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Finals Revision > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

When can the combined test (blood & NT) be done for Downs Syndrome?

A

11 to 13+6 weeks

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2
Q

When is a booking visit usually done?

A

8 to 12 weeks

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3
Q

When can solely blood tests be done for Downs syndrome?

A

15 to 20 weeks

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4
Q

When is an anomaly scan done?

A

18 to 20+6 weeks

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5
Q

When is anti-D prophylaxis given?

A

28 weeks (+/- 34 weeks)

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6
Q

What investigations should be carried out at the booking visit?

A

Bloods (FBC, ABO, Rhesus, syphilis, HIV, HepB&C)
Urinalysis (MSSU for culture and sensitivities)
USS ( confirm viability, no of fetuses, gestation)

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7
Q

Is HCG increased or decreased in babies with downs syndrome?

A

Increased

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8
Q

Is PAPP-A increased or decreased in babies with downs syndrome?

A

Decreased

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9
Q

Is AFP increased or decreased in babies with downs syndrome?

A

Decreased

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10
Q

In what circumstances would AFP be raised in pregnancy?

A

Multiple pregnancy, placental abruption, anencephaly, spina bifida

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11
Q

What level of risk from the initial downs syndrome testing warrants invasive testing?

A

Risk of 1 in 150 or more

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12
Q

What are the two invasive tests for Downs syndrome?

A

Chorionic Villous sampling

Amniocentesis

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13
Q

When is chorionic villous sampling carried out?

A

11-13 weeks

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14
Q

When is amniocentesis carried out?

A

15+ weeks

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15
Q

What is the risk of miscarriage in chorionic villous sampling?

A

2%

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16
Q

What is the risk of miscarriage with amniocentesis?

A

1%

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17
Q

When should Anti-D be given acutely?

A

Within 72 hours of a sensitising event (e.g. CVS, amniocentesis, ectopic, miscarriage, termination)

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18
Q

How is Anti-D administered?

A

IM injection into deltoid muscle

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19
Q

What maternal factors can cause poor growth of the fetus?

A

Age (>35, <16), low socioeconomic status, parity (0 or >5), interpregnancy interval (<6 months, >120 months), medical conditions (e.g. SLE, asthma, pre-eclampsia etc), previous SGA, drug abuse, ART, maternal infection (TORCH, malaria, TB, UTIs, BV)

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20
Q

What fetal factors can cause poor growth?

A 
Chromosomal anomalies (trisomies 13, 18, 21)
Major congenital anomalies
Congenital infections
Multiple pregnancy
Genetic syndromes
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21
Q

What placental factors can cause poor growth?

A 
Placental dysfunction (e.g. pre-eclampsia)
Placental abruption
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22
Q

What is symmetrical IUGR?

A

Global growth restriction

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23
Q

What are the causes of symmetrical IUGR?

A

Aneuploidy, infection, maternal substance abuse

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24
Q

What is an asymmetrical IUGR?

A

Reduced abdominal circumference (normal head circumference, biparietal diameter and femur length)

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25
Q

What are the causes of an asymmetrical IUGR?

A

Placental insufficiency

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26
Q

What are the main features of IUGR?

A

Decreased fundal height
Reduced liqor
Reduced fetal movements

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27
Q

What investigations should be done to assess growth of fetuses?

A

CTG
Biophysical assessment (looking at fetal movement, breathing, tone and liqor)
Doppler USS of umbilical artery

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28
Q

What does absent or reversed end diastolic flow on doppler USS of the umbilical artery indicate?

A

It indicates placental resistance which means there is a problem. The placenta is usually a low resistance, high flow organ.

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29
Q

What are the causes of large for dates?

A 
Constitutionally large
Polyhydramnios
Multiple pregnancy
Diabetes
Beckwith-Widemann syndrome
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30
Q

What are the causes of polyhydramnios?

A

Twins, fetal anomaly, maternal diabetes, idiopathic, hydrops fetalis

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31
Q

What is Hydrops fetalis?

A

Abnormal accumulation of fluid in 2 or more fetal compartments. Caused by rhesus disease, infection, congenital anomalies

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32
Q

What are some symptoms of polyhydramnios for the mother?

A

Discomfort, breathlessness, heartburn

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33
Q

What are some potential complications of polyhydramnios?

A

Cord prolapse, placental abruption, preterm labour

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34
Q

How is polyhydramnios managed?

A

Expectant management

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35
Q

Which type of twins are at the most risk of complications?

A

Monochorionic monozygotic

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36
Q

What are the signs/symptoms of multiple pregnancy?

A

Exaggerated pregnancy symptoms, high AFP, large for dates

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37
Q

What is twin to twin transfusion syndrome?

A

Placental anastamoses result in blood being moved disproportionately from one twin to another. Donor twin becomes dehydrated and has reduced growth. Recipient twin becomes fluid overloaded.

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38
Q

What twin type is at risk of TTS?

A

Monochorionic twins

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39
Q

Can twins be delivered normally?

A

Yes as long as one is cephalic

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40
Q

What dose of folic acid should pre-existing diabetic patients take?

A

5mg

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41
Q

In pregnant pre-existing diabetics, what drugs should be stopped/ continued?

A

All should be stopped except metformin and insulin

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42
Q

What are complications of pre-existing diabetes and pregnancy?

A 
Hypoglycaemia unawareness
Pre term labour
Stillbirth
Polyhydramnios
Macrosomia or IUGR
Congenital anomalies
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43
Q

When should diabetics be offered induction of labour?

A

From 38 weeks to prevent macrosomia

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44
Q

What are complications for large for dates babies?

A

Risk of birth injuries e.g. shoulder dystocia
Prone to immaturity of suckling and swallowing
Hypoglycaemia
Hypocalcaemia
Polycythaemia (increased risk of jaundice)

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45
Q

By what week of pregnancy is the placenta functional?

A

Week 5

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46
Q

What vessel transports oxygen rich fetal blood?

A

Umbilical vein

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47
Q

What vessel transports oxygen low maternal blood?

A

Uterine vein

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48
Q

What 3 things mean fetal oxygen carrying capacity is good?

A

Fetal Hb can carry more oxygen
Fetus’ have more Hb
The Bohr Effect

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49
Q

What happens to cardiac output in pregnancy?

A

Increases (can cause ECG changes, murmurs etc)

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50
Q

What happens to stroke volume in pregnancy?

A

Increases

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51
Q

What happens to blood pressure in pregnancy?

A

Decreases in 2nd trimester and then steadily starts to increase until term

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52
Q

What happens to respiratory rate in pregnancy?

A

Increases

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53
Q

What happens to both tidal volume and minute volume in pregnancy?

A

Increase

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54
Q

Do oxygen requirements in pregnancy increase or decrease?

A

Increase

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55
Q

What happens to plasma volume in pregnancy?

A

Increases

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56
Q

What happens to RBC count in pregnancy?

A

Increases

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57
Q

What happens to Hb in pregnancy?

A

Decreases by dilution (due to increased RBC)

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58
Q

What happens to platelets in pregnancy?

A

Decrease

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59
Q

What happens to GFR in pregnancy?

A

Increases

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60
Q

When does HCG peak?

A

10 weeks then declines

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61
Q

What oestrogen is an indicator of fetal vitality?

A

Estriol

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62
Q

When is the anabolic phase of pregnancy?

A

1-20 weeks

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63
Q

When is the catabolic phase of pregnancy?

A

21-40 weeks

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64
Q

What hormone causes growth of the ductile system in the breast?

A

Oestrogen

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65
Q

What hormone causes the development of the lobular alveolar complex in the breast?

A

Progesterone

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66
Q

What hormone stimulates milk production?

A

Prolactin

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67
Q

What hormone is released following a suckling stimulus?

A

Oxytocin

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68
Q

What is pre-existing HTN of pregnancy defined as?

A

Hypertension occurring before pregnancy/before 20 weeks gestation

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69
Q

How should women with pre-existing HTN be managed?

A

Switch patient to labetalol from ACEi/ARB
Do urine dip
Start aspirin 75mg from 12 weeks

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70
Q

What is pregnancy induced hypertension?

A

Hypertension occurring after 20 weeks with NO proteinuria or symptoms of pre-eclampsia

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71
Q

What is pre-eclampsia?

A

Pregnancy induced hypertension, proteinuria (>0.3g/l) +/- oedema

72
Q

What is thought to be the underlying mechanism behind pre-eclampsia?

A

Abnormal trophoblastic invasion leading to abnormal placental perfusion and placental ischaemia. This causes release of anti-angiogenic substances into the circulation, causing the presentation of PET

73
Q

What are risk factors for pre-eclampsia?

A

Age >40, BMI >30, personal history, family history, nulliparity, multiple pregnancy, pre-existing renal disease/hypertension/diabetes/SLE

74
Q

What are symptoms of pre-eclcampsia?

A

Headache, visual disturbance, epigastric/RUQ pain, N&V, rapidly progressive oedema

75
Q

What are some signs of pre-eclampsia?

A 
Increased BP
Proteinuria
Oedema
Abdominal tenderness
Disorientation
Intra-uterine death/SGA
Hyperreflexia/clonus
76
Q

What is eclampsia?

A

Tonic-clonic seizure with features of pre-eclampsia

77
Q

How is eclampsia treated?

A

BP control (IV Labetalol/Hydralazine)
Neuroprotection - IV Magnesium Sulphate 4g over 5 mins
Deliver baby

78
Q

How should fluids be managed in eclampsia?

A

The patient should be run DRY - 80ml/hr as the main cause of maternal death is pulmonary oedema

79
Q

What is HELLP syndrome?

A

Haemolysis
Elevated Liver enzymes
Low Platelets

80
Q

When should women with hypertension be admitted?

A

BP >170/110 or >140/90 with ++proteinuria
Significant symptoms
Significant proteinuria
Fetal compromise

81
Q

What blood pressure in pregnancy is an indication to initiate treatment?

A

> 150/100 regardless of aetiology

82
Q

What medications are used to treat blood pressure in pregnancy?

A

Labetalol, nifedipine, methyldopa, hydralazine

83
Q

What is the only cure for pre-eclampsia?

A

Delivery of the baby

84
Q

How is blood pressure treated post partum?

A

Slow reduction of medications based on blood pressure readings

85
Q

How soon after delivery should methyldopa be stopped and why?

A

By day 2 as it poses a risk of depression

86
Q

What is antepartum haemorrhage?

A

Bleeding after 24 weeks and before delivery of the baby

87
Q

What are the main causes of APH?

A 
Placenta praevia
Placental abruption
Placenta accreta
Uterine rupture
Vasa praevia
Local causes (ectropion, polyp, cancer etc)
88
Q

What is a minor APH defined as?

A

<50mls of blood that has settled

89
Q

What is a major APH defined as?

A

50-1000mls of blood with no clinical signs of shock

90
Q

What is a massive APH defined as?

A

> 1000mls of blood and/or significant shock

91
Q

What is placenta praevia?

A

Placenta is partially or totally implanted in the lower uterine segment

92
Q

What is the difference between a minor and major placenta praevia?

A

Minor does not cover the os, major does

93
Q

What are risk factors for placenta praevia?

A

Previous c-section, previous placenta praevia, asian ethnicity, smoking, previous TOP, age >40, multiparity, multiple pregnancy, ART

94
Q

How does placenta praevia present?

A

Painless bleeding, unusually unprovoked but can be triggered by sex. Uterus soft, non-tender. CTG normal. No fetal distress.

95
Q

How does placenta praevia affect delivery?

A

If within 2cm of os - c-section

If over 2cm from os - vaginal delivery

96
Q

What is placental abruption?

A

Premature separation of the uterus from the placenta.

Vasospam leads to arteriole rupture, blood then escapes into the myometrium which causes tonic contraction of the uterus leading to disrupted circulation and in turn hypoxia.

97
Q

What are risk factors for placental abruption?

A

Pre-eclampsia, hypertension, trauma, smoking, cocaine, renal disease, diabetes, polyhydramnios, multiple pregnancy, previous abruption

98
Q

How does a placental abruption present?

A 
Severe, continous abdominal pain
Bleeding (may be concealed)
Pre-term labour
Maternal collapse
'Woody hard abdomen and tense uterus' 
CTG - IUD/irritable
99
Q

How does placental abruption affect delivery?

A

Urgent delivery needed by c-section or ARM and induction

100
Q

What is placenta accreta?

A

When the placenta invades the uterine wall

101
Q

How is placenta accreta diagnosed?

102
Q

What are placenta increta and placenta percreta?

A

Increta - invasion of myometrium

Percreta - invasion of serosa/bladder/bowel

103
Q

What are some risk factors for placenta accreta?

A

Previous c-section, placenta praevia

104
Q

How is placenta accreta managed?

A

Insert prophylactic internal iliac balloon
May need caesarean hysterectomy
Expect >3L blood loss

105
Q

What is uterine rupture?

A

Full thickness opening of the uterus

106
Q

What are risk factors for uterine rupture?

A

Previous c-section, uterine surgery, multiparity, syntocinon use, obstructed labour

107
Q

How does uterine rupture present?

A

Shoulder tip pain, severe abdominal pain, maternal collapse, PV bleed, loss of contractions, peritonism, fetal distress

108
Q

What is vasa praevia?

A

Fetal vessels lie in the fetal membranes across the os

109
Q

What are risk factors for vasa praevia?

A

Placental anomalies (e.g. bilobed placenta, succeturiate lobe), placenta praevia, multiple pregnancy, ART

110
Q

How is vasa praevia diagnosed?

A

USS with colour doppler

111
Q

How does vasa praevia present?

A

Sudden PV bleed, painless
Fetal bradycardia, IUD
Fetal Hb may be found in PV bleed

112
Q

How is delivery affected in vasa praevia?

A

Must do c-section

113
Q

How are all APHs generally managed?

A

Admit to hospital
IV access via 2 large bore cannulae
FBC, LFTs, U&Es, Kleinhauer test
Crossmatch 4-6 litres of blood
Give IV fluids/transfuse if blood available
Anti-D if Rh-ve
FOR FETUS - CTG monitoring, administer steroids and MgSO4 for lung development and neuroprotection

114
Q

What is post-partum haemorrhage?

A

Loss of blood following delivery of baby

115
Q

What is a minor PPH defined as?

A

500-1000ml blood loss

116
Q

What is a major PPH defined as?

A

> 1000ml blood loss

117
Q

What are some antenatal risk factors for PPH?

A

Previous PPH or retained placenta, BMI >35, APH, multiparity, maternal age >35, fibroids, large placental site, overdistended uterus

118
Q

What are some labour risk factors for PPH?

A

Prolonged labour
Induction/oxytocin use
Operative delivery/c-section

119
Q

What are the causes of PPH?

A

The 4 T’s - Tone, trauma, tissue, thrombin
TONE - uterine atony, vessels don’t get clamped. May occur due to prolonged labour/overdistension
TRAUMA - vaginal/vulval lacerations
TISSUE - retained placental
THROMBIN - haemophilia, von willebrands etc

120
Q

How is PPH prevented?

A

Use of uterotonics - syntocinon

121
Q

What is given if a woman has no risk factors for PPH and has a vaginal delivery?

A

Syntocinon 10iu IM injection

122
Q

What is given if a woman has no risk factors for PPH and had a c-section?

A

Syntocinon 5iu by slow IV infusion

123
Q

What is given if a woman has risk factors for PPH?

A

Syntometrine (CI in hypertension)

124
Q

How is the bleeding managed in a minor PPH?

A

Uterine massage - expel any clots
5 units syntocinon IV stat
40 units syntocinon in 500ml Hartmanns - 125ml/hr

125
Q

How is the bleeding managed medically in a major PPH?

A

Confirm delivery of placenta and membranes complete
500mcg ergometrine IV
Prompt repair of vaginal/perineal trauma
Carboprost 250mcg IM every 15 mins (max 8 doses)
Misoprostol 800mcg sublingual./PR
Tranexaminc acid 1g IV
Packs, balloons, tissue sealants, arterial emboliztion

126
Q

How can a major PPH be managed surgically?

A

Undersuturing, B-Lynch sutures, uterine/internal iliac artery ligation, hysterectomy

127
Q

What fluid should be given in PPH?

A

Up to 2L of warmed crystalloid (e.g. saline, hartmanns) given asap
Up to 1.5L of warmed colloids until blood arives
Can do intra-operative cell salvage

128
Q

What is the first stage of labour?

A

Cervical dilatation

129
Q

What is the latent phase of the first stage of labour?

A

Up to 4cm cervical dilatation. Mild irregular uterine contractions, cervix softens and shortens

130
Q

What is the active phase of the first stage of labour?

A

4-10cm cervical dilatation. Contractions become increasingly rhythmic and strong.

131
Q

What is the second stage of labour?

A

From complete cervical dilatation to delivery of the baby

132
Q

How long should the second stage of labour last in nulliparous women?

A

Up to 2 hours or 3 hours if given regional anaesthesia

133
Q

How long should the second stage of labour last in multiparous women?

A

Up to 1 hour or 2 hours if given regional anaesthesia

134
Q

What is the third stage of labour?

A

After delivery of the baby until expulsion of the placenta and fetal membranes

135
Q

What are braxton-hicks contractions?

A

Tightening of the uterus muscles to prepare the body for birth. Felt from 2nd/3rd trimester onwards. Do not increase in frequency/intensity. Relatively painless, resolve on ambulation

136
Q

What are labour contractions?

A

Tightening of the top of the uterus, pushing the baby down into the birth canal. Described as a wave.

137
Q

What hormone initiates and sustains contractions?

138
Q

What is the lie of the fetus?

A

Relation of the longitudinal axis of the fetus to the longitudinal axis of the mother

139
Q

What is the normal lie of a fetus?

A

Longitudinal

140
Q

What is vertex?

A

The baby being head down in the uterus

141
Q

What is fetal presentation?

A

The leading part of the fetus which occupies the lower pole of the uterus (e.g. cephalic, breech)

142
Q

What is fetal position?

A

Relation of the denominator of the presenting part to the quadrants of the maternal pelvis

143
Q

What is normal position for delivery?

A

Occipito-anterior

144
Q

What is station?

A

The location of the presenting part of the fetus in the birth canal (from -5 to+5) above and below the ischial spines

145
Q

What is it called when the head of the baby reaches the vulval ring and perineum stretches over its head?

146
Q

Which shoulder is delivered first?

A

Anterior shoulder

147
Q

What signs indicate separation of the placenta from the uterus?

A

Uterus contracts, hardens and rises
Umbilical cord lengthens
Gush of blood

148
Q

What are the analgesia options for labour?

A 
Paracetamol/co-codamol
Entonox
Diamorphine
Epidural
Remifentanyl
Combined spinal epidrual
149
Q

With regard to puerperium, how long does it take for the funal height to reach the umbilicus?

150
Q

In what conditions is there increased nuchal translucency?

A

Downs syndrome
Congenital heart defects
Abdominal wall defects

151
Q

When and how much folic acid should be taken?

A

400mcg from trying to concieve until 12 weeks

152
Q

24 hours after delivery. Pain, vaginal bleeding, heavy offensive lochia, boggy poorly contracted uterus

A

Retained products

153
Q

What diabetic medication is safe in breast feeding?

154
Q

When should methotrexate be stopped before trying to concieve?

A

For at least 3 months

155
Q

What scale is used to measure post natal depression?

A

Edinburgh Scale

156
Q

What is the criteria for hyperemesis gravidarum?

A

Dehydration
Electrolyte imbalance
5% pre-pregnancy weight loss

157
Q

What is the first line treatment for hyperemesis?

A

Antihistamines used first like (e.g. cyclizine, prochloperazine)
Metoclopramide and ondansetron second line

158
Q

What is hyperemesis associated with?

A

Multiple pregnancy, trophoblastic disease, hyperthyroidism, nulliparity, obesity

159
Q

What is fetal fibronectin?

A

Protein released from gestational sac. High level correlates with increased chance of premature labour

160
Q

What are indications for instrumental labour?

A

Fetal or maternal distress in 2nd stage

Failure to progress

161
Q

What are requirements for instrumental delivery?

A 
Fully dilated cervix
OA or OP position
Ruptured membranes
Cephalic presentation
Engaged presenting part
Pain relief
Sphincter (bladder) empty
162
Q

How should a non-immune pregnant woman who has been in contact with someone with chicken pox be managed?

A

Single dose varicella zoster immunoglobulin

163
Q

What are indications for induction of labour?

A

Prolonged pregnancy
PPROM
Diabetic mothers >38 weeks
Rhesus incompatibility

164
Q

What are the methods of inducing labour?

A

Membrane sweep
Intravaginal prostaglandins
Breaking waters
Oxytocin

165
Q

How does obstetric cholestasis present?

A

Widespread itch worse on palms and soles of feet

166
Q

What risk does obstetric cholestasis cause?

A

Preterm birth

167
Q

How is obstetic cholestasis managed?

A

Induction at 37 weeks
Urseodoxycholic acid
Vitamin K

168
Q

What Bishops score indicates that labour is unlikely to start without induction?

A

Less than 5

169
Q

What Bishops score indicates that labour is likely to start spontaneously?

170
Q

Which vitamin in high levels is teratogenic?

171
Q

What is the management of a breech baby before 36 weeks gestation?

A

Nothing - most babies turn around before this stage

172
Q

When should external cephalic version be performed?

A

From 36 weeks for nulliparous women

From 37 weeks if multiparous

173
Q

What is McRoberts manouevre for?

A

Shoulder dystocia

174
Q

How is the McRoberts manouevre done?

A

Patient lies supine with hips fully flexed and abducted. Suprapubic pressure is applied

175
Q

What is the antibiotic treatment for PPROM?

A

Oral erythromycin (10days)

176
Q

What treatment is used for prevention of pre-eclampsia in at risk women?

Finals Revision (22 decks)

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