Obstetrics 2 Flashcards
What blood test can be done to investigate preterm labour?
Fetal fibronectin
What imaging may be useful in assessing preterm labour?
TVUS of cervical length
From what time period will steroids definitely need to be given in preterm labour?
24-34 weeks
What are tocolytics mainly used for?
Delaying labour for 24 hours to either give time for steroids to work or transfer to special care facility
What is the main thing to keep an eye out for in preterm labour or PPROM?
Chorioamnionitis
What type of presentation is more common in preterm labour?
Breech
What is the definition of PPROM?
Rupture of membranes before 37 weeks
What proportion of prelabour deliveries are preceded by PPROM?
1/3
When has delivery usual followed PPROM by?
48 hours time
What is funisitis?
Infection of the umbilical cord
What is the speculum sign of PROM?
Clear fluid pool in posterior fornix
Symptoms of chorioamnionitis?
Fever, tachycardiaAbdo painUterine tendernessColoured/offensive liquor
What constitutes an infection screen for chorioamnionitis?
High vaginal swabFBCCRP+/- amniocentesis, ctg
When should IoL follow PPROM?
After 36 weeks
What needs to be done if there are any signs of chorioamnionitis?
Deliver!
What maternal antibiotic carries a risk of necrotising enterocolitis?
Co-amoxiclav
What does SGA mean?
Weight under specific centile (10, 5, 2) for gestational age
What is IUGR?
Failure to reach full growth potential - a fetus may be IUGR but still ‘normal’ size for gestation
What may ‘falling off’ a growth curve suggest?
Fetal compromise leading to IUGR
What is fetal distress?
An acute situation seen most often in labour - e.g. Hypoxia
What is Fetal compromise?
A chronic situation whereby there are suboptimal conditions for Fetal growth and neuro development
What does Fetal compromise often result in?
IUGR
What suture technique may be employed to prevent preterm labour?
Cervical cerclage
6 causes of IUGR?
Pre-eclampsia or pregnancy induced HTNDMMaternal smokingMaternal alcoholCongenital abnormalitiesMaternal thyrotoxicosis
What may happen with head circumference and abdominal circumference in IUGR?
Abdo circumference plateaus giving asymmetrical picture as head circumference carries on as normal
What Doppler methods are available in to investigate IUGR?
Doppler umbilical arteryDoppler Fetal circulation - MCA, Ductus venosus
What indicates placental dysfunction in Doppler umbilical artery waveforms?
A high resistance circulation
What is the biophysical profile?
5 features each worth 0-2 pointsLimb movementBreathing movementsToneLiquor volume (AFI)CTG
What medical condition may accompany IUGR/SGA?
Pre-eclampsia
How does SGA become IUGR after investigation?
SGA + unusual UAD/MCA
What is appropriate investigation for preterm IUGR?
Regular UAD, daily CTGSteroids if
Before when is IoL inappropriate unless otherwise indicated?
41 weeks
What assessment and management is done from 41 weeks onwards when thinking about IoL?
Vaginal exam and bishops score of cervical suitabilityIf no IoL, do sweep and daily CTG monitoringIf CTG abnormal, IoL straight away or CS
What 4 things are associated with multiple pregnancy?
GeneticsAgeIncreasing parityAssisted conception
What are the most common kinds of twins?
Non identical - dizygotic
What are identical twins otherwise known as?
Monozygotic
What are the most common type of monozygotic twins?
Monochorionic Diamniotic
In order of increasing time of cell division, what are the different types of multiple pregnancy?
DCDAMCDAMCMAConjoined
What are some early indicators of multiple pregnancy?
HyperemesisSFH palpable at umbilicus before 12 weeks
What does being able to palpate 3 Fetal poles suggest?
Multiple pregnancy
3 maternal complications of multiple pregnancy?
GDMPre-eclampsiaAnaemia
Fetal complications of all multiple pregnancies?
Increased morbidity and mortalityPreterm labourIUGR
Fetal complications of MCDAs?
Twin twin transfusion syndromeCongenital abnormalities IUGRCo-twin death
In what type of twins can TTTS occur?
MCDA
What happens to the donor baby in TTTS?
Gets anaemic, Oligohydramnios and IUGR
What happens to the recipient baby in TTTS?
It gets polycythaemia, volume overload (cardiac failure) and polyhydramnios
3 intrapartum complications of multiple pregnancy?
MalpresentationFetal distressPPH
What USS sign indicates DCDA twins?
Lambda sign
What USS sign indicates MCDA pregnancy?
T sign
What causes decreased glucose tolerance in pregnancy?
Human placental lactogen, progesterone and cortisol
What happens to glucose tolerance in pregnancy?
It decreases
What urinary abnormality can occur physiologically in pregnancy?
Glycosuria
Unofficial diagnostic criteria of gestational DM?
Fasting glucose >7mmol/L2 hr post prandial glucose >7.8mmol/L
What will happen to insulin requirements in pregnancy?
They will increase
Where does delivery need to take place in a diabetic mother?
In a unit with a neonatal ICCU
What prenatal management needs to take place in a pre-existing diabetic?
Insulin dependent women need retinal, renal and BP screenGlucose control needs to be optimisedLower BP if necessary with labetalol or methyldopa
What is an ideal hba1c for diabetes in pregnancy?
Less than 6.5% (47)
When checking BM at home, what should diabetic women aim to keep it below?
6mmol/L
What prophylactic measure should be given to diabetic women from 12 weeks?
Aspirin 75mg to prevent pre-eclampsia
When does delivery need to happen by for diabetic women? Why?
39 weeksRisk of stillbirth and macrosomia
What is a common neonatal complication of DM babies?
Neonatal hypoglycaemia due to high insulin production and suddenly lowered blood glucose
Fetal complications of maternal DM in pregnancy?
MacrosomiaPolyhydramnios IUGRBirth trauma and shoulder dystociaFetal compromise, deathPreterm labourCongenital defects - NTD, cardiac
What congenital defects are more common in DM babies and what does the risk of these depend on?
Cardiac and NTDsRisk depends on periconceptual glucose control
Maternal complications of DM in pregnancy?
Insulin requirementsIntervention e.g. LSCSPre-eclampsiaAcceleration of complicationsKetoacidosis and undetected hypoglycaemia Infection - UTI, endometritis, wound infection
RFs for GDM?
Previous GDM, macrosomic baby (>4.5kg) or unexplained stillbirthFH of DMBMI >30RacePolyhydramnios Persistent GlycosuriaPCOS
When should screening for GDM take place if woman has had previous GDM?
18 weeks
What is the screening method for GDM?
GTT
When does ‘regular screening’ for GDM take place?
28 weeks
What oral hypoglycaemics are safe in pregnancy?
Metformin
What normally happens to BP and protein excretion in pregnancy?
BP drops by 30/15 in second trimesterProteinuria but not >0.3g in 24 hours
What is pregnancy induced hypertension?
BP >140/90 after 20 weeks in a normally normotensive woman
What are the two subtypes of pregnancy induced hypertension?
Gestational hypertension - BP but no proteinuriaPre-eclampsia - BP with proteinuria
What is the basic pathophysiology behind pre-eclampsia?
Incomplete trophoblastic invasion -> reduced flow in spiral arteriesEndothelin release and exaggerated maternal immune response
3 underlying factors of pre-eclampsia that lead to symptoms?
Increased vascular permeabilityVasoconstrictionClotting abnormalities
RFs for pre-eclampsia?
Previous pre-eclampsia or nulliparityPre-existing hypertensionGDM or DMObesity, metabolic syndromeIncreasing maternal ageMultiple pregnancy HIV
What infection is a risk factor for pre-eclampsia?
HIV
When does pre-eclampsia typically present?
3rd trimester - 24-26 weeks
What is the first sign of pre-eclampsia?
Hypertension
What does increased vascular permeability in pre-eclampsia lead to?
OedemaProteinuria
What does the vasoconstriction in pre-eclampsia lead to?
HypertensionHeadaches, visual disturbance -> eclampsiaLiver damage (nausea, vomiting, epigastric pain)
What rise in BP suggests pre-eclampsia in someone with pre-existing hypertension?
> 30/15
Appropriate investigation of proteinuria in pre-eclampsia?
Urine dip at least +PCR - can do spot test (>0.3) or >30mg/nmol24 hour protein collection >0.3g/24hr
Hypertension criteria in a normotensive person for pre-eclampsia?
> 140/90
Prophylaxis against pre-eclampsia?
Aspirin 75mg/day from 12 weeks
When should delivery be aimed for in mild pre-eclampsia?
37 weeks
When should delivery be aimed for in moderate-severe pre-eclampsia? What extra care should be taken?
34-36 weeksGive steroids, use regular ctg and fluid monitoring
If any pre-eclampsic woman deteriorates or shows signs of complications what should be done?
Deliver!
Initial management of mild-moderate pre-eclampsia?
Give anti-hypertensives if BP >150/100Labetalol or nifedipine first line
What is MgSO4 used for in pre-eclampsia management?
Treatment and prevention of eclampsia
What 2 things should be monitored if giving MgSO4 for eclampsia?
Patellar reflexesRenal function
During delivery in pre-eclampsia what needs to be monitored?
Fluid balance via catheter, Central venous pressure
When can BP peak post-natally?
Around 5 days
Why don’t you give ergometrine in 3rd stage of labour for pre-eclampsic women?
Can cause BP to rise
What is a major respiratory cause of death in pre-eclampsia?
Pulmonary oedema
What does HELLP stand for?
Haemolysis - dark pee, raised LDHElevated Liver enzymes - pain, liver failureLow Platelets - bleeding
How might a stroke arise in pre-eclampsia?
Haemorrhage - esp during pushing in 2nd stage of labour with massive HTN
4 Fetal complications of pre-eclampsia?
IUGRPreterm birthPlacental abruptionFetal hypoxia and morbidity/mortality
Any contraindications to VBAC?
Vertical Caesarean scar
What is there a greater risk of in VBAC than normal labour?
Need for emergency section
Methods of induction of labour?
Prostaglandins (E2)Amniotomy and oxytocinOr both
Fetal indications for IoL?
Prolonged pregnancy (>41 weeks)Prelabour term ROMIUGR
Maternal indications for IoL?
Pre-eclampsiaDMSocial factors
Absolute contraindications to IoL?
Fetal distressPlacenta praeviaWhere ELSCS is indicated
Relative contraindications to IoL?
Previous LSCS
Potential complications of IoL?
Need for LSCS or other interventions in labourLong labourHyperstimulation and precipitate labourPPH
What is prelabour term rupture of membranes?
Rupture of the membranes after 37 weeks
Common indications for ventouse/forceps delivery?
Prolonged active second stage or Fetal distress during thisMaternal exhaustion
Prerequisites for instrumental delivery?
Head can’t be palpable abdominally I.e. Deeply engagedHead must be at or below level of ischial spines Cervix must be fully dilated (I.e. In second stage)Known head positionAdequate analgesiaEmpty bladder/catheterisation
In what type of woman (nulliparous or multiparous) is instrumental delivery more common?
Nulliparous
Indications for emergency CS?
Prolonged first stage of labour (not fully dilated within 12 hours)Inefficient uterine action such that criteria for instrumental delivery is not reachedFetal distress if CS is quickest route
Common reasons for ELSCS?
Placenta praeviaSevere antenatal fetal compromiseUncorrectable abnormal liePrevious CS
Relative indications for ESC?
BreechSevere IUGRMultiple pregnancyDM
Complications of LSCS?
Fetal respiratory morbidityHaemorrhageUterine or wound sepsisVTEAnaesthetic relatedNeed for CS in subsequent pregnancies
Maternal complications of instrumental delivery?
TraumaHaemorrhageThird degree tears
What is shoulder dystocia?
Failure of the shoulders to be delivered after normal downward traction
Major RF for shoulder dystocia?
Macrosomia
What is the major complication of shoulder dystocia and how is it avoided?
Erb’s (waiters tip) palsyAvoid by not pulling too hard
What is cord prolapse?
After membranes have ruptured, cord descends below presenting part potentially becoming compressed/spasming
RFs for cord prolapse?
Preterm labourBreechPolyhydramniosAbnormal lieTwin pregnancy Artificial amniotomy
What is amniotic fluid embolism?
Liquor enters maternal circulation causing essentially a VTE
Sequelae of amniotic fluid embolism?
Pulmonary oedemaARDSDIC
RFs for amniotic fluid embolism?
ROMPolyhydramnios
What might lower abdo pain, Fetal heart rate abnormalities and PV bleed/stopped contractions/maternal collapse indicate in the context of a VBAC?
Uterine rupture
What is the definition of the puerperium?
The 6 week period postpartum where the body returns to pre-pregnancy state
What 2 hormones does lactation depend on?
ProlactinOxytocin
The drop in which 2 hormones causes lactation after birth?
OestrogenProgesterone
What is colostrum?
Yellow fatty milk, IgA protein and minerals passed for first few days of lactation
5 advantages of breastfeeding?
Protection of neonatal infectionBondingProtection against maternal CancerCan’t give too muchCost saving
What vitamin should be given after birth and why?
K - avoid haemorrhagic disease of newborn
