Obstetrics 3 - Pregnancy Problems 2 Flashcards
What are risk factors for ectopic pregnancy?
Endometriosis IUCD Assisted conception Smoking PID
Define ectopic pregnancy
Implantation of a conceptus outside the uterine cavity
What are the symptoms of ectopic pregnancy?
Amenorrhoea
Abdo pain
Small brown PV bleed
Collapse if ruptured
How is ectopic pregnancy diagnosed?
TVUS
Serum progesterone <20nmol/L (failing pregnancy)
Serum HCG rise less than 66%
Laparoscopy
What are the requirements for expectant management of ectopic pregnancy?
Clinically stable
Asymptomatic
Falling HCG
Detail medical management of ectopic pregnancy
IM methotrexate 50mg/m2
Anti-D if Rhesus negative
How would you surgically treat ectopic pregnancy?
Laparoscopy
Salpingectomy unless other risk factors for infertility - salpingotomy
What are the risk factors for hyperemesis gravidarum?
Primiparity Hyatidiform mole Younger or obese women Previous history Multiple pregnancies
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
What are the complications of hyperemesis gravidarum?
Thiamine deficiency, liver failure
Which syndrome is trisomy 13?
Patau syndrome
What are the characteristics of Patau syndrome?
Cyclopia, microcephaly, severe LD, congenital abnormalities
What is foetal hydrops?
Accumulation of serous fluid in 2+ foetal compartments
Name some non-immune causes of foetal hydrops
Severe anaemia from G6PD deficiency
Cardiac abnormalities
Trisomies
TTTS
What is the pathophysiology behind foetal hydrops?
Obstructed lymphatic flow leads to decreased plasma oncotic pressure
How is foetal anaemia diagnosed?
Ultrasound, peak systolic velocity in MCA, foetal blood sampling
How is non-immune hydrops treated?
Amniocentesis if severe polyhydramnios
Treat cause
3rd trimester - delivery
What is immune hydrops?
Maternal antibody response against foetal red blood cells (if blood types don’t match)
What is the consequence of immune hydrops?
Haemolytic anaemia, jaundice/high-output cardiac failure, foetal hydrops, death
Give three sensitizing events for Rhesus disease
Ectopic pregnancy
ECV
Delivery
How is immune hydrops treated?
Irradiated Rh-negative packed red cells transfused into umbilical vein at cord insertion/hepatic vein
(umbilical vein transfusion)
How is immune hydrops prevented?
Anti-D given if Rhesus negative at 28w, 34w, and within 72 hours of sensitizing event.
What is reduced amniotic fluid volume?
Oligohydramnios
Give three causes of oligohydramnios
IUGR
PROM
Pre-eclampsia
Utero-placental insufficiency
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
