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Phase 3a > Obstetrics 2 - Pregnancy Problems 1 > Flashcards

Obstetrics 2 - Pregnancy Problems 1 Flashcards

1
Q

Define malpresentation

A

Any presentation other than a vertex lying in close proximity to the internal os of the cervix

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2
Q

Give three causes of malpresentation

A 
Multiparity
Prematurity
Multiple pregnancy
Macrosomia
Polyhydramnios
Placenta praevia
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3
Q

What is brow presentation?

A

Head occupies a position between full flexion (vertex) and full extension (face)

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4
Q

What is the management of brow presentation?

A

Diagnosis via VE
May revert to face/vertex
Vaginal delivery not possible - CS if it persists

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5
Q

What causes face presentation?

A

Hyperextension of the foetal neck

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6
Q

What are the two types of face presentation?

A

Mentoanterior and mentoposterior

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7
Q

What is the management of face presentation?

A

Mentoposterior - CS

Mentoanterior - head can flex to allow vaginal birth, if not then CS

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8
Q

What is cord/funic presentation?

A

One or more loops of cord lie below the presenting part with membranes still intact

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9
Q

What indicates cord presentation on the CTG?

A

Persistent variable decelerations

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10
Q

What is contraindicated in cord presentation and why?

A

Artificial rupture of membranes will cause cord prolapse

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11
Q

What is abnormal lie?

A

The axis of the foetus is across the axis of the uterus

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12
Q

What is unstable lie?

A

Lie changes several times a day, variable presentation

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13
Q

What are the causes of abnormal lie?

A

Multiparity, multiple pregnancy, polyhydramnios, placenta praevia, fibroids

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14
Q

What are the risks of abnormal lie?

A

Obstructed labour

Uterine rupture

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15
Q

What is the management of abnormal lie?

A

Unstable lie - CS at 41 weeks
Stable abnormal lie - CS at 39w
May revert - common before term but only 1% foetus after 37 weeks

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16
Q

What is breech presentation?

A

Baby’s buttocks lie over the maternal pelvis and head is in the fundus

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17
Q

Give three causes of breech presentation

A 
Idiopathic
Preterm delivery
Previous history of breech delivery
Fibroids
Placenta praevia
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18
Q

What are the three types of breech presentation?

A

Extended, flexed, footling

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19
Q

What is the management of breech presentation?

A 
External cephalic version
Caesarian section (esp. if footling)
Vaginal birth (without oxytocin) only if foetal weight <4kg, no foetal compromise, extended breech, spontaneous labour
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20
Q

What is the name of the condition where the placenta is inserted into the lower segment of the uterus?

A

Placenta praevia

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21
Q

How does placenta praevia present?

A

10% asymptomatic
70% painless APH
20% APH associated with contractions

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22
Q

What are the risk factors for placenta praevia?

A

Previous PP
Increased maternal age
Multiparity/multiple pregnancy
CS

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23
Q

What grade of placenta praevia is a placenta that partially covers the internal cervical os?

A

Partial

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24
Q

What is the difference between minor (marginal) (grade I or II) and major (grade III or IV) placenta praevia?

A

Minor - placenta lies close to cervical os

Major - placenta completely covers the cervical os

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25
How is placenta praevia diagnosed?
Transvaginal ultrasound
26
What is the management of placenta praevia diagnosed in the 2nd trimester?
Repeat ultrasound at 30-32 weeks as PP can resolve with development of the lower uterine segment
27
What is the management of a patient with a major placenta praevia, who is experiencing some bleeding?
Admit from 34 weeks and determine foetal lung maturity with amniocentesis CS if lungs are mature
28
What occurs when the placenta completely separates from the uterus before delivery of the foetus?
Placental abruption
29
How does placental abruption present?
``` Severe constant abdominal pain Woody tender uterus 50% in labour Dark bleeding Maternal shock and hypovolaemia ```
30
What are the risk factors for placental abruption?
``` Maternal hypertension Previous abruption IVF pregnancy Short umbilical cord Polyhydramnios ```
31
Why may the extent of bleeding in placental abruption be greater than apparent loss?
Concealed haemorrhage (20%) - blood goes upwards towards the fundus
32
What is the management of placental abruption?
AB: high flow oxygen C: IV access, FBC, coagulation screen, U&E, Kleihauer test, Crossmatch 4 units. Left lateral position. Until blood is available: 2L warmed crystalloid Hartmann's or 1-2L colloid. Up to 4 units FFP and 10 units cryoprecipitate D: Alive foetus: Caesarian
33
What is the most common cause of DIC in pregnancy?
Placental abruption
34
What is the main complication of placental abruption?
Foetal hypoxia/neurological impairment and death
35
Define retained placenta.
Placenta not delivered within 30 minutes of active management or 1 hour of physiological management
36
What are three causes of retained placenta?
Trapped behind closed cervix, placenta adherens, partial placenta accreta
37
What is the management of retained placenta?
Revert to active management Empty bladder Rub uterus and VE to see if placenta has detached Manual removal followed by IV and IM ergometrine
38
What indicates placental separation in the third stage of labour?
Sudden rush of blood, fundus moves higher and becomes more rounded, increased length of cord visible.
39
Name three placental conditions which increase the likelihood of retained placenta.
Succenturiate lobe, bipartite placenta, placenta membranacea
40
What is placenta accreta?
Chorionic villi are attached to the myometrium
41
What is placenta increta?
Chorionic villa have invaded the myometrium
42
What is placenta percreta?
Chorionic villi pass through the myometrium up to the serosa/peritoneum
43
What is Nitabuch's layer?
Fibrinoid deposits that occur between the compact and spongy layer of decidua basalis. Incomplete development in placenta accreta.
44
What is the management of severe haemorrhage in a woman with placenta accreta?
ABCDE. Replace blood, tamponade with balloon, hysterectomy
45
What is the management of minimal haemorrhage in a woman with placenta accreta?
Uterine artery embolization, elective hysterectomy
46
Define primary postpartum haemorrhage
Blood loss >500ml from the genital tract within 24 of delivery (or >1000ml after CS)
47
Define secondary post-partum haemorrhage
"excessive blood loss" between 24h and 12w after delivery
48
What is the most common cause of PPH?
Uterine atony
49
Apart from uterine atony, give three causes of PPH
``` Genital tract trauma Retained placenta Abnormal placenta site Uterine inversion/rupture DIC ```
50
What are three risk factors for uterine atony?
Vitamin D deficiency Prolonged labour Overdistension of the uterus - multiple pregnancy, polyhydramnios, macrosomia
51
What is the most likely cause of secondary PPH?
Disruption of placental site scab/placenta fragments | Subinvolution of the uterus
52
What is uterine atony?
Failure of the uterus to contract after placental separation, allowing bleeding to occur from myometrial spiral arterioles and decidual veins
53
What peptide is released in uterine atony to cause uterine relaxation?
Parathyroid hormone-related peptide
54
How do you prevent PPH?
Vaginal delivery: 5-10IU IM oxytocin Caesarian: IV oxytocin for 6h Inspect vagina and perineum for lacerations Assess placenta for missing cotyledons
55
What is the treatment of PPH?
Resuscitation with ABCDE approach. 2x14 gauge cannulae, cross match 4 units, blood transfusion (2L warmed crystalloid Hartmann's +/- 1-2L colloid whilst waiting) If uterine atony, the following in order: Bimanual uterine compression Slow IV Oxytocin 5IU Slow IV or IM ergometrine 0.5mg IM carboprost 0.25mg (repeat up to 8 doses) PR misoprostol Balloon tamponade/B-lynch suture/bilateral ligation of uterine or internal iliac arteries
56
Why might a woman choose home birth?
Familiar setting Fear of hospitals More family members
57
What are the risks of home birth?
If a complication arises, transfer to hospital is advisable but may be delayed, which can lead to intrapartum foetal hypoxia or PPH.
58
What is an anomaly scan?
Detailed ultrasound scan at 20 weeks
59
Define antepartum haemorrhage
Bleeding from the genital tract <24 weeks, before the onset of labour
60
What is the main cause of antepartum haemorrhage?
97% unexplained, usually minor placental abruption | Other - PP, infection, trauma, varicosities
61
True or false, APH is painless
False - can be painful or painless
62
What is the management of APH?
Estimate amount of blood loss and combine with signs of clinical shock Resuscitation if necessary If rhesus negative give 500IU anti-D Ig Determine local causes of bleeding/if membranes have ruptured with VE Exclude placenta praevia with TVUSS Mother's life should take priority but foetal distress = delivery regardless of gestational age
63
Why do pregnant women experience more constipation and heartburn?
Increased progesterone levels causes the relaxation of the gastro-oesophageal sphincter and bowel smooth muscle
64
What is the cause of backache in pregnancy?
Hormonal softening of ligaments and altered posture due to weight of uterus
65
How is maternal blood pressure affected by pregnancy?
BP decreases in early pregnancy due to decreased vascular resistance By 24 weeks, BP increases because of increased stroke volume
66
What is important to exclude in a pregnant woman with a rash?
Obstetric cholestasis
67
Why do pregnant women experience urinary frequency in the first trimester?
Increased GFR and uterus pressing on bladder
68
What causes increased vaginal discharge (white/clear) in pregnancy?
Increased blood flow to the vagina and cervix
69
What is important to be excluded in a pregnant woman with vaginal discharge?
``` Ruptured membranes (would be watery) STI/candidiasis (increased chance of PROM and preterm birth) ```
70
What is pre-eclampsia?
New onset hypertension in pregnancy
71
What is the diagnostic criteria for pre-eclampsia?
BP>140/90 >300mg proteinuria over 24h collection If already hypertensive, then rise of 30/15 (either/or)
72
What are three risk factors for pre-eclampsia?
``` Previous severe or early onset PREC Extremes of maternal age FH Obesity Primiparity Pre-existing HTN/DM/renal disease ```
73
What is the clinical presentation of pre-eclampsia?
Frontal headache, visual disturbance, facial oedema, RUQ pain, nausea, vomiting
74
What would the biochemistry be of a newly diagnosed pre-eclamptic lady?
Prolonged PT and APTT Increased urate, urea, creatinine, transaminases, LDH Haemoconcentration, thrombocytopenia, anaemia
75
How do you prevent pre-eclampsia in subsequent pregnancies?
Lose dose aspirin (75mg OD PO) from 12 weeks
76
What investigation is predictive of early onset or severe pre-eclampsia?
Uterine artery dopplers
77
Detail the monitoring of a mild pre-eclamptic lady.
Monitor BP four times a day | Twice weekly bloods for FBC, electrolytes, renal function, and LFTs
78
What are indications for immediate delivery in a pre-eclamptic lady?
Worsening liver/renal function, severe maternal symptoms, foetal distress, HELLP syndrome, eclampsia
79
At what point would you initiate anti-hypertensive medication in pre-eclampsia?
BP>160/110 (either/or)
80
What medication would you prescribe in severe pre-eclampsia?
IV or PO labetalol IV hydralazine PO nifedipine IM betamethasone if 24-34 weeks and delivery suspected within 7 days
81
What are the complications of pre-eclampsia?
``` DIC Eclampsia HELLP syndrome Cerebral haemorrhage Renal failure Placental abruption ```
82
What are the components of HELLP syndrome?
Haemolysis Elevated Liver enzymes Low Platelets
83
What is eclampsia?
The presence of new-onset grand mal seizures in a woman with pre-eclampsia
84
What are the risk factor for development of eclampsia?
Very severe pre-eclampsia, large placenta, HTN/DM, extremes of age, twins
85
When can seizures occur in eclampsia?
Antenatally, intrapartum, and postpartum
86
What other cerebral signs may be present in eclampsia?
Nausea Vomiting Headaches Cortical blindness and other visual disturbance
87
What are the complications of eclampsia?
Foetal bradycardia IUGR Pulmonary oedema/aspiration HELLP syndrome
88
Detail pharmacological stabilization of a eclamptic seizure.
IV magnesium sulfate: 4g loading dose, then maintenance dose of 1g/hour for 24h after the last seizure
89
What are signs of magnesium toxicity and how would you treat this?
Decreased tendon reflexes, respiratory depression | Calcium gluconate
90
How is eclampsia completely resolved?
Delivery once hypoxia is corrected, seizures are controlled, and BP is reduced to x/90-100
91
What is a risk factor for fraternal/dizygotic twins?
Assisted reproduction - clomiphene, IVF
92
At what point has a DCDA embryo cleaved?
0-72 hours
93
Cleavage of an embryo at 4-8 days produces what kind of twins?
MCDA
94
MCMA twins cleave at 9-12 days. What is a complication of this pregnancy?
Cord entanglement
95
How is multiple pregnancy diagnosed?
2 foetal heart rates Hypermesis gravidarum Large uterus for dates 3+ foetal poles palpable >24 weeks
96
When is multiple pregnancy most commonly diagnosed?
1st trimester
97
What are three intrapartum risks of multiple pregnancy?
Malpresentation Foetal distress of 2nd twin TTTS Cord entanglement if MCMA
98
Detail the monitoring in a multiple pregnancy
Detailed anomaly scan Serial growth scans at 28, 32, 36 weeks Establish presentation of leading twin by 34w More intensive surveillance if MCMA or higher multiples
99
What are three foetal risks of multiple pregnancy?
Neural tube defects/cerebral palsy IUGR Preterm labour Stillbirth
100
What are three maternal risks of multiple pregnancy?
``` Hyperemesis gravidarum Pre-eclampsia Anaemia APH/PPH Operative delivery Gestational diabetes ```
101
What is the pathophysiology of twin-to-twin transfusion syndrome?
Presence of unbalanced anastomoses in placenta | Redistribution of foetal blood
102
What is the clinical presentation of the recipient twin in TTTS?
``` Polycythaemia Hypervolaemia Cardiomegaly Polyhydramnios Foetal hydrops Hypertension ```
103
What is the clinical presentation of the donor twin in TTTS?
Anaemia Hypovolaemia Oligohydramnios IUGR
104
How is TTTS diagnosed?
Ultrasound - small twin and large twin
105
What is the main treatment of TTTS?
Laser ablation of the placental anastomoses | Serial amnioreduction for symptomatic relief
106
What is round ligament pain?
Bilateral pain from stretching of the round ligaments Aggravated by movement Radiates to groin 1st and 2nd trimester
107
What occurs to uterine fibroids if present during the 12-22nd week of pregnancy?
Red degeneration - constant pain localised to fibroid due to increasing size
108
How is red degeneration of fibroids diagnosed?
Ultrasound to identify fibroids | FBC - leucocytosis
109
When is surgical termination of pregnancy (TOP) appropriate?
Any gestation
110
What must occur before surgical TOP?
Cervical preparation with PV/SL 400mcg misoprostol
111
What are the methods of surgical TOP?
<14w: vacuum aspiration | 14-24w: dilatation and evacuation
112
What are the complications of TOP?
``` Bleeding Genital tract infection Uterine perforation if surgical Failed TOP Retained products of conception ```
113
What is miscarriage?
The expulsion or removal of a pregnancy at a stage when it is incapable of independent survival Includes all losses before 24 weeks, majority are before 12 weeks
114
What is a common cause of miscarriage?
Abnormal foetal development | Placental failure
115
What is the most common presentation of miscarriage?
PV bleed, severe pain Products of conception may be seen Shock
116
How is miscarriage diagnosed?
TVUSS Serum hCG | Presence of cardiac activity AND CRL>7mm or gestational sac >25mm
117
What are the signs of threatened miscarriage?
Bleeding and abdo pain, closed cervix
118
What are the signs of incomplete miscarriage?
Bleeding, POC, pain, open cervix
119
What are the signs of inevitable miscarriage?
Bleeding, pain, open cervix
120
What are the signs of complete miscarriage?
Bleeding and pain cease, closed cervix
121
What are the signs of missed miscarriage?
Bleeding, pain, closed cervix
122
When is anti-D given in miscarriage?
Surgical management of a miscarriage over 12 weeks
123
Which types of miscarriage require surgical or expectant management?
Incomplete, missed
124
What is surgical management of miscarriage?
Manual vacuum aspiration under LA, or | ERPC - evacuation of retained products of conception under GA
125
When is expectant management of miscarriage appropriate?
Minimal bleeding, ruptured sac
126
What is medical management of miscarriage?
PV misoprostol | Expect <3w bleeding is reasonable
127
Give three causes of recurrent miscarriage
``` Fibroids Anti-phospholipid syndrome Foetal chromosomal abnormalities Cervical weakness Thrombophilia ```
128
How is recurrent miscarriage investigated?
``` Parental blood for karyotyping Cytogenic analysis of POC Pelvic US Thrombophilia screening LA or aCL antibodies ```
129
What is the treatment of anti-phospholipid syndrome?
Aspirin and heparin
130
What level of fasting venous plasma glucose is required for a diagnosis of diabetes?
>7.0mmol/L
131
Which trimester does diabetes usually occur in pregnancy?
2nd
132
Detail the initial management of a woman with PPH
ABC Uterine massage Syntocinon/ergometrine/carboprost
133
Chorioamnionitis is suspected in women with PPROM and what triad?
Maternal pyrexia Maternal tachycardia Foetal tachycardia
134
What is the management of chorioamnionitis?
IV antibiotics and immediate Caesarian section
135
In what situations are oxytocin and prostaglandin contraindicated?
Foetal distress/bradycardia
136
In what situation is the MMR vaccine given in the first trimester?
If the mother is non-immune
137
Which is the most dangerous type of breech presentation?
Footling | 5-20% risk of prolapse
138
What are the two types of emergency contraception?
Ella One (ulipristal acetate) - within 120 hours of UPSI Levonelle - within 72 hours of UPSI IUD - within 120 hours
139
What is the biggest risk factor for a baby to develop group B strep infection?
Mother had a previous baby with GBS growth
140
What is the management of a woman with previous baby with Group B Strep growth?
Intrapartum antibiotics
141
What are the risks of a type 1 diabetic woman with premature labour?
Corticosteroids can cause hyperglycaemia, but they are not contraindicated
142
Which drug inhibits prolactin production in breastfeeding cessation?
Cabergoline (dopamine receptor agonist)
143
What secretes HCG?
Syncytiotrophoblasts
144
When is HCG detecting in maternal blood?
Day 8 after fertilisation
145
When is ECV offered to woman with breech presentation?
Nulliparous - 36 weeks | Multiparous - 37 weeks
146
What is seen on TVUSS in ectopic pregnancy?
Empty uterus | Free fluid in adnexae/pouch of douglas
147
What is the best management of a patient with threatened miscarriage?
Watchful waiting
148
In what condition are brisk tendon reflexes seen?
Pre-eclampsia
149
Where is the most common site of ectopic pregnancy?
Ampulla of fallopian tube
150
When should an ultrasound be requested if lochia is persisting?
After 6 weeks
151
What is the most common cause of severe early onset (before 7 days) infection in neonates?
Group B strep sepsis
152
What is false labour?
Braxton-Hicks contractions Lower abdo pain in last 4 weeks of pregnancy Irregular
153
A pregnant lady has come into close contact with a child with chickenpox, and is not sure if she has had chickenpox before. What is the management?
Check for non-immunity - VZV antibodies Give VZIG within 10 days of the exposure Give acyclovir if rash begins Varicella vaccine contraindicated in pregnancy as it is a live vaccine
154
Which type of ectopic pregnancy is associated with an increased risk of rupture?
Isthmus
155
What is first line antibiotic for mastitis?
Flucloxacillin
156
When are antibiotics indicated in mastitis?
Systemically unwell Milk culture positive Nipple fissure Symptoms do not improve after 12-24 hours of milk removal
157
When is expectant management of an ectopic pregnancy contraindicated?
``` Abdominal pain bHCG>200IU Rupture Cardiac activity Foetal pole>30mm ```
158
What is Asherman's syndrome?
Intrauterine adhesions Commonly after dilatation and curettage after miscarriage Causes amenorrhoea
159
What are the contraindications of ergometrine and carboprost?
Erg: hypertension Carb: Asthma
160
How is APH classified?
Minor: blood loss<50ml and stopped Major: 50-1000ml, no shock Massive: >1000ml and/or shock
161
Define uterine hyperstimulation.
A series of single uterine contractions lasting 2 minutes or more, or a contraction frequency of five or more in 10 minutes.
162
What is the medical method of TOP?
200mg PO mifepristone followed by misoprostol 24-48h later

Phase 3a (18 decks)

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