Obstetrics 2 Flashcards
What blood tests do you want in pre-eclampsia?
FBC
- low Hb
- Low platelets
- Haemolysis on film
U&Es
- increase urea and creatinine
LFTs
- raised AST, ALT
Coagulation studies
- prolonged
What would be the definitive treatment in pre-eclampsia to control blood pressure?
Delivery of fetus and placenta
What is are the complications of hyperthyroidism in pregnancy?
• Increased miscarriage
• Intrauterine growth restriction
• Increased preterm delivery
Increased perinatal delivery
What aspects in the history would you want to establish for pre-eclampsia?
Headaches
Visual changes
Swelling of the body
Abdominal pain
- especially RUQ
Bruising
- bruising due to platelet consumption
List the complications of pre-term prelabour rupture of the membranes:
Pre-term delivery
Chorioamnionitis
Cord prolapse
Oligohydramnios
Outline the definitions of PROM:
• Pre-labour rupture of membranes / PROM
- >37 weeks - rupture of membranes prior to onset of labour
P-PROM
- <37 weeks
- rupture of membrane prior to onset of labour
Accounts for 40% of preterm babies
What investigations should be done into suspected PROM:
Sterile speculum examination
- fluid build up in the posterior fornix of vagina
- patient should of been lying down for 30mins
- look for fluid
- do high vaginal swab whilst there
- check cervical dilation
Nitrazine paper test
- paper turns blue
Ultrasound testing
- oligohydramnios
High vaginal swab
- for infections that may have caused it
- Group B strep
Ferning test
What is the management of P-PROM?
<34 weeks:
- Monitor for chorioamnionitis
- prophylactic erythromycin for 10 days
- steroids
- if no labour after 48 hours discharge. Advise no tampons, no swimming, no sex.
- IV antibiotics at time of delivery
34- 36 weeks
- induction of labour
- IV antibiotics to cover for delivery
- steroids
> 36 weeks
- induction of labour
- IV antibiotics to cover for delivery
**IV antibiotics are Benzylpenicillin
What are some complications of P-PROM?
Chorioamnionitis
Oligohydramnios
Cord prolapse
Placental abruption
How can fetal wellbeing be assessed?
Measurement of fetal:
- head circumference
- Abdominal circumference
- Femur length
Liquor volume measurement
Doppler ultrasound of umbilical artery
During labour - what fetal signs would suggest distress on the CTG?
Abnormal Baseline HR (<100 or >180)
Reduced variability in the HR (<5 and >25) and no more than >50mins of no variability
Decelerations
- late deceleration
- placental insufficiency
- asphyxia
- variable deaccelerations
- early is fine
What are the short and long term consequences of intrauterine growth restriction?
Short:
- ARDS
- Hypothermia
- hypoglycaemia
- Low birth weight
Long:
- coronary artery disease
- T2DM
- Cerebral palsy
- Reduced intellect
Other than HR and Heart sounds, how else can a fetal wellbeing be monitored?
Liquor volume
umbilical artery doppler
MCA doppler
Estimated fetal weight
In a woman of child baring age who presents with amenorrhoea and bleeding, what important aspects of the history do you want to establish?
If she has had a positive pregnancy test
Abdominal pain (ectopic pregnancy?)
- type
- onset
Change in bowel habit (appendicitis/ G.I related?)
Previous history of pregnancies
What are your most important investigations when considering an ectopic pregnancy?
Urinary pregnancy test
FBC
Group and Save
hCG levels
TVS
What is the general management for a miscarriage?
Conservative management
Medical management: Misoprostol - prostaglandin agonist \+ Analgesia
Surgical management:
- Vacuum curette
What are the risks associated with a premature baby?
Respiratory distress syndrome
Hypothermia
Hypoglycaemia
Sepsis
Jaundice
Unable to suckle - may require NG
Intraventricular bleeding
What are some of the risk factors for IUGR?
Pre-eclampsia Smoking Alcohol Chromosomal abnormalities Poor maternal health Maternal infections - CMV, Rubella, Toxoplasmosis
What are some differentials for fluid leakage in a pregnant female?
Rupture of membranes (PROM/ PPROM) Vaginal secretions Cervical discharge Semen Perineal sweat
What score is used for post-natal depression?
Edinburgh score
What are some of the symptoms of post-natal depression?
Clouded thinking/ difficulty making decisions
Lack of concentration
Poor memory
Avoidance
Not feeling like a proper mother
What are some of the signs of post-partum psychosis?
Fear/ even terror Restlessness Insomnia Purposeless activity Fear for baby
What is the management of cord prolapse?
Recognise Condition:
- deaccelerations
- cord felt
**call for senior help
- Wrap cord in warm gauze and do not push back in or handle.
- place mother on all 4’s or modified sim’s position
and/ or - use to fingers to push babies head of cord
- deliver baby as fast as possible.
- if cervix is fully dilated proceed with use of tocolytic agents
- if cervix is closed C-section
What is the management of localised (stage I and II) endometrial cancer?
Open abdominal radical hysterectomy + Bilateral salpingo - oophorectomy
Out line the investigations wanted into amenorrhea:
Pregnancy test
Gonadotrophin levels - FSH/ LH
Prolactin
Androgen levels
Oestrogen
Thyroid levels
How often should an HIV patient have their cervical screening done?
Every year
What is the quantitative definition of heavy menstrual bleeding?
> 80mls
Which bacterial infection is most likely to produce malodorous smell with yellow/ green discharge? What other clinical finding may be seen with it?
Trichomonas vaginalis
Strawberry cervix
What are some differentials for PID?
Appendicitis
UTI
Ectopic pregnancy
List some differentials for gynaecological causes of pelvic pain:
Mittelschmerz syndrome
PID
Ectopic pregnancy
Endometriosis
Ovarian Abscess
Ovarian torsion
What are some complications of ovarian cysts?
Torsion
Haemorrhage
Rupture
What can be measured which is suggestive of early premature labour onset, and if positive what measures should be taken?
Fetal fibronectin - fFN
- released from fetal sac. Suggests early labour will come on
start:
- IM steroids
- Inform neonatal care
A woman who has epilepsy and gets pregnant - what should the management be?
5mg of folic acid starting immediately (even before confirmation of pregnancy)
Detailed US at 18-22 weeks
Aim for monotherapy of medication - if possible remove sodium valproate
Vitamin K analogue
+
IM Vitamin K to new born
How should IV magnesium be continued for following an eclampsia seizure?
24 hours
What is the antibiotic of choice for group B strep?
Benzylpenicillin
What are some key tests done during antenatal visits and on what weeks:
8-12 weeks - booking visit
- FBC
- Rhesus status
- Hep B, syphilis, rubella screen
- HIV
- Urine culture
10-14 weeks - multi pregnancy scan
11-14 week - nuchal scanning - down’s syndrome
18-20 week - anomaly scan
28 week - FBC, Anti D given
What are the indications to admit a patient with hyperemesis gravidum into hospital?
- unable to keep fluids down despite antiemetics
- ketonuria present
- Weight loss >5%
- Co - morbidities
- unable to keep antibiotics down
What is the criteria of hyperemesis gravidum?
5% pre-pregnancy weight loss dehydration electrolyte imbalance \+/- Ketones
What are some complications of hyperemesis gravidum?
Wernicke's encephalopathy Mallory Weiss tear central pontine myelinolysis AKI VTE*
If a mother has a history of DVT what should be started on and for how long?
LMWH
Start immediately - 6 weeks postpartum
What is the non-invasive test that can be done to test for chromosomal abnormalities?
Non - invasive prenatal screening test - NIPT
What signs may be seen on the anomaly scan for neural tube defects?
Frog like appearance - anencephaly
Banana shaped cerebellum
Spinal cord abnormalities
- spina bifida
Where anatomically are epidurals delivered? and what are spinals and epidurals used for?
Epidural:
- delivered into the potential space filled with fat and blood vessels between the ligamentum flavum and dura (first level of meninges)
Spinals into the intrathecal space (into CSF) causing complete nerve dysfunction - C-section.
Epidurals - epidural space causing predominantly nociceptive reduction - Labour
What are the risks with epidurals?
Prolonged second stage
Hypotension - patient should be laid flat and in the left lateral position
What are the two options for management during 3rd stage of labour and what are they?
Active
- use of uterotonics - syntrometrine
- cord traction
- delayed cord clamping
Physiological:
- no use of uterotonics
- cord only clamped when pulsations have stopped
- maternal effort of placenta
Inspection of the placenta to make sure it is complete.
Outline how the progression of labour is monitored:
Maternal:
- HR
- BP
- contractions
- Urinalysis
- 4hrly vagina examination (dilation, effacement)
Fetus:
- 15 mins HR
- position
- engagement degree (>2/5ths)
- Caput oedema (+,++,+++)
- moulding of the head
What is precipitate labour?
> 5 uterine contractions per 10mins
usually results in rapid labour of less than 2-3 hours.
*often implicated with oxytocin and prostaglandin use
What will a diabetic mother need to be put on if there is premature labour?
Variable rate insulin infusion (VRII).
- because steroids will be administered to promote fetal lung maturity which will effect the mothers glycaemic control.
What are some of the fetal complications of diabetes in pregnancy?
1st trimester congenital abnormalities
Macrosomia
Polyhdrymonias
Polycaethemia
How is a diagnosis of small for gestational age made?
and what are some main causes?
Ultrasound using circumference of the abdomen
- if <10% then diagnostic
- constitutionally small
- intrauterine growth restriction
- genetic abnormalities
- multiple pregnancy
How can IUGR vs conditionally small be differentiated?
Risk factors towards IGUR
Change in growth charts (IUGR may drop off whereas SGA usually remains on a constant low decile)
Umbilical artery doppler
What is the biggest risk factor for cord prolapse?
Artificial rupture of membranes
What is the first line drug used for PPH, following Bimanual uterine compression and how is it delivered?
Syntocinon - IV (synthetic oxytocin) 10 units
or
Ergometrine - IV
2nd line:
Carboprost - IM
If a synthetic prostaglandin has to be used in PPH, how is it supplied and what is it called?
Carboprost
- IM
If a pregnant woman has previously been seen to be group B strep positive, what action should be taken?
IV antibiotics at birth
or
Late pregnancy testing
If a mother has previously had a child that suffered from Group B sepsis they should be offered prophylactic antibiotics
Testing and antibiotics should be given 3-5 weeks prior to their due date.
What is the most appropriate next line investigation if there is late accelerations or variable accelerations noted on the CTG?
Fetal blood sample
- looking for acidosis - if present then Emergancy section should be done
What are the layers cut through during a C-section:
Skin
Subcut tissue
Camper’s fascia
Scarpers fascia
Anterior Rectus sheath
Rectus muscle
**this is usually cut at the linae alba and pushed to the side
Transverse fascia
Parietal peritoneum
Visceral peritoneum
Uterus muscle
What is a Omphalocele?
Fetal abdominal wall defect
What are the symptoms and management of chorioamnionitis?
Potentially fatal to both mother and fetus as infection enters a usually sterile environment.
- signs of infection
- malodours amniotic fluid secretions
Emergancy C - section
IV antibiotics
What are the clinical features of a misciarage? and highlight investigations:
Vaginal bleeding
Passing of products of conception
Cramping abdominal pain
Haemodynamic instability
Investigations: Bloods: - FBC - Group and save/ cross match - Beta - hCG
Imaging:
- TVS
What are some common minor aliments of pregnancy?
Nausea + vomiting
GORD
Constipation
Carpal tunnel syndrome
Oedema
Leg cramps
List the factors that influence fetal growth, highlighting some that may lead to small for gestational age:
Fetal:
- genetic
- chromosomal abnormalities
- fetal anomalies (can be caused by infections)
Maternal:
- pre-pregnant disease
- drugs/ smoking
- pregnancy disease (pre-eclampsia)
Placental:
- trophoblast invasion (pre-eclampsia if inaffective)
- vascular flow
How much can insulin doses need to increase by in pregnant women with diabetes?
and outline management of diabetes in pregnancy:
50 -100% as pregnancy continues.
- due to increased insulin resistance.
Antenatal care:
- Fetal anomaly scan - 20 weeks
- Education
- Monitoring of glucose + increased in insulin
- 32- 34 weeks fetal monitoring
Medication: - Diet and exercise 2nd line: - Metaformin \+/- - Insulin
Delivery:
- 37-39 week delivery
- variable rate insulin infusion during delivery
Managed by:
- diabetic team
- anenatal team
Define gravity and parity:
Gravity - number of times the mother has been pregnancy regardless of outcome
Parity - (X+Y)
X - Any live or still birth >24 weeks
Y - Any pregnancy <24 weeks
List some indications for CTG antenatal monitoring:
Reduced fetal movement
Maternal disease
- hypothyroidism
- CRD
- DM - insulin dependent
Polyhydramnious/ oligo
what investigations should be conducted into reduced fetal movement and the varying weeks?
<26 weeks
- History
- Examination
- Auscultating HR
> 26 weeks
- History
- Examination
- CTG
- USS
- if near term plan for delivery
Highlight the potential complications of a prolonged pregnancy:
Prolonged pregnancy >42 weeks
- Placenta insufficiency
- Meconium aspiration
- Cord complication
- Neonatal hypoglycaemia
- C-section
- Pelvic floor trauma
- Instrumental delivery
What are the types of invasive implantation?
Accreta: penetration into myometrium but not full thickness
Increta: penetrate through the entire myometrium
Percreta: penetrate through the entire uterus and into surrounding organs
