obstetrics Flashcards
chord prolapse
where chord decends after rupture of membranes either through cervix (occult) or past most prominent bit of baby (overt)
rare- 0.1% to 0.6% in normal presentation. breech 1%.
can cause asphyxia in babies + venospasm in the placenta.
exclude at every vaginal exam in labour.
palpable pulsatile mass in the vaginal vault.
S+S: fetal bradycardia.
Rx:
knee chest face down position.
ceserian, dont handle loops out the body.
ectopic pregnancies
affects 2% of pregnancies worldwide. around 7.2 weeks after LMP.
RF: PID, smoking, endometriosis, prior tubal surgery, assistive reproductive techniques.
fallopian tube site of 90% of issues
S+S: pain, vaginal bleeding.
Ix: blood tests for HCG and uss transvag.
Rx: if caught early + no sig pain –> hcg less than 5000 IU/L and less than 35mm- single dose methotrexate.
look for 15% drop between days 4-7
if larger- 5000 or more.- salpinostomoy, or salpingectomy.
epilepsy in pregnancy
1-4% risk of seziure in labour
2/3 have no seziures
1/6th have inc, 1/6 have dec seziuer.
no reccomendation for monitoring anti epilepsy drugs in preg.
home births not reccomended. consultant let care.
AVOID pethidine as lowers seziure threshold
if does seize: benzoz- IV loraz (4mg usually) - repeated every 10-20 mins.
if not effective iv pheyntoin 10-15mg/kg (usually about 1000)
If feotal heartbeat does not recover after 5 mins- expediate delivery.
1mg vit k im to prevent hem disease of newb
hydraditiform mole
weird one- where egg has no genetic info, or does but replication goes wrong.
either 46Xy- but all sperm dna (complete)
or 69XXY - partial. – these may have some viable fetal tissue.
complete moles cause 50% of choreocarcinoma.
S+S: painless bleeding 5-6 months into preg. may be larger than expected.
maybe more vom.
v high hgc on testing.
RF: uner 20 or over 40. low protein diet, low folic acid.
almost always end up in spontaneous abortion.
Ix: diagnosis is by histological examination.
USS strongly suggestive.
Rx: womb excavation with suction.
f/u untill hcg drops to undetectable.
avoid preg again for 6-12/12.
invasive or metastatic moles treated well with methotrexate chaemotherapy.
choriocarcinoma
malignant trophoblastic cancer usually of placenta.
goes early to the lungs.
can also be from testes and ovaries.
S+S: increaced hcg, bleeding, SBO, haemoptysis, testicle enlargement, gynacomastia.
50% caused hy preg moles.
if gestational- methotrexate is really good.
if not- a more involved treatment regeme needed (5 meds)
hysterectomy if not wanting more children.
stage 1- womb linning only
2- womb and ovary
3- womb and lung
4- womb lung and 1 more organ.
hyperemesis gravidarum
really bad morning sickness
need 5% BW loss and ketonurea
diagnosis of exclusion as many things can cause vomiting.
peaks at 9-13/52 but can continue through pregnancy,
effect on infant: lower birth weight, small for gest age, neurobehavioural diagnoses, give birth before 37 weeks usually.
BHCG theory.
Ix: urinanalyisi (ketourea)
assess electrolite balances.
Rx: dry bland food
may need iv fluids/ nutrition
can give a picc line if recurrent and be treated at home.
meds: promethazine, metoclopramide.
if still bad consider ondans - but can be assoc with cleft lip.
misscarreage
unplanned spontaneous loss of baby before 24 weeks, stillbirth after 24 weeks.
spont vag bleeding +/- suprapubic pain. (pain without bleeding isnt misscarreage, but could be ectopic)
Rf: age, uterine malfomatio, bacterial vaginosis, thrombophilia, vit d def, chromosonal abnormality.
Ix: transvag- if bigger than 7mm should see heart beat.
if gest sac bigger than 25 with no yolk sac – both indicative
hcg monitoring- if 50% drop in 48 hrs.
Rx:
threatened- paracetamol (avoid nsaids)
vag progesterone, RhD if needed.
can let the miscarrage products pass naturally, or can help assist them.
misoprostol can help expel or suction can help remove if big.
councelling, analgesia,
obesity in pregnancy
increaces risks of DM
pre-ecclampsia
gestational hypertensino
macrosomia
ceserian deliveries.
VTE big risk (57% of all DVT were in obese cat)
slows labour progression
inc stillbirth.
pe/dvt in pregnancy
V/Q slight more risk ro baby in childhood cancer
CTPA slight more risk for breast ca
rx LMWH- min 3/12 treatment or 6/52 after birth - whichever is longer.
use warfarin if post natally.
factors 78910 all increace.
RF: inherited thrombophilias
age, parity, obesity, smoking
OHSS, C sect, sepsis, hemorrhage.
score of 4 or more on scalr- give prophylactic lmwh
overweght gives you 1, obese 3
elective c sect 1, emergency 2
etc, lots of scoring.
placenta previa
where the placenta covers the cervical os
considered low lying is within 2cm.
bleeding is a sign, painless. usually in 2-3 tris.
generally diagnosed in 2nd.
may become torrential, avoid digital vaginal exams untill position is known.
Rf: uterine scarring (prev C sect)- exponential increace per each one), IVF, prev PP.
Ix: seen on ultrasound.- any position. more than 20mm away from os- normal
less than 20 mm - low lying
covering- praevia
Rx: most resolve spontaneously.
if persists beyond 36 weeks- ceserian.
placental abruption
seperation of the placenta from its normal position on the wall.
causes hemorrhage, but can cause a hidden hemmorhage within the uterus.
S+S: bleeding with abdo pain and contractions in 2nd half of preg. uterine tenderness + hardness.
quite bad- inc maternal and perinatal morbid and mortal.
Rf: smoking, trauma, hypertensive disorders, and cocaine, prev babies.
Dx: clinical- some ultrasound may be useful.
Rx: 34 weeks or more
happy fetus- induce with oxytocin/ wait a bit + replace bits.
unhappy fetus- C secs
if less than 34 = magnesium sulphate (neuro protection), + steroids (lung maturation).
manage symptomatically 2x cannulas ect.
diabetes in pregnancy
Capillary glucose
< 5.6 mmol/L (fasting)
<7.8 mmol/L 1 hour after meals
<6.4 mmol/L 2 hours after meals
Provided this can be done without causing hypoglycaemia.
hba1c below 48mm
dont try it if 86
test urgently for ketones if hyperglycaemia occurs.
Ix: 75g OGTT
Rx: fasting below 7- diet + exercise
no change in 1-2 weeks- metformin.
if above 7- immediate insulin.
ANY COMPLICATIONS- insulin.
hypertension in pregnancy
ACEi and ARB should be stopped in pregnancy
can use labetalol
or
nifedipine- 2nd line or if asthmatic
3rdd- methyldopa
can giv aspirin 76-150mg OD.
test for pre ecclampsia with placental growth factor testing between weeks 20-36.9
if develops severe pre-ecclampsia deliver baby before 37 weeks.
but if less than 160/90 then wait till after 37 weeks.
shoulder dystocia
where after the head pops out the shoulder gets stuck on pelvic bone.
occurs in about 0.5-1.5% of vaginal births.
‘turtle sign’
brachial plexus injury or clavicle fracture.
tears for the mum.
2’- place women on all fours.
RF: age, short, small pelvis, over 42 weeks gest.
Rx for shoulder dystocia
Ask for help. obstetrician, anesthesia, and for pediatrics
Leg hyperflexion and abduction at the hips (McRoberts maneuver)
Anterior shoulder disimpaction (suprapubic pressure)
Rotation of the shoulder (Rubin maneuver)
Manual delivery of posterior arm
Episiotomy
Roll over on all fours
