Obstetrics Flashcards
1
Q
Define antepartum haemorrhage
A
A vaginal bleed that occurs after 24 weeks gestation
2
Q
What is abruptio placenta?
A
- It is when the normally positioned placenta has separated from the uterus before delivery
- There is continuous severe abdominal pain
- Blood is dark with red clots
- Absence of fetal movement following bleeding
3
Q
What are the risk factors for Abruptio placenta?
A
- Previous abruptio placenta (10%; 25%)
- Pre-eclampsia / Hypertensive disorder of pregnancy
- Smoking
- IUGR
- Poor socio-economic circumstances
- History of abdominal trauma
4
Q
What are the clinical findings in abruptio placenta?
A
- Patient is shocked out of proportion to blood loss
- Severe abdominal pain
- Tonically contracted hard and tender uterus
- Rigid abdomen
- Fetal parts not palpable
- Uterus big for dates
- Low Hb
5
Q
What is the classification of abruptio placenta?
A
- Grade 1 - Small amount of vaginal bleeding and some uterine contractions, no signs of fetal distress or low blood pressure in the mother.
- Grade 2 - Mild to moderate amount of bleeding, uterine contractions, the fetal heart rate may shows signs of distress.
- Grade 3 - Moderate to severe bleeding or concealed (hidden) bleeding, uterine contractions that do not relax (called tetany), abdominal pain, low blood pressure, fetal death.
6
Q
What is the management of abruptio placenta?
A
- If in doubt DO NOT PV!
- Certain signs and symptoms of abruptio - PV
- If cervix >9cm - ROM and NVD or emergency C/S
- If fetus not viable - NVD
- While preparing for delivery - resus and intrauterine resus
- If fetal distress + viable fetus - C/S
7
Q
What is Placenta preavia?
A
When the placenta is implanted completely or partially in the lower segment of the uterus
8
Q
What are the risk factors for placenta preavia?
A
- Grande multiparity (>5)
- Previous C/S
- Multiple pregnancy
- Threatened abortion
- Abnormal presentation
9
Q
What are the clincal finding of placenta preavia?
A
- Patient shocked in proportion to blood loss
- Painless bleeding and bright red in colour
- Uterus soft and non-tender
- Fetal parts easily palpated and FH present
- Abnormal presentation
- Fetal head high in cephalic presentation
10
Q
What is the classification of placenta preavia?
A
- Minor
Type I - Low-lying placenta - placenta implanted in the lower uterine segment >2cm from the os
Type II - Marginal placenta previa - placental edge at margin <2cm from the internal os - Major
Type III - Partial placenta previa - internal os partly covered by placenta.
Type IV - Complete placenta previa - internal os completely covered by placenta.
11
Q
What is the management of placenta preavia that is not bleeding?
A
- <38 weeks and not bleeding
- U/S to localize placentae
- Hospitalized, bed rest, conservative management till 38 weeks / active bleeding
- steroids for lung maturity if >28 and <34
- > 38 weeks
- U/S to localize placentae
- PV in theater if no U/S and C/S
12
Q
What is the management of placenta preavia that is bleeding?
A
- > =38 weeks + bleeding
- If actively bleeding - C/S
- Grade 1 - ROM, NVD
- Grade 2 - C/S
- 36 weeks + grade 4 - Emergency C/S
13
Q
What are the types of Antepartum haemorrhage?
A
- Abruptio placentae
- Placenta preavia
- Ruptured uterus
- Decidual bleeding
- Vasa Placentae
- Cervical cancer
- Local lesions
- APHUO
14
Q
What are the causes of Postpartum haemorrhage?
A
- Primary
- Uterine atony
- Contracted uterus
- Uterine inversion
- Lower genital tract laceration
- Coagulopathy
- Haematoma
- Secondary
- Endometriosis
- Haematoma
- Gestational trophoblastic neoplasm
15
Q
What is the management of postpartum haemorrhage?
A
- Prevention
- Refer to higher level of care
- Antepartum correction of anaemia
- Consent for possible hysterectomy
- Counselling regarding sterilization
- Medical
- Uterine atony
- Fundal massage
- Empty bladder
- Oxytocin infusion
- No retained products of conception
- Misoprostol PR
- Prostin
- Surgical
- Local suturing
- Uterine packing
- Subtotal abdominal hysterectomy
- B-lynch suture
16
Q
What is the definition of preterm labour
A
The onset of labour before 37 completed gestational weeks OR if the gestation is unknown when the estimated fetal weight is less than 2500g
17
Q
What are the causes of preterm labour?
A
- Maternal
- Chorioamonionitis
- Pyrexia of other causes
- Cervical incompetence
- Fetal
- Multiple pregnancy
- Congenital fetal anomaly
- Placental
- Placenta preavia
- Abruptio placenta
18
Q
What are the risk factors for preterm labour?
A
- History of PTL
- Unbooked - No ANC
- Smoking, EtOH
- Coitus in second half of pregnancy
19
Q
Management of Preterm labour?
A
- Determine GA
- <24 weeks - Inevitable abortion
- 24-33 weeks - Suppression
- 34-36 weeks - If pulmonary mature – allowed to continue
- Any fetal distress ? - Prompt delivery if viable
- Treatable causes addressed (eg pyelonephritis)
- Suppression of labour
- CCB (Nifedipine)
- Salbutamol (acute suppression, eg cord prolapse)
20
Q
Contraindications for suppression of labour?
A
- Fetal distress
- > 34 weeks OR <24 weeks
- Chorioamnionitis
- Congenital abn incompatable with life
- Pre-eclampsia
- APH of unknown cause
21
Q
DDx for poor SF-growth?
A
- Constitutional (familial)
- Fetal
- congenital abnormalities
- congenital infection
- Placental insufficiency
- Pre-placental (malnutrition, PE)
- Abruptio placentae
- Post-term pregnancy
22
Q
DDx for large for gestational age
A
- Wrong dates
- Maternal obesity
- Multiple pregnancy
- Polyhydramnios
- Macrosomia (DM)
- Uterine leiomyomas
23
Q
DDx for Polyhydramnios
A
- Multiple pregnancy
- Maternal Diabetes
- Fetal anomaly
- spina bifida
- anencephaly
- oesophageal atresia
24
Q
DDx for oligohydramnios
A
- IUGR
- Urinary tract obstruction/abnormality of the fetus
25
Management of Breech presentation at term
1. External cephalic version
2. Counsel about mode of delivery
- C/S - elective at 39 weeks
- Vaginal delivery upon request if suitable
Vaginal Birth:
- If good progress in labour, allow for spontaneous delivery to the scapula
- Assist delivery of the head
26
Management of Cord prolapse
A. General
- Cord presentation – do C/S
- Cord prolapse – Indication for immediate delivery if viable
B. Assessment
- Replace cord in vagina or cover with warm, wet towel
- Avoid unnecessary handling
- Determine the degree of dilatation of cervix
- Determine nature and station of presenting part
- Elevate presenting part digitally
- Confirm that fetus is alive by lightly palpating the pulsatile cord and confirm viability
C. Delivery (only if longitudinal, full dilatation, presenting part at pelvic floor)
D. Tocolysis
- Reassure patient
- Administer oxygen by face mask
- Tocolytic – Salbutamol
- Position patient in knee-chest position or insert 300ml into bladder with catheter
E. C-section
- Prepare for fetal resus
- Empty bladder
- Prophylactic antibiotics
27
What is Gestational Diabetes?
Diabetes which develops in pregnancy and resolves spontaneously after delivery
28
What are the complications of gestational diabetes?
- Infection - candida and UTIs
- Congenital abnormalities
- Pre-eclampsia
- Polyhydramnios
- Large baby - Cephalopelvic disproportion / shulder dystocia
- Increased risk of PPH
- Neonatal hypoglcaemia
- Hyaline membrane disease
29
Management of Gestational diabetes
- Admit to secondary level of care
- Control blood sugar - Diabetic diet and ?Metformin
- Adjust insulin levels accordingly
- @36 weeks test placental function and determine fetal size
- Induce labour if macrosomia at 36 weeks
- @38-40 weeks induce labour
