Obstetrics Flashcards
obstetric history acronym for obs part
…
gets(2) a family Gestation - weeks Estimated due date Twins or singleton Sspecialist in charge (2) Scans ok? Anticipated or planned? Folic Acid Movement of fetes ILness? Your choice or birth location?
Obstetric exam
General exam
Hands- cap refill, pulse, BP, Face (anaemia), peripheral oedema
Inspect abdo: shape, fetal movements, linea nigra, striae gravidarum,
Palpation: abdo tenderness in 9 regions
- Uterus borders
- determine fetal lie
- determine fetal presentation
- assess engagement
- measure SFH
- auscultate fetus heart rate
visits
initial contact
booking
dating scan which week?
16 weeks
18-20 weeks
28
34 weeks
36 weeks
38+40
41 weeks what do you offeR?
- each time check urine for protein + BP
INITIAL - information giving, folic acid, food hygiene, screening tests offered
booking: before 10 weeks- offer screening tests, offer dating scan, booking bloods, calculate BMI, measure bp + urine
Dating: 11-14 weeks. determine gestational age, finalise eddoes, Detect multiple pregnancies
16: review test results, offer quadruple test if not screened for downs
18-20 ultrasound for structural abnormalities (anatomy/ anomaly)
28 weeks: provide info with - second screen for anaemia and red cell antibodies. anti d prophylaxis
34 = info on labour given. and borth. 2nd dose anti d prophylaxis
36: K for newborn, post-natal issues, breastfeeding info, palpate for presentation
38-40 palpate for presentation
141- OFFER MEMBRANE SWEEP
BOOKING VISIT
- FBC
- BLOOD Group AND RBC antibodies
- URINALYSIS
- RUBELLA
- HEP B
- HIV
- HAEMOGLOBINOPATHIES
- shyphillus
combined screening
gets offered at initial plan - opt in
done in week 11-14
1) crown rump length
2) nuchal translucency scan + maternal blood test for hCG and PAPA = Pregnancy Associated Plasma Protein-A
indicates downs, pauatu and edwards
–> when higher liklihood comes back: offer chronic villous sampling (11 weeks) or amniocentesis (15 weeks)
common MSK problems
backache
symphysis publus dysfunction
carpal tunnel syndrome
GI problems
Constipation
Morning sickness
GORD
haemorrhoids
Lower limbs
Varicose veins
Oedema
Obstetric cholestasis
Abnormal flow of bile duct –> causes bile salts to build up and leak into blood stream
Itching appearing last 3 months most commonly hands and feet
Worse at night
RF: multiple pregnancies, high dose oral contraception, south asian
Diagnosis: LFTs, serum bile salts
Management: Give birth, cream and antihistamine
URSODEOXYCHOLIC ACID
- Vitamin K offered as can affact ability of blood to clot
UTI
Recurrent cystitis and diabetes RF
presents different in pregnancy
general malaise (e.coli)
CANT give trimethoprim in 1st trimester (folate issue)
or nitrofurantoin in 3rd trimester
- cephalexin is fine in all
problems due to pelvic organ abnormality
Fibroids may enlarge during pregnancy (if lower cervix may prevent descent of presenting part)
Red degeneration: as it grows, fibroids may become ischamic and –> acute pain, vomiting
Retroversion of uterus: If it doesnt flip during pregnancy, then baby will grow in uterine cavitiy and –> stretch on bladder may cause urinary retention classically week 12- 14
Congenital abnormality: bicornate uterus: may cause PROM, pre-term, miscarridge.
Ovarian cysts: large ones can haemorrhage or twist –> acute abdo pain and may cause pre-term or miscarrriage.
hyperemesis gravidarum
Severe intractable nausea and vomiting
Diagnosis criteria triad:
5% pre-pregnancy weight loss, dehydration, electrolyte imbalance.
Severe cases may cause wernikes encephalopathy, oesophageal tear mallory weis, malnutrition
VTE prophylaxis
RF - >35 parity >3 smoker cross varicose veins current pre-elampsia immobility fhx multiple pregnancy
- 2 risk factors –> low risk so mobilisation in pregnancy and avoidance of dehydration + 10 days post-natal prophylaxis
3 risk factors- prophylaxis from 28 weeks + 6 weeks post natal - 4+ = prophylaxis from 1st trimester + 6 weeks post natal
- intermediate risk = antenatal prophylaxis with LMWH
- high risk- antenetal prophylaxis with lmwh + refer to expert
based on booking scan weight
small for dates
<10th centile
Mostly reflect intra-uterine growth restriction
- head growth may be slow less as its prioritised
- doppler used to diagnose placental insufficiency
- reduced end-diastolic flow suggests increased placental resistance
large for dates
- weight leg or head above 90th centile for gestational age
- major factor is uncontrolled maternal/ gestational diabetes
- increased risk of shoulder dystocia
- hypoglycaemia in post-natal period
polyhydramnios
- excess amniotic fluid >95th centile
- may present as severe abdo swelling and discomfort
- abdo appears distended
- fetal poles hard to palpate
- may need to perform amniodrainage
oligohydramnios
Amniotic fluid <5TH DECILE
may be suspected following history of PROM
- small for date uterus
- nsaids can cause
LOW AMNIOTIC FLUID
reduced fetal movement
First noticed between 18 and 20 weeks
Fetal movements increase until 32nd week then flatten
report any change in pattern after 28 weeks
(Move out the house at 18 so fetus starts to move at 18 weeks)
Prolonged pregnancy
Extended beyond 42 weeks
more likely need c section
PPROM = preterm prelabour rupture of membranes
Rupture of membranes before 37 weeks
gush of clear fluid followed by leaking of liquor
- hospital admission and fetal steroids if <34 weeks.
reduces risk of neonatal respiratory distress syndrome.
- prophylactic erythromycin may be used to prevent infection
- induction of labour if 36 weeks
- preterm delivery follows within 48 hrs in 50% cases
1st trimester
week 1- week 12
common issues
hyperemesis gravidum
ectopic pregnancy
miscarriage
fatigue
2nd trimester
week 12- week 27
miscarriage (before 20) placental previa / abruption preterm labour PPROM pre-eclampsia (more common in 3rd)
3rd trimester
week 28- birth
gestational diabetes pre-eclampsia -preterm labour PPROM placenta previa/abruption malpresentation antepartum haemorrhage
symmetrical IUGR
HC - head circumference is relative to the AC- Abdo circumference.
- usually just genetically small
- need fortnightly scans
asymmetrical IUGR
head stays right size and baby uses brown fat stores to supply it energy. body small compared.
if blood reedirected for too long, other organs can become ischaemic –> nectrotosing enterocolitis.
tx - fortnightly scans, weekly doppler of umbilical circulation.
all dizygotic pregnanies
there are 2 placentas (dichorionic) and 2 amniotic sacs (diamniotic).
chorionicity
whether the babies share a placenta or chorion or not
multiple pregnancy treatment
- Oral iron, folic acid, 75mg aspirin
- DCDA 4 weeky scans from 16 weeks
- MC twins 2 weekly from 16 weeks
timing of delivery - DCDA 37-38 weeks
- MCDA 36 week
MCMA 32-34 wees by C section
pre-elampsia
> 20 weeks of pregnancy (normally normotensive)
BP >140/90 on two occasions 4 hours apart
300mg protein in a 24 hr collection of urine
Resolves by 6th week postpartum
pre-existing diabetes
aim to deliver before 39 weeks (more stillbirths)
increased risk cardiac + neural tube defects
fetal macrosoma (big baby) + shoulder dystocia
pre-eclampsia risk
- can get worsening of diabetic retinopathy so
RETINAL SCREEN
1) booking, 2) 16 weeks, 3) 28 weeks
insulin sliding scale introduced in labour
gestational diabetes
those with 1+ risk factor should be tested
RF:; obestity, fhx, previous baby 10lbs +
oral glucose tolerance test
fasting blood sample, then given 75g sugar,
2 hours later another sample taken
performed between 24-28 weeks,
- 6 = fasting diagnosis
- 8 = two hour glucose level
management:
1. 1-2 weeks lifetsyle trial
2. Metformin
3. Targets still not met = Insulin (or FBG was >7 at time of diagnosis)
commonest acquired thombophillia
antiphospholipid syndrome
- lupus antibody + / anti-cardiolipin antibody
often history of recurrent miscarriage
treatment of VTE in pregnancy
- stockings
- LMWH as it does not cross placenta
- dose calculated against mothers booking weight
women taught to self inject
used till at least 6 weeks post natally.
when labour starts- discontinue lmwh/ 24 hrs before C section
VBAC
vaginal birth after C section
70% chance of normal delivery after
increased risk of uterine rupture
2+. c section scars = CI
uterine rupture
severe lower abdo pain vaginal bleeding haematuria cessation of contractions maternal tachy fetal compromise
C section risks
increased risk of: infection bleeding injury to bowel scalpel injury to baby anaesthesia risk prolonged recovery future pregnancy rupture risk
sickle cell tx in pregnancy
5mg folic acid (high dose)
75 mg aspirin
epilepsy in pregnancy
reduce to monotherapy where possible
5mg folic acid
Na valproate worst risk associated with neural tube defects
lamotragine safer option
may need to increase dose as drug levels tned to decrease
cardiac in pregnancy
increased blood flow produces an ejection systolic murmer is 90% pregnant women
ecg: t wave inversion and L axis deviation
warfarin and ace inhibitors CONTRAINDICATED
pulmonary hypertension in pregnancy
high maternal mortlaity = usually contraindicated and terminated.
depression in pregnancy
tricyclic antidepressants are safe and carry no teratogenic effects
SSRis increase risk of congenital abnormalities
tokophobia
anxiety about labour
drug affetcs on pregnancy lithium.. valproate.. SSRI.. BZ..
L.. fetal cardiac disease and fetal anticonvulsant syndrome
V..neural tube defects and fetal anticonvulsant syndrome
SSRI.. feta cardiac disease + persistant pulmonary HTN
BZ.. facial clefting and depressed resp effort at birth, hypotonicity and poor feeding = floppy baby syndrome
autoimmune hashimotots thyroiditis
- maternal thyroxine important in 1st trimester for developmental delay
tx should be carbimazole (not radioactive iodine) as completely obliterates fetal thyroid gland.
uncontrolled thyrotoxicosis is assocaited with risk of miscarriage, preterm delivery and FGR.
recurrent miscarriage
3 or more consecutive pregnancies that end in miscarriage of the fetus before 24 weeks of gestation
- investigate for antiphospholipid antibodies
TX: heparin and low dose aspirin
- inherited thrombophillia screen also
mid-trimester loss
12-24 week baby dies.
after 24 weeks = still birth
movement of head in passage
1) engagement in occipito-transverse
2) descent (uterine action) then flextion
3) internal rotation 90 degrees to occipito anterior
4) descent
5) extension to deliver head
6) restitution and delivery of shoulders (anterior first)
first stage of labour
time of onset to full dialatation 10cam
Latent phase 0cm-4cm- cervix becomes effaced (2-3 days)
Active phase / established labour: up to 10cm
2cm 4 hours
management of slow progress in 1st stage
artificial rupture of membranes
syntocinon
2nd stage
time from full dialatation to delivery of the foetus (4-5 hours)
passive stage: no maternal urge to push
active stage: maternal urge to push. fetal head is low.
40 min primp, 20 min multiple.
methods to help in 2nd stage
vaccum extraction
traction forceps: need episiotomy - OA only
rotational forceps: can be used in OA, OP or transverse
third stage
time from delivery of fetus to delivery of placenta
cord clamping
active: recommended as reduces PPH. 10 IU of oxytocin an controlled cord traction, deferred clamping and cutting of cord by 1min.
physiological: placenta delivered by maternal effort and. no uterogenic drugs
thick bright green meconium
sign of intrauterine hypoxia or acidosis
fetal monitoring in labour
intermittent ausculatation of fetal heart using doppler or pinard steth
high risk women : continuous monitoring ctg.
- Fetal scalp electrode: indication- poor contact with abdo transducer, high BMI, twins, abdo scarring,
CTG
normal variaability ?
Normal baseline rate?
early and late decelerations- which is concerining?
definition of acceleration?
DR, C BRAVADO.
Define Risk
Contractions: per 10 minutes. >5 hyper? cant measure intensity- so palpate for this
Baseline Rate: 110-160 (range 15)
Accelerations: they are encouraging
Decelerations: ‘early’ = not concerning
‘late’ = concerning (fetal hypoxia)
Accelerations = increase in baseline heart rate of >15 bpm for >15 seconds.
Variable
- typical : <60s <60 change
- atypical: >60s >60 change
Overall assessment: reassuring? normal?
bishop score
score +8 indicates will deliver soon and easier shorter induction
cervical ripening
- insert tampon in posterior fornix that releases prostaglandins for 24 hours
e.g. propess: 10mg over 24 hrs
prostin gel: 1mg released over 6 hours
artifical rupture of membranes
- breaks waters - amnihook inserted through partially opened cervix and makes hole in membranes
often give oxytocin samr time
syntocinon
oxytocin = slow IV drip until 3 contractions every 10 mins
membrane sweep
vaginal examination inserting finger through cervix and strips chorionic membrane from the underlying deducide. releases natural prostaglandins.
offered at 40 and 41 week antenatal visits.
malpresentation
any presentation that is no cephalic
e.g. breech
- transverse lie: fetal long axis transverse
- oblique lie: long axis of fetus crosses maternal long axis
malposition
ocipito-anterior is normal
ocipitotransverse or posterior = abnormal
vertex vertex
breach breach
vertex breach
twins both head down
twins both bum down
one twin head down one with one bum down
shoulder dystocia
need for additional obstetric manouvres to release shoulders after gentle downward traction has failed.
can be heped with McRoberts manoevre
Management of symptomatic women in preterm labour
Name 2 tocolytics?
Drug for baby neuroprotection?
When offer maternal steroids?
<22-24 weeks not viable with life
maternal steroids should be offered from 26-34 weeks
two injections of 12 mg IM dexamethasone 12 hours apart
- Tocolytics: Nifedipine or Terbutaline = anticontraction medications
- broad spec antibiotics
- Magnesium sulfate: neuroprotection of baby if 24-29 weeks
Maternal steroids: 12 mg Dexamethasone between 26 - 33 weeks to reduce resp disress syndrome
GBS positive: group b strep
preterm infants more susceptibe to early onset GBS infection
allow consideration of intrapartum prophylaxis with benzylpenicillin.
placental abruption
separation of normally sited placenta from uterine wall –> vaginal bleeding
syx: constant or frequent short lasting contractions - caused by irritable effects of blood within uterus
- hard uterus
- pain
- shock disproportional to blood loss (lots inside still)
- uterus may be firm and wooy = spasm
- fetal HR may be hard to auscultate
placenta previa
major: covering internal cervical os
minor: placenta covering lower segment of uterus but not os
placenta accreta
increta
percreta
- placenta implanted into lower segment of uterus
- placenta accreta = abnormally adherant to uterine scar
- placenta increta: invading part of utering wall
- placenta percreta: through uterine wall
chronic hypertension pregnacy
treat if 150/100 with medication - oral labetalol
admit if >160/110
pre-elampsia
- incomplete trophoblastic invasion of spiral arterioles and atheromatous lesion –> exaggeration maternal inflammatory response –> widepsread endothelial damage
- glomeruloendotheliosis = renal lesion highly characteristic
HELLP
- haemolysis
- Elevated Liver enzymes
- Low platelets
pre eclampsia syx?
sign
Frontal headache
oedema
visual disturbance
epigastric pain
sign:bp 140/90, +++ protein, hyperreflexia, oedema
pre eclampsia managememnt
- antihypertensives
Labetalol (not if asthmatic), methydopa or nifedipine
Seizures: magnesium sulphate IV and prophylactically to prevent seizures 48 hrs post partum
12mg dexamethasone
cord prolapse
presentation of umbilical cord below fetal presenting part when the membranes are ruptures
move women onto all 4s then c section
PPH
tone, tissue, traume and thrombin
1) communication: altert midwife and obstetrican and anaesthesit
2) resus A-E- fluid iv hartmans clotting screen etc
3) arrest bleeding: bimanual uterine compression
- uterotonic drugs: rapid oxytocin infusion or iM bolus
- intauterine balloon tamponade
- hysterectomy if really bad
SYNTOCINON inusion !!!!
+ ERGOMETRINE IV bolus
HELLP syndrome
Haemolysis
Elevation of liver enzymes
Low platelets
SYX: Malaise, N+V,
Prevention of pre-elampsia in hgih risk women?
75 mg aspirin OD started at 12 weeks
What is Colostrum?
Yellowish fluid secreted by the breast as early as 16 weeks, replaced by milk 2nd day post-partum.
Laxative effect to help baby get rid of meconium.
Best contraception post birth?
POP - progesterone only commenced day 21 following delivery
Peupeural psychosis
When occurs?
TX?
Usually occurs after day 4 postpartum
Admit to Mother and baby psych unit
Tx: Haloperidol and antidepressants
Obstetric cholestasis
Itching druring pregnancy
COCP contraindicated in women who have had this
TX: ursodeoxycholic acid
What is carbergaline?
stops lactation post partum for women not breast-feeding
