy itself, parity over 4, gross varicose veins, long haul travel
What is puerperal pyrexia?
Fever over 38 degrees in a woman within 6 weeks of her having given birth
What are some predisposing factors for puerperal pyrexia?
C-section, PROM, prolonged labour, anaemia, internal foetal monitoring
What is the presentation of puerperal pyrexia?
Fever, foul smelling bloody discharge, subinvolution of uterus and tender, bulky uterus on examination
What do UTIs in pregnancy increase the risk of?
Preterm delivery, low birth weight and pre-eclampsia
What are some symptoms of a lower UTI?
Dysuria, suprapubic pain, polyuria, urgency, incontinence and haematuria
What are some symptoms of pyelonephritis?
Fever, loin or back pain, vomiting, loss of appetite, renal angle tenderness
What is present on urine dipstick for UTI?
Nitrites (nitrate breakdown by bacteria)
Leukocyte esterase
What is the most common cause of a UTI?
E coli
What is the 1st line treatment for UTI in pregnancy?
Nitrofurantoin (not in 3rd trimester)
Trimethoprim (not in 1st trimester)
7 days
What is oligohydraminos?
Abnormally low volume of amniotic fluid surrounding the foetus
When does amniotic fluid volume peak?
38 weeks to ~1L
What are some causes of oligohydraminos?
Increased fluid loss or decreased production
Most common is ROM
Foetal growth restriction
HTN
Maternal NSAIDs or ACEi
What is polyhydraminos?
Too much amniotic fluid surrounding the foetus
What is amniotic fluid volume at term?
500ml
What is amniotic fluid made up of?
Foetal urine and secretions and placenta contribution
What are some causes of polyhydraminos?
Maternal diabetes
Foetal hydrops
Chromosomal abnormalities
Duodenal atresia
Swallowing abnormalities
What is indomethacin used for in polyhydraminos?
Enhances water retention so reduces foetal urine output
What is cephalopelvic disproportion?
Foetus head is either too big or pelvis is too small so normal delivery cannot occur
What is a breech presentation?
Legs and bottom present first
What is cephalic presentation?
Head first
What is stillbirth?
Birth of a dead foetus after 24 weeks
What are some causes of stillbirth?
Placental abruption
Pre-eclampsia
Idiopathic
DM
Vasa praveia
Cord prolapse
What are 3 key symptoms to report in pregnancy?
Abdominal pain
Vaginal bleeding
Reduced foetal movements
What is the 1st line management for still birth?
Vaginal birth
What can be used to suppress lactation in stillbirth?
Cabergoline (dopamine agonists)
What is uterine rupture?
Myometrium ruptures leading to significant bleeding
What is the presentation of uterine rupture?
Abnormal CTG, vaginal bleeding, abdominal pain, hypotension, tachycardia and collapse
What is defined as premature?
Before 37 weeks
What is extreme preterm?
Under 28 weeks
What can vaginal progesterone do in preterm labour?
Decreases activity of myometrium and prevents cervix remodelling to maintain the pregnancy for longer
What is cervical cerclage?
Stitch in the cervix to keep it closed to prevent premature labour
What is premature prelabour ROM?
Amniotic sac ruptures releasing amniotic fluid before labour onset in a preterm pregnancy under 37 weeks
What is the protein present in amniotic fluid that can be tested for?
IGFB-1
What is cord prolapse?
Umbilical cord descends below the presenting part of the foetus, through the cervix and into the vagina after foetal membrane rupture
What is the management of cord prolapse?
Emergency C-section
What can minimise contractions?
Tocolytic medications such as Terbutaline
What are some indications for instrumental delivery?
Failure to progress, foetal distress, maternal exhaustion
What main 2 nerves in the mother can be damaged in pregnacy?
Femoral and obturator
What can forceps cause in the baby?
Facial nerve palsy
What can ventouse delivery cause in the baby?
Cephalohaematoma
What is a 3rd degree tear?
Anal sphincter
What is placenta accreta spectrum?
Placenta implants deeper through and past the endometrium making it difficult to separate after delivery
What are the 3 layers of the uterine wall?
Endometrium, myometrium and perimetrium
How can placenta accreta present in the 3rd trimester?
Antepartum haemorrhage
What is placenta praevia?
Placenta is attached in lower portion of uterus, lower than presenting part of the foetus
What is a low lying placenta?
Placenta is within 20mm of internal cervical os
What is placental abruption?
Placenta separates from wall of uterus during pregnancy
What are some risk factors for placental abruption?
Pre-eclampsia
Bleeding early in pregnancy
Trauma
Multiple pregnancy
Foetal growth restriction
Smoking
What is the presentation of the abdomen in placental abruption?
Woody on palpation suggesting a large haemorrhage
What are the symptoms of placental abruption?
Antepartum haemorrhage
Sudden severe abdominal pain
Shock
CTG abnormalities
What is a concealed abruption?
Cervical os remains closed and any bleeding remains in the uterine cavity
What is vasa praevia?
Vessels are placed over internal cervical os before the foetus
What are the 4 T’s of the causes of postpartum haemorrhage?
Tone (uterine atony) - most common
Trauma - perineal tear
Tissue - retained placenta
Thrombin - bleeding disorder
What can be given during C-sections to reduce risk of haemorrhage?
IV tranexamic acid
What is carboprost?
Prostaglandin analogue that stimulates uterine contraction
What is the last resort treatment for postpartum haemorrhage?
Hysterectomy
What is haemolytic disease of the newborn?
Incompatibility between rhesus antigens on the surface of RBCs of mother and foetus
What is the presentation of haemolytic disease of the newborn?
Jaundice, oedema, anaemia, enlarged liver or spleen
What is the treatment for haemolytic disease of the newborn?
Exchange transfusion
Phototherapy
IV immunoglobulin
What is the Kleihauer test?
Used to check how much foetal blood has passed into mothers blood
What is the most common cause of low birth weight?
Placental insufficiency - infarction, abruption, tumours, abnormal umbilical cord
What is classed as a low birth weight?
Under the 10th percentile for gestational age
What is a category 4 c-section?
Elective
What is a category 1 c-section?
within 30 minutes of decision
What is uterine inversion?
Fundus of uterus drops down through uterine cavity and cervix turning the uterus inside out
What is the presentation of uterine inversion?
Postpartum haemorrhage
Maternal shock
Collapse
What is the johnson manoeurve?
Using hand to push fundus back up into the abdomen
What is a hypoactive uterus?
Irregular, infrequent and ineffective uterus contractions causing prolonged delivery
When does pre-menstrual syndrome occur?
Luteal phase
