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ONG > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

how to calculate expected date of delivery

A

EDD = LMP - 3months + 7 days and 1 year + days if cycle is longer than 28 days
can use USS and crown-rump length at 12 week scan (11-13+6 week scan)

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2
Q

diagnosis of GDM (16% preg women)

A

fasting glucose of 5.6mmol/L or more

GGT at 24-28 weeks (2hrs after 75mg glucose) >7.8mmol/L

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3
Q

why is pregnancy diabetogenic

A

glucose tolerance decreases due to

  • altered carb metabolism
  • antagonistic effect lactogen, cortisol and progesterone
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4
Q

fetal and maternal complications of DM

A

Fetal: congen ab (NTD) 3-4x increase, prem >10%, lung maturity decreased, macrocosmic, dystocia and birth trauma
Mat: increase insulin requirements, UTI, ketoacidosis, wound/endometrial infection, HTN, preE , IHD worsens, CS or instrumental, nephtopathy and retinopathy

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5
Q

what weight in DM should you go to ECS and when

A

deliver 37-39 weeks, >4kg ECS

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6
Q

fetal consequences of premature

A

50% of CP, 20% perinatal mortality, CLD, blind, minor disability, cog, behavioural, RD. risk <5% at 32 weeks but at 24 weeks 1/3 handicapped and 1/3 die

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7
Q

IX prem

A

negative point of care test for prem = fetal fibronectin assay
TVUSS cervical length (>15mm unlikely in next week)
CTG USS fetus
swabs, CRP, WCC
VE unless ROM/PP

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8
Q

Mx prem

A

steroids 23-34 weeks
tocolytics (nifedipine/oxytocin R antag)
Abx if infection
chorioamnionitis - IV ABx and asap delivery
MgSO4 4g slow injection IV <12hrs neuroprotectIVE, 23-34 weeks
transfer NICU esp if <27 weeks and <800g
delivery: vaginal if can but most breech so CS; paediatric facilities mobilised; cord not clamped for 45 secs unless reusus; ABX if premature

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9
Q

define preterm prelabour ROM and what proportion of prem labours does this occur in

A

Membranes rupture <37weeks before labour
occurs in 1/3 prem
pre term labour follows in >50%

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10
Q

HX and complications Preterm prelabour ROM

A

gush then leak liquid. infection fetus, choriamnionitis, funisitis, prolaptse cord

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11
Q

Ix preterm prelabour ROM

A

(actim partus and other point of care tests not v reliable)
USS (may decrease liquor)
HVS, FBC, CRP, ?lactate, CTG

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12
Q

Mx preterm prelabour ROM

A
  • admit for 48hrs at least
  • steroids
  • obs
  • deliver if 34-36 weeks
  • infection -> IV ABx and deliver
  • erythromycin prophylaxis
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13
Q

causes of APH

A
  • placenta praevia
  • placental abruption
  • vasa praevia (vessels in membranes in front presenting part, normally with velamentous insertion)
  • uterine rupture
  • Gynaecology origin bleed
  • undetermined origin
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14
Q

classic presentation of Placenta praevia vs placental abruption

A

PP - small painless bleeds (red) increasing in pregnancy, transverse lie, not engaged, USS, no fetal distress
Placental abruption - painful, dark bleeds, uterine tenderness, labour may ensue, ss of blood loss, fetal distress (ab/absent fetal tones)

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15
Q

management PP

A

woman with bleed: Admit, FBC, cross match, clotting factors, antiD if neg, CTG, IV access, steroids if <34. if severely prem may give transfusion to prolong. severe loss -> CS
without bleed: delay admission til delivery (ECS 39 week or earlier if heavy)
placenta accrete/percreta: ECS with interventional radiology. incision away from placenta then Rush balloon compression.

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16
Q

key compilation following Placenta praevia or abruption

A

PPH

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17
Q

management of placental abruption

1) fetal distress
2) no FD >37 weeks
3) no FD <37 weeks
4) fetal death

A

All: Admit, FBC, cross match, clotting factors, antiD if neg, CTG, IV access, steroids if <34, analgesia

1) urgent CS
2) IOL with amniotomy, urgent CS if fetal distress develops
3) monitor on antenatal ward, may discharge if minor, steroids, serial USS for growth
4) IOL with amniotomy, transfuse blood and FFP as likely to have coagulopathy

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18
Q

what is SGA and IUGR

A

SGA = <10th decile or <2.7kg at term

IUGR about genetic potential

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19
Q

what does decreased PAPP-A indicate

A

?Chr. ab, higher risk IUGR, placental abruption, still birth

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20
Q

what percentage decrease in abdominal growth indicated IUGR on USS

A

30% Decrease in rate

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21
Q

what does absent end diastolic flow or reversed end diastolic flow indicate on umbilical a Doppler waveform

A

severe placental dysfunction

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22
Q

what is combined with umbilical a doppler after 34 weeks

A

MCA doppler and cerebroplacental ratio

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23
Q

what would indicate compromise on MCA doppler

A

MCA low resistance pattern compared to thoracic aorta or renal vessels as increase dia, head sparing.
only used in high risk preg or ?anaemia. not routinely used.

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24
Q

what is ductus enosis waveform a measure of

when would you use doppler waveform of fetal venous circ

A

fetal cardiac function.

use if v prem <28 weeks, to assess twin-twin transfusion syndrome. only fetal med centres.

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25
Q

how to differentiate SGA and IUG

A

USS and umb A doppler. decrease growth velocity 30% abdomen circ = IUGR
often oligohydramnios
CTG for fetal distress

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26
Q

management SGA

A

recheck growth with USS at 2-3 weekly intervals. >37 weeks arrange delivery or wait til spontaneous at term if no abs and >3rd centile

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27
Q

what would the next steps be if EFW <10th centile and ab umbilical A doppler at <34 weeks

A
  • repeat anomaly scan
  • check maternal CMV and toxoplasmosis (IgM) status
  • consider uterine a, karyotype, MCA doppler
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28
Q

next steps for: placental origin of IUGR, gest <24, EFW <500g

A

see in 1-2 weeks til >24 or >500g -> umbilical a doppler

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29
Q

next steps for: placental origin of IUGR, >24 weeks and 500g, umbilical a doppler normal

A

repeat 2-3/wk

monitor BP and urinalysis

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30
Q

next steps for: placental origin of IUGR, >24 weeks and 500g, umbilical a doppler ab

A
  • <32wks do daily CTG

- >/=32 deliver CS

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31
Q

classification of CTG

  • normal
  • suspicious/non-reassuring
  • pathological
A
  • normal = all reassuring
  • suspicious/non-reassuring = 1 non-reassuring and 2 reassuring
  • pathological = 1 ab or 2 non-reassuring
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32
Q

normal baseline variability and ab

A

10-25bpm, ab <5

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33
Q

types of deceleration

A

early - with contractions. benign.
variable - cord compression and fetal hypoxia
late decals - maternal hypo, preE
Prolonged decals >3mins, ab

34
Q

how often are maternal obs done

A

temp and BP very 4 hours

pulse every hour first stage then every 15 mins second

35
Q

how often is FHR measured

A

15 mins first stage, 5 mins second stage

36
Q

what to do if slow progress in active first stage

A

if slow after latent tx with ARM -> slow -> oxytocin (in null and multi once exclude malpresentation)

37
Q

management face presentation

A

if chin ant, VD, if post CS

38
Q

brow presentation management

A

fetal compromise common. CS

39
Q

ph <7.2 FBS

A

= fetal compromise. deliver fastest route

40
Q

CTG indications

A

PreE, IUGR, prev CS, IOL

meconium, oxytocin, >38degree temp, epidural

41
Q

SE systemic pain relief eg pethidine, Meptid IM

A

RD newborn, out control, sed, nausea (prescribe antiemetics)

42
Q

CI to epidural anaesthesia

A

severe sepsis, coagulopathy, active neuro H disease, hypovolaemia

43
Q

when to contact maternity services

A

contractions reg, painful, last 30 secs every 3-4 min or ROM

44
Q

how often are contractions in first stage of labour and what is dilation

A

every 2-3 mins

latent <4cm, active 4-10

45
Q

when to do instrumental delivery in second stage

A

2hrs null/1multi -> ventouse/forceps

46
Q

when to go to CS in first stage

A

not fully dilated 12-16 hrs -> CS

47
Q

what is used in active 3rd stage

A

IM oxytocin to help contract and decrease PPH

48
Q

what is used in active 3rd stage and define retained

A

IM oxytocin to help contract and decrease PPH

>30 mins

49
Q

success rate ECV

A

50%. 3% return and 3% not done do turn

50
Q

CI to ECV

A

fetal compromise, VD CIs, twins, recent APH, ROM

51
Q

procedure ECV

A
  • tocolytic (nifedipine, atosiban)
  • USS guidance, in hosp
  • CTG after
  • Anti-D if need
52
Q

key points in breech birth vaginal delivery

A

only push once buttocks visible

may use forceps to deliver head

53
Q

how many CS is an absolute CI to IOL

A

> 1 (ie 2 or more)

54
Q

Methods of induction:

A
  • PGE2 (allows amniotomy)
  • amniotomy, then plus oxytocin infusion if labour not started
  • amniotomy if SROM
  • Natural induction with cervical sweeping
55
Q

what do you do after IOL

A

CTG for 1hr. if oxytocin use CTG t/o

56
Q

VBAC CIs

A

2 or more CS
vertical
all indications for CS
prev uterine rupture

57
Q

VBAC success rate

VBAC maternal death rate

A

72-75%. but increase in emergency CS needed compared to plan.
13/100000 (double planned CS)

58
Q

presentation scar rupture and management

A

FD, scar pain, stopped contractions, vaginal bleed, mat collapse
laparotomy and CS

59
Q

2 risks of prelabour term ROM

A
  • neonatal infection

- cord prolapse

60
Q

management prelabour term ROM

A

check lie/presentation
avoid VE unless risk cord prolapse. sterile.
fetal auscultation/CTG
wait <24hrs labour. if 18-24hrs/meconium of ?infection -> induce, Abs for GBS
OR just induce

61
Q

indications instrumental delivery

A 
Prolonged 2nd stage (1-2hrs pushing)
FD
prophylactic eg if don't want to push HTN/cardiac disease
breech
if mod traction doesn't do descent do CS
62
Q

difference between Simpsons and keillands and what positions to use in

A

simpsons: non rotational for OA.

Keilland’s rotational for palpositioned.

63
Q

prerequisites for instrumental delivery

A 
head not palpable abdominal ie engaged
head at/below ischail spines
cervix fully dilated
know head position
adequate analgesia
bladder empty
64
Q

pain relief for mid and low cavity delivery

A

low : pudendal n block with perineal infiltration

mid : spinal or epidural

65
Q

emergency CS indications

A

acute antepartum issue eg abruption
prolonged first stage (full dilation not imminent by 12-16hrs) or if was fast now v slow
or if 10cm but cant do instrumental eg insufficient uterus or other Ps
FD (FHR, FBS) CS if fastest route

66
Q

CS absolute indications

relative

A

pp, severe antenatal compromise, uncorrectable ab lie, prev vertical CS, gross pelvic deformity

breech, severe IUGR, twin, med disorders, prev CS, older nulliparous.
<34 weeks eg PreE, severe IUGR

67
Q

Presentation amniotic fluid embolism and management

A

ss: anaphylaxis, dyspnoea, hypoxia, hypotension, seizure, cardiac arrest. >30 mins would present DIC, pul oedema ARDS.
MX: massive ob haemorrhage protocol, rests and supportive, clotting, x match, FBC, U and E s

68
Q

manoeuvres for shoulder dystocia

A

1) McRoberts (legs hyperextended into abdomen and suprapubic pressure)
2) episiotomy for manual rotation Woodscrew manouvre (pressure behind posterior shoulder, rotate 180 degrees or oblique) or get posterior arm and bring down
3) symphisiotomy
4) zavanelli manœuvre (push back in and CS. likely already damaged)

69
Q

Management cord prolapse

A

Give tocolytics eg terbutaline. if above Introitus, push back gently. if below do not force back inside, keep cord warm. all 4s and deliver safest route. normally CS. Instrumental if appropriate (fully dilated and low head).

70
Q

mx uterine rupture

A

resus, IV fluid and blood for cross match, clotting, give blood, laparotomy repair or removal uterus

71
Q

mx uterine inversion

A

(haemorrhage, pain, shock)
push up into vagina. GA and replacement performed with hydrostatic pressure of several litres of saline over clenched fist

72
Q

mx epiletiform seizure

A

clear airway, suction, o2
cardiopulmonary resus
if no cardiopulmonary collapse, diazepam. only give magnesium sulphate if sure eclamptic seizure.

73
Q

management pre-existing HTN in preg

A

IX: assess renal function, proteinuria measured and uric acid level as baseline, rule out Phaeochromocytoma with 24hr measurement of catecholamines

ss often not present: check renal bruits, radio femoral delay and fundal changes

management: ideally change meds before pregnancy. ACEI stopped as teratogenic. labetalol or nifedipine.
low dose aspirin (high risk preE). deliver 38-40.

74
Q

dx process of Pre-eclampsia

A

urine dipped
if 1+ quantified by 24hr protein or Protein creatinine ratio
>0.3g/day or 30mg/nmol = significant
bloods: increase uric acid, Hb often high
rapid fall platelets or increase LFTs (ALT) = HELLP
renal function mild impair: rising creatinine means RF
USS, umbilical a doppler and CTG for fetal monitoring

uterine a doppler at 20 weeks screens
ratio sFlt-1:PIGF in maternal blood can show who will develop

75
Q

diagnosis of pre-existing HTN in preg

A

<20 weeks >140/90. usually not proteinuria unless renal cause

76
Q

diagnosis of pre-existing HTN in preg

A

<20 weeks >140/90. usually not proteinuria unless renal cause

77
Q

management preE (before delivery)

A

assessment: >140/90 assessed. sFlt:PIGF. if no oproteinuria and mild/mod HTN manage as output. BP and urinalysis repeated 2x per week and USS every 2-4 weeks unless show feral compromise

admit if severe HTN or proteinuria signif (>0.3g/day/30mg/nmol)

antiHTN to keep BP 140/90: if 150/110 give labetalol for maintenance (nifedipine second). if serious oral nifedipine for initial control or 2nd line IV labetolol if severe

magnesium sulfate: treatment and prevention. IV loading dose then infusion. deliver if need this. toxicity can -> RD, hypotension

steroids if <34 weeks

78
Q

prevention PE

A

75mg aspirin if 1 high risk factor or 2 moderate

high dose vit D and Calcium

79
Q

mx PreE delivery

A

by 36 weeks
if deteriorate, complications or reduced SVT on CTG -> deliver
CS indications: (epidural help lower BP), <34 weeks, severe GR, ab CTG
>34 weeks can induce with prostaglandin
anti HTN in labour
avoid pushing in 2nd stage if BP 160/110
Oxytocin deffo for 3rd stage (not ergometrine)

80
Q

when should you deliver if gestational HTN

A

at 40 weeks as long as monitor fetes

81
Q

postnatal care in preE

A

BB
nifedipine and ACE-i second line
for several weeks

ONG (6 decks)

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