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Phase 4 Question Knowledge > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

Physiological changes in pregnancy

A

See notes

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2
Q

Ectopic pregnancy

A

Implantation of fertilised ovum outside uterine cavity

Commonly - ampulla, isthmus of fallopian tube

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3
Q

Ectopic RFs

A

Tube damage - PID, surgery
Previous ectopic
endometriosis
IUS/D
POP
IVF

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4
Q

Ectopic Px

A
  • 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
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5
Q

Ectopic DDx

A

Miscarriage, ovarian cyst, PID, UTI, abdo ddx

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6
Q

Ectopic Ix

A

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)

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7
Q

Ectopic Mx

A

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

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8
Q

Miscarriage

A

Loss of pregnancy <24wks gestation

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9
Q

Miscarriage RFs

A

> 30-35yo
Previous miscarriage
Obesity
smoking
chromosomal abnormalities, uterine abnormalities
aPL syndrome
coagulopathies

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10
Q

Miscarriage types

A

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

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11
Q

Miscarriage Px

A

PV bleed +/- clots, POC
Haemodynamically unstable
Tender abdo / pain / cramp
POC in cervical canal
Uterine tenderness / adnexal masses

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12
Q

Miscarriage Ix

A

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

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13
Q

Miscarriage Mx

A

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

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14
Q

Recurrent miscarriage

A

> 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

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15
Q

Termination of pregnancy (TOP)

A

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

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16
Q

TOP Mx

A

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

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17
Q

Hyperemesis gravidarum (HG)

A

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

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18
Q

HG Ix / assessment

A

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

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19
Q

HG Mx

A

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

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20
Q

Molar pregnancy

A

pregnancy related tumours (premalignant) from placental trophoblast

includes complete hydatidiform mole, partial hydatidiform mole, choriocarcinoma

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21
Q

Complete hydatidiform mole

A

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

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22
Q

Partial hydatidiform mole

A

Normal egg fertilised by 2 sperms, or one sperm with duplicate chromosomes

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23
Q

Choriocarcinoma

A

Cancer of trophoblastic cells of placenta

Mets to lungs

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24
Q

Antenatal care timetable

A
  • 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……

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25
Q

Pre-eclampsia

A

Hypertensive disorder - placental disease

Triad of -> new HTN, proteinuria, oedema

Issue w/ spiral arteries - high resistance, low flow circulation

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26
Q

Pre-eclampsia RFs

A

Moderate
nulliparity
>40yo
>35BMI
FHx
pregnancy interval >10yrs
multiple pregnancy

High
Chronic HTN
HTN / pre-eclampsia / eclampsia in previous pregnancy
CKD
DM
autoimmune (SLE, aPL etc)

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27
Q

Pre-eclampsia Px

A

Asym
Headache, visual disturbance, epigastric pain (hepatic capsule distension / infarction)
Sudden oedema
Hyperreflexia
Papilloedema

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28
Q

Pre-eclampsia Dx

A

New onset BP >140/90 >20wks and 1 of:
- proteinuria
- other organ involvement - eg renal (raised creat), liver, neuro, haem…)

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29
Q

Pre-eclampsia DDx

A

Essential HTN (HTN <20wks)

Pregnancy induced HTN (PIN) - w/o proteinuria

Eclampsia - seizure

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30
Q

Pre-eclampsia Ix

A

Urine dip + 24hr collection - protein +++

BP

FBC (low Hb + platelets)
U/E (high urea + creat)
LFTs (raised ALT, AST)

Raised PlGF - placental growth factor

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31
Q

Pre-eclampsia Mx

A

Labetalol / nifedipine (if asthmatic) / methyldopa

Mg during labour + 24hrs after

> 37wks - initiate birth

34-37wks -> deliver if cannot control BP, reduced sats, deterioration, neuro sx, placental abruption (give steroids)

<34wks - monitor unless indications as above, give Mg + steroids

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32
Q

Pre-eclampsia prophylaxis

A

aspirin 75mg OD

for women with 1 high RF or >2 moderate

12wks -> birth

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33
Q

Eclampsia

A

1+ seizure + pre-eclampsia

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34
Q

Eclampsia Px

A

New onset tonic clonic seizure

Pre-eclampsia (new HTN, proteinuria, >20wks)

Headache, hyperreflexia, N+V, oedema, RUQ pain +/- jaundice, visual disturbance, reduced GCS

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35
Q

Eclampsia Ix

A

Fundoscopy - papilloedema

Bloods - FBC, U/E, LFTs, coag, BM

Abdo USS + CTG - monitor fetus

CT head

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36
Q

Eclampsia Mx

A

A-E, left lateral position

MgSO4
- 4g prophylaxis
- 4g with first seizure
- 1g/hr maintenance
- 2g bolus with recurrent seizures
- Too high -> hyperreflexia, resp depression

Labetalol + hydralazine

C-section

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37
Q

Oligohydramnios

A

reduced amniotic fluid

Amniotic fluid index (AFI) <5th %tile

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38
Q

Oligohydramnios causes

A

PROM
Fetal renal agenesis (fetus swallows fluid, excreted in urine normally)
IUGR
pre-eclampsia, placental insufficiency (blood to fetal brain rather than kidneys - reduced UO)

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39
Q

Oligohydramnios Px

A

may have sx of leaking fluid, damp all the time

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40
Q

Oligohydramnios Ix

A

Fundo-symphysis height

Speculum - pool of fluid in vagina

USS - liquor volume, fetus kidneys, measure size

Bedside tests for proteins if ?PROM

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41
Q

Oligohydramnios Mx

A

ROM - labour likely in 24-48hrs - if preterm - steroids + IOL

Placental insufficiency - baby likely to be prem - monitor with scans, doppler for umbilical artery

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42
Q

Polyhydramnios

A

increased amniotic fluid >95%tile

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43
Q

Polyhydramnios causes

A

idiopathic 50%
fetus cannot swallow - oesophageal atresia, CNS abnormalities
Duodenal atresia - double bubble sign on US
anaemia
fetal hydrops
macrosomia - big babies produce more urine
lithium
maternal diabetes

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44
Q

Polyhydramnios Px

A

mum can present SOB

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45
Q

Polyhydramnios assessment

A

Tense uterus on palpation

USS - liquor volume, fetal size

OGTT for mum

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46
Q

Polyhydramnios Mx

A

Nothing in most

Amnioreduction if severe - but risk of infection / abruption

Indomethacin - enhance water retention, reduce fetal UO, but not >32wks (premature PDA closure)

Examine baby before 1st feed - eg TOF, oesophageal atresia

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47
Q

Breech presentation

A

Fetus presents buttocks / feet first

Complete - flexed at hips/knees
Frank - flexed at hips, extended at knees (most common)
Footling - one / both legs extended at hip - foot is presenting part

RFs
Multiparity, uterine malformations, fibroids, placenta praevia, prematurity, macrosomia, polyhydramnios, twin pregnancy

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48
Q

Breech px Ix

A

Examination

USS

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49
Q

Breech px Mx

A

External cephalic version
- at 36wks, 50% success
- CIs - c-section needed, APH, membrane rupture, multiple pregnancy, previous c-section

C-section
- elective

Vaginal breech birth
- CI - footling

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50
Q

Fetal lie

A

Fetus against mother long axis

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51
Q

Fetal presentation

A

fetal part that enters maternal pelvis

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52
Q

Fetal position

A

Position of head as it exist birth canal

OA / OP

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53
Q

Placenta praevia

A

placenta fully / partially attached to lower uterine segment

Leads to APH (wk24-term)

Minor - low placenta, doesn’t cover os
Major - lies over internal os

RFs
prev c section, high parity, >40yo, multiple pregnancy, previous praevia

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54
Q

Placenta praevia Px

A

Antepartum haemorrhage (APH) - painless, spotting/massive bleed

Pain if in labour

Shock in keeping with visible loss

VE -> risk of bleed (do not do)

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55
Q

Placental praevia Ix

A

Bloods

CTG

USS - at 20wks, can do TVUS
- minor - rpt at 36wks
- major - rpt at 32wks, plan delivery

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56
Q

Placenta praevia Mx

A

C-section

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57
Q

Placental abruption

A

Placenta separates from uterine wall prematurely -> APH, possible fetal compromise

Revealed - bleed drains through cervix

Concealed - bleed remains in uterus, clot forms retroplacentally

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58
Q

Placental abruption Px

A

APH
Pain
Woody / tense uterus
Shock out of keeping with visible loss

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59
Q

Placenta abruption Ix

A

Bloods
CTG
USS

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60
Q

Placental abruption Mx

A

A-E
Fetal distress - emergency c-section
No distress
- <36wks observe, steroids
- >36wks ?vaginal delivery, IOL

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61
Q

Gestational diabetes mellitus (GDM)

A

Glucose intolerance / insulin resistance in pregnancy

Body can’t produce enough insulin to meet demands, progressive insulin resistance, higher vol needed for normal blood glucose level

RFs
BMI>30, Asian, previous, FHx, PCOS, prev macrosomia

Leads to macrosomia, organomegaly…

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62
Q

GDM Px

A

Asym
polyuria, polydipsia, fatigue

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63
Q

GDM Ix

A

OGTT
- measure fasting glucose, drink 75g glucose, rpt plasma glucose in 2hrs
- >5.6 fasting / >7.8 on repeat (2 hour)- dx
- at booking, 24-28wks, at any point if 2+ glycosuria

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64
Q

GDM Mx

A

Diet / exercise if <7

Metformin if not met within 1-2 weeks

Insulin (straight away if fasting >7)/ not reacted to metformin

Short acting insulin for treatment

Offer insulin if 6-6.9

If pre-existing DM
Weight loss, stop drugs apart from metformin, start insulin, folic acid 5mg preconception ->12wks

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65
Q

Obstetric cholestasis

A

Aka intrahepatic cholestasis of pregnancy

Cause unsure

Px
3rd trim, pruritis (palms, soles, abdo), jaundice (20%), nausea, anorexia, fatigue, RUQ pain, dark urine, pale stools

DDx
HG, pre-eclampsia, HELLP

Ix
LFTs - raised bilirubin, high PTT?

Mx
Monitor LFTs weekly
IOL at 37-38wks
Risk of prem birth
Ursodeoxycholic acid
Vit K supplements

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66
Q

Anaemia in pregnancy

A

Low Hb <110 in 1st trim, <105 in 2/3rd trim, <100 post-partum
Check at booking, 28wks

Px
Dizzy, fatigue, SOB, asym, pallor, koilonychia, angular cheilitis

Ix
FBC, serum ferritin (not routine), B12/folate

Mx
Iron supplements, folate if needed

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67
Q

Antiphospholipid (aPL) syndrome

A

Autoimmune - ABs target phospholipid binding proteins -> thrombosis, miscarriage

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68
Q

aPL Px

A

Stroke, DVT
Miscarriage
IUGR
Pre-eclampsia
livedo reticularis
renal impairment
Libmann-Sacks endocarditis
Thrombocytopenia

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69
Q

aPL Ix

A

Anticardolipin AB

Lupus anticoagulant AB

Anti-B2-glycoprotein I AB

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70
Q

aPL Mx

A

LMWH, continue >6wks post partum

Low dose aspirin 75mg

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71
Q

VTE in pregnancy

A

Pregnancy is RF - assess risk at booking, any further admission

RFs
>35yo, >30BMI, parity >3, smoker, varicose veins, FHx, multiple pregnancy, IVF, low-risk thrombophilia

Px
DVT / PE

Ix
Doppler first - if positive, avoid scanning chest
ECG, CXR, CTPA if necessary

Mx
LMWH
- >4 RFs - start immediately -> 6wks postnatal
- 3 RFs - 28wks -> 6wks postnatal
- DVT at delivery - continue for >3mo

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72
Q

Fetal varicella syndrome (FVS)

A

1% risk if mum exposed <20wks, less 20-28wks, none >28wks

Skin scarring, eye defects, limb hypoplasia, microcephaly, LDs

Also shingles in infancy

Severe neonatal varicella - if mother develops rash 5d before birth -> 2d after
- tx - VZIg +/- acyclovir

73
Q

Mx of chickenpox exposure in pregnancy

A

If mum had chickenpox, no tx

If doubt mum had chickenpox - check VZV ABs - if none:
- <20wks - give VZIg asap - effective <10d post-exposure
- >20wks - acyclovir 7-14d post exposure

New guidance seems to be oral aciclovir given at 7-14 days post exposure, not immediately for all stages of pregnancy

74
Q

Mx of chickenpox in pregnancy

A

> 20wks - oral acyclovir <24hrs of rash

<20wks, consider acyclovir with caution

Serial USS - for abnormalities

75
Q

GBS colonisation

A

infant exposed in labour

Streptococci - G+ chain - Strep agalactiae

RFs
prem, prolonged ROM, prev sibling GBS infection, maternal pyrexia

76
Q

GBS Px

A

May manifest as chorioamnionitis, endometritis

neonatal sepsis

UTI

77
Q

GBS Ix

A

not routinely screened for

Swabs - rectum + vagina

At 35-37wks, or 3-5wks before delivery date

78
Q

GBS Mx

A

IV benpen throughout labour if:
- +ve swabs, GBS UTI this pregnancy, previous GBS baby, labour fever, <37wks labour, >18hrs ROM

Abx not needed in c-section

If ROM >37wks, GBS+ve -> IOL - reduce time fetus exposed

If previous GBS infection - offer intrapartum abx prophylaxis - test in late pregnancy, more abx if still +ve

79
Q

Hep B in pregnancy

A

Offer screening

Vaccine + Ig to babies born to +ve mums

No breastfeeding transmission

C-section doesn’t really reduce vertical transmission

80
Q

HIV and pregnancy

A

Offer screening

4 factors to reduce vertical transmission
Maternal antiretrovirals
C-section
Neonatal antiretrovirals
Bottle feeding - spread by breastfeeding

81
Q

CMV infection pregnancy

A

Herpes virus 5, 1/3 transmitted vertically, 5% cause damage

Px
Flu-like sx
Fever, splenomegaly, impaired liver function

Ix
Viral serology for CMV IgM, IgG

Mx
- refer to fetal medicine
- Maternal - no tx if immunocompetent
- Dx fetus - amniocentesis, PCR, >21wks
- Offer TOP if infected
- If no TOP - serial USSs for congenital CMV (IUGR, HSM, low platelets, jaundice, microencephaly)

82
Q

Parvovirus B19 in pregnancy

A

Slapped cheek syndrome

Resp droplet / blood spread

Px
Asym, symmetrical arthralgia
Children URTI, flu, erythema infectiosum (slapped cheek)

Ix
Viral serology - IgM, IgG

Mx
Refer to fetal medicine
Mum self-limiting
Risk of fetal hydrops - fluid accumulation, severe anaemia - intrauterine transfusion if found

83
Q

Rubella infection in pregnancy

A

Not screened, vaccines, but infection in pregnancy serious for fetus, airborne droplet spread

Px
asym
malaise, headache, coryza, lymphadenopathy, fine maculopapular rash

Ix
IgM, IgG

Mx
- refer to fetal medicine, inform public health
- mother - self-limiting
- <12wks - likely defects - TOP
- 12-20wks - amniocentesis + PCR to confirm - then TOP / US surveillance
- >20wks - no action

Fetal rubella syndrome
Sensorineural deafness, congenital cataracts, congenital heart disease, reduced growth, HMS….

84
Q

Listeria in pregnancy

A

G+, causes listeriosis - more likely in pregnant women

From unpasteurised milk, processed meats, blue cheese

Px
asym, flu, pneumonia, meningoencephalitis

Miscarriage, intrauterine death (IUD), severe neonatal infection

85
Q

Congenital toxoplasmosis

A

Parasite infection - from faeces of cat which is host

Triad of:
intracranial calcification
hydrocephalus
chorioretinitis

86
Q

Obesity in pregnancy

A

increased risk of cx - miscarriage, VTE, GDM, pre-eclampsia, PPH….

Risks to fetus - prematurity, macrosomia, stillbirth….

Mx
Don’t reduce weight by diet whilst pregnant
5mg folic acid
OGTT screen

87
Q

Placenta accreta spectrum

A

attachment of placenta to myometrium - past endometrium - due to defective decidua basalis

Placenta does not separate properly during labour -> PPH risk

RFs
Previous c section, placenta praevia

Types
Accreta - attached to myometrium
Increta - invade into myometrium
Percreta - invade through perimetrium

Px
APH in 3rd trim
May dx on antenatal US scans
PPH

Mx
Planned delivery 35-37wks to reduce risk of spontaneous delivery
Antenatal steroids
Several options
- Hysterectomy
- Resect part of myometrium - preserve uterus
- Leave placenta in - reabsorbed over time - bleeding / infection risk

88
Q

HTN in pregnancy

A

> 140/90, or increase above booking readings >30/15

Pre-existing HTN
No proteinuria / oedema
Stop ACEi, ARB, thiazides
Target BP 135/85
Labetalol / nifedipine
75mg aspirin 12wks->term

Pregnancy induced HTN (PIH)
>20wks, no proteinuria / oedema
resolves 1mo after birth
Test for PlGF - r/o pre-eclampsia
Labetalol / nifedipine

Pre-eclampsia
PIH + proteinuria, maybe oedema

89
Q

HELLP syndrome

A

Haemolysis, Elevated Liver enzymes, Low Platelets

Px
N+V, RUQ pain, lethargy

Ix
Bloods - as above

Mx
deliver baby

90
Q

Chorioamnionitis

A

Ascending bacterial infection of amniotic fluid / membranes / placenta

RFs - PPROM (can occur without)

Mx - deliver fetus, c-section if needed, IV abx

91
Q

Hypothyroidism in pregnancy

A

Untreated –> miscarriage, anaemia, SGA, pre-eclampsia

Increase levothyroxine dose (crosses placenta during pregnancy) - titrate based on TSH

92
Q

Epilepsy in pregnancy

A

Folic acid 5mg from before conception

Pregnancy - worse seizure control - avoid valproate (neural tube defects)

Levetiracetam, lamotrigine, carbamazepine - safer

93
Q

RA in pregnancy

A

Should be well controlled for 3-6mo before becoming pregnant

Methotrexate teratogenic

1st line - hydroxychloroquine
Sulfasalazine safe
Corticosteroids for flare ups

94
Q

Medications in pregnancy

A

NSAIDs
Block prostaglandins (which keep PDA open) - avoid, esp in 3rd trim

BBs
IUGR, low BM/HR in neonate

ACEi/ARBs
teratogenic

Opiates
withdrawal sx

Warfarin
teratogenic

valproate
neural tube defects

lithium
Ebstein’s anomaly
monitor levels every 4wks, then weekly from 36wks
Avoid in breastfeeding

SSRIs
Balance +/-s
1st trim - congenital heart defects
3rd trim - pulm HTN

Isotretinoin
related to vit A, highly teratogenic

95
Q

UTI in pregnancy

A

Pregnant women more at risk
increased risk of preterm, SGA, pre-eclampsia
Test at booking for asymptomatic bacteriuria - higher risk of developing UTI - dip + MC+S

E coli, Klebsiella commonly….

Mx
Nitrofurantoin (avoid 3rd trim - neonatal haemolysis)
Amoxicillin, after sensitivities known
Cefalexin
Avoid trimethoprim 1st trim - spina bifida

96
Q

Vasa praevia

A

Fetal vessels (2x arteries, 1x vein) normally in umbilical cord, but are in fetal membranes + travel across internal cervical os - prone to bleeding

Px
Dx by US
APH
Fetal distress
Bleed after ROM

Mx
Steroids from 32wks
Elective c-section at 34-36wks
APH - emergency c-section

97
Q

Multiple pregnancy

A

Zygote - mono/dizygotic
Amniotic sac - mono/diamniotic
Placenta - mono/dichorionic

Diamniotic, dichorionic twins best outcomes - each fetus has own blood supply

Dx
Booking US scan
- dichorionic, diamniotic - membrane between - lambda / twin peak sign
- monochorionic, diamniotic - T sign
- monochorionic, monoamniotic - no membrane

Mx
FBC (anaemia), regular scans, plan birth for earlier
Steroids, elective c-section, can do vaginal

98
Q

Twin-twin transfusion syndrome

A

Fetuses share placenta, one gets all blood, other starved

Recipient - fluid overload, HF, polyhydramnios

Donor - IUGR, anaemia, oligohydramnios

Tx at tertiary centre - laser tx to destroy connection between blood vessels

99
Q

Twin anaemia polycythaemia sequence

A

Similar to transfusion syndrome, less acute

One twin anaemia, other polycythaemic

100
Q

Reduced fetal movts

A

Can be fetal distress - reduced O2 consumption due to chronic hypoxia - risk of stillbirth, IUGR, placental insufficiency

Fetus felt more and more 18/20wks->32wks, defo by 24wks

RFs - posture, distraction, meds, fetal position, placental position, small fetus

Ix
Handheld doppler
USS if no fetal HB >28wks
CTG if HB >28wks - 30 mins monitoring
If no movts by 24wks - refer to maternal fetal medicine unit

101
Q

Rhesus incompatibility patho

A

If mum RhD-, and child RhD+ - if fetal blood enters maternal circulation, RhD Ag recognised as foreign - mum produces ABs (sensitised) to RhD Ag

In later pregnancies, ABs then destroy RBCs in fetus (haemolytic disease of newborn)

Give anti-D prophylaxis to RhD- women - destroys RhD Ags from fetus in maternal bloodstream - prevent sensitisation occurring

102
Q

Rhesus incompatibility Maternal Mx

A

Take ABO group + RhD typing at booking, rpt at 28wks

Routine anti-D given:
28wks
34wks

Sensitisation - give anti-D <72hrs
APH, amniocentesis, abdo trauma, at birth of Rh+ infant, TOP, miscarriage >12wks, ectopic, ECV

> 20wks (I think 2nd/3rd trimester)+ sensitisation event - perform Kleinhauer test - see how much fetal blood in maternal bloodstream - see if further anti-D needed - add acid, mum’s cells die, fetal RBCs survive

103
Q

Rhesus incompatibility baby Mx

A

When baby born - take cord blood - FBC, group and DAT (direct antiglobulin test) -Coombs - if shows ABs on RBC of baby - haemolysis

Affected fetus:
Hydrops fetalis, jaundice, anaemia, HSM, HF, kernicterus
Mx - transfusions, UV phototherapy

104
Q

Small for gestational age (SGA)

A

<10th centile, birth weight <2.5kg
Assess size by estimated weight / abdo circumference

SGA causes - constitutional, IUGR

SGA RFs - previous SGA, obesity smoking, DM, HTN, pre-eclampsia, >35yo, multiple pregnancy

IUGR causes
- placenta mediated - idiopathic, pre-eclampsia, smoking, anaemia…
- fetus mediated - genetic, infection….

IUGR other signs
oligohydramnios, abnormal dopplers, reduced fetal movt, abnormal CTGs

Monitoring
US, SFH, scan uterine artery doppler, amniotic fluid levels….

Mx
Stop smoking, early delivery if concern with growth, test for infection

105
Q

Large for gestational age (LGA)

A

macrosomia, >4.5kg, >90th centile

Causes
Constitutional, GDM, prev, maternal obesity, overdue, male

Risks
To mother - shoulder dystocia, failure to progress, perineal tears, instrumental delivery, PPH, uterine rupture
To baby - birth injury, neonatal hypoglycaemia, obesity, T2DM

Ix
USS - r/o polyhydramnios
OGTT

Mx
Deliver in hospital, c-section if needed

106
Q

Acute fatty liver of pregnancy

A

Rare cx in 3rd trim / after birth - rapid accumulation of fat in liver - from impaired processing of fatty acids in placenta

Px
abdo pain, N+V, headache, jaundice, hypoglycaemia, ascites, pre-eclampsia

Ix
Raised ALT, AST, bilirubin, WCC
deranged clotting, low platelets

DDx
HELLP - more common

Mx
deliver baby
mx acute liver failure
consider liver transplant

107
Q

Stillbirth

A

Birth of dead fetus >24wks - from intrauterine fetal death (IUFD)

Causes
unexplained, various cx - pre-eclampsia, abruption, vasa praevia….

Prevention
Regular scans, stop smoking
report reduced fetal movts, abdo pain, vaginal bleeding

Ix
USS - visualise fetal HB

Mx
Vaginal birth, unless c-section indicated
Induce labour
Dopamine agonist (cabergoline) - suppress lactation
Testing for cause - genetic, post-mortem, XR/MRI, infection tests

108
Q

Signs of labour

A

Show - mucus plug

Rupture of membranes

Regular, painful contractions

Dilating cervix

109
Q

Stages of labour

A

FIRST STAGE
- Onset of contractions -> 10cm dilatation
- <4cm latent phase, >4cm established phase
- Latent phase - 0-3cm, 0.5cm/hr, irregular contractions
- Active phase - 3-7cm, 1cm/hr, regular cont.
- Transition phase - 7-10cm, 1cm/hr, strong + regular cont.

SECOND STAGE
- 10cm -> delivery of baby

THIRD STAGE
- delivery of placenta

110
Q

Braxton-Hicks contractions

A

irregular contractions of uterus, 2/3rd trim - temporary, not labour

111
Q

Monitoring in labour

A

FHR/15mins / continuously on CTG

Contractions/30mins

Maternal HR/60mins

Maternal BP, temp/4hrs

VE/4hrs

112
Q

Lochia

A

PV discharge, blood, mucus, uterine tissue- for 6wks after birth

113
Q

Cardiotocography - DR C BRaVADO

A

Define Risk - CTG Indications
- sepsis, maternal tachy, meconium, pre-eclampsia, induction of labour, labour delay….

Contractions
- No of cont./10mins
- Too few - not progressing
- Too many - uterine hyperstimulation - risk of fetal compromise

Baseline HR
- 110-160 reassuring
- Brady - increased vagal tone, BBs
- Tachy - maternal fever, hypoxia, prem,

Variability
- 5-25 normal
- loss of this - prem, hypoxia

Acceleration
- good sign - occurs with contractions

Decelerations
- Early - dip with contraction - fine (vagal)
- Late - after cont - hypoxia
- variable - intermittent cord compression - hypoxia
- prolonged - 2-10mins - concern

Features are reassuring, non-reassuring, abnormal

CTG categories - normal, suspicious, pathological, need for urgent intervention

Mx
- escalate
- reposition mother, IV fluids if low BP
- fetal scalp stimulation - should see acceleration in response
- fetal scalp blood sampling - eg acidosis
- deliver baby - instruments / emergency c-section

Fetal bradycardia
- 3 mins - call for help
- 6 mins - move to theatre
- 9 mins - prepare for delivery
- 12 mins - deliver baby (by 15 mins)

114
Q

Drugs in labour

A

Oxytocin - syntocinon
- Produced in hypothalamus, secreted by pos pit.
- Ripens cervix, stimulates contractions, role in lactation in breastfeeding
- Used for - induction, progression, improve contraction frequency / strength, prevent PPH

Ergometrine
- Stimulates smooth muscle contraction
- Delivery of placenta, prevent PPH - only after delivery of baby
- S/Es - HTN, D+V, angina. Avoid in eclampsia / HTN

Syntometrine
- Combination of oxytocin + ergometrine

Nifedipine
- CCB - first line for tocolysis in preterm labour

Atosiban
- Oxytocin receptor antagonist
- For tocolysis, eg premature labour, when nifedipine contraindicated

Prostaglandins - dinoprostone (prostaglandin E2)
- Induction of labour - stimulate contractions, ripen cervix
- Pessaries, tablets, gel
- (Lower BP - vasodilation, NSAIDs inhibit this action - increase BP - avoid in pregnancy)

Misoprostol
- Prostaglandin analogue
- Medical mx in miscarriage, IOL in IUFD - used alongside mifepristone

Mifepristone
- Anti-progesterone, halts pregnancy, ripens cervix, stimulates contractions
- Used with misoprostol for abortions, IOL in IUFD

Carboprost
- Synthetic prostaglandin analogue, stimulates uterine contraction
- Given IM in PPH, where ergometrine and oxytocin have been inadequate
- Avoid in asthma

Terbutaline
- B2 agonist - suppresses uterus smooth muscle contractions - used for tocolysis in uterine hyperstimulation

TXA
- Antifibrinolytic, binds to plasminogen, prevents it converting into plasmin (which dissolves fibrin in clots), reduces bleeding
- PPH

115
Q

Failure to progress

A

Labour not progressing at satisfactory rate - increased risk to fetus and mother - more likely in first labour

Causes
Power - contractions
Passenger - baby size, presentation
Passage - pelvis etc
Psyche - motivation

Delay definitions
1st stage - <2cm dilatation 4hrs / slowing if multiparous
2nd stage - 2hrs pushing if 1st baby, 1hr if multiparous
3rd stage - >30mins with active mx, >60mins physiological

Mx
- ARM - amniotomy
- oxytocin infusion
- instrumental delivery
- c-section

116
Q

Pain relief in labour

A

Paracetamol, codeine, entenox

IM pethidine / diamorphine
- opioids, make mum drowsy, can cause resp depression in neonate

PCA - remifentanil
- anaesthetic support - naloxone + atropine on standby

Epidural
- catheter in epidural (outside dura) space - inject levobupivacaine + fentanyl
- S/Es - headache, hypotension, weak legs, nerve damage, prolonged 2nd stage, likely instrumental delivery

Spinal - in CSF, subarachnoid

Combined spinal + epidural (CSE)

117
Q

Instrumental delivery

A
  • After 3 pulls, abandon
  • Give single dose co-amox

Indications
- inadequate progress, maternal exhaustion, ?fetal compromise, clinical concern (eg APH)

Need to be
- fully dilated, ROM, cephalic px, empty bladder, adequate pain relief…

Ventouse
- vacuum cup on baby head
- less painful, less maternal injury
- cephalohaematoma, fetal retinal haemorrhage

Forceps
- lower fetal cx risk, higher maternal risk
- 3/4th degree tears
- facial nerve palsy to baby

Maternal injuries
Femoral
Obturator

118
Q

Perineal tears

A

1st degree
- superficial, no muscle, no repair

2nd degree
- perineal muscle, suture on ward

3rd degree
- perineum + anal sphincter - external/internal - theatre repair
- 3a - <50% EAS thickness torn
- 3b - >50% EAS torn
- 3c - IAS torn

4th degree
- Perineum, EAS/IAS + rectal mucosa - theatre repair

Give PR diclofenac + abx

Episiotomy
- cut perineum, use LA, cut 45 degrees diagonally

Perineal massage
- reduce tear risk, massage from 34wks on, warm towels during delivery

119
Q

Mx of 3rd stage

A

Physiological
Deliver placenta by maternal effort

Active
IM oxytocin
helps uterus contract
Careful traction of umbilical cord, suprapubic pressure
Reduces bleeding risk
N+V S/E

120
Q

Premature labour

A

SROM - spontaneous ROM

PROM - prelabour rupture of membranes - rupture >1hr before labour onset, >37wks

PPROM - preterm PROM - <37wks - cx

Prematurity - birth <37wks, non-viable <23wks

121
Q

Prophylaxis of preterm labour

A

Offer to women with cervix length <25mm, 16-24wks

Vaginal progesterone
- Gel / pessary
- maintain pregnancy

Cervical cerclage
- put stitch into cervix (under GA / spinal)
- Rescue cerclage - 26-28wks, cervical dilatation, w/o ROM

122
Q

PROM / PPROM

A

Fetal membranes normally weaken in time for labour, but may rupture early due to - early activation of normal processes, infection, genetics

RFs
- smoking, previous PROM / prem, PV bleed in pregnancy, infection, amniocentesis, polyhydramnios, multiple pregnancy

123
Q

PROM / PPROM Px

A

Broken waters - painless pop + gush, may be gradual

Lack of normal discharge (washed away)

Pooling in posterior fornix - speculum

124
Q

PROM / PPROM Ix

A

Actim-PROM - swab for IGFBP-1 - high in amniotic fluid

Amnisure - for PAMG-1

High vaginal swab - GBS

125
Q

PROM / PPROM Mx

A

Majority go into labour in 24-48hrs

Penicillin / clindamycin if GBS

> 36wks
- w+w for 24hrs
- IOL >24hrs

34-36wks
- prophylactic erythromycin (10d course / until labour)
- corticosteroids
- IOL + delivery

24-33wks
- erythromycin, steroids
- expectant until 34 wks
- avoid sex

126
Q

Preterm labour + intact membranes

A

Regular painful contractions, cervical dilation, no ROM

Dx
- speculum - dilatation seen - <30wks clinical assessment only to offer Mx of preterm labour, >30wks offer TVUS assess - <15mm offer mx, >15mm preterm labour unlikely
- fetal fibronectin - in vagina

Mx
- CTG
- Tocolytics - nifedipine
- <35wks - dexamethasone
- <34wks MgSO4 - prevent CP

127
Q

Induction of labour (IOL)

A

Start labour artificially

Indications
- Prolonged gestation
- P/PROM
- maternal health problems - HTN, preclampsia
- IUGR
- IUFD

Contraindications
- same as vaginal birth CIs
- if prev c-section - can only induce if consultant says

128
Q

Methods of IOL

A

Vaginal prostaglandins - prostaglandin E2
- ripen cervix, role in uterus contraction
- tablet, gel, pessary

Amniotomy - amnihook
- rupture membranes artificially
- add IV oxytocin - increase contractions

Cervical ripening balloon (CRB)
- insert into cervix, gently inflate

Membrane sweep
- insert gloved finger through cervix, rotate against fetal membranes

If IUFD - mifepristone + misoprostol

129
Q

IOL monitoring

A

Bishop Score - assess cervical ripeness, likelihood of need of IOL
- considers dilatation, length, station (relative to ischial spine), consistency, position
- >_8 - cervix ripe, high chance response to IOL / spontaneous
- <5 - IOL likely needed

CTG
- continuous
- fetal scalp electrode (FSE) alternative

130
Q

IOL Cx

A

Failure, cord prolapse, infection

Uterine hyperstimulation
- contractions too long / frequent - fetal distress
- give terbutaline (tocolytic)

131
Q

C-section + indications

A

99% lower segment c-section, classic was longitudinal in upper segment

Indications
- placenta praevia, pre-eclampsia, IUGR/fetal distress, failure to progress, breech, abruption, infection (eg herpes), cervical cancer, previous 3/4th

132
Q

C-section categories

A

Cat 1 - 30 mins, immediate threat to life of mother/baby

Cat 2 - 75 mins - maternal / fetal compromise - not immediately life-threatening

Cat 3 - delivery required, mother + baby stable

Cat 4 - elective c-section, >39wks to reduce TTN

133
Q

C-section risks

A

Serious
Emergency hysterectomy, further surgery, ICU, VTE, bladder/ureter injury, death, future uterine rupture, placenta praevia/accreta

Frequent
Persistent abdo pain, rpt c-section, haemorrhage, infection, fetal laceration

134
Q

C-section procedure

A
  • Send FBC, group and save
  • Prescribe ranitidine (H2 receptor antagonist) +/- metoclopramide - reduce vomit / aspiration risk
  • Calculate VTE risk score - Stockings, LMWH
  • Epidural / spinal / general anaesthetic
  • Left lateral position
  • Skin incision
  • Sharp / blunt dissection through layers - skin, camper fascia, scarpa fascia, rectus sheath, rectus muscle, abdominal peritoneum (parietal)
  • Visceral peritoneum cut, pushed down to reflect bladder
  • Uterine incision made below, baby delivered
  • Oxytocin 5 units given IV to aid delivery of placenta
  • Everything closed
135
Q

Vaginal birth after c-section (VBAC)

A

Most appropriate method >37wks with 1 previous c-section
70-75% successful

Mx
deliver in hospital
continuous CTG
Avoid induction / augmentation

CIs
uterine rupture, classical caesarean scar

136
Q

Shoulder dystocia

A

anterior shoulder stuck on pubic symphysis in delivery

leads to fetal hypoxia, risk of brachial plexus injury

(less commonly posterior shoulder on sacral promontory)

137
Q

Shoulder dystocia RFs

A

Pre-labour
Previous, macrosomia, DM, BMI>30, IOL

Intrapartum
prolonged 1st/2nd stage labour, secondary arrest, IV oxytocin augmentation, instrumentation

138
Q

Shoulder dystocia Px

A
  • Difficulty delivering head/chin
  • failure of restitution - remains OA, doesn’t turn to look to side
  • Turtle head sign - fetal head retracts
139
Q

Shoulder dystocia Mx

A

Call for help, stop pushing, routine axial traction, ?episiotomy

1st line
- McRoberts - knees to chest
- suprapubic pressure

2nd line
- posterior arm - insert hand + grab
- internal rotation - pressure on shoulders to rotate baby 180 degrees
- roll onto all 4s, repeat

Further
- cleidotomy - fracture baby clavicle
- symphysiotomy - cut pubic symphysis
- Zavenelli - return fetal head to pelvis, deliver via c-section

Post-delivery
- active mx 3rd stage
- PR - exclude 3/4th tear
- debrief parents,
- physiotherapy / paediatric review

140
Q

Amniotic fluid embolism (AFE)

A

rare cause of maternal collapse

fetal / amniotic fluid enters mother’s bloodstream, stimulates reaction

141
Q

AFE Px

A
  • majority in labour / c-section / post-partum
  • chills, shivering, sweating, anxiety, coughing
  • cyanosis, hypoxia, resp arrest, hypotension, shock, seizure, MI, DIC
142
Q

AFE Ix

A
  • Dx of exclusion
  • post-mortem - fetal squamous cells + debris in pulmonary vasculature
  • bloods, ECG, CXR
143
Q

AFE Mx

A

A-E

Anaesthetics, haem, ICU

144
Q

Umbilical cord prolapse

A

Cord descends through cervix with / before presenting part of fetus

Fetal hypoxia from occlusion of cord / vasospasm from cold

Overt / complete - cord past presenting part
Occult / incomplete - alongside presenting part

RFs - ARM, prem, multiparity…..

145
Q

Cord prolapse Px

A

Non-reassuring fetal HR

Examine to confirm

May have PV bleed

146
Q

Cord prolapse Mx

A

Avoid handling cord (keep warm + wet) - reduce vasospasm

Manually elevate presenting part of fetus

Fill bladder with 500ml warm normal saline

Knee/chest position / left lateral position

Tocolysis - terbutaline

Deliver via c-section

If fully dilated / vaginal imminent - encourage pushing / instrumental delivery

147
Q

Uterine rupture

A

Full thickness tear of uterine muscle / serosa - typically occurs during labour

Incomplete - peritoneum intact, remains within uterus
Complete - peritoneum torn, uterine contents escape

RFs
prev c-section / uterine surgery, IOL, obstructed labour

148
Q

Uterine rupture Px

A
  • sudden severe abdo pain, constant
  • shoulder tip pain (diaphragmatic irritation)
  • PV bleed
  • shock
  • fetal distress
  • contractions stop
149
Q

Uterine rupture ddx

A

Abruption - abdo pain +/- PV bleed - woody/tense uterus on palpation

Placenta praevia - painless PV bleed

Vasa praevia - ruptured membranes, painless PV bleed, fetal bradycardia

150
Q

Uterine rupture Ix

A

CTG

Catheter - look for haematuria

USS

151
Q

Uterine rupture Mx

A

A-E

Blood resus

C-section to deliver, repair uterus or remove

152
Q

Primary PPH

A

> 500ml PV bleed <24hrs delivery

Minor - 500-1000
Major - >1000

153
Q

Primary PPH causes

A

Tone
Uterus fails to contract properly

Tissue
retention of placental tissue, prevents contraction

Trauma
from instrument, episiotomy, c-section

Thrombin
coagulopathies
vascular (placental abruption, HTN, pre-eclampsia)

154
Q

Primary PPH Px

A

PV bleed
Haemorrhagic shock
Dizzy, SOB, palpitations…

155
Q

Primary PPH Ix

A

Bloods - FBC, G+S, crossmatch 4-6 units, coag, U/E, LFTs, gas

156
Q

Primary PPH Mx

A

A-E
MHP

Atony
- Bimanual compression, insert catheter
- Oxytocin (syntocinon), ergometrine (avoid in HTN), carboprost, misoprostol
- Surgery - intrauterine balloon tamponade, B-lynch suture, artery ligation, hysterectomy

Trauma
- surgical repair

Tissue
- IV oxytocin
- surgery for evac

Thrombin
- correct

Active mx of 3rd stage to prevent

157
Q

Secondary PPH

A

PV bleed 24hrs->12wks post-partum

Causes - endometritis, retained placental tissue

158
Q

Secondary PPH Px

A

Excessive PV bleed, spotting

10% massive haemorrhage

If infection - fever, rigors, lower abdo pain, foul smelling lochia

159
Q

Secondary PPH Ix

A

Bloods, inc cultures

Pelvic USS - retained tissue

160
Q

Secondary PPH Mx

A

Abx
- Ampicillin (clindamycin if pen allergic) + metronidazole
- Add gentamicin if endomyometritis / sepsis

Uterotonics
- eg oxytocin, prostaglandins

Surgery
- if bleeding heavily, eg balloon catheter

161
Q

Uterine inversion

A

uterus turns insure out, fundus drops down through uterine cavity

Complete - through to introitus

162
Q

Uterine inversion Px

A

PPH
Maternal shock / collapse
Palpate on VE
See uterus at introitus

163
Q

Uterine inversion Mx

A

Johnson manoeuvre - push back up with hand, oxytocin to stimulate contraction

Hydrostatic - fill vagina with fluid, tight seal needed

Surgery - laparotomy

164
Q

Routine post-natal care

A

6wk check
- GP, general stuff

Menstruation
- Lochia to begin
- breastfeeding -> more oxytocin -> more bleeding
- lactational amenorrhoea - absence of periods with breastfeeding
- bottlefeeding - periods begin 3wks after birth

Contraception
- fertility returns 21d after birth
- lactational amenorrhoea 98% effective as contraception up to 6mo post partum
- POP + implant safe for breastfeeding
- if breastfeeding, avoid cOCP until >6wks
- coil - insert <48hrs >4wks after birth

165
Q

Baby blues

A

60-70%, 3-7d after birth, more common in primips

Px
mood swings, low mood, anxiety, irritable, tearful

Mx
reassure, support
health visitor important
sx resolve <2wks

166
Q

Post-natal depression

A

10%, start <1mo, peak at 3mo

Px
depression sx - low mood, anhedonia, low energy….

Ix
Edinburgh Postnatal Depression Scale - >10/30 suggests dx

Mx
CBT
Sertraline, paroxetine

167
Q

Puerperal psychosis

A

0.2%, <2-3wks birth

Px
mood swings - depression / mania
Hallucinations, delusions
confusion, thought disorder

Mx
Admit to mother + baby unit
CBT
Antidepressants, antipsychotics, mood stabilisers, ECT if needed
25-50% recurrence

168
Q

Endometritis

A

infection of endometrium, more common in c-sections

Px
foul smelling discharge
bleed, abdo / pelvic pain, fever, sepsis
can be weeks later

Ix
Vaginal swabs, urine culture, US to r/o POC

Mx
Sepsis - clindamycin + gent
Oral coamox if more well

169
Q

Retained POC

A

pregnancy related tissue (eg placenta, fetal membrane) remains in uterus after delivery

Can happen after miscarriage / TOP

Px
PV bleed, unresolving
Abnormal PV discharge
Lower abdo / pelvic pain
Fever - infection

Ix
US

Mx
ERPC - evacuation of retained POC - under GA

170
Q

Post-partum anaemia

A

Hb<100 post-partum
Often PPH

Mx
FBC
<100, start oral iron
<90, iron infusion - but risk of reaction, also active infection is CI
<70/80 - blood transfusion

171
Q

Mastitis

A

Inflammation of breast tissue +/- infection, common cx of breastfeeding - S aureus
risk of abscess development

Px
Breast pain, tender, unilateral
Warm, red, inflamed
Nipple discharge, fever

Mx
continue breastfeeding, heatpacks / analgesia
No improvement - fluclox / erythromycin
Milk -> MC+S
Fluconazole for candida

172
Q

Post-partum thyroiditis

A

Changes to thyroid function in first year

Stages
thyrotoxicosis <3mo
hypothyroid 3-6mo
function normal <1yr

Px
thyrotoxicosis - anxiety, irritable, sweating, heat, tachycardia, wt loss, fatigue, diarrhoea
hypothyroid - wt gain, fatigue, dry skin, coarse hair, hair loss, low mood, fluid retention, heavy periods, constipation

Ix - TFTs
Thyrotoxicosis - raised T3/4, low TSH
Hypothyroid - low T3/4, raised TSH

Mx
TFTs every 6-8wks
Propranolol for thyrotoxicosis
Levothyroxine for hypothyroid
Annual monitoring after resolution

173
Q

Sheehan’s syndrome

A

Rare cx of PPH - drop in BV -> avascular necrosis of pituitary gland

Only ant pit - TSH, ACTH, FSH, LH, GH, prolactin (oxytocin, ADH not affected)

Px
reduced lactation
amenorrhoea
adrenal insufficiency / crisis, hypothyroid

Mx
Endo referral
Oestrogen, progesterone
Hydrocortisone
Levothyroxine
GH

174
Q

Puerperal infection

A

T>38 <14 after birth

Causes
endometritis, UTI, wound infection, mastitis, VTE

Px
Fever >38, rigors, low abdo pain, foul PV discharge

Mx
Endometritis - IV abx - clindamycin + gent
Tx cause

175
Q

Injectable contraceptives?

A

Depo provera- given IM every 12 weeks

Inhibits ovulation. Also thickens cervical mucus

Cannot be reversed, fertility return can take up to 12 months

Adverse effects-
Irregular bleeding
Weight gain
Osteoporosis risk

CI- Current breast cancer UKMEC 4

176
Q

COCP missed pill advice?

A

If 1 pill missed at any time in the cycle- take the last pill even if it means taking two pills in one day and continue taking pills daily, one each day, no additional contraception needed

If 2+ missed pills
Take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily
Use condoms or abstain until taken pills for 7 days in a row
If pills are missed in week 1- emergency contraception should be considered if she had unprotected sex in pill free interval or in week 1
Week 2- no need for emergency contraception after 7 days of pill
Week 3- finish pills in current pack and start a new pack the next day, omitting the pill free interval

177
Q

Postpartum contraception

A

After giving birth, women require contraception after day 21

Progestogen-only pill POP
Can start at any time postpartum
After day 21 addition contraception should be used for first 2 days

COCP-
UKMEC 4 if breastfeeding <6 weks post partum
UKMEC 2- if breast feeding 6weeks-6months postpartim
May reduce breast milk prodcution
Not used in first 21 days due to increased VTE risk
Additional contraception for first 7 days

IUD or IUS can be inserted within 48 hours of childbirth or after 4 weeks

Lactational amenorrhoea method (LAM)- 98% effective providing women is fully breast feeding, amenorrhoeic and <6 months post partum

178
Q

UKMEC 4 for COCP?

A

More than 35 years old and smoking more than 15 cigarettes/day

Migraine with aura

History of thromboembolic disease or thrombogenic mutation

History of stroke or ischaemic heart disease
breast feeding < 6 weeks post-partum

Uncontrolled hypertension

Current breast cancer

Major surgery with prolonged immobilisation

Positive antiphospholipid antibodies (e.g. in SLE)

179
Q

Prematurity risks?

A

Increased mortality depends on gestation

Respiratory distress syndrome

Necrotizing enterocolitis

Intraventricular haemorrhage

Hypothermia, infection, jaundice, chronic lung disease

Retinopathy of prematurity- cause of visual impairment in premature before 32 weeks

Hearing probelms

Phase 4 Question Knowledge (30 decks)

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