Obstetrics Flashcards
Physiological changes in pregnancy
See notes
Ectopic pregnancy
Implantation of fertilised ovum outside uterine cavity
Commonly - ampulla, isthmus of fallopian tube
Ectopic RFs
Tube damage - PID, surgery
Previous ectopic
endometriosis
IUS/D
POP
IVF
Ectopic Px
- Lower abdo pain
- 6-8wks amenorrhoea
- PV bleed later
- Brown PV discharge
- Pregnancy sx - breast tenderness
- Cervical motion tenderness
- adnexal mass maybe - don’t examine for - risk of rupture
Ectopic DDx
Miscarriage, ovarian cyst, PID, UTI, abdo ddx
Ectopic Ix
urine pregnancy test
Urinalysis - eg UTI - r/o DDx
Pelvic USS - ?intrauterine pregnancy
TVUS - if nothing seen on pelvic
No pregnancy on US + pregnancy test +ve = pregnancy unknown location -> take serum bHCG
- if bhCG >1500 - ectopic until proven otherwise
- bhCG <1500 - rpt in 48hrs (doubles if viable, halves if miscarriage)
Ectopic Mx
If Rh-, give anti-D
Medical
<35mm, unruptured, no pain, no heartbeat, hCG <1500
- IM methotrexate
Contraception for 3-6mo after as methotrexate teratogenic
Follow up required
Surgical
>35mm, may be ruptured, pain, heartbeat, hCG>5000
- Salpingectomy - if no infertility RFs
- Salpingotomy - if contralateral tube damaged
Conservative
Not 1st line
Stable pts, rupture unlikely, no pain, low bHCG, <35mm
Monitor bHCG to ensure fall
Miscarriage
Loss of pregnancy <24wks gestation
Miscarriage RFs
> 30-35yo
Previous miscarriage
Obesity
smoking
chromosomal abnormalities, uterine abnormalities
aPL syndrome
coagulopathies
Miscarriage types
Threatened
PV bleed, ?painless, os closed, viable
Inevitable
heavy bleed + clots + pain, os opened, non/viable, likely to progress to incomplete
Incomplete
not all POC expelled, pain, PV bleed, OS open, expectant / medical / surgical mx
complete
Hx of bleed, passing clots, pain, now settled, no POC in uterus + proof of prev pregnancy (eg scan), os closed
missed
gestational sac contains dead fetus, no expulsion, light PV bleed / discharge, os closed, no fetal heartbeat on USS
Septic
infected POC, fever, rigors, cervical motion tenderness, discharge/pain, increased WCC/CRP, features of in/complete
medical/surgical mx, IV abx, fluids
Miscarriage Px
PV bleed +/- clots, POC
Haemodynamically unstable
Tender abdo / pain / cramp
POC in cervical canal
Uterine tenderness / adnexal masses
Miscarriage Ix
Urine pregnancy test -> see in EPAU
Bloods - maybe serial serum bHCG (drop if miscarriage, rise if ectopic)
FBC, G+S, rhesus, triple swabs + CRP if fever
TVUS
Measure crown rump length (CRL) - estimate gestation
- <7mm, no fetal heart - rpt scan 7d, then confirm dx if no change
- >7mm + no HB - 2nd opinion before dx
Measure mean sac diameter - if growing alone -> anembryonic pregnancy
- <25mm + no fetal pole - 2nd scan 7d before dx
- >25mm + no fetal pole - 2nd opinion then dx
Miscarriage Mx
Anti-D if needed
Preventing miscarriage
- R/o ectopic
- vaginal pessary progesterone, take until 16wks
- only if PV bleed, threatened miscarriage + hx of miscarriage
Conservative / expectant
- POC pass naturally, remain at home, but unpredictable
- Rpt scan 2wks, pregnancy test 3wks
- Not if heavy bleed / tissue >50mm
- Medical / surgical after 2wks if no change
Medical
- Vaginal misoprostol (prostaglandin E) - stimulate cervical ripening + myometrial contractions - 2nd dose if not passed by 48hrs
- can be at home if <9wks, <40mm
- pregnancy test 3wks, further dose if still +ve
Surgical
- <12wks, manual vacuum aspiration - LA
- Evacuation of retained products of conception (ERPC) - GA - blind suction, risk of uterine perf
- give misoprostol before (soften cervix)
- for unstable pts, infected tissue, molar pregnancy
Recurrent miscarriage
> 3 consecutive miscarriages
Causes
aPL syndrome, DM, thyroid, PCOS, uterine abnormalities, cervical weakness, chromosome abnormalities, smoking, infections, thrombophilias
Ix
aPL ABs, thrombophilia screen
Karyotyping
Pelvic USS - anatomy
Mx
Tx cause
Refer to recurrent miscarriage clinic / geneticist
Termination of pregnancy (TOP)
Elective end to pregnancy
2 registered medical practitioners must agree, <24wks gestation, carry out in NHS approved premise
Can perform at any time during pregnancy if:
- woman’s life at risk
- prevents grave injury to physical / mental health of woman
- substantial risk child would suffer physical / mental abnormalities
TOP Mx
Medical
Mifepristone - antiprogesterone, halts pregnancy
Misoprostol - prostaglandin, softens cervix, stimulates contraction
Surgical
- Under LA / GA
- Dilate cervix, suction if <14wks, forceps evacuation if 14-24wks
Post-abortion
Urine pregnancy test 3wks after to confirm complete
Hyperemesis gravidarum (HG)
Persistent severe vomiting during pregnancy
Starts wk4-7, settle by 20wks, from increase in bHCG
leads to >5% pre-pregnancy wt loss, dehydration, electrolyte imbalances
RFs
First pregnancy, previous HG, raised BMI, multiple pregnancy, molar pregnancy (raised beta-hCG)
Smoking associated with decreased risk
HG Ix / assessment
Triad of 5% pre-pregnancy weight loss, dehydration, electrolyte imbalace is reccomended for diagnosis of HG
H/E - dehydration sx
PUQE score for severity
Measure weight
Urine dip - 1+ ketones, MSU sample
Bloods - FBC, U/E, LFT, amylase, TFTs, ABG
USS fetus - doppler
Referral criteria:
Continued N+V and is unable to keep down liquids or oral antiemetics
Continued N+V with ketonuria and/or weight loss (greater than 5% body weight), despite treatment with oral antiemetics
A confirmed or suspected comorbidity
HG Mx
Oral fluids, diet advice, oral antiemetics
Admit if severe - IV fluids, IV antiemetics, thiamine, KCl if needed
1st line - cyclizine, prochlorperazine, promethazine, chlorpromazine
2nd line - metoclopramide (5d max - EPSEs), domperidone, ondansetron (1st trim cleft lip/palate risk)
3rd line - IV hydrocortisone, PO prednisolone
Molar pregnancy
pregnancy related tumours (premalignant) from placental trophoblast
includes complete hydatidiform mole, partial hydatidiform mole, choriocarcinoma
Complete hydatidiform mole
Benign tumour of trophoblastic material - empty egg fertilised by single sperm, then duplicates itself
Px
- bleeding in 1/2nd trim
- exaggerated sx of pregnancy - eg HG
- uterus large for dates
- high serum bHCG
- HTN, hyperthyroid (hCG mimics TSH)
Ix
USS - snowstorm appearance
Mx
surgical evacuation
contraception - avoid pregnancy for 12mo
Partial hydatidiform mole
Normal egg fertilised by 2 sperms, or one sperm with duplicate chromosomes
Choriocarcinoma
Cancer of trophoblastic cells of placenta
Mets to lungs
Antenatal care timetable
- 10 visits in 1st pregnancy, 7 visits later on
- 1st trim start ->12wks
- 2nd trim 13->26wks
- 3rd trim 27->term
- Whooping cough vaccine >16wks, flu when available
<10wks - booking, baseline assessment, plan pregnancy
10-14wks - Dating scan - CRL, multiple pregnancy
11-14wks - Down’s screening (increased nuchal thickness, increased bHCG, low PAPPA)
16wks - antenatal appt - results, discussion etc
18-21wks - anomaly scan
24-28wks - OGTT
25,28,31,34,36,38,40,41,42 - other appts
Screening offered for:
anaemia, bacturia, group + Rh, Down’s, fetal abnormalities, hep B, HIV, neural tube defects, RFs for pre-eclampsia, syphilis
No screening for BV, chlamydia, CMV, fragile X, hep C, GBS, toxoplasmosis
Lifestyle advice
400mcg folic acid from before conception -> 12wks (5mg in epileptics, obesity), take vit D, not too much vit A, don’t smoke, avoid certain foods……