Obstetrics Flashcards
1
Q
Define Gravidity (1)
A
Total number of pregnancies she has had, including the current one
2
Q
Define Parity (1)
A
Pregnancies that resulted in delivery beyond 24 weeks
3
Q
What does it mean if she is para 2+1?
A
She has had 2 deliveries after 24 weeks and 1 pregnancy which ended before 24 weeks
4
Q
What is the gravidity of a para 1+2 who is currently pregnant?
A
4
5
Q
What is the gravidity and parity of a first time Mum who has had one abortion?
A
gravidity 2
para 0+1
6
Q
Dating a Pregnancy (1)
A
Expected delivery date = 1 year and 7 days after the LMP minus 3 months
7
Q
If LMP was 09/04/20, what is due date?
A
16/01/21
8
Q
Antenatal Booking Visit (5)
A
8-12 weeks
General info + advice (including folic acid until 13 weeks)
Routine care: BP, urine dipstick, BMI
Booking bloods: FBC, blood group, rhesus status, HIV, hep B, syphilis serology
Booking urine culture for asymptomatic bacteriuria
9
Q
General Changes in Pregnancy (3)
A
Ligamentous laxity: ligaments relax to soften symphysis pubis but this can cause SP joint dysfunction, back and joint pain
Linea nigra
Spider naevi
10
Q
Endocrine Changes in Pregnancy (3)
A
Breasts: increased oestrogen increases size and vascularity, leading to tenderness and colostrum
Thyroid: BhCG mimics T4 leading to reduced TSH, mimicking hyperthyroidism
Placenta: BhCG causes morning sickness, progesterone produced by placenta increases body temperature
11
Q
GI Changes in Pregnancy (2)
A
Stomach: progesterone mediates pyloric sphincter relaxation, increased bile in stomach, reduced peristalsis
Large bowel: increased progesterone and reduced motilin cause constipation
12
Q
Cardiovascular Changes in Pregnancy (4)
A
Antenatal cardiac output: circulating volume increases by 50-70%, high CO, high SV, low VR, high HR when supine due to IVC
Intrapartum cardiac output: 100% increase in CO2 due to autotransfusion of contractions and catecholamine release
Postnatal cardiac output: VR high above pre-pregnancy levels in first 2 weeks, HR normal after 2 weeks, CO2 normal by 24 weeks
BP: reduced in first trimester and continues to fall until 20-24 weeks, then increases to pre-pregnancy levels at term
13
Q
Respiratory Changes in Pregnancy (2)
A
Increased O2 demand: increased ventilation, increased RR, increased TV (can cause SOB), peak flow + FEV1 unchanged
Progesterone acts centrally to reduce PCO2 leading to physiological respiratory acidosis
14
Q
Renal Changes in Pregnancy (3)
A
Dilation of collecting system: increased blood flow to kidneys, high gFR and creatinine clearance
Increased renin and angiotensin in response to hypotension
Increased protein excretion causing oedema
15
Q
Haematological Changes in Pregnancy (4)
A
Increased plasma volume: low Hb, MCV normal, low platelets
Increased iron and folate requirements
Increased WCC
Hypercoagulability (DVT + PE)
16
Q
Sonography
Early Pregnancy USS (<11w) (3)
A
Not routine
Purpose: date pregnancy/determine location
Indications: hyperemesis gravidarum, bleeding, pain
17
Q
Sonography Early USS (10-13+6w) (2)
A
Purpose: viability, multiples, anomalies incompatible with life
Calculate gestational age: crown rump length (or BPD if 12-20w)
18
Q
Sonography Anomaly scan (18-20+6w) (1)
A
Purpose: identify structural problems
19
Q
Sonography Fetal echocardiography (5)
A
If high risk of cardiac abnormality Maternal/family history Increased nuchal translucency Drugs in pregnancy Pre-existing DM
20
Q
Sonography
Fetal growth scans (2)
A
If require accurate gestational age: SGA/LGA
Abdominal circumference + head circumference + femur length used to calculate estimated fetal weight, as well as liquour volume
21
Q
Sonography Doppler ultrasound (3)
A
Blood flow to uterus, placenta and fetus
Uterine artery Doppler: high resistance indicates PET, IUGR
Umbilical artery Doppler: high resistance indicates placental failure + risk of intrauterine death
22
Q
Down Syndrome Screening
Risk (2)
A
1:700
Increased with maternal age
23
Q
Down Syndrome Screening Normal screening (4)
A
Offered to all
Only provides estimation of risk (need further tests to confirm)
Combined test at 11-13+6w: high serum BhCG and low PAPP-A (pregnancy associated plasma protein A) + increased ultrasound fetal nuchal translucency
Triple/quadruple test if 15-20w: reduced alpha-fetoprotein + unconjugated oestriol + high BhCG (+inhibin A)
24
Q
Down Syndrome Screening Prenatal Diagnosis (2)
A
Chorionic villus sampling at 10-14w
Amniocentesis if >15w
25
Testing for Neural Tube Defects (4)
Screening not routine, offered if personal/family history
1st trimester USS: anencephaly and spina bifida detectable
2nd trimester biochemical screening: maternal AFP >2 warrant further testing
Anomaly scan detects 90% (lemon shaped skull and curved cerebellum)
26
Pre-Existing Hypertension in Pregnancy
| Epidemiology (1)
3-5% of pregnancies
27
Pre-Existing Hypertension in Pregnancy
| Investigations (2)
Urinalysis (no proteinuria, but these women are at a high risk of pre-eclampsia)
Investigate for an underlying cause if a new finding (eg. CKD, aortic coarctation)
28
```
Pre-Existing Hypertension in Pregnancy
Preconception Management (2)
```
Stop ACE-i, ARB, thiazides as risk congenital abnormality
| Labetalol (combined alpha/beta blocker) or methyldopa
29
```
Pre-Existing Hypertension in Pregnancy
Antenatal Management (3)
```
Aim BP <150/90 or 140/90 if end-organ damage
Labetalol/methyldopa
Fetal US every 4 weeks from 28 weeks to assess fetal growth, amniotic fluid volume and umbilical artery dopplers
30
```
Pre-Existing Hypertension in Pregnancy
Intrapartum Management (3)
```
Monitor BP hourly if <159/109 or continuously if >160/100
Continue drugs
Give oxytocin alone for 3rd stage because ergometrine causes severe hypertension, risking stroke
31
```
Pre-Existing Hypertension in Pregnancy
Postnatal Management (3)
```
Check BP on days 1,2 and once between days 3-5 and then at 2 weeks
Change methyldopa after delivery as risks postnatal depression
Avoid diuretics if breastfeeding
32
Pre-Existing Hypertension in Pregnancy
| Complications (3)
Pre-eclampsia
IUGR
Placental abruption
33
Gestational Hypertension
| Epidemiology (1)
6-7% of pregnancies
34
Gestational Hypertension
| Definition (1)
Hypertension (>140/90) in 2nd half of pregnancy in the absence of proteinuria or other features of pre-eclampsia (although at higher risk of developing it)
35
Gestational Hypertension
| Investigations (3)
Urinalysis: no proteinuria
Bloods: FBC, U&E, AST/ALT and bilirubin if high BP (at presentation and weekly)
USS: 4-weekly growth scans
36
```
Gestational Hypertension
Antenatal Treatment (2)
```
140-159/90-109: labetalol or methyldopa
| >160/110: admit, if can't stabilise on anti-hypertensives then deliver
37
```
Gestational Hypertension
Intrapartum Treatment (2)
```
Continue anti-hypertensives
| BP measured hourly (continuously if >160/110), do operative delivery if won't settle
38
```
Gestational Hypertension
Postnatal Treatment (2)
```
Reduce when 130/80
| Stop methyldopa
39
Pre-Eclampsia
| Epidemiology (1)
5% of pregnancies
40
Pre-Eclampsia
| Pathology (2)
Failure of trophoblastic invasion of spiral arteries leaving them vasoactive (when they are properly invaded they can't clamp down in response to vasoconstrictors and thus protects placental flow)
Increase in BP to compensate
41
```
Pre-Eclampsia
Risk factors (10)
```
```
Previous severe or early (<20 weeks) onset pre-eclampsia
Chronic hypertension or previous gestational hyperetension
CKD
Diabetes
1st pregnancy
Pregnancy interval >10 years
Increasing maternal age
High BMI
Multiple pregnancy
Family history of pre-eclampsia
```
42
Pre-Eclampsia
| Symptoms (5)
```
Headache
Flashing lights
Epigastric/right upper quadrant pain
Nausea and vomiting
Facial/finger/lower limb swelling
```
43
Pre-Eclampsia
| Investigations (7)
Urinalysis: proteinuria
Protein:Creatinine ratio >30
FBC + LFT: HELLP syndrome (Haemolysis= +bilirubin, Elevated liver enzymes= high AST + ALT, Low Platelets)
Clotting: prolonged PT + APTT
U&E + creatinine: high creatinine
CTG
Growth scan with umbilical artery Doppler (may have IUGR + polyhydramnios)
44
```
Pre-Eclampsia
Traget BP (1)
```
135/85
45
```
Pre-Eclampsia
Antenatal Management (6)
```
1st labetalol
2nd nifedipine
3rd methyldopa
Induction at 37 weeks
Admit if severe (>160/110), IV labetalol
If very severe, give magnesium sulphate for seizure prophylaxis
46
```
Pre-Eclampsia
Intrapartum Management (4)
```
If planned and uncomplicated just continue anti-hypertensives and monitor BP hourly or every 15-30mins if severe
Early C-section (<37 weeks) if unable to control BP, low sats, HELLP, eclampsia, abruption, worrying fetal monitoring
Deliver at 37 weeks onwards in emergency- induction if not severe, otherwise C-section
3rd stage only use oxytocin because Synto/Ergometrine contraindicated due to high risk of severe hypertension --> stroke
47
Pre-Eclampsia
| Complications (8)
```
Eclampsia
HELLP syndrome
Microaneurysms develop in arteries (contributing to DIC)
Cerebral haemorrhages
IUGR
Renal failure
Placental abruption
Stillbirth
```
48
Eclampsia
| Definition (2)
Tonic-clonic seizure and pre-eclampsia (occurs in 1% of pregnancies with pre-eclampsia)
Most fits occur postnatally
49
Eclampsia
| Treatment (4)
Magnesium sulfate for prevention and treatment (IV bolus 4g over 5-10min then 1g/h for 24h)
For repeated seizures: diazepam
If antenatal/intrapartum then C-section once stable
Manage 3rd stage with oxytocin as Synto/Ergometrine are contraindicated as risk severe hypertension + stroke
50
HELLP Syndrome
| 3
Haemolysis, Elevated Liver enzymes, Low Platelets
Symptoms: epigastric/RUQ pain, nausea and vomiting, dark urine due to haemolysis
Treatment: delivery and same treatment as eclampsia§§
51
Pre-Existing Diabetes
| Pathology (3)
Maternal insulin requirements increase
Because placental lactogen, beta hCG, progesterone and cortisol are anti-insulin
Maternal glucose crosses the placenta leading to fetal hyperinsulinaemia and macrosomia
52
Pre-Existing Diabetes
| Pre-pregnancy management (4)
Optimise control (aim glucose 4-7mmol/l and HbA1c <48mmol/l)
5mg folic acid daily
Stop oral hypoglycaemics except metformin
Stop ACE-i, ARBs and statins
53
```
Pre-Existing Diabetes
Antenatal management (2)
```
Continue insulin type 1 and metformin type 2 (although may require insulin for tighter control)
Growth scans every 4 weeks from 28 weeks
54
```
Pre-Existing Diabetes
Intrapartum Management (4)
```
Induction/C-section at 38 weeks
Corticosteroids to promote fetal lung maturity if premature
Continuous fetal monitoring
Sliding scale infusion of insulin (halve rate of infusion after placental delivery in type 1 and stop in type 2)
55
```
Pre-Existing Diabetes
Postnatal Management (1)
```
Metformin and insulin fine for breastfeeding
56
```
Pre-Existing Diabetes
Maternal complications (3)
```
Hypoglycaemia unawareness (especially 1st trimester)
Increased risk of pre-eclampsia
Increased risk of infection
57
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Pre-Existing Diabetes
Fetal complications (7)
```
```
Miscarriage
Increased risk of malformation
Macrosomia (risk of shoulder dystocia)
Polyhydrammnios
Growth restriction
Preterm labour
Stillbirth
```
58
```
Gestational Diabetes
Risk Factors (6)
```
```
BMI >30
1st degree relative
Previous baby >4.5kg
Previous gestational diabetes
Increasing age
Ethnicity
```
59
Gestational Diabetes
| Investigations (2)
OGTT (if any risk factors) >7.8
| HbA1c to exclude undetected pre-pregnancy type 2 diabetes
60
Gestational Diabetes
| Treatment (2)
Diet and exercise for 1-2 weeks (after this start medical therapy)
Metformin/insulin
61
Gestational Diabetes
| Complications (7)
```
Type 2 DM (50%- so give lifelong dietary advice and follow up)
Macrosomia
Birth trauma
Shoulder dystocia
Polyhydramnios
Prematurity
Stillbirth
```
62
Hyperemesis Gravidarum
| Definition (1)
Persisting vomiting in pregnancy which causes weight loss (>5% of pre-pregnancy weight) and ketosis
63
```
Hyperemesis Gravidarum
Risk factors (3)
```
Multiple pregnancy (due to high BhCG)
Molar pregnancy
History of hyperemesis
64
Hyperemesis Gravidarum
| Signs + symptoms (5)
```
Inability to keep food/fluids down
Weight loss
Dehydration
Electrolyte disturbance with hypokalaemia and hyponatraemic shock
Haematemesis from Mallory-Weiss tear
```
65
Hyperemesis Gravidarum
| Investigations (4)
Urinalysis: ketones
U&E: hypokalaemia, hyponatraemia
FBC: raised haematocrit
US: diagnose multiple pregnancy and exclude a mole
66
Hyperemesis Gravidarum
| Treatment (5)
Admit for rehydration and correction of metabolic disturbance if unable to keep anything down despite oral anti-emetics
Fluids: 0.9% NaCl + K or Hartmann's (maintenance fluids)
Folic acid
Anti-emetics eg. promethazine, cyclizine, metoclopramide
Thiamine (eg. pabrinex) to avoid Wernicke's encephalopathy
67
Hyperemesis Gravidarum
| Complications (5)
```
Wernicke encephalopathy
Mallory-Weiss tear
VTE
SGA
Pre-term birth
```
68
Venous Thromboembolism in Pregnancy
| Pathology (3)
Increased venous stasis
Trauma to pelvic vessels at delivery
In factors X, VIII and fibrinogen
69
```
Venous Thromboembolism in Pregnancy
Risk factors (7)
```
```
Increasing age
High BMI
Increasing parity
Smoking
Pre-eclampsia
Family history of unprovoked DVT
Multiple pregnancy
```
70
Venous Thromboembolism in Pregnancy
| Signs + symptoms (2)
DVT: swelling, pain, redness
PE: SOB, chest pain, haemoptysis
71
Venous Thromboembolism in Pregnancy
| Investigations (3)
Compression/duplex US for suspected DVT
D-dimer inaccurate in pregnancy as they are raised anyway due to changes in the coagulation system
For suspected PE: duplex USS then CXR + V/Q scan
72
Venous Thromboembolism in Pregnancy
| Treatment (2)
LMWH for 3 months
| Stop during labour and resume after delivery (if too high risk to stop anticoagulants consider unfractionated heparin)
73
Small for Gestational Age
| Definition (1)
Estimated fetal weight <10th centile for their gestational age or abdominal circumference <10th centile
74
Small for Gestational Age
| Aetiology (2)
Placental: abnormal trophoblast invasion eg. pre-eclampsia, infarction, abruption (tends to cause a symmetrical growth restriction with head sparing + reduced abdo circumference) OR poor nutrient transfer (low pre-pregnancy weight, undernutrition, cocaine, alcohol, smoking)
Fetal: genetic abnormalities eg. trisomy 21 and Turner syndrome OR congenital abnormalities OR infection eg. CMV, rubella OR multiple pregnancy
75
Small for Gestational Age
| Major risk factors (9)
```
Age >40
Smoking
Cocaine
Previous SGA baby
Previous stillbirth
Family history of SGA
Diabetes
Chronic hypertension
Pre-eclampsia
```
76
Small for Gestational Age
| Minor risk factors (5)
```
Age >35
Nulliparity
BMI >20
IVF
Gestational hypertension
```
77
Small for Gestational Age
| Investigations (2)
Serum growth scans
| Umbilical artery Doppler
78
Small for Gestational Age
| Complications (6)
Higher mortality
Higher incidence of cerebral palsy
More likely to have intrapartum fetal distress, meconium aspiration and emergency C-section
Neonatal hypothermia
Neonatal hypoglycaemia
As adults, higher risk of hypertension, type 2 DM
79
Twin Pregnancies
| Epidemiology (1)
1 in 65
80
Twin Pregnancies
| Classification (2)
Monozygotic: identical, develop from single ovum which has divided to form 2 embryos
Dizygotic: non-identical, develop from 2 separate ova fertilised at same time
81
```
Twin Pregnancies
Predisposing factors (4)
```
Induced ovulation and IVF
Previous twins
Family history of twins
Increasing maternal age
82
Twin Pregnancies
| Complications during pregnancy (5)
```
Polyhydramnios
Pre-eclampsia (30% in twins)
Anaemia more common
APH
Gestational diabetes
```
83
```
Twin Pregnancies
Fetal complications (5)
```
Increased perinatal mortality
Prematurity (mean gestation 37 weeks)
Growth restriction
Increased malformation rates (especially if monozygotic)
Twin to twin transfusion syndrome: monochorionic twins share a chorion and blood vessels that anastomose so donor twins blood supply disproportionately goes to recipient so donor gets IUGR + oligohydramnios and recipient is larger + polyhydramnios
84
Twin Pregnancies
| Complications of Labour (4)
PPH
Malpresentation
Vasa praevia rupture
Cord prolapse
85
```
Rhesus Disease (Isoimmunisation)
Aetiology (1)
```
Mother Rh-ve and Father Rh+ve
86
```
Rhesus Disease (Isoimmunisation)
Pathology (2)
```
Rh-ve mother carrying Rh+ve fetus in her 1st pregnancy develops anti-D antibodies when fetal RBCs enter maternal circulation
In subsequent pregnancies with a Rh+ve fetus, anti-D crosses the placenta leading to fetal RBC destruction and haemolytic disease of the newborn
87
```
Rhesus Disease (Isoimmunisation)
Investigations (1)
```
Screen at 8-12 weeks for rhesus status
88
```
Rhesus Disease (Isoimmunisation)
Treatment (1)
```
Prophylactic anti-D IgG at 28 + 34 weeks to prevent woman making her own anti-D
89
```
Rhesus Disease (Isoimmunisation)
Additional indications for anti-D (5)
```
```
Miscarriage >12 weeks
Threatened miscarriage
Ectopic pregnancy
APH
At delivery if baby is Rh+ve
```
90
Antepartum Haemorrhage
| Definition (1)
Genital tract bleeding from 24 weeks gestation
91
Antepartum Haemorrhage
| Aetiology (9)
```
Placental abruption
Placenta praevia
Vasa praevia
Circumvallate placenta
Cervical polyps
Cervical erosions
Cervical cancer
Cervicitis
Vaginitis
```
92
Antepartum Haemorrhage
| Treatment (5)
Admit (unless spotting has stopped and the placenta is not low-lying)
If bleeding severe, IV fluids, take bloods, raise legs and give O2
If shocked, give transfusion until BP >100
C-section for placenta praevia (sometimes for abruption or induction) and beware PPH (manage 3rd stage with Syntometrine)
If bleeding mild: for placenta praevia keep in hospital until delivery (C-section at 37-38 weeks), for abruption can go home if settles then treat as high risk
93
Placental Abruption
| Associations (8)
```
Pre-eclampsia
Smoking
IUGR
Preterm rupture of membranes
Multiple pregnancy
Polyhydramnios
High maternal age
Cocaine use
```
94
Placental Abruption
| Signs + symptoms (5)
```
Shock out of keeping with visible loss (bleeding maybe well localised to one placental area and there may be delay before bleeding is revealed)
Pain constant
Tender, tense uterus
Normal lie and presentation
Fetal heart: absent/distressed
```
95
Placental Abruption
| Consequences (5)
Placental insufficiency may cause fetal anoxia/death
Compression of uterine muscles by blood causes tenderness and may prevent good contractions
Posterior abruptions may present with backache
Thromboplastin release may cause DIC
Concealed bleeding may cause maternal shock after which beware renal failure + Sheehan's syndrome
96
Placenta Praevia
| Associations (6)
```
C-section
Multiparity
Multiple pregnancy
Mother >40
Assisted conception
Fibroids
```
97
Placenta Praevia
| Signs + symptoms (6)
```
Shock in proportion to visible loss
No pain
Uterus not tender
Abnormal lie and/or abnormal presentation
Fetal heart usually normal
Small bleeds before large
```
98
Placenta Praevia
| Investigations (3)
US at <24 weeks shows low-lying placenta in many women but by term only 3% lie low (TVUS superior to TAUS)
Combine US with Doppler/MRI to diagnose vasa praevia/placenta accreta
Avoid digital PV examination but speculum is safe, avoid penetrative intercourse
99
Placenta Praevia
| Grading (4)
Grade I- encroaches lower segment but doesn't reach the os
Grade II- reaches os but doesn't cover it
Grade III- partially covers os
Grade IV- completely covers os
100
Placenta Praevia
| Treatment (2)
Major (III + IV) requires C-section
| Minor (I + II) aim for normal delivery unless within 2cm of internal os
101
Vasa Praevia
| Definition (3)
Fetal vessels from velamentous insertion or between lobes risks damage at membrane rupture causing fetal haemorrhage
Velamentous insertion: umbilical vessels go within the membranes before placental insertion
Placenta succenturia: separate lobe forms away from main placenta which may fail to separate normally and cause a pPH
102
Placental Accreta
| Definition (1)
There is abnormal adherence of all or part of the placenta to the uterus (placenta increta if myometrium infiltrated, placenta percreta if reaches serosa), predisposing to PPH
103
Retained Placenta
| Associations (7)
```
Previous retained placentauterine surgery
Preterm delivery
Maternal age >35
Placental weight is low
Parity >5
Induced labour
Pethidine used in labour
```
104
Retained Placenta
| Treatment (5)
Avoid excessive cord traction as it may snap
Put baby to breast to stimulate oxytocin production
Give oxytocin into umbilical vein and clamp cord
If placenta still not delivered 30 min after oxytocin, do manual removal
If fails to transfer to theatre for removal
105
Normal Labour
| Definition (1)
After 37 weeks and results in spontaneous vaginal delivery of baby within 24h of the onset of regular spontaneous contractions, often follows a 'show'- plug of cervical mucus and blood as the membranes strip from the os
106
Normal Labour
| First stage- latent phase (2)
Painful, irregular contractions
| Cervix initially effaces (becomes shorter and softer) then dilates to 4cm
107
Normal Labour
| First stage- established phase (6)
Regular contractions with dilation from 4cm
Rate of dilation should be 0.5cm/h
Takes 8-18h in primip, 5-12 in multip
Check maternal BP + temp every 4h
Assess contractions every 30 min (ideally up to 3-4 per 10 min, lasting up to 1 min)
Vaginal exam every 4h
108
Normal Labour
| Second stage- passive stage (2)
Complete cervical dilatation but no pushing
| Seen particularly in epidurals, where you should allow 1-2 hours to reduce instrumental delivery rate
109
Normal Labour
| Second stage- active stage (4)
Maternal pushing
Within 3h if primip, 2h if multip
Prevent precipitate delivery (and so intracranial bleeding) by putting pressure over perineum
1 min delay in clamping cord in vigorous term babies, 3 min delay in prematurity (reduces anaemia)
110
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Normal Labour
Third stage (3)
```
Delivery of placenta
Physiological management takes less than 1 h
Use of syntometrine (ergometrine + oxytocin) as anterior shoulder is born decreases 3rd stage time to 5min
111
Induction of Labour
| Epidemiology (1)
20% of UK labours
112
Induction of Labour
| Indications (8)
```
Hypertension
Pre-eclampsia
Prolonged pregnancy
Rhesus disease
Diabetes
Placental abruption
Fetal death in utero
Placental insufficiency
```
113
Induction of Labour
| Contraindications (5)
```
Malpresentation
Fetal distress
Placenta praevia
Cord presentation
Vasa praevia
```
114
Induction of Labour
| Bishop's Score (6)
```
Cervical dilation
Length of cervix
Station of head (cm above spines)
Cervical consistency
Position of cervix
Score >5 favourable and if >7, induction with artificial rupture is possible, avoiding prostaglandins
```
115
Induction of Labour
| Method (3)
Prostaglandin PGE2 in pessary or gel form OR misoprostol
Artificial rupture of membranes
After 2-4hours if no contractions start oxytocin infusion
116
Induction of Labour
| Complications (5)
```
Failed induction
Uterine hyperstimulation
Infection
Cord prolapse
C-section (20%) and instrumental delivery (15%) rates are higher
```
117
Delay in Labour
| Causes (3)
Power: poor uterine contractions
Passenger: malpresentation, malposition, large fetus
Passage: inadequate pelvis
118
```
Pain Relief in Labour
Nitrous oxide (2)
```
Contraindications: pneumothorax
| Side effects: nausea, vomiting, faintness
119
```
Pain Relief in Labour
Narcotic agents (3)
```
Eg. pethidine, diamorphine
Side effects: maternal drowsiness, nausea, vomiting, fetal short term respiratory depression and drowsiness
Give with an anti-emetic
120
Pain Relief in Labour
| Pudendal nerve block (1)
Sacral nerve roots 2,3 + 4
121
Pain Relief in Labour
| Epidural (4)
Anaesthetising pain fibres carried by T10-S5
Reduced maternal catecholamine secretion
Helps to lower BP in pre-eclampsia
Complications: patchy block, hypotension, dural puncture
122
```
Malpresentations
Breech presentation (6)
```
Commonest malpresentation
Causes/associations: idiopathic, uterine abnormalities (bicornuate uterus, fibroids), prematurity, placenta praevia oligohydramnios
30% present undiagnosed in labour
Mother may present with pain under ribs
On palpation the tie is longitudinal, no head felt in pelvis
Most delivered by C-section
123
```
Malpresentations
Face presentation (3)
```
Many are due to congenital abnormality such as anencephaly
Most occur by chance as head extends rather than flexes as it engages
Almost all rotate so head can be born by flexion but if not then do C-section
124
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Malpresentations
Brow presentation (2)
```
Head is between full flexion and full extension and may revert to either
If it persists, vaginal delivery not possible
125
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Malpresentations
Shoulder presentation (3)
```
Lie is transverse
Causes: multiparity, multiple pregnancy, polyhydramnios, placenta praevia
High risk of cord prolapse
126
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Fetal Monitoring in Labour
Intermittent auscultation (3)
```
For low risk women
Every 15 min in 1st stage
Every 5 min in 2nd stage
127
Fetal Monitoring in Labour
| Indications for CTG (10)
```
Induction of labour
Postmaturity
Previous C-section
Pre-eclampsia/hypertension
Prematurity
Prolonged rupture of membranes (>24h)
Diabetes
Oxytocin
Epidural
Pyrexia
```
128
Fetal Monitoring in Labour
| Describing a CTG
DRCBRAVADO
DR: determine risk, why is she having CTG?
C: contractions, how many in 10 mins?
BRA: baseline rate (reassuring 100-160)
V: variability
A: accelerations
D: decelerations (downward spikes of >15bpm for >15seconds, late decels = peak decel after contraction passed and are a sign of acidosis)
O: overall (normal, non-reassuring, abnormal)
129
Fetal Monitoring in Labour
| Improving a CTG (3)
Left lateral position to shift weight off maternal vessels and correct cord compression
IV fluids if hypotensive
Reduce/stop oxytocin
130
Fetal Monitoring in Labour
| Fetal blood sampling (2)
Take when trace abnormal, unless immediate delivery required
Normal: pH >7.25
131
Cord Prolapse
| Definition (2)
Descent of cord through the cervix, below presenting part, after rupture of membranes
An emergency because cord compression and vasospasm from exposure of the cord causes fetal asphyxia
132
Cord Prolapse
| Associations (5)
```
2nd twin
Prematurity
Polyhydramnios
Transverse/unstable lie
Male
```
133
Cord Prolapse
| Treatmetn (4)
Deliver fetus immediately (C-section or instrumental if operative delivery)
Displace presenting part by putting a hand in the vagina, push it back up during contractions
Knee-to-chest position so that her bottom is higher than her head
Tocolysis (terbutaline) reduces contractions and helps bradycardia
134
Shoulder Dystocia
| Definition (1)
Delivery requiring additional obstetric manoeuvres to release the shoulders after gentle downward traction has failed
135
Shoulder Dystocia
| Associations (5)
```
Large fetus
High maternal BMI
Induction/oxytocin
Prolonged 1st/2nd stage
Assisted vaginal delivery
```
136
Shoulder Dystocia
| Complications (4)
Increased rate of fetal mortality (asphyxia)
Brachial plexus injuries
PPH
4th degree perineal tears
137
Shoulder Dystocia
| Treatment (7)
May need episiotomy for space for internal manoeuvres
(1) McRoberts position (hyperflexed lithotomy)
(2) Suprapubic pressure
(3) Internal manoeuvres: rotate baby by 180 degrees and deliver posterior arm
(4) Roll mother onto all fours
Maternal symphysiotomy
C-section after replacement of head by firm pressure of hand to reverse movements of labour
138
Operative Vaginal Delivery
| Epidemiology (1)
10-15% of UK births
139
Operative Vaginal Delivery
| Criteria for use (8)
```
Consent
1/5th or less head palpable per abdomen
Ruptured membranes
Adequate analgesia: epidural/pudendal block
Adequate contractions
Full dilatation
Cephalic presentation
Neonatal doctor in attendance
```
140
Operative Vaginal Delivery
| Indications (4)
Prolonged 2nd stage
Fetal distress
Cord prolapse in 2nd stage
Maternal exhaustion
141
Operative Vaginal Delivery
| Forceps vs Ventouse (3)
Forceps safer for baby
Forceps cause significant maternal genital tract trauma
Ventouse more likely to fail
142
Operative Vaginal Delivery
| Complications (3)
Maternal genital tract trauma
Fetal injuries with forceps (rare): facial nerve palsy, skull fractures, orbital injury, intracranial haemorrhage
Fetal injuries with ventouse: cephalhaematoma (most common), retinal haemorrhage
143
Operative Vaginal Delivery
| When to Abandon (3)
No descent with each subsequent pull
Delivery not imminent after 3 pulls
Head impacted in pelvis
144
Caesarean Section
| Layers (7)
Skin -> fat -> rectus sheath -> rectus abdominis -> parietal peritoneum -> visceral peritoneum -> uterus
145
Caesarean Section
| Indications (7)
Repeat CS
Fetal compromise eg. cord prolapse, scalp pH <7.2
Failure to progress/failed induction
Malpresentation
Severe pre-eclampsia
Twin pregnancy with non-cephalic presenting twin
Placenta praevia
146
Caesarean Section
| Complications (3)
Intraoperative: blood loss, uterine lacerations, bladder laceration
Post-op: wound infection, endometritis, VTE (all emergency C patients get 7 days LMWH)
Higher risk of placenta praevia/accreta in subsequent pregnancies
147
Postpartum Haemorrhage
| Primary PPH definition (1)
Loss of >500ml in first 24h after deliverry
148
Postpartum Haemorrhage
| Primary PPH causes (4)
Tone: uterine atony (most common cause)
Tissue: retained products of conception
Trauma: genital tract trauma
Thrombin: clotting disorders
149
Postpartum Haemorrhage
| Secondary PPH definition (2)
Excessive blood loss from the genital tract after 24h from delivery
Usually occurs between 5-12 days and usually due to retained placental tissue or clot, often with infection
150
Postpartum Haemorrhage
| Antenatal risk factors (8)
```
Previous PPH/retained placenta
High BMI
Low Hb in mother
APH
Multiparity
Increasing maternal age
Large placental site (eg. twins, rhesus disease, large baby)
Low placenta
```
151
Postpartum Haemorrhage
| Intrapartum risk factors (3)
Prolonged labour
Induction/oxytocin
Operative birth/C-section
152
Postpartum Haemorrhage
| Treatment (10)
IV fluids
Deliver placenta and empty the uterus
Massage uterus to generate contraction or perform bimanual compression
Give drugs to contract uterus eg. Syntometrine, oxytocin, ergometrine, misoprostol, carboprost
Repair tears
If bleeding after 2 carboprost doses or suspect retained tissue, theatre for examination under anaesthesia
In theatre, Rusch balloon
Then B-lynch suture
If still ongoing, internal iliac/uterine artery ligation
Then uterine artery embolisation/hysterectomy
153
```
Tears
First degree (3)
```
Superficial
Don't damage muscle
Suture
154
```
Tears
Second degree (1)
```
Involve perineal muscle
155
```
Tears
Third degree (4)
```
Damage involves anal sphincter
3a: external anal sphincter thickness <50% torn
3b: external anal sphincter thickness >50% torn
3c: both external and internal anal sphincters torn
156
```
Tears
Fourth degree (1)
```
Anal/rectal mucosa involved
157
Episiotomy
| Indications (3)
To hasten birth of a distressed baby
For instrumental/breech delivery
To prevent 3rd degree tears
158
```
Postnatal Mental Health
Baby blues (3)
```
75% of new mums
Most often 3-5 days after delivery
Commonly lasts 1-2 days but may persist for up to 2 weeks
159
```
Postnatal Mental Health
Postnatal depression (3)
```
10% if no psychiatric history
Most resolves within 6 months
Short-term antidepressants (tricyclics/SSRIs)
160
```
Postnatal Mental Health
Postpartum psychosis (2)
```
Peak onset 2 weeks
| Previous postpartum psychosis has 30% recurrence rate
161
Miscarriage
| Definition (1)
Loss of a pregnancy before 24 weeks gestation
162
Miscarriage
| Epidemiology (1)
15-20% of pregnancies
163
Miscarriage
| Aetiology (8)
Abnormal conceptus (chromosomal or structural)
Uterine abnormality (fibroids or congenital)
Cervical incompetence
Maternal factors (high age, DM, high/low weight)
Bacterial vaginosis (particularly 2nd trimester loss)
Antiphospholipid syndrome present in many women with recurrent miscarriage
Thrombophilia
Unknown
164
```
Miscarriage
Threatened Miscarriage (4)
```
Viable pregnancy
Cervical os closed
Symptoms mild
Treatment: conservative, often settles and progresses as normal pregnancy
165
```
Miscarriage
Inevitable miscarriage (3)
```
Symptoms severe
Cervical os open
Treatment: conservative, ergometrine IM if profuse bleeding, surgical management if unacceptable bleeding (>2 weeks) or pain or retained products
166
```
Miscarriage
Incomplete miscarriage (3)
```
Most products of conception expelled
Remaining tissue may lead to infection
Treatment: conservative, ergometrine IM if profuse bleeding, surgical management if unacceptable bleeding (>2 weeks) or pain or retained products
167
```
Miscarriage
Complete miscarriage (3)
```
All products of conception expelled
Os closed
Bleeding stopped
168
```
Miscarriage
Missed miscarriage (4)
```
Fetus dead but remains in utero
Cervix closed
Ultrasound: fetal pole >7mm with no fetal heart activity, or mean gestation sac diameter >25mm with no fetal pole or yolk sac
Treatment: expectant (wait 7-14 days for spontaneous completion), 1st vaginal misoprostol, mifepristone, surgical management
169
```
Ectopic Pregnancy
Risk factors (7)
```
```
Damage to the tubes (pelvic inflammatory disease, previous surgery)
Previous ectopic
Endometriosis
IUCD
POP
IVF
Smoking
```
170
Ectopic Pregnancy
| Site (2)
97% tubal, most in ampulla, risk of rupture greatest in isthmus
3% implant on ovary, cervix, peritoneum
171
Ectopic Pregnancy
| Signs + Symptoms (8)
```
Abdominal pain
Bleeding
Fainting
Diarrhoea and/or vomiting
Amenorrhoea and +ve urine BhCG
Referred shoulder tip pain: haemoperitoneum causes diaphragmatic irritation
Normal sized uterus
Cervical excitation +/- adnexal tenderness
```
172
Ectopic Pregnancy
| Investigations (5)
FBC
Group and save
Serum BhCG (if >1500 a uterine pregnancy would be visible on USS)
Serum progesterone (<20 indicates failing pregnancy)
TVUSS: adnexal mass, no visible intrauterine pregnancy
173
Ectopic Pregnancy
| Treatment (5)
Conservative: closely monitor, if BhCG levels rise or if become symptomatic then intervene (strict criteria for conservative management- no heartbeat, <30mm, BhCG <2000 and declining)
IM methotrexate
Laparoscopic salpingectomy if other tube healthy, if not then do salpingotomy
174
Gestational Trophoblastic Disorders
| Definition (1)
Spectrum of disorders ranging from premalignant hydatidiform mole to choriocarcinoma
175
Gestational Trophoblastic Disorders
| Pathology (3)
Large chorionic villi with overgrowth of trophoblastic cells
Complete mole: empty egg fertilised by sperm that duplicates its own DNA
Partial mole: normal egg fertilised by 2 sperm and are triploid (2 sets of paternal haploid genes, 1 haploid maternal set), may have fetal parts or red cells, much commoner
176
```
Gestational Trophoblastic Disorders
Hydatidiform moles (3)
```
Signs + symptoms: heavy bleeding, molar tissue like frogspawn, severe morning sickness, large uterus
Investigations: serum BhCG very high
Treatment: evacuation of uterus, anti-D if rhesus -ve, monitor hCG for 6 months and if they don't drop then give methotrexate
177
Gestational Trophoblastic Disorders
| Choriocarcinoma (3)
Pathology: from following a benign mole, miscarriage or normal pregnancy
Signs + symptoms: may be years after pregnancy, general malaise, uterine bleeding, signs of metastases
Treatment: methotrexate
