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Phase 2 > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

What are the key components of a history in pregnancy?

A 
Amenorrhoea
Previous periods
Contraception
Whether planned pregnancy
Date positive pregnancy test
Smoking, alcohol, drugs, infections, blood group
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2
Q

What are the criteria for instrumental delivery?

A

Adequate analgesia
Abdo exam: head either 1/5 or 0/5 palpable
Vaginal exam: fully dilated, known fetal position
Adequate maternal effort and regular contractions for ventouse
Empty bladder

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3
Q

What are the complications of instrumental delivery?

A 
Genital tract trauma
Haemorrhage
Infection
Fetal scalp oedema
Bruising
Facial nerve palsy
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4
Q

What are the indications for emergency C-section?

A 
Placenta praevia
Breech
Abnormal CTG
Cord prolapse
Delay in 1st stage
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5
Q

What are the indications for elective C-section?

A 
2 previous LSCS
Maternal disease eg pre-eclampsia
Maternal request
Active genital heroes
HIV depending on viral load
Twin pregnancy if twin 1 not cephalic
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6
Q

What are the complications of C-section?

A 
Haemorrhage
Gastric aspiration
Bladder or bowel injury
Infection
VTE
Future pregnancy
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7
Q

What should be done at a pregnant lady’s first contact with a healthcare professional?

A

Folic acid 400mcg daily
Food hygiene
Smoking cessation, drug and alcohol use
Screening: haemoglobinopathies, anomaly screen and screening for down’s

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8
Q

When is the “booking” appointment?

A

Ideally by 10 weeks

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9
Q

Who should have screening for gestational diabetes?

A 
BMI over 30
Previous macrosomic baby >4.5 kg
Previous gestational diabetes
1st degree family history
Ethnicity
Hypertension
Pre-eclampsia
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10
Q

What are the risk factors for pre-eclampsia?

A 
>40
Nulliparity / pregnancy interval >10y
Family history
Previous history
BMI>30
Hypertension
Renal disease
Multiple pregnancy
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11
Q

What are the symptoms of pre-eclampsia?

A 
Severe headache
Problems with vision
Severe pain just below ribs
Vomiting
Sudden swelling of face, hands or feet
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12
Q

What is the routine screening for Down’s syndrome?

A

Combined test between 11 and 14 weeks
Nuchal translucency, beta-hCG and PAPP-
Confirmatory diagnostic CVS or amnio if positive

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13
Q

What is the quadruple test for Down’s syndrome?

A

Can be used from 14+2

hCG, AFP, uE3 and inhibin-A

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14
Q

What is defined as high risk for Down’s?

A

1 in 150

This is the level at which patients are offered further testing (CVS or amnio)

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15
Q

When is the anomaly scan done?

A

Between 18 and 21 weeks

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16
Q

What is the purpose of the anomaly scan?

A

Reproductive choice (TOP)
Parents can prepare
Managed birth in a specialist centre
Intrauterine therapy

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17
Q

How many appointments do women have in an uncomplicated pregnancy?

A

10 for primips

7 for multi

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18
Q

What happens at every antenatal visit?

A

BP and urinalysis
From 24: symphysis-fundal heigh
From 36: check presentation

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19
Q

When is anti-D prophylaxis given?

A

28 weeks

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20
Q

What are the common symptoms of pregnancy?

A 
Nausea and vomiting
Heartburn
Constipation
Haemorrhoids
Vaginal discharge
Varicose veins
Backache
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21
Q

What happens in pregnancy over 41 weeks?

A

Offer membrane sweep
Induction if beyond 41
If IOL declined after 42 weeks, increased surveillance with CTG and USS

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22
Q

What is the management of breech presentation at term?

A

Offer external cephalic version in uncomplicated singleton

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23
Q

What is the management of baby blues?

A

If not resolved after 10-14 days, assess for PND. If symptoms persist then seek urgent further action

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24
Q

How do you manage perineal pain postnatally?

A

Offer to assess
Signs of infection, wound breakdown or non-healing require urgent action
NSAIDs, topical cold therapy

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25
Q

What life-threatening conditions may present postnatally?

A 
PPH
Infection or genital tract sepsis
Pre-eclampsia / eclampsia
PE
DVT
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26
Q

What does smoking in pregnancy increase risk of?

A 
Premature rupture of membranes
Placental abruption
Placenta praevia
Premature birth
Small placenta
Umbilical cord problems
Pregnancy-induced hypertension
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27
Q

What are the effects on a newborn child of smoking during pregnancy?

A

Low birth weight
Sudden infant death syndrome
Cerebral palsy
Future obesity

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28
Q

How does smoking affect breastfeeding?

A

Decreases milk production
Alters milk composition
Nicotine can enter breast milk

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29
Q

How should you examine a woman with a gravid uterus?

A

Not lying flat
Risk of postural supine hypotension syndrome - pregnant uterus compresses aorta and reduces blood flow back to maternal heart

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30
Q

What are the components of abdominal palpation of a pregnant woman?

A
  1. Uterine size
  2. Number of foetuses
  3. Fetal lie
  4. Fetal presentation
  5. Engagement
  6. Position of presenting part
  7. Liquor volume
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31
Q

How do you palpate for uterine size?

A

Use medial border of hand and move down starting at the xiphisternum
Measure distance from fundus to symphysis pubis in cm

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32
Q

What levels equate to what weeks of pregnancy?

A

Symphysis pubis 12 weeks
Umbilicus 20 weeks
Xiphisternum 36 weeks

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33
Q

What is fetal lie?

A

Relationship of long axis of fetus to long axis of uterus

Longitudinal, transverse or oblique

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34
Q

What is fetal presentation?

A

The part of the fetus that presents to the maternal pelvis

Cephalic, breech, oblique

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35
Q

What is malpresentation?

A

Any presentation other than cephalic

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36
Q

When is the fetus engaged?

A

When the widest diameter of the head (biparietal diameter) has passed through the pelvic brim

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37
Q

How do you determine whether the fetus is engaged?

A

Determine what proportion of the fetal head is palpable abdominally
>3/5 palpable per abdomen means it is not engaged

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38
Q

How do you decide the position of the presenting part?

A

Relationship of the denominator of the presenting part (eg occiput in cephalic) to the maternal pelvis

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39
Q

How can you clinically assess liquor volume?

A

Best by USS, but can determine if:
SFD uterus & easily palpable fetal parts - decreased liquor vol
LFD uterus, smooth and rounded and fetal parts difficult to palpate - increased liquor volume

40
Q

What is the vulva likely to look like in pregnancy?

A

Swollen and oedematous due to engorgement ( increased blood flow in pregnancy)

41
Q

How do you determine dilatation?

A

In fingers’ breadth: 1 finger is 1cm

42
Q

What is the normal length of the cervix (when not in labour)?

A

3cm

43
Q

What happens to the length of the cervix in labour?

A

Shortens as it effaces

44
Q

What happens to the consistency of the cervix as pregnancy progresses?

A

Softens

Can be firm, mid-consistency or soft

45
Q

What is the Bishop score?

A

Evaluates the ripening or favourability of the cervix

Higher the score, more favourable the cervix and the more likely induction of labour will be successful

46
Q

What features are used to calculate the Bishop score?

A 
Dilatation in cm
Cervical length
Station of presenting part
Consistency of the cervix
Position
47
Q

What aspects should be taken into account when commenting on progress in labour?

A 
Engagement of head
Cervical dilatation
Cervical effacement
Station of head in relation to ischial spines
Position of head
Liquor colour
48
Q

What is term?

A

37 weeks

49
Q

What is pre-term?

A

24-37 weeks

50
Q

What are the main problems with premature babies?

A

Brain damage
Poor lung maturation
Jaundice
Small size

51
Q

What questions should you ask in a patient presenting to MAU?

A 
Abdominal pain
Bleeding
Discharge
Pelvic pain
Fetal movements
Lower urinary tract symptoms
Bowels
Generally well?
52
Q

What are the symptoms of pre-eclampsia?

A

Dizziness
Oedema
Visual disturbance
Epigastric pain

53
Q

What are the signs of labour?

A

Contractions (CTG)
Regular uterine contractions that are increasing in frequency
Cervix dilated and effaced
Show should have been lost

54
Q

What is the show?

A

Cervical mucus plug

55
Q

What is the key differential for abdominal pain in the 2nd and 3rd trimester?

A

Is the pain obstetric or non-obstetric?

56
Q

What are the obstetric differentials for abdo pain in the 2nd and 3rd trimester?

A 
Labour
Placental abruption
Symphysis pubis dysfunction
Ligament pain
Pre-eclampsia / HELLP syndrome
Acute fatty liver of pregnancy
57
Q

What are the other differentials for abdo pain in the 2nd and 3rd trimester?

A

Gynae
GI
GU

58
Q

What are the features of placental abruption?

A

Pain more commonly associated with PV bleed
Uterus tender on palpation
Symptoms/signs of pre-eclampsia

59
Q

What are the symptoms of acute fatty liver of pregnancy?

A

Epigastric / RUQ pain
Nausea and vomiting
Anorexia
Malaise

60
Q

How do you listen to the fetal heart?

A

Before 26 weeks used pinard or sonicaid

CTG after 26 weeks

61
Q

How is pregnancy established?

A

Blastocyst enters uterine cavity 4-5 days after fertilisation
After a day or so it implants into the endometrium
Interaction between trophoblast cells and uterine epithelium

62
Q

What happens to the placenta during pregnancy?

A

Becomes progressively thinner as the needs of the fetus increase

63
Q

What are the aims of implantation?

A

Establish basic unit of exchange
Anchor the placenta
Establish maternal blood flow within the placenta

64
Q

Name 2 implantation defects

A

Ectopic pregnancy

Placenta praevia

65
Q

What is decidualisation?

A

Decidual reaction
Provides balancing force for invasive force of the trophoblast
Stimulated by progesterones

66
Q

Why do spiral arteries remodel?

A

To create a low resistance vascular bed which maintains high flow to meet fetal demand

67
Q

In pathophysiological terms, what is pre-eclampsia?

A

Placental insufficiency

Due to lack of low-resistance, high-flow vasculature

68
Q

What forms the maternal part of the placenta?

A

Decidua basalis

69
Q

What are the intervillous spaces?

A

Filled with maternal blood

Between chorionic and decidual plates

70
Q

What are the placental compartments?

A

Cotyledons
Decidual septae project into intervillous space but don’t reach the chorionic plate, so divide the placenta into cotyledons

71
Q

What is the placenta like in the 1st trimester?

A

Barrier to diffusion still thick

72
Q

What is the term placenta like?

A

Surface area for exchange increased

Placental barrier thin

73
Q

How many umbilical arteries are there and what do they do?

A

2

Carry deoxygenated blood from the fetus to the placenta

74
Q

How many umbilical veins are there and what do they do?

A

1

Carries oxygenated blood from the placenta to the fetus

75
Q

What are the maternal blood vessels of the placenta?

A

80-100 spiral arteries - Carry blood to cotyledons

Endometrial vein carries blood back from the chorionic plate

76
Q

What factors affect diffusion across the placenta?

A

Concentration gradient
Barrier to diffusion
Diffusion distance

77
Q

Why is pre-conception counselling so important?

A

Organogenesis occurs in the 1st 9 weeks of pregnancy

This is the time when teratogenic medications have the greatest impact - so important for women on these meds

78
Q

What hormones does the placenta produce?

A

hCG
hCS
Progesterone
Oestrogen

79
Q

How does oxygenated blood reach the fetus?

A

Via umbilical vein from the placenta

80
Q

What is the ductus venosus?

A

Allows blood to bypass fetal liver

81
Q

What is the foramen ovale?

A

Oxygenated blood passes from the right atrium to the left atrium

82
Q

What is the ductus arteriosus?

A

Allows blood to avoid the lungs

Goes from pulmonary artery to the aorta

83
Q

What are the fetal lungs like?

A

Very high resistance due to hypoxic pulmonary vasoconstriction

84
Q

What happens to the fetal lungs after birth?

A

Hypoxic pulmonary vasoconstriction removed when neonate takes its first breath

85
Q

What happens to the foramen ovale at birth?

A

Closes within minutes

Due to greater venous return to left atrium, increasing its pressure above that of the right atrium

86
Q

What happens to the ductus arteriosus and the umbilical artery after birth?

A

Increased O2 sats and decreased prostaglandins causes constriction of both

87
Q

What happens to the ductus venosus and umbilical vein after birth?

A

Stasis of blood causes clotting and closure due to fibrosis

88
Q

Describe the oxygenation of fetal blood

A

ppO2 in fetal blood very low compared to adult
Fetal HbF has much higher affinity for O2, so carries more O2 at a lower pH
Higher Hb levels than adult

89
Q

Describe fetal haemoglobin

A

HbF has much higher affinity for O2 than adult meaning it carries more O2 at lower partial pressure
Fetus has higher level of Hb (180 at birth)

90
Q

How is placental CO2 transfer made more efficient?

A

Lower maternal pCO2 due to hyperventilation (stimulated by progesterone) means diffusion gradient is more

91
Q

What are the functions of amniotic fluid?

A

Mechanical protection

Moist environment to prevent dehydration

92
Q

What is the quantity of amniotic fluid at 8 weeks and at term?

A

8 weeks: 10ml

38 weeks: 1 litre

93
Q

How does amniotic fluid production change during pregnancy?

A

Early: formed from maternal fluids and from fetal ECF

Later turnover is by fetus

94
Q

How is fetal urine produced?

A

Metanephros is functional embryonic kidney

Fetus swallows amniotic fluid constantly, absorbs water and electrolytes and debris accumulates in fetal gut

95
Q

What happens to fetal bilirubin?

A

Fetus can’t conjugate
Bilirubin crosses placenta and is excreted by mother
Neonate becomes jaundiced if conjugation doesn’t establish quickly - exposure to light stimulates this

Phase 2 (21 decks)

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