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Obs & gynae > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

Diagnostic criteria for gestational DM

A

Fasting glucose of >= 5.5

2 hour post glucose intake value of >=7.8

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2
Q

When to perform an GTT (glucose tolerance test)

A
  1. previous gestational DM
  2. certain gestational groups (eg asian descent)
  3. mother older than 40
  4. mothers over 90kg, or BMI > 40
  5. first degree family member
  6. Hx of diabetic symptoms (polydipsia, polyuria, vaginal candidiasis.
  7. Previous infant >4.5kg
  8. previous stillbirth of unknown cause
  9. severe polyhydramnios with no structural anomalies
  10. repeated glycosuria
  11. Polycystic ovarian syndrome
  12. Acanthosis nigricans
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3
Q

Which hormone produced by the placenta results in increased insulin resistence.

A

Human placental lactogen

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4
Q

Antepartum effects of diabetes on pregnancy

A
  1. Increased prevelence of congenital abnormalities
    - cardiac
    - neural tube
    - skeletal
  2. Macrosomia (N head, big body)
  3. Intrauterine death
  4. Polyhydramnios
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5
Q

Problems at delivery, diabetic mom

A

shoudler dystocia …Erbs palsy

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6
Q

Postpartum effects of diabetes on pregnancy

A
  1. Neonatal hypoglycaemia
  2. Polycythaemia
  3. Hyperbilirubinaemia
  4. Respiratory distress syndrome

*poor cardiac function due to fetal heart hypertrophy from excess glycogen stores

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7
Q

Which fetal complication may occur in a mother with longstanding mircrovasc disease due to DM

A

IUGR

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8
Q

Glucose values, management guidelines

A

Fasting below 5.5
2hr postprandial <7.0
HbA1c <6.5%

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9
Q

Type 1 Diabetic management

A

Insulin + good diet

  • 3 injects (actrapid) breakfast, lunch, supper
  • 1 intermediate acting insulin before bed…Protaphane
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10
Q

Type 2 diabetic management

A

Metformin 500mg BD
Can be increased to 850mg TDS
+
good diet

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11
Q

How to calculate total amount of insulin needed per day

A

0.4U/kg/day

*40% for late eve protophane
20% for each meal

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12
Q

When does reactive hyperglycaemia (somogyi) occur

A

When too much insulin is given at night, resulting in hypogylcaemia. Body reacts by starting glycogenolysis and gluconeogenesis

Rx: lower night time insulin amount

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13
Q

How should diabetic mother regulate her glucose at home

A

test 2 hour post meal + first thing in the morning (glucose profile)

Measured once every 2 weeks in health care setting, and then once weekly after 36wks

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14
Q

General Antenatal managament and investions in diabteic mother

A
  1. fundoscopy
  2. 24 hour urine protein test and renal functions
    -rule out diabetic nepropathy
  3. Ultrasound @ 13, for general wellbeing
    23, to check for gross anomalies, nuchal translucency
  4. 32 weeks, detailed scan.. check for anomalies
  5. 38weeks, for morphometry and to estimate weight
  6. HbA1c @ first visit, and then again at 8weeks
  7. Urine MC&S, asympto bacteruria
  8. CTG´s weekly from 34wks
  9. Patient should be made aware to look out for quiet pattern..count fetal movements
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15
Q

Wjat is issue with using Beta 2 receptor stimulants in diabetic mothers with preterm labour

A

B2 stimulants, stimulate the conversion of liver glycogen to glucose, which causes maternal hyperglycaemia

  • adjust insulin dose accordingly
  • Administer in saline solution, not dextrose
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16
Q

When do we deliver diabetic moms, and why

A

38weeks, due to danger of stillbirths

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17
Q

preferred method of delivery in diabetic mom

A

vaginal delivery

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18
Q

When do we do c sections in diabetic moms

A

When there are obstetric complications
fetal weight >4kg

If labour has lasted longer than 18 hours

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19
Q

Is oxytocin safe to use in diabetic mothers during delivery

A

yes

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20
Q

Delivery management in insulin dependant mom

A
  1. Induction in the morning
  2. Continuous IV insulin
  3. Short acting insulin 1U/ hour administered by infusion pump
    - if no infusion pump, add 10U insulin to 1 litre of 5% dextrose
    - Albumin first placed in vaculitre (prevents adherence of insulin on the sides ). Mixture given @ 100ml/ hr

4.Give 5% dextrose solution simultaneously @ rate of 100ml/hr.

Blood glucose monitored hourly
Pts on oral agents continue as per usual

Continuous monitoring of fetus throughout
All patients delivered in lithotomy position, with preparation for shoudler dystocia.

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21
Q

What to do if ketonuria present at delivery (diabetes)

A

Increase insulin and glucose dose

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22
Q

What to check in the newborn

A

Hourly blood glucose
haematocrit (polycythemia)
Clinical exam for anomalies (esp cardiac)
Examination of neonate for hyperbilirubinemia
Be alert for resp distress syndrome

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23
Q

Definitions of post partum hemorrhage

A
  1. blood loss 500ml with vag delivery
    blood loss 1000ml with c section
    2.Vag bleeding, or blood loss at csection with hypotension and tachy
  2. Bleeding associated with drop in hematocrit of 10% or more
  3. Bleeding at delivery necessitating blood transfusion
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24
Q

Estimation of blood loss and rx

A

mild increase in pulse: 700ml-fluids
increase pulse and tachypnoae-1500ml-fluids
Fall in blood pressure: 2000ml-fluids and blood
Cold, drowsy, high pulse rate, low BP: 2500ml, large transfusion.

25
Q

When Can I transfer a patient with post partum haemorrhage…

A

Systolic > 90mmHg
Two Large bore IV in: one with blood, one with oxytocin
Foley´s cathether
Bimanuael compression if actively bleeding

26
Q

What is primary PPH

A

with in 24hours

27
Q

What is secondary PPH

A

from 24hr to 42 days

28
Q

Causes of Primary PPH

A 
UTERINE
 -uterine atony  
   retained products
   abnormal placentation 
   overdistention 
   idiopathic 
 -contracted uterus 
   cervical laceration 
   uterine rupture 
 -uterine inversion 
NON UTERINE CAUSES 
 Lower genital lacerations 
 coagulopathy 
 haematoma
29
Q

Causes of secondary PPH

A

Endometritis
Haematoma
Trophoblastic neoplasia

30
Q

Risk factors for uterine atony

A 
Full bladder
retained products of conception 
Overdistention of uterus (multiple fetus, polyhydram) 
Augmentation of labour with oxytocin 
Halothane 
Prolonged labour 
Chorio-amnionitis 
Grand multiparity 
Administration of magnesium sulphate 
Uterine tumours such as fibroids
Congenital abnormalitie of the uterus
Previous episodes of uterine atony 
Abnormal placentation
31
Q

Does c section increase the risk for future abnormal placentation

A

yes

32
Q

How to prevent PPH (Rx)

A
  1. Make sure bladder empty
  2. Start oxytocin infusion, 20-40IU/L for at least 3hours. (6-8hours in high risk cases)
  3. Monitor
    - Vital signs
    - Uterine fundal height
    - Vaginal bleeding
33
Q

When is bleeding excessive, practical tip

A

when pads have to be replaced every hour

34
Q

Management of PPH

A
  1. Feel uterus
  2. Manually massage the uterus (myometrial contraction)
  3. Empty the bladder
  4. Insert 2IV lines
  5. Initiate oxytocin infusion
  6. Oxytocin infusion, 40IU/ L crystalloid fluid infused at 40 drops per minute
  7. Syntometrine can be given IM
  8. CALL FOR HELP
  9. Cross match , order 2 units of packed red cells
  10. Arrange for internal examination in theatre
  • IF no retained products or lacerations:
    Misoprostal, 2-5, 200microgram tablets rectally
    Prostaglandin F2 alpha IM, or injected directly into
    myometrium(1 ampoule). Repeat after half an hour if
    needed.
    Maintenence dose: 5mg in 500ml 0.9% saline
    @ 10-30 drops per min IV
35
Q

Ergometrine and prostaglandin F2 alpha are contraindicated in

A

Hypertension
active cardiac or renal disease
Pulmonary disease
hepatic disease

36
Q

Management of massive hemorrhage

A

Fluid therapy:
2 IV lines, warm fluids ( if access difficult, do CVP)
2 litres of ringers, thereafter colloids
Cross match 4-6 Units of blood ( O neg ) FFP can be used too
Elevate patients legs and give oxygen @ 6l/min

*evaluate clotting profile:
Platelet count (reduced with massive transfusion)
Prothrombin time
Partial thromboplastin time (lenghthened with massive
transfusion)
Thrombin time (lengthened with DIC)
Fibrinogen (reduced in DIC)
If fibrinogen defect suspected, give FFP

  • give calcium gluconate, 1 ampule for every 4 units of blood given
37
Q

Monitoring of PPH

A

Systolic more than 100
Pulse rate we want below 100
Urine output of 30ml/ hour
SATS monitor

Check haematocrit, clotting profile, U & E

38
Q

Indications for surgery in PPH

A

Uncontrollable hemorrhage
Sever clotting defect and DIC
Organ failure

39
Q

Rx of retained placenta

A

IV 20-40IU/L oxytocin running at 30 drops per min
1. if no bleeding
allow 1 hr for seperation to take place, then attempt
manual removal in theatre (MROP)
Before theatre try:
steady cord traction with uterine counterpressure
Inject 10IU of oxytocin IV

  1. With bleeding
    Administer syntometrine 0.5mg IV, start oxytocin infusion
40
Q

Uterine rupture:

A 
Pain continuous between contractions 
sudden onset of acute fetal distress with vag bleeding 
abscence of contractions
sudden fetal death
Hematuria
41
Q

How to diagnose retained products of conception

A

Uterus may be slightly enlarged, US will show products.

Rx: evacuation in theatre. If bleeding cannot be controlled, hytesterectomy is indicated.

42
Q

Management of haematomas (PPH)

A

Small vulvar hematoma <5cm must be drained with analgesic and anti inflamm drugs

Larger hematomas need drainage: with incision at medial side.

Subperitoneal and supravaginal haematomas need laparotomy, tertiary level care

43
Q

Up to how many weeks is the size of uterus determines by bimanual examination

A

12 weeks

44
Q

How do we determine duration of pregnancy from 13 to 17 weeks

A

Abdominal examination

45
Q

When how many weeks do we use the SF height to determine duration of pregnancy

A

18 weeks

46
Q

uterus bigger than dates suggests

A

Multiple pregnancy
Polyhydramnions
A fetus which is large for gestational age
DM

47
Q

Uterus smaller than dates suggests

A

IUGR
Oligohydramnios
Intra uterine death
Rupture of membranes

48
Q

Causes of breech presentation

A

UTERINE

  • congenital abnormalities, for eg unicornuate uterus
  • Uterine tumours, leiomyomata
  • Pelvic tumours compressing the uterus

FETAL

  • Motor, or neurological abnormalities, for eg: spina bifida
  • Hydrocephalus
  • Short cord
  • Fetal death

PREGNANCY

  • Placenta previa
  • Multiple pregnancy
  • Polyhydramnios
  • Oligohydramnios
49
Q

In which head is the position in vaginal breech delivery

A

Head is in flexion

50
Q

How to differentiate between cephalic and breech on vaginal exam

A

BREECH

  • Irregular presenting part
  • Buttox, sarcrum, genitals
  • Anus in found in straight line between ischial tuberosities

FACE

  • nose can be felt
  • mouth forms triangle with the cheek bones.
51
Q

Antenatal care in breech

A

refer to hosp
US to exclude multiple pregnancies and obvious abnormalities
External cephalic version
Delivery plan

52
Q

How to do external cephalic version

A

Lift presenting part out of pelvis
Then turn fetus around to cephalic presentation

  • may be facilitated by placing her in right lateral condition.
  • Administer salbutamol 200micrograms IV slowly (to relax uterus)
53
Q

Contraindications to external cephalic version

A
  • APH
  • ROM
  • Multiple pregnancies
  • Pregnancy <37 weeks
  • HIV +
#prev c section-relative C/I
#Hypertensive disorder-relative C/I
#Suspicion of placental insuffiency -relative C/ I
54
Q

Complications of External cephalic version

A

-ROM
-Abruptio placentae
-Tightening of a loop of umbilical cord
-feto maternal hemorrhage
Rutured Uterus

55
Q

wHT must you do immediately after external cephalic version

A

Monitor fetal wellbeing with CTG

Administer 100micrograms anti-D if mother is RH neg

56
Q

T/F: in breech presentation, vaginal delivery is less risky for baby

A

false

57
Q

Is oxytocin augmentation allowed in breech delivery

A

no

58
Q

Complications of breech presentation

A

Asphyxia in second stage of labour, delay in delivery

Cord prolapse, poorly fitting presenting part

Physical injury -difficulties with obstetric manoeuvres

Obs & gynae (2 decks)

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