Obstetrics Flashcards by Kim Lim

Maternal Reasons for Induction of Labour? (7)

Gestational Diabetes, Hypertension &amp; Obstetric Cholestasis.
Maternal Request.
Prolonged pregnancy (>41-42w)
Symphysis Pubis Dysfunction
Recurrent Antenatal Haemorrhage.

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Fetal Reasons for Induction of Labour? (5)

IUGR
Reduced fetal movements.
Previous Stillbirth or Current Intrauterine Death
Prolonged Pregnancy
Isoimmunisation

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Contraindications to induction of labour? (5)

Previous uterine surgery or lower segment C-section.
Active genital herpes &amp; HIV
Placenta praevia &amp; Vasa Praevia
Umbilical cord prolapse
Abnormal lie

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What are the risks of induction of labour? (7)

Failure leading to need for C-Section or operative vaginal delivery.
Uterine hyperstimulation
Uterine rupture
Cord prolapse
Fetal Compromise
Intrauterine infection (chorioamnionitis)
Post-partum haemorrhage

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What is the step-by-step interventions used for induction of labour? Before-during

Before: Membrane Sweep w finger.

Start: Prostaglandin
Oral/Gel - one dose/6hrs then another (max 2)
Pessary - one dose/24 hours

If frequent/long contractions: Amniotomy

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What is the risk of prostaglandin for induction of labour?

Risk of uterine hyperstimulation

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What do you monitor during induction?

CTG for fetal wellbeing

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What if the mum cant take prostaglandins due to risk of uterine hyperstimulation?

Amniotomy with or without oxytocin.

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What happens if hyperstimulation occurs during induction of labour?

tocolysis

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What happens if uterine rupture happens during induction of labour?

emergency c-section

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Maternal (1) and foetal (3) complications of preterm-prelabour rupture of membrane?

M: Chorioamnionitis
F: Infection, respiratory hypoplasia, prematurity

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Management of PPROM

Admit for observation and also start antibiotics.
Erythromycin (PO) for 10 days and corticosteroids (respiratory)
Consider delivery if past 34 weeks.

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Risk factors for Gestational Diabetes

Previous Gestational Diabetes
First degree relative with Diabetes

*Previous baby > 4.5kg (macrosomia)
Previous unexplained stillbirth

*BMI > 30
Age > 40
*Racial origin

Smoking

Polyhydramnios
Persistent glycosuria
Polycystic ovarian syndrome

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Maternal Complications of Gestational Diabetes

Worsens pre-existing Ischaemic Heart Disease, hypertension and pre-eclampsia

UTIs and endometrial infection
Can develop T2DM
Ketoacidosis and hypoglycaemia
Diabetic retinopathy and nephropathy

Caesarean & instrumental delivery

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Foetal complications of gestational diabetes

Fetal compromise, fetal distress in labour,
Sudden fetal death

Macrosomia, shoulder dystocia
Hyperinsulinaemia/Hypoglycaemia

Polyhydramnios
Preterm labour
Reduced lung maturity
Neural tube & cardiac defect

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What diabetes medication can u continue and not ?

Continue metformin +- insulin

Stop all other oral glucose lowering drugs.

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In terms of heart related drugs what should be discontinue pre-conception and during pregnancy?

ACE-I & Angiotensin 2 receptor blockers

Statins

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True or False?

Use fasting plasma glucose, random blood glucose, HbA1c, glucose challenge test or urinalysis for glucose to assess risk of developing gestational diabetes.

False. Do not use fasting plasma glucose, random blood glucose, HbA1c, glucose challenge test or urinalysis for glucose to assess risk of developing gestational diabetes.

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What investigations can mums get if they are at risk of Gestational Diabetes?

2hr 75g oral glucose tolerance test.

If previous gestational, offer asap after booking and then 24-28 weeks if normal initially.
If not just 24-28 weeks.

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What is a diagnostic result for Gestational Diabetes?

Either:

Fasting equal to or more than 5.6 mmol/L
2hours plasma glucose of more than or equal to 7.8 mmol/L

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Management for GD?

Advice regarding diet and exercise.
Referral to a dietician.
Metformin (if exercise aint cutting it after 1-2 weeks)
If still not met, add insulin.

If fasting above 7 mmol/L from the start, just go straight to insulin with or without metformin.
If there are complications, then can start insulin from 6.

Pruritus affecting palms and soles.

Investigations show: elevated bile salts and liver enzymes during 3rd trimester?

Obstetric Cholestasis

Risk factors for Obstetric Cholestasis?

Multiple pregnancy (Twins)
Calculi - gallstones
Hepatitis C

What investigations would you order in a pregnant woman presenting with itch (palms and soles) but no rash.

Bedside: urinalysis (proteinuria) and blood pressure

Blood:
Liver function test & Bile Acids
Hepatitis ABC, EBV, CMV
Liver auto-immune antibodies - PBC (anti-SMA, anti-mitochondrial antibodies)

Imaging: Liver ultrasound

What is the definitive management for Obs Chole?

Delivery (IoL at week 37) | Ursodeoxycholic acid and sedating anti-histamines (chlorphenamine)

What is the triad for Hyperemesis Gravidarum?

Dehydration, more than 5% pre-pregnancy weight loss and electrolyte disturbances

What is the PUQE score?

Management stratification for HGE.

What are the risk factors for HGE?

Multiple pregnancy & Obesity Nulliparity Trophoblastic disease Hyperthyroidism

What is first line treatment for HGE?

antihistamines (promethazine or cyclizine) --> odansetron or metoclopramide (max 5 days)

Complications of HGE?

``` Mallory Weiss Tear Central Pontine Demyelination Acute Tubular Necrosis Wernicke's Encephalopathy Foetal: SGA, pre-term birth ```

Causes of polyhydramnios? | Hint - increased fluid production & impaired swallow

Increased fluid production: Maternal diabetes & hydrops fetalis due to: rhesus haemolysis, infection (CMV, parvovirus), trisomies and anaemia. Impaired swallow: duodenal/oesophageal atresia, neuromuscular disease (myotonic atrophy), idiopathic

Complications of polyhydramnios [2]

Prematurity & malpresentation

What is pre-eclampsia? What is gestational hypertension?

New onset hypertension (>140mmHg systolic or >90mmHg diastolic) after 20 weeks of pregnancy with proteinuria or major organ dysfunction (renal, liver, neurological, haematological, urteroplacental) G.Htn: New onset hypertension (>140 or >90) without proteinuria

What are the risk factors (High and moderate) for pre-eclampsia?

High: - Hx of previous hypertension disease in previous pregnancies - Chronic Hypertension - Chronic Kidney Disease - T1/2DM - Autoimmune disease (SLE, anti-phospholipid) Moderate: - Nulliparous - Multiple pregnancy - BMI > 35 - Pregnancy interval more than 10 years - More than 40 years old - Family history of pre-eclampsia

What 3 investigations would you order to investigate pre-eclampsia?

Urine dipstick = 0/+1/+2 24 hour urine collection = > 0.3g/24hr Protein:creatinine ratio = >30mg/nmol Urine dip for protein = 0/+1/+2

What is HEELP syndrome?

A severe form of pre-eclampsia associated with:

Risk factors for ectopic? [6]

``` Previous ectopic IVF Surgery or salpingitis Endometriosis IUCD Progesterone only pill ```

What beta-hCG levels would you expect in ectopic pregnancy?

more than 1500

Investigations for ectopic pregnancy?

Pregnancy test kit first (positive) then trans-vaginal ultrasound.

Mum is fitting what do you give? she also has severe hypertension

Magnesium Sulfate bolus then infusion over 24 hours

Mum has high blood pressure what do you give?

labetalol if not then nifedipine

Features of Placenta Praevia? | Bleeding, pain, uterine tenderness, fetus lie, shock?, Ultrasound findings?

``` Red & profuse. No pain. No uterine tenderness. Abnormal lie - breech? Normal heart rate Shock consistent with blood loss Placenta is low. ```

Features of Placenta Abruption? | Bleeding, pain, uterine tenderness, fetus lie, shock?, Ultrasound findings?

``` Dark, sometimes absent. Pain is common & severe & constant Uterus - woody tenderness Lie is normal, distressed heart rate Inconsistent with blood loss. Ultrasound normal ```

Risk Factors for placenta praevia?

``` Smoking. Previous praevia Previous myomectomy or C-section High age High parity or large number of closely spaced pregnancy. ```

Risk Factors for Placenta Abruption?

PMH: pre-eclampsia or hypertension or abruption smoking, increased age IUGR

Complications of praevia:

Placenta Accreta (prevents separation) or precreta (penetrate through uterine wall) IUGR Premature delivery or death Post-partum haemorrhage

Complications of abruption?

Placental insufficiency - fetal hypoxia and death | MUM: DIC, kidney failure, post-partum haemorrhage

Who gets anti-d, how much units, and when?

rhesus negative mums get 1500 units at 28 weeks and after any bleeding episodes and also after delivery if baby is rhesus positve

Complications of rhesus isoimmunisation?

Haemolysis leading to jaundice hydrops fetalis and fetal death if severe. jaundice and anaemia if mild

Risk factors for LGA

Previous LGA Family Hx of LGA High BMI mum PMH: diabetes Male infants