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
