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Obs + Gynae > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

What is gravidity?

A

Number of pregnancies

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2
Q

What is parity?

A

Number of deliveries beyond 24w gestation

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3
Q

Describe Naegele’s rule:

A

EDD = 1 year and 7 days after LMP minus 3 months

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4
Q

At what gestation can uterus start to be felt?

A

12 weeks

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5
Q

Where can the fundus be felt at 16 weeks?

A

Halfway between pubic symphysis and umbilicus

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6
Q

Where can the fundus be felt at 20-24 weeks?

A

Umbilicus

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7
Q

Where can the fundus be felt at 36 weeks?

A

Under the rib cage

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8
Q

What should the symphysis fundal height be between 16 to 26 weeks?

A

SFH (cm) = date (in weeks)

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9
Q

What should the symphysis fundal height be between 26 to 36 weeks?

A

SFH ± 2cm = date (in weeks)

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10
Q

What should the symphysis fundal height be between 36 weeks and term?

A

SFH ± 3cm = date (in weeks)

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11
Q

What are the important features to palpate in an obstetric examination?

A 
SFH
Number of foetuses
Fetal lie
Presentation 
Engagement of head
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12
Q

When are fetal movements first noticed?

A

18-20 weeks

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13
Q

Why is there physiological anaemia during pregnancy?

A

Plasma vol. rises, red cell vol. also rises but at lower rate hence Hb falls due to dilution

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14
Q

What cardiovascular changes occur during pregnancy?

A

CO rises due to increase in SV and pulse rate
Peripheral resistance falls
BP falls in 2nd trimester, normal at term

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15
Q

What investigations should be done at booking visit?

A

Hb, blood group, rhesus status, antibody screen, rubella, HBsAg, HIV, sickle test, Hb electrophoresis, MSU

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16
Q

When should the booking visit take place?

A

8-12 weeks

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17
Q

What should be done at all antenatal visits?

A

Urine, BP, SFH

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18
Q

When should anomaly scan and placental localisation take place?

A

18-20 weeks

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19
Q

When should GDM screen take place? What weeks if previous GDM

A

28 weeks

16 and 28 weeks if previous GDM

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20
Q

When should the second screen for Hb and Rh antibodies be completed?

A

28 weeks

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21
Q

If needed, when should the first dose of anti-D be given?

A

28 weeks

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22
Q

If needed, when should the second dose of anti-D be given?

A

34 weeks

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23
Q

If needed, when should external cephalic version take place?

A

36 weeks

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24
Q

If needed, when should a membrane sweep take place?

A

41 weeks

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25
Q

When should a dating scan be completed?

A

10-13+6 weeks

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26
Q

What conditions are associated with an increased nuchal translucency?

A

Down’s

Cardiac abnormalities

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27
Q

What does a uterine artery Doppler measure and what does high resistance indicate?

A

Resistance within the placenta

High resistance increases risk of maternal pre-eclampsia and fetal growth restriction

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28
Q

What does a umbilical artery Doppler measure and what does high resistance indicate?

A

Resistance in the placenta

High resistance indicates placental failure and risk of intrauterine death

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29
Q

What are the components of the combined test?

A

NT + free hCG + pregnancy associated plasma protein (PAPP-A) + women’s age

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30
Q

When should the combined test be performed?

A

11-13+6 weeks

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31
Q

If a women books late and misses the combined test, what other tests can be offered and what are the components?

A

Triple or quadruple test (15-20 wks)

AFP, unconjugated oestradiol, hCG (+ inhibin)

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32
Q

What is the name for trisomy 18 and what are some features?

A

Edwards’

Small chin, low-set ears, rocker bottom feet and VSD

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33
Q

What is the name for trisomy 13 and what are some features?

A

Patau’s

Microcephaly, holoprosencephaly, exomphalos, cleft lip and palate

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34
Q

Between which dates can chorionic villus biopsy be carried out?

A

10-13 weeks

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35
Q

Between which dates can amniocentesis be carried out?

A

From 16 weeks onwards

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36
Q

List some common minor symptoms of pregnancy:

A 
N+V
Headaches
Palpitations
Urinary freq
Abdo pain
Breathlessness
Constipation
GORD 
Symphysis pubis dysfunction
Carpal tunnel syndrome
Itchy rashes
Ankle oedema
Leg cramps
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37
Q

What are the core features of hyperemesis gravidarum?

A

Persistent vomiting leading to weight loss, dehydration, ketosis and electrolyte imbalances

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38
Q

What increases risk of hyperemesis gravidarum?

A

Molar pregnancy

Multiple pregnancy

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39
Q

What scoring system can determine severity of hyperemesis gravidarum?

A

Pregnancy-Unique Quantification of Emesis (PUQE)

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40
Q

What investigations should be performed on a woman who may be suffering from hyperemesis gravidarum?

A 
Urine dip for ketones
FBC, U+Es, LFTs, albumin
ABG
Blood glucose
USS
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41
Q

How should mild hyperemesis gravidarum be managed?

A

Oral antiemetics (promethazine or cyclizine), hydration and dietary advice

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42
Q

How should hyperemesis gravidarum not responding to oral antiemetics be managed?

A 
Admit for rehydration and correction of metabolic disturbance
Daily U+Es 
Antiemetics, corticosteroids
High dose folic acid and thiamine
VTE risk assess
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43
Q

How is anaemia defined in pregnancy?

A

Hb <110g/L at booking and <105g/L at 28 weeks

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44
Q

What are some risk factors for anaemia in pregnancy?

A 
Menorrhagia previously
Haemoglobinopathies
Frequent pregnancies
Twin pregnancy
Poor diet
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45
Q

What investigations should be performed in a pregnant woman with suspected anaemia?

A

FBC, serum iron, TIBC, serum ferritin, folate

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46
Q

What is the management of anaemia in pregnancy?

A

Iron and folate supplements

Parenteral iron or blood transfusion if not responding

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47
Q

How can HIV transmission to babies from mother be reduced?

A

Maternal anti-retroviral use
Elective CS
Bottle feeding

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48
Q

Below what viral load, can a HIV +ve woman have a vaginal delivery?

A

<50 copies/ml

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49
Q

What drug can be given to suppress lactation in those not wishing to breastfeeding or where breastfeeding is not recommended?

A

Cabergoline

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50
Q

What should a neonate born by a HIV +ve mother be given after birth and for how long?

A

ART for 4-6 weeks

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51
Q

What pre-conception advice should be given to diabetics?

A

Aim for HbA1c <6.1%

Take 5mg folic acid daily

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52
Q

What are some maternal complications of diabetes in pregnancy?

A

Hypoglycaemia, pre-eclampsia, infection, higher rates of CS

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53
Q

What are some fetal complications of diabetes in pregnancy?

A 
Miscarriage
Malformation rates
Macrosomia 
Polyhydramnios
Preterm labour
Stillbirth
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54
Q

What fasting glucose level should be aimed for during pregnancy?

A

3.5-5.3mmol/L

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55
Q

What daily medication should be given to pregnant diabetics from week 12?

A

Aspirin

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56
Q

What are the cut offs for OGTT and fasting blood glucose in gestational diabetes?

A

OGTT ≥7.8mmol/L

Fasting ≥5.6mmol/L

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57
Q

List some reasons as to why a woman may be screened for GDM:

A

1st degree relative, previous baby >4.5kg, BMI >30,

ethnicity at risk, previous GDM

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58
Q

List some management options for GDM:

A

Diet and exercise
Metformin
Insulin

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59
Q

How should those who suffered with GDM be followed up?

A

Dietary advice

Fasting glucose 6 weeks postpartum and screen annually

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60
Q

What tests can be performed for a pregnant lady with jaundice?

A

Urine tests for bile, serology, LFTs, US, bile acids

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61
Q

What is the major symptom of obstetric cholestasis?

A

Pruritus

Esp. palms and soles in second half of pregnancy, without a rash and worse at night

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62
Q

What are the risks of obstetric cholestasis?

A

Preterm labour
Fetal distress
Meconium
Still birth

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63
Q

What medication can reduce pruritus in obstetric cholestasis?

A

Ursodeoxycholic acid

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64
Q

How should obstetric cholestasis be managed?

A

Weekly LFTs
IOL from 37-38w
Vit K

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65
Q

What are the features of acute fatty liver of pregnancy?

A 
Abdo pain
Jaundice
Headache
Vomiting
\+/- thrombocytopenia and pancreatitis
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66
Q

How should acute fatty liver of pregnancy be managed?

A

HDU or ITU
Supportive treatment
Correct clotting disorders
Expedite delivery

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67
Q

What pre-conception advice should be given to patients suffering from epilepsy?

A

Seizure control on lowest dose
Avoid polypharmacy
5mg folic acid daily for >3m pre-conception to delivery

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68
Q

Which AEDs shouldn’t be prescribed to women of childbearing age?

A

Valproate

Carbamazepine

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69
Q

Which antidepressants should be avoided in pregnancy?

A

Paroxetine

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70
Q

What are the risks of taking lithium in pregnancy for the fetus?

A

Teratogenicity (heart defects, Ebstein’s anomaly)
Neonatal thyroid abnormalities
Floppy baby syndrome

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71
Q

What fetal malformations are benzodiazepines linked with?

A

Cleft lip and palate

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72
Q

Due to the risk of IUGR, how often should pregnant women suffering with CF have growth scans?

A

Every 4 weeks from 28w

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73
Q

Why should NSAIDs be avoided in the third trimester?

A

Can cause premature closure of ductus arteriosus

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74
Q

How is RA usually affected by pregnancy?

A

Usually alleviated

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75
Q

How is SLE usually affected by pregnancy?

A

Exacerbations are more common

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76
Q

What medications can be used in pregnant women suffering from SLE?

A

Azathioprine
Hydroxychloroquine
Should take daily aspirin

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77
Q

How should pregnant women with antiphospholipid syndrome be managed?

A

Regular fetal assessment (Doppler and US)
Aspirin 75mg daily throughout and heparin from when fetal heart identified
Postpartum heparin or warfarin

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78
Q

What are the risks of HTN in pregnancy?

A

Pre-eclampsia, fetal growth restriction, placental abruption

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79
Q

What anti-hypertensives can be used in pregnancy?

A

Labetalol, nifedipine or methyldopa

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80
Q

What BP should be aimed for during pregnancy if woman has chronic HTN?

A

<150/90 but diastolic ≥80

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81
Q

What additional medication should be prescribed to pregnant women suffering with HTN?

A

Aspirin daily

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82
Q

What is the definition of pregnancy induced HTN?

A

HTN in second half of pregnancy (>140/90) in the absence of proteinuria

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83
Q

When should treatment be started in pregnancy induced HTN? What drug?

A

Labetalol if >150/100

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84
Q

At what BP, should a pregnant woman be admitted to hospital?

A

> 160/110

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85
Q

Why is pregnancy a risk factor for VTE?

A

Venous stasis
Trauma to pelvic veins at delivery
Procoagulant changes to clotting cascade

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86
Q

What are some features of a DVT?

A

Leg swelling, pain, redness, tenderness, pyrexia, oedema

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87
Q

What are some features of a PE?

A

SOB, chest pain, haemoptysis, faint, raised JVP, hypoxia, low BP, tachycardia, collapse

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88
Q

What investigations should be performed on a patient with suspected VTE?

A 
FBC, U+Es, LFTs, clotting screen
ABG
CXR
Duplex US 
CTPA or V/Q scanning
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89
Q

How long after the last dose of LMWH until an epidural/spinal can be inserted?

A

12 hours

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90
Q

What are some features of congenital rubella syndrome?

A

Cataract, deafness, cardiac lesions, growth

retardation, hepatosplenomegaly, cerebral palsy

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91
Q

What are some CMV-associated congenital defects?

A

IUGR, purpuric skin lesions, microcephaly, hepatosplenomegaly, motor and cognitive impairment, deafness

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92
Q

If there a baby is born to a Hep B infected or carrier mother, what should the baby be given at birth?

A

Immunoglobulins and vaccination

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93
Q

What is the management for primary genital herpes in last trimester of pregnancy?

A

Oral aciclovir and ELCS

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94
Q

What are some features of fetal varicella syndrome?

A

Skin scarring, eye defects, neurological abnormalities

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95
Q

What is the drug used in Group B strep prophylaxis?

A

Benzylpenicillin IV

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96
Q

What are some reasons to give Group B strep prophylaxis during labour?

A 
\+ve GBS HVS 
Baby previously infected with GBS
GBS bacteriuria in this pregnancy
Gestation <37w
Intrapartum fever
\+ve with PROM
RoM >18h
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97
Q

What problems affecting the uterus can cause abdominal pain in pregnancy?

A

Uterine rupture
Fibroids - torsion, red degen
Uterine torsion
Abruption

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98
Q

What are some risk factors for sepsis in pregnancy?

A

Obesity, diabetes, impaired immunity, immunosuppressants, anaemia, pelvic infection, prolonged RoM

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99
Q

What are the common organisms causing sepsis in pregnancy?

A

Group A beta-haemolytic strep and E. coli

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100
Q

What are some features of sepsis in pregnancy?

A 
Fever
Rigors
D+V
Rash
Abdo or pelvic pain
Offensive vaginal discharge
Productive cough, urinary symptoms
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101
Q

Should obese women be given folic acid pre-conception?

A

Yes, 5mg from 1 month prior and through first trimester

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102
Q

What are the risks of being pregnant with sickle cell?

A

Increased risk of painful crises
Perinatal mortality
Premature labour
Fetal growth restriction

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103
Q

What drug should pregnant sickle cell women be given from 12 weeks gestation?

A

Aspirin daily

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104
Q

What VTE prophylaxis should be given post-delivery in women with sickle cell? And for how long?

A

7 days of heparin prophylaxis post vaginal delivery, 6

weeks if CS

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105
Q

Describe postpartum thyroiditis:

A

Hyperthyroidism is followed by hypothyroidism (4

months postpartum)

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106
Q

How should UTI be treated during pregnancy?

A

Cefalexin, trimethoprim (not 1st trimester) or nitrofurantoin (not 3rd trimester)

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107
Q

Describe the movement of the baby during labour (6 steps):

A
  1. Descent with increased flexion as head enters cavity
  2. Internal rotation at ischial spine and increase in head flexion
  3. Disengagement by extension as head comes out of vulva
  4. Shoulders rotate to lie in AP diameter of pelvic outlet. The head externally rotates
  5. Delivery of anterior shoulder
  6. Delivery of posterior shoulder
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108
Q

What are some dangerous causes of antepartum haemorrhage?

A

Abruption
Placenta praevia
Vasa praevia

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109
Q

What is placental abruption?

A

Part of the placenta becomes detached from the

uterus

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110
Q

What is a revealed placental abruption?

A

Bleeding drains through cervix resulting in PV bleed

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111
Q

What is a concealed placental abruption?

A

Bleeding remains within the uterus, clotting retroplacentally

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112
Q

What are the two types of placental abruption?

A

Revealed and concealed

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113
Q

What are some features of placental abruption?

A

Painful vaginal bleeding
Uterus tense and painful
Shock out of keeping of loss
Fetal distress

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114
Q

What are some risk factors for placental abruption?

A 
Pre-eclampsia
Previous abruption
Smoking
Abnormal lie
Polyhydramnios 
Abdo trauma
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115
Q

What investigations should be performed on someone with suspected placental abruption?

A

FBC, clotting, Kleihauer, G+S, cross match, U+E, LFTs, USS, CTG

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116
Q

What is placenta praevia?

A

Placenta is fully or partially attached to the lower

uterine segment

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117
Q

Describe the difference between Grade I + II placenta praevia and Grade III + IV:

A

Grade I and II are minor are don’t cover the internal cervical os
Grade III and IV are major and cover the os

118
Q

What are the risk factors for placenta praevia?

A

Previous CS

High parity, increasing age, multiple pregnancy, previous PP

119
Q

What are some features of placenta praevia?

A

Painless PV bleed, uterus non-tender

120
Q

When can placenta praevia be identified?

A

20 week USS

121
Q

If minor placenta praevia is identified, when should a repeat scan be carried out?

A

36 weeks

122
Q

If major placenta praevia is identified, when should a repeat scan be carried out?

A

32 weeks

123
Q

What is the pathophysiology of pre-eclampsia?

A

Failure of trophoblastic invasion of spiral arteries leaving them vasoactive and able to respond to vasoconstrictors, limiting placental flow. Increasing BP
partially compensates for this failure

124
Q

When does pre-eclampsia develop from?

A

20 weeks

125
Q

What are some risk factors for pre-eclampsia?

A 
Previous pre-eclampsia
Chronic HTN
CKD
DM
Autoimmune (SLE, antiphospholipid)
Obesity 
Age
126
Q

If risk factors for pre-eclampsia are present, what drug should be started at week 12?

A

Daily aspirin

127
Q

What are some features of pre-eclampsia?

A

HTN, proteinuria

Headache, flashing lights, RUQ pain, N+V, brisk reflexes, IUGR

128
Q

How should labour be managed in those with pre-eclampsia?

A

IOL after 37 weeks

If severe and >34w, deliver - MgSO4 + steroids

129
Q

What are some complications of pre-eclampsia?

A

Eclampsia, HELLP syndrome, cerebral haemorrhage, IUGR, renal failure, placental abruption, DIC

130
Q

What is eclampsia?

A

Tonic-clonic seizure + pre-eclampsia

131
Q

What is the management of eclampsia?

A

MgSO4
IV labetalol
CTG
Delivery once stable

132
Q

What are the features of HELLP syndrome?

A

Haemolysis, Elevated Liver enzymes, and Low Platelets

133
Q

What are some symptoms of HELLP syndrome?

A

RUQ pain, N+V, dark urine, raised BP

134
Q

What is the management of HELLP syndrome?

A

Delivery of fetus

May need platelet transfusion

135
Q

What is the definition of prematurity?

A

Infants born before 37 weeks gestation

136
Q

What are some risk factors for prematurity?

A

Previous preterm birth, multiple pregnancy, cervical surgery, uterine abnormalities, pre-eclampsia, IUGR

137
Q

What is PPROM?

A

Preterm, premature rupture of membranes

138
Q

What is the management for PPROM?

A

Admit for 48h
If evidence of infection, expedite delivery
Give corticosteroids and erythromycin
Discharge if labour doesn’t occur in 48h, IOL at 34w

139
Q

What can be given to suppress uterine contractions in preterm labour?

A

Tocolytics e.g. nifedipine

140
Q

Why are glucocorticoids given in preterm labour?

A

Help with fetal surfactant production, lowering mortality and complications of RDS

141
Q

What corticosteroid is used in preterm labour and how is it administered?

A

Betamethasone IM

142
Q

What neuroprotective drug is given for babies less than 34 weeks?

A

MgSO4

143
Q

What are the risks of prematurity to the neonate?

A 
Increased mortality 
Respiratory distress syndrome
Intraventricular haemorrhage
Necrotizing enterocolitis
Chronic lung disease, hypothermia, feeding problems, infection, jaundice
Retinopathy of newborn, hearing problems
144
Q

What is the definition of small for gestational age?

A

Estimated fetal weight <10th centile for their gestational age

145
Q

What should happen if a SFH measurement is below 10th centile or there is static growth?

A

Refer for fetal US

146
Q

What placental factors can lead to a fetus that is SGA?

A

Pre-eclampsia

Abruption

147
Q

What fetal factors can cause a fetus to be SGA?

A

Genetic abnormalities including trisomies and Turner’s CMV, rubella
Multiple pregnancy

148
Q

What are some risk factors for having a fetus that is SGA?

A

> 40yrs
Smoker, cocaine
Previous SGA, parental SGA
HTN, DM, pre-eclampsia, anti-phospholipid

149
Q

What are some complications associated with SGA?

A 
Higher mortality
Cerebral palsy
Fetal distress
Meconium aspiration
Emergency CS
150
Q

What are some causes of a fetus that is large for gestational age?

A

Constitutionally large (usually familial)
Maternal diabetes
Obesity

151
Q

What are the risks for a fetus that is large for gestational age?

A

Birth injury

Hypoglycaemia, hypocalcaemia, left colon syndrome and polycythaemia

152
Q

What is the definition of postmaturity?

A

Pregnancy exceeding 42 weeks

153
Q

What are the problems caused by postmaturity?

A

Intrapartum and early neonatal death
Operative delivery
Macrosomia
Fetal distress and meconium

154
Q

What is the initial management for postmaturity and when should this be carried out?

A

Membrane sweep

41 week visit

155
Q

What is the management for postmaturity following a membrane sweep?

A

Induction with vaginal prostaglandin followed by oxytocin

156
Q

What signs of postmaturity may be seen in the neonate?

A

Dry skin
Decreased subcutaneous tissue
Hollow abdomen
Meconium staining of nails

157
Q

What are some obstetric causes of maternal collapse?

A 
APH or PPH 
Eclampsia
Intracranial haemorrhage
Amniotic fluid embolism
Post-surgical haemorrhage 
Severe sepsis
158
Q

What is the main cause for concern in PROM?

A

Chorioamnionitis

159
Q

What is PROM?

A

Rupture of membranes prior to the onset of labour in women at or over 37 weeks

160
Q

If spontaneous labour has not commenced 24h after PROM, what is the management?

A

Induce using vaginal prostaglandin (followed by oxytocin if contractions don’t start)

161
Q

What are the two parts of the first stage of labour?

A

Latent and established

162
Q

What is latent part of the first stage of labour?

A

Painful, irregular contractions as the cervix effaces then dilates to 4cm

163
Q

What is the established part of the first stage of labour?

A

Regular contractions with dilatation at a rate of >0.5cm/hour

164
Q

How long does the first stage of labour take in a primip?

A

8-18h

165
Q

How long does the first stage of labour take in a multip?

A

5-12h

166
Q

What should be monitored during labour?

A

Maternal BP and temp 4-hourly, pulse hourly and assess contraction strength and frequency every 30 mins
VE every 4 hours
Intermittent auscultation

167
Q

What are the two parts of the second stage of labour?

A

Passive and active

168
Q

What is the passive part of the second stage of labour?

A

Cervical dilatation complete but no pushing

169
Q

What is the active part of the second stage of labour?

A

Maternal pushing using abdominal muscles and Valsalva manoeuvre until baby is born

170
Q

How long does the second stage of labour last in primips and multips?

A

Expect birth within 3h in primips and 2h in multips

171
Q

What is the third stage of labour?

A

Delivery of placenta, as uterus contracts

172
Q

Describe intermittent auscultation and how often it is used during labour:

A

With Doppler US for a full minute after a contraction

Every 15 min in 1st stage and every 5 min in 2nd stage.

173
Q

Describe what a CTG is:

A

Continuous cardiotocograph (CTG) uses two transducers on the abdomen of the pregnant woman. One records the fetal HR and one monitors contractions of the uterus

174
Q

What are some indications for a CTG?

A 
IOL
Post//pre-maturity
Previous LSCS
Maternal cardiac problems
Pre-eclampsia or HTN
Diabetes
Ante or intrapartum haemorrhage
Small for gestational age
Multiple pregnancy
175
Q

How should a CTG be described (think acronym)?

A

DR C BRaVADO: DR define risk, C contractions, BRa baseline rate, V variability, A accelerations, D decelerations, O overall

176
Q

What is the normal fetal HR?

A

100-160bpm

177
Q

What can cause fetal tachycardia?

A

Fetal hypoxia, chorioamnionitis, hyperthyroidism, anaemia

178
Q

What can cause fetal bradycardia?

A

Postdate, occiput posterior presentation, prolonged cord compression, cord prolapse

179
Q

What is variability on a CTG?

A

Variation in fetal HR from one beat to the next

180
Q

What is normal variability on a CTG?

A

Each small square should have variation of >5bpm but no more than 25bpm

181
Q

What can cause a reduction in variability on a CTG?

A

Sleep, fetal hypoxia, malformation, prematurity, drugs

182
Q

What is an acceleration on a CTG?

A

Upward spike of >15bpm for >15 seconds

183
Q

What is a deceleration on a CTG?

A

Downward spikes of >15bpm for >15 seconds

184
Q

What is an early deceleration on a CTG?

A

Mimic the shape and timing of contractions and

are due to head compression

185
Q

What is a late deceleration on a CTG?

A

Begin at peak of contraction and recover after the end

Maternal hypotension, pre-eclampsia, uterine hyperstimulation

186
Q

What can cause variable deceleration on a CTG?

A

Umbilical cord compression

187
Q

What are some indications for induction of labour?

A 
Risk to mother
HTN
Pre-eclampsia
Prolonged pregnancy
PPROM
Diabetes
Abruption
IUGR
188
Q

What are some contraindications for induction of labour?

A

Malpresentations, fetal distress, placenta previa, cord

presentation, vasa previa

189
Q

What score can be used during the decision making for induction of labour?

A

Modified Bishop score

190
Q

How can labour be induced?

A

Vaginal PGE2 (gel/tablet or pessary)
Membrane sweep
Foley’s catheter

191
Q

What should be given after IOL if there are no contractions after 2-4hrs?

A

IV oxytocin

192
Q

What are some problems associated with IOL?

A 
Failure
Uterine hyperstimulation
Infection
Bleeding
Cord prolapse
C-section and instrumental delivery
193
Q

How is oligohydramnios defined?

A

Amniotic fluid index that is below the 5th centile for the gestational age

194
Q

What are some causes of oligohydramnios?

A

PPROM
Renal agenesis/non-functional fetal kidneys, Genetic/chromosomal abnormalities
Placental insufficiency

195
Q

What investigations may be done to investigate oligohydramnios?

A 
SFH
Speculum
USS 
Karyotyping
Actim-PROM
196
Q

What are some causes of polyhydramnios?

A 
Idiopathic (50-60%)
Oesophageal/duodenal atresia
Muscular dystrophy
Anaemia
Twin-twin transfusion syndrome
Macrosomia
197
Q

What are some non-pharmacological pain relieving methods in labour?

A

Education
Breathing exercises
Relaxation techniques
Labouring in warm water

198
Q

What are some pharmacological methods of pain relief in labour?

A

Nitrous oxide
Pethidine/diamorphine
Pudendal nerve block

199
Q

What is an epidural?

A

Anaesthetizing pain fibres from T10-S5

200
Q

Where is an epidural usually placed?

A

L3/4 space usually used

201
Q

What are some complications of an epidural?

A

Failure to site
Patchy block
Low BP
Dural puncture + post-dural puncture headache

202
Q

When is spinal anaesthesia often used?

A

CS

203
Q

When may a combined spinal epidural be used?

A

Cover CS that has potential to take more time than usual e.g. placenta previa

204
Q

What do the terms monochorionic and monoamniotic refer to in terms of twin pregnancy?

A

Monochorionic twins share same placenta

If monoamniotic share one amniotic sac

205
Q

What type of twin pregnancy is at the lowest risk?

A

Dichorionic, diamniotic

206
Q

What are some predisposing factors to multiple pregnancy?

A

Previous twins
FH of twins
Increased maternal age
Induced ovulation or IVF

207
Q

What are some features that often occur in multiple pregnancy?

A

Uterus large for dates
Hyperemesis
Polyhydramnios

208
Q

What are some antenatal complications of multiple pregnancy?

A

Polyhydramnios, pre-eclampsia, anaemia, APH, gestational diabetes

209
Q

What are some fetal complications of multiple pregnancy?

A

Perinatal mortality, prematurity, growth restriction,

malformation

210
Q

What are some labour complications of multiple pregnancy?

A

PPH, malpresentation, vasa praevia, cord prolapse, placental abruption, cord entanglement

211
Q

How often should women with multiple pregnancy have USS?

A

Monthly from 20 weeks

212
Q

How often should women with multiple pregnancy have antenatal visits?

A

Weekly from 30 weeks

213
Q

When should elective birth be aimed for in dichorionic and monochorionic twins?

A

37 and 36 weeks respectively

214
Q

What is external cephalic version and when should it be done?

A

Turning the breech through a forward somersault

Only if vaginal delivery planned, after 36-37 weeks

215
Q

What are some contraindications for external cephalic version?

A 
Placenta praevia
Multiple pregnancy
Recent APH
Ruptured membranes
Growth restriction
Abnormal CTG
216
Q

List some malpresentations/malpositions:

A 
Breech
Occipitoposterior 
Face 
Brow
Transverse
217
Q

Why is cord prolapse an emergency?

A

Cord compression and vasospasm from exposure cause fetal asphyxia

218
Q

What can increase incidence of cord prolapse?

A 
2nd twin
Footling breech
Prematurity
Polyhydramnios
Unengaged head
ARM
Transverse or unstable lie
219
Q

What are some management options in cord prolapse?

A 
Keep cord in vagina
Stop presenting part from occluding cord
Fill bladder with saline
Tocolytics
Deliver fetus ASAP either by CS or instrumental
220
Q

What gets stuck in shoulder dystocia?

A

Anterior shoulder impacted on pubic symphysis or posterior on sacral promontory

221
Q

What are the risks of shoulder dystocia?

A

Higher risk of fetal mortality, PPH, 4th degree tear, brachial plexus injury

222
Q

What are some conditions associated with shoulder dystocia?

A

Large fetus, BMI >30, induced labour, prolonged labour, previous SD, diabetes

223
Q

What initial management for shoulder dystocia works in 90% of cases?

A

McRoberts position (hyperflexed lithotomy)

224
Q

If McRoberts position fails to work in shoulder dystocia, what are some other management options?

A

Suprapubic pressure
Rotate fetal shoulder to oblique diameter
Roll mother onto all fours
Maternal symphysiotomy, replacement of fetal head and CS (Zavanelli), cleidotomy (fracture fetal clavicle)

225
Q

What are the issues with passage of meiconium?

A

May indicate fetal distress

Aspiration leading to pneumonitis

226
Q

What are the criteria for an instrumental vaginal delivery?

A 
1/5th or less head palpable per abdomen
Ruptured membranes, fully dilated cervix with head at ischial spines or below
Adequate contractions
Adequate analgesia
Bladder empty
227
Q

What are some maternal indications for instrumental delivery?

A

Prolonged second stage, maternal exhaustion, medical avoidance of pushing e.g. cardiac disease

228
Q

What are some fetal indications for instrumental delivery?

A

Suspected fetal distress, for head in breech delivery

229
Q

Describe forceps delivery:

A

Curved blades to fit round fetal head and round pubic symphysis

230
Q

Describe ventouse delivery:

A

Uses a suction device to suck fetal scalp tissues into ventouse cup

231
Q

Which instrumental delivery is safer for the fetus and which is safer for mother?

A

Forceps for fetus

Ventouse for mother

232
Q

What are some maternal complications of instrumental delivery?

A

Maternal genital tract trauma, VTE, incontinence, PPH

233
Q

What are some fetal complications of forceps delivery?

A

Facial nerve palsy, skull fractures, orbital injury,

intracranial haemorrhage

234
Q

What are some fetal complications of ventouse delivery?

A

Cephalhematoma, retinal haemorrhage, scalp

lacerations, subgaleal haematoma

235
Q

Describe a Cesarean section procedure:

A

Lower uterine segment incision by Joel-Cohen or Pfannensteil incision followed by blunt dissection

236
Q

What layers are cut through from the skin to reach the uterus in a CS?

A

Camper’s fascia -> Scarpa’s fascia -> rectus sheath -> rectus muscles -> abdo peritoneum -> gravid uterus

237
Q

What are some indications for CS?

A 
Repeat CS
Fetal compromise
Failure to progress in labour
Malpresentation
Severe pre-eclampsia
IUGR with abnormal Doppler
Placenta praevia
Primary genital herpes in 3rd trimester
238
Q

After what week should elective CS be carried out and why?

A

After 39 weeks, reduces transient tachypnoea of the newborn

239
Q

What are some intraoperative complications of CS?

A

Blood loss, uterine lacerations, bladder laceration, fetal

lacerations, hysterectomy

240
Q

What are some postoperative complications of CS?

A

Wound infections, endometritis, UTI, VTE

241
Q

Why is ranitidine given prior to CS?

A

Neutralise and empty gastric contents

Minimises risk of post-op aspiration which can lead to Mendelson’s syndrome

242
Q

What are the features of Mendelson’s syndrome?

A

Cyanosis, bronchospasm, pulmonary oedema and tachycardia

243
Q

What are some long term consequences of having had a CS?

A

Higher incidence of placenta previa and accreta
Risk of uterine rupture
Risk of stillbirth

244
Q

What are some risk factors for uterine rupture?

A

Previous CS, obstructed labour, previous uterine surgery, high forceps delivery

245
Q

What are some features of uterine rupture?

A

Pain, vaginal bleeding, maternal tachycardia, shock, fetal distress, continuous PPH

246
Q

How often is vaginal birth successful after CS?

A

75%

247
Q

What are some advantages of VBAC over CS?

A

Shorter stay
Good chance of future VBAC
Lower maternal death risk

248
Q

What are some advantages of CS over VBAC?

A

Lower risk of uterine rupture

No risk of anal sphincter injury

249
Q

What are some contraindications for VBAC?

A

Classical C-section scar, previous uterine rupture

250
Q

What is the definition of a stillbirth?

A

Babies born dead after 24 weeks gestation

251
Q

What test should be done following a stillbirth? And what medication may be given?

A

anti-D for Rh-ve and do Kleihauer to diagnose fetomaternal haemorrhage

252
Q

What is the definition of primary PPH?

A

Loss of >500ml in first 24h post-delivery

253
Q

What are the different categories of primary PPH?

A

Major is >1L

Massive obstetric haemorrhage if >1.5L

254
Q

What are the causes of primary PPH (4Ts)?

A

Tone: uterine atony (90%)
Tissue: retained POC
Trauma: genital tract trauma (instrumental, episiotomy, CS)
Thrombin: clotting disorders

255
Q

What are some risk factors for uterine atony?

A

> 40 years, BMI >35, multiple pregnancy, fetal

macrosomia, induction, prolonged labour, placental issues

256
Q

What is bimanual compression in terms of PPH?

A

Fist into anterior fornix to compress anterior

uterine wall while other hand applies pressure on abdomen at posterior aspect of uterus

257
Q

What drugs may be given during a primary PPH?

A

Syntometrine, oxytocin, ergometrine

258
Q

If initial management of PPH fails and pt is still bleeding, what further management options are available?

A

EUA, insert Rusch balloon
B-lynch suture
Internal iliac or uterine artery ligation or hysterectomy

259
Q

What is a secondary PPH?

A

Excessive blood loss from genital tract after 24h from delivery

260
Q

When do secondary PPH often occur and what is often the cause?

A

Between 5 and 12 days due to retained placental tissue or clot, often with infection

261
Q

When can the third stage of labour be called delayed?

A

If not complete by 60min

262
Q

What is the management for retained placenta?

A

Rub up a contraction or put baby on breast to stimulate oxytocin
Give oxytocin into umbilical vein and proximally
clamp cord
Empty bladder
Manual removal

263
Q

What can cause uterine inversion?

A

Mismanagement of third stage e.g. cord traction in an atonic uterus
Fundal insertion of placenta

264
Q

What is the management for uterine inversion?

A

Immediate replacement
Push fundus through cervix
Infuse warm saline into vagina and sealing labia
Laparotomy and pull uterus up

265
Q

What is velamentous insertion?

A

Umbilical cord inserts into fetal membranes and travels

within membranes to placenta

266
Q

What is placenta succenturia?

A

Separate lobe away from main placenta which may fail to separate normally and cause a PPH

267
Q

What is placenta accreta? What are increta and percreata?

A

Abnormal attachment of all or part of placenta to the
myometrium
Termed increta if myometrium infiltrated, percreata if penetration reaches serosa

268
Q

What is vasa praevia?

A

Fetal vessels from velamentous insertion or between lobes cross the internal cervical os and risk damage at membrane rupture causing fetal haemorrhage

269
Q

What are some risk factors for amniotic fluid embolism?

A

Multiple pregnancy, >35 years, CS, instrumental delivery, eclampsia, polyhydramnios, placental abruption, uterine rupture, IOL

270
Q

What are some features of amniotic fluid embolism?

A 
Dyspnoea
Chest pain
Hypoxia leading to ARDS
Hypotension and collapse
Fetal distress
Seizures
DIC within 48h
271
Q

What is cephalhaematoma?

A

Fluctuant, subperiosteal swelling on head that spontaneously resolves within months. Doesn’t cross suture lines

272
Q

What is caput succedaneum?

A

Oedematous swelling of scalp due to venous congestion caused by pressure against cervix during labour

273
Q

What are some risk factors for perineal tears?

A

First vaginal delivery, large baby, persistent OP

position, IOL, epidural, prolonged 2nd stage, instrumental delivery

274
Q

What is a first degree tear?

A

Superficial and don’t damage muscle

275
Q

What is a second degree tear?

A

Involve perineal muscle

276
Q

What is a third degree tear?

A

Involve anal sphincter muscle

277
Q

What is a fourth degree tear?

A

If anal/rectal mucosa involved

278
Q

How should third and fourth degree tears be managed?

A

Repair by surgeon under epidural/GA with Abx
High fibre diet and lactulose
Pelvic floor exercise, physio

279
Q

Why are episiotomies perfomed?

A 
Enlarge outlet (fetal distress, instrumental)
Prevent 3rd degree tears
280
Q

What is the technique for an episiotomy?

A

Hold perineal skin away from fetus with fingers in vagina and give LA
Cut mediolaterally, starting midline to avoid Bartholin’s glands

281
Q

What is lochia?

A

Endometrial slough, red and white cells, passed PV

282
Q

What are the common causes of puerperal pyrexia?

A

UTI or genital tract infection

283
Q

What are some features of endometritis?

A

Lower abdo pain, offensive lochia and a tender uterus

284
Q

When are post-partum blues often noticed?

A

3rd and 10th day postpartum

285
Q

A women presents asking for emergency contraception, 17 days post partum. What should you tell her?

A

Emergency contraception not needed until 21d post partum

286
Q

When can the combined contraceptive be restarted if breastfeeding?

A

6 months post partum

287
Q

When can the IUCD be fitted post partum?

A

Within first 48h postpartum or delayed until 4 weeks

288
Q

In what situations should anti-D be given?

A 
Delivery of a Rh +ve infant
TOP
Miscarriage if gestation is > 12 weeks
Ectopic pregnancy (if managed surgically)
ECV
APH
Amniocentesis, chorionic villus sampling, fetal blood sampling
Abdominal trauma
289
Q

What tests should be carried out on babies born to Rh -ve mother?

A

Cord blood taken at delivery for FBC, blood group and direct Coombs test

290
Q

What is the treatment for mastitis and should the woman continue to breastfeed?

A

Flucloxacillin for 10-14 days

Breastfeeding should continue

291
Q

What is a sign of fetal distress or placental insufficiency on an umbilical artery Doppler?

A

Absent or reversed end diastolic flow

Obs + Gynae (4 decks)

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