Obstetrics Flashcards
Management of Shoulder dystocia
H: Get Help E: Evaluate for episotomy L: Legs in Mc Roberts position P: Suprapubic pressure E: Enter - internal measures pressure behind foetal anterior shoulder woods screw manœuvre - frequently requires episotomy R: Remove posterior arm R: roll the patient ‘Gaskin” Increase pelvic diameter
Causes of pregnancy related hyperthyroidism
Gestational transient thyrotoxicosis
Graves’ disease
Less common
Toxic multi modular goitre
Toxic adenoma
Thyroiditis
Define Gravidity
number of pregnancies a woman has had (to any stage)
Define parity
number of pregnancies that have resulted in delivery beyond 28 weeks gestation
Naegele’s Rule
Expected delivery date (EDD) is 1 year and 7 days after LMP minus 3 months
Characteristic signs of shoulder dystocia in infant?
Turtle necking (appearance and retraction of head) Erythematous face
McRobert’s position
hyper flexing the mother’s legs tightly to her abdomen - widens the pelvis and flattens lumbar spine
Gaskin manouevre
moving mother onto all fours with the back arched, widening the pelvic outlet
Zavanelli manœuvre
cephalic replacement and C section
Maternal symphysiotomy
opening of the birth canal laxer by breaking the connective tissue between the two pubes bones facilitating the passage of the shoulders
maternal complications of shoulder dystocia?
increased blood loss
vaginal lacerations
uterine rupture
main cause for antepartum haemorrhage?
Placenta praevia
what is placenta praevia?
an obstetric complication in which the placenta is inserted partially or wholly in the lower uterine segment
Grades of placenta praevia
I Placenta is in lower segment, but the lower edge does not reach the internal os II Lower Edge of the Placenta reaches internal os but does not cover it III Placenta covers internal os partially IV Placenta covers internal os completely
Presentation of placenta praevia
pain bright red vaginal bleeding
commonly occurs around 32 weeks gestation, but can be as early as late mid trimester
Diagnosis of placenta praevia
Praevia can be confirmed with an ultrasound
transvaginal ultrasound has superior accuracy compared to transabdominal
Abruptio placenta
Refers to bleeding due to the untimely separation of a normally sited placenta from its attachment to the uterus
What is CTG
Cardiotocography
electronic method of simultaneously recording foetal heart rate, foetal movements and uterine contractions to identify the probability of foetal hypoxia
Indications for antenatal CTG
Previous abnormal CTG or doppler
Maternal hypertension or other complications or medical conditions (e.g. cardiac, thyroid, etc.)
Suspected antepartum haemorrhage (>50mL)
Previous caesarian section
Multiple pregnancy
Oligohydroamnios (deficiency of amniotic fluid)
Isoimmunisation (Rhesus reaction)
Indications for intrapartum CTG
Preterm labour (42 weeks)
Breech presentations
Induction of labour
Maternal pyrexia (>38C)
Vaginal bleeding during labour in addition to the show
First stage labour >12 hours
Prolonged second stage labour >1 hour of active pushing
Insertion of epidurals or other modifications
Normal foetal Heart rate
Normal = 110-160 bpm
Preterm FHR is expected to be in the upper range of normal
Baseline variability on CTG
= fluctuation of FHR from beat to beat, from highest peak to lowest trough over a 1 minute period
Normal Variability = 5-25 bpm
Reflects a normal foetal autonomic nervous system
Reduced Variability = 3-5 bpm (look at CTG for up to 60 minutes)
Reduced by sleep states, activity, hypoxia, foetal infection and drugs (e.g. opioids, hypnotics)
Absent Variability = <3 bpm (indicates very compromised/hypoxic foetus)
Accelerations on CTG
transient increases in FHR by more than 15 bpm above the baseline for 15 seconds or more
Accelerations are normal (their presence is a good sign)
No accelerations with an otherwise normal FHR doesn’t indicated foetal compromise
Decelerations on CTG
transient decreases in foetal HR 15 below baseline for at least 15 seconds
Decelerations are abnormal!
Early deceleration
peaks as the contraction due to compression of placenta / blood vessels peaks
Not too concerning if everything else is normal
Late deceleration
Peaks after end of uterine contraction
Normally associated with hypoxic foetus
prolonged late deceleration
Deceleration lasting for >90 seconds but less than 5 minutes after a uterine contraction
Bad indicator for foetus
variable deceleration
Rapid onset drop of at least 60bpm for at least 60 seconds with quick recovery and good variability
Vagal in origin (thought to result from stimuli such as cord or head compression)
Complicated variable deceleration
Reduced variability prior to deceleration of at least 60bpm with quick recovery and ‘overshooting’ of the baseline (large amplitude shoulder)
sinuosoidal pattern CTG
oscillating, wavy, smooth, fixed pattern with amplitude between 5-15
Associated with severe anaemia of foetus and foetal death)
Foetal Scalp pH
f concerned by CTG findings, a foetal scalp pH may be requested
If >7.25, wait and hour then repeat
If stops between 7.21-7.24, may leave for another 30 minutes depending on the baby’s condition
If <7.21, then straight to theatre for emergency caesarian section
Classic triad of endometriosis
dysmenorrhoea, dysparaeunia, dsychezia (unable to defecate)
Infertility rate in endometriosis
30-40% will be infertile
What is endometriosis?
chronic inflammatory condition defined by endometrial stroma and glands found outside of the uterine cavity.
Diagnosis of endometriosis
direct visualisation of lesions typical of endometriosis at lapaoscopy
biopsy and histologic exam of specimens (2 or more of endometrial epithelium, glands, strooma, haemosiderrin laden macrophages
What is seen at laparoscopy in endometriosis?
mullberry spots: dark blue or brownish- black implants on the uterosacral ligaments
endometrioma “chocolate” cysts on the ovaries
“powder burn” lesions on the peritoneal surface
early white lesions and clear blebs
peritoneal “pockets”
What tumour marker may be elevated in patients with endometriosis?
CA-125
When does gestational diabetes develop?
3-8% of pregnant women develop gestational diabetes around the 24th to 28th week of pregnancy
pathophysiology behind gestational diabetes?
anti insulin factors produced by the placenta and high maternal cortisol levels create increased peripheral insulin resistance -> higher fasting glucose -> GDM
Oral glucose challenge test
at 26-28 weeks GA
a non- fasting 50 gram glucose drink is given to the pregnant woman
after one hour venous blood is taken
a one hour venous blood glucose level of >7.8mmol/L indicates the need for an oral glucose tolerance test
Oral Glucose tolerance test
standard test is a 75g 2 hour oral glucose test
can be performed at any time during the pregnancy if signs and symptoms of abnormal glucose tolerance
consider an early test for womb with a past history of gestational diabetes if a recent OGTT has not been performed
ensure a normal diet containing at least 300 grams of carbohydrate is consumed for at least 3 days before the test
performed after an hour fast (food and fluids)
obtain fasting venous blood glucose
a 75g glucose drink is then given
measure venous blood at 2 hours
a fasting glucose >5.5 or glucose >7.8 at 2 hours indicates the need for dietary advice and home glucose monitoring
When to treat gestational diabetes
Treatment will be considered if:
Fasting values are ≥ 5.5 mmol / L once or more a week
Post prandial values ≥7.5 mmol / L twice or more a week are recorded in the absence of dietary non compliance
Post partum follow up after gestational diabetes
test glucose post partum day 3-4
also test at 6-12 weeks post partum
What is hydrops fetalis?
condition of the foetus characterised by an accumulation of fluid, or oedema in at least 2 foetal compartments
Locations of fluid in hydrops fetalis
subcutaneous tissue/ scalp
pleura (pleural effusion)
pericardium (pericardial effusion)
abdomen (ascites)
oedema is usually seen in the foetal subcutaneous tissue, sometimes leading to spontaneous abortion. It is a prenatal form of heart failure, in which the heart is unable to satisfy its demand for a high amount of blood flow.
What does hydrops fetalis usually stem from?
Foetal anaemia (the heart needs to pump a much greater volume of blood to deliver the same amount of oxygen)
Immune cause for hydrops fetalis?
Rh Disease
can be prevented by administration of anti D IgG injections to RhD negative mothers during pregnancy and/ or within 72 hours of the delivery
Non immune causes of hydrops fetalis?
iron deficiency anaemia
paroxysmal supraventricular tachycardia resulting in heart failure
deficiency of the enzyme beta-glucuronidase
congenital disorders of glycosylation
Parvovirus B19 infection of the pregnant woman
CMV in mother
maternal syphilis and maternal diabetes mellitus
a thalassemia can also cause hydrous fetalis
tumours
twin twin transfusion syndrome
maternal hyperthyroidism
How long does it take after giving birth for the physiological changes to return to normal?
About 6 weeks
When is dilutional anaemia most common in pregnancy
2nd-3rd trimester (28-32 weeks)
Haematological changes in pregnancy
Increased red blood cell volume Increased WCC Decreased platelets Increased fibrinogen and coagulation factors Increased ESR
CVS changes in pregnancy
Increased Cardiac output Widened pulse pressure Decreased BP Displaced Apex beat functional systolic flow murmur
Renal changes in pregnancy?
Increased GFR Decreased urea and creatinine Decreased urates dilated ureters Increased bladder capacity Increased frequency of micturition
Most common infection in pregnancy?
UTI
What is increased urates a marker for?
Pre eclampsia
What is Chadwick’s sign
Bluish discolouration of cervix, vagina and labia due to pelvic congestion
Can be observed 6-8 weeks after conception
Gastrointestinal changes in pregnancy?
Cravings Decreased gut motility constipation compression of stomach nausea and vomiting
Average weight gain in pregnancy?
12KG
larger women may gain 3-4 kg
First Trimester Screening test for trisomy 21 and trisomy 18
blood collected at 9W to 13W to 6D gestation for biochemical analysis of
- pregnancy associated placental protein A (PAPP-A)
- free BhCG
combined with
- ultrasound measurement of foetal nuchal translucency 11W to 13W 6D
Second Semester for Trisomy 21, Trisomy 18 and neural tube defects
Blood is collected at 14W to 20W (ideally 15-17) gestation for biochemical analysis of:
- alpha fetoprotein (AFP)
- Free BhCG
- unconjugated estriol
When can you feel the uterus per abdomen?
12 weeks gestation
primip
female during her first pregnancy
What makes a clinically favourable pelvis?
sacral promontory cannot be felt
ischial spines are not prominent
suprapubic arch and base of supraspinous ligaments both accept 2 fingers and the inter tuberous diameter accepts 4 knuckles when the woman is examined
bregma
anterior fontanelle
the brow
lies between the bregma and anterior fontanelle
Vertex
area between the fontanelles and the parietal eminences
Restitution
The fetal head turns through 45 degrees to restore its normal relationship with the shoulders, which are still at an angle.
How is labour diagnosed?
onset of regular painful uterine contractions in association with evidence of cervical change
7 mechanisms of labour
Engagement Descent Flexion Internal rotation extension: delivery of head restitution expulsion
usual mechanism to deliver shoulders?
Gentle downward traction
Braxton Hicks contractions
‘practice contractions’ = false labour
sporadic uterine contractions not resulting in cervical changes and delivery
usually painless
can confuse women as to whether they are going into labour
What is ‘false labour’
nulliparous women thinks labour has started: aware of uterine contractions
not distracted when uterus contracts
no show
on examination the cervix is not yet dilating
Ideal rate of cervical dilation
1cm/per hour
What does the first stage end with?
Full dilation of the cervix
What phase of labour is normally most difficult?
Transition phase
Second stage?
begins with full dilation of the cervix, ends with birth of baby
Third Stage?
delivery of the placenta
How do we assess progress in labour?
vaginal assessment
standard is to assess every 4 hours
more frequent if complications suspected
assess progress on partogram with ‘action’ line
Median duration of the second stage?
median duration for nulliparous and multiparous women 50 and 20 minutes respectively
How is the third stage managed?
oxytoxic with delivery anterior shoulder
early cord clamping
placenta with controlled cord traction
reduction in blood loss associated with active management of labour.
Reasons for induction of labour?
maternal: hypertension gestational diabetes antepartum haemorrhage PROM other medical conditions foetal post dates T + 10 growth restriction Social or convenience
How to predict successful induction of labour?
assessed by Bishop’s score
The higher the score - the easier it is to induce
How do we induce labour?
Mechanical
membrane sweeping
foley catheter
artificial rupture of membranes +/- oxytocin
Medical
prostaglandin preparations: PGE2 vaginal gel most commonly used, PGE1 (misoprostol) oral or vaginal
soften the cervix and initiate onset of contractions
nausea, vomiting, diarrhoea, uterine hyperstimulation
possible complications of induction of labour (IOL)
inability to establish labour uterine hyperstimulation cord prolapse abruption uterine rupture
Incoordinate uterine activity
failure of uterine activity to result in dilation of the cervix as expected
Managing incoordinate uterine activity
vaginal examination
artifical rupture of membranes
commence syntocin to augment contractions
reasess 3-4 hours to ensure ongoing process
How do we grade perineal tears?
1st degree perineal skin or vaginal mucosa 2nd degree perineal skin and muscles 3rd degree skin, muscles, sphincter 4th degree complete sphincter disruption (internal and external), with extension to rectal mucosa
Risk factors for perineal trauma or episotomy?
first vaginal birth increasing foetal size, head diameter and weight foetal malposition prolonged labour/ prolonged second stage instrumental vaginal birth
Complications after perineal trauma or episotomy
pain (short and long term) dyspareunia abscess formation wound breakdown rectovaginal fistula psychological
How do we manage perineal trauma?
recognition of the damage + rectal examination
call for assistance
ensure adequate analgesia and lighting
technique of sphincter repair
follow up post partum
continuous suture associated with reduce pain, reduced dysparaunia
Indications for instrumental vaginal birth?
maternal maternal exhaustion prolonged 2nd stage Foetal abnormal foetal heart rate trace malposition
Prerequisites for instrumental vaginal birth
full dilation engaged head known foetal position empty bladder adequate analgesia informed and consenting patient appropriate level of training and skill
Instruments that can be used for instrumental delivery?
obstetric forceps
vacuum extractor or ventouse: less likely to deliver baby, more likely to cause baby injury, less likely to cause maternal injury, less need for analgesia
Indications during labour to convert to C section?
maternal failure to progress/ inadequate progress medical condition Foetal abnormal foetal heart rate malposition/ presentation
Issues to raise in consent process for C section?
maternal risks damage to bowel or bladder infection general post op complications foetal and neonatal risk skin lacerations traumatic delivery transient tachypnoea of the newborn
How are women cared for after C section
observations analgesia oral intake IDC thromboembolism prophylaxis chest physiotherapy
Puerperium
post partum period
Key aspects of care in post partum period?
ensure normal physiological involution (pelvic organs and mothers physiology returns to normal)
regular checks of mother and baby
establish and support breast feeding
manage any medical complications
common postnatal problems
psychlogical problems day 4 blues and more serious variations breast engorgement breastfeeding problems bowel and bladder problems post partum fever
define post partum fever and list causes?
temp >38
measured on 2 occassions
> 48 hours after birth
breast engorgement mastitis breast abscess endometritis UTI wound infection - CS/episotomy/ tear
usual discharge procedure for mother?
medical check emotional wellbeing vaginal discharge, breast feeding, wound observations, examination, inspection contraception follow up mode of birth in subsequent pregnancy
Usual discharge procedure for baby?
well baby check feeding check that returned to birth weight breast vs artificial feeding local doctor domicillary midwife/ CYWHS nurse
Contraception options in mother post partum?
lactational amenorrhoea full breast feeding effective contraception for 98% of women less effective if bleeding, solids condoms progesterone only pill combined OCP if not breastfeeding
Normal foetal presentation at the onset of labour?
longitudinal lie with cephalic presentation.
The head is normally flexed, presenting the smallest diameter to the maternal pelvis, which is defined as the vertex — the area lying between the anterior and posterior fontanelles and bounded by the parietal eminences.
Disadvantages of epidural pain relief in pregnancy
maternal motor blockade which prevents ambulation, the need for continuous foetal monitoring, possible maternal hypotension causing non reassuring foetal heart patterns and the loss of bladder sensation requiring an indwelling catheter, may also increase the duration of 2nd stage and the risk of having an instrumental birth
TORCH infections in pregnancy
T: Toxoplasmosis O: other R: Rubella C: Cytomegalovirus H: Herpes simplex virus -2
Other coxsackie virus chickenpox chlamydia HIV Human T-lymphotrophic virus syphilis
Treatment of influenza in pregnant woman
early antiviral therapy with neuraminidase inhibitors after onset of symptoms should be standard management along with supportive care including antipyretics
Clinical presentation of rubella in pregnant women?
mild febrile illness with a fleeting rash 14-21 days after exposure, however 25-50% of cases are asymtpomatic
Management If maternal rubella infection is confirmed in the first 12 weeks of pregnancy
termination of pregnancy should be offered due to the high likelihood of fetal infection and the severe consequences of CRS
Advice for Non immune women for rubella on prepregnacny screening
should be offered vaccination and advised to wait one month before getting pregnant, as the vaccine is live attenuated virus.
transmission rate of primary maternal infection with CMV
30%
Treatment for a Seronegative pregnant woman with exposure to varicella in pregnancy
offered zoster immune globulin (ZIG) within 96 hours of exposure to decrease her risk of varicella
definitive host of the parasite Toxoplasma gondii
cat
major sources of infection for toxoplasmosis
ingestion of uncooked meats and contact with contaminated soil are
toxoplasmosis foetal syndrome features
chorioretinitis, intracranial calcification and hydrocephaly in approximately 10% of cases
Syphilis causes which congenital anomalies?
hepatomegaly, rash, generalised lymphadenopathy and skeletal and dental anomalies
Gold standard treatment for syphilis in pregnancy
hepatomegaly, rash, generalised lymphadenopathy and skeletal and dental anomalies
Dietary recommendations to avoid listeria monocytogenes
safe food handling practices, avoid unpasteurised milk, soft cheese, prepared salads, uncooked seafood and processed meat
chorioamnionitis
infection of the amniotic fluid, placenta, membranes and/or decidua
primarildy due to ascending infection and usually polymicrobial
Newborns at risk of vertical transmission of Hep B management
given hepatitis B immune globulin (HBIG) within 12 hours of birth, and a subsequent course of active hepatitis B vaccination should be commenced within 12 hours of birth
Main strategies to decrease perinatal transmission of HIV
combined antiretroviral therapy neonatal antiretroviral therapy avoidance of breastfeeding elective C section where maternal viral load is less than 1000 copies/mL then added benefit of elective C section delivery is unclear with transmission rates less than 2%
A woman who consults her doctor after discovering that she was immunised against rubella 3 weeks after conceiving should be offered:
A termination of pregnancy.
B paired rubella IgM and IgG antibody titres 2 weeks apart.
C chorionic villous sampling.
D reassurance and standard antenatal care.
E varicella serology.
A - termination of pregnancy
When is the best time for maternal screening of GBS
Maternal screening for GBS is best performed at 35–37 weeks gestation.
Infections causing teratogenesis
rubella cytomegalovirus varicella parvovirus B19 toxoplasmosis syphilis
Which of the following diseases can both cause serious maternal illness in pregnancy and a fetal malformation syndrome? A hepatitis C B varicella (VZV) C group B streptococcus D toxoplasmosis E listeriosis
Varicella
CMV in pregnant women
usually symptomatic, or mild non specific illness, unless mother is immunocompromised
IgM
immediate
IgG
later response
choriocarcinoma
malignant tumour of trophoblast cells
Risk Factors for molar pregnancy
defects in the egg
abnormalities of the uterus
nutritional deficiencies
women 40 years higher risk
diets low in protein, folic acid and carotene
being of Asian or mexican background
a previous molar pregnancy or other gestational trophoblastic tumour (one in 100 women who have had one molar pregnancy will have another).
Ultrasound appearance of molar pregnancy
mole resembles a bunch of grapes, increased trophoblast proliferation and enlarging of chorionic villi
Treatment for molar pregnancy
evacuate the uterus by uterine suction or by surgical curettage as soon as possible after diagnosis in order to avoid the risks of choriocarcinoma
Karyotype of complete mole
Diploid — mostly 46XX
usual origin of complete mole
Paternal only
Fertilisation of an oocyte without genetic material by one spermatozoon that subsequently doubles its chromosomes
Diagnosis of malignant trophoblastic disease
hCG levels that do not decreased by at least 10% 3 weeks after evacuation of a molar pregnancy, or an increase of more than 10% over a 2 week interval
persistence of detectable levels of hCG more than 6 months after molar evacuation
histological evidence of choriocarcinoma in the products
Invasive mole
persistent trophoblast that invades deeply into the myometrium following a molar pregnancy. There may be metastases, usually in the lungs and vagina. Microscopically, it is characterised by oedematous chorionic villi with trophoblast proliferation, as seen with a non-invasive mole.
Placental site trophoblastic tumour
his consists of placental-bed trophoblast invading the myometrium from the site of placental implantation. This differs from choriocarcinoma in that the hCG level is usually much lower and the diagnosis is made only histologically. The condition is rare, accounting for only 0.1–0.2% of trophoblastic tumours.
miscarriage definition
the spontaneous loss of an intrauterine pregnancy before 20 weeks gestation
missed or delayed miscarriage
the failure to expel the products of conception after death of the embryo
often diagnosed when a first trimester ultrasound reveals an absence of embryonic (6-9 weeks) or foetal (>9 weeks) heartbeat
empty sac on ultrasound
clinically the woman loses the symptoms of pregnancy
on examination the uterus is smaller than expected for length of amenorrhoea and the cervix is closed
aetiology of miscarriage
as many as 50-60% of embryos miscarried in the first trimester will have a chromosomal abnormality - autosomal trisomies are the most common, involving chromosomes 13,16,18,21 and 22
Miscarriage presentation
per vaginal (PV) bleeding and lower abdominal pain
Threatened miscarriage
vaginal spotting or light bleeding with minimal pelvic or lower back pain
on vaginal examination the cervix is closed
ultrasound scan reveals a live intrauterine foetus
Inevitable miscarriage
characterised by lower abdominal pain and vaginal bleeding
on vaginal examination the lower uterus appears to be ballooning while the internal os is closed
the products of conception have not yet been passed
Incomplete miscarriage
history of increasing bleeding, cramping lower abdominal pain and passage of some products of conception
on vaginal examination the internal os of the cervix is open and often products of conception are present in the canal
Septic miscarriage presentation
fever, bleeding and significant tenderness in the lower abdomen and uterus
Complete miscarriage
products of conception are passed and on pelvic examination the cervix is closed
ultrasound scan reveals an empty uterine cavity
who needs surgical evacuation of the uterus with suction curettage
haemodynamically unstable and septic patients
complications of surgical evacuation
perforation, cervical tears, intrabdominal trauma, haemorrhage and intrauterine adhesions (Ashermann’s syndrome)
cornerstones of management in miscarriage
low dose aspirin, heparin and supportive care
What is an ectopic pregnancy
results from implantation of the fertilised ovum (blastocyst) in tissue other than the endometrium of the uterine cavity
most common site for ectopic pregnancy
fallopian tube ( most commonly in the ampulla)
Believed cause for ectopic pregnancy
ectopic pregnancy is believed to be due to endothelial tubal damage secondary to salpingitis, disturbed tubal oocyte transport or proliferation of refluxed endometrial tissue arrested within the fallopian tube
Risk Factors for ectopic pregnancy
STIs
prior ectopic
prior tubal surgery including tubal ligation
hormonal factors such as diethylstilbestrol exposure and progesterone, contraceptive failures (e.g intrauterine devices), increasing age and cigarette smoking
IVF
Ectopic pregnancy vaginal examination
there may be bleeding, a closed cervix, a small uterus for gestational age, an adnexal mass (with or without tenderness) and localised tenderness
most important diagnostic tools in ectopic pregnancy
Transvaginal ultrasound scan (TVS) and serial BhCG determinations
What rise in BhCG would increase suscpicion of ectopic?
less than 60% increase in 48 hours
What is important to monitor after conservative surgery has been performed (eg. salpingostomy)
monitor BhCG - follow levels til <5
When can methotrexate be used as treatment for patients with ectopic pregnancy?
the asymptomatic patient with no free fluid in POD, small tubal ectopic pregnancy on TVS, absence of foetal heart beat and low serum β hCG (< 3500 IU)
Role of methotrexate in ectopic
an antimetabolite that prevents the growth of rapidly dividing cells by interfering with DNA synthesis
what in particular affects future pregnancies after an ectopic?
periadnexal adhesions
post term
42 weeks or more
46XX DSD
defined by the presence of both ovarian tissue and testicular tissue in the one person
what is the major determinant of foetal growth and wellbeing
quality of placental implantation
from what does the placenta develop
trophoectoderm
what is the most accurate way of dating the pregnancy?
first trimester ultrasound: crown - rump length
what is oligohydramnios?
decreased amount of amniotic fluid for a given gestational age
What do you use to diagnose oligohydramnios?
(MVP) or the sums of the MVP in four quadrants; this is known as Amniotic fluid index (AFI)
Potter’s Syndrome
the atypical appearance of foetus or neonate due to olioghydramnios in the uterus - clubbed feet, pulmonary hypoplasia and cranial anomalies)
Eitiologies for oligohydramnios
maternal medical conditions, foetal anomalies, rupture of membranes and idiopathic oligohydramnios and conditions associated with placental insufficiency
Women at risk of oligohydramnios
women with pre eclampsia
women with post term pregnancy
women with other conditions associated with placental insufficiency, including intrauterine growth restriction and autoimmune diseases
women with multiple pregnancies
Complications of olioghydramnios
cord compression MSK abnormalities IUGR pulmonary hypoplasia Potter’s syndrome
clinical presentation of oligohydramnios
in general olioghydramnios is asymptomatic but may present with decreased foetal movement, inadequate fundal height growth or evidence of PROM
How can you test if fluid leakage is amniotic fluid
Nitrazine paper can detect amniotic fluid utilising the pH of the vaginal fluid, normal vaginal pH is 3.8-4.2 while amniotic fluid has a pH of 7-7.3
fern test - second confirmatory test using microscopic examination that looks for the presence of ‘ferrying’ on a microscopic slide after allowing a sample of fluid to dry
“what does oligohydramnios mean for my baby?”
The baby requires amniotic fluid to grow—especially the lungs—so a lower amount means that there is a chance of underdeveloped lungs if the low fluid is longstanding. If low fluid is diagnosed in the third trimester, there is also an increased chance of adverse outcomes
clinical signs of polyhydramnios?
it is suggested clinically by a uterus that feels large for dates or measures more than 10% above the normal fundal height for gestational age
Diagnosis of polyhydramnios
defined as an amniotic fluid index more than 24cm or a single deepest pocket of fluid at least 8cm
causes of polyhydramnios?
50% idiopathic
20% associated with foetal anomalies, including anencephaly, hydrocephaly, tracheoesophageal fistula, oesophageal atresia, gastroschisis, duodenal atresia, spin bifida, cleft lip and palate, cystic adenomatoid lung malformation
twin pregnancy 7%
maternal Diabetes mellitus 5%
8% other - Rh isoimmunisation, hydrous foetal is, infection
what is uterine rupture most commonly associated with?
previous uterine scar
Preterm prelabour Rupture of membranes
Rupture of membranes at least 1 hour prior to onset of labour at less than 37 weeks gestation
3 causes of neonatal death related to PPROM
prematurity,sepsis and pulmonary hypoplasia
Diagnosis of spontaneous rupture of the membranes
best achieved by maternal
history followed by a sterile speculum examination.
Diagnosis for clinical chorioamnionitis
maternal pyrexia, tachycardia, leucocytosis,uterine tenderness,offensive vaginal discharge and fetal tachycardia.
prophylactic antibiotics for PPROM
Erythromycin should be given for 10 days
corticosteroid use in PPROM decreases the incidence of what?
Respiratory distress syndrome and necrotising enterocolitis
tocolytic
anti contraction medication or labour repressants - used to suppress premature labour
- nifedipine most commonly used
contraindications for tocolytics
> 34 weeks gestation increase risk of infection severe pre eclampsia intrauterine death IUGR Abruptio placenta maternal problems - heart disease, diabetes
What is pre eclampsia?
presence of hypertension 140/90 arising after the 20th week of pregnancy.
Symptoms of pre eclampsia
non-specific headaches, visual scintillations (like migraine aura), epigastric or right upper quadrant pain radiating into the back as a reflection of hepatic ischaemia, oliguria, lower abdominal pain and bleeding caused by placental abruption, or reduced fetal movements.
Hyperesmesis gravidarum
is excessive pregnancy-related nausea and/or vomiting that prevents adequate food and fluid intake and is associated with weight loss of more than 5% of body mass
What is a fibroid?
compact masses of smooth muscle that lie in the cavity of the uterus (sub mucous) within the uterin muscle (intramural) or on the outside surface of the uterus (subserous)
causes of backache in pregnancy
hormone induced laxity of spinal ligaments
a shifting in the centre of gravity as the uterus grows;
additional weight gain
advice for backache in pregnancy
maintenance of correct posture, avoiding lifting heavy objects, avoiding high heels, regular physiotherapy and simple analgesia
Symphsis pubis dysfunction
excruciatingly painful condition most common in the third trimester, although it can occur at anytime during pregnancy
the symphysis pubis joint becomes loose, causing the two halves of the pelvis to rub on another when walking or moving
pathophysiology of reflux in pregnancy
altered structure and function to the normal physiological barriers to reflux namely the weight effect of the pregnant uterus and hormonally induced relaxation of the oesophageal sphincter, explain the high incidence in pregnancy
pathophysiology of haemorrhoids in pregnancy
effects of circulating progesterone of the vasculature, pressure not he superior rectal veins by the gravid uterus and increased circulating volume
pathophysiology of varicose veins in pregnancy
they are thought to be due to the relaxant effect of progesterone on smooth muscle and the dependent venous stasis caused by the weight of the pregnant uterus on the inferior vena cava
most common complication of fibroids in pregnancy?
red Degeneration
What is red degeneration?
asa fibroid grows it may become ischaemic; this manifests clinically as acute pain, tenderness over the fibroid and frequent vomiting
if these symptoms are severe, uterine contractions may be precipitated causing miscarriage or preterm labour
red fibroid degeneration requires treatment in hospital, with potent analgesics
symptoms usually settle within a few days
Pinard’s manouvre
this entails using a finger to flex the leg at the knee and then extend at the hip, first anteriorly then posteriorly
What is a pessary?
plastic device that is placed in the vagina to provide support
What is a prolapse?
Prolapse is a descent of pelvic organ out of its normal anatomical position due to luck of its support.
vaginal vault prolapse
occurs in women who have had a hysterectomy previously, the vault (top of the vagina) moving downwards
cystocoele
When the supports of the front wall of the vagina are weakened, the bladder can protrude through
rectocoele
weakening of the back wall, where the bowel bulges through
enterocoele
If the upper part of the vagina allows bowel to bulge through
what symptom is pathognomic of prolapse
a bulge or dragging sensation
What do you use to stage prolapse
POPQ - pelvic organ prolapse quantification system
Chloasma
Blotchy pigmentation of the nose and face
Estrone
After menopause
Adipose
From adrenal steroids
Estriol
Pregnancy
Placenta
From fetal adrenal DHEAS
Estradiol
Non pregnant reproductive years
Follicle
Granulomatous
Müllerian duct
Primordium of the females reproductive tract
Wolffian duct
Primordium of the male internal reproductive tract
complications of multiple gestation
nutritional anaemias (iron and folate) pre eclampsia gestational diabetes thromboembolism preterm labour (50%) malpresentation Caesarean delivery post partum haemorrhage
What is cord prolapse?
descent of the umbilical cord alongside or past the presenting part in the presence of ruptured membranes
What is cord presentation?
the umbilical cord presents in front of the foetal presenting part with or without membrane rupture
4Ts of post partum haemorrhage
tone, tissue, thrombin, tear
Sheehan’s Syndrome
acute hypopituitarism after massive PPH deficiency of GH, prolactin, cortisol, TSH, LH and FSH failure of lactation failure of hair growth poor wound healing generalised weakness
Complications of PPH
DIC, Acute renal failure, Sheehans syndrome, death
most commonly acquired congenital viral infection
CMV
causes of small placenta
maternal vascular diseases (pre eclampsia, hypertension, DM with renal disease), chronic infections
causes of large placenta
hydrops fetalis, immune/non immune causes, maternal DM, syphilis
Placenta in hypertensive conditions
multiple infarcts and decidual vasculopathy
what medication can you take for hyperesmesis gravidarum?
metoclopramide
what do you avoid eating with hyperesmesis gravidarum?
Foods that are high in fat, dairy and spice are best avoided.
why is trimethoprim relatively contraindicated in the first trimester?
anti folate effect
What ultrasound findings would support congenital CMV infection of this fetus?
ascites
3 major diseases of late pregnancy
Pre eclampsia
Growth restriction
Pre term birth
2 key mechanisms of pre eclampsia
Impaired Placentation
Endothelial cell activation/ Inflammation
Tests to perform in suspected congenital syphilis
thorough examination
dark field microscopy of any skin or mucosal lesions
and a quantitative nontreponemal serum test (e.g., rapid plasma reagin [RPR], Venereal Disease Research Laboratory [VDRL])
infants with clinical signs should also have a lumbar puncture with CSF analysis for cell count, VDRL, and protein
CBC with platelet count
liver function test
long bone X-rays
Strategies to decrease perinatal transmission of HIV
combined antiretroviral therapy
neonatal antiretroviral therapy
avoidance of breastfeeding
elective C section
waiters tip position
Extended, internally rotated arm with wrist flexion
what condition is most often associated with placental abruption?
pre eclampsia
True or False
In placenta previa the initial haemorrhage is usually painless and rarely fatal
True
what percentage of total blood volume is lost with a complete abruption?
50% or greater
In a term pregnancy what is the management of vasa previa that has been confirmed with colour Doppler ultrasound
Elective lower segement C section
polyspermy
egg that has been fertilised by more than 1 sperm
- usually unviable
Low birth weight
Very low birth weight
Extremely low birth weight
Small for gestational age
Large for gestational age
> 90th centile for gestational age
Most important sign of respiratory distress in newborn
Increased rate of breathing
Most common cause of respiratory distress in a post mature baby
Meconium aspiration syndrome
Most common cause of respiratory distress in term infant
Transient tachypnoea of the newborn
Commonest cause of respiratory distress in preterm baby
Primary surface disease - respiratory distress syndrome
Contraindications to external cephalic version
fetal abnormality (hydrocephalus) placenta praevia previous C section hx of antepartum haemorrhage multiple gestation pre eclampsia or HTN plan to deliver by c section
Risks of ECV
placental abruption premature rupture of membranes cord accident transplacental haemorrhage foetal bradycardia
Predisposing factors for breech presentation
fibroids congenital uterine anomalies uterine surgery multiple gestation prematurity placenta previa abnormality - anencephaly or hydrocephalus fetal neuromuscular disorder olioghydramnios polyhydramnios
largest cause of death in pre eclampsia?
intracranial haemorrhage
pre eclampsia prevention
low dose aspirin and supplemental calcium
Eclampsia prophylaxis
magnesium sulfate
When can a urine pregnancy test be positive
7-10 days after conception
how long after unprotected sex can the emergency contraception pill be taken?
Up to 5 days
Has higher rates of efficacy the sooner it is taken
Human Placental Lactogen
produced by the syncitiotrophoblast
decreases insulin sensitivity
progesterone production during pregnancy
luteal cells of the corpus luteum
after 9 weeks: placenta
Function of progesterone in pregnancy
Early pregnancy: induces endometrial changes favourable for blastocyst implantation
Later pregnancy: function is to induce immune tolerance for the pregnancy and prevent myometrial contraction
main oestrogen during pregnancy
Estriol
DHEAS fromt he foetal adrenal gland is the precursor for 90% of estriol converted in the placenta
main oestrogen during menopause
Estrone
Adrenal androstendidione is converted in peripheral adipose tissue to estrone
oestrogen in the non pregnant reproductive years
Estradiol
produced from cholesterol in the follicular theca cells
Chadwick sign
bluish or purple discolouration of the vagina and cervix as a result of increased vascularity
LInea Nigra
increased pigmentation of the lower abdominal midline from the pubis to the umbilicus
Cholasma
Blotchy pigmentation of the nose and face
POst conception week 1
starts at conception
ends with implantation of blastocyst
week 2
bilaminar germ disk with epiblast and hypoblast layers (give rise to 3 primordial germ layers)
POst conception week 3
trilaminar germ disc with ectoderm, mesoderm and endoderm
Ectoderm
central and peripheral nervous systems; senosory organs of seeing and hearing, integument layers (skin, hair and nails)
Mesoderm
Muscles, cartilage, CVS, urogenital
Endoderm
lining of GI and Resp tract
Mullerian Duct (Paramesonephric duct)
primordium of the female internal reproductive system
No hormonal stimulation is required
In males the Y chromosome induces gonadal secretion of mullerian inhibitory factor, whch causes the mullerian duct to involute
Wolffian Duct (mesonephric)
present in all early embryos, is the primordium of the male internal reproductive system
Testosterone stimulation is required for developement to continue
Male External Genitalia stimulation
Need DHT stimulation for differentiation of external genitalia into penis and scrotum
What cell produces anti Mullerian hormone
Sertoli cell
What cell produces testosterone
Leydig cell
IOnising radiation as a teratogen
no increase is seen in fetal anomlies or pregnancy losses with exposure
Effect of lithium on pregnancy
Ebstein’s Anomaly (right heart defect)
Effect of streptomycin on pregnancy
VIII nerve damage, hearing loss
Effect of Isoretinoin on pregnancy
Congential deafness, microtia CNS defects, congenital heart defects
Valproic acid, pregnancy
neural tube defects
Warfarin and pregnancy
chondrodysplasia
Aneuploidy
numeric chromosome abnormalities in which cells do not contain 2 complete sets of 23 chromosomes
occurs because of nondisjunction
most common anueploidy is trisomy
Most common trisomy in first trimester losses
16
most common trisomy at term
21
Polyploidy
sets of extra chromsomes
Triploidy: 69 chromosomes
Tripolidy = incomplete molar pregnancy
Chromosomal Mosaicism
When an individual has 2 or more cell populations with a different chromosomal makeup
Anatomical structures cut in an episiotomy
vaginal epithelium, transverse perineal and bulbocavernosus muscles; and perineal skin
Risk Factors for Cord Prolapse
Polyhydramnios Preterm delivery Malpresentation Unstable pregnancy multiple pregnancy
Sudden CTG deceleration after membrane rupture in polyhydramnios. What is the most likely cause
Cord prolapse
How do you confirm cord prolapse
Vaginal Examination: a loop of umbilical cord will be palpated in the vagina and will be pulsatile
Avulsion of what can cause an anterior vaginal prolapse
ATFP: Arcus Tendineus Fascia Pelvis
How is prolapse staged
POPQ system Pelvic organ quantification system Stage 0-4 0= no prolapse 4= complete eversion of the genital tract
Non surgical management options for prolapse
Reasurane Manage medical conditions that worsen prolapse (constipation, chronic cough) address lifestyle issues pelvic floor exercises oestrogen replacement pessary
Side Effects of pessary use
Vesicovaginal fistula
vaginal discharge
vaginal bleeding
Recommended folic acid dose in pregnancy
0.5mg
recommended folic acid for diabetics in pregnancy
5mg (daily for 6 weeks before conception
How long should second stage last?
2 hours in nulliparous
1 hour in multi
(epidural add 1 hour)
