Obstetrics Flashcards
What are the features of foetal varicella syndrome?
Skin scarring Eye defects (microphthalmia), limb hypoplasia, microcephaly, learning disabilities
What should you do if there is any doubt regarding mother previously having chicken pox?
Check maternal blood for varicella antibodies
If mother is found not to be immune to varicella what should be given?
Varicella zoster immunoglobulin
If a mother has not received MMR vaccine when should they be offered it?
In the postnatal period
What is the main cause of lactation mastitis?
Milk stasis due to over production or insufficient removal.
What are the clinical features of lactation mastitis?
Breast pain usually unilateral
Associated erythema, heat and tenderness
What is the most common infectious cause of lactation mastitis?
Staph aureus
What is the 1st line management of lactation mastitis?
Analgesia and encourage effective milk removal (continue breastfeeding or expressing)
If symptoms of lactation mastitis do not improve after 12-24hrs of conservative management what is the first line abx?
Flucloxacillin 500mg qds for 14days
Erythromycin If pen allergic
2nd line is co amoxiclav
What is intrahepatic cholestasis of pregnancy (obstetric cholestasis) and how does it present?
Stasis of cholesterol occurs during pregnancy
Presents with pruritus (typically worse on palms, soles and abdomen)
Raised bilirubin
How do you manage obstetric cholestasis?
Induction of labour at 37weeks due to risk of still birth
Ursodeoxycholic acid
Vit k supplementation
What is lochia?
Vaginal discharge containing mucous and uterine tissue which may continue for 6weeks after childbirth
Can start red and then go brown.
Describe the 4 degrees of perineal tears
1st degree: tear within vaginal mucosa only
2nd degree: tear into SC tissue
3rd degree: laceration extends into external anal sphincter
4th degree: laceration extends through external anal sphincter into rectal mucosa
What is the secondary prevention of pre-eclampsia in weeks 12-14 in at risk mothers?
Low dose aspirin (75mg OD from 12 weeks until birth of the baby)
which groups of people are at risk of HTN in pregnancy?
HTN in previous pregnancy
CKD
autoimmune disorders such as SLE or antiphospholipid syndrome
T1 +2DM
Describe the normal variation in BP during pregnancy
BP usually falls in 1st trimester (particularly diastolic) and continue to fall until 20-24 weeks
after this the BP increases to pre-pregnancy levels by term
Define HTN in pregnancy
systolic BP >140mmHg or diastolic BP>90mmHg
or an increase above booking readings of >30mmHg systolic or >15mmHg diastolic.
What are the 3 classifications of HTN in pregnancy?
Pre-existing HTN
Pregnancy induced HTN ( gestational HTN)- this occurs after 20 weeks
Pre-eclampsia
What biochemical test results would you expect in a molar pregnancy?
v high b hCG
low TSH
high thyroxine
hCG can mimic TSH causing hyperthyroidism
What are gestational trophoblastic disorders?
they describe a spectrum of disorders originating from the placental trophoblast:
complete hydatiditform mole
partial hydatidiform mole
choriocarcinoma
What is a complete hydatidiform mole and why does it develop?
it is a benign tumour of trophoblastic material that occurs when an empty egg is fertilised by a single sperm that then duplicates its own DNA hence all 46 chromosomes are of parental origin.
What are the presenting features of a molar pregnancy?
bleeding in 1st or early 2nd trimester exaggerated symptoms of pregnancy e.g. hyperemesis uterus large for dates very high serum hCG HTN and hyperthyroidism may be seen
what is the management of a molar pregnancy?
urgent referral to specialist centre for evacuation of the uterus
effective contraception is recommended to avoid pregnancy in the next 12months
what is a partial molar pregnancy?
a normal haploid egg is fertilised by 2 sperms
what % of patients with complete hydatidiform moles go on to develop choriocarcinoma?
2-3%
What is hyperemesis gravidarum?
a serious complication of pregnancy causing severe “morning sickness” leading to life threatening dehydration and metabolic derangements.
if severe can result in vitamin and mineral deficiencies –> diplopia ad ataxia suggestive of Wernicke’s encephalopathy
It can present with vomiting, dry skin, tiredness and raised B-hCG. Wt loss can occur in severe cases
At hat time in the pregnancy is hyperemesis gravidarum most common?
between 8-12 weeks but may persist until 20weeks
what scoring system can be used to clarify the severity of nausea and vomiting in pregnancy?
PUQE score
what is hyperemesis gravidarum associated with
multiple pregnancies trophoblastic disease hyperthyroidism nulliparity obesity
what is the management of hyperemesis gravidarum?
antihistamines are 1st line e.g. promethazine
ondansetron and metoclopramide may be used 2nd line
admission for IV hydration may be needed
if they develop wernickes encephalopathy they will need IV Pabrinex (Vit B and C)
what are the layers an obstetrician needs to cut through in a C-section?
Skin Superficial fascia Deep fascia Anterior rectus sheath Rectus abdominis muscle (not cut, rather pushed laterally following incision of the linea alba) Transversalis fascia Extraperitoneal connective tissue Peritoneum Uterus
what are the 2 main types of C-section?
Lower segment C-section (99%)
classic C-section (longitudinal incision un the upper segment of the uterus
what are some indications for c-section?
placenta praaevia grades 3/4
pre-eclampsia
post- maturity
IUGR
foetal distress in labour or a prolapsed cord
failure of labour to progress
malpresentations
placental abruption (if foetal distress- if dead deliver vaginally)
vaginal infections e.g. active herpes
cervical cancer (disseminates cancer cells)
true or false
If a women has had a previous caesarean section due a factor such as fetal distress the majority of obstetricians would recommend a trial of normal labour
true
what causes peripheral oedema in pregnancy?
increased fluid pressure both from sodium and water retention and venous stasis from pelvic obstruction.
(* this is normal)
what cause pulmonary oedema in pregnancy?
change in hydrostatic press either from the heart or from reduced osmotic pressure.
what food is a good source of folic acid?
green leafy vegetables
what is the function of folic acid?
important in DNA and RNA synthesis
what causes folic acid deficiency?
phenytoin
methotrexate
pregnancy
alcohol excess
what are the consequences of folic acid deficiency?
microcytic megaloblastic anaemia
neural tube defects
how do you prevent neural tube defects during pregnancy ?
all women should take 400mcg folic acid until the 12th week of pregnancy
women at higher risk should take 5mg of folic acid from before conception until the 12th week of pregnancy
what makes you at higher risk of having a child with neural tube defects?
either partner has NTD or have a previous pregnancy affected by it women on anti epileptics coeliac disease diabetes thalassaemia trait obesity BMI>30kg/m2
when is your booking visit during pregnancy?
8-12 weeks (ideally <10weeks)
when is the Down’s syndrome screening including nuchal scan?
11-13+6weeks
when is the anomaly scan>
18-20+6weeks
Management of shoulder dystocia
According to guidelines on shoulder dystocia management:
Immediately after shoulder dystocia is recognised, additional help should be called.
Fundal pressure should not be used.
An episiotomy is not always necessary.
Induction of labour at term can actually reduce the incidence of shoulder dystocia in women with gestational diabetes.
McRoberts manoeuvre is the first line intervention as it is known to be simple, rapid and effective in most cases
what is shoulder dystocia?
the inability to deliver the body of the foetus using gentle traction, the head having been delivered.
what is shoulder dystocia associated with?
postpartum haemorrhage, perineal tears, brachial plexus injury
neonatal death can occur.
what does the McRoberts manoeuvre in shoulder dystocia entail?
flexion and abduction of the maternal hips, bringing the mothers thighs towards her abdomen. this rotation increases the relative anterior posterior angle of the pelvis and often facilitates delivery.
when can pregnancy related causes of HTN be diagnosed?
after 20 weeks!!
what is the Kleihauer test?
A Kleihauer test is a test for Foetomaternal haemorrhage which detects fetal cells in the maternal circulation and, if present, estimates the volume of FMH to allow calculation of additional anti-D immunoglobulin. According to BCSH guidelines, it is required for any sensitising event after 20 weeks gestation.
what is the bishop score used for?
to assess whether induction of labour will be required
<5 labour unlikely to start without induction
>9 labour will most likely commence spontaneously
what variables are considered in the bishop score?
cervical position cervical consistency cervical effacement cervical dilation foetal station
name or describe 4 ways to induce labour
membrane sweep
intravaginal prostaglandins–>cervical ripening
breaking of waters
oxytocin
what is a contraindication of using epidural anaesthesia during labour?
coagulopathy
what is eclampsia?
a condition characterised by seizures in a pregnant woman with preeclampsia
what are the signs and symptoms of pre-eclampsia?
HTN (after 20weeks) proteinuria abdo pain nausea vomiting visual disturbance
what are the complications of preterm premature rupture of membranes?
foetal: prematurity, infection, pulmonary hypoplasia
maternal: chorioamnionitis
Describe the management of preterm premature rupture of membranes
admit
regular obs to ensure no chorioamnionitis
oral erythromycin for 10days
antenatal corticosteroids to reduce risk of respiratory distress syndrome
deliver should be considered at 34weeks
what drugs are contraindicated in breastfeeding?
lithium aspirin BDZs carbimazole sulfonylureas amiodarone cytotoxic drugs methotrexate certain abxs e.g. ciprofloxacin, tetracycline chloramphenicol sulphonamides
how long should treatment with magnesium infusion for eclampsia continue for?
continue for 24hrs after delivery or after last seizure
how can you suppress lactation?
stop the lactation reflex ie stop suckling/expressing
supportive measures: well supported bra and analgesia
cabergoline is the medication of choice if required
is it safe for a mother with Hep B to breastfeed her newborn?
yes!
If a mother is found to be non-immune to varicella zoster virus what is the most appropriate management?
Varicella zoster immunoglobulin as soon as possible.
What is an omphalocele?
a foetal abdominal wall defect which is associated with a raised maternal AFP.
What foetal abnormalities are associated with low levels of maternal AFP?
Down’s syndrome, maternal DM, Edwards syndrome (trisomy 18) and maternal obesity.
What foetal abnormalities are associated with increased levels of maternal AFP?
Neural tube defects (meningocele, myelomeningocele and anencephaly)
Abdominal wall defects (omphalocele and gastroschisis) and multiple pregnancy
True or false
In induced labour epidural anaesthesia increases BP
false
In induced labour epidural anaesthesia reduces BP
What is cord prolapse?
When the umbilical cord descends ahead of the presenting part
if cord prolapse is left untreated what can happen?
It can lead to compression of the cord or cord spasm which can cause foetal hypoxia and eventually irreversible damage death.
What are some risk factors for cord prolapse?
prematurity multiparty polyhydramnios twin pregnancy cephalopelvic disproportion abnormal presentations e.g. breech, transverse lie placenta pavia long umbilical cord high foetal station
when do the majority of cord prolapses occur?
at artificial rupture of membranes
When is the diagnosis of cord prolapse usually made?
when the foetal HR becomes abnormal and the cord is palpable vaginally or if the cord is visible beyond the level of the introitus
how would you manage cord prolapse?
you can push the presenting part of the foetus back into the uterus to avoid compression
tocolytics may be used
if the core is past the level of the introits it should be kept warm and moist but should not be pushed back inside.
the patient should go on all fours until immediate c-section can occur
A 35-year-old nulliparous lady with Factor V Leiden has come for her first antenatal appointment; she has previously had an unprovoked venous thromboembolism (VTE). The attending doctor discusses thromboprophylaxis with her due to her history. Based on her risk, which treatment pathway should be used?
LMWH antenatally and throughout pregnancy until 6 weeks postpartum
what is the first line drug to treat pregnancy induced HTN?
labetolol
when do mothers usually get the “baby blues”?
3-7 days after birth
what is the scoring system used to screen for post natal depression?
Edinburgh postnatal depression scale
Which anti epileptic is recommended for epileptic patients in pregnancy?
lamotrigine
what is the first line treatment for eclampsia?
magnesium sulphate
what is erbs palsy?
it is when the arm is adducted and internally rotated with pronation of the forearm. (also called “waiters tip”. it is a complication of shoulder dystocia due to damage of the brachial plexus
What is HELLP?
Haemolysis, elevated liver enzymes and low platelets
presents with HTN, vomiting and abdomen pain (pain is due to stretching of the liver capsule)
What food should mothers avoid in pregnancy?
Liver should be avoided in pregnancy as it contains high levels of vitamin A, a teratogen.
unpasteurised milk and ripened soft cheeses
pate or undercooked meat
If a mother is found to not have rubella immunoglobulins what is the most appropriate course of action?
Advise her of the risks and the need to keep away from anyone who has rubella.
what is the wood screw manoeuvre?
The woodscrew manoeuvre describes the action of putting a hand in the vagina an rotating the foetus 180 degrees in attempt to ‘dislodge’ the anterior shoulder from the symphysis pubis.
What secretes hCG during pregnancy?
syncytiotrophoblasts
hCG acts to maintain the production of progesterone by corpus lute in early pregnancy.
What is an amniotic fluid embolism?
when foetal/amniotic fluid enters the mothers bloodstream and stimulates a reaction which results in the signs and symptoms
what is the clinical presentation of amniotic fluid embolism?
The majority of cases occur in labour , though they can also occur during caesarean section and after delivery in the immediate postpartum.
Symptoms include: chills, shivering, sweating, anxiety and coughing.
Signs include: cyanosis, hypotension, bronchospasms, tachycardia. arrhythmia and myocardial infarction.
how does foetal alcohol syndrome present?
Foetal alcohol syndrome presents with a range of features depending on the severity of alcohol exposure:
microcephaly (small head)
short palpebral fissures (small eye opening)
hypoplastic upper lip (thin)
absent philtrum
reduced IQ
variable cardiac abnormalities.
