Obstetrics Flashcards
What % of couples have a problem with conceiving?
85% will conceive within a year of regular unprotected sex. 1 in 7 couples will struggle to conceive naturally.
When are investigations done for infertility?
Investigation and referral for infertility should be initiated after the couple has been trying to conceive without success for 12 months. This can be reduced to 6 months if the woman is older than 35, as her ovarian stores are likely to be already reduced and time is more precious.
List causes of infertility
Sperm problems (30%)
Ovulation problems (25%)
Tubal problems (15%)
Uterine problems (10%)
Unexplained (20%)
40% of infertile couples have a mix of male and female causes.
Suggest investigations for infertility.
Initial investigations, often performed in primary care:
Body mass index (BMI) (low could indicate anovulation, high could indicate PCOS)
Chlamydia screening
Semen analysis
Female hormonal testing (see below)
Rubella immunity in the mother
Female hormone testing involves:
Serum LH and FSH on day 2 to 5 of the cycle
Serum progesterone on day 21 of the cycle (or 7 days before the end of the cycle if not a 28-day cycle).
Anti-Mullerian hormone
Thyroid function tests when symptoms are suggestive
Prolactin (hyperprolactinaemia is a cause of anovulation) when symptoms of galactorrhea or amenorrhoea
Suggest treatments for anovulation.
Weight loss for overweight patients with PCOS can restore ovulation
Clomifene may be used to stimulate ovulation
Letrozole may be used instead of clomifene to stimulate ovulation (aromatase inhibitor with anti-oestrogen effects)
Gonadotropins may be used to stimulate ovulation in women resistant to clomifene
Ovarian drilling may be used in polycystic ovarian syndrome
Metformin may be used when there is insulin insensitivity and obesity (usually associated with PCOS)
Outline how sperm problems are managed
Surgical sperm retrieval
Surgical correction of an obstruction in the vas deferens may restore male fertility.
Intra-uterine inseminsation
Intracytoplasmic sperm injection (ICSI)
Donor insemination with sperm from a donor is another option for male factor infertility.
How is a sperm sample taken?
Abstain from ejaculation for at least 3 days and at most 7 days
Avoid hot baths, sauna and tight underwear during the lead up to providing a sample
Attempt to catch the full sample
Deliver the sample to the lab within 1 hour of ejaculation
Keep the sample warm (e.g. in underwear) before delivery
What is measured in a sperm sample?
Semen volume (more than 1.5ml)
Semen pH (greater than 7.2)
Concentration of sperm (more than 15 million per ml)
Total number of sperm (more than 39 million per sample)
Motility of sperm (more than 40% of sperm are mobile)
Vitality of sperm (more than 58% of sperm are active)
Percentage of normal sperm (more than 4%)
What terms are used for sperm cell numbers?
Normospermia (or normozoospermia) refers to normal characteristics of the sperm in the semen sample.
Oligospermia (or oligozoospermia) is a reduced number of sperm in the semen sample. It is classified as:
Mild oligospermia (10 to 15 million / ml)
Moderate oligospermia (5 to 10 million / ml)
Severe oligospermia (less than 5 million / ml)
Cryptozoospermia refers to very few sperm in the semen sample (less than 1 million / ml).
Azoospermia is the absence of sperm in the semen.
What are the features of OHSS?
Early OHSS presents within 7 days of the hCG injection. Late OHSS presents from 10 days onwards.
Features of the condition include:
Abdominal pain and bloating
Nausea and vomiting
Diarrhoea
Hypotension
Hypovolaemia
Ascites
Pleural effusions
Renal failure
Peritonitis from rupturing follicles releasing blood
Prothrombotic state (risk of DVT and PE)
How is OHSS managed?
Oral fluids
Monitoring of urine output
Low molecular weight heparin (to prevent thromboembolism)
Ascitic fluid removal (paracentesis) if required
IV colloids (e.g. human albumin solution)
What is the bagel sign?
Ectopic pregnancy
What hcg represents an ectopic pregnancy?
A rise of less than 63% after 48 hours may indicate an ectopic pregnancy. When this happens the patient needs close monitoring and review.
How are ectopic pregnancies managed?
There are three options for terminating an ectopic pregnancy:
Expectant management (awaiting natural termination)
Medical management (methotrexate)
Surgical management (salpingectomy or salpingotomy)
Criteria for expectant management:
Follow up needs to be possible to ensure successful termination
The ectopic needs to be unruptured
Adnexal mass < 35mm
No visible heartbeat
No significant pain
HCG level < 1500 IU / l
Define gravida
Gravida (G) is the total number of pregnancies a woman has had
Define para
refers to the number of times the woman has given birth after 24 weeks gestation, regardless of whether the fetus was alive or stillborn
What is nulliparous, primiparous and multiparous?
Nulliparous (“nullip”) refers to a patient that has never given birth after 24 weeks gestation
Primiparous technically refers to a patient that has given birth after 24 weeks gestation once before (see below)
Multiparous (“multip”) refers to a patient that has given birth after 24 weeks gestation two or more times
What are the trimesters?
The first trimester is from the start of pregnancy until 12 weeks gestation.
The second trimester is from 13 weeks until 26 weeks gestation.
The third trimester is from 27 weeks gestation until birth.
What vaccines are given in pregnancy?
Whooping cough (pertussis) from 16 weeks gestation
Influenza (flu) when available in autumn or winter
What vaccines are avoided in pregnancy?
MMR and live vaccines
What are some milestones for pregnancy?
Between 10 and 13 + 6 -Dating scan
16 week antenatal appointment
Between 18 and 20 + 6 - anomaly scan
Oral glucose tolerance test in women at risk of gestational diabetes (between 24 – 28 weeks)
Anti-D injections in rhesus negative women (at 28 and 34 weeks)
Ultrasound scan at 32 weeks for women with placenta praevia on the anomaly scan
Serial growth scans are offered to women at increased risk of fetal growth restriction
What tests are done during antenatal testing?
Discuss plans for the remainder of the pregnancy and delivery
Symphysis–fundal height measurement from 24 weeks onwards
Fetal presentation assessment from 36 weeks onwards
Urine dipstick for protein for pre-eclampsia
Blood pressure for pre-eclampsia
Urine for microscopy and culture for asymptomatic bacteriuria
Discuss advice given to pregnant women.
Take folic acid 400mcg from before pregnancy to 12 weeks (reduces neural tube defects)
Take vitamin D supplement (10 mcg or 400 IU daily)
Avoid vitamin A supplements and eating liver or pate (vitamin A is teratogenic at high doses)
Don’t drink alcohol when pregnant (risk of fetal alcohol syndrome)
Don’t smoke (smoking has a long list of complications, see below)
Avoid unpasteurised dairy or blue cheese (risk of listeriosis)
Avoid undercooked or raw poultry (risk of salmonella)
Continue moderate exercise but avoid contact sports
Sex is safe
Flying increases the risk of venous thromboembolism (VTE)
Place car seatbelts above and below the bump (not across it)
When must pregnant women stop flying?
The RCOG advises flying is generally ok in uncomplicated healthy pregnancies up to:
37 weeks in a single pregnancy
32 weeks in a twin pregnancy
After 28 weeks gestation, most airlines need a note from a midwife, GP or obstetrician to state the pregnancy is going well and there are no additional risks.
What are some booking bloods?
A set of booking bloods are taken for:
Blood group, antibodies and rhesus D status
Full blood count for anaemia
Screening for thalassaemia (all women) and sickle cell disease (women at higher risk)
Patients are also offered screening for infectious diseases, by testing antibodies for:
HIV
Hepatitis B
Syphilis
Screening for Down’s syndrome may be initiated depending on the gestational age. Bloods required for the combined test are taken from 11 weeks onwards.
What is combined testing?
Ultrasound measures nuchal translucency, which is the thickness of the back of the neck of the fetus. Down’s syndrome is one cause of a nuchal thickness greater than 6mm.
Maternal blood tests:
Beta‑human chorionic gonadotrophin (beta-HCG) – a higher result indicates a greater risk
Pregnancy‑associated plasma protein‑A (PAPPA) – a lower result indicates a greater risk
What are the tests for Downs syndrome?
Triple testing = BAO = Bhcg, AFP, Oestrogen
Quadruple testing
NIPT
Amniocentesis and CVS
How are chronic diseases managed in pregnancy?
Hypothyroidism - increase levothyroxine
RA - hydroxchloroquine, sulfazalazine and steroids to be used
Hypertension - change medications
Epilepsy - change medications
Why are ACE inhibitors contraindicated in pregnancy?
Oligohydramnios (reduced amniotic fluid)
Miscarriage or fetal death
Hypocalvaria (incomplete formation of the skull bones)
Renal failure in the neonate
Hypotension in the neonate
What is the effect of opiates on the foetus?
The use of opiates during pregnancy can cause withdrawal symptoms in the neonate after birth. This is called neonatal abstinence syndrome (NAS). NAS presents between 3 – 72 hours after birth with irritability, tachypnoea (fast breathing), high temperatures and poor feeding.
What is the effect of warfarin on the foetus?
Fetal loss
Congenital malformations, particularly craniofacial problems
Bleeding during pregnancy, postpartum haemorrhage, fetal haemorrhage and intracranial bleeding
What is the effect of SSRIs on the foetus?
First-trimester use has a link with congenital heart defects
First-trimester use of paroxetine has a stronger link with congenital malformations
Third-trimester use has a link with persistent pulmonary hypertension in the neonate
What is the effect of valproate on pregnancy?
The use of sodium valproate in pregnancy causes neural tube defects and developmental delay.
What is the effect of beta blockers on the foetus?
Fetal growth restriction
Hypoglycaemia in the neonate
Bradycardia in the neonate
Still used like labetolol
What is the triad of toxoplasmosis?
There is a classic triad of features in congenital toxoplasmosis:
Intracranial calcification (IT)
Chorioretinitis (inflammation of the choroid and retina in the eye) (C)
Hydrocephalus (H)
What is the effect of congenital CMV on the foetus?
Fetal growth restriction
Microcephaly
Hearing loss
Vision loss
Learning disability
Seizures
(everything gets smaller except seizures)
What is the effect of rubella on the foetus?
Congenital deafness
Congenital cataracts
Congenital heart disease (PDA and pulmonary stenosis)
Learning disability
What is the effect of chickenpox on the foetus?
Fetal growth restriction
Microcephaly, hydrocephalus and learning disability
Scars and significant skin changes located in specific dermatomes
Limb hypoplasia (underdeveloped limbs)
Cataracts and inflammation in the eye (chorioretinitis)
What is the effect of listeria in the foetus?
Listeriosis in pregnant women has a high rate of miscarriage or fetal death. It can also cause severe neonatal infection.
What is the effect of parvovirus in the foetus?
Hydrops fetalis
How long should pregnant women be treated for UTI?
7 DAYS
What are the thresholds for anaemia?
Booking bloods
> 110 g/l
28 weeks gestation
> 105 g/l
Post partum
> 100 g/l
What is the Lamda sign or twin peak?
The lambda sign, or twin peak sign, refers to a triangular appearance where the membrane between the twins meets the chorion, as the chorion blends partially into the membrane. This indicates a dichorionic twin pregnancy (separate placentas).
What is the T sign?
Represents a monochorionic and moniamniotic pregnancy
What are the types of twin pregnancy?
Dichorionic diamniotic twins have a membrane between the twins, with a lambda sign or twin peak sign
Monochorionic diamniotic twins have a membrane between the twins, with a T sign
Monochorionic monoamniotic twins have no membrane separating the twins
What are the risks to the mother for twin pregnancies?
Anaemia
Polyhydramnios
Hypertension
Malpresentation
Spontaneous preterm birth
Instrumental delivery or caesarean
Postpartum haemorrhage
What are the risks to the feotuses in twin pregnancy?
Miscarriage
Stillbirth
Fetal growth restriction
Prematurity
Twin-twin transfusion syndrome
Twin anaemia polycythaemia sequence
Congenital abnormalities
What is the definition of pre-eclampsia?
Pre-eclampsia refers to new high blood pressure (hypertension) in pregnancy with end-organ dysfunction, notably with proteinuria (protein in the urine). It occurs after 20 weeks gestation, when the spiral arteries of the placenta form abnormally, leading to a high vascular resistance in these vessels.
What is the triad for pre-eclampsia?
Pre-eclampsia features a triad of:
Hypertension
Proteinuria
Oedema
What are the symptoms of pre-eclampsia?
Headache
Visual disturbance or blurriness
Nausea and vomiting
Upper abdominal or epigastric pain (this is due to liver swelling)
Oedema
Reduced urine output
Brisk reflexes
What are complications of pre-eclampsia?
HEC
RIP
What scoring system is used in pre-eclampsia?
Scoring systems are used to determine whether to admit the woman (fullPIERS or PREP‑S)
Blood pressure is monitored closely (at least every 48 hours)
Urine dipstick testing is not routinely necessary (the diagnosis is already made)
Ultrasound monitoring of the fetus, amniotic fluid and dopplers is performed two weekly
What does PIER stand for?
Preeclampsia integrated estimate of risk
How is pre-eclampsia managed?
Labetolol is first-line as an antihypertensive
Nifedipine (modified-release) is commonly used second-line
Methyldopa is used third-line (needs to be stopped within two days of birth)
Intravenous hydralazine may be used as an antihypertensive in critical care in severe pre-eclampsia or eclampsia
IV magnesium sulphate is given during labour and in the 24 hours afterwards to prevent seizures
Fluid restriction is used during labour in severe pre-eclampsia or eclampsia, to avoid fluid overload
Steroids and delivery
What is used to determine pre-eclampsia?
FullsPier
Hypertension
Proteinuria
Oedema
Multi organ failure
What is SGA?
<10th centile
Establish if causes can be constitutional or growth restriction
IUGR or non-placental.
What is LGA?
> 90th centile
Constitutional or disease related
Risk of tears and shoulder dystocia
What are the risk factors for gestational diabetes?
Previous gestational diabetes
Previous macrosomic baby (≥ 4.5kg)
BMI > 30
Ethnic origin (black Caribbean, Middle Eastern and South Asian)
Family history of diabetes (first-degree relative)
What would an OGTT show for gestational diabetes?
An OGTT should be performed in the morning after a fast (they can drink plain water). The patient drinks a 75g glucose drink at the start of the test. The blood sugar level is measured before the sugar drink (fasting) and then at 2 hours.
Normal results are:
Fasting: < 5.6 mmol/l
At 2 hours: < 7.8 mmol/l
How is gestational diabetes managed?
Fasting glucose less than 7 mmol/l: trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin
Fasting glucose above 7 mmol/l: start insulin ± metformin
Fasting glucose above 6 mmol/l plus macrosomia (or other complications): start insulin ± metformin
What can be used if insulin or metformin is not tolerated?
Glibenclamide (a sulfonylurea) is suggested as an option for women who decline insulin or cannot tolerate metformin.
How is hypoglycaemia of the newborn managed?
Babies need close monitoring for neonatal hypoglycaemia, with regular blood glucose checks and frequent feeds. The aim is to maintain their blood sugar above 2 mmol/l, and if it falls below this, they may need IV dextrose of nasogastric feeding.
Why does neonatal hypoglycaemia occur?
Babies become accustomed to a large supply of glucose during the pregnancy, and after birth they struggle to maintain the supply they are used to with oral feeding alone.
How does intrahepatic cholestasis present?
Obstetric cholestasis typically present later in pregnancy, particularly in the third trimester.
Itching (pruritis) is the main symptom, particularly affecting the palms of the hands and soles of the feet.
Other symptoms are related to cholestasis and outflow obstruction in the bile ducts:
Fatigue
Dark urine
Pale, greasy stools
Jaundice
NO RASH! this is in atopic eruption
How is intrahepatic cholestasis managed?
Ursodeoxycholic acid is the primary treatment for obstetric cholestasis. It improves LFTs, bile acids and symptoms.
Symptoms of itching can be managed with:
Emollients (i.e. calamine lotion) to soothe the skin
Antihistamines (e.g. chlorphenamine) can help sleeping (but does not improve itching)
Vitamin K
What causes acute fatty liver in pregnancy?
The most common cause is long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency in the fetus, which is an autosomal recessive condition. Very RARE so consider HELLP first
What are the symptoms of acute fatty liver disease?
General malaise and fatigue
Nausea and vomiting
Jaundice
Abdominal pain
Anorexia (lack of appetite)
Ascites
Raised ALT: AST
How is placental abruption managed?
- Senior involvement i.e. senior obstetrician, midwife and anaesthetist (Sasha)
- Grey cannula x 2 (Grey)
- Bloods include FBC, UE, LFT and coagulation studies (Brings)
- Crossmatch 4 units of blood (Clever)
- Fluid and blood resuscitation as required
CTG monitoring of the fetus
Close monitoring of the mother
How are pregnant women managed with CPR?
Immediate caesarean section is performed in a pregnant woman when:
There is no response after 4 minutes to CPR performed correctly
CPR continues for more than 4 minutes in a woman more than 20 weeks gestation
How is labour induced?
Sweep at 40 weeks
Cervical ripening Balloon
Dinoprostone
Oxytocin
What are the components of the Bishop score?
Fetal station (scored 0 – 3)
Cervical position (scored 0 – 2)
Cervical dilatation (scored 0 – 3)
Cervical effacement (scored 0 – 3)
Cervical consistency (scored 0 – 2)
What do deccelerations mean?
Name some procedures used in prevening shoulder dystocia.
Episiotomy can be used to enlarge the vaginal opening and reduce the risk of perineal tears. It is not always necessary.
McRoberts manoeuvre involves hyperflexion of the mother at the hip (bringing her knees to her abdomen). This provides a posterior pelvic tilt, lifting the pubic symphysis up and out of the way.
Rubins manoeuvre involves reaching into the vagina to put pressure on the posterior aspect of the baby’s anterior shoulder to help it move under the pubic symphysis.
Wood’s screw manoeuvre is performed during a Rubins manoeuvre. The other hand is used to reach in the vagina and put pressure on the anterior aspect of the posterior shoulder. The top shoulder is pushed forwards, and the bottom shoulder is pushed backwards, rotating the baby and helping delivery. If this does not work, the reverse motion can be tried, pushing the top shoulder backwards and the bottom shoulder forwards.
Zavanelli manoeuver involves pushing the baby’s head back into the vagina so that the baby can be delivered by emergency caesarean section.
What are the treatments for retained products of conception?
Evacuation of retained products of conception (ERPC) is a surgical procedure involving a general anaesthetic. The cervix is gradually widened using dilators, and the retained products are manually removed through the cervix using vacuum aspiration and curettage (scraping). The procedure may be referred to as “dilatation and curettage”
How are missed miscarriages managed?
What are the causes of recurrent miscarriage?
What are the types of molar pregnancy?
Causes of pre-eclamspia?
Do women with pre-eclampsia need to be admitted to hospital?
How is HELLP managed?
What are some conditions linked to pre-eclampsia?
HEC RIP
How long till pre-eclampsia develops after pregnancy?
What is deemed the correct values for minor and major PPH?
How is PPH managed?
Call for help - Critical
A-E - Anaethetists
Two wide bore - Take
Blood - blood
Warm IV - when
Activate major haemorrhage - admitting
Oxygen high flow - old
Massage - munchkins
Transfusion 4 units of blood - to
4 units of FFP - the
Catheterise - closest
Theatre - toilet
What is the surgical management of PPH?
What questions should be asked for endometriosis?
What are given with GnRH analogues?
GnRH and tibolone
What findings may be found on diagnostic laproscopy?
What strains are offered in HPV vaccine?
9 strains
How does HPV affect the cervix?
What charity can be recommended for stillbirths?
Discuss VTE in pregnancy?
What criteria needs to be considered for managing VTE in pregnancy?
What is Mendelson syndrome?
Treated with aminophylline and steroids.
