Obstetrics Flashcards
Infertility risk factors
Age >35 Smoking Coital frequency (er, infrequency) EtOH Weight (high or low) Drugs (NSAIDs, chemo, cimetidine, sulfasalazine, androgen injections) Occupational hazards
Clomiphene
Helps induce ovulation
If >3 follicles develop (i.e. response too high), don’t complete cycle or avoid sex or may have multiple pregnancy
Tx-PCOS as cause infertility
- Clomiphene
- Metformin
- Recombinant LH/FSH
- Ovarian diathermy
Complications ovarian hyperstimulation
Hypovolemia Electrolyte disturbances Ascites Thromboembolism Pulmonary edema
Female sterilization
1/200 failure Clips preferred method If failure occurs-most likely ectopic Both doc and woman must be satisfied that there will be no regret--older, completed family, disease contraindicates pregnancy Can do IVF in future. Reversal not on NHS
Male sterilization
1/2000 failure–must wait for 2 semen-free analyses (may take up to 6/12)
Clips preferred method
Complications: infection, chronic pain, “sperm granulomas” (lump at end of vas)
Not associated with prostate or testicular cancer
Reversal not on NHS
Steps to assisted repro
- S/C gonadotrophins OD for 2/52 and HnRH analog/antag to prevent endogenous LH surge
- Ovulation and egg collection; single injection hCG or LH for oocyte maturation
- Incubate egg with washed sperm
- Transcervical uterine transfer
Causes female subfertility
Anovulation Hypothalamic gonadism Hyperprolactinemia Hyper or hypo-thyroidism Adrenal hyperpalsia Ovarian causes (PCOS, gonadal dysgenesis) Tubal factor Infxn Endometriosis Previous sx Cervical factor Abs to sperm Inadequate mucus Cone biopsy
Causes male infertility
Idiopathic Varicocele Abs Genetic Drug/chemical exposure CF kartageners
Complete mole
Two sperm (90%) or haploid sperm that duplicates (10%) and fertilizes empty ovum. 46XX or 46XY
Cystic swelling chorionic villi
No fetal tissue
Grape-like clusters/snowstorm appearance on USS
2-3% risk choriocarc
Partial mole
2 sets paternal, one maternal. 69XXY or 69XXX
Fetal tissue present
Minimal risk choriocarc
Choriocarcinoma mets
To lungs, liver, brain
RF gestational trophoblastic disease
Asian
Sxs-GTD
Amenorrhea, HMB, irregular bleeding, uterine enlargement greater than expected for dates, hyperemesis
Red flags: Dyspnoea, neuro sxs, abdo pain weeks-months after last pregnancy
Tx-GTD
Suction curettage if small enough
Medical evacuation if large (not if risk embolization/disseminated trophoblastic tissue through venous system)
Down’s screening
Nuchal scan 11-14w Combined test (nuchal, b-hCG, papp-a): 11-13+6w
Screening for gestational diabetes
If previous GDM: 16 week OGTT
Other risk factors: 24-28 weeks
Not routine screening
Glucose should be
RFs for pre-eclampsia
Nullip BMI>30 >40yrs FHx pre-eclamp Previous hx pre-eclamp Multiple preg Pre-existing renal or vascular disease Pregnancy interval >10yrs Autoimmune disease, e.g. antiphospholipid, SLE Afro-Caribbean, Asian
NB smoking decreases risk so go wild
Indications for immediate health care advice (in terms pre-eclampsia)
Severe HA Vision problems, blurring, flashing Severe pain just below ribs Vomiting Sudden swelling face, hands, feet
Pre-eclampsia
Proteinuria >0.3g/24 hrs
HTN
Vasa previa
Fetal BVs cross/run near external orifice of uterus. At risk rupture when membranes rupture….can lead to fetal exsanguination/death
RF: multiple gestation, IVF
triad: membrane rupture, painless vaginal bleeding, fetal bradycardia
Tx: immediate emergency CS
Placenta previa
Leading cause APH (1/3 cases)
“Low lying palcenta”
Grades I-IV
Sxs: painless bright red vaginal bleeding, oft around 32/40. Suspect this dx if bleeding after 24/40
May also present with failure engagement
Dx: US. TVUS>TAUS
Tx: if grades I, II can do vaginal birth. Placenta must be >2cm from os…have consultant and anesthetist present
‘Roids 24-34/40 if bleeding in case pre-term
CS if high grade or fetal/maternal disress
No CS if DIC–may require hysterectomy
Point at which gestational sac seen on TVUSS
4-5 weeks
Point at which yolk sac seen on TVUSS
5 weeks
Point at which embryo seen on TVUSS
5-6 weeks
Point at which heart beat seen on TVUSS
6 weeks
Threatened miscarriage
Bleeding in early pregnancy
Inevitable miscarriage
Cervix open
Complete miscarriage
Successfully expelled all pregnancy tissue
Early weeks-like heavy period
Late first tri-may resemble sac
Incomplete miscarriage
Partially expelled.
Heavy bleeding and cramping
Missed miscarriage
Preg tissue dies but not expelled.
No fetal heart, devel
Empty gestational sac
CVS
Aka CVB (B=biopsy)
Biopsy trophoblast cells from developing placenta
From 11 weeks
2% risk MC
Amniocentesis
15-20mL amniotic fluid sampled (contains amniocytes and fibroblasts shed from fetus)
From 15 weeks
1% risk MC
Cordocentesis
From 20 weeks.
Can get fetal blood and full culture for karyotype
2-5% risk MC
Quad screen results for Downs
Decreased AFP and estriol
Increased b-HCG and inhibin A
(Also decreased PAPP-A)
Ectopic pregnancy:
RFs
H&E
Roughly 1%
95% in fallopian tubes
RFs: anything that causes tubal scarring–PID, previous ectopic, pelvic surgery (esp tubal), smoker
Hx: lower abdo pain, scanty dark vaginal bleeding.
Syncope and shoulder tip pain if intraperitoneal blood loss
May have abdo and rebound tenderness, cervical excitation (PID), tender adnexa, smaller uterus than expected, closed os
If positive for hCG and uterus empty, quantify hCG
Management ectopics
If small,unruptured, location unclear, hCG
Dizygotic twins: #amnions, chorions
Always dichorionic, diamniotic
Monozygotic twins: # amnions, chorions
Depends on when egg splits: Days 1-3: DCDA 4-8: MCDA 8-13: MCMA 13-15: conjoined
Which is more dangerous: monochorionic or dichorionic
Monochorionic
RF twins
IVF, older mother, high parity, Afro-Caribbean, maternal FHx
Twin-Twin transfusion
In monochorionic–placental vascular anastamoses
Donor: hypovolemia, oliguria, oligohydram
Recipient: hypervolemia, polyuria, polyhydram, myocardial damage, high output failure
Can drain large volumes amniotic fluid every 1-2w
Post-partum hemorrhage: management
ABC, fluid resusc, oxytocin (40 units in 500mL saline over 4hrs)
Uterine massage, bimanual compression
VE for tears-compress
Ergometrine, PGF2alpha, misoprostol (uterine contrac)
Catheter
FFP, paltelets, cryoprecip
Sx: uterine tamponade, occlude uterine vessels, iliac artery ligtion, uterine compression sutures, hysterectomy
Mechanism pre-eclampsia
BV endothelial damage–exaggerated inflamm response causing vasospasm, increased capillary permeability, clotting dysfunction
Maternal complications pre-eclampsia
Eclampsia Cerebrovascular hemorrhage HELLP syndrome DIC, liver failure, liver rupture Renal failure Pulmonary edema -->ARDS
Fetal complications of pre-eclampsia
IUGR Pre-term delivery Stillbirth Abruption Hypoxia
Indications for 75mg aspirin treatment from 16/40
Hypertensive disease in previous preg CKD AI (antiphosph syndr, SLE) DM Chronic HTN
Urgent delivery in pre-eclampsia
Persistent BP >160/100 with signif proteinuria HELLP Eclampsia Anuria Significant fetal distress
Delivery: mild pre-eclampsia
By 37/40
Delivery moderate-severe pre-eclampsia
34-36/40
Delivery severe pre-eclampsia with fetal distress
Deliver regardless of gestational date
First line for HTN in pregnancy
Nifedipine PO
First line severe HTN in pregnancy
Labetalol IV
Why isn’t methyldopa first line for HTN in pregnancy
While has longest record of safety takes 24 hrs to work
Prevention and treatment seizures (eclampsia)
MgSO4
Tx-GDM
- Diet and exercise (most ok with only this)
- Insulin (doesn’t cross placenta)
- Metformin
- Other oral hypolycemics (glibencamide)
Pre-existing DM
RETINAL SCAN booking and 28/40
Renal assessment and booking, refer if Cr>120 umol/
Complications GDM
Oligohydr causing pre-term delivery Neonatal hypoglycemia Big baby (shoulder dystocia) Fetal RDS (insulin inhibits surfactant)
Pulmonary hypertension before conception
Don’t conceive. If you do, get abortion.
Extremely high maternal mortality. Pregnancy contraindicated
Metal valves in pregnancy
Only indication for warfarin despite teratogenicity
Asthma in pregnancy
Meds safe
Same chance asthma will improve, stay same, or deteriorate
Thyrotoxicosis in pregnancy
No radioactive iodine
Carbimazole or PTU in smallest dose possile
Epilepsy in pregnancy
Continue meds. Add 5mg folic acid
Avoid valproate if possible.
Carbamazepine, lamotrigine safest
If no seizures in >2 years, can consider stopping
Seizure control can deteriorate in preg and labor..can cause maternal death
MS in pregnancy
Can use a;; MS drugs except cyclophosphamide and MTX
Migraine in pregnancy
Usually improve in pregnancy
Analgesics, anti-emetics, trigger avoidance
If severe–low dose aspirin, beta blockers
Acute fatty liver in pregnancy
May be a part of pre-eclamp
High maternal and fetal mortality
Sxs: malaise, vomiting, jaundice, epigastric pain (early), thirst
tx: correct clotting defects, hypoglycemia. Supportive: dextrose, blood, fluid balance, maybe dialysis
Intrahepatic cholestasis in pregnancy
Itching without rash, abn LFTs. FAmilial
50% recurrence
Risk sudden stillbirth, preterm delivery
Tx: monitor LFTs. Vit K 10mg/day
UCDA decreases itching and reduces obs risk
Advice induction at 38/40
Consultant care
Antphospholipid syndrome
Lupus anticoagulant and/or anticardiolipin Abs (measured twice, 3/12 apart)
Associated with adverse preg outcomes, incl RMC
PLACENTAL THROMBOSIS
SLE in preg
Steroids, azathioprine, sulfasalazine, hydroxychloroquine ok in preg. Avoid NSAIDs 3rd tri
Aspirin, LMWH antenatally and 6/52 post-natally
Manage preg as v high risk: serial USS, elective IOL by at least term
Combined test for Downs
USS (NT)
Blood: PAPP-A, beta HCG
Breast cancer in pregnancy
Tricky.
If earlier, may consider termination
Tamoxifen contraindicated
Radiotherapy contraindicated unless life saving
Chemo potentially teratogenic but may be used mid to third trimester….deliver minimum 2-3w after last treatment
Placenta accreta
Firm adhesion placenta to uterine wall without extending through full myometrium
Placenta increta
Extends through full myometrium
Placenta percreta
Extends through myometrium and beyond
RF -accreta,increta, percreta
Uterine scar tissue, e.g. Ashermans
Routine infection tests in pregnancy
HIV
Syphilis
Rubella
HBV
First line treatment for PPH
Fluid resuscitation, oxytocin, uterine massage
First line treatment for PPH didn’t work. Now what?
IV ergometrine and bimanual uterine compression
Tx-Bartholins
Marsupialization
IVF risks
Increased risk ectopics, congenital abnormalities, multiple pregnancy, SGA babies, low birth weight babies
If donor eggs, increased risk PIH
Initial subfertility tests
Day 1-3 LH and FSH
Mid-luteal progesterone
Semen analysis
Normal semen analysis
1.5-6mL pH 7.2-8 >4% normal morphology >15million sperm/mL 50% have normal motility
Ovarian hyperstimulation syndrome
Due to ovarian stimulation in IVF
Abdo pain, swelling, vomiting
Hemoconcentration, hypoproteinemia, ascites
Enlarged ovaries
High risk VTE
Oliguria if severe
Suspicious CTG
1 non-reassuring feature
Pathological CTG
2 non-reassuring or 1 abn feature
Non-reassuring CTG features
HR 160-180 or 100-109
Variability
Abnormal CTG features
HR >180 or 90min
Single prolonged decel >3min
Atypical variable decels
Management suspicious CTG
Fetal blood sampling.
Deliver if abnormal
Management cord prolapse
Help help help
Deliver immediately in theatre
If cervix not fully dilated–CS
Elevate presenting part with midwive’s hand or fill up bladder (reduces compression on cord)
Induction for stillbirth
Mifepristone (cervical ripening)
Misoprostol (contractions)
Turtleneck sign
Head delivered but then appears to retract
Heralds shoulder dystocia
Management shoulder dystocia
McRobert’s position
(Flexion everything)
In majority of cases, baby will spontaneously deliver this way
Management uterine rupture during normal labor
Crash CS with subsequent repair uterus.
Risks for third degree tears
Forceps and ventouse 2nd stage >1hr Shoulder dystocia Big baby (>4kg) Primip Induction OP position Midline episiotomy
Management PPROM
10 days Abx to prevent chorioamnionitis
Roids
Expectant management until 34w
Management PE in pregnancy
Enoxaparin (clexane)
Vasa previa
At time rupture of membranes
Painless bleed and sudden fetal demise
Management RhD negative woman if dad is also RhD negative
Still give anti-D because 1/10 “dads” aren’t the actual father…. :/
HSV (genital) in pregnancy
No vaginal deliveries for six weeks. Do CS
if refuses, give IV acyclovir during labor and tell her she’s a bad person
Obstructive cholestasis
Itching and deranged LFTs, esp bile acid (>20)
Main concern is stillbirth. Increase in pre-term labor and mec-stained liquor
UDCA decreases pruritis and bile acids but no evidence it reduces stillbirths
Continuous CTG
Management eclamptic fit
Help help help
Lie woman flat and in left lateral position
Prepare MgSO4
Travel to malaria-endemic region during pregnancy—prophylaxis
Chloroquine
Proguanil if take 5mg folate
Caution with mefloquine
Do not use malarone, doxy
First line hyperemesis gravidarum
Promethazine (anti-histamine)
Causes hyperechogeniec bowel
CF
Down’s
CMV infection
