Obstetrics Flashcards
What is the management for Hyperemesis Gravidarum?
- IV fluid replacement
- Metclopromide or cyclizine
- Thromboprophylaxis with enoxaparin + stocking
- Avoid dextrose but correct electrolytes
What type of laxatives should you avoid in pregnancy?
- Stimulant
How do you define small for gestational age?
< 10th centil for age
What is the commonest cause of stillbirth?
Brain sparing effect of placental insufficiency
If there is evident IUGR, when should you deliver?
After 34 weeks ideally after 37
If a baby is larger for dates, at what weights should you consider an elective C-section?
- Diabetic - >4500g
- Non-Diabetic >5000g
What are the risks of Large for gestational age for baby?
- Neonatal death
- Birth trauma
- Hypoglycaemia
- Jaundice
What are the ranges for normal amniotic fluid in utero?
2cm - 8cm (outside of these boundaries = poly/Oligohydramnios)
What is Foetal Hydrops?
Abnormal accumulation of fluid in two or more fetal compartments, including ascites, pleural effusion, pericardial effusion, and skin oedema
When are the first foetal movements felt?
18-20weeks
If a woman cannot feel movements what advice do you give?
- Lie of left side
- Focus for 2 hours
- If they do not feel 10 movements in 2 hours, contact midwife/MAU
- If first time, reassure that 70% pregnancies with 1 episode are uncomplicated
At which point should escalation be considered if no foetal movements are felt by?
24 weeks
What is the difference between PROM and PPROM?
- PROM = labour not started within 1hr of rupture, >37weeks
- PPROM = Membranes break before 37 weeks
Give 4 signs of Chorioamnionitis
- Maternal pyrexia/tachycardia
- Uterine tenderness
- Foetal tachycardia
- Offensive, yellow vaginal discharge
What is the management for PPROM <34 weeks?
- Betamethasone IM BD for one day
- Erythromycin for 10 days
- Admit 24hrs for close monitoring
- MAC twice a week with regular CTG and infection monitoring
What is the management for PROM (>37 weeks)
- Go home and come back in 24hours for induction
What advice is important when sending a mother home for PROM?
- Call MAC in infection risk/red flag
- Change pad every 4 hours
- No tampons, no sex, no soap
What risk to the foetus of CMV infection is there?
- Deafness
What is offered to women who get Rubella infection <16 weeks
- Termination
How do you define hypertension in pregnancy?
> 140/90 on more than one occasion
What is your target blood pressure treatment in pre-eclampsia/gestational hypertension?
<150/80-100 as over treatment can cause IUGR
What is the first and second line treatment for gestational hypertension if diagnosed before 20weeks
Labetolol
Nifedipine
Hydralazine
What is should be given if the woman has HTN from 12 weeks?
aspirin
What are red flag signs of Pre-eclampsia?
- Headache
- Visual disturbance
- Epigastric or RUQ pain
- Breathlessness
What are signs of Eclampsia (asides from fitting)
- Peri-orbital oedema
- Hyper-reflexia
- Clonus > 3 beats
- Fits
What is HELLP Syndrome?
Haemolysis, elevated liver enzymes, low platelets - Self-limiting but permanent liver damage can occur
What HbA1C level should indicate avoiding pregnancy?
> 86
What is used for the diagnosis of diabetes in pregnancy?
OGTT
List 4 factors that makes a woman eligible for a OGTT
- BMI >30
- Previous DM in pregnancy
- 1st degree relative with diabetes
- Previous large baby >4.5kg
- South Asian, Black Caribbean or Middle Eastern
What are the 4 steps of management for Gestational Diabetes?
1 - lifestyle
2 - Metformin with food and increase dose after 1 week
3 - Single injection of intermediate acting insulin - Isophane
4 - Add short acting insulin before meals - Novorapid
Give 3 comorbidities for VTE
- Parity >3
- Smoking
- Gross varicose veins
Give 4 Medical comorbidities for VTE
- Cancer
- Active SLE
- IBD
- Type I Diabetes
What Blood disorders can increase risk of VTE in pregnancy?
- Thrombophilia
- Protein S deficiency
- Protein C deficiency
- Factor V Leiden
- Antithrombin deficiency
Whats the treatment for VTE?
- LMWH - Enoxaparin or Dalteparin
How long should therapeutic anticoagulation be continued for after VTE in ooregnancy
6 months
How long should treatment continue for for VTE?
6 weeks
Is Warfarin safe for breast feeding?
Yes but additional growth scans required
Prevention - 4+ risk factors/previous VTE
Prophylactic LMWH throughout antenatal period
Prevention - 3 risk factors for VTE
LMWH for 28 weeks and 6 weeks post-partum
Prevention - 2 risk factors for VTE
LMWH 10 days post partum
Prevention - Heritable thrombophilia
High dose LMWH antenatally and 6 weeks post partum
When would a C-section be planned for Monochorionic Monoamniotic twins?
32-34 weeks
When would a delivery be planned for Monochorionic Diamniotic twins?
36-37weeks
How frequent do appointments need to be for expecting twins?
Every 2 weeks
What would you use to treat hyperthyroidism in pregnancy?
Propylthiouracil as Carbimazole is toxic
What blood test would indicate acute fatty liver disease?
Raised ALT
How would you treat Cholestasis in pregnancy?
Vit K + supportive and close monitoring
Which infections can increase the risk of miscarriage?
- Listeria
- Toxoplasmosis
- Varicella zoster
- Malaria
What is the risk of expectant management of miscarriage?
- Haemorrhage particularly if late 1st trimester
- Higher risk of emergency intervention and blood transfusion
What is used for the medical management of miscarriage?
- Vaginal Misoprostol
What is Antiphospholipid syndrome?
- Autoimmune, hypercoagulable state caused by antiphospholipid antibodies
- Provokes thrombosis in arteries and veins
How do you diagnose Antiphospholipid syndrome?
- One clinical event - thrombosis or pregnancy complications
- 2 antibody blood tests spaced at least 3 months apart confirming lupus anticoagulant or anti Beta-2 glycoprotein I
What is the management of stillbirth?
- Mother is induced from prostaglandins administered vaginally
What is a complete hyatidiform mole?
- Empty egg fertilised by single sperm
- 46XX
What is a partial hyatidiform?
- Normal haploid egg fertilised by 2 sperm or by one sperm with duplication of paternal chromosomes
- 69 XXX
- 69 XXY
What advice is given following a hyatidiform mole?
- Urgent referral for evacuation
- Avoid pregnancy until hCG reaches 0/next 6-12 months - tested every 2 weeks
- Future pregnancies need serial hCG monitoring
What level of hCG might indicate conservative management of an ectopic pregnancy?
< 1000IU
What effects can a Rhesus negative mother have on a foetus?
- Hydrops foetalis
- Jaundice
- Anaemia
- Hepatosplenomegaly
- Heart failure
To encourage the 3rd stage of labour, after deliver of the anterior shoulder, what drug can be given?
IM Syntometrine
If no signs of placental separation during the 3rd stage of labour, what drug should be given?
Syntocinon
What is the causative agent of Group B strep?
Streptococcus agalactiae
Why can’t you use NSAIDs during labour?
Causes premature closure of the ductus arteriosus
Which opioids can be used during labour?
Pethidine / Meptid
Give 4 advantages of an epidural
- Lowers BP in HTN
- Abolish premature urge to push
- Analgesia in place for emergency CS
- Pain free
Give 4 disadvantages of an epidural
- Hypotension - IV fluids
- Increased instrumental delivery rate
- Urinary retention
- Local anaesthetic toxicity
Where is an epidural inserted?
Between L3 and L4
What is an absolute contraindication of epidural/spinal anaesthetic during labour?
Anticoagulant bleeding disorders
Give 4 absolute contraindications of induction
- Abnormal lie
- Placenta praevia
- Pelvic obstruction - mass/deformity
- Acute foetal compromise
What factors may make you consider not allowing induction?
- Previous LSCS
- Prematurity
- High parity
What Bishops score would indicates ripening?
< 5
What is involved in cervical ripening?
Prostaglandins
Membrane sweep
Oxytocin
What is the management if labour does not start after ARM?
- 2 hours for primip
- 4hours for multip
- Oxytocin/syntocinon infusions started
What are potential complications of induction?
- Instrumental delivery
- Hyperstimulation of uterus causing rupture/foetal distress
- PPH
- PGE2 side effects - N+V, diarrhoea, bronchoconstriction
After how many hours following prostaglandin must oxytocin not be given?
6hrs
What position must the baby be in to indicate operational delivery?
Occipito-anterior
What is the main contra-indication of using tocolytics?
Ruptured membranes
What does FFN indicate?
Positive means that likely to go into labour
How many days does it take for the Os to close after birth?
3 days
How is lactation achieved?
Oxytocin + prolactin
What is colostrum?
Thick yellow fatty fluid passed for 1st 3 days before milk comes in
What differential diagnoses are there for an amniotic fluid embolus?
- MI
- PE
- Anaphylaxis
- Sepsis
- Eclampsia
What are 4 causes of abdominal pain during pregnancy?
- HELLP
- Placental abruption
- Pre-eclampsia
- Acute fatty liver of pregnancy
How would you manage an atonic uterus causing PPH?
Oxytocin +/- ergometrine IV
PEG2a infected into myometrium
When does puerperal psychosis commonly start?
3-5days post partum
Which methods of contraception are recommended post-partum?
Condom, IUD, POP, NOT COC
When is lactational amenorrhoea effective as a method of contraception?
- Complete amenorrhoea
- Woman is fully breast feeding - 4hrly feeds a day, 6hrly at night
- Baby no more than 6months old
When is it safe to insert a IUD after pregnancy?
- Either 48hrs after or
- wait 4 weeks
