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Phase 3a - Obs & Gynae > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

What is ectopic pregnancy and where does it commonly occur?

A

When a pregnancy implants outside of uterus.

MC - fallopian tubes (ampulla followed by isthmus, fimbria)
Other: abdomen, ovary, cervix

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2
Q

What are the RF for ectopic pregnancy?

A

Previous hx of ectopic pregnancy, PID, damage to fallopian tubes, STI’s
IUD (coils)
Endometriosis
Older age >35 yrs
Smoking

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3
Q

Sx for ectopic pregnancy and which week gestation do the Sx usually begin?

A

6-8 week gestation
Vaginal bleeding - dark brown colour
Missed period
Unilateral lower abdominal pain + tenderness - can lead to shoulder tip pain if severe due to irritation of phrenic vein
Cervical motion tenderness (bi-manual examination)
LOC

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4
Q

Ix and findings for ectopic pregnancy

A

Pregnancy test - B-hCG levels - both in urine and and serum
FBC - to detect blood loss
Transvaginal USS (yolk sac on fallopian tube, empty uterus or fluid filled uterus)

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5
Q

Tx for ectopic pregnancy

A

Immediate termination - watch hCG levels if it’s not decreasing then active management:

  1. Expectant tx (natural termination but hCG <1500)
  2. Methotrexate (folic acid antagonist therefore targets developing cells from producing)
  3. 1st line - salpingectomy (fallopian tube + ectopic pregnancy removal) or salpingostomy
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6
Q

What are the requirements for giving methotrexate in ectopic pregnancy and what is it’s side effects?

A

Requirements:
low hCG levels < 5000
Confirmed absence of intrauterine pregnancy

SE
Teratogenic
N+V
Vaginal bleeding
Abdominal pain
Stomatitis

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7
Q

What is postpartum haemorrhage and what would be classified as a PPH according to blood loss?

A

Loss of blood after delivering baby + placenta
Classified as PPH if:
* 500ml blood loss - post vaginal delivery
* 1000ml blood loss - post c-section

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8
Q

What is classified as:
1. Minor PPH
2. Major PPH: further classified into moderate and severe
3. Primary PPH
4. Secondary PPH

A
  1. Minor - <1000ml blood loss
  2. Major - >1000ml blood loss:
    Moderate - 1000-2000ml blood loss
    Severe - >2000ml blood loss
  3. Primary - occurs within 24hrs of birth
  4. Secondary - occurs after 24hrs of birth up to 12 wks post birth
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9
Q

Causes of PPH? (4)

A

Remember 4 T’s
* Tone - uterine atony
* Trauma - perineal tear
* Tissue - retained placenta
* Thrombin (clotting disorders) - extreme blood loss

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10
Q

RF for PPH (6)

A

Previous PPH
Perineal tear
Multiple pregnancies
Obesity
Large baby
Pre-eclampsia
Retained placenta
Instrumental delivery
Placenta accreta

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11
Q

Preventative measures for PPH?

A

Tx anaemia before birth
Empty bladder - full bladder can supress uterine contractions
Active 3rd stage of labour - IM oxytocin post birth - stimulate uterine contractions

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12
Q

Tx of PPH to stop bleeding:
1. Mechanical
2. Medical
3. Surgical

A
  1. Mechanical
    Uterus rub
    Catheterisation
  2. Medical (meds to stimulate uterine contractions)
    Oxytocin, ergometrine, carboprost (CI - asthma)
  3. Surgical
    Intrauterine balloon tamponade
    B-lynch suture
    Hysterectomy
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13
Q

What is secondary PPH, cause and what is the management?

A

Bleeding 24hrs up to 12 wks post birth

Cause: remained product of conception or infection

Tx: surgical or abx for infection

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14
Q

What is placenta accreta spectrum?

A

When placenta implants deeper than endometrium layer therefore difficult to separate post birth

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15
Q

What are the 3 layers of the uterine wall and where does placenta usually attach to?

A
  • Inner layer - endometrium (connective tissue and blood vessels)
  • Middle layer - myometrium (smooth muscle)
  • Outer layer - perimetrium (serous membrane)

Placenta = endometrium

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16
Q

Define:
1. Superficial placenta accreta
2. Placenta increta
3. Placenta percreta

A
  1. Attaches surface of myometrium
  2. Implants deep into myometrium
  3. Implants past myometrium and perimetrium
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17
Q

RF for placenta accreta (4)

A

Previous placenta accreta
Previous C-section
Previous endometrial curettage procedures for miscarriage or abortion
Low-lying placenta
Placenta praevia
> maternal age

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18
Q

Sx and Ix for placenta accreta diagnosis

A

Sx: usually aSx but causes PPH
Ix: USS detects + MRI scan to investigate or can be diagnosed post birth

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19
Q

Tx of placenta accreta

A

If found before birth - Plan delivery at 35 - 36 weeks gestation + give antenatal steroids to mature foetal lung

If found post-birth:
1st line - hysterectomy
Uterus preserving surgery
Expectant management - risk of infection

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20
Q

What are the 3 main causes of antepartum haemorrhage?

A

Placenta praevia
Vasa praevia
Placental abruption

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21
Q

What is placenta praevia? How does it differ from low lying placenta?

A

When the placenta covers the internal cervical os, under the foetus.

Low lying placenta - when the placenta is 20mm away from the internal cervix os.

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22
Q

What are the risks of having placental praevia? (3)

A

Antepartum haemorrhage
Stillbirth
Preterm birth
Emergency c-section and hysterectomy
Maternal anaemia

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23
Q

RF for placenta praevia (3)

A

Previous c-section or placenta praevia
> maternal age
maternal smoking
Uterine abnormalities (fibroids)
Assisted reproduction (IVF)

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24
Q

Sx and Ix for placenta praevia

A

aSx but bright red painless vaginal bleeding during pregnancy (especially later on in pregnancy at or over 26 weeks)

Ix - USS at 20 week scan
Transvaginal USS repeated at 32 and 36 weeks

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25
Q

Management of placenta praevia

A

Increased risk of pre-term pregnancy - give corticosteroids to mature foetal lungs

Planned c-section

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26
Q

What is placental abruption?

A

When the placenta detaches from the endometrium. Separation from site can cause excessive bleeding leading to antepartum haemorrhage.

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27
Q

RF for placental abruption (4)

A

Previous placental abruption or c-section
> maternal age
Smoking
Cocaine use
Multiple pregnancies
Multi gravida
Pre-eclampsia
Trauma (i.e. domestic abuse)

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28
Q

Sx of placental abruption

A

Sudden onset continuous severe abdominal pain
Vaginal bleeding
Shock (tachycardic and hypotension)
Woody abdomen on palpation

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29
Q

What is concealed abruption?

A

When the cervix os is blocked therefore bleeding is contained within uterine walls.

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30
Q

Mx of placental abruption

A

Induce labour initially and attempt vaginal delivery if not then emergency c-section

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31
Q

What is vasa praevia?

A

When the foetal vessels are within the foetal membranes (chorioamniotic membranes) and travel across the internal cervical os.

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32
Q

Describe pathophysiology of vasa praevia:
1. What does the foetal vessel consist of?
2. Where are the foetal vessels usually located? How is it protected? How does it change in vasa praevia?

A
  1. two umbilical arteries and single umbilical vein
  2. Usually located within umbilical cord and are always protected by the cord which contains Wharton’s jelly or placenta. In vasa praevia the foetal vessels are exposed. It can then travel through chorioamniotic membranes and pass across cervical os
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33
Q

What are the two types of vasa praevia?

A

Type 1 - the foetal vessels are exposed as a velamentous umbilical cord (a condition where the umbilical cord inserts into the foetal membranes instead of the placenta)

Type 2 - the foetal vessels are exposed as they travel to an accessory placental lobe

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34
Q

RF for vasa praevia (3)

A

Low lying placenta
IVF pregnancy
Multiple pregnancy

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35
Q

Sx for vasa praevia

A

Antepartum haemorrhage, with bleeding during 2nd/3rd trimester of pregnancy

Pulsating fetal vessels are seen in the membranes through the dilated cervix during labour

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36
Q

Management of vasa praevia

A

If aSx:
Corticosteroids (from 32 wks to develop foetus lungs)
Elective C-section

If symptomatic:
Emergency c-section

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37
Q

What is cord prolapse?

A

When the umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina, after rupture of the fetal membranes.

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38
Q

Cord prolapse diagnosis?

A

Sx of fetal distress on the CTG.

A prolapsed umbilical cord can be diagnosed by vaginal examination.

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39
Q

Management of cord prolapse

A

Emergency c-section

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40
Q

What is pre-eclampsia?

A

New onset htn that occurs from 20 weeks gestation associated with end organ damage and proteinuria.
BP of > 140/90

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41
Q

What is the difference between pre-eclampsia and gestational (pregnancy-induced) hypertension?

A

Gestational htn is increased BP without proteinuria whereas pre-eclampsia is with organ damage + proteinuria.

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42
Q

What is eclampsia?

A

Seizures (tonic clonic seizures) that occur as a result of pre-eclampsia

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43
Q

Describe pathophysiology of pre-eclampsia

Hint: What is the name of the artery? How does damage to that artery cau

A

Spiral arteries are located in placenta → normally dilated → inc. blood supply to foetus

In pre-eclampsia → abnormal spiral arteries → dec. placental perfusion:
* In foetus → blood supply decreases → intrauterine growth restriction or foetal demise
* In mother → inflammatory response → proteins are released → endothelial damage → leads to:
1. Inc. permeability → oedema (in legs, hands, cerebral)
2. Thrombin formation (HELLP syndrome)
3. Na+ retention in kidney → kidney damage → proetinuria
4. BV narrowing → inc. BP

44
Q

RF for pre-eclampsia (5)

A

High RF:
* Pre-existing htn
* Autoimmune cdtns
* Diabetes
* CKD

Moderate RF:
* >40 yrs
* >35 BMI
* Smoking
* First pregnancy or multiparity
* Fhx

45
Q

Sx for pre-eclampsia

A

Oedema
Headache
Visual disturbance
Dizziness
N+V
Upper abdo pain (due to liver swelling)
Brisk reflexes

46
Q

Diagnosis of pre-eclampsia

A

Measure BP → >140/90
Urine dipstick → protein
FBC and U&E’s

47
Q

Management of pre-eclampsia

A
  • Prophylaxis → aspirin (given from 12 weeks)
  • If pre-eclampsia:
    1. Labetolol (1st line)
    2. Nifedipine (2nd line)
    3. Methyldopa (3rd line)

Fluid restriction during labour

48
Q

Tx of eclampsia

A

IV Magnesium Sulphate

49
Q

What is the HELLP syndrome?

A

Haemolysis
Elevated Liver enzyme
Low Platelet

In FBC look for haemolytic anaemia, liver enzymes and platelet levels

50
Q

Define instrumental delivery and what are the different types

A

Vaginal delivery assisted by the use of forceps or ventouse suction to aid delivery

  • Venthouse - suction cup attached to a cord
  • Forceps - Two metal tongs
51
Q

What are the indications for an instrumental delivery?

A

Maternal exhaustion
Foetal position
Foetal distress
Failure to progress

52
Q

Risks of an instrumental delivery?

Both to mother and baby

A

Mother:
PPH, episiotomy, perineal tear, anal sphincter injury

Baby:
* Cephalohaematoma - by venthouse suction
* Facial nerve palsy - by forceps

53
Q

Which nerves could be affected by an instrumental delivery?

Bonus points if youknow how injury to these nerves affects the legs.

A

Femoral nerve - affects patella reflexes, knee extension, numbness to anterior thigh and middle lower leg

Obturator nerve - affects hip adduction and numbness to medial thighs

54
Q

What tx is given after an instrumental delivery?

Hint: it’s to reduce risk of infection

A

Co-amoxiclav

55
Q

What are some causes of an obstructed labour? (3)

A
  1. Foetal malpresentation - breech or transverse presentation
  2. Foetal macrosomia
  3. Maternal pelvic abnormalities
  4. Uterine dysfuction
  5. Multiparity
  6. Prolonged labour
56
Q

Describe factors that cause Intrauterine Growth Restriction (IUGR)

  1. Maternal Factors
  2. Foetal Factors
  3. Placental Factors
A

1. Maternal:
- BMI (i.e. poor weight gain for pregnancy)
- Co-morbidities (diabetes, htn, anaemia, CVD, coeliacs, etc)
- Smoker, alcohol, substance abuse
- Structural uterine malformations

2. Foetal:
- Chromosomal defects
- Multiple pregnancy
- Vertically transmitted infections (i.e. rubella, CMV)

3. Placental:
- Utero-placental insufficiency
- Pre-eclampsia

57
Q

Sx of IUGR

IUGR = Intrauterine Growth Restriction

A

Reduced foetal movement
Abnormal fundalheight for gestation week
Complications like stillbirth and pre-eclampsia

58
Q

Ix for IUGR

IUGR = Intrauterine Growth Restriction

A

USS to assess foetal growth, volume of amniotic fluid
Doppler to assess blood flow
Biophysical profile

59
Q

Mx of IUGR

IUGR = Intrauterine Growth Restriction

A

Monitor foetal growth
Early delivery if foetal distress noted

60
Q

What is a uterine rupture?
Describe the difference between a complete and incomplete rupture.

A

Rupture of the myometrium layer

1. Incomplete rupture = only myometrium tears, perimetrium stays intact

2. Complete rupture = Perimetrium tears, so uterus contents released into peritoneal cavity. This is an Emergency as baby could be released into peritoneal cavity which increases mortality and morbidity of baby.

61
Q

RF for uterine rupture (4)

A

VBAC (vaginal birth after c-section)
Previous uterine surgeries
Increased age
Higher BMI
High parity
Induction of labour
Oxytocin use

62
Q

Sx for uterine rupture

A

Unwell mother
Abnormal CTG
Abdominal pain
Vaginal bleeding
Ceasing of uterine contractions
Hypotension
Tachycardic
LOC

63
Q

Mx for uterine rupture

A

EMERGENCY C-SECTION!!

64
Q

Define rupture of membrane

A

Amniotic sac is ruptured

65
Q

At which week gestation is a baby considered premature (preterm)?

A

Before 37 weeks gestation

66
Q

Prophylaxis of preterm labour?

Who is prophylaxis offered to?

A
  1. Vaginal progesterone - via gel or pessary as progesterone protects pregnancy
  2. Cervical cerclage - stitch put into cervix opening taken out during labour or at term

Prophylaxis is offered to women with a cervix shorter than 25mm and between 16 and 24 weeks gestation.

67
Q

Preterm Prelabour Rupture of Membranes

  1. Definition
  2. Ix
  3. Tx
A
  1. Rupture of amniotic sac which releases amniotic fluid before 37 weeks gestation
  2. Speculum or IGFBP-1 (enzyme found in high concentrations in amniotic fluid)
  3. Prophylactic abx (erythromycin to prevent chorioamnionitis) + possible induction of labour
68
Q

Preterm Labour with Intact Membranes

  1. Definition
  2. Ix
  3. Tx
A
  1. Regular, painful contraction + cervical dilation without amniotic sac rupture
  2. USS
  3. Tx:
    - Foetal CTG
    - Tocolysis w/ Nifedipine
    - Maternal corticosteroids
    - IV magnesium sulfate
    - Delayed cord clamping

  • Tocolysis involves using medications to stop uterine contractions. It is only used as a short term measure (i.e. less than 48 hours).
  • Nifedipine (tocolysis) is a calcium channel blocker that suppresses labour.
  • Corticosteroids helps to develop the fetal lungs and reduce respiratory distress syndrome after delivery.
  • IV magnesium sulfate helps protect the fetal brain during premature delivery. It reduces the risk and severity of cerebral palsy. Given within 24 hours of delivery.
69
Q

What does rhesus status mean?

A

Whether someones blood group is +ve or -ve

70
Q

What does it mean if someone is rhesus +ve or -ve?

A

Rhesus +ve = Rhesus antigen on RBC
Rhesus -ve = No rhesus antigen on RBC

71
Q

Describe the pathophysiology behind how immune system deals with rhesus incompatibility.

What would happen if mum is rhesus -ve and baby is rhesus +ve

A
  • If someone is rhesus +ve → antigen present → body’s immune system recognises it → no attack happens
  • BUT if someone is rhesus -ve → but comes across antigen → body recognises it as foreign pathogen → immune system attacks → Anti-D antibodies released

Therefore in context of pregnancy:
* If mum rhesus +ve → no problem → won’t attack baby’s RBC’s
* If mum rhesus -ve → comes into contact with baby’s blood (+ve) → produces ab’s to attack the foreign antigen:
If this happens in first baby → nothing will happen to baby → mum just attacks the foreign antigen and creates ab’s that stays in her immune system
HOWEVER, in future pregnancies → ab’s previosuly created → cross placental membrane → attack baby’s RBC’s → haemolysis → can cause permanent brain damage and learning disabilities.

72
Q

Define sensitisation events and give some examples. (4)

A

Events which cause foetal blood to cross the placenta into the maternal circulation and thus these are indications for anti-D prophylaxis.

Examples of sensitisation events include:
* Antepartum haemorrhage
* Placental abruption
* Abdominal trauma
* Intrauterine death, miscarriage or termination
* Ectopic pregnancy
* Delivery (normal, instrumental or caesarean section)

73
Q

Mx of rhesus negative mum.

A

Anti-D Ig’s is given to all non-sensitised rhesus negative mothers at 28 weeks

74
Q

What is puerperal psychosis?

A

A severe mental illness that suddenly starts in the days or weeks after having a baby. They can include mania, depression, confusion, hallucinations and delusions.

75
Q

What is the definition of miscarriage?

A

Loss of pregnancy prior to 24 wks gestation.

76
Q

Sx of miscarriage?

A
  • Vaginal bleeding
  • Pain - worse than usual period pain
  • Vaginal tissue loss
77
Q

Describe the following different types:
1. Threatened miscarriage
2. Inevitable miscarriage
3. Complete miscarriage
4. Incomplete miscarriage
5. Missed miscarriage

A
  1. Some mild sx of bleeding with foetus retained within uterus as cervical os is closed.
  2. Heavy bleeding + pain where foetus is currently intrauterine but cervical os is open.
  3. Intrauterine pregnancy which has now fully miscarried with all products of conception expelled.
  4. When miscarriage has began but products of conception remain and not completely cleared.
  5. Uterus still contains foetal tissue but foetus no longer alive.
78
Q

Mx of miscarriage?

A
  • Expectant mx: Allow natural expulsion of conception products
  • Medical mx: Misoprostol
  • Surgical mx: Dilatation and curettage

D&C = surgical procedure where cervix is dilated so that endometrium can be scraped with a curette (spoon-shaped instrument) to remove abnormal tissues.

79
Q

What medications are used for medical termination of pregnancy?

A
  • Mifepristone = blocks progesterone required for preggo
  • Misoprostol = cx smooth muscle contractions resulting in uterine content expulsion
80
Q

What are causes of macrosomia? (3)

A
  • Gestational diabetes
  • Previous macrosomia
  • Maternal obesity
  • Male baby
  • Overdue
81
Q

What are the risks of macrosomia? (4)

Note both to mother and baby

A

To mother:
* Shoulder dystocia
* Perineal tears
* Instrumental delivery or c-section
* PPH
* Failure to progress

To baby:
* Birth injury (fetal distress and hypoxia)
* Neonatal hypoglycaemia
* Obesity in childhood
* T2 diabetes in adulthood

82
Q

Ix for a large for gestational age baby?

A

USS - exclude polyhydramnios
Oral glucose tolerance test - gestational diabetes

83
Q

Define the following terms:
* Monozygotic
* Dizygotic
* Monoamniotic
* Diamniotic
* Monochorionic
* Dichorionic

A
  • Monozygotic: identical twins (from a single zygote)
  • Dizygotic: non-identical (from two different zygotes)
  • Monoamniotic: single amniotic sac
  • Diamniotic: two separate amniotic sacs
  • Monochorionic: share a single placenta
  • Dichorionic: two separate placentas
84
Q

How would you determine the type of twin (Dichorionic diamniotic vs Monochorionic diamniotic) on an USS?

A
  • Dichorionic diamniotic = lambada sign or twin peak sign
  • Monochorionic diamniotic = T sign
85
Q

Risks of a multiple pregnancy (e.g. twin pregnancy)? (4)

Both to mother and babies

A

To mother:
* Anaemia
* Polyhydromnios
* Htn
* PPH
* Instrumental or C-section

To fetuses:
* Miscarriage
* Stillbirth
* Fetal growth restriction
* Twin-twin transfusion syndrome

86
Q

What is twin-twin transfusion syndrome?

A

When fetuses share a placenta. When there’s a connection between blood supplies of 2 fetuses, one fetus may receive majority of blood from placenta while other fetus is starved of blood.

87
Q

What are the risks for gestational diabetes? (3)

A
  • Previous gestational diabetes
  • Previous macrosomic baby (>4.5 kg)
  • BMI > 30
  • Ethnic origin (black Caribbean, Middle Eastern and South Asian)
  • Fhx of diabetes (first-degree relative)
88
Q

What is the screening test of choice for gestational diabetes? What are the normal results?

A

Oral glucose tolerance test (OGTT)

Normal results are:
* Fasting: < 5.6 mmol/l
* At 2 hours: < 7.8 mmol/l
Results higher than these values are used to diagnose gestational diabetes.

89
Q

Mx of pts with gestational diabetes?

A
  • If fasting glucose <7: trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin
  • If fasting glucose >7: insulin ± metformin
  • If fasting glucose >6 + macrosomia: insulin ± metformin
90
Q

What are the maternal complications of gestational diabetes?

A
  • Increased risk of hypertension and pre-eclampsia
  • Future risk - Increased risk of developing type 2 diabetes and GDM in subsequent pregnancies
91
Q

What is gestational HTN?

A

Onset of high BP after 20 wks gestation without presence of proteinuria.

92
Q

Sx of gestational HTN?

A

aSx but are detected through elevated BP. Presents after 20 wks gestation w/no proteinuria.

93
Q

Mx of gestational HTN?

A
  • 1st line - Oral labetalol
  • Is not tolerated - alternatives: methyldopa and nifedipine
  • Regular urinalysis
94
Q

What are RF that increase womens likelihood of developing VTE in pregnancy? (3)

A

> 35 yrs
BMI >30
Parity >3
Smoker
Immobility
Fhx of unprovoked VTE
IVF preggo

95
Q

What is haemolytic disease of the newborn?

A

Immunological cdtn when rhesus -ve mother becomes sensitised to rhesus +ve blood cells of her baby while in utero.

96
Q

Sx of haemolytic disease of the newborn?

A
  • Hydrops fetalis - appears as fetal oedema
  • Yellow coloured amniotic fluid - excess bilirubin
  • Neonatal jaundice
  • Fetal anaemia - skin pallor
  • Hepatomegaly or splenomegaly
  • Severe oedema
97
Q

Ix for haemolytic disease of the newborn?

A

Direct Antiglobulin Test (DAT)
USS - detect foetal oedema
Liver function tests (LFTs)

98
Q

Tx for gonorrhoea in pregnant or breastfeeding women?

A

Single dose of intramuscular ceftriaxone or oral azithromycin

99
Q

What bacteria causes group b strep infx?

A

Bacterium Streptococcus agalactiae

100
Q

Sx of group b strep infx in newborn?

A

Sepsis
Pneumonia
Meningitis

101
Q

What are the RF that increase the risk of neonatal GBS infx?

A
  • Positive GBS culture in current or previous pregnancy
  • Previous birth resulting in neonatal GBS infection
  • Pre-term labour
  • Prolonged rupture of membranes
  • Intrapartum fever >38 degrees Celsius
  • Chorioamnionitis
102
Q

Mx of GBS infx?

A

Intrapartum abx prophylaxis.

Abx such as penicillin are administered IV during labour and delivery if RF for GBS infx present.

103
Q

What is the tx for UTI during pregnancy (w/no haematuria)?

A

1st line: nitrofurantoin for 7 days (avoid at term)

2nd line: if nitro not suitable - amoxicillin/cefelexin for 7 days

104
Q

What is congenital VZV?

A

When non-immune women contracts VZV during 1st trimester of preggo. When contracted in early preggo, virus can have teratogenic effects leading to congenital varicella syndrome in newborn.

105
Q

Sx of congenital varicella syndrome?

A

Low birth weight
Limb hypoplasia
Skin scarring
Microcephaly
Eye defects
Learning disabilities

Microcephaly is a condition where a baby’s head is much smaller than expected.

106
Q

Mx of congenital varicella syndrome?

A

If non-immune preggo comes into contact with infected person - give immunoglobulin as preventative measure

If maternal infx occurs - Acyclovir (within 24hrs of rash onset)

Post delivery - give neonate IV acyclovir + monitor

Phase 3a - Obs & Gynae (7 decks)

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