Obstetrics Flashcards
Ectopic pregnancy
Aetiology/RF Location Presentation Investigations Management Complications
Aetiology/RF POCP Previous ectopic Endometriosis Adenomyosis IUD IVF
Location
- Tubular - ampulla most common, isthmus most dangerous
- Ovary etc
Presentation
- Abdo pain
- Cervical excitation
- period of amenorrhoea
- PV bleed - dark blood - light flow
- Shock if rupture + shoulder tip pain
Investigations
- USS location
- b-hCG
Management (depends on hCG and how well the pt is)
- Conservative <300
<30mm - Methotrexate <1500
+ progesterone
<35mm
No pain/ rupture - Surgical explorative laparotomy - salpingio-ooporectomy
>1500
If pain/ rupture
Complications
Rupture of fallopian tube
Shock
Death
Management of ectopic
Management (depends on hCG and how well the pt is)
- Conservative <300
<30mm - Methotrexate <1500
+ progesterone
<35mm
No pain/ rupture - Surgical explorative laparotomy - salpingio-ooporectomy
>1500
If pain/ rupture
Miscarriage
Aetiology RF Definition Presentation/ Types investigations Management
Aetiology
- Aneulopidy
- infection
RF
- Infection (late)
- Chromosomal abnormalities (most common)
- APLS/ blood disorders
- Autoimmune
- Thyroid
- Diabetes
- Smoking, weight, alcohol
Definition - loss of pregnancy <24w
Presentation/ Types
Threatened - cervical os closed, small painless PV bleed, foetal pole intact
Inevitable
Cervical os open
PV bleed - may be larger, may be passing clots
Incomplete
- Cervical os open, large PV bleed
- uterus is still large
Missed/delayed
empty gestational sac
Cervical os closed
Complete
Cervical os closed, clots have passed, no foetal parts
Small uterus
investigations
- USS
- b-hCG
- FBC and cross match - sensitising event so anti D if >12w and Rh-
Management Expectant wait 7-10 days Medical: Mifepristone Misoprostol 48hrs later
Surgical - ERPC/ suction
if heavy bleed/ infection
Termination of pregnancy
Abortion act
Methods
> 24 weeks if:
Abortion act
1) Would endanger woman’s life
2) Carrying on is > risk than risk of termination
3) Risk to health of children
4) Mental or physical health would suffer if she carried on
5) The child born would be severely disabled/mentally handicapped
Methods
<9w
Mifepristone
+ Prostaglandin 48hrs later
Surgical 9-13w -suction
> 13w - surgical dilation and evacuation
> 24 - KCl
Complications of TOP
Infection
Psychological
Rh- event if >12w
Haemorrhage
Uterine perforation
Retained products
Placenta previa
Definition Aetiology RF Presentation/ Types investigations Management Complications
Definition - where the placenta lies near or over the cervical os
Aetiology previous previa/ CS Multiple pregnancy Multips Maternal age ^
RF - smoking
Presentation/ Types
Presentation
Painless PV bleed - red blood
No uterine abnormalities on palpation
Investigations USS - placenta overlying the os Foetal CTG normal Usually an incidental finding on scans Abnormal lie
Management
Rescan again at 34 weeks then every 2 weeks from then
Delivery at 37/8 if still there
Complications
- PPH
- Death
Vasa previa
Definition Aetiology RF Presentation/ Types investigations Management Complications
Definition
Where the foetal vessels overlie the cervical os
Aetiology
Associated with villamentous insertion, multiple pregnancy
RF Presentation/ Types TRIAD PV bleed (painless Foetal bradycardia ROM
Investigations
USS
Management
If ROM –> deliver cat1 CS
If no ROM - induce at 36w
Complications
- Maternal PPH
- Foetal exsanguination
Placenta accreta
Definition Aetiology/ RF Presentation/ Types Investigations Management Complications
Definition - abnormal insertion of the placenta into the uterine wall
Types
Accreta - to the myometrium
Increta - into the myometrium
precreta - past - serosa + beyond
Aetiology
Previous CS/ surgery
previous accreta
Presentation/ Types
May not realise until delivery –> PPH
Investigations
- USS - swiss cheese appearance
- FBC + cross match
Management
- CS at 37/8 weeks
Complications
- PPH
- Uterine prolapse/ rupture
- Foetal death
Placental abruption
Definition Aetiology/ RF Presentation Investigations Management Complications
Definition
When the placenta separates from the uterine wall before foetal delivery
Aetiology/ RF HTN Pre-eclampsia Smoking Previous
Presentation Foetal brady/ CTG abnormality Maternal shock WOODY UTERUS May be no PV bleed/ or it would be light flow/ DARK blood
Investigations
- USS
- FBC + cross match
Management - foetal distress --> CS - No foetal distress <37w - admit and monitor >37w - deliver
Complications
PPH
Death
Pre-eclampsia
Definition Aetiology/ RF Presentation Investigations Management Complications
Definition - HTN + proteinuria diagnosed after 20w
Aetiology/ RF High risk CKD Autoimmune HTN in previous pregnancy Diabetes Chronic HTN
Intermediate risk FHx First pregnancy Multiple pregnancy BMI >35 Age >40 Interval between pregnancies >10 years
Presentation
HTN + Proteinuria >0.3/24hrs
Hyperrefelxia + ankle clonus Headaches Visual disturbances Papilloedema RUQ pain
Investigations
- BP
- Urine dip
- LFTs - check platelet levels for HELLP syndrome
Management
- if high risk - give 75mg aspirin from 12w
- Labetalol (others - nifedipine/hydralazine)
- Delivery - 34-36w
Complications
- Eclampsia
- HELLP
- DIC - liver failure/ renal failure
- Pulmonary oedema
- Death
Foetal
- IUGR
- Prem delivery
- Placental abruption risk
Eclampsia
Pre-eclampsia +seizures
Rx
Magnesium + deliver
WHEN TO USE MAGNESIUM
- High risk pre-eclampsia/ eclampsia
- When having a seizure
- As soon as you decide to deliver –> 24hrs post seizure or delivery
Can have a seizure up to 6 weeks after delivery - continue labetolol 2 weeks after delivery
HELLP syndrome
Presentation
N+V
RUQ pain
Lethargy
Haemolysis Elevated Liver enzymes Low Platelets
Labour definition
Onset of painful and regular contractions
Cervical dilatation and effacement
May be ROM
Examples of Presentation Presenting part Position Attitude Lie Engagement Station
Presentation - the foetal part that is the lowest eg cephalic
Presenting part - what is in the canal + palpable
Position - OA/OT/OP
Attitude - face, brow, vertex
Lie - cephalic, oblique, transverse - where it is in the longitudinal plane
Engagement - widest part has passed through the pelvic brim
Station - where in the pelvis the head is (in relation to ischial spine)
Labour overview of timings
Stage 1 - dilation
Latent - 0-3cm - 6hrs
Active 3-10 2cm/hr for multips, 1cm for nullips
Stage 2 - delivery of foetus Passive - few mins Active - active pushing 20m for multips 40m for nullip
Stage 3 - delivery of afterbirth
15 mins
Movements in labour
1) Engage in OT
2) Descend in flexion
3) Internal rotation to OA
4) Descend in OA
5) Crowning
6) Delivery via extension of head
7) Shoulders internal rotate to AP
8) Head restitutes
9) Shoulders delivered by lateral flexion
Induction of labour
Indications
Methods
Contraindications
Complications
Indications
- Post-date
- IUGR
- Maternal - diabetes/ eclampsia
Methods
Assess bishop’s score
1) Prostaglandin E2 - inserted in post. fornix of vagina
2) ARM - amniotic hook + oxytocin - beware strong contractions
3) Cervical sweep
Contraindications Maternal - something in the way Vasa previa Placenta previa Cord prolapse Uterine mass
Foetal - distress, abnormal lie
Complications
- painful long labour
- Oxytocin use –> foetal distress
- PPH
- Cord prolapse
Bishops score
Cervical
- Dilatation
- Effacement
- Consistency
- Position
Foetal station
<6 - consider induction
Prolonged labour
Definition + causes
Definition
Stage 1 active
= <2cm/4hrs
Stage 2 active:
Consider in 1, diagnose in 2hrs in nullip
Consider in 30, diagnose in 1hr in multips
Causes - the Ps!!
Power
- Uterus is not strong - nulliparous - insufficient uterine contractions
- Maternal exhaustion eg cardiac disease
Passenger - malpresentation/abnormal lie
Passage - CPD
Management of prolonged labour
Power - augmentation
Amniotomy - ROM - then if no cervical dilation in 2hrs –>
Oxytocin
Passenger - if malpresentation forceps/ventouse/CS
Preterm labour
Definition Aetiology investigations Management Complications
Definition
Labour in 24 - 37weeks
Aetiology Too much in the castle - MulityP, polyhydramnios Defence mechanism - IUGR, maternal illness, chromosomal abnormalities Wall breach - cervical incompetency Enemy - infection
Management
Prevention -cervical cerclage
Progesterone
Foetal reduction
investigations - Foetal fibronectin - TVUS - cervical length - CTG - swab for infection Actual - Steroids - Tocolytics - give time for steroids to work - magnesium
Complications
Foetal
- RDS
Investigations for premature labour
Foetal fibronectin
TVUS - cervical length
CTG
Swabs for infection
Pre-term rupture of membranes
Aetiology
Management
Aetiology
- idiopathic
- Cervical incompetency
- Infection
Management
- Abx –> 24hrs later - induce labour
PPROM
Aetiology
Management
Aetiology
- idopathic
Management
- Admit + monitor
- Steroids
- Abx - erythromcyin
- deliver
Forceps
Indications
Prerequisites
Indications /why
- Prolonged labour
- Foetal distress but cannot CS
- reduce maternal exhaustion
Prerequisites Fully dilated OA Ruptured membranes Cephalic Empty bladder Pain relief S - pelvic
Cord prolapse
Aetiology Presentation Investigations Management Complications
Aetiology - Baby not ready Malpresentation Polyhydramnios Premature Multiple pregnancy ARM Uterine abnormalities Vasa previa Placenta previa
Presentation
- Foetal distress of CTG
- V/E - can see or palpate cord
Investigations
- V/E/CTG
Management
- Trendelenberg
- Tocolytics
- Push back up and wait to immediately deliver - CS
- If past interoitus –> keep warm + moist don’t push back in
Complications
- Foetal - hypoxia/ CP/ death
CTG findings, normal etc and management of abnormal readings
Normal - non reassuring - abnormal
Baseline - 110-160 // 110-100 or 160-180 // >180 or <100
Variability - >5/ <5 for 40-90 mins - <5 for >90 mins
Accelerations - should be present
Decels - early/ variable/late
1 non reassuring
LLP
Fluids O2 and monitor
2 non reassuring or 1 abnormal
FBS
2 abnormal
or brady <100 for >3 mins - C1CS
Foetal distress
Definition
Aetiology
Diagnosis
Management
Definition - foetal hypoxia
Aetiology Not enough direct blood supply: - APH - Cord prolapse Excessive uterine contractions eg in oxytocin prolonged labour
Diagnosis
- CTG
- Meconium stained liqour
- premature labour
Management
LLP, O2, fluids
Terbutaline / stop oxytocin
Vaginal exam - exclude prolapse
- FBS >7.2 - reassess or if maternal deterioration - another sample - if no improvement - CS
FBS >7.2 - C1CS
Uterine rupture
RF
Presentation
Rx
RF
- VBAC - main
- Multiple pregnancy
- Previous surgery
Presentation
- Cessation of uterine contractions
- PPH
- Abdo pain
- Foetal distress
- Shock etc
Rx
- Immediate delivery
- Surgical repair +/- hysterectomy
