Obstetrics 3 Flashcards
How is intrauterine growth restriction measured?
Asymmetrical intrauterine fetal growth - measured in 2 weekly separations
Low amniotic fluid index score
Umbilical artery flow
What features on CTG are seen on intrauterine growth restriction?
Absent accelerations
decreased baseline variability
shallow decelerations
What needs to be monitored during/ after administration of MgS04- in eclampsia?
15mins:
- blood pressure
- respiratory rate
Hourly sp02
Patella reflexes
Temperature
Urine output
What are some of the immediate side effects the mother may expereince with administration of MgS04-?
Feeling of impeding doom
Facial flushing
Heat traveling up arm
Metallic taste
N&V
What drug is given to reverse MgS04 toxicity?
Calcium gluconate
Which drug should not be used in the 3rd stage labour management for patients with pre-eclampsia?
Ergometrine
- i.e. syntometrine
List 4 indications for a forceps delivery:
Fetal distress during 2nd stage of delivery
Maternal distress during 2nd stage of delivery
Failure to progress
Control of head during a breech delivery
When should Anti-D immunoglobulin be given immediately?
Delivery of Rh + alive or still born
Any termination of pregnancy
Miscarriage >12 weeks
Surgical management of an ectopic
External cephalic rotation
Amniocentesis
*and in obstetric emergencies
What does the AFP do in Down’s syndrome and neural tube defects?
High in Neural tube defects
Low in Down Syndrome
What is the major cause of cord prolapse?
Artificial rupture of membranes
When are twins delivered and why is there different monitoring processes for them?
DCDA: 37 weeks
MCMA: 36 weeks
*if the first is cephalic presenting then vaginal delivering may be possible.
Different monitoring is used to prevent confusion/ or the same twin being monitored twice.
- CTG
- Fetal scalp electrode
A cord sample is taken and the cord blood is low in oxygen but the pH is normal, why is this?
it is normal for the fetus to undergo times of hypoxia, especially during birth. it adapts. this is through:
- increase O2 extraction (fetal Hb)
- redistribution of blood
- increased anaerobic metabolism (this is usually more severe)
What are some of the risk factors and signs of a uterine rupture?
Risk factors:
- previous C section
- Vaginal birth after C section
- previous uterine surgery
- Multiparity
- use of oxytocin
- RTA
Signs:
- abdominal pain not related to contractions
- ceasing of uterine contractions
- shoulder tip pain
- pain over uterine scar
- Shock
- palpable fetus in the abdomen
- fetal distress
- loss of station and/or presenting part
In uterus inversion how should it be managed?
Resuscitation
- 4 units cross matched
Manual or hydrostatic can be used.
Manual
- push uterus back up and hold with fist and hold it there to allow uterus to constrict around it
Hydrostatic
- inflating the uterus with fluid to compress it back into shape
Surgical:
- laparotomy to stitch the uterus back into position
**do not remove placenta.
What are the major causes of secondary PPH and how should they women be managed?
secondary: 24hours - 12weeks.
Endometritis
Retained products of conception
- High vaginal swap + Antibiotics + admit
- US of uterus for retained products
What are the main postpartum care for women?
7 B’s
- Breastfeeding
- Bladder - urine retention (within 6 hours)
- Bowel (constipation, iron tablets)
- Bleeding (secondary PPH)
- Bottom - pain from tears etc
- Birth control
What are the three main factors are associated with placental abruption?
Trauma
Multiparity
Increased maternal age
How should placental abruption be managed?
- Senior obstetrician, midwife and anaesthetist
- Blood products + Fluid
- CTG monitoring of fetus and careful monitoring of mother
- Anti - D prophylaxis (determined by Keilhauer test)
+/- Steroids and magnesium sulphate
+/- emergency C section
*active 3rd stage management as there is a high risk of PPH
What can be the complications of placental abruption?
Hypovolemic shock
Sheehan syndrome
AKI
DIC
Fetal:
- intrauterine death
- intrauterine hypoxia - cerebral palsy
What test is conducted to asses the dose of anti-D prophylaxis needed?
Keilhauer test
What is used to assess the progress of the of labour?
Partogram
- cervical dilation *recorded very 4 hours
- Decent of fetal head
- Maternal BP, HR
- Fetal HR
- contractions
How often are uterine contractions measured and what would 2/10 mean?
every 10 mins
Means 2 contractions every 10mins
What are definitions for the delay in 3rd stage?
30mins - active management
60mins - physiological management
What are the main options for the management of failure to progress?
Artificial rupture of membrane (if membranes still intact)
Oxytocin infusion
Instrumental delivery
C- section
What are the values for preterm babies?
<37 weeks preterm
32- 37 weeks - moderate to late preterm
28-32 weeks - very preterm
<28 weeks - Extreme preterm
What prophylactic options are there for prevent preterm?
Progesterone pessary
- offered to those with a cervix <25mm length at 24 weeks
Cervical cerclage
- offered to those with a cervix <25mm length at 24 weeks
What is the diagnostic investigation and management of pre-term labour?
Fetal fibronectin
- the glue between the cervix and chorion
Management:
- CTG monitoring
- Nifedipine (tocolytic)
- Maternal steroids
- Magnesium sulphate
- Antibiotics
Delivery:
- Delayed cord clamping
In PROM, PPROM and preterm labour when examining what is a very important point:
Sterile speculum examination
- prevent introducing infection tracking up causing Chorioamnionitis
Which are more effective at achieving vaginal delivery within 24 hours, PG’s vaginally or Syntocinon?
Vaginal PG’s are more effective at achieving vaginal delivery within 24 hours
What is the most common type of breech presentation?
Frank
- hips flexed and legs extended
How does polyhydramonis and oligodramonis related to breech presentation?
Both can cause breech:
Poly = more room to move
Oligo = if it gets stuck its unable to turn
What is are the complete contraindications to External cephalic version?
Rupture of the membranes
Placenta previa
Recent antepartum haemorrhage
Major uterine abnormalities
- uterine fibroids
In order for an instrumental delivery what needs to be in place?
An empty bladder
Adequate analgesia
Ruptured membranes
Cervix fully dilated
What type of delivery should be avoided in very-preterm babies and why?
Use of ventouse
- it can cause large haematomoas and head deformities
Which STI testing is not routinely done at booking appointment?
Chlamydia testing
- may be done in <25 year olds
When does obstetric cholestasis usually present?
> 30 weeks
*women who have cholestasis are usually recommended for delivery at 37
Which has a higher risk of miscarriage CVS or Amniocentesis?
CVS
- it can be carried out at 10 weeks as opposed to 15 weeks but carriers a higher risk of miscarriage
Why might polyhydramnios indicated rhesus isoimmunisation?
Fetal hydrops through destruction of the RBCs
When is Anti D prophylactically given?
28 weeks and 34 weeks
At the initial appointment what examination and investigations are usually undertaken?
Examination:
- BP
- HR
- BMI
- Urine sample
Investigations:
- FBC (anaemia, thrombocytopenia)
- Blood group - ABO, Rh
- Rubella status
- Hb Electrophoresis
- Hepatitis B status
- Syphilis screen
- HIV status
What are the benefits of skin to skin contact of the baby and the mother following birth?
Calms baby
Releases oxytocin in mother:
- aids contraction of the uterus
- Stimulates lactation
If a pregnant women is >20 weeks pregnancy and exposed to chickenpox and develops the rash within 24 hours which drug should be administered?
Aciclovir
*note this is different from exposure to actually having it in which VZV immunoglobulin is of no use
She also needs to be seen by a specialist
What is the dose of folic acid that should be administered for pregnant mothers on anti-epileptic medication and obese >30BMI?
5mg
At which point would lochia require further investigation?
> 6 weeks
What are the targets for gestational diabetes and what should be offered if not met?
Fasting: <5.3mmol.
1 hour after meal: <7.8mmol
or
2 hours after meal: <6.4mmol
If over a management of diet and exercise should be done, if this doesn’t correct in 1-2 weeks then:
- metformin
if still not adjusted after 1-2 weeks then:
- insulin
If >7mmol fasting at diagnosis then insulin
If there is late deaccelerations on the CTG what would your next line of management be?
Fetal blood sampling
- to assess for acidosis.
- if <7.2 then induction is needed
What is a syndrome which can occur with the thyroid following pregnancy?
Post-partum thyroiditis.
- initially hypothyroidism followed by hypothyroidism.
Treated with propranolol
Which skin pathology in pregnancy can cause bullae and does not spare the umbilicus? name severe complications associated with it.
Pemphigoid Gestationis
complications:
- Premature delivery
- fetal restriction
- transient blistering of child
What is the definitive management for a prolapsed cord?
After calling for help and placing the mother into appropriate positions (Modified Sims, all fours) the definitive management of:
- delivery.
C- section with tocolytic agents to stop contractions if cervix is closed
Assisted vaginal delivery if closed
At what stage do you refer if no fetal movements have been observed?
24 weeks
Name a diagnostic test that can be done to diagnose PPROM:
On speculum examination test for:
- Insulin like growth factor - Binding protein
Define G+P
G is how many pregnancies <24 weeks
P is how many over 24 weeks regardless of outcomes.
**If a woman has 2 children, has had 2 miscarriages and she is currently pregnant at 33 weeks she is:
G5 P2
**if a woman is pregnant for first time at 33 weeks she is:
G1 P0
What is the management for a miscarriage?
If stable and <12 weeks:
- conservative (let the POC pass themselves)
Medical:
- Misoprostol *vaginally or orally
- Analgesia + Antiemetics
*mifepristone is not routinely given in UK
Surgical:
- manual vacuum aspiration (LA)
- Electrical vacuum aspiration (GA)
*surgical is done is hemodynamical unstable or infection
**if surgery or >12 weeks anti-D should be given
Small for gestational age can be broadly broken down into what? and what is one of these subheading further divided into and reflect on time scales relating to it:
In the <10% centile
- Constitutionally small
- IUGR
IGUR is further broken down into:
- Placental causes (pre-eclampsia, Maternal health)
- Non placental causes (chromosomal abnormalities, inborn errors, fetal infections)
IGUR can also be thought of in terms of late and early onset.
Early tends to be symmetrically small and more related to non-placental causes
Late tends to be asymmetrical and more related to placental causes
How is SGA monitored?
Serial growth scans
Umbilical artery doppler
Amniotic fluid index
Maternal assessment can also be carried out:
- BP
- Urine dip
- Infection screen (TORCH)
Genetic testing may also be carried out
