Obstetrics 4 Flashcards
When a placenta previa is picked up at 20 week scan when are they next scanned for the position?
32 weeks
What are the risk factors for preterm:
Too much inside:
- multiple pregnancy
- polyhydramnios
Placenta defects (fetus wants out)
- IUGR
- Chromosomal abnormalities
Poor integrity of the uterus:
- short cervix (previous LETZ procedure)
- lots of previous pregnancies (uterus
stretched)
Maternal:
- smoking
- Low BMI
- Alcohol
- Maternal disease (Gestation diabetes)
- maternal age
Infection
- UTI infection
- Chorioamnionitis
What investigations do you want into a woman who you think is about to go into preterm labour?
Bloods: - FBC - U&Es - G&S (incase they go into labour)
+/- blood cultures - looking for causes of going into preterm
Orifices:
- Urine dip
- High vaginal swap
Preterm labour tests:
- fetal fibronectin
- Actim
What are some differentials for contractions?
Braxton Hicks
- doesn’t lead to cervical changes
MSK
UTI
- very common
How long are tocolytics used during pre-term labour?
48 hours
they don’t stop labour they just give time for steroids to work
What are two non-pharmacological managements to help prevents PPH?
Uterine rub
- massaging the fundus to stimulate contraction
Early suckling
- increases oxytocin release causing contraction
What are the core reasons for failure of progression?
Insufficient uterine contractions
- maternal fatigue
Palpresentation
Malposition
- anterior occipital
Cephalo-pelvic disproportion
Cervicle dystocia
What are the components of the Bishop score?
Position of the cervix
Dilation
Effacement
Consistency (how firm does it feel)
Fetal station
What are the risks of oxytocin?
Uterine Hyperstimulation
- normal is <4 contractions per 10mins
- excessive contraction can cause fetal distress
Uterine rupture
- more common in multiparous women
Water intoxication
- oxytocin has ADH like properties
What are some complications of artificially ventilating a a preterms lungs?
Retinopathy of prematurity
Pneumothorax
Pulmonary interstial emphysema
If there is artificial rupture of the membranes and patient starts to bleed and there is fetal distress what is the likely underlying diagnosis?
Vasa praevia
What are some risk factors for placental abruption?
Previous placental abruption C-section ECV Cocaine use pre-eclampsia
When is Antepartum officially diagnosable and what is before it?
Antepartum is >24 weeks
<24 weeks is miscarriage type bleeding
In a woman with antepartum bleeding what questions, examinations and investigations do you want to do?
Questions:
- Pain
- Fetal movement?
- When are they due?
- Ask about risk factors?
- Sex before bleeding?
Examination:
- Abdominal
- Speculum
- do not do vaginal examination due to risk of placenta previa
Bloods:
- FBC
- U&Es
- Coagulation
- LFTs
- CXM
- Keilhauer test
Orifices:
- Urine analysis
X-rays:
- USS
Baby:
- CTG
List some current risk factors in a pregnancy that would warrant it to be high risk and thus consultant led on the red pathway.
Multiple pregnancy
PV bleeding in 1st sememster
> 2 UTIs
Hypertension
Proteinuria
Pre-eclampsia
Placenta abnormalities
Malpresentation at 36/40
When should Anti-D be given following a sensitising event and how is it administered?
Within 72 hours of the event
- IM injection
What screening can be done to assess the risk of a woman going into pre-term labour? and which women are offered this screening?
Cervical length screening
Offered:
- Previous preterm birth
- 2nd trimester loss
- Previous LETZ operation
- Cone biopsy
What tests do you want in in someone you suspect has entered preterm?
Bloods:
- FBC
- G&S
Orifices:
- High vaginal swab
- MSUS
Baby:
- CTG
Special tests:
- Fetal fibronectin
- Actim Partus
What are the complications of epidurals?
Hypotension
Prolonged 2nd stage
Risk of instrumental delivery
In a normal delivery when is syntocinon given? and by which route?
IM following delivery of anterior shoulder
Or if there is failure to progress - oxytocin can be given to speed things up
When has established labour said to begun?
Regular painful contractions with >4cm dilation
What is it called when the fetus head enters into the pelvis and when may this occur?
Engagement
- usually occurs some 2-3weeks prior to delivery
- sits in flexed position
Why does the baby enter into the pelvis cavity at a transverse position then move into a anterior-occipital position and what is the final movement of the head to allow allow delivery of the shoulders?
Engagement: occipital transverse position
- widest part of head fits through widest part of pelvic inlet
Entering into pelvis floor: Flexion of head
- compressed against the floor the baby will flex its neck
- creates smaller size
Passes further down: Occipital - anterior position
- this is seen as crowning
Passing under the arch: extension of head
External rotation of head to a occipital transverse position
- head is delivered
Restitution: shoulders rotate transversely to follow
What are some contraindications to fetal blood sampling?
Maternal infection
- HIV
- herpes
<34 weeks
Haemoglobinopathies
Breech presentation
List some indications for induction of labour:
Post term
Maternal compromise
- if mother has underlying health conditions it may be safer to carry out induction at 37 weeks
Diabetes
Fetal distress
PROM
- if >37 weeks and spontaneous labour hasn’t occurred then induction is usually done since the risk of infection outweighs preterm complications
Maternal age
What are two of the main complications of oxytocin use?
Uterine hyperstimulation
Fluid retention and reduced urine output
- has ADH like properties
What can be done prior to induction:
Membrane sweep
This is a help adjunct which can stimulate labour increasing the chances of labour within 48 hours.
typically used at 40-41 weeks.
For a still birth what is the most appropriate management to induce labour?
Use of misoprostol and mifepristone
*misoprostol has increased risk of uterine hyperstimulation which is harmful to an alive baby but in this situation it is not warranted
What are the values for gestation diabetes and does it resolve following pregnancy? what are some risk factors for it?
Fasting glucose: >5.6
OGTT: 7.8
Yes it resolves following pregnancy
Risk factors:
- previous GDM
- BMI >30
- Previous macrosomia baby
- South Asian
- PCOS
*any of the above risk factors should initiate the fasting and OGTT
What are the complications of GDM for the mother and fetus?
Maternal:
- increased UTIs
- increased risk of pre-eclampsia
- increased risk of C-secretion or instrumental delivery
- increased risk of PPH
Neonate:
- hypoglycaemia
- macromania - shoulder dystocia
- Respiratory distress syndrome of new born due to poor production of surfactant
How is gestational diabetes managed during pregnancy?
Multi-disciplinary care:
- endocrine
- obstetrics
- dieticians
Aim for bloods between 4-7mmol.
1st line:
- diet exercise
If not met:
- metformin
> 7mmol
- Insulin
Delivery:
- CTG monitoring
- at a centre with NICU
- remove insulin postpartum
- aimed for 38-39weeks induction
Does having gestational diabetes increase the likely hood of the mother developing diabetes in the future?
Yes.
*6 weeks postpartum women should be offered a fasting blood glucose test.
50% likely to in the next 10 years.
Where does the rupture occur in placenta abruption? and list some risk factors:
Occurs in the decidua basalis
Risk factors:
- previous placental abruption
- C-section
- Smoking
- Pre-eclampsia
- external cephalic rotation
Is smoking a risk factor for pre-eclampsia?
no.
In pre-eclampsia what is looked for on US and how often should they be done?
Every 2 weeks:
looking for:
- Monitoring growth
- liquor volume (this demonstrates fetal urine output which is proportional to placenta function)
- Umbilical artery flow
When are ant-hypertensives started in pre-eclampsia?
150/100mmHg
or
>30mmHg from baseline
What can be given prophylactically at intra-partum for pre-eclamptic women and when should they followed up and what’s the prognosis?
Magnesium sulphate can be given prophylactically at birth for severe cases
Follow up 6 weeks in primary care
- assess BP
- urinalysis
Prognosis:
- 25% likely to have pre-eclampsia in another pregnancy
- increased likely hood of cardiovascular disease in the future
What are some differentials for preterm labour?
Essentially differentiating if someone is in labour:
- Braxton Hicks contractions
- MSK pain
- UTI
Placental differentials:
- placenta abruption
- uterine rupture
Whats your management of preterm labour?
Identify causes:
- UTI, infection etc
Confirm:
- fibronectin
if <4cm:
- corticosteroids
- tocolytics (for 48 hours)
- inform neonatal team
> 4cm:
- corticosteroids
- inform neonatal team
- <30 weeks magnesium sulphate
- IV antibiotics if group B strep
What are some risk factors for preterm labour?
previous pre-term smoking pre-eclampsia cervical incompetence infection multiple pregnancy
**these are also the risk factors for PPROM
What are the investigations that should be done into suspected chorioamnionitis and what is the gold standard investigation? and what are some risk factors?
Bloods:
- FBC
- CRP
- U&Es
- ABG
Orifices:
- high vaginal swab
- urine culture
Chest x-ray
CTG monitoring
gold standard:
- amniotic fluid cultures
- this is rarely done though as it usually adds little to the evidence of chorioamnionitis
Risk factors:
- group B step colonisation
- Pro-longed rupture of membranes
- preterm
- Young mother
- UTI infection
What measurements are used to assess the estimated fetal weight and list the general management of IUGR along with some risk factors:
Measurements:
- head circumference
- abdominal circumference
- femur length
General management for suspected IUGR
- umbilical artery doppler studies
- Growth scans (to guide delivery management)
- maternal assessment (BP, infection etc)
Delivery:
- <36 weeks: steroids
- <30 weeks: Magnesium sulphate
C-section at 37 weeks
C-section at 34 weeks if reverse diastolic flow
*C-section due to risk of fetus during delivery.
Risk factors:
- Maternal age >40
- maternal illness (diabetes)
- Drugs and smoking
- pre-eclampsia
- maternal nutrition
What is the management for Haemolytic disease of the fetus/ newborns and list some sensitising events and what is the major complication in-utero?
Sensitising events:
- Abortion
- Ectopic
- External cephalic rotation
- Amniocentesis
- Antepartum bleeding
- Trauma
Management:
- Delivery at 36 weeks.
Severe:
- intrauterine blood transfusion
- Delivery of fetus then blood transfuse
Newborns:
- Jaundice management - usually needs transfusion
Major complication in-utero:
- fetalis hydrops
When is Anti-D given?
28 weeks
Following sensitising events
At birth
- following sampling of the umbilical cord to see status of child
How is delivery of a still birth conducted and what important drugs should be considered for another side effect which may be distressing to the mother:
Mifepristone
+
Misoprostol
Dopamine agonists
- to supress lactation
What is the ‘best’ treatment for pre-eclampsia?
Delivery of baby and placenta
What advice can be given to parents following a miscarriage?
Next menstrual cycle will be different and heavier
- endometrium returning to normal
Avoid trying to conceive for another month
80% chance of successful future pregnancy
What is Asherman’s syndrome?
Adhesions within the uterus due to surgical procedures
Why might seizures become more frequent in pregnancy in patients who suffer from epilepsy?
Change in medication
Increased dilution of anti-epileptic medication due to increased blood volume
Increase in steroid binding hormone can lower anti-epileptic medication
Increased amounts of vomiting
What is general management of epilepsy in pregnancy?
Consultant led with obstetricians and neurologists.
Folic acid 5mg in first trimester
Mono-therapy - carbamazepine is ideal
Life style advice
- no swimming
- adequate sleep
Labour:
- careful hydration
- avoidance of pethidine (lowers seizure threshold)
- birth in special unit
- continual CTG monitoring
Post-partum:
- anti - epileptics are safe in breast feeding
- if on COCP dose adjustment may be needed due to CYP450 enzyme activity
What is the follow up of Gestational diabetes?
6 weeks follow up - assess blood glucose levels
50% chance of developing DM within 10 years
What are some neonatal complications of diabetes in pregnancy?
Hypoglycaemia
Birthing injuries
Respiratory distress
- high glucose shuts off surfactant production
Jaundice
Still birth
What are the risks associated with hypothyroidism in pregnancy?
Miscarriage/ still birth
PPH
Reduced IQ of child
IUGR
Deafness
If a mother has hypothyroidism what should be done to the levels of medications following confirmation of pregnancy?
Increase dose by 25%
*returns to normal after pregnancy
