Obstetrics 3 - Pregnancy Problems 2 Flashcards by Lucy Searle

What are risk factors for ectopic pregnancy?

Endometriosis
IUCD
Assisted conception
Smoking
PID

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Define ectopic pregnancy

Implantation of a conceptus outside the uterine cavity

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What are the symptoms of ectopic pregnancy?

Amenorrhoea
Abdo pain
Small brown PV bleed
Collapse if ruptured

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How is ectopic pregnancy diagnosed?

TVUS
Serum progesterone <20nmol/L (failing pregnancy)
Serum HCG rise less than 66%
Laparoscopy

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What are the requirements for expectant management of ectopic pregnancy?

Clinically stable
Asymptomatic
Falling HCG

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Detail medical management of ectopic pregnancy

IM methotrexate 50mg/m2

Anti-D if Rhesus negative

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How would you surgically treat ectopic pregnancy?

Laparoscopy

Salpingectomy unless other risk factors for infertility - salpingotomy

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What are the risk factors for hyperemesis gravidarum?

Primiparity
Hyatidiform mole
Younger or obese women
Previous history
Multiple pregnancies

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How is a patient with hyperemesis gravidarum managed?

Admit if not tolerating oral fluids
IV fluids, nutritional support, thiamine supplements
Daily UEs (replace potassium)
NBM 24 hours, then light diet
1st line: promethazine or cyclizine
2nd line: metoclopramide, prochlorperazine, ondansetron

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What are the complications of hyperemesis gravidarum?

Thiamine deficiency, liver failure

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Which syndrome is trisomy 13?

Patau syndrome

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What are the characteristics of Patau syndrome?

Cyclopia, microcephaly, severe LD, congenital abnormalities

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What is foetal hydrops?

Accumulation of serous fluid in 2+ foetal compartments

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Name some non-immune causes of foetal hydrops

Severe anaemia from G6PD deficiency
Cardiac abnormalities
Trisomies
TTTS

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What is the pathophysiology behind foetal hydrops?

Obstructed lymphatic flow leads to decreased plasma oncotic pressure

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How is foetal anaemia diagnosed?

Ultrasound, peak systolic velocity in MCA, foetal blood sampling

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How is non-immune hydrops treated?

Amniocentesis if severe polyhydramnios
Treat cause
3rd trimester - delivery

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What is immune hydrops?

Maternal antibody response against foetal red blood cells (if blood types don’t match)

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What is the consequence of immune hydrops?

Haemolytic anaemia, jaundice/high-output cardiac failure, foetal hydrops, death

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Give three sensitizing events for Rhesus disease

Ectopic pregnancy
ECV
Delivery

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How is immune hydrops treated?

Irradiated Rh-negative packed red cells transfused into umbilical vein at cord insertion/hepatic vein
(umbilical vein transfusion)

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How is immune hydrops prevented?

Anti-D given if Rhesus negative at 28w, 34w, and within 72 hours of sensitizing event.

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What is reduced amniotic fluid volume?

Oligohydramnios

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Give three causes of oligohydramnios

IUGR
PROM
Pre-eclampsia
Utero-placental insufficiency

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What is amniotic fluid index?

Total volume of the deepest pools in the 4 quadrants of the uterus

Define low AFI

<8cm (deepest pool <2cm)

How would you manage SROM before 37 weeks?

Prophylactic PO erythromycin | Daily CTGs

How would you manage SROM after 37 weeks

Induce labour

Define polyhydramnios in terms of AFI

>24cm (deepest pool >8cm)

Give three causes of polyhydramnios

Foetal hydrops TTTS Foetal GI tract obstruction (can't swallow) e.g. duodenal atresia

What are the complications of polyhydramnios?

``` Malpresentation Preterm delivery (uterine stretch) ```

What is intrauterine growth restriction?

The foetus is pathologically small

What factors affect growth and birth weight?

``` Maternal height more than paternal height Maternal weight Parity Ethnic origin Gender of foetus ```

What are the commonest causes of IUGR?

Uteroplacental insufficiency Congenital conditions Maternal chronic disease

What are the two types of IUGR?

Symmetric: entire body, early onset, chromosomal abnormalities Asymmetric: head sparing effect, UPI.

What are the complications of IUGR?

Meconium aspiration Childhood attention and learning deficits Stillbirth Emergency CS

What measurement is used for monitoring of foetal growth?

Symphysis fundal height

What does increased resistance in umbilical artery found on Doppler investigation indicate?

Placental failure

What does increased resistance in uterine artery found on Doppler investigation indicate?

High risk of developing pre-eclampsia

What patients usually get acute fatty liver of pregnancy?

Obese women in 3rd trimester

How is AFLP managed?

``` Treat hypoglycaemia Correct coagulopathy with IV vitamin K and FFP Control BP Delivery after stabilization Then treat liver and renal failure ```

What does maternal hyperglycaemia lead to?

Foetal hyperglycaemia --> hyperinsulinaemia --> beta-cell hyperplasia --> macrosomia Foetal polyuria = polyhydramnios

What are three neonatal complications of diabetes?

Jaundice Shoulder dystocia Polycythaemia Hypoglycaemia/hypocalcaemia/hypomagnesaemia

What is the effect of pregnancy on pre-existing diabetes?

Increased risk of ketoacidosis, retinopathy, nephropathy, pre-eclampsia, and IHD.

How is a diabetic mother monitored in labour?

Continuous EFM IV insulin sliding scale Check blood glucose hourly

How is a diabetic mother managed postpartum?

Halve insulin sliding scale | Change to SC insulin when eating and drinking

How often is HbA1c measured antenatally?

Every month

What is gestational diabetes?

Diabetes diagnosed in pregnancy, usually 2nd trimester

What are the risk factors for gestational diabetes?

FH of DM, obesity, previous large baby, previous history, polyhydramnios, PCOS

What is required in an oral glucose tolerance test?

Overnight fasting 75g glucose load in 250/300ml water Plasma glucose measured at fasting and 2 hours

What OGTT results are seen in diabetes and impaired glucose tolerance?

Diabetes: fasting >7mmol/L, 2hr>11.1mmol/L IGT: fasting >7mmol/L, 2hr>7.8mmol/L

What are the clinical requirements for a diagnosis of anti-phospholipid syndrome?

Vascular thrombosis | 3+ consecutive miscarriages <10w/ 1 foetal death>10w

Give three causes of puerperal pyrexia

``` UTI Perineal wound infection Endometritis Thrombophlebitis Mastitis or breast abscess ```

What are the symptoms of endometritis?

Fever Foul profuse bloody discharge Subinvolution of uterus Tender bulky uterus

Which antibiotics are used for endometritis?

Clindamycin and gentamycin | Admit until >24h afebrile

What are the risk factors for uterine inversion?

``` Strong traction on umbilical cord Excessive fundal pressure Placenta accrete Previous history Short cord Uterine abnormalities ```

What are the signs and symptoms of uterine inversion?

Haemorrhage Severe lower abdo pain Uterine fundus not palpable, mass in vagina

What is the name of the manoeuvre whereby the uterus is replaced up the cervix when it inverts?

Johnson manoeuvre

How much blood loss is required in massive obstetric haemorrhage?

30-40% patient's blood volume | Usually 2 litres

Give three causes of massive obstetric haemorrhage

Antepartum - placental abruption, PP Intrapartum - Uterine rupture, accrete Postpartum - atonic uterus, coagulopathy, uterine AVM

What is the most useful measure of measuring blood loss in massive obstetric haemorrhage?

Pulse rate

What are the complications of MOH?

Hypovolaemia and cardiac decompensation DIC ARDS Multiorgan failure

Why is left lateral tilt useful in MOH?

Relieves venocaval compression

How is MOH managed?

Treat the cause e.g. uterine atony | Replace blood and clotting factors

What is the management of foetal distress of the 2nd twin?

Deliver by the fastest, safest route

What occurs in amniotic fluid embolism?

Amniotic fluid enters the circulation of the mother and mechanically blocks vessels or causes an immunological/inflammatory reaction

What is the biggest risk of cord prolapse?

Compression of umbilical vessel by the presenting part

How is cord prolapse managed?

Delivery ASAP, reduce cord into vagina, mother in knee-chest or head-down tilt position whilst waiting for emergency caesarean section

What are the risk factors for cord prolapse?

Cord presentation Multiple pregnancy Abnormal lie Prematurity

What is shoulder dystocia?

Obstructed delivery where additional manoeuvres are needed after downward traction of the head has failed to deliver the shoulders

What are the causes of shoulder dystocia?

Foetal macrosomia BMI>30 Prolonged pregnancy Augmentation of labour/induction of labour

What are the complications of shoulder dystocia?

Foetal hypoxia | Maternal PPH and genital tract trauma+-

What the commonest cause of lactational mastitis?

Milk stasis

What is the treatment of mastitis?

Continue breast feeding, simple analgesia and warm compresses Flucloxacillin if: nipple fissures, breast milk culture positive, symptoms not improving after 2 days of conservative treatment

What is the ultrasound finding in molar pregnancy?

Uterus large for dates

What medication is contraindicated during the first trimester of pregnancy?

Trimethoprim (folate antagonist) - use nitrofurantoin | Nitrofurantoin is CI if breastfeeding

What is the triad of obstetric cholestasis?

Pruritus No rash Abnormal LFTs

What is raised in obstetric cholestasis?

Bile acids

What is the treatment of obstetric cholestasis?

Ursedeoxycholic acid

When is urine cultured for asymptomatic bacturia?

8-12 weeks

The first screen for anaemia and alloantibodies occurs at the booking visit (8-12 weeks). When is the second screen?

28 weeks

Why is metoclopramide contraindicated in patients under 20 with hyperemesis gravidarum?

Increased risk of extra-pyramidal side effects