Obstetrics Flashcards
Booking bloods for pregnancy
Hb and platlets
HIV, syphilis, Hep B
Blood group and antibody status
Sickle cell and thalassaemia
When is the routine date scan usually done?
8+0 to 13+6 weeks
Blood tests for Down’s syndrome
A PAPPA-A
HCG
The quad test comprises of -
AFP
Inhibin A
Oestriol
Beta - Hcg
When is the quad test done ?
14-20 weeks
Diagnostic tests for Downs syndrome
Chorionic villous sampling
Amniocentesis
Private test for Downs syndrome
Cell free fetal DNA test
At what time is the anomaly scan done?
18+0 - 20+6
Risk factors for gestational diabetes
BMI >30 Some ethnic origins FH PCOS Previous baby >4.5kg Previous gestational diabetes
Potential sensitising events for Anti D
Spontaneous miscarriage Termination of a pregnancy Invasive procedures Traumatic events Placental abruption Fetomaternal haemorrhage Blood transfusions
When should prophylatic anti D be given?
28 weeks
Ages at risk if pregnant
<18
40+
What events in past pregnancies are significant ?
Premature labour Fetal growth restriction APH Gestational diabetes HTN Thrombocytopenia Types of delivery 3rd / 4th degree tear PPH Previous stillbirth, late miscarriage or neonatal death
Which family Hx is it important to elicit in this context?
Diabetes
HTN / pre eclampsia
Fetal growth restriction =
baby who does not reach it’s growth potential
risk factors for FGR -
Previous small baby pre-eclampsia / HTN reduced fetal movements maternal disease smoking
3 measurements used on US to estimate fetal weight -
abdo circumfrence
head circumfrence
femur length
How can a placental problem be identified?
Fetal vessel resistance
Reduced liquor volume
Management of FGR
Exclude underlying causes
Monitor
Timely delivery - fetal HR and blood flow
C-section?
Pregnancy induced hypertension =
HTN after 20 weeks
Pre-eclampsia -
HTN after 20 weeks with proteinuria
Risk factors for PET
First pregnancy Previous pre eclampsia >40 y/0 BMI 35 Multiple preg Pre-exisiting conditions
Maternal blood test when diagnosed with PET
u&e
LFTs
Urate
FBC
Fetal monitoring in a mum with PET
USS - fetal growth restriction
Markers of placental function
what infusion for eclampsia
magnesium sulfate
What happens in HELLP ?
Haemolysis, raised LFTs and low platelets (severe form of pre eclampsia)
What are obese women at risk of when pregnant?
Miscarriage Congenital malformations PET GDM Macrosomia VTE
What is the aim for BMI before falling pregnant?
<30
How is diabetes impacted by pregnancy
Increased insulin during preg
Worsening neuropathy and retinopathy
Increase in hypoglycaemic attacks
Maternal impacts of diabetes
Increase miscarriage risk Increase risk of PET Worsening renal disease Infections Higher induction rate LSCS rate higher Shoulder dystocia risk
Fetal impacts of diabetes
congenital malformations
unexplained still birth
Maternal hyperglycaemia leads to….
fetal hyperglycaemia which means there is increased production of insulin from the fetal pancreas. Therefore macrosomia can occur.
Before getting pregnant women with diabetes should….
lose weight quit smoking and alcohol take folic acid for 3m Switch to metformin / insulin HbA1c <48 Screened for retinopathy and nephropathy
How often should pregnant women be checking their BM?
Fasting
pre meal (omit if oral / diet controlled)
1hr post meal
bedtime
BM targets during pregnancy
Fasting <5.3
l hr post meal <7.8
maintaining above 4
USS app for women with diabetes in preg
Normal dating at 8-13 wks
Routine anomaly at 18-20
Serial growth scans every month from 28/40
What should be offered in terms of delivery for women with diabetes in preg
Elective delivery - IOL/ LSCS at 37-38+6
If complications can offer before 37 weeks
When should only LCSC be offered in women with diabetes in preg
EFW of >4.5kg
Which women are at risk of gestational diabetes?
BMI >30 Previous baby >4.5kg Previous GDM FH Ethnic origin
How is GDM diagnose?
28 weeks glucose tolerance test
fasting glucose >5.6
2 hr plasma glucose >7.8
Previous GDM what additional test should be done?
12-16/40 additional glucose tolerance test
When is FBC measured in preg?
Booking
28 weeks
Threshold for anaemia treatment in preg
<11g/dL @ booking
<10.5g/dL @ 28 weeks
What is the first line treatment for anaemia in preg?
Diet and ferrous sulfate.
Risk factors for VTE in pregnancy
Thrombophilia Age >35 BMI <30 Parity of >3 Smoker Immobility Gross varicose veins Multiple preg Medical co-morbidities Systemic infection
Up to when post delivery are women at risk of VTE?
6 weeks
Which group of women are particularly at risk of VTE post delivery and how are they treated?
C-section
given 7 days of LMWH
Initial imaging investigation for PE in pregnancy =
And what can be done next depending on the results?
CXR
normal / V/Q scan
Abnormal - CTPA
treatment of choice for VTE in pregnancy
LMWH
NOT WARFARIN
Management of HTN in preg
12weeks +
Aspirin 75mg OD
Treatment for eclampsa
MgSO4 - as decision to deliver is made
Monitor the urine output, reflexes, RR and SpO2
Fluid restriction - prevent overload
Advice on folic acid and pregnancy
400mg should be taken from roughly 3m before conception up to 12 weeks
Risks of not giving Anti-D in a preg.
Baby may become anaemic, fetal hydrops (accumulation of fluid) and risk of still birth
When is anti D given
28 weeks
or divided dose at 28 and 34 weeks
postnatally if sensitizing event
Obstetric causes of abdo pain in 2nd and 3rd trimester
Labour Placenta abruption Symphysis pubis dysfunction Ligamental pain Pre-eclampsia / HELLP
Gynae causes of abdo pain in 2nd and 3rd trimester
Ovarian torsion
Cyst rupture / haemorrhage
Uterine fibroid de-generation
GI causes of abdo pain 2nd and 3rd trimester
Constipation Pyelonephritis Gall stones / cholestasis Pancreatitis Peptic ulcer Cystitis Renal stones
from what number of weeks can a CTG be used?
26
How does labour present?
Uterine tightening
Fetus engaged
Cervical changes on vaginal exam
How does placental abruption present?
Mild - severe pain and vaginal bleeding
Uterus tender and tense
May be signs / symptoms of pre-eclampsia
Symphysis pubis dysfunction presentation
Pain low and central
Tender SP
Symptoms worse on movement
Ligament pain presentation
Sharp
Bilateral
Associated with movement
Pre eclampsia presentation
Epigastic / RUQ pain N&V Headache Visual disturbance HTN and proteinuria
Acute fatty liver of pregnancy presentation
Epigastric pain / RUQ
N&V
Anorexia
Malaise
Ovarian cyst presentation
Unilateral intermittent pain
May be associated with vomiting
Uterine fibroid presentation
localised constant pain
fibroid may be palpated - tender
Appendicitis presentation
Pain associated with N&V
Guarding and rebound tenderness
May localise to RIF
Gall stones / cholecystitis presentation
RUQ / epigastic pain
May radiate to the back / shoulder tip
Tenderness in R Hypochondria
Pyrexia
Pancreatitis presentation
epigastric pain radiating to the back
N&V
More common in 3rd trimester
Renal stones / renal colic / pyelonephritis presentation
Loin to groin pain
Associated vomiting and rigors
Pyrexia with pyelonephritis
50% of antepartum vaginal bleeding caused by?
Placenta praevia and placental abruption
Kleihauer test =
examine maternal blood film for the presence of fetal blood cells - suggests feto-maternal haemorrhage
Uterine causes of antepartum haemorrhage
Placenta praevia
Placental abruption
Vasa praevia
Circumvallate placenta
Lower genital tract causes of antepartum haemorrhage
Cervical ectropion Cervical polyp Cervical carcinoma Cervicitis Vaginitis Vulval varicosities
Risk factors for placenta praevia
previous c section previous pp advanced maternal age multiparity multiple preg smoking succenturiate placental lobe
Placenta praevia on examination
Uterus soft and non tender
non engaged / malpresentation
minor bleeding
What to avoid if suspect placenta praevia?
Digital exam
When is a follow up scan performed for placenta praevia?
36 weeks
When should a c - section be performed in placenta praevia?
if placenta encroaching within 2cm of the cervical os
if going to deliver a baby early what should you consider?
steroids for fetal lung maturity
Complications of placenta praevia?
Risk of PPH
What is placental abruption ?
Placental attachment to the uterus is disrupted by haemorrhage as blood dissects under the placenta.
Risk factors for placental abruption?
Previous abruption Advanced maternal age Multiparity PTE Abdo trauma Smoking Cocaine use External cephalic version
What condition is strongly linked with placental abruption?
PTE
Complications for placental abruption
Blood loss - DIC and renal failure
PPH -> Sheehans syndrome
At what point do you induce labour post term?
Term + 10 days IF NO PROBLEMS
Maternal indications for the induction of labour?
severe pre eclampsia
recurrent APH
Pre-existing disease
Fetal indications for the induction of labour?
prolonged pregnancy
IUGR
Rhesus disease
Active management of the 3rd stage of labour involves
Clamping and cutting the cord
Controlled cord contraction
oxytocin
D R C B R A V A D O
define risk contractions baseline rate accelerations variability and decelerations over all assessment
normal range of fetal HR
110 - 160 bpm
Complications of a breech birth
increase in perinatal mortality/ morbidity
difficult to deliver the head - can be entrapment
rapid compression and decompression of the fetal head
3 management options in breech presentation
External cephalic version
Elective c-section
Planned vaginal breech
Contraindications to ECV
Pelvic mass Antepartum haemorrhage Placenta praevia previous c-section / hysteroscopy multiple preg ruptured membranes
How is an ECV performed
On the labour ward
Monitoring
Tocolytics
US control
How often is ECV successful?
1/2 the time
What should be given in conjunction with ECV ?
anti - D
What is the weight cut off for breech vaginal delivery?
> 4kg
Risks for shoulder dystocia
Previous Diabetes BMI >30 Induced labour Long labour Assisted vaginal birth
When is delayed labour diagnosed in a nulilparous women?
2 hrs after active second stage of labour started
When is delayed labour diagnosed in a multiparous women?
1 hour after active second stage of labour started
When should you suspect delayed delivery in nulilparous?
progress is inadequate after 1hr
When should you suspect delayed delivery in multiparous?
progress inadequate after 30mins
Conservative measures to be used when a suspicious CTG
Mobalise the mother Adopt another position Offer IV fluids if hypotensive Stop oxytocin Offer tocolytic drug like terbutaline
Management with a pathological CTG
urgent review by an obstetrician and a senior midwife \+ measures used in conservative Offer digital fetal scalp stimulation Consider fetal blood sampling Consider expediating the birth
When is urgent intervention needed based on the CTG
Acute bradycardia / single prolonged deceleration >3 mins
From when can ventouse delivery methods be used?
34 weeks
Maternal indication for ventouse delivery
Delay in the 2nd stage of labour due to maternal exhaustion
Fetal indications for ventous delivery
Abdnormal CTG / slow progress in the 2nd stage of labour due to fetal malposition
What is needed in terms of maternal condition for ventouse delivery?
Adequate maternal effort and regular contractions
Two types of forceps
Non rotational / traction
Rotational
What is not required in terms of maternal condition for forceps delivery ?
maternal effort / adequate contractions
2 maternal indications for forceps
Medical conditions complicating labour
Unconscious mother
fetal indications for forceps
Gestation less than 34 weeks face presentation known / suspected fetal bleeding disorder for the after coming head in a breech c -section
Maternal complication of instrumental delivery
Genital tract trauma with risk of haemorrhage / infection
Fetal complication of instrumental delivery
Ventouse - scalp oedema / subperiosteal bleeding
Forceps - bruising / facial nerve palsy / depression skull fracture
Maternal indications for c-section
Two previous LSCS Placenta praevia Maternal disease Maternal request Active genital HSV HIV - viral load depending
Fetal indications for c-section
Breech presentation
Twin pregnancy - if first twin not cephalic
Abnormal CTG/ abnormal fetal blood sample in 1st stage of labour
Cord prolapse
Delay in 1st stage of labour due to malpresentation / malposition
Complications of LSCS
Haemorrhage - should have cross match w/ group and save
Gastric aspiration - use routine antacids
Visceral injury
Fetal laceration
Infection - can use routine prophylatic AB
VTE
Increase risk of complications in future pregnancies
VBAC
if LSCS due to unrepeatable cause then can trial vaginal delivery
APGAR score stands for?
Appearance Pulse Grimmace Activity Respiration
When is the APGAR score done?
1 min
5 mins
APGAR normal score
7+
APGAR score that indicates neurological damage
<3
4 causes of postpartum haemorrhage (4 Ts)
Tone
Trauma
Tissue
Thrombin
90% of PPH due to?
Uterine atony
Risk factors for uterine atony?
Multiple pregnancy Grand multiparity Fetal macrosomia Polyhydramnios Fibroid uterus Prolonged labour Previous PPH Antepartum haemorrhage
Cause other than uterine atony of PPH?
genital tract trauma retained placenta placenta accreta coagulation disorders uterine inversion uterine rupture
Preventative measures for PPH
Treat anaemia before labour
avoid long traumatic labours
active management of the 3rd stage of labour
Options if placenta in situ and PPH
Deliver by controlled cord contraction
If retained - manual removal under anaesthesia
What to assess the uterus for if PPH but placenta delivered?
uterine contraction
management for uterine atony
ABC
Large bore IV access
Send FBC, Xmatch, clotting, U&E
Rub up uterine contractions by massaging the uterine fundus
Give oxytocin
Prostaglandin can be given
Consider surgical options / uterine artery embolism
Management of PPH
ABC Lie flat high flow O2 Large bore access Take bloods and give fluids Rhesus status - give anti D if indicated Rub up contraction Bimanual compression Catheterise Give progesterone Consider tranexamic acid
If the above don’t work - take to theatre and examine under GA
Surgical techniques apply
Last resort - hysterectomy
1st line screening for Downs syndrome
the combined test is now standard: nuchal translucency measurement + serum B-HCG + pregnancy associated plasma protein A
these tests should be done between 11 - 13+6 weeks
Increased nuchal translucency indicates
Down’s syndrome
congenital heart defects
abdominal wall defects
External cephalic version is contraindicated in individuals with a …
a recent antepartum haemorrhage,
ruptured membranes
uterine abnormalities
or previous Caesarean section.
When does morning sickness commonly take place
4-7week to second trimester
N&V in pregnancy with volume depletion treatment
Hartmanns rehydration - replace the calculated deficit, and maintenance
adjunct - ondansetron 4-8g every 12hrs as required (IV)
consider giving a PPI
Conditions to ask about at pregnancy booking
VTE Thrombophilia Heart disease Sickle cell SLE Obesity Anaemia DM HTN
How much vit D should be taken during pregnancy
10 micrograms through to breast feeding
conditions which can be identified on us scan
anencephaly spina bifida cleft lip diaphragmatic hernia gastroschisis exomphalos serious cardiac abnormalities
At what BP do you consider labetalol in pre eclampsia
> 160 systolic
>110 diastolic
Presentation of pre eclampsia
NandV HTN Proteinuria Brisk tendon reflexes RUQ / epigastric pain Headache facial oedema
Acute treatment for suspected HELLP
Magensium sulfate IV
IV dex
Consider BP therapy
What is Lochia
Lochia may be defined as the vaginal discharge containing blood mucous and uterine tissue which may continue for 6 weeks after childbirth.
Score for severity of hyperemesis gravidarum
The Pregnancy-Unique Quantification of Emesis (PUQE) score can be used to classify the severity of nausea and vomiting in pregnancy
