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Obstetrics Flashcards

1
Q

What is an ectopic pregnancy?

A

embryo implanted outside the uterus

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2
Q

What is the most common site for ectopic pregnancy?

A

fallopian tube

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3
Q

What are possible locations for an ectopic pregnancy?

A
  • MC tubal (ampulla)
  • most danger of rupture in isthmus
  • ovary, cervix, peritoneum
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4
Q

What are the risk factors for ectopic pregnancy?

A
  • previous ectopic
  • previous pelvic inflammatory
  • tubal damage
  • IVF
  • IUD/IUS/POP
  • older age
  • smoking
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5
Q

What is the presentation of an ectopic pregnancy?

A
  • vaginal bleeding
  • missed period
  • lower abdominal pain (L/RIF)
  • lower abdo/pelvic tenderness
  • cervical motion tenderness - chandelier sign
  • shoulder tip pain (bleeding irritates diaphragm)
  • dizziness
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6
Q

What investigations are done for an ectopic pregnancy?

A
  • transvaginal ultrasound scan
  • gestational sac containing a yolk sac or fetal pole
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7
Q

What is seen on USS for an ectopic?

A
  • non-specific mass containing empty gestational sac
  • blob/bagel/tubal ring sign
  • mass moves separately to ovary (corpus lutem would move with ovary)
  • empty/fluid filled uterus
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8
Q

What are the criteria for conservative management of an ectopic?

A
  • for minimal/no symptoms
  • repeat β-hCG testing
  • unruptured ectopic
  • adnexal mass <35mm
  • no visible heartbeat
  • no significant pain
  • hCG < 1500 IU/l
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9
Q

What does medical management of an ectopic pregnancy involve and what are the criteria?

A
  • hCG <1500IU/L
  • confirmed absence of IU pregnancy on USS
  • IM methotrexate in buttock
  • teratogenic - spontaneous termination
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10
Q

What are the side effects of methotrexate?

A
  • vaginal bleeding
  • n+v
  • abdo pain
  • stomatitis
  • advised not to get pregnant for 3 months
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11
Q

What are the criteria for surgical management of ectopic pregnancy?

A
  • ruptured
  • pain
  • adnexal mass >35mm
  • visible heartbeat
  • hCG >5000 IU/l
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12
Q

What is a salpingectomy?

A

removal of the fallopian tube (containing the ectopic pregnancy)

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13
Q

What is a salpingotomy?

A
  • used in women with inc risk of infertility due to other damaged tube
  • cut made in tube, ectopic removed and tube closed
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14
Q

What is pregnancy of unknown location?

A
  • positive pregnancy test but no intra/extrauterine evidence of pregnancy on transvaginal USS
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15
Q

How is pregnancy of unknown location monitored?

A
  • serum hCG tracked and repeated over 48hrs
  • monitor clinical signs or symptoms
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16
Q

What rises in hCG indicate which types of pregnancy?

A
  • rise of > 63% intrauterine pregnancy
  • <63% indicates ectopic
  • fall of >50% indicates miscarriage
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17
Q

What is a missed miscarriage?

A
  • fetus no longer alive
  • no symptoms occurred
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18
Q

What is a complete miscarriage?

A
  • full miscarriage
  • no products of conceptions left in the uterus
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19
Q

What is an incomplete miscarriage?

A
  • products of conception retained in the uterus
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20
Q

What is a threatened miscarriage?

A
  • vaginal bleeding
  • closed cervix
  • fetus is alive
  • little/no pain
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21
Q

What are the symptoms of an inevitable miscarriage?

A
  • heavy vaginal bleeding
  • pain
  • open cervix
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22
Q

How is miscarriage diagnosed?

A
  • transvaginal ultrasound
  • mean gestational sac diameter
  • fetal pole and crown-rump length
  • fetal heartbeat
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23
Q

How does fetal heartbeat affect crown-rump length?

A
  • heartbeat expected when length is 7mm or more
  • if less than 7mm, scan is repeated after 1 week to ensure heartbeat develops
  • 7mm+ and no heartbeat = non-viable pregnancy
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24
Q

What is an anembryonic pregnancy?

A
  • gestational sac is present
  • no embryo
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25
Q

When is a fetal pole seen?

A
  • expected when mean gestational sac diameter is >25mm
  • if this is present without a fetal pole:
  • repeat scan after 1 week then confirm anembryonic pregnancy
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26
Q

How is a miscarriage of <6 weeks gestation managed?

A
  • expectant management
  • awaiting without investigations and treatment
  • repeat urine pregnancy test after 3 weeks
  • if negative a miscarriage can be confirmed
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27
Q

How is a miscarriage of >6 weeks gestation managed?

A
  • early pregnancy assessment service referral (EPAU)
  • arrange USS to confirm location and viability
  • consider and exclude ectopic
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28
Q

What is expectant management of a miscarriage?

A
  • 1st line without risk factors for heavy bleeding and pregnancy
  • 1-2 weeks to allow it to occur spontaneously
  • repeat urine pregnancy after 3 weeks to confirm complete
  • persistent/worsening bleeding requires further assessment and repeat USS in case of incomplete miscarriage
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29
Q

What is medical management of a miscarriage?

A
  • misoprostol
  • vaginal suppository or oral
  • causes heavier bleeding, pain, vomiting, diarrhoea
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30
Q

What is surgical management of miscarriage?

A
  • give misoprostol
  • manual vacuum aspiration
  • electric vacuum aspiration
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31
Q

How does manual vacuum aspiration work?

A
  • local anaesthetic applied to cervix
  • syringe inserted through
    -<10 weeks gestation
  • more appropriate for parous women
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32
Q

How does electric vacuum aspiration work?

A
  • traditional surgical management
  • general anaesthetic
  • cervix widened with dilators
  • pregnancy removed with electric powered vacuum
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33
Q

How is incomplete miscarriage managed?

A
  • retained products carry infection risk
  • misoprostol or evacuation
  • ERPC using vacuum aspiration and curettage (scraping)
  • complication is endometriosis
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34
Q

What is hyperemesis gravidarum?

A
  • vomiting a lot during pregnancy
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35
Q

What are the RCOG guidelines for hyperemesis?

A
  • more than 5% weight loss compared with before pregnancy
  • dehydration
  • electrolyte imbalance
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36
Q

How is the severity of hyperemesis assessed?

A
  • pregnancy-unique quantification of emesis (PUQE)
  • <7 = mild
  • 7-12 = moderate
  • > 12 = severe
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37
Q

What is the management of hyperemesis?

A
  • antiemetics
    1. prochlorperazine
    2. cyclizine
    3. ondansetron
    4. metoclopramide
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38
Q

How is severe hyperemesis managed?

A
  • IV/IM antiemetics
  • IV fluids
  • KCl for hypokalaemia
  • thiamine and folic acid to prevent Wernicke’s encephalopathy
  • TED stockings and LmwH
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39
Q

When should admission be considered in hyperemesis?

A
  • unable to tolerate antiemetics
  • more than 5% weight loss vs prepregnancy
  • ketones present (2+ is significant)
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40
Q

What is the definition of recurrent miscarriage?

A
  • three or more miscarriages
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41
Q

What are the causes of recurrent miscarriage?

A
  • smoking
  • antiphospholipid syndrome
  • hereditary thrombophilia
  • uterine abnormalities
  • chronic disease: diabetes, SLE, thyroid
  • genetic factors
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42
Q

What is PPH?

A
  • post partum haemorrhage
  • bleeding after delivering baby and placenta
  • most common cause of significant obstetric haemorrhage
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43
Q

How much blood loss is needed to be classified as PPH?

A
  • 500ml after vaginal delivery
  • 1000ml after c-section
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44
Q

What is the difference between major and minor PPH?

A
  • Minor: under 1000ml
  • Major: over 1000ml
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45
Q

How can major PPH be subclassified?

A
  • Moderate: 1000-2000ml loss
  • Severe >2000ml loss
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46
Q

What is the difference between primary and secondary PPH?

A

Primary: within 24hrs of birth
Secondary: between 24hrs - 12 weeks after birth

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47
Q

What are the causes of PPH (4 T’s)?

A
  • tone (uterine atony)
  • trauma (perineal tear)
  • tissue (retained POC)
  • thrombin (bleeding disorder)
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48
Q

What are risk factors for PPH?

A
  • previous PPH
  • retained placenta
  • placenta accreta
  • instrumental delivery
  • multiple pregnancy
  • macrosomia
  • prolonged 3rd stage
  • failure to progress from 2nd stage
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49
Q

What are some preventative measures for PPH?

A
  • treating anaemia during antenatal period
  • giving birth w empty bladder
  • active management of 3rd stage
  • IV tranexamic acid (in 3rd stage C-section in high risk pt)
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50
Q

What is mechanical treatment of PPH?

A
  • rubbing uterus to stimulate contraction
  • catheterisation (bladder distention prevents contractions)
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51
Q

What is medical treatment of PPH?

A
  • oxytocin
  • ergometrine (IV/IM) stimulates smooth muscle contraction
  • carboprost/misprostol: prostaglandin analogues stimulating uterine contraction
  • tranexamic acid: antifibrinolytic
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52
Q

What is surgical treatment of PPH?

A
  • IU balloon tamponade: presses against bleeding
  • B-lynch suture: suture around uterus to compress
  • uterine artery ligation
  • hysterectomy
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53
Q

What causes secondary PPH?

A
  • most likely due to retained products of conception or infection
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54
Q

How is secondary PPH investigated?

A
  • USS for RPOC
  • endocervical and high vaginal swabs for infection
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55
Q

How is secondary PPH managed?

A
  • surgical evacuation for RPOC
  • Abx for infection
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56
Q

What is placental abruption?

A

when the placental separates from the uterine wall during pregnancy

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57
Q

What does placental abruption lead to?

A
  • site of attachment can bleed
  • significant cause of antepartum haemorrhage
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58
Q

What are risk factors for placental abruption?

A
  • prev abruption
  • pre-eclampsia
  • trauma
  • multiple pregnancy
  • inc maternal age
  • smoking/cocaine
  • multiparity/gravida
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59
Q

How does placental abruption present?

A
  • woody, hard uterus
  • sudden onset, severe, continuous abdo pain
  • vaginal bleeding
  • hypovolaemic shock
  • dec fetal movements and distress on CTG
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60
Q

How is the severity of antepartum haemorrhage defined?

A
  • spotting: spots on underwear
  • minor: <50ml blood loss
  • major: 50-1000ml loss
  • massive: >1000ml or signs of shock
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61
Q

What is a concealed abruption?

A
  • cervical os remains closed
  • bleeding remains within uterine cavity
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62
Q

When are steroids given in placental abruption?

A
  • between 24 and 34+6 weeks
  • mature fetal lungs
  • in anticipation of preterm delivery
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63
Q

What is the management of abruption?

A
  • FBC, U&Es, LFT, coagulation
  • crossmatch 4 units
  • CTG of foetus and monitor mother
  • fluid and blood resus as required
  • senior obstetrician, midwife, anaesthetist
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64
Q

What is placenta praevia?

A
  • low lying placenta, potentially covering cervical os
  • lower than presenting part (part of baby to be delivered first - head in cephalic presentation) of the fetus
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65
Q

What is the difference between low-lying placenta and placenta praevia?

A
  • low-lying: within 20mm of os
  • praevia: placenta is over os
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66
Q

What can placenta praevia cause?

A
  • antepartum haemorrhage
  • emergency c-section
  • emergency hysterectomy
  • maternal anaemia and transfusion
  • preterm birth and low weight
  • stillbirth
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67
Q

What are risk factors for placenta praevia?

A
  • prev c-sections
  • prev praevia
  • older age
  • smoking
  • uterine abnormalities
  • IVF
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68
Q

What are the grades of praevia?

A
  • minor/grade 1: in lower uterus but not reaching os
  • marginal/grade 2: reaching but not covering os
  • partial/grade 3: partially covering os
  • complete/grade 4: completely covering os
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69
Q

What is the presentation of placenta praevia?

A
  • painless bright red vaginal bleeding
  • occurs after 24 weeks
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70
Q

What is the management of placenta praevia?

A
  • if diagnosed early:
  • repeat TVUS at 32 and 36 weeks
  • corticosteroids 34 - 35+6 weeks to mature fetal lungs
  • planned delivery 36-37 weeks
  • planned C-section
  • emergency c-section if premature labour/antenatal bleeding
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71
Q

What is a perineal tear?

A
  • when external vaginal opening is too narrow for baby
  • tearing of skin and tissues
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72
Q

What are risk factors for perineal tears?

A
  • first baby
  • large baby (over 4kg)
  • shoulder dystocia
  • Asian ethnicity
  • occipito-posterior position
  • instrumental deliveries
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73
Q

How are perineal tears classified?

A
  • 1st degree: frenulum of posterior labia minor and superficial skin
  • 2nd: including perineal muscles
  • 3rd: including anal sphincter
  • 4th: including rectal mucosa
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74
Q

How are 3rd degree tears subcategorised?

A
  • 3a: <50% of ext sphincter affected
  • 3b: >50% ext sphincter affected
  • 3c: ext and int sphincter affected
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75
Q

What are the short term complications of tears?

A
  • pain
  • infection
  • bleeding
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76
Q

What are the long lasting complications of perineal tears?

A
  • urinary incontinence
  • anal incontinence/altered bowel habit (3rd/4th degree)
  • rectovaginal fistula
  • sexual dysfunction and dyspareunia
  • psych and mental consequences
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77
Q

What is the management of tears?

A
  • 1st: none
  • 2nd: suture
  • 3rd/4th: theatre + elective C-section for subsequent pregnancies
  • antibiotics
  • laxatives
  • physio and followup
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78
Q

What is an episiotomy?

A
  • cuts perineum before delivery - anticipation
  • 45 degree diagonal from vagina, downwards and laterally
  • mediolateral episiotomy
  • sutured after delivery
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79
Q

What is perineal massage?

A
  • reduces risk
  • massaging skin and tissues
  • from 34 weeks
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80
Q

What is shoulder dystocia?

A
  • anterior shoulder becomes stuck behind pubic symphysis after head has been delivered
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81
Q

What is a cause of shoulder dystocia?

A
  • macrosomia (large baby)
  • secondary to gestational diabetes
  • advanced maternal age
  • short stature
  • small pelvis
  • gestation >42 weeks
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82
Q

How does shoulder dystocia present?

A
  • difficulty delivering face and head
  • failure of restitution (baby head remains downwards (occipito- anterior))
  • turtle-neck sign: head is delivered then retracts back into vagina
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83
Q

What are complications of shoulder dystocia?

A
  • fetal hypoxia (+ subsequent cerebral palsy)
  • brachial plexus injury
  • perineal tear
  • PPH
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84
Q

Why should fundal pressure not be applied in shoulder dystocia?

A
  • can lead to uterine rupture
  • may exacerbate shoulder impaction
  • discouraging maternal pushing
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85
Q

What is the 1st line manoeuvre for shoulder dystocia?

A
  • McRobert’s manoeuvre
  • hyperflexion of hip to provide posterior pelvic tilt
  • knees to abdomen
  • moves pubic symphysis out of way
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86
Q

What is the second line manoeuvre for shoulder dystocia?

A
  • suprapubic pressure
  • pressure on the posterior aspect of the anterior shoulder
  • encourages it down and under the pubic symphysis
87
Q

What is Rubins and Wood’s screw manoeuvre?

A
  • Rubins: reaching into vagina to put pressure on posterior aspect of anterior shoulder to move under symphysis
  • Wood’s: other hand reaches inside to put pressure on anterior aspect of posterior shoulder
  • top shoulder pushed forwards and bottom pushed back
  • rotates baby and helps delivery
  • opposite can be tried
88
Q

What is the last line manoeuvre for shoulder dystocia?

A
  • Zavanelli manoeuvre
  • pushing baby’s head back into vagina for emergency C-section
89
Q

What is instrumental delivery?

A
  • vaginal delivery with ventouse suction cup or forceps
90
Q

What are key indications for instrumental delivery?

A
  • failure to progress
  • fetal distress
  • maternal exhaustion
  • control of head in various fetal positions
91
Q

What are the risks to the mother with instrumental delivery?

A
  • PPH
  • episiotomy
  • perineal tears
  • injury to anal sphincter
  • bladder/bowel incontinence
  • obturator/femoral nerve injury
92
Q

What are the key risks to the baby with instrumental delivery?

A
  • cephalohaematoma with ventouse
  • facial nerve palsy with forceps
93
Q

What more serious risks are there to the baby with instrumental delivery?

A
  • subgaleal haemorrhage
  • intracranial haemorrhage
  • skull fracture
  • spinal cord injury
94
Q

What is a cephalohaematoma?

A
  • collection of blood between the skull and periosteum (membrane covering bones)
95
Q

What is ventouse?

A
  • a suction cup on a cord
  • cup goes on baby’s head
  • careful traction on cord to pull baby out
96
Q

What are forceps?

A
  • two pieces of curved metal allowing grip of baby’s head
  • can cause facial nerve palsy or facial paralysis
  • can cause bruising or fat necrosis
97
Q

What occurs in femoral nerve compression?

A
  • femoral nerve compressed against inguinal canal
  • weakness of knee adduction
  • loss of patella reflex
  • numbness of anterior thigh and medial lower leg
98
Q

What occurs in obturator nerve compression?

A
  • weakness of hip adduction and rotation
  • numbness of medial thigh
99
Q

At how many weeks gestation is induction of labour offered?

A
  • 41-42 weeks
100
Q

When is induction of labour beneficial?

A
  • pre labour ROM
  • fetal growth restriction
  • pre-eclampsia
  • obstetric cholestasis
  • existing diabetes
  • IU fetal death
101
Q

What criteria are assessed in the Bishop score?

A
  • fetal station (0-3)
  • cervical position (0-2)
  • cervical dilatation (0-3)
  • cervical effacement (0-3)
  • cervical consistency (0-2)
  • 8 or more predicts success
  • <8 - cervical ripening needed
102
Q

What is a balloon and how is it used to induce labour?

A
  • cervical ripening balloon
  • silicone balloon is inserted into cervix and gently inflated to dilate it
  • used in multiparous women (≥3), prev c-section, vaginal prostaglandin failure
103
Q

What is a membrane sweep?

A
  • inserting finger into cervix to stimulate and begin labour
  • should produce onset within 48hrs
  • used from 40 weeks
104
Q

What is ARM?

A
  • artificial rupture of membranes
  • oxytocin infusion
  • can be used to progress labour
105
Q

What are prostaglandins?

A
  • vaginal prostaglandin E2 (dinoprostone)
  • inserting gel, tablet or pessary into vagina
  • similar to tampon, releases local prostaglandins over 24hrs
  • simulates cervix and uterus
106
Q

How is labour induced in IU fetal death?

A
  • oral mifepristone
  • is an anti-progesterone
  • plus misoprostol
107
Q

How is induction of labour monitored?

A
  • CTG for fetal HR and uterine contractions
  • Bishop score
108
Q

What are the criteria for uterine hyperstimulation?

A
  • individual contractions lasting >2 mins in duration
  • more than 5 contractions every 10 mins
109
Q

What is the main complication of induction of labour?

A
  • uterine hyperstimulation
  • occurs with vaginal prostaglandins
  • prolonged and frequent uterine contraction
  • causes fetal distress and compromise
110
Q

What are the consequences of uterine hyperstimulation?

A
  • fetal compromise > hypoxia and acidosis
  • emergency c-section
  • uterine rupture
111
Q

How is uterine hyperstimulation managed?

A
  • removing vaginal prostaglandins
  • stopping oxytocin infusion
  • Tocolysis with terbutaline
112
Q

What is cord prolapse?

A
  • umbilical cord descends below presenting part of fetus, through cervix and into vagina after ROM
113
Q

What is a risk factor for cord prolapse?

A
  • abnormal lie after 37 weeks gestation
  • unstable, transverse or oblique
  • cephalic: head is in pelvis so no room for cord
114
Q

How is cord prolapse diagnosed?

A
  • fetal distress on CTG
  • vaginal exam
  • speculum to confirm
115
Q

How is cord prolapse managed?

A
  • emergency c-section
  • NVD has high risk of cord compression and hypoxia to baby
  • minimal handling otherwise vasospasm
116
Q

What position can be used to manage baby compressing cord prolapse?

A
  • presenting part pushed upwards
  • woman lies in left lateral position or knee to chest on all fours
  • terbutaline used to minimise contractions
117
Q

What is the pathophysiology of rhesus?

A
  • rhesus +ve baby’s blood may mix with mother’s
  • blood mixes and mother’s body makes antibodies against Rh D antigen
  • mother becomes sensitised affecting future pregnancies
118
Q

What happens if a rhesus negative woman becomes pregnant again?

A
  • anti Rh D antibodies cross placenta
  • if placenta is Rh + then haemolysis of RBC occurs
  • called haemolytic disease of newborn
119
Q

How are rhesus negative women managed?

A
  • IM anti-D injections into the women
  • attaches itself to Rh D antigens in mother’s circulation
  • destroys antigens and prevents mother becoming sensitised to Rh D antigen
120
Q

When are anti-D injections given?

A
  • 28 weeks
  • birth (if baby’s blood is +ve)
  • antepartum haemorrhage
  • amniocentesis procedures
  • abdo trauma
121
Q

What is the Kleihauer test?

A
  • how much fetal blood has passed into mother’s blood
  • used after any sensitising event past 20 weeks gestation
  • assesses whether further anti D needed
122
Q

How does the Kleihauer test work?

A
  • add acid to sample of mother’s blood
  • fetal Hb is more resistant so protected from acidosis
  • fetal Hb persists, mother’s Hb destroyed
  • No of cells remaining is calculated
123
Q

What is pre-eclampsia?

A
  • new hypertension
  • end-organ dysfunction
  • proteinuria
124
Q

When does pre-eclampsia occur and why?

A
  • after 20 weeks
  • spiral arteries of placenta form abnormally
  • leads to high vascular resistance
125
Q

Describe the pathophysiology of pre-eclampsia

A
  • high vascular resistance in spiral arteries
  • poor perfusion of placenta > oxidative stress
  • release of inflammatory chemicals into systemic circulation
  • systemic inflammation and impaired endothelial function
126
Q

What is the triad featured in pre-eclampsia?

A
  • hypertension
  • proteinuria
  • oedema
127
Q

What are high-risk factors for pre-eclampsia?

A
  • pre-existing hypertension
  • prev hypertension in pregnancy
  • existing autoimmune conditions
  • diabetes
  • CKD
128
Q

What are moderate risk factors for pre-eclampsia?

A
  • age >40
  • BMI >35
  • > 10yrs since prev pregnancy
  • multiple pregnancy
  • first pregnancy
  • family history
129
Q

What prophylaxis is offered for pre-eclampsia and when?

A
  • 75-150mg aspirin from 12 weeks
  • one high-risk factor
  • two or more moderate-risk factors
130
Q

What is HELLP syndrome?

A
  • complication of pre-eclampsia and eclampsia
  • haemolysis
  • elevated liver enzymes
  • low platelets
131
Q

What is eclampsia?

A
  • seizures associated with pre-eclampsia
132
Q

How is eclampsia treated?

A
  • IV magnesium sulphate
133
Q

What is chronic hypertension?

A
  • high blood pressure existing before 20 weeks gestation
  • not caused by dysfunction in placenta
134
Q

What is gestational hypertension?

A
  • hypertension occurring after 20 weeks gestation
  • without proteinuria
135
Q

What are the symptoms of pre-eclampsia?

A
  • headache
  • visual disturbance/blurriness
  • nausea and vomiting
  • upper abdo/epigastric pain (liver swelling)
  • oedema
  • dec urine output
  • brisk reflexes
136
Q

What are the NICE criteria for diagnosis of pre-eclampsia?

A
  • over 140 systolic or 90 diastolic
  • PLUS
  • proteinuria (1+ or more)
  • organ dysfunction
  • placental dysfunction
137
Q

What indicates organ dysfunction in pre-eclampsia?

A
  • raised creatinine
  • elevated liver enzymes
  • seizures
  • thrombocytopenia
  • haemolytic anaemia
138
Q

What values indicate proteinuria in pre-eclampsia?

A
  • protein:creatinine above 30mg/mmol
  • albumin:creatinine above 8mg/mmol
139
Q

What is medical management of pre-eclampsia?

A
  • labetolol (antihypertensive)
  • nifedipine
  • methyldopa
  • IV hydralazine in critical care
  • fluid restriction during labour
140
Q

How is gestational hypertension managed?

A
  • aim for BP below 135/85
  • admit if above 160/110
  • urine dipstick + bloods weekly
  • serial growth scans
  • placental growth factor testing
141
Q

How is pre-eclampsia managed after diagnosed?

A
  • scoring system (fullPIERS or PREP-S)
  • BP monitored at least every 48hrs
  • USS monitoring of fetus, amniotic fluid and dopplers fortnightly
142
Q

How is pre-eclampsia managed after delivery?

A
  • BP monitored + returns to normal after placenta delivered
  • enalapril
  • nifedipine or amlodipine (black patients)
  • labetolol
143
Q

How is delivery managed for pre-eclampsia?

A
  • planned early delivery if BP uncontrolled or complications
  • corticosteroids for premature
144
Q

What are the risk factors for gestational diabetes?

A
  • prev gestational diabetes
  • prev macrosomic baby <4.5kg
  • BMI >30
  • black Caribbean, Middle Eastern, South Asian
  • FH of diabetes
145
Q

What is gestational diabetes?

A
  • diabetes triggered by pregnancy
  • reduced insulin sensitivity during pregnancy
  • resolves after birth
146
Q

What complications are there of gestational diabetes?

A
  • large for dates fetus
  • macrosomia >shoulder dystocia
  • long-term: higher risk of T2DM
147
Q

When and how is gestational diabetes screened for?

A
  • OGTT
  • at booking if prev GD or 24-28 weeks
  • large for dates fetus
  • polyhydramnios
  • glucose on urine dipstick
148
Q

How is an OGTT performed?

A
  • morning after a fast
  • pt drinks 75g glucose
  • blood sugar measured before drinking and 2hrs after
149
Q

What results in an OGTT indicate gestational diabetes?

A
  • fasting ≥5.6mmol/l
  • at 2hrs ≥7.8 mmol/l
150
Q

How is gestational diabetes monitored?

A
  • joint diabetes and antenatal clinic
  • dieticians
  • monitoring BMs
  • 4-weekly USS from 28-36 weeks for fetal growth and amniotic fluid vol
151
Q

What is the medical management of gestational diabetes?

A
  • fasting glucose <7mmol/l: trial diet and exercise for 1-2 weeks > metformin > insulin
  • > 7mmol/l: insulin ± metformin
  • > 6mmol/l + macrosomia: insulin ± metformin
152
Q

What are the blood sugar targets in gestational diabetes?

A
  • fasting: 5.3mmol/l
  • 1hr post meal: 7.8mmol/l
  • 2hr post meal: 6.4 mmol/l
  • avoid levels of 4mmol/l or below
153
Q

What alternative medication can be used for women declining insulin?

A
  • glibenclamide
  • sulfonylurea
  • used if not tolerating metformin
154
Q

How are women with pre-existing diabetes managed in pregnancy?

A
  • 5mg folic acid from preconception - 12 weeks gestation
  • aim for same insulin target levels
  • metformin ± insulin - other diabetes medications stopped
155
Q

How is labour altered for women with pre-existing diabetes?

A
  • planned delivery 37-38+6 weeks
  • gest diabetes can go up to 40+6
  • sliding scale insulin: dextrose and insulin infusion
156
Q

What screening is done for pre-existing diabetic women in pregnancy?

A
  • retinopathy screening
  • shortly after booking and at 28 weeks
  • ophthalmologist referral to check for diabetic retinopathy
157
Q

What happens to gestational diabetes postnatally?

A
  • diabetes improves immediately after birth
  • stop diabetic medications
  • followup fasting glucose after 6 weeks
  • if pre-existing: lower insulin dose and be wary of hypoglycaemia
  • insulin sensitivity inc after birth and w breastfeeding
158
Q

What risks of complications are there for babies of diabetic mothers?

A
  • neonatal hypoglycaemia
  • polycythaemia
  • jaundice
  • congenital heart disease
  • cardiomyopathy
159
Q

How is neonatal hypoglycaemia monitored?

A
  • regular BM checks and frequent feeds
  • aim to maintain above 2mmol/l
  • If falling below then IV dextrose nasogastrically
160
Q

What is obstetric cholestasis?

A
  • intrahepatic cholestasis of pregnancy
  • reduced outflow of bile acids from liver
161
Q

What are the causes of obstetric cholestasis?

A
  • resulting from inc oestrogen and progesterone levels
  • genetics
  • more common in south asians
162
Q

What is the pathophysiology behind obstetric cholestasis?

A
  • bile acids produced from breakdown of cholesterol
  • flow from liver to hepatic ducts, past gallbladder and through bile duct into intestines
  • outflow reduced causing buildup in blood
163
Q

How does obstetric cholestasis present?

A
  • third trimester
  • pruritus of palms and soles
  • fatigue
  • dark urine
  • pale, greasy stools
  • jaundice
  • NO rash
164
Q

What are differentials for obstetric cholestasis?

A
  • gallstones
  • acute fatty liver
  • autoimmune hepatitis
  • viral hepatitis
165
Q

What investigations are done for obstetric cholestasis?

A
  • LFTs and bile acids
  • abnormal LFTs: ALT, AST, GGT
  • raised bile acids
166
Q

How is obstetric cholestasis managed?

A
  • emollients
  • chlorphenamine (antihistamine)
  • water-soluble vit K if clotting is deranged
  • planned delivery if severely deranged bloods
167
Q

What complication can occur from obstetric cholestasis?

A
  • stillbirth (intrauterine death)
168
Q

What is anaemia?

A
  • low concentration of Hb in blood
169
Q

When are women screened for anaemia in pregnancy?

A
  • booking clinic
  • 28 weeks gestation
170
Q

What is the pathophysiology behind anaemia in pregnancy?

A
  • plasma volume increase in pregnancy
  • dec Hb conc
  • blood is diluted
  • must be treated so woman has reserves if significant blood loss in delivery
171
Q

How does anaemia in pregnancy present?

A
  • SOB
  • fatigue
  • dizziness
  • pallor
172
Q

What are the normal ranges for haemoglobin in pregnancy?

A
  • booking bloods: >110g/l
  • 28 weeks gestation: > 105g/l
  • post partum: 100g/l
173
Q

What screening for anaemia are women routinely offered at booking clinic?

A
  • haemoglobinopathy screening
  • for thalassaemia and sickle cell disease
174
Q

How is iron deficiency in pregnancy managed?

A
  • iron replacement e.g. ferrous sulphate
  • 200mg 3x a day
  • if not anaemic but low ferritin > supplementary iron
175
Q

How is B12 deficiency managed?

A
  • test for pernicious anaemia
  • IM hydroxocobalamin
  • oral cyanocobalamin
176
Q

How is folate deficiency managed?

A
  • should already be taking 400mcg/day
  • started on 5mg daily
177
Q

How are thalassaemia and sickle cell anaemia managed?

A
  • managed jointly with specialist haematologist
  • high dose folic acid (5mg)
  • close monitoring
  • transfusions
178
Q

What is prematurity?

A
  • birth before 37 weeks gestation
  • <28 weeks: extreme preterm
  • 28-32 weeks: very preterm
  • 32-37 weeks: moderate-late preterm
179
Q

Below what gestation are pregnancies considered non-viable?

A
  • non-viable <23 weeks
  • 23 weeks = 10% chance of survival
  • > 24 weeks = inc chance and full resus offered
180
Q

What is tocolysis?

A
  • medication to stop uterine contractions
  • nifedipine (CCB)
  • used 24 - 33+6 weeks gestation
181
Q

Why is tocolysis used?

A
  • delays delivery
  • allows for fetal development, maternal steroids or transfer to specialist unit
182
Q

What is an alternative tocolytic?

A
  • atosiban
  • oxytocin receptor antagonist
183
Q

What antenatal steroids are given and why?

A
  • 2 doses IM betamethasone
  • develop fetal lungs
  • reduce resp distress syndrome
  • used in suspected preterm labour <36 weeks gestation
184
Q

Why is magnesium sulphate used?

A
  • IV
  • protects fetal brain in premature delivery
  • reduces risk and severity of cerebral palsy
185
Q

When is magnesium sulphate given?

A
  • within 24hrs of delivery of preterm babies
  • <24 weeks gestation
186
Q

What are key signs of magnesium toxicity?

A
  • 4hrly obs
  • reduced RR
  • reduced BP
  • absent reflexes
187
Q

How does vaginal progesterone prevent preterm labour?

A
  • gel or pessary
  • maintains pregnancy and decreases myometrial activity
  • prevents cervical remodelling
188
Q

What is P-PROM?

A
  • preterm prelabour ROM
  • amniotic sac ruptures before labour and in preterm pregnancy
189
Q

How is P-PROM diagnosed?

A
  • speculum for pooling of amniotic fluid in vagina
  • IGFBP-1 testing
  • PAMG-1 testing
190
Q

How is P-PROM managed?

A
  • prophylactic Abx to prevent chorioamionitis
  • erythromycin 250mg QDS for 10 days
  • induction of labour offered from 34 weeks
191
Q

What is placenta accreta?

A
  • placenta implants deep
  • through and past endometrium
  • difficult to separate placenta after baby delivered
192
Q

What is superficial placenta accreta?

A
  • placenta implants in surface of myometrium
193
Q

What is placenta increta?

A
  • placenta attaches deeply into myometrium
194
Q

What is placenta percreta?

A
  • placenta invades past myometrium, reaching other organs
195
Q

Where does the placenta usually attach?

A
  • to the endometrium
196
Q

What are risk factors for placenta accreta?

A
  • previous accreta
  • previous endometrial curettage
  • previous C-section
  • multigravida
  • increased maternal age
  • low-lying/placenta praevia
197
Q

How is abortion accessed?

A
  • self-referral, GP, GUM or family planning clinic
  • doctors who object should pass on the referral
198
Q

Which 2 acts constitute the legal framework for an abortion?

A
  • 1967 abortion act
  • 1990 human fertilisation and embryology act
199
Q

What does the 1990 HFEA act say?

A
  • expanded the criteria for abortion
  • reduced latest age from 28 to 24 weeks
200
Q

What are the criteria for abortion before 24 weeks?

A
  • continuing pregnancy involves greater risk to physical or mental health of the woman or existing children of the family
  • threshold is a matter of clinical judgement
201
Q

Which factors allow an abortion to be performed after 24 weeks?

A
  • continuing pregnancy risks woman’s life
  • terminating prevents ‘grave permanent injury’ to woman
  • substantial risk that the child would suffer physical/mental abnormalities > severe handicap
202
Q

What are the legal requirements for abortion (who agrees/carries it out)?

A
  • 2 registered medical practitioners must sign to agree
  • must be carried out by registered medical practitioner in an NHS hospital or approved premise
203
Q

Which symptoms may be experienced post-abortion?

A
  • vaginal bleeding
  • abdominal cramps for up to 2 weeks
  • UPT performed 3 weeks after to confirm complete
204
Q

What are the treatments used in a medical abortion?

A
  • mifepristone
  • misoprostol 1-2 days later
  • additional misoprostol doses every 3hrs until expulsion
205
Q

What is the action of mifepristone?

A
  • anti-progestogen
  • blocks action of progesterone
  • halts pregnancy
  • relaxes cervix
206
Q

What is the action of misoprostol?

A
  • prostaglandin analogue
  • activates receptors
  • softens cervix
  • stimulates uterine contractions
207
Q

What types of anaesthetic are used in surgical abortion?

A
  • local
  • local + sedation
  • general
208
Q

What are complications of an abortion?

A
  • bleeding
  • pain
  • infection
  • failure of abortion
  • damage to cervix, uterus or other structures
208
Q

Which medications are used prior to surgical abortion?

A
  • cervical priming
  • misoprostol
  • mifepristone
  • osmotic dilators
209
Q

What are the options for surgical abortion?

A
  • cervical dilatation and suction of contents (<14 weeks)
  • cervical dilatation and evacuation with forceps (14-24 weeks)
210
Q

How are pregnant women protected against chickenpox?

A
  • if not immune: given varicella zoster immunoglobulins
  • protection post exposure
211
Q

What is the risk of chickenpox in pregnancy before 28 weeks?

A
  • developmental problems in fetus
  • congenital varicella syndrome
212
Q

What is the risk of chickenpox during delivery?

A
  • can lead to neonatal infection
  • treated with VZ immunoglobulins and Aciclovir

Osha 3a (15 decks)

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